3/16/06njm

**Cardiology Topics for Primary Care Providers**

-   Moderator: Jim Galloway, MD\
    Director, Native American Cardiology Program

**Questions\*:**

-What, in your opinion, is the most important question that was not
asked in the above history?

-How would you proceed to evaluate this patient?

-Do you think a CRP would be particularly helpful? Why or why not?

-Would your approach be different if the patient was not CHS eligible?

-How would you modify this patient's medications for optimal CVD
prevention?

\* **Full Cardiology for Primary Care Forum is here**

<http://www.ihs.gov/MedicalPrograms/MCH/F/PCdiscForumMod.cfm#cardio>

JG

First of all, I would like to offer my apologies to you all as the
e-mail gnome is at work again and I am not directly receiving your
e-mail responses. However, Dr. Murphy has been kind enough to forward
them on to me. This problem, which we are actively working on,
unfortunately will add a delay factor to my responses. Again, my
apologies....

**From: Johnson, David E \[David.Johnson3@ihs.gov\]**

**Thu 2/16/2006 9:07 AM**

I will jump in and start the discussion.

 

1\. There are a number of questions that I would want to know to assess
cardiac risk factors, but let\'s go with the duration of his diabetes.

2\. Get a resting EKG (if possible during an episode of this discomfort)
would be the first step.  Given significant risk factors (uncontrolled
DM2, HTN and dyslipidemia and age and sex) and symptoms at rest, I think
you would have to take this pretty seriously.  If you had the
capability, cardiac enzymes would be helpful as well since he is
apparently having symptoms at rest, indicating the possibility of
unstable angina.  If not, then the patient should be referred to a
facility where he can be urgently evaluated.  Medication wise, he should
probably chew an aspirin and try a nitroglycerin.

3\. I don\'t know that a CRP would significantly change your pretest
probability of CAD.

4\. Theoretically no.  I think if you think this could be cardiac pain,
and his risk is high due to CRF\'s and he has symptoms at rest, the
initial management would be the same.  I think ultimately, the choice of
which stress test might be important because of cost considerations.

5\. As above, plus maximizing BP (increase ACE or add beta blocker),
glucose control (the choice of agent would depend on whether he
ultimately ends up having CAD or not), and cholesterol (probably a
statin, depending on the rest of the FLP.  Also the LDL goal would vary
(100 vs. 70) depending on the presence of CAD).

 

Well I\'m sure I\'ve opened myself up to a barrage of shotgun pellets,
but at least I\'m in good company.

 

David Johnson

JG - Thank you, Dr. Johnson, for your courage and insight. Indeed, you
are right on the mark about these items...The assessment of his CV risk
factors, including the duration of DM is an extremely important
assessment overall and the most important immediate component of the
history that has been left out will assist us, as you implied, in
determining whether this history suggests the need for immediate
admission, testing and observation as it is certainly consistent with
the possibility of unstable angina or acute MI. The time of the most
recent episode of chest pain is extremely important. For instance if he
is having chest pain at the time of evaluation or, say, less than 8
hours ago (regardless of the presence or absence of current ECG
changes), your approach would be substantially different than if his
last episode was a month ago or more, including the assessment of
enzymes, as you suggest.

I agree I would find no use for the assessment of CRP acutely in this
patient...

I also agree that our initial approach should not be modified based on
the presence or absence of CHS eligibility. Of course, reality does, all
too frequently, interfere with our idealism. However, our acute
interventions should not be affected by lack of third party or CHS
availability as, even if transfer is needed, we should be able to
arrange this acutely. Outside follow up interventions and care may be a
different matter, of course.

**Muench, Justine \[Justine_Muench@HEALTH.STATE.AK.US\]**

**Thu 2/16/2006 2:47 PM**

I would think you would go with an ECG pretty quickly and then transfer
if he has any ST changes. If you have access in the clinic to a stress
test equipment then I would schedule him soon for a stress test (if he
can walk long enough for a conclusive test). May need to consider fast
EBCT. Justine

Justine Muench RN MN

Heart Disease and Stroke Prevention

PO Box 110616

Juneau, AK 99811-0616

\(907\) 465-8234

\(907\) 465-2770 Fax

JG - Very good point. An ECG should be performed promptly in this
individual to assess for ischemia or potentially recent damage. Remember
that up to 20% of acute MIs may have a normal initial ECG, however, and
consider repeat ECGs and the performance of enzymes as indicated by the
history. Remember, similarly the first set of enzymes may also be
negative in an Acute MI, depending on the duration of symptoms or the
length of time since the episode of pain.

