Pravesh Vishwakarma

Calcified Aorto–Right Ventricular Tunnel in a Patient With Multiple Lentigines Syndrome

From the *Department of Cardiology, C.S.M. Medical University (King George’s Medical College), Lucknow, Uttar Pradesh, India; and the †Department of Radiodiagnosis, C.S.M. Medical University (King George’s Medical College), Lucknow, Uttar Pradesh, India. Manuscript received June 5, 2012; revised manuscript received June 14, 2012, accepted June 26, 2012. A12-year old boy with multiple pigmented nevi and lentigines (A) presented to us with symptoms of effort dyspnea and recent onset cyanosis. He had mild thoracolumbar scoliosis, unilateral sensorineural hearing loss, and growth retardation. The 2-dimensional transthoracic echocardiogram revealed a circular echolucency lateral to the tricuspid annulus (B, Online Video 1) (LA left atrium; LV left ventricle; RA right atrium; RV right ventricle), and color Doppler echocardiogram showed a tunnel-like structure with turbulent jet filling the right ventricle (C, Online Video 2). Two-dimensional echocardiogram with continuous-wave Doppler showed severe valvular pulmonic stenosis (D), and contrast echocardiogram revealed right to left shunt across the foramen ovale (Online Video 3). Cardiac catheterization showed spiral calcification and catheter passage from the aorta to the RV (E, Online Video 4), and the aortogram revealed flow across the tunnel (Online Video 5). Sixty-four slice computed tomography angiography showed a dilated aortic root (DA) with a tortuous aorto–right ventricular tunnel (F). Computed tomography volume-rendered imaging showed a giant tunnel and single left coronary artery giving branches (Bs) to the RV (G), with massive dilation of the aortic root and presence of calcified bands at the origin of the tunnel (H). LAD left anterior descending artery; MPA main pulmonary artery; PA pulmonary artery; RAA right atrial appendage. Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jacc.2012.06.066

Landmark Trials in Cardiology in 2017—Celebrating 40 Years of Angioplasty

Abstract Cardiovascular (CV) diseases continue to be the leading cause of morbidity and mortality worldwide. Significant progress has been made in the management of coronary artery disease (CAD) and acute coronary syndrome (ACS) over the past 3 decades. The year 2017 marks 40th anniversary of the first coronary angioplasty performed by Andreas Gruentzig in the year 1977. Evidence‐based medicine and research has been the key driving force of these positive outcomes. The year 2017 witnessed presentation of several landmark studies at major meetings and many of them getting published in literature simultaneously. These trials evaluated wide range of issues from novel percutaneous coronary intervention (PCI) strategies to newer drugs to innovative devices in management of CAD. We selectively discuss a few major landmark studies that have the potential to alter our daily practice in 2018.

Correlation between carotid ultrasonography findings and SYNTAX score in South Asian patients with coronary artery disease: A single-center study

Objective: The objective of the study was to examine the correlation between the carotid ultrasound findings (i.e., carotid intima-media thickness [IMT] and plaque score) and complexity of coronary artery disease (angiographic SYNTAX score) in Indian patients with stable ischemic heart disease. Materials and Methods: This was a hospital-based, prospective, consecutive comparative case series. The study population comprised 117 Indian patients with stable ischemic heart disease, who underwent carotid ultrasonography for the estimation of mean carotid IMT and plaque score and coronary angiography for the estimation of SYNTAX score. Groups comprising patients with low SYNTAX score (0–22; n = 88) and patients with intermediate (23–32) and high (≥33) SYNTAX score (n = 29) were compared for various demographic factors and carotid ultrasound findings. Results: Patients with intermediate or high SYNTAX score had significantly higher prevalence of diabetes (51.7% vs. 15.9%), hypertension (89.7% vs. 30.7%), and hypercholesterolemia (100% vs. 31.8%) as compared to patients with low SYNTAX score (P < 0.001). Further, the mean IMT and plaque scores increased with increasing SYNTAX score. Patients with intermediate and high SYNTAX score had significantly higher mean IMT (1.1 ± 0.1 vs. 0.9 ± 0.1 mm) and plaques score (6.6 ± 1.2 vs. 1.9 ± 1.9 mm) as compared to patients with low SYNTAX score. Significant correlation between SYNTAX score and mean IMT (r = 0.73; P < 0.01) and plaque score (r = 0.68; P < 0.01) was observed. Conclusions: Carotid ultrasound findings showed a significant correlation with the degree of complexity of coronary artery lesions.

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.

