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Archive for March, 2013

A comprehensive , evidence based . . . “unethical” STEMI guidelines !

Posted in Cardiology -Interventional -PCI, cardiology -Therapeutics, cardiology- coronary care, cardiology-ethics, tagged , , , on March 24, 2013| 1 Comment »

Acute MI kills a few million people world-wide every year .It does not differentiate rich from poor. Logic would  tell us  , principles of management  should  not differentiate  the people  when  dealing with a myocardium in distress .

Unfortunately , we scientists do it with passion !

The problem is enormous  . . . the rich is suffering from too much* care and the poor is suffering from want of care !

The following flow chart  is a result of my observation from close quarters  about the management strategies in corporate as well as Govt hospitals .

The first chart exposes the problem .The second one tries  to address the issue

Please bear with me . . .  if the  stuff  sounds  too crazy !

* Too much care is also referred to as inappropriate care

Practical and ethical guidelines for stemi management corporate

And for the solution  . . . try this

Practical and ethical guidelines for stemi management

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Primary PCI gimmicks :Thrombus jailing and . . .controlled release of thrombus !

Posted in Cardiology -Interventional -PCI, PCI PTCA Hardware, STEMI-Primary PCI, tagged , , , , , , on March 24, 2013| Leave a Comment »

Soft skills in pPCI 

Experience  would tell  us only about 70-80 % of STEMI are truly eligible for a  good  quality pPCI .(Multivessel CAD, Complex bifurcation lesion, difficulty in identifying IRA, No IRA-sapsms , complete spontaneous reperfusion )  The remaining 20-30 %  should , logically  be included in the failed pPCI category .This fact is largely concealed in the literature .

Beware of huge thrombus load in every patient with STEMI .The  contribution of  mechanical occlusion  vs thrombus  (in the total occlusion )  is the single most important factor in determining the intervention strategy.

Deploying a stent in a poorly  prepared (debrided of thrombus  ) lesion confers  further continuous  risk of a STEMI .Stents smartly jail  even large thrombus against the coronary vessels and they release it into the lumen in a controlled fashion  and prolong  the  acute coronary  risk phases

If thrombus aspiration  does a neat job and establishes a good   flow , if the   lumen  appear   good , think twice or even thrice before deploying a stent .It is akin to stent a  zero % lesion and we know it is foolish to do that at any stretch of imagination .(Stenting has never been proven to convert a vulnerable ulcerated lesion into stable one )

IVUS, OCT are not the answer in the above situations  as we are dealing with  emergency coronary  fire fighting !

Of course the intensive anti-platelet   protocols , will take care of  potential after effects of the intra coronary contact sport we play  !    . But . . . there is a limit for every thing. So spend as little time as possible when attempting catheter based reperfusion during STEMI.

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Heros of electrocardiology : Sodi pallares -The great Mexican cardiologist !

Posted in cardiology -ECG, Great websites in cardiology, history of cardiology, tagged , on March 23, 2013| Leave a Comment »

In the early  20th century , Waller invented the ECG machine. Wilson  created  leads and  methods to record it. Eienthoven  formulated the concepts the electrical theory behind ECG.

Between 1940-197os one man ruled supreme in the world of electro cardiography .   He is Dr Sodi pallares from Mexico. His deep insights revolutionised  and helped  us  understand how the cardiac electricity is generated  and propagated  in various pathological states that is the beginning new age electrocardiography! It adds much to his  credit , as in those days scientists  from non American and European countries   were hard to come  in the  global limelight.

Some of his thought processes and Inventions

  • He laid the foundation  for deductive electrocardiography.
  • Applied  vectorocardiographic  principles to scalar  ECG and helped  understand mechanism of ventricular chamber enlargements
  • He was instrumental  to analyse  the genesis of current from the myocardium . He tried to reason out  the contribution  of  cell metabolism, hypoxia, electrolytes to the current genesis.
  • Polarising myocardium with GIK infusion STEMI was proposed by him
  • Finally he tried to incorporate the laws of thermodynamics into electrocardiography .

