On my vida Leica

I am an amateur photographer – at a very basic skill level. I take, what I would kindly refer to as, populist photographs (i.e. lots of color, often oversaturated and contrast filled). I enjoy taking pictures intensely. Although I initially started with a P&S Leica V-lux, I graduated to a GF-1 with the PL25 1.4  (four thirds lens), moving to an EM-5 with a PL 14-150 zoom as well as a GH2 with the PL 45 2.8 and finally to an M9P with a summilux 50. I recently acquired an X vario that I enjoy intensely as well. Here is a group of pictures that I feel represent a bit of  everything.

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With my pictures, I usually aspire to get a perspective that is different from what anyone else can get. I’m not trying to get the best picture there is, just the one that I like best. For this reason, I usually shoot RAW (RW2, DNG, ORF whatever) and process the pictures on either Aperture or Lightroom (I really do prefer the former). I often post my favorite pictures to facebook and use that as my photo repository. My favorite subject is Alpana, my companion of these last 20 years and my two “ickles” – Lavanya and Raghav. My passion is shooting sunsets and I’ve been blessed with a west facing house on a hill with big skies.

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My journey with Leica started when I bought the Leica V-lux because I wanted to own a Leica. I knew that it was the same camera as the Panasonic FZ but there is something to owning a Leica that appealed to my inner (not really very far inner) snob. Sluggish to focus and often noisy, the camera was occasionally capable of some very fun pictures. Still works like it used to. Now given to the kids featured in this picture.

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In 2009, I started looking at everyone who had a dSLR with considerable envy. As a gadget freak, it cut me to the quick to see this bevy of delights in the hands of others. Benign elitist with more money than brains, I, obviously, insisted on buying the GF-1 with a gigantic F1.4 25mm Leica D lens. For what I spent at the time, I could have easily gotten a good mid range Nikon or Canon product, but alas…

… But not that I have any regrets. Unlike the relative small aperture mid range stuff, this lens was a beast. With a beautiful DOF control (equivalent to a F2.8 50 mm on full frame), this lens had a beautiful bokeh. One thing unique to Leica coatings is the way that shadows, particularly on skin tones are dealt with. This engenders a very special look and some very beautiful pictures. Unfortunately, the camera got lost during an adventure at the Shedd Aquarium in Chicago. I just hope the thief is enjoying it as much as I did.

GH2 Pana Leica 14-150

I really bought the GH2 as an afterthought. I already had migrated to the EM-5 after losing my GF-1. Reading all the reviews of the GH2’s video capabilities really made me get this camera. In a lot of ways this is more of a traditional appearing camera compared to both the EM-5 and the GF-1. The images can have a strange yellowish color to them and often needed post work to make them look like I’d seen them.

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In this picture at the Portland Japanese garden, I had the Panasonic Leica Vario Elmar D 14-150mm lens (set if I remember right to about 50mm) at F11 with 2 circular polarizers, mounted on a tripod with a fairly long exposure. I post processed this on Aperture initially. The Vario Elmar D is a lens designed for the four thirds digital SLRs and is a beast of a lens that requires an adaptor on a M4/3 body. It is strikingly sharp and has the same leica look when shooting. Always look at the way the lenses handle the shadows and you can tell.

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My Dad insists on regularly buying a new point(less) and shoot camera at regular intervals. As an old school film SLR shooter, he often admired my pictures but wanted something simple to use. I bought him a d5100 with an 18-55 kit lens. He never uses it, still sticking to a plethora of pointless and shoots and phones.

While attending a family wedding, I took my favorite picture of my grandmother. For this particular picture, I had taken my Dad’s old Nikkor 1.4 50 manual SLR lens. Wide open, center sharpness was excellent and because of the 1.5x crop sensor the vignetting was reasonably controlled. It was impossible to focus in the dark through the VF, but being the true amateur, I used the live view mode to focus.

Nobody uses the camera or lens anymore but it showed me that non-Leica lenses were still capable of some interesting stuff.

