Serum Gamma Glutamyltransferase (GGT) in Coronary Artery Disease: Exploring the Asian Indian Connection

Background:There is a need to identify novel markers for CAD, independent of traditional CV risk factors. One of these is gamma?glutamyl transferase (GGT), a marker of increased oxidative stress. Given the high prevalence of CAD in Asian Indians, the link of GGT and CAD in them needs to be studied. Aim: To assess GGT in patients with angiographically documented CAD. Methods and Results: Two hundred patients aged 58.1 ± 9.95 years, 73% males, hypertension 56%, diabetes 40% were included. Mean GGT was 63.6 ± 44.33 (10–269 U/L). The levels of GGT progressively increased in those with single/double or triple?vessel CAD (36.5, 61.5, and 87 U/L, respectively, P < 0.001). Using objective criteria of CAD burden (SYNTAX and Gensini scores), we reaffirmed these findings. GGT in patients with SYNTAX tertiles 0–22, 23–32, and 33 was 33, 62, and 97 U/L, respectively and in Gensini tertiles 0–17.65, 17.66–56.65, ?56.66 was 32, 52, and 88 U/L, respectively, all P < 0.001. SYNTAX score 23 was present in only 23% patients in GGT tertile 1 (<41 U/L), whereas60% and 94% in GGT tertiles 2 and 3 had SYNTAX 23. Significant positive correlation was seen between GGT and SYNTAX (r = 0.634) and Gensini score (r = 0.772). Conclusions: In this study, GGT had an independent correlation with angiographic severity of CAD and SYNTAX and Gensini scores. Although the existing evidence seems biologically plausible, more studies are needed to explore the potential role of this inexpensive marker for predicting disease burden in patients with CAD.

Analgesic effect of continuous adductor canal block versus continuous femoral nerve block for knee arthroscopic surgery: a randomized trial

Abstract Background and objectives Anterior cruciate ligament reconstruction (ACLR) is one of the most frequently performed orthopedic procedures. The ability to perform ACLR on an outpatient basis is largely dependent on an effective analgesic regimen. The aim of the study was to compare the analgesic effect between continuous adductor canal block (cACB) and femoral nerve block (cFNB) during arthroscopy guided ACLR. Method In this prospective, randomized, controlled clinical trial, 60 ASA I/II patients for arthroscopic ACLR were recruited. Patients in Group I received cACB and those in Group II cFNB. A bolus dose of 20 cc 0.5% levobupivacaine followed by 0.125% 5 mL.h-1 was started for 24 hours. Rescue analgesia in the form of paracetamol 1 g intravenous (IV) was given. Parameters assessed were time of first rescue analgesia, total analgesic requirement in 24 hours, and painless range of motion of the knee (15 degrees of flexion to further painless flexion). Results The time-to-first postoperative analgesic request (hours) was earlier in Group II (14.40 ± 4.32) than Group I (16.90 ± 3.37) and this difference was statistically significant (p< 0.05). The cumulative 24-h analgesic consumption (paracetamol in g) was 0.70 ± 0.47 in Group I and 1.70 ± 0.65 in Group II (p< 0.001). The painless range of motion (degree) was 55.67 ± 10.40 in Group I and 40.00 ± 11.37 in Group II (p< 0.001). Conclusion The findings of this study suggest that continuous adductor canal block provides superior analgesia in patients undergoing arthroscopic ACLR when compared to continuous femoral nerve block.

Exploring the Association of Fibrinogen and CRP with the Clinical Spectrum of CAD and Periprocedural Outcomes in Patients Undergoing Percutaneous Coronary Interventions

Background:The pathophysiology of an atherosclerotic plaque is mediated by the mechanisms involving thrombus formation and systemic inflammation. While C-reactive protein (CRP) levels are useful in predicting a cardiovascular event in intermediate risk population, the usefulness of routinely measuring fibrinogen in patients with acute coronary syndrome (ACS) is debatable. Also, data on the association of these markers with periprocedural outcomes in patients undergoing percutaneous coronary interventions (PCI) is scarce. Aims: The study aimed to determine whether the levels of fibrinogen and CRP vary across the different spectra of CAD and whether they have any correlation with cardiac Troponin I levels. Materials and Methods: A total of 284 patients with coronary artery disease undergoing percutaneous coronary intervention were included in the study. Complete blood count, serum lipid profile, serum CRP, fibrinogen, and troponin I were measured for all patients. Results: Patients with STEMI had significantly higher levels of CRP as compared to those with unstable angina (USA) and chronic stable angina (CSA). Patients presenting with ACS had significantly higher baseline fibrinogen as compared to those with CSA. A significant positive correlation between CRP and admission Troponin I (r = 0.50; P < 0.05) as well as fibrinogen and admission troponin I (r = 0.30; P < 0.05) was observed. The CRP levels were significantly higher in 15 patients with periprocedural MI as compared to those who did not develop periprocedural MI. Conclusions: The levels of the markers of inflammation and atherothrombosis vary with presentation across varied spectra of CAD with generally higher levels in acute presentation and in those who develop periprocedural MI.

