MALAYSIAN INTERVENTIONAL CARDIOLOGY 2000-2010

To continue the story.
At the turn of the century, in 2000, we begin to hear of the initial results of the first-in-man trial of a drug-eluting stent. We all know that the "achilles heel" of POBA and coronary stent is re-stenosis. Having done a good job, after 2-3 months, 20-30% of the lesions will recur. So interventionist the world over were working hard to see how to reduce that. The early work was done in Sao Paulo, Brazil. They published their first 40 patients, first-in-man use of the sirolimus eluting stent ( made by JnJ cordis ). The results were very impressive. That led quickly to a clinical trial in Europe. The trial was called RAVEL, and the results were very good. Of course, I asked my JnJ manager for permission to use the stent.
On 28th May 2002, I implanted our first DES ( DES ). Over, across the city, my colleague Dr Robayaah Z in IJN was also doing the same for her patient. Both implants were successful.
In turns of progress, the 2000-2010 decade did not see much. More and more companies brought out their drug eluting stents. Before the close of 2010, we now have second generation and also almost final improvement of what could be 3rd generation DES.
I have always stuck on to pure, cardiac interventions. I did not venture into peripherals, renals or carotids, as I felt that to be good and excellent, you must do hundreds, if not thousands of them. Doing 5-10 carotids a year, is not being fair to my patient. But that is very much a personal philosophy. I am writing that because, 2000-2010 also saw tremendous progress in our understanding and role of renal interventions ( now larger proven not to be helpful in controlling resistant hypertension, except transiently ). There was also much progress with carotid angioplasty, but its role is still highly controversial, proven in many large trials not to be any better and in some sub sets, to be worse then standard carotid enarterectomy.
The last few years of the decade of 2000-2010 saw the innovation towards percutaneous valve implantation, without the heart-lung machine, through the femoral artery. Nice procedure for those who were too ill for surgery, but the cost of one of those TAVI ( tranfemoral aortic valve implantation ) device, is about RM 100,000, and they are trying it out in IJN, with tax payers money. In all these extra-coronary procedures, I have stayed clear. Let the young boys learn and be good.
The new millennium also saw the development of cardiac centers in all the major public hospitals. Johore Baru cardiac unit, took off after some initial teething problems, then the Kuching Heart Center, the Pinang Heart Center, and more recently, the Serdang Heart Center. The Kota Kinabalu heart center was started early, but its development was stunted by some " political" issues and issue of "tuft". It is still there but undergoing revamp ( as I understand it ). These developments are healthy, and allow the public to get treatment at hospitals nearer to them. This also means that there are now 200 hundred or so interventionist ( starting from 3 in 1998 ).
This decade also saw the social development of interventional cardiology. I am a founder member of the " INTERVENTIONAL CARDIOVASCULAR SOCIETY OF MALAYSIA", which is a society under the auspices of the National Heart Association of Malaysia, of which I am a member. You will not believe the amount of racial politics going on in the association and society. Even medical professional societies, suffer from the national disease. I left the committee. We are too straight-forward for all the twisting and turning required, to work in the system. They have gone ahead to run their annual live demo courses, at tremendous cost to the device companies and pharmas, who have no choice but to support, as they need the help of the organisers of these expensive live demo courses, to get their products into the public hospitals. They forget that all the money given to sponsor such big ( can I say wasteful ) meetings, come from the A&P ( advertisement and promotion ) budget of their companies, which ultimately return to the higher cost of product. I was involved in the planning for the first live demo course back in 2004, but found that we could not get along, because of some personalities, who have their own selfish agenda. Together with a small group of like minded interventionist, we have gone to organise our low cost, year end interventional cardiovascular forum. A forum of discussion,case reviews, amongst interventionist only. At 10% the budget of the expensive ( not necessarily well attended by interventionist ), we are able to share our experience and expertise with the younger group of up and coming interventionist, hopefully for the betterment of cardiac care in the country.
I still travel across Asia, to some " friendly" meetings as faculty, to help share our experience. Working without publicity ( low key ), is a challenge, but frees you from all the politics, and you can be true to yourself. I felt that for someone without connections, who loaf publicity and politics and with no government support ( all private or self funded ), what we have achieved for the country is reasonable.
Seeing that the " sun is setting ", yearly we also oversee two weekend seminar in cardiology for GPs. One in the Klang Valley and another through the country, at various location. It is our attempt to improve cardiac care in the country.
As we come to the close of 2010, I can see that interventional cardiology innovations have come to a plateau. We should see the coming to the market place of the 3rd generation DES, what I would term the biodegradable drug eluting stents. The early results now, look promising. Hopefully, the " stem cell" boys ( those working on stem cells to regenerate dead heart muscles ) will get their act together, and discover for us, new ways to grow heart muscles, which we can incorporate into our standard PCI. Of course there will be more devices coming to the market place, some of use to patient care, some is only hype, and ultimately fall away. In my 30 years in this field, I have seen many fall away. The wisdom is to know which to go for, that will stand the test of time and that will make treatment cost effective. The business of practice of medicine, is fast encroaching on the good clinical practice of medicine. So far, I believe, we have made more good choices in the devices that we adopted, and promoted, good clinical practice of medicine, than choose harmful ones.
Well, no regrets for 30 interesting and challenging years in interventional cardiology. If I have the blessings to see to the next decade, I will write my thoughts on 2010-2010, as I see it.
In the meantime,
WISHING ALL YOU READERS,
A VERY HAPPY, HEALTHY AND PROSPEROUS 2011.

Talk to you all next year.