OM-D with Leica Vario Elmar D F3.5-5.6 14mm-150mm 

When I had to replace the GF-1, I landed up buying the OM-D. Unfortunately, as a new release, the EM-5 could only be bought from Hong Kong at a hefty premium. Still, I took the plunge. The in-body IS is still one of the most amazing features I have seen. It has a wonderfully sharp sensor and pairs beautifully with the 14-150 Vario Elmar. The body and the nokton F0.95 25 mm lens in the night with ISO 1600 and 1 second handheld exposures could turn night into day.

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In this picture, taken at the Rose Garden in Portland, I managed to take the OM-D paired with the Leica zoom into the arena without bothering the ushers. While there is some crop that has been done, the picture was taken from about  a hundred yards away (we had great seats to hear but no necessarily see). The image stabilization meant that with a 300 mm zoom lens, I could take this picture HANDHELD. I’ll let the picture speak for itself.

OM-D with Olympus m.Zuiko F4.0-5.6 12-50mm

Ok. So I have pictures not taken with Leica lenses. The EM-5 comes with a weather sealed kit lens. It is clearly not as pleasing in the way it handles colors and needs much more work in post processing but it can go anywhere (including the pool), it has AF – which means the family can use it and it is small. In fact, the EM-5 with this lens, rivals most prosumer point and shoots in it’s small size.

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It is only fitting that I am putting up a picture taken by Alpana at the Legoland park. I really like the framing and colors and the picture turned out beautifully – even when printed on a 11 x 17 format. Another thing with all of the above cameras is the 4×3 arrangement of the picture. It really is better and even though I land up shooting the 2×3 frame in my new cameras, I much preferred the added height of the frame in these.

OM-D with Voigtlander Nokton F/0.95 25 mm

When I lost my GF-1, I also lost my prime Summilux 50 mm lens. In transitioning to the OM-D, I really missed both that focal length and the shallow DOF. Being a half frame sensor, most lenses for this format have depth of field effects more like compacts than SLRs. This is great for making sure your subject is in focus (because it often is) but also means EVERYTHING else often is too.

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The nokton has the usual voigtlander flaws but is superb wide open, Although mounted on a tripod, this picture was a really nice one of the vista at Mt. Shasta shot at night. I still prefer the way the leica lens deal with faces but in a pinch, this is a wonderful lens with the OM-D and it’s magical OIS.

Leica M-9P with the Summilux – M F/1.4 50 mm ASPH – the fun of  challenging dogma!

Everybody turns 40. Most men use this as an excuse to buy a Corvette to indicate that their mid-life crisis has begun.  (Isn’t it funny not only how men have crises from birth to death (Teething, weaning, terrible-twos, immaturity, teenage angst, fraternities, adjustment to grown up life, mid life crises, retirement, end-of-life crises) but also the fact that each of these is an excuse for a big ticket purchase?) So I bought the Leica that I had lusted for. The M240 had just been launched but was not widely available. I managed to get a hold of a mint M9P from a reliable Leica dealer. Having looked at a series of reviews on the “Internets”, I really preferred the pop, crackle and fizz of the CCD sensor compared to the Sony like look of the M240.

Then, it was on to lens selection. With leica lenses starting when new at at nearly $2000 for a basic prime – all the way upto $12,000 for the mighty noctilux, you really have to choose carefully. The first leica lens I would recommend to anyone would be either a 35 mm or a 50 mm lens. The reason is that these are the perspectives  that closely match normal vision. The 35 mm is on the wider side and does not really match my traditional photographic perspective. Even when shooting with my zooms on prior cameras and point and shoots, this is the focal length I would often find my preferred perspective. The way you look at the object at hand differs with the focal length. The nifty fifty is just perfect. If I need more in the shot, I step back (my feet are the best zoom I’ve had), if I need less, forward.

Keeping this in mind, I looked at a bunch of available lenses. The Nocticili (Old F1 and new F0.95) have less than razor thin DOF and have a strange stressful bokeh (less stressful than Voigtlander). The Summarit, Summicron and Elmarit lenses are beautifully sharp and have the leica look, but the king of lenses to me is the Summilux F1.4. The APO is a different beast but was too expensive and a little too clinical looking for my tastes. Moreover, the Lux 50 was the perfect starter lens for me because that is what I started out with in the first place (GF-1 with a Leica Summilux -D).

