Tanuj Bhatia

Erectile Dysfunction Precedes and Is Associated with Severity of Coronary Artery Disease among Asian Indians

INTRODUCTION Erectile dysfunction (ED) and coronary artery disease (CAD) often share common risk factors, and there is growing evidence that ED might serve as a clinical marker for cardiovascular disease. Despite rising trends of CAD in Asian Indians, limited data are available on the prevalence of ED and its correlation with CAD severity in such patients. AIM To study the prevalence of ED in Asian Indian patients undergoing coronary angiography and to assess if the severity of ED correlates with angiographic severity of CAD. METHODS In all patients undergoing coronary angiography, ED was assessed using the International Index of Erectile Function-5 questionnaire. MAIN OUTCOME MEASURES AND RESULTS Among 175 male patients, ED was present in 70%; patients with ED had a higher incidence of multivessel CAD (80% vs. 36%, P 0.001), diffuse CAD (81% vs. 34%, P 0.001), and higher number of mean coronary vessels involved compared with those without ED. Those with severe ED had higher prevalence of multivessel CAD and higher number of mean coronary vessels involved compared with those with milder grades of ED. Onset of symptoms of ED preceded symptoms of CAD by a mean of 24.6 months in 84% of patients. The presence of severe ED was associated with a 21-fold higher risk of having triple-vessel disease (odds ratio [OR] 21.94, 95% confidence interval [CI] 3.41-141.09, P = 0.001) and an 18-fold higher risk of having diffuse angiographic CAD (OR 17.91, 95% CI 3.11-111.09, P = 0.001). CONCLUSION Asian Indians with angiographic CAD frequently have ED; symptoms of ED precede that of CAD in most patients. Incidence of multivessel and diffuse CAD is significantly more common in patients with ED. It is important for physicians to be aware of the close relationship between the two conditions so that patients with ED can have optimal risk stratification for concomitant CAD whenever required.

Impaired flow-mediated vasodilatation in Asian Indians with erectile dysfunction.

Endothelial dysfunction is the postulated link between coronary artery disease (CAD) and erectile dysfunction (ED). Brachial artery flow-mediated vasodilatation (FMD) is a non-invasive surrogate marker for endothelial function assessment. Despite Asian Indians representing a considerable global CAD burden, data on FMD and ED in these patients are lacking. Of the 225 patients undergoing coronary angiography, 72% had ED (assessed using the International Index of Erectile Function (IIEF-5) questionnaire); ED was moderate to severe in 61% of the patients. ED patients had a higher incidence of severe and diffuse angiographic CAD, a greater number of coronary vessels involved and a lower mean brachial artery FMD (6.40%±4.60% vs. 9.10%±4.87%, P<0.001) compared to non-ED patients. A progressive reduction in FMD was noted with increasing severity of ED. Impaired FMD (≤5.5%) was twice as common in ED patients (52% vs. 24% without ED). Patients with impaired FMD had higher ED prevalence (85% vs. 62%) and lower mean IIEF-5 scores compared to those with normal FMD. Impaired FMD was a significant ED predictor independent of other risk factors (odds ratio, 2.33; 95% confidence interval: 0.59-9.23; P=0.03). An inverse correlation between FMD and ED severity was observed (r=-0.22; P=0.004). ED is common among Asian Indians with angiographically documented CAD. Patients with ED have impaired FMD independent of other risk factors, suggesting that endothelial dysfunction is the underlying pathophysiology. Urologists and cardiologists need to be aware of the association between ED, CAD and endothelial dysfunction.

Left ventricular remodeling after late revascularization correlates with baseline viability.

The ideal management of stable patients who present late after acute ST-elevation myocardial infarction (STEMI) is still a matter of conjecture. We hypothesized that the extent of improvement in left ventricular function after successful revascularization in this subset was related to the magnitude of viability in the infarct-related artery territory. However, few studies correlate the improvement of left ventricular function with the magnitude of residual viability in patients who undergo percutaneous coronary intervention in this setting. In 68 patients who presented later than 24 hours after a confirmed first STEMI, we performed resting, nitroglycerin-enhanced, technetium-99m sestamibi single-photon emission computed tomography-myocardial perfusion imaging (SPECT-MPI) before percutaneous coronary intervention, and again 6 months afterwards. Patients whose baseline viable myocardium in the infarct-related artery territory was more than 50%, 20% to 50%, and less than 20% were divided into Groups 1, 2, and 3 (mildly, moderately, and severely reduced viability, respectively). At follow-up, there was significant improvement in end-diastolic volume, end-systolic volume, and left ventricular ejection fraction in Groups 1 and 2, but not in Group 3. We conclude that even late revascularization of the infarct-related artery yields significant improvement in left ventricular remodeling. In patients with more than 20% viable myocardium in the infarct-related artery territory, the extent of improvement in left ventricular function depends upon the amount of viable myocardium present. The SPECT-MPI can be used as a guide for choosing patients for revascularization.

