Monday, September 07, 2015


Taking the cue from Dr Alan Teh, I thought that I better read up on what happened at the just concluded ESC ( European Society of Cardiology), Annual Congress 2015, London . I found a very interesting presentation, which to me, had a very important and practical message for Malaysian Cardiology and Cardiac investigation scene.
Dr Pamela Douglas ( that sharp lady ), from Dukes Clinical Research Institute, Durham, N Carolina, presented the results of the PLATFORM ( Prospective Longitudinal Trial of FFRct : Outcome and Resource Impact ) study. Basically, this study looked into the usefulness and impact of a plain CTA, against a CTA with FFR analysis with the Heartflow software, done offline. PLATFORM has 2 different arms and I will describe that arm that has to do with comparing CTA without FFR and CTA with FFR or FFRct. ( these are non invasive FFR ).
Dr Douglas and colleagues studied 380 patients, who had CTA, who were all scheduled for coronary angiogram, She divided them into 2 groups. One group when straight for coronary angiogram ( 187 patients ), Gp A and the other group ( 193 pts ) had FFRct before Coronary angiogram, Gp B.
They found that in Gp A, 73% of patients had NO significant coronary artery disease and after 3 months followup, non had any coronary events. While in Gp b, following FFRct, they were confident to cancel 61% of the coronary angiogram, without any follow-up incidences, and in the remaining 39% who had coronary angiogram done, 12% had no significant coronary disease.
Take awhile to have the message sink in. After all these years, if PLATFORM is to be believed, we have a 73% coronary angiograms where no significant disease is found. And in 61%, the coronary angiogram could be safely excluded.
Just imagine the abuse all these years and which will probably will be carried on by the CTA-philes for many more years to come. I suppose it would be too drastic to say that  these people are  "CTA for bread".

When I saw these figures, I was appalled. Thanks Dr Douglas for enlightening us. I hope that many more centers, especially local ones will repeat this study and see where we stand. I firmly believe that FFRct is the way to go.
We have been advocating a clinical approach to investigation of CAD,, instead of a factory, everyone get CTA approach, as often done in many medical centers on the rational that what you see is real. Well I hope that cardiologist will wake up and realise that what you see may not be real and adding a functional component would greatly assist in the accuracy and patient care management aspect of diagnosis of CAD. I of course assume that we are clinicians and not businessmen.

Saturday, September 05, 2015


Bersih 4.0 has come and gone. We each have our take on it. The pro-Bersih have their slant. The anti-Bersih have their views too. I thought that as a witness to all 34 hours of the event, I shall also pt on record, my take. I will try to state the facts, although I would confess that I am a Bersih 4.0 supporter. I will try and state the facts. Please read and if you do not agree, please tell me. If you agree, please tell all your friends. We must pass on the real message.

Fact 1. It cannot be denied that the crowd was big. On day 1 ( 29th Aug ), Jln Tun Perak / Pasar Seni probably had the biggest crowd. We were full up all the way to Kota Raya bus station. The Sogo area had the next largest, the Brickfields next and the smallest crowd was from Masjid Negara ( I was told, a crowd of about 5,000 ). All in all, I eyeball estimate about 150-200,000.
Besides the crowd, the next obvious thing was the racial composition. Having been to 5 mass street rally, it was quite obvious that the crowd was mainly Chinese, and Indians. The number of Malays was small. ( I apologise for being racist here. I don't like to but it looks like in Malaysia '15 we all seem to be abit ).
On Day 2, the crowd as bigger. Easily 2-300,000 at the peak. What was more heartening was the racial composition. We saw more Malays appearing, young and old. That was heartening.

Whether the larger crowd and more Malays attending, is due to the wily old fox appearance, is a mood point. I personally feel that he is the cause of all our problems, so he is certainly no hero of mind.

Fact 2. One of the sights that will leave a big impression on me, is the 1am 29th Aug seen on Jln TAR and Jln Tun Perak.

