Tomorrow the big day..

I will be starting tomorrow at my new clinic. Very excited. Hopefully I can help a lot of people and I pray to God that my venture would be a spiritually rewarding one.

I would like to thank these people to make it happen for me..

My wife

She has been very patient and hard working past few weeks sorting out the clinic and our new home. She also have given me comfort and shoulder to lean on through difficult times.

My 4 lovely kids

Siti Aishah, Muhammad Adam, Siti Umayrah and Muhammad Amirul. They may not understand much but they are the ones who have inspired me to become who I am. And all these are for them..

My parents

They were initially have mixed feelings about me coming back to Ipoh. They were very happy indeed as I am closer to them but on the other hand they felt that I should stay in Kedah. Nevertheless, they helped me find a house, clean it fix a few broken glasses and finally help me move in. They do this with sincerity and nothing in this world can replace them.

Syariman and Haslina

I sincerely thank them with the bottom of my heart, particularly Syariman. He single handedly fix the Astro and few other things. Haslina too has been very helpful...

Mr Yau of Binnova Interior Decorator

He has done an excellent job with my clinic renovation.

Tn Hj Nasiruddin, ISH General Manager

He has helped me a lot with the clinic and a few other things..

Dr Ng Teng Chun, Cardiologist ISH

Well, he was then one who called me somewhere in April 08 and telling me that ISH is looking for another cardiologist.

ISH personel

Especially the PR department, Store department and Cleaners...

So tomorrow is the big day...

Let us all pray for it..

Dr Hasral Noor Hasni

Cardiologist and Physician

Suite 2-10

ISH

UPDATE ON CLINIC RENOVATIONS DEC 25TH 08..

Finally my clinic is almost ready... except for my chair, patient and relative chairs in my consultation room and sofa in the clinic waiting area.

View from the corridor.. my clinic is at an angle..

compass at waiting area

Consultation room, and finally sink is been installed

Clinic counter

display built in cabinet..

my degrees...

This evening I prayed Jemaah Asar with some of Abah's friends our relatives and of course Man in my consultation room. I am really grateful that I can start my practice in Ipoh.

MERRY CHRISTMAS AND HAPPY NEW YEAR

ayat seribu dinar

CLINIC RENOVATION by 23rd December 2008..

waiting area.. wall paper just paste yesterday evening..

looks cool with the chinese writing..

may add some flowers and side table..

inside the clinic..

they have not fix the johnson suisse sink..

nurse counter

LCD TV 32inch LG..

contractor talking on phone...

by the way..

my clinic in Ipoh Specialist Hospital will be officially open on 29th December 2008. This coincide with Awal Muharam and Siti Umayrah's birthday

DR HASRAL NOOR HASNI

CONSULTANT CARDIOLOGIST AND PHYSICIAN

SUITE 2-10

IPOH SPECIALIST HOSPITAL

This afternoon, will go out for furniture hunting..

LOW MOLECULAR WEIGHT HEPARIN

ANTICOAGULATION IS VERY ESSENTIAL IN MANAGEMENT OF ACUTE CORONARY SYNDROME. (ANTICOAGULATION = MAKING THE BLOOD THINNER THAN USUAL) IT HAS BEEN SHOWN TO IMPROVE MORTALITY AND MORBIDITY. PREVIOUSLY WE USED UNFRACTIONATED HEPARIN (UFH) AS AN INFUSION FOR ABOUT 48 HOURS. THE DRUG ITSELF IS VERY CHEAP. HOWEVER, IT REQUIRES INFUSION PUMP AND CLOSE MONITORING APTT (A MEASUREMENT OF THE DEGREE OF THINNING OF BLOOD).

THEN THE LOW MOLECULAR WEIGHT HEPARIN (LMWH) CAME INTO PICTURE. THE ATTRACTIVENSS IS THAT IT IS ONLY GIVEN AS SUBCUTANEOUS INJECTION (LIKE INSULIN) TWICE A DAY FOR TOTAL OF 6 DOSES. ENOXAPARIN (CLEXANE), ONE OF THE LMWH HAS BEEN SHOWN TO BE MORE SUPERIOR THAN UFH. THE PROBLEM IS THAT THE EARLIER GENERATION LMWH IS PORCINE BASED. THIS MAY NOT BE VERY PLEASING TO THE EARS OF MUSLIMS...

