Thursday, October 23, 2014

IS VIAGRA GOOD FOR THE HEART?


Viagra is a popular drug, frequently used in Malaysia as treatment for erectile dysfunction. That is the medical indication. However, many young men are using it as a tonic for sexual enhancement.
Now, they are asking , if I should take Viagra often ( chronically for some ) will it harm my heart.
Well, a recent study by the Italian group seemed to suggest that it surely does not harm the heart but in fact may help the heart. It that true?
This issue was highlighted in the lay press recently showing that it is of public interest. So I thought that I should have a look at it.
The study is an Italian one, published in the BMC Medical, 19th Oct 2014. The Article is entitled " Is chronic inhibition of Phosphodiaesterase Type 5 cardioprotective and safe? A meta-analysis. This Italian group from the Sapienza University of Rome, went into the medical data base of Medline and Embase to look over 24 RCT involving PE 5 inhibitors usage from 4 weeks to 1 year, where cardiac indices were also measured. There were 1,622 patients deemed suitable. 954 were on PD 5 inhibitors and 772 were on placebo. They were enrolled from March 2012 till Dec 2013.The indications for PD 5 usage was not clear. They researchers only wanted all patients to have placebo control and also to have taken PD 5 inhibitors chronically. Most of the patients were taking sildenafil citrate ( viagra ). Fewer were taking Levitra and Cialis.
They concluded from their meta-analysis ( which had a lot of statistics ), that PD 5 was safe to use chronically. That there was some improvement in LV function indices, that it helped the heart with LVH to remodel better, that with usage in patients with heart failure, the pro-BNP estimation improved, and there was also better peripheral vasodilation.

So I had a look at the paper. It must have been a big ask to take so many diverse study and try and match them together. There were many variables. I did not know how the investigators were able to analyse the data coherently. Yes, there was improvement in LVEF but it was in the region of 3-4%, and they were using echocardiogram as a means of determining the LV function. Surely, 3-4 % may not be significant. The methodology to measure vaso-motion was not detailed.
All in all, in my opinion, a rather weak study, using statistics to mesmerise us. Drawing big poster concusions based on rather flimsy data.

I am quite sure that it is safe to consume PD 5 inhibitor chronically but remember NOT to use it together with GTN. If used chronically, it may reduced Pulmonary artery resistance and improve RV function somewhat. As for improvement in LV function, we should take that with a large pinch of salt.

To be certain, we will have to wait for more data, and more evidence.

Friday, October 17, 2014

LAWYERS WALK FOR PEACE

Yes, I was out there yesterday to join and also assist in the Bar Council organised, "Lawyer's Walk for Peace ". We were there as supporters as well as to provide Medical cover as a Medical team on duty. I manage to enrol about 4 others. There were five of us. I had also got the assistance of Mr Genta ( SJA ), so there was also an ambulance on standby.

I when down to Masjid Jermak by LRT, and walked to Padang Merbok. Somehow managed to take the wrong road up the hill and so was lost for a while. So it tok me longer than anticipated to reach Pdg Merbok. I managed to reach there at about 11am just before Mr Christopher Leong started his address. It was a bit hot, and I had forgotten my golf cap ( stupid me ).

At the peak of the gathering, I think there were about 1,000 mainly lawyers with some people in civilian clothes. The lawyers' response was indeed heartening. Some were from Pahang and Johore Baru. Even before we started to walk to Parliament, there was a medical alert for a "collapsed" patient. I went to have a look. The most senior member of my medic team had felt dizzy like near faint. He had no breakfast and so we got him some sweets and fluids and that took care of that.
We started to walk at around 12 noon, I think. Up the hill to Parliament house to hand a memorandum to the PM. I understand that the President and 9 members of his council met with Datuk Mah and handed the memorandum to Datuk Mah for PM. The delegation of 10 returned at around 1pm.
By that time, there were 2 more near faints.

