The ultimate journal on cardio- vascular physiology

http://ajpheart.physiology.org/

Many of the wonderful breakthrough articles are totally free . Enjoy and enrich .

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Academic cowardise and medical obfuscation !

 

* Obfuscation:  hiding of intended meaning in communication, making communication confusing, wilfully ambiguous, and harder to interpret

This world can not be a perfect place and  it is foolish to expect the same !   What is published in medical literature is at best , an abstract thinking  of an unfinished agenda . Still public think  science is   . . . what doctors say ! They feel doctors can not simply watch a person  dying. They want us  act like  God. This is  how medical men became Demi-Gods  by default.

Here was a big opportunity . Who exploited it ? Obviously the greedy corporates  who embarked  on a dirty journey to en- cash this trust  and fill their coffers .This is the foundation  on which the  basics of medical market economy rides !

It is an un-pardonable on-going deceit among  modern human civilization . It has  spoiled  the trust between the patient and doctor and  probably  irreversibly  contaminated  in recent decades !

There are very few positives  though,  with occasional noble medical  souls (Like  BMJ,Lancet )   trying to keep the sinking ship afloat !

This sounding board article (Now we rarely  get to see )  from NEJM way back  in 1975  exposes a  shocking revelation  politely . Now, 40 years after ,  the importance of such article has grown  many fold . We are witnessing  every day ,  medical scientist break  stories ( Yes  . . . it is story )  in general media  with  absolute academic cowardice !

We expect more such  face bashing articles from NEJM . It would definitely  make   immense  good  for  our profession  which needs it  desperately !

Reference

I’m linking the original NEJM article ; Hope it does not violate copy right !

http://www.bumc.bu.edu/facdev-medicine/files/2011/03/Crichton_M_nejm1975_293_1257_medical-obfuscation_structure-function.pdf

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Right ventricle structure and function: A review

A one stop  solution  for every  thing you need about  right ventricle !

http://circ.ahajournals.org/content/117/11/1436.full.pdf+html

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Modern medical quotes: Why evidence based medicine is sufferring ?

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Catheter whip + Calcium in aortic valve = Stroke . . . but TAVI is safe !

There was a time  , even  cardiac catheterisation was contraindicated if the aortic valve  is  significantly calcified. LV angiogram was judiciously  avoided in all such patients . Why ? A significant increase in disabling strokes were witnessed .Those were the time  a sense of  fear (common sense ?)   prevailed . Every one was following this dictum with sanctity .

Now in 2010 .TAVI has  arrived with great fanfare . We not only cross the calcific valve , we literally play  a violent contact sport   in the aortic root  for over two hours with all sorts of pushes  and passes  on  a  fragile valve.And  we are happy to  claim that  stroke rate is comparable to aortic valve surgery and TAVI is not-inferior to AVR in high risk surgeries .

How is this possible ? As the times  changed ?  Is it true , our stroke  fears are just imaginations  or have we lost our  faculty of  reasoning and  sense ? (Will it be logical to  fund a research  if someone claims a  surgical  technique  to replace  aortic valve in  a beating heart without aortic cross clamping !)

Data shows  even if  distal protection devices are  used the stroke rates  can reach to  objectionable levels .It remained  a mystery ,  at least to me how no body was  questioning this ? I was happy to find this editorial in NEJM which  just stopped  short  of   banishing  this modality in its current form.

http://www.nejm.org/doi/full/10.1056/NEJMe1103978

What price it asks ?  and leaves the readers to guess  the answer ? NEJM wants to be too decent and polite , but in science politeness is generally not required  ,  as long as  your  observations are  correct !

For all those enthusiastic  interventional cardiologists  here is  a positive message .

Nothing comes easy in science.Great  inventions do have problems  initially .  Without  major hurdles  there can be no progress ! It is  because of   you  modern cardiology is making giant strides . Remember  the early days of angioplasty , early days of pacemaker  .  But  please realise  the most important issue  is ,  whatever  we   innovate or discover it  should be shown   superior to the  best  existing modality in all aspects(Technique,  procedural  complications, long term  outcome ,costs, side effects etc  ) .It is awful  to note   new drugs or devices  are  rarely compared with  the best treatment that is currently available .

A  new  treatment that simply  complements  or proves  non-inferiority  can never be considered an invention. How can we   portray radio frequency  renal denervation (  a complex  lab procedure ) for controlling blood pressure   as a great innovation for man kind  while we  have   so many drugs and  modalities  available  at a fraction of the cost  with  little  consequence .

