FROM ACC 2009 : THE POLYPILL

It has been many a cardiologist dream to have a "polypill " containing an anti-platelet, a statin, and some anti-hypertensive drugs, in the hope that this will primarily or secondarily prevent CAD. Well, the first step has been taken by Dr Salim Yusuf and co-workers, mainly from India. I am sure that Dr Yusuf was there to lend his name and his considerable contacts in the drug trial world, to be the PI and also show the Indians how to do large scale clinical trials. Well, in India, without the FDA, Dr Yusuf can concort drug regimes that he will otherwise be unable to do in Canada / USA.
Be that as it may, Dr Yusuf and co-workers, undertook the TIPS trial, the results were presented at the ACC yesterday. TIPS was the accronym for The Indian Polycap study. They studied 2,000 over patients between the ages of 40-80 years. These subjects had no know cardiovascular disease. They were given the polycap pill, or aspirin alone, or zocor alone, or each anti-hypertensive ( tenormin, ramipril, HCT ) either alone or in various combination for 3 months and followed up. Obviously it was not a test of clinical events, but only to see if the concept is possible and that there be no important ill-effects. They were just measuring BP lowering and LDL-C lowering. These were essentially surrogate end-points. Nothing hard. The Polycap pill contain asprin 100mg, Ramipril 5 mg, Zocor 20 mg, HCT 12.5 mg, Tenormin 50mg. Well, to cut a long "Indian " story short, they found that, the Polycap pill was safe and relatively free of side effects. There was an 18% default rate, Some of the Indian centers were not so geared towards clinical trials and so the BP level reduction and also the LDL-C level reduction was less than when they were taking the drugs alone.
All in all, this study did not seem to be well done. I suspect that it got to ACC because it was of public health interest and also the lobbying power of Dr Yusuf.
Anyway, we can take heart that a first step has been taken to invent a polypill, and that it can be safe combined and administered. Much work still needs to be done.

FROM ACC 2009 : JUPITER RE-VISITED

Well, as expected, this ACC 2009 at Orlando will have a few re-visits on the JUPITER ( the use of rosuvastatin in the primary prevention of CAD ) results that were presented last year. One of the early presentations yesterday was a re-analysis of the JUPITER data looking to see which is the best subsets, in terms of biochemical parameters, that will benefit from the use of statin therapy. It was obvious from the re-analysis, that patients or rather subjects ( since this is a primary prevention study ) with low LDL-C and low hs-CRP has the best long term outcome with the use of statins.
I must say that this JUPITER re-analysis of the data and the results are not surprising. We knew this almost 5 years ago when we had a look at the PROVE-IT data. In that study, the statin used was Atorvastatin. A close look at the Prove-IT data aklso showed that the subjects with low LDL-C and hs-CRP had the best outcome.
Well, it would appear that LDL-C was not the only reason for less cardiac events, with the use of statins. This is inline with the current theory that atherosclerosis may have a large inflammatory component, in many patients, and hs-CRP is a measure of the amount of inflammation and that statins here may be acting on the vessel wall as an inflammatory agent.
This on the whole is easy for clinician. BUT what we have learned is that hs-CRP is something that is not easy to measure. The spread of normality is so wide, that clinicians sometimes have difficulty trying to understand the results. Any small source of infection or inflammation, will raise the CRP and give us spurious readings. I will always interprete the hs-CRP ( especially with our labs ) with a common ESR finding. If the ESR is also raised, that hs-CRP reading showed be ignored. Do not frighten the patient. I am certain that with the strong push from JUPITER, labs will begin to standardise their techniques better and allow us a better hs-CRP assessment kit. In the meantime, know that statins work, both by lowering LDL-C and also by lowering hs-CRP. The lower the LDL-C and hs-CRP, the better for your heart and arteries in the long run.

FROM THE ACC 2009. IS THE GENOUS STENT READY FOR PRIMETIME?

