Friday, April 18, 2014


We have always advocated that a reduction in salt intake is good for health. Many studies have shown that a low salt intake, is associated with a reduction in strokes, stroke mortality and also heart attacks and heart attack mortality. In the days of old, when hunters have to travel over long distances through rugged terrains, they have to carry preserve meat and in order to keep them healthy, the preserved food were salted. That is not so nowadays where we could get fresh food at will and preserved meat is independently bad anyway.
Well to emphasise this "no added salt" dogma, Dr Feng He and colleagues of the University of London, has published an article in the April 14th issue of the British Medical Journal, on reduction of salt intake and their effects.
They review data from the Health Survey of England from 2003 - 2011. They noted that over this period of 18 years, salt intake has reduced by about 1.4 gms/day using urinary sodium as a measurement ( in those who had their urine analysed ). Smoking has reduced by 5%, Cholesterol levels has reduced by 0.4 Mmols / L and the consumption of greens and veges had increased by 0.2 servings per day. This was related with a reduction of overall BP by 3.0 mmHg. In those not on anti-hypertensive therapy, the BP reduction was an average of 2.7 mmHg systolic and 1.1 mmHg diastolic. Having adjusted for all the other CV risk factors, they concluded that this reduction in BP resulted in a 42% reduction in stroke mortality and 40% reduction in AMI mortality. This is wonderful, NO?
No need for pills and we have a 40% reduction, just from not adding any salt in our food.
As we all know, there is salt intrinsic in all the foods that we consume. Some food more than others. Added salt is an acquired thing. It can be done without. The second point is that when we avoid salt for a week or two, we get use to it and food will taste OK again. Should you re-introduce salt then it gets almost nauseating. We can do without salt.

Thursday, April 17, 2014


                             Karpal Singh ( 1940-2014 )
He took the road less travelled, and paid the price many times.
Karpal Singh, the Tiger of Jelutong. A man of Malaysia. A true Malaysian.
Our deepest condolences to his family and all the love ones too.
We will miss him. May you rest in peace.

He died in a road traffic accident along the North South Highway this morning.

Wednesday, April 16, 2014


We are holding another Heathcamp in Kajang on the 27th April 2014, from 9 am- 12 noon.
I would like to invite doctors or paramedic to help. We need paramedics to do registration, glucometer and measure BMI, GPs who can help to screen and triage, and of course medical specialists who can review patients and offer treatment and health advice.

Please write a comment and also let me have your email, if you wish to help.

Thank you.

Monday, April 14, 2014


When I was in Medical School, we were taught that fatty liver is a minor insult on the liver, probably from alcoholism and that if we stop drinking, they all recover.
Lately we have been seeing a spate of fatty livers discovered on ultrasound of the liver. What is the significance, if any?

Well two interesting papers were presented at the recent meeting of the Liver Congress, in London ( last weekend ). One paper was from Japan, and the other from France.
The Japanese paper was presented by Dr H Yamazaki from the Teine Keijin Hospital, Sapporo, Japan. He and colleagues followed up 3074 patients with non-alcoholic fatty livers over 10 years ( a mean of 11.3 years ). They all have an ultrasound of the liver, and had their coronary risk factors looked at. They found that of the 3074 patients, 24% had non-alcoholic fatty liver and of these 16.1% were diabetic. They followed these patients up for 10 years and repeated their liver scans. They found that there was improvement in 110 patients. And that these patients with fatty liver resolution also had improvement in T2DM status. Those who had no improvement in fatty liver scans at 10 years, also had no improvement in T2DM status.
It looks like fatty liver may be associated with the onset of T2DM and that improvement in Liver status may improve their T2 DM status. In non-alcoholics in Japan ( quite a rarity ).

The other study is the French study. This French study was led by Dr Raluca Pais of University Pierre at Marie Curie and Hospital de la Pitrie-Salpetrire, Paris. They used ultrasound scan of liver and carotid ultrasound to measure carotid intima thickness. They scan 5671 patients aged 20-75 years, who were non alcoholics. All these patients had two or more cardiovascular risk factors. They found that the carotid intima was thicker and there were more carotid plaques in the 1871 patients who had fatty liver in liver ultrasound, when compared to the rest who did not have fatty live. When these 1871 patients were followed up for 8 years and the carotid ultrasound was repeated, there was increase in carotid intimal thickness of 34%. They concluded that fatty liver may be a risk factor for atherosclerosis.

I suppose if you think about it, maybe fatty liver in non-alcoholics, may be an indicator of metabolic syndrome and visceral obesity, and should be consider a cardiovascular risk factor. We do not yet know all the correlations but fatty liver may not be as innocent as it was previously thought.

