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Simpe tips to suspect secondary hypertension .

May 31, 2013 by dr s venkatesan

95 % of hypertension is designated as primary HT .What does it mean ?  It means  95 % of times  we do not   know what  exactly is the cause for raised blood pressure  . Simply stated  . . . it  reflects 95% ignorance .

So what is secondary hypertension ?

Secondary HT is the one,  in which we have specific reason for the raised BP.  The most important cause is Renal  ,  endocrine etc.

When will you suspect renal HT ?

https://drsvenkatesan.wordpress.com/2010/09/01/when-will-you-suspect-reno-vascular-hypertension/

How is secondary HT different ?

  • Occur at relatively at young age (<45)
  • It is generally more severe.
  • Diastolic BP is proportionately  higher ,
  • End organ damage is more.
  • It is very unlikely primary HT to present as acute LVF.  One rule of thumb is ,  if diastolic blo0d pressure is > 120 never diagnose  primary HT . Some amount of renal component is very likely.

Is stress related HT a form of secondary HT ?

https://drsvenkatesan.wordpress.com/2013/04/26/why-stress-obesity-related-hypertension-is-not-considered-as-secondary-hypertension/

Posted in cardiology -Therapeutics, Cardiology hypertension | Tagged , | 1 Comment »

PTCA : Percutaneous Transluminal “Credit” Angioplasty

May 31, 2013 by dr s venkatesan

Heart disease was  once considered as   rich man’s disease  . . .  It’s no longer  true .  We in India ,  are witnessing an epidemic of CAD . The reasons are  varied  . Apart from  conventional factors ,   social   factors  like changing demographic pattern  ,  life style , ethnic  risk  like  south  Asian metabolic profile are responsible .

While  Rheumatic heart disease (RHD ) continues to be a huge burden , CAD  is  the number one  cause for cardiovascular morbidity and mortality .

CAD affect the poor and rich with equal vengeance . The later is better equipped financially to tackle it . Of course ,  it has resulted in maximum inappropriate interventions. The poor (or borderline poor ) have  no  other  option  but  to knock the doors of Government  hospitals. It is heartening to note, various state  Governments   are  gradually involving insurance schemes.

Still , many struggle to find the required  finance for  a major cardiac intervention. It roughly costs 100,000 rupees  for PTCA  .While  PCI is required in all symptomatic ,  critical coronary occlusions , still . . .  majority of the  CAD in general population  do not require it . There are 675 cath labs in India performing 180000 angioplasties every year  on an average of   15000  PCI per month ( 500 /day )  This is grossly inadequate . We  have huge potential

What is the hurdle ?

  • Expertise ?
  • Hard ware ?
  • Awareness ?

No  . . . it is all about  financial resources

Recently I stumbled upon an  advertisement on Times of India

cardiology ad ptca

Disclaimer: This article does not in any way defame any hospital that offers the scheme.It just want to debate the concept.

Hospitals  want  to  market the procedure . Convert angiograms  to angioplasties . That’s   corporate boardroom mantra  . And one fine day ,  bankers and medical doctor sat together and brought a brilliant idea.

Why not do the procedure  on credit and  push the patient  life long  into a financial debt !

Wonderful idea  . . . many thought .Thus came the financing scheme for  cardiac procedures.

Final message

Financing a poor patient  with good intention is welcome. But, there is big caveat .In a vast country   with high  illiteracy , inappropriate  procedures   may be thrusted upon  on   the  poor  souls.

After thought

Now ,  our patients   have  one more  risk parameter to  assess   ” Number of remaining EMI( Equal monthly instalment )  and incidence of stent thrombosis”   “Accumulated  interest  and angina”   What a wonderful way to provide cardiac care !

I can recall a  patient who sold his livestock  (his sole income source ) for undergoing a open heart surgery and lost his life as well in the process  leaving the family stranded !

Solution

The only solution is  to  provide  a strictly regulated Govt sponsored  insurance scheme.  High tech procedures should be  continuously and meticulously  audited for cost effectiveness .

 

Posted in Cardiology -guidelines, Cardiology -Interventional -PCI, cardiology -Therapeutics, cardiology innovation | Tagged , , , , , , , | Leave a Comment »

ECG clues one should look for after reverting a VT ?

May 31, 2013 by dr s venkatesan

Ventricular tachycardia is a common cardiac arrhythmia. The significance of which can be very dangerous to relatively benign  depending upon the etiology and underlying heart disease . The ECG during VT is rarely useful to identify the etiology .Often times  ECG after reversal will  throw more light .

What are the ECG clues one should look for once VT is  reverted ?

