Impact of Complete Revascularization in the ISCHEMIA Trial.

BACKGROUND: Anatomic complete revascularization (ACR) and functional complete revascularization (FCR) have been associated with reduced death and myocardial infarction (MI) in some prior studies. The impact of complete revascularization (CR) in patients undergoing an invasive (INV) compared with a conservative (CON) management strategy has not been reported. OBJECTIVES: Among patients with chronic coronary disease without prior coronary artery bypass grafting randomized to INV vs CON management in the ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) trial, we examined the following: 1) the outcomes of ACR and FCR compared with incomplete revascularization; and 2) the potential impact of achieving CR in all INV patients compared with CON management. METHODS: ACR and FCR in the INV group were assessed at an independent core laboratory. Multivariable-adjusted outcomes of CR were examined in INV patients. Inverse probability weighted modeling was then performed to estimate the treatment effect had CR been achieved in all INV patients compared with CON management. RESULTS: ACR and FCR were achieved in 43.4% and 58.4% of 1,824 INV patients. ACR was associated with reduced 4-year rates of cardiovascular death or MI compared with incomplete revascularization. By inverse probability weighted modeling, ACR in all 2,296 INV patients compared with 2,498 CON patients was associated with a lower 4-year rate of cardiovascular death or MI (difference -3.5; 95% CI: -7.2% to 0.0%). In comparison, the event rate difference of cardiovascular death or MI for INV minus CON in the overall ISCHEMIA trial was -2.4%. Results were similar but less pronounced with FCR. CONCLUSIONS: The outcomes of an INV strategy may be improved if CR (especially ACR) is achieved. (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches [ISCHEMIA]; NCT01471522).

Impact of complete revascularization in the IschemiaTrial

BACKGROUND: Anatomic complete revascularization (ACR) and functional complete revascularization (FCR) have been associated with reduced death and myocardial infarction (MI) in some prior studies. The impact of complete revascularization (CR) in patients undergoing an invasive (INV) compared with a conservative (CON) management strategy has not been reported. OBJECTIVES: Among patients with chronic coronary disease without prior coronary artery bypass grafting randomized to INV vs CON management in the ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) trial, we examined the following: 1) the outcomes of ACR and FCR compared with incomplete revascularization; and 2) the potential impact of achieving CR in all INV patients compared with CON management. METHODS: ACR and FCR in the INV group were assessed at an independent core laboratory. Multivariable-adjusted outcomes of CR were examined in INV patients. Inverse probability weighted modeling was then performed to estimate the treatment effect had CR been achieved in all INV patients compared with CON management. RESULTS: ACR and FCR were achieved in 43.4% and 58.4% of 1,824 INV patients. ACR was associated with reduced 4-year rates of cardiovascular death or MI compared with incomplete revascularization. By inverse probability weighted modeling, ACR in all 2,296 INV patients compared with 2,498 CON patients was associated with a lower 4-year rate of cardiovascular death or MI (difference -3.5; 95% CI: -7.2% to 0.0%). In comparison, the event rate difference of cardiovascular death or MI for INV minus CON in the overall ISCHEMIA trial was -2.4%. Results were similar but less pronounced with FCR. CONCLUSIONS: The outcomes of an INV strategy may be improved if CR (especially ACR) is achieved. (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches [ISCHEMIA]; NCT01471522).

Role of High-Sensitivity C-reactive Protein Levels in Predicting the Risk of Six-Month Event Rates in Patients With Chronic Stable Angina Undergoing Percutaneous Transluminal Coronary Angioplasty With a Drug-Eluting Stent.

Introduction This prospective observational study reports the association between baseline high-sensitivity C-reactive protein (hs-CRP) levels and adverse events at six months in patients who were diagnosed with symptomatic chronic stable angina and then underwent percutaneous transluminal coronary angioplasty (PTCA) with a drug-eluting stent (DES). Methods A total of 104 patients were examined with chronic stable angina over a period of six months. Before conducting percutaneous coronary intervention (PCI), the baseline levels of hs-CRP were measured, and based on the levels, the patients were grouped into high and low hs-CRP groups. Results The primary causes of death or the need for repeat revascularization or myocardial infarction or angina were concluded after assessing the patients for six months. A total of 104 patients were studied, among which 72 (69.23%) had low hs-CRP and 32 (30.77%) had high hs-CRP levels. The number of males in this study was 68 (65.38%) and females were 36 (34.62%). The mean age of the patients was 55.26 ± 10.31 years. There were no significant differences among the groups in terms of gender, age, comorbidities, and risk factors except for certain predisposing factors like dyslipidemia and smoking. Moreover, we did not find any significant difference among the groups in the cause of death and myocardial infarction after a follow-up of six months. However, we observed a higher need for revascularization and angina outcomes in the group with high hs-CRP compared to low hs-CRP. Conclusion It can be concluded that a higher risk of angina and repeat revascularization is related to a high baseline hs-CRP but there is no evidence whether it is somehow linked to myocardial infarction and mortality or not.

