RNI Number: TELENG/2015/65122 th th Posted on 15 & 16 of every month

at Mail Business Centre, Plat Form No. 10, Secunderabad Railway Station, Secunderabad

thPublished on 10 of every month

Postal Registration No.: HCD-5001-2016-2018

Volume-2 Issue-9 September - 2016

Notional Cost: Rs. 20/-Pages: 12

A Physician with No Boundaries

New drug therapies for

Pulmonary Hypertension

Imaging for Coronary

Atherosclerosis

Quiz

Prime News

How low should the BP be in

a Diabetic Hypertensive Patient?

DASH Diet (Eating Right) to Lower Blood Pressure

Dear Colleagues,

When should a doctor retire?

“Doctors die but never retire” is a quote commonly used. Prime Minister Narendra Modi's announcement to bring parity on the retirement age for doctors to 65 years is a welcome move. This is an important step by the government considering the rapid improvement in the life expectancy to 68 years over the past five years. Certain state governments have also pursued a similar strategy. The MCI has increased the retirement age to medical teachers up to 70 and propose to increase further to 75 years. Last month a group of doctors from Army Medical Corps have approached the Supreme Court requesting it to intervene and increase the retirement age from the current 60 or 62 years (depending on the rank) to 65 years or else transfer to the central government services. This question is still under the consideration of the tribunal for Armed Forces.

Personally I feel that this move is an apt move considering the scarcity of medical professionals especially in the public hospitals. In addition professionals such as doctors become better with accumulation of experience both clinical and administrative. But young doctors who plan to pursue career in the government sector and as medical teachers will get frustrated owing to the stagnation of career. So government needs to find solutions for career enrichment and enhancement for the younger doctors too. Time bound promotions instead of vacancy determined, incentives for the younger doctors based on outcomes as well as volumes of patients treated, promotion of research and publication as a measure for promotions and most importantly a feed back from the patients could be certain parameters by which younger doctors could be motivated to perform better and contribute to the society.

Unfortunately, many retirees haven't saved enough or planned carefully enough to finance their usual lifestyle after they retire from a career in medicine. The amount of funds needed at the time of retirement varies and is dependent on four factors: longevity, tax rate, investment returns and spending level. Doctors in private practice should plan a transition structure, as the value of patient volume accumulated over decades cannot be allowed to wither away. A good idea (akin to the West) is to sell the practice when the practice is in good shape. Leasing out the existing building to a younger colleague with an escalation clause (should match inflation) when the practice is in good shape and gradually reduce the number of working days and hours is a good strategy to add value to the hard work over many decades. A common mistake is to look for a person to purchase the building and infrastructure without the practicing doctor. We need to understand that retirement for doctors happens only after attaining financial security, availability of pursuits for a happy retirement (you need to be engaged otherwise boredom sets in) and patients with whom you have been associated for decades are handed over to a responsible colleague.

I am sure these strategies help you in planning a retirement which is as important as planning a career.

Warm regards, Raghu Cherukupalli

For appointments: text or call +91 95420 81999 or

appointments@drraghu.commail

+91 98481 55650

raghu@drrraghu.com

www.drraghu.com

drraghu-cardiologist

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Dr C RaghuMD, DMInterventional - Cardiologist & Vascular specialist

practo.com/hyderabad/doctor/raghu-c-cardiologist

Myocardial infarction is the leading

cause of death and a major health-care

burden. Treatments have evolved rapidly

over the past 50 years, but myocardial

infarction remains an unpredictable

event and one that is frequently the first

clinical manifestation of the underlying

atherosclerotic disease process.

Cardiovascular risk scores based on

traditional risk factors are widely

employed, but they remain imprecise in

estimating the risk of myocardial

infarction on an individual basis.

Advances have occurred in a variety of

both invasive and noninvasive imaging

modalities. Invasive coronary imaging

relies on gaining access to the arterial

system and administering contrast

media and specifically designed

catheters into the coronary vessels.