Please remember , Sodi pallare’s  conscience  is still largely unexplored .There are lots of hidden truths .We now know fever can influence qrs voltage and febrile illness can trigger  ventricular tachycardia as in  of Brugada syndromes.

Today’s youngsters can take a  few cues from this great man and enlighten the field of electro-cardiology

DOCTOR DEMETRIO SODI PALLARES

Demetrio Sodi Pallares (1913-2003 )

If  modern-day cardiologist is able to  interpret the  ECG by a cursory 3 second scan of  strip of waves  , we are greatly  indebted to the knowledge imbibed by this great man from Mexico !

Sodi pallares

Reference

http://onlinelibrary.wiley.com/doi/10.1002/clc.4960110616/pdf

Sodi-Pallares D,Medrano GA, Bisteni A, Ponce de Leon J:
Deductive and Poly-paramerric Elecrocardiography.Instituton acionalde
Cardiologia de Mexico, Mexico,DF1970,VII,VIII
Sodi-Pallares D, Testelli MR, Fishleder BL, Bisteni A, Medrano GA, Friendland C, De Micheli A. Effects of an intravenous infusion of a potassium-glucose-insulin solution on the electrocardiographic signs of myocardial infarction: a preliminary clinical report. Am J Cardiol. 1962;9:166–181

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How does the onset of AF modify the auscultatory signs of mitral stenosis ?

Posted in Cardiology - Clinical, tagged , , on March 21, 2013| Leave a Comment »


mid diastolic murmur

mid diastolic murmur in  sinus rhythm

With the onset of Atrial fibrillation

  1. The  first heart sound becomes variable in Intensity (Soft to loud in pliable valve / Soft to softer in calcified valve )
  2. Opening snap continue to occur as long as the  valves are  pliable and noncalcified  .The timing may vary but Intensity remain same .
  3. A 2-OS interval is usually less influenced by AF  as it is primarily determined by mean LA pressure at the onset of diastole which has little variation beat to beat .
  4. Length of the diastolic murmur varies . In Short cycles  MDM  can be  very brief  or even in audible.
  5. In long cycles MDM will be distinct.
  6. A late diastolic murmur in long cycle indicates severe MS.
  7. Even pre-systolic accentuation may be appreciable in some of the long cycles .

Link  to  Echo Image of  Mitral stenosis .

https://www.youtube.com/watch?v=3qvOMwOshg4

How to assess the severity of  MS in the presence of AF ?

  1. Presence of AF by itself indicate presence of severe MS  in most .
  2. A2-OS interval  may be useful
  3. Concentrate on long cycle .Look for ( rather listen !)  for late diastolic component of  MDM .If  you hear it ,  MS is usually severe

Other signs  are often useful

Low volume pulse

Inconspicuous LV impulse

Presence  of  any significant Pulmonary hypertension

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Dynamic asucultation : Effect of squatting on MVPS -MR

Posted in Cardiology - Animations, Cardiology - Clinical, Clinical cardiology, dynamic auscultation, valvular heart disease, tagged , , , , on March 17, 2013| Leave a Comment »

Squatting is a simple physical  maneuver that can  be done in bed side.

  • Squatting  increases  systemic venous return.
  • Raises aortic after load and SVR

It is  ideal to do  “Stand -Squat -Stand” sequence to appreciate the attenuation during squatting and augmentation during standing

squatting dynamic auscultation mvps mitral valve prolapse

Hemodynamics

MVPS-MR is  a pre load (LV volume )  dependent phenomenon.The degree of prolapse is inversely proportional to the LV size.

Squatting increases the venous return and after load both tend to  increase the LV volume. More blood in the LV  , means mitral leaflet floats much closer to the  mitral annulus . Hence the  force of LV contractility is not only  less on the prolapsing  leaflet , it  reaches late ,  hence the click is delayed  and murmur is short (It may be less intense as well * )

(* Squatting increases aortic after load hence the murmur of MR  may  get amplified .)

Reference

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