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MYTH #1: The M9 is not good in low light…

With most new cameras able to take ISO 9 million and shoot in the dark, people have often criticized the older cameras (like the M9) as being dinosaurs and limiting in the dark. My rebuttal centers on two points. Firstly, in my experience, F1.4, ISO 250-640 with a 1/15 sec exposure pretty much matches what you can see with your eyes. Secondly, the ISO boosted images are often what the camera sees, how can you compose something that your eyes aren’t really seeing. Anyone who tries to use the Ansel Adams long exposure argument, must remember that the long exposures  were for pictures he saw with his native vision and were only a requirement of the recording format. Photography, to me, is an art form focusing on recording what you see, not what the camera sees. High ISO is fine for astrophotography or forensics but takes the joy out of available light photography for me.

10497313_546075655498889_4623187452735396384_oIn this picture, I was shooting the fireworks on the 4th. Having misplaced my tripod, I had to use my forearms as a poor arms’s tripod as I sat and took this picture. With a 1/3 second exposure, there is some shake in the capitol at the lower edge of the frame but I quite like the overall picture. Again, without silly ISOs.

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A moonless New Year’s Midnight in a field in New Jersey seems a perfect excuse for a high ISO camera… … or does it. People forget that with black and white as well as using a flash, it is still possible to get good pictures with manual focusing and manual exposure cameras. Using a non-TTL flash (I’m cheap) and guesstimating the exposure, I managed to get the narrow DOF, the action and acceptable exposure in this picture.

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Sometimes, using the light that you have is a matter of position. In this picture the focus light on the lion, as well as some vignetting in post, makes for a nice picture too. The shallow DOF keeps the lion in focus but keeps the rest of the frame out of focus.

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In this picture, (kinda hard to focus), I used the light from the fireworks to illuminate Raghav’s face and vignetting in post to remove other details. I love his expression. Completely misleading. He was actually having a barrel of fun but when he’s focused on something, that is often the expression he gets.

Myth # 2: If you want to take pictures of kids in action, you need a real dSLR (preferably a waterproof one!)

Most of my SLR friends often pride their weather sealed bodies with speedy autofocus that take the action pictures. As they say, a little planning goes a long way with my manual focus, manual exposure F1.4 prime lens and rangefinder. In the pictures below, I show how fast a rangefinder can really be.

10704436_602084019898052_3536254348270443424_oUsing a combination of relatively fast exposure and some coaching of the kids, I managed to catch them as they made their jump out of the water. I love the expressions on their faces and the splash. This is a perfect example of the 50 mm perspective where objects look the way we see them.

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In contrast, using a slow exposure in this picture, I managed to just get Lavu in focus while getting a brighter overall picture. Some vignetting from the F1.4 is not a terrible thing for this picture. As you can see, the lights are on in the background, this was pretty dark too.

10661745_581726001933854_4077883327993818534_oIn the daylight, the Leica is undoubtedly king. With no real shutter lag, it was relatively easy to get a well focused picture of Lavu making the catch, although her catching style is unusual.

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This is a great example of Leica’s colors and the moment.

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I have nothing to say, this picture makes its own statement.

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This is slightly cropped to a square format but I took this sitting waist deep in water in Lake Michigan while Ragu splashes about. Another good example of the toughness of the leica.

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This is Lavu’s first picture taken with the Leica. Wide open, I helped her with focus and exposure but the framing of the shot (which really is everything) was all her. All that junk about figuring out exposures and focus speed mean nothing to me. I just chimp the frames, recompose and reshoot. I may have missed a few but the ones I have are all keepers. It’s also nice to have control over all the aspects of the picture rather than have the camera make all the decisions for you. This is, therefore, the exposure and focus that I wanted, not the camera’s suggestion.

