Screen patients with broken heart syndrome for cancer

People with broken heart syndrome, also known as Takotsubo syndrome (TTS), should be screened for cancer, suggests a new study published in the Journal of the American Heart Association. And, a history of malignancy might increase the risk for TTS.

In the study of 1,604 people with broken heart syndrome, 16.6% showed an association with malignancy. The most frequent type of malignancy was breast cancer 26.2%, followed by tumors affecting the gastrointestinal system 16.1%, respiratory tract 15.4%, internal sex organs 14.6%, skin 13.1%, lymphatic system 7.1%, endocrine organs 6.7%, urinary tract 5.2%, hematologic 3.0% and the central nervous system 2.2%.

Patients with malignancy were older and more likely to have physical triggers (after a medical intervention or physical trauma), but less likely to have emotional trigger as the inciting event compared with those without malignancy. Long‐term mortality was higher in patients with malignancy while short‐term outcome was comparable. Malignancy was as an independent predictor of long‐term mortality.

C‐reactive protein levels were significantly higher in the TTS patients with malignancy in those without malignancy, while the total white blood cell counts were not different between the groups. The raised CRP levels were attributed to as a marker of the comorbidity.

TTS patients with malignancy on initial presentation experienced chest pain less frequently, but had dyspnea more often.

(Source: Journal of the American Heart Association, Published July 17, 2019)

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA

Rule out other causes of before initiating ESAs in cancer patients

The American Society of Clinical Oncology (ASCO) and the American Society of Hematology (ASH) have updated their clinical guideline for the use of erythropoiesis-stimulating agents (ESAs) in patients with cancer. The guideline also advises blood transfusion as a treatment option in these patients.

Some key recommendations are:

·         ESAs may be offered to patients with chemotherapy-associated anemia whose cancer treatment is not curative in intent and hemoglobin (Hb) is < 10 g/dL.

·         Do not offer ESAs for chemotherapy-associated anemia to patient in whom cancer treatment is curative in intent.

·         ESAs should not be considered for nonchemotherapy-associated anemia except for selected patients with myelodysplastic syndromes (those with lower risk myelodysplastic syndromes and a serum erythropoietin level ≤ 500 IU/L).

·         Before considering an ESA, observe the hematologic response to cancer treatment in patients with myeloma, non-Hodgkin lymphoma, or chronic lymphocytic leukemia.

·         First rule out other causes of anemia or an underlying hematopoietic malignancy. 

·         Epoetin beta and alfa, darbepoetin and biosimilar epoetin alfa are comparable in effectiveness and safety.

·         During ESA treatment, Hb may be increased to the lowest level required to avoid transfusions.

·         Discontinue ESAs if no response is evident within 6 to 8 weeks and re-evaluate the patient.

·         Iron replacement may be used to improve Hb response and reduce RBC transfusions for patients receiving ESA with or without iron deficiency.

(Source: Journal of Clinical Oncology. Published online April 10, 2019)

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA

Why universal medical insurance is on the way

Dr KK Aggarwal

Universal health care (universal health coverage, universal coverage, universal care, or socialized health care) is a national health care system that provides health care and financial protection to all citizens of a country. It provides a specified package of benefits to all members of a society with an aim of providing financial risk protection, improved access to health services, and improved health outcomes. The health care does not cover everything for everyone.

The critical components are

·         Who is covered?

·         What medical services are covered?

·         How much of the cost is covered?

As part of Sustainable Development Goals (SDGs), United Nations member states have agreed to work toward worldwide universal health coverage by 2030.

In India with a population of 133.92 crores, Ayushman Bharat will cover 50% of the population (40% or 50 crore people in conventional scheme + additional 10 % people with income less than 8 lakh per annum). For them insurance premium will be paid and shared by the central government (60%) and state government (40%) from the central and state taxes collected from the people.

Another 32% of the population is medically covered by Employee State Insurance (ESI) (8% employees + 10% unrecognised sector); Railway (9%); Defence (1.1%), state health insurance schemes (1%), Municipal corporations (1%); CGHS (36,67,795 people) and PSUs (0.75 crore family beneficiaries) [1%] another 1% is covered through private companies (corporates).

The remaining 18% of the population comprises people with annual income of more than 8 lakh per annum who can easily afford individual private insurance.

To make universal coverage possible the options include:

·         The government should make it mandatory to have insurance for those not covered by any government, PSU or NGO scheme.

·         Like ESI, it should be mandatory to have the employee insured by the employer as part of his or her salary package.

·         Around 41% of the population has some life cover, which should provide some medical cover.

·         Any individual with salary up to Rs 21,000 per month is entitled for ESI insurance; this should also be allowed for all those will salaries less than Rs 8 lakh per annum.

