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Archive for February, 2011

The review published in the prestigious NEJM seems to suggest

PCI  , the most  commonly  performed  therapeutic cardiac intervention  may  result in  more  myocardial  infarction in the community  than  the deadly atherosclerosis itself.


Can it be true in any  stretch of imagination ?

Yes , it seems so . But the only issue  is the  criteria   used to define MI  .

Comments are welcome on this article .

You won’t get the full text article free  .Try to get it from your library .It is worth the time spent  !

http://www.nejm.org/doi/full/10.1056/NEJMra0912134

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This is one of the wonderful corporate initiatives to assess the coronary angiogram and reporting . This calculator and teaching material was created by Boston scientific and Syntax study team . This  was used primarily during the  SYNTAX study.  This scoring system ,  though  appear  elaborate,  is a very  useful ,  objective way to assess coronary angiogram.

http://www.syntaxscore.com/calc/start.htm

Final message

It is encouraged to use this scoring system liberally . This will help us  to take more scientific decisions .

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  • Coronary collateral circulation continues to be a poorly understood phenomenon.
  • It reduces the impact  of ischemia , salvage myocardium, keep it viable, and  can  even  be  life saving during a STEMI
  • It can support either the same coronary artery  or the contra lateral coronary artery (Like the above patient )
  • The usefulness of  collaterals  at times of exertion is controversial .Most interventionists do not believe in  it . (Facts are opposite of course !)
  • Bridging coronary  arterial collateral often indicate hardened total occlusion and success of  PCI is reduced

Here is  the  angiogram  which shows classical intra coronary bridging  collaterals.



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We have thousands of  medical videos.When I stumbled upon this  one  ,from you tube which  I thought  will be immensely useful and   is crisply made.

It  proposes a 5  simple rules  to diagnose diastolic dysfunction .There is  also a new concept* discussed in this  video .

* What is super normal diastolic function ?  How can it be mis- interpreted as a pathological ?

Over to the video clip from  (123sonography 0

http://www.youtube.com/watch?v=qdLkbcFe_DI&feature=related

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Bicuspid aortic valve is  probably the commonest congenital heart disease.

  • It can be a totally benign entity and can be incidental finding in many .
  • Only a fraction progress to pathological entities like aortic stenosis , aortic root dilatation  etc .
  • Those afflicted need periodic echocardiography
  • These valves are prone for premature degeneration
  • Intervention is rarely required

Here is a complete review on the topic from the  top rated cardiology journal circulation.

 

Link to the article

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Coronary angiogram is probably the commonest invasive cardiac investigation done  world wide. It should run into millions every year. The procedure once thought dangerous  is now performed in few minutes in day care centers . While doing a  coronary angiogram  has become a minuscule task to most cardiologists, interpreting  it correctly remains a huge task !

Many  of the young cardiologists  get fascinated in   doing a coronary  angiogram and hardly spend enough time and mind in interpreting it.

Most of  us  succumb to the popular occulo  coronary reflex and describe a coronary  artery  lesions as though it is a  number game . It is very rarely we use the quantitative angiography tools available  in the machine. We need to meticulously  analyse   the length , morphology , distal flow, thrombus  , collaterals  etc . (FFR a new avatar tries to do some justice )

Calling   atherosclerois   by numbers alone,   such as  50 %  LAD  and 70 %  diagonal    20 % left main  is a huge  insult    to the deadly  & diffuse  disease process of atherosclerosis .We are paying the penalty for it .This is  the fundamental  flaw in our  reporting , that  makes every coronary intervention redundant.We must first  remember  we are looking at the lumen not the wall of coronary  artery.

Coronary  interventions is not about removing obstructions but  regression of  atherosclerosis  load within the coronary artery , prevent progression of it and ultimately reduced cardiac events and improve  survival. It  is obvious, it can not be achieved by wires and catheters alone . At best they can be adjuncts.One can  easily understand  why medical therapy  scores over wires  as it can take care of the overall disease process.

But still  ,  most* of  the  learned cardiology community  considers medical therapy   to be an adjunct to coronary intervention  , which  is  a  gross ignorance at it’s best !

