Kiron Varghese

Intra-aortic balloon pump in toxic myocarditis due to aluminum phosphide poisoning.

IntroductionAluminum phosphide (ALP) is a pesticide that is highly toxic. It is a mitochondrial toxin that causes death by cardiac and metabolic toxicity. The most ominous effect is cardiac toxicity, which may range from minor electrocardiographic abnormalities to severe depression of cardiac contractility secondary to toxic myocarditis. There is no documented report of the use of Intra-aortic Balloon Pump (IABP) for toxic myocarditis from ALP poisoning, although it has been used effectively for toxic myocarditis due to other toxins.Case ReportWe are reporting a young female who presented with ALP poisoning, in cardiogenic shock due to myocarditis. We used an IABP for cardio-circulatory support until the effects of ALP resolved. She is the only reported survivor of ALP poisoning, presenting with cardiogenic shock.DiscussionSeveral reports describe the use of IABP for cardiogenic shock due to toxic myocarditis. There is no report in the medical literature using IABP for cardiogenic shock caused by ALP toxin-induced myocarditis. Our patient presented with cardio-circulatory shock, necessitating the use of inotropes and mechanical ventilation. As she did not improve despite ventilation and maximal doses of inotropes, IABP was used for cardio-circulatory support until the effects of ALP resolved.

Management of statin intolerance.

Statins are the revolutionary drugs in the cardiovascular pharmacotherapy. But they also possess several adverse effects like myopathy with elevation of hepatic transaminases (>3 times the upper limit of normal) or creatine kinase (>10 times the upper limit of normal) and some rare side-effects, including peripheral neuropathy, memory loss, sleep disturbances, and erectile dysfunction. Due to these adverse effects, patients abruptly withdrew statins without consulting physicians. This abrupt discontinuation of statins is termed as statin intolerance. Statin-induced myopathy constitutes two third of all side-effects from statins and is the primary reason for statin intolerance. Though statin intolerance has considerably impacted cardiovascular outcomes in the high-risk patients, it has been well effectively managed by prescribing statins either as alternate-day or once weekly dosage regimen, as combination therapy with a non-statin therapy or and by dietary intervention. The present article reviews the causes, clinical implications of statin withdrawal and management of statin intolerance.

A look into Lee's score: peri-operative cardiovascular risk assessment in non-cardiac surgeries-usefulness of revised cardiac risk index.

OBJECTIVE The revised cardiac risk index (RCRI/Lees score) was designed for peri-operative risk assessment before elective major non-cardiac surgeries. Through this article, we report the usefulness of RCRI in our daily practice, while evaluating patients undergoing surgeries of varying risk. METHODS Only referred patients, aged ≥ 40 years, were included. Risk stratification was done using RCRI scoring system. Patients were categorised into 4 classes depending on 0, 1, 2, and ≥3 risk predictors (risk predictors were high-risk surgery, history of ischaemic heart disease (IHD), diabetes on insulin, history of stroke (cerebrovascular accident [CVA]), history of congestive heart failure (CHF) and serum creatinine of >2 mg%). Electrocardiograms (ECG) were done in all patients, while troponin I in intermediate and high-risk patients, and in others if symptomatic. Perioperative cardiovascular events were managed appropriately. RESULTS Of the 920 patients included, only 853 patients were analysed as 67 patients were not operated upon. The mean age was 59 ± 11years and 46% of the patients were women. Two hundred and ninety-two underwent high-risk surgeries, 97 patients had history of IHD, 89 had history of CHF, 36 gave history of CVA, 269 patients were diabetics on insulin and 68 had serum creatinine >2 mg%. Number of patients in Lees classes I, II, III, and IV were 311, 347, 150, and 52, respectively. 26 out of 853 patients had peri-operative events. Of the six variables in RCRI, only history of IHD was an independent predictor of events. Event rates increased as the RCRI class increased, i.e. 1.7%, 2.0%, 6.7%, and 7.7% for classes I-IV, respectively. Age >70 years, poor general medical condition, emergency surgery and left bundle branch block (LBBB) on ECG, were significantly associated with peri-operative events. CONCLUSION The RCRI is a useful tool in pre-operative risk stratification. It should perhaps be further updated to improve its predictive accuracy.

Visceral adiposity in young patients with coronary artery disease—a case control study

AIMS Central obesity is associated with an increased cardiovascular risk. We carried out a hospital based case control study in young patients with coronary artery disease (CAD) to assess the importance of visceral fat METHODS Coronary artery disease was established by coronary angiogram in all cases. Controls were age- and sex-matched subjects with normal coronary angiogram. Computed tomography scan performed at the level of the umbilicus to measure subcutaneous and visceral fat area (VFA). RESULTS Cases and controls were well matched in height, weight, and body mass index (BMI). Visceral fat area was significantly higher (122.58 ± 37.59 vs. 88.4 ± 36.95 cm(2); P=0.003) in cases whereas subcutaneous fat area was similar in cases and controls. Visceral fat area was an excellent predictor of cardiovascular risk (area under receiver operating characteristics curve 0.915 cm(2)). Visceral fat area correlated with BMI, waist hip ratio, blood sugar, triglycerides, and C-reactive protein significantly. CONCLUSION Visceral adiposity is associated with an increased risk of CAD and it correlated with anthropometric, metabolic, and inflammatory markers.

