[HSF] Coronary Case
prasannasimha
prasannasimha at gmail.com
Thu Feb 1 08:23:00 EST 2007
Yes Chand,
Patients can buy health care of any level of quality if they can pay
for it but a patient who wants subsidization of health care costs
better stop smoking - if he wants to smoke he doesn't need the subsidy
as he can afford to buy those packets of cigarettes.
One pack of Wills = Rs 40 assuming 4 packs per day - 160 * 365 = 58400
which is nearly the cost of his CABG !!
If he wants that subsidy in my opinion he shouldn't waste it on
something that will ultimately jeopardize his operation either in the
short or long term. A smoker is wasting health care subsidies -better to
do surgery on a young diabetic rather than an old smoker. If he wants to
"lead his life style" - so be it but let him pay for it fully. He can't
have his cake and eat it too. At least the younger diabetic didn't "ask"
for his disease. (Having said that we have to iterate the importance of
tight glucose control).Also the whole process of attempting to stop
smoking can be a part of educating him about his disease.
I have known quite a few people in private practice who would not take
up elective patients till they had made an attempt to stop smoking. I
agree that this may be very trying at times Another factor is that most
patients in India tend to be "passive" and "obedient" about Doctor's
orders (as I said we usually set the Wife into "nagging mode" which she
does with pleasure !!!) This is changing but then most patients do take
their Doctor's orders as sacrosanct at least for now !! The situation
with patients are different in other countries but at least for my
practice it needs to be done not just for the patients sake but also
for just allocation of resources.
Prasanna
Ramaiah, Chandrashekar wrote:
> Dear NFA,
> Your point is well taken but unfortunately it does not apply to our country. You or prasanna may be able to carry out what you are saying. I don't know about your country, but I can guarantee you that in India people that have the money can and are buying the type of health care they want (even smokers and alcoholics). Does that make the doctors who provide care for them greedy and irresponsible?
> For your information in US most surgeons (100% of the surgeons I work or worked with in the past) operate on patients who are smoking for CAD if surgery is indicated. We are strict in this policy only with transplants because of what Ani has said.
>
> Money is not the main issue for us to operate on these patients as I am in an Academic institution with salary. I don't think anyone in private practice will opertate to make a few bucks more if the risk of doing it was excessive (due to smoking). As you know cardiac surgeons in USA are the most scrutinized compared to any other professional in the world. If you want you can go to the web and get mine or any US surgeon's report card for a nominal fee. I don't know if you have such kind of reporting and accountability in your country. Infact the expectations in US are higher than even the western european countries ( see what risk scores for a patient with Euro score and compare it to STS you will understand the differential standards).
> Finally one should not criticize without knowing the norms/or standards that exist in other countries. I could go on and critize about many things you could do to change the pathophysiology in your patient population instead of operating (i.e. Stop eating red and and eat more veggie or the `other white meat' but am not that ignorant or foolish to do that as I do know a little bit about the religion and the culture of your country).
>
> Sincerely,
>
> Chand
>
> .... I am not trying to be defensive but just trying to educate those that live and practice outside US.
>
>
> -----Original Message-----
> From: "Nasser F. Abou'Seada" <nfaabouseada at gmail.com>
> To: "OpenHeart-L at lists.hsforum.com" <OpenHeart-L at lists.hsforum.com>
> Sent: 1/30/07 9:40 PM
> Subject: RE: [HSF] Coronary Case
>
> Yes I agree that it is easier to be said than done. for sure. No one said it
> is an easy thing ...... especially when you see the patients going for
> another colleague to have the operation done .... at the same centre ...
>
> still, it has got a relation as to the definition of "my job" .... is it
> just to handle a knife and start putting grafts in graftable vessels even
> with no certain indication? ..
>
> Albeit, I can see that you are adopting a similar policy as mine regarding
> transplant patients.
>
> the bottom line is that is it better to increase my workload for more income
> and more cutting? .... or is it application of the best policy and strategy
> to deal with the pathophysiological process ????
>
>
>
> NFA
>
>
>> From: Ramaiah, Chandrashekar
>> It is easier said than done, especially in US. If I say no to everyone
>>
> that smokes then
>
>> I better find another job.
>> We do have policy of not even listing a patient for Heart or Lung
>>
> transplantation until
>
>> we are sure that they are tobacco free for 6 months.
