Ram Kirti Saran

Impact of a Worksite Intervention Program on Cardiovascular Risk Factors: A Demonstration Project in an Indian Industrial Population

Cardiovascular diseases (CVDs) are the leading cause of death in many regions of the world ([1][1]). Elevated blood pressure, blood sugar, serum cholesterol, body mass index, and tobacco use, all established risk factors for CVD, have a direct and linear relationship with CVD ([2–7][2]). All of

Impact of alcohol on coronary heart disease in Indian men.

BACKGROUND Moderate alcohol consumption is known to be protective against coronary heart disease (CHD). However, the INTERHEART study, a case-control study of acute myocardial infarction (MI) patients, revealed that alcohol consumption in South Asians was not protective against CHD. We therefore planned to study cardiovascular risk factor and CHD prevalence among male alcohol users as compared to age matched lifetime abstainers. METHODS The subjects for this study were recruited from a cross-sectional survey carried out among employees and their family members aged 20-69 years in 10 medium-to-large industries from diverse sites in India, using a stratified random sampling technique. Information on education, behavioral, clinical and biochemical risk factors of CHD and alcohol use was obtained through standardized instruments. CHD diagnosis was based on Rose Questionnaire or a prior physician diagnosed CHD. RESULTS A total of 4465 subjects were present or past alcohol users. The mean age of alcohol users and lifetime abstainers was 42.8+/-11.0 years and 42.8+/-11.1 years, respectively (p=0.90). Systolic blood pressure and diastolic blood pressure were significantly higher in alcohol users (128.7+/-17.6 mmHg/80.1+/-11.3 mmHg) as compared to lifetime abstainers (126.9+/-15.9 mmHg/79.5+/-10.3 mmHg, p<0.01). Fasting blood sugar in alcohol users (98.7+/-30.5 mg%) was also significantly higher than lifetime abstainers (96.6+/-26.0 mg%, p<0.01). Total cholesterol was lower in alcohol users (179.1+/-41.1 mg%) as compared to lifetime abstainers (182.7+/-38.2 mg%, p<0.01). HDL cholesterol was higher in alcohol users (42.9+/-10.8 mg%) as compared to lifetime abstainers (41.3+/-10.0 mg%, p<0.01). Body mass index (BMI) was lower in alcohol users as compared to lifetime abstainers (22.7+/-4.1 kg/m2 vs. 24.0+/-3.3 kg/m2, p<0.001). Tobacco use was significantly higher in alcohol users (63.1% vs. 20.7%). The odds ratio (OR) of having CHD after adjusting for tobacco use, BMI and education was 1.4 (95%CI 1.0-1.9) in alcohol users as compared to controls. The OR was 1.2 (95%CI 0.8-1.6) in occasional alcohol users, 1.6 (95%CI 1.0-2.2) in regular alcohol users and 2.1 (95% CI 1.1-3.0) in past alcohol users as compared to controls. CONCLUSION We did not observe an inverse (protective) association between alcohol intake and the prevalence of CHD. In contrast, our study indicated an association in the reverse direction, suggesting possible harm of alcohol for coronary risk in Indian men. This relationship needs to be further examined in large, prospective study.

Delineation of Anatomy of the Ruptured Sinus of Valsalva with Three-Dimensional Echocardiography: The Advantage of the Added Dimension

The rupture of sinus of Valsalva is a rare complication of infective endocarditis. Three‐dimensional (3D) echocardiography represents an important adjunctive tool to demonstrate the ruptured sinus of Valsalva with better delineation of its characteristics. We present an adult patient with rupture of right sinus of Valsalva aneurysm due to infective endocarditis of the aortic valve, in whom the two‐dimensional (2D) transthoracic echocardiogram erroneously localized the site of rupture into the right atrium. Whereas, 3D transthoracic echocardiogram accurately delineated the site of rupture into the right ventricle and it was confirmed on subsequent cardiac catheterization and angiogram. In addition, 3D echocardiography clearly showed the size and shape of the defect, which helped in successful transcatheter closure of the defect with amplatzer duct occluder device. (Echocardiography 2012;29:E148‐E151)

Left Hemitruncus With Tetralogy of Fallot and Right Aortic Arch: Rare Survival Beyond the First Decade

Hemitruncus is an uncommon congenital anomaly that has been described in isolation or in association with other congenital cardiac malformations. This report describes a rare case of left hemitruncus with tetralogy of Fallot and a right-sided aortic arch. The patient presented to us in the early second decade. The diagnosis was suspected with echocardiography and confirmed with cardiac catheterization. The patient underwent successful surgical correction of the anomaly.

