There is a hip….I must fix it

[PainDrain]

Heart health warning: Man scheduled for hip replacement winds up with quadruple bypass surgery | Fox News

David Holland of New York City thought he would be having a hip replaced. Instead, after a cardiology checkup, he wound up needing quadruple bypass surgery. Here's his story.

www.foxnews.com

Shur told Fox News Digital that as an orthopedic trauma specialist and joint replacement surgeon, he believes it is important to be thorough. "I am not just putting metal into a patient," said. "The patient has to be looked at medically," he said — noting that it is "very important to be sure the patient is fit for surgery before it is too late."

This guy should teach some of his colleagues how to “do the medicine stuff.”

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[ambiturner]

Heart health warning: Man scheduled for hip replacement winds up with quadruple bypass surgery | Fox News

David Holland of New York City thought he would be having a hip replaced. Instead, after a cardiology checkup, he wound up needing quadruple bypass surgery. Here's his story.

www.foxnews.com

This guy should teach some of his colleagues how to “do the medicine stuff.”

Good story, but it reads like a paid article for the hospital system. Wonder if he would have done fine if he just had the hip replaced?

 

[GassYous]

I thought they shut down beth Israel and turned it into a bunch of clinics

 

[anbuitachi]

ive never heard of those words out of a orthopedic surgeons mouth before

 

[DocVapor]

ive never heard of those words out of a orthopedic surgeons mouth before

Surgeon to ED Doc: "Have medicine admit."

 

[coffeebythelake]

Good story, but it reads like a paid article for the hospital system. Wonder if he would have done fine if he just had the hip replaced?

If his coronary disease is that bad and he had minimal to no symptoms he probably had a lot of collateral flow

 

[dannyboy1]

This article has a picture of the patient and he is morbidly obese. Family history of early coronary disease and personal history of elevated cholesterol. Basically a slam dunk for a pre op cardiology evaluation. This should have been caught way before the orthopod “heard a murmur “.

 

[anbuitachi]

This article has a picture of the patient and he is morbidly obese. Family history of early coronary disease and personal history of elevated cholesterol. Basically a slam dunk for a pre op cardiology evaluation. This should have been caught way before the orthopod “heard a murmur “.

really? i looked at him and first thought i had was hes not that obese

 

[vector2]

This article has a picture of the patient and he is morbidly obese. Family history of early coronary disease and personal history of elevated cholesterol. Basically a slam dunk for a pre op cardiology evaluation. This should have been caught way before the orthopod “heard a murmur “.

This guy is an elite bodybuilder in comparison to most of my patient population

 

[PainDrain]

This article has a picture of the patient and he is morbidly obese. Family history of early coronary disease and personal history of elevated cholesterol. Basically a slam dunk for a pre op cardiology evaluation. This should have been caught way before the orthopod “heard a murmur “.

One thing that jumped out, when was the last time you heard a murmur and thought heart disease? I mean, outside of a flail segment/ruptured papillary muscle of the mitral would a murmur really indicate CAD?

 

[VA Hopeful Dr]

This article has a picture of the patient and he is morbidly obese. Family history of early coronary disease and personal history of elevated cholesterol. Basically a slam dunk for a pre op cardiology evaluation. This should have been caught way before the orthopod “heard a murmur “.

Speaking from the PCP "medically optimized" perspective, not necessarily. If he's got that history but his cholesterol is controlled on meds and he's having no symptoms whatsoever, he hasn't bought a cardiac work up by our current guidelines.

 

[dannyboy1]

Speaking from the PCP "medically optimized" perspective, not necessarily. If he's got that history but his cholesterol is controlled on meds and he's having no symptoms whatsoever, he hasn't bought a cardiac work up by our current guidelines.

Meh. Family history of early heart disease is the one that scares me the most. If I were reviewing the chart I would send to cards. Not saying i would cancel on day of surgery of nobody worked him up. How many of our “asymptomatic” patients can barely move from bed to operating table. Means nothing.

 

[nimbus]

Calcium score is pretty sensitive

Correlation of coronary calcification and angiographically documented stenoses in patients with suspected coronary artery disease: results of 1,764 patients

OBJECTIVESThis study correlated the electron beam computed tomographic (EBCT) calcium scores with the results of coronary angiography in symptomatic p…

reader.elsevier.com

 

[nimbus]

Speaking from the PCP "medically optimized" perspective, not necessarily. If he's got that history but his cholesterol is controlled on meds and he's having no symptoms whatsoever, he hasn't bought a cardiac work up by our current guidelines.

And he would likely have done fine with his hip replacement too. Most people with advanced coronary disease do fine with surgery and anesthesia.

