ESC Congress 2017 – Further advances in cardiology with many positive clinical trials?

20170828_084722

The European Society of Cardiology (ESC) Congress this year took place in Barcelona, Spain from 26th to 30th August. The start of the event was just about a week before the alleged terrorist van attack at the street of Barcelona – La Rambla. No, it did not deter the hardcore cardiologists and scientists from attending, out of more than 32,000 attendees, there were only 40 who cancelled in the last minute. So, they were with the Spanish people, showing their sympathy and solidarity of the recent tragedy, chanting the magic words ‘No Tinc Por’ means I am not afraid. Aggrieved but not at all shaken by the threat, they move forward.

 

By far this could be the one ESC Congress that have presented with a significant number of groundbreaking clinical trials. Among the most notable ones are:

COMPASS – Cardiovascular OutcoMes for People using Anticoagulation StrategieS (COMPASS) trial

CANTOS – The Canakinumab Anti-Inflammatory Thrombosis Outcomes Study

PURE – Prospective Urban-Rural Epidemiology (PUREstudy

CASTLE AF – Catheter ablation versus standard conventional treatment in patients with left ventricular dysfunction and atrial fibrillation

Determination of the Role of Oxygen in Suspected Acute Myocardial Infarction (DETO2X-AMI)

 

New perspective in diet and CVD? Highlight from PURE study

This is a study which is set to challenge existing dietary guideline for CVD presented by the researches from Hamilton Canada. Prospective Urban-Rural Epidemiology (PUREstudy is a long term study involving more than 18 countries worldwide looking at the relationship between dietary behaviours and total and CVD mortality.

This was conducted in the form of Food frequency questionnaire in which the cohort is being followed up over time.

A total of 135,335 subjects were available for analysis.

It found that consumption of Fuit, vegetables and legumes was associated with moderately lower risk of mortality but not CVD mortality. The benefit was seen at 3-4 servings per day. Further they looked into dietary fat & carboydrate and found that, contrary to existing guidelines, dietary fats was protective against total mortality (but not CVD mortality) while increasing quartile intake of carbohydrate was harmful!

People might wonder, do all fats render the same benefit or some types of fats? How about saturated fat which the guidelines advise strict control? Surprisingly there was decreasing overall mortality with increasing concumption of saturated fat (SFA) and again, no effect on CVD mortality with the exception of a decrease in stroke risk.

Carbohydrate also did not increase CVD outcome, only overall mortality, so there were questions as to what mode of death associated with this increased total mortality, which the study did not address fully.

The results challenge current guideline recommendations on intake of saturated fat and carbohydrates.

So what can we learn form the result of this study? The cholesterol and statin skeptics may quickly jump to conclusion and claims the findings support their long term skepticism on the role of cholesterol in CVD…things may not be as simple, maybe we can adopt the advise from the principle investigator, Salim Yusuf – it is all about moderation. In dealing with food intake, we should strike a balance. In this case, clearly fruits and vegetable, including legume should be part of healthy diet, while controlling carbohydrate intake including sugar is important. Fats, you may ease off from the strict diet (provided your lipid profile is within ‘normal’), while decreasing your sugar and carbo, avoid trans fat (not covered in this study), do watch the total calorie intake though, since high calorie would be associated with the prevalence of obesity and metabolic syndrome which are still culprits in CVD.

 

Beyond LDL and conventional risk factors, time to focus on Inflammation –CANTOS trial

There had been debates on the role of inflammation in atherothrombosis. The earlier finding on role of hsCRP in development of CV events among people with low LDL had been highlighted by no one else but Paul Ridker, in 1999. Among patients diagnosed with ACS, despite advances in treatment, there are still residual risk remaining, it has been thought that this ‘residual risk’ areas could fall into either of Residual Cholesterol risk (highlighted by recent finding of further lowering of LDL resulting in better CV outcomes – FOURIER, IMPROVE-IT), Residual thrombotic risk (role of long term dual antiplatelets? Eg DAPT/PEGASUS study) or Residual inflammation risk – this was earlier demonstrated by Ridker when people, despite having low LDL still having excesse events, and JUPITER study that recruited people with ‘normal’ LDL level but high hsCRP treated with statin demonstrating reduction in risk of CV events in this primary prevention study).

