PEA cardiac arrest, ROSC, and no STEMI on ECG. Randomized trials say emergent reperfusion is not indicated, right?
This study had a fatal flaw: they did not keep track of all the " Non-STEMI patients " who were NOT enrolled, but instead were sent for immediate angiogram. It was done in Europe, where the guidelines suggest taking all shockable arrests emergently to the cath lab. So it is highly likely that physicians were very reluctant to enroll patients whom they suspected had Occlusion MI (OMI), even if they did not have STEMI. These physicians did not want a patient with an OMI that was not a STEMI to be randomized to no angiogram. This strong suspicion is supported by their data: only 22 o...
Source: Dr. Smith's ECG Blog - November 4, 2021 Category: Cardiology Authors: Pendell Source Type: blogs
ISCHEMIA trial is a tough nut to crack : Don ’ t lose heart, we will some how tame it !
This study (Ref 1) talks about an important issue. How much of the CAD populations in the real world will match the ISCHEMIA trial population? It concludes it is just 32%. It suggests caution to the cardiologists to understand this trial from a proper perspective. Don’t give too much importance, lest we may end up with Inappropriate non-intervention.
https://www.tctmd.com/news/only-minority-stable-pci-patients-meet-ischemia-criteria-study-contends
Sounds too good?
But is it real?
The authors of ISCHEMIA have countered this claim. (Ref 2)If we include all mild and moderate symptom cohort Ischemia s...
Source: Dr.S.Venkatesan MD - November 2, 2021 Category: Cardiology Authors: dr s venkatesan Tags: Uncategorized ACC AHA ESC guidelines for cad stable angina cardiology journal club COURAGE BARI 2D ORBITA ISCHEIMIA ISCHEMIA trial Limitations of ISCHEMIA trial Source Type: blogs
Arrest at the airport, with an easy but important ECG for everyone to recognize
Written by Pendell MeyersEvery once in a while we need to go back and cover some easy but important ECGs.This will be far too easy for most readers of this blog, so please go find a learner and show them this case. Make sure they understand this case well, so that they will be able to learn from the harder versions of this case.A middle aged female suffered sudden witnessed cardiac arrest at the airport, with quick bystander CPR.EMS arrived and found her in VF. She was successfully defibrillated.Her EMS ECG on the way to the ED was sent to us:What do you think?There is likely sinus tachycardia with a prolonged PR int...
Source: Dr. Smith's ECG Blog - September 23, 2021 Category: Cardiology Authors: Pendell Source Type: blogs
Cardiac Arrest at the airport, with an easy but important ECG for everyone to recognize
Written by Pendell MeyersEvery once in a while we need to go back and cover some easy but important ECGs.This will be far too easy for most readers of this blog, so please go find a learner and show them this case. Make sure they understand this case well, so that they will be able to learn from the harder versions of this case.A middle aged female suffered sudden witnessed cardiac arrest at the airport, with quick bystander CPR.EMS arrived and found her in VF. She was successfully defibrillated.Her EMS ECG on the way to the ED was sent to us:What do you think?There is likely sinus tachycardia with a prolonged PR int...
Source: Dr. Smith's ECG Blog - September 23, 2021 Category: Cardiology Authors: Pendell Source Type: blogs
Intravascular Lithotripsy for Severely Calcified Coronary Arteries
Intravascular lithotripsy uses acoustic pressure waves to modify calcium inside the blood vessels, increasing the compliance of the vessel and facilitates stent deployment [1]. The device takes care of one of the important night mares of an interventionalist, the calcified coronaries!
Disrupt CAD III was a prospective multicenter study for the regulatory approval of intravascular coronary lithotripsy [1]. Optical coherence tomography (OCT) was used to assess the mechanism of modification of calcium in a substudy. Primary safety endpoint of Disrupt CAD III was freedom from major adverse cardiovascular events (MACE) of card...
Source: Cardiophile MD - September 15, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiology Source Type: blogs
Laser atherectomy
Laser atherectomy is a novel technique useful in in-stent restenosis, stent under expansion, balloon uncrossable lesions and chronic total occlusions [1]. An important advantage of excimer laser atherectomy over other atherectomy devices is delivery on a standard 0.014-inch guidewire [2]. The technique can be mastered after a short period of training.
Major limitation is the presence of heavy calcification, which requires rotational atherectomy for clearance. But when there is inability to pass a rota wire, laser may be useful in creating an upstream channel to permit rota wire passage.
Laser device works by producing mon...
Source: Cardiophile MD - September 11, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiology Source Type: blogs
How did all those calcium entered my father ’ s coronary artery doctor ?
“It was severe double vessel disease & turned out to be a complex angioplasty in LAD ”
Why doctor? what happened?
It was a hard lesion, there was plenty of calcium deposits. It was not clearly visible in the angiogram. I had to do IVUS. Curiously, the calcium was clustered in all the three planes of the vessel ( intima the media and adventitia) and they projected into the lumen blocking the path.
Image collage representation purpose
Thank you, doctor, how did you manage to remove it,?
It was a real struggle. I had to break the calcium shell before deploying the stent. (What we refer to as...
Source: Dr.S.Venkatesan MD - September 3, 2021 Category: Cardiology Authors: dr s venkatesan Tags: Cardiology -unresolved questions calcium supplementation coronary calcification intimal medial adventitial calcium ivl wolverine angiosculpt opn balloon orbitel atherectomy osteoporosis plaque calcium rotoablator serum calcium vs coron Source Type: blogs
This RCA is trying to teach some basic lessons in ACS
Inferior STEMI, and see the first shot in RCA below. The patient was pain-free and hemodynamically stable at the time of the angiogram. (Don’t wonder how this is possible, defying the fundamental rules learned from animal experiments after acute ligation of the coronary artery)
What needs to be done ?
