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   Table of Contents - Current issue
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October-December 2019
Volume 9 | Issue 4
Page Nos. 181-239

Online since Wednesday, March 11, 2020

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ORGINIAL ARTICLES  

Impact of early chronic kidney disease on left atrial function and volume p. 181
Ramy Saafan, Mohamed Khalfallah, Suzan Elhefnawy, Hanan Kassem
DOI:10.4103/JICC.JICC_29_19  
Background: Chronic kidney disease (CKD) is one of the most important factors affecting cardiovascular morbidity and mortality. Left atrial (LA) volume indexed (LAVI) for body surface area is the most accurate measure of LA size that was obtained by standard echocardiography. The aim of this study was to investigate the value of strain analysis and LA volume in the detection of myocardial involvement in early CKD. Methods: The study included 60 patients divided into two groups: Group I: patients with early CKD (estimated glomerular filtration rate >30 ml/min/1.73 m2) without any previous cardiac illness and Group II: healthy age-matched controls with normal renal function. Echocardiographic examinations including LAVI and LA strain were measured in all participants. Results: LA wall systolic strain values decreased in the CKD group compared to the healthy control group (16.23% ± 6.33% vs. 38.84% ± 9.37%, P < 0.0001, on the lateral wall; 14.16% ± 3.64% vs. 26.66% ± 9.75%, P < 0.0001, on the septal wall; 17.23% ± 8.41% vs. 32.23% ± 7.92%, P < 0.0001, on the anterior wall; and 19.65% ± 7.58% vs. 47.48%–11.24%, P < 0.0001, on the inferior wall). LA systolic strain was more reduced in Stage 3 CKD than Stages 1 and 2. LAVI was significantly larger in the CKD group compared to healthy controls (36.20 ± 8.21 vs. 22.18 ± 3.00 ml/m2, P < 0.0001). Conclusion: LA function evaluated by strain is reduced and LA volume is increased in the early stages of CKD, and Stage 3 CKD is the most affected stage.
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A clinical study of prognostic significance of left atrial volume index in patients with acute coronary syndrome Highly accessed article p. 186
Praveen Nagula, Subba Reddy Venkata Yerrabandi, Adikesava Naidu Otikunta, Suneetha Karumuri
DOI:10.4103/JICC.JICC_39_19  
Background: The aim of the study is to determine the relationship of left atrial volume index (LAVI) with the clinical presentation, comorbidities, and adverse events in acute coronary syndrome (ACS) patients at admission and during their follow-up. Methods: A total of 160 ACS patients enrolled have been divided into Group A (LAVI > 34 ml/m2) and Group B ( LAVI ≤ 34 ml/m2). The symptoms and the LAVI have been assessed at 1, 6, and 12 months of follow-up. The primary end point was cardiovascular (CV) mortality. The secondary end point is the occurrence of major adverse CV events, i.e., repeat hospitalization postdischarge for heart failure, reinfarction, atrial fibrillation, or ischemic stroke. Results: Overall, the median age at presentation was 55 years. There was no sex predilection for increased LAVI or an association with conventional risk factors. The echocardiographic E wave velocity divided by propagation velocity had a positive correlation with the LAVI (r = 0.321, P = 0.0036). The relative risk of morbidity with an increased LAVI was 2.74. The hazard ratio for adverse events in patients with increased LAVI was 2.81. The total number of deaths was 21 (16 and 5 in Group A and B). The LAVI was found to be the independent predictor of mortality than left ventricular ejection fraction on multivariate regression analysis. The receiver operating characteristic curve analysis had an area under the curve of 0.801 for increased LAVI. Conclusion: The LAVI is an independent predictor of adverse events and mortality during the initial hospital stay and at follow-up in ACS patients.
