Arvind Kandoria

Myocardial infarction in young adults-risk factors and pattern of coronary artery involvement

Background: Coronary artery disease (CAD) mostly occurs in persons older than 45 years of age. In India, CAD manifests almost a decade earlier than in Western countries. This study was done to study the risk factors and angiographic profile in young patients presenting with acute myocardial infarction (AMI). Patients and Methods: One hundred and twenty four consecutive patients presenting with AMI at less than 40 years of age were studied for risk factors. Coronary angiography was done in all. Results: Out of 124 patients, 123 were male. Mean age was 35.94 ± yrs. One hundred and eighteen had ST elevation myocardial infarction (MI) (95.16%) and six had non ST elevation MI (5.84%). Anterior wall MI was present in 88 patients (70.97%), inferior wall MI in 31 patients (25%) and lateral wall MI in five patients (4.03%). Seventy three patients (58.8%) were smoker, 55 were hypertensive (44.35%), 10 were diabetic (8.06%). Family history of CAD was present in 22 (17.7%) patients. Low High-density lipoprotein (HDL) was seen in 53 patients (42.7%), and high triglycerides in 60 patients (48.38%). Significant CAD was found in 88 (70.96%) patients, 13 (10.48%) had normal coronaries. Single vessel disease was seen in 57 patients, two-vessel disease in 15 patients and three-vessel disease in eight patients. Total 125 lesions were seen and left anterior descending (LAD) was the commonest vessel involved, with 78 lesions (62.4%). Conclusion: AMI in young almost exclusively occurs in male, and ST elevation MI is the main presentation. Anterior wall MI is most common, with LAD being involved in around 2/3 patients. Smoking, hypertension, low HDL and high triglycerides are the major risk factors.

Epidemiological Study of Chronic Mountain Sickness in Natives of Spiti Valley in the Greater Himalayas

AIMS This study determined the prevalence of chronic mountain sickness (CMS) and its predisposing factors among natives of Spiti Valley in the northern state of Indian Himalayas. A cross-sectional survey study was conducted in natives of Spiti Valley aged ≥ 20 years residing at altitudes of 3000 to 4200 meters. CMS was diagnosed using Qinghai criteria. Demographics, behavioral characteristics, specified symptoms of CMS were recorded, including BP, anthropometrics, evidence of RHF, PAH, and severe cyanosis. ECG, echocardiography, PFT, and Sao2 were recorded, and Hb level was estimated with the cyanmethhemoglobin method. RESULTS 694 subjects free of cardiorespiratory diseases were analyzed. Prevalence of CMS was 28.7%, (95% C.I. of 25.9%-32.8%) and was higher in women than in men (36.6% vs. 15.7%, p<0.001). Erythrocythemia and hypoxemia were recorded in 10.5% and 7.5%, respectively. Age, truncal obesity, female gender, altitude of residence, and physical activity index were independent predictors of CMS with z statistics of 4.2, 2.29, -3.7, 2.8, and -2.8, respectively, and were statistically significant p<0.001. 6.2% of the surveyed population had HAPH. CONCLUSION 28.7% (95% C.I. of 25.9%-32.8%) of the natives of the Spiti Valley in the Indian Himalayas are affected with CMS. Higher prevalence of CMS amongst women needs further studies. Westernized lifestyle appears to have predisposition to CMS.

Prevalence of High Altitude Pulmonary Hypertension Among the Natives of Spiti Valley—A High Altitude Region in Himachal Pradesh, India

The study aimed to determine the prevalence of high altitude pulmonary hypertension (HAPH) and its predisposing factors among natives of Spiti Valley. A cross-sectional survey study was done on the permanent natives of Spiti Valley residing at an altitude of 3000 m to 4200 m. Demographic characteristics, health behavior, anthropometrics, and blood pressure were recorded. Investigations included recording of 12 lead electrocardiogram (ECG), SaO2 with pulse oximeter, spirometry and echocardiography study, and measurement of Hb levels using the cynmethhemoglobin method. HAPH was diagnosed using criteria; tricuspid regurgitation (TR) gradient of ≥46 mmHg. ECG evidence of RV overload on 12 lead ECG was documented based on presence of 2 out of 3 criteria; R>S in V1, right axis deviation or RV strain, T wave inversion in V1 and V2. Data of 1087 subjects were analyzed who were free of cardiorespiratory diseases to determine the prevalence of HAPH and its predisposing factors. HAPH was recorded in 3.23% (95% C.I. of 0.9-8.1%) and ECG evidence of right ventricular (RV) overload was 1.5% in the study population. Prevalence of HAPH was not different in men and women 2.63% vs. 3.54% p<0.2. Age (Z statistics of 3.4 p<0.0006), hypoxemia (Z statistics of 2.9 p<0.002), and erythrocythemia (Z statistics of 4.7 p<0.003) were independently associated with HAPH. Altitude of residence was not found to be significantly associated with HAPH, although there was a trend of increasing prevalence with increasing altitude. It can be concluded that HAPH is prevalent in 3.23% of natives of Spiti Valley. Increasing age, erythrocythemia and hypoxemia are independent predisposing factors.

Prevalence of congenital heart disease in rural population of Himachal – A population-based study

Aim There is no community-based study about the prevalence of congenital heart disease (CHD) in Himachal; hence, we undertook this study. Methods and results A population-based survey was done in four villages of different districts of Himachal Pradesh. In total, 1882 persons were examined. 909 were male and 973 were female. There were 12 cases of CHD in the population (6.3/1000): four of these were male (33.3%) and 8 were female (66.6%). Mean age of these patients was 19.5 ± 11.07 years. Atrial septal defect (ASD) was the commonest lesion followed by ventricular septal defect (VSD). Conclusion Prevalence of CHD in general population was 6.3/1000. ASD was the commonest lesion. CHD was more common in female.

