Safety and efficacy of ARNI (valsartan/sacubitril) vs ACEI (enalapril) in acute heart failure - A prospective observational study.

OBJECTIVE: To compare the safety and efficacy of valsartan/sacubitril (angiotensin receptor neprilysin inhibitor [ARNI]) against enalapril (angiotensin-converting enzyme inhibitor [ACEI]) in patients with acute heart failure at 6-month follow-up. METHODS: In this prospective, single centre, and observational study conducted between September 2017 and February 2020 in India, patients with acute decompensated heart failure with reduced ejection fraction (<40%) were included. Patients were divided in two groups: valsartan/sacubitril (ARNI) group and enalapril (ACEI). Patients were followed up for at least 6 months after administration of first dose and were evaluated for safety, efficacy, and tolerability of target drug. Student's independent t-test was employed for comparing continuous variables. Chi-square test or Fisher's exact test, whichever appropriate, was applied for comparing categorical variables. RESULTS: A total of 200 patients were included in the present study, 100 each in ARNI and ACEI group. The mean age of the population was 61.2 ± 8.4 years and 62.6 ± 8.6 years in ARNI group and ACEI group, respectively. The mean maximum tolerated dose by population in ARNI group was 203.6 mg and 8.9 mg in ACEI group. Readmission for heart failure were seen significantly higher in ACEI group than ARNI group (p value = 0.001). Parameters like ejection fraction, left ventricular end diastolic and systolic dimensions, 6 min walk test and Kansas City Cardiomyopathy Questionnaires (KCCQ) showed p values < 0.05 between the groups. CONCLUSION: The ARNI study group showed better safety and efficacy outcomes at the end of 6 months follow-up compared to ACEI group.

Phase contrast cardiac magnetic resonance imaging versus transoesophageal echocardiography for the evaluation of feasibility for transcatheter closure of atrial septal defects.

BACKGROUND: This prospective study was aimed at comparing phase contrast cardiac magnetic resonance imaging (PC-CMR) with 2D transoesophageal echocardiography (TEE) for determining potential candidature for transcatheter closure in ostium secundum ASD (OS-ASD) patients. We included consecutive adult patients with OS-ASD for the evaluation of feasibility for transcatheter closure using 2D-TEE and PC-CMR over a period of 2 years. Patients who fulfilled the conventional criteria for transcatheter closure, i.e. maximum ASD diameter ≤ 34 mm, adequate rims (≥ 5 mm, except for anterosuperior rim), and normal pulmonary venous drainage on both imaging modalities, were taken for device closure. In patients where there was discrepancy in the measurements of ASD diameter or rim size, making them eligible for device closure on one imaging modality and ineligible on the other hand, provisional device closure was attempted. All patients who underwent transcatheter closure were followed up to 6 months to rule out any complications. RESULTS: A total of 58 patients (mean age 35.93 ± 10.59 years) were enrolled in the study. Overall, there was significant positive correlation between 2D-TEE and CMR measurements of maximal ASD diameter and rim size (p < 0.001). However, TEE significantly underestimated maximal ASD diameter and posteroinferior rim size in comparison with CMR (p = 0.013 and p = 0.023, respectively). 46 (79.3%) patients were suitable for transcatheter closure on CMR, while 44 (75.9%) were eligible on TEE. Transcatheter closure was attempted in 48 patients based on imaging findings and was successful in 46 (95.8%) patients. Device closure was unsuccessful in 2 patients with defect size < 34 mm on TEE but > 34 mm on CMR. Among 7 patients with deficient posteroinferior rim on TEE, 5 had sufficient rim on CMR and underwent successful transcatheter closure. CMR detected anomalous pulmonary venous drainage in one patient which was missed on TEE, hence excluding the patient from transcatheter closure. Mean device size was 28.3 ± 7.4 mm and correlated more strongly with the defect dimensions on PC-CMR (r = 0.85, p < 0.001) compared to TEE (r = 0.71, p = 0.02). CONCLUSIONS: PC-CMR may to be superior to 2D-TEE for the preprocedural planning and feasibility assessment for transcatheter closure in adult patients with ostium secundum ASD.

