Posted in acute coronary syndrome, anti platelet drug, cardaic pharmacology, Uncategorized, tagged aspirin vs clopidogrel in post pci dapt vs mapt, current guidelines for dapt after pci, dapt, dapt what is it ?, focused guideline for dapt after pci des bms, jacc 2016 dapt, Levine GN et al. 2016 ACC/AHA guideline dapt, nejm dapt guidelines on November 2, 2016| Leave a Comment »
DAPT -Dual anti-platelet therapy has become a standard in many clinical situations of CAD.There has been significant confusion about ,Indications, best combination, duration of DAPT, withholding of DAPT, conversion to MAPT (mono) etc.The JACC september 2016 issue brings much needed clarity on this issue.
Link to key summary from NEJM journal watch.
http://www.jwatch.org/na42407/2016/09/28/update-dual-antiplatelet-therapy-patients-with-coronary?
Full text guideline
Posted in Uncategorized on September 22, 2016| Leave a Comment »
Ventricular tachycardia is a regular wide qrs tachycardia.It can be monomorphic or polymorphic.
General diagnostic rules In VT (Gross though, with considerable overlap)
*Its important to realise any VT will transform to polymorphic just prior to degenerating into VF.
Management Issues.
The management of VT in acute setting is same irrespective of morphology of QRS complex.Either you DC shock or administer Amiodarone, Lignocaine , and other reserve drugs.
The issue comes only in stable VTs.In stable VT or if VT recurrence it’s advisable to bother about the ethology and choose a drug.Its believed , Amiodarone is contraindicated in true polymorphic VT that was precipitated by prolonged QT interval or Brugada syndrome.
In Ischemic VT , lignocaine may be preferable over Amiodarone as the later may prolong the QT interval and VT could recur if the index VT was triggered by ischemia induced prolonged QT and subsequently gets worsened by the drug Amiodarone.(please note, Lignocaine has neutral or even shorten the QT)
Let me conclude with a controversial observation, many of VT storms we are witnessing only in the era of Amiodarone.Most episodes of VT Storm are polymorphic and often precipitated after blouses of Amiodarone punctuated with DC shock. With an explicit pro arrhythmic potential of this drug, I strongly believe some of the episodes of VT Storm is iatrogenic and it tends to disappear as the drug effect of Amiodarone weans off.
Final message
In monomorphic VTs, drug choice and selection may not be that important , polymorphic it could make a big difference !
Always ask a query whether the VT you are tackling (in any setting )is likely to have precipitated by prolonged Action potential duration (Read as QT Interval ) ? Of course ,one can’t get a clear answer to this in bed side .But, if you have strong reasons to suspect , better to avoid drugs that prolong action potential duration ( Amiodarone comes top in this list, though it can terminate VT of any ethology with any morphology because it has all 4 group action of Waghaun williams !)
Comments welcome from EP experts , still to understand things in perspective.
Posted in Uncategorized, tagged brugada syndrome, structural abnormalities in brugada on September 17, 2016| 1 Comment »
Brugada syndrome is probably the most fascinating discovery in Inherited cardiac Ion channel dysfunction that linked the basic sciences to bedside . Its due to genetic defect in SCN gene that results in sodium channel blockade of phase of action potential to cause troublesome ventricular tachycardia (Phase 2 reentry ) . Now we realise, there are some phenotypic expressions to this gene defect . RV epicardial anatomical substrates are found to responsible for these Arrhythmias.
So ,does Brugada turn out to be a structural heart disease (At least histological ) ? Where is the evidence coming from ?
Now, we realise RF ablation of epicardial aspect of RVOT / Adjacent anterior RV wall can eliminate Brugada pattern confirming anatomical defect at cellular level. Our changing perception of Brugada from pure functional to anatomical cause is exciting and intriguing as well ! ICDs were the specific therapy so far.This discovery make it RF ablation an option.
The recent data from Brugada himself was presented in World congress of electrophysiology / European Heart Rhythm Association (EHRA) EUROPACE-CARDIOSTIM 2016 confirming the therapeutic benefit of targeting the epicardial structural phenotypic substrares (Ref 3 )
Final message
We have been taught Brugada syndrome is a primary electrical disease .It was never considered as structural heart disease. Knowledge evolves slowly, so we shouldn’t conclude prematurely .Shall we conclude , Brugada syndrome is truly a structural heart disease at least in some ?*. This makes RF ablation a new cure for Brugada , making it a useful alternate modality to ICD , Of course there can be an overlap between ARVD and Brugada syndrome. Mind you RF ablation scores over ICD on any given day as its potential cure , while ICD is just a back up device and it simply wait & watch for the VT to occur.We also know ICDs are still learning human EP data, and are not intelligent enough to differentiate true VT from false ones with acceptable error** margin.
* Let the experts decide
**Acceptable ? What do you mean by that ?
Reference
Questions queued
2.Is Amiodarone Indicated in Brugada syndrome ?
.
