Say no to smoking say yes to healthy living

Medanta The Medicity organised a Cessation of Smoking Workshop on World No Tobacco Day on May 31 to spread awareness about the harmful impact of smoking on one's health and well-being.

As part of the Workshop, a smoking clinic and a no smoking programme for the general public. The head of the departments of cardiology and oncology explained the problems associated with smoking. There was a panel discussion followed by a question and answer session with experts. In the smoking clinic, smokers were advised on how and why they should quit smoking and prepare strategies to do so. A smoker is prone to lung cancer, but also at the risk of falling prey to the tongue, food pipe, mouth and pancreatic cancer, among many other deadly forms of diseases.

A passive smoker is vulnerable and chances of him having cancer increases by 20%.

The doctors who organised the workshop said that there are medicines and counselling are available to help a smoker quit this bad habit.

Those who attended this workshop stated that they have become wary of smoking and would like to quit it right away.

"Nicotine in cigarettes makes a smoker yearn. There are doctors, counsellors, psychiatrist and medicines to help a smoker find a replacement fit and quit," a doctor said.

Avoid consumption of tobacco in any form as it is injurious to health; it leads to around 40% of cancer across the world.

Many NGOs also participated in the workshop.

The best way to tackle the the tsunami of cardiac disorders

“India is facing an epidemic of lifestyle diseases like hypertension, diabetes, dyslipidemia, which culminate into strokes, heart attacks and peripheral vascular disease, especially with relevance to the young population,” Dr. RR Kasliwal tells Dr. Rishi Jain in an interview. Prevention of these risk factors eventually boils down to lifestyle modification – quitting tobacco, living stress-free, eating right, sleeping right and reverting to the eastern way of living with yoga and exercise. With a special focus on value of proper sleep and rest, Dr. Kasliwal says, “If your body is tired and the heart needs rest, it has to be given that rest. Sleep disorders can cause hypertension, it can precipitate arrhythmias or even heart failure.” Smoking, taking stress, not taking time out to eat, relax or exercise is resulting in increasing incidence of acute MI, devastating families and contributing to the economic burden of India. “In JACC, Journal of the American College of Cardiology, there is an article saying, curing atherosclerosis should be the new paradox. India has to pick up preclinical atherosclerosis and cure it.” “We neither have the monetary nor the capital resources to treat every heart attack with a PCI or CABG. We will just have to prevent, prevent and prevent.”

Health Awareness Talk & Car Free Day Programme

There are studies that mention that air and even noise pollution is related to several health concerns. With the amount of pollution and unhealthy people in Gurgaon, cycling should be made mandatory for all residents", said Dr RR Kasliwal, chairman, the division of clinical and preventive cardiology, Medanta- The Medicity.

He added that cycling at least thrice a week can prevent many cardiovascular diseases. Check Full News http://goo.gl/6pA3SR

2_4 Vascular Stiffness: Most Powerful predictor of CAD by Dr Ravi R Kasliwal @ wccpci 2014

Hypertension Encyclopedia – 1 Seminar Attended By Dr Ravi R Kasliwal (Session 3)

Question from Audience: Sir, from the morning, we have heard lectures on the basics of hypertension and also the panelist have talked about it, but nobody has talked especially about stress and it is effect on hypertension or coronary artery disease and the interaction. Is it that we talk about it only when we have episodes or events in cardiologist or physicians who have these cardiovascular events. I mean that is one issue. The second thing is, Dr. Hiremath very rightly said in the secondary prevention beta-blockers with ACE inhibitors or ARBs should be the drugs of choice. If that is so, suppose we get a big amount of patients in the age group of around 30 with a very strong family history of coronary artery disease who were only hypertensive and dyslipidemic.

Dr. Siddharth Shah: In Mumbai, every one has got stress, but acute stress does cause problems and that acute stress has to be managed, it does cause problem.
I think Dr. Kasliwal is known for his lifestyle modification, what do you think about the stress and hypertension.

Dr. R. R. Kasliwal: Absolutely correct, what you said acute stress can to the extent cause dissection of aorta because of huge rises in pressure, but truly in the environment that we all are, whether it is Mumbai or Delhi or wherever, there is huge chronic stress and that actually adds to the other co-existing risk factors of the psychosocial stress with cigarette smoking or obesity or metabolic syndrome. I think that is what we are talking about and why no body talked about individually because it was clumped as lifestyle measures, so I think that chronic stress has definitely contributed towards increase of blood pressure and its aftermath.

