Fitness

ARTICLE XXII - Balloons and Heart

2009-07-06T21:58:00.000-07:00

The entry of balloons has heralded a new era in the world of medicine with profound effects in its various important fields. The strongest ripples were however felt in cardiology and specialties dealing with gastroenterology, anaesthesia and urinary system. In cardiology it has revolutionized the approach to many commonly encountered problems. Many more fields await the application of this exciting ‘balloon technology’!

What can balloon do for us? It has been used to track into blood carrying tube – vessels, as air is lighter than blood, so this travels along the course of the vessels. It has been used for retention of a tube in a cavity, with balloon inflated on an end of tube after the entry has been secured prevents its slippage. Similarly it has been used to retain the urinary catheter in the bladder by inflating the balloon at the end. Tubes used in anaesthesia used to have leaking of air around it, that problem is solved by inflating balloon around it. Balloons have been used to arrest bleeding in patients with bleeding varices in dire emergency by exerting direct pressure on bleeding varices.

The biggest breakthrough came with the realization that these balloon could be employed to ‘blow up’ blockages in various parts of body. Balloons of different sizes and quality mounted on different structures have been successfully used for this purpose. They have been used to open up obstructions in gastrointestinal tract without surgery. Blockages in urinary system have been dilated by balloons with minimal patient discomfort and without surgery.

The epic of balloon technology can be witnessed in cardiology where the whole scenario has changed in cardiac catheterization laboratory. Initially cardiac catheterization laboratory was used truly as a laboratory where different diseases were diagnosed based on the information gleaned from catheterization. Now the emphasis is shifting from diagnosis to therapeutics. With the advent of echocardiography, most diseases can be accurately diagnosed without cardiac catheterization. In cardiac cath lab, catheter based therapeutics is predominantly dependent on “poor old balloon”, small balloons blowing up obstruction in coronary and other vessels with excellent results and large balloons opening up narrowed valves with enviable results obviating the need for surgery.

Valvuloplasty:
Large balloons ranging from 10 to 30 mm in diameter are used to open up different valves. Obviously, size of balloon depends on the target and size of patient. These valves are either congenitally narrow or narrow down in later life due to various disease process. Previously surgery was required to open up the stenosed valves and remove the impediments in blood flow. Not any more! The procedure is performed without anaesthesia. As an initial step baseline data is recorded, then access beyond the narrowed valve is secured by manipulating a flexible catheter across it. A long wire is left across the valve and a narrow balloon mounted catheter is manipulated on the wire across the narrowed valve. Once satisfied with the position, the balloon is inflated, first a waist appears confirming the impinging valve on balloon and then it slowly gives way. The The valve is open! No ugly scar on chest, no confinement to bed for days, no need for prolonged antibiotics, no loss of work and the beauty is that the patient can actually walk home the next day.

Obviously these balloon mounted catheters are made of very sophisticated material and a lot of research has been done to perfect the technique and hardware. The catheter system to open Mitral valve is named after Inoue. The only way to cut down the costs are to reuse the balloon after proper sterilization. The chances of success are more than ninety five percent and complication rate is quite low. The balloon used for Pulmonic and Aortic valves are different in size and shape.

Angioplasty (PCI)
Balloon have only recently been tamed, to be used in small vessels supplying heart. It started with Andrea Grundzick in 1979, when a blockage in a vessel was opened in a patient. Since then there has been an explosion in the cath lab of angioplasties. In USA, it is called ‘occulo dilating reflex’ which implies that as soon as a cardiologist sees an obstruction in a vessel, he has an irrepressible urge to dilate it. Or, according to our not very good friends, cardiologists on seeing a blockage develop severe stomach ache which can only be relived on opening up that lesion. No doubt there has been a mad race in opening of the lesions and technology is witnessing tremendous progress in this field.

Most research taking place in cardiology is focused on small balloons used in vessels supplying heart. The aim is to produce tough balloons which can endure high pressure without deforming, mounted on catheter which should have very small profile so that it can negotiate the bends and cross the blockage, the catheters should have enough strength to be pushed around and cross the lesion. Similar research is taking place in paraphernalia like catheter and guide wire.

How is it done? After identifying the blockage a strategy is devised regarding the approach and hardware to be employed. The procedure is similar to angiography where no anaesthesia is administered. After doing angiography, the lesion is crossed with the help of a very find guide wire. Care is taken to float this wire across the lesion preventing it from going to small branches. It is like going through a large tree to a specific branch which might take a minute or a couple of hours. Once the lesion is crossed balloon mounted catheter is introduced and parked at the lesion. The size of balloon chosen depends on the size of the vessel. Satisfied with the position of catheter, the balloon is inflated under X-ray control. Patient experiences pain when balloon is inflated as blood supply to a part of heart is totally prevented. The balloon is kept inflated for as long as a patient can tolerate, varying from a few seconds to a minute. The appearance of waist and later giving way is apparent on X-ray. The lesion gives way with increase in lumen size.

Balloon are also being used to dilate obstructions in vessels supplying brain, kidneys and extremities. New territories are being ventured into and with the development of proper hardware the need for surgery will be obviated in most cases.

Introduction of balloon technology is a fine example of application of common sense to common problems. Balloons have been used for retention, and opening up blockages. This has proven to be a major advance in medicine and surgery and almost all specialties are benefiting from this simple but very exciting technology.

___________________________________________________
Ref: Heal Thy Heart written by Prof: Dr. Muhammad Hafizullah

ARTICLE XXI - Heart Transplant - Is it a Viable Option?

2009-07-06T21:54:00.000-07:00

“Heart transplants have been successfully performed since 1967. Latest figures tell us that 85 percent of those who receive heart transplants survive for more than one year, and 70 percent live five years following the procedure,” I told John Plant, a 40 years old bank with a dilated and poorly pumping heart. He had been in and out of the hospital many times in the last six months. He was on maximal treatment but his effort tolerance remained severely impaired. We had proposed ‘heart transplant’ to him and his first knee jerk reaction was a big ‘no’. “A dream has been transformed into a reality and many patients are enjoying nearly normal life after heart transplant. Today’s heart transplant recipients live longer after surgery than those who received heart transplants just 10 years ago. Many transplant patients go back to work and many participate in moderately strenuous activities, such as walking, swimming and even running,” I added to convince him and eventually he agreed to go for it. Two years down the lane, he was active, playing golf and enjoying holidays in Paris.

Heart transplant has emerged as an established safe and effective theraphy for patients with severe heart problems. Technique of heart transplantation has made great strides of development over the years. Indeed it is a major surgery, in which a severely diseased or damaged heart is replaced with a healthy heart from a recently deceased person. Mortality during surgery is acceptable and the biggest problems are find a heart and prevention of rejection. Patients continue to face a lengthy waiting list to receive a donor heart. According to the recent figures approximately 3,800 patients were waiting for a heart transplant as of June 2007. Only 2,148 people received a donated heart in 2007. According to the American Heart Association, at the present time all over the world, the majority of heart transplant patients were while males. More than half are between the ages of 50 and 64, and about 20 percent are between the ages of 35 and 49. Researches are working to develop equipment to improve the health and comfort for patients waiting for a donor heart and, ideally, to develop a mechanical heart that could permanently solve the shortage problem.

Who needs heart transplant?
When a patient is diagnosed as having an end-stage heart disease, and all medical interventions have failed, and the patient is stable enough to sustain a major surgery then he or she is considered for transplant. End stage heart disease due to decrease in blood supply – coronary artery disease and disease of heart muscle called cardiomyopathy are the most common conditions that may lead to a heart transplant. Heart diseases due to inborn heart problems which are not amenable to surgery are the most common reasons for heart transplant in children. Patients with failure of a previous bypass and persistent angina and heart failure are considered for heart transplant.

Heart transplants are sometimes performed along with lung transplants for individuals with end-stage lung disease that also involves the heart. These conditions are elevated pressures in right sided circulation called pulmonary hypertension. High blood pressure in blood vessels of lungs arising from right side of heart is consequent to either primary – where the cause is not known or Eisenmenger syndrome where the cause is a congenital heart disease. The condition accounts for nearly half of all heart-lung transplants.

Who donates the heart?
Unlike most organs, the heart can only be obtained from donors who die a “brain death,” meaning that the brain dies while the body remains on life support. Organs are obtained from people who give their consent to have certain organs donated. They can also be obtained by permission of next of kin when a suitable donor is considered to be “brain dead.” Although almost 40 percent of donated kidneys are surgically removed from living donors, most major organ donations (e.g., the heart, lungs and liver) are pledged while living and removed when the donor dies. Because of the great demand for organ donors, generally healthy people are strongly encouraged to become donors.

How the heart is transplanted?
Patients waiting for a donor heart are required to report to the hospital immediately on finding a donor. If the donor heart is in the same hospital as the recipient, then the surgery is performed as soon as all preparations have been made. If the donor heart is being transported by ambulance or by air, then the surgical team responsible for the transfer keeps the hospital team informed of their progress.
When the time is right, the patient is given general anesthesia. An incision is made through the chest and sternum, and the ribs are separated. A heart-lung machine takes over the functions of heart and lungs, freeing heart from its normal function so that it can be removed. Some heart muscle is reserved during extraction to act as a support for the new heart as it is sewn into place. When the new heart is positioned and blood vessels are reattached, a heart incision is closed, heart is restarted and blood circulation and oxygen are stored. The warmth of blood should “wake up” the heart and stimulate it to start beating. If this does not occur, it may be necessary to start the heart using an electric shock (defibrillation). Once blood is flowing through the new heart normally and without any leaks, the heart-lung machine is disconnected and chest incision is closed.

After the heart transplant, patient is kept in ICU and monitored during this critical time by cardiac surgeon, cardiologist and other members of the hospital staff. They watch closely for any signs of heart rejection or infection. Medications that suppress the body’s natural immune system are administered to counter the body’s tendency to reject the new heart, and these medications have dramatically reduced the number of rejections.

Patients are unlikely to be very active in the next couple of days, but should be able to walk around in just three or four days. The total length of a hospital stay after a heart transplant is 10 to 14 days. Once a patient is discharged from the hospital, cardiologist and primary physician provide regular medical support, including biopsies and other diagnostic tests several times a year.

The improved life expectancy of patients after a heart transplant is largely due to a new drug called cyclosporine. It is an immunosuppressive drug that appeared in 1983. From its unique way of suppressing the immune system, cyclosporine has become a mainstay in minimizing the body’s tendency to reject a new heart. This is a major risk associated with transplant surgery. When rejection occurs, the immune system sends out antibodies to destroy the new heart, which is perceived as foreign or ‘invading’ tissue cells. Left unchecked, this rejection can result in extensive damage and failure of the transplanted heart.

Problems after the transplant:
Three main problems associated with transplant are rejection, infection and accelerated atherosclerosis.

a. Rejection: Certain tests are required on a regular basis to predict whether the heart is being rejected. These tests include regular biopsies and serial blood tests. Serial biopsies are done to monitor body’s response to the transplanted heart. This involves using a thin tube to remove a small piece of heart tissue. The tube is inserted through a vein either in the groin or side of the neck. Biopsies are outpatient procedures that can be done in under an hour. They are performed often in the first four months after transplantation and, less frequently, in months and years after that. The risk of transplant failure is three times greater among recipients with high levels of troponin I than those with normal levels of this enzyme.
Patients can monitor themselves, as some symptoms may signal rejection, including dizziness, nausea or vomiting, chest pain, shortness of breath, flu-like symptoms like chills, sore throat and fever. Rejection, however, is not necessarily an irreversible event. It can be controlled with different dosage regimen or timing of medications. Patients are encouraged to immediately contact their transplant centre or team, should any of the above symptoms occur.

b. Infection. Patients are urged to immediately report to their physician if any of the following signs of infection like fever, redness, swelling and drainage of fluid appear.

c. Accelerated atherosclerosis. When patients receive a new heart, they also receive new coronary arteries on the surface of that heart. Although these new coronary arteries may have less blockages than their original coronary arteries, heart transplant recipients are more like to develop coronary artery disease (CAD). This disease is thought to be part of the slow rejection process in the transplanted hearts. About 50 percent of heart transplant patients develop CAD. Therefore, patients must undergo cardiac tests periodically to check for the disease.

A longer-term goal for some researchers is the genetically engineered heart. The organ is composed of human tissues – perhaps one’s own – and is cultured or grown over a period of months to match detailed specifications. Currently, this “heart-in-a-box” project exists only in a university research facility, but researchers have a goal to have cryogenically (defined as ‘low-temperature”; in this case, very cold) stored organs available for transplant in less than a decade.

The dreams of yesterday have worn the attire of reality today. Heart transplant is a viable option in selected patients with heart failure, who do not respond to maximal therapy. Due to recent technological advances, the outlook has improved, survival being more than 83% at one year.

___________________________________________________
Ref: Heal Thy Heart written by Prof: Dr. Muhammad Hafizullah

ARTICLE XX - Bypass Surgery - Anything new?

2009-07-06T20:50:00.000-07:00

Farhan, a thirty five year old banker, underwent bypass surgery three years ago. He is back to work, working full time and enjoying his game of golf every evening. He flies abroad to attend meetings and makes full contribution to his job. He is only taking a couple of tablets and observes a few restrictions in his diet. For all practical purposes, he is leading a very active and productive life. And so are most people at different ages, employed in different jobs, from both sexes who had bypass surgery!

Bypass surgery is the most commonly performed heart surgery for coronary artery disease. Persons who develop blockages in their tubes that supply the heart called coronary arteries are the candidates for such surgery. More than 300,000 people have successful by pass surgery only in the United States each year. Bypass surgery is now being routinely performed in major centres of Pakistan with acceptable morbidity and mortality.

What is bypass operation?
Arteries supplying heart, called coronary arteries, develop blockages and can become clogged. Bypass surgery improves blood flow to heart employing a new route, or by “bypassing” blockages in the clogged or diseased artery. The surgery involves using a part of vein from leg or an artery from chest or another part of body to bypass the blocked part of the diseased coronary artery. This creates a new route for blood to flow, so that the heart muscle gets uninterrupted oxygen-rich blood.

How is bypass operation performed?
During bypass surgery, the breast bone (sternum) is divided, heart is stopped, and blood is circulated through a heart-lung machine which performs the function of heart and lungs. Unlike other forms of heart surgery, the chambers of heart are not opened during the operation. Heartlung machine takes over circulation and given enough time to operation on a stand still heart which makes surgery like this possible. The use of machine allows the surgeon to stop heart while the vital organs continue to receive blood and oxygen. Meticulous surgery can be done without interference from bleeding or heart’s pumping motion. Used successfully for the first time in 1953, the machine has proved to be a revolutionary piece of equipment. A perfusion technologist operates the machine. Before hooking upto this machine, a blood-thinning medicine called an anticoagulant is given to prevent blood from clotting. Two large sized cannulas are put in and sewn in major vessels which carry the blood back from inferior and superior vena cava. This blood is oxygenated by the machine like lungs as blood passes in close vicinity of controlled oxygen. A mortorized system then drives this blood back to body where it is delivered to aorta through a cannula to be further distributed to all over body. Meticulous control of speed of motors is required, drawing blood out of body and then delivering back. The amount of oxygen and anticoagulation has to be managed carefully.

The surgical team is led by a cardiovascular surgeon and includes other assisting surgeons, an anesthesiologist, and surgical nurses. A long piece of vein from leg (the saphenous vein) is removed. This piece of vein is called a graft. One end of the graft is attached to ascending aorta, the large artery that carries oxygen-rich blood out of the heart to the body. Other end of the graft is attached to coronary artery below the blockage. The surgeon may choose to use an artery from the inside of chest wall (the internal mammary artery) instead. Or the surgeon may use both vein and artery. The procedure can take from 1 to 2 hours, depending on the number of bypasses needed. The stay in the hospital is about a week, including at least 1 to 3 days in the Intensive Care Unit (ICE). It may prolong in case of any complications. Usually the patient is up and about after two to three days and is encouraged to walk liberally after that.

Advances in bypass surgery:
There have been continuous attempts to make bypass surgery lesser invasive and more patient friendly. Minimally invasive coronary artery bypass surgery has been a major advance. It is done through smaller incisions. It may involve using the mammary artery as a graft. Saphenous veins may also be used. The procedure may be done without stopping heart. Some patients can leave the hospital within 48 hours. This operation is only used for patients whose blockages can be bypassed through this smaller incision and whose risk of complications is low.

Off pump surgery has been heralded as a major step forward to improve post operative course and complications besides reducing the cost. Like conventional bypass surgery, off-pump coronary artery bypass surgery (OPCAB) bypasses blockages in coronary arteries. Off-pump bypass involves the same two procedures that are performed during traditional bypass surgery. In the first, the surgeon removes (harvests) one of the patient’s blood vessels – usually either saphenous vein in leg or mammary artery. In the second procedure, the surgeon uses the blood vessel to create a detour (bypass graft) around the blockages in coronary arteries.

Off-pump bypass allows the surgeon to sew the bypass grafts into place in the chest without stopping heart. This eliminates all risks associated with stopping heart that is necessary during traditional bypass surgery. It also reduces the risk that a patient may experience depression and/or mood swings following surgery – a common side effect with traditional bypass surgery. The surgeon uses certain heart stabilizers and positioners to keep the targeted region of heart virtually motionless while working on a particular coronary artery. The stabilizers restrict heart’s motion to create a stable and nearly still work area for the surgeon. Heart maintains its own rhythm throughout the procedure. In addition, bleeding is greatly reduced, so patients are less likely to need blood transfusion.

What does life promise after bypass?
A person can go back to normal life and job in four to six weeks following an uncomplicated surgery. It may take longer in older age group, those with poor heart function and those with coexistent serious medical problems. One can usually go back to work in 4 to 6 weeks for an office job. Those who have more physically demanding jobs may need to wait longer. In some extreme cases, one may need to find a job that is not as physically demanding. Twenty percent or less of bypass patients may need a second procedure like angioplasty or repeat bypass after 10 years.

Does bypass mean an end to walking and abstinence from cholesterol rich diet?
Is bypass surgery a panacea? Does it give a license to eat and drink as one pleases? Two things are of vital importance after bypass operation: first, meticulous control of risk factors and second, regular exercise. After bypass surgery, the diet has to be modified and one has to limit fat and cholesterol. Risk factors have to be regularly watched and scrupulously controlled. Exercises like walking and swimming are recommended, to get the strength back and develop stamina. The role of exercise has been discussed in details in controlling various risk factors. A cardiac rehabilitation program may be joined on doctor’s recommendation. These programs can help to make lifestyle changes like starting a new diet and exercise program, quitting smoking, and learning to deal with stress.

To conclude, bypass surgery has been a landmark in our fight against coronary artery disease. This is an exquisite application of common sense employing body’s own vessels as alternate paths to deliver blood to viatal parts of heart. The operation has seen many advances and is being done as a routine in many centres. The operative mortality is very acceptable and most patients are back to work in four weeks and most can go back to the previous level of activity.

Heart Transplant - Is it a Viable Option?
“Heart transplants have been successfully performed since 1967. Latest figures tell us that 85 percent of those who receive heart transplants survive for more than one year, and 70 percent live five years following the procedure,” I told John Plant, a 40 years old bank with a dilated and poorly pumping heart. He had been in and out of the hospital many times in the last six months. He was on maximal treatment but his effort tolerance remained severely impaired. We had proposed ‘heart transplant’ to him and his first knee jerk reaction was a big ‘no’. “A dream has been transformed into a reality and many patients are enjoying nearly normal life after heart transplant. Today’s heart transplant recipients live longer after surgery than those who received heart transplants just 10 years ago. Many transplant patients go back to work and many participate in moderately strenuous activities, such as walking, swimming and even running,” I added to convince him and eventually he agreed to go for it. Two years down the lane, he was active, playing golf and enjoying holidays in Paris.

Heart transplant has emerged as an established safe and effective theraphy for patients with severe heart problems. Technique of heart transplantation has made great strides of development over the years. Indeed it is a major surgery, in which a severely diseased or damaged heart is replaced with a healthy heart from a recently deceased person. Mortality during surgery is acceptable and the biggest problems are find a heart and prevention of rejection. Patients continue to face a lengthy waiting list to receive a donor heart. According to the recent figures approximately 3,800 patients were waiting for a heart transplant as of June 2007. Only 2,148 people received a donated heart in 2007. According to the American Heart Association, at the present time all over the world, the majority of heart transplant patients were while males. More than half are between the ages of 50 and 64, and about 20 percent are between the ages of 35 and 49. Researches are working to develop equipment to improve the health and comfort for patients waiting for a donor heart and, ideally, to develop a mechanical heart that could permanently solve the shortage problem.

Who needs heart transplant?
When a patient is diagnosed as having an end-stage heart disease, and all medical interventions have failed, and the patient is stable enough to sustain a major surgery then he or she is considered for transplant. End stage heart disease due to decrease in blood supply – coronary artery disease and disease of heart muscle called cardiomyopathy are the most common conditions that may lead to a heart transplant. Heart diseases due to inborn heart problems which are not amenable to surgery are the most common reasons for heart transplant in children. Patients with failure of a previous bypass and persistent angina and heart failure are considered for heart transplant.

Heart transplants are sometimes performed along with lung transplants for individuals with end-stage lung disease that also involves the heart. These conditions are elevated pressures in right sided circulation called pulmonary hypertension. High blood pressure in blood vessels of lungs arising from right side of heart is consequent to either primary – where the cause is not known or Eisenmenger syndrome where the cause is a congenital heart disease. The condition accounts for nearly half of all heart-lung transplants.

