Rationality of Ayurvedic Prescriptions & Hridroga
Part-5
Dr. Muralidhara Sharma
based on the lecture available at- Rationality of Ayurvedic Prescriptions & Hridroga
When a patient presents with ischemic disorders, particularly myocardial infarction in the contemporary context, it’s essential to keep in mind that this issue is continuously evolving. The diagnosis and definition of myocardial infarction are rapidly changing. Before 1950, myocardial infarction was mostly diagnosed postmortem after the patient had passed away. It was only during postmortems that evidence of ischemic heart disease was revealed. Clinical diagnosis of myocardial infarction, specifically, was almost negligible.
The first definition, established by WHO in 1959 of myocardial infarction as sub-sternal pain accompanied by ECG changes. However, this definition has undergone revisions at periodic intervals. The latest definition, as of 2019, is the 4th guideline for the diagnosis of myocardial infarction, released in January 2019. This current definition is based on five categorizations.
Type one myocardial infarction is an acute pathology resulting from the sudden rupture of blood vessels or plaque, causing a sudden obstruction. In this type, there are minimal pre-existing symptoms, and it often leads to a critical and serious outcome. Currently, there is limited scope for management because it’s challenging to prevent these sudden and severe conditions. Clinically, identifying this condition relies on features such as severe chest pain accompanied by sweating. If a patient experiences pain and sweating, immediate specific investigations are necessary for a diagnosis.
Type three myocardial infarction is again a secondary event, characterized by the sudden development of pathology without clear reasons. These events may occur due to embolism or thrombosis, and they are challenging to identify. For both type one and type three, it is advisable to refer the patient to a cardiologist or a facility with continuous monitoring capabilities, as these conditions require ongoing observation.
Type two myocardial infarction involves patients experiencing symptoms of cardiac ischemia, elevated troponin levels, or other indicators. However, it’s often related to chronic conditions like hypertension or other chronic ischemic condition where we have opportunity to treat.
Types four and five conditions are limited to operative situations. Type four pertains to patients with stents or catheters who develop ischemia. Type five involves the development of ischemia during surgery, which falls outside the scope of our practice and is a cardiologist’s concern. Therefore, types four and five are specific to issues within the cardiac surgery and cardiology domain.
Another aspect to consider is the definition of myocardial infarction, which has been expanded to include non-ischemic injuries. This is a new addition to the definition and something we encounter in our routine clinical practice.
No myocardial injury:
Fourth universal definition of myocardial infarction (2018) Kristian Thygesen, Joseph S Alpert, Allan S Jaffe, Bernard R Chaitman, Jeroen J Bax, David A Morrow, Harvey D White European Heart Journal, Volume 40, Issue 3, 14 January 2019, Pages 237–269,
Non-ischemic myocardial injury conditions present a variety of causes that we frequently encounter and manage. These include patients with chronic conditions such as hypertension, renal disorders, and hyperthyroidism. Features resembling ischemic pathologies are often observed in cardiac conditions, leading to clinical symptoms that may mimic ischemia. In such cases, there is no need to panic. Instead, we should focus on addressing the primary conditions. For instance, efficiently managing severe anemia can mitigate cardiac complications, even regulating troponin levels. Thus, cardiac injuries resulting as secondary complications are distinct from true cardiological conditions. The key challenge lies in clinically identifying these conditions.
In situations where it’s feasible, we can manage these primary conditions effectively. However, if a patient has a condition like severe renal failure with a creatinine level of 9 or 10, it might be beyond our capabilities. The question of whether we can manage such patients becomes a complex issue. Therefore, it’s crucial to recognize our limitations. Within these limitations, there is some room for management.
ECG identification:
I am not planning to take ECG classes, as I find the details of ECG findings in ischemic pathology quite challenging. However, ST segment variations are common in ECGs, and clinics often provide ECGs with opinions from experts. If you come across an ECG with ST segment variation and you lack confidence in your interpretation, I recommend seeking a second opinion. While many of these ST segment changes may not be critical in our course, some of them can be crucial. When you are unable to make a clinical assessment, it’s better to seek a second opinion to identify and address those critical conditions. That’s the point, so you won’t miss those critical conditions.
The fundamental issue here is the need to identify two notches: the P-wave notch and the Q-wave notch. If there is a significant gap between them, I’ve attempted to provide a very concise and straightforward explanation of potential ischemic findings. When you come across an ECG recording with a notable gap between these lines, you should try to diagnose it. If you lack confidence or a thorough understanding of ECG interpretation, that’s perfectly fine. I’m not suggesting that these notches are always a definite indicator of an infarction. However, if you encounter this and feel uncertain, it’s advisable to seek a second opinion. This confirmation can help determine whether it is a genuinely serious and critical condition, as these are often ECG signs observed in the critical phase, representing initial indicators. So, exercise caution. Of course, there is always a reservation. I’m not implying that we should rely solely on this; a more detailed examination of ECG findings can provide a better understanding. However, it’s important to recognize that even ECG findings have limitations, with an accuracy of only 70% to 80%. This means there is a possibility of missing a diagnosis in more than 20% of cases.
The latest and perhaps the most contemporary method for confirming a diagnosis is by measuring troponin levels. In the past, the criteria were based on CK-MB levels, but now high-sensitivity troponin assays have become the standard for diagnosing myocardial injury or ischemia, including both infarctions and other forms of injury. Troponin investigations can be somewhat costly, but they provide highly reliable and established benchmarks for diagnosis.
In a typical infarction, you would observe a gradual trend in troponin levels. About 24 hours after the infarction, there is a tendency for the levels to rise, and they remain elevated for about 48 to 72 hours. After that, there is a gradual reduction in troponin levels. It’s important to note that within the first 24 hours, even troponin levels may not be very dependable. Therefore, a series of troponin investigations would be necessary whenever there is suspicion of myocardial ischemia.
