POST AMI ; BEWARE OF DRUG INTERACTION

Acute Myocardial Infarction ( AMI ) or Heart attack is a very serious, life-threatening condition. One heart attack is bad enough Recent studies have shown that after the first heart attacks, certain medication combination may increase your risk of a second heart attack.
Canadian researchers, in their Jan 28th online edition of the Canadian Medical Association Journal, studied 13,000 patients post-MI. Of these 734 patients were readmitted within 90days. 27% of those admitted with re-MI, were on a Plavix - PPI combination. PPI or proton pump inhibitor is a drug often used by the gastroenterologist to reduce acid production in the stomach, to lessen gastrotoxicity due to aspirin and other drugs. They also noticed that the patients who were on the older Zantac ( H2 antagonist ) or on a newer PPI called pantoprazole, did not seem to have this re-MI risk effect.
This study is important because, many patients post-MI are on an aspirin-plavix combination, besides many other pills. In order to lessen the risk of GIT toxicity, including GIT bleed, we often prescribe a PPI ( often omeperazole ). It is true that plavix is also metabolised by the CYP450 system, as are the PPIs. It is true that the activation of plavix may be affected by the presence of PPIs, thereby making the plavix less effective. I have always maintained that polypharmacy is bad for our patients and drugs metabolised by the CYP450 system ( which is alot of drugs ) should be used very judiciously. If fact, if you have a choice of agents, always chose one that does not affect the CYP450 system.
The other agent that should be mentioned in passing are the statins and plavix. There were also reports that atorvastatin may affect plavix as they are also both metabolised by the CYP450 system.
The message today is that if you have suffered a heart attack, please know that plavix and PPI interact and PPI may attenuate the the effect of plavix, thereby resulting in a higher incidence of re-infarction. If you wish to avoid gastro-toxicity, try using good old Zantac with the aspirin, or if you need a PPI, try using Pantoprazole ( incidentally pantoprazole is manufactured by Wyeth, a company recently bought over by Pfizer ).
The morale of the story would be use drugs only when it is absolutely necessary, and always beware of drug interactions. Use as few drugs a needed.

THE IMPORTANCE OF NATIONAL HEALTH DATA, THE PROBLEM OF RHEUMATIC HEART DISEASE

The 18th Dec 2008 issue of Circulation carried an article by Dr Jonathan Carapetis, on new information about an old problem. He highlighted the problem of Rheumatic Heart Disease in Asia. I use to see a lot of Rheumatic Heart disease when I was serving at the University Hospital back in the early 80's. We even had a full specialist cardiac clinic for it. The Chronic Rheumatic Heart Disease clinic. When I left for private practice, I hardly saw any. I took it that chronic rheumatic heart disease was a problem of living in over-crowded conditions with poor sanitation, usually in the lower social economic groups. Therefore, many of them ended up in the public hospitals. I suppose that is largely true. I attend and organise many postgraduate seminars and still I do not see many rheumatic heart disease cases presented.
Well, Dr Carapetis highlighted that many countries in Asia do not have adequate data, even with WHO, on the incidence of Rheumatic Heart Disease. Available statistics come from India, Bangladesh, Pakistan, Philippines, China, Taiwan, Iran, Cambodia, and Saudi Arabia. Of course there are data from Australia and New Zealand. Malaysia is significantly missing from this list. Even Cambodia and Bangladesh, have statistics on this disease. All the reports from these countries, seem to suggest that Rheumatic Heart Disease is these countries is still a formidable problem and we need to be constantly aware to diagnose and this problem. Even more important is the fact that these rheumatic heart disease can be prevented, and therefore lives saved. Unless we have meaniful statistics, we cannot have a meaningful preventive program.
That is what I mean. Cardiac centers of excellence must lead the way, to highlight important cardiac issues to us, so that the country can work towards a good preventive program and thus save lives. Not just trying to outdo private centers in how many angioplasties they have done.
Gong Xi Fa Cai.

