N-3 OMEGA FATTY ACIDS AND THE HEART. NEWS FROM THE ESC 2010

The European Society of Cardiology congress is currently in session in Stockholm. I have a glance at the program. Nothing earth shuttering is coming out. Data and clinical trials will be announced, but nothing that ( in my opinion, ??bias ) will change the practice of cardiology.
When I open my Star newspaper this morning, I saw that the Star medical editor had picked out a report from the ESC meeting, saying that Omega 3 fatty acid fish oils, did not help the heart. This generalisation is not accurate, nor correct. I suppose, it does sell newspaper. The facts .........
In the ESC ( still on-going ), the Dutch workers, led by Dr Daan Kromhout of the Wageningen U, reported on the Alpha Omega Trial. This was a study of 4,837 patients aged 60-80 years. These patients had all suffered a heart attack and were on follow-up. They were followed up for 40 months. These 4,837 patients were divided into 4 arms. One arm was given omega 3 FA + omega 6 FA, the second arm plant alpha linolenic acid. The third arm, all three FA, and the fourth arm placebo. After 40 months of follow up, the investigators found no difference in the 4 groups in terms of any cardiovascular events, including death, re-MI, the need for revascularisation. Thus the headlines in Star.
Of course the Star was comparing this result with previous established studies which showed that Omega 3 FA reduces serum triglycerides and serum fibrinogen, and also reduces sudden cardiac death. These are the reasons we use omega 3 FA.
These established findings were based on work done by the Italian and Japanese workers in the 90s and early 2000.
How then to explain the difference?
Well, this present study in much smaller then the previous two, especially as these group of Dutch workers chose to divide an already small cohort, into 4 arms, thereby making it more difficult to get to a significant number, by virtue of their small numbers per group. It was also important to note that this Dutch study had an older population. Both the earlier Italian and Japanese study had a younger population. The dose of omega 3 FA was way too small and they chose to add omega 6 FA and also plant alpha linolenic acid. How much effect these other FA had negatively, needs further study. I think the present Dutch workers were surprised that the number of deaths in their study, were way lower then the number of deaths expected, telling us that the background medical medical and lifestyle changes had positively impacted on the number of expected deaths from heart attacks between the 90s and presently. Heart attack patients were doing better now and so it was harder to find a difference.
Be that as it may, fish oil, or omega 3 FA acid, or more precisely " eicosapentaenoic acid " is good for the heart and good for post heart attack victims. Medical management of the post heart attack patients is much better now when compared to the 90s.
So Star. the details are important.

ANOTHER COMBO PILL APPROVED FOR TREATMENT OF HYPERTENSION

Novartis was quick to announce that on Friday, the FDA had approved their aliskerin / amlodipine combo pill for the management of hypertension.
Aliskerin is a new group of BP lowering pill that is essentially anti-renin or renin lowering. As we are all aware, BP control has much to do with control of the renin- angiotensin-aldosterone system ( or commonly called the RAS system ). Hypertension may essentially be a derangement of the RAS system, The RAS is a system given to us by God to maintain and adjust our BP as we face the day to day stress and changes in fluid volume and cardiac output. BP equals cardiac output x total peripheral resistance. Both cardiac output and peripheral resistance is dictated by the RAS. When the RAS system goes dysfunctional, the BP is maintained abnormally high all the time ( a situation called hypertension ). In fact the earlier seminal work of Dr John Laragh, in the 70s, was to classify hypertension in 3 forms, the low renin group, the normal renin group and the high renin group. Although this classification sounded very neat and tidy, it was difficult to apply clinically, as the measurement of renin was very involved, complicated and not clinically practical. Thereafter, in the 90s, the concept largely fell out of favour and pharmas began to developed drugs that attacked the mid-portion ( ACE-I ) of the RAS and also the end receptor of the RAS ( the ARBs ).
The trouble that we face with blockers of the RAS system, is that chronic blockade of any part of the RAS, gives rise to escapes from the RAS. Acute blockade works very well, but chronic blockade, allows the system to find alternative pathways of compensation. The RAS is a survival maintaining system. It cannot be blocked forever. It will adapt, escape, so that fluid volumes and cardiac output can be maintained, for survival of the human.
Novartis is leading the way to try and block the beginning of the RAS, with the discovery of " aliskerin ". I believe that aliskerin is the first of many such drugs. It has been shown to be effective and safe, but I found the data on it rather weak. The drug is also rather weak, in terms of BP control. Escape routes from the renin blockade sets in quite quickly. And aliskerin is expensive. Therefore aliskerin alone may not be cost effective.
Looks like Novartis has taken note of this and have combined aliskerin with the more established CCB ( calcium channel blocker ), in a single combo pill, just approved by FDA yesterday. This certainly enhances the efficacy of aliskerin in BP control.
Looks like combo pills for BP control is the way to go, and Novartis is just pushing the case further. They now have a ARB + diuretic combo, ARB + CCB combo, now anti-renin + CCB combo, and also a ARB + CCB + diuretic combo.
The war against hypertension carries on at a new level. Novartis has just raised the bar.
I must say that I very much prefer life style modification ( lose weight ), green veges and fruits ( DASH diet ), regular exercise and single, or at most double pill combo. I find this very cost effective. The solution for a chronic lifestyle disease, must be chronic lifestyle modification. Hypertension is a chronic lifestyle disease.