Clinical diagnosis confirmed by troponin levels:
Troponin levels can serve as another guideline to support prognosis. The higher the troponin level, the higher the mortality risk. Therefore, it’s a fundamental concept that if you have a patient with a very high troponin level, it’s advisable to transfer the patient to another facility. This way, you can avoid taking unnecessary blame for potential complications. On the other hand, if the troponin level is lower, there is some room for management and treatment. When I select patients for management, I take these factors into consideration. Troponin levels are one of the criteria that influence my decision to continue treatment for the patient. For higher troponin levels, it’s better to transfer the patient to a facility where more dependable and objective assessments can be made, which can also help in managing the patient and reduce the burden on your end.
When dealing with a patient who has a normal ECG, it’s generally reassuring, and you can consider the situation as being 80% safe. However, there’s always that 20% uncertainty. In such cases, you can choose to manage and observe the patient, adopting a ‘wait and watch’ approach. If there are any changes in the clinical symptoms, you may then make a decision. If there are no S. T segment changes but the troponin or CK-MB enzyme levels do not show any changes, there’s still room for a ‘wait and watch’ approach, but you should exercise caution, and repeated examinations may be required.
However, when the troponin levels are elevated and there is ST segment elevation, it strongly indicates a definite myocardial infarction. In such cases, I would always consider the situation as beyond the scope of what we can manage. This is how I go about selecting patients with ischemic cardiac pathology.So in such conditions, when I consider that it could be managed, my prescription would include Prabhakar Vati, Chandraprabha, and Arjunarishta. I would only prescribe these when I believe that the patient can be effectively managed under our care. Of course, our management should address the patient’s specific needs.
If the patient already has a prescription for hypertension, it’s crucial to continue managing their hypertension. If the patient experiences fluctuating blood pressure, then appropriate management is essential. As I mentioned earlier, for those who are already prescribed platelet aggregation inhibitors, there should be no changes in that medication. It can be a lifeline for preventing complications.
Lifestyle modifications, such as dietary changes and exercise, play a significant role in managing chronic ischemic heart disease conditions. These changes can have a positive impact and are an integral part of our approach to management.
Type two conditions are quite common, and the blue line represents type two myocardial infarction. When I mention this, it doesn’t mean you have a lesser opportunity to treat it. I’ve stated that there are significant limitations in treating cardiac pathology, but it’s important to understand that the number of patients with type two myocardial infarction is substantial.
The prevalence of type one or type two myocardial infarction can vary with age. In younger patients, type one is more frequent, while in older patients, particularly as age progresses, type two conditions become more common. So, when considering patients, the age of the patient is one of the factors I take into account. For younger patients, we would explore treatment options with the possibility of type one infarction in mind. For older patients, there is a greater level of safety, and it tends to be more manageable. This is the approach I take when selecting and opting for patients with myocardial infarction, and with this approach, we can achieve significant results.
CVDs are Largest Causes of Death in India Million Death Study
One of the leading causes of death in India, and particularly the most common, is cardiovascular disease, as observed in the 2000 registered general records. The key takeaway here is the need to be vigilant about this issue and to take measures to safeguard yourself when you face a high risk of a fatal outcome.
Another crucial issue is the increasing incidence of myocardial pathology, especially in younger individuals. The incidence has been on the rise, even in those under 30 years of age, with the numbers increasing each year. This data pertains to India and is not just for management considerations but also for clinical identification. In the past, there was a general norm that cardiac pathology was not considered in those below 30 years of age, but the incidence is now growing. In fact, in the last decade, from 2009 to 2019, the incidence has notably increased, reaching a significant percentage, with it being 27% in 2019. This underscores the importance of being more cautious. This information is sourced from authentic data.
Another reason for the increasing incidence of myocardial pathologies is that they are on the rise in developing nations, while they are decreasing in developed nations. Naturally, modern textbooks, often of Western origin, tend to portray a more optimistic picture, indicating better outcomes. However, the reality is quite different in our conditions, particularly in developing countries. This issue is not limited to India alone, although it’s more pronounced here.
Perspective on coronary interventions & cardiac surgeries in IndiaUpendra Kaul, Vineet BhatiaIndian J Med Res. 2010 Nov; 132(5): 543–548.PMCID: PMC3028952
In India, another important issue in all these coronary interventions, there’s a distinction between interventional cardiologists and non-interventional cardiologists. There has been an ongoing debate between these two categories, with numerous articles addressing the matter. I won’t delve into that controversy. However, the management with interventions like angiography has become quite common. In many cases, there is unnecessary intervention. People have reached a point where, at the age of 40, it’s almost like getting an engine flush for your car; they opt for angiography. This perception is somewhat exaggerated. I believe such over-exaggeration is unnecessary.
The fundamental aspect is that we need to emphasize the importance of diet and lifestyle. If we can address these issues, we can bring about a significant change. Additionally, budgetary provisions for the cardiovascular stent market are a significant concern. With schemes like Ayushman Bharat, the cost of stents has reduced significantly, making them more accessible. Stents and these procedures have become increasingly common, leading to practical clinical issues.
One challenge we face is managing preexisting medications in these patients. When it comes to patients on anticoagulants or platelet aggregation inhibitors, my caution is not to alter those prescriptions. They should be maintained. In such cases, it’s advisable to share the responsibility with a cardiologist because once a patient has undergone such procedures, there is always a perceived threat. Therefore, keeping the option of cardiological consultations and management open is crucial. This way, we can work together to address the patient’s needs with extra precaution.