To estimate the serum level of N-terminal pro-brain natriuretic peptide levels in acute coronary syndrome

Background: Acute coronary syndromes caused by a sudden blockage of a coronary artery. According to degree and location of the blockage, it ranges from unstable angina to non–STsegment elevation myocardial infarction (NSTEMI), ST-segment elevation myocardial infarction (STEMI), and sudden cardiac death. The levels of serum cardiac markers get elevated during myocardial necrosis in ACS. B-type natriuretic peptide (BNP), cardiac neurohormone, and its Nterminal fragment (NT-proBNP) are synthesized and secreted from the ventricular myocardium. It is well known that the stimulus for their release is the increase in left ventricular wall stress. Aim and objectives: To estimate the serum level of N-terminal pro-Brain natriuretic peptide levels in acute coronary syndrome, to assess the levels of NT-pro-BNP and its relationship between STEMI, NSTEMI and Unstable angina patients. Materials and methods: The study included 40 patients admitted in the medicine ward of RMMCH. The study period was from January 2018- July 2018. Patients with acute coronary syndromes were identified over a period according to the criteria and were included in the study. The patients were completely evaluated and their serum NT-pro BNP levels were noted. Killips Class was recorded if the patient was in acute MI. In NSTEMI, STEMI and unstable angina, TIMI scoring was also calculated. Results: The common age of the patients was 51 to 60 years (50%). In the age group of 41 to 50 years, 30% was observed. In the age category of 31 to 40 years, 20% was observed. The mean age was 49.10 years. There was 55% of patients with NT pro BNP > 500 in the age category 51- 60 years whereas only 16.7% in this range in the age category 41 to 50 years and again only 8% Mohamed Yasar Arafath, K. Babu Raj. To estimate the serum level of N-terminal pro-brain natriuretic peptide levels in acute coronary syndrome. IAIM, 2019; 6(1): 8-15. Page 9 in the age category 30 to 40 years. The Majority of 30 to 40 years had NT pro-BNP of 100 to 500 (62.5%). In the age category of 41 to 50 years, 50% had NT Pro BNP of 100 to 500 while only 35% was in this range in the age group of 51-60 years. In the age category of 41 to 50 years, 33.3% had NT pro-BNP of < 100 whereas only 10% of 51 to 60 years had NT pro-BNP of < 100 and in the age category of 30 to 40 years, no one had NT pro-BNP of <100. The chi-square test of association was insignificant. Cardiac enzymes (Troponin T and CKMB) was elevated for the majority of the patients (N=27, 67.5%). Cardiac enzymes (Troponin T and CKMB) were normal for only 32.5% of the patients. The correlation of TIMI score with NT pro-BNP was peak positive i.e. if NT pro-BNP is higher, TIMI score was also higher and vice versa but the correlation was insignificant (r=2.54, p = .64). Conclusion: Even though the study is done in patients without clinical signs of heart failure, the levels of NT-proBNP had an inverse relationship with Ejection Fraction. Low NT-proBNP levels at the time of admission rule out high-risk patients or patients with heart failure.

Cystatin-C as a potential risk factor for acute myocardial infarction with normal renal function

Background: Myocardial Infarction accounts for 20% of all medical emergency admissions and has the highest risk for adverse effects and deaths. Risk of CAD could be prevented by various strategies and most of the developed countries could reduce the incidence and mortality related to CAD especially Myocardial Infarction by various preventive methods. Cystatin-C thus acts as an independent risk factor for Myocardial Infarction and heart failure. Aim and objective: To estimate the Serum level of Cystatin-C in Acute Myocardial Infarction with normal renal function Materials and methods: The study included 40 patients admitted in the medicine ward of RMMCH. The study period was from February 2018- July 2018. Patients with acute coronary syndromes were identified over a period according to the criteria and were included in the study. Primary complaints like angina, dyspnea, symptoms of cardiac failure were recorded. Risk factors for coronary artery disease like diabetes mellitus, systemic hypertension, smoking, hyperlipidemia, renal failure, and other complaints if any were noted. Clinical examination included a detailed general examination including vital signs and systemic examination of cardiac, respiratory, gastrointestinal, and nervous systems. 2 ml of blood was withdrawn from all patients within 12 hours of onset of symptoms for measuring Cystatin-C. Results: The common age was 52 to 59 years (47.5%) and 45 to 51 years (45.0%). The mean age of the study patients was 51.10 ±5.47 years. The majority of the patients had ST-elevated MI (N=27, 67.5%). Among STEMI, 14 patients were AWMI (N=14, 51.9%) IWMI- STEMI was identified in 18.5% patients. Likewise, posterior wall MI-STEMI was the diagnosis for 18.5% and Inferior-lateral- Bharat Lochan, K. Babu Raj. Cystatin-C as a potential risk factor for acute myocardial infarction with normal renal function. IAIM, 2019; 6(1): 1-7. Page 2 STEMI was the feature for 11.1%. The mean Cystatin-C for STEMI was 1.24 + 0.26 whereas it was 1.38 ± 28 for NSTEMI. The difference was statistically insignificant (t=1.46, p=151). The overall Cystatin-C Mean was 1.29 ± .27, which was higher than the normal level. The correlation of CystatinC with LV function is poor (r = .181, p=26). The relationship was weakly positive and insignificant. That was when Cystatin ‘C’ was more, LV function was less and vice-versa. The correlation of Cystatin-C with TIMI was negative i.e. when Cystatin was more, TIMI was less and vice-versa but the relationship was poor (r=.126, p = .44) and insignificant. Conclusion: Cystatin-C plays an important role in the pathogenesis of Acute Myocardial Infarction, and one of the mechanisms is thought to be that Cystatin-C facilitates the progress of atherosclerosis by regulating inflammation. Cystatin-C is less influenced by age, gender, and muscle mass and thus may be a better indicator of cardiovascular risk especially Myocardial Infarction.

