Prevalence of familial hypercholesterolemia in premature coronary artery disease patients admitted to a tertiary care hospital in North India.

AIMS: The prevalence of premature coronary artery disease (CAD) in India is two to three times more than other ethnic groups. Untreated heterozygous familial hypercholesterolemia (FH) is one of the important causes for premature CAD. As the age advances, these patients without treatment have 100 times increased risk of cardiovascular (CV) mortality resulting from myocardial infarction (MI). Recent evidence suggests that one in 250 individuals may be affected by FH (nearly 40 million people globally). It is indicated that the true global prevalence of FH is underestimated. The true prevalence of FH in India remains unknown. METHODS: A total of 635 patients with premature CAD were assessed for FH using the Dutch Lipid Clinical Network (DLCN) criteria. Based on scores, patients were diagnosed as definite, probable, possible, or no FH. Other CV risk factors known to cause CAD such as smoking, diabetes mellitus, and hypertension were also recorded. RESULTS: Of total 635 patients, 25 (4%) were diagnosed as definite, 70 (11%) as probable, 238 (37%) as possible, and 302 (48%) without FH, suggesting the prevalence of potential (definite + probable) FH of about 15% in the North Indian population. FH is more common in younger patients, and they have lesser incidence of common CV risk factors such as diabetes, hypertension, and smoking than the younger MI patients without FH (26.32% vs.42.59%; 17.89% vs.29.44%; 22.11% vs.40.74%). CONCLUSION: FH prevalence is high among patients with premature CAD admitted to a cardiac unit. To detect patients with FH, routine screening with simple criteria such as family history of premature CAD combined with hypercholesterolemia, and a DLCN criteria score >5 may be effectively used.

Reducing the burden of coronary artery disease in India: challenges and opportunities.

UNLABELLED: Asian Indians--living both in India and abroad--have one of the highest rates of coronary artery disease (CAD) in the world, three times higher than the rates among Caucasians in the United States. The CAD among Indians is usually more aggressive at the time of presentation compared with whites or East Asians. The overall impact is much greater because the CAD in Asian Indians affects the "younger" working population. This kind of disproportionate epidemic among the young Indians is causing tremendous number of work days lost at a time when India is experiencing a dizzying economic boom and needs a healthy populace to sustain this boom. While the mortality and morbidity from CAD has been falling in the western world, it has been climbing to epidemic proportions among the Indian population. Various factors that are thought to contribute to this rising epidemic include urbanization of rural areas, large-scale migration of rural population to urban areas, increase in sedentary lifestyle, abdominal obesity, metabolic syndrome, diabetes, inadequate consumption of fruits and vegetables, increased use of fried, processed and fast foods, tobacco abuse, poor awareness and control of CAD risk factors, unique dyslipidemia (high triglycerides, low HDL-cholesterol levels), and possible genetic predisposition due to lipoprotein (a) [Lp(a)] excess. The effect of established, as well as novel, risk factors is multiplicative, not just additive (total effect>sum of parts). The management would require aggressive individual, societal, and governmental (policy and regulatory) interventions. Indians will require specific lower cut-offs and stricter goals for treatment of various risk factors than is currently recommended for western populations. To this end, the First Indo-US Healthcare Summit was held in New Delhi, India on December 14 and 15, 2007. The participants included representatives from several professional entities including the American Association of Physicians of Indian origin (AAPI), Indian Medical Association (IMA), Medical Council of India (MCI), and Government of India (GOI) with their main objective to address specific issues and provide precise recommendations to implement the prevention of CAD among Indians. The summary of the deliberations by the committee on "CAD among Asian Indians" and the recommendations are presented in this document. OBJECTIVES: Discussion of demographics of CAD in Indians-both in India and abroad, current treatment strategies, primordial, primary, and secondary prevention. Development of specific recommendations for screening, evaluation and management for the prevention of CAD disease epidemic among Asian Indians. Recommendations for improving quality of care through professional, public and private initiatives.

