Microsoft word - case_3.doc
Brief History Mr J S
was truly at his wits end. At 64, the ageing process had been far from beautiful and the years sat
on him more like the proverbial Sword of Damoceles rather than an achievement of life. Eight years earlier, his coronary artery system had become disease afflicted. This resulted in a heart attack that severely curtailed his normal lifestyle. In order to remain physically functional, he had to undergo a bypass
surgery. This in turn necessitated a reliance on drugs and other medication to control his potentially dangerous health condition – a process that kept him stable but left him generally weak. Unfortunately,
contrary to medical assurances, the bypass had far from solved Mr Singh’s ‘heart problem’. After the operation he found that, instead of achieving even the minimum level of fitness, he now had to make
even more frequent visits to the doctors on some pretext or the other and, on many occasions had to either be hospitalised for various illnesses or be repeatedly subjected to extensive and exhausting clinical
investigations. Seven years after the bypass, the arteries got clogged again and this time around, to unblock and facilitate normal blood flow, not only was he subjected to a balloon angioplasty but also had to have a stent fitted.
Both these procedures being heavily body-invasive, it was as good as having another surgery. Recuperation entailed, of course, further medication and more drugs which, rather than benefit, played havoc with his
already weakened condition. The truly crushing blow came just six months later when, despite taking the prescribed medication, his
coronary arteries started calcifying thereby causing further blockages. In store for him was another invasive procedure, known as Angiogenesis, which entailed gene therapy. What next ? You guessed it - a whole
host of additional medication and drugs ! The post-operative nine months of drug-dependent existence had literally reduced Mr Joginder Singh to a nervous wreck. He suffered from hypertension, was almost completely bedridden, could’nt walk without pain, the slightest exertion caused severe chest pangs and
breathlessness, he consumed 10 sorbitrate tablets a day AND was totally dependent on other heavy medication for almost every breath that he gasped. The worst news of all was that his doctor had thrown in
the towel by conceding that nothing more could be done and THIS was how he would probably have to spend
After all the heavy expenses, physical trauma, pain and discomfort that he had endured, would these dark clouds continue to blot out the sunshine from Mr J S’s life ? Was he really doomed to spend the rest of his life
in this almost-crippled manner ? Was this the END ? Certainly not ! Silver linings appeared on the day he discovered that alternative and effective forms of medication and treatment were not only a reality but
also very much available. The very moment that the new therapy commenced at our clinic - the sun magically again ! The best news of all was that - no hospitalisation or surgery was involved - no heavy
invasive procedures were being resorted to - the painless treatment was to be accomplished in relative comfort as an out-patient - heavy medication was to be mostly done away with - the therapy WAS
comparitively cheaper and, most importantly, the treatments offered a positive cure as opposed to being a mere means of relief. Suffice it to say that after nine ‘miracle’ months of Plaquex therapy, Mr J S is on his feet once again and has resumed all normal activities without undue stress and strain. Due to his age, and
the fact that he had previously undergone various surgical procedures, he has to continue certain essential heart medication and must consciously take it easy. All this notwithstanding, the fiestiness is back in his
step as is the smile on his face ! Brief History 1. Mr J S, aged 64 years, visited us on April 15, 2000 with the following complaints :-
Unstable angina (breathlessness and chest pains on exertion. In addition to normal heart medication, used to consume almost 10 sorbitrates per day).
2. The patient is an old case of CAD/TVD since 1992. Till the date of his visit, he had undergone
the following procedures at various hospitals :-
CABG x 2 (SVGs to LAD and RCA), as a result of Q wave inferior wall MI, in 1992 following
which he remained asymptomatic though on medication.
CAG carried out on 21/01/99 revealed blocked SVG to RCA with native triple vessel
On 23/01/99, balloon Angioplasty on Posterolateral and SVG plus Intracoronary Stenting
on SVG were successfully carried out.
