FALLING RATES OF HEART ATTACKS AND DEATH FROM HEART ATTACKS IN UK. 2002-2010. HOPE FOR MALAYSIA

The 25th Aug issue of the British Medical Journal, has an article by Dr Kate Smolina of Oxford, UK. She and colleagues looked into hospital records and mortality data for UK from 2002 - 2010, to examine the number of heart attack cases and also death from heart attacks.
They found that over the period of 2002-2010, there 861,134 heart attacks in 840,175 patients.
From 2002 -2010, the death from heart attacks had declined by 50% in males and 53% in females, contributed mainly by fewer heart attacks over these periods, and also fewer sudden deaths should heart attack occurred.

This is very encouraging telling us that preventive measures like lifestyle modification, control of coronary risk factors and also perhaps the use of statins and aspirin in the high risk group is beginning to take an effect. Less people were also dying from sudden cardiac death, telling us that the UK resuscitation Council has done a good job of teaching bystander resuscitation and also triaging them effective to the nearest medical centers
Similar trends were also seen in the USA.

Of course these are good things that we must emulate from the West, as it saves lives.
Life style modification is cheap and must be encouraged by the government vigorously. Sometimes the governments approach seems half hearted. Yes, the government does encourage exercise and there are adverts and campaigns to reduce obesity and diabetes. But this is often offset by promoting nasi lemak ( most unhealthy ) and teh tarik as a national food and drink. Both of which are very bad for the body and heart. We have also advised the government to limit the sugar content in carbonated drinks and to have compulsory food labelling so the we know what we are eating. that campaign also seemed to have run out of steam.
I certainly hope that a day would come when we ca also report that over the last 8 years, malaysia has also seen a 50% drop in heart attack rates and death from heart attacks.

NOT ALL FRIED FOODS ARE BAD FOR THE HEART. SPANISH STUDY SHOWED THAT FOOD FRIED IN OLIVE OIL OR SUNFLOWER OIL IS OK

It has always been thought that fried foods, full of lard is bad for the heart as it promotes cholesterol deposits in the coronary arteries.That remains true. A recently reported study now tells us that not all fried foods are bad. How you fry and wht oil you use is also important.
Prof Pilar Castillion and colleagues at the Autonomous University of Madrid has published their study in the 24th Jan issue of the British Medical Journal, on this subject. They analysed data from the EPIC ( European Prospective Investigation into Cancer and Nutrition ) study, and data from hospital records of their cohorts. In the cohorts were 40,757 subjects who had no heart disease at the start of study. They were aged between 29-69 years. They followed them up for 11 years. They studied their nutritional history especially regarding the number of times they had meals with fried food and what oil was used in frying. They then divided the cohort in to 4 quartiles according to their fried food intake. The lowest quartile with the lowest intake and the 4th quartile with the highest intake. After 11 years of follow up, there were 606 subjects with heart disease and 1,134 deaths. They found no difference in the heart disease rates between those in the lowest quartiles and the highest quartile. This is as oppose to previous study which showed that subjects who consume fried foods were associated with a higher incidence of heart disease.
Basically, a Mediteranean diet is good for the heart and also olve oil and sunflower oil.

PILLOW TALK. AHA ADVICE ON SEX AFTER AMI

The online edition of Circulation carries a scientific statement ( means medical advice by AHA ), on the issue of sex after a diagnosis of CAD or heart attack. The lead author is Dr Glenn Levine of Baylor's Houston.
Sex after AMI, or a diagnosis of CAD, is a rarely discussed issue by cardiologist with their patients. maybe it is a question of "shyness" as many of us are uncomfortable talking about sex in a consult clinic. Patients also rarely bring up the issue, probably for the same reason. maybe we all feel that sex is unnatural for a 60 year old ( the mean age of many of our patients ).
The AHA scientific statement asks that cardiologist discuss the issue of sex with their patient openly. I do not think that they mean "Karma Sutra" details, but they mean that we must understand that 60 or 70 year olds may still be sexually active and the cardiologist should assure them that that is natural, and that they can indulge in sex, just as they can walk up 2-3 flights of stairs. Perhaps, the only two categories of patients who should not are those still with angina, and those who are taking require "viagra" for stimulation and who are also on nitrates.
cardiologist must assure their patients that it is natural and OK to have sex with their partners.
After reviewing all the available, published data, Dr Levine and colleagues found that the risk of an acute coronary event is only very slightly elevated, but the benefit of a healthy sex life may outweigh the risk.
We must each live life to the fullest. Sex need not be avoided after a coronary event. Doctors must be comfortable talking about it and patients must have the courage to ask a very natural thing.

SELANGOR / KL HEALTHCARE PUBLIC FORUM. 12th February 2012.

Calling all friends for change. Please attend and bring as many friends as possible along.

NEW STENTS DO BETTER THAN OLD STENTS.

