THANK GOD. EO6 IS FREED

I just heard that the EO 6 had been released without harm and without conditions at 5.30pm
Thank God. At least some good sense prevailed.

Thank God

VIGIL FOR EO6

This is the other side of me.
I was at the Brickfields water fountain last night at about 8.30pm to lend support to the candle light vigil for the EO6 ( Emergency ordinance 6 ). The EO 6 signifying the 6 Parti Socialist Malaysia members who were detained since 2nd July. There were about ( eyeballing ) 2-300 in the crowd around the fountain, holding candles ( it is quite a skill to keep the candle burning against the breeze ) and posters to seek the release of the EO6. We were guarded by about 20-30 uniformed police, and also about 10-15 " red head" police. There were many on-lookers and also tourist, some of whom also came to light candles.
At about 840pm or so, the Police chief ( I do not know who or his rank ) came, and over a loud haler shouted that we all have to disperse in 3 mins. We then dispersed. There were murmurs that we should march towards Bukit Aman, but I never saw a crowd doing that, so I do not know if they did. We mingled for awhile and at about 9pm, I went home.
I felt very sad that 6 people, who did not break the law, can be detained without trial, and is still in detention. Of course I know Dr JeyaKumar, the son of my good friend Dr Devaraj, and the nephew of my mentor Prof TJ Danaraj. Kumar. as he is usually called, is a good doctor who cares very much for his patients. His services and conduct as a medical officer, is exemplary.
I wish that the Police / government, will released them, as I think they did no wrong. Or if they did, charge them with their crime, and bring them to court, so that they can defend themselves. We like to see the Police show prove that they did wrong, and if they did, we will surely support the Police in jailing them. The longer the Police wait, changing one offence ( planning to overthrow the King ), to another ( organising an illegal rally ), makes a mockery of their detention.
Do we arrest people and wait to see which crime they may have broken, and what to charge them with?? Arrest first, which crime ( let me think about it?) later.

DIABETES AND CAD. HbA1C AND CARDIAC RISK

For many years, we have always said that diabetes is a cardiovascular disease, meaning that diabetics are at high risk of cardiovascular disease and many of them die from heart disease. The saying is that Diabetes is a CVS risk equivalent.
However the latest study on this subject, published in the July 25th issue of the Arch of Int Medicine, throws more light on this. Dr Nina Paynter and colleagues from the Bringham and Womens hospital, Boston, did an analysis of 10 years followup of diabteics in the 24,000 strong Women Health Study and the 11,000 strong Physician's Health study. Of the whole population, there were 563 and 685 diabetics respectively, in the two cohorts. They were of course matched for the CV events, over 10 years. Dr Paynter and colleagues found that not all diabetics have the same CV risk. Their CV risk could be stratified by their HbA1C levels. Those with high HbA1C had higher CV risk then those with low HbA1C levels, and many of the cohort had low HbA1C levels. In fact, this was a criticism of this study.
Be that as it may, it makes sense, that those diabetics with good control, had lower risk, or those with mild diabetics had lower risk and those with poorly controlled diabetes or more severe diabetes, had higher risk.
There was quite alot of heavy statistics in this article. I have just summarised them.
I suppose this article in many ways confirm that not all diabetics are the same, and HbA1C is a good way to sort out the good ones from the bad.

TOP 10 CARDIAC HOSPITALS IN USA

The US news and World report, on the 19th July, released the ranking for the top 10 US cardiac hospital in USA. As usual ( as for the last 17 years ), Cleveland clinic tops the list.

The ranking are as follows :-

1. Cleveland Clinic
2. Mayo Clinic
3. Johns Hopkins
4. Texas Heart Institute at St Luke's Episcopal
5. Massachusetts General
6. New York Presbyterian University
7. Duke University Medical Center
8. Brigham and Women's Hospital
9. Ronald Reagan UCLA Medical Center
10. Hospital of the University of Pennsylvania

This is nice to know as we sometimes have to refer patients there either for treatment or for follow-up.

SECONDARY PREVENTION. THE DANGERS OF STOPPING ASPIRIN

Good old, headache relieving aspirin is good for the heart, especially when we use low dose aspirin to prevent further cardiovascular events following previous heart disease ( secondary prevention ). A new study has shown that if you discontinue your low dose aspirin, when you should be taking it for secondary prevention, you increase your risk of getting another CV event. This was conclusively shown in an epidermiological study by Dr Luis Gracia Rodriguez and colleagues from the Spanish Center of pharmaco-epidermiologic Research, in Madrid Spain. They looked into the UK Health Improvement Network database of 39,513 patients who were on low dose aspirin for secondary prevention. These were patients who were started on low dose aspirin from 2000-2007, aged 50-84 years. Almost half of the patients had stopped their aspirin. They followed those who stopped and those who continued, for about 3 years. They found that of those who stopped, there were an increase rate of CV events. In fact they calculated that for every 1,000 of those who stopped, there were 4 more episodes of heart attacks. Now this is significant. This same findings had been reported before, perhaps in a smaller scale, in major institutional studies.
It is quite important, in our context to emphasize this to our patients, as Malaysian patients have the habit of doctor hopping, default on therapy, changing to traditional medication, or just simply lost to follow-up. We must tell them, after their heart attack, that low dose aspirin will prevent further heart attacks, and if they should discontinue ( except under medical supervision ), they run an increase risk of another heart attack.
I was also hoping to see from this large epidermiologic study, the incidence of gastro-toxicity. It was not mentioned.