DANGERS OF BINGE DRINKING, ie HEMORRAGHIC STROKE AND DEATH

It is not often that we see an article in the Stroke journal, by a Korean author. However, it is getting more often, as Korea prepares to host the coming world congress on Stroke.
This simple piece of epidermiological work was done by Dr Jae Woong Sull and colleagues from the Yonsei University, Seoul, and published in the online edition of Stroke, Aug 19th 2010. It was entitled, " Binge Drinking and Mortality From All Causes and Cerebrovascular Diseases in Korean Men and Women.". They followed up 6,291 residents in the Kangwha county in South Korea, for 20.8 years ( the study started in 1985 ). They were studying the drinking habits of these residents. 63.4% of them were binge drinkers ( defined as having six or more alcoholic drinks in a single occasions ). They found that after 20 years of followup, those who indulged in binge drinking had a 12 fold increase in mortality, principally from hemorraghic strokes, when compared with non-drinkers. Many who suffered the stroke, died and many of them were also hypertensive. There was however no correlation between female binge drinkers and strokes or death.
It looks like in Korea, many drink, and a significant number, binge.
It is true that binge drinking is associated with acute hypertension which may result in a stroke, particularly in patients who are known hypertensives. This has been proven by many other trials.
A gentle warning to hypertensives, not to drink excessively, and if you have weak self-control, it is better not to drink at all.

MORE GREENS PLEASE. I FEAR DIABETES

For many years now, since the DASH diet has shown that green veges and fruits prevent and lower hypertension, medical practitioners all over the world had encouraged the eating of more vegetables and fruits. We know that green leafy veges and fruits are very good for healthy living. At least 5 portions daily, is what is recommended.
The latest issue of the British Medical Journal, carried a piece of research by the researchers from Leicester University, on the good effects of green leafy veges on the prevention of T2 Diabetes Mellitus. They took 6 large scale studies where diet and the effects on diabetes were studied, analysed them ( meta-analysis ), and came to their conclusion. The meta-analysis included 220,000 subjects, who had filled in questionaires about their diet and their medical status. The researchers found that eating one and the half portions of green leafy veges like cabbage and spinach, reduced the incidence of diabetes by 14%. That is significant. One portion of veges is about 80 grams. ( in UK, their veges come packed by portions ). 80grams is not very much. The diabetic association, still recommend the consumption of 5 portions of green leafy veges daily, though.
We are not certain why this is so? Is it because of the vitaminC, or the potassium, or the magnesium, or other minerals, but it seem to work. There is obviously no downside side-effects? Is that true?
Well some of my patients have gone on to organic, or hydrophonic veges, because of the fear of chemicals and other pesticides or insecticides, that are often sprayed on the veges, to prevent their destruction by the pest. Well, there is a small risk of pesticide poisoning. The risk that these pesticide and insecticides may be carcinogenic, has also been raised.
I suppose we should eat more green leafy veges, but wash them well before consumption. I supose cooking them should also make them safe, though not so healthy.