**Muench, Justine \[Justine_Muench@HEALTH.STATE.AK.US\]**

**Thu 2/16/2006 2:51 PM**

Wouldn\'t the LDL goal be 70 anyway as he is obviously high risk.

Would you add a second medication for BP control instead of upping the
current dose according to JNC7?

By not being CHC eligible, would you refer him to an ER immediately
rather than a workup?

JG -- Great points! Yes, while that is a bit open to interpretation
based on ATP III, I would consider this 62 year old hypertensive,
dyslipidemic gentleman with diabetes at high risk and would personally
shoot for an LDL goal of 70 or less but the absolute answer to that
question in someone without known CVD await the results of several
studies currently underway, including the SANDS study, being performed
with American Indians with DM - being randomized to LDL goals of 100 vrs
70. With known CAD or other atherosclerotic disease in those with DM,
clearly the goal is 70.

As far as the current management of the blood pressure goes, to me, it
depends on whether our decision is that this is likely CVD or not after
the remainder of the history and appropriate evaluation. If CVD remains
as high on our list as it currently is, I would intervene with beta
blockers acutely (after NTG if current pain). Otherwise, I would
probably add another agent such as low dose diuretic chronically,
depending on what his BP was before the 20 mg. If it was very effective,
I might try a further increase in the Lisinopril first.

Finally, I again think you are correct that if you are unable to fully
assess his history and you are unsure, an ER visit is the appropriate
intervention acutely for the necessary evaluations and interventions, if
you have one in your facility. If not, some of these things can likely
be performed in your facility while awaiting transfer, such as ECG and
acute interventions with meds & O2 for instance.

**Reidhead, Charles \[Charles.Reidhead@IHS.GOV\]**

**Fri 2/17/2006 5:25 AM**

First off, Dr. Johnson... there will be no shotgun pellets flying among
friends!

My reading of the ATPIII updated criteria is that a goal LDL of \<70 is
optional in this patient at high risk for CAD with DM... but should
definitely be considered in the appropriate patient. 

<http://www.nhlbi.nih.gov/guidelines/cholesterol/atp3upd04.pdf>

Unfortunately, this case illustrates the difficulty that we face all too
frequently = a difficult history in a patient with a high cardiovascular
risk, in the middle of nowhere.  I will try my hand at the questions
also:

1.  I want to know if the patient is having "the feeling" right now, but
    I also want to know what his physical exam is like (is he in CHF?),
    and what his EKG looks like.

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1.  My w/u in Whiteriver would include transfer to our ED (fortunately,
    on the other side of the building) where he would get EKG,
    monitoring, Troponin I and a second one 8 hours after onset of "the
    feeling," CXR, BMP, LFT's, and CBC.  He would at a minimum be
    watched in the ER, until he has two negative Trp I's and EKG remains
    normal. 

    a.  If he is asymptomatic now and throughout the ED course, and all
        is negative, then he would be released on ASA 325mg, atenolol
        25mg, and nitroglycerine SL to return immediately if symptoms
        return.  We would try to get him a treadmill in WR within the
        week (not optimal as we would prefer to get this directly from
        the ED -- but this is all that we can do).

    b.  If he has symptoms in the ED and everything negative, then
        stress test sooner -- hopefully a treadmill here.

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1.  CRP would not be helpful to me.  My understanding is that an
    elevated CRP may imply increased risk of CAD (no use in the acute
    setting, unless I have missed something) regardless of LDL, but in a
    patient with LDL \> 100 and not on a statin... the LDL is all that I
    need to say he is at increased risk.

2.  I agree with Dr. Johnson... On the front line, insurance status
    should not dictate appropriate medicine.

3.  Beta-blocker (if not bradycardic \< (?)55 and no other
    contraindications), increase ASA 325mg, and Simvastatin 40mg daily. 
    I would not consider other dyslipidemia agents unless triglycerides
    are \> 500, and HDL would not change my initial management.

