AAFP: Review May 1, 2009 Emory Family Medicine

1. AAFP: Review May 1, 2009 Emory Family Medicine Susan Schayes M.D. Assistant Professor-CT Family Medicine, Emory University School of Medicine

2. Learning objectives • Review May 1, 2009 AAFP highlights • Overview of Changes to Asthma Guidelines: Diagnosis and Screening • Zinc, an Essential Micronutrient • Cardiomyopathy: An Overview

3. Asthma Guidelines: Dx and Screening- Part 1 • Assessment of severity and control be considered two domains: impairment and risk • Impairment: limitations in activity or the degree of symptoms on a day-day basis. • Risk assessment: takes into consideration what the physician thinks will happen if the patient remains on their meds.

4. Asthma Guidelines • Severity: history of exacerbations, objective measures of lung function, and treatment-related adverse events. Final decisions about severity or control classifications are guided by the most severe category in which any feature of impairment or risk occurs

5. Asthma- Key recommendations for practice • A – Inhaled corticosteroids improve asthma control more effectively in children and adults than any other single long-term controlled medications • B – Written action plans detailing medications and environmental control strategies tailored for each patient are recommended for all patients with asthma

6. Asthma- Key recommendations for practice • C – Every patient with asthma should be able to recognize symptoms that suggest inadequate asthma control • C – All, patients, regardless of management step, should be given a prescription for a short acting beta agonist and instructed in its appropriate use. Validated questionaires

7. Asthma- Assessment • Assess – day time symptoms, nighttime awakenings, frequency of short-acting beta agonist use for symptom relief, and inability or difficulty with normal activities because of symptoms • Assess –Spirometry to determine current impairment . Future risk is categorized by the frequency of oral systemic corticosteroid useage.

8. AsthmaSeverity classification • Intermittent • Persistent-mild • Persistent-Moderate • Persistent-Severe

10. Stepwise approach for Asthma Management • Step 1 Intermittent asthma Inhaled short acting beta agonist prn • Step 2 Persistent asthma: Daily Tx Preferred low dose inhaled corticosteroid daily Alternate: cromolyn (Intal), leuotriene receptor agonist (singulair), nedocromil or theophylline

11. Stepwise approach for Asthma Management • Step 3 Preferred low dose inhaled corticosteroid, plus long-acting inhaled beta agonist or Medium dose inhaled corticosteroid • Step 4 Medium dose inhaled corticosteroid, plus long a long acting inhaled beta agonist

12. Stepwise approach for Asthma Management • Step 5 High dose inhaled corticosteroid, plus long-acting inhaled beta agonist consider omalizumab (Xolair) for patients who have allergies • Step 6 High dose inhaled corticosteroid, + long acting beta agonist, plus oral steroid and consider omalizumab

13. Asthma exacerbations • 70% of FEV1 or more As criteria for discharge from urgent care center • 40-69% FEV1- identify patients whom response is incomplete and who usually require continued treatment or hospitalization.

14. Stuff to Do for Asthma • Written Asthma Action plans detailing medications and environmental strategies • Control strategies tailored to each pt • Planned asthma care visits for adequate teaching and asthma control- controller agents 2-4X yearly.

15. Zinc: An Essential Micronutrient • Zinc deficiency cause by malnutrition I the 11th major risk factor in the global distribution of disease burden, and is associated with 1.8 million deaths annually. • Diagnosis is clinical, serum zinc levels are not reliable measures of zinc stores

16. Symptoms of Zinc deficiency • Growth retardation • Diarrhea • Alopecia • Glossitis • Nail dystrophy • Decreased immunity • Hypogonadism in males

17. Characteristics of Zinc deficiency • Associated diseases: Crohns disease, celiac disease, chronic alcoholism, cirrhosis, sickle cell disease, acrodermatitis enteropathica • Associated conditions: Pregnancy, lactation, prolonged IV feeding, vegan diet, short bowel syndrome, intestinal surgery-GI bypass

18. Zinc- Key recommendations for practice • A – Zinc reduces the severity and duration of acute and chronic diarrhea in children from developing countries • B – Zinc acetate is an effective maintenance therapy for Wilson disease • B – Zinc in combination with Vit C & E andbeta-carotene may slow the progression of Intermediate and advanced age-related macular degeneration

19. Zinc- Key recommendations for practice • C – Clinical zinc deficiency in adults should be treated with zinc supplements at two to five times the recommended dietary allowance

20. Zinc- Key points for practice about zinc supplements • Effectiveness – Probably effective in zinc deficiency and Wilson disease Possibly effective: slow progression of age-related macular degeneration; childhood diarrhea, and URI in developing countries Probably ineffective:UTI, wound healing HIV

21. Zinc- Key points for practice about zinc supplements • Adverse effects – Metallic taste, nausea, vomiting, abdominal cramping, diarrhea, suppressed immunity, reduced levels of HDL cholesterol, decreased copper stores, UTI, nephrolithiasis Contraindications – use with caution in pregnancy and lactating women

22. Zinc- Key points for practice about zinc supplements • Dose – Zinc deficiency: 2-5 times the recommended dietary allowance depending on severity for 6 months. • ( dietary allowance for men 11 mg elemental zinc, women 8 mg elemental zinc daily po ) ( tolerable upper intake level per day adult 40 mg elemental zinc daily )

