Ventricular Tachycardia During Ajmaline Challenge
We report the case of a 63 year old woman who comes to an ajmaline challenged. After 8 minutes of infusion her baseline ECG showed significant QRS complex prolongation and switched over to the typical coved-type ECG. Subsequently a sustained monomorphic ventricular tachycardia was developed, followed by a sustained polymorphyc VT onset, which finally degenerated in a hemodynamically non relevant sustained monomorphic VT. Finally, a 200J defibrillation was required to terminate the arrythmia. Sustained ventricular arrhytmia (SVA) is infrequent but not an exceptional event (0.1-18%) and ajmaline is considered a valuable drug. In addition, provocation testing must be performed in an appropiate environment with advanced life support facilities. The evidence shows that the occurrence of ajmaline-induced sustained ventricular arryhtmia in patients with BS might not identify a category at higher risk for further arrhythmic events during follow-up.
Copyright (c) 2017 Picon Heras R, et al. https://creativecommons.org/licenses/by/4.0
Dysautonomia: A Novel Approach to Understanding of Vasculitis and Type II Diabetes
Understanding of the atherosclerosis process has evolved from simple plaque build-up causing blockage to inflammation and endothelial dysfunction. The underlying etiology for endothelial dysfunction and vascular inflammation is autonomic imbalance. Autonomic imbalance also causes hormonal dysregulation and cellular receptor sensitivity. Therefore, dysautonomia is the underlying etiology behind type2 diabetes and vascular inflammation that predispose to atherosclerosis. Regulating dysautonomia is a more definitive and long-term solution to effectively treat type2 diabetes and vascular atherosclerosis.
Copyright (c) 2017 Adiraju R https://creativecommons.org/licenses/by/4.0
Quadricuspid Pulmonary Valve in a European Young Male Diagnosed by MRI
Quadricuspid pulmonary valve is a rare congenital cardiac entity. Because of its usual asymptomatic course, it has been almost exclusively diagnosed after death or at cardiac surgery, and few cases have been documented in living patients by trans thoracic echocardiography or computed tomography, let alone by cardiac magnetic resonance imaging (MRI). We report the case of a young European male diagnosed with quadricuspid pulmonary valve detected on cardiac MRI.
Copyright (c) 2017 Heras RP, et al. https://creativecommons.org/licenses/by/4.0
Particularities of Coronary Artery Disease in the Elderly in a Black African Country in the South of the Sahara (Senegal)
Due to the demographic progression of our societies and the increasing prevalence with age of coronary artery disease, we will increasingly face the treatment of acute coronary syndrome in elderly patients (> 70 years). Very little data has been published in Africa, particularly in the South of the Sahara. This series shows the severity of coronary lesions in subjects aged over 70 years admitted to the cardiology department of the Aristide Le Dantec hospital and the interest of the invasive strategy in this population. Introduction: Coronary artery disease in the elderly is often more diffuse and severe. The objective of our study was to describe the results of coronary angiography and angioplasty in the elderly in Senegal. Methodology: A monocentric, retrospective and descriptive study over a period of 39 months from 1 May 2013 to 31 July 2016 was carried out within the cardiology department of the teaching hospital: Aristide Le Dantec in Dakar. Were included all patients who had coronary angiography with a complete clinical record. Results: A total of 380 records were collected during the study period. The prevalence of subjects over 70 years of age was 12.7% (n = 38). The mean age was 74.37 +/- 4.1 years. The sex ratio was 2.35 in favor of men. The main risk factors were hypertension (51%), sedentary lifestyle (46.8%) and diabetes (27.7%). The main indications were SCA ST + in 14 cases (29.8%) and the angina of effort in 11 cases (23.4%). Nearly half (51.1%) of the patients had angina pain at discharge. LV systolic dysfunction was noted in 21 patients (58.3%). Nine (19.1%) patients were able to benefit from thrombolysis. Coronary angiography was programmed in most of our patients (80.9%), the right femoral approach was preferred (70.2%). The average duration of the procedure was 66.24 min.At the angiogram, a mean Syntax score was high in 4 patients (8.5%) in subjects over 70 years, with diffuse coronary involvement both in the proximal but also distal segments; And with many more coronary occlusions within this population group. Coronary angioplasty with stent placement was proposed in 13 patients (27.7%), with almost as many active stents as bare stents and good result And TIMI 3 streams in 84.6%. Very few incidents and complications related to angioplasty were noted. Conclusion: Our work confirms the greater severity of coronary lesions in the elderly black African. Coronary angioplasty is achievable with a high success rate.
Copyright (c) 2017 Mingou JS, et al. https://creativecommons.org/licenses/by/4.0
Most Ignored ECG Lead, aVR can be Lifesaver! “Short of Breath in Seattle!”