Target Vessel Versus Complete Revascularization in Non-ST Elevation Myocardial Infarction Without Cardiogenic Shock.

Introduction The role of complete revascularization (CR) vs target vessel revascularization (TVR) in non-ST-elevation myocardial infarction (NSTEMI) in patients without cardiogenic shock is still not established. In this study, we compared outcomes at one and six months among patients with NSTEMI with multivessel disease (MVD) undergoing CR vs TVR. Methods It was a prospective, observational study carried out among 60 NSTEMI patients with MVD (30 undergoing TVR and 30 CR) from October 2018 to November 2019. They were assessed at one and six months for primary and secondary outcomes. Results The mean age of the patients was 56.13 ± 9.23 years and both the groups were well matched with respect to age, gender, risk factors, and comorbidities. In the majority of patients, the target vessel was left anterior descending (LAD) followed by right coronary artery (RCA) and left circumflex (LCX) in both groups. The primary outcomes of death from any cause, non-fatal myocardial infarction, and the need for revascularization of the ischemia-driven vessel showed no significant difference at one and six months follow-up between the CR and TVR groups. However, the secondary outcomes of heart failure hospitalizations and angina episodes were significantly more in the TVR group than CR group at one month (6 vs 1, P=0.044), (8 vs 2, P=0.038) and six months (8 vs 2, P=0.038), (9 vs 2, P=0.02), respectively. Conclusion CR was associated with no difference in death from all-cause or future revascularization but significantly lesser secondary outcomes of heart failure hospitalizations and angina episodes as compared to TVR in NSTEMI without cardiogenic shock.

Outcomes in the ISCHEMIA Trial Based on Coronary Artery Disease and Ischemia Severity.

BACKGROUND: The ISCHEMIA trial (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches) postulated that patients with stable coronary artery disease (CAD) and moderate or severe ischemia would benefit from revascularization. We investigated the relationship between severity of CAD and ischemia and trial outcomes, overall and by management strategy. METHODS: In total, 5179 patients with moderate or severe ischemia were randomized to an initial invasive or conservative management strategy. Blinded, core laboratory-interpreted coronary computed tomographic angiography was used to assess anatomic eligibility for randomization. Extent and severity of CAD were classified with the modified Duke Prognostic Index (n=2475, 48%). Ischemia severity was interpreted by independent core laboratories (nuclear, echocardiography, magnetic resonance imaging, exercise tolerance testing, n=5105, 99%). We compared 4-year event rates across subgroups defined by severity of ischemia and CAD. The primary end point for this analysis was all-cause mortality. Secondary end points were myocardial infarction (MI), cardiovascular death or MI, and the trial primary end point (cardiovascular death, MI, or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest). RESULTS: Relative to mild/no ischemia, neither moderate ischemia nor severe ischemia was associated with increased mortality (moderate ischemia hazard ratio [HR], 0.89 [95% CI, 0.61-1.30]; severe ischemia HR, 0.83 [95% CI, 0.57-1.21]; P=0.33). Nonfatal MI rates increased with worsening ischemia severity (HR for moderate ischemia, 1.20 [95% CI, 0.86-1.69] versus mild/no ischemia; HR for severe ischemia, 1.37 [95% CI, 0.98-1.91]; P=0.04 for trend, P=NS after adjustment for CAD). Increasing CAD severity was associated with death (HR, 2.72 [95% CI, 1.06-6.98]) and MI (HR, 3.78 [95% CI, 1.63-8.78]) for the most versus least severe CAD subgroup. Ischemia severity did not identify a subgroup with treatment benefit on mortality, MI, the trial primary end point, or cardiovascular death or MI. In the most severe CAD subgroup (n=659), the 4-year rate of cardiovascular death or MI was lower in the invasive strategy group (difference, 6.3% [95% CI, 0.2%-12.4%]), but 4-year all-cause mortality was similar. CONCLUSIONS: Ischemia severity was not associated with increased risk after adjustment for CAD severity. More severe CAD was associated with increased risk. Invasive management did not lower all-cause mortality at 4 years in any ischemia or CAD subgroup. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01471522.