Evaluation of short-term outcomes of impaired creatinine clearance in patients with acute coronary syndromes: A prospective cohort study at tertiary care center

Background: Chronic kidney disease is commonly seen in patients presenting with acute coronary syndrome (ACS), and it has been shown to have poor outcomes. We evaluated the prevalence of impaired creatinine clearance and its impact on short-term clinical outcomes in patients admitted with ACS without prior documented chronic renal disease. Materials and Methods: The present study was an observational, prospective cohort study conducted at a tertiary care center in North India. In patients admitted with a diagnosis of ACS, glomerular filtration rate was estimated (eGFR) by the Modification of Diet in Renal Disease Study Equation. Patients with eGFR <90 mL/min were taken as study group and those with values >90 mL/min comprised control group. The study group was further categorized into three subgroups on the basis of eGFR (<30 mL/min; 30–59 mL/min; 60–89 ml/min). The primary outcomes compared between study and control group were major adverse cardiac event (MACE) (composite of death, reinfarction, congestive heart failure, cardiogenic shock, and arrhythmia). The secondary outcome measures were individual components of primary outcome. Results: Among the 200 enrolled patients with ACS, the prevalence of impaired creatinine clearance was 29.5%. The study cohort had higher rates of MACE (28.8 vs. 9.2%, P ≤≤ 0.0001), in-hospital mortality (13.6 vs. 3.5%, P = 0.009), and overall mortality (15.3 vs. 5.1%, P = 0.014) as compared to control group. However, the 30-day mortality was not significantly different. The MACE in the study subgroups was higher in eGFR 30–60 mL/min (odds ratio [OR] 3.97) subgroup followed by eGFR <30 mL/min (OR 3.04) and eGFR 60–90 mL/min (OR 1.38). Using eGFR <90 mL/min as cutoff (as compared to serum creatinine [SCr] >1.5 mg/dl) enhances the ability to predict death by 33% and MACE events by 143%. The OR for predicting death with various cutoff of eGFR was as follows: eGFR <30 ml/min – 3.61, eGFR: 30–60 ml/min – 4.2 and eGFR: 60–90 ml/min – 0.5. Conclusion: Almost one-third of the patients presenting with ACS have impaired creatinine clearance. Patients with impaired creatinine clearance have worse outcome in hospital vis-a-vis their contemporary groups with normal eGFR. eGFR is a better risk assessment parameter than SCr for predicting MACE and overall mortality in ACS patients.

Incidence and predictors of 30-day mortality in patients with ventricular septal rupture complicating acute myocardial infarction

Objective We sought to investigate the incidence and predictors of 30-day mortality associated with ventricular septal rupture (VSR) complicating acute myocardial infarction (AMI) in a cohort of patients admitted to a single centre in India. Methods From October 2013 to February 2016, a total of 6560 patients with a diagnosis of AMI were admitted to our institution. Among these patients, those with a diagnosis of VSR were retrospectively included in this registry. Clinical and echocardiographic features were collected in all cases. The primary outcome was 30-day mortality. A Cox proportional hazard regression analysis explored the predictors of 30-day mortality. Results During the observation period, a total of 51 consecutive patients (mean age 63.8 years (9.1); 51.0% male, 41.2% were patients with diabetes) with a diagnosis of VSR complicating AMI were included. On echocardiography, left ventricular ejection fraction was 42.5% (6.5), and the most frequent location of VSR was apical (78.4%). Overall, 27.4% of the patients received reperfusive therapy (pharmacological, 23.5%; mechanical, 3.9%) and 19.6% of the patients underwent surgical repair. The mean time to surgery was 7.7 days (2.4). At 30-day follow-up, death occurred in 80.4% of patients. Advanced age (HR 1.07, 95% CI (1.02 to 1.13), p=0.004), previous cerebrovascular accident (HR 52.2, 95% CI (3.98 to 685.06), p=0.003) and surgical repair (HR 0.05, 95% CI (0.01 to 0.26), p<0.001) were effect modifiers of the 30-day risk of death. Conclusions In this retrospective cohort of patients with AMI, the occurrence of VSR was not rare and carried a considerable risk of 30-day mortality. Advanced age, previous cerebrovascular accident and surgical repair influenced the risk for 30-day mortality.

Decoding the 2017 hypertension guidelines: The ten commandments

Hypertension (HTN) is a public health menace contributing up to 45% of cardiovascular diseases (CVD) deaths and 51% of stroke deaths.[1] In India up to 33% of urban and 25% of the rural population are afflicted with the disease.[2] Attainment of blood pressure (BP) goals in the population at large is a major challenge and area of focus of health systems worldwide. Over the years, BP targets have been continuously redefined as the armamentarium of drugs has expanded. The recently published the American College of Cardiology/American Heart Association (ACC/AHA) 2017 HTN guidelines advocate a paradigm shift in the way we manage abnormal BP.[3]