Dr. Satyavan Sharma: Let me define your question, the question which you asked. There are two aspects of stress; one is the role of stress in causation of chronic diseases. Right, I do not think any one of us was allowed to speak on that, so nobody touched it. What you are trying to ask is the role of stress as a trigger in some short of acute coronary syndromes or in short of some acute situations. Now, these are completely two different things. Stress plays a role in triggering many acute coronary syndromes, sudden cardiac death, acute hypertensive episodes, but that is different than the role of stress and causation of hypertension, causation of diabetes, and causation of coronary artery disease, so these are two different areas.

Dr. C. Venkata S. Ram: I think we talked about heart rate, the role of ivabradine and outcomes.

Dr. Ravi Kasliwal: If there is hypertension and increased heart rate, there is no role of ivabradine, beta-blocker should be given, nebivolol, bisoprolol what ever your choice is.

Dr. M.S. Hiremath: Suppose it is hypertension with bronchial asthma and tachycardia?

Dr. Ravi Kasliwal: If it is hypertension with bronchial asthma, still bisoprolol is a better choice than to give ivabradine.

Dr. C. Venkata S. Ram: There are no comparative studies between chlorthalidone and indapamide, but there are comparable outcomes studies with the drugs. With indapamide, I think somebody has mentioned the HYVET, PROGRESS, EUROPA. With chlorthalidone SHEP, SHEP extension, so they are separate, nobody has compared chlorthalidone with indapamide. Anybody wants to differ?

Dr Kunal Kothari: One comment, I would like to know what happens say continued use of diuretic particularly in elderly has been advocated. Is there are any role of giving twice a week or once a week or twice a week giving diuretic and taking care.

Dr. C. Venkata S. Ram: Let me tell you one comment I have and then we will go to the goal pulse pressure, what happens with the diuretics is the volume reduction that happens, it only happens initially. With long-term diuretic therapy, the volume comes back to baseline, so the continued use of a diuretic does not mean you cause continued volume depletion because if you cause continued volume depletion, there is a consequence, known as death, people die with continued volume depletion, so what happens is volume goes down, but it comes back again, so other mechanism that is coming into play. Now, Ravi, are there any guidelines for goal pulse pressure.

Dr. R. R. Kasliwal: I do not think so. The only thing they have eluded to is in the European Society Guidelines, but not to that extent, I think systolic and diastolic.

Dr. C. Venkata S. Ram: I will ask one question, where you can also comment, for Dr. Shah. Hypotension, I do not know how one defines this is hypotension. Do you want to treat it with sodium intake.

Dr. Siddharth Shah: First of all comment is that hypotension is not a known entity. It has been conjured up to and I do not think hypotension is a relative term and if it is due to drug, then it has to be treated; otherwise, hypotension per se does not exist.

Dr. C. Venkata S. Ram: Sodium treatment for hypotension is only for people who have adrenal insufficiency. People who have adrenal insufficiency, if you do not give sodium supplements, they are going to very, very ill.

Dr. M.S. Hiremath: Incidentally, there is something like tablet Mephentine, which is available in the market.

Dr A N Rai: I think one should treat the underlying cause of hypotension, not the sodium supplementation.

Dr. N.R. Rau: I think best way hypotension be seen in clinical practice, now that summer is coming, acute gastroenteritis, then we start with treatment.

Dr A N Rai: Treat the underlying cause.

Dr. C. Venkata S. Ram: Multiple medicines, the blood pressure is not controlled, the next option? Let us presume the patient is compliant, let us not question patient's compliance, because then there is no discussion.

Dr A N Rai: Sympathic renal denervation is the one for resistant hypertension.

Dr. C. Venkata S. Ram: And proper use of aldosterone antagonist.

Dr. Santanu Guha: It is mentioned that if the patient has not received the aldosterone antagonist whether he has resistant hypertension it is a question.

Dr. M.S. Hiremath: I think we should go further to eplerenone also.

Dr. C. Venkata S. Ram: In fact, some other renal denervation studies have been criticized that the patients were inducted into RDN trial without sufficient exposure to spironolactone. Dr. Hiremath mentioned the renal denervation does reduce heart rate, but Dr. Kasliwal will be pleased to know that it also has been shown to decrease pulse wave velocity, so multiple things happen.

Dr. M.S. Hiremath: I think sleep apnea, which correlates so much with hypertension that also is expected to benefit with RDN therapy.

Dr. C. Venkata S. Ram: What is this, nobody asking from the right side, this is like Lok Sabha or something, only one section is voiceless, what happened right side. We want some balance.

