Posts Tagged ‘coronary angiogram’
Posted in bio ethics, Cardiology quotes, Clinical cardiology, Venkat quotes, tagged acc aha guidelines for ptca, cath lab ethics, Cath lab philosophy, coronary angiogram, corornary stenting, inappropriate coroanry angioplasty, pci on April 30, 2012 | Leave a Comment »
This is an RCA of a patient who had chronic stable angina , class 2 with moderate anti anginal medication.
What shall we do ?
- The RCA needs multiple stenting
- Multiple plain balloon angioplasty
- CABG to PDA
- No intervention ?
- It depends upon status of LAD and LCX
The correct response would be 5
Without knowing the status LAD and LCX . . . RCA should not be touched . Further, the concept of tackling the coronary artery by itself is fundamentally wrong ! We are supposed to tackle patient’s symptom , reduce future risk of events and not merely their coronary artey !
His LAD and LCX was near normal. In the weekly cath meet PCI to mid RCA covering the critical segment was strongly debated but lost a close race .
The final decision was to allow the patient to continue intensified medical management (Statin 80mg /Metoprolol 100mg ) . He is comfortable with that .
Medical management in a tight single vessel disease can never be digested by any Interventional cardiologist whatever may be the guidelines !
Do not decide PCI on the basis of how ugly a coronary artery looks , rather spend some time on true symptomatology , optimise baseline therapy and re assess risk profile
One learned dictum is , do not meddle a RCA , however severe the lesion may be if LAD and LCX are fine.*
*This rule is not applicable in ACS
Posted in cardaic physiology, cardiac physiology, Cardiology - Clinical, cardiology -ECG, Cardiology -Interventional -PCI, tagged 64 slice ct scan mdct, border line positive stress test, collaterals and tmt negativity, coronary angiogram, does medical mangement reverse tmt positivity, exercise stress testing, mildly positive est, mildly positive tmt, thallim stress, tmt, tread mill testing, treted cad and st segment, upsloping st segment on August 7, 2011 |
In this politically and scientifically uncertain world nothing is in black and white. How can you expect EST to behave differently ?
Even as we are fully aware of the limitations of EST , it does not make sense to categorize EST result into either positive or negative .
In fact , our estimate suggests a significant bulk of the patient would fall in the grey zone .
It is referred in various terms by the reporters of EST .
- Borderline positive
- Mildly positive
What does all these terms mean to the patient ?
It mans only one thing . . .
Physician who reports the EST is unable to conclude whether his patient has significant CAD or not . It is a dignified way of expressing the limitations .
Many factors may play a role. (See the illustration above )
- Patient factors : Poor exercise stress levels and conditioning
- Lesion factors: Collateralised CAD, treated CAD can result in partial or mild changes.
- Machine factors :Caliberation errors.
- Interpreter : (Physician ) factors
Error in measurement of ST segment . What is borderline for one doctor may indeed be true positive for the other and vice versa .
How will be the EST in a revascularised or medically treated CAD ?
If revascularization is a complete success , stress test would revert back to normal or it can be a borderline as we have just mentioned.
To our surprise , it may remain positive in spite of apparently successful procedure.(Residual wall motion defects , scar mediated ?)
How to proceed after this borderline EST/TMT ?
Few options are available for the physician/patient
Talk with the patient again , assess the baseline risk of CAD if it is low ignore the TMT result and reassure.
- Repeat stress test after a month.
- Stress thallium
- Doubutamine stress
- CT angiogram
- Regular Cath angiogram* (May be the best , of course it also carries a risk of labeling the condition as mild CAD / non critical CAD etc )
For the patient the easiest option may be , self referral to a different cardiologist . (Also called second opinion )
There is indeed an entity called borderline EST . Do not dare to ignore it or else face the consequences .
Read related articles in this site .
How to rule out critical left main or proximal LAD disease with near 100% specificity without coronary angiogram ?
Posted in Cardiology - Clinical, Cardiology -Interventional -PCI, cardiology -Therapeutics, Cardiology -unresolved questions, tagged 64 slice ct scan, abuse of coroanry angiogram, atrio pulmonary sulcus, cad, coronary angiogram, etics in cardiology, how to r/o left main disease, how to r/o proximal lad disease, left main disease, left main disease by echocardiogram, mdct, misuse of coronary angiogram, proximal lad on July 10, 2011 | 4 Comments »
Very often in clinical practice cardiologists are asked to R/O significant coronary artery disease in asymptomatic persons .This population includes people with multiple risk factors like diabetes, HT dyslipidemia and non specific ST/T changes in ECG.
Many of us have lost the confidence of ruling out CAD in these population without looking at their coronary angiogram.
Is it a right way of practicing cardiology ?