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Value of QRS distortion and ST-segment shift in acute coronary syndrome patients in relation to gensini score p. 193
Wael Ali Khalil, Aly Saad, Manar Elzaky, Mohammad Sofan
DOI:10.4103/JICC.JICC_6_18  
Background: Terminal QRS complex distortion on admission electrocardiography (ECG) has been used to estimate the final infarct size and the prognosis after acute coronary syndrome (ACS); however, it is not sure whether the QRS distortion is more reliable for predicting the severity of coronary artery lesions or not. The Aim of the Work: The aim is to analyze the admission ECG in ACS based on abnormality observed in the terminal QRS complex distortion and ST-segment and its relation to coronary artery lesion severity. Patients and Methods: We included 150 patients presented with ACS. Patients were divided according to the presenting ECG in two major groups, 120 patients presented with ST-segment elevation myocardial infarction (STEMI) who were classified into two groups according the presence or absence of the QRS distortion: 42 patients with +ve QRS distortion (Group I) and 78 patients with −ve QRS distortion (Group II), and 30 patients presented with non-ST-segment elevation (NSTE)-ACS who were also further classified according the magnitude of ST shift by millimeter into three groups. All patients underwent primary percutaneous coronary intervention, and Gensini score defined the severity of coronary artery lesions. Results: In this study, in STEMI patients groups, we observed that QRS distortion on admission, ECG has a significant relationship with high Gensini score values, whereas in NSTE-ACS patients, we demonstrated no significant difference between the extents of ST-segment shift and Gensini score values. Conclusion: QRS distortion has a significant value in predicting severe coronary artery lesions in STEMI patients while the extent of ST-segment shift has no benefits in predicting the severity of coronary artery lesion in NSTE-ACS patients.
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Relation between Fragmented Electrocardiogram and Myocardial Reserve in Patients with Cardiac Syndrome X p. 198
Islam Elsayed Shehata, Ashraf M A. Belgasem, Ragab A Mahfouz, Omar F Tawfik
DOI:10.4103/JICC.JICC_51_19  
Background: We hypothesized that fragmented QRS (fQRS) is an early marker of myocardial involvement in patients with cardiac syndrome X (CSX) which had updated term “Microvascular angina (MVA)”. Therefore, we aimed to investigate the possible relationship between fQRS and myocardial reserve in patients with MVA. Patients and Methods: A comparative cross-section study was conducted on 89 patients with typical angina symptoms, positive exercise treadmill test, and normal coronary angiography. All patients were subjected to history taking, electrocardiogram, echocardiography, dobutamine stress echocardiography, coronary angiography and measurement of body mass index, blood pressure and serum lipid profile. Results: The prevalence of fQRS in patients with MVA was 61%; there were nonsignificant difference in baseline echocardiography left ventricular mass, dimensions, and ejection fraction (EF%) between patients with and without fQRS; on the other hand, patients with fQRS showed a significant decrease in myocardial reserve at dobutamine stress echocardiography, and significant decrease in values of stroke volume and EF in comparison with patients without fQRS, fQRS was inversely correlated with cardiac output, stroke volume, EF as well as cardiac reserve; furthermore, number of leads with fQRS had a significant positive correlation with degree of reduction in cardiac reserve. Conclusion: In MVA patients, fQRS was correlated with reduced cardiac reserve; it has an important clue for microvascular and cardiac contractile dysfunction in these patients. Further follow-up data should be done on a large scale to show how to follow and treat those patients.
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Exercise electrocardiogram testing in asymptomatic patient with type 2 diabetes and left ventricular diastolic dysfunction p. 205
Ahmed Shaker
DOI:10.4103/JICC.JICC_21_19  
Background: Type 2 diabetes mellitus (DM) is an established risk factor for cardiovascular events and the development of congestive heart failure (HF). Diastolic dysfunction is considered a precursor of HF and may be diagnosed noninvasively by echocardiography. Diastolic dysfunction is common in well-controlled type 2 diabetic patients without clinically detectable heart disease. Left ventricular diastolic dysfunction represents the earliest preclinical dysfunction and that it can progress to asymptomatic HF. Aim of the Work: The aim of the study is to evaluate if diastolic dysfunction in diabetic patients is due to silent ischemia. Methods: This study included 80 asymptomatic patients with type 2 DM. Echocardiography was done to all patients to assess systolic and diastolic functions. Exercise electrocardiogram (ECG) was done for all patients to detect ischemic heart disease. Coronary angiography was done to patients with positive exercise ECG test. Results: The incidence of diastolic dysfunction was 75%; among the studied groups. Impaired relaxation was detected in 87 % and pseudo normal pattern was detected in 13 % of subjects with diastolic dysfunction. Patients with normal diastolic function had negative stress exercise test, while those with diastolic dysfunction, 12 patients had positive exercise stress ECG (40%) and 18 patients had negative exercise stress ECG (60%). Conclusion: These findings indicate that coronary artery disease is not uncommon in diabetic patients with diastolic dysfunction and increase markedly in patients with positive stress exercise electrocardiography.
