Myocardial infarction with nonobstructive coronaries (MINOCA) following rabies postexposure prophylaxis: A case report.

Key Clinical Message: This case underscores the importance of considering myocardial infarction with nonobstructive coronary arteries (MINOCA) in patients experiencing acute chest pain following rabies vaccination, emphasizing the need for heightened awareness and further research into the association between MINOCA and Rabies vaccination. Abstract: Rabies is a vaccine-preventable deadly viral disease prevalent in Asia and Africa that causes thousands of deaths annually. Rabies pre (PrEP) and postexposure prophylaxis (PEP) is highly effective in annulling rabies-associated deaths. The adverse reactions following rabies vaccination are typically mild. Myocardial infarction with non-obstructive coronary arteries (MINOCA) is a rare condition, and its association with rabies vaccination is unprecedented. We present a case of a 43-year-old male with MINOCA following Rabies PEP. A 43-year-old male, nonsmoker and nonalcoholic, presented to the ER with complaints of acute onset left sided chest pain following the completion of the third dose of intradermal rabies vaccine, whose clinical features, ECG changes and lab reports were suggestive of acute presentation of inferior wall MI. Coronary angiography was performed, which however revealed normal coronaries with only slow flow being noted in the left anterior descending (LAD) artery. Echocardiography later showed a normal study with no other relevant diagnosis unveiled on further investigations. Hence a diagnosis of vaccine-induced MINOCA was made. Treatment included antiplatelet therapy, statins, and beta-blockers. MINOCA following rabies vaccination is an unprecedented finding. The clear etiology behind this couldn't be ascertained. The patient's treatment was conventional, emphasizing the need for further research and clinical trials in MINOCA diagnosis and management. This case highlights the need for clinicians to consider MINOCA in patients with acute chest pain post-rabies vaccination. Further research is essential to unravel the association between MINOCA and rabies vaccination, paving the way for optimal management strategies.

Percutaneous transluminal coronary angioplasty in a 52-year-old patient with porcelain aorta and calcified coronaries: A case report.

Porcelain aorta, characterized by extensive calcification of the aortic wall is often associated with coronary calcification. It can pose an increased risk of thromboembolic complications during interventional and surgical procedures. We present a case of a 52-year-old female, a chronic smoker with dyslipidemia with complaints of exertional chest pain for past 6 months. She was diagnosed as a case of non-ST elevation myocardial infarction (NSTEMI) with multivessel CAD, with porcelain aorta and calcified coronaries based on abnormal ECG, elevated troponin and coronary angiography findings. Percutaneous transluminal coronary angioplasty (PTCA) was the treatment modality chosen considering the risk of thromboembolism with aortic manipulation during coronary artery bypass grafting (CABG). Repeat ECG after the procedure showed resolution of ST segment depression. Her hospital stay was uneventful. She was discharged on dual antiplatelet therapy, statin and metoprolol. One-week follow-up revealed normal ECG and blood reports, with further outpatient department visits scheduled every 3 months. Porcelain aorta and coronary calcification is a challenging case for cardiologists. PTCA if done meticulously could be preferable to coronary-artery by-pass grafting (CABG) in such patients. Despite the risks like aortic rupture and thromboembolic complications, PTCA in a case of multivessel CAD with porcelain aorta and calcified coronaries could be a life-saving procedure.

Effect of ABCA1-R219K Polymorphism in Serum Lipid Parameters in Patients under Statin Therapy Visiting Tertiary Cardiac Center of Nepal.

