Here is a video recipe !
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It is often said life is a cycle , time machine rolls without rest and reach the same point again and again . This is applicable for the knowledge cycle as well .
We live a life , which is infact a “fraction of a time”(<100years) when we consider the evolution of life in our planet for over 4 million years.
Man has survived and succumbed to various natural and self inflicted diseases & disasters. Currently, in this brief phase of life , CAD is the major epidemic , that confronts modern man.It determines the ultimate life expectancy . The fact that , CAD is a new age disease and it was not this rampant , in our ancestors is well known .The disease has evolved with man’s pursuit for knowledge and wealth.
A simple example of how the management of CAD over 50 years will help assess the importance of “Time in medical therapeutics”
- 1960s: Life style modification and Medical therapy is the standard of care in all stable chronic CAD The fact is medical and lifestyle management remained the only choice in this period as other options were not available. (Absence of choice was a blessing as we subsequently realised ! read further )
- The medical world started looking for options to manage CAD.
- 1970s : CABG was a major innovation for limiting angina .
- 1980s: Plain balloon angioplasty a revolution in the management of CAD.
- 1990s: Stent scaffolding of the coronaries was a great add on .Stent was too dangerous for routine use was to be used only in bail out situations
- Mid 1990s : Stents reduced restenosis. Stents are the greatest revolution for CAD management.Avoiding stent in a PCI is unethical , stents should be liberally used. Every PCI should be followed by stent.
- Stents have potential complication so a good luminal dilatation with stent like result (SLR) was preferred so that we can avoid stent related complications.
- 2000s: Simple bare metal stents are not enough .It also has significant restenosis.
- 2002: BMS are too notorius for restenosis and may be dangerous to use
- 2004 : Drug eluting stents are god’s gift to mankind.It eliminates restenosis by 100% .
- 2006: Drug eluting stents not only eliminates restenosis it eliminates many patients suddenly by subacute stent thrombosis
- 2007 : The drug is not the culprit in DES it is tha non bio erodable polymer that causes stent thrombosis. Polymer free DES or biodegradable stent , for temporary scaffolding of the coronary artery (Poly lactic acid ) are likely to be the standard of care .
- All stents are potentially dangerous for the simple reason any metal within the coronary artery has a potential for acute occlusion.In chronic CAD it is not at all necessary to open the occluded coronary arteries , unless CAD is severely symptomatic in spite of best medical therapy.
- 2007: Medical management is superior to PCI in most of the situations in chronic CAD .(COURAGE study ) .Avoid PCI whenever possible.
- 2009 :The fundamental principle of CAD management remain unaltered. Life style modification, regular exercise , risk factor reduction, optimal doses of anti anginal drug, statins and aspirin is the time tested recipe for effective management of CAD .
So the CAD therapeutic journey found it’s true destination , where it started in 1960s.
Every new option of therapy must be tested against every past option .There are other reverse cycles in cardiology that includes the role of diuretics in SHT , beta blockers in CHF etc. It is ironical , we are in the era of rediscovering common sense with sophisticated research methodology .What our ancestors know centuries ago , is perceived to be great scientific breakthroughs . It takes a pan continental , triple blinded randomised trial to prove physical activity is good for the heart .(INTERHEART , MONICA studies etc) .
Medical profession is bound to experience hard times in the decades to come , unless we constantly look back in time and “constantly scruinise” the so called scientific breakthroughs and look for genuine treasures for a great future !
Common sense protects more humans than modern science and it comes free of cost too . . .
The diastolic mitral filling pattern has been named and graded umpteen times in the last decade. We believe it has reached some semblance of clarity.I beg to differ.
There need to be one more grade between Grade 1 and grade 2 .Grade 1 is defined as A velocity > E velocity . This is the commonest abnormal pattern and is often man made.We can’t help it . We have to report it anyway. Significant number of elderly show this pattern without any pathology. It simply represents augmented atrial contribution at times of apparent ventricular stress .
I wish a good chunk of grade 1 pattern , especially in elderly or during tachycardia should be labelled as physiological grade 1 pattern (or simply as normal variant ) . However I would prefer it to be named as pseudo abnormal pattern* !
* In my experience , currently medicine is taught in a complex manner .Facts that are told in simple terms are rejected straightaway . It would seem,too much clarity is not good for science So,let us get confused one more time for the sake of our patients !
Posted in Cardiology -unresolved questions, Diastolic dysfunction, Echocardiography - LV dysfunction | Tagged doppler lv diastolic filling, grading of diastolic dysfunction, pseudo abnormal lv filling, pseudo normal filling | Leave a Comment »
Coronary artery disease (CAD) is man-kind’s greatest threat in modern times.CAD ,diabetes ,Hypertension, obesity, mental illness has become an epidemic even among the young !
There is a simple solution for lifestyle diseases !
Just . . . Remove style from your life !
Instead . . . try to live like these Tibetian villagers
One study which researched all lives who crossed 100 Years concluded something like this !
