MY APOLOGIES, BUT THESE PORNOS MUST STOP

I would like to apologise to my readers as this is a medical / cardiac blog. However, I am very upset that the authorities are doing nothing when a bunch of criminals are posting porno videos at will, and the national media is even showing it on national TV. How can this be?
There are obviously two sets of laws in this country. One for the ordinary folks and another for the UMNOPutras.
I am of course referring to the sex video that is receiving headline news. ( THERE IS NO NATIONAL SHAME ANYMORE ). It is no longer an issue of who is the actor and the actress or the Omega watch. It is now a question of abiding by the law.
How can a bunch of connected criminals be allowed to break the country's law at will and with impunity. I am very sad that the police and government seem to be involved, if not by commission, surely by omission. If a porn VCD seller can be arrested ( harshly ), packed into a black maria, off to a police station, for displaying porn VCD, what more of individuals, screening VCD for public viewing, uploading into blog sites, even have them screened on TV3, without any reaction from the police and government. And what more, with the whole world watching.
What will foreign investors, foreign governments think of us?
Do the UMNOPutras and the government and the police care? All these because of some personal vendetta, and also just to discredit the opposition leader? Is it worth it, to destroy the country's image, just to stay in power? How desparate are you?
Does the police and government care that non of us citizens agree with the Datuk Trio and also all of us respect the Police and government even less now. How can we trust the Police, when there is one set of laws for them and another for us. Some are obviously above the law. They are still ( after 3 videos shown ), walking free and appearing in public with arrogance and impunity.

Dear government, dear Prime Minister, please wake up. Please do the right thing. The Datuk Trio have to go to jail and face the full weight of the law. Enough is enough.

Needless to say, I am very upset, as I love Malaysia, my country, and my own government is discrediting the country. They are not concern about our National and International image anymore.

God please help us to restore some sanity to Malaysia.
The next general election is coming. It is time to change the Tenant at Putrajaya.

TAI CHI HELPS HEART FAILURE PATIENTS

Tai Chi is a rather popular form of exercise in China and also locally. When I was in Beijing, senior citizens will gather in parks to do their exercises and more often then not, it would be some form of Tai Chi. Well, it is true that tai Chi helps seniors, especially those with heart failure.
There is a small paper by Dr Gloria Teh of Beth Israel Deaconess Medical Center, published in the 25th April issue of the Arch of Int Medicine entitled "Tai chi exercise in patients with chronic heart failure: a randomized clinical trial". They studied 100 patients with class 1-3 heart failure, and poor LVEF, all less then 40% with a mean LVEF of 29%. 50 patients were given 12 weeks of TaiChi exercise and 50 were send for heart failure education lessons. At the end of 12 weeks, those on Tai Chi class had much better quality of life indices. The indices used included the Minnesota Heart Failure questionaire, the Cardiac Exercise self Efficacy instrument, and the Profile of Mood state.
I suppose, it is not surprising, that with exercise, fitness should improve and so mood states, confidence and quality of life. What I was quite keen to see, was whether the LVEF showed any difference. Well, that was not stated. I suppose it probably did not differ. I suppose, 12 weeks is too soon for structural changes. There is a possibility however, that when one feels better, the circulating serum adrenaline should reduce, and so the LV should perform with less stress. It would also have been helpful if Dr Teh and colleagues have also measured the serum BNP, adrenaline and noradrenaline levels, to give us an idea of how these stress hormones responded to exercise and a more calm state.
Anyway, a simple paper to discuss a simple point. It does, obviously call for more study which I fear will not materialised as more studies will cost more, and very few pharmas would be willing to invest in something which they cannot patent and get returns.
In the meantime, all patients with heart failure should know that TaiChi does no harm and infact, may do good for you.

