Is it ok if I Drink alcohol?

AHA Recommendation
Consuming alcohol in moderation can reduce the Heart disease risk; this means an average of one to two drinks per day for men and one drink per day for women is the recommendation. 
(A drink is one 12 oz. beer / 4 oz. of wine / 1.5 oz. of 80-proof spirits or 1 oz. of 100-proof spirits.)
(1 oz=30 ml)

Therefore,
12 oz of beer= 360ml
4 oz of wine=120ml
1.5 oz of 80-proof spirits=45ml
1 oz of 100-proof spirits=30ml

RED WINE-particularly of more importance
Red wine is a particularly rich source of antioxidants flavonoid phenolics, particularly resveratrol and the flavonoids. Resveratrol, found in grape skins and seeds, increases HDL cholesterol and prevent blood clotting. Flavonoids, on the other hand, exhibit antioxidant properties helping prevent blood clots and plaques formation in arteries.
Red wine can raise HDL cholesterol and prevent LDL cholesterol from forming. Red wine may help prevent blood clots and reduce the blood vessel damage caused by fat deposits.

what are the measures that can increase HDL?

1. Aerobic exercises like walking, swimming, bike riding and jogging.
2. Weight loss.
3. Smoking cessation.
4. Cutting ingestion of trans fats can increase HDL. Trans fats are found in abundance in fats that are solid at room temperature. The fats described as “hydrogenated oils” on the food packages have lots of harmful trans fats. New York City recently took the lead in banning use of trans fats in the city restaurants.
5. One or two drinks of alcohol daily can increase HDL. There is however, a down side to prescribing alcohol as an HDL enhancing measure. One of the possible problems is alcohol’s addiction potential.
6. There are good fats and there are bad fats. The good kind monounsaturated fats such as canola oil, avocado oil, olive oil and those found in peanut butter can help increase HDL. A word of caution: very low fat diets are known to lower HDL and too much of any fat increases calorie content which can lead to weight gain. The later in turn can decrease HDL.
7. Fibers found in oats, fruits, vegetables and legumes can help increase HDL.
8. The statins like Pravastatin, Simvastatin, Lovastatin, Crestor and Lipitor as a general rule are not good HDL enhancers. High doses of a B group vitamin called Niacin can help increase HDL. The patient acceptance however continues to be a challenge due to side effects like flushing and itching after taking this drug. Some tips on decreasing the chance of side effects from niacin are: taking an aspirin 30-60 minutes before taking niacin, taking niacin at night and avoiding high fat diet at night. Some long-acting niacin manufacturers claim fewer side effects as compared to short-acting niacin.

Questions have been raised about the efficacy of DES, wondering whether they are as safe as projected by the manufacturers. How have Indian interventional cardiologists reacted to the revelations?

The result shown with the long-term follow-ups on DES at WCC, Barcelona is surely of concern. Having said that, let me state that DES is definitely an answer for restenosis, which is of major concern since the use of BMS from the early 1990s. DES, without doubt, has shown a major decrease in restenosis rates, though at the cost of some cases of late thrombosis. The answer to this is right selection of cases for the use of DES (diabetics, long length lesions and small calibre vessels). One can still use BMS in 40-60 per cent (with almost comparable results) of cases, which do not fall in the above subset. Therefore, the concern is not of increase in MI or death due to late thrombosis, but it of over-use of DES. Of late, in my clinical practice, on many occasions when I wanted to use BMS for low-risk patients for restenosis, patients have demanded DES due to the hype surrounding it.

Please comment on the recent Swiss study that found 3.3 more heart attacks and deaths per 100 patients with DES than with the bare-metal ones.

The results which are seen with DES Vs BMS show more MI and death in DES group due to the non-re-endothelialisation with DES even at 33 months. Endothelialisation is a thin layer which is protective in nature and is supposed to grow within the stent in one month after stent implantation. The drug which is eluted from the first generation DES not only inhibits the smooth muscle cell proliferation of the vessel wall, but it non-selectively inhibits the growth of endothelium, sometimes permanently, unlike in BMS and now the more recent second generation stents. Therefore, when the free flowing blood is exposed to underlying naked stent (devoid of endothelium), it has a tendency to form clot.