MALAYSIAN INTERVENTIONAL CARDIOLOGY 1991-2000

To continue the story.
Well, when we had done 100 plain old balloon angioplasty ( POBA ), it was the beginning of 90's. Dont exactly remember the dates. I began to realise that balloon angioplasty was getting too expensive. Cost was becoming an issue. This is also an important development. In the 80s, CABG was costing about RM 12K-15K ( average ). Few private centers were doing it. When the CEO of SJMC asked me how to charge, I reasoned to myself that if POBA had a restenosis rate of 50%, then I must factor in two POBA for one CABG. So I suggested that POBA should have a total cost of about RM7-8K. We worked out a packaging cost, of about RM8K ( if one balloon was used ). At that time, the balloons were over-the-wire balloons and they were high profile. Each balloon cost about RM3K. When we started with single vessel disease, we could get by with 1-2 balloons. But when we started to do double and even simple triple vessels, we were using 2-3 balloons per case. The balloon cost was putting up the price of POBA. I was very concerned that if POBA was too expensive, and with a 50% re-stenosis rate, the PTCA program may not take off. Patients may opt for CABG ( coronary artery bypass surgery ).
So, I was looking high and low as to how to safely re-cycle balloons. From my UH days, I remember that we used to re-cycle diagnostic catheters, by washing them clean right after the procedure, packing them, and sending them for EO gas sterilisation. I did this with the balloon catheters. After a awhile, I found that the balloon failure rate was too high. The balloons failed, because I could not inflate them. There was of course no danger to the patient, but just that the balloons could not be used. I wasted all my effort. The balloon failure rate was almost 70-80%. This was mainly because the balloon had a central guide-wire lumen and also a balloon lumen to inflate and deflate. To help us see our balloon well, we had to fill the balloon lumen with diluted contrast ( 50-50, or 70-30 ). The contrast tended to stick in the lumen and was difficult to flash clean, and complete. So the retained residue crystals were causing a problem of blocked balloon lumen so that we could not inflate.
I began to look for a solution. It was obvious to ask the device company ( at that time there was essentially only one company). USCI Bards, we knew well from our UH days. The USCI Bards products were distributed by a local company called "Somedico". So I asked the local Somedico sales manager to look around and see which country was doing angioplasty and which country was using re-cycled balloons. We found that of all the developed country doing angioplasty, France, French interventionist were using re-cycled balloons safely ( because in France, angioplasty was not insurance re-imbursible ).
They were very kind to me. They contacted their French counterpart and arranged ( also paid for my air-ticket and lodging in Paris for a week. ) for me to visit and learn from the French. I left to go to Paris, in the summer of 1991. My tutor there was Dr Thierry Corcos who was working in his own Interventional Center in Les Cheney, just outside Paris. I remember that I had to take a train out there and walk back from the train station to my hotel, each day, after the cases were done. I use to buy French loaf ( which I like ), and eat on the way back to the Hotel. Anyway, I learn that re-cycling was simple. All they did ( and it was safe, so they say ), was to clean the balloon catheter thoroughly right after each use. Drip the lumens overnight, and then soak it in 50% cidex. Cidex is an antiseptic agent that is use regularly for cleaning medical equipment. It is bactericidal. When you need to use the catheter, just take it from the cidex tray, and soak it in water, flush it thoroughly free of cidex, and then it is ready for use. In the new millennium, we have stopped using cidex, although I still hear of some centers which are still using this method. We stopped using in this millennium because of the fear of AIDS, Hepatitis C, and of course the toxic fumes from concentrated cidex, that can potentially harm the lungs.
But the good news from Les Cheney, was that, one day, while we were doing a case, Dr Corcos mentioned to me that his friend in Toulouse, was using a metal stent with his POBA and getting good results. His short term and intermediate term results were better and that he could treat acute dissection ( the bain of all interventionist then ), without the need to go for emergency bypass. So I asked him to arrange for me to go and observe and meet his friend in Toulouse. So he called his friend in Toulouse who turned out to be Dr Jean Marco and made the arrangements for me. I took an overnight train from Paris to Toulouse and spend a day at the Clinic Pasteur in Toulouse. On that day, I observed Dr Marco put down two coronary stents. Both in the RCA. They were the original PS 153 ( Palmaz Schatz stent by JnJ ). The post stent angiographic results were seductive. Th arterial lumen was so wide and smooth. It was like nothing that you can achieve with the best POBA. I was most impressed.
Upon my return from Paris, I asked the JnJ manager here for permission to use the stent ( PS-153 ). The regional manager was from Cordis Niche. She was very kind, and told me that since the stent was not FDA approved ( this was in 1991 ), I had to be proctored and become an FDA co-investigator, in order to use the stent. So I filled in the paper-work and became a FDA co-investigator for the Palmaz Schatz stent, the legendary PS-153. For proctoring, the nearest center to me was in Japan, the Kokura Memorial Hospital. The senior interventionist there was the world famous, Dr Masakio Noboyushi ( monthly angiography to study POBA re-stenosis fame ). I had to get his permission. JnJ arranged for me to meet him, late one night during the November 1991 AHA Annual Scientific meeting. Noboyushi san gave his blessings. I was on the way to Kokura at Kita-Kyushu in the spring of 1992. I spend 10 days there under-studying him, received his approval and upon my return purchase the stent to use in my patients.
