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Coronary Artery Revascularization: Recent Update

Dec 25 | 1:30 PM

On 3rd December, the American College of Cardiology published an update on Coronary Artery Revascularization, which detailed the improvement in prognosis, the treatment choices available in stable but symptomatic patients, when to take a CT Angiography, and the need for revascularisation in multi-vessel disease patients, to name a few. To help break down the complexity of these guidelines, endorsed by the Society for Cardiovascular Angiography and Interventions, Dr. Kamal Sharma will join us live and exclusive on Medflix!

[Music] so good evening everyone and merry christmas to all i welcome you and you on behalf of team netflix for a session on recent updates on coronary artery revascularization let's welcome our faculty for today dr kamal sharma dr kamal sharma is the chief interventional cardiologist at sal hospital zamdabat he has a vast experience of 25 years and is an expertise in the field of coronary angioplasty stenting primary angioplasty valvuloplasties and also pediatric interventions like pda and asd closures he also has numerous publications to his name like clinical cardiology ecg simplified and clinical medicine which are text books for fellows in training for cardiology as well as the md and mbbs students over to you sir i think we can start i'll just stop my presentation hi good evening everyone uh thank you for having me and thank you for joining us today on netflix or and especially my channel today the whole purpose of keeping this discussion was i think there was one debate that was already there on netflix which was about angioplasty vs bypass and then of course we have a lot of other things coming into our support people talk about alternative therapy alternate doctors alternate management strategies babajis everything for their heart attacks and their blockages now for doing that do you need any evidence or not that's the other aspect that we all should know so evidence based medicine is what we all deal in with we have guidelines which are formed primarily because of the trials and evidences that exist from the practice guidelines and that's why the american college of cardiology after quite a while it's been already the last guidelines but i think in 2015 it's been six years since it got updated and now the american college of cardiology has come out with a guideline in 2021 for and a coronary artery revascularization what it means whether which kind of a patient should undergo what kind of remask firstly who need it needs it how does he need it how do you arrive at a decision to need or whatever do whatever we want to do for that patient and what type of rivas whether the patient goes for bypass or whether a patient goes for angioplasty now that distinction that people grossly had that one or two vessel do angioplasty three vessel or left wing do a bypass does it always hold true that's what the whole guideline is talking about and does it has it changed since 2015 now this is almost 140 slide presentation uh which was published recently they're almost running into pages and what we have done today is try to simplify that into simple 10 12 slides i'm going to give you 10 important slides and then i'll also share with you a flowchart which is the simplified crux of the whole guideline so what we are doing in today's session is to give you the nutshell of whole of those big complicated lot of pages stuff into one short small talk of 14 15 slides and that's how you know what the guidelines are talking about which patients of what kind of carbonyl cardiac blockages should get what kind of revascularization whether he should go for bypass whether he should go for angioplasty this is a consensus guideline statement from american college of cardiology and then we will be also looking into as to based on who takes that decision now there is recently a controversy some people are saying that the surgeons have refused to endorse some of these guidelines and then probably with the discussion we'll also try to discuss that out why they are not endorsing it or why that discussion is slightly different why the american college cardiology guideline is is having some aspects of discussion happening between surgeons and the cardiologists but the american college of cardiology guidelines are endorsed and uh by the uh other associations from the american society as well so what we have been looking today is the what the crux of these that so we'll have top 10 important take home messages from the 2021 guideline on coronary artery revascularization the number one that the decision should be based on clinical indication you should not be going purely on angiographic decision this is the common problem a lot of patients will tell you sir i i have a cd of an angiography you need to opine what to do for this patient so you don't do that i mean of course coronary anatomy matters but it's not the cd of the angiography that you treat ultimately what you treat is the patient so you need to look at the clinical scenario of the patient the clinical scenario would mean that you have patients who have either an unstable angina acute mi hemodynamic crisis cardiogenic shock no shock diabetes blood pressure angina rest pain all these factors and parameters are important you cannot just jump to a conclusion for a angiographical diagram given in the picture with the three arteries and different kinds of block in that picture and then you say sorry so you cannot do just the look at the pictures of the angiogram alone i'm not saying they are not important coronary anatomy is important but what also matters and is very important is the clinical indication whether the patient is having acute mi unstable angina stable angina uh a non-stee elevation mi st elevation mi with um the cardiogenic shock without correct all those parameters need to be taken into consideration no evidence is found linking the benefit to which patient's gender race or ethnicity it would matter so there is no difference that for our