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Dr KK Aggarwal

From the Desk of Editor in Chief
Padma Shri and Dr B C Roy National Awardee

Dr KK Aggarwal
President, Heart Care Foundation of India; Sr Consultant Physician, Cardiologist and Dean Medical Education Moolchand Medcity; Member Delhi Medical Council; Chairman (Delhi Chapter) International Medical Sciences Academy; Hony Director IMA AKN Sinha Institute (08–09); Hony Finance Secretary National IMA (07–08); Chairman IMA Academy of Medical Specialties (06–07); President Delhi Medical Association (05–06), President IMA New Delhi Branch (94–95, 02–04); Editor in Chief IJCP Group of Publications & Hony. Visiting Professor (Clinical Research) DIPSAR


Dear Colleague

25th April, 2010 Sunday

Should clopidogrel be reloaded for PCI in patients taking chronic therapy?

Yes, also reload with 80 mg atorvastatin.

There was no overall benefit of reloading clopidogrel prior to PCI in patients already receiving chronic clopidogrel in the ARMYDA–4 RELOAD study, although patients with acute coronary syndrome (ACS) did appear to do better with the extra loading dose.1 The study is published online on April 2, 2010 in the European Heart Journal.

Unstable patients benefit from clopidogrel reloading. They have angry plaque and higher platelet activity, so another clopidogrel loading dose is beneficial. There is no excess bleeding risk, there is no harm to this approach.

The ARMYDA–4 RELOAD study involved 503 patients already taking chronic clopidogrel who required PCI. They were randomized to a 600–mg clopidogrel loading dose 4–8 hours before PCI or placebo. In the overall population, this was slightly reduced in the loading–dose group but not significantly so. But those patients with ACS (about 40% of the trial population) did show a better outcome when given the additional loading dose. There was no excess bleeding in the reload arm (6% in both groups).

The ARMYDA–4 RELOAD results were not dissimilar to those of the statin trial, ARMYDA–RECAPTURE, in which the rate of major adverse cardiac events was significantly lower among patients reloaded with atorvastatin before PCI. In that study, there was also more benefit of additional atorvastatin in the unstable patients.

In an accompanying editorial2, Drs Steffen Massberg and Adnan Kastrati (Deutsches Herzzentrum, Munich, Germany) suggest that reloading may be appropriate for all patients, not just the unstable ones as it did show some benefit though not significant and it caused no harm.

Message: In all patients with angina going for PTCA, give 80 mg atorvastatin and 600 mg clopidogrel loading 4 hours before the procedure.


  1. Di Sciascio G, Patti G, Pasceri V, et al. Clopidogrel reloading in patients undergoing percutaneous coronary intervention on chronic clopidogrel therapy: results of the ARMYDA–4 RELOAD (Antiplatelet Therapy for Reduction of Myocardial Damage During Angioplasty) randomized trial. Eur Heart J 2010; DOI:10.1093/ eurheartj/ ehq081. Available at: http://eurheartj.oxfordjournals.org. Abstract.

  2. Massberg S, Kastrati A. Is it naive to load only clopidogrel-naive patients prior to PCI? Eur Heart J 2010; DOI:10.1093/ eurheartj/ ehq082. Available at: http://eurheartj.oxfordjournals.org. Abstract.

Dr KK Aggarwal
Padma Shri Awardee and Chief Editor

Photo feature

Workshop organized by DMA on Tobacco-Free Delhi on 23rd April 2010. In the picture are: Dr Narendar Saini President DMA; Padma Shri and Dr BC Roy Awardee Dr KK Aggarwal; Mr Gautam Mana (Delhi Legal Service); Dr GM Singh, Dr AK Israni (Jt Secretary DMA); Dr Ashok Hansh (Fin. Secretary, DMA)

Dr k k Aggarwal

International Medical Science Academy Update (IMSA): What’s New

A randomized trial found that in patients with normal left ventricular function at baseline who required a pacemaker, right ventricular pacing led to decreased left ventricular function compared with biventricular pacing. (N Engl J Med 2009;361:2123.)

News and Views

What’s good for the heart may be good for the brain

A diet rich in fruits and vegetables as well as omega–3 fatty acids may reduce the risk of developing Alzheimer’s disease. Analysis of data from more than 2,000 dementia–free adults ages 65 and older revealed that persons who consumed a Mediterranean–type diet regularly were 38% less likely to develop Alzheimer’s disease over about a four–year follow–up (HR 0.62, 95% CI 0.43 to 0.89).