The first coronary stent in Malaysia was implanted on 13th May 1992, in a lady in her mid-60s who had a single vessel disease-the RCA. The PS-153 then was mounted on a SDS ( stent delivery system ), covered with a sheath. The stent was a slotted tube, closed cell design and the crossing profile was 5F. I had to use an 8F guiding catheter. It was quite a chore, and you had to be very careful, as stents could get dislodged. It was like driving a bulky military truck into a small coronary artery. Also, post-stenting anti-coagulation regimes were scary. It included 50% dextran, aspirin and warfarin. Bleeding became a major issue. Blood transfusion were frequent. Groin hematomas were frequent. Anyway, this patient did well. The stent remained patent and she lived to a good old aged, and passed away a few years ago.
During this venture, I became acquainted with Dr Richard Schatz. Nice man. He must have made a lot of money, with the PS-153 patent and also the shares in JnJ.
I was reminded that I forgot to mention another important milestone in Malaysia. That is, on September 1992, the country launch the National Heart Institute, built at taxpayers expense, to provide cardiac care to the Rakyat. It is a corporatised body, funded by taxpayers, for care of public patients and also "fee for service" private patients. For very many reasons ( that may form another story ), in my opinion, it has not been able to fulfill its role well, for the tremendous amount of money that the tax payer has put into it, causing the government to set up its own heart centers in government hospitals.
After another two years, the results of the STRESS ( USA ) and BENESTENT ( European ) studies were released, showing that the PS 153 was safe and reduced re-stenosis, and was also good to treat acute dissections. The stent re-stenosis rate was about 20-30% ( quite an improvement from 50% with POBA ). With the released of these two pivotal studies, the PS 153 received FDA approval. Its result were duplicated by many centers. And as the saying goes, because of the PS-153, coronary stents became an established device to treat CAD.
But the scene was not so clear then. Why? Firstly, there was a competitor to the PS-153 on an SDS system. It was the Gianturco Rubin ( GR ) coronary stent. This was a coil designed stent. Because it was of coil design, it was easy to put down, but also because it was of coil design, it had a very high rate of re-stenosis ( almost 80-90% ). It was too open and lacked hoop strength. Some of my colleagues in this country, did not liked being proctored ( despite my offering to arrange for them ), chosed to use the GR stent. They quickly learned that almost all of them came back.
Besides the stents, the 90's also see the experimental use of many other devices, like the lasers, laser balloons ( hot balloons, cold balloons ), atherectomy devices, rotablators, and some others which I have forgotten. I remember the CEO of SJMC calling me for tea and asking me to see if the hospital should buy the laser machine to laser the coronary artery. This was the period when lasers in medicine was the cure for everything. It was the in-thing. I told him that we should not touch the lasers as it was bad for the coronary arteries. In fact, accept for rotablators, all the other devices slowly fell out of favour, one by one, and we settled with coronary stenting as the mainstay of treatment for CAD. I did go to Madras to spend 2 weeks with Dr Matthew Samuels ( my good friend there at Apollo Hospital ) to learn how to use the rota. He was the king of rotas. He could rotablate anything. Of all the devices, we chosed the two, that have lasted the test of time. Of course, in the early 90's, I didn't know that.
The other significant development that should be mentioned was the strategy for PCI ( percutaneous coronary intervention ). When we first started in 1988, we were taught to do the diagnostic angiogram, and stage the angioplasty for 2 weeks later or a month later. This was medically sound as it allows the patient to seek other opinions and also allowed a better planned PCI procedure. It also allowed us to schedule cardio surgical back-up. However, after the initial few months, some patients complained and requested that for convenience and also cost savings, they would prefer to have it all done in one go. After some initial reluctance, i decided that it made sense to have it all done in one go. It was cost savings and many of my patients were self pay ( out of own pocket ). Also, by this time, we were stenting alot and so cardio-surgical backup became unnecessary. Sometimes I regret this decision, because it realised now, that it can be missused by some, to do unnecessary stenting and unnecessary PCI. The interventionist became the one to diagnose the illness, and also the one to execute treatment, all in one day. If the interventionist is less than credible, there could be miss-use. The patient does have have a chance for a second opinion.
Anyway, the 90's saw the wide spread use of the bare metal stents in PCI. The anti-coagulation regimes became simpler. There was no longer any need for Dextran ( we have seen dextran causing asthma and heart failure ), and warfarin. We simplified the regime to aspirin ( low dose ) and ticlopidine ( this were the days before plavix ). Then the stents became lower profile. The initial stents were made with surgical grade stainless steel ( or 316L grade ). The later stents were made of cobalt chromium, which was a strong alloy, and so the stents could be made thinner, with lower profile. They then became 7F and then 6F compartible. The PS-153 slowly became obsolete. My overseas colleagues reported re-stenosis of 20-30%. s usual, after 100 coronary stents, we publishes our experience in the Malaysian Medical Journal. We had a re-stenosis rate of about 14%, bearing in mind that ours was clinical re-stenosis and many of my overseas colleagues were talking about angiographic re-stenosis, which was obviously more sensitive, but which in my opinion was unnecessary.
After the PS-153, a whole host of coronary stents were produced by a whole host of companies. The GR stent also became obsolete, and the company ( Cooks ) stop this line and went on to other devices. Other companies like Boston Scientific came in with their stents, and also AVE, Guidant ( now Abbott ), Medtronic International ( previous USCI Bards ), with their stents. Now we are spoilt for choice. There is even a made in India stent, and a made in Singapore stent ( the S stent ). The marketplace is so competitive.
However, a re-stenosis rate of 20-30% was still higher. Every third patient would complain of angina again and would need a repeat procedure. Things were not yet good enough.


