Redefining the polypill: pros and cons in cardiovascular precision medicine.

Polypill is a multi-drug formulation in a single pill intended to simplify the drug regimen and reduce medication-induced adverse effects. The most common multidrug combinations in a polypill are used to treat cardiovascular diseases and are targeted against key modifiable risk factors such as hypertension and hyperlipidemia. These contain blood-pressure lowering agents, statins, and anti-platelet agents usually in a fixed dose. Polypills can be an affordable therapeutic intervention for treating high-risk patients, as these are proven to increase patients' adherence to medication and improve clinical outcomes. Over the previous years, randomized clinical trials of several polypills have yielded contradictory findings, raising skepticism regarding their widespread use in primary disease prevention. Here, we have reviewed the concept of polypills, the evidence-based strengths, the limitations of this polypharmacy intervention strategy, and discussed future directions for their use in the primary and secondary preventive management of cardiovascular diseases and associated risk factors.

Rare complication of doxorubicin-induced complete heart block in a patient with Hodgkin's lymphoma: a case report.

Anthracyclines are associated with cardiotoxic manifestations that are mainly dose-dependent, with onset varying from a few days to many years after stopping treatment. Frequent monitoring for toxic manifestations, early detection, cessation of anthracycline use and appropriate treatment is the key to preventing morbidity and mortality. Complete heart block with doxorubicin use in Hodgkin's lymphoma is rarely reported, and is a severe toxic manifestation necessitating withdrawal or changing of regimen to etoposide + bleomycin + vinblastine + dacarbazine (EBVD), as in this case.

Dextromethorphan Induced Dystonia: A Rare Case Report.

Dextromethorphan is a distant derivative of morphine, used as an antitussive agent indicated in standard care for various infections and respiratory conditions ranging from the common cold (rhinoviruses) to severe acute respiratory illness (SARI). Being a derivative of morphine, a natural central nervous system (CNS) depressant, dextromethorphan produces little to no action on CNS when ingested in the prescription dosage. We present a case of a 64-year-old female patient, a known case of ischemic heart disease post angioplasty and stenting to the left anterior descending artery (LAD), with heart failure with reduced ejection fraction (HFrEF), diabetes, hypertension, chronic kidney disease, and hypothyroidism who developed extrapyramidal symptoms post dextromethorphan administration. The incidence of dextromethorphan-induced dystonia is unknown, and the literature review suggests 4 case reports indicating dextromethorphan-induced dystonia, and each of those reports is a case of either accidental overdose or overdose in substance abuse disorder. No cases of these CNS side effects are described among adults with a therapeutic dose of dextromethorphan. This case report serves to sensitize the clinician about this rare occurrence.

Pseudocoarctation of the Arch and the Abdominal Aorta: A Review.

Pseudocoarctaion of the aorta is a rare congenital anomaly occurring in isolation or with other congenital heart diseases. The anatomical basis of the condition is linked to an elongated, redundant aorta which may affect the arch, or the abdominal aorta rarely giving rise to kink and buckling without causing any significant functional stenosis. It should be carefully differentiated from the common true coarctation of the aorta. No clinical features are specific to pseudo coarctation and are often diagnosed incidentally. Although asymptomatic in the majority, few patients can have nonspecific symptoms and complications due to aneurysm formation, dissection, or rupture of the aorta. Hence Pseudocoarctaion should be closely followed for the onset of symptoms or possible complications. Without recommendations, no specific therapy is indicated in asymptomatic patients, although symptoms and complications warrant definitive treatment. As the natural history of the disease is unknown, the condition, when diagnosed, should be closely followed up for the occurrence of any complications. This article reports a pseudo aortic coarctation involving the arch and a brief literature review of this rare congenital anomaly.

Amiodarone-Induced Hyponatremia in An Elderly Patient: A Rare Case Report.

