Posts Tagged ‘drsvenkatesn’

Human body is a bundle of mystery.   In an  average  life span of human beings,   millions of   afflictions come and go . Most are benign . Our body has a  full-fledged defense ministry    armed with sufficient weaponry in the form of , immune cells, thousands of regulating enzymes, hormones ,  cell service molecules  etc  .It can tackle most of  the ailments our body encounters  with out a doctors help (Jungle animals rarely die of disease!)  .

Of course , the body  needs  external help  when it’s  intrinsic resources fail . There are few   serious disorders that has to be intervened .However ,a big  fraction of them  will   die  in spite of whatever we do .

Is it not  fascinating to know more than  100s  of chemicals  act day in, and  day out ,  to  prevent our  blood  from clotting and keep it flowing .  If only the natural lytic mechanism fails  for an hour , and  create a  vascular  chaos   we will realise  importance of it !

Even as we debate appropriateness of medical care  in this  21st century   here is startling scenario ,

When a child  presents  with physiological hypertrophy of lymphoid tissue  , as their body begin to  learn and record the micro biological mysteries  of our environment  , it is  often “cross labeled ” as  tonsillitis  or appendicitis and  end up in surgical tables.

This article just released  in  European heart journal , tells us ,  how the rampant use of appendectomy and tonsillectomy in the early child hood  may make them susceptible for CAD in later age group.

The role of medical professionals is identify the trivia ! and prevent unnecessary interventions.

Unfortunately  or (Should I say dangerously)   many of  the   professionals  understood it  in a diagonally  opposite manner . Identify the trivia ,  instill fear in our patients  and intervene ,   in the process injure  our great biological system.This is also applicable to many cardiac  interventions.

Final message

Heavens sake ,  youngsters  , please  remember  , medical  profession is all about removing suffering from patients  . Do not fish out “non -existing” illness from your patients  body !   Let me remind you ,  professional approach means  , whatever you do it should be in the  interest of our patients . The moment  you deviate ,  you cease to be professional .

Also realise  ,  good   intentions can never be an excuse for  inappropriateness !



Read Full Post »


 Rescue thrombolysis in acute   myocardial   Infarction  

 *Venkatesan sangareddi ,Madras medical college,Chennai.India



   Back ground  Failed thrombolysisin acute myocardial infarction occurs in 30-40% of patients. The incidence of progressive pathological remodelling and cardiac failure is high in these patients. The approach to the patient with failed thrombolysis is generally considered to be catheter based and the outcome is not clear. Bleeding can be troublesome in patients, taken for interventional procedures in the immediate post thrombolytic state. The option of repeat thrombolysis has not been studied widely and is not popular among cardiologists.

Methods:We present our experience with six patients (Age 42-56, M-6, F-0) who were thrombolysed for failed first thrombolysis. All had anterior MI and had received either urokinse or streptokinase (between four to nine hours) after the onset of chest pain. All of them had persistent ST elevation, angina not responsive to maximal doses of IV NTG and beta blockers. The initial thrombolysis was deemed to have failed. Repeat thrombolysis with streptokinase (15 lakhs) was given between 16 and 24 th hour. The clinical outcome following the second thrombolysis was rewarding. It relieved the angina, ST segment elevation came down by 50% and coronary angiogram done at 2-4 weeks showed complete IRA patency in four out of six patients. The factors responsible for failed thrombolysis is complex and multifactorial. A logical explanation from the fundamentals of clinical pharmacology would suggest that a common cause of failure of any drug is due to a inadequate first dose.

Conclusion :We conclude that repeat (Rescue) thrombolysis can be an effective medical intervention for failed thrombolysis in AMI.

Personal perspective                  

                             Repeat  thrombolysis for failed ( initial ) thrombolysis  is still   considered  a  fantasy treatment  by most of the cardiologists !  The utility and efficacy of this modality of  treatment (Rescue thrombolyis ) , will never be known to humanity , as planning  such a  study , in a large population  would  promptly be  called unethical by the modern day cardiologists.

                     While a cathlab based cardiologist  take on the lesion head on with multiple attempts  , it is an irony , poor  thrombolytic agents are given only one shot  and if failed in the first attempt,  it is doomed to be a  failure for ever.Currently,  the incidence of  failed thromolysis could be up to a whooping 50 %  .There has not been much scientific initiative  to enhance the efficacy of these drugs.

                            Common sense and logic would suggest it  is the  inadequate first dose ,  improper delivery , pharmacokinetics is   the major cause of failure of action of  a drug in clinical therapeutics.

If the first  dose is not working ,  always think about another  incremental dose if found safe to administer.

Can we increase the dose of thrombolytic agents  as we like ? Will it not increase the bleeding risk to dangerous levels ?

This is a clinical trial  question.

  • In patients with prosthetic valve thrombosis and acute pulmonary embolism we have safety data of administering of  1 lakh units for an hour for up to 48 hours.

Can  the same regimen be tried in STEMI if the initial thrombolysis has  failed  and emergency intervention is not possible  ?

Logic would say yes . Unfortunately we can’t go with logic alone in medicine .We need scientific data ( with or without logic ! ).But now ,  as we realise common sense is also a integral part of therapeutics  It is called as level 3 evidence / expert consensus by AHA/ACC .

Applying  mind , to all relevant issues ,  continuous streptokinase infusion 1 lakh/hour for 24-48 hours in patients with failed thrombolysis can indeed be an option,  especially when the patient is sinking and  no immediate catheter based intervention  possible .This study question is open to all researchers , and may be tested in a scientific setting if feasible.

Read Full Post »