IV VERNAKALANT, A REASONABLE SUBSTITUTE FOR ELECTRO CARDIOVERSION FOR A.FIB.

Last night, tired though I was, I attended a close door conference of MSD, as they had invited a German expert, Prof Andreas Goette, to speak to us about the use of IV Vernakalant in the chemo-version of Atrial Fibrillation. Nice dinner first followed by the talk, at KL Hilton.
As we all know, atrial fibrillation is gaining importance as the world's population grow older. It is the most common arrhythmia in the elderly. I use to think that it was part and parcel of old age. Anyway, pharmas have gone on the bandwagon, trying to emphasize that for the elderly to live better, we must treat atrial fibrillation aggressively. So atrial fibrillation, especially recent onset ones, can cause palpitation and be rather uncomfortable. Previous, when there was no bread on the table, these little palpitations were ignored as part of life. Nowadays, that wont do. We must revert all atrial fibrillation. I have one patient whose grandson who is studying medicine in Australia, send an email to me asking me to investigate the episodic palpitation in his grandmother who is 84 years old, and who is now in sinus rhythm. I laughed and explain to the patient and son ( father of medical student ) that I am not keen to chase every rhythm abnormally in a 84 year old. I hope that they can accept that.
Anyway, so now, Prof Andreas taught us that all recent onset atrial fibrillation can be treated with IV Vernakalant, and there is a 45-50% chance of conversion to sinus rhythm. The conversion rate with IV Vernakalant, in the ANVRO study, is certainly better then IV Amiodarone ( the alternative ), but looks like, unless the underlying pproblem is corrected, the atrial fibrillation will recur. It is true that IV Vernakalant is easier to use, the electro-cardioversion, as it does not require long hospital admission and the need for anaesthetic consult.
Vernakalant, like all new anti-arrhythmic agent is a mix class anti-arrhythmic ( is you still follow the Vaughn-Williams classification. It is an atrial slow de-polariser, so it will prolong atrial action potential, with minimal effect on prolonging ventricular depolarisation, thereby avoiding the dreaded torsade de pointe.
Of course MSD ( the maker of IV Vernakalant ), is applying for Malaysian DDA approval ( I gather that that is why it is close door ), so they cannot market it yet.
Well it is good to know that there is another effective atrial anti-arrhythmic around. Lets see what happens in the medium and long term. many anti-arrhythmic have fallen by the way side, after great starts. Only time will tell. We certainly need more data.

THE TAKO-TSUBO CARDIOMYOPATHY, OR STRESS CARDIOMYOPATHY

There is a medical syndrome, first described by the Japanese about 10 years ago, called the Tako-tsubo cardiomyopathy. It affects main post-menopausal females in Japan. Those affected usually had a severe emotional shock, and ended up with markedly distorted ventricular aneurysmal dilatations. detected on MRI ( magnetic resonance imaging ).
Well, the latest issue of the Journal of the American medical Association carried a large study on this rather rare condition. The workers from University of Leipzig Health Center ( we are seeing more and more papers out of the former East Germany ). Led by Dr Ingo Eitel, they studied 256 patients who had MRI of their heart for evaluation after a stressful period. The MRI showed severe ballooning of certain portions of the heart. It can involve either ventricles. The structural defect is usually anuerysmal dilatation of the LV apex, free wall, biventicular or right ventricular. A repeat MRI 6 months later, showed that these changes had all returned to normal. 70% ( not all ) of these patients had a severe emotional stress preceeding the "cardiac" problem. All of them had no ECG or biochemical markers of any acute coronary syndrome. 80% of them were post-menopausal ( not all ), and there were some 10% males as well.
No specific therapy is required. They recover well.
Looks like this is a rather new and yet not so well defined cardiac syndrome. The features of post-menopausal females, severe emotional stress, absence of signs and biochemical markers of acute coronary syndrome or other cardiac disease, the presence of characteristic changes on the MRI of the heart, and of course the most important feature, complete recovery in 6 months, gives basis for a syndrome.
I can see that the features are at best, vague, and may form a waste paper basket for many poorly defined cardiac problems, in stressful, post-menopausal females.
However, it is good to know.

