One of my favorite quote about Happiness from Buddha !
Posted in Uncategorized | Tagged happiness quote, happy doctor |
When a patient comes with angina at rest , it could mean two things .Either a STEMI or an NSTEMI .This , we can diagnose only after seeing the ECG .
Can we differentiate these two by the character of chest pain alone ?
Very tough task isn’t ? But there are some definite clues .
Infarct pain
- Is mostly sudden .
- Likely to be crescendo , lasts more than 20-30 minutes .
- Fails to get relived by rest or even Nitrites.
- Sweating due to sympathetic activation is more pronounced.
Unstable angina
- Is rarely sudden .Often has a pro-drome.
- UA is mostly precipitated by an increased demand situation or a stress.
- It has a typical waxing and waning pattern . Rarely assume a true crescendo character as myocytes does not necrose (Just threaten to die !)
- The chest pain radiation to shoulder is less conspicuous , instead it tends to reach the jaw area .(* An observation,Is it something to do with multi-vessel CAD in UA ?)
Mechanism of the difference : Epicardial vs Endocardial angina
The pain of UA is due to subtotal occlusion and endocardial ischemia , while STEMI is sudden total occlusion and the resultant transmural ischemia . In STEMI epicardial surface is always involved (Which lifts the ST segment in ECG .).We know epicardium is same as visceral layer of pericardium which is well innervated .Hence pain of STEMI acquires more of somatic character than a predominately visceral type pain that occurs with UA/NSTEMI where epicardial ischemia is absent.
Clinical importance
The demarcation between unstable angina and Infarct pain becomes vital when we calculate the time window for thrombolysing STEMI .Many of them have a phase of pre infarction angina which is a type of unstable angina. If we mistake it for Infarct pain then one may falsely calculate a prolonged time window and deny re-perfusion therapy.
Post -amble
It is tricky issue to differentiate the chest pain of STEMI and NSTEMI .A significant overlap can occur in real coronary care scenario . We know chest pain that occurs in both pre and post infarct phase is considered as unstable angina .(With infarct pain sandwiched between them!) Hence differentiating them may even be termed as futile.
Still,clinical cardiology can be made fascinating by indulging in such exercise !
Posted in Cardiology - Clinical, Cardiology -Clinical signs, Cardiology -Mechnisms of disease, cardiology- coronary care, Clinical cardiology | Tagged angina vs infarct, difference between stemi and nstemi, epicardial angina vs endocardail angina, heberden angina, how is chest pain different between nstemi and stemi ?, rca vs lad angina | Leave a Comment »
Most of my students were struggling to answer this seemingly simple question . I realised later it is indeed a difficult one !
Some thoughts
Tall T waves are observed in very early phase of STEMI .(Within 30 minutes ?) What is the mechanism ? Since ST shifts occur little later than T elevation ( considerable overlap may occur) it may not be related to current of Injury.It is an inherent alteration in the T wave genesis .T wave is inscribed when rapid phase 3 K+ efflux happen (Mainly by Iks and also IKr )
What is the effect of ischemia on K + channels ?
No uniform answer.(Blocks, stimulates, irritates, Bi-phasic, variable ?)
There are 6 important K channels in every cardiac myocyte adding to the complexity.
Does the Ischemic cells leaks potassium or accumulates it ?
Though It does both , predominantly it should leak .If it’s leaking there is local extracellular hyperkalemia . Is that the explanation for tall T waves ?
What is the influence of QT interval on T wave morphology ?
Long QT as occurs in hypokalemia pulls the T down and it may even invert it. .Short QT tends to push it up as in ERS .The effect of ischemia on QT interval is again unpredictable.Further regional and remote ischemia in a given patient can alter this.
Once the ST begins to elevate the T waves losses it power to grow tall .It only can regress. I think this is the time the QT is sort of prolongs .
Effect of reperfusion on T waves
The tall T tend to regress as some form perfusion takes place as K+ Is pushed back into the cells or flushed away from the vicinity.