MULTI COLOUR CT ; MARKING THE VULNERABLE PLAQUE

It has been a cardiologist dream for the last 30 years, to try and see how to identify the " vulnerable plaque ".
Many of us, as we grow older ( >40years ) have coronary artery disease. There are cholesterol plaques accumulating in the walls of our arteries, especially our coronary arteries. However, most of the plaques are stable and therefore silent, and does not cause any untoward incidences. A stable cholesterol plaque, is quite compartible with normal life. When learned this lesson from autopsies done with young soldiers fighting in the Korean war and Vietnam war. These were presumably healthy young soldiers, tough enough for battle. Yet, post-mortem examination of their coronary arteries often revealed that they have significant coronary artery disease, some single vessel, some double vessel and some even triple vessel and left main stem disease. Then again, we often hear ( and I often get asked ), about healthy young men who suddenly collapsed and die ( including medical doctors ). These people have no evidence of heart disease. Upon autopsy, they have established cholesterol accumulation in many of their coronary arteries and one of the plaque had cracked ( or ruptured ), causing coronary thrombosis. The plaques that had ruptured are the vulnerable ones ( the unstable ones ). Medical science had spend a considerable amount of time, money and effort to identify the vulnerable plaque. This business about " you have heart artery blockage, so you are going to die, unless you let me do a balloon angioplasty or bypass surgery, is more a scare tactic then based on facts. Of course, if your plaques are the unstable, vulnerable ones, then you may run the risk of a heart attack ( coronary thrombosis ) and you may die.
The trick therefore is to know, if you plaque ( your coronary artery blockage ) is of the unstable ( vulnerable ) one or the stable ( non-vulnerable ) one.
The July 28th issue of Radiology carried a piece of work in mice, by Dr David Cormode and colleagues at the Mount Sinai School of Medicine, which showed that they can identify the vulnerable plaque in mice, using a multi-colour CT.








We know from earlier work that a plaque becomes vulnerable when it becomes inflamed, and filled with macrophages. High accumulation of LDL-Cholesterol on its own, can cause inflammation. What Dr David and colleagues did was to inject gold tagged high density nanoparticles and inject it into the blood stream. This will get attached to the macrophages in the vessel wall and light up the artery wall. The amount of yellow ( lighting ) when superimposed on the background image with normal contrast, shows up the amount of macrophages accumulated, and therefore the degree of vulnerability. This owkr appears promising.
The trick now is to move for the bench ( animal lab ) into the bedside, to comercialise it and see how it can be applied to the patient. We are probably 10-20 years away from reality.
Interesting idea, workable, I just thought that I will share it with all of you.

MORE GOOD NEWS ON DARK CHOCOLATE. THIS TIME EFFECT ON HEART FAILURE

Looks like if you need dessert, after a nice meal, dark chocolate would be a good choice, noting its many cardiac goodness. I think that we have written about the potential BP lowering effects, the cardiovascular protective effects, and now, the potential heart failure risk reduction effects.
The 17th August issue of Circulation : Heart Failure, carried an article on the effects of dark chocolates on heart failure. This group of researchers from the Beth Israel Deaconess Medical Center, Boston, led by Dr Elizabeth Mostofysky, followed prospectively, 31,823, females age 48-83, over the last nine years, in what is called the Swedish Mammography Cohort. ( I have no idea how the Boston people, got to followup Swedish subjects ). Anyway, at their annual followup, they had to fill in a questionaire about their weight, body mass index, exercise program, and also their eating habits, food patterns, and of course, their admission to hospitals. It appears that after 9 years of follow-up, those who were on dark chocolates, 1-2 times a week and those on dark chocolates, 1-3 times a month, should a significant reduction in incidence of heart failure. ( 26% reduction if you take dark chocolates 1-3 times a month, and 32% reduction if you take dark chocolates 1-2 times a week ). Surprisingly, if you take more then twice a week or less then once a month, there is no correlation. Interesting.
It is important to know that Swedish dark chocolates contain about 30% cocoa, unlike US dark chocolates that contain only about 15% cocoa. The amount of milk does not seem so important, if you have 30% cocoa.
I suppose, we should not that this is very much an observational study, and by no means conclusive. Much more work need to be done about flavinoids and their cardio-protective effects, for us to be firm. Of course there is always the sugar / calories issue. Too much chocolate ca make you fat, although I do not think that 100 gms of dark chocolate daily, twice a week would make you fat. If you wish to indulge yourself into whole bars daily, then that is indulgence, and not " medical nutriceuticals ".
It just struck me that should you be visiting a friend who is hospitalised with heart failure, a small bar of dark chocolate, may be a good get well present to bring.

