[HSF] Coronary Case
Ramaiah, Chandrashekar
crama01 at email.uky.edu
Thu Feb 1 09:58:03 EST 2007
Prasanna,
I know you can do that in your setting. But here in US I cannot decline
to treat the patients without insurance also because they refused to
quit smoking. I agree it is very important to modify or control the risk
factors. We are required to educate the patients about smoking and
document that we did advise them about the ill effects. As far as
Diabetes control is concerned we have been following the protocol to
strictly control blood sugars in the peri-op periods for almost 7 years
now and our hospital is implementing this to all services.
Chand
-----Original Message-----
From: openheart-l-bounces at lists.hsforum.com
[mailto:openheart-l-bounces at lists.hsforum.com] On Behalf Of
prasannasimha
Sent: Wednesday, January 31, 2007 9:53 PM
To: OpenHeart-L at lists.hsforum.com
Subject: Re: [HSF] Coronary Case
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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