TEAS AND CORONARY RISK

There is an ongoing belief that tea drinking washes away the fats that we eat and so reduces fat accumulation in arteries and lowers the incidence of CAD. Is this true? Many Chinese believe that after a fatty meal, drinking tea is essential.
Well, it is not entirely wrong, I think.
The Jan 19 issue of the American Journal of Clinical Nutrition carried an article from China on this topic. Dr Ze-Mu Wang and colleagues from the First Affiliate Hospital of the Medical University of Nanjing did a meta-analysis of 18 clinical trails involving the drinking of black tea and risk of CAD, and another 5 studies of the drinking of green tea and the risk of heart disease. They found that the drinking of black tea was not associated with any reduction in risk of CAD. But the drinking of green tea seem to confer some protection against CAD.
The theory is that tea contains a substance called " catechins " which has the effect of inhibiting oxidation, and reducing inflammation, two words that are very important in the initiation of CAD. The amount of catechins in the tea depends on the fermentation process and green tea contains more catechins.
I suppose there is nothing wrong with drinking green tea, as there is no downside, besides cost, I suppose. Whether it helps or not, will need much more work. Remember that this is a meta-analysis, with all its deficiencies. The samples and cohorts, may not all be properly matched and the studies may have slightly different endpoints, although they all have to do with the use of green tea in the reduction of CAD. As always, it is best to take meta-analysis ( a cheaper way of doing research ), with a small pinch of salt.
Be that as it may, if you wish to drink tea, no harm choosing green tea. It may help. At worse, it does no harm, and it is quite nice to drink. I like it. As for white tea, there is almost no data.

HYDROCHLORTHIAZIDE AS AN ANTI-HYPERTENSIVE. THE CONTROVERSIES.

When I was a medical student, Hydrochlorthiazide ( HCTZ ) was already in use as an anti-hypertensive agent. I remember using alot of it in UHKL, as it was cheap and fairly effective. We were using HCTZ at 50 mg daily. It is true that at that dose, we also saw some patients with hypokalemia, and also impaired glucose tolerance ( those were the days before pre-diabetes ). There were quite a few clinical studies then to support the teaching and use of HCTZ. These were small studies. The larger studies tended to use chlorthalidone and some indapamide.
So it came as somewhat of a surprise to me, when Novartis first came out with an ARB+ diuretic combination, and they chose HCTZ as the diuretic. I remember telling the Novartis rep covering me that your company had made a bad choose. They should have chosen chlorthalidone.
There is a paper now in JACC ( Journal of the American College of Cardiology ), Feb 1st 2011, examining the use of HTCZ as first line in the management of hypertension, as in the current NHLBI guidelines. The paper entitled "Antihypertensive efficacy of HCTZ as evaluated by ABPM. A meta-analysis of randomized trials". J Am Coll Cardiol 2011; 57:590-600. by Dr Frank Messerli et al. is a meta-analysis of 14 large hypertension trials, in the use of HCTZ evaluated by ABPM. The authors concluded that HCTZ at the dose of 12.5-25 mmHg hardly lowers BP. One will need to use 50 mg daily to have any significant effect. And we all know that at HCTZ 50 mg daily, we may run into the side effects of hypokalemia, insulin resistance and also sudden cardiac death.
One wonders why many of the large pharmas, including Novartis, Sanofi Aventis, Boeringher Ingelheim, and Pfizer, had gone on to add HCTZ 12.5-25 mg to their ARB? If what Dr Messerli says is true, then adding the HCTZ would have minimal effect and may in fact be viewed as a marketing strategy, of having you use a diuretic as first-line, and the convincing the practitioner that the logical step next is to have add an ARB i the form of a HCTZ + ARB combo. Knowing full well that HCTZ at 25 mg may do no good. That may not be true if the diuretic used initially was indapamide or chlorthalidone. It would have been better if the large pharmas, hoping to promote combo pills as a firstline, to have an ARB + Chlorthalidone combination, or an ARM + indapamide combination. I suspect that there are such combos on the way. Maybe we have not yet seen it in Malaysia.
I suppose we must keep watching the scene and not take anything for granted. Combination pills are a good concept, but one must also have the right combination. Dr Messerli, seem to suggest that there may be some advantage in a HCTZ + Renin blocker. Early studies seem to suggest that. Of course Novartis have launch their Renin blocker ( aliskerin ). We will need to see more work and results before we are convinced ourselves.
For the moment, it would seem that small dose HCTZ may avoid side effects, but may not be efficacious. So all the Co-ARB drugs may not be as effective as the plain ARB. I think we will be seeing more ARB-chlorthalidone combo pills ans we will certainly watch development in the HCTZ + renin blocker field.

