Correlation of head-up tilt table test time interval with future risk of recurrent syncope.

BACKGROUND: Head-up tilt table test (HUTT) is widely used for the investigation of syncope and presyncope. Time required for positive response has a probable relationship to the sensitivity of neural reflex mechanism underlying syncope. METHODS: We evaluated patients with history of syncope. Group A included patients with recurrent syncope defined as two or more episodes of syncope and group B included those with one episode of syncope. Time required for the test to become positive in both the groups was analyzed. Patients with positive HUTT were followed for 1 year. RESULTS: Of 80 patients, 68 eligible study patients were divided into group A (32.35%) and group B (67.65%). HUTT was positive in 41 patients (positivity rate  =  60.29%). Positivity rate was 100% in group A and 41.3% in group B. Median time interval for positive response in groups A and B were 12.5 and 30.0 minutes, respectively. An inverse association was found between recurrent syncope and time interval for positive response (R  =  - 0.282, P  =  0.002). Time interval of less than 19.5 minutes for positive response had 94.5% sensitivity and 97.89% specificity for recurrent syncope. On follow-up, positive association was found between time interval for positive response less than 19.5 minutes and future recurrence of syncope (odds ratio  =  22.75, 95% confidence interval  =  4.37-118.34, P  =  0.000). CONCLUSION: HUTT time interval of less than 19.5 minutes for positive response predicted future recurrence of syncope. Hence, it may serve as an important predictor of future recurrence of syncope.

3D Xplane Echocardiographic Technique for Validation of Mitral Leaflet Separation to Assess Severity of Mitral Stenosis.

BACKGROUND: Determining the severity of mitral stenosis (MS) is important for both prognostic and therapeutic implications. Mitral valve area (MVA) calculation techniques have more limitations. Mitral leaflet separation (MLS) is a precise and operator friendly alternative to planimetry. In contrast to previous researchers, we have used a novel 3D Xplane technique to validate MLS for assessing the severity of MS. 3D Xplane is superior for validation of MLS due to simultaneous real time acquisition of MLS in parasternal long-axis view and corresponding MVA by planimetry in parsternal short-axis view. METHODS: It was a prospective observational single center study. A total of 174 patients with MS were evaluated for MVA estimation by various echocardiographic modalities. Maximum leaflet separation and corresponding planimetered MVA were measured using novel 3D Xplane technique. RESULTS: With 3D Xplane technique, there was strong positive correlation between planimetered MVA and MLS (R = 0.925, P < 0.001), irrespective of coexisting MR (R = 0.886, P < 0.001) or AF (R = 0.912, P < 0.001). Receiver operating characteristic curves of MLS demonstrated AUC for mild and severe MS to be 0.966 and 0.995, respectively. MLS less than 8.62 mm predicted severe MS with 95.5% sensitivity and 94.7% specificity and MLS more than 12.23 mm predicted mild MS with 93.2% sensitivity and 91.4% specificity. CONCLUSION: In our study, a strong correlation between planimetered MVA and MLS was found using 3D Xplane technique. 3D Xplane thus validates and standardizes MLS by excluding errors due to temporal and spatial variations which are important limitations of 2D echocardiography.

Transulnar versus Transradial Access as a Default Strategy for Percutaneous Coronary Intervention.

BACKGROUND: Percutaneous coronary interventions (PCI) are undergoing a paradigm shift from femoral to forearm approach due to obvious advantages in terms of patient safety, comfort, and faster ambulation. Transradial access (TRA) has been established as a primary forearm access site. Use of transulnar access (TUA) as an alternative to radial route can serve as novel forearm access to the interventionalists. AIM: The aim of this study is to evaluate TUA versus TRA access as a default strategy for PCI. MATERIALS AND METHODS: This was a prospective, single-center randomized controlled trial involving 2700 patients, of whom 220 underwent PCI in 1:1 randomization to TUA (n = 110) or TRA (n = 110). The primary endpoint was composite of major adverse cardiac events during hospital stay, cross-over to another arterial site, major vascular events of the arm during hospital stay (large hematoma with hemoglobin drop of ≥5 g%) and occlusion rate. Secondary endpoints were individual components of primary endpoint and spasm of the vessel. RESULTS: Two groups did not differ in baseline characteristics. On intention to treat (ITT) analysis, primary end point occurred in 10.91% of TUA and 12.73% of TRA arm (odds ratio [OR]: 0.84; 95% confidence interval [CI], 0.37-1.91; P = 0.68 at α = 0.05). Further on per protocol (PP) analysis, primary end point occurred in 9.21% of TUA and 11.11% of TRA arm (OR: 0.81; 95% CI, 0.29-2.30; P = 0.68 at α = 0.05). Secondary endpoints also did not differ significantly between the two groups in ITT and PP analysis. CONCLUSIONS: TUA is an excellent alternative to TRA, while performing PCI when performed by an experienced operator. When utilized as an option, TUA increases the chance of success with forearm access and reduces the need for cross over to femoral route.

High versus low dose statin therapy in Indian patients with acute ST-segment elevation myocardial infarction undergoing thrombolysis.