Is Indexed Left Atrial Volume (LAVi) in Indian Patients with Acute Coronary Syndrome (ACS) Undergoing Revascularization a Predictor of Cardiovascular Outcomes?

Background: Left atrial volume indexed to body surface area (LAVi) is the recommended method for LA size quantification. Assessing LAVi in Indian patients undergoing coronary interventions for acute coronary syndrome (STEMI, NSTEMI, and UA) is clinically relevant. Methods and Results: Amongst 190 patients (66.4 yrs, 68.4% males), 29.5%, 40.5%, and 30% respectively had STEMI, NSTEMI and UA. Mean LAVi was 32.29 ± 12.06 ml/m2 and 111 (58.4%) had LAVi ?32 while 79 (41.6%) had LAVi <32. Patients were divided into 2 groups (group 1 LAVi >32 and group 2 LAVi <32). Group 1 patients had higher prevalence of TVD [n = 49 vs n = 5, p = <0.001] and higher mean Syntax score (24.47 vs 14.64, p = <0.001). Despite similar LVEF, those with higher LAVi had had higher incidence of mild MR (50.4 vs 27.8, P = 0.0002) and moderate/severe MR was present only in Group 1 patients (27.9% and 5.4%). Grade I, II, and III diastolic dysfunction was present in 71.2, 17.1, and 9.9% patients in Group 1 vs 45.6%, 0%, and 0% in group 2. Diastolic parameters like septal E/e’ and lateral E/e’ratio were also higher in Group 1. Major adverse cardiovascular events? (MACE) at 30 days was significantly higher in group 1 (20.7 vs 6.3%, P = 0.006). On multivariate analysis, triple vessel disease and LAVi were the only predictors of MACE while LVEF was not. ROC curve analysis for LAVi demonstrated that a cut?off 33.35 ml/m2, predicted 30 day MACE with Area under curve (AUC) 0.775 (95% CI 0.700?0.850); sensitivity and specificity of 86.7% and 61.4%. Inter?quartile analysis of LAVi (<26.3, 26.3?33.35, 33.36?36.3, and >36.3 ml/m2) demonstrated that 30 day MACE increased across quartiles (4.16%, 4.25%, 22.44%, and 28.26%, respectively, P < 0.001). Conclusion: Amongst patients with ACS undergoing revascularization, those with higher LAVi had more severe CAD, diastolic dysfunction and higher 30 day MACE. LAVi provides superior prognostic information as compared to conventional LV systolic and diastolic parameters in patients with ACS and should be incorporated in routine echocardiographic analysis. More studies with larger numbers and longer follow up are required to further elucidate on this.

Mental health, functional ability, and health-related quality of life in elderly patients attending a tertiary hospital of Patna

With changing socioeconomic, demographic, and development scenario, there is a cultural shift in looking after the elderly population which may lead to depression in this age group. Materials and Methods: The study was a hospital-based cross-sectional study conducted in the orthopedic department of a tertiary care setting on 157 elderly individuals. This study was conducted with objectives to estimate the proportion of depression using the Geriatric Depression Scale Short Form (GDS-SF) questionnaire along with its associated factors in geriatric population coming to the orthopedic department of the institute. The study tools were GDS-SF, Katz Index of Independence in activities of daily living (ADL), the Lawton instrumental ADL, and health-related quality of life by the Centers for Disease Control. Results: The proportion of depressed individuals was 70/157 (44.6%) using GDS as a tool. The maximum number was in the age group of 60–74 years. Women outnumbered men (51.3% vs. 38.31%) for depression. The depression using GDS score was more prevalent in rural elderly, illiterate, and elderly who were economically dependent on their children and who belonged to lower middle socioeconomic status. Approximately 98% of the study participants were found to be independent using ADL. Approximately 60% males and 68% females were dependent for the instrumental ADL using Lawton score. Most of the study participants had arthritis as a major impairment sharing almost equal proportion among males and females. Conclusion: The current study concludes that there is a very high proportion of elderly subjects who are experiencing depression using the GDS-SF tool. There should be regular screening for this disease in this age group even in a tertiary care setting.

