Mitral leaflet separation index-a simple novel index to assess the severity of mitral stenosis.

BACKGROUND: Mitral leaflet separation (MLS) index is a recently recognized method to assess the severity of mitral stenosis. The aim of this study is to assess the severity of mitral stenosis (MS) using the MLS index. METHODS AND RESULTS: One hundred and fifty consecutive patients with MS who underwent 2D echo were studied. In each patient the severity of MS was assessed using 2D mitral valve area, pressure half time and MLS index. The mitral leaflet separation was measured in diastole, as the maximal separation at the tips in long axis and apical 4 chamber views. There were 34 (22.7%) patients with mild MS, 52 (34.7%) patients with moderate MS and 64 (42.7%) patients with severe MS. One hundred and ten (73.3%) patients were in sinus rhythm and 40 (26.7%) patients were in atrial fibrillation. The MLS index correlated very well with MVA by planimetry (r = 0.87, P < 0.0001) and pressure half time (r = 0.86, P < 0.0001). Good correlation was found even in atrial fibrillation (r = 0.87 and r = 0.87, respectively). ROC curve demonstrates that MLS index of 0.80cm or less identified severe MS with 92% sensitivity and 92% specificity. MLS index of >1.11 cm identified mild MS with 97% sensitivity and 97% specificity. CONCLUSION: The MLS index can be used as a screening method to semi quantify patients with mitral stenosis. This should be added into yet another method to assess the severity. This index will complement the other methods in our practice.

Serum leptin levels in acute myocardial infarction.

BACKGROUND: Several studies have shown an association of serum leptin levels with cardiovascular diseases. The present study was undertaken to assess levels of serum leptin in patients presenting with acute ST segment elevation myocardial infarction. METHODS AND RESULTS: Ninety-four consecutive patients presenting with acute ST segment elevation myocardial infarction were studied and 46 controls were taken from patients who presented with chest pain but had no history of myocardial infarction in the past. There were 59 patients with anterior wall infarction and 31 had inferior wall infarction and in 4 it was a combination of anterior and inferior wall infarction. The serum leptin levels in patients with myocardial infarction was 6.51 +/- 6.76 ng/ml versus 2.86 +/- 2.22 ng/ml in controls. In the multivariate analysis the odds ratio for serum leptin with myocardial infarction was 1.45 with a 95% confidence interval of 1.2 to 1.8. CONCLUSIONS: Our results suggest that serum leptin level is elevated in patients with acute ST segment elevation myocardial infarction.

Torsade de pointes in a case of pheochromocytoma--an unusual presentation of an uncommon disease.

We report the case of a middle aged lady with dilated cardiomyopathy, presenting with recurrent syncope due to torsade de pointes. Further evaluation revealed that she had a pheochromocytoma which caused the arrhythmia.

Mortality and morbidity of acute ST segment elevation myocardial infarction in the current era.

BACKGROUND: The mortality rate of acute myocardial infarction has come down considerably in the past three decades. In view of paucity of literature on this issue, present study was done to find out the in-hospital mortality and 30-day event rate in patients with acute ST segment elevation myocardial infarction presenting to a tertiary care hospital in India. METHODS AND RESULTS: Consecutive patients (n=1320) with the diagnosis of acute ST segment elevation myocardial infarction admitted in our institution were included in this study. The in-hospital mortality and 30-day event rates (mortality, reinfarction, recurrent angina and heart failure) were analyzed. The mean age of study population was 56+/-13 years. There were 1106 (83.8%) males and 214 (16.2%) females; 569 (43.1%) patients were smokers, 504 (38.2%) patients had hypertension, 531 (40.2%) patients were diabetic and 154 (11.7%) patients had past history of myocardial infarction. Anterior wall infarction was present in 752 (57%) patients, 517 (39.1%) patients had inferior wall infarction, 324 (62.7%) patients had associated right ventricular or posterior wall infarction and 51 (3.9%) patients had antero-inferior infarction; 1093 patients (82.8%) received thrombolytic therapy while 227 patients were not thrombolyzed due to various reasons. Of the total 1320 patients, 223 (16.9%) patients died during in-hospital stay while 1097 patients were discharged from the hospital in stable condition after a mean stay of 5.3+/-3.4 days. Thirty-day event rates of death, reinfarction and recurrent angina following hospital discharge was 18.8% (134/715 patients) and 36 (5%) patients presented with heart failure. CONCLUSIONS: The in-hospital mortality rate of acute ST segment elevation myocardial infarction in a tertiary care hospital is 16.9%, which is higher compared to reports from the West.

Prevalence of coronary artery disease in patients with rheumatic heart disease in the current era.

BACKGROUND: This study was undertaken to determine the prevalence of coronary artery disease in patients with rheumatic heart disease undergoing valve surgery. METHODS AND RESULTS: Consecutive patients with rheumatic heart disease (n=376) who were above the age of 40 years, and scheduled for valve surgery underwent diagnostic coronary angiogram to delineate coronary arteries. The patients were divided into three groups based on valve involvement (mitral valve, aortic valve, and combined aortic and mitral valve). Significant coronary artery disease was considered to be present if one or more coronaries showed 50% or more luminal stenosis. There were 287 (76.3%) males and 89 (23.7%) females. The mean age of the study population was 51.2+/-8.2 years. Eighty-nine (23.8%) patients had typical chest pain, 116 (30.6%) patients had atypical chest pain and 171 (45.5%) patients had no chest pain. Hypertension was noted in 88 (23.4%) patients, 65 (17.3%) patients had diabetes, 98 (26.1%) patients were smoker, and 66 (17.6%) patients had dyslipidemia, and 15 (4.0%) patients gave past history of myocardial infarction. Of the total 376 patients, 46 (12.2%) patients were found to have significant coronary artery disease. In patients with mitral vale disease the prevalence was 13.5% (13/96), while it was 15.3% (19/124) in patients with aortic valve disease and 9% (14/156) in those with combined mitral and aortic valve disease. CONCLUSIONS: Our results suggest that the overall prevalence of coronary artery disease in a group of patients with rheumatic heart disease undergoing valve surgery in the current era is 12.2%. This prevalence is much lower than the figures reported earlier in the Western literature.

