About the Author

Dr. Edgar H. Tan finished his Bachelor of Science (major in Biology) degree in Silliman University where he graduated with honors (cum laude) in 1982. He earned his medical degree at Cebu Doctors' College of Medicine. He was a consistent honor student, received a Faculty Silver Medal Award and graduated with honors (cum laude) in 1986. He did his Post Graduate Internship at the Philippine General Hospital from 1986-1987. He passed his Philippine Medical Licensure Exam rank #15 in August of 1987. He decided to pursue further studies in the United States and did his Internal Medicine Residency Training at Lincoln Medical and Mental Health Center in New York, a program affiliated with the New York Medical College in Westchester, New York from 1989-1992. He served as the Administrative Chief Medical Resident (ACMR) in the same program from 1992-1993 and received an award recognizing his excellent performance as ACMR by the graduating residents of that year. He subsequently pursued his Three-year Fellowship Training in Clinical and Invasive Cardiology at Metropolitan Hospital and Westchester County Medical Center Consortium, affiliated with New York Medical College Program from 1993-1996. He practiced in the State of South Carolina after his training in New York with privileges in Marlboro Park Hospital in Bennettsville SC and McLeod Regional Hospital in Florence SC from 1996-1997. He holds an active medical license in the State of Carolina since 1996 until present. He came home to start his own medical practice in Cebu in February of 1998 at Cebu Doctors' University Hospital. His US training, expertise and active medical licensure in the State of South Carolina remain handy not only to the locals but also to the American retirees knowing that the expertise of an American-trained and licensed physician is available right in the heart of Cebu City. Dr. Tan is board certified by the American Board of Internal Medicine and American Board of Cardiovascular Disease. He is also trained and certified in the field of Nuclear Cardiology. He is Board Certified by the Philippine College of Physicians as well. As a Fellow of the American College of Physicians and American College of Cardiology, he regularly travels abroad for his continuing medical education in the field of cardiology. His practice includes General Internal Medicine, Clinical as well as Interventional Cardiology i.e. diagnostic coronary angiography, percutaneous coronary intervention (stenting/angioplasty), permanent pacemaker implantation (single chamber & dual chamber pacers) etc. etc. He is affiliated with Cebu Doctors' University Hospital /Cebu Cardiovascular Center where he was the former Section Head of the Cardiac Catheterization Laboratory & currently appointed as the Section Head of the Department of Cardiology. Dr. Tan received recognition and was awarded the Presidential Medal Award given at Cebu Doctors' University Hospital on Sept. 2, 2020 for his contribution using a radical approach in the treatment of a critically ill Covid-19 infected patient with the combined use of Therapeutic Plasma Exchange and Convalescent Plasma Therapy which was first in the Philippines. His office is located at Cebu Doctors' University Hospital Medical Arts Building 1, Suite 303-A, Osmeña Blvd. Cebu City Philippines. His office hours are 9am-12pm Mon-Sat. Tel: 032-511-2857 Mobile/Viber: 0918-457-4762 . Calling for an appointment is a must. Walk-ins are no longer acceptable especially with the current covid pandemic.

Email: mailto://EdgarTan62@yahoo.com/ (Primary) or mailto://EdgarTanMD@gmail.com/ (Secondary)

Covid Breakthrough Infection....a Big Misnomer!

 The reason covid is still raging hard around the world is because of high prevalence of unprotected people mainly for two reasons. Inequitable distribution of vaccines and the predominance of antivaxers. Vaccine non-believers  continue to deny the value of not only personal protection but also against the benefits of covid immunization. For whatever reason it maybe one thing that fuels more of their skepticism is perfectly our own fault of which I shall explain.  

We've pretty much heard of the word "breakthrough infection" after covid vaccination including those that received their booster shot. This is the wrong word to use in light of the fact that immunization did not and was never intended to prevent infection 100% of the time. The idea dates back to our experience with the common flu virus. We give flu shots yearly despite the fact that  we know it cannot be prevented symptomatic infection 100% of the time, however should an immunized person gets the flu, it is easier and manageable. That has always been the idea of immunization. Fast forward covid vaccine, for some reason somehow the standards changed with the idea that immunization is thought of as a 100% shield against symptomatic infection...a big MISTAKE! This dates back from the time how mRNA vaccine makers define vaccine efficacy. Their phase-3 trials have shown that at least 95% of the time symptomatic infection is prevented and since then the bar on vaccine efficacy has become so high that it is virtually impossible to replicate it in the real world. The word breakthrough implies failure and therefore should be discouraged. This definition merely fuels the  antivaxers into believing that despite immunization people are still getting sick so why should we get immunized?

We know from real world experience that with our current surge the mortality from  Omicron variant were almost always coming from the unvaccinated while those who got immunized and boosted death was prevented 95% of the time. Isn't this a big enough proof of vaccine efficacy? Experts are now starting to believe that the bug is slowly behaving like an ordinary flu for  the vaccinated and boosted. 

