For Physicians - DrCRaghu - Page 2

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Globally, coronary artery disease (CAD) is a common cause of death. Traditional coronary angioplasty bypass grafting (CABG) and percutaneous coronary intervention (PCI) are popular methods for managing CAD. PCI is a preferred intervention, while CABG is reserved for complex cases. However, some patients have associated risk factors that make them unsuitable for surgery.

Cardiologists now use the CHIP (Complex, High-Risk Indicated) angioplasty approach for patients with complex, high-risk, and severe coronary disease..

Who is eligible for CHIP angioplasty?

Once after reviewing the medical condition of the patient, the CHIP program team will decide whether the person is a potential candidate for CHIP angioplasty. However, individuals who meet the following criteria are considered as potential candidates for CHIP angioplasty:

  • Advanced age- People with advanced age may not be able to tolerate bypass surgery and its complications.
  • History of kidney disease, stroke, or diabetes- The presence of co-morbid conditions may complicate the surgery and its outcome.
  • Location of CAD, including left main or bifurcated disease- The blood vessel is difficult to access and treat.
  • Chronic total occlusion (CTO) of the coronary arteries- CTO may cause sudden heart attack, and are dangerous.
  • History of open-heart surgery- Patients who have undergone open-heart surgery may be poor candidates for bypass surgery.
  • Advanced stage of heart failure- The failing may not be amenable to the stress of the bypass surgery.

How is the treatment plan developed?

The CHIP team will review and discuss the patient condition. Based on the extent of CAD (despite medical therapy), co-morbidities, and hemodynamic state, the treatment plan may include:

  • Surgical intervention
  • Conventional PCI
  • Protected PCI
  • Medical management

The success of a CHIP program is dependent upon:

  • Highly skilled and experienced doctors
  • Advanced equipment
  • An expert and well-coordinated team of doctors, paramedics, nursing and support staff

CHIP angioplasty techniques

CHIP angioplasty comprises of advanced techniques like:

  • Rotational atherectomy: It is a common type of atherectomy device for plaque removal. Currently, this technique is used for ostial and heavily calcified lesions, which cannot be treated with balloon angioplasty.
  • Complex bifurcation stenting: This type of stenting is used to remove the blockage from the site where the blood vessel divides into two.
  • Specialized antegrade and retrograde chronic total occlusion (CTO) approaches.

What are the benefits of CHIP angioplasty?

CHIP angioplasty offers the following benefits:

  • Reduces symptoms
  • Improves the quality of life
  • Confers lower risk of re-hospitalization

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  • Coronary arteries are the vessels which supply blood (oxygen and nutrients) to the heart. With age, cholesterol and fats (called plaques) are deposited on the inner walls of the arteries (atherosclerosis), thereby narrowing the lumen of the arteries.
  • The deposition of plaque is more likely at the site where the main coronary artery branches (bifurcation) due to the forces associated with the changes in blood flow. Narrowing (or stenoses) of the main coronary artery and the adjoining side-branch vessel is called bifurcation lesion or bifurcation blockage.
  • Treating bifurcation lesions is more challenging than treating the blockage of the blood vessels that do not involve branches, as there are no stents with “Y” configuration available. Percutaneous coronary intervention is the current treatment option recommended for bifurcation lesions.
  • Percutaneous coronary intervention (PCI) is a minimally invasive, non-surgical procedure that involves placing a stent (a small metal mesh) using a catheter (a thin, flexible tube) to treat the blockages in the arteries. For bifurcation blockages, two stents may be placed simultaneously.

What are the complications of PCI procedure for bifurcation lesions?

The complications associated with PCI procedures for bifurcation lesions include:

  • Low success rate
  • Complete obstruction of the artery caused by the formation of thrombus in the first month after implantation (subacute stent thrombosis)
  • Recurrence of the blockage or the narrowing of the blood vessels (restenosis)
  • Periprocedural myocardial infarction
  • Stent deformation
  • A gap between the stent and the arterial wall, which is greater than the stent thickness (mal-apposition)

What are the different types of PCI techniques performed for bifurcation lesions?

The following are the different types of PCI techniques used for bifurcate lesions. These techniques may vary in different cases.

T stenting technique: This technique involves positioning two stents in a ‘T’ shape. In this technique, the first stent is placed in the side branch close to the ostium (opening of the side branch), while the main branch is inflated with a balloon at low pressure. Then the second stent is placed in the main vessel.