1MALAYSIA HEALTHCARE TRANSFORMATION

I read with great interest and agreement, the article by Dr HT Ong and company, on the planned 1Malaysia Healthcare transformation. This article appeared in " Fit for Life" column. A summary of this article ( by the same authors ) had actually appeared in " NST Letters to the editor" about 3 days earlier.
I have actually written about this year year ago when we were invited to attend by the YB Minister of Health. Even at that launch, when we broke up into discussion groups, we ( the Federation of Private Medical Practitioners Association ) had already protested that this Healthcare transformation of introducing a national health insurance, will not help patient care. In fact, it may retard patient care and cause the healthcare system to be " piratised". Of course, we hear that the government is going ahead.
Just to recap, in the proposed 1Malaysia Healthcare transformation :-
1. There will no longer be public and private healthcare. It will take the form of a national health insurance, almost like the UK, NHS system ( which by the way, is in trouble with long waiting list ).
2. All citizens will be tax by way of a consumption tax, maybe GST + 7% for healthcare? I think the form of taxation or subscription ( a very sensitive issue ) has not been firmly decided, as it will certainly raise a large hue and cry.
3. All residents will be allocated to their GP in their locale, and given a number. They must see the GP in their locale should they require medical help. The GP will act as their primary doctor and if necessary, will refer them for a specialist opinion and tertairy care.
4. All hospitals ( no longer demarcated as private of public ) will treat the patients referred and charge the national health insurance who will re-imburse on a " fees schedule ".
5. Patients can buy additional private insurance should they wish.

The official reasons to justify this healthcare transformation is :-
1. The inefficiencies in the present healthcare system, especially the long waiting list.
2. Of course, there is the forever issue of rising healthcare cost, that the government can no longer afford.
3. Of course to solve the brain drain to the private sector.

What we doctors fail to see ( and we have discussed this extensively amongst ourselves ), is how can this transformation solve what it was planned to solve ( unless there are hidden agendas that we suspect, but are not told. Not to forget that the healthcare industry is a multi-billion dollar industry ) )
1. What is planned will only increase waiting list. Look at UK as a prime example, where it is recently reported in the BBC news, that elective surgery waiting list is in the months ( like waht we have now ).
2. The healthcare cost will surely rise, because you are now creating another layer ( the health insurance payers ) who must add some extra " admin cost " so that they can profit. I am sure that this national insurance company or corporation are not doing it for free. The CEO needs a pay of tens if not hundreds of thousands a month ( look at the CEO of "Syabas" ).
3. The rakyat is burdened with more taxes, whether direct or indirect.
4. Of course the government will decide on the success of this healthcare transformation, by their KPI, KRA or what ever government indices, non of which have to do with patientcare. Take for example, the KPI for the home ministry and police. Their KPIs are all glorious, and yet every feels even more unsafe, so unsafe that they all have their gated, and guarded communities.

The solution suggested by Dr HT Ong and company is what we also suggested. Increase the present government healthcare budget to 6-7% and that will improve the efficiency of the present public sector, which will prompt more patients to stay in the public service and control the extravagant charges of the private sector. Once the public sector is more efficient, more people can be taken care of at lower cost. It is true, that the standard of patient care in some public hospital is good. This waiting list problem can also be solved with more budget and less bureaucracy and redtape.
If at all the government wish to control the rising cost, control the rising cost in the private hospitals, as we suggested. by having a private hospital fees schedule. But the government is dragging their feet on that, as the Association of Private Hospital has a very strong say. As the saying goes, they are on very good terms with the Minister, who is their friend.

As I tell all my colleague, if there is a change of government at the next GE, then all this will be transformed too. If the present government wins the next GE, I am sure that they will go go for the " Billion dollar booty". So let the rakyat decide.