THE CARDIOMYOPATHIC GENE, MYBPC3 DELETION, IN INDIANS

Last week, I read, first from our NST, then BBC and then studied the article in heart.org, of the deletion of 25-base pair of the MYBPC3 genes. It took awhile for me to refresh my genetics ( my weakest subject in med school ), before I was confident enough to post this blog. I felt that it was important to note this study, by a group of Indian researchers, and published in Nature Genetics, Jan 18th 2009. The MYBPC3 gene is the gene that codes the synthesis of the cardio-myosin bond. A deletion of the 25 base pair, would result in flawed synthesis of the essential protein, and so cardio-myosin weakness and cardiomypathy, heart failure and death from heart failure or ventricular arrhytmias. My concern is that this genetic defect is found in 4% of the Indians especially those from the south - western part of the Indian sub-continent. For some reason ( maybe the caste system ) the northern Indians are spared. Dr Dhandapany and colleagues claim that 400 per 100,000 deaths in South Western Indian is due to heart failure, probaly as a result of this genetic defect. That is alot.
It is important to note that, we are not talking about coronary artery disease here. It is cardiomyopathy, probably dilated and also hypertrophic cardiomyopathy.
In Malaysia, a large propation of our Indians are from southern eastern and also southern western India. Therefore, as cardiologist we must be aware of the present of cardiomyopathy as a result of the defect in the MYBPC3 gene.
The second point that I would like to make is that, I wish that our local cardiac centers of excellence, especially those with public funding, who have the resources, should look into this genetice defects and see if Malaysians ( with our increasing prevalence of inter-racial marriages ), have this same genetic defect. After all, if the prevalence is 4%, a program of genetic counselling may be in order, so that our Malaysians will not have to suffer from heart failure and cardiomyopathy. As I have said in the past, this is what centers of excellence are for.

GLOBAL FINANCIAL CRISIS AND CLINICAL TRIALS

I have just read from "heart.org " that clinical trials has seen her first casualty in the global financial crisis. COGENT 1 is a clinical trial, targeted to enroll 4,000 patients, over 500 sites in USA, Canada, Mexico, Europe, with a followup of 12 months. They were testing a combination pill of clopidogrel+omeprazole versus clopidogrel alone, in ACS, post-STEMI and post DES patients, to see if the combo pill have less GIT side effects. The study was sponsored by Cogentus Pharmaceuticals of USA. They began enrolment in early 2008. In December, the trial was abruptly stopped, citing financial reasons. Now the researchers have trouble trying to finance the followup of patients and all the staff that had been hired.
Looks like the global financial crisis has hit the medical shores. In fact I have been repeated spoken to, to remind me that the many CME programs that I help organise may run into financial trouble, as pharmas that support us find sales dropping and their coffers thinning out. I have been asked not to expect too much and to be thrifty. As a matter of fact, we have been very thrifty in the many CMEs that we conduct, making sure that everything is transparent and that we do not waste. Running clinical meetings with an attendance of 600, at the cost of RM 110K at a conference venue in the Klang Valley, I think is cost effective. I hear of clinical meetings running to over a million dollars locally, with attendance far less then 600. I am not sure how the organisers can hope for support, unless there is severe arm twisting going on ( something that poor us cannot do ).
Doctors must begin ( if they do not already know ) that CMEs and study trips abroad that they are sometimes send to, comes from marketing and promotional budget of the pharmas, and will go back to cost of products. The famous cliche is that there is no free lunch. I know of " big " consultants who travel for international conferences every month on drug or device companies, business class, sometimes with accompanying relatives, who are also taken shopping overseas. well lets see what happens with this credit crunch ahead of us.
As for me, we have tightened up our belts, in an attempt to survive, and continue to provide our patients with affordable cardiac care.
In short, Wall Street USA has hit main street USA, and I suspect also main street Malaysia. Let us all hope that our patients do not suffer.

CVD IN ASIA : SPECIAL CIRCULATION ISSUE

The December 16th issue of Circulation very aptly focused on Cardiovascular Disease in Asia. Led by the Japanese workers, the issue highlights the problem of CVD in Asia, its rising trends and the differences between CVD in Asia and CVD in Western countries. We know from WHO data, that CVD in western countries seem to be under control and that by 2010, cancer will replace CVD as the number 1 cause of death in Western countries. We also know that by then 85% of CVD deaths worldwide will occur in low and middle-income countries ( or mainly developing and second world countries ). Reading the reports, it is also interesting to note that while the Western countries CVD problem are mainly cardiac, ie cardiac deaths, AMI and revascularisation, in Asia, the CVD problem is mainly hypertension and strokes as a cause of CVD. It looks like smoking and high salt in our Asian diet is causing people in India and China to develop hypertension ( there is a higher incidence of hypertension in India and China then Western countries ), which often results in strokes. The Japanese seem to be different in that they are more " Western " and have more cardiac atherosclerosis then the Indians and Chinese.
Yes, as alluded to in the newspaper today, there also seem to be a genetic component to the CVD problem in Asia. This will form the basis of another blog in the near future.
I suppose I learn from the Circulation report, that our Japanese colleagues have again taken the lead in trying to highlight the CVD problem in Asia, on the world stage, so that countries can know the problem and divert important healthcare resources to it. I only wish that our own local centers of excellence have done that.
I also learn that diet ( salty, fatty foods prevalent in Asia ) and also smoking, are important root causes of the CVD problems. And so the CVD problem can be controlled in Asia, if the health care authorities wishes to.
I also learn that hypertension and strokes are more important that cardiac atherosclerosis as a cause of CVD deaths and morbidity, in Asia for the moment.
So let us all eat less salt, and also get our BP checked and controlled. Eat more greens and fruits. Stroke is a great killer and one stroke can change your life forever.

