Archive for 2015

An antidote for new oral anticoagulants (NOACs)?


The direct factor Xa inhibitors apixaban, rivaroxaban, and edoxaban (NOACs) are indicated for prevention of stroke in patients with non-valvar atrial fibrillation (AF).

There has Been no specific antidote to reverse the anticoagulant effects of these agents. They tested the effects of andexanet, which has been designed to neutralise the anticoagulant effects of direct and indirect factor Xa inhibitors. It seems to work, in healthy volunteers! I bet it will be very expensive when it comes out. But, bleeding needing reversal is thankfully very rare.

Siegal DM, Curnutte JT, Connolly SJ, et al. Andexanet alfa for the reversal of factor Xa inhibitor activity. NEJM2015; doi:10.1056/NEJMoa1510991.

Dr Iqbal Malik

My heart stops when I faint/ blackout. Do I need a pacemaker?

Dr Boon Lim, Consultant Cardiologist and Clinical Lead for the Imperial Syncope Diagnostic Unit Hammersmith Hospital has recently published an article analysing the long term outcomes in patients who have syncope (fainting) who appear to have long pauses on tilt table testing (> 15 seconds heart stopping (asystole). The majority of patients appear to do extremely well, even in the absence of pacemaker therapy, which underscores the importance of adhering to the conservative advice such as:-

1) increasing fluid intake and keeping well hydrated

2) recognising situations which provoke fainting, and avoiding these.

3) performing isometric counter-pressure measures such as teeth and buttock clenching and tensing of the leg muscles to avoid an impending faint

Of the 26 patients reported to have prolonged episodes of asystole on tilt testing (>15s), only 6 patients had pacemaker implantation, but even 80% of patients without pacemaker therapy had improved with conservative advice outlined above after a follow-up period of 8 years.

In summary, a majority of patients with asystole on tilt testing can improve if adhering to simple conservative advice as outlined.

To see a syncope specialist in London, please contact LCC on : 02074360669


A long-term follow-up of patients with prolonged asystole of greater than 15s on head-up tilt testing.

Sau A, Mereu R, Taraborrelli P, Dhutia NM, Willson K, Hayat SA, Francis DP, Sutton R, Lim PB.

Int J Cardiol. 2015 Oct 21;203:482-485.

Dr Malik conducts live ASD closure

Dr Malik does a “live” ASD closure.
Atrial Septal Defect Closure with an umbrella device is used more often than open heart surgery to close holes in the heart. This was a filmed case from 2014.
The case was not straightforward but the final result was excellent and the patient is very well 1 year later with a near normal heart.
If you are a patient that may need this procedure then watch and several happens whilst you are asleep.

Syncope session at the European Society of Cardiology in London Aug 2015

Dr Lim is the clinical lead for the Imperial Syncope Diagnostic Unit, based at Hammersmith Hospital where approximately 700 tilt table tests are performed each year. He has recently been invited to speak about his experience in managing patients with dizziness, syncope and blackouts in London at the European Society of Cardiology Conference based in the Excel centre in London.

The focus of this talk was on the clinical history, initial investigations, and diagnosis, and set out a step-wise management strategy in patients with syncope. Key elements of his talk were the importance of detailed history taking in making a diagnosis of vasovagal syncope, and some of the more innovative work in treatment of severe cases of vasovagal syncope, which he has an active research interest in.


Uses of Balloon Aortic Valvuloplasty

Dr Malik leads the TAVI program at Imperial College, Hammersmith Hospital, London. He has done over 200 TAVI procedures. This recent publication from his group highlights the use of Balloon Aortic Valvuloplasty (BAV) either as:

An assessment tool to see the aortic stenosis is the cause of symptoms

  1. As destination therapy when nothing else is available
  2. As treatment to get over a crisis in preparation for a TAVI