Is FFR heart rate dependent ? If yes, how significant it is?
FFR is the ultimate hemodynamic test that measures the physiological Impact of lesions. Just pass a manometer tipped wire across the lesion and note the pressure drop (with or without Adenosine) All you have to remember is two cut off values  .8 for FFR and .9 for IFR. Abracadabra . . . yes you got the answer , whether to proceed with PCI or not? It’s as simple as that. We are no longer blind to physiology to which many coronary purists often criticize us. Coronary physiology simplified Now , answer this question. Is FFR heart rate dependent? If yes, how significant it is? This simple question on coronary physio...
Source: Dr.S.Venkatesan MD - October 2, 2019 Category: Cardiology Authors: dr s venkatesan Tags: fame study ffr quantitative coronary angiogram fractional flow reserve ffr ifr IFR QFR instantaneous flow reserve Limitations of FFR pressure wire channel in gruentzig original ptca balloon zurich Source Type: blogs

FFR negative & OCT positive LAD lesion: What shall we do ?
Rules of the PCI game  Mind the physiology. It is the new norm in selecting the lesions for stenting. Now, If physiology is ok, you have to mind the Anatomy and vice versa. If Anatomical (severity of block )is ok, then, you have to mind the morphology and vulnerability. Finally. and most importantly mind the patient’s symptoms and clinical scenario. So what should we do in a case of 70 % LAD with  .9 FFR ? (Still shabby looking, eccentric plaque, looks vulnerable  with a thin cap on OCT) I will stent, no doubt. I shall wait, and treat with Intensive optimal medical management (OMT).High dose statins...
Source: Dr.S.Venkatesan MD - October 2, 2019 Category: Cardiology Authors: dr s venkatesan Tags: Uncategorized acc aha esc steminstemi ccs management guidelines acute coroanry syndrome managment decision making in pci evidence based coronary care fame 1 fame 2 ffr cut off value ffr vs oct forza trial study tct 2019 nstemi unstable a Source Type: blogs

Ischemic cardiomyopathy: Why is it, still searching for a definition?
The term Ischemic cardiomyopathy(ICM)  was originally coined by Dr. Burch from Tulane University, New Orleans, USA in 1970. For many decades there was skepticism regarding the existence of such entity. WHO classification over the years never included this term. ESC working group of 2008  (Elliott P,  European Heart 29(2):270–276) decided not to include CAD as a cause for cardiomyopathy. Even the current MOGES system doesn’t invoke CAD as a cause for cardiomyopathy.  But, I am sure, most of practicing cardiologists would agree, there is a need for such an entity. Why there is m...
Source: Dr.S.Venkatesan MD - September 21, 2019 Category: Cardiology Authors: dr s venkatesan Tags: Criteria and Nomenclature ischemic cardiomyopathy Uncategorized defintion of ischemic cardiomyopathy MOGES classification what is ischemic cardiomyopathy who whf classification of cardiomyopathy Source Type: blogs

The “ World anti-platelet ” boxing championship 2019 !
Conclusions in science is a misnomer . . . )       (Source: Dr.S.Venkatesan MD)
Source: Dr.S.Venkatesan MD - September 20, 2019 Category: Cardiology Authors: dr s venkatesan Tags: anti platelet drug anti platelet drugs antiplatelet guidleines acc aha esc clopidogrel dapt mapt ISAR REACT PLATO trial prasugrel THEMIS TRIAL ticagrelor triton timi 38 treat plato twilight trial Source Type: blogs

Who is the “ Real master ” in Master health check up clinics ?
Master health checks* , superficially look like a perfect modality to practice the greatest medical concept ie “Prevention is better then cure” .Let us detect all human diseases early , prevent its progression, regress it or completely cure it . Absolute bliss is it not? Why then articles such as this one should ever get published, that too in one of the prestigious journal of medicine? *Master health check .( Also referred to as annual General health checks.) While the title itself is provocative, it adds a tag line which is still more a shocker. There are specific well-researched reasons for this prevent...
Source: Dr.S.Venkatesan MD - September 17, 2019 Category: Cardiology Authors: dr s venkatesan Tags: Uncategorized master health check up medical ethics Source Type: blogs

Digoxin in Heart failure: Foxglove blossoms again, please don ’ t crush it this time!
William Withering the British Botanist of 18th century now laid to rest in the St Barthomlew Churchyard ,Edgbaston is known for his astonishing isolation of the wonder moelcule Digoxin from Foxglove. (Of course, let us not forget original old lady Ms. Hutton from Shropshire who was treating epidemic dropsy with a concoction of herbal Tea ) He reported this in the seminal paper “An account of Foxglove’ in the year 1750 and subsequently became a fellow of Royal college of science. (The story of Withering and Digoxin is extensively researched and written by Dr Dennis M, Krikler in a classic review article of 198...
Source: Dr.S.Venkatesan MD - September 14, 2019 Category: Cardiology Authors: dr s venkatesan Tags: cardiac failure history of cardiology dig trial radiance proved history of digoxin Source Type: blogs

