Mahesh Bikkina

Acute ST-segment elevation myocardial infarction in young adults: who is at risk?

ObjectiveLess than 10% of patients presenting with acute myocardial infarction (AMI) are young adults. The primary objective of this study was to provide an overview of similarities and dissimilarities among younger and older patients presenting with AMI with the expectation of using the information as an aid in primary and secondary preventions in the future. MethodsFrom the database of 3527 patients with AMI admitted from January 2001 to December 2008, young adults aged 21–40 years (n=43) who were diagnosed with ST-segment elevation myocardial infarction were identified. They were then compared with their older counterparts who were admitted from January 2007 to December 2008 subdivided into age groups of 41–60 (n=86) and 61–80 years (n=51). Data on clinical cardiovascular risk factors, demographic features, and angiographic findings were gathered and analyzed. ResultsOnly 2.58% of ST-segment elevation myocardial infarction patients who were admitted to our hospital over an 8-year period were less than 40 years. Young adults were found to be predominantly male patients (P=0.04) and had positive family history for coronary artery disease (P=0.0005). Diabetes and hypertension were less prevalent in the younger group (P=0.048 and 0.078). Analysis of lipid profile showed comparatively higher total cholesterol, low-density lipoprotein and high-density lipoprotein values in the younger group (⩽P=0.004). Angiographically, youngsters had propensity toward single-vessel involvement (P=0.0001). ConclusionThe risk factor profile and the angiographic involvement differ considerably in the high-risk younger adults and substantiate the need for an aggressive approach directed toward primary and secondary preventions of premature cardiovascular disease.

Percutaneous Coronary Interventions in Nonagenarians: In‐Hospital Mortality and Outcome at One Year Follow‐up

Limited information is available regarding outcome of very elderly patients referred for percutaneous coronary intervention (PCI).

Coronary anomaly and coronary artery fistula as cause of angina pectoris with literature review.

Coronary artery fistulas are rare anomalies of the coronary arteries that may sometimes cause symptoms by shunting blood flow away from the myocardial capillary network. We report the case of a 46-year old lady which shows the right coronary cusp giving rise to left main coronary artery called anomalous origin of a coronary artery (AOCA), and also a fistula between the left coronary artery and pulmonary artery. We describe our diagnostic approach and review the literature on the epidemiology, pathophysiology, the diagnostic modalities, and treatment options.

Rapid Progression of Coronary Atherosclerosis: A Review

Atherosclerosis is chronic disease, the prevalence of which has increased steadily as the population ages. Vascular injury is believed to be critical initiating event in pathogenesis of spontaneous atherosclerosis. Syndrome of accelerated atherosclerosis has been classically described in patients undergoing heart transplantation, coronary artery bypass graft, and percutaneous transluminal coronary angioplasty. In contrast to spontaneous atherosclerosis, denuding endothelial injury followed by thrombus formation and initial predominant smooth muscle cell proliferation is believed to be playing a significant role in accelerated atherosclerosis. There is no universal definition of rapid progression of atherosclerosis. However most studies describing the phenomenon have used the following definition: (i) > or = 10% diameter reduction of at least one preexisting stenosis > or = 50%, (ii) > or = 30% diameter reduction of a preexisting stenosis <50%, and (iii) progression of a lesion to total occlusion within few months. Recent studies have described the role of coronary vasospasm, human immunodeficiency virus, various inflammatory markers, and some genetic mutations as predictors of rapid progression of atherosclerosis. As research in the field of vascular biology continues, more factors are likely to be implicated in the pathogenesis of rapid progression of atherosclerosis.

Percutaneous coronary intervention in nonagenarian: a meta-analysis of observational studies.

Background Developed countries are facing a sustained increase in life expectancy. Along with all social and cultural implications of increase lifespan, very elderly patients are undergoing percutaneous coronary intervention (PCI) with increasing frequency. However, there is limited evidence to guide clinicians in evaluating pros and cons of PCI in this very frail patient population. We, thus, aimed to perform a systematic review and meta-analysis of clinical studies reporting on PCI with stenting in nonagenarians. Methods Studies reporting on five or more nonagenarians undergoing PCI were systematically searched in PubMed (last updated on November 2011). Baseline and clinical characteristics, in-hospital and long-term outcomes were systematically appraised. End points of interest were in-hospital and long-term follow-up incidence of death and Major Adverse Cardiac Events (MACE; i.e. the composite of death from all causes, myocardial infarction or repeat revascularization). Events were pooled with a random-effect model, generating summary estimates of incidence rates [95% confidence intervals (CI)]. Results A total of 10 studies were included, reporting on a total of 575 nonagenarians undergoing PCI with stenting who represented 1.99% (1.34–2.5) of those undergoing revascularization in the cath lab in a mean period of 5 (3–7) years. Twenty-three percent (13–45) of patients presented with STEMI (ST Segment Elevation Myocardial Infarction), 10% (7–12) with cardiogenic shock and in 78% (64–88) of cases a multivessel disease was diagnosed. Meta-analytic pooling of event rates showed an in-hospital death risk of 12.61% (9.71–15.50) with MACE in 16.41% (13.36–19.47). After a follow-up ranging from 6 to 29 months (median 12), the risk of long-term death was 31.00% (17.10–45.52), with MACE in 37.00% (19.56–55.95; all CI 95%). Conclusion Our meta-analysis, pooling the largest cohort ever of nonagenarians undergoing PCI with stents, confirms the feasibility of percutaneous coronary stenting even in this very frail patient subset, despite the expected severe event attrition during follow-up. Thus, nonagenarians with an acceptable risk profile, recent clinical instability and/or disabling symptoms should not be denied the possibility of percutaneous coronary revascularization.