To study the effect of high dose Atorvastatin 40mg versus 80mg in patients with dyslipidemia.

OBJECTIVE: Primary objective was to compare the effects of atorvastatin 40mg vs 80mg on LDL-C in Indian patients with atherosclerotic dyslipidemia. Secondary objectives were to compare the effects of atorvastatin 40mg vs 80mg on HDL-C and triglycerides and also comparing of side effects (myopathy, hepatotoxicity and new onset diabetes mellitus) of both doses. METHOD: This Study is A Prospective, randomized, open-label, comparative study. This study was conducted on 240 patients of dyslipidemia (as per ACC/AHA 2013 lipid guidelines) attending the OPD/wards/CCU of department of cardiology, Sir Ganga Ram Hospital. They were randomly divided into 2 groups of 120 each. Group A consisted patients who received Atorvastatin 40mg daily and Group B Atorvastatin 80mg daily. The follow up period was 6 months. RESULTS: At 3 and 6 month follow up, Atorvastatin 40mg leads to mean LDL cholesterol reduction of 47.18±20.81 & 50.03±18.06 respectively. While Atorvastatin 80mg results in LDL reduction as 50.11±15.85 & 52.30±13.72. The comparison between two doses revealed a non-significant difference (p=.118 & p=.149 respectively). At 6 months of follow up, few patients reported myalgia (2 in group A and 7 in Group B). The difference between groups was significant (p=.045). Although none of our patient had significant elevation of CPK. CONCLUSION: This study concluded that both doses of atorvastatin (40 & 80mg) are equally efficacious in improving dyslipidemia but higher dose leads to more incidence of myalgia.

Serum lipid response to introducing ghee as a partial replacement for mustard oil in the diet of healthy young Indians.

Ghee (clarified butter) has generally been assumed to be hypercholesterolaemic on the basis of its composition but there is hardly any study to support or refute the assumption. The present study was conducted on sixty-three healthy, young, physically active adult volunteers (52 male, 11 female). The study design was that of a randomized controlled trial with a parallel design. After a lead-in period of 2 wk, the subjects were randomly divided into two groups, Group A (n = 30; 25 male, 5 female) and Group B (n = 33; 27 male, 6 female). Group A (experimental) consumed for 8 wk a diet in which ghee provided 10% of the energy intake. The only other visible fat in the diet was mustard oil, and total energy from fats was 25% of the energy intake. Group B (control) consumed for 8 wk a similar diet except that all visible fat came from mustard oil. The serum total cholesterol level showed a significant rise in the experimental group at 4 wk; the rise persisted at 8 wk. A similar rise was also seen in HDL cholesterol. Hence the total cholesterol/HDL cholesterol ratio did not show any significant change. In the control group, there was a trend towards a fall in LDL cholesterol but the change was not significant. The study does not indicate any adverse effect of ghee on lipoprotein profile. However, more studies are needed on older subjects, hyperlipidaemic subjects, and on subjects following less healthy lifestyles before the results of this study can be extrapolated to the general population.

Apolipoprotein C3 SstI polymorphism and triglyceride levels in Asian Indians.

BACKGROUND: A close association between Sst I polymorphism in the 3' untranslated region of the apolipoproteinC3 (APOC3) gene and levels of plasma triglycerides (TG) had been reported by different investigators. Hypertriglyceridemia(HTG) is a known risk factor for coronary artery disease (CAD) in the context of Asian Indians. We conducted a study on the relationship between APOC3 SstI polymorphism (S1S1, S1S2 and S2S2 genotypes) and plasma TG levels in a group of 139 male healthy volunteers from Northern India. METHODS: DNA samples were analyzed by polymerase chain reaction (PCR) followed by SstI digestion. Digested PCR products were run on 3% agarose gel and visualized by ethidium bromide staining. RESULTS: Rare S2 allele was highly prevalent in our study population (0.313) as compared to the Caucasians (0.00-0.11). The genotypic distribution was in agreement with Hardy-Weinberg equilibrium. S2 allele was almost two times more prevalent in the HTG group (N = 34) as compared to NTG group (N = 105) (p = 0.001). Multiple logistic regression revealed S1S2 individuals had age-adjusted odds ratio of 2.43 (95%CI = 0.99-6.01, p = 0.054) and S2S2 had 9.9 (95%CI = 2.66-37.29, p = 0.0006) for developing HTG in comparison to S1S1 genotype. CONCLUSIONS: Our study shows a significant association between rare S2 allele and HTG in Asian Indians.

