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Fractional flow reserve for guiding coronary intervention and functional SYNTAX score
Coronary angiography gives a visual impression about the severity of the stenosis. But it need not imply the actual functional significance of the stenosis in terms of flow physiology. It is often difficult to decide which are the flow limiting lesions when there are multiple stenoses in same or different territories. It is here that the fractional flow reserve estimation helps. FFR is estimated using a guide wire with a pressure transducer. FFR wires have properties similar to the floppy guide wires so that they can passed across coronary lesions back and forth easily to assess the pressure drop across the lesions. The f...
Source: Cardiophile MD - April 22, 2024 Category: Cardiology Authors: Johnson Francis Tags: General Cardiology Source Type: blogs

Is OMI an ECG Diagnosis?
Written by Jesse McLaren A 70 year old with prior MIs and stents to LAD and RCA presented to the emergency department with 2 weeks of increasing exertional chest pain radiating to the left arm, associated with nausea. The pain recurred at rest 90 minutes prior to presentation, felt like the patient ’s prior MIs, and was not relieved by 6 sprays of nitro. Paramedics provided another 3 sprays of nitro, and 6mg of morphine, which reduced but did not resolve the pain. What do you think of the ECG, and does it matter?There ’s normal sinus rhythm, LAFB, old anterior Q waves, and no diagnostic sign of OMI. I sent th...
Source: Dr. Smith's ECG Blog - April 18, 2024 Category: Cardiology Authors: Jesse McLaren Source Type: blogs

What is the risk of ACS after PCI in a CTO related artery ?
CTOs are opened primarily for four reasons Angina which is refractory to drugs Stress test positivity with or without angina Anxiety of having a blocked coronary artery in a self educated patient Cardiologist’s clandestine pride & pursuit* * Personal experience included Some evidence based observation Most of the studies as on today do not give survival advantage of opening a CTO.(DECISION-CTO,EURO-CTO,EXPLORE,IMPACTOR) Opening a CTO, for reasons other than angina (i.e. for relief of dyspnea or improving functional capacity) is largely conjectural and based on randomly accrued data back...
Source: Dr.S.Venkatesan MD - March 16, 2024 Category: Cardiology Authors: dr s venkatesan Tags: Uncategorized cto cto hardware cto trials jcto score open artery hypothesisacc esc aha guidelines Source Type: blogs

No, we can ’ t call OMT, as a re-vascularisation  procedure.
Hi, welcome Mr George, I just reviewed your records. You have three blocks in your arteries supplying the heart. Are they serious Doctor ? Not really, but one of them appear tight What should I do Doctor ? But, I am comfortable Doctor. You may be. But I am not .You need to undergo some re-vascularisation procedure . What do you mean by that Doctor ? It means either a percutaneous coronary intervention with a stent or CABG. Can I get my heart re-vascularised by drugs alone Doctor ? No we can’t . Hmmm , wait, we do have something called OMT/GDMT. Can you put on hold for some time Mr George, ...
Source: Dr.S.Venkatesan MD - February 25, 2024 Category: Cardiology Authors: dr s venkatesan Tags: Uncategorized Source Type: blogs

Acute OMI or " Benign " Early Repolarization?
Written by Willy FrickA man in his 50s with a history of hypertension, dyslipidemia, type 2 diabetes mellitus, and prior inferior OMI status post DES to his proximal RCA 3 years prior presented to the emergency department at around 3 AM complaining of chest pain onset around 9 PM the evening prior. He described it as severe, sharp, and substernal with associated nausea, vomiting, chills, and diaphoresis. The following ECG was obtained. Note that the machine read is" normal sinus rhythm, normal ECG. " Cardiology over read the tracing and signed the interpretation without modification.ECG 1What do you think?The Queen of Hear...
Source: Dr. Smith's ECG Blog - December 27, 2023 Category: Cardiology Authors: Willy Frick Source Type: blogs