We dismissed at about 1.10pm and I returned to LRT and train back to Subang Jaya. Wonderful but tiring morning.
#MANSUHAKTAHASUTAN

Wednesday, October 08, 2014

THE FPMPAM HEALTHCARE WISHLIST - BUDGET 2015

THE FPMPAM HEALTHCARE WISHLIST - BUDGET 2015
Kuala Lumpur, 8 October 2014 - In view of the upcoming announcement by the
government on the 2015 Budget, the Federation of Private Medical Practitioners’
Associations Malaysia (FPMPAM) has circulated its wish list for healthcare for 2015. These
are as follows:
1. Put more money in Rakyat’s healthcare
We urge the Government to increase the Healthcare allocation in the budget to 6% -
7% GDP.
With the increased allocation, the Government should strengthen the primary care
system by increasing the level of Private / Public integration via outsourcing care of
out-patients with chronic illness from the public hospital outpatient clinics to the
private primary care clinics (in the same vicinity) for follow-up treatment. All private
primary care, GPs and family practitioner clinics should be invited to take part in this
program. The present one-stop prescription and dispensing system in private clinics
should be continued as it is patient-friendly and cost-effective.
Likewise, for patients requiring surgery and procedures, if the wait list in the public
hospitals is too long, these patients should be referred to local private healthcare
facilities instead of being sent overseas.
Rationale: This will allow a shorter waiting list for public out-patient clinics. Shorter
waiting time is patient-friendly, allows better patient-doctor interaction and translates
as improved productivity for both the patient and the healthcare system. Referring
patients to local private facilities will save time and cost and strengthen local
expertise.
2. Designate healthcare services as GST zero rated.
Rationale: Healthcare is a right of the rakyat. The sick is already suffering from the
ravages of ill-health and should not be taxed.
3. Do not privatise public hospitals and public healthcare clinics
With the current escalating cost of living, we urge the Government to abide by its
promise made two elections ago, not to privatise the public hospitals and public
healthcare facilities. Privatisation of public healthcare facilities will only further worsen
the situation and gravely affect the safety net for healthcare for the lower income
groups and those not who are not insured.
Rationale: The provision of this safety net allows for affordable and universal
accessibility of our healthcare system for this sector of the population and should
remain as the responsibility of the Government.
4. Control Healthcare Cost by implementing the following:
i) Implement immediately a schedule for hospital fees
Escalating hospital fees are a major cost in increasing healthcare cost. There is at
present no laws to regulate the hospital fees and the fees of commercialised
healthcare services. It is escalating by leaps and bounds since 2000. We urge the
immediate implementation of regulations to require all private hospitals to declare
their fees for their index 50 hospital procedures.
Rationale: This will allow initiation of some form of containment of private hospital
fees with the eventual target of a schedule for hospital fees. This hospital fee
schedule is vital for the long-term viability of the system.
ii) Enforce Pathology Laboratory Act 2012 to control unregulated
health screening and medical tests
We urge the Government to immediately enforce the Pathology Laboratory Act.
Unnecessary blood tests and health screening, random wellness checks by
business-driven private laboratories and business entities must be regulated. All
