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Archive for the ‘Cardiology-Land mark studies’ Category

Maude -E -Abbot 

The  first book on congenital  heart disease

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This man enters your cath lab  every morning !  . . .  He is Mr Stent !

Endo-prothe`ses coronariennes autoexpansives.”

    “Endo-prothe`ses coronariennes autoexpansives.”  This is the official name given to coronary stents  when it was first used in man in 1986 in France . The first  stent in human coronary artery was implanted by Puel . Followed by Sigwart  ,Puel combine .

Later on  , the name Stent came into vogue . Surprisingly stent is not a technical name . It is a name of British dentist. To know more about the historical aspects of coronary stents read the following review from Circulation.

References

http://www.fauchard.org/history/articles/jdh/v49n2_July01/charles_stent_49_2.html

1 .Puel  J, Joffre  F, Rousseau  H;  et al.  Endo-protheses coronariennes auto-expansives dans le prevention des restenoses apres angioplastie transluminale, Arch Mal Coeur 8 1987 1311-131

2. Sigwart U, Puel J, Mirkovitch V, Joffre F, Kappenberger L. Intravascular stents to prevent occlusion and restenosis after
transluminal angioplasty. N Engl J Med. 1987; 316: 701-706.

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The principles of pre-discharge EST  

This concept came about 20 years ago (1980s) to risk stratify patients following  ACS to triage early coronary angiogram and revascualrisation. Generally patients are discharged by 5-7 days after an MI  (May be  3-5 days in some hospitals)  . Doing an exercise stress test  early within  2 weeks has not been very popular with many cardiologist even though it was recommended by many guidelines.The type of stress recommended  here  , is heart rate limited sub maximal 70% of  THR (Usually around  140 /mt )  is performed . This is due fear of precipitation another ACS.

Still,  there are definite  advantages for  pre-discharge EST .It help us  identify  high risk  subsets of  STEMI and reduce the  intermediate term mortality .More importantly it  gives  us an opportunity  to  exclude  inappropriate  revascualriations  even without an angiogram . (The well known coronary dogma  ie  if a post STEMI patient performs > 10  METS ,  his  heart carries little  risk  for  future events  still holds good  !)

With the advent of liberal usage of CAG and improved techniques of revascularistion ,  most  patients  directly undergo pre-discharge CAG rather than EST !

Further reading

Does any cardiologist have guts to do a pre- discharge EST after  a successful primary PCI ?

Read a related article in this blog .

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Who said  knowledge comes at a cost . Here is a great resource . Everything about 3D echo

A sample of   3D echo  evaluation of  mitral valve anatomy

http://www.escardio.org/communities/EAE/3d-echo-box/3d-echo-atlas/mitral-valve/Pages/normal-mitral-valve.aspx

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We owe a lot to our past genius minds for our current understanding of  cardiology.Youngsters   should  know how the filed of cardiology  evolved .Few  great  brains  taught us how to think   hemodynamically  in the setting of  STEMI.

The Diamond and Forrester classification is  an  undisputed achievement of  modern cardiac  hemodynamics.They gently converted the  clinical classification of  Killip into more scientific  hemodynamic  one .Both these classification continue to fascinate  us even in the era of instant PCI for STEMI .

And youngsters  should read this again and again and critically evaluate their patients  within this system.The two key parameters he used was PCWP of  18mmhg /And cardiac Index 2.2liters . He also suggested a simplified version where  intra- arterial monitoring is not feasible.  The   cardiac Index could be replaced by systemic blood pressure  lung congestion   represents PCWP >18mmhg .

The DF classification would become

An important inference from DF classification !

The class 3  of   DF   grading  has no pulmonary congestion  but persistent hypotension . What does it mean ?

It is a stunning proof of a great concept.  As the patient moves (Worsens)  from  DF  two  to   DF three  , the lung congestion tends  to regress . This sub-set  actually  means   development of  bi-ventricular failure or isolated RV failure  . This is an ominous sign and indicate a bad prognosis . ( One may call it a paradox  , according to conventional thinking   “The more the lung crackles  , dismal  is the outcome”   DF  grading clearly proves this is  not  always true ,  as long as  the systemic pressure is maintained  crackles can be managed effectively  . In  DF 3  the right ventricle  as a pump is  becoming so weak it is not able to congest the lungs  at the same  process leads to  systemic hypotension.

James Forrester

http://www.cedars-sinai.edu/Bios—Physician/A-G/James-Forrester-MD.aspx

Forrester is also a pioneer in how we evaluate chest pain in the emergency rooms and cardiology OPDs .  His thoughts on utilization of Besean theorem revolutionized   the interpretation of exercise stress testing.