 

In this study presented by Paul Ridker as the lead researcher, they recruited over 10,000 stable coronary artery disease patients post MI with high hsCRP (>2mg/dl) on statin and optimal medical therapy including statin (OMT). Patients were randomised to receive 50mg, 150mg or 300mg Canakinumab SC injection (3 monthly) vs placebo (4 equal arms).

Canakinumab is an interleukin 1B inhibitor which reduced IL6 and in turn causing reduction in the hsCRP. At a median follow up of 48 months, the groups treated with Canakinumab showed reduction in hsCRP between 26 to 41 % compared to placebo. It showed 15% reduction in endpoints of CV mortality, stroke and MI combined (150mg dose met the prespecified endpoints). There was no effect on cvd mortality or all cause mortality

The effect was observed to be consistent over large number of subgroups, with greater reduction of risk among those with greater hsCRP reduction (>median) 27% reduction in primary outcome.

There was additional non CV benefit including reduction in cancer mortality, 51% reduction in lung cancer. Groups treated with Canakinumab suffered less from arthritis incuding gouts and osteoarthritis

This was definitely a proof of concept that target inflamm (ILIB) resulting in further reduction of cardiovascular endpoints, independent of LDL. As to how it could be implemented in clinical practice still awaits further analysis and expert deliberation, bearing in mind the steep cost of the drug (price about USD 14000 per injection of 150mg dose!). There is also a concern on the increased incidence of fatal infection in Canakinumab recipients.

 

 

Afib Ablation early in Heart Failure to save life and improve symptoms

Castle AF is a study that helps to answer the question whether or not patients in heart failure who developed atrial fibrillation should benefit from conversion to sinus rhythm.

Out of 3000 patients screened (US sites), 397 (after further screening 165 vs 153 patients entered randomisation) patients with paroxysmal or persistent Afib and ejectioin fraction <35% were randomised to conventional treatment or AF ablation. They were special group of patients with optimal treatment, proven by the fact that all included patients have AICD or CRTD (resynchronization device with ICD) implanted – though it may not have any confounding issue in this trial. Pulmonary vein ablation was the standard procedure performed plus additional lesions/repeat ablation after blanking period, in the ablation arm.

Primary composite endpoint of 38% reduction favouring ablation. All cause mortality was also reduced, HR 0.53 p = 0.01. In addition, improved CV mortality and CV hospitalisation also seen among the active arm. The ablation group also saw increase in ejection fraction of 8%. High number of patients in the ablation arm remained in sinus rhythm at th end of study (AF burden of 28% vs 65%).

The caveat? The procedure was associated with increased incidence of acute pericardial effusion and severe bleeding (combined figure of 6%). Less Stroke, other notable adverse events were pneumonia, pulmonary vein stenosis, groin infection and acute heart failure.

 

COMPASS – addressing the residual thrombotic risk in high risk CVD patients

Another groundbreaking study in high risk patients with coronary artery disease and/or peripheral arterial disease is called COMPASS – Cardiovascular OutcoMes for People using Anticoagulation StrategieS (COMPASS) trial

This landmark trial recruited over 20000 patients (602 sites, 33 countries)

with coronary or peripheral artery disease with additional risk factors to receive either rivaroxaban (2.5mg BD) plus aspirin, rivaroxaban 5mg BD or aspirin alone with median follow up of 23 months. There were 2200 primary outcome events with the event rate 4.1, 4.9, 5.4% in R+A, R and A groups respectively (primary components – cv death, stroke, MI). Individual components of All cause mortality, CV death and stroke also were significantly reduced in the R + A group. This came at a cost of increased major bleed 3.1, 2.8, 1.9% respectively, excess 1.7 HR (R + A), 1.51 (R alone) HR but not fatal bleeding or ICH

Further analysis combining the outcomes/efficacy and adverse events (fatal/critical organ bleed) showed net clinical benefit favouring Riva plus aspirin (2.5mg) for this high risk group with HR 0.80, (p=0.0005)

 

Further evidence in support of no Oxygen in acute MI? – DETO2X study

The subject of harmful effect of oxygen therapy in acute MI has been going around for a while. Earlier there was AVOID study which suggested that supplement of oxygen in patients with acute MI without hypoxia could be harmful, resulting in increase in early myocardial injury and infarct size at 6 months.