Life, Liberty and the pursuit of… … the perfect pictures

Recently, we made a road trip to the Capital of the World. Despite having lived in New York for nearly 10 years, this was our first trip to Liberty Island. Here are some pictures of a very cold and blustery Jan 1 2015.

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In the first picture, I liked the composition of this picture for many reasons. Firstly, the light, I love how Lady Liberty’s face plays on dark and light. The contrails from the jet above, seem to emerge from the torch and finally, the details are well preserved when pulled from the shadows in post.

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This is my “spooky” picture. It shows the Stars and Stripes in the foreground with the new WTC tower in the backdrop. If you look carefully at the clouds over downtown, it almost looks like an angelic figure flying over. To add to the mischief, an aircraft over the Hudson is also seen adjacent to the WTC (albeit in a different plane). As someone who experienced 9/11, as a New Yorker at the time, those are difficult memories to let go of.

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As an immigrant to a new country and a new home, this picture of crowds milling towards the promise of America says everything. It is a wonderful place to call home. It is good to be here.

A Tale of two cities

They say that when you have a Leica, the sky is the limit. Here I present three extraordinary vistas. All three were captured because I had the perfect camera in hand at the time, I needed it. Another myth I debunked with these is my use of a circular polarizer to capture a greater sense of drama in the sky.

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This is the Chicago skyline with the Shedd aquarium in the foreground. The skies are a midwest special – really making it look like the “windy” city.

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These two pictures are taken about 15 minutes apart from my hotel room window in Las Vegas. It is almost never cloudy in Vegas but here is a cloudy evening in Vegas with a spectacular sunset. There may have been some work in post, but not as much as you would think. Most of the view is as I saw it that evening.

New York in a single frame!!!

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Many good pictures are not necessarily a matter of skill but more often being at the right place at the right time. This is a beautiful perspective of NYC from Liberty Island with the sun behind me – lighting the city. In this picture, Times Square is at the  left corner while the Brooklyn Bridge is on the right. The WTC forms the most dominant object while the Empire State looks like a lonely outcropping in midtown. The mouth of the Hudson provides a lovely contrast.  Thanks to the lens performance, the picture even printed to huge sizes retains most of the details – including window details in the buildings of the foreground.

Adventures with Vario (The real Mini M rangefinder and I don’t care what the experts say!)

One of the most controversial cameras made by Leica is the X Vario. It was correctly described by Leica AG as a mini M. What is a “mini M”, you ask? In order to know that, you need to know what is an “M”. An “M” is a unique style of photography. With an M, you want to have something compact with minimum fuss. Something with complete creative control. Something with incredible image quality and a sparkling lens. On all these fronts, the X vario checks all the boxes. The lens may be slow at F3.5 at 28mm equivalent going up to F6.4 at a 70 mm equivalent but it is enough to keep the lens compact enough to handle. Anyone who has seen the Tri Elmar M lenses or even the Vario Elmar R and D lenses, keeping these compact is often impossible. For those who want to manual focus, the experience is EXACTLY like the M with a distance scale, short throw and a center focusing patch that appears on the large rear display. It is a camera I can hand to my wife to shoot like a point and shoot or to a waiter in a restaurant to get a picture while being the adaptable tool in my hand at other times. It has excellent higher ISO performance (as compared to the M9 and even my OM-D EM-5 I) that makes up for the light transmission of the lens.

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In this picture shot during our local Holi celebration, I was able to get this to focus manually using the firelight in the foreground to light my subjects in the background. To me, this picture captures many elements of the memory itself.

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And finally…

A wiser man than I once said, “the best camera is often the one you have with you”. All the cameras mentioned above are small and relatively compact devices that are easily carried and seldom burdensome. They are often ready when the moment is right and mirror my style of photography in looking for an innovative way of storing the moment. Photography is not always about honesty but more often about injecting the photographer’s viewpoint into his camera’s viewfinder. There is no shortage of criticisms that may be leveled at my pictures but I did not take them to be critically acclaimed. I took them because it is fun taking them and I love doing it.

