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| HEALTH & FITNESS |
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Choosing between stent and surgery Gout, ‘disease of kings’, is on the way back Anti-anxiety drug benzodiazepine 'raises elderly dementia risk'
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Choosing between stent and surgery The real dilemma starts when one is found to be having significant coronary artery disease, which requires interventional treatment. As of now, two types of interventions are available (both are invasive and require hospitalisation). These are angioplasty and bypass surgery. There can be situations where both can be offered as treatment of coronary artery disease and, of course, bypass surgery can be applied and is the solution in any type of situation. Angioplasty means that the diseased area of coronary artery is repaired by dilating the diseased portion with a balloon catheter. Bypass surgery means surgically the diseased part is bypassed with a new route of blood supply via a graft taken from the human body only in the form of a vein or an artery. Angioplasty is less invasive than surgery as it is done under local anaesthesia and there are no major incisions. Bypass surgery has also become less invasive now because it is being done on beating heart and no longer the heart is arrested to carry out these grafts. So, the stressful effect of the heart-lung machine on the body is gone, and recovery is much faster. Bypass surgery is beyond doubt a long-term, time-tested solution which improves the quality of life and prevents sudden heart attacks. Freedom from second procedure is also considerable. Angioplasty with stents also improves the quality of life but the other two factors do not hold good. If the stent fails or blocks again, it will lead to a fresh heart attack and also the chances of blockages second time are more with stents where a second procedure may be required early. Bypass surgery is a proven and durable treatment for coronary artery disease, but when a patient is detected to have this disease there are certain situations where both treatments can be applied, and there the dilemma starts. If you look at human psyche, anybody and everybody in the world will want a less traumatic treatment and, therefore, angioplasty comes in mind immediately. But, at the same time, no one wants to suffer again and again and one wants a long-term solution to the disease or its eradication (which though is not possible), and something close to that is possible with bypass surgery. As new route of blood flow is created via grafts, which are disease-free, bypassing the diseased part of the artery. This means, in an indirect sense, removing the diseased path from the route of blood supply to the heart. In the case of angioplasty versus surgery, the key issues are: Is angioplasty in multi-vessel disease evidence based? Are the limitations of angioplasty known to the patient? Is it economical in multi-vessel disease as compared to surgery? There is another major issue. The trials on which we base our treatment are conducted on western population, which is genetically different than Asian or Indian population. In the western population the size of coronary arteries is much bigger than in Asians — it is 4-6 mm as compared to 2-4 mm in Asians. So, the treatment applied there cannot hold good here. As such, if we look at angioplasty vs CABG, the two forms of treatment are not equivalent in the following terms: Bypass surgery not only tackles the culprit lesion but also deals with future lesions as it is done distal to the diseased part. In certain situations angioplasty carries very high mortality like left main disease. Even the repeat revascularisation or second procedure requirement is higher with angioplasty in multi-vessel disease. As two latest trials show, even in the western population arterial revascularisation therapy study (ARTS), stent or surgery (SOS) trials indicate that the incidence of a second procedure in angioplasty is three times higher than patients treated with surgery. Also, the risk of death in both trials with surgery is very low — 1.2 per cent in ARTS trial and 0.8 per cent in SOS trial. Again in diabetes, bypass surgery scores over angioplasty in terms of long-term benefits as in ARTS trial it was 43 per cent in angioplasty as compared to 10 per cent in surgery patients. Surgery offers more complete revascularisation with better durability, especially arterial grafts. eft main disease is a very serious situation, which requires urgent intervention, and bypass surgery so far has been the best form of treatment. Another major disadvantage with drug-coated stents is what we call “Late Stent Thrombosis” or sudden occlusion of the stent after a year or so when the blood thinners or antiplatelets are withdrawn or reduced and, in fact, FDA in the US has issued a warning to all these companies for this dreaded complication. Other myths about angioplasty safety have also been proved wrong. 1. Risk of heart attack during angioplasty is 10 per cent. 2. Risk of restenosis in the first year is 10 per cent to 30 per cent. 3. There is no reduction in neurological complications with this. 4. Even in trials, including drug-coated stents’ multi-vessel disease, small vessels, long lesions, diabetes and restenosis patients have been excluded but in practice they are applied in even these subset of patients also. The father of interventional cardiology, Andreas Gruntizg, who died prematurely in a plane crash at the age of 46, stated in 1979, “We estimate that only about 10-15 per cent of candidates for bypass surgery have lesions suitable for angioplasty. A perspective randomised trial will be necessary to evaluate the usefulness in comparison with surgical and medical management.” So, stent or surgery is not/should not be a physician’s choice. It should depend on what the disease demands keeping in view the long-term benefits and economic advantages. Pros and cons of both procedures should be made known to the patient in detail. Durability of treatment rather than a short stay should be the goal. The best way to remove this dilemma is have a multidisciplinary team consisting of a physician, a cardiologist and a cardiac surgeon to decide about the treatment plan for coronary artery disease in a particular patient on an individualised basis. The writer is senior consultant, Dept of Cardiothoracic and Vascular Surgery, Max Super-Specialty Hospital, Mohali. |
