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Patient guided Investigation . . . is here to stay . . . and the future looks bright !

Posted in Uncategorized, tagged , , , on November 11, 2011| Leave a Comment »

A patient  walks  into the consultation suit in an  upscale cliniq  of  a  south Indian Metro.

Good evening doctor !

Welcome . . .   what brings you here ?

Doc ,  I  have a vague chest  and back pain since two days . It  had been a  strenuous   week  . . .  I  had to travel a lot ,

I am worried  it could be a heart attack

Let me examine you ,

(After  the examination )

Will you please  lie down for an  ECG  ( Records it  in a minute , Glances it )

Every thing looks fine , i believe  you are under some stress and  I am sure it  is  a  pain from your muskulo – skeletal system

You should  be alright by few days . I will  prescribe  some pain killers .

It is not uncommon to find a  patient wear a doctor’s mask

Doctor , why don’t  you prescribe  a 10 second 64 slice heart scan*, I just saw  an  ad in yesterday’s  “Times of India”

I want to confirm every thing is fine with my heart doc  ,   I believe  there is  a  special   World heart day offer too !

You will  not need a scan for that ! I can confidentially rule out a heart problem right now , and  you can schedule a  exercise stress test later.

You may sure doctor ,    but  I am not !

Please ,  will  you advice  a  scan for my satisfaction ?

It is not correct  for patients to demand investigation  . . .  thinks for a moment   . . .umhh   .. yeh  . . .ok . . .  any way   I  will do just that   . . . after all  we are here to satisfy you.

By the way , you  take  the  scan  in this a particular  centre  , (Let me also benefit  by your foolishness  ! )

Thanks doc ,  you are  really great   !   upholding the dignity of  the noble profession !

(* A single 64 slice CT scan of heart  is equivalent to radiation of 100 chest  x rays , which is equal to   a  life time dose of medical radiation)

Can a patient demand an investigation and a prescription ?

It is an  awkward question .  Our medical schools do  not teach about these issues. If the answer is yes , it would be  diagonally opposite  against  the  principles of practice of  medicine  ,  It is same as self medication  with a  non academic  ratification  by the doctor !

The patient   guided medical practice  has a niche market by itself . Now patients tend to  ch0ose  not only  hospitals  and  doctors   but also  they want to  decide the  investigation and treatment as  well  , fueled by crazy  mass  media advertising  . It  all started with  from simple master health check now extended into  all common disorders.

And  no wonder  . . . future looks  bright for medical  practice .

**Please note  : When the treatment  is debatable and outcomes are not clear in certain complex  diseases ,  one has to involve  the patient and their relatives  with an informed consent and allow them to make a  learned decisions.This is an acceptable form of patient and family guided disease management.

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How do you tackle this man’s RCA ?

Posted in Uncategorized, tagged , , , , on November 3, 2011| 2 Comments »

This is an  RCA of   a  patient who had chronic stable angina  , class 2  with moderate anti anginal medication.

What shall we do ?

  1. The RCA needs  multiple stenting
  2. Multiple plain balloon angioplasty
  3. CABG to PDA
  4. No intervention ?
  5. It depends upon status of LAD  and LCX

The correct response would be 5

Without knowing  the status LAD and LCX . . .  RCA should not be touched . Further,  the concept of tackling  the  coronary artery  by itself  is   fundamentally wrong !  We are supposed to tackle patient’s symptom ,   reduce future risk of  events and   not merely  their coronary artey !

His LAD and LCX was near normal. In the weekly  cath   meet   PCI to mid RCA  covering  the critical segment was  strongly debated but  lost a close race .

The final decision was to allow the patient to continue   intensified   medical management (Statin 80mg /Metoprolol 100mg ) . He is comfortable with that .

Medical management  in a tight  single vessel disease  can never be digested by  any   Interventional cardiologist  whatever   may be  the guidelines !