Who donates the heart?
Unlike most organs, the heart can only be obtained from donors who die a “brain death,” meaning that the brain dies while the body remains on life support. Organs are obtained from people who give their consent to have certain organs donated. They can also be obtained by permission of next of kin when a suitable donor is considered to be “brain dead.” Although almost 40 percent of donated kidneys are surgically removed from living donors, most major organ donations (e.g., the heart, lungs and liver) are pledged while living and removed when the donor dies. Because of the great demand for organ donors, generally healthy people are strongly encouraged to become donors.

How the heart is transplanted?
Patients waiting for a donor heart are required to report to the hospital immediately on finding a donor. If the donor heart is in the same hospital as the recipient, then the surgery is performed as soon as all preparations have been made. If the donor heart is being transported by ambulance or by air, then the surgical team responsible for the transfer keeps the hospital team informed of their progress.
When the time is right, the patient is given general anesthesia. An incision is made through the chest and sternum, and the ribs are separated. A heart-lung machine takes over the functions of heart and lungs, freeing heart from its normal function so that it can be removed. Some heart muscle is reserved during extraction to act as a support for the new heart as it is sewn into place. When the new heart is positioned and blood vessels are reattached, a heart incision is closed, heart is restarted and blood circulation and oxygen are stored. The warmth of blood should “wake up” the heart and stimulate it to start beating. If this does not occur, it may be necessary to start the heart using an electric shock (defibrillation). Once blood is flowing through the new heart normally and without any leaks, the heart-lung machine is disconnected and chest incision is closed.

After the heart transplant, patient is kept in ICU and monitored during this critical time by cardiac surgeon, cardiologist and other members of the hospital staff. They watch closely for any signs of heart rejection or infection. Medications that suppress the body’s natural immune system are administered to counter the body’s tendency to reject the new heart, and these medications have dramatically reduced the number of rejections.

Patients are unlikely to be very active in the next couple of days, but should be able to walk around in just three or four days. The total length of a hospital stay after a heart transplant is 10 to 14 days. Once a patient is discharged from the hospital, cardiologist and primary physician provide regular medical support, including biopsies and other diagnostic tests several times a year.

The improved life expectancy of patients after a heart transplant is largely due to a new drug called cyclosporine. It is an immunosuppressive drug that appeared in 1983. From its unique way of suppressing the immune system, cyclosporine has become a mainstay in minimizing the body’s tendency to reject a new heart. This is a major risk associated with transplant surgery. When rejection occurs, the immune system sends out antibodies to destroy the new heart, which is perceived as foreign or ‘invading’ tissue cells. Left unchecked, this rejection can result in extensive damage and failure of the transplanted heart.

Problems after the transplant:
Three main problems associated with transplant are rejection, infection and accelerated atherosclerosis.

a. Rejection: Certain tests are required on a regular basis to predict whether the heart is being rejected. These tests include regular biopsies and serial blood tests. Serial biopsies are done to monitor body’s response to the transplanted heart. This involves using a thin tube to remove a small piece of heart tissue. The tube is inserted through a vein either in the groin or side of the neck. Biopsies are outpatient procedures that can be done in under an hour. They are performed often in the first four months after transplantation and, less frequently, in months and years after that. The risk of transplant failure is three times greater among recipients with high levels of troponin I than those with normal levels of this enzyme.
Patients can monitor themselves, as some symptoms may signal rejection, including dizziness, nausea or vomiting, chest pain, shortness of breath, flu-like symptoms like chills, sore throat and fever. Rejection, however, is not necessarily an irreversible event. It can be controlled with different dosage regimen or timing of medications. Patients are encouraged to immediately contact their transplant centre or team, should any of the above symptoms occur.

b. Infection. Patients are urged to immediately report to their physician if any of the following signs of infection like fever, redness, swelling and drainage of fluid appear.

c. Accelerated atherosclerosis. When patients receive a new heart, they also receive new coronary arteries on the surface of that heart. Although these new coronary arteries may have less blockages than their original coronary arteries, heart transplant recipients are more like to develop coronary artery disease (CAD). This disease is thought to be part of the slow rejection process in the transplanted hearts. About 50 percent of heart transplant patients develop CAD. Therefore, patients must undergo cardiac tests periodically to check for the disease.

A longer-term goal for some researchers is the genetically engineered heart. The organ is composed of human tissues – perhaps one’s own – and is cultured or grown over a period of months to match detailed specifications. Currently, this “heart-in-a-box” project exists only in a university research facility, but researchers have a goal to have cryogenically (defined as ‘low-temperature”; in this case, very cold) stored organs available for transplant in less than a decade.

The dreams of yesterday have worn the attire of reality today. Heart transplant is a viable option in selected patients with heart failure, who do not respond to maximal therapy. Due to recent technological advances, the outlook has improved, survival being more than 83% at one year.

Balloons and Heart
The entry of balloons has heralded a new era in the world of medicine with profound effects in its various important fields. The strongest ripples were however felt in cardiology and specialties dealing with gastroenterology, anaesthesia and urinary system. In cardiology it has revolutionized the approach to many commonly encountered problems. Many more fields await the application of this exciting ‘balloon technology’!

What can balloon do for us? It has been used to track into blood carrying tube – vessels, as air is lighter than blood, so this travels along the course of the vessels. It has been used for retention of a tube in a cavity, with balloon inflated on an end of tube after the entry has been secured prevents its slippage. Similarly it has been used to retain the urinary catheter in the bladder by inflating the balloon at the end. Tubes used in anaesthesia used to have leaking of air around it, that problem is solved by inflating balloon around it. Balloons have been used to arrest bleeding in patients with bleeding varices in dire emergency by exerting direct pressure on bleeding varices.

The biggest breakthrough came with the realization that these balloon could be employed to ‘blow up’ blockages in various parts of body. Balloons of different sizes and quality mounted on different structures have been successfully used for this purpose. They have been used to open up obstructions in gastrointestinal tract without surgery. Blockages in urinary system have been dilated by balloons with minimal patient discomfort and without surgery.

The epic of balloon technology can be witnessed in cardiology where the whole scenario has changed in cardiac catheterization laboratory. Initially cardiac catheterization laboratory was used truly as a laboratory where different diseases were diagnosed based on the information gleaned from catheterization. Now the emphasis is shifting from diagnosis to therapeutics. With the advent of echocardiography, most diseases can be accurately diagnosed without cardiac catheterization. In cardiac cath lab, catheter based therapeutics is predominantly dependent on “poor old balloon”, small balloons blowing up obstruction in coronary and other vessels with excellent results and large balloons opening up narrowed valves with enviable results obviating the need for surgery.

Valvuloplasty:
Large balloons ranging from 10 to 30 mm in diameter are used to open up different valves. Obviously, size of balloon depends on the target and size of patient. These valves are either congenitally narrow or narrow down in later life due to various disease process. Previously surgery was required to open up the stenosed valves and remove the impediments in blood flow. Not any more! The procedure is performed without anaesthesia. As an initial step baseline data is recorded, then access beyond the narrowed valve is secured by manipulating a flexible catheter across it. A long wire is left across the valve and a narrow balloon mounted catheter is manipulated on the wire across the narrowed valve. Once satisfied with the position, the balloon is inflated, first a waist appears confirming the impinging valve on balloon and then it slowly gives way. The The valve is open! No ugly scar on chest, no confinement to bed for days, no need for prolonged antibiotics, no loss of work and the beauty is that the patient can actually walk home the next day.

Obviously these balloon mounted catheters are made of very sophisticated material and a lot of research has been done to perfect the technique and hardware. The catheter system to open Mitral valve is named after Inoue. The only way to cut down the costs are to reuse the balloon after proper sterilization. The chances of success are more than ninety five percent and complication rate is quite low. The balloon used for Pulmonic and Aortic valves are different in size and shape.

Angioplasty (PCI)
Balloon have only recently been tamed, to be used in small vessels supplying heart. It started with Andrea Grundzick in 1979, when a blockage in a vessel was opened in a patient. Since then there has been an explosion in the cath lab of angioplasties. In USA, it is called ‘occulo dilating reflex’ which implies that as soon as a cardiologist sees an obstruction in a vessel, he has an irrepressible urge to dilate it. Or, according to our not very good friends, cardiologists on seeing a blockage develop severe stomach ache which can only be relived on opening up that lesion. No doubt there has been a mad race in opening of the lesions and technology is witnessing tremendous progress in this field.

Most research taking place in cardiology is focused on small balloons used in vessels supplying heart. The aim is to produce tough balloons which can endure high pressure without deforming, mounted on catheter which should have very small profile so that it can negotiate the bends and cross the blockage, the catheters should have enough strength to be pushed around and cross the lesion. Similar research is taking place in paraphernalia like catheter and guide wire.

How is it done? After identifying the blockage a strategy is devised regarding the approach and hardware to be employed. The procedure is similar to angiography where no anaesthesia is administered. After doing angiography, the lesion is crossed with the help of a very find guide wire. Care is taken to float this wire across the lesion preventing it from going to small branches. It is like going through a large tree to a specific branch which might take a minute or a couple of hours. Once the lesion is crossed balloon mounted catheter is introduced and parked at the lesion. The size of balloon chosen depends on the size of the vessel. Satisfied with the position of catheter, the balloon is inflated under X-ray control. Patient experiences pain when balloon is inflated as blood supply to a part of heart is totally prevented. The balloon is kept inflated for as long as a patient can tolerate, varying from a few seconds to a minute. The appearance of waist and later giving way is apparent on X-ray. The lesion gives way with increase in lumen size.

Balloon are also being used to dilate obstructions in vessels supplying brain, kidneys and extremities. New territories are being ventured into and with the development of proper hardware the need for surgery will be obviated in most cases.

Introduction of balloon technology is a fine example of application of common sense to common problems. Balloons have been used for retention, and opening up blockages. This has proven to be a major advance in medicine and surgery and almost all specialties are benefiting from this simple but very exciting technology.

Beyond Balloons and Springs
“You people have been creating havoc in tiny little coronary arteries of the heart, what are you people up to now?” is a question very commonly asked. “Nothing much, after blowing up balloons in the depths of chest, now we are venturing on new territories. Shaving off plaque has been on the cards for a long time with the help of ‘atherectomy’ devices, we have been putting up strong metal scaffolding ‘Stents’ in certain obstructions and using laser in the vessels either to create holes or increase the lumen size. Radiotherapy is being used to prevent restenosis. The name of the game is to enlarge the lumen size with balloon or some other technology,” I brief the gentlemen inquisitive about new technology and his heart, “the other major advance had been to put tiny ultrasound probe mounted catheter into the vessels hence opening a new window to study the vessel before and after the dilatation.”

Balloons have been used for tracking, retention, prevention of leakage, and opening up of stenosis in vessels, valves or other organs. They have been used to track into blood carrying vessels as air is lighter than blood so this travels along the course of the vessel. Swan Ganz catheters are balloon mounted catheters used for pulmonary artery and left heart pressure measurement and determination of cardiac output. Similar balloon tipped catheters have been used as temporary transvenous pacemaker lead. Balloons have been used for retention of the tube in a cavity with balloon inflated on an end of tube after the entry has been secured to prevent its slippage. Most commonly this technique is employed to retain the urinary catheter in the bladed by inflating the balloon at the end.

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Ref: Heal Thy Heart written by Prof: Dr. Muhammad Hafizullah

ARTICLE XIX - A Drug With Many Roles – Angiotensin Converting Enzyme Inhibitors (ACE Inhibitors)

2009-07-06T20:47:00.000-07:00

“We know what we are but we know not what we may be.” Shakespeare (Ophelia, in Hamlet).

Angiotensin converting enzyme inhibitors are a group of drugs for which many more indications were ‘invented’ as the experience accumulated in clinical practice for some time. Initially introduced in early eighties, as a treatment for difficult to control high blood pressure, it has now been used in most heart related diseases. There are very few patients with a significant heart ailment, who leave a cardiology unit without an ACE inhibitor on their discharge slips.

Angiotensin converting enzyme inhibitors are the most widely prescribed drugs in patients with heart problems due to high blood pressure and heart failure. They have an extremely successful track record for lowering systolic and diastolic blood pressure and have been employed usefully in the setting of symptomatic and asymptomatic heart failure and after a heart attack. There are many agents with distinct chemical characteristics and metabolism. Some are given thrice a day and others with long half life are used once a day. They are available in many preparations like Captopril, Enalapril, Lisinopril, Ramipril, Fosinopril etc.

How do they work? They work by inhibiting the formation of a very potent chemical called Angiotensin II, which causes most intense contriction/narrowing of vessels. Due to reduced formation of this agent, vessels are prevented from constricting or conversely allowed to dilate. Besides direct physical effects, it also exerts many other potentially beneficial effects by influencing the hormone release from brain like RAA and sympathetic system.

1. High blood pressure:
They were introduced in the market as potent drugs to reduce both systolic and diastolic blood pressure. They are very effective in bringing blood pressure down in both genders and all age groups. It works quickly and has a sustained effect. Left ventricle – the main pumping chamber develops thickness of walls as a response to pumping blood against high blood pressure. It has been shown to be most effective in reducing this thickness and reversal to normal. It has a benign profile and is well tolerated by majority of patients. As against other classes of anti hypertensive agents, it has no major contraindication so it is a drug of choice in most patients. It is used in preference to others in patients with thickened heartwalls, those in heart failure, poor heart function and after a heart attack. It should not be used in pregnant patients.

2. Heart failure:
Heart failure is the end result of all disease processes effecting the heart. Heart failure implies a condition where heart cannot meet the demands of body. Previously doctors had to solely rely on water tablets to reduce water in body and decrease load on heart. In many short term and long term trials the benefit of ACE inhibitors have been proven to reduce the load on heart – both pre load and after load. In our practice, we ensure that all patients of heart failure receive adequate doses of ACE inhibitors and continue to use them for all times to come. Under the umbrella of ACE inhibitors, the dosage of water tablets called diuretics can be reduced and sometimes totally stopped. Patients feel a lot better with improvement in their symptoms and exercise capacity. The drug can be used for patients in severe, moderate or mild failure. The benefits are equally impressive in all three groups of patients. These effects are independent of blood pressure reduction. Moreover, even patients with low blood pressure, can tolerate adequate doses of ACE inhibitors.

3. Poor heart (LV) function:
Having proven its benefit in patients with obvious heart failure, ACE inhibitors were then tried in patients with no signs of heart failure but having evidence of poor heart function documented on echocardiography or nuclear studies. By using ACE inhibitors in this specific group, patients’ progress to development of symptomatic heart failure can be decreased in a majority of patients or totally avoided in a minority of subjects. This has significant bearing on their eventual outcome in terms of frequency of hospitalizations and death.

4. Heart attack:
In a heart attack a portion of heart is rendered dead/necrotic due to cessation of blood supply. This area stops moving hence makes no contribution towards contraction and pumping of blood. Depending on the site and the vessel involved this may be a small or a large area. Heart tries to compensate for this loss and tries to preserve the output. This puts extra load on adjoining segments. Heart size might increase as the dead tissue is stretched by over zealous contraction of normal segments. This is called remodeling on heart. ACE inhibitors have been used to reverse this process. They have been shown to reverse the remodeling and prevent enlargement of heart size. This would naturally mean lesser number of patients developing heart failure with fewer deaths. ACE inhibitors have become an integral part of treatment for patients sustaining a heart attack.

5. Stroke:
High blood pressure remains the most important contributing factor towards stroke. The reduction of blood pressure is associated with most significant effects on reduction of stroke. Patients with stroke have a high propensity to develop another stroke especially if risk factors are not addressed and corrected. Beyond the reduction of blood pressure, ACE inhibitors have been shown to have a beneficial effect on prevention of stroke and reduction of associated mortality and morbidity. The theory has been postulated that certain ACE inhibitor may have a specific role to play which cannot be explained merely on reduction of blood pressure. Many neurologists, now, routinely use ACE inhibitors in patients after stroke even if the blood pressure is not very high.

6. Stable angina:
Patients with stable angina are normally treated with drugs for symptomatic relief and disease modifying drugs. Whereas Nitrates, Beta blockers and Calcium channel blockers may be employed for symptomatic relief, drugs like Aspirin and Statin have effects on modifying the course of disease. Similarly, ACE inhibitors have now been shown to have disease modifying effects, with significant effects on eventual events like episodes of angina, hospitalization, requirement of procedures like angiography and angioplasty and reduced frequency of death. It has been recommended as a drug to be used in patients with angina with normal or raised blood pressure.

7. High risk patients:
Considering multitude effects of ACE inhibitors, a new challenging role was investigated in a large well conducted trial. Patients with multiple risk factors and higher risk of developing coronary artery disease were studied in a large trial by administering ACE inhibitors and compared with placebo. The results were very encouraging with significant reduction in development of heart attacks and episodes of unstable angina. There was a dramatic decrease in requirement of angiography, angioplasty and bypass surgery. The effects of ACE inhibitors were independent of blood pressure. Here ACE inhibitors are claiming a new role, independent of their ‘traditionally recognised’ effect on blood pressure. Many cardiologists believe that every one with multiple risk factors and high risk of developing heart problems should be prescribed ACE inhibitors for an indefinite time.

8. Renal Protienuria:
At one time patients used to be given Albustix with administration of Captopril – the first ACE inhibitor to monitor any release of protein in urine. The pendulum has swung in opposite direction and beneficial role of ACE inhibitors has been proven in patients with leakage of protein in urine. It has been established in various studies that ACE inhibitors reduce the total amount of protein leaked in twenty four hours with or without its effect on blood pressure.

9. Anti Ischaemia:
Newer ailments are being added to the conditions benefiting from Angiotensin converting enzyme inhibitors. Their new role of possessing anti ischaemic properties has come to limelight only recently. Do angiotensin converting enzyme inhibitors have anti ischaemic properties? ACE inhibitors do not have any consistent short term anti anginal effects. Attention has been focused on the potential long term benefits of ACE inhibitors in preventing ischemic events in patients with stable heart disease. This came as an unexpected finding from large clinical trials conducted in patients with severe, moderate and mild heart failure. A large trial called SOLVD study, for example, demonstrated a reduction in the risk of heart attacks (either first or recurrent) by 23% and the risk of unstable angina by 20% in the treated group. In another study, there was 25% reduction in recurrent heart attack as well as a significant reduction in the rate of revascularization including percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass grafting (CABG) in the treated group.

It is unlikely that the observed reduction in ischaemic events can be explained by the blood pressure lowering action of ACE inhibitors alone, since the magnitude of risk reduction was substantially larger than that expected from short term modest reductions in blood pressure. In a recent analysis of 14 trials of blood pressure treatment, diastolic blood pressure reduction of 5 mmHg for about 5 years showed a 14% reduction in fatal and nonfatal heart related events. In a large trial, diastolic blood pressure was reduced by an average of 4 mmHg; this was associated with a 23% reduction in fatal or nonfatal heart attacks and a marked reduction in cardiac deaths. Moreover, the risk reduction in ischemic events were similar in patients with different levels of blood pressure at baseline. In another study, the effects of ACEI were studied on stable patients with heart disease, and the results were impressive reduction in adverse heart related events. Similar results were obtained in high risk population with and without heart diseases. ACE inhibitors exert an indirect anti atherogenic action by reducing vascular smooth muscle growth and proliferation, restoring endothelial function and by reducing the propensity for a plaque to rupture.

Side effects:
By and large ACE inhibitors are very well tolerated. The side effects profile is benign except that it produces persistent hacking cough, which does not respond to cough suppressants. This has been reported differently in different trials but can be observed in up to 10-15% of patients. The cough responds only to stopping of the drug. In patients presenting with persistent cough, sister products of ACE inhibitors called Angiotensin receptor blockers have been used with almost similar efficacy but without cough. Many trials have documented the efficacy and safety of this relatively new group of drugs.

To conclude, ACE inhibitors, initially introduced as anti hypertensive agent, in difficult to control patients at high dosage, newer roles have been discovered and the drug is being used in almost all types of heart problems. ACE inhibitors seem to possess some anti ischemic properties and confer the beneficial effects through various mechanisms but more direct evidence should be sought from large clinical trials to further clear the picture. The question that should all patients with heart disease be receiving ACE inhibitors has now entered into a practical phase and needs serious consideration.

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Ref: Heal Thy Heart written by Prof: Dr. Muhammad Hafizullah

ARTICLE XVIII - Should everyone take statins?

2009-07-06T20:46:00.000-07:00

“Statins, especially in combination with a good diet and regular exercise, have been proven to decrease the risk of heart attack and stroke, lessen the need for heart surgery and angioplasty, and reduce the risk of death significantly. An overview of prevention trials using both drugs and diet to lower cholesterol demonstrated an approximate 25% reduction in nonfatal and 14% in fatal (deadly) heart attacks,” explained my cardiologist after diagnosing my illness and reviewing the investigations. This stimulated me to learn more about the subject of high cholesterol and specially about this new class of drugs. The conclusion of my ‘google search’ was, “Statins are the new class of drugs, introduced in the current decade. These have been shown to have a major impact on heart disease progress. They have been studied extensively and have proven to be a safe and effective way to help patients lower their cholesterol levels,”

As a literate patient I wanted to update my self on current information and intend to share it with you. My first priority was to understand, what is primary and secondary prevention? Primary prevention is for people without any evidence of heart problem and secondary prevention is for patients who already have evidence of cardiac problems. My second aim was to look at the basic data and try to learn about the landmark studies which revolutionized the way the patients of coronary artery disease are treated. My aim was to learn the actual figures beyond non specific terms like mild, moderate and severe. Many small and large studies have been conducted with statin in the scenario of primary and secondary prevention and it is not possible to go over all of them, therefore we will confine our discussion to some important trials. My third aim was to look at safety data for personal reassurance.