Reverse T-stenting: This is a modified method of the classical T stenting technique. In this method, the first stent is placed in the main vessel crossing the side branch, and the second stent is placed in the side branch.

*Note: T-stenting and reverse T-stenting techniques are considered when the angle between the side branch and the main vessel is >70 degrees.

Culotte technique: In this method, the first stent is deployed into the vessel with the sharpest angulation, which covers both the main vessel and the side branch. Then, a second stent is passed through the struts of the first stent and is positioned in the main vessel only. This technique allows complete coverage of the lesion and has low rates of in-stent restenosis and periprocedural myocardial infarction.

Crush technique: In this technique, the two stents are passed at the same time in both the vessels; the stent in the main vessel more proximal than the stent in the side branch. First, the side-branch stent is paced, ad its wire and balloon are removed. Then, the main vessel stent is positioned, which flattens the protruding part of the side branch stent.

Simultaneous kissing technique: In this method, the two stents are advanced into the side branch and the main vessel and the stents are simultaneously positioned. This positioning of the two stents creates a new carina (the inflection point where the side branch separates from the main branch) in the proximal portion of the main vessel. This technique is considered only when the proximal vessel can accommodate both stents.


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  • Acute myocardial infarction (AMI) is the necrosis of the heart muscles
    resulting from acute obstruction of a coronary artery.
    “Time is Muscle” in AMI .
  • Primary angioplasty is a minimally invasive procedure that uses treats the
    obstructed areas of the coronary arteries causing a myocardial infarction
  • Considering long travel distances and lack of cath lab in many districts –
    “Lyse now and stent soon” is the apt strategy for managing AMI.

Approach for managing AMI:

Benefits of Primary angioplasty:

  • Class I therapy for AMI
  • Preserves heart muscles
  • Immediate restoration of blood flow
  • Fast recovery
  • Saves lives, immediate and long-term benefits

Procedure of primary angioplasty:

  1. A balloon catheter is inserted into the main artery in the groin or arm
  2. The catheter is passed gently into the aorta
  3. The balloon is inflated at the narrowed area(s) of the artery, thereby opening and widening it.
  4. A stent may also be placed to keep the artery open



Acute myocardial infraction is a sudden obstruction in the blood flow to the heart muscle. It is an emergency condition in which the plaque formed due to the deposition of fat, cholesterol, calcium, or cellular waste products is ruptured leading to the formation of thrombus. This leads to the obstruction of the coronary vessels resulting in an acute reduction of blood supply.

Signs and Symptoms:

The symptoms of Acute myocardial infraction include:

  • Chest Pain

Uninterrupted and intense chest pain often radiates to the neck, shoulder, jaw, and down to the left arm. The chest pain is usually experienced as pressure, squeezing, aching, or burning sensation, and can also be presented as a feeling of indigestion or fullness of gas.

The important signs of the patient to be considered include the following:

  • Increase in the heart rate
  • Irregular pulse
  • Elevated blood pressure
  • Coughing and wheezing
  • Nausea and vomiting
  • Shortening of breath
  • Distended neck veins
  • Production of frothy sputum
  • Excessive sweating, light headedness and palpitations.
  • Loss of consciousness due to inadequate blood flow to the brain

Causes:

Coronary artery blockage is the primary cause of acute myocardial infarction. It is due to the accumulation of cholesterol in the arteries. The increase in LDL levels (bad cholesterol) in the body leads to plaque formation in the arteries. Saturated and trans fats are other types of fats which also lead to the formation of plaque in the arteries and obstruct the blood flow. Certain dairy products including butter and cheese, meat, beef, and processed foods are the main sources of saturated and trans fats.

During a heart attack, the plaque gets ruptured and spills cholesterol into the bloodstream. This leads to the formation of blood clots, when are big enough can block the artery at the site of rupture and deprives the heart muscle from obtaining enough oxygen and nutrients. There can be a partial block of the artery or a complete block of the artery. A complete block refers to an ST level elevation Myocardial Infraction (STEMI) and a partial block refers to a non-ST elevation Myocardial Infraction (NSTEMI).

Risk Factors:

Some of underlying risk factors of the acute myocardial infraction are modifiable.

  • Sex
  • Age
  • Family History
  • Male Pattern Baldness
  • Smoking
  • Diabetes Mellitus
  • Hypertension
  • Obesity
  • Lack of exercise
  • Poor oral hygiene
  • Presence of peripheral vascular disease
  • Elevated levels of homocysteine

Other factors include

  • Trauma
  • Drug use (Cocaine)
  • Vasculitis
  • Coronary artery anomalies
  • Coronary artery emboli
  • Aortic dissection
  • Hyperthyroidism, anemia

Diagnosis:

Electrocardiogram
Electrocardiogram remains a crucial tool used to diagnose a patient with acute myocardial infraction. One of the significant finding is the presence of the raised ST segment.

