SUDDEN CARDIAC DEATH, REVISITED

I have written on this earlier, and because of popular enquiry, I would like to post it again.

One of the most often topic of conversation at the golf club, is " you know Doc, my friend who is ....... so young suddenly collapsed and died". This happened again last Saturday.
I will try and do this one in a question and answer manner, hoping that it will be easier to understand.

1. What is sudden cardiac death ( SCD )?
Sudden cardiac death ( SCD ) is death whithin 24 hrs upon presentation of symptom. In this case, the presentation is sudden collapse. Barring foul play, the majority of deaths occurring within 24 hrs of presentation is due to cardiac causes, ranging from an acute heart attack, to sudden prolonged irregular heart rhythm causing the heat to beat so chaotically that it seizes to function normally. We call this life threatening heart rhythm irregularity, ventricular fibrillation.

2. Can a young person, who appears hale and hearthy, playing golf, exercising regularly, suddenly collapse and die?
The simple answer is " Yes ". Many may appear hale and hearthy and perfectly normal, but that does not mean they ARE hale and hearthy, especially in the case of heart disease, that can be silent, and only picked up or uncovered through a good cardiac checkup. I will take up the issue of good cardiac checkup later.

3. What actually happen, for an apparently healthy guy / or gal for that matter, to suddenly collapsed and die?
Many who have stable coronary artery disease may appear hale and hearthy. Coronary artery disease is disease of the arteries of the heart, due to cholesterol piling up in the walls of the artery. The cholesterol usually built up in the space between the middle layer of the heart artery and the innermost layer ( also called the endothelium ). As long as the inner lining, the endothelium, is intact, the plaque ( cholesterol built up ) is stable and does not cause any problem apart from maybe chest pains, when the built-up is critical. If the bulit-up is non-critical in proportion, the whole process is silent and the subject appears hale and hearthy and normal ( including some famous athletes and sportmen ).
However, should the inner lining of the artery wall crack ( unstable plaque ), or rupture, as a result of many factors, including stress, excitement, hypertension, cigarette smoking, cocaine abuse, etc, the pile of cholesterol below the endothelium, is exposed to the blood flowing pass. This contact of blood with the cholesterol is a fatal combination, as blood clots quickly when it touches the cholesterol. The sudden blood clotting obstructs the heart artery lumen completely, resulting in NO BLOOD flow to the heart muscle, causing a heart attack, or chaotic irregular heart rhytm and sudden cardiac death.
Medical science have yet to have a reliable means to see which of the many plaques in our artery is stable, and will remain so, and which is potentially unstable, with the tendency to heart attacks and sudden cardiac death. Much work has been done and we are getting there but not yet. Therefore the strategy is to identify all with coronary artery disease, especially the silent majority, and treat them so that SCD become a thing of the past.

4. How do I know if I have heart disease?
The first thing is to see your family doctor who will help you to identify your cardiac risk profile and who would give you a thorough cardiac check. If he cannot perform all the test himself / herself, you may be refered to a cardiologist.
Cardiac risk factors include cigarette smoking, high clolesterol, hypertension, diabetes mellitus, obesity, males above 40yrs, females above 50 yrs, a family history of heart disease, stressful lifestyle.
As a general rule, we would advise all males above 40 yrs and females above 50yrs, to go and see your favourate GP and get a checkup done. A consultation with some blood test and ECG may cost about RM200-300 and if he includes a stress ECG, it may come to RM500-600. I think that money is well spend. If the check up is normal, an annual consultation with annual blood test ( RM200 ), is sufficient and a stress ECG every 2-3 years.
By going for a ckeck-up, we hope to pick up most of the silent CAD cases and treat them so that SCD can be prevented.

5. What else can I do, to protect myself?
As always, a healthy cardiac lifestyle, is important. Eat in moderation, low fat and low salt. Keep onto green veges, fruits and white meat. Use vegetable oil for cooking and avoid fast foods ( with all the transfats ), watch your weight and DO NOT gain weight. Exercise regularly, at least 3 times a week.

We will write about other forms of cardiac testing, pros and cons later. I need to start my clinic.