To be continued. " Malaysian Interventional Cardiology 2000-2010".

MALAYSIAN INTERVENTIONAL CARDIOLOGY 1980-1990

I did my undergraduate medical studies in the University of Malaya from 1970-1975. During the junior clerkship, the consultant teaching me my early clinical skills was a very nice American gentleman, the late Dr Ward Kennedy. He was an eminent cardiologist from Seattle, Washington, USA, who worked out how to calculate left ventricular ejection fraction correctly from an LV cineangiogram. He was a big name and he was my teacher. From him, I became interested in cardiology. I must say that he was not so proficient in in neuro signs and symptoms or in gastero signs and symptoms. He was very good with murmurs and cardiac signs. No, I am not here to talk about undergraduate days.
The other important reason was that Dr Kennedy was here to help set up the cardiac unit in University Hospital ( as it was then known). He was a personal friend of the late Prof TJ Danaraj and his wife Prof HO Wong. The three of them, together with Prof NK Yong ( Cardiac Surgeon and professor of Surgery ), set up the first cardiac unit in Malaysia, I believe in 1968. Prof Wong and Dr Kennedy wil do the cardiac work-up and confirmatory angiography ( at that time, there was no echocardiogram ), and Prof Yong will operate. The priority at that time ( a priority decided by Prof TJ Danaraj and Prof HO Wong ) was to treat mainly congenital heart disease, which was the first form of corrective cardiac surgery practiced here and in the West. It was indeed very rewarding to see a "blue baby", turn pink after corrective cardiac surgery. Of course at that time, surgical techniques were developed only for the most common and easiest to correct, as cardiac surgery itself was at its infancy. We saw alot of ASDs, VSDs, Tetralogy of Fallots, Coarctation of Aorta, some Transpositions of Great Vessels, and the rest were rare, or died before reaching us. We also saw much Chronic Rheumatic Heart Disease and we were quite good at listening to murmurs.
After my graduation in April 1975, I was asked to stay behind in UH, to join the cardiac team, at that time centered on Ward 4A of UHKL. The team, at that time in 1976, consisted of Prof Wong as head of department, Dr KT Singham ( now in Australia ), and Dr Anuar Masduki. I was the most junior and was in the position of clerking in patients, preparing them for cardiac catherisation, and when time permitted, also holding on to the distal end of catheters. I learn that most of the equipment for the cath lab was donated by the China Inland Mission. via USA, and we were reusing catheters, which nonetheless work safely and well. In this way, I horned my skills, and got my first taste of cardiology, first hand.
The late Prof TJ D, as he was affectionately called, was a very strict disciplinarian, and inculcated in all of us a strong sense of discipline and responsibility. It was always patient first. The business of medicine NEVER entered into our minds, or any of our discussions. He had a great passion for medicine and medical education.
After passing my MRCP primary, I decided to go to UK-Glasgow to write my part 2. I did a short attachment ( about 1 month ) in Glasgow Royal Infirmary ( GRI ), to get use to the Glaswegian accent. After passing my part 2, the Consultant in GRI offered me an SHO's ( senior house officer ) post, as it was vacant. It was a paid job and I could get training. So I stayed in Glasgow for 18 months to be trained in coronary angiography. My supervisor was Dr Ross Lorimer at the GRI. I could see then then coronary angiogram was discovered in USA and was gaining popularity. At about the same time, my colleague, the late Dr Nik Zainal, was training in St Mary's Hospital, London, also in coronary angiography. After 18 months, I told Dr Lorimer ( the GRI cardiology consultants were very nice to me ), that it was time for me to go home to serve. They very nicely offered my job to another Malaysian. When I wrote back to UH, they told me that they do not need anymore cardiologist, so the job was given to someone else.
I return to UH as a medical lecturer in 1980, and again join the cardiac team together with Dr KT Singham, Dr A Masduki, and rotating MOs and HOs. The work was still mainly congenital heart disease and Rheumatic Heart disease. Coronary Heart Disease was deemed to be a rich man's disease and as the cardiac list was very crowded ( with congenitals and rheumatics ), there was no place or time for coronary artery disease. The cardiac surgeon also feels the same. They would rather operate on congenitals and rheumatics. We all, the UH group felt that at that point, with so much congenital heart disease, it was more worthwhile to cure a child with congenital heart disease. He will have a fruitful future for himself, his family and the country. So the UH emphasis was in congenital hearts and rheumatic hearts.
But, in the government side, they see things differently. The late Dr Nik Zainal, was trained to do coronary angiography by the Sones technique. He had a cardiac surgeon trained in Melbourne, Dr Rozalli who was also trained in Bypass surgery. For the both of them, their training in congenital heart disease investigations and surgery were minimal. Coronary artery disease was a disease of the rich and richer and had lucrative private practice possibilities. So the GHKL team ( this was before the IJN ) was concentrating on adult CAD ( coronary artery disease ), and the UH was doing mainly congenital hearts and rheumatic hearts, right up until, Dr NK Yong and later Dr Saw HS left.
So there we were, cathetherising congenital hearts and rheumatic hearts. But almost once a year from 1982, Dr Joe Eravelly ( a prominent physician in KL ), will bring a VIP to UH with Dr Singham's permission, for angioplasty. He would also arrange for Dr Simon Stertzer ( an innovator of the balloon angioplasty technique ), to come and perform the angioplasty. Dr Stertzer would bring his own catheter, and do the case in the UH angio lab with Dr Singham and Dr Masduki assisting. So UH did do the occasional balloon angioplasty by the visiting Dr Stertzer.
In 1984, I left UH to join Pantai Bangsar Medical Center, and started the angiogram program there. When Pantai wanted to start a cardiosurgical program there, I arranged for Dr HS Saw to come up from Singapore, to do some cases, beginning with close heart surgery. More of that later, if we have time.
In June 1985, I obtain practising rights in SJMC ( Subang Jaya Medical Center ), to do angiogram cases there. Those patients, after coronary angiograms, who had important disease were referred to Singapore for Bypass Graft surgery by Dr HS Saw. Even then we had heard of angioplasty as a technique, being done in Switzerland and USA. However, I felt that the technique was just being developed and not yet matured. We were watching the scene. In fact, Dr A. Greuntzig, the innovator of the balloon angioplasty technique, came by Kuala Lumpur, to give a talk. sometime in the mid 80s ( I forgot exactly when). The results that he showed were impressive, but I felt needed some more confirmation, by more workers in this field.
In late 1987, a few of us, had a discussion and decided that it was time for Malaysia to learn and use the balloon angioplasty technique to treat our patients. I organised for 3 of us, one from the government ( Dr Robayaah Z ), one from the university ( Dr Samuel Ong-HUKM ), and myself to fly across to St Francisco to attend a live demo course run by the St Francisco Heart Institute ( SFHI ) in the spring ( April ) 1988. The course directors were Dr Richard Myler ( one of the innovators of the balloon angioplasty technique ), Dr Simon Stertzer ( another pioneer of the balloon angioplasty technique ) and Dr David Clark ( senior consultant cardiologist at SFHI ). At the live demo sessions, we felt that the technique was well established and that we could master it. We decided that we should make a start. At the last evening of the live demo course, at the gala dinner, I took Dr David Clark aside and ask if he would be agreeable to come to Malaysia, to help us start the balloon angioplasty program in Malaysia. He was most keen.
So I began to get it organised upon my return.
It was October 1988 when we planned for Dr David Clark to come. He also brought along his very good friend, Dr Tim Fischell ( now head of cardiology and director of cardiac cath lab at Western Michigan University at Kalamazoo ), to help so that they could work independently in two centers. We had organised about 10 cases per center, at three centers ( SJMC, GHKL, UHKL ) to do the cases. All the patients knew that we were doing this cases first time, with the help and supervision of the American experts. The centers also were in agreement and gave their consent. Cardio surgical back-up was arranged for all the participating centers. We obtained temporary practising certificates for Dr Clark and Dr Fischell. Dr Clark and Dr Fischell stayed in KL for 10 days, to do the cases with us. The first 5 cases in each center was done with the Americans as the first operator, and when they feel that we were proficient enough, we will do the case and they would assist us. We were all told to keep a log book and to document all the cases well. They also advise that we should choose single vessel disease and simple cases first. We all had to arrange for cardio-surgical backup ( this was the days before cardiac stents ). Dr Simon Yap, use to standby for me. Dr Clark and Dr Fischell, both came gratis ( no pay ). We sponsored their tickets through the device company ( USCI Bards ).
After their departure, I began to do cases with Dr K Chin assisting. There were so many cases that before long, I had clocked 100 cases. I kept a registry as taught, and presented my cases at the quarterly academy of Medicine scientific meeting, regularly. The first hundred cases were submitted and published in the Malaysian Medical Journal. Our results were comparable with those overseas. I tried to show that with all new procedures, we must keep a logbook, publish our figures regularly and present it to the medical community to comment and correct. Peer review was important.
Over at the government centers, I hear that my colleagues there were much slower to progress. Some went overseas again, to train further. So in balloon angioplasty, the private sector was far more progressive.

Tomorrow I will write about the development of stents, viz bare metal stents.

