Anunay Gupta

Aetiology, outcomes & predictors of mortality in acute respiratory distress syndrome from a tertiary care centre in north India

Background & objectives: Acute respiratory distress syndrome (ARDS) is a common disorder in critically ill patients and is associated with high mortality. There is a paucity of literature on this condition from developing countries. This prospective observational study was designed to find out the aetiology, outcomes and predictors of mortality in ARDS. Methods: Sixty four consecutive patients who satisfied American-European Consensus Conference (AECC) definition of ARDS from medical Intensive Care Unit (ICU) of a tertiary care centre in New Delhi, India, were enrolled in the study. Demographic, biochemical and ventilatory variables were recorded for each patient. Baseline measurements of serum interleukin (IL)-1β, IL-6, tumour necrosis factor-alpha (TNF-α), procalcitonin (PCT) and high sensitivity C-reactive protein (hsCRP) were performed. Results: Common causes of ARDS included pneumonia [44/64 (68.7%)], malaria [9/64 (14.1%)] and sepsis [8/64 (12.5%]. Eight of the 64 (12.5%) patients had ARDS due to viral pneumonia. The 28-day mortality was 36/64 (56.2%). Independent predictors of mortality included non-pulmonary organ failure, [Hazard ratio (HR) 7.65; 95% CI 0.98-59.7, P=0.05], Simplified Acute Physiology Score (SAPS-II) [HR 2.36; 95% CI 1.14-4.85, P=0.02] and peak pressure (Ppeak) [HR 1.13; 95% CI 1.00-1.30, P = 0.04] at admission. Interpretation & conclusions: Bacterial and viral pneumonia, malaria and tuberculosis resulted in ARDS in a considerable number of patients. Independent predictors of mortality included non-pulmonary organ failure, SAPS II score and Ppeak at baseline. Elevated levels of biomarkers such as TNF-α, PCT and hsCRP at admission might help in identifying patients at a higher risk of mortality.

Clarifying the atrioventricular junctional anatomy in the setting of double outlet right atrium

Double outlet atrium is a rare cardiac anomaly wherein one of the atriums, most frequently the right atrium, opens into both the ventricles. Although seen more commonly in the setting of atrioventricular septal defect, this arrangement can also be found when one of the atrioventricular connections is atretic due to absence of the atrioventricular connection and the other atrioventricular valve straddles the muscular ventricular septum. It is the specific anatomy and connections of the atrioventricular junction that clarifies the situation and distinguishes between these two types of double outlet atrium. In this report, we present a case of double outlet right atrium co-existing with the absence of left atrioventricular connection. We then discuss the morphologic aspects of this interesting anomaly.

Correlation of pacing site in right ventricle with paced QRS complex duration

Background Pacing from RV mid septum and outflow tract septum has been proposed as a more physiological site of pacing and narrower paced QRS complex duration. The paced QRS morphology and duration in different RV pacing sites is under continued discussion. Hence, this study was designed to address the correlation of pacing sites in right ventricle with paced QRS complex duration. Methods Two hundred fifty-two consecutive patients who underwent pacemaker implantation were enrolled. Baseline clinical characteristics were recorded for each patient. All patient underwent fluoroscopy, electrocardiogram and echocardiography post pacemaker implantation. Paced QRS duration was calculated from the leads with maximum QRS duration. Results Mean paced QRS (pQRS) duration was significantly higher in apical septum group with a mean of 148.9 ± 14.8 m s compared to mid septum (139.6 ± 19.9 m s; p-value 0.003) and RVOT septum (139.6 ± 14.8 m s; p-value 0.002) groups, respectively. There was no significant difference between mid-septal and RVOT septal pQRS duration. On multivariate analysis, female gender, baseline QRS duration and RVOT septal pacing were the only predictors for narrow pQRS duration (<150 msec). Conclusion RV mid-septal and RVOT septal pacing were associated with significantly lower pQRS duration as compared with apical pacing. Based on multivariate analysis RVOT septal pacing appears to be preferred and more physiological pacing site.

Clinical and angiographic profiles and six months outcomes of smokers with acute ST segment elevation myocardial infarction undergoing primary percutaneous coronary angioplasty

Background Outcomes of primary percutaneous coronary intervention (PCI) for acute STEMI (ST-segment elevation myocardial infarction) in smokers are expected to be better than non-smokers as for patients of acute STEMI with or without fibrinolytic therapy. Objectives This comparative study was designed to evaluate the outcomes of primary PCI in patients with acute STEMI in smokers and non-smokers. Clinical and angiographic profile of the two groups was also compared. Methods Over duration of two year, a total of 150 consecutive patients of acute STEMI eligible for primary PCI were enrolled and constituted the two groups [Smokers (n = 90), Non-smokers (n = 60)] of the study population. There was no difference in procedure in two groups. Results In the present study of acute STEMI, current smokers were about a decade younger than non-smokers (p value = 0.0002), majority were male (98.9% vs 56.6%) were male with a higher prevalence of hypertension and diabetes mellitus (61.67% vs 32.28% and 46.67% vs 14.44%, p = 0.001) respectively. Smokers tended to have higher thrombus burden (p = 0.06) but less multi vessel disease (p = 0.028). Thirty day and six month mortality was non-significantly higher in smokers 4.66% vs 1.33% (p = 0.261) and 5.33% vs 2.66% (p = NS) respectively. Rate of quitting smoking among smokers was 80.90% at 6 months. Conclusion The study documents that smokers with acute STEMI have similar outcomes as compared to non smokers with higher thrombus burden and lesser non culprit artery involvement. Smokers present at much younger age emphasizing the role of smoking cessation for prevention of myocardial infarction.

