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  Most popular articles (Since March 22, 2019)

 
 
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REVIEW ARTICLE
Pathophysiology, etiology, and recent advancement in the treatment of congenital heart disease
Jyoti Upadhyay, Nidhi Tiwari, Mahendra Rana, Amita Rana, Sumit Durgapal, Satpal Singh Bisht
April-June 2019, 9(2):67-77
DOI:10.4103/JICC.JICC_11_19  
The most common birth anomaly occurring in infants is the congenital heart disease (CHD). It is the important cause of mortality and morbidity among children. The aim of this review is to conduct searches for peer-reviewed research papers published since 1980, with keywords “congenital heart defects,” “incidences,” “pathophysiology,” and “congenital anomalies.” Recent advances in the treatment of CHD have allowed many children to survive, causing a growing population of adults with the congenital heart defect. Lesser information exists regarding survival, prevalence, comorbidities, and late outcomes in this emerging group and several barriers hampers research in congenital heart defect. Some investigating research of congenital heart defect offers good opportunity in understanding and identifying high-risk population. This review provides an overview of the etiology, prevalence, pathophysiology, and advances in the treatment of congenital heart defect. Future research is needed to understand congenital heart defects, by the health-care providers and families, who are taking care of these patients. Experimental and epidemiological studies will provide us important information related to the physiology of congenital heart defects and identifying the etiological hypothesis behind it.
  1,902 177 -
CASE REPORTS
Adverse effects of statins – Myths and facts
D Prabhakar
July-September 2019, 9(3):165-168
DOI:10.4103/JICC.JICC_35_19  
Treatment with statins for dyslipidemia is confronted by both patient and doctor and social media-related myths. The common myths and the relevant facts in light of the recent ACC/AHA guidelines on the management of blood cholesterol 2018 are interesting. Most common side effects listed with statins are statin-associated muscular symptoms, new-onset type 2 diabetes mellitus, intracranial hemorrhage, and elevation of liver enzymes. The current article reviews the myths and the facts about the side effects associated with statins and how to tackle the side effects practically.
  1,155 46 -
ORGINIAL ARTICLES
Treatment delayed is treatment denied: The tortuous pathway to care for acute coronary syndrome
Kathiresan Jeyashree, Yogakeerthiga Paramasivam, A Mathavan, Ramalingam Vadivelu, Rizwan Suliankatchi Abdulkader
January-March 2019, 9(1):17-23
DOI:10.4103/JICC.JICC_1_19  
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.
  852 140 -
Assessment of left ventricular filling pressure and its correlation with severity of chronic kidney disease
Vijesh Anand, Arun Prasath Palamalai, Hemachandar Radakrishnan
April-June 2019, 9(2):78-82
DOI:10.4103/JICC.JICC_26_19  
Aims: This study was aimed to assess the left ventricular filling pressure (LVFP) and its relationship with severity of chronic kidney disease (CKD). Methods: One hundred CKD patients were subjected to standard echocardiography and the new modality of tissue Doppler imaging. The LVFP is calculated with E/e' ratio (early diastolic mitral inflow velocity – E to early diastolic mitral annulus velocity – e'). All these patients were divided into five subgroups depending on their estimated glomerular filtration rate (eGFR: ml/min/body surface area). Results: The analysis of echocardiographic parameters (E and e') showed that in CKD patients, the stage of renal failure was associated with the significant increase in LVFP with P < 0.001. There was a significant correlation between LVFP and eGFR with r = −0.467 and P < 0.001. Conclusion: These data suggest that LVFP starts to raise early in the case of CKD. The increase in LVFP is directly proportional to the severity of renal failure.
  899 86 -
The relation between retinopathy grade and coronary artery disease in acute coronary syndrome diabetics
Ahmed Shawky Shereef, Nader T Kandeel
April-June 2019, 9(2):83-87
DOI:10.4103/JICC.JICC_24_19  
Background: Diabetic retinopathy (DR) was found to be associated with an increased risk for coronary artery disease (CAD). However, there are less data about the relation between the degree of DR and the angiographic severity of CAD. Objective: The objective of the study is to examine the relation between the degree of DR and the angiographic severity of CAD in patients with acute coronary syndrome (ACS). Patients and Methods: Fifty diabetic patients with ACS were enrolled in this study. History, clinical examination, echocardiography, coronary angiography, and fundus examination were done to all patients. According to the degree of DR, patients were classified into two groups: Group I – patients with no or mild nonproliferative (NP) DR (n = 27) and Group II – patients with moderate or severe NP DR or with proliferative DR (n = 23). Results: Population characteristics, risk factors, diabetes duration, insulin use, and echocardiographic measures were comparable in the two groups. Patients in Group II had significantly more number of diseased vessels, more maximum stenosis, and higher Gensini score than those of Group I. There was a significant correlation between the degree of DR and the number of diseased vessels (r = 0.358, P =0.011) and highly significant correlation between the degree of DR and maximum stenosis (r = 0.452, P =0.001) and Gensini score (r = 0.706, P < 0.00001). Conclusion: There is an obvious relation between the degree of DR and angiographic severity of CAD in diabetic patients with ACS. Patients with a higher degree of DR had more severe CAD.