* Killip is a genius of different caliber would be discussed later .

Reference

Forrester, J, Diamond, G, Chatterjie, K, et al Medical therapy of acute myocardial infarction by application of hemodynamic subsets (first of two parts). N Engl J Med 1976;295,1356-1362


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Aspirin under attack  . . . not by  Gastro-enterologists  this time ,  but by cardiologists themself  !

Aspirin , after all may not be safe ,  as a primary prevention drug against CAD . It  seems ,  it considerably increases  the risk of   bleeding . The  new meta analysis just published in Archives of internal medicine  says so !

Be cautious it concludes  !  Since the  track record of evidence  based  medical science  ( and its reproducibility  )   looks   pathetic  in recent times  ,  we may expect another  stunning  study  very soon , with an exactly opposite conclusion  !

After thought

So , we have a  “vacancy  in  the top slot”  for primary prevention of CAD . Mind you ,  makers of  Prasugrel and  Ticagrelor  are already  fastening their seat belts !

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Moderator band is a ubiquitous structure  found inside right ventricular   cavity , often overl0oked by cardiologists. God has created no structure  without any purpose ! Moderator band has important role to play  both in physiology and pathology .

Image credit and courtesey : Whoever has created

The table attempts to summarise  the features  of moderator band. The  structural and functional behavior of moderator band  in , RV cardiomyopathy , RV non compaction and arrhythmogenic  RV dysplasia is not fully studied yet  . Reference :Content is taken from various sources and with a personal input in few places.  The anatomical data is largely taken from the pioneering  work of cardiac  pathologist and morphologist  RH Anderson of  United kingdom.

Here is an article  from my institute Madras medical college  published in Indian journal of Thoracic and Cardiovascualr surgery in 1982.

An autopsy study  on moderator band   by Paul Ravindran and   Solomon victor

http://www.springerlink.com/content/g35616v662976g1r/

http://circ.ahajournals.org/content/67/6/1268.full.pdf+html http://www.ncbi.nlm.nih.gov/pubmed/20235167

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How do you tackle  In-stent restenosis  (ISR) ?

  1. Deploy another BMS
  2. Use a third generation  DES
  3. No . . . first  generation DES(Paclitaxel )
  4. Consider Plain balloon angioplasty.(POBA)
  5. Refer for CABG.
  6. Fall back on medical management.(Ingloriously  referred to  as  “No option” patient !)

Answer:  Please  note , there is no single response answer for this question .

Instent restenosis (ISR) is   commonly seen with BMS .This is primarily because  we are busy blaming DES  for stent thrombosis  and we do not want to give a double blow to DES .There is a  significant population  roaming with ISR  involving  DES .  BMS is in vogue for nearly 2 decades, hence it is natural to see more of it.  In due course ,  DES  is expected to catch up with BMS  and would lead in ISR as well .

The issues in PCI for ISR

Though any of the above 6 strategies may be appropriate ,the urge to put another stent within the IRS ,  prevails over all other options in most centers. This is more off an Interventionist talent  show off  !

Please remember , the common  principles  must apply in all patients before an PCI  . Simply stated , this  principle involves  assessing  symptoms, residual  resting  ischemia, myocardium at risk  during stress, viable muscle mass etc .Lesion characteristics  should come last in the work up. ( A cardiologist  should not  report  a coronary angiogram  , if   does not  not know  basic clinical parameters.)

It is  good  to have a  rule  that  “reserves  intervention”  for ISR  only if the  patient  has refractory angina. 

Can you promise  relief from dyspnea

Contemplating  PCI for  patients with dyspnea as the main symptom is really tricky one.Unlike angina ,  dyspnoea  can be attributed to so many factors other than coronary blood flow.(Apart from LV EF , Iscehmic MR,  A transient diastolic dysfunction , lung function , volume status, renal function , physical conditioning etc)

Opening  ISR in the belief it would improve LV function is highly questionable even if viability is documented.

What is the most important step in the decision making prior to PCI for ISR ?

* Most important step  in ISR management is  probably  spending  sufficient time ,  involving  experts ,  ” democratically  debating”  the indication and techniques  in your institutional cath conference.

Once you document the necessity of intervention* The following things  are possible .

