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Archive for June, 2008

                                   ACS   is the  most common cardiac emergency .  Management of STEMI is relatively straight forward.  The  only decision that to be taken is the  modality of reperfusion. (Primary PCI   or thrombolysis.) There is no need to risk stratify  STEMI on arrival. All STEMI patients are considered high risk on admission. Whereas  NSTEMI consists of  a heterogeneous  population. They need to be   triaged into low intermediate  or high risk categorizes on arrival.There is two management  approaches for unstable angina .All high risk UA should enter early invasive strategy . And low risk and intermediate risk group will get early conservative management. 

                                       The principle of management of  UA differ from STEMI in a fundamental way , as there is no issue of myocardial salvage in UA .The primary aim is to provide relief from pain and prevent an MI. So in the strict sense there is no time window in unstable angina /NSTEMI.

 

                                       But it is generally considered 48 hours is the time limit for an early invasive approach.If the patient has crossed this time there is apparently no great difference in outcome for conservative and invasive approach. 

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Why should 2b 3a Blockers like abciximab or eptifibatide produce thrombocytopenia ?

After all they  are not designed to kill  the platelets.

But in reality serious thrombocytopenia occur in a significant number of patients after reopro

That may demand platelet infusion

Answer to this question open for posting

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Infective endocarditis  remains a  major cardiac emergency.

Medical management has an initial role and  the many will require some form of surgery

( Mainly valve  replacement). But the surgeons request a realtively stable patients to operate upon as

surgical mortality is high in patients with uncontrolled infection and destabilsed CHF.

Even though there are battery of antibiotics, and volumes of texts written on the medical management

of infective endocarditis the medical therapy fails in bulk of the patients.

We have observed  emprical (Scientific guess work ) therapy has helped many patients .

While rifampicin according to scientific worls it’s useful only in prosthetic valve endocardtis

we have found it quiet useful in all resistant IE patients.

IE being a chronic inflammatory state rifampicin might work 

also as an anti inflammatory or immune   modulator.

This paper was presented in Cardiological society of India , Annual scientific sessions at  Mumbai 2005 . Download PPT

 

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Coronary artery disease has a strong   predilection  to involve proximal segments.

But in a significant population it affects only the distal vascular bed ! What is the extent of this problem ?

This paper was presented in  the annual sessions of Cardiological society of India , Mumbai 2005

Down load presentation

distal-cad-csi-2005

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2b -3a antagonists have revolutinised ACS management .

But the irony is Reo pro is approved for use only  inside cath lab or on the way to cath lab ! when PCI is done . 

If PCI with stenting is planned,  then subsequently cancelled due to  minimal coronary lesion or spontaneous reperfusion  what will be the effect of Abxicimab on outcome ?

Message 1

Abxicimab (Reopro,Faximab)

Useful only if PCI and stenting is done.

Dont use it for regular managment of UA/NSTEMI

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Aberrant cardiac conduction can occur in any of the specialized cardiac conduction tissues. Rate dependent aberrancy is the most common cause of aberrant conduction.

Generally it is thought only supra ventricular impulses can undergo aberrant conduction. But it is not always true.

Many of the ventricular tachycardia which  have inherently wide QRS complex can further widen their QRS width when it conducts fast down stream.This is especially true  in many of the septal VTs and fascicular VT  which  are falsely diagnosed as myocardial VT. These proximal VTs which other wise would have been a narrow QRS VT are converted into wide QRS VT by functional aberration .

Message :

Don’t always think SVT only has a potential to undergo with aberrancy

The VTs also can  behave similarly.

 

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Patients  with permanent pacemaker  can have disastrous consequences  if inappropriate sensing of external  electrical events during surgery. Electro cautery or diathermy should be used judiciously .

1. Aviod diathermy if possible.

2. If neccessary use only bi- polar diathermy .

3. If bipolar diathermy not available use the indifferent electrode pad away from pacing  zone , behind  the thigh.

Other options.

A .Use a magnet to remove the sensing function of PPM. Application of magnet converts VVI into VOO mode so that external current will not be sensed by the pacemaker and diathermy can be safely used.

B.The other option is use the magnet only if interference problem occur .Magnet should be availableas safety measure.

 

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