Sharad Bajaj

Acute ST-segment elevation myocardial infarction in young adults: who is at risk?

ObjectiveLess than 10% of patients presenting with acute myocardial infarction (AMI) are young adults. The primary objective of this study was to provide an overview of similarities and dissimilarities among younger and older patients presenting with AMI with the expectation of using the information as an aid in primary and secondary preventions in the future. MethodsFrom the database of 3527 patients with AMI admitted from January 2001 to December 2008, young adults aged 21–40 years (n=43) who were diagnosed with ST-segment elevation myocardial infarction were identified. They were then compared with their older counterparts who were admitted from January 2007 to December 2008 subdivided into age groups of 41–60 (n=86) and 61–80 years (n=51). Data on clinical cardiovascular risk factors, demographic features, and angiographic findings were gathered and analyzed. ResultsOnly 2.58% of ST-segment elevation myocardial infarction patients who were admitted to our hospital over an 8-year period were less than 40 years. Young adults were found to be predominantly male patients (P=0.04) and had positive family history for coronary artery disease (P=0.0005). Diabetes and hypertension were less prevalent in the younger group (P=0.048 and 0.078). Analysis of lipid profile showed comparatively higher total cholesterol, low-density lipoprotein and high-density lipoprotein values in the younger group (⩽P=0.004). Angiographically, youngsters had propensity toward single-vessel involvement (P=0.0001). ConclusionThe risk factor profile and the angiographic involvement differ considerably in the high-risk younger adults and substantiate the need for an aggressive approach directed toward primary and secondary preventions of premature cardiovascular disease.

Rapid Progression of Coronary Atherosclerosis: A Review

Atherosclerosis is chronic disease, the prevalence of which has increased steadily as the population ages. Vascular injury is believed to be critical initiating event in pathogenesis of spontaneous atherosclerosis. Syndrome of accelerated atherosclerosis has been classically described in patients undergoing heart transplantation, coronary artery bypass graft, and percutaneous transluminal coronary angioplasty. In contrast to spontaneous atherosclerosis, denuding endothelial injury followed by thrombus formation and initial predominant smooth muscle cell proliferation is believed to be playing a significant role in accelerated atherosclerosis. There is no universal definition of rapid progression of atherosclerosis. However most studies describing the phenomenon have used the following definition: (i) > or = 10% diameter reduction of at least one preexisting stenosis > or = 50%, (ii) > or = 30% diameter reduction of a preexisting stenosis <50%, and (iii) progression of a lesion to total occlusion within few months. Recent studies have described the role of coronary vasospasm, human immunodeficiency virus, various inflammatory markers, and some genetic mutations as predictors of rapid progression of atherosclerosis. As research in the field of vascular biology continues, more factors are likely to be implicated in the pathogenesis of rapid progression of atherosclerosis.

Acute Myocardial Infarction Caused by Infective Endocarditis

![Figure][1] [![Graphic][3] ][3][![Graphic][4] ][4][![Graphic][5] ][5] A 65-year old man with a history of intravenous drug use and bioprosthetic aortic valve replacement 1 year ago because of infective endocarditis presented to our emergency department with new-onset chest

Aortic Dissection Caused by Percutaneous Coronary Intervention: 2 New Case Reports and Detailed Analysis of 86 Previous Cases.

Aortic dissection, a rare sequela of percutaneous coronary intervention, can be fatal when it is not recognized and treated promptly. Treatment varies from conservative management to invasive aortic repair and revascularization. We report the cases of 2 patients whose aortic dissection was caused by percutaneous coronary intervention. In addition, we present detailed analyses of 86 previously reported cases. Aortic dissection was most often seen during intervention to the right coronary artery (in 76.7% of instances). The 2 most frequently reported causes were catheter trauma (in 54% of cases) and balloon inflation (in 23.8%). The overall mortality rate was 7.1%. We conclude that most patients can be treated conservatively or by means of stenting alone, with no need for surgical intervention.

Diagnostic Yield of Echocardiography in Syncope Patients with Normal ECG.

