Retrospective Analysis of Hospital Acquired Infection and Antibiotic Resistance in Coronary Care Unit (CCU), Adult, and Pediatric Cardiology Wards.

BACKGROUND: Antibiotics resistance is an paramount threat affecting the whole world but nowhere situation is as gloomy as in India. No study till date regarding epidemiology of hospital acquired infections in coronary care units(CCU) and cardiology wards from India. From Indian perspective it is the first observational study to analyse microbiological profile and antibiotic resistance in CCU. The purpose of this observational study is to explore the epidemiology and importance of infections in CCU patients. METHODOLOGY: After ethics committee approval, the records of all patients who were admitted in coronary care units, adult and pediatric cardiology wards surgery between January 2020 and December 2021 were reviewed retrospectively. The type of organism,source of infection ,age wise distribution and seasonal variability among patients who developed hospital acquired infection (HAI) were determined. RESULTS: 271 patients developed microbiologically documented HAI during from January 2020 to December 2021. Maximum number of organisms(78/271 28.78%) are isolated from urinary samples ,followed by blood stream(60/271 22.14%) and Endotracheal tube (54/271 19.92%). Acinetobacter baumanii (53/271, 19.5%) being the most common isolate among all the samples taken . Acinetobacter was the most frequent pathogens isolated in patients with LRTI and blood stream infection while E. coli was from urinary tract infection . In the adult population, infection with E. coli(24.6%) is the most common followed by Klebsiella pneumoniae (12.8%) and Acinetobacter baumanii (10.1%). In the pediatric population Acinetobacter baumanii (38.6%%) is the most common followed by Klebsiella pneumoniae (20.5%) and Methicillin Resistant Staphylococcus aureus, MRSA (6.8%). Commonly used antibiotics eg ciprofloxacin,ceftazidime and amikacin were found to be resistant against the top three isolates. CONCLUSION: Urinary tract was the most common site of infection and Gram-negative bacilli, the most common pathogens in adult as well as pediatric population. Antibiotic resistance was maximum with commonly isolated microorganisms.

Significance of QTc interval in chronic hypoparathyroidism and its correlates.

CONTEXT: Hypocalcemia predisposes patients with chronic hypoparathyroidism (cHypoPT) to an increased risk of QTc prolongation and life-threatening arrhythmias. Information on clinical and biochemical correlates of QTc in cHypoPT is limited. DESIGN AND SETTING: Observational cohort study at tertiary-care-center. SUBJECTS AND METHODS: Eighty-eight non-surgical cHypoPT (mean age 44.1 ± 15.4 years, 45 males) were assessed for QTc interval and its possible correlates including arrhythmic symptoms (palpitation/giddiness/syncope), serum total-calcium, phosphate, 25(OH)D and iPTH. RESULTS: The mean QTc in HypoPT cohort was 428 ± 34 ms with 13.6% having prolonged QTc. There was a significant inverse correlation between QTc interval and serum total-calcium measured on the same day (r = -0.43, p < 0.001). The mean serum total-calcium was significantly lower in patients with prolonged QTc (7.05 ± 1.94 vs. 8.49 ± 1.01 mg/dL, p = 0.02). 21.6% of cHypoPT patients had arrhythmic symptoms. They had significantly higher mean QTc (p = 0.02) and also tended to have lower mean serum total-calcium during follow-up (p = 0.06). In multivariable regression, female gender, higher current-age, higher BMI, and low serum total-calcium showed significant association with prolonged QTc. For every mg/dL decrease in serum total-calcium, QTc increased by 13 ms. Receiver-operating-characteristic analysis revealed serum total-calcium at cut-off of 8.3 mg/dL discriminated prolonged QTc with area-under-curve being 0.72 [95% CI: 0.51,0.93]. CONCLUSION: One-fifth of cHypoPT had arrhythmic symptoms and a significant proportion had prolonged QTc. This highlights the need for close monitoring of cHypoPT patients for arrhythmic symptoms and QTc prolongation. The serum total-calcium should be maintained to at least 8.3 mg/dL to minimize the risk of potentially life-threatening arrhythmia in cHypoPT.

South African flag sign to a giant coronary artery aneurysm.

Background: Coronary arteritis leading to aneurysm is one of the unusual presentations of IgG4-related disease. Acute myocardial infarction as a complication of IgG4-related giant coronary artery aneurysm is even rarer. Case summary: We describe the case of a 56-year-old gentleman who presented to our institute with Canadian Cardiovascular Society (CCS) class III angina. His symptoms were persistent even with high-dose antianginal medications. He had an acute coronary syndrome two weeks back for which he was treated conservatively in a peripheral health centre. His 12-lead electrocardiogram at the time of the event was suggestive of high lateral ST-segment elevation myocardial infarction (South African flag sign). His transthoracic echocardiography showed mild left ventricular dysfunction and a large echogenic mass lateral to the left ventricle. Coronary angiography followed by cardiac computed tomography revealed a giant pseudoaneurysm of the proximal and mid-left anterior descending coronary artery. FDG-PET scan showed significant metabolic activity in the aneurysm wall and mediastinal lymph nodes suggesting active inflammation. IgG4-related coronary arteritis was suspected, and the patient underwent aneurysmectomy and coronary artery bypass (CABG) surgery. The histopathology of the resected segment showed diffuse IgG4-secreting plasma cells confirming the diagnosis. Discussion: Atherosclerosis is the most common cause of coronary aneurysms in adults. However, cardiologists should be aware of atypical causes like IgG4-related disease that can even present with acute coronary syndrome. Although multimodality imaging is beneficial during early evaluation, histopathological analysis is the cornerstone for the diagnosis of IgG4-related disease. The management involves both immunosuppressive medication and endovascular or surgical repair.

