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Coronary arteries are the vessels which supply blood (oxygen and nutrients) to the heart; this supply may be disrupted due to buildup of cholesterol and fatty deposits, called plaques, on the inner walls of the arteries (atherosclerosis) causing narrowing of the vessel lumen.

A bifurcation lesion is the stenosis or abnormal narrowing of greater than 50% that occurs in a coronary artery at the origin of the side branch or adjacent to the origin of the side branch. It is a difficult to treat lesion.

Signs and symptoms:

Most of the complex lesions have similar sign and symptoms which are as follows:

  • Acute angina pectoris syndrome (set of sign and symptoms due to decreased blood supply to coronary arteries which leads to malfunction or complete damage of the heart muscle)
  • Chest pain, usually left-sided, radiating to the neck, jaw, or left shoulder of the arm
  • Shortness of breath
  • Palpitations
  • Weakness
  • Lightheadedness
  • Nausea or vomiting
  • Sweating
  • Anxiety
  • Indigestion

Causes and risk factors:

The causes and risk factors involved are like those evident in most of the coronary artery disease, which are as follows:

  • Family history of heart disease
  • Kawasaki disease commonly found in children under 5 years of age
  • Obesity
  • Diabetes
  • Hypertension
  • Age
  • Smoking
  • Hyperlipidemia (elevated levels of lipids in the plasma)

Diagnosis:

Laboratory studies:
There is no specific lab test to diagnose a bifurcation lesion but if the lesion has resulted in acute coronary syndrome there could be an elevation in the white blood cell count. Cardiac specific biomarkers (troponin T and troponin I) will be elevated 4 to 8 hours after the injury which reach its peak in about 12 to 24 hours.

Electrocardiography (ECG):
It is performed to investigate the electrical activity of the heart and to detect any abnormality in its functioning. There are variable findings in the ECG depending on the clinical scenario.

Stress testing:
Exercise ECG is the procedure of choice for the patients who are stable and when their diagnosis is unclear. In individuals who can’t exercise, pharmacologic stress test (with adenosine or dobutamine) may be suggested.

Coronary angiography:
It is the most standard method used for diagnosing coronary lesions wherein a special dye and x-rays shows the blood flow in the arteries of heart and in this case it enables to determine the extent of stenosis (abnormal narrowing) of the coronary arteries. Thus, enabling the evaluation of the further treatment with medical therapy or stent procedure.

Cardiac catheterization:
In this procedure, a catheter is guided through an artery in the arm or leg and eventually into the coronary arteries, simultaneously a high-speed x-ray records the course of the injected dye which flows through the arteries enabling the detection of any blockages.

Prevention:
These lesions usually develop gradually over a period and thus it is possible to prevent it. Prevention can be accomplished by controlling or avoiding the risk factors involved in coronary artery lesions disease and is possible by adopting proper lifestyle modifications and diet which are as follows:

  • Maintain healthy weight by following proper diet and exercise.
  • Avoid smoking.
  • Manage stress.
  • Keep a check on blood pressure and sugar levels.
  • Go for regular health checkups if diagnosed with previous heart problems or having a family history of heart diseases.

Treatment:

Complex coronary lesions cause a higher mortality rate than non-complex lesions. Hence it is essential to treat it immediately and appropriately. However, the medical interventions carry their own risk of associated complications, and it must be managed by proper patient care and education.
Based on the coronary angiography or cardiac catheterization, the following treatment options can be recommended:

Percutaneous coronary intervention: It involves cardiac catheterization, insertion of a stent (usually a metallic tube) which helps to clear the blockage in the artery. Sometimes, two stents may be placed simultaneously. DES (drug eluting stents) are highly recommended than BMS (bare metal stents) as it prevents restenosis.

Medications: The prescribed medications are given in the event of detecting a stenosis which don’t require the use of stents and can be resolved by the drugs alone to clear up the blockage in the coronary artery.

When to seek immediate medical attention?