Protective actions of a thromboxane receptor antagonist, SQ 29548 on the ischemic myocardium: morphologic and hemodynamic effects.

The effects of thromboxane A2 (TXA2)/prostaglandin endoperoxide receptor blockade on myocardial infarct size and cardiac dynamics were determined in a canine model of 24 h acute myocardial infarction. Anesthetized open-chest dogs were subjected to left anterior descending (LAD) coronary artery occlusion. Twenty minutes post-occlusion the dogs were given i.v. saline (0.9% NaCl solution) (n = 12) or the TXA2 receptor antagonist SQ 29548 (0.2 mg/kg i.v. loading dose +0.2 mg/kg/h i.v. for 4 h) (n = 10). SQ 29548 treatment resulted in a significant (P < 0.01) reduction in infarct size. Heart rate (HR) and systolic blood pressure (SAP) were not markedly affected by the drug. The sharp rise in the left ventricular end diastolic pressure (LVEDP) in the saline-treated animals was significantly lowered by SQ 29548 treatment and the correction of this variable was maintained till 24 h post-occlusion. The lowered maximal rate of rise of left ventricular pressure (LVdP/dt max) in the saline-treated animals was corrected albeit non-significantly by the drug treatment. Thus, SQ 29548 treatment resulted in a significant salvage of myocardial tissue and marked alterations in left ventricular dynamics. The study suggests a deleterious role for thromboxane A2 in ischemia; indicating that TXA2 blockade may have potential as a mode of therapy for ischemic heart disease.

The involvement of the sympathetic nervous system in the centrogenic pressor and tachycardiac effects of prostaglandins E2 and F2 alpha in anaesthetised cats.

The intracerebroventricular (i.c.v.) administration of prostaglandin E2 (PGE2, 1 micrograms) and prostaglandin F2 alpha (PGF2 alpha, 10 micrograms) produced prolonged pressor and tachycardiac responses in chloralose-anaesthetised cats. Phenoxybenzamine-pretreatment completely prevented the pressor response without altering the tachycardiac response, whereas propranolol intervention completely inhibited the tachycardiac response and also attenuated the pressor response. The pretreatment with pentolinium completely antagonised both the pressor and tachycardiac responses to i.c.v. PGE2 and PGF2 alpha. The results suggest that the centrally administered PGE2 and PGF2 alpha augment sympathetic outflow to the heart and vascular system and thereby cause excitatory cardiovascular responses in anaesthetised cats.

Combination treatment with trimetazidine and diltiazem in stable angina pectoris.

