Sanjeev Asotra

Gender differences in the management of acute coronary syndrome patients: One year results from HPIAR (HP-India ACS Registry)

INTRODUCTION Data from high-income countries suggest that women receive less intensive diagnostic and therapeutic management than men for acute coronary syndrome (ACS). There is a paucity of such data in the Indian population, which is 69% rural and prior studies focused mostly on urban populations. The objective of the present study was to identify the gender based differences in ACS management, if any, in a predominantly rural population. METHODS Data from 35 hospitals across Himachal Pradesh covering >90% of state population were collected for one year (July 2015-June 2016). A total of 2118 ACS subjects met inclusion criteria and baseline characteristics, in-hospital treatments and mortality rates were analyzed. RESULTS Women constituted less than one-third of ACS population. Women were older compared to men and were more likely to present with NSTEMI/UA. Misinterpretation of initial symptoms and late presentation were also common in women. Fewer women received optimal guideline based treatment and PCI (0.9% vs 4.2%, p<0.01). Compare to men, women more often had Killip class >1 (27.3% vs 20.4%, p<0.01) and higher in-hospital mortality (8.5% vs 5.6%, p=0.009). On multivariate analysis the association between female gender and mortality was attenuated (adjusted odds ratio [OR]=1.36 [0.77-2.38]). CONCLUSION The present study from India, is the first of its kind to evaluate the gender based differences among ACS patients, in a predominantly rural population. Our analysis demonstrates a significant gender based difference between symptom awareness and delay in presentation, management and in-hospital outcome. Further studies are warranted across other parts of country to investigate this gender disparity.

Epidemiological Study of Chronic Mountain Sickness in Natives of Spiti Valley in the Greater Himalayas

AIMS This study determined the prevalence of chronic mountain sickness (CMS) and its predisposing factors among natives of Spiti Valley in the northern state of Indian Himalayas. A cross-sectional survey study was conducted in natives of Spiti Valley aged ≥ 20 years residing at altitudes of 3000 to 4200 meters. CMS was diagnosed using Qinghai criteria. Demographics, behavioral characteristics, specified symptoms of CMS were recorded, including BP, anthropometrics, evidence of RHF, PAH, and severe cyanosis. ECG, echocardiography, PFT, and Sao2 were recorded, and Hb level was estimated with the cyanmethhemoglobin method. RESULTS 694 subjects free of cardiorespiratory diseases were analyzed. Prevalence of CMS was 28.7%, (95% C.I. of 25.9%-32.8%) and was higher in women than in men (36.6% vs. 15.7%, p<0.001). Erythrocythemia and hypoxemia were recorded in 10.5% and 7.5%, respectively. Age, truncal obesity, female gender, altitude of residence, and physical activity index were independent predictors of CMS with z statistics of 4.2, 2.29, -3.7, 2.8, and -2.8, respectively, and were statistically significant p<0.001. 6.2% of the surveyed population had HAPH. CONCLUSION 28.7% (95% C.I. of 25.9%-32.8%) of the natives of the Spiti Valley in the Indian Himalayas are affected with CMS. Higher prevalence of CMS amongst women needs further studies. Westernized lifestyle appears to have predisposition to CMS.

Prevalence of High Altitude Pulmonary Hypertension Among the Natives of Spiti Valley—A High Altitude Region in Himachal Pradesh, India

The study aimed to determine the prevalence of high altitude pulmonary hypertension (HAPH) and its predisposing factors among natives of Spiti Valley. A cross-sectional survey study was done on the permanent natives of Spiti Valley residing at an altitude of 3000 m to 4200 m. Demographic characteristics, health behavior, anthropometrics, and blood pressure were recorded. Investigations included recording of 12 lead electrocardiogram (ECG), SaO2 with pulse oximeter, spirometry and echocardiography study, and measurement of Hb levels using the cynmethhemoglobin method. HAPH was diagnosed using criteria; tricuspid regurgitation (TR) gradient of ≥46 mmHg. ECG evidence of RV overload on 12 lead ECG was documented based on presence of 2 out of 3 criteria; R>S in V1, right axis deviation or RV strain, T wave inversion in V1 and V2. Data of 1087 subjects were analyzed who were free of cardiorespiratory diseases to determine the prevalence of HAPH and its predisposing factors. HAPH was recorded in 3.23% (95% C.I. of 0.9-8.1%) and ECG evidence of right ventricular (RV) overload was 1.5% in the study population. Prevalence of HAPH was not different in men and women 2.63% vs. 3.54% p<0.2. Age (Z statistics of 3.4 p<0.0006), hypoxemia (Z statistics of 2.9 p<0.002), and erythrocythemia (Z statistics of 4.7 p<0.003) were independently associated with HAPH. Altitude of residence was not found to be significantly associated with HAPH, although there was a trend of increasing prevalence with increasing altitude. It can be concluded that HAPH is prevalent in 3.23% of natives of Spiti Valley. Increasing age, erythrocythemia and hypoxemia are independent predisposing factors.

