Archive for the ‘cardiology journals’ Category

Primary PCI (pPCI) is a  glorious revascularization strategy for STEMI practiced for over 2 decades  but still has not proved its perceived mettle convincingly as a large population based strategy. In the mean time, the utility value  of  thrombolysis  was systematically  (Intentionally too! )  downgraded in the minds of both academic and public mind.
Truth can’t be buried for long. Series of revelations are coming up restoring the superiority of early thrombolysis over pPCI even in PCI capable centers.
In 2013, the high Impact STREAM trial argued  for pharmacoinvasive approach within 3 hrs as it was at equipoise with a pPCI. Now, EARLY -MYO  from China vouch  for pharmaco- Invasive approach  till 6 hours. (Just published in Circulation September 2017 )
 I think we need to wait for some more time , for another prevailing  falsehood that need to be busted ,(Looking  out for some straight thinking new generation cardiologist to do it !)
What is that ?
Many of us have misunderstood(rather made to !)  that pharmaco Invasive has a defined therapeutic endpoint ie taming  & stenting the IRA . This is absolute ignorance  happening even in state of the art centres ,ironically this beleaguered concept is  backed by peer-reviewed papers from premier journals. The fact of the matter is , If thrombolysis is stunningly successful (Which at the least happens in 50 % ) one can stop with that , it’s also a therapeutic endpoint at least for time being .
Is coronary angiogram a baseline test like ECG ?
That’s what current cardiologists with cutting edge knowledge  seem to believe !  Do you agree ! I am sure I’m not !
 Patients with STEMI who had successful thrombolysis who had an  apparently uncomplicated course (Assessed by strict clinical ECG, ECHO criteria) need not go for coronary angiogram in the immediate future.In fact some good guidelines strongly argue for it and call it as Ischemia driven PCI ! but very few seem to respect that concept.)This will not only contain the cost and ensure the vast majority of Inappropriate (  scientific quackery) coronary plumping activity in human race.
Searching for an elusive data ! Can some one help ?
I have been searching for data , from all those major pharmaco invasive studies (Which is not being reported /shared or analysed )
How many  patients in the “success cohort” after thrombolysis  who subsequently land up with urgent PCI related complications when trying to stent an already reperfused IRA or while tackling  coexisting Innocent or non-innocent non IRA lesions ?
* Complications and adverse events  may be acceptable in patients who had failed thrombolysis or who are  unstable  but even minor adverse events are forbidden in patient with a truly successful and asymptomatic patient.
Final message
So called scientific facts have very short half life !  for the simple reason they are let loose in human domain prematurely !

Read Full Post »

Medical research   often ventures into a directionless and meaningless  exercise with or without intention .The reason is simple , unlike  other fields,  scientists enjoy  the ultimate freedom of expression.

How to find genuine treasures from this chaos ?

We need people like Valentine Fuster ,

valentine fuster global cardiology what is the future

Here is link to the article in   circulation 2011  which I consider a must read for all cardiologists !

global  cardiovascular health valentine fuster circulation 2011

Read Full Post »

I stumbled upon this  web   site . I think this  can be  glorified as the  standing  example  for     “Democracy  of science”

INTECH open science  open mind


Read Full Post »

Add PollGreat journals in cardiology american physiological review heart and circulation


americal  journal of physiology

Many of the wonderful breakthrough articles are totally free . Enjoy and enrich .

Read Full Post »


* Obfuscation:  hiding of intended meaning in communication, making communication confusing, wilfully ambiguous, and harder to interpret

This world can not be a perfect place and  it is foolish to expect the same !   What is published in medical literature is at best , an abstract thinking  of an unfinished agenda . Still public think  science is   . . . what doctors say ! They feel doctors can not simply watch a person  dying. They want us  act like  God. This is  how medical men became Demi-Gods  by default.

Here was a big opportunity . Who exploited it ? Obviously the greedy corporates  who embarked  on a dirty journey to en- cash this trust  and fill their coffers .This is the foundation  on which the  basics of medical market economy rides !

It is an un-pardonable on-going deceit among  modern human civilization . It has  spoiled  the trust between the patient and doctor and  probably  irreversibly  contaminated  in recent decades !

There are very few positives  though,  with occasional noble medical  souls (Like  BMJ,Lancet )   trying to keep the sinking ship afloat !

This sounding board article (Now we rarely  get to see )  from NEJM way back  in 1975  exposes a  shocking revelation  politely . Now, 40 years after ,  the importance of such article has grown  many fold . We are witnessing  every day ,  medical scientist break  stories ( Yes  . . . it is story )  in general media  with  absolute academic cowardice !

We expect more such  face bashing articles from NEJM . It would definitely  make   immense  good  for  our profession  which needs it  desperately !


I’m linking the original NEJM article ; Hope it does not violate copy right !


Read Full Post »

A one stop  solution  for every  thing you need about  right ventricle !


Read Full Post »

Read Full Post »

There was a time  , even  cardiac catheterisation was contraindicated if the aortic valve  is  significantly calcified. LV angiogram was judiciously  avoided in all such patients . Why ? A significant increase in disabling strokes were witnessed .Those were the time  a sense of  fear (common sense ?)   prevailed . Every one was following this dictum with sanctity .

