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Uncomplicating the Diagnosis of Coronary Artery Diseases
Humans have a complicated circulatory system; we need to understand some of its peculiar characteristics, to understand how to deal with coronary artery disease (CAD). Coronary arteries are not end-arteries. They grow extensive collaterals when the need arises. There are two of them, left and right, each taking origin from a sinus of Valsalva at the aortic root. The left main coronary artery quickly divides into the anterior descending and the circumflex arteries that run around the heart at the level of the atrio-ventricular grove. Of the two coronaries, the one which feeds the posterior descending artery is called the dominant coronary artery.
Coronary arteries feed only during the diastolic phase of the cardiac cycle while the rest of the arteries in the body feed during the full cardiac cycle. That is why we should not try and reduce diastolic pressures to very low levels. Coronary arteries have no rest during life. As a result, there are thousands of small perforating coronary arteries that take origin from the two main vessels and dip into the heart muscle perpendicularly.
In a healthy state, these perforating vessels have the capacity to dilate five times their normal lumen to accommodate extra blood when needed. This is called coronary reserve. As age advances, this reserve goes down in most of us, making us more vulnerable to coronary ischemia on exertion. The main coronary vein that runs in the atrio-ventricular grove always has 30% oxygen left behind during rest or exertion. Congenital abnormalities or ectatic dilations are seen occasionally in coronary arteries.
Everyone has atherosclerosis. The question is: Do you have unstable plaque? One function of the body’s repair system is to clear cholesterol from the cells lining the artery wall, a role that falls to cellular garbage trucks called macrophages. They swoop in and suck up the cholesterol from the plaque and haul it away. But, when the plaque is fatty, the immune-system macrophages can become engorged with so much cholesterol that they can’t do their job effectively. They turn into, what we call, foam cells, because they are full of fat. Unable to perform their duties, they die and add their contents to the cauldron of plaque bubbling under the fibrous cap. This lays the groundwork for the plaque to rupture.
With all the advances in the field of cardiac diagnosis, myocardial ischemic heart disease diagnosis depends only on good bedside history and examination. In fact, there was a plea to control coronary angiography to prevent unnecessary coronary interventions which, today, are one of the main avoidable causes of intervention and death. Resting ECG can, in almost all cases, give a suggestive clue and, in some cases, a clear cut diagnosis of CAD. The usual stress tests (tread mill or cycle test) are not conclusive and unnecessary. The specificity and sensitivity of those tests are less than 50%, thus making them unreliable, to say the least.
The diagnosis of chest pain could tax the best medical brain. Most chest pains that are vague are not due to coronary artery disease. Angiographically blocked coronary artery is not symptomatic of CAD. Even healthy young adults have significant blocks in the coronary arteries, as was seen in American soldiers in Korea and Vietnam. Intra-luminal blocks are but an attempt at sealing a damaged vessel. The vulnerable plaque can only be seen angioscopically.
Apart from chest pain, confirmation could come from thallium scanning, to map the area of ischemia. Tests like C-reactive protein, leucocytosis and serum CRP levels—tests that reveal the presence of intra-mural inflammation—would be of additional help in deciding who needs interventions like a bypass surgery. The last will have to be done only for the rarest of the rare cases. Because atherosclerosis is a systemic, multi-genic, and multi-focal disease, optimal care is likely to require systemic and multi-focal diagnosis and therapy, including local plaque therapy, in some patients.
(Professor Dr BM Hegde, a Padma Bhushan awardee in 2010, is an MD, PhD, FRCP (London, Edinburgh, Glasgow & Dublin), FACC and FAMS.)
Satinder Paul Dhillon has been fighting for his right to say the truth in the face of court orders, which led to criminal contempt proceedings being initiated against him.
In a few days from now, 36 year old Satinder Singh Dhillon, a Canadian citizen born to Indian origin parents, will know his fate under the Contempt Law in Canada. His case stems from an involuntary bankruptcy proceeding against Mr Erwin Braich, which was initiated all the way back in 1999, as Mr Dhillon says, in an attempt to extort Mr Braich. KPMG was engaged as the administrator of the allegedly insolvent's assets, Mr Dhillon was one of the creditors to the allegedly insolvent party and was owed $3 million at the time. Mr Dhillon has pointed out over the years of the proceedings that KPMG has not executed the court's orders on the involuntary bankruptcy for over 14 years, making it the longest running bankruptcy case in Canada.
In 2009, then Chief Justice of the Supreme Court of British Columbia passed an order which said, “all persons having notice of this Order shall not, either directly or indirectly, make or continue to make or continue any publication of any kind including in a pleading which expresses any disparaging or defamatory statements about the Trustee, or any other person or entity connected to the administration of this bankruptcy." The trustee in this case was KPMG, the global consulting giant.
However, It is alleged that Mr Dhillon later published a blog titled “KPMG Stifles Freedom of Speech in Desperate Move.” Consequently, Satinder Dhillon was arrested and interrogated under section 127 of the Criminal Code of Canada, which deals with contempt of court. Mr Dhillon, a businessman and an activist himself, has been through various health troubles in the course of this fight. Finally, on 17 September 2014, the court convened to rule on whether “truth can be used as a defence” in cases of contempt.
Mr Dhillon has been arguing his own case, sometimes dramatically appearing in court with a wheelchair and a yoga mat and pillow handy in case he collapsed. There is bound to be more drama with Mark Stephens, lawyer of Wikileak's founder Julian Assange joining the last phase of his defence, along with Mumbai based advocate Jamshed Mistry, who even stood up for Mr Dhillon at the last hearing in the Supreme Court of British Columbia on 17th September.
Contempt laws have been decried as draconian and unfair all over the world. A vestige of the colonial past, it was recently in the limelight following Justice Katju's tirade against contempt laws. In this present case too says Mr Dhillon, “the arguments being presented will be to see if truth is allowed as a defence in this great nation!(sic)”
In contempt cases like that of Sahara's Subroto Roy, the court eventually acted against him when his disobedience of court orders was clear. The prosecutor on behalf of the Crown (Canadian state still pleads under the Crown) has argued that Mr Dhillon's alleged actions directly disobeyed the court's instruction. “I am fed up with being treated as a second class citizen and having to live at the whim of KPMG's power in this country,” he said in a release uploaded on the internet.
Finally, the judgement will test whether Mr Dhillon's arguments that his freedom of expression has been impinged, and in exercise of his freedom of expression whether a contempt law can ignore the contents of what is said or written. Mr Dhillon insists that what is written is true and in public interest, therefore the contempt proceedings are not justified and that the larger public good is also compromised by not allowing him to speak out against KPMG's actions. Mr Dhillon also alleges that KPMG is involved in trying to cover up what could quite possibly be the largest income tax fraud in the history of Canada. The well-known Mumbai-based lawyer Jamshed Mistry has been helping Mr Dhillon and has also appeared for him in the court.