Transcript

MIC CAVAZZINI: Welcome to Pomegranate Health, a podcast for physicians of the RACP.

I’m Mic Cavazzini, and in the previous episode, we went through the diagnostic workup of acute coronary events. Today we talk about stopping them from happening again. 

One-fifth of people discharged with a diagnosis of ACS have another ischaemic event within six months, and the risk of dying increases the second time round. There is an established strategy for secondary prevention of acute coronary syndrome that includes pharmacotherapy, cardiac rehabilitation and lifestyle management. But as we’ll hear from today’s guests, a worryingly large number of patients are discharged from hospital without one or more of these tools.

Failing to prescribe recommended drugs at discharge is likely to ensure patients won’t be on best-practice care when they’re followed up later, according to a study just published in the Internal Medicine Journal. That study was directed by Professor David Brieger, of the University of Sydney.

DAVID BRIEGER: So, my name's David Brieger, I'm an interventional cardiologist. I'm head of the coronary care here at Concord Hospital. And I've also spent a lot of time focusing on improving quality of care primarily through the conduct of multi-centre registries, both in Australia and overseas.

MIC CAVAZZINI: We’ll get into the IMJ paper later, but first, David Brieger spells out the pharmacotherapy regimen advised in the guidelines of the Cardiac Society of Australia and New Zealand and the Australian Heart Foundation. This starts with aspirin, a COX inhibitor that blocks one pathway of platelet aggregation. All patients without an allergy to it should take 100 to 150 milligrams a day.

DAVID BRIEGER: In addition to that, there is now strong evidence that aspirin should be complemented by a second antiplatelet. Aspirin and clopidogrel, as the audience will know, work in a synergistic fashion, they operate on different platelet pathways. Clopidogrel acts on the ADP receptor. There are two additional drugs which are now available which do so but more effectively. The newer generation agents are probably better and the guidelines, which I know you've referred to, do recommend the use of ticagrelor over clopidogrel. And the second is a drug called prasugrel, which has limited indications primarily because of the way the clinical trials were designed.

MIC CAVAZZINI: Ticagrelor does have a couple of notable contraindications, however.

DAVID BRIEGER: Well, it has some side effects. The main contraindication is in patients with heart block—anything over first-degree heart block is a contraindication to the drug. Otherwise it is associated with dyspnea in a minority of patients. And so for that reason we have to be vigilant when we prescribe it, looking for symptoms of worsening shortness of breath, because these patients often have a degree of left ventricular dysfunction. They may have a background of heart failure, or their heart may be compensating the context of their acute event. In clinical practice, though, it turns out that this is not a terribly troublesome scenario. Usually you can sort out whether they've got heart failure or not clinically. And the dyspnea that's associated with the drug often wears off over a period of days. So you can gently encourage the patient through it.

MIC CAVAZZINI: Yeah, so the guidelines say to look out for patients with asthma or COPD, but you can titrate appropriately in those patients?

DAVID BRIEGER: Yeah, the link with asthma and COPD is interesting. The guidelines say that only because you've got this coupling of dyspnea and the two conditions. It turns out that there aren't any changes in lung function tests with this drug. This dyspnea seems to be mediated through a different pathway rather than bronchospasm per se, and it doesn't behave in the same way as an exacerbation of asthma or COPD would do.

MIC CAVAZZINI: Now, the standard duration of dual antiplatelet therapy has been put at 12 months following a diagnosis, but this might be extended or shortened depending on the relative risk of ischemia to bleeding. How do you determine this balance?

DAVID BRIEGER: That's a really good question and a very topical issue. The factors that may persuade you to go longer are generally seen in patients that have complex percutaneous interventions. If you have a large number or large length of narrow-calibre stents placed, if there are lots of overlapping stents, if there's bifurcations, if they're placed in very important sites like the left main, you may tend to prolong the duration of the antiplatelet therapy based on a couple of trials that have suggested there's some benefit in that cohort.

There's always a cost though, and the cost is bleeding. So the things that typically predict an increased risk of bleeding are patients that are the elderly, those that have a past history of bleeding interestingly. And the reason I highlight that is because it's not really modifiable. There are a range of other factors that predict bleeding and they're somewhat modifiable. So if you have patients that are taking a lot of non-steroidal anti-inflammatories you can counsel them on changing those therapies so that they're not taking that terrible combination.