>> Chand
>>
>>
>>
>> -----Original Message-----
>> From: "Nasser F. Abou'Seada" <nfaabouseada at gmail.com>
>> To: "OpenHeart-L at lists.hsforum.com" <OpenHeart-L at lists.hsforum.com>
>> Sent: 1/30/07 5:27 PM
>> Subject: RE: [HSF] Coronary Case
>>
>> you are right Prasanna
>> I do the same
>> should she prefer smoking ... better save my time
>> a policy I have learned long ago from my professors as a resident ....
>> if not keen on her "Oxygen carrying capacity" .....
>> hahaha
>> no "graft" will do
>> I think it would be a Hippocratic thing ... doing an elective operation
>>
> for
>
>> someone smoking ... while we know that stopping smoking can have the same
>> effect or even much better ...
>>
>>
>> NFA
>>
>>
>>> -----Original Message-----
>>> From: openheart-l-bounces at lists.hsforum.com [mailto:openheart-l-
>>> bounces at lists.hsforum.com] On Behalf Of prasannasimha
>>> Sent: Tuesday, January 30, 2007 7:36 AM
>>> To: OpenHeart-L at lists.hsforum.com
>>> Subject: Re: [HSF] Coronary Case
>>>
>>> I don't take any elective case if they smoke !! They have to choose
>>> between smoke and surgery. That is why I said she needs to go to a
>>> shrink. If she can undergo 12 caths and not understand that she has to
>>> quit smoking she needs professional help urgently as she seems self
>>> destructive.
>>> She probably will drive Ani nuts after surgery - she will probably whine
>>> and whine and drive everyone around her crazy and at the end of it all
>>> have "anginal" symptoms all over again.
>>> Smoking can cause microvascular Ischemia that could exist even upto 1
>>> month after cessation of smoking.
>>>
>>> Prasanna
>>>
>>> hgrmd at aol.com wrote:
>>>
>>>> Ani,
>>>> Before you wade into a possibly elective, ineffective, CABG
>>>>
> nightmare,
>
>> I would
>>
>>> insist that the lady absolutely undergo a trial of smoking cessation.
>>>
> If
>
>> necessary, this
>>
>>> should be confirmed by urine screening for nicotine metabolites. It
>>>
> could
>
>> be that
>>
>>> heavy smoking is producing disabling spasm. I am usually not that
>>>
> tough
>
>> on patients
>>
>>> about smoking (though I should be), but this is possibly the exception.
>>>
>> Tough case.
>>
>>>> Hal
>>>>
>>>>
>>>> -----Original Message-----
>>>> From: prasannasimha at gmail.com
>>>> To: OpenHeart-L at lists.hsforum.com
>>>> Sent: Tue, 30 Jan 2007 6:42 AM
>>>> Subject: Re: [HSF] Coronary Case
>>>>
>>>>
>>>> Could you dig out the IVUS report ??
>>>>
>>>> I agree that angiography could underestimate the disease but you also
>>>> say there is no inducible Ischemia on Thallium (that doesn't go hand
>>>>
> in
>
>>>> hand)
>>>> Assuming that the lesion is the cause of Ischemia, I would have to
>>>>
> graft
>
>>>> LAD with all the diagonals and probably the RCA. It still seems like
>>>>
> we
>
>>>> are being "tricked" into saying graft. That makes me suspicious.
>>>> I am still curious of the possibility of the open highway and blocked
>>>> side roads.If that is really the case what you need to do then is
>>>>
> stent
>
>>>> endartrectomy, open up side branches and place a large patch over all
>>>>
> of
>
>>>> this and place an IMA or distal IMA and grafts (sequentialize the IMA
>>>>
> to
>
>>>> all the involved diagonals)
>>>> No arterial graft on the RCA would use an SVG.
>>>> Could probably consider partial cardiac denervation (though I am not
>>>> sure if if the blessed thing works).
>>>>
>>>> 12 caths over 36 months still is a bit too much - one cath every 3
>>>> months on the average for 3 years still is a pincushion situation !!
>>>> I strongly suspect that she will not have good relief of symptoms post
>>>> surgery unless there is some objective evidence of Ischemia. Is the
>>>>
> gun
>
>>>> at our heads because she has become a pincushion and someone is trying
>>>> to finally dump a problem on you ??
>>>> Prasanna
>>>> Ani Anyanwu wrote:
>>>>
>>>>
>>>>> Thanks for responses.
