Presidential Oration

Conference Newsletter9th December 2012

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64th ANNUAL CONFERENCE CARDIOLOGICAL SOCIETY OF INDIA & SAARC CARDIAC CONGRESS

2012CSI News

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Cardiology Medilaw The essential components of negligence as recognised are three: “duty”, “breach” and “resulting damage”

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In management of STEMI, time to treatment is critical. PCI is always better than throm-bolytic therapy. According to ACC/AHA guidelines, door to balloon time for PCI should be less than 120 minutes. However, according to data from MITI trial if the patient is seen within 70 minutes of onset

of symptoms, prehospital fibrinolytic therapy is very useful and is associated with better outcomes. Even if the patient is seen within 120 minutes, fibrinolytic should be given before transferring the patient to a PCI centre. If the patient is seen later than 120 minutes he should be loaded with clopidogrel and transferred for primary PCI.

Dr Bernard Gersh

Sudden cardiac death and ischemic heart disease have an enigmatic relationship. IHD is the most common cause of SCD. We have data from very few countries like those in North America and Europe. The challenge in the Indian scenario is that the data are not reliable. Globally the burden of SCD is 5.6% of all deaths while in India it is 10% of all deaths, which is a sizable number. Also, while the mean age of patients of SCD is 74 years globally, in Indians most of the SCDs occur in a much younger age group (50-70 years), the mean age being 60 years. Additionally, majority of SCDs in Indians occurred in hypertensives, diabetics and smokers. To tackle the problem of SCD in India, which is facing an epidemic of diabetes and CAD, we need to screen and treat people for coronary risk factors, treat ACS timely with timely revasculariza-tion, ensure compliance with proper medication (ACEIs, statins, aspirin, etc.) and identify patients at high risk and provide them with ICDs.

Dr B Hygriv Rao

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STEMI and Reperfusion Therapy 25 Years of Interventional Cardiology

Dr Ashok Seth

SCD and IHD- Global and Indian Perspective

Dr Ashok Seth started his Presidential Address by paying a rich tribute to Dr KK Haridas who had contributed greatly to the growth of interventional cardiology in India. While talking of the development of percutaneous coronary techniques from the times of the crude balloons to the present

day when we have drug eluting and bioabsorbable stents, he fondly remembered Geoffrey O. Hartzler, an early pioneer of angioplasty whom he held in great esteem. He emphasized the need to practice evidence-based medicine and that we owed it to our patients to be compassionate and instill confidence in them. His vision was that CSI should play a greater role in forming Guidelines and Govt. policies, It should have a voice which is audible, heard and followed.

CSI @ SCCT

FDA boxed warning on clopidogrel: Diminished effectiveness in poor me-tabolizers.Prasugrel: More efficiently metabolized, more potent, more rapid onset of action than clopidogrel.TRITON TIMI-38: Prasugrel more superior to clopido-grel, significant reduction in CV deaths but at the risk of more bleeding; net clinical benefit was in favor of prasugrel; dramatic reduction in stent thrombosis.Ticagrelor: Faster, greater & more consistent platelet inhibition; potential advantage if needing to stop therapy due to surgery as reversible. Ability of platelet function to recover faster vs clopidogrel.

Antiplatelet Therapy in ACSState of The Art

Dilligent attention should be paid to history, physical examination for ECG. Also vital is screening at 12-14 years of age and periodic updates. DrAditya Kapoor

Smt. Uma Rani Banerjee Memorial Oration

Goodbye New Delhi!!! See you in Bangalore...

65th Conference of the Cardiological Society of India, December 5-8, 2013

BIEC, Tumkur Road, Bangalore

Transcatheter Aortic Valve ReplacementTAVR and surgical valve repair have simi-lar mortality rates at 2 years in high-risk patients with aortic stenosis who are consid-ered eligible for either procedure, according to results presented March 26, 2012, at the annual American College of Cardiology (ACC)/i2 Scientific Session. The results, simultaneously published in the New England Journal of Medicine, suggest fewer late strokes with TAVR in the long term and may quell some of the worries sur-rounding the issue. The 2-year data from cohort A of the PARTNER (Placement of AoRTic traNscathetER valves) trial, following up on the 1-year findings presented in April 2011 at the annual ACC meeting, which showed similar mortality rates between TAVR and surgery but prompted concern over stroke rates with TAVR.

Dr BB Chanana

Faculty Speak

Dr Gary L Schaer

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CSI News

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“You are never too old to set another goal or to dream a new dream.” C. S. Lewis

Cardiology Medilaw The basic principle relating to medical negligence is known as the Bolam rule.

