CORONARY ANGIOGRAM. WHAT IS NORMAL? MILD? SIGNIFICANT?

You may be surprise to find that after about 56 years of doing coronary angiography ( or arteriography ), cardiologist are still struggling to define significant coronary artery disease. At what point of luminal narrowing do we consider as significant or important? Some use a cut-off of 50% while others use 70%. All the time we know that coronary angiogram is a 2D picture, so it must also be the 50% or 70% on the severest orthogonal view. Some views may show 50% from one angle, and be 30% on another angle. Some cardiologist use 0% as normal, while others use <50% as normal.
So you can see that such a basic thing like coronary angiography do not even have a full agreement by cardiologist after 56 years.
All this is important, because the degree of stenosis ( or narrowing ), in many ways decide on the form of therapy, be it medical therapy, balloon angioplasty ( PCI ) or CABG ( by-pass surgery ). Here again, the cardiac surgeon will take a position that any heart artery with a narrowing of >50% or more should be by-passed.
Recently, a group called the Cardiac Care Network ( an NGO ), decided to do a survey. Led by Dr Jon David Schwalm of McMaster University, Hamilton, Ontario, they send out 188 survey forms, each containing 13 questions on defining significant CAD, to 18 major cardiac centers in Ontario. They received a 64% respond rate.

This is what they found.
Definition of single-vessel disease

Extent of disease	1 major epicardial vessel >70%	1 major epicardial vessel >50%
Responders (%)	65	35

Definition of double-vessel disease

Extent of disease	2 major epicardial vessels, each >70%	2 major epicardial vessels >50%
Responders (%)	58	37

Definition of triple-vessel disease

Extent of disease	3 major epicardial vessels, each >70%	3 major epicardial vessels >50%
Responders (%)	60	36

Moreover, 41% of respondents defined "mild" disease as <30% stenosis, while 35% used a cutoff of <50% stenosis. A full 69% of responders had very strict definitions of "normal": 0% stenosis and no luminal irregularities.

Can you see the confusion? They also found that ( upon breaking down the survey forms ), those cardiologist with <10 years experience tend to have a stricter definition of significant narrowing, while those of >10 years experience tended to have a less strict definition of significant disease.

Translated, it would mean that some are doing more revascularisation, then others. It is so difficult to see who is right and who is wrong. Whats is most interesting is the fact that a lot of work is now done to see if the anatomical narrowing is functionally significant, meaning that what may appear as an important narrowing, is not actually causing "problems" as evidence by improved outcome upon revascularisation. I was at a meeting in Beijing last March, when I saw data presented by the Koreans which showed that even some 90% narrowing angiographically, corresponded to non-ischemia producing by FFR. Of course, this data was derived from the FAME study, which I am waiting to see duplicated.

I am very concerned about patients being brought into the angio room for evaluation, based on CCTA. These patients may have no symptoms, no stress induced reversible ischemia. They are healthy, every day Joe, with a questionable CCTA, and subjected to coronary arteriography, and based on what is seen, subjected to re-vascularisation.

As for my own philosophy, I would like to take someone to the angio room when they have evidence of ischemia, either from a positive stress ECG or clinical chest pains. I feel that if these two are present, then whatever disease seen may be deemed as significant, if they are 70% or more narrowing in the severest orthogonal view. I feel that this is proper and supported by a large body of evidence. If the patient is going for by-pass surgery, as it is a major undertaking, all disease 50% or more should receive a by-pass graft because of the possibility of disease narrowing worsening, in the ensuing few years.

I suspect that over the coming years, more and more data will come out supporting the use of the FFR ( functional flow reserve ), as a means of defining a significant narrowing. This can be used non-invasively ( FFRCT ), and invasively. That would be good, but again, cost will rise.

DOCTORS, PRACTICE WHAT YOU PREACH AND YOUR SERMONS WILL GO FURTHER.