  • Any evidence for old MI
  • Low voltage QRS/ LBBB/RBBB may indicate DCM
  • LVH -HOCM features
  • VPDs – Multiple , LBBB morphology / suggest  RVOT  VT
  • QRS slur or notching  indicating scars
  • Epsilon waves indicate  ARVD
  • RBBB pattern would  suggest  Brugada
  • Prolonged QT interval
  • Tall  T waves/ U waves /  Inverted  T -and other electrolytic abnormality.
  • Delta waves would indicate anti-dromic tachycardia.

Posted in Cardiology - Electrophysiology -Pacemaker, cardiology -ECG, Uncategorized | Tagged , , | Leave a Comment »

Adventures of “Animal kind” !

May 30, 2013 by dr s venkatesan

It happens only in India

adventure

About  150,ooo people die in road accidents in India every year . . . highest in the world !  Myocardial infarction  kills  only slightly  more !

Image courtesy : Times of India , 18th April 2013 . Picture  by  S.L. Shanth Kumar .

 

Posted in Social medicine | Tagged , , , , , | Leave a Comment »

The fractured rule of thumb in localising VPD by ECG !

May 30, 2013 by dr s venkatesan

We are taught in  medical schools  early in our career ,   ventricular premature  depolarization (VPD ) takes  LBBB morphology if it arise from right ventricle , and  RBBB morphology if it arise from left ventricle .This is a rough rule of thumb.

Why this rule is  unreliable ?

VPDs have a focus of origin—–a short circuit——and an epicardial  breakthrough . All these together influence the morphology. Within  the left ventricle , a deep endocardial focus  can  behave  vastly different  from superficial epicardial focus  . The  course of VPD is influenced by the myocardial status ( scars etc ) . Further,  the electrical  properties of  interventricular septum is shared  by both ventricles .

  • Generally – LBBB morphology  has  more localizing value .
  • Most RV focus have LBBB morphology (but not vice versa!)
  • LV focus can either have LBBB or RBBB

What happens to  a VPD  arising from  interventricular septum ?

IVS is  not only shared by both ventricles , it does  not have  true  epicardial  surface  (Both side  bordered by endocardium ) In most septal VPDs , breakthrough occur on either side of the ventricle  . However , It  keeps trying  to break through  epicardial surface  !  .  Hence , septal VPD  is like cat on wall situation .So the morphology varies quiet frequently.Further , the VPD can capture  the specialised conduction tissue occurs  more commonly with septal VPDs. This can alter both the width and morphology of QRS.

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

ICD shocks during sexual acts . . . Is the partner at risk for electrical Injury ?

May 29, 2013 by dr s venkatesan

Modern human life is driven by technology  . We are gradually taken over by gadgets .Heart is not an exception . Implantable cardiovertor defibrillator (ICD )  is major innovation  where in , an  electrically  wayward heart  is brought under control  by series of automatic shocks . One of my patients with old MI and significant LV  dysfunction for whom ICD was an option  taught me a lesson in physics  . During  counseling ,  he was asking me about  the quality of life issues etc .
ICD shocks during sex 2
First,   he wanted to know  how  stressful  the  sexual acts  are ?  . . .Then he  surprised me with this  question .  He wanted to know ,  the  risk of  developing a VT/VF  during the act and  will the ICD  shock  his spouse as  well ?  That was a real  cracker of  a  question  I thought .   I had to do  a mini  research   and found that  these are  low energy shocks (30 Joules)  and transmitted electrical injury is a non issue  .
I realised   then  . . .  we live in a era  where   physicians often get educated from their patients !
Here is the  FAQs on ICD from the patient pages of circulation . With  due courtesy I  reproduce it here.
ICD shocks during sex
Final message
ICD shocks are  low energy shocks delivered  Intra cardiac ,  and  rarely  reach the surface  ,  hence has little risk for electrical injury  for those in contact.
References
1. Vazquez LD, Sears SF, Shea JB, Vazquez PM. Sexual health for patients with an implantable cardioverter defibrillator.

2.Steinke EE. Sexual concerns of patients and partners after an implantable cardioverter defibrillator.
Dimens Crit Care Nurs. 2003;22:89–96
3. A  review article on the  broad issue.
sexual activity in cardiovascular disease circulation 2012

Posted in Cardiology - Electrophysiology -Pacemaker, cardiology -Sexual health | Tagged , , | Leave a Comment »

An unusual cardiac arrhythmia : This ectopic beat * arises right from sinus node itself !

