Posterior reversible encephalopathy syndrome following coronary angiography.

Posterior reversible encephalopathy syndrome (PRES) is a relatively rare neurotoxic disorder. A 56-year-old male underwent elective coronary angiography. A Few hours postprocedure, the patient developed bilateral painless vision loss, headache, vomiting and hypertension and was subsequently diagnosed with PRES. Possible trigger factors could be contrast agent used, or hypertension. Contrast agent-induced PRES in hypertensive patients is benign and reversible, and a high-grade suspicion about this possibility is critical for precise management. Our patient was successfully treated with supportive management and was doing well on follow-up.

Kolkata-Coventry comparative registry study of acute heart failure: an insight into the impact of public, private and universal health systems on patient outcomes in low-middle income cities (KOLCOV HF Study).

INTRODUCTION: Survival gaps in acute heart failure (AHF) continue to expand globally. Multinational heart failure (HF) registries have highlighted variations between countries. Whether discrepancies in HF practice and outcomes occur across different health systems (ie, private, public or universal healthcare) within a city or between countries remain unclear. Insight into organisational care is also scarce. With increasing public scrutiny of health inequalities, a study to address these limitations is timely. METHOD: KOLCOV-HF study prospectively compared patients with AHF in public (Nil Ratan Sircar Hospital (NRS)) versus private (Apollo Gleneagles Hospital (AGH)) hospitals of Kolkata, India, and one with universal health coverage in a socioeconomically comparable city of Coventry, England (University Hospitals Coventry & Warwickshire (UHCW)). Data variables were adapted from UK's National HF Audit programme, collected over 24 months. Predictors of in-hospital mortality and length of hospitalisation were assessed for each centre. RESULTS: Among 1652 patients, in-hospital mortality was highest in government-funded NRS (11.9%) while 3 miles north, AGH had significantly lower mortality (7.5%, p=0.034), similar to UHCW (8%). This could be attributed to distinct HF phenotypes and differences in clinical and organisational care. As expected, low blood pressure was associated with a significantly greater risk of death in patients served by public hospitals UHCW and NRS. CONCLUSION: Marked differences in HF characteristics, management and outcomes exist intra-regionally, and between low-middle versus high-income countries across private, public and universal healthcare systems. Physicians and policymakers should take caution when applying country-level data locally when developing strategies to address local evidence-practice gaps in HF.

Expert Opinion on P2Y12 Inhibitors Use in Management of Acute Coronary Syndromes: Focus on Ticagrelor.

Ticagrelor is a potent, oral P2Y12 inhibitor used as a part of dual antiplatelet therapy (DAPT) in acute coronary syndromes (ACS). New evidence has emerged for its use in ACS, which may be crucial for the Indian context. This brought together nearly 150 experts in ACS management across the country who reviewed the current evidence and discussed the same through a series of 10 meetings on an online platform. With all experts' agreement, the key expert opinions for the P2Y12 inhibitors use in ACS management were finalized. These include the following. In ACS patients aged <75 years, with diabetes, a history of stroke/transient ischemic attack, and chronic kidney disease, ticagrelor may be preferred over other P2Y12 inhibitors. It may also be preferred in the elderly above 75 years with clopidogrel is a suitable alternative in patients at high-risk of bleeding. Rates of stent thrombosis are lower with ticagrelor than clopidogrel. In patients managed with fibrinolysis, use ticagrelor after 48 hours if streptokinase was the fibrinolytic agent or it can be used after 12 to 24 hours if fibrin-specific fibrinolytic was used. Rates of major bleeding in patients treated with fibrinolysis are similar to clopidogrel. Prehospital administration may be preferred over in-hospital administration with expected bleeding rates similar to clopidogrel. Switching among P2Y12 inhibitors should be done with due consideration of their pharmacodynamics. At present, DAPT should be continued for 12 months with discontinuation after three to six months in patients with high bleeding risk. The use of low dose ticagrelor may be considered in cases with high-bleeding risk. DAPT or ticagrelor continuation beyond one year should be individualized considering ischemic and bleeding risks. Dyspnea is a common, mild, and transient and does not necessitate ticagrelor discontinuation. Severe dyspnea should be investigated thoroughly. In conclusion, ticagrelor (180 mg, 90 mg, and 60 mg doses), a potent antiplatelet is expected to reshape the antiplatelet use in the management of ACS.

SGLT2 inhibitors in heart failure with reduced ejection fraction.

