如何作个好介入医生 林延龄教授 MBBS PhD FRACP FACC FESC FSCAI FCSANZ FAPSIC University...
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Transcript of 如何作个好介入医生 林延龄教授 MBBS PhD FRACP FACC FESC FSCAI FCSANZ FAPSIC University...
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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
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好介入医生• 先作个好臨床医生
• 才能作个好介入医生
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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
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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)
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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
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A Good Doctor before a Good Interventionist
先作个好臨床医生再能作个好介入医生
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望 Inspection
闻Auscultation
切 Palpation &Percussion
问History Taking
Bedside Diagnosis in Western & Chinese Medicine
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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
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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)
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Bedside Diagnosis is Essential
• Diagnosis after detail history
• Diagnosis after Physical Examination
• Diagnosis after Investigations
(Ocum’s razor applies)
• Investigation > Examination > History
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Essential Qualities of a Doctor 医生本質
Literature 智 (頭 )(Linacre)Science 智 (頭 )(Harvey)Practice 技 (手 )(Sydenham)Humanity (心 )(Osler)
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• 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
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醫生非醫匠 ( 畫家非畫匠 )“ Doctor not Technician; Artist not Artisan”
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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
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三等醫生 醫生 - 治 病人
醫匠 - 治 病
醫 死 - 治 病變
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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 )
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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 )
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“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)
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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
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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)
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• 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”
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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
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Accurate Lesion Assessment
Visualization of CTO by CT-CA
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CT (MPR) LAD CT (MPR) LCx CT (MPR) RCA
CT Coronary Angiography as 1st Diagnostic Test for Unstable Angina (-ve ECG & TnI)
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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?
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PCI for CAD at the Expenseof Optimal Medical Therapy
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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
C
E
G
S
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Which Coronary Revascularization ?Which Coronary Revascularization ?
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Increasing Need for Coronary Revascularization
Incresin
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verity o
f Sx, Inte
nsity M
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. R
xE
xten
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When to perform PCI in Stable CAD ?
Patel et al JACC 2009;53:530-553
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Better Devices to reduce Ischemia
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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)
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Risk of Stenting Non-ischemic Lesions
FAME Substudy EuroPCR 2010
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If true, then 2/3 STEMI pts do not require stenting !
“Remove versus Replace” STEMI PCI Approach ( 少放入多取岀岀 )
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Early Coronary Revascularization is Beneficial For All Risk Categories of ACS
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REMOVE
Not
REPLACE
少放入多取岀
Paradigm Shift in STEMI PCI Needed
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Thrombus (Platelet & Thrombin) is ACS Culprit
“Man lives with Atherosclerosis, dies with thrombosis”. Anonymous German
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Monotherapy with Bivalirudin Bleeding for STEMI PCI – HORIZONS AMI 3 y
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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
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3: Know Yourself ( 知己 )Individual’s Volume Mortality & Morbidity Results
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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
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“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
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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”
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Paradigm Shift in CAD Treatment Prof. Yean Leng Lim, TICT, Hangzhou 2010
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