  879 75 -
Statistical correlation of severity of coronary artery disease with insulin resistance and other clinical parameters
Jay Rabindra Kumar Samal, Abhijeet Sinha, Deepak Uppunda
January-March 2019, 9(1):7-16
DOI:10.4103/JICC.JICC_1_18  
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.
  771 117 -
REVIEW ARTICLE
Pulmonary hypertension in people living with HIV/AIDS
Shailesh Singh
January-March 2019, 9(1):1-6
DOI:10.4103/JICC.JICC_6_19  
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.
  732 135 -
ORGINIAL ARTICLES
Serum cystatin c and renal dysfunction in transradial versus transfemoral approaches in primary percutaneous coronary intervention
Wael Ali Khalil, Mohammad Gouda Abdelhameed, Mahmmoud Diaa Elmenshawy, Ahmad Elhelaly
April-June 2019, 9(2):88-94
DOI:10.4103/JICC.JICC_4_18  
Objectives: Contrast-induced nephropathy is one of the most common adverse side effects in ST-segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI). Serum cystatin C level is a biomarker of the renal function test. We aimed to compare the degree of renal dysfunction in transradial primary PCI versus transfemoral primary PCI and to use of serum cystatin C as a predictor of contrast-induced nephropathy. Methods: This study included 90 patients who were admitted to the hospital with STEMI and who underwent a primary PCI and they were divided into Group I (45 patients): a primary PCI via femoral approach and Group II (45 patients): a primary PCI via radial approach. We estimated both serum cystatin C and serum creatinine after 72 h of primary PCI. Results: Serum cystatin C level post-PCI had high sensitivity results in correlation with CIN and non-CIN groups. Further, the significant effects were found in all patients in association with serum cystatin C before and after PCI. The cutoff value of serum cystatin C with receiver operating characteristic curve analysis before PCI was 1.1 mg/dL and after PCI was 1.3 mg/dL. Conclusion: The transradial approach for a primary PCI is an effective and safe approach alternative to the femoral approach. Serum cystatin C is a biomarker and a predictor of the occurrence of contrast-induced nephropathy in STEMI patients who underwent a primary PCI and is one of the most sensitive renal markers regarding CIN in comparison to serum creatinine level.
  787 68 -
Role of Vitamin D deficiency among patients with acute coronary syndrome
Ahmed Shawky Shereef, Nader Talat Kandeel
April-June 2019, 9(2):95-99
DOI:10.4103/JICC.JICC_22_19  
Background: Previous studies demonstrated that low Vitamin D levels are associated with hypertension, obesity, dyslipidemia, and diabetes mellitus, reflecting an increased cardiovascular (CV) risk burden. However, high levels can be associated with increased total and CV mortality. Hence, we aimed to evaluate the prevalence of Vitamin D deficiency and if it has a role in the occurrence of acute coronary syndrome (ACS). Patients and Methods: This study was carried out on 71 patients presented with ACS, undergoing coronary angiography at the cardiology department, Zagazig university hospitals. Exclusion Criteria: Disorders causing Vitamin D deficiency. Methods: All our patients were subjected to (1) careful history-taking; (2) thorough clinical examination; (3) resting electrocardiogram; (4) routine laboratory investigations beside thyroid, parathyroid hormone, Mg, Ph, and Vitamin D levels; (5) echocardiography; and (6) coronary angiography. Results: In the present study, receiver-operating characteristic curve analysis shows that the serum Vitamin D has a cutoff value ≤41.5 nm/L to predict ACS with 94.4% sensitivity and 83% specificity, a cutoff value ≤41.5 nm/L to predict unstable angina with 97.3% sensitivity and 83% specificity a cutoff value ≤52.625 nm/L to predict ST-elevation myocardial infarction (STEMI) with 100% sensitivity and 76.6% specificity, and a cutoff value ≤41 nm/L to predict non-STEMI with 100% sensitivity and 83% specificity. Conclusion and Recommendations: Vitamin D deficiency and insufficiency are common in patients with ACS. Further, larger multicenter studies are needed to assess Vitamin D level in ACS patients and to investigate its relationship with long term prognosis.
