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Dr KK Aggarwal

From the Desk of Editor in Chief
Padma Shri and Dr B C Roy National Awardee

Dr KK Aggarwal
President, Heart Care Foundation of India; Sr Consultant Physician, Cardiologist and Dean Medical Education Moolchand Medcity; Member Delhi Medical Council; Chairman (Delhi Chapter) International Medical Sciences Academy; Hony Director IMA AKN Sinha Institute (08–09); Hony Finance Secretary National IMA (07–08); Chairman IMA Academy of Medical Specialties (06–07); President Delhi Medical Association (05–06), President IMA New Delhi Branch (94–95, 02–04); Editor in Chief IJCP Group of Publications & Hony. Visiting Professor (Clinical Research) DIPSAR


Dear Colleague

24th April, 2010 Saturday

Why heart attacks in smokers have better outcome with clot dissolving drugs?

Smoking is linked to the development of heart blockages but smokers treated with clot dissolving drugs for an acute heart attack have a better outcome than nonsmokers.1–8 This phenomenon is called the "smoker’s paradox.

The International Tissue Plasminogen Activator/Streptokinase (Clot dissolving drugs) Mortality trial, which involved 2366 nonsmokers, 2244 exsmokers, and 3649 active smokers, found that non smokers, compared to the other two groups, had a higher incidence of in–hospital complications including shock, paralysis, and bleeding.1

Nonsmokers also had a higher in-hospital and six month mortality than exsmokers or active smokers.

GUSTO I was the largest trial to evaluate the impact of cigarette smoking on outcome as it included 11,975 nonsmokers, 11,117 exsmokers, and 17,507 current smokers.3

Nonsmokers had a significantly higher rate of in–hospital complications and a higher in–hospital (9.9 versus 3.7) and 30 day mortality (10.3 versus 4.0 percent).

The reasons are

  1. Smokers have a hypercoagulable state due to higher hematocrit and baseline level of fibrinogen.4, 5

  2. The mechanism of heart attack in smokers is more often thrombosis (clot) over a less critical atherosclerotic lesion (Blockage) than in nonsmokers.4

  3. More active thrombogenic mechanisms in smokers lead to a larger thrombus (clot) component that is more susceptible to fibrinolytic clot dissolving therapy, resulting in smokers having a higher patency rate and being more likely to have TIMI–3 flow in the infarct artery after fibrinolysis or clot lysis.4,5,9

  4. Smokers also have an otherwise better risk profile than nonsmokers.

  5. Smokers tend to be significantly younger (mean 11 years in GUSTO I).

  6. Smokers have a lower incidence of diabetes, hypertension, previous heart attack, and severe coronary disease than nonsmokers.1–8

  7. Smokers are more likely to have an inferior rather than anterior wall infarction.4, 5, 8


  1. Barbash GI, White HD, Modan M, et al. Significance of cigarette smoking in patients receiving thrombolytic therapy for acute myocardial infarction. Experience gleaned from the International Tissue Plasminogen Activator/Streptokinase Mortality Trial. Circulation 1993;87:53.

  2. Mueller HS, Cohen LS, Braunwald E, et al. Predictors of early morbidity and mortality after thrombolytic therapy of acute myocardial infarction. Analyses of patient subgroups in the Thrombolysis in Myocardial Infarction (TIMI) trial, phase II. Circulation 1992;85:1254.

  3. Barbash GI, Reiner J, White HD, et al. Evaluation of paradoxic beneficial effects of smoking in patients receiving thrombolytic therapy for acute myocardial infarction: mechanism of the "smoker’s paradox" from the GUSTO-I trial, with angiographic insights. Global Utilization of Streptokinase and Tissue–Plasminogen Activator for Occluded Coronary Arteries. J Am Coll Cardiol 1995;26:1222.

  4. Grines CL, Topol EJ, O’Neill WW, et al. Effect of cigarette smoking on outcome after thrombolytic therapy for myocardial infarction. Circulation 1995;91:298.

  5. Gomez MA, Karagounis LA, Allen A, et al. Effect of cigarette smoking on coronary patency after thrombolytic therapy for myocardial infarction. TEAM–2 Investigators. Second Multicenter Thrombolytic Trials of Eminase in Acute Myocardial Infarction. Am J Cardiol 1993;72:373.

