Non-HDL as a Valid Surrogate Marker of Small Dense LDL in a Young Indian Population.

Small dense (sd) LDL is a significant independent risk factor for premature coronary artery disease (CAD). Unfortunately, its estimation is not popular, due to the limited availability of specialized equipment, high cost and time-consuming technique. Non-HDL is a calculated, single index measure of all atherogenic apolipoprotein-B containing lipoproteins. This study aimed at identifying non-HDL as a superior surrogate marker of sdLDL cholesterol in a young Indian population. 161 healthy subjects < 45 years were tested for lipid profile, apolipoproteins A1 and B, and sdLDL particle size. sdLDL particles showed negative correlation with non-HDL (r = - 0.283, p < 0.001), LDL (r = - 0.195, p = 0.013) and apoB/apo A1 (r = - 0.175, p = 0.026), the significance being greatest with non-HDL. ROC showed AUC for non-HDL, LDL and apoB/apo A1 as 0.704, 0.686, and 0.596 respectively. For LDL < 130 mg/dL, sdLDL showed a more significant negative correlation with non-HDL (r = - 0.291, p < 0.001) as compared with apoB/apoA1 (r = - 0.172, p = 0.037). For triglycerides < 200 mg/dL, sdLDL particle size showed higher significant negative correlation with non-HDL (r = - 0.213, p = 0.015) than with LDL (r = - 0.176, p = 0.045) while for triglycerides between 200 and 400 mg/dL, significant negative correlation was observed only with non-HDL (r = - 0.372, p = 0.043). Hence, our study suggested that non-HDL is a superior surrogate marker of sdLDL particle size as compared to LDL and apoB/A1 ratio in a young healthy Indian population and should be used for optimum assessment of dyslipidemias and CAD risk.

Prevalence of familial hypercholesterolemia in premature coronary artery disease patients admitted to a tertiary care hospital in North India.

AIMS: The prevalence of premature coronary artery disease (CAD) in India is two to three times more than other ethnic groups. Untreated heterozygous familial hypercholesterolemia (FH) is one of the important causes for premature CAD. As the age advances, these patients without treatment have 100 times increased risk of cardiovascular (CV) mortality resulting from myocardial infarction (MI). Recent evidence suggests that one in 250 individuals may be affected by FH (nearly 40 million people globally). It is indicated that the true global prevalence of FH is underestimated. The true prevalence of FH in India remains unknown. METHODS: A total of 635 patients with premature CAD were assessed for FH using the Dutch Lipid Clinical Network (DLCN) criteria. Based on scores, patients were diagnosed as definite, probable, possible, or no FH. Other CV risk factors known to cause CAD such as smoking, diabetes mellitus, and hypertension were also recorded. RESULTS: Of total 635 patients, 25 (4%) were diagnosed as definite, 70 (11%) as probable, 238 (37%) as possible, and 302 (48%) without FH, suggesting the prevalence of potential (definite + probable) FH of about 15% in the North Indian population. FH is more common in younger patients, and they have lesser incidence of common CV risk factors such as diabetes, hypertension, and smoking than the younger MI patients without FH (26.32% vs.42.59%; 17.89% vs.29.44%; 22.11% vs.40.74%). CONCLUSION: FH prevalence is high among patients with premature CAD admitted to a cardiac unit. To detect patients with FH, routine screening with simple criteria such as family history of premature CAD combined with hypercholesterolemia, and a DLCN criteria score >5 may be effectively used.

Everolimus Eluting Stents in Patients with Diabetes Mellitus and Chronic Kidney Disease: Insights from the TUXEDO Trial.