  744 104 -
Arterial stiffness parameters derived by oscillometric pulse wave analysis are related to estimated glomerular filtration rate but not proteinuria in Gujarati diabetics
Jayesh Dalpatbhai Solanki, Rajkumar Bharatkumar Patel, Ila N Hadiyel, Hemant B Mehta, Hirava B Munshi, Param J Kakadia
January-March 2019, 9(1):32-38
DOI:10.4103/JICC.JICC_5_19  
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.
  754 85 -
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
Mohamed Zahran
January-March 2019, 9(1):28-31
DOI:10.4103/JICC.JICC_4_19  
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.
  674 119 -
Relationship between angiographic outcomes and occurrence of acute kidney injury in st-segment elevation myocardial infarction patients treated by primary percutaneous coronary intervention
Mohamed Zahran
January-March 2019, 9(1):24-27
DOI:10.4103/JICC.JICC_3_19  
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.
  670 102 -
CASE REPORTS
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!”
Pankaj Jariwala, Sridhar Kale Satya
January-March 2019, 9(1):55-57
DOI:10.4103/JICC.JICC_12_19  
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.
  603 80 -
A rare case of cardiac metastasis from non-small cell lung cancer
Manish Sharma, Sumit Goyal, Manoj Gupta, Ullas Batra, Ankush Jajodia, Venkata Pradeep Babu
January-March 2019, 9(1):50-51
DOI:10.4103/JICC.JICC_8_19  
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.
  574 108 -
An unusual case of acute promyelocytic leukemia manifesting with pulmonary embolism
Gopi Aniyathodiyil, Veena Nanjappa, Neethi Shelly Selvam
January-March 2019, 9(1):52-54
DOI:10.4103/JICC.JICC_10_19  
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.
  593 77 -
ORGINIAL ARTICLES
The relation between insulin resistance and left ventricular mass in hypertensive nondiabetic patients
Ahmed Shawky Shereef, Nader Talat Kandeel
April-June 2019, 9(2):100-104
DOI:10.4103/JICC.JICC_25_19  
Background: Patients with essential hypertension (EH) are often associated with left ventricular (LV) hypertrophy (LVH) and insulin resistance (IR). Insulin may have a direct growth-promoting effect on cardiomyocytes. Hence, the aim of this work was to study the effect of IR on LV geometry in newly diagnosed arterial hypertensive nondiabetic patients not taking any antihypertensive medication. Methods: One hundred and eight patients were included in our study including 88 newly diagnosed hypertensive nondiabetic patients and 20 healthy controls. Fasting glucose, insulin levels, total cholesterol, high-density lipoprotein-cholesterol (HDL-C), low-density lipoprotein-cholesterol, and triglyceride levels were measured. Homeostasis Model Assessment (HOMA) index was calculated for the assessment of IR. Echocardiography measurements of LV dimensions such as LV mass (LVM) and LVM index (LVMI) were calculated. Results: Fasting blood insulin and HOMA index were significantly higher in patients with LVH than patients with normal LV dimensions and controls. We found highly significant positive correlations between insulin levels, LVM, and LVMI. In addition, we found highly significant positive correlations between HOMA index, LVM, and LVMI. Conclusion: We conclude that cardiac changes in hypertensive patients including those with increased wall thickness, LVM, and LVMI are mediated, at least in part, by increased insulin levels and the HOMA index.
  569 50 -
CASE REPORTS
Percutaneous closure of atrial septal defect after surgical patch degradation
Sweta Mohanty, D Pradeep Kumar
January-March 2019, 9(1):45-46
DOI:10.4103/JICC.JICC_2_18  
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.
  536 73 -
LETTER TO EDITOR
Thrombocytopenia after primary angioplasty: Choosing between scylla and charybdis
Pankaj Jariwala
January-March 2019, 9(1):58-59
DOI:10.4103/JICC.JICC_5_18  
  494 88 -
CASE REPORTS
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”
Pankaj Jariwala
January-March 2019, 9(1):47-49
DOI:10.4103/JICC.JICC_2_19  
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.
