Transulnar versus Transradial Access as a Default Strategy for Percutaneous Coronary Intervention.

BACKGROUND: Percutaneous coronary interventions (PCI) are undergoing a paradigm shift from femoral to forearm approach due to obvious advantages in terms of patient safety, comfort, and faster ambulation. Transradial access (TRA) has been established as a primary forearm access site. Use of transulnar access (TUA) as an alternative to radial route can serve as novel forearm access to the interventionalists. AIM: The aim of this study is to evaluate TUA versus TRA access as a default strategy for PCI. MATERIALS AND METHODS: This was a prospective, single-center randomized controlled trial involving 2700 patients, of whom 220 underwent PCI in 1:1 randomization to TUA (n = 110) or TRA (n = 110). The primary endpoint was composite of major adverse cardiac events during hospital stay, cross-over to another arterial site, major vascular events of the arm during hospital stay (large hematoma with hemoglobin drop of ≥5 g%) and occlusion rate. Secondary endpoints were individual components of primary endpoint and spasm of the vessel. RESULTS: Two groups did not differ in baseline characteristics. On intention to treat (ITT) analysis, primary end point occurred in 10.91% of TUA and 12.73% of TRA arm (odds ratio [OR]: 0.84; 95% confidence interval [CI], 0.37-1.91; P = 0.68 at α = 0.05). Further on per protocol (PP) analysis, primary end point occurred in 9.21% of TUA and 11.11% of TRA arm (OR: 0.81; 95% CI, 0.29-2.30; P = 0.68 at α = 0.05). Secondary endpoints also did not differ significantly between the two groups in ITT and PP analysis. CONCLUSIONS: TUA is an excellent alternative to TRA, while performing PCI when performed by an experienced operator. When utilized as an option, TUA increases the chance of success with forearm access and reduces the need for cross over to femoral route.

Study of APOE Gene and D2S439 Marker in Patients of Rheumatoid Arthritis and their Correlation with Severity of Disease: A Case Control Study.

AIM: To delineate the genetic differences in polymorphism of the APOE and D2S439 marker genes for patients with and without rheumatoid arthritis and to study the distribution frequency of the prevalent alleles of these genes in clinically defined sub groups of patients/controls of Indian origin, specifically and their correlation with severity of disease using DAS score. MATERIAL AND METHODS: This is a case control study where peripheral blood samples 160 cases and 150 controls were collected. RESULTS: We evaluated the association of the tetra nucleotide repeat microsatellite marker D2S439 lying at 231.27cM position on the q arm of chromosome-2. The alleles of this marker ranged in size from 163bp-203bp in PCR product length corresponding to 5-15 (CTAT)n tetra repeats. The allele frequencies for this marker in the North Indian population are different from the CEPH populations. The longer alleles, >199bp (=14 or 15 CTAT repeats) were not observed. The genotypes after bimodal distribution differ significantly among cases and controls (p=0.003). Statistically significant difference was seen between cases and controls for ≥(CTAT) 10 longer allele which was more prevalent in the adult RA cases than in controls. Severity of RA was defined by a DAS28 score of >6 on a scale of ten. No significant association was seen with the APOE polymorphism and disease severity. CONCLUSION: The long allele of D2S439 marker representing an expansion of the CTAT, tetranucleotide repeat doubles an individual's the risk for developing RA.

Acute Fulminant Uremic Neuropathy Following Coronary Angiography Mimicking Guillain Barre Syndrome.

A 55 yr old diabetic lady suffered a posterior wall STEMI. She developed Contrast induced nephropathy following coronary angiography. Acute fulminant uremic neuropathy was precipitated which initially mimicked Guillan Barre Syndrome, hence reported.

Comparison of lower loading dose of prasugrel with conventional loading dose of prasugrel in Indian patients undergoing percutaneous coronary interventions.

