Hypertension & dyslipidemia panel

Diabetes panel

Chronic coronary syndrome & PAD panel

Acute coronary syndrome panel

Heart failure panel

Arrythmia panel

Venous thromboembolism panel

Valvular heart disease panel

Hypertension & dyslipidemia panel

1^st Case

• Learning objectives
  • Importance of out-of-office BP measurement
  • BP staging based on clinic , ABPM & HBPM
  • Algorithm for initiating, titrating & adding medications
  • Appropriate medications & doses
  • How to follow-up
  • Necessary diagnostic tests
• Case
  • 65 Y/O lady
  • 1^st time visit in your clinic
  • Asymptomatic for follow-up
  • PMH: HTN & T2DM
  • DH:
  • Aspirin 80 mg daily
  • Atenolol 50 mg daily
  • Hydrochlorothiazide 50 mg daily
  • Metformin 500 mg BID
  • BP: 170/100  mmHg (Right hand), 165/90 mmHg (left hand)
  • Physical examination is otherwise normal 
  • No recent lab tests
  • What are the next steps in evaluating, managing & following her HTN?

2^nd case

• Learning objectives
  • How to set the LDL goal?
  • How to initiate statin & follow the patient?
  • Role of non-statin LDL lowering medications?
  • LDL number is important or statin?
  • How to monitor statin side effects?
  • How to approach to hypertriglyceridemia?
• Case
  • 73 Y/O gentleman
  • Recent typical chest pain, CCS II
  • PMH: T2DM & HTN
  • S/P Anterior MI 10 years ago, SVD with PPCI on LAD
  • DH:
  • ASA 80mg daily, Rosuvastatin 10 mg daily
  • Metoprolol tartrate 25 mg  BID
  • Valsartan 160 mg daily, Indapamide 1.5 mg daily
  • Linagliptin/Empagliflozin 2.5/5  mg BID
  • Pantoprazole 40 mg daily
  • Recent lab tests:
    TC: 180 mg/dL, LDL: 68 mg/dL, HDl: 50 mg/dL, TG: 310 mg/dL
    HgbA1c: 7.1%, Metabolic panel, TFT & LFT: Nl
  • ECG; Unremarkable, TTE: LVEF: 45%, Moderate MR
  • Recent MPI: High risk ischemia
  • SCA: Moderate RCA & CX lesions, Insignificant in-stent restenosis
  • Next approach to LDL & TG & how to follow?

Diabetes panel

1^st Case

• Learning objectives
  • Prevalence of T2DM in ASCVD patient
  • ASCVD definition
  • Diagnosis of T2DM
  • Glycemic target
  • Screening for CVD in T2DM
  • CV Risk stratification of T2DM patients
  • Multifactorial approach for the treatment of T2DM
• Case
  • 58-year-old gentleman with history of HTN and diabetes, presented to clinic for routine follow-up.
  • PMH:
  • HTN (8 y)
  • DM (5 y)
  • Smoking (10 pack-year)
  • Drug Hx:
  • Atorvastatin 20 mg OD
  • Amlodipine 5 mg OD
  • Triamterene-H ½ Po OD
  • Metformin 1000 mg BID
  • Glibenclamide 5 mg TDS
  • ECG: Unremarkable
  • Ph/Ex: BMI: 31 kg/m2, BP: 139/91 mmHg, otherwise Unremarkable
  • Echo: Normal EF (60%), Mild MR
  • Lab Test:
  • Hb=15 mg/dl
  • TG=240 mg/dl
  • TC= 190 mg/dl
  • LDL=95 mg/dl
  • HDL= 60 mg/dl
  • HbA1c= 7.2 %
  • FBS= 122 mg/dl
  • 2hPP= 180 mg/dl
  • UACR= 55 mg/g
  • eGFR=72 ml/min
  • What is your next plan for better glycemic control in this patient?

2^nd case

• Learning objectives
  • Paradigm shift in the management of T2DM
  • Treatment algorithm for T2DM patients
  • Comparative efficacy and safety of different antihyperglycemic agent in T2DM & ASCVD
• Case
  • 65-year-old gentleman with history of PCI on LAD 3 months ago, after anterior MI
  • PMH:
  • HTN (10y)
  • DM (3 m)
  • Drug Hx:
  • ASA 80 mg OD
  • Ticagrelor 90 mg BID
  • Atorvastatin 40 mg OD
  • Carvedilol 12.5 PO BID
  • Enalapril 5mg PO OD
  • Metformin 500 mg BID
  • Glibenclamide 5mg Daily
  • Ph/Ex: BMI: 27 kg/m2, BP: 127/75, otherwise Unremarkable
  • ECG: Normal Sinus Rhythm, Q in v1-3, T inversion in V1-4, Poor R wave progression in V1-5
  • Echo: Near Normal EF (50%), Anterior Wall Motion Abnormality
  • Lab Test:
  • Hb=14.7 mg/dl
  • TG=150 mg/dl
  • TC= 130 mg/dl
  • LDL=65 mg/dl
  • HDL= 35 mg/dl
  • HbA1c= 7.4 %
  • FBS= 136 mg/dl
  • 2hPP= 230 mg/dl
  • UACR= 5 mg/g
  • eGFR=88 ml/min
  • What is your recommendation for better prognosis in this case?