Advances in catheter

design and technology

now allow for an array

of additional invasive

approaches, beyond

t h e s t a n d a r d

assessments of luminal

stenosis.

Coronary physiology

c a n b e r o u t i n e l y

a s s e s s e d u s i n g

fractional flow reserve

(FFR), whereas coronary

plaque imaging has

become possible using

intravascular ultrasonography (IVUS),

and, more recently, optical coherence

tomography (OCT), near-infrared

spectroscopy (NIRS), and near-infrared

fluorescence (NIRF). Each approach

provides different capacities and

potentially complementary information

Noninvasive imaging has undergone

similar developments. In assessing

physiology, absolute quantification of

myocardial blood flow has become

Imaging for Coronary Atherosclerosis

maximal hyperemia. The use of FFR

m e a s u r e m e n t s t o g u i d e

revascularization decisions seems to

improve outcomes after intervention

compared with standard visual

estimations of stenosis

Technological advances in CT now allow

for noninvasive imaging of the coronary

arteries with high spatial resolution.

Coronary CT angiography (CCTA) is

performed during a breath-hold using

scanners with fast detector rotation

times. As with invasive coronary

angiography, a step-

wise deterioration in

prognosis associated

with one-vessel, two-

vessel, and three-vessel

d i s e a s e h a s b e e n

established in multiple

studies using CCTA. The

major current strength

of CCTA is its negative

predictive value: as high

as 95% to 99% in several

studies. Coupled with

the excellent prognosis

of patients found to

have normal coronary arteries, CCTA is

perhaps most useful in ruling out

coronary artery disease in those

considered to be at low or intermediate

risk.

The use of coronary magnetic resonance

angiography for the assessment of

coronary stenosis is attractive in principle

Coronary CT angiography.

C o r o n a r y m a g n e t i c

resonance angiography.

possible, and detailed coronary plaque

imaging is now feasible through

developments in computed tomography

(CT), cardiovascular magnetic resonance

imaging (MRI), and positron emission

tomography (PET).

Invasive coronary angiography involves

the intracoronary administration of

radio-opaque contrast to opacify the

lumen and delineates any existing

stenoses. The presence of luminal

stenoses in one, two, or three vessels is

associated with a step-wise increase in

adverse outcomes. However, the visual

assessment of luminal stenosis correlates

poorly with hemodynamic significance,

particularly for coronary stenosis

between 30% and 80%.

Pressure-wire-derived FFR has become

the favored technique, providing a

lesion-specific surrogate measure of flow

limitation derived from the difference in

arterial pressure proximal and distal to a

coronary lesion of interest during

Assessment of Stenosis,

Obstruction, and Ischemia

I n v a s i v e c o r o n a r y

angiography:

Fractional Flow Reserve (FFR):

3

Coronary artery calcium

scoring

Virtual histology IVUS

Optical Coherence

Tomography (OCT)

Coronary artery calcium (CAC) scoring

using electrocardiogram-gated CT

provides an accurate and simple measure

of the overall atherosclerotic burden in

the coronary arteries. Without the need

for contrast, CAC scoring quantifies

macroscopic calcium within these

vessels, which is pathognomonic of

atherosclerosis.

Virtual histology (VH)-IVUS is an invasive

technique that uses spectral analysis of

the ultrasound backscatter signal to

categorize plaque constituents into

fibrous, fibro-lipidic, calcific, and

necrotic tissue in real time

OCT incorporates an intracoronary fiber-

optic wire, which emits light in the near-

inf rared spect rum (wave length

1,250–1,350 nm) and measures the

backscatter from tissues during a

Imaging for adverse plaque

characteristics

given the avoidance of ionizing

radiation. However, in practice, major

challenges persist in correcting for

coronary artery motion while delivering

the necessary spatial resolution.

Therefore, although its diagnostic

accuracy is improving, coronary

magnetic resonance angiography

remains inferior to CCTA, and is rarely

used in clinical practice.