Evidence based errors in cardiology . . . urgent need for special cognitive skills !
Preamble Hey dudes, will you stent this 76 year old  fragile man’s Aortic valve ?  It looks shaggy and it seems to be leaking as well.Iam not sure its really tricuspid or not .It is so distorted . By the way , he also has a left main lesion with no protection.What shall we do ? Will the Jena valve do the trick ? My experienced collegue threw this question to a flock of freshly hatched senior residents of a upscale cardiac center.  After rapidly feeding the necessary risk predicting numericals, clinical and hybrid imagery data , they dug deep into the iOS-powered gadget, loaded with latest TAVR app fuse...
Source: Dr.S.Venkatesan MD - September 13, 2019 Category: Cardiology Authors: dr s venkatesan Tags: Uncategorized cognitive skills in cardiology tavr for bicuspid aortic valve Source Type: blogs

DM cardiology course suffers from a 50% entry block … A NEET angioplasty done.
The most premier course in medicine, DM cardiology just got an entry makeover. The qualifying mark was lowered to 20% from the current 50th percentile The reason is many private medical college seats went vacant after the Initial counselling in NEET superspeciality exams. Becoming a cardiologist was a dream come true for those days for us. “You have to read the red covered 3rd edition Brunwald and all clinical chapters from Hurst for two full years” before even to think of writing DM entrance, my senior used to tell me in late 1980s.Yes, life may still be tough in post graduate entrance but, there is an exclus...
Source: Dr.S.Venkatesan MD - September 8, 2019 Category: Cardiology Authors: dr s venkatesan Tags: Uncategorized Source Type: blogs

Whenever my ego bloats up . . . I see this video, to get it deflated !
Whenever we have difficulty in accepting our mistakes or unable to forgive other’s mistake,or when we make big fuss about trivial events in life, I was advised to ask these three questions and Introspect. 1. Who you are? 2.From where did you come ? 3.What for, you are present in this world? It was a really tough ask , until I saw this video. It not only stuns but also humbles us and whatever little knowledge we acquired over the years looks nothing.Yes, whenever my ego tend to bloat up… this 3-minute video never fails to get it deflated. Just one requisite , you need to Imagine it’s you lying there inste...
Source: Dr.S.Venkatesan MD - August 17, 2019 Category: Cardiology Authors: dr s venkatesan Tags: Uncategorized art of forgiving ego ethics education principles of living purpose of life Source Type: blogs

FAQs in STEMI : Why is the 3 hour gap recommended before pharmaco Invasive strategy?
Background STEMI knowledge check : Evidence-based Ignorance I think , It was unfortunate, In the management of STEMI , the two popular strategies of myocardial reperfusion was made to fight with each other as if they are perennial enemies for over two decades. Suddenly, someone with a rare coronary insight thought, why fight each other , they can have a friendly hug and work together. That brought the concept of pharmco -Invasive approach or strategy(PIA) backed up by STREAM, FAST-MI, and TRANSFER AMI studies.Yes, it appears to work well and devoid of all the early adverse events of pPCI. (Much to the dismay of ardent fans...
Source: Dr.S.Venkatesan MD - August 14, 2019 Category: Cardiology Authors: dr s venkatesan Tags: acute coronary syndrome Cardiology - Animations Cardiology -Interventional -PCI Cardiology -unresolved questions cath lab tips and tricks Infrequently asked questions in cardiology (iFAQs) open artery hypothesis STEMI STEMI -Managment ST Source Type: blogs

Localising “ Angina related artery ” ( ARA ) in UA/NSTEMI : Can we differentiate culprit artery from lesion ?
Identifying the culprit after a criminal event may be easy for the police.For cadiologists investigating  the crime scne after a coronary event, It is a different story. (Of course, localization of IRA after a STEMI may not be really difficult.) But , when a patient is having UA  and coronary artery shows multiple lesions, we do have real diagnostic issue. The general dictum could be tightest lesion or  complex eccentric lesions with thrombus is likely to be the culprit. This has important therapeutic Impication as we are argued to address the active lesions first. The following study was done in 2009 trying...
Source: Dr.S.Venkatesan MD - August 11, 2019 Category: Cardiology Authors: dr s venkatesan Tags: Uncategorized Source Type: blogs

Understanding Ischemic mitral regurgitation
The mechanism of MR in ischemic /Functional is complex. Technically, pure ischemic MR should have a structurally normal leaflet and the subvalvular mechanism dominates But,the combination of the two is also prevalent. In fact, a degenerative component is added to this in many elderly patients. Mechanism of Ischemic mitral regurgitation Any of the following may contribute either alone or in in different combinations. Global LV dilatation with or without annular dilatation Spherical left ventricle Altered inter papillary muscle distance (Degree and direction of  posterior vs apical displacement of pap muscle) Chordal s...
Source: Dr.S.Venkatesan MD - July 16, 2019 Category: Cardiology Authors: dr s venkatesan Tags: Mitral annulus -Functional mitral regurgitation ischemic functional mitral regurgitation mitraclip mitral valve tethering neo chordae implantation papillary muscle papillary muscle dysfunction secondory mitral regurgitation valve in valve Source Type: blogs

