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Dr. Andrew Rynne

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Exp 50 years

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Got the ECHO report. Suggest treatment depend upon this

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Dr. Anil Grover

Cardiologist

Practicing since :1981

Answered : 922 Questions

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Posted on Mon, 24 Dec 2012 in Hypertension and Heart Disease
Question: Dear Doctor,
I am enclosing following reports and details of medicines I am taking-
1.ECHO reports 2 number ,in latest report you will see that there is major changes in sizes and evaluations made by local Cardiologist. Guide that what does this mean and what are expectations in future?
2.CAROTID reports 2 number, in latest carotid report looks that there is some major changes, for this you please guide for expectations and present course of action.
3.Test report of Aorta and Bilateral - you will find that there is some confusion in interpretation, so you please guide and clarify with complications.
4.Parotid report is enclosed, you please guide for this too.
5.Medicine list
doctor
Answered by Dr. Anil Grover 6 hours later
Hi XXXXXXX
Thanks for writing in.
I am a qualified and certified cardiologist and I read your mail with diligence.
Sevemty persons of cardiology patients I treat in India, have diabetes too. I have gone through the reports of Mr XXXXXXX I have not seen the patient and XXXXXXX makes suggestions but not prescribe medicines.
My first suggestion will be please do not go into values of any particular report when overall impression is written. These will only add to confusion and does not help the patient.
Mr XXXXXXX is suffering from Hypertension, Diabetes Mellitus, hypothyroidism and we have to exclude carotid and coronary artery disease. No information on lipid profile, diabetes control and thyroid satatus is available.
There is nothing abnormal reported in two echocardiography reports, he has normal ejection fraction that is systolic function of heart is normal. There is not much left ventricular hypertrophy as reported in echo report. So, he is well controlled hypertensive on drugs. Without doing echocardiography and carotid Doppler myself I am afraid I can not resolve the confusion but can comment on conclusion. Similarly, there is suspicion of carotid atherosclerotic disease which in a person correlates with coronary artery disease. My suggestion would be get a CT angio done of carotid and coronary if you are not willing for coronary and carotid routine angiography. That will be more definitive than plethora of other investigations. Evaluation by your cardiologist is important, for there are certain things which is told to a doctor by the patient which no other person can substitute. Furthermore there is physical examination for example murmur/Bruit over carotid will have some significance. I suggest you ought to have faith in your doctor and if need be go for second opinion on Doctor's advice. Inflammatory changes of parotid are to be correlated with conditions of teeth which only examining doctor can do therefore by reading report I recommend a thorough examination by your doctor. What is his fasting blood sugar. For diabetes follow up most important test is that of glycated hemoglobin (HbA1c), which tells about control over diabetes in preceding 12 weeks. I do not see that report but I see anti diabetic drug prescription, I can only please continue that for the doctor must have seen reports which I am not privy to. So is the case with thyroid.
Please rephrase the question and supply the abovesaid information, I may be able to help you. In the interim continue with the same drugs, these are effective medicines and prescribed with competence. There is no reason for me to change it. And please do not increase your worry about reading into reports in between the reported lines, that will lead to no where.

If you have any more query I will be most happy to answer it.
Regards
Dr Anil Grover,
Cardiologist & Internist
M.B.;B.S, M.D. (Internal Medicine) D.M(Cardiology)
http://www/ WWW.WWWW.WW
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Anil Grover 20 hours later
Thanks.
Please clarify border line dilation of aortic root and ascending aorta.
Does mildly atrium dilated need any further assessment.
As you said that Mr XXXXXXX is a Patient, no Sir ,it is not XXXXXXX but patient is myself Kuldip as mentioned on the reports, name of XXXXXXX is only mentioned just to name the file of report.
You will see that there is a major difference in sizes +/_ under 2 D ECHO reports like
IVSd= 9/10 mm, LVIDd=54/55 mm, EDV (Teich)143/150ml,
LVd MASS=227.41/255.68g, LVd mass index =106/118 g/m2,
LVd mass (ASE)193/216g, LVd maSS Ind(ASE) 90/100g/m2, LVIDs=36/33mm, ESV (Teich)56/46ml, SV(teich)=87/105ml, SI (Teich)=41/48ml/m2,
LA DIAM=40/44MM,
Ao Dia=43/42mm,, Ao Asc =37 mm/37mm,
Dopler details has been mentioned on new report.
See if you can evaluate these major changes towards dilation and borderline dilation factor.
As you asked for Details of blood work done will be sent today because Healthcare magic is not accepting reports in excess to 2 MB. in a day or so
doctor
Answered by Dr. Anil Grover 4 hours later
Dear Mr XXXXXXX