I saw young ( mainly ) and some old, sleeping on the streets, on the pavements, and on the road divider. On sleeping bags, on simple mats, on cardboards, on papers, with their water bottle and bags beside them. Some even had their helmet next to them. This was a sight to behold.

Fact 3. After 1am on 29th Aug, I could see many walk pass me at my Pasar Seni base to go home to sleep. Mainly the senior citizens. They would wave to us at the medic base, and say thank you or good night, as they stroll pass to go home.
        The next morning, I woke up at 6.15 am to go wash up. I could see the seniors walking back in the direction of Jln Tun Perak, to join the rally again. This was heart warming. Why would seniors, who had already attended the Rally on 29th Aug, come back again on Sunday. Have they nothing better to do, or are they so angry, that day of rest also must come.

That really make me think how committed they are to the cause.
Mind you, I know for certain that non in the crowd was paid to attend. As a medic team leader, I lost money, making "medical vest", buying food, medication, and the little nitty gritties. My team had to buy first aid kits, donate masks and googles, etc etc etc. These people gave up their sunday rest to send the government a clear message.

Fact 4. Why do I bother to go attend this historical rally, called Bersih 4.0. I will sum it up in two pics which I think summaries well why I took part, besides the fact that it is my calling to help people who may be injured or sick who needed my help.
I only hope that this government will listen to the people. Will give us back our voice. We are out there because we have no choice. We try talking to the government politely, strongly, even more strongly. But they sack, they ban, the declare illegal, they transfer out, they "promote", they shut down, the withdraw licence, they do all manners of evil to deny us information and accountability.
Bersih 4.0 is because the people have lost their voice, and they want it back.

Thanks to Mdm Maria Chin and committee for a job well done.
Thanks to brave Malaysians, THANKS FOR STANDING UP.

Monday, August 17, 2015


Many of us use Troponin T as an enzymatic marker for unstable coronary artery disease, thinking that these trop T elevation is due to enzymatic leakages from death of myocardial cells. In fact, this is one of the WHO criteria for diagnosis of AMI. Now, is this true all the time?

In an article published in the 13th August issue of New England Journal of Medicine, Dr Brendan Everett and investigators looked into the BARI-2D data, and found that in 2,285 patients with diabetes mellitus and stable coronary artery disease, 40% had elevation of Troponin T without chest pains. Trop T levels > 14ng/L was the cut off. 27.1% of those with Trop T had a clinical event, defined as CV death, MI or strokes in 5 years. While 12.9% of those with normal Trop T had any clinical events in 5 years.. This was statistically significant at
Those with Trop T elevation also had a 19.6% risk of dying at 5 years compared to 7.1% who had no Trop T elevation. This was also highly significant. ( < P=0.001).
The other surprising thing is that, those with Trop T elevation who were revascularised, did not normalise their Trop T, neither did it improve the outcome. Now this is puzzling.
It then bags the question, where is this Trop T coming from, and what is the cause of its elevation?
What then shall we do wit diabetics who present to ER with chest pains that are like that of acute myocardial infarction? Shall we treat them all as AMI? knowing that it may not alter prognosis? or shall we repeat serial Trop T in an attempt to better define this group.
Is Trop T a reliable indicator of myocardial necrosis? Or are there other reasons for Trop T elevation like poor glucose control? presence of metabolic syndrome and high TG levels?, Or is it hypertension with myocardial over-stretch?
I suppose as always, there is so much that we do not yet know. Obviously more studies need be done, to look nto this.


Yes, I have not been posting for almost 1 month now, due to a combination of factors. Have been rather busy with my many social duties, ranging from organising medical meetings, medical camps, fund raising, teaching and the latest is organising a medical team for the coming Bersih 4.0. I am told that the Bersih organisers are trying to get 400,000 to walk in the streets of KL on the 29th August and also to sleep over at Dataran Merdeka on 29th night.
Yes, we are local and global too.

