Posts Tagged ‘64 slice ct scan’

Very often in clinical  practice  cardiologists are asked to R/O significant coronary artery disease in asymptomatic persons .This population includes  people with multiple risk factors like diabetes, HT dyslipidemia  and non specific ST/T changes in ECG.

Many of us have lost the confidence of   ruling out CAD   in these population without looking at their  coronary angiogram.

Is it a right way of practicing cardiology ?

What we need to realise is,  we are asked  to rule out any critical lesions that are going to make a impact on these  other wise comfortable patients.  Nothing wrong if you miss a 30% lesion in PDA or OMs or diagonals !

Can we do this without doing coronary angiogram ?

Yes ,  we can .

Step by step  Ask these questions

  1. Ask the patient , if  he /she   can climb three  flight of  stairs  without any difficulty or
  2. Walk briskly for  20 minutes (5km/hr)

If yes , give  a   certificate   that he  has no critical  left main or proximal LAD  disease.

If you do not believe in his words , put him on a tread mill ,  if he crosses   stage  3   Bruce in TMT ( 9 mts)

give the above certificate  “with a frame”  now .

For still suspicious  physicians ,  We have  one more  investigation called  echocardiography !

Echo : The forgotten tool  for screening left main lesion.

Modern day echo machines have a  3mm resolution power (Many have 2mm ) .While ,  we are expected to look for 3mm vegetation to R/O Infective endocarditis , rarely is  a  cardiologist ,  tuned to  look for the left main ostium  in routine echocardiography  which averages 4-5mm is size. (Left main by echo link to another article)

In short axis  view just tilt at the level of pulmonary valves  (Atrio- pulmonary sulcus) one can visualise the left main ostium and the proximal left main emerging from the 4 o clock position. If you are lucky you can see the entire left main.

If nothing satisfies the physician (Or the patient)  ,Refer him for sliced CT scan , catheter coronary angiogram , or a  nuclear Imaging .Be ready for the attendant anxiety, interpretation errors, corporate  pressures , urge to  balloon ,  kick backs etc etc

By the way , how can  one  be happy by ruling out only left main disease ?  Is it not other lesions possible ?

Experience (Not science) has taught us  no  critical coronary obstruction is  possible ,  if  a patient walks for  9 minutes  in treadmill (10METS).

Even if it is there (A remote chance)  there is little documented benefit of any revascularisation procedure.

Counter point ?

Is it not a “crazy idea  to rely on patients history in ruling out  CAD   in these era , where   angiograms relayed  live  into   cardiologists  ipad  ?

Science has no value if it is not applied  for the patients welfare. Meticulous clinical  examination (And application of mind)  is the foundation stone on which  any medical investigation and therapy  should be based  upon. Most of the inappropriate coronary revascularisation are due to  neglect   of  this vital  component of clinical examination.

(I wonder ,  is it  really possible  these ” acts of omission”   be  deliberate some times  ! )

Final message

Clinical interrogation  may  miss an insignificant  CAD  ,  but it can never miss a critical CAD* .


Do not do coronary angiogram routinely to R/O  CAD.

It is not the way cardiology is to be practiced !

If only we apply  those  simple,  time tested concepts in every day practice we not only  save millions of  Rupees ,   but also thousands of futile   diagnostic tests and associated untoward effects can be avoided.

* Senstivity of  ruling out any CAD is about 70% , but it’s capcity to R/O critical CAD approaches 100%.


Please refer your own Brain.

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Great things happen in India nowadays  .Economy is growing    at  9% , the growth of  automobile industry is  fastest in the world. But in  scientific  research and development  it   has  been traditionally lagging behind . Things are set to change. The medical science , (If you want to call it as industry it is fine !)  especially  the imaging science is making rapid strides. The proliferation of  private and corporate hospitals and institutes   has helped us practice the latest .

Pulmonary atresia with VSD is a rare congenital disease where  there is partial or  total (chaotic  )pulmonary arterial blood supply .

When the pulmonary  artery becomes atretic , what will the lung do ?

It has to get perfused somehow ! It tries to snatch the  blood from the aorta  in whatever  possible manner . Depending on the severity of pulmonary atresia  , there  can be  a total anomalous pulmonary  arterial supply (Type 4 ) .Here , few twigs directly originate  from Aorta, few from branches of  Aorta  and sometimes bilateral  PDA etc .These are collectively called major arotopulmonary collateral  (MAPCAS) .In fact differentiating a PDA from a MAPCA can be extremely difficult .(It has only academic purpose though !)

