S.K. Dwivedi

Clinical presentation, management, and outcomes in the Indian Heart Rhythm Society-Atrial Fibrillation (IHRS-AF) registry

Aim A national atrial fibrillation (AF) registry was conducted under the aegis of the Indian Heart Rhythm Society (IHRS), to capture epidemiological data-type of AF, clinical presentation and comorbidities, current treatment practices, and 1-year follow-up outcomes. Methods A total of 1537 patients were enrolled from 24 sites in India in the IHRS-AF registry from July 2011 to August 2012. Their baseline characteristics and follow-up data were recorded in case report forms and subsequently analyzed. Results The average age of Indian AF patients was 54.7 years. There was a marginal female preponderance – 51.5% females and 48.5% males. At baseline, 20.4% had paroxysmal AF; 33% had persistent AF; 35.1% had permanent AF and 11% had first AF episode. At one-year follow-up, 45.6% patients had permanent AF. Rheumatic valvular heart disease (RHD) was present in 47.6% of patients. Hypertension, heart failure, coronary artery disease, and diabetes were seen in 31.4%, 18.7%, 16.2%, and 16.1%, respectively. Rate control was the strategy used in 75.2% patients, digoxin and beta-blockers being the most frequently prescribed rate-control drugs. Oral anticoagulation (OAC) drugs were used in 70% of patients. The annual mortality was 6.5%, hospitalization 8%, and incidence of stroke 1%. Conclusions In India, AF patients are younger and RHD is still the most frequent etiology. Almost two-third of the patients have persistent/permanent AF. At one-year follow-up, there is a significant mortality and morbidity in AF patients in India.

Giant coronary artery aneurysm following implantation of Endeavour stent presenting with fever

Coronary artery aneurysms are a known but uncommon complication of percutaneous coronary intervention (PCI) probably related to effects of vessel wall trauma and possibly a combination of hypersensitivity and incomplete endothelisation associated with drug-eluting stents (DES). We present here a case of giant coronary artery aneurysm 3 months following implantation of a zotarolimus eluting endeavour stent presenting with fever.

Efficacy of multi-detector coronary computed tomography angiography in comparison with exercise electrocardiogram in the triage of patients of low risk acute chest pain.

OBJECTIVESnTo compare the safety and diagnostic efficacy of coronary computed tomography angiography (CTA) with exercise electrocardiography (XECG) in triaging patients of low risk acute chest pain.nnnBACKGROUNDnNoninvasive assessment of coronary stenosis by CTA may improve early and accurate triage of patients presenting with acute chest pain to the emergency department (ED).nnnMETHODSnLow risk patients of possible acute coronary syndrome (ACS) were included in the study. The patients in CTA arm with significant stenosis (≥ 50%) underwent catheterization, while those with no or intermediate stenosis (<50%) were discharged from ED and followed up periodically for six months for major adverse cardiovascular events (MACE). The same protocol was applied for XECG arm. Outcomes included: safety and diagnostic efficacy.nnnRESULTSnA total of 81 (41 CTA and 40 XECG) patients were enrolled. In this study CTA was observed to be 100% sensitive and 95.7% specific in diagnosing MACE in low risk patients of chest pain presenting to the ED, with a PPV of 94.7% and an NPV of 100%.The overall diagnostic efficacy was 97.6%. XECG was observed to be 72.7% sensitive and 96.6% specific in diagnosing MACE with a PPV of 88.9% and NPV of 90.3% in low risk chest pain patients presenting to the ED. The overall diagnostic accuracy was 90%.nnnCONCLUSIONnCTA is an excellent diagnostic tool in ED patients with low risk of ACS, with minimum time delay as compared to XECG, and also is safe for triaging such patients.

