19 Year Old Having Angina; Myths Are Now Reality

I was having lunch with our anaesthetist sir, Dr. Elvin. We had been talking all of politics, cricket and food.

When food came to discussion, he told,  “anybody among us can have disease; even coronary artery disease.” I admitted but added, “Sir, I am diseased. but definitely not the heart.” He looked serious and added, “yesterday night, I was in a case for primary angioplasty and the patient’s age was only 19.”  “confirmed twice before believing” he forced it for me as he looked strangely while taking a carrot piece to his mouth.

It was hard for me to believe too. I questioned him,  “Is he still in the hospital?”

“Yes, he will be in CCU” dr. Elvin added.

I was looking for a peculiar case to write for my blog. I told him to tell me the name and bed of the patient. Seeing my interest he took me to the patient after we finished our lunch.

A heavily built young man, over 90 kg in weight, lying in the bed and smiling at us when we stood beside him. Dr. Elvin told me, “this is the patient.”

The patient was muscular and obese both. Though he was looking strong but had managed to get up from supine to sitting posture when he tried to reply to our questions.

Patient had come to casualty with complaints of typical chest pain, retrosternal type, radiating to both arms, associated with sweating and uneasiness, not responding to pain killer and relieved on sublingual nitrates, that had been given in the casualty.

Fig: ST Elevation in the Inferior leads. Lead II, III and aVF.

ECG showed ST elevated Inferior Wall Myocardial Infarction. Trop T was elevated. After loading dose of dual anti platelets, patient was shifted to cathlab for coronary angiography.

 

 

Fig 2: Complete occlusion of the mid RCA ( Upper panel). Restored flow after PTCA stent (lower panel)

ECG never lies and same reflected in the coronary angiography. Patient had complete occlusion of the mid right coronary artery. PTCA with stent to RCA was done. Patient was stable after that with relieve of the symptoms.

Strangely, patient had no family history of coronary artery disease, no history of smoking or diabetes or hypertension.

How common is coronary artery disease becoming in the society? The disease we used to think is a disease of old  has now grippled all age groups. Young as old as 19  are not spared. Other coronary vessels were also diseased.

Dr. Elvin tapped me on both shoulders before he left me with the patient. His last word was, “I had seen a young boy of 17 year needing coronary intervention.”

I have always neglected chest pain in young. I used to say, “its nothing.” “Take some antacids or PPI, it is gastric burns.” But the scenario could be totally different and life threatening if otherwise !!

 

LAA On Chest X Ray?

More than a year back. It was a tensionful day. I was waiting for my turn for the viva-voce. Every one ahead of me were taking one hour in their turn. I was hopelessly hovering over the pages. Friends were chattering questions after questions… all needing search.

Fig: The anterior 3rd rib designated in blue lines, joining the left border of heart. The point is the joining of the pulmonary artery above and the left atrial appendage below.

My turn came. R G Kar Medical College with their Eminent Surgeons sitting in a straight line. A single hard wooden chair for me to hurt me hard.

First question as I make myself comfortable, “where is the left atrial appendage in this chest X Ray” , a white beard man asked looking towards the X Ray hung in the view box.

Left atrial appendage? In chest X ray? I looked at the glowing box. Thousands of pages of the book flashes before my eyes, nowhere i noticed myself reading the same.  As the silence in the room prevails, i managed to force an answer- ” Sir, out of the double atrial shadow, the extreme left of the left atrium is the left atrial appendage.”

Everybody looked at me, though i know it was not the right answer but i have nearly puzzled them. I sit nearly confident as the X ray was the patient of a Mitral Stenosis with shadow in shadow appearance of the atria.

One of the interviewer asked me show in the X ray. I got up and pointed my finger to the area. Someone wanted ,” be more specific”. “More specific.” Wow no!

They later switched over to read the X Ray in details. I showed my rapping  talent there.

Till this day, I was a lay man, when I read about the location of the left atrial appendage. Those tunes in the examination hall “be specific” rang over my ears with its very purpose.

I read it again, again and again and quoting it for you, ” Anterior border of the left third rib where it meet the left heart border is the junction of the pulmonary artery and left atrial appendage.”

Wow no! How did I pass. That day, when i come out of the examination hall with a smile in my face,  but today i feel it was a blessing of those examiners.