Immediate impact of percutaneous transvenous mitral commisurotomy on right ventricle longitudinal strain in patients of mitral stenosis.

BACKGROUND: Right ventricular (RV) function has prognostic value in terms of survival and symptoms in patients with mitral stenosis (MS). The aim of the study was to assess RV function by strain analysis in the patients of mitral stenosis and the effect of percutaneous transvenous mitral commisurotomy (PTMC) on it. METHODS: Eighty patients of severe mitral stenosis without overt right heart failure and normal sinus rhythm undergoing PTMC were included. Conventional echocardiography and RV function by TDI-derived longitudinal strain and strain rate were assessed prior and 24 hours post PTMC and compared with 40 healthy age-matched controls. RESULTS: Eighty subjects (mean age 31 + 10 years, 70% females) were included. Patients with MS had significantly lower RV strain of basal and mid-free wall, tricuspid annular plane systolic excursion (TAPSE), and RV fractional area change (FAC) as compared to controls. There was a significant increase in pre- and post-PTMC in TAPSE (19.5 ± 2.7 mm vs 21.4 ± 3.3 mm; P < 0.001), RV basal free wall longitudinal strain (-24.4 + 6.1% vs -27.7 + 5.8%; P < 0.001), and right ventricle mid-free wall longitudinal strain (-25.6 + 5.5% vs -28.6 + 5.1%; P < 0.001), respectively. There was no significant change in RV Tei index (0.43 + 0.06 vs 0.41 + 0.03; P = 0.06). There was a significant negative correlation between RV longitudinal strain and right ventricle systolic pressure, left atrium diameter, RV Tei index, and pulmonary capillary wedge pressure, and positive correlation between RV FAC and RV TAPSE. CONCLUSION: Patients with severe MS with normal RV systolic function had decreased RV strain, which was significantly increased after a successful PTMC with reduction in afterload.

Investigation of OPG/RANK/RANKL Genes as a Genetic Marker for Cardiac abnormalities in Thalassemia Major Patients.

OBJECTIVE: The aim of the study was to investigate the role of osteoprotegerin (OPG)/RANK/RANKL variants in left ventricular hypertrophy (LVH) and diastolic dysfunction in thalassemia major patients MATERIALS AND METHOD: One hundred and five beta-thalassemia patients who were older than 10 years of age were enrolled for the study. Two-dimensional and M-mode echocardiography analysis was done in all patients. Genotyping for OPG [rs2073617 (950 T>C), rs2073618 (1181G>C)], RANK [(rs1805034(+34694 C>T), rs12458117 (+34901 G>A) and rs75404003 (+35966insdelC)], and RANKL (rs2277438, rs9594782) variants was done using the PCR-RFLP method. Serum OPG levels were estimated by ELISA. RESULTS: Mean age of patients was 16.36 ± 5.08 years. LVH and diastolic dysfunction was present in 33 (31.4%) and 24 (22.8%) patients, respectively. Thalassemia patients having minor allele of OPG rs2073618, RANK rs75404003 and RANKL rs9594782 SNPs were at high risk for LVH as suggested by high odds ratio of 2.470, 3.783, and 2.148, respectively; however, none of the SNPs tested were statistically significantly associated after applying Bonferroni corrections for multiple testing adjustment. No significant association of any SNP with diastolic dysfunction was observed. Serum OPG levels were found significantly higher in thalassemia patients with diastolic dysfunction (P = 0.006). CONCLUSION: OPG rs2073618, RANK rs75404003, and RANKL rs9594782 SNPs may predispose LVH in thalassemia patients. Patients with diastolic dysfunction showed increased levels of serum OPG.

Do practice gaps exist in evidence-based medication prescription at hospital discharge in patients undergoing coronary artery bypass surgery & coronary angioplasty?