asians you would do this for a caucasian you would do that for a male patient you should do bypass or for females bend your plastics but nothing of that sort is proven irrespective of ethnicity gender of the patient the guidelines are broad open and applicable for across the class and same option must be offered to all patients based on clinical assessment and hence you must reduce disparities of care what does it mean that whether the patient is rich or poor going to a government institute or private going to america or to india for every patient the guideline should be a uniformly acceptable and translated to one and for all because in africa cost of a stent is say more that's why you would not do an angioplasty to right coronary and do a bypass surgery for a right graft for a single vessel disease is not justified this is what it means if you have a single vessel small disease single vessel artery even in those cases whether you're dealing in africa or america you would end up with an angioplasty in the second important point is in patients who are considered for coronary vascular upon whom the option treatment strategy is unclear you would have to go by a heart team approach now this is something new for example if you have a patient who's got led austere disease and circumflex also basically it's a double vessel disease now the patient is uh is open for both and if they want to take a decision a surgeon is saying that he should go for bypass because my left internal memory arteries do better than stand and an angioplasty a cardiothoracic cardiologist is saying that no angioplasty is going to do better because you don't have to go for an invasive in such a case uh scenario now they are talking about rather than fighting out the team approach of the surgeon and the cardiologist would matter so the treatment decision should be patient-centered they should incorporate patient preferences and goals and also have a shared decision making you have to discuss with the patient that an angioplasty is a surgery which angioplasty is where the patient is conscious awake you don't put an incision you go through the artery you reach the heart you dilate it you put a stand the chances of blockage coming back are x percent when you do a bypass you open up the chest you give anesthesia wishes and intubated a lot of surgeons would tend to shy away of saying all this they would just talk about lima doing better than the stents which is again a fallacy and maybe in some other days we can have that debate and discussion on one of the forums of our own but the decision should be patient-centered and hence you should go also and include patient preferences so if both occasions the posh options are available you should be discussing both to the patient and in that case you would be going what the patient prefers to do the third important take home is now going by the important anatomical points so third point is for patients who have got left main disease so what is the left main you have the on the left side you have two coronary arteries and on the right you have one so the two coronary arteries the left anterior descending and the less are complex they both arise from a common trunk which is called left main this left main disease when surgical revascularization it was clearly proven even previously and now it is endorsed again that if a patient has got left main disease this patient must undergo revascularization either by a bypass or an angioplasty but in both the cases the survival improves so in a left main you cannot keep a patient conservative even if it's a stable coronary artery disease if you have a left main disease revascularization will improve chances of survival we reduce death left main whether is asymptomatic stable unstable stmi no stmi even in stable left main whether it is symptomatic or asymptomatic must get revascularization again pci means percutaneous angioplasty is a reasonable option to improve survival compared to medical therapy in selected cases with low medium anatomic complexity so in left main also if it's a proximal left main austere left means shaft left main it's not a distal or a bifurcation left main then angioplasty is surely doing better than just keeping a patient on a very high dose of statin alone you can do an angioplasty even in those patients and it's going to do better than medicines alone the updated evidence from contemporary trials actually now endorses what we already knew with regard to mortality benefit even in stable systemic heart disease even with normal lv function but triple vessel disease so the mortality benefit when you do an angioplasty or a bypass surgery compared to when you don't do anything and just keep them on medicines is now documented not only for left main but also for ns it was previously also known for non-stmi it was known for st elevation mi unstable angina but it was controversially talked about in stable cid especially because of trials like courage there were which was previously published and there were some more trials which came later on all these trials actually talked about how the medicines could do as good as you know the invasive strategy but now there are a lot of evidences which tell us even in patients with triple vessel disease with normal lv function though they have stabilised chemical disease the mortality benefits can be achieved and revascularization decision has to be hence managed not only based on the anatomy or the disease complexity but also how feasible is the treatment and again you have to discuss with the surgeon as a team approach and take the call the use of radial now a lot of times the radial has got two points from the cardiologist's perspective and the thoracic surgeon's perspective the surgeon when he does a bypass what does he use when there is a block you bypass it with putting a new graft your new channel to reach to beyond the block so if there is an artery which is occluded say at this point and this is the heart which where from the where the blood is coming so before the block the blood is reaching and this point