I have been keeping an eye on the electronic media reports of the happenings in ACC 2009 at Orlando. Well, one of the earliest late breaking trials presented on 28th March, was the "Genius-STEMI" trial, a study of the use of the GENOUS EPC capture stent in STEMI patients.
The Genous stent is a rather unique stent. It is strictly not a DES. The stent platform is basically stainless steel, coated with a layer of monoclonal antibodies that can capture the EPC ( endothelial progenitor cell ), which promotes healing ( supposedly natural healing ). On this premise, we feel that it should have less stent thrombosis ( since it is lined by natural endothelial cells ), and also probably less scar tissue ( less restenosis ) since it is clinically promoted healing.
This Genous stent is also unique because, although the inventor of this concept stent is American, the owner of the stent company ( Orbus Niche ) is Chinese. Mr Teddy Chen is a very rich Chinese gentleman who owns the company. He is a philantrophist and has helped in many ways to advance interventional cardiology in the Asian Pacific region. Many of the senior management staff in Orbus Niche are also good friends of mine from the "early days ".
The third uniqueness of the Genous stent is that it has not attracted the attention of the interventional hot-shots in Washington. I was rather surprised. To get to the big market ( and USA is probably the biggest market presently, while we await the awakening of the Chinese market ), Orbus Niche must certainly want to get to the CRF fellows involved along the way?
Anyway, while reviewing the ACC 2009 late breaking trials, I saw that Dr Cervinka from the Czech republic had presented the data from the Genius-STEMI trial. A study of 100 STEMI patients with STEMI, half of which received the Genous stent and the other half a standard cobalt chromium stent. Lo and behold, the Genous stent came out worse than the bare cobalt chromium stent. After 6 months, the Genous stent had more stent thrombosis and also more repeat target vessel re-vascularisation. The authors concluded that the study was too small, and we will need larger trials to be sure. So we should wait for more data. It also show that the bare cobalt chromium stent is a very good stent.
So all the nice concepts and pictorials that came with any presentation of the Genous stent, was not supported by clinical trial data. There was an earlier clinical trial on the Genous stent, that was presented in the Japanese Circulation society meeting with showed some better results, but that was a non-randomised group, with some degree of patient bias.
Basically, the Genous stent looks like is not quite ready for clinical use. I understand that some Singapore medical centers are using them, on a clinical trial basis. Locally, I have always kept shy of it. I have told Mr Teddy Chen and his senior management staff that I do need more data. Some of my colleagues have been implanting them with impunity. Suffice to say that the Genous stent is NOT FDA approved and may carry some dangers, if the data from the Genius-STEMI, is to be believed.
Alas, nice pictorials and nice concept video taped and showed to the public is just that, nice pictures. We will need more clinical trials to tell us that Genous stent is safe and good. We should all wait for more data.

ACC, ORLANDO, 29th-31st MARCH 2009

Well the " big one " starts this weekend, almost as Tiger Woods ( I hope he makes the cut ), takes to the Tee Box 1 at the Arnold Palmer Bayhill Invitation. By the " big one " I mean the Annual Scientific Meeting of the American College of Cardiology. I had a quick look at the Scientific program, especially the late breaking trial. Looks interesting, but nothing revolutionary. There will be those trials on STEMI management, statin therapies, " combo pills" , and a couple of interesting trials in interventional cardiology. In fact, on the side lines ( now almost part of ) the ACC is the i-2 summit, this time without the participation of the Society for Cardiac Angiography and Interventions, but in collaboration with the " business minded " CRF organisation. In fact, the ACC is said to have been queried by the US government on the business relationship between CRF and ACC. But suffice to say that the i2 Summit at ACC 2009 is chaired by the pragmatic and balanced interventionist, Dr David Holmes of Mayo.
Anyway, the Orbus Niche people are presenting their 6 months trial data in the use of the GENOUS stent in the management of STEMI patients. I was made to understand ( corridor talk ) that the results are good. I will venture a guess that the results are like the rest. It should be a safe stent, with low Stent thrombosis rates ( at 6 months, it will be too short to tell ) amd a usual late loss of about 0.4-0.5 mm and a low 6 months TLR. But then we know that at 6 months, you can hardly tell anything. I wonder why Orbus Niche is so keen to present the data at 6 months and not 1 year, unless they are afraid of losing ground to their competitor.
I am also quite keen to see the results of Salim Yusuf's group, on the use of a 3 in 1 combo pill for high risk CAD prevention. Of course JUPITER, the sensation of the last ACC is back in some rehash form, to tell us that the marketing goes on, and to sub-analyse some of the data. Well, rosuvastatin is doing well locally and globally, especially with the lost of patency of atorvastatin.
All in all, the ACC 2009 program looks interesting and will teach us more for the care of our patients, but I do not think that it is worth travelling 24 hours across many time zones, when I can learn it all with a few clicks of the mouse. But then again, I do not have the thrill of being there. Some of us do not mind watching the European Cup from the comfort of our homes while some would rather go to Rome to watch it. Your choice.