The world can only heal as one and for as long as there is an no equitable distribution of vaccines normalcy will be difficult to achieve.  For now the  question we should ask ourselves as healthcare providers is to avoid using the word  breakthrough infection as I have already alluded to earlier. It is time to get our act together and get over with our alarmist view and look at all these based on reason rather than emotion.

Covid-19 " Cytokine Storm " a Misnomer?

When Covid-19 came into this world, we soon realized that the havoc wreaked by such a novel virus is due to the accumulation of inflammatory cytokines of which medical experts describe as " Cytokine Storm". This remains to be the prevailing theory up to this time and our local experience echos what has been observed.   The presence of a persistent and unrelenting rise in measurable inflammatory cytokines among Covid-19 infected patients that is responsible for determining the overall clinical outcome. 

After having seen quite a few Covid-19 infected patients, my view has changed. I look at “cytokine storm” as a misnomer because it seems to imply a sudden unpredictable surge in inflammatory levels. I prefer to describe Covid-19 infection as  "an inflammatory condition associated with a progressive cytokine build-up".  Our body compensates very well early on as these cytokines start building up but,  it comes to a point when the body’s compensatory mechanisms start to fail and clinically failure comes in two phases:

1st Phase is Respiratory:  As the name implies, this is characterized by a progressive increase in patients' need for oxygenation along with lung infiltrates on the CXR that could progress and lead to intubation on some select patients.  One important observation is that these infiltrates are often inversely proportional  to the degree of hypoxemia suggesting that there is more to it that what meets the eye when you look at the chest X-ray. Simply put, the degree of hypoxemia more often than not is disproportionately worst when compared to the degree and extent of pulmonary infiltrates seen on the chest X-ray.

2nd Phase is Autonomic Collapse:  This is usually a terminal event associated with hyperinflammatory cytokines with the patient having intractable hypotension with multiorgan failure & eventual death. This is a very common terminal event that we see & call as cytokine storm.

 

In the most recent randomized clinical trial from Harvard, by John H. Stone et. al. published in the NEJM Oct. 21, 2020 "Efficacy of Tocilizumab in Patients Hospitalized with Covid-19." (https://www.nejm.org/doi/full/10.1056/NEJMoa2028836) on patients with severe respiratory distress syndrome, the use of Tocilizumab did not seem to confer any benefit in terms of preventing intubation. Furthermore patients randomized on that study had a very wide range of baseline inflammatory levels suggesting that patients have different thresholds with regard to when they show signs of clinical decompensation. This observation suggests that if we try to seek the answer and predict decompensation by looking at levels of inflammatory cytokines, we  might not find one. It reenforces my belief that the presence of known comorbidities like obesity, diabetes, heart disease (CAD and CHF), COPD play  a greater role in determining the overall clinical course and outcome of Covid-19 infected patients. These highly variable inflammatory cytokine levels at baseline on recruited patients is in keeping with my proposition that best describes Covid-19 infection as a condition characterized by  “progressive cytokine build-up” alongside clinical deterioration determined largely by the presence or absence of comorbidities as mentioned earlier.

Unmasking AF and its Evil Twin: STROKE

Atrial Fibrillation (AF) is a rhythm associated with increasing prevalence alongside aging. It is often quoted in our literature that the prevalence of AF is about 2-5% as you hit age 60yrs old and above. This is the most common stable arrhythmia we cardiologists and medical practitioners see in our practice. AF is very well tolerated and patients can do their usual chores but, unknown to many, the ugly side of AF is the risk for stroke. Stroke is  very unforgiving and can be potentially life changing with disabilities of various severity. 

Facts about the strong association of AF and aging are well established, yet despite all these, not much  is done  to unmask AF and prevent stroke. Our college is silent just as our guidelines are muted on how we could preempt this ugly side of this arrhythmia. It is often quoted that as much as 30% of all strokes are secondary to cardiac arrhythmia called Atrial Fibrillation. At present, we as medical practitioners simply play the waiting game and wait for the next stroke patient. We scratch our head once we are presented with a patient coming into the  ER and only then will a series of tests ordered to find the cause. One of the tests usually done is called holter monitoring. Holter monitor is a gadget that records your heart's electrical activity continuously for a fixed duration of time ranging from 24hrs to 72hrs or even up to a week depending on the gadget you use. The question that begs to be answered is why not use it to screen our at risk patients and help unmask AF rather than do it only after the fact when damage has already been done?