these must be compliant with the Pathology Laboratory Act, the Private Healthcare
Facilities and Services Act (PHFSA) and all other laws to stop the current trend of
unnecessary tests.
Rationale: Unnecessary medical tests and health screening is a big business.
Unfortunately it is a health and moral hazard. An independent registered medical
practitioner assessment, preferably by the family doctor, must be required before any
test is allowed to be done. All such tests should only be ordered by a registered
medical practitioner based on patient’s health needs and the doctor must have no
vested interest in the investigating facility.
iii) Regulate the middle-men in healthcare
We urge the Government to immediately implement and enforce regulations in the
PHFSA 1998 to regulate this business of medicine. No such regulations exist to date.
Rationale: Middleman services are draining away patient’s healthcare money at
source. This affects simple taken-for-granted items like medical examination, seeing
a doctor when one is sick and now, even the dispensing of medicines. Eventually the
terms and conditions of the middleman and not the doctor will end up determining the
care of the patient.
This business is unregulated and many such entities have come and gone leaving
patients and doctors with millions of ringgit of unpaid bills. If this is allowed to
continue, the private healthcare system will eventually be broken beyond repair.
iv) Enforce the Medical Devices Act 2012
The use of medical devices should be in the hands of properly trained registered
medical practitioners and in a medical setting. The Act has been passed in
Parliament but yet to be enforced. To avoid a conflict of interest, doctors teaming with
entrepreneurs to own high end equipment must also declare their interest.
Rationale: These devices are capable of inflicting damage and injury when used by
unauthorised individuals and is a danger to the sick and the suffering
v) Implement Alternative Dispute Resolution for Medical Mishaps
We urge the Government to urgently implement the Alternative Dispute Resolution
for medical mishaps.
Rationale: The current system of resolving medical mishaps occurring for whatever
reason takes too long and is not fair to the patients. The system is already backlogged
by many existing cases. The increase in new cases both in the private and
the public sector is expected to worsen the situation. At the end of the day the overall
cost of healthcare escalates as reflected by increasing medical indemnity fees,
increased defensive medicine and increased absolute cost of provision of care.
ADR for medical mishaps is a proven system worldwide which lessens the need for
expensive long-drawn court proceedings.
5. Set up Multi-Agency Dengue Task Force in every State Health Department
We urge the Government to set a target to control Dengue Fever incidence by 50%
in year 1, 60% in Year 2, 70% in year 3, 80% in Year 4 and 90% in year 5. Target
reduction in Dengue mortality by 75% in year 1, 80% in year 2, 90% in Year 3, 95%
in year 4 and 99% in year 5
Rationale: The Dengue epidemic has gone on for too long. It is a major disease
burden and is taking away too many lives. It must be controlled and we must be more
focussed. The Dengue Task Force must be empowered to inspect all sites posing a
Dengue hazard and empowered to take all necessary measures until a particular
Dengue hazard is rectified. It is clear that present enforcement measures are not
effective in construction sites and areas under the jurisdiction of local authorities.
Dr Steven K W Chow
President
Federation of Private Medical Practitioners’ Associations, Malaysia