As if to rhyme with the famous Hollywood movie titled, 'Sleepless in Seattle', I saw a 64-year old man in my office in cardiac consultation who after having dinner with his son and daughter-in-law in Seattle was extremely short of breath while walking up a few stairs to his hotel room. He is from upstate New York area and was visiting them in Seattle. He never had any symptoms like this before. He did have some chest discomfort at the time but the shortness of breath was quite concerning to him. He did not have palpitations, dizziness, diaphoresis or syncope.
Copyright (c) 2017 Jagdish P Mishra, et al. https://creativecommons.org/licenses/by/4.0
Cardiovascular Outcomes with Liraglutide: An Update following LEADER
Diabetes Mellitus is one of the most important causes of cardiovascular disease in the United States and worldwide. Few antidiabetic drugs (e.g. Rosiglitazone) have faced cardiovascular (CV) safety related controversies in the recent past. The FDA mandatory advisory states that the CV safety concerns of any new antidiabetic drug should be thoroughly addressed in a dedicated longitudinal outcome trial. Liraglutide, a long-acting GLP-1 agonist, approved as a 2nd line agent in the treatment of type 2 diabetes mellitus (DM), has shown some promising effects on the cardiovascular system in various preclinical and early clinical studies. In accordance with the FDA recommendation, a large, multicenter trial (LEADER) was undertaken in 2010 to look for long-term CV outcome data on liraglutide. Primary outcome (Death due to CV causes, nonfatal MI or, nonfatal stroke) occurred in significantly fewer patients in the liraglutide group, with a lower incidence of cardiovascular and all-cause mortality. Besides, a better glycemic control, fewer hypoglycemic events, significant weight loss, and beneficial effects on nephropathy were observed in patients on Liraglutide. ELIXA trial on Lixisenatide did not reveal any significant CV benefit. So, Results from the ongoing CV outcome trials on other GLP-1 agonists (EXSCEL for Exenatide, HARMONY for Albiglutide, and REWIND study for Dulaglutide) will guide us better to determine whether the observed benefit is indeed a class effect or a molecule effect. Here we have summarized all the cardiovascular outcome data so far available on liraglutide, with special reference to the recently published LEADER trial results.
Liraglutide and cardiovascular mortality
Copyright (c) 2017 Ghosh RK, et al. https://creativecommons.org/licenses/by/4.0
Fatal Evolution of an Aortic Ring Abscess in a Multiple Valve Heart Diseases Patient
The aortic ring abscess is a rare and serious complication of infectious endocarditis. Echocardiography remains the diagnostic key, the treatment is expensive and the prognosis is generally dark .we report the case of a 29 years old patient with multiple value diseases who presented an aortic ring abscess. Observation: This is Miss M. D, 29, known with a rheumatic multiple valve disease: a combined mitral and tricuspid disease and an aortic regurgitation for over 15 years, with a history of multiple hospitalizations. At admission, she was in bad condition, suffered significant weight loss, was pale, a congestive heart failure, mitral regurgitation and stenosis signs, aortic regurgitation and pulmonary hypertension on a background of fever in the long course. The biology test noted anon specific inflammatory syndrome and negative blood cultures. Echocardiography showed, in addition to the multiple valve disease, a fluid collection at the valsalva sinus, suspicious of an abscess and multiple vegetation at the aortic valves.The patient received probabilistic anti biotherapy and congestive heart failure treatment. Surgery was indicated.Under probabilistic anti biotherapy, evolution was favorable at first then the clinical condition has deteriorated resulting in the death of the patient. The check up echo cardiographic noted a significant increase in the volume of the abscess. Conclusion: The aortic ring abscess is a serious complication of infectious endocarditis on native and prosthetic valve. Diagnosis is based mainly on Transthoracic and transosoephagial echocardiography. Surgery is indicated.
Pericardial Tamponade: Diagnostic and Evolutive Aspects in a Cardiology Department in Dakar, Senegal
Tamponade is one of the major complications of pericarditis which is immediately life threatening. The objective of the study was to evaluate the diagnostic and evolutive aspects of pericardial tamponade in a cardiology department of Dakar. We included 40 patients who had a tamponade with a file that could be exploited over a period of 3 years and 6 months (January 2010 to June 2014). The mean age of the patients was 41 years (range between 15 and 80 years). There was a male predominance with a sex ratio (23/17) of 1.35. Signs were dominated by dyspnea (95.0%), pain (85.0%) and fever (40%). Signs of poor hemo dynamic tolerance were evidenced by weak peripheral pulses (21.16%), paradoxical pulse (5%), and hypotension and/or shock (15.0%). The diagnostic means, besides the clinic examination, was mainly by conducting an echocardiography. Thus, there was a proto-mesodiastolic collapse of RV in 82.5% of cases, a telediastolic collapse of the right atrium in 87.5% of cases, a fibrin network in 55% of cases. Emergency treatment with per cutaneous pericardiocentesis was performed in all our patients using the subxiphoid approach. There was a favorable evolution in 77.5% of cases. Were corded 8 cases (or 20%) of death in all admitted cases. Pericardial tamponade is a medical emergency. The diagnosis is easy using echocardiography but the etiological diagnosis is always problematic in our working context.
