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| HEALTH & FITNESS |
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Severe heart disease: Bypass surgery remains the best option
How to prevent back problems in old age
Studies find heart can affect how we feel fear
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Severe heart disease: Bypass surgery remains the best option
Coronary artery disease (CAD) — the commonest form of heart disease in adults – has reached epidemic proportions in India. In a case of advanced symptomatic disease, not responding to full medical therapy, the interventional treatment of CAD is surgery or stenting. A comparison of coronary artery bypass graft (CABG) surgery, known as ‘bypass surgery’ in simple terms, and percutaneous coronary intervention (PCI), popularly called ‘stenting’, who needs an intervention has been extensively debated during the past two decades. The conclusion is that CABG is safer in the long term and reduces the need for a repeat intervention. Two important and extensive studies have recently been published in the most prestigious medical journals – Lancet and New England Journal of Medicine (NEJM).
The first is the five-year culmination of a large series called the SYNTAX trial. SYNTAX is arguably the most important trial of CABG and PCI ever undertaken and is unique for several reasons. First, and by contrast with all previous such trials, SYNTAX randomised 1800 patients with severe coronary artery disease. Even so a further 1275 patients (around 40 per cent of the total) were deemed ineligible for randomisation because their coronary artery disease was too complex for PCI; these patients were followed up in a nested parallel registry. A second unique feature of the trial was the introduction of the SYNTAX score, categorising the anatomical severity of coronary artery disease as low (<23), intermediate (23–32), or severe (>32). In simple terms – all CAD is not the same – some is more severe and can be quantified – the higher the score, the worse stage of the disease. The results of surgery are much better in all groups, but much better in the higher risk group. Because of the ability of this scoring system to predict clinical outcomes in PCI it has already been adopted into both European and American heart guidelines. In India, partly because of the high incidence of diabetes most patients fall into the high risk group (just the presence of diabetes is also a relative weightage to the advantage of surgery over stenting). The results of SYNTAX are clear. Overall, at the stage of one year, three years and five years CABG significantly reduced major adverse cardiac and cerebrovascular events (MACCE) in the CABG group. The investigators noted no significant difference as all cause death or stroke. This result made it crystal clear that surgery does not carry a higher risk than stenting (a viewpoint perpetuated wrongly in the public). Another landmark trial —— the FREEDOM trial — published in the NEJM reported that in 1900 patients with diabetes at 140 international centres (including India), CABG was much better than stenting. Interestingly, this trial had an Indian professor of cardiology.The editor stated that the trial, involving such a large number of patients and such a long follow-up, finally lays the debate — surgery versus stenting — to rest. “Bypass surgery is not as daunting an option as it used to be and has evolved greatly over the years. It is a robust and safe procedure, especially for diabetics.” The results of SYNTAX are entirely in accordance with several propensity-matched registries — which consistently report that CABG offers a strong survival benefit and significant reductions in myocardial infarction and repeat revascularisation in routine clinical practice. The reason for the difference in the results: CABG and PCI provide their benefits through quite different patho-physiological effects. Pathologically, in most cases, coronary artery disease is located in the proximal coronary arteries and bypass grafts to the mid-coronary vessels not only make the complexity of proximal disease irrelevant but also offer protection against the development of new proximal disease. Surgery elegantly and scientifically bypasses the blocks totally. By contrast, although PCI can be highly effective in directly treating less complex proximal coronary artery disease, its benefits are mitigated by the development of new disease proximal to within or immediately distal to the stent. In this scenario the actual type of stent becomes irrelevant — whether it is the ‘normal’ or bare metal stent or the more expensive drug-coated one. The cost factor is also important, especially in our country. A triple bypass costs much less than stenting. Also