The first possible presentation of complex coronary lesions is acute coronary syndrome (unstable angina) which can be detected by the following characteristic features:

  • Chest pain occurs at rest or sleep or with minimal exercise
  • Sudden onset of chest pain that lasts longer than usual
  • When medicines and rest don’t provide relieve from the chest pain


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.


What is Hypertensive emergency?

  • BP – 180/110 to 120 mm Hg
  • Associated with acute Target Organ Damage (TOD)

What is Hypertensive Urgency?

  • BP – 180/110 to 120 mm Hg
  • Absence of acute TOD

How to identify Target Organ damage (TOD)?

  • TOD associated with signs and symptoms and listed below
Brain
  • Stroke
  • Intra cranial hemorrhage
  • Encephalopathy
Heart
  • Acute Coronary Syndrome
  • Acute Heart Failure
Eye
  • Hemorrhages
  • Exudates
  • Papilledema
Kidney
  • Acute Kidney Injury
Large vessels
  • Aortic Dissection
Small vessels
  • Micro Angiopathic Hemolytic Anemia

What is the difference between Hypertensive Emergency vs Urgency?

Emergency Urgency
Level of BP (mm Hg) 180/110 to 120 180/110 to 120
Target organ damage Present Absent
Setting Acute rise of BP Chronic BP elevation
Hospitalization Needed – ICU Not needed – OPD
Morbidity & Mortality Increased Not increased
Medicines Intra venous Oral

Causes of Acute Severe Hypertension in out patient setting

  • Drug non-compliance
  • Dietary sodium indiscretion
  • Over-the-counter drugs, NSAIDs, Steroids
  • Anxiety or panic
  • Acute stroke/Heart failure
  • Renal disease

Causes of Acute Severe Hypertension in-patient setting

  • Withholding of antihypertensive medications
  • Urinary retention
  • Pain
  • Intravenous fluids

When to suspect secondary hypertension?

Despite treatment of hypertension if BP remains high during follow up

What is the importance of cerebral blood flow auto regulation?

  • Chronic uncontrolled hypertension patients have normal cerebral flow despite high BP levels. This prevents development of cerebral edema.
  • If BP is controlled rapidly this leads to cerebral hypoperfusion and should not be done.

How to manage Hypertensive Urgency?

  • Most managed as out patient
  • Guideline directed management of hypertension
  • Out patient visit within next 5 days
  • Intra venous medicines for BP control are discouraged
  • Symptoms related to hypertension like headache, atypical chest pain or epistaxis is present
  • Choose rapid acting drugs such as clonidine, labetalol, captopril, prazosin etc.
  • Avoid Nifedipine sub lingual because of unpredictable BP reductions causing cardio vascular event
  • BP medicines to be administered every 30 minutes till BP controlled
  • Patient to be sent home after BP stabilizes below 160-180/100-110

How to manage Hypertensive Emergency?

  • To be admitted into intensive care unit.
  • Intra venous medicines needed
  • Choice of the agent depends on TOD


Your heart needs to work 24/7 to keep your body systems working. Like any other body tissue, the heart too needs oxygen and nutrients to function efficiently. For this, we have a network of arteries that supply blood to the heart muscles which are called the coronary arteries. There are two chief coronary arteries:

the left and right coronary arteries, that branch out from the aorta near the point where the aorta and the left ventricle meet.

The right coronary artery supplies blood to the right atrium, the right ventricle, a small bottom area of the left ventricle and the back portion of the septum.

The left coronary artery supplies blood to the left atrium and ventricles and the front portion of the septum.

These coronary arteries give out various branches that supply blood to different parts of the heart.

Coronary artery disease:

When there is high level of unhealthy fats in the blood, they gradually start depositing in the insides of the coronary artery vessel wall and form a fatty plaque(atherosclerosis). This gradually narrows the lumen of the coronary arteries which obstructs blood supply to the heart. This condition is called as coronary artery disease. disruption of blood supply to the heart gives rise to a cluster of symptoms, the most important being chest pain or angina.

