Here is a video recipe !
Posted in dr s venkatesan -Personal, general medicine | Tagged best cardiologist india, cardiologist, cardiology fellows training, crash course on cardiology, dr s venkatesan, drsvenkatesan, ethical cardiologist, good cardiologist, madras medical college, teaching video in cardiology, venkatesan sangareddi | 5 Comments »
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 . . .
Most of my students were struggling to answer this seemingly simple question . I realised later it is indeed a difficult one !
Tall T waves are observed in very early phase of STEMI .(Within 30 minutes ?) What is the mechanism ? Since ST shifts occur little later than T elevation ( considerable overlap may occur) it may not be related to current of Injury.It is an inherent alteration in the T wave genesis .T wave is inscribed when rapid phase 3 K+ efflux happen (Mainly by Iks and also IKr )
What is the effect of ischemia on K + channels ?
No uniform answer.(Blocks, stimulates, irritates, Bi-phasic, variable ?)
There are 6 important K channels in every cardiac myocyte adding to the complexity.
Does the Ischemic cells leaks potassium or accumulates it ?
Though It does both , predominantly it should leak .If it’s leaking there is local extracellular hyperkalemia . Is that the explanation for tall T waves ?
What is the influence of QT interval on T wave morphology ?
Long QT as occurs in hypokalemia pulls the T down and it may even invert it. .Short QT tends to push it up as in ERS .The effect of ischemia on QT interval is again unpredictable.Further regional and remote ischemia in a given patient can alter this.
Once the ST begins to elevate the T waves losses it power to grow tall .It only can regress. I think this is the time the QT is sort of prolongs .
Effect of reperfusion on T waves
The tall T tend to regress as some form perfusion takes place as K+ Is pushed back into the cells or flushed away from the vicinity.
The dynamic nature of reperfusion makes the behavior of T wave amplitude further complex. But one thing is certain , a well perfused IRA is associated with inverted T wave which we call it as completion of the process of evolution of MI .
Finally and most importantly this hyper acute T phase is not a constant phenomenon. In fact it is uncommon in persons who have baseline T inversion .After analysing many things we are back to the original state of ignorance .
Researchers with intra-myocardial micro electrodes try to decode the mysteries in electrophysiology . Still there is a huge disconnect between clinicians and physiologists.
In simple terms I would believe the mechanism of ischemic tall T waves are almost similar to renal hyperkalemia. (A local , transient extracellular k + excess ) The base of the T waves are not narrow and tented as in CKD because some degree of ST elevation (that always is expected ) widens the base of T wave. Further ,the prolonged QT interval in renal hyperkalemia stretches the QT and encroach the base of the T wave to the left making it appear narrow.
A simplest version for students
Tall T waves are due to transient local extra cellular hyperkalemia , when K + leaks due to cellular Ischemia.
Caution: This is a superficial scientific attempt .I need inputs from more scientific brains and electrophysiologists.
I got this alert from World health organisation yesterday .Click over the image to read more .
Why should a cardiologist affected about this ?
When we are fighting in cath lab day in night day out to extinguish the myocardial fire set by coronary thrombosis and the resultant STEMI . . . the solemn attempt to salvage whatever myocardial cells we can !
See . . . what is happening elsewhere every 40 seconds a healthy heart in toto is executed by weak minds !
What should the WHO do ?
Just publish these data and forget . No,they should organise the world leaders to take a resolve !
Either , we should prevent these unnatural deaths or else we should have world organ net work. Why can’t we use these weak hearts for those courageous men and women who lose their life daily with end stage cardiomyopathy who long for living !
Is this possible ?
Why not ? Ain’t the world leaders group together periodically to impose a sanction or bomb other countries for personal reasons !
Posted in Public Health, Public health issues | Tagged better world, brain death defintion, cadaver organ sharing india, ethical medicine, future of man kind, heart transplantation in India, humane medicine, kidney transplantation india, net work for organ sharing, organ transplant act india, role of who health, sucide and cardiology, sucide victims as heart donors, unos, who, world health issues | Leave a Comment »
I stumbled upon a TV reality show where a mother of a child was crying inconsolably ,whom she lost when it fell into a open bore-well pit .She was blaming it as her fate and the hole was sent by Lord Yama (God of death )
I just got curious ! This article was written in a flash.
I used to get questions from anxious parents of children with holes in the heart .(Asymptomatic small VSDs or ASDs who come for periodic echo-cardiograms) .I reassure and convey the message , most of these holes are tiny and will close automatically and they need not worry.Even if it doesn’t, it poses little problem.
But .after watching that haunting TV show, I have started to warn the parents that holes in the heart may not be that dangerous but be wary of holes in the roads and unclosed bore wells in our country !
Every single parent was amused with my statement ! Some how it appeared sense to me !
I made a mini google research. It is estimated thousands of bore-wells are dug every day and kept open in allover the country side .It is like live land mines . Some press reports suggest at least one child dies in India every day due to uncovered bore-wells and man holes ! (May be really true !)
The following are some of the samples.
You can understand the gravity of the problem , one engineer has devised a special child retrieval Robot for such accidents.
A news report in Times of India .What shall we do about these ?
It is a horrific truth in this civilised world .Nature creates holes in the heart due to defective gene in some . It appears less dangerous to me. After all a hole in the heart threatens only one life,while a hole in the road kills many people.
As a cardiologist , I am saying this with anguish as our team along with surgeons work over time to close intra-cardiac holes with device , the holes in the road are often callously kept open forming death traps for our children .The men responsible for such things deserves no pardon.
The story is never ending . . .
Posted in Public health issues | Tagged asd vsd pda, bore-well deaths in India, congenital heart disease, hippocrates oath, hole in the heart, hole in the heart and hole in the road, Indian association of pediatrics iap, public health issues, safety issues for children, who child safety | Leave a Comment »
- CRT -Cardiac resynchronisation is done by putting multiple wires and electrically organizing the contraction sequence and improving mechanical function.
- ICD-Implantable cardiovertor defibrillator shocks whenever VT or VF occur and suden death is prevented.
- CRT-D (Combo device which functions as both )
CRT is done for advanced heart failure to improve exercise capacity and hence the quality of life .It does not do any thing significant in prolonging life .ICD is again implanted in advanced LV dysfunction with either documented VT/VF or patients who are at propensity for VT .It has dramatic benefit in preventing sudden cardiac death.
Both CRT and ICD has some overlapping indication in cardiac failure. Attention young cardiologists, please realise among these two the value of ICD is many many fold higher than CRT.This fact is rarely discussed and disseminated.
True benefits of CRT is realised only when it is combined with ICD.
- Ideally all advanced cardiac failure patients should receive both ICD and CRT (CRT-D)
- ICD as stand alone therapy has a distinct role in patients with severe LV dysfunction (LV EF<30%) without wide QRS in ECG
- There is no role for CRT as a standalone procedure in cardiac failure .it should always be combined with ICD (ie CRT-D) *
*Except in patient with degenerative complete heart block , both ventricles are paced the term Bi-Vi pacing is used instead of CRT.Since LV function is normal here , there is no de-synchrony in the first place .The synchronised BIVI pacing is meant to prevent future heart failure
Always use a combo device in advanced symptomatic heart failure which is refractory to medical therapy.
After all , there need to be a life in the first place so that we can improve it . ICD ensures life while CRT tries to improve it.
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 »