Narasimha D. Pai

Antihypertensive therapy: nocturnal dippers and nondippers. Do we treat them differently?

Hypertension is a major independent risk factor for cardiovascular diseases. Management of hypertension is generally based on office blood pressure since it is easy to determine. Since casual blood pressure readings in the office are influenced by various factors, they do not represent basal blood pressure. Dipping of the blood pressure in the night is a normal physiological change that can be blunted by cardiovascular risk factors and the severity of hypertension. Nondipping pattern is associated with disease severity, left ventricular hypertrophy, increased proteinuria, secondary forms of hypertension, increased insulin resistance, and increased fibrinogen level. Long-term observational studies have documented increased cardiovascular events in patients with nondipping patterns. Nocturnal dipping can be improved by administering the antihypertensive medications in the night. Long-term clinical trials have shown that cardiovascular events can be reduced by achieving better dipping patterns by administering medications during the night. Identifying the dipping pattern is useful for decisions to investigate for secondary causes, initiating treatment, necessity of chronotherapy, withdrawal or reduction of unnecessary medications, and monitoring after treatment initiation. Use of this concept at the primary care level has been limited because 24-hour ambulatory blood pressure monitoring has been the only method for documenting dipping/nondipping status so far. This monitoring technique is expensive and inconvenient for routine usage. Simpler methods using home blood pressure monitoring systems are evolving to document basal blood pressure in the night, which would help in greater acceptance and use of the concept of dipper/nondipper in managing hypertension at the primary care level.

Descending Thoracic Aortic Aneurysm Rupture During Postpartum Period

Abstract:  Aortic aneurysm refers to the pathological dilatation of the normal aortic lumen involving one or several segments. Thoracic aortic aneurysms are much less common than aneurysms of the abdominal aorta. Descending thoracic aortic aneurysm leading to dissection and spontaneous rupture is a potentially catastrophic illness. Although rare, dissection and rupture of a preexisting aortic aneurysm have been reported during pregnancy and early puerperium. To the best of our knowledge, such cases among young pregnant women are rarely reported in literature. Herein, an autopsy case of spontaneous rupture of a clinically undiagnosed descending thoracic aortic aneurysm during early puerperium in a young woman is presented along with the review of relevant literature. The victim was found dead on her hospital bed on the seventh day of puerperium. Autopsy with ancillary investigations revealed that the young woman died because of hemothorax from a ruptured dissecting descending thoracic aortic aneurysm secondary to chronic aortitis.

Evaluation of baseline ECG in patients undergoing Oral Flecainide Challenge test for suspected Brugada Syndrome: An analysis of lead II

Background and Objectives We analyzed Lead II in patients undergoing an Oral Flecainide Challenge test (FCT), to identify any pointers that could predict a positive FCT and thereby help in recognition of latent BS. Methods The following parameters in lead II were retrospectively analyzed from the pre-test ECG in 62 patients undergoing FCT for suspected BS: The presence or absence of S waves, S wave amplitude, duration and upslope duration; J point parameters- Early repolarization, QRS notch, and QRS Slur; ST segment parameters-lack of isoelectric ST segment, ST duration and QT interval. Results 48 had positive FCT (Group-1) while 14 were negative for FCT(Group-2). Lack of an isoelectric ST segment (50% vs 14.29%, p = 0.018) and slurring of QRS (33.33% vs 0%, p = 0.014) was more common in Group-1 than Group-2. Group-1 had shorter ST segment duration (median 81.5 (IQR 64–103.5) vs 110 (IQR 90–132), p = 0.002) and shorter ST: QT ratio (median 0.28 (IQR 0.22–0.35) vs 0.23 (0.18–0.27), p = 0.007). QRS notch/depressed J point (87.5%), QRS slur (100%), and lack of isoelectric ST segment (92.31%) had high sensitivity for predicting an inducible Type 1 Brugada pattern. Combining two parameters- ST: QT ratio<0.24 and lack of isoelectric ST segment-considerably improved the specificity (73.3%), and the positive predictive value of the test to 76%. The results remained accurate when validated in a small prospective cohort. Conclusion Shortened ST segment in Lead II, lack of isoelectric ST segment, slurred QRS and ST/QT ratio <0.24 are predictive of underlying Brugada pattern in baseline ECG.

Severity of coronary artery disease in type 2 diabetes mellitus: Does the timing matter?

AIM The aim of our study was to compare the angiographic changes in 53 nondiabetic patients, 54 type 2 diabetic patients of less than 5 years of duration, 41 patients with 5-10 years of diabetes, and 27 with more than 10 years of diabetic duration. METHODS In this cross-sectional study, 175 patients, who underwent coronary angiogram for the evaluation of the coronary artery disease (CAD), were recruited. Based on the angiographic findings, syntax score, vessel score, and coronary collaterals grading were analyzed. The biochemical analysis was done by using the auto analyzer. RESULTS A significant increase in the mean syntax score (p=0.019), vessel score (p=0.007), and coronary collateral grade (p=0.008) was observed in the patients with 5-10 years of diabetes when compared to those with less than 5 years of diabetic duration. There was no significant difference in the mean syntax score (p=0.979), vessel score (p=0.299), and collateral grade (p=0.842) between the patients with 5-10 years and more than 10 years of diabetes. The difference in the mean syntax score (p=0.791), vessel score (p=0.098), and collateral grade (p=0.661) between the nondiabetic and the patients with less than 5 years of diabetes was not significant. CONCLUSION A significant structural change in the coronary arteries was found among the patients with 5-10 years of diabetes.

Factors correlating with severity of coronary artery disease in type 2 diabetic patients on treatment for more than 5 years.