Posted in Uncategorized, tagged heartfailure and obesity, wieght loss in cardiac failure, WISH study on August 16, 2016| Leave a Comment »
Cardiac failure is defined as a clinical syndrome where the cardiac output is inadequate and fails to fulfill the metabolic demands of body or its able to do so, only at a raised filling pressure, causing the classical symptoms of exertional dyspnea.
Consider this simple equation,
A 70 kg normal human requires an EF of 60 % to supply blood to his total body mass. If his EF falls to 30 % , certainly he is going to struggle with reduced cardiac output by 50 %. Now , theoretically if he loses his weight by 50 % (70 to 35 kg ) in-proportion to the loss in EF, . . . isn’t likely , he goes back to the original ” comfort zone” again as his metabolic demands are declined by 50 % and hence easily managed with the severely compromised EF of 30 % .
Is this a scientific or quixotic logic ?
By all means , it appears the later is right ! but wait . . nothing is Idiotic in a true scientific democracy ! Human beings can live a near normal life with one kidney, one lung, half the liver function and brain function ! Nothing wrong in wondering why not , one can live comfortably with “half heart” function?(ie EF of 30 %)
Having said that ,cardiac failure is not a simple mathematics of EF % .It’s extremely important to understand cardiac failure is systemic disease (often an inflammatory reaction as well) which progress to a net catabolic sate .Numerous named and unnamed counter hormone response(ACE,NEP, BNP etc) retains salt and water.At some stage the body either adopts or mal-adopts to it.Countering or mimicking these hormones has been a major therapeutic strategy.(ACEI, ARBs )
The final end point of cardiac cachexia is nothing but extreme response of the body to reduce its weight (with Tumor necrosis factor /IL6) .Survival occurs with whatever available cardiac output that matches metabolic supply to tissue.
Now ,coming to the title discussion, If weight-loss is the ultimate compensatory mechanism in chronic HF , what about conditioned and monitored weight reduction regimen ?
The management of cardiac failure after addressing all specific problems like structural ,functional abnormalities plus or minus revascularization should include a mandatory exercise training program that help optimize the weight.Reducing total body mass is directly going to improve the cardiac function, or at-least make it static and might dramatically relive symptoms and increase survival.However , the beneficial effect of exercise is mainly attributed to improving muscle mitochondrial function and augmenting exercise capacity.
Where is the evidence coming from ?
A point of controversy !
There are few reports that suggest good-weight is essential as a body reserve during the catabolic state of HF.In fact, low fat and cholesterol was unwelcome in some statin and HF studies. Some provocative papers even suggested a paradox where weight loss could be counterproductive in HF (I strongly dispute this as do many others.)
Final message
Unfortunately , truths without evidence is worse than plain falsehood !
When heart as a pump is failing , we go for sophisticated drugs, ICDs CRT devices, variety of surgeries etc . Shall I say , none of them has conquered the inevitable. We know ,HF’s mortality and morbidity is next only to burden of cancer.Applying all our wisdom , intentional and monitored weight reduction may be best bet to unload the heart in many of the HF patients .Mind you, this comes free of cost ! and that is not the only reason it should be tested in every such patients .My own experience and interpretation of available data would suggest its going to work in all and the benefits are going to be overwhelminng in overweight patients .
Dear heart failure patients . . .Wishing you all a controlled weight loss and a happy life !
Posted in acute coronary syndrome, Cardiology -Therapeutic dilemma, cardiology -Therapeutics, Cardiology -unresolved questions, Primary PCI, Uncategorized, tagged failed thrombolysis, pharmaco Invasive strategy, primary pci on July 2, 2016| Leave a Comment »
Less than a century ago an easy chair was enough to manage this most important medical emergency of mankind. Of course, at that time mortality of STEMI was estimated to be around 30%.We have since pushed the in-hospital death rate down to less than 10 % and its around 5-8% currently.(*The lifeless chairs were able to save 70 lives is a different story!)
Heparin , thrombolytic agents, critical coronary care has helped us to achieve this , of course It must be admitted primary PCI also played a small role (at best 1 % ) in our fight against this number one killer.
Now, why not combine both lysis and PCI ?
The concept of PIA (Pharmaco Invasive approach) came into vogue primarily for two reasons.
1.If thrombolysis and pPCI are powerful strategies by individual merits why not combine both and achieve double the benefit ?
2. Since pPCI is going to be a logistical nightmare in most points of care and we can’t afford to lose time . So, let us lyse first and consider PCI later !
Unfortunately medical science is not math .One plus one in medicine is rarely two !
Though , it looks attractive , Pharmaco invasive approach has its own troubles.Fortunately , most of them are man-made, few are beyond our knowledge though.
Following general rules may help us
The key “branch points” in decision making after lysis
One issue with Rescue PIA
Though by current definition PIA is to be done 3-24 hours , don’t wait for the 4th hour if you have recognized a failed thrombolysis earlier than three hours.( Ofcourse , as the gap between P and I gets too narrowed it may carry some adverse effects witnessed in routine facilitated PCI -Refer FINESSE study ) Similarly,there need not be a blanket ban on PCI beyond 24 hours if residual ischemia is active.