The dynamic nature of reperfusion makes the behavior of T wave amplitude further complex. But one thing is certain , a well perfused IRA is associated with inverted T wave which we call it as completion of the process of evolution of MI .
Finally and most importantly this hyper acute T phase is not a constant phenomenon. In fact it is uncommon in persons who have baseline T inversion .After analysing many things we are back to the original state of ignorance .
Summary
Researchers with intra-myocardial micro electrodes try to decode the mysteries in electrophysiology . Still there is a huge disconnect between clinicians and physiologists.
In simple terms I would believe the mechanism of ischemic tall T waves are almost similar to renal hyperkalemia. (A local , transient extracellular k + excess ) The base of the T waves are not narrow and tented as in CKD because some degree of ST elevation (that always is expected ) widens the base of T wave. Further ,the prolonged QT interval in renal hyperkalemia stretches the QT and encroach the base of the T wave to the left making it appear narrow.
A simplest version for students
Tall T waves are due to transient local extra cellular hyperkalemia , when K + leaks due to cellular Ischemia.
Caution: This is a superficial scientific attempt .I need inputs from more scientific brains and electrophysiologists.
Read further
Posted in Uncategorized | Tagged Mechanis m of tall T in hyperacute MI stemi | 1 Comment »
I got this alert from World health organisation yesterday .Click over the image to read more .
Why should a cardiologist affected about this ?
When we are fighting in cath lab day in night day out to extinguish the myocardial fire set by coronary thrombosis and the resultant STEMI . . . the solemn attempt to salvage whatever myocardial cells we can !
See . . . what is happening elsewhere every 40 seconds a healthy heart in toto is executed by weak minds !
What should the WHO do ?
Just publish these data and forget . No,they should organise the world leaders to take a resolve !
Either , we should prevent these unnatural deaths or else we should have world organ net work. Why can’t we use these weak hearts for those courageous men and women who lose their life daily with end stage cardiomyopathy who long for living !
Is this possible ?
Why not ? Ain’t the world leaders group together periodically to impose a sanction or bomb other countries for personal reasons !
Posted in Public Health, Public health issues | Tagged better world, brain death defintion, cadaver organ sharing india, ethical medicine, future of man kind, heart transplantation in India, humane medicine, kidney transplantation india, net work for organ sharing, organ transplant act india, role of who health, sucide and cardiology, sucide victims as heart donors, unos, who, world health issues | Leave a Comment »
I stumbled upon a TV reality show where a mother of a child was crying inconsolably ,whom she lost when it fell into a open bore-well pit .She was blaming it as her fate and the hole was sent by Lord Yama (God of death )
I just got curious ! This article was written in a flash.
I used to get questions from anxious parents of children with holes in the heart .(Asymptomatic small VSDs or ASDs who come for periodic echo-cardiograms) .I reassure and convey the message , most of these holes are tiny and will close automatically and they need not worry.Even if it doesn’t, it poses little problem.
But .after watching that haunting TV show, I have started to warn the parents that holes in the heart may not be that dangerous but be wary of holes in the roads and unclosed bore wells in our country !
Every single parent was amused with my statement ! Some how it appeared sense to me !
I made a mini google research. It is estimated thousands of bore-wells are dug every day and kept open in allover the country side .It is like live land mines . Some press reports suggest at least one child dies in India every day due to uncovered bore-wells and man holes ! (May be really true !)
The following are some of the samples.
One
One more
Two
You can understand the gravity of the problem , one engineer has devised a special child retrieval Robot for such accidents.
Three
A news report in Times of India .What shall we do about these ?
It is a horrific truth in this civilised world .Nature creates holes in the heart due to defective gene in some . It appears less dangerous to me. After all a hole in the heart threatens only one life,while a hole in the road kills many people.
As a cardiologist , I am saying this with anguish as our team along with surgeons work over time to close intra-cardiac holes with device , the holes in the road are often callously kept open forming death traps for our children .The men responsible for such things deserves no pardon.
The story is never ending . . .
Post-amble:
Doctors are not just the noble professional who provide relief from illness . They have other social responsibilities too !