BACKGROUND: Patients with diabetes and those with chronic kidney disease (CKD) are at increased risk of cardiovascular events. Everolimus eluting stents (EES) have been shown to be superior to paclitaxel eluting stents (PES) in patients with diabetes. However, it is not known if EES is as beneficial in diabetic patients with CKD compared with those without CKD. METHODS AND RESULTS: Patients enrolled in the TUXEDO-India trial, which is a clinical trial of patients with diabetes and coronary artery disease (CAD) randomly assigned to EES vs. thin-strut PES (Taxus Element), with data on baseline renal function were selected. CKD was defined as an estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m2 using the Cockcroft-Gault formula. Primary outcome was target vessel failure (TVF-defined as cardiac death, TV myocardial infarction (MI) or ischemia driven TV revascularization) at 1 year. Various secondary outcomes including stent thrombosis were evaluated. Among the 1821 patients with diabetes included in this analysis, 344 (19%) had CKD. In a propensity score adjusted analysis, patients with CKD had a significant increase in MACE (HR = 2.02; 95% CI 1.17-3.50; P = 0.01); death/MI/TVR (HR = 1.99; 95% CI 1.18-3.34; P = 0.009); death/MI (HR = 2.31; 95% CI 1.30-4.08; P = 0.004); cardiac death/MI (HR = 2.40; 95% CI 1.31-4.42; P = 0.005); death (HR = 2.88; 95% CI 1.35-6.13; P = 0.006) driven by an increase in cardiac death (HR = 3.33; 95% CI 1.42-7.83; P = 0.006) when compared with those without CKD. However, stent related events (TV-MI, TVR, TLR and stent thrombosis) were not different between CKD and non CKD groups. A significant interaction between CKD status and stent type (EES vs. PES) was noted for the outcomes of TVF (Pinteraction = 0.046), MACE (Pinteraction = 0.02), cardiac death or MI (Pinteraction = 0.05), non-target vessel related MI (Pinteraction = 0.04), non-Q-wave MI (Pinteraction = 0.03) and deaths/MI/TVR (Pinteraction = 0.04) such that EES was superior to PES in the non-CKD cohort but not in the CKD cohort. CONCLUSIONS: In subjects with diabetes, CKD is an independent predictor of adverse cardiovascular outcomes including increased risk of death driven largely by non-stent related events. While EES was superior to PES in patients without CKD, this was not the case in those with CKD (Clinical Trials Registry-India number, CTRI/2011/06/001830).

To study the effect of high dose Atorvastatin 40mg versus 80mg in patients with dyslipidemia.

OBJECTIVE: Primary objective was to compare the effects of atorvastatin 40mg vs 80mg on LDL-C in Indian patients with atherosclerotic dyslipidemia. Secondary objectives were to compare the effects of atorvastatin 40mg vs 80mg on HDL-C and triglycerides and also comparing of side effects (myopathy, hepatotoxicity and new onset diabetes mellitus) of both doses. METHOD: This Study is A Prospective, randomized, open-label, comparative study. This study was conducted on 240 patients of dyslipidemia (as per ACC/AHA 2013 lipid guidelines) attending the OPD/wards/CCU of department of cardiology, Sir Ganga Ram Hospital. They were randomly divided into 2 groups of 120 each. Group A consisted patients who received Atorvastatin 40mg daily and Group B Atorvastatin 80mg daily. The follow up period was 6 months. RESULTS: At 3 and 6 month follow up, Atorvastatin 40mg leads to mean LDL cholesterol reduction of 47.18±20.81 & 50.03±18.06 respectively. While Atorvastatin 80mg results in LDL reduction as 50.11±15.85 & 52.30±13.72. The comparison between two doses revealed a non-significant difference (p=.118 & p=.149 respectively). At 6 months of follow up, few patients reported myalgia (2 in group A and 7 in Group B). The difference between groups was significant (p=.045). Although none of our patient had significant elevation of CPK. CONCLUSION: This study concluded that both doses of atorvastatin (40 & 80mg) are equally efficacious in improving dyslipidemia but higher dose leads to more incidence of myalgia.

Paclitaxel-Eluting versus Everolimus-Eluting Coronary Stents in Diabetes.

BACKGROUND: The choice of drug-eluting stent in the treatment of patients with diabetes mellitus and coronary artery disease who are undergoing percutaneous coronary intervention (PCI) has been debated. Previous studies comparing paclitaxel-eluting stents with stents eluting rapamycin (now called sirolimus) or its analogues (everolimus or zotarolimus) have produced contradictory results, ranging from equivalence between stent types to superiority of everolimus-eluting stents. METHODS: We randomly assigned 1830 patients with diabetes mellitus and coronary artery disease who were undergoing PCI to receive either a paclitaxel-eluting stent or an everolimus-eluting stent. We used a noninferiority trial design with a noninferiority margin of 4 percentage points for the upper boundary of the 95% confidence interval of the risk difference. The primary end point was target-vessel failure, which was defined as a composite of cardiac death, target-vessel myocardial infarction, or ischemia-driven target-vessel revascularization at the 1-year follow-up. RESULTS: At 1 year, paclitaxel-eluting stents did not meet the criterion for noninferiority to everolimus-eluting stents with respect to the primary end point (rate of target-vessel failure, 5.6% vs. 2.9%; risk difference, 2.7 percentage points [95% confidence interval, 0.8 to 4.5]; relative risk, 1.89 [95% confidence interval, 1.20 to 2.99]; P=0.38 for noninferiority). There was a significantly higher 1-year rate in the paclitaxel-eluting stent group than in the everolimus-eluting stent group of target-vessel failure (P=0.005), spontaneous myocardial infarction (3.2% vs. 1.2%, P=0.004), stent thrombosis (2.1% vs. 0.4%, P=0.002), target-vessel revascularization (3.4% vs. 1.2%, P=0.002), and target-lesion revascularization (3.4% vs. 1.2%, P=0.002). CONCLUSIONS: In patients with diabetes mellitus and coronary artery disease undergoing PCI, paclitaxel-eluting stents were not shown to be noninferior to everolimus-eluting stents, and they resulted in higher rates of target-vessel failure, myocardial infarction, stent thrombosis, and target-vessel revascularization at 1 year. (Funded by Boston Scientific; TUXEDO-India Clinical Trials Registry-India number, CTRI/2011/06/001830).

