mal 3.9-5.5 ). LDL 4.9m 3.5 ), HDL 2.0mmol / L ( no After discussing
11 OCTOBER 2024 ausdoc . com . au
Clinical Focus describes “ stress-relate occurred during a rec
day . She experienced in
Case Report
All ’ s well that ends well
An imminent potentially catastrophic MI is averted thanks to the clinical acumen of a clued-in GP .
Dr Michael Hoopmann GP in Nuriootpa , SA .
XIE is a 41-year-old regular practice patient who attends for results of recent routine blood tests . She has a history of diet-controlled gestational diabetes mellitus in her second pregnancy five years ago and has been attending for routine metabolic surveillance checkups , as recommended , every two years since .
She is otherwise well , a lifelong nonsmoker , with a BMI of 26 and no other medical history of note . She takes no regular medications and for contraception her partner had a vasectomy . Her father had an AMI at the age of 67 .
The pathology results show her HbA1c is 5.2 %, total cholesterol is 6.6mmol / L ( normal 3.9-5.5 ), LDL 4.9mmol / L ( normal 1.7-3.5 ), HDL 2.0mmol / L ( normal 1.7-3.5 ).
After discussing the results , Xie describes “ stress-related ” symptoms that occurred during a recent camping holiday . She experienced intermittent bouts of upper neck tightness and restless and achey arms , which she attributed to the relative stress of juggling her young family while camping .
Since returning five days ago , and with life settling back into its normal rhythm , the sensations have not recurred . She had attended the local hospital on her return , to be sure it was just nerves , where she was informed her symptoms were due to panic attacks .
Xie comments in passing that during the trip they had done a lot of hiking , and that she noticed the neck tightness was more marked when she was walking faster , or uphill .
Examination
On examination her weight is 67.5kg , BMI 26.7 , BP 130 / 87mmHg , heart rate 104bpm and regular . Cardiorespiratory examination is unremarkable . A slight prominence is noted in the anterior neck , clinically a slightly enlarged thyroid which is non-tender .
Investigations
The GP sends Xie through to the practice nurse for blood tests including FBC , EUC , TSH , CRP , ESR , troponin and CK , and an ECG . The GP reviews her ECG after her bloods have been taken and notes a Q wave in V1-2 , slight ST elevation in V2 , and T wave inversion in V1-4 . The GP notes that the features are consistent with Wellens ’ syndrome and gives Xie 300mg of aspirin while the practice nurse calls for an immediate dispatch lights and
sirens ambulance , which transfers her to the vessel disease but some diffuse atheroma in nearest coronary care centre . The pathology non-culprit vessels . Aggressive management lab calls later in the day to notify that Xie ’ s of cardiovascular risk is therefore considered troponin is elevated at 59ng / L ( normal < 12 ) essential to prevent progression .
CASE REPORT with _ otherwise Wellen ' s syndrome normal / pathology Acute dacrocystitis .
_ 05APR24 Echocardiogram . indd 28 demonstrates moderate left ventricular dysfunction , with an ejection
Diagnosis fraction of 40-45 %.
Xie proceeds directly to the catheterisation lab on arrival in hospital , and coronary angiogram reveals a 99 % left anterior descending ( LAD ) stenosis , which is stented . The angiogram demonstrates predominantly single
Management
Xie is discharged four days later on aspirin , ticagrelor , bisoprolol , ramipril and rosuvastatin .
ESTROGEL ® PRO PRIMARY ADVERTISEMENT For her .
Medicine co-pack containing one pack of Estrogel ® ( estradiol hemihydrate ) plus one pack of Prometrium ® ( micronised progesterone ) for women with a uterus
PBS Information : These products are not available on the PBS .