FPMPAM DOCTOR'S DAY IN IPOH. 10th Oct -

INAUGURAL DOCTORS’ DAY 2014 KICKS OFF WITH BLOOD AND
ORGAN DONATION DRIVE
Kuala Lumpur, 30 September 2014 – Malaysia’s first ever Doctors’ Day will kick off on the
10th of October this year with a blood and organ donation drive at a Community Service
Project to be held at AEON Ipoh Garden, Ipoh. Malaysia’s inaugural Doctors’ Day is
organized by Federation of Private Medical Practitioners’ Associations Malaysia (FPMPAM),
the Perak Medical Practitioners’ Society (PMPS) and the Malaysian Medical Association
(Perak) with the collaboration of the Jabatan Kesihatan Negeri Perak.
To celebrate this milestone event for the medical community in Malaysia, the FPMPAM has
organised a short weekend retreat in Ipoh for doctors, their families and guest. Further
details and updates will be posted on the Federation website and Facebook.
Besides the Community Service Project, a whole host of other activities have been
organized including a full-day free medical screening health camp manned by volunteer
doctors. Members of the public are also invited to a public forum focussed on “Stress &
Drugs” at the Ipoh Specialists Centre conducted by two experts, Mr. Chris Sekar, Certified
Addiction Therapist and Consultant Psychiatrist Dr. Esther G. Ebenezer. Admission is free.
The main event is the Doctors’ Day Gala Dinner to be held on 10 October at the Ipoh City
and Country Club. At this dinner, the Doctors’ Day Awards will take place where the
FPMPAM will present awards to doctors who have dedicated their life in service of the
community and medical education.
Dr Kamalanathan Raju, President of the PMPS and Chairman of the Organizing Committee
for Doctors’ Day, adds, “Doctors’ Day is especially dedicated for the medical community and
the public to reflect on their present doctor-patient relationship and to share their views of
what the future of Malaysian healthcare would likely to be as the year 2020 approaches”.
According to Dr Steven Chow, President of the FPMPAM, “Doctors’ Day has been
celebrated in many other countries in Europe, the United States and India. The time has now
come to celebrate Doctors’ Day in Malaysia. The date 10 October was chosen as it
represents precision – ten out of ten. Doctors are expected to give their ten out of ten each
and every time they see a patient – it is the professional duty that they owe to their patients.
This Doctors’ Day, those interested to show their gratitude can send a simple card, a kind
note of appreciation or simply wish their doctors on the special day. These simple gestures
can go a long way to strengthen the doctor patient relationship”.
Doctors’ Day is also a day for the public to express the importance of a harmonious patientcentred
therapeutic relationship which places the patient’s interest at the forefront. “We are
of the view that public policy on healthcare must be determined by public consensus.
Commercial forces should not be allowed to shape this policy. Patients and public are invited
2
to post their questions and views on the Federation’s Facebook. All these will be collated
and brought up by the Federation in the next stakeholders’ meeting on Malaysian
Healthcare” Dr Chow adds.
Commenting on the introduction of Doctors’ Day, Dr. Steven Chow shares, “Healthcare in
Malaysia has come a long way. We have a good cost-effective system that have won
praises from healthcare experts at home and abroad. The doctors, nurses, pharmacists and
all the other healthcare professionals are the backbone of this system and due effort must be
made to appreciate their contribution and sacrifices. We hope that with the introduction of
Doctors’ Day, all Malaysians will join with us and voice their views on how to make this
system even better and more patient-centred”.
For more information on Doctors Day or initiatives introduced by FPMPAM, please visit
www.fpmpam.org or https://www.facebook.com/fpmpam.