is if it is occluded beyond this point this occlusion you will put another channel to connect it from the aorta that's what a bypass is so when you do a bypass the blood flow beyond the occlusion is reached in through the conduit now what a surgeon uses is either of the three one he uses left internal memory which is supposed to be the best graft amongst the three choices that a surgeon has second he can choose a reverse vein graft so he uses a stiffness vein great stiffness when puts it inverted because you have the valves because the valves will will not allow the fluid to go as you remember it's a unidirectional flow so they may derive it off the valves and then put it inverted way so syphenous vein graft is what is put in in the second choice and third is the radial artery now they are now telling very clearly that the radial arteries are better than the vein grafts so if a surgeon chooses internal memory perfect beyond it now you should be using radial arteries not the vein graft because they do better and hence it is the second most important target vessel should be grafted beyond left internal memory with the radial graph because of it is superior patency in terms of being remaining open for a longer duration and also reduces cardiac events and improves survival also from a cardiologist perspective radial artery axis is now recommended as the preferred route of intervention even in patients who are undergoing acute coronary or a stable ischemic heart disease so if you have an acute mi you do an angioplasty through radial root versus you do from a femoral root the likelihood of bleeding complicating your outcomes are lower if you go radial so even in big trials like matrix trial which evaluated radial versus femoral they found out that the radial patients had a better survival because these patients had lesser bleeding only problem in the learning curve in the initial few years some of times it may you may not be able to do it but then remember that if you can puncture a radial artery that the rest of the things are not very complicated so it reduces the bleeding risk complications of the vascular you can have a hematoma retroperitoneal bleeds drop in hemoglobin in the femoral root immobilization in patient comfort apart and the patient's hence with acute coronary syndrome should also benefit from the reduction in mortality rate from the radial root and hence the radial excess angioplasty is preferred mode of intervention as compared to femoral this is again from the guideline so this is the sixth point that i talked about another important thing a lot of our patients get clopidogrel even without angiography without acute mi a lot of them end up on angioplasty and then they are non tropical light drugs for forever now it's very clearly known that a very short duration with the new generation of drug looting strength of dual antiplatelet therapy that is a p two y twelve inhibitor which is either clopidogrel pressure along with aspirin in stable ischemic heart disease if you give it a shorter duration which is just short as one to three months you can stop aspirin and just continue with single antiplatelet now for stable coronary artery disease if you do an angioplasty you all need to do is to give single antiplatelet beyond three months especially with the new generation of drug eating stents and bet because of that the advantage is lesser bleeding but it does not increase risk of strength thrombosis so no point of you know continuing lifelong forever uh dual antiplatelets for patients gone on angioplasty with the new generation of drug eluting stent you stop aspirin continue only clopidogrel or only tachycarol or only pressure after three months of a stint and that's it so you have lesser bleeding with one antiplatelet which is a more potent one than aspirin of course and it's now believed that aspirin is one responsible for most of the bleedings so you take off aspirin after three months and just continue single antiplatelet stage revascularization so these are two important trials one was called complete trial another was called culprit shock trial based on these two a lot of evidences have emerged culprit shock trial what was it so when your patient comes with an acute mi shock and you do an angiography so one of the arteries hundred percent occluded because of the mi and there is another artery which is like 80 90 percent occluded and this is not the one responsible for acute mi now when this is not a acute mi causing artery non-culprit artery would you do both arteries at the same sitting or would you do only the acute mi artery first and you will not do the non culprit artery at that moment that analysis was done in culprit shock trial and they found out that in acute mi you should only tackle the culprit artery the non-culprit artery you should tackle a couple of days later when the patient is still in the hospital or maybe after discharge you call him back and do it later on so staged revascularization for the non-culprit artery patient coming with the stmi is now recommended so a lot of time patient would decide why you didn't do it at the same time we it's now evidence based that i give an example if you are at war with your neighbor on the left on the west side don't go and fire a bomb in the east if you're fighting pakistan don't pick up a fight with china it's a different scenario but you would wish not to have two fighting like two two countries to fight with two enemies to fight with so when you're in shock you just manage the vessel responsible for acute mi in shock you defer the non-culprit vessel do it after a couple of days call him back or take him back again in the cath lab and then do the second artery after a while or maybe after two days so percutaneous intervention of the non-corporate rd at the time of primary pci is less clear and may be considered unstable with uncomplicated remask of the culprit low complexity non-culprit and normal renal function only these group of patients you can actually go ahead and do it when to do but you'll have to again look at the overall clinical