* This is my perception. If  I am proven wrong ,  I am happy our patients  will be benefited !


Final message

Do not reduce  the importance of coronary angiogram   to a  farce  number game !

Do not get excited  by visualizing your patient’s  coronary artery. It may make you richer by few thousands. Realise , what you are seeing in a CAG is a fraction of coronary  circulation.

It is estimated coronary  circulation we visualize  daily in cath lab as epicardial coronary arteries  is less than  2  % of entire cross section of coronary  circulation.

This means we are 98 % blind ! ( or  2 % wise  !) .Spend  adequate  time and  mind to interpret it correctly  , so that logical and useful  ( non ) interventions can  be done .This only can make you a  true cardiac professional and your patients will respect you.


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Healthy heart syndrome (HHS) . This is  essentially a state of mind  , being in constant worry  that something  will happen to their  heart , in spite of  having  normal parameters.

HHS is a new age medical entity  of   the mankind   .  Here  the heart suffers   because  of excessive  knowledge  , affluence and entry of market forces into health care .

  • It is often a media driven frenzy . Having an insurance policy is the biggest risk factor
  • May be cured after taking few scans and some times end up in invasive Angiograms or even a PCI
  • In a  few it takes a course of  malignant anxiety disorder . Those afflicted indulge in daily BP check weekly cholesterol check , monthly cardiologist visit and yearly  64 slice CT scan.
  • Curiously ,   the definite cure  occurs only    after they suffer a heart attack .This makes them less anxious as the inevitable  has  been experienced .
  • There are occasions when too much anxiety  (for not developing a heart problem !)  will trigger a real event .
  • Some of the   medical institutions and health care providers   are also part of the problem as  many  of them perpetuate the condition as  they  keep these vulnerable  people (with healthy heart) guessing  and  do not fully disclose the reality .
  • The incidence of HHS seems to be rampant  as  there are  recurring instances of multiple stents deployed  in  apparently healthy hearts  .

Final message : Let us suffer from disease not from health !

While , many  patients with  multiple blocks ,  bye -pass surgeries   and  half- functioning  hearts  ,  lead  a   near normal life  ,  it is  ironical ,  a substantial number suffer    with  HHS and inappropriate  interventions .

Let us hope ,  modern medicine  which  goes deep into Nano medicines  and bio Robotics look  into this issue also !


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A must read for all clinical cardiologists  and fellows  .   A comprehensive review on pericardial diseases.

It also  highlights a new diagnostic parameter in cath lab to differentiate constrictive pericarditis  from  restrictive cardiomyopathy .The area subtended by RV pressure curve and LV pressure curve moves discordantly in constrictive  pericarditis   while it moves concordantly     in restrictive  cardiomyopathy

Source : Mayo Clin Proc. 2010;85(6):572-593

 

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Coronary collateral circulation is probably the most poorly understood circulation than any other.This  is ignorance at it’s best ,  in spite of the life saving potential  of this circulation. A popular  (mis )perception is  coronary collaterals  can support only  resting blood flow and it would  struggle  to compensate at times of exertion. This is based on few case studies and not based on large , authentic scientific data.

Does this reasoning mean  , coronary  collaterals   can never / ever be complete  ?

If we believe so   . . .we are grossly underestimating the power of  nature .(In fact , mankind  was humiliated by the nature  time and again !)

Lessons  from  a unique patient we have  encountered.

Here is an example of total LAD/LCX  occlusion with good collateral  from  RCA. He was having  stable  angina on medical  management . This patient  was not only  asymptomatic and was also negative for exercise  stress test at moderate work load .

 

 

 

 

 

 

 

 

 

 

 

There was an  intense debate about the management  when this angiogram was presented in the cath meeting .


 

 

 

 

 

 

 

 

 

 

  • Most of the cardiologists believed so !  But they had no answers why his stress test was negative.
  • The other argument for CABG was one can not allow a patient with a functionally single coronary  artery (RCA) However good is the collateral circulation.This at least  has some logic. not the first one !
  • One more suggestion was to quantitate  and map the real extent of ischemia by PET scanning and then decide about revascularisation.
  • One critical opinion was , since he was doing well with medical management what was the need to do coronary  angiogram at all ?