Impact of COVID-19 on Thrombus Burden and Outcome in Acute Myocardial Infarction.

Background Cardiovascular manifestations are one of the most common complications in coronavirus disease 2019 (COVID-19) infection and are associated with increased mortality. However, the impact of COVID-19 infection on thrombus burden and the outcome of acute myocardial infarction (AMI) has not been studied. Methods This was a retrospective, observational study that included all adult patients (>18 years) diagnosed with AMI with or without COVID-19 infection. Epidemiological, laboratory, clinical, interventional, and outcome data were extracted and the impact of COVID-19 on thrombus burden and the primary clinical composite endpoint of all-cause death during hospital admission or 30 days after discharge was studied. Results The study population included 336 patients, including 56 patients with COVID and AMI and 280 patients with AMI without COVID-19 infection. Chest pain was the most common symptom (84.8%) while one or more co-morbidity was present in 117 (34.8%) patients. Forty-eight patients in the AMI with COVID group had ST-segment elevation myocardial infarction (STEMI) while 256 patients in the AMI without COVID group had STEMI, eight patients in the AMI with COVID group had non-ST-segment elevation myocardial infarction (NSTEMI), and 24 in the AMI without COVID group had NSTEMI. Patients with COVID-19 co-infection had a higher thrombus burden as compared to the patients without COVID-19 AMI group (p-value 0.008). The primary outcome in the form of all-cause mortality was seen in 13 (3.9%) patients, which was also more in the AMI with COVID group. Conclusion COVID-19 in AMI is a state of high thrombus burden associated with higher mortality, especially in patients with chronic co-morbidities.

Looking Deep Into the Palpitation - Pheochromocytoma Presenting as Sinus Node Dysfunction.

A 23-year-old male came to the outpatient department with a history of intermittent palpitations and headaches for the past six to eight months. He was diagnosed with hypertension and had a junctional rhythm on an electrocardiogram (ECG). On further workup for his hypertension, he was found to have elevated levels of serum metanephrines and computed tomography (CT) and positron emission tomography (PET) scan revealed pheochromocytoma. He was subsequently operated upon and his arrhythmia subsided after surgery. We discuss our approach to this scenario, which leads us to a rather rare cause of sinus node dysfunction.

Outcomes in the ISCHEMIA Trial Based on Coronary Artery Disease and Ischemia Severity

BACKGROUND: The ISCHEMIA trial (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches) postulated that patients with stable coronary artery disease (CAD) and moderate or severe ischemia would benefit from revascularization. We investigated the relationship between severity of CAD and ischemia and trial outcomes, overall and by management strategy. METHODS: In total, 5179 patients with moderate or severe ischemia were randomized to an initial invasive or conservative management strategy. Blinded, core laboratory­interpreted coronary computed tomographic angiography was used to assess anatomic eligibility for randomization. Extent and severity of CAD were classified with the modified Duke Prognostic Index (n=2475, 48%). Ischemia severity was interpreted by independent core laboratories (nuclear, echocardiography, magnetic resonance imaging, exercise tolerance testing, n=5105, 99%). We compared 4-year event rates across subgroups defined by severity of ischemia and CAD. The primary end point for this analysis was all-cause mortality. Secondary end points were myocardial infarction (MI), cardiovascular death or MI, and the trial primary end point (cardiovascular death, MI, or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest). RESULTS: Relative to mild/no ischemia, neither moderate ischemia nor severe ischemia was associated with increased mortality (moderate ischemia hazard ratio [HR], 0.89 [95% CI, 0.61­1.30]; severe ischemia HR, 0.83 [95% CI, 0.57­1.21]; P=0.33). Nonfatal MI rates increased with worsening ischemia severity (HR for moderate ischemia, 1.20 [95% CI, 0.86­1.69] versus mild/no ischemia; HR for severe ischemia, 1.37 [95% CI, 0.98­1.91]; P=0.04 for trend, P=NS after adjustment for CAD). Increasing CAD severity was associated with death (HR, 2.72 [95% CI, 1.06­6.98]) and MI (HR, 3.78 [95% CI, 1.63­8.78]) for the most versus least severe CAD subgroup. Ischemia severity did not identify a subgroup with treatment benefit on mortality, MI, the trial primary end point, or cardiovascular death or MI. In the most severe CAD subgroup (n=659), the 4-year rate of cardiovascular death or MI was lower in the invasive strategy group (difference, 6.3% [95% CI, 0.2%­12.4%]), but 4-year all-cause mortality was similar. CONCLUSIONS: Ischemia severity was not associated with increased risk after adjustment for CAD severity. More severe CAD was associated with increased risk. Invasive management did not lower all-cause mortality at 4 years in any ischemia or CAD subgroup.