The importance of high cholesterol as an important risk factors had always been appreciated by doctors and lay people. Many studies done in the past, employing large populations and different cholesterol lowering strategies failed to show any significant reduction in death rate. Statins used in this setting for the first time have shown very reliable data, that shows reduction of death rate in persons without any evidence of coronary artery disease. The data is not only convincing for people with high cholesterol but also very encouraging in patients with not so high cholesterol.

For the first time, the world of medicine received the news of statins’s efficacy in a population with no existing heart problem, by a study done in Scotland. This evaluated the role of statin in primary prevention in a relatively high risk population. After a 5-year period treatment a significant reduction of 31 percent was achieved in the defined primary endpoint. Total death rate was reduced with no increase in noncardiac death rates. When taking into account suspected coronary events, deaths from coronary artery disease decreased by 33 percent. It reported marked reduction in requirement of coronary angiography and revascularization procedures. The trial established the benefit of statin therapy in a high-risk group. The statin (Pravastatin) demonstrated a significant reduction in death and nonfatal heart attacks.

What does it mean to us as patients? Pravastatin therapy in male subjects with similar patient characteristics to the trial would prevent one event in 31 subjects who take statin therapy over a 5-year period. A conservative estimate of the feasibility of treating patients like those was determined to be well within the range of interventions that are considered to be cost effective approximately $ 13,000 US per year of life saved.

After evaluating the effects of lowering cholesterol in high risk patients, I searched for effects of cholesterol lowering in medium or low risk groups. I found a study that examined the potential impact of statin therapy in subjects including both middle-aged men and women whose total cholesterol approximated the average cholesterol. Lovastatin therapy resulted in a statistically significant 37 percent reduction in the incidence of primary endpoint event. Lovastatin therapy resulted in consistent reductions in event rates in the secondary endpoints: a moderate riask reduction in evascularizations, unstable angina, and nonfatal or fatal heart attack. Among patient subgroups in the group (e.g., women, smokers, and hypertensives), the benefit of lovastatin treatment was comparable with the benefit in the overall cohort. This was the first major clinical trial of a statin to demonstrate reductions in first coronary events in a low-risk subgroup whose profile approximates the general population.

Secondary prevention studies are conducted in patients with established coronary artery disease, offering new insights and directions in the management of coronary artery disease. For the first time we have very convincing data that shows mortality benefit by altering cholesterol levels favourably in patients with high and not so high cholesterol and established coronary artery disease.

A new piece of information that set new trends in heart diseases management came from a study called 4S. This landmark trial demonstrated clearly that statin therapy could reduce total mortality in a secondary prevention situation. The most significant impact on mortality was due to the reduction in heart events. A number of substudies were also performed and demonstrated that Simvastatin therapy was effective in women and older patients - age more than 60 years. Cerebrovascular events (strokes) and new carotid bruits were also significantly reduced by the therapy. This was a large-scale trial that evaluated the effect of Simvastatin therapy in patients with high cholesterol who were either heart attack survivors, patients with angina, or both in a 5.4 year trial.
Very interesting and exciting data was provided by an extremely large secondary prevention trial that evaluated statin (Pravastatin) in patients over a period of 6.1 years. Overall death rate was 22 percent less in the group randomized to statin, which was highly statistically significant. The relative risk reduction by statin in deaths from heart diseases was reduced by 24 percent as compared to placebo. A number of secondary endpoints, including the incidence of heart attacks, revascularization procedures like angioplasty and bypass, hospitalization for unstable angina, stroke and hospital days, were significantly reduced by Statin therapy.

This trial provided extremely strong evidence because of its large and diverse population. It showed that treatment with statin (pravastatin) in secondary prevention is of clinical benefit across a broad range of baseline cholesterol values and is associated with a reduction in total and cardiac mortality without an increase in noncardiac deaths. It became easy, to understand the magnitude of benefit, when I learnt that for every 1000 patients assigned to treatment with statin (pravastatin) over a period of 6 years, a total of 30 deaths, 28 nonfatal heart attacks, and nine nonfatal strokes could be avoided.

New trends were set by a remarkable trial called Heart Protection Study (HPS) that involved 20,000 volunteers, who were at high risk of coronary heart disease. Cholesterol lowering with statin treatment, reduced the risk of heart attacks and strokes by at least one-third. It reduced the need for bypass surgery, angioplasty and amputations by one third. Reductions of at least one-third in these ‘major vascular’ events were found in a very wide range of high risk patients for whom, there had previously been uncertainty about using cholesterol lowering therapy: women as well as men, people aged over 70 as well as younger people, people with blood levels of total cholesterol below 200 mg/dl or of ‘bad’ LDL cholesterol below 120 mg/dl, as well as those considered to have ‘high’ levels.

It was easy for me to understand that about 5 years of statin treatment typically prevents heart attacks, strokes or other major vascular events in: 100 of every 1000 people who previously had a heart attack, 80 of every 1000 people with angina or some other evidence of heart disease, 70 of every 1000 patients who previously had a stroke, 70 of every 1000 people with occlusive disease in leg or other arteries, 70 of every 1000 people with diabetes. I appreciated that in addition, cholesterol lowering reduces the risk of being hospitalized because of worsening angina typically, about 30 fewer admissions per 1000 treated for 5 years. The interesting aspect was that the benefits increased throughout the study treatment period (so more prolonged therapy might be expected to produce even bigger benefits), and are additional to those of other treatments used to prevent heart attacks and strokes.
My third aim was to study the side effects profile. Main side effects pertaining to statins are the effects on muscles and liver. The muscles can be effected by statins ranging from asymptomatic rise in a blood test called creatine kinase and muscle pain to frank rhabdomylosis-destruction of muscles. The evidence that statin drugs may also be associated with development of rhabdomyolysis (destruction of muscles) and kidney failure is understandably of concern. But we have to be careful to understand the extent of problem and not to throw the baby out with the bath water. Whether different statin-fibrate combinations have different risks for rhabdomyolysis (destruction of muscles) is not yet known. In fact, several recent studies have shown other statins and combinations to be effective without evidence of abnormal biochemical test. Results confirm that in large patient data base employing different statins, rhabdomyolysis (destructions of muscles) was extremely rare. Rise in CPK, indicating muscle involvement is comparable with placebo. However this side effect should be kept in mind and drugs which increase the likehood of muscle disese – myopathy should be avoided. Patients on statins presenting with muscle pain and aches should have their CPK checked. The drug should be discontinued if myopathy is suspected, if CPK levels rise markedly, or if the patient has risk factors for rhabdomyolysis (destruction of muscles).

Liver can be effected by statins. Effects can be asymptomatic mild to marked rise of blood test of liver called serum transaminase or frank jaundice. In majority of cases the rise of enzyme is transitory and almost always reversible on discontinuation of therapy. Mild increase in transaminsase (2-4 upper limit of normal), does not warrant cessation of therapy. Close monitoring and reduction of dose is usually sufficient. If the rise is more than 4 times then the drugs should be stopped. A different statin at a lower dose may be initiated and the dose built up slowly. Liver function should be monitored, before treatment is started and periodically checked thereafter like twice a year, for the first year of treatment or until 1 year after the last elevation in dose. Patients titrated to high dosage should receive an additional liver function test at 3 months.

To conclude, it has been proven that an average reduction of cholesterol by 40 mg/dl for about 5 years will result in reduction in non fatal and fatal heart attack by about one fourth. Similar effects are seen in people with no evidence of coronary artery disease and having high or not so high cholesterol. The data is quite encouraging for patients with evidence of coronary artery disease and having high or normal levels of cholesterol. Similar benefits await persons with average or high cholesterol with no heart problem.

The side effects may sound alarming but are very rare and do not require very close monitoring in majority of patients: these side effects should not prevent the more wide spread application of this “new aspirin”.
American College of Cardiology and Amerian Heart Association reassured patients about statin effectiveness and safety and the President of ACC Douglas P Zipes declared.

“While statins like all other drugs have side effects the benefits of using statins to manage patients cholesterol far outweighs the risk of serious side effects from their use. We want to reassure patients that statins have proven to be safe and very effective drugs and we urge patients who are taking statins and have no side effects to continue taking the drug.”

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Ref: Heal Thy Heart written by Prof: Dr. Muhammad Hafizullah

ARTICLE XVII - Clopidogrel – The Drug of Tomorrow!

2009-07-06T20:43:00.000-07:00

Very few drugs have been received in the world of medicine with so much enthusiasm as Clopidogrel. It is one of the few drugs which received wide spread acceptance in its ‘infancy’. It was introduced in the world as Plavix but is available in the country under more than a dozen names like Cloxidil, Noclot, Lowplat, Ogrel, Dogrel, Clogrel, Deplat, Deplug, Platagg, Cumplat etc. Antiplatelet drugs are useful means of preventing acute blockages of vessels causing occlusions in cardiovascular diseases. Clopidogrel is a thienopyridine compound and produces irreversible platelet inhibition.

Clpidogrel inhibits platelet aggregation and that can be seen 2 hours after single oral dose of clopidogrel. Early and more pronounced inhibition can be achieved by using a loading dose using 4-8 tablets providing 300 – 600 mg. Such doeses are used when early inhibition of platelets is required in emergency situations like angioplasty and stenting in unprepared patients and patients presenting with unstable angina and heart attack. Repeated doses of 75 mg clopidogrel per day inhibit platelet aggregation on the first day, and inhibition reaches a steady state between Day 3 and Day 7. Plateleet aggregation and bleeding time gradually return to baseline values after treatment is discontinued, generally in about 5 days. Absorption is rapid and is not affected by food or antacids. It is extensively metabolized through liver and the elimination half-life is 8 hours.

Many major trials have been conducted to test the efficacy and safety of the drug in various expanding list of indications.

1. Clopidogrel in Angina:

In a large trial employing patients from 16 countries was carried for three years. The aim was to assess the relative efficacy of Clopidogrel and aspirin in reducing the risk of storke, heart attack, or vascular death. There was a relative-risk reduction in favor of Clopidogrel. There were no major differences in terms of safety for both Clopidogrel and Aspirin. So it proved that Clopidogrel was as effective as Aspirin in patients with stable angina and Clopidogrel can be used in patients who cannot tolerate Aspirin.

2. Clopidogrel in Unstable Angina:

Clopidogrel has become the drug of choice in patients presenting with unstable angina. The drug was studied in patients presenting with unstable angina in a study called CURE – Clopidogrel in unstable angina to prevent recurrent events. The aim was to assess the safety and efficacy of combination of clopidogrel and aspirin in tweleve thousand patients presenting within 24 hours of unstable angina. There were significant reduction in primary and secondary outcomes. Significantly fewer patients had recurrent chest pain and underwent angioplasty or surgery. Overall, there was no significant excess of major bleeding episodes after coronary grafting.

3. Clopidogrel in Heart Attack:
The effects of Clopidogrel were studied in a large study employing patients from many centres in China. The trial proved that adding Clopidogrel to Aspirin in acute heart attack prevents around ten major vascular event per thousand treated. There was no excess bleeding in breain-fatal or major. The result confirmed that each million heart attack patients treated for more than two weeks would avoid 5000 deaths and 5000 non-fatal events. Nowe it has become manadatory to administer loading dose 4-8 tablets to patients after a heart attack as soon as possible.

4. Clopidogrel in Angioplasty and Stenting:
One of the major advantages of Clopidogrel lies in prevention of clot formation in patients undergoing stenting with different types of stents. In a large study, patients planned for percutaneous coronary intervention (PCI) were randomized to either Clopidogrel and Aspirin as a loading dose or placebo and aspirin prior to PCI. Patients receiving Clopidogrel with Aspirin showed fewer cases of acute blockage due to clots in the stent. Recent guidelines dictate to start Clopidogrel a few days before the procedure or administer loading dosage of Clopidogrel immediately before the procedure.

The long term effects of antiplatelet therapy in patients following PCI have been evaluated in many trials. The drug has to be continued for long term (3-12 months) in patients receiving bare metal stents and one year to indefinite in those receiving drug eluting stent. The rationale behind this recommendation being the delayed healing of inside layer – endothelium of the vessel after drug eluting stent.

5. Stroke and Transient Ischaemic Attacks:
Clopidogrel is the focus of research in many fields in Cardiology, vascular medicine and neurology. It has been shown to produce salutary effects in prevention of stroke in patients with minor strokes called transient ischemic attack (TIA). Further strokes can be prevented by using Clopidogrel in ischemic stroke patients.

6. Peripheral Vascular Disease:
Clopidogrel has been evaluated in patients with blockages in vessels supplying arms and legs and internal organs. It has been used after surgery, angioplasty and stenting in such vessels and also when intervention is required, with gratifying results. A large trial is being conducted, focusing peripheral arterial disease patients.

7. Irregular Beating of Heart:
Patients with irregular beating of hear called atrial fibrillation develop pooling of blood in left sided storage chamber called left atrium. This stasis of blood can lead to formation of clot, which can dislodge and hit any vessel/part of the body. This results in blockage of that vessel hence cessation fo blood supply to that organ or part. Stroke and heart attack can be result of embolism of clot to brain or heart. Blood can be thinned down and such clots can be prevented by using Dispirin and Clopidogrel on their own or in combination.

Clopidogrel Compared To Other Antiplatelet:
It has some major advantages over ticlopidine – another potent antiplatelet drug. Clopidogrel is six times more potent thatn ticlopidine. It has reduced metabolic burden on liver – the main site of clearance. It has an improved benefit/risk ratio. Clopidogrel related reduction in white blood cells called neutropenia has not been reported whereas all of the earlier trials on ticlopidine reported severe neutropenia.

Side Effects Associated with Clopidogrel:
Clopidogrell may cause side effects, most frequent side effects are rash, bleeding, gastrointestinal upset, and gastro –intestinal bleeding. The personal physician should be informed if a patient experiences excessive tiredness, headache, dizziness, upset stomach, stomach pain, diarrhea, or nose blood. Some side effects can be serious. The following symptoms are uncommon, but if experienced one should report to doctor immediately; black and tarry stools, blood in stools, bloody vomit, vomiting material that looks like coffee ground, unusual bleeding or bruising, fever, sore throat, chills, and other sings of infection, slow or difficult speech, weakness or numbness of an arm or a leg or vision loss.

Clopidogrel is a novel antiplatelet, has definite advantages over aspirin like less severe gastro intestinal bleeding and superiority in reducing major ischemic events. In most of clinical indications clopidogrel is combined with aspirin but it can safely substitute aspirin if the drug cannot be tolerated due to stomach upet. With every passing day, newer indications are being discovered. There has been an exponential increase in the usage of the drug on both sides of Atlantic. All this has been possible because of well conducted mega trials proving the efficacy and safety in large groups of patients.

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Ref: Heal Thy Heart written by Prof: Dr. Muhammad Hafizullah

ARTICLE XVI - Aspirin – A Panacea?

2009-07-06T20:39:00.000-07:00

If Aspirin was to be discovered today, the discoverer will be a nominee for Nobel prize and the drug will be sold in the market fifty times of its current price. This has been one of the most ‘wonderful’ discoveries in the world of science but the credit goes to the ‘rediscovery’ of its many ‘potentials’. The story of Aspirin is that of ‘rags to riches’ starting from a very humble background, it has become one of the most widely prescribed drugs. To start with, it was used only as a pain killer and now it has an application in almost all the fields of medicine directly and indirectly.

The strongest effects have been felt in the field of cardiology. Anyone with the diagnosis of a heart ailment has to have Aspirin. There was a time when ‘digoxin’ was synonymous with cardiac problems and every one with the ‘possibility’ of a heart problem would be prescribed the drug, the same is now true for aspirin. More than that we have entered in an era where it is being ‘over prescribed’ and we have to make special efforts to rationalize its usage to the ones who really need to have it.

The utility of Aspirin has been proven in the courts of statistics – the world of numbers by conducting large clinical trials where it was tested in a ‘blind’ fashion again placebo and other drugs. The results are very impressive and highly significant. The essential role of Aspirin is to reduce the aggregability or stickiness of an important constituent of blood called platelets. Platelets stick together and form a plug which blocks the tubes carrying the nutrition – blood. Hence they reduce or in many cases totally block the blood supply to a part of body which may happen to be heart, brain or kidney.

There is an elaborate system of blood supply, operating in the body which ensures optimal nutrition/blood to each and every part of body and at the same time same medium is used for getting rid of toxic material. Any blockage in the system causes reduction of blood supply to that particular part of body which results in impairment of function of that part or system. Some of the blockages may be due to inborn problems but mostly they are due to the process of atherosclerosis (athero – cheesy and sclerosis-hardening). This is a process by which cheesy material is deposited inside the tube or vessels. This process starts early in life and is progressive. Known risk factors like diabetes, high blood pressure, high cholesterol and smoking predispose to this process and accelerate it. On top of these blockages blood supply may be further reduced with the formation of platelets plugs. Aspirin prevents formation of these plugs hence it has its application in preserving the blood supply to all the systems of the body.

The major advantage is found in preventing the blockage in the blood supply system to heart and brain. It is an important player in ischaemic heart disease presenting as angina, acute coronary syndrome and heart attack. The most convincing effects are seen in the setting of acute myocardial infarction where Aspirin is recommended to be chewed for quick action as soon as possible. Very few treatment modalities have been so well and widely received and practiced as aspirin in heart attack. Aspirin in does of 40 mg can acetylate all the platelet cyclo-oxycenase hence reducing the aggregation property of platelets. In a summary of 33 trials conducted in heart attack, mortalilty in patients on aspirin was reduced from 25% to 11%. The effects are comparable to the use of clot dissolving drugs like streptokinase. It is mandatory for all doctors and paramedical staff to administer a tablet of Aspirin to anyone who presents with chest pain and is suspected to have a heart attack. In the setting of CCU first thing to be given to the patient should be Aspirin. Many doctors carry Aspirin with them, to be taken in case of an emergency.

In patients presenting with unstable angina or acute coronary syndrome Aspirin has been shown to be highly effective in reducing platelets stickiness and restoring blood supply to heart. The usage has been shown to reduce the complications and further progress of disease. Similar salutary effects are seen in patients labeled as stable angina experiencing chest pain on exertion. Every patient with suspicion of heart attack, unstable angina or stable angina should take Aspirin and continue indefinitely in dosage of 75mg per day. Various enteric coated brands are available in the market to reduce hyperacidity.

As a step further, Aspirin is being recommended for patients who have risk factors for developing heart problems. In patients who are diabetic, have high blood pressure or elevated cholesterol, the introduction of Aspirin has been shown to decrease the risks for further problems. Many doctors recommend Aspirin to all the patients above forty years of age, regardless of other risk factors. The evidence to support such treatment is not very robust. In the present day scenario Aspirin is being used in all the presentations and even for the prevention of Ishaemic heart disease.

Aspirin has been used for ages as a first choice in a disease which afflicts the joints and heart at the same time called rheumatic fever. This is a disease, still quite prevalent in the developing countries, in the lower social strata and in childhood. This results in damaging the valves-doors of heart causing heart failure in young children. Many of these children require operation of the valve and some succumb to it. The response to Aspirin is dramatic and quick. The response is taken as evidence of the validity of the diagnosis.

The usage has increased in other cardiovascular diseases where platelets are discouraged to stick together and form clumps. Patients with irregular beating of heart called a trial fibrillation have the propensity of clot formation due to whirling of blood in left storing chamber. These clots can get dislodged and find their way into different circulations. Aspirin is indicated in such situations to prevent clump formation and prevention of stroke.

Aspirin is being used for the prevention of stroke and in patients of transient ischaemic attacks (TIA) enthusiastically in the light of over whelming evidence provided by many large well conducted trials. An analogy can be drawn between stroke and TIA to heart attack and acute coronary syndrome respectively. Blockages in blood supply produce symptoms and these blockages can be prevented by Aspirin. Same as ischaemic heart disease, people at a higher risk of developing stroke are treated with Aspirin for the prevention. Same risk factors as for heart attack are taken into account and treated aggressively.

A unique role for Aspirin has been discovered in pregnancy. Certain patients go into premature labour before their due time. Aspirin plays an important role in preventing that through its action on arachidonic acid. This has been a new tool in the hands of Obstetricians with very good response.

Aspirin can potentially cause gastric erosions and ulcers beside hyperacidity. Paitnets with proven ulcer on endoscopy or barium meal, history of gastrointestinal bleeding or thos receiving antiulcer treatment should not be given aspirin. Patients with known allergy should not be given aspirin. Other platelet inhibitors may be considered in patients who have allergy or who cannot tolerate aspirin.

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Ref: Heal Thy Heart written by Prof: Dr. Muhammad Hafizullah

ARTICLE XV - Beta Blockers – An Answer to All Problems!

2009-06-30T07:56:00.000-07:00

The drug that is closest to the heart of cardiologists and most widely prescribed for a variety of indications. Literally responsible for saving millions of lives every year and making people survive through the painful angina and even drag them out of the hopelessness of myocardial infarction. The drug that is used most extensively for high blood pressure and which has given a new lease of life to patients with cardiac failure. The drug that is being used for anxiety and migraine in millions of patients in the general practice – this drug is called BETA BLOCKER.

