Feeds:
Posts
Comments

Learning crucial cardiology lessons from the patients !

July 31, 2013 by dr s venkatesan

One of my otherwise  well behaving  patient ,  suddenly asked me this question ,  before leaving my  clinic  after a 15 minute consult .

Doctor  . . . I am taking the clopidgrel and aspirin  for 5 years like a vitamin tablet  . . . is that all right  doctor ?

I just got curious, I checked  the prescription again . Yeh ,  he was right !

I have  been mechanically writing  Tablet Clopitab  A  since 2008 !

Clopidogrel abuse long term

For what ?

Some sort of CAD !   Was it for ACS ?   No , it was for chronic stable angina . No PCI,  . . . no DES !

Why the hell  he is taking dual anti-platelet  therapy for 5 years ?

Some  body  , some  where  , has  prescribed it . This man  is taking it  for years together with absolute sanctity.

I was amused  . . . it is also  my mistake . Why it never struck me  to scrutinize the prescription ?

I thanked him . I  removed clopidogrel  from the list , and asked him to continue tablet Ecosprin 150mg  for some time .

( And  now I  had a genuine doubt  ! Does he have CAD at all ! I browsed his file , I couldn’t  find a true documentation for CAD  as I feared  !)

I asked him to get back with an  exercise test ,  . . .  if it comes negative i  can even stop the aspirin as well  I  explained  him  ! (Now he got amused !)

Final message

Who wants Knowledge ?

It is  dumped every  where , free of cost  . . .  both in real and cyber world .Applying it requires more sense  .  and my patient  taught me that  !

Patients  not only  help us  earn  our  bread  and butter , they  do  enrich  our brain  as well ! Never get humiliated when a patient teaches  you a lesson in medicine !

Posted in bio ethics, cardiology-ethics, Clinical cardiology, general medicine | Tagged , , , , , , , , , , | 1 Comment »

Emergency cardiology consult for Acute abdomen !

July 18, 2013 by dr s venkatesan

The other day my fellow got a call  from surgical ward for emergency ECG opinion for a  suspected Inferior MI .It later turned out to be an acute cholecystitis.

One of the important  anatomical mis-perception  among physicians ,  is to consider  inferior, posterior  and diaphragmatic surface  of heart  as separate entities .They are all  closely linked.In fact, they  more often  mean  the same  anatomical zones !

Heart is a dynamic suspended organ within the middle mediastinum .It  can assume a vertical or horizontal position due to number of surrounding anatomical  and physiological factors. (Diaphragm, Lung , being  important ).The ratio of intra thoracic vs Intra abdominal  volume  &  pressure determine whether the posterior surface of the heart is going to face the back of chest  or simply sit and  rest on the diaphragm .We know a horizontal heart is likely to inscribe q waves  in inferior leads .

acute abdomen diaphragm inferior wall mi cholecystitis pacreatitis

Courtesy : Basic image source from digitallab3d

The  diaphragm can be termed as an  anatomical causeway , that isolates   thorax  from the  abdominal  cavity .Close encounters between the organs separated by this delicate biological  membrane is  always possible .This is especially true for electrical signals  which show little  respect for anatomical barriers .

This is the reason there are too  many abdominal conditions that mimic  inferior MI during a painful  emergency (and vice versa  when inferior  MI mimics  acute abdomen .) In  our  department , we   have witnessed  the following conditions mimicking Infero-posterior ACS.

  1. Acute ascites with polyserositis
  2. Gross obesity with APD
  3. Posterior fat pad ( Necrosis ?)
  4. Thickened pericardium
  5. Minimal posterior pericardial effusion
  6. Diaphragmatic pleurits
  7. Esophageal spasm
  8. Fundal air  trapping and ballooning after a heavy meal !
  9. Acute duodenal ulcer perforation ( With gas under diapharam causing q waves)
  10. Acute cholecystits
  11. Diphragmatic hernia
  12. Achalasia cardia
  13. Pancreatitis

Final message

Do not rush to make a diagnosis of inferior wall MI when  you encounter inferior q waves  with  or without ST /T changes , especially  when the symptoms are atypical .

Posted in cardiology -ECG, Clinical cardiology, myocardial disease | Tagged , , , , | Leave a Comment »

Why the hell , my chief is able to hear the murmur . . . Iam unable to !

July 6, 2013 by dr s venkatesan

cardiac auscultation murmurWe know clinical auscultation is an art . It is more of a  special sens rather ! It is a combination of natural and acquired ability of your brain to phase out a sound or series of sounds . Sound perception also has  two point discrimination  like touch .(Auditory cortex -Temporal lobe maturity)

It involves selective blanking  and noise cancellation techniques. Ambient noise  contamination is more in youngsters . Elderly men  often have otosclerois so they are benefited by  this handicap .Your chief maybe one of them .So simply do not bother.

Finally ,  clinical acoustics   require lot of imagination . Seniors professors  know what they are expected to hear in a given patient . They look for it rather than  they hear  it  .This is the secret of their  magic ears .

