Pravin K. Goel

Slow Coronary Flow: A Distinct Angiographic Subgroup in Syndrome X

Patients evaluated for chest pain with angiographically normal coronary arteries are usually labelled syndrome X. A portion of these patients may not have a cardiac cause for their symptoms. The authors aimed to study a subset within this group who showed the phenom enon of slow coronary flow (SCF) as evidenced by a slow antegrade progression of the dye on the coronary arteriogram to see if this could be used as a marker of myocardial ischemia. This observational study included 207 patients being evaluated for suspected coronary artery disease and found to have normal coronary angiograms. SCF was seen in 49 of these patients (23.7%) while the remaining 158 (76.3%) had normal coronary flow (NCF), as detected by the corrected thrombosis in myocardial infarction (TIMI) frame count method (TIMI frame count more than 2 SD of normal). Forty of the 49 patients (82%) in the SCF group had classical angina as compared with only 51 of the 158 patients (32%) in the NCF group (p<0.01). Also, a definitively positive exercise test was observed more commonly in the SCF group than in the NCF group (71% vs 42%, p<0.01). The authors conclude that SCF patients constitute a definite subset within the wide spectrum of syndrome X and that the phenomenon of SCF could be used as a marker for myocardial ischemia.

Use of dopamine in prevention of contrast induced acute renal failure — A randomised study

We report the use of dopamine in renal doses (5 micrograms/kg/min) to prevent contrast induced nephropathy (CIN). Forty patients with diabetes mellitus who were undergoing coronary angiography were randomly divided into two groups. Gr I (20 patients) was infused with dopamine starting 30 min before cardiac catheterization and continued for 6 h thereafter. Gr II (20 patients) did not receive dopamine. Baseline blood chemistry was performed before catheterization and then repeated 24 h after the procedure. The mean age and sex distribution were similar in both the groups. Urograffin (76%; 120-150 ml) was used in all the cases. The mean serum creatinine and blood urea nitrogen (BUN) levels in Gr I patients before catheterization were 1.5 +/- 0.32 mg % and 16.3 +/- 8.05 mg %, respectively. The corresponding values for Gr II were 1.52 +/- 0.68 mg % and 19.6 +/- 13.4 mg %, respectively. After angiography, Gr I patients did not show significant changes in renal parameters (serum creatinine, 1.37 +/- 0.25 mg % and BUN, 14.7 +/- 5.5 mg %) while Gr II patients showed a significant rise (serum creatinine, 1.96 +/- 1.2 mg % and BUN, 23.25 +/- 12.7 mg %; P = 0.01 and P = 0.05, respectively). Ten patients in Gr II (50%) developed a 25% rise in serum creatinine levels within 24 h of injection of the contrast. None of the patients developed renal failure severe enough to warrant dialysis. Hence alterations of renal function are common after cardiac catheterization. Dopamine in renal doses appears to be an effective means to prevent deterioration in renal function induced by contrast.

Slow coronary flow--a cause for angina with ST segment elevation and normal coronary arteries. A case report.

We report three cases of angina-like chest pain with documented ST segment elevation and slow coronary flow in the absence of any significant obstructive coronary artery disease and no evidence of any major epicardial coronary arterial spasm.

Double-inversion technique for coronary angiography viewing in dextrocardia.

This report describes a simple angiographic viewing rule for coronary angiography in patients of dextrocardia with obstructive coronary artery disease, which could correct the unfamiliar angulated pictures of the coronary tree in dextrocardia into the familiar conventional angiographic pictures of a normally located heart and its associated ease of interpretation.

Hemoglobin A1c in Nondiabetic Patients: An Independent Predictor of Coronary Artery Disease and Its Severity