Let’s explore the role of this group in many cardiac problems starting from high blood pressure to heart failure and heart attack.

HYPERTENSION AND BETA BLOCKERS:
Beta-blockers makes the heart beat more slowly and less strongly. They work by blocking the action of nerves supplying the heart that release a chemical called Noradrenalin. This helps to control the rhythm and force of heart muscle movement. It also effects and tones down the central sympathetic activity. Beta blockers have been in the forefront of antihypertensive arsenal for the last two decades. They have been shown to be highly effective in reducing systolic and diastolic blood pressure specially in persons with high sympathetic drive or who are tense. They are effective in reducing total death rate, strokes and kidney failure in patients with high blood pressure. Beta blockers can effectively reduce the thickness of muscle of heart due to high blood pressure. Beta blockers are well tolerated by a majority of patients and have been found to very safe in all age groups and both genders. They have a special role to play in patients with compelling indications like angina, heart attack, and heart failure. This is the only group of drugs to show reduction in heart attacks in white, non smoker males.

Being highly effective drugs with extremely safe profile, the group has earned a special place, for itself in the drugs used for hypertension. These are the most commonly used and often the drug of first choice for this indication.

ANGINA AND BETA BLOCKERS
The commonest presentation of Coronary artery disease – when a person develops blockages in the blood supply of heart, is angina. Physical or mental stress leads to increasing heart rate and blood pressure, which leads to chest pain called angina. Beta-blocker slow the heart rate and reduce the heart’s workload. When the heart does not have to work as hard, it requires less oxygen. This in turn can help relieve or prevent chest pain (angina). To treat and prevent these pains, beta blockers have proved to be very effective. Beta-blockers are often used with the medications to treat angina. Beta blockers are the drugs of first choice in most patients presenting with angina. There is ample data to support its role in angina where it decreases the frequency of angina episodes and increase effort tolerance/ exercise capacity. The severity of anginal attacks decreases markedly with Beta blockers.

Role of beta blockers in Heart attack:
Heart attack is a common presentation of coronary heart disease. Here the blood supply to a part of heart blocks completely causing death of that portion of heart. There are two ways to approach a patient with myocardial infarction. The first one is opening the blockages in arteries to re-initiate blood going to the heart, the other one is decreasing the demand of blood supply to muscles of heart and this is what this magical drug does. Beta blockers have been shown to reduce the size of myocardial infarct – dead portion of heart in animal and human models. Beta blockers reduce lipolysis, that is the break down of fats. Beta-blockers given within hours of the start of a heart attack reduce both the risk of death and recurrent heart attack. They have well established anti-ischemic, anti-arrhythmic and anti-hypertensive effects. Large trials have shown impressive reduction of morbidity and mortality with oral and intravenous beta blockers. Evidence strongly suggests that most people should take beta-blockers for at least 6 months and may be two years after a heart attack, and probably longer to get the most benefit. It applied to both genders regardless of age. It is a must for all those who suffer from hypertension. The intake is oral and should be taken continually for about two years. Almost all drugs show similar effects, although water soluble beta blockers have a clear advantage over others. But for people who have asthma and hypotension, this drug is not recommended, however controlled diabetes is not a contraindication to beta blockers as the benefits outweigh the hazards.

Role of Beta-Blockers in Heart Failure
Heart failure is a significant public health problem effecting 15 million people world wide. There has been an increasing incidence of heart failure in contrast to the decreasing incidence of heart diseases. The associated hazards as found in Framingham study, mortality rate 17% in one year, 30% in two years and 50% in five years.

For the past 40 years medical students have been taught to avoid Beta Blockers in heart failure. Beta Blockers work by blocking adrenaline which increases force of contraction of heart muscle and improve its performance. Beta blockers are like double edged sword. Due to their negative effects on heart rate and contractility, they can worsen the heart failure but, used properly and judiciously they ameliorate the patients status and have salutary effects on the clinical status, exercise capacity and reduce death rate. This has been one of the most wonderful ‘rediscovery’ of the effects of beta blockers. This is also an example of how clinical experience and experimentation can alter the course of action and carve new place.

Many large trials have been conducted to evaluate the efficacy of beta blockers in large populations with mild, moderate and severe heart failure and patients with left ventricular dysfunction after a heart attack. There was a definite and marked reduction in mortality. All cause mortality and hospitalization was reduced significantly. Hospitalization due to any cause was reduced markedly.

Who are the patients that will benefit from beta blockers therapy? All patients with mild, moderate or severe but compensated heart failure on standard treatment of ACE Inhibitors and diuretics are candidates for beta blockers. There are important points to be kept in mind as only stable patients should start beta blockers. Preferably, doses should not be changed of ACE Inhibitors for one month and diuretics for 2 weeks. Ideally patients should not have required intravenous supporting drugs in the last one month.

This is an exercise that requires persistence and patience! One has to start with a very small does and then the dose has to be increased very slowly over weeks while monitoring heart failure status, blood pressure and heart rate. Some patients may deteriorate initially, that is why persistence is very important and patients have to be encouraged to adhere to the therapy. Many patients may not see any change in their clinical status initially that is why patience is required and patients have to be motivated to hold on to the treatment.

Various trials have now documented that Beta Blockers used carefully reduce heart failure symptoms and improve the quality of life. Beta blockers have been shown to reduce the risk of all cause mortality, such as sudden death and death from progression of heart failure. Beta blockers have been effective in reducing hospitalization. Compelling evidence now exists to support the safety and efficiency of Beta Blocker therapy in heart failure.

What are the specific side effects? Patients may complains of fatigue, slow heart rate and low blood pressure. Speciation caution has to be exercised in patients with reactive airway disease and decompensated stated.

Tachycardias:
Many patients with structurally normal heart have the propensity to develop very fast beating of heart – tachycardia, presenting as palpitations, fluttering or loss of consciousness in severe cases. Because of their effects on sinus node and AV node – two important pulse generators, this fast beating can be effectively controlled. The drug may be used intravenously for immediate effects and it is effective in most cases. It is used in oral preparation for the prevention of further attacks.

Other cardiac problems:
Beta blockers have found an application in many other fields.

· It is used to relieve the obstruction in patients presenting with severe outflow obstruction like right pumping chamber outflow obstruction.
· It is effective in reducing heart rate where patient has very fast heart rate specially accompanied by obstruction like narrowing of the valve – door between left storing and pumping chambers.
· It is used effectively in reducing rapid and powerful contraction in patients with markedly thickened interventricular septum called hypertrophic obstructive cardiomyopathy HOCM.

Miscellaneous:
There was a time when newer indications were found for the usage of beta blockers every week. The drug was tried and many times quite successfully in many scenarios outside the world of cardiology.

· The drug alleviates anxiety and are used by many for allaying anxiety in stressful situations like presentations, examinations and speeches. They do not impair intellectual powers but reduce the ‘fast beating’ of heart and the unwanted ‘tremors’ and ‘cold sweat’. These drugs are used extensively by psychiatrists, all over the world, for reducing anxiety and counter the tachycardic effects of some drugs.
· They are used for tremors – mainly senile tremors.
· Many people with migraine (headaches) have been able to reduce the severity and frequency of episodes.
· Beta blockers are used in patients with liver disease like Cirrhosis for reduction of pressure in liver.
· They are used in patients with thyroid gland hyperactivity called thyrotoxicosis for controlling their symptoms.

Side Effects
Like all potent drugs beta blockers have side effects and pros and cons have to be weighed for all clinical conditions and patients. Side effects of beta-blockers may include lack of energy or drive, fatigue, vivid dreams and erection problems (impotence). It can decrease blood flow to fee and hands, causing them to feel cold and increase leg pain brought on by exertion (intermittent claudication). May cause dizziness and lightheadedness, more likely to occur when started or when the dose is increased. In people with diabetes, beta-blockers can insignificantly increase blood sugar levels. More importantly beta blockers may mask warning signs of low blood sugar, such as increase in pulse rate and sweating. Beta-blockers may worsen medical conditions such as asthma, heart failure, and certain heart arrhythmias. Beta-blockers should not be stopped without first discussing with the doctor. The risk of heart attack may be increased when beta-blockers are stopped suddenly.

Beta blockers are drugs with multiple actions and have been used in many cardiac diseases like high blood pressure, angina, heart attack and heart failure. They have wide-spread applications in non cardiology world. By and large they are well tolerated and have certain side effects which have to be watched.

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Ref: Heal Thy Heart written by Prof: Dr. Muhammad Hafizullah

ARTICLE XIV - Evidence Based Medicine – What is it?

2009-06-30T07:46:00.000-07:00

“Where is the wisdom we have lost in knowledge and the knowledge we lost in information?” Richard Smith.

There are new trends being followed in medicine, and new winds are blowing in this rather progressive field! The focus of this new ‘trend’ is, ‘what is the evidence?” You cannot get away by saying anything which cannot be supported by ‘evidence’. We need evidence to make a diagnosis and we need evidence to request investigations as to what are the chances of clinching the diagnosis by employing a certain investigation. To use a certain group of drugs we need evidence of its benefit and safety record. There are some very interesting stories about drugs. Many drugs which were though to be good for one indication turned out to be a remedy for another ailment. A drug called Captopril in the beginning was suppose to cause leakage of proteins from kidneys and we used to give albustix to our patients to check this. Now, it is being used for the treatment of the same leakage of proteins. A drug was introduced to treat high blood pressure but it was found that it had more effect on growth of hairs and now it is being used for baldness in the form of creams. Aspirin till very recently was used only as a pain killer, now it is being used for a host of new indications which were never through of before. It is become a ‘darling’ drug of doctors specially cardiologists, neurologists and all interested in blood vessels.

Where do we get this evidence from? We conduct trials, which means we give the drug to half of the defined population and the other half gets tablets similar in shape but without any active material. Or similarly we apply a certain diagnostic test to half of randomly selected and the other half serves as ‘control’ population. Statistical tests are applied to find out any ‘objective significance’. Trials are being conducted everywhere and the purpose is to answer a question. Most of these trials are placebo controlled and double blind which means to study the effect of drugs and compare with placebo and both patients and doctors do not know about the placebo, so that we can study the real effect of the drug per-se. Many trials are sometimes put together to answer a specific question and this is called meta analysis.
The reason ‘trials’ were invented land are being practiced so fervently, is that in the world of medicine two plus two is not always equal to four. Some drugs which appear very good in laboratory and animal experiments, produce disastrous results when tried in a large number of human beings. In the current scenario, whenever a new medicine or a new diagnostic technique is introduced, it is evaluated objectively and evidence is collected before it can be marketed and accepted for human use. A new drug has to be tested in head to head comparison with established therapy to prove its efficacy and establish its safety.

Evidence based medicine has been defined as, ‘the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.” But perhaps it can be more accurately defined as, “the enhancement of clinician’s traditional skills in diagnosis, prevention and related areas through the systemic framing of the relevant and answerable questions and the use of mathematical estimates of probability and risk.”

Most doctors have so far been making decisions on what we learnt from text books, on the basis of anecdotes – personal or those experienced by colleagues and seniors, press cuttings, expert opinions (known as eminence based medicine) and guided by cost minimization. But the correct way is to formulate ‘an answerable question’ from the available information. This may be about symptoms diagnosis correlation, diagnostic signs, diagnosis per-se, prognosis of illness, cost effectiveness of a procedure or treatment and other issues. Having formed a question best evidence is sought from clinical examination, laboratory workup and current literature consisting of published trials and meta analysis. The data is critically evaluated for its validity and usefulness in terms of clinical applicability. Then an opinion is formed in the light of this evidence. Next two steps are perhaps more important and essential. This evidence has to be incorporated in the clinical practice and then the performance has to be evaluated at regular intervals.
The critics among doctors who believe in traditional medicine are against it on the following grounds: “Evidence based medicine seems to replace original findings with subjectively selected, arbitrarily summarized, laundered and biased conclusions of indeterminate validity or completeness. It has been carried out by people of unknown ability, experience, and skills using methods whose opacity prevents assessment of the original data.”
Medical practitioners belonging to any walk of health science realize that many a times we have faltered on assuming things on their face value. Two plus two is not always four in the world of medicine, it can swing in any direction by any multiple. Estimates from early eighties suggested that only around 10-20% of medical interventions including drug therapies, surgical operations and X-rays and blood tests were based on sound scientific evidence.
Howe can doctors incorporate evidence based medicine in our clinics and hospitals so that our patients can benefit from it? There is no doubt that we should be all practicing evidence based medicine in our personal capacity and as health managers at the level of a unit, hospital or provincial level. How do we enforce evidence based medicine in our clinical practice? First of all identify and prioritize clinical, psychological and social problems. Perform a complete and competent clinical examination to establish a diagnosis. Consider additional problems and risk factors needing attention. Where ever necessary seek evidence from systematic reviews, guidelines, clinical trials, and other sources. Assess the evidence on account of completeness, quality and strength. More importantly ask yourself if valid and relevant evidence is being applied and is it both scientifically justified and intuitively sensible? Present the pros and cons of different options to the patient in easy to understand fashion and help to formulate a final recommendation. Most importantly arrange for review, recall, referral and further case wherever required.

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Ref: Heal Thy Heart written by Prof: Dr. Muhammad Hafizullah

ARTICLE XIII - Heart Diseases in Eve – What’s new?

2009-06-30T07:43:00.000-07:00

“Women are immune to heart problems,” is a wrongly held belief. The biggest killer of women is neither breast cancer nor uterine problems. Most women lose their lives to heart problems and strokes. Though, they may be less common in women before menopause but afterwards the disease is not only more common in females, it is more aggressive and flows a more serious course. Most women, even in the West, are not aware of the gravity of situation. This requires urgent attention and a well coordinated prevention plan.

A landmark meeting of specialists was held in Canada called the ‘First International Conference on Women, Heart Disease and Stroke’, on May 10, 2000. This took account of the situation and made elaborate recommendations. Some of the recommendations made there were to involve women in the development, implementation and evaluation of programs and services. To remove barriers to women’s participation in leadership positions in all sectors. Most importantly, to tailor programs and services to women’s needs including primary prevention, screening, diagnosis and treatment, prevention of recurrence, rehabilitation and support programs and services

What are the major factors?
Important factors have been identified which play a substantial role in the causation of heart diseases and strokes in both men and women.

a. Poverty:
It is the biggest curse around the World. The picture becomes more obvious when one realizes that more than 1000 million people live in absolute poverty, approximately 900 million are illiterate, about 2000 million people are deprived of potable water and approximately 800 million people go hungry every day. Though it may seem incredible but the truth is that there are 150 million undernourished children under 5 years of age and 14 million children less than 5 years old die every year. Women are the worst sufferers of this appalling poverty.

b. Response to stress:
Individuals cope in a variety of ways to external stress. Health effects of stress are shaped by social and cultural factors. Western assumption is that host response mechanisms operate only at the level of individual. The cross-cultural research suggests that many other factors have important roles to play and determine the response to stress. The response to stress of women in developing countries may be different and more severe.

c. Roles of Women
The women of today and yesterday has been “E”-woman which means EVERYTHING TO EVERYONE AT EVERY TIME. Women have various roles which vary by culture and country. Women tend to have primary responsibility for maintaining a home and caring for family members – young and old. This creates double workload, looking after family and in many cases earning money. As compared to men more efforts have to be put in by women in looking after family and fulfilling all family members’ need.

d. Inequalities of society:
Though health services are inadequate for the general population but of what is available women face great inequalities due to unequal access to and use of basic resources. Major reason for that is unequal access to primary care across all strata. Health policies and programs do not address this problem objectively and positively and this leads to persistence of inadequate and inappropriate health services for women.

How to promote women’s heart health?
Considering the risk factors for heart problem and stroke, a policy was decided upon to work on some guiding principles. For the promotion of women’s heart health and prevention and management of heart diseases and stroke following goals may be considered and worked at:

· Heart healthy habits:
Women have same risk factors as men. Conglomeration of risk factors has to be appreciated. Recognition of risk factors and control of risk factors is the foremost principle. Modifiable risk factors are high blood pressure, high cholesterol, smoking, lack of exercise and obesity. Health promoting dietary habits and regular physical activity have to be promoted. Health promoting dietary habits should be conducive in reducing weight by reducing caloric intake and regular exercise. Diet has to be modulated to keep cholesterol in lower limits. Regular physical activity for all ages and both sexes should be ingrained in our priorities and emphasis should be placed on it from young age. Women in developing countries are not encouraged to exercise and participate in sports. These civil barriers have to be broken and females have to be encouraged to remain active and take regular exercise.

· Research:
There is a need to address the issues of heart disease and stroke among women, including cardiovascular health and disease among women and the impact of preventive and therapeutic intervention on women. This should include gender sensitive research, education, training and supportive environments for women researchers. There is dire need, especially in Pakistan for involvement of women directly in the identification of women’s research issues, methods, analyses and interpretation of results.

· Dissemination of information:
There is urgent need to develop an “info-structure” to effectively disseminate the latest research pertinent to women. Recommendations on latest guidelines issued by various bodies have to be made public. Burning issues in women’s health need media attention and any conclusion drawn need to reach the end users. Ongoing programs need surveillance and monitoring of their findings and to be made available to general public on print and electronic media.
In conclusion, we have to recognize that heart diseases and stroke are the leading causes of death among women in the developed world and are fast approaching the same status in the developing world. Gender inequity, poverty, illiteracy, unemployment, and lack of access to health services influence women’s health, and we have to take appropriate actions to address these and other underlying determinants of health, and promote a healthy lifestyle that would help prevent heart diseases and stroke in women.

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Ref: Heal Thy Heart written by Prof: Dr. Muhammad Hafizullah

ARTICLE - XII - How to treat heart failure? (Part-II)

2009-06-30T07:37:00.000-07:00

Treatment depends on the cause of heart failure, the type and severity of symptoms and how well the body is able to compensate. Early testing is important because early treatment can sometimes prevent heart failure from worsening or even reverse its progress. Lifestyle changes and medication can improve the quality and length of life.

Life style modifications:

Regardless of cause of failure and severity of symptoms, there are certain rules to follow for every one. Diet and lifestyle modifications are important in managing the symptoms.

Limit Fluid intake. Excessive fluid puts extra load on heart and can make it harder for the already weakened heart to pump. Monitoring fluid intake can reduce complications and hospitalization. All foods that melt such as ice cream, gelatin, or frozen ice treats and foods that contain a lot of liquid such as soup are considered liquids. To relieve thirst without taking extra water, chewing gum or rinsing mouth with water and spitting it out can be tried.

Limit sodium intake: When a patient has heart failure, one need to eat less sodium, a component of salt, Excessive sodium leads to retention of water that makes it harder for the weakened heart to pump and leads to worsening of heart failure. Fluid may build up in the lungs – making it harder to breath. It may accumulate in feet, ankles, legs, and abdomen. Sodium intake should be limited to less than 2 g (2000 mg) per day and keeping track of sodium intake is the surest way of evaluating diet. Processed and restaurant food are high in sodium. Remember, food can be tasty and still be low in sodium.

Exercise: Exercise is very important for people with heart failure. If the patient is not already active, he should be encouraged to start an exercise program. Prescribed exercise is often part of a cardiac rehabilitation program.

Weight: Heart is entrusted with the responsibility of supplying nutrition in the form of blood to all parts of body. Losing weight can favourable lessen the load on heart. Over weight patients should be very strongly urged to lose weight.

Smoking: Smoking increases the risk of heart disease and makes it more difficult to exercise.

High blood pressure: Exercising, limiting salt intake, and controlling stress can help keep blood pressure in a healthy range.

2. Drugs: We are lucky that we have a host of drugs available, to not only control the complaints associated with heart failure but also favourably effect the eventual outcome. Added medications may be used depending on how well the patient tolerates the prescribed medications:

· Diuretics: Water tablets form the corner stone of heart failure treatment. The body is over loaded with extra fluid and the only way to get ride of this is through increased urine output. The drug has to be used very carefully because excessive use can lead to loss of salts and water leading to dehydration. Supplements of potassium are required on a regular basis to compensate for the loss. Some diuretics have special Potassium retaining effect and the combination of a loop diuretic and potassium sparing diuretic makes a logical choice. Renal function may dictate the type of diuretic to be used.
· ACE inhibitors: ACE inhibitors have been a wonderful addition in the armamentarium of anti-failure drugs. They have been proven to reduce death rate and improve symptoms in patients with mild, moderate or severe heart failure. Their efficacy has been established in patients with poor heart function but no obvious evidence of heart failure. This medication reduces the heart’s workload, lowers blood pressure, and optimizes heart function. Every patient with heart failure should benefit from ACE inhibitors. Some patients develop intractable cough with ACE inhibitors, they can benefit from the new class of drugs called Angiotensin receptor inhibitors.
· Beta Blockers: Beta blockers have revolutionized the management of heart failure patients. The research one the use of Beta blockers in heart failure, has shown that Beta blockers prevent worsening heart failure and in some cases improve heart function. However, some patients are not able to take them because of their side effects.
· Additional medications for coronary artery disease (CAD), high blood pressure, diabetes, infection or inflammation of the heart muscle (such as myocarditis), thyroid problems, heart valve problems, and abnormal heart rhythms (arrhythmias) may be required.