Sodium - glucose co-transporter 2 (SGLT2) inhibitors reduce blood glucose by inhibiting reabsorption of glucose from the proximal renal tubules. Initial studies showed that apart from reducing blood glucose they also reduce the combined endpoint of myocardial infarction, stroke, and cardiovascular death, hospitalization from heart failure, and occurrence of renal failure in patients with known cardiovascular disease or at high risk of developing cardiovascular disease. Recent studies have shown that these drugs also could be used in patients to treat heart failure or to slow the progression of renal failure, irrespective of whether the patients have diabetes or not. In this review, we discuss the clinical trial evidence for the use of SGLT2 inhibitors for the treatment of patients with heart failure with reduced ejection fraction and for the prevention of heart failure in patients with diabetes who are at high risk of cardiovascular events. We also discuss the plausible mechanisms of action for the cardiovascular beneficial effects of SGLT2 inhibitors. EMPA-REG OUTCOME TRIAL, DECLARE-TIMI 58, CANVAS, VERTIS-CV studies have shown that SGLT2 inhibitors namely empagliflozin, dapagliflozin, canagliflozin and ertugliflozin reduce the chances of hospitalisation in patients who have cardiovascular disease or at high risk of cardiovascular disease. The DAPA-HF study and the EMPEROR-REDUCED TRIAL have further shown that Dapagliflozin and Empagliflozin could be used to treat patients with heart failure, with or without diabetes. SGLT2 inhibitors provide us with a new armamentarium for treatment of patients with a triad of diabetes, heart or renal disease. Their mechanism of action in prevention or treatment of patients with heart failure however still remains speculative.

Integration of 18F-Fluorodeoxyglucose Positron Emission Tomography-Computed Tomography in Diagnostic Algorithm of Prosthetic Valve Endocarditis: A Case Report and Review of Literature.

Prosthetic valve endocarditis (PVE) is a sinister complication, with high morbidity and mortality. Diagnosis is conventionally based on modified Duke Criteria. 18F-Fluorodeoxyglucose (18F-FDG) positron emission tomography-computed tomography (PET-CT) has shown high accuracy in diagnosing PVE. Positive 18F-FDG uptake in prosthetic valves on PET-CT is now considered major criteria for diagnosis of PVE. We share our experience of 18F-FDG PET-CT imaging as a problem solving tool in a case of suspected PVE and review the relevant literature.

Prevalence of Cardiovascular Risk Factors among Executive and Nonexecutive Workers in an Urban Public Sector Office Setting: A Cross-Sectional Epidemiological Study from Eastern India.

AIM: The aim of the study is to determine the prevalence of cardiovascular risk factors among executive and nonexecutive workers in an urban public sector office setting. METHODS: A prospective, cross-sectional survey of employees in a public sector office in Eastern India was done using a structured questionnaire to collect data on demographic and lifestyle details and health conditions. Clinical examination, anthropometric measurements, blood sugar, and lipid levels were measured. The employees were divided as executives and nonexecutives based on whether they held gazetted or nongazetted posts. RESULTS: A total of 502 participants were surveyed - 140 executives and 362 nonexecutives; majority were male (88.23%). The executive group had a significantly greater number of participants with older age, hypertension (57.9% vs. 39%), and overweight (40% vs. 30.6%) than the nonexecutive group. Significantly, more nonexecutives had a physically active lifestyle and relatively less presence of conventional cardiovascular risk factors such as tobacco use, hypertension, diabetes, hypercholesterolemia, and weight. The prevalence of ≥3 cardiovascular risk factors was significantly high in executives (27.9%) as compared to nonexecutives (14.1%). CONCLUSION: A higher prevalence of mostly lifestyle-related modifiable cardiovascular risk factors was seen among the executives in an urban public sector office setting in Eastern India.

A patient with atrioventricular block and ventricular tachycardia: think sarcoid!

Cardiac involvement in sarcoidosis is often difficult to diagnose, and most alarmingly can lead to sudden cardiac arrest as its first manifestation. We report the case of a 45-year-old Indian woman with an implanted permanent pacemaker for atrioventricular block, who presented with haemodynamically stable ventricular tachycardia and was found to have impaired left ventricular function. Subsequent investigations established the diagnosis of cardiac sarcoidosis. The patient was treated with prednisolone initially at 40 mg a day for 3 months. Left ventricular function improved over 3 months of treatment and there was no further recurrence of ventricular tachycardia. Screening for cardiac sarcoidosis should be considered in a patient with unexplained atrioventricular block and ventricular tachycardia, particularly if young, even in the absence of clinical findings of extracardiac sarcoidosis. Treatment of the cardiac sarcoidosis could control ventricular tachycardia and improve left ventricular function.