AS I SEE IT. THE DEVELOPMENT OF INTERVENTIONAL CARDIOLOGY IN MALAYSIA. 1980-2010

As the year 2010 draws to a close, I am sure that all of us are reflecting on what the past year had been and what the future holds. Looking at the past, helps us to work better for a future. And when you are in your twilight years, some ruminations and re-collection of memories come by naturally and helps us see ourselves better. What have we achieved?
I was fortunate enough to be apart of the development of cardiology in Malaysia, being born at this very interesting times for health care development in Malaysia generally and development of treatment of cardiac disease in particular.
I suppose, I should begin by saying that this is my account, as I see it. Some may dispute, some may agree. I sometimes get to hear different versions of it. Let the "interested Malaysians" decide. This is the scientific way. The way of collecting information ( data ), both pros and cons and arrive at a conclusion.
I must also begin by apologising to those who may feel offended, either by my including them or by my excluding them ( unknowingly ) in my account. This literary journey is not meant to offend anyone. It is just to set on record, what had happened as we journey from 1980-2010, helping to develop cardic treatment modalities to help our people.
I will try and be as apolitical as I can. I am sure that all of you know that it this country, almost everything is political, however much you do not wish it to be. I tried very hard to keep out of politics, especially racial politics, but it was virtually impossible. You will know as you read, that some parties, major on it, to try and stiffle progress. I am very much a clinician.
We have three more days till 2011, so I have chosen to write today about the development of cardiology in Malaysia from 1980-1990. I graduated in 1975. Tomorrow ( God willing ), I will write about developments from 1990-2000, and on Friday, the developments from 2000-2010.
Without fear or favour ( to borrow a cliche from the late Dr Tan Chee Khoon), I shall proceed, to the best of my ability.

GARLIC, THE NATURAL MEDICINE

It has been known for a longtime that garlic contains medicinal properties, and has been associated with cures for "flu", increase natural immunity, lowering cholesterol, fighting cancers, helps the lungs and digestion, and a whole host of health claims.
The recent issue of the Journal of Maturitas ( what journal is this? ), from Australia, published a small piece of work by workers from the university of Adelaide, that garlic lowers blood pressure.
They studied 50 subjects with hypertension and found that when compared to placebo, 4 garlic capsules ( aged garlic ) daily for 12 weeks lowered blood pressure by 10mmHg. A small study, and obviously not confirmatory. Interesting. I have posted before that garlic may lower LDL-Cholesterol. I suppose all these good effects of garlic must be due to the high sulphur content in garlic, acting as some form of anti-oxidant. No, I would not advise anyone to stop their blood pressure pills without consulting their doctor. I would encourage the eating of garlic, in moderate amounts with food ( eat healthily ), so that we can get some of the good benefits of garlic. If you do not like the strong smell, you could take aged garlic capsule. If you are in mosquito infested jungles, a strong meal of garlic may serve to keep the mosquitoes away. The downside maybe that it may also keep all your friends away.

As the year ends, I suppose it is good to remember that this blog is now about 5 years old, having began in 2005. Time flies. Hope that you all had a good and beneficial time reading and enjoying this blog. Lets look forward to a more healthy year in 2011.

TICAGELOR ; FDA WAITS. NEED MORE ANALYSIS

Ticagrelor is a new anti-platelet agent ( like clopidogrel ) in treatment of atherothrombosis. It is manufactured and marketed by Astra Zaneca. Last July, I wrote i this blog that the FDA advisory Panel for CVS and Renal drugs had met and voted 7:1 to recommend approval for ticagrelor to be used in the treatment of acute coronary syndrome. They based their recommendation largely in the outcomes of the study " Platelet inhibition and Patient Outcomes" trial. This is a very large controlled trial of 18,000 patients, half on ticagrelor + aspirin, and the other half on clopidogrel and aspirin. They compared the outcomes after 12 months. The primary composite endpoint was CV deaths, AMI and strokes. This showed a benefit for ticagrelor + aspirin over clopidogrel + aspirin. The P value was < 0.001.
Having read that, I flt that with the recommendation by the advisory committee, that the drug would be approved. So the headlines in July 2010.
But this was not to be. Last week, the European Drug Authority approved it for use in Europe, but the US FDA met and decided to withhold approval, and asked for more detailed analysis. Now this is a bit strange as AstraZ was waiting to time their launching.
So cyberspace is flying with all kinds of arguments for and against approval. The communications by the "big boys" is quite interesting, to see how the system works.
Apparently, the small prints are important here. What I did not know in July was that there seemed to be a difference in outcome in the US, Canada, Russia centers. Remember, this was a multi-center trial across 43 countries. Apparently, most centers that were monitored by AstraZ, returned positive results ( Ticagrelor was more efficacious than Clopidogrel ). Some centers were monitored by independent observers. These included US, Canada, Russia, Denmark, Australia, Taiwan, Norway. With US, Canada, Russia, ticagrelor was less efficacious than Clopidogrel. In the rest monitored by independents, the results were neutral. About 20% of patients were contributed by Poland and Turkey, and monitored by AstraZ. The results here were positive for Ticagrelor. Interesting. No wonder FDA wants a re-look at the data and analysis.
Reading between the lines, it also seem that the FDA may not be very pleased that the US, Canada data, is over-ridden by the Polish, Turks data. That positive results from Poland and Turkey, may influence treatment practice in US, when the US data is at odds. Interesting.
Lets see what the new analysis will end up with. Keep a watch out on this page, all those interested. I am sure there will be more coming.

WISHING ALL READERS, A VERY MERRY XMAS AND A VERY HAPPY, HEALTHY AND PROSPEROUS NEW YEAR 2011.

EAT HEALTHILY TO LIVE LONGER. SIMPLE SECRET TO LONGEVITY

It has been man's dream since ancient times, to know the secret of longevity. Many of us wish to live longer and some of us wish to live better. Both are difficult to fulfill. Perhaps the first is easier, especially with the latest study on diet and longer life, published in the Journal of Dietetic Association.
In that study, the American group studied 2,500 adults aged 70-79 years, and divided them into 6 groups, each with a different diet, varying from low fat, green veges, fruits diet, to high fats, milk, cheese and creamy foods. After ten years of followup, they found that the group that was on low fat, green veges and fruits ( veges and fruits, 5 servings a day ), live longer. For every 100 in the group, 12 lived longer then those on the other diet. I suppose 12% improvement, over a 10 year period is good. I only wonder if they are living longer and living well.
I was looking for an explanation. Perhaps, those who were on the high fats, creamy diet, were obesed and so suffer all the chronic lifestyle disease of obesity, including hypertension, diabetes, heart disease and strokes. I am sure ( based on medical evidence ) that those on low fat, green veges and fruits diet, will be leaner, have less hypertension and less diabetes. So also less heart disease and strokes.
I do spend some time with my patient after each consultation, to teach them a healthy diet. I found that most Chinese adults like the " tua pek kong" look, and do not like the lean and hungry look. They feel that the lack of the " middle kingdom " is an insult to them and their family. It would take quite awhile, I think, to re-educate them.
Of course, with so many fast food joints and their adverts targetting at all the adolescent and teenagers, my effort gets so much tougher.
Well, to live longer and better, eat less fats, 5 servings of fruits daily and much green veges. Some white meat would be great.

