Wednesday, July 24, 2013

.....they are getting younger and younger : Primary Myocardial Infarct Angioplasty and Stenting



Zain S A, 33 , KLIA limo driver [ not his real name of course ]
Smokes 2 packs a day, recently diagnosed insulin dependent diabetic on Novo-rapid subcutaneous insulin, 3 times a day and  a long acting insulin, Novomix  12 unit at bedtime. 
Diabetic control seem quite optimal.

11.30 pm just now had sudden onset gripping chest pain while watching TV at home. Wife, who is a nurse brought him to our ER at 1 am just now.

" Doc Nik, we have a young diabetic with an acute inferior infarct for you...", my medical officer in ER woke me up with a start at 0130 hours.
I used to curse quietly under my breath before in my younger days at this kind of  'rude' interruption to my 'dream', but now at 61, I  have somewhat mellowed a wee bit. I now consider this kind of calls  in the wee hours of the morning as a very polite and welcomed 'wake  up call to tahajjud'. 

Patients are getting younger and younger. It used to be ' I am younger than my patients' some 25 years ago, now they are about my eldest son's age! Time certainly waits for no man.

By 2.15am the emergency team were all ready for action in the thearte  and Zain S A already on the table. In 'Manhattan Fish Market' linggo, 'it cannot get any fresher than this !'

Angiogram showed he has a totally occluded right dominant coronary artery. An inferior infact from the right coronary artery occlusion is usually smaller than a left coronary infarct and but a dominant right coronary artery is a 'different cattle of fish'. Patients with these type of occlusion behave badly if not opened fast enough. It is geographical. It supplies more myocardial muscle, therefore its occlusion impacts more. They will be more muscle loss and heart muscle death.

We did not have much time to work on him as his pulse rate was already going 'bradycardic' [ 36 beat per minute ], which duly responded to an intravenous atropine, for the time being. His right coronary artery, being dominant  supplies blood to his SINOATRIAL NODE, the 'natural' pacemaker  of the heart, and ' bradycardia' is it's  way of 'complaining' that it is getting 'suffocated due to no blood flow' and if 'you guys are too slow, I have to call it a day! '. 

Asystole  and cardiac arrest may follow extreme bradycardia..if that happened, we would have a 'wayang kulit' on the table and possibility of instant death , much, much higher, even though it remian that the cardiac thearte table must be about 'the safest place for any cardiac arrest in the whole hospital'!

" Dont get too excited Zain, you just concentrate on your Kul Huwallah, and insyaallah, you will be OK soon......", and I say mine as well. Divine blessing and help is a bonus in this kind of  dicey, life threatening situation.

We ballooned up the artery in no time with a 20mm by 2.5mm balloon, and then duly stented it with a  drug eluting XIENCE stent ,3.0mm by 28mm at 18 atmospheres pressure, x 2

By 3.30 am patient was dozing deeply in CCU helped by the initial dose of morphine given at ER and in the cardiovascular lab for pain management.

This morning at nine he is already asking me when he could be discharged.



What Is A Heart Attack
https://www.youtube.com/watch?v=n8P3n6GKBSY

Coronary Angioplasty and Stenting [ cartoon ]:
https://www.youtube.com/watch?v=S9AqBd4RExk



How A Heart Attack Is Treated
https://www.youtube.com/watch?v=ApJvxgjUOjc



Angioplasty and Stenting of Occluded Left Anterior Descending Artery:
https://www.youtube.com/watch?v=3Z2DaU0GBAE&feature=related









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