DOES TWO WRONGS MAKE IT RIGHT. THE IDEA OF McSTATINS?

The August 15th issue of the American Journal of Cardiology ( the blue journal ), carried an article by the workers from London's Imperial College, entitled, " Can a statin neutralise the cardiovascular risk of unhealthy dietary choices." The authors, Dr Ferenczi et al, did a meta-analysis of 7 large randomised clinical trial of statins from the 80's, involving 42,848 ( even the number is auspices ) patients, to determine the degree by which statins can reduce cardiovascular risk, in terms of LDL-C reduction. They then calculated the cardiovascular risk of a 7 oz McBurger, and found that statins can neutralise the CV risk of a 7oz McBurger. So they concluded that we should encourage McDonalds to include a sachet of statins with every McBurger, so that after eating a McBurger, should our conscience prick us, we can consume the sachet of statins. Does it make sense to you?
This is almost like what some of my patients, and even some of my medical colleagues do. They eat all the fat pork, and crabs, and then pop in a tablet of statins.
It would appear that as a primary prevention strategy, the medical community has tried her best to discourage the consumption of unhealthy diet, exemplified by McDonalds and all the other fast foods, with some success, and they now wish to accept that some will never listen, and perhaps giving them some statins, will still help prevent heart disease. This is almost akin to the strategy of giving condoms to teenagers, or giving clean syringes to drug addicts. But, we are not there. Primary preventive programs have been quite successful. It is true that mortality and morbidity from heart disease in the West, have declined, since the 90's. What we are very concern is that in the 2000's, there is a growing incidence of obesity and diabetes, blamed on lack of exercise and also the fast food culture, or in our Malaysian context, " the hurry, curry, instant " culture. Quick meals ( curry ), to meet a dateline and stress. The instant ( everything now ) culture.
Statins have known side effects and the UK experiment of OTC sale of low dose simvastatin, has proven to be of limited success, not much impact of heart disease. To stretch the idea further, shall we put a small dose of aspirin in drinking water so that we can all have primary prevention with aspirin ( the data here has proven to be weak ). What happens is a kid drinks the water and develops a cerebral hemorrhage, or GIT bleed?
Does two wrongs make it right?