3. Definitive treatment:
In some cases, heart failure can be reversed when the underlying problem can be corrected, such as heart valve replacement surgery and treatment for hyperthyroidism. Sometimes heart failure develops shortly after a heart attack; heart failure can sometimes be reversed in these cases when treatments such as coronary artery bypass surgery or angioplasty, medication, and cardiac rehabilitation improve blood flow.

4. New treatment options:
Recent research has focused on developing devices that can help cardiac failure.

· Cardiac resynchronization therapy: Biventricular pacemakers can synchronize the rhythm of the heart’s chambers (cardiac resynchronization). Cardiac resynchronization is typically used for people with heart failure who also have certain problems with their heart’s electrical system. A recent study suggests that cardiac resynchronization may offer improvements in heart function, exercise capacity, and quality of life beyond that seen with medications alone in these people.
· In some cases when standard medical treatment does not help worsening symptoms of heart failure, other measures are considered. These include heart transplant, artificial hearts, and left ventricular assist devices (LVADs) – mechanical pumping devices that are implanted into the chest. However, these options are only for a very small number of people.

Heart failure is a life long malady and it demands understanding and commitment by the patient. Patient’s attitude and level of participation in the treatment can strongly effect the treatment outcome. Making the required changes in life style and complying with dietary restrictions can have a positive impact on the eventual prognosis. Taking the medications as directed, controlling the diet, and getting regular exercise are key lifestyle changes to control heart failure symptoms and preventing worsening of heart failure.

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Ref: Heal Thy Heart written by Prof: Dr. Muhammad Hafizullah

ARTICLE XII - How to pass the ‘Failed Heart’ (Part-I)

2009-06-30T07:29:00.000-07:00

“No, this is not possible, I cannot have heart failure,” said Abdul Qayyum, 50 years old bureaucrat with clenched fists and raised eyebrows. His argument were, “I can walk around and attend my office, so I cannot be too unwell!”It took him some time to accept the diagnosis. His next question was, “Is it the end of story? Shall I ask for retirement and confine my activities?” He was very happy to learn that firstly, heart failure was not synonymous with cardiac arrest/death and secondly, near to normal life was possible with new medical treatment. Some new drugs have effects on improving the outlook of disease and new technology is evolving to mitigate the suffering of patients with heart failure.

Heart failure is the end result of many diseases that effect the heart. Some diseases effect muscles of heart either through infections or deprivation of blood supply – coronary artery disease. Certain diseases effect the doors of heart called valves, either by restricting their motion or rendering them incompetent and leaky. High blood pressure puts extra load on heart and heart muscle has to generate higher pressure to pump blood. This extra effort taxes heart and eventually leads to heart failure. Heart tries to compensate by either beating fast or increasing in size, but eventually gives in. This stage is called heart failure as heart cannot meet the demands of body.

For the management of heart failure, prompt and accurate diagnosis of the disease causing heart failure is of paramount importance. There are several causes of heart failure. Several different tests are required to determine the exact cause of heart failure. In some cases the cause of heart failure can be reversible (such as a heart valve defect) or treatable (such as a thyroid problem) but in a majority of cases drug treatment is used to reduce the symptoms and improve the outlook.

How to work up heart failure? In patients with symptoms suggestive of heart failure, many tests may be required. Recently there has been a lot of research on a special blood test called brain natriuretic peptide (BNP), which can be used to diagnose heart failure and correlates well with severity of failure. The level rises when heart failure worsens. Electrocardiography (ECG) and Chest X-ray are the bare minimum cardiac tests. Echocardiography (echo) is the best and simplest way to determine heart function and whether it is systolic or diastolic heart failure. Echocardiography can also help to determine the cause of heart failure and help guide treatment decisions.

Nuclear scanning – a non invasive nuclear test is done to identify areas of the heart that are not receiving adequate blood flow (ischemic areas) and assess the left ventricle’s ability to function. Cardiac blood pool scan (radionuclide ventriculography) is often used when echocardiography results are less likely to be accurate due to a person’s weight or breast size of the presence of severe lung disease. Radionuclide ventriculography provides an accurate method for assessing the pumping ability of the left ventricle. However, it is less useful for evaluating the presence of heart valve disease and thickening of the heart muscle. ThalliumRadionuclide ventriculography provides an accurate method for assessing the pumping ability of the left ventricle. However, it is less useful for evaluating the presence of heart valve disease and thickening of the heart muscle. ThalliumRadionuclide ventriculography provides an accurate method for assessing the pumping ability of the left ventricle. However, it is less useful for evaluating the presence of heart valve disease and thickening of the heart muscle. Thallium/MIBI scan can detect reduced blood flow to heart. Cardiac catheterization and angiography can be used to identify blocked or narrowed coronary arteries and to measure pressures inside heart. Test results can help diagnose conditions that might cause or worsen heart failure symptoms.

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Ref: Heal Thy Heart written by Prof: Dr. Muhammad Hafizullah

ARTICLE XI - So you had a Heart Attack – What next!

2009-06-30T07:23:00.000-07:00

Khalid seemed visibly upset and was trying to hold back his tears. He was in his early forties and had just entered his pratical life. He had two small kids and a very lucrative job. He had many dreams and many unfulfilled plans. He was perfectly healthy so far and it had not occurred to him in his wildest dreams that he will end up in CCU one day. But as luck would have it, he suffered a heart attack one morning, and here he was in CCU on the second day of his admission.

I could see a hot of questions written all over his face. Is it the end of his career and will he lead a nearly crippled life? Does it imply that he will be confined to his house for the rest of his life? Does it mean that he necessarily has to go for a bypass operation< Will he not be able to enjoy golf again? Does he have to remain content with a boiled diet without any meat? Should he pursue his MBA degree? Should he still consider an addition in his family?

Heart attack can mean different things to different people. For most patients it is an important event but it passes off like another event and the person can go back to normal life. There is a definite mortality attached to it. Half of the persons who die of heart attack die within first hour and that too because of irregular beating of heart. In a few cases, it is not even recognized as a heart attack. Later, once patient is stable in CCU and has received definitive treatment then the death rate does down. Ninety percent of patients will leave CCU and hospital alive on their feet.

There was a time when patients were kept in the hospital for weeks and they were not allowed to lave the bed for a month. Things have changed for the better! Patients who are otherwise stable are mobilized after forty eight hours. They are discharged if they are otherwise stable on third or fourth day. If they have any problems – mechanical or electrical, they are kept under observation for as long as necessary. Patients who undergo angioplasty after heart attack may be discharged the next day and allowed to return to work much earlier. Patients are advised rest and leave from work for four weeks. Gradual mobilization is recommended after discharge. Starting from ten minutes on an empty stomach at a leisurely pace morning and evening and then building it up slowly to thirty minutes twice a day. Most patients can expect to go to work after four weeks.

When and what tests does one require after a heart attack? The basic philosophy is firstly to document the extent of damage in terms of function of left ventricle – main pump. Secondly, determine the extent of blockages in vessels supplying heart – coronary arteries, and thirdly look for all risk factors and try to improve them. Most patients will be required to undertake tests like effort tolerance test and echocardiography. This is to identify patients who will be requiring further tests like coronary angiography and hence requiring interventions like angioplasty and bypass operation. Not every patient who suffers from heart attack needs angiography or bypass surgery. Patients on very demanding and physically tough jobs or those who are young are advised coronary angiography irrespective of the result of effort tolerance test.

Big question for the family is what to allow the patient to eat? Many patients on their first visit after heart attack bring their youngest child who demands a list of forbidden food. This young lad turns out to be mama’s detective on a special duty. Depending on other risk factors like diabetes, high blood pressure and high cholesterol, there is not a lot that a patient should be denied. Preferably, food should be low in cholesterol within no ghee, butter, fat, egg, and internal organs. Small quantity of chicken and meat are allowed and fish is encouraged. No bar on bread or rice unless the patient is fat and calories have to be watched. Soups are allowed but should not replace normal food. Some roughage in the form of salad and fresh or boiled vegetables should be encouraged as it prevents constipation. Half cream or skimmed milk may be consumed. Juices especially fresh may be encouraged if the patient is not diabetic. Fresh fruits are always welcome.

Most patients are able to retain their job and follow their pursuits unless it is very risky and demanding. A few months down the lane most people will have forgotten about the event and gone back to their old life styles. Competitive sports and jobs in armed forces may be difficult to retain. Most intellectuals and bureaucrats have had a heart attack by the fifth decade but they continue to follow their jobs and hobbies.

Can one have another heart attack after the first one? Why not! So one has to put in efforts to correct one’s risk profile. For those who are diabetic, blood sugar level has to be meticulously controlled by keeping a very vigilant watch on diet and taking prescribed medicines regularly. Patients with high blood pressure have to bring their blood pressure to normal range or lower than that. Salt has to be restricted and treatment plan adhered to. Cholesterol has to be brought down regardless of the baseline levels. Strict control on diet is required and nowadays we are very liberal in prescribing cholesterol lowering drugs like statins. They have been shown very convincingly to reduce deaths and requirement of angiography and interventions like bypass and angioplasty in treated patients with salutary effects on lipid profile.

With modern treatment, like clot dissolving drugs and angioplasty – opening of vessels with balloons and stents, the outlook has improved remarkably. Most patients can go back to their original job and life style in four weeks. Regular exercise, discretion in diet and adherence to treatment are the golden rules to follow. For the majority of patients who sustain a heart attack, it is not the end of the world!

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Ref: Heal Thy Heart written by Prof: Dr. Muhammad Hafizullah

Article X - Management of Heart Attack – the Recent Advances!

2009-06-29T23:51:00.000-07:00

The immediate management of heart attack called acute myocardial infarction, entails accurate and prompt diagnosis of heart attack based on history, ECG and blood test for release of cardiac enzymes. For monitoring and definitive treatment, quick assessment and early referral to a coronary care unit (CCU) is required. Management includes general measure and drugs – pharmacotherapy. Effort has been made to describe various strategies and drugs under the headings of rationale and evidence, indications, protocol and dosage and precaution.

MOBILITY:

Patient is confined to bed for the first 24 hours being monitored in CCU. Patients with persistent chest pain, irregular beating of heart called arrhythmias or heart failure are immobilized for longer duration. In uncomplicated heart attack gradual mobilization according to a set protocol should be followed.

OXYGEN:
Rationale and Evidence
Increased oxygen concentration is helpful at the time of heart attack to protect jeopardized heart muscle. It is helpful in reducing ventilation and perfusion mismatch. Administration of 100% oxygen has been shown to reduce ECG changes and have some effect on reduction of heart attack severity and size in animal and human models.

Who should get it?
Supplemental oxygen to all patients with overt breathlessness and those who have low oxygen saturation. Routinely it may be administered to all the patients with uncomplicated heart attack during the first 2-3 hours. There is no convincing evidence of any significant benefit in uncomplicated heart attack beyond 3 hours. Oxygen may be administered by nasal prongs or mask. The rate may be adjusted in arterial desaturation guided by repeat estimation. Nasal prongs may cause nasal irritation and mask may cause claustrophobia.

PAIN KILLERS
Rationale and Evidence:
Heart attack pain is very severe and capricious accompanied with impending feeling of death. Pain increased sympathetic activity hence increasing oxygen metabolic demand. This has to be relieved in shortest possible time with effective analgesics in appropriate dosage through proper route and repeated at proper intervals.

Who should get it?
Every patient with severe chest pain with ECG evidence should receive adequate analgesics. Those patients presenting after pain resolution may not be candidates for analgesics.

Precaution:
Morphine and analogues may depress breathing and extra caution must be exercised in old patients and those with chronic chest problems. Morphine and analogues cause vomiting, so anti-emetics should be given prophylactically.

CLOT DISSOLVING TREATMENT (Thrombolytic therapy):
Rationale and Evidence:
Last decade has been the decade of clot dissolving drugs called Thrombolytics. Convincing evidence from many large trials involving large patient population has secured a steady place for Thrombolytic therapy in the management of heart attack. This has revolutionized the management of acute heart attack. There has to be a solid reason for withholding Thrombolytic therapy. Dewood studies showed that a clot is involved in hart attack in more than 85% of cases.

This aim is early, complete and sustained blood flow to heart muscle. Cloth dissolving strategy involving intracoronary and intravenous administration of various agents has eventually reached a state of consensus. Clot dissolving therapy to reperfuse reduces death rate by 21% in patients with heart attack that means saving 21 lives per 1000 patients. The effects are time dependent as evidence suggests maximal benefit within two hours, optimal within six hours though definite benefit lasts till 12 hours. An estimated 35 lives per 1000 are saved when initiated within one hour as against 16 lives per 1000 when given 7 – 12 hours after the onset of symptoms.

Who should get it?
Clot dissolving drugs benefit all patients irrespective of age, gender, and presences of other conditions like diabetes mellitus. All patient presenting with heart attack within six hours of onset of symptoms must be administered clot dissolving Thrombolytics. Patients presenting within 6-12 hours should be considered for Thrombolytics. Patients presenting with symptoms suggestive of heart attack with left bundle branch block an ECG finding, should be candidates for Thrombolysis. Patients presenting after 12 hours with persisting pain and ECG changes should be considered for reperfusion theraphy after weighing pros and cons. More aggressive approach is desirable in younger patients and those with large heart attacks. It is, however, the elderly who get more benefit from Thrombolytic therapy.
Concerted efforts should be made that maximum number of patients benefit from this therapy. Initial evaluation in casualty department and CCU should be prompt and should not take more than twenty minutes in total. Consolidated data shows that 1.6 lives can be saved per hour per 1000 patients. Time is muscle, and every effort should be made to administer Thrombolytics as soon as possible.

Precautions:
Patients with contraindications to clot dissolving thrombolytics, like active internal bleeding, history of stroke, brain tumour, suspected aortic dissection, prolonged resuscitation, proliferative retinopathy, acute pancreatitis, fixed accelerated high blood pressure and bleeding disorders should not be given Thrombolytics. Streptokinase should not be used after 7 days and before 6 months of first administration due to the presence of antibodies.

ANGIOPLASTY:
Rationale and Evidence:
Coronary angioplasty provides the distinct advantage of not only opening the occluded artery by taking care of the superimposed clot but also dilating the primary lesion. The success rate of opening the infarct related artery is 95%. With the employment of stents the results are getting better. Infarct related artery has to be opened quickly, with lower rates of acute and subacute occlusion and restenosis. A pioneer study showed higher patency rates of coronary artery with reduced morbidity and mortality rates. It can be employed as the first and only procedure called primary angioplasty. In case of failure of clot dissolving treatment it is used as a rescue procedure called rescue angioplasty. Primary angioplasty should be performed by skilled operators backed by experienced personnel.

Who should get it:
The evidence from different trials support better outcome in terms of morbidity and mortality with anagioplasty as compared to thrombolytics. This mode of reperfusion is preferable wherever the facilities and expertise are available. It is the treatment of choice for patients presenting with low blood pressure called cardiogenic shock associated with large infarcts. It is of great importance for patients who cannot receive clot dissolving thrombolytic therapy. Patients who have received thrombolytic therapy in the last six months or who are allergic to it can derive benefit from angioplasty. Patients who fail to respond to thrombolytic therapy should be subjected to angioplasty.

The time taken from reporting to hospital to inflation of balloon in patients undergoing angioplasty should be comparable to the time taken in patients receiving clot dissolving drugs. This requires prompt assessment and management in the casualty department and CCU. Quick and in time referral to the Catheterization laboratory is mandatory. Round the clock availability of skilled operators and experienced staff and a well stocked Catheterization laboratory are very essential for the success of any programme. Cardiac surgical team should be available in case of emergency.

Precautions:
This mode of reperfusion involves high cost due to high cost of catheterization laboratory and hardware involved. It is subject to the availability of highly skilled and experienced operator and staff round the clock. Very few hospitals have such facilities so this can be offered to a very small segment of society.

ASPIRIN:
Rationale and Evidence:
Very few treatment modalities have been so well and widely received and practiced as aspirin in heart attack. Aspirin in does of 40 mg can reduce the aggregation property of platelets. In a summary of 33 trials, heart attack in patients on Aspirin was reduced from 25% to 11%. Many trials have shown remarkable beneficial effect.

Who should get it?
Every patient with no contra-indication to aspirin should be given aspirin as soon as possible. Administration of beta blocker, ACE inhibitors, reperfusion with thrombolytic therapy or primary PTCA, presence of hypotension, hypertension, bundle branch block, complete heart block, diabetes pose no contraindication to aspirin.

Every patient with suspicion of heart attack should be given aspirin 300 mg to chew as soon as possible and continued indefinitely in dosage of 75 mg per day. Various enteric coded brands are available in the market to reduce hyperacidity.

Precautions:
Patients with proven ulcer on endoscopy or barium meal, history of gastic bleeding or those receiving antiulcer treatment should not be given aspirin. Patients with known allergy should not be given aspirin. Other platelet inhibitors may be considered in patients who have allergy or who cannot tolerate aspirin.
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VESSEL DILATOR – NITRATE:
Rationale and Evidence:

Nitrates have muscle relaxation effect hence causing dilation of all vessels. This causes reduction in load on heart hence reducing oxygen demand. Intravenous therapy has been shown in animal and human models to reduce infarct size.

Who should get it?
Patients presenting, with heart attack in the first 24-48 hours, specially in large anterior heart attack, persistent chest pain and high blood pressure. It may be continued beyond 48 hours in patients with persistent chest pain or recurrent angina and breathlessness. Routine use after 24-48 hours is not recommended.

Nitroglycerine or Nitrate infusion is started and titrated while monitoring heart rate and blood pressure. Blood pressure reduction by 10% or heart rate increase by 10% should warrant reduction in dosage and closer monitoring. Long term oral therapy has not been found to have any significant effect on morbidity and mortality.

Precautions:
Patients presenting with blood pressure less than 90 mmHg, or slow heart rate should not be given Nitrate infusion. Lowering of blood pressure and increase in heart rate should be closely monitored.

BETA BLOCKERS:
Rationale and Evidence:
Beta blockers reduce heart rate and contractility hence decreasing oxygen demand. This has been shown to reduce heart attack size in animal and human models. Beta blockers decrease fatty acids. They have a well established role in ischaemia – reduce blood supply, arrhythmia – irregular heart beating and high blood pressure. Large trial and meta analysis have shown impressive reduction of morbidity and mortality with oral and intravenous beta blockers.

Who should get it?
Every patient regardless of age, gender, reperfusion strategy and therapy, time period, type of heart attack, associated comorbid condition should get it. It is of particular importance in patients with recurring chest pains, fast heart rate and high blood pressure.
Evolving heart attack should be given intravenous beta blocker watching blood pressure and heart rate closely. Oral therapy in appropriate dosage should be instituted at the earliest and continued preferably for two years. Perhaps all beta blockers in proper dosage confer similar effects. Beta blockers with longer half life have the advantage of convenience of dosage and lesser side effects.

Precautions:
Patients with asthma, chronic chest problems, low blood pressure – hypotension, overt heart failure, slow heart rate, uncontrolled or brittle diabetes should not be given beta blockers. Mild heart failure may be challenged with beta blockers under close supervision. Controlled diabetes is not a contraindication to beta blockers as the benefits outweigh the hazards.

ACE INHIBITORS:
Rationale and Evidence:
Dead – infracted segments stop contracting following a heart attack, other segments become hyperactive to maintain heart function. Heart undergoes remodeling in which it enlarges in size with increased wall tension on non infracted segments. Studies have shown that higher volumes are associated with higher chances of heart failure and increased morbidity and mortality. ACE inhibitors (ACEI) have been shown to reduce load on heart hence reducing wall tension and help is not increasing heart volumes. Use of ACE inhibitors in patients with symptoms of heart failure or evidence of reduced function derive maximal benefit with significant reduction of mortality and morbidity as shown in many large well conducted trials.

Who should get it?
All patients without contra indications to ACE inhibitors should be considered for it. It is particularly helpful in patients with symptoms and signs suggestive of heart failure or who have evidence of heart dysfunction – large dimensions and poor contraction even in absence of symptoms.

ACE inhibitors should be started with small dosage to obviate any low blood pressure episodes. The dose has to be built up gradually if patient can tolerate it. Systolic blood pressure should be mentioned closely. Optimal effects can only be expected at appropriate dosage Determined efforts should be made to optimize the dosage during hospitalization.

Precautions:
Patients with systolic blood pressure less than 90 mmHg should not be given ACEI. Those showing marked decrease in blood pressure, ACEI should be withheld and restarted at small dosage after some time. Those having persistent cough or intolerance to ACEI may be considered for Angiotensin receptor blockers like Losartan, Valsartan, Candesartan etc.

ANTI COAGUTANT – HEPARIN:
Rationale and Evidence:
Clot dissolving Drugs can open up the infarct related artery but for sustained patency Heparin had been advocated for a long time. Recent evidence from a large trial analysis does not support the regular use of Heparin following Streptokinase unless patient is at high risk for clot formation and dislodgement. Those patients who do not receive Thrombolytics may derive some benefit from Heparin. In the setting of unstable angina, intravenous Heparin has been shown to reduce morbidity and mortalilty.

Who should get it?
Patients presenting with unstable angina should get Heparin. Patients presenting late for thrombolytics should be considered for Heparin. In patients at high risk for clot formation and dislodgement like large or anterior infarction, irregular heart beat, or left ventricular clot, intravenous Heparin is preferred. Intravenous (IV) Heparin in patients receiving selective thrombolytics like tpa or alteplase is recommended.