Incidence and predictors of forearm hematoma during the transradial approach for percutaneous coronary interventions

Background The transradial approach for percutaneous coronary intervention (TRA-PCI) reduces vascular complications compared with the transfemoral approach (TFA). Although hematoma formation is less frequent with the TRA than TFA, it is not uncommon, and its presentation ranges from mild hematoma to compartment syndrome. Incidence and predictors of hematoma have not been well studied. Methods and results The present study was conducted to prospectively evaluate the incidence and predictors of forearm hematoma after TRA-PCI. The study population consisted of consecutive patients undergoing TRA-PCI. Baseline and procedural characteristics and clinical outcomes were prospectively collected. All patients were observed for forearm/arm hematoma immediately after procedure, after band removal, before discharge, and whenever the patient complained of pain/swelling in the limb. Logistic regression analysis was performed to determine the predictors for hematoma formation. A total of 520 patients who had successfully completed TRA-PCI were included in the final analysis. The mean age was 55.2 ± 9.5 years, and 24% patients were women. Hematoma occurred in 53 (10.2%) patients. Hematomas were of grade I, II, III, and IV in 22 (4.2%), 9 (1.7%), 18 (3.5%), and 4 (0.8%) patients, respectively. On multivariate logistic regression analysis, age, body mass index, multiple puncture attempt, glycoprotein IIb/IIIa receptor blocker use, nonclopidogrel agent use for dual antiplatelet therapy, and multiple catheter exchanges emerged as independent predictors for hematoma formation. Conclusions Forearm hematoma following TRA-PCI occurs in about 10% patients. Most hematomas occur near the puncture area. The independent predictors for hematoma formation are age, body mass index, multiple puncture attempts, intensive antiplatelet therapy, and multiple catheter exchanges.

The dilemma of the “ischemic-looking” electrocardiogram: Pulmonary embolism or acute coronary syndrome?

Pulmonary embolism (PE) may be potentially fatal if not diagnosed and treated in time. Although specific electrocardiogram (ECG) findings often suggest the diagnosis of PE, occasionally, the ECG may mimic that of an acute coronary syndrome (ACS). We report an interesting case of a 45-year-old female presenting with sudden onset chest pain and shortness of breath with widespread ST depression in anterior precordial leads. Although initially treated and referred as a case of ACS, careful analysis of the ECG and subsequent echocardiography and computed tomography imaging confirmed the diagnosis of PE. Intensivists and cardiologists need to be aware that diagnostic dilemma between PE and ACS is not uncommon due to such “ischemic-looking” ECG as well as elevated troponin levels in both conditions. The use of multimodality imaging techniques is helpful in arriving at the correct diagnosis.

Heart rate manipulation in dilated cardiomyopathy: Assessing the role of Ivabradine

Background Heart rate (HR) reduction is of benefit in chronic heart failure (HF). The effect of heart rate reduction using Ivabradine on various echocardiographic parameters in dilated cardiomyopathy has been less investigated. Methods Of 187 patients with HF (DCM, NYHA II–IV, baseline HR > 70/min), 125 patients were randomized to standard therapy (beta blockers, ACEI, diuretics, n = 62) or add-on Ivabradine (titrated to maximum 7.5 mg BD, n = 63). Beta-blockers were titrated in both the groups. Results At 3 months both groups had improvement in NYHA class, 6 min walk test, Minnesota Living With Heart Failure (MLWHF) scores and fall in BNP, however the magnitude of change was greater in Ivabradine group. Those on Ivabradine also had lower LV volumes, higher LVEF (28.8 ± 3.6 vs 27.2 ± 0.5, p = 0.01) and more favorable LV global strain (11 ± 1.7vs 12.2 ± 1.1, p = <0.001), MPI (0.72 ± 0.1 vs 0.6 ± 0.1, p = <0.001), LV mass (115.2 ± 30 vs 131.4 ± 35, p = 0.007), LV wall stress (219.8 ± 46 vs 238 ± 54) and calculated LV work (366 ± 101 vs 401 ± 102, p = 0.05). The benefit of Ivabradine was sustained at 6 months follow up. The % change in HR was significantly higher in Ivabradine group (−32.2% vs −19.3%, p = 0.001) with no difference in blood pressure. Resting HR < 70/min was achieved in 96.8% vs 27.9%, respectively in the two groups. Conclusion Addition of Ivabradine to standard therapy in patients with DCM and symptomatic HF and targeting a heart rate < 70/min improves symptoms, quality of life and various echocardiographic parameters.