CIT 2009 - BEIJING

I spend the last weekend in Beijing performing my duty as " Guest faculty " in the China Interventional Therapeutics ( CIT ) 2009 meeting. This year about 4 thousand doctors and paramedics attended. It was quite large meeting ( by Asian standards ) , with many concurrent sessions and live transmission from many centers, mainly centers from China. There were of course the live transmission from Washington and Paris. All in all, it was a very fruitful meeting. I particularly enjoyed the local sessions seeing the how local Chinese doctors do their cases, and how they tackle their complications. I can only say that they are a very brave lot and they like putting stents. It was common to see, 2-3 DES implanted in relatively simple lesions. China of course have developed their own local DES ( Drug-Eluting Stents ), which is not bad. They are namely the " Excel" stent and the " Firebird " stent. They are both copycat versions of the more established Johnson&Johnson Cyper stent. They have innovated and improved on it and is now coming out with a third improvement . That is how fast they are improving. Of course the Americans view this with disdain. Let me share a small anecdocte with you.
I have posted last year, that there is a good cardiac interventionist in China called Dr Han AiLin. She led a clinical trial called CREATE, with the use of the China made " EXCEL " stent. The results were very good. Maybe better then the American results with the Cyper stent. At this meeting, Dr Han reported her two year followup, on the patients treated 2 years earlier. The results were excellent after two years, with a very low rate of complication and a very high rate of effectiveness. Chairing the session where she presented her results was a certain gentleman call Dr Marty Leon, the founder of Cardiovascular Research Foundation ( CRF ), and who organises the year large TCT meeting in Washington and this year to be held in San Francisco. Anyway, Marty was of course rather impress with the results and was maybe a little jealous that the Chinese maybe outdoing the Americans. In his question to Dr Han, he express that he was very impress with the 2 year followup result of CREATE. He asked Dr Han to speculate as to why the Chinese results were so good. He asked , and I quote " I am very impress with your results, and I do not understand why your results are so much better than the our results. Do you think that your very good results was due to 1. The Chinese disease being different from the American disease? 2. The very good techniques of the Chinese doctors in doing the intervention? or 3. That somehow, your reporting and statistics were different from the US? ( implying that the Chinese were less than honest ). How rude can he be? Dr Han merely replied that she is not sure, but it could be all three. That is how the Americans see good work done outside USA.
Anyway, China is rising.
Well, on a lighter note, it was obvious that Beijing airport and Tian An Men was not so pack. The economic downturn can be seen in the streets of Beijing. The weather was very good and pollution was mild. They are still enforcing the even number, odd number car rule to reduce traffic congestion in Beijing.
All in all, it was a good trip. I learn from my colleagues in China. I met many old friends, both overseas and Chinese, and I also made many new friends, especially from China, as we share our work. It was a good trip.
I am so tired and maybe a bit under the weather.