In myocardial perfusion imaging

(MPI), radioactive tracers are

used that distribute to the

myocardium according to blood

flow. In particular, single-photon

e m i s s i o n c o m p u t e d

tomography (SPECT) and PET

could be used to measure

myocardial perfusion at rest and

during stress, identifying regions

of reversible ischemia associated

with obstruct ive luminal

stenoses.

IVUS involves a miniaturized ultrasound

transducer to record the reflection of

h i g h - f r e q u e n c y s o u n d w a v e s ,

generating grey-scale cross-sectional

images of the arterial wall. This process

provides accurate assessments of

luminal dimensions and plaque volume

that can aid in the evaluation of luminal

stenoses, particularly in the left main

coronary artery. In addition IVUS can

provide accurate quantification of

plaque burden, acting as a powerful

predictor of disease progression and

adverse clinical outcomes.

Myocardial perfusion

imaging

Intravascular

Ultrasonography (IVUS)

Imaging of

Atherosclerotic Plaque

Burden

4

rotational pullback along the artery.

Image acquis i t ion requires the

generation of a blood-free field, using

small flushes of saline or contrast media.

A particular advantage of OCT is its

excellent axial resolution (12–18 μm

versus 150–200 μm for IVUS), which

allows detailed microstructural analysis

of the superficial plaque layers. In

particular, OCT allows imaging of

thrombus, plaque rupture, and

superficial plaque erosion with

improved sensitivity compared with

alternative modalities. OCT is also

increasingly being used clinically to

assess stent deployment and for

post-intervention complications.

NIRS relies on the phenomenon that

organic molecules absorb and reflect

l ight d i f ferent ly at spec i f ic

wavelengths. When near-infrared

light is emitted into a tissue, the

spectrum of absorbance, therefore,

reflects its chemical composition.

This technique can be tuned to

detect lipid within atherosclerotic

plaque creating a 'chemogram' that can

be used to identify lipid-rich lesions and

quantify the lipid core burden index.

Imaging markers of luminal stenosis,

myocardial ischemia, plaque burden,

adverse plaque characteristics, and

disease activity provide complementary

i n f o r m a t i o n a b o u t c o r o n a r y

atherosclerosis — itself a complex,

multifaceted condition. Novel imaging

approaches combining these different

factors might del iver not only

pathological insight, but also major

improvements in cardiovascular risk

prediction.

Near-Infrared

Spectroscopy (NIRS)

Multi-parametric imaging

Current protocol based on Imaging foratherosclerosis

Dr. Bernard Lown, a Nobel Peace

Laureate,is currently the Professor

Emeritus at the Harvard School of Public

Health and Senior Physician at the

Brigham and Women's Hospital in

Boston. He is also the founder of the

Lown Cardiovascular Group and the

Chairman Emeritus of the Lown Institute

that aims to reform both the health care

system and the society.

During his research career spanning

more than 50 years, Dr. Lown's

achievements changed the practice of

cardiology. He was the original developer

of the DC defibrillator and the

cardioverter. He developed the

cardioverter for correcting rapid

disordered heart rhythms and the direct

current defibril lator for cardiac

resuscitation – now the standard of care

for cardiac resuscitation.

Dr. Lown kept his focus on and

relentlessly pursued the arduous

problem of sudden cardiac death, a

leading cause of death in most of the

developed countries. He has been an

ideal clinical educator and lecturer who

inspired hundreds of students pursuing

medicine and more than 200 research

fellows in the Lown Training Program.

Dr. Lown also introduced the new use for

the drug l idoca ine to contro l

disturbances in the heartbeat. All

through his medical career, he focused

on two major medical challenges:

= The problem of sudden cardiac death

= The role of psychological stress on

the cardiovascular system

Dr. Lown's investigations led to many

medical breakthroughs. Among those

were the coronary care unit. In addition,

apart from host of other innovations, his

meticulous work made possible and also

made much of modern cardiac surgery

safe.