Regards,

Ty

C. Ty Reidhead, MD

National Chief Clinical Consultant in Internal Medicine

JG - Ty, what can I say....Internist extraordinaire!

Thank you for your comments. I would agree completely with your
assessment and plan as well as your reasoning with the minor exception
that I may possibly hold off on the beta blockers until after his CV
assessment (in the ER or with stress test) and proceed promptly with
them if positive. However, there is clearly no 'right' answer here and
either answer would be completely acceptable.

**Tobe Propst \[TobePropst@SEMTRIBE.COM\]**

**Fri 2/17/2006 6:41 AM**

I would also certainly "hold my fire" towards Dr. Johnson.  I think he
offered a good plan.  Hopefully I will also offer my 2 cents and come
out unscathed...perhaps if I wear my bright orange vest....

 

1.  I agree with Ty that if you must choose "the most important question
    that was not asked" it would be whether the "unusual feeling" is
    present now.  I'd also want to try to finish assessing his cardiac
    risk factors as Dr. Johnson alluded, but there's no question he's
    already high risk based on what we already know.  I've wondered
    about the diabetes issue before...if the diagnosis has been there
    longer, or if there on insulin, or if they're uncontrolled, do such
    things make the diabetic any higher risk for CAD?  Is a
    recently-diagnosed, well-controlled diabetic on only oral meds at
    relatively lower risk?  How much lower?  Would the difference be
    enough to affect any management decisions?  That big UK study talked
    about how tight glucose control reduced microvascular risks, but
    couldn't say for sure about macrovascular risk reduction...one would
    assume intuitively that tight control would help, though.

> I'd also like to ask whether he's had belching, spitting-up in the
> back of his throat, and if the "feeling" was a burning type pain along
> the path of the esophagus, if I could get that through the translator,
> because it's sort of sounding GI.  We'd still have to r/o the serious
> possibility of unstable angina, but if it sounded like GERD we could
> start treating with an H2/PPI earlier than later and hopefully get him
> better that much sooner.
>
> Also, does that "blue pill" have something to do with this?  Maybe a
> med list.

2.  We'd want an ECG in the office, but if he's currently having the
    feeling, we'd want to immediately give O2, NTG SL, and chewable 325
    ASA to address the possible cardiac etiology and further workup
    would require an ER setting where cardiac markers can be checked,
    the pt can be monitored appropriately, and possibly stress testing
    done (or hospitalization/cath lab if his clinical status
    deteriorated).

3.  I think a CRP wouldn't be likely to add any useful information
    here.  It would help with a piece of info in someone at intermediate
    CAD risk, but not a high risk pt like this.

4.  If not CHS eligible, we'd do that same things here at our tribal
    facility, and I'd still want to refer him to the nearest ER in our
    community...he'd just have to pay for it and any f/u specialist
    care/studies through other insurance or his own pocket.  This
    unfortunate situation gets tricky as you feel bad for these patients
    and often times they decline on your recommendations.

5.  I believe some med changes could have significant benefit.  Assuming
    he has a normal ER workup/stress test, I think you could keep the
    ECASA at 81mg/day.  From what I've read, that's as useful as higher
    doses for primary prevention.  Since the a1c is not at goal, I'd add
    a glitazone, since they (like metformin) are supposed to offer some
    CAD risk reduction benefit.  I might also increase the metformin if
    goal not met after glitazone titration.  Certainly a beta blocker
    would be a good choice if his pulse permits, due to his CAD risks. 
    Cozaar is also said to offer some glucose control benefit, so I
    might substitute that for the lisinopril.  Plus, assumably he's a
    type II diabetic anyway.  Technically they say ARBs are 1^st^ choice
    in type II diabetics, though I can't say I completely understand
    why.  One might also use ramipril instead of lisinopril as it has
    more data behind it for nephro/cardio benefits.  So, his BP's
    138/84.  If it stays too high like that on a couple of repeat BP's,
    I'd 1^st^ add some low dose metoprolol, d/c the lisinopril for
    Cozaar, then go from there.  Also, we shoot for the LDL \< 70 in our
    setting, so he's very likely to get a statin in our clinic.  I'm
    hearing that some even advocate statins for [all]{.underline}
    diabetics, even with lipid panels that are already at goal!  I also
    work with a former "homocysteine-ologist", although we've seen an
    article lately that casts doubt over whether foltex treatment is of
    any benefit, or perhaps even could cause harm, so we've backed off
    from that issue of late.  Of course, all of these med changes have
    significant cost issues to consider, and here is where the insurance
    issues may again come into play. 

