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Archive for the ‘Cardiology -Interventional -PCI’ Category

Is septal branches of left anterior descending coronary artery immune to atherosclerosis ?

Posted in Cardiology - Clinical, Cardiology -Interventional -PCI, Cardiology -unresolved questions, cardiology- coronary care, tagged , , , on January 19, 2009| Leave a Comment »

                                         Coronary arteries are the major site for human atherosclerosis .CAD is considered the ultimate determinant of  cardio vascualr health of our global population.Coronary atherosclerosis has a predilection for proximal sites and branching points.Typically it occurs in leftmain, LAD ostium, LCX ostium, proximal LAD, diagonal origins, OMs RCA  and its branches .

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Septal branches , even though divide very early  from the LAD , it  is  uncommon  to get affected by coronary atherosclerosis.  Even for an experienced   interventional cardiologist  , it  would be very rare to have  performed a  PCI for septal disease.

Why septal branches of LAD is rare to suffer from atherosclerosis ?

We don’t know the answer yet.

But , it is thought,septal branches are near perpendicular branches .The branching angle and incidence of atherosclerosis has a peculiar relationship.IAt any bifurcation  point , the atherosclerosis tend to occur ,  if the angle is more acute , and is  less common in abtuse angles .It is  almost rare  ,  if branching happens at   exact  90 degree angle or so !

The other reason for septal branches being immune to atherosclerosis is  , it runs within the muscle in its major course. The constant squeezing action(. . . and possibly bridging also)  makes it difficult for the  process of atherosclerosis to sustain and grow .

Can you still get a  septal CAD ?

Yes,  usually as  a component of bifurcation or trifurcation lesion. Some times a diagonal and septal are very close together and  atherosclerosis involves  both ostia.

What is  the implication for the  cardiologist to perform  a PCI with stenting in a septal branch of LAD  ?

PCI and stenting in the septal branches are more prone for crushing and fracture   as it is constantly exposed to the mechanical effects of muscle contraction.

Any other significance for septal branches of LAD ?

  • Isolated septal myocardial infarction can occur.This could be even a embolic manifestation.
  • Septal branches of LAD are potential target for therapeutic embolisation (By injecting alcohol)  in patients  with hypertrophic obstructive cardiomyopathy(HOCM) .This manover aims to produce a controlled septal myocardial infarction and thus paralysing the left ventricular outflow tract and reduce the dynamic LVOT gradient. This form of treatment, was glorified till recently now considered experimental !

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Land mark concepts in cardiology : Biochemical diagnosis of aortic dissection

Posted in cardiac surgery, Cardiology - Clinical, Cardiology -Interventional -PCI, cardiology -Therapeutics, Uncategorized, tagged , , , , , , , on January 19, 2009| Leave a Comment »

                                       Aortic dissection is a complex cardiac problem and a  killer disease .Even though it is a fancier to make a  diagnosis  of aortic dissection in any intractable chest (or back )pain   the  most common error  committed by physicians is failure to recognise it  .

Is it possible to diagnose or atleast suspect aortic dissection  by a rapid screening biochemical test ?

Yes,  it seems so, 

  1. D Dimer , a product released consequent to  intravascular thrombosis is elevated  by >500ng in most of the patients with dissection.
  2. Aortic smooth muscle heavy chain estimation is the other option.

aortic-dissection-d-dimer

Read this original article by Patrick Ohlmaan

Click on the link

http://www.medscape.com/viewarticle/530783_print   Courtesy Medscape

 What happens once a diagnosis of aortic dissection is made ?

It is not a great achievement to make a diagnosis of aortic dissection.It is only, a  beginning of a long  and often   tedious decision making process . A real tough task , on hand for the cardiothoracic  surgeons. It is a team work , needs the interaction of cardiologists, radiologists and cardiac surgeons to bring an optimal outcome.