Final message
PIA is a dynamic coronary re -perfusion strategy . Nothing is fixed in science. . The optimal gap between Pharmaco and invasive strategy can be anywhere between 1 hour to “Infinitely deferred” depending upon individual risk perception and wisdom of the treating cardiologist.
I
Posted in Uncategorized, tagged bio ethics, digoxin, drugs for atrial fibrillation, how to practice medicine on July 1, 2016| Leave a Comment »
It was delicate few minutes in one of my recent visits to a corporate hospital , when I noticed an emergency physician hesitated to follow my advice to prescribe IV Digoxin for a patient with Atrial fibrillation and fast ventricular rate.His fear was, his consultant, a modern day cardiologist wouldn’t like it as Amiodarone has become a default drug for atrial fibrillation in that Institution. I could sense. . .he felt so out of place to take on my suggestion.
I reminded the young physician , the uniqueness of Digoxin and its un-diminished value for this particular indication ,still he was reluctant and didn’t oblige.
I realised , it was my mistake to expect a place for the humble fox glove in corporate crash-carts of centrally climate controlled cardiology suits !
“Medicine need to be practiced not only with best science(Truth) but also in a holistic and cost efficient manner . There is no place for glamor, glitter and commerce in your prescriptions ! In near future , teaching Medicine to students would essentially become “more of moral” than “science” .
Reference
Link -Which is the best combination for rate control in Atrial fibrillation
Posted in Uncategorized on June 25, 2016| Leave a Comment »
We know, atrial fibrillation is the commonest clinical cardiac arrhythmia , that is extensively studied , subjected to exotic investigations and state of the art treatment strategies.Interestingly , this arrhythmia also drags the economics of cardiology practice of a community in a big way with heavy influence on drug , device and usage.We know, RF ablation of pulmonary vein is one of the modern ways to manage this arrhythmia.
Iam sharing this article from medscape by an EP specialist Dr. Jhon Mandrola , surprisingly exposes our fundemental ignorance about this arrhythmia and the near futility of certain procedures.
Posted in Uncategorized on May 6, 2016| Leave a Comment »
ICDs are revolutionary devices in the management of patients at risk for electrical sudden death .Its is indeed a boon for patient’ s with a primary electrical disease with occasional risk for VT.
Unfortunately , the usefulness of ICD in patients with severe mechanical dysfunction is marginal at best as these patients succumb sooner or later inspite of ICD, especially if the episodes of arrhythmia is more.
This is understandable as electrical events are directly linked to primary mechanical problem and one begetting the other.Of late , we realised these patients require some methods to stop the arrhythmia generation in the first place rather than terminating it after it manifest.
ICD may be great devices but it simply does nothing in preventing an episode VT.It trys to battle the fire after its ignition.Not a great concept to be pride upon.At best it can be called as back up safety device.So , for long term therapy it seems we need additional support system to ICD .
This can either be RF ablation or medical therapy (Amiodarone ,Sotolol, Mexiletene).It is likely , intensive anti -arrhymic therapy is essential in most.In some patients all three modalities(ICD, RF ablation, drugs) will be required for complete protection.
The VANISH trial has added important data on this issue .
Posted in bio ethics, Cardiology -guidelines, Cardiology -Patient page, cardiology -Preventive, Cardiology quotes, medical quotes, Uncategorized on May 5, 2016| Leave a Comment »
We all know to err is human , but most of us probably won’t agree medical mistakes , (bulk of which happen in the name of practicing state of the art of science ! ) could be the dominant theme in modern medical care !
BMJ exposes this well known secret with the help of most authentic data from an apex scientific body CDC , Atlanta .
Reference
Posted in Uncategorized on May 1, 2016| 1 Comment »
Bifurcation lesions (BFL) remain a true challenge to interventional cardiologists. For over two decades , at least a dozen strategies are being tried to conquer it without true success . . . if iam allowed to say that.
We often talk about side branch in BFLs.Ironically , the importance of side branch is largely determined by our cortical linguistic perception of the word “side”
The much famed Medina classification does little to clarify the importance of side branch with reference to left main vs non left main bifurcation lesions.
In true sense , both LAD or LCX can be side branches in left main BFL depending upon how one views it.
Commonsense would tell us, since LAD is a major vessel , LCX gets the side branch tag by default.
However, If LAD is diminutive, or its serving a infarcted , non functional zone and if LCX is really big and dominant, it has every right to reject the humiliation of being refered to as a sidekick.
Note , in non left main BFL there is no much confusion since main branch continues as main and side branch just exit.
Final message
Interventional cardiologists use the term “side and main branch ” in variety of ways .Though, it could mean vitally important things , oftentimes its simply semantics prevailing over complex coronary hemodynamics.
Dr.S.Venkatesan MD 