ACUTE CORONARY SYNDROME WITH COMORBIDITIES: A Therapeutic Challenge
ACUTE CORONARY SYNDROME WITH COMORBIDITIES: A Therapeutic ChallengeAuthor Gurunath Parale MD DM FACC FCSI FICP Professor Department of Medicine Ashwini Rural Medical College Chief Cardiologist Ashwini Cooperative Hospital Solapur, Maharashtra, India Editorial Assistance Virupaksha Joshi MBBS DMRD Radiologist Ashwini Cooperative Hospital Solapur, Maharashtra, India Forewords D Prabhakaran George Joseph Jagdish S HiremathCK Ponde
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Acute Coronary Syndrome with Comorbidities: A Therapeutic Challenge/ Gurunath Parale
First Edition: 2020
ABOUT THE AUTHOR
I dedicate this book to my teachers at medical school who instilled in me, during those formative years, a sense of enquiry and inquisitiveness about everything. They gave me not just the fish, but also the fishing rod and moreover taught me how to use the rod.
- DM Cardiology from PGIMER (Chandigarh)
- Trained in CMC (Vellore), CTC (Liverpool)
- Chief Cardiologist, Ashwini Hospital, Solapur
- Professor Medicine, Ashwini Rural Medical College, Solapur
- Fellow of American College of Cardiology
- More than 30,000 Angiographies/Angioplasties
- More than 300,000 Echocardiograms/Stress Tests
- More than 40 Publications in International and National Journals
- 122 Citations by Authors from all over the World
- Numerous Paper/Case Presentations/Lectures in India and Abroad including Prestigious Conferences like PCR in Paris, TCT in San Francisco, ESC in Rome
- Recipient of Rotary Millennium Award, Sharad Puraskar, Gandhi Forum Award
- Authored a Book ‘Sahriday’ and VCD for Patient Education.
D Prabhakaran MD DM (Cardiology) MSc FRCP FNASc
Vice President - Research and Policy, Public Health
Foundation of India (PHFI)
Professor, Department of Epidemiology
London School of Hygiene and Tropical Medicine, UK
Former Professor, Cardiology
All India Institute of Medical Sciences
Cardiovascular diseases have become the leading cause of death in India. According to the state level disease burden published recently they contribute nearly 20% of total mortality. Despite this they pose both a great challenge as well as an immense opportunity to healthcare providers in the world. While the survival has considerably improved, the biggest challenge in India is that the disease occurs at younger ages imposing an unaffordable financial burden to individuals and their families. In addition, comorbidities have emerged as a major determinant of survival among patients with coronary artery disease.
When I was asked to review the book titled “Acute Coronary Syndrome with Comorbidities: A Therapeutic Challenge“ by the well-known cardiologist Dr Gurunath Parale from Solapur, Maharashtra. I wondered as to the need for another book of cardiology given the profusion of textbooks that are currently available. However, ongoing through the book in detail, I am sure that this book will find a unique niche both for students and practicing cardiologists. One of the most ignored aspects in the management of coronary artery diseases is the presence of comorbidities and there is hardly any patient without involvement of another organ system which substantially influences outcomes and increases mortality. Dr Parale has had years of experience in handling such comorbidities and has shared his experiences through case studies. This format provides a real-life scenario and many of us can easily relate to such situations. In addition, he has provided several practical tips in handling patients with comorbidities. Further, the simple English makes it easily readable and I am sure this book will become a ready reckoner for the practicing cardiologist in handling complex situations.
