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Archive for the ‘Cardiology – Clinical’ Category

When a patient comes with angina at rest , it could mean two things .Either a  STEMI or an NSTEMI .This , we can diagnose only after seeing the ECG .

Can we differentiate these two by the  character of chest pain alone ?

Very  tough task isn’t  ? But there are some definite clues .

Infarct  pain

  • Is mostly sudden .
  • Likely to be crescendo , lasts more than 20-30 minutes .
  • Fails to get relived by rest or even  Nitrites.
  • Sweating due to sympathetic activation is more pronounced.

Unstable angina

  • Is rarely  sudden .Often has a pro-drome.
  • UA is  mostly precipitated by an increased demand situation or a stress.
  • It has  a typical waxing and waning  pattern . Rarely assume a true  crescendo character  as myocytes  does not necrose (Just threaten to die !)
  • The chest pain radiation   to  shoulder is less  conspicuous , instead it  tends to  reach  the  jaw area .(* An observation,Is it something to do with multi-vessel CAD in UA ?)

Mechanism of the difference : Epicardial vs Endocardial angina

The pain of UA is   due to subtotal occlusion and  endocardial ischemia , while STEMI is  sudden total occlusion  and the resultant  transmural  ischemia . In STEMI  epicardial  surface is always involved (Which lifts the ST segment in ECG .).We know epicardium  is same as  visceral layer of pericardium which is well innervated .Hence  pain  of STEMI   acquires  more of somatic character  than a  predominately visceral type pain  that occurs with  UA/NSTEMI where epicardial ischemia is absent.

Clinical importance

The demarcation between unstable angina and Infarct pain becomes vital when we calculate the time window for thrombolysing STEMI .Many of them have a phase of pre infarction angina which is a type of unstable angina. If we mistake it for Infarct pain then one may falsely calculate a prolonged time window and deny re-perfusion therapy.

Post -amble

It is tricky issue  to differentiate the  chest pain of  STEMI and NSTEMI  .A significant overlap can occur  in  real coronary care scenario . We know   chest pain  that occurs in both   pre and post infarct  phase  is considered  as unstable angina .(With infarct pain sandwiched between them!) Hence differentiating  them may even be termed as futile.

Still,clinical cardiology  can be  made  fascinating by indulging in such exercise !

 

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This  query often  evokes  confusion  among fellows and General physicians .

              The answer is simple .Yes ,  you can.(With few conditions)

  • Thrombolysis  or PCI  is  done  with reference to  the  presence  or absence of ST elevation and chest pain.
  • If there is ongoing chest pain  and  significant new onset ST elevation  thrombolysis or PCI is indicated whether there is associated q  waves or not.

Clinical situations 

 Ischemic  q waves: Q wave can occur  with transmural ischemia which result in electrical stunning and loss of R waves . (Many of them  regenerate this R within few days after STEMI ,  indicating the q  waves can be  ischemic  in origin)

Reinfarction : Patients with  old  MI can develop fresh ST elevation  in q leads due to tachycardia and dyskinetic infarct segment .This group  of patients  should be carefully evaluated before labeling them as  re-infarction

* q RBBB in early hours of  anterior STEMI is fairly common which  may revert later. qRBBB is not a contraindication for re-perfusion .

Final  message

Presence of q waves does not  imply one should not  entertain  thrombolysis or PCI .The decision  to reperfuse  , rather  goes with  presence of  chest pain , ST elevation and  of course  within the  acceptable   time window!

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The right ventricle  is considered as a docile cardiac chamber with passive filling and  emptying  properties .

This belief  was reinforced when Fontan  in early 1970s suggested a principle in the management of  cyanotic heart disease  when  the right side of the heart is underdeveloped. He  proved  RV can be by-passed safely , with  great veins  (IVC/SVC)  by  themselves  take care of filling the pulmonary circulation  without the need of RV pumping function.

While it is true for few complex cyanotic heart disease, largely this a misleading  concept. In clinical cardiology practice  ,sudden or non sudden  RV deaths happen every day in the form of . . .

  • RV Infarction
  • Acute RV dysfunction in massive pulmonary embolism
  • COPD with RV dysfunction
  • Most cases dilated cardiomypathy  the terminal event is due to RV  failure.

So , RV function can never be dispensable in day to day cardiac hemodynamics.

RV has some unique properties in terms of shape , size and  hemodynamics . We are getting more insights from  modern blood pool imaging by MRI , about  how the RV handles the blood volume .

We know RV has a unique shape  triangular ( partially  pyramidal ) . It can be inferred the RV cavity is formed by fusion of  many  eccentric spacial planes. We have always believed  RV handles the blood it receives from right atrium in a unique way .Now we are beginning to understand it .It is now documented the RV segregates the blood it receives into 4 components.

 

right ventricle physiology anatomy hemodynamics

It is curious  to know  RV inflow is connected to the outflow by an invisible   physiologic Bridge . About 44% of  blood traverse the RV in this fashion.

 

RVOT blood flow right ventricle

Note : RV blood flow preferentially enters the RVOT with out transiting RV body and apex.Image courtesy http://ajpheart.physiology.org/

 

Which is the most important part in RV ? (Among Inflow, Body, Apex, Out flow)

After reading this article it seems to me , the mechanical  function of RVOT could be most  vital. If it fails to handle the first increment  which  comes directly from  RV inflow, stasis  is likely in RV body and apex , elevating RVEDP and later promoting stasis leading to clinical events.