Letters to the editor: Generic vs Branded Drugs

This is a copy of a letter sent to the editor of The Star

Dear Editor,

I refer to the article by Ms Cecilia Kok, titled "Generic Drugs vs Branded ones" that appeared in the Star (14th March 2009 Biz Week). I must say that this piece of investigative journalism is rather incomplete. No doctor (referring to the people who sees patients and treat them), were interviewed. With all due respect to the dons from USM, their eye is only focused on the theoretical and not the practical. You cannot blame them. They live in ivory towers. I would like to declare from the offset, that I have no conflict of interest to declare. I am not employed nor do I receive any renumeration from any drug company to write this response.

Let us take the first issue. There is no doubt that generic drugs are cheaper. After all, they are essentially copycats, waiting for patents to expire and then to produce the drugs as if it is the equivalent (they call it bio-equivalenc ). When branded companies spend millions of dollars to research a drug and then do clinical trials to make sure the drugs are safe and efficacious, the end product will certainly be expensive. Of course when you copy their drugs, without the need to do research and clinical trials, your drug will be cheaper. What will happen when branded drug companies, because of a price war with generic companies, stop doing research on new drugs for new treatment of disease? We will end up with the same old treatment for the same old condition. Medical therapy will be stunted and patients will suffer. The branded companys also fulfill a role of helping to update and refresh doctors. We depend on drug companys to help sponsor CMEs (continual medical education) for doctors. Generic drug companys have not stepped up to provide such education. Perhaps in a world where there are only generics, you will less for less choice and then pay more to the doctor who has to pass on his cost of CME.

Of course, cost of drugs is important. But so is the issue of efficacy and safety. Generic companies, and so also my learned dons, assume that my copycat drug is like the real thing. Let's get something very clear from the outset. Copycat drugs were never subjected to large, randomised clinical trials. Generic drug manufacturers like us to believe that because their drug contain, for example amlodipine besylate, it must behave (in the human patient) the same as amlodipine besylate of Pfizer. Nothing can be further from the truth. Oh yes, they will tell me that they have done "bio-equivalence studies" on their amlodipine besylate and they behave the same, in their laboratory. Well, it may be important to note that, there are many steps in the production of a medical drug. The important active substance, in this example, amlodipine besylate, is important. The chemical must have enough shelf life, to remain active for the period that it is listed for. But besides that active compound, other chemicals are added which are important to stabilised the drug and also to allow it to be safely delivered into the body and also to the target organ site of action. With that many steps involved in the manufacturing, quality control is of paramount importance. Any "short-cuts" taken by the manufacturer may result in a drug that may be inactive by the time that it is ingested, or worse still, may be harmful to the body. Manufacturers sometimes buy chemicals that are near expiry dates, to cut down cost, so as to improve profit margin. The active ingredients are near expiry dates, the preserving chemicals, the stabilising chemicals, and even the coating material, may all be near expiry dates. Chemicals near expiry dates are obviously cheaper, thereby enhancing profit margin. Of course, in a way, it all boils down to quality control and enforcement of safety standards in the manufacturing of generic drugs, two aspects where Malaysia does not exactly excel. It is a common joke in our circle, that the first batch of generic drugs, that are to be tested by the Drug Control Authority of Malaysia, will be manufactured with the highest stringent standards and all the chemicals are top quality without any compromise. Of course, that first batch will be costly. But once approved, the post-marketing surveillance is so weak , that the subsequent batches (these ones makes profit) will have compromised quality. It is well known that many of the drugs sent to sub-Saharan Africa for AIDS treatment contain "duds". Looks like the right pills, may taste like the right pills, but it is not the right pill. It is as useful as flour powder or sugar.
I may agree that as a cost saving measure, some non-life threatening condition may be treated with generic drugs, for example anti-fever pills or pain-killers, OTC (over the counter) drugs, etc. If those generic drugs do not work, the patient may not die. They may have fever or the pain continues, that is all. However, if the patient is suffering from life threatening conditions like hypertension, or needs blood thinners for drug-coated stents, one or two "dud" generic tablets could make the difference between life and death.

