Association between Lipoprotein(a) concentration and adverse cardiac events in patients with coronary artery disease: An observational cohort study.

This prospective study investigated the association between lipoprotein (a) [Lp(a)] levels and adverse cardiac events in patients undergoing percutaneous coronary intervention (PCI) for coronary artery disease. Among 600 patients, 79.16 % were male. Kaplan Meier analysis revealed significantly higher incidence rates of cardiac death, major adverse cardiac events, myocardial infarction, revascularization and stroke in patients with elevated Lp(a) (≥30 mg/dL). The Cox Regression model identified Lp(a) ≥30 mg/dL as a significant risk factor for adverse events (HR: 4.2920; 95%CI: 2.58-7.120; p < 0.05). Elevated Lp(a) levels were associated with an increased risk of adverse cardiac events in coronary artery disease patients undergoing PCI.

Confounding Factors Responsible for Elevated Lp(a) Levels in Patients with Coronary Artery Disease.

BACKGROUND: Cardiovascular diseases (CVDs) are a leading cause of global mortality, motivating research into novel approaches for their management. Lipoprotein(a) (Lp(a)), a unique lipoprotein particle, has been implicated in atherosclerosis and thrombosis, suggesting its potential as a therapeutic target for CVDs. AIM: This study aimed to investigate the association of Lp(a) levels with various cardiovascular parameters and events among patients with confirmed cardiovascular disease. METHODOLOGY: A prospective study was conducted, enrolling 600 participants, predominantly comprising males (79%), with a mean age of 52.78 ± 0.412 years diagnosed with cardiovascular disease. The follow-up was done for 18 months. Patient demographics, blood investigations, and occurrence of major adverse cardiac events (MACE) were collected. SPSS version 21 was used to statistically analyze the relationships between elevated Lp(a) levels and factors such as age, glycated hemoglobin, mortality, MACE, cardiac death, target vessel revascularization, and stroke. RESULTS: The study revealed significant (P < 0.05) associations between elevated Lp(a) levels and advanced age, increased glycated hemoglobin levels, as well as occurrences of all-cause mortality, MACE, cardiac death, target vessel revascularization, and stroke. Notably, a significant (P < 0.05), association between high Lp(a) levels and acute coronary syndrome (ACS) emerged, suggesting Lp(a)'s role in advanced cardiac events. CONCLUSION: The findings highlight the potential significance of Lp(a) as a notable risk factor in cardiovascular health. The observed associations between elevated Lp(a) and adverse cardiovascular events, including ACS, underscore its pathogenic role. Consequently, this study supports the rationale for further research into Lp(a)-specific therapeutic interventions, offering substantial promise in refining the management strategies for cardiovascular diseases.

Takotsubo cardiomyopathy in India and its electrocardiography (ECG) comparison to myocardial infarction.

BACKGROUND: Owing to the limited research on Takotsubo Cardiomyopathy (TCM) in Asia, we aim to evaluate in detail the clinical profiles, lab parameters, investigations, and major adverse cardiovascular events (MACE) seen in patients with TCM in the Indian subcontinent. Additionally, we have compared the electrocardiographic findings of patients with TCM to those of patients with myocardial infarction (MI). RESULTS: The average age of the patients affected was found to be 60 ± 11 years. Women (87.5%) and patients with hypertension (40%) were found to be at an increased risk of developing the syndrome. The most common presenting symptom was dyspnea (48%) following a trigger most commonly emotional (45%). ST elevation and significant T wave inversions were observed in 40% of patients with TCM. Echocardiography revealed a low left ventricular ejection fraction of 43 ± 9%. Coronary angiography was normal in 60%, the rest had mild/subcritical stenoses. The 6-month MACE was 20% and the mortality rate was 7.5%. Follow-up echocardiography of patients with TCM showed improvement in EF in 75% patients. CONCLUSIONS: TCM was majorly seen in postmenopausal women following an emotional trigger, but a variety of other triggers were noted. T-wave inversions in TCM follow a diffuse pattern in contrast to specific leads seen in MI. Normal or subcritical stenosis in coronaries at presentation, along with a low EF which improves on follow up provide greater evidence for the diagnosis of TCM.

