Mitral Valve Prolapse: No longer indicated for Endocarditis Prophylaxis

A recent update from the Amecian Heart Association convention is the exclusion of MVP (Mitral Valve Prolapse) with or without Mitral Regurgitation as an indication for Subacute Bacterial Endocarditis prophylaxis. Preventing disease based on lifetime risk is no longer a justified mode of approach to these subset of patients. Prophylaxis in preventing valvular infection is reserved to the higher risk groups of patients e.g. prosthetic valves etc. etc.

Homocysteine and CAD: Are Folates Protective?

Homocysteine levels have been associated with coronary artery disease (CAD) however, after the Western Norway B-Vitamin Intervention Trial (WENBIT) failed to find protective effects of vitamin B supplementation especially with Folates and Vitamin B6, known to reduce homocysteine......the relationship remained just as it is "An Association", with no causal relationship between CAD and Homocysteine.

The Study included 3090 patients with established CAD randomized into vitamin B6 alone, Folic + Vitamin B12, Folic + Vit. B6 and B12 followed for 38months. Inspite of the lowering of folate by 28% in the folate group and unchanged in the non-folate group, there were no observed protective benefits in terms of reducing cardiac hard end points (MI, ACS and cardiac death)

This trial confirms the findings of similar trials in the past and may just be the last nail on the coffin regarding vitamin B supplementation as a secondary prevention for cardiac heart events.

It's SIESTA TIME!

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A recent study in Greece published in the Annals of Internal Medicine showed that siesta is good for the heart. They studied 23,681 apparently normal and healthy population and their behaviors regarding siesta time.

They were followed up for 6.3yrs and after controlling for cofounders, they found that those who regularly take a 30minute siesta at least 3x/week had a 37% lower mortality rate compared to those that did not. Those irregularly taking siesta defined as those taking less than 3x/week had a 12% risk reduction only. There is an inverse relationship between siesta time and major adverse cadiovascular effects. This maybe explained by the lowered sympathetic response during the rest period..

This data seems to suggest that lifestyle modification should not only include dietary modification, BP control, lipid control and regular exercise but also a regular dose of rest as well. Naps make us feel reenergized and obviously with this study there is more to it and that siesta is at least safe.

Cardiac Application of 64-Slice CT

Ever since CDUH (Cebu Doctors' University Hospital) got it's first GE 64-slice CT, a lot of queries arose about the usefulness of this machine in the evaluation of coronary artery disease. Indeed it is revolutionary in the sense that we can now have a noninvasive tool to evaluate out patient acutely with less time delay once they get admitted with chest pains from the ER. Here are some of the facts:

1. It is a good screening tool for coronary artery disease (CAD) by detecting coronary calcium score. Calcium scoring is used as a surrogate marker for CAD. It is good but just like anything else in life we live with statistical data and probabilities hence, it is never to be considered fool proof.

2. Multislice CT angiography, is a diagnostic tool for the evaluation of the vasculature including the coronary ciculation, pulmonary, renal, peripheral vasculature and many more. I reserve this test to patients who are adverse to doing the invasive coronary angiography.

3. This test is not for all, there are limitations to each and every test including, the presence or absence of renal insufficiency, cardiac arrhythmias, degree of coronary calcification and the like. The best way is to consult your own physician regarding the appropriateness of such test in your case.

4. Patients with documented or a highly probable CAD (prior MI, strongly positive stresstest) need not take this test. It is preferable to go ahead and proceed with the invasive angiography because this is not only a diagnostic but also an avenue for therapeutic intervention (Angioplasty). CT angiogram is purely a diagnostic test only.

5. MSCT is a good and excellent diagnostic tool we have for the evaluation of acute chest pains in the ER because CT personnel in the hospital are almost always ready 24/7.

Avandia & Heart Attack?? FEAR NOT!

A recent twist of fate has led many to panic about the implied increase risk of heart disease and the use of a drug called Rosiglitazone (AVANDIA) from a recently published meta analysis of diabetes trials using Avandia. .

First, we should learn how to classify the already known fact that this drug should be used with caution in patients with heart failure because it is known to cause sodium retention and therefore may aggravate the condition. This may happen to some but not to all patients hence, it remains to be a relative contraindication and not an absolute one. The US FDA has required the relabelling of this class of drugs and should not be confused with the current controversy hounding avandia.