Any answers  . . .

He  ultimately went on to receive CABG (By popular opinion ) , but the point here is the collaterals were  good enough to support exertion.We have  documented quiet a few similar patients with collateral circulation supporting exercise.

What  happened to the collaterals  and (of course ) the patient after surgery ?

I will post you the  curious story soon   . . .

Final message

Coronary  collateral circulation , if well developed  can provide hemo-dynamically useful support even at times of exertion *

* The existing literature  is  biased against this concept. It generalizes all grades of collaterals into a single   entity. It is better  if we  spend more time to understand the nuances of coronary collateral circulation .

This is the  message from our observation. Do not ever believe whatever is published as facts in scientific literature. Observe, analyse , create your own inference ,  and concepts. Mainstream cardiologists would brand it unscientific  , Simply ignore it . Many times it is rewarding  to our patients.

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It is often said optimism is key to success . From the patient’s and physician’s  perspective   it is the willpower that has saved many lives. Positive minded patients  do not die without fighting. We  know self belief can do wonders in medical  care  !

If  self  belief is  the ultimate healer ,   trusting the   doctor  and  the hospital  are  equally important  . Patients believe in  doctors and doctors believe in science . Science is not sacred .It is man-made   .Those men  who create  science  need not be  holy  either !

Can  we  trust modern medicine in the current form  ?

I am afraid the answer is  too tilted towards  . . . “No”   I am not a pessimist  in the strict sense  . However ,   the future   looks bleak  in most places  ! unless some strong remedial measures are under taken.

Statistics   suggest , patients  are  rapidly losing   the belief   in their physicians   ,  considering the track record of our  health care management in recent  times . Global trends in the last 5 decades indicate the health care delivery system has gradually  been  hijacked from the Govt to the private hands.

It is  quiet a shocking  revelation ,   the private  sector  health care  has done  more damage  than  the state   driven health care . How  foolish   our expectation  can  be !   For fulfilling the millennium  goal ( Health for all )  most  countries  have  handed  over the  baton  to the  greedy corporates .

How on earth , one can expect  the   private / corporate  sector  to provide  equitable health   for all  . It  would be wealth for all  those involved in  this flawed medical care  system  at the cost of  poor !

Read this book  . . .To understand the nuances of how our health care industry is bulldozing  , like an army tank into the population  and  most of us  is a victim or a partner to this .

Click here  for  the  Book review

From The Hindu January 2011

Final message

Entry of capitalism into health sector is probably the worst  infliction   man kind  has suffered , than all those deadly viruses and bacteria   over a last few centuries !

Medical science is a phenomenal  gift  created , nurtured and grown by the sixth sense of our ancestors .Their only aim was to provide relief to the sufferings.  Now their dreams,  vision and goals lie  shattered .

No hospital  has a  specialty called  “humane care”  , while  many  have  a separate  department   to  do a  neuro  metabolic imaging    for a  depressed  man with Alzheimer  disease   in his nineties   and  a  Bio – Robot  driven    fuzzy logic  lab   to  predict cardiac  events  in a soon to die rich man . Absolute waste of resources !

There is  no doubt , we have become a  sort of  salves to  science  . . . (Irrational science to be precise ! ) It is a man-made monster.  Even a most conservative person  (including the author )  could    be causing  some damage as we  are forced to follow  the unruly scientific publications .  Probably  . . .yes . . . we can’t eliminate  it   but   identify  futility of modern science try to get  rid of it . !

http://www.amazon.com/Morbid-Symptoms-Capitalism-Socialist-Register/dp/1583672036

A related article

Those were the days   . . .  When doctors practiced medicine  . . .and much more  . . .

A  wonderful  piece of writing   by Dr Susikaran  Thangasamy from the open pages of  India’s national newspaper

‘The Hindu” http://www.thehindu.com/opinion/open-page/article1137935.ece

What is the remedy ?

First of all , every one should answer this question to their conscience

What ails  our health care  system  today ?

Do not be part of it . . .  solutions  will come automatically !

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