The famous quote  “What the mind do not  know  . . . the eyes do not see”   is very much  applicable  for the ears as well ! 

What your  temporal lobe  do not expect  . . . the ears do not hear!

Beware , even experienced cardiologists  mistake   systolic events   with that of  diastolic and vice versa !

Final message

With due courtesies  to great men like  Potain ,  Leatham , Austin flint,   and other pioneers of cardiac auscultation , I would modify  the  title  of this article .

The science of  cardiac auscultation  may appear more of an  auditory illusion to many  youngsters today  . Still , dedicated  auscultation , with a sound clinical knowledge in a quiet  room  with  a good stethoscope  would  make this illusion  into a  reality !

Posted in Cardiology - Clinical, Infrequently asked questions in cardiology (iFAQs) | Tagged , , | Leave a Comment »

Classification of dual LAD

June 28, 2013 by dr s venkatesan

Dual LAD is an interesting coronary artery anomaly proposed  originaly  by Spindola in 1983 .He classified it into 4 types. In recent years the  dual LAD has increased from 4 to 6 types.

The essential criteria to diagnose  could be summarised.

  1. Two LADs should be identified.
  2. One would be  large and another small
  3. Both should give a  diagonal  branch .

* Ramus is virtually unknown  if there is dual LAD .

The origin  of second LAD can be from

  • LMCA
  • RCA
  • Direct from Right coronary sinus

Course

  • Can be epicardial
  • Intra -myocardial
  • Or both

Branches

  • Diagonal
  • Septal
  • or Both

Drainage area

  • Highly variable

Implication for intervention

  1. Apart  from  the surprise element , the second LAD   has  little impact on the interventional protocol.
  2. However , it may confer a  ischemic protection  as the critical anterior wall has a twin blood supply.
  3. Whether  they are protected from primary  VT or VF is to be studied  because of better electrical stability
  4. Second LAD may act as an additional collateral channel.

Spindola’s  classification of Dual LAD (Types 1 to 4  was called sometimes A,B,C,D )

classification of dual LAD

Source : Lee et al. BMC Cardiovascular Disorders 2012, 12 :101

Spindola type 1 to 4 classification of dual LAD

An illustration of  first 4 types  of Dual LAD .Note  the type 4 originates from RCA. Image courtesy : Prachi P. Agarwal Ella A. Kazeroon . AJR:191, December 2008

Surgical issues ( This is  excellent data  from India . I convey  my   greetings to one  the authors Dr D.B Baruah,  my friend  from  CMC Vellore !)

dual lad classification Spindola-Franco H, Grose R, Solomon

Reference

Spindola-Franco H, Grose R, Solomon N. Dual left anterior descending coronary artery: angiographic description of important variants and surgical implications. Am Heart J 1983:105;445-55

Dual Left AnteriorDescending CoronaryArterySurgical Revascularization in 4 Patients Tex Heart Inst J 2000;27:292-6

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3509398/pdf/1471-2261-12-101.pdf

Dual LAD  CT  Angiogram : http://www.ajronline.org/doi/pdf/10.2214/AJR.08.1193

Posted in cardiology -congenital heart disease, Cardiology -Interventional -PCI, cardiology-Anatomy | Tagged , , , , , | Leave a Comment »

Cullotte technique for bifurcation stenting . . . a best technique . . . under utilised

June 28, 2013 by dr s venkatesan

culotte technique for bifurcation senting
Original article
Chevalier B, Glatt B, Royer T, Guyon P. Placement of coronary stents in bifur-

cation lesions by the ‘culotte’ technique.Am J Cardiol 1998;82:943 – 949

Posted in cath lab tips and tricks | Tagged , | Leave a Comment »

Do you know the exact definition of ECG ?

June 28, 2013 by dr s venkatesan

The humble looking strip of ECG  recorded  in millions ,  every day across the globe  has a complex definition.

And this definition  is  the most apt I have found.

An electrocardiogram (ECG) is a curve showing the potential variations against time in the whole body stemming from the heart, which is an electrochemical generator suspended in a conductive medium.

Einthoven(Dutch)  is the the man who invented the ECG  ,  got a Nobel price for not only inventing the string galvanmeter to record ECG,  but also  making us understand   the rules  of the  electrical wave front  that emanates from the heart.( Not to forget the  original concept  of who demonstrated electrical activity from heart by by capillary electrometer.  by Waller.(British). In my opinion waller should have shared the Nobel prize. I am  sure ,even Einthoven would agree to it.

Of course , do not ask  which  comes first  ” Ionic  flow” or  “the current”  that  comes with it !

Credit goes to  the creators of this  wonderful book  on medical physiology and put that free on the net . Three cheers to  them .

