Mukul Misra

Xanthine oxidase as a marker of myocardial infarction.

In the present communication, we report remarkably elevated levels of xanthine oxidase activity in the blood of the patients with myocardial infarction when compared to age and sex matched healthy persons. Highly significant increase of malondialdehyde, serving as an index of lipid peroxidation and thus free radical mediated damage, has also been found in the patients. We propose the measurement of the blood levels of xanthine oxidase, a very simple, reliable and less time consuming method as an indicator of myocardial infarction.

Oral administration of L-arginine in patients with angina or following myocardial infarction may be protective by increasing plasma superoxide dismutase and total thiols with reduction in serum cholesterol and xanthine oxidase

Administration of L-arginine has been shown to control ischemic injury by producing nitric oxide which dilates the vessels and thus maintains proper blood flow to the myocardium. In the present study attempt has been made to determine whether oral administration of L-arginine has any effect on oxidant/antioxidant homeostasis in ischemic myocardial patients [represented by the patients of acute angina (AA) and acute myocardial infarction (MI)]. L-arginine has antioxidant and antiapoptotic properties, decreases endothelin-1 expression and improves endothelial function, thereby controlling oxidative injury caused during myocardial ischemic syndrome. Effect of L-arginine administration on the status of free radical scavenging enzymes, pro-oxidant enzyme and antioxidants viz. total thiols, carbonyl content and plasma ascorbic acid levels in the patients has been evaluated. We have observed that L-arginine administration (three grams per day for 15 days) resulted in increased activity of free radical scavenging enzyme superoxide dismutase (SOD) and increase in the levels of total thiols (T-SH) and ascorbic acid with concomitant decrease in lipid per-oxidation, carbonyl content, serum cholesterol and the activity of proxidant enzyme, xanthine oxidase (XO). These findings suggest that the supplementation of L-arginine along with regular therapy may be beneficial to the patients of ischemic myocardial syndromes.

Protective Role of l-Arginine Against Free-Radical Mediated Oxidative Damage in Patients with Unstable Angina

Unstable angina is a critical condition of heart resulting from narrowing of vessels supplying blood to heart. Ischemia of the myocardium leads to oxidative stress and severe tissue damage. The objective of the present study was to determine the effect of l-arginine administration on the oxidant–antioxidant homeostasis which otherwise gets imbalanced in patients with cardiovascular diseases. The results obtained, show improvement in the oxidant–antioxidant levels of the subjects upon incorporation of l-arginine. Our findings suggest that supplementation of l-arginine along with regular anti-anginal therapy may be beneficial to the patients of unstable angina.

Juvenile rheumatic mitral stenosis in association with perimembranous ventricular septal defect in a 3-year-old boy.

Rheumatic mitral stenosis (MS) is a well-known entity in the developing world. Though rarely seem, MS can present at a very young age with severe symptoms. We describe here an unusual association of a large perimembranous ventricular septal defect with juvenile rheumatic MS leading to severe pulmonary hypertension and heart failure in a very young child.

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.

Aneurysmally Dilated Giant Coronary Sinus Mimicking Accessory Cardiac Chamber

A 35-year-old female was referred to our hospital for evaluation of atypical chest pain with fatigue. Her physical examination was unremarkable. The electrocardiogram was normal and chest x-ray postero-anterior view revealed mild cardiomegaly. She underwent two-dimensional transthoracic echocardiographic examination (Aloka Prosound alpha 6, Aloka Medical Systems, Tokyo, Japan) (parasternal long-axis view) which revealed an unusually dilated (4.8 9 4.8 cm) circular structure (Fig. 1A and movie clip S1) posterior to left ventricle which had the appearance of an accessory cardiac chamber or submitral aneurysm. The posteriorly tilted apical fourchamber view showed the aneurysmally dilated coronary sinus at the atrio-ventricular groove (Fig. 1B) with wide ostial opening into the right atrium. The agitated air saline contrast from the left antecubital vein was injected which showed the filling of dilated coronary sinus (Fig. 1C and movie clip S2) with air bubbles from the persistent left superior vena cava (SVC) that was also seen as a linear contrast filled structure opening into the coronary sinus. From coronary sinus, the contrast opacified the right atrium and subsequently right ventricle. The patient underwent