DETO2X AMI is a registry-based randomised clinical study conducted by the Swedeheart group involving all major cardiac centres in Sweden. In contrast to the usual prospective randomised study, a registry based randomised study recruits all subsequent patients in a non-restricted criteria, via randomisation process. All patients with suspected of AMI (O2 sats >90%) that were recruited, were randomised to receive 6L/min oxygen for 6-12 hours or room air. Primary endpoint was death from any cause at 365 days.

Over 6600 patients were recruited, making it the largest ever study on oxygen therapy in AMI so far.

Mean spO2 was 97% in both groups (Oxygen vs Ambient), More than 65% of subjects underwent PCI.

There was no difference in mortality at the end of the study. There was a trend towards increased cardiac arrest and death in the Oxygen group (non significant). Analysis of all subgroups showed similar pattern, except in compaing those with spO2 >95% or <95%, trend favouring oxygen for those with the lower saturation.

As a conclusion, Oxygen therapy was not associated with any benefit in mortality in Acute MI. The ESC have got this early and incorporated it in their guideline, therefore chaning the recommendation to only give oxygen in those with spO2 < 90% .

 

There are a number of other positive clinical trials that you may hear about in due course. Among notable one – in hypertension – promising result on blood pressure reduction (off medication) among patients treated with renal denervation (SPYRAL HTN OFF-MED study). Is this going to see renal denervation making a comeback in the treatment armamentarium of resistant hypertension? Too early, as Medtronic is yet planning a full scale randomised study with long term result.

The battle of New Oral Anticoagulation is till going – with the result of RE-DUAL PCI (Dabigatran in Afib patients undergoing percutaneous intervention), showing dual therapy regime of dabigatran and P2Y12 antiplatelet to be safer, causing less bleeding compared to warfarin.

DSC02046

I would also like to share our abstract which we presented in poster form at the ESC Congress, entitled: Open-labeled randomised controlled study of double dose clopidogrel versus ticagrelor in stable coronary artery disease (CAD) patients with clopidogrel resistance – we found 29% of stable CAD patients resistant to clopidogrel (measured by multi-electrode aggregrometer, Multiplate). They were subsequently randomised to receive double dose clopidogrel for one month OR standard dose ticagrelor (90mg BD). The result showed both groups reached a mean value of AUC (this is how the platelet suppression measured) within therapeutic range. However, only the ticagrelor group showed uniform and consistent platelet suppression, with all of the patients treated reached target platelet suppression, compared to double dose clopidogrel (33% failure rate). This result is fairly convincing of the efficacy of the new P2Y12 antiplatelet ticagrelor, which we are using more often now particularly in patients with acute coronary syndrome or those with complex coronary disease undergoing PCI.

Besides the above late breaking clinical trials, there were also presentations on the new guidelines of practice, as well as number of sessions that focused on certain key issues in cardiology practice such as:

Acute coronary syndrome STEMI – new recommendations including multivessel PCI (but still a debate as to when to be done, perhaps as in patient rather than during the primary PCI), removal of the door to balloon or door to needle time, now changed to First ECG diagnosis, giving interventional cardiologist more control of their performance. A ‘comeback’ of fibrinolysis where it is still recommended when there is a possible delay of over 120 minutes from first diagnosis to primary PCI. This should be followed by ‘pharmacoinvasive’ strategy, means patients should undergo coronary angiogram within 3-24 hours post fibrinolysis.

