Clinical profile of acute myocardial infarction in elderly patients.

CONTEXT: The aim of study was to determine the difference in presentation, risk factors, complications, management and outcome of elderly and young patients with acute myocardial infarction (AMI). SETTINGS AND DESIGN: Tertiary care center; prospective observational study. MATERIALS AND METHOD: The study included 200 consecutive patients with AMI admitted in the ICCU, in a tertiary care center in West India. The group I consisted of 107 patients aged equal to or above 65 years and the group II consisted of 93 patients aged below 65 years. STATISTICAL ANALYSIS: Two tailed student's t test and Chi-square statistics (Fisher's test) for P value. RESULTS: The male female ratio was 1.27:1 and 3.43:1 in group I and group II respectively. Atypical presentations were more likely in the elderly, with shortness of breath as the most common presentation (40.18% versus 15.05%; P < 0.05. Risk factors like hypertension, dyslipidemia and diabetes were equally present in both groups but obesity, smoking and family history of coronary artery disease was more prevalent in younger age group (P < 0.05). The elderly were significantly less frequently revascularized (P < 0.05). Time from symptom onset to hospital admission was significantly longer in the case of elderly patients (P < 0.05). The elderly were more likely to have complications of cardiac failure (P < 0.05) and arrhythmias especially atrio-ventricular (AV) blocks. The elderly were also less likely to receive beta-blockers (P < 0.05). In-hospital mortality was higher in the elderly (P < 0.001). CONCLUSION: We conclude that the manifestations of AMI are more subtle in the elderly, with different risk factors.

Detection of silent myocardial ischaemia in asymptomatic diabetic patients during treadmill exercise testing.

BACKGROUND: Diabetic patients have an increased prevalence of atherosclerosis and coronary artery disease. They may also experience higher morbidity and mortality after acute coronary syndrome compared with non-diabetic subjects. AIM: The objective of this study was to determine the presence of silent myocardial ischaemia by treadmill test in asymptomatic diabetic patients and to compare it with age- and sex-matched subjects without diabetes mellitus. METHODS: The study design was cross-sectional and the setting was a tertiary care centre. Fifty (42 males, 8 females) asymptomatic patients with diabetes in the age group of 30-70 years were included in the study group and 30 (24 males, 6 females) non-diabetic subjects of comparable age, sex and physical activity were the control group. They were assessed for the presence of silent ischaemia by a standard treadmill test using the Bruce protocol. RESULTS: Twenty-five of 50 diabetic patients showed a positive response to the exercise stress test, while 7 of 30 controls showed stress test positivity (p < 0.05). The stress test positivity showed a female predilection among diabetic patients (50% in diabetic patients and 16.67% in controls; p < 0.05). Diabetic patients with a positive stress test showed higher prevalence of hypertension (36%) and dyslipidaemia (84%) compared with diabetic patients with a negative stress test (12% and 28%, respectively) [p < 0.001]. The controls showed a better exercise capacity compared with diabetic patients; diabetic patients with a negative stress test had better exercise capacity than those with a positive stress test. CONCLUSIONS: The treadmill test is a useful, specific, cost-effective, non-invasive tool for detection of silent myocardial ischaemia in asymptomatic diabetic patients.

Plasma exchange with immunosuppression in pulmonary alveolar haemorrhage due to leptospirosis.

BACKGROUND & OBJECTIVES: Pulmonary involvement due to leptospirosis carries high case fatality rate and is the commonest cause of death due to leptospirosis. Immune mechanisms play a key role in the pathogenesis of leptospiral pulmonary haemorrhage. As other immune pulmonary haemorrhages due to non leptospiral causes are treated with plasma exchange and cyclophosphamide we evaluated their efficacy in patient with leptospiral pulmonary haemorrhage. METHODS: Of the 602 confirmed patients of leptospirosis, 236 (39.2%) had pulmonary haemorrhage. Of these,144 had mild haemorrhage (acute lung injury score < 2.5) and were included in the study. One hundred and fourteen patients were given two cycles of plasma exchange, 24 h apart, 25 ml/kg body weight of plasma was removed in each cycle. Cyclophosphamide (20 mg/kg body weight) was given after the first plasma exchange cycle. The remaining 30 patients were not given this treatment, and used as control. RESULTS: In the control group only 5 (16.6%) patients survived while in the treatment group 70 (61.40%) patients survived. Thrombocytopenia was observed in 111 (77.08%) patients. Renal and hepatic involvement was seen but did not account for mortality. Minor complications were seen in group I patients after plasma exchange and cyclophosphamide treatment, but none were serious. INTERPRETATION & CONCLUSIONS: Our findings showed that plasma exchange with immunosuppression improved survival in patients of pulmonary alveolar haemorrhage due to leptospirosis, suggesting that immune mechanisms play a key role in the pathogenesis of the disease.

Cyclophosphamide in pulmonary alveolar hemorrhage due to leptospirosis.

BACKGROUND AND AIMS: Severe pulmonary involvement in leptospirosis carries high mortality rates. It is the most common cause of death due to leptospirosis in many parts of India and the world. Exacerbated immune response of the host plays an important role in its pathogenesis. Hence, immunosuppressive drugs could be useful in its treatment. Glucocorticosteroids have been found to be useful in several studies. Cyclophosphamide, an immunosuppressive agent, has been found to be useful in a majority of pulmonary alveolar hemorrhages due to non leptospiral causes. This study was carried out to study the effects of cyclophosphamide in patients with leptospiral pulmonary alveolar hemorrhage. METHOD: A total of 65 patients with confirmed leptospirosis with severe pulmonary involvement admitted to a tertiary care center in south Gujarat were included in the study. All of the patients were treated with injection crystalline penicillin, methyl prednisolone pulse therapy, and non invasive mechanical ventilation. A total of 33 patients were given parenteral cyclophosphamide 60 mg/kg body weight stat on diagnosis. Their outcomes were compared with the remaining 32 patients who had not been given this drug. Survival was considered the main outcome indicator. RESULTS: Out of the 33 patients treated with cyclophosphamide, 22 (66.7%) survived, while in the control group out of 32 patients, three (9.4%) survived. On statistical analysis, the odds ratio was 19.33 (4.22-102.13) and the P-value was < 0.001. Leucopenia (78.78%) and alopecia (18.75%) were the main side effects noted. No mortality was noted due to these side effects. CONCLUSION: Cyclophosphamide improves survival in cases of severe pulmonary alveolar hemorrhage due to leptospirosis. Statistically, the improvement is highly significant.