STANDARD OF CARE ; LOWERING CHOLESTEROL

Raise cholesterol level is undoubtedly an important coronary risk factors. This risk factor is bi-directional, meaning that when you lower it, you also lessens the coronary risk. But it is important to note that cholesterol is not the only coronary risk factor. Large population study have shown that 40-50% of heart attacks occur in patients with normal cholesterol levels in the blood. But because we know that cholesterol levels can be reduced with dietary control or with drugs, and that lowering it helps to lower your coronary risk, it becomes important to lower it. This statement has spun the development of a billion dollar pharmaceutical industry. Each cholesterol lowering agent becomes a block buster, almost.
However, it is important too, to note that cholesterol is also required in the body, to built cell walls and also for good cellular metabolism, like the production of sex hormones, and brain function. So zero cholesterol in the body is also a bad option.
The main culprit in the generation of the cholesterol plaque ( atherosclerosis ), is the small dense LDL-cholesterol fraction. What I mean is that Cholesterol and LDL-cholesterol is not just a single moiety. There are subfractions, and some are very harmful ( like oxidised LDL-C ), while others are also harmless, large the large LDL-C.
Amongst the cholesterol, there are also the good cholesterol, the HDL-cholesterol, as opposed to the bad cholesterol, as we have said previously, the small dense LDL-C.
We can lower serum cholesterol, and also the LDL-C by one of two ways. This will form the bulk of this article.
We can lower cholesterol with the use of an effective life-style modification program, or with drugs.
I much prefer the life-style modification way, as it is free of side effects and it also saves money. However, it would require some discipline, and sacrifice. Of course, taking a pill a day, is so much easier, but it does cost money, and more importantly, exposes you to the potential of side effects.
I usually spend about 15 mins, counseling my patients on life-style modification, especially diet. Everyone with a raised serum cholesterol level or a raised LDL-cholesterol level, should embark on a life-style modification program. If you are at a higher coronary risk, you require stricter life-style modification, and if you have no other coronary risk factors. you require a less strict life-style modification program. As you know, the important coronary factors that we talk about will include raised LDL-Cholesterol, hypertension, cigarette smoking, and diabetes. Of course, anyone with a previous history of documented heart disease ( previous heart attacks, previous angioplasty or bypass surgery ) , are at increase risk of another heart attack, and they would be treated as high risk.
For those with two or less coronary risk factors, life-style modification with a good diet, is usually the way to go. Using of drugs should only be researved for those with diet resistant raised serum cholesterol level. A good cholesterol reducing diet includes avoiding all the food with raised cholesterol or other fats ( saturated fats ), which can be converted into LDL-C molecules. The cholesterol rich food, in our culture, would include egg yolk, coconut milk products like curries, most of the seafood, except fish. ( even amongst the fish family, there are some fish better than others ), fat pork, chicken skin, lards, and saturated fatty acid based cooking oil like ghee. The higher coronary risk you are, the stricter need for the diet. The lower the coronary risk, the less strict you need to be. The effectiveness of your diet program, can be regularly assessed with 3-6 monthly serum cholesterol checks. Failure to bring it down would require a stricter approach. A good exercise program also helps, not directly in lowering LDL-C, but indirectly, it protects by increasing HDL-C, and also losing weight, and maybe blood pressure. Fish oils does not lower LDL-C, but it is helpful, as it lowers triglyceride, and also thins the blood.
Drug therapy is the easier, and more effective way but it does involve cost, and the occasional patient does develop some side effects. The most commonly used and the most effective cholesterol lowering and clinically effective group of drugs are the "statins". They belong to a group of drugs called the HMG CoA reductase, simply meaning that it acts on a certain enzyme, to lower the production of LDL-cholesterol. They are a bit pricey, except those that have lost their patents. Their most common side effect is muscle aches and pains, something that is so common in the coronary risk age group, that I am sure its incidence is severely underestimated. Many of my patients ( by the way, they are about 60-75 years old ), have muscle aches and pains. So how do you tell them apart. Once the muscle aches and pains begin to affect their life-style, what they wish to do, I often stop the "statins" for 3 months to see if the aches and pains get less. Those that do, I deemed them as "statin intolerant", and take them off the "statins" and use an alternative, like ezetimide ( which is costly). Thsoe that are "statin intolerant" and financially tight, I change them to"hypochol", and chinese red yeast product, which does lower LDL-cholesterol and is quite reasonable price. I suspect this chinese red yeast rice, does contain some herbal "statin".
Who then should be started on a "statin"? Those who have 1. previous heart disease, 2. those who have 2 or more coronary risk factors, and whose LDL-C does not come down with a good life-style modification program.
Probably the most controversial part of cholesterol lowering, are the target levels. How low should we go? Here cardiologist are divided. Many ( myself excluded ) would like to lower it till an LDL-C of 75 mg%. Some like me would only lower it to an LDL-C of 100mg%. Of course, the former group reason that the lower the LDL-C level, the less coronary problem. This is true, except that I know that the lower I go, the more side effect I get, so that the little benefit from too lower an LDL-C may not be off-set by the risk of side effects, and also the cost. So that's my approach. I am also rather suspicious, that the clinical trials showing the benefit of very low LDL-C levels may be severely pharmaceutically biased.
The other controversial ( less than the former ), is the age to treat to target. I see some trying to lower cholesterol to low levels when the patient is 80 years old. I tell the family, that the clinical trials showing benefit at this age is so few, and the cost of keeping low LDL-C levels are so high ( human cost and money cost ), that at age 80 years. I would rather enjoy life. Heart attack, especially sudden cardiac death maybe a peaceful and good way to go too, if you know what I mean.
So let us follow a healthy life-style and be moderate in all that we do ( pun intended ). For those at high risk of heart disease, ie, 2 or more coronary risk factors, or previous heart disease, who are below 75years of age, please be strict, or stricter.
Prevetuion is always better then cure.