There was also guidelines on dual antiplatelet therapy – this time focusing on patients rather than procedures, so the whole issue of duration of therapy has undergone extensive revision, which may make things more elaborate for treating physicians. Standard duration of therapy post PCI has been adjusted to 6 months DAPT for all, regardless of bare metal stents, any drug eluting stents (DES) or even drug eluting balloons (DEB)! However, there is some flexibility in which a patient who is deemed to need shorter duration of DAPT maybe given as little as one month therapy. On the other hand, there was also a concomitant recommendation for a more prolonged DAPT, extending up to 30 months (result of analysis of two studies – DAPT and PEGASUS), in those with high risk of events and low risk of bleeding, subject to physician’s discretion.

As regard blood pressure, a number of sessions on the new target blood pressure were highlighted. Basically as result of the much hyped SPRINT trial which advocated lower blood pressure target in those at risk population, now to below 130/80. But to avoid <120/80 and in elderly, the target maybe <140/90. However, this must not be confused as to the absolute threshold for treatment, in those without other associated risk factors or organ damage, in which the benefit is not seen till the level of >145mmHg SBP (as shown in HOPE 3 trial).

In the field of intervention, the congress coincides with the 40 year celebration of Angioplasty. 40 years of rapid advances in intervention now expanding to coronaries, peripherals, valves, structural and beyond. It only means more patients are able to be treated (nature of percutaneous intervention which may simply be carried out even at relatively higher risk patients, compared to surgery), the next phase may see intervention such as transcatheter aortic valve implantation (TAVI/TAVR) coming soon to be at equal footing to surgery (barring the high cost!).

Advertisements

Playing with statistics in medicine…

Finally the therapeutic dilemma came to an end…
There was this young ex-pat patient came to my clinic with new onset atrial fibrillation (irregular heart), as she has hypertension we recommended blood thinning medication (anticoagulation) called warfarin on her. Soon after, another doctor prescribed a new novel anticoagulant A, which costs >100 times more. When she came to my clinic she told me that she has not started the medication, as she was not sure whether it was good or not..
Apparently there was some lack of communication. So I went through a brief counselling till she asked, which one is better? I told her comparing the two, the new one, drug A is of course far better, as has been proven in clinical trials. However, taking warfarin strictly with good INR (a way to check your blood thinning index) is likely going to give you similar protection, with overall higher risk of bleeding – the cost however is the main obstacle.
Now the patient said: I trust your decision, doctor. And I am willing to spend the money….
Knowing she has a very young daughter diagnosed with SLE, I really pity her, and this put me in serious dilemma having to recommend a treatment costing over RM400 (or higher cost for her as foreigner) – and yet there is no sure way to tell her she will benefit more compare to her current treatment – its all about statistic – if the ‘number needed to treat’ is below 30 – then it is something very compelling – but in this case it is far more (167 for efficacy & 67 for serious bleeding)…of course there are other benefits like less interaction with food, drugs, and no need for blood test (INR clinic).
Sighed….in the end I advised her give it a try and see how she tolerates the new medication…today, she came back telling me that the new medication had caused her to have pain, cough and shortness of breath. She happened to suffer from flu as well. Well, not a direct adverse event from the medication, however, to remove the doubt, and due to her reluctance I advised her to revert to warfarin.
The lesson here, decision making in medicine may not be very straight forward especially when cost effectiveness is concerned. Patient counselling is an important part of management, do make the patient aware and understand the benefits and risk of the treatment, as well as potential cost effectiveness.

More on TIMI score

A lot of people have visited my posting on TIMI score, which had been posted quiet a good while ago. Let me update you a bit. There are TIMI score classification for both STEMI and UA/NSTEMI, they are separate of course.

The STEMI TIMI score takes into account many parameters that include ECG changes, presentation time and Killip’s score.

Killip score is a simple but useful risk stratification score of patient’s with MI based on their heart failure status (1 – no failure, 4 – cardiogenic shock).

Both scores are reproduced here (pic linked from cardiachealth.org). From Morrow et al, Antman et al Circ, JAMA 2000

Image

Image

Is there an ‘easy’ way out to reduce blood pressure?

Anecdote of my personal experience managing my hypertensive patients this week.

At last I was relieved. What I have nearly lost last week, now is back under control!

