Cardiological society of India document on safety measure during echo evaluation of cardiovascular disease in the time of COVID-19.

An echocardiographic investigation is one of the key modalities of diagnosis in cardiology. There has been a rising presence of cardiological comorbidities in patients positive for COVID-19. Hence, it is becoming extremely essential to look into the correct safety precautions, healthcare professionals must take while conducting an echo investigation. The decision matrix formulated for conducting an echocardiographic evaluation is based on presence or absence of cardiological comorbidity vis-à-vis positive, suspected or negative for COVID-19. The safety measures have been constructed keeping in mind the current safety precautions by WHO, CDC and MoHFW, India.

The nuances of atherogenic dyslipidemia in diabetes: focus on triglycerides and current management strategies.

Diabetes mellitus (DM) is a pandemic disease and an important cardiovascular (CV) risk factor. The atherogenic dyslipidemia in diabetes (ADD) is characterized by high serum triglycerides, high small dense LDL levels, low HDL levels and postprandial lipemia. Insulin resistance is a primary cause for ADD. Though statins are highly effective for CVD prevention in DM but a significant residual CV risk remains even after optimal statin therapy. Fibrates, niacin and omega-3 fatty acids are used in addition to statin for treatment of ADD (specifically hypertriglyceridemia). All these drugs have some limitations and they are far from being ideal companions of statins. Many newer drugs are in pipeline for management of ADD. Dual PPAR α/γ agonists are in most advanced stage of clinical development and they have a rational approach as they control blood glucose levels (by reducing insulin resistance, a primary factor for ADD) in addition to modulating ADD. Availability of dual PPAR α/γ agnosits and other drugs for ADD management may improve CV outcomes and decrease morbidity and mortality in diabetic patients in future.

Role of omega-3 ethyl ester concentrate in reducing sudden cardiac death following myocardial infarction and in management of hypertriglyceridemia: an Indian consensus statement.

INTRODUCTION: Sudden cardiac death (SCD) is the most lethal manifestation of heart disease. In an Indian study the SCDs contribute about 10% of the total mortality and SCD post ST elevation myocardial infarction (MI) constitutes for about half of total deaths. OBJECTIVE: Given the limitations of existing therapy there is a need for an effective, easy to use, broadly applicable and affordable intervention to prevent SCD post MI. Leading cardiologists from all over India came together to discuss the potential role of n-3 acid ethyl esters (90%) of eicosapentaenoic acid (EPA) 460 mg & docosahexaenoic acid (DHA) 380 mg in the management of post MI patients and those with hypertriglyceridemia. RECOMMENDATIONS: Highly purified & concentrated omega-3 ethyl esters (90%) of EPA (460 mg) & DHA (380 mg) has clinically proven benefits in improving post MI outcomes (significant 15% risk reduction for all-cause mortality, 20% risk reduction for CVD and 45% risk reduction in SCD in GISSI-Prevenzione trial) and in reducing hypertriglyceridemia, and hence, represent an interesting option adding to the treatment armamentarium in the secondary prevention after MI based on its anti-arrhythmogenic effects and also in reducing hypertriglyceridemia.

Biodegradable-polymer-based, paclitaxel-elutingInfinnium™ stent: 9-Month clinical and angiographic follow-up results from the SIMPLE II prospectivemulti-centre registry study

Background: SIMPLE II was a multi-centre, prospective registry study aimed at investigating the safety andefficacy of the Infinnium™ (Sahajanand Medical Technologies Pvt. Ltd, India) paclitaxel-eluting stent forthe treatment of single de novo lesions in the native coronary arteries.Methods: One hundred and three patients with symptomatic coronary artery disease were treated for singlede novo native coronary artery lesions using the Infinnium™ stent (paclitaxel concentration1.4 mcg/mm2 released over 48 days) in a multi-centre, prospective study performed on 3 continents (Asia,Europe and South America). The primary safety endpoint was major adverse cardiac events at 30 days(MACE 30d) and efficacy was assessed by in-stent binary restenosis as measured by quantitative coronaryangiography (QCA) at six-month follow-up. A clinical follow-up was scheduled at nine months.Results: The mean patient age was 58.5 years; 70.9% were males; 43.7% had unstable angina and 38.8%previous myocardial infarction. Risk factors included hypertension in 62.1%, hypercholesterolemia in52.4%, current smoking in 32.0% and diabetes in 28.2%. Stent implantation was successful in all patients,with more than one stent being implanted in 9 patients (8.7%). Hierarchical MACE 30d was 2.9%. At ninemonths, 101 patients had clinical follow-up (1 patient had died and 1 refused). There was one death(1.0%), one Q-wave myocardial infarction (Q MI) (1.0%), three non-Q MIs (2.9%), one clinically-driven targetlesion Coronary Artery Bypass Grafting (CABG) (1.0%), and one clinically-driven target lesion repeatpercutaneous coronary intervention (re-PCI) (1.0%). The overall event-free rate at nine months was 93.2%.QCA revealed in-stent and in-segment late loss of 0.38±0.49 mm and 0.18±0.46 mm, resulting in binaryrestenosis rates of 7.3% and 8.3%, respectively. There was one case of late stent thrombosis in the patientexperiencing the Q MI and subsequent re-PCI...