CARDIOPULMONARY RESUSCITATION. NEW AIDS TO HELP IMPROVE SURVIVAL AND QUALITY OF LIFE.

I was reviewing my medical literature sites when I came across this article which is very intriguing. When we were dealing with the PHCFS Regulations amendments, we proposed to the Ministry of Health that GPs should be able to resuscitate to the standards of the UK resuscitation council 2007, which is basically Basic Life Support ( BLS ). After some initial resistance, we managed to convince them and I think this should come out in the Amendments to the Regulations. BLS is basically identification of a cardiac arrest, call for help, chest compression and mouth to mouth respiration ( kiss of life ).
Progress since our amendment discussions ( shows how long we take to get amendments through, and it is not even through yet ), has now showed us that just compresion, compression and compression, is probably the best. Of course, identification and call for help is still there.
Workers in the Medical College of Wisconsin, led by Dr Tom Aufderheide, have carried out a controlled trail using two simple devices to help in chest compression and breathing.
They studied a group of about 1,650 cardiac arrest victims.The treatment group ( 840 ) had resuscitation aided by the ResQPump and ResQPod. The ResQPump, ( Advanced Cardiovascular Systems, Santa Clara, CA) is essentially a double-grip handle that attaches to the patient's chest with a suction cup, allowing the rescuer to push for delivering compressions and lift for decompressions. The ResQPOD, ( Advanced Cardiovascular Systems) in the patient's mouth limits passive lung inflation during the chest-decompression phase, boosting intrathoracic pressures and enhancing perfusion of the heart and brain. The control group had the usual manual chest compression which is standard practice now. The study was carried over 42 months, and clinical followup for survival was over 1 year.
It is important to note that for out of hospital cardiac arrest, survival till discharge is about 6-9%, same in both arms. The survival at 1 year was better in the treatment arm, and even more importantly, the CNS function was better at 1 year in the treatment group. These results are very encouraging. If the use of a device could help these cardiac arrest victims, then we should go buy it and use it.
A word of caution, however. These trails were done before, and the results were rather mixed. Some studies, showed that it made no difference. It is important to note that this study, although funded by National Institute of Health, had generous support from Advanced Cardiovascular system, and in fact the inventor of the ResQPump and ResQPod, is a coauthor of the paper. I understand that with this paper, they are applying for FDA approval.
We have to keep looking out for how this devices pan-out. Maybe it is too good to be true. But then if it can help my patients survive better, I must look into it.