BACKGROUND & OBJECTIVES: Prescription patterns of guideline-directed medical therapy (GDMT) after coronary artery bypass surgery [coronary artery bypass graft (CABG)] and percutaneous coronary intervention (PCI) at hospital discharge are often not optimal. In view of scarce data from the developing world, a retrospective analysis of medication advice to patients following CABG and PCI was conducted. METHODS: Records of 5948 patients (post-PCI: 5152, post-CABG: 796) who underwent revascularization from 2010 to 2014 at a single tertiary care centre in north India were analyzed. RESULTS: While age and gender distributions were similar, diabetes and stable angina were more frequent in CABG group. Prescription rates for aspirin 100 per cent versus 98.2 per cent were similar, while beta-blockers (BBs, 95.2 vs 90%), statins (98.2 vs 91.6%), angiotensin-converting enzyme inhibitors (89.4 vs 41.4%), nitrates (51.2 vs 1.1%) and calcium channel blockers (6.6 vs 1.6%) were more frequently prescribed following PCI. Despite similar baseline left ventricular ejection fraction (48.1 vs 51.1%), diuretics were prescribed almost universally post-CABG (98.2 vs 10.9%, P<0.001). Nearly all (94.4%) post-CABG patients received a prescription for clopidogrel. Patients undergoing PCI were much more likely to receive higher statin dose; 40-80 mg atorvastatin (72 vs <1%, P<0.001) and a higher dose of BB. INTERPRETATION & CONCLUSIONS: Significant differences in prescription of GDMT between PCI and CABG patients existed at hospital discharge. A substantial proportion of post-CABG patients did not receive BB and/or statins. These patients were also less likely to receive high-dose statin or optimal BB dose and more likely to routinely receive clopidogrel and diuretics. Such deviations from GDMT need to be rectified to improve quality of cardiac care after coronary revascularization.

Evidence of apoptosis in right ventricular dysfunction in rheumatic mitral valve stenosis.

BACKGROUND & OBJECTIVES: Right ventricular (RV) dysfunction is one of the causes of morbidity and mortality in valvular heart disease. The phenomenon of apoptosis, though rare in cardiac muscle may contribute to loss of its function. Role of apoptosis in RV in patients with rheumatic valvular heart disease is investigated in this study. METHODS: Patients with rheumatic mitral valve stenosis formed two groups based on RV systolic pressure (RVSP) as RVSP <40 mmHg (group I, n=9) and RVSP ≥40 mmHg (group II, n=30). Patients having atrial septal defect (ASD) with RVSP <40 mmHg served as control (group III, n=15). Myocardial performance index was assessed for RV function. Real-time polymerase chain reaction was performed on muscle biopsy procured from RV to assess expression of pro-apoptotic genes (Bax, cytochrome c, caspase 3 and Fas) and anti-apoptotic genes (Bcl-2). Apoptosis was confirmed by histopathology and terminal deoxynucleotide-transferase-mediated dUTP nick end labelling. RESULTS: Group II had significant RV dysfunction compared to group I (P=0.05) while caspase 3 (P=0.01) and cytochrome c (P=0.03) were expressed excessively in group I. When group I was compared to group III (control), though there was no difference in RV function, a highly significant expression of pro-apoptotic genes was observed in group I (Bax, P=0.02, cytochrome c=0.001 and caspase 3=0.01). There was a positive correlation between pro-apoptotic genes. Nuclear degeneration was present conforming to apoptosis in valve disease patients (groups I and II) while it was absent in patients with ASD. INTERPRETATION & CONCLUSION: Our findings showed evidence of apoptosis in RV of patients with valvular heart disease. Apoptosis was set early in the course of rheumatic valve disease even with lower RVSP, followed by RV dysfunction; however, expression of pro-apoptotic genes regressed.

Assessment of endothelial dysfunction in Asian Indian patients with chronic kidney disease and changes following renal transplantation.

BACKGROUND: Endothelial dysfunction may explain increased cardiovascular risk in patients with chronic kidney disease (CKD). METHODS: Brachial artery was imaged during reactive hyperemia (endothelium-dependent, flow-mediated dilatation, FMD) and during glyceryl trinitrate-mediated dilatation (nitroglycerine-mediated dilatation, NMD, endothelium-independent) in 108 patients with CKD and three months following renal transplantation (RT) in 60 of them. RESULTS: Patients with CKD had significantly lower FMD vs. controls (9.1% vs. 18.3%, p < 0.001) while NMD was comparable (19.8% vs. 21.8%, p = ns). Impaired FMD (<4.5%) was observed in 26.8% patients with CKD and was more common in those on hemodialysis (HD; 28.4% vs. 15.4%) vs. those not on dialysis. FMD for patients with glomerular filtration rate (GFR) 15-60 vs. <15 mL/min/1.73 m(2) was 12.9% and 8.8% (p = 0.05; respectively -29% and -52% lower vs. controls), indicating reduced FMD with increasing CKD severity. There was +72% increase in FMD following RT (9.1 to 15.7%, p < 0.001) while mean NMD was unchanged. Following RT, only 3.3% had impaired FMD. CONCLUSIONS: Patients with CKD have endothelial dysfunction as evidenced by reduced FMD. Decreased FMD indicating worsening endothelial function was noted with increasing severity of CKD. Within three months of RT, there was significant improvement in FMD, while NMD values did not change.

Does high dose statin pretreatment affect global strains in patients undergoing valve replacement.

