REVASCULARISATION IN DIABETICS WITH 3VD-CAD ; PCI OR CABG

It has been debated for along time. Which is the prefered strategy for diabetics who require revascularisation, PCI or CABG ? Eversince the advent of balloon angioplasty, all the clinical trial data ( right from BARI, in the beginning ) have always favoured CABG. But the reality is that most diabetics prefer a lesser invasive strategy like angioplasty. So clinical trials keep getting done, as the gold post keeps changing ( in the beginning, we only had balloons, and then bare-metal stents, and now drug-eluting stents ).
The November 25th online edition of the Journal of the American College of Cardiology published the results of the CARDIA ( Coronary Artery Revascularisation in Diabetes ) study. The results of this study ( from continental Europe ) was initially presented at the European Congress of Cardiology in Munich in 2008. I suppose it took along time to come out because it is from this side of the pond and also because, although they planned to enrolled 600 patients into the study, they finally only managed 510. As this was a non-inferiority study, it may affect the statistics a little. Nontheless, the final conclusion by the authors led by Dr Anil Kapur of UK was that in diabetics with 3VD-CAD, PCI ( even with drug-eluting stents ) was inferior to CABG. The results somewhat mirror that of the SYNTAX trial. The clinical events at 1 year were basically the same on both arms apart from the need for repeat revascularisation, which wer clearly more often in the PCI arm. The CABG arm suffered from a higher incidence of strokes. We have heard all these findings before. They are amazingly consistent.
If you are diabetic and you require revascularisation, you should go for CABG, but you would run the risk of a stroke. If you should choose PCI, know that you may need more then one procedure within a year ( DES or not ).
I have always wondered how the results will pen out, if we sebset the patients into their severity and mode of treatment. There are diabetics and there are diabetics. Those on Insulin as opposed to those on medical therapy? Those with renal dysfunction as opposed to those without renal dysfunction. Also, as the goal post changes, does the second generation DES make a difference? Will thin strut cobalt-chromium be bettered? Will polymerless be better?
I suppose no clinical trial can answer all the questions, as disease understanding changes and as treatment modality changes. Maybe that is why there is still a need for clinicians and clinical judgements. But sometimes insurance and third party payers who follow guidelines cannot understand this.

POOR MAN'S FIGHT AGAINST A H1N1 PANDEMIC : GARLIC, THE CHINESE WAY

It has been reported by the XinHua news agency that the price of garlic in China is soaring. In Shandong province where the price of garlic used to be 0.2 yuan / kilo has now 9 yuan / kilo. This severe rise in price reflects a severe demand for garlic, on the Chinese belief ( little medical evidence that garlic does protect a person against viruses, including A H1N1. This also happened in China with the SARS outbreak, not so long ago. A school in HangZhou is said to have bought 200kilos of raw garlic for the students to eat it at lunchtime, to prevent A H1N1 from infecting the school ( I wonder what happened, besides a lot of bad breathe ) thereafter. I must emphasize that we are talking about raw garlic here. Cooked garlic is useless. I am sure that there is some sort of smart business men involved too, hoping for a quick buck. China is one of the world's largest producer of garlic.
Looking at it medically, it is true that garlic is a sulphur containing flavinoids, with some medicinal properties. Of the many touted, perhaps the one that is best documented is the cholesterol lowering and anti-inflammatory effects of garlic. There is reasonable medical evidence that garlic is good for the heart. Along with this, it has also been reported thatgarlic may also ontain anti-oxidant and anti bacterial properties. There are also mention of some anti-viral properties. As I search around, these claims are shrouded in vague language, and nothing very scientific.
I suppose, if your loved ones can stand garlic-breathe, there is no harm to take some raw garlic daily, in the hope of protecting your heart and also, maybe ( and this is a big maybe ) protect you against A H1N1. It is certainly safer than the A H1N1 vaccines. I hope that the cost of Malaysian garlic does not increase under the guise of rain and poor harvest. It is all business afterall.

EATING FISH IS GOOD FOR THE HEART? ARE ALL FISHES THE SAME?

