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OBJECTIVES: To study the safety of stent avoidance, frequency of change in management decisions, and its cost implications while using a fractional flow reserve (FFR)-guided treatment strategy for intermediate-grade coronary artery stenosis. BACKGROUND: The impact of FFR in guiding management decisions and its cost implications has not been studied after imposition of a ceiling on stent prices by the Government of India. METHODS: In 400 patients with 477 intermediate-grade coronary lesions for whom coronary intervention was planned, functional assessment using FFR was done. Incidence of the primary composite endpoint (major adverse cardiac event [MACE], cardiac death, myocardial infarction, objective evidence of ischemia, and target vessel revascularization) in the stent avoided subset was compared with the stented group at follow-up. Micro-costing analysis was done using a computed model with current stent and FFR wire prices. RESULTS: The overall incidence of MACE was 4.9%, 0.9% in the stent-avoided subset and 6.9% in stented group (p = 0.04, comparing the latter two) at a median follow-up of 21 months (interquartile range 12-31 months). Serious adverse events occurred only in 1% of patients receiving adenosine. The average cost saving was Indian rupees (INR) 51,847 [United States Dollar (USD) 746] per patient, resulting in total savings of INR 15,813,379 (USD 227,530). Cost savings persisted but were lower by 36% (INR 18,613/USD 268 per patient) after the ceiling of stent prices. CONCLUSION: FFR-guided percutaneous coronary intervention (PCI) strategy is safe and cost-effective in countries where majority of patients self-finance their health care, resulting in stent and PCI avoidance in approximately one in three patients referred for coronary angioplasty.
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Enfermedad de la Arteria Coronaria , Estenosis Coronaria , Reserva del Flujo Fraccional Miocárdico , Intervención Coronaria Percutánea , Angiografía Coronaria , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Enfermedad de la Arteria Coronaria/terapia , Estenosis Coronaria/diagnóstico por imagen , Estenosis Coronaria/terapia , Humanos , Intervención Coronaria Percutánea/efectos adversos , Resultado del TratamientoRESUMEN
BACKGROUND: Type D personality has been linked to negative outcomes following acute myocardial infarction (AMI). Our objective was to determine the factor structure, reliability, and validity of the Type D personality construct among people with AMI in the Indian clinical setting. MATERIALS AND METHODS: In a cross-sectional study conducted between August 2016 and July 2017, 200 consecutive patients with AMI admitted to a tertiary care center completed the Tamil version of the Type D scale-14 (DS-14). The Eysenck Personality Questionnaire Revised-Short Form (EPQR-S) was also administered to check the convergent/divergent validity. RESULTS: The prevalence of Type D personality was 24%. Results of the principal components analysis revealed a four-factor solution for the Tamil version of the DS-14 which explained more than 75% of the variability. Strong convergent validity with the neuroticism subscale of EPQR-S (r = 0.84, P < 0.001) and divergent validity with the extraversion subscale (r = -0.75, P < 0.001) was noted. The two subscales of the Type D scale, negative affectivity and social inhibition (SI), demonstrated good reliability (Cronbach's alpha of 0.85 and 0.76, respectively). Dropping item no 14 from the DS-14 led to significant increase in internal consistency (Cronbach's alpha 0.81) for the SI subconstruct. CONCLUSION: Among an Indian Tamil-speaking clinical sample of patients with AMI, Type D is a valid construct and can be assessed using the regional version of the DS-14 which showed a four-factor structure and good psychometric properties. Item no. 14 of the DS-14 scale may need modification for the Indian setting.
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Double-chambered left ventricle is a rare cardiac anomaly. We report a case of double-chambered left ventricle in a one-and-half-year-old asymptomatic boy. We depict the use of three-dimensional echocardiography in the demonstration and diagnosis of the condition.
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Cardiopatías Congénitas/diagnóstico por imagen , Cardiopatías Congénitas/fisiopatología , Ventrículos Cardíacos/anomalías , Ventrículos Cardíacos/diagnóstico por imagen , Ecocardiografía Doppler en Color , Ecocardiografía Tridimensional , Humanos , Lactante , Imagen por Resonancia Magnética , MasculinoRESUMEN
Pulmonary hypertension (PH) is a relatively commoner complication of systemic sclerosis (SSc) with estimated prevalence ranging between 8% and 12% as compared to much lower figures in other connective tissue diseases (CTD). It is a major cause of morbidity and mortality in CTDs. PH is classified into five major groups. CTD-associated PH belongs to group 1 PH, also known as pulmonary arterial hypertension (PAH). Around 30% of scleroderma-related deaths are due to PAH. Underlying pathogenesis is related to pulmonary vasculopathy involving small vessels. The Evidence-based Detection of Pulmonary Arterial Hypertension in Systemic sclerosis (DETECT) algorithm outperforms the current European Society of Cardiology/European Respiratory Society guidelines as a screening tool in SSc-PAH; it can, therefore, suggest when to refer a patient for right heart catheterization. CTD-PAH patients constitute at least 20% of patients included in all major trials of PH-specific therapy and the results are comparable to those of idiopathic PAH. The role of anticoagulation in CTD-PAH is associated with a high risk-benefit ratio with the caveat of its potential role in those with severe disease. There appears to be no role of immunosuppression in scleroderma-PAH; however, immunosuppressive agents, namely the combination of glucocorticoids and pulse cyclophosphamide / possibly mycophenolate, may result in clinical improvement in a subset of patients with systemic lupus erythematosus and mixed connective tissue disease-related PAH.
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Enfermedades del Tejido Conjuntivo , Hipertensión Pulmonar , Anticoagulantes/uso terapéutico , Antihipertensivos/uso terapéutico , Presión Arterial , Cateterismo Cardíaco , Enfermedades del Tejido Conjuntivo/diagnóstico , Enfermedades del Tejido Conjuntivo/tratamiento farmacológico , Enfermedades del Tejido Conjuntivo/mortalidad , Enfermedades del Tejido Conjuntivo/fisiopatología , Quimioterapia Combinada , Ecocardiografía , Humanos , Hipertensión Pulmonar/diagnóstico , Hipertensión Pulmonar/tratamiento farmacológico , Hipertensión Pulmonar/mortalidad , Hipertensión Pulmonar/fisiopatología , Inmunosupresores/uso terapéutico , Valor Predictivo de las Pruebas , Pruebas de Función Respiratoria , Factores de Riesgo , Resultado del Tratamiento , Función Ventricular DerechaRESUMEN
We describe the case of a 27-year-old gentleman who developed late-onset clubbing and cyanosis. Transoesophageal echocardiography revealed a 27-mm ostium secundum atrial septal defect and a large, floppy Eustachian valve directing right atrial blood to the left side of the heart.