JG - Excellent points as well! You all are really good! They say that if
a person has DM the best care in the US health care system is within the
Indian Health system. Well, that might as well be true for acute
coronary syndromes as well!

Personally, I have no idea what the blue pill is.... But would be
important to find this information out as you suggest....

I would agree with your comments, although as above I would not likely
use Cozaar in place of Lisinopril or add metoprolol immediately unless
CAD or appropriate other ASCVD manifestation or documentation is present
in most cases. Absolutely agree with ASA (I personally would use 325 mg
but not too concerned about dose), I would maintain or increase ACE-I
(and ramipril, if available would be fine) but one could reasonably
switch to an ARB, if desired and I also would add in a moderate dose of
a statin as long as no contraindications and triglycerides are less than
500.

**Chris Lamer \[chris.lamer@IHS.GOV\]**

**Fri 2/17/2006 2:25 PM**

1\. Based on the fact that he is currently taking only Metformin 500mg
BID, I would assume that despite his age he hasn\'t had diabetes for a
very long time - or he is in great health (eats well, exercises, and is
not provoked by many stresses in life).  \
I would be concerned by the fact that he has an odd presentation pain
(not aggravated by exercise and not improved by food makes me consider
unstable angina). I would want to know what helps to relieve the pain.
\[Be glad I work in the pharmacy and not the ER - I\'ll leave the
diagnosing to the experts!!\] Although, I\'m really curious to know what
the blue pill is?\
\
2. What is the next best step after ECG? Is stress testing sensitive and
specific enough to rule out ACS? Is ultrasound a better option?\
\
3. It looks like the patient has numerous risk factors for CAD. I don\'t
think a CRP will add much benefit in the presence of elevated LDL. What
are the patient\'s TG and HDL? With uncontrolled diabetes, I would
assume high and low. Also - just curious - will unstable angina cause
false reduction in LDL levels (as in an AMI)?\
\
5. As mentioned by David, I would certainly try to improve glucose
control with an agent selected based on the diagnosis.\
I\'m not a true believer in lowering everyone\'s LDL below 70, but in
this case, there is enough risk and compelling evidence that a statin
will provide benefit for the patient (4S demonstrated the greatest
benefit of statin therapy in older patients with multiple risk factors
and HPS & PROSPER demonstrated similar results in elders).\
Knowing the blood pressure is slightly high; an increase in the ACEI or
addition of low dose beta blocker may be warranted. I would also assess
OTC medication therapy - if he is taking any NSAIDs for his knee pain,
this could raise his BP.\
Thanks!\
Chris

JG - Sorry - it you and your pharm colleagues I always go to in order to
find out what the little blue pill is -- I really have no idea....

Great points, Chris!

Related to number 2, the ECG and enzymes together are the best way to
initially rule out acute MI. A routine stress test is about 60 to 70%
sensitive and with specificity close to the same in general for ruling
out significant CAD. Luckily, if exercise tolerance is adequate, it
allows us to capture those with the highest risk of future AMI (i.e.
those we are most concerned about). However, the stress echoes and
nuclear stress evaluations (although the quality is somewhat provider
specific) generally, at the best centers run in the range of about 82 --
88% sensitive and specific. So a routine ETT \[within 3 days of
admission for rule out MI protocols (in those that rule out, of course)
and in those with suspected Acute Cornary Syndromes\] is the currently
recommended protocol and many non-IHS facilities are doing them
pre-discharge from the ER as discussed by Ty above.

Thanks for your comments!

**Muench, Justine \[Justine_Muench@HEALTH.STATE.AK.US\]**

**Fri 2/17/2006 3:17 PM**

Good point Chris on the OTC med assessment and especially the NSAIDS.

Justine

JG - Agreed!

**Tobe Propst \[TobePropst@SEMTRIBE.COM\]**

**Fri 2/17/2006 4:48 PM**

Errata:

Sorry, sorry, got my \"C\'s\" crossed for a minute there.