I reead this medical posting with great interest and humour. Dr Brian McCrindle of The Hospital for Sick Children, Toronto, gave a talk at the recently concluded Canadian Cardiovascular Congress 2011 at Vancouver, on " Physicians take a good look at yourself". I felt that it was very appropriate. Not often do we look at ourselves and see the impact that it may have on patients whom we are counselling.
In preparing his talk, he took a look at the wellknown Physician Health Study and found that 38% of physicians there had BMI >25 and 6% had BMI >30. Similarly, in the Nurses Health Study, 23% of nurses had BMI >25 and 5% had BMI >32. He also noted that in a Canadian Physician survey, 37% had BMI 25-30 and 8% had BMI >30.
He also found that, physicians who are themselves overweight tend not to stress healthy cardiac lifestyle in their counselling of patients, or at least only do it very casually. Those who are practising what they preach, tend to spend more time and seriously counsel their patients on healthy lifestyle, including diet, and exercise.
He also surveyed some hospitals in USA and Canada, and found that 89% of US and Canadain hospitals, had fast food joins in the hospital premises, with vending machines for carbonated drinks and unhealthy snacks all along their corridors leading to the casualty department, and outpatient clinics. We are surely sending the wrong message.
Coming nearly back home, we see the same. I have not done a survey myself, but I must say that the incidence of obesity among Malaysian physicians must be in the region of 30-40%. I also notice that quite a few physicians still smoke although they tell their patients not to smoke. This is what many patients have told me, with a glee, after they consulted that physician. Going to many local hospitals in my travels, I also see snack vending machines and drink vending machines ( I dare say ), in all the major hospitals. It sometimes look like a small supermarket corridor for instant snacks and drinks. This is true in private and also public hospitals. I suppose the excuse is that patients and visitors sometimes need a drink and some quickie food, and so we cater for them, and of course, we also make some rental money.
How then can we cut down obesity and other chronic lifestyle diseases as expressed by the Ministry of Health?
Doctors, please practice what you preach so that your patients can take you seriously, and Minister of Health, also practise what you say, so that we can reduce our health expenditure on chronic lifestyle diseases.

FFRCT : THE POTENTIAL GAME CHANGER

I wrote in August on FFRCT, work by the Koreans and also the Latvians.
Well, the November issue of the Journal of the American College of Cardiology carried the print article of the Korean work, on the DISCOVER FLOW study. A multicenter study on the correlation between non-invasive FFR and coronary angiogram correlation. They studied 159 vessels in 103 patients. All these patients received FFRCT and also coronary angiogram. The study was headed by Dr Bon-Kwon Koo of Seoul National University Hospital, Seoul. Significant angiographic lesion was taken as 50% or greater, and significant flow limiting FFR was taken as <0.8.

Per vessel diagnostic accuracy FFRCT and CCTA (reference for both was invasive FFR)

Imaging technology	Accuracy (%)	Sensitivity (%)	Specificity (%)	Positive predictive value (%)	Negative predictive value (%)
FFRCTa	84.3	87.9	82.2	73.9	92.2
CCTAb	58.5	91.4	39.6	46.5	88.9

a. Ischemic defined as <0.80

b. Ischemia defined as stenosis >50%

This table tells me 2 things. The normal 64slice CTA is not so good. Adding the FFRCT on to it, is so much better. I would have liked the investigators to have done FFR of the boderline lesions, during coronary arteriorgraphy, so that we can correlate and also make therapeutic decisions. If that decision is well correlated to FFRCT, then in future, we can do a FFRCT, analyse the data, and plan our PCI approach. I think that will save time and money and also better patientcare, instead of these adhoc PCIs that we now do,
I understand that that is the basis for the coming study the DEFACTO study, which results will be presented at the American Heart Association, annual scientific meeting in Orlando, next month.
I believe that this FFRCT is a game changer and will look forward to its clinical use. Now with the latest CT machines, the radiation dose is so small, that that has now become a non issue.
Alas, we await to see how much this FFRCT will cost, and I am told that it is very time soncuming. This will add to professional fees and cost.

DAPT FOR DES ; FOR HOW LONG?

