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 ".

Tips to Handle the Anxious Patient

As a cardiologist I get to see a lot of patients either referred or self referral complaining of palpitations & chest pains for which many will eventually turn out to be negative for heart disease. Many times I can sense and pick them up the moment they come and start talking with their typical facies, body language, and overall demeanor....call it "SIXTH SENSE" if you may! These are some of the common things most doctors must observe their patient.

1. Typically young & middle aged female and less often males and the older age group. They are unaware that it is their heightened anxiety that is triggering all the " weird " manifestations that some feel as if it is the end of the world.

2. They may or may not have been seen by other doctors who has done tons of work up  to them and all are negative. Since they have nothing else to give, they may prescribe medications like vitamin B complex or for some astute physicians may give them anxiolytic drugs.

3. I believe this has some genetic component because I still have to see an  anxious patient with no family history of anxiety disorder. It is either the father or mother or both with the same problem....believe me! Patients typically suffer unconsciously from " Don't Ask, Don't Tell " policy....so if you as the doctor won't ask for these information typically patients don't seem to find this history important.

4. These patients are the most skeptical of all, so in order to fix them you need to understand that reassurance won't cut it out unless you prove to them that you have concrete basis for doing so. In my practice, I would typically do some routine things like physical exam, an office ECG and to some extent I find it necessary to do noninvasive work up like Echocardiogram and Exercise treadmill stress test. These tests I find it necessary to convince them that there is nothing wrong with their heart otherwise your advise won't hold water at all. For the severest forms I find counseling and with the help of anxiolytics help a lot.

5. In order for you to be successful at treating them you must:  Talk, Sympathize, Understand and Intervene. A combination of all these are very effective in fixing the anxious patient. Their trust can only be heightened if you tell them how the anxious patient feel even before they start talking. More often than not they will start to realize that all the things you said are true and by this time your patient has gained your trust and are cured 80% of the time. 

I can safely say that if doctors have the right skill and approach......only a few will end up requiring the help and intervention of a psychiatrist. Successful treatment needs the combination of physician understanding, counseling with lots of reassurance and sometimes with the help of anxiolytic  medications.

Simple Tips on How to find the right doctor!

Inspite of the internet making life easier for the tech savvy to research their doctor before the visit, there is no way to replace the good old face to face interaction to see if you found the right one for you. Here are some of the tips on how to make the experience a little easier in this day and age!

1. RESEARCH: In this day where information is readily available on the internet, it would be best if you can research your own doctor as much as possible including the ailment that you think you have. This way you are armed with the information about your condition and shoot all the questions you have when you go to see your doctor. Evaluate your doctor by the way he/she answers your questions. Try to test and shoot questions that you already know what the answer is and let him/her explain. His explanation will be your best tool to evaluate your doctor. Remember that doctors are humans, we are educated to treat but just like anything else in life, we are not created equal, so do your homework.

2. KNOW YOUR RIGHTS: It is the patients' right to ask and be enlightened. Some doctors get defensive when questions are asked of them. Professionals and properly trained docs should not feel insecure and should properly answer all questions asked of them....it is the patient's right to ask and be educated.

3. SECOND OPINION MATTERS: A second opinion from another health care professional couldn't hurt especially in major health decisions. Some doctors feel bad when their patients seek another doctor for a second opinion to the point of reprimanding the patient and this to me is not only wrong but absolutely unacceptable.  Doctors are humans and therefore can sometimes make mistakes so he/she must not feel bad if their patients seek other opinions. It is not  the doctors' decision to make but yours and yours alone. You as the patient should demand the place that is rightfully yours.......that's the drivers' seat.

4. ASK AROUND: There are places where doctor's information maybe quite scarce. Try to be resourceful and ask around,  colleagues, close friends, a neighbor, or maybe from the hospital personnel where the doctor works and get their overall evaluation as to who would be the best for your condition. The information you get may not necessarily be right but, at least you can have a start off point to do further research!

5. YOU GET WHAT YOU PAY FOR:  Personally just like anything else in life, if I need to purchase an item and I have no clue what is the best? The price is generally a good guide, the more expensive the better it must be and  while this is true to most it is not a 100% guarantee that you will like what you get.  In medicine, this dictum  has it's own validity as well, " You get what you pay for". Remember that "Health is wealth", don't settle for anything less. I remember one patient telling me this same quote and I just burst into laughter nodding in agreement.