Prevalence of type 2 diabetes mellitus and association of HbA1c with severity of coronary artery disease in patients presenting as non-diabetic acute coronary syndrome.

BACKGROUND: Acute coronary syndrome (ACS) indicates the serious clinical manifestation of coronary artery disease (CAD) and is closely associated with cardiovascular prognosis in patients with ACS. This study was aimed to study the prevalence of type 2 diabetes mellitus (T2DM) and the relation of HbA1c with the severity of CAD in patients presenting as non-diabetic ACS. Diabetic status of the patients was assessed with fasting blood sugar (FBS) and HbA1c levels, and coronary artery disease burden was assessed by coronary angiography. RESULTS: Out of 208 patients, 85.1% were males, and 14.9% were females; 73.56% cases were hypertensive. 80.77% of cases had STEMI, 17.79% had NSTEMI, and 1.44% had unstable angina. Out of 168 STEMI patients, 64.3% were thrombolysed, 21.42% presented late, 2.38% had contraindications to thrombolysis, and 11.9% underwent primary PCI. FBS in diabetic range was found in 44.23% of cases, impaired FBS in 36.54%, and 19.23% of patients had FBS in non-diabetic range. According to HbA1c, 41.8% were diabetic, 39.4% were pre-diabetic, and 18.8% were non-diabetic. A significant positive correlation was found between HbA1c and Gensini score and between HbA1c and the number of vessels involved. CONCLUSION: This study emphasises the importance of evaluating the presence of diabetes in patients presenting as non-diabetic acute coronary syndrome in developing countries. Acute coronary syndrome may be considered as one of the presentations of diabetes mellitus.

Clinical profile in arrhythmogenic cardiomyopathy and a recessive plakophilin-2 gene mutation.

OBJECTIVE: Arrhythmogenic cardiomyopathy (ACM) is not an uncommon cause of cardiac morbidity in Kashmir valley. This study was designed to document various clinical features and to sequence exons 11 and 12 of plakophilin 2 (PKP2) gene in these patients. METHODS: ACM patients who attended cardiology outpatient department of our institute from January 2014 to April 2015 were included in the study. Their records were reviewed. Controls were randomly selected, who had no history or family history of cardiac illness and had a normal cardiac examination. A blood sample was also taken from both the groups for sequencing of exon 11 and 12 of PKP2 gene. ACM patients were followed up until July 2016. RESULTS: Eleven ACM patients and seven controls were included in the study. Most common mode of presentation was ventricular tachycardia (VT). Two patients had left ventricular (LV) systolic dysfunction. One patient had a splice site mutation in exon 12 of PKP2 gene and one patient died during follow-up. One of the controls had an intronic variation that has no pathogenic significance vis-à-vis ACM. CONCLUSION: Our study describes various clinical parameters in ACM patients and a recessive plakophilin 2 mutation after a limited PKP2 gene sequencing.

The effect of percutaneous coronary revascularization on plasma N-terminal pro-B-type natriuretic peptide levels in stable coronary artery disease.

BACKGROUND: This study was conducted to assess the effect of percutaneous coronary revascularization (PCR) on plasma NT-proBNP concentration in patients with chronic stable angina (CSA). METHODS: This prospective open label interventional study included 22 patients with moderate to severe CSA, normal left ventricular (LV) systolic functions and critical (>90%) proximal stenosis in one of the three major epicardial coronary arteries. After stabilization of medications for 8 weeks, resting supine plasma NT-proBNP levels were measured and patients underwent PCR of the involved vessels. Eight weeks later, with medications unaltered; plasma NT-proBNP levels were repeated and compared with the baseline levels. LV systolic and diastolic functions were assessed before and after PCR. RESULTS: The mean age of the patients was 61.27±8.87years. Out of 22 patients, 20 were male and 2 were female. PCR was performed on left anterior descending coronary artery (LAD) in 12 patients and in a non-LAD vessel in 10 patients. After 8 weeks of successful PCR, there was a significant overall reduction in mean plasma NT-proBNP levels (from 244.36±218.99 to 168.68±161.61pg/mL, p=0.016). The patients who underwent PCR of LAD demonstrated significantly reduced NT-pro-BNP levels after PCR (p=0.009). In the non-LAD group, NT-proBNP levels also decreased, albeit insignificantly (p=0.432). Reduction in NT-proBNP was independent of change in LV systolic functions. CONCLUSION: Successful PCR, by relieving myocardial ischemia, significantly reduced plasma NT-proBNP levels in majority of the patients with chronic stable angina secondary to critical epicardial coronary artery stenosis.