The study by Dr Nikolaos Scarmeas, of Columbia University in New York City is published online in Archives of Neurology. The dietary pattern is characterized by eating more salad dressing, nuts, tomatoes, fish, poultry, cruciferous vegetables, fruits, and dark and green leafy vegetables and lesser quantities of red meat, organ meat, butter, and high–fat dairy products.

Underage drinking linked to breast disease risk

Data from almost 7,000 young women revealed a 50% increased risk of biopsy–confirmed benign breast disease with every additional drink a girl typically consumed per day at age 15 to 22 (95% confidence interval 19% to 90%). Those who drank almost every day were at 5.5–fold risk (95% CI 1.23 to 24.53) compared with those who drank less than once a week or never drank, Catherine S. Berkey, of Harvard’s Channing Laboratory in Boston, and colleagues reported online in Pediatrics.

Glucocorticoids and atrial arrhythmia

A population–based study has found that glucocorticoid use is associated with a doubling of risk of atrial fibrillation and flutter, particularly in new users. The increased risk was unrelated to the presence of underlying pulmonary or cardiovascular disease.

Mnemonic of the Day (Dr Prachi Garg)

Peripheral neuropathy – DANG THE PAPIST



Nutrition (B1, B2, B12)

Guillian Barre



Environmental (lead, drugs)






Tumors of nerves

What’s New


The US Food and Drug Administration (FDA) was not able to verify a relationship between the use of stimulant therapy for ADHD and sudden unexpected death (SUD) and found methodological limitations with a retrospective study that reported this association.

  1. Food and Drug Administration Med Watch. Available at:
    www.fda.gov /Safety/ MedWatch/ Safety Information/ Safety Alerts for Human Medical Produc ts /ucm175843.htm. (Accessed September 29, 2009).

  2. FDA Public Health Alert: Potential medication errors with Tamiflu for oral suspension. Available at: www.fda.gov /Drugs/ DrugSafety /Information by Drug Class /ucm183649.htm. (Accessed on September 28, 2009).

Quote of the day

"To understand the heart and mind of a person, look not at what he has already achieved, but at what he aspires to."
Kahlil Gibran

Diabetes Fact

Osmolality= Na + K × 2 + RBS ( BS/18) + BUN ( 14/2.8). Normal osmolality, 280–300 (dependent on NA). Low BP with hihgh osmolality give normal saline but if normal BP treat with N/2 saline.

Question of the Day

How do you deal with Foreign body in Nose?

The aim is to first remove the foreign body.

  • Lift the tip of the nose with your thumb (no speculum) to visualize the foreign body; if it is not seen, then an X–ray or nasal endoscopic examination is required.

  • After seeing the foreign body, a Vectis or Eustachian catheter (instruments) is taken and carefully passed beyond it.

  • Once the foreign body is in firm contact with the instrument, it is gradually withdrawn with the foreign body.

  • During the procedure the child is to be held firmly in the lap of the parent or nurse.

  • In case of pain/swelling, analgesic – anti-inflammatory medications are required.

  • If bleeding occurs, the nostrils are pinched between the thumb and middle finger for a period of 5 minutes. Rarely does bleeding persists later, if occurs then it is controlled by packing the nose with gelfoam, which is hemostatic, self absorbable and an inert material.

Public Forum (Press Release for use by the newspapers)

Write legibly or shift to electronic records

Speaking at the IMA New Delhi Branch Annual Meet and a seminar–cum–workshop on ‘Lifestyle Disorders’, Padma Shri and Dr B C Roy National Awardee, Dr K K Aggarwal said that over one lakh people die in US alone because of preventable medical errors. Most common out of them are related to prescription. Writing legibly, using electronic prescriptions and crosschecking the drugs with the patients can reduce most of these medical errors. Dr Aggarwal further said that a time has come that every practicing doctor should have a nurse practitioner and pharmacist practitioner attached to his or her practice so that a patient is given proper counseling both in terms of diet and drugs.

Dr Girish Tyagi, Registrar, Delhi Medical Council, said that it is mandatory for every doctor practicing in the city of Delhi to get registered with Delhi Medical Council to practice.

Dr Mohan Bhargava, Senior Cardiologist, Max Hospital, said that today with the advent of latest techniques, it is possible to place stents in most patients with heart disease not responding to medical treatment.