Prognostic value of Angiographic Perfusion Score (APS) following percutaneous interventions in acute coronary syndromes

INTRODUCTIONnIdentifying reperfusion and predicting post procedure risk is important following Percutaneous Coronary Interventions (PCI). An Angiographic Perfusion Score (APS) combining TIMI flow (TFG) and myocardial perfusion (TMPG) grades before and after PCI can accurately measure both epicardial and myocardial perfusion and predict Major Adverse Cardiac Events (MACE).nnnPATIENTS AND METHODSnAPS was calculated in 226 (88 ST elevation Myocardial Infarction (STEMI) and 138 Non STEMI) patients. Maximum score being 12, reperfusion was defined as failed: 0-3, partial: 4-9, and full APS: 10-12. Thirty day MACE were observed.nnnRESULTSnAPS identified reperfusion significantly more than TMPG alone (STEMI: 50.6% vs 11.8% (p < 0.001); Non STEMI, early reperfusion: 69.4% vs 52.8% (p < 0.01) and Non STEMI late reperfusion: 38.2% vs 7.8%; (p ≤ 0.001) respectively. A significantly lower incidence of MACE was observed in the full as compared to the failed APS group (1.8% vs 22.5%) (p < 0.001). No differences were noted between TMPG 0-2 (9.8%, 9.4%, 7.3%, respectively) (p = NS).nnnCONCLUSIONnCompared to MPG alone APS detects more low risk reperfused patients, post PCI.

Comparative assessment of platelet GpIIb/IIIa receptor occupancy ratio with Eptifibatide/Tirofiban in patients presenting with ACS and undergoing PCI.

BACKGROUNDnThe level of platelet inhibition by a Glycoprotein IIb/IIIa (GpIIb/IIIa) antagonist therapy necessary to minimize thrombotic complications in patients undergoing percutaneous coronary intervention (PCI) is a subject of debate. The degree of platelet inhibition obtained 10 min after start of GpIIb/IIIa antagonist therapy predicts adverse events after PCI. The aim of this study was to look at platelet inhibition and to compare platelet GpIIb/IIIa receptors occupancy ratio (GpRO) with Eptifibatide and Tirofiban using various dose regimens and correlate with 30-day clinical outcomes in patients presenting with high-risk acute coronary syndromes (ACS) and undergoing PCI.nnnMETHODSnThe patients were divided into four sub groups: (1) Eptifibatide two intracoronary bolus (180 μg/kg) alone (E(B)); or (2) two intravenous bolus (180 μg/kg) followed by infusion at 2 μg/kg/min for 24 h (E(B + Inf)); and (3) Tirofiban standard bolus dose (0.4 μg/kg) over 30 min followed by infusion at 0.1 μg/kg/min (T(Std)); or (4) at ADVANCE dose bolus (25 μg/kg) over 3 min, followed by infusion at 0.1 μg/kg/min (T(Adv)). Number of GpIIb/IIIa receptors was assessed by flow cytometry at baseline and 10 min after the bolus and percentage of free receptors was determined to calculate the GpRO. Patients were followed for 30 days for any major adverse cardiac events (MACE).nnnRESULTSn200 consecutive patients (including 74% with ST-elevation ACS) were enrolled. GpRO in groups E(B) (n = 48) and E(B + Inf) (n = 44) were 62.7% ± 27.2% and 61.4% ± 6.1% respectively while in the groups T(Std) (n = 96) and T(Adv) (n = 12) groups were 35.1% ± 17.74% and 68.8% ± 27.3% respectively. The GpRO was similar in E(B), E(B + Inf) and T(Adv) groups and was significantly higher than T(Std) group (p < 0.0001). The 30-day MACE rates in E(B) (4.2%), E(B + Inf) (4.5%) and T(Adv) (4.2%) were significantly lower than T(Std) group (12.5%) (p < 0.01).nnnCONCLUSIONSnStandard dose Tirofiban results in significantly lower rates of GpIIb/IIIa receptor occupancy ratio and this correlated with higher incidence of 30-day MACE in high-risk ACS patients undergoing PCI.

Syndrome ‘Z’: A Predictor of Angiographic Severity of Coronary Artery Disease in Patients of Acute Coronary Syndrome