Dr. Lown has been instrumentals in

involving physicians worldwide in raising

awareness of the catastrophic

consequences of a Nuclear War and the

urgent need to stop these weapons of

mass destruction. He co-founded the

organization, International Physicians for

the Prevention of Nuclear War, along with

Soviet Cardiologist Dr. Yevgeny Chazov

who later was Minister of Health of the

then USSR. He accepted the Nobel Peace

Prize in 1985, on behalf of the

International Physicians for the Prevention

of Nuclear War.

Dr. Lown is the author and co-author of

four books and over 400 articles that had

been published in leading global medical

journals. His book, 'The Lost Art of

Healing' is worth a special mention here.

Drawing on his 50-plus years of practice

as a cardiologist with vast knowledge of

literature and medical history, Dr. Lown

probes the heart and soul of the doctor-

patient relationship in this book. While

his wisdom stimulate reflection, the

dramatic accounts of real-life characters

and problems throughout his 50-plus-

year career will surely move you. Don't

miss this significant conversation with a

profound individual.

A graduate from Summa Cum Laude

from the University of Maine, Dr. Lown

received his MD from the Johns Hopkins

University of Medicine.

A Physician with No Boundaries

5

"Now the doctor, by virtue of

accepting science so totally,

creates a total imbalance,

forgetting the art of healing,

fo rge t t ing the a r t o f

engagement, forgetting the

art of listening, forgetting the

art of caring and ceasing to

invest time with the patient.

So I believe medicine has lost

its human face. "

– Dr. Bernard Lown, Physician and Nobel prize winner

Clopidogrel Approval by US FDA

Endothelin Receptor

Antagonists

Nitric Oxide pathway

Prostacyclin pathway

Tyrosine kinase inhibitor

Ambrisentan

Bosentan Macitentan

Sildenafil Tadalafil

Vardenafil Riociguat

Beraprost Epoprostenol

Iloprost Treprostinil

Selexipag

Imatinib

Yes

Vardenafil

not approved yet

Beraprost approved in

Japan Trepostinil in

subcutaneous and

inhaled forms only

Selexipag not approved

Unapproved

Examples

Drug therapy for Pulmonary Hypertension

Therapy for Pulmonary Hypertension (PH)

has evolved rapidly over the past 2

decades from the era where only

Nifedipine was the only approved

therapy to the current era where we have

four different groups of drugs (Table 1).

= Acute vasoreactivity testing should

be performed in all patients with

Idiopathic PAH (group 1).

= Vasoreactive patients should be

treated with high and optimally

tolerated doses of CCBs adequate

response should be confirmed after

3 to 4 months of treatment.

= N o n - r e s p o n d e r s t o a c u t e

vasoreactivity testing who are in

WHO-FC II should be treated with

a n o r a l c o m p o u n d .

= N o n - r e s p o n d e r s t o a c u t e

vasoreactivity testing should be

cons idered cand idates fo r

treatment with any of the approved

PAH drugs.

10 steps in management of

Pulmonary Hypertension

The suggested initial approach after the

diagnosis of PAH is the adoption of the

general measures, the initiation of the

supportive therapy, and referral to an

expert center.

New drug therapies for

Pulmonary HypertensionDrug Review

= As head-to-head comparisons

among different compounds are

not available, no evidence-based

first- line treatment can be

proposed (see previous) for either

WHO-FC II or III patients.

= Continuous IV Epoprostenol is

recommended as first- line therapy

for WHO-FC IV PAH patients

because of the survival benefit in

this subset. In absence of IV

Epoprostenol all other compounds

may be utilized.

= Although Ambrisentan, Bosentan,

and sildenafil are approved in

WHO-FC IV patients in the United

States, most experts consider these

treatments as a second line in

severely ill patients.

= In case of inadequate clinical

response, sequential combination

therapy should be considered. In

case of inadequate clinical response

with double combination therapy,

triple combination therapy should

be attempted.

= It seems reasonable to consider

eligibility for lung transplantation

after an inadequate clinical

response to the initial monotherapy

and to refer the patient for lung

transplantation soon after the

inadequate clinical response is

c o n f i r m e d o n m a x i m a l

combination therapy.

