Archive for 2019

Dr Malik on new agents in Diabetes – when should I take them?

When should I take the new agents in Diabetes?

The SGLT-2 Inhibitors have been around for a few years (Empagliflozin, Canagliflozin, Dapagliflozin).

The data on cardiovascular benefits are increasing, but as with all powerful drugs, they can’t be used in all patients.

They are useful in a type 2 Diabetic, with good renal function (eGFR>45 ml/min/kg), but evidence of cardiovascular disease, heart failure, and some albuminuria. Your cardiologist will need to carefully consider if it is worth while in your particular case. Caution is needed as they can cause low blood sugar, ketoacidosis (esp in Type 1 diabetics), dehydration, and genital infections.

How do they work? They block the reabsorption of sugar in the kidney- you pass more sugar and water out.

The Figulla ASD device – see it in action!

Dr Malik says:

It is worth seeing what I put inside you to close a hole in the atrial septum (an atrial septal defect-ASD).

The indications for closure are:

  1. Dilated right heart, showing strain from the abnormal shunting
  2. The shunt from left to right across the ASD being large (comparing flow on the left and right 1.5:1 shunt)
  3. A paradoxical embolism- clot moving from the right to the left

ASD closure is done under general anaesthesia with X-Ray and echo guidance. It is a very safe and effective procedure- please see some of my cases on YouTube.





Evolutionary medicine: hypercholesterolaemia

Dr Malik says:

My summary of this interesting article: as humans evolved in a cycle of mainly food shortage, and occasional feast, and did not live into a ripe old age, the authors argue that having more lipids in the blood leads to a reproductive survival advantage. Perhaps you survived starvation better, perhaps you could run from a sabre tooth tiger faster.
Who knows – but to cope with 21st century risks, the reproduction is perhaps not the issue: living well and living longer is; thus the focus on diet, exercise, control of risk factors especially smoking, blood pressure and diabetes.
For the Medics, it explains lipid metabolism. For the non-medics, biologically plausible mechanisms to explain why we are built as we are… BUT it does not mean that is the truth.

Octopus Pot Heart – Takotsubo Cardiomyopathy

Takotsubo Cardiomyopathy occurs when extreme physical or emotional stress causes, not a blocked artery, but a direct effect on the heart muscle – it stops working properly. It looks and feels like a “heart attack”, and it can be fatal.

We need to exclude a blocked artery (a coronary problem) and infections that can sometimes affect the heart i.e. myocarditis.

However, it we can tide you over in the 1st week, the amazing thing is that the heart can go back to normal function again.

Read more here.

How much radiation do cardiac tests give me?

Dr Malik says: “We will pick the best test for you. All are safe. If you are worried about radiation doses – don’t be.”

A dose can be measured in Seiverts.
A 1000 microSeiverts (uSv) makes a milliSeivert (mSv) and a 1000 mSv makes a single Seivert.
Usually we quote in milliSeiverts (mSv).

Ultrasound based tests and MRI scans have no radiation involved.
A CT calcium scan provides about 1 mSv, which is similar to the radiation from a mammogram.
A CT Coronary angiogram ranges from 2 to 7 mSv.
Nuclear medicine stress tests ranges from 4 to 10 mSv.

The average person receives about 3 millisieverts (3 mSv) of background radiation per year from natural sources.

Dr Malik: an update on lipids and cholesterol

Cholesterol elevation in your blood is bad for you.

How high is too high, and how low is too low?

  • Too low? I think not. The lower the better. At birth LDL is about 0.4 mmol/l.
  • Too high?
    • LDL>3.5 on statins after a vascular event means you may need subcutaneous (SC) injections of more powerful drugs.
    • LDL >5 with a family history, and again you will need the SC injections even if you have not had a cardiovascular event- prevention is better than cure.
  • What if the LDL is already “good” at <2 mmol/l, but coronary disease is progressing? There is some data to measure Lp(a), and if >50mg/dl, then risk is increased.

So, the target is really an LDL<2, total cholesterol <4, a ratio of TC:HDL <4 as the bare minimum when you have had a heart attack, or non HDL cholesterol <3.8.

How to I persuade a patient who is reluctant?

I look for established hardening of the arteries – atherosclerosis:

  • USS carotid – looking at intimal hyperplasia- early hardening- no radiation exposure, but not as good as CT
  • CT calcium score – it that is high, then people will usually listen to medical advice. The radiation dose is low nowadays.

What are the choices?

It is all about lipid lowering. However you do it, whether drugs or diets, 1mmol/l reduction reduces your risk by the same amount.

  1. Diets – They lower LDL by 0.2-.04 mmol/l-not enough
  2. Statins – These are the most evidence based- can lower your LDL by 1/3.
  3. Fibrates
  4. Ezetimibe
  5. PSK-9 inhibitors (Alirocumab (Praluent) at 75mg every 2 weeks or 150mg every 2 weeks; or Evolucumab 140mg every 2 weeks – Proven to reduce LDL on top of statins
  6. Bempedoic acid

Who should we screen for Familial Hyperlipidaemia?

  1. LDL >4.9, Total cholesterol >7.8
  2. Family history of premature Coronary disease
  3. Personal history of MI <55 in men, or 60 in women.