The major issues are

  1. Never try to  manage this problem in a small hospital or facility. Always send the patient to a teaching hospital ( of course , not all teaching hospital can  tackle  this   either , so enquire about their expertise ! )
  2. No credits for making a simple diagnosis of dissection.One has to exactly locate the entry point and exit points if any.
  3. Aortic root and arch  involvement  is of major importance in determining the modality of therapy.
  4. Debaky classification is not  of academic interest ! it has a purpose . Generally type A dissection(Proximal ) require emergency surgery
  5. Differentiating true lumen from false lumen is of critical importance , it needs a meticulous transesophageal echocardiogram.( Some times one may , never  be  sure which is true and which is false lumen  , funnily .in descending aortic  dissection it may never matter for the patient !) Self healing of many dissections with thrombus is possible. 
  6. Controlling hypertension with powerful parentral antihypertenive drugs (Labetalol . . . ideally )  is vital.
  7. Side branch  involvement (spiral dissections) especially arch vessels and renal arteries  make this entity much more complex
  8. Isolated distal dissections and some low risk proximal dissections  can indeed  be managed conservatively(Also called non surgical ! ) Some cardiologists or even institutions  hesitate to  put a aortic dissection with medical management .They feel it is inferior form of treatment . . . but realise , it is not  necessarily so !)

 

What is the other bichemical marker for disscetion ?

The aortic smooth Muscle Myosin Heavy Chain was proposed as a useful marker for diagnoisng dissection.

Diagnostic Implications of Elevated Levels of Smooth-Muscle Myosin Heavy-Chain Protein in Acute Aortic Dissection: The Smooth Muscle Myosin Heavy Chain Study  Toru Suzuki, MD; Hirohisa Katoh, PhD; Yasuhiro Tsuchio, MD;  Annals of internal medicine 3 October 2000 | Volume 133 Issue 7 | Pages 537-541

 The abstract from annlas of internal medicine follows Readers from India can get the full text article free

  1. http://www.annals.org/cgi/content/abstract/133/7/537 
  2. http://www.annals.org/cgi/content/full/133/7/537
  

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Drug eluting stents : A slap on the face of Evidence based cardiology . . .

Posted in bio ethics, Cardiology -Interventional -PCI, cardiology- coronary care, tagged , , , , , , , , , , on January 1, 2009| Leave a Comment »

Drug eluting stents : A slap on the face of Evidence based cardiology . . .

Click the BMJ link or read below

 

venkat-bmj

It is often said science is sacred and unfortunately we forget ,  science is not a heavenly creation and it is the creation of scientist of varying grades of integrity fueled by the vested interest of medical industry . It has been a almost a daily affair , some of the devices and drugs are recalled or found to be unsafe on patients.

Now the big cat has come out .The Drug eluting stent has fallen from Hero to Zero in a short span of 5 years. It was projected to have zero percent restenosis in 2002 . And now we realize it is Zero percent truth.

What has started as anecdotal reports of late stent thrombosis has indeed become an epidemic in all DES patients. The five studies that has been published in the NEJM this month (March 2007) has convincingly proved how unsafe these stents are in most of the coronary population .

Millions of patients in whom this stent was implanted will carry an impending stent thrombosis and possibly an SCD . Who is to take care of them ?

The DES story is a clear cut case of getting premature approval for a dangerous form of treatment inside human coronary arteries.

It is amazing how the scientist’s eyes are shut by the illusion of knowledge and lure of wealth. How foolish they were to think drug which was administered via the stent will selectively prevent vascularisation and leave the normal endothelium intact . Now they realized , one should not suppress the endothelial growth around the stent and got the fundamental point wrong. Which was the key reason for the astonishing episodes of late stent thrombosis. When we play with biology of nature we have to be little more careful .God has created man and his heart for over a million years . One can not alter it by a 6 month follow up study of DES .

When ICDs were exposed last year , of similar disastrous outcome they were recalled and explanted . How are we going to unstent the millions of coronary arteries ?

Somewhere along the line the medical professionals have lost the battle against the Wall street and NASDAQ . Or how else we can explain repetition of similar events.

The wages for the modern technology , the patients have to pay a heavy price.

Let us all hope common man with common sense will reign supreme over the sixth sense of the uncommon man . . .