 

[VA Hopeful Dr]

Meh. Family history of early heart disease is the one that scares me the most. If I were reviewing the chart I would send to cards. Not saying i would cancel on day of surgery of nobody worked him up. How many of our “asymptomatic” patients can barely move from bed to operating table. Means nothing.

That I have "cleared" without further work up?

Zero.

I put that in quotes because we all know I don't clear anyone but if I don't write that Ortho throws a fit.

 

[aafisahar]

Asymptomatic patients getting bypass surgery is great for Porsche payments (or alimony) for cv surgeons but problem doesn't help the patient. No angina, normal EF, go to surgery.

 

[nimbus]

One thing that jumped out, when was the last time you heard a murmur and thought heart disease? I mean, outside of a flail segment/ruptured papillary muscle of the mitral would a murmur really indicate CAD?

I wonder if the off pump cabg made his murmur go away.

 

[teacher2md]

Asymptomatic patients getting bypass surgery is great for Porsche payments (or alimony) for cv surgeons but problem doesn't help the patient. No angina, normal EF, go to surgery.

Even for angina— PCI doesn’t improve outcomes as far as I’m aware (see ORBITA trial).

Unless you’re having an active MI, isnt it basically a sham procedure?

 

[teacher2md]

With that said, I’ll definitely cancel a case since the lawyers don’t know better.

 

[greatnt249]

Even for angina— PCI doesn’t improve outcomes as far as I’m aware (see ORBITA trial).

Unless you’re having an active MI, isnt it basically a sham procedure?

Depends on what your definition of "improving outcomes" is.

 

[dannyboy1]

Asymptomatic patients getting bypass surgery is great for Porsche payments (or alimony) for cv surgeons but problem doesn't help the patient. No angina, normal EF, go to surgery.

Really? You get a patient with a coronary angiogram showing significant 4 vessel disease and your answer is “well, patient is asymptomatic so let’s proceed to elective hip surgery “?

 

[nimbus]

Really? You get a patient with a coronary angiogram showing significant 4 vessel disease and your answer is “well, patient is asymptomatic so let’s proceed to elective hip surgery “?

We put a lot of pre-CABG/AVR patients to sleep to have all their rotten teeth pulled or to get their carotids done. They mostly do fine.

>99% of CABG patients do fine with GA when they get GA for their CABG.

CABG itself is not risk free. For these patients, you have to thoughtfully weigh the risks of:

1. CABG+THR
vs
2. THR alone
vs
3. nothing (no CABG and no THR).

 

[Hoya11]

Even for angina— PCI doesn’t improve outcomes as far as I’m aware (see ORBITA trial).

Unless you’re having an active MI, isnt it basically a sham procedure?

I had a 60yo guy for a meniscus repair.

He went to cardiologist after being seen in ER for chest pain.

Had EKG changes. Had positive stress test with a clear area of ischemia. Yet no intervention was done.

I call cardiologist who is a young guy 1-2 years out of an ivory tower residency.

He gives me the same line about the stents not improving morbidity/mortality, and that this guys presenting chest pain was "atypical"

I did the case but did not feel great about it. No issues of course.

But I did not trust that the chest pain was not related to the observed ischemia..

 

[vector2]

 

[dannyboy1]

I had a 60yo guy for a meniscus repair.

He went to cardiologist after being seen in ER for chest pain.

Had EKG changes. Had positive stress test with a clear area of ischemia. Yet no intervention was done.

I call cardiologist who is a young guy 1-2 years out of an ivory tower residency.

He gives me the same line about the stents not improving morbidity/mortality, and that this guys presenting chest pain was "atypical"

I did the case but did not feel great about it. No issues of course.

But I did not trust that the chest pain was not related to the observed ischemia..

In this case cards obviously wanted to, and did, revascularize. Why are people trying to tell cards/CT surgery how to do their jobs ? When the heart doctor says the heart is ok then the bone doctor can fix the bone and the sleep doctor can put to sleep. Keep it simple enough that a jury can understand….

 

[dannyboy1]

I had a 60yo guy for a meniscus repair.

He went to cardiologist after being seen in ER for chest pain.

Had EKG changes. Had positive stress test with a clear area of ischemia. Yet no intervention was done.

I call cardiologist who is a young guy 1-2 years out of an ivory tower residency.

He gives me the same line about the stents not improving morbidity/mortality, and that this guys presenting chest pain was "atypical"

I did the case but did not feel great about it. No issues of course.

But I did not trust that the chest pain was not related to the observed ischemia..

So patient had a positive stress then no follow up angiogram?? Then the cardiologist cleared the patient for elective surgery just based on his word that the chest pain was “atypical”. Plaintiffs attorney is gonna love this guy.

 

[coffeebythelake]

I had a 60yo guy for a meniscus repair.