CVS DANGERS IN CHRONIC NSAID USE.

Back to cardiology after the BERSIH postings. I just could not stand people not facing up to the truth.
Anyway,
There is a relevant paper published in the July issue of the American Journal of Medicine entitled "The harmful effects of NSAID amongst patients with hypertension and CAD". The lead author is Dr Anthony Bravry from the University of Florida, Gainsville. They did a post hoc analysis ( not the best way ) of the data from the large INVEST trial. The INVEST trial enrolled 22,000 patients. The main aim of INVEST was to compare the beneficial cardiac effects of controlling blood pressure with Verapramil ( CCB ) against Trandolipril ( ACE-I ), in patients who had hypertension and CAD. At each visit, with follow up of 2.7 years, the patients were asked, if they were taking NSAIDs regularly ( 882 patients ), intermittently ( 7,285 patients ) or never ( 14,408 patients ). After 2.7 years follow-up, they found that those who were taking NSAID had twice the CV events compared to those who never took. The intermittent takers were in between. The common NSAIDs were ibuprofen, naproxen and celecoxib. The study analysis could not separate as to which was more harmful. They all came out almost the same. They were taking the NSAIDs for a variety of conditions, including low backache, rheumatoid arthritis and osteoarthritis.
What then shall we do if our patients with CAD and HBP, should have chronic pain from osteoarthritis. I suppose, the easiest would be to add a low dose aspirin to the pain killer regime. However, one then have to worry about gastro-toxicity. Or, you could try and tail down the dose and frequency of the NSAIDs to lessen the CV risk. Of course, if paracetamol is adequate for pain control, that would be preferred.
As always, talk to the patient and discuss the CVS dangers of chronic NSAIDs, and have them understand it.

OUR JOINT STATEMENT ON THE SITUATION AT TUNG SHIN HOSPITAL AND CHINESE MATERNITY HOSPITAL ON AFTERNOON OF 9th JULY 2011

We have just agreed on a joint statement at 9pm. By 9.15PM, I was told that the internet media had already published our statement. I would like the real statement known, so I am posting it here.

AN INCONVENIENT TRUTH
We, the undersigned doctors, wish not to enter into the polemics of the Bersih 2.0 march on
9th July 2011 but would like to clarify the inconvenient truth.
We are outraged at the incidents, and the subsequent responses from the authorities, to the
events where tear gas and chemical laced water were shot into the compounds of Tung Shin
and Chinese Maternity Hospitals, two adjacent buildings along Jalan Pudu, Kuala Lumpur, with
scant regard for the safety of patients, staff and the general public who were at the
buildings that afternoon.
Hospitals are considered as safe sanctuaries for all, even during war times, but these
consecrated places of refuge and protection were violated by the defence forces that
afternoon. Police even entered the buildings in search of some of these peaceful
marchers. What was most frightening and witnessed by many was the unprovoked violent
assault within the hospital compounds and apprehension of several protesters who had merely
run into the hospitals to seek shelter from the tear gas and the water cannons!
It is repulsive that the authorities entrusted with policing the nation and protecting the weak
and needy, have shamelessly denied publicly, the occurrence of these incidents IN SPITE of
countless photo/video and eye witness accounts of what was evident to all independent
observers.
A few of the undersigned were actually visiting or working in the hospitals concerned at the
time of the events and will gladly provide sworn affidavits, if required, as to veracity of the
incidents
The Malaysian public expect holders of high public office to honour their positions accorded by
the citizens, by discharging their duties with moral integrity, dignity and transparency.
Their failure to do so raises the public's doubts in their competence and credibilty as much as it
demeans those high offices.
Dr Ng Kwee Boon - Consultant Obstetrician & Gynaecologist
Datin Dr Low Paik See - Consultant Paediatrician
Dato’ Dr Musa Mohd Nordin - Consultant Paediatrician & Neonatologist
Dr Mazeni Alwi - Consultant Paediatric Cardiologist
Dr David Quek - Consultant Cardiologist
Dr Sheikh Johari Bux - Consultant Obstetrician & Gynaecologist
Dr Steve Wong - Consultant Plastic Surgeon
Dr Ahmad Farouk Musa - Consultant Cardiothoracic Surgeon
Dr Ng Swee Choon - Consultant Cardiologist
Dr Mary Cardosa - Consultant Anaesthesiologist
Dr Jeffrey Abu Hassan - Consultant Chest Physician