Amiodarone is an antiarrhythmic drug belonging to Vaughan-Williams Class III with additional Class IV effects, which is known to cause many adverse drug reactions (ADRs) necessitating close monitoring. In about 20% of patients, their therapy is discontinued due to adverse effects such as hepatic impairment, thyroid dysfunction, and several pulmonary complications. Although dyselectrolytemia is a common adverse reaction reported with many cardiac medications, the incidence of hyponatremia associated with amiodarone intake is not reported widely in the literature. We are reporting a case of a 73-year-old female patient, with hypertension and ischemic heart disease (IHD) receiving oral amiodarone, presenting with severe hyponatremia, requiring recurrent hospitalization. Amiodarone was found to be responsible after evaluating for the possible causes of hyponatremia. As the incidence of amiodarone-associated hyponatremia is unknown, and not many cases are reported, this case report serves to sensitize the clinician to consider amiodarone-induced hyponatremia as one of the differential diagnoses in cases of unexplained hyponatremia.

Study of pattern & distribution of adverse drug reactions in acute coronary syndrome patients in a tertiary care hospital.

Background & objectives: With the availability of a wide range of drugs to treat patients with acute coronary syndrome (ACS), adverse drug reactions (ADRs) have become inevitable in clinical practice. Thorough knowledge of such reactions is essential for the treating physician for optimal treatment and better outcomes. There are many scales to define, measure and assess the ADRs, but there is a dearth of data available on such drug reactions among ACS patients. Hence, this study attempted to analyze the pattern, causality, severity, predictability and preventability of ADRs in ACS patients. All the ADRs reported during the study period were analyzed for causality by the World Health Organization-Uppsala Monitoring Centre (WHO-UMC), Naranjo's and Karch and Lasagna scales; severity by modified Hartwig and Siegel scale; predictability by Rawlins and Thompson criterion and preventability by Schumock and Thornton scale. Methods: A single-centre, record-based analysis for the occurrence of ADRs was done among ACS patients admitted to the department of Cardiology between January and October 2017. Demographic data, comorbid conditions, reported ADRs and ADR assessment details were noted from the hospital case records and ADR monitoring centre (AMC) records. The data were analyzed and presented in a descriptive manner using percentages, mean and standard deviation. The Pearson's chi-squared test was used to ascertain the significance of the association between different groups. Results: Out of 324 patients under evaluation, 67 had developed one or more ADRs. There were 30 different types of ADRs reported, headache being the most common. Among the drugs, heparin was the most common factor, causing 27 per cent of ADRs. Definite causality of a suspected drug causing ADRs was seen in 11.9 (n=8), nine (n=6) and 7.5 (n=5) per cent cases as per WHO-UMC, Naranjo (Naranjo algorithm) and Karch and Lasagna scales, respectively. In the severity of ADRs, the most severe reactions according to the modified Hartwig-Siegel scale (level 4a in our study) were seen in 17.5 (n=12) per cent of patients, and the rest were either level 2 or 3 reactions. Nearly 92.5 (n=62) per cent of reactions were predictable according to the Rawlins and Thompson criterion. Application of the modified Schumock-Thornton scale showed that 22.4 per cent of ACS patients had preventable reactions, and the rest were not preventable. Interpretation & conclusions: The study results suggest that ADRs are relatively common among ACS patients. Most of these can be identified and assessed for causality, severity, predictability and preventability using various available scales. Diligent pharmacovigilance for identifying and assessing ADRs may help manage and mitigate morbidity associated with these in high-risk ACS patients.

The Emergence of Artificial Intelligence in Cardiology: Current and Future Applications.

Artificial intelligence technology is emerging as a promising entity in cardiovascular medicine, potentially improving diagnosis and patient care. In this article, we review the literature on artificial intelligence and its utility in cardiology. We provide a detailed description of concepts of artificial intelligence tools like machine learning, deep learning, and cognitive computing. This review discusses the current evidence, application, prospects, and limitations of artificial intelligence in cardiology.

Large right-sided pneumothorax with Takotsubo cardiomyopathy.

Patients with left-sided pneumothorax presenting with electrocardiogram (ECG) changes resembling acute coronary syndrome (ACS) have been reported in the literature. Takotsubo cardiomyopathy (TCM) occurs predominantly in post-menopausal women with underlying intense emotional or physical stress. However, as this case report shows, it can complicate any acute illness leading to intense stress. We report a rare combination of ECG changes mimicking ACS in a man with a large right-sided pneumothorax and TCM.

