It is not uncommon to come across a patient brought into the emergency for syncope. Experienced clinicians are well aware that often despite extensive examination and investigations the cause cannot be confirmed. A recent paper has studied the prevalence of pulmonary embolism in patients admitted for syncope (NEJM 2016; 375:1524-31).
Continue reading “SYNCOPE DUE TO PULMONARY EMBOLISM IS NOT RARE”
The Mayo Clinic has published a paper on the surgical approach in patients hypertrophic obstructive cardiomyopathy (HOCM) accompanied by mitral regurgitation (MR). The study has confirmed what is already well known that MR in HOCM is dependent upon systolic anterior motion (SAM) and in most patients this can be corrected by extended myectomy alone.
Hypertrophic cardiomyopathy (HCM) is characterized by asymmetrical myocardial hypertrophy plus fiber fibrosis and disarray. About one third of HCM patients have resting left ventricular outflow tract obstruction (LVOTO) with >30 mm gradient at rest. Another third have a resting gradient < 30 mm but obstruction can be triggered by exertion, increased myocardial contractility or afterload.
Continue reading “SURGERY IN HOCM ACCOMPANIED BY MITRAL REGURGITATION”
The mandarins in the Indian health ministry have decided to include coronary stents in the National List of Essential Medicines (NLEM) to bring down the pricing by a staggering 50%. There were almost 500,00 coronary stents inserted across India in 2015. More than 60% of these stents were imported while the remainder were made in India. Health ministry officials insist that Indian stents are equal in efficacy and safety as compared to foreign stents, without a single head to head comparison of the device. But then one should never expect common sense or scientific temper from the bureaucrats hunched in Nirman Bhawan, Delhi.
Heart disease continues to be the biggest killer of the globe; more than 17.5 million die in a year. Millions of patients with heart disease get treated by coronary stents; including patients with stable angina and acute coronary syndrome. It is well recognized that drug eluting stents (DES) are more effective than bare metal stents (BMS) in preventing restenosis, and the newer generation DES have the lowest rate of stent thrombosis (ST). It has been suggested that the newer generation DES would therefore have the advantage of reduced rates of death and myocardial infarction.
Continue reading “IS THIS THE NEW BEGINNING FOR THE BARE METAL STENT ?”
We now know that elections and are being rigged, both in the developing world, and in the first world. This realization is no longer the monopoly of conspiracy theorists. More startling however is the gradual clearing away of the fog over the publication of manifestly tailored scientific data that have been going around for quite a few years with the active connivance of leading medical journal editors. It has now become imperative to scrutinize every bit of the methods employed in a study, and the results presented to draw ones own conclusion, which more often than not may vary considerably from that of the researchers. Most, if not all, of these trials are industry sponsored and therefore guarantee reprint orders to the tune of hundreds of thousands of dollars. There is an extra-ordinary grip by the corporates on the major medical journals of the world. The main stream media have been all along unwittingly or by choice, pliable.
The Danish Study to Assess the Efficacy of ICDs in Patients with Nonischemic Systolic Heart Failure on Mortality (DANISH) randomized about 1100 patients with symptomatic heart failure, LVEF <35% on optimal medical therapy but without coronary artery disease to implantable cardioverter defibrillator (ICD) therapy without finding any lowering of all cause death with the device. A nonpacing ICD prevents sudden death from arrhythmia, particularly in patients with coronary disease heart failure. The evidence for efficacy of an ICD in nonischemic heart failure is not very robust. DANISH enrolled patients of systolic nonischemic heart failure and an elevated N-terminal probrain natriuretic peptide (NT-proBNP); half received an ICD while the other half were assigned to contemporary heart failure therapy.More than 90% of patients in both groups received beta-blockers, ACE inhibitors or angiotensin receptor blockers (ARBs) and 60% of patients in both groups took mineralocorticoid inhibitors. Almost 58% of patients had a CRT (cardiac resynchronization therapy) pacemaker in them. In fact CRT were implanted in 93% of patients who had left bundle branch block and QRS >150 ms. The median follow up was 67 months.
Continue reading “ICDs MAY NOT WORK FOR PRIMARY PREVENTION IN NON-ISCHEMIC HEART FAILURE”
The New York Times has made the astounding revelation that not a single athlete or visitor got infected by the Zika virus in the recently concluded Rio Olympics. The Times quotes health specialists from the WHO, who of course do not provide any reliable piece of evidence as to how they came to the conclusion that no one has the Zika virus incubating inside him or her without the benefit of serological or PCR molecular tests. For al we know dozens or even hundreds must have got infected keeping in mind that almost 80% of people infected by the Zika virus do not show any symptoms but are quite capable of transmitting the disease.