OSTEOPOROSIS, CALCIUM, VIT D AND THE HEART

Osteoporosis is a very common problem as we age, especially females. Bones scans are nowadays, part of a diagnostic package offered by many laboratories. Soon after a bone scan showing osteoporosis, subjects, are advised to take all kinds of supplements, often even without a physician or orthopedic consult. Commonly advocated are calcium tablets, Vit D capsules and the light. This is indeed a multi-million dollar industry.
Well, there must now be a serious re-think of this strategy.
The April 19th issue of BMJ carries an article by a group of New Zealand doctors into this issue of Calcium, Vit D and Cardiac and stroke risk. The paper is entitled "Calcium supplements with or without vitamin D and risk of cardiovascular events: reanalysis of the Women's Health
Initiative limited access dataset and meta-analysis. BMJ 2011" The lead author is Dr Bolland, who had written before on this issue. The present study is actually a meta-analysis, combining his earlier study, plus the landmark paper called the Women's Health Initiative, and his current study. The is a total of 30,000 patients in the cohort. They found that taking calcium and Vit D increases your risk of heart attacks by 25-30% and your risk of strokes by 15-20%. Now this is significant.
Obviously, there is some controversy, as the earlier Women's Health Initiative concluded that there was no increase risk. However, in that study, many of those in the placebo arm, were actually consuming their own dietary supplement of Calcium and Vit D. They were not Calcium and Vit D naive. Therefore, their conclusion may have to be taken with a pinch of salt.
As usual, the authors concluded that more studies are needed, but who is going to fund these, "no pharma gain" studies?
For the time being, if I can offer some advice. Please do not consume calcium and Vit D supplements, without proper medical advice. It is not as innocent as you think. There is a link between micro-calcification and the start of coronary artery disease. Also, the age group of people who may suffer from osteoporosis are also the age group of people likely to get heart attacks.
It did cross my mine as to whether giving these people with osteoporosis. and who needs calcium / Vit D some aspirin to mitigate against the risk of heart attacks and strokes.
Interesting idea. I suppose, we do need more clinical studies. Lets see who will take it up.

HIGHLIGHT ON CHILDHOOD OBESITY, BY MOH

I read with interest, the Minister of Health's announcement this morning, that there are about 1.7 million obese kids in Malaysia. He announced that 30% of kids are overweight and another 30% are obese. Therefore, he has asked teachers to record the child's BMI ( body mass index ), on the child's report card, and if they are obese, to let the parents know, so that remedial actions can be taken. He however, did not specify on what cut off level is used in his definition of obesity and overweight. Whether it will be 24-20 for overweight and >30 for obesity. Some will shift that goal post a bit lower, so as to have more on weight reduction programs so as to nip the butt earlier, in our fight against chronic life-style diseases.
He has also announce the MOH's intention to ban soft drinks and junk food from the school canteens and also hawkers outside the school premises. These bans has widespread consequences. All these measures from the medical standpoint, are very commendable.
Now we await, the parent's response, and also the NGO's response. Somehow, I cannot help but feel that it is not so simple. can you imagine banning soft drinks and junk food? I wonder where the catch is? Is there a new company selling measuring devices for measuring BMI to MOH or Ministry of Education? In our clinic, we use a weighing scale and also a height ruler. Is there a vendor with connection, about to market these products ( ? inflated prices ), to schools and government clinics. It is so wrong of me to feel this way, but, I can't help but feel that way.
Of course, theoretically, BMI is individual medical information and cannot be displayed without the " patient's consent", except if you feel that this is a police state where the good of the country override individual freedom, and patient confidentiality. Should we start with weight ( a noble thing to do ), where do we end? Should we also allow our records about diabetes, hypertension, heart disease, etc to be display for public view? Should children with "thalassemia" or " rare blood groups" have their personal information be displayed? Where is the end?
Will children ( boys and girls ) with a BMI of 35 be the butt of jokes and humiliated in their schools, and ostracized? Worse still, will it cause girls to develop anorexia nervosa, in an attempt not to be obese. There are psychological issues here. Are we about to have schools for kids with BMI 20-24, and then for the rest.
These are all factors to consider, before drawing out such a policy, however good the intentions maybe. Were the "Parent-Teachers association" and the teacher's union been consulted for advice?, or is it another of those shooting off the hip political announcements, just for the occasion. " We are so cynical" are we not?
I trust that the YB minister has, but somehow, I am not too confident that they have.
Anyway, it is an announcement, and we have heard many government announcements where it remains just an announcement.
Malaysia boleh.

