Almost 60% of patients with diabetes suffer from PAD- Prof. Amber Malik


 CARDIOCON 2016 Proceedings-III

Almost 60% of patients with diabetes
from PAD- Prof. Amber Malik

Almost 50% of the patients with lower limb PAD has no symptoms
and some may present with low back pain-Dr. Masood Ahmad

FAISALABAD: One of the sessions on November 27th 2016 third day of the CARDIO CON 2016 held here recently was devoted to Acute Coronary Syndrome.  It was chaired by Prof. Sheharyar Sheikh along with others.  Dr. Amber Ashraf was the first speaker who talked about acute coronary syndrome in cardiac emergency.  He highlighted the importance of using Aspirin therapy in ACS in primary and secondary prevention. Early detection, she further stated, will prevent complications.

Prof. Zahid Jamal from NICVD discussed Sudden Cardiac Arrest in community and how to predict cardiac arrest in healthy individuals. He pointed out that 7-10% chances of success reduces every minute in these patients, hence the importance of immediate management of these patients. One should alleviate the symptoms of patients at risk of syncope as it may be serious cardiac problems. He also talked about family history of sudden death, recurrent episodes, and chest pain with palpitation and cardiac dysrhythmias. Family history and unexplained syncopy patients are at great risk of sudden death.  Syncope triggers with loud music. It is important to identify high risk patients before they develop sudden cardiac death, he remarked.

Dr. Maria Viqar from USA speaking about management of syncope said that reflex syncope is a benign disease with good prognosis in long term survival. It is important to identify triggering factors. It accounts for 6% of hospital admissions in United States. One should rule out stroke, ECG will allow you risk stratification of the patient. Physical counter maneuvers are effective as it reduces the risk of recurrent VVS.  It is important to educate and reassure these patients, life style modifications helps a lot.

Dr.Farhat Mahmood from USA discussed Atrial Fibrillation and its management. He demonstrated cryo balloon ablation and pointed out that sometimes one may have to deflate the balloon and go to the other artery and then come back. He hoped that in the coming days, cryo ablation facilities will be available in many cardiac centers in Pakistan. There is high risk of AV block in children and the catheters used are different.

Peripheral Arterial Disease

The session devoted to Peripheral Arterial Disease and structural Heart Disease was chaired by Dr. Manzoor Tariq along with others. Dr. Amber Malik was the first speaker who pointed out that PAD is very common. Almost 60% of patients with diabetes suffer from PAD. She then showed some slides of diabetics with non-healing ulcers and toe gangrene. There are different stages of PAD and it eventually leads to tissue loss. There is high morbidity in symptomatic and asymptomatic disease. Early detection of critical limb ischemia can reduce and prevent complications and also reduce mortality. Patients should be advised to stop smoking. One can reduce pain, salvage limb, prevent gangrene development and death if these patients are identified early and managed properly. One cannot manage these patients alone but it requires a multidisciplinary team which consists of internists, orthopaedic surgeons, diabetologist and physiotherapist. She then showed management of a few patients with excellent results. Interventional cardiologists should broaden their vision as there are lot of vascular interventions which are waiting for them, she added.

Dr. Masood Ahmad from Lahore discussed Endovascular interventions in cardiovascular diseases to salvage the limb. He pointed out that most often these patients come to us when they have already developed gangrene. Diabetes is not picked up early by GPs and dermatologists. Speaking about non-healing ulcers and ischemia, he said that almost 50% of the patients with lower limb PAD has no symptoms. The risk factors include diabetes, hypertension, smoking, age more than sixty years. These patients can present with low back pain. It can be due to ischemic pain. We usually do not have a humble attitude to look at the patient and sometimes these patients are sent by orthopaedic surgeons before amputation. He suggested that one must do angiogram before amputation even if it is a small one. Even for limited amputation, look at the angiogram. He also referred to the missed opportunities and delayed amputations in diabetic vasculopathy. It is extremely important that one should look at the feet of the patients with diabet5es, he remarked.

Dr. Najibullah from NICVD talked about their TAVI experience (replacement of valve without surgery) at NICVD. He pointed out that they were using CORE valve which are self-expandable. It is a team work and members of the team are interventionist, surgeons, anesthetists and imaging specialist. TAVI program was started at NICVD during 2015-2016. This procedure is for high risk patients. Age of the patients should be over sixty years of age. Team members have their designated duties.  Pre and post procedure monitoring of these patients is extremely important. While planning for these procedures, we discuss every case. So far we have done 28 cases of TAVI. Most of the patients were male. TAVI, it was re-emphasized was for the elderly patients. Out of these twenty eight, we lost three cases, one of these patients died before the procedure. It was our initial experience. We had some complications like valve malfunctioning.  In one patient valve slipped down and in this patient, valve in valve was placed. We lost one patient due to LV perforation. He was of the view that it is a safe and effective way of treating high risk aortic stenosis.