Continue reading “CHIKUNGUNYA SHOULD NOT BE UNDERESTIMATED.”
Beta-blockers are the foundation of drug treatment for patients of angina. The COURAGE trial convincingly confirmed the fact that medical therapy was equivalent to percutaneous coronary intervention (PCI) in patients with stable angina. The rates of death and myocardial infarction did not differ in both groups; this was a randomized study. Medical therapy almost always consisted of a beta-blocker with addition of a calcium blocker and nitrates. Beta-blockers are successful in treatment of stable angina by their ability of reducing myocardial oxygen consumption.
Recently an elegant research paper (JACC 2016;68(7)727-38) has reported clinical outcomes and cardiac magnetic resonance imaging (CMR) in patients with and without diabetes randomized randomized to intracoronary (IC) or intravenous bolus injection of abciximab at the time of primary percutaneous coronary intervention (PPCI). Continue reading “INTRACORONARY ABCIXIMAB BOLUS IN DIABETIC PATIENTS WITH ST-ELEVATION MYOCARDIAL INFARCTION.”
Great emphasis has been laid upon the SYNTAX Score (SS) for stratifying patients for coronary intervention. All cardiology societies unanimously agree that an SS of >22 merits coronary bypass surgery (CABG) as opposed to percutaneous coronary intervention (PCI) with a drug eluting stent (DES). This conclusion has been drawn from the SYNTAX Trial published in 2009. This was the largest randomized trial conducted that compared CABG to PCI in patients of coronary artery disease. About two thirds patients had stable angina while the remaining suffered from unstable angina. It was necessary that there was 50% diameter stenosis of a concerned artery and the smallest vessel taken into account was at least 1.5 mm in diameter.
A recent report in JACC (2016;68:450) provides the stunning realisation that of more than 67,000 patients admitted with heart failure in the USA, less than half a percent of patients underwent stress echocardiography to pick up coronary artery disease (CAD) as the underlying cause despite the fact that 50% to 60% of heart failure patients have CAD as the underlying triggering factor. Astoundingly more than 80% of patients did not undergo any form of testing for ischemic heart disease. Continue reading “GROSS UNDER-UTILISATION OF TESTS TO DETECT ISCHEMIC HEART DISEASE IN HEART FAILURE PATIENTS.”
It is well known that diabetes is associated with cognition impairment (CI). Recent studies have recorded a link between diabetes and mild cognitive impairment in parsons of earlier onset and greater severity of diabetes. There is evidence that lack of glycemic control resulting in hypo- or hyperglycemia leads to CI in patients with diabetes. Cognition impairment can present as changes in memory, mood swings, perception, reaction times and concentration. While the association between CI (and dementia) and diabetes is clear, researchers do not fully understand the mechanism of how diabetes triggers dementia.
Continue reading “THE FIRST WORLD LEADER FROM THE WEST TO HAVE TYPE 1.5 DIABETES.”
Fibromuscular dysplasia (FMD) is a non-inflammatory disease that manifests as stenosis, dissection, aneurysm, beading or tortuosity. The disease affects mainly women between 30 and 60 years but can affect both sexes and all ages. A rough estimate of prevalence has been estimated from kidneys donated for renal transplant. It was first described in 1938 in a 5- year old boy with hypertension due to unilateral renal artery involvement. It took another 30 years to realize that arteries other than renal could also be involved. In 1964, coeliac, superior mesenteric, splenic and external iliac arteries were found to be involved with FMD.
Continue reading “FIBROMUSCULAR DYSPLASIA AND CORONARY ARTERY DISSECTION”
Transcatheter aortic valve replacement (TAVR), performed for the first time in 2002, is now considered a suitable alternative to surgical valve replacement (SAVR) in high-risk patients with severe symptomatic aortic stenosis. The PARTNER trial was the first to directly compare TAVR to SAVR head to head in high surgical risk patients; at 1 year TAVR performed with balloon expandable Edwards-Sapien valve was non- inferior to SAVR (24% vs. 27%). This was maintained at 5 years follow up (68% vs. 62%).
