INTERVENTIONAL CARDIOLOGIST SENTENCED TO 10 YEARS JAIL.

The attorney general's office of Lafayette, Louisiana, USA, has announced that Dr M Patel, has been convicted and sentenced to 10 years jail having been found guilty of performing unnecessary angioplasties and implanting unnecessary stents. It is indeed a sad day. Dr Patel is a well trained interventionist, respected in his community. It is always sad to hear that one of our doctors have been found guilty of committing a crime. Apparently, complaints were lodged by some of his patients who discovered that they had stents implanted in what were apparently normal arteries or arteries with minimal disease. He was also found guilty of falsifying case notes and documents, stating that patients had chest pains when they did not have and also filed false insurance reports.
I am posting this hoping that our local interventionist will take note and also that patients will take care, when they consult their doctors, to always ask relevant questions to see if treatment and procedures recommended by doctors, are necessary, or also discuss the pros and cons of all procedure, especially when the procedures carry a risk.Interventional cardiology, as a discipline is particularly prone to abuse, because the same doctor who first sees the patient, is also usually the one who performs the non-invasive test that decides the need to do the invasive coronary angiogram, which also usually results in the in his interpretation and conclusion that the patient needs an angioplasty or coronary intervention. As many had claimed ( when we discuss such issues ) that we are the judge, jury and also executioner. This then can result in abuse.
I always advice my patients that in all medical treatment strategy, if the condition is an emergency, you must trust the doctor who came to take care of the emergency and depend on his advice to carry out the emergency treatment. ( An emergency is defined as a situation that requires emergency treatment, otherwise the condition can result in death, like perforated appendicitis, cerebral hemorrhage, acute heart attack, etc ). In all elective situation ( like patient who walks in for a consult ), whenever an invasive strategy is advised, always ask if the treatment is necessary and if you can have a second opinion. It will be good, to make such request, in a very polite and non-offensive manner. It is the right of all patients to have a second opinion, if they wish and no medical doctor should be offended.
Maybe, by doing that, we can avoid abuses and certainly we hope not to see another Dr Patel, go to jail. It is bad for him, his family, his patients and also for the profession.

DOING MORE DOES NOT MEAN BETTER; DOES RENAL ARERY STENTING HELP ATHEROSCLEROTIC RENAL ARTERY STENOSIS

It is not uncommon for me to be asked at professional ( Interventional ) meetings on whether I thought that renal artery stenting help improved BP control and renal function, in patients with atherosclerotic renal artery stenosis and deteriorating renal function. Does renal artery stenting help improve renal function.
I have often held the view that the answer is no. Renal artery interventionist ( probably because of the oculo-stenotic reflex ) often considered that any stenosis, if relieved, will help the patient, and that stents ( and nowadays drug-eluting stents ) will help.
The 16th June issue of Annals of Internal Medicine, carried a study by Dutch aorkwers led by Dr Liesbeth Bax, on 140 patients comparing medical therapy with renal artery stenting, in patients with artherosclerotic renal artery stenosis, and poor renal functions. The results showed that whether you had just good medical therapy and renal artery stenting + medications, there was no difference in outcome as far as renal function is concerned. Good medical therapy was just as good as intervention + medication. Again, the oculo-stenotic reflex should be severely controlled by interventionist ( and dare I say, by young, aggressive interventionist ). Not as far as evidence based medicine is concerned. Not to say that renal artery intervention does carry some risk. I note from Dr Bax study that there were two deaths in about 40 odd patients who received renal artery intervention ( something like 4% ). That is high.
This study by Dr Bax also looks like a renal, mirror image of the "COURAGE TRIAL " for management of coronary artery disease. Coronary artery interventions in assympotomatic CAD ( as one would find in mass public MSCT screening of CAD ), does no better than intensive medical therapy. Of course, that is not to mention the financial angle.
I was concerned because 2 weeks ago, a patient was refered to me for renal artery artery intervention with hypertension. This patient also had significant CAD. In fact, I ended up stenting his important coronary disease, but also took a quick angiographic look at the renals, and found them to me normal.
Now I know that medical therapy for hypertension and renal failure is still very good therapy, as good as interventional therapy.
Stated in another way, doing less may be as good as doing more.