Reference

http://www.escardio.org/congresses/esc-2009/news/Pages/Transcatheter-Aortic-Valve-Implantation.aspx

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Metabolic Imaging of atheroscerosis

Non invasive imaging of inflamed macrophages  within athersclerosis

The medical  imaging science is  reaching new heights. With most of the  research so far within the anatomical arena we are moving into the  physiologic  and metabolic  imaging. Identifying vulnerable  plaques  within the coronary  artery is a separate field. Most of them are catheter based and invasive investigations.

We  have ben  searching for an  ideal PET scan based metabolic imaging of atherosclerosis. Macrophages are the key elements in an inflamed plaque.

Image Source : Circulation. 2008;117:379-387 .Note the Acttive Macrophages in the Aortic arch area and Coronary ostia

Can we take a photograph of these  inflamed zones   within  the  atherosclerotic plaque  ?

• It seems we are approaching  that possibility. Every time we screen a person for CAD we can risk stratify on the basis of  percentage inflammation of their coronary artery or aorta .
• This will complement the CT  or conventional angiogram .
• If this technology is perfected it can be useful in the evaluation of response to medical interventions .
• It  could also tel us  the  significance of  raised CRP /cytokines in other wise asymptomatic individuals

PET scan with newer tracers are constantly evolving . One such tracer is  based on copper molecule   64cu-TNP.

Reference

http://jnm.snmjournals.org/cgi/reprint/45/11/1898.pdf

 

 

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TRANSFER-AMI study : Transfer with caution . . . bumpy roads ahead !

Preamble

The much published TRANSFER -AMI study  has few important queries to ponder about.It was supposed to test the role of routine PCI following  thrombolysis. In other words it compared  rescue only strategy with routine strategy.The caveat is , even among  failed thrombolysis, the   rescue strategy has not convincingly proven superior to medical management  (if the time is lapsed ) as much of the damage is done .

In essence , Acute MI is  more about time management than drug or cath lab management

1. Why the 67 % of  standard therapy cohort underwent PCI. Technically , you are supposed to transfer for rescue only if there is a  failed thrombolysis ?That is the standard approach , if  most of the cases are any way land up in cath lab , then you are trying to compare two similar groups .
2. Why the rate of   failed thrombolyis with TNK-TPA in both arms not disclosed ?
3. How can a 92% of study population be in class 1 Killip still considered to be high risk group ?
4. Why the recurrent ischemia  was very vaguely  defined and still included and clubbed with primary end point along with deaths. If only recurrent ischemia was removed from primary end point . . .this study will straight away land in a regret bin.
5. Why there were 6 additional deaths at 30 days  in routine early  PCI group ,  What was he cause of death ? Mind you these deaths have happened in a 92 %  Killip class  one cohort . Is it  not important ? The trend looks vitally   significant .We can not afford take refuge under a false  statistical roof .
6. How many patients died or  developed MI  because of the early PCI in-spite of having  successful thrombolysis.This again could be vital . Complications during intervention  for a failed thrombolysis may be acceptable. While ,complications , when we try to  improve upon the already  successful thrombolysis is simply not acceptable .

Will the investigators share their experience ?

Finally

Why the title of the paper says it is about “Routine angioplasty” and  the conclusion emphasizes  it is indeed   “high risk subsets ofangioplasty” (While the study itself involves a 92 %  least risk Killip class 1 ) .  Why this double dose of confusion ?  (Is it deliberate  ! Which i think is unlikely )

NEJM please take note of this  . . .

All that glitters  are  not natural glitter . . .some are made to glitter !

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

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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Landmark articles : New Orleans and the “ASD” connection

It was those great  years  1974 -1976.  Even before the concept of  PTCA was born, few  committed cardiologists  of New  Orleans were on a mission. Closing the ASD in cath lab. They  achieved it successfully with a umbrella device.

 

But 35 years later as on 2010 ,the concept though proven still struggles to prove itself.

Link to related article .

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Lesser known cardiology journals : “Heart view” – A treasure from Qatar !

Great people  do not boast  . While there are thousands of hyped up publications in cardiology ,

This one form Qatar excels , which  I  stumbled upon recently  contains very useful information about wide ranging issues in cardiology .

Let us congratulate the   Hamad medical corporation for  their unique  academic vision  .

http://www.hmc.org.qa/hmc/heartviews/ARCHIVES/ARCHIVES.HTM

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