Introduction ATP-binding cassette transporter A1 (ABCA1) encoded by ABCA1 gene is one of the important protein involved in lipid metabolism. The effect of statin therapy on dyslipidemia varies among individuals and it may be due to different genetic polymorphism. The R219K polymorphism of ABCA1 gene is found to have a significant role in the response of statin. Objective This study was designed to evaluate the effect of R219K polymorphism in lipid-lowering action of statin in patients with dyslipidemia. Material and Methods This study was conducted in 88 patients. Blood samples were taken from patients before and at the end of 3 months of statin use and were analyzed for lipid profile. Whole blood was analyzed for R219K Polymorphism using polymerase chain reaction-restriction fragment length polymorphism. Results R219K polymorphism was associated with significant percentage reduction of serum triglyceride/high-density lipoprotein (TG/HDL) ratio and total cholesterol/high-density lipoprotein (TC/HDL) ratio in atorvastatin users. However, there was no significant association of polymorphism with change in serum TC, HDL-C, LDL-C, TG, and very low-density lipoprotein (VLDL). Among KK genotype individuals, value of TG, VLDL, TG/HDL, and TC/HDL were significantly lower than in RR genotypes. Also, TG/HDL and TC/HDL were significantly lower in RK genotype than in RR. Treatment of dyslipidemia with statin was found to be comparatively better in patients having the genotypes KK and RK. Conclusion Our study demonstrated association of R219K polymorphism with the significant reduction of TG/HDL and TC/HDL and particularly the KK genotype was associated with significant improvement of lipid parameters following atorvastatin treatment.

Arrhythmias: Its Occurrence, Risk Factors, Therapy, and Prognosis in Acute Coronary Syndrome.

BACKGROUND: Patients with acute coronary syndrome may lead to various metabolic and electrophysiological changes that induce both asymptomatic and symptomatic life-threatening arrhythmias, which increases morbidity and mortality. METHODS: This observational retrospective study was conducted at Manmohan Cardiothoracic Vascular and Transplant Center, Institute of Medicine, Maharajgunj, Kathmandu, Nepal. Three hundred ninety-five patients with a diagnosis of acute coronary syndrome were enrolled in the study. RESULTS: A total of 395 patients were included in the study with a mean age of patients 61.29± 13.5 years and with male predominance. A total number of 115 cases of arrhythmia were recorded among which the most common were atrioventricular block (10%), reperfusion arrhythmia (9.6%) followed by ventricular premature complex (8%), atrial fibrillation/flutter (6%), and ventricular tachycardia/fibrillation (5%). There was a significant difference in the incidence of arrhythmia in acute coronary syndrome group. STEMI (39.7%), NSTEMI 26(20.8%) and unstable angina11(14.8%) respectively (p=<0.001). Reperfusion arrhythmia was present in 89.47% of STEMI and 10.4 % of NSTEMI/ unstable angina and was statistically significant (p-value <0.001). A total of three patients (0.7%) needed permanent pacemaker insertion in the acute coronary syndrome group. All of these patients were STEMI which was 1.5% of total STEMI, two in inferior wall STEMI (2.6%) and 1 in anterior wall STEMI (0.8%). The total in-hospital mortality was 20 (5.06%), 17(8.6%) among STEMI and 3(2.4%) among NSTEMI, and none in unstable angina (P =<0.001). Pulmonary edema (12.9%) was the most common in-hospital outcome followed by cardiac arrest (7.6%). CONCLUSIONS: Arrhythmia in acute coronary syndrome is a common problem and may lead to structural and functional impairment of myocardial function.

Occluded Coronary Artery among Non-ST Elevation Myocardial Infarction Patients in Department of Cardiology of a Tertiary Care Centre: A Descriptive Cross-sectional Study.

Introduction: Non-ST elevation myocardial infarction is frequently thought to be caused by incomplete blockage of the culprit artery, whereas ST elevation myocardial infarction is frequently thought to be caused by total occlusion of the culprit artery. The objective of the study was to find out the prevalence of occluded coronary arteries among non-ST elevation myocardial infarction patients department of cardiology of a tertiary care centre. Methods: A descriptive cross-sectional study was conducted among non-ST elevation myocardial infarction patients in a tertiary care centre from 22 June 2020 to 21 June 2021 after taking ethical approval from the Institutional Review Committee [Reference number: 4271 (6-11) E2 076/077]. A total of 196 patients were included in the study by simple randomized sampling. Data on the patient's clinical profile, angiographic findings, and in-hospital complications were recorded. Point estimate and 95% Confidence Interval were calculated. Results: Among 126 non-ST elevation myocardial infarction patients included in the study, the prevalence of occluded coronary artery was 41 (32.54%) (24.36-40.72, 95% Confidence Interval). Conclusions: The prevalence of occluded coronary arteries was similar to the studies done in similar settings. Keywords: coronary angiography; MINOCA; Non-ST elevation myocardial infarction.

