Monika Bhandari

A comparative study of tirofiban plus enoxaparin versus enoxaparin alone along with dual antiplatelet blockade in the management of patients with non-ST elevation acute coronary syndrome

Introduction: Antithrombotic therapy in patients with non-ST elevation acute coronary syndrome (NSTE-ACS) includes dual antiplatelet therapy (DAPT) along with enoxaparin. However, resistance to antiplatelet action of aspirin and clopidogrel is well known and is about 27% (0-57%) and 30%, respectively. Hence the use of GPIIb/IIIa inhibitor appears to be a reasonable option as they act on the final common pathway of platelet aggregation. Though frequently used in patients undergoing percutaneous intervention (PC1), their use in patients not undergoing such procedure is not popular despite evidence in literature. Materials and Methods: This study was done on 44 patients of NSTE-ACS managed conservatively. The patients were randomized in a 1:1 fashion in two groups. The patients in group 1 received tirofiban(0.4μg/kg/min i.v for 30 min followed by 0.1μg/kg/min for 48 hours) in addition to aspirin (325 mg stat followed by 75 mg P.O. daily), clopidogrel (300 mg stat followed by 75 mg P.O. daily) and enoxaparin (1 mg/kg S.C bid for 5 days). The group 2 patients received DAPT and enoxaparin only, in similar doses. Both the groups received antianginal therapy as appropriate and statins. Results: The study showed the benefits of adding tirofiban to enoxaparin and DAPT irrespective of age, sex, presence or absence of diabetes and dyslipidemia, ECG changes, troponin positivity and TIMI score in patients with NSTE-ACS. There was a significant reduction {Risk reduction (RR) of 45.4% P <0.01} in composite of primary end points refractory ischemia myocardial infarction (MI) and death with Tirofiban. No major or minor bleeding episodes were seen in any patients. Conclusion: Thus, we conclude that tirofiban in addition to DAPT and enoxaparin reduces the risk of refractory ischemia, MI and death in patients with NSTE-ACS without any additional risk of major or minor bleeding. Therefore, we advocate this regimen in patients with NSTE-ACS managed conservatively. Large randomized study is needed to recommend this regimen.

Pulmonary vein compression by paravertebral abscess: An atypical presentation of tuberculosis

Tuberculosis is a common disease in developing countries. It can cause dyspnea due to primary involvement of lungs with pulmonary Koch′s, but one of the uncommon presentations may be solely due to compression of pulmonary veins (PVs) and/or left atrium resulting in exertional dyspnea resembling cardiac disease. Though there are case reports of lung metastasis, pulmonary artery aneurysm and left atrial myxoma causing PV compression, in literature PV compression due to cold abscess is extremely rare. Here, we report a case of paravertebral cold abscess causing symptoms effectively due to PV compression who got cured with anti-tubercular therapy.

A rare form of presentation of truncus arteriosus in adult

Truncus arteriosus is a rare congenital heart disease with average survival up to 5 weeks, and unrepaired truncus cases surviving into adulthood are very few. For these reasons, the natural history of the unrepaired defect is not very well-known, and is backed by only a handful of such cases that are reported. We report this very rare case of adult survival of an uncorrected truncus arteriosus, with certain aspects of presentation unique and insightful with regards to its natural history.

Infective endarteritis in a case of supravalvular aortic stenosis

Supravalvular aortic stenosis is the rarest form of congenital left ventricular outflow tract obstruction. It can be associated with Williams syndrome or it may be an isolated anomaly. Although infective endocarditis is common in valvular aortic stenosis, in supravalvular aortic stenosis infective endocarditis/endarteritis is rarely reported. We report a case of infective endarteritis in a case of supravalvular aortic stenosis due to resistant enterococci, causing prolonged fever. Blood culture-directed antibiotic therapy cured the infection. <Learning objective: Infective endarteritis in supravalvular aortic stenosis is a rarely reported but treatable entity. Although it may respond to empirical antibiotics, occasionally some resistant organism, causing infective endarteritis, may not respond to empirical therapy. Multiple blood culture with culture-directed antibiotic administration may be lifesaving, as in our index case.>.

Infantile presentation and rapid progression of coarctation of aorta in a case of Williams syndrome

Williams syndrome is a multisystem disorder caused by the deletion of multiple genes on chromosome 7. Many patients are identified through presence of dysmorphic features and associated cardiac abnormalities. Cardiovascular abnormalities in Williams syndrome is characterized by presence of supravalvular aortic stenosis which is most common followed by pulmonary artery stenosis, mitral valve prolapse, aortic hypoplasia, coarctation of aorta, and septal defects. Usually, these obstructive lesions are mild and do not present in infancy and progress slowly. If severe in infantile age-group, they often require surgery. We are reporting a case of Williams syndrome who presented with heart failure demonstrating supravalvular aortic stenosis (a common feature of Williams syndrome) and rapidly progressive coarctation of aorta with refractory symptoms.