TELL THE TRUTH. STOP THE LIES

I was quite upset by the government in continuing to deny the events of 9th July 2011. I have just written to NST and STAR to protest this. I am not sure if they will publish.
I am sorry, I thought I should do my social duty, and publish it here.

TELL THE TRUTH AND STOP THE LIES

Dear Editor,

I am very concern as to the approach taken by all those in authorities ( Politicians and the Police ), regarding the events of the afternoon of the 9^th July 2011 in Kuala Lumpur. Please notice that because of the hype whipped up in the lead up to the 9^th July 2011, the whole world was watching. In this “flat” world, nothing can be hidden, as pressmen ( both local and foreign ) were out there in the streets of Jalan Tun Sambanthan, Jln Sultan, Pudu Road, Batu Road, Jalan Tun Perak, and Stadium Merdeka, just to name a few. They were loaded with big cameras and videos. Everything was recorded. Al Jazeera had a live feed on the afternoon. Everything happening is recorded and broadcast to the world. How can we hide the facts? The authorities attempt to deny and hide the truth is futile, and make us liars in the eyes of the world.

1. The whole afternoon’s events were fully recorded. There were you tube videos in many, many blogs, and there are pictures by press and individuals, literally hundreds, I think. I doubt everyone of them is wrong. All the videos appeared within 24 hours, barely enough time to doctor.

2. I was told that at least 4 of the demonstrators were hospitalized, and some even had surgery, from actions taken by the Police. Again did they all hurt themselves accidentally? Did Mat Sabu, fell accidentally and hurt himself? There are clinical notes and hospital records of their injuries? Are we to be convinced that these clinical records will not be doctored? The fact that the Police used excessive force is not in doubt. Maybe not all the Police but certainly many of the Police.

3. Police did fire with intention to injure, hurt and maim. There is a video available at a blog, that clearly show the Police aiming the teargas gun at shoulder height, obviously to shoot at individuals. This video appeared within 24 hours. Are you saying that it had been doctored?

4. There are numerous photos and videos of tear gas being shot into Tung Shin Hospitals and Chinese Maternity Hospital, within 24 hours. They too cannot be doctored?.

5. The late Encik Baharuddin died. His death had also been videoed. Clearly the Police denied him his medications, which may have saved him. Consult your own cardiologist and hear the truth from them. The post-mortem will probably show acute myocardial infarction, leading to Ventricular Fibrillation, resulting in his death. Prompt medical treatment ( which was denied him), may have saved him.

I am writing to ask the authorities to stop denying, and come out with the truth, and try and regain your credibility, or what is left of it, to regain our trust and confidence. If you keep up your denials, despite overwhelming evidence to the contrary, any remaining trust in the government will rapidly diminish. How can we as parents and elders teach our children and the young to tell the truth?

Please start facing up to the truth, and tell the truth. Stop the lies.

For the love of Malaysia, please tell the truth.

Let see if the mass media will publish.

BERSIH 2.0, THE LESSONS THAT I LEARNED

I was present and witness BERSIH 2.0 first hand. I had gathered at Tung Shin Hospital at about 2pm. managed to get pass the very tight Police cordon.
Among the many lessons ( no hype, just facts ), I learned,
1. Many Malaysians care, and they are brave. They came out in large numbers, despite the very severe Police clampdown in KL, and all the threats and pre-emptive arrest. At the Tung Shin gathering, I estimated about 5-6,000. From the video clips circulating, I think the Brickfields group was the largest. I believe there must have been 50,000 at least.
2. They have a true 1Malaysian spirit. A Malay gentleman, whom I do not know, lifted me up the gates of CMH to avoid the Police cordon. Another elderly Malay offered salt for my eyes against the tear gas. Another elderly Chinese man offered this Malay man water to wash and to drink, and he never asked if it is halal.
3. The Police, in particular the FRU were brutal. They ran passed me chasing a Mala yman into Tung Shin hospital, cornered him, beat him up before handcuffing him. They were firing teargas outside the PUDU road, and of course the fumes was all over Tung Shin. They aimed the water cannon into Tung Shin Hospital. It is true.
4. That the authorities lie, twist and turn, throughout the whole episode. How can we trust them?
5. The demonstrators were peaceful. No one carried any weapons. Amongst their own, they were exercising discipline, so that no one will damage properties, or shout abuses at the Police. In fact, at one point we had to warn some of the youth, not to abuse the Police. I think that the Police did more damage,
6. The call for change is real and cannot be ignored.

