Myocardial Infarction Presenting as Both Left Ventricular Aneurysm and Ventricular Septal Defect.

Acute myocardial infarction can result in various mechanical complications, although they have become rare with the advent of reperfusion therapies. Among these complications, ventricular septal rupture (VSR) and left ventricular aneurysm (LVA) are infrequent but life-threatening conditions associated with high morbidity and mortality. We present a rare case of a 67-year-old male with acute myocardial infarction who developed concomitant apical LVA and ventricular septal rupture. LEARNING POINTS: Mechanical complications of myocardial infarction, such as a ventricular septal rupture (VSR) and left ventricular aneurysm (LVA), are rare but life-threatening.Early diagnosis is critical. A ventricular septal defect (VSD) requires immediate surgical closure, while surgery for LVA is only considered in specific cases such as chest pain or thromboembolism.Diagnostic tools such as echocardiography and left ventriculography play a vital role in identifying and characterising these complications, enabling timely treatment decisions.

Vascular complications and outcomes following transcatheter aortic valve replacement in patients on chronic steroid therapy: a meta-analysis.

BACKGROUND: Chronic steroid (CS) therapy was reportedly linked to increased vascular complications following percutaneous coronary intervention. However, its association with vascular complications after transcatheter aortic valve replacement (TAVR) remained uncertain, with conflicting results being reported. OBJECTIVE: The authors aimed to compare the rate of vascular complications and outcomes between patients with and without CS use after TAVR. METHODS: The authors conducted a comprehensive literature search in PubMed, Embase, and Cochrane databases from their inception until 18th April 2022 for relevant studies. Endpoints were described according to Valve Academic Research Consortium-2 definitions. Effect sizes were pooled using DerSimonian and Laird random-effects model as risk ratio (RR) with 95% CI. RESULTS: Five studies with 6136 patients undergoing TAVR were included in the analysis. The included studies were published between 2015 and 2022. The mean ages of patients in both study groups were similar, with the CS group averaging 80 years and the nonsteroid group averaging 82 years. Notably, a higher proportion of patients in the CS group were female (56%) compared to the nonsteroid group (54%). CS use was associated with a significantly higher risk of major vascular complications (12.5 vs. 6.7%, RR 2.32, 95% CI: 1.73-3.11, P <0.001), major bleeding (16.8 vs. 13.1%, RR 1.61, 95% CI: 1.27-2.05, P <0.001), and aortic annulus rupture (2.3 vs. 0.6%, RR 4.66, 95% CI: 1.67-13.01, P <0.001). There was no significant difference in terms of minor vascular complications (RR 1.43, 95% CI: 1.00-2.04, P =0.05), in-hospital mortality (2.3 vs. 1.4%, RR 1.86, 95% CI: 0.74-4.70, P =0.19), and 30-day mortality (2.9 vs. 3.1%, RR 1.14, 95% CI: 0.53-2.46, P =0.74) between both groups. CONCLUSION: Our study showed that CS therapy is associated with increased major vascular complications, major bleeding, and annulus rupture following TAVR. Further large multicenter studies or randomized controlled trials are warranted to validate these findings.

A meta-analysis of outcomes of aspiration thrombectomy for high and intermediate-risk pulmonary embolism.

BACKGROUND: Aspiration thrombectomy has gained popularity in patients with massive and sub-massive pulmonary embolism (PE) and having contraindications to thrombolysis. METHODS: A meta-analysis was conducted including studies on aspiration thrombectomy in patients with high-risk and intermediate-risk PE. The pooled odds ratio for efficacy parameters, including change in heart rate, blood pressure and right ventricle/left ventricle (RV/LV) ratio, and safety parameters including major bleeding and stroke, was calculated using a random effects model. RESULTS: The meta-analysis of 24 selected studies revealed that intermediate and high-risk pulmonary embolism (PE) patients demonstrated significant improvements: modified Miller score odds ratio of 10.60, mean pulmonary artery pressure reduction by 0.04 mm Hg, and an overall all-cause mortality odds ratio of 0.10. Considerable heterogeneity was observed in various outcomes. CONCLUSION: Aspiration thrombectomy has success rates in both high-risk and intermediate-risk PE, however, procedural risks, including bleeding, must be anticipated.