  486 91 -
ORGINIAL ARTICLES
The relation of brachial fractional flow dilatation and coronary artery disease in nondiabetic patients with or without insulin resistance
Wael Ali Khalil, Ragab AbdElsalam, Mohamed Abdou, AbdAllah Hamed, Khaled Younnis
January-March 2019, 9(1):39-44
DOI:10.4103/JICC.JICC_3_18  
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.
  490 86 -
Effect of ischemic reversal program on high-Sensitivity C-reactive protein in patients of coronary heart disease: An observational study
Rohit Sane, Gurudatta Amin, Snehal Dongre, Rahul Mandole
July-September 2019, 9(3):119-122
DOI:10.4103/JICC.JICC_34_19  
Background: Chronic inflammation leads to rupture of atherosclerotic plaque, ultimately causing acute coronary syndromes. High-sensitivity C-reactive protein (hsCRP) is an inflammatory biomarker which is known to predict cardiovascular events in ischemic heart disease (IHD) patients. Ischemic reversal program (IRP) has been found to improve exercise capacity of IHD patients but action on hsCRP is unknown.Methodology: This retrospective study was conducted between July 2018 and December 2018, for evaluating the effect of IRP on hsCRP levels in IHD patients. The data of only those patients were considered who had been given the IRP-based treatment for a minimum of five sittings. The mean serum hsCRP at day 30 of treatment initiation was compared with day 1 values. The association between the comorbidities with decrease in the hsCRP levels was assessed by calculating odds ratio (OR) using regression analysis. Results: Of the 78 enrolled IHD patients, 54 were male with a mean age of 59.94 ± 9.46 years. The mean hsCRP levels at day 30 of the treatment initiation were significantly lower than day 1 values (2.01 ± 2.15 vs. 2.83 ± 3.07 mg/L, P < 0.05). The OR for the decrease in the hsCRP levels in IRP-treated IHD patients having comorbidities such as hypertension and myocardial infarction were insignificant; however, the OR with diabetes was significantly < 1 (OR: 0.35, P < 0.05). Conclusion: IRP treatment leads to a significant decrease in the serum hsCRP levels in majority of the IHD patients, indicating an additional anti-inflammatory action.
  482 61 -
CASE REPORTS
Isolated acute right heart failure syndrome in a young male with severe sepsis: An unusual pathophysiology in a normal heart
Raghuram Palaparti, Sudarshan Palaparthi, Gopala Krishna Koduru, PS S Chowdary, Hari Krishna Marri, Purnachandra Rao Kondru, Somasekhar Ghanta, Prasad Maganti, Sasidhar Yendapalli
April-June 2019, 9(2):111-115
DOI:10.4103/JICC.JICC_28_19  
Acute right heart failure is being increasingly recognized in intensive care unit (ICU) and when severe, can contribute to hemodynamic instability. Sepsis-induced myocardial dysfunction is also a known entity in critical care ICU. However, isolated right ventricle (RV) dysfunction in patients with sepsis after excluding chronic heart and lung disease is underdiagnosed and reported uncommonly. Whether RV is a bystander or a major contributor to hemodynamic instability in that scenario has not been studied clearly. Here, we report a 42-year-old male patient with no major cardiovascular risk factors who presented to us in shock with a history of low-grade fever, generalized weakness, and decreased urine output for 3 days. On physical examination, he had pedal edema and neck vein distension. He was found to have neutrophilic leukocytosis, deranged renal function test, and liver function test. His chest X-ray posteroanterior view showed cardiomegaly with pulmonary congestion. His electrocardiography (ECG) showed right bundle branch block (RBBB). He was anuric and started on dialysis for severe acidosis. In view of shock, renal failure and RBBB on ECG, a transthoracic echocardiography was done which showed gross dilatation of right atrium, and RV with severe RV dysfunction with normal left ventricle function. Contrast-enhanced computerized tomography chest was negative for pulmonary thromboembolism. His blood culture has grown Escherichia coli. With intravascular (IV) fluids, ionotropic support, renal replacement therapy, IV antibiotics, and other supportive therapy, he gradually improved. His serial ECGs showed resolution of RBBB. Two-dimensional echo showed improved RV function. He was discharged on day 9 and his 2-week follow-up echo showed normalization of RV function. During follow-up, his coronary angiogram showed normal coronaries. This case illustrates the importance of identifying acute RV failure in patients with severe sepsis with shock. It also underscores the necessity for more studies and research on understanding the pathophysiology of RV dysfunction in critical care patients and its contribution to hemodynamic instability.
