Dr.S.Venkatesan MD

What is the purpose of “24-hour” upper limit cut off in the pharmaco invasive strategy ?

March 30, 2026 by dr s venkatesan

Why 3-24h ?

The famous & popular 3-24 hr time window for pharmaco-invasive strategy (PIPCI) was adopted, blindly from STREAM (prehospital Tenecteplase + PCI <6-24h in <3h presenters) and FAST-MI trials  assuming uniform IRA patency. It fails to stress the importance Initial time window to lysis, and its response . This makes the distinction between true rescue vs routine pharmaco invasive PCI  a hazy excercise . Thus, both inappropriately  delayed or a hastily-routine  PCI has become all too common.

The 24-hour upper cutoff in pharmacoinvasive strategy serves to prevent reocclusion, or to address any residual mechanical stenosis . It is not meant for myocardial salvage, which is irrelevant if lysis was successful.

Mind you, IRA optimisation  is not a time bound emergency in a well recannalised vesseel. In fact,  PCI is not an absolute neccesity for long term IRA patency especially if it an coronary erosion. If there is TIMI 3 flow ,and there is  little ischemic substrate , there is no need to chase the , supposedly sacred 24 hr time window. If the lysis achieves complete( or almost complete) IRA patency, PCI can safely  be extended to 48-72 hours, or even permanent deferral (No-PCI , stand alone thrombolysis) in stable patients with optimal medical therapy.

An interesting study is published , from my institute in the current issue of AJC with a title ” Extended Pharmacoinvasive PCI Compared to Primary PCI: Insights From Madras Medical College STEMI Registry” . This study argues for extending the time window for pharmacoinvasive strategy to 48 hrs. (It could still be higher.) It suggests , this flexibility suits the LMIC, due to logistical realities. ( Glad to be listed as a co-athour)

Link to the PDF of the article

I am sure, this study, demands to reset the 24 hr upper limit of cut off for pharmaco invasive strategy.Looking beyond this study, there is an urgent need to clarify the specifc purpose of the generalised time window of “3 to 24” hr time window in pharmaco invasive strategy.

A call for new sub defintions in the time windows in PIPCI

1.Successful Lysis* (TIMI 2-3, in about 70%): Routine angiography/PCI 3-24h (prevent reocclusion/residual stenosis) .Extendable to 48-72h + is possibel. Permanent deferral if the pateint and myocardiumare , with a patent IRA . (Implying no need for further salvage at all , we should allow a green corridor for patients with successful standalone thromolysis to exit the hospital without a PCI ) Doing a PCI onlu t0 prevent fear of reocclusion in the first 30 days is not backed with good data.

2.Failed Lysis* (TIMI 0-1, 30%): Rescue PCI immediately (<3-6h post-lysi, like PPCI) Here the time window should be hastened and can never afford to extend it, at any stretch of imagination.

* Ironically, the 24hr cut of has no place in both the above subsets. (May be in failed lysis , 24 hr cut off might apply , again it is 12 hr longer than primary PCI )

Final message

“Time is no longer muscle , if the Intial lysis is successful“

What is the purpose of “24-hour” upper limit cut of time in pharmaco invasive strategy ? The 24 hr is not universally valid. Pharmaco Invasive  strategy time windows need to be  based on timing and  efficacy of the Initial  lysis.

Postamble

Commenting this paper as a third person :

One limitation in this study is to be admitted. I think, the generalised comparative efficacy of extended PIPCI with primary PCI can not be made, for the simple reason, the extension of time window is possible only in patients who had successful lysis. This study may ideally be concluded as  “3-24h pharmacoinvasive PCI can be extended to 48h if the initial lysis successful” . Further, If initial lysis fails (30% TIMI 0-1), any extension is contraindicated and requires immediate rescue PCI akin to PPCI. Also, data regarding non-IRA intervention might help understand the importance of the extension of the time window better.

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Posted in Uncategorized | Tagged acc, dr s venkatesan, esc, extended pharmaco invasive strategy, fast mi trial, madras medical college, pharmaco Invasive strategy, primarypci, stemi, stemi nstemi guidelines, stream trial, why 3 to 24 hour time window in pharmaco invasive strategy |

Can you find the type of pacemaker in this ECG ? 

