Posted in Uncategorized, tagged BARI 2D, courage, jasp, medical therapy vs pci for angina on March 31, 2012| 1 Comment »
COURAGE , BARI 2D , JASP
What is common in all ?
These are the studies which nailed the routine PCI in chronic stable angina . Please note these articles came in prestigious journals more than 5 years ago.
Nobody* seemed to listen or learn . Now the Archives of Internal Medicine has come out with another punch to PCI .
Hope we refuse to learn again . . . and keep the interventionist spirit high !
And for a change read this landmark paper from Forbes
Posted in Cardiology - Clinical, Cardiology -Interventional -PCI, cardiology -Therapeutics, tagged BARI 2D, cabg, cabg vs PCI, cad, cass study, coroanry artery disease, courage study, medcial maangement vs pci, oat study on June 18, 2011| 2 Comments »
Coronary atherosclerosis is the number one killer of mankind. Many would consider it as an essential process of aging .Modern life styles and habits make this appear very early in life . There is currently an endemic (or even a pandemic ) of CAD due to premature atherosclerosis. We need to recognise CAD is not a primary heart disease .It is an irony, heart is an innocent bystander to the biological derangement of coronary vascular system when it is infested with atherosclerotic plaques .
So , when we are confronted with serious atherosclerotic lesions in a coronary artery what shall we do ?
We have three options
2 .Next method is to find the basic cause of terrorism , identify the perpetuates, facilitators and try to correct the root cause of it (CAD ) .This approach also refered to as medical management in cardiology community* . It aims at regression of plaque by statins, and life style modification and preventive cardiology. This modality is most ridiculed and insulted by the main stream cardiologists.
*Comparable to bilateral peace talks for a political solution to terror
3. And third option is a real surprise ! This neither confronts the lesion nor does it address the initiating factors . It just ignores the lesion and by pass it with a LIMA /SVG fly over , as if nothing has happened in this vital high way leaving the culprit scot-free .This option is executed by surgeons as CABG surgery . . . and for mysterious reasons this is a well accepted one .
CABG :Here the atherosclerotic burden is untouched by surgery . The graft can get diseased sooner or later , native vessel disease shall progress some times encroaching the ostia of distal graft site . Incidence of acute coronary syndrome following CABG is not greatly reduced for the simple reason we are not doing anything primarily to the inflamed plaques .These issues are left , to be taken care by the medical management .
* This article does not want to defame these great development in cardiology(PCI/CABG) . They have a specific role to play. CABG AND PCI remain the only option for critical lesions with limiting angina .But please remember without proper medical management ( ie Targeting the perpetuates of crime ) both PCI and CABG will be a big sham !
Final message
Avoiding the lesion or attacking the lesion is a primitive method to tackle CAD . Passifying the lesions in a slow and gentle manner, preventing further progression or regression of lesions is the only “sane” method for combating CAD . PCI and by pass surgeries can be termed as 21st century’s medical adventure sports which has limited role , in the overall control of CAD for the human kind .
And now answer this question . . .
Cardiologists attack the lesion and surgeon avoids the lesion ? Who is the winner in our fight against CAD ?
Both of them are clear losers .The winners are all those humble physicians and parmedical workers (or even the responsible lay public ) who help recognise the early forms of CAD and counsel properly to prevent it .
This is what Dean Ornish in 1991 documented in Lancet which was never considered scientific for the simple reason it has no commercial value !
Reference:
http://www.thelancet.it/journals/lancet/article/PII0140-6736(90)92230-F/fulltext
Posted in cardiac surgery, Cardiology - Clinical, Cardiology -Interventional -PCI, cardiology -Therapeutics, Cardiology -unresolved questions, cardiology- coronary care, cardiology-ethics, tagged BARI 2D, cabg, chronic toal occlusion, coroanry collateral circulation, courage trial, ethics, heart, hippocrates, home collaterals, ischemic preconditioning, living with single coronary artery, medical management of cad, myths in cabg, myths in cardiology, nature power in cardiology, oat trial, ptca vs cabg, ramus intermedius, toat on March 26, 2011| Leave a Comment »
We are at the mercy of the three major coronary arteries (LAD,LCX,RCA) that sustain our life . Their job is clear cut .It has to perfuse about 300 Grams of live bundle of energy for an average of 6-7 decades.
What are the hurdles it faces , how it overcomes these obstacles forms the fascinating story of “survival of human heart”
When coronary blood supply is confronted with a sudden compromise as in ACS , often the heart has little time to respond . Hence the damage and risk of death is more. Even here there are lots of safety mechanisms and natural lytic process that limit the loss of life to less than 30 % of all STEMIs. This implies nature protects against the death in 70 % of individuals and help them to reach hospital.*
*Among those who reach hospital , we the cardiologists try to reduce the mortality to about 6-7 % (20% without treatment ) with all those hi-tech gadgets .It is a different story and will be addressed elsewhere .
When it comes to chronic insults , the heart has a unique potential to stage long haul battles. It has many tricks under its sleeves when challenged in a slow fashion.