picture of the patient if the patient is having altered creatinine you don't want to give a lot of dye you would wait instead you just do a culprit and come out and do the other vessel later on however dimension of non-confort vessel can be harmful if especially in patients with cardiogenic shock so this is coming from the culprit shock trial this was one of the largest trial and there was another trial called complete which said that if you do complete revascularization you fix the later other arteries later on it is always better then rather than leaving some vessels behind and unbreak asked so revascularization decision in patients with diabetes in multivessel are optimized again by the heart team approach if you have multivessel disease or you can discuss with the surgeon you can take cross opinion a lot of times we mention both options and then ask the patient to take the call along with the discussion with surgeon patients with diabetes and triple vessel should preferably go for bypass surgery so this is uh now very clear in diabetics the reason is when you put a stand the blockage coming back of the new development of atherosclerosis or the graft or the strength getting occluded are much higher and they do better we know this from barry trial body two trial body d trial and there are some more trials that have laid off late including the syntax which told us that you should go for bypass surgery especially in patients who are triple vessel and diabetic diabetic triple vessel bypass is the first choice angioplasty is considered if they are poor candidates so you have a patient who's got triple vessel disease and he's diabetic and he's also got a bad copd and you're not sure if you're going to be able to extubate him once you put him on ventilator he's got say a previous history of stroke if the patient has got borderline creatinine and you need to go say on pump because if you go on heart lung machine then you go into hypotension it will increase creatinine further you can fix say suppose that with a minimal die then maybe angioplasty so you'll have to individualize the call but in the non-fit candidates when the surgeon feels you can go ahead and still do an angioplasty angioplasty is not a contraindication even in this case the treatment decision for patient undergoing revs for coronary artery disease and should include looking at the patient's surgical risk now it's not always what is the risk in angioplast you will also have to look at the risk of bypass surgery and there are various calculators available so the calculator for surgical risk is called as sts score which is society of thoracic surgeon score so this is a score based on the individualized parameter creatinine nyh class ejection fraction number of occlusions recent demi etc etc these are available on apps these are available on the websites of the st ats american thoracic society you can log into there click on the patient parameters and you'll get what is the operative risk same way you can use another score which is called a syntax score so this syntax core is basically another scoring system again you can check on the websites go and search syntax core google it you'll find a lot of links you can just put on the various occlusions and graphs where are the disease whether it's angulated whether it's calcified and there is a syntax core 2 where the clinical syntax core as they call it that also you can calculate but this is very less clear because of the inter-observable variability being there because the surgeon audiologists will feel this is thrombus somebody will say this is not i mean less less angulated somebody say this is a long occlusion calcified something so it's not so much calcified it can still be managed by angioplasty so there is inter observer variability uh and its absence of clinical parameters in the non-clinical score of the syntax there might be more confusion so but syntax can be recommended by a cardiologist and the american thoracic society or the sts core also is uh gives the scoring for the surgical risk and then you can sit and discuss this with the surgeon and then take a call when there is a complexity so one vessel two vessel you can go ahead exit proximal led you can choose either but again diabetic patients in triple vessel left main disease elevators function you would prefer bypass other cases it's an angioplasty so now otherwise it's it's fine to choose between the two between single vessel long led lesions there is no controversy there's no question no surgeon would ask you to do a bypass surgery unless you have a very compelling case like you have a single coronary artery etc so now i will take you to a single slide of flowchart so this is what the crux and summary of the whole presentation is this is what the guideline is so what does i'll zoom it in for you so that you can see uh you can zoom it yourself as well so if if the patient who's having acute mi there is no controversy in acute mi you'll have to go and fix that artery the whole of the problem on the confusion and the debate and the challenge uh remained around stable coronary artery disease so if you have acute mi uh you so you can't do a bypass surgery it's very rare if you have an unstable enzyme on nstmi again you have to do angioplasty but in a patient who's got stable coronary artery disease how to choose this is the algorithm so sihd means stable ischemic heart disease this patient will of course always be given a chance of medical management first and if there is angina which is refractory to medical therapy if yes then you will fix the angioplasty or you will do a revascularization so first the therapy has to be medical it will depend on the anatomic indication and also indication of improving the symptoms now once you have known decided that this patient is refractory on medical management now you need to do more what you will choose is to look at the anatomy this patient is having left main disease if yes is it the significant left main with high complexity of coronary artery disease yes then is the patient's fit enough to undergo