I believe , as physicians bound by Hippocratic oath , we should help tackle issues that threaten our pubic health system , especially in this case were the victims are vulnerable children !
In fact , pediatricians should come forward to work with Govt to improve safety issues for children and orthopedicians should help prevent road traffic accident while cardiologists shall work with the Govt to prevent heart disease . . . etc etc .
Though bore-well deaths are a pan India phenomenon , One state in India ( TN) has taken a new initiative recently and has banned digging bore-wells without prior permission and stipulated strict guidelines .Others can take a cue from here !
Posted in Public health issues | Tagged asd vsd pda, bore-well deaths in India, congenital heart disease, hippocrates oath, hole in the heart, hole in the heart and hole in the road, Indian association of pediatrics iap, public health issues, safety issues for children, who child safety | Leave a Comment »
- CRT -Cardiac resynchronisation is done by putting multiple wires and electrically organizing the contraction sequence and improving mechanical function.
- ICD-Implantable cardiovertor defibrillator shocks whenever VT or VF occur and suden death is prevented.
- CRT-D (Combo device which functions as both )
CRT is done for advanced heart failure to improve exercise capacity and hence the quality of life .It does not do any thing significant in prolonging life .ICD is again implanted in advanced LV dysfunction with either documented VT/VF or patients who are at propensity for VT .It has dramatic benefit in preventing sudden cardiac death.
Both CRT and ICD has some overlapping indication in cardiac failure. Attention young cardiologists, please realise among these two the value of ICD is many many fold higher than CRT.This fact is rarely discussed and disseminated.
True benefits of CRT is realised only when it is combined with ICD.
Summary
- Ideally all advanced cardiac failure patients should receive both ICD and CRT (CRT-D)
- ICD as stand alone therapy has a distinct role in patients with severe LV dysfunction (LV EF<30%) without wide QRS in ECG
- There is no role for CRT as a standalone procedure in cardiac failure .it should always be combined with ICD (ie CRT-D) *
*Except in patient with degenerative complete heart block , both ventricles are paced the term Bi-Vi pacing is used instead of CRT.Since LV function is normal here , there is no de-synchrony in the first place .The synchronised BIVI pacing is meant to prevent future heart failure
Final message
Always use a combo device in advanced symptomatic heart failure which is refractory to medical therapy.
After all , there need to be a life in the first place so that we can improve it . ICD ensures life while CRT tries to improve it.
Posted in cardiac resynchronisation, Cardiology - Electrophysiology -Pacemaker | Tagged crt vs icd, when should i use combo device ?, when should i use crt and icd ? | 1 Comment »
The correct answer could be any of the above , depending upon the level of your knowledge.
Ever since Herrick reported coronary thrombosis as a cause for MI and Davies documented it by angiogram many decades later (1980) ,the fate of thrombus and the mechanism of its dissolution is the key to our understanding of ACS.
Even though we are now able to take on this thrombus in a direct fight by aspiration techniques ,still the hematological aftermath and the aberrant coronary behavior can fool us at any time ! The major lesson learnt in recent times is the success of pPCI is not in clearing the thrombus but ensure it never accumulates again at the site in the future .This is why there is whole big industry working on post PCI anti coagulation and anti platelet strategies .
Clinical correlates of poor perfusion in micro circulation.
Plugging of micro circulation is the most under-recognised issue.This results in no reflow in acute fashion or LV dysfunction and micro-vascular angina in long term . Late recovery of LV function is attributed to late clearance of thrombotic debri.
RCA vs LCA thrombus load.
*One interesting observation is RCA thrombus clears more slowly as it has no well formed venous circuits .most RCA blood drains through thebesian veins which traverses RV myocardium .this can be hemodynamic hurdle unlike the LCA venous drainage
Posted in Uncategorized | Leave a Comment »
As the medical care advances human care has taken the back seat. It is said super specialists read more and more about less and less ! In the process they fail to see the patients as a single biological unit instead as collection of organs .
While organs in turn are looked as pile of data.Hence the treatment they provide lack the soul !