A Rare Coexistence of Simultaneous Cardio-Cerebral Infarction.

Background: Contemporaneous acute myocardial infarction (AMI) and acute ischemic stroke (AIS), termed cardio-cerebral infarction (CCI), is a rare medical emergency. The effectual management of this situation is exigent since early management of one condition will inevitably delay the other. Case Presentation. A 60-year-old woman presented to our hospital with concurrent AMI of the inferior left ventricular wall, complicated by cardiogenic shock and transient complete heart block, and AIS of more than 4.5 hour duration. The cerebral computerized tomography angiography revealed a right-sided terminal internal carotid artery (ICA) occlusion, and the coronary angiogram depicted double vessel disease with a culprit lesion in the right coronary artery (RCA). The patient underwent mechanical thrombectomy for the ICA occlusion by an interventional neuroradiologist followed by the primary percutaneous coronary intervention of the culprit RCA by the interventional cardiologists in the same setting. Conclusion: A patient with concurrent AMI and AIS is a challenging situation to treat in the emergency department, and the treatment must be individualized for each patient.

Prevalence of Myocardial Bridging in Angiography Study.

BACKGROUND: Myocardial bridging is a congenital anomaly in which a segment of epicardial coronary artery takes an intramyocardial course, the systolic compression of which could be asymptomatic or may lead to major hemodynamic changes such as myocardial ischemia, arrhythmias or sudden cardiac death. The prevalence is highly variable depending upon different investigational modalities to diagnose it. Here we have aimed to study the prevalence through invasive coronary angiography. METHODS: This retrospective study was carried out at Manmohan Cardiothoracic Vascular and Transplant center, Kathmandu, Nepal. The invasive coronary angiography of 5096 patients were studied from March 2018 to April 2021 done for various indications. RESULTS: Among all the patients, the myocardial bridging was identified in 257 (5.04%) patients. About 177 (68.9%) were males and 80 (31.1%) were females. The mean age of the patients having myocardial bridging was 54.52 ± 10.31years. Diabetes mellitus was found in 33(12.8%) and hypertension was found in 77(29.9%) patients with myocardial bridging. Stable angina (29.2%) was the most common clinical presentation. Treadmill test was positive in about 70 (27.2%) patients. Majority of patients had myocardial bridge in left anterior descending artery alone (89.9%) and located mostly in mid-part (74.9%). CONCLUSIONS: The myocardial bridging is not an uncommon finding on invasive coronary angiography in middle aged people who present with typical angina.

Risk Factors of Coronary Artery Disease: A Hospital-Based Study.

BACKGROUND: Coronary artery disease is among the leading cause of morbidity and mortality worldwide. There are limited scientific evidence on the risk factors for coronary artery disease specific to the Nepalese context. This study aimed to determine the association of various modifiable cardiovascular risk factors with coronary artery disease in Nepal. METHODS: It is a hospital-based case-control study conducted among 300 participants. Case group comprised of 150 newly diagnosed coronary artery disease patients attending Manmohan Cardiothoracic Vascular and Transplant Centre while the Age and sex matched non-cardiac patients (n=150) from the outpatient department of the Department of General Practice and Emergency Medicine of Tribhuvan University Teaching Hospital were recruited as controls. Adjusted odds ratios (AOR) were calculated using multivariable logistic regression. RESULTS: Of the 300 participants, 208 (69.3%) were males and 92 (30.7%) were females. The mean age was 59.8 years ± 11 years (standard deviation). In multivariable analysis, current smoking (AOR=3.05, 95% CI: 1.61-5.78), hypertension (AOR=1.82, 95% CI: 1.08-3.09), diabetes (AOR=3.78, 95% CI: 1.91-7.47), family history of coronary artery disease (AOR=2.92, 95% CI: 1.27-6.71), and low high density lipoprotein (AOR= 2.0, 95% CI: 1.17-3.42) were significantly associated with coronary artery disease. Current alcohol use (AOR=0.51, 95% CI: 0.29-0.89) was identified as a protective factor for coronary artery disease. CONCLUSIONS: Among the modifiable cardiovascular risk factors, smoking, hypertension, diabetes, and low level of high density lipoprotein were significantly associated with coronary artery disease, which should be considered while developing public health interventions for cardiovascular disease prevention in Nepal in future.