One of the burning questions left in the use of Drug Eluting Stents ( DES ), is the optimal duration of Dual Anti-Platelet Therapy ( DAPT ). As we all know, the use of DES has definitely reduced the restenosis rates following PCI by reducing neo-intimal hyperplasia. However after 5 years of usage of DES ( back in 2006, Barcelona, EuroPCR ), we learned that the use of DES has spurn a new disease called Stent Thrombosis, be it acute ( due to procedural factors ), subacute, late, and very late. The last 3 varieties maybe due to reaction to the polymer or just local factors where the stent is deployed, or as some have suggested, accelerated atherosclerosis following DES implantation. Stent thrombosis carries a 100% risk of an acute myocardial infarction which results in a 30-40% risk of death. It occurs about 4% in the first year and about 0.5% yearly thereafter. Few are affected if your PCI volume is low, but when you consider 3-4 million DES implantation in USA per year, the problem is substantial.
So patients with DES are given a small sermon, about the importance of taking their DAPT. This is the best way to counter the issue of stent thrombosis ( besides deploying the stents better and also perhaps a better selection of DES ).
The next question the patient will ask is, for how long? as DAPT does have their problems. There is the issue of bleeding risk?, including strokes, the issue of non-cardiac surgery? and of course, the issue of cause, as clopidogrel, and now prasugrel, are not cheap drugs. They cause about RM3-400 per month. In fact, there is a strategy that if the patient cannot afford DAPT for 1 year, it may be better to implant bare metal stents. This issue is commonly faced in public hospitals where the patients may be poorer.
In the 20th October 2011 issue of Journal of the American College of Cardiology, Dr David Kandzari and colleagues studied the issue of duration of DAPT in patients implanted with the Endeavor DES. He compared the risk of stent thrombosis in those following 6 months of DAPT and those following 3 years of DAPT. There were 2,032 patients who had The Endeavor DES, followed for 3 years on DAPT. He found that there was no difference in MACCE rates following DAPT for 6 months or 3 years. The rates were the same. He concluded that for patients who had the Endeavor stent implanted, 6 months of DAPT should be sufficient.
Well, this sounds good and cost savings. In fact, we have all suspected this for quite a while, but many physicians just do not have the courage of stopping at 6 months because DES are implanted in such a great variety of anatomical conditions. Obviously, those patients with DES across the left main stem must need longer DAPT protection, perhaps for life ( unless contr-indicated ), those with complex bifurcation, those with long overlapping stents ( full metal jackets ), those with DES in situations of high thrombus loads, etc, etc. You see, there can be so many sub-clauses, that sometimes, I get so confused as to who, I can syop, and who I should not. Sometimes, it is the patient who request to stop, and I will look back on the PCI report and then decide.
Anyway, it is good to know that as least for one type of DES, we do not need routine DAPT for 1 year or more. I am sure that the interventionist in public hospitals, especially in Malaysia, will take note of this.
Looks like it may be a good marketing point for the Zotarolimus eluting stent.

TAVI : UPDATES FROM PCR LONDON VALVES 2011

Last week saw the commencement of the PCR London Valves summit in London. The UK boys were out in large numbers to present their UK TAVI registry. As we all know TAVI stands for Transcatheter Aortic Valve Implantation. Also present were the Italians led by Dr Antonio Colombo, and the French TAVI registry was presented as well.
Anyway, the London boys ( UK TAVI ) presented their registry of 877 patients followed up to 2 years. There were 877 when they started in enrollment from January 2007, till Dec 2009. And by Dec 2010, 213 patients have reached 2 years followup. They were using mainly the two market leaders, the Sapien Valve from Edwards lab., and the Corevalve from Medtronic International. They were both equally good. We did learn a lot from their presentations and the subsequent presntations as well.

First the 2 year results.

End point	CoreValve (%)	Sapien (%)	p
30-d mortality	5.8	8.5	0.11
1-y mortality	21.7	20.6	0.68
2-y mortality	23.9	28.3	0.14
Moderate/severe aortic regurgitation	17.3	9.6	0.001
Conversion to surgery	0	1.5	0.01*
Pacemaker implantation	24.4	7.4	<0.001
Repeat procedure	1.6	0	0.02*

Sure looks like the two valves are just as good and just as safe. I suppose the obvious point to learn is that the 1 year mortality is significantly more than the 30 day mortality. We all wonder why. After 1 year, the mortality flattens out again. Basically, at 1 year, about a third would have died. I also learn that the replaced valves can leak giving rise to the need for a re-do in some patients. There is also the need for pace maker implantation as the aortic valve ring is very near the conduction bundles and can be injured.

Following this UK TAVI presentation ( incidentally the paper is also out in the Oct 19th online edition of Journal of the American College of Cardiology ), the other papers also presented the registries of individuals and countries.
Dr Daniel Blackman of Sussex Heart Center, presented his experience with 1,600 patients with 1 year follow-up.

His results merits some close observation.