OBJECTIVE: To assess antianginal efficacy and possible adverse haemodynamic effects of combination treatment with trimetazidine and diltiazem in patients with stable angina. DESIGN: Double blind, randomised, placebo controlled trial of four weeks duration. SETTING: Outpatient department of two Indian hospitals. SUBJECTS: 64 male patients with stable angina, uncontrolled on diltiazem alone. INTERVENTIONS: Diltiazem 180 mg and trimetazidine 60 mg, or diltiazem 180 mg and placebo daily. MAIN OUTCOME MEASURE: Change in exercise time to 1 mm ST segment depression. RESULTS: 33 patients (55%) had no exercise induced angina at 3 mm ST segment depression at inclusion in the study (silent ischaemia). Intention to treat analysis showed that of 32 patients in each treatment group, the number (%) of patients responding to trimetazidine compared to placebo was: for anginal attacks, 28 (87.5) v 15 (46.9), p < 0.001; for exercise time to 1 mm ST segment depression, 21 (65.6) v 9 (28.1), p < 0.003; for exercise time to angina, 12 (37.5) v 5 (15.6), p < 0.05; and for maximum work at peak exercise, 17 (53.1) v 8 (25), p < 0.02. Compared to placebo, there was net improvement with trimetazidine in mean anginal attacks of 4.8/ week (95% confidence interval (CI) 7.5 to 2.1; p < 0.002); in mean exercise times at 1 mm ST segment depression of 94.2 seconds (95% CI 182.8 to 5.6; p < 0.05), and at onset of angina of 113.1 seconds (95% CI 181.6 to 44.6; p < 0.02); and in mean maximum work at peak exercise of 1.4 metabolic equivalents (95% CI 2.4 to 0.3; p < 0.05). CONCLUSIONS: Patients with stable angina uncontrolled with diltiazem had a clinically important improvement after combination treatment with trimetazidine, without adverse haemodynamic events or increased side effects.

The vagal involvement in the antiarrhythmic and arrhythmogenic effects of prostaglandin F2 alpha on ouabain-induced cardiac arrhythmias in cats.

The effects of prostaglandin F2 alpha (PGF2 alpha) on ouabain-induced cardiac arrhythmias were investigated in chloralose-anaesthetized cats. Bilateral vagotomy and atropine intervention were employed to elucidate the involvement of vagal neural influences. PGF2 alpha (2-16 micrograms/kg i.v. bolus) predominantly suppressed the ouabain-induced ventricular and supraventricular arrhythmias and less commonly aggravated them in vagi-intact cats. The antiarrhythmic effect of PGF2 alpha was considerably, but not statistically significantly, decreased while its arrhythmogenic effect was significantly (p less than 0.05) increased in atropine-pretreated group. In vagotomised group PGF2 alpha failed to abolish the arrhythmias but it aggravated them to a degree comparable to that observed in vagi-intact group. It is concluded that the PGF2 alpha exhibits both antiarrhythmic and arrhythmogenic properties and these are largely due to elicitation of two opposing neural reflexes - one being protective and another being deleterious to ouabain-induced arrhythmias.

Treatment of stable angina with low dose diltiazem in combination with the metabolic agent trimetazidine.

BACKGROUND: The risk/benefit of moderate to high doses of calcium antagonists in stable angina is uncertain. This study investigates the efficacy and acceptability of low dose diltiazem in combination with trimetazidine for the treatment of stable angina. METHODS: In a 28-day, randomized, double blind study, treatment with 90 mg diltiazem in combination with 60 mg trimetazidine or placebo per day was compared in 50 patients with stable angina. The primary outcomes were time to 1-mm ST segment depression and the Duke treadmill score. RESULTS: Of the 25 patients in each treatment group, the number (%) of patients responding to trimetazidine compared to placebo was, in time to 1-mm ST segment depression, 13 (52) versus 5 (20), P<0.05; in the Duke treadmill score, 18 (72) versus 8 (32), P<0.01; and in angina 17 (68) versus 3 (12), P<0.01. Compared to placebo there was an improvement with trimetazidine in mean exercise time to 1-mm ST segment depression of 128 s (95% confidence interval 45.0-208.5; P<0.01); in the mean Duke treadmill score of 57.4% (95% confidence interval 9.9-100; P<0.02); and in mean anginal attacks of 5.1 per week (95% confidence interval, 3.1-7.3, P<0.01). CONCLUSION: The combination of low dose diltiazem with trimetazidine is effective with few side-effects in the symptomatic control of patients with stable angina.

Reduced physical work capacity at high altitude--a role for left ventricular dysfunction.