Understanding Ischemic mitral regurgitation … think of a tethered cow that ’ s randomly grazing !
The mechanism of MR in ischemic /Functional is complex. Technically, pure ischemic MR should have a structurally normal leaflet and the subvalvular mechanism dominates But,the combination of the two is also prevalent. In fact, a degenerative component is added to this in many elderly patients. Mechanism of Ischemic mitral regurgitation Any of the following may contribute either alone or in in different combinations. Global LV dilatation with or without annular dilatation Spherical left ventricle Altered inter papillary muscle distance (Degree and direction of  posterior vs apical displacement of pap muscle) Chordal s...
Source: Dr.S.Venkatesan MD - July 16, 2019 Category: Cardiology Authors: dr s venkatesan Tags: Mitral annulus -Functional mitral regurgitation ischemic functional mitral regurgitation mitraclip mitral valve tethering neo chordae implantation papillary muscle papillary muscle dysfunction secondory mitral regurgitation valve in valve Source Type: blogs

Was the past perfect ? I don ’ t know, but the future looks tense … welcome on-board, to automated ACS management.
Charles river esplanade ,Boston* : A healthy middle-aged man who was jogging quietly, while his heart was under intense scrutiny by the bionic eyes of Apple i-watch’s smart patch electrode. Suddenly, it detected some bizarre ST segment fragmentation (Seems it can predict in advance , Ischemic signals 10 minutes prior to onset of ACS ) The built-in cosmos direct GPS instantly alerted & summoned a titanium powered Space X drone that pulled the patient from the riverside to the nearest human wellness port . It dropped him through a remotely accessed split glass roof right inside the hybrid heart lab, to find , men ...
Source: Dr.S.Venkatesan MD - June 23, 2019 Category: Cardiology Authors: dr s venkatesan Tags: acute coroanry syndrome Clinical cardiology Ethics in Medicine Hippocratic oath history of cardiology Histroy of medicine Left main disease Medical ethics Primary PCI Source Type: blogs

Syncope evaluation from ECG: A check list and a focused review.
In the evaluation of syncope, history is most important to arrive at a diagnosis.The first step is to confirm whether its truly a syncope or (Metabolic/TIA or seizure. We are easily carried away by the urge to order a Holter monitoring routimely. In reality, the yield is too low (3-5sec Or it may lead to Brady (Pause) dependent escape VT. A pause can be a sinus arrest, Pause or SA block .If pause ends with a junctional escape it becomes a arrest. Look PR interval specifically(A bifasicular block shouldn’t be missed .It can be more dangerous than say a congenital CHB)PR interal represents condcution from SA node to Pu...
Source: Dr.S.Venkatesan MD - June 10, 2019 Category: Cardiology Authors: dr s venkatesan Tags: Uncategorized Source Type: blogs

Master health musings : Where did Alexander the Great, checked his LDL and Chenghis khan recorded his BP ?
A middle-aged man a Biotech engineer, who is just back from his annual health check, sitting in front of me with a deeply anguished face and said “Doctor my LDL is 130mg, and my diastolic BP is 90 mmHg and fasting sugar is 120 mg .I am very much worried about my future” Wait , let me go through your file, I said , Isn’t a serious Issue doctor? No, its not , But , doctor, I have read about ASCOT, SPRINT and HOPE-3 trials. I guess they tell us to keep the LDL, blood sugar and diastolic BP all these three parameters around 80. Isn’t doctor? He went on to add, that his old fashioned family physician ha...
Source: Dr.S.Venkatesan MD - June 2, 2019 Category: Cardiology Authors: dr s venkatesan Tags: Uncategorized master health check up in cardiology preventive health care Source Type: blogs

Five cardinal principles of practicing “ Modern Medicine ” (un)successfully
Somehow the concept of  Evidence based medicine (EBM )never excited me in spite of great strides it has made. Probably the main reason for this is, EBMs origin, quality, and credibility is currently severely compromised. (Though It appears to ooze science 24/7 and make us believe in it too !) Herewith, sharing some of the forbidden thoughts(with lots of pun)  for a (un)successful practice of EBM. This is definitely not meant for young and novice medical professionals. Strictly for the ones who can segregate sense from non (S) Evidence-based Doubting    Reference (Source: Dr.S.Venkatesan MD)
Source: Dr.S.Venkatesan MD - May 19, 2019 Category: Cardiology Authors: dr s venkatesan Tags: Uncategorized bioethics dr venkat quotes ethics of medicine evidence based medicine future of medicine hippocratic quotes practice guideline for medicine principles of practice of medicine Source Type: blogs

Watch this for a minute . . . keep your blood vessels healthy life long !
https://drsvenkatesan.files.wordpress.com/2019/05/vid-20190504-wa0014-1.mp4   Yes, Its “evidence-based fun”. Forget all those anti-platelet trial dramas … showing in the cardiovascular theatres near you . There is only one genuine drug , that’s the good old humble Aspirin . Mind you ,none of other  actors can ever be imagined for primary prevention. By the way , there is absolutely no controversy for the role of Aspirin in secondary prevention after established CAD.(We know , how Aspirin has taken up a critically  Integral role in saving the life of the stents  as well as  ...
Source: Dr.S.Venkatesan MD - May 5, 2019 Category: Cardiology Authors: dr s venkatesan Tags: Uncategorized arrive and ascend study primary prevention of cad with aspirin Source Type: blogs