Diagnostic potential of SORT1 gene in coronary artery disease.

BACKGROUND: Genome-wide association studies identify SORT1 gene associated with risk of coronary artery disease (CAD). Sortilin protein enhances LDL absorption, form cell development, and atherosclerosis in macrophages. AIM: We therefore explored SORT1 expression in CAD patients and its gene expression's predictive usefulness for the severity of the disease. METHODOLOGY: This is a case control study and Quantitative real-time PCR; Sandwich ELISA and western blotting were used to determine the expression of SORT1 gene at the mRNA and protein level in two hundred healthy controls and two hundred patients with various CAD syndromes. RESULTS: CAD patients exhibit higher SORT1 gene expression in CAD patients, a higher concentration of sortilin in their plasma, and distinct expression patterns in various CAD syndromes. The study reveals a positive correlation between gene expression and the severity of coronary artery stenosis, the number of diseased vessels, and the presence of diabetes. ROC curve analysis of SORT1 gene expression both at mRNA and protein level showed strong discrimination between significant CAD and control subjects. CONCLUSION: Therefore, elevated SORT1 gene expression in various CAD syndromes may be a potential biomarker for the disease.

Cardiopulmonary Outcomes in Covid-19 Patients Discharged From a Tertiary Care Center: A Prospective Study.

To determine the cardiopulmonary changes in the survivors of acute COVID-19 infection at 3-6 month and 6-12 month. We followed up 53 patients out of which 28 (52%) had mild COVID-19 and 25 (48%) had severe COVID-19. The first follow-up was between 3 month after diagnosis up to 6 month and second follow-up between 6 and 12 month from the date of diagnosis of acute COVID-19. They were monitored using vital parameters, pulmonary function tests, echocardiography and a chest computed tomography (CT) scan. We found improvement in diffusing capacity for carbon monoxide (DLCO) with a median of 52% of predicted and 80% of predicted at the first and second follow-up, respectively. There was improvement in the CTSS in severe group from 22 (18-24) to 12 (10-18; p-0.001). Multivariable logistic regression revealed increased odds of past severe disease with higher CTSS at follow-up (OR-1.7 [CI 1.14-2.77]; P = 0.01). Correlation was found between CTSS and DLCO at second follow-up (r2 = 0.36; p < 0.01). Most of patients recovered from COVID-19 but a subgroup of patients continued to have persistent radiological and pulmonary function abnormalities necessitating a structured follow-up.

Coronary artery disease and its vascular associates in patients with chronic nonsurgical hypoparathyroidism.

OBJECTIVE: Patients with chronic hypoparathyroidism (cHypoPT) are prone to intracranial-calcification, cataract and nephrocalcinosis. In this study, we systematically investigated the possibility of increased coronary artery calcification (CAC) and coronary artery disease (CAD) in them. DESIGN: Cross-sectional. PATIENTS AND MEASUREMENTS: Ninety-four nonsurgical cHypoPT (M:F = 50:44; age = 45 ± 15 years) with 18.6 ± 9.3 years of illness were assessed. Those with dyspnoea, angina, syncope, abnormal electrocardiogram, echocardiography or significant CAC underwent coronary angiography or myocardial-perfusion-stress imaging. Their lipid parameters and high-sensitivity C-reactive protein (hsCRP) were compared with age-matched healthy controls (Group A, n = 101). The prevalence of CAC in cHypoPT was compared with that of subjects referred from cardiology-clinics (Group B, n = 148, age = 52 ± 11 years). RESULTS: One of 94 cHypoPT had known CAD. On screening, 17 cHypoPT required evaluation for CAD. Two of 17 had severe coronary stenosis, and 12 showed subclinical CAD. CAC and aortic-valve calcification occurred in 21.5% and 11.8%. Clinical and subclinical CAD, CAC and aortic-valve calcification in cHypoPT ≥50 years of age was 8.1%, 27.0%, 52.8% and 27.8%, respectively. Frequency of age-adjusted CAC was comparable between cHypoPT and control Group B (30.2% vs. 30.7%, p = .93). Elevated hsCRP was higher in cHypoPT than in controls A (52% vs. 32%, p < .01). Factors associated with CAD in cHypoPT were CAC and hypertension. However, CAD and CAC showed no association with long-term calcemic or phosphatemic control and intracranial-calcification in cHypoPT. CONCLUSIONS: Clinical and subclinical CAD was observed in 3.2% and 12.8% of cHypoPT patients. The increased prevalence of CAD, CAC and aortic-valve calcification in cHypoPT above 50 years of age suggested their careful cardiac evaluation during follow-up.