BRUSHING YOUR TEETH AND YOUR HEART

The 27th May issue of the British Medical Journal, carried an interesting article by Prof Richard Watt of University College London. His team carried out a survey in Scotland ( the Scottish have a high incidence of Coronary Heart Disease ) of 11,000 adult Scots and asked them questions regarding their life-style ( smoking, exercise, diet ) and dental hygeine ( including how often they brush their teeth and how often they visited their dentist. They were also asked abut their history of heart disease, family history of heart disease and clinical biochemical profile. ( Lets not ask why an English team is study heart disease in Scotland )
What Prof Watts and team discovered was that people who brush their teeth less them twice a day, had a higher incidence of heart disease, when compared with those who brush their teeth twice per day. No, they did not enquire as to the tooth paste brand and toothbrush used.
This is probably the first and largest survey, that showed a correlation between dental hygeine and heart disease.
We have always suspected that chronic inflammation may be a risk factor for coronary artery disease, in some ways supporting the inflammation hypothesis of atherosclerosis. They were earlier small studies which correlated gingivitis and chronic peridontitis with heart disease.
However, the earlier trials when antibiotics were given to patients with raised LDL-C did not seem to reduce the incidence of heart disease. ( In the PROVE-IT TIMI 18 trial, statins but not antibiotics rduce the incidence of MACE ).
I suppose, it is reasonable that we should take care of our oral hygeine, and besides many good reasons, it may also reduce heart disease. It is also important to note that the study did not show that if you brush more then twice a day is better. Everything in moderation.

SNIPPETS FROM EUROPCR 2010, PARIS

There may be some of you out there, like me, who has interest in Interventional Cardiology but not the opportunity or interest to travel so far to Paris. I have given up doing that, and rely on contacts and the " Net" to hear what is happening there. The EuroPCR started in Paris over the weekend. Looks like nothing revolutionary. Many evolutionary, improvements. I thought that I will update you all on the latest from Paris, EuroPCR 2010.
Looks like Medtronic International must be very pleased when they announced the results of " Resolute All-comers " trial, showing that out to 1 year, the Endeavor Resolute stent performed as well as the Xience V stent, and was " non-inferior". Remember that the Xience V is now considered by many to the benchmark DES, second generation. Many DES would rather compare with the Taxus family ( first generation DES ).
The other important news from Paris is that the NEVO stent ( JnJ Cordis ) continue to math the Taxus Liberte ( first generation DES ) after 1 year followup. These was the results of the RES-1 study, reported by Dr Abizaid at Paris. Remeber that the NEVO stent is a re-invented version of the previous failed Conors stent ( the stent with the pit technology ). This time, they filled the pits with sirolimus and no polymer, and showed that they are just as good as the Taxus liberte DES at 1 year.
The third important finding ( my opinion ) was the release of the 1 year results of the Taxus Element stent. This is a platinum chromium alloy based paclitexal coated, ultra thin struts DES. I was a liitle disappointed with the results from the PERSEUS study ( comparing Taxus element with Taxus express ), because the Taxus express is really a crude first generation DES, and it has fared the worse in all the DES trials. Also, I hear that there were two instances of stent strut fracture in the Taxus Element group, although the author reported that there were no untoward incidences resulting from the fracture. I was concern that if this stent is so strong ( platinum chromium ), then it should not fracture especially when they are implanted by experts chosen to implant them. That is worrying, as we have seen Cypher stent fractures resulting in re-stenosis and also stent thrombosis.
Well Euro PCR is almost ending, and Roland Garros is on st this time. It may have been more exciting at Roland Garros then EuroPCR. Did not see anything revolutionary at EuroPCR but many talented youngsters at Roland Garros.