FRUITS AND GREEN VEGES. GOOD FOR THE HEART

There has been much work now, mainly funded by institutions and governmental bodies, on the good effects of fruits and green veges. both for cancer prevention and also for heart disease prevention.
One of the latest study is by the group from Oxford U, led by Dr Francesca Crowe, and published in the Jan 19th 2011 issue of the European Heart Journal. The study is called the EPIC-Heart study. EPIC stands for European Prospective Investigations into Cancer and Nutrition. They studied 313,074 subjects who had no previous history of heat attacks or strokes, followed them for an average of 8.4 years. The subjects were asked to keep a food record, to see how much fruits and green veges they consume a day. They were then followed up and screened for heart disease and cancers. After 8.4 years ( average ) follow up, they found that those who consume 8 portions or more of green veges and fruits had a 22% reduction in the incidence of heart disease. Each portion is about 80grams, and is something like a small banana, a medium size apple or a small carrot. In England ( the last time I was there ), they sell food in the supermarket in portions. There also seem to be some correlation between the number of portions ingested and the cardiac benefits. For every portion over 8 portions a day consumed, there was a further 4% reduction. So the more you consume, the more the cardiac benefit.
What is more difficult to answer is the why? Is it due to the flavinoids ( anti-oxidants ) in the green veges and fruits? Does the freshness of the fruits or green veges matter? Is drinking mixed, squeeze fruit juices the same? We are not too certain at the moment. We will have to depend on institutions to work out the why. Is it BP reduction?
Earlier in Nov 2010, there was a report out of UK, in the American Journal of Clinical Nutrition, stating that green veges, red berries and blue berries, can lower blood pressure. Of course we are all familiar with the DASH diet in lowering BP.
There is a noticeable trend in my neighbourhood, of more fruits shops opening up, selling more fresh fruits and green veges. There are also more shops selling squeeze juices, and more patients are buying blenders to drink fruit juices. All these are moving the the right direction.
We are very blessed in this country to have an abundance of fresh fruits and green veges. I can only hope that we will all take advantage of it and keep our BP low so that we can all have less heart disease and strokes.
Maybe this is a good new year resolution. By the way, it may also prevent certain forms of cancers too. The data here too is good.

THE 'STATIN' CONTROVERSY

"Statins" is a very useful drug in the prevention of heart disease. Because of this fact, pharmas with statins make plenty of money. This is a billion dollar industry. Much advertisement and promotion is done to hype up the usefulness of statins so that all and sundry will buy it, so-called " to protect their heart ". I have friends who would ingest a statin, after taking a cholesterol rich meal, purely to pacify their conscience. Then they also do not have to diet.
Because of all the widespread publicity, hype and promotional marketing it has brought about its own controversy. After a while, even good, evidence base doctors have difficulty separating the "truth from the facts ".
The latest controversy result from the just released Cochrane Report. There is a Cochrane Database in the London School of Hygiene and Tropical Medicine. They undertook a meta-analysis of 14 mega statin trials, which included 34,272 patients. They took the trials that compared the use of statin against placebo on standard medical treatment at that time, to see if statin use was beneficial. They concluded from their meta-analysis that statin use in patients at moderate or high risk of CAD was obviously beneficial, but statin use in patients with low risk ( less then 10% chance of CAD in 10 years ), was of minimal benefit. In fact in this group, the statins may do more harm than good. In other words, statin use should not be for those at low risk of heart disease. Most of us will define low risk as those individuals without established CAD and less then 2 major coronary risk factors, like dyslipidemias, hypertension, diabetes, cigarette smoking, family history of heart disease.
If you are keen on numbers, it goes something like this. The use of statins in this low risk group of 1,000 patients, over 1 year, will safe 1 life. Wheres in may cause 1.7 renal problems, 25.2 cataracts. 6.5 liver dysfunctions, and 3.2 cases of myopathy. Putting in this light, the use of statins should be carefully considered and individualised by the medical practitioner.
These facts are seldom emphasized by the pharmas in their promotion. But those are the facts.
Before I am completely misunderstood, statins are very useful in individuals at moderate or high risk of heart disease, and especially in those who are known to have heart disease. In this group, statins are obviously beneficial, and side effect risks may have to be accepted, as statins clearly do more good than harm in this group. However, in this group, the pharmas have also driven their own controversy by trying to push LDL-Cholesterol level to 70mg/dL ( to under the ground I call it ). It is true, that the lower the LDL-C, the lower the risk, BUT one must not forget that the higher the dose of statins, also the higher the risk of side effects. Again, in my view, the risk benefit ratio, does not support the use of statins to lower LDL-C to 70 mg/dL.
As always in all of us who share in blogs, if you are on statins, before you change anything, please talk to your own doctor, who is better to advise you on your case.
For me, the lure of money, both by pharmas and practitioners, may be partly to blame for this controversy, in the use of a very important drug.

CAUTION ; UNAPPRECIATED SEVERE SIDE EFFECTS OF SOME CARDIAC DRUGS

Over the last week, two of our cardiac drugs have been reported with serious side effects.

