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 . . .
Inserting an ICD for DCM may a be great therapeutic success for the physician as well as the patient . But there is one big truth hidden behind the statistical screen.
Following study provides dramatic data from Maanhiem in Germany in about 561 patients who had ICD .The long term patient outcome after appropriate shocks were much worse than those without shocks .This was more pronounced in Ischemic DCM .
The fact that these patients continue to throw VT , some thing is wrong in the cellular milieu or a fresh scar / fibrosis / ischemia is progressing .Further , the VTs and the subsequent shocks set in temporary hemodynamic instability .We have evidence , EF can be depressed for days worsening the long-term out come.
While it is easy to blame it on natural course of DCM , there are solid reasons to believe , shock induced myocardial damage is definitely contributing to this excess mortality.
One important clinical tip is to screen all these so called Idiopathic DCM patients who had appropriate shocks. They should be monitored for fresh signs of any systemic illness , like a connective tissue disorder , chronic granulomatous lesions like sarcoid etc .To our surprise some specific myocardial disease may unmask themselves in the natural history. Identifying them may offer a dramatic cure .
Some where along our EP mind-set we are conditioned to think , as along as there is an ICD in situ and it appropriately shocks, every thing is bliss ! Blame it on semantics . The word “appropriate” inappropriately soothes our nerves.
The fact of the mater is , every appropriate shock is a grim reminder that the heart in question is restless electrically and VT continue to emanate from diseased myocardium . It could mean either the LV is destabilising , or the original disease is progressing or a new disease is evolving .
Mean while, paradoxically , inappropriate shocks give us a quixotic comfort , since the heart is not really throwing any dangerous arrhythmia, after all it is the device related false alarm that could be easily reprogrammed!
Posted in cardiac resynchronisation, Cardiology - Electrophysiology -Pacemaker, Cardiology -unresolved questions, Dilated cardiomyopathy, Electro physiology, ICD -Tips and Tricks, Infrequently asked questions in cardiology (iFAQs), Land mark articles in cardiology, Pace maker Tips and tricks, Permanent pacemaker | Tagged appropriate and inappropriate shocks post icd, dilated cardiomyopathy, icd in dcm, ICD tips and tricks, ischemic vs non ischemic dcm, myocardial damage following icd shocks, outcome after appropriate shocks | Leave a 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 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 | Leave a Comment »
Current guidelines advice us to wait for 40 days following STEMI to implant ICD in most high risk patients.
Why this cool off period.? *
- Essentially we are waiting for the Infarct healing process to be completed.
- By this time electrical stability may be restored. The risk of VT/VF declines per naturalis.
- LV function recovery is possible. As stunned and hibernating myocardium resumes its mechanical function and patient might jump out of the MADIT-2 cutoff point. (EF< 30%)
- Introducing ICD very early after STEMI may be a myocardial irritant and that it self can generate arrhythmias.
- There is a possible interference by the leads in the physiological remodeling process.
So the cool off period is not only to reduce the unnecessary ICD implantation but also to avoid lead related issues .
* This 40 day rule is based on one large study from Germany. (DINAMIT, 2004 ) . However few believe the rule is not absolute. There can be individual exceptions in high risk patients with critical LV dysfunction .
Other wise . . . How do you digest a death occurring on 35th day in a patient who is waiting for an ICD scheduled one week later ?
How to bridge the 40 day gap in really high risk post MI patient ?
We can’t keep him in CCU. Here comes the role of WCD (Wearable cardiovertor defibrillator.) Life vest is from Zoll . WCD can act like a bridge till the 40 days when the patient becomes eligible for ICD.
Posted in Cardiology - Electrophysiology -Pacemaker, Cardiology -Pacemakers and ICD, Cardiology -Therapeutic dilemma, cardiology -Therapeutics, Cardiology -unresolved questions | Tagged Indication fo ICD | Leave a Comment »
One of oldest hospital in the world , is now an UNICEF heritage site. Santa Creu , Sant Pau original hospital built in 1400 AD rebuilt in 1900 by Catalonian modern architect Montaner.
TVI is a hemo-dynamic echo parameter measure from Doppler spectrum usually in the outflow.This parameter is used to calculate cardiac output.
Time velocity Integral
One of the hottest debate in the recent world cardiology forum in Barcelona WSC 2014 , was about how to tackle incidentally detected non IRA lesions during primary PCI.
So far , the dictum is , one should not meddle the non culprit lesions unless demanded by hemodynamic instabilty .The next option is to do a staged PCI for these lesions. (Few days later). or just forget about these lesions unless they are critical.
Now new studies are appearing that suggest doing all “do-able” lesions must be stented in one go ! This is obviously inviting trouble .The worry is not in the concept but with the dubious track record , fragile guidelines and potential ethical debacle of the cardiology community !
Stent “As you want and as you please” has already invaded our mindset in the chronic coronary scenario. Now in 2014 , we want more freedom in acute coronary syndrome as well ! We can’t ask for a referee less game of soccer !
We clearly know coronary arteries are to be respected and do not deserve indiscriminate stenting especially in ACS where the early hazard is more.
A recent story which I heard was a height of futility . A semi experienced cardiologist in the suburbs of a big southern Indian city , opened successfully a LAD which was the IRA and subsequently caused acute LCX STEMI , while trying to tackle an insignificant non culprit lesion due to procedural mishap ! (Some suggested migration of LAD thrombus !)
What a pity , when we are supposed to arrest the culprit, in reality it is simply chased down to another territory !
Here comes unique advantage of thrombolysis , you need not locate the culprit artery the drug chases it wherever it is , even if they are multiple ! Read in this link :
We call it as fate when thrombus suddenly occlude a coronary artery and the IRA becomes a culprit . We need not compete with fate and end up creating potential new culprits.Let the sixth sense prevail over the five .Use judicious discretion when trying to stent muti-vessel CAD during PCI. Please realise ,the concept of multivessel stenting during pPCI is not wrong . How we interpret is the issue !
There is no excuse to indulge as you like , simply because your intentions are good !