Wednesday, April 09, 2014


Radiofrequency ablation for cardiac arrhythmias have been with us for the last 15-30 years. It was Dr Scheinmen ( UCSF ) in 1981 who first used catheter based electrical ( at that time it was DC current ) to ablate SVT from W-P-W syndrome. It was Dr James Cox 1987 who first showed that interruption of intra-atrial pathways could treat atrial fibrillation. He was doing it with cardiac surgery. This is the Cox Maze procedure. Then in 1998, Dr Michelle Haissaguerre of Bordeaoux who applied the same technique to ablate atrial fibrillation. Dr Michelle discovered that often the foci triggering atrial fibrillation originated from around and from the inside of pulmonary veins.. He mapped out these foci in his patients and proceeded to isolate the foci, thereby doing a non-invasive interventional maze. His initial success rate was about 60-70 %.
Since then, the technique has taken of and RF ablation for atrial and ventricular arrhythmias is an acceptable way to treat arrhythmias.

                   Common foci for atrial fibrillation
After 15-30 years down this path, how are we doing?

               The catheter for RF ablation
Well, in the March 31st online edition of the Journal of the American Medical Association, Dr Michael Curley of the Medical College of Wisconsin in Milwaukee, reviewed the data from the American National In-patient Registry ( NIS registry ). From 1998 - 2009, the registry recorded 115,955 procedures of RF ablation. The mean age was 60 years. The indications were the usual, atrial arrhythmias ( SVT, A flutter and A Fib ). There were also some done for ventricular arrhythmias. The in hospital mortality was about 0.6% and the complication rate was about 15.2%. The complications varied from complete heart block requiring pace maker implantation ( 12.9 % ) to pericardial tamponade ( 0.2 % ).
In 2012, Dr Abhishek Deshmukh of the University of Arkansas, Little Rock, presented a review of the European Registry for RF ablation fro Atrial Fibrillation, at the 2012 ESC. The cohort from that registry was 1,400 patients with atrial fibrillation. They had a in-patient mortality of 0.07% and a complication rate of 7.7%.
I think the mortality is quite acceptable, but I do hope that the complication rate can be lower.
Afterall, the European Registry, showed that procedural success rate was 73.7% and 88% were in sinus rhythm at 1 year. In Dr Haissaguerre's own registry, most patients had recurrence 2-3 years down the road and needed a repeat ablation. Then on followup for a year ( European registry ) there were 30% readmission for cardiac events, 21% were arrhythmia related. Many still required  anticoagulation, and there were 4 deaths ( 0.3 % ) some of which were from stroke.

Putting all these together, would you subject an asymptomatic atrial arrhythmia to RF ablation, without a good trial of medical therapy?

Saturday, April 05, 2014


This has been a very popular topic and I hear and seen some patients who told me that they have stem cells from some of my colleagues across the Klang Valley. Is there enough evidence to do this, and does it work?

Well, at the recently concluded Annual Scientific session of the American College of Cardiology, in Washington, one of the trials presented was the MSC-HF trial. The autologous mesenchymal cell in heart failure trial ran by our European colleagues. This trial was presented by lead investigator, Dr Anders Mathiasen of Rigshospitalet University of Copenhagen, Denmark. They enrolled 59 patients with NHYA class 2-3 heart failure, and randomise them in a 2:1 fashion, to receive either autologous mesenchymal stem cell injected into the LV myocardium guided by the NOGA XP ( Cordis ) machine for LV mapping. The control received LV  intramyocardial saline injection. These were all patients who were on maximal anti CCF medications and were not candidates for revascularisation.
After 6 months follow-up, they found that although there were significant improvements in some LV indices like LVEF, stroke volumes, LV end systolic mass, when compared to baseline and when compared to control, there were no improvements in LV end diastolic volume and mass and more importantly NYHA classification, the 6 min walk test and also the Kansas City Cardiomyopathy Questionaire. There were improvement in these indices when compared to baseline, but no significant difference when compared to placebo, because placebo also improved.

Changes in Cardiac Measures Six Months after Mesenchymal Stromal Cell (MSC) Therapy or Placebo in MSC-FH
End points at 6 moMSC group (p vs baseline)Placebop (MSC vs placebo)
LV end-systolic volume* (mL)-8.2 (0.001)+6.00.001
LVEF (percentage points)+5 (<0 .0001="" td="">-1.4<0 .0001="" td="">
Stroke volume (mL)+17.4 (<0 .002="" td="">-3.1<0 .0001="" td="">
End-systolic myocardial mass (g)+10.1 (<0 .0001="" td="">-2.1<0 .0001="" td="">
Scar-tissue mass (g)-4.4 (<0 .017="" td="">-0.5NS
*By MRI or CT, primary end point
Well, well well. What are we to make of this? Was the follow-up not long enough, or was the sample size too small, meaning that the improvement in this rather serious condition, minimal, therefore requiring a much larger sample size. It must also mean that maximal medical therapy in these people can still be further enhanced with counselling and close follow up, as must have happened, as they are on a clinical trial. Could it be that NOGA misled them? Or could it be all of the above.