  6. Gottlieb S, Boyko V, Zahger D, et al. Smoking and prognosis after acute myocardial infarction in the thrombolytic era (Israeli Thrombolytic National Survey). J Am Coll Cardiol 1996;28:1506.

  7. Ishihara M, Sata H, Tateishi H, et al. Clinical implications of cigarette smoking in acute myocardial infarction: Acute angiographic findings and long–term prognosis. Am Heart J 1997;134:955.

  8. Ruiz–Bailen M, de Hoyos EA, Reina–Toral, A, et al. Paradoxical effect of smoking in the Spanish population with acute myocardial infarction or unstable angina: results of the ARIAM Register. Chest 2004;125:831.

  9. de Chillou C, Riff P, Sadoul, N, et al. Influence of cigarette smoking on rate of reopening of the infarct–related coronary artery after myocardial infarction: a multivariate analysis. J Am Coll Cardiol 1996;27:1662.

Dr KK Aggarwal
Padma Shri Awardee and Chief Editor

Photo feature

Lighting of Lamp (inauguration) of World Earth Day Campaign on 22nd April 2010 at DPS School, Mathura Road.
In the Picture from Left to right: Padma Shri and Dr B C Roy Awardee Dr KK Aggarwal; Mr R Mehta, Advisor, Ministry of Env. & Forests, Govt. of India; Mr Virindra Kataria, Sr. Statesman and former parliamentarian, Kathak dancers Kamalini and Nalini.

Dr k k Aggarwal

Internationsl Medical Science Academy Update (IMSA): What’s new

A four–week randomized trial of 47 patients with neuropathic pain (most with diabetic polyneuropathy) found that the combination of nortriptyline with gabapentin was more effective than either agent alone for reducing the intensity of pain (Lancet 2009;374:1252)

News and Views

Urine test for kidney cancer a step closer to development

After studying patients with kidney cancer, a team of researchers at Washington University School of Medicine in St. Louis has identified a pair of proteins excreted in the urine that could lead to earlier and more accurate diagnosis of the disease. The research, published online in the May issue of Mayo Clinic Proceedings, is the first to identify proteins secreted in urine that appear to accurately reveal the presence of about 90 percent of all kidney cancers. The researchers focused on two proteins that previously had been found in kidney tumors: aquaporin–1 (AQP1) and adipophilin (ADFP). They discovered large amounts of those proteins in urine samples from kidney cancer patients.

Excessive alcohol consumption may lead to increased cancer risk

Researchers have detected a link between alcohol consumption, cancer and aging that starts at the cellular level with telomere shortening. Results of this cross–sectional study were presented at the American Association for Cancer Research 101st Annual Meeting 2010, held from, April 17–21, at the Walter E. Washington Convention Center.

Two hours after feeding mice a single modest dose of resveratrol, a compound found in the skins and seeds of red grapes, the scientists induced an ischemic stroke by essentially cutting off blood supply to the animals’ brains. They found that the animals that had preventively ingested the resveratrol suffered significantly less brain damage than the ones that had not been given the compound.

Body mass index gain throughout adulthood may increase risk of postmenopausal breast cancer

Reported mid–life increase in body mass index (BMI) may lead to substantially higher risk of postmenopausal breast cancer, according to results of a prospective cohort study presented at the American Association for Cancer Research 101st Annual Meeting 2010.

In developing countries, shorter maternal height associated with higher death rates for children

Among 54 low–to middle–income countries, a mother’s shorter height is associated with a higher rate of death for her children and a greater likelihood of these children being underweight and having a reduced rate of growth, according to a study in the April 21 issue of JAMA.

Fish oil supplements provide no benefit to brain power in elders, study shows

The largest ever trial of fish oil supplements has found no evidence that they offer benefits for cognitive function in older people. The OPAL study investigated the effects of taking omega–3 long–chain polyunsaturated fatty acid supplements over a two year period on the cognitive function of participants aged 70–80 years.

Mnemonic of the Day (Dr Prachi Garg)

Parkinson's – PARKINSONS

Pill rolling





Neck titubation

Shuffling gait

Oculogyric crisis

Nose tap (glabellar)

Small writing

What’s New

Pediatric Cardiology

The American Academy of Pediatrics (AAP) and the American Heart Association (AHA) have concluded that it remains uncertain whether neonatal pulse oximetry screening for congenital heart disease (CHD) should become standard of care. Although data have shown that most cases of CHD are detected by neonatal pulse oximetry, the cost effectiveness of screening is unknown. (Mahle WT, Newburger JW, Matherne GP, et al. Role of pulse oximetry in examining newborns for congenital heart disease: a scientific statement from the AHA and AAP. Pediatrics 2009;124:823).