Unprotected LMCA Stenting Follow up Surveillance Angiography

No consensus on necessity and timing. Angiography follow-up timing should be 3-4 months. If early angiography reveals patent stent perform stress testing at 6-9 months. If angiographic restenosis is observed:

In LM artery: If occurs early and is severe then consider CABG & if it occurs late and is moderate, then consider PTCA.In ostial LAD/LCX: IVUS/FFR to confirm physiologic significance (asymptomatic). If restenosis involve both ostia: Consider CABG. If restenosis involves one ostium: PTCA.Offer LM PCI to patients at high risk for surgery due to comorbidities, suboptimal distal targets and if the patient cannot get a LIMA to the LAD.Offer PCI if the patient does not fulfill the above & refuses CABG with the following caveats: Do not perform ad hoc LM stenting. During informed consent emphasize CABG as the traditional approach and ask a cardiac surgeon to speak to the patient. Ensure that the patient commits to long-term antiplate-lets and short-term surveillance angiography.

Dr Rajiv Bhagwat

Faculty SpeakDr Amit Vora: PET CT is a useful tool for diagnos-ing infected pacemakers.Dr Rajiv Bajaj: Echo guided programming must be tried for CRT non responders.Dr Sameer Srivastava: Every ER should have an echo machine for evaluation of chest pain.Dr SK Parashar: Stress echocardiography, unless contraindicated should be done in all patients with valvular heart disease.Dr Shantanu Sengupta: 3D echo will be the future in the cath labs.Dr Sanjeev Bhattacharya: Dynamic evaluation of valvular heart disease by stress echo can provide new diagnostic information in patients with unmasking symptoms.Dr Harendar Kumar: Fixed dose combinations not only reduce blood pressure in a shorter time than single drugs but may also have more synergistic actions.Dr AK Barooah: Majority of patients with ISH need single or dual combination of drugs.Dr Saumitra Ray: Volume overload is the commonest pathogenic cause of resistant hypertension.Dr AK Sinha: Treat hypertension with non drug therapy, in stage 1 for upto one year with no risk factors and six months with risk factors.

Percutaneous Valve Treatment Gains TractionNew guidelines on valvular disease, released jointly by the ESC and European Association for Cardiothoracic Surgery, were shared by Dr Rajnish Kapoor (Director, Interventional Cardiology, Medanta- The Medicity, Gurgaon)In patients with aortic valve disease, the guidelines advice, TAVR should only be done at hospitals with a multidis-ciplinary heart team and on-site surgical backup. The noninvasive therapy received a class I B recommendation in patients with severe symptomatic aortic stenosis who are judged by a heart team to be unsuitable for surgical replacement and are likely to gain improvement in quality of life and have a life expectancy of more than 1 year. TAVR was classified as class IIa B for patients who may still be suitable for surgery but are thought by the heart team to be better candidates for TAVR based on their risk profile and anatomic suitability.For mitral regurgitation, the guidelines position surgical repair as the preferred approach due to its durability. But percutaneous repair was described as safe and generally well tolerated. Though less effective at reducing mitral regurgitation, the percutaneous approach may be considered for symptom relief in high-risk or inoperable patients who do not respond to medical therapy and have a life span greater than 1 year (class IIb C).

Faculty Speak ...

Dr Rajnish Kapoor

State of The Art

Will CTA Replace Conventional Coronary Angio?The answer is Yes. The Cath lab will become an interventional suite for PCI following triage by CTA. The disease is better defined with CTA. It is possible to spot bifurcation stent stenosis, inadequate stent expansion, stent aneurysm. Stent sizing & calculation of FFR can also be done.

CTA CCACoronary anatomy +++ ++Significant stenosis +++ +Plaque +++ 0Cost + +++Safety +++ ++Radiation + ++

Corrigendum: This story was erroneously published yesterday. The corrected story is carried today. We sincerely regret the error.

Cardiology Jeopardy Quiz...A 1st in CSI

Dr John Gorscan...the QuizmasterCricketer Team (Dr Sundeep Mishra, Dr S Ramakrishnan)

Bollywood Team (Dr Praveen Chandra, Dr Manish Bansal)

Emperor Team (Dr JC Mohan, Dr Sandeep Bansal)

The Winners

Faculty Speak ...