Myocarditis With Cardiogenic Shock in a Young Female With Severe Ulcerative Colitis Flare.

Myocarditis is a rare extraintestinal manifestation of inflammatory bowel disease. Myopericarditis-associated inflammatory bowel disease can be a side effect of the medications used to treat inflammatory bowel disease or the disease process. We present a 25-year-old female with history of ulcerative colitis presented with abdominal pain associated with sharp and central chest pain. She was in a flare of ulcerative colitis with bloody diarrhea. She developed shock and was in intensive care unit. Echocardiogram showed reduced ejection fraction and pericardial effusion. Coronary artery disease, sepsis, thyroid disease were ruled out. She was treated with systemic antibiotics, intravenous steroids, and guideline-directed medical therapy for presumed ulerative colitis associated with myopericarditis and had symptomatic improvement. Treatment of IBD-associated myopericarditis includes the standard induction treatment for IBD with steroids and guideline-directed medical therapy for heart failure.

Migraine and heart: A reality check.

Migraine is a common neurological disorder affecting 12% of the global population. The common risk factors are adolescent age, genetics, and female sex, and are triggered by hormonal fluctuations, emotional stress, sensory overload, weather changes, alcohol consumption, fasting, cheese, chocolate, smoked fish, yeast extract, cured meats, artificial sweeteners, food preservatives containing nitrates and nitrites, and sleep disturbances. Migraine with aura is associated with an increased risk of cardiovascular disease events, such as myocardial infarction, angina pectoris, and cardiac arrhythmias, and has recently been added to the QRISK3 cardiovascular disease prediction score. Population-based cohort studies have shown a significant association of migraine with aura and cardiac arrhythmias, most importantly atrial fibrillation. Patients suffering from migraine with aura are at an increased risk for cardiac arrhythmias; thus, it is essential to screen these patients for undiagnosed cardiovascular disorders.

Case report of culture-negative endocarditis in lupus nephritis.

Background: Cardiovascular involvement is frequent in systemic lupus erythematosus (SLE). Valvular abnormalities are increasingly being recognized with the advent of echocardiography. Case summary: We present a case of a 46-year-old lady who presented to the emergency department with upper limb ischaemia. On examination, she had poor dentition and a short systolic murmur on auscultation. A blood workup revealed a diagnosis of SLE. Further investigations showed vegetations on the mitral valve. Initially, an infective endocarditis (IE) diagnosis was made, which was treated with antibiotics. High-dose steroids and immunosuppressants were initiated due to her clinical deterioration and biopsy-proven lupus nephritis. She improved clinically before being discharged home. Discussion: It can be difficult to distinguish between IE and Libman-Sacks endocarditis (LSE), especially in the setting of risk factors for both. Antibiotics and immunosuppressants might be started simultaneously in these cases. A multidisciplinary team is required to manage challenging cases of culture-negative endocarditis. Procalcitonin may have a role in differentiating bacterial endocarditis and LSE.

A Classic Pattern of Wellens Syndrome on ECG: A Case Report.

Wellens syndrome is usually diagnosed in asymptomatic patients with normal or only slightly elevated cardiac enzymes. There are two different ECG patterns (Type A and Type B) described in the literature. Earlier studies demonstrated that the appearance of the Wellens pattern had a specificity of 89% and a positive predictive value of 86% for severe stenosis of the left anterior descending artery (LAD) hence a timely recognition and therapeutic approach may prevent fatal outcomes in the patients. Here we are presenting a case of a 69-year-old gentleman with chest pain and Type A Wellens Syndrome pattern on ECG who was found to have LAD stenosis.