RECENTLY GLAXOSMITHKLINE PRODUCED A NEW ANTICOAGULATION, FONDAPARINUX (ARIXTRA) WHICH IS NOT PORCINE BASED. ARIXTRA HAS BEEN SHOWN TO BE SUPERIOR THAN LMWH IN REDUCING FURTHER MORTALITY AND MORBIDITY IN ACUTE CORONARY SYNDROME. IT IS GIVEN AS ONCE DAILY SUBCUTANEOUS INJECTION FOR 3 DAYS.

SO PLEASE ASK YOUR DOCTOR REGARDING THE CHOICES OF ANTICOAGULATION.

HOW CORONARY ANGIOPLASTY/STENTING BEING DONE

Coronary intervention is a medical procedure to relieve the narrowings or blockages of the coronary arteries. These blockages are caused by cholesterol deposits.  They are called either plaques or stenoses. Almost 98% of coronary angioplasty nowadays uses stent, tiny metal scaffolding, which have been shown to reduce the chances of renarrowing (restenosis). Patients are usually given antiplatelet medications (aspirin and clopidogrel prior to this procedure) and antithombotic agent (low molecular weight heparin or unfractionated heparin).

Using the same access as coronary angiogram, the doctor will insert a different catheter called the guiding catheter. This catheter’s tip will be placed at the origin of the coronary artery. Guide wire which is as thin as our hair is then inserted into the guiding catheter. The doctor will gently glide the guide wire to pass across the plaque or stenosis. The tip of the guide wire is usually placed at the far end of the coronary artery (distal end). All the coronary devices that enter the coronary arteries over ridding the guide wire.

The plaque or stenosis is the prepared further with either predilatation or rotational arterectomy prior to stent insertion. Predilatation uses small coronary balloon. The doctor places the coronary balloon at the stenosis, expand the balloon and pushes the cholesterol filled stenosis or plaque into the coronary artery wall.

The doctor places the stent at the stenosis or plaque. The balloon is then inflated and pushes the stent to the coronary artery wall. It forms scaffolding and holds the artery open. The stent is left behind to maintain blood flow down the coronary artery.

After all the balloon and guide wire removed from the coronary artery, final pictures is taken and the procedure is completed.

If its transradial approach, the sheath is removed and NICHBAN is applied immediately. If its transfemoral approach, the sheath is removed only after the ACT is below 150 (usually after 1 to 2 hours upon completion of the procedure).

THIS TIME ITS ON VIDEO MODE...

THIS IS THE VIDEO MODE OF THIS PREVIOUSLY POSTED CASE..

TRANSRADIAL PRIMARY PTCA TO RCA

No objection to Sime Darby stake in IJN: Najib

This is probably one of the saddest day in my life. IJN shares will be bought by a public listed company. Which means that profit will come into play now. I have worked in IJN 2003 to 2007 and felt very proud that IJN had mould me into what I am now.

I am not too sure why the government agree to selling stakes to IJN to PLC. At the end of the day, the patients will suffer. About 85% of patients are government officers, pensioners and from poor social economic status. They may not be able to afford further care from this institution.

The newly developed Cardiology Department in Hospital Serdang has only 2 cardiac catheteization labs, as compared to 4 (may be up to 8 if the new wing is fully functioning) in IJN. The infrastructure is not there to cope with the demands from the public.

If IJN wants to be more profitable, then they should tap to medical tourism. Get more international patients and use their reputation as one of the world's best.

Leave IJN alone!

Once again, hands off IJN, please!

Sime Darby eyes IJN

Sime Darby Confirms Its Interest In Aquiring IJN Stake - Bernama

Sime Darby eyes stake in hospital operator IJN

TOWARDS BETTER HUMAN RELATIONSHIP

This is something I found during my visit to dentist. He put up a nice poster without the name of the author. Something I like to share to make this world a better place to live..