Physical work capacity is reduced in sea level residents--lowlanders (LL) as compared to high altitude residents--highlanders (HL). To determine possible etiologies, cardiac performance was studied in two groups of healthy male volunteers (13 LL and 11 HL) utilizing systolic time intervals during rest, submaximal and maximal exercise. The LL were studied at sea level and subsequently during 10 days of residence at an altitude of 3658 m. The HL were studied at high altitude alone. The LL were restudied 30-45 min after administration of intravenous furosemide at high altitude. Mean maximal oxygen uptake (VO2max) was reduced by 26% in the LL group at high altitude in comparison to sea level values and by 20% in relation to the HL group. Cardiac performance was estimated by the pre-ejection period/left ventricular ejection time ratio. This index was significantly increased in the LL group at high altitude in comparison to sea level values during submaximal and maximal exercise (P less than 0.01). Intravenous furosemide in the LL group increased the heart rate (P less than 0.05) at rest and during exercise but VO2max and cardiac performance were unchanged. It is hypothesized that reduced physical work capacity at high altitude in the LL group may be related to depression of cardiac performance in these subjects. Administration of intravenous furosemide did not influence cardiac performance in the LL group at high altitude.

Comparative evaluation of transthoracic and transesophageal echocardiography in detection of left atrial thrombus before percutaneous transvenous mitral commissurotomy. Do all patients need transesophageal examination?

We postulated that the sensitivity of transthoracic echocardiography in detection of left atrial cavity or appendage thrombi is better in south-east asian patients with rheumatic mitral stenosis. This was considering that these patients are generally younger, have lesser body weight and thinner chest walls resulting in better transthoracic echogenecity than their western counterparts. We prospectively performed transthoracic and transoesophageal echocardiography in 150 consecutive Indian patients (mean age 28.8+/-7.2 years; 78 men) being evaluated for percutaneous transvenous mitral commissurotomy. The overall sensitivity of transthoracic echocardiography was 74% (95% C.I. 59-88%). This was significantly higher than the pooled estimate from five western reports which evaluated similar patients (overall sensitivity 12%; 95% C.I. 0-25%; P<0.0001). The sensitivity rose to 83% when patients with poor echogenecity were excluded. Amongst patients with good echogenecity (81% patients) the diagnosis of left atrial thrombi was correctly made or suspected on transthoracic examination in all patients subsequently shown to have thrombi on transoesophageal echocardiography. Significant savings in cost may be safely achieved by limiting transoesophageal echocardiography to patients in whom left atrial cavity or appendage is not adequately visualized on transthoracic examination due to poor echogenecity, or in whom there are shadows suggestive but not diagnostic of thrombi.

Percutaneous balloon mitral valvuloplasty using the Inoue balloon: analysis of echocardiographic and other variables related to immediate outcome.

To determine whether the mitral valve morphology influences the results of percutaneous balloon mitral valvuloplasty for mitral stenosis, two-dimensional echocardiography was performed before valvuloplasty in 126 patients (mean age 25.5+/-9.4 years) and in 30 normal controls. The 2D echocardiographic features of mitral valve leaflets: thickness, length and motion; diastolic mitral valvular excursion; chordal length; mitral annular diameter; subvalvular distance ratio; distance between mid mitral annulus to left ventricular apex, base and tip of papillary muscle and effective balloon dilating area, effective balloon dilating area/body surface area and effective balloon dilating diameter/mitral annular diameter were then correlated to the immediate post-valvuloplasty mitral valve area. For the total patients population, post-valvuloplasty valve area increased from 0.67+/-0.17 to 2.1+/-0.86 cm2 (P<0.0001), mean transmitral diastolic gradient decreased from 24.5+/-9.0 to 6.0+/-3.0 mm Hg (P<0.0001), mean left atrial pressure decreased from 29.7+/-6.2 to 12.7+/-4.8 mm Hg (P<0.0001), mean pulmonary artery pressure decreased from 44.8+/-14.2 to 25.4+/-9.5 mm Hg (P<0.0001) and cardiac index increased from 2.7+/-0.38 to 3.1+/-0.55 l/min/m2 (P<0.0001). The patients were divided into three groups on the basis of post-valvuloplasty mitral valve area. Group I had valve area <1.5 cm2, group II had valve area from 1.5 to 1.9 cm2 and group III had valve area > or =2.0 cm2. On comparison, no statistically significant difference was found in any of the echocardiographic variables in the three groups. On univariate, multivariate, multiple regression and discriminate function analysis, none of the variables were found to have significant influence on immediate result of valvuloplasty. There was no significant difference in the incidence of mitral regurgitation in any of the three groups. We conclude that the extent of mitral valvular and subvalvular deformity do not have a significant effect on the immediate outcome of mitral valvuloplasty using the Inoue balloon and it can be successfully performed in patients with severe subvalvular fibrosis. Unique balloon geometry and stepwise balloon sizing may explain these acceptable immediate results in severely deformed valves.