A clinical study of incidence, risk factor profile, and prognosis in cases of posterior circulation stroke

Background: The etiology of posterior circulation ischemia has been thought to be primarily due to local arterial atherosclerosis (large artery disease) and penetrating artery disease (lacunes). However, there is increasing evidence that cardiogenic embolization is more common than previously suspected and is responsible for 20-50% of posterior circulation strokes. Aim and objective: To study the clinical manifestations, risk factor profile, and prognosis in this sample of patients. Materials and methods: 54 cases of posterior circulation strokes, admitted to the Department of Medicine, Rajah Muthiah Medical College, and Hospital, Chidambaram, during the period from September 2016 to October 2017, who fulfilled the inclusion criteria, were taken up for the study. Results: Out of 54 patients, 48.1% had hypertension, 37.0% had diabetes, 37.0% had tobacco abuse, 37.0% had alcohol abuse, 40.7% had dyslipidemia, 7.4% had TIA/Stroke, 11.1% had RHD, 27.8% had IHD and 7.4% had MVP as predisposing factors. Majority of the patients had hypertension as a risk factor followed by dyslipidemia. Many patients had multiple predisposing factors. 46.3% had their consciousness impaired, 59.3% had speech disturbances, 13.0% had cranial nerve involvement, 55.6% had motor disturbances, 13.0% had sensory disturbances, 48.1% had cerebellar signs, 37.0% had nystagmus and 44.4% had fundal changes. Majority of the patients had speech disturbances on clinical examination. Conclusion: Majority of the patients had Hypertension (48.1%) as a risk factor followed by Dyslipidemia (40.7%). Many patients had multiple predisposing factors. There is an increased K. Babu Raj, B. Nageswaran. A clinical study of incidence, risk factor profile, and prognosis in cases of posterior circulation stroke. IAIM, 2018; 5(9): 28-33. Page 29 association between coronary artery disease and posterior circulation strokes in our study (27.8%). Infratentorial lesions (50%) were more common than supratentorial lesions (38.9%) and both combined (11.1%). The mortality associated with posterior circulation strokes in our study is 16.7%. Majority of the patients had no disability (22.2%) or slight disability (18.5%).

Study of hypoglycemia in elderly diabetes mellitus

Background: The etiology of diabetes in India is multifactorial and includes genetic factors coupled with environmental influences such as obesity associated with rising living standards, steady urban migration, and lifestyle changes. It is a chronic disease, and as it prolongs it has many serious effects on multiple organs of the body. Keeping a view of the above-said problem, there arises a need for rigorous control of diabetes mellitus. However, rigorous control of diabetes leads to more incidence of hypoglycemia in elderly diabetic patients. Hypoglycemia has serious complications leading to various morbidity and mortality. Aim and objective: To study the risk factors associated with the development of hypoglycemia in elderly diabetic patients, to study about the symptoms occurring during the hypoglycemic episodes. Materials and methods: The study included 100 patients: Group –A 50 diabetics and Group B controls. Age and sex-matched diabetic patients >60 years admitted during the same period in RMMCH. Details of the hypoglycemic episode (symptoms, severity, glucose level, risk factors identified, treatment and outcome), comorbidities, polypharmacy, alcohol use and assessment of functional status Assessment of the functional status was done using Katz score. Results: Functional status of patients were assessed with KATZ index only 10 out of 50 study patients had poor (Katz score=0) functional status. 52% patients had their episodes during night time. 34 patients (68%) had come to the hospital with hypoglycemia and the rest of the patients developed hypoglycemia in-hospital stay. 70% of patients had symptoms and 30% had no symptoms. Neuroglycopenia was predominant in most patients. Conclusion: Asymptomatic hypoglycemia was common in the elderly diabetics. In symptomatic patients, neuroglycopenic symptoms were more commonly encountered than autonomic symptoms. K. Babu Raj, R. Prabhakaran. Study of hypoglycemia in elderly diabetes mellitus. IAIM, 2018; 5(9): 14-20. Page 15 The mean duration of diabetes mellitus was longer in the group of study patients with no symptoms of hypoglycemia as compared to patients who were symptomatic for hypoglycemia.

