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   Table of Contents - Current issue
January-March 2019
Volume 9 | Issue 1
Page Nos. 1-59

Online since Friday, May 10, 2019

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Pulmonary hypertension in people living with HIV/AIDS p. 1
Shailesh Singh
Pulmonary hypertension (PH) can be defined as a group of disorders characterized by an elevated mean pulmonary arterial pressure (≥25 mmHg) at rest. The exact pathophysiologic mechanism underlying the development of PH in HIV/AIDS patient is unknown. Various hypotheses have been proposed to explain the genesis of PAH in HIV/AIDS patients. These theories have talked about the role of HIV itself, opportunistic infections, inflammation, and endothelial cell dysfunction. The role of highly active antiretroviral therapy (HAART) on the outcome of PH secondary to HIV is still controversial. Various guidelines and bodies have suggested that HIV–PAH, because of the similar disease process as idiopathic PAH, may require the same treatment as PAH in the general population.
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Statistical correlation of severity of coronary artery disease with insulin resistance and other clinical parameters Highly accessed article p. 7
Jay Rabindra Kumar Samal, Abhijeet Sinha, Deepak Uppunda
Objective: The objective of the study is to find the correlation of severity of coronary artery disease (Gensini score) with insulin resistance (IR) and other clinical parameters. Methods: Clinical data set (Gensini score, glycated hemoglobin, fasting insulin (FI), IR, total cholesterol, triglycerides, high-density lipoprotein, low-density lipoprotein, age, body mass index, waist circumference, high-sensitivity c-reactive protein and fasting plasma glucose) of 100 patients was collected. The individuals included in the data set were classified into four groups based on IR and phenotypic obesity. R programing language was used to find correlation between the clinical parameters and the Gensini score. Further, the data were normalized and data plot on cftools of Matlab was used to find equations to relate the parameters. The variation of Gensini score among the four groups was also analyzed. Results: The variation of Gensini score among the four groups suggests that IR can drastically increase the severity of CAD and has a more pronounced effect on the Gensini score as compared to phenotypic obesity. It was also observed that age, triglyceride levels, glycated hemoglobin, and FI had the highest positive correlation with the Gensini score, while parameters such as body mass index and high-sensitivity C-reactive protein had a higher negative correlation. Equations correlating various clinical parameters to the Gensini score were generated. Conclusion: The equations may be used to develop a software model which can predict the Gensini Score of a patient with an acceptable margin of error. As the parameters included in the study can be obtained during a regular check-up of a person, his/her risk of CAD can be predicted during the regular check-up.
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Treatment delayed is treatment denied: The tortuous pathway to care for acute coronary syndrome p. 17
Kathiresan Jeyashree, Yogakeerthiga Paramasivam, A Mathavan, Ramalingam Vadivelu, Rizwan Suliankatchi Abdulkader
Background: Time duration between symptom onset and treatment in acute coronary syndrome (ACS) is important in determining survival outcomes. This study aimed to determine the extent of delays that occur in the pathway to seeking specific treatment among ACS patients and to explore the associated factors. Materials and Methods: This cross-sectional study was conducted in the emergency department of a tertiary care hospital in Madurai, Tamil Nadu, India, among patients with ACS. A questionnaire was used to collect information on demographic details, clinical features, time duration, and health system-related factors. The time delay at various levels was expressed as median and interquartile range (IQR). Nonparametric tests were applied to test for statistical differences in subgroups. Results: Among 232 ACS patients, the median (IQR) delay from symptom onset to decision-making was 30 min (10, 240), from decision-making to arriving at the first facility was 30 min (15, 45), and from decision-making to receiving specific treatment was 23.3 h (1, 170). Nearly 91% of the patients contacted private health facilities first and only 21.1% received any specific treatment at the first facility they contacted. The two most common reasons for referral from a lower level health facility were lack of infrastructure and lack of a specialist. Conclusions: Significant delays occurred in the pathway to receiving specific treatment for ACS, especially due to delays in decision-making and number of facilities contacted in the initial period not being able to provide specific treatment. Private health facilities are more sought after for emergency care of ACS.