Outcome	Edwards transfemoral, n=389 (%)	CoreValve transfemoral, n=706 (%)	p	Edwards transapical, n=409 (%)	CoreValve subclavian, n=91 (%)	p
30-d mortality	4.3	5.2	NS	11.2	4.4	<0.01a
12-mo survival	84.5	80.8	0.453	74.5	75.4	<0.001b
New permanent pacemaker	6.2	21.6	<0.001	5.6	22.1	<0.001
Aortic regurgitation >2	8.4	13.4	0.015	6.4	9.5	0.34

Very interesting. As we all know, the Sapien Valve can be implanted transapical, or trans-femoral, while the Corevalve can be implanted trans-femoral or trans-subclavian. In Dr Blackman's experience, they were 50% with the Corevalve and 50% with the sapien valve. These different routes obviously have to do with patients fitness for the procedure ( Euroscore ) or the availability of access sites. Anyway, the London Blackman's experience seemed to suggest that those by the trans-femoral route do the best, be it with the Sapien or Corevalve. There is again the 30 days low mortality and morbidity, and the rise in mortality at 12 months. Those done through the transapical route do the worse. Those done through the trans-subclavian route do well like the trans-femoral, but catchup over 12 months to be like the transapical. Interesting observations.

I do not do and will not learn to do TAVI, as I believe that interventionist do best for their patients that which they do all the time. In their recommendation during the PCR London Valve 2011, doctors who do 3-5 per week are recognised as competent, and those that do less are under training. I do not see TAVI, which cost USD 30,ooo currently, as something that I will get to do 3 times a week, so I will leave it to the younger boys and the centers of excellence, who I hope will do 3-5 per week, and not 3-5 a year. I understand that as we were holding our ICF 2011 meeting in Kuching, a TAVI meeting was taking place at an institution in Kuala Lumpur. This is where my fear is. That the experts come and give talks, and physicians ( interventionist ), see one or two cases and try it when they get back home, and then use unsuspecting patients as their guinea pigs, as they try and get over their learning curve. I do not think that this is fair, as the patients have no way of knowing that someone is actually trying it out on them. This is one of my greatest fear, as I observe the interventional scene unfold in Malaysia.

The US FDA have asked for all the clinical papers on the Sapien velve as Edwards Lab has filed for approval. Both the Sapien and Corevalve has received CE mark approval and are current in use in Europe. That is why, most of the experience and data is coming out of Europe.
Well, I suppose the TAVI does have a role to play in patients who are too ill for Aortic Valve Surgery. I only hope that the phrase " too ill for surgery" will not be misused by physicians and patients for their own gains. That is always the danger with less invasive surgical procedures.

IS THERE SUCH A THING AS EVIDENCE BASED MEDICINE ( EBM ).

I have for many years ( whenever I am given a platform / forum ) held the view that true evidence based medicine is a myth. More than half the clinical trials undertaken by industry, was never completed, as they were yielding negative results and so industry did not wish to have it know. Just under half the results of clinical trails undertaken by universities and governmental bodies were published, a figure higher than industry funded research. Even the FDA is not given all the data, except for the ones that apply for registrations. Negative trial data, may prove to be as important as positive trial data, for patient care, in the sense that negative trial data, may help us to avoid pitfalls in therapy.
This blog is in some way prompted by 2 reports in the medical journals last week.
In the Oct 11th issue of the British Medical Journal, Dr Jennifer Neuman of the Mount Sinai School of Medicine New York, looked into the guideline committees of the USA and Canada from 2000 - 2010, writing guidelines on management of T2DM and dyslipidemia. There were 14 guideline committees in all. She found that there were 288 committee members involved from 2000-2010. 138 had declared conflicts of interest with industry with interest in the committees guidelines, ranging from honorarium, to trips, consultancy fees and lecture fees, etc. 6 were even chairperson of the panel ( who had declared conflict of interest ). 5 of the members did not even declare their conflict. Showing that about 50% were conflicted, with 6 as chairperson.
I remember, way back in the 90s, I was asked to serve in a guidelines committee to write the Malaysian guidelines on management of hyperlipidemia. Of course I was giving opposing opinions to the chairperson. I was never invited again to any guidelines committee.
The second paper is a bit more serious. Drs Harlan Krumholz and Dr Joseph Ross of the Yale University, New Haven, wrote a commentary in the Journal of the American Medical association, calling for more transparency and ful disclosure of all clinical trial data, to the professionals and also public, so that we can see the raw data for ourselves, and not through the eyes of so called conflicted ( some severely conflicted ) experts. They were largely in support of a movement called the "Cochrane Collaboration" which had called for full disclosure of clinical trial data to not only the governing body, but also to the professionals and the public. That these data should be freely available.
Perhaps by so doing, we could have avoided the approval and then recall of Vioxx and also avandia ( two recent examples ).
Now, only information required for approval, is declared to the FDA, prompting severe massaging of numbers to make it look robust and very clean, when the truth in fact may not be so. The industry calls it marketing. Once approved by the FDA, we in 3rd world countries, accept it as gospel truth. Many of our guidelines writing committee are essentially "cut and paste" committees as they do not have the raw data, and accepts all the p-values and hazard ratios told to us by the Europeans and Americans. So sad. When they are wrong, we automatically follow too.
We in the 3rd world are easily "bought off". I can say that in my little and limited experience with Malaysian guideline committees, 100% of the committee members are conflicted. Can I also say that some of them are "severely" conflicted. They travel, the shop, they eat, and they holiday with industry, regularly.
Take the guidelines, especially those in 3rd world countries, who like to ape the West, with a large pinch of salt. Know the guidelines and also know your "stuff". Be very critical of the information, when it does not make medical sense. Do not just follow blindly. The life of your patients is in your hands. They trust that you would have done that before you treat them. We owe that to our patients.
Evidence based medicine, nice to have, difficult to achieve. Doctors, you are each responsible to your patient