= Balloon atrial septostomy should

be regarded as a palliative or

bridging procedure in patients

deteriorating despite maximal

medical therapy.

6

A 45-year male had MI 10 days prior to admission and

referred for coronary angiography and possible

revascularization. His admission ECG is shown in Figure 1.

Coronary angiography revealed two-vessel disease critical

stenosis of Left Anterior Descending and Left circumflex

coronary arteries. He underwent adhoc angioplasty and

stenting for both.

Post angioplasty on day 2 had a broad QRS tachycardia

(Figure 2). He was hemodynamically stable.

7

Q & A in the next page

8

Questions:

1. The baseline ECG (Figure 1) reveals:

2. The broad QRS tachycardia ECG (Figure 2) shows:

3. How do you treat this patient initially?

A.

B.

C.

D.

A.

B.

C.

D.

A.

B.

C.

D.

Infero-Posterior MI

Atrio-ventricular dissociation

Complete RBBB

Complete LBBB.

Ventricular tachycardia

Supravent r i cu la r tachycard ia withaberrancy

Rate dependent broadening of the QRS complex

SVT with bundle branch block

iv Adenosine

iv Amiodarone

Cardioversion

iv Metoprolol

Key to ECG Quiz: E. Concordant pattern in precordial

leads suggests VT, but positive 1. QRS duration more than 120 msec

concordancy may occur during SVT indicates complete bundle branch

with AV conduction over a left block. QRS duration in this ECG is about

posterior AP 80 msec. Presence of prominent R in

F. R nadir S>100ms in one or more lead V1 is suggestive of RBBB if the QRS precordial leads suggests VT, but duration is prolonged. The differential may be found in: diagnosis for a prominent R in lead V1

include: right bundle branch block, left SVT on drugs slowing intra-ventricular ectopy, right ventricular ventricular conduction hypertrophy, acute right ventricular

SVT with AV conduction over an AP dilation (acute right heart strain), type a

Pre-existent BBB (especially LBBB) Wolff-Parkinson-White syndrome,

posterior myocardial infarction,

h ype r t roph i c ca rd iomyopa thy, G. QR complexes during VT suggest

progressive muscular dystrophy, previous myocardial infarction as

dextrocardia, misplaced precordial aetiology

leads, and normal variant1.

The correct answer is APresence of prominent R in V2 (R/S >1)

is indicative of posterior MI and 3. Correct answer is B as the presence of QS in inferior leads

patient is hemodynamically suggestive of inferior MI.stable . But i f unstable ,

Answer for question 1 is Option A.cardioversion is the appropriate

treatment.

2. Broad QRS tachycardia of RBBB Take Home Messages

morphology is seen here. Do not panic when confronted with a

Approach to broad QRS tachycardia is broad QRS tachycardia. Look for clinical

based on these features2: signs of AV dissociation and evaluate the

A. AV dissociation suggests VT, but VA 12 lead ECG systematically. Also, when

conduction may be present during available, look at the 12 lead ECG during

VT sinus rhythm. This approach usually gives

the correct diagnosis of VT versus SVT. B. A QRS width of > 160 ms suggests

Keep in mind that statistically VT is much VT, but need to rule out:

more common than SVT in the broad C. Left axis deviation (to the left of −30) QRS tachycardia. Never make the

suggests VT, but is not helpful in: mistake of rejecting VT because the

b r o a d Q R S t a c h y c a r d i a i s LBBB shaped QRS haemodynamically well tolerated. When

SVT with conduction over a right in doubt, do not give verapamil or

sided or postero-septal AP adenosine; procainamide should be used

SVT during use of class 1 C drugs instead.

D. Right axis deviation (to the right of

+90) suggests VT in LBBB shaped

QRS.

=

=

=

=

=

=

References:

=

=

Prominent R wave in lead V1: Electrocardiographic differential diagnosis. Am J Emerg Med 2001:19; 504-13

Ventricular tachycardia: diagnosis of broad QRS complex tachycardia: Heart 2001;86: 579–585

How low should the BP be in a Diabetic Hypertensive Patient?