This is a mini review article of tetralogy of Fallot. This review article will discuss historical, anatomical, pathophysiologic, clinical and surgical management of tetralogy of Fallot. Author also discussed his experience with postoperative follow up in 45 patients with tetralogy of Fallot. Incidence of congenital heart defect is 8 per 1000 life birth. Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart defect (CHD) constitutes 5-10% of all CHD. Prevalence of TOF ranges from 0.26-0.48 percent per 1000 live birth.
Copyright (c) 2017 Agarwala B https://creativecommons.org/licenses/by/4.0
Inferior Wall Myocardial Infarction Haemodynamically Complicated by Associated Ebstein Anomaly
Ebsteins anomaly is an uncommon cardiac malformation affecting tricuspid valve and right ventricle. We report aware case of previously asymptomatic undiagnosed Ebstein anomaly presenting with decompensated haemodynamic status and cyanosis due to acute inferior wall myocardial infarction. Following aspects of this case makes it a rare presentation. Firstly, the unusual presentation of Ebstein anomaly as inferior wall myocardial infarction and atrio-ventricular dissociation. Secondly, the long asymptomatic period with two successfully completed pregnancies. Thirdly, particularly only right coronary artery involvement in Ebstein anomaly in this as well as previously reported 3 cases. Fourthly, coexistence of Ebstein anomaly with inferior wall myocardial infarction which lead to acute haemodynamic compromise and cyanosis. Lastly, this highlights the importance of early revascularization to salvage myocardium in already congenitally thin and fibrosed ventricles in Ebstein anomaly.
Copyright (c) 2018 Vinayak M and Sharma A https://creativecommons.org/licenses/by/4.0
Right Bundle Branch Block in Right Ventricular Apical Pacing
Right ventricular (RV) apical pacing results in left bundle branch block pattern with left axis deviation in electrocardiogram (ECG). Appearance of right bundle branch block (RBBB) pattern on electrocardiogram after RV apical pacing commonly denotes septal perforation or coronary sinus pacing. 59 year old male underwent permanent pacemaker implantation (VVI) for symptomatic complete heart block with tined pacing lead fixed in right ventricular apex. 12 lead ECG showed RBBB pattern after implantation, despite the lead in RV apex. Some of the mechanisms proposed are incorrect lead placement, left ventricle getting activated first through anomalous pathways, pacing stimulus travelling through right bundle to atrioventricular node retrogradely and down the left bundle branch and lastly diseased right ventricular conduction system leading the pacing stimulus to penetrate left ventricular conduction system early.
Copyright (c) 2018 Gnanavelu G, et al. https://creativecommons.org/licenses/by/4.0
Coronary Traffic Jam Caused by a Trifurcating Left Main in a Cardiac Arrest STEMI Patient
Case Report: A 64 year old male presented to the emergency room as a case of cardiogenic shock. He had history of previous percutaneous coronary intervention (PCI) to left anterior descending artery (LAD) two years ago.ECG taken at emergency room (ER) showed acute inferolateral ST elevation myocardial infarction (STEMI). Coronary angiogram (CAG) revealed trifurcating left main with ramus as the culprit lesion. PCI of trifurcating left main (LM) is a complex procedure. But the challenge was overlapping previous LAD stent in the setting of trifurcating left main with acute angles between LAD, Ramus and LCx with medina classification (1 1 0 1)
Copyright (c) 2018 Rajan R, et al. https://creativecommons.org/licenses/by/4.0
Modeling Atrial Fibrillation with Human iPSCs
Atrial fibrillation (AF) is the most common arrhythmia worldwide; it is associated with increased risk for stroke, heart failure, inconsistent blood supply, and additional heart rhythm problems. Despite recent advances in antiarrhythmic drugs (AADs) therapies, variability in response to AADs in individual patients is caused either by heterogeneity of the underlying electrical substrate in patients or by our inability to select mechanism-based therapies. Currently, it has been increasing interest in developing cellular models of disease that are genetically-matched to specific patients using human induced pluripotent stem cells (human iPSCs). The generation of hiPSC-derived cardiomyocytes (hiPSC-CMs) from patients peripheral mononuclear blood cells has provided novel insights into underlying mechanisms of inherited arrhythmia syndromes. This mini-review will discuss this innovative genotype-guided approach for Atrial fibrillation (AF) therapy, which would prove to be a formative step for the field of personalized medicine.
