Fibrinolysis and clinical outcomes in acute pulmonary embolism. Madras medical college pulmonary embolism (M-PER) registry from India.

BACKGROUND: Acute pulmonary embolism (APE) is the third most common cause of vascular death. Data on APE from India and other low-and middle-income countries is sparse. OBJECTIVES: Study the clinical characteristics, prognostic factors, in-hospital mortality (IMH) and 12 months mortality of patients with APE in India. METHODS: We prospectively enrolled 186 consecutive patients diagnosed with APE between November 2016 and November 2021 in Madras Medical College Pulmonary Embolism Registry (M-PER). All patients had electrocardiography and echocardiography. High risk patients and selected intermediate risk patients underwent fibrinolysis. RESULTS: 75 % of our patients were below 50 years of age. 35 % were women. The mean time to presentation from symptom onset was 6.04 ± 10.01 days. 92 % had CT pulmonary angiography. Intermediate risk category (61.3 %) was the more common presentation followed by high risk (26.9 %). Electrocardiography showed S1Q3T3 pattern in 56 %. 76 % had right ventricular dysfunction and 12.4 % had right heart thrombi(RHT) by echocardiography. 50.5 % received fibrinolysis. Patients with RHT received fibrinolysis more frequently (78.3 % vs 46.6 %; p = 0.007). In-hospital mortality (IHM) was 15.6 %. Systemic arterial desaturation and need for mechanical ventilation independently predicted IHM. Ten patients (5.3 %) were lost to follow up. One year mortality was 26.7 % (47/176). One year mortality of patients discharged alive was similar among high, intermediate and low risk groups(14.8 % vs 1.9 % vs 10.5 %; p = 0.891). CONCLUSIONS: Patients with PE are often young and present late in India. The in-hospital and 12 months mortality were high. Low and intermediate risk groups had a high post discharge mortality similar to high risk patients.

Pregnancy outcomes in women with heart disease: the Madras Medical College Pregnancy And Cardiac (M-PAC) Registry from India.

AIMS: To evaluate the feto-maternal outcome, identify the adverse outcome predictors and test the applicability of modified WHO (mWHO) classification in pregnant women with heart disease (PWWHD) from Tamil Nadu, India. METHODS AND RESULTS: One thousand and five pregnant women (mean age: 26.04 ± 4.2) with 1029 consecutive pregnancies were prospectively enrolled from July 2016 to December 2019 in the Madras medical college pregnancy and cardiac (M-PAC) registry. Majority (60.5%; 623/1029) had heart disease (HD) diagnosed for the first time during pregnancy. Rheumatic HD (42%; 433/1029) was most common. One third (34.2%; 352/1029) had pulmonary hypertension (PH). Maternal mortality and composite maternal cardiac events (MCEs) were the primary outcomes. Secondary outcomes were foetal loss and composite adverse foetal events (AFEs). MCEs occurred in 15.2% (156/1029; 95% CI: 13.0-17.5) pregnancies. Heart failure was the most common MCE (66.0%; 103/156; 95% CI: 58.0-73.4). Maternal mortality was 1.9% (20/1029; 95% CI: 1.1-2.8), with highest rates in patients with prosthetic heart valves (PHVs) (8.6%; 6/70). Left ventricular systolic dysfunction (LVSD), PHVs, severe mitral stenosis, PH and current pregnancy diagnosis of HD were independent predictors of MCE. The c-statistic of mWHO classification for predicting MCE and maternal death were 0.794 (95% CI: 0.763-0.826) and 0.796 (95% CI: 0.732-0.860). 91.2% (938/1029; 95% CI: 89.392.8) of pregnancies resulted in live births. 33.7% (347/1029; 95% CI: 30.8-36.7) of pregnancies reported AFEs. CONCLUSION: Maternal mortality is high in PWWHD from India. Highest death rates occurred in women with PHVs, PH and LVSD. The mWHO classification for risk stratification may require further adaptation and validation in India.

Outcomes of ST Segment Elevation Myocardial Infarction without Standard Modifiable Cardiovascular Risk Factors - Newer Insights from a Prospective Registry in India.

