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Archive for the ‘Cardiology-Land mark studies’ Category


Professional competence is defined as doing things, always in the Interest of patients. It’s generally believed small hospitals are not competent enough to treat cardiac emergencies . . .Do you agree with that ? No, Its largely a myth . Do you know there is a absolute  lack of proficiency  threatening to plague our country’s coronary care system. ? It’s the professional  Incompetence by the space age, star hospitals (mis)managed by masters of the noble business. None (am I right ?) of this hospitals either monitor or publish the outcome of their treatment.

Backed by pseudo scientific data , amplified by unrealistic expectations of ill Informed patients , some  hospitals are avoiding Initial emergency treatment of acute MI  , instead they waste time ( load DAPT ofcourse !) in securing the finance  for the costly Invasive procedures or refer them out of their premises if they can’t afford for it.In the ensuing emotional and financial melee many of the ill-fated patients lose vital  time window of thrombolysis as well ! and carry risk of fatality or damaged myocardium.

Every stake holder in the current  coronary care system simply assume the enforced modality  must be far superior because they administer the most modern and costly treatment suggested by few high intensity cared clinical trials originating from west. The wisemen who run the corporate hospitals  never realise medical competence and outcome is not entirely defined by science. Their primitive cognition wouldn’t allow to think beyond business equations either.

Please believe me, time and again, I have witnessed patients reaching Government hospitals  after being shunned away by  big (Some times even medium sized )  hospitals who boast themself only as PCI enabled care. Even if they want to lyse they stock only the Tenekteplace .

I think tragedy  is a lesser word to describe the scenario , where a distressed family is trying to arrange  for a Rs30,000 shot of Tenekteplace when thirty times cheaper still equally efficacious (Rs 1000 Streptokinase)  is concealed from their visibility .The Govt should urgently look into instances of large private hospitals avoiding Govt insurance scheme patients  even in  cardiac emergencies ! To label our poor patients as unaffordable ones is a outright misnomer, rather its the rich hospitals that are “not affordable” to lose profit and treat our countrymen , in a cost effective manner is the reality !

Who is Poor ? You decide.

Two forbidden things in coronary care

 1.Cajoling  and manoeuvring a distressed  family for a primary PCI as a routine treatment  hyping its beneficial effect and underplaying the true advantages of thrombolysis in largely technical jargons is the current norm in most coronary care units.

2.Another issue is , after confused confabulations with the duty medical officer,  if a rare patient family  choose the option of thrombolysis , comes the next googly*.  Many noble minded hospitals do not stock the low-cost and equally efficacious thrombolytic agent and offering  only the costly option to the anxious families when the myocardium is on fire.

Hospitals that  practice these two coronary protocols  need to be shamed and labeled as  “Coronary Incompetent  ” In spite of having 24/7 cath labs.  (Realise , they are just like  any remote rural hospitals , at least  the later can’t be faulted  as they don’t  withhold  a  reperfusion strategy  !)

Final message

I think , mindless proliferation of cath lab based cardiac care , which follow this theme , ie  “Thrombolysis incapable but PCI capable “ are  biggest threat to coronary care in our country ! For the best coronary care for any country ,what we need is efficient prehospital thrombolysis team .We have conveniently forgotten the great study of CAPTIM wherein the ambulance drivers replicated the same effect of primary PCI performed by highly trained cardiologists in modern labs.

In India,  primary health centers which is within  few km reach of entire population  can be designated as static ambulance equivalents  with basic resuscitation facility . If a multipurpose health worker can be trained to lyse, with remote supervision that will accomplish  90 % of what the cathlab guys can achieve ! Selective shifting is suffice.

Postample :  Ofcourse, not doing  pPCI for high risk or complicated STEMI is unscientific and we need to have proper consenting and referring frame-work for such patients.

Counter point : One of my colleagues asked me ? Why do I enjoy attacking the established scientific practices ?  May be I have a problem , yes, but  I think in a  true medical democracy we have right to debate anything , absolute truth is a ongoing journey !