Final  message

Do not decide PCI on the basis of   how ugly a coronary artery looks , rather spend some time on true  symptomatology ,  optimise baseline therapy  and re assess risk profile

One learned dictum is ,  do not  meddle a RCA ,  however severe the lesion may be   if  LAD and LCX are fine.*

*This  rule is not applicable in ACS

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Coronary comrade show : An unique “Ramus”

Posted in cardiology- coronary care, cardiology-Anatomy, Uncategorized, tagged , , , on October 20, 2011| Leave a Comment »

Human coronary artery anatomy would  rank  top among  all human biological mysteries. The variations in their branching pattern is next only to palmar creases and cerebral gyri !

The left coronary artery can divide in to two , three  or even four branches occasionally.The trifurcation  occurs in upto 20 % of population .The ramus intermedious  can some times be a major division .Usually it supports the diagonal or OM territory.

It is very rare to see a ramus  take a long course . Here  is a patient whose LAD is small  which  falls  short of LV apex . Sensing this , the ramus travels all the way to apex and support the LAD in distress !

RAO caudal view shows the Ramus reaching all the way to LV apex! Note the diminutive LAD and absence of true OMs from LCX.

* Technically  this can  also be  referred to as a rare form of dual LAD system .

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Different “Avatars” of ventricular tachycardia : Multifocal vs Polymorphic VT !

Posted in Uncategorized, tagged , , , , , , , , on September 23, 2011| Leave a Comment »

Ventricular tachycardia can be classified in a variety of ways. Monomorphic VT  and polymorphic VT  is one such classification based on VT morphology.Polymorphic VT  generally conveys a meaning of origin from multiple focus .But in reality  bulk of the polymorphic VT originate from a single focus .

How does a single focus have a multiple QRS  morphologies ?

This is possible because ,  even though VT arises from a single focus , the route it takes to exit  from the myocardium is different and hence they inscribe different QRS morphology for each  beat. It is also possible ,  as the conduction time varies with each  exit route  the VT  becomes  irregular. This  phenomenon   is called  polymorphic VT.

It is assumed the VT focus  is often located in the sub endocardium and breakthrough occur in the epicardial side as  we record  the activity  in the surface ECG. Electrophysiology of VT is not that simple ,  focus  of VT can be anywhere ,  the focus can be single or multiple and exit pathways  can also be multiple it and  it may even exit into endocardial cavity . Please note , even  a single  electrically abnormal cell  shall  act as a  focus . To confuse us further ,  some of  VTs  may not exit at all , extinguishes before reaching the surface.

It is  a  difficult  job to fix  a given  polymorphic VT  to arise   from a single focus or from multiple focus  .  Multifocal VT  can be  diagnosed  with  confidence only  after a through electro physiological  study.Clinically few clues are there. Electrolytic disorders and ischemia  are usually  multifocal,  while scars VT gives single focus .Other famous  example  of polymorphic VT are Torsedes de pointes .

Polymorphic VTs are  usually hemodynamically unstable but it is not a rule. Surprisingly ,some of the polymorphic  VTs are well tolerated . This is especially common in  multi focal polymorphic  VTs  which are hemodynamically and electrically  better off  . Ironically ,   presence of  multiple focus may be  a blessing  as they    compete with each other ,  in the process  pulling  down the other focus from triggering a VF . It  is possible  one focus acts like a natural anti tachycardia pacing for a  VT from another focus.

Ventricular fibrillation can be termed as an extreme form of irregular polymorphic VT as the wavefront breaks into innumerable fragments  each exiting the myocardium at will in a random fashion bringing ventricles to a standstill.

Final message

The term multifocal polymorphic  VT  is generally been abandoned at the bedside  as distinguishing  it from single focal  polymorphic VT  is a difficult task*.Still  the concept of  multifocal VT  is alive and  kicking in the EP labs ,  giving sleepless nights to  our Electro-cardiologists!

*Please note , multi focal VPDs can be recognised  with ease by different coupling intervals, but  it is difficult to identify during a  run of VT .

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Femoral approach for permanent pacing : Innovative idea . . . still , under-utilised !

Posted in Cardiology - Electrophysiology -Pacemaker, tagged , , , , , , , , , on September 22, 2011| 1 Comment »

Venous access for permanent pacing can be troublesome . Especially with anomalous subclavian ,  second implantation  ,obese patients with upper limb DVT . Temporary pacing through femoral vein is a well known concept.

