Radhakrishnan Ramaraj

Reverse or Inverted Takotsubo Cardiomyopathy (Reverse Left Ventricular Apical Ballooning Syndrome) Presents at a Younger Age Compared With the Mid or Apical Variant and Is Always Associated With Triggering Stress

Takotsubo cardiomyopathy is usually caused by triggering stress. It has 4 different subtypes. There has been no consensus to differentiate various types with regard to characteristics of the patient population. The goal of this study was to evaluate any clinical differences between the reverse type in comparison to common apical and mid-cavitary types using case series of reported cases. The authors searched published articles in PubMed and Medline on takotsubo or stress-induced cardiomyopathy. They included only cases that reported different types of takotsubo cardiomyopathy with baseline clinical characteristics. They identified 60 patients for the final analysis. The types of takotsubo cardiomyopathy seen in this study are classified as classic (66.7%), mid-cavitary (10%), or reverse (inverted) (23.3%). Patients with reverse-type takotsubo cardiomyopathy were significantly younger compared with those with other types (mean age, 36 for reverse vs 62 for other types; P<.001). Furthermore, all patients with the reverse type had physical or mental stress, whereas those with other types had no triggering stress in 02% of the reported cases (P<.0001). Among patients presenting with takotsubo cardiomyopathy, the reverse or inverted variant presents at a younger age and is always associated with a triggering of emotional or physical stress.

Peripartum cardiomyopathy: Causes, diagnosis, and treatment

Peripartum cardiomyopathy is a life-threatening condition of unknown cause that occurs in previously healthy women during the peripartum period. It is characterized by left ventricular dysfunction and symptoms of heart failure that can arise in the last trimester of pregnancy or up to 5 months after delivery. We review its possible causes and how to recognize and manage it.

Degenerative aortic stenosis

#### Summary points Aortic stenosis is the most common valvular lesion in Europe and North America. It primarily presents as calcific aortic stenosis in 2-7% of the population aged >65 years.1 About 80% of adult patients with symptomatic aortic stenosis are male. As 1-2% of the population is born with a congenital bicuspid aortic valve and populations are ageing, aortic stenosis is becoming more common. By 2020, about 3.5 million people in England are expected to have aortic sclerosis and 150 000 will have severe aortic stenosis.2 Here we provide an overview to help diagnosis and a summary of the management of AS and its sequelae. Many of the points made in this review are based on randomised controlled trials. However, observational studies and the guideline recommendations of the American Heart Association and the American College of Cardiology and of the European Society of Cardiology are also included to provide comprehensive overviews that are beyond the scope of this article. The most common cause of aortic stenosis in adults is calcification of a normal trileaflet (fig 1⇓). Calcific aortic stenosis is thought to be a degenerative process that shares many features with coronary artery disease, such as lipid accumulation, …

Indian Poverty and Cardiovascular Disease

Cardiovascular disease is among the worlds leading causes of death, and nearly 80% of deaths occur in developing countries. Cardiovascular disease is becoming a major health problem in India, where life expectancy has increased with decreases in infectious disease and childhood mortality. It is well established that this population experiences coronary artery disease at a younger age than other populations. With infectious diseases still endemic, noncommunicable diseases are a lower priority for the governments of developing countries. There is a clear progression to degenerative and lifestyle-related diseases such as cardiovascular disease as a result of current social and economic change. The lack of a public response to the increasing risk for cardiovascular disease thus far is due mostly to a perception among policy makers and the public that cardiovascular disease is largely a problem of the urban rich. In conclusion, this review addresses the imminent threats and ways to tackle the epidemic in India.

Rate of acute ST-elevation myocardial infarction in the United States from 1988 to 2004 (from the Nationwide Inpatient Sample).

Advances in the management of atherosclerosis risk factors have been dramatic in the previous 10 years. The goal of this study was to evaluate any decrease in age-adjusted incidence of acute ST-elevation myocardial infarction (STEMI) in a very large database of inpatient admissions from 1988 to 2004. The Nationwide Inpatient Sample database was used to calculate the age-adjusted rate for STEMI from 1988 to 2004 retrospectively. Specific International Classification of Diseases, Ninth Revision, codes for MIs consistent with STEMI were used. Patient demographic data were also analyzed and adjusted for age. The Nationwide Inpatient Sample database contained 1,352,574 patients >40 years of age who had a diagnosis of STEMI from 1988 to 2004. Mean age for these patients was 66.06 +/- 13.69 years. Men had almost 2 times the age-adjusted STEMI rate as women (men 62.4%, women 37.6%). From 1988 the age-adjusted rate for all acute STEMIs remained steady for 8 years (108.3 per 100,000, 95% confidence interval [CI] 99.0 to 117.5, in 1988 and 102.5 per 100,000, 95% CI 94.7 to 110.4, in 1996). However, from 1996 onward, the age-adjusted incidence of STEMI steadily decreased to 1/2 the incidence of the previous 8 years (50.0 per 100.000, 95% CI 46.5 to 53.5, by 2004, p <0.01). This decrease was similar across various races and genders. In conclusion, the incidence of STEMI was stable from 1988 to 1996, with a steady linear decrease to 1/2 by 2004. The cause of the steady decrease in STEMI rate most likely reflects the advancement in management of patients with atherosclerosis.