“Ignorance is better than illusion of knowledge”

Dr Venkatesan Sangareddi MD , Assistant Professor of cardiology , Madras medical college Chennai, India

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Why is angina pectoris silent in diabetes mellitus ?

Posted in Cardiology - Clinical, Cardiology -Interventional -PCI, cardiology -Therapeutics, Cardiology -unresolved questions, cardiology- coronary care, Infrequently asked questions in cardiology (iFAQs), tagged , , , , , , , , , , , , , , on January 1, 2009| 1 Comment »

Anginal pain is a type of visceral pain.It is carried by type  C  unmylinated  nerve fibres.The perception of angina is a complex process.It is a combination of visceral and cutaneous referral pain.

How often is angina silent in diabetes mellitus ?

Presence of  diabetes per se does not make an angina silent. In fact,  if  one takes 100 patients with diabetes  , if angina occur in them , it is more often  , manifest than silent. So , only few of  the  diabetic patients who develop diabetic autonomic neuropathy fail to have angina.The exact incidence is not known.It could be around 20%.

If angina can be silent in diabteics , can they have anginal equivalents ?

This again is not answered in literature. Among the anginal equivalents , the most common is  dyspnea , which  can occur in diabetics.But now , we know dyspnea also needs thoracic nerve signals  from the intercostal muscle spindle and colgi organs.This can also be impaired in diabetics.

Can silent and mainfest episodes occur in a same  patient  ?

Yes.

Once silent does not mean always silent, and similarly once angina is felt it  does not mean he is going to feel the next episode as well !

This  strongly reminds us medical science  is  much a complex  subject and what we know is very little in pain perception.

How is silent ischmia different from silent angina ?

There is considerable  overlap  between  silent ischemia and silent angina

The questions to be answered are 

Which is silent  ?  Is it the angina or is it the ischemia or both ?

Silent ischemia can occur in any individual ,  this is also called as silent CAD . When  ischemia occurs  but  fails  to generate pain it is silent ischemia .Undiagnosed  CAD in asymptomatic individuals is also called silent ischemia or CAD.In this population  Exercise stress testing detects  CAD which was otherwise silent and masked.These patients may develop angina during EST.

During exercise stress testing many times patient has significant ST depression  more than 2mm but still chest pain may not occur.These episodes may either be silent ischemia or  ngina. Many times the EST is terminated before angina is manifest .( Chest pain is the last to occur in the chain of events following ischemia- Concept of ischemic cascade )

What are the other situations where angina can be silent ?

  • Pain perception  and threshold  level is  high ,  so patient indeed has anginal  signals but fails to feel it .
  • Patients on  antianginal medication , fail to feel the angina.

  • Chronic betablocker therapy can exactly mimic  autonomic neuropathy

Is it a blessing for the patient  to have painless episodes of angina ? 

When their  ischemic colleagues , suffer a lot with chest pain it is tempting to think these diabetic patients  are blessed!

Scientifically , this could be true in at least in  some  especially in a patients  who’s coronary anatomy is known  and devoid of any critical proximal lesions. For example a small PDA  lesion can produce  severe angina  , but may be silent  in diabetic and be comfortable .This lesion is  insignificant other wise * !

It should  also be recalled , pain relief has been an important goal for treatment  of CAD .In olden days,  thoracic sympathectomy was done for angina . In fact ,  even in  CABG  , one of the the  mechanisms  for  angina  relief  is attributed  to cardiac denervation.

Caution: Even a small  episode of ischemia can trigger an electrical event .But it is rare.

 How common is silent infarct (STEMI) in diabetic patients ?

In a simple questionnaire we asked the diabetic patients in our CCU how they felt their pain during MI.Most felt it normally as do other non diabetic .  Diabetes  does not make  all anginal episodes  silent. Severe episodes of ischemia may be painful while less severe episodes may be painless. Diabetic autonomic neuropathy  is a  least recognized and  poorly understood complication of diabetes.Diabetes , involves  the vasanervorum of the autonomic nerves.