Hither to ,  visualising  the  MAPCAS was a  huge  task . Aortogram with selective cannulation of MAPCA  was  neccessary.Now,  with the advent of  MDCT we can get some stunning  images  of these collaterals non invasively.

Why is visualizing and delineating MAPCA anatomy important ?

This will facilitate the surgeon to plan  the  unification of pulmonary  arterial flow    and reenginnering the pulmonary circulation  (with or with  out  conduits)

Here is a rare  publication originating from India  in  American journal of radiology  . An  exclusive   article  with  CT scan  images of the  defect .

Amrita  Institute , from  the southern   Indian  state of  Kerala (  also known as God’s  own country )  is doing a phenomenal  cardiology  work  especially  in pediatric cardiology.

Three cheers to the team which published this  master piece . With the courtesy of   AJR the link to the article is placed here.

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Common sense would  indicate  medical care is  meant for the sick and ill  . Relieving  the mankind  from all those  suffering  with a healing hand has made the  medical profession noble and sacred .Medical science   grew with this sole aim  many centuries ago  .Some  times  we succeeded   and many times we failed  and the journey is  continuing .

In those days ,scientists were dedicated , inventions were genuine and were driven by a need to conquer a diseases .Some where along the line, (May be in the last 2-3 decades?)   our quest for money power exceeded commonsense  . Commerce entered   every  walk of life and  medical science became the biggest causality.

The purpose of noble   profession was forgotten . Simultaneously   public awareness and quality if life vastly improved in many of the developed countries . So the traditional illnesses  either disappeared  or reduced   to a great extent . Then came the life style diseases.The cost of treating  an illness spiraled too much especially   in the scientifically advanced countries . What was perceived  as great health care system  became  the  most ridiculed  health system in the planet  ?

Why ?  The simplest answer to this q  is

In the name of science  and  modernity , medical treatment  was glorified beyond the level it deserves ,  and hence  the  cost of treatment is  kept at artificially  & foolishly high  (This often involves  diagnostic   exploration of human body with modern gadgets without any meaningful   purpose )  .

ie , In  a  nutshell  of modern medicine is   often a medical mirage than a miracle . We know ,  the chances of success  as we  try  to chase it. If we think the  world is   waking  on this issue .

We are in for a surprise ! Even as  every one  is asking for outcome analysis in modern health care

more and more countries just imitate the failed ( Scientific and moral failure ) western models of health care .

When major illness are reducing in a society what will the health care providers do ?

Feel happy ?  Yes that’s what   a  sane   mind  would   do .  In a capital  rich ,   health conscious ,   knowledge  driven  society the opposite happens .

When  the patient  input  into a top hospital  reduces , the MBAs   in  them plan strategies  to bring  increase the bed occupancy rate and  maintain  patient  parity.

If sufficient  patients  are not there in a community what shall we do ?

Create  more  patients

Creating  new patients is a too dangerous game ,  what shall we do ?

In the  name  of preventive screening   let  us  label   normal  persons as patients .

How to do it ?

The following examples  are personal observation made in  huge city of educated elite  in a developing country . Excuse me if it offends a few  . . .

Define, redefine all criteria that define the disease (There are

  • Make, 130/85mmhg of blood pressure as pre hypertension and make them visit our HT clinic every month.
  • In the  name of risk stratification do CRP, Micro HDL , Apo a   etc and  catch them  for primary risk reduction for a non existing illness
  • Let us  label  all the   age related  bone loss as  deadly osteoporosis and do bone graft.
  • Let us  call  the occasional post dinner stiff stomach as non ulcer dyspepsia   and  insert a  endoscope  into the patient tummy .
  • Do a 64slice CT  in a master health check and convert many  of the healthy  normals into carriers   soft  coronary plaques.
  • Do a ultra sound scan  in every one who takes alcohol and  give our brains a temptation to label  the normal  fatty streaks  as infiltrative  fat disorder .
  • Do routine pelvic scan and detect  sub clinical fibroid uterus as potentially  malignant and  post them for hysterectomy on the next operation day.
  • Convert all healthy women as a  potential cervical cancer  and administer  herpes vaccine and help  the vaccine company share  move up in wall street !
  • Finally , screen  all  our  playful   kids for   learning disability and   label them as slow attention deficit disorder  and  make their  life permanently   miserable .