Purpose: To study the effect of rosuvastatin 40 mg (initiated 7 days prior to surgery) in patients undergoing valve replacement (VR) for rheumatic mitral valve disease on left ventricular (LV) strain and biomarker release kinetics. Methods: In this randomized study, cardiac biomarkers viz. troponin I (TnI), Creatine kinase MB (CK-MB), N-terminal pro B-type natriuretic peptide (NTPBNP) were measured before surgery; and 8, 24 and 48 h postoperatively. Global LV (circumferential, global circumferential strain (GCS); longitudinal, GLS; radial, global radial strain (GRS)) strains were measured preoperatively; and 48 h and 30 days postoperatively. Results: Following VR, Global Longitudinal Strain (GLS), Global Circumferential Strain (GCS) and Global Radial Strain (GRS) declined at 48 h in both statin loaded (SL) and non loaded (NL) groups. The %decline in strain was significantly lower in SL group (% change in GLS 35.8% vs 38.8%, GCS 34% vs 44.1%, GRS 45.7% vs 52.6%; p < 0.001).All strain values improved at 30 days with higher improvement in SL group (GLS -15.92 ± 2.00% vs -12.6 ± 1.66%, GCS -15.12 ± 2.93% vs -13.04 ± 2.44%; GRS 22.12 ± 6.85% vs 19.32 ± 6.48%). While TnI, CKMB, NTPBNP increased following surgery, values at 8, 24 and 48 h were lower in the SL vs. NL group. Mean change (baseline to peak biomarker value) was also significantly lower in SL group.The SL group had shorter hospital and Intensive Care Unit (ICU) stay. On Receiver Operating Characteristic Curve (ROC) analysis, baseline GCS ≤ 14% best predicted postoperative 30 day Left Ventricular Ejection Fraction (LVEF) ≤ 50%. Conclusion: Pre-operative high dose rosuvastatin was "cardioprotective" with favorable effect on LV global strain and release kinetics of biomarkers. These cut-offs (described for the first time for rheumatic VR) can be used as prognostic predictors.

Erectile dysfunction precedes and is associated with severity of coronary artery disease among Asian Indians.

INTRODUCTION: Erectile dysfunction (ED) and coronary artery disease (CAD) often share common risk factors, and there is growing evidence that ED might serve as a clinical marker for cardiovascular disease. Despite rising trends of CAD in Asian Indians, limited data are available on the prevalence of ED and its correlation with CAD severity in such patients. AIM: To study the prevalence of ED in Asian Indian patients undergoing coronary angiography and to assess if the severity of ED correlates with angiographic severity of CAD. METHODS: In all patients undergoing coronary angiography, ED was assessed using the International Index of Erectile Function-5 questionnaire. MAIN OUTCOME MEASURES AND RESULTS: Among 175 male patients, ED was present in 70%; patients with ED had a higher incidence of multivessel CAD (80% vs. 36%, P 0.001), diffuse CAD (81% vs. 34%, P 0.001), and higher number of mean coronary vessels involved compared with those without ED. Those with severe ED had higher prevalence of multivessel CAD and higher number of mean coronary vessels involved compared with those with milder grades of ED. Onset of symptoms of ED preceded symptoms of CAD by a mean of 24.6 months in 84% of patients. The presence of severe ED was associated with a 21-fold higher risk of having triple-vessel disease (odds ratio [OR] 21.94, 95% confidence interval [CI] 3.41-141.09, P = 0.001) and an 18-fold higher risk of having diffuse angiographic CAD (OR 17.91, 95% CI 3.11-111.09, P = 0.001). CONCLUSION: Asian Indians with angiographic CAD frequently have ED; symptoms of ED precede that of CAD in most patients. Incidence of multivessel and diffuse CAD is significantly more common in patients with ED. It is important for physicians to be aware of the close relationship between the two conditions so that patients with ED can have optimal risk stratification for concomitant CAD whenever required.

Pharmacological measures to increase HDL-C among high risk isolated low HDL cases: a randomized study amongst north Indians.