The Swedish Coronary Angiography and Angioplasty Registry ( SCAAR ), have just reported their latest report in the 9th Jan 2012 European Heart Journal. Dr Stephan James and colleagues reviewed 95,000 patients who had stents implanted. 64,631 patients with bare metal stents, 19,202 patients with the first generation DES ( Drug Eluting Stents ) ,and 10,551 patients with the second generation DES. The defined first generation as the Cypher, Taxus, and Endeavor , and the second generation as the Endeavor Resolute, Xience V or Xience Prime., Promus and the Promus Element.
They reported that DES is better than BMS ( That is for sure ), but they also reported that the second generation ( when compared to the first DES ), has 38% less restenosis, 43% less stent thrombosis, and most importantly, 23% less risk of death.
I must say that we can attest to the first two, and I do not have enough figures to attest to the last. But it must be comforting for our patients to know that the newer stents are better. I am only glad that our preferred DES are the Xience Prime / V and the Endeavor Resolute.
While in Singapore, I heard that we should be getting our disappearing DES ( the bioabsorbable, artery reparative stent by Abbott Vas. ) sometime in the middle of the year. I wonder what the price will be? Is the cost worth it for most of our patients.

AsiaPCR / SingLive 2012. 12-14th Jan 2012.

I spend my last weekend in Singapore, taking part in AsiaPCR / SingLive 2012. This year the meeting seems better attended. I was told registration was 1,800. The meeting halls are scaled down and so the rooms look full, especially for the morning sessions. As I walk around the booths, I was told that the booths are very reasonably priced ( less booths this year ), but the registration fees for physicians and exhibitors remain high.
I was moderating a few sessions and the discussions were good. I can see that this meeting allows cardiologist from Asia to show their cases. Actually some of the work done in India ( smaller cities ) and China ( smaller cities ), were quite good. They seem to have more intravascular ultrasounds, even in their smaller city hospitals than us.
As for interventional cardiology, as we have noted previously, Percutaneous Coronary Interventions ( PCI ) have plateaued. Drug eluting stents have almost reached their peak per performance. Of course, the topic of the day for PCI is left main stem stenting and bifurcation stenting, and chronic total occlusions ( CTO ). many of us have imbibed the strategy of provisional stenting, and that continues to be the preferred strategy, and the Japanese are still spreading their mantra of retrograde recanalisation of CTOs. Looks like in Japan, they are still fighting with their cardiac surgeons for cases. One case shown as a teaching case had 2 CTOs, and was a fairly healthy male with no surgical risk factors. Of course my first question is, why did he not get referred to the cardiac surgeon?
Well, it was also a good occasion in Singapore, to meet up with old friends that we get to meet once a year. I keep telling them that old friends of our vintage are getting fewer and fewer.
See you next year, if Prof Koh TH invite us again.

REVIEWING OLD NEWS. THE STORY OF ASPIRIN IN HEART ATTACK PREVENTION

I remember speaking at a public forum on aspirin back in the 80s on the role of low dose aspirin in preventing heart attacks. The audience was thrilled and convinced, and low dose aspirin was launched bigtime into the Malaysian market. That marketing blitz was sponsored by Rekitt Coleman ( at that time ), and they were launching cardiprin.
Well much water has gone under the bridge, and much mor medical evidence has emerged since then on the good, and bad of low dose aspirin.
Now we are certain that low dose aspirin is a good anti-platelet agent, and has an established role in preventing heart attacks ( fatal and non-fatal ) in patients withe established CAD. It has a definite role in preventing stent thrombosis both in bare metal stents and also drug eluting stents.
It does have a role in stroke prevention especially in patients with chronic atrial fibrillation and low CHADs score. It probably have a role in prevention of Ca Colon, especially in the context of Polyposis Coli.
well, if low dose aspirin is so useful, a help for all ills, why don't we all take it or better still, put some in our drinking water, just as we add some chlorine.
well the issue is the side effects. When I spoke in the 80s, we thought that normal dose aspirin, 365 mg for fever, and pain, increases the risk of GI bleed and worse still intra-cranial bleed. So the early studies then showed that low dose aspirin of 100mg daily ( a third the dose ) will have less bleed. That is true. But there still is, and that raises the issue of safety. How safe is low dose aspirin.
well, the latest issue of the Archives of Internal Medicine carried a piece of work by Prof Kausik ray et all, from St Georges Hospital, University of London. They followed up 102,621 patients who were on low dose aspirin to prevent heart attacks. These were patients who had no history of previous heart disease ( primary prevention of heart attack ). These patients were followed up for 6 years. They found that after 6 years of low dose aspirin, there was a 20 % reduction in the incidence of non fatal heart attacks. No difference in the incidence of fatal heart attacks. There was a price. There was a 30% increase incidence of potentially life threatening bleed including intra-cranial hemorrhage. What that means is that for every 160 patients treated with low dose aspirin for 6 years, you prevent one non fatal heart attack. BUT for every 73 patients in the same group, you may get one troublesome bleed.
So the balance of evidence must be that we should not use low dose aspirin to prevent heart attacks in patients without previous CAD, as it may do more harm than good.
That seem to be the consensus presently. Except for particular subsets like Diabetics with diffuse atherosclerosis, we would no longer use low dose aspirin as a means of primary prevention. There is certainly no role to give low dose aspirin to all and sundry.
As for ca Colon prevention, I think the jury is still out on that. We have to wait and see. Certainly, if I have Polyposis Coli and also diabetes, I may be tempted to taking a low dose aspirin.