The main weapons are two
1. Coronary collateral circulation.
2. Ischemic preconditioning.
Here is a patient who fights his life even after all his three coronary arteries totally blocked and surviving with one of the branches of left main -Ramus intermedius .
If you have thought his RCA was the savior you are mistaken .
To every one’s surprise his RCA was awful as well !
He had angina which was troublesome but manageable .Was able to live a life with acceptable standards (Indian standard ) After the angiogram he received CABG. A turbulent post operative course ensued due to various reasons . He struggled but fully recovered . . . and ultimately reached the previous standard of life !
Final message
Modern cardiology is all about not trusting powers of nature .
But youngsters should realise the enormous potential of those invisible powers.It may sound philosophical , but please remember . . .after all . . . philosophy is nothing but search for truths. Atleast believe in them once in a while !
Posted in Best books in cardiology, Cardiology - Clinical, tagged BARI 2D, courage study, heart repair manual, MASS 2 study, medcial vs pci, pci stent, zerbini foundation mass 2 study on January 20, 2011| 1 Comment »
Manuals are not only for doctors . There are few heart maintenance manuals for patients as well.
This one from Philadelphia , is worth reading and of-course following thereafter !
Posted in Cardiology -Interventional -PCI, Cardiology -unresolved questions, Uncategorized, tagged BARI 2D, bari study, brazil mass 2, cass study, circulation journal mass 2 study brazil, courage, courage study, management of chronic stable angina, mass 1, MASS 2 10 year follow up, MASS 2 5 year follow up, mass 2 5 year folow up, mass 2 circulation, MASS 2 study, mass 2 trial, medical verses surgery verses pci, oat trail, stent or surgery study, what is MASS 2 study ?, zerbini foundation on October 28, 2010| 1 Comment »
MASS 2 study , the 10 year follow-up results are just out in circulation september 2010 .
It is a rare study , where “one to one vs one” was compared ie the effect of medical, CABG , and PCI in chronic CAD .This was done in a single centre in Brazil, between 1995 -2000 . It was followed up till 2010. Interestingly , such a study may not be possible in the future , as many of us have prematurely glorified the PCI and CABG over medical therapy . Recruiting patients for medical therapy alone is becoming a difficult job even in developing countries. Even if we recruit , huge cross over is likely to PCI, CABG for all fancy reasons.
So , in MASS 2 we have a rare treasure on hand . . . Let us give three cheers to those Brazilians who did this study , and shall carefully analyse and interpret the results.
Highlights ( According to my interpretation)
CABG tended to prevent future MI in this study . This could be most significant observation from this study ,( A revelation in fact ! ).It is against the popular belief created by CASS legacy.
What are the observed difference between MASS 2 – 5 year results , which was published in 2004 , and the 10 year follow-up , as on 2010 ?
At the end of 5 years in 2004 , the differences among the three groups were not obvious.The benefits of CABG mainly appeared after the 5th year and at 10 years it was significant.
Shortcoming of MASS 2
Intriguing thoughts
When we say medical therapy is being compared with PCI and surgery , we are actually comparing ,
Medical therapy alone
Medical therapy+ PCI
Medical therapy + CABG .
Every patient in all three groups receive statin , antiplatelet and beta blocking drugs and so on. Even though statistics would vouch for additional benefit , over and above medical therapy , in a given CABG individual , how much of the the accrued benefit is contributed by co- administering medical therapy .It is beyond reasoning even with all gimmicks of statistics.
To exactly quantify the individual benefits and efficiency of PCI , CABG and medical therapy two more study limbs are necessary .
Such a study is possible only in a virtual world ! . Decision making in favor of CABG , especially in chronic stable angina , will continue , to be difficult in the absence of refractory angina .This is due to the modest benefit of CABG , that is expected, at an additional risk , cost and expertise.
Please remember, a person can survive , only with medical therapy for > 10 years but no one can ever live with PCI or CABG for that period of time without adjunct drugs . Guess which modality is going to win the race against CAD in the long run ?
Final message
If any one asks for conclusion of MASS 2 study , don’t ever say “CABG is superior to medical therapy” . Please emphasize , “CABG + medical therapy could be , marginally superior to medical therapy alone in some of the patients with chronic stable angina. (Each word in the above statement is important !) .
So . . . MASS 2 : Is it a shot in the arm or shot in the head for CABG , we do not know !
http://circ.ahajournals.org/cgi/content/abstract/122/10/949
http://circ.ahajournals.org/cgi/content/full/122/10/949 .This study was done by Zerbini foundation Brazil
Posted in Uncategorized, tagged BARI 2D, chronci stable angina, courage study, csa, drsvenkatesan, ethics in cardiology, journal of clinical cardiology, oat study, pci vs cabg vs medcial on September 25, 2009| Leave a Comment »
Medical profession has evolved over centuries with humble discoveries by genuine researchers in the past . As we pursued science vigorously , we looked for innovations , when innovation work ( or many times shown to work !) we jump to sky , even as some of these innovations fail and crash down to earth , many times we continue to be in the clouds . This is the fundamental problem of modern medical science . When our expectations reached unrealistic proportions , we tend to lose the common sense . Prolonging life and reducing human suffering may be the ultimate aim of the medical profession , but If we try to fight the death with science and money without application of mind , our current life may become miserable ! Thats what is happening for the majority of the population of this planet . After all , death is an essential and final component of life !