Pharmacological measures to increase HDL-C among high risk isolated low HDL cases: A randomized study amongst north Indians.

Background & objectives: Low serum levels of high density lipoprotein cholesterol (HDL-C) is an established risk factor for coronary heart disease (CHD). Among a variety of lipid modifying drugs, the best single drug therapy to increase HDL-C levels, especially among high risk, isolated low HDL-C (ILHDL-C) cases is yet to be identified. The objectives of the present study were to evaluate the best pharmacological measure among atorvastatin, fenofibrate and niacin aimed to raise HDL-C and its effect in decreasing the estimated Framingham-10-year CHD risk percentage (CHD-RP) among high risk ILHDL-C cases in north India. Methods: Two hundred CHD equivalent (CHD-RP≥20), ILHDL-C cases were randomly assigned for treatment either with atorvastatin 10 mg/day (n=70), micronized fenofibrate 160 mg/day (n=65) or niacin-extended release (ER) 750 mg/day (n=65). After 6 wk of treatment, the dosages of drugs were doubled and the patients were finally assessed after 12 wk for their lipid values. Results: Baseline characteristics were similar in the three groups. Niacin therapy 750 mg and 1.5 g/day resulted in a significant rise in HDL-C by 8.10 ± 3.19 and 12.41 ± 4.39 per cent (P<0.001), respectively. Fenofibrate 160 and 320 mg/day also resulted in a significant rise in HDL-C by 3.85 ± 3.48 and 6.24 ± 4.43 per cent (P<0.001), respectively, while atorvastatin 10 and 20 mg/day resulted in a non-significant increase in HDL-C by 0.13 ± 2.92 per cent and 0.51 ± 2.63 per cent, respectively. By increasing HDL-C values, niacin was found to be most effective in reduction of 10-year CHD-RP (P<0.001), followed by fenofibrate (P=0.010), while atorvastatin had no effect. Interpretation & conclusions: Our findings indicate that niacin rather than fibrates or statins seems to provide a safe and effective therapy for increasing HDL-C, thus reducing the cumulative CHD risk among ILHDL-C cases.

Metabolic syndrome & Framingham Risk Score Observations from a coronary angiographic study in Indian patients.

Background & objectives: Metabolic syndrome (MS) is an important determinant of cardiovascular (CV) risk. Framingham Risk Scores (FRS) often underestimate the CV risk in Asians, younger patients and those with MS. Asians often develop coronary artery disease (CAD) at a younger age and also have a high prevalence of MS. Only limited data are available on the relationship between MS and FRS in such patients and the present study was undertaken to report on this aspect in an Indian patient population with angiographically documented CAD. Methods: Two hundred patients undergoing coronary angiography during a three months study period were included. Diagnosis of MS was based on modified south Asian guidelines. Results: Of the 200 patients (age 56.5 ± 8.6 yr) undergoing coronary angiography, MS was diagnosed in 77 per cent n=154; abdominal obesity, low HDL and hypertension were the commonest of the diagnostic criteria of MS, being present in >70 per cent cases. Patients with MS had significantly higher mean FRS than those without MS (15.1 vs 8.65, P<0.0001). Most patients with MS (74%, n=148) had an intermediate to high 10-year CV risk (>10%) as estimated by FRS. The proportion of patients with MS progressively increased in those with low, intermediate and high FRS (61, 87 and 92%, respectively). Though the prevalence of MS was uniformly similar (74-84%) in all age groups (<45, 45-55, 55-65 and > 65 yr, respectively), amongst those <45 yr, none of the patients could be categorized as having high CV risk as estimated by FRS despite having angiographic CAD, highlighting the limitation of age dependence of FRS. Interpretation & conclusions: MS is common in Indian patients with angiographically documented CAD; most patients with MS have 10-year risk of >10 per cent as estimated by FRS. Though MS is uniformly prevalent across all age groups, using the FRS may underestimate the CV risk in Indian patients despite documented CAD. These findings have significant implications for Asian patients with CAD in whom onset of CAD is often at a younger age than their Western counterparts. There should be continued health care emphasis on detection of MS and intensification of targeted preventive strategies.