March 16, 2026 by dr s venkatesan

This pateint has

A. Single lead AAI pacemaker

B. DDD in AAI mode* (A pace V sense )

C.Single lead AAIR pacemaker

D. Can never answer this question without X ray or the implantation records.

Answer : I think, we can’t answer this question with this ECG strip. So we can only guess it is DDD, as single chamber AAI pacemaker is not in vogue , even though it is the most physiological pacemaker possible in ideal conditions.( If any one has any points to differentiate , please comment)

* A pace V sense in DDD, though  equivalent to AAI mode , can not be compared to AAI pacemaker, for the simple reason, ventricles just don’t have a lead in the later.

Final message

This post might appear as a EP parody. The purpose was different. It is sad to note AAI pacemaker might be dead , but the AAI as a mode will always be a great concept.It can beat on any day , the much hyped LBBBp in bulk of the pateints with SND in terms of physiology and synchrony.Fellows should realise single lead AAI can be most physiological , while, the DDD can become a pathological pacing , if it frequently switches to VVI mode , inspite of good AV conduction.

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Part 2 : How do modern day DDD pacemakers reduce ventricle based pacing ?

Pacemaker vendors  have unique   proprietary algorithms designed to minimize unnecessary right ventricular pacing (%Vp) while maintaining atrial-based pacing (effectively mimicking AAI/R behavior) in patients with intact or intermittently preserved AV conduction (e.g., sinus node dysfunction without significant AV block). These algorithms promote intrinsic ventricular activation to avoid dyssynchrony, reduce atrial fibrillation risk, and potentially improve long-term outcomes.

There are two main categories:

1. Mode-switching algorithms (AAI(R) ↔ DDD(R)): Operate primarily in atrial-based mode (AAI-like) with ventricular backup; switch to full DDD when AV block criteria are met.
2. AV hysteresis / search algorithms: Stay in DDD(R) but dynamically extend the AV delay to search for and favor intrinsic conduction.

Annexure : Company brands and different modes and algorithms (Compiled by Grok)

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Posted in Uncategorized | Tagged aai va ddd in aai mode, atrial paced pacemaker, ddd vs vvi, lbbb area pacing, lbbbp, lbbbp vs aai, mode switching, pacemaker choice in sinus node dysfunction, single lead physiological pacemaker, vdd pacing |

Forbidden medical quotes : Perils of patient & family empowerment

March 9, 2026 by dr s venkatesan

Link to a related post , that might add some sense to the above quote

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Posted in Uncategorized | Tagged acc aha, best medcial quotes on ethcis, esc, medical ethics, medical guidelines, patient empowerment |

Many second opinions might be wrong too … consume it with caution !

March 8, 2026 by dr s venkatesan

Getting a second opinion from another expert is a valuable option for our patients when they face a complex decision-making process, especially when a cardiac intervention is advised. No doubt, it is their fundamental rights too.But this could be hard, if the second opinion is sought regarding indication for coronary or interventional procedure.

It is much, much comfortable to concur with the original decision if it is pro -Intervention. (even if it is against your conscience). Vetoing a procedure which was advised by some big hospitals is almost impossible for cardiologists sitting at their office, however experienced they may be. This is because it is sort of going against, the mainstream and defying science as well. Both doctors and physicians are stuck.

I confront such situations often from patients following elite cardiology consults. I had been forthright and genuine and said a firm no or yes to many such procedures . I understood much later, that only a minority of the patients followed my No advice , while invariably they accepted my yes.

After much confabulations , recently, I have made some recalibarations on my values, (decent term for compromise ) despite all the ethical stuff I write in these columns. But, three things I ensure , before giving my opinion which goes against my assessment.

“This procedure is not indicated in the true scientific and moral sense, but 1.If you lack full trust,  or 2. If you are not ready to accept the risks of not doing it, or 3. If the fear (of not doing it ), would nag you constantly, then get it done as per the advice of  the big guys”.

Final message

Until we acquire the courage to express our true opinion , we certainly fall under the tag of medically incompetent.

Very soon, getting a second* or even third opinion may not really matter. Doctors are silently persuaded to follow the guidelines thursted  by  big scientific syndicates along with compulsion to go with patient wish & preference.