I am really sorry about mentioning the name wrong that was because of obvious reasons.
Having worked in both the countries, unlike in India, echocardiography is not done under direct supervision of the doctor (either by doctor who has seen the patient himself or the technician), in the US echocardiographer is not aware of clinical diagnosis or the previous echocardiography report and it is an isolated test.

In hypertension, there is turbulence and dilatation of acending aorta beyond the aortic valve. You will find more or less the readings of aortic root in both the report are the same. For measurement of any distance the plane of transducer ought to be perpendicular to the plane of the tube whose diameter is sought to be measured. A deviation upto 20 degrees is allowed (for the computing involves a formula and the angle being theta then it is constant factor f multiplied by cosine of the angle f cos theta). Due to patient's body structure and at times these variations in readings are obtained as the technician is not aware of first reading and five degree deviation in angle can produce the change in ascending aorta diameter. Secondly, where the technician is getting good window will determine the size of ascending aorta. So, knowing that qualitatively ascending aorta is dilated I will not used the values beyond this purpose or qualitatively. Had it been at the root of aorta I would have reported the finding and looked for dissection of aorta which is a complication of Hypertension. But both, in India or in the US, doctor would have suspected first for echocardiographer to look.
The cosine of the angle also applies to measurement of LA. Cardiologists know that in hypertension the left ventricle is a little stiff. LA is filling chamber it has to dilate to a degree to push the blood into LV in cardiac cycle. Therefore, qualitatively it is enlarged. Echocardiography with the present setting can not be used as comparative assessment of LA size and the variations in echo LA size are also due to blood volume at the moment of echocardiography of patient. So, cardiologists tend to ignore quantitative difference unlike they would do for left ventricle.

Measuring of muscle mass assumes too many calculations by the computer. Some of which are preload dependent (that is how much patient has taken in terms of fluids before echo and what kind of window echocardiographer gets). Qualitatively, unless done by the echocardiographer who has access to previous report, this much variation is acceptable.

Lastly these reports are always read in the context of the patient's condition by a qualified cardiologist, if he/she is not worried I am not worried and I will suggest to you nor should you. You may ask the direct question to your cardiologist and if you find answers different then answers of the doctor who has seen the patient are right not the one who has been asked to interpret 'in between the lines' reports of a rather subjective test. For the first time in my career of 30 years of cardiology I have been asked this question (other than medical students whom I had taught) so I appreciate your curiosity.
If you have any further direct query I will be most happy to answer.Regards
Sincerely,

Dr Anil Grover
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Anil Grover 1 hour later
Thanks a lot Dr XXXXXXX
I am enclosing test reports, where some tests are low and some are high, see if you can guide with high end knowledge and expertise.
doctor
Answered by Dr. Anil Grover 27 minutes later
Dear XXXXXXX

Thanks for writing back. I appreciate the sarcasm. That adds to intrigue and mistrust. I am a trained medical specialist with additional training in cardiology from one of the best medical university in the world (it is one of the two topmost Univesities in India) and I have held New York State University Practising License for few years before returning to India. I am willing to take your test. Two things are important. Tell about the reference values of laboratory (these vary from lab to lab) and diagnosis before investigations for the patient. I will get back within few minutes for each value you want to test me far. Writing "here in Canada" will not do. These are international values. To take one example from your reports, Glycated Hemoglobin (HbA1C) reflects Diabetes Control for the preceding 12 weeks in any individual:

Below 7 : You are either non diabetic or very well controlled diabetic.
7-8 : Good Control of a Diabetic patient.
8-8.5 : Fair Control (not very satisfactory) control of Diabetes
8.5-9 : Poor Control (Unsatisfactory Diabetic Control)
>9 : Needs serious control of this diabetic patient which is poorly controlled.

Now same thing can be described differently in Canadian English, US English and UK English language. As all the answers will be this much explanatory, please ask a direct question and limit your values.
Personal Regards

Sincerely,

Dr Anil Grover
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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