SEX AND THE HEART ; SEX AFTER A HEART ATTACK

It is true that doctors are shy people and often have difficulty talking about the issue of sex, much more so in the Asian context. Yet sex forms a very important part of many peoples' life, even though they maybe 50, 60 or 70 years old. One cannot say that we have fully recovered from a heart attack inless one have fully return to ones own regular activity ( those activity level as it was prior to the heart attack. More so with all the new interventional technigue that allows fuller and faster recovery.
At the recent AHA sponsored meeting on " Quality of Care and Outcomes Research in Cardiovascular Disease and Stroke 2010, Prof Stacy Tessler Lindau, a professor of OG and also medicine and geriatrics, from the University of Chicago, presented an interesting paper entitled " Translational Research Investigating Underlying Disparities in Recovery from Acute Myocardial Infarction: Patients' Health Status (TRIUMPH) study. ( What a nice and appropriate acronym ). In this paper, she described a study of 1184 males and 516 females, and interviewed them on their sexual habits before the index heart attack ( obviously these people were from from on-going research, as we cannot predict anheart attack ), following discharge from the index heart attack, 1 year later following the heart attack and more then 1 year later. She found that most of the patients were still sexually active before their heart attacks. That at discharge less then half were given counselling on sex after the heart attack. At 1 year, less then half of the patients were having regular sex, but by 2 years, many had returned back to their usual sexual habits. It also clearly shown in the study, that males are more likely to talk about sex and to raise the subject then females, and less females care for sex after their heart attacks.
The lesson I learn is that sex is part of normal life and age is no barrier. Even following a heart attack, many still wish to have sex. However, because of lack of cardiac counselling, immediately follwoing the heart attack, many were cautious, did not know what to do, and so refrain from doing, just in case. After 1 year, the urge to have sex is strong and so they experiment and continue, and return to their normal habits.
For those who wish to know, it is OK to have sex following a heart attack, once your doctor allow you to return back to moderate activity. Basically, if you can climb 2 flights of stairs, sex should not be an issue. It may be wiser for the non-heart attack partner to take a more active role. It would be good to avoid viagra. These advice are eaier to give now that angioplasty has improved the outcomes following a heart attack, allowing aptients to return back to their normal life style faster, and that includes sex.
As for doctors, the take home message must be that we should spend more time counselling our patients following their heart attacks and that includes talking about their sex life.

PUTTING THE USE OF STATINS IN PERSPECTIVE, THE GOOD AND THE BAD

The 20th May issue of BMJ ( British Medical Journal ), carried an interesting piece of work by Prof Julia Hippisley-Cox and colleagues from the University of Notthingham. They studied about 2 million patients prescribed statins by 350 GP group practices throughout UK. They were studying the adverse reactions to statins, hoping to see some patterns and set up a computer algorithm, so that GPs can use statins more wisely and hope to get the benefits of statins without getting the side effects. That is all well and good, as we are all aware that the benefits of statins far outweigh the harm of statins and this study des give us more evidence of that, from the GP practice in UK.
However, I did learn a few things reading the article. It looks like ( as we all know ), many of the liver dysfunctions and myopathies, are somewhat dose related. When you use superstatins or statins at superdoses ( rosuvastatin 20mg and above, atotvastatins 40mg and above, simvastatin 20 mg and above ) you must be prepared to accept some adverse effects. In fact, in their study, Prof Julia found that for every 10,000 high risk women treated with statins, there were 74 more cases of liver dysfunction, 23 more cases of acute renal failure, 307 more cases of cataract and 39 more cases of myopathy. These adverse effects were not any statin specific and seemed to be a class effect. However, what was surprising was that fluvastatin ( in the British experience ) seemed to be associated with a higher incidence of liver dysfunction. However, it must also be said that for the 10,000 high risk women treated by statins, 271 less CVS events were recorded. I will take this with a pinch of salt as all the high risk women in UK must be on statins by now, so that there cannot be a control arm to measure against.
I suppose, the point to make is that statins are good for the heart. It definitely reduces major adverse cardiac events, but it must not be carelessly used as there could be profiound adverse reactions. It is true that most of the adverse reactions are reversible, but some maybe too severe and some have resulted in deaths.
The study also does make a statement that they did not see an increase incidence of cancers in the 2 million or so patients treated, and in fact, they claimed a reduction in the incidence of oesophageal cancers in the study cohort.
Certainly, their algorithm is helful for those of us who sees high risk CAD patients. It will help us to make better decisions as to who to teat and with what dose. Whatever it is, always use a drug only when it does more good then harm. If it cant do much good ( low risk group ), then any potential harm is not acceptable.