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Relationship between angiographic outcomes and occurrence of acute kidney injury in st-segment elevation myocardial infarction patients treated by primary percutaneous coronary intervention p. 24
Mohamed Zahran
Introduction: Acute kidney injury (AKI) complicates 7%–10% of the cases of critically ill patients; several studies found a similar incidence among ST-segment elevation myocardial infarction (STEMI) patients, especially those complicated by cardiogenic shock. Primary percutaneous coronary intervention (PPCI) is the gold standard treatment for STEMI patients, and using contrast during the procedure is mandatory and inevitably increases the risk of development of AKI. AKI complicating STEMI is associated with poor long-term clinical outcomes with mortality reaching nearly one-third of the affected patients. Patients and Methods: This study included 110 STEMI patients treated by PPCI presented to our Cath lab at Ainshams university hospitals (a 24/7 Tertiary Referral Center for PPCI) during the period between February 2014 and May 2015. The patients with impaired kidney functions, chronic kidney disease, and those on hemodialysis were excluded from the study. Results: AKI was defi ned as an increase of ≥0.3 mg/dL in serum creatinine within 48 h after admission. Eleven patients (10%) developed AKI. The presenting hemodynamics were worse in the patients complicated by AKI (systolic blood pressure 80 ± 35 mmHg vs. 105 ± 60 mmHg, P < 0.001). The pain-to-door time was signifi cantly higher in the patients that developed AKI (156 ± 68 min vs. 114 ± 53, P < 0.001). The volume of contrast was signifi cantly higher in the patients that developed AKI (192 ± 54 ml vs. 128 ± 63 ml, P < 0.001). The patients that developed AKI were signifi cantly more likely to have multivessel affection during their PPCI (5/11 [45.5%] vs. 16/99 [16.2%], P < 0.001), anterior wall location of the infarction (7/11 [63.6%] vs. 40/99 [40.4%], P < 0.001), and no-refl ow phenomenon (5/11 [45.5%] vs. 21/99 [21.2%], P < 0.001). Conclusions: Multivessel affection in PPCI patients, anterior wall location of the infarction and no-reflow phenomenon were significantly associated with occurrence of acute kidney injury in STEMI patients undergoing PPCI.
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Heart rate variability patterns in anterior st-segment elevation myocardial infarction versus inferior st-segment elevation myocardial infarction patients treated by primary percutaneous coronary intervention p. 28
Mohamed Zahran
Introduction: Heart rate variability (HRV) has been known as a measurable parameter of the cardiac autonomic function. The cardiac autonomic innervation is heterogeneous and hence leads to different patterns of autonomic modulation. The normal pattern of autonomic modulation is altered in the case of myocardial infarction, the pattern of alteration is not uniform, and it depends on the infarcted wall or region of the heart. Primary percutaneous coronary intervention (PCI) is the gold standard therapy for revascularization of ST-segment elevation myocardial infarction (STEMI) cases, but still conflicting and nonconclusive data are available on the modifications that happen to the cardiac autonomic function after a successful primary PCI with restoration of the Thrombolysis in Myocardial Infarction III flow in the infarct-related artery (IRA). Aim of The Work: Studying and comparing the pattern of autonomic modulation between anterior STEMI patients and inferior STEMI patients. Methods and Results: A total of 93 consecutive patients (56 males and 37 females) presented by STEMI and treated by primary PCI at our cath lab at Ainshams university hospitals (a 24/7 tertiary referral center for primary PCI) during the period between February 2016 and March 2017; 48 had an anterior wall STEMI (ANT) and 45 had an inferior wall STEMI (INF). Mean duration for hospital stay was 4 ± 2 days. Electrocardiogram and respiration were recorded within the day of admission (DA) and at day of discharge (DD). Cardiac autonomic modulation was evaluated using symbolic analysis (SA) of HRV. The first recording for HRV by SA (DA recording) was performed after 18 ± 6 h from primary PCI as soon as the IRA has been opened and the patient stabilized in the cardiac care unit (CCU) for 12 h at least. The second recording for HRV by SA (DD recording) was performed at the DD (duration of admission was 4 ± 2 days). SA recordings showed a significantly predominant of vagal modulation in anterior STEMI patients compared to inferior STEMI at DA, as indicated by 2LV% (10% [7–15] vs. 6% [2–9], P = 0.03). Moreover, at DA, inferior STEMI patients had a significantly higher 0V%, index of sympathetic modulation, compared to anterior STEMI patients (33% [18–47] vs. 19% [12–29], P = 0.02). The second recordings on the DD (DD recording) showed nonsignificant difference between the anterior STEMI and the inferior STEMI groups. Conclusion: After revascularization by primary PCI for STEMI patients, the group presenting by inferior STEMI were characterized by a sympathetic predominance, while those presenting by anterior STEMI were characterized by a predominant vagal modulation. This difference in the sympathetic modulation between the two groups disappeared at the time of discharge from the hospital.
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Arterial stiffness parameters derived by oscillometric pulse wave analysis are related to estimated glomerular filtration rate but not proteinuria in Gujarati diabetics p. 32
Jayesh Dalpatbhai Solanki, Rajkumar Bharatkumar Patel, Ila N Hadiyel, Hemant B Mehta, Hirava B Munshi, Param J Kakadia
Introduction: Diabetes mellitus (DM) imposes significant cardiovascular risk beyond raised blood pressure. Pulse wave analysis (PWA) infers directly about the same by arterial stiffness (AS) assessment. We studied the relation between AS and diabetic nephropathy (DN) in type 2 diabetics (T2D). Materials and Methods: We evaluated 164 T2Ds in a cross-sectional study. Oscillometric PWA performed by Mobil-o-Graph (IEM, Germany) reported AS parameters such as augmentation pressure (AP), augmentation index at heart rate 72, reflection magnitude, and aortic pulse wave velocity (aPWV). DN was evaluated by creatinine, proteinuria, and estimated glomerular filtration rate (eGFR). Parameters were further analyzed for the effect of gender, proteinuria, and grades of DN by eGFR. Multiple linear regressions were used to find significant predictors. P <0.05 was taken as statistical significance. Results: Case group constituted 91 males, with mean age 56 years, with mean duration 4.48 years, 70% prevalence of hypertension and poor glycemic control. There was mild to moderate DN and 34% prevalence of proteinuria. AS parameters were not affected significantly by proteinuria, but by increasing grades of DN. aPWV and AP were predictors of eGFR, whereas AP was a predictor of creatinine. Conclusions: AS was related with estimated GFR but not with proteinuria in Gujarati diabetics with high co-existing hypertension and predominantly mild-to-moderate grade nephropathy.