Here is a concept of implanting the PPM  through femoral vein ,    in the upper thigh and the pacing  lead all the way reaches the right ventricle .There were few  issues which were  thought to be critical .As patients ambulate   there could be more  generator motion  than the sub pectoral location .(By the way , upper limb movement is equally common daily living is isn’t !)

Surprisingly excess  motion is  rarely an issue .  Even dual chamber  pacers were implanted  through femoral approach.Implantation  procedure  are simpler than one would have thought  and  complications are less as well .Since most of the leads are now screwing type  and  actively fixed   dis-lodgement  is never an issue.

Final message

The femoral venous access can be considered in all in whom SVC approach is difficult or not possible . 85cm lead is ideal . It is routinely available.

Always consider trans-femoral approach  whenever you encounter difficulty in subclavian .  Falling back on  epicardial  approach in such cases should be avoided at all cost. After all , epicardial approach is a major procedure.

Unfortunately,  very   few centers   practice transfemoral modality  for PPM right now . Brazil has some experience I understand.Royal Brompton  hospital ,London , Memorial  heart institute ,Long beach , California  have advocated this approach with good success.

We Indians , have a huge potential to propagate this useful concept.I wonder  why Femoral –  IVC approach  could  not be a  first choice for permanent pace maker implantation  especially in small children and adults ! The  main issue is  not technical , it is more of   perceived  fear  and reluctance to change the tradition.

Reference

The  article  by Ellsted  http://onlinelibrary.wiley.com

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What are the causes of ST segment depression in V1 , V 2, and V3 in inferior myocardial infarction ?

Posted in Uncategorized, tagged , , , , on September 20, 2011| Leave a Comment »

ST segment depression is a fairly common observation in anterior precardial leads. It   is  due to

  1.  Pure electrical phenomenon (Referred to as reciprocal changes)*
  2.  Additional  ischemia in LAD territory
  3.  It could imply  the IRA  is  a critically occluded  LCX and STEMI is actually an   infero -posterior STEMI
  4.  Simply  indicate a  multi vessel disease.
  5. Many times  reciprocal changes may simply indicate extensive nature of the  index  inferior MI.

How to differentiate reciprocal ischemia from true  remote ischemia ?*

  • Logically true ischemia patients  should suffer from double dose of angina (Infarct pain plus ischemic). Most of these patients will present in a   scenario of  post infarct persistent  angina . Patients with   pure electrical reciprocal  changes are relatively  quiet and  severe distress is uncommon.
  • In true ischemia  , both patterns are  not temporally related  in time. If its a  pure electrical phenomenon they should be linked in time .
  • Disproportionate ST segment depression  (ST elevation  in inferior lead  is  2 mm  while ST depression in v1,v2, v3 is >  3 mm )
  • Persistence of ST depression even after thrombolysis  or PCI to IRA.
  • Worsening with thrombolysis would suggest ST depression in V1V2 and v3  is indeed an  episode of  true NSTEMI  of LAD , where thrombolysis is contraindicated. (Also  read  – A  related article  dual acute coronary syndrome in this site )
  • Echocardiogram will give us a clue .One can  detect ischemic the wall motion defect in the segment in dispute .(Reciprocals do not show WMA )
  • Coronary angiogram   would provide   definite  answer to the speculations in most  . Still , it may   require a FFR  to confirm ischemia in the contra lateral artery.

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Contrast nephropathy : Every cardiologist should get trained to shoot with this RIFLE !

Posted in Uncategorized, tagged , , , , , , , , , , , , on September 4, 2011| Leave a Comment »

This RIFLE  shoots without  bullets . Yes ! it  helps the cardiologist to  trouble shoot  the kidneys which often  suffer from  cath lab cross fires .

As  the cardiologists indulge in sophisticated cardiac procedures ,  in more and  more  sick and co- moribund  patients , it is becoming increasingly  important  for them ,  to   give due  respects  to  other organs as well !

Renal function is an important determinant   in the  over all outcome  in any cardiac patient.

  1. How to assess  the baseline renal function ?
  2. How to measure  the impact  of the  cardiac procedure ?
  3. How to  follow  up and monitor the  progress of  renal function   in coronary  care unit.
  4. How to  reduce the enhanced renal  risk ?
  5. When do you call for  the Nephrology consult ?