OBJECTIVES: This study sought to compare high dose versus low dose statin therapy in Indian patients with ST-segment elevation myocardial infarction (STEMI) undergoing thrombolysis. BACKGROUND: Randomized trials have demonstrated that statin treatment reduced major adverse cardiac events (MACEs) in patients with stable angina pectoris and acute coronary syndrome. However, randomized studies of statin therapy in Indian patients with STEMI are scarce. METHODS: Of 1859 patients with acute STEMI, 1027 eligible patients were randomized to 80-mg (n=512) or 10-mg (n=515) atorvastatin. Primary end point was 30-day incidence of MACE (death from any cause, myocardial infarction, NSTE-ACS requiring readmission, ischemia driven revascularization, and stroke). Secondary end points included individual components of primary end point and ST-segment resolution at 90min after thrombolysis. RESULTS: Two groups did not differ in primary endpoints of MACEs (8.79% in high dose vs 9.32% in low dose atorvastatin group, OR=0.938, 95% CI=0.612-1.436, P=0.764). With 80mg atorvastatin, there was insignificant reduction in rate of reinfarction, revascularization and death. Stroke and readmission for NSTE-ACS increased in 80mg atrovastatin group, but was not statistically significant. ST-segment resolution was significantly higher in 80-mg atorvastatin arm (45.90% vs. 37.67%; p=0.008). Myalgia was more in 80mg statin group (18.06% vs 7.57%, p=0.0001). CONCLUSIONS: High-dose atorvastatin did not show significant difference of MACEs in STEMI patients undergoing thrombolysis but showed significant improvement in immediate coronary flow depicted by ST-segment resolution. This benefit of high dose statin is to be weighed against greater myalgia, drug discontinuation and cost in Indian patients.

Ivabradine vs metoprolol in patients with acute inferior wall myocardial infarction-"Expanding arena for ivabradine".

BACKGROUND: Atrioventricular (AV) blocks are of concern with the use of beta blockers in inferior wall myocardial infarction (MI). Ivabradine lowers heart rate with a lesser risk of AV blocks. OBJECTIVES: To compare ivabradine with metoprolol in acute inferior wall MI in terms of feasibility, tolerability, and efficacy. METHODS: It was a prospective double-blind single-center randomized controlled study. Of 1032 patients with acute inferior wall MI, 468 eligible patients were randomized in 1:1 manner to ivabradine (group A) and metoprolol (group B). Intention to treat analysis of 426 patients (group A-232 and group B-232) was performed. The primary endpoint was 30-day incidence of major adverse cardiovascular events including death, reinfarction, complete heart block (CHB), and heart failure. Secondary endpoints included 30 days incidence of recurrent angina, readmission, first- or second-degree AV block, and tachyarrhythmias. RESULTS: Both the drugs decreased the mean heart rate to 62.22±2.95 (group A) vs 62.53±3.59 (group B) beats per minute (P=0.33). Ejection fraction improved in both the groups (5.15±1.93% in group A vs 5.52±2.18% in group B, P=0.065). The two groups did not differ significantly in their primary endpoints in terms of death (group A=1.72% vs group B=1.72%, OR=1.00, 95% CI=0.25-4.05, P=1.00), reinfarction (group A=0.86% vs group B=0.86%, OR=1.00, 95% CI=0.14-7.16, P=1.00), heart failure (group A=4.31% vs group B=2.59%, OR=1.70, 95% CI=0.61-4.75, P=0.31), or CHB (0% vs 2.59%, OR=0.07, 95% CI=0.00-1.34, P=0.08). There were no significant differences in the secondary endpoints of recurrent angina, readmission, and tachyarrhythmias except for more first- and second-degree AV blocks with metoprolol (12.93% vs 2.59%, OR=5.59, 95% CI=2.28-13.72, P=0.0002). CONCLUSIONS: Ivabradine is well tolerated and equally effective as metoprolol in acute inferior wall ST elevation myocardial infarction patients for lowering the heart rate with lesser risk of AV blocks.

Sweating: A Specific Predictor of ST-Segment Elevation Myocardial Infarction Among the Symptoms of Acute Coronary Syndrome: Sweating In Myocardial Infarction (SWIMI) Study Group.

BACKGROUND: Today, cardiologists seek to minimize time from symptom onset to interventional treatment for the most favorable results. HYPOTHESIS: In the acute coronary syndrome (ACS) symptom complex, sweating can differentiate ST-segment elevation myocardial infarction (STEMI) from non-ST-segment elevation ACS (NSTE-ACS) during early hours of infarction. METHODS: This single-center, prospective, observational study compared symptoms of STEMI and NSTE-ACS patients admitted from August 2012 to July 2014. RESULTS: Of 12 913 patients, 90.56% met ACS criteria. Among these, 22.51% had STEMI. Typical angina was the most common symptom (83.82%). On stepwise multiple regression, sweating (odds ratio: 97.06, 95% confidence interval [CI]: 82.16-114.14, P < 0.0001) and typical angina (odds ratio: 2.72, 95% CI: 2.18-3.38, P < 0.001) had significant association with STEMI. For diagnosis of STEMI, positive likelihood ratio (LR) and positive predictive value (PPV) were highest for typical angina with sweating (LR: 11.17, 95% CI: 10.31-12.1; PPV: 76.09, 95% CI: 74.37-77.75), followed by sweating with atypical angina (LR: 3.6, 95% CI: 3.07-4.21; PPV: 50.61, 95% CI: 46.45-54.76), typical angina (LR: 1.05, 95% CI: 1.03-1.07; PPV: 22.97, 95% CI: 22.11-23.84), and atypical angina (LR: 0.77, 95% CI: 0.69-0.87; PPV: 18.09, 95% CI: 16.32-19.97). C statistic values of 0.859 for typical angina with sweating and 0.519 for typical angina alone reflected high discriminatory value of sweating for STEMI prediction. CONCLUSIONS: Presence of sweating with ACS symptoms predicts probability of STEMI, even before clinical confirmation. Sweating in association with typical or atypical angina is a much better predictor of STEMI than NSTE-ACS.