MERRY CHRISTMAS AND HAPPY NEW YEAR 2011

CAROTID STENTING VERSUS CAROTID ENARTERECTOMY FOR CAROTID ARTERY STENOSIS IN STROKE PREVENTION. THE IMPORTANCE OF EXCELLENCE

This has been a highly contentious issue. Some studies are in support of carotid artery stenting and some are for endarterectomy, and some find them equivalent. the pendulum swings back and forth, and a definitive answer is not in sight. Every year, when I go to moderate at international interventional meetings, there will be some carotid artery stenting been demonstrated, and taught. ( we are interventionist after all ).
Part of the reason seemed to be that when clinical trials are being performed, the selected centers are centers who do them regularly ( good at them ), and so deliver good results, which are often not reproducible by centers ( or interventionist ), who do say 2 or 3 a year. It may therefore not be the procedure per sa, but the medical expertise in doing them. many of us ( myself included ), who have advocated a principle that these complex procedures should only be undertaken by centers, and individuals who do them regularly. In Malaysia, there is often a philosophy that after seeing one being done, doing one with some supervision, he is now an expert. Even worse, some travel around the region ( they are not acceptable except in the ASEAN region ), learning and teaching as he goes along. After travelling around for 1 year and learning as he goes along, he becomes an expert. It is not difficult to travel around the ASEAN region, where there is little quality standards control ( except perhaps in Singapore ). After device companies will gladly introduce you as an "expert" and bring you around to propagate their device. It is marketing wa... So the game goes on. There are some interventionist in Malaysia, who are experts in coronary stenting, carotid stenting, renal stenting, peripheral stenting, and I suppose eventually internal pudental ( penile ) artery stenting as well, as long as ther is money ( for some fame ) to be made.
Well, this blog is prompted somewhat by an article in the December issue of the Journal of Vascular Surgery, by Dr Kristina Giles. She and her research team from the Beth Israel Deaconess medical center, looked into the Database Agency for Healthcare Reasearch and Quality, for outcomes in carotid artery stenting and enarterectomy, to compare them. They collected ( with adequate outcomes documentation ) of 56,564 cases of carotid artery stenting versus 482, 394 cases of carotid enarterectomy, to compare their outcomes. They found that in virtually all subsets ( symptomatic versus assymptomatic, high risk versus low risk ), carotid enarterectomy carried a higher stroke rates and higher death rates. This database of course reflect the real world practice in the US community ( across the board, across all hospitals ). What this means is that, when you are not part of a clinical trial, and in everyday practice, in the average center, carotid enarterectomy does better. In selected centers, then perhaps both procedures are equivalent, and in some studies, stenting may actually have been shown to be superior.
Of course databases are not a very accurate way of comparing outcomes, but it does reflect real world and the large numbers ( although the numbers in both arm are not equivalent ), does moderate the good and the bad. We would like them to be matched, but with databases, that is sometimes impossible.
The last point that I wish to make is that the Ministry must begin to licence certain medical centers to focus ( become centers of excellence ) in certain procedures, so that we can excel. Every Tom, Dick and Harry doing everything, the Jack of all trades approach, is not good. How can they excel, when some centers are doing 1 angioplasty a week, or less then 100 a year. By the time the staff and interventionist have learn something, they would have forgotten, and the next case is a " start all over" to learn again. We need case loads in the hundreds, if not thousands to get good. When I visited Beijing to help them in 1993, they were doing a few angioplasties, a month. Now the same center is doing hundreds a month and thousands a year. China is doing about a quarter million coronary interventions a year, with two centers per province and, I thin, 37 province in China. They are probably much better then us now.
How to become a high income economy, if we do not have a plan also to develop centers of excellence for our people?

DOING LESS IS MORE ( BETTER ). A CASE OF CCTA

I have written about CCTA ( Coronary Computerised Tomography Angiography ), pointing that it is not without its risks and also that the current generation ( 64MSCT ), is not yet good enough.
Well, the recent issue of Archives in Internal Medicine, Dec 13, illustrates the point. My sympathies to the patient.
A 52yrs old White Female Nurse had gone to see her own cardiologist for some mild chest pains not suggestive of angina. Her resting ECG was normal, her ipids were normal, the Hs-CRP was normal. The cardiologist decided ( although she was in the low coronary risk category ), to undertake a CCTA. The CCTA done showed discrete, noncalcified, nonobstructive plaque in the mid and distal segments of the left circumflex and dominant right coronary arteries and diffuse, complex calcification in the proximal left anterior descending coronary artery (LAD). Seeing this, the cardiologist advised a coronary angiogram, which was basically normal. However, on completion of the coronary angiogram, she complained of a severe pressing sensation on her chest. The angiographer proceeded to do an aortogram which showed a dissection of the ascending aorta, with involvement of the left main stem. The coronary circulation was severely compromised. The cardiac surgeon was called, and she underwent emergency CABG ( coronary artery bypass graft surgery ). The LVEF then was 37% ( this is a healthy 52yr old nurse ). Bad luck, the bypass graft failed and she developed cardiogenic shock. The interventionist was called and she had multiple DES ( drug eluting stents ), implanted. The DES to the left circumflex graft developed subacute stent thrombosis. The cardiogenic shock could not be reversed. She underwent urgent orthothropic cardiac transplantation.
All she needed, when first seen was a good history taking, perhaps a stress ECG ( as she was low cardiac risk ), and plenty of re-assurances, with perhaps some advice on diet, and healthy cardiac lifestyle.
Yes, this is an extreme example. Yes, this is a patient with " bad karma". But no, she did not need a CCTA, which led to the whole chain of events. CCTA is not without its risk ( including bad decision making in response ). Coronary arteriography is also not without its risk. That is why we have indications to see who needs and who does not need. CABG has risks too, and so also PCI/DES. Those of us who has done enough, have a very healthy respect for all these medical technologies, and procedures. Sometimes the " younger ones " are too "aggressive".
This case illustrates all these. That is why, I say, doing less can sometimes be more rewarding, and better for the patient.

