The Cardiologist’s Notebook

In medical school, we are taught to think of the human body as a masterpiece of engineering, and like all engineering, it is subject to the laws of physics. In cardiology, the dominant law has long been the law of flow. We were trained to look for the “narrowing” – the bottleneck where the artery is constricted. We believed that if we could find the bottleneck before it closed entirely, we could save the patient.

But there is a haunting category of patient that every cardiologist knows. It is the fifty-year-old executive who exercises four times a week, whose blood pressure is “borderline,” and who passes a treadmill stress test with flying colours on a Tuesday. On Thursday, while reading the morning paper, he collapses from a massive myocardial infarction.

When this happens, the medical system often calls it “bad luck.” But if we look closer at the biology, it isn’t luck at all. It is a failure of our focus. We have been preoccupied with the openness of the artery while remaining blind to the fragility of its lining.

The Illusion of the Clear Path

For decades, our diagnostic gold standard has been the detection of “ischemia” – the point at which a blockage is so severe that it restricts blood flow. The Treadmill Test (TMT) and the standard ECG are designed to catch these late-stage obstructions. They are, in essence, tests of the “lumen,” the open space through which blood travels. If the space is wide enough, we declare the heart healthy.

This is where we fall into a trap. We assume that a heart attack is the final, predictable act of a pipe slowly closing.

In reality, a heart attack is less like a pipe clogging and more like a volcano erupting.

Inside the wall of the artery, microscopic mounds of “soft plaque” build up slowly over time. Crucially, these plaques often do not narrow the lumen enough to cause a pathological obstruction of flow or clinical symptoms. The path remains open. The blood flow remains perfect. The stress test remains normal.

However, these plaques are structurally unstable. They are composed of a volatile “mush” of cholesterol and inflammatory cells, held back by a cap that is sometimes only a few cells thick. When this delicate cap tears, the “mush” spills into the bloodstream, triggering an instant, catastrophic clot.

The “perfectly clear” path becomes a dead end in seconds.

We didn’t miss a blockage; we missed a structural weakness. This is what I call the Architecture of Rupture.

The Paradox of the “Passed” Test

The tragedy of this paradigm is that a “normal” stress test often acts as a license for complacency. Because the test measures performance rather than disease, it provides a false sense of security. It is like checking the health of a city by counting the cars on the road; you might see a smooth flow of traffic, completely unaware that the bridge they are driving over has structural cracks in its foundation.

When a patient “passes” a stress test, the urgency for aggressive prevention often vanishes. The patient feels invincible and skips their medication; the physician is reassured and hesitates to escalate treatment for “mild” hypertension or early-stage diabetes.

We treat the absence of symptoms as the absence of disease, but in the architecture of rupture, the first symptom is often the final one.

Seeing the Wall, Not Just the Space

To fix this, we need a shift in our clinical intuition. We must move from a “reactive” model of rescue to a “proactive” model of stabilisation. This requires two fundamental changes.

First, we must utilise tools that can see the architecture of the wall itself. Technologies like CT Coronary Angiogram (CTCA) allow us to look beyond the flow and see the plaque before it ever becomes a bottleneck. It allows us to identify the “vulnerable” patient years before they become the “emergency” patient.

Once we see the disease, we must be uncompromising. “Optimal medical management” is not a secondary consolation prize to a stent; it is the primary treatment.

This means driving LDL cholesterol to levels that would have seemed radical a decade ago – treating it not as a lifestyle metric, but as a way to stabilise the fragile cap of the plaque. It means managing blood pressure and blood sugar not as numbers to watch, but as the corrosive forces that weaken the arterial walls.

The Quiet Heroism of Prevention

There is no drama in a heart attack that never happens. There is no surgical theatre, no beeping monitors, no heroic “save” in the middle of the night.

As a profession, we have a bias toward the visible. We value the “fix.” But the future of cardiology lies in the invisible – the quiet, disciplined work of stabilising the architecture of the heart before it has a chance to rupture. We must stop congratulating patients for passing a stress test that was never designed to find their true danger. We must start treating the wall, not just the hole.

Only then can we move from being plumbers of the heart to being its true stewards.

In 2009, I was at home with my family. The aroma of home-cooked food filled the air, my two sons were laughing at the dinner table, and my wife was telling me about her day. Then my phone rang.

A man had arrived at the emergency room in critical condition.

I rushed to the hospital, where fluorescent lights revealed a team working frantically to revive him. His wife stood in the hallway, clutching their young daughter’s hand. The little girl’s worried eyes locked on mine. Three hours had already passed since his heart attack began. His odds of survival were less than 5%. That evening, as I delivered the hardest news of my career to a young family, one thought echoed relentlessly in my mind:

Why couldn’t he have come sooner?

Heart disease is the world’s number one killer, claiming more than 20 million lives every year. In India alone, over 3 million families lose a loved one annually to heart attacks and strokes.

We know that the “golden hour” — the first 60 minutes — is critical. If patients are diagnosed and treated within that window, lives can be saved. But in reality, most patients around the world reach proper treatment only after an average of six hours. By then, hope is slipping away.

The heartbreaking truth is this: if we could diagnose heart attacks earlier, we could save half of those lives. Half. Imagine the impact.

In India, where more than a billion people live, there are only a few thousand cardiologists. That’s one specialist for every 250,000 people — and almost all of them are concentrated in major cities. For a villager in rural India, the nearest cardiologist may be hours away. By the time they reach care, it’s often too late. We can’t solve this problem by training more specialists alone. It took me 10 years to become a cardiologist. We need a way to bring expertise to the patient, wherever they are.

That realisation led Zainul and I to start Tricog in 2014, with a bold mission: to screen 100 million patients for heart disease and identify the 2 million most at risk of death.

Our solution was simple but powerful: a small mobile communicator that connects any ECG machine to the cloud. A patient’s heart data is uploaded instantly to our AI system, which flags critical conditions within seconds. A specialist then confirms the diagnosis and sends it back to the clinic — all in under six minutes.

For a patient, those six minutes can mean the difference between life and death. Let me share one story closer to home. In a small town in northern Karnataka, a 52-year-old farmer walked into a clinic complaining of chest discomfort. The clinic staff weren’t sure what was wrong. They connected his ECG machine to Tricog’s device. Within minutes, the AI flagged a severe heart attack, and our team guided the doctors to rush him to the nearest hospital capable of performing an emergency angioplasty. That quick diagnosis saved his life. Just days later, he was back on his farm with his family.

Stories like this are why Tricog exists. They remind us that technology, when applied with purpose, can bend the odds in favour of families who would otherwise lose everything.

What began as a single idea has grown into one of the largest cardiac AI networks in the world. Today, Tricog powers more than 12,500 clinics and hospitals across India and 13 other countries. So far, we’ve touched the lives of over 28 million patients and identified nearly a million critical cases that needed urgent care. Each number represents a life saved, a family kept whole, a story rewritten.

Medicine is built on trust. Technology alone isn’t enough; doctors and patients need to believe in it. Building that trust takes time. But once it’s earned, it becomes a bridge — one that connects world-class expertise to the most remote villages and towns.

For me, Tricog is about more than algorithms or devices. It’s about fairness. About ensuring that no family loses a loved one simply because the right care was too far away.

Back in 2009, standing in that ER, I knew things could have been different if that patient had only reached care sooner. Today, I know we can create that difference — not just for one family, but for millions.

At Tricog, our mission is simple: Every heartbeat deserves a chance.

And until that chance is universal, our work isn’t done.

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