Chronic coronary syndrome & PAD panel

1^st Case

• Learning objectives
  • How to assess pre-test probability and
    clinical likelihood of CAD?
  • How to select appropriate testing?
  • Ant-ischemic drugs
  • When to consider invasive coronary angiography?
• Case
  • 60 Y/O lady
  • Retrosternal chest discomfort, since 6 m ago, lasts 10-15 min
    exertional CCS II & sometimes at rest, resolves spontaneously
  • PMH: Unremarkable except mentioned Hx
  • DH:
  • Aspirin 80 daily, Atorvastatin 40 daily, Metoprolol 25 BID
  • Ph/Ex:
  • BMI: 27 kg/m2, BP: 128/82  mmHg (Right hand), HR: 82
  • Heart & lungs: Unremarkable
  • Lab tests:
    CBC: Nl, HgbA1c: 5.1%, Cr: 0.7, K: 4.2, TFT & LFT: Nl
    TC: 205, LDL: 116 , HDL: 51 , TG: 180
  • ECG: NSR, No specific ST/T changes
  • TTE:  LVEF: 60%, No RWMA, No VHD
  • MPI: Mild ischemia in inferolateral wall, SSS: 5
  • How was the previous plan & What are the optimum next steps? 

2^nd case

• Learning objectives
  • Appropriate antiplatelet regimen in CAD & PAD
  • When to consider revascularizing in CCS?
  • How to interpret ABI?
  • When to consider noninvasive & invasive
    imaging for PAD?
  • Optimal management of PAD
  • When to consider revascularization of PAD?
  • Management of asymptomatic carotid artery disease
• Case
  • 56 Y/O gentleman
  • Typical chest pain CCS II (1 year ago)
    Right intermittent claudication (6months ago)
  • PMH:
  •  T2DM, CKD
  • SH: Current cigarette smoker (30 pack/year)
  • DH:
  • Aspirin 80 daily, Rosuvastatin 20 daily
  • Metoprolol 50 BID, Metformin 1000 BID
  • Ph/Ex: Wt: 82kg, BMI: 22, BP: 141/86, HR: 86, Heart & lungs: Nl
  • Recent lab tests:
    CBC, LFT & TFT: Nl, A1c: 7.1, Cr: 1.7 (stable), K; 4.6, LDL: 41, TG: 115
  • ECG: NSR, LBBB with secondary ST/T changes
  • DSE: GLVEF: 55%, No VHD, WMA in anterior wall in stress phase
  • ABI: Left: 0.9, Right: 0.7
  • Carotid doppler: LICA: Nl, RICA: 70% proximal stenosis
  • SCA: Significant LAD mid-part lesion, CX & RCA: Nl (film included)
  • What are the optimum next therapeutic plans?

Acute coronary syndrome panel

1^st Case

• Learning objectives
  • Diagnostic approach for ACS in ED
  • Initial Pharmacological/Antithrombotic therapy in ED
  • Invasive strategy in NSTEMI: indication/timing
  • Timing of delay invasive management
  • Medical therapy at hospital
  • Medical Therapy at discharge
• Case
  • 58-year-old gentleman visited in ED due to chest heaviness with mild exercise since few hours ago. He denied any relevant history of cardiovascular disease.
  • PMH: unremarkable
  • Drug Hx: nothing
  • Ph/Ex.: BMI: 27 kg/m2, BP: 127/75, otherwise Unremarkable
  • ECG: Normal Sinus Rhythm, flat T wave in anterior leads
  • Limited Bedside Echo: Near Normal EF (55%), Mild MR
  • What is you next step in the management of this patient?

2^nd case

• Learning objectives
  • Initial Antithrombotic therapy in ED
  • Reperfusion strategy
  • Timing of delay invasive management
  • Length of hospital stay
  • Medical therapy at hospital
  • Medical Therapy at discharge
• Case
  • 68-year-old lady with history of smoking and HTN, transferred to ED, in a non-PCI capable center, due to nausea and chest heaviness, started 3 hours before ED visit.
  • PMH: HTN (8 y), Smoking (10 pack-year)
  • Drug Hx: Atenolol 100 mg OD
  • ECG: Anteroseptal STEMI (V1-6)
  • Ph/Ex: BMI: 35 kg/m2, BP: 154/95 mmHg, otherwise Unremarkable
  • Beside Echo: EF=35%, Mild MR, anteroseptal WMA, no clot
  • Fibrinolytic therapy was done with successful clinical and ECG response.
  • Initial Lab Test: Hb=15 mg/dl, TG=240 mg/dl, TC= 190 mg/dl, LDL= 95 mg/dl, HDL= 60 mg/dl, HbA1c= 6.1 %, FBS= 87 mg/dl, eGFR= 88 ml/min, cTnI: 650
  • What is you next step in the management of this patient?

