Head Office: 39 Daryacha, Hauz Khas Village, New Delhi, India. e-Mail: drkk@ijcp.com, Website: www.ijcpgroup.com
emedinews is now available online on www.emedinews.in or www.emedinews.org
Dr KK Aggarwal

From the Desk of Editor in Chief
Padmashri 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

27th February 2010, Saturday

Coronary Artery Disease in the Young (Part 2)

How does young CAD clinically present?

The clinical presentation of CAD in younger patients differs from that in older patients. A higher proportion of young patients do not experience angina.

What is the the first clinical presentation of young MI?

An acute coronary syndrome (ACS) that progresses rapidly to MI (most often an ST– elevation MI) if left untreated is the first manifestation of CHD.

Is the diagnosis always easy in young CAD?

A potential diagnostic problem encountered most in younger subjects is that myocarditis can mimic an acute MI. This disorder should be particularly considered in young patients with a clinical presentation of an ACS who have a normal coronary angiogram.

What are the typical angiographic findings?

Younger patients have a higher incidence of normal coronary arteries, mild luminal irregularities, and single vessel coronary artery disease than do older patients.

How is MI treated in the young?

The overall approach to therapy in MI is generally not dependent upon age.

What is the role of risk factor reduction in young MI?

Risk factor reduction plays a central role in survivors of the MI. This includes smoking cessation; aggressive lipid lowering, and, in appropriate patients, treatment of diabetes and hypertension.

How is ST–elevation MI treated?

Young patients with an acute ST–elevation MI should be treated with primary PCI or, if not available, thrombolytic therapy. Both young and old patients have a better outcome with PCI than thrombolysis. However, young patients do better than older patients regardless of the therapy received. Young patients also appear to respond well to thrombolytic therapy.

How is non–ST elevation ACS treated?

Patients with a non–ST elevation ACS — non–ST elevation (non–Q wave) MI or unstable angina — are first stabilized with medical therapy since they do not appear to benefit from immediate coronary reperfusion. Once stable, most such patients undergo coronary angiography and revascularization, if appropriate. The current recommendtion is not to go for routine coronary angiography in young patients who have had a non–ST elevation ACS. These patients should undergo exercise stress testing, and only those with high–risk features should be referred for cardiac catheterization.

What is the prognosis after MI?

Myocardial infarction occurring at an early age raises the disturbing potential of a malignant atherosclerotic diathesis and an adverse prognosis. However, many such patients do not have severe coronary disease and most series have noted favorable short– and long–term prognosis in such patients.

What is the in–hospital mortality?

The in–hospital mortality in young patients has ranged from 0 to 4 percent, a value lower than that in older patients.

What is the long–term outcome of young CAD?

Young patients also have a good long–term outcome after MI. Survival rates at seven years after an MI are 84 versus 75 percent for young and older men and 90 versus 77 percent for young and older women.

How common is recurrence?

Recurrent coronary events are not uncommon.

What is the management of chronic CAD?

The management of stable angina, including the indications for revascularization, is similar in younger and older patients. Routine coronary angiography is not recommended in young patients who have stable CAD. However, when indicated, both PCI and CABG are effective and are associated with lower risks in younger compared to older patients.

Management should also include intensive risk factor reduction including smoking cessation, initiation of an exercise program. aggressive lipid lowering, screening for depression, and, in appropriate patients, treatment of diabetes and hypertension.

Dr KK Aggarwal
Chief Editor

News and Views

High levels of vitamin D in older people can reduce heart disease and diabetes

High levels of vitamin D in the middle–aged and elderly can reduce their chances of developing heart disease or diabetes by 43%, according to researchers at the University of Warwick.

Green tea may help fight glaucoma

Healthful substances found in green tea, renowned for their powerful antioxidant and disease–fighting properties, do penetrate into tissues of the eye. A report, documenting how the lens, retina, and other eye tissues absorb these substances, raises the possibility that green tea may protect against glaucoma and other common eye diseases. The report appears in the Journal of Agricultural and Food Chemistry.

Diabetic Nephropathy: Glomerular Classification (contd. from yesterday)

Class I (Mild or nonspecific light microscopy changes and mesangial expansion–proven glomerular basement membrane thickening): Biopsy does not meet any of the criteria mentioned below for class II, III, or IV; glomerular basement membrane >395 nm in women and >430 nm in men ≥ 9 years of age.

