Archive for May, 2013

Modern human life is driven by technology  . We are gradually taken over by gadgets .Heart is not an exception . Implantable cardiovertor defibrillator (ICD )  is major innovation  where in , an  electrically  wayward heart  is brought under control  by series of automatic shocks . One of my patients with old MI and significant LV  dysfunction for whom ICD was an option  taught me a lesson in physics  . During  counseling ,  he was asking me about  the quality of life issues etc .
ICD  shocks  during sex 2
First,   he wanted to know  how  stressful  the  sexual acts  are ?  . . .Then he  surprised me with this  question .  He wanted to know ,  the  risk of  developing a VT/VF  during the act and  will the ICD  shock  his spouse as  well ?  That was a real  cracker of  a  question  I thought .   I had to do  a mini  research   and found that  these are  low energy shocks (30 Joules)  and transmitted electrical injury is a non issue  .
I realised   then  . . .  we live in a era  where   physicians often get educated from their patients !
Here is the  FAQs on ICD from the patient pages of circulation . With  due courtesy I  reproduce it here.
ICD  shocks  during sex
Final message
ICD shocks are  low energy shocks delivered  Intra cardiac ,  and  rarely  reach the surface  ,  hence has little risk for electrical injury  for those in contact.
1. Vazquez LD, Sears SF, Shea JB, Vazquez PM. Sexual health for patients with an implantable cardioverter defibrillator.

2.Steinke EE. Sexual concerns of patients and partners after an implantable cardioverter defibrillator.
Dimens Crit Care Nurs. 2003;22:89–96
3. A  review article on the  broad issue.
sexual activity in cardiovascular disease  circulation 2012

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This is an  ECG which  I reported  yesterday in my clinic . I thought it was a  near perfect example for sinus node premature beat .

sinus premature beat spb 2

(Of course I need to explain  why the  P morphology  slightly  differs )

A  sudden unexpected  QRS  complex is often called as  ectopic beat . If it occurs prematurely (ie earlier than anticipated )  it is called as premature beat. If it occurs late it is refereed  to as escape beat .Please note the difference is not absolute .

Sinus node is a dramatic bundle of energy with divine powers that  drives rhythm of life !

The pacemaker cells are arranged in a compact fashion with  differential properties from cranial cells firing fast and caudal cells little slower. The neural control is under constant Neuro/electro/humoral  servo control mechanism.It is well known the pacemaker shifts it’s firing location within the SA node in fairly regular fashion .The entire SA node has rich adrenergic and  cholinergic  innervation , with  a dominant control by the later . (This is  why the intrinsic heart rate is  in the tachycardia  range (around 116 )  when SA node is denerved  pharmacologically )


sinus premature systole spd sinus node ectopics002

SA node ,  being  a complex structure ,  it is not surprising to note  few beats to fire  slightly late  or  prematurely.If it occurs late it is called sinus pause ,  if it occurs early it is sinus premature beat , if  both occurs  interchangeably  we refer it as  sinus arhhytmia. (Read  about sinus pause here)

What is the clinical significance  of   SPD ? (Sinus premature depolarisation )

It is a  very benign entity that it is  merely an  academic fascination . By  stretching my  imagination  I  can  correlate  it  with few possible  clinical issues.

  • May be it has potenital to trigger a  SA nodal reentry tachycardia  or In appropriate sinus tachycardia/bradycardia.
  • It may be imporatnt in sinus node modification process.
  • However ,the main issue is  thee  cardiac physicians  in their enthusiasm should not mistake it for some serious  cardiac arrhythmia !

Related article


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April-May is carnival time in India . . . cricket carnival. In IPL . . . Indian premier league , eight teams will fight for the cup . IPL 2013 became a smashing hit , until last week when three players were arrested for spot fixing in an over . And for the past 10 days the entire Indian media has gone into manic reaction over it !

Still , the sport was wonderful , the skills shown were extraordinary , and what happened was an aberration just like in any other aspect of life . IPL is perfect mix of sports , business , commerce and some sleaze . Actually in a successful business model , one should actually be surprised if corrupt practices does not occur !

The game of cricket can never be killed by money ! The way the issue was handled by the media and the reactions and public debates for me looks irrelevant . Is it justified ?

We the people and media has much much important things to do in India !

scandals in india

Fixing a Fix . . .