Objectives: Patients with ST elevation myocardial infarction (STEMI) without standard modifiable cardiovascular risk factors (SMuRFs; dyslipidaemia, hypertension, diabetes mellitus and smoking) are reported to have a worse clinical outcome compared to those with SMuRFs. However, robust prospective data and low-and middle-income country perspective are lacking. We aimed to study the patients with first STEMI and assess the influence of SMuRFs on clinical outcomes by comparing the patients with and without SMuRFs. Methods: We included all consecutive STEMI patients without prior coronary artery disease enrolled in the Madras Medical College STEMI Registry from September 2018 to October 2019. We collected baseline clinical characteristics, revascularisation strategies and clinical outcome. We analysed suboptimal self-reported sleep duration as a 5th extended SMuRF (eSMuRF). Primary outcome was in-hospital mortality. Secondary outcomes included in-hospital complications and one-year all-cause mortality. Results: Among 2,379 patients, 605 patients (25.4%) were SMuRF-less. More women were SMuRF-less than men (27.1% vs 22.1%; P = 0.012). SMuRF-less patients were older (57.44 ± 13.95 vs 55.68 ± 11.74; P < 0.001), more often former tobacco users (10.4% vs 5.0%; P < 0.001), with more anterior wall MI (62.6% vs 52.1%; P = 0.032). The primary outcome [in-hospital mortality (10.7% vs 11.3%; P = 0.72)] and secondary outcomes [in-hospital complications (29.1% vs 31.7%; P = 0.23) and one-year all-cause mortality (22.3% vs 22.7%; P = 0.85)] were similar in both groups. Addition of suboptimal self-reported sleep duration as a 5th eSMuRF yielded similar results. Conclusions: 25% of first STEMI patients were SMuRF-less. Clinical outcomes of patients without SMuRFs were similar to those with SMuRFs. Suboptimal sleep duration did not account for the risk associated with the SMuRF-less status.

Modified limb lead ECG system effects on electrocardiographic wave amplitudes and frontal plane axis in sinus rhythm subjects.

OBJECTIVE: Modified Limb Lead (MLL) ECG system may be used during rest or exercise ECG, or atrial activity enhancement. Because of modification in the limb electrode placement, changes are likely to happen in ECG wave amplitudes and frontal plane axis, which may alter the clinical limits of normality and ECG diagnostic criteria. The present study investigated the effects of the modified limb electrode position on the electrocardiographic waveforms, ST segment amplitudes (STa) and frontal plane axis. METHODS: The observational study included sixty sinus rhythm subjects of mean age 38.85±8.76 (SD) in the range 25 to 58 years. In addition to 12-lead ECG, MLL ECG was recorded with, the RA electrode placed in the 3rd right intercostal space to the right of the parasternal line, the LA electrode placed in the 5th right intercostal space to the right of the mid-clavicular line and the LL electrode placed in the 5th right intercostal space on the mid-clavicular line. RESULTS: The modification produced profound changes in ECG wave amplitudes and STa amplitudes in frontal plane leads. The QRS and T wave axis shifted on the average by -17o and 41o, respectively, with considerable individual variation, which altered the diagnostic criteria. CONCLUSION: The ECG amplitudes and STa changes produced by the MLL system showed that all remains within the clinical limits, except the R wave amplitude in the modified lead I. It is evident that the MLL system produced deviations in frontal plane QRS axis which altered the diagnostic interpretation.

Unmasking of atrial repolarization waves using a simple modified limb lead system.

OBJECTIVE: In the present study, a modified limb lead (MLL) system was used to record the Ta wave in sinus rhythm and with AV block in male patients. METHODS: Eighty male subjects (mean age 36 ± 7 years) in sinus rhythm and 20 male patients with AV block (mean age 72 ± 5 years) were included in this study. Standard limb lead (SLL) ECGs and MLL ECGs were recorded for 60 seconds each with an EDAN SE-1010 PC ECG system. RESULTS: In sinus rhythm subjects, the observable Ta wave duration was 109 ± 4.7 ms, the P-Ta duration was 196 ± 5.1 ms, and the corrected P-Ta duration was 238 ± 7.2 ms. The Ta wave peak amplitude was -42 ± 8 µV. In AV block patients, the Ta wave duration was 314 ± 28 ms the P-Ta duration was 418 ± 29 ms and the corrected P-Ta duration was 46 ± 31 ms, while the Ta wave peak amplitude was -37 ± 9 µV. A correlation was found between the P and Ta wave amplitude, and no correlation was found between the P and Ta wave duration or the Ta amplitude and Ta duration in sinus rhythm and AV block subjects. CONCLUSION: The end of the Ta wave is not observable in sinus rhythm subjects, as it extends into the QRS complex and ST segment. In AV block patients, the Ta wave duration was generally three times longer than the observable Ta duration in sinus rhythm subjects.