DANGERS IN SLIMMING MEDICATIONS AND SLIM FORMULAS

The US FDA has just issued another list of products used for slimming which may harm more than help. The list includes - Phyto-shape, Extrim Plus 24hr Reburn, Body Creator, Body Slimming. I gather that most of these are formula diets that is sold over the counter ( OTC ) for those who wish to have a quick fix for obesity, without the rigors of diet and exercise. Please be warned that many of these quick fix diet actually contain medications which can harm, if used without medical supervision. Many of these diets contain Sibutramine, phenytoin, phenolphthalein, bumetanide, and these drugs have side effects.
I suppose all these OTC products become popular partly because we are emphasizing the rising incidence of obesity and also the dangers of obesity. Some opportunistic businessmen ( or women ) see the possibility of making some quick money, without thinking that it can harm. There is no easy solution to losing weight. Diet and exercise still remains the best, cheapest, most effective and healthy way. The sweating is what makes it work and also makes it worth while. I tell my patients ( many of whom are not so educated ) that all they need to do is work out a sweat 3-4 times a week. Yes, we know about 15 KM a week on divided portions and keeping a heart rate of 120-150 / min, etc. but for some, this remains too technical. I am very glad to see so many gyms and fitness centers sprig up and marketing and recruiting members. This is a healthy signs. I also have heard of many fitness centers that have short-change their patrons. What to do, there are always uncrupulous businessmen ( or women ) out there.
Anyway, beware of all the slimming diets marketed out there. Check the product labels carefully. If in doubt, avoid, despite all the strong recommendations from " friends " and all the anecdotal reports of great outcomes.
There is no shortcut to losing weight. Diet and exercise remains the best for all of us.

THE DANGERS OF TOBACCO. LESSONS FROM CHINA

The ills of tobacco abuse is well known. We have been trying to control the tobacco menace, for quite a few years now. The " Tak Nak " campaign is still ongoing. The corridor talk is that it is not meeting its objective and tobacco abuse is still rampant. Asking the public to just stop without any other recourse, may work well for some, but certainly not for all. Pfizer have these nicotine -like drug, " champix " for those who need some form of substitute, to help them wean off their tobacco abuse. Pfizer tells me that " Champix " worldwide has been very successful. In Malaysia, their use is still not significant to make an impact.
Well, China faces the same problem The first ( 2009 ) issue of the New England Journal of Medicine carried an article by Prof Dongfeng Gu from Fu Wau Heart Institute, estimating that in 2005, there were 700,000 tobacco related deaths in China. This was part of the China National Hypertension Survey, started in 1991. China with a population of 1.3 billion, have about 350 million smokers. About 60% of males in China smoke. Most of the tobacco related deaths are cancers. The second most common cause is cardiac related diseases and thirdly, pulmonary diseases. In India, the other country with over a billion population, it is estimated that by 2010, 1 million will die from tobacco related deaths.
Faced with these statistics, can we see how much health care resources is spend on treating tobacco related illnesses. Also how many productive males ( I mean economically productive ), lose their lives and productivity because of tobacco.
As Prof Gu wrote in his article, the problem with most countries is that we are severely ambivalent. We ban smoking and yet state run companies sell cigarettes and tobacco related products and derive good revenue from them. How then can we stop the scourge of tobacco. So it is in China, and I am afraid, so it is in many other countries, including India and Malaysia.
I am sure the government knows what needs to be done. But doing it, is another matter all together.