At the end of the day, after your visit you as a patient you and you alone can judge whether your doctor is the one that will be best for you.

Top 5 important information about Hypertension

I frequently meet patients being treated for Hypertension but inadequately informed or shall I say inadequately educated about their disease condition. This lack of important information can lead to a chain of problems like noncompliance to medications and therefore poor control of blood pressure. These are the top FIVE issues that are often overlooked by many physicians taking care of their hypertensive patients.

1. Hypertension must be understood as equal or above 140/90mmHg taken at rest. Elevated blood pressures taken during stressful situations i.e. emotional, mental or physical stress should not be qualified as these are stressors associated with a normal (physiologic) increase in BP. Normally BP returns to normal when the stress condition has been resolved.

2. Hypertension has a genetic predisposition in more than 90% of the time. In short, this is a genetic problem that we inherit from our parents and blood related relatives.

3. Since hypertension is an inherited disease, doctors can only prescribe medications to control and NOT CURE. It is in this light that your medicine therefore, needs to be taken for life in most cases. BP control is very important as it has been shown to reduce the risk of Congestive Heart Failure, Stroke and Heart Attack.

5. You must ask your doctor the most common side effect that is unique to the drug you are taking. Doctors often miss out on this information which I consider as vital. I have seen so many patients coming to see me for a simple side effect that would have prevented undue stress to them had they been forewarned. Example: Leg swelling is common for Calcium Channel Blockers, or electrolyte imbalance with diuretics and headache for ARB's (Angiotensive Receptor Blockers) not to mention cough that may affect roughly about 10% of patients taking ACE-Inhibitors.

If you have more questions about your condition feel free to ask your physician on your next visit to your doctors office.

Calcium Supplements can break your heart!!

Calcium supplements taken to reduce the risk of fractures from osteoporosis among elderly women has been found to be associated with a 30% risk of developing myocardial infarction (heart attack) according to a recent study published in the British Medical Journal published July 30, 2010.

This study result showed that the use of calcium supplementation amongst our elderly women to reduce the risk of fractures should therefore be reconsidered. Previous trials on the calcium supplementation through changes in diet does not increase the incidence of cardiovascular side effects seen in exogenous calcium supplementation suggesting that perhaps these adverse effects maybe limited only to orally taken calcium supplements.

This finding is in keeping with what we already know with most other studies on the benefits of supplements including antioxidants where no documentation of benefit were seen when these supplements taken orally in a tablet form.

A good and balanced diet remains superior to any attempts to supplement in the hope of boosting your health........so the next time you pop in your vitamins?.........think again and ask yourself.........is this really good for the body? or just for the mind?

As a physician I see these everyday and I always have reservations against supplements and my patients can attest to that.........this study just affirms and has been consistent with my beliefs!

Common misconceptions about EGGS!

Fact: Eggs are a good source of nutrients. One egg contains 6 grams of protein and some healthful unsaturated fats. Eggs are also a good source of choline, which has been linked with preserving memory, and lutein and zeaxanthin, which may protect against vision loss.

Fact: Eggs have a lot of cholesterol. The average large egg contains 212 milligrams of cholesterol. As foods go, that’s quite a bit, rivaled only by single servings of liver, shrimp, and duck meat.

Myth: All that cholesterol goes straight to your bloodstream and then into your arteries. Not so. For most people, only a small amount of the cholesterol in food passes into the blood. Saturated and trans fats have much bigger effects on blood cholesterol levels.

Myth: Eating eggs is bad for your heart. The only large study to look at the impact of egg consumption on heart disease—not on cholesterol levels or other intermediaries—found no connection between the two. In people with diabetes, though, egg-a-day eaters were a bit more likely to have developed heart disease than those who rarely ate eggs.

If you like eggs, eating one a day should be okay, especially if you cut back on saturated and trans fats. Other ways to enjoy eggs without worrying about cholesterol include not eating the yolk, which contains all the cholesterol, or using pourable egg whites or yolk-free egg substitutes.

A final word of caution however, is that if you have a strong family of heart disease the ill effects of eating high cholesterol foods like eggs may be detrimental to your health.