1. Be polite and well-mannered

2. Remember people’s name

3.Be cheerful and remember to smile

4. Practice appreciation

5. Show a sincere interest in others

6. Be a good listener

7. Be patient, tolerant and understanding

8. Always be kind and helpful

9. Don’t argue with people

10. Watch your speech

11. Never criticize without complementing

12. Avoid controversial or sensitive issues

13. Don’t brag, be humble

14. Observe punctuality

15. Always keep promises

16. Treat others with respect

17. See the good in people

18. Admit our mistakes

19. Nurture relationship

20. Do unto others as you would have others do unto to you

21. Try our best to be the best

PTCA LAD TRANSFEMORAL APPROACH

For this presentation, I used Windows Movie Maker..

The patient had no periprocedural complications and was discharged well the following day. I decided not to proceed with ptca to lad during the acute setting due to financial constrains.

WHAT IS CORONARY ANGIOGRAM?

1. Medical procedure to look at degree of narrowing (stenosis) in coronary arteries that run on the surface of heart muscle.

2. Patient and family will be advice regarding its indication, risk and preparation by the physician.

3. Coronary angiogram can be done either as inpatient or outpatient (daycare) basis. The choices of either depends upon the patient's condition. If the patient is stable, usually the coronary angiogram can be done as daycare.

4. Patient is required to fast at least 4 hours prior to this procedure.

5. The procedure is performed by puncturing an artery either at the wrist (transradial) or groin (transfemoral). 

6. A small tube about 2mm diameter called diagnostic catheter is inserted through the arterial access.

7. Using guide wire, the diagnostic catheter is then positioned just at the mouth/origin of the coronary blood vessels.

8. Contrast solution is then injected though the catheter. As it flows down the coronary arteries, CINE is taken.

9. A few views were taken for each left and right coronary systems.

10. This procedure takes about 5 to 10 minutes.

11. At the end of the procedure, the doctor will explain to patient and family members regarding the findings and further plans.

12. If the plan is for coronary angioplasty, then with the same sheath, the doctor can proceed immediately. This will take further 30 to 60 minutes, depending on the complexity of the procedure.

13. At the end of this procedure, the sheath is removed. If the procedure was transradial (wrist), a specialized plaster, NICHIBAN, is applied to the wrist for about 4 hours. If the procedure was transfemoral (groin), a technician will press manually over the groin for about 15 minutes followed by lying flat for 6 hours.

14. Patients are advised  not to move the wrist excessively for about 5 days if the procedure is transradial.

15. Patients are advised not to carry heavy objects and walk vigorously after transfemoral angiogram.

16. Patients are usually advice to seek medical attention if the developed pain, swelling at puncture site, fever and chest discomfort.

TRANSRADIAL PRIMARY PTCA TO RCA

THIS IS AN INTERESTING CASE THAT I DID RECENTLY. 47 YEAR OLD MAN PRESENTED 4 HOURS CHEST DISCOMFORT. CORONARY RISK FACTORS ARE SMOKER AND HYPERTENSION. 12 LEAD ECG SHOWED ST ELEVATION IN INFERIOR LEADS. HIS HAEMODYNAMICS REMAINED STABLE. CRUSHED ASPRIN 300MG, CLOPIDOGREL 300MG AND SUBLINGUAL GLYCERINE TRINITRATE WAS GIVEN STAT TO PATIENT.

HE WAS TAKEN TO CATH LAB 50 MINUTES AFTER PRESENTATION. THE ARTERIAL ACCESS WAS FROM THE RIGHT RADIAL ARTERY. USING DIAGNOSTIC OPTITORQUE 5F DIAGNOSTIC CATHETER, THE LEFT AND RIGHT CORONARY ARTERIES WERE CANNULATED. THE LEFT CORONARY SYSTEM WAS ESSENTIALLY NORMAL.

THE RIGHT CORONARY ARTERY (RCA) WAS OCCLUDED WITH THROMBUS FROM THE PROXIMAL SEGMENT.

I THEN PROCEED TO PERFORM CORONARY ANGIOPLASTY OF RCA. THE RCA WAS ENGAGED WITH JR 3.5 6F GUIDING CATHETER. THE LESION WAS CROSSED EASILY USING COUGAR XT GUIDE WIRE. THROMBUS ASPIRATION WAS PERFORMED USING EXPORT CATHETER. I FOUND MINIMAL AMOUNT OF RED THROMBUS. THE LESION WAS PREDIALATED WITH SPRINTER LEGEND 2.0X10MM INFLATED AT 12 ATM

I PROCEED WITH STENTING USING ENDEAVOUR 2.5X30MM STENT DEPLOYED AT 14 ATM. THE IMMEDIATE ANGIOGRAHIC RESULTS WAS GOOD WITH NO RESIDUAL STENOSIS, TIMI III FLOW FLOW AND TMP III MYOCARDIAL BLUSH

THE DOOR TO BALLON TIME WAS 65 MINUTES. THE RADIAL ACCESS SHEATH WAS REMOVED AND NICHIBAN WAS APPLIED FOR HAEMOSTASIS. 