The list is endless  . . .

Final message

We  are in a  era ,  where  even   a  simple  illness  ( common cold ? )  can be converted into a billion dollar industry . ( Are you aware of H1N1 fiasco ,  The role of   WHO  and  mystery labeling of pandemic !)

While the above  misadventure  with scientific excesses   goes  on merrily  , lest we forget , millions of children  and adults  suffer in misery for want of  live saving  investigations and drugs  in any country .

When a person with a head injury dies due a  missed   subdural  hematoma for want of CT scan in one hospital  ,  ” in the adjacent hospital”  a wealthy and healthy man  ( who got admitted for master health check up ) undergoes  a series of scans  all over the body   even as he is  watching   the  satellite TV in  the comfort of a  five star suite   !

God will never  forgive  the  noble professionals   if they are part of this  negative health care  forces

Finally  ending with a very positive note !

The new   initiative by  Obama   , ” Health care  for  the uninsured ” is to be welcomed as great move  and will do a world of good .

But , our  only  request  to WHO ( or related   bodies )  is to create a forum or authority  to  impeach all fancy diseases from the medical   literature  !

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                                                      Coronary arterial circulation is the life line for  the human heart  and it’s survival.Typically it is supplied by two coronary arteries,  left and right coronary artery.Both, together carry about  250ml of blood every minute.( Approxinately  equal to a  cup of  coke !  ).These coronary arteries  generally divide in a predetermined  fashion , and have multiple branches . It is a  mystery , what  decides this  branching pattern

Is it like a our palmar crease  ? or the cerebral gyri ?

However , it does follow a certain rule,  one major coronary artery  will follow the  four  important grooves of heart. In the left side ,  left main coronary artery (LM) originates in the left coronary sinus (Size varying between 1mm -20mm)  and usually bifurcates into LAD and LCX. The left anterior descending artery (LAD) runs in anterior interventricular  groove while ,  the right atrio ventriculo groove carries the right coronary artery(RCA) .Left  circumflex artery (LCX) traverses the  left atrio ventricular groove.The most inconstant branch is the posterior descending artery (PDA) which runs in the posterior interventricular  groove.PDA  can arise from either RCA, LCX or both or even from LAD.

The major branches of LAD are called diagonal and septal  while the branches of LCX are called obtuse marginal(OM).There can be two to three diagonal and OMs. 

What is ramus intermedius coronary artery ? What is the incidence of Ramus ?

The left main coronary artery  instead of bifurcating into two ,  it trifurcates into three vessels.(LAD, LCX, Ramus)

The real incidence could vary betweenn (10% to 30%) depending upon the series.


What course it takes ?

It generally goes in the angle between the LAD and the LCX.It may either behave like a large OM or a diagonal branch.It supplies the lateral free wall of the LV many times.The peculiarity of this vessel is it does not run in a anatomical groove .It simply slides over the free surface of LV.Rarely, a  very abnormal course of ramus,  criss cross the aorta and pulmonary artery .

How common is atherosclerosis within  Ramus ?

We don’t know yet. But it is very likely since it is an early branch from left main, it  might  have a  predilection for atherosclerosis  as like LAD or LCX ostium.In fact now we recognise more of  trifurcation lesions involving  three branches of left main .

What would be the ECG finding if a large ramus is the culpirit vessel during STEMI ?

This scenario could be rare.

ACS in ramus could  present as ST elevation in 1/Avl /V5,V6

  • Lateral MI
  • Apical MI
  • High lateral MI

But it is realised , whenever the ECG changes are not fitting with typical ASMI or a lateral MI one should suspect a ramus lesion

 What is the significance of ramus for an interventional cardiologist ?


                                                   PCI in ramus is a rare opportunity for a cardiologist .The issue here  is,  if ramus is involved  adjacent LAD and LCX is also likely to be involved .So it would logically be a multivessel , complex angioplasty.Isolated ramus lesion could be tackled easily.Another issue here could  be ,since this vessel is not within  any anatomical groove  stent deployment would have a poor  support and prone for mobilisation and migration .

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