Wednesday, February 5, 2014

Ten tips on how to recognize symptoms of heart attack

  1. A heart attack most often causes chest pain.
  2. The pain is located in the center of the chest, is intense in its severity and most victims describe it as the worst pain they've ever felt in their lives.

  3. The character of the pain is very difficult to describe accurately. Chest pain in a heart attack has been variously described as being crushing, tearing, binding or feeling like a heavy weight has been placed on one's chest.

  4. The pain lasts longer than a few minutes. In angina pectoris, a milder version of a block to the heart's blood supply, the pain typically stops within five minutes.

  5. The chest pain in a heart attack may spread or radiate to the neck, jaw, left arm and sometimes even to the fingertips or back.

  6. During a heart attack, in addition to chest pain, there may be associated nausea with or without vomiting, a sudden bowel movement, profuse sweating and an ashen pallor.

  7. In severe heart attacks, the heart's pumping action may be so badly impeded that the victim loses consciousness.

  8. Due to the decreased pumping capacity of the heart, the patient's pulse feels feeble and thready, and the heart rate is extremely fast.

  9. In rare cases, as in patients who are diabetic, the heart attack may not be very painful, and sometimes can even be entirely painless.

  10. Other disorders that could be confused with a heart attack include acute gallbladder infection, perforation of stomach or intestine, pulmonary embolism and aortic dissection.

  11. Confirmed diagnosis of a heart attack can be made in a hospital, by recording an ECG or by analysing the levels of various enzymes in the blood.

Sunday, February 2, 2014

Ten tips on healthy heart

1. Stop smoking. Quitting smoking is the single most important thing a person can do to live longer. If you are a smoker, you are twice as likely to have a heart attack than a non-smoker. But from the moment you stop smoking, the risk of heart attack starts to reduce.

2. Cut down on salt. Too much salt can cause high blood pressure, which increases the risk of developing coronary heart disease. Avoid foods like crisps, salted nuts, canned and packet soups and sauces, baked beans and canned vegetables, pork pies, pizzas and ready meals.

3. Watch your diet. A healthy diet can help to reduce the risk of developing heart disease, and can also help increase the chances of survival after a heart attack. You should try to have a balanced diet, containing plenty of fresh fruit and vegetables, oily fish, starchy foods such as wholegrain bread, pasta and rice.

4. Monitor your alcohol. Too much alcohol can damage the heart muscle, increase blood pressure and also lead to weight gain. Binge drinking will increase your risk of having a heart attack, so you should aim to limit your intake to one to two units a day.

5. Get active.The heart is a muscle and it needs exercise to keep fit so that it can pump blood efficiently round your body with each heart beat. You should aim for 30 minutes of moderate intensity exercise a day.

6. Manage your weight. Carrying a lot of extra weight as fat can greatly affect your health and increases the risk of life-threatening conditions such as coronary heart disease and diabetes. If you are overweight or obese, start by making small, but healthy changes to what you eat, and try to become more active.

7. Get your blood pressure and cholesterol levels checked . The higher your blood pressure, the shorter your life expectancy. High levels of cholesterol in the blood - produced by the liver from saturated fats - can lead to fatty deposits in your coronary arteries that increase your risk of coronary heart disease, stroke, and diseases that affect the circulation. You can help lower your cholesterol level by exercising and eating high-fibre foods such as porridge, beans, pulses, lentils, nuts, fruits and vegetables.

8. Learn to manage your stress levels. If you find things are getting on top of you, you may fail to eat properly, smoke and drink too much and this may increase your risk of a heart attack.

9. Check your family history . If a close relative is at risk of developing coronary heart disease from smoking, high blood pressure, high cholesterol, lack of physical activity, obesity and diabetes, then you could be at risk too.

10. Make sure you can recognise the early signs of coronary heart disease . Tightness or discomfort in the chest, neck, arm or stomach which comes on when you exert yourself but goes away with rest may be the first sign of angina, which can lead to a heart attack if left untreated.

Saturday, January 18, 2014

Ideal heart healthy numbers

Learn these important numbers to improve your heart-healthy knowledge.