YOGA LOWERS BLOOD PRESSURE. SOME EVIDENCE

It has been wellknown for a longtime that our blood pressure is in many ways affected by adrenaline levels, and in the normal human being, that means " stress " as adrenaline is very much an interanl stress hormones. That explains why, whenever we are stressed, our BP rises, be it by lack of sleep, tense preparation for an important report or interview, arrival at the doctor's clinic, confronted by a threat ( thief, robber, kidnapper police person, etc .).
In the just concluded EuroPrevent 2010 at Prague ( should have gone for this one. Prague is a nice city ), Dr Wolfgang Mayer-Berger of Germany, presented a study comparing the effect of Yoga ( in its traditional Indian form ) against PMR ( Progressive muscle relaxation ), in BP lowering, in 340 male hypertensives. The PMR was as practiced in Germany ( the control ). It was a stress relaxation technigue, pioneered by Dr Edmud Johnson, and had been extensively used in Germany for " de-stressing ". The Yoga, as used in this study is the ViniYoga, a form of positional Yoga, the positions were used for the purpose of relaxation. The 340 patients were divided into two groups and given 5 sessions of the relaxation exercise ( PMR or Yoga ) over 3 weeks. Each sessions were to last 30 mins. At the end of 3 weeks, the patients BP were measured and it was found that the patients from the Yoga arm had significantly lower BP then those in the PMR arm. Mind you, all these patients were asked to continue with their usual manti-hypertensive medications. Some of them were on triple therapy. The higher their starting BP, the greater the reduction by Yoga.
This study just gives us some data on what we had suspected all along, that physical methods of relaxation and good lifestyle can signifiacntly reduce BP in hypertensives. The reliance on drugs, should be minimised, although it is so much easier to dish out a pill, and for some, so much more profitable too.
I was also very impressed on congresses for the prevention of heart disease as EuroPrevent is trying to do. I wonder who is financing this meeting. It cannot be greatly supported by pharmas or divice companies and I dont see European Union supporting it. But it is certainly a step in the right direction, and I certainly hope that our own heart foundation will organise the same.
Chronic life-style diseases ( as CAD are ) must be prevented, not treated, as a main strategy.

NUTS ARE GOOD FOR THE HEART. ANOTHER NUTRICEUTICAL

It was alongtime ago when I posted a piece on nuts, cholesterol and the heart. At that time it was thought that there were some differences in their effectiveness and protection. That walnut was superior to the other nuts. I remember this because, after reading the article, I went out to buy walnuts to try it out.
Well, Dr Joan Sabate and colleagues at the Loma Linda University in California, undertook a meta analysis of the data on nuts and the heart. The analysed 25 studies involving about 583 patients, who had baseline lipid levels and also a history of nuts consumption. Their findings was published in the May 11 issue of the Archives of Internal Medicine. Basically, they found that consuming 4 servings of nuts a week, could reduce your LDL-C by about 8% and extrapolated, could reduce your risk of coronary heart disease by about 40%. This seem to be true whichever nuts you consume. It could be almonds, pecans, pistachios, hazelnuts. walnut or even peanuts. The more nuts, the better the reduction and the higher the initial baseline cholesterol, the more the reduction. Not to forget the lowering the troublesome cholesterol is onething. Nuts also improve endothelial function, and so allow for better flow characteristics. I must say that nuts, a nice conversation and a good glass of wine, is so good to relax, and maybe that is why it is good for the heart.
However, one must not forget that nuts also contain some aflotoxins which could potentially be harmful to the liver.
Well, the world cup football is almost upon us. Perhaps the preferred "munchies" this time should be nuts, and for the wine lovers, a good glass of reds.

FPMPAM WEEKEND SEMINAR IN CARDIOLOGY FOR GPs 2010

I spend sunday in Ipoh, Tower Regency Hotel, running the FPMPAM Weekend seminar in Cardiology for GPs 2010. The whole event went well and we covered a whole range of cardiac issues, from controversies to primary and secondary prevention of heart disease. From diabtic management to hypertension and also angioplasty and drug eluting stents. The GPs ( who made up about 70% of the 200 present ) also had tutorials in ECG, in view of the Healthcare Facilities Act. There was also a short talk on the bisuness of medicine, which is getting more relevance nowadays, what with rising cost of healthcare, and big corporate institution owning hospitals and medical centers, whose only objective is " the bottomline " of profit.
I was very impress by the large turnout ( as I was warn earlier that 40-50 was the usual number ) and most of them stayed till the last session at 5pm. I was also very grateful to the faculty, some who drove all the way from KL to help to teach. This augurs well for the country in future. That young doctors in the private sector will take their valuable time off to help other doctors.
I must say that Ipoh could do with better conference facilities in hotels for these meetings of a few hundred people. Even the toilet was inadequate and the lifts was confusing, some going to some floors and not other floors.
All in all, it was a good meeting and all who came found it beneficial. In fact, two spoke to me to do it regularly. I am not sure if I have the energy to do that as we are all growing older and tire easily.
I must also thank the sponsors who turn up in good nymber to lend a festival admosphere to the event, displaying their wares and products and I see one company making direct sales, with money exchanged. This is the only one who made hard cash yesterday at the event. I am always grateful to the sponsors, as without them, I believe, this country will not have effective CME for her doctors. I hear one syory told to me that the attendance would have been better, if I had written that the meeting admission was free ( the meeting admission had a fee, paid for by the sponsors ). Some thought that they must pay. They decline to come. But when they were told later that the company would sponsor them, they signed up. That is the state of CME interest in Malaysia.
Be that as it may, the overall interest was good. We did our teaching and sharing and I hope that the doctors and the country as a whole befitted.
That was our weekend in Ipoh.