OBJECTIVE To examine the association between hemoglobin A(1c) (HbA(1c)) and the presence, severity, and complexity of angiographically proven coronary artery disease (CAD) in nondiabetic patients. PATIENTS AND METHODS We performed a single-center, observational, cross-sectional study of 1141 consecutive nondiabetic patients who underwent coronary angiography from January 1, 2011, through December 31, 2011. The study population was divided into 4 interquartiles according to HbA(1c) levels (<5.5%, 5.5%-5.7%, 5.8%-6.1%, and >6.1%). RESULTS Patients with higher HbA(1c) levels tended to be older, overweight, and hypertensive, had higher blood glucose levels, and had lower glomerular filtration rates. Higher HbA(1c) levels were associated in a graded fashion with the presence of CAD, disease severity (higher number of diseased vessels and presence of left main and/or triple vessel disease), and disease complexity (higher SYNTAX score, higher number of patients in intermediate or high SYNTAX tertiles, coronary calcium, and chronic total occlusions). After adjustment for major conventional cardiovascular risk factors, compared with patients with HbA(1c) levels less than 5.5%, the odds ratios of occurrence of CAD in the HbA(1c) quartiles of 5.5% to 5.7%, 5.8% to 6.1%, and greater than 6.1% were 1.8 (95% CI, 1.2-2.7), 3.5 (95% CI, 2.3-5.3), and 4.9 (95% CI, 3.0-8.1), respectively. CONCLUSION The HbA(1c) level has a linear incremental association with CAD in nondiabetic individuals. The HbA(1c) level is also independently correlated with disease severity and higher SYNTAX scores. Thus, HbA(1c) measurement could be used to improve cardiovascular risk assessment in nondiabetic individuals.

Delayed and repeated cardiac tamponade following microleak in RCA successfully treated with intra arterial sterile glue injection

Postinterventional pericardial leaks mostly occur intraprocedure or immediately postprocedure and call for an aggressive management right then. Also, once controlled for 24–48 hr, the leaks usually seal themselves spontaneously. We herein describe an unusual case of delayed and continued pericardial leak over 10 days as a result of micro perforation of RCA from the distal wire tip and which was successfully managed by intracoronary injection of sterile synthetic glue, which to the best of our knowledge is the first report of its kind.

Platelet aggregability and occurrence of restenosis following coronary angioplasty

Restenosis following percutaneous coronary angioplasty (PTCA) is a complex medical problem occurring in nearly a third of the patients undergoing PTCA with no single definite predictor demonstrated in an individual patient. Platelets are known to play an important role in the pathogenesis of the restenotic process. However, no known parameter of platelet function or activity has been studied as a risk factor predicting the occurrence of restenosis. We prospectively assessed platelet activation in twenty two consecutive patients with stable angina who underwent a successful PTCA for single vessel coronary artery disease. Platelet activation levels were measured using aggregability curves derived from unclotted blood samples on a platelet aggregometer using varying concentrations of adenosine di-phosphate (ADP) in the following time sequence: (1) Basal i.e. pre-PTCA, (2) post-PTCA day 1, (3) post-PTCA day 7, and (4) post-PTCA day 28. Occurrence of restenosis was studied using angiographic follow-up in all patients. At follow-up, seven of the twenty two patients studied developed restenosis. There was no significant difference or any specific trend noted over time in the levels of platelet aggregability in the study group as a whole (basal: 30.0 +/- 15.4%, post-PTCA day 1: 32.5 +/- 16.1%, post-PTCA day 7: 34.6 +/- 15.4% and post-PTCA day 28: 32.6 +/- 16.1%). However, when the patients were subgrouped into those with and without restenosis, the patients with restenosis had a significantly higher basal platelet aggregability (38.7 +/- 16.3%) versus those who did not develop restenosis (25.0 +/- 12.1%), p = 0.0128. We conclude that patients developing restenosis after PTCA have a significantly higher basal platelet aggregability and this could be used as a marker for its occurrence in an individual patient.

Lipoprotein (a) levels in relation to severity of coronary artery disease in north Indian patients

Background: Lipoprotein (a) [Lp (a)] is an established risk marker of coronary artery disease which is independent from other risk factors. Objective: The aim was to address the association between Lp (a) and CAD risk in North Indians. To evaluate whether high levels of lipoprotein (a) [Lp (a)] is a predictor of risk and is related to the severity of CAD. Materials and Methods: This was a cross-sectional study done on 360 patients presenting with chest pain. Coronary angiography revealed CAD in 270 patients and 90 patients without CAD. Lipoprotein (a) level, lipid profile, fasting blood glucose, anthropometric and clinical parameters were analyzed. Results: Lipoprotein (a) 21.0 mg/dL is associated with the presence of coronary lesions (P = 0.0001). A highly significant difference in Lp (a) levels was observed between normal coronaries vs. single-vessel disease, double-and triple-vessel disease ( P < 0.0001). Body mass index (BMI) was significantly raised in CAD group compared to normal coronary. Conclusion: Multivariate analysis found that Lp (a) was considered an independent predictor for severity of CAD and Lp (a) levels 21.0 mg/dL are associated with severe patterns of coronary atherosclerosis.