Every step becomes  vital . Do not ever think , a  cardiologist’s job is over  once few  stents are deployed . Wheeling   out a  sick  and fragile diabetic  with borderline  creatinine    out of the cath lab  may be  considered   as a procedural success  , but the real success happens only after  every organ of the  your patient  comes  out  unscathed  after the procedure .  In this  context  , we should first aim to  become a nephron  savvy and a nephron friendly cardiologist .

I have witnessed  cardiologists  spend hours  together  in cath lab with liberal injections of contrasts  even in  elderly  who have delicate kidneys .Cardiologist should realise  kidneys are soft and gentle  organs  which unlike the heart  , do not  know  how to cry  (Angina) at times of stress  as they lack  well developed pain fibers  (unmedulated  type c fibers to be precise!) .Only thing they  know  is ( like touch me not plant !)   they  strike work  the next   next morning (What we refer to  technically as Acute renal  shut down !)

Now , we see little  interaction  occurring between a  cardiologist and nephrologist  prior to PCI , even though  those two organs ( The   respective experts behold )  are  constantly in touch  with each other , every minute ,  by neural and hormonal mechanisms. The new generation organ  specialists  has to learn  a lot   from these sincere , interactive  , democratic  human   biological system.

Coronary arteries can gulp any amount of dye but  not the renal  arteries .The   future looks still more frightening ,  as we have a variety of devices lined  up  to invade human vascular tree (TAVI, Renal ablation, per cutaneous aortic pumps etc)

So what should we do ?

  • Patients  prone for  CIN should be promptly  recognized .
  • Ask repeatedly  the question .  Am  I   sure  ?  . . .does this patient  require this  procedure at all ?  If  so , have I taken all the precautions ?
  • Use the nephrologist’s services more liberally

Finally ,  read the basics of  nephrology   lessons  once again .  The international consensus group has  classified   the Acute kidney  injury  (AKI)   with a  simple and lovely criteria  for  risk  triaging .     It is a  five faceted ,  inverted  (Tip less ) triangular  cartoon called  RIFLE .

The beauty of  RIFLE   lies in its  simplicity . All  it requires  is  serum  creatinine   (eGFR)  levels  and urine output.  Let  every  cardiologist  master this scheme of AKI . It will immensely  help  our  patients   and make us  a  complete  physician   instead of   being  labelled as a  “master of  an  organ”   or   ” An accessory sub physician”

The CIN prevention recipe.

Source Catheterization and Cardiovascular Interventions 69:135–140 (2007)

References

For review about Contrast nephropathy (CIN)  there are lots of excellent articles.

One company is trying to find a new  solution for  this complication . Let us welcome it ! The device is called rena  guard .

Renal Guard : A new technology to prevent CIN

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Drug eluting stents fail in crucial board EXAMINATION in STEMI !

Posted in Cardiology - Clinical, Cardiology -Interventional -PCI, Uncategorized, tagged , , , , , , on August 31, 2011| Leave a Comment »

Interventional cardiologist are excessively  talented  guys .They always  lead ahead in innovations  .The only issue is , their  enthusiasm  (   many times  overtake  the pace of science .  In the name of off label indications  they indulge   in drug and device extravaganza   in uncharted territory .

Even as we boast of practicing evidence  based cardiology   scientific  adventures  happen  without  proper  evidence  . . .   rather  we  have wait for evidence to come later .” A clear case of  cart pulling the horse “

The wide-spread of use of  second generation DES in STEMI has not been found to superior to BMS in the  EXAMINATION trial just released in ESC 2011 Paris. It failed miserably ,  when every one took  the superiority  for  granted.( Some may claim  non inferiority is  not a failure , but for a DES which was perceived a revolution,  it is definitely a failure in the  STEMI subset )

Further,  what  EXAMINATION  trial did not  address  is  acute and sub acute  stent thrombosis .Even as the DES is credited  with a dubious  record for  sub acute stent thrombosis ,   there is every reason to  suspect , in  the milieu of STEMI the thrombotic risk of DES  would increase many fold.