What we need to realise is, we are asked to rule out any critical lesions that are going to make a impact on these other wise comfortable patients. Nothing wrong if you miss a 30% lesion in PDA or OMs or diagonals !
Can we do this without doing coronary angiogram ?
Yes , we can .
Step by step Ask these questions
- Ask the patient , if he /she can climb three flight of stairs without any difficulty or
- Walk briskly for 20 minutes (5km/hr)
If yes , give a certificate that he has no critical left main or proximal LAD disease.
If you do not believe in his words , put him on a tread mill , if he crosses stage 3 Bruce in TMT ( 9 mts)
give the above certificate “with a frame” now .
For still suspicious physicians , We have one more investigation called echocardiography !
Echo : The forgotten tool for screening left main lesion.
Modern day echo machines have a 3mm resolution power (Many have 2mm ) .While , we are expected to look for 3mm vegetation to R/O Infective endocarditis , rarely is a cardiologist , tuned to look for the left main ostium in routine echocardiography which averages 4-5mm is size. (Left main by echo link to another article)
In short axis view just tilt at the level of pulmonary valves (Atrio- pulmonary sulcus) one can visualise the left main ostium and the proximal left main emerging from the 4 o clock position. If you are lucky you can see the entire left main.
If nothing satisfies the physician (Or the patient) ,Refer him for sliced CT scan , catheter coronary angiogram , or a nuclear Imaging .Be ready for the attendant anxiety, interpretation errors, corporate pressures , urge to balloon , kick backs etc etc
By the way , how can one be happy by ruling out only left main disease ? Is it not other lesions possible ?
Experience (Not science) has taught us no critical coronary obstruction is possible , if a patient walks for 9 minutes in treadmill (10METS).
Even if it is there (A remote chance) there is little documented benefit of any revascularisation procedure.
Counter point ?
Is it not a “crazy idea“ to rely on patients history in ruling out CAD in these era , where angiograms relayed live into cardiologists ipad ?
Science has no value if it is not applied for the patients welfare. Meticulous clinical examination (And application of mind) is the foundation stone on which any medical investigation and therapy should be based upon. Most of the inappropriate coronary revascularisation are due to neglect of this vital component of clinical examination.
(I wonder , is it really possible these ” acts of omission” be deliberate some times ! )
Clinical interrogation may miss an insignificant CAD , but it can never miss a critical CAD* .
Do not do coronary angiogram routinely to R/O CAD.
It is not the way cardiology is to be practiced !
If only we apply those simple, time tested concepts in every day practice we not only save millions of Rupees , but also thousands of futile diagnostic tests and associated untoward effects can be avoided.
* Senstivity of ruling out any CAD is about 70% , but it’s capcity to R/O critical CAD approaches 100%.
Please refer your own Brain.
Posted in Cardiology - Clinical, Cardiology -Interventional -PCI, cardiology -Therapeutics, cardiology innovation, cardiology- coronary care, Cardiology-Coronary artery disese, Hemodynamics, Infrequently asked questions in cardiology (iFAQs), tagged 100% lad, 99% lad, bernouli principle in coroanry artery, coroanry doppler, coroanry perfusion pressure, coronary angiogram, coronary collateral circulation, coronary hemodynamics, coronary microvasculature, coronary stump with timi 3 flow, courage trial syntax score, distal coronary resistance, hanging the lad, intra coronary pressure, lad total timi 3 flow, ressitance in series, timi 3 flow on May 15, 2011 | Leave a Comment »
Thousands of coronary angiograms are done every day. Cardiologist no longer get excited to see exotic coronary lesions .Still , some images can be striking and dramatic. Here is an angiogram from a middle aged man with stable angina , who was one among the routine early morning diagnostic studies in our cath lab.
How this man was able to fill up the distal LAD almost completely? (With a complete cut off right in the neck of LAD )
Do you get any clue ?
- Can a trickle of ante grade flow sustain a TIMI 3 FLOW ?
- Or is it a very efficient instant collaterals from LCX ?
Yes . The first one is right . An almost invisible antegrade channel doing a exemplary job !
How is it possible ?
Realize an important fact . The distal flow beyond an obstruction is not primarily dependent on degree of obstruction but the status of the distal vascular bed . If it is normal even a hair-line patency can profusely perfuse the distal myocardial segment. This is what is happening to this man with a stable angina and perfectly normal micro vascular bed.
Lessens from this Image.
Do not get fooled by the lay man’s logic. Realise there is no simple relation between the degree of obstruction and degree of blood flow impediment.It can be linear , curvilinear , or even inverse depending upon the evolution and timing of obstruction , number of lesions , presence or absence of collateral support , finally and most importantly the integrity of microvascular bed .