Precaution:
Strick regimen should be followed as under dosage leads to treatment failure and overdosage causes bleeding complications.

FURTHER MANAGEMENT
This depends on the further course of disease. Uncomplicated heart attack patients are mobilized and discharged on 4th to 7th days of admission. An exit exercise tolerance test is favoured by some groups to identify patients at high risk requiring early angiography and intervention. Any mechanical, electrical or ischaemic complication is dealt with according to its merit.

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Ref: Heal Thy Heart written by Prof: Dr. Muhammad Hafizullah

Article IX - Unstable Angina – How to Stabilize it?

2009-05-20T00:31:00.000-07:00

“Is it a heart attack?” a newly admitted forty years old banker asked me and I replied in negative. His tenses face mellowed down and started wearing a smile. “Then it must be an episode of angina!” he concluded. My shaking head in negative perplexed the patient. “This is a stage in between the two, it is neither stable angina nor is it a heart attack but some thing between the two,” I explained. When angina becomes more frequent and brought on by milder exertion or starts occurring at rest without any exertion, it is called unstable angina. This disease forms the main bulk of admissions to a cardiology unit and coronary care unit. Unstable angina has to be taken very seriously as an episode of unstable angina may lead to heart attack or death. Inspite of aggressive medical therapy 30 days rate of death and myocardial infarction approximates 9.1 percent. This has resulted in employing several therapeutic agents and strategies in the treatment of unstable angina. We now understand that the heterogeneity in presentation and clinical course followed by unstable angina is due to heterogeneity in causation.

“What causes unstable angina?” he asked. Last decade witnessed strides of advances in our understanding of the causation of unstable angina. “Unstable angina develops due to rupture and fissuring of the blockage called plaque which leads to activation and aggregation of blood particles called platelets producing a clot and blocking the vessel hence reducing blood supply to heart muscle,” I updated his knowledge. A blockage/plaque is composed of a core made of lipid and has a fibrous cap. If the core is hard the chances of rupture are slim, on the other hand if its soft it can fissure and expose the inside sticky material. When lipid core increases beyond 40%, the plaque becomes soft and liable to fissure and rupture. The cap made of fibrous tissues may be thin or thick. This cap covering the plaque may rupture at shoulders more easily. Plaque cap usually gives way at lateral margins where it is attached to more normal intima. Blood enters the plaque and clot is formed due to thrombogeneity of exposed subendothelial tissue. The thrombus can extend into the lumen of coronary artery and propagate distally.

“How does a stable blockage become unstable?” asked Hameed. The factors that may come into play before a plaque/blockage ruptures are like increase in blood pressure, heart rate, and blood viscocity. External factors that exert mechanized stress on the plaque and lead to eventual rupture includes increased vasomotor tone, and disruption of nutrient vessels.

“What are the new advances in treatment?” he changed the topic from causes to treatment. “Well, the culprit is blockage in the vessel and the ideal treatment would be to restore blood supply by opening the vessel,” I replied and quickly added, “but opening of blockage may not be always possible, practical or feasible.” In the last two decades unstable angina was treated conservatively as wait and watch policy. Recently angioplasty has been advocated in patients with unstable angina resistant to conservative therapy or in preference to medical treatment. It is an effective revascularization procedure but is associated with a higher risk of complications including heart attack, emergency surgery, repeat angioplasty and in-hospital death, when performed in patients with unstable angina as compared to those with stable angina. Coronary angioplasty is an option to consider in the management of patients with unstable angina when the coronary anatomy is suitable, preferably as a semielective procedure after initial pharmacologic stabilization or more urgently in patients who have refractory symptoms of unstable angina.

Despite the fact that the world has advanced so much, not all acute coronary care units have enough facilities for complex intervention, so majority of patients with unstable angina are treated conservatively. The data supports the current policy of initially treating, the patient with unstable angina at the closes medical facility, rather than sending them to medical centers with advanced facilities. Patient with on going ischemia or hemodynamic instability can be transferred from noninvasive facility to invasive facility for specialized treatment.

Furthermore, angioplasty or surgical revascularization procedures are expertise dependent and are not available round the clock. Supporters of invasive approach argue that early angiography has several benefits like early identification of blockages which need urgent bypass surgery e.g left main coronary artery disease. It offers early identification of normal coronary arteries, hence excluding coronary disease so preventing risk of prolonged antiplatelet or antithrombin therapy. It has the potential cost saving effect in terms of decreased hospital stay.

One study suggested a long term benefit by reducing death and heart attack in invasive group, but the intervention in this group was either selective or was performed a few days to weeks later, allowing the patients to be stabilised. However other studies have failed to show any benefit in patients treated invasively as opposed to those treated conser-vatively in terms of death and heart attack.

“What if a patient does not want to have angiography, cannot afford angiography or a hospital does not have facilities for the procedure?” he was determined to learn every thing about unstable angina. Addition of aspirin, clopidogrel and intravenous Heparin to conventional angina treatment has improved clinical outcome. Newer strategies have been developed to improve the unstable angina treatment. Platelet function can be inhibited by various drugs to variable degree for variable duration. SAccordingly various drugs are used for multiple purposes in different clinical situations. Newer agents, by blocking IIb IIIa receptors are more effective as they block the common pathway receptor and lead to complete inhibition of platelet aggregation. Theraphy in the form of heparin plus oral aspirin is the current mode of treatment for patients hospitalized with unstable Angina.

Low molecular weight Heparin are prepared from fractionation of standard Heparin – several preparations of Low molecular weight Heparin exist e.g. Nadroparin, Deltaparin, Panaparin, Enoxaprin etc. A number of studies have documented that Low molecular weight Heparin adds a significant clinical benefit to that of aspirin in the treatment of acute unstable angina. However, it is not clear whether Low molecular weight Heparin offer better outcome. Many studies have concluded that Low Molecular Weight Heparin have a definite role in the management of unstable angina.

Unstable angina is a medical emergency. It needs prompt and accurate diagnosis and institution of treatment. Coronary angioplasty should be offered to patients with continued chest pain, haemodynamic instability, worsening of ECG or resistance to treatment. All patients should be treated with antianginal drugs plus heparin and antiplatelets agents.

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Ref: Heal Thy Heart written by Prof: Dr. Muhammad Hafizullah

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Article VIII - Put a Leash on the Silent Killer – High Blood Pressure

2009-05-20T00:29:00.000-07:00

“Doctors are lowering the goal post every few years, what was desirable a few years ago has become unacceptable now,” commented Ansaar, a patient of high blood pressure for the last ten years, as I drew his attention to the new targets of blood pressure. “Initially I was told that blood pressure of 160/90 is the goal and now I am being told that it is too high,” he continued. I tried to explain, “New research has established that the risk of heart disease has a continuous relationship with blood pressure and there is no safe lower limit. We have recognized that lower blood pressure accrues more benefits for the patient with reduction in death rate and lesser complications pertaining to heart, brain, eyes and kidneys.”

The aims of blood pressure treatment are to reduce cardiovascular diseases like heart attack, angina and stroke and reduce and prevent kidney related complications and deaths. This is achievable by aiming to treat blood pressure to less than 140/90 mmHg in general population and less than 130/80 mmHg in patients with diabetes or chronic kidney disease. It is important to achieve systolic blood pressure goal, especially in persons more than 50 years of age.

It is important to take steps to keep blood pressure under control. How to control elevated blood without resorting to drugs? In this section we will learn about blood pressure-lowering lifestyle habits and blood pressure medications.

1. Lifestyle:
Adopting healthy lifestyle habits is an effective first step in both preventing and controlling high blood pressure. Physical activity is perhaps the best way to counteract high blood pressure. It helps to reduce weight, lowers cholesterol and hence the risk of heart disease. If lifestyle changes alone are not effective in keeping the pressure controlled, it may be necessary to add blood pressure medications.

2. Reduction of salt:
A key to healthy eating is choosing foods low in salt and sodium. Most people consume more salt than they need. The current recommendation is to consume less than 2.4 grams (2,400 milligrams) of sodium a day. That equals 6 grams (about 1 teaspoon) of table salt a day. This includes all salt and sodium consumed, including that used in cooking and added at the table. For someone with high blood pressure, the advice is to eat less salt and sodium. Recent research has shown that people consuming diets of 1,500 mg of sodium have lower blood pressure. The lower-sodium diets prevent blood pressure from rising and help blood pressure medicines work well.

3. DASH Diet.
A diet known as Dietary Approaches to Stop Hypertension (DASH) is now recommended as an important step in managing blood pressure. This diet is not only rich in important nutrients and fiber but also includes foods that contain more electrolytes, potassium, calcium, and magnesium, than are found in the average diet.

Avoid saturated fat although include calcium-rich dairy products that have no or low-fat. When choosing fats, select monounsaturated oils, such as olive or canola oils. One study reported a reduced need for anti-blood pressure drugs in people with a high intake of virgin olive oil, but not sunflower oil a polyunsaturated fat.

Choose whole grains over white flour or pasta products. Choose fresh fruits and vegetables every day. Many foods are rich in fiber, which may help lower blood pressure. Important foods include most fruits (especially potassium-rich fruits including bananas, and oranges) and vegetables (especially carrots, spinach, mushrooms, beans, potatoes), includes nuts, seeds, or legumes (dried beans or peas).

Choose modest amounts of protein (preferably fish, poultry, or soy products). Soy in combination with fiber-rich foods or supplements may have specific benefits. Oily fish may also be particularly beneficial. They contain omega-3 fatty acids, which have been associated with heart and never protection.

In one study, after eight weeks on the diet, subjects from a broad range of backgrounds, experienced a significant reduction in blood pressure. Evidence now also suggests that it may be a good diet for lowering LDL cholesterol levels – although the beneficial HDL levels also decline.

4. Weight Loss
Weight gain seems to be a primary determinant in blood pressure increase, and weight loss may be even more important than salt restriction in controlling blood pressure. Losing weight, particularly in the abdominal area, immediately reduced blood pressure. Weight loss, particularly accompanied by salt restriction, may allow patients with mild hypertension, even older people, to safely reduce or go off medications. The benefits of weight loss on blood pressure appear to be durable.

5. Stress Reduction and Psychological Therapy
Improving mood or relieving stress may be helpful. The following are some studies suggesting possible benefits:

Two small studies reported that active religious faith was associated with healthy blood pressure levels, possible indicating the combined benefits of a strong social network and reduced stress from spiritual activities.
Studies suggest that stress reduction programs, such as those that use cognitive-behavioral therapy, can reduce blood pressure. In some cases people can even go off medication.
Even pets can provide healthful support. In a small 2001 study, medication had no effect on blunting blood pressure that increase in response to stress, but owning a pet did.
In another study, a simple relaxation technique called transcendental meditation (TM), which involves silent repetition of a single sound, was shown to be effective in reducing blood pressure. This is equivalent to our Tasbeehat which we ought to offer regularly.

6. Drugs:
If above measures are unable to normalize blood pressure, then one has to resort to drugs. Here is brief description of main types of drugs and how they work, their benefits and main side effects. Often, two or more drugs work better than one.

1. Diuretics
Diuretics are called “water pills” because they work in the kidneys and flush excess water and sodium from body. For decades, diuretics, have been the mainstay of antihypertensive therapy and are still considered the first choice by many experts.

Benefits of Diuretics. Diuretics significantly reduce the risk for stroke; they may in fact be the most important agent for preventing brain attack. They also appear to protect against stroke in people without high blood pressure. They are associated with a lower risk for heart attack (although this not as significant as their protection against stroke).
Diuretic Types. Diuretics are available in many types and are generally inexpensive. Most need to be taken once a day. Three primary types of diuretics are:

Thiazides. Thiazides are most frequently used and most effective agents for the treatment of high blood pressure. They may either be taken alone for mild to moderate hyper-tension or used in combination with other types of drugs.

Loop diuretics. Loop diuretics block sodium transport in parts of the kidney; they act faster than Thiazides and have a great diuretic effect. It is important to use the medication cautiously and avoid dehydration and potassium loss.

Potassium sparing agents. These diuretics conserve potassium. Potassium-sparing diuretics include Amiloride, and Spironolactone.

· Side Effects and Problems:
The loop and Thiazide diuretics deplete the body’s store of potassium, which, if left untreated, increases the risk for arrhythmias. Arrhythmias are heart rhythm disturbances that can, in rare instances become serious. As such, we either prescribe low dose diuretic, recommend potassium supplements, or use potassium-sparing diuretics in combination. Potassium-sparing drugs have their own risks, which include dangerously high levels of potassium in people with existing elevated levels of potassium or in those with damaged kidneys. However, mild diuretics are well tolerated and in general diuretics are more beneficial than harmful.

Common side effects of diuretics are fatigue, depression, irritability, urinary incontinence, loss of sexual drive, breast welling in men, and allergic reactions. Diuretics can trigger attacks of gout. Diuretics may raise cholesterol level marginally.

2. Beta-Blockers
· Benefits: They affect the force and frequency of heart beats, slow certain metabolic processes and ease the workload of heart. They are very effective in reducing blood pressure and have been associated with the reducing the number of deaths from heart diseases. They have an added advantage in patients with high blood pressure, angina and hyper dynamic circulation.
· Side Effects and problems:
Because they can constrict bronchial airways, patients with asthma, emphysema, and chronic bronchitis should avoid them. Beta blockers should be used with caution in patients with poor heart function, and those who have heart failure. As they can reduce heart rate so patients with slow heart rates should not be prescribed beta blockers. Fatigue and lethargy are the most common psychological side effects. Some people experience vivid dreams and nightmares, depression, and memory loss. Dizziness and lightheadedness may occur upon standing. Exercise capacity may be reduced. Other side effects may include coldness of extremities that is, legs and toes, arms and hands. Angina, heart attack, and even sudden death have occurred in patients who discontinued treatment without gradual withdrawal.

3. Angiotensin Converting Enzyme Inhibitors
They are the first line drugs and are being prescribed most commonly for blood pressure. Angiotensin converting enzyme (ACE) inhibitors block the effects of the angiotensin-renin-aldosterone system, which is though to have many harmful effects on heart and blood vessels.

· Benefits: They may be very important agents for patients with diabetes. They may help protect kidneys and heart of these patients, independently of their effect on blood pressure. They may help prevent changes in heart muscle cells leading to heart failure, specifically in reducing enlargement of the left side of the heart, a major risk factor for heart failure. ACE inhibitors can improve a patient’s odds of surviving a heart attack.

· Side effects and problems:
Major side effect of ACE inhibitors is severe persistent irritating cough. This cough does not respond to any medication except for cessation of the drug. Although ACE inhibitors can protect against kidney disease, they also increase potassium retention in kidneys. This increases the risk for cardiac arrest if levels become too high. Because of this action, they are not generally given with potassium-sparing diuretics of potassium supplements.
Side effects include excessive drops in blood pressure, and allergic reactions.

4. Vasodilators
Vasodilators, which widen/dilate blood vessels, are often used in combination with a diuretic or a beta-blocker. They are rarely used by themselves. Some of these drugs should be used with caution or not at all in people with angina or who have had a heart attack.

5. Calcium Channel Blockers
Calcium channel blockers, or calcium antagonists, have an immediate effect on reducing blood pressure. Studies continue to report that they are equally effective or better than other anti-hypertensive agents in preventing heart events, stroke, or kidney complications. Recent research support their positive role in reducing death and complication rate as compared to other classes of drugs.

· Benefits: Calcium channel blockers are effective and safe. They are used in preference in patients with angina. Certain Calcium channel blockers have a useful role in controlling arrhythmias. They are very well tolerated and have no serious side effects.
· Side Effects and problems.
Side effects vary among different preparations. Most drugs can cause fluid accumulation in feet, along with constipation, fatigue, impotence, gingivitis, flushing, and allergic symptoms. Interactions with drugs also differ depending on the drug. For example, Verapamil and Diltiazem interact with Digoxin, but Dihydropyridines do not.

6. Angiotensin – Receptor Blockers
Drugs known as angiotensin-receptor blockers (ARBs), also known as angiotensin II receptor antagonists, are similar to ACE inhibitors in their ability to lower blood pressure.

· Benefits: ARBs may have fewer or less severe side effects, including cough. Recent studies have documented that ARBs protect the heart and kidneys as were benefits found with ACE inhibitors. Many comparison studies are underway. In a very promising study, the ARB Losartan reduced the risk of heart attack, death, and stroke more effectively than the beta blocker Atenolol. This is the first study finding any drug superior to a beta blockr for achieving these results. They may even improve quality of life when added to a drug regimen—a finding also found with no other anti-hypertensive drugs.
· Side effects and problems: The side effect profile is benign and most patients tolerate the drug very well. Though initially the drug was very expensive and out of reach of most people, it is now available at comparable cost.

7. Alpha Blockers
Alpha blockers widen arterioles and veins and thereby reduce blood pressure. They are recommended for reducing blood pressure along with other agents, as their side effects profile is benign.

8. Combinations:
To achieve desirable reduction in blood pressure different groups of drugs may be combined. Adding different drugs add the effects and decrease the side effects attached to higher dosage. New guidelines have issued clear directive to start therapy with two agents, if blood pressure is considerably higher than the target blood pressure.

High blood pressure is a common disease afflicting a large population. It has been termed as a silent killer as it can be asymptomatic in spite of effecting target organs. Life style modifications should be employed in the start but drugs can be added if desirable effects are not achieved.

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Ref: Heal Thy Heart written by Prof: Dr. Muhammad Hafizullah

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Article VII - How to Control the Monster of Cholesterol?

2009-05-20T00:25:00.000-07:00

“I have been fasting for nearly a month but my cholesterol wouldn’t budge!” complained forty year old Naseem who was diagnosed with high cholesterol a month ago. “What have you been eating?” I asked him. “Honest to God nothing – just nothing. Only two boiled eggs in the morning, butter and two toasts with nothing else in the evening and a glass of milk with a little piece of cheese at night!” confessed Naseem. “With your dietary regimen you are bound to push cholesterol up than bring it down. You have to alter the quality of diet and not the quantity of diet,” I said in a matter of fact way.

How can one reduce cholesterol? There are three cardinal features around which this philosophy revolves. Dieting, exercise and drugs. All of the are equally important. One always starts with diet and exercise. It has to be emphasized in crisis or recovery, before and after an intervention, with drugs and without drugs.

1) DIET: Diet involves:
a) reduction of calories essentially to reduce weight
b) reduction of total fat intake
c) reduction of saturated fat and cholesterol
Obese people are more at risk for atherosclerosis that those at desirable weight. Obese people are more likely to have other risk factors like sugar (diabetes) and high blood pressure (hypertension) etc. First step towards reduction of cholesterol is to reduce intake of food rich in calories. All foods items containing sugar like cold drinks, hot drinks, ice creams, bakery items and desserts etc. should either be avoided or have to be reduced drastically. Fats are a very rich source of calories. Oil has an equal content of calories as compared to ghee, so for reduction of weight both have to be avoided. Many people change over to oil from ghee and think that this should suffice. In the fight against obesity ghee and oil both have to be discarded from diet.

More stress should be laid on fresh fruits and vegetables. Boiled vegetables and pulses (without the tarka) are good sources of nutrition without a high caloric count. An ideal will be to have a couple of glasses of water before attacking the food, take a bowl full of fresh salad followed by a bowl full of boiled pulses like beans, gram (with adequate spice to make it tasty) followed by another two glasses of cold water. Fresh fruit may be eaten after it. The beauty of this is no ghee or oil, no sugar or high caloric stuff and enough variety to choose from.

Fat is present in four main forms in the food we eat, saturated fatty acid, mono saturated fatty acids, poly unsaturated fatty acid and cholesterol. It is advisable to restrict intake of fat to less than 30% of total calories for a day with less than 10% from saturated fatty acid and the rest from unsaturated acids.

1) Saturated fatty acids are mainly responsible for increase in cholesterol. Main animal sources are butter, cream, cheese, fat in beef, lamb and poultry. Coconut oil, palm oil and kernel oil are the main sources of saturated fat from plants. Every effort should be made to avoid this class of food as it is the main source of cholesterol.
2) Mono unsaturated fatty acids are found in olive oil, canola oil, rapeseed oil, peanut oil and sunflower oil. These oils do not contribute towards increase in cholesterol. In fact these help to lower cholesterol. These oils may be used rather liberally but with care because increase in content may increase caloric intake, which may in turn increase weight.
3) Poly unsaturated fatty acids are derived from animal and plant source. These fatty acids reduce total and LDL cholesterol in body. Vegetable oils like sunflower, soybean and corn contain omega-6 fatty acids. Certain fish like trout, sardine, coho and ping salmon and atlantics halibut are rich sources of omega-3 fatty acids. These fatty acids offer protection against atherosclerosis by retarding the process. Intake of omega oils is encouraged to the extent of taking fish two to three times a week (not cooked in ghee). Fish oil capsules containing large quantity of omega oils have not been shown to have any definitive effect on hear problems.
4) Cholesterol is only derived from animal sources like egg yolk, internal organs, milk, butter, cheese etc. Total cholesterol intake should be less than 300 mg per day. It should be reduced further in people with high cholesterol. Every one should be wary of high cholesterol contents of certain food stuff and should make a determined effort to avoid it.