Quote of the day

"Mere longevity is a good thing for those who watch Life from the side lines. For those who play the game, an hour may be a year, a single day's work an achievement for eternity."
Gabriel Heatter

Diabetes Fact

Diabetes may have high TG, called secondary dyslipidemia. All secondary dyslipidemias cause high TGs except hypothyroidism and nephrotic syndrome (high LDL).

Question of the Day

What is the best way to manage ingrowing eyelashes?

When there is a single inturned eyelash it is reasonable to remove it using epilation forceps. Recurrent lashes or larger groups can be removed by electrolysis. This is done with specialist equipment under local anaesthetic. More generalised lash problems are treated by cryotherapy in an attempt to destroy the follicles and prevent regrowth. This is a fairly uncomfortable procedure and usually only done if the cornea is being damaged. (Dr.G M Singh)

Public Forum (Press Release for use by the newspapers)

Elderly Beware : ant anti cholinergics please

Anti–cholinergics, a commonly prescribed group of drugs, may cause elderly people to "slow down" in their daily physical activities, said Padma Shri and Dr B C Roy Awardee Dr KK Aggarwal, President Heart Care Foundation of India.

Two reports from Wake Forest University School of Medicine support findings that anti–cholinergic drugs – used to treat acid reflux, Parkinson’s disease and urinary incontinence – may cause older people to lose their thinking skills more quickly than those who do not take the medicines.

Anti–cholinergic drugs work by stopping acetylcholine, a chemical that enhances communication between nerve cells in the brain, from binding to its receptors in nerve cells.

Older adults taking anti–cholinergics become more likely to walk more slowly and to need help in other daily activities. These results are true even in older adults who have normal memory and thinking abilities.

For older adults taking a moderately anticholinergic medication, or two or more mildly anticholinergic medications, their function is similar to that of someone three to four years older.

Common anticholinergic medicines include blood pressure medication, nifedipine; the stomach antacid, ranitidine, and the incontinence medication, tolterodine.

Cholinesterase inhibitors, a family of drugs used to treat dementia by increasing levels of acetylcholine include donepezil, galantamine, rivastigmine and tacrine. About 10 percent of patients may be taking tolterodine and dozepezil together. The two drugs are pharmacological opposites, which led to the hypothesis that the simultaneous treatment of dementia and incontinence could lead to reduced effectiveness of one or both.

Examples of Tobacco Warning: (Dr G M Singh)

  • Cigarettes are highly addictive.

  • Quitting now reduces your risk of serious disease.

  • Tobacco smoke hurts babies.

  • The smoke from your cigarette harms people around you.

  • Smoking causes lung cancer.

  • Tobacco can make you impotent.

  • Children who see adults smoking are more likely to start smoking.

  • Smoking when pregnant harms your baby.

  • Smoking causes bad breath, tooth loss and mouth cancer.

  • Smoking can cause a slow and painful death.

  • Smoking clogs your arteries and causes heart attacks and strokes. and/or physical address where more.

eMedinewS Try this it Works

Making the acetaminophen antidote more palatable

Acetylcysteine smells like rotten eggs, and swallowing it can be a challenge. Oral solution can be made more palatable by diluting it to 5% with soda or juice. Other ways to improve palatability include diluting the solution even more, changing the diluent, chilling the solution, sipping slowly, using a straw, and drinking from a covered container.

Dr Good Dr Bad

Situation: A patient with early onset diabetes was found to have A1C of 7.6%.

Dr Bad: This value is usual in diabetes.

Dr Good: We need to test A1C levels every 3 months and need tight control of diabetes.

Lesson: Subjects with early-onset type 2 diabetes mellitus were more likely to have poorer glucose control (approximately 70–78%), untreated hypertension (26.3%) and a substantial number did not receive statin treatment for primary prevention (34.8%). (QJM 2009 Sep 4. Epub ahead of print)

Make Sure

Situation: A 70–year–old male with antibiotic–associated diarrhea and TLC of 24000 died.

