NEWS FROM ORLANDO : QUALITY OF CARDIAC CARE STUDIES. STRETCHING THE HEALTHCARE DOLLAR

The just concluded American Heart Association Annual Scientific Meeting at Orlando, had an interesting presentation one of the finl sessions.
The clinical trial was entitled EFFECT ( Enhanced Feedback for Effective Cardiac Treatment ) . The results of the trial was presented by Dr Jack Tu of Toronto. The researchers asked for report cards ( process of care indicators ) of 86 hospitals, with about 16,000 patients who were admitted for treatment for heart attacks and heart failure, as regards their medical treatment algorhythms, nursing and medical professional care and supporting staff quality of care. Basically how treatment was being administered. Then they have a repeat assessment one group after two years and the other ( control group ) after four years. These reports cards were made public. What they found was that with this yearly assessment being made public, the standard of care improved and more patients received treatment faster and better, therby reflecting better outcomes.
I was very taken by this study as it would allow us, if we wish to improve and stretch our healthcare dollar, to also, without much additional cost, do the same. Have a public report cards for selected hospitals ( public and private ), to start, to see the standard of care. I am confident that once the report cards are made public, people all along the line will pull up their socks and improve. This will be to the betterment of patientcare and stretching the healthcare budget. Of course I can see resistance all the way, but using the government initiative to assess government ministries by KPIs, the ministry of health can also do the same.
Unless there are some who are afraid of report cards.

SAD NEWS FROM ORLANDO. IT ALSO HAPPENS IN USA

This is a not so good news from the on-going American Heart association Annual Scientific meeting at Orlando, Florida.
A senior cardiologist from the Brigham and Women's Hospital, Boston was out jogging yesterday morning when he was knocked down by a car, and died. So sad and tragic.
I do not know Dr Kenneth Baugham personally, but I am saddened by the untimely death of a colleague who was doing what he was preaching. Early morning exercise is good for the heart.
My condolences to his family and love ones.
I also want to ask those who exercise in the morning to take due care. There are just too many motor vehicles ( motor cycles and cars ) on the road nowadays. When I do have the time ( like during my recovery from hip surgery ), I would walk at the opposite side of the road ( counter-flow to traffic ), wear a bright coloured shirt. Nowadays, they have flourescent reflectory shoes, and always keep on the edge of the road. When you have to cross road junction, be extra careful. Hopefully, you will chose an area where the traffic volume is low, or just a playing field. Aways remember that you are on an exercise program, and time is not an issue. Don't rush as that will make you make hurried decision. Let the cars pass and take your time.
In our context, you also have to worry about snatch thieves. Hopefully, we are all jogging without a large amount of money on us. As I am near my home, I do not carry any purse, money or IC. I felt it safer.
Remember, prevention is better than cure. Please take due care.

NEWS FROM ORLANDO : PEP-CAD - 3

There are some of us who no longer visit USA following the US response to 9/11. Anyway, the American Heart Association is meeting in Orlando, Florida, this week for their annual scientific meeting. So we should hear a few relevant updates on Interventional Cardiology, this week.
One of the earlier paper presented yesterday was PEP-CAD-3. For those of us in interventional cardiology, PEP-CAD will stand for " Paclitaxel-Eluting PTCA Balloon Catheter in CAD. This is the third trial in the series, and it compares the use of the paclitaxel-eluting balloon followed by placement of a bare-metal stent ( the BBruan Coroflex cobalt-chromium bare metal stent ), against the CYPHER ( sirolimus-eluting stent) in the treatment of CAD. The cohort of 609 included patients with stable or unstable angina pectoris, with documented ischemia, randomised into the DEB/BMS ( drug-eluting balloon / bare metal stent ) group Vs the CYPHER group, on a non-inferiority comparison. The end-point being angiographic follow-up with measurements of lumen late-loss ( LLL ) and target lesion revascularisation ( TLR ). The investigators were very brave to challenge CYPHER. I suppose when they compared their DEB ( drug-eluting balloon ) against the Taxus stent ( paclitaxel-eluting stent ), in PEP-CAD-2. they came out better, and preliminary animal work supports that the DEB/BMS combination will not be inferior to CYPHER.
Well, they were surprised. After 9 months follow-up, 542 of the cohort underwent coronary angiography and this should that the DEB/BMS combination was inferior to the CYPHER stent for treatment of ischemia proven CAD. The late loss was better with the chpher stent and the TLR was much less with the cypher stent.
I suppose, PEPCAD-3 only serves to show that the first generation cyper stent is still a very good stent. With in-segment late loss of 0.16mm and angiographic TLR of 4.7% after 9 months, is very good.
I was hoping ( I have been talking to my friend Dr Martin U who was doing this piece of work for BBruan ) that the DEB will come out good as it would mean that I do not have to use so much drug coated stents. But it is not too be. Presently, I do use the DEB to treat in-stent restenosis, so that I do not have to place a metal across another metal ( if I were to use a DES ).
We will have to think again as to why DEB/BMS failed to best cypher. Afterall, some of the second generation DES have already been pproven to be non-inferior to cypher.
I suppose, that is why we do clinical trials, so that we can see how ur theory pens out. Animal experiments are necessary, but clinical trial results, properly conducted is also indispensible.

