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Posts Tagged ‘Gross obesity’

Obesity is a major cardio vascular risk factor.We earnestly  believe  this  by  evidence from Framingham and other studies.However , epidemiological  truths   can be dissociated from individuals .

We now understand  some  of the obese  patients fare better in CHF outcomes  apparently because of the obesity ! Even patients who undergo PCI show some benefits.This concept  is being proved in large data base of  > 200,00 patients.

Possible mechanisms

The lay man’s logic may apply (Science hidden somewhere !) Obese persons  have basically a  large heart with better cardiac reserve and  muscle mass .These hearts are  pre-conditioned to extra burden of MVO2  in it’s life time . So it  is able to tackle  hypoxia better, takes more time  to get fully exhausted .After all heart can consume fatty acids for it’s energy requirement.

Adipose tissue may also  secrete favorable anti-inflammatory  chemicals , though majority of adipocytokines are detrimental  except adiponectin .Paradoxically  the tumor necrosis factor TNF  (Same as cachectin or Interleukin 6)  is less  in obese patients .

 

Reference

obesity paradox

obesity paradox 3

obesity paradox 4

obesity paradox 3 jama archives of internal medicine

Reference

The landmark Lancet article that first raised the question of obesity paradox

http://www.ncbi.nlm.nih.gov/pubmed/16920472

http://care.diabetesjournals.org/content/36/Supplement_2/S282.full.pdf+html

Counter to the  concept

obesity pardox does it exist

http://science.howstuffworks.com/life/human-biology/obesity-paradox.htm/printable

Obesity   paradox applies in stroke too ! This study (TEMPIS) from Berlin  Germany  suggest controversially though

 

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The other day my fellow got a call  from surgical ward for emergency ECG opinion for a  suspected Inferior MI .It later turned out to be an acute cholecystitis.

One of the important  anatomical mis-perception  among physicians ,  is to consider  inferior, posterior  and diaphragmatic surface  of heart  as separate entities .They are all  closely linked.In fact, they  more often  mean  the same  anatomical zones !

Heart is a dynamic suspended organ within the middle mediastinum .It  can assume a vertical or horizontal position due to number of surrounding anatomical  and physiological factors. (Diaphragm, Lung , being  important ).The ratio of intra thoracic vs Intra abdominal  volume  &  pressure determine whether the posterior surface of the heart is going to face the back of chest  or simply sit and  rest on the diaphragm .We know a horizontal heart is likely to inscribe q waves  in inferior leads .

acute abdomen diaphragm inferior wall mi cholecystitis pacreatitis

Courtesy : Basic image source from digitallab3d

The  diaphragm can be termed as an  anatomical causeway , that isolates   thorax  from the  abdominal  cavity .Close encounters between the organs separated by this delicate biological  membrane is  always possible .This is especially true for electrical signals  which show little  respect for anatomical barriers .

This is the reason there are too  many abdominal conditions that mimic  inferior MI during a painful  emergency (and vice versa  when inferior  MI mimics  acute abdomen .) In  our  department , we   have witnessed  the following conditions mimicking Infero-posterior ACS.

  1. Acute ascites with polyserositis
  2. Gross obesity with APD
  3. Posterior fat pad ( Necrosis ?)
  4. Thickened pericardium
  5. Minimal posterior pericardial effusion
  6. Diaphragmatic pleurits
  7. Esophageal spasm
  8. Fundal air  trapping and ballooning after a heavy meal !
  9. Acute duodenal ulcer perforation ( With gas under diapharam causing q waves)
  10. Acute cholecystits
  11. Diphragmatic hernia
  12. Achalasia cardia
  13. Pancreatitis

Final message

Do not rush to make a diagnosis of inferior wall MI when  you encounter inferior q waves  with  or without ST /T changes , especially  when the symptoms are atypical .

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