2D Echocardiographic Findings, NT-ProBNP Levels, and Outcomes in Dyspnoeic Patients: Results from the Pro-BNP Investigation of Dyspnoea in the Emergency Department- a Single Centre Experience

Background: Dyspnoeic in the emergency department with multiple co-morbidities is a diagnostic challenge. Approximately 15-20% of acute dyspneic in the Emergency Department due to ADHF (acute decompensated heart failure) are misdiagnosed. B-type peptide (BNP) and its amino-terminal fragment (NT-proBNP) accurately identify HF in dyspnoeic patients. In the general population with dyspnoea, plasma pro-BNP concentrations are increased in left ventricular dilatation, hypertrophy, systolic dysfunction, or diastolic dysfunction but are unaffected by pulmonary dysfunction. Aims and Objectives: To study the relation between NT pro-BNP & echocardiographic findings in acute dyspnoeic patients, and the relation between NT pro-BNP and In-hospital Mortality. Materials and Methods: Source of data- Patients admitted to the Emergency Room or cardiac intensive care unit with a history of acute dyspnea in a tertiary cardiac care center in south India, meeting inclusion & exclusion criteria, were studied. Results: The study population is predominantly constituted of the elderly population. The most common co-morbid condition was hypertension. The present study uses an NT pro BNP level of 900pg/ml as the cut-off level. 78 patients were positive for the test. Echocardiography showed that 58% had LV systolic dysfunction, 60% had diastolic dysfunction. 42 patients had EF >55%, 10 patients between 55-45%, 33 patients between 44-30% and 15 patients had EF < 30%. Mortality rate was 6% in the whole study population. However, Mortality was seen in only NT pro-BNP positive group it was not statistically significant (p=0.46). Conclusions: NT pro-BNP correlates well with the worsening of LV systolic function; as the EF decreases, NT pro-BNP increases. Increase in NT pro-BNP levels has to be interpreted in the clinical context, and it is not a substitute for echocardiography for assessing cardiac abnormalities and dysfunction.

The effect of mobile application-based technology use on medication compliance and modification of risk factors in post PTCA cohort of patients

Mobile application-based technology was used to study medication compliance and influence on cardiovascular lifestyle in ischemic heart disease (IHD) patients who undergo percutaneous transluminal coronary angioplasty (PTCA). The Mobile-app was made available at Google play store; the app was downloaded and instructions to use were thought to patients by the research team during hospitalization in the study group. A total of two hundred patients with ischemic heart disease who underwent PTCA were enrolled into the study. The control group had telephonic follow up at periodic interval. Both groups had clinical follow ups at appropriate time intervals. Higher medication compliance, smaller number of adverse events and regular follow ups were significantly more in mobile-app group than in control group.

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.

Clinical and etiological profile of acute heart failure: an observational study

Background: Acute heart failure (AHF) is a common and growing medical problem associated with major morbidity and mortality. It is the leading reason for hospital admission among patients over age 65 years. Not much of data is available from India, there are a lot of differences between the western data and available Indian data. Prompt diagnosis, identification of reversible causes and supportive management in ICU is of paramount importance.Methods: This study was conducted at Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bangalore, Karnataka after the institutional ethics committee approval. Those patients who were diagnosed to have AHF, were evaluated and treated as per the institution protocols in ICU and standard medical care which includes diuretics, inotropes and vasopressors. All the patients were prospectively studied; investigated for the etiology of AHF.Results: Majority of patients presenting as Acute Heart Failure are of 60 years mean age, with 63% males. Ischemic heart disease is the leading cause of Acute Heart Failure. Shortness of breath was the commonest presentation followed by crackles. Abdominal pain was the most common (28%) non cardiac symptom. There is no significant correlation between the presence of anemia and mortality. Hyponatremia had relation with mortality. 22% had HFpEF, rest had HFrEF. The mean hospital stay was 8.3 days. The study mortality was 9 % and the 30-day mortality was 13 % in our study.Conclusions: Current available data from Indian studies and registries has a lot of difference from the western data with regards to causes, response to treatment, and more such data is needed to frame regional guidelines for better understanding of presentation of heart failure ,treatment and risk factors for mortality.

Demographic and Clinical Features of Left Atrial Tumors in South Indian Population: A Case Series

Myxomas are the most common type of primary cardiac tumor. They cause a variety of clinical manifestations depending on size and anatomical location. Sometimes, manifestations are atypical challenging differential diagnosis and the therapeutic approach. Left atrial myxomas are commonly missed clinically and often lead to grave consequences. We present here a series of 6 cases of left atrial myxomas with demographic and clinical characterization of the patients that were managed successfully.