Other factors that are not reversible are anticoagulant drugs. So you often wind up in situations where patients have atrial fibrillation, for argument's sake, come in with an acute coronary syndrome and then require the anticoagulant for prevention of a stroke for their AF, and antiplatelets for the prevention of coronary thrombotic event. The decision as to how long you continue that therapy for can be challenging, although we've got some trials that are emerging now that give us some guidance.

MIC CAVAZZINI: And then of course there are statins. Long term statin therapy following a hospitalisation with ACS is supposed to lower the annual risk of major vascular events by about 20 per cent for every millimole per litre reduction in low-density lipoprotein. So what consideration is there with regards to dose or duration of the statin therapy?

DAVID BRIEGER: So, statins are really the next platform of therapy for which we have a very convincing and strong evidence base. If you've had an event you have too much cholesterol circulating, so the accepted therapy is that you really should start at a high dose of a statin, and we know that often doesn't happen.

MIC CAVAZZINI: And finally, in terms of the pharmacotherapy regimen, long-term therapy with beta-blockers or ACE inhibitors is also sometimes recommended.

DAVID BRIEGER: ACE inhibitors or ARBs, angiotensin-receptor antagonists. They operate on the renin-angiotensin system. They're vasodilators, and they have some reasonably solid data showing that they've got prognostic benefit in patients with left ventricular dysfunction hypertension diabetes in that particular cohort.

The beta-blocker drugs decrease the heart rate and they decrease myocardial work. They were shown to be very effective back in the early days of therapy of myocardial infarction before we embarked on aggressive reperfusion strategies. And a number of groups have now gone back and looked at the literature and it's been difficult to show a mortality benefit in the context of patients who are very well reperfused and aggressively treated with these other drugs that we've already talked about. They may have a role to play in suppressing ventricular arrhythmias, and we know that they're very effective in the context of patients with left ventricular dysfunction, and we haven't yet been brave enough to say that you should not use them in a post-MI patient.

MIC CAVAZZINI: In the previous episode, Louise Cullen described how accelerated diagnostic protocols in the emergency setting can be used to predict whether a low-risk patient might have a major cardiac event 30 days after discharge. For patients with confirmed ACS however, you can use GRACE scores to assess outlook over six months. Can you explain what the GRACE risk calculations take into account?

DAVID BRIEGER: Yes, that's another good question, and a very common misconception amongst those of us that treat these patients.

So, when a patient with chest pain comes through the emergency department the primary focus is to work out, ‘Could these patients have coronary disease and if they do, should I really worry about them?’ Once they're in the hospital and you've decided that they definitely are having an acute coronary event, we use the GRACE score and other scores like it to determine what their prognosis is both in hospital and subsequently. So it's related to the initial triage decision, but it's slightly different.

The GRACE risk score takes into account things like heart rate, blood pressure, the presence of heart failure. And they're really markers of insult to the left ventricle, which we know is a very powerful prognostic marker. The other factors that feed in the GRACE score are age and kidney function, which are sort of these irreversible factors that we know carry mortality with them. And then finally there are the ECG and troponin levels which overlap with both risk scores in fact.

It’s fair to say that there haven’t been any prospective studies that have taken a cohort and randomised them to various interventions on the basis of their risk score. But we've done a number of post-hoc studies that have showed that if you take a cohort with a high GRACE risk score, those that undergo coronary angiography have better outcomes than those that don't.

***

MIC CAVAZZINI: Just to recap, the guidelines recommend aspirin, a second antiplatelet, a statin and a beta-blocker for all patients with acute coronary syndrome. ACE inhibitors or ARBs are also indicated for all patients who’ve had a STEMI, or other cases of ACS in addition to heart failure, diabetes or hypertension.

Drugs make up just one aspect of an optimal discharge plan, however. The guidelines also advise that a patient follow up with their GP, be referred for cardiac rehab, and receive advice about diet, physical exercise and smoking cessation.

But in three quarters of patients discharged with an ACS diagnosis, at least one component of this is missing, as shown in a 2014 study led by Associate Professor Julie Redfern of the University of Sydney. She’s also Deputy Director of the Cardiovascular Division at The George Institute for Global Health, and a practising physiotherapist.

JULIE REDFERN: So, I think physiotherapists tend to be good at learning and understanding how to get people to do things they don't really want to do. And that is a strength of mine, is all that sort of goal-setting behaviour change, and supporting risk factor management. So I think that's how I really ended up in this space.

