Kunal Mahajan

Gender differences in the management of acute coronary syndrome patients: One year results from HPIAR (HP-India ACS Registry)

INTRODUCTION Data from high-income countries suggest that women receive less intensive diagnostic and therapeutic management than men for acute coronary syndrome (ACS). There is a paucity of such data in the Indian population, which is 69% rural and prior studies focused mostly on urban populations. The objective of the present study was to identify the gender based differences in ACS management, if any, in a predominantly rural population. METHODS Data from 35 hospitals across Himachal Pradesh covering >90% of state population were collected for one year (July 2015-June 2016). A total of 2118 ACS subjects met inclusion criteria and baseline characteristics, in-hospital treatments and mortality rates were analyzed. RESULTS Women constituted less than one-third of ACS population. Women were older compared to men and were more likely to present with NSTEMI/UA. Misinterpretation of initial symptoms and late presentation were also common in women. Fewer women received optimal guideline based treatment and PCI (0.9% vs 4.2%, p<0.01). Compare to men, women more often had Killip class >1 (27.3% vs 20.4%, p<0.01) and higher in-hospital mortality (8.5% vs 5.6%, p=0.009). On multivariate analysis the association between female gender and mortality was attenuated (adjusted odds ratio [OR]=1.36 [0.77-2.38]). CONCLUSION The present study from India, is the first of its kind to evaluate the gender based differences among ACS patients, in a predominantly rural population. Our analysis demonstrates a significant gender based difference between symptom awareness and delay in presentation, management and in-hospital outcome. Further studies are warranted across other parts of country to investigate this gender disparity.

Comparison of Risk Factor Profile and Angiographic Pattern AmongPre-Menopausal and Post-Menopausal Women Presenting with Angina:Results from a Prospective Single Center Observational Study

Background: Coronary artery disease (CAD) has become the major killer in women. The exact mechanism of postmenopausal increase in CAD is still under research. Limited data exists on the comparison of risk factor profiles and angiographic disease patterns in premenopausal and postmenopausal women. Methods: This prospective study included a total of 674 consecutive female patients who underwent coronary angiogram for suspected ischemic heart disease over a period of 2 years from March 2015. Detailed risk factor profiles and angiographic patterns of disease were recorded and analyzed using EPIINFO statistical software. Results: Out of total 674 patients, 137(20.3%) were in the premenopausal group with mean age of (42.05 ± 4.40) years, and 537(79.7%) in the postmenopausal group with mean age of (59.05 ± 8.01) years. Premenopausal women were more likely to be obese (57.7% vs 46.9%, p=0.0), hypothyroid (23.4% vs 10.2%, p 3 risk factors more frequently (42.1% vs 30.7%, p=0.009). Atypical chest pain was more common as presenting diagnosis among premenopausal women (23.4% vs 10.2%, p<0.0001). They were also more likely to have positive exercise stress test (62.1% vs 38.3%, p<0.0001) and normal coronary angiogram (59.9% vs 32%, p<0.0002) with endothelial dysfunction (84.7% vs 66.8%, p<0.0001) than post-menopausal women. Post-menopausal women had greater burden of obstructive CAD characterized by more prevalent multivessel disease in the form of double vessel (17.5% vs 8%, p=0.06) and triple vessel disease (20.5% vs 5.8%, p<0.0002). Conclusion: There is a distinct difference between the risk factor profile and angiographic disease pattern among women according to the status of menopause. Recognition of these differences would help in better understanding of relationship of menopause to development of CAD.

