如何作个好介入医生

林延龄教授 MBBS PhD FRACP FACC FESC FSCAI FCSANZ FAPSIC

University of Melbourne, Australia

好介入医生• 先作个好臨床医生

• 才能作个好介入医生

普通医生 ( 小医 ) 培訓

專家學院4-8 年內外科其他特專

設區私人医生診所

政府註册全囩通行医疗執照

專家医生 ( 大医 ) 培訓

医學院本科大學 5-6 年硏究生 4 年本科 4 年医學院 4 年

澳洲医生培訓

普通家庭医生

公立 , 私立医院私人医生診所

家庭医生 / 專家轉診医疗制度 專家医生

Good Doctor & Good Medicine好医生好医疗

• 看病貴 ( 臨床訓練不善 医匠非医生 )Expensive Medical Consultations (Technocrats rather than Doctors; Poor Clinical skills)

• 看病難 ( 医疗体質不善 大医看小病 )Difficult Medical Consultations(Specialist/Generalist non-distinction)

Good Doctor = Good Medicine

McAllen Hospital• Worse outcome;• Fragmented care• High-cost Low-quality

($15600/disease Rx)• Profit (Quantity) driven• Practitioner-orientated • More testing less

Thinking

Mayo Clinic• Best outcome hosp• Coordinated care• Low cost high quality

($6688/disease Rx)• Outcome (Quality) driven • Patients-orientated• More Thinking Less

Testing

A Good Doctor before a Good Interventionist

先作个好臨床医生再能作个好介入医生

望 Inspection

闻Auscultation

切 Palpation &Percussion

问History Taking

Bedside Diagnosis in Western & Chinese Medicine

乡城老百姓的基本卫生保健Case History in Rural China

• 70 yr farmer, awoke 6 am with anorexia, epigastric pain, coughing

• S/B village LMO 730am, given 2 pills for Sx relief; told to go to teaching hospital in the nearest city

• Pt traveled 1 hr by bus to ED of a tertiary teaching Hosp• 12 md, Dx as lung disease, admitted to resp. ward• 230pm ECG revealed acute anterior MI• 330pm urgent PPCI, stenting of LAD; Pt survived

好臨床医生治病人(Patient, Disease, Lesion 病人 - 病 - 病

变 )• Patient 病人

70 yr farmer, married with 1 child suffering AMI due to sudden LAD occlusion

• Disease 病70 man with single vessel LAD disease

• Lesion 病变Coronary angiogram showing 100% LAD occlusion (Target for therapy)

Bedside Diagnosis is Essential

• Diagnosis after detail history

• Diagnosis after Physical Examination

• Diagnosis after Investigations

(Ocum’s razor applies)

• Investigation > Examination > History

Essential Qualities of a Doctor 医生本質

Literature 智 (頭 )(Linacre)Science 智 (頭 )(Harvey)Practice 技 (手 )(Sydenham)Humanity (心 )(Osler)

• Competence 合格• Knowledge 智識• Wisdom 智慧• Compassion 憐憫• Integrity 誠实• Leadership 領導

医生基本條件 Essentials of a Doctor

• Art of Detachment 中立

• Virtue of Method 系統• Thoroughness 仔细• Humility 謙卑• Equanimity 隠重

醫生非醫匠 ( 畫家非畫匠 )“ Doctor not Technician; Artist not Artisan”

仁智的醫生

“醫生要有求智的熱情誠實與謙卑的精神 ,辦別是非的能力 .不只追求科技與知識 ,更要有內涵的智慧 ,有仁愛的心 ,怜憫的精神 .仁與智可作為醫生所追求的總結 .

林延齡

三等醫生 醫生 - 治 病人

醫匠 - 治 病

醫 死 - 治 病變

三等介入醫生 介入”醫生” - 治 病人 ( 頭手心 )

介入”醫匠” - 治 病 ( 頭手 )

介入“醫死” - 治 “病”變 (手 )

好介入医生基本素質• 先作个好臨床医生才能作个好介入医生• 好介入医生”三知” 1 知病人 ( 適應証 )

为何要作 ? ( 答不出來不要作 ) 完美的冠脈照影舆仔細分析病变 ( 画不出來不能作 )

2 知証据 ( 循証医学 )如何作 ? ( 简單化 , 治病人不治病变 )

3 知己 ( 手术成功率 )

“3 Knows” of PCI ( 介入三知 )

1 Know the Patient ( 知病人 )Clinical Indications & secondary factors (Cultural, Financial etc)

2 Know the Evidence ( 知證据 )Latest Clinical Trial results

3 Know Oneself ( 知已 )Know your results (Hospital & Individual operators)

6 Paradigm Shifts towards Quality PCI

1 Patients vs Lesions ( 治病人 不治病変 )2 Coronary Flow vs % stenosis3 Staged (Culprit) vs Single (Complete)

Revascularization 4 “Remove versus Replace” STEMI PCI

Approach ( 少放入多取岀 )5 Bleeding versus Ischemia minimization6 Clinical versus Procedural emphasis

Paradigm Shift 1: Consider Clinical NOT Angiographic Diagnosis

“Treat Patients NOT Lesions”