Coming to the issue of CAD , in our country , a rich gets a 4th generation drug eluting stent for a insignificant asymptomatic PDA lesion , and poor fellow with left main dies without any intervention .This is fairly acceptable to this uneven world , where a rich westerner dies due to obesity related disease and a poor African dies to malnutrition .
This article is in response to my recent experience when . . . I advised
Simple life style modification & few drugs for a patient with chronic multivessel CAD , I was made to look ordinary , inferior and funny by many of the current generation cardiologists .
Further , the term optimal medical therapy(OMT) for chronic stable angina has evoked laughter in one of the interventional cardiology conferences I attended !
It is a sorry state of affairs for the whole cardiology community , a genuine scientific fact , proven by real life experience as well, is being ridiculed.
Richard Conti tells in this excellent editorial in his journal Clinical cardiology about the issue of medical management of CAD
“Respect in clinical trials”
Click here to reach the article http://www3.interscience.wiley.com/cgi-bin/fulltext/122512853/PDFSTART
A similar study which suggested exercise could be better than PCI in the recent 2009 ESC is suffering the same fate !
What if regular exercise were as good as a stent for stable angina?
Posted in Uncategorized, tagged BARI 2D, cad, chronic stable angina, cost benefit ratio, courage study, ethics in cardiology, medical management of cad, medical vs surgical, nstemi, pci vs medical, ptca vs medical, risk benefit ratio, stemi, sufferings of the rich on June 14, 2009| Leave a Comment »
Poverty is the number one killer in this world . Malnutrition, infectious diseases , poor maternal child and health are the leading killers. The life expectancy is short in many underdeveloped countries.
While the scenario is dismal for most of the poor people in this world.
Can affulence be a risk factor for poor health ?
Yes. This seemingly awkward answer is many times true. The disease acquired by affluence is labeled attractively as life style diseases . They are : Obesity, Diabetes mellitus, cardiovascular diseases, some forms of cancer etc .
How else can affluence affect the health of an individual ?
Apart from affluence being a risk factor , it is a powerful risk factor for getting inappropriate medicines, procedures & surgeries , hence the resultant adverse effects.
It is a non-established fact , in both developed and developing world , the single important predictor of a given form of treatment say revascualrisation or surgery for CAD is affordability to the treatment (Either by insurance or self payment) .Financial well being , interferes with applying valid scientific principles on them . Applying the results of the land mark trials CAD trials , COURAGE & BARI 2D are very difficult for them , which argues for simple , less costly , less glamorous medical therapy for CAD.
Example 1
A wealthy adult male who lands up for master health check up in a big state of the art hospital found to have a borderline stress test , CAG reveals a single vessel distal RCA disease .He was given an option of PCI , undergoes it , and ends up in a complication and damages his entire inferior myocardial territory.
Had he been a poor uninsured guy , he would have promptly be labeled as stable CAD and would have been on good medical therapy* and his myocardium could have been saved .
* PCI can never be an option for him , courtesy : His wealth status !
Mind you , this is not an isolated example, such affordability guided treatment modalities are rampant in the society and has a potential to make our rich and affluent a major health risk target !
Final message
Being wealthy and affluent can also be a health risk factor. While the poor suffer from lack of health care the rich many times suffer because of too much health care ! (or Is it care less , health care ?)
Coming Soon
How reccession time is a boon for human health !
Posted in Uncategorized, tagged BARI 2D, CABG vs medical, cabg vs PCI, courage study on June 11, 2009| Leave a Comment »
CAD management has been riddled with controversy for over decades. Should we revascularise all obstructive CAD we encounter ? Logic and scientific presumptions argued a strong case for it , and hence most of these patient population got some form of revascularisation .(PCI or CABG ) .
This continued for years till COURAGE study threw a shocker ! ie medical management is as good as any from revascularisation in stable angina patients. While , the cardiology community was divided over the COURAGE conclusion , here comes another shocker from the New England journal of medicine ( June 2009 ) , against revascularisation The BARI 2D trial . It shattered the ultimate myth, in diabetic CAD patients , neither PCI nor CABG has survival advantage among diabetic population .
The art of unlearning cardiology:
The beauty of evidence based medicine (EBM ) is , genuine science will ultimately prevail over pseudo science. But the danger with EBM is , it conquers the truth in it’s own time frame .In the process , EBM has to overcome so many hurdles , both natural , man made, advertent or inadvertent but ultimately truth must triumph , at least we hope it triumphs . In the intervening time , it has become absolutely essential , for the humans to suffer . The only way , mankind , can be protected from this deadly game of EBM is that , our physicians should have the inherent fore- sight to identify & ignore the “Would be doomed evidence” !
There are many such physicians in this world . . . who ignore some of the standard scientific guidelines for the betterment of their patients
Reference
Dr.S.Venkatesan MD 