Occlusion myocardial infarction is a clinical diagnosis
Written by Willy Frick (@Willyhfrick).  Willy is a cardiology fellow with a keen interest in the ECG in OMI.A woman in her late 70s presented with left arm pain. The arm pain started the day prior when she was at the dentist ' s office for a root canal. Her systolic blood pressure at the dentist was over 200 mm Hg. She was given nitroglycerin which improved her blood pressure, and she completed the procedure. Her arm pain abated. The pain returned that evening and woke her from sleep. She eventually fell back asleep, and woke up feeling normal the next day (the day of presentation). After dinner the day of presentatio...
Source: Dr. Smith's ECG Blog - December 11, 2023 Category: Cardiology Authors: Willy Frick Source Type: blogs

STEMI Breakthrough: Looking beyond Primary PCI with “ Intra-coronary liquid oxygen ”
This study was sponsored by ZOLL® TherOx® . A possible deterrent is the problematic and complex concept of reperfusion Injury. The term Oxygen radicals always sounds sinister .Really I can’t understand how a cell which get injured by the lack of a a particuar gas, get damaged by the same gas .(Oxygen in liquid from might behave differently as in this study ?) I think,its all in timing of delivery of oxygen, and if we start thinking like Einstein, then ,there is nothing called time. cit0923_ft_zoll-1Download Final message Innovation and experimentation is must be allowed as liberally as possible....
Source: Dr.S.Venkatesan MD - November 25, 2023 Category: Cardiology Authors: dr s venkatesan Tags: Uncategorized Source Type: blogs

See this " NSTEMI " go unrecognized for what it really is, how it progresses, and what happens
Written by Nathanael Franks MD, reviewed by Meyers, Smith, Grauer, etc.A man in his 70s with past medical history of hypertension, dyslipidemia, CAD s/p left circumflex stent 2 years prior presented to the ED with worsening intermittent exertional chest pain relieved by rest. This episode of chest pain began 3 hours ago and was persistent even at rest.Triage ECG at Time = 0: Smith: I am suspicious for posterior OMI due to ST depression in V2 and V3Baseline EKG (several months prior):Smith: Now I am even more suspicious of posterior OMI, as the baseline ECG has normal ST elevation in V2 and V3ECG Interpretation:The tri...
Source: Dr. Smith's ECG Blog - November 3, 2023 Category: Cardiology Authors: Pendell Source Type: blogs

What do you think of this ECG that was texted to me?
This ECG was texted to me by a colleague.  I assumed it was from a patient with symptoms compatible with ACS/OMI.What do you think?There is sinus rhythm with RBBB and ST Elevation in V2 which is concordant with the QRS.  The ST segment in RBBB should be ST depression, discordant to the positive R ' -wave (i.e., opposite direction of the upright R ' -wave).  But we sometimes see this concordant STE even in non-ischemic ECGs:PseudoSTEMI and True ST elevation in Right Bundle Branch Block (RBBB). Don ' t miss case 4 at the bottom.This STE suggests OMI, but we have seen many cases like this th...
Source: Dr. Smith's ECG Blog - November 1, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs

STREAM -2, bats for “ half dose ” TNK-Tpa in elderly over pPCI
STREAM trial (New Engl J Med 2013) was a sort of paradigm-creating study, that made Pharamco-Invasive approach – PIA an authentic via-media strategy, trying to accure benefits from both lysis and PCI in the management of STEMI. However, one question remained. Does PIA work safely in the elderly, where bleeding risks are higher? Do they tolerate the double whammy of P and I ? Both procedures keep the blood clotting process tentative for a prolonged period of time. Emprical usage of half dose lysis is not new, is existingn, for more than 4 decades, right from streptokinase days. Now the multi-center STREAM-2 ...
Source: Dr.S.Venkatesan MD - October 13, 2023 Category: Cardiology Authors: dr s venkatesan Tags: Uncategorized Source Type: blogs