MIC CAVAZZINI: TheSNAPSHOT study spanned 45 hospitals across Australian and New Zealand. The team noted all admissions for possible ACS over a period of two weeks, and captured every detail about care and clinical outcomes that was entered into the medical record.

JULIE REDFERN: We wanted to really focus on three areas that we thought were of the most significance and one was a referral to cardiac rehabilitation, one was receiving the appropriate evidenced based medications, and one was receiving any form of ‘lifestyle’ advice during their admission or at the point of discharge. And when we collapsed all those things together, we found only a quarter of patients in Australia and New Zealand actually receiving that combination at discharge. And obviously some states, some hospitals, did better than others. It was part of our philosophy not really to compare hospitals, we weren't in that business. But I think very worrying, very concerning, and a lot of opportunity for improvement that people aren't having the most basic things documented as being provided to them before they leave hospital, after a serious heart event.

MIC CAVAZZINI: If you zero down on those three areas, what were the biggest gaps that that study found?

JULIE REDFERN: In terms of the medications specifically about two-thirds, so 65 per cent did receive at least four of the recommended medications. A bit under half were referred to cardiac rehabilitation. Now I think it's important to say in this particular study, we only collected data that was entered in a person's medical record during their stay. About half of people who smoked cigarettes had any mention of smoking cessation. Now, the lifestyle advice is much more vague, so we really collapsed it into a very low denominator option. So around a third received any form of any documented mention of dietary advice or physical activity.

MIC CAVAZZINI: And if you drilled down into predictors of receiving recommended care it depended what they went in for, so 50 per cent of STEMI patients versus only 15 per cent of those with unstable angina were given the full package of discharge. And also those who had received PCI during admission. Is the moral of the story that the non-revascularised patients need to be taking more?

JULIE REDFERN: Absolutely. So their risk is as high or higher perhaps, depending on their individual circumstances of coming back, because perhaps their risk factors don't get managed and they keep smoking and they continue on with high cholesterol and high blood pressure, or whatever the case may be, and not prescribe to medications. And absolutely, within a very short space of time they'll be back.

DAVID BRIEGER: I think that is something we've emphasised—both non-revascularised patients and the patients that undergo bypass surgery tend to be undertreated. The reasons why the bypass patients are undertreated are complex. In part it's driven by the fact that until recently there was antipathy to using dual antiplatelet therapy in these patients because of the association with bleeding, and it's the surgeons that tend to drive therapies at hospital discharge. I might say that that's changed because we've now got emerging data that graft patency actually improved with dual antiplatelet therapy, versus aspirin alone. So anecdotally, the surgeons are increasingly prescribing dual antiplatelet therapy in these patients post discharge.

The medically-managed group, through, are difficult. They really fall into two cohorts. There's the group with relatively mild coronary disease. They may not have an evident acute plaque rupture or they might be left without any objective obstructive coronary disease. There's a perception that they're at a lower risk and in some cohorts that's true. In others, diabetic women for example, it's not. But in general, they're often under-treated. But then there are a second group of medically managed patients who are those who are typically old and more frail and deemed to be too high-risk for interventional services like angioplasty or surgery.

MIC CAVAZZINI: Yeah, the finding you just mentioned about older patients that was the central finding of a 2000 paper in the MJA led by Ian Scott and colleagues, who found that the intensity of secondary therapy as well as acute care was inversely related to disease risk. Using GRACE scores to stratify they found that for lipid-lowering drugs most patients in the low-risk group received a script but only two-thirds in the high-risk group did, and the driving factor seemed to be age there, the perceived frailty of the patients.

DAVID BRIEGER: Yeah, it's age and prevalence of comorbidities. So, we've looked at that in a number of our studies and there's a very, very consistent ‘treatment-risk paradox’ we call it, and this concept of frailty is now emerging as an important one as our therapies becomes arguably safer and more widely applied. And of course the goal posts are shifting when you talk about age. We're very comfortable treating patients in their 90s now, which is something I wouldn't have contemplated 20 years ago when I started interventional practice. So the message in these cohorts is that we push our naturally conservative tendencies away and allow us to at least initiate these therapies in these patients, these antiplatelet therapies, these ACE inhibitors even though the blood pressure might be border line.