An Unusual Complication During Bronchoscopy: Hypotension, Global ST Segment Elevation, and Acute Severe Left Ventricular Systolic Dysfunction

Bronchoscopy is widely performed and generally considered safe. Cardiac complications during bronchoscopy are uncommon, and usually occur in elderly patients with coexistent coronary artery disease, hypertension, or severely impaired pulmonary function and resting hypoxemia. We report a patient who developed sudden onset restlessness, chest discomfort, hypotension, global ST elevation in multiple electrocardiogram leads, and acute severe left ventricular systolic dysfunction during a bronchoscopic transbronchial lymph node biopsy. Differential diagnosis included a massive myocardial infarction, apical ballooning (Tako-tsubo syndrome), or coronary vasospasm. The electrocardiogram changes resolved spontaneously, and a coronary angiogram 48 hours later revealed normal coronary artery anatomy and normal LV function. The patient made an uneventful recovery. It is important for physicians to be aware of such unusual complications to be able to appropriately manage these patients in clinical practice.

Rheumatic severe mitral stenosis with complete heart block.

Rheumatic fever presenting with complete heart block is very rare and usually transient. We describe a child with chronic severe rheumatic mitral stenosis with persistent complete heart block with interesting echocardiographic findings.

Tetralogy of Fallot With Infective Endocarditis: An Echocardiographic Explanation of Misleading Clinical Signs

Echocardiography has a known key role in the diagnosis of infective endocarditis, the diagnosis of complications, follow-up evaluation after therapy, and prognostic assessment Habib (Eur J Echocardiogr 11:202–219, 3). This report describes a boy with tetralogy of Fallot who presented with infective endocarditis and large vegetation occluding the ventricular septal defect, thus resulting in a hemodynamically restrictive ventriculoseptal defect with misleading clinical signs. This case illustrates the role of echocardiography in both explaining clinical signs and providing hemodynamic data.

ASSOCIATION BETWEEN ERECTILE DYSFUNCTION AND SEVERITY OF CORONARY ARTERY DISEASE: OBSERVATIONS FROM A CORONARY ANGIOGRAPHIC STUDY IN ASIAN INDIANS

Objectives Erectile dysfunction (ED) and coronary artery disease (CAD) often share common risk factors and there is growing evidence that ED might serve as a clinical marker for cardiovascular disease. Despite rising trends of CAD in Asian Indians, limited data are available on prevalence of ED and its correlation with CAD severity in such patients. Aim To study the prevalence of ED in Asian Indian patients undergoing coronary angiography and assess if the severity of ED correlates with angiographic severity of CAD. Methods The prevalence of ED was assessed using the International Index of Erectile Function IIEF-5 questionnaire, amongst 175 male patients undergoing coronary angiography. Any degree of Erectile Dysfunction was present in 70%; it was severe in 39.2%, moderate in 23.5%, mild to moderate in 22.7% and mild in 14.6%. Patients with ED had higher incidence of multi-vessel CAD (80% vs 36%, p 0.001), diffuse CAD (81% vs 34%, p 0.001) and higher number of mean coronary vessels involved compared to those without ED. Mean IIEF score in patients with single vessel, double vessel and triple vessel CAD was 18.4±5.8, 14.4±5.8 and 9.5±5.9 respectively (p<0.001 for each group); mean IIEF-5 score for patients with diffuse CAD was also significantly lower (12.1±6.5) as compared to those without diffuse CAD (19.1±6.5, p <0.001). Patients with severe ED had higher prevalence of multi-vessel CAD and higher number of mean coronary vessels involved compared to those with milder grades of ED. Onset of symptoms of ED preceded symptoms of CAD by a mean of 24.6 months in 84% patients. Presence of severe ED was associated with a 21 fold higher risk of having triple vessel disease (OR 21.94, 95% CI 3.41 to 141.09, p=0.001) and 18 fold higher risk of having diffuse angiographic CAD (OR 17.91, 95% CI 3.11 to 111.09, p=0.001). Results The prevalence of ED was assessed using the International Index of Erectile Function IIEF-5 questionnaire, amongst 175 male patients undergoing coronary angiography. Any degree of Erectile Dysfunction was present in 70%; it was severe in 39.2%, moderate in 23.5%, mild to moderate in 22.7% and mild in 14.6%. Patients with ED had higher incidence of multi-vessel CAD (80% vs 36%, p 0.001), diffuse CAD (81% vs 34%, p 0.001) and higher number of mean coronary vessels involved compared to those without ED. Mean IIEF score in patients with single vessel, double vessel and triple vessel CAD was 18.4±5.8, 14.4±5.8 and 9.5±5.9 respectively (p <0.001 for each group); mean IIEF-5 score for patients with diffuse CAD was also significantly lower (12.1±6.5) as compared to those without diffuse CAD (19.1±6.5, p <0.001). Patients with severe ED had higher prevalence of multi-vessel CAD and higher number of mean coronary vessels involved compared to those with milder grades of ED. Onset of symptoms of ED preceded symptoms of CAD by a mean of 24.6 months in 84% patients. Presence of severe ED was associated with a 21 fold higher risk of having triple vessel disease (OR 21.94, 95% CI 3.41 to 141.09, p=0.001) and 18 fold higher risk of having diffuse angiographic CAD (OR 17.91, 95% CI 3.11 to 111.09, p=0.001). Conclusions Asian Indians with angiographic CAD frequently have ED; symptoms of ED precede that of CAD in most patients. Incidence of multi-vessel and diffuse CAD is significantly more common in patients with ED. It is important for physicians to be aware of the close relationship between the two conditions so that patients with ED can have optimal risk stratification for concomitant CAD whenever required.