My hearty congratulations to Dr Parale in writing this book which must have been a love of labor for him. I am sure this book will be widely read and used.FOREWORD
George Joseph DM FCSI
Professor of Cardiology
Christian Medical College
Vellore, Tamil Nadu, India
An outstanding masterpiece from a brilliant academician, this gem of a book is a must-read for any clinician dealing with coronary artery disease patients. Dr Gurunath Parale has a captivating style of presentation, starting each chapter by narrating related real-life dilemmas he encountered candidly and with endearing honesty. Having whetted the appetite to know more about the subject, Dr Parale then launches into a masterly review of the relevant literature, providing fascinating insights into the pathophysiology and management of acute coronary syndrome encountered in association with various comorbidities. The primary focus is on the practical difficulties one often faces when dealing with patients with acute coronary syndrome and specific comorbidities. Dr Parale provides clear solutions to each problem, based on a thorough but succinct review of the state-of-the-art and the latest guidelines. And if this was not enough to indelibly imprint these facts in one's memory, Dr Parale provides a deft finishing touch to each chapter with a precise summary of the key points. I am sure anyone fortunate enough to lay hands on a copy of this book will enjoy reading it as much as I did.FOREWORD
Jagdish S Hiremath DM (Card) DNB (Card) FACC
Cath Lab Ruby Hall Clinic
Pune, Maharashtra, India
I have been associated with Dr Gurunath Parale as a professional colleague for many decades. His astute clinical judgement supported with exceptional hand skill makes him one of the leading interventional cardiologist of the country. Present book of comorbid conditions with acute coronary syndrome, the subject of the book itself indicates a thinker in Dr Gurunath Parale. The chapters that you will read are real-world experiences. Dr Parale always follows guideline science, but also adds original experience in the narration. He is a master of science of medicine, but also introduces art of medicines which comes from the book of experience.
I find this book exceptionally useful for all interventional cardiologists. It is an excellent reference book in one's shelf and in one's computer. Every chapter can guide one when faced with “associated comorbid conditions with acute coronary syndrome”. I congratulate Dr Gurunath Parale for having thought of this unusual topic and passing the benefit of his own thought process to many of his colleagues like me and also thousands of junior budding cardiologist of the country.FOREWORD
CK Ponde MBBS MD DM
PD Hinduja National Hospital and Medical Research Centre
Mumbai, Maharashtra, India
It gives me great pleasure and pride to write a foreword for Dr Gurunath's venture. Postgraduate medicine is ever evolving and this is the era of evidence-based medicine. The textbook knowledge of the disease process forms the base of the pyramid and pyramid keeps on going taller when more and more data is added derived from randomized trials and registries. A clinician is supposed to have mandatory knowledge of clinical trials and registry data which help him in decision making in day-to-day clinical practice. Despite this knowledge, there are frequent occasions where a clinician is faced with a case where decision making is extremely difficult, complex and challenging.
I myself firmly believe that the use of clinical case discussions is one of the best method of teaching and learning medicine not only for the medical students, but also for experienced consultants.
Dr Gurunath Parale is known to the medical world for a very long time. He was the pioneer cardiologist in the district of Solapur and has practiced medicine and all the facets of cardiology including clinical cardiology, echocardiography and interventional cardiology in the most versatile manner. He has maintained his academic excellence even when having the busiest practice and that too in a place like Solapur. He has written books for patients, has published several articles in national and international journals and also has presented complex interventional cases in conferences like TCT and EuroPCR.
This compilation of challenging case scenarios and dilemmas in cardiovascular medicine comes as a breath of fresh air. He has beautifully discussed each case/topic, its complexity in a most lucid manner with extensive coverage of the relevant literature. What is most important is that the clinicians will get a very clear idea about how to deal with such dilemma when they face such a patient. The selection of cases and the topics explore those areas of cardiology which remains untouched in textbooks, journals and even conferences.
I am extremely impressed with this book because it bridges the gap between the established knowledge and the gray areas and this is so very important for a clinical cardiologist today, because he/she is invariably faced with patients with multiple comorbidities.
I and Dr Gurunath have a very long association of over 30 years, as we both have taken our postgraduate degrees in medicine from the same institute, VM Medical College, Solapur, Maharashtra. When I look back and see his growth it makes me immensely proud and ecstatic.
At the end, I must say that if every clinician keeps on contributing such pearls of experience to help his colleagues and budding consultants the world will become a different place.PREFACE
Gurunath Parale MD DM FACC FCSI FICP
Department of Medicine
Ashwini Rural Medical College
Ashwini Cooperative Hospital
Solapur, Maharashtra, India
It is almost 25 years since I embarked on my practice of cardiology in the ‘textile town’ of Solapur, Maharashtra, India. Since I was the only cardiologist with super-specialist qualification for a long time, it was not surprising that patients from all corners of this large district were referred to me for consultation on various heart ailments. The diagnosis and treatment of ischemic heart disease used to be a relatively simple affair with straight-forward approach as guided by the standard textbooks. Once the acute myocardial infarction (AMI) was diagnosed acute coronary syndrome (ACS) is a recent nomenclature, based on TMT and ECG findings, the treatment options were 2-fold, i.e. either intravenous thrombolysis, if the patient reached the hospital within the so-called ‘window’ period or a conservative line of management with bed-rest and medications. It was the era before the hi-tech cath labs and percutaneous re-perfusion techniques became the standard, first-line methods of treatment.