PROBLEMS WITH AF ABLATION

Much has been written about radiofrequency ablation in the treatment of atrial fibrillation. Since, the pioneering work of Dr Michel Haissaguerre in 1990s, this technique has gain popularity as it avoids the risk of cardiac surgery and the Maze-Cox procedure to try and eradicate atrial fibrillation. I have been following the work, and although all my colleagues tell me that the procedure is good, easy and highly successful, I had my doubts, and have continued to keep my chronic AF patients on long term anticoagulation with warfarin and also rate control, getting the heart rate down to 60-70 beats per minute. I ws not convinced that the procedure is simple, as I see that the catheters are complicated and they are working, almost blindly in a large left atrial chamber. To me, it needs some skill and of course very good training and guidance. The super specialist in dedicated centers that do 100 a year are like ly to get good results and those that do the occasional ( 1-2 a month ) are likely to have disasters.
Well this blog is partly prompted by a paper in the Journal of the American College of Cardiology, Jan 10th 1012, authored by Dr Rashme Shah of the Cedar Sinai Medical Center, USA. They reviewed 4,156 cases of RF ablation for Atrial Fibrillation from the Healthcare Utilisation Project California State Inpatient Data base, to see the outcomes of patients who had undergone RF ablation for AFib. This will mimick real world pratice as the data base will have outcome data from academic centers of excellence that do 100 cases a year, and some medicare institutions that do a handful of cases. What they found is very revealing.
Of the 4,156 cases on record, there was a peri-procedural complication rate of 5.1%. Half of these were bleeding and half were cardiac tamponade. There was also one death and 10 strokes.
Of those who survive, about 9.4% had to be readmitted within 30days mainly for recurrence of AFib / AFlutter, although deem procedural success after the procedure. 2.3% died within 30days and 4.9% ( about 200 ) had a stroke within 30days.
We are not told the procedural success rates. I guess that it must be around 60-70% at the academic institution and about 30-40% at the medicare centers.
Within 1 year, about 20% had a recurrence of AFib and at 2 years 30% had recurrence. These would require a repeat, and it is not uncommon to have 2-3 ptrocedures in 5 years.
Well, to me, the numbers are not so encouraging. It is obviously a tough procedure to master and the current equipment may need much improvement.
So, I am not so wrong in keeping to good old medical therapy of rate control and anticoagulation , different degree for different AFib disease subsets. I still use aspirin for those with low CHAD scores, and warfarin for those with high CHAD scores. This strategy has work well with me and my patients.
I firmly believe that the practice of medicine must have good basic theory, sound medical reasoning and good clinical data to back up. Each without the other can lead to harmful practice.

MEDICAL COST OF PUBLIC HOLIDAYS

I read in the STAR today about the many holidays that we have in Malaysia. I was quite upset last year when the government declared a public holiday when the Malaysia football team won the ASEAN football trophy, so I wrote this piece. I did not have time to send it in then, so I send it in this afternoon. Lets see if they will publish it.

Dear Editor,

I read with interest, your article in the STAR today, 5th Jan 2012, about the many public holidays in Malaysia.

Malaysia is one of those countries with too many public holidays ( in my opinion ). There are national holidays, state holidays, religious holidays, ethnic group holidays and even emergency ( unplanned ) holidays for winning sports trophies. This can total to almost 2 months, if you add in the paid annual leaves for employees. Is this not too much?

As an employee ( working for a fixed salary ), you would like as many holidays as possible, as you get money for no work. As an employer, you will be greatly aggrieved, as you are paying out ( losing money ), for no work done ( loss of productivity ).

What is often forgotten, is the medical cost of holidays, especially unscheduled ones. Every time a holiday is declared, all the outpatients scheduled ( and there are literally thousands in public hospitals, are re-scheduled. Meaning that they run out of medications, they miss their appointments with their specialists, they miss their checkups for surgical assessments, etc. Re-scheduling them becomes even more difficult, because, the public hospital outpatients list is already over-filled. What with public service doctors going on leave, going to Putrajaya for meetings, specialist accompanying VIPs for overseas trips, etc. So the 3 months waiting now now becomes 6 months of even longer.