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Can QRS duration predict microvascular reperfusion after primary percutaneous coronary intervention? p. 211
Mohammad Mustafa Al-Daydamony, El-Sayed Mohammad Farag, Ahmed Fathy, Ghada Ebraheem, Ahmed Shawky, Nader Talaat Kandeel, Hany Abdelwahab, Iman Samy
DOI:10.4103/JICC.JICC_32_19  
Background: In patients with ST-segment elevation myocardial infarction (STEMI), primary percutaneous coronary intervention (PCI) was associated with early and sustained restoration of blood flow compared to fibrinolytic therapy. Impaired myocardial blush grade (MBG) may be present in many after successful PCI. Prolonged QRS was found to be associated with an increased morbidity and mortality after STEMI. Aim: This study aims to find out if prolonged QRS in STEMI patients can predict low MBG after primary PCI. Patients and Methods: Sixty STEMI patients were included in our study. History taking, clinical examination, electrocardiography with measuring of QRS duration, primary PCI, and echocardiography were done to them. QRS duration was measured before and after PCI, and the change was calculated. Results: Patients with low MBG (0–1) had significantly higher QRS duration before and after PCI and significantly lower change after PCI (P < 0.00001 for each). Independent predictors for MBG were in order of significance: QRS duration before PCI (P < 0.00001), QRS duration after PCI (P < 0.00001), troponin level (P < 0.00001), symptom to balloon time (P = 0.0063), and creatine kinase MB level (P = 0.015). QRS duration 89 ms could predict low MBG with sensitivity 82.6%, specificity 86.5%, positive predictive value 79.2%, and negative predictive value 88.9%. Conclusion: In STEMI patients undergoing primary PCI, prolonged QRS duration was associated with a low MBG, a sign of impaired microvascular reperfusion. QRS duration before and after PCI were found to be independent predictors for low MBG (0–1).
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Female predominant coronary tortuosity is related to significant coronary artery disease. A prospective observational study p. 216
Ayman K M. Hassan, Elhussein Ahmed Mohamed, Tarek A N. Ahmed, Hosam Hasan-Ali, Salwa R Demitry
DOI:10.4103/JICC.JICC_27_19  
Background: Coronary tortuosity (CT), quantified by our new tortuosity severity index (TSI), strongly predicts anginal pain in patients with normal coronary angiography (CA). The connection between CT and coronary arteriosclerosis is still imprecise. Objectives: The objective was to study CT in patients with coronary artery disease (CAD). Patients and Methods: This is a prospective study at university hospitals between May 2016 and January 2017. We included 331 consecutive patients who underwent CA due to typical chest pain and showed CAD with a lesion >30%. Patients were prospectively divided into two groups based on the presence (n = 186) or absence (n = 145) of significant CAD (≥70%) and compared for clinical, echocardiographic, and CA characteristics. The TSI was either significant (mild/moderate CT with >4 curvatures in total or severe/extreme CT with any number of curvatures) or not significant TSI (mild/moderate CT with curvatures ≤4 curvatures in total). Results: Patients with significant CAD had the highest rate of CT (66% vs. 17%, P ≤ 0.001) and significant TSI (69% vs. 20%, P < 0.001) compared to those without. CT affects the left anterior descending coronary artery in middle and distal segments as a single vessel in 80% of patients. Patients with CT were more commonly females and hypertensives with small body surface area. Multivariate logistic regression analysis identified female gender (odds ratio [OR] = 4.7, confidence interval [CI] = 2.4–8.9) and CT as the main predictors of significant CAD (OR = 6.7, CI = 3.2–14.2). Conclusions: CT with significant TSI is positively related with significant CAD. This finding is more pronounced among hypertensive females with small body surface area.