The COVID-19 Pandemic Surge and Impact on Rheumatic Valvular Heart Disease Patient Care.

The COVID-19 crisis has surged worldwide, putting immense stress on the health care services, leading to institutions deferring elective procedures and struggling to triage the emergency care of cardiac patients. This has affected the management of the rheumatic valvular heart disease patients especially, in developing countries, potentially placing these patients at enormous risk for complications like congestive cardiac failure, stroke and death. This article explores the COVID-19 pandemic and its impact on rheumatic valvular heart disease patient care. We try to provide a framework that addresses the procedural considerations of interventions like percutaneous transluminal mitral commissurotomy (PTMC), mitral and aortic valve surgeries. This article also highlights the implications for the outpatient valve clinic, and safety issues of the patient and health care workers during this ongoing pandemic.

COVID-19 Pandemic and the Impact on the Cardiovascular Disease Patient Care.

The COVID-19 pandemic has emerged as a serious global threat causing a large number of fatalities and putting enormous strain on the health care resources across the world. This has resulted in preferentially triaging the coronavirus infected patients and placing others, especially cardiovascular patients at increased risk for adverse complications. The effective management of cardiac patients in the hospital environment during this COVID-19 pandemic has emerged as a real challenge. We try to address this issue and also highlight the interplay between COVID-19 and cardiovascular diseases. We hereby review the available literature and emerging guidelines about cardiovascular implications related to COVID-19 which will have a bearing on the patient care, health care professionals and cardiac centres.

Disseminated Actinomycosis Presenting as Chronic Right-Heart Failure Due to Right Ventricular and Pericardial Infiltration.

Actinomycosis is an indolent, slowly progressive bacterial infection prevalent in tropical countries, commonly affecting cervicofacial, thoracic, abdominal, or pelvic regions. With early diagnosis and appropriate therapy, the prognosis is excellent. However, late presentation and widespread dissemination can be fatal. This paper reports a rare case of disseminated actinomycosis with fatal cardiac involvement. (Level of Difficulty: Intermediate.).

Normal Proximal Coronary Artery Diameters in Adults from India as Assessed by Computed Tomography Angiography.

INTRODUCTION: The normative data of coronary artery size among Indians are sparse. It is often essential to know the coronary dimensions especially during interventions such as stenting to choose the appropriate size of the stent and to decide the very need for stenting. In current practice it is the luminal angiography which is most widely employed to assess the coronary artery size. However, luminal angiography is not very accurate in estimating the epicardial coronary artery size as it does not take into account the mural thickness of the arterial wall. Hence it is prudent to assess coronary artery size by other methods such as Computed Tomography (CT) coronary angiography, quantitative coronary angiogram, Magnetic Resonanace (MR) angiogram, etc. In this study we chose computed tomography as it demonstrates mural thickness along with lumen of the vessels and hence measures the diameter more accurately. AIM: To establish normative data for diameters of the proximal coronary artery segments during life by using MDCT in a cohort of individuals without any structural heart disease. MATERIALS AND METHODS: Between October 2012 and April 2013, 168 consecutive patients who did not have any structural heart disease underwent CT coronary angiography for evaluation of Coronary Artery Disease (CAD) with atypical symptoms with low pretest probability. Patients who were found to have no coronary artery disease on CT-CAG were recruited in this study. The baseline clinical status and demographic data were obtained from the hospital records. RESULTS: In our study we found that the mean indexed diameter to BSA among females for LMCA 2.32±0.12mm, LAD 1.95±0.15mm, LCX 1.73±0.20mm and RCA 1.84±0.22mm. For males the values were LMCA 2.33±0.13mm, LAD 1.94±0.16mm, LCX 1.74±0.21mm, and RCA 1.79±0.20mm. These values are comparable to other studies. CONCLUSION: We attempted to establish normative data for normal proximal coronary artery dimensions among South Indian population. Coronary artery dimensions in Indians (in-dexed to BSA) for proximal major epicardial coronary arteries are similar to that reported in the West.