CRESCENDO, rimonabant's "obituary," published in Lancet

I thought that I should close the chapter on Rimanobant nicely, just as my US colleagues did.
We will all recalled rimanobant, hailed at the turn of the millenium as a breakthrough drug for the then " in fashion " cardio-metabolic syndrome. Rimanobant belonged to a new group of drugs called the Endocannabinoid receptor blocker. Endo-cannabinoid comes from the word cannabis, meaning that this new group of drugs attacks a cannabis-like receptor that in the brain, to cause one to not feel hunger, not eat so much, therefore lose weight and help correct all the downsides of obesity, like diabetes and hypertension and prevent heart disease. It sounded so good. Almot too good to be true. It was hailed as a block-buster drug. There were many large scale studies done, led by some very prominent cardiologist, to show that it could help patients lose weight, have less hypertension, and diabetes, and so less heart disease.
I remember being invited to the local launch for this new block-buster drug. Even before the launch, I had already given my imput ( privately ) to the local MNC pharma boss that this drug was trouble, and not to worse too much money on it. Of course, our coloured skin opinion was largely ignored as the MNC had to listen to their head office in faraway land. The launch was a bid affair, with speeches, and dinner ( I think ). We again, registered our reservations ( in a gentle, unobtrusive way ).
Our reasoning was simple ( I am no great research worker, not in clinical private practice anyway ). Cannabis make us want to fly like a bird. If you block the cannabis like receptor, it will make us sink like a stone. I warned that I see neuro-psychiatric side effects as a big problem. Obesity itself may have a neuro-psychiatric component.
Sad to say, our fears were proven right. In 2008, the European drug authority removed the drug from Europe, because of reports of suicides and depression. The large clinical trial " CRESCENDO ) which were enrolling patients then were told to stop the study. The authors protested, that it was important to establish if Rimanobant does help to lose weight and lessen cardiac disease. The authorities allowed the study to go on, but the doctors were fearly to recruit patients. Basically, the study was halted.
Anyway, after 14 months of followup and two years later, the CRESCENDO results were published in the Lancet, 14th August. Please remember that it was a shortened study and enrollment was incomplete. It showed that rimanobant did not better then placebo, in terms of CV mortality and morbidity. There were however 4 suicides in the rimanobant arm, and 1 in the placebo arm. There were also more attempted suicides ( 9 ) in the rimanobant arm and less ( 5 ) in the placebo arm. There were more depresions and anxiety discorders in the treatment arm. Basically, the authorities were right in withdrawing the drug.
I felt very bad that I loss a patient and friend who was on rimanobant. He was obesed with diabetes, hypertension and established heart disease ( I had done a triple vessel angioplasty ). I gave him rimanobant to help him lose weight. This was before the ban and withdrawal of rimanobant. He did well. The sugar / BP control was better and he lost weight. When the Ministry of Health advised that rimanobant should be withdrawn, I told him and asked him to stop taking. He decided that he wished to continue. I gave him whatever stock I have left. A month or so later, I was told that he had gone on an out-station business trip alone and was found dead in his hotel room. There was no suicide note and he was not depressed before the trip. When I heard that, I felt so bad. I will never know whether the rimanobant contributed, in anyway to his death, or was it just sudden cardiac death.
Well, now we can close the chapter on rimanobant. The pharma developing the drug, must have lost millions of dollars, on an unfulfilled dream.
It was good that CRESCENDO was completed ( in a way ). We now have scientific facts to support our opinion. It is always sad that for progress, some had to die on the way. We only hope that they did not die in vain.

DARK CHOCOLATE FOR HEALTH, REDUCE BP. GOOD OR BAD?

It has always been held that some food substances can aid our health. There is a very popular branch of medicine called the nutriceuticals that are basically food substances with health values. Good examples are wines, fish oils, garlic, and of course dark chocolates.

There were many onservational studies which seemed to show that 50 grams of dark chocolate daily ( the darker the better, the more bitter the better ), seem to be cardio-protective and also lower BP. We think that it is the flavinoids in these dark ( full of cocoa ) chocolates that confer the cardio-protectiveness.

In the August 10 issue of the British Medical Journal ( BMJ ), there is an interesting article on dark chocolates and blood pressure, with an unusual twist. Dr Karin Ried and colleagues at the University of Adelaide, Australia, carried out a study on 36 subjects, with pre-hypertension ( these are subjects whose BP are borderline - 130/90 mmHg ), and gave them dark chocolates, tomato juice and placebo, over 6 months, to see if either of this will help to reduce BP in pre-hypertensives. Well, the simple answer is, the study is negative. Neither dark chocolate ( 50 gms daily or half a bar daily ), or tomato juice, lower BP in prehypertensives. What was unusual was that 50% of the subjects, could not tolerate taking half a bar of dark chocolate a day for 3 months ( each group had either dark chocolates, tomato juice or placebo for 3 months and then they switch to the other ). The study was not blinded, but placebo controlled and randomised.

It would appear that taking dark chocolates for fun is trendy and nice, but to take it as a " medication " for 3 months or life long, that's another story.

So, it would appear that the first effort to find evidence of dark chocolate lowering BP is negative. Obviously we need more evidence. I must say that, if we can, dark chocolates maybe weekly, may be cardio-protective. It may also lower blood pressure. However, one must be careful that the dark chocolates do not contain too much calories, as that may give rise to obesity and become counter productive.