7th July is a memorable day. I am proud to be part of it.

STANDARD OF CARE ; PERCUTANEOUS CORONARY INTERVENTION 2011

Percutaneous coronary intervention had her humble beginnings in 1977 in Zurich when Dr A Greuntzig, under flouroscopy guidance passed a very high profile and crude catheter ( rubber tubing ) with a balloon at the distal end. Once across the lesion ( which was at the proximal LAD ), he inflated the balloon repeatedly, until the lesion ws flattened and there was no longer any more pressure gradient across the lesion. The patient was a dentist, and the simple balloon angioplasty lasted him about 15 years.
Right across the "pond" in the USA, Dr Simon Stertzer and Dr Richard Myler were also experimenting with the same, with good results.
Angioplasty, or percutaneous coronary intervention ( PCI ) was born.
This small band of innovators went about conducting life demo courses hoping to teach and transfer knowledge of this new, and effective technology to as many cardiologist as possible, and they were successful. I had learn the technique from Dr David Clark who had worked with Dr David Myler.
In 2011 ( the last AHA PCI appropriateness criteria was issued in 2009 ), the indications remain as it was in 1977. The patient should have reversible myocardial ischemia as evidence by the presence of troublesome angina, and or stress ECG or other forms of investigation to document reversible ischemia, like thallium nuclear scans, stress echocardiogram. Positive MSCT is not considered an indication for PCI.
PCI should be performed by specialist, who has been trained to performed PCI, and it should be carried out in an institution where there are adequately trained paramedical staff both to assist in the safe performance of PCI and also to monitor the patient after PCI. With the advent of coronary stents, many of us feel that there in no longer a need for on-site cardio-surgical backup although the latest guidelines still say so.
As for disease subset when PCI should be performed, for patients with reversible ischemia and single or double vessel disease PCI is appropriate, unless the anatomy is unsuitable for PCI. For 3VD-CAD and Left Main Stem disease, we need to calculate what we call the Syntax score. Patients with high syntax score, should be recommended to go for CABG ( coronary artery bypass surgery ).
Coronary angiogram carries a mortality risk of 0.1% and on the average PCI carries a mortality risk of 1%.
They both require an overnight stay in hospital. Some, doing via the radial approach need on stay in hospital 6-8 hours for observation post-PCI.
The average cost of PCI show by RM 12K + the cost of stents or special devices. On the average, a drug eluting stent in my set-up cost about RM 8K, so PCI with 1 DES, would cost about RM 21K with tax. Of course, I am talking about FDA approved stents. Please be aware that there are many copycat stents in the market.
A bare metal stent in Malaysia should cost about RM 3K. It is true that stent cost to institutions also depends on whether the institution is buying, on having the stents consigned. If the institution buys a large volume, the price per stent would be cheaper, as there is cost savings with purchase and bulk purchase.
What we often do not emphasize enough is that with PCI, especially with drug eluting stents, the immediate cost is one thing. The followup cost with the use of clopidogrel or prasugrel, can also be substantial ( about RM 250 per month for 12 months with plavix ).
It must also be said, that with the latest generation of bare metal stents, the longterm results is only marginally inferior to drug eluting stents, if they are well implanted. In some situations, bare metal stents may even be safer and preferred.

DRONEDARONE ( MULTAG ) IS IN TROUBLE.

Dronedarone is a drug that was FDA approved in 2009. It was indicated for the treatment of non-permanent atrial fibrillation. Atrial fibrillation is the arrhythmia of the decade. In the ATHENA trial, dronedarone was shown to be efficacious in reducing the number of first hospitalisation from atrial fibrillation and also seem to reduced the number of cardiovascular deaths. That all sounded good, and Dronedarone was launshed at the beginning of this year, in Malaysia, with some Greek pomp.
Now, in a press release by Sanofi-Aventis, the maker of Dronedarone, the company has stopped an on-going dronedarone trial name PALLAS ( Permanent Atrial fibriLLation outcome Study using dronedarone on top of standard therapy). This study started in 2010, and was still enrolling patients. It is due for completion in 2013. It targeted 10,800 patients and to date, it had just completed enrollment of 3,149 patients. Its aim was to study to see if dronedarone therapy will improve the cardiovascular outcomes in patients with permanent atrial fibrillation.
The data safety monitoring committee that met recently, noticed an increase in the number of CV events in the dronedarone arm, so the trial has been halted. This obviously is of great concern to me as I do have some patients on dronedarone for non-permanent atrial fibrillation. Although the company advised that it is still safe for non-permanent atrial fibrialltion, I am concerned, and wonder if I should withdraw the drug.
It is true that the PALLAS population is sicker then the ATHENA population. In PALLAS, besides the presence of permanent atrial fibrillation, the patients also have one important cardiovascular risk factor including previous stroke or heart attack.
The company was not willing to tell us, which cardiovascular side effects seemed related to the drug. This is also of importance to us.
Dronedarone in Malaysia is marketed under the trade name of MULTAG.