Hypertension Encyclopedia – 1 Seminar Attended By Dr Ravi R Kasliwal (Session 2)

Question from Audience: I just like to emphasise one thing regarding all these debate, acute or chronic situation, whenever using ACE inhibitor, you have to judge the circulating volume, filling pressure properly. If filling pressure is low, you are not going to use and how to judge it clinically is by postural fall, that is one thing, and if you are not sure, you can use your echocardiography, many of you are doing and filling pressure, and then if you find it is low, then do not use ACE inhibitor, it would be dangerous.

Dr. C. Venkata S. Ram: There is question, are we doing a lot of injustice to beta-blocker, I presume for hypertension. We can start quickly from here, brief comments, if we are taking criticism on beta-blockers too much or is there a middle ground.

Dr. R. R. Kasliwal: There is a middle ground, certainly.

Dr A N Rai: I think we are biased about the beta-blocker. Beta-blocker, no doubt we are using in compelling indication, but in certain other conditions we can use if there is no acute contraindication. It can be used.

Dr Kunal Kothari: If there is no contraindication and if it is a young person with a lot of tachycardia and with the mild hypertension, we might use a beta-blocker and otherwise not.

Dr. N.R. Rau: I agree with them, it becomes the drug of first choice in hypertension with coronary artery disease. It recedes to the background if there is a hypertension with diabetes.

Dr. M.S. Hiremath: I think they are all not the same, I mean we have to make a difference between atenolol one side and something like bisoprolol on the other side, like your question with some degree of bronchospasm, bisoprolol is still okay. I mean unless it's overt asthma. I guess we have enough data for bisoprolol to be continued under this setting. Correct, so nebivolol/bisoprolol what we can call as a new generation beta-blockers, I think they are quite helpful.

Dr A N Rai: Most of the studies are with atenolol that is why all beta-blocker, but all beta-blockers are not the same.

Dr. M.S. Hiremath: But you know having used atenolol for so many years, I think the drop in blood pressure, which I think is the key, which is very strong with atenolol. You cannot go away from the fact that atenolol can give you the drop, which metoprolol cannot give in so many cases.

Dr A N Rai: Especially for a stroke, I think beta-blockers should be the second choice.

Dr. C. Venkata S. Ram: As Dr. Hiremath mentioned, I can tell you JNC is likely to make a distinction between older beta-blockers exemplified by atenolol and they will comment on not really newer, but nebivolol and carvedilol because of their metabolic effects and because effects on glucose insulin resistance and also pulse wave velocity, there a lot of advantages to it and there is a comment here, control of heart rate, there is a lot of data looking at a epidemiologically the heart rate and the prognosis, but generally you do not treat the heart rate, usually not, you treat the underlying cause, so it is correct that studies have shown that inverse correlation between heart rate and survival, but I think heart rate is like a sedimentation rate, it is marker of something.

Dr. Siddharth Shah: Yes, the latest guideline on hypertension has already commented on this that atenolol is going down worldwide as far the usage is concerned and newer beta-blockers are recommended for control of hypertension. Atenolol has come down in the use as a recommendation for control of blood pressure.

Dr. M.S. Hiremath: I think going back on the issue of heart rate, I think it tells me a lot of things, you know if you have somebody in front of you who has high blood pressure, which is in the moderate range and heart rate of 100 or 90 on one side and same kind of pressure with heart rate of 60 in front of you, I think the drug choice is clearly different and beta-blockers would certainly be very, very crucial. The RDN therapy, which we use for uncontrolled blood pressure, where you need more than 3 medications that has also shown to bring down the heart rate, so heart rate to me is something like excessive sympathetic activity, MSNA (muscle sympathetic nerve activity), and this has to be controlled and I guess the beta-blocker would be a very strong option.

Dr. Satyavan Sharma: The question is, is it necessary to control severe isolated hypertension vigorously? Practically not possible without side effects. Let me answer this way, I do not think we should control any patient of blood pressure vigorously. We should control the patient of hypertension meticulously with a systematic approach. It is the important to control the patient, where there is isolated systolic hypertension and if the hypertension is severe. This is also true that sometime side effects do develop and as I was mentioning and as Dr. Hiremath also pointed out, we have to use most of the times even in systolic hypertension a combination of drugs, so maybe by using judicious combinations, trying to avoid the side effects, we control the blood pressure, not that our aim should be to bring down the blood pressure vigorously on day one, but our aim should be as possible in a due course of time, in a safe time, minimizing the side effect to control the blood pressure.