However, in the past decade or so, the scene of cardiology practice changed in significant ways. Firstly, I was no longer the only cardiologist and the hospital, where I worked was not the only hospital catering to the district inhabited by a million people. The so-called simple and uncomplicated cases of ACS were successfully treated in smaller nursing homes at the periphery of the district. Secondly, the not-so-simple cases were being referred to the tertiary care hospital where I work. Many of the patients referred to me with heart disease suffered from other comorbid conditions. Some of them had a long history of chronic obstructive airway disease, while some others had suffered a recent cerebrovascular accident. Many of these patients with heart disease had a hitherto undetected kidney disease or a hematological disorder or even a connective tissue disease. Some of the patients who were referred to me for cardiac evaluation were even treated and declared as cured from malignant disease such as breast carcinoma. At least two of the patients suffered from chronic liver disease and one of them was even wait-listed for a liver transplant. Therefore, the present scene was a far cry from the old days when I diagnosed AMI and treated it with thrombolysis or waited with crossed fingers for the patient to recover after prescribing medicines.
However, with the advent of primary angioplasty as the treatment of choice for AMI, a paradigm shift took place in the manner in which MI or ACS was treated. Introduction of drug-eluting stents was a path-breaking innovation and dual antiplatelet therapy became the mainstay of medication to prevent thrombosis within the stent. However, the changing demography of the patients referred to a tertiary care hospital had its own share of challenges. Apart from the cardiac disease, associated comorbid conditions in some of them threw up special challenge for the treating cardiologists like me. For instance:
- Could I go ahead with a PCI with a drug-eluting stent followed by heparin and dual antiplatelet therapy in a patient with advanced liver disease and GI bleed?
- Can I proceed with PCI and dual antiplatelet therapy in a patient with a recent intracerebral hematoma and risk further increase in the size of the hematoma and neurological deterioration?
- How safe it is to proceed with coronary angiography involving potentially nephrotoxic contrast media in a patient with pre-existing renal dysfunction?
These are some of the vexed issues troubling the cardiologist like me practicing in a tertiary care hospital. Moreover, there is scanty and sketchy material available in present day medical literature to guide the physician and help him practice evidence-based medicine. The book in your hand now is a culmination of my decade-long effort to find meaningful answers and dependable protocols to deal with the vexed problem of heart disease with comorbid conditions. It is my ardent hope that the reader will find answers in this book to the dilemma he/she must be facing in his/her daily practice.ACKNOWLEDGMENTS
I am indebted to my wife Dr Neha, without whose moral support this book would not have been possible. Silently but stoically, Dr Neha put up with my obsession to write this book and the manner in which this obsession intruded our ‘we’ time even during weekends and holidays. I am grateful to my elder son Dr Chinmay for his insightful comments and suggestions. I discovered during these interactions what a fine young man he has turned out to be. I also acknowledge my younger son Hrishikesh whose encouraging words have kept me steadfast on my path toward academic pursuit.
I am honoured and obligated to well acclaimed quartet of cardiologists Dr D Prabhakaran, New Delhi, Dr George Joseph, Vellore, Dr Jagdish S Hiremath, Pune, Dr CK Ponde, Mumbai. Each one of them not only set aside his precious time to read excerpts of this book but also readily agreed to write a foreword. Without the encouraging forewords from such accomplished cardiologists and prominent academicians, this book would not have acquired the legitimacy I hope it would.
I also acknowledge Dr Satyawan Sharma, the famous cardiologist at Bombay Hospital who gave me some useful suggestions.
Last but not the least, important is the invaluable help I got from my colleague radiologist Dr Virupaksha Joshi. Although his specialty is far different from the topics in this book, he put his mind, brain and most importantly heart into this project and helped me to complete it which at one point of time I thought was not possible.