BACKGROUNDnOwing to the growing evidence that the pathophysiology of obstructive sleep apnoea (OSA) and metabolic syndrome (MS) overlap considerably and both adversely impact cardiovascular health, we hypothesised that the presence of OSA with MS additively and adversely affect the severity of coronary artery disease (CAD). Exploration and understanding of this may have direct implications for the development of targeted, preventive strategies for CAD. Thus, this prospective study was aimed to determine the prevalence of Syndrome Z in patients of MS who present with an acute coronary event and to correlate it with the angiographic severity of CAD in these patients.nnnMETHODSnThe present study was a single centre, cross sectional study conducted in a university teaching hospital. In a span of 6 months, 922 patients with acute coronary syndromes (ACS) were screened for the study. Among these, 861 patients had no evidence of MS. The remaining 61 patients who were diagnosed to have MS were then subjected to an overnight sleep study. Only 58 had good sleep data so were included for further analysis. Angiographic parameters in terms of number of vessels involved and culprit lesions were noted and correlated with presence and absence of OSA and also with its severity based on the Apnoea/Hypopnoea Index (AHI).nnnRESULTSnThe prevalence of OSA positivity in patients with MS who presented with ACS was 34.5% (n=20). Most of the patients in the OSA negative group (78.9%, n=30) had disease limited to only one vessel while in the OSA positive group only a minority (15%, n=3) of patients had their disease limited to a single vessel (p=0.001). The number of lesions in the culprit vessel was also significantly less in the OSA negative group compared to the OSA positive group. While in the OSA negative group 68.4% (n=26) patients had a solitary lesion, followed by two and three lesions in 15.8% (n=6) of the patients each, multiple lesions were more common in OSA positive patients, involving 80% of cases (45.0%, n=9 with two lesions; 35.0%, n=7 with three lesions; only 20%, n=4 had a solitary lesion).nnnCONCLUSIONSnPrevalence of Syndrome Z is high in patients having MS presenting with ACS and it correlates with the angiographic severity of CAD.

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.

The prediction of left main and/or triple-vessel coronary artery disease by tissue doppler-based longitudinal strain and strain-rate imaging

Background: In the absence of evident regional wall motion abnormality (RWMA) at rest, detection of severe coronary artery disease (CAD) usually requires a stress test. Ventricular strain is a more sensitive parameter of myocardial systolic function and may be abnormal in patients with severe CAD. Thus, this study aimed to evaluate the longitudinal strain and strain-rate imaging for prediction of left main (LM) and triple-vessel disease CAD with normal left ventricular ejection fraction (LVEF) and no RMWA. Materials and Methods: Patients included were of stable CAD, unstable angina, or non-ST segment elevation myocardial infarction with LVEF >50% and without RWMA. A thorough echocardiographic evaluation to assess peak systolic longitudinal strain (PSLS) and PSLS rate (PSLSR) in 16 segments of the left ventricle was done. The visual evaluation of percent diameter stenosis of the angiographic lesions was done according to the American Heart Association classification. Patients were grouped into high-risk group (LM or triple-vessel CAD), low-risk group (CAD other than high risk), and normal group (absence of CAD). Results: A total of 86 patients were studied. Of which, 60 were male and 26 were female. The global PSLS and PSLSR were lower in the high-risk group as compared to the other two groups (P < 0.001). The combined basal plus mid-PSLS and PSLSR were lower in the high-risk group (P < 0.001). Receiver operating characteristic curve analysis showed an optimal cutoff value of −17.3% (sensitivity 82% and specificity 80%) for global PSLS and −15.0% (sensitivity 75% and specificity 73%) for basal plus mid-PSLS for detection of high-risk CAD. Similarly, a cutoff value of −0.74 s−1 (sensitivity 82% and specificity 73.6%) for global PSLSR and −0.66 s−1 (sensitivity 85.7% and specificity 86.7%) for basal plus mid-PSLSR were calculated for the prediction of high-risk CAD. Conclusion: The PSLS and PSLSR were lower in patients having high-risk CAD that included LM and triple-vessel disease, even when resting wall motion and LVEF were normal. The study concluded that PSLS and PSLSR are sensitive and specific noninvasive modalities for predicting the possibility of high-risk CAD in the presence of normal LV systolic function and absence of resting RWMA.

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.

Percutaneous balloon pericardiotomy for the treatment of recurrent malignant pericardial effusion.

Malignant disease with pericardial metastasis is one of the most common causes of recurrent pericardial effusion (PE) with tamponade. While surgical pericardiotomy in these patients is very morbid and may not be a viable option, a palliative treatment percutaneously with percutaneous balloon pericardiotomy (PBP) can be a preferred treatment. We report herewith a case of PBP technique done using our day-to-day catheterisation laboratory equipment.