Heart failure panel

1^st Case

• Learning objectives
  • Ischemia work-up in HF: Who & how?
  • Role of Pro-BNP in Dx & F/U?
  • How to initiate, add & titrate GDMT?
  • Anemia treatment in HF: Who & How?
  • AF in HF: When refer for ablation?
  • Role of statins in HF?
  • ICD & CRT: When to be considered?
  • MR: when refer for repair?
• Case
  • 52 Y/O gentleman
  • DOE FC-I, II in the past 3 months
  • PMH & DH: Unremarkable
  • Ph/Ex:
  • BMI: 31 kg/m2
  • BP: 138/92  mmHg (Right hand), 136/88 mmHg (left hand)
  • Heart & lungs: Unremarkable
  • Lab tests:
    Hgb: 10.1, HgbA1c: 6.1%, Cr: .8, K: 4.1, TFT & LFT: Nl
    TC: 230 , LDL: 139 , HDl: 45 , TG: 230
  • ECG: AF & LBBB with secondary ST/T changes
  • TTE:  LVIDd: 6.9cm, LVEF: 15%, Severe MR
    mid-RV: 3.6, TAPSE: 13mm, TRG: 50 mmHg
  • What are the next steps
    in evaluating, managing & following his heart failure?

2^nd case

• Learning objectives
  • Role of clinical pharmacist in HF care?
  • Drug-Drug & Drug-Disease Interactions in HF
  • How to adjust & follow GDMT in HF & CKD?
  • How to manage medication complexities in elderlies?
• Case
  • 76 Y/O lady
  • DOE FC II in the past 1 month & 1 pillow orthopnea
  • PMH: CABG & HFrEF (15yrs), PAF, Aortobifemoral bypass 5 yrs ago
  • DH:
  • ASA 80mg daily, Rivaroxaban 10mg daily
  • Rosuvastatin 40 mg daily, Cilostazol 50mg BID
  • Carvedilol 3.125 BID, Enalapril 10 mg daily
  • Eplerenone 25mg daily, Nortriptyline 10mg daily
  • Furosemide 40mg daily, Digoxin 0.25 daily except weekends
  • Ph/Ex: Weight: 76kg, BMI: 24, BP: 138/82, HR: 82, Heart: Nl
    Lungs: Bibasilar rales, 1+ pedal edema
  • Recent lab tests:
    Hgb: 12.8, Plt: 165.000, LDL: 51, TG: 110
    Cr: 1.8 (1.7 last yr), K: 4.1, Na: 128, Pro-BNP: 1800, TFT & LFT: Nl
  • ECG: NSR, Old ST/T changes
  • TTE: GLVEF: 35%, Moderate MR, Low probable for PAH
  • How to adjust the medications & follow the patient precisely?

Arrythmia panel

1^st Case

• Learning objectives
  • AF Definitions and classification
  • Diagnostic work-up and follow-up
  • Anticoagulation/Stroke risk/ drug choices
  • Bleeding risk
  • Symptom control (rate/rhythm control)
  • CV risk factor/comorbidities
• Case
  • 67-year-old lady visited in ED due to history of recent onset rapid palpitation, and ECG that showed A.Fib rhythm.
  • She is now asymptomatic with NSR in ECG.
  • PMH: HTN (5 years)
  • Drug : Amlodipine 5mg OD, Bisoprolol 2.5mg BID
  • Ph/Ex.: BMI: 32 kg/m2, BP: 143/85 mmHg, otherwise Unremarkable
  • What do you recommend as the next steps?

2^nd case

• Learning objectives
  • Syncope: Definition, Classification & Associated conditions
  • Management in the ED & admission criteria
  • Diagnostic work-up
  • When to treat?
  • How to treat?
• Case
  • 40-year-old lady visited due of transient loss of consciousness with spontaneous recovery, after palpitation and sweeting at work. She denies any other medical condition. She has good functional class.
  • PMH: Recreational smoker
  • Drug Hx: nothing
  • Ph/Ex.: BMI: 25 kg/m2, BP: 110/70, otherwise Unremarkable
  • ECG: NSR, otherwise unremarkable
  • Bedside Echo: EF=65%, MVP mild MR, Mild TR
  • What do you recommend as the next steps?

