Reverse cardio-oncology: A budding concept.

Having established the significance of cardiovascular side-effects of anti-neoplastic drugs, present day cardio-oncology has forayed into newer territories buoyed by research into the multiple connections that exist between cardiovascular disease and cancer. An emerging concept of reverse cardio-oncology focuses on the heightened risk of cancer in patients with cardiovascular disease. Common mechanistics of cancer and heart failure (HF) like chronic inflammation and clonal haematopoesis as well as common predisposing factors like obesity and diabetes underline the relation between both cardiovascular disease and various cancers.This review discusses the potential magnitude of the problem, the underlying pathophysiological mechanisms and classification of this novel subject.

Clinical characteristics and 30-day outcomes in patients with acute decompensated heart failure: Results from Indian College of Cardiology National Heart Failure Registry (ICCNHFR).

BACKGROUND: Acute decompensated heart failure (ADHF) is a challenging medical emergency with high mortality and its prevalence is increasing in India. There is paucity of data on ADHF in the country. METHODS: Indian College of Cardiology National Heart Failure Registry (ICCNHFR) is an on-going observational registry on ADHF contributed by 22 hospitals across India; and we present the in-hospital and 30-day outcomes of ADHF patients enrolled from August 2018 to July 2019. Major objective included capturing demographics, comorbid conditions, aetiology, prescription patterns and assessing clinical outcomes. RESULTS: Of 5269 patients (mean age: 61.90 ± 13.85 years) enrolled in this study, males were predominant (67.09%). Mean duration of hospitalization was 5.74 ± 4.74 days. Ischemic heart disease was the most common (75.44%) aetiology. Abnormal electrocardiogram readings were found in most patients (89.86%). LVEF of ˂40% was found in 68.29% of patients. In-hospital mortality rates were 6.98%. The 30-day cumulative mortality was 12.35% and 30-day rehospitalization rate was 7.98%. At discharge, all guideline-based medical therapy (GDMT) were prescribed only to 24.99% of patients and 23.72% adhered to the prescription until 30 days. Older age, high serum creatinine levels and poor LVEF contributed to high mortality and rehospitalization. CONCLUSION: Patients with ADHF were younger and predominantly males. Usage of GDMT in ADHF patients was low (24.99%) and the in-hospital mortality was high. Older age, high serum creatinine levels, poor LVEF contributed for 30-day mortality and rehospitalization. This data on ADHF, could help in developing strategies to improve outcomes for HF patients in India.

Cardiovascular manifestations of people living with HIV/AIDS: Report from a hot spot in eastern India.

OBJECTIVE: To study the profile and characteristics of cardiovascular abnormalities among patients living with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) at a tertiary care hospital in India. The association of cardiovascular abnormalities with the CD4 count and disease stages, according to the World Health Organization (WHO) classification, was also analyzed. METHODS: A total of 200 patients with HIV/AIDS were compared with 50 healthy controls. All patients underwent blood investigations, chest X-ray, electrocardiography, and echocardiography. RESULTS: The mean age of the patients was 38.66 ± 9.22 years, with a male-to-female ratio of 3.25:1. Echocardiographic abnormalities were found in 52% of the patients and 12% of the controls, with the most common abnormality being left ventricular diastolic dysfunction. Echocardiographic abnormalities were markedly more common in patients with a CD4 count of <200/µL. The advanced stage of the disease, according to the WHO classification, was also associated with an increased incidence of echocardiographic abnormalities. CONCLUSIONS: Cardiovascular abnormalities in the form of electrocardiogram and ECHO findings were present in 54.5% and 52% of patients, respectively. Echocardiographic findings showed significant correlation with CD4 count and WHO disease stage.

ST-Segment Elevated Acute Myocardial Infarction: Changing Profile Over Last 24 Years.