Comparison of Risk Factor Profile and Angiographic Pattern AmongPre-Menopausal and Post-Menopausal Women Presenting with Angina:Results from a Prospective Single Center Observational Study

Background: Coronary artery disease (CAD) has become the major killer in women. The exact mechanism of postmenopausal increase in CAD is still under research. Limited data exists on the comparison of risk factor profiles and angiographic disease patterns in premenopausal and postmenopausal women. Methods: This prospective study included a total of 674 consecutive female patients who underwent coronary angiogram for suspected ischemic heart disease over a period of 2 years from March 2015. Detailed risk factor profiles and angiographic patterns of disease were recorded and analyzed using EPIINFO statistical software. Results: Out of total 674 patients, 137(20.3%) were in the premenopausal group with mean age of (42.05 ± 4.40) years, and 537(79.7%) in the postmenopausal group with mean age of (59.05 ± 8.01) years. Premenopausal women were more likely to be obese (57.7% vs 46.9%, p=0.0), hypothyroid (23.4% vs 10.2%, p 3 risk factors more frequently (42.1% vs 30.7%, p=0.009). Atypical chest pain was more common as presenting diagnosis among premenopausal women (23.4% vs 10.2%, p<0.0001). They were also more likely to have positive exercise stress test (62.1% vs 38.3%, p<0.0001) and normal coronary angiogram (59.9% vs 32%, p<0.0002) with endothelial dysfunction (84.7% vs 66.8%, p<0.0001) than post-menopausal women. Post-menopausal women had greater burden of obstructive CAD characterized by more prevalent multivessel disease in the form of double vessel (17.5% vs 8%, p=0.06) and triple vessel disease (20.5% vs 5.8%, p<0.0002). Conclusion: There is a distinct difference between the risk factor profile and angiographic disease pattern among women according to the status of menopause. Recognition of these differences would help in better understanding of relationship of menopause to development of CAD.

Infravalvular type of Gerbode defect: a rare cardiac anomaly

A Gerbode defect is a rare type of ventricular septal defect (VSD), classically described as a direct communication between left ventricle (LV) and right atrium (RA).1 However, it may be supravalvular (direct shunt), infravalvular (indirect shunt) or mixed. The infravalvular type is a VSD with a left-to-right shunt at the ventricular level, associated with tricuspid regurgitation (TR), which directs the high-velocity shunt into RA.2 ,3 A 43-year-old woman presented with symptoms of dyspnoea and palpitations. Clinical examination revealed a pansystolic murmur and grade 2 parasternal heave. ECG depicted biventricular hypertrophy along with biatrial enlargement. Echocardiogram showed a 9 mm perimembranous VSD with left-to-right shunt (figure 1). Careful observation revealed two …

Inferior wall STEMI presenting with a ruptured intraseptal pseudoaneurysm

A 78-year-old man presented with progressively increasing dyspnoea, 2 weeks after experiencing ST elevation inferior wall myocardial infarction that was not thrombolysed because of late presentation. He was Killip class 2 with raised jugular venous pressure. Cardiac auscultation revealed a grade 4 harsh systolic murmur in the lower left parasternal area, and a loud S2 with a prominent right ventricular S3. Echocardiography demonstrated akinetic and thinned out basal inferior and basal inferior septal segments (video 1). A pseudoaneurysm extending from the inferior septum was noticed (video 1 and figure 1A), which was thin walled and had a relatively narrow entrance, with a shelf-like overhanging edge (figure 2). Colour flow signals demonstrated marked turbulence of blood flow from the cavity of the left ventricle (LV) into the pseudoaneurysm and then into the right ventricular cavity, confirming rupture into the right ventricle (RV) (figures 1B and 3). An emergent cardiac MRI confirmed …

Hypercholesterolaemic valvulopathy in a young woman with heterozygous familial hypercholesterolaemia