Last week, I was quite frustated by two cases of severe hypertension patients that came to my clinic. One swas a very elderly lady whom I saw first time, previously treated at another centre. According to her daughter, home BP had been quite labile however lately better controlled around 140mmHg systolic. She was otherwise well with cocominant dyslipidaemia only, no diabetes. Her clinic BP at first measurement was 190/90mmHg. When I rechecked it was still at 180/90. Due to her age and the fact that she was due to undergo cataract surgery, I suggested a few days admission. The daughter declined. She was already on Losartan 100mg daily, so I added 5mg amlodipin to start with, urging the daughter to monitor the BP closely.

Early this week she turned up at the ward for preop admission. Her BP in the ward was still very high at 170-180mmHg. I increased her amlodipin to 5mg BD (sometimes I started this way just to allow patients to cope with the sudden increase in antihypertensive, usual dose of amlodipine is once daily). The next day, her BP was still around 170-190mmHg systolic! I allowed her anyway to undergo the surgery under LA. It went uneventful however the ophthalmologist now handed her case to me for postop BP control.

She is already on amlodipine max dose for at least 48 hours, BP still unchanged. Changing the meds to single pill ARB and CCB combination won’t do much I think, since she was already on both separately, therefore I decided to target a different system. Aldosterone, yes, some of these resistant hypertension may have secondary aldosteronism. I therefore started her on spironolactone 12.5mg once daily. After three doses of this drug, here is the BP monitoring chart…

20130118_174308

Even a minute dose has worked so well in dropping the BP by 20mmHg or more, awesome. This is an indirect evidence of her high sodium retention state (salt retention…secondary to secondary hyperaldosteronism). Well, we have also advised her to curtail salt intake.

Second case was another elderly lady whom I saw before, with severe hypertension. In the past the BP had been under control on atenolol and perindopril. This time she presented again because, according to her, BP check by clinic doctor has been persistently high. At my clinic her BP was 185/100mmHg. Heart rate 88, means not fully betablocked. There was no specific reason, she could be nervous, nothing showed on the ECG. Repeated check found no reduction in her systolic BP, looked dubious, however she also refused admission. I sent her TFT and renal function, and started her on diltiazem slow release (Herbesser R100mg). Last Friday she returned to my clinic, this time her BP had dropped to 140mmHg at home, around 156mmHg at clinic. Not yet at target, but she had moved away from danger zone. Now I changed her perindopril to Coversyl plus adding the diuretic component, to obtain an optimal BP reduction.

In both of these cases we have seen big drop in BP with addition of a single agent. I have maintained my practice of using the first three line of drugs A+C+D in most occasions (A=ACEI/ARB, C=CCB, D=Diuretics), however, there are times when I skip this rule especially in dealing with resistant cases. Whatever it is, the first aim in treating hypertension is to reduce BP to target. Next you have to think of the most appropriate agent, ie one that is likely to confer optimum benefit in term of prognosis. Then I will address comorbidity and risk factors, low threshold in initiating statin especially when there are two or more CVD risks present.

Help, how do I entertain this request to talk about a product I do not really favour…?

I am a doctor, I do not do marketing, I only present evidences…

If someone ask you to give talk to an audience about a product that you do not support, for the purpose of promoting it…what will you do? Hold on, there is some attractive honorarium for it, will you do it?

I was not in that kind of situation, but nearly. Now they had asked me to talk about this product H, that I do use, indeed, but not as my first choice. I have kindly obliged since they approached me in a very persuasive way and I know there is nothing wrong with this product anyway, just that I do not use it enough. Did I do it for money, no way, coz, I gave my agreement even before the rep told me that there is going to be honorarium – true, some company do not really give you anything substantial for speaking for them, I still do accept the invitation. For one, I treat this request as an academic exercise aka my own CME, furthermore it gives me opportunity to meet new people and broaden the horizon of my national appearance.