It is Carvedilol/Coreg the beta blocker that was shown in GEMINI to have
some glycemic benefits over metoprolol for diabetics since it\'s not
deleterious on a1c and shows some benefit with insulin
resistance\...that would be expected to equate to some CVD risk benefit.
It also seems to have more data than the other beta blockers overall for
CVD prevention.

ARBs like Cozaar are supposedly a little better than ACEI\'s, at least
renally, for type II diabetics if there\'s any albuminuria, but no
glycemic benefit that I know of.

JG - Agreed, but I am not convinced of significant differences in this
regard for beta blockers or for individuals not in heart failure (and
very significant price differences) although we do preferentially use
Coreg for functional, relatively youthful folks in heart failure for its
cardiovascular benefits...

**Unzicker, Eric, MD (CRP) \[Eric.Unzicker@IHS.GOV\]**

**Fri 2/17/2006 8:37 PM**

Not to get too far afield from this case study - but EBCT (electron-beam
computed tomography) has been mentioned as a potentially useful
diagnostic modality (though clearly not in an acute setting). I know my
colleagues in private practice in my Midwest hometown community are
recommending this for some patients. Is anyone in the IHS using this? Is
there an evidence-based niche for this, or is it a test in search of a
purpose?

JG -- Good questions!

EBCT is being recommended by some as a mechanism for risk stratification
and, although quite expensive, has been shown, with some difficulty
previously, to give some additional information above the Framingham
risk score related to the risk of CVD in an individual. Like many of the
studies in the literature, the few studies that showed benefit were
generally performed by those radiologists/cardiologists owning or
primarily using the machines. Most of the academic cardiologists around
the country use them quite infrequently, if at all. No one in IHS is
using them regularly, at least that I am aware of. I have never ordered
one but I might consider it on a very rare occasion if it was easily
available. If I used it, I would tend to use it in the same realm as I
currently use CRP - as additional information in a person with low or
mid-level risk I was very concerned about from a prevention perspective.
An example might be a 40 year old man with a very positive family
history with a father dying at 42 and minimal risk factors. If either
were significantly positive, it would significantly alter my approach,
such as the use/dose of statin, etc....

On the other hand, I strongly believe MR/CT will take the place of
invasive cardiac catheterization for diagnostic purposes in the next 5
years or so....

Cardiac cath will be saved for diagnostic evaluations in which the MR/CT
is non-diagnostic or cannot be performed or for interventional therapy
based on the MR/CTR results....

**Placide, Frances (CIHA) \[Frances.Placide@IHS.GOV\]**

**Sun 2/19/2006 6:26 PM**

Thank you for this case

1\) 1 of the most important questions would be if the chest pain was
occurring during the present visit. If so, I would transfer him to the
ER for Cardiac work-up and monitoring. If no current chest pain and it
had been several days since last episode, I would get EKG in the office
and request stress test ASAP- next day preferably. If he was not CHS
eligible I would make the same management decision and present the
importance of the workup to patient. It would be important to try and
tease out if this chest pain was cardiac or digest-related based on hx,
however given his risk factors I would still want to r/o cardiac origin
further.

2\) In light of his Risk factors CRP would not change my initial
management.

3\) I would modify his medication management by starting a statin
(Simvastatin 20mg) to reduce LDL to 70-100; Until we ruled out cardiac
failure I would not increase Metformin but consider adding a glitazone
to improve glycemic control initially; Increase Lisinopril to 40mg
daily.

I appreciate the opportunity to read everyones\' thoughts and share my
own.

France Placide

JG -- Very good points! Right on the money...Thank you for the comments.

I agree with the minor exception that I would likely add a moderate dose
of statin initially....Thanks

**North, Charles \[Charles.North@IHS.GOV\]**

**Thu 2/23/2006 8:26 AM**

Thanks to Dr.'s Galloway and Murphy for the excellent discussion
generated by this topic.  The mystery of the "blue pill" remains and I
would like to suggest that it is Viagra.  None of the pills listed are
blue and we often prescribe Viagra for patients to buy outside the IHS
pharmacy system since many sites do not have it on the formulary.  Drug
information on Viagra side effects uses the figure 7% for dyspepsia
which could be the bloating that our patient experiences after taking
the blue pill.  Viagra is blue and not on the drug list, so it meets the
criteria for the mystery pill.  It is encouraging that our patient feels
well enough to use Viagra and has tolerated sexual activity without
having a coronary event.  Let us hope that when his medication is
maximized and his chest pain evaluated that he will be able to continue
wanting to put up with a bit of dyspepsia!