1. In the first report last week, Sanofi Aventis reported that they have reports of severe liver toxicity with their new anti-arrhythmic, dronedarone. This is a rare side effect, but can be serious. Two of the liver failures resulted in liver transplantation. Dronedarone is the new anti-Atrial fibrillation agent that is in the process of being launch in Malaysia. The FDA has just ( 17th Jan. 2011 ) issued a letter of safety communication, on this side effect of dronedarone. The timing is certainly awkward for Sanofi Aventis in Malaysia.

2. The Jan 17th online edition of the Canadian Medical Association carried a publication, senior author Dr Alissa Wright and Dr David Juurlink, of the occurrence of hypotension requiring hospitalisation resulting from the use of a macrolide antibiotic in patients also on a calcium channel blocker. They recommended that Erythromycin and clarithromycin, should not be used together with a CCB, as this may result in clinically significant hypotension. If we need to use a macrolide with a CCB, the better choice of a macrolide antibiotic is azithromycin. This is because of the metabolism pathway. Both macrolide antibiotics ( except azithromycin ), and CCB are metabolised through the cytochrome PY450, and the macrolide antibiotic prolongs the metabolism of the CCB by inhibiting the enzyme. Since CCB is very commonly used anti-hypertensive agent, especially in Malaysia, this is worth remembering. I only wonder about all the other drugs that are also metabolised by CYP450 ( and there are many ), for example the statins, will they also interfere with the metabolism of the CCB. A timely word of caution when prescribing a drug. Obviously, if the patient does not need a drug. do not use it. Can mild incidental labile hypertension with no target organ damage, be treated with life style modification, weight loss, no added salt diet, green veges and fruits?

PAIN KILLERS AND THE HEART AND CIRCULATION

This issue of analgesics and their CVS dangers have never been fully resolved. Looks like there is a problem, but how big is the problem, why does it occur? and are all analgesics affected, have not been fully resolved.
When I was in Singapore, I was looking over the study done by our Swiss colleagues on cardiovascular safety of NSAID ( non-steroidal anti-inflammatory ). I thought that this study should be highlighted as many of us take pain killers every so often. We must understand better the risk and benefit.
Dr Sven Telle and colleagues from the University of Berne, did a meta-analysis ( the fashion nowadays ), of all the randomised clinical trails comparing NSAID and COX2 inhibitors, and placebos. They looked through 31 large clinical trails, involving116,429 patients. The analgesics studied included naproxen, ibuprofen, diclofenac, celecoxib, rofecoxib, etoricoxib, and lumiracoxib.
They found a high correlation between taking the analgesic listed and heart attack rates, stroke rates and also CV deaths. A quick look at the table below will give you a good idea. Looks like rofecoxib and luminaricoxib is not good for the heart and ibuprofen and diclofenac increases stroke rates and etoricoxib and diclofenac increases CV deaths. We do not understand why? In fact, some practitioners still doubt that there is a risk with COX2 and NSAID.

Rate ratio (95% CI) of NSAID on outcomes

NSAID	MI	Stroke	Cardiovascular death
Naproxen	0.82 (0.37-1.67)	1.76 (0.91- 3.33)	0.98 (0.41-2.37)
Ibuprofen	1.61 (0.50-5.77)	3.36 (1.00-11.60)	2.39 (0.69-8.64)
Diclofenac	0.82 (0.29-2.20)	2.86 (1.09-8.36)	3.98 (1.48-12.70)
Celecoxib	1.35 (0.71-2.72)	1.12 (0.60-2.06)	2.07 (0.98-4.55)
Etoricoxib	0.75 (0.23-2.39)	2.67 (0.82-8.72)	4.07 (1.23-15.70)
Rofecoxib	2.12 (1.26-3.56)	1.07 (0.60-1.82)	1.58 (0.88-2.84)
Lumiracoxib	2.00 (0.71-6.21)	2.81 (1.05-7.48)	1.89 (0.64-7.09)

I am very concerned as we do use alot of NSAID / COX 2 specially in the elderly CVS population. Joint aches and pains are not uncommon.
There is another clincial trial comin comparing the safety of celecoxibs with ibuprofen and naproxen, called the PRECISION study. Perhaps this study will shade somemore light.
In the meantime, if I do have to use a COX 2 or an NSAID, I would use them with a low dose aspirin, or even with clopidogrel, if necessary.
Of course, should aches and pains be minimal, they should be relieved with simple massage or deep heat treatment with topical ointment. No medicine is the best policy to avoid medication side effects.