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*Caution and clarification

Second clinical opinion for helping to arrive at a medical diagnosis  is of immense value and a great thing to do. In fact, doctors themselves ask for it when they are in doubt. This article is about second opinion regarding the appropriateness of various interventional procedures that is defining modern medicine.

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Posted in Uncategorized | Tagged appropriate procedure, bio ethics, bmj, british journalmof medcial ethcis, clinical decision making, dr s venkatesan, esc, inappropriate interventions, lancet, madras medical college, medcial decsion making, medcial errors, medcial ethics, medical education, medical incompetence, nejm, pateint empowerment, principles of practice of medicine, private vs public health, second opinion, third opionion, venkatesan sangareddi, what ails modern medicine |

How is that ? A self prescribed PCI (s-PCI) , is an accepted professional medical decision

March 7, 2026 by dr s venkatesan

Decision making  for PCI in chronic CAD continues to be delicate. This is especially true, if the lesion is Intermediate and the plaque vulnerablity is susepcted.

How to tackle this stress positive Intermediate LAD lesion. Functional capacity good. Non-diabetic, mildly elevated lipids. Now, continuing medical management with intensive lipid control is the best possible management. (We have evidence for medical management being good even in significant 90% lesion) Above is a case report from https://www.acc.org/education-and-meetings/patient-case-quizzes/medical-therapy-for-cad

Reassurance is a revascularization equivalent

Sharing a similar experience with one of my patients in his early fifties. After getting a fairly convincing consultation, he accepted medical management. However, guided by both NI & AI, he sought a second opinion to confirm whether my assurance was indeed correct. He underwent FFR and OCT, and both he and his plaque became vulnerable. The FFR was normal. He was too intelligent to ask about the FFR – Stress test discordance, for which his cardiologist had no answer. Still, they did not advise a PCI and the decision was left to him, respecting the current patient-oriented guidelines.

The patient went home empowered but spent sleepless nights, fearing about potential fissures,  in the life sustaining fibrous cap.He believed that he was at the mercy of a 75-micron thin cap covering his plaque. In one of the anxious days,in the following week , he got admitted himself in a posh downtown cardiac center. A as per the guidelines, the patient chose his own pathway for a PCI. Cardiologists obliged piously to his wishes. Now, he feels better. He says he is happy to undergo a self prescribed stent.

I was glad, he had the courtesy to come back and showed the results. I learnt. it costed him 6 Lakhs and his insurance covered it fully. I realised , my 30 minutes reassurance was busted by the insurance card in few minutes. I wasn’t surprised.It’s okay, it’s all in the game. I learned it long ago. Fear* (either spontaneous or induced), the power to decide & affordability are the most powerful determinants of any inappropriate medical procedure.

Learning cardiology from UN & WHO

We have United Nations and WHO, the two global guardians. Any one with average intelligence will agree, these instituions can never bring either peace or health to this world.Let us ensure, the practice guidelines of cardiology doesn’t go that way. We boast ourselves, that we have a strongly evidence based vigorously scrutinized cardiology practice framework. How true it is ? Are we hiding behind pateint preference, and pushing  science to the  background ? Let us be transparent. I think it’s time, the powerful bodies like ACC/ESC should connect all the missing dots. .One important issue  is,  fear or anxiety-driven PCI, which usually overtakes other true indications.

Final message

In an ideal world , reassurance and GDMT , if properly done, should be a revascularization equivalent in most CAD patients .The  reality is, fear* prevails over reassurance, for a variety of reasons.

Postamble

*Anxiety thrives well, in an environment of uncertainty. It is mutually inclusive among both patients and physicians.However  most Professional physicians are expected to tackle it. Still many struggle. Patient : What if the block worsens? Physician: What if the patient comes back with an event and oh .. my pride and practice?  May be, physicians are not to be blamed much. I think. it is all about a unexplained,  biased human mind set. Even a death during an inapproproate Intervention is pardoned off, but an error, raising out of an appropriate medical mangment is rarely forgiven.

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Posted in Uncategorized | Tagged acc, aha, bari 2 d, bmj, courage, esc, fear driven pci, ffr, ffr driven pci, guideliens cad, indication 2a vs 2b, indication for pci in cad, insurance driven pci, iscehmia driven pci, jama net work, lancet, nejm, oct, pci, scai, symptom driven pci |

How many lives are saved by ECMO in refractory cardiogenic shock ?

