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Posts Tagged ‘cardiology’

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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There are many  cardiology journals we read , trust , and celebrate  . . .

Many of us are not aware of   few other excellent journals

This is one is different

It is  from  Scandinavia &  deserves a special status.

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As the name suggests   dilated cardiomyopathy  would imply  cardiac chambers will dilate , at least some time in the course of the disease .It can be minimal, mild or massive. A new entity called  non dilated cardiomyopathy is also gaining wider acceptance . (That will be dealt seperately )

Logic would suggest , the first chamber to dilate in DCM  should be the left ventricle because it is  facing the direct load of systemic blood. But we also know , whenever  LV is stressed , left atrium comes to it’s assistance .

Left atrium does this    by total self sacrifice ( by all  means!)  increases  it’s  force of contraction, elevating it’s  mean pressure or even increasing it’s rate (AF) .

Like most  other critical questions in cardiology  ,  the factors that determine LV dilatation in DCM ,  is  also poorly understood !

  1. Is it the after load ?
  2. Is it the  muscle mass ? or it’s turgid  or flabbiness ?
  3. Is it the interstitial integrity?
  4. Is it the blood volume ?(LVEDV ,  LV residual volume )

When the issue is complex , it is  usual  to  make the   the unknown  genetic defects  ,  the scapegoat !

As of now the most important determinant of LV dilatation  could be  the behavior of the desmins, the gap junctions and myosins the titins etc

If  the LV of a DCM patient  refuses  or  resists  dilatation what  might happen ? Is it good or bad for the patient ?

Here is a catch .  A  LV  that does not dilate  obviously should be  be good for the patient  is in’t ? Medicine is not that simple.

When   LV  fails to  dilate  it means it has become  too  stiff and rigid    and pass on the  burden to  to LA which  faces the music. And in the process it dilates.This is the reason , we  observe  diastolic dysfunction in vast number of DCM patients.( Currently it is estimated > 75% DCM will have significant diastolic dysfunction )

So , now we can imagine how complex the sequence of hemodynamic stress in DCM that determine the chamber enlargement.( RA, RV  dimension in DCM is a separate issue !)

So now answer this question :  Which chamber dilates first in DCM ?

  1. Left ventricle
  2. Left Atrium
  3. Any of the above
  4. Both of the above dilate simultaneously

The answer must be 3 .

Why  recognising this sequence of  chamber enlargement  in DCM   is important ?

  • It gives us an opportunity to assess the dominant mechanism of LV dysfunction.There are reports , where some  DCMs  have more diastolic dysfunction than systolic dysfunction  .This will have important therapeutic implication.Further , many of the infiltrative   disorders of LV can have features of both DCM & RCM .
  • When a RCM begins to dilate it is usually  a harbinger of terminal heart failure. But,  it need not be always true .  A small restrictive LV  , when  dilates ,   may acquire a  slightly improved diastolic properties , as the  LV becomes more placid . And ,  if it happens the LA size may regress.
  • The role of LV restriction devices like, Acron mesh, Dor procedure, plication  in refractory  DCM is not well defined. All these   modalities actually  adds  a small dose of diastolic dysfunction in these patients who have grossly dilated ventricles. This fact is  very important  , as presence of any preexisting  significant diastolic dysfunction in DCM makes  the role of LV restrictive devices and surgery a big question mark !

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  • It is going to be the era of non invasive imaging  in  cardiovascular  diseases .Future looks very exciting
  • We have now ability to slice the heart 356 times a second !
  • Image resolutions are getting sharper .
  • The only worry ( Of course a major one !)  would be the radiation , that has to be addressed .

Now we have a dedicated journal for cardiovascular CT scan .

Does it surprise you  ?   For me  . . . It  is  !

Link to the current journal page . Get updated  !

http://www.journalofcardiovascularct.com/current

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STEMI is the major cardiac emergency .The acute mortality is about 20% (Both prehospital and in CCU )  STEMI occurs whenever a coronary artery is occluded  suddenly in toto .We traditionally believe that STEMI occurs only in the major  epicardial vessels. (LAD/LCX/RCA .)

The total length of   coronary tree is much  longer than the length of the three vessels put together.The diagonals , the ramus, the OMs ,the septals  run for varied  distances. The caliber of these vessels can be quite large.It is estimated the diameter  of   first diagonal ,   the first OM  or the   ramus can be as big as LAD proper in 30% of CAD population . Law of statistics tells us sudden occlusion can occur any where in the coronary tree in  ACS prone patients.

What is the real incidence of side branch STEMI ?

The  dogmatic answer is   ” We do not know”

Will we ever know ?

How will a  Diagonal / OM /Ramus   or PDA   STEMI  behave ?

