Metabolic risk factors in first acute coronary syndrome (MERIFACS) Study.

OBJECTIVES: In acute coronary syndrome (ACS) patients the focus is on major conventional risk factors - CRF [diabetes, hypertension, elevated low-density cholesterol (LDL-C) and smoking] whereas others - specific metabolic risk factors - MRF [high-density lipoprotein cholesterol (HDL-C), body-mass index (BMI), waist-hip ratio (WHR), and triglycerides, and HbA1c get less attention. METHODS: This is a prospective case-control observational study from 15 tertiary care hospitals in India. CRF and MRF in patients presenting with first incidence of ACS (n = 2153) were compared with matched controls (n = 1210). RESULTS: Propensity score matching (PSM) yielded 1193 cases and matched 1210 controls. Risk factor prevalence in cases vs. controls were CRF: hypertension - 39.4% vs 16.4% (p < 0.0001), diabetes - 42.6% vs 12.7% (p < 0.0001), smoking - 28.3% vs 9.3% (p < 0.0001) and elevated LDL-C - 70.2% vs 57.9% (p < 0.0001). MRF: High BMI - 54.7% vs 55.1% (p = 0.84), increased waist: hip ratio 79.5% vs 63.6% (p < 0.0001), high HbA1c - 37.8% vs 14.9% (p < 0.0001), low HDL-C - 56.2% vs 42.8% (p < 0.0001) and elevated triglycerides - 49.7% vs 44.2% (p = 0.007). Adjusted Odds ratios by multivariate analysis were CRF: hypertension - 2.3 (p < 0.001), diabetes - 4.7 (p < 0.001), high LDL-C - 3.3 (p < 0.001) and smoking- 6.3 (p < 0.001). MRF: High waist: hip ratio - 2.4 (p < 0.001) high HbA1c - 3.2 (p < 0.001), low HDL-C 2.2 (p < 0.001) and elevated triglycerides - 0.878 p = 0.17. CONCLUSION: In India, the risk of ACS conferred by specific metabolic risk factors (High waist: hip ratio, Low HDL-C and High HbA1c) is comparable to that caused by CRF.

Hormone sensitive idiopathic ventricular tachycardia associated with pregnancy: successful induction with progesterone and radiofrequency ablation.

Successful Induction With Progesterone and Radiofrequency Ablation. Verapamil-sensitive idiopathic left ventricular tachycardia in pregnancy is a rare diagnosis. We report a case of a primigravida female with new onset fascicular ventricular tachycardia that was managed with oral verapamil. Post pregnancy, the tachycardia was not inducible in the electrophysioplogy lab. Progesterone, a hormone associated with pregnant state, was used to successfully induce the tachycardia, which was ablated. This is the first reported case of an idiopathic ventricular tachycardia associated with pregnancy that could be induced later by recreating the hormonal milieu associated with pregnant state.

Patterns of ventricular dyssynchrony in congestive heart failure- comparison with controls and implications for patient selection for cardiac resynchronization therapy.

BACKGROUND: Assessment of ventricular dyssynchrony by Tissue Doppler Imaging (TDI) is being increasingly used in patient selection for Cardiac Resynchronization Therapy (CRT). Regional distribution of dyssynchrony has been sparingly addressed in dyssynchrony studies in heart failure population. METHODS: TDI was used to assess prevalence and regional distribution patterns of ventricular dyssynchrony in heart failure (HF) patients with systolic LVdysfunction (LVEF equal or less than 40%) in sinus rhythm. Inter-ventricular dyssynchrony (IVD) and left ventricular dyssynchrony (LVD) equal or greater than 40 msec were considered significant and LVD equal or greater than 65 m sec indicated severe dyssynchrony. RESULTS: 100 HF patients (Wide QRS, Gp I, N =70 & Normal QRS Gp II, N=30, and 25 normal individuals with complete LBBB (n=14) or RBBB (n=11) underwent TDI. IVD was seen in 35 (35%) patients (74% LV delay & 26% RV delay) and LVD in 68 patients (68%). The relative prevalence of lVD and LVD respectively in Group land Group II HF patients was47% vs. 7% (p < 0.001) and 70% vs. 67%. (p=ns) while LVD in Groups A (LBBB, n=41) & B (RBBB, n=26) was 76% and 58%, p=ns. The prevalence ofsevere LVD was similar in Gp I & II (37% and 57%, p=ns), and in Gp A & B (46% & 26%, p=ns). Regional distribution patterns of LVD in normal individuals with bundle branch block showed septal delay in 20%, a prevalence of similar to heart failure population (23%, Gp I, and 21% Gp II, p=ns). Lateral wall delay was demonstrated only in the HF population seen in 33% of Gp I and 47% of Gp II patients, p=ns. CONCLUSIONS: LVD is distributed amongst HF patients with narrow or wide QRS and with LBBB or RBBB with a similar regional distribution. Dyssynchrony in normal individuals with bundle branch block is in the form of septal delay. These findings may have implications for patient selection for CRT and site of LV pacing.