MIC CAVAZZINI: It will be interesting to know whether these variations in care are conscious, thought-out decisions or whether there's some bias that's not—

DAVID BRIEGER: —well, we've done some work on that and there's one very interesting experiment I've done with a series of cardiologists, where I've described a patient to them objectively and I've asked them to tell me whether they would take this patient to the cath lab, and I've asked for a show of hands. And what I've done subsequently is I've shown them a picture of a frail elderly woman lying in bed and I've asked them how many of them—and I haven't given them any information—and I said, “How many of you are going to take this patient to the cath lab?” And even though I drew the clinical descriptors from this patient the response is entirely different.

MIC CAVAZZINI: Already in 2012 you published a paper in the MJA, I believe, a successful intervention in 49 hospitals around Australia for staff training called DMACS. Was it ‘Discharge Management of Acute Coronary Syndrome’?

DAVID BRIEGER: Yep.

MIC CAVAZZINI: And that did show an improvement in prescription of therapies. So what was involved in that intervention?

DAVID BRIEGER: It involved a process whereby allied health professionals and doctors came into the sites and lectured all of the relevant staff around the importance of secondary prevention therapies. Coupled with that there are a whole series of discharge tools that were provided to the hospital. For example, there was a checklist as to, ‘Have these patients been prescribed with these particular therapies? Have they been enrolled in a cardiac rehab program?’ And one of the things that struck me was that despite the cost and intensity and engagement the improvement was actually relatively modest. We managed to improve things from what, 55 per cent to 70 per cent?

MIC CAVAZZINI: 57 to 69, but there was a decline at three months.

DAVID BRIEGER: Yeah, which is really disappointing. So at our best we've still got almost a third of our patients not being discharged on optimal therapies—and when they are, they're falling off. So we've run a cluster-randomised trial which we're just about to finish, and the main purpose of this study is to say, ‘Is the problem one of knowledge, or is it actually an active decision?’ We're also asking them to justify non-prescription or a decision not to take the patient to the cath lab. So that will provide us with some really fascinating answers to the questions that you ask.

***

MIC CAVAZZINI: Variation in the package of care that patients are discharged with is a concern in its own right. The problem is compounded by the influence this has down the track. In a study published in May’s Internal Medicine Journal, David Brieger and colleagues followed six and a half thousand patients discharged with ACS from across Australia. They called patients six months later to ask which of the five guideline-recommended medications they were taking.

To be considered adherent, patients needed to be regularly taking at least four of these. In cases where one of the drugs was not indicated, then three was considered adequate. The researchers gauged adherence against aspects of the original presentation, hospital-care and post-discharge management. They found, for example, that patients diagnosed with STEMI or unstable angina were more likely to be on recommended drugs than those with a non-STEMI. Similarly, 82 per cent of patients who’d undergone PCI were adherent at six months, compared to fewer than half of patients who’d had a coronary bypass

But when these variables were statistically integrated, they were weak predictors of appropriate pharmacotherapy, compared to the scripts with which patients had left hospital.

DAVID BRIEGER: So if we assume that all of these factors that I’ve mentioned are responsible for 100 per cent adherence at six months, the things that were most important, in fact contributed about 50 per cent, was being discharged on the appropriate therapies. That half of the game was won if you did that.

MIC CAVAZZINI: I'm slightly confused here. It's not a tautology to say that if you weren't prescribed something in the first place, you can't be adherent to it six months later, is it?

DAVID BRIEGER: Yeah, when we started on this analysis we had taken the simple approach that you're describing. But as we thought about that question the relevance and importance of that question I think became less exciting, when we recognised how many of these patients weren't being discharged on these therapies in the first place.

MIC CAVAZZINI: And I guess doing it the way that you've done it also leaves the way open for cardiologists or GPs at subsequent visits to say, ‘Oh hey, you should—this is what my guidelines say, you're missing this drug or that drug.’

DAVID BRIEGER: It does exactly that. But even more importantly, undergoing rehab or seeing a GP I think only accounted for a couple per cent. Statistically significant, but quantifiably quite disappointing. And if you think about what happens in those scenarios, I guess it makes sense. They believe that the cardiologist takes care of the acute problem and sets the ship off, fully revascularised and appropriately medicated, and their job is just to stay the course. It’s very uncommon I think, we’ve learned from this, for the GPs to initiate therapy off their own bat. It makes a small contribution. I guess what it certainly doesn’t do, is make up for the failure to prescribe.

MIC CAVAZZINI: That’s the take home message.

DAVID BRIEGER: Yeah.

