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Archive for the ‘Wintage cardiology’ Category

How do you evaluate the success of thrombolysis or primary PCI  ?

If you say its coronary angiogram and the final snapshot  of  TIMI flow , you need to read further. If you thought its actually the quantum of ECG ST regression . . . great ,  you can exit this page  with credits.

CAG  may not be the gold standard in defining PCI success , it just tells you whether IRA is patent or not .Instead , the good old ECG tells you about whether  the myocardium is successfully reperfused or not .  TIMI flows are simply not good enough to identify  adequacy of  myocardial reperfusion .

By the way ,  who is telling this  ?

knowledge-2

It appears there is only a  narrow gap between Ignorance and Knowledge !

That’s what the simple message I got  from this landmark study  published in year the 2000 in JACC by Shah.A in the thrombolytic era.The Importance of this paper  has far reaching consequences (If and only if we are  willing to accept and  understand  the concept and apply  as a whole in PCI era )

While success of thrombolysis is faith fully subjected to  the acid tests  of myocardial perfusion , primary PCI is rarely ever assessed in terms of  ST segment regression.

What is the next logical step this study should lead  us to ?  

I think I am not provocating  , . . How to  get rid of the prevailing practice of jacking up the success rate of primary PCI  ? ( Conveniently,  Ignoring the echo detected significant LV dysfunction on follow up ) Mind you, this has resulted in  creating a new crop of patient sub group called  “Angiographic success and myocardial failure”

Reference.

Dear colleagues , please go thorough this article . Its from the thought leaders , Duke University ,North Carolina. I would argue the cardiology fellows to discuss this paper in detail in their  journal club as “classic paper”  till they  completely understand the conclusion .Though its  done with GUSTO 1 data  in primarily  lytic population,  its  conclusions are very much valid as an assessment tool  in reperfusion by any means.I am afraid, even 16  years after this paper  got published ,the truth has not penetrated to the targeted population within the cardiology community.

Prognostic implications of TIMI flow grade in the infarct related artery compared with continuous 12-lead ST-segment resolution analysis. Reexamining the “gold standard” for myocardial reperfusion assessment. Shah A1, Wagner GS, Granger CB, J Am Coll Cardiol. 2000 Mar 1;35(3):666-72.

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Men are from Mars , and  Women are from Venus  ” . . . Do you agree ?

Many probably witness the much talked  differential behavior among the gender  every day. Its argued , men take more risk in life ( often  senseless !) , some go to the extreme to  suggest  Men are Idiots and decorate them with a  provocative title  MIT (Men Idiot Theory ) (Mcpherson 2011).Risk taking is important in life, but at  what cost ? Does women (Who  are caring by nature )  help themselves  and the society by less risk taking behavior ?

I stumbled upon this rare piece of writing from BMJ which  would demand  in depth analysis  into this gender phenomenon based on  evolutionary biology and genetics.

This article concludes, Yes, men  . . . indeed  tend to take some foolish risks in various life situations that result in potential harm.

Gender difference in medical outcome men are from mars women venus male idiotic theory darwin theory

What is the influence of MIT on medical profession and patient outcome ?

Now , Iam compelled to ask  a hypothetical question .Does women medical professionals take  less aggressive stance and low risk taking behavior  and in the process result in less mortality and morbidity to our patients  ?

I would think the answer to that question  would be in affirmative .I wish  BMJ or anyone  should design a study on this issue.

Reference

1.Harris CR, Jenkins M, Glaser D. Gender differences in risk assessment: why do women take fewer risks than men? Judgm Decis Mak2006;1(1): p. 48-63.

2.Eckel CC, Grossman PJ. Men, women and risk aversion: experimental evidence. In: Plott CR, Smith VL, eds. Handbook of experimental economics results. Vol 1. North-Holland, 2008:1061-73.

3.McPherson J. Women are from Venus, men are idiots. Andrews McMeel, 2011

4.Northcutt W. The Darwin Awards: The official Darwin Awards: 180 bizarre true stories of how dumb humans have met their maker. Orion, 2004.

 

 

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As we practice this Noble  (&  Delicate )  profession ,we often tend to Ignore the  warnings  even from our learnt colleagues , Why ?

Wisdom ego quotes brainy best dr s venkatesan top inspirational

 

 

 

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News : In any developed nation , 90 % of  total  health expenditure is  exhausted in prolonging  final few days of  human  life !

When cost of dying   . . .  exceeds cost of living   . . . this world will go nuts !