Which patient has the more severe chest pain?
ConclusionOnly a weak association between pre-hospital chest pain severity and markers of myocardial injury was identified, supporting more judicious use of opioid analgesia with a focus on patient comfort.___________This article shows that pain intensity is associated with shorter door to balloon times and thus smaller infarcts.  Having severe pain drives people to the ED for faster treatment!  It is good to have terrible pain!  And as we have shown before, morphine leads to slower times to treatment and worse outcomes.Chest Pain Severity Rating Is a Poor Predictive Tool in the Diagnosis of ST-Seg...
Source: Dr. Smith's ECG Blog - September 26, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs

What happens to FFR after stenting ?
A simple question with mammoth repercussions in the revascularization world. How was the question ? Was it difficult ? Don’t worry, it wouldn’t be the same even for elite cardiology experts worldwide. It is not a Himalayan task, though, to find an answer. All it requires is a simple FFR run through pre and post PCI (Now RFR, iFR, QFR). Surprisingly, very few inquisitive minds wanted to do this. I can find 5 related papers. The fifth one is very specific: REPEAT-FFR study. Go through at least that one paper and find the answer yourself. Cardiology fellows it is worth reading about this important stud...
Source: Dr.S.Venkatesan MD - July 8, 2023 Category: Cardiology Authors: dr s venkatesan Tags: Uncategorized acc aha bari 2 d courage study eapci epicardial myocardial dissociiation es guideinnedmt ffr ffr rfr qfr ffr vs oct ISCHEMIA trial medical management for cad myocardial revascularisation ORBITA study Source Type: blogs

Non-Left Main Bifurcation Lesion PCI Strategies
Bifurcation lesions may be noted in almost one third of cases for percutaneous coronary intervention. Outcomes for bifurcation lesions are worse compared to non-bifurcation lesions. The two important strategies for addressing a coronary bifurcation lesion are planned one stent strategy or provisional stenting and elective two stent strategy. In provisional stenting, side branch is stented only if unavoidable. A multicenter registry of 2044 patients compared the two strategies in non-left main bifurcation lesions. There were 1551 bifurcation lesions of left anterior descending coronary artery and 493 non-LAD bifurcation le...
Source: Cardiophile MD - April 16, 2023 Category: Cardiology Authors: Johnson Francis Tags: Angiography and Interventions Coronary Interventions Source Type: blogs

A man in his 50s with chest pain
 Sent by anonymous, written by Pendell MeyersA man in his 50s with no prior known medical history presented to the Emergency Department with severe intermittent chest pain. He had episodes of chest pain off and on all night, until about 1 hour prior to arrival when the pain became constant, crushing, 10/10 chest pain that radiated to both arms. He denied any lightheadedness, shortness of breath, vomiting, or abdominal pain. Vitals were within normal limits.Here is his triage ECG at 0343:What do you think?Meyers interpretation: Diagnostic of LAD OMI, with hyperacute T waves in a large LAD distribution including precord...
Source: Dr. Smith's ECG Blog - March 9, 2023 Category: Cardiology Authors: Pendell Source Type: blogs

A woman in her 50s with acute chest pain
Submitted and written by Anonymous, edits by Meyers and SmithA 50s-year-old patient with no known cardiac history presented at 0045 with three hours of unrelenting central chest pain. The pain was heavy, radiated to her jaw with an associated headache.Triage VS: 135/65 mmHg, 95 bpm, 94% on room air, 16/min, 98.6 FTriage ECG:ECG Interpretation:Sinus rhythm with normal QRS. There is slight STE in V1, V2, and aVR, with STD in V3-V6, I, aVL, and II. There are T waves in lead III which are suspicious for hyperacute T waves, with reciprocal negative large T wave inversions in aVL. I do not think this ECG is by itself diagnostico...
Source: Dr. Smith's ECG Blog - January 6, 2023 Category: Cardiology Authors: Pendell Source Type: blogs