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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

25th June, Friday, 2010

Hypertension Strongest Predictor of Stroke

There are 10 factors that make up the vast majority of stroke risk, and half of those are modifiable. Hypertension is the strongest predictor of stroke, along with smoking, abdominal obesity, diet, and physical activity, according to Martin J. O’Donnell, MB, PhD, of McMaster University in Hamilton in Ontario, Canada.

The results are from the INTERSTROKE study, a large, multicenter, case–control study that included patients from low– and middle–income countries, published online June 18 in The Lancet. The same group of researchers had also conducted INTERHEART, which had concluded that there were nine risk factors for myocardial infarction: hypertension, smoking, abdominal obesity, diet, physical activity, diabetes, alcohol, psychosocial factors, and cholesterol.

The researchers found that a history of hypertension was the strongest risk factor for stroke, with nearly a threefold increased risk and the association was stronger for hemorrhagic stroke.

Atrial fibrillation was the most common cardiac source of thromboembolism in ischemic stroke, but overall there was a relatively low prevalence of cardiac causes of stroke –– especially in India and China.

Just five of these risk factors: hypertension, smoking, abdominal obesity, diet, and physical activity account for more than 80% of the overall risk of stroke. Adding the other five brings that figure to 90%.

Dr KK Aggarwal
Padma Shri Awardee and Chief Editor


Photo Feature


6th International Widows Day was observed on 23.06.2010 at India Habitat Center, New Delhi jointly by Heart Care Foundation of India and The Loomba Foundation to promote the cause of many widows and their children live in poverty. They are malnourished, exposed to diseases and social pressure. It is thus important that more and more people should adopt underprivileged widows and their children.

Dr k k Aggarwal

In the photo: Prof Dr. Kiran Walia, Minister of Health, Govt. of Delhi lighting the event. Also in the photo: Padma Shri & Dr BC Roy Awardee Dr. K K Aggarwal President HCFI; Mr Lalit Man Singh, Mrs Aruna Oswal, Mrs Sushmita Malik, Trustees, The Loomba foundation


News and views

1. FDA approves test to detect both HIV antibodies and antigen (Dr GM Singh)

A new blood test to detect HIV antigen and antibodies simultaneously has been approved by the FDA. This test will help diagnose HIV1/HIV2 infection including acute or primary HIV1 infection in adults, pregnant females, and children aged 2 years or older. The Architect HIV Ag/Ab Combo assay will be able to detect the p24 antigen days before HIV antibodies emerge. Most other diagnostic HIV tests detect only antibodies.

2. Early menopause may Be linked to increased heart risks (Dr Monica and Brahm Vasudeva)

Women who have menopause early have more than twice the risk of cardiovascular diseases (heart attack and stroke) later in life. The study was presented at the Endocrine Society 2010 annual meeting. More than 2000 American women aged 45 to 84 were studied. Of these, about 28% had reported having an early menopause (defined as occurring before the age of 46). Dr Melissa Wellons of the University of Alabama at Birmingham, said that their study findings do support the possible use of age at menopause as a marker of future heart and vascular disease risk.

3. Aspirin for primary prevention of cardiovascular events in people with diabetes: ADA /AHA/ACCF Position Statement (Dr Varesh Nagrath)

a. Lowdose aspirin (75162 mg/d) use for prevention is reasonable for adults with diabetes and no previous history of vascular disease who are at increased CVD risk (10-year risk of CVD events over 10%) and who are not at increased risk for bleeding (based on a history of previous gastrointestinal bleeding or peptic ulcer disease or concurrent use of other medications that increase bleeding risk, such as NSAIDS or warfarin). Those adults with diabetes at increased CVD risk include most men over age 50 years and women over age 60 years who have 1 or more of the following additional major risk factors: smoking, hypertension, dyslipidemia, family history of premature CVD, and albuminuria.


Legal Column

DMC Decision

Can the council look into complaints for compensation?