  • Warning signs of heart disease
  • Risk factors for heart disease
  • Possible complications of heart disease


Your lifestyle, age, family history and your other health condition can dictate your risk to develop a heart disease. However, the three key risk factors are- smoking, high blood pressure and high cholesterol. Learn about the risk factors and see if you are at risk:

  1. High blood pressure: It is an important factor for many diseases. Blood pressure, if not controlled, can lead to heart disease, stroke, kidney failure and other organ system disorders. Decreasing blood pressure by lifestyle changes and medication can greatly reduce your risk for heart disease.
  2. High cholesterol: Did you know that our hardworking liver can generate all the cholesterol that our bodies need? But we all do take in extra bad cholesterol from diet. These bad cholesterol tend to get deposited in our blood vessels and cause heart disease.
  3. Smoking: Cigarette smoking damages your heart and blood vessels. Nicotine present in cigarette smoke also reduces the amount of oxygen that your blood can carry. Not only that, if you smoke, the people around you are also at a higher risk of getting heart disease.
  4. Obesity: Obesity is linked with high level of bad cholesterol level and low levels of good cholesterol levels. Obesity is not only a risk factor for heart disease, but also increases risk of diabetes and high blood pressure.
  5. Diabetes: People with diabetes or high blood sugars are at greater risk of having heart disease than those who don’t have diabetes.
  6. Unhealthy diet: Oily, junk foods which are high in bad cholesterol, saturated fats and trans fats an can increase your risk of heart disease. Foods that are very salty(have high sodium levels) can also increase your risk of high blood pressure and heart disease.
  7. Physical inactivity: Physical inactivity increase your risk of having high blood pressure and diabetes and eventually heart disease.
  8. Alcohol: Excess and frequent alcohol intake can increase the risk of high blood pressure and hypercholesterolemia. Ideally, women shouldn’t have more than 1 drink a day and men shouldn’t have more than 2 drinks a day.
  9. Family history: Genetic factors seem to play a role in conditions like high blood pressure and heart diseases. However, it is also likely that the members of the family sharing common external environments and culture may be exposed to the same set of risk factors for heart diseases.
  10. Age: The risk of heart disease increases as the a person ages.


There are an array of heart diseases but they do share some common symptoms. If you experience any of these symptoms, it is perhaps a good idea to get yourself tested. Check these out here:

  1. Angina or chest pain described as heaviness, pressure, aching, burning, fullness, squeezing, or painful feeling in your chest.It is often accompanied by pain in the n the neck, jaw, throat, upper abdomen or back
  2. Shortness of breath
  3. Easy fatiguability
  4. Palpitation and rapid heartbeat
  5. Weakness/dizziness
  6. Sweating
  7. Nausea and vomiting
  8. Swelling in the lower extremities
  9. Fainting(syncope)
  10. Coughing and wheezing


For continuous circulation, the left and the right side of the heart must work together. Here are the series of steps that causes the blood to flow in the heart, lungs and body.

  • The right atria receives deoxygenated blood from two large veins- the superior and inferior venacava.
  • When the atria contracts and the blood passes from the right atrium to the right ventricle through the tricuspid valve.
  • When the ventricle fills, the tricuspid valve closes.
  • Next, the ventricle contracts and pushes blood to the pulmonary artery through the pulmonary valve.
  • The pulmonary artery carries the blood to the lungs where the blood gets oxygenated.
  • This oxygenated blood enters the left atria of the heart through the pulmonary vein.
  • Next, the left atria contracts and the blood flows from left atrium into your left ventricle through the open mitral valve.
  • When the ventricle is full, the mitral valve shuts,
  • Next, the ventricle contracts and oxygenated blood is passed to the aorta through which it is sent to various parts of the body.




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Designed & Developed by R R Deepak Kambhampati.



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