Dr. M.S. Hiremath: Dr. Satyavan what is your treatment plan, which is your first drug, which is your next when you have isolated systolic hypertension.

Dr. Satyavan Sharma: I did mention in my presentation that one can begin depending on the overall profile of the person.

Dr. M.S. Hiremath: I give you 180/80 is the pressure and no other disease.

Dr. Satyavan Sharma: Actually, most of the time the choice will be a calcium channel blocker and next can be addition.

Dr. M.S. Hiremath: It is not easy to get isolated systolic hypertension down, so many times we struggle, so amlodipine is the first drug, then we go for chlorthalidone.

Dr. Satyavan Sharma: ACE inhibitor or ARB.

Dr. M.S. Hiremath: Not the diuretic?

Dr. Satyavan Sharma: You can go to diuretic also.

Dr. M.S. Hiremath: It is so easy I mean?

Dr. Satyavan Sharma: Yeah, you can go to diuretic.

Dr. M.S. Hiremath: I thought my second drug would be a chlorthalidone kind of diuretic and then I go to ARB. ARB again would probably be more effective in elderly compared to ACE inhibitors.

Dr. Satyavan Sharma: Actually, I have seen our Indian patients, particularly elderly patients, particularly in Mumbai heat, and I am sure Pune weather is almost the same, the diuretics are not well tolerated by our Indian patients. In a hospital where we have a lot of cross referrals, lot of patients get problems with diuretics.

Dr. Siddharth Shah: Especially when there is dehydration, you will have to very careful with ACE inhibitors and ARBs, because that can create problems.

Dr. B R Bansode: Sometimes I am reading the literature after literature and volumes of literature on hypertension, what has happened today? If you see 4 or 5 decade previously, half reserpine was controlling everything about the hypertension. Today, whether the pathology has gone wrong because of the lifestyle or the disease has gone differently, why we are getting 4-5 drugs to control the hypertension, still today the blood pressure is uncontrolled. Was it the same true 50 years or 60 years back, where we are wrong?

Dr. Satyavan Sharma: Actually, let me answer part of the question. Dr. Bansode, I do not think during those days the blood pressure used to be ever controlled. I was a resident when you know we have used lot of reserpine. I and Ravi used to be batchmates in Jaipur. We have used lot of reserpine and the amount of side effects, which reserpine, blood pressure hardly used to be controlled. The patient used to move with 180, 190 on reserpine and then Adolphine came, so I do not think blood pressure was well controlled those days, may be our aims to control and then we are now not only looking at blood pressure, we are looking at organ protection with that, so our aims have certainly changed that is why we are trying to achieve better control.

Dr. N.R. Rau: Sir, may I add one thing, even the definition of hypertension 160/95 when I was in PG.

Dr. C. Venkata S. Ram: Let us also in all fairness, there are also questions written, so we will manage floor versus written questions. I will just comment on it unless somebody differs. Beta-blockers and central aortic pressure, I think the older beta-blocker CAFÉ trial Dr. Kasliwal shown does not lower the central aortic blood pressure. There is one non-outcome trial with nebivolol showing that it lowers the central aortic pressure. Anybody differs from this.

To Be Continued............. 

Hypertension Encyclopedia – 1 Seminar Attended By Dr Ravi R Kasliwal (Session 1)

Hypertension Encyclopedia – 1 Seminar(Organized By Hypertention Society of India)

Attended By: Dr Ravi R Kasliwal | Dr. C. Venkata S. Ram | Dr. Siddharth Shah | Dr. N.R. Rau | Dr. M.S. Hiremath | Dr. Kunal Kothari | Dr. A N Rai | Dr. Santanu Guha | Dr. C. Venkata S. Ram

The whole idea of this interaction that have a robust exchange of comments, by comments that don’t mean agreements, you can always say what you feel is appropriate for the subject always considered that these kind of interactive sessions probably are the most crucial foundation of anything, more than the structured lectures.

Dr. R. R. Kasliwal: I was just saying that I agree, what I tell my patients is do a couple of things, one is APC, you know avoid achar, papad and chutney. It is easy to remember APC, but then there is an important thing that many of the patients come from regions where temperatures go up to 45 degrees and they are exposed to the sun, they are exposed to the summer, so do not be so categorical in saying, shut off all salt. It will not work. The patient will fall, so generally in these people I say don’t sprinkle salt, do not take it excessively all these salty things that we have. The other thing that we have to see is that in many families in Rajasthan particularly they still add salt to the roti, that pointedly you should tell, that look this should be without salt. So, management of hypertension on a long-term basis is very practical, very, very practical and you have to go down to that level.