THE "-GATRANS", " XABANS" VERSUS WARFARIN

These two years, and the years ahead will see a proliferation of drugs to fine tune anticoagulation. Last year, we saw the release of the Re-Ly data, showing that dabigatran was superior to warfarin in preventing strokes in patients with Atrial Fibrillation ( more later ). This year, we see a well orchestrated presentation, on 15th Nov in AHA Chicago, of the data on the ROCKET-AF trial ( nothing to do with DAP ), comparing Rivaroxaban with Warfarin, for stroke prevention in patients with Atrial Fibrillation. Rivaroxaban was non-inferior to warfarin in this aspect, in ROCKET-AF. Well, obviously good drugs attract imitators. There is a whole host of "-xabans" on the way. Trials are under way with Apixaban, Edoxaban, TAK-442 ( only a Jap company will do this name ), Betrixaban, and Darexaban. These are the few in the pipeline that I could find. Of course, Dabigatran had a predecessor called ximelagatran, which which was studied and then withdrawn, in view of a hepato-toxic side effect. Dabigatran remains the sole member now of the "-gatran" family. For how long we do not know. There are a few problems with dabigatran. More of that later.
It must be noted that the dabigatran is a competitive thrombin inhibitor, quite unlike the "-xabans" which are direct Factor Xa inhibitors. They are both anti-coagulants but working on different pathways.
Dabigatran in Re-Ly was shown to be superior to warfarin, in preventing strokes. That is the gist of the results of the Re-Ly trial. But a closer look at the analysis, revealed that both in the warfarin arm and the dabigatran arm of Re-Ly, the optimal PT-INR was achieved in the minority of the patients. Basically, proper anti-coagulation, may not have been achieved. If we sub-analyse the population with optimal PT-INR in both arms, dabigatran anti-coagulation was no longer superior to warfarin. But then this is a subgroup analysis. Also, the other troubling thought about dabigatran seemed to be a slight increase in the number of heart attacks in the dabigatran arm, although the total cardiac mortality was the same. An increase in heart attack rates is worrying. There is also the 10% side effects of dyspepsia with dabigatran. Of course, as always, there is the issue of cost. Dabigatran costs much more than warfarin. However, in a costing analysis, if you take into account closer monitoring with warfarin, intra-cranial bleeds and repeat hospitalisation with warfarin, the total cost analysis seem to favour dabigatran. At least that is what the Re-Ly investigators will have us believe. Obviously, they managed to persuade the FDA, as dabigatran is FDA approved for use in Atrial Fibrillation and DVT.
Rivaroxaban, dont seem to have some of the dabigatran problems. Dyspepsia is less, and heart attack rates are the same in the rivaroxaban arm and warfarin arm. However, the ROCKET-AF study is a smaller one, and may not be as definitive as the Re-Ly study.
It is true that good old warfarin ( rat poison ), is a very fussy drug. It is cheap ( that is about its only selling point ) and it is effective. But it does have significant side effects, the worse of which is intra-cranial hemorrhage. It also interacts with hundreds of other drugs and also veges, fruits and meat. It is rather difficult to maintain a good and reliable therapeutic level, avoiding bleeding at the same time. But it can be done, and the cost savings are substantial.
I would like to spend a few lines to dwell into this issue of cost. Can a developing nation like ours afford to use a drug that cost RM 15 daily, for lifelong to replace a drug that cost about RM 2 daily?, in an attempt to prevent a stroke for every 1-2000 treated? Of course ( as always ), if you are the one stroked out, you will say yes. but if you are those well controlled, you will probably count the RM 450 monthly expenditure on dabigatran, and tell me no ( as some of my patients have ). A tough one. I wonder what the UK NICE will decide. Will they make dabigatran available for NHS patients?
Anyway, there are more "-xabans " coming. Maybe that will bring the price down.
For the moment, all my AF patients are still on warfarin and close monitoring.

ASPIRIN ( ACETYL SALICYLATE ), THE MOLECULE OF THE YEAR

Last week I forgot to post the article from Lancet 7th on aspirin and cancer deaths.
We all know well that aspirin was first discovered in the 17 century as a pain killer and also an anti-pyretic ( reduces fever ). It was the drug of choice for reduction of fever and joint pains in kids suffering from acute rheumatic fever. Later, in the 19th century, we learn that low dose aspirin ( half the pain killing dose ) reduces the incidence of heart attacks and heart attacks related deaths in those would were at high risk of heart attacks. Later, we found that this was also true for strokes. That low dose aspirin was a very effective anti-atherothrombotic agent. Of course now we have many more potent anti-atherothrombotic agents, like ticlopidine, clopidogrel, prasugrel, ticagrelol, and I am sure many more to come. We also know that low dose aspirin reduces stroke rates in people with low risk atrial fibrillation.
Now in a 7th Dec article in Lancet, we learn that low dose aspirin may confer a protective effect from cancer deaths, especially cancer of the colon. In a long term study, 4-8 years with follow-up till 20 years, aspirin was shown by the Oxford Research group, to reduce cancer deaths by 20-25%. We are talking about 100-75mg of aspirin daily ( the pain killing dose is nearer 325 mg or more. With cancer of the colon, the death rates can be reduced by up to 40%. I must say that this is very good. Actually, we suspected this all along, since the new millenium when we found that COX 2 inhibitors could reduce cancer rates in patients with polyposis coli. It looks like all anti-inflammatories may have this common benefit, and aspirin is probably the best studied and the best of the lot.
The why is more difficult to understand, probably because there are so many mechanisms for the formation of cancers. The most popular theories ( and it remains much a theory ), remains that aspirin is able to reduce mutation of the cells to form cancer cells. They also have some properties of improving program cell deaths ( apoptosis ) so that old cells will die on time and naturally. There is some suggestion that aspirin also lessens neo-vascularisation and vasculogenesis. All these remain theories that researchers are still working on. They probably all have some truths with some cancers, but probably not with all cancers.
Say what you may, it is very appealing that perhaps all middle age men ( the data on females are scarce ), should take 75 mg of aspirin a day. However, this is not without its risk.
The biggest risk with aspirin therapy is gastro-toxicity. Aspirin is acidic and can irritate the stomach. Gastric pain is perhaps bearable, but gastric bleeding can be life threatening. The average middle age men has an 0.1% chance of a gastric bleed, and some one on low dose aspirin has double that risk ( about 0.2% risk of bleed ).
That means that before you go out and buy low dose aspirin to take, you should consult your own doctor. That is also why we cannot lobby the government to add aspirin to drinking water. Gastric bleed is life threatening, but cerebral hemorrhage ( another potential risk with aspirin ), can be life threatening and very incapacitating.
So although aspirin is a very good friend, it can also be e very bad enemy. Be careful.
All things said and done, aspirin has proven to be a marvellous molecule, certainly a good candidate for the award of " molecule of the century ), if ever that is such an award.

