Brugada syndrome has three distinct type of ECG pattern.ST segment in V1 to V3 shows the maximal changes .All manifest as subtle forms of ST elevation .
This is an ECG of a young male who was suspected to have CAD with an abnormal ECG .(Which was Infact Brugada . )
He was adviced EST by a physician .Compare the leads V1 to V3 pre and post exercise
Prompt normalization indicate correction of repolarization heterogeneity and suggest relative immunity for development of ventricular arrhythmia at fast rates.
In contrary , new appearance or worsening of Brugada pattern would help us identify high risk subsets of Brugada.
Message : We have sophisticated genetic and EP studies available EST is a simple test to risk stratify these individuals.( Not a perfect screening test though !)
Can we close an ASD in a 25 year old women severe pulmonary hypertension ?
Volumes of literature has been written on the subject.Dedicated cath studies have been done with multiple parameters .
Still , there is a lingering doubt !
Here is a 3 minute practical* solution based on 5 easily available parameters. (*Also referred to as unscientific in medical parlance !)
1. O2 saturation
2. Pulmonary artery diastolic and pulse pressure
3. RV function,
4 .Systemic pressure
5. Functional class
If O2 saturation is > 90 % consistently there is likely to be significant left to right shunt .Closure is to strongly considered
If 02 saturation is near 95 % there is absolutely no contraindication at any level of PVR.
Systolic pulmonary artery pressure derived by TR jet is least useful index.Pulmonary artery diastolic pressure reflects true vascular reactivity of the pulmonary circulation.A wide swinging pulmonary arterial pulse indicates dynamism in circulation and hence operablity.
If pulmonary artery pulse pressure is wide (>50) , or PA diastolic BP is < 30 one can safely presume irreversible damage to pulmonary vasculature has not occurred and these patients would benefit from surgical closure .
RV function should be assessed carefully in every patient.This is as important as PVR .Significant RV dysfunction is an absolute contraindication.
Never close the shunt in patients who is in class 4 symptoms.
Never close a shunt if the systemic blood pressure is low( 90mmhg)
Some believe PDA may be closed at any given PVR , while worst outcomes occur with ASD as supra-systemic pulmonary pressure is possible.
Always monitor these patients meticulously especially in the initial days following surgery for deterioration .Most patients will do well if they cross the first 30 days. The RV learns to adopts with new pulmonary hemodynamics !
Many readers of this site might have wondered , about a series of biased articles pulling down the superiority of pPCI in STEMI.
This French study (FAST-MI) throws stunning data from the real world. Initial Fibrinolysis* defeated pPCI in all aspects of coronary reperfusion !
*When we say fibrinolysis arm it means Pharmaco -Invasive approach .Today our brain is irreversibly conditioned to believe standalone fibrinolysis is forbidden in STEMI . (Which I strongly disagree!) I am sure, very soon another stunning study will unmask the truth about standalone fibrinolysis as well !
Final message
The truth is , pPCI is really a superior modality in some of the complicated subsets of STEMI that too if performed fast.
In all other situations Initial fibrinolysis will rule supreme !
pPCI is not an Innovation for mass consumption!
Hence, “the roof top call” for pPCI for every STEMI is nether desirable nor feasible.
Now, we have this evidence from France (Which was well known to us a decade ago) As always , truth takes time to arrive , while falsehood can come instantly !
In 2014 , after two decades of celebration of pPCI the flagship Circulation journal throws this Editorial !
Unfortunately, there is a strong bias towards raw basic science when it is given in the filed of medicine.Do you know ,there is no Nobel prize exclusive for medical science ? It shares with human physiology the only field included for Nobel prize in medicine.
Evolution of human history reveals it is not the stunning scientific discoveries that impact the mankind . It is largely dependent on how we use them . It is true and natural ,invention of sub atomic particles , decoding quantum mechanics and trans-cellular signals always generate great interest than others.
In medical science, time and again we have seen problems arise in applying fruits of scientific research into practical usage in the patient domain in the bedside.
What is use of rewarding inventor of nitric oxide with a Nobel prize , when billion-dollar nitrate industry is thriving on a non existing life long indication of stable angina .
It is surprising to note , Nobel committee does give credit to wisdom & intellect while awarding prize in peace, literary or economic sciences. For some reason it lacks such a vision when it comes to medical sciences !
We have seen Nobel prize being awarded to organization that strive for peace and welfare of society and community like UN ,EU etc.The world health organization is the premier power supposed to provide and regulate the health in this planet.I do not recall any time WHO was close to considered for the Noble prize in medicine !
Nobel Ironies
Nobel committee rewards economists who point out lacunae in vital world macro and micro economics theories.
Dubious men(Heads of state ) are decorated with Noble peace prizes for preventing a war in one geographical area while doing exactly the opposite elsewhere !
In this modern millennium where scientific pursuits are contaminated and many of the research questions are misdirected or irrelevant , Nobel committee needs a through rejig in the manner in which medical Nobel prize is being awarded. We know ,Noble’s death wish was to award the brightest mind with highest scientific breakthroughs in those world . . . but
I guess Alfred Nobel if alive would have changed his rules .He wouldn’t have imagined modern science would systematically devalue common sense and reinventing it would also deserve an award equivalent to Nobel !
Some of the medical discoveries that deserve noble medical prize
States which excel in school health nutrition and other basic health programs for the downtrodden
Doctors who promote bed side clinical skills
Tobacco eradication networks
Organisations like medicine san-frontiers which strives for basic life saving medication for all
Journal houses that specialise on Medical ethics and clinical sciences
Medical professionals and institutions provide value education
Medical economists who expose the wasted financial resources that widen the gap between sick and rich
How about Nobel prize in cardiology for preventive cardiologist who successfully terminates a million statin prescription and restoring natural exercise directed lipid regulation in them ?
How about Noble prize for a noble physician sitting in corporate hospital infested with all commercial ingredients who could resist and argue successfully against inappropriate tonsillectomies and appendectomies ?
I am sure , such a man will be a laughing stock for most of us !
An appeal to Nobel committee
It is a wish , Noble prize in medicine is to be included for people who do yeomen services in preventive and clinical care and professional who carry forward the legacy of caring for the sick with clinical application of available scientific wisdom !
In this scientifically obsessed world , It will be a new beginning in the way future medical research will be directed and nurtured ! Only then the true power of Noble prize in medicine will be realised !
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Please Note
The author acknowledges all the queries posted by the readers and wishes to answer them .Due to logistic reasons only few could be responded. Inconvenience caused is regretted.
Dr.S.Venkatesan MD 