BACKGROUND: Coronary artery disease (CAD) is rising in epidemic proportions with India not being an exception. CAD in Indian scenario has its onset at a younger age with multitude of risk factors. OBJECTIVE: This study was carried out to obtain complete information about demographic profile, risk factors, clinical scenario, therapeutic modalities, natural course, outcome and changing profile of acute ST-segment elevated myocardial infarction (STEMI) patients. METHODS: This cross-sectional study was conducted in 45,122 acute STEMI patients admitted 1st March 1990 to 1st March 2014. A predefined performa was completed in every patient with detailed clinical history, physical examination, laboratory and investigation parameters, therapeutic interventions and inhospital outcome. RESULTS: Our population cohort presented with STEMI at age of 56.34±11.88 years with 82.48% male. Urban residency (64.35%), lower level of education (61.03%), middle and low socioeconomic status (81.01%), unemployment (56.47%), lack of exercise (78.80%) and poor dietary pattern including low intake of fruits and vegetables (58.80%) were pivotal players. Smoking was prevalent in 48.80% cases, with overweight and obesity (51.11%), diabetes mellitus (27.34%), hypertension (38.85%), hyperlipidemia (28.15%), alcoholism (28.80%) and family history (16.66%). Our population had mildly elevated LDL (101.4±33.38 mg/dl), low HDL (36.6±10.7 mg.dl) and high TC/HDL ratio (4.05±1.36). Majority harbored (52.06%) two or more risk factors, while in 16.60% no conventional risk factors were identified. Anterior wall STEMI (56.78%) far exceeded the inferior wall (37.55%). Less than half (47.77%) presented within the window period of 12 hours while only 0.8% of patients availed the golden period of 1 hour. 50.27% presented in Killip Class II or beyond. Angiography revealed single vessel disease (46.76%) with LAD involvement being most common (58.85%). Thrombolytic therapy was provided in 38.95% and primary PCI in 2.1%. Complications in the form of CHF (34.7%), cardiogenic shock (8.65%), reinfarction (6.5%), arrhythmia (59.2%) and mortality (10.57%) were seen. Mortality decreased from 13.9% (from 1990-2000) to 8.8% (2000-2014). CONCLUSIONS: With recent increased use of ß-blocker, ACEI/ARB, aldosterone antagonist and reperfusion strategy, we have brought down the mortality to lower level.

Synthesis, crystal structure, and magnetic properties of novel intermetallic compounds R2Co2SiC (R = Pr, Nd).

The intermetallic compounds R2Co2SiC (R = Pr, Nd) were prepared from the reaction of silicon and carbon in either Pr/Co or Nd/Co eutectic flux. These phases crystallize with a new stuffed variant of the W2CoB2 structure type in orthorhombic space group Immm with unit cell parameters a = 3.978(4) Å, b = 6.094(5) Å, c = 8.903(8) Å (Z = 2; R1 = 0.0302) for Nd2Co2SiC. Silicon, cobalt, and carbon atoms form two-dimensional flat sheets, which are separated by puckered layers of rare-earth cations. Magnetic susceptibility measurements indicate that the rare earth cations in both analogues order ferromagnetically at low temperature (TC ≈ 12 K for Nd2Co2SiC and TC ≈ 20 K for Pr2Co2SiC). Single-crystal neutron diffraction data for Nd2Co2SiC indicate that Nd moments initially align ferromagnetically along the c axis around ∼12 K, but below 11 K, they tilt slightly away from the c axis, in the ac plane. Electronic structure calculations confirm the lack of spin polarization for Co 3d moments.