VITAMIN C AND BLOOD PRESSURE IN YOUNG FEMALES

I do have an interest in " nutriceuticals ". I am quite impress that certain food substances can have medicinal value. A good example being fish oil and prevention of CAD and wine and prevention of CAD. The Dec 17th edition of " the nutrition journal " ( a small journal ), reported a study by Dr G Black from the University of California at Berkeley, that Vitamin C levels were inversely proportional to BP ( both systolic and diastolic ). It was a small study of 240 young girls between the ages of 18-21, who were followed for 10 years and had their 10th year annual ascorbic acid levels taken. It is important to note, perhaps, that more than two thirds of the cohorts were afro-american and the average BMI was 26 ( slightly overweight ). The 10th year ascorbic acid levels were inversely correlated with BP. Meaning that those with high ascorbic acid levels had significantly lower systolic and diastolic BP.
Of course this is a small study and Dr Black herself said that at best, this is hypothesis generating and will require a much larger clinical trial before it can be conclusively proven, Of course the dilemma, in our present system is, who will undertake such a trial as there can be no patent on ascorbic acid. It is found in all friuts.
Well, I was happy to note that my often quoted advice to patients to take as much greens and fruits, so as to reduce BP ( the DASH study ) has been supported by this small study.
If you wish to lower your BP, by up to a level of 10mmHg, take more greens and fruits.

ST JUDES MEDICAL IN MALAYSIA

One of the lesser highlighted news last week was a small announcement by the Penang state government that an American company, namely St Judes Medical, is setting up a factory in Penang. Earlier on in April 2008, there was a preliminary announcement by the Penang state government that St Judes will be investing in the state, with about RM100million.
I think that this is an important step forward as St Judes Medical is an important medical device company, that manufactures a good range of pacemakers. They are obviously the makers of the St Judes heart valves, which very good bi-leaflet heart valves, implanted in many of our Malaysian patients. The St Judes heart valves is arguably the best mechanical heart valve. It is probably the most physiological in its function, for a mechanical bi-leaflet valve. St Judes also have vascular closure devices. Lately, St Judes Medical has also acquired the Swiss company, Radi Medical, that makes pressure wires that we can use to more accurately assess the significance of heart artery blockages. St Judes brings with it a whole range of cardiovascular products that we use to treat heart patients. Of the many products in their armentarium, I am particularly impress with their pacemakers and heart valves. Now that they also have a pressure wire, and should they become cheaper, we can also consider its use in the more borderline lesions.
I am not sure how the business aspect will work out. I am obviously hoping that because St Judes is now in Penang, their products will hopefully be cheaper for our patients. They obviously will be employing Malaysian engineers and technical staff, and that will allow a certain amount of technology transfer, and perhaps enhance our bio-medical industry. Perhaps, using this as a lead, we could look to the day when Malaysians can innovate and design cardiac devices, to help our Malaysian patients.
All in all, the coming of St Judes Medical will be good for Malaysia and Penang. It brings business, gives employment, and may even spur on a new medical device industry.

OVERWEIGHT AND HEART FAILURE

Let me first begin by wishing all of you a very Happy and Prosperous 2009.
The 22nd Dec 2008, online issue of Circulation, published an interesting article on a piece of work by Dr S Kenchaiah of Bringham and Women's, Boston, on data from the ongoing Physician Health Study ( PHS ). The PHS was initiated in 1982. It is an ongoing study of about 22,000 physicians, studying their health and disease patterns and have been ongoing for the last 27years and has given us much information about hypertension,, obesity, diabetes, use of aspirin, etc.
Anyway, Dr Kenchaiah and colleagues, looked into the correlation between obesity, overweight and heart failure and found that overweight physicians ( BMI 25-30 ) were about 50% more likely to develop heart failure compared to the lean physicians. Obviously, when they are obese, the likelihood of heart failure is about 80%. Obese, overweight, beware.
Also, exercise will help to reduce the incidence, but not necessarily will weight reduction. Exercise, until you break a sweat will help to reduce the possibility of heart failure.
Since this was a epidermiological study, it did not suggest possible reasons. I suppose the explanantion for overweight and heart failure, must be the increase incidence of hypertension, and diabetes in these overweight or obese physicians. Perhaps lack of exercise could also play a part. It is important to note that this study's definition of heart failure is mainly that of symptoms of breathlessness, leaving it as a very mixed bag of systolic, diastolic and perhaps even non-cardiac dyspnea. Not the most accurate way. Nonetheless, the message is taken that keeping lean and physically fit, lessens breathelessness, and that is good for the population.
Once again, Happy New Year.