OLD ISSUE OF ARBs AND CANCER RISK RE-VISITED

You all may remember that in June 2010, I reported on a meta-analysis by the now world famous Dr Sipahi, which showed that the use of ARB may be assocaited with an increase cancer risk, especially lung cancers. This prompted the FDA and European EMA to look into this issue before deciding on the long term safety of ARBs.
Well this month of April, saw tow studies, trying to answer this question. One is a Dutch observational study and the other is another meta-analysis.
The Dutch observational study was reported in the April 11 issue of Circulation. It was led by Dr Bjorn Pasternak. The researchers looked into the records ob more then 300,000 patients. 107,466 were on ARBs and 209,692 were on ACE-I, for hypertension. At the end of 3 years of follow up, they found no increase incidence of cancers among those who were on ARBs.
The second study was a meta-analysis, called the ARB trialist collaboration. They looked at 15 RCT, involving about 140,000 patients, comparing the use of ARBs, with comparable medications, including ACE-I, CCBs etc. After 5 years follow-up, they also also concluded that there was no increase in cancer rates among ARB users. The authors also mentioned, in particular that there was also no increase in cancer risks amongst those who were taking ARB+ACE-I.
This last statement was put in, because a Nov 2010 meta-analysis, led by the hypertension expert, Dr Frank Messerli, seemed to suggest that although there was no increase in cancer risk amongst ARB users, his meta-analysis reported in Nov 2010, seemed to suggest that there was an increase risk amongst those taking ARB + ACE-I.
Whenever these kinds of statements are made at the end of an expert's statement, it always leave a slightly bitter taste, leaving one to wonder, whether there was or there was not. Afterall, ARB+ACE-I, is like a very powerful ARB. Then the worries go on.
Well, at the moment, the score seems to be 3-1 in favour of ARBs having no increase risk of cancers, or to put it more crudely, it is Sipahi versus the rest. say what you like, we should in a way thank Dr Sipahi, and group for bringing up the potential issue. It has certainly generated more work for researchers. Unfortunately, it may have scared off some potential ARB users as well.
Personally, looking at all the evidence, I would think that in those who are susceptible to cancers, ARBs and ARB+ACE-I should be used with caution. The complex physiological reactions that the powerful ARBs can trigger, may provoke cancers ( in those who are somewhat susceptible. I have always wonder why researchers did not look into the issues of ARB use, in those who have survived Ca Lungs, or Ca Prostates, and see their outcome after 5-10 years.
I am also concerned that all our meta-analysis and follow-up, may not be long enough. This was one of the concerns raised after Dr Sipahi's paper in June 2010. Maybe, with longer follow-up, the findings may be different, especially in those proned to cancers.
Well, for now, the score is 3-1, but I am sure, the debate will go on. Exercising caution and close monitoring of patients on ARBs should continue, and also a close watch on the literature, as we are doing.

WEEKEND SEMINAR IN CARDIOLOGY for GPs 2011

So we held our annual " Weekend Seminar in Cardiology for GPs 2011" from 9-10th April 2011, at the Sime Darby Convention Center. It was a great success. We had preregistered 960 attendees by Friday 8th April and we had 100+ on-site registration. In the room on 9th afternoon were 700+ attendees. I had 700 seats place in Ballroom 2, and I had to add more seats. The breakout sessions at the end of the day was also packed, with standing room at the ECG tutorial on Saturday and the Hypertension workshop on Sunday. There were 18 exhibitors and the tea-foyer was crowded. In fact, I had a feedback that it was too crowded.
The scientific program was well received. There was special mentioned in the feedback on the symposium on diabetes. Dr Hew, who organised it, had a very basic approach, like talking about empowering the patient, and practical diabetic diet practical tips from a Malaysian dietician, currently residing in Hong Kong, whom we brought back for the event. I was happy that all the speakers kept their time well, and time overrun ( which we faced before ) was minimal at the meeting. We kept our program time well.
A few things I noticed that was different from my nine other seminars ( this is the 10th in the series ). The crowd was bigger and obviously younger. I could hardly recognise more then 10% of the attendees. I remember that at the earlier years, I use to know about 30-40% of the attendees. There were also more females. Of course, I wonder whether they were paramedics. I was told ( and I am awaiting the statistics breakdown ), that there were probably 70-80% doctors. Looks like the younger doctors are also keen on refreshing themselves. They came with their cameras and were also willing to ask questions. I was observing the ECG tutorial in in the Dillenia room, and there was active participation. These are good signs.
The dinner symposium ( Pfizer ) and the lunch symposium ( Boeringher-I ) were both well attended, and the sponsors were happy. BI brought in an overseas caucasian speaker to speak on dabigatran at the sunday lunch symposium and he was suitably impressed.
All in all, I think that the organising committee and the secretariat put in a stellar effort and credit goes to them. For RM8K sponsorship, I believe all the sponsors got their money-worth. In fact, I saw that one sponsors was selling their devices, and business was brisk.
The venue was quite ideal for our purpose. It was easy to access, just off the Mont Kiara road, and parking was ample. There was no shopping center distraction. There was ample space for the exhibit tables and tea-foyer. The ballroom was big enough for 700 people. The staff there was quite helpful, and co-operative. The AV was reasonable, although we had some small issue with the microphones.
I believe that all had a good time, and I certainly enjoyed it. Another weekend seminar is over. Now I have to start preparing for the national weekend seminar in Cardiology for GPs 2011, which will be held in Kuantan, on the 11th September.