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64th ANNUAL CONFERENCE CARDIOLOGICAL SOCIETY OF INDIA & SAARC CARDIAC CONGRESS

CSI News

This is what I tell my patients. Following are the options to manage any traffic:

Placing traffic signals, which can be equated to Do’s and Don’ts of lifestyle management.Posting a traffic inspector on the crossing. This can be equated to a clinical cardiologist.Diverting the traffic from main road to side roads. This can be equated to opening collaterals by drugs, exercise.Hiring the architect to draw a blueprint. This can be likened to an angiographer doing angiography.Looking for the possibility of widening the roads. This is balloon angioplasty.To prevent encroachment of widened roads to place rallying around the widened roads can be equated to placement of metallic stent.To prevent rallying from mishandling, grills are put on the rallying. This can be equated to drug-eluting stents.When the roads cannot be widened, flyovers are made. This is bypass surgery.Flyovers can be made by stopping the traffic. This can be equated to open bypass surgery.Flyovers can be made without disturbing the traffic. This is heart bypass surgery.

Dr KK AggarwalPadma Shri and Dr BC Roy National AwardeeSr. Physician and Cardiologist, Moolchand MedcityPresident, Heart Care Foundation of IndiaGroup Editor-in-Chief, IJCP Group and eMedinewSChairman Ethical Committee, Delhi Medical CouncilDirector, IMA AKN Sinha Institute (08-09)Hony. Finance Secretary, IMA (07-08)Chairman, IMA AMS (06-07)President, Delhi Medical Association (05-06)emedinews@gmail.comhttp://twitter.com/DrKKAggarwalKrishan Kumar Aggarwal (Facebook)

From the Desk of IJCP Group Editor-in-Chief

How to Explain Cardiac Interventions to Your Patients?

Antithrombotic therapy for patients with atrial fibrillation: An oral direct thrombin inhibitor or a factor Xa inhibitor should be preferred over warfarin in patients with atrial fibrillation (AF) in whom anti-coagulant therapy is indicated. In 2010, the US FDA approved the use of dabigatran for patients with AF who are at risk for stroke.

Connolly SJ, et al. N Engl J Med 2009 Sep;361(12):1139-51.Granger CB, et al. N Engl J Med 2011 Sep;365(11):981-92.

Patel MR, et al. N Engl J Med 2011 Sep;365(10):883-91.

Advances that Have Changed Cardiology Practice In 2012

CARDIOLOGY UPDATE 2012Spontaneous coronary artery dissectionA single-center report from the Mayo Clinic of 87 pa-tients who presented over three decades concluded SCAD affects a young, pre-dominantly female popula-tion, frequently presenting as STEMI. Spontaneous coronary artery dissection should be considered in the differential diagnosis

of any young woman who presents with acute MI, particularly if traditional risk factors for coronary heart disease are absent.

Tweet MS, et al. Circulation12;126(5):579-88.

Mitral valve surgery at the time of CABGAdding mitral valve repair to CABG in patients with left ventricular dysfunction and moderate to severe

MR may improve survival compared with CABG alone or medical therapy alone.

Deja MA, et al. Circulation2012;125(21):2639-48.

Timing of surgery for nat ive valve endocarditisEarly surgery (within 48 hours of randomization) in patients with infective endocarditis and large vegetations significantly

reduced the composite end point of death from any cause and embolic events by effectively decreasing the risk of systemic em-bolism as compared with conventional treatment (surgery during the ini-tial hospitalization/during follow-up).

Kang DH, et al. N Engl JMed 2012; 366(26):2466-73

(Contd. on next page)

Conference Newsletter9th December 2012

For live proceedings of the Conference, Follow on Facebook/drkkaggarwal-CSInews page, Twitter, www.csinews.emedinews.in

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Cardiology Medilaw If you are not registered with the State Medical Council, it cannot take action against you for misconduct.

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Elective, nonelective surgery in prosthetic mechanical valve. No guidelines available. We are overusing hepa-rins after stopping warfarin for non cardiac surgery. In low risk procedures, stop warfarin for three days, do the procedure, restart on day 5. Only in high risk patients for PTE patients, switch to heparins during the period of surgery. In emergency surgery, give vitamin K, and perform the surgery.

Dr RakeshYadav

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Endoscopic vs open vein-graft harvesting for CABG Among patients undergo-ing CABG surgery, the use of endoscopic vein-graft harvesting compared with open vein-graft harvesting was not associated with increased mortality.

Williams JB, et al. JAMA2012; 308():475-4.

Vorapaxar in stable CVD In the TRA 2P-TIMI 50 trial of patients with stable cardiovascular disease who

Dr. Good and Dr. BadSITUATION : An obese hypertensive was found to have

morning hypertension and impaired fasting glucose.