Thoracic Aorta Aneurysm-Endovascular Aortic Repair.

Endovascular aortic repair (EVAR) is the treatment of choice for patients with descending thoracic aortic aneurysm who are unfit for open surgery. We report a 50-year-old Asian woman who presented with a saccular symptomatic thoracic aortic aneurysm and underwent EVAR with a covered stent with prompt relief of symptoms and no residual complications at 1 year of follow up.

Transcatheter Intervention for Infantile Hepatic Hemangioendothelioma with Amplatzer Duct Occluder II.

Introduction: Infantile Hepatic hemangioendothelioma is characterized by multifocal benign vascular dilatations involving the liver. The clinical course depends on tumor size, localization and complications. Case Report: 15 days old neonate with stormy postnatal period was referred for intractable congestive cardiac failure. Transthoracic 2D echocardiography showed multiple vegetations on all the four valves, noncompaction of left ventricle with multiple vascular channels in left lobe of liver. Computed tomography angiogram showed 58x29x50 mm markedly enhancing lesion in left lobe of liver suggestive of infantile hepatic hemangioendothelioma. The neonate was treated for bacterial endocarditis. Later 6x6 Amplatzer duct occluder II was parked in hepatic vein, then gel foam and polyvinyl chloride particles were injected into infantile hepatic hemangioendothelioma. Cardiac failure resolved with marked regression of lesion. Discussion: Infantile hepatic hemangioendothelioma is a rare anomaly causing heart failure in neonate causing death in up to 70% of untreated infants without adequate regression of lesion. Therefore aggressive treatment is warranted. For the first time in the world, we report a case of infantile hepatic hemangioendothelioma in a neonate, with pump failure due to noncompaction of left ventricle and vegetations on all four valves, successfully treated by combination of transcatheter deployment of Amplatzer duct occluder II to occlude the venous end and hand injection of gel foam and polyvinly chloride particles from the aortic end to close the feeder artery. Conclusion: The combination of closure of hepatic vein by Amplatzer duct occluder II and injection of gel foam and polyvinyl chloride particles is safe and effective in infantile hepatic hemangioendothelioma in neonate with heart failure.

Predicting mortality after congenital heart surgeries: Evaluation of the Aristotle and Risk Adjustement in Congenital Heart surgery-1 risk prediction scoring systems: A retrospective single center analysis of 1150 patients.

Aims and Objectives: To validate Aristotle basic complexity and Aristotle comprehensive complexity (ABC and ACC) and risk adjustment in congenital heart surgery‑1 (RACHS‑1) prediction models for in hospital mortality after surgery for congenital heart disease in a single surgical unit. Materials and Methods: Patients younger than 18 years, who had undergone surgery for congenital heart diseases from July 2007 to July 2013 were enrolled. Scoring for ABC and ACC scoring and assigning to RACHS‑1 categories were done retrospectively from retrieved case files. Discriminative power of scoring systems was assessed with area under curve (AUC) of receiver operating curves (ROC). Calibration (test for goodness of fit of the model) was measured with Hosmer‑Lemeshow modification of χ2 test. Net reclassification improvement (NRI) and integrated discrimination improvement (IDI) were applied to assess reclassification. Results: A total of 1150 cases were assessed with an all‑cause in‑hospital mortality rate of 7.91%. When modeled for multivariate regression analysis, the ABC (χ2 = 8.24, P = 0.08), ACC (χ2 = 4.17, P = 0.57) and RACHS‑1 (χ2 = 2.13, P = 0.14) scores showed good overall performance. The AUC was 0.677 with 95% confidence interval (CI) of 0.61-0.73 for ABC score, 0.704 (95% CI: 0.64-0.76) for ACC score and for RACHS‑1 it was 0.607 (95%CI: 0.55-0.66). ACC had an improved predictability in comparison to RACHS‑1 and ABC on analysis with NRI and IDI. Conclusions: ACC predicted mortality better than ABC and RCAHS‑1 models. A national database will help in developing predictive models unique to our populations, till then, ACC scoring model can be used to analyze individual performances and compare with other institutes.

Indigenous recombinant streptokinase vs natural streptokinase in acute myocardial infarction patients: Phase III multicentric randomized double blind trial.