Copyright (c) 2018 Hong L https://creativecommons.org/licenses/by/4.0
Prevention and Early Detection of Congenital Heart Defects. Where do we Stand
Introduction: Since the origin of Medicine in 4th BC. Century research has taught us that learning and practicing preventive medicine is properly the best method to prevent disease from happening in the first place. Preventive health care must be planned and executed ahead of time, even when illness/ disease, is absent, especially for those that are common and fetal. Among neonates and infants, congenital heart disease (CHD) is responsible for the largest proportion of mortality caused by birth defects. Actual numbers of patients and mortality resulting from CHD reportedly is increasing. In the developed world the treatment of CHD has escalating costs for health care systems and private covered patients, while in low-income countries it is not always available. Prevention is urgently needed to tackle the increasing needs. Aim: To present the current practice in preventing/early detecting CHD and justify why pulse oximetry is the best available, early detecting postnatal screening test we currently have. Methods: The existing in use preventing/early detecting methods for avoiding or early diagnosing CHD are: 1. Eliminate the maternal risk factors by obtaining a good level of health and medical surveillance during pregnancy. 2. Avoiding teratogenic agents, 3. Detecting risk factors from Family History, 4. Delivering a balanced Nutrition during Pregnancy 5. Obtaining at least an experienced 4-chamber view and outflow tracts imaging during the 20-weeks anomaly scan. 6. Fetal Echocardiography when indicated 7. Postnatal evaluation by experienced Pediatricians. 8. Pulse Oximetry, screening test after 72 hours post-delivery in term babies.9. Hyperoxia test when indicated. Conclusion: Although CHDs are the most common, high morbidity and mortality, congenital malformations, we still lack a single, easy to apply, non-invasive and low-cost screening test, for prevention/early detection. The current preventive methods must be combined to counterbalance the CHD prevalence. Meanwhile, they are costly and partially accessible. The most advantageous method for minimizing CHD deaths worldwide seems to be currently, pulse oximetry combined with clinical assessment.
Prevention/early detection of Congenital Heart Diseases
Pulse oximetry screening test for critical Congenital Heart Disease
Copyright (c) 2018 Petropoulos AC https://creativecommons.org/licenses/by/4.0
Atherosclerosis and Remnant Lipoproteinemia
Atherosclerosis is the development of complex lipid-laden lesions in the vasculature with the potential to contribute to cardiovascular events including myocardial infarction, stroke and peripheral vascular disease. The normal endothelial cell phenotype is anti-atherogenic, with injury, endothelial cell tight junctions are weakened, allowing egress of lipoproteins into the sub endothelial space, leading to decreased vasodilatory nitric oxide secretion, and finally decrease in flow mediated dilation (FMD). The risk of experiencing a cardiovascular event is 13% lower per 1% higher FMD. Elevated serum LDL is strongly related to the development of atherosclerotic diseases. Epidemiologic studies reveal that hypertriglyceridemia is also associated with atherosclerosis independent of other coronary risk factors. This is a challenge to distinguish high-risk patients from all subjects with hypertriglyceridemia. Atherosclerotic diseases with high triglyceride levels can be found in patients with familial combined hyperlipidemia, diabetes mellitus, and metabolic syndrome, in which triglyceride-rich lipoproteins, especially chylomicron remnants and VLDL remnants, accumulate in the circulating blood and contribute in atherosclerosis. Many researchers have focused on these remnant lipoproteins as atherogenic particles. Remnant lipoprotein (RLP) not only increases in abnormality of lipoprotein metabolism, it is also associated with the progression of atherosclerosis, and coronary artery disease (CAD).
Copyright (c) 2018 Mona Mohammed El Tamalawy https://creativecommons.org/licenses/by/4.0
Unusual Case Presentation of Intermittent Aortic Prosthetic Valve Dysfunction
Mechanical valve dysfunction can be classified as endogenous and exogenous according to the etiology. Endogenous dysfunctions are caused by valve damage or defect, which has become extremely rare with the improvement of design, materials, and manufacture and detection methods in vitro. Exogenous causes include inappropriate selection of prosthesis, technical issues or other complications, such as thrombosis, excessive pannus overgrowth into the prosthetic rim, excessively long knot end, residual chordate tendineae stuck in the prosthetic sewing ring, extremely long residual papillary muscles in left ventricle or calcified tissues under the prosthesis hampering leaflet mobility. We are reporting a case of intermittent malfunction of prosthetic aortic valve [21 mm Medtronic hall mechanical prosthesis] in a 37-year-old female, who underwent Aortic Valve Replacement (AVR) eighteen year back for aortic valve endocarditis and severe Aortic Regurgitation (AR).