  1. If  the patient has diffuse in-stent stenosis , especially  the  proximal ones or that  involves  branch points,  it is wiser to refer  them for CABG.
  2. Discreet and focal ISRs can safely be attempted for repeat PCI.
  3. BMS or DES  ?  This  is  debated. Current preference is to use  a DES. (Many feel ,first generation DES -(Paclitaxel)  scores over Everolimus in this situation )
  4. Is POBA  possible for IRS ? Can a balloon do a job where a stent has failed ? . No  body is trying it .Many Feel guilty to  do it .  POBA for IRS is a failed concept without even trying it !  One  way of reasoning  is IRS occurred  only  because stent was  never indicated in the first place  in that  location  and a POBA would have been the choice in the initial attempt itself .So let us not make the second error !  ( May be , if  Gruientzig is alive today ,  might have  used  POBA  for ISR very effectively ! )

Issues for which  we will never ever know the answer !

In future any of the following combination of  stents  will occur in tackling ISR.

  • DES covered  BMS
  • BMS covered DES
  • Two BMSs
  • Two DESs
  • Paclitaxel covered Everolimus
  • Everolimus covered Cypher.
  • Overlapped DES and BMS
  • DES covered beta irradiated IRS
  • Rotablated BMS (Yeh metal crushing !)  followed with  DES jacket !

How does the two metals ,  two drugs in various combinations interact with  the tender coronary  endothelium ?

Endothelium is an endocrine organ. It has  to secrete as  many pro and anti homeostatic molecules (Nitric oxide, endothelin etc).This has to be  kept in mind when we develop newer and exotic devices. Of course ,  we claim our  aim is primarily  to provide  relief  to  our ailing patients , but, as things stand today  , there is a distinct risk of  converting human coronary arteries into corporate playgrounds !

Reference :

http://circ.ahajournals.org/content/100/18/1872.full.pdf+html

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  • How do you classify  stent thrombosis ?

  • What is target vessel revascularisation ?

  • How do  you define  peri-procedural MI ?  Is  troponin elevation alone  enough ?

Want answers for all these ? Your search ends here  . . . The academic research consortium criteria committee provides everything free .

A must read for both  mature and immature  cardiologists . http://circ.ahajournals.org/content/115/17/2344.full.pdf+html

Here is a cartoon for classifying  stent thrombosis (Time based )

There is another etio-pathological /Geographical classification for  stent thrombosis  that will be discussed later.

( Entry block , exit block  , diffuse thrombosis  etc  Read -Geographical miss.)

A word about Academic research consortium

ARC is a consortium of clinical research  from the  Harvard medical school and their associates . The aim of which is  to bring clarity in the  definition of  medical  terminologies and study endpoints.A universal  criteria is being prepared  so that  the study results are comparable which currently use  different criteria  and end points.

For cardiology ARC came out with standardized definition in the year 2007.

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It was  the year 1812 ,  exactly 100 years before the Titanic sank  over the Atlantic  , a  small bulletin from  Massachusetts General Hospital was  released .  It  later on became  the  single most  important  journal  for the medical community.  The appearance of  an article about  angina pectoris in the inaugural issue ,   reiterates the  importance of cardiology  even in those   days of primitive  medical care .

The volume. 1  : No. 1  issue of NEJM egan with a classical and critical observation of angina pectoris written  by Jhon Warren .

http://www.nejm.org/doi/pdf/10.1056/NEJM181201010010101

The first issue of NEJM . . . Witness to 200 years of medical excellence

Those were the days  when angina  was treated with tincture  opium and Fowler solution (Arsenic  potash ) .They  can be  termed as  height  of  inappropriateness  and  also  condemnable acts  . . .  is it not  ? 

200 years  later   . . .  in 2012  what  do you think has changed ,  in terms   of  appropriateness  of management   of angina pectoris  ?

What a surprise ,  two centuries  later ,  even as we are  treating  angina  in hi-tech cath labs  with bio-degradable stents and metabolic modulators   ,   bulk of our  population is  grappling with inappropriate therapy for angina pectoris .

Today ,patients are subjected to  questionable modalities  in the management of CAD ,  which the following paper   tries to expose !

Keeping the inappropriate flag high . . .200 years later in 2012


What a way to progress in Medicine !  The reason for this  “200 year  old ailment”  is  attributed to  extreme scarcity of common sense !

( A study , which says regular exercise  can be  as good as PTCA in multivessel CAD ,  would  sound  as a  “nonsense article”  for most  cardiologists  of  current  generation  !)

Finale

When we look  at human history , where billions  lived ( and continue to live ) in this  age old planet , it  would appear  a trivial matter  whether you treat angina pectoris with Tincture opium / Arsenical potash or  Prasugrel  / Rosuvsatin . . .

Whatever be the scientific advancement  the ultimate outcome on human health will depend on how we apply it. So, all young  medical fellows beware of this   !

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