Politicians fix voters by giving money !
Media fixes news for money !
Students of the noble profession are desperate to fix examiners with money !
Finance ministry’s annual budget is fixed by business tycoons !
Private medical colleges fix entrance exams after getting money !
Super powers fix terrorists selectively for money for self benefits !
Drug companies fix doctors with money !
Doctors fix labs by getting money !
Anxious parents try to fix marks of their children for money !
Government fixes tender for money !
Live kidney donors are fixed by criminal cartels for money !
Advocates fix false evidence with money !
Innocents are fixed as criminals after getting money !
Thousands of marriages are fixed with money after hiding illicit relations !
Huge bank loans are fixed based on false affidavits and promises !
TV reality shows are fixed with mad money !
Even pilgrims fix Darshan time by paying huge money !
And finally . . . One cricketer bowled one of the balls . . .wide . . . . in one of the over after getting money !
The whole world erupted !
cricket scam India
Can there be any justification for justifying wrong things in life ?
If life is a fight between good and evil , I thought it is absolutely absurd to justify it until recently . . . but a great epic of India , Bhagawad Gita which is considered as the ultimate guideline for living ,differs (Or is it my perception !)
The summary of the epic goes something like this
  • Whatever happened has been good.
  • Whatever happens is good
  • Whatever will happen is also good.
Bhagavad Gita has one more sermon to confuse us ( me ) completely !
“Do your duty , do not expect any returns and do not watch injustice silently , protest and fight it with your full potential” !
I welcome the experts of the Bhagawatham to clarify me on this issue !

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Multivessel PCI during acute STEMI is forbidden except in cardiogenic  shock . (or in some very unstable patients without cardiogenic shock)

The reason

  • During acute MI   hemodynamics  are precariously balanced.We do not know yet how  emergency multivessel plasty alters this .
  • Our  initial aim should be   confined to myocardial salvage in the IRA . Total myocardial revascularization is niether  the  priority nor its desirable.
  • The more  time  you spend  within the inflamed coronary artery , more its  hazardous.
  • Multiple stenting  is prone for thrombus   and  migration  into side branch .
  • Stent opposition is sub optimal in many thrombus infested lesions.

Still  . . .  in real world it is extremely difficult to curtail the urge to stent  all eligible lesion during primary PCI !

multivessel angioplasy during stemi

How to avoid it ? 

If the patient is poor or the insurance limit is low , the issue  of multi vessel stenting does not arise at all  !

Always  ignore  complex  non IRA lesions  during primary  PCI. Be happy if a non IRA has a bifurcation lesion !

Still , some lovely looking lesions in non IRA  would be  tempting  and inviting .  Indulge at your own risk !

* Please remember if  the proximal  LAD  has a non IRA lesion , it may be sensible to attempt  simultaneous revascularisation even if the patient is stable !

Other unrealistic advice

  • Keep the professional fee and other benefits   fixed whether  we do a single or multiple   vessel stenting (Realise  . . .  surgeons do not charge more for a  4  vessel by-pass graft  than a single  ! )
  • Keep the current AHA/ACC/ESC guidelines pasted right next to the fluroscopy monitor .
  • Ask your subordinates to repeatedly caution   you  about the possible  excesses and ask them to wave a red flag !
  • You may  empower the   senior staff nurse   with a veto power  to shut off the cath lab once IRA plasty is  completed and the patient  is stable.
  • In extreme  situations , keep a cath  marshal ready to manually evacuate  the primary operator  from cath lab !


multivessel angioplasty during stemi


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The link between brain and the  hand  starts right from fetus .  It is a well known fact  vertebral artery   competes with hand blood flow  . In the right side , there  is one more  vascular issue !  .Bracho cephalic  artery  arises  directly  from aorta and supplies the  right  hand and  right half of brain.

It remains a mystery  why left brain  is   blessed with a  separate  origin ,  while right has to share it with blood meant for hand  .It is beyond science  . . . isn’t

It is possible the left hemisphere  of brain   has more   purpose   to be alive  ,  with bulk of the cognition work to do . Hence   God created a  separate  supply to it !  Of course , he  would   have never  thought ,  the  possibility of  his ” mean” creations   adventuring  within the   arterial tree  !

Click over the Image for animation

right radial artery coronary angiogram  pci  risk of stroke 002

Please remember  whenever  we   play with   catheters and wires  through   radial route , we  are  hugging  and scraping   the artery meant  for cerebral circulation !

Final message

Femoral Interventions  enjoys a proven  track record. Currently ,  radial route has virtually taken over with  few  advantages . However , the  overall stroke risk in the two approaches  remain  low but genuine (.4 %) .It may be true , arch manipulation is more  with  femoral but  the threat to  vertebral and brachiocephalic circulation  is more with radial .  When the available evidence are  not conclusive  and  new ones are not forth coming  . . . it is wiser to rely on common sense !


I think  this 2011  study  from the  prestigious stroke journal  has convincingly answered the issue

cholesterol and ateromatous emboli following coroanry intervention 2

cholesterol and ateromatous emboli following coroanry intervention  radial vs  femoral 2

It concludes , the right radial approach  is indeed risky  to develop cerebral  micro embolism   when compared to right femoral

A Review article in  Circulation

cholesterol and ateromatous emboli following coroanry intervention 2  radial vs  femoral 2

Other references


2.Transient Cortical Blindness after Coronary Angiography Journal of International Medical Research. 2009;37:12461251,

3. Stroke and Cardiac Catheterization Circulation. 2008;118:678683,

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