120/80 mmHg -- Blood Pressure
These two numbers represent the pressure in your arteries as your heart pumps (systolic pressure; the upper number) and the pressure between beats, when the heart is at rest (diastolic pressure; the bottom number). High blood pressure, defined as at or above 140/85, greatly increases heart attack risk. Between 120/80 and 140/85 is considered pre-hypertension, which research suggests is more harmful than was previously believed, so aim to keep yours at or below 120/80.

50 mg/dL (women) or 40 mg/dL (men) -- HDL cholesterol
HDL cholesterol is the “good” cholesterol that actually helps protect you from heart disease by helping to remove cholesterol from the blood. Relatively high HDL levels are heart protective.

100 mg/dL -- LDL Cholesterol
LDL cholesterol is the bad cholesterol that contributes to heart disease by clogging the arteries. Although some charts indicate up to 160 mg/dL is acceptable for people with little risk of heart disease, optimal levels are below 100 mg/dL regardless of individual risk. People at very high risk of heart disease, including those with active disease, should aim for an even lower number, 70mg/dL.

200 mg/dL -- Total Cholesterol
This number is somewhat less important than knowing the breakdown between LDL and HDL, because even if your total number appears healthy, if it includes low HDL then you are still at increased risk. Just the same, heart-healthy total cholesterol is below 200 mg/dL.

150 mg/dL -- Triglyderides
Triglycerides are another type of fat. You body makes them when it digests sugars, and evidence suggests that this number might be an even better predictor of heart disease risk than cholesterol. Risks increase above 150 mg/dL, so keep yours below that.

100 mg/dL -- Fasting Glucose
Diabetes greatly increases your risk for coronary heart disease. Do your best to avoid developing it, and if you do, keep it under control, including fasting glucose levels under 100 mg/dL.

7% -- Hemoglobin A1c (Hg A1c)
Hemoglobin A1c levels measure long-term control of blood sugar levels, and are an even better indicator of heart disease risk than fasting glucose. Currently 7% is the accepted safe upper limit.

25 kg/m2 -- Body Mass Index (BMI)
Despite minor flaws (it cannot account for a higher than normal percentage of muscle mass), BMI provides a useful gauge for determining a heart-healthy weight. Keep your BMI just below 25.

35 inches (women) or 40 inches (men) -- Waist Circumference
Studies suggest that people with larger waists are more likely to develop heart disease.

If you don’t know your numbers, see your doctor for a checkup and blood tests. Once you know how your numbers compare to the ideal, formulate a plan to bring any out-of-range numbers back in line.