Class IIa (Mild mesangial expansion): Biopsy does not meet criteria for class III or IV; mild mesangial expansion in >25% of the observed mesangium

Class IIb (Severe mesangial expansion): Biopsy does not meet criteria for class III or IV; severe mesangial expansion in >25% of the observed mesangium

Class III (Nodular sclerosis [Kimmelstiel–Wilson lesion]): Biopsy does not meet criteria for class IV; at least one convincing Kimmelstiel–Wilson lesion

Class IV (Advanced diabetic glomerulosclerosis): Global glomerular sclerosis in >50% of glomeruli; lesions from classes I through III.

Heart failure worsens when right ventricle goes bad

New research from the University of Alabama at Birmingham suggests that the ability of right side of the heart to pump blood may be an indication of the risk of death to heart–failure patients whose condition is caused by low function by the left side of their heart. In findings reported in January in Circulation, a journal of the American Heart Association, researchers say that low right–ventricular ejection fraction (RVEF) increased the risk of death in patients with systolic heart failure –– heart failure associated with low left–ventricular ejection fraction.

Anemia drugs require risk management

Erythropoiesis-stimulating agents (ESAs), now require a risk management program for their prescription and use, the FDA has announced. The program, known as a risk evaluation and mitigation strategy (REMS), has been instituted in response to studies showing that ESAs can increase the risk of tumor growth and shorten survival in patients with cancer and increase the risk of heart attack, heart failure, stroke or blood clots in patients who use these drugs for other conditions, according to an FDA press release.

Conference Calendar

India Live 2010 – (Inaugural Course on Percutaneous Cardio-vascular Interventions)
Date: February 26–28, 2010
Venue: Hotel Taj Palace, New Delhi.

Quote of the Day

Grow flowers of gratitude in the soil of prayer. (Verbena Woods)

Diabetes Fact

Drug of choice for adult diabetes is metformin. It has anorexic effect, reduces hepatic glucose outflow and increases peripheral utilization.

Health Budget 2010-02-26: Kuch Khatta Kuch Meetha

The increase in allocation of budget by 2766 crores is a welcome step, however one expected more increase.

Following are few health implications

74. An Annual Health Survey to prepare the District Health Profile of all Districts shall be conducted in 2010-11. The findings of the Survey should be of immense benefit to major public health initiatives particularly the National Rural Health Mission, which has successfully addressed the gaps in the delivery of critical health services in rural areas.

75. To increase the plan allocation for the Ministry of Health and Family Welfare, from Rs.19,534 crore to Rs.22,300 crore for 2010-11.

164. Medical equipment, instruments and appliances are subjected to a very complex import duty regime based on several long lists that describe individual items. Multiple rates coupled with descriptions not aligned with tariff lines, result in disputes and at times prevent state-of-art equipment from getting the benefit of exemption. A uniform, concessional basic duty of 5 percent, CVD (Countervailing duty) of 4 percent with full exemption from special additional duty on all medical equipment has been proposed. A concessional basic duty of 5 percent is being prescribed on parts and accessories for the manufacture of such equipment while they would be exempt from CVD and special additional duty. Full exemption currently available to medical equipment and devices such as assistive devices, rehabilitation aids etc. is being retained. The concession available to Government hospitals or hospitals set up under a statute is also being retained.
165. The manufacturers of orthopaedic implants have represented that their inputs attract a higher rate of duty than the finished product. Specified inputs for the manufacture of such implants from import duty have been exempted.

Allocation of budgets

There are significant increases in outlays for Health Human Resource, Cancer Research North East, and District Hospitals.

  1. NRHM 1391.45 crores
  2. Hospitals 982.10 crores
  3. Medical education and training 2678.84 crores
  4. National disease control program: 1050.14 crores
  5. Contraception 358 crores
  6. Public health 7457.46 crores
  7. Cancer research 164 crores
  8. North East 2100 crores

Public Forum (Press Release)

Heart patients beware of ‘bhang’

Heart patients should either avoid ‘bhang’ or consult their cardiologist before taking it. Indiscriminate use can increase heart rate and BP. Pretreatment with beta–blocker can help.