ON MOBILE PHONES AND THEIR DANGERS

I was send this piece by a friend. I thought that it was of public interest, so I am posting it for all your information.

ON MOBILE PHONES.

REDUCE SUDDEN CARDIAC DEATH WITH HEALTHY LIFESTYLE

A recent study, published in the Journal of the American medical association, showed that an unhealthy lifestyle is the cause of 80% of the sudden cardiac death that we see, and implementing a healthy lifestyle reduces this risk by 92%.
Sudden cardiac death ( SCD ) is defined as death within 24 hours of symptom onset, without prior evidence of vascular collapse. Literally, drop dead.
Dr Stephanie Chiuve and colleagues from the Harvard Medical School, Boston, studied a subset of the US nurses health study cohort. They picked out 81,722 nurses enrolled in the Nurses Health Study, followed them from 1984 - 2010. Did 2 yearly diet and general health questionnaire, to ascertain their diet and also exercise protocols.
They found that over 26 years, unhealthy lifestyle was the cause for 80% of SCD. If the nurses improve on 4 parameters, they may avoid SCD by 92%. The 4 healthy parameters are, stop smoke, a BMI of <25Kg/m2, exercise 30 mins or more daily, and a Mediterranean diet. Keeping these 4 parameters for females would reduce the risk of SCD by 92%.
This study again proves the usefulness ( as if it needed anymore proof ), that a healthy lifestyle is good for us. I suppose the 4 parameters are not difficult to achieve, so we should all try our best to achieve it, unless you are one of those who will keep a healthy lifestyle till age 75 yrs, and then hope for SCD as a good, peaceful end. That would be programmed suicide aided by good medical knowledge, which I better not comment. To each his / her own life philosophy.
As for today's lesson. a healthy lifestyle, involving 4 parameters, can reduce SCD. These 4 important parameters are stop cigarettes, keep body weight <25 Kg/m2, exercise 30 mins or more daily, and eat a Mediterranean diet.

THE DANGERS OF VARENICLINE. CVS RISKS

Varenicline is a drug that is marketed to help patients kick the smoking addiction. Obviously, this is another "TAK NAK" strategy to try and reduce the smoking cardiovascular risk. This drug is quite potent and if taken correctly with counselling, it is said that 1:10 taking the drug will kick the habit. That is the good side.
In the 4th July online edition of the Canadian Medical Association Journal, Drs Sonal Singh ( John Hopkins University School of Medicine, Baltimore ) and Curl Furberg ( Wake Forest Baptist Medical Center, North Carolina ), published their meta-analysis of 14 clinical trials done with varenicline. It involved 8,216 patients, taking varenicline from 7-52 weeks, comparing the rate of cardiovascular events in those taking the drug and those on placebo. 13 of the trials had patients who had no known cardiac disease in the past.
They found that those taking varenicline had a 72% more incidence of cardiovascular events. Now this is worrying. We all remember that varenicline is also associated with know neurological disorders, including suicides, momentary lost of awareness, nervousness, agitations etc. So much so that the US army has ban the use of varenicline in officers manning missiles sites, pilots, truck drivers etc. They are obviously worried.
The numbers seemed to show that you need to treat 28 patients to get one with CV side effects. Now this is worrying. If we treat 10 subjects, to get one to quit, and you treat 28 to get one CV side effects, Is it worth-it? one must ask. If pilots should not take it, what about bus drivers, car drivers?
This is not the only paper of the CV side effects of varenicline. There were previous signals.
Those who oppose varenicline, now have more ammo to ask the government to ban the use of this drug, seeing the CVS and CNS dangers. Those who support the use of this drug, to help people quit, will say that stopping smoking does more good then the potential harm.
Now each of us must weight the equation for ourselves?
As for me, I have never been impressed with the data on the usefulness of varenicline. I was rather concerned about the CNS side effects. With this new meta-analysis, I am even more concern. Perhaps there is some justification is restricting its use. You cannot help 1:10 and endanger 1:28. The benefit does not outweigh the risk ( in my opinion ).
Afterall, there is something call the will to stop, if one really ones too. The good old method of cold turkey, is another way, though somewhat arcade.
Varenicline, is marketed in Malaysia as Champix.