a bypass surgery so he can go ahead and fix a bypass surgery if no then you have to discuss with the heart team and take a call that you will keep him only on medicine or you will also advise to go for an angioplasty if there is no significant stenosis or high complex anatomy then you can choose between the bypass and left main in even in left main and angioplasty pci which is still a class two indication plus one is for cabg for the left main now if the patient is not having left main disease and it's a multivessel disease with anatomy which is suitable for either of the two if it's not suitable you put him on medical management but if the patient is having anatomy which is suitable for both angioplasty as well as bypass surgery you look for ejection fraction so in triple vessel patient if the ejection fraction is less than 50 means the patient has got elbow dysfunction if he has and is he suitable for bypass surgery ps and if ef is less than 35 bypass is preferred between 35 to 50 though bypass can be done but it's a class two-way indication if not a suitable candidate of course you can go ahead and fix a hard team discussion with an angioplasty in patients whose ef is more than 50 percent and is a triple vessel disease bypass and angioplasty is equally indicated as 2b so in without eleven dysfunction without diabetes triple vessel you can choose either and both have class to be indication so apart from guideline directed therapy this is how it is so this flowchart is to make it simplified in the areas of controversy otherwise it's very clear that in patients who are say acute mi you do an angioplasty in a single vessel double vessel you do an angioplasty left main you would prefer bypass surgery if triple vessel diabetic you would prefer bypass surgery especially in the patients with ejection fraction less than 35 if it's more than 50 you can choose either in non-diabetic step of equations so this was um the flow chart which i thought i will summarize for stable cad i think i should be ending my presentation uh here and we can go ahead by the discussions that are there in the chat box yes yes [Music] thank you so much sir it was a very nice presentation very self-explanatory and uh i'm sure our audience loved it because you like you said it was a vast topic with vast updates which came and you summarized it perfectly in 10 slides and it was just amazing so i think go over to the question and answer sir so dr tarini prasad is asking what is high anatomical complex cad yeah good question so because it mentioned a complex cad to be going for bypass surgery complex is defined as you know angiographically you have type a type b type c lesions type c lesions are the lesions which are more than 20 centimeters in length but nowadays that's no more a criteria on the country those which are more calcified have got side branch axes which are uh having a thrombus burden which are tortuous which are angulated say you can have an artery which is bent like this so put a stenting across that would be a difficult not only job but it will straighten up the artery because you put a metal inside it so these are type c lesions which have been predefined as complex lesions when you have a complex anatomy like these that's when you are saying that you choose the cbg and that's why how do you justify or calculate or merge the angiographic occlusion with the complexity that is what is syntax code so you can go to uh google on syntax core see there is a picture that will come in and you can just for random you know try to click on some options as you want to do for a hypothetical case and then you'll see it will give you all the options that it will show is it a blind stump how is the length is it tortuous is it thrombus containing is there a side branch is there a collateral present uh is it angle is more than 50 degree which branch you are choosing which artery is it and based on that it will give you all uh scoring and based on that score it will tell you whether the bypass is better or angioplasty is better so that's the syntax but as i said the interpersonal inter observer variability is much more syntax score there is another one which is called a syntax clinical score which is in text two which is slightly better which is includes creatinine etc as well so this is what a complex anatomy is when you have a simple straight forward focal short lesion uh without thrombosis calcium etc that's a type a lesion so type is do much better than type b's type b is do better than c b is also categorized b1 and b2 but rather to complex the complex question i'll simplify it that if you have longer lesions tortuous lesions calcified region these are complex regions i hope dr tarani that answered your questions so just uh what is the role of like functional tests in a patient of non-lms disease stable disease or asymptomatic patient uh what do you suggest the guidelines does not specify about this uh in whatever discussion ten points yeah [Music] uh probably because of ischemia trial you can say has been pushed to a back burner it's not clarified as to whom you should go for ischemia evaluation but it is assumed that for a stable ischemic heart disease the definition is non uh acute even which means the patient should not have nstmi stmi biomarkers should be normal and ischemic heart disease would mean that there is ischemia documented by a stress testing either a treadmill test or a radio nuclear or any other modality of stress assessment but it does not specify how to evaluate which one to choose amongst the various modalities and i think with an intervention angle i think the acc did not deliberate into how to evaluate or which modality to choose amongst the ischemia evaluation methodology [Music] okay so the next question we have is uh from dr balwan chauhan ct angiography versus regular angiography for diagnostic purposes yeah i think dr balwan we already have a session which we had recorded there was a debate we had kept and asked the radiologist versus a cardiologist in on my channel itself you can go back and look at that whole session