A study of Clinical Profile and in Hospital Outcomes of patients undergoing Percutaneous Transvenous Mitral Commissurotomy at a Tertiary Care Center of Nepal.

Introduction: Rheumatic heart disease (RHD), is a common cause of mitral stenosis (MS) in developing nations. As per current recommendation, Percutaneous Transvenous Mitral Commissurotomy (PTMC) is advised as a Class IA (I-Class Of Recommendation, COR; A-Level Of Evidence, LOE) indication in patients with symptomatic severe mitral stenosis. We aim to examine the clinical profile and in-hospital results of PTMC for mitral stenosis. Methods: A cross-sectional retrospective study was conducted at Manmohan Cardiothoracic Vascular and Transplant Center from April 2020 to May 2022. A structured questionnaire was used to collect the data and ethical approval for conducting the study was taken from the Institutional Review Committee (IRC) of Institute of Medicine (IOM). The data was collected in Microsoft Excel (Ver. 2013). For statistical analysis, SPSS 21 (IBM Corp. Released 2012. IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp.) Association was measured using a parametric and non-parametric test (depending upon the distribution of data) and p value < 0.05 was considered significant. Results: A total of 104 patients who met the inclusion criteria underwent PTMC during the study period. The mean age group of the patient was 41.7 ± 12.5 years, of which 23 (22.1%) were males and 81 (78.9%) were females. Mean mitral valve area prior to PTMC was 0.98 ± 0.19 mm2 that increased to 1.69 ± 0.19 mm2 after the procedure and it was statistically significant (p=<0.001). The post PTMC MVA varied with PTMC Wilkin's score with less than or equal to 8 having favorable outcomes. Conclusion: Successful PTMC is highly influenced by the patients' increasing age, valve morphology (calcification, thickness, mobility), Left atrial dimensions, Pre PTMC mitral valve area, Degree of Baseline mitral regurgitation. Post procedure development of MR is usually well tolerated but rarely be severe enough requiring surgical valve replacement.

Anterior wall STEMI in a patient with paroxysmal atrial fibrillation due to coronary embolism: A case report.

Introduction: Coronary embolism (CE) is a rare cause of acute ST-elevation myocardial infarction (STEMI). Atrial fibrillation (AF), left ventricular thrombus, septic emboli from infective endocarditis, myxoma, and paradoxical embolism can induce emboli in coronary arteries. Case presentation: Here we present a case of anterior wall STEMI secondary to paroxysmal AF in a 60-years-old female with a previous history of right-sided ischemic stroke. Discussion: The major criteria for diagnosis of coronary embolism include (1) non-atherosclerotic wall of coronary vessels under angiography; (2) concomitant involvement of multiple sites; (3) histological proof of venous thrombus; (4) imaging by echocardiography/CT/MRI showing intra-cardiac thrombus. The minor criteria include (1) <25% stenosis of other vessels supplying to infarct-free myocardium; (2) atrial fibrillation history; (3) risk factors like (prosthetic valve, bacterial endocarditis, patent foramen ovale, atrial septal defect, dilated cardiomyopathy). Conclusion: Our case highlights the importance of cardiac embolus as a diagnosis in a patient with a history of stroke secondary to atrial fibrillation as a cause of acute STEMI and its management.

A rare case of atrial and biventricular thrombi with dilated cardiomyopathy as a delayed presentation in a patient with COVID-19.

Introduction: Coronavirus 2019 (COVID-19) can cause cardiovascular manifestations including myocardial injury and thromboembolic events. Case presentation: Here, we report a case of a 27-year-old female with dilated cardiomyopathy, right atrial and biventricular thrombi infected with COVID-19. Discussion: There are several complex coagulation abnormalities in COVID-19 patients that have been suggested to create a hypercoagulable state. Evidence have shown that endothelial injury potentially leading to thromboembolic events is caused by direct invasion of endothelial cell by SARS-CoV-2 and complement activation contributed by the virus spike protein. Conclusion: DCM can be complicated by atrial and biventricular thrombi due to coagulation abnormalities that are likely to persist after recovery from COVID-19. Thus, long-term careful monitoring of cardiac function is necessary after recovery of COVID-19.

