I was recently asked to suggest a topic for debate on STEMI in a major Indian cardiology conference. I wished , this is what we should be mulling over, with a set of virtual guest lectures and special invitees from heaven ! Plenary session : State of the Art STEMI care Time : 11.AM , Speaker : Dr Hippocrates Topic : Aren’t we erring on either side of the Noble profession ? Moderator: Dr. William Osler Chairperson : Dr .Harvey Cushings, Dr,Sir Thomas Lewis ,Dr Paul Wood , Excerpts : “While , vast number of our country-men’s culprit artery doesn’t even get that mandatory Aspirin on time . . . an urban rich man’s distal non-culprit artery is decorated with a fancy bio-vascular scaffold making that innocuous lesion vulnerable in the process as well ! Aren’t we erring on either side in the Noble profession ?
Posts Tagged ‘ethics in cardiology’
As I was mulling about the misplaced priorities in modern health delivery , today’s (25-01-2015) edition of “The Hindu” , India’s National newspaper carries an exact article by Dr B.M.Hegde .
No doubt ,his articles are constantly criticized by the scientific community for the simple reason, he is forcibly trying to add wisdom to science !
Posted in Cardiology -Therapeutic dilemma, cardiology -Therapeutics, Cardiology -unresolved questions, tagged csa, ethics in cardiology, interventional cardiology, management of pci, pci ptca in a nutshell, priamry pci vs thrombolysis, stemi vs nstemi on October 3, 2014 | 1 Comment »
Your clock starts now !
Chronic stable angina : Most can be effectively managed by optimal /intensive medicines and life style Interventions .About 10% will require PCI/CABG.
ACS – STEMI: Primarily managed with rapid and competent pre-hospital care with prompt thrombolysis in or out of hospital .Patients with large STEMI who develop complications (Again about 10 %) require PCI and few additional lives can be saved.
ACS-NSTEMI : This is the group that demand an important role for PCI . All true high risk UA/NSTEMI patients should receive urgent coronary angiogram and critical lesions should either be stented or sent for CABG (If the lesions are multiple and complex ) The field of interventional cardiology is expected to play a major role in this category of patients for the simple reason , we not only give dramatic relief from angina and also prevent a potentially a huge MI that is waiting to happen !
* It is vital to emphasise the “Aim and objective” in NSTEMI management is critically different from other two. We know , in CSA the aim is to give relief symptoms and improve excercise capacity . Both PCI/CABG are unlikely to prevent a future MI in CSA..In STEMI it has already occurred .The aim is to salvage myocardium and prevent future events. While PCI can do the former , it can’t do the later . In STEMI scenerio ,we have very good alternate modality called thrombolysis which can easily beat the pPCI in , cost , availability and time (and hence efficiency as well in most countries !)
The above suggestion is too simplified ,generalized , misleading , and unscientific, should strongly be disagreed. For those people who disagree , I provide an alternate scheme .It is ultra short ,comes in 5 lines .Very practical and scientific too !
In any patient , who is suspected to have either acute or chronic coronary syndromes ,take them to the cath lab in an urgent or semi urgent fashion .Do an angiogram and stent all lesions that you feel important . If stenting is not possible manage with optimal medicines and /or send them to the surgeons.
The essence of catheter based coronary care is simple.We complicate it. To understand this concept 100’s of cardiology journals and as many conferences and infinite number of books are churned out every year !
Posted in bio ethics, Cardiology - Clinical, Cardiology -Pacemakers and ICD, cardiology -Therapeutics, Cardiology -unresolved questions, medical quotes, tagged ethics in cardiology, thromolysis vs priamry pci, vvi vs ddd pacemaker on December 29, 2013 | Leave a Comment »
Following are revered facts . . . among the “Guardians of Cardiology” !
- Primary PCI is a greatest innovation in modern day cardiology .Without this modality most STEMI patients will buy Instant tickets to grave yard !
- A cardiologist who intends to thrombolyse a STEMI is considered as a low quality cardiologist .
- Streptokinase should have no place in the crash carts of modern coronary care units.
- There is nothing called “Time window” for rescue angioplasty.
- VVI pacemaker will convert an electrical problem of heart block into a mechanical one by depressing LV function .
- Digoxin is an obsolete drug even in well established cardiac failure with dilated heart.
- Beta blockers not only fail to control blood pressure smoothly , it often converts a hypertensive individual into a unhealthy one by it’s prohibitive side effects !