On most occasions, this is taken care by the long-term usage of dual antiplatelets (blood thinners). The question is for how long to take these antiplatelets. Another hypothesis for late restenosis is the presence of a polymer which remains permanently on the stent, even after the elution of drug is complete. However, the BMS tend to endothelialise in one to two months after implantation. Let me also state that even BMS has some incidence of stent thrombosis, though early. Most patients who are resistant to Aspirin and /or Clopidogrel will have a possibility of stent thrombosis, irrespective of the stent type used.

Evidence from an 18-month patient follow-up programme has suggested that DES might be worthwhile in just one of three cases. Please comment

Yes, correct patient selection is of utmost importance. We must keep in mind that restenosis does not kill a person, it only increases need for repeat revascularisation. Early stent thrombosis is not a big issue as it can be seen in all types of stents, including BMS. However, most of us will admit that late stent thrombosis resulting in MI/death is definitely of some concern. Presently, imparting patient education for need to continue long-term dual antiplatelets is of prime importance to avoid late thrombosis phenomenon in those patients necessarily requiring DES.

Is DES too hyped?

Not really. Every landmark technology/ breakthrough is always a big welcome to mankind. But advanced technology always comes with some problems attached to it. This is applicable to all fields of scientific progress. We should be bold enough to admit the problems so that it helps in betterment of technology.

Reportedly, in the US, doctors have tapered their use of DES in the last six months. Will Indian cardiologists do the same?

I do not think most Indian cardiologists overuse DES. There is still a huge BMS market, and I guess it will continue for times to come, till we have some more data with the second generation stents.

What impact will the controversy have? Will it give BMS market a boost?

To start with, I do not believe that there is any controversy. The established first generation DES will still hold in 40-60 per cent of high risk (for restenosis) group. Rather than BMS getting a boost, many cardiologists are looking for other alternatives.

One such alternative is the polymer devoid second generation DES, which many cardiologists have started using. Initial data appears encouraging, in fact in some types, the Clopidogrel can safely be stopped as early as two months. We do not have data for more than 24 months for these stents, hence, it will be a bit early to compare the long-term results available with the first generation DES. However, like in all technological progress, the second generation stents would eventually replace the first generation one, once long-term safety data is available.

Also, we are talking about encouraging results of so called 'bioactive' stents, which in strict sense are not DES, but are metal stents coated with bioactive materials like titanium nitrous oxide which are presently in commercial use. Data has shown that these bioactive stents have lesser restenosis than BMS (but slightly more that DES) and also much safer on stent thrombosis issue. In the future, we can look at 'bio-absorbable' stents, which are currently under research.

In the weeks following the controversy, have you been flooded with queries from patients and their relatives about DES?

Like most patients in our country are not aware of problems with DES to start with, similarly most of them are not aware of any controversies about it. Despite it being in the news, there has been no real phobia surrounding it.

What about patients who already have the device?

The need for dual antiplatelet therapy for a long-term period is going to be important for such patients. I and most of my colleagues believe that if the dual antiplatelets are continued religiously, it is not of any issue. Problems will come up only if for any non-cardiac surgery that these patients with previously implanted DES have to undergo, the dual antiplatelets are to be discontinued. My take as a cardiologist is to accept a slightly higher risk of bleeding and continue the antiplatlets in most surgeries, if not all.

Will Indian cardiologists be cautious while using DES now?

Caution is not the word, selection of right cases is the key.

Are Indian cardiologists not affected by the controversy in anyway? Should they adopt a conservative approach, awaiting more data?

In our country, long-term follow-up on the patients post angioplasty is an issue. I think that it is better for us to exercise caution and to be careful since death is irreversible. Data collection and availability is an ongoing process throughout our lives. It always helps in improving technology. This does not mean that we have to adopt a conservative approach.

