Cardiovascular Theme Peer Group Discussion

Anticoagulants

The safe and effective use of dabigatran and warfarin in primary care

1. In your experience, are most newly anticoagulated patients now prescribed dabigatran rather than warfarin?
2. Do you have a personal preference for prescribing one over the other? If so, why?
3. Are you aware of the different dosing regimens for dabigatran based on renal function and age? Do you regularly review a patient prescribed dabigatran to ensure they are taking an appropriate dose and whether they have developed any contraindications for use?
4. How do you manage INR monitoring for patients taking warfarin? Does your practice have a protocol that is used to determine warfarin dosing? If so, is it used consistently within the practice and have there been any issues with doing (or not doing) this?
5. What method do you use to assess and monitor renal function when prescribing anticoagulants and why?

Atrial fibrillation

An update on managing patients with atrial fibrillation

1. Do you routinely calculate CHA₂ DS₂ -VASc scores for patients with atrial fibrillation to determine their risk of stroke and therefore whether they require anticoagulation? Do you feel that doing so can help guide appropriate management or can this be determined without a score from your knowledge of the patient’s clinical factors?
2. Do you have patients with atrial fibrillation in your practice who are still prescribed an antiplatelet medicine, such as aspirin, rather than an anticoagulant? Would you feel confident changing them to an anticoagulant? What about stopping an antiplatelet if a patient was prescribed one at the same time as an anticoagulant, e.g. initiated in secondary care after a MI
3. Do you have a system for re-assessing or reviewing the appropriateness of anticoagulant prescribing in your practice, and if so what is it?
4. Are you finding that patients who require rate control in atrial fibrillation are being increasingly managed in primary rather than secondary care? How comfortable are you with the management options and when do you find referral is useful?

Beta-blockers

Beta-blockers for cardiovascular conditions: one size does not fit all patients

1. Were you surprised at the high proportion of patients taking metoprolol succinate in New Zealand?
2. Do you have a particular beta-blocker that you are most comfortable prescribing?
3. Do you think your prescribing of beta-blockers may change after reading this article?
4. The recommended duration of beta-blocker treatment post-myocardial infarction is uncertain. What is your current approach to this issue?

Blood pressure

Go low or no? Managing blood pressure in primary care

1. What are your thoughts about treating patients with hypertension to a specific BP target or treating to reduce cardiovascular risk?
2. Did the publication of the SPRINT trial alter the way you managed patients with hypertension? Why or why not?
3. How effective do you find lifestyle interventions in the management of high blood pressure?
4. Apart from green prescriptions, are there any services or tools that you find useful for patients in effecting lifestyle changes?
5. What is your approach to measuring blood pressure? What is the threshold at which you normally begin pharmacological treatment and is this influenced significantly by other patient factors? If so, what are these factors and how do they influence your decision making?

Prescribing statins

Prescribing statins to reduce cardiovascular risk

1. How do you see the role of lifestyle modification in cholesterol and cardiovascular disease management? Do you have a defined period of time to trial a conservative approach before starting a statin?
2. Do you have any favourite online tools, e.g. risk calculators that you find useful in assessing and communicating risks and benefits? Consider letting us know if you have a specific online tool that you feel would be useful to alert other clinicians to.
3. What is your approach to discussing the risks and benefits of statins?
4. How do you manage discussion about possible adverse effects that patients may experience while taking a statin?
5. Do you think after reading this article you might try other prescribing strategies such as alternate day dosing or pulse dosing if patients have problems with statin-associated symptoms?