The relationship between blood pressure and blood including 49 randomized, controlled trials comprising

glucose has been known for >40 years, when Leren 73,738 participants mainly with type 2 diabetes (Table

et al. reported positive correlations between blood 1). The meta-analysis included only trials with >100

glucose levels and systolic and diastolic blood patients with diabetes who were treated for >12

pressure in a healthy population of white men. months. The included trials involved comparison of an

However, the association between blood pressure antihypertensive agent versus placebo, two agents

and glucose received little or no attention until versus one agent, or any blood-pressure target with

1998. In this year, the findings from the another blood-pressure target. Comparative trials

Hypertension Optimal Treatment trial and the UK between antihypertensive agents or combined

Prospective Diabetes Study addressing the interventions were excluded.

treatment of hypertension in patients with diabetes The systematic review and meta-analysis confirmed were published, and the interest in and awareness that, if the systolic blood pressure before treatment was of hypertension in patients with diabetes escalated. <140 mmHg, no benefit was obtained with the Large outcome trials have been performed in antihypertensive treatment, but was instead associated patients with diabetes and hypertension, and other with an increased risk of cardiovascular death. If systolic hypertension outcome trials have been enriched blood pressure at baseline was >150 mmHg, with large subgroups of patients with diabetes. antihypertensive treatment reduced the risk of all-cause

Today, the question is mostly how low should blood death, cardiovascular death, myocardial infarction,

pressure be lowered in patients with diabetes in stroke, and end-stage renal disease. When the systolic

order to protect against cardiovascular and renal blood pressure was 140–150 mmHg, the risk of all-

disease, because the recommended blood-pressure cause death, myocardial infarction, and heart failure

target of <130/80 mmHg has been questioned. A was reduced. The meta-regression analyses, which

well-designed, single mega-trial with appropriate included a large amount of previously unpublished

statistical power is yet to be conducted. However, data, revealed that the beneficial effect of

Brunström and Carlberg have assessed the effect of antihypertensive treatment on cardiovascular mortality

antihypertensive treatment on mortality and and myocardial infarction decreased with each unit

cardiovascular morbidity in patients with diabetes, decrease in baseline systolic blood pressure, and was

at different blood-pressure levels, in a meta-analysis harmful below certain levels.

9

BaselineSystolic BP

>150mmHg

140-150mmHg

<140mmHg

Effects

â

â Cardiovascular mortality

â Myocardial infarction

â End-stage renal disease

All-cause mortality

â

â Myocardial infarction

â Heart failure

All-cause mortality

á Cardiovascular mortality

á All-cause mortality

Table-1 | BP-lowering therapy & diabetes

DASH Diet (Eating Right) to Lower Blood Pressure

10

What diet consumed affects a person's chances of getting

High Blood Pressure (BP)?

A healthy eating plan can both reduce the risk of

developing high blood pressure and lower a blood

pressure that is already too high.

For an overall eating plan, consider DASH (Dietary

Approaches to Stop Hypertension) plan. A Hypertensive

person (person with High BP) can reduce blood pressure by

eating foods that are low in cholesterol, saturated fat and

total fat, and high in vegetables, fruits and low-fat dairy

foods. The DASH eating plan includes whole grains, nuts,

poultry and fish, and has low amounts of fats, red meats,

sweets as well as sugar-laced beverages. The DASH diet is

also high in magnesium, calcium and potassium, including

protein and fiber. Eating foods lower in salt and sodium

also can reduce blood pressure. Fruits and vegetables are

rich in potassium and should be included in the diet. Sweet

potatoes, tomatoes, orange juice, bananas, peas, and

prunes and raisins should also be added to the diet.

The DASH Diet has the following features…

The Diet Box below gives the servings and food groups for the DASH eating plan. The number of servings that is right for a patient suffering from high blood pressure may vary, depending on the caloric need. The DASH diet has more servings of fruits, vegetables and grains daily than the person may be used to eating. However, those foods are high in fiber, and eating more of them may temporarily cause diarrhoea and bloating. In order to get used to the DASH diet, servings of fruits, vegetables and grains has to be increased gradually.