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Gout, ‘disease of kings’, is on the way back Gout, once the "king of diseases and the disease of kings", is making a painful resurgence. Hospital admissions for the condition, which has afflicted sufferers from Alexander the Great to Leonardo da Vinci, and Queen Victoria to Laurence Olivier, have almost doubled in a decade. New research shows that admissions are increasing at around 7 per cent a year, with more than 4,000 people seeking treatment each year, many of them as emergencies. A new study, reported in the journal Rheumatology, revealed there were 32,741 hospital admissions of gout sufferers in England – a 7.2 per cent annual increase – between 1999 and 2009. Emergency admissions increased 86 per cent from 1,875 to 3,496. The study also showed a smaller, but still substantial increase in gout sufferers in New Zealand. "We have shown that hospital admissions for gout are increasing significantly over time," said Dr Philip Robinson of the University of Queensland, who led the study – one of the world's largest. "We are seeing this trend in all countries that have reported figures. Why is gout increasing? The prevalence of obesity is increasing worldwide due to people taking in too many calories and not exercising." The results also revealed that gout sufferers tended to have other health problems, including high blood pressure (39 per cent), diabetes (20 per cent) and cardiovascular disease (39 per cent). Gout is a type of arthritis caused by a build-up of uric acid in the blood after the kidneys fail to deal with it. This results in needle-shaped crystals, which form in and around joints, particularly the big toe, causing severe pain. Historically, the disease was linked almost exclusively to wealthy people, who could afford the luxury of a fine lifestyle. Famous members of the gout sufferers' club include Henry VIII, Isaac Newton, the poet Alfred Lord Tennyson and the US founding fathers Thomas Jefferson and Benjamin Franklin. Nowadays, though, the disease is no longer the preserve of the rich, with an estimated one in 70 UK adults suffering from symptoms. A number of risk factors for the condition have been identified, including alcohol, diet, obesity, high cholesterol and hypertension, all of which increase uric acid levels. Alcoholic drinks raise the level of uric acid in the blood by increasing its production in the liver, and by reducing how much is passed out in urine. Beer is known to be a particular problem. Professor Anthony Jones, who specialises in neuro-rheumatology at Manchester University, said: "The figures are interesting, and it is a huge study. Essentially, gout is increasing because of bad habits. We drink too much, eat the wrong food, do little exercise and are overweight. I can remember only a small number of gout patients who were thin. People tend to associate heavy drinking with young people but, in fact, older people consume more, and gout is a disease of older people." — The Independent |
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Anti-anxiety drug benzodiazepine 'raises elderly dementia risk'
A popular anti-anxiety drug has been linked with an increased risk of dementia in pensioners, according to new research. Patients over the age of 65 who start taking benzodiazepines, also known as benzos, have a 50% increased chance of developing dementia within 15 years compared with people who had never used the drug, according to the study. Researchers from the University of Bordeaux, France, warned that "indiscriminate widespread use" of the drugs, which are also used to treat insomnia, should be cautioned against. The drug is widely used in many countries. In France 30% of people over the age of 65 take benzodiazepines. Many administer the drug for long periods despite guidelines suggesting it should only be used for a few weeks. The research, which is published on bmj.com, examined 1,063 people with an average age of 78 over two decades. They had never taken the drug before and were all free from dementia. They found that 95 patients started taking benzodiazepine during the study. After a 15-year follow-up, 253 people developed dementia. Of these, 30 had begun to take the drugs between three and five years into the study. The chance of dementia occurring in those who had taken the drugs was 4.8 per 100 "person years" — a statistical measure representing one person at risk of development of a disease during a period of one year. Of those who had not taken the drugs the likelihood was measured to be 3.2 per 100 person years, the researchers found. "In this large, prospective, population based study of elderly people who were free of dementia and did not use benzodiazepines until at least the third year of follow-up, new use of benzodiazepines was associated with a significant, approximately 50% increase in the risk of dementia," the authors wrote. "Benzodiazepines remain useful for the treatment of acute anxiety states and transient insomnia. However, increasing evidence shows that their use may induce adverse outcomes, mainly in elderly people, such as serious falls and fall-related fractures,” they added.