Life goes on.

NAGOYA HEART STUDY

This paper was also presented at the just concluded 60th Annual Scientific meeting of ACC 2011.
The study was led by Dr Toyoaki Murohara of Nagoya University. I am very pleased to note that the Japanese, and also the Koreans, are putting out more and more papers in big American meetings. I have always felt that Asian Trials are much more applicable to us.
Anyway, Dr Murohara and colleagues studied 1150 patients with T2DM ( 82% confirmed T2DM and 18% IGT ) and hypertension. They wanted to study the effect of using either a CCB ( norvasc ) or an ARB ( Valsartan ), in the control of the hypertension and their effects on cardiac major adverse events ( MACCE ), including heart attacks, strokes, need for revascularisation, admission for heart failure, and sudden cardiac death. This is probably the largest such trial in hypertensive diabetics.
After 3.2 years of follow-up, they found that both agents did just as well. They were essentially equivalent, for the primary end-point. Of course the BP control and HbA1c control were equivalent.
The only difference was in admission for heart failure. In this subset, valsartan was better. Less patients on Valsartan needed to be admotted for CCF during the study period ( and these are patients who had LVEF>40% at the start of study ).
I was looking high and low for the effect of these regimes, on renal function. I could not find it. Obviously because ARBs are suppose to protect the kidneys in patient with diabetes and hypertension. In Japan, ACE-I are unpopular because of the problem of cough with ACE-I.
The other issue is of course, duration of study. It could be that at 3.2 years, the differences have not shown yet. It would be interesting to see the outcomes at 5, 7 and 10years.
We will be discussing more about this at the coming " Weekend seminar in Cardiology for GPs 2011" this Saturday, over dinner sponsored by Pfizer.

MORE NEWS FROM 60 th ANNUAL SCIENTIFIC MEETING OF THE ACC, NEW ORLEANS

Some trial results from New Orleans, as the 60th ACC draws to a close.

1. MAGELLAN : This was a trial mainly for the West, where DVT and Pulmonary embolism following prolong recumbency is an issue. Dr Alexander Cohen and group from King's College, UK, studied 8101 patients with serious medical condition requiring prolonged bed rest, like CCF, severe respiratory insufficiency, serious infectious disease, stroke, etc. He gave half of them Rivaroxaban 10 mg daily for 35 days, and half of them subcut Enoxaparin ( lovenox ) 40 mg for 10 days ( standard therapy now ), to see if there is any benefit, in terms of DVT and acute pulmonary embolism. They found non. Rivaroxaban is a new Factor 10a inhibitor, that can be taken orally. From the findings of this study, looks like rivaroxaban is just as good as Enoxaparin ( Low molecular weight heparin ), in reducing DVT and APEs in patients at risk of DVT and APE. In the subgroup analysis however, there were more bleeding complications in the rivaroxaban group. In a way, we are trading ease of primary prophylaxis of DVT, with an increase incidence of bleeding.

2. The other paper presented on 5th April at ACC was OSCAR, a study in high risk elderly hypertensives, with one or more CVS risk factors, comparing high dose ARBs against an ARB / CCB combination. The study involved 1164 patients with a mean age of 74 years, and at least one other cardiovascular risk factor. The primary endpoint here was MACCE at 36months. This study was led by Dr Hisao Ogawa of Kumamokam U, Japan. Interestingly, they found that high dose olmesartan controlled BP as well as Norvasc / olmesartan combination. However when they did some sub-group analysis, they found that although BP control was good in both arms, there were less CV events in the group with pre-existing CV risk factors, treated by the CCB / ARB combination. The reverse was also true, that in those with pre-existing diabetes, the high dose ARB seemed to reduce the incidence of renal function deterioration.. The authors then suggested that high dose ARBs was just as good as CCB / ARB combination and which therapy we choose depends on the hypertensive subset, depending on their pre-existing CV risk factors. Apparently ARBs are very popular in Japan because ACE-I has a high incidence of cough, and so is not often used.

