It was 1912 , Titanic had just sank off the Atlantic . When the world attention was elsewhere , An unassuming young Dr.Herrick J.B silently working in his Michigan lab inquisitively proposed thrombus occluding the coronary artery is the chief culprit in acute myocardial Infarction.It took seven more decades when Davis et all from Glasgow .UK. proved it by doing dramatic angiographic studies soon after STEMI in year 1979.
Now, even after 100 years , we, the confused cardiologists debate endlessly in glamorous global conclaves in exotic locales whether to aspirate these humble looking thrombus, threatening to damage the myocardium with every passing moment !
Why is this controversy ?
My answer
I am failing to understand the concept and the answer is elusive .While every one agrees that thrombus is true culprit, in bulk of the STEMI , still we are not authorised (In an assertive fashion ) either to lyse as first choice or to aspirate as second choice.
It seems vital, thrombus must be tackled vigorously by any means. Drugs,lytics,(Intravenous or Intra-coronary.) by micro and rheolytic catheters .Only documented, flow limiting complex mechanical lesions must be stented. If we are convinced tackling thrombus by mechanical means is problematic (As studies would suggest ) lysis should prevail over aspiration as a routine measure by default isn’t ?
*It’s a been quite a while , the world cardiology community has made it appear thrombolysing a patient who is otherwise eligible for primary PCI ! a “coronary crime*” Ofcourse , I must say , I proudly commit that crime with rewarding results in many MI patients.
*In fact , I would think not promoting or delaying prompt lysis should qualify for the definition.
In the management of STEMI, prehospital lysis followed by a Intensive care in a good coronary care center is best modality.
This doesn’t mean in-hospital lysis is banished. Yes, STEMI is a cardiac emergency , but triaging STEMI patients must be done by scientific means (STEMI risk score) as well with accumulated wisdom .Rush only true emergencies into cath lab. (A best estimate is about 20 % of all STEMI) If we are not able to decide which STEMI will require prompt PCI , it would Imply we need to go back and do once more the basics postings in coronary care of resident days !
An angry counter from a young Interventionist
Only God can tell whether a given patient with STEMI will (or will not) derive maximum benefit from pPCI. We are not yet trained to make that decision by looking at patient and his ECG.So my logic is all STEMIs are equal. I will continue to do emergency angioplasty in all STEMI patients . I expect them blindly to accept all the potential complications arising out of poking the thrombotic milieu in those low risk patients who might have done well with thrombolysis.
Never afraid of challenges. It is like going to war. Casualties are bound to happen.We have enough technology , Imaging , expertise, to tackle all those complex lesions we encounter during primary PCI especially in elderly comorbid patients. We can even do a triple vessel angioplasty , left main etc. Only Yesterday I posted in my nonstop whatsapp group , where I did a dramatic acute angled bifurcation angioplasty for a stable STEMI patient that required a iFR guided jailed side branch assessment and 3d OCT transmitting stunning snaps of fresh thrombus, ending with a semi culotte procedure.The patient is doing well with a Impella 2.5 device and a high frequency ventilator support and my anesthetist has promised me to wean him soon ! I must actually thank his Glo-Health plus Insurance company for clearing the procedure.
An Important tip for complex lesions during STEMI
We need to know there is always a saving grace , if for some reason we couldn’t accomplish PCI due to complexities of the lesion with multiple IRA mimickers. We can always sheepishly thrombolyse these patients inside cath lab . . . a modality just few minutes ago would have been ridiculed with all our vigor to convince the anxious family for a costly Invasive procedure !
Reference
2.Davies W. F. M. Fulton W. B. Robertson The relation of coronary thrombosis to ischaemic myocardial necrosis M. J. Journal of pathology February 1979
ORBITA trial : First let us do some harm . . . second , we shall . . !?
Posted in Cardiology -Interventional -PCI, Cardiology -Technology, Cardiology -Therapeutic dilemma, cardiology -Therapeutics, Cardiology -unresolved questions, cardiology journal club, cardiology wisdom, Medical education, Medical ethics, Uncategorized, tagged ABUSE OF STENTS, ACC AHA ESC ORBITA GUIDELIES, CHRONIC STABLE ANGINA GUIDELINES, drsvenkatesan, HOW ORBITA TRIAL WILL CHANGE MY PRACTICE, INAPPROPRIATE USE CRITERIA AUC STENTS, LANCET ORBITA STUDY, ORBITA COURAGE BARI2D FAME 2, ORBITA IMPERIAL COLLEGE, ORBITA study, ORBITA TRIAL LANCET, ORBITA trial review and comments, ORBITA VS COURAGE, reviewing ORBITA trial study critically, TCTMD 2017 ORBITA, WAHT WE LEARN FROM ORBITA STUDY on November 6, 2017| 2 Comments »
Cardiologists at confused cross roads !
Perils of limited Intellect & Infinite greed
When not so appropriately trained cardiologists do Inappropriate things “use becomes misuse” . . . then, it won’t take much time for science to become total abuse. That’s what happened with the murky world of coronary stents .No surprise, it’s time to firefight the healers instead of the disease !
Now ,Comes the ORBITA study . Yes , it looks like a God sent path breaking trial that spits some harsh truths not only in cardiology, but also in behavioral ethics .Let us not work over time and hunt for any non-existing loop holes in ORBITA. Even if it has few, it can be condoned for sure as we have essentially lived out of flawed science for too long Injuring many Innocent hearts !
Yes , its enforced premature funeral times for a wonderful technology !
GIF Image courtesy http://www.tenor.com
Meanwhile, let us pray for a selective resurrection of stenting in chronic coronary syndromes and stop behaving like lesser professionals !
Postample
Extremely sorry . . . to all those discerning academic folks , who are looking for a true scientific review of ORBITA , please look elsewhere !
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