Identifying high risk patients post myocardial infarction with reduced left ventricular function using loop recorders INSPIRE-ELR clinical study

Aims: Sudden cardiac death (SCD) continues to be a devastating complication amongst survivors of myocardial infarction (MI). Mortality is high in the initial months after MI. The aims of the INSPIRE-ELR study were to assess the proportion of patients with significant arrhythmias early after MI and the association with mortality during 12 months of follow-up. Methods: The study included 249 patients within 14 days after MI with left ventricular ejection fraction (LVEF) _x0001_35% at discharge in 11 hospitals in India. Patients received a wearable external loop recorder (ELR) 5 ± 3 days after MI to monitor arrhythmias for 7 days. Results: Patients were predominantly male (86%) with a mean age of 56 ± 12 years. In 82%, reperfusion had been done and all received standard of care cardiovascular medications at discharge. LVEF was 32.2 ± 3.9%, measured 5.1 ± 3.0 days after MI. Of the 233 patients who completed monitoring (7.1 ± 1.5 days), 81 (35%) experienced significant arrhythmias, including Ventricular Tachycardia/Fibrillation (VT/ VF): 10 (4.3%); frequent Premature Ventricular Contractions (PVCs): 65 (28%); Atrial Fibrillation (AF): 8 (3.4%); chronic atrial flutter: 4 (1.7%); 2nd or 3rd degree Atrioventricular (AV) block: 4 (1.7%); and symptomatic bradycardia: 8 (3.4%). In total, 26 patients died. Mortality was higher in patients with clinically significant arrhythmia (at 12 months: 23.6% vs 4.8% with 19 vs 7 deaths, hazard ratio (HR) ¼ 5.5, 95% confidence interval (CI) 2.3 to 13.0, p < 0.0001). Excluding 7 deaths during ELR monitoring, HR ¼ 4.5, p < 0.001. Conclusion: ELR applied in patients with acute MI and LV dysfunction at the time of discharge identifies patients with high mortality risk.

Exploring knowledge, attitude and practice regarding yoga among patients attending cardiology and neurology clinics in a tertiary care hospital in northern India

BACKGROUND The use of complementary and alternative medicine, particularly yoga is increasing in non-communicable diseases (NCDs). We assessed the overall awareness regarding yoga among patients and their opinion about it as an adjunct therapy for NCDs. METHODS We included 384 patients attending the cardiology and neurology clinics at a tertiary care centre in northern India. A questionnaire was developed to assess the knowledge, attitude and practice of yoga as a therapy.RESULTS Ninety per cent of patients were aware of yoga, mainly through print and electronic media. Of the surveyed patients, 22% practised yoga. Lack of time and knowledge were cited as the main reasons for non-practice among the non-practising patients (88%), of which 82% believed that yoga could be practised along with modern medicine. In addition, 61% were ready to accept treatment if offered at the surveyed tertiary care centre. CONCLUSIONS Adequate knowledge, awareness and attitude towards yoga appears to be present in contrast to the low practice among the patient population surveyed. If implemented in an integrated fashion, the patients were willing to accept yoga as an adjunct therapy for their cardiac and neurological disorders—an encouraging sign given the burden of NCDs in India.

Desmin-related restrictive cardiomyopathy in a pediatric patient: A case report.

Restrictive cardiomyopathies in the pediatric population have diverse etiologies, including storage diseases like hemosiderosis, glycogenoses and desmin with its associated proteins. Desmin-related myopathy is a rare familial disorder of the cardiac and skeletal muscle characterized by intrasarcoplasmic accumulation of desmin-reactive deposits in the muscle cells. The patients commonly present with cardiac involvement such as conduction blocks and/or restrictive cardiomyopathy. Diagnosis of desmin cardiomyopathy depends on light microscopic evaluation of endomyocardial biopsy, where abnormal deposition of desmin can be documented on immunohistochemistry and ultrastructural examination. The index report presents the clinical, light microscopic and ultrastructural fi ndings of desmin cardiomyopathy.

Prevalence of symptomatic and asymptomatic coronary artery disease in patients with stroke.

Background. Studies have shown that myocardial infarction is a leading cause of death in patients recovering from stroke or transient ischaemic attacks. We aimed to study the prevalence of symptomatic and asymptomatic coronary artery disease (CAD) in patients with stroke. Methods. Eighty-six patients with stroke were evaluated for risk factors and presence of CAD. Patients without a previous diagnosis of CAD underwent stress–rest gated technetium-99m (Tc99m) tetrofosmin myocardial perfusion SPECT (MPS) scan to estimate the presence or absence of a reversible perfusion deficit. Results. Thirty-three patients (clinically asymptomatic for CAD) did not consent for the MPS scan. Among the remaining 53 patients, 13 patients had been previously diagnosed to have CAD, 8 patients were suspected to have underlying CAD and 32 patients were asymptomatic. Among the patients with suspected CAD, 2 had abnormal MPS scans and one had triple-vessel disease on coronary angiography. Of the asymptomatic patients, 6 had CAD. The overall proportion of CAD among patients with stroke was 41.5% (22/53) and that of asymptomatic CAD 18.8% (6/32). Conclusion. A considerable number of patients with stroke may have associated CAD. An optimal management strategy in stroke patients who have silent CAD may improve clinical outcomes.