Right bundle branch block pattern after uncomplicated right ventricular outflow tract pacing in a patient with a left sided superior vena cava and corrected tetralogy of Fallot

Usually an electrocardiogram after right ventricular (RV) pacing should yield left bundle branch block (LBBB) pattern. However, the presence of right bundle branch block (RBBB) pattern after pacemaker implantation should alert the physician to a malposition of lead. We report a case of 18-year-old female who underwent dual chamber pacemaker implantation and had RBBB pattern post implantation. Detailed evaluation revealed an uncomplicated right ventricular outflow tract pacing. The possible causes of this abnormal pattern after an uncomplicated RV pacing are also reviewed.

Tilted ECG - An unusual tilt test response

Tilt testing is a commonly used diagnostic tool to evaluate syncope of undetermined etiology. We hereby describe a twelve year old male child who developed presyncope during provocative head up tilt testing along with ST segment elevation in cardiac monitor during presyncope. Patient underwent repeat head up tilt testing along with holter monitoring which showed a left bundle branch block escape rhythm. Hence development of ST elevation was due to the improper filter application in single lead ECG monitor. This case highlights the importance of filters in electrocardiographic monitoring.

“Innovation, Information Technology and Task Sharing for Management of Burden of Hypertension in India”

Hypertension is a disease of paradoxes. The detection of high blood pressure is very easy but the awareness about hypertension in the population is very low. The disease is easy to treat; still the treatment rates in the population are disappointing. Finally, while there are several potent drugs to control high blood pressure, yet control rates of hypertension are abysmal. High Blood pressure (HBP) is ranked as the third highest attributable risk factor for burden of disease in South Asia. Hypertension is responsible for 57% stroke deaths and 24% coronary artery disease (CAD) deaths in India. A recent systematic review revealed that the prevalence of hypertension in adult Indians is estimated to be 30% (34% in urban and 28% in rural areas). This analysis was based on review of various investigator initiated epidemiological studies from different regions of India and the prevalence rates of hypertension had regional variation. The study also revealed that the overall prevalence of awareness, treatment and control of hypertension was disappointingly low at 25.3%, 25.1% and 10.7% respectively in rural India and 42.0%, 37.6% and 20.2% respectively in urban India. The PURE (Prospective Urban and Rural Epidemiological study) study data also revealed that in low income countries (with large majority of LIC participants coming from India) low educational status was associated with lower rates of awareness, treatment, and control of hypertension. The estimated number of individuals with hypertension is expected to double from 118 million in 2000 to 213.5 million by 2025. The average blood pressure in India has increased in the last two decades, while in most western nations it has shown a decline. A rural community study from Maharastra published in this issue of the journal measured prevalence of hypertension in the population.[8_TD

False positive retroaortic left circumflex coronary artery in a patient with atrial septal defect

DIFF] The prevalence of hypertension detected by recordings on multiple occasions was 21.6% which was same as the prevalence of hypertension detected by blood pressure recording on a single occasion. This prevalencewas similar to that reported in the western rural communities in the systematic review. However, this study highlights that the prevalence of hypertension in these areaswas lower than other populations in the same region with similar population demographics. This reduction is attributed to the community based Comprehensive Rural Health Programme (CRHP) which was launched in this area in 1970 and is a widely acclaimed programme internationally. This is a population based primary health programme and its BP reduction arm focuses on individuals and groups by promoting salt reduction, opportunities for exercise, healthy diet and weight reduction. This study brings into focus the importance of health promotion for reducing the burden of hypertension. The staggering number of individuals with hypertension and other chronic diseases in low resource settings like India calls for innovation in management to mitigate this burden, given the severe limitation of physicians especially in rural settings. One of the measures is to employ task shifting/sharing with use of frontline health workers in the prevention of chronic conditions as in this study. Other initiatives are empowering community workers with guideline based validated decision support system (DSS) on a smart phone/tablet platform and using it to manage hypertension in rural settings under the supervision of physicians. These strategies have been successfully used in communicable diseases. [9_TD

Chapter-04 Left Main Coronary Intervention

DIFF] Some similar interventions are currently ongoing for prevention and treatment of Non-Communicable Diseases (NCDs) in rural settings. A recent trial called SIMCARD Trial[10_TD

Chapter-022 Management of Hypertension in Acute Stroke

DIFF] conducted in villages of Tibet, China and Haryana in India tested the use of community health workers equipped with mobile health technology for blood pressure control. It was a cluster-randomized, controlled trial conducted in 47 villages (27 in China and 20 in India) with an objective to develop and evaluate a simplified cardiovascular management program delivered by health workers with help of smartphone-based electronic DSS among individuals with high cardiovascular risk. They were supported by licensed physicians at * Corresponding author. E-mail address: drambujroy@gmail.com (A. Roy).