Friday, April 25, 2014


This year, the program will be very interactive ( according to feedback ) with minimal ( only total of 4 ) lectures. There will be 5 sessions of case studies on management of diabetes, CCF, hypertension and dyslipidemia. There will also be self assessments on ECG. The experts will be there to answer questions and queries.
The Pullman Hotel is new, in Pantai Bangsar, and is a 5 min walk from the Kg Kerinchi LRT station.
Please do register early to avoid disappointment. First come first serve basis. Registration is free, either through the PMPASKL website, or through your favorate pharma company. Or let me know.

Thursday, April 24, 2014


It is obvious that Interventional cardiologist deals alot with radiation. All our techniques uses Xrays to help us track what we do and also document our results. Xrays are indispensable to our work. Some of us literally spend hours in the cath lab, next to big Xray machines. Do these pose a danger?
Well we have known for years that interventional cardiologist face cancer problems, back problems, thyroid problem and some blood disease.

Well, at the ongoing SOLACI ( Societad Latinoamericana de Cardiologia interventionista ) 2014 meeting at Beunos Aires, Dr Ariel Roguin ( Rambam Medical Center, Haifa, Israel ), reported on his updates. He had written an earlier paper in 212 on the number of brain tumours in interventionists. Since then, he has received numerous more reports from colleagues on this issue. He now has a series of 36 cases of brain cancers. 86% were on the left side ( the side of the image intensifier for right handers ). 50% of the brain tumours were glioblastoma multiforme, 14% were meningiomas and 7% were astrocytomas.
In this cohort there were 28 interventional cardiologist, 2 electrophysiologists, and 6 interventional radiologist. Some have been doing interventions for 25 years. The annual radiation dose of this cohort was about 20-30 mSv annually.
Well 86 cases is a lot, but I am not sure what the national average is for countries where these interventionist come from. Are these cases in excess of the national average?
I had suffered an avascular necrosis of my left hip ( the side of the image intensifier ) and had atotal left hip replacement done in 2009.

This report is to highlight the fact that radiation is a necessary evil for us, and we should take precaution. Beside gowning with all those heavy lead shield and gowns, we should also take some training perhaps, in radiation education. We surely hope for the day, when everyone is aware, an the incidence. Maybe one day we will be wearing total body suits and also a head gear against radiation.

Monday, April 21, 2014


General Statement 
21 April 2014 


Youth Solidarity Malaysia (SAMM) with state support and the support of the Assembly May 1, 2014 are scheduled to be held by way of a number of locations and 'towards Dataran Merdeka. The main course is from KLCC to Dataran Merdeka. 

The event will start from May 1 lunch at KLCC and will end around 2 pm. The event in KLCC made ​​by a group of organizations that work together to form the May 1, 2014. Perbagai leadership speech events, performances and affirmations labor day. Around 2 pm will move away from 5 points start to accumulate toward including KLCC Square itself. As usual 4 other places is Brickfeilds, Sogo and Masjid Negara. 

SAMM believe everyone involved is playing its best to ensure the assembly is held good by delivering masej and achieve considerable repertoire. 

Labor day 2014 collection with the theme of protest GST, this corresponds to the call of the Prime Minister while presenting a buget and when he mentioned the GST clause would want to see the response of the people. If the amount is large down SAMM believe Najib will cancel the GST. 

The SAMM urge all to make this collection as a manifestation of the people who did not think her voice is heard along termasukkan Malaysians must protest the abuse of the court in denying the Pakatan leaders also imprison Anwar. 

If this regime might follow the script of the last great collection of Anwar and several key leadership with people. 

Authorities hoped to avoid panic not surprising. This process of democracy in which the people gathered out the rights and views. This is guaranteed in the Constitution of Malaysia. 

Take for example the collection of new year's eve, participants entered the Dataran Merdeka and no untoward incident occurred. Everything was going well. Cooperation between authorities and demonstrators. Extremely confident again this cooperation can be done in Assembly May 1. 

SAMM SAMM has mengkerahkan all comrades from all over the country are preparing to join 100 well experienced marshals to help oversee the rally. 
official directive Youth Pass
SAMM congratulate all the brave and responsible organizations in mobilizing their members success of this collection. For example, PAS Youth was officially already mobilizing its youth members. 

Come May 1 with the largest assemblage of people in Kuala Lumpur. 


Youth Solidarity Malaysia (SAMM) 


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.