Found the secret of successful medical practice … in just three seconds !
  *When I tried to condense three decades of my learning into the medical profession in three lines, I scribbled this. Sorry folks, if It doesn’t sound scientific for some of you!  By the way, What is successful medical practice? Success for the Doctor, patient or both?  The answer to this question is never simple.        (Source: Dr.S.Venkatesan MD)
Source: Dr.S.Venkatesan MD - April 29, 2019 Category: Cardiology Authors: dr s venkatesan Tags: cardiology-ethics Quotes Science and Religion Uncategorized best medical quotes briany quotes dr venkatesan quotes hippocrates quotes madras medical college dr s venkatesan chennai medical ethics sir william osler Source Type: blogs

Physiological pericardial effusion of pregnancy : Incidence and mechanism
Pericardial effusion can be detected in many normal pregnancies. The Incidence is up to 40%.The normal fluid within the pericardial sacs is around 25ml.A thin sheet of echocardiogrspbuc fluid collection in diastole and up to 5mm is considered mild. A trace  or minimal effusion may be a better terminology that describes most physiological pericardial fluid compartment. They have no physiological significance. Mechanism is due to overall increase in size of vascular compartment and especially the right heart volume overload. Pericardial fluid drains through systemic pericardial veins and lymphatic channels alos drain in...
Source: Dr.S.Venkatesan MD - April 26, 2019 Category: Cardiology Authors: dr s venkatesan Tags: Uncategorized Source Type: blogs

Random thoughts: If extreme poverty is a disease . . . what about uncontrolled affluence ?
Poverty is the cruelest  disease of mankind , the infective vector is not any deadly HINI or retro virus , but mostly the fellow humans themselves ! This is why WHO has included poverty in the ICD code (Z59.5 ) as a disease . I used to wonder , as a member of Noble profession , should we fight against this disease or be happy to  spend my entire life time cleaning the coronary arteries of affluent human-beings and earn few bucks ! Can growth of money eliminate poverty ?  We may think so  . . .  but it  doesn’t most times .Of course affluence can get more jobs to poor and logically redu...
Source: Dr.S.Venkatesan MD - March 8, 2019 Category: Cardiology Authors: dr s venkatesan Tags: bio ethics medical quotes affluence as a disease medical ethics mitosis of money modern medical care money and life oncological aspects of money multiplication principles of life Source Type: blogs

“ Myocardial intelligence ” and ability to survive Ischemia !
One popular definition of Intelligence goes something like this  “It’s a global capacity  of a living organism  to deal effectively with environment and live peacefully” When myocytes are confronted with acute ischemia , they  don’t always  jitter . It expresses many behavioral pattern.The damage inflicted is variable as  the molecular mechanism of ischemic tolerance appears to be a virtue ! This might make  much revered time window of myocyte ischemia irrelevant .Each cell has got a unique capacity to survive or die . In chronic ischemia this myocyte intelligence ...
Source: Dr.S.Venkatesan MD - March 1, 2019 Category: Cardiology Authors: dr s venkatesan Tags: cardiac physiology acc aha stemi guidelines ischemic post condtioning ischemic post condtionining ischemic precondtioning myocardial intelligence no reflow Source Type: blogs

Some thoughts about Origin , Genesis and Mechanism of palpitation !
Not every one feels the palpitation during tachycardia / Bradycardia /VPDs , Why ? Palpitation is awareness of one’s own heart beat. It is a complex perception of sensation at cortical level (like dyspnea) . It can occur during physical and mental exertion.However , if it occurs without any physiological reasons , it becomes abnormal. It can mean an abnormally heart in terms of  heart rate , rhythm or  raise in stroke volume. The first rule of palpitation is both tachycardia and bradycardia can cause it. Tachycardic palpitation is due to valve motion and braducardic palpitation is due to both moti...
Source: Dr.S.Venkatesan MD - February 24, 2019 Category: Cardiology Authors: dr s venkatesan Tags: cardinal symptom in cardiology Cardiology - Clinical Cardiology -Clinical signs Clinical cardiology Palpation mechansim of palpitation receptors for palpitation sensation of palpitation Source Type: blogs

Safe MR jets in PTMC : They should be a central jet , can even be little more than mild !
Significant MR is a contraindication for PTMC. However,  If MR jet is central , and mild (some times little more than mild as well ) PTMC can be safely done. The MR may not worsen .It may even disappear. Note: Eccentric MR jets are indirect evidence for sub valvular disease. Its very likely to get worsened and may require a mitral valve replacement . Here is patient with severe mitral stenosis, the MR is in all probability safe. Angle of eccentricity  One must realise , the eccentricity of a jet is not very objective .What may appear as central jet in long axis may be wall hugging in 4 chamber view. This...
Source: Dr.S.Venkatesan MD - February 14, 2019 Category: Cardiology Authors: dr s venkatesan Tags: PTMC PTMC -Tips and tricks rheumatic heart disease Uncategorized Source Type: blogs

Safe MR jets in PTMC : They should be central jet and can even be more than mild !
Significant MR is a contraindication for PTMC. However,  If MR jet is central , and mild (some times little more than mild as well ) PTMC can be safely done. The MR may not worsen .It may even disappear. Note: Eccentric MR jets are indirect evidence for sub valvular disease. Its very likely to get worsened and may require a mitral valve replacement . Here is patient with severe mitral stenosis, the MR is in all probability safe.   Incidentally this patient also had another antomical adversary , the bulge of IAS into right atrium. This can happen two ways .Septal aneurysm or a normal septum bulging to RA ...
Source: Dr.S.Venkatesan MD - February 14, 2019 Category: Cardiology Authors: dr s venkatesan Tags: PTMC PTMC -Tips and tricks rheumatic heart disease Uncategorized Source Type: blogs