I challenged and asked myself how and my conscience answered....why not?  It is precisely for this reason I routinely do "stroke screening" sans guidelines recommendation. Since it is a largely benign and  noninvasive test,  I  routinely advise patients at risk most importantly those with  a known family history of stroke to get screened NOW! and not wait another day as history will repeat itself if we continue to ignore. I have also come to realize that patients who denies having any family history of stroke  may not necessarily mean "NONE at ALL" but, may simply be that they just don't know or not aware. The best recourse therefore is to deploy such a readily available and noninvasive tool to all patients whom I think are at risk and wants to be screened.

As I have been doing this, I came to realize that I may have inadvertently opened a can of worms when I started to frequently encounter short bursts of Supraventricular Tachycardia or abnormal heart beats for which there are no clear guidelines regarding management at the present time. My instinct however, tells me to intervene and take it seriously despite paucity of information to support such action. Interestingly, in  the last Asia Pacific Congress of Cardiology in May of 2019, I attended, the talk by Professor John Camm, MD from UK entitled "Changing Lanes: AF Risk Assessment". He presented a new concept called Micro-AF,  from the study of Dr. Fredrikkson et. al. July 2018 Am. J. Cardiology as a risk for AF. Patients with Micro-AF (4 supraventricular beats up to less than 30secs. ) followed up for 2 years had a 50% risk of getting full blown AF on that study. Our current guideline defines AF when irregular supraventricular beats  last up to 30 seconds duration and unknown to many that this is simply based on consensus. Consensus recommendations are devoid of evidence as they are based on how the experts in the field want us to believe and follow. Furthermore, in the STROKESTOP Study published in the Circulation, June 2015 showed that Micro-AF was associated with stroke 1.5% of the time. It became obvious to me that the frequently encountered arrhythmias currently ignored by many are actually a double-edged sword....that it is not only a risk for developing AF but, may actually be associated with stroke as well. I felt relieved, vindicated and happy when all these came to fore for obvious reasons. If all these gets the validation from large randomized clinical trials in the future, then my patients are not only getting the lucky break ahead of the pack but, most importantly  some of my patients may have actually dodged the ugly twin called STROKE.

I do this because I strongly believe that almost all, if not all catastrophic events start small when the early warning signs are either missed or simply ignored.  That these little short bursts of abnormal beats could be a harbinger of something big that would eventually lead to catastrophic events if taken for granted. I always ask myself if I  should  just sit and wait for stroke to happen? or should I proactively look out for them with the hope of preventing the dreaded stroke from happening in the first place?  Whenever I see these rhythm abnormalities, I discuss with the patients my sentiment, what we know at this time and plan of action.  In most cases they do trust me and go along and accede with my preconceived plan and that is to  intervene. Most of the time, the seemingly asymptomatic patients are treated  and much to my surprise, many would come back feeling better for which I have a simple and logical explanation. These rhythm abnormalities are chronic and longstanding where patients eventually adapt or get used to  and eventually consider it as part of normal. When the arrhythmias are fixed and they start feeling good, they start to  recognize the difference and more often than not, they voice it out to me on their next office visit. This is obviously a subjective feel and considered anecdotal at best since only the patient can feel it. I took all these with a grain of salt initially and relegated it as maybe due to chance, however, as soon  as many more patients would come back echoing the same, I started to pause, look back and took it seriously as real. This is a very interesting finding if true as this is an area that is largely unexplored in the field of cardiology. Subjective feelings generally don't hold much ground  in medicine to defend and used as proof of concept but,  I will take this positivity anytime despite the absence of support from randomized clinical trials.

While 24-hr Holter monitoring is the norm, I routinely recommend doing 72-hr Holter instead on patients I consider at risk for AF as it has been shown to be far superior in detecting silent AF vs 24hrs Holter recording on the study by Martin Grond et. al. published in Stroke, 2013. In this study, 24-hr Holter monitoring missed up to 70% of arrhythmias vs 72-hrs recording.

I believe and abide by our hippocratic oath, that is "Do no Harm", and  this will always be my guiding principle as a physician in my day to day practice.

The Art of Medical Practice: What is the Ideal BP?

Medical practice has evolved into a science that has become too guideline-centric. New graduates and practitioners alike are now so focused with guidelines-driven medical practice that they have now forgotten the very fundamental ethics in medicine and that's not only to " Do No Harm " but also must include us to think in a more rationale way on how to treat our individual patients.  HMO's find guidelines very handy as their bible to decide on which modality of treatment to cover or not and this is where the flaw and cracks start to irritate in me as a medical practitioner.

Blood pressure management has been a focus of endless debates and revisions over what is ideal and what is not. Too many guidelines that has confused not only the medical community but patients alike. We know for a fact as doctors of medicine of one fundamental truth....that is  " normal blood pressure has been conclusively shown to be associated with lower major cardiovascular events i.e. congestive heart failure, heart attacks and strokes " yet, our guidelines have always focused on cut-offs as if all patients are created equal. Authorities as what they call themselves must realized that we are not into the McDonalds business where french fries tastes the same regardless of which outlet you get it from. Our patients are not the same and will never be and that's where the fundamental flaw comes into play. 