The distal vascular bed drops its resistance drastically once it senses the problem in proximal segment . This is based on Bernoulli principle and is akin to how a garden hose pipe can simply increase the velocity by tightening the nozzle.*
* The garden hose analogy is a gross simplification of complex factors that determine coronary blood flow.But it effectively clarifies a point ie coronary blood flow is least dependent on coronary stenosis (until very late stages)
**Note further : This hemodynamic principle may not apply in acute occlusion as in STEMI , where acute obstruction often has a linear relationship with the quantum of blood flow.
By the way what happened to the above patient ?
Since he had significant angina there were no debates regarding management. He is posted for elective PCI this week-end .(We can’t get a stent just like that unless it is a real emergency .Ours is a Govt hospital !)
What is your take . Is it a going to be tough cross ?
I feel so , but my colleague Dr Gnanavelu strongly differs !
Let me post our experience during PCI shortly.
Posted in Cardiology -Interventional -PCI, tagged coronary angiogram, intra stenotic coroanry artery dilatation, lapalce law, post stenotic dilatation, post stenotic dilatation vs ectasia, pre stenotic, pressure recovery in coroanry obstruction, timi 3 flow on March 25, 2011 | Leave a Comment »
Newtons third law of motion says for every action there is an equal and opposite reaction .
In vascular hemodynamics whenever there is a an obstruction , there tend to be a dilatation of the same blood vessel somewhere distally.
It may not be linked to newtons law but it is observed in many .It is more common in large vessels than small ones.
Here is a patient with a tight LAD lesion with a significantly dilated segment located immediately beyond the obstruction.This can be considered as a post stenotic dilatation. Coronary ectasia is also a possibility but since it is related to site of obstruction the former is likely .
What determines the post stenotic dilatation ?
The exact mechanism is not clear. There is a definite ,sudden pressure drop distal to the obstruction. This pressure drop recovers beyond a certain distance . At this point , the rate of increment in velocity of peaks .This somehow has an effect on the distending pressure and the adjacent vessel wall gets radially stressed and begins to dilate. (Opposite of what is expected in Bernoulli effect ?)
Is there a anatomical defect in post stenotic dilatation ?
Not every one goes for post stenotic dilatation.There is a possibility it occurs only in genetically susceptible individuals .
Significance in interventional cardiology
The post stenotic segment has a potential to misbehave in the period following PCI . If the distal instent stenosis occur (even if it is minor ! ) it can induce a cycle of post stenotic eversion of normal segment and risk of edge effect or stent thrombosis is more.
Read also Glagovian phenomenon – A form of intra stenotic coronary artery dilatation
Posted in Cardiology -Interventional -PCI, Cardiology-Land mark studies, tagged coronary angiogram, coronary artery disease, interpretation of coroanry angiogram, syntax scoring system, syntax study on February 10, 2011 | Leave a Comment »
This is one of the wonderful corporate initiatives to assess the coronary angiogram and reporting . This calculator and teaching material was created by Boston scientific and Syntax study team . This was used primarily during the SYNTAX study. This scoring system , though appear elaborate, is a very useful , objective way to assess coronary angiogram.
It is encouraged to use this scoring system liberally . This will help us to take more scientific decisions .
Posted in Cardiology -Interventional -PCI, cardiology -Therapeutics, Cardiology -unresolved questions, Uncategorized, tagged contraindication for doing coroanry angiogram, coronary angiogram, drug eluting stent, ectasia, guidelines for doing coronary angiogram, indications for coronary angiogram, pci, ptca, reporting a coronary angiogram, stents on February 6, 2011 | Leave a Comment »
Coronary angiogram is probably the commonest invasive cardiac investigation done world wide. It should run into millions every year. The procedure once thought dangerous is now performed in few minutes in day care centers . While doing a coronary angiogram has become a minuscule task to most cardiologists, interpenetrating it correctly remains a huge task !
Many of the young cardiologists get fascinated in doing a coronary angiogram and hardly spend enough time and mind in interpreting it.
Most of us succumb to the popular occulo coronary reflex and describe a coronary artery lesions as though it is a number game . It is very rarely we use the quantitative angiography tools available in the machine. We need to meticulously analyse the length , morphology , distal flow, thrombus , collaterals etc . (FFR a new avatar tries to do some justice )
Calling atherosclerois by numbers alone, such as 50 % LAD and 70 % diagonal 20 % left main is a huge insult to the deadly & diffuse disease process of atherosclerosis .We are paying the penalty for it .This is the fundamental flaw in our reporting , that makes every coronary intervention redundant.We must first remember we are looking at the lumen not the wall of coronary artery.