It is surprising this question is not addressed by us  for  so long . Some may even question  the existence of  such an entity(Side branch STEMI ). This is most likely ,  reflect our ignorance on the issue . We know  bifurcation lesions at  the   side branch  origin is very common . Further , thrombus can migrate from a main stem to a side  branch  immediately after formation .

Clinical presentation of side branch STEMI

  • Acute presentation is identical  to  that of a major main branch STEMI . The  pain  can be severe , the primary arrhythmic threat is real . Ischemic VF , once initiated does not  modify it’s  character  according to the  quantum of insult .
  • ECG is the major variable.  You ,  don’t expect gross , ST elevation in many leads as one would see in LAD MI /RCA MI.
  • The  age old teaching that  an ECG can be entirely normal in acute MI ,  could actually imply the side branch STEMIs . When a small D2 or D3  gets occluded the ECG may not pick up the ST shifts .
  • The commonest site of atherosclerosis apart from proximal LAD is the bifurcation of PDA in RCA.  STEMI due to PDA occlusion is  the most  difficult thing to recognise. Many of them have very subtle ECG and clinical findings.
  • There has been reports of acute complete heart blocks with isolated AV nodal infarcts. Here sudden cardiac deaths are reported

It is very much possible ,  many of the  side branch  MIs   may be wrongly diagnosed as unstable angina by us , for the simple reason the myocardial necrosis is not large enough to produce ST elevation .They may actually respond to thrombolysis ,  as there is total occlusion in the coronary artery.  Since, they do not manifest ST elevation there is a lost opportunity here  . This ,   probably  is the population in TIMI 3B  trial that showed some ( statistically   insignificant ) benefit for   thrombolysis in NSTEMI.

Is primary PCI justified in side branch STEMI ?

May not be . The chances of side branch STEMI   to result in LV dysfunction and progressive adverse remodeling is considerably less . The hazards of primary PCI for exceeds the risks of  MI  due to a   septal  or diagonal branch lesion .

Final message

  • STEMI due to   branch coronary artery  occlusion is a less recognised entity among ACS.
  • Cardiologists ,  need to  look into this  issue with little more seriousness as it could represent a new  intermediate risk  category   among the much  flaunted  classification  of  acute coronary syndrome. Triaging and risk stratification of  ACS  needs  a revamp.
  • It is possible  many of the UA  patients  ,  may in fact represent total occlusion of side branches.
  • There is a  definite  case  for showing less aggression in these patient  subsets  ,  provided we are sure  about  the location of lesion.

Counter point

* Identifying  a side branch STEMI with confidence  may be very difficult at bed side in an emergency . Implication of wrongly  calling a STEMI  as benign  can be  dangerous . So it will be argued ,  one need not do this exercise of traiging STEMI into main branch or side branch .

Image courtesey

Coronary tree : http://www.southcharlestoncardiology.com/64cta.html

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When we get contaminated with excess  knowledge , we lose our ability to think !   &  Common sense is the casuality . . .

Human beings differ from other forms of life by their sixth sense . Our planet is  few billion years old . Life came into existence over a million years ago .Our life has  evolved over many  thousands of years .The average life span of  human race   is  75 years . We need to realise , our life constitutes  only a fraction of our planet’s life (<.0000001% ) . A  may fly , which lives a life of  less than a  day ,   does it in style  , looking for the light  throughout  the night ,  says good bye ,  to earth by morning  leaving  it  unharmed . Actually ,  in terms of time , the life of the fly is  just a  fraction less than  human life span , when compared  to  our planet’s life !

When these children are  longing for food , some of  earthly humans go to  spend millions for  obesity surgery ! That is  the progress of knowledge driven society . . .

It is  extremely common to  experience the following  scenario  in any corporate hospitals of  both developing and developed country .A   uninsured  or half insured !  person is  refused entry into a hospital even for an  emergency care  while a wealthy person is lying comfortably watching TV in a five star suit of the same hospital after an inappropriate coronary angioplasty for  an   innocuous   lesion of his heart !

The irony is ,  in this short span  of  earthly life  ,  we want to prevail over the nature and conquer the planet . God is watching  this human  behavior silently . And he is smiling  . . .

With all our knowledge base ,  modern science  have done the maximum possible  damage to our  planet  .We have made many lives extinct. If  we  tend to  think , with the help of  6th sense  we can become immortal , it would be the ultimate foolishness. When every one of us ,  is  obsessed with our own  health  , we are deaf  to  the silent cries  of  our beloved planet earth .

Now , all of a sudden we realise all the accumulated knowledge & development has actually worked against us. We find our knowledge is dissociating our thoughts   and now , we are fighting  vigorously  over acquiring the rights to damage our planet  .