Dr KK Aggarwal

LESSON : The worse clinical variables and relatively poorly-controlled BP of those with morning hypertension supports a potential relationship of morning hypertension with poor cardiovascular outcome. Morning BP should be monitored at home for the optimal treatment of hypertension. The study found that impaired fasting glucose and metabolic syndrome were more prevalent in the patients with morning hypertension. The morning hypertensives took more antihypertensive drugs and displayed higher BP in the clinic and at home.

KoreanCircJ2011.41(12):733-43.

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were receiving standard therapy, inhibition of PAR-1 with vorapaxar reduced the risk of cardiovascular death or ischemic events. However, it increased the risk of moderate or severe bleeding, including intra-cranial hemorrhage.

Morrow DA, et al. N Engl JMed 2012;366(15):1404-13.

Prognostic significance of right precordial T-wave inversion T-wave inversions in right precordial leads are rela-tively rare in the general

population, and are not associated with adverse outcome. Increased mor-tality risk associated with inverted T waves in other leads may reflect the pres-ence of an underlying structural heart disease.

AroAL, et al. Circulation2012;125(21):2572-7.

Coronary CT angiography A CCTA-based strategy for low-to-intermediate-risk patients presenting with a possible ACS appears to allow the safe, expedited discharge from the emer-

gency department of many patients who would other-wise be admitted. Patients undergoing CCTA had higher ED discharge rates, shorted length of stay and a higher rate of detection of coronary disease.

Litt HI, et al. N Engl J Med2012; 366(15):1393-403.

TAVR vs medical therapyTAVR reduced the rates of death and hospitalization, with a decrease in symp-toms and an improvement in valve hemodynamics that were sustained at

2 years of follow-up among appropriately selected pa-tients with inoperable severe AS . Extensive coexisting conditions may reduce the survival benefit of TAVR

Makkar RR, et al. N Engl JMed 2012;366(18):1696-704.

TAVR vs surgical therapyIn a 2-year follow-up of patients in the PARTNER trial, the two treatments were similar with respect to mortality, reduction in symptoms, and improved valve hemodynamics, but paravalvular regurgitation was more frequent after TAVR and was associ-ated with increased late mortality.

Kodali SK, et al. N Engl JMed 2012;366(18):1686-9

Beta blockers in hypertrophic cardiomyopathy Treatment with β-blockers can prevent the develop-

ment of LVOT obstruction triggered by physiologic exercise in patients with HC with mild or no symp-toms. β-blocker treatment for one year resulted in significantly lower post-exercise LVOT gradients (36 mmHg vs 87 mmHg at baseline).

Nistri S, et al.Am J Cardiol2012; 110(5):715-9

Risk of major bleeding with aspirinIn a population-based cohort of almost 200,000 Italian citizens, aspirin use was significantly associ-ated with an increased risk of major gastrointestinal or cerebral bleeding epi-sodes compared to aspirin non-users (5.6 versus 3.6 per 1000 person-years). Patients with diabetes had a high rate of bleeding that was not independently as-sociated with aspirin use.

De Berardis G, et al. JAMA2012;307(21):2286-94

CARDIOLOGY UPDATE 2012(Contd. from previous page)

Loss from gambling, horse race and speculations only can be adjusted against income from same business.

Medi Finance ‘Doctor, doctor! Can you help me? My tongue keeps sticking out.’

‘That’s good. Now, if you can just lick these stamps...’

“The key is to keep company only with people who uplift you, whose presence calls forth your best.” Epictetus

Cardiology Medilaw If the complaint filed is not within the defined prescribed manner, it stands to be rejected.

in definite VLST

The prevalence of ADHF has risen by 150%Acute decompensated heart failure Is linked to advancing age and fe-male sexEcho and BNP together at bed side and in ER are diagnosticsBNP more than 400 is diagnostics along with rise in filling pressuresMilrinone, nesiritide and early intervention with BIPAP may be life savingSlow continuous ultrafiltration is also the answer

Dr HK Chopra

Rescue angioplasty has definite silver lining if done early. Use of radial approach will limit bleeding complications at the access site.

Dr Brian Pinto

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CSI News

Low platelet reactivity does not affect outcomes in ACS: Among patients with ACS without ST-segment elevation and initially managed without revascularization, prasu-grel was associated with lower platelet reactivity than clopidogrel, regard-less of age, weight and dose. No significant dif-ferences were observed as regards the occurrence of the primary efficacy end point between prasugrel vs clopidogrel in the plate-let substudy through 30 months. A lower platelet reactivity with prasugrel vs clopidogrel has no impact on ischemic outcomes.

Gurbel PA, et al. JAMA2012;308:1785-94.