Heart failure: what proportion of patients satisfy the electrocardiographic criteria for cardiac resynchronization therapy?

BACKGROUND: Cardiac resynchronization therapy has emerged as a new therapeutic modality for patients with congestive cardiac failure and associated intraventricular conduction delay. The purpose of this study was to find out what proportion of Indian patients with congestive heart failure may be candidates for cardiac resynchronization therapy based on electrocardiographic characteristics. METHODS AND RESULTS: One hundred twenty-one consecutive patients with congestive cardiac failure due to various etiologies whose left ventricular ejection fraction was less than 40% were included in the study. Standard 12-lead electrocardiogram was recorded in all the patients, and various parameters (rhythm, conduction, QRS axis, chamber enlargement, chamber hypertrophy, and the presence of Q waves) were analyzed. The study population comprised 82 male (67.8%) and 39 female (32.2%) patients with a mean age of 53 +/- 13 years. Thirty-nine patients (32.2%) had NYHA class I-II symptoms, and 82 (67.8%) had NYHA class III-IV symptoms. The mean QRS duration was 111 +/- 27 ms. Bundle branch block was seen in 43 patients (35.5%), of whom 30 (24.8%) had left bundle branch block, and 13 (10.7%) had right bundle branch block. Of the 30 patients who had left bundle branch block, 19 (15.7%) had a QRS duration of between 120 and 149 ms, and 11 (9%) had a QRS duration > or = 150 ms. In the latter group, 7 patients (5.8%) were in NYHA classes III and IV. As the clinical severity of heart failure increased, the mean QRS duration also increased, but this increment was not statistically significant. CONCLUSIONS: Based on our data, it can be estimated that of the patients with heart failure who attend a tertiary care center, 2 5% of patients present with left bundle branch block. If we use the criteria for NYHA class III and IV congestive cardiac failure with QRS duration of > or = 150 ms in patients with left bundle branch block, 6% of patients are likely to need cardiac resynchronization therapy.

Timing of surgery in regurgitant lesions.

For both aortic and mitral regurgitation if the patient has irreversible LV dysfunction, then they are at increased risk of postoperative LV dysfunction and death from heart failure. To justify the risk of surgery, the ideal timing for surgery is to do the same at the onset of LV dysfunction. There are several clinical and non-invasive indicators of the same.

Declining prevalence of rheumatic heart disease in rural schoolchildren in India: 2001-2002.

BACKGROUND: Rheumatic heart disease is still a major health problem in developing countries such as India and, for the health planners to allocate funds, the actual prevalence of the disease should be known. This study aimed to assess the prevalence of rheumatic heart disease in rural school children in India. METHODS AND RESULTS: A total of 229,829 children between 6 and 18 years of age were screened as part of a school health program. All children with a valvar heart disease detected by the screening doctor were referred to a tertiary care center for evaluation by a cardiologist. The presence of cardiac lesions was confirmed by color Doppler examination. All children with known congenital heart disease were excluded from this study. A total of 374 children were found to have heart disease. Of these, 157 children were found to have rheumatic heart disease, confirmed by echocardiogram. Thus, the current prevalence of rheumatic heart disease is 0.68 per 1000 children. CONCLUSIONS: In the largest school survey conducted to date in India, we report the prevalence of rheumatic heart disease to be 0.68 per 1000 children. Our study suggests that there may have been a dramatic decline in the prevalence of rheumatic heart disease in India.

Lipoprotein (a) phenotypes in south Indian patients with coronary artery disease.

BACKGROUND: Plasma lipoprotein (a) levels in the Indian population are varied; this study was undertaken to determine the relationship between plasma lipoprotein (a) levels and their phenotypes in a group of south Indian patients with coronary artery disease. METHODS AND RESULTS: A total of 104 patients with angiographically proven coronary artery disease were compared with 104 age- and sex-matched controls with no risk factors such as hypertension, diabetes and smoking. Lipoprotein (a) levels were measured by an in-house ELISA method and its phenotyping was done by SDS agarose gel electrophoresis. Plasma lipoprotein (a) levels were significantly elevated in patients with coronary artery disease as compared to controls (33.4+/-26.1 mg/dl v. 21.4+/-12.8 mg/dl; p<0.01). Lipoprotein (a) phenotyping showed that low-molecular weight isoforms were found only in 19.2% of the patients with coronary artery disease and their plasma lipoprotein (a) levels were significantly elevated compared to coronary artery disease patients with higher molecular weight isoforms (50.9+/-34.2 mg/dl v. 29.24+/-20.06 mg/dl; p<0.001). CONCLUSIONS: Plasma lipoprotein (a) levels are significantly elevated in patients with coronary artery disease as compared to controls. The commoner phenotype in a South Indian population is the larger apolipoprotein (a). in which the lipoprotein (a) levels are lower. Hence the contribution of lipoprotein (a) phenotype to the lipoprotein (a) levels in our population, if any, is modest.