  467 45 -
Kounis syndrome: Allergic myocardial infarction!!
Deepak Kadeli, Deepthi Mangesh, R Keshava, A Gopi
April-June 2019, 9(2):108-110
DOI:10.4103/JICC.JICC_16_19  
Anaphylaxis is a type 1 hypersensitivity reaction where the body reacts to an allergen within minutes. Free antigens cross-link the IgE on mast cells and basophils, which causes a release of vasoactive biomolecules which cause systemic vasospasm. A wide range of causes include insect bites and stings, foods, and medications. It can manifest with a constellation of symptoms, but common manifestations include urticaria, shortness of breath, vomiting, lightheadedness, and low blood pressure. Some unusual presentations include gastrointestinal symptoms such as loose stools and abdominal pain, but in rare cases, they may present as myocardial infarction. We present a case of a 49-year-old female who presented with effort angina and developed severe anaphylactic reaction to the dye used in angiogram, precipitating an inferior wall myocardial infarction.
  447 57 -
An unusual presentation of acute pulmonary embolism secondary to upper extremity deep vein thrombosis
Khadhar Mohamed Sarjun Basha, PB Jayagopal
April-June 2019, 9(2):105-107
DOI:10.4103/JICC.JICC_14_19  
Acute pulmonary embolism (PE) secondary to congenital venous malformation of the upper limb is a rare clinical entity. Clinical manifestation may range from vague shoulder discomfort to features of superior vena cava or thoracic outlet syndrome. We report a case of a 43-year-old adult patient who was referred as acute coronary syndrome and on evaluation was diagnosed as acute PE secondary to upper extremity deep vein thrombosis. Magnetic resonance venogram of the right upper limb revealed congenital venous malformation with thrombus as the cause for deep vein thrombosis.
  440 46 -
ORGINIAL ARTICLES
Determinants of microvascular dysfunction in normotensive offsprings of hypertensive parents
Ragab A Mahfouz, Mohamed Arab, Mohamed S Ghareb
July-September 2019, 9(3):141-147
DOI:10.4103/JICC.JICC_38_19  
Objective: Microvascular dysfunction usually precedes the onset of hypertension. We hypothesized that offspring of offsprings of hypertensive parents (OHP) would have coronary microvascular dysfunction. Yet, the determinants of microvascular dysfunction in OHP are not fully determined. We, therefore, studied coronary flow reserve (CFR) in OHP in relation to ambulatory blood pressure and lipid profiles. Subjects and Methods: One hundred and twenty-five healthy normotensive offsprings with family history of hypertension and 40 age- and sex-matched healthy normotensive offsprings without family history of hypertension (ONP) were enrolled for the study. All participates underwent transthoracic color Doppler echocardiography at rest and during adenosine (0.14 mg/kg) infusion. CFR was calculated as the ratio between hyperemic diastolic coronary flow to the resting diastolic coronary flow. All participates had ambulatory blood pressure monitoring. In addition, lipid profile was obtained, and triglycerides (TGs)/high-density lipoprotein cholesterol (HDL-C) was calculated. Results: CFR was significantly reduced among OHP compared with ONP (P < 0.001). Moreover, 61 of the OHP (49%) had CFR <2.0. OHP had an exaggerated morning blood pressure surge (MBPS) compared with ONP (P < 0.001). TG/HDL-C was significantly higher in OHP with reduced CFR compared with both OHP without reduced CFR and ONP (P < 0.001). TG/HDL-C was negatively correlated with CFR (P < 0.001). Furthermore, TG/HDL-C ratio was positively correlated with MBPS (P < 0.001). Multivariate analysis showed that BPMS and TG/HDL-C were independent predictors for reduced CFR in OHP (P < 0.001). Receiver-operating characteristic analysis showed that TG/HDL-c ratio ≥3.8 and MBPS ≥49 mmHg were the optimal cutoff values to predict reduced CFR among OHP, with (area under the curve = 0.91 and 0.92, respectively; P < 0.001). Conclusion: Our study suggests that microvascular function is significantly impaired in OHP. TG/HDL-C ratio and MBPS are independently associated with reduced CFR. These relationships could potentially reflect a subclinical precursor of cardiovascular risks and future hypertension, a premise that warrants close follow-up.
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