Copyright (c) 2018 Hakim Irfan Showkat, et al. https://creativecommons.org/licenses/by/4.0
Laughter Yoga for Patients with Hypertension, India
Objective: To evaluate the effects of laughter Yoga on selected haemodynamic variable of hypertensive patients. Design: quasi experimental design. Setting: Magalir Maruthava Maiyam Veeriamplayam, Coimbatore. Sample: Forty samples diagnosed to have hypertension were selected for the study, of which 20 were assigned to the control group. Outcome measures: Haemodynamic variables namely blood pressure pulse and mean arterial pressure were measured before each session of laughter Yoga and after laughter Yoga and recorded. Intervention: laughter Yoga techniques were practiced by the patients for 20-30 minutes. It was given at one session per day for 5 days. Results: Subjects who received laughter Yoga reported significant reduction in blood pressure of 125.15/82.2.25 mm of Hg than 140.50/91.50mm of Hg in control group, pulse 79.86 than87.6 in control group, MAP of 97.79 than 108.33 in control group. There was no association between haemodynamic variable and demographic variables of age, sex and BMI. Conclusion: The results supported that the incorporation of laughter Yoga as one of the best alternative therapy to reduce hypertension.
Copyright (c) 2018 Angeline K and Madhavi R https://creativecommons.org/licenses/by/4.0
Study of Prognostic Role of High Sensitivity C - Reactive Protein and Serum Fibrinogen Levels in Unstable Angina Patients in Eastern India
Introduction: Patients with unstable angina are heterogeneous in terms of risk of cardiac death and nonfatal ischemic events. Assessment of the prognosis in these individuals guides the management protocol. C - reactive protein (CRP) and serum fibrinogen are established prognostic markers in UA. Aim: This study assessed the prognostic role of high sensitivity CRP (hs CRP) and serum fibrinogen levels in unstable angina patients in eastern India with no other high risk factors. Material and methods: It was a prospective single centre observational study which included patients admitted with diagnosis of unstable angina in medical ICU from August 1, 2009 to June 1, 2011. Cases with concomitant inflammatory or neoplastic condition, valvular heart disease, left ventricular (LV) failure, ST elevation/ new or presumably new ST depression and T wave inversion in ECG, elevated cardiac biomarkers (CPK MB/ Troponin T), LV dysfunction (LVEF<50%), suspected pulmonary thrombo embolism, age>60 years, known case of coronary artery disease, heart failure, diabetes, hypertension, dyslipidemia and chronic kidney disease were excluded from the study. Patients were observed for 72 hours in medical ICU. Serum fibrinogen and high sensitivity C - reactive protein (hs CRP) levels were estimated at the time of admission, and at the end of 48 hours and 72 hours. Primary endpoints were death, myocardial infarction, heart failure and secondary endpoints were hemodynamically unstable ventricular arrhythmias, and refractory angina or recurrent angina. Patients who met the study endpoints were grouped as unfavourable group and others as favourable group. Results: Of 1034 patients with unstable angina, 927 met the exclusion criteria and 7 were lost on follow up. On follow up, 30 (30%) patients were in unfavourable group and 70(70%) were in favourable group. Primary endpoints were met in 9% patients, death- 1(1%), myocardial infarction- 3 (3%), heart failure- 5 (5%). Secondary endpoints were met in 21% patients, ventricular arrhythmias- 4 (4%), refractory angina- 17 (17%). Patients in recurrent angina 10 (10%). Patients in unfavourable group had significantly high hs CRP (4.47±1.22 mg/L vs 1.98±0.37 mg/L, p<0.0001) and serum fibrinogen (600.93±49.94 mg/dl vs 404.1±94.01mg/dl, p<0.0001) levels at the time of admission. Patients with hsCRP levels <1mg/L or serum fibrinogen 500mg/dl at the time of admission had favourable outcome while those with hsCRP>3 mg/L or serum fibrinogen > 600mg/dl had unfavourable outcome. 16.67% of patients with hs CRP between 1 to3mg/L and 40% with serum fibrinogen between 501 to 600 mg/dl had unfavourable outcome. Among these patients, those with unfavourable outcome showed increasing trend of hsCRP and serum fibrinogen, so that by the end of 72 hours, they had hsCRP level >3mg/L and serum fibrinogen level >600mg/dl. Conclusion: High sensitivity C - reactive protein and serum fibrinogen levels at admission were independent prognostic markers of adverse hospital outcome in unstable angina patients. These markers can be useful in risk stratification of patients with unstable angina and early referral to cardiac care centre for destination curative therapy.
Copyright (c) 2018 Priti K and Jha CM https://creativecommons.org/licenses/by/4.0
Heart failure (HF) is a chronic disease associated with significant mortality and morbidity. HF management contains of non pharmacologic, pharmacologic, and invasive strategies to limit and reverse its manifestations. Despite improvement in the treatment modalities, hospitalizations for HF remain frequent and mortality rates are still high. In this mini-review current treatment strategies are discussed.