Persistent truncus arteriosus: a rare survival beyond the first decade.

![Figure][1] [![Graphic][3] ][3][![Graphic][4] ][4][![Graphic][5] ][5] An 11-year-old cyanotic boy presented to our department with worsening effort intolerance. Two-dimensional transthoracic echocardiography with color Doppler ( A to D, [Online Video 1][5]) showed a common

Effect of Ivabradine on Heart Rate and Duration of Exercise in Patients With Mild-to-Moderate Mitral Stenosis: A Randomized Comparison With Metoprolol.

Background: Symptoms in mitral stenosis (MS) are heart rate (HR) dependent. Increase in HR reduces diastolic filling period with rise in transmitral gradient. By reducing HR, beta-blockers improve hemodynamics and relieve symptoms, but the use may be limited by side effects. The present randomized crossover study looked at comparative efficacy of ivabradine and metoprolol on symptoms, hemodynamics, and exercise parameters in patients with mild-to-moderate MS (mitral valve area, 1–2 cm2) in normal sinus rhythm. Material and Methods: Baseline clinical assessment, treadmill stress testing, and an echocardiographic Doppler evaluation were performed to determine resting HR, total exercise duration, mean gradient across mitral valve, and mean pulmonary artery systolic pressure (PASP). Patients were then allocated to either metoprolol or ivabradine to maximal tolerated doses over 6 weeks (metoprolol: 100 mg twice a day, ivabradine: 10 mg twice a day). Reevaluation was done at the end of this period, and all drugs stopped for washout over 2 weeks. Thereafter, the 2 groups were crossed over to the other drug that was continued for another 6 weeks. Assessment was again performed at the end of this period. Results: Thirty-three patients of 34 completed the protocol. Fifteen were male, mean age was 28.9 ± 6.6 years, all were in New York Heart Association class 2, and mean resting HR was 103.5 ± 7.2/min. Mean mitral valve area was 1.56 ± 0.16 cm2, mean PASP was 38.1 ± 5.1 mm Hg, and mean gradient across mitral valve was 10.6 ± 1.6 mm Hg. Significant decrease in baseline and peak exercise HR was observed at the end of follow-up with both drugs. Reduction in mitral valve gradient after ivabradine (42%) and metoprolol (37%) and reduction in PASP after both ivabradine (23%) and metoprolol (27%) were to a similar extent. Significant reduction in total exercise duration after both ivabradine and metoprolol therapy was observed. One patient developed blurring of vision with ivabradine therapy but did not require discontinuation of drug. An improvement in dyspnea of one grade was observed in all the patients by treatment with both ivabradine and metoprolol. Conclusions: Both metoprolol and ivabradine reduced symptoms and improved hemodynamics significantly from baseline to a similar extent. Ivabradine thus can be used effectively and safely in patients with MS in normal sinus rhythm who are intolerant or contraindicated for beta-blocker therapy.

Giant right atrial aneurysm presenting as right heart failure.

Idiopathic aneurysmal dilatations of the right atrium are rare anomalies. We report one such case of a young man presenting with fatigue, abdominal distension, pedal oedema, unremarkable cardiac examination except for raised jugular venous pressure, an electrocardiogram showing normal sinus rhythm with right bundle-branch block, and an radiograph of the chest showing cardiomegaly. The echocardiographic examination revealed a giant right atrium with low pressure tricuspid regurgitation. The computed tomography confirmed the findings of two-dimensional echocardiography. He was put on medical treatment and remained symptomatically controlled on follow-up.