the cost of a second and third hospital admission for a heart attack case and a second procedure (which can be stenting or surgery) leads to additional expenses. A self-paying patient can generally afford just one procedure. Also the schemes offered by insurance companies and even the government’s ESI schemes now do not cover the costs of multiple stents. Surgeons are today improving their skills with the aim of further reducing the trauma of surgery. The new techniques include minimally invasive surgery (surgery done via small incisions) and beating heart surgery (this writer is a pioneer in this field). With beating heart surgery, complication rates are dramatically reduced even in very elderly and sick patients). In a nutshell, the learned investigators estimated that currently the majority of patients with complex coronary artery disease are best treated with CABG. They emphasised that treatment recommendations need to be made by a heart specialists’ team after a deliberation — rather than an ad hoc decision taken on the spur of the moment by a single specialist — with the patient already lying on the catheterisation table. This heart team concept will ensure that the most appropriate interventional strategy is adopted for individual patients. The writer is the Head of Cardio-Vascular & Thoracic Surgery at Christian Medical College & Hospital, Ludhiana. Earlier, he was at the Escorts Heart Institute, New Delhi, and St Vincents Hospital, Sydney. Email: drhsbedicmc@gmail.com |
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How to prevent back problems in old age
As we age, our muscles become weak, bone strength decreases and, therefore, our capacity to hold the spine also decreases. It is observed that elderly individuals generally do not incorporate exercises to strengthen the back and abdomen muscles with the result that they suffer from low back pain even with mild stress and strain. It is, therefore, mandatory to add strengthening exercises to aerobic activity like walking, cycling, etc.
The common causes of lower back pain in the elderly include degenerative disc disease, spinal stenosis, facet joint arthritis, compression fracture and degenerative spondylitis. Osteoarthritis of the spine generally affects individuals beyond 50 years of age. Degenerative disc disease is basically arthritis of the disc and occurs as a result of the aging process. Discs normally serve as cushions between bones of the spine. With advancing age, the disc loses water thereby becoming dried, desiccated and brittle. Usually there are not many symptoms exhibited but with mild stress and strain it can cause injury to the disc. The damaged disc can cause both inflammation and slight instability in the lower back, bringing about pain and sciatica. Aging of the spine with disc degeneration reduces the inter-vertebral space thereby reducing an individual’s height. In women suffering from osteoporosis this could be doubly distressing (due to the generally shorter height in females) as they may face difficulty reaching high shelves, driving a car, etc.
Treatment
Conservative treatment includes analgesic medicines, lumbar support and exercises. In case of no relief, an epidural steroid injection may be recommended. Physical therapies: Walking is an excellent exercise followed by stationary cycling and swimming. Physical therapy is advised keeping in view the curvature of the spine, muscle flexibility/strength, etc.
Exercises
Hamstring stretch: Lying on the back, raise one leg at about 90 degrees and pulling it by holding the thigh. Hold for a count of 15, and repeat three times thus experiencing a stretch on the back of the thigh. Both knees to chest: Lying on the back with knees bent, pull both knees towards the chest. Hold for a count of five and then return slowly. Repeat 10 times. Modified sit-ups: Lying on the back with knees flexed, keeping your feet on the floor, and crossing the arms across the chest. Instead of sitting up straight, move forward alternately towards the left and right knee. Repeat it 10 times. Arthritis of the spine may be a natural process of aging but it does not imply that one has to live with pain. It is, in fact, not a death sentence. Proper treatment and physical activity can enable an individual to live a normal, healthy, pain-free active life. Hence the importance of being aware and undergoing proper treatment The writer is a former doctor/physiotherapist, Indian Cricket Team. E-mail —chadhar587@gmail.com |
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Studies find heart can affect how we feel fear
Fear may be felt in the heart as well as the head, according to a study that has found a link between the cycles of a beating heart and the likelihood of someone taking fright.