Contrast venography vs. microwire assisted axillary venipuncture for cardiovascular implantable electronic device implantation.

Aims: This study was conducted to compare the safety and efficacy of microwire assisted technique with contrast venography guided axillary venipuncture in patients undergoing cardiovascular implantable electronic device (CIED) implantation. Methods and results: This prospective randomized study included 212 consecutive adult patients undergoing CIED implantation at our institute between 2013 and 2015. Patients were randomized to either venography guided technique (Group I; n = 105) or microwire assisted technique (Group II; n = 107) for axillary venipuncture. In Group I axillary venogram was used as a roadmap for guiding the puncture. In Group II, a 0.014 inch hydrophilic coronary guidewire ('microwire') was introduced through the ipsilateral antecubital vein and puncture needle was aimed to hit the microwire over the first or second rib. Outcome measures including technical success rates; number of attempts to successful puncture; puncture duration; fluoroscopy times and adverse events were compared in the two groups. Overall success rates were similar in both groups (97.4% in Group I and 100% in Group II, P = 0.061). We demonstrated significantly higher first attempt success rates; shorter puncture durations and fluoroscopy times; and lower number of attempts to successful puncture with microwire assisted technique (89.3% vs. 65.6%; 36.7 ± 23.1 s vs. 67.8 ± 44.9 s; 62.4 ± 35.3 s vs. 118.9 ± 63.2 s; and 1.21 ± 0.82 vs. 2.16 ± 1.54 respectively, P < 0.001). Adverse event rates were significantly lower with microwire assisted technique (0.9% vs. 8.6%, P = 0.009). Conclusion: Microwire assisted technique is a simple, quicker, safer and more efficacious alternative to contrast venography guided axillary venipuncture.

Clinico-angiographic profile and procedural outcomes in patients undergoing percutaneous coronary interventions: The Srinagar registry.

BACKGROUND: This study was aimed at exploring the clinical profile, angiographic characteristics and procedural outcomes in patients undergoing PCI at our institute. METHODS: This prospective observational study included all consecutive patients who underwent PCI at our hospital between January 2014 and December 2015. Data including clinico-demographic profile, angiographic details and lesion characteristics were recorded in all patients. Procedural details including devices and drugs used, procedure related complications, and in-hospital outcomes of these patients were analysed. RESULTS: A total of 624 patients (mean age- 59.30±11.17years) with 84.8% males and 15.2% females were included in the study. Smoking and hypertension were the most common risk factors, present in 79.8% and 74.8% patients respectively. Diabetes mellitus, dyslipidemia, and obesity were observed in 24.5%, 26.1%, and 25.0% patients respectively. Anterior wall MI was the most common mode of presentation (32.1%). Single Vessel Disease (SVD) was most common angiographic pattern, observed in 50.3% patients; left anterior descending artery (LAD) was the most frequently involved vessel (65.9%); and type B lesions were most prevalent (52.3%). Most of the procedures were elective (61.4%) and femoral route was used in the majority (82.6%). Drug eluting stents were deployed in 99.1% of the cases. The overall procedural success rate was 93.6%. Procedural mortality was 1.0% and periprocedural complications occurred in 9.9% patients. CONCLUSION: This first prospective PCI registry from the state of Jammu & Kashmir provides an insight into the patterns of CAD among Kashmiri population, and highlights the spectrum of PCIs performed with their outcomes.

An Innovation in Pacemaker Lead Implantation via Persistent Left Superior Vena Cava: The "3D Alpha Curve" Stylet.