Critical appraisal of left ventricular function assessment by the automated border detection method on echocardiography. Is it good enough?

Many studies have attempted to validate the echocardiographic automated border detection (ABD) method for assessing left ventricular ejection fraction (LVEF) by comparing it with various echocardiographic and non-echocardiographic standards. The main basis of assessing its accuracy has been the coefficient of correlation. The fallacy of using coefficient of correlation for assessing agreement between two methods of measurement has been well emphasized in the literature. In the present study we used the Bland and Altman test for testing the accuracy of the ABD method. We compared the ABD method for LVEF assessment with the manual edge detection technique on echocardiography and with radionuclide ventriculography in 34 patients. The majority of patients (76%) had regional wall motion abnormality. The ABD method could be adequately performed in 25 (74%) patients. LVEF was significantly underestimated by the ABD method with very wide limits of agreement when compared with radionuclide ventriculography and the manual edge detection technique (-9.2+/-21.7 and -2.7+/-18.4 respectively, mean error+/-2 standard deviations). Stated simply, the ABD method could overestimate LVEF by 12.5 and 15.7 or underestimate by 30.9 and 21.1 when compared with radionuclide ventriculography and manual edge detection technique, respectively. This large error is by no means acceptable for clinical purposes. It is concluded that at the present stage, the ABD method cannot replace radionuclide ventriculography and manual edge detection technique for assessing LVEF.

Cardiac myxomas: clinical and echocardiographic profile.

We reviewed our clinical and echocardiographic experience in 70 consecutive patients with 73 cardiac myxomas, diagnosed over an 11 year period. There were 21 males and 49 females, ages ranged from 18 to 80 years. Only in 5.7% cases was the diagnosis of myxomas made clinically. 88.6% cases were initially diagnosed as having: mitral valve disease (70%), tricuspid valve disease (10%), ischemic heart disease (5.7%), cardiomyopathy (2.9%), and the remaining 5.7% were detected during family screening and follow-up. The mean duration of symptoms was 10.6 months. The commonest symptom was dyspnoea (80%), followed by constitutional symptoms (45.7%), embolization (30%), palpitation (25.7%), syncope (15.7%), pedal oedema (15.7%) and pain chest (12.9%). The sites of myxomas were as follows: left atrium, 58; right atrium, 9; and, biatrium, 3. All myxomas except 3 were attached to the interatrial septum. The site, size, shape, attachment, mobility, prolapse into ventricle, and surface characteristic of myxomas were accurately assessed by 2D-echocardiography and confirmed in all (65 of 70) who underwent surgery. When the morphological characteristic of myxomas were studied and correlated with clinical features large left atrial myxoma size was closely related with constitutional symptoms, congestive heart failure, with syncope and auscultatory findings suggestive of mitral valve disease, whereas smaller myxoma size and irregular surface were associated with embolization. Constitutional symptoms were only present in left atrial myxoma. Post-operative mean echocardiographic follow-up of 60 months showed no recurrence except in 2 with familial myxoma. We conclude that the majority of myxomas mimic many cardiovascular diseases and were detected in symptomatic patients, so a high index of clinical suspicion is important for its early and correct diagnosis. The size and appearance of the myxomas correlated with the presenting symptoms.