Tests on healthy volunteers found that they were more likely to feel a sense of fear at the moment when their hearts are contracting and pumping blood around their bodies, compared with the point when the heartbeat is relaxed. Scientists say the results suggest that the heart is able to influence how the brain responds to a fearful event, depending on which point it is at in its regular cycle of contraction and relaxation. Sarah Garfinkel, a researcher at the Brighton and Sussex Medical School, said: “We demonstrate for the first time that the way in which we process fear is different dependent on when we see fearful images in relation to our heart.” The study, presented at the British Neuroscience Association Festival in London, tested the fear response of 20 healthy volunteers as they were shown images of fearful faces while connected to heart monitors. “Our results show that if we see a fearful face during systole – when the heart is pumping – then we judge this fearful face as more intense than if we see the very same fearful face during diastole – when the heart is relaxed,” Dr Garfinkel said. “From previous research, we know that if we present images very fast then we have trouble detecting them, but if an image is particularly emotional then it can ‘pop’ out and be seen. “We demonstrated that fearful faces are better detected at systole, when they are perceived as more fearful, relative to diastole. Thus, our hearts can also affect what we see and what we don’t see – and guide whether we see fear.” To investigate the phenomenon further the scientists used a brain scanner to show how an almond-shaped region of the brain called the amygdala, which is sometimes called the “seat of emotion”, influences how the heart changes a person’s perception of fear. “We have identified an important mechanism by which the heart and brain ‘speak’ to each other to change our emotions and reduce fear. We hope to explore the therapeutic implications in people with high anxiety,” Dr Garfinkel said. — The Independent
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Lower abdominal fat raises fracture risk in elderly women
Washington: Older women with lower abdominal fat mass are at a substantially higher risk for fractures, particularly of the vertebrae, an Australian prospective study found. Higher body weight is associated with greater bone mineral density (BMD) and lower fracture risk. However, the relationship between abdominal fat mass and fracture risk is unclear due to limited prospective data. The new study, reported in the Journal of Clinical Endocrinology and Metabolism, sought to examine the association between abdominal fat mass, BMD and fracture risk. The study was designed as a prospective investigation, in which a sample of 1126 participants (360 men and 766 women) aged 50 plus years had been continuously followed up for an average of five years. — ANI Eating whole fruit is better
than juicing for weight loss Washington:
Juicing is being promoted by many as a useful strategy for weight loss. But for those who have undergone surgical weight loss, the trend of extracting the liquid from produce can pose many risks. “Juicing in general reduces the fiber content and therefore decreases the feeling of fullness gained by eating fresh, crisp fruits and vegetables,” says Ashley Barrient, dietitian, Loyola Center for Metabolic Surgery and Bariatric Care.” Patients who consume whole fruit and vegetables report greater fullness and overall satisfaction with their diet. Barrient specializes in working with weight-loss patients. “The concentrated sugar and caloric content of juice can result in Dumping Syndrome which includes diarrhea, rapid pulse, cold sweats, nausea and uncomfortable abdominal fullness,” says Barrient. — ANI Your skin can reveal underlying health issues Washington: If facial lines appear, or you have unsightly fingernails, or suffering from hair loss, then you may be having health problems. Integrative medicine specialist Dr. Molly M. Roberts, of the Institute for Health and Healing, in San Francisco, and president of the American Holistic Medical Association, has asserted that these flaws can signal underlying health issues, Fox News reported. Some physical signs can tell trouble may be lurking beneath the skin’s surface. Wrinkles: Although wrinkles are inevitable, they may be a sign of osteoporosis. New research reveals an association between wrinkles and bone health in early-menopausal women. The worse the wrinkling, the greater the risk of lower bone density. Most wrinkles are the result of aging, but excessive exposure to cigarette smoke or the sun can speed the process. — ANI
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symptomatic disease, not responding to full medical therapy, the interventional treatment of CAD is surgery or stenting. A comparison of coronary artery bypass graft (CABG) surgery, known as ‘bypass surgery’ in simple terms, and percutaneous coronary intervention (PCI), popularly called ‘stenting’, who needs an intervention has been extensively debated during the past two decades. The conclusion is that CABG is safer in the long term and reduces the need for a repeat intervention. Two important and extensive studies have recently been published in the most prestigious medical journals – Lancet and New England Journal of Medicine (NEJM).