BACKGROUND: Although conventional 60 mg of prasugrel allows for rapid and potent platelet inhibition within 30 min after loading dose, the efficacy and safety of lower doses of prasugrel in Indian patients has not yet been investigated. OBJECTIVE: The study sought to compare the efficacy of a lower loading dose of prasugrel with conventional loading dose of prasugrel in Indian patients. MATERIAL AND METHODS: Three hundred thirty-two Indian patients undergoing elective percutaneous coronary intervention (PCI) were enrolled in the study. Participants were randomly administered loading doses of prasugrel 60 mg (group A, n = 166) or 30 mg (group B, n = 166) before undergoing elective PCI in a 1:1 manner. Primary efficacy end point was composite of in-hospital death and stent thrombosis at 96 h, while safety end point was in-hospital bleeding. RESULTS: The two groups did not differ in their baseline characteristics. The primary efficacy end point was 0.6% in both the conventional 60 mg loading dose (LD) and lower 30 mg LD groups (p = not significant). Minor bleeding was significantly less in group B [Bleeding Academic Research Consortium 1, A = 6.63% vs B = 1.81%, odds ratio (OR) = 3.86, 95% confidence interval (CI) = 1.06-14.08, P = 0.05]. Major bleeding was higher in group A (A = 3.61%, vs B = 1.81%, OR = 2.04, 95% CI = 0.50-8.29, P = 0.50). CONCLUSION: In Indian patients, 30 mg of prasugrel loading is as effective as 60 mg of prasugrel with significantly less minor bleeding.

Correlation of head-up tilt table test time interval with future risk of recurrent syncope.

BACKGROUND: Head-up tilt table test (HUTT) is widely used for the investigation of syncope and presyncope. Time required for positive response has a probable relationship to the sensitivity of neural reflex mechanism underlying syncope. METHODS: We evaluated patients with history of syncope. Group A included patients with recurrent syncope defined as two or more episodes of syncope and group B included those with one episode of syncope. Time required for the test to become positive in both the groups was analyzed. Patients with positive HUTT were followed for 1 year. RESULTS: Of 80 patients, 68 eligible study patients were divided into group A (32.35%) and group B (67.65%). HUTT was positive in 41 patients (positivity rate  =  60.29%). Positivity rate was 100% in group A and 41.3% in group B. Median time interval for positive response in groups A and B were 12.5 and 30.0 minutes, respectively. An inverse association was found between recurrent syncope and time interval for positive response (R  =  - 0.282, P  =  0.002). Time interval of less than 19.5 minutes for positive response had 94.5% sensitivity and 97.89% specificity for recurrent syncope. On follow-up, positive association was found between time interval for positive response less than 19.5 minutes and future recurrence of syncope (odds ratio  =  22.75, 95% confidence interval  =  4.37-118.34, P  =  0.000). CONCLUSION: HUTT time interval of less than 19.5 minutes for positive response predicted future recurrence of syncope. Hence, it may serve as an important predictor of future recurrence of syncope.

High versus low dose statin therapy in Indian patients with acute ST-segment elevation myocardial infarction undergoing thrombolysis.

OBJECTIVES: This study sought to compare high dose versus low dose statin therapy in Indian patients with ST-segment elevation myocardial infarction (STEMI) undergoing thrombolysis. BACKGROUND: Randomized trials have demonstrated that statin treatment reduced major adverse cardiac events (MACEs) in patients with stable angina pectoris and acute coronary syndrome. However, randomized studies of statin therapy in Indian patients with STEMI are scarce. METHODS: Of 1859 patients with acute STEMI, 1027 eligible patients were randomized to 80-mg (n=512) or 10-mg (n=515) atorvastatin. Primary end point was 30-day incidence of MACE (death from any cause, myocardial infarction, NSTE-ACS requiring readmission, ischemia driven revascularization, and stroke). Secondary end points included individual components of primary end point and ST-segment resolution at 90min after thrombolysis. RESULTS: Two groups did not differ in primary endpoints of MACEs (8.79% in high dose vs 9.32% in low dose atorvastatin group, OR=0.938, 95% CI=0.612-1.436, P=0.764). With 80mg atorvastatin, there was insignificant reduction in rate of reinfarction, revascularization and death. Stroke and readmission for NSTE-ACS increased in 80mg atrovastatin group, but was not statistically significant. ST-segment resolution was significantly higher in 80-mg atorvastatin arm (45.90% vs. 37.67%; p=0.008). Myalgia was more in 80mg statin group (18.06% vs 7.57%, p=0.0001). CONCLUSIONS: High-dose atorvastatin did not show significant difference of MACEs in STEMI patients undergoing thrombolysis but showed significant improvement in immediate coronary flow depicted by ST-segment resolution. This benefit of high dose statin is to be weighed against greater myalgia, drug discontinuation and cost in Indian patients.

Acute Fulminant Uremic Neuropathy Following Coronary Angiography Mimicking Guillain-Barre Syndrome.