SYNTAX AT 4 YEARS. EACT 2011, LISBON

Last week, Dr Patrick Serruys was our spokesman at the European Association of Cardiothoracic Surgeons Annual Meeting in Lisbon. He was there to present the 4 years follow-up of the Syntax trial. The Syntax trial, which began enrollment in 2004, is a study of 1,800 patients with LMS and 3VD CAD randomised to CABG or PCI using the TAXUS stent. At the 1st year, PCI was inferior to CABG, driven mainly by the higher TLR rate in PCI. There was no difference in the hard endpoints of death/CVA/AMI. At 2 years the trend was basically the same with the curve diverging slightly. Last year ( 3 years ), the curve was still diverging but the CVA rates ( which was more in the CABG arm at year one ) had flattened out. Now at year 4, the CABG arm was clearly better as the end points of death ( CV and all cause mortality ) and AMIs were both higher in the PCI arms and the stroke rates were flat for the last 2 years.

SYNTAX 4-year cumulative results

Outcome	CABG surgery, n=819 (%)	PCI, n=879 (%)	p
MACCE	23.6	33.5	<0.001
Death/stroke/MI	14.6	18	0.07
All-cause mortality	8.8	11.7	0.048
Cardiac death	4.3	7.6	0.004
Stroke	3.7	2.3	0.06
MI	3.8	8.3	<0.001
Repeat revascularization	11.9	23	<0.001

Basically, it looks like after 4 years, CABG is better than PCI with the TAXUS stent. Of course, interventionist will argue that 4 years later, we know that the TAXUS stent was not as good as we first thought and now we have the scond generation Xience V / Prime stent, which will match CABG. In fact, this is the subject of the on-going EXCEL study, whose results we await, expectantly. The best form of treatment is always a moving target, as science and cardiology evolve better and better. Say what you may, but PCI is a very reasonable alternative for patients with complex CAD but whose Syntax Score is <32. This was the recommendation after Syntax 3 years. Now after Syntax 4 years, I will be happy to offer PCI to patients with complex CAD whose Syntax score is <22. It will be terrible ( in my opinion ) to open someone's chest for 3 discrete stenosis, when in 1 hour, and 3 stents, I can take care of the symptoms and be as good as CABG.
In the current scheme of things, this will be my strategy.

AUSTRALIAN WARNING ON DABIGATRAN

On the 5th October 2011, the Australian equivalent of US FDA, called the Therapeutic Goods Administration, issued a safety advisory on the use of Dabigatran.
Dabigatran is a anti-thrombin, factor 10 inhibitor, shown in the be effective in the prevention of ischemic strokes in patients with non-valvular atrial fibrillation. It was initially shown to be effective in the prevention of DVT in patients following hip replacement surgery. Many of us remember it as an expensive warfarin equivalent without the need for PT-INR monitoring. This has both good and bad consequences. It is good that there is no need to prick you every 3 months to check on your warfarin effects, ( as warfarin is a very fussy drug affected by many other drugs and foods ). However, if there is no way of effectively monitoring dabigatran, then when things go awry ( like things sometimes do ), there is no way to know.
The Australian warning came after they notice a significant increase in the number of bleeding following the increase use of Dabigatran. In 2009, Dabigatran was indicated ( in Australia ) for the prevention of DVT following lower limb surgery. The number of bleeders then were few. In April this year, Dabigatran was release for the indication of prevention of ischemic strokes in patients with non-valvular atrial fibrillation. Since that release, the number of bleeds following dabigatran use has increased. Now, the risk of bleeding with Dabigatran is about 16.6% in those taking the 150mg BD dose, and 14.7% in those taking the 110mg BD dose. This is against a risk of 18.4 % in those taking warfarin at therapeutic doses.
Should bleeding occur with the use of Dabigatran, it is usually gastro-intestinal, as oppose to warfarin, where bleeding may be largely intracranial.
It is important to note that such safety advisory has also been issued in japan and also New Zealand recently, for the same concern about bleeding.
Looks like cost is not the only downside to the use of Dabigatran. Bleeding is also a issue. It is good to note that all the three countries mentioned are Asian Pacific countries, where diet, and size may be more like us.
I think that physicians and patients should take note of the safety advisory, and use Dabigatran wisely, when proper indication.
Should bleeding occur, PT-INR is not helpful, and one may have to monitor the effects of Dabigatran crudely using aPTT and Thrombin Time, or even very crudely, the whole blood clotting time.
So this new kid has issues.