Patient has to keep a diary and enter his/her current eating

habits in it. This is an excellent way to change to the DASH

diet plan. Eating habits like what a patient eats, how

much, when and why has to be noted, both by the

physician and the patient. Detailed diet habits like whether

a patient snacks on high-fat foods while watching the

television or if he/she skips breakfast and eats a big lunch

has to be noted.

=

=

=

=

=

=

=

=

=

Low in sodium – reducing salts (sodium) intake to

1,500 milligrams per day (i.e; about 2/3 teaspoons)

Low in saturated fat.

Low in cholesterol.

Low in total fat

Rich in fruits and vegetables

Rich in low fat dairy foods

Rich in dietary fibres or wholegrain products

Includes fish, poultry, and nuts

Low in red meat, sweets, and sugar-containing

beverages

Grains and grain products

Vegetables

Fruits

Low-fat or fat free

dairy foods

Lean meats,

poultry, and fish2 or fewer

Nuts, seeds,

and dry beans4–5 per week

Fats and oils

Sweets Sweets

2–3

7–8

4–5

4–5

2–3

The DASH Eating Plan

The DASH eating plan shown below is based on 2,000 calories

a day. The number of daily servings in a food group may vary

from those listed, depending upon your caloric needs.

Food Table Source:

*Serving sizes vary between 1/2 cup and 1 1/4 cups. Check the product's nutrition label.

Fat content changes serving counts for fats and oils: For example, 1 tablespoon of

regular salad dressing equals 1 serving, 1 tablespoon of low-fat salad dressing equals

1/2 serving, and 1 tablespoon of fat free salad dressing equals 0 servings.

www.nhlbi.nih.gov

Dr. C. Raghu was at Wipro office located at

Gachibowli, Hyderabad on 4 August and 11

August 2016 to deliver a wellness talk on

"Boosting Energy – Tips from a Cardiologist".

11

Dr C Raghu was Guest faculty at the

Telangana state Cardiological Society of

India held at Hotel Avasa on the 28

August 2016. He delivered a lecture on

"Primary Angioplasty – Radial/Femoral".

Dr. Raghu at Wipro Office, Hyderabad

Dr. C. Raghu talking as faculty for the first batch of CCMH

(Certificate Course in Management of Hypertension) Cycle -

I course for Hyderabad Centre at Aster Prime Hospitals.

Initiated in association with Public Health Foundation of

India, Center for Chronic Disease Control, International

Society of Hypertension and British Hypertension Society,

CCMH is an evidence-based learning, up-to-date curriculum

and on-the-job training for general physicians in India.

stDr. Raghu Taking Class for 1 Cycle of CCMH

Dr. Raghu as Guest Faculty at TS CSI

RNI Number: TELENG/2015/65122 th th Posted on 15 & 16 of every month at Mail Business Centre, Plat Form No. 10,

thSecunderabad Railway Station, Secunderabad, Published on 10 of every month,

Notional Cost: Rs. 20/-Printed at New Classic Printers, H.No. 6-3-840/A, Near MCH Market, Ameerpet, Hyderabad - 16, Telangana

Postal Registration No.: HCD-5001-2016-2018,

Printed and Published by Smt. Uma Sreedevi,

Owned by Smt. Uma Sreedevi

Registered Address: G2, Krishna Apartments, Ameerpet Cross Roads, Yellareddyguda, Hyderabad - 73, Telangana

Editor: Dr. C. Raghu

If undelivered please return to

Flot No. 201, 2nd Floor, Manjeera Square, Plot No. 6 & 7, Ameerpet, Hyderabad - 500 038

Ph: 8096398789

Dr C Raghu along with Dr Wataru Nagamatsu from Hokusetsu General Hospital, Osaka,

Japan and Dr Srinivas Movva from Aster Prime Hyderabad, have performed a complex thangioplasty of Chronic Total Occlusion of right coronary artery on 24 August 2016.