BACKGROUND & OBJECTIVES: Low serum levels of high density lipoprotein cholesterol (HDL-C) is an established risk factor for coronary heart disease (CHD). Among a variety of lipid modifying drugs, the best single drug therapy to increase HDL-C levels, especially among high risk, isolated low HDL-C (ILHDL-C) cases is yet to be identified. The objectives of the present study were to evaluate the best pharmacological measure among atorvastatin, fenofibrate and niacin aimed to raise HDL-C and its effect in decreasing the estimated Framingham-10-year CHD risk percentage (CHD-RP) among high risk ILHDL-C cases in north India. METHODS: Two hundred CHD equivalent (CHD-RP≥20), ILHDL-C cases were randomly assigned for treatment either with atorvastatin 10 mg/day (n=70), micronized fenofibrate 160 mg/day (n=65) or niacin-extended release (ER) 750 mg/day (n=65). After 6 wk of treatment, the dosages of drugs were doubled and the patients were finally assessed after 12 wk for their lipid values. RESULTS: Baseline characteristics were similar in the three groups. Niacin therapy 750 mg and 1.5 g/day resulted in a significant rise in HDL-C by 8.10 ± 3.19 and 12.41 ± 4.39 per cent (P<0.001), respectively. Fenofibrate 160 and 320 mg/day also resulted in a significant rise in HDL-C by 3.85 ± 3.48 and 6.24 ± 4.43 per cent (P<0.001), respectively, while atorvastatin 10 and 20 mg/day resulted in a non-significant increase in HDL-C by 0.13 ± 2.92 per cent and 0.51 ± 2.63 per cent, respectively. By increasing HDL-C values, niacin was found to be most effective in reduction of 10-year CHD-RP (P<0.001), followed by fenofibrate (P=0.010), while atorvastatin had no effect. INTERPRETATION & CONCLUSIONS: Our findings indicate that niacin rather than fibrates or statins seems to provide a safe and effective therapy for increasing HDL-C, thus reducing the cumulative CHD risk among ILHDL-C cases.

Metabolic syndrome & Framingham Risk Score: observations from a coronary angiographic study in Indian patients.

BACKGROUND & OBJECTIVES: Metabolic syndrome (MS) is an important determinant of cardiovascular (CV) risk. Framingham Risk Scores (FRS) often underestimate the CV risk in Asians, younger patients and those with MS. Asians often develop coronary artery disease (CAD) at a younger age and also have a high prevalence of MS. Only limited data are available on the relationship between MS and FRS in such patients and the present study was undertaken to report on this aspect in an Indian patient population with angiographically documented CAD. METHODS: Two hundred patients undergoing coronary angiography during a three months study period were included. Diagnosis of MS was based on modified south Asian guidelines. RESULTS: Of the 200 patients (age 56.5 ± 8.6 yr) undergoing coronary angiography, MS was diagnosed in 77 per cent n=154; abdominal obesity, low HDL and hypertension were the commonest of the diagnostic criteria of MS, being present in >70 per cent cases. Patients with MS had significantly higher mean FRS than those without MS (15.1 vs 8.65, P<0.0001). Most patients with MS (74%, n=148) had an intermediate to high 10-year CV risk (>10%) as estimated by FRS. The proportion of patients with MS progressively increased in those with low, intermediate and high FRS (61, 87 and 92%, respectively). Though the prevalence of MS was uniformly similar (74-84%) in all age groups (<45, 45-55, 55-65 and > 65 yr, respectively), amongst those <45 yr, none of the patients could be categorized as having high CV risk as estimated by FRS despite having angiographic CAD, highlighting the limitation of age dependence of FRS. INTERPRETATION & CONCLUSIONS: MS is common in Indian patients with angiographically documented CAD; most patients with MS have 10-year risk of >10 per cent as estimated by FRS. Though MS is uniformly prevalent across all age groups, using the FRS may underestimate the CV risk in Indian patients despite documented CAD. These findings have significant implications for Asian patients with CAD in whom onset of CAD is often at a younger age than their Western counterparts. There should be continued health care emphasis on detection of MS and intensification of targeted preventive strategies.

Comparison of transradial and transfemoral artery approach for percutaneous coronary angiography and angioplasty: a retrospective seven-year experience from a north Indian center.

BACKGROUND: With the increasing prevalence of coronary artery disease, percutaneous coronary artery procedures have become even more important. Our study has compared transradial to transfemoral artery approach for coronary procedures in Indian population. AIMS AND OBJECTIVE: Comparison of transradial and transfemoral artery approach for percutaneous coronary procedures. MATERIAL & METHODS: 26,238 patients, who underwent percutaneous coronary artery procedures, were divided into two groups depending upon transradial and transfemoral artery approach and compared for the various demographic and clinical characteristics, risk factors profile, vascular access and procedural details. RESULTS: 26,238 patients underwent percutaneous coronary procedures at our center. 81% were male and 19% were female. 55.65% and 44.35% procedures were done through transfemoral and transradial approach, respectively. 17,417 (66.38%) coronary angiographies were done, out of which 53.92% were transradial and 46.08% were transfemoral procedures. 8821 (33.62%) Percutaneous Transluminal Coronary Angioplasty (PTCA) were done, out of which 25.46% and 74.54% were done through transradial and transfemoral approach, respectively. Mean fluoroscopy time was 4.40 ± 3.55 min for transradial and 3.30 ± 3.66 min for transfemoral CAG (p < 0.001). For PTCA mean fluoroscopy time was 13.53 ± 2.53 min for transradial and 12.61 ± 9.524 min for transfemoral PTCA (p < 0.001). Minor and major procedure related complications and total duration of hospital stay were lower in transradial as compared to transfemoral group. CONCLUSION: The number of percutaneous transradial procedures have increased significantly with reduced complication rates and comparable success rate to transfemoral approach, along with the additional benefits to patient in terms of patient comfort, preference and reduced cost of health delivery.