So it seems ,  the more we learn,  less wisdom we have  ! We may need to  learn important lessons  of living  from  all those  species   which  do not  boast to have  the  6th sense  !

Read a related article , excellent one published in British medical journal  nearly 2 decades ago

Knowledge disease BMJ. 1993 December 18; 307(6919): 1578.

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Modern era of cardiology aims to treat ACS  as and when it develops .That is , as soon as the vulnerable plaque ruptures or a thrombus  blocks the victim’s coronary artery.

But this can be achieved only if the patient reacts to this event.We know 20% of ACS can be totally silent. Some produce very vague symptoms especially in elderly and diabetics. ECG and enzyme changes may help us in patients who do not have clear symptoms.There are variety of markers available for STEMI & UNSTEMI.(CPK-MB, Troponin T , myoglobin etc) Now we are working at finding a marker for ischemia without necrosis. Ischemia modified albumin is one such molecule that is showing promise.

The ER department world over have vigorous screening protocols to diagnose ACS  for  the patients with chest pain. There are thousands of triaging protocol in the  emergency management of chest pain.In spite of  the highest awareness and availability of  scientific expertise , knowledge base the error rate of diagnosing  ACS  stands at an astonishing 58%.  This may seem odd , but this is what  this land mark article in NEJM tell us  (Data from Boston , Milwaukee etc).

Out of 10500 patients with suspected ACS. Only 17 % had real ACS.  55% were admitted initially as ACS  later turned out to be non cardiac .This may seem  acceptable for many  even if it is  an act of unnecessary admission and investigation. It gives us , a sense of satisfaction for not missing a diagnosis of ACS. But it has it’s own risk of complication arising out of unnecessary investigations.It is a chain reaction of  suspicion that  may end up in a coronary angiogram in many ! .It is also a well recognised fact these patients    spend  atleast an average of  2 days  to get rid of the ACS tag over their  necks .

Experience has taught us  simple presence of a human being as a patient within an  ICU ( however short the stay  may be ) can be a health hazard and risk .  This  55 % error ,  which does exactly  this to  our  patients with chest pain  who reach the ER  never bothers us  This is because  we feel credited both academically as well as financially .

In the same study 2.3 %  (About 25 patients) with true ACS  were sent home  after a missed  diagnosis . Paradoxically  this 2.3%  has worried the medical professionals too much . . . This happens  ,  even as we  do not have proper data on  how many of them had a real adverse event after a missed  ACS.

So the message here is even in best centres both missed and wrong diagnosis are  rampant. while wrong diagnosis (25 fold more here  )  is easily accepted by the medical community .We can justify  this as a screening camp for ACS  ,  akin to arresting  a group of suspected  criminals in a  preventive raid ,  later releasing for want of evidence.

In the morals of  criminal judiciary  , it is often said one can afford to  lose  a real offender from the clutches of law  , but a  innocent should  never be punished in any circumstance .

In medical parlance this  goes something like this  . . . Thousand patients shall die because of his or her illness but not even a single healthy person should die due to unnecessary treatment.

The above thoughts  were in response to  the excellent original article on missed diagnosis  of ACS from NEJM.  http://content.nejm.org/cgi/content/full/342/16/1163?ijkey=652d8337709a8bf84c813f4c9d685863ee053162

Final message : (Sorry for the  lengthy message !)

Can we afford to miss an  ACS in emergency room ?

“Definitely not” . . .but do we succeed in that ?  The answer is same “definitely not “

When we are able to accept with pride every time  we make  a  wrong diagnosis of  ACS  in perfectly normal people , It may to provocative to say  we can  also  afford  to do  the same  when we occasionally   miss a  diagnosis of ACS  as well .  Law of statistics dictates for every correct diagnosis made there is many fold number of wrong or missed diagnosis takes place. May be , reducing that is the only aim of medicine.

We need to realise  with even with a 55% of false positive initial  diagnosis  2%  real ACS  escape net !The only  fool proof method  for  not missing  ,  even a single case of ACS   is to label every patient with chest pain as ACS .

In this vexing  issue , we should realise  , in field of  medical decision  making ,  errors  due to acts of commission  ( Making an  inappropriate drug/procedure /surgery  is easily accepted by medical professionals as well as   the court of law !) . But acts of omission ,   like missing a diagnosis or failure to prescribe  a  drug or perform a procedure  is rarely accepted   and  is  considered   a great negligence and  bring intense guilty feeling among the physicians .

This  perception is definitely  not warranted in this  greatest profession  of glorious uncertainties ! Both acts of commission and omission  cause significant damage to  patients . In this modern era  ,  we have clear  statistics  that   reveal ,  acts of commission  leads far ahead over it’ s counterpart in injuring our people .

Hippocrates got it right over 2000 years  ago .  First let us do no harm  . . .

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