The potential of Cystatin C and small dense LDL as biomarkers of coronary artery disease risk in a young Indian population.

Coronary artery disease (CAD) affects Indians 5-6 years earlier than in the west, is diffuse and malignant, and poses a heavy burden on India's developing economy. Traditional risk factors have failed to explain this high incidence of premature CAD and hence this study investigated the association of two novel risk biomarkers, cystatin C and small dense LDL (sdLDL) with the presence and severity of CAD. Cystatin C and sdLDL were estimated in 204 CAD patients ≤45 years of age and compared with 161 age-matched healthy controls. The traditional lipid profile parameters, i.e., cholesterol, LDL, HDL, triglycerides, apolipoproteins A1 and B, and Lp(a) were also measured in both groups. Cystatin C was significantly raised and mean LDL particle size significantly reduced in CAD patients as compared to controls. 62.7 % of CAD patients showed pattern B while 37.3 % patients showed pattern A. Of the traditional lipid tests, only HDL and apolipoprotein A1 showed a significant decrease in the CAD group. sdLDL was significantly associated with the severity of CAD, while cystatin C was not. Both cystatin C and sdLDL emerged as independent risk factors, however, of the two, sdLDL was a more sensitive predictor of CAD events. Cystatin C and mean LDL particle size are significantly and independently associated with the presence of CAD events in patients ≤45 years with normal kidney function. Hence, these novel risk biomarkers can be useful tools in reducing the morbidity and mortality associated with CAD in the productive Indian workforce.

Left internal mammary artery to pulmonary vasculature fistulae closed with particle embolizaton: new form of percutaneous intervention.

The left internal mammary artery is frequently employed as a conduit in coronary bypass surgery. We report a 42-year-old male post-coronary artery bypass grafting patient with, angina on exertion who was found to have multiple atrioventricular fistulae arising from left internal mammary artery to pulmonary vasculature leading to coronary steal and positive stress thallium in left anterior descending territory. These fistulae were selectively embolized with polymer particles leading to improved flow in distal left anterior descending artery. Postintervention, the patient has been asymptomatic for more than 8 months.

Erección peneana intraoperatoria / Intraoperative penile erection

OBJETIVO: La erección peneana después de anestesia epidural es una presentación infrecuente, de una etiología muy poco clara. El realizar las intervenciones durante la erección del paciente provoca múltiples problemas al cirujano y complicaciones en el paciente. Presentamos tres de estos casos. La literatura y la patofisiología así como el tratamiento de esta erección intraoperatoria, se discuten en el presente trabajo. MÉTODOS: Hemos tratado 1800 pacientes quirúrgicamente bajo anestesia epidural, fundamentalmente para procedimientos transuretrales como cistoscopia, ureterocistoscopia, resección transuretral de próstata o de tumores de vejiga. RESULTADOS: De los 1800 casos encontramos erección peneana solamente en tres. Dos de estos casos se manejaron y se resolvieron perfectamente con la aplicación local de suero salino frío continuando con tratamiento de terbutalina. El tercer caso se pudo tratar con la aplicación local de suero salino frío en el pene y en el escroto. A continuación realizamos la intervención sin complicaciones. CONCLUSIONES: La patofisiología y el tratamiento de una erección intraoperatoria se conoce de forma muy superficial. Cuando ocurre la erección, el anestesista debe iniciar inmediatamente el tratamiento ya que la duración de la erección es el factor clave en la detumescencia del pene (AU)