The Delhi Medical Council examined a letter No. F.23/29/MSNHII/DHS/HQ/2008-09/12390 dated 24.3.2009 from Medical Superintendent Nursing HomesII, seeking an enquiry from Delhi Medical Council, on a legal notice dated 23.6.2008 of Shri Gopal Khanna, Advocate. On perusal of the legal notice, the Delhi Medical Council observed that the same does not constitute a complaint as per the provisions of Rule 32 of Delhi Medical Council Rules 2003. Moreover as per the legal notice, the Advocate is seeking compensation / damages from Addressees mentioned therein namely Director Health Services and Medical Superintendent Nursing Homes, Directorate of Health Services and has not asked for the complaint to be investigated. The Council, therefore, held that this matter does not merit consideration.

Forensic Column (Dr Sudhir Gupta, Ass. Professor, AIIMS)

Triage in medical care & emergency treatment. Can a doctor ignore a routine appointment if a serious patient arrives?

The term ‘triage’ is a French word used in military medical services which refers to the process of sorting injured/sick patient on the basis of urgency/priority of treatment. Triage in trauma care/emergency department is a very quick/necessary decision to first evacuate those with best chance of survival and to leave for later evacuation those who had little or no chance of survival. The doctors’ right to decide the issue of priority of attending the patients has been upheld by the Consumer Disputes Redressal Agencies (CDRAs).

The right of medical doctor is an important aspect of medical practice as often the patient’s perception of emergency differs from that of Doctors. In BS Hedge v Dr Sudhanshu Bhattacharya, the National Commission held that a doctor has the absolute right to decide which patient he would examine first and even out of turn depending on the condition of the patient. There is nothing improper or unreasonable if the doctor gives precedence to patients with active/acute cardiac problem/other medical/surgical condition where urgent medical attention of doctor is called for in preference to the routine consultation. In addition, it cannot be held that the patients must be examined at the appointed time irrespective of the time he may have to spend in examining the previous patients. (George, James E, Law and emergency care, The CV Mosby Co, St.Louise,1980 pp 66–67).


Experts’ Views

Stress and Doctors…(Part 2)

Dr Neelam Mohan, Consultant Pediatric, Gastroenterologist, Hepatologist, Therapeutic Endoscopist & Liver Transplant Physician Sir Ganga Ram Hospital, Delhi

Ways to overcome/ decrease stress

‘Boats are safer in harbour, but they are not meant for that purpose.’ We can’t sit back at home, we have to face problems at our work place and face stress. Therefore we should find ways to effectively handle stress.

1. Control your anger

The one who is slow to anger is stronger than the mighty and when the wise get angry they get their wisdom compromised. So try not to get angry by changing your outlook and avoiding unnecessary arguments.

Transparency in one’s dealings, explaining prognosis beforehand, making oneself available in emergency situations and avoiding argument with patients and attendants may help in preventing occurrence of unpleasant situation.

2. Stress can be reduced considerably by following means

Music / Dance: Soft, classical or instrumental music has the capacity to drive us in parasympathetic mode, reduces heart rate and induces sleep and thus relieves stress. We can choose the music of our liking form the vast variety available in market. Dancing also is a helpful tool in relieving stress.

Sports / literature: Sports, besides keeping us physically fit, also acts as stress reliever. Indian literature is second to none in the world. We can utilize our spare time in reading the kind of literature we are interested in.

3. Vacations

Carefully planned vacations give you relief from monotonous routine, rejuvenate and refresh you. A number of books are available in market detailing important tourist destination in India as well as abroad.

‘A vacation should be long enough for the patients to miss you, and not long enough for them to discover how well they can get along without you’.

4. Philosophy / Religion & Stress

Karmanye Vadhikaraste ma faleshu kadachana……………

……one must perform his duties without worrying about the results, such thinking reduces stress related to failure.

Vasansi jirnani yatha vihaya
Navani Granati naro parani

…… as people discard, their old clothes and wear new ones, in the same fashion, soul leaves the old and frail body and finds a new one.

