Friday, October 29, 2010


The whole of Argentina, the whole of South America and I believe also the whole world is surprise at the sudden demise of the immediate past Argentinian president, Mr Nestor Kirschner, on Wednesday. My condolences to his family and love ones. Officially, he died from sudden cardiac death. I believe that there are some lessons that we can learn, so that his death is not in vain.
The late Mr Nestor has multiple coronary risk factors, including stress +++, cigarette smoking, and probably hypertension. In February 2010, he had undergone carotid ultrasound which picked up a carotid artery stenosis, and he choose to undergo carotid endartrectomy. It may be that at that time, he was also found to have coronary artery disease. In early September 2010, he underwent coronary angioplasty and had a DES implanted ( we are not sure which artery ). It was uneventful, and it was alleged that he had gone for a political meeting, upon discharge from the Argentinian hospital. 6 weeks later, on Tuesday, he complained of flu-like symptoms, and on wednesday morning, he felt some chest pains and collapsed before he could reach the hospital. Technically, this is sudden cardiac death. But surely, for those of us who are interventionist,unfortunately, he had suffered a subacute stent thrombosis, on his DES. By ARC definition, this would be a probably stent thrombosis, and if it is autopsy proven, a definite stent thrombosis. I am sure that his interventionist must have given him dual anti-platelet therapy, be it clopidogrel + aspirin or Prasugrel + aspirin. There is of course the small possibility that he may have taken some PPI ( proton pump inhibitor ), for some previous gastric pproblem ( we are not sure ), or he may be " clopidogrel resisitant ".
Whatever the exact situation, we can learn that we must respect PCI and DES implantation. Sometimes, because, the devises are so good and success rates are so high, we implant them with impunity, and take short cuts. We do not spend time explaining the serious need for anti-platelet therapy ( with religious vigor ). We allow them back to stressful activity too quickly. Maybe CABG, brings about more patient respect and compliance with medical advice, because there is a painful scar to remind them of the severe disease, for a few months at least. We also learn that stent thrombosis kills, and can kill quickly.
I have often express the view that perhaps, angioplasty equipment should be difficult to use and the stents difficult to get down. Then less physician will dare try and thereby ensuring that only the most experience, with healthy respect for the procedure would dare undertake it, and so maintain good standards and success rates.
We are not sure, which Argentinian interventionist undertook the procedure, but I am sure that he/she is well qualified. I must say that there are some very good interventional centers in Brazil. In fact the " first-in-man" experience with the first DES - the Cypher stent, was in Sao Paulo, Brazil.
Again, my condolences to Mr Kirschner's family and love ones.

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