Heart patients should not take 'bhang' as it can precipitate increase in heart rate and sudden rise in blood pressure, said Dr K K Aggarwal, President, Heart Care Foundation of India and Editor eMedinewS. Those who are socially committed should consult their doctor. Pre–treatment with propranolol, a beta blocker, can block the cardiovascular effects of marijuana. It can prevent learning impairment and, to a lesser degree, the characteristic subjective experience. Marijuana is known to induce the typical subjective state (‘high’) with marked increases in HR, BP and conjunctival infection. It impairs performance on a learning test without significantly affecting attention.

About bhang

  1. Bhang is a traditional Indian beverage made of cannabis mixed with various herbs and spices, which has been popular in India since ages.

  2. Bhang is a less potent preparation than Ganja, which is prepared from flowering plants for smoking and eating.

  3. Charas, more potent than either Bhang or Ganja, consists of cannabis flower tops harvested at full bloom.

  4. Charas, which is dense with sticky resin, is nearly as potent as the concentrated cannabis resin preparation called hashish.


Genital Herpes Facts (Dr G M SingH)

Genital herpes can be caused by two different herpes simplex viruses (HSV-1 and HSV-2), although HSV-2 causes most cases. HSV-1 most commonly causes cold sores or fever blisters to appear on or around your mouth, lips or nose.

The herpes virus can be transmitted through any form of sexual contact (vaginal, anal or oral) or skin contact with an infected area of the skin.

Herpes can be transmitted even if the infected person is not currently having an outbreak. In fact, many people are not even aware they have genital herpes and can therefore infect their partners.

The National Institutes of Health (NIH) estimates that 90 percent of the U.S. population has been exposed to herpes simplex virus 1 (HSV-1), and 25 percent of the population ages 25 to 45 has been exposed to herpes simplex virus 2 (HSV-2).

The U.S. Centers for Disease Control and Prevention (CDC) estimates that 45 million people ages 12 and older in the United States have been infected with genital herpes. That equals one out of five adolescents and adults.

Between the late 1970s and the early 1990s, the number of Americans with genital herpes infection increased 30 percent. The percentage declined from the 1990s through 2004 (the last year for which statistics are available).

Genital herpes is more common in women (about one in four women are infected) than in men (of whom almost one in five are infected).

The American Social Health Association (ASHA) estimates that as many as 90 percent of people with genital herpes are unaware that they have it.

According to ASHA, a person with genital herpes experiences, on average, four to five outbreaks a year. In general, the frequency of outbreaks and the severity of symptoms tend to decrease over time.

Genital herpes cannot be cured, but the frequency and severity of outbreaks can be controlled with medication.

The only 100 percent effective method of preventing genital herpes is abstinence, but condoms and limiting your number of sexual partners can help reduce your risk of contracting the disease.

Quote: You get what you deserve and not what you desire.

Punjab & Sind Bank
Central Bank of India

Question of the day

What are the indications for colectomy in ulcerative colitis?

Patients with toxic megacolon (i.e. those with colonic dilation of 6 cm or greater who appear toxic) who do not respond to therapy within 72 hours should be considered candidates for colectomy. Surgical consultation should be obtained early on in such patients. Less severely ill patients usually respond to parenteral corticosteroids within 7–10 days. Despite advances in therapy, rates of colectomy for severe ulcerative colitis have not changed substantially in more than 30 years.

(Suggested reading: Turner D, Walsh CM, Steinhart AH, et al. Response to corticosteroids in severe ulcerative colitis: a systematic review of the literature and a meta–regression. Clin Gastroenterol Hepatol 2007;5:103–10)

eMedinewS Try this it Works

‘Socks first’ deters spread of infection

Patients with tinea pedis should be reminded to put on their socks before their underwear when getting dressed. Failing to do so can lead to contamination of the groin with dermatophytes.

Dr Good Dr Bad

Situation: A diabetic came with fasting sugar 90 mg%. 
Dr Bad: You are well controlled. 
Dr Good: Now get the PP sugar done also. 
Lesson: Recent evidence suggests that post meal hyperglycemia also plays an important role in the etiology of diabetes–associated complications and control of postprandial glucose (PPG) levels is vital to the achievement of recommended HbA1c targets. (Source: Int J Clin Pract 2008;62(12):1935–42)

Make Sure

Situation: A 40–year–old hypertensive with mild hypertension developed drug side effects.  
Reaction: Oh my God! Why was the drugs started so early?. 
Make sure, to first advise lifestyle modifications like exercise, low salt diet, high fiber diet, stress reduction etc. before advising antihypertensive medication, in mild essential hypertensives.