SERUM CHOLESTEROL ESTIMATION ; TO FAST OR NOT TO FAST?

We are all excited about cholesterol because it is a link to heart disease, and that may cause heart attacks and death. All that is true. However, that link must not be taken as religious truth ( I hope that there are still religious truths out there ), so that we live in " the cholesterol fear ". I would like to begin, by emphasizing that serum cholesterol levels, and in particular, the LDL-C ( low density lipoprotein cholesterol, or otherwise called the bad cholesterol ) levels, are correlated with the chance of developing heart artery disease. I reiterate, high LDL-C levels does not equal heart artery disease. It is correlated ( it is a risk factor ) for developing heart artery disease. It is important to note that 40-50% of people who have heart attacks, have normal cholesterol levels, at the time of their heart attacks. I emphasize this because many who consult me, virtually live in fear of cholesterol. When they are told by their GPs that their last blood cholesterol levels are elevated, they feel that they already have blockages and are going to die. That is simply not true. If your blood cholesterol levels are elevated, you maybe at risk of heart artery disease and you should try and bring it down ( so that you reduce your chances of getting heart artery disease ). That is reasonable. But there is no need to " freak-out ".
The issue I wish to raise today is whether it is necessary to have a 12hour ( or 10hours, as some would prefer), fast before taking your blood for cholesterol estimation. Is that an important pre-requisite. That had been the teaching from the very beginning, when we realised that blood cholesterol levels were related to the possibility of developing heart artery disease. This was firmly established for us in the mid-fifties by the Framingham and MRFIT studies. We rationalised that as food affects blood cholesterol levels, we should fast to try and standardise the levels. That made sense. However, we also know that some patients turn up for checkups, without fasting, and should we ask them to return, we may miss the opportunity of detecting his risk to CAD. Should we take his blood ( non-fasted) anyway, and is it accurate enough for clinical decision making?
The latest issue of the Journal of the American Medical Association carried a 68 years survey of 300,000 thousand patients, over 21 countries ( study was led by the research workers from Cambridge ), and found that there was no significance between fasting cholesterol levels and non-fasting cholesterol levels. There were however some difference in the serum triglyceride levels and therefore the levels of the LDL-cholesterol. This is not difficult to understand, as the LDL-C is a lipoprotein and will have fats ( triglycerides ) bound around it, to allow it t swim in the blood stream. These fats. which are triglycerides are easily affected by the ingestion of food and what types of food at what time. So on the one hand, yes, blood cholesterol levels are not really affected by the state of your stomach, but no, the important risk factor, LDL-C can be affected by the state of your stomach. It is also important to state that in commercial estimation of LDL-C, this LDL-C is a derived index. We do not measure LDL-C itself ( this is possible in the research labs. ), but we calculate it from knowing the cholesterol and triglyceride levels. And this calculation can be affected by the levels of triglycerides and this triglyceride levels could be affected by food.
In short, if you wish to have an accurate cholesterol or lipid profile done, it is better to fast, at least 10hours.
As a compromise, one could always do a spot ( non-fasted ) blood lipid profile,and should it be abnormal, then repeat it, truely fasted. Of course, that means two pricks with the needle, two cost and two test.
In my practice, I would rather have the blood taking in the fasting state, for proper heart artery risk profiling.