#Cardiology, #Gurgaon, 

Sunday, January 5, 2014

New CGHS Reimbursement Guidelines BEWARE Your Health is at Risk

Do we always have to be arbitrary in our decision making?  Or, do we feel that all stakeholders in healthcare are defrauding the State? Do we want better healthcare for our citizens? Or, Do we wish to condemn ourselves to inferior/ older devices and substandard care? The Government has issued new reimbursement guidelines for Central Government Health Scheme (CGHS)  beneficiaries for coronary angioplasty which defies logic.
Cardiovascular diseases are the No.1 GLOBAL KILLER (with India being the world capital of diabetes and cardio vascular diseases). Coronary Angioplasty with current generation Drug Eluting Stents in suitable patients has become the standard of care globally. Every patient is important and deserves the best therapy and device to ensure chances for superior outcomes, both in the long and short term. The devices under current use have been subjected to large clinical validation through extensive clinical trials. This ensures a reasonable creditability and optimal results. These trials cost billions of dollars in research. Global regulatory processes demand adequate evidence of superiority in terms of large scale outcome analysis.
There is a perception that the therapy may not always be ethical and appropriate. Most developed nations have formulated their own “appropriateness” criteria and carry out random reviews of procedure to ensure process driven utilisation of resources. Every patient deserves access to optimum world class healthcare, especially in an age where India is striving to become an attractive hub for medical tourism. Science and medicine can only progress if we constantly endeavor to improve our quality of care and patient outcomes. This is possible only in a scenario where we appropriately use the best resources available to us.
Most patients who require complex coronary angioplasty procedure are elderly pensioners with meager resources to spend on expenses of modern medicine. By subscribing to contributory health schemes, they try and insure their future in the twilight years of their lives. By enrolling in such schemes, they feel secure that they could fall back on them at a time of ill health and get appropriate and timely care. It is unfair to deprive them of modern health care and current devices available for use today and which are constantly improving and evoluting. They are now facing a bleak  future and face the prospect of poorer quality devices with higher risks just because the organisation to which they contributed all their lives has suddenly changed its mind. This is actually a breach of trust and contrary to expectations of the service class. The decision makers today must realise that they are the pensioners of tomorrow.
We all are interested in keeping costs down as it is the tax payer’s money which is being spent. But to deny critical lifesaving and appropriate modern health care to people is not justifiable. Here are the implications of the new reimbursement guidelines for various stakeholders:
GOVERNMENT: Apparent cost cutting, no accountability, no audit, no appropriateness (can still be taken for a ride by inappropriate and unethical practices). There is a potential that this Government notification will only help to make India a dumping ground for outdated older generation products.
PATIENT: More re-use, use of previous/old generation products, increased risk and complication, poor outcomes.
PHYSICIAN: Increasing complications, has to take chances with outcome, less enthusiastic for challenging PTCA,  more CABG referral- with more morbidity, longer recovery and hospital stays.
The purchase price of stents is lower than the tender prices approved by several Government institutions. The approved costs are less than those incurred by Government institutions, even though they do not have any capital or HR costs. Why are CGHS beneficiaries being treated so shabbily? … We all are interested in keeping costs down as it is the tax payer’s money which is being spent. But to deny critical lifesaving and appropriate modern health care to people is not justifiable.
HOSPITALS: Not keen to take CGHS/ECHS patients. They may make more re-use of devices due to these restrictions. They also face serious issues with delayed payment and large inexplicable deductions.
DEVICE INDUSTRY: Less enthusiasm to support educational initiatives; will not bring new/modern technology to the country.
It will be prudent to ask :
a)    Device Industry: Whether they can provide world class validated current generation products at lower cost?
b)    Hospitals: Whether it will be reasonable to treat CGHS panel patients?
c)    Physicians: What is the current data position?
d)    Pensioners: Do they want second class health care or to or be subjected to re-use of old hardware when what they need most is first class health care?
e)    Decision makers: What they would like for themselves and their family?
Some therapies have not been sustainable in the country simply because of financial non viability. Even in the previous CGHS guidelines, BMV procedure was reimbursed @ Rs.12000/, whereas the Inoue balloon itself costs Rs. 65000/- and the procedure with a new balloon costs a self-paying patient Rs.1.5 lakhs. Similarly, peripheral vascular intervention and cardiac electrophysiology has very poor reimbursement leading to the patients not benefitting from these procedures in private empanelled hospitals. Besides, the therapy area has not progressed as the basic procedure itself is not financially viable. This leads to a large section of patients who will either not be treated and will have to lose life/limb or will have inappropriate therapies or may need open surgeries.
The whole world is moving towards minimally invasive therapies, realising that less invasive therapies are more cost effective with decreased hospital stay and therefore use of hospital resources for more number of patients with a faster turn over.
All angioplasties are not the same. Some are simple and require little time, average training and minimal effort while others are complex and require time, planning, expertise and substantial risks. Modern PTCA is evidence based. The use of FFR (fractional flow reserve) has led to a paradigm shift in angioplasty as it now permits determination of the functional significance of coronary stenosis leading to avoidance of unnecessary angioplasties which further improves clinical outcomes. IVUS and OCT help to understand lesion morphology better. IVUS is also helpful in seeking entry to totally blocked vessels and both intra coronary imaging modalities serve to ascertain as to whether a stent has been deployed well. Vascular closure devices help us to ensure prompt hemostasis after a PTCA which leads to early mobilisation, less access site complications, less bleeding and better out comes.  All these modern devices improve angioplasty but add to cost.
All accessories are approved by the DCGI for one time usage. As there are “package rates” most hospitals are re-using these stores. There is no system for audit and verification of the microbiological, chemical or physical standards of hardware.  A package actually does not cover these costs and if new hardware is used each time, each angioplasty would be a loss making exercise.
The self stated national inflation rates vary from 7 to 10  per cent. There has been no decline in the rates of any of the stores used in an angioplasty. There has been an increase in the rates of Capital Equipment due to the rising value of Euro/ Dollar . There have  been an increase in logistic costs of fuel, electricity etc. There are increasing HR costs. There are new costs of NABH standards / approvals etc which have been added. There is increasing procedural complexity with more and more patients opting for PTCA over surgery. As the patient population is getting older and more complex, there are increasing costs of care .
Then how can we possibly have a reduced rate of reimbursement ??? How can we have one therapy area to be treated so perversely ??? Selectively , CGHS has reduced rates of PTCA and Stents. If we compare global reimbursement, our  figures stand out as being the lowest in the world . Furthermore, these figures are lower than free healthcare schemes for “below poverty line citizens” in some States. The purchase price of stents is lower than the tender prices approved by several Government institutions. The approved costs are less than those incurred by Government institutions, even though they do not have any capital or HR costs .Then why are CGHS beneficiaries being treated so badly ??? Is there a hidden agenda ?? These figures may set off a detrimental chain reaction among other payer organisations. Why can we not evolve a reasonable price structure ???
Preposterous as it may seem , in today’s day and age, the CGHS approved rate for a super speciality consultation in the National Capital Region ( NCR ) is Rs 58/=. At this rate, the Government expects patients to be attended to by senior physicians holding post-doctoral qualifications. The nobility of the medical profession and Hippocratic oath is invoked by all and sundry when discussing a physician’s reimbursement. It is rather hypocritical considering that the physician and his/her family also have to exist in the present times. Both society and the Government need to compare such absurd reimbursement to any other profession in the country and introspect.
Every human being, professional, organisation, institution or business has to have reasonable compensation and remuneration without misleading / cheating/ resorting to unethical practices. Achieving honest profits and financial viability has to be encouraged and it is the responsibility of the decision makers to avoid being unreasonable. We need to develop patient friendly strategies so that there is a WIN-WIN situation for all and this could include :
a)    Guidelines for procedures.
b)    Regular audit and application of appropriateness criteria.
c)    Spend on R & D and follow up.
d)     Validate Indian hardware and publish comparable DATA.
e)    Ensure single use of hardware.
f)    Reasonable pricing of current generation products with uniform monitoring.
g)    Doing away with MRP and credit notes.
h)    Transparency at all levels.
There is a new reimbursement coding guideline in the US. While our cost of living may be somewhat less than the US, procedural complexity and risks remain the same with the same expertise, training and difficulty in the performance of the procedure. So we can go ahead and develop our own reimbursement guidelines using a percentage of difference in living costs. It is better not to be penny wise and pound foolish.n
(Dr.) Col. Anil Dhall, Sena Medal, MD, DM, FACC, FESC, FSCAI, FHRS, FCSI is Director Cardiology, Delhi Heart and Lung Institute. He was formerly Senior Adviser & Professor Army Hospital (Research & Referral) Delhi Cantt, Senior Consultant & Unit Head Max Heart & Vascular Institute, Saket, New Delhi, Director & Head Department of Cardiology Artemis Health Institute, Gurgaon.