May 24, 2013 by dr s venkatesan

This is an  ECG which  I reported  yesterday in my clinic . I thought it was a  near perfect example for sinus node premature beat .

sinus premature beat spb 2

(Of course I need to explain  why the  P morphology  slightly  differs )

A  sudden unexpected  QRS  complex is often called as  ectopic beat . If it occurs prematurely (ie earlier than anticipated )  it is called as premature beat. If it occurs late it is refereed  to as escape beat .Please note the difference is not absolute .

Sinus node is a dramatic bundle of energy with divine powers that  drives rhythm of life !

The pacemaker cells are arranged in a compact fashion with  differential properties from cranial cells firing fast and caudal cells little slower. The neural control is under constant Neuro/electro/humoral  servo control mechanism.It is well known the pacemaker shifts it’s firing location within the SA node in fairly regular fashion .The entire SA node has rich adrenergic and  cholinergic  innervation , with  a dominant control by the later . (This is  why the intrinsic heart rate is  in the tachycardia  range (around 116 )  when SA node is denerved  pharmacologically )

wandering-pacemaker

sinus premature systole spd sinus node ectopics002

SA node ,  being  a complex structure ,  it is not surprising to note  few beats to fire  slightly late  or  prematurely.If it occurs late it is called sinus pause ,  if it occurs early it is sinus premature beat , if  both occurs  interchangeably  we refer it as  sinus arhhytmia. (Read  about sinus pause here)

What is the clinical significance  of   SPD ? (Sinus premature depolarisation )

It is a  very benign entity that it is  merely an  academic fascination . By  stretching my  imagination  I  can  correlate  it  with few possible  clinical issues.

  • May be it has potenital to trigger a  SA nodal reentry tachycardia  or In appropriate sinus tachycardia/bradycardia.
  • It may be imporatnt in sinus node modification process.
  • However ,the main issue is  thee  cardiac physicians  in their enthusiasm should not mistake it for some serious  cardiac arrhythmia !

Related article

https://drsvenkatesan.wordpress.com/2009/04/14/can-premature-ectopic-beats-occur-in-sa-node/

Posted in Cardiology - Electrophysiology -Pacemaker, cardiology -ECG, Cardiology -unresolved questions, Cardiology-Arrhythmias | Tagged , , | 1 Comment »

IPL 2013 : A cricket carnival derailed by manic media !

May 21, 2013 by dr s venkatesan

April-May is carnival time in India . . . cricket carnival. In IPL . . . Indian premier league , eight teams will fight for the cup . IPL 2013 became a smashing hit , until last week when three players were arrested for spot fixing in an over . And for the past 10 days the entire Indian media has gone into manic reaction over it !

Still , the sport was wonderful , the skills shown were extraordinary , and what happened was an aberration just like in any other aspect of life . IPL is perfect mix of sports , business , commerce and some sleaze . Actually in a successful business model , one should actually be surprised if corrupt practices does not occur !

The game of cricket can never be killed by money ! The way the issue was handled by the media and the reactions and public debates for me looks irrelevant . Is it justified ?

We the people and media has much much important things to do in India !

scandals in india

Fixing a Fix . . .

Politicians fix voters by giving money !
Media fixes news for money !
Students of the noble profession are desperate to fix examiners with money !
Finance ministry’s annual budget is fixed by business tycoons !
Private medical colleges fix entrance exams after getting money !
Super powers fix terrorists selectively for money for self benefits !
Drug companies fix doctors with money !
Doctors fix labs by getting money !
Anxious parents try to fix marks of their children for money !
Government fixes tender for money !
Live kidney donors are fixed by criminal cartels for money !
Advocates fix false evidence with money !
Innocents are fixed as criminals after getting money !
Thousands of marriages are fixed with money after hiding illicit relations !
Huge bank loans are fixed based on false affidavits and promises !
TV reality shows are fixed with mad money !
Even pilgrims fix Darshan time by paying huge money !
And finally . . . One cricketer bowled one of the balls . . .wide . . . . in one of the over after getting money !
The whole world erupted !
cricket scam India
Postamble
Can there be any justification for justifying wrong things in life ?
If life is a fight between good and evil , I thought it is absolutely absurd to justify it until recently . . . but a great epic of India , Bhagawad Gita which is considered as the ultimate guideline for living ,differs (Or is it my perception !)
The summary of the epic goes something like this
  • Whatever happened has been good.
  • Whatever happens is good
  • Whatever will happen is also good.
Bhagavad Gita has one more sermon to confuse us ( me ) completely !
“Do your duty , do not expect any returns and do not watch injustice silently , protest and fight it with your full potential” !
I welcome the experts of the Bhagawatham to clarify me on this issue !

Posted in cardiology-ethics | Tagged , , , | 2 Comments »

Basic instincts in cath lab : It is too tempting to poke the non IRA . . . What shall I do ?