Bronchial Artery Embolization for Moderate to Massive Hemoptysis

Purpose of study: Hemoptysis is a common emergency coming to the pulmonary medicine and general Medicine department. Massive hemoptysis has high mortality even after surgical treatment. Bronchial artery embolization is an effective alternative to surgery for controlling hemoptysis, with high success rate.

A constellation of cardiac anomalies: Beyond shone's complex

Shones anomaly is a very rare congenital cardiac malformation characterized by four serial obstructive lesions of the left side of the heart (i) Supravalvular mitral membrane (ii) parachute mitral valve (iii) muscular or membranous subaortic stenosis and (iv) coarctation of aorta. We report a unique presentation of Shones complex in a 14-year-old adolescent male. In addition to the four characteristic lesions the patient had bicuspid aortic valve, aneurysm of sinus of valsalva, patent ductus arteriosus, ventricular septal defect, persistent left superior vena cava opening into coronary sinus and severe pulmonary artery hypertension. This case report highlights the importance of a strong clinical suspicion of the coexistence of multiple congenital cardiac anomalies in Shones complex and the significance of a careful comprehensive echocardiography.

Aneurysm of an anomalous splenic artery arising from splenomesentric trunk: a rare presentation

A 30-year-old man presented with recurrent episodes of abdominal pain. Ultrasound revealed an aneurysm of the aberrant splenic artery. A CT scan showed a 32×26 mm saccular aneurysm just 3 mm after the origin of the splenic artery from the superior mesenteric artery (SMA) (figure 1). Absence of focal arterial disruption, perivascular inflammation and an irregular aneurysmal wall ruled out pseudo-aneurysm. Detailed work-up for pancreatitis, vasculitis, collagen vascular disease and infection was negative. There was no history of trauma. A selective angiogram was performed for consideration of endovascular intervention (figure 2 and video 1). On selective angiogram of the celiac artery, …

Prevalence, risk determinants and consequences of atrial fibrillation in rheumatic heart disease: 6 years hospital based-Himachal Pradesh- Rheumatic Fever/Rheumatic Heart Disease (HP-RF/RHD) Registry

Objective To report the prevalence, risk factors and consequences of atrial fibrillation (AF) in patients of rheumatic heart disease (RHD). Methods The Himachal Pradesh- Rheumatic Fever/Rheumatic Heart Disease (HP-RF/RHD) Registry database of 1918 patients was analyzed. AF was diagnosed with 12-lead ECG recording at entry in to the registry. The association of AF with nature and severity of valvular dysfunction was analyzed, adjusted for age, left atrial (LA) dimension and pulmonary arterial hypertension using multivariable logistic regression model and strength of association was reported as odds ratio (OR) with 95% confidence intervals (C. I.). Results The study population consisted of young (40.2 ± 14.3 years), predominantly females (72.3%) from rural area (94.1%). Prevalence of AF was 23.9% (95% C. I. 22.1%–25.8%). The independent determinants AF were age (OR 1.04, 95% C.I. 1.03–1.06), LA size (OR 1.10, 95% C.I. 1.08–1.11). The association of AF with age, New York Heart Association functional class, mitral stenosis severity and tricuspid regurgitation was statistically significant and graded. Mitral regurgitation and aortic valve disease had no significant independent association with AF. The prevalence of heart failure, stroke, peripheral embolism and mortality was significantly higher among patients with AF (p < .01). Conclusion AF is common in RHD patients and is significantly associated with heart failure and systemic thromboembolism. Age, mitral stenosis severity, tricuspid regurgitation and LA size were independently associated with AF.

Acute renal artery embolisation: role of local catheter-based intra-arterial thrombolysis

A 45-year-old man without previous comorbidity presented to us with acute onset right-sided flank pain for last 14 hours. His general physical and systemic examination was unremarkable, and there were no clinical signs of peritonitis. The ultrasonography did not reveal any evidence of nephrolithiasis or hydronephrosis. His contrast-enhanced CT scan revealed hypoattenuated areas of right kidney and evidence of right renal artery thrombosis. He was immediately shifted to cardiac catheterisation lab, and his renal angiography showed thrombotic occlusion of right renal artery. The bolus dose of streptokinase (250 000 IU) was given locally in renal artery by right judkins catheter followed by systemic infusion of streptokinase (100 000 IU/hour) for 24 hours. After that he was started on low molecular weight heparin. Repeat renal angiography done after 5 days showed completely normal right renal artery. His cardiac and thrombophilia work up was negative, and he was discharged on antiplatelets, oral anticoagulants and statins.

Right paratracheal mass on chest X-ray: an important part of the checklist before cardiac catheterisation.

Infrahepatic inferior vena cava (IVC) interruption with azygos continuation is a rare congenital anomaly with a prevalence of 0.6–2.0% in patients with congenital heart disease.1 Many of these patients are expected to undergo cardiac catheterisation through the femoral vein. For this, the catheter must pass up the IVC to the azygos vein and then down into the superior vena cava (SVC), making the procedure technically more difficult. A 19-year-old male patient with patent ductus arteriosus with severe pulmonary arterial hypertension was subjected to cardiac catheterisation to test the reactivity of the pulmonary vascular bed. Chest X-ray revealed a smooth mass at the right tracheobronchial angle (figure 1). During right heart catheterisation, there was difficulty in …