OBITUARY : SYMPATHY AND CONDOLENCES

I have just read that Dr Donald Baim, died on the 6th Nov from cancer of the adrenals.
Dr Baim is a prominent innovative cardiologist with a very sound clinical mind, not prone to "Hollywood" type endorsements and presentations. He is of the vintage of Dr John Simpson, a renown innovator after balloon angioplasty was discovered. He help to bring to fruition many of the devices. In the later part of hid carreer ( 2006 ) he left the ivy league Harvard, to join Boston. I never could understand why.
I would like to record my deepest sympathy and condolences to his family and loved ones, as the world has again lost an innovative and yet very clinically minded cardiologist.
God rest his soul.

LOW CHOLESTEROLS AND CANCERS

I have always have to niggling feeling that when you lower someones cholesterol too low, you are bound to have a consequence. For a longtime, I felt that the consequence was a higher incidence of cancers. I reasoned that God had given us cholesterol for a good reason ( and not to cause atherosclerosis ), and removing cholesterol drastically will upset the cell cycle. We do need cholesterol for cell wall formation, for hormonal production and for maturation of brain cells. There were some earlier studies, including the Atromid S studies, that seemed to show a relationship between lowering cholesterol and cancers. Even studies as recent as the SEAS and ENHANCE seem to suggest that too. However, non of these studies were conclusive for the association of cholesterol and cancers. But the lingering doubt was always there.
In the online edition of " Cancer Epidermiology, Biomakers and Prevention ", there were too studies publish which showed some relationship, but again were non conclusive.
Dr D.Albanes and colleague from both sides of the Atlantic conducted the " Alpha Tocopherol, Beta Carotene Cancer Prevention trial ". This trial was jointly sponsored by the US National Cancer Institute and the National Institute of Health and Welfare of Finland. They followed up 29,093 males who were smokers from 1993-2003. In those 10 years, there were 7,545 cases of cancers. They reported that there seemed to be a corelation between lower incidence of cancers in males with lower levels of total cholesterol. There was also a lower incidence of cancers in those with higher levels of HDL-cholesterol. That's interesting. There seemed to be no corelation between LDL-cholesterol and cancers, in this study.
Dr Elizabeth Platz and colleagues from the John Hopkins reported on the " Prostate Cancer Prevention Trial. They followed 5,586 males above 55years prospectively over 3 years and noted 1251 cases of cancer of the prostate of various stages. They found no corelation between pprostatic cancers and serum cholesterol.
So basically, we are left with a strong suspicion but nothing conclusive. In fact, one conclusion that one can draw is that the sudden lowering of serum cholesterol in some patients may not be just good " statin " effect, but rather an early sign of cancer. Is this possible?.
Be that as it may, I always believe that extremes are bad. Ultra low cholesterol, although favoured by pharmas producing cholesterol lowering pills, may not be a good idea. A moderate lowering is what I would advocate. The small percentage less heart attack gain ( if the numbers are true ), may not be worth the risk of cancers. Moderation in life has always been our philosophy.

CABG, TO PUMP OR NOT TO PUMP?