A 19-year-old woman presented with dyspnoea, angina and exertional syncope for the past 1 year. She had an ejection systolic murmur in the aortic area radiating to the carotids. She had multiple skin xanthomas over her feet, knees, hands and buttocks (figure 1). Echocardiography revealed severe calcific aortic stenosis (figure 2). Her serum low-density lipoprotein (LDL) was 391 mg/dL, while triglycerides were normal. Her father and brother also had very high LDL levels and a few xanthomas but no features of aortic stenosis. Her mother and two sisters had normal LDL levels. …

Successful device closure of a ruptured sinus of Valsalva aneurysm presenting with acute heart failure

A sinus of Valsalva aneurysm (SVA) is an uncommon cardiac anomaly that can be congenital or acquired. SVAs were present in 0.09% of cadavers in a large autopsy series and ranged between 0.14–0.23% in a Western surgical series.1 A congenital SVA is usually clinically silent but may vary from a mild, asymptomatic dilation detected in routine two-dimensional echocardiography, to symptomatic presentations related to the compression of adjacent structures or intracardiac shunting caused by rupture of the SVA into the right side of the heart. Approximately 65–85% of SVAs originate from the right sinus of Valsalva, while SVAs originating from non-coronary (10–30%) and left sinuses (<5%) are exceedingly rare. The most common …

Prevalence, risk determinants and consequences of atrial fibrillation in rheumatic heart disease: 6 years hospital based-Himachal Pradesh- Rheumatic Fever/Rheumatic Heart Disease (HP-RF/RHD) Registry

Objective To report the prevalence, risk factors and consequences of atrial fibrillation (AF) in patients of rheumatic heart disease (RHD). Methods The Himachal Pradesh- Rheumatic Fever/Rheumatic Heart Disease (HP-RF/RHD) Registry database of 1918 patients was analyzed. AF was diagnosed with 12-lead ECG recording at entry in to the registry. The association of AF with nature and severity of valvular dysfunction was analyzed, adjusted for age, left atrial (LA) dimension and pulmonary arterial hypertension using multivariable logistic regression model and strength of association was reported as odds ratio (OR) with 95% confidence intervals (C. I.). Results The study population consisted of young (40.2 ± 14.3 years), predominantly females (72.3%) from rural area (94.1%). Prevalence of AF was 23.9% (95% C. I. 22.1%–25.8%). The independent determinants AF were age (OR 1.04, 95% C.I. 1.03–1.06), LA size (OR 1.10, 95% C.I. 1.08–1.11). The association of AF with age, New York Heart Association functional class, mitral stenosis severity and tricuspid regurgitation was statistically significant and graded. Mitral regurgitation and aortic valve disease had no significant independent association with AF. The prevalence of heart failure, stroke, peripheral embolism and mortality was significantly higher among patients with AF (p < .01). Conclusion AF is common in RHD patients and is significantly associated with heart failure and systemic thromboembolism. Age, mitral stenosis severity, tricuspid regurgitation and LA size were independently associated with AF.

School-based surveillance for detection of children with acute pharyngitis, rheumatic fever/rheumatic heart disease in Shimla district, Himachal Pradesh, India—A cluster randomized controlled trial

Background The lack of surveillance system is a major barrier in prevention and control of rheumatic fever/rheumatic heart disease (RF/RHD). Efficacy of school-based surveillance was evaluated for detection of acute pharyngitis and RF/RHD in Shimla district, HP. Methods The schools in district Shimla were randomly assigned to intervention and controlled arm (442 vs. 441 schools). The trained nodal teachers reported children with symptoms of acute pharyngitis and or RF/RHD in intervention arm and children taken to hospitals by parents for symptoms of acute pharyngitis and or RF/RHD under control arm through mobile phone to coordinating centre. Final outcome for presence of RF/RHD or other heart Diseases was recorded after examination at nearest primary health centers and/or at Indira Gandhi Medical College Hospital, Shimla. Difference in detection rate between intervention arm and control arm was compared using Z test. Results The number of school children reported from intervention group was significantly higher than in control due to suspected symptoms of acute pharyngitis and or RF/RHD were 65 (2.84/1000) and 15 (0.60/1000), respectively (p < 0.01). Only 4 children in each arm were found to have heart diseases, with prevalence of (0.17/1000 and 0.16/1000), respectively, after clinical and echocardiography evaluation. In intervention arm, one child had RHD while three had congenital heart disease; in control arm, one child had congenital heart disease and three had RHD. Conclusions School based surveillance had higher rate of suspecting children with acute pharyngitis and or RF/RHD although with low specificity. There is a need of future studies to demonstrate the effectiveness of the proposed intervention in endemic regions of the state.