Comparison of non-invasive assessment for pulmonary vascular indices by two-dimensional echocardiography and cardiac computed tomography angiography with conventional catheter angiocardiography in unrepaired Tetralogy of Fallot physiology patients weighing more than 10 kg: a retrospective analysis.

AIMS: Assessment of pulmonary vascular dimensions (PVDs) in Tetralogy of Fallot (TOF) is an integral part of planning transcatheter and surgical interventions. We sought to examine the reliability and correlation of echocardiography (ECHO) and computed tomography angiography (CTA) measurements with those obtained by cardiac catheterization and angiography (CCA). METHODS AND RESULTS: Tetralogy of Fallot physiology patients undergoing ECHO, CTA, and CCA within a month prior to surgical correction during 2018-2020 were retrospectively enrolled. Indexed diameter of pulmonary annulus (iPAnn), indexed right pulmonary artery (iRPA), indexed left pulmonary artery (iLPA) and indexed descending aorta (iDA) were measured using ECHO and CTA followed by derivation of Nakata index (NI), McGoon's ratio (MGR), ratio of predicted peak right ventricular (RV) and left ventricular (LV) pressures (pRV/pLV) and Z-scores. Comparison with CCA-derived measurements was made and correlational equations were subsequently deduced. Pulmonary vascular dimensions for 54 patients with mean age of 15.5 ± 9.3 years (range: 3-34 years) were analysed. Computed tomography angiography and CCA measurements for iPAnn, iRPA, NI, MGR, pRV/pLV, and Z-score were comparable with each other while ECHO parameters were significantly lower than CCA. However, iLPA diameter was significantly underestimated by ECHO and overestimated by CTA. Correlational analysis showed stronger correlation between CTA- and CCA-derived PVD as against ECHO measurements except for iDA, pRV/pLV, and Z-score. CONCLUSIONS: For unrepaired TOF physiology patients weighing more than 10 kg, CTA-acquired PVD are reliable and comparable with CCA except for DA for which ECHO is non-inferior. Non-invasive modalities though are inferior to CCA for LPA sizing. Utilizing derived equations, precise estimation of PVD can be carried out using non-invasive tools.

Flecainide for conversion and maintenance of sinus rhythm after mitral valve replacement in rheumatic atrial fibrillation.

BACKGROUND: Despite successful mitral valve replacement (MVR), many patients remain in AF. Flecainide can be useful in these patients but has not been used because of underlying structural heart disease. METHODS: We assessed oral flecainide for conversion and maintenance of SR in 25 patients of chronic rheumatic AF following MVR (age 34.4 yrs, mean AF duration: 3.6 yrs). Non-converters underwent DC cardioversion at 24 h and 4 weeks. Patients received flecainide and bb/diltiazem at discharge. RESULTS: Single oral dose of Flecainide achieved SR in 6/25 (24%) while 19/25 achieved SR after DCC; at24 h 21/25 (84%) were in SR. With mean flecainide dose (93.10 ± 9.40 mg), successful maintenance of SR at 6 months was seen in 16/23 (69.5%). No significant changes in PR interval, QRS duration or QTc were noted; flecainide was well tolerated. Patients in SR had significantly better functional status, QOL scores and higher LA strain at 6 months (25.25 vs 17.43%, p < .0001). Baseline LA diameter ≤ 61 mm predicted SR at 6 months (sensitivity/specificity 93.7% and 85.71%) while the values for AF duration ≤ 4 years and LA strain > 21% for predicting SR were 87.5/71.43% and 100/85.71% respectively. CONCLUSION: Oral flecainide was safe and effective in post MVR rheumatic AF patients; maintenance of SR was achieved in 76% of initial converters and 64% of overall population, with better LA strain values. More studies are needed to validate these results.