THE PATIENT WAS NURSED IN ICU OVERNIGHT. 12 LEAD ECG SHOWED COMPLETE ST RESOLUTION AND HIS CK PEAKED AT 871U/L. HE WAS DISCHARGED WELL ON DAY 3 ADMISSION.

HIS MEDICATIONS UPON DISCHARGED ARE

1. CLOPIDOGREL 75MG DAILY

2. CARDIPRIN 100MG DAILY

3. ATORVASTATIN 80MG DAILY

4. RAMIPRIL 10MG BD

STRATEGY IN WEIGHT MANAGEMENT

1. LIFE STYLE CHANGES

2. ANTI-OBESITY DRUGS

3. VLCD (VERY LOW CALORIE DIET) - UNDER MEDICAL SUPERVISION

4. SURGERY

Lifestyle change is an important part of weight management. it consist of proper diet and physical activities. 

The aim is to achieve gradual weight  reduction of 0.5 to 1 kg per week. Ideally the negative energy balance should be about 500 to 1000 kcal per day. Its all about supply and demand.

Eg. If your daily food consumption is 3000 kcal per day (which is quite a lot), you need to exercise and burn your calories about 3500 to 4000 kcal.

MANAGEMENT OF OBESITY

GOALS OF OBESITY MANAGEMENT

1. Achieve weight loss

2. Maintain reduced weight

3. Prevent weight gain

4. Treat obesity complications

WEIGHT LOSS

1. Target initial weight loss of about 10%

2. Attempt weight loss about 0.5 to 1 kg per week

THE LATEST..

ITS OFFICIAL..

I AM JOINING IPOH SPECIALIST HOSPITAL FROM 15TH DECEMBER 2008

AS RESIDENT CONSULTANT CARDIOLOGIST AND PHYSICIAN

ALLAH IS GRACIOUS..

AMIN

BENEFITS OF WEIGHT REDUCTION

Blood Pressure

Reduction in systolic and diastolic blood pressure

Reduction in dose and number of antihypertensive drugs

Lipid Profile

Reduction in LDL cholesterol and triglyserides

Increase in HDL cholesterol

Diabetes

Reduction in development of type II DM

Improvement in blood glucose control (reduction in HbA1c)

Osteoarthritis

Reduction in development of secondary osteoarthritis

Reduction in obesity related death risk

HRH SULTAN KEDAH WITH ME

HRH Sultan of Kedah visit to Kedah Medical Center

HEALTH RISK FOR OBESITY

1. Hypertension

2. Hyperuricaemia (gout)

3. Dyslipidaemia (elevated and abnormal cholesterol levels)

4. Type II diabetes

5. Insulin resistance syndrome

6. Polycystic ovarian syndrome

7. Coronary heart disease

8. Heart failure

9. Left ventricular hypertrophy (abnormal thickening of heart muscle)

10. Cerebrovascular accident (stroke)

11. Obstructive sleep apnoea (snoring)

12. Gallstone disease

13. Fatty liver

OBESITY CLASSIFICATION

There are 3 methods of diagnosing and classifying obesity

1.       Body Mass Index (kg/m2) BMI = weight (kg)/[height x height (m2)]

Classification	BMI	Risk of Obesity Complications
Underweight	Less than 18	Low
Normal range	18 to 23	Normal risk
Preobesity	23 to 27	Increased risk
Grade I obesity	27 to 35	High risk
Grade II obesity	35 to 40	Very high risk
Grade III obesity	More than 40	Extremely high risk

 

2.      Waist Circumference (measured at umbilicus/belly button)

Male obesity      more than 90 cm (36inch)

Female obesity more than 80cm (32inch)

 

3.   Waist to Hip Ratio

Male obesity      more than 0.9

Female obesity more than 0.8

 

 

INVASIVE CARDIAC LABORATORY

FACTS ABOUT OUR HEART

Our heart beats on average 50 to 80 beats per minute or about 100,000 times per day. It pumps blood about 5 liters per minute or about 2000 gallons per day.