Here is what I did. First, yes, the product is genuine, endorsed by guidelines. I looked through the literature, some of which were old ie pre-2000, however, on browsing our own clinical practice guidelines, no doubt this product was mentioned as one of the approved treatments, listed at par with other, more established product that I frequently used. Therefore there is no conflict, it’s just that, I did not favour the product, due to my own exposure and previous experience.

fatih dilemma

Second, as usual the company gave me the presentation materials. As a practice, I do not adopt the presentation material completely, instead, I will go through each slides and ensure that the content genuine and does not contradict with my own understanding and the established evidence. Then I only picked materials that are fairly neutral in contents, ie not too patronizing of the product, I keep on the generic rather than brand name in almost all the labelling if possible. Any of the material that is doubtful or overbearing of the product will be put aside.

Then I drew my own concept and perspective for the lecture. I outlined what I wanted to present, rather than what the ‘company want me to talk’. Obviously I have to supplement more than half of the content with additional materials obtained from my own research. This is where I like being given the task of giving a lecture, since it gives me the opportunity to explore and hence broaden my understanding of the subject, in a fair and unprejudiced way. Fortunately, this day it is  not very difficult to search relevant references through internet.

On the day when I arrived, the company rep had already set up a computer, and projected the slides of the presentation! I quietly went to the stage, and asked to use my own laptop, telling them that I had prepared my own material, combining with the material they have supplied. They had absolutely no problem with this, so I showed them the entire content of my presentation, to assure them that the presentation ‘does justice to their product’. They appeared to be pleased, in fact at the end of the presentation the company manager praised me for the wealth of contents that I have presented.

Therefore, by carrying out this exercise, I had given a lecture, which was fair, unbiased and highly academic. This was proven, when during the discussion, audience had thrown various questions that were quite general rather than too focused on the product. At the same time, the company were happy since enough justice was given to introduce their product to the intended audience.

You may be interested to know, if there had been occasions when I refused to talk about products? Yes, as far as I can recall twice. One about a product that now is being withdrawn from the market – I was sent for a special training workshop for it, but later declined to take further steps to promoting it. Another was a product, which is good and genuine, but I do not use it so much (very much like this case), but I declined coz the company rep was so pushy, then it was passed on to my junior colleague. There was another invitation for a special expert group of another product, which I had some doubt about its strength of evidence, however, I sat there merely as adviser or to give expert opinion, if it come to the stage of endorsement or promotion, I will have to take a stand depending on the nature of the proposal.

In principle, I found most if not all companies (at least their senior management personnel) will not allow promotion of their products beyond its approved label. Therefore, some of them will insist on going through the presentation material in advanced, not because they want to see how much you are promoting their products, its rather to rule out any off label marketing being presented.

Hearty Sharing about Heart Disease at Batu Enam Mosque Gombak

As a sequel to our successful forum at Alam Damai Cheras last month, where I was the moderator, this time I was invited to speak to the congregation of men and women of this Masjid Lama Batu Enam, Gombak.

The place was a little vague to me, despite the fact that I lived in Gombak about 7 years ago when I first settled in Malaysia. It took me 2 stops at two other mosques that were located nearby. Professor Mokhtar who represented the mosque committee – who happens to be my senior colleague at work had been in communication via FB prior to the event.

There were quite a sizeable crowd of men and women, altogether must be close to 80. The mosque is quite old, it was first opened in 1931. Apparently, when the community  built another newer and bigger mosque, Masjid AsSyakirin, which is located about 1km apart, they decided to leave this mosque intact to continue its function. The unique thing about its mosque, apart from its modest size, is its location which is along the main Gombak road, therefore leaving the attending congregation no space for parking. I was given special previlige to park opposite the mosque entrance, leaving half of the car resting over the heightened kerb.