>>>>>
>>>>> I specifically had said to assume you will operate on the patient
>>>>>
> just
>
>> to
>>
>>>>> divert the discussion away from indications of surgery but as I
>>>>>
>> expected
>>
>>>>> that is where everyone decides to focus!
>>>>>
>>>>> The 12 caths were over 3 years not 18 months. She has been
>>>>>
> investigated
>
>> for
>>
>>>>> non-cardiac chest pain but it keeps coming back to the heart. Clearly
>>>>>
>> there
>>
>>>>> is a suspicion that something is not right with the stent or that
>>>>>
> some
>
>>>>> disease is being missed, which is why they keep re-imaging it. Had
>>>>>
> IVUS
>
>>>>> after second stent so they were clearly concerned about placement.
>>>>>
>> Symptoms
>>
>>>>> are almost certainly anginal and are relieved by nitrates (I know so
>>>>>
>> can
>>
>>>>> esophageal pain but that is rarely triggered by exertion). She did
>>>>>
> have
>
>> an
>>
>>>>> objective coronary lesion and ECG changes on first presentation and
>>>>>
>> also a
>>
>>>>> thallium that showed apical ischemia so the patient definitely has
>>>>>
> had
>
>>>>> symptomatic coronary disease. Has been worked up by cardiologists in
>>>>>
>> two
>>
>>>>> separate cities both of which come to same conclusion (coronary pain)
>>>>>
>> and
>>
>>>>> she has been managed on medical therapy. She shouldn't be smoking but
>>>>>
>> does
>>
>>>>> (again that's life - actually says she 'stopped' a month ago).
>>>>>
>>>>> Indication for CABG is intractable angina with angiographic (LAD)
>>>>>
>> disease.
>>
>>>>> Angiography can and does underestimate luminal narrowing so the
>>>>>
>> presumption
>>
>>>>> has to be that 40% ISR within a 5 cm of stent counts for more than
>>>>>
> that
>
>> (in
>>
>>>>> the absence of alternative explanations). The RCA spasm can be
>>>>>
> debated.
>
>> In
>>
>>>>> my view I suspect there may be a real lesion; I do not know if she
>>>>>
> had
>
>> pain
>>
>>>>> during the cath (I suspect many of them do if you watch what happens
>>>>>
> in
>
>> the
>>
>>>>> lab). She also has (minor) disease in her ramus. I am not sure if
>>>>>
> stent
>
>> has
>>
>>>>> pinched diagonals - will go back and have a look. I have not said I
>>>>>
>> would
>>
>>>>> graft any vessel - I was just presenting options of what is
>>>>>
> surgically
>
>>>>> graftable (the six vessels I listed) not what should be grafted
>>>>>
> (which
>
>> some
>>
>>>>> would say is none).
>>>>>
>>>>> Still waiting for operative suggestions - what if you had a gun to
>>>>>
> your
>
>> head
>>
>>>>> in the OR, what would you do for this lady!
>>>>>
>>>>> Ani
>>>>> ----- Original Message -----
>>>>> From: prasannasimha<mailto:prasannasimha at gmail.com>
>>>>> To:
>>>>>
>> OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com>
>>
>>>>> Sent: Tuesday, January 30, 2007 3:45 AM
>>>>> Subject: Re: [HSF] Coronary Case
>>>>>
>>>>>
>>>>> I still remember an elegant expose given by Unique pharma on cause
>>>>>
> of
>
>>>>> chest pain !!
>>>>> I would also check for an esophageal motility disorder (cork screw
>>>>> esophagus) and gall bladder dysfunction which can mimic angina in
>>>>>
> all
>
>>>>> aspects including relief with nitroglycerine. Especially in a
>>>>>
> smoker.
>
>>>>> Prasanna
>>>>>
>>>>> Tohru Asai wrote:
>>>>> > Dear Ani
>>>>> >
>>>>> > What is the indication for CABG? I don't think bypass will help
>>>>>
>> this
>>
>>>>> > patient. Coronary spasm may complicate the procedure.
>>>>> >
>>>>> > What is pulmonary status? I experienced a case with giant bulla,
>>>>>
>> causing
>>
>>>>> > angina-like symptom. It is rare but was writen in Shields'
>>>>>
> textbook
>
>> of
>>
>>>>> > General Thoracic Surgery.
>>>>> >
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