 The other mechanisms postulated in diabetic neuropathy are

  • Reduction in neurotrophic growth factors.
  • deficiency of essential fatty acids .
  • Reduced endoneurial blood flow and
  • Nerve hypoxia .

Is diabetic autonomic neuropathy treatable ?

Very difficult problem indeed.Controlling diabetes may partially correct  the neural dysfunction.Many add on neuro vitamins and aminoacids are having a good market !

If you successfully treat diabetic autonomic neuropathy will my patient  start feeling the  hitherto silent episodes of angina ?

We don’t know.Logic would answer ” YES”

What is the ultimate effect of cardiac autonomic neuropathy.

Cardiac denervation.  The manifestations  are

  • Tachycardia, exercise intolerance
  • Orthostatic hypotension

 

Silent Myocardial Infarction : A complete list

 

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FDA monitors and regulates abuse of drugs and devices ! Who monitors abuse of investigations in medicine ?

Posted in bio ethics, Cardiology -Interventional -PCI, cardiology -Therapeutics, Infrequently asked questions in cardiology (iFAQs), tagged , , , , , on January 1, 2009| Leave a Comment »

                                            The growth of medical science has been phenomenal .It is estimated , the quantum of break throughs  and development  in the  last  50 years  is   nearly equal  to  2000 years of evolution of our  knowledge  put together.  Along with this growth , came the  unavoidable misuse , and abuse of medical science. This  is mainly due to contamination of medicine with commerce . Federal drug authority (FDA) and it’s variants  were formed in all countries to monitor the proper usage of  these technologies for the benefit of mankind. It has an authority to ban a drug or device  , if it is found to bring more injury or side effects  than benefit !

But , unfortunately there is no legal authority to ban an  an  investigation  which is  potentially  or (really  harmful )

or  used  extensively without any valid purpose .

The list of such investigation is increasing in every speciality 

In  cardiology

  • Doing a Troponin assay in patients wuth classical STEMI
  • MDCT in general population
  • Pro BNP in all suspected cardiac  failure
  • Routine C reactive protein for CAD
  • Central venous catheters for all pateints with shock.

Is there a case for banning an investigation (Like banning a drug) for the benefit of  our patients ?

Looking superficially , it  may seem  ironical. But we realise many seemingly  innocuous investigations are responsible for uncontrolled misery for many patients.

This especially true in people who throng the wellness clinic (Also called master health check up)

A incidentally high C – reactive protein   can lead on to forearm blood flow assessment of endothelial dysfunction and carotid intimal plaque  that could  lead onto carotid stents ! and life long anticoagulation , and an  excess INR and sudden cerebral bleed and death !

This is one sample story  in one particular speciality

There is a definite case for banning ( Either total or partial)  some of the questionable investigations  which are done routinely !

Just because these investigation do not have any  physical , visible , adverse reactions like a drug , it should not be allowed to be abused  .The consequence of  false positive results of these investigations could be terrible and worse than the real disese itself !

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What is the clinical significance of ramus intermedius coronary artery ?

Posted in cardiology -ECG, Cardiology -Interventional -PCI, Cardiology -unresolved questions, Cardiology-Coronary artery disese, Infrequently asked questions in cardiology (iFAQs), tagged , , , , , , , , , , on December 16, 2008| 16 Comments »

coronary-artery1

                                                      Coronary arterial circulation is the life line for  the human heart  and it’s survival.Typically it is supplied by two coronary arteries,  left and right coronary artery.Both, together carry about  250ml of blood every minute.( Approxinately  equal to a  cup of  coke !  ).These coronary arteries  generally divide in a predetermined  fashion , and have multiple branches . It is a  mystery , what  decides this  branching pattern

Is it like a our palmar crease  ? or the cerebral gyri ?

However , it does follow a certain rule,  one major coronary artery  will follow the  four  important grooves of heart. In the left side ,  left main coronary artery (LM) originates in the left coronary sinus (Size varying between 1mm -20mm)  and usually bifurcates into LAD and LCX. The left anterior descending artery (LAD) runs in anterior interventricular  groove while ,  the right atrio ventriculo groove carries the right coronary artery(RCA) .Left  circumflex artery (LCX) traverses the  left atrio ventricular groove.The most inconstant branch is the posterior descending artery (PDA) which runs in the posterior interventricular  groove.PDA  can arise from either RCA, LCX or both or even from LAD.