but anyway uh just to summarize it again just my my whole topic today is to summarize so i'll summarize and give you the crux of that talk as well today in two minutes the point is in a patient who is moderately high risk you should go for an invasive and you have a documented ischemia like dr kuchil was saying if you have a patient whose stress test is abnormal strongly abnormal patient is diabetic elderly hypertensive family history dyslipidemia or any patient who's got an acute coronary syndrome so stmi st elevation try an sdmi drop positive original abnormality on echo these group of patients should go invasive because there is an intent to revascularize there is a definite like under likelihood of ischemia ongoing and troubling you so these patients should undergo invasive so don't subject ct angio for a diabetic hypertensive anginite rest troponin positive complaining of chest pain address tcg showing changes eco showing rwma and he's advised you okay you get a ct engine because you don't want to get ngo that is not the way probably you can push him more stronger to get an invasive one ctn however is advisable in patient whose low intermediate risk lower intermediate and the risk profile is role a young female atypical angina tmt is not able to do echo is normal biomarkers are normal non-specific std changes but has a lot of anxiety and there is a family history so this is a patient who falls into low risk patients so lower risk patient when you're looking at just as a marker of ruling out cat in a patient who's having persistent symptoms non-specific std changes not st elevation so this is a stable cad is likely but you don't have a documented ischemia this kind of a patient to rule out you can do a ctn also asymptomatic diabetics to prognosticate a lot of pain patients do people do it and there they look at the calcium score so what the advantage of ct and good advantage of ctnj over invasive enzo is that it calculates the calcium coronary artery calcium score score as you call cac score and this if the score is between 0 to 10 they say the likelihood of an acute event over next 10 years is less than 1 so that is scoring estimation is what the advantage of ctng so when you do a ctn always look at calcium score which is just the calcium amount that is present rather than just looking at the cubes being present you know how patent how broad how narrow that is not the good way of looking at a ctng and you should also look at the calcium that's what the ct angels have been for so lower risk patients ct angio high risk patients invasive angio ct and you look at the calcification again there are a lot of disadvantages of ct ngo motion artifact respiratory artifact you need to control the heart rate patient should have a constant heart rate no atrial fibrillation no vpc sometimes may require beta blocker hypo ready something to lower the rate etc etc and contrast of course you need much more you call it non-invasive but you still have a vein inside you inject the contrast into the vein here you put a radial artery here it's the way for patient the discomfort may be the same thank you so much so uh the next question is by dr muhammad saful why we shouldn't do the pci on the same setting for non-culprit artery good question so you should do when you come with an acute mi and the patient has a two lesions so they say if the patient isn't you've done an angioplasty to a shock vessel and if the patient's other lesion is also responsible for shock which means one artery is hundred other is 99 you fix it it's fine to come out of shock but if one lesion is hundred and other is eighty percent let do lesion yeah i'll just finish it in two minutes let me go ahead and do it i don't want to take the patient in again that should not be the reason because at least for that you will require more time you may put a wire and balloon in and you can create ischemia transiently during that tackling that vessel and on top of that you'll use some more dye so this patient is already in hypotension his renal perfusions are getting impaired and you're loading that god with more dilord you know that kidney is already tired and you're pushing it into with more kidney dilord and then you'll end up with renal failure so instead of you know pushing that kidney that's what they are saying so when you have a fight with one um neighbor just finish that fight don't create more trouble with the other neighbors picking it up so finish that trouble what is on your hand of course don't send him early if you think that legion is going to come back and the second lesion is going to trouble you you can take the patient back again after two or three days and fix that vessel and then send the patient no or if the patient is stable he can go back and he says no i'll come back this was emergency i'll come back after seven days no problem you can send back and call back and do the second whistle seven days that is the reason you should not but as your question is right that if the patient remains and persists into a shock in a vessel where the other vessel is not culprit but is likely to end up trouble immediately in the same hospitalization to the discretion of cardiologists you can fix it at the same time okay great next question by dr bhavik kumar chauhan if already on aspirin with taika grelor for 1.5 years so when to switch on single antiplatelet and with which agent i think good question it this is a common problem that we find if a patient is already on tiger grill or for beyond a year you should have probably stopped it much earlier because ticagrelor studied only for one year so patient is already loaded for beyond six months now he should have probably stable cd stopped it at three months of aspirin now however tycho grillo can be given beyond a year without aspirin up to three years but the dose is 60 milligrams so that is a trial called the gases trial which looked beyond plateau plateau was the trial of acute mi tecagrilla where you give it for one year but beyond a year you'll have to give if you want to give taika grill or you're a fan of