I just came across this small but interesting study that was presented as a poster, at the just concluded American Heart Association Annual Scientific meeting 2009 at Orlando. It was not a revolutionary study, but was practical, and I get asked this every now and then.
We all know that eating fish, helps the heart because of the omega-3-fatty acid that fish contains. This fact has spun a whole new industry of fish oil capsules for good health.
But how many of us are particular about the type of fish, and even more important, how the fish is prepared.
Well Dr Lixin Meng and her colleagues at the University of Hawaii undertook such a study. They studied and followed up 80,000 males and 100,000 females from age 45-75 yrs and followed them up for 12years. They cohort were from Los Angeles and Hawaii, and included Caucasians, Afro-Americans, Japanese, native Hawaiian, Latino Americans. Recruitment began in 1993-1996. After 12 years of follow up, they found that for the type of fishes, the deeper the sea, the better. So wild salmon and tuna were best. As for the type of cooking, raw and stir-fried ( Japanese style ) was best. Deep fried, dried, salted was worse. After 12 years of follow-up, there were about 4,500 deaths ( 2,604 males and 1,912 females ). Those who were on raw fish and stir-fried, had a 23% reduction in CV mortality ( compared to the control, who ate almost no fish ) and those who ate mainly fried, dried or salted fish had a 12-15% increase in CV mortality. This is very significant.
I suppose, the take home message will be that we should eat fish from clean deep seas ( whenever possible. Are there anymore clean, deep seas ) and we should either eat them raw or fried in the Japanese stir-fried way. It is good to know that cheap things no good, and good things no cheap. There is a cost for Japanese raw fish. As for fish-oil capsules that is so popular, we really have no data. Tuna shasimi anyone?

A H1N1 PANDEMIC : UPDATE 23th Nov 2009

The last update was on 23th Oct 2009
I thought that I should brief all of you on what's the situation.
Basically, nothing much. The US winter has began. We see the usual seasonal flu outbreak. We now cannot tell which virus is causing it. You see, in the face of the WHO declaration of pandemic ( a severe oversight or conspiracy, you decide ), doctors no longer do test to establish A H1N1. We only diagnose them as " Influenza-like illness OR ILI " and treat them. As a result, they are all now ILI, whether it is A H1N1, seasonal flu or other viruses. However, we know that the infection is mild and there is no increase in deaths. In the US, flu vaccines are optional. All the hype every now and then is from the media and pharma to keep the threat on. In China, there is an increase in reported cases. Because the deaths in the first phase ( August-September ) was so low, there is an increase in mortality. What we are very puzzled about China, is that there seem to be an increase in infection and yet, it seems to be all in China. With globalisation and mass transportation, some of it would have spill over to Hong Kong or Taiwan or even ASEAN countries. Yet we do not see that. The flu-virus is a very contagious virus with very high infectivity. One wonders whether the increase in ILI in China is due to the vaccines as China have undertaken to mass vaccinate.
As for Malaysia, we see a bit of ILI but no mortality. Things have quieten down, despite the rainy season being here in full force. In fact, it looks like Cholera, Dengue and the MCA crisis may be more important issues for YB MOH, than A H1N1. When we were talking with YB MOH, he was concerned ( and rightly so ) that with the raining season in Nov., we may see phase 2. So far ( thank God ), that has not materalised. Our vaccines, well just stock it properly, I hope. Better not to have to use it.
Since Oct 2009, there have been many web-postings of the harmful effects of the vaccines. I am sure that those of you active on the " net" would have read some of them. I have read many of them. I suppose, there is no smoke without fire. I will not elaborate on the potential harms with the vaccines. Looks like there are many out there who believes in the " conspiracy " theory.
Well, thank God that all is well, at least for the moment. However, we should all remain vigilant and keep up our standards of personal hygiene.

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

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

SAD NEWS FROM ORLANDO. IT ALSO HAPPENS IN USA

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

NEWS FROM ORLANDO : PEP-CAD - 3

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

SERUM CHOLESTEROL ESTIMATION ; TO FAST OR NOT TO FAST?

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

OBITUARY : SYMPATHY AND CONDOLENCES

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

LOW CHOLESTEROLS AND CANCERS

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

CABG, TO PUMP OR NOT TO PUMP?

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

FOOTNOTE

By the way, I wish to inform all that I am back to work. After 4 weeks of rest following my total hip replacement, I started my clinic and yesterday I have also resumed my angio list.
Thank God that all is well. The orthopedic surgeons and anaethetist are all good. Brilliant job.