BACKGROUND: Streptokinase is the most widely used thrombolytic agent and can now be made using recombinant DNA technology. The present trial was initiated to assess an indigenous recombinant streptokinase (Shankinase, r-SK). AIM: To compare the efficacy and safety of indigenous recombinant streptokinase (Shankinase, r-SK) and natural streptokinase (Streptase, n-SK). SETTINGS AND DESIGN: Double blind, randomized, non-inferiority, multicentric, parallel study. MATERIALS AND METHODS: Patients of AMI < 6 hours of chest pain and 2 mm ST elevation in 2 contiguous chest leads V(1)-V(6) or 1 mm in limb leads were randomized to receive 1.5 miu of either r-SK or n-SK. CK Peaking and decrease of > or = 50% ST segment were used to assess reperfusion. STATISTICAL ANALYSIS: Difference in the groups was assessed by chi-square or paired t test as required. Probability value < 0.05 was considered significant with 95% confidence interval. RESULTS: Overall 150 patients were recruited (96 r-SK group and 54 in n-SK group) and demographic and clinical profile of the groups was comparable. Reperfusion was seen in 68.2% (58) and 69.4% (34) patients in r-SK and n-SK groups respectively. Commonly seen adverse events were fever in 7 (8.5%), hypotension in 3 (3.6%), nausea in 2 (2.4%) patients. Minor bleeding were seen in 4 (4.8%) of patients. CONCLUSION: Indigenous recombinant Streptokinase (r-SK) is as efficacious as natural streptokinase (n-SK) in establishing reperfusion as assessed by non-invasive parameters with comparable side effect profile.

Electrocardiographic localization of the occlusion site in left anterior descending coronary artery in acute anterior myocardial infarction.

BACKGROUND: The site of occlusion of left anterior descending coronary artery is important in acute anterior myocardial infarction because, proximal occlusion is associated with less favorable outcome and prognosis. The present study attempted to evaluate the electrocardiographic correlate of the location of the site of the left anterior descending coronary artery occlusion with respect to first septal perforator and/or the first diagonal branch. METHODS AND RESULTS: The study included 50 patients with a first acute anterior myocardial infarction. The electrocardiogram with the most pronounced ST segment deviation before the start of reperfusion therapy was evaluated and correlated with the left anterior descending occlusion site as determined by coronary angiography. ST segment elevation in lead aVR, ST segment depression in lead V5 and ST segment elevation in V1>2.5 mm strongly predicted left anterior descending occlusion proximal to first septal, whereas abnormal Q wave in V4-6 was associated with occlusion distal to first septal. Abnormal Q wave in lead aVL was associated with occlusion proximal to first diagonal, whereas ST depression in lead aVL was suggestive of occlusion distal to first diagonal branch. For both first septal and first diagonal, ST segment depression > or =1 mm in inferior leads strongly predicted proximal left anterior descending artery occlusion, whereas absence of ST segment depression in inferior leads predicted occlusion distal to first septal and first diagonal. All the patients were followed during their in-hospital stay (median of 7 days), during which four patients in the proximal to first septal and first diagonal group and one patient in the distal to first septal and first diagonal group died (p < or = 0.001). CONCLUSIONS: In acute myocardial infarction electrocardiogram is useful to predict the left anterior descending occlusion site in relation to its major side branches and such localization has prognostic significance.

Lipoprotein (a) in coronary artery disease in Indian population.

Prevalence of coronary artery disease (CAD) in Indian population is gradually increasing at an alarming rate. Traditional risk factors fail to explain the high incidence of CAD. Although lipoprotein(a) has been shown to be a risk factor for atherosclerosis, there is very limited data regarding Indian patients. The present study was therefore undertaken to assess the role of lipoprotein(a) levels as a risk factor in CAD in Indian patients. Clinical profile, lipid profile, coronary angiography and lipoprotein(a) levels were assessed in 300 patients with CAD and 200 controls with no CAD. There was no significant difference in age, conventional risk factors like diabetes, hypertension, smoking, family history and lipid parameters between the two groups. The mean plasma lipoprotein(a) levels in patients with CAD was 32.18 +/- 1.37 mg/dl. The value was not significantly higher than that of the mean of 29.94 +/- 2.59 mg/dl of lipoprotein(a) in the control group. In the subgroup of diabetics and patients with myocardial infarction there was a trend towards increased lipoprotein(a) levels compared to controls but the difference was not statistically significant. Nor there was any relationship between lipoprotein(a) levels and number of stenosed coronary arteries. Thus the study shows that lipoprotein(a) levels do not significantly correlate with the presence of coronary artery disease.

Zinc in rheumatic heart valves.

This study included 48 patients with chronic rheumatic heart disease, 60 control subjects for plasma zinc comparison and 20 control specimens of heart valves from postmortem cases of accident deaths. Plasma and cardiac tissue levels of zinc in patients with rheumatic heart disease were significantly lowered compared to controls. Since zinc is important in the synthesis of nucleic acids and proteins it may influence tissue growth, reparative process and structure and function of biomembrane. Low zinc levels may also influence cell mediated immunity and may increase susceptibility of patients to infection and increased rheumatic activity which needs further study.