VITAMIN B SUPPLEMENTS AND CVS PROTECTION

For a long time, large population studies carried out in many communities seemed to suggest that high levels of homocysteine in the blood seem to be a cardiac risk factor. That people with high blood homocysteine levels have additional risk factors of heart attacks and strokes. Homocysteine is an amino acid formed in the body from one of the important protein building blocks, methionine. However, when we lowered the blood homocysteine level, we did not seem to lower our CV risk. It made no difference. We were puzzled. This is quite unlike blood cholesterol levels, where increase levels was an important risk factor and lowering cholesterol reduces the risk.
In the 4th August issue of Lancet Neurology, is another study concluding the same. Dr Graeme Hankey and colleagues of Melbourne Australia, carried out the VITATOPS ( Vitamins to prevent strokes ) study, in 8164 patients across 20 countries. This was a double blind, placebo controlled trial ( one half on placebo and the other half on Multi-vit B ). After a median followup of 3.4 years, they found no difference in stroke and heart attack rates. It may be that 3.4 years follow-up may not be long enough to show any difference, and the numbers may be too small. The homocysteine levels, which were raised at start of the study, did come down significantly.
Be that as it may, for all those out there who are taking all sorts of multi-vitamins ( and there are many of my patients who are taking all sorts of vitamin supplements ), please know that the multi-vits may not help the heart.
We are still puzzled by the role of homocysteine, in atherosclerosis. Although there is enough epidermiological evidence, there is limited understanding of the patho-physiological mechanism. Obviously much more work needs to be done. Many of us feel that homocysteine is a minor risk factor that maybe important in addition to other risk factors like cigarette smoking. Whatever it is, vitamin supplements are very popular and has spun a whole OTC pharma industry, stronger that the "statins " industry.
My advice is be aware. Take drugs only when you have too, with medical evidence. We do not wish to have a " Calcium supplement and Heart trouble issue " years later.

LOSING WEIGHT, SHOULD IT BE LOW CARBS OR LOW FATS?

Obesity, of course is the growing trends in developed and developing nations. In the US, there has been a noticeable decline in the number of deaths from CAD, but this is quickly offset by an increasing incidence of obesity. It would then be a matter of time before the decline in CVS mortality, be reversed. In Malaysia, we have also seen an increasing rate of obesity. Depending how you define obesity, the incidence of obesity could vary from 30-50%. It is a growing concern. Our calls to the government to take active measures, on a nationwide population basis, has met with limited success. The removal of sugar subsidy, is a step in the right direction ( although I doubt that health was the main reason ). It would have been good if the government can also limit the number of fast food joints, limit the amount of sugar in soft drinks and teh tarik, and also limit the amount of roti canai joints. All these foods are very very unhealthy.
Anyway, what I wanted to discuss today was a study by Dr Gary Foster, published in the Aug 3rd Annals of Internal Medicine, on weight loss and metabolic outcomes after 2 years, comparing the low carb diet ( modified Arkin's ) and a low fat diet. It is important to note that this is one of the few studies with a 2 year followup, and also in this study, in addition to the diet, subjects were also given comprehensive behavioural coaching, meaning that they had counselling sessions, food diary, weight diary, exercise programs, etc, all coached to them
Well with 307 subjects, half on the modified Arkin's ( low carbs diet ) and half on a low fat diet, after 2 years, the degree of weight loss was essentially the same ( about 7% after 2 years ). Neither diet was better then the other. However, the authors noted that with the low carb diet, there was a significantly higher rise in HDL-C at all points of the program. Some subjects on low carbs diet, had significant weight loss with an almost 50% increase in HDL-C after 2 years. I must say that this is not what I see in my medical practice. It is so very difficult to raise your HDL-C without the use of drugs. But Dr Foster and colleagues seem to be able to do it. Whether or not this will translate to a lower incidence of heart disease, I do not know, but it is certainly a step in the right direction.
No drugs, just discipline and some counselling, may be the best thing to help lose weight and also improve your cardio-protection.

