Amisha Patel

Coronary Aneurysm and Purulent Pericardial Effusion: Old Disease With an Unusual Cause

We describe the case of a 60-year-old man with prior rotational atherectomy and drug-eluting stent to the left anterior descending artery (LAD) who presented with shortness of breath and chest pain 8 weeks after stent placement. Further workup revealed a large pericardial effusion with gram stain positive for methicillin-resistant Staphylococcus aureus. Subsequently, this was shown to be related to an aneurysm at the site of the prior LAD stent. This case demonstrated coronary stent infection with mycotic aneurysm and purulent pericardial effusion as an extremely rare but serious complication of percutaneous coronary intervention.

Building the Case for Clopidogrel as a World Health Organization Essential Medicine

The World Health Organization (WHO) defines essential medicines as medicines that satisfy the priority healthcare needs of the population.1 These medicines are selected by the WHO based on their public health relevance, international availability, treatment details, efficacy and safety, comparative cost-effectiveness, the need for special requirements or training needed for the safe/appropriate use of the medicine, and regulatory status.1 The medicines that are considered highest priority are included on the WHO Model List of Essential Medicines or Essential Medicines List (EML). The EML was first published in 1977 and is revised every 2 years by an expert committee. It serves as a catalog of critical medicines and informs purchasing decisions of low- and middle-income country (LMIC) governments.1,2 Most individual nations align the WHO EML with the epidemiological profile and health priorities of their population to create a national EML.3 Medicines on the national EML are then subsidized by the public sector, making them more affordable to the general population.4 For example, in the national Mutuelle insurance system in Rwanda, members are eligible to receive national EML drugs for outpatient treatment with only a 10% copayment.3,5 In November 2012, the WHO announced its target to reduce the risk of premature mortality related to noncommunicable diseases by 25% by the year 2025.6 This goal is to be achieved, in part, through a health system target that assures availability of essential medicines and technologies to treat noncommunicable diseases, including cardiovascular disease (CVD), to at least 50% of eligible individuals. The 18th edition of the WHO EML includes several drugs for the treatment and control of acute and chronic CVDs, including aspirin, streptokinase, heparin, simvastatin, bisoprolol, and enalapril.7 However, clopidogrel, a thienopyridine often used in conjunction with aspirin as a second antiplatelet …

Sex Differences in the Presentation, Diagnosis, and Management of Acute Coronary Syndromes: Findings From the Kerala-India ACS Registry

BACKGROUND Previous literature from high-income countries has repeatedly shown sex differences in the presentation, diagnosis, and management of acute coronary syndromes (ACS), with women having atypical presentations and undergoing less aggressive diagnostic and therapeutic measures. However, much less data exist evaluating sex differences in ACS in India. OBJECTIVES This study sought to evaluate sex differences in the diagnosis, management, and treatment of patients with ACS in Kerala, India. METHODS The Kerala ACS Registry collected data from 25,748 consecutive ACS admissions (19,923 men and 5,825 women) from 125 hospitals in the Indian state of Kerala from 2007 to 2009. This study evaluated the association between sex differences in presentation, in-hospital management, and discharge care with in-hospital mortality and in-hospital major adverse cardiovascular events (defined as death, reinfarction, stroke, heart failure, or cardiogenic shock). RESULTS Women with ACS were older than men with ACS (64 vs. 59, p < 0.001) and were more likely to have a history of previous myocardial infarction (16% vs. 14%, p < 0.001). Inpatient diagnostics and management and discharge care were similar between sexes. No significant differences between men and women in the outcome of death (odds ratio [OR]: 1.05, 95% confidence interval [CI]: 0.80 to 1.38) or in the composite outcome of death, reinfarction, stroke, heart failure, or cardiogenic shock (OR: 0.99, 95% CI: 0.79 to 1.25) were seen after adjustment for possible confounding factors. CONCLUSIONS In Kerala, even though women with ACS were older and more likely to have previous myocardial infarction, there were no significant differences in in-hospital and discharge management, in-hospital mortality, or major adverse cardiovascular events between sexes. Whether these results apply to other parts of India or acute presentations of other chronic diseases in low- and middle-income countries warrants further study.