A study of ocular movements and pupillary changes in acute stroke patients

Background: Cerebrovascular disease or stroke rank first in frequency and importance, among all the neurological diseases of adult life. It is the third most common cause of death in the world. Different neuroanatomical pathways are involved in the control of pupil, the integrity and the functionality of these neurological pathways can be often be ascertained through the analysis and interpretation of pupillary behavior. This makes the pupil size and the pupillary light reflex an important factor to be considered in many clinical conditions. Aim and objective: To study the ocular movements and pupils in acute stroke patients with its clinical correlation and imaging. Materials and methods: The study sample included was 50 patients with acute stroke confirmed by CT/MRI findings of both sexes and who belonged to the age group of 20 to 80 years from RMMCH. A detailed clinical history was taken for these patients who were included in this study. All these patients were examined thoroughly with particular importance to ocular movements and pupils. Results: Of the 50 patients, 16 patients were having an altered level of consciousness(32%), 30 patients were having speech disturbances(72%), 18 patients were having gaze paresis(36%), all the patients who were included in the study were having facial palsy (100%), Of the 18 patients with abnormal pupillary findings, there were 9 patients (18%) with dilated pupils which were not reacting to light during the first 12 hours, i.e. from the time of admission, 9 patients (18%) with round, constricted pupils, sluggishly reacting to light and 32 patients (64%) did not show any changes in the pupils. Of the 20 patients (40%) with abnormal ocular movements, the commonly observed ocular changes in the study sample were 3rd nerve palsy, 6th nerve palsy, multiple cranial nerve palsies, conjugate eye deviation to the side of the lesion, nystagmus on left lateral gaze, horizontal nystagmus on lateral gaze to the side of lesion. K. Babu Raj, G. Arul Venkadesh. A study of ocular movements and pupillary changes in acute stroke patients. IAIM, 2018; 5(8): 9-16. Page 10 Conclusion: The Anterior circulation stroke (78%) was more common than the Posterior circulation stroke (22%) in our study group. Although the abnormal pupillary changes and ocular movements were very common in posterior cerebral artery territory infarcts, the incidence of abnormal pupillary changes and ocular movements was more common in posterior cerebral artery territory (50%) and also in middle cerebral artery territory (45%) in our study group.

A study on clinical profile of acute coronary syndrome in type 2 diabetes mellitus patients with relevance to HbA1c

Background: Cardiovascular disease (CVD) has emerged as the dominant chronic disease in many parts of the world. At the beginning of the twenty-first century, CVD accounts for nearly half of all deaths in the developed world and 25% in the developing world. Diabetes mellitus (DM) refers to a group of common metabolic disorders that share the phenotype of hyperglycemia. Vascular diseases account for most morbidity and mortality in patients with DM. Aim and objectives: To study the clinical profile of type 2 diabetic patients presenting with Acute Coronary Syndrome (ACS) with reference to HbAlc level. Materials and methods: After selecting appropriate samples for the study based on the inclusion criteria, a detailed history was elicited and clinical examination was done as per the proforma. The necessary investigations were done as per the proforma. The clinical profile of these patients was then analyzed and correlated with reference to HbAlc level and statistical analysis performed using paired’ test. Results: The prevalence of microvascular diabetic complications was high with nephropathy amounting to 62% and retinopathy amounting to 58%. Neuropathy was not documented. About 32% of patients were free of microvascular complications. Other macrovascular diabetic complications were not documented. Among complications of ACS, 24% developed hypotension and no other complication was noted. Remaining 76% did not suffer any complications. No mortality was documented. Patients with systolic dysfunction constituted 82% and diastolic dysfunction 66%. The percentage of patients with HbA1c >7% constituted 62% which was very high and only 32% of patients had their HbA1c level in the control range. K. Babu Raj, G. Sivachandran. A study on clinical profile of acute coronary syndrome in type 2 diabetes mellitus patients with relevance to HbA1c. IAIM, 2018; 5(8): 1-8. Page 2 Conclusion: A majority of diabetic patients developing acute coronary syndrome have poor glycaemic control as reflected by their HbAlc levels. The coronary event is likely to occur sooner after the detection of diabetes if good glycaemic control is not achieved. Exercise, in the form of regular day to day activities, does not achieve satisfactory glycaemic control and cannot prevent the development of adverse complications of diabetes.