Copyright (c) 2018 Caglar A and Nesligul Y https://creativecommons.org/licenses/by/4.0
Clinical Usefulness of the Pocket Echocardiographic Device: Potential Advantage and Reliability Compared to the Conventional Echocardiographic Equipment
We hypothesized that pocket echocardiography (PE) is a useful and has a potential advantage in clinical practice. Methods: Study population consisted of 200 patients who underwent both PE and conventional (CE) (male 107, age 56.6±16.6 years). Each patient was submitted to physical examination before echocardiographic assessment. The agreement, sensitivity, specificity between PE and CE were assessed based on the diagnostic results of CE. Results: About 77.5% clinical questions could be answered by PE, however, only 6% questions could be answer by physical examination. The sensitivities and specificities of PE to detect the enlargement of left ventricle, right ventricle, left atrium and right atrium detected by CE were 89%- 100% and 100% (AUC= 0.94- 1.00), respectively. The sensitivities and specificities of PE to detect significant valvular regurgitation by CE were 96% and 97% (AUC= 0.97), respectively. There was excellent agreement between PE and CE in evaluating severity of valvular regurgitation for the four valves (kappa= 0.905). Eight of 9 patients with congenital heart disease could be successfully diagnosed by PE and confirmed by CE. Eight patients with critical ills in emergency room had been correctly diagnosed by PE, which should be acute managements after diagnosis. Conclusions: With pocket size nature, good agreement between PE and CE. PE showed additive clinical value over the clinical physical examination. It may alter the current consultation mode in clinical practice in the future.
Copyright (c) 2018 Shen X, et al. https://creativecommons.org/licenses/by/4.0
Modern Day Cardiology: Expectations and Limitations
It gives me great pleasure to write this editorial for the Journal of Cardiology as we have been working on issues related to coronary artery disease (CAD) for over three decades. I just returned from a Cardiac Pathology Update2018. Much of the presentation at this meeting was limited to the discussion on the morphology of atherosclerotic plaque, which was based on the data generated by various imaging techniques. There was very little discussion on the pathogenesis of this plaque on the vessel walls or about the ways and means for prevention of this process.
Copyright (c) 2018 Rao GHR https://creativecommons.org/licenses/by/4.0
Vascular Disease Risks: Known and the Unknown?
Acute vascular events such as heart attacks, pulmonary embolisms, and stroke, are the leading causes of mortality and morbidity worldwide. Framingham heart study (FHS), developed by the National Heart Lung& Blood Institute (NHLBI), of the National Institutes of Health (NIH,) and the Boston University School of Medicine (BUSM), some 70 years ago, developed information about the modifiable risk factors, which promote the development of vascular diseases. Several studies have demonstrated that robust management of modifiable risk factors, leads to the decline in the deaths, due to vascular diseases. A comprehensive study done in 26 industrialized countries, has demonstrated a significant decline in deaths due to cardiovascular diseases (CVDs). The same study also noted that in spite of this observed decline in the CVD-associated deaths, there was an increase in the diabetes-related deaths. Another ongoing study by the National Health and Nutrition Education Survey (NHANES)of the USA, showed that 52% of adults with overweight, and 32% of adults with obesity, had no cardiac risk factors (CRFs), or only one CRF. Recent Scientific Statement by the American Heart Association, on the excess diabetes and heart disease in the South Asians living in the USA, also demonstrates the ethnic differences in the manifestation of specific risk factors, and their role in the precipitation of acute vascular events. These and other such observations, raise the question about the possible contribution of risks that are as yet unknown or less known, related to various ethnicity, demography, diet, physical activity, stress, and lifestyle. In this mini overview, we will touch upon the contribution of some known CRFs, speculate on the as yet unknow risks or relatively less known risks, and express our point of view on this very important topic.
Standard Conduits Used in Coronary Artery Revascularisation, an Immediate and Midterm Patency Comparative Study in the Population of Largest City of Uttar Pradesh, A Single Centre Study
Introduction: Coronary artery revascularisation is a mainstay technique to alleviate the morbidity of coronary artery disease. There are various conduits available for coronary bypass grafting, we hereby study the conduits routinely used for revascularisation and compare the results. Material and methods: In study 56 people were included, who visited the OPD, were in the IPD, or had come for follow up in OPD over a period of 1 year .Patient included in the study were cases of coronary artery disease in which CABG was a class I indication. A total of 215 conduits were grafted , which included left internal mammary artery graft, reversed saphenous vein graft, radial artery grafts and patients were evaluated for graft patency over a period of 1 year at intervals of 1 month and 1 year . Results: There were 56 LIMA grafts used, 150 RSVG and 9 RA grafts grafted. During follow up period the data was divided into graft failures (defined as total occlusion of the graft), graft failures that took place within 1 months of grafting were termed as early graft failure and graft failures that took place after 1 year were termed as intermediate graft failure. Out of 215 conduits that were grafted a total of 26 conduits were considered as graft failures over a period of 1 year. Conclusion: Reversed saphenous grafts had a greater graft occlusion rate in comparison to internal mammary graft and were better suited for non- LAD site for grafting and thus routinely practiced. Radial artery theoretically seemed to be a better option than RSVG but in our study the data was insufficient to come to a conclusion.