Thursday, October 02, 2014

A Doctor Accuses His Profession of Dangerous Dishonesty

This article appeared in the ASIA SENTINEL today, written by 
                                                                              Written by Shobha Shukla and Bobby Ramakant

I find that what is written is quite true even in Malaysia. Please read and enjoy. My profession is very corrupt.

The international medical profession is witnessing its worst decay, according to. Dr Peter Gotzsche, Director of the Nordic Cochrane Centre and a Professor at the University of Copenhagen, in a searing interview with Citizen News Service. 
"There is a lot that needs to change in healthcare,” Gotzche said. “It is one of the most corrupted sectors in society. In Denmark, for example, we have thousands of doctors who are on industry payrolls - they are consultants, they sit on advisory boards - but in reality it is a soft form of bribery because if you do not behave as expected you will no longer be on the payroll." 
Gotzsche, speaking at the sidelines of the 22n Cochrane Colloquium, is one of the sanest voices in a medical fraternity striving hard to bring evidence-based medicine, ethics and integrity back into fashionThe Cochrane Collaboration is an independent charitable international organization named after Archie Cochrane (1909-1988), a British epidemiologist who advocated the use of reliable evidence from randomised controlled trials in informing decisions about healthcare. The 22nd Cochrane Colloquium was held in Hyderabad sept. 21  to Sept. 26. 
Normalization of practices that stink of what he called “soft bribery” such as gifts, incentives or other financial favors from pharmaceutical companies and other medical manufacturers to medical professionals is a slap on the face of medical ethics, he said. The conflict of interest between pharmaceutical companies/medical manufacturers, and public health is seldom made evident. 
"This contributes to using expensive drugs, or at times using drugs that are not totally rational, or even using drugs instead of thinking of other evidence-based treatments,” he continued. “This has been well documented. I have tried to change attitudes towards accepting industry money. We should learn to say, 'No, Thank you'.".
Not just corrupted, but medical practices are often not evidence-based. Despite strong evidence pointing to the contrary, they remain popular as some strong opinion makers in medical field keep propelling them. Despite the Cochrane review showing that directly observed therapy for anti-tuberculosis treatment has no edge over self-administered therapy, there was no hesitation in aggressively promoting what we knew will not give any better results. 
Similarly mammography screening for breast cancer remains popular despite research evidence pointing against it.
"We have done research on using mammography screening for breast cancer for over 15 years and have documented that mammography screening does more harm than good.” Gotzsche said. “I am only waiting for the first country to stop mammography screening in wake of the existing strong evidence. We found that mammography screening leads to 50 percent over-diagnosis. All these additional 50 percent of women diagnosed with breast cancer (which probably they do not have) are just harmed by getting a cancer diagnosis. Many times we have found that breast disease disappears by itself and it would not have bothered many of these additional women who got detected by mammography screening.  
Radiotherapy is very good for use against dangerous breast cancer not detected by screening, he said.”But when we use radiotherapy on healthy women we kill some of them through increasing their likelihood of developing lung cancer, heart disease and other cancers.  Radiotherapy is lethal when we use it on healthy women." 
Mammography screening does not seem to have any mortality benefit because even if it had any effect on breast cancer deaths, the increase in deaths due to treating additional 50 percent over-diagnosed women far outweighs any benefit. 
"We also have false positives if we use mammography screening for breast cancer. If we screen 10 times for over 20 years, a quarter of all women will get at least one false positive diagnosis. What my colleagues at Copenhagen found was that even three years after false positive diagnosis, the women are still worried and anxious about it, and their anxiety lies between those who have breast cancer and those who were told that everything is fine on screening. So we should factor-in the psychological harm that hits one quarter of all women who go to such screenings. Also it is likely that it has no mortality benefit. Mammography screening is definitely harmful and it should definitely be stopped."
Is this another manifestation of gender-based inequalities in our patriarchal society? 
"It is a gender issue too. Males have been honestly informed that screening for prostate cancer is a very bad idea because there is no evidence that it has any benefit. We do not do prostate cancer screening in Europe but women have never been honestly informed about harms of breast screening. They have just been told 'come to screening'. This is a patronizing attitude that I do not understand but which women have accepted."
There is no additional benefit from general health checkups, he said. 
"People think general health checks are like sending your car for servicing every year. But it is not the same because human beings can heal themselves at times which a car can never do,” Gotsche continued. “We did a Cochrane review on general health checks and to our big surprise there were actually a number of very large trials out there. When we analyzed them we found that it does not work at all and does not decrease mortality. It leads more healthy people to get diagnosed that would not help them, but that might harm them. Because of our review Danish government decided not to introduce general health checks."
He added: "We were in a fortunate situation because the new Danish government had plans to introduce general health checks and then it is much easier to say 'no' when you have the evidence. Whereas in the UK they had introduced general health checks few years back and they did not pay any attention to our reviews which came later -- because that is how politics is –- when you have introduced something like that it is almost impossible to stop it again. Issue of general health checkup has come up again in Denmark because soon we will have general elections. 
The UK’s health minister has not paid any attention to the Cochrane review based upon evidence from 240,000 individuals, he said. “The whole idea is political – as it is popular to offer something to the population that they think will help them. This can give them votes. We have reacted strongly citing strong evidence against general health checks."
gOTSZCHE  and his PhD students were the first in the world who got access to unpublished clinical studies at the European Medical Agency - no one had ever got access to such studies anywhere in the world. The agency. He said, wouldn’t give them access because they wanted to protect commercial interests. 
Our health authorities do not think about protecting patients but they think about protecting the health industry, which is very bizarre,’ Gotzsche said. “We complained to the European Ombudsman and the process took three years, after which the European Ombudsman accused the European Medical Agency with maladministration. Then they needed to do something and they changed their policy and we got access."
He is also  working in the European parliament trying to influence the European trials directive, giving him access to much more data from all trials from 2016. 