Persistent left superior vena cava (PLSVC) draining into coronary sinus is typically detected incidentally during transcatheter interventions using left subclavian venous approach. In our experience, we have encountered this anomaly on a few occasions and in all these cases we successfully implanted leads in the right ventricle (RV) by shaping the stylet into a "U-shaped" or "pigtail-shaped" curve. Herein, we report a case of an adult male who underwent successful dual-chamber pacemaker implantation via PLSVC through left axillary venous approach. In this case, we were unable to deliver the lead into RV using aforementioned stylets. As an innovation, we used a "three-dimensional alpha curve"-shaped stylet that facilitated an easy entry of pacing lead into the RV.

Components and determinants of therapeutic delay in patients with acute ST-elevation myocardial infarction: A tertiary care hospital-based study.

BACKGROUND: Delayed reperfusion is associated with worse outcomes in ST-segment elevation myocardial infarction (STEMI). This study was conducted to assess the components and determinants of therapeutic delay in STEMI patients of our state. METHODS: This study included consecutive patients of STEMI admitted to the coronary care units of two tertiary care hospitals in Srinagar, between 2012 and 2015. Various components of treatment delay including the patient's decision to delay, referral delay, transportation delay, prehospital delay, and door-to-needle time were calculated. Factors associated with delayed treatment and clinico-demographic correlates of late presentation were identified. RESULTS: During a period of 3 years, 523 patients (mean age, 57.6 ± 10.5 years) were enrolled in this study. Thrombolysis was administered to 60.2% patients, while 39.8% of patients could not be thrombolysed because of late presentation. The median treatment delay was 250 minutes. Prehospital delay constituted about 83.8% of total treatment delay. Patient's decision to delay, referral delay, and transport delay constituted 59%, 16%, and 25% of prehospital delay, respectively. Median door-to-needle time was 40 minutes. Residence in rural areas [odds ratio (OR), 2.35; 95% confidence interval (CI), 1.60-3.46], absence of prior coronary artery disease (OR, 1.54; 95% CI, 1.00-2.39), and negative family history of coronary artery disease (OR; 2.76; 95% CI, 1.86-4.10), were identified as independent predictors of delayed presentation (p < 0.001). Interestingly, 44.7% of the patients presented late due to misdiagnosis by local healthcare providers. CONCLUSION: The standard of STEMI management in our state is far from ideal, and calls for a lot of improvement. Major efforts to reduce prehospital and in-hospital treatment delays are urgently needed.

Does plasma copeptin level at admission predict final infarct size in ST-elevation myocardial infarction.

BACKGROUND: Copeptin is a novel biomarker of potential diagnostic and prognostic value in patients with ST-elevation myocardial infarction (STEMI). This study was conducted to investigate the relationship between plasma copeptin levels at admission and final infarct size in STEMI patients. MATERIALS AND METHODS: This observational study was conducted in Sher-i-Kashmir Institute of Medical sciences, Srinagar, for a period of 1year. 60 patients with STEMI admitted within 24h of symptom onset were included in the study. Plasma copeptin concentrations were determined by ELISA from blood samples drawn at the time of admission. Infarct size was estimated on cardiac MRI after 5-14days of admission, in successfully reperfused patients. Correlations between plasma copeptin levels, infarct size and various clinico-hemodynamic variables were studied. RESULTS: Plasma copeptin concentrations showed a significant positive correlation with MRI determined infarct size (r=0.957; p≤0.0001). Copeptin levels were significantly higher in patients with anterior wall infarction (p≤0.0001), longer symptom duration (p=0.018), advanced Killip class (p≤0.0001), higher body mass index (p=0.019) and extensive coronary artery disease (p≤0.0001). On multivariate analysis, copeptin levels at admission independently predicted final infarct size, irrespective of the clinico-hemodynamic profile of patients or mode of reperfusion (p≤0.0001). The only independent predictor of copeptin level was symptom duration (p=0.018). CONCLUSION: Copeptin level at admission predicts final infarct size in STEMI patients. Further evidence is however needed before implementation of this biomarker into routine clinical practice.

