Online Clinical Case Study (December 2016)

Clinical Cardiology Series
臨床心臟科個案研究

The content of the December Cardiology Series is provided by:
Dr. WONG Chi Yuen
MBBS (HK), MRCP (UK), FHKCP, FHKAM (Medicine), Specialist in Cardiology
Dr. CHUI Shing Fung
MBChB (CUHK), MRCP (UK), FHKCP, FHKAM (Medicine), Specialist in Cardiology
十二月臨床心臟科個案研究之內容承蒙黃志遠醫生徐城烽醫生提供。

Choice of antiplatelet agents in coronary artery disease

Question:
For each of the following cases below, choose the appropriate antiplatelet regime (more than one answer is possible).

1. Stable angina with moderate stenosis in proximal left anterior descending artery (LAD), no percutaneous coronary intervention (PCI) or coronary artery bypass surgery (CABG) is done
A. Aspirin
B. Aspirin + Clopidogrel
C. Aspirin + Prasugrel
D. Aspirin + Ticagrelor
   
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2.

Stable angina with severe stenosis in proximal LAD, recently treated with PCI with a drug-eluting stent (DES) implanted
A. Aspirin
B. Aspirin + Clopidogrel
C. Aspirin + Prasugrel
D. Aspirin + Ticagrelor

   
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3.

Acute coronary syndrome with severe stenosis in proximal LAD, recently treated with PCI with a DES implanted
A. Aspirin
B. Aspirin + Clopidogrel
C. Aspirin + Prasugrel
D. Aspirin + Ticagrelor

   
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4 Acute coronary syndrome with unknown coronary artery status, patient opts for medical treatment and refuses PCI or CABG
A. Aspirin
B. Aspirin + Clopidogrel
C. Aspirin + Prasugrel
D. Aspirin + Ticagrelor
   
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5 Acute coronary syndrome with triple vessel disease, recently treated with CABG
A. Aspirin
B. Aspirin + Clopidogrel
C. Aspirin + Prasugrel
D. Aspirin + Ticagrelor
   
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Answer

Patient 1. a.
This is a patient with stable ischemic heart disease with no PCI or CABG performed. Dual anti-platelet therapy (DAPT), i.e. aspirin + P2Y12 inhibitor, are considered to be Class III indicated (not beneficial) in this group of patient in the 2016 American College of Cardiology/American Heart Association Guideline Focus Update on Duration of Dual Antiplatelet therapy.

Patient 2. b.
This patient suffered from stable ischemic heart disease (SIHD) with recent PCI done with DES implanted. So a course of dual anti-platelet therapy (DAPT) should be given to reduce the risks of stent thrombosis. According to the 2016 American College of Cardiology/American Heart Association Guideline Focus Update, this group of patients should be given DAPT with clopidogrel for at least 6 months (Class I) together with aspirin (75mg to 100mg daily) (Class I). For those with SIHD treated with DES implantation who tolerated DAPT without bleeding complication and who are not at high bleeding risk (e.g. prior bleeding on DAPT, coagulopathy, use of oral anticoagulant), continuation of DAPT with clopidogrel for longer than 6 months maybe reasonable (Class IIb).

Patient 3. b + c + d
This patient suffered from acute coronary syndrome (ACS) and recently had PCI done with DES implanted. This group of patients has high risks of ischemic event and required DAPT with P2Y12 inhibitor therapy (clopidogrel, prasugrel, or ticagrelor) for at least 12 months (Class I) together with aspirin (75mg to 100mg daily) (Class I). In patients with ACS treated with DAPT after coronary stent implantation, it is reasonable to use ticagrelor in preference to clopidogrel (Class IIa) and for those who are not at high risk for bleeding complications and who do not have previous history of stroke or TIA, it is reasonable to choose prasugrel over clopidogrel (Class IIa). For those who tolerate DAPT without bleeding complication and who are not at high bleeding risk (e.g. prior bleeding on DAPT, coagulopathy, use of oral anticoagulant) continuation of DAPT for longer than 12 months maybe reasonable (Class IIb).

Patient 4. b + d
This patient suffered from ACS and opted for medical treatment and not for revascularization (PCI or CABG). This group of patient should be treated with DAPT with clopidogrel or ticagrelor continue for at least 12 months (Class I) together with aspirin (75mg to 100mg daily) (Class I). It is reasonable to use ticagrelor in preference to clopidogrel (Class IIa) and for those who tolerate DAPT without bleeding complication and who are not at high bleeding risk (e.g. prior bleeding on DAPT, coagulopathy, use of oral anticoagulant) continuation of DAPT for longer than 12 months maybe reasonable (Class IIb).

Patient 5. b + c + d
This patient suffered from ACS with coronary angiogram done, so the patient should already be given with DAPT. However, coronary angiogram showed triple vessel disease and patient was sent for CABG. For this patient, P2Y12 inhibitor therapy should be resumed after CABG to complete 12 months of DAPT therapy after ACS (Class I) together with aspirin (75mg to 100mg daily) (Class I).

Further reading:
Levine GN, Bates ER, Bittl JA, et al. 2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines Circulation. 2016;134:e123-e155.

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Dermatology Series 皮膚科病例研究

Dermatology Series for December 2016 is provided by:
Dr. CHAN Hau Ngai, Kingsley, Dr. TANG Yuk Ming, William, Dr. KWAN Chi Keung, Dr. LEUNG Wai Yiu and Dr. CHANG Mee, Mimi
Specialists in Dermatology & Venereology
十二月皮膚科個案研究之內容承蒙陳厚毅醫生鄧旭明醫生關志強醫生梁偉耀醫生張苗醫生提供。

A few months-old girl with red nodule over right face

 

A 4-months old girl with good past health presented with reddish growth over right face. Physical examination showed a reddish nodular lesion over right cheek - 2 X 1.3 cm in size.

Answers

1. What is the diagnosis?
The diagnosis is a capillary haemangioma which is one of the most common soft tissue tumours in infancy.
 

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2. How common is this skin disease?
Around one in ten babies has a haemangioma. They are more common in girls, in premature babies, low birth weight babies and multiple births, such as twins.
 

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3. Where does this skin condition usually occur?
Haemangiomas can appear any part of the body. Most of haemangiomas appear on the head or neck, particularly on the cheek, lips or upper eyelid. They can also appear on the organs inside the body.
 

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4. How is the skin condition diagnosed?
Most of the haemangiomas can be diagnosed clinically and no special diagnostic test is needed. If a child has a haemangioma around the eye region, or involved deeper layer or one affecting the internal organs, further investigation ultrasound and/or MRI scans may be required.
 

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5. What are the managements?
Most haemangiomas do not require any further treatment as they will involute when grows older. However, there are circumstances when treatment might be needed which include: ulcerated haemangiomas, haemangioma over periorbital region affecting vision, haemangioma obstructing the airway. Treatment options for hemangiomas include propranolol, steroid treatment, laser, operation, etc.
 

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