It is very sad that medicine has become a business, where everything is driven by cost and profits. What about the patient? What about cost effective care? Are we going to sacrifice patient care just to cut down cost.

However, we should all appeal to the company that produces branded products, to be more responsible socially and corporately. Doctors who work with these companies to run CME (continual medical education) programs, must not abuse the money and trust placed on them, but use the drug companys' money responsibly. They must realise that CME budget, always goes back to cost of product. Senior consultants, who take the drug company for a ride whenever they are send overseas for a CME must behave more responsibly.

IF I HAD CHEST PAINS, WHAT SHOULD MY CARDIOLOGIST DO?

It has been hotly debated since 2007, when the COURAGE trial was first announced, that optimal medical therapy is the best for our patients with stable coronary heart disease. But this strategy is very poorly accepted by our local lay-population, who usually sees a blockage almost like a death sentence. When they have chest pains ( not due to a heart attack ), they get investigated, usually with a stress ECG, and now more and more with the 64MSCT. If either of these are positive, they are told that they need a coronary angiogram ( sometimes in the same afternoon, we call this a drive- through angiogram ), and upon seeing a stenosis ( God forbid ), they are told that they need an angioplasty to " clear the blockage " or else they may suffer a heart attack and die. Of course the poor patient ( mildly sedated ) and obviously very frighten, would agree and the interventional cardiologist will happily ( and gleefully ) go ahead to perform an angioplasty, and implant some drug-eluting stents ( sometimes generic, unapproved ones too ), and the patient ends up with a large bill.
Well, is there good medical evidence for that.
The straight-froward answer is NO. In fact the last issue of Lancet ( 14th March 2009 ) carried a large meta-analysis ( >25,000 patients, 61 clinical trials, from 1987-2007 ), by Dr T Trikalinios of Tufts, comparing optimal medical therapy against angioplasty in chronic stable angina pectoris, and found that both therapies were comparable in their longterm outcome. There was no difference in heart attack rates and no difference in survival rates, over 20 years. That angioplasties should be reserved for patients with an acute myocardial infarction, unstable angina or when medical therapy is unable to control the symptoms.
Of course, this is a re-affirmation of the 2007 COURAGE trial by Bill Borden.
Alas this message has still not sunk in. At least not to my knowledge. The local medical community is still exercising, what in our discipline, we call the " Oculo-stenotic " reflex and in fact, I suspect, many " dilate for bread ". After all, the consult fees for medical consultation and medical therapy is RM 100 and the fees for angioplasty procedure is about RM 3-7 K depending on which institution you may go to.
I can only conclude that medicine has become a business.
Patients be aware. If you had stable coronary heart disease, medical therapy is good therapy and the preferred therapy, angioplasty not withstanding.

THE BIOADSORBABLE STENTS

The March 14th issue of the Lancet carried an article by the prolific writer, Dr Patrick Serruys, on the ABSORB trial. The ABSORB study is a study on the new generation of DES ( Drug-Eluting Stents ). DES, as we all well know has this problem of stent thrombosis, which can occur at practically, anytime. From the early stages till the very late stages ( and I mean 2-3 years out ) after successful stent implantation. Some have reasoned that this could be due to the presence of metal and also the polymer. There was therefore alot of interest in the invention of a bioabsorbable stent, which hopefully will melt ( bioabsorbed ) away, months after implantation, thereby hopefully eliminating late stent thrombosis. Well, Dr Serruys and group, implanted this new generation everolimus bioabsorbable stent ( made by Abbott ) into 26 patients about 2plus years ago, and in the latest issue of Lancet, annouced their results. It showed basically that the concept was good and after two years, the stent was well absorbed by the vessel wall, leaving almost no stent material ( in one-third of patients ). The MACE rates were good.
I gather that this small study was basically a proof of concept and now we will see refinement of the stent, including new stent material and follwoing that larger clinical trials, with larger number of patients.
Well for a start, looks like the biuoabsorbable stent is on the way. We must be about 4-5 years from clinical usage.
Suffice to say that it is an improvement on the present generation DES ( the current second generation DES is very good ), but at what cost? I don't think that the bioabsorbable stent is going to be cheap or cheaper than the current second generation DES.
Well, we call this progress.

