Evidence Based Medicine Coming to Haydom

Evidence based medicine is the cornerstone of how we are now taught medicine and it's coming back to Haydom.Yes, I was a little misleading with the title, but I'll explain why in a second.

At Haydom Lutheran Hospital (HLH), where possible interventions are based on guidelines, however due to the lack of resources and staff education levels and availability of doctors, evidence-based medicine is not always practiced. And I think the key to practicing evidence-based medicine is continuing education.

This is where a new exciting initiative comes in. As of tomorrow we are running education sessions every Thursday (typically lead by the expats) for all the local interns and doctors, as well as the foreign volunteers. This a great chance for information exchange to occur between people, who have come from all over the world. It also opens up the information (that we often take for granted) to the local doctors.

Systolic Heart Failure
So for the first session we are taking a look at Systolic Heart Failure.

The paper we are using as pre-reading is;
Systolic Heart Failure by Dr John McMurray in the NEJM (2010)

We are also using ProfessorEBM's module on Heart Failure to guide the discussion.

WHERE YOU COME IN
Considering my involvement with FOAM back home, I thought it would be interesting to see if we could get an asynchronous discussion happening every week on twitter as well. Bringing the collective wisdom of even more people to this hospital in remote Tanzania.

So for now I've come up with the hashtag #HaydomJC (e.g. Haydom Journal Club). If anyone comes up with a better one let me know.

Below I've provided an overview of some of the key points of the article and additional information concerning systolic heart failure for those who don't have time to read the article.

AETIOLOGY

• Coronary Artery Disease (cause of 2/3)

PATHOGENESIS

1. ↑Afterload – due to ↑pulmonary / systemic resistance + ↑volume
2. ↑Contractility - due to SNS stimulation
3. NaCl & H2O retention – due to SNS and RAAS
4. LV remodelling – hypertrophy, dilation, fibrosis

INVESTIGATIONS

• Blood tests – FBC, LFT, urea, electrolytes, cardiac markers, thyroid
• ECG & CXR: Largely insensitive, but can provide useful findings
• Echo: allows confirmation of diagnosis and information about the heart
• Cardiac MRI: useful in difficult cases

TREATMENT
Lifestyle

• Exercise
• improved functional capacity and quality of life in patients
• Salt Restriction
• often recommended
• little evidence

 

Pharmacological

• Diuretics
• For relief of symptoms
• Loop diuretics should be given to patients with fluid overload
• ACEi
• Enalapril, Captopril, Perindopril, Lisinopril
• reduce ventricular size, increase the ejection fraction modestly, and reduce symptoms.
• Angiotensin-Receptor Blockers (ARBs)
• Irbesartan, Losartan, Candesartan
• similar effectiveness to ACEi, but more expensive
• Beta-Blockers
• Non-selective: Propanolol
• β1-selective: Atenolol, Metoprolol
• Aldosterone Antagonists
• The addition of an aldosterone antagonist should be considered for any patient who remains in NYHA class III or IV despite treatment with a diuretic, an ACE inhibitor (or ARB), and a beta-blocker.
• Hydralazine and Isosorbide Dinitrate
• Studies indicate that those of African descent respond more effectively to hydralazine–isosorbide dinitrate than Caucasian patients.
• Pneumococcal and influenza vaccinations are recommended.

Surgical

• Implantable Cardioverter–Defibrillator
• reduces the risk of sudden death in patents with left ventricular systolic dysfunction
• indicated for secondary prevention
• Coronary revascularisation
• Valve replacement / repair
• Cardiac Transplantation

Image Reference: Heart by Guga85