Cardiac Imaging
The coronary cardiac imaging is used to check for the presence or to rule out the coronary artery disease. The test is considered for the individuals who are at risk of having an acute myocardial infraction.

Laboratory procedures:

The laboratory tests should include identification of marker known as cardiac troponins, complete blood picture, lipid profile, renal function and metabolic panel.

Treatment:

Any patient diagnosed with acute myocardial infraction advised to take aspirin 165 mg – 325 mg immediately regardless of their condition (STEMI or NSTEMI). In STEMI the patient should receive dual antiplatelet agents, including heparin infusion. This should immediately be followed by a reperfusion with the percutaneous coronary intervention (PCI). If PCI is unavailable within 90 minutes of diagnosis of STEMI, an intravenous thrombolytic agent should be considered for reperfusion. NSTEMI in a stable asymptomatic patient can be managed with antiplatelet agents.

Prevention:

Any individual can improve heart health and prevent the occurrence of current heart condition by following the below-mentioned lifestyle changes:

  • Avoid smoking.
  • Go for regular health checkups.
  • Control blood pressure and cholesterol levels.
  • Get regular exercise and maintain a healthy weight.
  • Keep diabetes under control.
  • Manage stress.
  • Consume alcohol in moderation.


It is amusing for me when I see death certificates mentioning the cause of death as cardio-respiratory arrest. During my internal medicine residency at AIIMS, New Delhi one of the first things my seniors taught me was to how to document a death certificate. My Professors periodically used to check the death certificate during the Mortality and Morbidity (M&M) meetings.

Unfortunately training on death certificate documentation is sparse because it is filled in after death and teachers even during an M&M meeting focus on treatment gaps.

In this blog, let me explain how to document a logical and rational death certificate.

1. What is the importance of death certificate?
Death certificate is an important document that will help government to understand which diseases are causing deaths for the public.
This data obtained at local, regional and national level will help tailor the public health policy.
In the COVID 19 era an accurate death certificate is essential because it is a pandemic and a public health emergency.
If this data is faulty, government cannot institute appropriate public health policies.
Biggest challenge is training on how to prepare a quality death certificate is lacking in India.
2. Can we label cardiac arrest – respiratory arrest – cardio respiratory arrest as cause of death?
One cannot list cardiac arrest and respiratory arrest etc. as cause of death because these terms are synonymous with death. This is mentioned on the form itself.

3. What is cause of death?
Let me exemplify this, for example, a 73 year lady presents with fever and cough of 3 days duration and for the past one week she has fever. In the past she has diabetes and congestive heart failure for which she is taking medicines and is in stable condition.

She has been admitted in the hospital and succumbs within the next 24 hours. Just before her death the diagnosis of COVID 19 is confirmed by the RT PCR test report.

In a case like this one should not mention cardiac arrest as cause of death because cardiac arrest itself means death.

One should not mention diabetes or Congestive Heart Failure as these are co-morbidities and are not cause of death. They contribute to death and not cause death.

4. What are the components of a death summary?
Death summary has two parts.

Part I deals with the immediate cause for death and what disease/s caused this problem.

Part II deals with the underlying medical conditions that are not directly responsible to the disease causing death but could contribute for the same.


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  • Myocardial Infarction (MI) is of two types – STE elevation MI (STEMI) and non-ST elevation MI (NSTEMI)
  • STEMI patients are best managed by Primary Angioplasty and stent procedure where ever cath lab facilities are available
  • When cath lab is not available – pharmaco-invasive strategy is preferred – i.e.; thrombolyze as soon as possible and then transfer to cath lab center after initial stabilization. Angioplasty to be done within 24 hours of onset of chest pain.
  • NSTEMI is best managed medically at least initially and further management based on GRACE score
    • High GRACE score – Early angiography and revascularization
    • Low GRACE score – medical management
  • Cardiologists need to realize that COVID can masquerade as AMI and also differentiate myocarditis from AMI
  • Clinicians need to protect their staff by imparting knowledge as well availability of appropriate PPE in cath lab
  • Public should be educated not to ignore symptoms of heart attack and the need for timely reperfusion needs need to be emphasized.











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