Glycaemic Control and Cardiovascular Outcomes in Diabetes : Review

While type 1 diabetes mellitus (DM) is characterised by insulin deficiency due to pancreatic beta-cell destruction; type 2 DM is characterised by a state of longstanding insulin resistance (IR); compensatory hyperinsulinaemia and varying degrees of elevated plasma glucose levels (PG); associated with clustering of cardiovascular (CV) risk and the development of macrovascular disease prior to the diagnosis of DM. Coronary artery disease (CAD) accounts for 70of mortality and morbidity in patients with diabetes. Studies in diabetes care have helped prevent or reduce microvascular complications in type 1 and 2 diabetes. However the same cannot be said about macrovascular disease. Despite all data concerning the association between diabetes and cardiovascular disease (CVD); the exact mechanism by which diabetes is linked to atherosclerosis is incompletely understood; and this is especially true in the case of hyperglycaemia. The positive effect of intensive glucose management in comparison to non-intensive glucose control is far from proven. The DCCT and UKPDS studies have shown that while glycaemic control is important for preventing long-term macrovascular complications; early glucose control is far more rewarding (metabolic memory). Later trials such as ACCORD; ADVANCE and VADT do not advocate tight glycaemic control. In fact; the ACCORD trial has shown increased mortality with tight glucose control. Tight glucose control may be beneficial in selected patients with short disease duration; long life expectancy and no CVD. In critically ill patients; a blood glucose target of 140-180 mg is fairly reasonable and achievable. The ESC/EASD guidelines of October 2013; like those of the ADA; AHA and ACC; continue to endorse a treatment target for glucose control in diabetes of HbAlc level 7; based predominantly on microvascular disease with acknowledged uncertainty regarding the effect of the intensive glucose control on CVD risk. Management of hyperglycaemia in diabetics should not be considered in isolation; diabetics require multifactorial intervention for hypertension; dyslipidaemia and microalbuminuria besides hyperglycaemia. In fact; the combined use of antihypertensives; aspirin and lipid-lowering agents makes it difficult to discern the beneficial effects of antihyperglycaemic therapy

Gold network structures in rhombohedral and monoclinic Sr2Au6(Au,T)3 (T = Zn, Ga). A transition via relaxation.

Quantitative syntheses, structure determinations and interpretations, and band calculations are reported for the nonstoichiometric rhombohedral (R3c) and monoclinic (C2/c) Sr2Au6(Au(3-x)T(x)) (T = Zn, Ga) compounds. Several different compositions of the two Sr phases were similarly refined from single crystal X-ray diffraction data as R3c: a ≈ 8.43 Å, c ≈ 21.85 Å, Z = 6 and C2/c: a ≈ 14.70 Å, b ≈ 8.47 Å, c ≈ 8.70 Å, ß ≈ 123.2°, Z = 4. The R3c Zn phase is stable in the composition region x ∼ 2.5-2.9 whereas its C2/c neighbor is the major product at x ∼ 2.2-2.3. Gallium versions of both were also identified. Both R3c and C2/c structural types contain hexagonal-diamond-like gold superlattices stuffed with strings of interstitial Sr and disordered triangular (Au,T)3 units. The latter space group is a maximal, nonisomorphic subgroup of the former, and the decrease in interstitial radius from Ba to Sr (∼0.08 Å experimentally) evidently drives the symmetry reduction, relaxation, and small distortions, principally around the Sr sites. Au-Au bonding among the Au hexagons in the host lattices and with gold components in the triangular interstitials is dominant and reflected in their tight packing and short interatomic separations.

Hexagonal-diamond-like gold lattices, Ba and (Au,T)3 interstitials, and delocalized bonding in a family of intermetallic phases Ba2Au6(Au,T)3 (T = Zn, Cd, Ga, In, or Sn).

Au-rich polar intermetallics exhibit a wide variety of structural motifs, and this hexagonal-diamond-like gold host is unprecedented. The series Ba2Au6(Au,T)3 (T = Zn, Cd, Ga, In, or Sn), synthesized through fusion of the elements at 700-800 °C followed by annealing at 400-500 °C, occur in space group R3[overline]c (a ≈ 8.6-8.9 Å, c ≈ 21.9-22.6 Å, and Z = 6). Their remarkable structure, generated by just three independent atoms, features a hexagonal-diamond-like gold superstructure in which tunnels along the 3-fold axes are systematically filled by interstitial Ba atoms (blue) and triangles of disordered (Au,T)3 atoms (green) in 2:1 proportions. The Au/Zn mixing in the latter spans ~34 to 87% Zn, whereas the Au/Sn result is virtually invariant compositionally. Complementary bonding between the gold lattice and the disordered (Au,T)3 units is substantial and very regular. Bonding and charge density analyses indicate delocalized bonding within the gold host and the (Au,T)3 triangular units, and moderately polarized bonding between Ba and the electronegative framework. The new structure can also be viewed empirically as the result of an atom-by-triad [i.e., Ba by (Au,T)3 triangle] topological substitution in a BaAu2 (AlB2-type) superstructure.