Prevalence of atrial high-rate episodes and the risk factors in Indian patients with cardiac implantable electronic devices: Real-world data.

BACKGROUND: In patients with cardiac implantable electronic devices (CIEDs), atrial high-rate episodes (AHREs) are associated with an increased risk of developing atrial fibrillation (AF) and thromboembolism. We report here the characteristics of "real-world" patients that may be associated with the occurrence of AHREs. METHODS: This was an observational, cross-sectional, data collection study. Data of 234 patients with dual-chamber CIEDs, who visited our clinic over a period of 3 months, were evaluated. Occurrence of AHRE was defined as atrial tachyarrhythmia with an atrial rate of ≥180 beats/min lasting for ≥5 minutes. Multivariate logistic regression analyses were performed to evaluate clinical risk factors associated with AHRE. RESULTS: The mean age of the group was 66.9 ± 9.95 years, and 25% were females. AHREs were recorded in 48 (21%) patients. Multivariate logistic regression analysis revealed that hypertension (HTN) (OR = 4.14; 95% CI: 1.74-9.85; P = .0013) and type II diabetes mellitus (T2DM) (OR = 2.09; 95% CI: 1.04-4.23; P = .0392) were significantly and independently associated with the occurrence of AHRE. CONCLUSION: This real-world data report the prevalence of and risk factors associated with AHRE occurrence in Indian patients with dual-chamber CIED. Known risk factors for AF, such as HTN and diabetes mellitus, were also associated with AHRE occurrence, thus supporting the risk prediction for AF, stroke, or thromboembolism in such patient population.

Delayed onset Takotsubo syndrome following exercise ECG: a case report.

BACKGROUND: Takotsubo syndrome usually occurs immediately following a physical or emotional trigger. In some cases, a triggering stress may not be evident. A delayed manifestation of the syndrome may account for such cases. CASE SUMMARY: An asymptomatic 69-year-old woman presented for a routine cardiac check-up, which revealed normal electrocardiogram (ECG), echocardiography, and exercise ECG. She did not complain of any chest pain during or immediately after the tests. After about 24 h, she developed chest pain for which she was admitted with the provisional diagnosis of acute coronary syndrome. ECG showed dynamic T-wave changes with QTc prolongation. Cardiac biomarkers were mildly elevated. Characteristic reversible left ventricular dysfunction in absence of coronary stenosis ultimately led to the diagnosis of Takotsubo syndrome. DISCUSSION: Our case represents a delayed occurrence of Takotsubo syndrome triggered by a treadmill exercise stress test, which manifested about 24 h following the stressor. Such delayed manifestation may account for those cases of Takotsubo syndrome where no immediate triggering stressor is evident.

Acute coronary syndromes presentations and care outcomes in white, South Asian and Chinese patients: a cohort study.

OBJECTIVES: Successful treatment of acute coronary syndrome (ACS) relies on its rapid recognition. It is unclear whether the accepted presentation of chest pain applies to different ethnic groups. We thus examined potential ethnic variations in ACS symptoms and clinical care outcomes in white, South Asian and Chinese patients. DESIGN: Cross-sectional survey. SETTING: Participants were hospitalised at 1 of 12 Canadian centres across four provinces. PARTICIPANTS: 1334 patients with ACS (630 white; 488 South Asian; 216 Chinese). MAIN OUTCOME MEASURES: ACS presentation symptoms (classic/typical midsternal pain/discomfort with or without radiation to the left neck, shoulder or arm) were assessed by self-report. Clinical care outcomes (time to emergency room [ER] presentation, cardiac catheterisation; receipt of cardiac catheterisation, percutaneous coronary intervention [PCI] or coronary artery bypass grafting [CABG]) were obtained by health record audit. RESULTS: The mean age of the sample was 62 years and 30% had ST-elevation myocardial infarction (STEMI). The most common presenting symptom was midsternal pain/discomfort of any intensity regardless of ethnic status. Yet, a substantial proportion of patients reported atypical symptoms (33% white, 19% South Asian, 20% Chinese; p<0.006). After adjustment for age, sex, education, current smoking, extent of coronary artery disease, presence of diabetes or chronic kidney disease and STEMI vs non-STEMI/unstable angina, South Asians were more likely to present with at least moderate intensity midsternal pain/discomfort (adjusted OR [AOR] 1.44; 95% CI 1.05 to 1.98), whereas Chinese were less likely to present with radiating symptoms (AOR 0.53; 95% CI 0.38 to 0.74) compared with whites. South Asians with atypical pain (relative to those with midsternal pain/discomfort) took significantly longer to present to the ER (p=0.037), and were less likely to receive PCI (p=0.008) or CABG (p=0.041). CONCLUSIONS: Atypical presentations were associated with greater delays in arrival to the emergency department and reduced invasive cardiovascular care in South Asians.