FROM SINGLIVE 2011 TO ASIA PCR 2011 - THE PASSING OF AN ERA

I spend Thursday - Saturday last week in Singapore attending the Asia PCR 2011 ( formerly SingLive ). Looks like my Singapore colleagues have signed an agreement with EuroPCR ( the big live demo course held in Paris annually, run by the French Interventionist and their Dutch / Belgium colleagues ). I am not sure of the terms and conditions, but it looks like the Europeans are running the show. I felt a bit sad that something so Asian and Asean, has now taken a European outlook. The SingLive ( I still prefer this name ), has been in existent for the last 20 years ( if I am not mistaken ). I started attending ( invited faculty ), with them since we started stenting, and that was in 1992. At that time, it was held in Singapore General Hospital ( SGH ), at their auditorium. It was a much smaller affair. The course was organised by the SGH Heart Center team led by Prof Arthur Tan and assisted by Prof Koh Tian Hai. I was then staying in Apollo Hotel. Things were smaller and simpler then.
We were then discussing balloon angioplasty, and all the other niche devices, many of which have fallen by the wayside. The coronary stents remained and stood the test of time. Today, they are easily the most popular coronary device that works and that help us to treat our patients better. I remember when stents first appeared, we had a thick handbook to study, and we only had a few choices. The front runners then was the slotted tube Palmaz Schatz ( PS ) stent and the coiled Giantarco Rubin stent. I still remember that Gary Rubin ( the inventor of the GR stent ) came to conduct a half day stent course on the use of the Rubin stent. After the half day stent course on the Rubin stent, the attendees were certified as licensed to use the GR stent. I never attended because I felt, even then that the GR stent was too weak and open, and would easily re-stenosed. At that time, the GR was FDA approved and indicated for use in treating acute closures ( for which it was quite good, as it was easy to deploy ). It was not indicated for De Novo lesions as it carried a high re-stenosis rate, but some interventionist then used it ( off label ) on De Novo lesions. As time will tell, I was proven right. I also felt that the PS was better longterm, although it was much, much more difficult to implant. The PS stent delivery system was 5F in size and needed an 8F guiding catheter. Remember, in my last blog on the stent program, I mentioned that I had to be proctered in Japan. I could deliver it to treat acute closures as well as De Novo CAD. We were getting good at it and it serve us well when we had the newer bare metal stents thereafter. It was so easy to deliver all the other stents when you can deliver a PS-153 stent. When we got good with the PS 153, I remember cutting the stent, hand- crimp them on the balloon and delivering them without the Stent Delivery System. Of course, we lost some stents ( I lost 4 of them ) without any significant consequences.
Anyway, that was a bit of rumination, and nostalgia. Time flies.
Asia PCR 2011 was obviously of a much smaller scale. The main arena was smaller. The number of attendees ( I guess ) must be around 1,000. The exhibition halls was smaller too with less exhibitors. I hear that the registration fees was high ( and in Euros ). The discussion side rooms were fewer. All in all, things were scaled down, perhaps reflecting the times.
It was a good time to catch up with all my interventional cardiology friends from the ASEAN region and those from abroad. We saw a few live cases from Singapore, KL, Dubai. Nothing unusual, just the same, bifurcation cases, left main stem stenting, CTOs, calcified lesions, vein grafts. Nowadays, they are showing fewere live cases but trying to spend more time in discussion.
Perhaps what I remembered most out of Asia PCR 2011, was this rather provoking, controversial faculty member from Washington, USA. Dr Aggusto Prichard, propounds a view of planting fully deployed, fully expanded, but undersize stents in vein grafts, a very controversial concept. His reason was that, with a fully expanded stent, he will get full blood flow, and have less plaque prolapse into the stent and so less debris will go downstream ( that makes sense ). But when you implant a 3.0 mm stent into a 5.0 mm vein graft, the stent will be floating in the vein graft. It will be poorly anchored and it may float and get dislodged either by the balloon or the other devices that we pass down sometimes after stenting. I hate to thing of what will happen when less experience operators try this on their patients. There is certainly no good data ( to my knowledge ), proving his hypothesis or concept. I can only surmise from the worldwide literature, that there will be more stent thrombosis ( under deployed stents are a reason for stent thrombosis ) and also re-stenosis ( under deployed stents are a reason for stent re-stenosis, drug or no drug coated).
Probably the best session is the opening talk on the bioabsorbable scaffolding, the ABSORB, by Abbott Vascular. He showed some new data and also some OCT pictures, on the outcomes of the ABSORB after 3 years. Looks good.
So an era has pass away, a new are is beginning. SingLive has given over to Asia PCR. Let us all hope that this is for the better.