Aim. This study aimed to assess the role of echocardiography as a diagnostic tool in evaluating syncope patients with normal versus abnormal electrocardiogram. Methods. We conducted a retrospective study of 468 patients who were admitted with syncope in 2011 at St. Josephs Regional Medical Center, Paterson, NJ. Hospital records and patient charts, including initial emergency room history and physical, were carefully reviewed. Patients were separated into normal versus abnormal electrocardiogram groups and then further divided as normal versus abnormal echocardiogram groups. Causes of syncope were extrapolated after reviewing all test results and records of consultations. Results. Three hundred twelve of the total patients (68.6%) had normal ECG. Two-thirds of those patients had echocardiograms; 11 patients (5.7%) had abnormal echo results. Of the aforementioned patients, three patients had previous documented history of severe aortic stenosis on prior echocardiograms. The remaining eight had abnormal but nondiagnostic echocardiographic findings. Echocardiography was done in 93 of 147 patients with abnormal ECG (63.2%). Echo was abnormal in 27 patients (29%), and the findings were diagnostic in 6.5% patients. Conclusions. This study demonstrates that echocardiogram was not helpful in establishing a diagnosis of syncope in patients with normal ECG and normal physical examination.

The Prevalence of Peripheral Arterial Disease in HIV Patients

Background: The actual prevalence of Peripheral Arterial Disease (PAD) in Human Immunodeficiency Virus (HIV) infected patients is still unknown. Aim: The aim of our study was to assess the prevalence of PAD using Ankle Brachial Index (ABI) (both rest and exercise) measurement in HIV infected patients with head-to-head comparison with the sex-matched non-HIV controls. Methods: We randomly enrolled total of 214 patients (70 HIV patients and 144 non-HIV controls), from March 2009 to December 2009. The Edinburg Claudication Questionnaire and ABI were used as study tools. Normal ABI was defined as 0.9 to 1.3. Data was analyzed using the Fischer’s Exact Test. Various cardiovascular and infectious risk factors for PAD were also analyzed. Results: Claudication was reported using Edinburgh questionnaire in 28.5% HIV patients as compared to 12.5 % patients in non-HIV group (p value 0.0069). Abnormal ABI suggestive of PAD i.e. ABI 15% absolute drop on exercise was reported in 10% HIV patients as compared to 1.3% in non-HIV group (p value 0.006). Based on multivariate analysis, age, Caucasian race, hypertension, diabetes mellitus, hyperlipidemia, metabolic syndrome and low CD4 count were found to be independent predictors of PAD. Conclusions: The prevalence of PAD is higher in HIV patients as compared to sex-matched non-HIV controls. Hence, HIV patients should be routinely screened for PAD using rest and exercise ABI. Apart from correlation with cardiovascular risk factors, strong association between lower CD4 cell count and abnormal ABI exists. This warrants more aggressive approach in managing cardiovascular and infectious markers in HIV patients with abnormal ABI.

A Giant Left Atrial Myxoma

Atrial myxomas are the most common primary cardiac tumors. Patients with left atrial myxomas generally present with mechanical obstruction of blood flow, systemic embolization, and constitutional symptoms. We present a case of an unusually large left atrial myxoma discovered incidentally in a patient with longstanding dyspnea being managed as bronchial asthma.

Role of an Implantable Cardioverter Defibrillator in Emery Dreifuss Muscular Dystrophy: A Case Report and a Review of the Literature

Role of an Implantable Cardioverter Defibrillator in Emery Dreifuss Muscular Dystrophy: A Case Report and a Review of the Literature Emery dreifuss muscular dystrophy (EDMD) is one of the three most common inherited muscular dystrophies characterized by a triad of contractures, muscle weakness, and cardiac involvement (conduction abnormalities and/or cardiomyopathy). It can be inherited as X-linked recessive, autosomal dominant or autosomal recessive pattern. Cardiac involvement is evident in virtually all cases by the end of 4th decade. There is no relationship between the severity of cardiac and skeletal muscle involvement, irrespective of the mode of inheritance and type of mutations.