Follicular thyroid carcinoma with tumour thrombus extending into superior vena cava and right atrium - A case report.

Intra-cardiac extension of tumour thrombus of follicular carcinoma of thyroid is uncommon. We report a case of advanced thyroid carcinoma where tumour thrombus was well profiled with CT scan and transesophageal echo images and extension was noted from SVC into right atrium, with clinical features of superior vena cava syndrome. The clinical significance of the "ring sign" is discussed.

Calcified subaortic left ventricular aneurysm causing right pulmonary artery obstruction in a child.

A 14-year old asymptomatic boy was diagnosed as having a large calcified subaortic left ventricular aneurysm that was found to obstruct flow across the right pulmonary artery during systole. Surgical patch closure of the neck of the aneurysm resulted in relief of obstruction. The case is reported for its rarity, massive calcification, absence of aortic regurgitation and dynamic compression of the right pulmonary artery.

Sudden cardiac death early after ST elevation myocardial infarction with and without severe left ventricular dysfunction.

INTRODUCTION: There is high incidence of SCD in the early period following STEMI. We compared the temporal patterns and predictors of SCD amongst patients with LVEF ≤35% and LVEF >35%. METHODS: Data from STEMI patients was prospectively collected. SCD cases formed the study cohort and were categorized into 2 groups based on their LV function. RESULTS: There were 929 patients (mean age 55 ± 17 years) with a follow up of 41 ± 16 months. 154 pts (16.6%) had LVEF ≤35% (Group A, LVEF-29.9% ± 6%) and 775 pts had LVEF >35% (Group B, LVEF - 49% ± 14%). The two groups were similar with respect to sex distribution, age, prevalence of hypertension, and mean period of presentation. They differed in incidence of anterior wall MI (77.2% vs 55%), reperfusion (69% vs. 75%), prevalence of diabetes (50.6% vs 42%), and medication non-compliance (34% vs. 13%). The total SCD was 78 [Gp A, 25 (16.2%); Gp B, 53 (6.8%); p < 0.001]. The temporal cumulative SCD related mortality in the 2 groups was 1st month (8% vs. 4% p = 0.075), 3 months (14% vs. 5%, p < 0.001), 6 months (17% vs. 5%, p < 0.001), 1 year (18% vs. 6%, p < 0.001), at end of follow up (27% vs. 8%, p < 0.001). Multivariate predictors of SCD were medication compliance in the first month, and severe LV dysfunction with medication compliance beyond 1st month. CONCLUSION: The incidence of SCD is high in first month after STEMI, irrespective of LV function. The number of SCD is higher in Group B patients. Algorithms to assess risk of SCD in early post STEMI period are urgently needed.

ST elevation after intracoronary administration of Papaverine for fractional flow reserve estimation.

INTRODUCTION: Intracoronary (IC) papaverine which is one of the commonly used agents for Fractional Flow Reserve (FFR) estimation has been reported to cause transient ST elevation in some patients. This phenomenon has not been systematically studied. MATERIAL AND METHODS: This is a prospective, observational study. Consecutive patients, who underwent FFR at our institute using IC papaverine from May 2012 to April 2013, were included. FFR was done when clinically indicated. The procedure involved administration of 20 mg papaverine (Paparin)--Troikaa, Ahmedabad) as a fast bolus by intracoronary route followed by a 10 cc contrast flush, following which pressure measurements were made. Continuous ECG recording by Philips Hemodynamic Laboratory was obtained for all patients throughout the procedure. Post procedure, they were observed for any delayed effects and eventual outcome was documented. Fischer's mid-p test was used for statistical analysis. RESULT: Twenty-five patients (18 males, 7 females, mean age 57.9 ± 20 years) underwent FFR using Papaverine. The mean LVEF was (51 ± 15%). Fourteen patients (56%) developed transient ST elevation ≥0.5 mm in one or more leads which resolved spontaneously in all cases without any sequelae. The presence of a significant lesion either in the coronary artery being evaluated or in a remote coronary artery did not predict the ST elevation. 70.5% of diabetics (p = 0.02), 75% of hypertensives (p = 0.008) and 75% of patients with LVH (p = 0.008) had ST elevation. None of the 5 patients without any one of these comorbidities showed ST elevation. CONCLUSION: Transient ST elevation occurs in a significant proportion of cases receiving IC papaverine which is not associated with any adverse clinical outcomes. Micro vascular dysfunction is the most likely mechanism of this phenomenon.