Now in 2010 .TAVI has  arrived with great fanfare . We not only cross the calcific valve , we literally play  a violent contact sport   in the aortic root  for over two hours with all sorts of pushes  and passes  on  a  fragile valve.And  we are happy to  claim that  stroke rate is comparable to aortic valve surgery and TAVI is not-inferior to AVR in high risk surgeries .

How is this possible ? As the times  changed ?  Is it true , our stroke  fears are just imaginations  or have we lost our  faculty of  reasoning and  sense ? (Will it be logical to  fund a research  if someone claims a  surgical  technique  to replace  aortic valve in  a beating heart without aortic cross clamping !)

Data shows  even if  distal protection devices are  used the stroke rates  can reach to  objectionable levels .It remained  a mystery ,  at least to me how no body was  questioning this ? I was happy to find this editorial in NEJM which  just stopped  short  of   banishing  this modality in its current form.


What price it asks ?  and leaves the readers to guess  the answer ? NEJM wants to be too decent and polite , but in science politeness is generally not required  ,  as long as  your  observations are  correct !

For all those enthusiastic  interventional cardiologists  here is  a positive message .

Nothing comes easy in science.Great  inventions do have problems  initially .  Without  major hurdles  there can be no progress ! It is  because of   you  modern cardiology is making giant strides . Remember  the early days of angioplasty , early days of pacemaker  .  But  please realise  the most important issue  is ,  whatever  we   innovate or discover it  should be shown   superior to the  best  existing modality in all aspects(Technique,  procedural  complications, long term  outcome ,costs, side effects etc  ) .It is awful  to note   new drugs or devices  are  rarely compared with  the best treatment that is currently available .

A  new  treatment that simply  complements  or proves  non-inferiority  can never be considered an invention. How can we   portray radio frequency  renal denervation (  a complex  lab procedure ) for controlling blood pressure   as a great innovation for man kind  while we  have   so many drugs and  modalities  available  at a fraction of the cost  with  little  consequence .



Read Full Post »

Non invasive imaging of inflamed macrophages  within athersclerosis

The medical  imaging science is  reaching new heights. With most of the  research so far within the anatomical arena we are moving into the  physiologic  and metabolic  imaging. Identifying vulnerable  plaques  within the coronary  artery is a separate field. Most of them are catheter based and invasive investigations.

We  have ben  searching for an  ideal PET scan based metabolic imaging of atherosclerosis. Macrophages are the key elements in an inflamed plaque.

Image Source : Circulation. 2008;117:379-387 .Note the Acttive Macrophages in the Aortic arch area and Coronary ostia

Can we take a photograph of these  inflamed zones   within  the  atherosclerotic plaque  ?

  • It seems we are approaching  that possibility. Every time we screen a person for CAD we can risk stratify on the basis of  percentage inflammation of their coronary artery or aorta .
  • This will complement the CT  or conventional angiogram .
  • If this technology is perfected it can be useful in the evaluation of response to medical interventions .
  • It  could also tel us  the  significance of  raised CRP /cytokines in other wise asymptomatic individuals

PET scan with newer tracers are constantly evolving . One such tracer is  based on copper molecule   64cu-TNP.





Read Full Post »


The much published TRANSFER -AMI study  has few important queries to ponder about.It was supposed to test the role of routine PCI following  thrombolysis. In other words it compared  rescue only strategy with routine strategy.The caveat is , even among  failed thrombolysis, the   rescue strategy has not convincingly proven superior to medical management  (if the time is lapsed ) as much of the damage is done .

In essence , Acute MI is  more about time management than drug or cath lab management

  1. Why the 67 % of  standard therapy cohort underwent PCI. Technically , you are supposed to transfer for rescue only if there is a  failed thrombolysis ?That is the standard approach , if  most of the cases are any way land up in cath lab , then you are trying to compare two similar groups .
  2. Why the rate of   failed thrombolyis with TNK-TPA in both arms not disclosed ?
  3. How can a 92% of study population be in class 1 Killip still considered to be high risk group ?
  4. Why the recurrent ischemia  was very vaguely  defined and still included and clubbed with primary end point along with deaths. If only recurrent ischemia was removed from primary end point . . .this study will straight away land in a regret bin.
  5. Why there were 6 additional deaths at 30 days  in routine early  PCI group ,  What was he cause of death ? Mind you these deaths have happened in a 92 %  Killip class  one cohort . Is it  not important ? The trend looks vitally   significant .We can not afford take refuge under a false  statistical roof .
  6. How many patients died or  developed MI  because of the early PCI in-spite of having  successful thrombolysis.This again could be vital . Complications during intervention  for a failed thrombolysis may be acceptable. While ,complications , when we try to  improve upon the already  successful thrombolysis is simply not acceptable .

Will the investigators share their experience ?


Why the title of the paper says it is about “Routine angioplasty” and  the conclusion emphasizes  it is indeed   “high risk subsets ofangioplasty” (While the study itself involves a 92 %  least risk Killip class 1 ) .  Why this double dose of confusion ?  (Is it deliberate  ! Which i think is unlikely )

NEJM please take note of this  . . .

All that glitters  are  not natural glitter . . .some are made to glitter !

Read Full Post »

Older Posts »