Monday, September 29, 2014

CURRENT STATE OF HEALTH THERAPIES AVAILABLE FOR PATIENTS AND CONSUMERS ( besides conventional, evidence based medicine- EBM ).


I was asked to reply to an article that appeared in the Star yesterday entitled " The Art of Dispensing Drugs".

This is what I wrote. I would like to post it here.

INTRODUCTION
There are currently 4 forms of heath therapy.
1.       Firstly there is Evidence Based Medicine ( EBM) . This is commonly called western medicine,  which has been extensively studied, has a lot of clinical data, with set training programs ( undergraduate and post graduate ) and with clinical practice guidelines for their use.
2.       Secondly there is alternative therapy. This refers to the use of approaches that are not part of EBM medicine but is used  as replacements for, rather than complements to, EBM.
3.       Thirdly complementary medicine. This refers to a group of diverse medical and health care systems, practices, and products that are not generally considered to be part of conventional medicine ( EBM ).  This Complementary Medicine is often  practiced by holders of M.D. (medical doctor) or D.O. (doctor of osteopathy) degrees and by their allied health professionals such as physical therapists, psychologists, and registered nurses. . Complementary medicine includes natural products, such as dietary supplements, herbs, and probiotics, as well as mind and body practices, such as meditation, chiropractic, acupuncture, and massage. This form of therapy is very common and is often used together with ( complements ) evidence based medicine.
4.       Fourthly, there is integrative medicine. Integrative medicine combines conventional and complementary approaches in a coordinated way.
      Number one we all know well and has proven itself to be safe and largely effective ( except for a few exceptions like certain malignant diseases.  As EBM physicians, we all have taken an oath that we will first do no harm, and so EBM is largely safe. Although it is true that we comfort always, relief often and cure sometimes. Sad to say, in this day and age, there are still many conditions that we do not yet fully understand, and some we cannot cure.
      Number 2, I shall dismiss by just reminding that it should NOT be undertaken except with advise from trained professionals, because it may do harm. Stage 1 Ca Breast, which in this day and age, is curable, may be fatal, if proper therapy is delayed because of the use of alternative therapy.
     Number 3 is where we will spend some time discussing.
Complementary medicine
This is gaining much popularity because it is often perceived to be safe with no side effects and since the marketing of these therapy is not regulated as strictly as conventional medicine, the advertisements are often too good to be true. Nonetheless, worldwide, there is an increasing trend. It makes money.
A few important  points must be emphasized and consumers are advised to take note.
  1. Firstly, this market is very poorly regulated. Any registered company  can manufacture and market a product.  Before we dwell into the issues of effectiveness ( clinical efficacy ) let us spend some time on safety standards. There is little  oversight  during the stage of manufacture. ( good example can be found in milk powder manufacture in China ). There is some oversight when it comes to the Ministry of Health  for approval. Besides paper documentation, there is also batch testing of the drug and also random testing post approval. However, as often the case, for batch testing for approval by the Ministry, the company will very likely follow  all the procedure but as for random batch testing, your guess is as good as mine. Thereafter, we depend on adverse reaction reports for the seller and customer.  Again, your guess is as good as mine. So there is a big question mark over safety. There have been many who have suffered renal failure, liver failure, occult malignancies, and of course, allergies with these medications. In some ways, all these batch testing steps are easier when you are dealing with chemical compounds known to science. What about those herbal preparations which appear in almanacs and past me down records, where the chemistry department do not even know how to analyse the main ingredients. How then can you predict the effects and side effects? How then do you know it is safe when we do not even know the herbal compounds?. Some like “cordiceps” we know. There are so many that we have no idea.
2.Secondly, there is the issue of effectiveness. Obviously, complementary medicine have almost no clinical data. No one will invest in doing medical trials on complementary medicines, because they cannot be patented. Many of these complementary medicines are natural  products  and belong to nature.  So if you try to do a clinical trial on a certain product, that you cannot patent, ( after spending millions and you prove  that the product effective, your competitor will just produce their version and sell. That is why, for example, no one wants to prove the effectiveness of Co-enzyme Q10, papaya leaves for dengue, snake grass for cancers, etc etc, ( except perhaps a non-profit organization, or a government agency ).
So effectiveness of complementary medicine is based very much on here say and also a theoretical basis. For example, normal brain function uses Omega 6 fatty acid, so the more I give a young child, the better the child’s brain. In a way, I appeal to reasoning and emotions of “helping my child”. Data is lacking. The body cells has enzyme Q10 for energy generation, so if I give you Co-enzyme Q10, it will benefit you. That is the kind of reasoning. No data.
3.Thirdly, the marketing strategy for these companies are usually very aggressive. They use direct selling and unethical advertisements, making all sorts of claims, usually half truths. Regulators are over stretched to cope with them and there are usually multiple government agencies overseeing their marketing techniques, and so unless there is a death, or a catastrophe, these companies get away scott free.
Conclusion
Evidence based medicine has evidence to support its used or tell us its dangers. In that sense, its use is safe and regulated. Alternative medicine should only be embarked upon with good medical advice. Complementary medicine has little medical data on safety and effectiveness and should not be simply consumed. Many have suffered from consequences of taking the wrong complementary medicine. Some have even died. Integrative medicine will have the benefit of medical advice because it still has an element of conventional medicine.
  


Thursday, September 25, 2014

TREATING MILD HYPERTENSION IN PEOPLE AT LOW RISK

Mild Hypertension in people at low risk
                                                       BMJ 2014, Vol 349
Dr Stephen Martin ( Dept of Family Medicine and community health, University of Mass. Medical School ).