Go ahead and do a primary PCI as we do in any other IRA.
Be watchful, just pass on the wire, feel the lesion, and decide thereupon. Consider intracoronary lysis.
How about a long stent from proximal to distal RCA?
Kissing the lesion with DEB in the tightest segment (Not a funny opt...
Source: Dr.S.Venkatesan MD - August 22, 2021 Category: Cardiology Authors: dr s venkatesan Tags: Uncategorized ectatatic coronary rca guidewire angioplasty oac noac for coronary ectasia plain balloon angioplasty primary pci Source Type: blogs
How to find which lesion is causing angina in multivessel CAD ?
Yes, it is a triple vessel disease, with one tight lesion and at least two other significant lesions. One of them appears diffuse as well.
Representative Image: Source courtesy DOI: 10.14740/cr548w LicenseCC BY-NC 4.0
“What to do next?. Is he symptomatic? Yes. Definitely has significant angina” but LV function is normal.
“Ok then. If you are daring enough, ask this question”.
Which lesion is causing angina?
No easy answer at all. Try looking for some clues right from history, ECG, stress ECHO, meticulous assessment of individual lesions. Realize, even sophisticated imaging l...
Source: Dr.S.Venkatesan MD - August 20, 2021 Category: Cardiology Authors: dr s venkatesan Tags: Cardiology - Clinical Cardiology -Definitions cardiology- coronary care Ethics in Medicine Uncategorized ACC AHA ESC Guidelines for multivessel cad angina related artery ara vs ira approach to tvd cabg vs pci vs medical maangement ov cad Source Type: blogs
How much ST depression in V2 and V3 is acceptable before you suspect ischemia?
A 60-something woman with h/o bioprosthetic MV replacement and COPD, who is not on anticoagulants (bioprosthetic valves generally do not require anticoagulation), presented after 14 hours of left sided chest pain with radiation down left arm. It woke her up at 0200. She states that now it is worse with deep inspiration and associated with SOB. Here is her triage ECG:What do you think?Here I magnify leads V2-V4:There is almost 1 mm ST depression at the J-point, relative to QRS onset, in lead V3. We don ' t really know about lead V2 because it was placed too high (Negative P-wave shows that it wa...
Source: Dr. Smith's ECG Blog - August 3, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs
Cardiology MCQs
Modified Blalock-Taussig shunt is:
End to side anastomosis of subclavian artery to a pulmonary artery
Side to side anastomosis of main pulmonary artery to aorta
Side to side anastomosis of subclavian artery to a pulmonary artery using a conduit
Anastomosis of superior vena cava to right pulmonary artery
Correct answer: 3. Side to side anastomosis of subclavian artery to a pulmonary artery using a conduit
In classic Blalock-Taussig shunt, the subclavian artery is divided and anastomosed to the pulmonary artery as an end to side anastomosis. In modified Blalock – Taussig shunt, a Gore – Tex graft is used to connect th...
Source: Cardiophile MD - July 4, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiology MCQ DM / DNB Cardiology Entrance Source Type: blogs
Cardiology MCQs
Ischemic preconditioning is mediated by:
ATP-sensitive potassium channel (KATP)
Sodium channel
Ikr, the rapid component of delayed rectifier potassium current
L-type calcium channel
Correct answer: 1. ATP-sensitive potassium channel (KATP)
Blockers of ATP-sensitive potassium channel (KATP) like glibenclamide can prevent ischemic reconditioning. KATP channel opener nicorandil can mimic ischemic preconditioning and it is known as pharmacological preconditioning. Stimulation of adenosine receptors is known to simulate ischemic preconditioning. [Tomai F, Crea F, Gaspardone A, Versaci F, De Paulis R, Penta de Peppo A, Chiari...
Source: Cardiophile MD - July 2, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiology MCQ DM / DNB Cardiology Entrance Source Type: blogs
Ischemic preconditioning
The concept of ischemic preconditioning is that multiple short episodes of ischemia can protect the heart from a later sustained ischemia later [1]. In an experimental study, 4 episodes of 5 minutes each, separated by 5 minutes of reperfusion followed by 40 minutes of occlusion showed 75% reduction in infarct size compared to controls. But this benefit was not there when the final occlusion time was 3 hours. Authors suggested that multiple pre-infarction anginal episodes may have a similar effect on limiting infarct size if myocardial infarction occurs subsequently. Others have suggested that similar mechanism might opera...
Source: Cardiophile MD - July 1, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiology Source Type: blogs
Right ventricular infarction
Right ventricular infarction can be associated with inferior wall infarction. It is due to occlusion of the right ventricular branches of the right coronary artery. The actual prevalence of right ventricular infarction may be underestimated because right sided chest leads are not part of routine 12 lead ECG. In a study which included right sided chest leads V3R, V4R, V5R and V6R, ST elevation of 1 mm or more in any of these leads was found to be a reliable sign of right ventricular involvement. It was a study of 67 patients who underwent serial electrocardiograms and 99mtechnetium pyrophosphate scintigraphy and a dynamic ...
Source: Cardiophile MD - June 25, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiology Source Type: blogs
Percutaneous left ventricular assist devices
This study also documented significantly greater increases in cardiac index and mean arterial blood pressure as well as significantly greater decreases in pulmonary capillary wedge pressure with TandemHeart. Severe adverse events and overall mortality were not significantly different between the two groups.
So we need more large scale studies on both types of percutaneous left ventricular assist devices and possibly improvements in their technical aspects to have a greater impact on survival in cardiogenic shock. Ongoing DanShock trial is one such study to look forward to.
References
Ergle K, Parto P, Krim SR. Percutaneou...
Source: Cardiophile MD - June 22, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiology Source Type: blogs