Use of inhaled nitric oxide in the treatment of right ventricular myocardial infarction

In 50% of acute left ventricular inferior-posterior wall myocardial infarction (MI), concomitant right ventricular MI (RVMI) has been reported, with a dramatic increased rate of mortality. We report the case of a woman with RVMI complicated by cardiogenic shock due to dissection of the right coronary artery. She was treated with liquid infusion, epinephrine, milrinone, and an intraaortic balloon pump, but clinical condition decreased. She was then intubated, and prolonged inhalation of nitric oxide (12-15 ppm) was added. Both clinical and hemodynamic parameters slowly improved with decrease of systemic (2513 ± 708 shifted to 1802 ± 369 dynes × s/cm5) and pulmonary vascular resistance (365 ± 183 to 309 ± 80 dynes × s/cm5) and central venous pressure (fell from 13 ± 4 mm Hg to 6 ± 4 mm Hg) and improvement of cardiac index (from 2.2 ± 0.5 to 3 ± 0.3 L/min per square meter). Inhalation of nitric oxide (iNO) withdrawal on day 7 caused a significant rebound pulmonary hypertension with decrease of cardiac output. Inhalation of nitric oxide was then reinstituted until day 8 and was finally gradually withdrawn without major hemodynamic variations. The patient was weaned from the ventilator on day 9 and was stable clinically and hemodynamically. Although current international recommendations concerning the use of iNO in adults seem to limit the use of iNO as a rescue treatment in patients with severe acute pulmonary arterial hypertension and/or severe refractory arterial hypoxemia, beneficial effect of iNO in the RVMI seems to be strongly supported in the setting of cardiogenic shock. The first demonstration that inhalation of nitric oxide (iNO) decreases pulmonary artery pressure in patients with pulmonary hypertension was in the mid-1980s [1,2]. The licensed indication of iNO is restricted to persistent pulmonary hypertension in neonates, with both idiopathic and postsurgical pulmonary hypertension in the setting of congenital heart disease. Inhalation of nitric oxide has ☆ Intensive care unit at Department of Cardiothoracic Vascular Anesthesia and Intensive Care, IRCCS Policlinico S. Donato, Milan, Italy. 0735-6757/

Pre-hospital acute coronary syndrome care in Kerala, India: A qualitative analysis

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Organizing a Career in Global Cardiovascular Health

Objective Ischemic heart disease is the leading cause of death in India. Many of these deaths are due to acute coronary syndromes (ACS), which require prompt symptom recognition, care-seeking behavior, and transport to a treatment facility in the critical pre-hospital period. In India, little is known about pre-hospital management of individuals with ACS. We aim to understand the facilitators, barriers, and context of optimal pre-hospital ACS care to provide opportunities to reduce pre-hospital delays and improve acute cardiovascular care. Methods and results We conducted a qualitative study using in-depth interviews and focus group discussions with 27 ACS providers in Kerala, India to understand facilitators, barriers, and context to pre-hospital ACS care. Six themes emerged from these interviews and discussions: (1) individuals with ACS misperceive their symptoms as non-cardiac in origin; (2) emergency medical services are infrequently used; (3) insufficient pre-hospital healthcare infrastructure contributes to pre-hospital delay; (4) multiple stops are made before arriving at a facility that can provide definitive diagnosis and treatment; (5) relatively high costs of treatment and lack of widespread health insurance coverage limits care delivery; and (6) novel mobile technologies may allow for faster diagnosis and initiation of treatment in the pre-hospital setting. Conclusions Individualized patient-based factors (general knowledge of ACS symptoms, socioeconomic position) and broader systems-based factors (ambulance networks, coordination of transport) affect pre-hospital ACS care in Kerala. Improving public awareness of ACS symptoms, increasing appropriate use of emergency medical services, and building a infrastructure for rapid and coordinated transport may improve pre-hospital ACS care.