A Novel TPM1 Mutation Causes Familial Hypertrophic Cardiomyopathy in an Indian Family: Genetic and Clinical Correlation.

Hypertrophic cardiomyopathy (HCM) is a common inherited cardiac disorder characterised by unexplained left ventricular hypertrophy in the absence of abnormal loading conditions. The global prevalence of HCM is estimated to be 1 in 250 in the general population. It is caused due to mutations in genes coding for sarcomeric proteins. α-tropomyosin (TPM1) is an important protein in the sarcomeric thin filament which regulates sarcomere contraction. Mutations in TPM1 are known to cause hypertrophic cardiomyopathy, dilated cardiomyopathy and left ventricular non-compaction. Mutations in TPM1 causing hypertrophic cardiomyopathy are < 1%. However, some high-risk mutations causing sudden cardiac death are also known in this gene. We present a case of a novel heterozygous TPM1 mutation, NM_001018005.2:c.203A>G, p.Gln68Arg; co-segregating in an Indian family with hypertrophic cardiomyopathy. Our report expands the mutational spectrum of HCM due to TPM1 and provides the correlated cardiac phenotype.

Yoga as an adjuvant therapy in heart failure patients on optimal medical management analysed using echocardiographic parameters.

BACKGROUND: Heart failure (HF) is a chronic complex disease that prevails as a prime cause of concern for healthcare sectors worldwide, with a concordant objective to improve the long-term prognosis. Analysis of the available literature is evidence that yoga therapy and basic lifestyle modifications have considerably augmented heart failure patients' quality of life and enhanced left ventricular ejection fraction and NYHA functional class. AIM: Our study aims to establish the long-term outcomes of yoga therapy to validate the addition of yoga therapy as a complementary treatment in managing HF. METHODS: A prospective non-randomized study was conducted at a tertiary care center including seventy-five HF patients with NYHA class III or less who underwent coronary intervention, revascularization, or device therapy within the past six months to one year and continuing guideline-directed optimal medical therapy (GDMT). Thirty-five participants were part of the Interventional Group (IG), and forty were in the Non-Interventional Group (Non-IG). The IG received yoga therapy and GDMT, while the non-IG were only under standard GDMT. Echocardiographic parameters were compared at various follow-ups up to one year to see the impact of Yoga therapy on HF patients. RESULTS: A total of 75 heart failure patients, including 61 males and 14 females. The IG and non-IG had 35 subjects (31 males and 4 females) and 40 subjects (30 males and 10 females), respectively. Echocardiographic parameters were observed to compare the IG and Non-IG groups, and those did not demonstrate any significant difference between the two groups (p-value > 0.05). But, the echocardiographic parameters of the IG and non-IG from baseline to six months and one year showed a significant improvement (p-value of <0.05). The functional outcome (NYHA classes) was assessed after follow-up, and a p-value <0.05 showed a substantial improvement in the IG. CONCLUSION: Yoga therapy results in better prognosis, functional outcome, and left ventricular performance in HF patients with NYHA III or less. Hence this investigation has attempted to justify its importance as adjuvant/complimentary treatment for HF patients.

A comparative analysis of conventional and speckle-tracking strain echocardiographic findings in diabetic and non-diabetic kidney disease patients with normal ejection fraction.

This study aimed to compare the differences in echocardiographic and strain parameters in patients with diabetic kidney disease (DKD) and non-diabetic kidney disease (NDKD) in a cohort with pre-dialysis chronic kidney disease (CKD) and normal ejection fraction (EF). In this single-center prospective study, patients with CKD stages 3-5 and EF > 55% were included. We compared cardiac structure and function using conventional and speckle-tracking strain echocardiography among DKD and NDKD groups. Cardiovascular outcomes were assessed at the end of the study. Of the included 117 patients, 56 (47.9%) had DKD, and 61 (52.1%) had NDKD. Patients with DKD had higher ratios of early mitral inflow velocity and mitral annular early diastolic velocity (E/e') (11.9 ± 4.4 vs. 9.8 ± 3.5; p = 0.004), lower septal e' velocity (7.1 ± 2.5 vs. 8.2 ± 2.8; p = 0.031), lower lateral e' velocity (9.2 ± 2.9 vs. 10.4 ± 3.8; p = 0.045) and longer deceleration times (209.2 ± 41.5 vs. 189.1 ± 48.0; p = 0.017), compared to those with NDKD. Left ventricular mass index (LVMI), global longitudinal strain (GLS), early diastolic strain rate (SRE), and E/SRE were similar. At a median follow-up of 239 days, 3-P MACE (11.5% vs. 4.9%; p = 0.047) and 4-P MACE (28.6% vs. 11.5%; p = 0.020) were observed to be higher in the DKD group. Diastolic dysfunction was more common in patients with DKD, compared to those with NDKD, although both groups had similar LVMI and GLS. Those with DKD also had poorer cardiovascular outcomes. This highlights the importance of the assessment of diastolic function in CKD, particularly in those with diabetic CKD.