The Danes have shown measurement improvements but no clinical improvements. That brings out two questions.
    1. How do we explain indices improved without symptoms improvement? Does that mean that the heart has enough reserves and that we are only improving the reserves?
Or 2. Does it mean that the indices are too crude and may not reflect improvement in clinical function.
So so much more to learn.

One thing for sure, if one the Danish way, it is safe. I wonder whether local interventionist harvesting bone marrow, centrifuging it and injecting into the infarct related artery, is it safe, and does it work. That is a mood point and we will never know unless submitted into a rigorous trial. I do not hear of any on the horizon.

I am aware of a small study by the dean of UTAR medical school who did a study in collaboration with some local private cardiologist. Again it did show some cardiac index improvement. There was no clinical assessment of symptoms improvement.

Well, one thing is for sure. Much more work needs to be done. We are not yet ready for primetime. We are NOT yet ready for guidelines and clinical use, for the moment until more works are done and results known.

By the way, it is not cheap and is potentially hazardous. 

Friday, April 04, 2014


Photo credit: AP


Chicago, Illinois - The American Psychiatric Association (APA) has officially confirmed what many people thought all along: taking ‘selfies’ is a mental disorder.
The APA made this classification during its annual board of directors meeting in Chicago. The disorder is called selfitis, and is defined as the obsessive compulsive desire to take photos of one’s self  and post them on social media as a way to make up for the lack of self-esteem and to fill a gap in intimacy.
APA said there are three levels of the disorder:
  • Borderline selfitis : taking photos of one’s self at least three times a day but not posting them on social media
  • Acute selfitis: taking photos of one’s self at least three times a day and posting each of the photos on social media
  • Chronic selfitis: Uncontrollable urge to take photos of one’s self  round the clock and posting the photos on social media more than six times a day
According to the APA, while there is currently no cure for the disorder, temporary treatment is available through Cognitive Behavioral Therapy (CBT).  The other good news is that CBT is covered under Obamacare.
This is unwelcome news for Makati City in the Philippines, especially for its mayor, Junjun Binay, son of the incumbent vice president.  Makati was recently named selfie capital of the world by Time Magazine. The mayor even organized a ticker tape parade after his city was bestowed the rare honor.

Monday, March 31, 2014


The journey of  Renal Denervation RDN ) begins with a small company called Ardian. Medtronic International acquired the "Ardian company". With that the catheter and the technic of ablating renal artery sympathetic nervous plexuses. This technique was innovated to treat the condition of resistant hypertension.
Initially when the results of Simplicity 1 and 2 were announced, we all felt that this was a promising technique There was hope for our patients with resistant hypertension.
The Europeans were quick to approve this technique, and it was CE mark approved. BUT the US FDA with held approval until the results of Simplicity HTN 3. They felt that Simplicity HTN 1,2 had no controlled arm.
For the same reason I also did not quickly embark on this Renal Denervation ( RDN ) program. I was also troubled that not only was there no controlled arm, there was also noway to know if your ablation was effective. BP response to RDN could lack up till 8-9 mths after the procedure and that 20%  were non responders. So I also waited for Simplicity 3.
Well, Simplicity 3 results were announced by the PIs Dr Deepak Bhatt, at the ongoing Annual Scientific Meeting of the American College of Cardiology, on the 29th March, at Washington. Simplicity HTN 3 involved 535 patients with resistant hypertension and half of them received a sham procedure and the rest of the 50% received the RDN..
Actually, in January 2014, the Medtronic International had already announced that Simplicity HTN 3 had failed to achieved its primary endpoint. This was carried in the Asian Wall Street. Well the full results were announced on 29th March. It showed that Those who received RDN had a 14.13 mmHg reduction in office BP and the controlled arm had a 11.74 mmHg reduction. The difference of 2.39 mmHg was NOT statistically significant. Using 24hrs BP monitoring, those who received RDN had a 6.75 mmHg reduction and the control arm had a 4.79 mmHg reduction. Again, the difference of 1.69 mmHg was NOT significant. So Simplicity HTN 3 did not meet its primary endpoint and so was a negative trial. But all agree that the RDN procedure is safe.
What lessons did we learn from Simplicity HTN 3. Well the most obvious for the scientific community is that we now see negative trials reported and that is good. Secondary, although we call it resistant hypertension, good medical therapy, including intensive monitoring and also life style modification can still reduce BP. Thirdly, that maybe the Simplicity HTN 3 investigators were in too much of a hurry to get results. 6 months maybe too short, in my opinion. Perhaps they should have waited for 9 months or 12 months, to see results. Fourthly, we need procedures that we can know the success of denervation immediately. Others, it is essentially no better than a sham procedure. Moving forward, maybe we may find a use for RDN is patients who have "white coat" hypertension, as these patients are usually very nervous with an over active SNS.
In my discussions with foreign faculties, maybe Medtronic will try and re-promote RDN as a procedure to modulate the sympathetic nervous system of the body for many other nervous disorders.
RDN certainly is not dead and buried. It may have to re-invent itself, and perhaps find other uses.
After the good results with Simplicity HTN 1,2, many other companies ( I counte 6-7 ) have also introduced their own cathers to ablate renal artery nerves. There are also on going trials. I hear that ENLIGHHTN using the St Judes catheter is still ongoing.
A for me, no RDN yet, until with get better results and also preferably, if there is a way of knowing success of procedure immediately, like in angioplasty.