There are currently millions of patients with diabetes in India, which is rapidly becoming the world’s capital for diabetes largely due to the horrendous life styles adopted by the general population. India is home to more than 60 million diabetics (95% are people with Type 2 diabetes).There will be more than a 100 million by the year 2030. Almost 2.1% of the Indian GDP is spent in treating diabetes and its complications, including myocardial infarction, heart failure, stroke, blindness, kidney failure and amputation. The average Indian loves his or her food and the only exercise done is sitting up watching a game of cricket on TV.
Continue reading “THE “NEW ERA” IN THE TREATMENT OF TYPE 2 DIABETES, WITH INJECTION LIRAGLUTIDE.”
Thoracic aortic aneurysm (TAA) is associated with the extreme complication of acute aortic dissection (AOD). People with genetically associated TAA are at greater risk of AOD due to structural alterations in their aorta. Marfan Syndrome (MFS), bicuspid aortic valve (BAV), Ehlers-Danlos syndrome, Loeys-Dietz syndrome, Turner syndrome, and familial TAA are the usual causes of genetic TAA, and of these MFS and BAV are the commonest.
Continue reading “PREDICTING ACUTE AORTIC DISSECTION IN GENETIC AORTOPATHY.”
The latest issue of JACC (2016;67:2593-603) reports a randomized study that assesses the efficacy and safety of high dose vitamin D (D) in patients with chronic systolic heart failure (HF) accompanied with deficiency in vitamin D. 229 patients of HF and low D (< 20 ng/ml) were provided 100 mcg or 4000 units of 25(OH) vitamin D3 (cholecalciferol) supplementation. The primary endpoint was 6 minute walking distance and secondary endpoints were change in left ventricle ejection fraction (LVEF) at one year. Safety measures of renal function and serum calcium concentration were measured every 3 months.
Continue reading “VITAMIN D 3 CAN INCREASE LEFT VENTRICLE EJECTION FRACTION BY 8%.”
The hallmark of drug eluting stents (DES) is the reduction of restenosis, which is achieved by anti-proliferative drugs that elute from a polymer covering the struts of the DES (neo-intimal hyperplasia being significantly reduced). But first generations DES were associated with increased risk of stent thrombosis (ST) as compared to bare-metal stents (BMS), because of strut size and the inflammation/hypersensitivity triggered by the polymer. Late ST sparked off interest in development of DES with biodegradable polymers (BP) to improve safety profile. A pooled analysis of the ISAR-TEST 3, ISAR-TEST 4 and LEADERS trials found that BP-DES were associated with significantly reduced ST and clinically driven target lesion revascularization (TLR) at the end of 4 years (Eur Heart J 2012; 33:1214-22).
Continue reading “BIODEGRADABLE POLYMER DRUG ELUTING STENTS.”
A recent paper addressing etiology of sudden death in sports has been published by JACC (2016;67:2018-15) against the background that accurate knowledge of sudden cardiac death (SCD) in athletes and its precipitating factors is necessary to establish preventive strategies. Data is provided from a United Kingdom regional registry. The study investigated causes of SCD and their association with intense physical activity in a large cohort of athletes. The study includes 357 consecutive cases (mean age 29 years, males 92%, Caucasian 76%, competitive 69%), who underwent detailed post-mortem evaluation, including histological analysis by an expert cardiac pathologist.
The derision and hostility of the audience was palpable, when in a recent cardiology conference in Delhi, I stated that substantial data published in the leading medical journals of the world not only exaggerated drug effects but could also be considered misleading. There was stunned silence when I mentioned the New England Journal of Medicine (NEJM) as one of the leading culprits publishing manipulated data because the NEJM is considered by most as the holy grail of medical journals.
Continue reading “THE BUSINESS OF INDUSTRY-SPONSORED PUBLICATION IN MEDICAL JOURNALS”
The Takotsubo syndrome (TTS) is an acute heart failure syndrome that largely affects post-menopausal women. It was (first) described by the Japanese in 1990; the disease is defined by transient systolic and diastolic left ventricle dysfunction accompanied by a range of wall motion abnormalities. It predominantly affects elderly women and is usually preceded an emotional or physical trigger. It is accompanied by substantially increased morbidity and mortality that equal those of acute coronary syndrome (ACS). The clinical presentation in the acute phase consisting of electrocardiographic findings and biomarker profiles are not dissimilar from ACS. In fact 1% to 2% of suspect6ed patients of ACS are actually suffering from TTS. Both TTS and ACS have many common clinical features at admission.