Late survival in Ellis-van Creveld syndrome - a case report.

Ellis-van Creveld syndrome (EVC) is an autosomal recessive disorder characterized by chondrodystrophy, polydactyly, ectodermal dysplasia, and cardiac anomalies. Acromelic shortening of upper and lower limbs, genu valgum, multiple frenula, deformed teeth, short ribs and narrow thorax and congenital heart diseases complete the picture. The patients with the syndrome rarely survive into adulthood. Here, we report a lady with EVC presenting for the first time in middle age.

Left ventricular systolic and diastolic dysfunction and their relationship with microvascular complications in normotensive, asymptomatic patients with type 2 diabetes mellitus.

OBJECTIVE: Diabetes mellitus is an established risk factor for cardiovascular events. Aims of the study were to assess left ventricular systolic and diastolic function in asymptomatic patients with type 2 diabetes and evaluate the relations among left ventricular function and specific diabetic complications. METHODS: Seventy-three normotensive patients with type 2 diabetes and no clinical evidence of cardiac disease were studied. Thirty-four healthy subjects served as control group. Echocardiographic studies were performed to assess left ventricular systolic and diastolic function. Microangiopathy was assessed by fundoscopy. Autonomic function was evaluated by standing blood pressure and heart rate response to Valsalva maneuver. RESULTS: Patients with type 2 diabetes had a lower ejection fraction (54 +/- 10.8 vs. 67 +/- 6.1%, p < or = 0.001), E-velocity (50.1 +/- 10.6 vs. 58.4 +/- 6.3 cm/s, p < or = 0.001), and E/A ratio of <1 (54.8 vs. 5.8%, p < or = 0.01) of the mitral diastolic flow compared with the control subjects, respectively. Patients with ejection fraction <50% had higher prevalence of retinopathy (52.9 vs. 26.7%, p < or = 0.05), abnormal blood pressure response to standing (52.9 vs. 7.1%, p < or = 0.001), and proteinuria (70.5 vs. 14.2%, p < or = 0.05). An inverse correlation was found between duration of diabetes and both ejection fraction (r = -0.53, p = 0.05) and E/A ratio (r = 0.36, p = 0.003). E/A ratio of <1 was associated with higher prevalence of retinopathy (45 vs. 18.1%, p < or = 0.05) and abnormal blood pressure response to standing (25 vs. 9%, p < or = 0.05). Multiple logistic regression model showed that diabetes was the strongest independent correlate of diastolic dysfunction (odds ratio 8.91, 95% CI: 4.18-18.52, p < or = 0.001). CONCLUSION: Asymptomatic diabetic patients have reduced left ventricular systolic and diastolic function as compared with healthy subjects. Left ventricular systolic and diastolic abnormalities are correlated with the duration of diabetes and with diabetic microangiopathies, like retinopathy and neuropathy. Diabetes mellitus is the strongest independent correlate of left ventricular diastolic dysfunction.

Diagnosis and management of diastolic dysfunction and heart failure.

Diastolic heart failure occurs when signs and symptoms of heart failure are present but left ventricular systolic function is preserved (i.e., ejection fraction greater than 45 percent). The incidence of diastolic heart failure increases with age; therefore, 50 percent of older patients with heart failure may have isolated diastolic dysfunction. With early diagnosis and proper management the prognosis of diastolic dysfunction is more favorable than that of systolic dysfunction. Distinguishing diastolic from systolic heart failure is essential because the optimal therapy for one may aggravate the other. Although diastolic heart failure is clinically and radiographically indistinguishable from systolic heart failure, normal ejection fraction and abnormal diastolic function in the presence of symptoms and signs of heart failure confirm diastolic heart failure. The pharmacologic therapies of choice for diastolic heart failure are angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, diuretics, and beta blockers.

Prevalence, prognostic importance and therapeutic implications of anemia in heart failure.