A REPORT ON ICF 2011, 8th-9th October 2011, Pullman Hotel, Kuching.

This meeting was successfully carried out from 8th-9th Oct 2011. at Kuching's new Pullman Hotel. The event went well. we saw 49 Malaysian and 15 Thai interventionist in the room on Saturday morning and about 40 Malaysian and 10 Thais in the room on Sunday morning. Some of the Thais had to leave early to catch the Kl and then the Bangkok connecting flights to return home to the Thai province. There was a healthy mixture of senior and young interventionist, and they were able to interact and fellowship.
We saw about 16 cases presented by the Thais and about 20 cases presented by the Malaysians. Some cases were indeed very interesting, and we learned much from the cases. There were two lectures ( Prof Koh TH of Singapore on " Optimising DES results" and Dr Elvin Kedhi of the Netherlands on " Preventing Stent Thrombosis" ), which were also expertly presented and very informative.
The faculty ( Prof Ge JunBo - Shanghai, Prof TH Koh - Singapore, Dr Elvin Kedhi - Netherlands, Dr Kirti - Mumbai and Dr Wasan - Thailand ) was wonderful. They were very interactive and forthcoming with their very excellent suggestions and advice on the many clinical problems presented. They were very approachable and friendly, mixing freely with the delegates, both formally and informally. They were just great, these 5 experts.
The gala dinner on Saturday night saw a full attendance and everyone had a gala time. We ran out of wine, as usual. We also almost ran out of food, due to the many who came.
Pullman Hotel welcomed us well, and the service was good. They were very accommodative whenever we had something to discuss with them, like when the screens were too small, they quickly went out to find bigger screens.
The support from the Sarawak Heart Center, headed by Dr TK Ong, was very good. Dr Sim Kui Hian too was present on both days, mixing with one and all. Dr Ong's team also showed us some very interesting cases.
The sponsors also showed up in good number. I have never had to place up 14 exhibit tables, as I had to this time. Yes, some companies did not show up, but a record number of 10 showed up. It was good to know that JnJ Cordis ( having stopped their sales of the Cypher stent ), is still with us at ICF 2011, and still in the marketplace.
Of course Apxara travels and the secretariat Boston made my work so much easier, when they did all the food work, and I only had to provide some directions and leadership.
All in all, it made for a wonderful weekend to be amongst friends and colleagues, sharing our work together.
I must say that as with last year, the Thais are still ahead of us, in terms of standard of practice and we still have someway to go, to keep up with them. Our presentation skills also have to improve. There is room for improvement, although we have improved.
It was a wonderful weekend of cardiac intervention and interaction. I only hope that all returned home safely to their families and their work.
Hope to see all at ICF 2012, and let's see how to improve to make ICF 2012 even better. ( I have yet to see the feedback forms.

SAME DAY DISCHARGE FOR PCI

When angioplasty became established, being minimally invasive, many of us felt that we should be able to discharge our patients after 4-6 hours of observations, even more so with all the wonderful stents that we now have. This had not worked out to be so. I am aware of a few centers who do day cases ( same day discharge ), but this is by and large few and far in between.
In the Oct 5th issue of the Journal of the American medical Association ( JAMA ), Dr Sunil Rao ( a Radialist ), has published a paper comparing event rates between same day discharge PCI and next day discharge PCI, and found no difference in the 2-30days event rates. Their data were taken from the Medicare Registry ( as most patients are Medicare patients ). They reviewed a cohort of 107,018 patients, aged >65years, of which 1339 had same day discharged, and found no difference in the event rates.