And now, a word from the sponsors : The "Weekend Seminar in Cardiology for GPs 2011" is on this weekend at Sime Darby convention Center. We have registered 900 attendees so far. Please do come and join the annual GP Cardiology carnival.

FROM NEW ORLEANS. AMERICAN COLLEGE OF CARDIOLOGY 60th ANNUAL SCIENTIFIC MEETING 2011

I was away doing PCI yesterday. When I got to review the presentations made at 4th April 2011 sessions, there were many papers in my area of interest that is worth highlighting.

1. Looks like the second generation DES has arrived, and they are all better then the first generation DES. For example, Dr Greg Stone presented data comparing the new Promus Element stent against the Promus ( actually a carbon copy of Xience V ) stent, and showed that the Promus Element was non-inferior at 1 year. Results were good. The Promus Element stent is on a platinum chromium platform, making it thinner and much more deliverable. It is also easier to see on flouro. Dr Martin Leon presented the Resolute US 1 year results and showed that the Endeavor Resolute was non-inferior to historical controls, namely the Endeavor Driver ( or the old ABT 578 ).
Dr Patrick Serruys presented the Resolute All Comers 2 years results and showed that at 2 years, there was no catchup. That Endeavor Resolute was still as good as Xience V. The numbers look good.
Looks like now, the benchmark gold standard for the moment is Xience V, and everyone is comparing their stents with Xience V.
There are a whole host of stents not mentioned in ACC 2011. Well lets not go there.

2. 4 th April also showed papers on the non-superiority of Transradial versus Transfemoral PCI, in the RIVAL study. These 7,000 or so patients had ACS. They were across 32 international sites. They were both equivalent. There was no difference in MACE, but there seemed to be some difference in major access site bleeding. I could not find details of which site participated. Obviously with transradials, familiarity and skill is important, working through a smaller artery. Of course, the issue of patient comfort was not measured.

3. The 4th April also saw some results from the RAP ( Radial Artery Patency ) study. 561 patients across 13 sites in North America, followed for 5 years. The RAP study showed that Radial artery Grafts were slightly superior to Saphenous Vein Grafts, in terms of 5 year patency rates. The patients all had Radial and Saphenous Vein grafts and so act as their own control. About half had 5 year angiographic follow up. Some of the saphenous veins were harvested by junior trainees, some were harvested endoscopically, while the Radial Grafts were all harvested by the senior man. How much difference these made, we will never know.

4. Before I finish, there is one study on the 3rd April, which I miss writing on. PRECOMBAT. This is a study on PCI for unprotected left main stem disease, comparing the sirolimus eluting stent ( Cypher ) with conventional CABG. This study was led by Dr SJ Park from Asan Medical Center, Korea. It showed that DES ( Cypher ) was non-inferior to CABG. What impressed me most was that in both arms, the event rates were so low. Well for those of us who do unprotected left mains, take heart. Your are OK.

I suppose, tomorrow, I should try and post some medical developments coming out of ACC 2011. I think the summit ends today, in New Orleans.

AMERICAN COLLEGE OF CARDIOLOGY ANNUAL SCIENTIFIC MEETING. PARTNER COHORT A.