The book is from  University of Copenhagen  , Pannum Institute of Medical Physiology.

physiology text book paulev Zubieta sweden

Reference
British physiologist Augustus D. Waller of St Mary’s Medical School, London publishes the first human electrocardiogram. It is recorded with a capilliary electrometer from Thomas Goswell, a technician in the laboratory. Waller AD. A demonstration on man of  electromotive changes accompanying the heart’s beat. J Physiol (London) 1887;8:229-234
Willem Einthoven introduces the term ‘electrocardiogram’ at a meeting of the Dutch Medical Association. (Later he claims that Waller was first to use the term). Einthoven W: Nieuwe methoden voor clinisch onderzoek [New methods for clinical investigation]. Ned T Geneesk 29 II: 263-286, 1893

Posted in cardiology -ECG, Cardiology journal links, Cardiology teaching websites, Infrequently asked questions in cardiology (iFAQs) | Tagged , , , | Leave a Comment »

Coronary angiogram in Corrected Transposition (C TGV, L TGV)

June 28, 2013 by dr s venkatesan

In L TGV  ventricles are Inverted . Since , coronary  arteries go with  the respective ventricle  , LAD originates from Right sinus , and RCA arises from Left sinus . (Complex anomalies  in origin, course still possible )  LAD supplies   venous ventricle . RCA  supplies systemic ventricle .

The most surprising Irony is that major epicardial  branches run in their respective grooves in the bulk of the patients with L TGV .The LAD runs  in anterior interventricular  groove and LCX in left AV groove etc. (That’s real  power of nature , these epicardial branches home in to their grooves even in the midst of bizarre AV and VA connection !)

Here is the the ultimate reference  article ;  A  study from 255 hearts with C TGV . I wonder ,  we will  never  get a study like this ! 

coronary anatomy in corrected transpostion og great arteries ltga c tgv Ltgv annals of thoracic surgery 1994

Questions to ponder

  1. Is RCA  blood flow adequate to support systemic ventricle ?
  2. If this RCA is a non dominant  one what happens to this ventricular function ?

Implication in surgery

Progressive RV dysfunction is a major determiant of long term outcome . Unless we do an arterial switch  diverting respective ventricular flow  it  is not going to help much in the long term

coronary anatomy in corrected transpostion og great arteries ltga c tgv Ltgv 2
Link to full text article

Posted in cardiology -congenital heart disease, Cardiology-Land mark studies | Tagged , , | Leave a Comment »

P wave twisting : An extreme form of wandering pacemaker .

June 28, 2013 by dr s venkatesan

Wandering pacemaker is benign  cardiac arrhythmia . The only danger  is , it can create false alarm .This patient was referred   as  AV dissociation

wandering pacemaker

Read a related article  from this site .  ( A restless pacemaker goes for a walk down the  lane )

wandering pacemaker

wandering pacemaker

Posted in Cardiology-Arrhythmias | Tagged , , , | Leave a Comment »

Look AHEAD . . . and feel depressed about this Insensitive study !

June 28, 2013 by dr s venkatesan

In the  2013 American diabetic association(ADA)  annual meet  a paper was presented   which raised  many eye brows ! . The  results were flashed across mainstream media. Published in New England journal of medicine online.

Look Ahead ADA lifes style NEJM

It may be a  well conducted  trial  but  poorly interpreted  one . It reports one of  the dubious   observations  as a major conclusion  and  confuse the public.

Life style modification is the key to prevent  major diabetic  and cardiac events  . This is well  proved beyond doubt.

Epidemiological evidence  from various  global health  statistics  accumulated over a century will vouch for primary prevention of  diabetic and cardio vascular disease .

Link to Editorial on Look Ahead  : http://www.nejm.org

Why this study wants to make  a mockery of this fact ?  .Fortunately the accompanying  editorial  has  realistically  reported the implications of this study.

Final message

I argue the medical fraternity and patients to ignore this  study . It can be convincingly concluded something is seriously wrong with the outcome analysis  ,  however  modern may be the statistics. Some  groups are obviously worried about the natural and effective control of diabetic by good life style alone . It is a clear case of confusing the public .

There is huge collective evidence  and  common sense  for the  increased physical activity to reduce  cardio vascular risk  (INTERHEART)

Final Message

If life style modification is not going to help  . . . what is the alternative  to our patients ?

Drugs . . . yes  . . . one has to depend on it   . . . this study  seems to suggest .

To me, this is  a dangerous study   . It  plays a spoil sport on a great fact and  belief . This paper  should never have been published in a journal  like  NEJM . Atleast the conclusion  should  have  been re-written !

I guess this study would  promote the  Homo-sapiens  to  be inactive  and  make them diabetic and  consume drugs  perennially !

Reference

http://www.nejm.org/doi/full/10.1056/NEJMoa1212914?query=OF 

Posted in Diabetes and Heart, Social medicine | Tagged , , | Leave a Comment »

Medical Education in India : The future looks bleak and tense !

June 28, 2013 by dr s venkatesan

This is a wonderful   and  realistic article on the Issue by none other than  former Health secretary of the Government of India  Ms Sujatha Rao

medical education In India

http://www.thehindu.com/opinion/lead/doctors-by-merit-not-privileg

Posted in bio ethics, Medical education | Tagged , , , | Leave a Comment »

« Newer Posts - Older Posts »