A pilot study evaluating the role of ivabradine for rate control in patients with rheumatic atrial fibrillation.

OBJECTIVES: Ivabradine may have a role in rate control of atrial fibrillation (AF) due to effects on HCN channels in AV node. We studied role of Ivabradine in rate control of rheumatic AF. METHODS: 80 patients, rheumatic AF, HR > 100 bpm (age 47 ± 11 yrs, AF duration 6.8 ± 2.9 years, rate 131 ± 16 bpm) on maximally tolerated ßß or CCB's, randomized to Ivabradine or escalated ßß/CCB. Ivabradine started @ 2.5 mg BD; increased to 5 mg BD if inadequate response at 1 week (failure to decrease HR < 10% vs baseline). After Holter at 1 month, dose escalated to 7.5 mg BD if needed. RESULTS: Ivabradine resulted in significantly lower HR (81 ± 10 vs 99 ± 9) at 3 months and 6 months (79 ± 8 vs 94 ± 8, p < 0.001). Absolute reduction in HR: 56 ± 15 vs 31 ± 14 bpm and % change in HR: 41 ± 7 vs 24 ± 9%, both p < 0.00001). At 6 months, Ivabradine group had. 1Significantly lower NT Pro BNP (1168 vs 1314 pg/ml), higher 6 min walk distance (410 ± 47 vs 349 ± 54 m, all p < 0.001) 2Better symptom class (EHRA score 1: asymptomatic 84% vs 40%), improvement >1 EHRA class; baseline 60% vs 17% 3Better LA Strain (22.8 ± 2.8% vs 20.6 ± 2.5%) Ivabradine was well tolerated and there was no drug withdrawal. CONCLUSION: Our data suggest that Ivabradine can be an option for rate control in rheumatic AF.

A study of clinical presentation and delays in management of acute myocardial infarction in community.

To assess the medico social demographics of acute myocardial infarction (AMI) in our community we studied 609 patients presenting between January 2008 to December 2008 with a detailed questionnaire in four centres of UP. Medical attention was sought late (> 6 hours) in 316 (51.6%), thrombolysis was obtained in 45.2% (275) and presentation was atypical in 16.3% (99). 36.2% (221) had pre-monitory symptoms of which 68% (150) ignored the same while of 32% (71) who did seek medical attention 47.9% (37) were brushed away as non-cardiac in origin. 20.3% (46/226) of hypertension, 23.2% (43/185) of diabetes and 83.4% (91/109) of hyperlipidaemia was diagnosed post event. We conclude that at least half of patients with AMI do not get definitive therapy, at least one in 10 patients do not have the classical symptoms, reasonable proportion are unaware of their risk factors, and a good majority have pre-monitory symptoms which get overlooked.

Patterns and determinants of dyslipidaemia in 'Young' versus 'Not so Young' patients of coronary artery disease: a multicentric, randomised observational study in northern India.

AIMS: The aims of the study were to ascertain difference in lipid levels of 'Young' onset of coronary artery disease (CAD) (≤ 45 years) vs. 'Not so Young' onset of CAD (≥ 55 years) among north Indians and also to investigate determinants of 'dyslipidaemia' in CAD patients. METHODS: This was a prospective, multicentric, randomised, observational study carried in eight centres of UP, India. All blood investigations were performed employing a central laboratory. RESULTS: Out of a total 435 patients studied, 218 were in the 'young group' (YG) and 235 were in the 'Not so Young Group' (NSYG). Dyslipidaemia was more common in YG as evident by significantly higher levels of total cholesterol, triglycerides, low- and very low-density lipoprotein cholesterol as compared to NSYG. Diabetes, hypertension, urban lifestyle, and family history of CAD were found to be important determinants of dyslipidaemia in YG. CONCLUSION: We conclude that lipid levels among north Indians are significantly higher in younger patients with CAD when compared with elderly.

Status of Catalase, Glutathione Peroxidase, Glutathione S-Transferase, and Myeloperoxidase Gene Polymorphisms in Beta-Thalassemia Major Patients to Assess Oxidative Injury and Its Association with Enzyme Activities.