MIC CAVAZZINI: A 2012 meta-analysis in the American Journal of Medicine of a few hundred thousand patients found that one-third of patients with a myocardial infarction were non-adherent to cardiovascular medications two years down the track. That review took studies that used prescription refill frequency as their measure, as their record, and also found that adherence was largely unrelated to the drug classes being prescribed. The authors suggested that discontinuation of medicines wasn't to do with side-effects. Is that your sense also, just from day-to-day speaking to patients?

DAVID BRIEGER: You get all sorts of reports. We did specifically ask them why they'd stop their medications, but we had a fairly poor response. There are some side effects we're very well aware of and the patients are very well aware of also, so patients on statins if we tend to see about a 10 per cent attrition rate per year, so that by five years half of the patients are no longer taking the statin drugs.

MIC CAVAZZINI: And have you had to counsel patients through the media hype about statins?

DAVID BRIEGER: We certainly have, and it's ongoing. There's a nocebo effect where the patients are expecting that they'll be getting pains when they take these drugs, and it's been very elegantly shown quite recently in a range of lipid studies in a double-blinded fashion that patients who think they're taking statins wind up with these muscle pains. And in fact, there were anecdotes of patients stopping their drugs in the wake of the Catalyst report several years ago, and presenting to hospital with coronary events.

So, we feel quite strongly that this is a practice that should be discouraged. The difficulty we have with this condition is that the vast majority of patients following their coronary event feel well. We tend to revascularise them early which tends to alleviate their symptoms, we put them on to effective symptom controlling therapies for the most part, and they feel well. So they don't like taking treatments for which they don’t see a benefit.

***

MIC CAVAZZINI: The problem of non-adherence to therapy isn’t just about medication. As we’ve heard, fewer than half of patients with acute coronary syndrome are referred to cardiac rehabilitation, and only half of those actually complete the program.

It should be no surprise then, that referral made only a 3 per cent contribution to medication adherence in the IMJ paper we’ve been talking about.

But Julie Redfern explains how the traditional cardiac rehab model might be outdated, and that a more individualised approach is needed to engage people in self-managing prevention. Nutrition and lifestyle advice in particular is often missing from medical consultations.

JULIE REDFERN: Look, I think the area of cardiac rehabilitation is something that is under intense review, I think, at the moment. Really, cardiac rehabilitation originated back in the 60s and 70s when people would be in bed and sit on chairs and that was it after heart attacks, and people were very de-conditioned and needed this level of physical rehabilitation because they had been very immobile for very long periods of time.

Obviously we're at the extreme point now where someone can have a heart attack this morning, have a stent put in at lunchtime and go home this afternoon. If they're quite an active person they actually have no need for ‘rehabilitation’ or ‘reconditioning’ in its traditional form. So they then don't go to cardiac rehabilitation because it's perceived as being exercise in a group.

But what they then miss out on is the information around cholesterol or blood pressure or taking medication. So the challenge for the cardiac rehabilitation community at the moment is to find ways that they can support people in life-long management of risk factors and cardiovascular disease—really target the things that each individual person needs thinking about in other ways it can be delivered, so people don't have to physically be at a hospital at 10 o'clock on a Tuesday and Thursday morning, which is highly problematic.

MIC CAVAZZINI: And medication management is one of the main focuses of cardiac rehabilitation programs, and patients are also taught how to measure and control certain biomedical indices. Can you give us some specific examples?

JULIE REDFERN: If I think about one of my own patients, she measures her blood pressure every morning and every evening and that can be challenging for a lot of patients. And I find it interesting that she, her GP has encouraged her to do that. She records that blood pressure morning and afternoon and she sort of titrates her blood pressure medication according to that. Now she's quite health-literate, this particular lady, and I would say in most cases that would be very difficult to achieve. But as the population become more educated, more independent, perhaps this will be able to be more frequently used in the future.

MIC CAVAZZINI: Yeah, let's go into some of those individual factors then. There was also a study in the IMJ last year from the Framingham Heart Study, they've found that older patients were more likely to be non-adherent to medications for cardiovascular disease and you can speculate that they've already got so many other medications often to deal with. There was a correlation between depression scores and low medication adherence. So really each of these subgroups requires a different approach, doesn't it?

JULIE REDFERN: Yeah absolutely. Experiencing depression is common for people after heart disease and it is recommended that everyone has a simple sort of screening process to check if there's any signs of depression. And we found only 10 per cent of people were screened for depression. So it’s about thinking about individually tailoring, I suppose, management to each person. That has to be tackled ideally in a multidisciplinary way.