STANDARD OF CARE ; INDICATIONS FOR A CORONARY ANGIOGRAM

Last Monday, we wrote about the problem of chest pains., and how they can be sorted out at the outpatients clinic level. As stated in last week's discussion, there can be many causes for chest pains and it is always, the cardiac variety that should give cause for alarm and urgency. Also that cardiac causes for chest pains, can usually be demonstrated by the presence of inducible ischemia, like on the stress ECG.
Very often, the defining test is the stress ECG, and not as some quarters will wrongly propagate, the MSCT ( multi-slice CT scan ) or a newer version, the multi-detector CCTA. As we have stated in many discussions, the MSCT and MD-CCTA, sees artery outline, from computer reconstruction, which seem to indicate stenosis, where there may be non, or seem to indicate severe blockages, when there are only minor blockages. But, if the MSCT or MD-CCTA shows a normal artery, it is likely to be a normal artery. That is why the MSCT or MD-CCTA should ( as used by the Americans ) be used to exclude disease.
Coming back to today's discussion, the indications for a coronary angiogram, must include significant anginal type chest pains, together with inducible ischemia on stress testing, or other forms of functional testing, either, or both. Some cardiologist may modify further by saying that in the elderly, chest pains, uncontrolled by medications, would require investigations with the coronary angiogram. In the young ( those below70years ), the threshold for doing an angiogram is lower, and for those above 70 years, the threshold to do an angiogram is higher, meaning that we do not simple do coronary angiograms "for bread".
The presence of inducible ischemia, either by way of symptomatic chest pains or assymptomatic positive stress ECG is important, because, a positive coronary angiogram may lead on to coronary angioplasty, and we really must not angioplasty or treat stenosis that are not clinically important. We define a clinically important stenosis as one that causes significant myocardial ischemia, as evidence by chest pains or a positive stress ECG ( or other equivalent means of ischemia induction). This is because clinical studies have shown us ( unequivocally ) that the are many stenosis that do not actually cause problems. Such stenosis can be dealt with, with optimal medical therapy. Assymptomatic, non-ischemia producing stenosis do just as well with optimal medical therapy as with angioplasty.
Once, the clinician is satisfied that the patient myocardial ischemia, uncontrolled by medical therapy, then a coronary angiogram is indicated. The coronary angiogram is an accurate ( although not infallible ) way of diagnosing coronary artery disease. It tells us the anatomy, the probable culprit lesion, and also the prognosis. Taken together, it allows us to draw-up a medical strategy for the patient, indicating what is the best thing to do for good short, intermediate and longterm outcome. Often, a coronary angiogram may lead on to an ad-hoc ( at the same sitting) angioplasty, or less often nowadays, a coronary angiogram may lead to cornary artery bypass surgery ( CABG ).
These will form the basis of another blog.
I just wish to emphasize today, that there are certain indications for a coronary angiogram, as it is expensive and does carry a risk ( albeit a small risk ). Inducible ischemia, either in the form of symptoms ( chest pains ), or positive stress ECG, stress echo or stress radionuclide scans.

TAKING BLOOD PRESSURE MEDICATIONS AT NIGHT.

It is traditionally belief that blood pressure medications should be taken in the morning, if it is once a day, and the daytime, if it is two or three times a day. Nowadays, the pharmaceutical companies are so good that almost all drugs are once a day, and also in combination, so that you do not have to carry two or three BP pills, just one, maybe two pills.
However, this does go against the body physiology as we know it currently. We know that there is a circadian BP pattern, that BP seems to spike as we awaken, in the early hours of the morning. We also know that many cardiovascular events, meaning heart attacks, and strokes, tend to occur, in the early hours of the morning. It seems that the Renin-Angiotensin-aldosterone system is stimulated at night ( I wonder why ), and so blocking the RAAS system at night makes sense.
In my reading, I picked up a study, done in Spain, that seem to suggest that there is much benefit in taking your blood pressure pills at night, before bedtime. The same group did two studies. The earlier study called MAPEC ( Ambulatory BP monitoring in prediction of cardiovascular events and effects of chronotherapy ). This study was publishes last year.
At the just concluded European Renal Association/European Dialysis and Transplant Association 2011 Congress, Dr Hermida RC presented a paper entitled "Influence of circadian time of blood pressure-lowering treatment on cardiovascular risk in resistant hypertension." They took out 776 patients with resistant hypertension, measure their ambulatory BP over 24 hours, gave half at least one BP medication at night and the other half their medications at the usual morning hour. After 8 years of followup, they found that those who take at least one BP medication at bedtime, had an event free survival of 81% compared to those who took their medications in the usual way ( 64% event free survival at 8 years ).
This will lend some proof to the original hypothesis that the active RAAS at night may be the cause of our problem, and so blocking the night surge, would make sense. I must say that I would like to see more work on this, as the data all seem to be coming out of the University of Vigo, Spain, by this group.
I do ask some of my patients to take their BP pills at night, but not routinely. In all hypertensives, I do routinely enquire about their sleep pattern as there are numerous study which showed that poor sleep, is correlated to poor BP control and also with more CV events.
So food for thought. Should we advocate taking BP pills at night, instead of the morning, and is there a downside. Looks like there may be an advantage.