 

 

*Googly:  An unplayable ball delivered to a batsman in the game of  cricket.

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Today , we  post cases for coronary angiogram , just like sending clients to breakfast table ! Close your eyes. Think for a moment. It is heartening to know how cardiac catheterization grew from a humble beginning . We know , Forssman , Cournand  and Richardson  who shared the Nobel price  for Inventing  cardiac catheterization in 1930s .

Soon after it’s  invention it was criticized by most, few ridiculed it outright , few others wondered about it . One man from the iconic  Grady memorial hospital  , attached to Emory silently  adopted this  procedure and almost single-handedly  did more than 1500 cardiac catheterization procedure. (Between 1940-50s)

How many of us know this man  from  Atlanta ,Georgia  ?

Some times history appears unkind. He is Dr Steads . . . to be precise Dr.Eugene Anson Stead Jr. ( 1908,  –  2005)

stead_eugene

Born in a humble background in the suburbs of Atlanta , became a great medical teacher , researcher and educator . He is one of the founding  fathers  of cardiac catheterization . Defined it’s usage in  clinical cardiology . The other major  achievement was his strong conviction that  medical science is indeed simple  but made complicated by complex concepts .This  thought transformed  in him ,  as he found the concept of physician assistant . He believed focused medical knowledge in young and enthusiastic  mind can make huge  difference in the way medical knowledge  is disseminated, applied and consumed .What a stunning truth even today !

grady_hosptial_pc

The legacy of Grady continues which is one of the largest public hospital in USA with special affinity to poor and low-income population.

The lab which Dr Stead worked was later taken over by Dr  Noble O Fowler* , another great cardiac physician continued the research and wrote the famous book on cardiac diagnosis and treatment.( * I think it should be in early 1950s when Dr Stead left for Dukes)

Final message

Invention of a concept is one thing . Accepting it , trying it ,  improving it ,  disseminating it , is an equally important  contribution to science. Dr Stead did exactly that .He remained  a positive force in  propagation of medical knowledge, made it  available for those  people who need it .

He passed away on June 12, 2005 at the age of 96 leaving behind a huge legacy .It will be  an  error if we don’t teach our  young students history of such great men , in medical  schools today  !

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Few Innovations are real breakthroughs in cardiology . Here is an imminent technology waiting to explode in the  permanent pacing . Expected to hit market next year (2014 in Europe ) FDA approves clinical studies .

nanastim

Click over for the animation video  of the procedure .

  • The wireless pacemaker has many advantages. (It’s devoid of all those pocket and wire related issues.)
  • The ability to change batteries is  a  going to be a  new paradigm shift in the filed of electro physiology. .
  • Down side would be,  right now it can be only VVI pacing . All that hype about    physiological pacing  will go to the background !

Future directions in Permanent pacing.

The only threat for this technology is the  concept of biological pacemaker Converting ordinary myocytes into  pacing cells by genetic engineering.This is expected to happen within few decades.

biological pacemaker

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Scientific studies can be fun .In our spare time we often Indulge in rapid  fire sessions. We tested 30  wide qrs ECGs from our archives  (All proven VTs)  and  asked  our  cardiology fellows to apply Brugada criteria . They could   correctly  diagnose  VT  in 18* patients.The same ECGs were shown to the staff nurses of coronary care unit . 24  VTs were correctly identified  it.They did it by  their clinical sense and Instinct. (*12 vs 6  VTs missed)

wide qrs tachycardia svt with aberrancy and vt brugada verecki  griffith002

And now , four  clinical data was  provided. (Age , sex , Blood pressure , and  past H/o  MI were given )   The Nurses were able to predict it  28/30  VTs correctly.(97 % accuracy ) and the cardiologists  were able to equal the score now. So obviously clinical sense  was far superior .

Cardiology fellows were more likely to  mistake VT as SVT. This is far more common than SVT mistaken as VT. It is a strange academic  irony ,even the junior most nurses never missed a VT !

Summary

Simple sequence of history and clinical presentation is still far more powerful than ECG data in predicting wide qrs  arrhythmias . Nurses guess work is far superior than cardiologists  in predicting a wide QRS tachycardia as VT.