Large free-floating left atrial thrombus with normal mitral valve.

Left atrial thrombus in the presence of diseased mitral valve and atrial fibrillation is a well known entity. But it is very rare to occur in the presence of normal mitral valve apparatus. We report the case of a 36 year old female who presented with left atrial ball valve thrombus and normal mitral valve apparatus and underwent surgery. This patient with gangrene of right lower limb came for cardiac evaluation. She had infarct in left middle cerebral artery territory- ten months prior to this admission and was on treatment for infertility. She had atrial fibrillation. Emergency surgery to remove the thrombus should be considered given its potential life threatening embolic nature.

An echocardiographic assessment of cardiovascular hemodynamics in patients with large pleural effusion.

BACKGROUND: The close relationship between pleural space and pericardial space and the dependence of their pressure kinetics are well known. This study evaluates the effects of increased intra pleural pressure due to pleural effusion on cardiovascular system. METHODS: Forty patients above the age of 12 who had massive unilateral/bilateral pleural effusion due to non-cardiac etiology were included in the study. Therapeutic thoracocentesis was done for massive pleural effusion. The echocardiographic parameters measured before and after thoracocentesis were compared. RESULTS: Mean age of the patients 46.6 years. Out of 40 patients 8 were females (20%). 7 patients had right atrial collapse on echo. 85% of patients had significant flow velocity changes across both tricuspid valve and mitral valve during phases of respiration.11 patients (47.82%) had IVC compressibility of <50% during inspiration. Mean flow velocity respiratory variations across tricuspid valve before thoracocentesis and after thoracocentesis E 45.04 ± 10.3,32 ± 11.3% (p value <0.001), A 53.71 ± 28%, 32.08 ± 12.5% (p < 0.001) across mitral valve E 32.30 ± 12%, 19.78 ± 7.8% (p < 0.001), A 26 ± 11.2%, 21 ± 9.3% (p 0.006) across pulmonary artery 42.63 ± 31.3%, 17.70 ± 6.2% (p < 0.001), across aorta 21.57 ± 11.4%, 14.08 ± 7.6% (p < 0.001). CONCLUSION: Large pleural effusion has a potential to cause adverse impact on the cardiovascular hemodynamics, which could manifest as tamponade physiology. Altered cardiac hemodynamics could be an important contributor in the mechanism of dyspnea in patients with large pleural effusion.

Isolated noncompaction of right ventricle--a case report.

Isolated noncompaction of ventricular myocardium (INVM) is a genetic cardiomyopathy due to abnormal arrest in endomyocardial embryogenesis between fetal 5th and 8th week. Noncompaction of right ventricle alone is rare. Here we present one such case where a young man presented with progressive right heart failure and atrial fibrillation. Subsequent evaluation by echo and cardiac magnetic resonance imaging confirmed our diagnosis. The cardinal manifestations of INVM are heart failure, arrhythmia, and embolic events and our case presented with former two manifestations. Echocardiographic criteria for diagnosing INVM are discussed.

Canadian Cardiovascular Society classification of effort angina: an angiographic correlation.

BACKGROUND: The Canadian Cardiovascular Society classification (CCSC) remains the standard for grading angina in patients with chronic stable angina. The utility value of this angina grading system in predicting the severity of coronary artery disease is not clear. AIM: We studied the relationship between the clinical angina grade and the angiographic severity of underlying coronary artery disease. MATERIALS AND METHODS: The participants in the study were 493 patients with stable angina who had undergone coronary angiography from 1998 to 2001. They were grouped according to their anginal grading and the number of vessels diseased. Significant lesions were defined as 50% narrowing for the left main and 70% for the left and right coronaries and their major branches. STATISTICAL ANALYSIS: The chi2-test was used for statistical analysis and a P-value <0.05 was taken as significant. RESULTS: There was no significant difference between the four angina class patients and the incidence of single-, double- and triple-vessel involvement. Class 1 patients had less left main trunk disease than class 4 patients. Class 3 and 4 patients had significantly fewer normal coronary angiograms. CONCLUSIONS: There is generally little correlation between coronary artery disease and the CCSC of effort angina except for left main disease. Presence or absence of angina rather than the CCSC should indicate the need for coronary angiography.