First of all the study conclusion was based on a pooled analysis of data from 42 trials not designed to look for cardiac death, hence this was a conclusion based on a flawed design. We also have to understand that we are dealing with a population of patients at risk for heart attack whether on therapy or not. We sometimes call Diabetes as a "Cardiovascular disease masquerading as an endocrine disorder" because of its propensity to develop heart disease. Nevertheless, let's go to the controversial data and give it the benefit of the doubt.

Their data suggests that the relative risk of having a heart attack while taking rosiglitazone is 86/14,371 or 0.0059% and all CVD (Cardiovascular Death) is 39/14,371 or 0.0027% while the risk of heart attack on diabetics not taking rosiglitazone is 72/11,634 or 0.0061% and the risk of death from all CVD causes is 22/11,634 or 0.0018%. The risk is nearly identical to the risk of having a heart attack in treated diabetics not on Rosiglitazone (0.0059% vs 0.0061%) hence, there is hardly anything to sneeze at. .

Furthermore, in a bit of a rush to quell these negative information on avandia an interim analysis of an ongoing trial RECORD (Rosiglitazone Evaluated for Cardiac Outcomes and Regulation of glycemia in Diabetes) was published in June 6, 2007 in the NEJM (New England Journal of Medicine) after a 3.5yr follow up showed no association between the risk of cardiovascular mortality and avandia. The full study is slated to be completed and full data available in late 2008. In the meantime, I would not rush into stopping this drug as of this time. The news on Avandia (Rosiglitazone) made headlines that prompted me to look into this matter because a lot of my diabetics have concerns that begs to be answered!

The Mindset of Being a Doctor: Is he your Friend?

On being a doctor! It’s difficult and it’s tough! Damn if you do, damn if you don’t!!

How often have you heard of patients complaining of the massive cost and expenses going out of hand? How often have we heard of patients with terminal illness being bombarded with interventions to prolong a life? How often have we heard of patients saying, had they known what would happen they would have chosen a different path? These are patients advising us to do everything possible and only later to blame us for the massive costs after all is said and done?

These are just few of the sad realities of medical practice we face everyday and the doctors’ are not the only one to blame. Our society becoming highly litigious and the emergence of super specialization in medicine are partly to blame. Doctors tend to be defensive and call on other specialties to protect themselves. When the various medical personalities are on board, both cost and the primary physicians’ control of the situation gets out of hand. It is a common site to see a patients’ chart literally covered by the different doctors helping in the case. It is an offshoot of relatives saying “go ahead and do everything” but it pains my heart to see the less endowed ending up broke when all is said and done.

We tend to blame doctors for whatever wrong happens. We tend to forget that doctors’ are just humans. We try our best to make the most of it but sometimes we just fall short. As we always say, we win some, we lose some.

Physicians are “mostly” driven by the desire to serve and make a difference on peoples’ lives. It is unfortunate how the profession has deteriorated of late. The animosity increasing and the distrust becoming more and more evident in our day to day practice. I believe that doctors’ must evaluate themselves, maintain a good line of communication and be transparent.

As a physician, I am very conscious of the economic burden of a given situation and I believe that doctors’ have the best perspective on a given patient. We should look at our patients as a whole rather than the sum of each part. We may not be perfect but at least we try to be objective and lay out the whole nine yards for our patients to understand. If we don’t do that who will? It is always good to have an informed patient so that the key factor called “ TRUST” remains solid. Life is precious, we should not take it for granted. As doctors we are taught to do no harm, and focus not only on what we can do to make a living but most importantly on what we can do to make a difference and make living worthwhile.

How to Minimize Cardiac Risks if you are a DIABETIC!

1. Lifestyle modification including reduction of fat intake to <30% of total daily intake and regular aerobic exercise of about 20min 3x/week especially for those more than 40yo with a family hstory of heart disease.

2. Maintain a BP of <130/80 mm Hg.

3. LDL cholesterol (considered the bad cholesterol) should be <100mg/dl and those with established heart disease the goal is even lower at 50-70mg/dl.

4. HgA1c (Hemoglobin A1c) should be <7%. This is measure of good glycemic control.

5. Just as the chinese saying goes, "a good doctor treats the disease, while a superior doctor prevents the the disease". This emphasizes to us the importance of prevention in whatever we do in life. The choice is yours!

What you need to know before undergoing Angioplasty/Stenting!