Ultrafiltration unsuccess-ful acute HF: The use of a stepped pharmacologic (di-uretic)-therapy algorithm was superior to ultrafiltra-tion for the preservation of renal function at 96 hours in patients with acute de-compensated heart failure with cardiorenal syndrome. The weight loss was simi-lar with the two strategies. Ultrafiltration was associ-ated with a higher rate of adverse events.

Bart B, et al. N Engl J Med2012.

Monitoring to adjust antiplatelet therapy for stenting of no use: The ARCTIC trial showed no significant improvements in clinical outcomes with platelet-function monitor-ing and treatment adjust-ment for coronary stenting, as compared with standard antiplatelet therapy with-out monitoring. The study data do not support the rou-tine use of platelet-function testing in patients undergo-ing coronary stenting.

Collet J-P, et al. N Engl JMed 2012.

Cardiac re-arrest in-creases chances of death: Patients who experienced even transient loss of pulses prior to hospital arrival after the success-ful return of spontaneous circulation were more likely to have a unfavor-able outcome. Patients who had unresolved prehospital re-arrest after an out-of-hospital cardiac arrest had greater than six-fold odds of death prior to hospital

AHA 2012 Highlightsdischarge. Survival rate was 7.8% among cases of unresolved pre-hospital re-arrest as compared to 33.3% in cases without.

Salcido DD, et al.AHA2012;Abstract 68.

Dalcetrapib increases HDL but has no impact on CV events: In a phase III trial in patients with recent ACS, dalcetrapib, the CETP inhibitor signifi-cantly increased HDL but had no effect on outcomes. . The combined risk of death from heart disease, nonfatal MI, ischemic stroke, hospitalization for unstable angina, and re-suscitated cardiac arrest wasn’t any lower than with placebo.

Schwartz GG, et al. N EnglJ Med 2012.

A novel drug for heart failure: Treatment of acute heart failure with serelaxin (recombinant human re-laxin-2, is a vasoactive peptide hormone) relieved dyspnea and improved other clinical outcomes, but did not affect hospital readmission rates in the RELAX-AHF (RELAXin in Acute Heart Failure) trial. Serelaxin treatment was well tolerated and safe, supported by the re-duced 180-day mortality.

Teerlink JR, et al. Lancet2012.

Blood group may predict risk of stroke: If your blood group is AB, then you are at greater risk of stroke. In two cohorts with more than two mil-lion person-years of fol-low-up, individuals in the AB blood group were at a significantly increased (26%) risk of developing stroke than those with type O blood group. Women with type B blood group had a slightly significant 15% higher risk of stroke compared to women with type O blood group.

Qi L, et al.AHA 2011;Abstract 16887.

Polypill strategy improves adherence to therapy: A fixed-dose combination pill (aspirin + a statin + 2 an-tihypertensives) improved adherence to medications for secondary prevention in patients with or at high risk for cardiovascular disease in the Use of a

Multidrug Pill In Reduc-ing cardiovascular Events’ (UMPIRE). At 15 months, more patients in the polyp-ill group were adherent than those who continued with usual care; 86% vs 65 %, respectively (a relative 33% increase).

Thom S, et al. AHA 2012.

Supervised exercise and stents work for claudi-cation: Supervised exer-cise improved walking in patients with moderate to severe claudication; but, stenting scored more on quality-of-life points in the CLEVER (CLaudication: Exercise Vs Endoluminal Revascularization) study. Change from baseline in the peak walking time (the primary endpoint) at six

A person can make a gift of any property movable or immovable during his lifetime.

Medi Finance

months in the supervised exercise group was 4.6 minutes and 2.5 minutes for those in the stenting group (P=0.02) vs medical therapy alone.

Murphy T, et al.AHA 2011;Abstract 18642.

Low dose aspirin fails to prevent recurrent VTE: Compared with placebo, aspirin did not significantly reduce the rate of recur-rence of venous throm-boembolism in patients with a first unprovoked event but significantly reduced major vascular events (VTE, myocardial infarction, stroke, or car-diovascular death) in the ASPIRE trial.

Brighton TA, et al. N Engl JMed 2012;367(21):1979-87.

Approved Cardiology Drugs from 1.1.2012 to till date

Name of drug Indication Date of issueColesevelam Hydrochloride Tablets 625 mg & Sachets for oral sus-pension 3.75 gm/1.875gm

Indicated as an adjunct to diet and exercise to reduce elevated LDL-C in adults with primary hyperlipidemia as monotherapy or in combination with an hydroxymethyl-gluta-ryl-coenzyme A (HMG CoA) reductase inhibi-tor (statin).