Clinical implication of this study

  • Differential dilatation RV chambers to pressure or volume  overload is observed .
  • We need to analyse why RV dilates in some   but   goes for hypertrophy in others when confronted with pressure overload (VPS vs PAH)
  • RV apical clot in restrictive cardiomyopathy  is a direct consequence of stasis  of blood  in RV apical zone .
  • RVOT pacing  may have a hemodynamic advantage  over RV apical pacing  . However , for anatomical reasons RV apical pacing  is  far safer than RVOT pacing where the lead  is subjected to constant life long strain due to this busy RV inflow to outflow express  high way !

Final message

Traditionally we have labeled  RV  as a  passive venous chamber .It is clearly a misnomer.It  has to handle both the venous and pumping function beat to beat with precision  without  back log .Obviously ,  RV has to think and work  more than it’s  big brother !

Reference

I wonder , if  there is  any other site other than APS . . . to  find crucial  answers in cardiac physiology  !

 

Right ventricle physiology blood flow  3d 4d analysisAfter thought

  • There is huge gap between physiologists  who work in research labs and the physicians at bed side .
  • I appeal all young cardiologists  to visit  APS  once in a while ,between your busy cath lab schedule and help narrow this gap.
  • Without understanding the physiology properly how are we going to intervene the pathology ?

 

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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 !

 

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nobel prize in medicine 2

Why not Nobel prize for clinical  science ?

 

nobel prize for medicine

Nobel prize was constituted  to reward people or organisation  who make a  huge impact on the welfare of man kind. It is given in various categories  for  outstanding contributions in Physics, Chemistry, Literature, Peace, Physiology or Medicine, and Economic Sciences

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 !

Reference

Link to Wikipedia Nobel prize in Medicine

 

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What happens to diastolic blood pressure in severe Aortic stenosis ?

Traditional answer: The diastolic BP remain unchanged. Only systolic BP falls as it is related to LV  stroke volume .(What we refer to as systolic decapitation of BP  )

Reasoning :Diastolic BP is related to peripheral vascular resistance , hence aortic stenosis has  little impact on diastolic BP .

 Further analysis

If we assume only the systolic blood pressure  is bound to decrease in  AS , at one  critical point of time*  systolic BP  should  approach  the diastolic pressure and pulse pressure should approach zero .This can not happen , hence at that point  diastolic pressure will also fall.

*What is that  point ?

No one really knows !

Correct answer

In severe aortic stenosis  both systolic and diastolic pressure falls , but the fall in systolic BP is more striking .

* Though it is customary for clinicians  to discuss them in isolation both systolic and diastolic  blood pressure are closely coupled parameters..In the absence of peripheral run off one of the  strong determinant of diastolic BP  is . . .  systolic BP !

Complex concepts

1. What happens in combined aortic stenosis and regurgitation ?

In  combined AS and AR   we get  pulsus bisferiens. implying  AR will  elevate the systolic blood pressure in spite of obstruction.

2.What happens in associated systemic Hypertension  and aortic stenosis . (Which is very common combo in elderly )

Since HT will increase the  aortic pressure , the LV-Aorta gradient tend to fall.

However ,this  does not happen always as if the original cause for HT was  dependent  more on the stroke volume rather than peripheral mechanisms .

3. Aortic stenosis with aortic  atherosclerosis .

A stiff aorta augments the percussion wave amplifying the symbolic BP and blunting the  classical anacrotic pulse of AS.

4.What happens to BP  during exercise in  severe AS ?

Exercise demands raise in systolic BP and temporary reduction in diastolic BP due to peripheral  vaso dilatation in exercising muscles.

If a fixed  crtical AS does not allow the systolic BP to raise  as required , diastolic continue to fall pulse pressure should still become wide .

Excercise testing is a tricky business in AS. Some have attempted it to assess the functional capacity.(Read below)

Reference

 

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Learned physicians will agree, BP recording by classical auscultatory   method  is  not always an  easy task !

Such an important clinical sign is left to the whims and fancies of human ear’s ability to detect  of low pitched vibrations emanating from deep seated brachial artery .(5 phases of Korotkoff )

Since  Korotkoff sounds are low frequency sounds , it is best heard with bell of the stethoscope ? How many of us do it ?

There is little surprise , two BP  recordings  rarely  match even if it’s performed minutes  apart  !

korrotkoff sounds

While phase one is easily identified , the gap between phase 4 and 5 can be very  narrow and  differentiating  them is often an auditory illusion.

Korotkoff sounds is  subjected to severe tissue plane damping esepcailly in low flow states and obese arms.

So is there an alternative  method to measure diastolic BP ?

Most will agree , systolic BP can be  well measured by palpation ,

What about diastolic BP ?

In this technological era , it may appear foolish to depend on a tactile measurement . But as these articles suggest , it is worth a try!

 

diastolic blood pressure by palpation korrotkoff

In certain population  we know the kortokoff sounds are low quality .Auditory interference can be more than tactile sensation. In those hands ,Korotokoff  equivalents  can be felt by sensitive fingers.

After thought

How does automated BP recorders  sense systolic and  diastolic BP ?

Does it sense the sound or feel the vibrations.

Reference

measurement of diastolic blood pressure by palpation

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