Dr Kumud Mohan Roy, Vascular Surgeon, Max Hospital, said that all people above the age of 50 years should be screened while undergoing echocardigraphy or ultrasound for presence of abnormal dilatation of abdominal aorta called aneurysm. It is noteworthy to note that Pandit Nehru died of a chest aneurysm. It is now possible to correct aneurysms and detect them in time.

Dr Ramneek Mahajan, Orthopedic Surgeon, said that osteoporosis is no more a disease of women. Young men in India too are getting osteoporosis because of reduced exposure to sunlight.

Dr Narender Saini, President; Dr Vinod Khetrapal, President Elect; Dr Ashwini Dalmia, Secretary, Delhi Medical Association in a joint statement said that in order to improve doctor patient relationship, every doctor should give more time to communicate with the patients and their relations.

Dr Sanjay Sood took over as President IMA New Delhi Branch from the outgoing President, Dr PPS Sethi.

Public Forum (Press Release)

Live with nature: Ajay Maken

Inaugurating the daylong, 15th Environment Protection and Ethical Consciousness Conference, Shri Ajay Maken, Minister of State for Home Affairs, Govt. of India, said that one should live in accordance with the laws of nature. He said that nature is mix of five elements – air, space, fire, water and earth, and disturbance in any one of them can lead to natural disasters. Also, he said that internal environment within the human body also collectively reflects the changes in the external environment. A society where in people are calm and live a satvik life, suffers less from environmental disasters.

The Guest of Honour of the event, Dr. Yoganand Shastri, Speaker, Delhi Vidhan Sabha said that to live a normal stress free life, one should concentrate on vegetarianism. In today’s world, where one is living a sedentary life, living a non–vegetarian life can lead to lifestyle disorders including heart attack and paralysis.

In his message Mr Pradeep Jain, Minister of State for Rural Development, Govt. of India, said that every dharma talks about environmental protection.

In her message, Kumari Shaileja said that it is important to make the city full of plants and trees to check the already rapidly warming earth. Acharya Dr. Sadhvi Sadhna Ji Maharaj, moderating a session on Ethical Consciousness said that one should do pranayama, meditation and learn relaxation techniques to clear the mind on a daily basis.

Dr KK Aggarwal, Padma Shri and Dr BC Roy National Awardee, said that stress is the reaction of the body and the mind to the interpretation of a known situation. The best way to manage stress is to change the interpretation or live a yogic lifestyle so that stress does not bother one.

Various religious leaders who spoke on the occasion were Acharya Dr Sadhna Ji Maharaj, Acharya Manmuni Ji Maharaj, Mahamandaleshwar Swami Pragyanand Ji Saraswati, Mahamandaleshwar Acharya Sarvanand Ji Saraswati, Shri L.J. Lama, Swami Dayanand Saraswati, Mr I I Malekar, Mahant Kailashnath, Mufti Muqarram Ahmad, Shri Mahamantradas Ji Hare Krishna, Satnam Singh Uppal ji, Dr A K Merchant ji.

eMedinewS Try this it Works

Stretch to quell the cramps

Over–the–counter quinine may alleviate these symptoms, but it has many side effects, including tinnitus.
Leg stretching exercises before bedtime alleviate painful legs cramps as effectively or more effectively than quinine––with no untoward side effects.

Dr Good Dr Bad

Situation: An elderly man was found to have low testosterone levels.

Dr Bad: Take testosterone injections.

Dr Good: First get diabetes ruled out.

Lesson: Low free and bioavailable testosterone concentrations are associated with diabetes, independent of adiposity suggesting that low androgen levels may be a risk factor for diabetes in men. (Diabetes Care 2007;30(2):234–8.)

Make Sure

Situation: A patient was brought to the ICU in cardiogenic shock.

Reaction: Oh my God! Why didn’t you take him for emergency angiography and subsequent PTCA.

Make Sure to perform an emergency diagnostic angiography and mechanical revascularization with PTCA in patients of cardiogenic shock. Results of NRMI–2, an ongoing trial suggest that this intervention is much better than thrombolytic therapy in such patients.


Laughter the best medicine

IMANDB Joke of the day

Patient to optometrist: I'm very worried about the outcome of this operation, doctor. What are the chances?

Optometrist to patient: Don’t worry, you won’t be able to see the difference.

Formulae in Critical Care

Calculation of unsaturated binding capacity (UIBC)

Formula: UIBC = TIBC – Serum iron

Normal value: 150–300 mg/dl.

Serum iron

Males: 60–160 mg/dl.