March 3, 2026 by dr s venkatesan

How many lives are saved by ECMO in refractory cardiogenic shock following STEMI ?

A. Substantial

B. Many

C. Atleaset few

D. None

E. It may even Increase the fatality

Answer

While the popular answer swings between A to D , depending upon the level of optimism & belief system of cardiologists.

However, the correct answer is likely to be D(Ref 1) .

*While C, is quiet possible, E is very much a reality all experienced cardiologist would know.

Postamble

* My non-academic opinion is, ECMO and other MCS devices, are primarily,  “guilt-relieving or professional  pride delivering”  toolkits for the patient’s family and cardiologists, respectively.

Reference

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(23)01607-0/abstract

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Posted in Uncategorized | Tagged ecmo |

Does CABGs  really prevent future MIs and deaths ?

March 2, 2026 by dr s venkatesan

This is a very crucial question debated,  by cardiologists , cardiac surgeons for long decades (of course our patients  too need an answer desperately)

Will CABG prevent or reduce future MI  risk ?

The answer is not at all simple , most of us are still tentative.

Have a  look at the conclusion of these two famous studies. STICH and STICHES. Hope, we could reach closer to a clear answer.Ofcourse, the study population may not fit in to all the CAD population we come across.  Still,  it conveys some useful  information about this issue.

Final mesage

It is indeed true a STICH in time , really saves nine.

Postamble

The toughness of answering this question lies in the fact, it takes hardly three minutes , for a  non flow limiting 30% lesion to transform to a life threatening ACS. 

Real world data reveals, most patients with multivessel CAD harbor, a minimum of half a dozen non flow limiting lesions. CABG has a huge edge, in this situation ,as most of these lesions are proximal to bypass conduit.

Counter point

Lastly , and most importantly, it is the intensive medical management and life style modifications, that will determine, whether CABGs are going to work,  as it  did , to the lucky patients of STICHES cohort.

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Posted in Uncategorized |

Journal club : Pregnancy as a cardio vascular stress test

February 19, 2026 by dr s venkatesan

The study in recent issue of JAMA Cardiology examines clinical factors and biomarkers (likely NT-proBNP, troponins, SfLT, lipids) measured during pregnancy to predict long-term maternal cardiovascular disease (CVD) risk, positioning pregnancy as a “stress test” window. Its strengths include a large cohort, long-term follow-up, and subgroup consistency, offering actionable early risk stratification to guide preventive interventions and improve outcomes in women

Design Flaws

This cohort analysis reports CVD prediction over a median follow-up ( 10+ years). The major problem with this study is , it has omitted several key confounders that could bias long-term CVD predictions from pregnancy biomarkers, including pre-pregnancy BMI/obesity, smoking status, family history of CVD, socioeconomic status, psychosocial stress/depression, air pollution exposure (e.g., PM2.5), genetic/epigenetic factors (e.g., polygenic risk scores), These time-varying elements, unadjusted in Cox models, likely inflate biomarker associations over the long follow-up period .

Boxplots show the distribution of biomarker concentrations, stratified by the occurrence of CVD during follow-up  at gestational up to  29 weeks. hs-cTnI indicates high-sensitivity cardiac troponin I; NT-proBNP, N-terminal pro-B-type natriuretic peptide; PlGF, placental growth factor; sFlt-1, soluble fms-like tyrosine kinase-1; HDL, high-density lipoprotein cholesterol.

Final message

It is well known that pregnancies complicated by HT and GDM may add future risk for CVD. Using pregnancy as a universal cardiovascular stress test may appear good on paper …but it can’t be purely biochemical prediction. It should be primarily clinical follow-up and accounting for other influential risk factors. This study is too much extrapolated and biochemistry focused. Suggesting a costly biochemical panel to predict CVD risk in a huge population of pregnant women appears a futile extravaganza.

Reference

1.Bacmeister L, Glintborg D, Kjer-Møller J, et al. Clinical Factors and Biomarkers During Pregnancy and Risk of Cardiovascular Disease. JAMA Cardiol. Published online February 18, 2026. doi:10.1001/jamacardio.2025.5595

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Posted in Uncategorized | Tagged gdm and oih in pregnancy, jam study on pregnancy, preganancy and cad risk, pregancy and heart disease |

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