In fact , the  cardiology fellows are  preconditioned to   get confused   whenever they get a wide qrs tachycardia . Why  not aberrancy ?  In my  experience I have seen this question keeps  erupting inappropriately .Even  shrewd fellows suffer  from an  oscillatory  mind between VT and SVT .This is primarily because , every wide qrs ECG  is likely to  have at least two  criteria that fulfill both VT and SVT.

The implications are  genuine  and far reaching . While nurses  show a patient centric thinking  cardiology fellows  thought process revolves around ECG . Many modern-day cardiac physicians  are disconnected from clinical reality  and are obsessed with  complex EP concepts  and end up with a miserable face in the bed side !

This is not a new  revelation in 2013 . Masood Akthar told this  three decades ago.

Caution
Never try to glorify  guess-work . EP is a great science .The  pioneering concepts have made us understand how a VT emanates, travels , and exit from myocardium . We are able to localise it and ablate it .All credit goes to science . But , when it comes to bedside recognition of VT ,  clinical  sense  is a clear winner .With a  consistently > 90 % predictive value   it  can no longer be called as  a  guesswork   and becomes a hard scientific fact. Especially so , when the  intellectual  analysis of surface ECG   could predict  it  with paltry 70 %  accuracy (Read Reference 1)
Reference
This  analysis startlingly reveal  a fact .The over all accuracy  rate of predicting the wide qrs criteria  by  popular algorithms  is   between 66-77% ,  just 16 numerals   more than  gross   guess work  of 50 : 50 ( This  . . . or  . . . that )
Link to  Masood Akthar article

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I wish to  be in New Zealand , not only because of the stunning  natural beauty but also to pay tribute to one of the great  cardiac surgeons  of our time from Auckland .
An alluring  country side cricket ground  abutting the runway  . . . Queenstown I think !

Sir Brian Gerald Barratt-Boyes (1924-2006), Who pioneered all forms of  heart surgery that  specifically included  complex congenial heart disease . Thousands of Kiwi   children are alive and leading a  magnificent life today  because of this  man from Green lane an alumni of Mayo .

barret boyce tof intra cardiac repair cardiac surgeon

Many heart surgeons from India and Asia pacific have trained under him .

greenlane

Green lane Hospital Auckland.

This is the  hospital where Barrat Boyes worked headed the department of cardiac surgery .He had to over come large bureaucratic hurdles before becoming world ‘s leading cardiac surgery center. And , he lives everyday  in all cardiac units   through this book .

barratt boyce kirklin

Here is a link to pay tribute to this extraordinary man.

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In L TGV  ventricles are Inverted . Since , coronary  arteries go with  the respective ventricle  , LAD originates from Right sinus , and RCA arises from Left sinus . (Complex anomalies  in origin, course still possible )  LAD supplies   venous ventricle . RCA  supplies systemic ventricle .

The most surprising Irony is that major epicardial  branches run in their respective grooves in the bulk of the patients with L TGV .The LAD runs  in anterior interventricular  groove and LCX in left AV groove etc. (That’s real  power of nature , these epicardial branches home in to their grooves even in the midst of bizarre AV and VA connection !)

Here is the the ultimate reference  article ;  A  study from 255 hearts with C TGV . I wonder ,  we will  never  get a study like this ! 

coronary anatomy in corrected transpostion og great arteries ltga c tgv Ltgv annals of thoracic surgery 1994

Questions to ponder

  1. Is RCA  blood flow adequate to support systemic ventricle ?
  2. If this RCA is a non dominant  one what happens to this ventricular function ?

Implication in surgery

Progressive RV dysfunction is a major determiant of long term outcome . Unless we do an arterial switch  diverting respective ventricular flow  it  is not going to help much in the long term

coronary anatomy in corrected transpostion og great arteries ltga c tgv Ltgv 2
Link to full text article

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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

http://www.intechopen.com/subjects/cardiology-and-cardiovascular-medicine

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