·         Ayushman Bharat provides coverage for up to 5 lakh for the family. However, most packages are capped, and the average expenditure is only Rs 18000/- per admission. Till today in the last 4 months, only 10 lakh people have been treated with an expenditure of only Rs 1800 crores (@ Rs 18000/- per person). At this rate, the annual expenditure will be only Rs 7200 crore (shared by center and state in a ratio of 60:40). This amounts to very little for the country.

·         If required, the government can cover additional 18% of the population also. With this the government will be able to ensure coverage for 100% population and provide general ward basic and emergent treatment to all admissions

For this to happen the government must also ensure affordable health care by implementing one company - one drug - one price policy; incentives to open Ayushman-only hospitals by small healthcare doctor-owned setups and capping the prices of National List of Essential Drugs, devices, reagents, investigations, equipment and disposables.

The government should also make it mandatory for all establishments to provide 10% beds for Ayushman patients.

The cost of providing universal national immunization; “nationalizing” diseases and health issues of national importance like TB, AMR, Leprosy, cancer, dialysis and providing free treatments to all should continue via the national health annual budget, which itself should be raised by another 25% to be made around Rs 75000 crores. This budget should cover the proposed 1.5 lakh wellness centers.

To further improve the health budget, the total budget for environmental pollution (air, water, earth); budget for women and child health, mid-day school meal, Swachh Bharat, road safety, pharma sector, food industry etc. should be merged with an aim to reduce the disease burden.

The government should provide coverage only for general ward treatment. There will still be enough business left for private and national insurance companies for additional insurance coverage for private wards and diseases not covered under Ayushman Bharat.

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA

Person Centric Medicine: Aspirin for primary prevention of cardiovascular disease and cancer

People Centric Approach in secondary prevention of cardiovascular disease: the absolute benefits of aspirin on occlusive events are greater than the absolute harm of major bleeding. All must get it.

Personal Centric Approach in primary prevention: the decision whether to use aspirin for primary prevention of cardiovascular disease and cancer be made based on shared decision-making, taking into account the probable benefits and harms of aspirin relative to the specific patient.

Three recent large randomized trials evaluating all-cause mortality associated with aspirin use indicate that the benefits and harms of aspirin for primary prevention are very closely balanced [1-5].

In both the ASCEND trial in patients with diabetes as well as the ARRIVE trial in patients with moderate CVD risk, the risk of all-cause death was similar with or without aspirin [1,5].

In the ASPREE trial of individuals 70 years or older, the risk of death was higher with aspirin (13 versus 11 percent) [2-4].

References

1.      ASCEND Study Collaborative Group, Bowman L, Mafhac approachm M, et al. Effects of Aspirin for Primary Prevention in Persons with Diabetes Mellitus. N Engl J Med 2018; 379:1529.

2.      McNeil JJ, Woods RL, Nelson MR, et al. Effect of Aspirin on Disability-free Survival in the Healthy Elderly. N Engl J Med 2018; 379:1499.

3.      McNeil JJ, Wolfe R, Woods RL, et al. Effect of Aspirin on Cardiovascular Events and Bleeding in the Healthy Elderly. N Engl J Med 2018; 379:1509.

4.      McNeil JJ, Nelson MR, Woods RL, et al. Effect of Aspirin on All-Cause Mortality in the Healthy Elderly. N Engl J Med 2018; 379:1519.

5.      Gaziano JM, Brotons C, Coppolecchia R, et al. Use of aspirin to reduce risk of initial vascular events in patients at moderate risk of cardiovascular disease (ARRIVE): a randomised, double-blind, placebo-controlled trial. Lancet 2018; 392:1036.

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Immediate Past National President IMA

Ask Dr KK:What is the number one cancer in India?

The number one cancer in females is cervix in rural and breast in urban area. In males is  is oral cavity in rural and lung in the urban area.

Ask Dr KK:How is CT radiation comparable to X ray Chest?

The dose from a single abdominal CT scan is comparable to the collective dose of 400 chest x-rays or natural background radiation for three years. 

About the author: Dr K K Aggarwal is Padmashri and Dr B C Roy National Awardee, President Heart Care Foundation of India, Dean Board of Medical Education Moolchand Medcity, Sr. Physician & Cardiologist, Visiting professor Clinical Research DIPSAR, Past President Delhi Medical Association, Past Academic and Research Wing Head IMA, Chairman Ethics Committee Delhi Medical Council.  

Ask Dr KK:How to counsel about diagnostic radiation to a patient?

All patients should be given a general idea about the magnitude of the proposed radiation dose. The exposure should be compared with an estimated effective dose to a single chest x-ray (0.02 mSv), a transcontinental airplane flight (0.02 mSv), or annual individual radiation dose from the natural background (3.0 mSv). 