In the prevailing circumstances , how do we ensure modern medicine does not interfere with these vulnerable souls,either to live in peace or leave in peace ?
Image : Source and Courtesy of http://illuminationstudios.com
It appears doctors are not at fault . The system is biased towards raw science .Highly trained doctors are tied down by both true and pseudo scientific Intellect .Often times they are compelled to do some procedure or interventions just to justify the premier status of the hospital .While few do it to show off their expertise or to impress their peers others are simply bound by rigid and obsessive protocols and guidelines . Few others do it for the burning desire of scientific accomplishment .
One can offer hundred reasons for doing a procedure . . . but we always struggle to justify with a valid reason for not doing a investigation or procedure !
In fact , the concept of appropriateness criteria came out with good intention .But , it had failed miserably.
The irony is . . . we need to indulge in something to avoid something.
Example 1 If homocystiene and hsCRP vanish from the CAD screening industry Adiponectin and Vitamin D3 comes in with a thunderous applause like a new Hollywood movie !
Example 2: In cath lab for leaving alone an insignificant coronary stenosis , we have to do another procedure called FFR to satisfy scientific ego ! (I know one senior doctor , who left a 80% LAD lesion for medical management without FFR ( with all his clinical acumen ) was ridiculed for being unscientific !)
Here is a recent perspective article NEJM has discussed this important issue that plague us
Why should big Tertiary teaching hospital are flooded with super specialists which by default shun basic human care ?
Read this article*
*The article I have quoted may not be completely relevant here . . . It answers few of the queries raised!
Posted in bio ethics, Cardiology -Emerging technology, Cardiology -guidelines, Cardiology -Interventional -PCI, Cardiology -Patient page, Cardiology -Therapeutic dilemma, Cardiology -unresolved questions, medical quotes | Tagged father of modern medicine, medical ethics, primary health care in tertiary health centre, primary secondary tertiary health care | Leave a Comment »
The diastolic mitral filling pattern has been named and graded umpteen times in the last decade. We believe it has reached some semblance of clarity.I beg to differ.
Image template taken from http://www.learntheheart.com
There need to be one more grade between Grade 1 and grade 2 .Grade 1 is defined as A velocity > E velocity . This is the commonest abnormal pattern and is often man made.We can’t help it . We have to report it anyway. Significant number of elderly show this pattern without any pathology. It simply represents augmented atrial contribution at times of apparent ventricular stress .
I wish a good chunk of grade 1 pattern , especially in elderly or during tachycardia should be labelled as physiological grade 1 pattern (or simply as normal variant ) . However I would prefer it to be named as pseudo abnormal pattern* !
* In my experience , currently medicine is taught in a complex manner .Facts that are told in simple terms are rejected straightaway . It would seem,too much clarity is not good for science So,let us get confused one more time for the sake of our patients !
Posted in Cardiology -unresolved questions, Diastolic dysfunction, Echocardiography - LV dysfunction | Tagged doppler lv diastolic filling, grading of diastolic dysfunction, pseudo abnormal lv filling, pseudo normal filling | Leave a Comment »
Coronary artery disease (CAD) is man-kind’s greatest threat in modern times.CAD ,diabetes ,Hypertension, obesity, mental illness has become an epidemic even among the young !
There is a simple solution for lifestyle diseases !
Just . . . Remove style from your life !
Instead . . . try to live like these Tibetian villagers
Final message
One study which researched all lives who crossed 100 Years concluded something like this !
“To live a longer and healthy life* ,Get up early , have a purposeful daily chore that must include a physical component , work with conscience ,love every one sync with the nature and lastly and most importantly remove style from your life !
Choose your life . . . It is simply there in your hand for grabs !
Post-amble.
* Please note , Doctors are never listed in the top with relevance to health of mankind ! They simply cure some illness !
Posted in bio ethics, Cardiology -Patient page, cardiology -Preventive, cardiology -Therapeutics, Cardiology classics, Cardiology Risk assesment | Tagged cad epidemic, how to prevent lifestyle diseases ?, life style disease, smoking alcohol cad |
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Dr.S.Venkatesan MD 