By the time we reach 70 years old, our heart has been beating for 2.5 billion times and pumping blood about 50 million gallons.

PENANG CARDIOVASCULAR SYMPOSIUM 2008

ACEI, ARB OR COMBINATION FOR HEART FAILURE

http://docs.google.com/Presentation?docid=dfkxwwtm_3fw6bt9c7&hl=en

Selamat menyambut ramadhan

selamat menyambut ramadhan

SECONDARY PREVENTION FOR PATIENT WITH CORONARY ARTERY DISEASE (AHA/ACC 2006)

Smoking	Complete cessation No exposure to environmental tobacco smoke
Blood Pressure Control	130/80mmhg
Lipid Management	LDL-C, less than 2.0mmol/l
Physical Activity	30 minutes, 7 days per week
Weight Management	BMI 18 to 23kg/m2 Waist circumference (Men <38>
Diabetes Management	HbA1c <7%
Antiplatelet	Aspirin indefinitely (75 to 162mg daily) Add Clopidogrel 75mg daily post acute coronary syndrome or stenting Warfarin for AF
Renin Angiotension Aldosterone blockers	ACE Inhibitors for all patients ARB for ACE Inhibitor intolerance ACE Inhibitor and ARB combination for heart failure Aldosterone receptor blocker for NYHA class III and IV
Beta Blockers	Myocardial infarction, acute coronary syndrome, heart failure

Secondary prevention: "Post cardiac event"

RISIKO PENYAKIT JANTUNG KORONARI

RISIKO BOLEH DI UBAH

1. Tekanan darah tinggi
2. Kandungan lemak berlebihan/hypercholestrolaemia
3. Kencing manis/Type 2 Diabetes Mellitus
4. Tabiat merokok
5. Kegemukan
6. Kurang aktiviti fizikal
7. Ketegangan/stress

RISIKO TIDAK BOLEH DIUBAH

1. Keturunan
2. Jantina lelaki
3. Umur

thesecret

A very interesting video i picked up.
Here is the link..
http://video.google.com/videoplay?docid=-1052811701025164889&ei=N5WGSJ6FOpKywgOVxIiRCA&hl=en

The myth and truth about cardiac CT

I think I am jumping the gun talking about cardiac CT before talking about coronary heart disease in general. The reason being there are a lot of us simply request for cardiac CT for no obvious reason. (cardiac CT=multislice CT=CTA coronary).

Advantage of multislice CT coronary
1. Avoidance for arterial puncture and coronary catheter manipulation, in which deemed fairly safe.
2. Cheaper than conventional coronary angiogram
3. Outpatient setting
4. Highly sensitive for proximal lesions

Disadvantages of multislice CT coronary
1. Excessive radiation exposure – 3x standard coronary angiogram
2. Excessive contrast use – 3x standard coronary angiogram, hence higher risk for kidney complication
3. Image quality dependent upon patient heart rate
4. Distal segments may be poorly visualized in some patient
5. Presence of calcium may cause underestimation of coronary artery narrowing

In my opinion, multisclice CT coronary is appropriate for
1. "Intermediate risk" chest pain that has an equivocal/non interpretable stress test.
2. Atypical chest pain in patients who can’t adequately perform treadmill stress test.
3. Unusual coronary anatomy.
4. New onset heart failure
(based on Appropriateness Criteria for Cardiac Computed Tomography and Cardiac Magnetic Resonance Imaging (JACC Vol 48, No 7, 2006, 1475-97)

Mulitslice CT coronary is not suitable for
1. Known coronary heart disease
2. High probability coronary heart disease based upon clinical assessment

Tasik Temenggor Trip 2008

Dr Suresh, Dr Regu and Me

Concerning Heart

There are quite a lot of my patient asking me to blog, as one of the way to educate the public.

So I thought this is really exciting. But the problem is, I have never done this before. So one fine night, after a good hiking adventure at Bukit Tongkat Ali, Pokok Sena, with my trustworthy colleague, Dr. Regunathan (his a plastic surgeon), I take the first step.