Aortic Dissection With Complete Occlusion of Left Main Coronary Artery Presenting as Acute ST-Segment Elevation Myocardial Infarction.

Acute Aortic Dissection (AAD) is a life-threatening condition, which presents with a wide variety of symptoms ranging from being asymptomatic to sudden cardiac death. A retrograde extension of AAD can lead to partial or complete occlusion of coronary vessels, leading to an exceedingly rare presentation in the form of acute Myocardial Infarction (MI). A prognosis of AAD depends on prompt diagnosis and urgent surgical intervention to re-establish coronary blood flow. Here, we report a case of AAD, presenting as acute anterolateral wall MI, due to total occlusion of the left main coronary artery.

An Unusual Intracoronary Honeycomb Pattern in a Patient with Coronary Artery Disease with Dextrocardia.

This case highlights the diagnostic dilemma and emphasis the role of Optical Coherence Tomography (OCT) to differentiate between spontaneous coronary artery dissection and recanalized thrombus with multiple channels in a patient with dextrocardia.

Impact of the 2017 ACC/AHA guidelines on the prevalence of hypertension among Indian adults: Results from a cross-sectional survey.

BACKGROUND: The impact of the 2017 American College of Cardiology (ACC)/American Heart Association (AHA) guidelines for diagnosis and management of hypertension on the prevalence of hypertension in India is unknown. METHODS: We analyzed data from the Cardiac Prevent 2015 survey to estimate the change in the prevalence of hypertension. The JNC8 guidelines defined hypertension as a systolic blood pressure of ≥140 â€‹mmHg or diastolic blood pressure of ≥90 â€‹mmHg. The 2017 ACC/AHA guidelines define hypertension as a systolic blood pressure of ≥130 â€‹mmHg or diastolic blood pressure of ≥80 â€‹mmHg. We standardized the prevalence as per the 2011 census population of India. We also calculated the prevalence as per the World Health Organization (WHO) World Standard Population (2000-2025). RESULTS: Among 180,335 participants (33.2% women), the mean age was 40.6 â€‹± â€‹14.9 years (41.1 â€‹± â€‹15.0 and 39.7 â€‹± â€‹14.7 years in men and women, respectively). Among them, 8,898 (4.9%), 99,791 (55.3%), 35,694 (11.9%), 23,084 (12.8%), 9,989 (5.5%) and 2,878 (1.6%) participants belonged to age group 18-19, 20-44, 45-54, 55-64, 65-74 and â€‹≥ â€‹75 years respectively. The prevalence of hypertension according to the JNC8 and 2017 ACC/AHA guidelines was 29.7% and 63.8%, respectively- an increase of 115%. With the 2011 census population of India, this suggests that currently, 486 million Indian adults have hypertension according to the 2017 ACC/AHA guidelines, an addition of 260 million as compared to the JNC8 guidelines. CONCLUSION: According to the 2017 ACC/AHA guidelines, 3 in every 5 Indian adults have hypertension.

Role of strain imaging for assessment of myocardial viability in symptomatic myocardial infarction with single vessel disease: An observational study.

PURPOSE: To study and evaluate the predictive value of strain imaging parameters in patients undergoing viability assessment postmyocardial infarction (MI) in comparison with Dobutamine stress echocardiography (DSE) alone. METHODS: This was a prospective observational study (October, 2016-March, 2018), which recruited 100 symptomatic patients with MI, and angiographically proven single vessel disease, LV dysfunction with severe hypokinesia/akinesia on 2D echocardiography and viability proven by baseline DSE. Patients undergoing primary PCI were excluded. Patients were recruited in two groups: DSE alone (first group) and strain imaging with DSE (second group). Revascularization was done in all patients. Patients were assessed at 3 months for functional recovery by 2D echocardiography. RESULTS: On 3 month follow-up after revascularization, 37 patients (74%) in first group and 33 patients (66.67%) in second group had functional recovery. Dobutamine-stimulated strain parameters such as circumferential strain (CS; P = .005), radial velocity (RV; P < .001), longitudinal strain (LS; P < .001), and longitudinal strain rate (LSR; P < .001) were found to be a significant predictor of viability. The greatest area under the curve (AUC) for the ROC curves was obtained for low dose dobutamine RV (AUC = 0.92), low dose dobutamine LS (AUC = 0.94), and low dose dobutamine LSR (AUC = 0.88). Positive predictive value of the combination of low dose DSE with strain parameters (RV-97.2%, LS-97.4%, and LSR-87.5%) for myocardial viability was significantly higher than low dose DSE positive/low dose strain parameters negative patients as well as low dose DSE group alone. CONCLUSION: Evaluation of strain parameters with low dose DSE is clinically feasible for the detection of myocardial viability and adds incremental value to the subjective and semiquantitative wall-motion scoring. LS at low dose DSE with WMSI was found to have the highest positive predictive value.