Prevalence and characterization of coronary artery disease in patients with symptomatic bradyarrhythmias requiring pacemaker implantation.

BACKGROUND: This study was conducted to assess the prevalence and characterization of CAD in high risk patients requiring pacemaker implantation for symptomatic bradyarrhythmias. METHODS: This study included 100 patients with symptomatic sinus node dysfunction or atrioventricular block, who were at high risk of CAD or had previously documented atherosclerotic vascular disease (ASCVD). Coronary angiography was performed before pacemaker implantation. CAD was defined as the presence of any degree of narrowing in at least one major coronary artery or its first order branch. Obstructive CAD was defined as ≥50% diameter stenosis. CAD was categorized as single vessel disease (SVD), double vessel disease (DVD), or triple vessel disease (TVD); and obstructive CAD in the arteries supplying the conduction system was sub-classified according to Mosseri's classification. RESULTS: Out of 100 patients (mean age 64.6±10.7 years), 45 (45%) had CAD. 29% patients had obstructive CAD while 16% had non-obstructive CAD. 53.3% patients had SVD, 15.6% had DVD and 31.1% had TVD. Among patients with obstructive CAD; Type I, II, III and IV coronary anatomies were present in 6.9%, 34.5%, 10.3% and 48.3% patients respectively. Presence of CAD significantly correlated with dyslipidemia (p=0.047), history of smoking (p=0.025), and family history of CAD (p=0.002). CONCLUSION: Angiographic CAD is observed in a substantial proportion of patients with symptomatic bradyarrhythmias and risk factors for CAD. It could be argued that such patients should undergo a coronary work-up before pacemaker implantation. Treatment of concomitant CAD is likely to improve the long term prognosis of these patients.

Immediate effect of percutaneous transvenous mitral commissurotomy on atrial electromechanical delay and P-wave dispersion in patients with severe mitral stenosis.

BACKGROUND: Mitral stenosis (MS) is associated with prolonged inter- and intra-atrial electromechanical delays and increased P-wave dispersion, which are markers of atrial fibrillation (AF) risk. This study was conducted to assess the immediate effect of successful percutaneous transvenous mitral commissurotomy (PTMC) on these parameters. METHODS: This single center observational study included 25 patients with severe MS (aged 34.1 ± 7.1 years, with mean mitral valve area (MVA) of 0.74 ± 0.13 cm(2)), in sinus rhythm, who underwent successful PTMC at our hospital. P-wave dispersion (PWD) was calculated by subtracting minimum P-wave duration (P min) from maximum P-wave duration (Pmax), measured on a 12-lead surface ECG obtained from each patient in supine position at a paper speed of 50mm/s and 20mm/mV. Inter-atrial (AEMD), left intra-atrial (L-IAEMD), and right intra-atrial (R-IAEMD) electromechanical delays were measured on tissue Doppler imaging. PTMC was performed using the standard Inoue Balloon technique. All these parameters were evaluated and compared before and 24-48 h after PTMC. RESULTS: Successful PTMC led to significant reduction in AEMD (p < 0.001), L-IAEMD (p < 0.001), and R-IAEMD (p < 0.001). There were no changes in Pmax, Pmin, and PWD immediately after PTMC. CONCLUSIONS: Successful PTMC has a favorable early impact on inter- and intra-atrial electromechanical delays, which are considered as novel parameters of atrial electromechanical remodeling in MS patients. Prospective large-scale studies are required to confirm whether improvement in these markers translates into reduced long-term AF risk.

Pentalogy of fallot with a single coronary artery: a rare case report.

Anomalies of origin, course, and distribution of coronary arteries, including single coronary artery, are well known in patients with Tetralogy of Fallot. However, to the best of our knowledge, there is no published case report of Pentalogy of Fallot with a single coronary artery. Herein, we introduce a 22-year-old female patient diagnosed via echocardiography and cardiac catheterization preoperatively as Pentalogy of Fallot with a single coronary artery arising from the left coronary sinus.