Week 1 Day 2 Cardiology Rotation

This morning we shadowed Dr. Chen as he performed echocardiograms on 4 outpatients & 2 inpatients. Interestingly enough, we saw tricuspid regurgitation (TR) on every patient, although not with every heartbeat, and Dr. Chen explained that TR is extremely common in the population, usually considered physiologic, and is more often seen with a heartbeat during inspiration. One of the inpatients had cardiomegaly due to congestive heart failure and the other had atrial fibrillation, while the 4 outpatients were receiving echocardiograms as part of routine physical exams. This was surprising to say the least because echocardiography is much less accessible to patients in the US since it costs $1000-$2000 and even those with insurance have co-pays that can be as much as half the cost of the test. It would be interesting to see whether heart conditions are screened for and detected at higher rates in Taiwan due to the prevalence of echocardiography in the healthy population. As we observed Dr. Chen this morning, I could see that it was incredibly logical for echocardiography to be so accessible to all patients, since an echocardiogram can be performed quickly and efficiently (he saw 6 patients in 90 minutes), with no side effects for the patient or large cost to the hospital. If only it could be like this in the US...

I asked Dr. Chen if the patient with atrial fibrillation would be given warfarin, since most A-fib patients in the US are started on an anticoagulant to reduce the rate of stroke, but he said that patients in Taiwan are actually not prescribed any anticoagulants for A-fib, since their research studies have not supported the effectiveness of using anticoagulants in A-fib patients. He emphasized the importance of considering each patient on a case-by-case basis, rather than going by convention to prescribe warfarin for every A-fib case or digoxin for every CHF patient. He informed us that in clinical practice in Taiwan, they expect every patient to be different and anticipate treating them in an individualized way, taking into consideration their other risk factors and pathologies before prescribing a drug that may or may not be indicated, according to evidence based medicine.

Even though we've only been rotating for two days, I can definitely see that several physicians here are trained in providing patient-centered care that resonates with our osteopathic training. In thinking about how commonly certain drugs are prescribed for certain conditions in the US, I wondered if the corresponding clinical trials (often funded or led by drug companies) are part of the reason for the widespread practice of prescribing the same drug for different patients with the same condition. I really liked that he emphasized that each patient is different, regardless of whether they present with the same condition, and I will try to keep that in mind as I continue my training.

In the cardiac catheterization lab this afternoon, we saw a case with a patient who had presented to the ER yesterday with severe chest pain. He had an MI several weeks ago and had been experiencing chest pain ever since he was discharged from the hospital, so he was admitted to the ICU with a diagnosis of post-MI unstable angina. During the coronary angiogram, Dr. Huang discovered a critical near total occlusion of the LCA due to an atheroma, which he informed us was a dangerous situation requiring emergency coronary artery bypass surgery, especially since the patient was symptomatic and at high risk for cardiovascular events (due to his recent MI and history of diabetes & hypertension). Dr. Huang brought the patient's family members into the catheter lab to explain the situation and presented them with 2 treatment options: prepare the patient for an emergent CABG or perform a PCI for the left main coronary artery lesion and then proceed with the CABG in a few weeks. The family eventually decided on the emergency CABG (scheduled to occur this evening) and the cardiologists performed preoperative insertion of a prophylactic intra-aortic balloon pump (IABP), which has been shown to reduce mortality and improve outcomes in high-risk patients undergoing CABG. For this procedure, he inserted the catheter via the femoral artery and positioned the balloon just inferior to the aortic arch, where it was set to inflate during diastole and deflate during systole. Dr. Huang explained that the IABP provides support for surgical recanalization by increasing coronary perfusion and blood pressure while decreasing afterload.

Although Taipei Hospital is a small community hospital with only 1 catheter lab and a small team of cardiologists, their ability to effectively manage patients (including emergencies) continues to be impressive!