A 55-year-old diabetic woman suffered a posterior wall ST-elevation myocardial infarction. She developed contrast-induced nephropathy following coronary angiography. Acute fulminant uremic neuropathy was precipitated which initially mimicked Guillan-Barre Syndrome, hence reported.

Ivabradine vs metoprolol in patients with acute inferior wall myocardial infarction-"Expanding arena for ivabradine".

BACKGROUND: Atrioventricular (AV) blocks are of concern with the use of beta blockers in inferior wall myocardial infarction (MI). Ivabradine lowers heart rate with a lesser risk of AV blocks. OBJECTIVES: To compare ivabradine with metoprolol in acute inferior wall MI in terms of feasibility, tolerability, and efficacy. METHODS: It was a prospective double-blind single-center randomized controlled study. Of 1032 patients with acute inferior wall MI, 468 eligible patients were randomized in 1:1 manner to ivabradine (group A) and metoprolol (group B). Intention to treat analysis of 426 patients (group A-232 and group B-232) was performed. The primary endpoint was 30-day incidence of major adverse cardiovascular events including death, reinfarction, complete heart block (CHB), and heart failure. Secondary endpoints included 30 days incidence of recurrent angina, readmission, first- or second-degree AV block, and tachyarrhythmias. RESULTS: Both the drugs decreased the mean heart rate to 62.22±2.95 (group A) vs 62.53±3.59 (group B) beats per minute (P=0.33). Ejection fraction improved in both the groups (5.15±1.93% in group A vs 5.52±2.18% in group B, P=0.065). The two groups did not differ significantly in their primary endpoints in terms of death (group A=1.72% vs group B=1.72%, OR=1.00, 95% CI=0.25-4.05, P=1.00), reinfarction (group A=0.86% vs group B=0.86%, OR=1.00, 95% CI=0.14-7.16, P=1.00), heart failure (group A=4.31% vs group B=2.59%, OR=1.70, 95% CI=0.61-4.75, P=0.31), or CHB (0% vs 2.59%, OR=0.07, 95% CI=0.00-1.34, P=0.08). There were no significant differences in the secondary endpoints of recurrent angina, readmission, and tachyarrhythmias except for more first- and second-degree AV blocks with metoprolol (12.93% vs 2.59%, OR=5.59, 95% CI=2.28-13.72, P=0.0002). CONCLUSIONS: Ivabradine is well tolerated and equally effective as metoprolol in acute inferior wall ST elevation myocardial infarction patients for lowering the heart rate with lesser risk of AV blocks.

Stormy Course of a Huge Submitral Aneurysm Causing Low Cardiac Output State.

Submitral aneurysm is a rare structural abnormality of congenital or acquired aetiology. Most reported cases are from Africa. Unless promptly treated surgically this condition is invariably fatal. We report a case of a young Indian male who presented with dyspnea of recent onset, diagnosed to have a massive submitral aneurysm causing low cardiac output and compression of cardiac structures.

3D Xplane Echocardiographic Technique for Validation of Mitral Leaflet Separation to Assess Severity of Mitral Stenosis.

BACKGROUND: Determining the severity of mitral stenosis (MS) is important for both prognostic and therapeutic implications. Mitral valve area (MVA) calculation techniques have more limitations. Mitral leaflet separation (MLS) is a precise and operator friendly alternative to planimetry. In contrast to previous researchers, we have used a novel 3D Xplane technique to validate MLS for assessing the severity of MS. 3D Xplane is superior for validation of MLS due to simultaneous real time acquisition of MLS in parasternal long-axis view and corresponding MVA by planimetry in parsternal short-axis view. METHODS: It was a prospective observational single center study. A total of 174 patients with MS were evaluated for MVA estimation by various echocardiographic modalities. Maximum leaflet separation and corresponding planimetered MVA were measured using novel 3D Xplane technique. RESULTS: With 3D Xplane technique, there was strong positive correlation between planimetered MVA and MLS (R = 0.925, P < 0.001), irrespective of coexisting MR (R = 0.886, P < 0.001) or AF (R = 0.912, P < 0.001). Receiver operating characteristic curves of MLS demonstrated AUC for mild and severe MS to be 0.966 and 0.995, respectively. MLS less than 8.62 mm predicted severe MS with 95.5% sensitivity and 94.7% specificity and MLS more than 12.23 mm predicted mild MS with 93.2% sensitivity and 91.4% specificity. CONCLUSION: In our study, a strong correlation between planimetered MVA and MLS was found using 3D Xplane technique. 3D Xplane thus validates and standardizes MLS by excluding errors due to temporal and spatial variations which are important limitations of 2D echocardiography.