KIDNEYS, THE SON OF THE HEART

12th March is world kidney day. Looks like nowadays, to emphasize something is to proclaim a day of remembrance for it. Well, it is a good ide as we wish to emphasize that people take care of their kidneys. I thought that I should do my part by writing a little about the kidney's relationship to the heart.
I should begin by saying that the kidneys are very closely related to the heart. Maybe, not as close as diabetes ( diabetes is very closely related to blood vessels and the heart ), but close enough for us to call it a father-son relationship. Whatever happens to the kidneys will affect the heart ( we call it the renocardiac syndrome ) and whatever affects the heart will affect the kidneys ( we call it the cardio-renal syndrome ). What do I mean? Well, when the kidney function becomes compromised, whether acutely or chronically, waste products will accumulate and they will ultimately affect blood vessels ( as waste products are toxic and produce inflammatory effects on the blood vesel walls ), and the same waste products will also act to depress cardiac function. We measure blood urea and serum creatinine, as markers of renal function. They are not the only toxic products resulting from renal failure. There are many others. Arteriosclerosis is also a common result of renal failure and many renal failure patients die from heart attacks, and strokes. This is well known. Similarly, when a patient suffers from a fall in cardiac or vascular function ( heart failure or vascular failure or shock ), the resulting hypo-perfusion of the kidneys will quickly result in renal failure, and the cycle goes on. Needless to say that in the background of this continuum, is hypertension and diabetes, both common associates and also cause of heart disease and renal disease. I believe that when Dr Victor Tzau and Dr Eugene Braunwaul drew up the cardio-vascular continuum, in the 90s, they did not place quite enough emphasis in the role of the kidneys and renal disease in their continuum. Well, it may be time to revise that. In the area of obesity leading to hypertension, diabetes, we should also add renal disease ( acute or chronic ) to reflect the importance of the kidneys, the younger son of the heart.
Happy World Kidney Day and please do take care of your kidneys. They may cause your heart to sink. Please do take care of your heart. They may cause your kidneys to sink, too.

PLAVIX / PPI DRUG INTERACTION

I must begin this blog by saying that I am sadden at the sudden death of Dr Phillip Poole Wilson of the Imperial College of London on then 4th March 2009. Although I do not know Dr Wilson personally, I have attend many of his lectures. I find that he is very articulate, and a good teacher, and always being very balance in his views. He is obviously an expert in heart failure management, besides being a gentleman and teacher. We will all miss him and his contribution. My condolences to his family and loved ones.

Today, I intend to re-emphasize our concern of the Clopidogrel-proton Pump Inhibitor interactions. It is obvious that many of our CAD patients requiring drug-eluting stents, are often prescribed aspirin and clopidogrel ( standard dual anti-platelet therapy ). Of late, there have been many reports of clopidogrel-PPI interactions, that will attenuate the effects of clopidogrel. Could this be one of the causes of subacute stent thrombosis? We sometimes forget that clopidogrel is a pro-drug, and so requires CYP450 2C19 to activate. But CYP 450 2C19 is inhibited by most of the PPIs, except possibly pantozezole. As a result of this interaction, the effects of clopidogrel may be weakened. This is seen in up to 25% of the patients using clopidogrel and PPI. This was again emphasize in the latest paper by Dr Micheal Ho of Denver in the March 4th 2009. Dr Ho found that there was a 25% increase in cardiac deaths and re-hospitalisation in the patients taking the clopidogrel-PPI combination.
The exhortation is that when we start patients on dual anti-platelet therapy ( especially with aspirin ), we may have to resist the temptation of using PPI prophylactically. Otherwise we risk the higher risk of coronary thrombosis or stent thrombosis ( if stents have been used ). I understand that pantazezole, is less often used in Malaysia. Perhaps Wyeth ( now a division of Pfizer ) will consider marketing pantazezole, seeing that there is a particular niche use.
I also wish to highlight the fact that doctors and cardiologist may have to pay freater attention to drug metabolism and interactions in the pursuit of better care for their patients. Not enough is taught about the cytochrome CYP450 system, which is very important for drug metabolism.