3rd GENERATION DES ( DRUG ELUTING STENT ) IS ON THE WAY

This morning, I have just received news from Abbott Vascular and I also read the initial reports that ABSORB, has been given CE mark approval in Europe.
ABSORB is a drug eluting, bioabsorbable stent maufactured by Abbott Vascular, for the treatment of CAD. Just to re-cap. DES ( drug eluting stents ), are drug coated stents used in angioplasty to lessen re-stenosis as the drugs coated on the stents are anti-proliferative. The first generation were thick surgical grade, stainless steel, of slotted tube design. They were either coated with sirolimus ( JnJ Cordis ) or with paclitexal ( Boston Scientific ). These were thick and bulky and also has a higher MACE numbers. The second generation were thin struts cobalt chromium stents coated with -limus, and they were more deliverable and had lower MACE numbers. However, interventionist were still worried about the 0.4% late stent thrombosis rates that these DES were producing, maybe because some of the second generation DES still had a polymer coating. The later versions of the second generation DES had biodegradable polymers. This seem to give better MACE numbers.
Over the last 4 years, Abbott Vascular had been working on a DES, made of polylactide, which is fully bio-absorbable. Polylactide, is the polymer fibre that bioabsorbable sutures are are made of. These stents were coated with their proprietary "everolimus" drug. It is implanted just like any other DES, and over the next few weeks the drug gets eluded, and over the next 6 months or so, the polylactide scaffolding gets absorbed, so that by 2 years, there will be no more metal scaffolding and the vessel is said to recover its physiological function. The clinical trial on the first 30 patients ( cohort A ) is now 4 years on, and the results were good. The cohort B has reached 3 years, and the results also were good. There were no late stent thrombosis out to 3 years, and the MACE at 3 years is still 5%, like all the other 2nd generation DES.
I am sure that based on the ABSORB results over 3 years, and also with a bigwig like Patrick Surreys leading the study, the ABSORB stent has now received its CE mark, meaning that it is safe for clinical use. I have been told by Abbott this morning that they will be launching it in Europe by end 2011, and maybe by then or by early 2012, we should get ours. Of course more studies are needed. It is safe, but is it as good as the second generation, bio-degradable polymer DES?
Although the idea is very novel ( some patients have "metal phobia" ), I am a little concern that there maybe a slightly higher rate of re-stenosis, when compared with 2nd generation DES, although it did not show in the ABSORB study. We need to see more numbers. I am severely biased because of the early poor results with the old bioabsorbable Tamai stent and also the first generation magnesium bioabsorbable stent by Biotronik. Of course the obvious advantage of the ABSORB stent is that we do not need long term dual anti-platelet therapy, as after 2 years, there is no more metal.
As always, what is the cost? Is the cost benefit ratio adequate for widespread use, or must it be for niche use. Well, I am awaiting end 2011, to see what Abbott declares. I don't think it will be cheap.