NURICEUTICALS : ANOTHER PROVEN. RED YEAST TO LOWER LDL-C

Another food product, this time red yeast, has been shown to lower LDL-Cholesterol. The study, by a group of workers from Philadelphia, was published in the June 16th issue of the Annals of Internal Medicine, by Dr David Becker and colleagues. They studied the use of red yeast, to lower LDL-C in patients who were statin intolerant. They studied 62 patients who had side effects from Statins. These patients had raised serum total and LDL-Cholesterol. 31 patients received placebo and 31 patients received red yeast rice at 1,800mg twice daily. After 12 weeks and 24 weeks their lipids were measured.
After 12 and 24 weeks of treatment with red yeast, the total cholesterol, triglycerides, and particularly LDL-cholesterol were significantly lowered, when compared to the placebo arm. There was almost no effect on HDL-cholesterol. Of course there was no significant side effects.
We have known for a longtime that red yeast rice contains lovastatin ( remember that lovastatin was discovered by the Japanese from a yeast ). I first learn if this from one of my patient years ago, when I started him on pravastatin. He brought to my clinic one day, a bottle of "Hypochol " which is the generic name for red yeast. He said that it is available in Singapore ( at that time ) and it was cheap, much cheaper than statins.
This study brings up two important points. I wonder why the authors ( these are Americans ) did not choose to use Ezetimide, as I do, when I am faced with a statin intolerant patient. The other point I noted was that it would appear that natural, yeast form of lovastatin does not have myalgia as opposed to manufactured lovastatin. Is it the statins or the other added ingredients?
Whatever it is, I am glad to note there there is evidence coming out that some herbs, in this case red yeast rice, can lower LDL-cholesterol. It is also interesting to note that American doctors are studying herbal compounds.
Of course, with more and more of these studies ( and I hope that there will be more ), soon it will be difficult to differentiate between "nutriceuticals " and " herbal medicine". Looks like in a broader aspect, there may be some basis for traditional complementary medicine. But before the TCM ( Traditional and Complementary Medicine ) people get too carried away, we certainly hope that they will also follow the path of evidence base medicine. This is our humble plea.

ONE NATION BEGINS TO CURB ITS SALT INTAKE ; THE PORTUGUESE STORY

At the recently concluded European Meeting on Hypertension 2009, held at Milan, DrLuis Martin from Porto, a member of the Portuguese Society of hypertension, reported their success story. They managed to get the Portuguese government to restrict the amount of salt in process foods, and also for foods to carry a salt label. At Milan, Dr Martin was given the oppoortunity to share the Portuguese experience in trying to restrict salt intake, thereby reducing hypertension, CAD and strokes. It is important to note that Portugal, a country of 10 million, has the highest stroke rate in Europe, many cases attributed to hypertension.
In his experience, it was important to use the mass media, with involvement of celebraties ( footballers, comedians etc ) to highlight the issues and lobby the politicians. They formed the Portuguese Action Against Salt and Hypertension ( PAASH ) society, to bring awareness of the dangers of salt. They found that Portugal bread had the highest salt content in Europe and that Portuguese were consuming about 12 gms of salt a day, when it should be one third that. PAASH then successfully lobbied the Portuguese Bakers association to reduce the amount of salt in Portuguese bread. Their mass media approach then bought the attention of the politicians, who subsequently drafted laws to limit salt in process foods.
The Milan meeting, in agreement with the Portuguese Society of Hypertension, concluded that " if you can reduce the salt intake for the whole population and shift their blood-pressure distribution, it has a major impact on the incidence of stroke and also coronary heart disease. The same thing should be tried in all countries."
Certainly we in Malaysia have a long way to go. I suppose one of the best ways to limit healthcare expenditure for the country is to prevent diseases, especially thos ethat can be prevented. The lifestyle diseases can certainly be prevented, including obesity, hypertension, diabetes and heart disease ( CAD ). I tell my patient no added salt or sauce in their food and warn them of a taste adjustment period of about 1 week. Can we do these on a nation wide scale. Perhaps we should start with some form of food labelling so that at least we know which are the heavy salt items and where to target our initiative.
Maybe we should follow the Portuguese example, but then we are Malaysians. Can we ever form a Malaysian Action Against Salt and Hypertension Society?