SINGLIVE2009

I spend the weekend in Singapore, joining my colleagues as part of the faculty for this annual interventional cardiology live demo course. This interventional cardiology course is probably the oldest interventional cardiology course around the world. It was started in the early 90s because of a need to teach the interventional cardiology technique to cardiologist in the ASEAN region. I have been part of the faculty from the beginning. The first course was actually organised by Dr Richard Ng ( probably the most senior Interventionist in the ASEAN region ) as part of his tenure as the first President of the ASIAN PACIFIC SOCIETY of INTERVENTIONAL CARDIOLOGY. Later on, the organisation for this meeting pass on to Dr Arthur Tan of Singapore General Hospital Heart Center, and now the organising Chairman is Dr Koh Tian Hai, the Director of the Singapore Heart Center. We are all good friends and have seen the discipline of Interventional Cardiology frow from strength to strength.
The good thing is that many have passed through this meeting encouraged and empowered with more knowledge and information as to how better take care of their patients. Many have come to share ideas, discuss complications and how to deal with them, be updated on the latest data on interventional trials and their application. The course does serve some benefit, over these many years.
The downside is that, it cost alot to run these large interventional meetings. Bringing 1,000 doctors, techs, and nurses out for three days in Singapore cost money. Live transmission from all over the world, cost money, renting the Suntec City complex cost money, having an event organiser cost money. The organisers must decide whether the meeting has met the objectives and whether the cost is worth it, in the 21st Century when interventional cardiology techniques are so established.
Well, I spend Friday-Sunday with the meeting, moderating at three of the sessions. It was nice, to see old friends and also new, young and eager interventionist, some presenting their cases for us to comment. It was interesting to see the differrent approaches to interventional cardiology from all over Asia, India, China, Japan and Singapore mainly.
I was commenting to one of my fellow faculty, that each year that I come, I will see fewere and fewer of our contemporaries. We hear of the sad demise of my friend and coleague Dr Tamai, a pioneer in interventional cardiology in Japan. He was a very good worker and innovator, working with bioabsorbable stents, in the early days, and also working to perfect the teachnique to do CTOs ( chronic total occlusions ). My condolences to his family and loved ones.
Of course the present economic downturn has affected the meeting. In my observations, I think that the meeting is quieter and the vendors' support, somewhat scaled down. I saw and appreciated the work of Dr Ochai and the Japanese who patiently work on complex CTOs, spending hours to open chronically occluded, collaterised coronary arteries. I must say that I do not have their skill and patience. Not to mention that my patients may not be able to afford the cost. It also reminds me that there are still limitations to this field of interventional cardiology, and that keeps me humble and my cardiac surgical colleagues, with work.
Needless to say, Drug-Eluting Stents are used all over the place. Although I personally think that the Endeavor ( and Endeavor Resolute ) and Xience V stents are probably the best around, I can see that the Drug Eluting Balloon and also the Biomatrix DES is being greatly promoted at this meeting. Personally ( as I mention to the manufacturers ) we need more data. I understand that the Drug Eluting Balloon should receive their CE mark soon and that we should soon see more data from the Leaders ( Biomatrix ) Trial. Until then we should keep on to the approved and proven stents, for the safety and benefit of our patients.
Overall, SingLive was an eye-opener. Syabas to Tian Hai and team for putting on a trremendous show.