What to avoid:
a) Whole milk: A cup of whole milk contains 5.1 mg saturated fatty acids, 33 gms of cholesterol and 150 calories. Where as skimmed milk contains 0.3 mg saturated fat, 4 mg of cholesterol and 86 calories. Skimmed milk should be substituted for whole milk to reduce cholesterol and caloric intake.
b) Butter and creams: One teaspoon of butter contains 36 calories, 11 mg of cholesterol and 2.5 mg of saturated fat. Avoid butter and cream specially used in bakery items, desserts and ice cream.
c) Eggs: One egg yolk contains 213 mg of cholesterol. Egg while is a rich source of protein and does not contain cholesterol. Egg yolk must be avoided with high cholesterol and the use should be reduced in those with borderline or normal cholesterol.
d) Cheese: Cheddar cheese has high cholesterol and should be avoided. Cottage cheese has 5 mg cholesterol in half a cup so it can be taken.
e) Meats and fish: Contrary to widely held belief, beef and lamb have equal amount of cholesterol that is 22 mg per three ounces. All visible fat should be removed. Poultry should be cooked without skin which is a rich source of cholesterol. Internal organs like brain, liver and kidney etc. are very rich in cholesterol and MUST be avoided. Fish has low cholesterol but shrimps and lobster have high cholesterol.
f) Horrible Combinations: We know ghee has large amount of saturated fatty acids so it has to be avoided. This follows a simple dictum that everything cooked in ghee is high in cholesterol and should be avoided. If an egg is fried in ghee or butter, the cholesterol content goes up – it simply multiplies. Internal organs are the richest source of cholesterol, if cooked in ghee or butter the content increases, add some eggs to it and make it worse and top it up with some bone marrow and make it the ‘deadliest’ of recipe. ‘Kat-a-Kat’ is perhaps what you should be offering to your enemies. ‘Karahi Ghosht’ is lamb cooked in its own fat, special attempts are made to use the fatty portions and extra fat is added to make it really high in cholesterol. Nehari savoured by a lot us is very high in cholesterol; meat with internal organs cooked in ghee with added bone marrow with plenty of spices – ‘finger licking’ but sticking stuff for arteries. What is ‘Chappali Kabab’? Minced meat with lots of unwanted fat cooked in highly saturated fat and topped with eggs and at times bone marrow. It may be tasty but very high in cholesterol. Unfortunately most of our exotic food is very rich in cholesterol.

We know full cream milk has high cholesterol, so does full cream ‘lassi’. What do you think of full cream ‘Khoya’ dissolved in Lassi or milk – is it fit for human consumption? Desset made with full cream milk, eggs and cream tastes sweet but has exorbitantly high cholesterol. So beware of ‘Kheer’, custards and trifles. Though cheese is not used liberally in our foods but pizzas have cheese which has a very high cholesterol content. Cottage cheese, however, is nutritious and does not have high cholesterol content.

‘Halwa’ is not bad except when it is cooked in ghee and has the wrong additives. It is rich in calories because of sugar, ghee/oil and ‘maida’ though cholesterol content varies according to the additives and oil used. Most of bakery items are made in ghee, have eggs in it and are topped by cream. So beware of those attractive colourful ‘snares of cholesterol’ called cakes and pastries. Finger licking ‘mithais’ with tall claims of being cooked in ‘desi ghee’ are rich source of calories rather bursting with calories. Most of ‘mithais’ use eggs and are cooked in ghee hence increasing cholesterol content. I am sure you will agree that the best desset is either fresh fruit or after dinner jokes!

It is quite obvious that to reduce cholesterol one has to use low fat, low cholesterol diet while avoiding dairy products – whole milk, cheese, bakery items, eggs and meat containing fat. Fruits, vegetables and whole grain should be encouraged.

When dieting is not enough – Exercise:
Exercise is a vital companion to any dieting program. It serves the threefold purpose of burning calories, fighting flab and improving efficiency of cardiovascular system. Studies show that individuals who exercise have a high amount of HDL ‘good’ cholesterol which protects against cardiac problems.

Domestic work burns 180 calories (cal), walking 2.5 miles per hour (mph) burns 210 cal, gold burns 250 cal. Walking 3.5 mph burns 300 cal and running 10 mph burns 900 cal per hour. The most accessible, easiest and least expensive means of aerobic exercise is fast walking. Start exercising after consultation with doctor if you have crossed forty. Start with fifteen minutes thrice a week and slowly build it up to 30 minutes four to five times a week.

Drugs – When dieting and exercise are not sufficient:
If dieting and exercise fail to deliver the goods the next step is drugs. Besides fibrates available for a long time a new group of drugs called statins have captured the market. These statins – simvastatin, fluvastatin, lovastatin, atorvastatin and pravastatin are very effective agents to lower cholesterol with quite a safe profit. These have been used in many trials and have been shown to be effective in reducing cholesterol, deaths associated with heart, investigational procedures needed in cardiology and the need for angioplasty and bypass surgery. These drugs should be taken according to the advice of doctors. The drug therapy needs regular monitoring and reduction (and not cessation!) of dosage when targets and achieved.

With sound knowledge and enough zeal, the problem of cholesterol can be conquered. In this war, we need patience and persistence as it is a life long war. The dosage may decrease though careful life long monitoring is required.

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Ref: Heal Thy Heart written by Prof: Dr. Muhammad Hafizullah

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Article VI - Quitting Smoking – Make it Possible

2009-05-20T00:22:00.000-07:00

“Smoking is the easiest thing to give up, I have given it up a hundred times,” commented Kareem, while puffing. The missing link was why did he restart ninety nine times? On the other extreme, a very accomplished doctor after undergoing bypass surgery and angioplasty told his wife in unambiguous terms, “I can leave you, but I cannot quit smoking.” Yet, there are many people who have given up smoking and feel very happy about it. They cannot stand the smell of cigarette and refused to inhale nicotine actively or passively. Having learnt their lesson, they openly question the wisdom behind smoking. They find it difficult to rationalize their previous ‘smoking status’. There has been an unending war against smoking and more than 60 million people around the world have quit smoking. You can, too! If you have never tried to quit smoking and failed, you are not alone. Many people try to quit smoking several times before they succeed.

This article will off you inspiration, reasons and ways to quit smoking. Every one knows and appreciates that smoking cigarettes is bad for health. Smoking causes more than a half million premature deaths worldwide each year. A smoker has a two to four time greater risk of sudden cardiac death than a nonsmoker. If a person has any other risk factors for heart disease, smoking synergistically increases overall risk of heart attack. Smoking predisposes to cancers of lung, upper respiratory airway, upper and one lower ends of food pipe and mouth. Smoking also predisposes a person to progressive narrowing of vessels involving brain and legs. Smoking worsens the health of the smoker and the people around the smoker. Infants and children exposed to passive smoking develop more respiratory problems like bronchitis, pneumonia, ear infections, coughing, wheezing, and worsen asthma. Passive smoke can cause heart disease and lung diseases in nonsmokers. Children of smokers are much more likely to smoke than children of nonsmokers. Pregnant women who smoke put their babies at risk for low birth weight, developmental problems, and even death of babies.

Can quitting smoking be beneficial?
The first question every smoker asks is, “ I have been painting my lungs black with smoking and depositing atheroma in my vessels and accumulating all types of carcinogens in my body, will it do any good if I stop smoking now?” Fortunately the answer is a BIG affirmative and various studies have documented the benefits of quitting smoking. When one stops smoking, the body starts repairing itself most immediately. The risk of heart attack, stroke, and cancer starts dropping immediately. Risk of a heart attack drops quickly within days as soon as one stops smoking. Stopping smoking reduces the risk of smoking-related cardiovascular disease by approximately 50% within one year, and to normal levels equivalent to people who never smoked within five years. The cough becomes less and less severe. Food starts to taste better. One’s sense of smell gets sharper and clothes start smelling laundry-fresh. The nicotine stains on hands or face start to disappear. Quitting smoking prolongs life and reduces the risk of disease including heart disease, heart attack, high blood pressure, lung cancer, throat cancer, emphysema, ulcers, gum disease and other conditions. One feels healthier and can endure prolonged activity by increasing stamina.

Can doctor’s intervention be effective?
All doctors have unwavering faith in the known hazards of smoking and the amply demonstrated benefits of cessation. But even now the literature continues to document the failure of doctors and other healthcare professionals to intervene with all of their patients who smoke. Even in the west, only half of current smokers report having been encouraged to quit and even fewer receiving specific counseling. Doctors have their own problems and report the following barriers to providing smoking interventions: a belief that they are not effective, poor intervention skills, a belief that patients do not want their doctors to intervene, and little time to fit intervention into their practice.

There is no doubt that healthcare settings like hospitals or clinics provide an important teachable moment for smoking cessation intervention specially after an acute illness like a heart attack, episode of angina or a procedure like angiography, angioplasty or bypass surgery. On average seventy-five percent of the adult population visit a physician at least once a year. In the doctor’s office, patients are often conscious of their health and most receptive to risk factor intervention. This provides an important opportunity for change. Many studies have documented that doctor-delivered counseling for smoking cessation can be effective. However, these studies have also shown that two factors are especially important: the doctor should receive skill-building training in counseling methods, and an office system that facilitates delivery of such counseling and enhances its effect, must be in place. We, in Pakistan lack both of them, but resources can be recruited for both as long as we appreciate and identify our goals. With such training and support, more intensive interventions produce a greater effect. In general, doctor-based primary-care interventions have yielded cessation rates of 10% to 20%, a threefold to fivefold increase over the 1-year maintained cessation rate of 4% seen in the general population.

What if smokers do not give up smoking, is it a wasted effort?
Even if patients do not give up smoking, smokers clearly value and appreciate their doctor’s advice and counsel. They believe that it is helpful in their efforts to quit smoking. Furthermore, they see the provision of such counsel as an indicator of caring on the part of the provider, and they appreciate it even if they do not intend to quit. Advice alone, taking no more than a few minutes, is of value. It helps to goad them on the path of ‘quit smoking’. For the healthcare professional interested and willing to do more, a patient-centered approach in which the patient is an equal partner is optimal. Such an approach helps smokers gain confidence in their ability to quit. Such an intervention process can be adapted to any time frame but optimally takes 5 to 10 minutes.

Multi-prolonged attack – any advantage?
The person who smokes often has one or more additional risk factors. There is substantial evidence for risk factor clustering, and the smoker is more likely than the nonsmoker to have elevated cholesterol and hypertension. Thus, smoking is often only one of several risk factors that must be addressed simultaneously. Important aspect of this is to recognize the importance of approaching all modifiable risk factors with equal zeal and vigor. Of all the risk factors smoking cessation is most cost effective and useful in more than one way. Patient-centered counseling methodology is as applicable to counseling for diet change or exercise as it is to smoking.

Specific multi-component programs entail treatment of patients who have already experienced a heart attack or an episode of unstable angina. One such developed by Debusk and colleagues demonstrated favorable effects on smoking, cholesterol, and exercise in patients who had suffered a heart attack, with an increase in 1-year smoking cessation rates from 53% to 70%. In this program trained nurse case managers follow computer-generated treatment program. We may not have access to such luxuries like computer generated programs and trained nurses but within our limited resources we can develop our own system and program and train our own staff.

Can drugs be helpful to quit smoking?
Most patients may not require any drugs but in certain smokers who consume more than fifteen cigarettes daily, craving for nicotine is strong enough to be substituted by other preparations of nicotine. Although various drugs have been used in the past to help smokers, nicotine replacement therapy has been shown to be more effective and should be an important constituent in all smoking cessation programs. Nicotine delivered through skin by special patches called transdermal nicotine, has been shown to be safe and effective. Its safety is amply documented in patients with known heart diseases. These are applied to skin and can be applied anywhere on the body. Nicotine-containing gum and the transdermal nicotine patch are equally efficacious an safe, but in general the patch is preferably for routine clinical use, although gum may be preferable in certain clinical situations like some persons prefer the oral stimulation that the gum provides. In addition, a nicotine nasal spray is now available in the west, and a nicotine inhaler is likely to be available soon.

There is little evidence available on the value of nicotine replacement therapy in light smokers less than fifteen cigarettes per day; in these patients, assessment of nicotine dependency should include time of starting smoking and number of cigarettes – whether increasing or decreasing. A new drug called ‘Chantix’ has been shown, in various studies to be effective in ‘motivated’ persons to quit smoking. The effects are apparent after a fortnight and the drug has to be continued for three months.

How you may feel after quitting?
There is a lot of mystery surrounding this topic. The world does not end after quitting smoking rather a new world unfolds – a world of reason, health and aroma of ‘good smell’. Most smokers who have quit smoking would not like to sit next to a smoker. Most of the quitters never want to restart smoking. Many of them regard smoking as absolute stupidity where a person is actually paying for his ill health and cancer. For sure this is one habit where one ‘invests’ in cancer and deadly diseases. Most people have no problems as all except for slight ‘off mood’ for a couple of days. So you should be mentally prepared for it. You may crave cigarettes, be irritable, feel very hungry, cough often, get headaches or have difficulty in concentrating. These symptoms of withdrawal occur because your body is used to nicotine, the active addicting agent within cigarettes.

When withdrawal symptoms occur within the first two weeks after quitting, stay in control. Think about your reasons for quitting. Remind yourself that these are signs that your body is healing and getting used to being without cigarettes. The withdrawal symptoms are only temporary. They are strongest when you first quit but will go away within 10 to 14 days. Your major inspiration should be to remember that withdrawal symptoms are easier to treat than the major diseases that smoking can cause. You may still have the desire to smoke, since there are many strong associations with smoking. People may associate smoking with specific situations, with a variety of emotions or with certain people in their lives. The best way to overcome these associations is to experience them without smoking.

A relapse is not a reason to lose hope. If you smoke again (called a relapse) do not lose hope. Seventy-five percent of those who quit relapse and most smokers quit three times before they are successful. If you relapse, don’t give up! Review the reasons why you wanted to become a nonsmoker. Plan ahead and think about the reasons for not smoking.

Steps You Must Take Today:
There are certain tricks which work very well for those who find quitting very difficult. If you have not decided to quit, try smoking one cigarette for two cigarettes so you can reduce by half. Smoke only half and throw away the other half. Smoke one less cigarette today and smoke two less tomorrow. Smoke in only one place and make it an inconvenient place. Keep your cigarettes, lighter, and ashtray in that one place and do not give yourself license to smoke anywhere else. Smoke with your opposite hand, the trick here is to break up your smoking routine. Allow yourself to run out of cigarettes before you buy another pack. Buy only one pack at a time and avoid buying cartons. Decide on a date to quit for good and write it down on your calendar and then stick to it.

To conclude, there is overwhelming evidence demonstrating both the cardiovascular hazards of smoking and the prompt benefits that occur with smoking cessation. The provision of advice alone significantly increases the smoking cessation rate, and even minimal counseling yields further benefits. Intervention with patients who have already suffered a cardiac event yields particularly significant benefits. The smoking status of all patients should be assessed and appropriate intervention offered to those who smoke. Doctors should be trained in counseling techniques and the use of nicotine replacement therapy. The universal application of these modalities will contribute to the continued decline of smoking and subsequently heart diseases and cancers.

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Ref: Heal Thy Heart written by Prof: Dr. Muhammad Hafizullah

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Article V - Ways to Relax

2009-05-19T01:38:00.000-07:00

“Doctor, I am working six days a week from seven am to seven pm but now I am losing concentration and have lost my energy!” discloses Ahmed a young thirty year old industrialist. He had been successful to increase his family fortunes from one sick unit to a conglomerate of profitable industries. He has worked very hard but he is finding it difficult to carry on. “What I could do in an hour? Now it takes me a day to do!” confessed a forty year old banker. He got his MBA from LUMS and had a very bright start. He is set for a very promising career. He put his hear and soul in his job and won laurels for his bank. But, for the last four months, had been noting a decrease in concentration and his output. Jamil a bureaucrat by profession started to feel pain in his chest and right arm, mostly at the end of day. He had a very difficult job and was under tremendous stress. He was a perfectionist and that made the matters worse. He would be sitting late in his office and would take a bundle of files home almost daily. He had a thorough medical checkup but was declared physically fit.

All these patients had two things in common – over wok and stress. They had all been working very hard and were still not past their middle age but ‘burnt out’. These are manifestations of tension and over wok. These are markers of lack of any relaxation strategies. All out lives we have been urged to work very hard – to give more than hundred percent. We heard similar lectures from our school and college teachers and later from our bosses. It was repetition of same story that we heard from our mother and father. So naturally we have learnt how to work hard, but no body at any stage, even casually mentioned that after all the hard work one needs to unwind and relax. Every ascent is followed by a descent and after hard work the body and mind has to be rewarded by some rest.

In the west they know the importance of relaxation. They have learnt how many hours a body can work hard and how much relaxation is required. They work hard forty hours a week and then for two days they are like kings. It takes at least forty eight hours to unwind and relax to be able to put a hard work the next week. Other than the weekends every one has also devised a way to relax after work. Some people walk, others hit gold balls in gold course, some splash water in swimming pool, other go to pub and some go riding and skiing.

Working abroad, you no longer have to ‘beg to state that I have an urgent piece of work’ or kill an aunt or grand mother to request leave. In our country leave is not considered a right, rather is a luxury and at the discretion of the boss. Abroad, holidays mean ‘holidays’ – any job that you join, first of all you declare that you will be off at such and such time. Holidays are neither to attend Janaza and nor to participate in Mehndi and Shaadi. Holidays are meant to relax, take your family away and just relax. Perhaps its more of recharging of batteries. Holidays are your right and no body can deny you that. A hospital has to find locum but your holidays cannot be cancelled.

In our stressful daily routine how can we relax? Surely taking tranquilizers cannot be the answer to our daily problems. We have to find ways to relax. Just as every one has his own way of working, every one has to devise his own way of relaxing. And this is as important and as cost effective as working hard. The relationship between hard work and relaxation has to be appreciated. In all daily time tables there should be clearly demarcated time for relaxation.

What are different ways to relax that can be adopted and practiced in our society? Exercise and walking are two very effective and time tested ways of relaxation. Many people use it for analysis and planning; others detract their mind and offer ‘tasbeehat’ during walk. Playing games and specially games like golf, tennis and squash can be rewarding. During a game one’s mind is detracted from all worldly problems and it revolves around one ball! One can learn relaxation exercises and practice them with great results. These offer very effective relief in a short time. Many people practice these in their offices without leaving their chairs.

But perhaps the best and most effective way is to offer prayers with utmost concentration. Nothing can be better than that! On the one hand five times a day one detracts one’s mind from worldly strife to the ‘real’, and on the other hand one gets a lot of inspiration from it. One feels closer to God and is reassured that He is the One who takes care of everything. One also realizes how humble a human being is! One can only work hard but the result is decided by Him. What could be better than to supplicate Him and have faith in Him. Most successful people find prayers as an ultimate form of relaxation and after every prayer they find themselves charged up for the next assignment.

There is no single remedy for this problem. One may select any method of relaxation but it has to be done ‘as soon as possible’. Once its defined, one has to follow it religiously and incorporate it in daily routine. By this body can be rewarded regularly and it will have a positive impact on productivity. One has to choose between ‘longer hours’ and ‘long years’. To chose for long productive years one has to work hard and even harder to relax!

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Ref: Heal Thy Heart written by Prof: Dr. Muhammad Hafizullah

Article IV - How to lose Weight?

2009-05-19T01:27:00.000-07:00

Ameena was in tears, “but honestly I try very hard, I go without food for days and have been trying to exercise.” I felt very sorry for the young medical student who had been struggling without overweight for the last few years. “What do you avoid?” I asked her. “I swear I do not eat anything, I starve myself but some times I have to eat something…” and purposely she did not elaborate on ‘something’. All along I believed in her and appreciated her determination and efforts but it is that ‘something’ which makes the difference and determines the eventual outcome.

“Bibi, for years, you have been slipping ‘prohibitive’ amounts of ‘proscribed’ food through this ‘silt’ (pointing to mouth) to please only a small part of your tongue. Do you realize that taste buds are only confined to the front one third of tongue? You have held the whole body hostage to the demands of a small part of tongue. All the illnesses you are inviting are the consequences of this imbalance of food and priorities of life,” I deliver an impromptu sermon. Many people have their mouth and eyes wide open as they grapple with the new ‘revelations’. “So, from now onwards, look after the rest of your body and deny the ‘extraordinary luxuries’ you are bestowing upon the ‘twittering tongue’,” I advise while concluding my oration.

The concept of bank account works well with some people. Weight is like an account, the more you put in and the lesser you take out, the amount increases. The sum will naturally decrease, if less money is put in and more is siphoned out. When one is consuming food, one is in fact putting more money in and when one is exercising that is like spending money. The interest rate may be different in different type of accounts but the basic philosophy remains the same. This is how I can explain, the much argued, different rates of metabolism in different people.

Different types of food are like different types of currency. Where as fats are like pounds, carbohydrates are like dollars and proteins are equivalent to the local currency. So if people consume fats, they are putting in more pounds and the account will increase proportionally. Similarly excessive consumption of sweets and carbohydrates contributes to the account (weight). Spending patterns mimic same analogy. Strenuous aerobic exercise like running, swimming, climbing stairs, playing competitive games – squash, football or hockey are like spending in pounds. Moderate aerobic exercises like brisk walking and playing indoor games, will be like spending in dollars. Leisure walking, playing golf and cycling are like spending money in local currency. As long as some money is being spent, the account cannot stay static and is bound to go down. Therefore some type of exercise has to be encouraged as it is bound to reflect in reducing the account/weight.