Zotarolimus-eluting Resolute Integrity versus everolimus-eluting Xience Xpedition stents in the management of very long (>30mm) de novo coronary artery stenosis.

BACKGROUND: Procedural and clinical outcomes in patients with very long (>30mm) coronary lesions who underwent stent-based percutaneous coronary interventions are still unfavorable. Therefore, we compared the relative efficacy and safety of resolute zotarolimus-eluting stents (R-ZES) and Xpedition everolimus-eluting stents (X-EES) for patients with de novo very long coronary lesions. METHODS: This comparative single-centre, retrospective study compared long R-ZES and X-EES in consecutive patients admitted with very long (≥30mm) native ACC/AHA type C coronary lesions in 2014. All patients were followed up clinically at 1, 3, 6 and 12months. In this study, only symptom-driven angiogram was advised. The study end point was to evaluate immediate procedural success and one-year rate of target lesion failure (TLF), which is a composite of cardiac death, target lesion myocardial infarction, or target lesion revascularization (TLR). RESULTS: Total number of patients enrolled in this study was 185 (R-ZES=107; X-EES=78). The baseline characteristics and post procedural success rate were similar between R-ZES and X-EES groups, including the post stenting lesion lengths (36.6±1.92mm vs 40.71±6.175mm, P=0.09). At 12-month follow-up, there were no significant between-group differences in the rate of adverse clinical events (death, myocardial infarction, stent thrombosis, target lesion revascularization, and composite outcomes). Procedural success was achieved in 94% in R-ZES group and 93% in X-EES group (P=0.24). The incidence of TLF was 5% in R-ZES and 4% in X-EES groups (HR-1.25; 95% CI-0.86-5.6; P=0.19). CONCLUSION: Patients with de novo long coronary artery disease, R-ZES implantation showed similar clinical outcome as compared with X-EES implantation.

A simple method for Bachmann's bundle pacing with indigenous modification of J-stylet.

BACKGROUND: Pacing in the Bachmann's bundle (BB) area (upper atrial septum) appears superior to right atrial appendage or free wall stimulation for the prevention of paroxysmal atrial fibrillation in patients with atrial conduction delay. However, insertion of active fixation lead in the upper atrial septal position is difficult and time consuming with conventional stylet, inhibiting application of this pacing method in routine practice. METHODS: The technique of positioning the atrial lead in BB with hand-made stylet is presented with emphasis on electrocardiographic P-wave pattern and fluoroscopic landmarks. RESULTS: The results demonstrate an acute implantation and short-term success of BB pacing of 14 patients out of 15 patients without major complications. Pacing parameters at implantation and 3 months postprocedure were noted which were within normal limits. CONCLUSION: These favorable initial results indicate that the positioning of active fixation atrial lead in BB with fluoroscopic landmarks is feasible and reproducible with a simple technique.

Coronary-Cameral Fistula Caused by Guidewire Trauma and Resolved by Coil Embolization.

A 57-year-old woman presented with effort angina. A coronary angiogram revealed critical 2-vessel disease, for which she subsequently underwent percutaneous coronary intervention. During angioplasty, a coronary guidewire-inadvertently passed into the right ventricle through the septal branches of the posterior descending coronary artery-caused a coronary artery-to-right ventricular fistula. This fistula was successfully closed percutaneously by coil embolization. To our knowledge, this is the first report of a case in which a coronary artery-to-right ventricular fistula caused by a guidewire was managed successfully by coil embolization.

Prevalence, awareness, and control of hypertension in the slums of Kolkata.