Two-day and 30-day rates of death and rehospitalization (adjusted for risk)

Outcome	Same-day discharge, n=1339 (%)	Overnight stay, n=105 679 (%)	p
2-d death or rehospitalization	0.37	0.50	0.51
2-d death	0.07	0.02	0.10
2-d rehospitalization	0.30	0.48	0.30
30-d death or rehospitalization	9.63	9.70	0.94
30-d death	0.30	0.22	0.53
30-d rehospitalization	9.56	9.60	0.96

These numbers must give some comfort to those who are doing day cases. It is fair to say that when you discharge PCI patients on the same day, you have to be very selective. I suppose these are straightforward maybe single of double vessel angioplasty, in the context of simple disease, without much co-morbidity. Despite that, the operator is still taking a chance.
I have not discharge patients on the same day routinely, as I do not derive a cost advantage for the risk that I take. In the mid-90s, when I was stenting a lot, I contemplated a same day discharge strategy, so I spoke to the hospital administrator, to see if same day discharge patients could have their hospital bills reduced by 30-50%, reasoning that I will save a bed for the hospital, and so the hospital can have a higher turn over. He was not interested and did not think so. Then if the day case and overnight stay cases have the same cost, there is no benefit to my patients, for the small risk that I take. So, whenever I do a colleague of the relatives of paramedics, who can abserve for puncture site bleeds, I would ask them if they wish to have a same day discharge. Those who agree, will be discharge the same day.
I suspect that until hospital beds become scarce and expensive, same day discharge for PCI, although feasible in many cases, will not become routine. In USA, hospital beds are expensive and scarce.

With this posting, I leave to go to Kuching to conduct ICF 2011 this weekend. Will write about it when I return.

Orbituary for the week

This week saw the passing away of two giants in different field.

Over the weekend, 2nd Oct 2011, Dr Willis Hurst, the author of the cardiology "bible", THE HEART, teacher of teachers, editor and influential American Cardiologist, died at the age of 90, almost 91 years. I use his textbook of cardiology to learn more about heart diseases. He will be sadly missed. I would like to record my condolence to his family and loved ones.

Of cause, on the 4th Oct, Mr Steve Jobs, the tech legend passed away. Besides an outstanding innovator and leader in humanising digital technology ( and almost all of us have felt his contribution), he is also the best marketing agent that I have come across. When he stands on stage with that black turtle neck and blue jeans, device in hand, he must be about the only guy ( non politician ), whose every word, can make the stock market go up and down. Not many can claim that. My condolence to his family and loved ones to. He will certainly be sadly missed. I fear that iPhone 5 ( if they get over the patent war with Samsung ), may be the last of the iPhone series.

HIGH TESTOSTERONE PROTECTS HEART OF ELDERLY

In the Oct 11th issue of the Journal of the American College of Cardiology, the swedish workers, led by Dr Claes Ohlsson of the University of Gotenberg, showed that elderly males with high testosterone levels have fewer cardiac events over a 5 year follow-up. They study male testosterone levels in 2,416 males aged 69-81yrs and followed them up through the central Swedish registry. These males were part of the MrOs ( Osteoporotic Fractures in Men study ) study. After 5 years follow-up, there were 485 cardiac events. The males in the highest quartile for serum testosterone, had the significantly lower rates of CV events.
This study is interesting, because previously, there were studies that showed that low testosterone levels were associated with less CV events.
The other problem with testosterone is the measurement. Measurement of free testosterone is cumbersome and even normal levels vary, and sometimes widely, so that it is not the easiest hormone to study. The easier measurement is sex hormone binding globulin levels SHBG ). But SHBG levels do not correlate so well with CV events.
So although elderly males may be happy that the most "male" they are at older age, the more they are cardio-protected, this is but one of numerous study on this topic and not all the data is consistent.
The other popular treatment is to inject male androgenic steroids. Somehow, this has not been shown to be cardio-protective. The best is still male free endogenous testosterone., the type that makes you a MAN, if you know what I mean.

CAN BETA BLOCKERS STOP DEATH FROM CA BREAST?

