Here is a video recipe !
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” This is post is 5 years old , Newer developments should be given considerations”
STEMI is the “Numero Uno” of cardiovascular emergency .The treatment has evolved over decades, right from the primitive arm chair approach to the air dropping of patients over the cath lab roofs for primary PCI ! We realise by now ,both are extreme forms of treatment and may have unique hazards. What we forget is the , the natural history of STEMI is too much dependent on the degree of initial damage to the myocardium , and it is very difficult to alter this, however good is the therapeutic strategy . We are yet to find an answer regarding the mechanism of primary VF and modes of preventing it. We also have no answer for , why some develop myocardial damage very fast and the cardiogenic shock occur in an accelerated fashion. (Fate ?)
Many would consider ” non availability of infrastructure and expertise ” is the major issue for primary PCI . But the real problem is much more than that .When an illusion of knowledge is created by constant bombardment of data , it is natural for human beings to believe whatever is told or printed in books and journals. We cardiologists are made to believe thrombolysis is a far . . . far inferior treatment than primary PCI in STEMI . It is not so in any stretch of imagination !
The fact that,there is no entity called ” Failed primary PCI ” in cardiology literature , would suggest how biased we are against thrombolysis. Every cardiology resident will recognise thrombolysis fails at least 40% of time .Yes , it is a fact , but the irony is , this is often used to convey a surrogate meaning , that is , primary PCI is near 100% successful !
How do you assess success of primary PCI ?
Unlike elective PCI where the criteria is too liberal, we can not afford to adopt the same in an emergency PCI. Here the aim of the procedure is entirely different (Salvaging dying myocardium vs pain relief ).
It’s still a mystery , while thrombolysis is vigorously assessed for it’s effectiveness primary PCI is rarely subjected to the same scrutiny . A check angiogram after the procedure , is all that is done . . . and every one leaves the cath lab happily. The effect of primary PCI on ST segment ECG resolution must be documented immediately after PCI. While , It is mandatory to take ECG after 60 -90 mts after thrombolysis , this sort of protocol is rarely followed after PCI.
If the ST segment fails to retract > 50% immediately following PCI the procedure should be deemed to have failed . Further , unlike thrombolysis in primary PCI , the ST segment has to regress within 10 mts , as IRA patency occur instantly .If we apply this criteria , the success rate of primary PCI would be far less than what we believe*
* Not withstanding the official lesion , hardware, related failure. If we encounter a severe triple vessel disease , with a bifurcation lesion and thrombus it’s a tough exercise as we are racing against time .
Primary PCI Camouflaging in semantics
- A successful but delayed primary PCI is actually a failed PCI
- A complicated primary PCI often reach the equivalence of failed PCI
- No reflow is almost synonymous with failed primary PCI as successful correction of no reflow occur in minority.
- Not all TIMI 3 flow is converted into myocardial flow.
- Renal dysfunction following excess dye has a high morbidity
- If patient develops significant LV dysfunction following primary PCI it is a failed PCI.
- Finally if the cost of primary PCI exceeds the insurance limit it is economically a failed primary PCI as the patient has to spend double or triple the amount of sum insured .This stress has resulted in many recurrent coronary events .
Why is it important to recognise failed primary PCI ?
For failed thrombolysis we have a strategy . Unfortunately , even in this modern era we have no useful strategy for failed primary PCI . Handing over a patient to a surgeon in a such a situation is considered by many as a great rescue strategy but in real world it does no good in most of the patient.
Doing an emergency CABG in a sinking patient with a battered coronary artery is no easy job /Many times it only rescues the cardiologists from the embarrassing situation of facing the relatives who ask for explanation.
So , what can be done at best , in failed primary PCI ?
- CABG can be an option but still questionable !
- Most times there is no other option except to fall back on the medical management.
- Intensive anticoagulation and one need to consider even a rescue thrombolytic treatment !
- Some times we can only prey ! Failed primary PCI for a patient in cardiogenic shock with IABP support is near death sentence !
- Remember , success of primary PCI is not in wheeling out a patient alive out of cath lab , with a TIMI 3 flow in the IRA , but in garnering significant myocardial salvage which should have an impact on intermediate and long term outcome .
- Do not ever think primary PCI is a sacred treatment modality in STEMI and the job of the cardiologists ends there. It is vested with lots of important complications – defined, undefined , recognised, unrecognised, reported, and unreported , concealed ,denied, poorly understood, etc etc.
- There are equally effective, less dangerous treatment modality available .
- Decision to do primary PCI must not be based only on the “affordability and availability” of cath lab and expertise !
- In clinical cardiology practice, no procedure is great & nothing is inferior either ! Every thing has to be used judiciously , appropriately and intelligently (Intelligence is synonymous with common sense many times!)
Surgeon’s real time experience of operating on a failed primary PCI. To our surprise , only a handful of surgeons have this experience
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 the 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 look back in time and “constantly scrutinize” 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 . . .