Single Coronary Artery from Right Sinus of Valsalva: A Single Center Experience of Seven Cases.

Background: Single coronary artery (SCA) is a rare anomaly with a prevalence of 0.024-0.066%. Some anomalies are merely benign anatomical variants, whereas some can result in myocardial ischemia or life-threatening arrhythmia. Case Presentation. We described seven cases in which all three major coronaries emerged from the right sinus of Valsalva via a single ostium and supplied the vast majority of the myocardium. A smaller branch arising from the left sinus supplied a modest quantity of myocardium in some of those few cases. These SCA variations do not exactly fit into any existing classification. It is unclear whether we need to modify previous classification systems or newer classification systems. Conclusions: SCA is divided based on its anomalous course and is usually a benign condition but it may present with cardiovascular complications. Clinicians should be aware of this entity along with the role of CT angiogram in its diagnosis and management.

Dabigatran for intracardiac thrombus, yet another promising role of a direct oral anticoagulant: a case report and short review of literature.

A left ventricular (LV) thrombus is a relatively common and well-known condition associated with significant LV systolic dysfunction. However, LV thrombosis is unusual in the absence of kinetic abnormalities. The elderly gentleman presented with subacute onset of bilateral lower limb discomfort and cold extremities, but no gangrene. With normal LV function, an echocardiogram revealed a massive movable LV apical clot. He was treated with dual antiplatelets and heparin at first. He switched to dabigatran 110 mg twice a day in combination with dual antiplatelets. The thrombus had entirely vanished and leg problems had improved after a 2-week follow-up. For the next six months, he was treated with aspirin and dabigatran and was asymptomatic at follow-up. There are no specific guidelines for treating an intracardiac thrombus. Experts agree that a hypermobile and pedunculated LV thrombus with a high embolic risk should be surgically removed as soon as possible. According to ESC/ACC guidelines, all patients with LV thrombus associated with myocardial infarction should be treated with anticoagulation. Warfarin requires regular International Normalized Ratio (INR) monitoring and has a small therapeutic window; hence a direct oral anticoagulant (DOAC) could be a viable therapeutic solution. However, there are no guideline recommendations to date to guide DOAC therapy for this indication.

Automated Diagnosis and Assessment of Cardiac Structural Alteration in Hypertension Ultrasound Images.

Hypertension (HTN) is a major risk factor for cardiovascular diseases. At least 45% of deaths due to heart disease and 51% of deaths due to stroke are the result of hypertension. According to research on the prevalence and absolute burden of HTN in India, HTN positively correlated with age and was present in 20.6% of men and 20.9% of women. It was estimated that this trend will increase to 22.9% and 23.6% for men and women, respectively, by 2025. Controlling blood pressure is therefore important to lower both morbidity and mortality. Computer-aided diagnosis (CAD) is a noninvasive technique which can determine subtle myocardial structural changes at an early stage. In this work, we show how a multi-resolution analysis-based CAD system can be utilized for the detection of early HTN-induced left ventricular heart muscle changes with the help of ultrasound imaging. Firstly, features were extracted from the ultrasound imagery, and then the feature dimensions were reduced using a locality sensitive discriminant analysis (LSDA). The decision tree classifier with contourlet and shearlet transform features was later employed for improved performance and maximized accuracy using only two features. The developed model is applicable for the evaluation of cardiac structural alteration in HTN and can be used as a standalone tool in hospitals and polyclinics.