“To live a longer and healthy life* ,Get up early , have a purposeful daily chore that must include a physical component , work with conscience ,love every one sync with the nature and lastly and most importantly remove style from your life !
Choose your life . . . It is simply there in your hand for grabs !
* Please note , Doctors are never listed in the top with relevance to health of mankind ! They simply cure some illness !
Posted in bio ethics, Cardiology -Patient page, cardiology -Preventive, cardiology -Therapeutics, Cardiology classics, Cardiology Risk assesment | Tagged cad epidemic, how to prevent lifestyle diseases ?, life style disease, smoking alcohol cad |
Answer is question is wrong : RAA clot do occur in AF and severe right heart failure.It is less often recognised , since echo views are difficult and clinical events are silent.
- RAA is broad flat ,thin , chamber comparable to elephant’s ear.The ostium is not that distinct as the body as it blends with crista terminalis .
- Rough pectinate muscles should make it prone for thrombus.Further , RAA has more sluggish flow than LAA increasing the propensity for thrombus.However , the flat nature of the chamber , absence of tortuous tracts , constant SVC flow which is abutting the RAA can counteract this.
- RAA clots are less recognised as echo views are difficult .TEE is often required.
- Overall RAA clot is 50% less common than LAA.
- RAA clot should be specifically looked for in chronic AF and any severe right heart failure. (Unlike MR jet TR jet has less efficiency in flushing the Right atrium )
- Finally,clinical events from RAA clot are less conspicuous as the emboli reaches the pulmonary bed silently.Unlike its colleague on the left side it neither triggers TIA nor a stroke !
1. Buğan B, Baysan O, Demirkol S, Güngör M, Yokuşoğlu M. Right atrial appendage thrombus in a heart failure patient with sinus rhythm. Gulhane Med J. 2011; 53(3): 214-215.
2.Subramaniam B, Riley MF, Panzica PJ, Manning WJ. Transesophageal echocardiographic assessment of right atrial appendage anatomy and function: comparison with the left atrial appendage and implications for local thrombus formation. J Am Soc Echocardiogr.; 2006; 19(4):429-33.
3.Sahin T, Ural D, Kilic T, Bildirici U, Kozdag G, Agacdiken A, Ural E. Right atrial appendage function in different etiologies of permanent atrial fibrillation: a transesophageal echocardiography and tissue Doppler imaging study. Echocardiography;2010; 27(4):384-93
4 .Ozer O, Sari I, Davutoglu V. Right atrial appendage: forgotten part of the heart in atrial fibrillation. Clin Appl Thromb Hemost; 2010; 16(2): 218-20
Posted in Atrial fibrillation, cardiology-Anatomy, Right atrial appendage | Tagged raa clot, raa clot view in tte tee, raa clots, raa thrombus, right atrial appendage, right vs left atrial appendage | Leave a Comment »
A tense anesthetist calls for help !
I had an unusual cardiac consult last week .A middle aged man who was to undergo routine ortho surgery wanted a cardiac clearance.
It was a through and through fracture of clavicle , why do they need a cardiology opinion , it seemed a simple procedure I asked over phone
The anesthetic fellow who was in charge of the patient told me ,”There is a wire just going parallel to the clavicle sir .I believe it is pacemaker lead” I agreed to see the patient immediately
This was the X-ray
It was obvious why they got tensed up as the pacemaker wire criss -crossed surgical field . His ECG showed own rhythm of 80/minute but occasionally VVI pacemaker was capturing his ventricles.
- Strict Intra-operative ECG monitoring
- Keep another temporary pacer ready .
- Hold a cardiologist on call and pacemaker programmer on site.
- Surgical field kept small with minimal manipulation .
- Issue of cautery : Free to do as long as it’s bipolar and good earthing plate.
- Ensure the cautery is applied in one or two second pulses with a gap of 10 seconds pause in-between
- Wiring the clavicle – Signal interference are very rare as the wires are inert
Use of magnet in such situations (Link to magnet and Pacemaker)
Keeping a magnet over the pacemaker generator removes the pacemaker sensing function and is an option if prolonged electrical interference.
*Caution : Response to magnet can be quiet variable .Should be done only with cardiologist supervision.
What happened to this patient during surgery ?
Nothing alarming.When anesthesia was induced he was entirely on pacemaker rhythm . limited cautery was used with ease. Patient tolerated well.
One need not panic when a pacemaker patient is taken up for non cardiac surgery .It is not a major issue .Few precautions are required .
Read a related article in this site .Electrical cautery in pacemaker patients.
The news that wasn’t . It is January 1 st 2016 .
NBC reports from Karolinska ,Sweden , Heparin the wonder drug has been reclassified as a thrombolytic agent and Jay Maclean who doscovered this drug in 1916 is awarded the Nobel prize in Medicine posthumously on the 100th anniversary of discovery of the glorius drug ! The entire Hopkins campus at Baltimore has erupted into a non stop party tonight !