Palmar arch anatomy: Ajmer Working Group classification.

INTRODUCTION: Forearm arteries are frequently used as workhorse site for cardiac catheterization, bypass grafting and haemodialysis access. There is paucity of data on palmar circulation in live human being and only cadaveric data are available till date. We, therefore, made an attempt to look at the various patterns of sufficient or insufficient palmar arch circulation and various anomalies of forearm arteries, to discuss their clinical implications. METHODS AND RESULTS: We obtained the forearm and hand arteriograms of patients (n = 302) through radial (n = 200) and ulnar routes (n = 102). Modified Allen's test was normal in all of our patients. On the basis of predetermined parameters angiograms were analysed and findings were divided into three groups. These three groups were further classified as type A, type B, type C superficial palmar arch. CONCLUSION: We concluded that type A superficial palmar arch is most suitable for providing adequate collateral circulation in case of harvesting of forearm vessel, whereas type C superficial palmar arch appears to be highly susceptible for digital ischemia in case of radial or ulnar artery occlusion. Modified Allen's test alone is not justifiable for documenting good collateral circulation and it should be supplemented by other tests to document good collateral circulation before proceeding to any radical procedure.

Sweating: A Specific Predictor of ST-Segment Elevation Myocardial Infarction Among the Symptoms of Acute Coronary Syndrome: Sweating In Myocardial Infarction (SWIMI) Study Group.

BACKGROUND: Today, cardiologists seek to minimize time from symptom onset to interventional treatment for the most favorable results. HYPOTHESIS: In the acute coronary syndrome (ACS) symptom complex, sweating can differentiate ST-segment elevation myocardial infarction (STEMI) from non-ST-segment elevation ACS (NSTE-ACS) during early hours of infarction. METHODS: This single-center, prospective, observational study compared symptoms of STEMI and NSTE-ACS patients admitted from August 2012 to July 2014. RESULTS: Of 12 913 patients, 90.56% met ACS criteria. Among these, 22.51% had STEMI. Typical angina was the most common symptom (83.82%). On stepwise multiple regression, sweating (odds ratio: 97.06, 95% confidence interval [CI]: 82.16-114.14, P < 0.0001) and typical angina (odds ratio: 2.72, 95% CI: 2.18-3.38, P < 0.001) had significant association with STEMI. For diagnosis of STEMI, positive likelihood ratio (LR) and positive predictive value (PPV) were highest for typical angina with sweating (LR: 11.17, 95% CI: 10.31-12.1; PPV: 76.09, 95% CI: 74.37-77.75), followed by sweating with atypical angina (LR: 3.6, 95% CI: 3.07-4.21; PPV: 50.61, 95% CI: 46.45-54.76), typical angina (LR: 1.05, 95% CI: 1.03-1.07; PPV: 22.97, 95% CI: 22.11-23.84), and atypical angina (LR: 0.77, 95% CI: 0.69-0.87; PPV: 18.09, 95% CI: 16.32-19.97). C statistic values of 0.859 for typical angina with sweating and 0.519 for typical angina alone reflected high discriminatory value of sweating for STEMI prediction. CONCLUSIONS: Presence of sweating with ACS symptoms predicts probability of STEMI, even before clinical confirmation. Sweating in association with typical or atypical angina is a much better predictor of STEMI than NSTE-ACS.

Ulnar Artery Interventions Non-Inferior to Radial Approach: AJmer Ulnar ARtery (AJULAR) Intervention Working Group Study Results.