The major branches of LAD are called diagonal and septal  while the branches of LCX are called obtuse marginal(OM).There can be two to three diagonal and OMs. 

What is ramus intermedius coronary artery ? What is the incidence of Ramus ?

The left main coronary artery  instead of bifurcating into two ,  it trifurcates into three vessels.(LAD, LCX, Ramus)

The real incidence could vary betweenn (10% to 30%) depending upon the series.

ramus

What course it takes ?

It generally goes in the angle between the LAD and the LCX.It may either behave like a large OM or a diagonal branch.It supplies the lateral free wall of the LV many times.The peculiarity of this vessel is it does not run in a anatomical groove .It simply slides over the free surface of LV.Rarely, a  very abnormal course of ramus,  criss cross the aorta and pulmonary artery .

How common is atherosclerosis within  Ramus ?

We don’t know yet. But it is very likely since it is an early branch from left main, it  might  have a  predilection for atherosclerosis  as like LAD or LCX ostium.In fact now we recognise more of  trifurcation lesions involving  three branches of left main .

What would be the ECG finding if a large ramus is the culpirit vessel during STEMI ?

This scenario could be rare.

ACS in ramus could  present as ST elevation in 1/Avl /V5,V6

  • Lateral MI
  • Apical MI
  • High lateral MI

But it is realised , whenever the ECG changes are not fitting with typical ASMI or a lateral MI one should suspect a ramus lesion

 What is the significance of ramus for an interventional cardiologist ?

ramus-2

                                                   PCI in ramus is a rare opportunity for a cardiologist .The issue here  is,  if ramus is involved  adjacent LAD and LCX is also likely to be involved .So it would logically be a multivessel , complex angioplasty.Isolated ramus lesion could be tackled easily.Another issue here could  be ,since this vessel is not within  any anatomical groove  stent deployment would have a poor  support and prone for mobilisation and migration .

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Why should a stent elute drug ?

Posted in Cardiology -Interventional -PCI, cardiology- coronary care, Cardiology-Coronary artery disese, cardiology-ethics, Infrequently asked questions in cardiology (iFAQs), tagged , , , , , , , , , on December 14, 2008| Leave a Comment »

Stents are mechanical  devices like  a  spring ,  used to  keep an artery open after a PTCA or PCI.

des-why4

                                Bare metal stents(BMS) were found to have restenois rate of about 25%.  So it was perceived a stent should have it’s own protective coat , so that it won’t get restenosed.For this the researchers thought  anti cancer drugs are ideal as they block cell proliferation and thus neovascualrisation and restenosis.Alas, they were found dismally wrong ,  after all , neointiaml proliferation is only a part of the problem of restenosis  and simple blocking of cell growth is insufficient . The issue doesn’t stop with that, the anti cancer drugs incorporated within the stent simply can not differentiate normal from abnormal cells and

DES effectively blocks the normal endothelisation over the stents and make this highly vulnerable for acute stent thrombosis .

This complication is unique to DES and can result in SCD.Further ,during the last 6 years of DES , we recognised the restenosis rate has increased form the much hyped O % to almost 15% and it’s still growing . These  complications  has made a huge question mark over the future of drug eluting stents !

des-coverage

The concept of DES may not die , but which drug it should elute should be answered ! This  again is  going to be a long battle. So it is currently   adviced,  based  on common sense ( With due respects to  those RCTs  funded by industry )

Whenever you encounter a block within the coronary artery* Ask the following  questions in sequence  ,

  • Whether we can leave it alone  with medical therapy  ,  if the answer is no , proceed  to the next step !
  • Is there a possibility for plain balloon angioplasty in a given vessel (POBA, Yes !  the concept is not dead yet !)
  • If you decide a stent is required , Will  the  bare metal  do the job ?
  • In multivessel CAD  , Did the issue of increased metal load on the  long term outcome was considered ?
  • If lesions appear complex,  should we  not strongly consider CABG as an option ?