Beta-thalassemic patients require regular blood transfusion to sustain their life which leads to iron overload and causes oxidative stress. The aim of this study was to investigate the status of variants in genes including GSTM1 , GSTT1 (null/present), CT-262 (C > T) and CT-89 (A > T), glutathione peroxidase (GPx), and myeloperoxidase (MPO). The genotype studies were conducted with 200 thalassemia major (TM) patients and 200 healthy controls. Genotyping of GST gene was performed by multiplex polymerase chain reaction (PCR), whereas for CT, GPx and MPO genesvariants PCR- restriction fragment length polymorphism technique used. However, the enzyme activities were measured only in the patients group to assess the association with the genotypes. All enzyme estimations were performed by ELISA. We observed higher frequency of GSTT1 null, CT-89 (A > T), GPx1 198 (C > T) and MPO-463 (G > A) polymorphisms in TM patient than healthy controls. However, CT-262 (C > T) polymorphism was not found to be statistically significantly different between patients and controls. Our results suggest that frequency of null allele of glutathione-S-transferase is significantly high among TM patients. The other alleles CT-89 (A > T), GPx1 198 (C > T), and MPO-463 (G > A) are linked to decreased CT, GPX, and MPO enzyme activities.

Neutrophil Gelatinase-Associated Lipocalin as a Marker for Contrast-Induced Nephropathy in Patients Undergoing Percutaneous Coronary Intervention: A Prospective Observational Analysis.

Introduction: Incidence of contrast-induced nephropathy (CIN) post percutaneous coronary intervention (PCI) varies between 5% and 20%. Neutrophil gelatinase-associated lipocalin (NGAL) is a sensitive marker for acute kidney injury. Data regarding the predictive accuracy of NGAL in Indian patients undergoing PCI is sparse. Methods: A total of 212 consecutive "all-comer" patients, undergoing PCI from March 2015 to April 2016 were recruited in this single-center observational study. Plasma NGAL levels were measured at 4 hours post PCI using commercially available enzyme-linked immunosorbent assay (Triage® Alere™, San Diego, CA, USA). Results: Twenty-five (11.8%) patients developed CIN. The 4-hour post-PCI plasma NGAL levels were significantly higher in patients with CIN than without (400.6 ± 269.3 ng/mL vs. 109.8 ± 68.0 ng/mL, P < 0.0001). Patients developing CIN had higher age, low estimated glomerular filtration rate (eGFR), and higher contrast volume usage during PCI. After adjusting for confounding factors, diabetes mellitus (adjusted odds ratio [AOR] 3.04; P = 0.039; 95% confidence interval [CI]: 1.06-8.73), hypotension at presentation (AOR 24.84; P < 0.0001; 95% CI: 4.65-132.83), and multi-staged PCI (AOR 13.45; P < 0.0001; 95% CI: 4.54-39.79) were found to independently predict the development of CIN. NGAL levels significantly correlated with age (r = 0.149, P = 0.031), eGFR (r = -0.385, P < 0.0001), hemoglobin (r = -0.214, P = 0.002), contrast volume (r = 0.185, P = 0.007), and 48-hour post-PCI serum creatinine levels (r = 0.334, P < 0.0001). At a cutoff of 256.5 ng/mL, plasma NGAL had a sensitivity of 68% and a specificity of 95.2% (area under the curve = 0.878; P < 0.0001; 95% CI: 0.801-0.955) to predict the occurrence of CIN. Conclusions: Plasma NGAL is an early and highly predictive biomarker of CIN in patients undergoing PCI. Patients having diabetes, hypotension at presentation and those undergoing second-stage procedures are at a high risk of developing CIN after PCI.

Is Indexed Left Atrial Volume (LAVi) in Indian Patients with Acute Coronary Syndrome (ACS) undergoing revascularization a predictor of cardiovascular outcomes?

BACKGROUND: Left atrial volume indexed to body surface area (LAVi) is the recommended method for LA size quantification. Assessing LAVi in Indian patients undergoing coronary interventions for acute coronary syndrome (STEMI, NSTEMI, and UA) is clinically relevant. METHODS AND RESULTS: Amongst 190 patients (66.4 yrs, 68.4% males), 29.5%, 40.5%, and 30% respectively had STEMI, NSTEMI and UA. Mean LAVi was 32.29 ± 12.06 ml/m2 and 111 (58.4%) had LAVi ≥32 while 79 (41.6%) had LAVi <32. Patients were divided into 2 groups (group 1 LAVi >32 and group 2 LAVi <32). Group 1 patients had higher prevalence of TVD [n = 49 vs n = 5, p = <0.001] and higher mean Syntax score (24.47 vs 14.64, p = <0.001). Despite similar LVEF, those with higher LAVi had had higher incidence of mild MR (50.4 vs 27.8, P = 0.0002) and moderate/severe MR was present only in Group 1 patients (27.9% and 5.4%). Grade I, II, and III diastolic dysfunction was present in 71.2, 17.1, and 9.9% patients in Group 1 vs 45.6%, 0%, and 0% in group 2. Diastolic parameters like septal E/e' and lateral E/e'ratio were also higher in Group 1. Major adverse cardiovascular events (MACE) at 30 days was significantly higher in group 1 (20.7 vs 6.3%, P = 0.006). On multivariate analysis, triple vessel disease and LAVi were the only predictors of MACE while LVEF was not. ROC curve analysis for LAVi demonstrated that a cut-off 33.35 ml/m2, predicted 30 day MACE with Area under curve (AUC) 0.775 (95% CI 0.700-0.850); sensitivity and specificity of 86.7% and 61.4%. Inter-quartile analysis of LAVi (<26.3, 26.3-33.35, 33.36-36.3, and >36.3 ml/m2) demonstrated that 30 day MACE increased across quartiles (4.16%, 4.25%, 22.44%, and 28.26%, respectively, P < 0.001). CONCLUSION: Amongst patients with ACS undergoing revascularization, those with higher LAVi had more severe CAD, diastolic dysfunction and higher 30 day MACE. LAVi provides superior prognostic information as compared to conventional LV systolic and diastolic parameters in patients with ACS and should be incorporated in routine echocardiographic analysis. More studies with larger numbers and longer follow up are required to further elucidate on this.