741045_521191494569454_1025261340_o

Most of the audience were of the older age, there were a few young people including the chairman. They provided a decent Powerpoint projector and a good public address system. I began by flashing a slide denoting someone’s status ‘how to have a good heart’. I assuredly said that people who attend the mosque are on the right way of getting a good heart, since everytime they are leaving their house to the mosque, they would recite the du’a among which so that Allah will give send light to their hearts…

Heart disease as number one killer, is no longer a strange statement, though by producing various data derived from the European and international studies, I boldly stated that the true prevalence of cardiovascular disease (that means all heart diseases plus stroke and peripheral arterial diseases) approaches 40-50% globally. However, most worrying is the increasing incidence among young people, which I spent a while demonstrating with examples, including angiogram picture of a 26 year old patient of mine who presented with MI and severe two vessel disease. Women, albeit young are no exclusion, again I mentioned how a 38 year old woman could present with acute MI and severe three vessels disease requiring coronary artery bypass graft. In addition, I brought another striking example of how I had to perform coronary angiogram on a very young patient of 23 year old, though it was almost normal, the guy has a very strong family history of MI, has diabetes and metabolic syndrome. My point was, coronary heart disease in Malaysia is very aggressive and affect people from a very young age group. The special thing about coronary disease in this young group, they tend to be severe and involve multiple vessels.

Further I went on showing alarming statistics of cardiovascular risk factors, based on the old NHMS figure that more than 60% of Malaysians have at least one cardiac risk factor. Accummulation of risk factors increases one’s risk of getting heart disease. Furthermore certain comorbidity especially diabetes doubles the risk. There are systematic risk predictors that can be used to guide therapy such as Framingham risk calculator and European ‘SCORE’.

Lastly, on prevention. Healthy eating, healthy lifestyle – exercise and weight reduction, plus smoking cessation were emphasised repeatedly throughout the lecture. I also gave brief outline of treatment for coronary disease including risk factors modification, medication and revascularisation. Videos of heart anatomy and function, atherosclerosis and MI, and revascularisations with CABG and PCI were shown.

The question and answer session was lively with audience throwing various questions covering medications, how to deal with symptoms of heart diseases, popular issue such as supplement and types of diets etc.

I would like to thank Prof Mokhtar, the committee of the mosque and all the audience present. I hope I have shared some useful highlight and motivate the people to adopt healthy heart living. Afterall, I feel more satisfied now with the changes in approach of the lecture this time. I do hope to improve this further and would not mind accepting future invitation to speak on the same topic. Well, it’s my small deed, at least I can contribute to the society and educate them on this subject that I posses some expertise on.

When all you see is blood….ugh not another complication!

I am starting the day free and easy. Good start of the weekend when I managed to join the Subuh prayer at the surau, and as usual excused myself as soon as prayer ended, went home and awoke the rest of the household between reciting daily portions of the Quran. Kids have school commitment and football but I didn’t need to send them coz they got their motors. Oh, but my mind is fully occupied and I got so many paperworks to do that I don’t think I am talking about going out – though we have at least 2 functions to attend today, and tomorrow evening is my public lecture at a mosque in Gombak (which I am yet to prepare). Therefore I have a good personal reason not to be at the Perhimpunan Rakyat today – furthermore as I stated in my FB status 2 months ago, I have minor disagreement with the nature of the organisation of this gathering, by any means, I do stand with the people and certainly support the spirit of this gathering. Between the time I am reading my PhD student’s thesis – need to be done by Monday, and I have yet to finalise the slides for my lecture to GPs this Wednesday. Now I must concentrate on all these jobs as my priority and not anything else, ooopss why I am writing my blog now??

Yesterday, at the conclusion of Friday prayers at our mosque at PPUKM, the Imam made an announcement inviting the congregations to join a congregational ‘Solat Hajat’ or ‘Supplication prayer’. Though I rarely join such activity, this time I decided for it, well why not, this would be a form of charity for the day, and there is one special reason, I wanted to make a special prayer for an elderly lady patient of ours (DH) who had sustained a complication from pericardiocentesis (a procedure to evacuate fluid accumulation in the pericardial space of the heart).

Here the (sad) story goes…DH is an 70 plus year old patient who had been diagnosed with left atrial myxoma (a kind of tumour in the heart) and chronic pericardial effusion, previous TB but not sure if the effusion was due to TB. Anyway, she was readmitted two days previously with dyspnoea. I reviewed the echocardiogram which showed features of cardiac tamponade, namely a huge accumulation of fluid giving that ‘swimming heart’ appearance with classic diastolic collapse of right ventricle. Since I was only alerted of the echo finding the day after, I immediately rushed to the ward to find out. A decision was made to transfer her to the coronary care for urgent pericardiocentesis. Patient and family, who initially were opposed to any form of cardiac interventions, had on this occasion agreed to undergo the procedure on the basis that it was urgent. Clinically she was quite stable, no tachycardia but had some features like Kussmaul’s sign and pulsus paradoxus.

