Morning MEDtalks with Dr K K Aggarwal

New Delhi, July 31, 2018 :

Approach to a patient on aspirin going for non-cardiac surgery

• Is the patient on aspirin for primary prophylaxis? Discontinue aspirin for five to seven days before the surgery and start as soon as the perioperative risk of major bleeding has passed.
• Is the patient on long term aspirin for secondary prophylaxis? Continue aspirin in patients with prior PCI with stenting and those undergoing carotid endarterectomy, unless the risk of major bleeding is thought to be high (POISE-2 trial) or the surgery involved is not likely to have bleeding controlled by homeostasis (prostate surgery, intra ocular surgery, intra cranial surgery)
• Aspirin can be safely continued in most patients undergoing minor dental surgery or dermatologic procedures.
• Guidelines from the American Society of Regional Anesthesia (ASRA) indicate that NSAIDs, including aspirin do not create a level of risk that will interfere with the performance of neuraxial blocks, and should not impact catheter techniques, timing of neuraxial catheter removal, or postoperative monitoring.
• Cilostazol should be discontinued for at least two to three days prior to elective surgery.
• There is no data on the safety of dipyridamole if continued in the perioperative period. If discontinued, the drug should be stopped at least two days before surgery.

Dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) with stenting

• Defer non-emergent noncardiac surgery for at least six months irrespective of stent type.
• In patients who must undergo non-emergent (time sensitive) noncardiac surgery prior to six months attempt to defer surgery for at least three months after bare metal or drug-eluting stent placement. In patients for whom surgery before three months is in their best interest after weighing risks and benefits refer patients as early as one month after stent placement.
• For most patients undergoing noncardiac surgery who are taking DAPT after PCI with stenting because they have not reached the recommended minimum duration of such therapy continue DAPT, as opposed to stopping it prior to surgery
• In patients for whom the risk of bleeding is likely to exceed the risk of a perioperative event due to the premature cessation of DAPT continue aspirin alone.
• In patients for whom a bleeding complication could be catastrophic, such as patients undergoing neurosurgical, prostate, or posterior eye procedures, stop both antiplatelet agents
• For patients taking DAPT after PCI with balloon angioplasty who are scheduled to undergo elective noncardiac surgery wait at least 14 days after PCI
• Clopidogrel, prasugrel, and ticagrelor when stopped should be stopped five, seven, and three to five days, respectively, before surgery.
• Clopidogrel, if stopped, should be restarted with a loading dose of 300 – 600 mg as soon as possible after surgery, perhaps even later in the day if postoperative bleeding has stopped.
• Surgery be performed in centers with 24-hour interventional cardiology coverage

A new oral drug for endometriosis pain

USFDA has announce the approval of the commercial version of the drug elagolix for the treatment of endometriosis pain. This is the first time in over a decade that an oral treatment specifically designed for endometriosis pain has been approved. Elagolix is the first and only oral gonadotropin-releasing hormone antagonist designed specifically for endometriosis.

Unregulated food additives could harm children

The University of Washington backed by the American Academy of Pediatrics (AAP) is now calling on the FDA to review more than 1,000 food additives generally recognized as safe. The US allows more than 10,000 additives to be used in modifying taste or the appearance of food, many of which were grandfathered in during the 1950s. Some additives to watch out for

• Artificial food colors: Are common in children’s food products. Now, they may be associated with worsened attention-deficit/hyperactivity disorder symptoms. Studies in the report found that kids who cut out synthetic food colorings from their diets had decreased ADHD symptoms.
• Bisphenols (BPA):  are used to harden plastic containers and line metal cans. They can act like estrogen in the body and may alter the timing of puberty, slow fertility, increase body fat, and negatively impact the nervous and immune systems. Currently, BPA is banned in baby bottles and sippy cups.
• Phthalates: are found in plastic and vinyl tubes to make them flexible, and may now affect male genital development, increase childhood obesity, and contribute to cardiovascular disease. In 2017, the use of some phthalates in childcare products, like teething rings, were banned.
• Perfluoroalkyl chemicals (PFCs):  are used in grease-proof paper and cardboard food packaging, and now may reduce immunity, birth weight and fertility. They may also affect the thyroid system, metabolism, digestion, muscle control, brain development and bone strength.
• Perchlorate: are added to some dry food packaging to help control static electricity. Now, it’s known to disrupt thyroid function, early life brain development and growth.
• Nitrates / nitrites: Are used to preserve food and enhance color, specifically in cured and processed meats. These additives can interfere with thyroid hormone production and hinder blood from moving oxygen in the body. It has also been linked with gastrointestinal and nervous system cancers. (Source Komonews, Dr. Sheela Sathyanarayana, a UW Medicine pediatrician and co-author of the study)

A Portfolio diet lowers many risk factors for heart disease

A Portfolio diet, a plant-based way of eating reduces not only LDL cholesterol, but also other risk factors for heart disease such as blood pressure, triglycerides and inflammation thereby reducing the overall risk for coronary heart disease by 13% as per a meta-analysis of seven trials reported in Progress in Cardiovascular Diseases.

The portfolio diet has four main components. Based on a 2,000 calorie diet, it includes 45 grams of nuts, or about a handful; 50 grams of plant protein such as soy, or pulses like beans and peas; 20 grams of viscous soluble fiber (oats, eggplant, apples, etc.) and plant sterols 2 gm (natural compounds that inhibit absorption of cholesterol and are often included in enriched products like margarine).

David JA Jenkins, MD, creator of the portfolio diet says, “Don’t think of the portfolio diet as a diet; think of it as an investment in lower cholesterol”.

Dr KK Aggarwal
Padma Shri Awardee
Vice President CMAAO
President HCFI