Monday, January 5, 2009

Pearls & Gem :The Four Jokers

Friends ,

If you are 'gin rummy hantus' you will definitely know what having four jokers amongst your deck of cards mean :Instant 'gin' and double penalty points for all you opponents .

Having 'four jokers' in cardiovascular disease ,[ I use this term 'loosely' to mean both combined coronary ,cerebrobrovascular and renovascular ie renal as for kidney ],mean also almost the same thing :you are living with a 'short fuse'.Just waiting for that inevitable stroke ,heart attack or kidney failure looming in the horizon .

The four jokers are :

1 .Hypertension or High blood pressure .Pressure generally above 140/90 on 2 or more occasions .Our BP is variable with time ,place and occasion .When new patients come to see for the 1st time for other problems I normally do not give heed if their 'pressures' are a wee bit highish since these are stressful situation for them .This we practitioners all know and term it "white coat hypertension" . Does not even help even as nowadays that I dress to work rather 'casually' .Of course 150/100 is definitely high and 180/110 is a no no and most doctors will start treatment and full 'blood' investigation rightaway .Hypertension is a common problem and all your family physicians are capable of handling this situation .See them .

2 .High Cholesterol .A reading of below 5 mmol is ideal .Very rare in Malaysians to find such values .Our Malay and Mamak food are soo very rich .Our Chinese 'warong food' are always loaded with lard .Our 'makan places' opens 24 hours .It is not in the culture of we Malays to exercise and burn away the excess 'fats' etc and etc .[ see my blog on longevity ].6 to 6.5 mmol is no man's land .Some doctors treat some dont .7 mmol ,we are getting interested .At 8 mmol ,even if you wake me up at 2 am I will say shut up ,go take medication indefinitely ,or if you are reluctant what whatever irrational reason [ God ! I am getting tired of hearing 'Doc ,I am afraid of the side effect so i stopped the medication !] ,'change you religion': go veggies ,come back see me in 6 weeks ,repeat your cholesterol test !At 8 mmol ,even veggies only and all the diet in the world will still need some help from the statins ,the most effective anti cholestrol drug .

3 .Smoking .I do not have to add anything here .You all already know but must insist you do continue .The funny thing is whenever one has to spend 1 or 2 nights in the CCU in the context of having an 'acute coronary syndrome' or a heart attack ,seeing and feeling the nearness of 'Izra'il' at your jugular ,the smoking just stop easily mostly for years to come .No 'gian' even on day 1 ,whatsoever .Friends ,I hope you would not have to wait for that .It is a wee bit too late .Of all the 4 jokers ,smoking is the easiest joker to eradicate :you either stop 100 % or you continue .Prevention is better than cure ,and mind you there is no cure for established cardiovascular disease .

4 .Diabetes .It is such a big problem now with increasing obesity and affluence and increasing 'sedentariness' in our daily life . I would write on this specifically in future .Around half of all my angioplasty and stented patients are diabetic .On any one day my outpatient clinic follow up is consisted of 30 % diabetic .My wife is an insulin dependent diabetic and I can see my 2 overweight, under exercised ,internet addicted sons could well be diabetic in a cuople of years time .[ Would rather give them a kick on their backsides but that don't seem to be fashionable these days and age !]It is Makan ,Makan ,and more Makan !And no exercise .

How do these 'four jokers' effect their way on our body ?To be simplistic ,through our arteries ,big ,small and medium .Look at it this way ,the arteries are our main 'roads ,highways and lorongs' for nutrient ,oxygen and toxins transport and redistribution .When 'they 'collectively ' age prematurely our 'end organs [ brain ,kidney ,heart and in men ,even the 'lowly' penis ]suffer .ED problem in the main is not a urological problem ,it is a symptom of 'clogged arteries and clogged arteries are usually also present elsewhere ,unless proven otherwise .If you have ED ,go see your cardiologist ,he will check your heart .You do not 'die' of ED but you can die of a 'heart attack ' .So your doctor will do a stress test 1st ,and only then talk about your ED .

Blocked roads in Puchong could well be also blocked roads in Damansara Heights ,as I always jokingly tell my patients !ED is usually an early manifestation of heart problem .The 'PWD people', when they are not efficient, you get bad roads with potholes in Puchong ,Damansara Heights and TTDI as well.Need to look at all of them .Especially Damansara Heights as they cause more damage !

Dr Nik Howk


Anonymous said...

What is your view on alternative medicines? Modern drugs always have side effects. There are now many herbal cure claims to control bp and reduce cholesterol etc. Our friend POPe seems to really benefitted from his lingzhi treatment. LanK made the mistake of stopping his normal medication too soon. I'm one of those who try to avoid taking any medication unless it becomes very necessary.

Mat Ribut a.k.a. amek

Anonymous said...

Dear Doc Nick and Our friend Mat Ribut,

I'm yet a convert (who is a medical doctor who believes and practices herbalism). After 31yrs of medical practice, a friend of mine in Langkawi left allopathy medicine and practices herbalism. He has a medicinal botanical garden called Herbalwalk.You can visit his wbesite;
I hope my friend could modernize Malays Herbal Pharmacopia, rather than current practice using 'periuk tanak' which cost RM 40 each.
My battery is running out.

Anonymous said...

Sorry Nik, I was at the Langkawi Airport when my battery was low.

I do agree with you that hypercholesterol should be treated with statin. But some physicians consider cholesterol scare is just a myth. You and I know, it is not true.
They argue that it's not the cholesterol per se is the culprit but rather than allergic inflammatory reaction to cholesterol is responsible for vascular pathology. According to them, it's through cytokines and etc to cause athrosclerosis and other vascular events (stroke and acute coronary syndrome).
Appreciate if you can comment on this issue.

Rahmat Subang Jaya.

Pearls & Gem said...

Amek ,Rahmat

There are 2 sides to herbalism .Yes and No .

Yes there are herbs out there that are good .But which ones ?.How much do one take ,How long ?And some can be outright dangerous .Remember the celebrated Singapore case of the young lady taking herbs to reduce weight .She end up needing a liver transplant .Not all herbs are 'innocent '.Even in the category of Yes ,we have not address the issue of :how much ? How long ? Which ones ?If it work for one person ,does it work for the rest ?Many issues .You can wait 50 years for your herbal friend to do his research but if you have an appendix or a heart attack ,you cannot wait for him !

No ,if you really want to go by 'evidenced based medicine ' .My colleague somewhere in KL made 5 times more than me selling 'ozone therapy ' in KL .Can be considered as Alternative medicine .Does it work ? "No but Doc even No .1 go for 'ozone therapy ".

That is precisely why we are quite in a mess now .

With respect to cholesterol ,"Yes" it is overwhelming evidence that high cholesterol contribute to heart disease .And yes ,'inflammation' in the arterial wall contribute to heart disease.For the former we have the statins as the most effective treatment . For 'inflammation' we have at present none yet !

If you have a heart problem now do you have 50 years before some smart aleck come up with an 'antibiotic' to smoothen out the inflamation or you would rather take the statin and pray that you do not die of a massive heart attack in say 5 years time .

Your choices .Tepuk dada tanya selera .This is a free country .

You combine pseudo religiosity and pseudo science and Presto ! you get a miracle cure !

Your choice .But remember it was Ibn Sina [ Avicenna] who was the founder of modern medicine ,not any Tom Dick or Harry from the West.He was a scientist par excellence during his time and knew the Quran by heart .Why are we then going back to the 'caves'?

Why must we Muslims be the champions for mediocrity ?