I'm giving a lecture later on today to some physiotherapy undergraduate students and I say to them that evidence-based care is not providing evidence-based information. Evidence-based care is not telling people, ‘You should be walking five days a week for a minimum of 30 minutes, because it will help with this and that and the other.’ It's about, ‘How do we actually tap into that person and get them to partake in the required levels of physical activity?’ And the former is much easier to do because you can give them a piece of paper and sit with them for five minutes and tell them what they should be doing.

There is a perception, I guess, among society and some of us and it's difficult to resist at times of saying, sort of blaming the individual—'Why didn't they do this, why didn't they do that, why didn't they take this, why they didn't take that?’ And sometimes it is important to actually have a higher view and think about what can we do as a system to help improve some of these things.

MIC CAVAZZINI: Yeah, so as that 2014 study showed, only around 40 per cent of inpatients received advice about diet and physical activity, and the figure is even lower in the broader setting of primary prevention of cardiovascular disease. Only 12 per cent of all consultations include counselling about nutrition according to a 2017 review in JAMA. Is it a really awkward conversation for physicians to have to bring up diet and lifestyle?

JULIE REDFERN: Yeah I think it is, and I think there's a little bit of, amongst health professionals, an element of ‘Someone else is going to do that bit’—whether it be the GP, whether it be the dietician, whether it be the physio, whether it be the physician.

MIC CAVAZZINI: ‘It's not real medicine.’

JULIE REDFERN: Yeah, it's sort of like, ‘Someone else is always going to do it.’ But how are we going to make sure that somebody does actually do it? Even, for example, the cardiac rehabilitation program. So usually there's a dietician involved in the majority of the programs, but that might only be a talk for an hour. Really to get into someone's diet in a very, very formal and detailed way, that takes a lot of time. And then that takes money. It's not always covered. There are I think five visits per year potentially covered across all allied health. Things like going to a psychologist as well, I think the use of psychology and cognitive behaviour therapy and similar strategies to that is really under utilised in these populations, where that might be a strategy to help encourage someone to walk regularly. Because it's about tapping into that person's behaviour, and behaviour change.

MIC CAVAZZINI: The motivational interviewing approach comes up very often. It's reported to be as good as CBT in decreasing alcohol misuse or in proving adherence diabetes management. There was a good little overview of the technique in Australian Family Physician. You know, first increasing their perception of the problems, then asking open-ended questions about what they hope to achieve, you know, ‘What worries you about your blood pressure?’ It's sort of letting them come up with the spark to proceed rather than—

JULIE REDFERN: —yeah absolutely. I mean that's the foundation of it, isn't it. We don't always like it when someone just tells us what to do, and sometimes if we feel we've got some say and some control we're more likely to head in the direction that perhaps is more ideal. I think it encourages that deeper reflection and thought about why or what we could do, rather than someone just telling us what to do that may or may not work for us.

One of the things that's really fascinating of the work that we've been doing recently is around text messaging. And at first I thought, ‘Text messaging? Too simple, too basic.’ Anyway about six years ago, we embarked on this program of work which is now quite significant, but every one of our messages based on behaviour change theory and as you said being very positive, giving practical suggestions that are feasible and reasonable for that person. And the patients have absolutely loved this kind of approach and really responded very well to it.

MIC CAVAZZINI: Many thanks to Julie Redfern and David Brieger for appearing in this episode of Pomegranate Health. The views expressed are their own, and may not represent those of the Royal Australasian College of Physicians.

If you like what you’ve heard, subscribe to Pomegranate Health through any podcasting app, or at our website you can also sign up to email alerts for each new episode. The address is racp.edu.au/pomcast, and once you click through to this episode you’ll find all the references listed, including Professor’s Brieger’s recent article in the Internal Medicine Journal.  There’s a link to a phone app for calculating GRACE risk scores from the Centre for Outcomes Research. They also present some useful case studies with expert commentary. In our College Learning Series is a video lecture on management of acute coronary syndromes by Associate Professor Lefkovits of Monash University. The CLS lectures are built on 20 years of Victoria’s seminal Physician Education Program for basic trainees, and are freely available to all members at elearning.racp.edu.au.

Please get in touch if you’ve got any feedback using the address pomcast@racp.edu.au. I’m Mic Cavazzini, and I hope you’ve enjoyed the show.