UPDATE IN THE MANAGEMENT OF ACUTE STROKES

The cream of neurology met in San Diego in Feb 2009, to review and update the management of acute strokes. This was published in Medscape, and now availbale on-line for review. Interesting. Looks like there have been much advance since my medical officer days. A stroke occurs when a brain artery gets blocked, causing sudden lack of blow flow to the brain and that results in sudden lost of function of that part of the brain that is supplied by that blood vessel. This usually results in paralysis on one half of the body. This sudden paralysis, can be catastrophic and devastating, causing an active individual to suddenly become dependant, not being able to take care of his/her own needs. Besides the obvious functional disability, there is the emotional and mental disability, resulting in a severe transformation of that persons whole life outlook. Yes, a stroke is devastating.
The neurologist have been working very hard to improve stroke outcomes. As a cardiologist, I can see that many of their advances is modelled on the advances in cardiology in the treatment of acute heart attacks. They now also have what they term, acute brain attack ( for strokes ) and the call to set up stroke units in major hospital, in an attempt to improve on the acute management of strokes. Yes, they are also on to the use of IV and also intra-cerebral arterial r-TPA as a acute thrombolytic agent to revascularise the infarcted brain. Of course, hemorrhage in the brain is much less well tolerated the myocardial hemorrhage following thrombolysis in AMI. Their time window for the benefit of rTPA is 3-4.5 hrs, not unlike the time window for AMI thrombolysis. Just as the acute ECG is all important for us, the acute CT scan of the brain is very important for them. Some stroke units also do acute CT angiograms to better demarcate the territory of supply. The neurologist have also tried acute angioplasty and the use of stents, but the conference concluded that there was not yet enough evidence to show benefit, and so is not yet ready for widespread use. Acute brain surgery also has a role, but a very limited role. Hemicrainectomy, prolongs life but does not improving quality of life ( if you know what I mean ).
I suppose, in many sense, the neurologist is not wrong in following many of the approaches of the cardiologist. Afterall, we are dealing with blood vessels and vascular supplies, and when occluded, a sudden loss of blood supply and their consequences. In this sense, stroke units ( like CCUs ) and thrombolysis and door-to-needle time becomes important similar concepts. We await large scale clinical trials ( I do not think that they can be blinded or randomised ) to show us if primary angioplasty for strokes will improve outcomes when compared to IV thrombolysis.
What I did not see enough in their San Diego conference was an emphasis on stroke prevention. Control of blood pressure, prevention of diabetes and obesity, stop smoking, lower serum cholesterol, and LDL-cholesterol, adequate exercise, adequate rest and sleep, are all as important, if not more important, in my opinion, than IV r-TPA and acute stroke units. Maybe there is nothing new there. I felt that strokes, like CAD and heart attacks are better prevented. An acute stroke is in many ways a failure of prevention, and doctors must do their most to avoid that. It is something that many doctors personally too, would like to avoid, myself included.

SLEEP AND BLOOD PRESSURE

Sleep is often undervalued as an important part of health maintainence. Sleep deprivation for short periods maybe ok, but certainly, chronic insomnics do face a health pproblem of cardiovascular upsets, general body malaise and poor immunity. The fact that we have 8 hours of rest at night allows the body to re-charge ( everyone knows that ). In our clinic ( which is obviously a CVS clinic ), I make it a point to ask about sleep in all my patients, many of whom are suffering from hypertension and sometimes even frequent " flus ". I have noticed for awhile now that poor bloop pressure control is often due to poor sleep patterns and insomnia.
Poor sleep patterns could be due to emotional stress ( a simple word for this is worry ), poor personal habits, age and maybe also a poor environment. When we do not get enough sleep, the body metabolism has no chance to rest and our catecholamine levels, remain chronically high. It is well shown that chronic lack of sleep is associated with high baseline catecholamine levels. And chronically high catecholamine levels drives sleeplessness. This is probably the reason why people who do not sleep well develop hypertension.
This is now confirmed in a study out of the U. of Chicago, by Dr K Knutson, and group published in the June 8th issue of the Archives of Internal Medicine. Their observation is part of the CARDIA study. In this sub-study, Dr Knutson studied the sleep pattern of 578 patients ( part of the CARDIA group ) who have no hypertension. He have them wear a wrist activity sensor, so that he can measure their wrist motions during sleep. Less motion more sleep and more motion less sleep. He followed them up for 5 years, and noticed that after 5 years, those with less sleep were one third more likely to develop hypertension. Thus lending credence to our theory that sleep affects blood pressure. That may also explain why senior citizens are more prone to hypertension and other CV events, as they have a higher incidence of insomnia.
Doctors, if your patient's BP is not easily controlled and seem to be bobbing up and down, check their sleep pattern. As a corollary, it is also wellknown that sleep apnea is associated with a higher incidence of hypertension.
It is therefore important in our healthy lifestyle campaign to inculcate a healthy sleep pattern, which may require a healthy and restive mind, at peace with itself.

DRUG COATED BALLOON - DEB, WHAT'S NEW?