Giant Aorto–Right Ventricular Fistula With Single Coronary Artery

A 15-year-old boy with symptoms of dyspnea and fatigue since early childhood was referred to our institution for evaluation. Physical examination of the patient showed long, slender extremities and a pectus carinatum deformity of the chest (Figure 1A). His arm span–to-height ratio was 1.03, and his upper segment–to–lower segment ratio was 0.82. He had blood pressure of 126/70 mm Hg, with a heart rate of 96 bpm; a grade 4/6 continuous murmur was present in the right lower parasternal area. A 12-lead ECG showed right bundle-branch block (Figure 2), and chest radiography (posteroanterior view) revealed mild cardiomegaly. Radiography of the thoracolumbar spine of the patient disclosed a mild degree of scoliosis (inset, Figure 1A). Two-dimensional echocardiography (parasternal long-axis view) showed a large fistula (2 cm in diameter) arising from the right aortic sinus (Figure 1B; online-only Data Supplement Movie I). A tilted apical 4-chamber view showed a turbulent jet (velocity 3.5 m/s) at the free wall of the right ventricle (Figure 1C; online-only Data Supplement Movie II). Three-dimensional echocardiography in a tilted apical 5-chamber view showed a broad tunnel arising from the aorta (Figure 1D; online-only Data Supplement Movie III). Computed tomographic cardiac angiography revealed the presence of a …

Prevalence and control of cardiovascular risk factors in stable coronary artery outpatients in India compared with the rest of the world: An analysis from international CLARIFY registry

Objectives We describe the clinical characteristics, prevalence and control of coronary artery disease (CAD) risk factors of the Indian cohort enrolled in the CLARIFY registry and compare them with data from rest of the world (ROW). Methods CLARIFY is an international, prospective, observational, longitudinal cohort study in stable CAD outpatients. The baseline data of Indian cohort (n = 709) were compared to ROW (n = 31994). Results The CLARIFY India patients were significantly younger than the ROW (59.6 ± 10.9 vs 64.3 ± 10.4). Indian patients were more likely than those in ROW to have diabetes (42.9% vs 28.8%) and angina (27.8% vs 21.9%). Mean heart rate was significantly greater in Indians measured by either palpatory method (76.1 ± 10.4 vs 68.0 ± 10.5) or ECG (74.9 ± 12.9 vs 67.0 ± 11.3). The use of aspirin (85.6% vs 87.8%), β-blockers (69.4% vs 75.4%), and lipid-lowering agents (90% vs 92.4%) was lower in India. A significantly greater proportion of patients in India exhibited low HDL cholesterol (41.6% vs 31.2%), and heart rate ≥70 bpm (82.2% vs 48.5%). The risk factors control was poor in India with heart rate goal of ≤60 bpm achieved in 2.5%; HbA1c <7% in 9.9%; and HbA1c <6.5% in 4.6% patients. Conclusion The CLARIFY registry demonstrates a high prevalence and poor control of cardiovascular risk factors in Indian patients. Systematic efforts to improve risk factor control are required.

Optimal fluid amount for haemodynamic benefit in cardiac tamponade.

Objectives: The present study was undertaken to assess the effect of volume expansion on cardiac haemodynamics in patients with cardiac tamponade and to ascertain an optimum amount of fluid that can produce the maximum benefit in tamponade patients. Background: In patients of tamponade, interim measures may occasionally be needed when facilities for pericardial fluid drainage are not immediately available. Intravascular volume expansion is the most commonly advocated measure but with limited scientific data. Methods: Patients ≥16 years of age with large circumferential pericardial effusion and showing echocardiographic evidence of cardiac tamponade were included. Haemodynamically unstable patients, those with structural heart diseases, pregnant females, and those undergoing haemodialysis were excluded. The various haemodynamic parameters were measured using Edwards Life Sciences Vigilance II monitor, Swan Ganz CCO catheter, intrapericardial access, and arterial access at baseline and after each 250 ml fluid over 5 min (total 1000 ml in 20 min). The entire fluid was drained at the end of the procedure. Results: A total of 28 patients constituted the study group, all of whom exhibited an improvement in haemodynamic parameters (systolic blood pressure, cardiac output) and a rise of the intracardiac pressures with volume expansion. Significant (p<0.05 ) increase in systolic and diastolic blood pressure, cardiac output, and cardiac index occurred up to 250–500 ml bracket; above which the significance was lost. A higher resting heart rate, a lower SBP at presentation, a higher initial intrapericardial pressure, and a lower cardiac index were the statistically significant predictors of a >15% increase in cardiac index. Conclusions: Rapid infusion of as little as 250 ml intravenous normal saline may improve the cardiac haemodynamics in a significant proportion of tamponade patients.