Acute pulmonary embolism: Diagnosis and management.

Acute pulmonary embolism (PE) can present with non-specific signs and symptoms and thus the diagnosis and management might not be as straightforward. This review outlines the new PE management guidelines in the Indian context. The exact prevalence in the Indian population is not well defined; despite recent studies suggesting an increasing trend in the Asian population. A delay in treatment can be fatal, especially in massive PE. The nuances associated with stratification and management have led to heterogeneity in acute PE management. The purpose of the review is. 1: To highlight the principles of stratification, diagnosis and management of acute PE with a special attention towards the Indian population. 2: To aid patient selection for newer catheter based therapies. To conclude, formulation of pulmonary embolism guidelines in the Indian setting is required underlying the role of further research in this area.

Percutaneous Coronary Intervention Outcomes in Patients with Liver Cirrhosis: A Systematic Review and Meta-Analysis.

There is a paucity of data and minimal literature on outcomes of percutaneous coronary intervention (PCI) among liver cirrhosis patients. Therefore, we conducted a systematic review and meta-analysis to evaluate the clinical outcomes among liver cirrhosis patients post-PCI. We conducted a comprehensive literature search in the PubMed, Embase, Cochrane, and Scopus databases for relevant studies. Effect sizes were pooled using the DerSimonian and Laird random-effects model as an odds ratio (OR) with 95% confidence intervals (CI). A total of 3 studies met the inclusion criteria, providing data from 10,705,976 patients. A total of 28,100 patients were in the PCI + Cirrhosis group and 10,677,876 patients were in the PCI-only group. The mean age of patients with PCI + Cirrhosis and PCI alone was 63.45 and 64.35 years. The most common comorbidity was hypertension among the PCI + Cirrhosis group compared with PCI alone (68.15% vs. 73.6%). Cirrhosis patients post-PCI were had higher rates of in-hospital mortality (OR, 4.78 (95%CI: 3.39-6.75), p < 0.001), GI bleeding (OR, 1.91 (95%CI:1.83-1.99), p < 0.001, I2 = 0%), stroke (OR, 2.48 (95%CI:1.68-3.66), p < 0.001), AKI (OR, 3.66 (95%CI: 2.33-6.02), p < 0.001), and vascular complications (OR, 1.50 (95%CI: 1.13-1.98), p < 0.001) compared with the PCI group without cirrhosis. Patients with cirrhosis are at a high risk for mortality and adverse outcomes post-PCI procedure compared to the PCI-only group of patients.

Septal Myectomy or Alcohol Ablation for Hypertrophic Cardiomyopathy: A Nationwide Inpatient Sample (NIS) Database Analysis.

BACKGROUND: Comparison of the real-world cohort on the relative safety of alcohol septal ablation (ASA) vs. septal myectomy (SM) for the management of hypertrophic cardiomyopathy (HCM) has been lacking. METHODS: The National Inpatient Sample (NIS) (2012-2019) was used to select all cases of HCM. The safety of ASA vs. SM was compared using a one:many propensity score matched (PSM) analysis. Adjusted odds ratios (aOR) for mortality and other in-hospital complications were computed. RESULTS: A total of 6208 HCM patients (ASA 3106 vs. SM 3102) were included using a PSM analysis. Post-procedural bleeding (aOR 0.18, 95 % CI 0.11-0.32, p < 0.0001) and the need for an intra-aortic balloon pump (aOR 0.51, 95 % CI, 0.28-0.96, p = 0.037) were significantly lower while permanent pacemaker (PPM) implantation was significantly higher in ASA group as compared with SM group (aOR 1.72, 95 % CI, 1.43-2.06, p < 0.0001). The total in-hospital mean adjusted cost and length of stay were also significantly lower in the ASA group. However, there were no significant differences in adjusted odds of all-cause mortality (aOR 0.91, 95 % CI 0.62-1.33, p = 0.61), stroke (aOR 0.91, 95 % CI, 0.59-1.4, p = 0.66), and major bleeding (aOR 1.0, 95 % CI 7.8-1.29, p = 0.99) between the two comparison groups. CONCLUSION: In patients with hypertrophic cardiomyopathy, alcohol septal ablation appears to be an acceptable alternative to septal myectomy due to a lower risk of post-procedural bleeding and the need for an intra-aortic balloon pump. However, ASA confers a higher risk of PPM placement.

