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Primary Care Late in the Day

Neda Frayha, MD and Paul Simmons, MD
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No me gusta!

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When Paul and Neda read a recent JAMA article on how time of day may affect our rates of ordering mammograms or colon cancer screening tests, they knew they needed to debrief about it. 

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Jennifer A. -

I wanted to see if you could provide some guidance or direct me to a good source for the following questions:
1. Is it ok to use a direct LDL when using the cardiovascular risk calculators? I have a lot of patients who are not fasting or when Triglycerides are over 150 have a significant difference (around 20mg/dl) between calculated and direct LDL
2. I am still a little confused when it may be appropriate to measure Apoprotein B, Apoprotein a, and NMR lipoprotein profile
Not sure if this is the correct forum to ask but feel free to redirect me if needed!

Neda F., MD -

Thanks for your questions, Jennifer. I'll add them to our mailbag list of topic requests. Have a great day! -- Neda

Paul S., MD -

Hi, Jennifer! If I can jump in here too, I'd answer:
1. Newer lipid machines do in fact measure the LDL directly, meaning that fasting is no longer necessary in most cases! So, yes, you can use that direct LDL measurement in your ASCVD calculations - it's as- or more accurate than old calculated LDLs!
2. Secondly, the apoprotein question is complicated, but in MOST cases (in primary care at least), measurement of these "subparticles" (as I call them) don't add a lot of actionable information to our clinical reasoning. We just don't have high-quality data about patient-oriented outcomes for these lipoproteins. I typically leave them to the cardiologists if they want them.

One guy's opinion! Thanks for the question, and Neda and I will get some more details for a mailbag segment!

PDS

Ian L., Dr -

The time out breaks after each consult and in the afternoon between 3..30-3.50 the energy trough with recharge by whatever works is a good idea . -In a several doctor clinic and with practice nurses it can be staggered so 1-2 doctors are present while the others take rest . -In competitive sports it is called the interchange bench .

Sara W. -

Two questions:
#1. For the lasix/diuretic segment: any comments regarding outpatient HFrEF (diastolic heart failure)? I find it very tricky to judge the appropriate increase in diuretic as they tend to be quite tenuous. If I double the oral diuretic they tend to get an Aki. I follow closely but Wondered if any studies here.
#2. For cholesterol guidelines- if we are no longer following the cholesterol number, then why do follow up lipids (unless it's one of the cases in which we need to confirm a 50 percent drop or certain LDL target)? Doesn't seem it would change management.

Neda F., MD -

Hi Sara. Which lasix segment? As for #2, my own practice is to check lipids less frequently unless it's one of those cases where I need to confirm the 50% decrease, just like you said. I've become so aware of what a pain it is for patients to go back and forth to the lab, and if it doesn't change management, I don't order the test. I asked Robert Reilly his thoughts, and here's his response:

"I would say there is still benefit to checking the numbers periodically.

For one thing, we need to remember that the lipid panel contains more than just the low density lipoprotein level. It includes triglycerides and high density lipoprotein values, which may help motivate our patients towards exercise and carbohydrate reduction.

Secondly, many cardiovascular societies still endorse certain goal points for the LDL value-for example, status post percutaneous coronary stent placement we seek an LDL of less than 70.

Finally, patients simply want to know how they’re doing. And checking lipids periodically is a satisfier for them and I believe helps to ensure compliance with statin dosing."

Sara W. -

I think it was the hospitalist corner lightning round #2 episode with diuresis in acute heart failure and discussed doubling the lasix dose (more discussion on IV). I'm outpatient but it did remind me of issues I've had with the diastolic heart failure patients. Thanks!

Neda F., MD -

Yes, got it. I agree with your approach of following them closely and doubling their diuretic/furosemide dose for a short period of time to improve their volume status, not indefinitely. Here are two articles I find helpful when it comes to HFpEF/diastolic dysfunction: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4347209/ and https://www.aafp.org/afp/2017/1101/p582.html. -- Neda

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Are We Better in the Morning? Full episode audio for MD edition 188:54 min - 88 MB - M4APrimary Care RAP September 2019 Written Summary 580 KB - PDF

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