We expect that with hundreds of thousands of Malaysians from all walks of life in the streets walking, there may be some who may need medical attention, being Police officers with faints, or citizens with asthmatic attacks. My task is to help raise a medical team, so that those who have medical needs on that day, can receive medical attention. We have already readied ambulances on standby, and AEDs ( just in case ), of course together with our first aid kits, and also our survival gears against tear gas and water cannon. This time, I have also advised members to bring along a sleeping bag, should they wish to sleep over at Dataran Merdeka.

Of course, I feel that this Bersih 4.0 rally is justifiable, because, our minority, elected ( on 47% popular vote ) government  no longer wish to listen to the people when we talk to them.
What then do you do, when the people who represent you, hide from you, give vague answers to simple questions, ban, sack, detain, and transfer government officers whom they do not like for speaking up. This is a gross abuse of power. You represent us ( so you say ), take our tax money, impose GST on us, and give us hardship, then do not respond to us in a reasonable manner, when we ask you for answers. This is unreasonable.
So we have no choice but to walk our talk. We want answers. The economy is failing. Soon, our money will be almost like "banana notes" during the Japanese occupation.

Please come out on the 29th August in large numbers. I hope that God will give us good weather and protect us from harm. It starts at 2 pm. There are 5 staging points for us to assemble. I expect that my stations will be Pasar Seni and Dataran Maybank.
Can you imagine Kuala Lumpur in a sea of yellow? Please come and make Kuala Lumpur a sea of yellow on 29th August. Let the 47% PM get a clear message that the rakyat wish to be heard, and we are important. In a democracy, the state may think that they have the power, but the real power is with the people. Afterall, it is a government, for the people, of the people and by the people, is it not.


Thursday, July 23, 2015


US News and World Report's "Best Hospitals" listing 2014
Top 10 Ranked Hospitals for Cardiology and Heart Surgery
  1. Cleveland Clinic, OH
  2. Mayo Clinic, Rochester, MN
  3. New York-Presbyterian University Hospital of Columbia and Cornell, NY
  4. Duke University Hospital, Durham, NC
  5. Brigham and Women's Hospital, Boston, MA
  6. Massachusetts General Hospital, Boston
  7. Hospitals of the University of Pennsylvania-Penn Presbyterian, Philadelphia
  8. Cedars-Sinai Medical Center, Los Angeles, CA
  9. St Francis Hospital, Roslyn, New York, NY
  10. Mount Sinai Hospital, New York, NY
The 2014 "Honor Roll" for Top Hospitals (Overall)
  1. Mayo Clinic, Rochester, Minnesota
  2. Massachusetts General Hospital, Boston
  3. Johns Hopkins Hospital, Baltimore, MD
  4. Cleveland Clinic, OH
  5. University of California, Los Angeles Medical Center
  6. New York-Presbyterian University Hospital of Columbia and Cornell, NY
  7. Hospitals of the University of Pennsylvania-Penn Presbyterian, Philadelphia
  8. University of California, San Francisco Medical Center
  9. Brigham and Women's Hospital, Boston, MA
  10. Northwestern Memorial Hospital, Chicago, IL

Thursday, June 25, 2015


The European Heart Rhythm Association, Cardiostim is currently meeting in Milan. One of the papers presented deals with the effect of smartphone ( which we all have one or two nowadays ) and their effect on pacemakers and other implantable cardiac devices like AICD and CRT pacers. These cardiac implantable devices are basically triggered by EMW ( electromagnetic waves ) and the smartphones emit EMW. What may happen is that the smartphone may emit EMW and the cardiac device may pick up the signal and stop firing causing bradycardia and syncope, or the ICD may fire and cause an unnecessary painful shock.