On death

I still remember my first childhood realization of mortality as a concept. It disturbed me intensely. I cried long and hard – more for the realization that my loved ones could die, rather than my own fate. It is only after much placating that I calmed down. Of all my childhood memories, that one is truly vivid in my mind.

35 years later, as a physician, I stare death in the face every day. I see the fear of dying writ on my patient’s faces – even the “brave” ones. As much as I see this, I have been blessed that my patients seem to have the knack of cheating death – even when all else looks bleak. Yet, despite my best efforts in some, death came for them in ways unexpected. It helped me realize that life (and death) takes its own course. Physicians only help ease the pain. Let me illustrate.

Some years ago, a patient was transferred to my facility with a suspected heart attack. I confirmed the diagnosis and took him to the cath lab. 3 stents later, he was pain free and appeared grateful that we made the diagnosis and made him feel better. As a young man, he returned to a normal lifestyle, including bicycling. Six months hence, he returned for his followup and reported non specific symptoms but a very active lifestyle. A stress test was negative for any new blockages and I sent the man on his way. Another 3 months later, I came across a police report detailing his death while driving his bicycle with no helmet. It made me question the point of it all. Why struggle with fixing hearts, when life seems so cheap?

The answer came to me later, and in Gita-esque manner. The man was predestined to meet death on that road at that time. He was doing what he must. I fulfilled my duty of making my best attempt of treating the man’s pain and allaying his  anxiety. He met his death, in his favored activity and I helped keep him pain free getting there.

 

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Why die?

Death is a renewal of the species. It is the essential evolutionary adjunct that keeps our species virile and robust. As a species we have outlived many long lived competitors to emerge the currently dominant species in our solar system (As far as we know!). At this time, the only threat to our dominance is from shorter lived entities like rats, cockroaches, mosquitoes, fungi, bacteria and viruses or combinations thereof. We look at them (often with irritation), much like (I like to believe) dinosaurs looking at puny prehensile mammals.

Why is dying “young” an advantage to the species? Doesn’t accepting that contradict everything that I do as a physician?

Let’s take an example of two wolf packs with 20 wolves each. In one (pack A), the wolves are of hardy stock, while in the other (Pack B), they are relatively delicate. Each pack has 10 males and 10 females. Pups (<1 year) don’t hunt and there are no old wolves – yet. Both packs are hunting well this summer. A disease affects both packs. In Pack A, their hardy constitution ensures that all the wolves survive. In Pack B, 2 pups and 2 older wolves die – a reflection of their delicate constitution and maybe poor environmental conditions. Months pass, a tough winter ensues. As expected Pack A survives but is tremendously weakened by starvation (more mouths to feed). Pack B has lost 1 more pup in the winter and 1 male. However with smaller numbers and more hunters, they did better with food. At this point, if there was to be a battle between packs, which do you think would do better, 20 starving and weakened wolves or 14 relatively intact but hungry ones?

 Fortunately, the standoff never happens. Fast forward to three years later. Pack A now has 35 wolves. Of these 8 are “geezers” (old wolves that don’t hunt) and 10 pups. Pack B has 35 wolves (thanks to better reproductive abilities in better fed females) but only 2 geezers and 10 pups. Less than half of Pack A hunts while 2/3 of Pack B catches more than they eat. A great famine and drought ensue. As expected, Pack B loses both geezers, 3 pups and 2 males. Pack A shows tremendous fortitude and loses just one geezer. However, this comes at extreme starvation and erosion of hunting ability.

A hungry pride of lions comes by and finds 2 wolf packs. After making easy pickings on Pack A, they are unable to catch up with Pack B and actually lose a young female in an ambush. Pack A’s lone surviving female is absorbed into Pack B. Pride of lions moves on.

As the instance above illustrates, the ability to die is an advantage, not a disadvantage. If you think beyond the paradigm of the individual but in terms of a family, a pack, a population, a nation or a species, the ability to dynamically keep the best features to fore, while minimizing liabilities is key to survival.