Aims: To evaluate the correlation between insulin resistance and other conventional risk factors with respect to severity of coronary artery disease (CAD) in patients with more than 5 years of treatment for type 2 diabetes mellitus. Study Design: Cross-sectional study. Place and Duration of Study: Department of Medicine and Department of Cardiology, Kasturba Medical College, Hospital Mangalore, between February 2013 and December 2013. Methodology: 61 people with more than 5 years of type 2 diabetes who underwent coronary angiogram for the evaluation of CAD were recruited in this study. Insulin resistance (HOMA-IR), anthropometric and biochemical parameters were determined, and was correlated with severity of CAD which was assessed by syntax score. Results: There was significant positive linear correlation between log HOMA-IR and syntax score in people with more than 5 years of type 2 diabetes [r=0.605 (95%CI 0.417–0.744), P<0.001]. The correlation of syntax score with other known risk factors of CAD was not significant. Further multivariate analysis after adjusting for conventional risk factors showed a significant association of Log-IR with severity of CAD in people with type 2 diabetes mellitus of more than 5 years of duration (β=0.667, P<0.001) Conclusion: In type 2 diabetes mellitus with treatment more than 5 years of duration, high HOMA-IR appears to be a good indicator of severity of CAD in Type 2 diabetes mellitus and might be a marker of severity of disease, thus helping us in identifying high risk type 2 diabetes mellitus subjects.

‘Optimized’ LV only pacing using a dual chamber pacemaker as a cost effective alternative to CRT

Background Cardiac Resynchronization therapy (CRT) remains largely under-used in developing countries owing to the high cost of therapy. In this pilot study, we explore ‘optimized’ Left Ventricle Only Pacing (LVOP) as a cost effective alternative to cardiac resynchronization therapy in selected patients with heart failure. Hypothesis In economically poorer patients with heart failure, left bundle branch block (LBBB) and intact AV node conduction, synchronization can be obtained using a dual chamber pacemaker (leads in right atrium and Left ventricle) with the help of 2D strain imaging. Methods and results 4 patients underwent LVOP for symptomatic heart failure. Post procedure ‘optimization’ was done using 12 lead electrocardiography and 2D- Strain imaging. Difference between Time to Peak longitudinal strain and Aortic valve Closure (Diff TPL-AC) was calculated for each segment at different AV delays and the AV delay with the smallest Diff TPL-AC was programmed. The mean AV delay that resulted in electrical and mechanical synchrony was 150 ms. After a mean follow up of 6 months, all patients had improved by at least 1 NYHA class. The mean reduction in QRS duration post procedure was −54.5 ± 22.82 ms and the mean improvement in EF was 7 ± 2.75%. Conclusion Optimized LVOP using 2D strain and ECG can be a cost-effective alternative to CRT in patients with LBBB, heart failure and normal AV node conduction.

Manipal diabetes coronary artery severity score

AIMS To develop a risk score, for identifying severe and complex CAD in patients with type 2 diabetes mellitus. METHODS In this cross sectional study, 179 patients with type 2 diabetes mellitus undergoing coronary angiogram for the evaluation of suspected coronary artery disease (CAD) were recruited at a tertiary-care hospital. Patients were divided into developmental (n=124) and validation (n=55) cohorts. Biochemical and anthropometric parameters were analysed. Predictors of severe and complex CAD (SYNTAX Score>22) were identified by multiple logistic regression analysis. RESULTS Insulin resistance>3.4 (OR: 21.26, 95% CI: 5.71-79.09), duration of diabetes>5years (OR: 13.50, 95% CI: 3.13-58.25), total cholesterol/HDL-C ratio>5 (OR: 2.75, 95% CI: 0.66-11.55) and waist circumference>96cm (OR: 5.08, 95% CI: 1.27-20.42) were independent predictors of severe and complex CAD, and Manipal Diabetes Coronary Artery Severity Score was developed. CONCLUSIONS The prediction of severe and complex CAD was achieved with this simple score, and thus enabling effective identification of patients beforehand, who are not likely to be suitable for angioplasty.

An unusual case of refractory wheeze

A 37-year-old man presented with a history of episodic wheeze and breathlessness of 3 years’ duration refractory to treatment. Physical examination revealed diffuse expiratory polyphonic rhonchi while the remainder of the examination including the cardiac examination was reported as normal. Pulmonary function testing revealed mild obstruction with bronchodilator reversibility. The patient was discharged on a 6-month course of antitubercular treatment (ATT) as bronchial brush cytology (obtained via bronchoscopy) was positive for acid-fast bacilli. The patient presented after completing 6 months of ATT with persistent symptoms, a loud S1 and a mid-diastolic murmur at the apex. High-resolution CT of the chest showed bilateral dependent ground glass opacities. An echocardiogram revealed a left atrial myxoma, and normal RV size and pressures. The patient underwent successful surgical removal of the same, and made a complete recovery. Refractory wheeze is a very unusual presentation of a left atrial myxoma.

Right ventricular endomyocardial fibrosis - A case report.

Endomyocardial fibrosis (EMF) is a progressive type of restrictive cardiomyopathy. It affects inflow portion of right and/or left ventricle and apex. It is a neglected tropical disease. Here we report a rare case of right ventricular endomyocardial fibrosis. A 70-year-old female presented to us with history suggestive of right-sided heart failure of two months duration. There was no eosinophilia. Chest X-ray showed cardiomegaly. Echocardiogram showed dilated right atrium and obliteration of the apex of the right ventricle. A diagnosis of Right ventricular Endomyocardial fibrosis was made. She was treated with diuretics and anticoagulants and she improved.