As for inpatients admitted, awaiting surgery in the ward ( and they may be awaiting cancer surgery ) or other life-saving angioplasty or cardiac surgery, cancer patients awaiting chemotherapy, etc, they will get discharged and re-scheduled. Some of them do die, while waiting. Of course emergency surgeries still go on. But should we not treat them before they become an emergency case?

I am writing to highlight to the public and the government that public holidays, under whatever guise, has a medical cost, and that should not be forgotten. It is good when the country wins a sporting event, but should that cause a patient to suffer and maybe die?

THE MITRACLIP DEVICE

Two weeks, one of our English national daily ( my patient did not tell me which one ), carried an press release by my colleagues at the IJN, stating that they have implanted the MitraClip device in some of their patients. Of course, the patients who asked me were also suffering from mitral incompetence, and they wondered whether they were candidates for the mitraclip device.
I suppose, I should begin by discussing about mitral incompetence. Mitral Incompetence is a condition where the mitral valve ( the left sided cardiac valve that channels blood from the left atrium to the left ventricle ) malfunctions and leaks. Between the early part of the 20 century, the most common cause was chronic rheumatic heart disease ( a post streptococcal condition affecting the heart valves, causing the valve apparatus to stick together, making them inefficient, not opening well and not closing well, almost like the valve is rusted. Over the years, we have been able to reduce the incidence of streptococcal infection, thereby also reducing the incidence of rheumatic heart disease. I am told that the public hospitals still see them, as they usually affect the lower social economic group who live in overcrowded conditions.
Nowadays, we see mitral incompetence caused by coronary heart disease and also mitral valve degeneration or the floppy mitral valve syndrome.
When the mitral valve leaks, when the left ventricle ( the power house of the heart ) contracts, the blood instead of being directed forward, only into the aorta by the left ventricle, is partly directed forward into the aorta, but some ( depending on the severity of the mitral incompetence ) is also allowed to regurgitates ( backwards ) into the left atrium. This makes the heart inefficient and stressed, and over months and years the heart enlarges, and slowly fails. The patient then develops heart failure, from which some succumb and die.


The standard medical treatment used to be cardiac surgery, using the heart-lung machine to stop the heart while maintaining an effective body circulation. With the heart arrested, the surgeon opens the heart and replace the defective valve with a tissue or mechanical valve.This is a good operation and the patient, after about 2-3 months of recovery, can resume normal life and function. Of course, mitral valve replacement carries a mortality of about 5% in the average center. It is a time tried surgery and we know alot about it. All cardiac surgeons are well trained to do this operation and over the years, the valves used are getting better and better.
In March 2011, at the spring meeting of the American College of cardiology meeting at Orlando, the US investigators presented the results of the EVEREST II trial. This was a study of 279 patients with severe mitral incompetence who were high risk for surgery. They were comparing one group who underwent open heart surgery with mitral valve replacement ( the standard treatment ) with the second group, who underwent a percutaneous insertion of a mitraclip device. After 24 months of follow-up, they found that the patients who had the mitraclip device did just as well ( borderline ) as those who underwent open heart surgery. The success rate was 66% in the open heart surgery group and 51% in the mitraclip group. Remember that these are high risk patients. The investigators concluded that mitraclip was just as group ( albeit marginally ) as the open heart surgery group.
A bit about the mitraclip. This is a device with the mitral valve clip crimped down and attached to the end of a catheter on a tube. The device is the inserted into the femoral vein, passed up into the right atrium, and delivered through a puncture across the interatrial septum into the left atrium and then opened across the mitral valve and the clip is deployed to clip the sub-mitral valvular apparatus, tightening them, to reduce mitral incompetence. Enough technical details. So boring.






Even before the EVEREST II results, the Europeans had already given the device CE mark approval. The US FDA, despite the fair EVEREST II results, have still not given FDA approval, so it is very much an investigational device. This is important, as I told the two patients. It is NOT yet standard treatment.
What is even more alarming were the reports that came out in April 2011, after the EVEREST II results, that there were three cases of part of the device breaking off, during the process of implantation and one patient died when they open him up, to retrieve the broken piece.
Probably, the most famous patient to have received the investigational device was the late Elizabeth Taylor, She died after about 2 years. I had a blog on that earlier.
So, it is important to note that this mitraclip device is still largely investigational, and they must improve on it. It has problems, which unless you are well trained in them, may cause harm. It is for use in patients who may not be able to withstand open heart surgery. It is expensive ( as can be expected ). ProbablyRM 100K or more. Open mitral valve replacement is still being performed. It has stood the test of time and is safe and well understood. cardiac aneasthesia has improved by leaps and bounds and patients recover much better and faster now.
The need to do something new and sensational must be balanced by the need to care for an individual who depend on you to make him better. First do no harm, has also stood the test of time.