Exploring the association of fibrinogen and CRP with the clinical spectrum of CAD and periprocedural outcomes in patients undergoing percutaneous coronary interventions.

BACKGROUND: The pathophysiology of an atherosclerotic plaque is mediated by the mechanisms involving thrombus formation and systemic inflammation. While C-reactive protein (CRP) levels are useful in predicting a cardiovascular event in intermediate risk population, the usefulness of routinely measuring fibrinogen in patients with acute coronary syndrome (ACS) is debatable. Also, data on the association of these markers with periprocedural outcomes in patients undergoing percutaneous coronary interventions (PCI) is scarce. AIMS: The study aimed to determine whether the levels of fibrinogen and CRP vary across the different spectra of CAD and whether they have any correlation with cardiac Troponin I levels. MATERIALS AND METHODS: A total of 284 patients with coronary artery disease undergoing percutaneous coronary intervention were included in the study. Complete blood count, serum lipid profile, serum CRP, fibrinogen, and troponin I were measured for all patients. RESULTS: Patients with STEMI had significantly higher levels of CRP as compared to those with unstable angina (USA) and chronic stable angina (CSA). Patients presenting with ACS had significantly higher baseline fibrinogen as compared to those with CSA. A significant positive correlation between CRP and admission Troponin I (r = 0.50; P < 0.05) as well as fibrinogen and admission troponin I (r = 0.30; P < 0.05) was observed. The CRP levels were significantly higher in 15 patients with periprocedural MI as compared to those who did not develop periprocedural MI. CONCLUSIONS: : The levels of the markers of inflammation and atherothrombosis vary with presentation across varied spectra of CAD with generally higher levels in acute presentation and in those who develop periprocedural MI.

Serum Gamma Glutamyltransferase (GGT) in coronary artery disease: Exploring the Asian Indian Connection.

Background: There is a need to identify novel markers for CAD, independent of traditional CV risk factors. One of these is gamma-glutamyl transferase (GGT), a marker of increased oxidative stress. Given the high prevalence of CAD in Asian Indians, the link of GGT and CAD in them needs to be studied. Aim: To assess GGT in patients with angiographically documented CAD. Methods and Results: Two hundred patients aged 58.1 ± 9.95 years, 73% males, hypertension 56%, diabetes 40% were included. Mean GGT was 63.6 ± 44.33 (10-269 U/L). The levels of GGT progressively increased in those with single/double or triple-vessel CAD (36.5, 61.5, and 87 U/L, respectively, P < 0.001). Using objective criteria of CAD burden (SYNTAX and Gensini scores), we reaffirmed these findings. GGT in patients with SYNTAX tertiles 0-22, 23-32, and ≥ 33 was 33, 62, and 97 U/L, respectively and in Gensini tertiles 0-17.65, 17.66-56.65, ≥56.66 was 32, 52, and 88 U/L, respectively, all P < 0.001. SYNTAX score ≥ 23 was present in only 23% patients in GGT tertile 1 (<41 U/L), whereas60% and 94% in GGT tertiles 2 and 3 had SYNTAX ≥ 23. Significant positive correlation was seen between GGT and SYNTAX (r = 0.634) and Gensini score (r = 0.772). Conclusions: In this study, GGT had an independent correlation with angiographic severity of CAD and SYNTAX and Gensini scores. Although the existing evidence seems biologically plausible, more studies are needed to explore the potential role of this inexpensive marker for predicting disease burden in patients with CAD.