Do we need more long-term studies to establish facts?

We have facts in front of us, hence the 'controversies'.

When so many patients' lives are affected, why are most Indian cardiologists avoiding to take any stand in the controversy? Are they afraid of spoiling relations with the DES manufacturers?

I am not. I cannot comment about others.

What is the future of DES in India?

Good. Even though you don't have to use DES for every patient, but because the sheer number of cases requiring percutaneous coronary interventions are increasing every year due to the increasing disease burden, I foresee greater usage of DES.

How has the constitution and design of stents changed over the years? What kind of research is going on in stents?

From heavier designed stents in earlier days, to more sleeker stents now with much less metal to artery surface ratio without compromising much on radial strength, the designs have changed majorly. Even the stent composition has undergone major transformation from stainless steel to nitinol, to tantalum, platinium and cobalt cromium stents. Then we had bioactive stents like heparin-coated to phosphotidyl-coated, carbon-coated (to make them more inert) to the present titanium-nitride-oxide-coated stents. Finally, we have the first generation polymer-based DES to more recent DES without polymer. And now, research is being conducted on bioabsorbable stents.

Robotic Angioplasty

What is the main difference between Robotic PCI and manual PCI?
The main difference between remote control robotic PCI and traditional hand held device manipulation
is that the physician operates from a workstation rather than at the bedside.
There is no difference felt or realized by the patient with robotic operation.


How does the Physician Workstation control the Bed-side Unit?
The CorPath™ converts physician commands into precise, mechanized guidewire and device movements at the femoral access site. The workstation and bed side unit work together via a communication line.


Does remote control robotic technique require special training?
No, physician expertise is based on eye-hand coordination and this relationship does not change using
remote control robotic device manipulation. The physician performs the procedure in the same sequence, relies on fluoroscopic images and specifies device movement via the workstation.


What additional information does the CorPath™ system provide?
The physician workstation console displays on-line device position and provides information such as
speed and distance of device movement. This can be especially helpful in an accurate stent placement and with post-dilatation following stent implantation.

I am accustomed to working with certain guide wires and catheter systems, can I still work with
them or will I need to use special devices from Corindus?
With the CorPath™ system you can use all standard interventional cardiology devices.


What happens if the patient moves?
The system halts and the physician can restart or switch to manual operation.


How can I still keep in contact with the patient during the procedure?
The system is an add-on in the Cath lab, the physician will still be in the Cath lab, but in a protected area,
typically just a slight distance from the patient.


What happens in the case of a system malfunction?
The system has built in safety mechanisms to alert and stop before any possible harm occurs. If a
malfunction occurs, the physician immediately switches to manual operation.


Will the procedure cost more with the Corindus system?
The CorPath system does not require the high cost of cath lab redesign, as with other systems. For each procedure there is a nominal cost for single use products.

Angioplasty - Angiogram

What is an ‘angiogram’ and why do I need it?

Your consultant will have explained that your symptoms are due to blockages in the arteries. For us to see exactly where and how severe these blockages are, we need to take pictures of the arteries. We do this by injecting a colourless dye (contrast medium) in to the artery and taking X-ray pictures. Only those parts of the artery with contrast medium in it can be seen. In this way any blockages can be seen. This is called an ‘angiogram’. It provides us with a ‘road-map’ of your arteries. Using this ‘road-map’ we can decide on the best treatment for you.

What is a ‘balloon angioplasty’ and why do I need it?

Some of the narrowed or blocked segments of the arteries we can see on the angiogram can be stretched open by expanding a special balloon in the ‘furred-up’ part of the artery. This can help to restore the blood supply to the tissues without having to resort to a bypass operation. Your consultant will discuss this with you once he has seen the angiogram. If the consultant radiologist feels that angioplasty would help you, then he will discuss this with you at the time of the angiogram and may proceed with this procedure to save you from having to come back again.

How long will I be in hospital?

About a week before your procedure (X-ray test) you will be asked to come to the hospital for a check-up. You will be seen by a junior doctor who will take your details. Remember to bring all your tablets to this clinic. Blood tests and a heart tracing (if necessary) will be taken. You will then be allowed home.