This is essentially a thought provoking editorial of the effectiveness of treating low risk mild hypertensives.
This paper is controversial. It is part of a series of papers on over-diagnosis and over-treatment                          

Introduction
                 Mild hypertension, as defined by BP of 140-159 / 90-99 mmHg ( JNC 7 and JNC 8 ) forms about 60% of the hypertensive population  presently. This is NOT a uniform class. We do have to separate them out into       1. White coat hypertension
                                           2. Primary Mild Hypertension without complications
                                           3. Primary mild hypertension with complications.
Conventional  View.
                             There is a large body of evidence that any rise in BP above 120/80 mmHg carries with it an increase cardiovascular risk of strokes, heart attacks and cardiovascular death ( example the Framingham studies and MR FIT ). There were some large scale studies which showed that treating hypertension, including mild hypertension, would reduced CVS mortality and morbidity. Most of these studies were done in the 90s and 2000. Since that time, two things have change. Medicine ( especially cardiology ) has found a new research tool. The office conducted “ trial by Meta-analysis “  and we have also realized that office BP may be erroneous and Home BP monitoring may be a better reflection of  genuine hypertension.
Till date all the hypertension clinical guidelines have been based on clinic BP monitoring and also clinical trials which included a whole bag of BP ranges. Some of those trials were based essentially on BP reduction and not on long term CVS morbidity and mortality reduction ( Just a numbers reduction ).

BMJ paper

                        What Dr Stephen and group is saying in the BMJ editorial is that we should re-think how we treat mild hypertensives discovered in the office clinics, especially the group without any co-morbidities ( the safe group, or low risk group ). Basing heavily on a meta-analysis carried out by the Cochrane Collaborators ( a group of experts who group together and analyze trials by meta-analysis ), published in 2012, together with analysis of some other studies.                         

They made a few points.
1.      1.  That the evidence for benefit in treating, safe, low risk mild hypertensives is small and may not out-weigh the risk of side effects.
2.       2. We need to encourage home BP monitoring and non-pharmacological means t lower BP
3.       3. That be treating almost 60% of hypertensives we increase healthcare cost , without any obvious benefits
4.       4. Treat the patient and NOT the number.
5.       5.  All the above does not apply to patients with mild hypertension with co-morbidities, like diabetes, or who have suffered previous CVS events like strokes, heart attacks, undergone by-pass surgery, renal impairment, etc etc.

My opinion
It is true, that we should treat the patient and not the number. We should empower the patient to
1.      1.  Do home BP monitoring.
2.      2.  Lifestyle modifications with diet, exercise, weight lost, stop smoking, prevent diabetes

My fear is that Patients may get the wrong message, that hypertension is not a serious disease. The danger from Stephen’s paper is that since it is low risk, mild hypertension is OK. That would be the wrong message for our population. There is a small risk with mild hypertension, and they need treatment but not necessarily with drugs.  They need to be monitored. In the event that they should develop co-morbidities like diabetes, then the mild HBP may require drug treatment.

And getting patients to do home BP monitoring is possible. More and more of my patients are doing it. I foresee that soon, smart phones will come with apps that can do that too.

Please know that this paper is controversial and thought provoking but is not yet the standard for medical practice.

Monday, September 22, 2014

IVABRADINE DID NOT DO WELL IN SIGNIFY.

I must say that nowadays, at clinical meeting, we are hearing reported, more negative trials.
In the recently concluded European Society of Cardiology Annual Scientific Congress,, one such trial reported was the SIGNIFY trial. This trial was to a randomised, double blinded, placebo control trial to test the benefits of Ivabradine against the placebo in patients with stable angina pectoris, without heart failure and worse heart rate was greater than 70 beats per minute. Ivabradine was a heart rate slowing drug working through the If  channel n the SA node. I suppose the investigators were hoping to show that by slowing the heart rate from 70 to 60 per minute, it would make a better outcome. The PI was Dr Kim Fox of London. The paper was also published simultaneously in the New England Journal of Medicine 371:1091, 2014. They managed to enrol 19,102 patients who had stable coronary disease without heart failure and whose heart rate was more than 70 / min. It is important to note that of the 19,000 or so patients, 12,000 or so had class 2 angina or more ( Canadian classification ). The primary endpoint was CVS mortality and non fatal MI. Half the patients were given Ivabradine and the other half, a placebo.