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The relation of brachial fractional flow dilatation and coronary artery disease in nondiabetic patients with or without insulin resistance p. 39
Wael Ali Khalil, Ragab AbdElsalam, Mohamed Abdou, AbdAllah Hamed, Khaled Younnis
Background: Endothelial dysfunction is the early sign of cardiovascular diseases and assessed by the flow-mediated dilatation (FMD) of the brachial artery. In patients with insulin resistance, endothelial dysfunction is reduced and assessed by FMD. The work aimed to study the association between (homeostatic model assessment of the insulin resistance) and the brachial fractional flow dilatation (FFD) with the presence of coronary artery disease (CAD) in nondiabetic individuals, with or without insulin resistance. Patients and Methods: A total of 100 nondiabetic individuals were following up in the cardiology department and divided into (Group 1) 40 patients with insulin resistance (Group 2). Sixty patients without insulin resistance. FMD of the brachial artery was measured then the nitroglycerin-mediated dilatation (NMD). We calculated the fractional flow dilatation (FFD) as follow: NMD-FMD/NMD. Results: The predictive value of FFD for the detection of CAD in insulin resistance group with a cutoff value >0.465 (P < 0.0001), with a sensitivity of 89.2% and specificity of 92.3%. The predictive value of FFD is ≥0.575 (P = 0.001), with a sensitivity of 78.9% and specificity of 74.2% in the non-IR group. Conclusion: FFD is independent predictors for CAD, especially in insulin resistance subjects.
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Percutaneous closure of atrial septal defect after surgical patch degradation p. 45
Sweta Mohanty, D Pradeep Kumar
Patch degradation after surgical repair of atrial septal defect (ASD) is an uncommon complication. We report a case of surgically repaired ostium secundum ASD that presented with degradation of the patch and a hemodynamically significant shunt, which was subsequently closed by the transcatheter approach.
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Trans-femoral-brachial (combined) approach for the percutaneous angioplasty of eccentric stenosis and unfavorable takeoff origin of the right brachiocephalic artery – “Entry from the back door” p. 47
Pankaj Jariwala
Right brachiocephalic stenoses are usually discrete short-segment lesions, but sometimes, they are the most difficult to intervene for certain reasons. Their takeoff from the arch of the aorta and eccentricity of the stenotic lesion may pose problems while intervention. Furthermore, there is an controversy for the use of distal protection device during angioplasty. There are many methods described for its interventions, but transbrachial access is easier to tackle difficulties those may arise with transfemoral approach. We describe a case of right brachiocephalic high-grade stenosis, which was difficult to access by transfemoral approach, but transbrachial access solved our problem, and we could deploy the stent across the lesion with ease.
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A rare case of cardiac metastasis from non-small cell lung cancer p. 50
Manish Sharma, Sumit Goyal, Manoj Gupta, Ullas Batra, Ankush Jajodia, Venkata Pradeep Babu
Heart is reported to be one of the least common sites of tumor metastasis. The lung is the most common cancer worldwide, and the metastasis to heart from lung cancer has rarely been described. Here, we describe a patient with lung cancer whose tumor metastasized to the left atrium of heart while on treatment.
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An unusual case of acute promyelocytic leukemia manifesting with pulmonary embolism p. 52
Gopi Aniyathodiyil, Veena Nanjappa, Neethi Shelly Selvam
Venous thromboembolism is four fold greater in patients with cancer. 5-20% of acute promyelocytic leukemia is M3 (Hypergranular promyelocytic leukemia) variety. Hemorrhagic complications are more common than thrombosis; Coagulopathy in acute promyelocytic leukemia is a very complex disorder and is under reported. Here is a case report of a rare presentation of acute promyelocytic leukemia manifesting with pulmonary embolism.
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Surgical ventricular restoration of the dilated left ventricle with large left ventricular thrombus following acute decompensated heart failure: A late complication of anterior wall myocardial infarction: “Tomb of Dead Myocardium!” p. 55
Pankaj Jariwala, Sridhar Kale Satya
There are various case reports and the original article in the literature about the formation of a left ventricular thrombus (LVT) after acute myocardial infarction as an early to a late sequel. However, there are no guidelines available for their management, as the clinical presentation of LVT is variable and there is no consensus about its management. Furthermore, there are no randomized controlled trials comparing different treatment strategies. Here, we present a case of a large LVT who presented as acute decompensated heart failure. After stabilization, he underwent surgical repair of left ventricular aneurysm and retrieval of a thrombus.
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Thrombocytopenia after primary angioplasty: Choosing between scylla and charybdis p. 58
Pankaj Jariwala
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