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Posts Tagged ‘medical management of cad’

How do you tackle this man’s RCA ?

Posted in Uncategorized, tagged , , , , on November 3, 2011| 2 Comments »

This is an  RCA of   a  patient who had chronic stable angina  , class 2  with moderate anti anginal medication.

What shall we do ?

  1. The RCA needs  multiple stenting
  2. Multiple plain balloon angioplasty
  3. CABG to PDA
  4. No intervention ?
  5. It depends upon status of LAD  and LCX

The correct response would be 5

Without knowing  the status LAD and LCX . . .  RCA should not be touched . Further,  the concept of tackling  the  coronary artery  by itself  is   fundamentally wrong !  We are supposed to tackle patient’s symptom ,   reduce future risk of  events and   not merely  their coronary artey !

His LAD and LCX was near normal. In the weekly  cath   meet   PCI to mid RCA  covering  the critical segment was  strongly debated but  lost a close race .

The final decision was to allow the patient to continue   intensified   medical management (Statin 80mg /Metoprolol 100mg ) . He is comfortable with that .

Medical management  in a tight  single vessel disease  can never be digested by  any   Interventional cardiologist  whatever   may be  the guidelines !

Final  message

Do not decide PCI on the basis of   how ugly a coronary artery looks , rather spend some time on true  symptomatology ,  optimise baseline therapy  and re assess risk profile

One learned dictum is ,  do not  meddle a RCA ,  however severe the lesion may be   if  LAD and LCX are fine.*

*This  rule is not applicable in ACS

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Living with a single coronary artery : Let us trust the nature atleast once in a while !

Posted in cardiac surgery, Cardiology - Clinical, Cardiology -Interventional -PCI, cardiology -Therapeutics, Cardiology -unresolved questions, cardiology- coronary care, cardiology-ethics, tagged , , , , , , , , , , , , , , , , , , 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 !

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Land mark reviews in cardiology : How to choose an ideal coronary intervention in unstable angina ?

Posted in Cardiology - Clinical, Cardiology -Interventional -PCI, cardiology -Therapeutics, cardiology journals, cardiology- coronary care, Cardiology-Coronary artery disese, Cardiology-Land mark studies, tagged , , , , , , , , , , , , , , on December 18, 2010| Leave a Comment »

Cleveland clinic is a leading centre for cardiac care .Major technological breakthrough occurs from this institute than any other place. Thousands of articles come out every year. Some articles , get global attention and make  a huge impact. These are usually related to a new hi- tech modality like CRT devices or percutaneous aortic valve deployment etc ,etc.

                                                Some articles , which are very important  may not get the due  attention . Journal editorial boards often  have a scorecard called impact factor .That is ,   how  a  journal  is  impacting the practice habits of  medical professionals . Ideally we need to have to grade individual   articles with impact factor .Many articles may not have any significant  impact  however good the impact factor of the journal.

Here is an article,  which excellently depicts the principles of management of ACS.  It was published in 2003 JACC,  by Steven Nissen  from Cleveland,  Ohio .It deserves more attention . Every cardiologist , involved in ACS management should read this, especially the interventionist.

Link to article placed her with courtesey of JACC

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Sufferings of rich in modern medicare !

Posted in Uncategorized, tagged , , , , , , , , , , , , , 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 .

coronary angiogram cardiology

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  !

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