Coronary Angiography Report of 16/04/99 was as follows :-
Shows 100% Proximal stenosis fills retogradly via LAD
Saphenous vein graft to RCA-RV shows 100% Ostial
stenosis. Patent Saphenous vein graft to LAD
Triple Vessel Disease
(e) Results of Echo test carried out on 17/04/99 were as follows :- PROCEDURES : M-MODE/2D/DOPPLER/CONTRAST MEASUREMENTS
Aortic Root Diameter 3.1 cm 2.0-3.7 cm < 2.2 cm/M2 Aortic Valve Opening
Left Vent. PW Thickness ED 0.8 ES 1.3 cm 0.5-1.0 cm
INDICES OF LEFT VENT. FUNCTION
M-mode examination revealed normal movement of both mitral leaflets during diastole. No SAM or mitral
valve Prolapse is seen. Aortic cusps are not thickened and closure line is central. Tricuspid valve is normal. Pulmonary Valve is normal. Aortic root is normal in size. Dimensions of left atrium and left ventricle are
2D imaging in PLAY, SAX and apical 4 ‘C’ views revealed a normal sized left ventricle. Hypokinetic distal septum, apex and lateral wall. Global LVEF is 30%. Mitral valve opening is normal. No evidence of mitral valve
prolapse is seen. Aortic valve has three cusps and its opening is not restricted. Tricuspid valve leaflets move normally. Pulmo- nary valve is normal. Interatrial and interventricular septa are intact. No intracardiac mass or thrombus is
seen. No pericardial pathology is observed.
Color flow mapping revealed presence of normal intracardiac flow characteristics. No valvular regurgitation or
intracardiac shunt was observed. FINAL DIAGNOSIS
1. Hypokinetic distal septum, apex and lateral wall, LVEF 30%.
2. All cardiac valves are normal.
3. No clot, vegetation or pericardial effusion seen.
(f) Echocardiogram Report of 13/07/99 was as follows :
2-D ECHOCARDIOGRAPHY FINDINGS
LV dilated with paradoxical motion of mid and anterior IVS (possibly due to post bypass effect) while other
segments are markedly hypokinetic. RV normal in size with adequate contractions. LA dilated. RA normal.
Aortic valve thickened, opens well. Mitral, tricuspid and pulmonary valves normal. No chamber hypertrophy.
No intracardiac mass. Pericardium normal. Estimated LV ejection fraction by area-length method
approximately 25%. COLOR FLOW MAPPING
No valvular regurgitation. DOPPLER STUDIES
MVIS A > E.
Peak systolic velocity across aortic valve = 0.9m/sec.
1. Wall motion abnormality.
2. Dilated LV with severe systolic dysfunction (LVEF 25%).
3. LV diastolic dysfunction.
4. RV normal in size with adequate systolic function.
5. Dilated left atrium.
6. Aortic sclerosis without any evidence of aortic stenosis. (g) Following the echo results, a further angiography was carried out on 14/07/99 . The
findings were :-
Is a medium sized vessel and shows 90% stenosis in its
Is totally (100%) occluded from its origin. There is no
antegrade filling of LAD on LCA injection suggestive of patent venous graft to
LAD. There is angiographic evidence of thrombus in proximal LAD.
Is a nondominant vessel and shows 95% stenosis in the proximal and distal
AV groove. There is no filling of any major OM branch on LCA injection.
Is a dominant vessel and is totally (100%) occluded soon after origin.
Shows filling of only SVG to LAD. There is no filling of any
Is normal throughout its entire course. There is good antegrade filling of LAD
which itself is of good size and normal. PDA branch of RCA fills retrogradely
through collaterals on injection into SVG to LAD.
Coronary Artery (Left Main with Triple Vessel) Disease. Right dominant system.
On 28/07/99 the patient underwent an ANGIOGENESIS (with Vascular Endothelial Growth Factor)
procedure successfully and was put on medication. However his symptoms were as before and no benefit had
occred to him 4. Plaquex therapy was commenced on 15/04/2000. After 24 sessions, the last of which
was on 24/01/2001, the level of success achieved is clearly indicated in the following results :- (a)
The patient is completely off sorbitrate. (b)
He is able to walk normally for limited distances. (c)
Breathlessness is not overtly obvious after exertion. (d)
No angina on exertion. 5. He is on regular heart medication.
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