Indicated as an adjunct to diet and exercise to improve glycemic con-trol in adults with type 2 diabetes mellitus.

29.08.2012

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Funny One linersSmile, it makes people wonder what you are thinkingThe light at the end of the tunnel may be an incoming train.

“What you get by achieving your goals is not as important as what you become by achieving your goals.” Henry David Thoreau

Cardiology Medilaw As long as the drug is approved by the Drug Controller of India (Central or state), it is of good quality.

For Trade Enquiries Please Contact: Email- infoatl@atl-global.com Phone- 01128742874

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Therapy for high risk PE patents: Mechanical fragmentation followed by intrapulmonary throm-bolysis can be offered as a primary therapy for high risk PE patents in experi-enced centers, similar to approach with coronary revascularization.

Garg B, et al. JACC2012;60(17 Suppl B):B1.

Impella assist device vs IABP outcomes in high risk PCI: In a treatment received analysis from the PROTECT-II trial, use of Impella LV was associated with non sig-nificantly different rates of death and large MI, but with lower rates of major arrhythmic events (MAE) and major adverse cardiac and cerebrovascular events

TCT 2012 Update(MACCE) during follow up through 3 months com-pared to intraaortic balloon pump.

Dangas G, et al. JACC2012;60(17 Suppl B):B21.

Intracoronary abciximab vs aspiration thrombec-tomy in large anterior MI: In patients with large anterior STEMI present-ing early after symptom onset and undergoing pri-mary PCI with bivali-rudin anticoagulation, infarct size at 30 days was significantly reduced by bolus intracoronary abciximab delivered to the infarct lesion site but not by manual aspirat ion thrombectomy (INFUSE-AMI Trial).

Stone GW, et al.JAMA 2012;307(17):1817-26.

Plaque exc i s ion for critical limb ischemia: One-year results of the DEFINITIVE LE study demonstrated that plaque excision for CLI results in high rates of limb sal-vage and good primary patency at 1 year as well as improvements in wound healing, clinical status as measured by RCC and ABI, and improved QOL. Also associated was a very low rate of stent use.

McKinsey J, et al. JACC2012;60(17 Suppl B):B2.

TEVAR for blunt tho-racic aortic injury: TEVR using the Valiant Captivia is a promising modality for blunt thoracic injury (RESCUE trial). The left subclavian artery was completely covered in 40% of patients and partially

covered in 18% of patients. The median procedure time was 90.5 minutes and median hospital stay was 11 days. There was 10% successful device delivery/deployment.

KhoynezhadA, et al. JACC2012;60(17 Suppl B):B1.

Biolimus A9-eluting stent beneficial in critical limb ischemia: In a retrospec-tive registry assessing the performance of a biode-gradable polymer-based BES in the treatment of focal below the knee ath-erosclerotic disease, treat-ment of focal infrapopliteal lesions with BES showed encouraging angiographic results and significant clinical improvement.

Stabile E, et al. JACC2012;60(17 Suppl B):B2.

Colchicine safely and ef-fectively prevents postop Afib: Colchicine reduced post operative atrial fibril-lation by 42.1% compared to placebo with shorter in-hospital and rehabili-tation stay, according to the results of the COPPS POAF substudy.

Imazio M, et al. Circulation2011;124(21):2290-5.

Increasing clopidogrel dose may be the answer: In patients with stable

cardiovascular disease, tripling the maintenance dose of clopidogrel to 225 mg daily in CYP2C19*2 heterozygotes achieved levels of platelet reactivity similar to that seen with the standard 75-mg dose in noncarriers; in contrast, for CYP2C19*2 homozygotes, doses as high as 300 mg daily did not result in com-parable degrees of platelet inhibition.

Mega J, et al. JAMA2011;306(20):2221-8.

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AHA 2012 Highlights

“Problems are not stop signs, they are guidelines.” Robert H. Schuller

Cardiology Medilaw In an Inquiry, the onus of the complaint lies on the complainant.

Decade of Evolution of Drug-eluting Stents: From Histopath lab to Cath Lab

First-generation drug-eluting stents (DES) have dramatically reduced reste-nosis as compared to bare metal stents (BMS); however, this comes at the price of increased risk of late and very late stent thrombosis (LST/VLST).Pathologic studies have demonstrated that delayed arterial healing characterized by poor endothelialization is the primary substrate respon-sible for LST/VLST following DES placement, which is associated with stent struts penetrated into the necrotic core (acute myocardial infarction [AMI] indication), hypersensitivity reaction (siroli-mus-eluting stents [SES]) and malapposition (SES and paclitaxel-eluting stents [PES]). Second-generation zotarolimus- (ZES) and evero-limus-eluting stents (EES) show significantly less uncovered struts with lower incidence of LST as compared to 1st-generation DES. However, stent fracture, neoatherosclerosis, and late catch-up phe-nomenon (restenosis) are still important issues in second-generation DES. Both biodegradable polymer DES and polymer-free drug-coated stent have shown promising results in animal models with significant reduction in neointi-mal growth similar to permanent polymer DES, with less inflammation and faster healing.Bioabsorbable scaffold showed promising results in preclinical studies with almost full degradation at 2-3 years in porcine and rabbit model, and complete degradation at 4 years, although the indication in man are likely to be limited.

