Suspecting and diagnosing transthyretin amyloid cardiomyopathy (ATTR-CM) in India: An Indian expert consensus

Transthyretin cardiac amyloidosis (ATTR-CM) is a rare and under-recognized disorder characterized by the aggregation of transthyretin-derived insoluble amyloid fibrils in the myocardium. Heterogeneity of symptoms at presentation, makes its diagnosis often delayed. An expert panel gathered on a virtual platform across India to conduct a meeting for developing a guiding tool for ATTR-CM diagnosis. The panel recommended younger age (40 years) for suspecting ATTR-CM and thick-walled non-dilated hypokinetic ventricle was considered as one of the important red flags. Electrocardiogram (ECG) and echocardiography (ECHO) findings were recommended as primary tests to raise the suspicion while nuclear scintigraphy and hematological tests were recommended to confirm the diagnosis and rule out amyloid light-chain (AL) amyloidosis. Cardiac magnetic resonance (CMR) and biopsy were recommended in case of ambiguity in the presence of red flags. Considering the lack of expert guidelines in the Indian scenario, a standardized diagnostic algorithm was also proposed.

Heart Failure with Preserved Ejection Fraction: Management Guidelines (From Heart Failure Association of India, Endorsed by Association of Physicians of India)

Heart failure with preserved ejection fraction (HFpEF) accounts for 15–20% of patients with heart failure (HF) in India. Diagnosis is by clinical features supported by biomarkers and echocardiography. Lifestyle modifications, control of risk factors to optimum levels, and treatment of comorbidities are essential in the management of HFpEF. Spironolactone and sacubitril-valsartan [angiotensin receptor neprilysin inhibitor (ARNI)] are beneficial in subsets of HFpEF, especially with lower range of ejection fraction (EF). Sodium-glucose co-transporter-2 inhibitors (SGLT2i)—empagliflozin and dapagliflozin and probably sotagliflozin are the only currently available drugs which have shown benefits in HFpEF, mostly by reducing hospitalizations. The benefit of SGLT2i is evident in both diabetic and nondiabetic subsets. Heart failure with preserved ejection fraction is defined as patients with HF with documented left ventricular ejection fraction (LVEF) equal to or more than 50%.1 Globally, HFpEF accounts for close to 50% of patients presenting with HF. As per the registry data like Trivandrum Heart Failure Registry2 and ASIAN-HF,3 the proportion of HFpEF in our country is approximately 19–25%, which is much lower as compared to that of western population. There is a possibility that many cases go undiagnosed in developing countries like India. The mean age of presentation of patients from India was around 58–68 years, which is about 10 years younger than the data reported from the west. Heart failure with preserved ejection fraction is characterized by elevated left ventricular filling pressures and/or reduced cardiac output either at rest or on exertion. Cardiac output is maintained at the cost of abnormally elevated filling pressure which is responsible for the symptoms and signs. Neurohumoral activation (sympathetic and renin-angiotensin-aldosterone system activation) is present only in a group of HFpEF patients unlike in patients with heart failure with reduced ejection fraction (HfrEF).

Coronary thrombo-embolic events after Covid-19 vaccination- a single centre study

Thrombo-embolic complications after Corona virus disease-19 (COVID-19) vaccination have been previously reported. We aimed to study the coronary thrombo-embolic complications (CTE) after COVID-19 vaccination in a single centre during the initial 3 months of vaccination drive in India. All patients admitted to our hospital between 1st March 2021 and 31st May 2021 with Acute coronary syndrome (ACS) were included. Of the 89 patients [Age 55 (47e64)y, 13f] with ACS and angiographic evidence of coronary thrombus, 37 (42%) had prior vaccination history. The timing from last vaccination dose to index event was <1, 1e2, 2e4 and >4 weeks in 9(24%), 4(11%), 15(41%) and 9 (24%) respectively. ChAdOx1 nCoV-19/AZD1222 (Covishield) was the most used vaccine- 28 (76%), while 9 (24%) had BBV152 (Covaxin). Baseline characteristics were similar in both vaccinated (VG) and non-vaccinated group (NVG), except for symptom to door time [8.5 (5.75e14) vs 14.5 (7.25e24) hrs, p ¼ 0.003]. Thrombocytopenia was not noted in any of the VG patients, while 2 (3.8%) of NVG patient had thrombocytopenia (p ¼ 0.51). The pre- Percutaneous Coronary Intervention (PCI) Thrombolysis in Myocardial Infarction (TIMI) flow was significantly lower [1 (0e3) vs2 (1e3), p ¼ 0.03) and thrombus grade were significantly higher [4 (2.5e5) vs 2 (1e3), p ¼ 0.0005] in VG. The in-hospital (2.7% vs 1.9%, p ¼ 1.0) and 30-day mortality were also similar (5.4% vs 5.8%, p ¼ 1.0). This is the first report of CTE after COVID-19 vaccination during the first 3 months of vaccination drive in India. We need further reports to identify the incidence of this rare but serious adverse events following COVID-19 vaccination.