Safe MR jets in PTMC
Significant MR is a contraindication for PTMC. However,  If MR jet is central , and mild (some times little more than mild as well ) PTMC can be safely done. The MR may not worsen .It may even disappear. Note: Eccentric MR jets are indirect evidence for sub valvular disease. Its very likely to get worsened and may require a mitral valve replacement . Here is patient with severe mitral stenosis, the MR is in all probability safe.   Incidentally this patient also had another antomical adversary , the bulge of IAS into right atrium. This can happen two ways .Septal aneurysm or a normal septum bulging to RA ...
Source: Dr.S.Venkatesan MD - February 14, 2019 Category: Cardiology Authors: dr s venkatesan Tags: PTMC PTMC -Tips and tricks rheumatic heart disease Uncategorized Source Type: blogs

Critical gaps in STEMI knowledge base : What is the relationship between “ Time window ” and “ Age ” of IRA thrombus ?
Cardiologists are grappling with at least  half a dozen time windows  in the management of STEMI. (It can be combinations of any of the following :Symptom – DAPT Loading – Door – Needle /Balloon-Sheath, wire crossing etc ) Time windows are Important in choosing the right (or no)modality of re-perfusion . Though superiority of  primary PCI  is thought to be established in academic community , it  may not be in real world. Published studies that suggest pPCI is superior to lysis at any time window  still lack good evidence. Why is this long drawn confusion&n...
Source: Dr.S.Venkatesan MD - February 10, 2019 Category: Cardiology Authors: dr s venkatesan Tags: cath lab tips and tricks PCI PTCA Hardware Primary -PCI STEMI STEMI -Managment STEMI-Primary PCI Thrombolysis how to estimate the age of thrombus in stemi acs soft vs hard thrombus in stemi thrombus hardening time thrombus organising t Source Type: blogs

What is Interventional cardiology ? I don ’ t know , . . I am in pursuit of a curious new definition !
Let me see how many find sense in this Nonsense ! (Source: Dr.S.Venkatesan MD)
Source: Dr.S.Venkatesan MD - February 2, 2019 Category: Cardiology Authors: dr s venkatesan Tags: Uncategorized cardiology definition for interventional cardiology ethics in cardiology What is Interventional cardiology Source Type: blogs

Evidence less cardiology : Is “ No-flow ” better than “ No-reflow ” in STEMI ?
Cath labs are propably the best place to practice preventive cardiology . . . Practice of medicine is primarily guided by Infinite Information , plenty of Intuition, little bit of Intelligence and unquantifiable amount of Ignorance.The science of coronary reperfusion is standing example for variable mix of the above.The term no reflow is a jargan used liberally in cath labs right from first year fellow to super consultant without knowing what exactly they mean by it. What really is No-reflow then ? The academic definition :According to Kloner no-reflow is defined as suboptimal myocardial reperfusion through a part of coron...
Source: Dr.S.Venkatesan MD - January 26, 2019 Category: Cardiology Authors: dr s venkatesan Tags: Uncategorized Source Type: blogs

How to ship a dead heart . . . with an assured life on delivery ?
Human body is intertwined collection of lives of Individual organs.We believe death occurs when brain dies , respiration stops and circulation ceases . Curiously ,when life ends , these organs  don’t die as a single unit . These three events can happen in any of the six possible permutations.Each organ takes different times to die after loss of life.It is like a crashed computer , where the mother board /RAM memory may be transferred to another and be functional . Out of these three , heart function appears to be supreme as it can function without the need of brain (Science of brain-death) and keep the body...
Source: Dr.S.Venkatesan MD - January 5, 2019 Category: Cardiology Authors: dr s venkatesan Tags: Heart transplantation donor heart transport transmedics Source Type: blogs

ACS mimickers in ER : Wish I call it “ Ischemic ” pleural effusion ?
A middle aged women , with acute onset left sided chest pain and ECG changes was seen by a general physician. He had little hesitation in labeling the patient as  ACS( To be precious he reported the ECG as lateral wall Ischemia) and asked for an echocardiogram to rule out a heart attack  (This is how cardiology is practiced in many areas) . This patient came to my lab  for the Echocardiogram .The echo window was poor , It showed a structurally normal heart and there was no pericardial effusion. I suspected something systemically wrong in this patient and asked for a X ray chest . Subsequent scrutiny o...
Source: Dr.S.Venkatesan MD - December 28, 2018 Category: Cardiology Authors: dr s venkatesan Tags: acute coronary syndrome Causes of T wave Inversion ECG changes in pleural effusion mechanism of ECG changes in pleural effsuion pleuro pericardial effusion pleuro pericardial ligamnet pleuro pericardial rub Source Type: blogs

R on P ventricular ectopic : How common it is ? What is the significance ?
    This post is being updated.   (Source: Dr.S.Venkatesan MD)
Source: Dr.S.Venkatesan MD - December 22, 2018 Category: Cardiology Authors: dr s venkatesan Tags: Uncategorized Source Type: blogs