Effectiveness of ultrasonography-guided cardiac sympathetic denervation in acute control of electrical storm: A retrospective case series.

Background and Aims: Ultrasonography-guided left cardiac sympathetic denervation (LCSD) or bilateral cardiac sympathetic denervation (BCSD) may be a useful intervention in the electrical storm (ES) that persists despite pharmacological therapy. The aim of our study was to evaluate the effectiveness of ultrasonography-guided LCSD or BCSD in the acute control of ES. We conducted a retrospective case series of patients who underwent ultrasonography-guided CSD for control of ES at a tertiary care hospital. Material and Methods: Data of all patients who underwent unilateral or bilateral CSD were collected from January 2017 to December 2019. Eleven patients with ES refractory to standard antiarrhythmic therapy underwent ultrasonography-guided pharmacological CSD (eight underwent LCSD and three underwent BCSD). Quantitative data was expressed as mean and median with interquartile range (IQR). Non-quantitative data was expressed in proportions. Results: Eleven patients underwent ultrasonography-guided pharmacological CSD (eight underwent LCSD and three underwent BCSD). Six of the eleven patients were female (54.5%). Ischemia was the underlying substrate in nine patients (81.8%). Five patients (46%) had complete resolution of ventricular tachycardia (VT) after CSD and one had 90% reduction in episodes of VT. The median follow-up duration was 8 months inter-quartile range IQR (7-18). One patient succumbed to heart failure and one patient was lost to follow up. The other patients had no further events and were well at last follow up. Conclusion: Ultrasonography-guided pharmacological CSD is effective in the acute control of ES. It is easily performed with equipment that is readily available and relatively safe in terms of immediate complications and is an ideal second-line intervention when ES persists despite drug therapy.

Effectiveness of self-care educational programme on clinical outcomes and self-care behaviour among heart failure peoples-A randomized controlled trial: Study protocol.

AIM: To evaluate the effectiveness of a self-care education programme on clinical outcomes, self-care behaviour and knowledge on heart failure (HF) among peoples with HF. DESIGN: Randomized controlled trial. METHODS: The participants (N = 160) will be randomly assigned (1:1) to the intervention and the control arms using block randomization. The participants assigned to the intervention arm will receive educational intervention on HF self-care comprising video-assisted teaching with teach-back technique, tailored teaching at discharge and a guide on self-care followed by telephonic calls and text messages after discharge for 6 months along with standard care. The participants in the control arm will receive only a guide on self-care with standard care. The clinical outcomes such as health-related quality of life, hospital readmissions, N-terminal pro-brain natriuretic peptide levels, symptom perception, functional status, left ventricular ejection fraction, Seattle HF score, self-care behaviour and knowledge on HF will be measured at the baseline, after 1 and 6 months of the intervention. DISCUSSION: Several studies conducted on self-care education interventions have shown positive effects, whereas few studies have shown no effect on the people outcomes. Providing the printed self-care guide alone may not improve behaviour associated with self-care and clinical outcomes. These peoples need continuous reinforcement on self-care. If this self-care educational intervention shows beneficial effects, it will contribute to the clinical practice and improve clinical outcomes. IMPACT: This research will contribute to the evidence on the effectiveness of an educational intervention on self-care among peoples with HF. The results would assist the nurses caring for peoples with HF. They can also implement this intervention for improving the peoples' self-care behaviour. TRIAL REGISTRATION: The trial is registered with the Clinical Trial Registry India and the reference ID number CTRI/2019/10/021724.

Spontaneous dissection of coeliac and superior mesenteric artery: double whammy.

Isolated dissection of one of the mesenteric arteries without concurrent involvement of the aorta is a rare clinical entity and an unusual cause of abdominal pain. It usually involves one artery, most commonly the superior mesenteric artery (SMA) followed by the coeliac artery. We are reporting a rare case where both coeliac and SMA were showing dissection. We are reporting a case of 60-year-old hypertensive male who came with worsening abdominal pain for 5 days; CT scan showed coeliac and SMA dissection without any imaging evidence of intestinal ischaemia. He was successfully managed medically with bowel rest and anticoagulation. Two weeks of follow-up CT scan showed no progression or thrombus formation. For complicated cases, percutaneous transluminal angioplasty of a visceral artery or open surgical exploration or hybrid approach is required. However, for stable uncomplicated cases, medical therapy alone is sufficient.