Syphilitic Aortitis: An Uncommon Cause of Acquired Aortopulmonary Fistula

Cardiovascular syphilis has become a medical curiosity with the advent of widespread use of penicillin for the treatment of early syphilis. We report a case of a 37-year-old man who presented with sudden onset breathlessness that worsened insidiously for 1 year. Diagnosis of syphilitic aortopulmonary fistula was confirmed by aortography, contrast computed tomography, and histopathology. The patient underwent successful surgical correction. A high level of suspicion and awareness is needed for the diagnosis of this now rare disease. This entity is only amenable to surgical correction, even as existing surgical techniques need constant improvisation and individualization to each patient.

Validation of the GRACE score for prognosis in Indian patients with acute coronary syndromes

AIM To validate the global registry of acute coronary events (GRACE) score in acute coronary syndromes (ACS) patients and study its angiographic correlation. METHODS AND RESULTS Two-hundred and thirty-five ACS patients were studied for the combined endpoint of all-cause in-hospital mortality and non-fatal infarction/reinfarction. We tested the predictive accuracy of the composite GRACE score using the receiver operating characteristics (ROC) curve. Lower systolic blood pressure (SBP) (odds ratio [OR] 7.93, P=0.005), ST-segment deviation (OR 7.79, P=0.02) and cardiac biomarker positivity (OR > 6.52, P=0.01) were significantly associated with events. Serum creatinine > 1.4 mg/dL showed a trend towards statistical significance (OR 4.14, P=0.05), whereas age > 50 years (OR 3.62, P=not significant [NS]) and Killips class 4 (OR 2.71, P=NS) showed good association. The best value for predicting events was a GRACE score of > 217 and these patients were more likely to have double/triple vessel disease (P = 0.0009). The C statistic for the GRACE score was 0.75. CONCLUSION Higher GRACE score predicts in-hospital events and more severe angiographic coronary artery disease (CAD).

An unusual etiology of recurrent cerebral abscesses—a report of 3 cases

BACKGROUND Cerebral abscess commonly occurs secondary to trauma, hematogenous spread from distant infection, or otitis media. Pulmonary AVF is an uncommon cause of recurrent cerebral abscess and is often overlooked. We report 3 cases of cerebral abscesses secondary to pulmonary AVF. CASE DESCRIPTION A 20-year-old man who presented with fever, headache, and vomiting of short duration was diagnosed as having right parietal abscess and underwent burr hole and tapping and antibiotic treatment. He later presented with many episodes of cerebral abscess at various locations involving both sides and required multiple surgical procedures. The routine workup for the source did not reveal any etiology. His hematological examination revealed polycythemia. A pulmonary angiogram was performed, which revealed pulmonary AVF. He underwent embolization of the fistula and had no further recurrence. Two other adult men were treated surgically for cerebral abscess. One patient had polycythemia and hypoxemia, and another had clubbing. Both patients were investigated with CT of the chest and were diagnosed as having pulmonary AVF. None of them had features of HHT. CONCLUSIONS Pulmonary AVF is an unusual cause of cerebral abscess. Patients with multiple recurrences of cerebral abscess, signs of pulmonary disease, and hypoxia should be investigated for pulmonary AVF.

The association of severity of retinal vascular changes and cardiac remodelling in systemic hypertension

Objectives: The aim of the study was to explore the association between hypertensive retinopathy, grades of retinopathy and cardiac remodelling. Methods: This was a cross-sectional observational study. A total of 500 consecutive hypertensive adults from the in-patient population were studied for the presence of hypertensive retinopathy by dilated fundoscopy. The presence of cardiac remodelling due to hypertension was studied both by electrocardiography (ECG) and echocardiography. Hypertensive target organ damage in other organs was also screened. In addition, the association of grades of hypertensive retinopathy with target organ damage was also analyzed. Results: Systolic blood pressure (BP) at presentation and duration of hypertension showed no relationship with markers of hypertensive heart disease. However, diastolic BP was significantly higher in patients with retinopathy. Hypertensive retinopathy was diagnosed in 324 subjects of whom 90 had grades 3 and 4 retinopathy. Patients with grades 3 and 4 retinopathy had significant associations with ECG evidence of left ventricular (LV) strain pattern and left atrial enlargement, and a weaker association with left ventricular hypertrophy (LVH) using QRS voltage criteria (Sokolov–Lyon). On echocardiography, grades 3 and 4 retinopathy were significantly associated with LVH, left atrial enlargement and reduced left ventricular ejection fraction (LVEF), as well as with higher creatinine values. A large number of these patients presented with heart failure. Cardiac remodelling was not seen in patients without retinopathy and was uncommon in patients with grades 1 and 2 retinopathy. Conclusion: Grades 3 and 4 retinopathy demonstrated a significant association with LV strain pattern and left atrial enlargement on ECG, LVH and reduced LVEF on echocardiography as well as with heart failure. There was no relationship with systolic BP and duration of hypertension, while diastolic BP showed a significant positive correlation. Signs of hypertensive heart disease were practically absent in patients without hypertensive retinopathy and uncommon in those with grade 1–2 alterations.