Venous thromboembolism panel

1^st Case

• Learning objectives
  • Ischemia work-up in HF: Who & how?
  • Role of Pro-BNP in Dx & F/U?
  • How to initiate, add & titrate GDMT?
  • Anemia treatment in HF: Who & How?
  • AF in HF: When refer for ablation?
  • Role of statins in HF?
  • ICD & CRT: When to be considered?
  • MR: when refer for repair?
• Case
  • 52 Y/O gentleman
  • DOE FC-I, II in the past 3 months
  • PMH & DH: Unremarkable
  • Ph/Ex:
  • BMI: 31 kg/m2
  • BP: 138/92  mmHg (Right hand), 136/88 mmHg (left hand)
  • Heart & lungs: Unremarkable
  • Lab tests:
    Hgb: 10.1, HgbA1c: 6.1%, Cr: .8, K: 4.1, TFT & LFT: Nl
    TC: 230 , LDL: 139 , HDl: 45 , TG: 230
  • ECG: AF & LBBB with secondary ST/T changes
  • TTE:  LVIDd: 6.9cm, LVEF: 15%, Severe MR
    mid-RV: 3.6, TAPSE: 13mm, TRG: 50 mmHg
  • What are the next steps
    in evaluating, managing & following his heart failure?

2^nd case

• Learning objectives
  • Role of clinical pharmacist in HF care?
  • Drug-Drug & Drug-Disease Interactions in HF
  • How to adjust & follow GDMT in HF & CKD?
  • How to manage medication complexities in elderlies?
• Case
  • 76 Y/O lady
  • DOE FC II in the past 1 month & 1 pillow orthopnea
  • PMH: CABG & HFrEF (15yrs), PAF, Aortobifemoral bypass 5 yrs ago
  • DH:
  • ASA 80mg daily, Rivaroxaban 10mg daily
  • Rosuvastatin 40 mg daily, Cilostazol 50mg BID
  • Carvedilol 3.125 BID, Enalapril 10 mg daily
  • Eplerenone 25mg daily, Nortriptyline 10mg daily
  • Furosemide 40mg daily, Digoxin 0.25 daily except weekends
  • Ph/Ex: Weight: 76kg, BMI: 24, BP: 138/82, HR: 82, Heart: Nl
    Lungs: Bibasilar rales, 1+ pedal edema
  • Recent lab tests:
    Hgb: 12.8, Plt: 165.000, LDL: 51, TG: 110
    Cr: 1.8 (1.7 last yr), K: 4.1, Na: 128, Pro-BNP: 1800, TFT & LFT: Nl
  • ECG: NSR, Old ST/T changes
  • TTE: GLVEF: 35%, Moderate MR, Low probable for PAH
  • How to adjust the medications & follow the patient precisely?

Valvular heart disease panel

1^st Case

• Learning objectives
  • Echocardiographic features of valvular AS
  • Staging of valvular AS
  • Diagnostic work-up and follow-up
  • Indication for stress test in valvular AS
  • Clinical & echocardiographic follow-up
  • Treatment (medical, surgical, interventional)
• Case
  • 58-year-old gentleman referred to the clinic due to newly-diagnosed hypertension and harsh systolic murmur at the base of heart.
  • He is asymptomatic.
  • PMH: Cigarette Smoking 5py
  • Ph/Ex.: BMI: 26 kg/m2, BP: 143/85, otherwise Unremarkable
  • ECG: NSR, LVH, Secondary ST-T change
  • Echo: EF=60%, Mild concentric LVH, calcified and thick AV with Vmax=4.5 m/s, MPG=52mmHg, AVA=0.9 cm2, Trivial AI, Mild MR, No MS
  • What do you recommend as the next steps?

2^nd case

• Learning objectives
  • Echocardiographic features of MS
  • Staging of valvular MS
  • Diagnostic work-up and follow-up
  • Clinical & Echocardiographic Follow-up
  • Treatment (medical, surgical, interventional)
• Case
  • 37-year-old lady referred to the clinic due to history of recent onset rapid palpitation, and ECG that showed A.Fib rhythm.
  • She complained of mild dyspnea on exertion (NYHA FC2) without significant limitation in daily activity science few months ago.
  • PMH: unremarkable
  • Drug Hx: Warfarin 5mg OD, Bisoprolol 5 mg OD,
  • Ph/Ex.: BMI: 25 kg/m2, BP: 116/71, irregular heart beat
  • ECG: AF with acceptable ventricular rate
  • Echo: EF=55%, Significant Rheumatic MS (MVA: 1.2 cm2 by planimetry, MPG: 12.5 mmHg, Wilkins score: 8), Severe LA enlargement, Mild MR, Mild TR, sPAP: 45mmHg
  • What do you recommend as the next steps?