The crazy science of coronary reperfusion : When TIMI 1 & 2 beats “ TIMI 3 ” in the myocardial salvage race . . . cardiologists get confused !
The prime job of cardiologists is to restore coronary blood flow in an emergency fashion. While we do this with reasonable success ,there is still a missing link between our Initial aim and achieved goal. It’s all too common situation in any busy cath lab , to see two similar STEMI patients with identical time window & proximal LAD as IRA , in totally different scenarios. In the first patient we find a trickle of flow in LAD , who is relatively comfortable  with normal LV function (In whom , emergency primary PCI might appear redundant.) While the other patient , even after rapidly established TIMI...
Source: Dr.S.Venkatesan MD - December 8, 2018 Category: Cardiology Authors: dr s venkatesan Tags: Uncategorized Source Type: blogs

Ignorance based cardiology : How common is “ myocardial congestion ” in cardiac failure ?
We learn from basic physiology  lessons that human body is made up of 60 % water. What about heart ? There is no reason for the heart should behave differently from rest of the body . If my  assumptions are correct when the normal heart weighs 300g  , 180g of which should be  be water. The same thing could be applicable for LV mass( * Reference requested) Is there myocardial congestion in cardiac failure ? Genesis of edema in any tissue depends on local hydrostatic pressures, tissue resistive forces, osmotic balance, and cell membrane permeability. In the myocardium individual contri...
Source: Dr.S.Venkatesan MD - November 27, 2018 Category: Cardiology Authors: dr s venkatesan Tags: cardiac failure Cardiac MRI Cardio Nephrology effect of dialysis on myocardial water content lv amss and myocardial edema myocardial edema and ckd chronic kidney failure myocardial interstitial edema myocardial water imaging water logging Source Type: blogs

My life time clinical coronary skill went in vain . . . when this patient entered my clinic with chest pain !
Evening cardiac clinic is generally a relaxing place until an occasional patient  with vague chest discomfort present with this sort of an ECG . He was a 68 y old hypertensive and was on Tablet Amlodipine .After a cursory look at his ECG , eyes wandered to look for some specifics. Suddenly ,my  ECG reading skill was stretched . Is it really LVH ? or Ischemia ? I asked for any old ECG which he couldn’t provide. I had to blink  more than a moment , before asking him to describe his chest pain in detail one more time . I got almost convinced it was not ACS  since he was having only localized pa...
Source: Dr.S.Venkatesan MD - November 10, 2018 Category: Cardiology Authors: dr s venkatesan Tags: acute coroanry syndrome acute coronary syndrome Clinical cardiology lvh vs ischemia primary vs secondary st t changes triaging chest pain Source Type: blogs

Why pleural effusion is more common on right side in cardiac failure ?
We know pleural effusion (hydrothorax) is disproportionately more common on right side in cardiac failure.Though its a well observed phenomenon, the mechanism of which  has not been clear to us. It could be due to multiple  anatomical , physiological factors.   *The are  right and left lymphatic (Thoracic) ducts that drain the corresponding lungs and pleural space . There can be overlap and contribute to the differential occurrence of pleural effusion   Reference  A meticulous paper written some 75 years ago (1946) from Harvard medical school teach us some important points in this phenome...
Source: Dr.S.Venkatesan MD - October 30, 2018 Category: Cardiology Authors: dr s venkatesan Tags: cardaic physiology cardiac physiology Cardiology Patho physiology Clinical cardiology Infrequently asked questions in cardiology (iFAQs) hydrothorax hydrothorax in cardiac failure pleural effusion in cardiac failure right vs left pleural e Source Type: blogs

Is cardiac valves really (a)vascular structures ?
Though heart is known primarily as a pump, it is the four cardiac valves that ensures the critical , non-stop unidirectional flow that sustain the circulation . It is to be recalled these valves originate in the very early days of cardiac development when the primitive heart tube loops , even as the chambers expand from primitive ventricle. Mesenchymal differentiation controlled by various genes that cleaves the valve from myocardial tissue. While heart by itself is the supreme vascular organ ,  its surprising  few structures inside the heart , like the valves are quiet avascular ( or is it really so ?)...
Source: Dr.S.Venkatesan MD - October 18, 2018 Category: Cardiology Authors: dr s venkatesan Tags: cardiac embryology Embryology : Heart valve development Infective endocarditis : Pathology valvular heart disease blood supply to heart valves hematogenous spread of infective endocarditis how bacteria reach mitral valve in infective endocardi Source Type: blogs

Coronary artery and veins are married life long . . . with a purpose !
Cardiologist are always worried about the supply side of coronary blood flow. It’s fair enough, we can condone our brain for this one way thinking , afterall arterial supply remain the life-line for the heart. Some of us could (should) realise the importance of these  humble coronary veins which are anatomically and physiologically tied together.Its existence is as unique as their arterial counterpart.Coronary blood flow of about 250 ml traverses both the arms every minute.Imagine the scenario if the veins refuse to clear the blood from previous cardiac cycle . . . total hemodynamic chaos rig...
Source: Dr.S.Venkatesan MD - September 9, 2018 Category: Cardiology Authors: dr s venkatesan Tags: cardaic physiology cardiology-Anatomy coronary sinus anatomy and physiology coronary sinus filling and emptying time drsvenkatesan coronary veno occlusive disorder coronary venous circulation acute coronary sinus syndrome coroanry vein cor Source Type: blogs