tycho gryllar it reduces acute mi probably if this is a post mi patient then you will give 60 milligram bdd not 90 milligram bdd and of course you will take aspirin off so beyond a year no aspirin if you want to give tiger okay dr sangeetha would like to ask what would be the course of management for refractory angina post pci so we need to know what's refractory angina like i mean this patient may have a refractory angina because of a vessel which is occluded or maybe the stent which is occluded maybe there is a branch which is occluded or maybe there is a vessel which has not been looked into or maybe this is because of some secondary cause like anemia thyrotoxicosis altered creatinine healthy dysfunction or this may be also because of some other etiologies like microvascular or diabetic or renal failure so once you've ruled all these out and you think it's not so i recently had one of the leading uh doctors of the city who had undergone angioplasty with somebody else and he had refractory angina and then i reviewed his angiogram we found out that there was another branch which was left in our left on medical management but that was a critical and a big branch and that was responsible for angina the other thing was that this could have been also not been on optical media optimal medical medic medications so which was like in this case this patient was only on and well anticipated and started no beta blocker no nitrates nothing so all i had to do was to put him on a beta blocker and nitrates and the patient did well so choosing an optimal drug choosing finding out so so see you you will treat when you know what you are dealing with you cannot treat fever as a fever you will have to find out whether fever is covered or malaria if you know it's malaria you treat with antibiotics if it's covered you treat the way it is to be treated so same way when you have a case of a refractory angina find out what is the cause is it secondary angina it's a primary angina it's a branch it's a small vessel it's a microvascular or it's because of the stent which is now getting occluded once you've ruled out all those things out that's how you optimize medical management what drugs to choose for refractory angina is a separate topic and i look forward to have you a session on that in future yes sir the next question by dr vijay sancheti is angiography solution for systemic heart diseases angiography is never a solution for anything so it's like opening your eyes and seeing is the same solution of knowing that the things exist seeing will tell you that things will be seeing a thing will make is the diagnosis angiography is to look what is there and what is not the solution is managing those blockages now those blockages whether they need to be managed with medicine only with angioplasty only with bypass only with combination of this with neither will all depend on patients overall clinical scenario not just on looking at the blocked pipes i'd always say arteries are not pipes you need to define identify each of them and treat the patient in totality you cannot be treating i did a successful angioplasty but the patient was not successful that did not happen you have to treat the patient as a whole that's why we are holistic doctors we need to be looking at the patient in totality you may be the super specialist or the left ventricle specialist but if the patient doesn't make it you're no more specialist so dr suyash would like to ask uh suppose am i a patient with recanalized vessel less than 50 percent shall be stented or kept on medical management so usually less than 50 you should be leaving it around anything that does not cause ischemia should not there is a trial called erosion trial which looked at the oct data and that showed that even in the patients who had acute mi and if there was a plaque erosion based on oct which means there was no blocker say just erosion of the plaque you can leave these patients on medical management but again it would depend if you're dealing with the thrombotic plaque if you have a dimitri flow if you have the thrombus which is protruding then you'll probably take a check shoot after anticoagulation etc so there is with erosion uh you may not but in a block rupture you will have to okay dr virendra gupta would like to ask what are the indications to switch on single antiplatelet if patient has developed hyper acidity and is it safe yeah so you can switch to a single antiplatelet as i say in stable cad from one month to three months um acidity alone may not be the reason but if you have a gi bleed if you have amateuria if you have a bleeding coming in somewhere then you'll have to switch and remember most of the trials and i talk about aspirin being the culprit of bleed so also you can take off aspirin continue the other antiplatelet you can stop it at a month or three months um depending on the clinical scenario in is however in acs in acute coronary syndrome you'll have to do it for a year beyond a year you can take it off with the anti-ah antacids etc you can manage hyper acidity that is the only troubling reason because taking off bapt in the early course can be troublesome and can kill you to induce ten thrombosis uh okay so dr gupta has asked the question in continuation of the previous can one stop aspirin and continue clopidogrel 150 after three years of primary angioplasty for iwmi uh so why after three years why do you want to give club photography i mean i would probably give just only aspirin um beyond a year you don't need either of the dual antiplatelet anyway for any guideline so aspirin alone would be a good idea but if you want to choose say only clopidogrel as a single antiplatelet beyond three years again not an indication only aspirin probably is good enough so beyond a year there is no role i think you should be going back and looking at the reasons why the patient was put on dapd beyond two years dr nurul would like to ask how to approach coronary artery aneurysm so depends on whether the aneurysm is acute or chronic whether it's post-procedure pre-procedure whether it's