BACKGROUND: Slum dwellers have poor socio-environmental conditions and less access to medical care, which make them susceptible to illnesses. Studies on urban slums have primarily focused on communicable diseases and less on lifestyle diseases, such as hypertension. Consequently, there is a paucity of prevalence studies of hypertension in slums in different parts of the country. The aim of the study was to provide estimates of the prevalence, awareness, and control of hypertension in an adult population sample of the slums of Kolkata. METHODS: A population-based cross-sectional study was conducted in the slums of Kolkata in collaboration with Kolkata Municipality Corporation. Door-to-door survey was conducted by trained healthcare workers using a structured questionnaire. Age, sex, religion, housing conditions (house/hut), average monthly household income, education status, current use of tobacco, history of hypertension, and whether on antihypertensive treatment were recorded. Blood pressure (BP) was recorded as per standard guidelines. Hypertension was diagnosed by JNC-VII criteria. A total of 10,175 adults aged ≥20 years were enrolled in the study. RESULTS: Overall prevalence of hypertension was 42%. Hypertension was newly detected in 19% of the population. Fifty-four percent of the hypertensive subjects were aware of their hypertension status, 38% were on antihypertensive treatment, and 12% had their BP controlled to target level. Subgroup analysis showed that the prevalence of hypertension was higher in men, above 60 years age, in the minority community, in those with a higher household income, and among the tobacco users. CONCLUSION: There is a high prevalence of hypertension in the slums of Kolkata. Although the awareness of the condition is high, the control of hypertension is poor.

Outcome of everolimus eluting bioabsorbable vascular scaffold (BVS) compared to non BVS drug eluting stent in the management of ST-segment elevation myocardial infarction (STEMI) - A comparative study.

BACKGROUND: The safety and efficacy of everolimus eluting bioabsorbable vascular scaffold (BVS) in the management of "ST" segment elevation myocardial infarction (STEMI) are yet to be established. AIMS: To evaluate immediate and short term safety and efficacy of the everolimus-eluting ABSORB BVS compared with non BVS drug eluting stent (DES) in patients with STEMI. METHODS: From December 2013 to December 2014, 220 patients with STEMI were included in this study. Among them, 35 patients treated with BVS were compared with a control group composed of 180 patients who underwent non BVS DES implantation in the same time period. The incidence of major adverse cardiac events (MACE: stent thrombosis: death, non-fatal myocardial infarction, or target vessel/lesion revascularization) before discharge and up to six months was evaluated. RESULTS: 1 vessel disease was more frequent whereas, 2 and 3 vessel disease was less frequent in BVS group. Procedural characteristics were also similar between groups, except for the use of post dilation (p=0.04). Procedural success, in-hospital, and up to six-month MACE rates were similar between both groups. Definite or probable stent thrombosis did not occur (according to the ARC criteria) in BVS patients, though two patients during the index admission and another two patients in the first month after DES implantation had stent thrombosis. CONCLUSION: The use of the ABSORB BVS for STEMI is feasible and associated with good procedural safety, and angiographic success rate.

The Indian consensus guidance on stroke prevention in atrial fibrillation: An emphasis on practical use of nonvitamin K oral anticoagulants.

The last ten years have seen rapid strides in the evolution of nonvitamin K oral anticoagulants (NOACs) for stroke prevention in patients with atrial fibrillation (AF). For the preparation of this consensus, a comprehensive literature search was performed and data on available trials, subpopulation analyses, and case reports were analyzed. This Indian consensus document intends to provide guidance on selecting the right NOAC for the right patients by formulating expert opinions based on the available trials and Asian/Indian subpopulation analyses of these trials. A section has been dedicated to the current evidence of NOACs in the Asian population. Practical suggestions have been formulated in the following clinical situations: (i) Dose recommendations of the NOACs in different clinical scenarios; (ii) NOACs in patients with rheumatic heart disease (RHD); (iii) Monitoring anticoagulant effect of the NOACs; (iv) Overdose of NOACs; (v) Antidotes to NOACs; (vi) Treatment of hypertrophic cardiomyopathy (HCM) with AF using NOACs; (vii) NOACs dose in elderly, (viii) Switching between NOACs and vitamin K antagonists (VKA); (ix) Cardioversion or ablation in NOAC-treated patients; (x) Planned/emergency surgical interventions in patients currently on NOACs; (xi) Management of bleeding complications of NOACs; (xii) Management of acute coronary syndrome (ACS) in AF with NOACs; (xiii) Management of acute ischemic stroke while on NOACs.

Inadvertent transvenous left ventricular pacing through an unsuspected atrial septal defect.

A 65-year-old male patient with a long standing history of chronic obstructive lung disease had permanent pacemaker implantation for symptomatic atrioventricular nodal blocks. Preoperative echocardiography showed dilated right heart chambers and moderate pulmonary arterial hypertension without any demonstrable intracardiac shunt. Postoperative twelve-lead ECG showed right bundle branch block configuration of paced complexes. This suggested left ventricular pacing which was confirmed by transthoracic echocardiography. Later, transoesophageal echocardiography showed the lead entering into left atrium from right atrium through a sinus venosus type of atrial septal defect. The patient refused any further intervention and continues to remain asymptomatic with stable pacing on aspirin-anticoagulant therapy at end of four years.