Dr Carsten Lennerz and colleague from the German Heart Center studied 308 patients who had implantable cardiac devices like pacemakers, AICDs and also CRT ( Cardiac resynchronisation therapy ). They tested 3 types of smartphones in near proximity to these implantable devices. The smartphone tested were the Nokia Luminia, Samsung Galaxy S III, and the HTC one XL. They administered 3,400 stimulations on the 308 devices ( 147 pacemakers, 96 ICDs and 65 CRT ). They found that of the 3,400 stimulation tests, only one test found interfernece, meaning that the chance of interference is low.
However the authors did not see it fit to alter the standard FDA advise on implantable cardiac devices and smartphone, which is to hold the smartphone about 15-20 cm away from the implantable cardiac devices. For example, to hold the smartphone to the opposite ear from the implantable device. And of course never to store the smartphone in the pocket on the same side as the implantable cardiac device.
This is to serve as a reminder since we have more and more smartphone users and also more and more patients having implantable cardiac devices.

Sunday, June 21, 2015


For those who have yet to join / pledge to 1000 PCPs (Primary care Providers) please do so. This is the brainchild of the TASK FORCE.
We are gathering 1000 GPs /PCPs to pledge to meet PM and VVIPs and a lot more are in store for us should this 1000 gathering become a reality.
Date & venue be announced and it is soon.......
We need the numbers for us to see this become a reality ..we will see this thru ..together.
For those who are yet to join / pledge...pls list your name , hp no and place of practice for us to add you into the respective whatsapp groups for daily updates.


Thank you. Please join, and let all of us stand together,

Friday, June 19, 2015


 Interesting. The issue of " Is chocolates good for you?", has come back again, in view of athe releas of an article in the Heart, online edition June 15 2015.
Dr Kwok Chun Shing and colleagues from the University of Aberdeen, Scotland, published their findings on Habitual chocolate eating and cardiovascular disease. They used the data from the UK's EPIC-Norfolk Study. This study involved about 21,000 UK citizens, who had 12 years follow up. There was a questionaire, including the amount of chocolates that each subject consumed. The researchers found that those who consume chocolate, after 12 years had a 11% reduction in risk of coronary heart disease, 25% reduction of CV death and most importantly 23% reduction of strokes. What is even more interesting was the finding that it did not really matter whether it was dark bitter cocoa full chocolates or white chocolates.

There was another study released almost the same time of 155,000 subjects, in USA which showed basically the same findings.
Neither of the studies, studied the reason why. So it is essentially a correlation.

It sure looks like we should all eat more chocolates.
So now we have nuts and chocolates are good for your heart. Will we eat Cardiologists out of a job?

Friday, June 12, 2015


I miss this study until I heard it discussed on BBC last night. This is a simple study, prospective cohort study, published in the latest edition of International Journal of Epidemiology.
Prof Piet Van den Brandt from the University of Mastricht looked into the daily consumption of nuts  of various types, and followed the subjects for 10 years to see the outcome after 10 years. They studied 120,000 subjects aged 55-69 years starting in 1986. They reviewed these same individuals after 10 years and see their condition. They found that after 10 years, those who consumed 15 gms of nuts daily had a 23% reduced risk of dying. There was also a 45% reduction in neurodegenerative disease, 39% reduction in respiratory diseases, and 30% reduction in incidence of diabetes.
This is the second large study to show this. If you remember, back in Nov 2013, the NEJM also published another large study done by the researchers in Harvard which showed essentially the same.
The fact that eating nuts ( part of the DASH diet ), reduces CAD is not in doubt.
Looks lie eating nuts is good for us. 15 gms is not much, probably a handful only, and yet over 10 years can have such a major impact. Note that this does not apply to peanut butter as that contains too much salt and transfat ( thats what they thing ).
Lets go for it.

Thursday, June 11, 2015


Having written about the facts of the Medical Camp, I thought that I should also show the Medical Camp in Pictures,
It took me a few days to figure out how to link them to slideshare. This is as far as I could manage. Please advise if you can improve on this.

Please enjoy the pics. If you feel inclined to join us, please do let me know