Copyright (c) 2018 Satsangi A, et al. https://creativecommons.org/licenses/by/4.0
Pattern of C - reactive Protein in Sudanese Patients with Acute Coronary Syndrome
Background and Objective: C-reactive protein (CRP) is an acute phase protein that is produced predominantly by hepatocytes under the influence of cytokines such as interleukin (IL-6) and tumor necrosis factor-alpha. C-reactive protein is an extensively studied inflammatory factor whose prognostic value in cardiovascular diseases in recent years has become increasingly important. This study aimed to determine pattern of C-reactive protein in patients admitted with acute coronary syndrome to the coronary care unit at Elobied Teaching Hospital. Patients and Methods: This is a prospective hospital-based study. The study included 102 patients who were consecutively admitted to the coronary care unit with the clinical diagnosis of acute coronary syndrome (ACS). The data were obtained through well-designed data sheet including age, gender, clinical presentation, risk factors together with complications and ECG findings. A written consent was obtained from each patient. Five milliliters of venous blood was withdrawn from each patient within 24 hours of admission, serum Troponin and C- reactive protein levels were measured. The data were analyzed using SPSS version18. Results: In this study, the mean age of patients was 58 ± 12 years. More than half of the patients were male (54%). Hypertension was found in 33% while 28% of patients were diabetic and 18% were smoker. In this series, STEMI was diagnosed in 40 % of patients. Mean level of serum troponin was12 ng/ ml. The level of CRP was remarkably high (Mean47 mg/l). Conclusion and Recommendation: In this study, the level of CRP was high in patients with acute coronary syndrome. Further studies are needed to evaluate the role of CRP as a predictor of cardiovascular outcome after ACS.
Copyright (c) 2018 Elfaki ASMH, et al. https://creativecommons.org/licenses/by/4.0
Risk Scores for Acute Vascular Events: Expectations and Limitations
Cardiovascular disease (CVD) is a major global health burden, despite declines in the mortality rate due to CVD in high-income and some middle-income countries, according to a study published in the Journal of American College of Cardiology (May 2017). The leading cause of healthcare related loss worldwide and in each region of the world is ischemic heart disease. Seventy years of dedicated research under the leadership of the National Institutes of Health and Boston University by the pioneering researchers of the now famous Framingham Heart Study, has provided a wealth of knowledge on the modifiable risk factor functions. One of the great contributions of FHS is that early work by this group opened up and supported the whole field of preventive cardiology by identifying modifiable risk factors for heart disease. Identification of these risk factors also raised the expectations of public in terms of possible reduction or reversal or prevention of this disease by the optimal management of these observed risks. In view of the fact, this was a one of a kind study that received the support of NIH for the longest time, generated more than 3000 articles; expectations of policy makers as well as general public have consistently remained high. Public health policies that were developed based on these findings have contributed significantly to the reduction in smoking, blood pressure, lowering of elevated levels of cholesterol and triglycerides. Considering the twin epidemics of obesity and type-2 diabetes, which are out of control worldwide, what we have gained in the management of modifiable risks may be lost, if the present trend in the increase of obesity and diabetes are not brought into control. Based on the results of FHS a Risk Score calculator has been developed. Development of new biomarkers, and new diagnostic imaging techniques, have provided additional data points for fine tuning the risk stratification for the development of the cardiovascular disease as well as for acute vascular events. In this brief overview, we have discussed some salient points and expressed our viewpoint on this topic of great public health importance.
Venous Thromboembolic Disease and Cardio Oncology
Venous thromboembolism along with peripheral arterial thrombosis and cardio toxicity are some terms from the vocabulary of Oncologists that have been used increasingly in recent years. Several mechanisms have been related to the increased thrombotic complications observed in patients with cancer: 1) the expression of tissue factor by circulating tumor cells, 2) the shedding of pro coagulant micro particles by malignant cells, 3) the interaction of cancer cells with blood platelets, 4) the generation of neutrophil extracellular traps and 5) the secondary deleterious effects of anti-cancer therapies. Cancer patients with venous thrombosis experience 3fold higher rates of recurrences and 2fold major anticoagulation-associated bleeding complications than do patients without cancer. Anticoagulation treatment for venous thromboembolism differs in various groups of patients suffering from malignancies and demands a detailed knowledge of advantages and side effects of available medications. Low Molecular Weight Heparins are the first line choice, followed by vitamin K antagonists, which are widely used when treatment has to be prolonged. The new oral anticoagulants have been proven effective for venous thromboembolism (in general) and for atrial fibrillation embolic disease and thus are promising, though more studies are needed in order to investigate their detailed behavior in cancer populations. The emerging interplay between Oncologist and Cardiologists is a new provocation for the two specialties, which will probably impel them to specify a new subspecialty, the Cardio Oncology.