BACKGROUND: Percutaneous coronary procedures are undergoing a paradigm shift from femoral to forearm approach due to obvious advantages in terms of patient safety and comfort, and faster time to ambulation. Transradial access (TRA) has been established as a primary forearm access site. We have tried to use ulnar artery access as an alternative to radial route and found that transulnar access (TUA) is an excellent alternative and non-inferior to TRA if performed by an experienced operator. METHODS: This was a prospective, single-center study involving 2532 patients who were randomized in a 1:1 manner to either TUA (n = 1270) or TRA (n = 1262). All cannulations were performed by operators who were experienced in radial artery (RA) cannulation and had performed a minimum of 50 ulnar artery (UA) cannulations. The primary endpoint was a composite of major adverse cardiac events during hospital stay, crossover to another arterial access route, major vascular events during hospital stay (large hematoma with hemoglobin drop of ≥3 g%) or vessel occlusion rate. To prove non-inferiority of TUA, a margin of 1.93 was derived by fixed-margin method (preserving 50% of difference of procedural failure rate [4.87%] between radial and femoral access from meta-analysis). RESULTS: The composite primary endpoint occurred in 14.6% of TUA and 14.4% of TRA patients (risk ratio, 1.01; 95% confidence interval, 0.83-1.2; P=.92 at α=0.05). All assessed parameters (except large hematoma, for which non-inferiority could not be proved conclusively) were non-inferior in TUA when compared with TRA. CONCLUSIONS: TUA is non-inferior to TRA when performed by an experienced operator. The utilization of TUA as an access site option increases the chance of success with forearm access and reduces the need for crossover to femoral route.

Eptifibatide in post-infarction angina patients who refused intervention: Ajmer postmyocardial infarction angina eptifibatide research (AJMER) study: a pilot study.

BACKGROUND: Early intervention is certainly a preferred strategy over conservative management in patients with post-infarction angina (PIA). But at times, it may not be feasible to intervene, especially if patient refuses for intervention. In a pilot study, we analyzed whether the addition of eptifibatide to intensified antianginal therapy would be of added benefit, in patients with PIA not willing to undergo intervention. METHODS: A total of 461 patients with PIA who refused intervention were randomized in a 1:1 manner to receive either eptifibatide along with intensification of antianginal therapy (group A; n = 229) or intensified antianginal therapy alone (group B; n = 232). The primary endpoints were composite of all-cause death and nonfatal myocardial infarction at 30 days. RESULTS: Primary composite endpoint did not differ between the two groups (16.2% vs. 18.9% in group A and group B, odds ratio [OR], 0.82; 95% CI, 0.5-1.30; P-value = 0.43). Significant earlier relief of angina (complete relief of angina within 12 h: 76% of patients in group A vs. 40.5% in group B; P-value <0.0001) was achieved in group A compared to group B. Although on Bleeding Academic Research Consortium (BARC) scale, type 1 and 2 bleeding was higher in group A (OR, 3.18; 95% CI, 1.76-5.74; P-value = 0.0001), the more serious (composite of type 3 and 5) bleeds did not show any difference (OR, 1.73; 95% CI, 0.7-4.08; P-value = 0.21). CONCLUSION: In patients with PIA who refused intervention, eptifibatide infusion resulted in earlier relief of angina albeit at the cost of increased non-life-threatening bleeding. Further, this effect was achieved in significantly higher number of patients receiving eptifibatide infusion when compared to patients not receiving it. Primary composite endpoints, however, did not differ in two groups, but being a pilot study, this needs to be confirmed by larger study of adequate sample size.

Feasibility of ulnar artery for cardiac catheterization: AJmer ULnar ARtery (AJULAR) catheterization study.

BACKGROUND: The ulnar artery is rarely selected for cardiac catheterization despite the expanding use of the transradial access (TRA). We tried to compare default transulnar access (TUA) with TRA in terms of feasibility and safety. MATERIALS AND METHODS: This was a prospective, open label, single center, observational study. We analyzed a total of 410 patients with normal Allen's test, who were then scheduled for coronary angiography through TUA with ad hoc PCI if necessary. Procedures were performed by a single operator who had an adequate transradial experience (≥150 transradial coronary procedures per year) but not trained in transulnar procedures. We analyzed observed findings with a retrospective cohort of patients undergoing TRA angiography under a previous study done at our center. We also performed selective ulnar arteriography of 200 patients, through radial route, to predict the bottlenecks of TUA. OBSERVATIONS: There is no statistically significant difference among the number of attempts made till the successful puncture, the total procedure time and the total fluoroscopy time for either radial or ulnar access angiography by an experienced operator (P > 0.05). However, the time taken in arterial access is statistically significant in the initial learning curve for the same (P < 0.05). On the contrary, the arterial access time, the total procedure time, and the total fluoroscopy time, all are statistically significant for the inexperienced operator (P < 0.05). There is a negligible incidence of nonmaneuverable anatomic obstruction in the real-world scenario in TUA, and so fear of the same should not impede the use of this route. Vasospasm in the use of this route is also not different from the radial route, with the experience of the operator. CONCLUSIONS: For an experienced operator, TUA is a safe and also an effective alternative to TRA in terms of feasibility and safety.