He went to cardiologist after being seen in ER for chest pain.

Had EKG changes. Had positive stress test with a clear area of ischemia. Yet no intervention was done.

I call cardiologist who is a young guy 1-2 years out of an ivory tower residency.

He gives me the same line about the stents not improving morbidity/mortality, and that this guys presenting chest pain was "atypical"

I did the case but did not feel great about it. No issues of course.

But I did not trust that the chest pain was not related to the observed ischemia..

And what are you going to do when this patient has the same EKG changes and chest pain from the repeat stress test that is his surgery? You have this clown cardiologist on speed-dial?

 

[teacher2md]

View attachment 366427

Agreed-- CABG for high-risk disease saves lives. And may (?) improve symptoms for other isolated lesions. I'm only referring to the cases where a patient would report some exertional angina in pre-op eval, stress test--> cath shows 70% LCX lesion, patient gets a stent, and everyone pats themselves on the back for a 'good save!'.

 

[vector2]

Agreed-- CABG for high-risk disease saves lives. And may (?) improve symptoms for other isolated lesions. I'm only referring to the cases where a patient would report some exertional angina in pre-op eval, stress test--> cath shows 70% LCX lesion, patient gets a stent, and everyone pats themselves on the back for a 'good save!'.


View attachment 366440

Yeah there's almost certainly not an all-cause mortality benefit in your hypothetical pt, but relieving angina (if clearly attributable to the culprit lesion) is still a worthwhile goal in and of itself.

 

[aafisahar]

Really? You get a patient with a coronary angiogram showing significant 4 vessel disease and your answer is “well, patient is asymptomatic so let’s proceed to elective hip surgery “?

it depends on how he got to an angiogram. if it was a pre-op stress test "just because" then yes, it's an asymptomatic patient without any indication to fish for cardiovascular disease. proceed with surgery.

if he had abnormal EF or chest pain, then by definition, they aren't asymptomatic.

View attachment 366427

a lot of that data is from the 90s and early 2000s in which medical therapy was bad. no one will do the trial now, but my hunch is that medical therapy is probably just as good as cabg when patients are truly asymptomatic (eg incidentally found CAD either through calcium or an inappropriate stress test). obv, if low ef, angina, or concomitant valve surgery, different story.

however, there are tons of people out there thinking they got a triple bypass that saved their lives when in reality, they would have been fine until they developed actual symptoms, and not just pad a cardiology practice's bottom line by ordering inappropriate stress tests.

 

[2Fast2Des]

So patient had a positive stress then no follow up angiogram?? Then the cardiologist cleared the patient for elective surgery just based on his word that the chest pain was “atypical”. Plaintiffs attorney is gonna love this guy.

Maybe this cardiologist is part of the clearance pathway for this Ortho. I know one high volume bariatric guy would threaten to stop referring pts to some specialists if they didn't green light his patients (regardless if they were optimized or not). If seemed he just wanted the train to keep chugging along and the specialist is the rubber stamp to say they're good for their unnecessary sleeve or bypass. Good times...

 

[dannyboy1]

Maybe this cardiologist is part of the clearance pathway for this Ortho. I know one high volume bariatric guy would threaten to stop referring pts to some specialists if they didn't green light his patients (regardless if they were optimized or not). If seemed he just wanted the train to keep chugging along and the specialist is the rubber stamp to say they're good for their unnecessary sleeve or bypass. Good times...

Then don’t do the stress test and clear them based on clinical risk factors and “no symptoms”. Once you have a positive stress test….

 

[vector2]

it depends on how he got to an angiogram. if it was a pre-op stress test "just because" then yes, it's an asymptomatic patient without any indication to fish for cardiovascular disease. proceed with surgery.

if he had abnormal EF or chest pain, then by definition, they aren't asymptomatic.



a lot of that data is from the 90s and early 2000s in which medical therapy was bad. no one will do the trial now, but my hunch is that medical therapy is probably just as good as cabg when patients are truly asymptomatic (eg incidentally found CAD either through calcium or an inappropriate stress test). obv, if low ef, angina, or concomitant valve surgery, different story.

however, there are tons of people out there thinking they got a triple bypass that saved their lives when in reality, they would have been fine until they developed actual symptoms, and not just pad a cardiology practice's bottom line by ordering inappropriate stress tests.

I’m also not champing at the bit to push revascularization on asymptomatic pts, but the flip side to your comment about when those studies were done….operative mortality for CABG is now lower, surgical techniques are better, and modern medical therapy after CABG makes that operation even more worthwhile. The 40-50% SVG occlusion rate at 10 yrs figure is also like 15 yrs old. It’s likely much lower at all timeframes in the age of good anti platelet drugs and pushing LDLs to <70.