May 19, 2013 by dr s venkatesan

Multivessel PCI during acute STEMI is forbidden except in cardiogenic  shock . (or in some very unstable patients without cardiogenic shock)

The reason

  • During acute MI   hemodynamics  are precariously balanced.We do not know yet how  emergency multivessel plasty alters this .
  • Our  initial aim should be   confined to myocardial salvage in the IRA . Total myocardial revascularization is niether  the  priority nor its desirable.
  • The more  time  you spend  within the inflamed coronary artery , more its  hazardous.
  • Multiple stenting  is prone for thrombus   and  migration  into side branch .
  • Stent opposition is sub optimal in many thrombus infested lesions.

Still  . . .  in real world it is extremely difficult to curtail the urge to stent  all eligible lesion during primary PCI !

multivessel angioplasy during stemi

How to avoid it ? 

If the patient is poor or the insurance limit is low , the issue  of multi vessel stenting does not arise at all  !

Always  ignore  complex  non IRA lesions  during primary  PCI. Be happy if a non IRA has a bifurcation lesion !

Still , some lovely looking lesions in non IRA  would be  tempting  and inviting .  Indulge at your own risk !

* Please remember if  the proximal  LAD  has a non IRA lesion , it may be sensible to attempt  simultaneous revascularisation even if the patient is stable !

Other unrealistic advice

  • Keep the professional fee and other benefits   fixed whether  we do a single or multiple   vessel stenting (Realise  . . .  surgeons do not charge more for a  4  vessel by-pass graft  than a single  ! )
  • Keep the current AHA/ACC/ESC guidelines pasted right next to the fluroscopy monitor .
  • Ask your subordinates to repeatedly caution   you  about the possible  excesses and ask them to wave a red flag !
  • You may  empower the   senior staff nurse   with a veto power  to shut off the cath lab once IRA plasty is  completed and the patient  is stable.
  • In extreme  situations , keep a cath  marshal ready to manually evacuate  the primary operator  from cath lab !

Reference

multivessel angioplasty during stemi

ACC GUIDELINES FOR STEMI 2013

Posted in Cardiology -Interventional -PCI, cath lab tips and tricks | Tagged , , , | Leave a Comment »

Does radial coronary Interventions increase stroke risk ?

May 5, 2013 by dr s venkatesan

The link between brain and the  hand  starts right from fetus .  It is a well known fact  vertebral artery   competes with hand blood flow  . In the right side , there  is one more  vascular issue !  .Bracho cephalic  artery  arises  directly  from aorta and supplies the  right  hand and  right half of brain.

It remains a mystery  why left brain  is   blessed with a  separate  origin ,  while right has to share it with blood meant for hand  .It is beyond science  . . . isn’t

It is possible the left hemisphere  of brain   has more   purpose   to be alive  ,  with bulk of the cognition work to do . Hence   God created a  separate  supply to it !  Of course , he  would   have never  thought ,  the  possibility of  his ” mean” creations   adventuring  within the   arterial tree  !

Click over the Image for animation

right radial artery coronary angiogram pci risk of stroke 002

Please remember  whenever  we   play with   catheters and wires  through   radial route , we  are  hugging  and scraping   the artery meant  for cerebral circulation !

Final message

Femoral Interventions  enjoys a proven  track record. Currently ,  radial route has virtually taken over with  few  advantages . However , the  overall stroke risk in the two approaches  remain  low but genuine (.4 %) .It may be true , arch manipulation is more  with  femoral but  the threat to  vertebral and brachiocephalic circulation  is more with radial .  When the available evidence are  not conclusive  and  new ones are not forth coming  . . . it is wiser to rely on common sense !

Reference

I think  this 2011  study  from the  prestigious stroke journal  has convincingly answered the issue

cholesterol and ateromatous emboli following coroanry intervention 2

cholesterol and ateromatous emboli following coroanry intervention radial vs femoral 2

It concludes , the right radial approach  is indeed risky  to develop cerebral  micro embolism   when compared to right femoral

A Review article in  Circulation

cholesterol and ateromatous emboli following coroanry intervention 2 radial vs femoral 2

Other references

1.http://stroke.ahajournals.org/content/38/7/2176.full.pdf+html

2.Transient Cortical Blindness after Coronary Angiography Journal of International Medical Research. 2009;37:1246–1251,

3. Stroke and Cardiac Catheterization Circulation. 2008;118:678–683,

Posted in Cardiology -Interventional -PCI, Cardiology -unresolved questions, Hardware techniques tips, Infrequently asked questions in cardiology (iFAQs), radial coronary angiogram PCI | Tagged , , , , , , , , , | Leave a Comment »

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