Anoop George Alex

Exercise for prevention of cardiovascular disease: Evidence-based recommendations

Sedentary lifestyle is one of the major risk factors for cardiovascular disease (CVD). In India, a large percentage of the people are physically inactive with fewer than 10% engaging in recreational physical activity. Physical activity has many beneficial effects on the risk factors for CVD. Apart from improving fitness level, it decreases myocardial oxygen demand and improves myocardial perfusion. There is an inverse association between physical activity and all-cause mortality. In primary prevention, physical inactivity is associated with a two-fold increase in the risk for coronary events. In secondary prevention, data confirm the existence of an inverse dose–response relationship between cardiovascular fitness and the all-cause mortality in large populations of cardiovascular patients. Guidelines from the American authorities as well as the European Society of Cardiology provide specific recommendations for exercise depending on the clinical setting (primary or secondary prevention of CVD) and the patient-specific factors (the patients physical activity level and the perceived CVD risk). The present review summarizes the clinical evidence regarding the role of exercise in CVD prevention and the exercise recommendations from the leading Cardiac societies.

Devil is in the detail

A 15-year-old girl of Asian origin, hailing from a rural agrarian background, presented with history of multiple episodes of dizziness for 3 years. The episodes were precipitated mostly by emotional and/or physical stress and relieved on lying down, with a few episodes culminating in transient loss of consciousness. As preliminary cardiac and neurological evaluation were normal, she was being treated by the primary physician as a case of probable psychogenic syncope, supported by the consistent association of the episodes with emotional stress. A detailed review of family history revealed that the premature demise of the patient’s siblings which were attributed to snakebite and head trauma by the family could have been in reality sudden cardiac deaths. Treadmill test revealed exercise-induced polymorphic ventricular tachycardia confirmatory for the diagnosis of catecholaminergic polymorphic ventricular tachycardia. She was initiated on beta-blocker therapy to which she showed remarkable response.

IndEcho study: cohort study investigating birth size, childhood growth and young adult cardiovascular risk factors as predictors of midlife myocardial structure and function in South Asians.

Introduction South Asians have high rates of cardiovascular disease (CVD) and its risk factors (hypertension, diabetes, dyslipidaemia and central obesity). Left ventricular (LV) hypertrophy and dysfunction are features of these disorders and important predictors of CVD mortality. Lower birth and infant weight and greater childhood weight gain are associated with increased adult CVD mortality, but there are few data on their relationship to LV function. The IndEcho study will examine associations of birth size, growth during infancy, childhood and adolescence and CVD risk factors in young adulthood with midlife cardiac structure and function in South Asian Indians. Methods and analysis We propose to study approximately 3000 men and women aged 43–50 years from two birth cohorts established in 1969–1973: the New Delhi Birth Cohort (n=1508) and Vellore Birth Cohort (n=2156). They had serial measurements of weight and height from birth to early adulthood. CVD risk markers (body composition, blood pressure, glucose tolerance and lipids) and lifestyle characteristics (tobacco and alcohol consumption, physical activity, socioeconomic status) were assessed at age ~30 years. Clinical measurements in IndEcho will include anthropometry, blood pressure, biochemistry (glucose, fasting insulin and lipids, urinary albumin/creatinine ratio) and body composition by dual energy X-ray absorptiometry and bioelectrical impedance. Outcomes are LV mass and indices of LV systolic and diastolic function assessed by two-dimensional and Doppler echocardiography, carotid intimal-media thickness and ECG indicators of ischaemia. Regression and conditional growth models, adjusted for potential confounders, will be used to study associations of childhood and young adult exposures with these cardiovascular outcomes. Ethics and dissemination The study has been approved by the Health Ministry Steering Committee, Government of India and institutional ethics committees of participating centres in India and the University of Southampton, UK. Results will be disseminated through scientific meetings and peer-reviewed journals. Trial registration number ISRCTN13432279; Pre-results.

Observational study comparing pharmacoinvasive strategy with primary percutaneous coronary intervention in patients presenting with ST elevation myocardial infarction to a tertiary care centre in India

Objective: The objective was to study whether the incidence of composite end points (mortality, cardiogenic shock and re-myocardial infarction [re-MI]) in pharmacoinvasive strategy was noninferior to primary percutaneous coronary intervention (PCI) in patients with ST-elevation myocardial infarction (STEMI). Methods: This was an observational study which included 138 patients. The study included patients admitted with a diagnosis of STEMI within 24 h of symptom onset, who underwent primary PCI or pharmacoinvasive therapy in a single center over a 9-month period. Primary end points (death within 30 days, re-MI within 30 days, and cardiogenic shock) and secondary end points (arrhythmias, bleeding manifestations, ischemic stroke, ejection fraction, mechanical complications, and duration of hospital stay) were compared between the two groups at 1 month after intervention. Results: At one month follow-up, the incidence rate for primary end points was 5 events per 43 patients (11.6%) in pharmacoinvasive arm and 18 events per 95 patients (18.9%) in primary PCI arm, a difference of - 7.3% (95% confidence interval: 18.5, 7.1). This finding shows that pharmacoinvasive strategy as compared with primary PCI in the management of STEMI was equivalent in terms of composite primary outcome. There was no significant difference between the secondary outcomes between the two groups. Use of thrombus aspiration device and in turn the thrombus burden was significantly lower in the pharmacoinvasive arm. Conclusion: This observational study showed that pharmacoinvasive strategy was as good as primary PCI in STEMI, in our setting, where primary PCI may be delayed or not possible at all due to financial and logistic constraints.

