HEALTH TRIBUNE
 

A safe detour to a healthy heart
by Dr Harinder Singh Bedi
C
ORONARY artery disease has reached alarming proportions. In India, the incidence of this disease ranges from 14.8 to 65.4 per 1000 population. In Punjab, the incidence is in the upper limit of the range, mostly due to the fat-rich and predominantly non-vegetarian and milk and milk product containing staple diet, increasing stress in all walks of life and a genetic predisposition to atheroschlerosis nearly three million people die every year in the age group 35 to 69 years from heart disease — one-third of these from coronary artery disease.

Diabetes: role of family physicians
by Dr R.J. Dash
T
HE impact of diabetes on an individual’s health, a country’s economy and health infrastructure is widely discussed in the media and physician forums. The disease occurs in nearly 12 per cent adults over the age of 20 years in urban India while it is 2-6 per cent in rural India. It shows no symptoms to begin with in the majority of the patients, while with an increase in duration and vascular damage in different body systems, its clinical expression varies.

Wild blueberries cut heart disease risk
Washington
Wild blueberries help reduce the risk of developing cardiovascular disease, concludes a two-year U.S. study.

 
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A safe detour to a healthy heart
by Dr Harinder Singh Bedi

CORONARY artery disease has reached alarming proportions. In India, the incidence of this disease ranges from 14.8 to 65.4 per 1000 population. In Punjab, the incidence is in the upper limit of the range, mostly due to the fat-rich and predominantly non-vegetarian and milk and milk product containing staple diet, increasing stress in all walks of life and a genetic predisposition to atheroschlerosis nearly three million people die every year in the age group 35 to 69 years from heart disease — one-third of these from coronary artery disease. India already has 50 million heart patients and, according to the WHO, by 2010 this figure will have doubled when 60 per cent of the world’s heart disease patients will be Indians.

The surgery done for coronary artery disease — coronary artery bypass grafting (CABG) — has been in vogue since 1967 when the first such surgery was performed at the Cleveland Clinic in the US. Since then the application of this surgery has increased tremendously, and today it is one of the most widely performed procedures.

The basic concept of the surgery is to bypass the blocked artery by using another tube as a conduit. The commonest conduit used so far has been the patient’s own greater saphenous vein graft (SVG). With this, the patient’s symptoms disappeared dramatically and he was able to lead a good quality life. However, as experience was gained and the patients who would otherwise have died survived for longer periods, it became obvious that the veins (which were used to only withstanding venous pressure, which is much lower than the arterial pressure, they were subjected to after bypass surgery) tended to degenerate and block off. This was to the extent of about 50 per cent of the veins being blocked in 10 years. Some of these patients with blocked veins would again start experiencing chest pain. A minority of them who had surgery done 10 years ago would need another surgery.

With this realisation came the concept of using arterial grafts. These conduits are morphologically more suited to withstand aortic pressure, have a better-size match with the coronary arteries and secrete the endothelial derived relaxing factor (EDRF) which helps in maintaining their patency. The first arterial graft used was the left internal mammary artery (LIMA). This vessel is taken from behind the sternum. Its distal (lower) end is divided leaving the upper end still connected to its source of blood supply — the subclavian artery. The lower end is now used to bypass the blocked coronary artery. This conduit has given excellent results with over 95 per cent patency in 10 years. It still serves as the “gold standard” by which all other arterial conduits are judged.

We have two internal mammary arteries running on each side of the breast bone. So, next came the idea that if the left internal mammary can be used, why not the right also? The right internal mammary artery has been extensively used now with the results matching those of the left. The main problem is that when we remove both mammary arteries from behind the breast bone, there can be problems with the healing of the bone, especially so in diabetic and elderly patients.

So, the mind of the cardiac scientist went to other arterial conduits. The stomach has a very rich blood supply with four different arteries feeding it. We have known for a long time from our general surgery colleagues that at least one of these arteries can be removed from the stomach without causing any damage to the stomach. The stomach artery used is called the right gastro-epiploic artery (RGEA). It is removed from the stomach through the same skin incision given for the bypass surgery. No separate skin incision is made its origin remains attached while its lower end is divided and used to bypass the blocked coronary artery. It has been used quite often and has given good results. It is especially useful in diabetics, in obese patients and in patients with lung diseases — cases where one may not take both internal mammary arteries. It cannot, however, be used in all patients like those with previous gastric or abdominal surgery.

The next arterial conduit used is the artery from the hand — the radial artery. The forearm has two arteries — the radial and the ulnar. Usually, the ulnar artery is so well developed that the radial artery can be removed without any problems to the hand. A test known as the Allens test is performed to confirm that the ulnar artery is indeed well developed and only then the radial artery is removed. This is removed from the non-dominant side (the left hand in right-handed individuals) though even bilateral radial arteries have been used in selected cases.