I was recently asked to suggest a topic for debate on STEMI in a major Indian cardiology conference. I wished , this is what we should be mulling over, with a set of virtual guest lectures and special invitees from heaven ! Plenary session : State of the Art STEMI care Time : 11.AM , Speaker : Dr Hippocrates Topic : Aren’t we erring on either side of the Noble profession ? Moderator: Dr. William Osler Chairperson : Dr .Harvey Cushings, Dr,Sir Thomas Lewis ,Dr Paul Wood , Excerpts : “While , vast number of our country-men’s culprit artery doesn’t even get that mandatory Aspirin on time . . . an urban rich man’s distal non-culprit artery is decorated with a fancy bio-vascular scaffold making that innocuous lesion vulnerable in the process as well ! Aren’t we erring on either side in the Noble profession ?
Atrial fibrillation is the most common arrhythmia we encounter in clinical cardiology .Ironically it is uncommon during ACS and extremely rare in association with UA/NSTEMI. Surprisingly , an entity ” Ischemic AF” is not to be found in cardiology literature.
The incidence of AF in STEMI is less than 5%. Occurs more often due to factors other than primary ischemia of atrial musculature. Of-course , AF in association with Infero posterio MI and RVMI is an important trigger for AF.LCX disease is more often associated with AF as it gives up a consistent branch to left atrium.
Though it is tempting to implicate ischemia as a trigger for AF ,most often it occurs , in elderly ,associated COPD ,hypoxia preexisting atrial disease .Acute elevation of LVEDP and stretch of left atrium could be a more logical mechanism.
- AF can bring down the blood pressure.
- Worsen ischemia by increasing the MVO2
- Could be very destabilising in RV infarction
- Surprisingly it is well tolerated in many STEMI patients.
AF in STEMI- Is it an emergency ?
It would appear so. But , if hemodyanmicaly stable one need not panic.Many times they are transient .Correcting hypoxia, optimizing beta blocker would help.
Role of DC Shock , Precautions before shocking & Post shock events
- DC shock is done only if there is hemodynamic instability or ongoing ischemia .(Very difficult to rule out the later )
- Mural LV clots can form even within 24 hours and DC shock embolic strokes may ensue .
- Hence it is mandatory to do an echocardiogram prior to shocking.
Drug of choice
- Class 1c -Flecanide.
- Class 3 -Amiodarone./Ibutilide/
Role of Digoxin
There used to be a concern about usage of Digoxin in the setting of ACS as it pro-arrhythmic , but it remains useful in the management of AF .There is no other anti-arrhymic drug available to control, the heart rate without depression of the LV function
Rate control vs rhythm control
Always aim for rhythm control in the setting of ACS.Rate control is may not be a logical concept in acute settings though Amiodarone does both.
Wide QRS Atrial fibrillation
As we know , AF in STEMI can conduct with aberrancy , and we have a traditional teaching all wide qrs tachycardia are VT in the setting of MI making our patients statistically vulnerable.
After all , both entities lack discernible p waves. At high rates it may be difficult to identify irregularity RR interval. However , one would shock such patients and both AF and VT would respond .All is well that ends well.
AF during STEMI is a risky arrhythmia and needs urgent intervention , but one need not be alarmed .There is a set of protocol . Only hemodynamically unstable AF require DC shock .Many times it is just transient.There has been instances of physician panicky that has resulted in more adverse events .
Posted in Atrial fibrillation, Infrequently asked questions in cardiology (iFAQs) | Tagged atrial fibrillation, atrial fibrillation in stemi, management of atrial fibrillation during stemi | Leave a Comment »
Cardiologists do magic inside the human coronary artery , that too in a live beating heart , unlike the surgeons.Blocks are removed , holes are closed, valves are inserted , scars are burnt, new electrical connections are laid .They do this with relative blind vision with good degree of success. Still, as we aim for more precise interventions we require excellent imaging modalities to assist us.
In PCI of CTO(Chronic total occlusion) the critical element to know is the morphology of the tissue plane , what exactly we borough ? as we navigate through complex, often hard shapeless tortuous tissue tunnels . Our patients will be surprised to know we are currently doing this with our eyes shut. If only we have a camera guide in the tip of the wire it give us tremendous advantage .
The exiting IVUS technology can only look sideways . Now a new vision is added by annular array of transducer at tip with CMOS sensor .The technology is just coming out it would be use for us in the near future .
Anatomy of the forward looking ultrasonic eye
In this era of synthesized evidence base, one of my intellectually aberrant student asked How can we indulge in a popular coronary procedure with class 1 indication backed by level C evidence ? (As defined by the seemingly invincible guideline committee of various International cardiology organizations .)
I told him ,
- Institutional protocols are to be followed
- Guidelines are to be respected
- Recommendations are to be considered
- Please be reminded all of the above can be rejected outright !
