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Archive for the ‘Cardiology News’ Category

Dr Malik reads a news story with interest…Regenerate the pancreas…

Dr Malik read a news story with interest: “Fasting regenerates the pancreas in Diabetes Mellitus (DM)”

However, this was a study in mice that were genetically prone to DM. They had 4 days severe dieting (perhaps an equivalent of 1000 calories, but mainly as fat, not carbohydrate or protein), and then a normal diet for 3 days. This was repeated.
Beta-cells in the pancreas make insulin. It seems that periodic starvation could get their beta-cells (which were withered away), to reactivate or regenerate.  In non diabetic mice, they found a drop in beta-cells activity in the diet, which could of course be alarming, but a recovery within 24-48 hours, and a better gene activation pattern. So the beta cells could be “tuned-up”.

Weight Loss is good for you

Weight loss is known to be important in treating type 2 DM in humans. Calorie control is vital in prevention and treatment. Bariatric surgery is now also a validated treatment for severe diabetes. So is pancreas transplantation. This study suggests that you might be able to “auto-transplant” a better pancreas into yourself by dieting.
DONT try this diet at home without medical advice. High fat diets also have risks. Losing weight gradually is a good idea. Long periods of starvation (as in famines and world wars) have been known to increase the lifespan of survivors, but how to apply that in daily life in the world today has not been fully worked out.
Mouse research can take a decade to get to a human equivalent.

Is coffee really good for you? Dr Malik says … probably

Is coffee really good for you?

I often tell patients with palpitations and even blackouts that coffee and tea may be the cause. Stopping it may avoid more investigations and invasive treatments.

Where did coffee come from?

This site  takes you through the origins of coffee. It appears that dancing goats in Ethiopia lead the goat gerder to look for the cause- coffee beans that they had eaten. Now it is one of the largest commodities traded in the world. And it tastes good!

Although originating in the Muslim world, initially declared “Haraam” or sinful, and then declared “Hala” or permissible by the Ottomans, Pope Clement VIII  sampled coffee for himself and decreed that it was indeed a Christian as well as a Muslim drink.

Inside the red fruit of coffea lie two  green coffee “beans”. The rich brown hue to appear only after roasting. In fact, they are fruit, and the seed is the coffee bean you need!

Evidence of benefit

Here is a tale from a very worthy journal suggesting that high coffee intake may be linked to reduced mortality. It was a randomised trial. This is the gold standard of evidence. BUT still it is by no means certain that these high coffee drinkers were not different from the non coffee drinkers in some other way, although the study did try to control for smoking habits, social class, body mass index etc.

Downside?

It will make you pass water. It can give you palpitations. It can make you anxious and irritable. It might increase your heartburn. And the Buzz can wear off.  Evidence suggests there can be a reliance on the drink, and tolerance builds over time.

Finally, it can be addictive. So beware. Going cold turkey now and again will keep the addictive tendancies at bay. Withdrawal symptoms include a headache, fatigue, irritability, difficulty concentrating, and depressed mood.

Message

If you like coffee and are not getting side effects, then keep on going. There seems no need to cut back on this ubiquitous and legal “high”.

Know your surgeons data- Why is it hard to say who is “The Best”? Dr Malik explains…

Professor Sir Bruce Keogh, previously Medical Director of the NHS, and a cardiac surgeon by trade, said all surgeons should have their operation statistics published. He felt that doing so would make the surgeon more  careful. The risk taken would not be just for the patient, but would now also hang over the surgeon.

This seems obviously a great idea.

But hang on a minute…

Like all issue, it is more complicated than it seems.

  1. Did it mean that some surgeons were previously “gung-ho”- I have not come across those- most are very balanced on their approach to risk.
  2. Will it mean surgeons will practice more safely- perhaps- if they were “gung-ho” in the 1st place, but perhaps it will make them risk averse. That is, they will refuse to take on the higher risk cases-as that will reflect badly on their Stats. This is the same as the school not entering your child in for an exam because they wont get a grade 7,8 or 9, and that will reflect badly on their school performance table.