This artery at present is the most widely used conduit after the left internal mammary artery. Its lower end is attached to the coronary artery and its upper end to LIMA as a Y graft or to the aorta. The radial artery because of the ease of harvesting (as opposed to the rather cumbersome harvesting of the RGEA), good handling characteristics and good mid-term results has now become the conduit of choice after the internal mammary artery. This writer has extensive experience with this conduit, being one of the first surgeons in Asia to have used it. The technique -the use of the radial artery in a femoro-popliteal bypass has been pioneered by the writer and acknowledged by the medical world. This technique has now been successfully copied by surgeons from all over the world. Another arterial conduit used at times is the inferior epigastric artery (IEA). This artery is taken from the lower abdominal wall. It can be removed from both left and right sides.

With the advancement in technology, most complicated bypass surgeries are now being performed on a beating heart and with no or minimal usage of blood. The risk of elective surgery has been brought to less than 0.5 per cent. The aim now is to bring the risk even lower so that bypass surgery may soon be safer than a delivery.

The writer, Executive Director of Ludhiana’s Sigma New Life Heart Institute, is a noted heart surgeon.
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Diabetes: role of family physicians
by Dr R.J. Dash

THE impact of diabetes on an individual’s health, a country’s economy and health infrastructure is widely discussed in the media and physician forums. The disease occurs in nearly 12 per cent adults over the age of 20 years in urban India while it is 2-6 per cent in rural India. It shows no symptoms to begin with in the majority of the patients, while with an increase in duration and vascular damage in different body systems, its clinical expression varies. It accounts for 25 times higher incidence of blindness, 15 times higher incidence in kidney failure and two-to-five times loss of a limb, heart attacks, decrease in sex function and proneness to infection. One’s life-span is decreased by about a decade while one’s work output declines much more.

India is widely recognised as the diabetes capital of the world with the highest adult population suffering from diabetes and impaired glucose tolerance. The prediction of an increase in the number of patients from 25 million in 1995 to nearly 60 million in 2025 is being revised upwards. Indulgence in lavish life-style by our urban population is reflected on the rising trend in the prevalence of obesity, hypertension and heart disease.

The adult-type of diabetes, typically described among those in their fifth decade and later, is noticed in the second decade and upwards in increasing numbers. Interestingly, more and more patients with type-1 diabetes (insulin-dependent diabetes) are also encountered in the Southhall area of London with inhabitants predominantly of Indian origin.

Vascular complications are dependent on the duration of diabetes, degree of hyperglycemia and high blood pressure. Blood sugar and blood pressure control in type-2 diabetes significantly lower the risk of kidney, eye, heart and foot problems. These observations from the US, Japan and the UK have prompted an active screening programme for early detection, effective therapy planning and diabetes prevention.

A strong familial aggregation of diabetes with a high prevalence in first degree relatives and vertical transmission through two or more generations is common in India, particularly in the South because of consanguinous marriages. Indians have a higher rate of insulin resistance due to ethnicity, high salt consumption and vitamin D deficiency. Sedentary life-style is increasingly leading to generalised and abdominal obesity.

Despite being less obese, Indians have a higher degree of abdominal obesity, which is an established risk factor for diabetes, hypertension and coronary heart disease. In many families, there is the clustering of risk factors, leading to a high incidence of diabetes.

The identifiable causes are stress, physical inactivity, obesity, family history, being large or small at birth, diabetes or glucose intolerance in pregnancy, steroid therapy, etc. It is recommended to have a fasting blood sugar test done every two-three years after 35 years of age and every year after 40 by all with a history of diabetes in parents, particularly when associated with progressive weight gain.

The number of diabetologists in the country is small if we look at the patient load. It is, therefore, necessary that family physicians come forward to shoulder the responsibility of diabetes care.

Information on diagnosis and principles of diabetes management is easily available.

With a motivated patient, his/her family, the family physician and the tertiary care physician-diabetologist, the problem of diabetes can be handled successfully and the complications in millions of patients prevented.

The writer is a former Professor and Head, Deptt of Endocrinology, PGI, Chandigarh.

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Wild blueberries cut heart disease risk

Washington: Wild blueberries help reduce the risk of developing cardiovascular disease, concludes a two-year U.S. study.

"Our experiments focused on the effect of whole wild blueberries on the biomechanical properties of arteries as related to cardiovascular disease. This is the first in-vivo study to examine this relationship," said study leader Dorothy Klimis- Zacas, professor in the Department of Food Science and Human Nutrition at the University of Maine. The researchers found that arteries of laboratory rats fed a diet enriched with wild blueberries generated less force in response to phenylephrine, a stress hormone, than did arteries of rats fed the same diet without blueberries.

The finding is important because the force with which an artery responds to stress can directly affect blood pressure. — ANI
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New drop helps treat dry eye syndrome

Washington: A new eye drop medication, containing cyclosporine, can help effectively treat dry eye syndrome.

Cyclosporine is a common immunosuppressive drug that is given orally to treat inflammation in certain autoimmune diseases and to prevent transplant rejection.

But this use of the drug for dry eye has a very small concentration, so it is absorbed into the eye tissue but not detected in the blood. This is important because it makes the development of side-effects less likely. — ANI

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