Posted in Cardiology -Interventional -PCI, cath lab tips and tricks, Infrequently asked questions in cardiology (iFAQs), Venkat quotes, tagged acc/aha criteria for coronary angiogram, appropriate coronary angiogram, can we manage cad without coronary angiogram ?, cardiologist behaviour, coronary angiogram in chronic stable angina, ethics in cardiology, hippocrtes, inappropriate coronary angiogram, Indication for coronary angiogram, indications for coronary angiogram, waht is the indication for coronary angiogram ?, what is inappropriate coronary angiogram ?, when do you do coronary angiogram ? on October 31, 2013 | Leave a Comment »
CAD is growing as an epidemic in most parts of the globe. It is a major determinant of health status of any country .Great strides in diagnostic, treatment modalities of CAD have been made in the last few decades. Still , the core principle of management of CAD resides in simple things like risk factor reduction / optimization , life style changes and few essential cardio-protective medications Aspirin, beta blockers and statins.
However , modern scientists have made a firm statement that knowing the coronary anatomy before starting the treatment is the only scientific approach . It is a huge assumption !
Is it practical ? or is it really required ?
CAD can be managed by means of medicines , interventions or surgery. Revascularisation is required only for those , who have critical , symptomatic lesions.
It is estimated , in only a fraction of CAD patients , we would require to know the anatomy . We have set criteria to choose patients for CAG , who are likely to have critical lesions.Physicians are trained for that elusive wisdom to choose such patients .Standard text books do mention clear-cut Indications for doing CAGs. Unfortunately , it is least respected and followed .
Cardiac physicians who would boast they can’t treat a CAD without knowing the coronary anatomy are clinically handicapped or poorly trained.
I am afraid such a class of cardiologists are rapidly breeding in the country side. They are encouraged to attend CME on clinical cardiology and basic principles of clinical decision-making .
We can’t keep on doing CAGs like ECG for every episode of angina . In fact treating CAD without knowing the anatomy remains (And it should be ) the dominant theme contemporary clinical practice . CAG is multi -edged sword
The most important side effect of routine coronary angiogram is , it ends up in infinite number of inappropriate interventions !
I think , we should pray in Hippocratic temples for sufficient wisdom to choose our patients. We can also learn it from Neurologists , they somehow manage most forms of cerebrovascular diseases (scientifically too ! ) without asking for angiogram of circle of Willis ! Mind you. . . brain is equally a vital organ !
It needn’t be a crime to treat CAD* without knowing the coronary anatomy. Rather . . . it would be so , to ask for CAG indiscriminately , in every episode of chest pain , without applying clinical sense !
* Emergencies included.
Posted in bio ethics, cardiology journal club, Cardiology quotes, tagged ethics in cardiology, ethics in medicine, evidence based cardiology, guidelines in cardiology, guidelines in medicine, principles of medicine on October 20, 2013 | Leave a Comment »
The current fad called EBM has lots of lacunae. Though evidence based approach is considered the ultimate journey towards truth ,lot of non academic factors contaminate it .In it’s current form , it is difficult to comprehend it.
This is an attempt to decode the mystery of EBM expressed in a simplified lay person’s term .They are the ones from whom we learn medicine. They are our teachers in the true sense.
And . . . the Genius approach to EBM for comparison
Posted in Cardiologt women, Cardiology -Interventional -PCI, cardiology -Therapeutics, Cardiology -unresolved questions, cardiology- coronary care, Cardiology-Coronary artery disese, Uncategorized, tagged acc/aha guidelines for stemi, affluence based cardiology, ethics in cardiology, how to manage stemi, inappropriate cardiac care, indication for pci following stemi, indications for coronary angiogram following stemi, maangement strategies following stemi, patient weath and health, relationship between wealth and health, stemi management protocol on November 13, 2011 | Leave a Comment »
What is the most important factor that will decide the revascularsation following a STEMI ?
- Patient’s symptoms
- Residual Ischemia documented by stress test /Perfusion scan
- Presence of significant LV dysfunction
- Coronary anatomy and lesion profile
- Wealth of the patient (Insurance limit and other financial resources )
Response 2 is academically correct , but practically and politically response 5 would be the right one for most cardiologists . At any given day , affordability and availability of PCI will prevail over all other factors .
Image courtesey : Jupeter images
What is the height of inappropriateness in modern cardiac care ?
This world will never forgive the medical profession , if they do not fight against grossly inappropriate medical care system especially in the life saving situations .While one cardiologist just watches a left main disease patient with unstable angina die peacefully in a Govt institution , while another patient with asymptomatic distal PDA lesion gets a 3rd generation drug eluting stent in a nearby corporate hospital !
Please note : Harm is the ultimate outcome in both rich and poor.One suffers with non availability while the other is the victim of affordability .