Reaction: Oh my God! Why was surgery not considered in this case?

Make sure that urgent surgical evaluation is done in patients with acute gastroenteritis who are ≥65 years and have a white blood cell count ≥20,000 cells/microL and/or a plasma lactate between 2.2 and 4.9 mEq/L.


IMANDB Joke of the day

Doctors’ Secret Handshakes

Left hand on your wrist, feeling pulse

Wears latex glove

Index and middle fingers extended

Thumb extended

Grasps his own hand

Formulae in Critical Care

Mean cell hemoglobin (MCH)

Formula: MCH = Hb × 10

RBC count (in millions)

Normal value: 30 ± 3 pg

Milestones in Diabetes

Sir Harold Himsworth, MD FRS (1905–1993), studied carbohydrate metabolism and the actions of insulin in the laboratory in normal volunteers and in patients. He demonstrated the effects of high and low carbohydrate diets on the glucose tolerance test in normal subjects, he devized a standardized insulin–glucose tolerance test, and used this to distinguish between "insulin–sensitive" and "insulin–insensitive" types of diabetes.

Lab Test (Dr Arpan Gandhi and Dr Navin Dang)


Alanine aminotransferase (ALT/ SGPT) – an enzyme found mainly in the liver; the one of the best test for detecting hepatitis. Aspartate aminotransferase (AST/ SGOT) – an enzyme found in the liver and a few other places, particularly the heart and other muscles.

List of Approved drug from 1.01.2009 to 31.10.2009

Drug Name


Approval Date

Clozapine Tablet 200mg (Addl. Strength)

Indicated in the management of Schizophrenic patients


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Contact: drkk@ijcp.com or emedinews@gmail.com

eMedinewS–PadmaCon 2010 

Will be organized at Maulana Azad Medical College, New Delhi on July 4, 2010, Sunday to commemorate Doctors’ Day. The speakers, chairpersons and panelists will be doctors from NCR, who have been past and present Padma awardees.

eMedinewS–revisiting 2010

The second eMedinewS–revisiting 2010 conference will be held at Maulana Azad Medical College, New Delhi on January 2, 2011. The event will have a day–long CME, Doctor of the Year awards, cultural hungama and live webcast. Suggestions are invited.

IMANDB Annual Day Meet : Scientific feast, in association with Board of Medical Education Moolchand Medcity, emedinews and IMSA (Delhi) ; No fee SMS 9811090206 for registration

Date: Sunday April 25, 2010,

Venue: Moolchand Medcity Auditorium, New Delhi

Scientific Program: 4–7 PM

4.00 PM–5.00 PM: Fatty Liver, Workshop for GPs: Padma Shri and Dr B C Roy Awardee Dr KK Aggarwal

5.00 PM–6.00 PM:

Cardiac Update (Max Hospital)

a. Dr JJ Sood Oration: Cardiac Interventions: Dr Mohan Bhargava

b. Dr K L Chopra Oration: Endovascular Approach to Aortic Aneurysm: Dr Kumud Mohan Rai (Max Hospital)

6.00 PM – 6.30 PM

Dr Sheila Mehra Oration: Management of osteoporosis: Dr Ramneek Mahajan

6.30 PM –7.00 PM

Medical Ethics: A panel discussion: Dr Ashok Seth, Dr Sudesh Ratan, Dr Rajiv Khosla, Dr KK Aggarwal, Dr Girish Tyagi, Dr Sanjiv Malik, Dr H K Chopra, Dr Madhu Handa, Dr Kumud Mohan Rai, Dr Archna Virmani

Annual Day Function: 7–8 PM

Eminent Guests: Padma Shri and Dr B C Roy Awardee Dr KK Aggarwal, Dr Narender Saini (President DMA), Dr Vinod Khetrapal (President–elect DMA), Dr Girish Tyagi (Registrar DMC), Dr Ashwini Dalmiya (Secretary DMA), Dr Naresh Chawla (Immediate Past President DMA)

Dinner: 8.00 PM onwards...

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Readers Responses

  1. Congratulations. It was a treat watching you receiving Padma Shri award: Jaiswal

  2. Congratulations Sir, May Almighty shower upon you more success: Madhu Gurun

  3. Congratulations for Padma Shri award: Bulbul & Kumar