Females: 40–140 mg/dl.

Milestones in Diabetes

1914 – Frederick Madison Allen introduced his Starvation Diet for diabetes patients. Patients were starved until the sugar disappeared from their urine and then put on a diet of about 1,000 calories per day. They weren’t allowed to ingest fat for fear of producing acidosis. Diabetic coma was avoided, but patients largely were unfit for ordinary life activities. In the absence of anything better, however, the Starvation Diet was widely used as a treatment.

Lab Test (Dr Arpan Gandhi and Dr Navin Dang)

Prothrombin time (PT)

This test may be ordered in a person with hepatitis or suspected hepatitis. Proteins used in the formation of a blood clot (coagulation factors) are mostly produced by the liver, and prolonged PT may indicate the severity of liver damage.

List of Approved drug from 1.01.2009 to 31.10.2009

Drug Name


Approval Date

Desvenlafaxine (as Succinate) ER Tablets 50mg/100mg

For the treatment of major depressive disorder (MDD)


(Advertorial section)



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Contact: drkk@ijcp.com or emedinews@gmail.com

eMedinewS–PadmaCon 2010 

Will be organized at Maulana Azad Medical College, New Delhi on July 4, 2010, Sunday to commemorate Doctors’ Day. The speakers, chairpersons and panelists will be doctors from NCR, who have been past and present Padma awardees.

eMedinewS–revisiting 2010

The second eMedinewS–revisiting 2010 conference will be held at Maulana Azad Medical College, New Delhi on January 2, 2011. The event will have a day–long CME, Doctor of the Year awards, cultural hungama and live webcast. Suggestions are invited.

IMANDB Annual Day Meet : Scientific feast, in association with Board of Medical Education Moolchand Medcity, eMedinewS and IMSA (Delhi); No fee. SMS 9811090206 for registration

Date: Today 

Venue: Moolchand Medcity Auditorium, New Delhi

Scientific Program: 4–7 PM

4.00 PM–5.15 PM: Fatty Liver, Workshop for GPs: Padma Shri and Dr B C Roy Awardee Dr K K Aggarwal, followed by a presentation by Dr Milind Patil

5.15 PM–6.15 PM:

Cardiac Update (Max Hospital)

a. Dr JJ Sood Oration: Cardiac Interventions: Dr Mohan Bhargava

b. Dr K L Chopra Oration: Endovascular Approach to Aortic Aneurysm: Dr Kumud Mohan Rai (Max Hospital)

6.15 PM – 6.45 PM

Dr Sheila Mehra Oration: Management of osteoporosis: Dr Ramneek Mahajan

6.45 PM –7.15PM

Medical Ethics: A panel discussion: Dr Ashok Seth, Dr Sudesh Ratan, Dr Rajiv Khosla, Dr KK Aggarwal, Dr Girish Tyagi, Dr Sanjiv Malik, Dr H K Chopra, Dr Madhu Handa, Dr Kumud Mohan Rai, Dr Archna Virmani

Annual Day Function: 7.15–8.00 PM

Eminent Guests: Padma Shri and Dr B C Roy Awardee Dr KK Aggarwal, Dr Narender Saini (President DMA), Dr Vinod Khetrapal (President-elect DMA), Dr Girish Tyagi (Registrar DMC), Dr Ashwini Dalmiya (Secretary DMA), Dr Naresh Chawla (Immediate Past President DMA)

Dinner: 8.00 PM onwards...

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Readers Responses

  1. The Independent: By: Presswatch. Computers beat doctors at diagnosing child illnesses Researchers have found that a computer has proved more accurate in diagnosing severe fever in children than doctors using their clinical judgement. Specialists in Australia who developed the computerised diagnostic model say it may improve early treatment in children with conditions such as pneumonia and meningitis who need an urgent administration of antibiotics. Researchers at the Westmead Children’s Hospital in Sydney, Australia, have developed a 28–item checklist which, when used with a statistical modelling technique, successfully distinguishes between ordinary viral illnesses and bacterial infections. (Dr Vivek Chhabra)

  2. Respected Sir, Namaskar: I acknowledge you for keeping us updated with the recent advances and laughter the best medicine. I need to add with my experiences that Statins do have a role in enhanced total bilirubin values also, apart from the liver enzymes. As I have seen commonly in most of my patients, people who are on statins show elevated total bilirubin levels. I know that the values in every individual differs: Dr Mudit Agarwal eMedinewS Responds: Yes, many others have observed the same.