The nurses in the clinic will determine if you are suitable to have the procedure as a day case or whether you will have to stay overnight. If you are diabetic on insulin, on blood thinning tablets (warfarin), have kidney failure or have no-one to look after you at home you will have to stay overnight after the procedure.

What will happen when I am admitted to the hospital?

You do not have to starve before the procedure. Take all of your tablets as normal. On the day of your procedure you will be admitted either to a ward or to the day case unit. You will be greeted by a nurse and your details confirmed. At the appropriate time you will be asked to change into a hospital gown before being taken to the X- ray department. There you will be greeted by the consultant radiologist (X-ray doctor), radiographer (the person who takes the pictures) and the X-ray nurse. The procedure will be explained to you and you will be asked to sign a consent form.

How is the procedure carried out?

You will be asked to lie down on a moving table. Please keep as still as possible. The doctor will make sure you are as comfortable as possible. The photograph shows the angiogram room with the table in the middle:

Most often the procedure is carried out through one the arteries (blood vessels that carry blood from the heart to the body organs and limbs) in the groin. Sometimes the doctor may have to use the artery in your arm (usually the left one). The skin will be cleaned and sterile drapes positioned to keep the procedure as clean as possible. Local anaesthetic will be injected into the skin. You will then feel some pushing as a thin tube (cannula) is inserted into the artery. A thin soft wire (guidewire) will then be threaded through this cannula and placed in the appropriate position using the X-ray equipment. You may be able to see the pictures on the video screens. A tube can then be threaded over the guidewire and the contrast medium injected through this tube. As the contrast medium is injected the table may move so that the whole of both legs can be X-rayed. This is an angiogram. During injection of the contrast medium you may experience a hot flush, a metallic taste, nausea (some patients vomit) and the feeling that you are passing water. Do not worry, this is only a feeling.

If you need an angioplasty the procedure will take longer as a balloon is positioned under X-ray control and used to stretch open the narrowed or blocked segment of the artery.

After the procedure the cannula will be removed from the groin and pressure applied for 5-10 minutes or longer if necessary. You will then be taken to the recovery area in the X-ray department before being taken back to the ward.

What are the possible complications of this procedure?

Although most procedures are straightforward and without complication, some problems can arise in 2-4% of cases. These are:

	Haematoma – this is excessive bruising and a collection of blood at the puncture site.
	False aneurysm ('pseudoaneurysm') – this is a pulsating clot next to the hole in the artery. It will need treatment either in the form of surgery or the injection of a substance to seal the hole in the artery.
	Embolism – during the procedures a piece of atheroma may dislodge and travel down the leg. This may be dealt with straight away in the X-ray department. Rarely it may mean having to undergo an emergency operation.
	Occlusion of the artery – this may make the situation worse requiring surgery to correct the problem.
	Rupture of the artery – this can rarely happen during angioplasty. It may need an emergency operation to correct.
	Contrast reaction – this is like an allergic reaction. If you have had problems in the past with a contrast medium you must inform the radiologist.
	Death – this is a rare possibility. It is usually due to a heart attack or a stroke following the procedure.

Stent

How successful is angioplasty and stenting?
Angioplasty/stenting is successful in treating the narrowing/blockage of the artery in the vast majority of patients (90-95%).  In the small number of patients in whom the procedure is unsuccessful, a surgical bypass operation may be offered as an alternative.

What happens next?
You will be sent an appointment for the pre-clerking clinic where specialist nurses will assess you a few weeks before you have the procedure to check that you are fit enough to have it and to take some blood for routine tests.  This will also give you the opportunity to ask any further questions you may have.

Is there anything I can do to help?
You cannot do anything to relieve the actual narrowing or blockage.  However, you can improve your general health by taking regular exercise, stopping smoking and reducing the fat in your diet.  These actions will help slow down the hardening of the arteries which caused the problem in the first place and may avoid the need for further treatment in the future