Rationale for continuous chest compression cardiopulmonary resuscitation

Every year more than a million cardiac arrests are documented in the industrialised nations of the world, with the majority occurring in settings outside hospital. A major factor in survival after out-of-hospital cardiac arrest (OHCA) is early institution of bystander resuscitation efforts. Sadly, the majority of OHCAs do not receive bystander resuscitation for a variety of reasons. One of them is the requirement for mouth-to-mouth (MTM) ventilation. The 2008 American Heart Association recommendation for “hands only” or continuous chest compression cardiopulmonary resuscitation (CPR) for untrained lay people was a welcome change. However, evidence indicates that MTM and other forms of positive pressure ventilation should be eliminated for all bystanders responding to primary cardiac arrest (unexpected witnessed collapse in an unresponsive person). The requirement for MTM ventilation may well be indicated for patients with respiratory arrest but is detrimental during early resuscitation efforts by anyone providing CPR to patients with primary cardiac arrest. This article provides rationale for continuous chest compression CPR by all bystanders.

Poor Correlation of Estimated Pulmonary Artery Systolic Pressure Between Echocardiography and Right Heart Catheterization in Patients Awaiting Cardiac Transplantation: Results From the Clinical Arena

BACKGROUND Pulmonary arterial pressure measurement is an integral part of the pre-heart transplant evaluation. In the clinical arena, the correlation and agreement between pulmonary artery systolic pressure (PASP) measured by Doppler echocardiography versus catheterization in pre-heart transplant patients has not been studied. METHODS Data on all patients evaluated for heart transplantation at our program between 2003 and 2005 (n = 176) were retrospectively reviewed. Patients with both transthoracic echocardiography (with interpretable images) and right heart catheterization performed were included (n = 108; mean time difference, 2.2 days; median, 2 days). The tricuspid valve regurgitant jet was identified by color flow Doppler and jet maximum velocity was measured by continuous wave Doppler. The PASP was estimated by using the modified Bernoulli equation and adding right atrial pressure. We correlated echocardiographically estimated PASP with that measured by right heart catheterization. RESULTS Mean estimated PASP by echocardiography was 46.6 +/- 13.7 mmHg versus 44.8 +/- 17.9 mmHg by right heart catheterization (P = NS). However, the correlation between echocardiographic and measured PASP was poor (r = 0.49, P < .001). The correlation was poor in both ischemic and nonischemic cardiomyopathy. CONCLUSION Among patients referred for heart transplant evaluation, there is poor agreement and correlation between echocardiographically estimated PASP and values obtained by right heart catheterization. Furthermore, echocardiographically obtained estimates of PASP should not be exclusively relied upon to exclude heart transplant recipient candidates.

Stress cardiomyopathy: aetiology and management

Stress cardiomyopathy is a condition caused by intense emotional or physical stress leading to rapid and severe reversible cardiac dysfunction. It mimics myocardial infarction with changes in the electrocardiogram and echocardiogram, but without any obstructive coronary artery disease. Due to the awareness created by the media and internet, every patient is aware that they should seek help immediately for chest pain. Therefore physicians should be aware of this new condition and how to diagnose and treat it, even though the causal mechanisms are not yet fully understood.

Declining In-Hospital Mortality in Patients Undergoing Coronary Bypass Surgery in the United States Irrespective of Presence of Type 2 Diabetes or Congestive Heart Failure

Significant advances in surgical techniques and postsurgical care have been made in the last 10 years. The goal of this study was to evaluate any decline in the age‐adjusted in‐hospital mortality rate of patients undergoing coronary artery bypass grafting (CABG) using a national database from 1989 to 2004 in the United States.

Nationwide trends in the age adjusted prevalence of non-ST elevation myocardial infarction (NSTEMI) across various races and gender in the USA

Abstract Background: Advances in the prevention and treatment of atherosclerosis have been dramatic. The goal of this study was to evaluate any decline in the age adjusted incidence of acute non ST elevation myocardial infarction (NSTEMI) using a large database. Method: The Nationwide Inpatient Sample (NIS) database was utilized to calculate the age-adjusted rate for NSTEMI from 1988 to 2004 retrospectively. Specific ICD-9-CM codes for NSTEMI were used to compile the data. Patient demographic data was also analyzed from the database and adjusted for age. Results: The NIS database contained a total of 1 423 156 patients who had a diagnosis of NSTEMI from 1988 to 2004. The age-adjusted rate for all acute NSTEMI gradually increased from 1988 until 2000—26.21 per 100 000 (95% CI: 23.9–28.4) in 1988 and 92.6 per 100 000 (95% CI: 86.0–99.3, P <0.01 in 2000,). It remained unchanged from 2000 until 2004 (91.7 per 100 000 (95% CI: 85.3–98.0). This trend was similar across different race and gender. Conclusion: The increasing incidence of NSTEMI from 1988 until year 2000 has suddenly stabilized by the year 2000. The cause of this finding is unknown. It could be related to the recent adaptation of troponin testing or recent advancement in the prevention and treatment of atherosclerosis.