36 year old planter with a big GLC.
Hypertensive for 5 years, on irregular treatment and clinic follow up.
Borderline cholesterol.
No family history of ischaemic heart disease.
Presented to me at the outpatient centre, SJMC, with a history of recent onset central chest discomfort related to mild exertion and occasionally , even at rest, with radiation of discomfort in between the scapulae bones in the upper back, and " classical " radiation to neck and jaws".
Hypertensive for 5 years, on irregular treatment and clinic follow up.
Borderline cholesterol.
No family history of ischaemic heart disease.
Presented to me at the outpatient centre, SJMC, with a history of recent onset central chest discomfort related to mild exertion and occasionally , even at rest, with radiation of discomfort in between the scapulae bones in the upper back, and " classical " radiation to neck and jaws".
"Dokto, saya rasa "senok di dada" dan "bebal" saja di tulae gerehae saya ". He is Kelantanese..,"bebal", means dull ache.." Gerehae means jaws!!.." senok" or "sekok" to me is angina , unless proven otherwise.
The Kelantanese vocab is one of the richest in the world, their wording very precise!!
To old "kakis" like me, " senok" or "sekok" , with pt pointing their closed palm centering around the chest is sine qua non to ANGINA, unless proven otherwise!!
This chap does not need an ECG or Stress test.....He is having ANGINA, fullstop......It is academic.
His Resting ECG, done earlier by his GP is normal anyway.
I now seldom do resting ECG in such a classical case of chest discomfort presenting at my outpatient...go straight for the jugular...i do Stress ECG...if stress ecg at rest show abnormalities, we stop there..if normal, I process with the exercise.
Stress ECG very abnormal with ST-T depression on mild work load , and this ECG changes took long to recover in the recovery phase.
Stress ECG very abnormal with ST-T depression on mild work load , and this ECG changes took long to recover in the recovery phase.
No play, play with calcium score or ct angio.
This young man needed an urgent coronary angiogram YESTERDAY!!!, and his blocked arteries opened!!.......YESTERDAY!!
He needs coronary angiogram to show me the exact " road map " for me to be able to triage him into one of possible 4 classes :
1. Normal coros, which is pretty unlikely in him but still possible......in which case, he has no coronary problem but the chest pain being "non cardiac" in nature, and he has a False Positive Stress ECG..
1. Normal coros, which is pretty unlikely in him but still possible......in which case, he has no coronary problem but the chest pain being "non cardiac" in nature, and he has a False Positive Stress ECG..
Very very unlikely, the way he present and the degree of positivity of his stress test, but nonetheless still possible.
2. Has coronary lesion/plaque or multiple plaques, but non-critical...also unlikely, the way he presents.
In this situation, if that is what the angio shows, he would need long term low dose aspirin and optimization of medical therapy and regular follow Stress ECG and high dose statin
3. Plaques, single or multiple and critical.
If amenable to angioplasty and stenting, it would be done either ad hoc, or staged, depending on complexities and number of lesions..
If complex and nature of lesions borderline, in between BYpass CABG surgery and endoluminal techniques seemed to be of equal standing, I would stop the procedure right there, and discuss the angio the next day for pt to deliberate and discuss.......or even get a 2nd opinion, if he wish.
4. Multiple lesions and diffusely diseased, involving both the medium size middle portion as well as the small tributaries and branches....in which case, both CABG and endoluminal technique are not optimum modalities of treatment strategy.
He is only for " optimization of medical therapy ".
A euphemism actually.
2. Has coronary lesion/plaque or multiple plaques, but non-critical...also unlikely, the way he presents.
In this situation, if that is what the angio shows, he would need long term low dose aspirin and optimization of medical therapy and regular follow Stress ECG and high dose statin
3. Plaques, single or multiple and critical.
If amenable to angioplasty and stenting, it would be done either ad hoc, or staged, depending on complexities and number of lesions..
If complex and nature of lesions borderline, in between BYpass CABG surgery and endoluminal techniques seemed to be of equal standing, I would stop the procedure right there, and discuss the angio the next day for pt to deliberate and discuss.......or even get a 2nd opinion, if he wish.
4. Multiple lesions and diffusely diseased, involving both the medium size middle portion as well as the small tributaries and branches....in which case, both CABG and endoluminal technique are not optimum modalities of treatment strategy.
He is only for " optimization of medical therapy ".
A euphemism actually.
Not a nice scenario to be in , at any age.
We see this often in pt with long standing diabetics
I personally would not wish to be in this group.
The 'coros' that follow that same evening........
A coronary angiogram view of the left coronary artery. Here the Left Anterior Descending Artery is missing. It is 99 % totally occluded and one can only see a small blot in the centre of the cine picture, just a 'ghost' view of rthe remnant of the LAD, supposed to be biggest artery supplying the front portion of the most important 'piston' in the heart, the left ventricle.
With a wee bit of 'persuasion' and difficulty, i successfully passed a 14th thousand of an inch diameter guide wire,
sonne blue wire, passed across the occlusion...when this is done, 80 % of the " battle" is won...
since opening the occluded artery and subsequent placement of stent is contingent on having a metallic wire passed the site of occlusion...it act as a " railway line for balloon and stent delivery in the artery.
An appropriate balloon is then slided over the wire and expanded up to appropriate atmospheric pressure to open up the occlusion...when this step is deemed adequate, the balloon is taken out, and the artery is then ready for stent placement.
This is the final cine after stent deployment at high pressures between 16 to 20 atm pressure...the occluded Left Anterior Descending Artery is a really big dominant artery in this young man!!!
The whole procedure took about an hour an a quarter.
I was quite"lucky" with him actually, since the wiring into the occluded artery just took me less than 5 minutes.
It could well be much much longer.
I remember chatting away with pt about his recent trip to a Musang King durian plantation and the nice time he had there!....Oftentimes a necessary diversion, to keep what actually is a quite considerable tense an hour or two for pts like him, lying flat on the radiological table, fully draped and strerilised from the neck down to his feet, with myself and my scrub nurse, working thru a small needle size hole via his femoral artery......" playing video game of sort", with help of
an overhead radiological image intensifier
As you can see, these procedures are all done under only light sedation, to keep risk lower , as doing under GA would entails another additional risk, apart from an additional unwarranted cost.
My game plan most time is to ask my pt to concentrate on his favourite zikr while we work, if he or she is Muslim, but this time the young man was a 'bundle of nerves', so the 'Musang King' or "nasi Beriani" diversion was a necessary adjunct.
Pt was discharged well the next day on low dose aspirin and plavix and a statin to bring down his ldl cholesterol to below 1.4 mmol.
................................................
PS :
I am reminded of a car mechanic and a top American cardiologist in Idaho
The mechanic, after repairing the cardiologist sleek looking Mustang, handed him a rather hefty, atypical bill, definitely double the usual Idaho 'going rate'.
" Why sooo much? ", quipped the cardio
" Doc, my bill is just peanuts compared to yours! "
" Well young man......your bill will not be peanuts, if you can repair my burst gaskets while the engine is still on! ", replied the cardiologist.
No comments:
Post a Comment