The latest JNC-8 published in December 2013 on BP management boldly raised the threshold and recommended therapy on over 60 years old if their BP goes >150/90mmHg and >140/90 mmHg for those younger than 60 yrs old. This was done despite the lack of evidence supporting their recommendation while virtually ignoring the very basic evidence we have that targeting  less than 140mmHg have been shown to save lives.

I have always believed that each patient is unique and must be dealt with and approached individually rather than just another warm body that is either 60yrs old or less.  My guiding principle has always been to individualize therapy rather than just blindly following what guidelines want us to do. We know our patients more than anybody else and I believe that a targeted BP of 120-130mmHg or lower (as long as tolerated) remains to be the optimum target REGARDLESS OF AGE. It has worked for many in the past with studies to back it up so why should we just change because of some JNC-8 authors believe otherwise?

In the latest publication from a NIH-sponsored study  SPRINT (Systolic Blood Pressure Intervention Trial) on 9,200 patients published Sept. 11, 2015 conclusively showed a significant reduction by almost a third in the incidence of myocardial infarction, congestive heart failure and stroke for those randomized to a target BP of 120mmHg vs the recommended 140mmHg. This same group also benefited by having a reduced incidence of overall death by almost a quarter.

With these most recent findings I feel vindicated on what I have always  been doing and believed in......to keep BP goal as low as possibly tolerated regardless of age. This is in keeping with the hippocratic oath we all vowed as medical practitioners to do no harm and with good intentions do whatever we think  is best for the patient regardless of guidelines. 

It is not the intention of this article to bash on guidelines because it is for the most part evidence-based and our way of measuring what good clinical practice is all about. It is my belief however, that physicians  must not feel hostage to it and it is hoped that we physicians exercise open-mindedness and independence even if it means thinking outside the box  to do what is best for our patient because after all, the practice of medicine is an art and not a perfect science.

The Healing Power of LOVE!

Scientific data and evidence supports the fact that  love  reduces stress, depression and anxiety, three major risk factors for heart disease.

Current data indicates that 30-35%  (about 1/3) of total mortality across the world are due to heart disease and stroke, six times more than infectious-related deaths.  This wealth of information makes it imperative  for doctors in stressing the importance of  not only adopting a healthy lifestyle but also making emphasis on  the positive impact that love can in order to stay healthy.

In one five-year study, 10,000 men at high risk of developing chest pains showed that men whose wives show them love have a lesser incidence of chest pains.  Another study of 1,400 men and women with coronary artery disease echoes the same positive impact of love and heart disease. After five years, 15% of those who were married or had a confidant were dead compared with 50% of those who were unmarried and had no confidant.

It is now generally believed  that love is indeed a powerful force to bring healing and if  given freely will heal not only the heart  but also heal the body. Spread love and  help heal the world one heart at a time.

Stem Cell Therapy: Fact? or Fiction?

Stem cells are the pluripotent cells responsible for healing and regeneration of the vaious organs that have been damaged like liver, skin and many more. It is present in the varous organs of our body and  has always been a subject of intense interest in the medical world for obvious reasons. While science can easily explain why cells or organs regenerate, it is very difficult to coax stem cells to become what we " scientists " want them to be. Just like anything else, it is easier said than done and it holds true for Stem cells as well.

The only medically approved and scientifically proven form of stem cell therapy to date is " Bone Marrow Transplantation " for patients suffering from various blood ailments like leukemia. Other than that, everything else that man wants the lay people to believe it can do is considered experimental and therefore of unproven benefit. These victims fall prey from friends giving them anecdotal claims of benefits from stem cell recipients. Have they not heard of  the word " Placebo effect? ", an effect where as much as 20-30% of patients may feel better even if they are not given real medicine?

We see a lot of patients fall for these unscrupulous medical practitioners promising rejuvenation as if they have finally solved the puzzle and the key to the fountain of youth. Typical patients include those that are elderly with a lot of money to splurge in the hope that they only lose money should it not work. These victims are victims of medical fraud much like " chelation for heart ailments " years back.....these would include the seemingly hopeless patients where medicine has reached the dead end and has nothing more to offer in terms of cure. 

To all patients considering stem cell therapy, I advise caution as this form of therapy is not scientifically proven and medical providers can't claim of any therapeutic benefit backed by randomized clinical trials at this time.  Until proven otherwise, I can only see " economics " as the main driving force for it's rapid growth in this country. This is not only unproven but also can be "potentially" harmful. 

To all medical professionals engaged in this form of therapy, I say to them, with the sincerest hope that they will remember our basic oath......our very own Hippocratic Oath we all subscribed to when we were sworn in as  Doctors of Medicine........that is...." To Do NO Harm ".