1. There is no outcome benefit in SINGLE VESSEL DISEASE (SVD) and CHRONIC STABLE ANGINA whether treated with optimal medical therapy or angioplasty & stenting!

2. Control of angina after a failed medical therapy is the only indication for recommending in SVD and patients with chronic stable angina to date!

3. Intervention may be an option for those at high risk for CABG (Coronary Artery Bypass Grafting) like patients with COPD and those with serious comorbid problems making them high risk for CABG.

4. Do your homework, ask your doctor, and lastly ask around for the reputation of your physician. An informed patient can help facilitate the decision and minimize animosity between you and your health care giver.

5. Make sure to ask for the different options and the risks and benefits of each intervention for your particular case. Remember each patient is unique. You can't compare your case with that of your friend or neighbor's case.

Low Sodium Diet for Everyone?

Low-sodium diet may have been validated as a direct route to prevention of heart disease, according to recent studies in Boston. Current recommendations for salt reduction have relied primarily on clinical trial evidence on hypertension trials. The connection between a low-sodium diet and prevention of heart disease has been long suspected but never conclusively proven. Prehypertensive patients who reduced salt intake had a 25% to 30% less adverse cardiovascular events over the subsequent 10 to 15 years, reported Nancy R. Cook, Sc.D., of Brigham and Women's Hospital.

To conclusively answer such questions, the researchers followed 2,415 patients from two earlier salt-reduction studies. "Despite its relatively small size, it provides some of the strongest objective evidence to date that low sodium intake reduces the risk of future cardiovascular disease," the researchers concluded.

Currently, the American Heart Association recommends a daily salt intake below 2,300 mg for most people. This evidence suggests that low salt intake maybe beneficial to the majority of people whether hypertensive or not.

Chronic Stable Angina Update!! FROM THE JAZZ CAPITAL OF THE WORLD! ACC "07

The latest information from ACC in New Orleans March 24-27, 2007 contradicts our common practice wisdom that percutaneous intervention (PCI) + medical therapy is superior compared optimal medical terapy (OMT) alone in patients with chronic stable angina (CSA). CSA patients typically have a regular and predictable chest pains on exertion that resolves with rest.

The latest data we have on the COURAGE trial showed that the use of PCI + OMT did not afford any additional reduction in cardiovascular mortality as compared to OMT alone.

This information should not be construed as if PCI is absolutely not needed in CSA patient because this may still be employed if patients persist to have chest pains inspite of optimal medical therapy.

Furthermore this latest medical update should not be confused with the scientific proofs we have regarding the benefit of PCI in patients suffering an acute myocardial infarction or "heart attack". The benefit on intervention in acute myocardial infarction remains undisputed to date.

On Drug-Eluting Stents- What the FDA has to Say?

This is an update following a two-day US FDA expert panel meeting in December 7 & 8, 2006 regarding clotting risks with these devices. After a rigorous review of available data, it has been concluded that Drug-Eluting Stents are SAFE and EFFECTIVE for the indication for which the approval for its use was based. Simply put, the panel agreed that it is safe to to continue using DES as labelled. While the panelists agreed that there is a slight increased risk of stent thrombosis in DES, the overall risk of myocardial infarction and death is not more than that seen in bare-metal stents.

The ACC/AHA/SCAI recommendation is for 12 months of dual antiplatelet therapy (aspirin plus Plavix [clopidogrel]), which the panel said should be mentioned in the label information, but the panelists shied away from changing the label to require at least 12 months of Atherosclerosis is a progressive disease hence, my personal bias has always been to continue the use of dual antiplatelet therapy indefinitely and the current changing of the guideline extending the duration of antiplatelet regimen post DES implantation has somehow proven me right. It has been my practice long before this issue of stent thrombosis came into the spotlight because I believe that dual antiplatelet is our best defense against heart attack to date. . .

This is purely my personal opinion but I think it is just a matter of time before studies would prove its worth and becomes part of the collective recommendation from the college. While recommendations are available, it is eventually the physician and patient who will have to decide the appropriate duration of dual antiplatelet therapy given the patients unique situation and circumstance. The FDA can only recommend what is best considering the available data and does not in any way regulate physician practices. It is estimated that about 50-60% of DES implantation in the US are considered off-label use. Definitely more studies are needed to address these subgroup of patients for which there is paucity of information regarding safety and appropriate duration of antiplatelet therapy.