However  if we  have the habit of  ask ing the following  question  you are likely to deviate from scientific approach  

Is it possible to put a stent  across  the block ?

Yes , will be the answer most of the time ,and the patient will invariably get one or more stents  and carry a life long  stent related problems.

*The rule does not apply in Acute coronary syndromes

Also read this letter  posted by the author published in  British medical journal

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Drug eluting stents bare it all ! and bare metal stents cover it all !

Posted in Cardiology -Interventional -PCI, cardiology -Therapeutics, Infrequently asked questions in cardiology (iFAQs), tagged , , , , , , , , , , , on December 14, 2008| 1 Comment »

                                      One of the important principles of  post PCI care is,   we need  to be very careful  till the metal struts are fully endothelialised . This is of vital importance as improper endothelialisation  is a powerful trigger and nidus for a  imminent thrombosis and  acute coronary syndrome.

stent

It is a billion dollor irony , the much hyped DES does exactly what we don’t want ! and still it’s  usage is  increasing world wide .  The drugs (Anti cancer agents)  which coat the DES   are the villains as it  prevents  the  metal struts  from being endothelialised  and  keep the metal surface  raw and vulnerable , while the  much maligned  bare metal stents allow  this natural endothelialisation  process  without any interruption ! So right now it is mandatory  to administer dual antiplatelet agents  life long( life of the stent !)   for the patients with DES.

 Just look , at the following image of  a stent in vitro at  30 days follow up

des

des-2

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Positive allen test following radial coronary angiogram

Posted in Cardiology -Interventional -PCI, cardiology- coronary care, tagged , , , , , , , , on December 9, 2008| 1 Comment »

This paper was presented in the just concluded 60th Annual scientific sessions of cardiological society of India , Chennai.India

POSITIVE  ALLEN’S  TEST  FOLLOWING RADIAL CORONARY ANGIOGRAM

Venkatesan  sangareddi , G.Gnanavelu, R.Alagesan,V.Jaganathan.

Department of cardiology, Madras Medical College, Chennai.

 

                          Radial  artery  has become the  major access  site for the interventional cardiologist in recent years. Radial approach has provided increased patient comfort and  less access site complication. Many  of  the   complications  are  unique to radial approach mostly due to  anomalies of origin, and course while others are  hardware related .Unlike femoral arterial access ,  compromise of blood supply to hand is never considered a  threat because of dual blood supply to hand  .But the fact  is that,  it  could be sub-clinical  and the hand is rarely assessed for vascular insufficiency after a radial procedure.

             The aim of the study is to assess the  impact of   radial  procedures  on the  blood flow  to  hand . 20 patients who had undergone routine  radial coronary  angiogram  formed the study population. All patients had negative Allen’s test prior to the procedure. The mean procedure time was   25mts (18-45) .Standard  hardwares were used. Difficulty in crossing at forearm and   subclavian   was observed in  4  patients. Extravasation of dye  in forearm was observed in two. Allen test  was  done 24 hours  after sheath removal and  repeated 48 hours after the procedure .  4 patients   showed positive Allen test  at 24hrs. One  patient   regained  Allen negativity at  48hours. The incidence of positive Allen test at  24 hours is 20%. The compromised blood flow was correlated with the  procedure time, and a difficult catheter course .

                 We propose,  radial procedures especially , when prolonged has a potential to compromise palmar arch flow .This phenomenon  is  either  permanent  or transient  and  may be attributable to enhanced  endothelial tone and sheath related injury. Irreversible  compromise  of blood flow to  palmar arch  may  also occur  in radial dominant hands. Further enhanced  sympathetic tone can  spill over to ulnar artery as well . 

             It is concluded, interventions through radial route has hitherto unreported adverse effect  of  “Post procedural  positive  Allen test”  . It  implies , radial  procedures  could  convert  a dual blood supply  pattern of the  hand to ulnar dependent  uni-modal  blood flow  in a significant  subset of patients. This is important   to recognise, as it   precludes further radial procedures in the same patient.