Coronary interventions is not about removing obstructions but regression of atherosclerosis load within the coronary artery , prevent progression of it and ultimately reduced cardiac events and improve survival. It is obvious, it can not be achieved by wires and catheters alone . At best they can be adjuncts.One can easily understand why medical therapy scores over wires as it can take care of the overall disease process.
But still , most* of the learned cardiology community considers medical therapy to be an adjunct to coronary intervention , which is a gross ignorance at it’s best !
* This is my perception. If I am proven wrong , I am happy our patients will be benefited !
Do not reduce the importance of coronary angiogram to a farce number game !
Do not get excited by visualizing your patient’s coronary artery. It may make you richer by few thousands. Realise , what you are seeing in a CAG is a fraction of coronary circulation.
It is estimated coronary circulation we visualize daily in cath lab as epicardial coronary arteries is less than 2 % of entire cross section of coronary circulation.
This means we are 98 % blind ! ( or 2 % wise !) .Spend adequate time and mind to interpret it correctly , so that logical and useful ( non ) interventions can be done .This only can make you a true cardiac professional and your patients will respect you.
Posted in Uncategorized, tagged abnormal coronary artery origin, absent leftmain, anomalous coronary artery, coronary angiogram, lad and lcx, lcx from right sinus, left anterior descending artery, left circumflex artery, left main artery, rare coronary angiograms, split left main on January 26, 2011 | Leave a Comment »
Is it not , boring to see normal coronary arteries every day ! There need to be surprises in cath lab to make our time lively and keep our brain alert . Have a look at this angiogram in RAO caudal view.One of our junior cardiology fellows thought it was a split left main artery .
How can an artery split . . .of course the image indeed looks like that !
It was indeed an absent left main. Also called as separate origin of LAD and RCA.
Note : There can be three types of absent left main.
- LAD and LCX from same ostia on the left coronary sinus*
- LAD and LCX separate ostia but both from same sinus**
- LAD from left coronary sinus, LCX from right sided sinus (Probably the common type )
* Some books mention about a left main of 0 -5mm .
** Very difficult to delineate and is rare
Zero mm left main is nothing but single ostial origin of both LAD and LCX. A very short left main , say 1 0r 2 mm will practically mimic an absent left main.
Here is the the dynamic angio image. It is surprising how a catheter in left sinus is able to visualise the LCX from right sinus so well !
Advantages of having absent left main .
- It requires no great brains , to predict the above patient is immune to develop Left main or true bifurcation disease
- Sudden death is presumed to be less common in this population.
Implications for interventional cardiologists
Guiding catheter selection and positioning could be difficult.
Posted in Cardiology - Clinical, Cardiology -Interventional -PCI, Cardiology -unresolved questions, cardiology- coronary care, tagged coronary angiogram, diagonal, left anterior descending, septal coronary artery on January 19, 2009 | Leave a Comment »
Coronary arteries are the major site for human atherosclerosis .CAD is considered the ultimate determinant of cardio vascualr health of our global population.Coronary atherosclerosis has a predilection for proximal sites and branching points.Typically it occurs in leftmain, LAD ostium, LCX ostium, proximal LAD, diagonal origins, OMs RCA and its branches .
Septal branches , even though divide very early from the LAD , it is uncommon to get affected by coronary atherosclerosis. Even for an experienced interventional cardiologist , it would be very rare to have performed a PCI for septal disease.
Why septal branches of LAD is rare to suffer from atherosclerosis ?
We don’t know the answer yet.
But , it is thought,septal branches are near perpendicular branches .The branching angle and incidence of atherosclerosis has a peculiar relationship.IAt any bifurcation point , the atherosclerosis tend to occur , if the angle is more acute , and is less common in abtuse angles .It is almost rare , if branching happens at exact 90 degree angle or so !
The other reason for septal branches being immune to atherosclerosis is , it runs within the muscle in its major course. The constant squeezing action(. . . and possibly bridging also) makes it difficult for the process of atherosclerosis to sustain and grow .
Can you still get a septal CAD ?
Yes, usually as a component of bifurcation or trifurcation lesion. Some times a diagonal and septal are very close together and atherosclerosis involves both ostia.
What is the implication for the cardiologist to perform a PCI with stenting in a septal branch of LAD ?
PCI and stenting in the septal branches are more prone for crushing and fracture as it is constantly exposed to the mechanical effects of muscle contraction.
Any other significance for septal branches of LAD ?
- Isolated septal myocardial infarction can occur.This could be even a embolic manifestation.
- Septal branches of LAD are potential target for therapeutic embolisation (By injecting alcohol) in patients with hypertrophic obstructive cardiomyopathy(HOCM) .This manover aims to produce a controlled septal myocardial infarction and thus paralysing the left ventricular outflow tract and reduce the dynamic LVOT gradient. This form of treatment, was glorified till recently now considered experimental !