Study of efficacy and safety of losartan (losar) in Asian Indian hypertensives.

Although there has been widespread dissemination of knowledge about hypertension, it remains poorly treated in most populations. Systemic hypertension is associated with increased risk for coronary artery disease, stroke, nephrosclerosis, peripheral vascular disease, etc. The treatment of hypertension includes non-pharmacological measures and the specific drug therapy. Losartan potassium is an orally active, non-peptide angiotensin II receptor antagonist. It is the first of this new class of drugs introduced for clinical use in hypertension. Data was obtained of 347 patients from 140 general physicians. The study revealed that losartan potassium is used in the treatment of mild to moderate hypertension with excellent to good response in 98.8% of the cases. Mild adverse reactions were reported in 5.8% of the cases. None of the adverse reactions were severe enough which required discontinuation of therapy or needed hospitalisation. Thus, the present postmarketing surveillance study confirms the safety and efficacy of losartan potassium in Indian population.

Balloon valvuloplasty of stenosed Carpentier-Edwards bioprosthesis at pulmonary position.

Bioprostheses frequently become calcified and stenosed, especially when implanted in younger patients. The general recommendation in such cases is to repeat surgery. Balloon valvuloplasty has hitherto been attempted with mixed success. Calcification and limitation of the balloon size due to the valve ring can lead to suboptimal long-term results. We report a case where balloon dilation of the stenosed bioprosthesis at pulmonary position was successfully performed with good immediate result. Cardiac catheterization after 3 years showed only a minimal increase (5 mmHg) in the gradient.

Anterior mediastinal teratoma presenting as cardiac tamponade.

Anterior mediastinal teratoma presenting clinically as cardiac tamponade is unusual. We report the case of a 58-year-old woman, with an unremarkable prior history, who was admitted with cardiac tamponade. Emergency pericardial aspiration showed a thick, yellow fluid. Computed tomography scan of the chest was suggestive of anterior mediastinal teratoma rupturing into the pericardium. Within 24 hours, just before the planned surgery could be performed, it re-ruptured, warranting emergency surgery. Histopathology confirmed the diagnosis of a teratoma. Early surgery is recommended for even asymptomatic benign mediastinal teratomas to avoid this potentially lethal complication of rupture into the pericardial cavity, and cardiac tamponade.

Combined presence of coronary artery ectasia and descending aortic dissection in polycystic kidney disease presenting as acute coronary syndrome.

We report the unusual case of a 55-year-old man with a history of hypertension and dyslipidemia who presented with acute coronary syndrome. Examination revealed that he had coronary artery ectasia and descending aortic dissection along with polycystic kidney disease.

Pulmonary embolism: an overview.

Pulmonary embolism and deep venous thrombosis account for hundreds of thousands of hospitalisation and afflict millions of individuals worldwide. A brief overview on the subject concerned is presented here.

A novel trigger for acute coronary syndromes: the effect of lunar cycles on the incidence and in-hospital prognosis of acute coronary syndromes--a 3-year retrospective study.

Circadian variations in the incidence of hypertension and coronary events are well known with early morning surges. Effect of lunar cycles on various medical illnesses like seizures and psychiatric disturbances are documented. However, the effect of lunar cycles on coronary events has been sparsely documented. The authors studied the incidence of acute coronary events and admission patterns in the departments of emergency medicine and cardiology. Inclusion criteria included unstable angina, non-ST elevation myocardial infarction (MI) and ST elevation MI. Exclusion criteria included chest pain syndromes which were subsequently deemed non-cardiac by invasive or non-invasive investigations. Data from 1999 to 2001 were analysed. Admissions on full moon days were compared with those on new moon days. There were 30 full moon days and 30 new moon days and 223 admissions on full moon days and 266 on new moon days. This difference was statistically significant [p = .005]. Sixty-seven per cent were males and the rest were females. Subgroup analysis of mortality, postinfarction angina, effect on diabetics and hypertensives were done which showed an increased trend in new moon days. It is concluded that there is increased incidence of acute coronary events associated with new moon days.

Acute intermittent porphyria as a cause of acute respiratory failure.

A fatal case of acute intermittent porphyria in a 22 years old Indian male is reported. He presented with abdominal pain and constipation, subsequently developed status epilepticus, acute respiratory failure and quadriparesis. He succumbed to the illness on the twelfth day. Among the neuromuscular causes of acute respiratory failure, requiring ventilatory support, porphyria is a condition potentially treatable, but rarely suspected.