Cath Lab Digest

I made a recent medical assistance trip to St. Vincent, West Indies, a picture-perfect island with homes for the rich and famous. The local hospital tour revealed some astonishing numbers in terms of vascular disease. The number of amputations in a year was about 228 for a population of 100,000. Also, the mean age of the amputees — 39 years old — was disturbing. In the U.S., the rate of amputation is 24.95 per 100,000. This emphasizes the need to improve primary prevention of atherosclerosis and to control diabetes mellitus.

I would also like to mention a brief conversation I had with an anesthetist and an internist. They informed me that the rate of stroke for this small island is also shockingly high: one cerebrovascular accident (CVA) per day. That means approximately 350 per 100,000 occur in one year. However, CAT scans are not available, hence patients are not receiving thrombolytics. Despite advances in medicine, we cannot determine a hemorrhagic CVA from an embolic CVA by history and physical examination alone. Although a history of a patient presenting with severe sudden onset of headache, seizure and fluctuating levels of consciousness should be predictive of hemorrhagic stroke, there are no good studies to prove this in comparison with a CAT scan. One can argue that the mortality rate of stroke based on the area of the brain and the artery involved can be high. MCA stroke can have a mortality rate up to 50%. The question is: Should practitioners on the island, without availability of a CAT scans, be administering thrombolysis on the basis of history and physical examination alone? The mortality and morbidity rates for an embolic stroke could be dramatically reduced. However, I would play the devil’s advocate and argue: Is it ethical to presume the etiology of stroke and administer a potentially lethal drug such as a thromboytic? My approach would be to conduct a prospective study regarding the history of patients with stroke aimed at differentiating hemorrhagic stroke from thromboembolic stroke and then compare the data with CAT scans in the U.S. Armed with data, one can proceed to administer thrombolytic to eligible patients in the small islands without CAT scans after a thorough consent and patient education process.

We in the U.S. are truly blessed to have advanced health care at our finger tips. The awareness of this advantage is appreciated only when you work in places where bare minimum support is provided for medical services.

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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.

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.