From a philosophical point of view, death is a renewal of the soul. After suffering the slings and arrows of the outrageous fortune that is our life, death is the opportunity to start afresh. It is returning weary at the end of a long day and falling asleep. It is as natural as eating, drinking, sex, evacuation and yes, birth. Yet, we view it with fear and loathing. If the soul is immortal, this body and this life are like clothes you have on today. Much like them, they are a bit rank at the end of the day and need to be laundered. Your soul moves on, the universe reutilizes your body.

What is the soul and do I have one? Is it better that the Joneses? 

No. Your soul is not some ethereal being arising from your belly button. It is not James Brown either.

It is the imprint you leave in space and time by your existence.

That is an indelible fact. Your existence is not only the proof but also a reflection of your soul. Just because you die next thursday, does not change the fact that you existed and lived Today. That is the immortal fact, your immortal soul. Whether you are moral or immoral, good or vile, dynamic or slothful, your soul is a reflection of that imprint on that part of space-time.

Do I know if my soul will be reborn? Why do I, or should I, need to know this?

I, frankly, don’t think I do. And I don’t think I care. What I do care about is making my soul the most beautiful thing I know. I live each moment, complete each action I do to the fullest. I live the dream.

If the soul is reborn, would you remember? When you wake up every morning, how much of the previous day do you really remember. Try looking and the details are pretty fuzzy when you start trying to make them out. When we are born, our souls take the information that they need from the prior existence to get things going. The brain and memory that they have to fit into is too small to carry the entire burden of memories of the last existence. And if you brought all your baggage with you, how would that be a renewal? We don’t even know why we exist, our minds lack the understanding. How could we cope with the burdens of a prior life. In an individual with infinite sagacity and peace, the ability to comprehend existence and the soul is such that they can carry the abbreviated memory of all their existences forward.

So where is the divinity of the soul?

The universal existence is divine. My soul is the space-time imprint of my part of that existence. By extension, logically, my soul IS a reflection of that divinity. In this, there is no good or evil. There is no past or present. It is just existence. Does that mean that I should be evil? Yes and No. You DON’T have to be evil. Evil is defined by perspective. In the story above, were the lions evil? They were just hungry. Was the disease evil for killing pups? You have to understand the purpose of your existence and live to fulfill it to the best of your ability. Today’s evil is often tomorrow’s hero, just as today’s hero is often tomorrow’s hated tyrant. Don’t worry about your labels, get on with your existence (and soul).

 

On Interventions.

Who is an interventionalist?

Is it only those of us that put in stents? How does my putting in a stent make me different from someone who makes a difference to the patient in any other way? I’ve often wondered the significance of calling myself an “interventional” cardiologist. Am I really making a difference to my patients or am I just feeding my ego and my wallet?

In the first two decades of the new millennium, interventional cardiology has grown in a meteoric fashion. With new devices and techniques becoming available, patients are undergoing a variety of new procedures. From reopening blood vessels to the heart, brain and limbs as well as other vital organs, to replacing heart valves, to stem cell therapy and cardiac devices, interventional cardiologists (myself included) are performing radical new procedures that could scarcely be imagined in the last century. Often, patients come back to thank me after the procedure and say: “Thank you for saving my life with the heart procedure”. In the initial days of my career, I used to believe that I was actually “saving lives” with my stents.

With age, comes wisdom.

As I followed these patients, as well as those in whom stents were deferred for a variety of reasons, I realized that human lives end for many reasons. Stents do improve symptoms but come with their own liabilities. When you traumatize the blood vessel with a balloon and a metal stent, you are causing direct injury with both short and long term consequences. Most of these consequence are trivial, some dangerous but rarely can be fatal. Stents do not change the disease process. They are palliative tools at best. They push the disease aside. They can’t prevent new disease within themselves, around their margins – either upstream or downstream. Rarely, they can clot  – often in catastrophic and fatal fashion. Keeping them open require blood thinners, which can make you bleed. Stopping blood thinners makes them more likely to clot.

Are they really that pointless?