This concept of storing and spending works well with most people. Saving and spending in different currencies clicks with a little more enlightened person. The resolve to avoid ‘pound foods’ at all costs, refuse ‘dollar foods’ most of the time and prefer ‘local currency food’ has to be inculcated forcefully. The concept may take some time to be swallowed but it is worth the effort. Similarly, classifying spending as pounds, dollar and rupees generates interest in intelligent persons. The emphasis on ‘pound exercises’ pays dividend and many patients refer to it in a light vein on their next visit.

“If you continue like this, I will be obliged to order a new tougher and bigger chair and a larger door for your next visit; on the contrary, you might surprise me by losing a lot of weight with a slim figure and an enviable waist line,” are the final words before the patient leaves the clinic. It contains both messages – admonition and encouragement. The approach has to be based on ‘carrot and stick’ theory. Many patients shuffle restlessly to get their weight checked on subsequent visits to register their success.

What are the goals? Goals have to be realistic and achievable. For moderately obese person an ideal target will be to lose 10% of weight in six months. So, if someone is weighing 100 kg, the aim will be to lose 10 kg over six months. This translates roughly to 2 kg every month. Of paramount importance is to emphasize that perseverance is the key to success. Initial enthusiasm can die very quickly. Encouragement from the family is most important. And comments like, “Oh, you look very smart,” or “you look a lot slimmer and healthier,” can go a long way.

What to eat and what not eat, is the crux of all bickering. Every fat man recognizes the fact, that the extra folds of fat are consequences of his overindulgence in food. But what to avoid and what to consume remains the most important question. What types of foods doctors ban, holds the key to compliance. This is more like introduction of ‘emergency’ where the person is instructed to avoid a few ‘calorie bombs’ and reduce ‘calorie missiles’. Talking in vague terms of ‘percentage of reduction’ in carbohydrate, fats and proteins is difficult to comprehend and implement by a majority of semi literate and even otherwise literate persons. The emphasis should not be on offering a ‘short course’ on nutrition and calories rather a list of ‘dos and don’ts’ while explaining the rationale in simple and comprehensible terms.

I have made the ‘lesson on food’ very easy to understand in theory, how ever it needs determination and conviction for ‘gluttons’ to put it to practice. I employ Urdu alphabet ‘chai’ to elaborate my theory. My single one liner message is to avoid edibles starting with ‘chai’ to lead a ‘happy, smart and enviable life’. Most of the food items bubbling with calories contain – cheeney, chawal and chiknai – all start with ‘chey’.

Cheeney (sugar) implies all sweet things including ‘sugar and gur’ in any form and combination; be it hot drinks – like tea, coffee, qehwa, lemon tea or cold drinks like fizzy drinks and sweetened drinks like sweet juices. Many women will fervently deny taking sugar in any form, just to concede a little later, of using tea prepared for the family containing sugar, using ‘gur’ in tea or adding honey to yogurt. Bakery items are loaded with calories as they contain sugar and fats. All exotics like alluring cakes, tempting pastries, appealing rolls and other must be avoided all together. Finger licking and ‘calories dipping’ sweets of the ‘halwai’ – like khoya, barfai, gulab jaman, rubric, laddu, balushahi have to be kept away from at all cost. Desserts – the better half of a meal – are usually encumbered with calories and may contain more ‘ingredients for obesity’ than the main course itself. Many of us find ice cream and local version – ‘Kulfi’ very alluring and hard to resist, but then, so are most of the sins. The luring combination of scoops of ice cream topped with cream may be very appealing but as they contain not one but at least two ‘cheys’ – sweet and fats they have to be from a weight reducing diet. Beware of these tempting snares of ‘tummy busters’, they come in different tantalizing forms and hues but the eventual effect on health and waist line is the same!

Chawal – rice has to be totally avoided as it is difficult to ascertain the quantity. A platful may mean different things to different people. Many of the accompaniments of ‘rice’ have a tremendous fattening effect. Chiknai – fats have to be avoided and extra effort has to be put in to avoid getting ‘pounds’ in account. Fats include gheeand oil besides butter, cheese and cream. Many overweight people will flatly refuse consuming fats believing that they do not drink oil and eat ghee. Most of our patients feverishly deny taking fats, only to realize that their last meal was cooked in fat and this is how most of the people consume fat. Many assume that oil is better than ghee; that may be true from cholesterol point of view but as far as they weight and calories are concerned, both are equally bad. The advice to take boiled, broiled, baked without fat, grilled or barbecued food is not swallowed very well. The traditional concept of gravy and rot (roties here) is a major impediment.

Another ‘chey’ – chapati needs special mention, though one would like to ban it all together yet a midway will be to reduce it by half. Here again many people will enter into argument regarding the number of ‘roties’ being consumed. The simple answer to this is the advice to reduce the number by half, regardless of what the person is consuming.

Exercise is like a medicine, the dose and frequency has to be prescribed by the doctor. By and large, fit persons should exercise for twenty to thirty minutes five times a week. Any aerobic exercise will serve the purpose, for example aerobic exercise, walking, jogging, swimming, competitive games or structured exercises. Walking, perhaps is an excellent form of exercise as it employs most of the muscles of the body and does not entail heavy expenses. It can be performed anywhere and does not require any special dress code or membership. Walking briskly five days a week will satisfy most of the demands of body. Walk has to be taken seriously like prayers.

Before undertaking walk, one has to determine how much to walk and for what length of time, more like ‘Niat’ of prayers. And after asking for Divine help, one should embark upon walking on a pre-specified route without resorting to engage in talking. “Tasbeehat’ enhance the utility of walk and confer sanctity to it. One has to concentrate to maintain the desired speed and achieve the goal in pre-specified time.

Every woman thinks that performing daily chores in the house is the most rigorous form of exercise and to ask for more will be against the norms of decency and natural justice. Men are convinced tht duties they perform in the office should be classified as exercise. And to expect them to exercise before or after working hours is asking for too much. Many of them will refuse point blank, and say, “I am so busy that I cannot afford to have time off.” “Oh, I am sorry, am I conversing with the president of Pakistan?” I ask, while purposely keeping my eyes down and add, “If a person as busy as him can find time for exercise, why can’t you?” Another trick up in our sleeves is to ask, “Do you offer your prayers regularly?” If reply is in affirmative then I add, “Isha prayers normally take 20 to 30 minutes; you have to be convinced that exercise is important for you, then you will have no problem finding similar time for exercise as well.”

After initial hesitation many would agree and some will try as well. But, not all will persist for a long time, as we all believe in quick results. They weigh themselves after every walk and if weight does not drop drastically, they are disappointed and give up walking and restrictions. At this time they have learnt all the theory, but they need active encouragement from their family and friends to persist to achieve the goals. Good habits have to be positively reinforced, like appreciating their determination, encouraging exercise and understanding difficulties in following restrictions.

What shall be the next step if dieting and exercising are not enough? Are there any drugs to help to reduce weight? Drugs can be helpful to decrease weight but dietary restrictions have to be followed and exercises have to be performed. There are drugs that work on satiety centre in the brain and suppress appetite and others that work on decreasing absorption of food. Previously, drugs used to reduce weight have been associated with serious side effects and have been withdrawn from the market. Recently introduced drugs are supposed to be safe and effective but none of them are supposed to perform wonders. Drugs like Orlistat have been used to reduce absorption hence it is administered with food. The experience has been rewarding and many persons have been able to reduce their weight significantly. Drugs that suppress the appetite have resulted in appreciable loss of weight in many patients At one time all these drugs were beyond the reach of common man but now they are available at reasonable price.

Surgery is an option in a limited number of persons who are grossly obese, cannot diet and find it difficult to exercise and are at high risk for obesity related diseases and death. It is reserved for patients in whom all other efforts have failed. The best option in such persons is wiring of jaws where they are denied food and fed through a tube via nose. Second form of surgery is gastro intestinal surgery with stomach restriction or stomach by pass.

The concept of a bank account has to be reinforced again and again. Food going in has to be regulated versus energy spent to lose weight. A balance has to be struck and a person has to be conscious of ‘income’ and ‘expenditure’ all the time. This calculator has to be followed in letter and spirit and excuses like ‘one meal will not make a difference, today is my birthday and why ‘perhaiz’ on Eid and Ramazan’ should not be entertained.

In the fight against obesity, the plan has to be well conceived and executed meticulously. It is not a one time affair, it needs life long commitment and hard work. But the benefits and joys are unlimited and perhaps not quantifiable. It is all worth it!

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Ref: Heal Thy Heart written by Prof: Dr. Muhammad Hafizullah

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Article III - Exercise – When, Why and How?

2009-05-19T01:20:00.000-07:00

“But I am so busy I have no time for walking,” Answers Ahmed rather curtly in response to my lecture on exercise. “Do you offer prayers?” I ask him in a matter of fact way. “Alhamdo Lillah, yes and at least three of them in congregation!” he replies. “Walking and exercising is as important as prayers for your,” I reveal to him the most well preserved secret. “When there is a will there are lots of ways,” I continue, “so if you want to walk you can always find time for it, just like you find time for prayers even when you are very busy and we also know that if you do not want to do something, you can find hundred of excuses for not doing it.” He agrees to the extent that if he really wants to do it, he should be able to find some time for it.

“I don’t need any exercise, I work in my house the whole day.” Farhat, a fifty year old lady weighing eighty kilos, replies after hearing my minutes lecture on exercise. “I don’t think anybody works harder than me, anywhere in the world,” she throws another spanner. “Bibi, working in the house and office work is not equivalent to exercise, because you cannot accelerate your heart rate rand it is not an aerobic exercise, “ I add and this is applicable to all men sweating in offices and ladies working at homes.

“If you offer just Alhamdo Lillah all day, will it be equivalent to offering prayers?” and falling into my trap she replies in negative. “There are set protocols for doing things; similarly there is a definite protocol for exercise as well! Before you offer prayers you have to do the ‘niat’, similarly before exercise you have to determine beforehand and announce it as well. You have to determine how much distance you want to cover and in what period of time? You also have to set your Qibla and know the direction where you are going to. More so, you have to be positive what you are doing it for?” I explain to the lady who has her mouth opened wide in astonishment and eyes popping out in incredulity. “So your niat should sound like this: I hereby solemnly resolve purely for the sake of my heart to take upon myself to walk three miles which I shall complete in thirty minutes, so help me God!”.

The lecture continues, “And just like prayers you have to concentrate, no chatting and no looking left and right!” “You have to fulfill a solemn duty so you have to focus and try to extract the maximum out of it,” I explain further. “ To keep your self busy and extort something more out of it you can offer a wazeefa or recite Holy Quran. This is to keep your self occupied and perhaps to derive some spiritual stimulation as well!” Another similarity between prayers and exercise is that you have to have special dress code for it, so do not start walking till you have comfortable shoes and proper clothes. I try to make it sound more like a religious duty and a Kar-e-Sawab. Most of the people are very excited about this new ‘revelation’ and the elevation in the status of exercise and at least in the clinical surrounding affirm very positively to start exercising the next day.

Many of our patients claim to walk for hours and when ever we test them on treadmill, their performance is far below than expectations. Determination of speed and total distance are equally important. “Its no use walking like a seventy year old lady, if you have to walk you have to walk like a man,” and I emphasis the work ‘man’, while urging our patients to take up exercise. While waging this war we consider everything ‘fair’ and use all the tools we can lay hands on.

How much to do? It is very important to understand that exercise is like medicine, it has a proper dosage and regimen to follow. Essentially for exercise to confer benefit on reduction of heart problems, it has to be undertaken at least five times a week. During exercise the heart rate should be higher than normal. Every one has a target heart rate which is roughly 220 minus age. Exercise will only be helpful if heart rate is increased to 85% of target heart rate for twenty to thirty minutes. This increase in heart rate is only possible with active exercise. Leisurely stroll after dinner is not very helpful. Preferably the heart rate has to be kept at this level throughout the exercise.

What is the best time for exercise? Any time is good time but it must not be done after a meal. Sometimes exercise taken after food can result in vomiting. For best results it should be done early in morning or in the evening. But for busy people any time specially after office is a good time. Those with exercise machine whether cycle or treadmill can do it any time at home. Some resolute persons make it a point to exercise before meal after office hours. Others do not get food served to them by their better halves unless they have earned it by performing their regular exercise.

Which is the best exercise? Whereas sportsmen and the professionals can devise their own exercises according to their requirements, other can follow simple rules. By and large, aerobic exercises are preferred. This includes walking, cycling, dancing and swimming etc. Walking is perhaps the most preferred exercise as it employs almost all muscles of body. Walking both on treadmill and ground confers similar benefits. Treadmill is preferred for busy people and otherwise as well, as one can exercise at any time. It is safe, informal, no strict dress code to follow, one has to walk at a pre-specified speed, its not dependent on outside weather, and one can make it more interesting by putting a TV in front of it. In many houses the treadmill is first housed in bedroom, moved to adjoining room and later demoted to attic. In many houses it is being used to hang clothes on! One needs determination and the best policy is to have a special time for it and it should not be missed under any pretext.

It is very boring! What can you do to make it more interesting? For a religious person ‘tasbeehat’ can be offered or one can recite Holy Quran during walking. For music lovers a portable walkman is the answer. Placing a TV in front of treadmill and making it a routine to listen to news while being on treadmill is very viable option. To walk in a group is very helpful and enjoyable but here one point is very important and that is adequate speed. A good exercise increases heart rate and makes one a little breathless – just enough that holding a conversation is rendered difficult.

Once one gets used to it one will find exercise very addicting and will feel lost if exercise schedule is not adhered to for any reason. Its more addicting than the morning cup of tea. The benefits are innumerable and there is absolutely no doubt about its benefits on physical and emotional well being. The golden principle is, ‘when there is a will there are lots of opportunities and time for exercising.’ So the important thing is to build up that strong will and the rest is easy!

In the coming articles we will discuss about some useful devices, with the aid of which much results can be obtained in a little time.

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Ref: Heal Thy Heart written by Prof: Dr. Muhammad Hafizullah

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Article II - Fitness, How to avoid heart attack?

2009-05-19T01:08:00.000-07:00

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Every body wishes to avoid heart attack very few people try to prevent it. The most important thing is how may people know how to prevent such a disastrous disease? Before we start to discuss how to prevent a heart attack, we have to consider the circumstances and estimate the risk profile.

We have to stare all the risk factors – modifiable and non modifiable and then start from there. The gravity of situation or otherwise determines the future plan. One has to be objective and practical. First of all, look at the non modifiable risk factors which determine one’s likelihood of developing a problem, but one cannot do anything about them. It is aggressive one has to be in modifying other modifiable risk factors. Important to know them because this will determine how aggressive one has to be in modifying other modifiable risk factors. Important factors are age, sex, and family history. The older the person, the higher the risk of heart attack. The risk of developing a heart ailment below the age of thirty is very slim in males and rather rare in female. The chances of developing a problem are very high as one enters in seventh decade of life. The risk is almost similar for both sexes, a little more for females. In between there is a gradual increase in risk for both sexes, whereas the risk rises sharply for women as they become post menopausal. Those with a positive family history are more at risk. There is a lot of confusion that surrounds family history. Family history is important when a parent or a sibling suffers a heart attack at a younger age – around forty. If someone’s mother dies of a heart attack at the age of eighty that does not come under a strong risk factory.

So if its a male, in his early forties and has a strong family history such as one of the parents succumbing to a heart attack at age thirty five, he should have a different plan. He has a very high risk profile and has to be aggressive in getting his baseline blood checked up and be more particular in his regular check ups. He should have a different threshold for treatment for his risk factors and should have different targets to achieve. As against that a sixty year old male with no positive family history has a rather benign profile, he should get his tests done annually and keep his eyes on laboratory values. A lady at fifty with positive family history of heart attack in a sibling or parent is at very high risk. She has to be aggressive in looking for all the risk factors and their reduction wherever required. She needs more frequent cardiac checkups and a strict eye on all the risk factors.

What are the modifiable risk factors? These are the risk factors which can be altered and have an important effect on eventual outcome. The list is very long and new factors are being added to it as the research continues. Most important among these are the presence of diabetes, high blood pressure, high level of total cholesterol and specially high LDL and low HDL cholesterol, and smoking. Obesity and lack of physical activity contribute directly and indirectly towards heart attack. Novel risk factors are newly identified risk factors and their role and the effects on reduction have not been thoroughly studied in large trials. Their cause effect has to be established and the cost effectiveness of their reduction has yet to be proved. These are important risk factors and assume more importance when the traditional risk factors are absent in a young person with heart attack.

The most important of modifiable risk factors is diabetes. There has been a growing awareness about diabetes and there is a large data base to establish the effects of diabetes on heart and vessels – tubes carrying blood to all parts of body. Diabetes mellitus is a scourge which is now assuming the status of an epidemic. Whereas other epidemics follow a certain course and wither away, unfortunately it has come here to stay for good! The real danger of diabetes is accelerated process of hardening of vessels called atherosclerosis with high mortality and higher morbidity. The worst effects are through involvement of small and medium sized vessels effecting almost all systems of body. Main targets are heart, brain, eyes and peripheries. Involvement of vessels in diabetics is more severe and diffuse.

Though effects on all target organs are profound and diffuse, let us focus on heart for the time being. More diabetics succumb to heart attacks as against non diabetics. Diabetics afflicted with heart attack have more complications and higher death rate. Lesser number of diabetics are amenable to procedures like by pass surgery and angioplasty as compared to non diabetics due to diffuse involvement of vessels. Diabetics undergoing these procedures are more likely to have complications during the procedure. The changes of recurrence of symptoms and disease are higher in diabetics. It is due to incomplete revascularization and the aggressive course of disease that follows.

Diabetes for all practical purposes is one of the strongest risk factors. According to new guidelines for treatment of high cholesterol, it is being considered as equivalent to established cardiac disease. Diabetes has accumulative effects in combination with other risk factors like high blood pressure, high levels of total cholesterol and especially high LDL and low HDL cholesterol, and smoking. The effect is synergistic and new goals for treatment have to be defined.

How can diabetics help themselves? Should there by a different strategy for diabetics? Should they wait for complications to occur and only then take action? Do diabetics get a fair deal and optimal therapy in our setup? The answers to all these questions are neither simple nor straight forward. Diabetic should have good working knowledge of diabetes and its complication. They should understand the importance of looking for other risk factors, effects on target organs and treating them aggressively. Over and above they should believe in aggressive treatment and the merits of such treatment right from the start. Recent studies have documented the importance of tight control with reduction in many end points because unless the patient is convinced he cannot demand better treatment from his doctor.

The strategy for diabetics has to be different. The criteria and goals of treatment for associated risk factors like high blood pressure and high cholesterol are different. For example diabetics should have lower blood pressure and the threshold of treating high blood pressure is lower and the aim is to bring it down to systolic 130 mmHg and diastolic 85 mmHg. Similarly cholesterol especially LDL has to be lower around 130 mg/dl to start therapy and the aim should be less than 100 mg/dl. The threshold of starting therapy and the necessity of lower goals has to be appreciated by the patient himself and only then it can be put in practice.

The importance of meticulous diabetic control has to be ingrained in the minds of diabetics and especially those at higher risk of developing heart attack. This can be done by strictly adhering to treatment regimen and observing all dietary restrictions and regular exercise and control of other risk factors. All diabetics should have the background to look for and monitor different complications. Though diabetics should not treat themselves like ‘people form Mars’ yet they need to have strong belief that meticulous control will mitigate their sufferings and keep them safe from heart attacks and many other complications.

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Ref: Heal Thy Heart written by Prof: Dr. Muhammad Hafizullah

Article I - Fitness, Changing Lifestyle can prevent Heart Problems

2009-05-14T02:44:00.000-07:00

Fitness is a great problem especially for the persons who are over weight. Although the fat is essential part of the body but to some extent, normally 12-15% for women and 3-6% for men. Many people are experiencing a life-long battle due to their weight. Despite their much struggle little people succeed in getting smart. While defining healthy person the WHO said health is a complete physical, mental and social well being and not merely absence of disease or infirmity.

The major aim is to raise fitness without tension. Jogging is a "high-impact" exercise that places stress on the body, especially the joints of the knee. This is in fact one of the vital reasons for doing the exercise, as the impact drives growth processes in the areas of the body strained by that impact. Some person leave jogging in order to take up alternate ways of exercises such as climbing stairs, swimming or cycling. Time and again Jogging is used by running as a source of active recovery during interval training.

Now a days like other health related problems blood pressure and heart diseases are common. The main object of all these exercises is to keep the man fit and prevent diseases like blood pressure, heart etc.

Merely eloquent about heart and its ailments does not solve the problem; action is required to avoid heart problems. Those afflicted with the bug of heart problems can become more eloquent and eager partners in the treatment, if they know the strategies being adopted by their clinician. The result will certainly be healthier with more convinced and enlightened patients in this prolonged war against the enemies of heart, which is being fought at many fronts.

In this article and subsequent other articles we will dwell on taming villains, changing lifestyles and giving the latest information on drugs and operations of the heat and more importantly interventional procedures like angioplasty, stenting involving wires, balloons and springs.

This is preface and in the next articles we will discuss non drug treatments which play a major role in recovery and prevention of heart diseases. Topics like how to stop smoking, how to exercise and how to relax are dealt comprehensively and in a practical format. Special emphasis has been placed on treatment of the newest and commonest malady of the world – obesity.

In Article II we will discuss how to prevent a heart attack? In article II we will mention exercise – when, why and how? In article III how to lose weight? In article IV we will learn way to relax? While in article V discusses about quitting smoking – make it possible!

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