Echocardiographic Findings in Patients with Atrial Fibrillation in a Tertiary Care Center of Nepal: A Descriptive Cross-sectional Study.

INTRODUCTION: Atrial fibrillation is the most prevalent supraventricular arrhythmia responsible for the large morbidity and mortality burden worldwide. There are various causes of atrial fibrillation that may affect the prognosis of patients. This study was intended to determine different echocardiographic findings in patients with atrial fibrillation in a tertiary care center. METHODS: A descriptive cross-sectional study was conducted at Manmohan Cardiothoracic Vascular and Transplant Center, Institute of Medicine, among 175 patients with atrial fibrillation admitted in the cardiology department from June 2017 to October 2018. It was approved by the Institutional Review Board of the Institute of Medicine (Ref.:411(6-11-E)2/073/074). Convenience sampling was used. Statistical analysis was done using Statistical Package for Social Sciences version 21.0. RESULTS: A total of 175 patients with atrial fibrillation were enrolled where Rheumatic heart disease 68 (38.9%) was the leading cause in which 54 (79.4%) had mitral valve lesion, 1 (1.5%) had aortic valve lesion and rest had a combination of both. The mixed lesion of mitral stenosis and mitral regurgitation was the commonest. The left atrium size was larger in valvular atrial fibrillation (47.296±651mm). The left ventricular systolic dysfunction was seen more in non-valvular atrial fibrillation. The commonest site of thrombus formation was left atrium 7 (63.6%). CONCLUSIONS: Atrial fibrillation was common in rheumatic heart disease, especially mixed lesions of mitral stenosis and regurgitation. Valvular atrial fibrillation had a larger left atrium. The thrombus was seen in mitral stenosis and left ventricular systolic dysfunction. The left atrium size and left ventricular ejection fraction were associated with the occurrence of atrial fibrillation.

A Patient Infected with SARS-CoV-2 Presenting with Complete Heart Block.

Complete heart block is a rare presentation in a patient with COVID-19 infection that may result when the virus enters the myocardial cell by the angiotensin-converting enzyme-2 receptor. Here, we report a case of forty-nine-year male with COVID-19 with complete heart block (CHB).

Correction to: Atrial myxoma with cerebellar signs: a case report.

In the publication of this article [1], there is an error in the name of one of the contributing authors.

Atrial myxoma with cerebellar signs: a case report.

BACKGROUND: Atrial myxoma remains a rare clinical entity with an incidence of surgically resected cases of 0.5-0.7 per million population and prevalence of < 5 per 10,000. It typically manifests in woman after third decade of life; symptoms vary greatly and may present with arrhythmia, intracardiac flow obstruction, embolic phenomenon, and associated constitutional symptoms. Neurological complications associated with atrial myxoma most frequently include cerebral infarct due to embolus. Cerebellar involvement is very rare and only a few cases have been reported in the literature. CASE PRESENTATION: A 55-year-old Brahmin man with no history of diabetes mellitus and hypertension, presented with complaints of dizziness, headache, vomiting, double vision, and unsteadiness of gait for 2 weeks. His headache was sudden in onset, of a pulsating type and localized on left temporal side. Vomiting was projectile and bilious. Double vision was present in all directions of gaze and he had uncoordinated movement of his body and tilting to the left side. On examination, his cerebellar functions were impaired. He was thoroughly investigated for the cause of stroke after abnormal magnetic resonance imaging results with normal computed tomography angiography of his brain. Echocardiography and computed tomography of his chest showed a mass attached to intra-atrial septum and prolapsing through mitral valve, which was suggestive of left atrial myxoma. Five days following admission, he developed abdominal pain due to thromboembolism causing splenic and renal infarct. CONCLUSION: Although rare, atrial myxoma has to be considered a cause of stroke and other embolic phenomenon causing multiorgan infarctions. Early and timely diagnosis of the condition can prevent further recurrence and inappropriate anticoagulant therapy. It would be pertinent to have echocardiography done in patients who present with a stroke, arrhythmias, and other constitutional symptoms. The tumor once detected must be removed surgically as early as possible, which not only reduces serious thromboembolic complications but can be potentially curative.