Probably not. In patients having a heart attack, they are “life saving”. When a combination of high blood pressure, a soft cholesterol plaque and increased cardiac demand, results in injury to the inner lining of the heart’s blood vessels, the blood vessel is either partially or completely obstructed by clot, inflammatory cells and the ruptured plaque. A timely stent in this setting helps repair the blood vessel and restore blood flow – saving muscle and maybe, lives.

In contradistinction to this, putting a stent in patients with chronic blocked arteries improves flow and may reduce symptoms (assuming they are from a lack of blood flow) but do nothing to prevent heart attacks or death. They may or may not improve heart function.

A chronic blockage, is exactly that. It is “chronic”. It has been there for a long time (chronos – gr. for time). In all probability, it will be there for a long time. Even the ones that are “90%” blocked. Most times, the body will develop alternate mechanisms around the blockage. Surprising to many, having chronic blockages in the heart’s arteries does not predict an increased risk of death but may cause at-times disabling chest pain. Much like chronic arthritis. These are just as well treated with medications as they are by stents. Most studies (not conducted by device companies) show that non-stent therapy is just as effective but demands efforts by both patients and physicians with regards to followup, compliance and lifestyle modification.

Stents, therefore, are the signs of a lazy approach to a problem in treating chronic blockages by both physicians and patients. From a physician’s perspective, it gets rid of the irritating complaints about chest pain and the anxiety thereof. There is no need to worry about side effects (mostly non-lifethreatening) of medications for angina. Most patients are happy and grateful, (lifesaving and all that jazz) as well as socially  keeping up with the joneses. Patients are alleviated of their guilt of having a poor lifestyle, by throwing money at their problem and gain absolution by getting a stent and rid of symptoms. Few people spend as much time talking about changing the lifestyle, controlling blood pressure, complying with statins or stopping smoking. All “interventions” that are clearly more effective (and cost-effective) at treating symptoms and also increasing event-free survival.

My personal approach to treating angina and heart disease has undergone a paradigm shift over the last few years. Each referral for chest pain is an opportunity to intervene. Not just with stents. But to change their lifestyle. To understand why controlling their blood pressure is important. To understand what diet does to their body. To make an effort to stop smoking. Most importantly, to realize the strongest tool in the treatment of heart disease is knowledge. An educated patient is an empowered patient and usually is more conducive to healthful habits. A healthy lifestyle is the keystone for the edifice of cardiovascular health.

So, does that mean I don’t believe in stents?

Heck no! I think they are an amazing device that in the right situations are lifesaving and in others, can be life altering. Take a 55 year-old construction supervisor with chest pain. Each time he “gets winded”, his employer wonders. Each time he pops pills, people notice. He is passed for promotions and is often the first guy to be “downsized”. Thanks to the threat of losing his job from his health, he “stress-eats” and smokes.  A stent (even with low risk disease) gets the patient back on his feet. With the right education from his “interventional” physician, has him losing weight and quitting smoking. Having been through the inconvenience of heart disease, he is more compliant to medications – especially because he now understands his disease better.

So to go back to the original question, who is an interventional physician?

Anyone who “intervenes” to ensure a good outcome is an interventionalist. Stents may be part of cardiac interventions but a true cardiac interventionalist is one whose actions improve your overall cardiac health. If you can put in a stent but not change the patient’s reasons for needing a stent, you are a proceduralist.

Many would argue that in the current healthcare milieu in the US, that it is not possible to achieve the lifestyle discussion and education (a task often left to nurses and cardiac rehab teams) by physicians. Many will cite need to cover the cath lab or see more patients as an excuse. This is humbug. I run a busy practice and perform a variety of procedures. I’m frequently on call at the hospital. When I walk into that patient’s room, he/she is paying my for my time to give them my best advice, not the quickest advice or short cuts. My focus is on the outcome, not the billing. If I can spend 3 or 4 hours in a complex procedure to get a blood vessel open, I owe it to the patient to spend the 10-15 minutes in each visit to make sure that I reiterate the importance of the real cardiac interventions that save lives.

To paraphrase Charlton Heston:

“Stents don’t save lives. Smart patients and physicians with stent save lives. ”

 

Kartik Mani