**Galloway, James M. \[jgalloway@UMCAZ.EDU\]**

**Thu 3/2/2006 12:06 PM**

Dear Friends and Colleagues:

As discussion on our CAD case has calmed down a bit, I thought I might
ask a general question on your thoughts regarding how we can improve the
quality of cardiovascular care and prevention we deliver at our local
sites. What are our optimal interventions? In my mind, systemic
implementation of standard guidelines would be an optimal intervention
but this is difficult within our facilities. Can you share your
thoughts, experiences and wisdom with the rest of us?

Thank you

Warm regards,

Jim

**Thompson, Chad C. (NNMC) \[Chad.Thompson@IHS.GOV\]**

**Fri 3/3/2006 9:55 AM**

I am a family physician at Northern Navajo Medical Center in Shiprock,
NM.

In response to Dr. Galloway\'s inquiry into improving the management of
CAD, I wanted to share the standardized inpatient orders which I created
for our patients admitted with a diagnosis of acute coronary syndrome.

Standardized admit orders reduce order-writing errors and create
efficient delivery of standards of medical care. Feel free to modify
them for your use. The orders currently do not include an ACE-I within
the orders but it is something our dept. is considering adding.

**Galloway, James M. \[jgalloway@UMCAZ.EDU\]**

**Mon 3/6/2006 7:45 PM**

Dr. Thompson:

Thank you so much for sharing these orders. Well done. I believe very
strongly that the development of standardized order sets as well as
discharge sets developed by consensus within our medical staffs go a
very long way towards the systemic standardization of intervention which
results in improved care for all our patients. Are there other examples
of systemic improvements that could be shared so that each service unit
does not have to redevelop them and we can build off each other?

Warm regards,

Jim

**Muench, Justine \[Justine_Muench@HEALTH.STATE.AK.US\]**

**Tue 3/7/2006 9:54 AM**

The Secondary Prevention Task Force with the Take Heart Alaska Coalition
is currently collecting hospital AMI order sets (admission, rule out,
inpatient and discharge) for an assessment goal we have. We have also
been looking at the outpatient setting for standard of care treatment
guidelines. This is more difficult without electronic health care
records to \"imbed\" the treatment guidelines. There are 2 outpatient
clinics that I am aware of that use electronic health care records in
Anchorage and Fairbanks and have embedded treatment guidelines for
cardiac diagnosis such as AMI, HF, high risk CAD. If you use RPMS, the
trick is getting a computerized menu into RPMS for standard treatment
guidelines!

If I can get the guidelines scanned into the computer I will send them
out to the group. Thanks for a great discussion. There are also many
order sets  online through ACC and large HMO such as Kaiser.

Thanks for a timely discussion. Justine

Justine Muench RN MN

**Bridges, Charles (TUC) \[Charles.Bridges@IHS.GOV\]**

**Sun 3/5/2006 1:51 PM**

Guidelines would be great for us.

Rb

**Galloway, James M. \[jgalloway@UMCAZ.EDU\]**

**Fri 3/10/2006 7:44 AM**

Dear Dr. Bridges:

Great to hear from you! In the past we were quite aggressive in writing
IHS specific guidelines because the initial sets of national guidelines
for Acute MI, etc just didn\'t quite fit many of our facilities and the
large distances to tertiary care centers. However, as the national
guidelines have been rewritten and further developed, these
considerations have been included nicely. Therefore, we at the Native
American Cardiology Program have decided to recommend the national
ACC/AHA guidelines for our uses in Indian health.

The direct website for these guidelines is

[[http://www.acc.org/clinical/topic/topic.htm#H]{.underline}](http://www.acc.org/clinical/topic/topic.htm#H)

In addition, the IHS National Guidelines site offers cardiovascular best
practice resources, along with many other guidelines and resources
indexed alphabetically and sub-divided by organ system at

[[http://www.ihs.gov/NonMedicalPrograms/NC4/nc4-clinguid.cfm]{.underline}](http://www.ihs.gov/NonMedicalPrograms/NC4/nc4-clinguid.cfm)

Hope this is helpful.