Finally , realise Individual decisions based on sound scientific understanding with zero non academic intrusions will be revered forever !
*Caution : If you think you haven’t yet reached that the level of individuality , come what may , you are expected follow these advisories which are primarily aimed at providing quality care and you will be pardoned of any adversaries as well !
Posted in Cardiology -guidelines, Infrequently asked questions in cardiology (iFAQs) | Tagged evidence based medicine, guidelines vs recommendatios, instituional protocols, medical ethics, protocols | Leave a Comment »
Answer : Most probably B .
What we feel in peripheral pulse , is one weak and the one strong beat in sequence .The later is due to post VPD potentiation. Since there is a compensatory pause , ECG rate (Number of QRS complexes /mt) and pulse rate are same .
Ironically , heart rate and ECG rate are not same as VPDs impact mitral valve more than aortic valve and cause additional S 1 than S 2 making heart rate considerably more than pulse rate and logically it must be double the pulse rate . This may be difficult to appreciate by auscultation, but can be documented by phono-cardiogram or by M mode echocardiogram.
Posted in Auscultation, Cardiology -unresolved questions | Tagged absent s 2 in pulse deficit, effect of vvpd on aortic and mitral valve closure, heart rate in bigeminy, mechanism of pulse deficit, more s1 and less s2, paired pacing and vpds, pulse deficitin bigeminy, pulse rate in bigeminy, ventricular bi-geminy, ventricular ectopic beats | Leave a Comment »
The gradient across coarctation is not simply (& solely ) determined by degree of obstruction , as one would believe.Understanding the hemodynamics and various factors that can influence the gradient is essential .Relieveing the obstruction /gradient by stent or surgery may not be synonymous with successful treatment as we understand now the entire aorta right from the root to abdomen can influence the gradient ,along with systemic factors.We also know , some of these patients harbor histological abnormalities in the entire stretch of Aorta what is being referred to as pan aortopathy , that may influence the long-term outcome.
Posted in Aortic diseases, coarctation of aorta, Infrequently asked questions in cardiology (iFAQs) | Tagged coarctation of aorta, collaterals in coarctation, cp stent in coarctation, effect of bicuspid valve on coarctation gradient, effect of ht on gradient in coarctation, gradient across coarctation of aorta, mechansim of hypertension in coarctation, renal hypertension in coarctation | Leave a Comment »
A cardiologist is a physician who has trained himself in a special way to deal with any problem of heart.Ironically , it exists only on paper.The field has developed so vast no one can master everything .There is no such “Pan or global cardiology expert” .In fact it would be shortly become unethical to try to become one !
Pediatric cardiology has developed into such a big field , doing a echo in newborn or infant has become a comprehensive job and requires special talent .This unique and excellent study from Narayana Institute , Bangalore published in the prestigious Annals of pediatric cardiology throws up interesting realities about the quality of echo report done by adult cardiologists in children .The error rate appears huge and stands at prohibitive 38%. While many errors were minor , major were also not insignificant (23%)
With bulk of the pediatric echo involves in the critical decision making process of device closures and interventions the data required becomes vital .The commonest cause for error is probably not due lack of knowledge and but to due to lack of commitment and continuous exposure in doing echocardiograms in those age group.
While this paper decently skirts the issue of quality of pediatric echo done in medium sized hospitals without pediatric cardiology service ,I can say the error rates or inadequate reportage could be significant in such hospitals with apparently good ranking .
Of course ,we have many adult cardiologist who do excellent pediatric work , It looks like , as a general rule performing pediatric echocardiograms by non -institutionalized adult cardiologist may not be appropriate ! It may be wise for them to avoid doing echocardiogram in small infants with truly complex disorders (even perceived complex) till they gain the required expertise and confidence.
I recall an adverse issue happened years ago , when I had missed an associated PAPVC in ASD that made my surgeon anxious on table .In a country like ours there is no one to audit our work , “our conscience remains the only option” to deliver the best for our patients especially so, when they are tiny lives in distress.
Who am I to suggest who should do echocardiogram ? , after all every cardiologist is licensed to do that . One simple suggestion would be , if not confident they can at least mention in their report it is only preliminary evaluation and need to be followed up with an expert . I do that whenever its required and gives me peace of mind as well !
More controversies* to come
Can adult cardiologist do pediatric intervention ?
* Controversy : One of the meaning for this word is “It is a thought process set into motion , that aids digging up hidden truths ”
Posted in bio ethics, Cardiology -Therapeutic dilemma, cardiology-ethics | Tagged adult vs pediatric echo report, echocardiography expertise required, errors in echo report, errors in echocardiography, ethical issues in cardiology, inadequate echocardiogram, incomplete echocardiogram, mistakes in echo report, pediatric echocardiography who should do ? | Leave a Comment »