• Stable Angina: Revascularization when refractory to Maximal medical therapy or significant reversible ischemia present

• NSTEMI: Early revascularization of culprit lesion(s) only; then manage as Stable subsets

• STEMI: Re-establishment of TIMI 3 flow is goal (minimal intervention + clot reduction)

• 先作个好臨床医生才能作个好介入医生• 好介入医生”三知”

1 知病人 ( 適應証 )为何要作 ? ( 答不出來不要作 )

完美冠脈照影 ; 仔細分析病变( 画不出來不能作 )

Good Interventional Doctor“Treats Patients Not Lesions”

1 “Know the Patient”

( 知病人 )Careful Detail Necessary:

• Pathophysiology of ACS

Chest Pain signifies suboptimal coronary flow (<TIMI 3) due to luminal obstruction by plaque +/- thrombus

• Obtain chronologically the entire natural history of a patient’s chest pain history

Accurate Lesion Assessment

Visualization of CTO by CT-CA

CT (MPR) LAD CT (MPR) LCx CT (MPR) RCA

CT Coronary Angiography as 1st Diagnostic Test for Unstable Angina (-ve ECG & TnI)

2: “Know the Evidence”

( 循証医学證据 )

Q1: Is Coronary Revascularization necessary ? (improving quality or quantity of life ?)

Q2: Is the patient Diabetic ?

Q3: Which revascularization procedure has the best long-term outcome?

PCI for CAD at the Expenseof Optimal Medical Therapy

Maximal Medical Therapy• Dual anti-platelet (aspirin 100mg + 75 mg clopidogrel) therapy

• Beta-blocker (BP & HR allowed)

• Calcium channel blockers (if BB contra-indicated or combined)

• ACE Inhibitor or ARB (max dose if BP >90)

• Nitrates: Max. Tri- Di- and mono- nitrates, topical, oral, S/L and iv

• High Dose Statin ± ezetimibe (LDL 70mmol/dL)

A

B

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S

Which Coronary Revascularization ?Which Coronary Revascularization ?

Increasing Need for Coronary Revascularization

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When to perform PCI in Stable CAD ?

Patel et al JACC 2009;53:530-553

Better Devices to reduce Ischemia

Different Approach to achieve Different Approach to achieve Complete Revascularization (PCI Complete Revascularization (PCI

versus CABG) versus CABG)

•CABGCABG : Full Revascularization : Full Revascularization achieved in ONE index procedure achieved in ONE index procedure (nature of CABG)(nature of CABG)

•PCIPCI: Revasculaize only “culprit : Revasculaize only “culprit lesions” and achieve eventual lesions” and achieve eventual complete revascularization in complete revascularization in stages ( days to years)stages ( days to years)

Risk of Stenting Non-ischemic Lesions

FAME Substudy EuroPCR 2010

If true, then 2/3 STEMI pts do not require stenting !

“Remove versus Replace” STEMI PCI Approach ( 少放入多取岀岀 )

Early Coronary Revascularization is Beneficial For All Risk Categories of ACS

REMOVE

Not

REPLACE

少放入多取岀

Paradigm Shift in STEMI PCI Needed

Thrombus (Platelet & Thrombin) is ACS Culprit

“Man lives with Atherosclerosis, dies with thrombosis”. Anonymous German

Monotherapy with Bivalirudin Bleeding for STEMI PCI – HORIZONS AMI 3 y

Risk Factors for Bleeding with PCI (ACUITY)

• Age (>70)

• Female gender

• GP2b3a Antagonists administration

• LMWH usage within 48 hours

• Renal dysfunction

• Anemia

• IABP useWhite H, Greenlane hospital, TCT 2009

3: Know Yourself ( 知己 )Individual’s Volume Mortality & Morbidity Results

Victorian DHS Mortality Categories

Category Description1A Death not unexpected in a patient where all

appropriate steps were taken in a timely fashion

1B Death not unexpected in a patient where all appropriate steps were NOT taken in a timely fashion 2 Dead on arrival3A Unexpected death which occurred despite preventative

steps being taken in an appropriate & timely fashion

3B Unexpected and preventable death where steps were NOT taken in an appropriate & timely fashion

4 Death resulting from a medical intervention/procedure

5A Foetal Death In Utero or Stillborn: A baby who, when born, fails to breathe or show any other sign of

life, who is over 20 weeks gestation or weighs over

400g5B Neonatal death: A baby who is born alive and then dies

within 28 days of birth at any gestation

“Superb technique,Sagacity and Good Ethics,Essentials of a healthy nation

Heart therapy with sincerity Essentials for patients’ “Peace of Heart”

Couplet written for CardiologistProf. Cia Quoliang of Xian, China

冠動脈图天地現余暉古短悲情牽仁心華佗降人世誓把良心還民間

“Presenting the Coronary painting

to the worldat the twilight of a

life so briefLike the

benevolent Hua T’uo born to earth

Vowing to return to common folksGoodness not

Grief”

Paradigm Shift in CAD Treatment Prof. Yean Leng Lim, TICT, Hangzhou 2010