Biodegradable-polymer-based, paclitaxel-eluting Infinnium stent: 9-Month clinical and angiographic follow-up results from the SIMPLE II prospective multi-centre registry study.

BACKGROUND: SIMPLE II was a multi-centre, prospective registry study aimed at investigating the safety and efficacy of the Infinnium (Sahajanand Medical Technologies Pvt. Ltd, India) paclitaxel-eluting stent for the treatment of single de novo lesions in the native coronary arteries. METHODS: One hundred and three patients with symptomatic coronary artery disease were treated for single de novo native coronary artery lesions using the Infinnium stent (paclitaxel concentration 1.4 mcg/mm2 released over 48 days) in a multi-centre, prospective study performed on 3 continents (Asia, Europe and South America). The primary safety endpoint was major adverse cardiac events at 30 days (MACE 30d) and efficacy was assessed by in-stent binary restenosis as measured by quantitative coronary angiography (QCA) at six-month follow-up. A clinical follow-up was scheduled at nine months. RESULTS: The mean patient age was 58.5 years; 70.9% were males; 43.7% had unstable angina and 38.8% previous myocardial infarction. Risk factors included hypertension in 62.1%, hypercholesterolemia in 52.4%, current smoking in 32.0% and diabetes in 28.2%. Stent implantation was successful in all patients, with more than one stent being implanted in 9 patients (8.7%). Hierarchical MACE 30d was 2.9%. At nine months, 101 patients had clinical follow-up (1 patient had died and 1 refused). There was one death (1.0%), one Q-wave myocardial infarction (Q MI) (1.0%), three non-Q MIs (2.9%), one clinically-driven target lesion Coronary Artery Bypass Grafting (CABG) (1.0%), and one clinically-driven target lesion repeat percutaneous coronary intervention (re-PCI) (1.0%). The overall event-free rate at nine months was 93.2%. QCA revealed in-stent and in-segment late loss of 0.38+/-0.49 mm and 0.18+/-0.46 mm, resulting in binary restenosis rates of 7.3% and 8.3%, respectively. There was one case of late stent thrombosis in the patient experiencing the Q MI and subsequent re-PCI. CONCLUSIONS: The Infinnium paclitaxel-eluting stent appears to be safe and efficacious for the treatment of single de novo lesions in coronary arteries in a patient population with symptomatic coronary artery disease (CAD).

Role of closed mitral commissurotomy for mitral restenosis.

Out of 1184 consecutive cases of rheumatic mitral stenosis treated surgically by closed mitral commissurotomy (CMC) at NRS Medical College and Hospital, Calcutta, 20 (1.68%) were mitral valve restenosis. Twelve cases (60%) were females, The median age was 32 years. Duration between the first operation and reappearance of symptoms varied with a mean of 8 years. The previous operations were digital dilatation and instrumental dilatation in 6 and 14 cases respectively. History of thromboembolism was present in 4 cases. On echocardiography, calcification of the mitral valve was present in 2 cases, left atrial clot in 4 cases, associated mild to moderate mitral regurgitation in 6 cases and mild aortic regurgitation in 4 cases. All cases presented with New York Heart Association (NYHA) III and IV symptoms. Critical stenosis (mitral valve orifice less than 0.5 cm2) was present in 12 cases. Re-do CMC was undertaken in all cases with Tubb's dilator. Median operating time was 2.5 hours. Satisfactory split was achieved in 13 cases. One patient died during surgery. Four cases having less than satisfactory split were asymptomatic on follow-up. In one case no split was possible and in another, gross mitral regurgitation was noted postoperatively. These 2 cases had to undergo open heart surgery. It is concluded that re-do CMC is a feasible and suitable alternative in mitral restenosis even in the presence of complications.