About the author: Dr K K Aggarwal is Padmashri and Dr B C Roy National Awardee, President Heart Care Foundation of India, Dean Board of Medical Education Moolchand Medcity, Sr. Physician & Cardiologist, Visiting professor Clinical Research DIPSAR, Past President Delhi Medical Association, Past Academic and Research Wing Head IMA, Chairman Ethics Committee Delhi Medical Council.  

Ask Dr KK: Can CT cause cancer?

Use of CT may account for 1.5 to 2 percent of all future cancers in the United States.

The 2006 Biological Effects of Ionizing Radiation VII lifetime attributable cancer risk model predicts that 1 in 1000 persons exposed to 10 mSv (single diagnostic CT scan of the neck, chest, abdomen, or pelvis) will develop cancer due to that single exposure.

The lifetime attributable cancer mortality risk attributable to a single radiation exposure in a one year-old child is 1 in 550 following an abdominal CT and 1 in 1500 following a brain CT.

It has been estimated that 29,000 future cancers could be attributed to CT scans performed in the US in 2007 alone.

1 in 500 women and 1 in 660 men will develop cancer from their abdominal CT scan if the procedure is performed at the age of 20.

A 45 year-old adult undergoing one single full-body CT procedure would accrue an additional lifetime attributable cancer mortality risk of 0.08 percent from a single scan.

The lifetime attributable cancer mortality risk is 1.9 percent lifetime for thirty years of annual scans.

About the author: Dr K K Aggarwal is Padmashri and Dr B C Roy National Awardee, President Heart Care Foundation of India, Dean Board of Medical Education Moolchand Medcity, Sr. Physician & Cardiologist, Visiting professor Clinical Research DIPSAR, Past President Delhi Medical Association, Past Academic and Research Wing Head IMA, Chairman Ethics Committee Delhi Medical Council.  

Ask Dr KK: How common is multiple radiation exposures?

Multiple medical tests involving radiation exposure lead to high cumulative doses of radiation. In one study in 20 year period a heart patient may end up with 15 procedures involving radiation exposure. Of these four may be high dose procedures (≥3 mSv). The cumulative estimated effective dose from all medical sources exceeds 100 mSv in 31.4 percent of patients.

About the author: Dr K K Aggarwal is Padmashri and Dr B C Roy National Awardee, President Heart Care Foundation of India, Dean Board of Medical Education Moolchand Medcity, Sr. Physician & Cardiologist, Visiting professor Clinical Research DIPSAR, Past President Delhi Medical Association, Past Academic and Research Wing Head IMA, Chairman Ethics Committee Delhi Medical Council.  

Ask Dr KK: What is the exposure in a cardiac cath and EP study?

A typical X ray procedure results in a total effective dose of 8.3 mSv per hour of fluoroscopy.  The mean cardiac fluoroscopy time in managing paroxysmal atrial fibrillation is 57 minutes, atrial flutter is 20 minutes, ablation is 22 minutes and Pulmonary Vein isolation is 39 minutes.

About the author: Dr K K Aggarwal is Padmashri and Dr B C Roy National Awardee, President Heart Care Foundation of India, Dean Board of Medical Education Moolchand Medcity, Sr. Physician & Cardiologist, Visiting professor Clinical Research DIPSAR, Past President Delhi Medical Association, Past Academic and Research Wing Head IMA, Chairman Ethics Committee Delhi Medical Council.  

Dr KK Answers: How severe is background radiation?

The effective dose related to any radiologic procedure can be considered in the context of the annual effective dose to individuals from natural background radiation sources, including radon, cosmic rays, terrestrial, and internal sources. This background effective dose, approximately 3 mSv, does not pose a significant risk of future cancer to individuals.

About the author: Dr K K Aggarwal is Padmashri and Dr B C Roy National Awardee, President Heart Care Foundation of India, Dean Board of Medical Education Moolchand Medcity, Sr. Physician & Cardiologist, Visiting professor Clinical Research DIPSAR, Past President Delhi Medical Association, Past Academic and Research Wing Head IMA, Chairman Ethics Committee Delhi Medical Council.  

Ask Dr KK: What is the severity of radiation?

Mild exposure is called when the exposure is < 3 mSv, Moderate >3 to 20 mSv, High 20 to 50 mSv and very high exposure means >50 mSv

About the author: Dr K K Aggarwal is Padmashri and Dr B C Roy National Awardee, President Heart Care Foundation of India, Dean Board of Medical Education Moolchand Medcity, Sr. Physician & Cardiologist, Visiting professor Clinical Research DIPSAR, Past President Delhi Medical Association, Past Academic and Research Wing Head IMA, Chairman Ethics Committee Delhi Medical Council.  