It takes the sting out of death and reduces stress related to it.

5. Charity

Our profession gives tremendous scope of doing charity and helping the person in the field of health and education.

6. Physical fitness

Keeping physically fit by yoga / exercise helps in maintaining mental fitness as well.

7. Role of a friend

One should have a friend whom one can confide in, because they say, ‘sorrow shared is sorrow halved.’

There are many forces which twist the hand that heals. Stress is one of them. Let us identify stress producing situations and try to handle them in a measured way. Finally, let us change our outlook if situation is not amenable to change, since somebody has aptly remarked, ‘If you can’t changes the force and direction of wind, adjust your sails.’

Stress, in simple terms, is like a fire, more precisely, embers, permanent embers. We can either control them to be harmless embers and enjoy their glow, or fan them into huge fires. Not knowing better, many of us do the later.

Question of the Day

How should one manage hypertension in diabetic patients?

HT in patients with diabetes should be managed aggressively; the goal BP of less than 130/80 mmHg should be attained if clinicians seek to reduce cardiovascular morbidity and mortality for these patients. Choice of antihypertensive drug in the diabetic patient should be guided by the presence of concomitant disease and the protection of the organ system that is most at risk.

  • Therapy for diabetic hypertensives with angina pectoris should include a ß–blocker or CCB (Calcium channel blocker) given their definite antianginal and possible antiatherosclerotic effects.

  • Patients with a previous history of myocardial infarction should be initiated on a ßblocker, given its proven benefit in preventing further cardiovascular events.

  • Diabetic hypertensives who have a poor left ventricular function, or a history of heart failure, should be initiated with diuretics and then start on ACE inhibitor and ßblocker.

  • If the patient has had a prior transient ischemic attack or stroke, then some evidence calls for therapy with a diuretic or a CCB.

  • For protecting the renal system, especially in the setting of albuminuria, an ARB or an ACE inhibitor is best to prevent and delay nephropathy.

In the diabetic hypertensive still free of clinical disease, all antihypertensives are able to prevent adverse events and can be used as initial therapy. Along with instituting medical therapy after HT is detected, lifestyle modifications need to be managed aggressively, together with strict glycemic and lipid control. ACE inhibitors and ARBs, generally in combination with a thiazide diuretic, should be considered as initial therapy. CCBs, ßblockers and alphaantagonists also have a role in this population of patients, usually as third and fourthline addons.

Mental exercise (to prevent dementia) (Dr Anupam Sethi Malhotra)

A North American landmark constantly moving backward: Niagara Falls. (The rim is worn down about two and a half feet each year because of the millions of gallons of water that rush over it every minute.)


Public Forum (Press Release for use by the newspapers)

You can have angina without blockages

Angina with no blockages in the heart is called cardiac syndrome X. It is different from angina pectoris due to typical blockages in the heart arteries. It has three characteristic features: angina or anginalike chest pain on exercise; ST segment depression on ECG on treadmill exercise testing and normal coronary angiography. This was stated by Padma Shri and Dr B C Roy National Awardee Dr KK Aggarwal, President Heart Care Foundation of India.

Cardiac syndrome X should not be confused with the metabolic syndrome, which is also called syndrome X but refers to the constellation of insulin resistance, obesity, hypertension, diabetes, and dyslipidemia.

Cardiac syndrome X is suspected in patients with suspected stable ischemic chest pain. There are two other settings in which angina occurs with normal or nearnormal coronary arteries (less than 50% stenosis) , which are not considered part of cardiac syndrome X. First, a minority of patients (914 percent) with an acute coronary syndrome have normal or nearnormal coronary arteries. Second, some patients present with stressinduced heart enlargement.

Among patients with chest pain who are referred for coronary angiography, 15 to 20 percent have normal vessels or no vessel with less than 50 percent stenosis.

