Close icon

Archive for the ‘Research’ Category

All stroke centres should offer “clot-extraction” to save lives and disability

New publication from Dr Malik’s group

If you have a heart attack, you are often best managed by going direct to a Heart Atack Centre (HAC),  where you are immediately assessed to see if an emergency operation to open the blocked blood vessel (a Primary Angioplasty and Stent) is suitable. In the whole of London, these HACs provide 24/7 coverage, 365 days a year.

What about Stroke?

Unfortunately, if you ahve a stroke, even if you get taken to a Hyperacute Stroke Unit (HASU), you may not be offered the same treatment as for the heart. Why? Several reasons:

  1. No 24/7 rota for Mechanical Thrombectomy (MT) or clot extraction- not enough skilled operators
  2. Too late to benefit
  3. wrong type of stroke

Dr Malik  and his team have publised a review of the evidence base- we have had many trials looking to see if MT works. It does, and saves lives. Logistic and political issues  prevent it being delivered. Dr Malik works at Imperial College Healthcare NHS Trut where it is now delivered to those who need it 24/7, 365 days a year. It is hoped that other centres will follow soon!

Read more here 

Our paper was reviewed at TCTMD

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.


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.


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”.

Drug eluting stents are the best for the heart

stentingDrug eluting stents (DES) have become the mainstay of treatment with coronary angioplasty, and the new generation seem safer than the previous versions, with less change of acute stent blockage with clot (stent thrombosis).

Now it seems that in acute heart attacks ( acute myocardial infarction or AMI), treated with emergency angioplasty, these DES appear to be better than older bare metal stents (BMS). The research did not look at the duration of blood thinning antiplatelet therapies, but none the less, the use of DES should be the norm, and BMS used only if there are specific risks identified that would make the DES less useful, such as high bleeding risk, or impending non-cardiac  surgery.

Bmj 2014;349:g6427

Heart Stentsstenting



HDL “good” Cholesterol is hard to alter

Total Cholesterol (TC), LDL-Cholesterol (Bad cholesterol), and HDL-Cholesterol (good cholesterol, are measures of lipid levesl in the blood. Which level should you focus on?

If the TC is >5 mmo/l, then think about the risk. But better is the ratio of TC :HDL. If that is >5:1 then you should worry. It should be lower, ideally <4:1.

Statins lower TC and LDL. That is good. And statins seem to do good in most people. The new NICE guidelines suggest that if your risk of heart disease over 10 years is >10%, then a statin should be considered.

Sometimes the issue is a very low HDL. Statins are not so good for that. Fibrates can do that, with some evidence that they could reduce heart attack rates, BUT NOT death rates and ONLY if not on a statin. Specific CETP inhibitors raise HDL, but appear to have NO BENEFIT at all, and one of them increased death rates.

Research by Dr Keene in my hospital suggests thatit is statins that should be considered 1st, and the others only after that- the others might affect the blood levels, but not what is important- death and heart attack rates.

BMJ 2014; 349 doi: (Published 18 July 2014)
Cite this as: BMJ 2014;349:g4379

Dabigatran perhaps not as safe as expected

As with many things, something new comes along and looks great. It gets approval from the great and good, and then problems appear. It was like that for the great Thalidomide scandal more than 30 years ago. Surely it is different now?

In fact, on the back of one, large, good looking study, the RE-LY study, Dabigatran was approved as a New Oral Anticoagulant (NOAC), with the advantage of simple dosing and no blood tests needed. A recent editorial in the BMJ suggests that there remain risks, and that in fact, blood levels of the drug vary more than expected. Some have suggested that blood levels be taken.

If you are on this drug, perhaps a re-evaluation is needed? It might still be the best thing for you but…the alternatives are:

1. Warfarin

2. Rivaroxiban

3. Apixaban

4. Left Atrial appendage closure- a mini-surgical procedure to reduce stroke risk.

BMJ 2014; 349 doi: (Published 23 July 2014)



New way to train cardiologists- immersive simulation at Imperial

Airline pilots do it.  It is becoming more common in surgery. Now trainee cardiologists can practice in simulators before getting to patients. Procedures, and more importantly, medical emergencies can be role-played to gain vital experience.

Dr Iqbal Malik leads a team that has delivered an exciting new program at St Mary’s Hospital, Imperial College, London.

The first course ran in November 2014, and was felt to be the most useful training received by all the trainees.

Imperial Cardiology Training Programme (Short) from SiMMS Imperial on Vimeo.

Imperial Cardiology Training Programme from SiMMS Imperial on Vimeo.