Question from Audience: Normally, daily requirement of salt is about 10 to 12 gram and the normal diet contains around 5 to 6 gram of the salt, so requirement is not more than 4 gram, so daily requirements of extra salt is 4 gram, that is sufficient. So if you take more than 4 gram extra salt and that will lead to the hypertensive patient and that is difficult to control.

Dr Sandhya Kamath: One last comment on salt in pregnancy, already a pregnant woman tends to develop postural drop in blood pressure and if you do not give her salt or ask her to take less salt or a salt-free diet that will further aggravate the situation.

Dr. C. Venkata S. Ram: Any comments or questions for the panelist here from any section, please raise your hand.

Dr. Siddharth Shah: Can we go beyond salt.

Dr. M.S. Hiremath: Imagine somebody who had blood pressure of 150 and he is on antihypertensive, whichever he choose, comes with LVEF, has some kind of LV dysfunction, ACS kind of scenario, blood pressure comes to about 100, may be 90. So, we have scene where we have LV dysfunction and the patient is previously hypertensive and we have to come down on his antihypertensives, so in long-term we are trying to push something like ramipril, because that is very a strong indication, so how do we keep adjusting between ramipril, something like carvedilol or metoprolol and diuretic under this setting.

Dr. Satyavan Sharma: I think, how we go in this patient is if the patient is at that particular time when the patient has come with ACS and patient is having LV dysfunction, if there is congestion, certainly we use diuretic at that time, let the congestion go away. If the patient is having lot of tachycardia, which many of them have, we start adding carvedilol and we get the carvedilol up in these patients to the tolerable dose and on a chronic basis then we have judicious balance between ACE and beta-blocker and both are going to be important for our patients and we try to get them you know as good dose of both as possible.

Dr Kunal Kothari: But the question is whether you can give ARB or ACE inhibitor in such situation or not.

Dr. M.S. Hiremath: I agree that they have to be given, the issue is how to build it up because only systolic pressure is very, very borderline, something like 90.

Dr Kunal Kothari: The only guidelines will come in due course of time with looking at the renal function and renal perfusion and that will determine what amount of dose and you have to give that while keeping a watch on this.

Dr. Satyavan Sharma: The patients in ICCU, when we treat the ACS patients with LV dysfunction even when their blood pressures are 100 or 110, we start with starting a small dose of ACE inhibitor because there was a time when we used to give them captopril and start with the small dose of captopril.

Dr. N.R. Rau: Sir, sometimes these patients of LVF, we may be able to give ACE inhibitors, but to start carvedilol, some of them have got severe bronchospasm?

Dr. Satyavan Sharma: If a person is having a bronchospasm, certainly you know we will have to avoid.

Dr. N.R. Rau: No, not bronchial asthma, bronchospasm coming along with LVF, non asthmatic.

Dr. R. R. Kasliwal: In a situation of acute coronary syndrome when the pressures are 90, there is tachycardia and may be there is a situation to put the patient on intraaortic balloon pump rather than to think of ACE inhibitors or because till the patient is euvolemic, ACE inhibitors will bring the patient down again. So, I think that in an acute situation, a chronic therapy is not advised.

Dr. Satyavan Sharma: I do not want to raise a debate here, but I think we do it everyday.

Dr. R. R. Kasliwal: Do it everyday, but if the pressures are low.

Dr. Satyavan Sharma: That every cardiologist knows.

Dr. Kunal Kothari: Renal profusion is alright and urine output is about 30 to 40 mL/hour, then there is no need to worry about it.

Dr. A N Rai: Intraaortic balloon pump is not available everywhere. The majority of hypertensives will not reach such place.

Dr. R. R. Kasliwal: We are not talking about hypertension here, we are about acute patients, a patient who has got acute coronary syndrome, LV dysfunction.

Dr. M.S. Hiremath: I am sorry, I started the whole issue. All that I meant was the patient was hypertensive, now he is leaving the hospital with a blood pressure of 90-100. He has finished the acute phase and he is leaving the hospital with a pressure.

Dr A N Rai: I think all the three combination; diuretics, beta-blocker, ACE inhibitor or ARB this should be used once the patient is leaving the hospital especially.

Dr. Santanu Guha: The other issue is even aldosterone antagonist is very much indicated and beneficial in this scenario.

To Be Continued.............