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Archive for September, 2022

Welcome to Kuna island. The Kuna Indians are really unique people. living off Panama, right in the isthmus connecting North and south America, The Kunas reside in the San Blas archipelago comprising about 360 islands, of which about 60 are populated by them. They have lived on these islands for centuries, but their exact origin is not completely understood.

 

These innocent tribes have taught an important lesson in human blood pressure regulation, vascular biology, and salt sensitivity. We know, that high blood pressure, is a maximally researched entity in medical science in terms of etiology, vascular effects, and its control. Still, we don’t know, what are the limits of normal BP for human beings. The debate will not end until we are clear about, whether human beings evolved from monkeys or emerged as de-nova organisms. Recent studies have revealed a remarkably low level of mitochondrial gene diversity in monkeys, suggesting that there has been remarkably little genetic admixture. (Ref 2)

What we know from 3000-years-old human history is, blood pressure is directly related to the physical work done by us and the diet we eat. While salt is considered pro hypertension, physical activity is a much more important determinant in bringing it down. Normal BP in a pre-civilized world was low compared to a civilized population. They also enjoyed better vascular health. Where is the evidence? It comes from the life cycle of Kuna Indians. Here is a very unique paper published in the Hypertension journal.(Ref 1) Three cheers to the authors for confirming this long pending speculation with meticulous data collection. (See the Image)

What was special in Kuna’s diet that prevented cardiovascular events? It is been shown in the study by Hollenberg, their diet contained rich in cocoa and flavonoids that made the difference.(The salt consumption was still high though)

As Kuna’s moved out from their primitive lifestyle to first, the  Kuna Nega,(a suburb) and subsequently to a fast-paced Panama city. See the impact on their systole and diastolic stress on the heart. The loss of protective effect of the native diet is obvious.

Final message

Lifestyle is the buzzword today. It is a by-product of the new civilized world that will define human health. The human vascular tree tries to sync with a new lifestyle pushing the BP curve to the north. The true normal BP for denova-human beings may still be very much lower than what we believe. A crazy suggestion was made, that human BP should match that of non-sedentary monkeys.  I Hope, we get more evidence later for such hyperboles. As of now, we have to accept, hypertension is largely due to disorder in human civilization, development, and prosperity.

 How about embracing the styleless lives of native Kunas to take control of our vascular health.

Reference

1.Hollenberg, Norman K.; Martinez, Gregorio; . “Aging, Acculturation, Salt Intake, and Hypertension in the Kuna of Panama”  Hypertension29 (1 Pt 2): 171–176.

 

BROWN (S.), ATKINS (C.), BAGLEY (R.), CARR (A.), COWGILL, DAVIDSON (M.), EGNER (B.), ELLIOTT (J.), HENIK (R.), LABATO
(M.), LITTMAN (M.), POLZIN (D.), ROSS (L.), SNYDER (P.), STEPIEN (R.) – Guidelines for the Identification, Evaluation, and
Management of Systemic Hypertension in Dogs and Cats. J Vet Inern Med, 2007, 21: 542-558

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This is the story of PCI to LAD from the customary bifurcation workshop for the budding experts, which ended up with a compulsive final OCT run-through, triggering a debate on what to do with the side branch.

What shall we do next?
  1. Just balloon dilate the distal strut
  2. Would consider a second stent. Maybe a TAP  depending upon LCX morphology
  3. At this stage, I would like to know the FFR or iFR across LCX Jail.
  4. Get rid of this OCT, Let me have look at regular CAG. I bet I can make a better decision.
  5. Leave it alone if the clinical status & profile is good

Leave it alone? Is it not an incomplete Job?

Definitely incomplete. Please realize, No job is complete in interventional cardiology. If we believe so, it exposes our Ignorance ( & some arrogance). Intentional side branch jailing is an integral part of  PCI techniques. Are we not ignoring day in and day out. 

Someone in the audience asked Why did you do OCT at all? 

The chief operator quipped “You can’t ask this silly question in a scientific workshop. We bought the OCT kit to improve the quality of PCI. We are proud of it. Really feel blessed to use it and I am sure my patients will benefit from it”. We have to agree with him. These new Imaging techniques though give us extra high-definition, but it comes with troubling revelations with their new vision. If you are pathologically honest and believe in empowering patients, it is absolutely necessary to convey the following facts in the discharge record as well. It would be something like this, “There was a 120-micron strut crossing the LCX ostium, that might continuously impede a chunk of platelets & RBCs every beat, for the rest of your life and might enhance the risk for thrombosis. (Of course, DAPT will take care of it and ask the patient not to worry)” 

OCT: One-minute review

OCT is Indeed a stunning Innovation. It can be useful in all 3 phases of PCI. 1. Assessment and preparation of lesion bed. 2. during stent deployment and optimization. ,3. Post-stenting follow up. The technology has grown so fast, now angiographic co-registration and longitudinal frame reconstruction comes inbuilt. It required 3 versions of LUMEN study and a 4 th one (LUMEN 4 ) is yet to come, expected in 2022  to prove the worthiness (or worthlessness)  of OCT. 