A Study on QT Dispersion before and after Thrombolysis in Acute Myocardial Infarction and its Prognostic Implications: A before and after Comparison Study.

Introduction: Acute myocardial infarction (AMI) stands as one of the most catastrophic occurrences in the progression of coronary artery disease. Measuring QT dispersion (QTd) is a fairly straightforward and noninvasive technique for predicting mortality in patients at high risk following a myocardial infarction (MI). Objective: To measure the QT, corrected QT interval (QTc), QTd, and corrected QT dispersion (QTcd) intervals before and after thrombolysis in patients with AMI and to determine prognostic implications of QTd in AMI. Materials and methods: This was a before and after comparison study conducted in the intensive care unit (ICU) of a tertiary care center in Central India. It was carried out in patients with AMI [ST-elevation myocardial infarction (STEMI)] who underwent thrombolysis in ICU. A total of 160 participants were enrolled over the time period of 24 months using the convenience sampling technique. Results: The most prevalent (68 patients) risk factor among MI patients was hypertension (HTN). QT parameters such as QT, QTd, and QTcd showed significant statistical variation of p-value < 0.0001 when compared at admission and after thrombolysis. No significant difference (p > 0.05) in QT parameters at admission (QTd, QTc, and QTcd) between anterior and inferior wall MI, except for QT interval (p = 0.0010). Among the 33 patients who experienced arrhythmia, ventricular tachycardia was the most prevalent arrhythmia in 22 patients (13.75%). There was a significant statistical correlation between the arrhythmic event and the outcome of the patient (p < 0.0001). Patients who died had higher QT parameter values at admission, and these remained on the higher side even after thrombolysis, whereas those who got discharged had lower QT parameter values at admission, and their values decreased after thrombolysis. Conclusion: Successful thrombolysis significantly decreases the QTd and thereby the arrhythmogenic potential, and thus can also be used as a reliable predictor of arrhythmia in patients of MI. How to cite this article: M A, Khandait H, Guralwar C, et al. A Study on QT Dispersion before and after Thrombolysis in Acute Myocardial Infarction and its Prognostic Implications: A before and after Comparison Study. J Assoc Physicians India 2023;71(10):14-18.

Retraction notice to "Association between sarcoidosis and cardiovascular Outcomes: A systematic review and meta-analysis" [IJC Heart Vasculat. 41 (2022) 101073].

[This corrects the article DOI: 10.1016/j.ijcha.2022.101073.].

Association between sarcoidosis and cardiovascular Outcomes: A systematic review and Meta-analysis.

Background: Sarcoidosis is a chronic inflammatory disorder of unknown etiology associated with high morbidity and mortality. Its association with cardiovascular outcomes is under-documented. Aim: The aim of this study was to assess the adverse cardiovascular outcomes in patients with sarcoidosis compared with that of non-sarcoidosis. Methodology: Online databases including PubMed, Embase and Scopus were queried from inception until March 2022. The outcomes assessed included all-cause mortality (ACM) and incidence of ventricular tachycardia (VT), heart failure (HF) and atrial arrhythmias (AA). Result: A total of 6 studies with 22,539,096 participants (42,763 Sarcoidosis, 22,496,354 Non-Sarcoidosis) were included in this analysis. The pooled prevalence of sarcoidosis was 13.1% (95% CI 1% to 70%). The overall mean age was 47 years. The most common comorbidities were hypertension (12.7% vs 12.5%), and diabetes mellitus (5.5% vs 4%) respectively. The pooled analysis of primary endpoints showed that all-cause mortality (RR, 2.08; 95% CI: 1.17 to 3.08; p = 0.01) was significantly increased in sarcoidosis patients. The pooled analysis of secondary endpoints showed that the incidence of VT (RR, 15.3; 95% CI: 5.39 to 43.42); p < 0.001), HF (RR, 4.96; 95% CI: 2.02 to 12.14; p < 0.001) and AA (RR, 2.55; 95% CI: 1.47 to 4.44); p = 0.01) were significantly higher with sarcoidosis respectively compared to non-sarcoidosis. Conclusion: Incidence of VT, HF and AA was significantly higher in patients with CS. Clinicians should be aware of these adverse cardiovascular events associated with sarcoidosis.