Dr Renu Virmani

Management of Acute IHD in 2012 Have We Reached the Limits?

Higher sensitivity troponin can iden-tify previously missed individuals with non-STEMI, and the potential for benefit.Risk scores are needed to accurately identify those for invasive therapy (evidence from NICE and GRACE programme).Novel imaging approaches can identify plaques and plaque inflammation.Most MIs and deaths occur in the longer follow-up after non-STE MI and novel treatments are needed to reduce these complications (on top of current evidence based therapy).Applying evidence based therapy on a national scale (MINAP UK Programme) has resulted in striking improvements in deaths and MIs (40% decline in cardiovascular deaths in 10 years).

Dr Keith AA Fox

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11053-000-EN_2810_CLIpos_BA9Family_520x930_r01d1_HR.pdf 10/31/2012 11:30:44 AM

“Set your goals high, and don’t stop till you get there.” Bo Jackson

Cardiology Medilaw Not maintaining medical record of patients for 3 years as per regulation is a professional misconduct.

A “U-shaped curve” denotes a non-linear association of a factor or variable with a specific outcome. Classical examples of a “U-shaped curve” in medicine includes the effect of alcohol consumption on CV outcomes or the effects of diabetic control on CV outcomes where both hypoglyce-mia (too much control) and persistent hyperglycemia (too high HbA1c) are bad. There are distinct “U-shaped” curves in HF including but not limited to:

Neurohormonal therapy “ceiling effect”: Some neurohormonal drugs reduce mortality and modify disease state while excess stack on therapy worsens survival.Obesity “paradox”: Though obesity predisposes to more and earlier development of heart failure, patients with obesity tend to have a survival benefit compared with those HF patients without it.“Failed” lipid therapy paradigm: The lower the cholesterol, the worse is the prognosis of HF pa-tients. Also, therapy with statins is favorable in all situations of CVD except that in HF there is no clear benefit noted.“Uncertain” Hb target effects: The outcome is worse in HF patients with very low and very high Hb. Also, therapy to treat anemia in HF is associated with variable effects, and can sometimes be harmful.HF is a condition where too little or too much of a thing are clearly bad: one must get it “just right”.

The following are my views and not on behalf of JNC. JNC 8 is delayed again ....will be released in mid-2013--finally!! New guidelines will provide revised approach on BB in HT; older BBs like atenolol will be deemphasized. Newer BBs like nebivolol will get special attention. Diuretics will also be reassessed in JNC 8. It is likely that chlorthalidone may get special mention over HCTZ.

Superaggressive treatment of HT in diabetics is not helpful (ACCORD). So, for a hypertensive diabetic, the goal will be same as before (130/80) but not any lower. HT in the elderly should be treated irrespective of age (HYVET study). Even in the very old, HT should be treated to prevent CHF and CVA. ARBs are as effec-tive as ACEIs to prevent TOD and CVD (ONTARGET study).

There are several major areas in which cardiac arrhythmias have major public health importance in diverse populations throughout the world. AF affects 5% of patients >65 years of age, and 10% of pa-tients >75 years old. Recent developments are altering our approach to these patients, including apparently contradictory trends. We are using less antiarrhythmic drugs to suppress AF, and more rate control in selected individuals. On the other hand, we are using more invasive approaches with catheter abla-tion instead of antiarrhythmic drugs. Trials are underway to evaluate preference of these approaches. In the area of sudden death, while ICDs are the primary therapy for high-risk individuals, this therapy is expensive and has risks. Multiple studies are evaluating more precise methods to determine which patients are most likely to benefit from this therapy. Non-traditional antiarrhyth-mic therapies: spinal cord stimulation to treat HF and ventricular arrhythmias, as well as CRT to both treat patients with advanced HF and prevent progression. Molecular therapies are being investigated to substitute for traditional treatments. Someday, injection of cells may be a substitute for cardiac pacemakers.

