Positive QRS complex in limb lead 2 with negative QRS in lead 3 on surface electrocardiogram: A novel predictor for anterior location of right-sided accessory pathways (10-1 o'clock on tricuspid annulus).

BACKGROUND: Localization of atrioventricular accessory pathways (AP) from Electrocardiogram (ECG) is crucial for successful ablation. We analyzed the value of limb lead 2 versus 3 QRS vector discordance on surface ECG among right-sided pathways. METHODS: Data from consecutive patients undergoing successful ablation of manifest AP were analyzed. They were categorized into two groups-Gr I: Endocardial ablation from anterior and anterolateral tricuspid annulus (TA, 10-1 o'clock, right anterolateral [RAL]); Gr II: Ablation outside this region (1-10 o'clock of TA). Inferior lead discordance (ILD) was defined as positive QRS complex (monophasic R, Rs) in lead 2 with negative/equiphasic QRS vector in lead 3 (rS, S, RS). Maximally pre-excited ECGs during electrophysiology study were compared for presence of ILD. RESULT: Among total 22 cases (Age 36 ± 18 years, 12 males), ILD was noted in 4/4 cases of Gr I. It was absent among 17/18 cases of right-sided AP in Gr II. The only case in Gr II having ILD was ablated near 8 o'clock (posterolateral). In contrast to the other four cases, aVF was negative, along with lead 3. A close differential was mid-septal AP (MSAP). However, the MSAP had absence of r in V1 and lead 2 having rS/RS complex in contrast to strongly positive QRS in RAL pathways. The sensitivity and specificity of ILD for RAL are 100% and 95%, respectively. The positive, negative predictive value, and accuracy are 80%, 100%, and 95%, respectively. CONCLUSION: Positive QRS complex in lead 2 with negative QRS in lead 3 in maximally pre-excited ECG is often predictive of anterior and anterolateral location among right-sided pathways.

Impact of COVID-19 on heart failure hospitalization and outcome in India - A cardiological society of India study (CSI-HF in COVID 19 times study - "The COVID C-HF study").

OBJECTIVES: The presentation and outcomes of acute decompensated heart failure (ADHF) during COVID times (June 2020 to Dec 2020) were compared with the historical control during the same period in 2019. METHODS: Data of 4806 consecutive patients of acute HF admitted in 22 centres in the country were collected during this period. The admission patterns, aetiology, outcomes, prescription of guideline-directed medical therapy (GDMT) and interventions were analysed in this retrospective study. RESULTS: Admissions for acute heart failure during the pandemic period in 2020 decreased by 20% compared to the corresponding six-month period in 2019, with numbers dropping from 2675 to 2131. However, no difference in the epidemiology was seen. The mean age of presentation in 2019 was 61.75 (±13.7) years, and 59.97 (±14.6) years in 2020. There was a significant decrease in the mean age of presentation (p = 0.001). Also. the proportion of male patients decreased significantly from 68.67% to 65.84% (p = 0.037). The in-hospital mortality for acute heart failure did not differ significantly between 2019 and 2020 (4.19% and 4.,97%) respectively (p = 0.19). The proportion of patients with HFrEF did not change in 2020 compared to 2019 (76.82% vs 75.74%, respectively). The average duration of hospital stay was 6.5 days. CONCLUSION: The outcomes of ADHF patients admitted during the Covid pandemic did not differ significantly. The length of hospital stay remained the same. The study highlighted the sub-optimal use of GDMT, though slightly improving over the last few years.

An Unusual Genetic Observation in a Case of Short-Coupled PVC-Triggered Ventricular Fibrillation.

Ventricular fibrillation induced by short-coupled premature ventricular complex is an uncommon cause of cardiac arrest in young individuals with no structural heart disease. The genetic substrate of this condition is heterogeneous and remains incompletely defined. We describe a case of short-coupled premature ventricular complex-triggered ventricular fibrillation with a likely pathogenic variant in the titin (TTN) gene. (Level of Difficulty: Advanced.).

Endothelial nitric oxide synthase gene haplotypes and circulating nitric oxide levels significantly associate with risk of essential hypertension.

Nitric oxide (NO), a potent vasodilator, plays a pivotal role in blood pressure regulation. Endothelial NO synthase gene (NOS3) polymorphisms influence NO levels. Here, we investigated the role of the -922A/G, -786T/C, 4b/4a, and 894G/T polymorphisms of the NOS3 and NO(x) levels in 800 consecutive unrelated subjects comprising 455 patients of essential hypertension and 345 controls. The polymorphisms were investigated independently and as haplotypes. Plasma NO(x) levels (nitrate and nitrite) were estimated by the Griess method. Genotype frequencies for the -786T/C, 4b/4a, and 894G/T polymorphisms differed significantly (P<0.001) between patients and controls and were associated with an increased risk of hypertension (OR=2.0, OR=3.8, OR=1.6, respectively). The 4-locus haplotypes ATaG (H1), ATaT (H2), and GCaG (H3) were significantly associated with essential hypertension and served as susceptible haplotypes (P

Lung ultrasound evaluation of diabetic patients with acute onset dyspnea and its relationship with established markers of heart failure.

