Curbsiders Review 1 – 5: Low Testosterone, Sprint Trial, Anticoagulation, Migraine, Chest Pain

In each Curbsiders Review, I’m going to quickly review five episodes and make brief notes and add additional resources on each of the topics.

Here is the the link to the Curbsiders’ Full Episode List.

Here are links and excerpts from the five episodes with links to additional resources:

#1: Miracle Cure of Libido Band Aid? Dealing with Male Hypogonadism and Low Testosterone FEBRUARY 17, 2016 By TONY SIDARI, MD

The podcast does not need to be reviewed again. Basically, the take home points cover it all.

TAKE HOME POINTS:

1. Order AM total testosterone x1. If less than 300 then repeat total T with prolactin, FSH, LH, SHBG and bioavailable testosterone. Consider a brain MRI in young men.
2. Treat modifiable risk factors: opiate abuse, heavy alcohol use, sleep apnea, obesity
3. Recommend a trial of topical therapy at 40 mg daily. Goal total T is 400-700.  Monitor PSA and CBC yearly.

See Resources And Guidelines On The Evaluation Of Low Testosterone And Erectile Dysfunction
Posted on December 18, 2020 by Tom Wade MD

#2: Are You Treating Hypertension Adequately? Discussing the Implications of SPRINT. MARCH 1, 2016 By MATTHEW WATTO, MD

Brief discussion of SPRINT trial. I’ve got a number of posts on the trial in this blog. Just search SPRINT in my search box for a list.

#3: For Anticoagulation, These Times They are a-Changin’
MARCH 15, 2016 By TONY SIDARI, MD

Note to myself: Consider  newer resources on anticoagulation:

• 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association of Cardio-Thoracic Surgery (EACTS) [PubMed Abstract] [Full Text HTML] [Full Text PDF]. Eur Heart J. 2020 Aug 29;ehaa612.
• Venous thromboembolic diseases: diagnosis, management and thrombophilia testing [Full Text HTML] [Full Text PDF].
  NICE guideline [NG158]Published date: 26 March 2020

Take Home Points:

1. Rivaroxaban, apixaban, edoxaban and dabigatran are the new oral anticoagulants (NOACs). In general they are as safe and effective as warfarin for VTE and afib.
2. CHEST guidelines were updated Jan 2016. Highlights include:
   1. NOACs as first line for VTE in patients without cancer.
   2. Low risk patients with subsegmental PE do not always require anticoagulation
3. Fall related bleeding is commonly overestimated. Several warfarin trials showed that fall related bleeds are uncommon and fall related intracranial hemorrhage is a rare complication.

#4: Are You Afraid of Patients with Migraines? An approach to diagnosis and management of chronic migraine headache.
MARCH 30, 2016 By TONY SIDARI, MD

For an up to date review of migraine, please see Acute Migraine Headache: Treatment Strategies [PubMed Abstract] [Full Text HTML] [Full Text PDF]. Am Fam Physician. 2018 Feb 15;97(4):243-251.

No need to rereview the podcast.

TAKE HOME POINTS:

1. Take a simple approach to the diagnosis of chronic headache syndromes.
   1. If patient is “sick” with their headache, then call it a migraine.
   2. If patient is not nauseous or debilitated with their headache, then call it chronic tension type headache.
   3. One in 1,000 will have cluster headaches. Other causes are even more rare than that
2. Rationale for preventive therapy: there are a number of drug classes to choose from and they more or less all cause 50% reduction in headache frequency for about two-thirds of patients. Therefore, tailor your therapy based on side effects and comorbid conditions.
3. Pitfalls:
   1. Stop thinking you need a Specialist. Primary Care Physicians can and should handle most headache cases.
   2. Don’t talk too much. Let the patient talk and DON’T interrupt them.
   3. Failure to start prophylaxis. Don’t be afraid. Know the side effects for each drug class and give patients at least a one month trial at therapeutic doses before calling treatment a failure.

#5: Want to dominate chest pain? Wield the power of cardiac imaging and stress testing.
APRIL 20, 2016 By TONY SIDARI, MD

TAKE HOME POINTS:

1. History and Physical are IMPORTANT! Make sure you listen…and examine your patient.
2. Understand who to test and who not to test for acute coronary syndrome.
   1. Low risk? The patient probably doesn’t need a test.
   2. Intermediate Risk? These people need risk stratification.
   3. High risk? These people can go straight to cath.
3. Don’t be afraid to stick with initial plan!  Negative stress test, but still worried?  Talk with your friendly neighborhood Cardiologist!

Note to myself: Review the following resources as they are more current.

Evaluation of Chest Pain in 2019 [PDF]
Mohit Bhasin MD, FACC
Norfolk, VA

Ep 128 Low Risk Chest Pain and High Sensitivity Troponin – A Paradigm Shift By Anton Helman|July 30th, 2019 from Emergency Medicine Cases

2020 Acute Coronary Syndromes (ACS) in Patients Presenting without Persistent ST-Segment Elevation (Management of) Guidelines
ESC Clinical Practice Guidelines [Full Text HTML].

2020 ESC NSTE-ACS Guidelines: Key Points
Aug 29, 2020 | Debabrata Mukherjee, MD, FACC