Accordion effect: A red herring during percutaneous angioplasty of arteriovenous dialysis access.

Accordion or concertina effect is the angiographic appearance of pseudostenosis caused by interaction of a stiff guidewire with a tortuous vessel during endovascular procedures. This phenomenon may often mislead the interventionist into performing unnecessary and potentially harmful procedures in a bid to treat the 'stenotic' lesion. The resolution of 'stenosis' on withdrawal of the guidewire clinches the diagnosis. While well described in coronary vessels, the occurrence of this phenomenon in arteriovenous fistula or graft has not been reported. We describe a case of accordion effect observed during endovascular intervention for arteriovenous graft salvage.

Risk Factors of Pulmonary Hypertension in Patients on Hemodialysis: A Single Center Study.

INTRODUCTION: Pulmonary hypertension (PH) is an underestimated cardiovascular consequence and a mortality predictor in patients on hemodialysis (HD). Thus, we studied its prevalence, risk factors, association with inflammation/oxidative stress, and cardiac changes in HD patients. METHODS: This was a single-center cross-sectional observational study conducted at a tertiary care hospital. Patients aged >18 years on hemodialysis for at least three months were included and divided into those with and without PH; patients with secondary causes for PH were excluded. Clinical characteristics, HD-related factors, lab parameters (C-reactive protein and malondialdehyde with thiol assay were used as markers of inflammation and oxidative stress, respectively), and echocardiography details were compared. PH was defined as a mean pulmonary artery pressure of >25 mmHg at rest, and it was further divided as mild (25-40 mmHg), moderate (40-60 mmHg), and severe (>60 mmHg). RESULTS: Of 52 patients, 28 patients had PH (mild 24, moderate 4, and none had severe PH) with prevalence of 54%. No difference was found in clinical characteristics, dialysis-related factors, biochemical parameters including inflammation (C-reactive protein; p=0.76), or oxidative stress (thiol; p=0.36 and MDA; p=0.46) between the groups. When compared to individuals without PH, HD patients with PH exhibited significantly more mitral regurgitation (p=0.002). CONCLUSION: Hemodialysis patients have a high prevalence of PH. PH was significantly associated with the presence of mitral regurgitation on echocardiography. Our study did not find differences in traditional risk factors, HD-related factors, and inflammation/oxidative markers between the groups with and without PH.

Percutaneous coronary intervention of anomalous left circumflex coronary artery - A case series.

We report a case series of 14 cases (mean age 54.14 ± 14.75 years) of successful percutaneous coronary intervention of anomalous left circumflex artery. While the intermediate-term follow-up (mean 36.0 ± 20.58 months) was uneventful in 12 patients, one died of a non-cardiac cause, while other lost to follow-up.

Role of deformation imaging in left ventricular non-compaction and hypertrophic cardiomyopathy: an Indian perspective.

BACKGROUND: Speckle tracking echocardiography (STE) has emerged as a novel feasible tool for the assessment of left ventricular rotational parameters. Since hypertrophic cardiomyopathy(HCM) shares morphologic features with left ventricular non-compaction (LVNC), we used this imaging modality to compare rotational mechanics between these two entities. RESULTS: We compared global and regional LV function and rotational mechanics between LVNC, HCM, and healthy subjects using STE. Longitudinal strain and torsion were obtained from echocardiographic images from parasternal short axis as well as standard LV apical views. Twelve patients with LVNC [mean age 46.12 ± 14.66 years; median 47.5 IQR (39.25-58.5) years] were compared with 18 HCM patients [mean age 49.48± 17.22 years; median 56 IQR (33-65) years] and 18 healthy subjects [mean age: 51.50± 12.51 years; median 51(45.75-58) years]. LVNC group showed a significantly reduced longitudinal strain at the apical region compared to HCM group (- 12.18 ± 6.25 vs - 18.37 ± 3.67; P < 0.05). Rigid body rotation(RBR) was found in 50% of patients whereas the other half had a normal rotation at the apex and the base. Among the patients with RBR, all patients had a uniform counterclockwise rotation. CONCLUSION: Longitudinal strain was impaired in both the forms of cardiomyopathy; however, LVNC showed a more significant reduction in the apical region compared to patients with HCM suggesting a development abnormality in these regions. A reduction in left ventricular torsion was specifically noted among patients with LVNC with a uniform anticlockwise rotation of LV base and apex.