Estimating the prevalence of elevated plasma neutrophil gelatinase associated lipocalin (NGAL) level in patients with acute coronary syndromes (ACS), and its association with outcomes

Objectives The principal objective of this study was to estimate the plasma levels of neutrophil gelatinase associated lipocalin (NGAL) in a cohort of patients with acute coronary syndromes (ACS) across their entire spectrum, and to correlate them with outcomes. Methods 87 patients with acute coronary syndromes were included in the study. Apart from the routine work up and management, all patients underwent determination of plasma NGAL and serum high sensitivity C reactive protein (HSCRP) levels at admission. The patients were followed up through the hospital stay as well as for one month after discharge for clinical outcomes, and echocardiographic parameters of left ventricular function. Plasma NGAL was studied for its predictive power for various defined outcomes. Results Plasma NGAL levels were detectably elevated in 67% of patients with ACS without any significant proportion with renal dysfunction, sepsis or overt infection. Plasma NGAL was the strongest independent predictor of all cause hospital mortality in Cox regression multivariate analysis with an odds ratio of 8.353, p = 0.0237. Plasma NGAL did not correlate with HSCRP, or severity of coronary artery disease (CAD). Conclusion This is a small study that shows that plasma NGAL in patients admitted with ACS can predict hospital mortality and forms the basis for consideration of this molecule as a possible new risk marker in ACS meriting further and more extensive investigation.

Penetrating mitral annular abscess ruptured into the left atrium: a rare cause of mitral regurgitation.

A man aged 27 years from Bangladesh was referred to our centre for evaluation of fever of unknown origin of 3 months duration. There was a history of progressively increasing dyspnoea of NYHA functional class II for 25 days. He had received antibiotic therapy for a week prior to his presentation to us. Physical examination revealed muffled first heart sound with loud pulmonary component of second heart sound. A grade IV/VI (Levine grade) pan systolic murmur was heard over the apex, radiating to the left axillae. There were no clinical stigmata …

Atrial septal defect with right-to-left shunt in the absence of pulmonary hypertension

We describe the case of a 27-year-old gentleman who developed late-onset clubbing and cyanosis. Transoesophageal echocardiography revealed a 27-mm ostium secundum atrial septal defect and a large, floppy Eustachian valve directing right atrial blood to the left side of the heart.

‘Chamber within a chamber’: a rare cardiac anomaly

Double-chambered left ventricle is a rare cardiac anomaly. We report a case of double-chambered left ventricle in a one-and-half-year-old asymptomatic boy. We depict the use of three-dimensional echocardiography in the demonstration and diagnosis of the condition.

Brugada syndrome presenting as incessant polymorphic ventricular tachycardia: a rare cause for a common outcome after cardiac arrest in a middle-aged Asian man

Brugada syndrome (BrS) is a familial disorder and an important though rare cause of sudden cardiac death (SCD). SCD occurs due to ventricular fibrillation (VF), though presentation with incessant polymorphic ventricular tachycardia has also been rarely reported in the literature. We report a case of BrS presenting with incessant polymorphic ventricular tachycardia that ultimately led to prolonged cerebral ischaemia and hypoxic ischaemic encephalopathy sequelae. A 34-year-old man, with no previous comorbidities, collapsed suddenly while attending to his morning routine work. He had a history suggestive of presyncopal episodes in the recent past. There was no family history of SCD. He was taken to a nearby hospital within 10–15 min of collapse, where cardiopulmonary resuscitation (CPR) was initiated. ECG monitor showed polymorphic ventricular tachycardia, so direct current (DC) shock and intravenous magnesium were given. After 20 min of CPR and five cycles of DC shock, the patient reverted to sinus rhythm. Simultaneously, he was intubated and put on ventilatory support. Intravenous amiodarone was …

T-wave inversions with a difference

A middle-aged patient presented to the acute chest pain unit (ACPU), due to retrosternal chest discomfort with bradycardia at 59 beats per minute. The electrocardiograph (ECG) showed sinus bradycardia with diffuse deep T-wave inversions. Troponin T was 38.76 pg/mL (normal ≤14 pg/mL). Suspecting an acute coronary syndrome, the patient underwent coronary angiography, which was, surprisingly, normal. Serum thyroid stimulating hormone level, sent as …