Clinical and echocardiographic predictors of left atrial clot and spontaneous echo contrast in patients with severe rheumatic mitral stenosis: a prospective study in 200 patients by transesophageal echocardiography.

The objective of this study was to prospectively investigate various clinical and echocardiographic variables to predict the left atrial and left atrial appendage clot and spontaneous echo contrast in patients with severe rheumatic mitral stenosis. We studied 200 consecutive patients (112 males and 88 females; mean age 29.6+/-9.6 years). Left atrial clot and spontaneous echo contrast were present in 26 and 53.5% of cases, respectively. There were no significant differences in the mitral valve area, mean transmitral diastolic gradient and left ventricular ejection fraction between patients with and without clot. Patients with clot were older (34.4+/-11.4 vs. 28.2+/-8.5 years, P<0.001), had longer duration of symptoms (41. 4+/-36.0 vs. 28.8+/-22.9 months, P<0.001), more frequent atrial fibrillation and spontaneous echo contrast (69.2 vs. 16.9%, P<0. 00001 and 76.9 vs. 45.3%, P<0.00001, respectively) and larger left atrial area and diameter (41.0+/-12.7 vs. 29.9+/-7.4 cm(2), P<0.00001 and 53.9+/-8.3 vs. 47.6+/-7.4 mm, P<0.0001, respectively) as compared to patients without clot. Similarly patients with spontaneous echo contrast were older (31+/-10.4 vs. 27.8+/-8.3 years, P<0.01), had more frequent atrial fibrillation (48.6 vs. 9.7%, P<0.0001), left atrial clot (37.4 vs. 12.9%, P<0.0001), larger left atrial area and diameter (37.6+/-11.2 vs. 28.1+/-6.7 cm(2), P<0.00001 and 52.2+/-8.3 vs. 45.9+/-6.5 mm, P<0.00001, respectively) and smaller mitral valve area (0.77+/-0.14 vs. 0.84+/-0.13 cm(2), P<0.01) as compared to patients without spontaneous echo contrast. There were no significant differences in the mean transmitral diastolic gradient and left ventricular ejection fraction. On multiple regression and discriminant function analysis, atrial fibrillation and left atrial area were independent predictors of left atrial clot formation. In a subgroup of patients with sinus rhythm, larger left atrial area and presence of spontaneous echo contrast were significantly associated with the presence of clot in left atrium and appendage. We conclude that in patients with severe mitral stenosis, the presence of atrial fibrillation and in the subgroup of the patients with sinus rhythm the presence of large left atrium (> or =40 cm(2)) and spontaneous echo contrast were associated with higher risk of clot formation in the left atrium and might be benefited by prophylactic anticoagulation.

Garlic-induced alteration in rat liver and kidney morphology and associated changes in endogenous antioxidant status.

The effects of chronic garlic intake on various endogenous antioxidant enzymes and lipid peroxidation on two major organs, the liver (L) and kidneys (K), were investigated. Wistar albino rats were fed with fresh garlic homogenate daily by gavage in three different doses (250, 500 and 1000 mg/kg/day) for 30 days. After this period, rats were sacrificed and liver and kidneys were harvested for biochemical estimation. In comparison to saline-treated rats, the 250 mg/kg/day dose significantly (P<0.02) reduced thiobarbituric acid reactive substances (TBARS) (L: 187.48+/-9.23 vs 150.66+/-11.45; K: 177.38 15.88 vs 120.66+/-9.39 nmol/g wet. weight) and glutathione peroxidase (GPx) (L: 0.2438+/-0.05 vs 0.0046+/-0.0005; K: 0.1459+/-0.034 vs 0.0055+/-0.0003 U/mg protein). There was no change in catalase and reduced glutathione (GSH) but superoxide dismutase (SOD) increased significantly (P<0.01) (L: 5.49+/-0.76 vs 18.38+/-2.26; K: 11.47+/-1.48 vs 21.22+/-3.19 U/mg protein). Both 500 and 1000 mg/kg/day doses significantly (P<0.05) reduced endogenous antioxidants (catalase and SOD) without altering TBARS. A 1000 mg/kg/day dose of garlic caused marked histopathological and ultrastructural changes in both liver and kidneys. The results suggest that garlic in low doses has the potential to enhance the endogenous antioxidant status, although at higher doses a reversal of these effects is observed. The present study also highlights the potential ability of a high dose of garlic to induce morphological changes in the liver and kidneys, indicating the need to identify a safe dose range for garlic.