One attractively named DOCTORS study asked the specific question directly (Does Optical Coherence Tomography Optimize Results of Stenting)”  This is from NSTEMI patients .read yourself for the conclusion. It is not convincing to me.  Meneveau N.,  DOCTORS study (Does Optical Coherence Tomography Optimize Results of Stenting)”Circulation 2016134: 906.

Mind you, OCT is not only an expertise-dependent procedure, it also has important imaging limitations. It has low penetration max 2mm, can not differentiate lipids from calcium, shadowing behind red thrombus is an issue and most importantly it may miss the external elastic lamina (EEL) and measurement errors are real. 

Cost-effectiveness

If an imaging technique to assess a stent *(*Still waiting to prove its worthiness) could cost more than the device itself, realize how good our economic intellect is. Just because your lab has an OCT console, it need not transform into a technically perfect PCI. There are at least half a dozen factors other than Imaging that matters. 

Final message

OCT is a breakthrough technology that needs to be used judiciously and it definitely helps us understand the nuances of coronary stenting, especially in complex lesion subsets, and its mechanical and histological contents. However, let us not propagate a false message, that without OCT we can’t perform a perfect PCI. Give due respect to all those sharp-eyed interventional cardiologists with good techniques, who can do a better job, beating the HD vision of OCT, with their native blindness. 

Reference 

https://eurointervention.pcronline.com/article/intracoronary-optical-coherence-tomography-state-of-the-art-and-future-directions

Post-amble

Can you guess how many PCIs are done with OCT guidance globally?

It is less than 5 %. In India, it must be, I guess it is < 2% So, we are living in a terrifying world of coronary interventions, where  98 % of PCI is happening blindly, sub-optimally, and unscientifically., Data from CLI-OPCI registry adds more panic:  Centro per la Lotta Contro l’Infarto – Optimisation of Percutaneous Coronary Intervention (CLI-OPCI) registry:  It says device-oriented cardiovascular event (DOSE) is high with OCT detected sub-optimal  PCI.

So, what are we going to tell our patients who will undergo PCI (undergone) without OCT guidance in the past, present, and future?

Simply ask them to forget this OCT stuff. Just reassure them. Nothing will happen.

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It brings a unique sense of greatness and gratitude to hear the voice of the father of Interventional cardiology decades after his demise.

The invention he made has evolved so much. Though, Dr. Gruentzig didn’t live to see any of them, the genius in him predicted most of them. This Interview was recorded a year before his small plane, which he loved next only to his pet balloons, crashed on the Atlantic coast along with his wife. That is history.

This is how the news was reported across US media on October 29th, 1985. (Reconstructed, click over the pic for high resolution)

It was a fact, that he defied the warning and flew in the adverse weather, what many of us were unaware of was, that he wanted to rush to Emory, only to see a patient whom he had done a PTCA, a few days earlier, developed some complication. This makes his death all the more poignant (Ref Dr. H.V. Anderson )

Reference
 
Here is a good account of the life history of Dr Gruentzig.  Link to the article 

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Why didn’t you do it … for this patient?

 “I thought, he was not the right patient for the procedure. I believe, what I did was the correct decision. Why all this fuzz? after all, the patient is doing so well without that procedure,.. are you worried about that? 

“No, I need an explanation, we have a fully functional cath lab in our center. The patient came in the right window period. Still, you haven’t offered the best mode of treatment”.

“I can reiterate it again sir. Just because a lab is available 24/7, it doesn’t make all patients eligible for a  PCI. I think I didn’t commit a professional misdemeanor when I decided in favor of fibrinolysis. In fact, I would be guilty had I rushed him to the cath lab, just to satisfy the misplaced scientific position we have decided to adopt. If you think, I am culpable for successfully treating a patient without taking the patient to the cath lab, you may proceed with the penal action.

Before that, I would request you to please read the current edition of this book we all revere. (Which continues to mentor physicians all over the globe for the past 50 years)

 

The current edition of Harrison 2022 is just out. I thought, there is something great learning point in Cardiology chapter, specifically about the reperfusion strategies in STEMI

My hearty thanks to the editors of the chapter for the crystal clear expression about this much-debated procedure* and specifically choosing the word “PCI appears* to be more effective ” (even) if it is done in experienced persons in dedicated centers. The choice of the word used by the authors is Intentional and must be applauded. This message must be propagated to all our fellow physicians. What a way to convey an important truth pertaining to the management of the most common cardiac emergency, while many in the elite specialty are so dogmatic in their assertion without verifying the reality.

*  The verdict is still under the jury even after 3 decades, since the PAMI days of the early 1990s. Thank you, Harrison. What a gentle, but righteous way to express an opinion about a procedure that is apparently enjoying a larger-than-life image based on a handful of studies and a flawed meta-analysis.

Final message 

Primary PCI is just an alternate form of treatment to fibrinolysis in STEMI. Both are equipoise in the majority of patients. Extreme care and diligence are required to harvest the small benefit the PCI seems to provide.  There are lots of ” if and buts” that decide the success of this procedure. Get trained, and do it selectively for those who really need it.

Postamble

You may call yourself a super-specialist. But, please realize, If you have any doubt about key management strategies, never feel shy to take a cue from Internal medicine books. The greatness of these warrior books is that, it comes devoid of all those scientific clutters backed by premature evidence. 

 

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