Evaluation of vaccine candidate potential of ΔaroA, ΔhtrA and ΔaroAΔhtrA mutants of Salmonella enterica subspecies enterica serovar Abortusequi in guinea pigs.

Salmonella enterica subspecies enterica serovar Abortusequi (S. Abortusequi), a host adapted Salmonella causes abortions, still births and foal mortality in equids. Though known since more than 100 years, it is still a problem in many of the developing countries including India. There is dearth of really good vaccine affording immunity lasting at least for one full gestation. In search of a potential vaccine candidate, three defined deletion mutants (ΔaroA, ΔhtrA and ΔaroAΔhtrA) of S. Abortusequi were tested in guinea pig model for attenuation, safety, immunogenicity, humoral immune response, protective efficacy and persistence in host. The ΔhtrA and ΔaroAΔhtrA mutants were found to be safe on oral inoculation in doses as high as 4.2×109 cfu/animal. Also through subcutaneous inoculation ΔaroAΔhtrA mutant did not induce any abortion in pregnant guinea pigs. All the three mutants did not induce any illness or death in 1-2 week-old baby guinea pigs except ΔhtrA mutant which caused mortality on intraperitoneal inoculation. Inoculation with mutants protected against challenge and increased breeding efficiency of guinea pigs. After >4.5 months of mutant inoculation, guinea pigs were protected against abortifacient dose of wild type S. Abortusequi and mother guinea pigs also conferred resistance to their babies to the similar challenge. Early humoral immune response of S. Abortusequi mutants was characteristic. Faecal excretion of ΔaroA and htrA mutants was detected up to 45 days of inoculation in guinea pigs while ΔaroAΔhtrA mutant could not be detected after 21 days of inoculation. The results indicated that the double deletion mutant (ΔaroAΔhtrA) was the most effective and safe candidate for vaccination against S. Abortusequi through mucosal route of inoculation.

Efficacy of combined modified and conventional ultrafiltration during cardiac surgery in children.

Thirty children undergoing cardiac surgery under cardiopulmonary bypass (CPB) were prospectively studied to assess beneficial effects of modified ultrafiltration (MUF) over and above conventional ultrafiltration (CUF). Transoesophaegeal echocardiography determined ejection fraction (EF), fractional area change (FAC) and posterior wall thickness in end-diastole and end-systole were measured and compared in two groups undergoing CUF (group I) and CUF plus MUF (group II). Haemodynamic data, haematocrit, temperature drift, postoperative chest tube drainage in first 48 hours, ventilation and intensive care unit (ICU) stay were also recorded. Within group data were analysed by general linear trend and intergroup comparisons were made with t-test. EF and FAC decreased at 0 min after CPB in both groups, but both recovered at 10 and 30 min after CPB in group II. Increase in EF and FAC in group II was about 12-15 % and 3-5 % from 0 min respectively. There was also significant improvement in posterior wall thickness and haematocrit (P<0.05) in group II. Patients in group II maintained better systolic blood pressure and heamoglobin after CPB. Chest tube drainage in first 48 hours was significantly less in group 1I (100 -18 verses 85 +/-20 ml, P<0.05), but ventilation and ICU stay were not different between the two groups. Combined ultrafiltration has beneficial effect an haemodynamics with improvement in EF and FAC. It improves haematocrit and decreases chest pulse drainage.

Haemolysins of Salmonella, their role in pathogenesis and subtyping of Salmonella serovars.

Haemolysin patterns of 175 strains of different Salmonella enterica subspecies enterica serovars isolated from different animal sources and places were determined using 11 different blood agar media made with either non-washed horse/sheep erythrocytes or with washed erythrocytes of cattle, sheep, horse, goat, rabbit, guinea pig, and human A, O and B blood groups. Study on 47 strains belonging to 10 serovars of Salmonella from buffalo meat (buffen), 42 strains of 11 serovars from goat meat (chevon): 16 strains of Salmonella enterica serovar Paratyphi B and 25 of S. enterica serovar Paratyphi B var Java from fish, meat, meat products and clinical cases; 45 isolates of S. Abortusequi from aborted mares (18), fetal contents (21), aborted donkey mares (2) and 4 reference strains, revealed that all host restricted Salmonella namely, S. enterica serovar Gallinarum, S. enterica serovar Anatum, S. enterica serovar Abortusequi and S. enterica serovar Paratyphi B could be divided into different haemolysin types based on their inability to produce haemolysis on one or more types of blood agar, while strains of all zoonotic Salmonella serovars induced haemolysis on all the 9 types of blood agar made of washed erythrocytes. None of 175 Salmonella could produce hemolytic colonies on blood agar made of non-washed horse/ sheep erythrocytes. Haemolysin type I (lysing all types of washed erythrocytes) was the commonest one among all serovars except S. Abortusequi, none of which lysed horse erythrocytes. Salmonella enterica serovar Abortusequi having hemolytic activity against sheep erythrocytes were more invasive but had lesser ability to survive in sheep mononuclear cells than non-hemolytic strains. Multiplicity of haemolysins appeared significant epidemiological tool.