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Here is a  video recipe  !

Please click here to  see more videos from my you tube site

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.

Final message

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

Some thoughts

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 .

Summary

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.

 

Read further

http://drsvenkatesan.wordpress.com/2012/02/10/basic-lessons-in-stemi-does-dying-myocytes-release-potassium-into-the-circulation/

 

 

 

 

I got this alert from World health organisation  yesterday .Click over the image to read more .

dr s venkatesan who sucide alert cardiology heart transplantation

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 !

 

WHO sucide prevention

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.

 

asd clsoure

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.

One

borewell deaths 4

One more

borewell deaths  3

Two

You can understand the gravity of the problem , one engineer has devised a special  child retrieval Robot for such accidents.

baby snare bore well cath lab snares asd vsd device av loop how to snare a device

Three

A news report  in Times of India  .What shall we do about these ?

asd vsd borewells pits holes in the heart

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 . . .

borewell deaths 2

Post-amble:
Doctors are not just the  noble professional who provide relief  from  illness . They  have  other social responsibilities  too !
I believe ,  as physicians bound by Hippocratic  oath , we should  help tackle issues that threaten  our pubic health  system , especially in this case were the victims are  vulnerable children !
In fact ,  pediatricians should come forward to work with Govt to  improve safety  issues for children  and  orthopedicians  should help  prevent road traffic accident while  cardiologists  shall  work with the Govt to prevent  heart disease . . .  etc etc .
Though  bore-well deaths are  a pan India  phenomenon , One state in India ( TN)   has taken a   new initiative recently  and has  banned digging  bore-wells without prior permission and stipulated strict guidelines .Others can take a cue from here !
  • 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.

Summary

  • 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

Final message

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.

http://europace.oxfordjournals.org/content/14/9/1236.long

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.

pseudo abnormal relaxation grade 1 003

Image template taken  from  http://www.learntheheart.com

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 !

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 !

 

Lifestyle diseases cad risk smoking alcohol

There is a simple solution for  lifestyle diseases !

Just  . . .  Remove style from your life !

lifestyle diseases coroanry cardiology medical ethics inappropriate stents over treatment excess medical care , bio ethics,

Instead . . . try to live like these  Tibetian villagers

life purpose of living

Final message

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 !

Post-amble.

* Please note , Doctors  are never listed in the top with relevance to health of mankind  ! They simply cure some illness !

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 right atrial appendage clot tee echocardiographyBrief account of RAA clot formation

  • 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 !

Reference

right atrial appendage clot raa clot in af atrial fibrillation

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

 

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