BACKGROUND: Despite advances in its management, heart failure, once established, remains highly prevalent and lethal. Anemia can exacerbate the hemodynamic burden in heart failure. The present study was undertaken to assess the presence of anemia and analyze how its control impacts the outcome in heart failure patients. METHODS AND RESULTS: From a cohort of 238 heart failure patients, 55 (231%) patients were found to be anemic. Twenty-nine patients (Group A) were given recombinant human erythropoietin for 12 weeks along with iron, and followed up for a mean period of 24 +/- 6 months. The patients improved substantially in terms of functional capacity (6 min walk test improved from 232 +/- 35 m to 278 +/- 41 m, p < 0.001), hemoglobin level from 10.1 +/- 0.90 gm/dl to 12 +/- 0.7 gm/dl, (p < or = 0.001), and ejection fraction from 33 +/- 7.1% to 41 +/- 6.9% (p < or = 0.001). Twenty-six patients (Group B) who were age- and sex-matched with Group A and had similar degree of functional disability and left ventricular dysfunction as that of Group A were not given erythropoietin and iron. Thus, Group B patients served as controls. In comparison to Group B, Group A patients demonstrated not only higher hemoglobin level (12 +/- 0.7 gm/dl v. 9.8 +/- 0.9 gm/dl, p < or = 0.001), and ejection fraction (41 +/- 6.9% v. 26 +/- 7%, p < or = 0.05), but also better survival (16/29 v. 7/26, p < 0.05, odds ratio 1.27). CONCLUSIONS: Anemia is a significant predictor of poor outcome in patients with heart failure. Administration of erythropoietin can correct anemia and help improve survival.

Percutaneous transatrial mitral commissurotomy by modified technique using a JOMIVA balloon catheter: a cost-effective alternative to the Inoue balloon.

BACKGROUND AND AIM OF THE STUDY: Percutaneous transatrial mitral commissurotomy (PTMC) is an established non-surgical treatment of rheumatic mitral stenosis. The study aim was to assess the safety and efficacy of PTMC using the Joseph mitral valvuloplasty (JOMIVA) balloon catheter, with a modified technique. METHODS: PTMC was performed in 252 patients (88 males, 164 females; mean age 39.2 +/- 13.8 years; range: 10-76 years) with symptomatic mitral stenosis. Among patients, 52 (20.6%), 182 (72.2%) and 18 (7.2%) were in NYHA classes II, III and IV, respectively. Atrial fibrillation was present in 52 patients (20.6%), and mild mitral regurgitation (MR) in 26 (10.3%); 92 patients (36.5%) had a mitral valve echo score > 8. Patients were followed up with detailed clinical and echocardiography studies at three-month intervals during the first year, and at six-month intervals thereafter. RESULTS: The procedure was technically successful in 247 patients (98%), and an optimal result was achieved in 228 (90.5%), with mean mitral valve area increased from 0.81 +/- 0.32 to 1.92 +/- 0.39 cm2 (p < 0.001). NYHA class was improved in most patients. Seven patients (2.8%) had cardiac tamponade during the procedure; one of these (0.4%) died from left ventricular tear. MR appeared (n = 10) or worsened (n = 20) in 30 patients (11.9%), among whom three (1.2%) developed severe MR. Each JOMIVA balloon catheter was used 10 to 20 times without being damaged. In total, 220 patients were followed up for between six and 54 months (mean 30 months). At follow up, 140 (63.6%) and 67 (30.5%) patients were in NYHA classes I and II, respectively. Seventeen patients (7.7%) developed mitral restenosis. CONCLUSION: PTMC using the JOMIVA balloon catheter is a cost-effective and safe alternative to the Inoue balloon when treating symptomatic severe mitral stenosis. The hemodynamic benefits were sustained long term in a majority of patients. In particular, cost is important factor in a less wealthy country such as India.

Current perspectives on statins.

As the epidemic of coronary artery disease rages on round the globe, research is always on to find suitable drugs to reverse the trend. While aspirin, beta-blockers and ACE inhibitors have been shown to reduce coronary mortality and morbidity, statins are rapidly coming to fore as another important cog in the wheel of primary and secondary prevention of coronary artery disease. Newer trial like Heart Protection Study suggests benefit of statin for high risk individuals, irrespective of initial serum cholesterol concentrations. This may be of great relevance in the Indian context taking into consideration the vast majority of coronary artery disease patients having normal to mildly elevated serum cholesterol in contrast to their western counterparts.