MANAGEMENT OF ATRIAL FIBRILLATION - A BRIEF REVIEW

Atrial fibrillation has been receiving much medical press lately. In the middle of the last decade, it was because of the advent of radio frequency ablation, as a treatment for A.F. ( atrial fibrillation for short ). Towards the end of the last decade, it was because of a new group of anti-coagulants to replace warfarin. It has become important enough for us to have a whole symposium on it, at our coming weekend seminar in Cardiology, to update the GPs.
Atrial Fibrillation ( A.F.), is an atrial arrhythmia characterised by an irregularly, irregular pulse. It is more common in the elderly, and although it can compromise the cardiovascular system, and trigger heart failure, its most common complication is strokes and TIAs ( transient ischemic attack ) cause by clots from the left atrial appendage, migrating to the brain.
The good old treatment strategy is to control the AF rate ( rate control so that the heart does not race too fast ), and to anti-coagulate with warfarin ( rat poison ), to prevent strokes, and TIAs. I like this strategy as it is cheap and effective, although I run the risk of bleeding with warfarin. But this simple, cheap strategy does reduce the rate of stroke to 1-2%, compared to 5% in non-warfarinised AF.
Of course there was always the wish that all patients with atrial fibrillation, be return to good old sinus rhythm. Sometimes, in patients with recent onset AF, this can be achieved with electric ( DC ) cardioversion. I usually try this once in all AFs. Sometimes, sinus rhythm can be restored with drugs. Recently, a new drug, Multag has been tried and seem better than the older drugs like cordarone, beta blockers, quinidine, etc..
This blog is partly due to an article published in the January 2011 issue of the Journal of the American College of Cardiology. The study comes from Bordeaux. Besides good red wine, Bordeaux is also the city in France that pioneered radio frequency ablation of the left atrium to treat atrial fibrillation, converting them from AF to sinus rhythm. When this group first published their work, many were hoping that this new method of radiofrequency ablation would be a cure for AF. Alas, this is not to be. Dr Rukshen Weerosooriya and Dr Michel Haissuguerra, both pioneers in this technique, reported their 5 year followup of 100 patients with the use of this technique. They reported that after 5 years, only 29% remained in sinus rhythm. There was an almost 8.9% recurrence annually following the ablation. So many of them need a repeat ablation ( almost like angioplasty ) after a year. So we now know that radiofrequency ablation, is a treatment and not a cure. Just like angioplasty. This findings is even more important because the technique was done by the pioneers ( real experts ), and also the case selection were of a younger, lower risk population. Should this technique be more widely used by all and sundry ( when it is open for all who are trained ), the numbers can only get worse. That is the real AF world.
Besides Multag ( dronedarone - SanofiA ) which is a new anti-arrhythmic agent, there are also new anti-coagulants for reducing strokes in AF, like the "gartans ", example Dabigatran, and the " xabans" example apixaban, and many more xabans in the pipeline. These new agents are good. It does reduce the risk of strokes ( data from the early trials ), the risk of bleeding and so the need for close monitoring with PT-INR. However, they are expensive, at RM 10 a tab, compared to Warfarin at a few cents a tablet. I told the manufacturer that so far, all my AF patients have decline a change to dabigatran.
There is no doubt, as always, that healthcare is getting better. We live longer and better, but at what cost? Can the country afford it? That is another issue.

