Cath Lab Digest

Every year a small group of multidisciplinary physicians of cardiology, neurology, dermatology, pastoral care and infectious disease organize the Annual Cardiovascular Disease of the Caribbean. The conference was held at Trinity School of Medicine, St. Vincent West Indies. The day of the conference, we saw two children with acute rheumatic fever at the Milton Cato Memorial Hospital in Kingstown, St. Vincent, West Indies. The two children had carditis, migratory polyarthritis, elevated ESR, a high white cell count and increased ASO titers, no subcutaneous nodules and no erythema marginatum. They had cardiomegally on chest X-ray and changes of pericarditis on electrocardiography. The island hospital does not have access to other imaging equipment such as echocardiography or magnetic resonance imaging. Physical examination was consistent with isolated mitral regurgitation in one child and combined aortic insufficiency and mitral regurgitation in the other child. Both children had acute heart failure managed effectively by ampiciilin, lasix, high-dose aspirin, corticosteroids and digoxin. They were in the recovery phase from acute congestive heart failure and will need long-term penicillin, follow up with echocariography and prophylaxis for invasive procedures. The two children will likely need valve replacement therapy or valuloplasty for mitral stenosis in the next three or four decades. As a physician from the Western world, I was humbled by the excellent diagnosis and treatment options offered by the lone pediatrician in the country. The nurses from the floor and the mothers of the two children told me that the pediatrician saw the children in the emergency and causality department, and without batting an eyelid, made the diagnosis within 20 minutes based on their history and physical examinations. Rheumatic fever is a clinical diagnosis that is based on the Jones criteria originally pioneered by Dr. Jones in the 1930s and further modified in 1991. The physical examination can be supplemented by laboratory tests such as ESR, ASO titers and WBC (Criteria supported by the WHO). I was apprehensive about the prospect of my own ability to make such a diagnosis if I were to see such patients on my own. Despite being an adult cardiologist, I wonder if I still retain the basic history-taking and physical examination acumen to diagnose such a dreaded disease. I might have very well sent the children home from the ER with a diagnosis of flu and missed this life-threatening condition. Hence the saying: “eyes cannot see what the mind does not know”. North America has witnessed the near-extinction of rheumatic fever, however, there are occasional outbreaks as recently occurred in Colorado. Thus, there is a need for continued medical education to learn and adot the skills of history-taking and physical examination.

Aravinda Nanjundappa MD RVT

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ARAVINDA NANJUNDAPPA, MD, RVT Dr. Nanjundappa completed medical graduation in Adichunchanagiri Institute of Medical Sciences, India. He is specialist in Internal Medicine and Cardiology. He has certification in Cardiovascular Disease, Internal Medicine and Interventional Cardiology. He has been resident and fellow at Seton Hall University, Shands Hospital, Washington Hospital Center. He has also served as Director of Vascular Medicine and Peripheral Interventions at Pitt County Memorial Hospital, Greenville, North Carolina. At present, he is working as an Associate Professor of Medicine and General Surgery at West Virginia University School of Medicine, Charleston, West Virginia. He is a Board-Certified Cardiologist and Interventionalist. Recipient of numerous teaching, research awards and grants, Dr. Nanjundappa is author of more than 60 peer-review journal articles and text book chapters. A frequent national and international guest lecturer, he serves on the editorial boards of eight journals including: Angiology; Interventional Cardiology (Associate Editor); and The Internet Journal of Endovascular Medicine (Chief Medical Editor). Dr. Nanjundappa has participated in several important Clinical Trials including: CLEVER, CORAL, CAPTURE, CREST, HERCULES, MOBILITY, and CHOICES.

ROBERT S. DIETER, MD, RVT Dr. Dieter is an interventional cardiologist and vascular medicine specialist. He has completed advanced fellowship in Vascular Medicine and Peripheral Vascular Interventions at Georgetown University/Washington Hospital Center in Washington, D.C. With a patient care emphasis in Vascular Medicine, he specializes in the management of patients with complex vascular diseases. He manages patients with stroke, TIA, and those at risk for stroke, particularly those with carotid artery blockages requiring angioplasty/stenting or those with PFO. He also specializes in renal artery stenosis. In fact, Dr. Dieter has published on new and potentially safer methods to treat blockages in the renal arteries. Dr. Dieter performs minimally invasive abdominal aortic aneurysm repair (endograft). Dr. Dieter has extensive training in the management of patients with claudication, as well as those with critical limb ischemia and non-healing ulcers — particularly in patients with diabetes. Furthermore, Dr. Dieter is board-certified in interventional cardiology and specializes in angioplasty, stenting and myocardial infarction treatment. Although Dr. Dieter is a vascular medicine specialist and interventional cardiologist, his underlying philosophy is the prevention of disease. He completed an advanced fellowship with renowned experts in Preventive Cardiology. Dr. Dieter actively treats patients with complex dyslipidemias. Dr. Dieter graduated Alpha Omega Alpha from medical school. He has written over 100 journal articles, eight book chapters, is on the editorial board of several medical journals, and lectures internationally on cardiovascular diseases. He is the editor of two textbooks on vascular disease.