Interesting. Is it true that a simple, common drug like beta blocker, which is used widely in management of hypertension or ischemic heart disease, apart from other diseases, like hyperthyroidism, stop the spread of breast cancer spread, thereby improving prognosis.
Dr Des Powe of Queen's Medical Center, Nottingham, in collaboration with Prof Frank Entschalen of Witten U Germany, looked into this question. Obviously it was just a small pilot trial. They followed 466 Ca Breast patients on treatment, and divided them into 3 groups. Group 1 had hypertension and were on beta blockers ( about 43 patients ), Group 2 were hypertensives, but were not on beta blockers, and group 3 were non-hypertensives. The researchers found that Group 1 had 71% less death when compared to group 2, and 3. I am sure we all can see that the numbers are small. Even that, a 71% reduction in mortality is a large difference, and cannot be easily ignored. They have just presented their paper at the European Breast Cancer Conference in Barcelona. I read it from BBC news, and have yet to see it in print.
Then comes the reason why? Is it that beta blockers stop the spread of the malignant cells, or is it that despite the spread, the patients live longer? or it is that the beta blockers somehow, make the breast cancer cells more susceptible to detection and so eradication with other agents? Is this phenomena peculiar to breast cancers only, or it is true for all cancers? or hormone dependent cancers?
There are so many questions, and of course, it calls for a large randomised control trial. The problem is that the older beta blockers are all off patent and the newer beta blockers are all beta blockers with some alpha agonist effects ( so not strictly a beta blocker ). So it will have to be funded by public funds which will obviously be limited and slow. I am sure the large Cancer research Foundation, UK will tae up the project as it does have wide ranging implications as cancer is fast catching up with heart disease as the number 1 killer in the western Hemisphere. More money seem to go into cancer research now then cardiovascular disease.
Anyway, if I have Ca Breast and am not allergic to beta blockers, I may be tempted to start myself on a beta blocker ( metoprolol is so widely available, or even propranolol ), while awaiting further clinical data. The downside to beta blockers besides allergies, is lethargy and loss of libido. I have Ca Breast, not a big give away.

SUDDEN CARDIAC DEATHS. THE MIND OVER MATTER

At the just concluded HFSA ( Heart Failure Society of America ) Annual Scientific Meeting 2011, there was an interesting presentation br Dr martin Samuels of the Bringham and Women's Hospital, Boston. It is not a very scientific paper, no p-values, or hazard ratios, but he outlines his observations that some cardiac deaths are related to natural catastrophies, or severe mental stress. He observed that following natural disasters, there were more cardiac deaths. Following 9/11 there were more cardiac deaths. There was a paper in the New England Journal of Medicine in 2008 by Dr Wilber Lampen U, that during the 2006 world cup, there were more cardiac deaths in Germany following each game that Germany played, than on those days that Germany did not play.
At a parallel meeting, held concurrently with the HFSA meeting, Dr Deepak Chopra, was speaking at a seminar, outlining his theory that the mind has a severe control over the body, and that medical doctors, must have a "holistic" view of the body and its processes. His theory the " the body is not just a structure, but a process" and also the mind. The mind is also not just a structure but a process. At his institute, they have worked out that when a message is given to a patient, depending on how it is received ( good news or bad news ) it triggers different sets of bodily reactions and initiates different biochemical processes as a result of what is heard and how it is received and appreciated. So what is said, is important and how it is said, and to whom, is also important. With each message, the body responses with production of adrenaline, cortisols, with their attendant BP responses and heart rate responses.
Even genes are influence by the mind. At Dr Chopra's institute, in their research on meditation, they found that after 4 months of mindfulness meditation, the level of telomerase ( the enzyme that determines the length of your telomeres in your chromosomes, increase by 30%. The telomeres are that part of our chromosomes that has to do with aging. The shorter the telomeres, the shorter the life, as it were.
I remember when I was just a lecturer ( such a longtime ago ), I had to tell a very nervous patient that he had an enlarged heart from severe mitral incompetence ( leaking mitral valve ), and that he will require mitral valve replacement surgery. Since I broke the news, he did not rest well for a few nights and one night he was found dead on his bed, although he was responding well to medical therapy. I was quite convinced then that he was " scared to death".
Well, what was discuss at HFSA, brings out a rather interesting and important part of medicine. The marriage of western medicine ( with all the clinical control trial results, p-values and hazard ratios ) and the soft part of eastern Medicine with their holistic approach ( not so scientific and hard ), but nonetheless, important and relevant. How can we combine them for the betterment of our patients.
Yes, there is nervous control over all our bodily functions and not all behaviours can be proven, as God made each individual different and so their responses can be so varied, that perhaps no two of us are alike.
Such is the beauty of the human body.