The role of the out-of-operating room anesthesiologist in the care of the cardiac patient.

Modern invasive cardiovascular procedures require patients to be both comfortable and cooperative. In addition, these procedures demand the complete attention of the attending cardiovascular specialist, and, to a large degree, the outcomes of these procedures depend on the amount of focus and concentration the cardiovascular specialist can give to performing the procedure itself. A team approach using the specialized skills of a cardiologist and an anesthesiologist frequently is required to optimize results. This article clearly delineates the procedures cardiologists perform that might involve anesthesiologists. Mutual knowledge, understanding, and respect are fundamental requirements for integration of cardiology and anesthesia services to optimize patient outcomes.

Diagnostic Yield of Echocardiography in Syncope Patients with Normal ECG.

Aim. This study aimed to assess the role of echocardiography as a diagnostic tool in evaluating syncope patients with normal versus abnormal electrocardiogram. Methods. We conducted a retrospective study of 468 patients who were admitted with syncope in 2011 at St. Josephs Regional Medical Center, Paterson, NJ. Hospital records and patient charts, including initial emergency room history and physical, were carefully reviewed. Patients were separated into normal versus abnormal electrocardiogram groups and then further divided as normal versus abnormal echocardiogram groups. Causes of syncope were extrapolated after reviewing all test results and records of consultations. Results. Three hundred twelve of the total patients (68.6%) had normal ECG. Two-thirds of those patients had echocardiograms; 11 patients (5.7%) had abnormal echo results. Of the aforementioned patients, three patients had previous documented history of severe aortic stenosis on prior echocardiograms. The remaining eight had abnormal but nondiagnostic echocardiographic findings. Echocardiography was done in 93 of 147 patients with abnormal ECG (63.2%). Echo was abnormal in 27 patients (29%), and the findings were diagnostic in 6.5% patients. Conclusions. This study demonstrates that echocardiogram was not helpful in establishing a diagnosis of syncope in patients with normal ECG and normal physical examination.

The Prevalence of Peripheral Arterial Disease in HIV Patients

Background: The actual prevalence of Peripheral Arterial Disease (PAD) in Human Immunodeficiency Virus (HIV) infected patients is still unknown. Aim: The aim of our study was to assess the prevalence of PAD using Ankle Brachial Index (ABI) (both rest and exercise) measurement in HIV infected patients with head-to-head comparison with the sex-matched non-HIV controls. Methods: We randomly enrolled total of 214 patients (70 HIV patients and 144 non-HIV controls), from March 2009 to December 2009. The Edinburg Claudication Questionnaire and ABI were used as study tools. Normal ABI was defined as 0.9 to 1.3. Data was analyzed using the Fischer’s Exact Test. Various cardiovascular and infectious risk factors for PAD were also analyzed. Results: Claudication was reported using Edinburgh questionnaire in 28.5% HIV patients as compared to 12.5 % patients in non-HIV group (p value 0.0069). Abnormal ABI suggestive of PAD i.e. ABI 15% absolute drop on exercise was reported in 10% HIV patients as compared to 1.3% in non-HIV group (p value 0.006). Based on multivariate analysis, age, Caucasian race, hypertension, diabetes mellitus, hyperlipidemia, metabolic syndrome and low CD4 count were found to be independent predictors of PAD. Conclusions: The prevalence of PAD is higher in HIV patients as compared to sex-matched non-HIV controls. Hence, HIV patients should be routinely screened for PAD using rest and exercise ABI. Apart from correlation with cardiovascular risk factors, strong association between lower CD4 cell count and abnormal ABI exists. This warrants more aggressive approach in managing cardiovascular and infectious markers in HIV patients with abnormal ABI.

Quadricuspid Aortic Valve: A Rare Congenital Cause of Aortic Insufficiency

Quadricuspid aortic valve (QAV) is a rare congenital cardiac anomaly causing aortic regurgitation usually in the fifth to sixth decade of life. Earlier, the diagnosis was mostly during postmortem or intraoperative, but now with the advent of better imaging techniques such as transthoracic echocardiography, transesophageal echocardiography (TEE), and cardiac magnetic resonance imaging, more cases are being diagnosed in asymptomatic patients. We present a case of a 39-year-old male who was found to have QAV, with the help of TEE, while undergoing evaluation for a diastolic murmur. The patient was found to have Type B QAV with moderate aortic regurgitation. We also present a brief review of classification, pathophysiology, and embryological basis of this rare congenital anomaly. The importance of diagnosing QAV lies in the fact that majority of these patients will require surgery for aortic regurgitation and close follow-up so that aortic valve replacement/repair is done before the left ventricular decompensation occurs.

Platelet reactivity unit in predicting risk of bleeding in patients undergoing coronary artery bypass graft surgery

Bleeding is a common complication of cardiac surgery, accounting for a significant proportion of the total transfusions performed in the United States and Europe. The relationship between platelet reactivity, bleeding, and other adverse events after coronary artery bypass graft surgery (CABGS) has been incompletely characterized. This study investigated the relationship between platelet reactivity and bleeding as a clinical outcome after successful CABGS. A total of 238 patients who underwent CABGS were retrospectively followed for postoperative bleeding. Platelet reactivity unit (PRU) values for all patients were obtained preoperatively to assess the platelet reactivity. The data showed that a range of 180–200 PRU suggests the likelihood of bleeding after CABGS (P = 0.004), with a statistically significant association only for dual antiplatelet therapy with aspirin and clopidogrel. In conclusion, by using PRU values as a method to assess platelet reactivity and antiplatelet responsiveness, our findings suggest that it may be possible to stratify patients undergoing CABGS for the risk of postoperative bleeding particularly patients on dual antiplatelet therapy.