So, the outcomes have to be risk-adjusted

  • If the expected death rate is 5% from the surgery and the surgeons ouctome are 5%, then she/he is performing as expected.
  • If in fact their outcomes are 3%, they are better than expected (or the risk scoring system is out of date- as all surgery is improving as time goes by- remember a Victorian era surgeon would chop a leg off without anaesthetic or antibiotic!).
  • If they are performing worse- say 7% death rate:
    • it could be that the risk scoring system is not taking some other factor into accout that is vitally important (eg frailty of the patient- which is easy to judge in front of you when seeing the patient walk in, but hard to quantify).
    • Or the surgeon as not done as many cases to even things up, and a play of chance has made the stats look bad.
    • Or of course, there is a genuine problem that needs to be looked into- This is rare

So. Do you want a surgeon with very low mortality for their procedures- YES

But. Do you want a surgeon used to dealing with high risk cases-YES because they will find the easier cases very simple and get great results. BUT this surgeon will a mortality rate that will of course be higher than for the average surgeon.

 

Conclusion

It is hard to know who is “the best”. A personal recommendation by someone in the know is probably better than searching for statistics that are harder to interpret. On average surgeons, including interventionalists like me, get appointed as Consultants (in USA speak, “Attending Physicians”) at about 35-40, and reach their peak of experience 45-55- when they have been around long enough to know all of the issues, experienced all of the complications, and thus know how to deal with them. Their data is also more stable- as they have done so many cases that their average mortality is a true representation of what they do.

UK surgeons are now moving AWAY from individual surgeon data, but presenting data for their unit. If the whole unit data is looking bad, then individual surgeons data should be examined. This makes more sense to me.

Finland vs Denmark Euro 2020: game ends with a player being resuscitated – and surviving!

Successful restart of the heart from a cardiac arrest during a game

I was watching the game and Christian Eriksen, the Denmark captain collapsed. It reminded me of Fabrice Muamba and his collapse at a premiere league game. He survived. https://www.youtube.com/watch?v=IChMmD5dx7I

What causes a collapse?

This can be due to the brain- eg epilepsy- a blackout.

This can be due to the heart- the heart can go too fast (tachycardia) or too slow (bradycardia)- a syncope.

In addition the heart can STOP. In younger perople this is uusually due to ventricular fibrillation (VF)– the electricity of the heart goes haywire, and there is no coordinated heart beat. In older patiients, you may see asystole– absolutely NO electrical activity, or PEA– then there is activity that looks normal, but the heart muscle can no longer respond. This is a cardiac arrest.

Most commonly, of course, it can be a simple faint- the heart does not stop, and recovery is quick.

What caused his collapse?

Obviously as yet, just after it has happened, no one will know. He is a professional athlete, and will have had regular medicals to ensure he is fit to play. Just as in other athletes that suddenly collapse, VF is the likely mechanism of his collpase, but WHY it occured will take time to sort out. The early news is that he has made it to hospital alive.

What tests will he have?

It is likely that he will have:

  • his coronary blood vessels assessed- an angiogram
  • be checked for blood clots- a CT scan
  • have blood tests to ensure it was not a salt imbalance on a warm day that caused his cardiac arrest.
  • He will have electrical tests to see if there is an underlying instability of his heart rhythm.

Summary

I wish his well in his recovery- the cardiology input will be key in sorting out what actually happened. As the resusitation was immediate and successful, one would hope for a full recovery.

Dr Malik is Medical Director of  OneWelbeck Heart Health and London Cardiovascular Clinic,  and is Clinical Director of Structural Heart Disease at Hammersmith Hospital, Imperial College Healthcare NHS Trust, London.

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Update June 2021

It was great  to see that Christian Eriksen left  Rigshospitalet Hospital in Copenhagen  following a successful operation to fit a defibrillator implant. This device will protect him in case the heart rhythm misbehaves again. I wish him well for the future.

What is a  Defibrillator?

This is a “shock box”. If the heart is too slow, it will “pace” to ensure it cant go slower. If the heart is in “VF”, then it will “Shock” to reset the heart electrically. See

this section.

We consult at One Welbeck Heart Health- and are proud of it, says Dr Iqbal Malik

Dr Malik, Professor Peters and Professor Mayet now consult at One Welbeck Heart Health, minutes away from Harly Street, and 60 seconds walk from Bond Street Station.

What we do there

Look at this animation of our facilities

We consult there. In additon we can do:

  • ECG
  • Echocardiography
  • ABPM
  • Holter
  • Bloods
  • CTCA
  • MRI

Take a Virtual Tour

This video shows you what the facility looks like

I hope you will agree when you visit that it is a special place to visit. We hope to give you a seamless experience with Consultation, Bloods, and Investigations all under one roof.