Primary prevention of CAD with Aspirin : Why we are asking same research question for over 50 years & still go wanting ?
Thousands of delegates* converge annually in glittering convention centers on a regular basis to present high quality research. It’s all about overflowing seminar halls, stunning speeches , Intense questions , adoring debates , cozy discussions in grand dinner nights . The meet continues further, as news breaks in global TV shows, spreads in non-stop handles of twitter after igniting the face books. Finally , it ends over the week-end ! (It has to you know ! ) . . . Every one flies back, only to come back next year to ponder “almost the same issue”  all over again. (Some times the questions are left ...
Source: Dr.S.Venkatesan MD - August 31, 2018 Category: Cardiology Authors: dr s venkatesan Tags: Preventive cardiology Primary prevention of CAD Primary prevention studies Public Health Public health issues What is the role of aspirin for primary prevention of cad Source Type: blogs

This Innocuous looking ECG made me scratch the basics of EP without an answer !
This 70 year old man in routine check up showed up this ECG. What is it ? a  quick debate ensued ! Is this RVH RBBB Or Both ? Neither RBBB nor RVH Wrong lead placement Is it a normal ECG after all ? I thought it was RVH. (do considered RBBB) but since lead V 2 showed tall R , I was more than sure RVH was likely . Many voted for RBBB. .Some others said RBBB can never occur in monophasic form.I said it’s possible. Some body challenged me without Echo Imaging a  monophasic RBBB can never be differentiated from RVH. After a mini argument I reluctantly agreed.Yes, it seemed there is no way to differentia...
Source: Dr.S.Venkatesan MD - August 11, 2018 Category: Cardiology Authors: dr s venkatesan Tags: cardiology -ECG RBBB vs RVH how to diagnose RBBB in RVH and vice versa rvh in rbbb tall r in v1 differential diagnosis Source Type: blogs

Doctor . . , What about “ Pharmaco-Non Invasive ” approach for my husband ?
A young man aged around 40 years, had a STEMI was promptly thrombolysed in a small hospital located about 40 KM away in the suburbs of my city Chennai. They did an awesome job of saving the patient life and salvaging the myocardium. Now begins the story . . . one of the non-medical person who is the owner of the hospital has an unfortunate working  business relationship with a frighteningly big nearby hospital  which had signed a memorandum of irresponsible understanding . It demanded any  patient who arrives in the small hospital with MI should be transferred at earliest opportunity to them. ...
Source: Dr.S.Venkatesan MD - July 21, 2018 Category: Cardiology Authors: dr s venkatesan Tags: Cardiology -Interventional -PCI Cardiology -Therapeutic dilemma Cardiology -unresolved questions Primary -PCI newer concepts in acute coronary syndrome pharmaco non invasive approach pharmaco-invasive approach rescue pci Source Type: blogs

Friendly Infarcts in ACS : Ischemic mitral regurgitation  and the Papillary muscle paradox !
Ischemic MR is a critical entity in determining the long-term survival in post MI patients as well as dilated cardiomyopathy. (Originally described  by J. H. Philips Ann Intern Med. 1963;59(4):508-520) The mechanism of MR  can really be complex .We know mitral apparatus consists of  six components.The sub valvular apparatus plays a key role. LV  free wall especially the inferior and lateral segments which subtends the two papillary muscle has a critical role in maintaining the mitral valve competency . There seems to me a complex mechano -anatomical behavior of subvalvular structures in ...
Source: Dr.S.Venkatesan MD - July 18, 2018 Category: Cardiology Authors: dr s venkatesan Tags: Dilated cardiomyopathy Mitral regurgitation mechanism of ischemic mitral regurgitation papillary muscle dysfunction Source Type: blogs

What is the blood supply for the coronary artery ?
One may recall some stunningly simple facts from our high school biology classes that every living cell needs energy on a moment to moment basis. Blood vessels which take care of the vital organ’s energy supply also need the same blood (Nutrients /Oxygen) for its own survival. Coronary arteries carry about 250 ml of blood every minute , 24/7 supplying ATP enriched fuel to the heart. Who is feeding these delicate vessels which carry on this life-sustaining work ? It is easier to assume the three layers of the blood vessels which are bathed with blood would never suffer from Ischemia. Reality is different .Blood ves...
Source: Dr.S.Venkatesan MD - July 10, 2018 Category: Cardiology Authors: dr s venkatesan Tags: Uncategorized Source Type: blogs

What is the blood supply for coronary artery ?
One may recall some stunningly simple facts from our high school biology classes that every living cell needs energy on a moment to moment basis. Blood vessels which take care of the vital organ’s energy supply also need the same blood (Nutrients /Oxygen) for its own survival. Coronary arteries carry about 250 ml of blood  every minute , 24/7  supplying ATP enriched fuel to the heart. Who is feeding these delicate vessels which carry on this life-sustaining work ?   It is easier to assume the three layers of the blood vessels which are bathed with blood would never suffer fro...
Source: Dr.S.Venkatesan MD - July 10, 2018 Category: Cardiology Authors: dr s venkatesan Tags: Uncategorized Source Type: blogs