Please review Product Information before prescribing , accessible at besins-healthcare . com . au / PI or 1800 BESINS ( 237 467 ), or by scanning the QR code :
Minimum Product Information Estrogel ( estradiol hemihydrate ) gel . Indications : Hormone replacement therapy ( HRT ) for estrogen deficiency symptoms in postmenopausal women . Prevention of osteoporosis in postmenopausal women at high risk of future fractures who are intolerant of , or contraindicated for , other medicinal products approved for the prevention of osteoporosis . The lowest effective dose should be used for the shortest duration . Contraindications : Known , past or suspected breast cancer ; Known or suspected estrogen-dependent malignant tumours ( e . g . endometrial cancer ); Undiagnosed genital bleeding ; Untreated endometrial hyperplasia ; Previous or current venous thromboembolism ( e . g . deep venous thrombosis , pulmonary embolism ); Known thrombophilic disorders ( e . g . protein C , protein S , or antithrombin deficiency ); Active or recent arterial thromboembolic disease ( e . g . angina , myocardial infarction ); Acute liver disease , or a history of liver disease as long as liver function tests have failed to return to normal ; Known or suspected pregnancy ; Lactation ; Known hypersensitivity to the active substances or to any of the excipients ; Porphyria . Precautions : Appraisal of the risks and benefits should be undertaken at least annually . Refer to full Product information ( PI ) for conditions which require supervision during treatment with Estrogel . Treatment should be withdrawn if the following occur , jaundice or deterioration in liver function ; significant increase in blood pressure ; new onset of migraine type headache ; pregnancy . Caution : endometrial hyperplasia and carcinoma , breast cancer , ovarian cancer , venous thromboembolism , coronary artery disease ( CAD ), ischaemic stroke , thyroid function , elderly , ALT elevations , paediatric use ( see full PI ). Interactions : use of concomitant skin medications , surface active agents or strong skin cleansers and detergents should be avoided at site of application , metabolism of estrogens may be increased by concomitant use of inducers of hepatic enzymes such as anticonvulsants ( phenobarbital , phenytoin , carbamezapine ) and anti-infectives ( rifampicin , rifabutin , nevirapine , efavirenz , ritonavir and nelfinavir ) and some herbal preparations ( St John ’ s wort ) reducing the effectiveness of estrogen . Estrogel as a transdermal administration might be less affected than other oral hormones by enzyme inducers . Concomitant use of estrogens with lamotrigine may decrease lamotrigine plasma concentrations . Caution is warranted for co-administration with hepatitis C virus ( HCV ) combination regimens ombitasvir / paritaprevir / ritonavir with or without dasabuvir and the regimen glecaprevir / pibrentasvir may cause greater than usual ALT elevations . Pregnancy Category B3 ; not for use in lactation . Adverse Effects : headache , nausea , abdominal pain , breast swelling / pain , breast enlargement , dysmenorrhea , menorrhagia , metrorraghia , leucorrhoea , endometrial hyperplasia , weight gain ( increase or decrease ), water retention with peripheral edema ( see full PI ). Dosage and Administration : Estrogel should be used daily on a continuous basis . Estrogel as an estrogen only product is indicated only for women without a uterus . In women with an intact uterus it is recommended to add a progestogen for at least 12 days of each month . Although some women will respond to 1.25 g daily ( 1 pump ), the usual starting dose is 2.5 g per day ( 2 pumps ). If after one month of treatment , effective relief of menopausal symptoms is not obtained the dosage may be increased to a maximum of 5 g ( 4 pumps ) ( see full PI ). The lowest effective dose should be used for maintenance therapy . The optimal daily maintenance dose needs to be reevaluated regularly ( e . g . annually ). Estrogel should only be continued for as long as the benefit outweighs the risk . The correct dose of gel should be dispensed and applied to clean , dry , intact areas of skin e . g . on the arms and shoulders , and / or inner thighs . The area of application should be as large as possible . Refer to Full Product Information before prescribing .
Minimum Product Information Prometrium ( oral , micronised progesterone ) Indications : menstrual irregularities ; adjunctive use with an estrogen in postmenopausal women with an intact uterus . Contraindications : known allergy / hypersensitivity to progesterone or excipients ; severe hepatic dysfunction ; undiagnosed vaginal bleeding ; known missed abortion / ectopic pregnancy ; mammary / genital tract carcinoma ; thromboembolic disorders ; thrombophlebitis ; cerebral haemorrhage ; porphyria . Clinically Significant Precautions : not a treatment for premature labour ; not a contraceptive ; discontinue if unexplained visual loss / changes , proptosis , diplopia , papilloedema , retina vascular lesions or migraine ; use caution in conditions affected by fluid retention and history of depression , diabetes , hepatic dysfunction , migraine , photosensitivity and during lactation ; increased risk of breast cancer and venous thromboembolism with estrogen concomitant therapy ( refer estrogen PI ); may cause drowsiness ; may affect laboratory test results . Clinically Significant Interactions : caution with P450 enzyme inducers and inhibitors ; may increase antidiabetic medication ; bioavailability may be reduced by smoking and increased by alcohol abuse . Very Common and Common Adverse Effects : menstrual disturbances ; headache . d1 – d25 . Secondary amenorrhoea : 400mg / d for 10d . Ovulation disorders / anovulation : 200 – 300mg for 10d ( d17 – d26 , inclusive ).
Estrogel ® and Prometrium ® are registered trademarks of Besins Healthcare . Besins Healthcare Australia Pty Ltd ABN 68 164 882 062 . Suite 5.02 , 12 Help Street , Chatswood NSW 2067 . Office phone ( 02 ) 9904 7473 . For medical information call 1800 BESINS ( 237 467 ). www . besins-healthcare . com . au EPR-EST-PRM-1969 January 2024