There is no “cookbook” approach to proper therapy for infective endo-carditis, especially when considering surgery.In selected patients, combined medical and surgical therapy offers substantial benefit vs medical therapy alone.Final outcome has never been related to duration and intensity of prior antibiotic treatment; surgery should not be delayed when clearly indicated in the vain hope that a sterile operative field can be achieved.IE surgery carries significant risk and decision on whether or not to operate must be carefully thought out with good communication between surgical and medical teams.

Management of EndocarditisU Shaped Curves in Heart Failure

Renal denervation therapy may play a key role for reducing cardiovascular mortality in future. SIMPLICITY II trial results are very encouraging.

Dr Subroto Mandal

Pharmacoinvasive strategy is the choice of Rx for STEMI management in India. Shortage of cath labs & interventional cardiologists prevents use of primary PCI as primary management strategy.

DrAlok Singh

Expectations & Implications from JNC 8

Mr. Tariq Zulfikar

Book Release by Dr Navin C Nanda

Dr Mandeep R Mehra

Growing Indications for Dysrhythmia Management

Dr Alfred Buxton

Dr C Venkata S Ram

The 64th annual conference of CSI and SAARC Cardiac Congress 2012 was really an academic feast par ex-cellence. We all enjoy reading the gist in the daily conference newsletter.

The 3rd day of the conference saw the visiting delegates attending very innovative scientific programmes covering the core subjects and advances in cardiovascular diseases. A public health awareness pro-gramme was also held. The delegates and accompanying persons enjoyed the entertaining cultural programme by noted Bollywood singer Shaan.

A Message From the Organizing Secretary

Dr Rakesh Gupta

Dr John G Harold

www.csinews.emedinews.in

2012

64th ANNUAL CONFERENCE CARDIOLOGICAL SOCIETY OF INDIA & SAARC CARDIAC CONGRESS

CSI News “Perseverance is not a long race; it is many short races one after the other.” Walter Elliot

Cardiology Medilaw Gross medical mistake will always result in a finding of negligence.

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In people >50, SBP is more important than DBP as a CVD risk factor. With each incre-ment of 10/20 mmHG, CVD risk doubles.Health promoting lifestyle is applicable to all adults & even children.ABPM is expensive & its widespread use in India is not feasible; HBPM is also ex-pensive and difficult due to high illiteracy levels.Branding as preHT may jeopardize a person’s QOL.Pre Rx tests are not possible in India so treatment should be started without them.Most Indian men and women are physically inactive, eat high fat diets, this means changing the habits of half of the population.Thiazides should be used with caution: hyponatremia (climate); DM, dyslipidemia, hyperuricemia may worsen with diuretics.BB should be used with caution due to high prevalence of DM & dyslipidemia. ACEIs and ARBs are expensive.

CSI @ SCCT

Approach to Manage HT as in JNC is Desirable but not Feasible in India

Dr Saumitra Ray

ARBs are not just ACEI without the cough & cough is not always deleterious opined Dr Ferrari very passionately! According to him cough is a protective mechanism and decreases the incidence of pneumonia with use of ACEI use.

Secondary Prevention of CAD by Interference with RAS

In a very lucid talk Dr Chandra began by pointing out the complex nature of the small but very sig-nificant platelet cell and stressed that it was due to this complex structure of multiple receptors that we are unable to find the per-fect agent to conquer it.

There is no agent that can specifically target platelets. Aspirin is the most ap-proved antiplatelet drug.The best dose is 75-100 mg daily.Adding different anti

New Antiplatelet Therapy in ACS Aligning Evidence to Practiceplatelet agents enhances its efficacy. Clopidogrel though a very good drug showed variable response in different patients causing it to be unpredictable.

Prasugrel is better and more reliable for platelet inhibition and controlling death, MI and stroke. But the risk of bleeding was more and it needs to be stopped 7 days before CABG. Ticagrelor showed decreased incidence of

stent throm-b o s i s a n d bleeding epi-sodes as also decrease in death, MI and stroke. It can also be used in both PCI and non PCI patients.Hence, aspirin should be given to all patients unless CI; clopidogrel remains drug of choice if bleeding risk is high. Prasugrel and Ticagrelor are very good options.

Dr Pravin Chandra

better than ARBs in CAD in decreasing mortality. If the medical community continues to ignore this evidence and prescribes ARBs over ACEI for HT then the benefit of ACEI will be lost.

Dr Roberto Ferrari

This discourages the dis-continuing of ACEI in those patients who can tolerate cough. The goal of HT treatment is to decrease BP and the risk of cardiac mortality. ACEI and ARBs are both equally effective in reducing BP. ACEI are

Glimpses of CSI