Emerging facets of diastolic heart failure.

One hundred patients with congestive cardiac failure (52 males and 48 females) with age ranging from 16 to 56 yrs (mean age 42 +/- 6) were studied to determine the relative prevalence of systolic and diastolic failures, their clinical profiles and common aetiologies. Age matched 25 control subjects were also studied to established a normal range of echocardiographic values for LV diastolic function. Thirty eight patients (38%) were found to have pure diastolic heart failure and another 5 (5%) and 57 (57%) were detected to have mixed and systolic failures respectively. An attempt to correlate the clinical assessment of diastolic failure with echo doppler study showed the sensitivity and specificity of the clinical criteria for diagnosis of diastolic heart failure to be 100% and 91.94% respectively. Of the 38 cases of diastolic failure detected 39.5% had hypertension, 31.6% ischaemic heart disease and 13.16% hypertrophic cardiomyopathy.

Cardiac involvement in non-specific aorto-arteritis.

Cardiac involvement in 75 cases (mean age 21.1 +/- 6 years) with non-specific aorto-arteritis was studied. Detailed clinical examination, echocardiography and cardiac catheterization, including angiography, were done in all the cases, as was coronary angiography. Features of cardiac failure like sinus tachycardia, cardiomegaly, left ventricular third heart sound gallop and pulmonary congestion were detected in 27 cases with reduction of left ventricular ejection fraction (25-48%). Systemic hypertension was seen in 60 cases. Central aortic pressure, left ventricular systolic pressure and left ventricular end-diastolic pressure were increased in 66 cases. Pulmonary hypertension and increased pulmonary vascular resistance were detected in 6 cases. Aortic and mitral regurgitation were seen in 15 and 12 cases, respectively. Three patients had features of dilated cardiomyopathy such as generalized cardiomegaly, systemic and pulmonary congestion but without any cardiac murmurs and with normal central aortic pressure. The coronary angiogram revealed obstruction of the left anterior descending artery in 3 cases and right coronary artery obstruction in another 3 cases. Histopathological studies revealed non-specific inflammatory changes with fibrosis in cardiac musculature and the great vessels.

Cardiac changes implicated in chronic heart block.

Fifteen cases of chronic heart block were studied. Eight of them could be designated as idiopathic or primary heart block; the others were associated with hypertension, diabetes and ischaemic heart disease, either singly or in various combinations. In six cases, the whole heart was available for histopathological study of the conduction system. In the other 9 cases, only a portion of the heart muscle was available for examination. A V nodal fibrosis extending upto the proximal bundle of His was seen in all the six whole heart autopsy materials. Fibrosis of the adjacent myocardium was seen in five cases. In three cases, conducting system fibrosis was associated with atherosclerotic (1 case) or diabetic changes (3 cases) of the intramural vessels. In the 9 partial autopsy studies, myocardial fibrosis was seen in two cases, diabetic microangiopathy in one and atherosclerotic changes in two including an old thrombus in one. Thus, diabetic microangiopathy was seen in total four cases. These changes may be responsible for the cardiomegaly and cardiac failure associated with conduction defects observed in diabetes. In the idiopathic group also, heart block could be considered as a significant facet of a primary myocardial degenerative process.

Early experience with percutaneous transluminal coronary angioplasty in unstable angina.

Percutaneous transluminal coronary angioplasty was done in 13 of 105 patients with unstable angina, 10 of whom were males. Diagnostic coronary angiography revealed single vessel disease in 10 cases and two vessel disease in 3 cases; the degree of stenosis varied from 70-90%. Only a single major coronary artery was dilated. Immediate angiographic success was achieved in 12(92.3%) cases. The success rate at the time of discharge from hospital was 10 (76.9%) cases. Immediate complications encountered were acute myocardial infarction in 2 cases, they refused coronary artery bypass grafting and unsuccessful dilation in 1 case. No death occurred during the hospital stay. During follow-up of 6-9 months, 8 patients were symptom free (66.6%), 2 patients required repeat percutaneous transluminal coronary angioplasty and 2 patients died. In conclusion, percutaneous transluminal coronary angioplasty may be undertaken relatively safely in unstable angina, it leads to substantial improvement in symptoms during the early follow-up period. This therapeutic approach is highly beneficial particularly in single vessel disease.