23. Common oral Zinc Preparations • Zinc acetate, 30% zinc, 25mg-------elemental 7.5mg • Zinc acetate, 30% zinc, 50mg--------elemental 15mg • Zinc gluconate,14.3% zinc, 50 mg----elemental 7mg • Zinc gluconate,14.3% zinc,100mg---elemental14mg • Zinc sulfate, 23% zinc, 110mg ------elemental 25mg • Zinc oxide, 80% zinc, 100mg--------elemental 80 mg

24. Zinc- Bottom line • No robust data support zinc supplementation alone in persons with a normal zinc status. However in combination with antioxidants may be modestly effective in slowing the progression of age related macular degeneration. • 80 mg of elemental zinc • 2 mg copper • 500 mg vitamin C • 400 IU of vitamin D

25. Zinc- Bottom line • Mild zinc deficiency should be treated with zinc supplementation at 2-3 times the recommended dietary allowance (RDA), moderate to severe deficiency can be treated at 4-5 times the recommended RDA • For acute diarrhea in malnourished kids 6-36 months of age, 20 mg daily of elemental zinc has been used

26. AAFP questions • In which one of the following situations should a physician consider “stepping down” therapy for a patient with asthma. • A. When the patient has had three nighttime awakenings in one week • B. When the patient has a forced expiratory volume in one second or peak flow of 60-80 percent of predicted or personal best • C. When the patient has been stable with well controlled asthma for at least 3 months • D. When the patient has had two exacerbations per year requiring oral steroids

27. AAFP question Which one of the following is the preferred first-line therapy for ongoing management of chronic asthma? A. Theophylline B. Inhaled corticosteroids C. Inhaled cromolyn (Intal) D. Leukotriene receptor antagonists

28. Cardiomyopathy: An overview Cardiomyopathy: is an anatomic and pathologic diagnosis associated with muscle and electrical dysfunction of the heart • Primary: genetic, mixed or acquired • Secondary: infiltrative, toxic, inflammatory

29. Cardiomyopathy Four major types: Dilated Hypertrophic Restrictive Arrhythmogenic

30. Dilated Cardiomyopathy • Most common form, 5/100,000 adults, .57/100,000 children • Third leading cause of heart failure in US behind CAD and HTN • Etiology in adults is CAD, HTN, viral myocarditis, valvular • Etiology in children is idiopathic, and neuromuscular diseases

31. Signs &Symptom based consideration for Cardiomyopathy • Dilated/ Hypertrophic: SOB, fatique, cough, orthopnea, PND, edema • Restrictive: Pulmonary congestion, DOE, syncope • Arrhythmogenic: Syncope, Atypical chest pain, VT, recurrent VT

32. Cardiomyopathy Commonest presentation is heart failure -Find treatable conditions

33. Key Recommendatons for Practice • B- heart transplant is Tx of choice for children with idiopathic restrictive cardiomyopathy • B- heart transplant should be considered in adults with cardiomyopathy who are refractory to maximal med Tx

34. Key recommendations for Practice • B- An implantable cardioverter-defibrillator shoulde be place in patients with cardiomyopathy who are at risk of sudden death • B- Cardiac resynchronization therapy should be considered in patients with New York Heart Association Class III or Class IV heart failure who remain symptomatic despite optimal medical management

35. Diagnostic consideration • Dilated cardiomyopathy:ECG: LVH, echocardiogram shows enlarged ventricular chamber, normal or decreased wall thickness, systolic dysfunction • Hypertrophic cardiomyopathy: ECG shows LVH, large QRS complex, q waves, frequent T wave inversion echocardiogram shows LVH with unknown etiology with reduction in ventricular chamber volume

36. Diagnostic considerations: • Restrictive: ECG LVH • Echocardiogram shows biatrial enlargement, normal or reduced ventricular volume, normal left ventricular wall thickness, normal systolic function, impaired ventricular filling

37. Diagnostic considerations: • Arrhythmogenic right ventricular: ECG abnormal repolarization, small amplitude potentials at end of QRS complex( epsilon wave )

38. Diagnostic considerations: • Arrhythmogenic right ventricular: • Echocardiogram shows segmental wall abnormalities with or without wall motion abnormalities • Consider electrophysiology testing, cardiac magnetic resonance imaging

39. AAFP question A 50 year old male with a history of sarcoidosis presents with cough, progressively worsening dyspnea on exertion. ECG shows LVH, and echo shows biatrial enlargement with poor ventricular filling. Chemistry normal, BNP elevated. Chest xray pending. The patient’s findings are suggestive of which one of the following cardiomyopathies? A. Dilated cardiomyopathy B. Hypertrophic cardiomyopathy C. Restrictive cardiomyopathy D. Arrthymogenic right ventricular cardiomyopathy

40. AAFP question A 75 year old woman with diabetes, HTN, and a history of CAD has a recent echo which showing dilated left ventricle. She denies any chest pain, dyspnea with exertion, orthopnea, or edema. She is currently taking metformin, calcium and aspirin daily. According to the 2005 ACC/AHA heart failure guidelines, which one of the following is the best next step? A. Add a diuretic to her regimen B. Refer her for implantable cardioverter-defibrillator C. Refer her for cardiac resynchronization D. Add an angiotension-converting enzyme inhibitor to her regimen

41. The End