Archive for 2018

MitraClip: yes or no?

Dr Malik says:
Two trials have come up with absolutely opposite results. Why?
The positive trial , COAPT, had more severe mitral regurgitation and less stretch of the heart.
Mean effective regurgitant orifice area (EROA):
-COAPT 41 mm2
-MITRA-FR 31 mm2
 Left ventricular end diastolic volume:
-COAPT 101 mL/m2
-MITRA-FR 135 mL/m
Also, the patients already had maximal medical therapy. But it took a long time to recruit- suggesting that real patients may not be the same as trial patients.
The negative trial, MITRA-FR was a European rather than US lead study, and was clear in showing no benefit.
For the moment let’s wait for RESHAPE-HF2. 

Dr Malik: Is mountain climbing dangerous?

Dr Malik says:
Forget the risk of falls, snow and ice.
Oxygen levels are lower at altitude – no good if you have heart or lung disease.
In addition, even healthy people can be prone to mountain sickness. The most serious types can lead to brain swelling (High Altitude Cerebral Odema – HACO) or lung swelling (High Altitude Pulmonary Odema- HAPO). Watch out for headaches or breathlessness!

Dr Malik: Watch out of narrowing in your leg arteries [PAD]

Dr Malik says:
Claudication (pain in your calves when walking) can be a sign of hardening of the blood vessels.
Get checked out and address your lifestyle, especially if you smoke.
Treatments include stenting the arteries open, and bypass surgery.

Dr Malik: What to do about High Blood Pressure

Dr Malik says:
Talk to the doctor, get your lifestyle sorted out, actually swallow the pills prescribed to you (they don’t work if not swallowed), monitor the BP.
For some people, home BP monitoring creates anxiety, but for most, it is more accurate than if I measure it in clinic.

Dr Malik: FREEDOM 8 year follow-up

Dr Malik reports:

I was involved in the CARDia trial of angioplasty (PCI) versus surgery ( CABG). FREEDOM was a larger trial that reported a few years ago confirming the benefit of CABG.

I thought you would want to know the 8 year follow up presented at the AGA meeting recently in October 2018.

If you look at all 1900 then CABG wins. If you look at the 950 that were followed up for a full 8 yrs, CABG very nearly wins- the stats are weaker as the groups are smaller. The trend is the same.

So a diabetic patient with complex coronary artery disease lives longer with CABG than with 1st generation drug eluting stents. We are on 3rd generation stents now, but CABG is still king in such patients unless a new trial shows otherwise.

Surgery is not dead, but alive and kicking, as are the diabetic patients!


Dr Malik on triglycerides

Dr Malik reports: I had fallen out of love with fish oils, Maxepa, and triglyceride lowering.
At the AHA meeting in Autumn 2018, triglycerides (TG) became interesting again. After you have lowered your cholesterol with statins, risk still remains. What about lowering TG – this has to date not reduced cardiovascular events. At this meeting, the REDUCE-IT trial showed a 20% reduction in cardiovascular death and 25% reduction in MACE ( the combination of death, death attack and stroke).

Why? A 4 g dose of EPA (omega-3 oil eicosapentaenoic acid) was used, not the low doses used before. The TG levels were elevated , and the patients were at higher risk- with previous CVS events, or with no events but diabetes and an additional risk factor.
Thus, it is worth considering this additional therapy if you want to lower risk further despite tolerating statin therapy.
The STRENGTH trial will look at a similar group and of it conforms this finding next year, that will be a game changer!
Read more here.