Pre-hospital policies for the care of patients with acute coronary syndromes in India: A policy document analysis

The World Health Organization, the Global Alliance for Chronic Disease, the Institute of Medicine, and the National Heart, Lung, and Blood Institute have all emphasized the need for global health research, particularly in chronic diseases [(1–4)][1]. However, the need for chronic disease

Comparison between Three-Dimensional Echocardiography and Computed Tomography for Comprehensive Tricuspid Annulus and Valve Assessment in Severe Tricuspid Regurgitation: Implications for Tricuspid Regurgitation Grading and Transcatheter Therapies

Background and objective Ischemic heart disease is the leading cause of death in India. In high-income countries, pre-hospital systems of care have been developed to manage acute manifestations of ischemic heart disease, such as acute coronary syndrome (ACS). However, it is unknown whether guidelines, policies, regulations, or laws exist to guide pre-hospital ACS care in India. We undertook a nation-wide document analysis to address this gap in knowledge. Methods and results From November 2014 to May 2016, we searched for publicly available emergency care guidelines and legislation addressing pre-hospital ACS care in all 29 Indian states and 7 Union Territories via Internet search and direct correspondence. We found two documents addressing pre-hospital ACS care. Conclusion Though India has legislation mandating acute care for emergencies such as trauma, regulations or laws to guide pre-hospital ACS care are largely absent. Policy makers urgently need to develop comprehensive, multi-stakeholder policies for pre-hospital emergency cardiovascular care in India.

Symptoms of men and women presenting with acute coronary syndromes.

Background: Tricuspid valve imaging is frequently challenging and requires the use of multiple modalities. Knowledge of limitations and methodologic discrepancies among different imaging techniques is crucial for planning transcatheter valve interventions. Methods: Thirty‐eight patients with severe symptomatic tricuspid regurgitation were included in this retrospective analysis. Tricuspid annulus (TA) measurements were made during mid‐diastole using three‐dimensional (3D) transthoracic echocardiographic direct planimetry (TTE_direct) and transesophageal echocardiographic direct planimetry (TEE_direct). Moreover, a semiautomated software was used to generate two‐dimensional (2D) and 3D perimeter and area on transesophageal echocardiography (TEE) images. Both methods were compared with direct computed tomographic planimetry (CT_direct) and cubic spline interpolation (CT_indirect). The different TA values were used to calculate the effective regurgitant orifice area and compared with 3D Doppler vena contracta area. For tricuspid valve area TEE_direct and CT_direct as well as CT_indirect were measured. Results: Agreement between TEE and computed tomography (CT) for TA sizing was obtained using semiautomated methods (3D TEE_indirect and CT_indirect). TTE_direct was overall less reliable compared with CT. TA area quantified by TEE_direct was 25% (difference 305 ± 238 mm2, P < .001, R = 0.9) and 19% (166 ± 247 mm2, P < .001, R = 0.89) smaller compared with CT_direct and CT_indirect, respectively. TA perimeter measurements by TEE_direct differed by 11% compared with CT_direct (12 ± 11 mm, P < .001, R = 0.87) and 3D CT_indirect (12 ± 11 mm, P < .001, R = 0.88), and 9% compared with 2D CT_indirect (7 ± 11 mm, P = .002, R = 0.87). TEE_direct of the TA allows the most accurate calculation of effective regurgitant orifice area compared with 3D vena contracta area (−8 ± 62 mm2, P = .50, R = 0.85). Tricuspid valve area by CT_indirect best correlated with conventional TEE_direct (80 ± 250 mm2, P = .11, R = 0.80). Conclusions: In patients with severe tricuspid regurgitation, semiautomated indirect planimetry results in high agreement between TEE and CT for TA sizing and measurement of the tricuspid valve area. TEE_direct of the TA allows the most accurate measurement of diastolic stroke volume for the calculation of regurgitation severity compared with 3D vena contracta area. HIGHLIGHTSTV imaging is frequently challenging and requires the use of multimodality imaging.Knowledge of methodologic discrepancies is crucial for preprocedural planning.Semiautomated indirect planimetry results in high agreement between TEE and CT.