Thursday, March 27, 2014


I still can't get over it. There are more questions than answers. Someone knows, but is not talking. We lost 239 people.
These are some of the salient points that keep going over my head. They were well enumerated by Mr Narinder Singh of the Fee Malaysia Today.
  • We can rule out a fire as well as a mechanical or electrical fault.
  • There was an aviation expert manoeuvring the plane for the entire period.
  • The air turn back was deliberate since the plane maintained a cruising altitude to reach the southern Indian Ocean.
  • All communication tools were disabled on purpose.
  • The turn back was executed during the grey period that the flight passed from Malaysian to Vietnamese air traffic control.
From official statements, we also know the following:
  • The Royal Malaysia Air Force detected the plane on radar but let it fly its course since it was found to be “non-hostile”. The military authorities of other countries, except Thailand, claimed they never detected the plane in their air space.
  • It took five days for the Malaysian government to confirm early data from Inmarsat suggesting that MH370 was nowhere near the South China Sea.
  • In the past week, the Royal Australian Air Force was given full charge of the entire search operation with rather full confidence it had the right leads based on unconfirmed satellite images of two floating objects.
  • The flight captain had a passion for aviation and had assembled his own flight simulator.
From this point onwards, we can expect more assumptions and theories to emerge that would be based on the parameters listed above.
The Malaysian government, on its part, must address the following issues:
The plane went off of all communications at 1.30 am on March 8. Vietnamese air control twice contacted it, but it did not respond. It flew for another 6.5 hours. What were our civil aviation authority and air force doing during this time? Who was alerted and what emergency steps were taken? That must be made public.
During those 6.5 hours, was there in fact some communication between the plane and Malaysian authorities, and the government is keeping this secret because it represented a threat to the nation?
Is it possible that the pilot, a strong supporter of the parliamentary opposition, took the plane and its passengers hostage and demanded the resignation of the government?
If suicide was the motive, a pilot need not fly for eight hours or so. It will be quick. Why fly the plane all the way south at cruising speeds when there is great chance of it being spotted and guided down?
If it was discreetly taken over by a third party with or without the cooperation of the pilots, were demands made and denied by either Malaysia or China while MH370 was air borne?
Although there is official confirmation that the plane crashed, there is no trace of the wreckage and all parties are talking about a “mystery”. Are the various search parties, especially those from the US, Australia and Europe, privy to information that is being kept secret for fear of a backlash, particularly from China?
Malaysia Airlines has not made public the cargo manifest. Why the silence? Could there have been items in the plane that were of interest to a second or third party, and hence the forced U-turn and disabling of all communications whilst private negotiations were going on, with the Vietnamese control tower cut off from following the trail?
Was the plane deliberately brought down by military action after it was hurriedly classified as a great threat to the national security of either Malaysia or one of its neighbours?
What is the outcome of investigations made by the Federal Bureau of Investigation (FBI) on the family of the flight captain and his political links?
It is baffling that bases in Indonesia and even Australia and Diego Garcia missed picking up the plane on their civil and military radars.
Why were there passengers on the waiting list when a Boeing 777-200ER can take at least 300 passengers on board? Who were on the waiting list?
Merely confirming that flight MH370 ended its journey in the Indian Ocean is not enough. Pandora’s box has been open wide. Some of the jittery reporting and statements coming from our official agencies are too glaringly conflicting.
Did MH370 end its flight or did it get ended by some party?

What do you think? What? How? Who? Why?

Tuesday, March 25, 2014


This is the flight that I take to Beijing every year for the last 8 years for CIT.
Board at mid-night, take a night cap, sleep and have the air stewardess wake me up for breakfast at about 5.30 am before arrival at Beijing Capital International airport at 6.30 am. Rush out catch my waiting  transport, beat the notorious Beijing traffic jam, and be at my Hotel at 8 am in time for the morning session at 10am.

Words will not be able to describe how I feel.
God bless you all.
To you and all your loved ones too.