atherosclerotic or infective it's ulcerated or not whether it's a small or big with a true aneurysm or a pseudo-aneurysm so a lot of things would come into picture sometimes you might have to image it with iverson ocity small aneurysms across the lesion you put a stent most of these aneurysms will collapse just like in intracranial aneurysms in subarachnoid hemorrhage when they put across laminar flow strains um you can actually end up coiling them if they are too big and sometimes very rarely you may have to do even a covered stent but some of these patients may actually if there are huge aneurysms then you will have to probably go for surgery doctor pal of mishra has a question what is the role of ffr guided angioplasty ffr would depend so the two important trials recently actually failed for ffr uh guided pci and there have been indications of doing ffr for these branch accesses etc but otherwise uh the indications of ffr guided pci except for a single order vessel that you're finishing beyond the acute coronary in a borderline lesion is fine but otherwise ffr guided pci for a non-culprit lesion at the same time is not a right strategy anymore dr puneet sharma would like to ask in an elderly post-bypass patient can calcium supplements be given yeah calcium is not what gets deposited per se because of itself because what you eat calcium is a surrogate marker of cell death if you go back to robin's textbook of pathology in second year it says calcium is the harbinger of cell death calcium is not calcium of what you eat calcium is calcification or calcification uh cause being represented by atherosclerotic necrostic plaque being calcified later on so calcium should be given there is no harm in calcium for bones the problem is the calcium comes because of the atherosclerosis it does not come because you eat a lot of calcium it's not the renal stone developing coronary artery disease uh approach to triple vessels with af i believe you are trying to ask how to anticoagulate so when you are giving an af you would give a novak depend if you are not dealing with an acs in that case you will have to give a new apt but if you're dealing with an acs you can actually choose a regime which would be short duration of triple antiplatelet and take off aspirin as soon as possible in an acute mi situation maybe a month continue with b2y12 antagonist especially proprietor along with the lower dose of noaak or you can give in some high risk patients a month of be a triple antiplatelet which is aspirin b2i12 and novac and then take it off so stable cats you can take off which much early you can just keep beyond three months and beyond six months and beyond a year depending on the algorithm from the european society of cardiology you can go through you can search and find it out and and those patients you can continue only with nox beyond the period of year and maybe just aspirin if you just want to continue and you can take me to white dwelling in some group of patients so next question is by dr thusly kareem what is the duration to appear for the next block after angioplasty if done in diabetic patients depends on where it is done how it is done who has done it in whom it is done so you can have re-stenosis covenanting in the coronary stent segment itself ranging from five percent to 15 percent in six months time if that is what you're asking he was trent mckinnon but new blockages at the edges beyond the edges new vessels also can develop but in a diabetic subgroup compared to the isr rate in non-diabetics which is ranging from three to four percent uh in the diabetic subgroup it goes up from from five to fifteen percent some say seven eight percent some say fifteen percent in some studies depending on which tent which subgroup and what type of lesion small vessel long lesion calcified tortuous which vessel how is it implanted high pressure dilatation done imaging done not done all those criteria will matter all right dr bhavik kumar is asking post pmi after years single antiplatelet need to be continued lifetime or can they be stopped i think beyond a year you'll have to continue probably aspirin as of now but there are now new trials which are looking at a b2 white fell rather than aspirin being evaluated so till that divergence emerges beyond the year you can continue single antiplatelet along with statins and the other disease modifying agents or guideline directed therapies okay great sir i think those were the questions and all the doctors whose questions we have answered we have got some very very nice thank you comments uh you have answered their questions they are like thank you so much golden words and clearly explained so thank you so much so i would like to thank everyone uh dr narayan thawker says fantastic session dr hassan says thanks a lot so the comments are just pouring in yes it was indeed a very good session very self-explanatory and very well done so i would like to thank everyone for being here on a christmas evening on the weekend thank you so much and merry our audiences to have their topics of their choice rather than me posting topics my choice i would be very well and happy to take topics what they want to listen on our channel so in our subscription modes you can text our on the emails that you have for the netflix you can write to them and you can demand topics on cardiology that you want and we are looking forward to very interesting sessions in future uh italy is always a pleasure being there with you all yes thank you so like uh sir said if anyone has some suggestions for the topics you can please write down in the comments section and we'll surely take it up with sir thank you so much sir thank you bye-bye take care merry christmas to all of you enjoy good to see you in 2022 keep yourself safe and healthy enjoy keep fitting fight bye take care thank you bye

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Dr. Kamal Sharma

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Dr. Kamal Sharma

Chief of Interventional Cardiology, SAL Hospi...

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