TRANSRADIAL PCI ( Percutaneous Coronary Intervention )

I was searching around to see what to highlight today, and this piece of news caught my attention. The Americans are beginning to wake up to transradial PCI. I just read an announcement that the Society for Coronary Angiography and Intervention is holding a summit and training program for transradial angiography in Boston in 5th Nov 2010. The faculty were mainly all Americans. I do not know why they do not want to bring over some Japanese or Dutch or French experts. Of course the Canadians are a no,no.
It has been traditional in many medical institution to teach PCI techniques via the transfemoral route. Before I proceed maybe it is bst to define what I mean. Transradial means to approach through the radial artery ( either right of left ) and transfemoral is to approach via the femoral artery ( either right or left ). In USA, the transfemoral approach is more popular as many of the hysicians were trained that way. Transradial approach is used in less then 10% of PCI procedures in USA. This is in stark contrast to elsewhere ( Europe and Asia ) where at least 50% of PCIs are done transradially. In fact, in some institution in Japan and China, 90% of PCIs are tarnsradial ( default transradial we call it ). That is also with us. In Malaysia, we are at least 50% transradial and with some operators, almost 90%.
I suppose an understanding of how we came this way is important. When Dr Mason Sones, first discovered coronary arteriography, he did it via a brachial artery cutdown. That was the way, when we began. A cutdown was a tedious procedure, isolating the brachial artery and securing access and then hemostasis. A good technique but took too much time, also more difficult to train and also has significant morbidity and complications.

Then came along Dr Melvin Judkins, who taught us that we could introduce tubes into artery safely, whith the use of percutaneous ( puncture through the skin ) technique. The Judkin's technique, as we call it, begins with a micro skin incision over the puncture site, a gentle puncture into the artery using a sharp needle ( either one piece or two piece ), and once the artery is properly punctured, a fine atraumatic guidewire is introduced, into the artery and over the guidewire, a sheath smaller then the artery size is introduced, and then the diagnostic and therapeutic cathers and devices are introduce.

Dr Melvin Judkins initiated the Judkin's technique for coronary arteriography via the femoral approach, as the femoral artery was big and easily felt and so easily punctured. All the cardiologist since the seventies were trained and master the art of percutaneous puncture of the femoral artery and did their angiograms and also teach their fellows to do the angiogram via the femoral artery puncture using the Judkin's technique. Soon the Sones's technique fell out of favour and many of us forgot how to do it. It was so cumbersome.

Then in the eighties, Dr Campeau ( Canadian ) and later Dr Kiemeneij ( Dutch ), began to promote the use of the radial artery for percutaneous angiogram and angioplasty. This radial artery catheterisation technique was actually first used by Dr Radner in 1948. Then the Japanese learned from the Dutch and we learned from the Japanese. For many of us, our teacher here was Dr Shigeru Saito, who taught us many things, including transradial angioplasty.

Having mastered it, we find that the transradial route was safer and more patient friendly. The bleeding issue was obviously less, being a smaller artery ( making nursing easier and less stressful for us ). There is a learning curve and initially we faced many issues, like radial artery spasm, difficulty in engaging the catheter especially in senior citizens, and occasionally, inability to puncture the radial artery.

Having done alot ( in the hundreds. I stopped counting after 500 ), I find that the cross over-rate ( unable to puncture and had to use the femoral artery route, at about 10% ). I also found that most Malaysians had good radial arch and the ulnar artery are usually large. and adequate. Our radial artery size ( I studied 20 samples when we first starte ) was about 2.5-3.0 mm in diameter, allowing us to use 6F and even 7F catheters.

There are more and more clinical trials coming out comparing the femoral route and the transradial route, and many came out in favour of the transradial route. The transradial route was proven to be safer, much less bleeding and more patient friendly. Patients can be ambulated after two hours of rest, and some patients can be discharged after 6 hours. So it can be cost saving too, especially in the USA. This bleeding problem is very important because, with all the new therapeutic regimes for unstable angina and coronary thrombus, many patients for cardiac interventions are on multiple anti-platelet agents, coupled with anti-thrombotic agents and maybe Glycoprotein 2B3A. One big bleeding millieu.

Perhaps, the biggest impediment to transradial catheterisation is " mind set". In our discipline, we cannot teach old dogs new tricks. Perhaps the Society for Coronary Angiogram and Intervention is taking on the task of trying to teach old dogs ( or not so old ones ), and some young dogs, new tricks ( old tricks for the rest of the world ). Perhaps Obama's healthcare reforms and cost cutting has something to do with this.

Welcome to my world.