Premature coronary artery disease in North India: an angiography study of 1971 patients.

BACKGROUND: South Asians, specially Indians, show increased risk for atherosclerosis and have the highest mortality rates due to coronary artery disease amongst all ethnic groups studied so far. We aimed to find out the differences in clinical-biochemical and angiographic profile of young patients versus older patients with angiographically proven atherosclerotic coronary artery disease. METHODS AND RESULTS: Group I (n=828) consisted of patients with age above 55 years (mean age: 63.15 +/- 5.76 years), group II (n=924, mean age: 49.13 +/- 4.25 years) consisted of patients between age 41-55 years and group III (n=219) consisted of patients with age < or = 40 years (mean age: 37.37 +/- 2.92 years). Among the conventional risk factors, smoking was significantly more frequent in group III, while diabetes mellitus and systemic hypertension were more prevalent in groups II and I. Q wave myocardial infarction was more frequently present in groups II and III. Only about one-third of the entire patient population in the myocardial infarction group received thrombolytic therapy. Total cholesterol, low-density lipoprotein cholesterol, and triglyceride levels were significantly higher in younger patients (groups II and III), while high-density lipoprotein cholesterol was significantly low in whole cohort but more so in older patients. Single vessel involvement was more common in group III, while multi-vessel involvement, diffuse disease and fluoroscopic calcium were more common in groups I and II. CONCLUSIONS: Significant differences were observed in the clinical, biochemical and angiographic profile of young patients with coronary artery disease as compared to elderly patients. The younger cohort had more atherogenic lipid profile, higher prevalence of smoking and more frequent single vessel disease. We observed that total cholesterol/high-density lipoprotein cholesterol ratio was a better predictor of coronary artery disease as compared to individual lipid levels.

Coronary angioplasty in a case of quadriostial origin of coronary arteries from right aortic sinus.

We report a case in which all three coronary arteries were originating from the right aortic sinus via separate ostia, and angioplasty of the normally arising right coronary artery was performed. In addition, the conal artery was also originating separately from same sinus, actually leading to a quadriostial origin of the coronaries. A combination of anteroaortic septal course of the left anterior descending artery and retroaortic course of left circumflex artery is an unusual coronary anomaly and was noted in this case.

Determinants of left atrial pressure in rheumatic mitral stenosis: role of left atrial compliance and "atrial stiffness".

BACKGROUND: A wide range of left atrial pressures exist in rheumatic mitral stenosis despite similar mitral valve area. Left atrial compliance may be an important determinant of left atrial pressure in mitral stenosis. Data regarding left atrial compliance in rheumatic mitral stenosis and changes following balloon mitral valvotomy are scarce. METHODS AND RESULTS: Left atrial compliance and predictors of left atrial pressure were analyzed in 85 patients with mitral stenosis undergoing balloon mitral valvotomy. The stroke volume was divided by systolic rise in left atrial pressure to calculate the left atrial compliance. Systolic rise in left atrial pressure was computed as difference between amplitudes of left atrial "v" wave and "x" descent. The mean left atrial compliance prior to balloon mitral valvotomy was 2.62+/-1.20 cm3/mmHg. Following successful balloon mitral valvotomy there was a significant fall in pulmonary artery pressure, mean left atrial pressure, transmitral gradient, and significant increase in cardiac output, stroke volume and mitral valve area. There was a marked increase in left atrial compliance from 2.62+/-1.20 to 6.1+/-3.16 cm3/mmHg. On univariate analysis pulmonary artery systolic pressure, pulmonary artery diastolic pressure, pulmonary artery mean pressure, mean transmitral gradient, mitral valve area and left atrial compliance were the only correlates of left atrial pressures, while no correlation was noted with age, gender, left atrial size, cardiac output and stroke volume. Those with higher pulmonary artery pressure, higher transmitral gradient, lower mitral valve area and lower left atrial compliance had higher left atrial mean pressure, and the strongest negative correlation was noted with left atrial compliance. On multivariate analysis the strongest predictors of left atrial mean pressure were transmitral gradient and left atrial compliance. CONCLUSIONS: Patients with rheumatic mitral stenosis have markedly depressed left atrial compliance and hence have "stiff" left atria. Left atrial compliance is an important determinant of left atrial pressure, and improves immediately after successful balloon mitral valvotomy, irrespective of pre-balloon mitral valvotomy left atrial pressures.