In-stent restenosis of drug-eluting stents in patients with diabetes mellitus: Clinical presentation, angiographic features, and outcomes.

OBJECTIVE: Diabetes mellitus (DM) is a risk factor for developing in-stent restenosis (ISR) following percutaneous coronary intervention (PCI). This study aimed to examine the presentation and outcomes of drug-eluting stent (DES) ISR in diabetics. METHODS: This retrospective study included consecutive patients with clinical DES-ISR, who were hospitalized between January 2013 and December 2017 and who were grouped based on the presence or absence of DM. Clinical, angiographic features and 1-year outcomes [composite of death, myocardial infarction (MI), and repeat-target lesion revascularization] were compared. RESULTS: Baseline characteristics of the DM group (n=109) were comparable to the non-DM group (n=82), except for the higher prevalence of hypertension and dyslipidemia in the former (60.6% vs. 46.3%, p=0.050; 74.4% vs. 57.8%, p=0.034, respectively). Clinical presentation was similar in both groups [acute coronary syndrome (ACS): 62.4% vs. 61%, p=0.843; MI: 34.9% vs. 34.1%, p=0.918). Diabetics had a higher prevalence of stent-edge restenosis (20.3% vs. 9.2%, p=0.019). The treatment strategy was similar in both groups with 52.3% in the DM group and 57.3% in the non-DM group undergoing PCI (p=0.513). One-year outcomes of the DM group were not different from those of the non-DM group (14.7% vs. 17.1%, p=0.683). Age [hazard ratio (HR), 1.05; 95% confidence interval (CI), 1.01-1.10; p=0.017], MI presentation (HR, 2.34; 95% CI, 1.14-4.80; p=0.020), and chronic kidney disease (CKD: HR, 2.82; 95% CI, 1.21-6.58; p=0.016) were predictors of poor outcomes. CONCLUSION: Stent-edge restenosis is more common in diabetics. Clinical presentation and 1-year outcomes following DES-ISR are similar in diabetics and non-diabetics. Age, MI presentation, CKD, and not DM were predictors of poor outcomes following DES-ISR.

In-stent restenosis of drug-eluting stents: clinical presentation and outcomes in a real-world scenario.

BACKGROUND: Drug-eluting stents (DES) have substantially reduced the incidence of coronary in-stent restenosis (ISR), but the problem persists. Clinical presentation and outcomes of DES-ISR in a real-world scenario remains underreported. RESULTS: In this retrospective study, we examined medical records of 191 consecutive patients with DES-ISR (210 ISR lesions) hospitalized between January 2013 and December 2017. ISR clinical presentation was classified as acute coronary syndrome (ACS) or non-ACS. Clinical, angiographic features and 1-year outcomes [composite of death, myocardial infarction (MI) and repeat-target lesion revascularization] for these two groups were compared. The mean age of study population was 61 ± 10 years and 81.2% were males. ACS was the dominant clinical presentation mode occurring in 118 (61.8%) patients. MI was seen in 66 (34.6%) patients. Female gender (odds ratio, 2.71; 95% confidence interval [CI], 1.13-6.52; P = 0.026) and chronic kidney disease (odds ratio, 3.85; 95% CI, 1.05-14.20; P = 0.043) correlated significantly with ACS ISR presentation. A majority [104 (54.5%)] of patients underwent percutaneous coronary intervention (PCI), of whom 72 (69.2%) received a new DES. The rest either underwent CABG (26.2%) or received medical therapy (19.4%). Patients presenting with ACS had a significantly worse clinical outcome at 1-year follow-up (ACS versus non-ACS presentation: hazard ratio [HR], 2.66; 95% CI, 1.09-6.50; P = 0.032). CONCLUSIONS: DES-ISR presents most commonly as ACS. Female gender and chronic kidney disease seem to be associated with ACS presentation. ACS presentation of ISR is associated with worse 1-year outcomes. Early identification of those with ACS risk and closer follow-up may improve outcomes.