Infravalvular type of Gerbode defect: a rare cardiac anomaly

A Gerbode defect is a rare type of ventricular septal defect (VSD), classically described as a direct communication between left ventricle (LV) and right atrium (RA).1 However, it may be supravalvular (direct shunt), infravalvular (indirect shunt) or mixed. The infravalvular type is a VSD with a left-to-right shunt at the ventricular level, associated with tricuspid regurgitation (TR), which directs the high-velocity shunt into RA.2 ,3 A 43-year-old woman presented with symptoms of dyspnoea and palpitations. Clinical examination revealed a pansystolic murmur and grade 2 parasternal heave. ECG depicted biventricular hypertrophy along with biatrial enlargement. Echocardiogram showed a 9 mm perimembranous VSD with left-to-right shunt (figure 1). Careful observation revealed two …

Inferior wall STEMI presenting with a ruptured intraseptal pseudoaneurysm

A 78-year-old man presented with progressively increasing dyspnoea, 2 weeks after experiencing ST elevation inferior wall myocardial infarction that was not thrombolysed because of late presentation. He was Killip class 2 with raised jugular venous pressure. Cardiac auscultation revealed a grade 4 harsh systolic murmur in the lower left parasternal area, and a loud S2 with a prominent right ventricular S3. Echocardiography demonstrated akinetic and thinned out basal inferior and basal inferior septal segments (video 1). A pseudoaneurysm extending from the inferior septum was noticed (video 1 and figure 1A), which was thin walled and had a relatively narrow entrance, with a shelf-like overhanging edge (figure 2). Colour flow signals demonstrated marked turbulence of blood flow from the cavity of the left ventricle (LV) into the pseudoaneurysm and then into the right ventricular cavity, confirming rupture into the right ventricle (RV) (figures 1B and 3). An emergent cardiac MRI confirmed …

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, …

Hypercholesterolaemic valvulopathy in a young woman with heterozygous familial hypercholesterolaemia

A 19-year-old woman presented with dyspnoea, angina and exertional syncope for the past 1 year. She had an ejection systolic murmur in the aortic area radiating to the carotids. She had multiple skin xanthomas over her feet, knees, hands and buttocks (figure 1). Echocardiography revealed severe calcific aortic stenosis (figure 2). Her serum low-density lipoprotein (LDL) was 391 mg/dL, while triglycerides were normal. Her father and brother also had very high LDL levels and a few xanthomas but no features of aortic stenosis. Her mother and two sisters had normal LDL levels. …

Successful device closure of a ruptured sinus of Valsalva aneurysm presenting with acute heart failure

A sinus of Valsalva aneurysm (SVA) is an uncommon cardiac anomaly that can be congenital or acquired. SVAs were present in 0.09% of cadavers in a large autopsy series and ranged between 0.14–0.23% in a Western surgical series.1 A congenital SVA is usually clinically silent but may vary from a mild, asymptomatic dilation detected in routine two-dimensional echocardiography, to symptomatic presentations related to the compression of adjacent structures or intracardiac shunting caused by rupture of the SVA into the right side of the heart. Approximately 65–85% of SVAs originate from the right sinus of Valsalva, while SVAs originating from non-coronary (10–30%) and left sinuses (<5%) are exceedingly rare. The most common …

Lantern on Dome of St. Paul’s – A Huge Cervical Fibroid

A 30-year-old woman, with an obstetrics history of gravid 3 para 2, last child birth by classical caesarean section, complained of history of retention of urine twice in past 3 months along with menorrhagia. The patient was told to have lower segment leiomyoma located on the lower segment when caesarean section was performed 3 years back. She subsequently was lost to follow up till she become symptomatic for her disease. Bimanual examination revealed a solid mass extending till umbilicus. Abdominopelvic examination revealed a huge myoma filling and enlarging the cervix. Ultrasonography showed a 28 × 15 cm myoma in the cervical region and bilateral hydrourteronephrosis.

SheehanâÂÂs Syndrome: A Rare but Potentially Life-Threatening Complication of Postpartum Haemorrhage

Sheehan’s syndrome (SS), also known as postpartum pituitary gland necrosis, is a rare but potentially life-threatening complication of postpartum haemorrhage. The diagnosis of Sheehan’s syndrome is based on the features of hormone deficiency, a suggestive obstetric history and decreased levels of basal hormones. Diagnosis of pan-hypopituitarism is straightforward, but partial deficiencies are often difficult to elicit. SS is a frequent cause of hypopituitarism in underdeveloped countries. The clinical features of hypopituitarism are often subtle, and years may pass before the diagnosis is made following the inciting delivery. History of postpartum haemorrhage, failure to lactate and cessation of menses are important clues to the diagnosis.

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.