There is a strong preponderance of women in patients with cardiac syndrome X, many of whom are peri-menopausal or postmenopausal. Patients are typically younger than those with angina due to coronary disease (mean age 50). The pain may be precipitated by effort, but also occurs at rest. The duration of anginaltype chest pain is often prolonged. The average duration of chest pain is more than 10 minutes in 53 percent, and more than 30 minutes in 35 percent. Many patients do not respond to sublingual nitrates.

The possibility of cardiac syndrome X should be considered when a patient (often a postmenopausal or perimenopausal woman) describes effortrelated anginal pain that lasts 10 minutes or longer after cessation of activity and that responds inconsistently to sublingual nitrates.

Patients with cardiac syndrome X with stable angina generally have a excellent prognosis, while those with acute coronary syndromes have an appreciable acute mortality although lower than that in patients with angiographic coronary disease.

There are no "set rules" for the treatment of cardiac syndrome X, and therapy should be tailored to the individual patient. Among patients with stable angina, one should start initial therapy with sublingual nitrates as needed, risk factor reduction, and reassurance of the patient regarding his or her condition. If this is ineffective, the administration of a beta blocker is often beneficial. A physical training program may improve exercise capacity and reduce the frequency of chest pain episodes.


IJCP Special

Dr Good Dr Bad

Situation: A patient with heartburn was diagnosed to be having laryngopharyngeal reflux.
Dr. Bad: It can never be asymptomatic.
Dr. Good: It can be asymptomatic.
Lesson: Most patients with laryngopharyngeal reflux are relatively unaware of reflux with only 35 percent reporting heartburn. (Laryngoscope 1991;101:1)

Make Sure

Situation: A 20–year–old girl suffering from dysmenorrhea wanted an analgesic for her pain.
Reaction: Give her Nimesulide.
Lesson: Make Sure to prescribe nimesulide since it is as effective as other analgesics in combating pain in gynecological conditions.

Mistakes in Clinical practice

Do not write ‘QOD" (for every other day): it can be mistaken as "QD" or "QID".

If the "O" is poorly written, it looks like a period or an "I"

Milestones in Orthopedics

David L. MacIntosh is a pioneer in sports medicine. He performed the 1st successful reconstruction surgery for the management of the torn anterior cruciate ligament (ACL) of the knee. This common and serious injury in skiers, field athlete career, and dancers invariably brought an end to their athletic career due to permanent joint instability. He also described the ‘pivot shift’ manoever which remains the gold standard in diagnosis of ACL injury.

Mnemonic of the Day (Dr Prachi)

Extra Gastrointestinal VOMITING: Differential diagnosis

Vestibular disturbance/ Vagal (reflex pain)
Migrane/ Metabolic (diabetic ketoacidosis, gastroparesis, hypercalcemia)
Toxicity (cytotoxic, digitalis toxicity)
Increased intracranal pressure, Ingested alcohol
Neurogenic, psychogenic


Drug Update

International Medical Science Academy Update (IMSA): Update

Diabetes can be diagnosed using one of four criteria: A1C ≥6.5 percent, fasting plasma glucose at or above 126 mg/dL (7.0 mmol/L), a 2–hour value in an OGTT (2–h PG) at or above 200 mg/dL, or a random plasma glucose concentration ≥200 mg/dL in the presence of symptoms. The diagnosis of diabetes must be confirmed on a subsequent day by repeat measurement, repeating the same test for confirmation.

List of Approved drugs from 1.01.2009 to 31.10.2009

Drug Name


DCI Approval Date

Bosentan (as monohydrate) Tablets 62.5/125mg

For the treatment of pulmonary arterial hypertension (WHO Group I) in patients with WHO Class III or IV symptoms, to improve excercise ability and decrease the rate of clinical worsening.



Underwriting Parameters

Limit of age is 570 years. The aforesaid limits would apply cumulatively in the event of there being more than one policy on the life of the insured person. The cover is worldwide. Cumulative bonus: 5% increase in sum insured each year on renewal of policy upto a limit of 50%. Earned cumulative bonus will not be lost if the policy is renewed within 30 days of its expiry.