ASPIRIN CONTROVERSY. TO TAKE OR NOT TO TAKE

I would like to begin by saying that I am not on aspirin. I have never had sugns and symptoms of heart disease ( Touch wood ), and I am not on statins. Those are my conflict of interest statements.
I am writing to add my little voice to the UK Royal Colege of GPs call and also the call of the UK " Drug and Therpeutics Bulletin ( DTB )" for subjects ( they are not patients as they have no disease ) or patients without documented heart disease, to stop taking aspirin, in the hope of preventing heart attacks, and death.
Obviously, since the mid-eigthies, there have at various times been various clinical trials published which seemed to suggest that taking aspirin in subjects at risk of heart disease, would prevent heart attacks. In fact, since 2005-2008, there have been 4 guidelines published by respected professional bodies, which seem to suggest that aspirin is beneficial in primary prevention, and secondary prevention. Here, we need to define a few terms. Primary prevention is a strategy to prevent a disease condition in someone who does not yet have the disease condition. So primary prevention of heart disease is a strategy to prevent heart disease in sometime who has no heart disease. Secondary prevention, on the other hand, is a strategy to prevent further disease and complication, in someone who has the disease and have survive the disease. So secondary prevention of heart disease would be to prevention further heart attacks or death, in someone with heart disease ( survivors of heart attacks, patients who had angioplasties, or by-pass surgery, etc ).
Well, it would appear ( no doubt ) that aspirin, or antiplatelet agents ( aspirin, ticlid, clopidogrel, or other newer anti-platelets that are on their way ), are beneficial in patients with know heart disease to prevent another heart attack, or cardiac death.
However, the evidence of aspirin preventing cardiac death in primary prevention is rather very weak. The DTB reviewed clinical evidence from 6 large " RCT-Randomised clinical trials ) involving 95,000 subjects, and found that the use of aspirin in primary prevention is associated with an increase risk of GIT and cranial bleed without a benefit in lower cardiac death rates ( so all risk, no benefit ). There is a minor reduction in non-fatal heart attacks. This reviewed was published in the Lancet recently.
So for all those out there who are taking aspirin for primary prevention, please note that you have given yourself the risk of a GIT bleed and even worse, hemorrhagic stroke, without much cardiac benefit. I suggest that you consult your favourite GP for advice, and reconsider.

NEWS UPDATE : STROKE AND SUDDEN CARDIAC DEATH

Over the weekend, we hear of two unpleasant news. Firstly on saturday, it was reported that a young boy from Penang, Master Edward Khoo, when to take a nap and never woke up again. You will remember the 10th Oct 2009 posting when we discussed preventable cardiac death. It is very like that the terminal event is primary ventricular fibrillation ( a condition where the ellectrical conduction system in the heart just goes chaotic, causing the heart to failure to contract in a co-ordinated manner, resulting in sudden collapse of the whole body circulation, resulting in death ). Such situation can occur from intinsic heart muscle disease ( we call cardiomyopathy ), or heart muscle disease due to secondary causes like virus infections ( including the seasonal flu virus ), chemicals and toxins, it may also be congenital ( meaning that he was born with flabby heart muscle, with vulnerbility to arrhythmias ( irregular heart rhythm ). We also mention in the 10th Oct article that sometimes the heart is normal, but they have heart muscle vulnerbility to ventricular fibrillation. Anyway, this death is most unfortunate and I hope that all the members of the immediate family will go for a thorough cardiological assessment to make sure that no one else will suffer this unfortunate fate.
The second event, reported on saturday too, is that of my former neighbour ( datuk Mohd Nadzmi ) who had traveled to Chenai on a trade mission, and came down with a mild stroke. He was hospitalised in Apollo Hospital ( one of the better private hospitals in Chenai ), and I understand from the news report today that he is making good recovery and should be ready for discharge in a few days. That certainly is good news and we wish him a speedy recovery. Nadzmi is a nice neighbour, very friendly and considerate, and have done very well. Coming from Kelantan ( I think ), he had successfully climbed the corporate ladder to become the chairman of Proton and also the MD of many other listed companies. He is also the chairman of BAM. He is chubby and obviously under tremendous stress. I have always joked with him ( he is always smiling ), whenever he invites us for his Hari Raya dos that he must watch his diet and get a medical checkup. A man in his position. I suppose after this scare, I am sure that his doctor will put the fear of God into him and have him lose weight and also handle the stress better, so that there is no repeat. well Nadzmi, get well soon. And please follow the doctors advice. Strokes can be prevented.