 

Final message

Hand function could be as vital as our heart’s ,   please handle with care to avoid this complication

 

Click on the slide to download PPT presentation

radial2

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What do we mean by conservative management” ? Why it is often considered as an inferior form of treatment in Medicine ?

Posted in Cardiology - Clinical, Cardiology -Interventional -PCI, cardiology -Therapeutics, cardiology- coronary care, Infrequently asked questions in cardiology (iFAQs), tagged , , , , , , , , , , , , on November 30, 2008| 3 Comments »

                                            The science of medicine has evolved over 2000 years since the stone age days.It has  currently reached  a glorious era with  cutting edge  scientifc  technology .Today  one can map the entire human genetic blue print and intervene in the  disease  even before they manifest .One can   keep dying people alive for years with multi organ transplantation. Modern medicine has taught us  how human sufferings can be prevented and life can be prolonged (with or without purpose !)

The term conservative management  conveys two different

meanings for medical professionals.

conservativ-3

For other group of physicians

 

conservative-4

                         

                             Ever since the days of  application of leech over the  head for treating migraine and a crude knife abdominotomy for emergency exit of babies from  pregnant mothers in distress  , healer’s   mind has always  perceived “something  has to be done  urgently when some body suffers”  this sort of  reaction is probably  inherited  and is related to  the primitive flight or fight response .

This may be true in  some of the emergencies but it is untrue in many of the non emergencies.

                                          Unfortunately ,  our mind  finds it difficult   to differentiate  between these  situations . With constant exposure to dramatic medical breakthroughs , modern day physician is made to believe   “Some thing  is always  better than nothing  when illness strikes. Human body is a wonderful machine which has it’s own service station ! in the form autoregulation  and the meticulous  homeostatic mechanisms. Only if the disease process overwhelms,  it needs intervention.( Typical example:In the routine viral fever , you don’t adminster Acyclovir or other antiviral  for all of them !) 

                                        The problem with early aggressive approach is,  it fails to give an oppurtunity  for the body’s natural defence forces  to respond. Further , we will  never ever know how the administered treatment is going to fare vis a viz the natural response.( With due respects to RCTs).   While the field of medicine   has  so much  evolved , our thought process,  especially  the  aspect of clinical  reasoning  has always been lagging behind .It is now considered  as inferior or even unscientific  treatment  if  some one follows a conservative approach to a problem even if  it  provides   same outcome of that of an invasive or aggressive approach ( The classical example is PCI for chronic stable angina The COURAGE study).

The other major issue is the hazards of unwarrnted  invesitigations , drugs and procedures

Classical example:No one knows how much morbidity or mortality the routine Swan ganz catheter  caused when it was rampantly used for over two decades to monitor central venous pressure .It is estimated  that in modern medicine  there are at least  few  drugs or devices  in each speciality waiting  for the same fate  as that of  the swan ganz catheter.

No body knows when it will be exposed .Our EBM will take it’s own time . . .Till that time humanity need to suffer.

This thinking is not new  The concept  “First do no harm is over 2000 years old”

hippocrates-primum-non-nocere

Questions in search of answers

 Does law of conservation of energy applicable to human body and medicine  ? 

 Can we defy death with modern medicine ?

Final message

  • Conservative management is still  a great medical concept  in many situations  and one should not allow it to die  by the whims and fancies of the modern scientific forces.
  • Whatever you do on the patent’s body  do it ,  only if it is going to helpful for him /her. If you are unsure  Whether a given  treatment  is going to help or not ask this question to an expert .
  • The widely prevailing  dogma  of aggression is always better than  non aggression  has absolutely no evidence.
  • So approach a clinical issue disease by disease ,  individual by individual.
  • Now , in this era  high tech  medicine  ,  It is lot more tougher to choose a conservative path as the pressure to do more and more  looms  larger ! It is easier to follow the crowd  than a path of your own .
  • Always remember it needs a  stronger  mind to  act according to our conscience !

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