Lab Medicine

Lab Test (Dr Arpan Gandhi and Dr Navin Dang)

Protein C
Hereditary protein C deficiency is a hypercoagulable state associated with an increased risk for venous thrombosis. The recommended initial test for protein C is an activity (functional) assay, which may be clotting time based or chromogenic.

MCI News

Streak of MCI scam reaches city pvt medical college (TOI News)

CBI on Wednesday reached the campus of a medical college in Balaganj locality under Thakurganj police station of the Old city and started a detailed inspection of documentation related to the registration, government sanction and approval of MCI to the institute. Subsequently, CBI conducted raids at two private medical institutes in Bareilly following reports that the two institutes had also bribed the MCI to procure its mandatory approval and recognition to start with the private medical college. Investigations provided CBI with a list of nearly a 100 medical colleges across the country which were awarded MCI approval and recognition by Desai despite the failure of the institutes' management to equip their institutes with prerequisites. 


Humor Section

IMANDB Joke of the Day

I was sitting in the waiting room of the hospital after my wife had gone into labor and the nurse walked out and said to the man sitting next to me, "Congratulations sir, you’re the new father of twins!" The man replied, "How about that, I work for the Doublemint Chewing Gum Company." The man then followed the woman to his wife’s room.

About an hour later, the same nurse entered the waiting room and announced that Mr. Smith’s wife has just had triplets. Mr. Smith stood up and said, "Well, how do ya like that, I work for the 3M Company."

The gentleman that was sitting next to me then got up and started to leave. When I asked him why he was leaving, he remarked, "I think I need a breath of fresh air." The man continued, "I work for 7–UP."

Funny Definitions

Cauterize………………Made eye contact with her

Medical bloopers on medical charts!

She stated that she had been constipated for most of her life until 1989 when she got a divorce.


Quote of the Day (Dr Ingole)

Golden words by Martin Luther King

If you can’t fly, RUN, If you can’t run, WALK, If u can’t walk, CRAWL, But whatever u do just keep on moving towards ur GOAL.

SMS of the Day (Nilesh Aggarwal)

Telling a lie is a fault for a little boy, an art for a lover, an accomplishment for a bachelor and a matter of survival for a married man.

The Ten Traits of the True Spiritual Warrior (Guy Finley) 3/10

The true spiritual warrior works every day, every moment, to sharpen her battle skills.


Readers Responses

What is optometry? While ophthalmology deals primarily with the medical and surgical treatment of eye diseases, optometry deals with the dispensing of eyewear (spectacles). Optometry is the first line of defence against blindness as it deals with the refraction, eyewear Rx, contact lens fitting, low vision aid evaluation and referrals…mainly to ophthalmology. (Dr Narendra Kumar)


Forthcoming Events

eMedinews Events: Register at emedinews@gmail.com

5th September: 3 PM to 5 PM A dialogue with His Holiness Dalai Lama at Parliament Street Annexe in association with Acharya Sushil Muni Ahimsa Peace Award Trust

12th September: BSNL Dil ka Darbar A daylong interaction with top cardiologists of the city.
8 AM – 5 PM at MAMC Auditorium, Dilli Gate.

17th MTNL Perfect Health Mela 2010 Events: Venue: NDMC Ground Laxmi Bai Nagar, New Delhi

24th October, Sunday: Perfect Health Darbar, Interaction with top Medical experts of the city from
8 AM to 5 PM

30th October, Saturday: eMedinewS Update from 8 AM to 5 PM

29th October, Friday: Divya Jyoti Inter Nursing College/ School Competitions/ Culture Hungama

30th October, Saturday: Medico Masti Inter Medical College Cultural festival from 4 PM to 10 PM

31st October, 2010, Sunday: Perfect Health Darbar, An interaction with top Cardiologists

eMedinews Revisiting 2010

The 2nd 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.

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