The Annual Scientific meeting of ACC started in New Orleans on Sunday, 3rd April and will go on till weds 6 th April. On day one, probably the most exciting presentation was on Partner Cohort A 1 year results, which many of us have been waiting. You may remember that the Partner trial was to compare Transfemoral Aortic Valve implantation ( TAVI ), using the first generation Sapien ( Edwards lab ) TAVI for the treatment of severe aortic stenosis in patients who were deemed either high risk for surgery or in-eligible for surgery. Cohort B ( whose results were presented in last years TCT ) was a comparison of TAVI versus standard medical therapy in patients who were deemed in-eligible for surgery, and cohort A was a non-inferiority comparison of TAVI against surgery in patients at high risk for surgery.
The Partners Cohort B results presented at TCT last year shows that TAVI reduced all cause mortality by 46% and cardiovascular mortality by 61%. TAVI ( cost not an issue ) is clearly a good alternative in patients with severe Aortic Stenosis, in patients not eligible for surgery.
The Partners Cohort A results was presented in the on-going ACC annual scientific meeting at New Orleans. Principal investigator is Dr Craig Smith. He presented the results for the 699 patients in Co0hort A who were seen in 26 centers across the US, 3 in Canada, and one in Germany. They were comparing the use of TAVI against conventional surgery of aortic valve replacement in patients who were deemed to be at high risk for surgery. The mean age was 84 years. At 30 days and at 1 year followup, the TAVI group and the conventional AVR group were equivalent in terms of all cause mortality. There was however a slightly higher incidence of strokes in the TAVI group at 30 days, and even at 1 year. Basically, TAVI was non-inferior to AVR ( aortic valve replacement ). Considering that this is the bulky first generation Sapien device, implantated by interventionist who were just learning to implant, compared with AVR by cardiac surgeons who were well trained in AVR, the results is actually quite good. Of course over time, the results should get better as second and third and fourth generation devices are in the offing. They will surely be smaller and even easier to implant.
Of course, we can also expect that in the future, the indications for TAVI will become more and more relaxed, as the devices do better and better. It is anyone's guess as to whether it will eventually replace cardiac surgical valve replacement.
Also remembering that interventionist are also working on the mitraClip procedure to repair mitral incompetence, the future does look somewhat gloomy for cardiac surgeons. maybe we should ask the cardiac surgeons to re-train as interventionist.
Anyway, I have included a presentation on TAVI in the coming " Weekend Seminar in Cardiology for GPs 2011" from the 9-10th April 2011 at the Sime Darby Covention Center.
Have you registered.

" WEEKEND SEMINAR IN CARDIOLOGY FOR GPs 2011"
9-10th April 2011, Sime Darby Convention Center
To register, contact Jeffrey Chung : 012 6186060.
Attendance is free - it is fully sponsored.

See you there.

NEW ONSET DIABETES WITH STATINS. MORE DATA

The April 5th ( coming ) issue of the Journal of the American College of Cardiology, carries an interesting article by Dr David Waters of San Francisco Heart Hospital, studying the association ( if any ) between atorvastatin and new onset diabetes. He was just re-confirming what Dr Naveed Sattar had documented last year when he publishes in the Lancet ( Feb 17th 2010 ), the association of new onset diabetes with statins. Dr Naveed of University of Glasgow, had done a meta-analysis of 13 mega trials of statins, and found that the use of statins was associated with a 9% increase of new onset diabetes.
Dr Waters wanted to re-confirm that, but his meta-analysis only contains 3 trials, all with the use of atorvastatin ( a powerful, lipophilic statin ). Dr waters found that the use of atorvastatin was associated with a 2% increase in new onset diabetes. Dr Waters group was able to conclude that the risk of new onset diabetes with statins, was particularly in patients who were obese, had higher initial fasting blood sugar, had increase fasting triglycerides, and hypertension. But these are also exactly the factors which promote new onset diabetes, on its own. So it does become quite difficult to separate the statin effect from these other diabetogenic effects.
Both studies documented well that statins save more lives and reduces heart attacks, much much more than increase the risk of new onset diabetes. Both papers emphasized that although their findings were interesting and gave much food for thought, it should not deter anyone from using statins as secondary prevention, and in some patients, even primary prevention.
The authors calculated that using statins in 255 patients over 4 years will cause 1 case of new onset diabetes, and save 5.4 lives or heart attacks, thus justifying that statins will continue to be used for secondary prevention.
This effect of risk of new onset diabetes, was seen with all statins, whether they be hydrophilic ones ( pravastatin, rosuvastatin ), or lipophilic ones ( atorvastatin, simvastatin ). The other fact that also came out from these two trials, was that the more powerful, or the higher the dose, the more diabetogenic. Most of these risk of new onset diabetes, was associated with high dose atorvastatin ( 80 mg ), and also rosuvastatin.
Interesting. We should still continue to use statins because it saves lives, but we are also aware that there is a small chance of new onset diabetes. Perhaps keeping the dose reasonable, would be a good idea. "The lower the better" does have added new onset diabetic risk.

And no, this is not an April Fools joke.