I first heard about the drug coated balloon three years ago, and have always wondered how a balloon coated with a drug, and then passing the balloon to the site of treatment, and attaching or contacting the balloon ( drug coated ) with the vessel wall for 30 secs, could allow the drug to work and cause less restenosis. Apparently it does. I was not convinced at first. Over many meetings, I had many occasions to meet Dr Martin, a pleasant German. He convinced me to try it. So I had actually used it on three patients over the last two years. These patients all had recurrent in-stent restenosis on drug eluting stents, on a previous bare metal stent. Since there was so much metal over the injured coronary arterial site, I thought that I will try the DEB ( Drug Eluting Balloon ). So far so good. They have all gone pass one year and no evidence problem. Stress test-wise ok.
This June 1 issue of Circulation carried an article by Dr Martin Unverdorben, on the use of the drug coated ( eluting ) balloon in the treatment of in-stent restenosis. The study, known as the Paclitaxel-Eluting PTCA-Balloon Catheter in Coronary Artery Disease-2 In-Stent Restenosis (PEPCAD-2 ISR) trial, was previously presented at the American College of Cardiology 2008 Scientific Sessions/i2 Summit-SCAI Annual Meeting. This study compared the use of the BBruan DEB against the Taxus stent in the treatment of in-stent restenosis. He studied 131 patients, divided into the treatment arm and the control arm ( Taxus stent ). After six months followup, the DEB arm has less MACE events, although the binary restenosis were the same.
I must say that in an earlier study, their competitor ( Eurocor ) DEB did not do so well.
The DEB, if proven longterm to be good offers many advantages in terms of cost, less metal implanted and maybe less longterm implications. However, 131 patients and 6 months followup is to smal and too short a time. We look forward to more patients being studied , over a longer period of time, to allow us to be more confident and to know how to use it.
For the moment, the BBruan DEB, Sequent Please, holds promise , in the treatment of in-stent restenosis, especially those that occurs after the implantation of a DES.

NEW CARDIAC NUTRICEUTICALS : TOMATOES AND CRANBERRIES

This week saw the announcement of two new nutriceuticals, that will reduce oxidised LDL or at least LDL-Cholesterol. Nutriceuticals are natural food products which have pharmaceutical value.
The Cambridge workers at Addenbroke's Hospital announced this week that they have produced a pill called Ateronon, from the skin of tomatoes, which they claim will lower oxidised LDL. Tomoato skin contains lycopenes, which are supposed to have reduced the level of oxidised LDL in the atheromatous plauques. The Cambridge scientist studied 150 patients with CAD who were given this new pill for 8 weeks and were found to have lower levels of oxidised LDL. We are given few other details in this BBC report. Obviously we need more data and perhaps some clinical trial with larger numbers. Surfice to say that there is no harm eating more tomatoes, especially if they are big and juicy. But please wash them well.
The medical news this week also carried a report by in Clinical Lipidology, which carried an article on the role of Functional Foods in the primary prevention of CAD : Cranberry extracts and cholesterol lowering. The authors review previous data on cranberry extracts and their ability to lower LDL-C by 12%, almost the levels of some of the weaker statins. There was however no effects on oxidised LDL and also hs-CRP. Cranberry contains some phytosterols and presumably it is this phytosterols that is the reason for this beneficial LDL-Cholesterol effects. Again, we need more data.
It appears that the data on most nutriceuticals is rather confusing and without the benefit of large randomised control trials, we will never be sure. Then again, the OTC sales of these "proven " nutriceuticals are a multi-million dollar industry and yet, we have so little data to recommend their use medically, with few exceptions like fish oils and red wine. Maybe the Italian or Spanish diet with red wine, cranberry sauce and lots of tomatoes, help to protect the Europeans.
As for the Chinese, we look forward to data from garlic and gingko extracts.

AN ASPIRIN A DAY KEEPS THE CARDIOLOGIST AWAY, OR DOES IT?

Whenever I talk to GPs or lay people, it is often that I will be asked if they should be taking aspirin to prevent heart attacks, and why do we not ask the government to put a little aspirin in our drinking water, so that all of us would have a bit of aspirin everyday?
The latest meta-analysis of the use of aspirin in primary and secondary prevention of cardiovascular events, in the latest issue of Lancet, seem to caution against routine use of low dose aspirin. Prof Baigent of Oxford, conducted a meta-analysis of 110,000 subjects / patients in 23 clinical trials, 6 trials involving about 95,000 subjects without prior history of heart disease and 17 clinical trials involving about 17,000 patients with known heart disease. They found that in this first group ( the subjects with no known heart disease ), low dose aspirin reduced heart attacks and strokes by about a fifth with no significant reduction in cardiac deaths, but this was at a cost of about a third increase incidence of gastro-toxicity ( gastric side effects ). In the second group ( the 17,000 patients with known heart disease ), the cardiac event reduction was easily significant, with the usual rate of gastric upsets. The conclusion must be ( and this makes sense ) that the use of low dose aspirin should be individualised and obviously should be given to all who have had a cardiac event or stroke. In other words, low dose aspirin is beneficial in secondary prevention of cardiovascular events and strokes but not in primary prevention.
An aspirin a day may keep the cardiologist away, but may keep the gastroenterologist busy.