Warm regards,

Jim

**Anthony Dekker \[DekkerClan@AOL.COM\]**

**Sun 3/5/2006 4:16 PM**

Greetings all,

Jim Galloway et al gave a great program in Phoenix at the annual
American Heart Association meeting today.  Several speakers (most from
Indian Country) covering a wide area including genomics, lipid issues,
CAD, CHD, Diabetes, Diet and PTSD.  Would it be possible to put the PPTs
or a concise review on line for all to see?

Tony Dekker, PIMC

**Galloway, James M. \[jgalloway@UMCAZ.EDU\]**

**3/6/2006 7:37 PM**

Thank you, my friend, for those generous comments regarding our
presentations\...

I have notified the AHA that we would like to have copies of all the
lectures and they will assist us in gathering them, if the speakers
agree.

In the interim, I can certainly share my presentation for anyone to use
as they would like. I believe the more broadly we spread the word, the
more impact we can have\....

Thanks again, Tony\...

Warm regards,\
Jim

**Galloway, James M. \[jgalloway@umcaz.edu\]**

**Wed 3/8/2006 7:56 AM**

Greetings, Friends and Colleagues: \
I was able to gather a couple more lecture slide sets from our
co-presenters as well and thought I would forward these on for your
reviews, if interested. I am still waiting on a couple more which I will
receive soon, hopefully. Thank you\...

Warm regards,\
Jim  

**Galloway, James M. \[jgalloway@UMCAZ.EDU\]**

**Wed 3/8/2006 9:08 AM**

Greetings, Friends and Colleagues: \
I was able to gather another lecture slide set from one of our
co-presenters and thought I would forward it on for your reviews, if
interested. I am still waiting on a couple more which I will receive and
forward on to you soon, hopefully. Thank you\...

Warm regards,\
Jim

**Galloway, James M.** \[jgalloway**\@UMCAZ.EDU\]**

**Wed 3/8/2006 9:11 AM**

One more slide set for your review, if interested, as suggested by Dr.
Dekker\...

Warm regards,\
Jim

**Neil Murphy**

**Tue 3/21/2006 5:40 AM**

1.) Thomas Richtsmeier at GIMC informally explained some of the
evolution of the GIMC pathway in a separate e-mail thread (see
Background below)

2.) In addition, I have attached the GIMC most recent iteration of their
guidelines, the 2005 version of THROMBOLYTIC  AND  ANTI-THROMBOTIC
THERAPY  DRUG   PROTOCOLS FOR  UNSTABLE  CORONARY  ARTERY  SYNDROMES
(ACUTE  ST ELEVATION MYOCARDIAL INFARTION,  NON ST ELEVATION MI,  AND 
UNSTABLE  ANGINA)

3.) If you have questions on this particular document, please contact
directly Tom at
[[Thomas.Richtsmeier@ihs.gov]{.underline}](mailto:Thomas.Richtsmeier@ihs.gov)

[Background]{.underline}

GIMC had developed a 5 pathway model to deal with chest pain or its
clinical equivalent. With more recent trials confirming that all acute
coronary syndromes should be considered for cor angio and possible
revascularization, I changed this to a 3 pathway model consistent with
ACC recommendations; 1. STEMI, 2. NSTEMI and high risk ACS patients, and
3. others. For us this is easy, but we deal with clinical likelihoods
based on Sx, EKG, and biomarkers that most others (including ER
physicians and some internists) are ofter less fascile at. If we were
going to teach IHS adult care providers, I would concentrate on EKG
reading of STEMI, ST-T abnormalities that confir increased risk, and
appropriate use of modern biomarkers (troponins, BNP, and maybe HS-CRP
or Myeloperoxidase.)

The history is so hard to get on elderly Navajos, that we simply use it
as likely or unlikely but not definitive. It is often misleading in
elderly diabetics. The elder Navajo history is very different approach
to the history from a born English speaker. The history helps focus on
what can be relied on, especially EKG and biomarkers.

**All Presentations Noted Above -- Are Here:**

<http://www.ihs.gov/MedicalPrograms/MCH/F/PCdiscForumMod.cfm#cardio>