Erectile Dysfunction Precedes and Is Associated with Severity of Coronary Artery Disease among Asian Indians

INTRODUCTION Erectile dysfunction (ED) and coronary artery disease (CAD) often share common risk factors, and there is growing evidence that ED might serve as a clinical marker for cardiovascular disease. Despite rising trends of CAD in Asian Indians, limited data are available on the prevalence of ED and its correlation with CAD severity in such patients. AIM To study the prevalence of ED in Asian Indian patients undergoing coronary angiography and to assess if the severity of ED correlates with angiographic severity of CAD. METHODS In all patients undergoing coronary angiography, ED was assessed using the International Index of Erectile Function-5 questionnaire. MAIN OUTCOME MEASURES AND RESULTS Among 175 male patients, ED was present in 70%; patients with ED had a higher incidence of multivessel CAD (80% vs. 36%, P 0.001), diffuse CAD (81% vs. 34%, P 0.001), and higher number of mean coronary vessels involved compared with those without ED. Those with severe ED had higher prevalence of multivessel CAD and higher number of mean coronary vessels involved compared with those with milder grades of ED. Onset of symptoms of ED preceded symptoms of CAD by a mean of 24.6 months in 84% of patients. The presence of severe ED was associated with a 21-fold higher risk of having triple-vessel disease (odds ratio [OR] 21.94, 95% confidence interval [CI] 3.41-141.09, P = 0.001) and an 18-fold higher risk of having diffuse angiographic CAD (OR 17.91, 95% CI 3.11-111.09, P = 0.001). CONCLUSION Asian Indians with angiographic CAD frequently have ED; symptoms of ED precede that of CAD in most patients. Incidence of multivessel and diffuse CAD is significantly more common in patients with ED. It is important for physicians to be aware of the close relationship between the two conditions so that patients with ED can have optimal risk stratification for concomitant CAD whenever required.

Comparison of transradial and transfemoral artery approach for percutaneous coronary angiography and angioplasty: a retrospective seven-year experience from a north Indian center.

BACKGROUND With the increasing prevalence of coronary artery disease, percutaneous coronary artery procedures have become even more important. Our study has compared transradial to transfemoral artery approach for coronary procedures in Indian population. AIMS AND OBJECTIVE Comparison of transradial and transfemoral artery approach for percutaneous coronary procedures. MATERIAL & METHODS 26,238 patients, who underwent percutaneous coronary artery procedures, were divided into two groups depending upon transradial and transfemoral artery approach and compared for the various demographic and clinical characteristics, risk factors profile, vascular access and procedural details. RESULTS 26,238 patients underwent percutaneous coronary procedures at our center. 81% were male and 19% were female. 55.65% and 44.35% procedures were done through transfemoral and transradial approach, respectively. 17,417 (66.38%) coronary angiographies were done, out of which 53.92% were transradial and 46.08% were transfemoral procedures. 8821 (33.62%) Percutaneous Transluminal Coronary Angioplasty (PTCA) were done, out of which 25.46% and 74.54% were done through transradial and transfemoral approach, respectively. Mean fluoroscopy time was 4.40 ± 3.55 min for transradial and 3.30 ± 3.66 min for transfemoral CAG (p < 0.001). For PTCA mean fluoroscopy time was 13.53 ± 2.53 min for transradial and 12.61 ± 9.524 min for transfemoral PTCA (p < 0.001). Minor and major procedure related complications and total duration of hospital stay were lower in transradial as compared to transfemoral group. CONCLUSION The number of percutaneous transradial procedures have increased significantly with reduced complication rates and comparable success rate to transfemoral approach, along with the additional benefits to patient in terms of patient comfort, preference and reduced cost of health delivery.