Bempedoic Acid (Nilemedo)- a new lipid lowering agent- Dr Malik explains what it is

What Nilemdo (Bempedoic Acid) ?

Dr Malik explains what this new drug does and when it might be used.

What Nilemdo is and how it works:

Nilemdo lowers levels of ‘bad’ cholesterol (also called “LDL-cholesterol”), a type of fat, in the blood.
Nilemdo contains Bempedoic Acid, which is inactive until it enters the liver where it is changed to its active form. Bempedoic Acid decreases the production of cholesterol in the liver and increases the removal of LDL-cholesterol from the blood by blocking an enzyme (ATP citrate lyase) needed for the production of cholesterol.

The dose is 180mg once a day

What Nilemdo is used for:

Nilemdo is given to adults with primary hypercholesterolaemia or mixed dyslipidaemia, which are conditions that cause a high cholesterol level in the blood. It is given in addition to a cholesterol-lowering diet.

Nilemdo is given:

• if a statin (such as simvastatin, a commonly used medicine that treats high cholesterol) and this does not lower your LDL-cholesterol sufficiently;
• alone or together with other cholesterol-lowering medicines when statins are not tolerated or cannot be used.

What you need to know before you take Nilemdo:

Do not take Nilemdo:
• if you are allergic to bempedoic acid or any of the other ingredients of this medicine (listed in section 6);
• if you are pregnant;
• if you are breast-feeding;
• if you take more than 40 mg of simvastatin daily (another medicine used to lower cholesterol).

Warnings and precautions:
Talk to your doctor before taking Nilemdo:
• if you ever had gout;
• if you have severe kidney problems;
• if you have severe liver problems.
Your doctor may do a blood test before you start taking Nilemdo. This is to check how well your liver is functioning.

Other medicines and Nilemdo

Tell your doctor if you are taking medicine(s) with any of the following active substances:

• atorvastatin, fluvastatin, pitavastatin, pravastatin, rosuvastatin, simvastatin (used to lower cholesterol and known as statins).The risk of muscle disease may increase when taking both a statin and Nilemdo. Tell your doctor immediately about any unexplained muscle pain, tenderness or weakness.
• bosentan (used to manage a condition called pulmonary artery hypertension).
• fimasartan (used to treat high blood pressure and heart failure).
• asunaprevir, glecaprevir, grazoprevir, voxilaprevir (used to treat hepatitis C)

Pregnancy and breast-feeding

Do not take this medicine if you are pregnant, trying to get pregnant, or think you may be pregnant, as there is a possibility that it could harm an unborn baby. If you get pregnant while taking this medicine, call your doctor immediately and stop taking Nilemdo. Do not take Nilemdo if you are breast-feeding because it is not known if Nilemdo passes into milk.

Nilemdo contains lactose and sodium

If you have been told by your doctor that you have an intolerance to some sugars, contact your doctor before taking this medicine.
This medicine contains less than 1 mmol sodium (23 mg) per tablet, that is to say essentially ‘sodium-free’.

How to take Nilemdo

The recommended dose is one tablet once daily. Swallow the tablet whole with food or between meals. If you take more Nilemdo than you should contact your doctor or pharmacist immediately. It is unlikely one exta dose will harm you.

If you notice that you forgot:
• a dose late in a day, take the missed dose and take the next dose at your regular time the next day.
• the previous day’s dose, take your tablet at the regular time and do not make up for the forgotten dose.

Possible side effects

Like all medicines, this medicine can cause side effects, although not everybody gets them. Side effects can occur with the following frequencies:

Common (may affect up to 1 in 10 people)
• lower number of red blood cells (anaemia)
• increased levels of uric acid in blood, gout
• pain in shoulders, legs, or arms
• blood test results indicating liver abnormalities

Uncommon (may affect up to 1 in 100 people)
• decreased haemoglobin (a protein in red blood cells that carries oxygen)
• raised creatinine and blood urea nitrogen (laboratory tests of kidney function)
• decreased glomerular filtration rate (a measure of how well your kidneys are working

 

Summary

This is a brand new treatment for lipids. Lipid lowering is known to reduce the risk of heart attack and stroke. Statins are the 1st line agents. This new tablet will not be 1st line. It is also , like any new tablet, expensive- costing about £300-400 per year. The fact that it is onec a day and a tablet, of course makes it easier to take.