And now to the True story
Heparin the wonder drug was discovered by Medical student Jay Maclean in 1916 at the Jhon Hopkins when the rest of the world was fighting the world war 1 . It was separated from the cannine liver and the name Heparin was coined by Maclean’s Guide at Hopkins William Henry Howell . Even though it was invented early it was available for human use only in 1936 when Swedish company Vitrum AB produced it .Since then It has a very distinguished career and still going strong after 100 years.
The only regret is Dr Maclean narrowly missed the Noble prize for this great invention .I still believe he should get it on its 100th anniversary in 2016.
A partial “curriculum vitae” of Heparin.
Heparin is an Anti-thrombin 3 agonist .It blocks the pro thrombotic cascade and hence a powerful anticoagulant. Further ,it completely tilts the balance towards fibrinolytic system.Hence the natural forces take over and start dissolving the thrombus in due course.
So Heparin is an indirect thrombolytic agent .No second thoughts on this.
But a century old teaching goes like this . . .
“Heparin prevents fresh clot formation . . . but it do not have any action on already formed clots “
What do you infer from this statement . Do you agree ?
Role of Heparin in real clinical scenario
Heparin is the key drug in all acute coronary syndromes when the coronary artery goes for sudden thrombosis . An un estimated one million prescriptions are done every day world wide for this indication alone.
(*And mind you it does have a significant impact on already formed thrombus as well ! Ref : HEAP Pilot study )
Apart from this.
1. Heparin dissolves post MI LV apical clot over a period of few weeks.
2.Heparin is very effective in most cases of sub-massive pulmonary embolism
3.Heparin infusion has opened up many near total coronary occlusion
4.Heparin clears the micro vascular from thrombotic debri in lungs in CTEPH.
5.Heparin dissolves deep vein thrombosis
6.Heparin almost result in complete cure and clears cortical venous thrombosis
7.Heparin is exceedingly successful in clearing thrombosis in placental micro-circulation (APLS) which threatens the fetus with IUGR.
Al these clinical events are well documented and well appreciated.
Still we feel awkward to call the heparin as thrombolytic agent
It is almost a scientific non- sense .We think a thrombolytic should show it’s action in vivo in the lab and it should shrink the clot on a petri dish ! What a wrong mind set ! We have tell-tale evidence for heparin’s magic act of vanishing clots inside the human vascular tree (However organized it may be ! ) .
I struggle to understand , why our scientific mind does not want to give credit to a drug which does a neat job of dissolving clots through its indirect action . Is it a curious bias ? or is it an act of ignorance or just a nomenclature error in the foundations of therapeutic pharmacology ?
At this point one should realise streptokinase too does not act directly on the clot.It acts indirectly through a TPA-enzyme complex.So can we call it an non thrombolytic agent ?
- Heparin is indeed a thrombolytic agent , through a chain of action and reaction which it confers to the naturally occurring lytic system.
- In vivo ,this indirect lytic action can be powerful than some of the direct acting thrombolytic agents .Not only that, it lacks the side effects vested with direct lytics.
- The only issue is , heparin is a slowly acting indirect thrombolytic it has to be given long-term or on an infusion .
- It is right time the pharmacologists and nomenclature authorities include heparin as indirect thrombolytic drugs.
1.High Dose Bolus Heparin as Initial Therapy Before Primary Angioplasty for Acute Myocardial Infarction: Results of the Heparin in Early Patency (HEAP) Pilot Study J Am Coll Cardiol. 1998;31(2):289-293.
3.Esteves FP, Braga JC, Latado A; Confirmation that heparin is an alternative to promote early reperfusion in acute myocardial infarction. the CHEAPER study [abstract]. Circulation. 94 (Suppl I) 1996:I-553
Reperfusion arrhythmia was described originally in the thrombolytic era .
It can be any of the the following .
- AIVR(Accelerated Idio Ventricular rhythm)
- Sinus bradycardia (In Infero posterior MI )
- VF can occur as Re-perfusion arrhythmia.
Does these arrhythmia occur following primary PCI ?
It should isn’t ?
In fact it must be more pronounced as we believe PCI is far superior modality for reperfusion !
Busy Interventional cardiologists of the current era either do not look for it or fail to document it . These arrhythmias occurs only with early Primary PCI (Say less than 2-3 hours) .If re-perfusion arrhythmias are really less common with primary PCI , are we missing some thing ?
Posted in Cardiologt women, Infrequently asked questions in cardiology (iFAQs), Primary -PCI | Tagged accelerated idio ventricular rhythm, aivr, primary PCI for stemi and reperfusion arrhythmia, reperfusion arrhythmias | Leave a Comment »
As we practice this Noble (& Delicate ) profession ,we often tend to Ignore the warnings even from our learnt colleagues , Why ?
Posted in bio ethics, cardiology innovation, Cardiology quotes, cardiology-ethics, Venkat quotes, Wintage cardiology | Tagged aga asd device ado 1 2 figulla flex 2, asd vasd pda device closure, cath lab nightmares, cath lab tricks and techniques, dr s venkatesan, ego vs wisdom, venkat quotes, wisdom quotes, wisdom vs knowledge | Leave a Comment »