Laughter the best medicine

Consciousness – the time between naps.

Formulae in Critical Care

Oxygen uptake (VO2)

Vo2 = Co x (Cao2 – Cvo2)
CaO2 – Arterial oxygen content
Cvo2 – Venous oxygen content

Milestones in Neurology

James Ramsay Hunt (1872 –1937) was an American neurologist. Hunt described three discrete syndromes, the best known of which is herpes zoster oticus, also known as Ramsay Hunt syndrome type 2.

Mistakes in Clinical Practice

Beware of decimal points, which can lead to excessive dosing if misinterpreted

1–7 April Prostate Disease Awareness Week: Prostate SMS of the Day (Dr Anil Goyal)

No man under the age of 30 has evidence of BPH. The prevalence rises with age with 88% of men above 80 years of age having prostatic enlargement.

11th March World Kidney Day (Dr N P Singh)

Reducing risks of developing kidney diseases

Check kidney functions, if one has one or more of the ‘high-risk’ factors

a. Diabetes

b. Hypertension

c. Obesity

d. One of the family members suffers from kidney disease

e. One is of African, Asian, Aborigine origin

Kidney terms (Dr G M Singh)

Complicated infection: The patient has conditions that predispose or promote the development or persistence of infection.

Lab test (Dr Navin Dang)

Discourage marriage between thalassemias carriers to prevent birth of a child with thalassemia disease.

List of Approved drug from 1.01.2009 to 31.10.2009

Drug Name Indication Approval Date
Darunavir (as ethanolate) Tablet 300mg
For the treatment of human immunodeficiency virus (HIV) infection in antiretroviral treatment experienced adult patients, such as those patients with HIV–1 strains resistant to more than one protease inhibitor when co–administered with 100mg ritonavir, and with other antiretroviral agents.

(Advertorial section)



Advertising in eMedinewS

eMedinewS is the first daily emedical newspaper of the country. One can advertise with a singe insertion or 30 insertions in a month. Contact: drkk@ijcp.com. 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.

Stress Management Workshop (April 17–18)

A stress management workshop with Dr KK Aggarwal and Experts from Brahma Kumaris will be organized on April 17–18, 2010.

Organizers: eMedinews, Brahma Kumaris, Heart Care Foundation of India, in association with IMA New Delhi Branch and IMA Janak Puri Branch

Venue: Om Shanti Retreat Center, National Highway 8, Bilaspur Chowk Pataudi Road, Near Manesar.

Timings: On Saturday (2pm onwards) and Sunday (7am 4pm). There will be no registration charges, limited rooms, kindly book in advance, stay and food (satvik) will be provided. For booking e–mail to emedinews@gmail.com or sms to Dr KK Aggarwal 9811090206/ BK Sapna 9811796962

Stroke Update Workshop for GPs

Indian stroke association and International Stroke Conference is organizing a Stroke Update Workshop on March 13-14, 2010 at AIIMS Auditorium. eMedinewS has tied up with the conference for free registration for first 200 GPs of NCR. Organizer: Dr Padma, Prof of Neurology, AIIMS, New Delhi. SMS for free registration to 9717298178 or email to isacon2010@gmail.com

Also, if you like emedinews you can FORWARD it to your colleagues and friends. Please send us a copy of your forwards.

Readers Responses

  1. Congrats. This is best tiding of 2010. Even sky is not the limit for genuine and sincere achievers: Dr. RPS Sethi

  2. My heartiest greetings to you for receiving Padmashree award: Dr. HL Kuntroo

  3. Congratulations on your achievement and receiving Padmashree award. I feel proud of you for your excellent continued services and educative programmes for the medical fraternity: Dr. MM Singh

  4. Congratulations on being conferred the Padmashree. A proud moment indeed for your students: Dr. Dharan


Why do people on cholesterol-lowering drugs still have heart attacks?

What role does cholesterol really play?

How can you lower your risk of heart disease and stroke?

What to Do About High Cholesterol

To get answer to these questions and to know why lowering your LDLs (the bad cholesterol) is even more important than previously thought. COME & JOIN: DR.K.K.AGGERWAL  CME's STUDY GROUP  FREE  CLASSES, It includes a step-by-step approach to clinical management. Next class Sunday 28th Feb. Subject Diabetes [DR.G.M.SINGH]