Side branch sacrifice : Smart cardiologists shall do it scientifically !
This study has taught us most side branches retain good FFR give us more confidence to sacrifice the sibling branches of main stem arteries. Final message Practicing cardiology in a truly professional way in cath lab can be tricky.We need to disrespect most of the side branches .Believe in your gut feeling (or your consultant’s.) If you are a sensitive scientific cardiologist do FFR pre / post procedure to the side branch .If compromised physiologically try probing the jailed struts and dilate one of them in absolute blindness , of course with a strong conviction of doing good for the science’s  sake. A R...
Source: Dr.S.Venkatesan MD - June 2, 2018 Category: Cardiology Authors: dr s venkatesan Tags: Cardiology-Coronary artery disese cath lab tips and tricks side branch jailing ffr in side branch jailing what is the significance of side branch compromise what is the significant side branch Source Type: blogs

As CABANA waves a final good bye to catheters in AF . . . let the pulmonary veins rejoice !
There is a tough ongoing rivalry between drugs and catheters to conquer the commonest electrical chaos in human heart, namely Atrial fibrillation (AF). Mind you,the confusion about the importance of this arrhythmia is huge and real.Bulk of these episodes are transient , paroxysmal and do not require rigorous management.While stroke prevention seems to be the major aim and target , the real world scenario seems to tell  a different story. The nomenclature conundrum  AF may be classified as many ways a learned cardiologists can think . Often it’s done with reference to etiology, duration , rate, neural (sympa...
Source: Dr.S.Venkatesan MD - May 31, 2018 Category: Cardiology Authors: dr s venkatesan Tags: Uncategorized ACC AHA ESC guidelines for AF affirm race cabana amiodarone for atrial fibrillation CABANA trial carto pulmonary vein ablations cryo balloon for af ablation heart rhythm society atrial fibrillation guidelines rate vs rhythm c Source Type: blogs

Why routine thrombus aspiration is prohibited in STEMI ?
 It was 1912 , Titanic had just sank off the Atlantic . When the world attention was elsewhere ,  An unassuming young Dr.Herrick J.B  silently working in his Michigan lab  inquisitively proposed thrombus occluding the coronary artery is the chief culprit in acute myocardial Infarction.It took seven  more decades when Davis et all from Glasgow .UK. proved it by doing dramatic angiographic studies  soon after STEMI in year 1979. Now, even after 100 years , we, the confused cardiologists debate endlessly in glamorous global conclaves in exotic locales whether to aspirate these humble lookin...
Source: Dr.S.Venkatesan MD - May 12, 2018 Category: Cardiology Authors: dr s venkatesan Tags: Cardiology -Criteria Cardiology -Therapeutic dilemma cardiology wisdom Coronary angiogram cost effectiveness in cardiology STEMI STEMI -Managment STEMI-Primary PCI Thrombolysis Thrombolysis -Tips herrick davis coronary thrombolysis v Source Type: blogs

Ignorance based cardiology : What is the relationship between blood cholesterol and plaque cholesterol ?
Hyperlipidimia is one of the well-known coronary  risk factor.Serum cholesterol ( Various fractions ) levels are measured to represent that risk. Epidemiologically ,it does a perfect job , however , the fact is , circulating lipids has little correlation with the lipids that’s deposited in the vessel wall. Time and again , we have proven this as severity of CAD has little  to do with the absolute levels of lipid levels.The number  volume of plaques , the thickness of lipid core, and degree of vulnerability  show  poor correlation with circulating lipid levels than  what we would expect.I...
Source: Dr.S.Venkatesan MD - May 5, 2018 Category: Cardiology Authors: dr s venkatesan Tags: Cardiology -Mechnisms of disease dyslipidemia hyperlipidemia stains and ldl cholesterol crystalisation plaque lipid vs serum lipid] relationship between serum lipid and plaque cad burden relationship between serum lipids and plaque lipid con Source Type: blogs

Madras medical college and Yale medical school : The 17th century siblings !
Indian subcontinent has a grand old  history with a great civilization that began even before  the ancient Greek and possibly Egyptian pharaohs .Post renaissance  Europe  made the  British monarchy enter the country in early 1600s .This could be perceived as  a new journey of modern India.In the early days  of  British colonization  through  East India company , the province in  southern Indian Coramandal coast called Madras (Currently  named Chennai) was a key economic and power center. Since the hospitals were the prime  requirement to take care&n...
Source: Dr.S.Venkatesan MD - April 22, 2018 Category: Cardiology Authors: dr s venkatesan Tags: history of cardiology Histroy of medicine elihu yale madras medical college history of madras medical college madras medical college and yale university Source Type: blogs

New generation X-ray chest : Adding an “ echo vision ” to a blind PA view !
Reading X -ray chest can be as blind as a bat flying in the dark . It needs lots of Imagination . (Many times the blindness continues to cath lab as well  during structural interventions is a different story !) Yes ,its true  any one can recognise a cardiomegaly in X-ray  . . . but  Which chamber is responsible for cardiomegaly ? and quantifying each ones contribution to the increased CTR is the critical question.  We know the 4 chambers in the heart are arranged in a complex pre-specified  (Antero -superior and right to left orientation ) still , the CT ratio in X-RAY chest is based on t...
Source: Dr.S.Venkatesan MD - March 25, 2018 Category: Cardiology Authors: dr s venkatesan Tags: cardiac X ray Cardiology - Animations Cardiology - Clinical basics of chest x ray ct ratio how to measure ct ratio in ra lv rv la enlargment xray chest pa view xray chest pa vs ap view xray echo fusion Images Source Type: blogs