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An observational study of out-of-hospital cardiac arrests reported in Indian print media p. 223
Srinivas Ramaka, Vemuri S Murthy, Navin C Nanda, Vasudeva Murthy Sindgi, Adil Sarvar Mohammed
DOI:10.4103/JICC.JICC_52_19  
Background: Newspapers in India often report incidents of cardiac arrest. Media reports are a source for raising awareness of cardiac arrest and cardiopulmonary resuscitation (CPR) among the public. This study is aimed at evaluating the reports of cardiac arrest published in Indian newspapers. Materials and Methods: This is an observational study of cardiac arrests reported in Indian newspapers between January 2001 and June 2019. The study included reports containing the word “cardiac arrest” referring to a cardiac arrest event in India. Data of demographics, location, time, clinical characteristics, performance of CPR, and survival using the Utstein template were extracted from the newspapers. Reports of out-of-hospital cardiac arrest (OHCA) were selected for analysis. Results: One thousand seven hundred seventy-nine reports of cardiac arrest were reviewed and 1703 reports were selected after excluding 76. Of these, 279 reports did not specify whether it was an in-hospital cardiac arrest (IHCA) or OHCA. Of the remaining 1424 reports, 377 reports were IHCA and 1047 were OHCA. One thousand forty-seven OHCA cases were selected for analysis. The study noted male preponderance and a median age of 51–60 years. OHCA commonly occurred in residential locations, followed by public buildings, other places, and street/highways. Prior risk factors, heart disease, and symptoms were reported in some reports. Of 15 subjects who received CPR, 11 were reported to have survived. Although demographic data are reported in the majority, there is poor reporting of clinical and resuscitation details. Conclusions: The study gives a glimpse of OHCA in India and emphasizes the need for elaborate reporting of data on cardiac arrest. The crucial role of media is recognized.
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CASE REPORTS Top

A rare case report on telmisartan-induced angioedema and mouth ulcers p. 230
Arundhati Diwan, Siddhi P Umarje, Priti Dhande, Bijoy Kumar Panda
DOI:10.4103/JICC.JICC_44_19  
A 67-year-old hypertensive female was hospitalized for painful, bleeding mouth ulcers, angioedema (lip swelling and glossitis), and dysphagia. A history reported by the patient and recent medication history revealed the onset of the symptoms on the initiation of telmisartan for hypertension. Telmisartan was discontinued, and the patient was managed symptomatically for pain, mouth ulcers, glossitis, and dysphagia. The symptoms completely resolved over 10 days of drug withdrawal. As per the World Health Organization and Naranjo adverse drug reaction assessment, telmisartan had a “Probable” association with the oral toxicity observed in this patient.
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A rare case of dengue myocarditis masquerading as st-segment elevation myocardial infarction: A Balance Approach p. 233
Venkata R. S Subrahmanya Sarma, G Madhavi, K Gopalakrishna, P Raghuram, PS S. Chowdary, G Somasekhar, K Purnachandrarao, M Boochibabu, M Prasad, Y Sasidhar
DOI:10.4103/JICC.JICC_46_19  
Dengue illness is a serious public health problem, contributing to significant morbidity and mortality. Cardiac involvement is common and is encountered in centers handling large numbers of dengue cases. Dengue myocarditis masquerading as ST-segment elevation myocardial infarction (STEMI) is a very rare presentation and only a few cases of dengue myocarditis masquerading as STEMI have been reported; it poses several challenging problems, as these patients are at high-risk bleeding and ischemic complications. Our case highlights the importance of the balance approach in the management of the bleeding and ischemic complications in a rare case of dengue myocarditis presenting as STEMI and the role of cardiac magnetic resonance imaging in determining the prognosis of the patient.
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Penetrating aortic root ulcer presenting as angina p. 237
Deepak Kadeli, R Keshava, Sanjay Reddy, A Gopi
DOI:10.4103/JICC.JICC_17_19  
We present a case of 58 year old female with acute aortic syndrome in a female presenting as angina. Acute aortic syndrome is a constellation of aortic pathologies which have been grouped together as they present in a similar manner. Penetrating aortic ulcer (PAU) and intramural hematoma (IMH) of aorta which were earlier considered to be part of the spectrum of aortic dissection are now considered to be acute aortic syndromes.
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