A Rare Case of Eustachian Valve Endocarditis in a Young Male With Poorly Controlled Type 1 Diabetes Mellitus.

The eustachian valve (EV) is a vestigial structure found at the junction of the inferior vena cava and the right atrium, a remnant of the embryological sinus venosus that may persist throughout life. Right-sided infective endocarditis of the eustachian valve remains a distinctly rare and under-diagnosed entity. Commonly known risk factors of eustachian valve endocarditis (EVE) are intravenous drug use, in-dwelling intracardiac devices, and central lines, although more recently immunocompromised states, e.g. uncontrolled diabetes mellitus and old age, have been recognized as risk factors for the disease. Although Staphylococcus aureus has been the most commonly implicated organism, cases of infections with gram-negative organisms are emerging. We present a 47-year-old male with uncontrolled type 1 DM who initially presented to the ED with complaints of low back pain and dysuria and was later found to have eustachian valve endocarditis ultimately treated with intravenous antibiotics.

Reactivation of Tuberculosis in the Setting of COVID-19 Infection.

Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV- 2) was declared a pandemic by WHO in March 2020. The causative organism has since undergone a series of mutations. COVID-19 primarily being a respiratory illness causes pre-existing pulmonary diseases to show worse clinical outcomes. About one-third of the world's population is thought to be infected with latent Mycobacterium tuberculosis (MTB). Both previous and newly developed tuberculosis (TB) infection are risk factors for COVID-19 and are associated with poor outcomes. T lymphocytes play a pivotal role in defense against MTB and with evidence suggesting depletion of T lymphocytes in COVID-19, it can be postulated that COVID-19 can increase the risk of reactivation of latent TB.  Given that a large population around the globe is infected with latent tuberculosis, it is interesting to study and note cases where the virus leads to the reactivation of latent tuberculosis infection. Herein, we present a 76-year-old Brazilian male recently treated for COVID-19 pneumonia, presenting with new-onset cough and weakness diagnosed with latent MTB reactivation.

A Rare Case of Elevated Osmolar Gap in Diabetic Ketoacidosis/Hyperosmolar Hyperglycaemic State in the Absence of Concomitant Toxic Alcohol Ingestion.

The serum osmolar gap, defined as the difference between measured osmolality and calculated osmolarity, is a convenient method to screen for toxins in serum. In normal circumstances, the difference between the two is 6-10 mol/kg. Typical contributors to serum osmolarity are sodium bicarbonate, sodium chloride, glucose and urea. An elevated gap, defined as a difference >10 mol/kg, can occur if a sufficient quantity of an additional solute other than those mentioned above is present in the serum or there are inaccuracies in sodium measurement secondary to hyperlipidaemia and hyperproteinaemia. An elevated serum osmolar gap should thus prompt clinicians to check for toxic alcohol levels. Treatment with fomepizole should not be delayed if suspicion is high. Isolated diabetic ketoacidosis can occasionally present with an elevated osmolar gap in the absence of concomitant alcohol ingestion. This finding is attributed to the production of acetone and glycerol. We describe the case of a 62-year-old man presenting with diabetic ketoacidosis/hyperosmolar hyperglycaemic state and an elevated osmolar gap in the absence of toxic alcohol ingestion. LEARNING POINTS: The osmolar gap is the difference between the measured and the calculated serum osmolarity and should be calculated in all patients presenting with elevated serum osmolarity; if elevated, toxic alcohol ingestion should be considered and prophylactic treatment with fomepizole immediately administered if the index of suspicion is high.Although toxic alcohol ingestion is one of the common causes of an elevated osmolar gap, hyperlipidaemia, hyperproteinaemia and less occasionally lactic acidosis and ketoacidosis have also been implicated.In the setting of ketoacidosis, the osmolar gap can be elevated in the absence of toxic alcohol ingestion, is attributed to increased production of acetone and glycerol, and is responsive to treatment with insulin and intravenous fluids.