During the discussion Dr. Sohail Hafeez said that they started TAVI procedure at AFIC. For this one needs a team and one needs to connect the lab with the operation theatre. Conflict of interest should be overcome. Cardiologists and Surgeons should come together. It is a very expensive procedure, each valve cost about twenty eight to thirty lac rupees and we got stuck up because of lack of finances.

Dr.Raza remarked that NICVD has taken the lead and now we need to develop a center in the North as well. Responding to a question Prof. Nadeem Rizvi said that they had no heart block. If valve goes down, it can be recaptured. We have not used Edward valve, he added.

Dr. Tariq Abbas from CPE Institute of Cardiology Multan talked about Tips and Tricks in PTMC. Dr. Masood Siddique from Children Hospital Lahore spoke about Grown up Congenital Heart Disease. This he pointed out was a challenge. He referred to the repaired and unrepaired lesions, ASD in repaired, Coarction of Aorta, cyanotic adults, repaired defects.  TOF, he further stated, will always be with you and they need follow up for the rest of their life. Pregnancy is a major factor.  Risk of infective endocarditis is there for life. Then there are issues of life style and anti-coagulation in low, moderate and high risk cases. Speaking about mitral cardiac lesions and risk, Dr. Masood Siddique said that that when patient with high risk becomes pregnant, the problem arises.  He opined that grown up congenital heart disease should be a specialty and people managing these patients will have to commit themselves. He then talked about closure of ASD, VSD, multiple ASD closures with two devices. Coarction of aorta, he said, is not a simple lesion. He also talked about stenting in aortic atresia. You do not correct TOF for life. They might come for valve repair after every ten years. Pulmonary valve replacement is going on but it is very expensive. These patients are being managed by pediatric cardiologists, adult cardiologists, obstetricians, psychologists, electro physiologists, pulmonary hypertension specialists and we need to learn how to collaborate with each other. It is a full time specially. Prof. Nadeem Rizvi suggested that we can start a Fellowship in this specialty with two years training in adult cardiology and one year training in pediatric cardiology. It was emphasized that a collaborative approach is needed. Adult patients will come to adult cardiologists and duration of training can vary.

PCS and ACC Joint Session

Update on Heart Failure was discussed in the joint session of Pakistan Cardiac Society and American College of Cardiology.  Prof. P. J.Mather from University of Pennsalvania School of Medicine was the first speaker in this Video conference session.  He discussed in detail diagnosis, initial evaluation and management.  He also spoke about adequacy of perfusion, triggering factors and co-morbidities, non-compliance with drug therapy, poor control of hypertension, ischemia, acute coronary syndrome, infections, pulmonary emboli and modern evolution of heart failure therapy. Diuretics have their good and bad image but they are the main stay of therapy in acute heart failure. He also referred to symptoms of dyspnea and edema. Diuretics resistance in heart failure, he said, was a big problem. Heart failure and chronic kidney disease are associated with this therapy. In current treatment, most commonly used drugs are diuretics. Vasodilators are also used as well as inotropics.

Inotropes, Prof. Mather said was not a success story. He then referred to in hospital adverse events like sustained hypertension, acute myocardial infarction. He also discussed etiology of chronic heart failure and its treatment and said that 35% of over sixty five years of age heart failure patients will die in one year.  There is a possibility of sudden death in 50% of these patients. Heart Failure accounts for 15,000,000 deaths worldwide. Prevalence increases in elderly population. Speaking about heart failure in Men, he said that almost 287,000 die in a year due to CHF in United States. Almost 7% of our health expenditures are on heart failure and management of cardiovascular diseases cost 503 Billion Dollars. Mortality is worse in increasing age. These days increasing obesity and diabetes mellitus are main worries in United States. Risk factors are changing. Causes for readmission of heart failure patients include lack of communication, lack of education, failure with medication and dietary compliance, cost of medications, cost of food, stress on patients and poor communication by the healthcare providers, he remarked.

Prof. Jagat Narula Editor of Journal of American College of Cardiology was the other speaker in this session who talked about who gets the Heart Attack. High risk includes atherosclerotic plaque and chest pain will not produce acute event. No solid plaque ruptures leading to sudden death.  He then discussed in detail the characteristics of plaque vulnerable to rupture which leads to sudden death. He also referred to clinical progression of asymptomatic lesions, plaque vulnerability to rupture and luminal compromise. He then talked about ischemia without stenosis, prediction of major CV events which are possible and pointed out that 50% of cardiovascular events are in non-high risk plaques. We need to look at the disease as a whole. He also talked about the Inter Heart Study which enrolled 21,408 patients and was conducted in fifty two countries besides discussing vascular calcification and atherosclerosis.