Copyright (c) 2018 Panagiotopoulos K and Kapouralos A https://creativecommons.org/licenses/by/4.0
Evaluation of Syncope: Who Needs an Implantable Loop Recorder?
Syncope is a frequently encountered condition and accounts for up to 3% of emergency department consultations and 6% of hospital admissions. Although clinical history and examination combined with laboratory testing are adequate in obtaining a diagnosis in many patients, there are some who experience infrequent episodes that are elusive in nature and the cause difficult to detect. This is because correlation between syncopal events and any alteration of physiological signals (ECG, blood pressure) is the gold standard for the diagnostic work-up. In these individuals, prolonged ambulatory monitoring with implantable electrocardiographic recorders can be of great benefit. Implantable loop recorder (ILR) is a relatively recent investigational tool in undiagnosed syncope that permits prolonged monitoring without external electrodes. It is ideally suited to patients with infrequent recurrent syncope thought to be due to an arrhythmic cause. The newly available REVEAL LINQTM is a miniature ILR device which could be literally injected under the skin without a surgical incision. The mean diagnostic yield of ILR reported in the literature is about 50-60%.
Copyright (c) 2018 Banerjee S https://creativecommons.org/licenses/by/4.0
Takayasu Arteritis in a Female- A Rare Case Report from Rural India
Takayasu arteritis is a rare large vessel vasculitis of autoimmune origin usually affecting young women. Here we describe a young female who presented primarily for dyspnea, polymyalgia, tingling sensation of limbs and headache since 1 year. She was diagnosed with Takayasu arteritis. Her evaluation revealed pulseless radial, brachial arteries and hypertension Computed tomography based aortic angiography revealed critical stenosis and surrounding inflammation in the branches of aorta. This case highlights how the diagnosis may be delayed due to nonspecific symptoms and how symptoms of early and late stage may coexist in the patient. Early diagnosis requires high degree of suspicion, delay in diagnosis can lead to critical stenosis and obstruction of aorta and its branches requiring surgical intervention.
Copyright (c) 2018 Tandon MS and Singh V https://creativecommons.org/licenses/by/4.0
Fitness, Lifestyle Changes, and Wellness: Cardiometabolic Health
Market size of Global health clubs industry is 83 billion, with over 200,000 clubs, and 160 million members worldwide. According to the Global Wellness Institute, the global wellness industry grew 10.6% from 2013 to 2015; from 3.6 trillion to 3.72 trillion market. The global corporate wellness market size was valued at USD 50 billion in 2017. According to the global wellness experts, the health and wellness industry is experiencing a healthy boom, - that is global anti-aging market is worth 250 billion in the US alone. As the theme of this mini review states, we would like to explore challenges and opportunities, in this growing area and take advantage of this huge fitness and wellness market trends, to develop an integrated preventive program, that will aim at a better health, as well as a healthy aging concept. Vascular diseases rank as the number one killer for decades. Development of preventive strategies, based on the modifiable risk factors for cardiovascular disease (CVD), identified by the Framingham Heart Study Group, has contributed significantly for the observed decline in heart disease related deaths worldwide. Having said that, we need to explain the discrepancy between the reported decline in CVD-related deaths, and the statement that CVD ranks the number one killer in the world. In our opinion, there is more to the mechanisms underlying vascular disease, than the modifiable risks identified by the Framingham Heart Group. In this overview, we would like to discuss the role of fitness, lifestyle changes, and wellness concept as they relate to the reduction, reversal, and prevention of metabolic diseases.
Spontaneous Coronary Artery Dissection Diagnosed by Coronary Computed Tomography Angiography
Spontaneous coronary artery dissection is a rare cause and, in many cases under suspected, and under diagnosed as an acute coronary syndrome. The incidence is higher in women, and younger patients without the traditional cardiovascular risk factors. Given the lack of appropriate randomized clinical trials, doubts remain regarding the best diagnostic method and the best therapeutic option for these patients. We describe the case of a 48-year-old woman who debuted as an acute coronary syndrome with persistent ST-segment elevation, for whose diagnosis a multimodal approach with imaging techniques was necessary.
Myocardial infarction with non-obstructive coronary arteries (MINOCA)
Copyright (c) 2018 Romero MJ, et al. https://creativecommons.org/licenses/by/4.0