Successful inoue balloon valvotomy in a difficult case of mitral stenosis using multiple modifications of technique: alternative method for loop formation of the Inoue balloon catheter.

Transseptal puncture was accomplished with difficulty at an unfavorable site in a case of severe mitral stenosis with distorted atrial and septal anatomy. Septal balloon entrapment could not be avoided during attempts to cross the mitral valve using the standard technique. This problem was circumvented by resorting to the loop method and the left ventricle was entered first with a guidewire, which then supported the balloon catheter. Successful mitral valve dilatation could thus be performed. A simple alternative method that was used to form the Inoue balloon catheter into a loop is also described.

Silent myocardial ischemia after percutaneous transluminal coronary angioplasty and its prognostic significance.

A cohort of 175 patients who underwent successful percutaneous transluminal coronary angioplasty (PTCA) were subjected to a treadmill exercise test to determine the prognostic significance of silent and symptomatic myocardial ischemia during the follow-up (average 11.7 months). The cardiac events during the follow-up were defined as cardiac death, nonfatal myocardial infarction, class III angina, and need for repeat angioplasty or coronary artery bypass surgery. During exercise, 39 patients (22%) had abnormal exercise-induced ST depression without chest pain (Group I). A group of 22 patients (13%) had both exercise-induced chest pain and ST-segment depression (Group II), and 114 patients (65%) had normal exercise test and no chest pain (Group III). The groups were similar in sex distribution, history of previous myocardial infarction, distribution of vessel disease, and presence of left ventricular dysfunction. Group III included more patients with complete revascularization. Follow-up data revealed that cardiac event rates in Groups I and II were significantly higher than in Group III (41%, 41%, vs. 16%) (p less than 0.01). The event rates in Groups I and II with multivessel angioplasty also were significantly higher than in Group III (58%, 61%, vs. 21%) (p less than 0.01). Exercise-induced silent myocardial ischemia is frequently seen early after successful PTCA and is more prevalent in patients undergoing multivessel angioplasty and incomplete revascularization. Both silent and symptomatic ischemia early after PTCA are predictors of an unfavorable prognosis.

Effect of chronic treatment with bark of Terminalia arjuna: a study on the isolated ischemic-reperfused rat heart.

Dried pulverized bark of Terminalia arjuna Linn (TA) was administered orally to Wistar albino rats (120-150 g) in two doses [500 and 750 mg/kg in 2% carboxy methyl cellulose (CMC)], 6 days per week for 12 weeks. Thereafter, rats were sacrificed either for determination of baseline changes in cardiac endogenous antioxidant compounds [superoxide dismutase (SOD), reduced glutathione (GSH) and catalase (CAT)] or the hearts were subjected to oxidative stress associated with in vitro ischemic-reperfusion injury (IRI). There was significant increase in the baseline contents of thiobarbituric acid reactive substance (TBARS) (a measure of lipid peroxidation) with both doses of TA. However, only in the 500 mg/kg treated group, this was accompanied by a simultaneous increase in SOD, GSH and CAT levels, but not in the 750 mg/kg treated group, where only CAT was raised. Significant rise in myocardial TBARS and loss of SOD, CAT and GSH (suggestive of increased oxidative stress) occurred in the vehicle-treated hearts subjected to in vitro IRI. Only hearts, harvested from the 500 mg/kg rats treated rats, were significantly protected from oxidative stress, when subjected to in vitro IRI. The results suggest that crude bark of TA augments endogenous antioxidant compounds of rat heart and also prevents oxidative stress associated with IRI of the heart.