Cost involved in an angioplasty procedure
The cost of angioplasty not only includes the price of a stent but also incorporates:-
a)    Percentage cost of capital expenses on setting up a cardiac catheterisation laboratory, coronary care unit, emergency room, non invasive cardiac hemodynamic laboratory etc.
b)    Percentage cost of capital expenses in setting up a hospital.
c)    Cost of disposable hardware i.e. sheaths (factor 2.4), 0.035”guide wire, 0.014” coronary guide wire (factor 2.2.), intra coronary balloon (factor 2.2.), intracoronary hardware for special situations like the thrombus extraction catheter, micro catheter, Corsair, Tornus etc. Contrast, Medicines with optional usage of Swan Ganz, Right heart catheter, Temporary Pacing.
d)    Cost of linen, sterilisation, logistics and supply chain.
e)    Cost of pre and post procedure care including nursing, linen, housekeeping and dietetics.
f)    Lab investigations and backend costs.
g)    Cost of nursing, technical and paramedical staff.
h)    Physician cost including cost of Cardiologist, Anesthesiologist and even stand by Surgical Team.
i)    Cost of stent.
j)    Cost of rotablator, if used.
k)    Cost of FFR (fractional flow reserve), IVUS (Intravascular ultrasound), OCT (Optical coherence tomography) if used.
l)    Cost of closure device if used.
m)     Cost of future expansion and training of personnel to remain abreast with advances in the field.
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