AMENDMENT TO THE 13TH SCHEDULE ( FEES SCHEDULE ) OF PRIVATE HEATLHCARE FACILITIES AND SERVICES ACT 1998

I spend yesterday morning at the Ministry of Health, Putrajaya, at an ad hoc meeting chaired by the Minister of Health, to discuss amendments to the Fees Schedule for private doctors. As we all know, the Private Healthcare Facilities and Services Act ( PHCFSA ) 1998 has attached to it, the Regulations 2006. Included in the Regulations is the 13th Schedule, which is a fees schedule for private doctors. This 13th Schedule was based on the MMA 4th schedule which was drawn up in 2002. It was 4 years out of date in 2006, and now 8 years out of date. So, we have been asking for an amendment to the 13th Schedule to increase our fees in line with inflation. Of course, the negotiations started in July 2010, but after about 7 meetings, we could only agree on about 80% of the fees. You will be surprise ( or are we ), almost all the "cutters" or surgeons, want to increase their fees by 100%. But of the Ministry's reason to allow fees increase, was because they realised that the fees now were too low, and creative doctors were unbundling their charges, so that one procedure became 5 procedures with their individual piecemeal codes.
The Minister also let out yesterday, that the main reason why the government is allowing fees increase was because of health tourism, which the government want to use in a big way to increase government revenue. It is health tourism, that is driving the whole exercise.
Anyway, he has allowed a 30% increase across the board, on all the existing items listed in the 13th Schedule. GP consultation fees will be a minimum of RM30-50. He has also allowed ad hoc procedures to follow diagnostic procedures with full charges for both. He has also assured us ( the DG also reassured us ), that there will be no fee reduction for MCOs and insurance companies, who come asking for discount. In fact, they clarified that they had a meeting with the MCOs and insurance companies and hospital owners, to say that asking discounts from doctors will not be tolerated and action will be taken against offenders. The DG said that he had already made a statement to that effect and will be issuing a circular soon to put it all in black and white, as we express that the practice was still going on. All new procedures not presently in the 13th schedule will be upgraded following the College of Surgeons proposal. All these fees amendment will be passed to the cabinet in March 2011 and operational ( hopefully ) by April 2011. Work will begin on the 14th Schedule soon after that.
We also made a speech to ask that hospital fees be controlled through a fees schedule. He agreed in a nice way, but kept mum. Obviously, there is no will to control hospital fees.
The members also brought out the " Competition Act" which cause the Singapore government to withdraw the doctors fess schedule in Singapore in 2007. He acknowledge the Competition Act but said that he do not think that the present government will be enforcing it, any time soon.
30% across the board increase? of course the last hurdle will be the public. I suppose upon the announcement, say in April of a fees increase, there will be a hue and cry, and with elections around the corner, everything may be shelf. So do not hold your breath. I am apart of the committee, but I am not confident that it will come true, may be a token bit will.
Anyway, the next committee meeting is scheduled for the 27th Jan. to hear the 20% who have not submitted their proposals. They still have not decided how much of the sky they wish to ask for. Doctors, they say that they are underpaid!! can anyone believe that. I think only the GPs are underpaid.

TREATMENT OF RESISTANT HYPERTENSION - MORE CHOICES NOW.

Resistant hypertension, by definition is hypertension, not responding to treatment with at least three anti-hypertensive agents at their proper doses. Often, this maybe due to secondary causes like coarctation of the aorta, primary arteritis, renal artery stenosis, Conn's syndrome, Pheochromacytoma, and others. The standard teaching is that when patients' BP do not respond, the doctor must always rule out a secondary cause.
Having done that, the other common reason for " resistant " hypertension is poor compliance with medication. Some patients just do not take their medications, because of side effects, like impotence with beta blockers, and are too embarrassed to discuss with their doctors. In our part of the world, it may be that they have stopped our " Western" medications with their side effects, for traditional herbal medication ( without side effects ).
In an attempt to increase compliance to reduce the incidence of resistant hypertension, pharmas have started to bring out double and triple drug combinations, so that instead of taking two pills, they take one pill, and instead of taking three pills, they take two. In 2009, FDA approved the Exforge HCT ( amlodipine+valsartan+HCT ) drug combination for treatment of hypertension. In July 2010, FDA approved Tribenzor ( Olmesartan+Amlodipine+HCT ) combination, and before the close of the year, FDA approved Amturnide ( Aliskerin+amlodipine+HCT ) combination. This combination ( the latest to be approved ), is the only one with a direct renin inhibitor. An interesting combination.
The Autumn meeting of the AHA, also saw the release of the Simplicity HTN clinical trial result. This is an interesting, novel approach to disrupt the sympathetic pathway at the region of the renal artery, in an attempt to do essentially a sympathectomy. The new approach is use to treat patients with severe resistant hypertension ( hypertension not controlled with 5 antihypertensive medications ). They do what we now call an Ardian procedure.
I believe that most cases of hypertension can be control with a combination of one to two medications, a good dose of counselling on lifestyle modification and also counselling on work and sleeping habits. Weight lost, greens veges and fruits are better alternatives to more drugs.
One of the biggest criticism to combination pills is that the cost of the combo pill may be more then the cost of individual pills. In some countries, this maybe be true, as they have good generics.