Ask Dr KK: How is radiation measured?

Effective dose of radiation is measured in sieverts (Sv) or millisieverts (mSv). A whole body radiation dose of 1 Sv is associated with a 4 to 5 percent increased relative risk of fatal cancer. (1 Sv = 1000 mSv).

About the author: Dr K K Aggarwal is Padmashri and Dr B C Roy National Awardee, President Heart Care Foundation of India, Dean Board of Medical Education Moolchand Medcity, Sr. Physician & Cardiologist, Visiting professor Clinical Research DIPSAR, Past President Delhi Medical Association, Past Academic and Research Wing Head IMA, Chairman Ethics Committee Delhi Medical Council.  

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Ask Dr KK: How long it takes for the X Ray radiations to harm the health?

 At doses used in diagnostic and interventional procedures, ionizing radiation releases free radicals that may cause DNA damage. This radiation-induced cancers may develop decades after exposure, and include myeloma, blood cancers, lung cancer, thyroid cancer, breast cancer, bone cancer, and skin cancer.

About the author: Dr K K Aggarwal is Padmashri and Dr B C Roy National Awardee, President Heart Care Foundation of India, Dean Board of Medical Education Moolchand Medcity, Sr. Physician & Cardiologist, Visiting professor Clinical Research DIPSAR, Past President Delhi Medical Association, Past Academic and Research Wing Head IMA, Chairman Ethics Committee Delhi Medical Council.  

Ask Dr KK:How safe is angiography radiation?

The mean duration of fluoroscopy in electro physiologic cardiac interventional procedures ranges from 15 to 67 minutes. The radiation dose from one hour of fluoroscopy during electro physiologic ablation procedures can result in 0.7 to 1.4 excess fatal malignancies per 1000 women and 1.0 to 2.6 per 1000 men as per two studies published in American Journal of Cardiology (1998) and Circulation (2004)

About the author: Dr K K Aggarwal is Padmashri and Dr B C Roy National Awardee, President Heart Care Foundation of India, Dean Board of Medical Education Moolchand Medcity, Sr. Physician & Cardiologist, Visiting professor Clinical Research DIPSAR, Past President Delhi Medical Association, Past Academic and Research Wing Head IMA, Chairman Ethics Committee Delhi Medical Council. 

Ask Dr KK:How safe is angiography radiation?

One should not opt for imaging studies unless it is a must; they are not safe and can cause cancers in long run.

A UK analysis published in the Journal Lancet in 2004 had shown that fluoroscopic X Ray radiation exposure during catheter-based coronary angiography can cause up to 280 cases of cancer per million examinations performed.

About the author: Dr K K Aggarwal is Padmashri and Dr B C Roy National Awardee, President Heart Care Foundation of India, Dean Board of Medical Education Moolchand Medcity, Sr. Physician & Cardiologist, Visiting professor Clinical Research DIPSAR, Past President Delhi Medical Association, Past Academic and Research Wing Head IMA, Chairman Ethics Committee Delhi Medical Council.  

Dr KK Answers: Should we do MRI in all cases?

Neuroimaging rules out patients who might have reversible causes of dementia that can be diagnosed with imaging studies (subdural hematoma, normal pressure hydrocephalus, treatable cancer). Structural neuroimaging with either a non-contrast head CT or MRI should be considered in the initial evaluation of all patients with dementia. 

HCFI Update: High fat diet cancer prone

Diets high in saturated fat increases the risk of prostate cancer said Padma Shri & Dr. B.C. Roy National Awardee Dr. K K Aggarwal and President, Heart Care Foundation of India and MTNL Perfect Health Mela.

As per a report from University of Texas M. D. Anderson Cancer Center in Houston published in the International Journal of Cancer.

1.       Men who consume high saturated animal fat diet are two times more likely to experience disease progression after prostate cancer surgery than men with lower saturated fat intake.

2.       There is also shorter "disease-free" survival time among obese men who eats high saturated fat diet compared with non-obese men consuming diets low in saturated fat.

3.       Men with a high saturated fat intake had the shortest survival time free of prostate cancer (19 months)

4.       Non-obese men with low fat intake survived the longest time free of the disease (46 months).

5.       Non-obese men with high intake and obese men with low intake had "disease-free" survival of 29 and 42 months, respectively.

 Take home messages

1.       High saturated fat diet has been linked to cancer of the prostate

2.       Reducing saturated fat in the diet after prostate cancer surgery can help reduce cancer progression.

3.       Cancer prostate has the same risk factors as that of heart blockages and both are linked to high saturated fat intake.

4.       With the increase in number of heart patients, a corresponding increase in prostate cancer patients is also seen in the society.