— ANI
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Myths and misunderstandings about preventing cancer Washington: Many people are highly misinformed about the important role lifestyle factors play in raising their risk of developing cancer, according to a new research. A large proportion of people overestimate the cancer risk attributable to genetics. On the other hand, many underestimate the cancer risks associated with obesity, alcohol and sunlight exposure, said Dr Derek Power, medical oncologist at Mercy and Cork University Hospitals, Ireland. "Many myths surrounding cancer risk are also still popular," said Dr Power, who was the lead author of the study. "For example, many people wrongly think that a blow to the breast, stress, wearing tight underwear, the use of mobile phones, genetically modified foods and aerosols are major cancer risk factors," he noted. Dr Power and colleagues used a 48-question survey to assess knowledge about cancer risks among the general population.
— ANI Smoking tied to early onset
of pancreatic cancer Washington:
Those who smoke and drink heavily are likely to develop pancreatic cancer at an early age than those who don't, according to a new study. Researchers from the University of Michigan Health System found that heavy smokers with pancreatic cancer were diagnosed around age 62 and heavy drinkers at age 61 — almost a decade earlier than the average age of 72. Smoking is a strong risk factor for pancreatic cancer and alcohol has been shown to cause oxidative damage to the pancreas, which sets the stage for the inflammatory pathways that can lead to cancer. The findings only indicate these habits can lead to developing pancreatic cancer earlier in life.
ANI Exercise boosts memory
after stroke Washington:
Just six months of exercise can improve memory and thinking by almost 50 per cent, says a study. Toronto researchers found that the proportion of stroke patients with at least mild cognitive impairment dropped from 66 per cent to 37 per cent during a research study on the impact of exercise on the brain. "People who have cognitive deficits after stroke have a threefold risk of mortality, and they're more likely to be institutionalised," says lead researcher Susan Marzolini of the Toronto Rehabilitation Institute. "If we can improve cognition through exercise, which also has many physical benefits, then this should become a standard of care for people following stroke." — ANI Fat-rich ‘cafeteria diet’ putting youth at risk of premature strokes Washington:
Fat- and sugar-rich junk food diets can increase the risk of stroke or death at a younger age, according to a study. Researchers found that a high-calorie, high-sugar, high-sodium diet nicknamed the 'cafeteria diet' induced most symptoms of metabolic syndrome — a combination of high levels of cholesterol, blood sugar, blood pressure and obesity — in rats after only two months. The animals were at an age roughly equivalent to 16 to 22 years in humans at the time of disease onset, according to lead researcher Dr Dale Corbett, scientific director of the Heart and Stroke Foundation Centre for Stroke Recovery. — ANI |
Heart disease is the largest single killer in our society. The changing life-style has added to the stresses and strains of life which have made this disease spread in a big way. In India, it is fast growing and soon we will be the number one country with patients of coronary artery disease. The incidence of this disease is rising in the younger population. Anybody who is above 35 years should have all his investigations carried out from the heart point of view at least once a year so that if there is any alarming sign it is tackled well in time. This particularly holds good in those persons who have a strong family history.