Prevalence of hypertension among Indian adults: Results from the great India blood pressure survey.

OBJECTIVE: Hypertension is the most important risk factor for cardiovascular morbidity and mortality. There is limited data on hypertension prevalence in India. This study was conducted to estimate the prevalence of hypertension among Indian adults. METHODS: A national level survey was conducted with fixed one-day blood pressure measurement camps across 24 states and union territories of India. Hypertension was defined as systolic blood pressure (BP) ≥140 mmHg or a diastolic BP ≥90 mmHg or on treatment for hypertension. The prevalence was age- and gender-standardized according to the 2011 census population of India. RESULTS: Blood pressure was recorded for 180,335 participants (33.2% women; mean age 40.6 ± 14.9 years). Among them, 8,898 (4.9%), 99,791 (55.3%), 35,694 (11.9%), 23,084 (12.8%), 9,989 (5.5%), and 2,878 (1.6%) participants were of the age group 18-19, 20-44, 45-54, 55-64, 65-74, and ≥ 75 years, respectively. Overall prevalence of hypertension was 30.7% (95% confidence interval [CI]: 30.5, 30.9) and the prevalence among women was 23.7% (95% CI: 23.3, 24). Prevalence adjusted for 2011 census population and the WHO reference population was 29.7% and 32.8%, respectively. CONCLUSION: There is a high prevalence of hypertension, with almost one in every three Indian adult affected.

LiNbO3 coating on concrete surface: a new and environmentally friendly route for artificial photosynthesis.

The addition of a photocatalyst to ordinary building materials such as concrete creates environmentally friendly materials by which air pollution or pollution of the surface can be diminished. The use of LiNbO3 photocatalyst in concrete material would be more beneficial since it can produce artificial photosynthesis in concrete. In these research photoassisted solid-gas phases reduction of carbon dioxide (artificial photosynthesis) was performed using a photocatalyst, LiNbO3, coated on concrete surface under illumination of UV-visible or sunlight and showed that LiNbO3 achieved high conversion of CO2 into products despite the low levels of band-gap light available. The high reaction efficiency of LiNbO3 is explained by its strong remnant polarization (70 µC/cm(2)), allowing a longer lifetime of photoinduced carriers as well as an alternative reaction pathway. Due to the ease of usage and good photocatalytic efficiency, the research work done showed its potential application in pollution prevention.

Surgical management of anomalous pulmonary venous connection to the superior vena cava--early results.

BACKGROUND: The anatomical variability in patients with anomalous pulmonary venous connection to superior vena cava presents a surgical challenge. The problem is further compounded by the common occurrence of postoperative complications like arrhythmias and obstruction of the superior vena cava or pulmonary veins. We present our experience of managing this subset using the two patch and Warden's techniques. PATIENTS AND METHODS: Between June 2011 and September 2012, 7 patients with APVC to the SVC were operated in our institute. After delineating the anatomy, five of them had a two patch repair and two were managed with Warden's technique. RESULTS: There was no in-hospital mortality or early mortality over a mean follow-up of 9.66 ± 3.88 months (range 6-15 months). All the patients on follow-up had unobstructed pulmonary venous and SVC drainage on echocardiography and all of them were in normal sinus rhythm. CONCLUSIONS: Anomalous pulmonary venous connection to superior vena cava is a challenging subset of patients in whom the surgical management needs to be individualized. The detailed anatomy must be delineated using echocardiography with or without CT angiography before deciding the surgical plan. This entity can be repaired with excellent immediate and early results. However, these patients must be closely followed up for complications like systemic and pulmonary venous obstruction and sinus node dysfunction.