Saturday, December 28, 2013


Well, we are seeing the end of one year, and soon the beginning of another.
What has been the main topics of interest in Cardiology for 2013? Let me try and pen my thoughts as I see another year go pass. The topics are listed in no definite order of importance. It is just as I recalled them.

Year 2013 taught me :-

1. PCI for management of CAD.
PCI is under siege. More and more evidence is accumulating that the " see stenosis and dilate" is bad practice. It looks like at the end of the day, PCI may only be genuinely indicated for patients with chest pains and even that we require unstable chest pains. The fact that optimal medical therapy is very good therapy for CAD, that the culprit lesion that are prognostic ally important are usually those less than 50% lesions, that PCI has not been shown to improve survival, all points to that PCI should be reserved for unstable angina, acute coronary syndromes and also MI ( STEMI / NSTEMI ). In fact there is even one meta-analysis which showed that even the presence of inducible ischemia is NOT a good indication for intervention.
In the land of the great eagles, many interventionist have been brought to court for "improper use of stents". However, practice sometimes differ from theory. When former president George Bush has a stent placed for an angiographically significant stenosis following a stress test done in Aug 2013, raised more than a few eyebrows. Evidence based medicine was not practised in this case, so some said.
Interventionist beware. "Dilating for bread" is not a good strategy. The public and insurance will soon regulate you.

2. Role of statins in management of CAD
I had to reply to many many emails about the use or rather the abuse of statins by doctors. Many lay people are very concerned that doctors are pushing statins and some have claimed side effects. Of course the social media is full of websites, articles by famous cardiac surgeons, on why doctors overuse statins. Obviously because they make money from statins.
However, two points should be well noted. Firstly, the latest AHA / ACC Cholesterol lowering guidelines advocates treating the patient at risk, rather than treating the numbers ( cholesterol levels ). Do not just try and get the numbers down. Try and lowers the patients risk for CAD events. Secondly, statins have side effects, and sometimes, tiredness and muscle aches from a hard day's work can be difficult to distiquish from statins muscle aches. So use it wisely.
And to the "statin bashing" social media people, we ask you to take a good look at the mirror. How many of you are also selling alternative medicines / herbs? So you are also profiteering from your views on statins.

3. Chelation therapy.
This one really astounded me. The TACT study was published in mid 2013. True, it took along time to come to press and there were great controversy about methodology. Be that as it may, the fact that in Diabetics, chelation therapy reduced MACE events rate by 13% is significant. In fact very significant. You need to treat 7 to save one. Compare that to statins and NOAC, where you have to treat hundreds to save one.
I suppose my way out is to ask that this chelation therapy be tested in a federal funded big RCT particularly in T2DM, and lets see the results. I have trouble acepting the results, but lets see if it can be replicated and if it is true.
The main medical establishment should take the results with an open mind.

4. The important role of sleep.
Over the last two years we have seen more and more data out, on the importance of sleep and CV events, particularly in hypertensives. There also seem to be a close relationship between sleep apnea and CV events, both in hypertensives and also in non hypertensives.
7 hours of good sleep with 4-5 cycles of RAM sleep.

5. NOAC ( novel oral anti-coagulants ).
Of course we are seeing more and more anti factor 10 agents coming into the market, including new anti-platelet agents. Many of them use this statistical tool of relative risk reduction to magnify ( also read falsify ) their exaggerated effectiveness, to fool poorly trained government agencies to approved the drug for wide use. Of course non of these new agents come cheap. It will make a significant dent in our healthcare budget, leaving us less money for treatment patients whose illness may be curable.
Say what you like, if properly used, cheap aspirin, and warfarin still has many good days left and should not be thrown out in the name of progress and luxury.
A very important field that we must all learn is cost effective medication, or pharmaco-economics.
We all do like to drive our Rolls Royce, but parking a Rolls Royce, in a shanty town is an eye sore.

6. JNC 8
I suppose I should try and refrain from calling it names, else I may be accused of JNC bashing.
But it is true, that JNC 8 is very late, the data reviewed is out of date, there seemed no consensus and so many committee members and associations have gone on to release their own "advisory". Even NHLBI declined  to lend her name to this document, for the first time.
Anyway, there is nothing much in JNC 8 anyway. They have kept to mainly the same advice. The numbers have not changed. Yes, there is silence as far a beta blockers are concerned, and you can start with diuretics or CCB if you wish. Less restrictions.
For many of us, it is late and it has nothing new, and so no impact.

7. Cardio-oncology
2013 has seen more papers out on cardiac side effects of chemotherapeutic drugs. We are also learning that radiation for CA breast, especially left breast may be associated with the development of CAD.
Just as more and more hematologists are learning cardiology ( we are bonded by the close association with the use of anti-platelet agents, anti factor 10 agents, anti-thrombin agents, LMWH ) so also oncologist may have to learn more about echocardiograms and ECG as they manage patients with cancers. Many of the onco drugs have cardiac side effects and also radiation.
I am sure that over the years, we will see more collaborations between us and the onco boys and girls.

8. The emergence of negative trials.
Negative trials cost big pharmas big bucks. We have always advocated that negative trials are also useful for us to understand the disease process and also the patient mix. For a long time, negative trials were closed early and left in cold storage.
In this years ESC, ACC and AHA, many negative trials were highlighted.
This departure from the norm should be encouraged. No, w do not wish that trials failed. But should they fail, we wish them published so that we can also study them and learn why they failed. There is a lesson there too.

9 Fraud
Sad to say 2013 also saw  Ranbaxy being sued and found guilty of fraudulent practice resulting in millions of USD in fines. It was so bad that there was one case of glass pieces being found on tablets manufactured by Ranbaxy.
We also saw Dr Matsubura of Kyoto University, being found guilty of cooking up results in the Kyoto Heart Study resulting in the paper being withdrawn, after publication and also him being disgraced.
This is not nice but had to be done as clinical trials have formed an important part of our data for decision making and so we have to have as pure a system as we can make it.
Frauds must be weeded ut.

10. Novel interventional therapies.
As I travel and attend interventional meetings across Asia ( I do not travel across time zones much anymore ), I find that interventional cardiology has plateaued. The advances are fewer and minor and nothing revolutionary has come on board.
TAVI is getting better and more centers are doing them. Indications are being extended. I will not be surprised, if soon, some are using it routinely for assymptomatic AVR because it is safer and possible. Then companies with their aggressive marketing will take over and medical control is lost.
Renal de-nervation early results seemed sustainable. There are more catheters in the market, many of them with multiple poles to burn and so make the procedure safer. Whether it will save lives and reduce MACE endpoints is left to be seen. After 6-8 months, the BP numbers are better. The fact that more and more companies are getting into it ( initially there was only one Medtronic International, now there are, I am told 7  ) must mean that there is money to be made. I wll not be surprised to see a rebound hypertension after 3-4 years and also an increase number of non-responders ( now numbering about 20% ).

Well, lets see what 2014 will bring. I know for sure that Malaysia will face inflation as every will cost more, as the spendthrift government waste our money and ask the rakyat to tighten their belt. We should call 2014 PRICE HIKE YEAR 2014. Toll, electricity, bus fares, train fares, assessment rates, stationaries, ?petrol, more subsidies withdrawal,  and to come GST 6%. What somemore government want?

The optimistic side of me says " Happy New Year 2014" but the pessimistic side of me says, " God help Malaysia". The days ahead are gloomy and uncertain.

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