MORE EVIDENCE ON NUTRICEUTICALS - BERBERINE, RED YEAST RICE AND POLICOSANOL

At the recent meeting in Prague, the EuroPrevent 2010, a group of Italian workers led by Dr Valentine Mercurio ( University of Naples Federico II School of Medicine ), presented a poster presentation on the use of the combo nutriceuticals in lowering cholesterol and also improved circulation and insulin resisitance. The nutriceuticals used is a combo pill of berberine 500mg, red yeast rice 200mg and policosanol 10mg. Berberine is a quaternary ammonium salt, found in Berberis, goldenseal (Hydrastis canadensis), and Chinese goldthread (Coptis chinensis). Red yeast rice is a red fermented rice, also known as red Koji rice or anka. Policosanol is a mixture of aliphatic alcohols derived from the waxes of plants such as sugarcane or yams or from beeswax. These were popular concoctions used in herbal, traditional Chinese treatment in the good old days for diabetes and heart disease.
The investigators tested these combo nutriceutical pill against placebo in 50 patients with hypercholesterolemia. After 6 weeks of therapy, they measured the cholesterol and LDL -C levels. They also made some other measurements including their triglyceride levels and their brachial artery flow parameters. They found that after 6 weeks of therapy, the treated group had significantly lower levels of total cholesterol and LDL-C. The rductions achieved were as good as standard statin therapy. They also found a significant increase in brachial artery flow and significantly lower triglyceride levels. All in all the results were very acceptable. Whatmore, there were supposedly no adverse reaction. All tolerated the therapy well. There were no dropouts.
I was very happy to note that there are more clinical evidence for the efficacy of traditional herbs and their effective role in treatment of dyslipidemia. What with no apparent adverse reactions. I suppose it is too early to tell as the sample was small. But it is heartening to know.
I must say that there are more and more of my patients turning to red yeast rice. Just this week, one of my statin intolerant patient, whom I had switched to ezetimide, came back to report to me that ezetimide was too expensive and that his friends had recommended red yeats rice. He came with a lipid profile and the parameters were all better. He also denied any adverse reactions.
Looks like there is some good in traditional herbs afterall.

COMPLETE GENOME SEQUENCING AND INTEGRATED ANALYSIS ; LANDMARK BREAKTHROUGH IN MEDICINE

We have always known that our genes carry all the information about us. We are particularly interested in the medical information carried in our genes. It will not only tell us who we are and where we come from, but also our makeup, our susceptibility to disease like heart disease, sudden cardiac death, cardiomyopathies, our response to medication ( pharmacogenomics ) and susceptibility to side effects.
Well, this blog is prompted by the landmark sequencing of the complete genome of a human by the genome team in Stanford University School of Medicine. Dr Euan Ashley and team from the Center for inherited Cardiovascular Disease, published an article in the May 1st issue of Lancet entitled, "Clinical assessment incorporating a human genome." They sequenced completely, the genome of Mr Stephen Quake, and discivered that he has a greater then 50% likelihood of developing heart disease and some types of cancers. It must have cost him about USD 20K to have the sequencing done and more for the integrated analysis. It maybe that at the moment, the cost of completely sequencing your genome and completely analysing it will set you back about USD 50K. Obviously, with time and more demand, the cost will go down, maybe to USD 10K each. Is that information worth the money?
I suppose, each of us, with our wealth, may see it differently. I can see that one area perhaps, that it maybe useful, and already undergoing much research is pharmacogenomics. Much work is now being done, to see who will benefit from which drug, in our large armanterium of drugs, say for treatment of hypertension. Rather that using a trial and error approach, could we be more specific and choose the drug with the best efficacy for each individual and also with the least likelihood of any edverse reaction.
Whatever it is, looks like medicine has arrived at an important threshold and we who have graduate from Med school in the seventies have much catching up to do, to learn about this whole new field of "genome-logy", if I may be allowed to coin a term.
I suppose, this advance is good for our patients, and so it is good.