Independent association of meteorological characteristics with initial spread of Covid-19 in India.

Whether weather plays a part in the transmissibility of the novel Coronavirus Disease-19 (COVID-19) is still not established. We tested the hypothesis that meteorological factors (air temperature, relative humidity, air pressure, wind speed and rainfall) are independently associated with transmissibility of COVID-19 quantified using the basic reproduction rate (R0). We used publicly available datasets on daily COVID-19 case counts (total n = 108,308), three-hourly meteorological data and community mobility data over a three-month period. Estimated R0 varied between 1.15 and 1.28. Mean daily air temperature (inversely), wind speed (positively) and countrywide lockdown (inversely) were significantly associated with time dependent R0, but the contribution of countrywide lockdown to variability in R0 was over three times stronger as compared to that of temperature and wind speed combined. Thus, abating temperatures and easing lockdown may concur with increased transmissibility of COVID-19 in India.

COVID-19 and Hematology-What Do We Know So Far?

The severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2), the causative agent of the novel coronavirus disease 2019 (COVID 19), was reported to the World Health Organization in late 2019. This disease quickly evolved into a public health concern and was declared a pandemic on March 11, 2020. COVID-19's high transmission rate and potential to cause a spectrum of systemic diseases makes it imperative for researchers and clinicians worldwide to collaborate and develop a strategy to manage and contain this disease. Studies have shown a wide range of hematological abnormalities and virus-related coagulopathies in affected patients, resulting in an increased propensity to develop serious thrombotic complications or disseminated intravascular coagulation (DIC) in severe cases. The fatal implications of coagulopathy in the form of pulmonary embolism (PE), myocardial infarction (MI), and cerebral infarction compelled us to study in-depth the pathophysiology and treatment options related to COVID-19. This analysis reviews published reports on patients with confirmed SARS-COV-2 infection and associated coagulopathy, defined as abnormalities in the coagulation parameters prothrombin time (PT), activated partial thromboplastin time (aPTT), antithrombin time, fibrinogen, fibrin degradation products, and D-dimer. In this review, we present the hematological manifestations of COVID-19, focusing on virus-associated coagulopathy and relevant pathophysiology, clinical outcomes, and treatment.

NAFLD and COVID-19: a Pooled Analysis.

The earliest evidence from China suggested that COVID-19 patients are even more vulnerable to succumbing from complications in the presence of a multimorbid status, including metabolic syndrome. Due to ongoing metabolic abnormalities, non-alcoholic fatty liver disease (NAFLD) appears to be a potential risk factor for contracting SARS-CoV-2 infection and developing related complications. This is because of the interplay of chronically active inflammatory pathways in NAFLD- and COVID-19-associated acute cytokine storm. The risk of severe disease could also be attributed to compromised liver function as a result of NAFLD. We systematically reviewed current literature to ascertain the relationship between NAFLD and severe COVID-19, independent of obesity, which is considered the major factor risk factor for both NAFLD and COVID-19. We found that NAFLD is a predictor of severe COVID-19, even after adjusting for the presence of obesity (OR 2.358; 95% CI: 1.902-2.923, p < 0.001).