When I was in training, coronary artery bypass surgery ( CABG ) was at its infancy and we were so excited that we could stop beating heart and attached good venous conduits on to the affected coronary artery, creating a new channel and restoring full or even supra-full blood flow. The we began to see that the venous conduits ( the veins from the legs ) were convenient conduits, but tended to re-occluded. You see when God made the veins for us, He made it to withstand pressures of 5-10 mmHg pressure. When Dr Rene Favaloro taught us to attach the veins to the arterial system, it had to take the pounding of the arterial blood pressure, which is most situation was 120-140 mmHg systolic. So the venous conduits hardened, and re-occluded. re-operations became hazardous. Then Dr Green and colleague began to start using the left internal mammary artery as the prefered conduit for bypassing the vital LAD ( left anterior descending artery ). This was great. The LIMA graft lasted well ( artery-artery ) and allowed CABG to have good outcomes. Only venous graft by-pass must have died with the late Dr Victor Chiang ( God rest his soul ), a great cardiac surgeon with very good venous graft results. He always say that the venous graft patency is not only a function of the blood pressure that it is subjected too, but also to the technique and skill ( atraumatic technique ) in harvesting the venous graft. His fellows are all well trained for that.
Then some physicians noted that some patients post-CABG seemed to develope some cognitive disorders. They began to say the wrong things, have a change in mood ( mood swings ) and also became forgetful. They wondered whether this was due to the use of the heart-lung machine used to maintain the circulation, while the cardiac surgeon was working on the non-beating heart. ( Tubes divert the normal circulation to the heart-lung machine to oxygenate the blood, remove the carbon dioxide, through filters, and then return in purified blood, back into the circulation. Basically it the machine takes the place of the heart and lungs ). The prevailing thought then was that the heart-lung machine maybe allowing particles to circulate to the brain causing the cerebral cognitive disprders, seen post-bypass. It could also be that when the cardiac surgeon cross clamps the aorta, to stop the circulation and divert it to the heart-lung machine, debris could be thrown off by the action of the cross clamp.
This gave rise to some American cardiac surgeon experimenting with a technigue of trying to do bypass surgery on a beating heart. They began to develop equipment and technique to minimise the force of contraction of the beating heart to allow them to sow on the venous or arterial conduit. They were able to develop clamps that will stick on to portions of the heart to stop the heart beating, focally, so that they can sow. One must also understand that this was also at an era of " minimally invasive surgery" to try and improve the pain in surgical procedures and also the cost. Patients were told ( without much clnical data to start ) that off-pump ( or beating heart ) surgery was just as good as standard on-pump bypass surgery ) with a smaller scar, less mental disorders post bypass, and less days of stay in hospital. This looks like wishful thinking, on almost no clinical data.
Well, then more and more studies comparing on-pump and off-pump surgery began to emerge with some countries ( like Canada ) keeping long-term registries. It became clear, that many of the claims were flawed. It is true that the operation scar was smaller, and the length of hospital stay was shorter. But it was not true that off-pump CABG was as good as on-pump CABG.
The latest study, reported in New England Journal of Medicine, 5th Nov 2009, again added to the growing body of evidence. Dr L Shroyer and colleagues studied 2,203 patients who underwent bypass surgery ( half had the CABG on pump and was compared to the other half who received CABG off pump. The study is called ROOBY ( Randomised on / off bypass ) study. Aftre 1 year follow up, they found that there was no difference in cerebral cognitive impairment between the two groups and also that those who receive the off-pimp technique, tend to have fewer graft ( because it was more technically challenging to graft with a beating heart ) and after 1 year, more of the grafts in the off-pump group were occluded, compared to those done on-pump. To be exact, at angiography at 1 year, 87.8% of the grafts in the on-pump group were patent, compared to 82.6% in the off pump group. Also, at one year 36.5% of the grafts in the off pump group were occluded compared with 28.7% in the on-pump group.
This is not at all surprising as sowing on a beating heart is also less exact, and tended to be associated with pooere graft placement, and so more re-occlusion.
Well one thing is for sure, working on a non-beating heart ( on-pump) allows better control and more precise surgery ( that makes sense ) and working on a beating heart makes surgery less precise, with all the attendant problems.
As a spinoff from this tudy ( I cannot resist saying this ), it is good to know that at 1 year angiographic follow-up, 28% of grafts are blocked. As an interventionist, we always tell our patients that angioplasty is associated with the problem of restenosis, which can occur in 20% of our patients post PTCA, and with the use of Drug Eluting Stents, restenosis occurs in less than 5%. We are not doing so badly after all. CABG also has restenosis ( not so often stated ), in the first year. That is another issue to be dealt with another day.