The current real world  experience  from India’s  five star  hospitals  indicate,  many elderly rich men and women  spend their  last few days  before being buried or burnt  .They spent an average of 15 lakh Rs per death . This amounts to the entire  “life time” cost of living   of  majority of Indians .

modern medicine art living and dying

Image courtesy from Flicker/ Rachel sian photostream

When   human organ donation is considered  a greatest philanthropic act, there is one more excellent alternative for those who can’t do it .If only every super rich translate  their cost of dying  into  cost of  others living !   many new lives  will bloom .

The exorbitant rise in  cost of  dying  in India ,  is a recent development and reflects the affluence , honor , pride and of course lots of prejudice lack of wisdom ! Instead of filling the  deep  pockets of greedy  corporates why not the rich add new  lives   ?  !

Final message

Let all elders  with irreversible conditions , who have finished their life , shall  die peacefully at home .Why don’t we ( Affluent  .  . . would  be cadavers !)  cross sponsor their dying cost to a  public  health , nutrition or medical fund .

After thought

Oh America ,  . . .  Am I right  ,?  Obama thought it and implementing it too !  I would believe , his health care policy is  a  small first step in this  direction  !

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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 the early 1980s , when cardiac physicians were confronting how to tackle intra coronary thrombus , one man from Japan  was  looking directly at the ground zero with fiber-optic coronary angioscope .He  provided live images  of coronary plaques and thrombus (long before the IVUS and OCT era) because of technical difficulties it did not get into  clinical utility  but gave us vital information like plaque morphology and behavior.

  • The concept of red and white thrombus
  • The yellow lipid enriched vulnerable plaques
  • Post lytic  clot surface
  • The fibrin strands within the clot etc.

coronary angioscopy Yasumi Uchida

The angioscopes have now given way to IVUS and OCT which provide indirect vision of the coronary arteries .Uchida has written a book tilted coronary angioscaopy which is a must read for all clinical cardiologists.

I think Japanese are  leading in this aspect of cardiac Imaging .Yasunori Ueda is another person who has  done lot of work on angioscopy . here is an  Image from his paper. Exciting  stuff  is isn’t !

coronary angioscopy  Yasunori Ueda www.invasivecardiology

Image source : Yasunori Ueda http://www.invasivecardiology.com

  Reference 

http://circ.ahajournals.org/content/104/24/e143.full

http://www.invasivecardiology.com/article/5571?page=3

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Dr Shirely Smith  from charring cross hospital London  wrote this masterpiece  in BMJ in the year 1962 . He was doing a research about the origin of angina like pain in patients who had  upper GI disease or disorders of cervical spine .He found a hidden invisible neural link between heart and it’s neighboring viscera. What he  referred it as linked angina . It links the  pain from ,Esophagus,  gall bladder ,  duodenum ,  cervical spine to the  heart .

This article I  consider as one of the  all time classics in  clinical cardiology . Here is the link for linked angina (Courtesy of BMJ)

linked angina atypical angina abdominal angina  shirley smith cornelio papp 2 bmj

linked angina atypical angina abdominal angina  shirley smith cornelio papp bmj

High lights ( Inferred )  from the  article

We know angina typically occurs on exertion .If it occurs at rest we call it as unstable angina .

Can it occur at rest other than unstable angina ?

Yes it can . ( Post prandial ,Nocturnal, emotional etc)

Can the  heart be the referral site for visceral pain ?

Yes .It seems so .

Can visceral pain be trigger for  developing true angina ?

Again possible . A Patient with documented CAD  develop  a true esophageal pain it is likely  to  induce a sensation of  angina  rather than abdominal pain .Similarly , cervical pain may represent a masked angina in a patient  with active cervical spondylitis .(Homing in of angina to the nearest non cardiac culprit )

 

Final message

Those were the times when the brain worked more than hands . Common sense prevailed over machine sense .This article argues for a  big debate about the origin of so called atypical angina in a patient with multiple common visceral conditions.Even 50 years later we have little clue  about alimentary -cardiac neural spill over !

Reference

http://www.bmj.com/highwire/filestream/276395/field_highwire_article_pdf/0/1425

Postamble

Today we live in a complex and confusing and commercial  medical world .We have atleast  a dozen chest  pain triaging protocols in ER . Still errors are  rampant. Errors are acceptable . . . but this one was an absolute  shocker  . . .  “I know a  patient with vague chest/epigastric  pain  , non specific T inversion ,  documented gall stones , landed in cath lab not by accident but  by meticulous planning !”

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