WEEKEND SEMINAR IN CARDIOLOGY 2011

We had our first organising committee meeting last evening for next year's " weekend seminar in Cardiology 2011". It was a business like meeting, conducted by Dr Lawrence Chan, and it started on time and lasted about 35 mins. I must say that very few meetings are so business like. Then again, this is our 10th weekend seminar, having started in 2001, so we are use to the formatt and what needs to be done. " Weekend Seminar in Cardiology 2011 " will be held from 2-3rd April 2011 at the Sime Darby Convention Center.
I was taken that it cost about RM 130K to fund this two half day cardiac seminar for GPs and government doctors. It is held under the auspices of the Private Medical Practitioners Association Selangor and KL. Of course, the host does not pay for the cost of the meeting ( she cant, having about 800 members, and collecting a subscription of RM 60 annually. So I spend much time last week ( I am sure Dr L.Chan and Dr Hew FL were doing the same ), ringing up sponsors ( pharmas ), to help sponsor the meeting. Finally, we managed to raise about 18 sponsors ( not a bad number ) and so each pharmas portion is about RM 8,500. We like to try and keep the cost per pharma down to below RM 10K. We must not waste and be too pricey.
So over the next 1 month, we will have to get the program out, so that the pharma sales force can go out and personally invite their target GPs or medical officers, and trainees doctors, to come and attend the seminar under their sponsorship. We expect to enroll 1,000 doctors for the meeting. That is partly why the cost is so high, as we are targetting a large crowd. After the successful completion of the seminar, a simple dinner is held to thank the sponsors and also to show the accounts, so that we are transparent.
We have been using this formula to organise medical meetings ( low cost, multiple sponsorship, large crowd and great transparency and accountability ), hoping that other medical association will do the same. The aim being to stretch the sponsorship dollar. The pharmas are facing much difficulties to meet their bottom line and I suspect, it will not be long before pharmas will being to tighten the belt ( as if it is not happening now ). I have never understood how people can justify asking companies for RM 200K ( or even RM 1,000K ) for sponsorship. I can do so many CMEs with that money. Anyway, I suppose we are all made differently. I only hope that they are all transparent and accountable. Some association pride themselves in acquiring great wealth, from pharma sponsorship money, I am not sure why? Anyway, we shall not bother about them.
As for the " WEEKEND SEMINAR in CARDIOLOGY 2011" it shall be held from 2-3rd April 2011, at the Sime Darby Convention Center. All those who wish to attend please take a note of the dates, and keep it free. Dinner and lunch will be provided for saturday night and sunday afternoon, as sponsors have taken up the lunchtime and dinner symposium, to market their product. Hope to see some of you there.

AHA / ASA GUIDELINES 2010 FOR THE PRIMARY PREVENTION OF STROKE

Undoubtedly, stroke is one of the major catastrophic diseases that we must all avoid. Striking adults at the prime of life or fifties, and sixties, incapacitates them, make them lose their independence and self belief, and make them ( in some cases ) totally dependent on others at the phase of their life when they wish to be independent to enjoy life in their twilight years.
In 1999, the American Heart Association ( AHA ) and the American Stroke Association ( ASA ), decided to set a target to reduce stroke by 25% by year 2010. They managed to achieve their target of 25% reduction by year 2008.
They have just released their Stroke primary prevention guidelines 2010, in a document published in STROKE Dec 2. The last such document was published in 2006.
In this present document, they again emphasize the importance of lifestyle modification, in the prevention of strokes. Stop smoking, lose weight, exercise, eat less salt, moderate alcohol consumption, low fat diet, green vegetables and fruits, ideal body weight. It is reported that these measures, if properly taken can reduce the risk of stroke by 80%, much better then any medication that we can prescribe to our patients. A few other key interesting areas from the guidelines should be highlighted.
1. Secondary smoke : the data here is incomplete although the conventional wisdom is to have a smoke free environment.
2. Screening of stroke risk factors by GPs and emergency room physicians ( or anywhere where a patient comes into contact with a medical personnel. There should be a universal awareness by all medical personnel, to screen for stroke risk factors and take lifestyle modification measures.
3. Assymptomatic carotid artery stenosis. The guidelines seemed to suggest that medical therapy is the way to go. All the scary carotid enarterectomy procedures, and carotid stenting, should be for thsoe with symptoms.
4. Low dose aspirin should be for those with moderate risk for strokes and not for everybody, or those with low risk of strokes.
5. Atrial fibrillation is becoming an important risk factor for strokes. The guidelines still recommend the use of warfarin. It should be noted that the guidelines were drawn up, before the important clinical trials which seem to suggest that new factor 10 inhibitors may provide an alternative to warfarin. Perhaps these will be highlighted in future guidelines.
I personally feel that we must do our utmost to prevent strokes, as it is a very debilitating disease. I saw my mother suffer 3 years with it, and it is terrible. If you are one of those who feel like me, then please lead a healthy lifestyle ( you can still have a life ), particularly, no added salt in food, and good control of blood pressure.
Perhaps the AHA/ASA should work towards reducing strokes by a further 50% by 2015?

SLEEP AND THE HEART - OBSTRUCTIVE SLEEP APNEA ( OSA )

The Radiological Society of North America ( RSNA ), is meeting in Chicago currently. One of the interesting paper presented was a paper on sleep apnea and the heart. Dr Joseph Schoepf and his team from Medical University of South Carolina, studied 95 patients, 49 with obstructive sleep apnea, and 46 without. They were matched for age and BMI. Using CT angiogram, as a means of diagnosing CAD, they found that patients with OSA had more extensive disease and also less calcification in their CAD.
What the authors are saying is that OSA may be associated with atherosclerotic plaques which has a higher lipid core and lesser calcium. An interesting thought. I suppose the weak part of this study, must be the small sample size and the use of CT angio as a means of diagnosis of CAD. True, they are using the later version of dual core technology for their CT angio, but I must say that this method of evaluation of CAD, tend to over-estimate. They tell me that the newer machines are much better, but I am not yet convinced. Yes, the newer machines have less radiation.
The issue is the increasing incidence of obesity in USA, Malaysia and world-wide. What the authors are saying is that obesity is associated with OSA, and CAD. It maybe that OSA is an important reason why obese patients with OSA have high CVS mortality? What is equally important is that a reduction in BMI is associated with a reduction in OSA and CAD.
The exhortation must be for us to reduce our weight, reduce obesity in the community, to help curb CAD.
US statistics have shown us that in the 90s we were able to gradually reduce the incidence of CAD and CVS mortality and morbidity, from our many prevention strategies, statins and revascularisation. In the new millenium we are seeing a rise in obesity, and we are very worried that this will negate all the CVS mortality and morbidity that we have achieved in the 90s.
Nice small study with an important message.