Eggs Galore.....

Limiting egg consumption has little effect on cholesterol levels, research has confirmed. A University of Surrey team said their work suggested most people could eat as many eggs as they wanted without damaging their health." The researchers said that previous warnings to limit egg consumption are "based on out-of-date evidence," and "eating saturated fats was far more likely to cause health problems." Researcher Professor Bruce Griffin said, "The ingrained misconception linking egg consumption to high blood cholesterol and heart disease must be corrected.

What Now for Vytorin? In? or Out?

Not too long ago Vytorin which is a combination of simvastatin and ezitimibe was lambasted after a negative study with the ENHANCE trial showing no proof of plaque regression despite a significant reduction in LDLc. It may have been a faulty study for which I think the study investigator maybe pushing this drug too much that their baseline thickness of the carotid intima maybe considered normal to start with......how can you expect further improvement when your baseline is already almost normal? It would have been better if they looked at a longer term trial comparing reduction of LDLc with inhibition of plaque progression rather than regression. I have always deep inside me believe that this was a flawed trial right from the beginning and I have continued to use the drug most importantly to my severely hyperlipidemic patients waiting for more proofs.

In medicine, our dictum is to do no harm. We have not seen harm done on patients with vytorin...that one study showed us that it " may " not be doing what it is supposed to do. We also need to mention that Simvastatin which is the statin component of vytorin has tons of proofs for the benefit our patients get from the drug hence, it just does not make sense why additional reduction of LDLc could hurt our patients?

Recently, the SANDS trial ( Stop Atherosclerosis in Native Diabetes Study) published in the Journal of the American College of Cardiology December 2008, a 36-month study, looking at regression in carotid intima in the diabetics showed that aggressive LDL reduction with ezetimibe + a statin or statin alone noted in patients with Type 2 diabetes mellitus was associated with a similar regression in carotid intima thickness. This is surely a a positive news and a welcome respite for this drug and a good reassurance not only to the medical practitioners but patients alike who got confused with earlier study results.

State of the Art in Cebu!

Finally the wait is over, our patients can now avail of the state of the art technology right at the heart of Cebu City. As Director of the Cebu Doctors' University Hospital Cardiac Catheterization Laboratory, I am proud to introduce our new GE Innova 2100 Flat Panel cardiac catheterization machine. This state of the art laboratory being made available to patients in the Visayas and Mindanao.

Cebu Doctors' University Cardiovascular Center is considered to be the most active cardiovascular center in Cebu City. This new laboratory would embolden our patients to take the right choice for their cardiovascular needs because they know we don't take their health for granted investing in high end machine to provide accurate and reliable result. We do various procedure including left and right heart catheterization, pacemaker implantation, hemodynamic studies, coronary angiography as well as percutaneous coronary intervention including surgical coronary bypass procedures, valvular replacements and many more.....

For more information, comments, or inquiries, please email me at: EdgarTan62@yahoo.com.

PCI vs CABG: Is it really an option?

In the real world, coronary disease remains to be the most prevalent cause of cardiovascular mortality and morbidity. The treatment options have continued to evolve especially with the rapid advances in percutaneous intervention blurring the difference between which form of therapy is better for a particular patient. The evolution of drug-eluting stent blurs the once mighty benefit of surgical bypass to the issue of lower incidence of repeated intervention rather than the hard end points of myocardial infarction and death.

PCI saves lives in acute coronary syndrome, these are patients brought to the emergency room with acute chest pains due to ischemia.

PCI has never been shown by various studies to be superior to optimal medical therapy in preventing MI in the stable patient. PCI in the setting of stable patient is best reserved for those that remain symptomatic inspite of maximal medical therapy.

Diabetics are a special group of patients at risk for repeated intervention if percutatneous intervention is employed hence, diabetics as a rule are best served with coronary artery bypass surgery rather than PCI. There are always exeption to the rule hence, an office discussion with your physician maybe warranted in this regard.

I will be giving a talk on revascularization options for patients with coronary artery disease during the Philippine Heart Association Post Graduate course on February 8, 2008 at the Waterfront Hotel, Cebu City. Feel free to email me at EdgarTan62@yahoo.com for any quesitons.

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!