After 27 months of follow-up. it was true that the Heart Rate was lower in the treated arm. There was however no significant difference in the primary endpoint. But in the 12,000 patients with Canadian class 2 or more angina, there were more deaths and non fatal MI. There also seemed to be a higher incidence of atrial fibrillation in the treated arm.

Now, this last two points have given rise to some concern. We now know ( 19,000 is a large number ) that there is no point using ivabradine in patients with stable angina pectoris without heart failure. Secondly, we have to be careful in those with Class 2 or more angina, as it may do harm. Why? we are not certain.

IMPROVING PATIENT SAFETY - REPLY.

I wrote this reply to A Prof Azmi article in Saturday's Star, on "Improving patient safety".

Having read the interesting article by Assoc. Prof Mohammed Azmi, it is important to emphasize a few crucial points. What ails Malaysian Healthcare is basically a lack of funding. With 4.6% of GDP, we have done remarkably well. Healthcare transformation with greater public – private integration of course is greatly welcomed. However, retaining a two tier system of public-private healthcare is crucial to a successful healthcare system. It provides for a check and balance. This promotes healthy competition and no one is left out without the care that he or she needs. Having just a one tier system ( like NHS-UK ) would be a step backwards, as the public has less choice, greater taxation and when that one system fails ( as evident in UK now ), many now buy their own private insurance. Alas, our wish would be that with a greater Healthcare expenditure budget the public sector may be transformed to be on par with the private sector.

We all agree that improving patient safety is very important. We differ that setting up another body is the answer. Medical care has now progress from just curative medicine to preventive medicine and in the area of curative medicine, from just diagnosing and treating a condition to diagnosing, treating and also counselling. It is in this area of counselling that much can be done to improve patient care especially patient safety. Doctors are spending more time to counsel patients on their illness, and their treatment regimes. And if drugs are involved,  their effects and side effects. In this y age of information and the internet, even if the doctor fail  to mention, the more knowledgeable patient will ask. This is the best way to improve patient safety. Patients talking to their doctors, and doctors empowering their patients. That is also why we are concern about this talk every now and then to restrict dispensing to pharmacy alone. Should the government be so silly as to do that, it invites trouble. Asking a family to go searching for a pharmacy at 2 am in the morning, when a crying, wailing child has fever is ridiculous, bordering on irresponsibility, when his doctor is sitting just in front of him and can explain the medications, the effects and side effects. Yes, the pharmacist has the theoretical knowledge of the effect and  side effects of drugs. but which drug and dose is  suitable for his illness and his body, only his caring doctor knows, unless the government is of the view that all patients are the same and all illnesses are the same and one size fits all. The current system of prescribing dispensing allows for choice.  No exclusiveness, allow free choice. We are certain that this is what the patient wants, although it may not be what the pharmacists want. 

This reply was send to the Star editor on Saturday evening.

Wednesday, September 17, 2014

KEMBALI NEGARA-KU

This morning I join the Kembali Negara-Ku Piknik at Taman Jaya. I reached the site at 8.20 am and found the action point, sat down and had breakfast with y friend Dr KB Ng.

The crowd started to build up at about 8.45 -9 am. By the time the speeches started, I think (guesstimate ) there were about 200 people, who had come fairly prepared. Some chit chat, like us. Some played badminton ( father and son ), and most just sat down and ate mostly nasi lemak.
Of course the VIP was Zaid, Samad, aand Ambiga. I also shock the hands of Maria Chin ( Bersih ) and Haris Ibrahim ( ABU ). maybe there were others there that I did not recognise. I believe there were no politicians there.
After some chit chat fellowship, the speeches started at about 9.45 am with Zaid ( chairman ) speaking first, then the poem by Samad, and a short encouragement by Ambiga.
Their speeches were all short. Samad seemed rather weak. I could hardly hear him reciting his poem. To conclude the morning of fellowship, Kembali Negara-Ku Piknik, we sand Negara-Ku with some gusto and also Rasa Sayang.
We dismissed at about 10 am.
It was a simple memorable morning.
Well we are 52 years old ( half a century ), and we are still as divided as ever. This racist UMNO must be held responsible for most of this.