OBJECTIVE: The aim of the study was to assess the interrelation between sonographic pleural B-Line, left ventricular function and Naturetic Peptides in type 2 Diabetics with acute onset class III-IV dyspnea. There is dearth of data in this subset of patients in Asian population. METHODS: Subjects (n=73) were divided into those with pleural B line (Group A, n=41) and those without (Group B) and their serum B type Naturetic Peptide (BNP) and Echocardiography evaluated. RESULTS: The serum BNP was significantly higher and mean Left Ventricular Ejection Fraction (LVEF) lower in Group A compared to Group B (p<0.001). There was a significant negative correlation between LVEF and BNP and positive correlation between E/E' and BNP. Among patients with LVEF 40% and above (n=36), patients with B line had significantly higher BNP and E/E' compared to those without. Group A had significantly more patients on insulin therapy and troponin positivity than Group B (p<0.01). On auscultation though crepitations was found more frequently in group A but it was present in only 50% of the subset. CONCLUSION: Pleural B-Lines, LVEF and mitral inflow E/septal E' can be used to rule in heart failure in the above population.

Acute demyelinating encephalitis after jequirity pea ingestion (Abrus precatorius).

INTRODUCTION: Castor and jequirity beans are uncommon causes of poisoning. The more common but less severe castor poisoning is well described, but jequirity bean (Abrus Precatorius) poisoning is rare. The toxicity is attributed to toxalbumins (ricin and abrin) that act by inhibiting protein synthesis. Their use as agents of biological warfare, mechanisms of action, and clinical features of poisoning are summarized. CASE REPORT: A 30-year-old previously healthy female presented with bloody diarrhea and deep coma following ingestion of 3-4 seeds of a plant called 'ratti.' Investigations, including an MRI brain scan, showed evidence of acute demyelinating encephalitis. The patient died three days later due to progressive central nervous system depression. DISCUSSION: This is a previously unreported manifestation of jequirity bean poisoning. Demyelination is immune-mediated, and Abrus is a well-known immuno-modulator and stimulator. A possible immunological pathogenic mechanism is hypothesized.

ß-T594M epithelial sodium channel gene polymorphism and essential hypertension in individuals of Indo-Aryan ancestry in Northern India.

BACKGROUND: The T594M variant of the ß-subunit of the sodium epithelial channel (ENaC) gene may contribute to hypertension in individuals of Indo-Aryan origin. METHODS: Present study was performed to assess the role of the ENaC gene variant as an independent risk factor for hypertension in subjects of Indo-Aryan ancestry. A total of 150 patients of recently detected essential hypertension and 150 matched controls were genotyped for the T594M polymorphism of the ENaC gene by PCR-RFLP method. RESULTS: ß-T594M mutation was found to be non-polymorphic. There was major genotype call in both the groups i.e. cases and controls. Other phenotypic parameters like age, sex and body mass index were also similar among hypertensive patients and controls (P > 0.05). Hypertensive patients had significantly higher total cholesterol and triglycerides compared with controls (P < 0.0001). CONCLUSION: These results do not suggest an important role for the T594M variant of the ENaC gene contributing to either the development or severity of hypertension in subjects of Indo-Aryan ancestry.

Psoriatic nephropathy--does an entity exist?

Psoriasis is an immune-mediated chronic inflammatory disorder of the skin. Association with kidney disease has been debated for a long time. Secondary renal amyloidosis in psoriatic arthropathy and drug-induced renal lesions secondary to methotrexate or cyclosporine are accepted accompaniments of psoriasis. IgA nephropathy is also known to occur in psoriatics. We report three interesting cases of renal involvement in long-standing established psoriasis on topical therapy alone. The patients presented with hypertension, significant proteinuria, hypoalbuminemia, and dyslipidemia. Kidney biopsies revealed "mesangioproliferative glomerulonephritis with IgA nephropathy," "focal proliferative glomerulonephritis," and "membranous glomerulonephropathy." The former two had marked active urinary sediment. Patients improved on prednisolone and angiotensin-converting enzyme inhibitors. Contrary to the belief that renal involvement in psoriasis is coincidental, we propose that kidney disease may be a common accompaniment of psoriasis, which may be labeled as "psoriatic nephropathy" or "psoriatic kidney disease." The exact mechanism of this entity is yet to be elucidated.