The  seemingly  low   incidence  of stent thrombosis with DES  in STEMI ,   in  EXAMINATION  trail  is a statistical mirage .This  trial was  neither  planned  nor powered to address the issue of stent thrombosis.

In the  ultimate  analysis of EXAMINATION ,   One could conclude   Cobalt chromium BMS,  has  cemented  its place ,  more firmly for use in primary PCI.

DES  at best ( *With all those conditions apply , Dual antiplatelet etc) can be equal to BMS,  while  BMS at any  day ,  would  casually will  win over DES without any conditions at a  huge cost advantage.

The above analysis is diagonally opposite to that of general  perception  that  emanated  from Paris  ESC meet 2011   trial   .

Please remember EXAMINATION trial did not reach its desired primary end point  !

That is  a strong point  against it  .What do you think ?

Reference

http://www.theheart.org/article/1272077.do

A  TV  debate on Examination  trial from EURO PCR

http://www.oxfordjournals.org/our_journals/eurheartj/ehjvideo.html

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What is the function of pectinate muscles of heart ?

Posted in Uncategorized, tagged , , , , , , on August 28, 2011| Leave a Comment »

Pectinate muscles are specialized Intracardiac  muscle

  • Pectinate muscles are located mainly in the right atrium  , more  in right atrial  appendage , sparse in left atrium
  • Has muscle fibers arranged in a  comb like fashion.
  • Has less mechanical activity, no significant contribution to atrial contractility.
  • Can stretch and improve the voluminous nature of right atrium
  • The pectinate muscle  folds act as RA volume reserve  during adverse loading conditions . It helps RA dilate with out much wall stress.
  • Rarely it can be a cell of origin for focal atrial tachycardia

Image Source : Greys anatomy

The concertina like effect of pectinate muscle .

The atrial infolding increases the surface area of atrial chamber at times of dilatation , like  the music instrument .So,  these macro  folds ( like intestinal villi )  help overcome the  constantly changing volume status of right atrium.Since the  variation  left atrial blood flow is  not that much ,  the pectinate muscles  are not well developed  in the left atrium.

The same rules would apply for  why  there is excess  trabeculations  in right  ventricle  than  left  ventricle .

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Silly questions in live cardiac work shops !

Posted in Uncategorized, tagged , , , on August 26, 2011| 3 Comments »

This  happened  in one  of the cardiology  work shops  I  recently attended ,  which  beamed  live cath lab procedures from across the  country.

An   interventional   cardiology  team  in a  bright sky  blue  suit was preparing a  patient for   graft angioplasty  in  a degenerated  SVG graft to left circumflex  . The patient had apparently had  CABG  few years ago  (LIMA to LAD still functional   )   . His LV  EF  was reported   to be  40 %.  The procedure was about to begin. The femoral artery was  being  cannulated . . .

As the audience  were encouraged  to ask questions.  A young cardiologist wanted to know what was the indication to open up the graft  / And what was  his symptom ?

“Do not ask such silly question”  . Prompt came the reply from  one  of a   senior interventional cardiologist from within the cath  lab. He further said  such questions can  not be entertained  as the   forum is meant for tips and tricks to cross a degenerated vessel graft .  When he insisted for an  answer , the entire panel  joined the  ridicule and  the questioner  quietly went out of the hall !

What  do you infer from such reaction?

What makes this question silly ? Why the cardiologist got annoyed and amused ?

This odd  reaction  implies  ,  the  cardiologist  has  something to hide or has guilt of   doing inappropriate procedure.

Such is the transparency in  cardiology workshops  transmitted  live all  over the  country  imagine   what  one can  expect in regular cath labs .

No doubt  JAMA has come out with most  important article  for us. http://jama.ama-assn.org/content/306/1/53.abstract

Live  workshops are not simply to train our hands . It is supposed to teach  us   the “what is right” and “what  is wrong” ,  “what is good” and “what is bad”  for our ailing patients. The senior  cardiologists who administer these workshops  should realise this fact. Very often a bad example is set .   When asking for  patient’s  true symptoms   looks  silly  for us  . .  .  guess where our profession is  heading for !

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