Two heart failure phenotypes in arterial hypertension: a clinical study

Arterial hypertension is the most prevalent comorbidity in Heart Failure with Preserved Ejection Fraction (HFpEF) [1]. The new HFpEF paradigm proposed has shifted emphasis to endothelial alterations, which lower myocardial Nitric Oxide bioavailability and removes the brake on prohypertrophic stimuli triggered by myocardial afterload excess. The development of HFpEF has been linked to microvascular involvement of the coronary vascular bed [2, 3]. In arterial hypertension it has long been recognized that retinal vascular changes parallel the associated end-organ damage, mainly the “hypertensive cardiomyopathy” or the concentric left ventricular hypertrophy due to chronic afterload. Retinal arteriolar narrowing, is seen to correlate strongly with the severity of coronary artery lesions and reduced myocardial perfusion indices on cardiac MRI [4]. The main objectives of this study were twofold: firstly, to compare the clinical picture of the two “phenotypes” of heart failure (preserved or reduced ejection fraction) that occur in patients with arterial hypertension, and second, to evaluate if retinal vascular alterations of hypertensive patients with HfpEF differ from that of hypertensive patients presenting with HFrEF, taking into account that the assumed pathogenic mechanism of HFpEF consists of a widespread microvascular dysfunction [3]. Out of 500 consecutive hypertensive inpatients from the Cardiology Department of St. John’s Medical College Hospital, Bangalore, India, we studied the patients who presented with symptoms of congestive cardiac failure (HF) and were diagnosed as heart failure on clinical examination as per the ESC guidelines [5]. We did not do the NT proBNP levels in all patients due to logistic constraints. All patients were diagnosed to have essential hypertension as per the Joint National Commission 7 guidelines [6]. All patients were submitted to clinical examination, ECG and Echocardiography, which had been carried out following guideline suggested by European Association of Cardiovascular Imaging [4]. Two groups of patients presenting with heart failure (NYHA class ≥ II) were selected taking into account left ventricular ejection fraction (LVEF). Patients with LVEF> 50% were considered representative of the HFpEF phenotype and those with LVEF< 40% of HFrEF phenotype [7, 8]. These groups were studied from a clinical standpoint (age, sex, hypertension severity and duration, ECG and associated comorbidities). On Echocardiographic examination LV remodeling was characterized as concentric or eccentric LV hypertrophy on the basis of posterior wall thickness to end-diastolic internal diameter ratio (Regional Wall Thickness RWT) [9]. Diastolic dysfunction was diagnosed following standard criteria based on mitral inflow Doppler indices [6]. Associations with other end-organ damage was assessed by evaluating serum creatinine levels, microalbuminuria, and evidence of hypertensive retinopathy [10]. All patients underwent a dilated fundoscopy performed by a staff Ophthalmologist. Hypertensive retinopathy was graded according to the Keith Wagner Barker classification [4]. The study was approved by the Institutional Review Board. All continuous normally distributed data are reported as mean ± SD and as median (quartile1, quartile3) if not normally distributed. Categorical data are reported as n(%). The normal distribution of continuous data was examined using normal Q–Q plots. Continuous data were compared between patients with LVEF> 50% and< 40% using independent sample t-test or non-parametric Mann–Whitney U test. The association with categorical characteristics was examined using Chi-square test. All * Srilakshmi M. Adhyapak srili2881967@yahoo.com

Long-term results of a sirolimus-eluting stent with biodegradable polymer (RAPSTROM™) in de novo coronary stenoses

OBJECTIVES To report long-term results of a novel sirolimus-eluting stent with biodegradable polymer BACKGROUND: Newer generation drug-eluting stents are characterized by thin struts, improved platform design and highly biocompatible polymer carrying the antiproliferative drug. The RapstromTM stent, sharing these features, showed promising outcomes in preclinical models and in a first-in-man trial. METHODS The present study is a multicenter, non-randomized post-market registry, including patients with de novo coronary artery disease treated with implantation of one or more Rapstrom stents. Primary endpoint of the study was the rate of major adverse cardiac events (MACE) at three-year follow-up. RESULTS 1073 patients were enrolled, with a high prevalence of diabetes (35%) and acute coronary syndrome at presentation (82%); at three-year follow up, MACE rate was 14.8%, with a low incidence of definite or probable stent thrombosis (0.75%). CONCLUSIONS These data confirm the good clinical performance of the Rapstrom stent, supporting the concept that the combination of thin struts and biodegradable polymer is associated with positive clinical outcomes.