Najma our previous Cardiac Medical Officer who is now incharged of the patient had requested my kind permission to perform the procedure, of course fully supervised by me. The first puncture was successful yielding straw colour fluid which clearly meant that the needle was in pericardial space. I helped her to thread the wire, next dilator followed by the pigtail catheter. However subsequent aspiration drew blood stained liquid which colour grew more intense and later evidence of clot. This was suspicious, and I performed bubble test which failed to show bubble appearance neither in the pericardial space nor heart chambers. We have drawn out almost a litre and the pericardial space now diminished. I was a bit wary, anyway concluded that there could have been small blood vessel torn by the wire or introducer, or injury to the pericardial surface in some sort.

The nightmare started when I was called half an hour later, DH collapsed with systolic BP of 50mmHg. Echo was repeated and showed re-accumulation of fluid. Not that fast so something must be wrong. The guys were fast in alerting the cardiac surgeons team. I was baffled, clearly the pigtail was in the pericardium, now still aspirating. In order to clear the confusion I decided to attempt a fresh puncture followed by a new pigtail, however this resulted in the same nature of aspirate, this time, of course more dense haemorrhagic fluid. Long discussion took place with the surgeon who were initially reluctant to proceed due to fear of TB pericarditis. In the end they took the patient to the OT. What was found, was phenomenal. Patient collapsed and went asystole on the table, on opening the pericardium huge amount of clot was found lining up the whole space. Once the clot cleared, the bleeder was found, a distal end of right ventricular branch of Right coronary artery perforation! Thankfully the operation went well and the patient is now recovering.

In this unique scenario of event, I must admit that we had taken all the necessary precautions with no shortcut. Diagnosis was made, supported by clinical assessment, explanation and consent obtained from the patient, family informed, they were made aware of the potential complications, the procedure was performed in the presence of a full compliment of cardiac team, the place was right. Each step of the procedure was taken in a systematic and appropriate manner. How human we are, to give a guarantee that a procedure will not cause complications? In fact, if you believe in Murphy’s law, well God’s law is above all, many times, complications happen when you least expect it. I mean at least in this case, I never expected that the procedure is of a high risk – what is pericardiocentesis if it is not one of routine cardiac procedure that required skill. The fact that the puncture was done by an MO (she was seriously traumatised by this event!) under a full supervision of a consultant – did not in any way make the procedure any riskier or of lesser quality assurance. Every step was done in the best way that we knew, of course it is a ‘blind’ procedure with known risk. I have not seen this kind of complication in my entire life.

20121214_100552

We had once, a junior specialist performed a tap in which the pigtail ended in the right ventricle (I promptly diagnosed this with the bubble injection) – patient survived following successful surgery – this sort of thing is  different in the sense that, something wrong was already detected at the start ie at puncture, in contrast to our situation when the puncture was clearly precise with clear fluid and no blood.

Nevertheless, this incident highlight a few important points. First, diagnosis is important, as much as prompt action. Correct diagnosis will justify the relevant treatment or management. This brings up the point on the necessity of performing the procedure, especially in a reluctant patient such as this case. Second, thorough consultation with patients and family must not be overlooked, explanation of the nature of the procedure and each potential major complications should be clearly expressed. Thirdly invasive procedures with potential for serious complications, must be done with appropriate preparations and techniques. Fourthly teamwork and the presence of adequate personnel helped. When complication happen, most of the time it is, more than likely, better to act in a most comprehensive manner, such as done in this case, when the surgeon was called early and treatment carried out immediately.

God knows what is best, we are only His deputies on this earth who should follow His rules and laws. Let’s pray for the wellbeing of this patient, and not to forget all the caregivers involved, may God keep them in the straight path and give them strength in their hearts and minds to face all these challenges without ever losing hopes.