Differential role of central and peripheral arterial stiffness in determining brachial artery resting retrograde flow in patients with ischemic heart disease vs healthy subjects.

Retrograde flow in endothelial cell cultures has been shown to induce a pro-atherogenic phenotype. Despite its potential role as a pathophysiological link between cardiovascular risk factors and atherosclerotic disease, resting retrograde flows between patients with cardiovascular disease and healthy subjects have not been compared. Further, the vascular characteristics governing retrograde flow in human arteries have not been systematically investigated. Association of central and peripheral vascular characteristics with retrograde flow profile was investigated in 32 healthy subjects and 47 patients with ischemic heart disease. Endothelial dysfunction was assessed by brachial ultrasound-based calculation of flow-mediated dilation (FMD) and sub-clinical atherosclerosis was estimated from carotid-intima media thickness (CIMT). Retrograde blood flow velocity (RBFV) and shear rate were comparable between the two groups (RBFV 1.82(0.97-3.32) vs 1.78(1.24-2.65) cm/s p = 0.79). Augmentation index was a significant determinant of retrograde flow in both patients and healthy subjects. Carotid artery incremental elastic modulus was an independent determinant of retrograde flow patterns in healthy subjects while ejection fraction, cf/cr PWV ratio and forearm vascular conductance emerged as independent determinants in patients. Retrograde flow patterns were also associated with FMD (RBFV r = -0.43, p = 0.004) and CIMT (r = 0.30, p = 0.041) in patients. The results of the study suggest a difference in the determinants of retrograde flow in patients and healthy subjects, with central arterial stiffness being a major contributor in healthy subjects while interaction between central, peripheral, and cardio-arterial factors influence retrograde flow in patients with ischemic heart disease.

Functional Association of miR-133b and miR-21 Through Novel Gene Targets ATG5, LRP6 and SGPP1 in Coronary Artery Disease.

BACKGROUND: Atherosclerosis, a progressive manifestation of coronary artery disease, has been observed to be regulated by microRNAs (miRNAs) targeting various protein-coding genes involved in several pathophysiological events of coronary artery disease. OBJECTIVE: In our previous report, we identified differential expression profiles of candidate miRNAs, miR-133b and miR-21, in patients with coronary artery disease as compared with controls, suggesting their possible implication in the pathophysiology of coronary artery disease. To better understand the functional role of these miRNAs, we sought to predict and validate their target genes while assessing the expression pattern of these genes in patients with coronary artery disease, as well as in macrophages. METHODS: Potential target genes of miR-133b and miR-21 were predicted bioinformatically followed by validation through the identification of their expression at  the protein level in patients with coronary artery disease (n-30), as well as in macrophages treated with respective miRNA inhibitors (antagomiRs), through immunoblotting. RESULTS: SGPP1, a gene associated with the sphingolipid pathway, was predicted to be a potential target gene of miR-133b while ATG5 and LRP6 were target genes of miR-21 while being associated with autophagy and Wnt signalling pathways, respectively. SGPP1 was observed to be upregulated significantly (p = 0.019) by 2.07-fold, whereas ATG5 and LRP6 were found to be downregulated (p = 0.026 and 0.007, respectively) by 3.28-fold and 8.46-fold, respectively, in patients with coronary artery disease as compared with controls. Expression patterns of all the genes were also found to be modulated when cells were treated with respective miRNA inhibitors. CONCLUSIONS: Results from the present study suggest that SGPP1, ATG5 and LRP6, target genes of miR-133b and miR-21, may serve as potential therapeutic hotspots in the management of coronary artery disease, which undoubtedly merit further experimental confirmation.

Efficacy of Bacillus Calmette-Guérin (BCG) Vaccination in Reducing the Incidence and Severity of COVID-19 in High-Risk Population (BRIC): a Phase III, Multi-centre, Quadruple-Blind Randomised Control Trial.

INTRODUCTION: Universal coverage of vaccines alone cannot be relied upon to protect at-risk populations in lower- and middle-income countries against the impact of the coronavirus disease 2019 (COVID-19) pandemic and newer variants. Live vaccines, including Bacillus Calmette-Guérin (BCG), are being studied for their effectiveness in reducing the incidence and severity of COVID-19 infection. METHODS: In this multi-centre quadruple-blind, parallel assignment randomised control trial, 495 high-risk group adults (aged 18-60 years) were randomised into BCG and placebo arms and followed up for 9 months from the date of vaccination. The primary outcome was the difference in the incidence of COVID-19 infection at the end of 9 months. Secondary outcomes included the difference in the incidence of severe COVID-19 infections, hospitalisation rates, intensive care unit stay, oxygen requirement and mortality at the end of 9 months. The primary analysis was done on an intention-to-treat basis, while safety analysis was done per protocol. RESULTS: There was no significant difference in the incidence rates of cartridge-based nucleic acid amplification test (CB-NAAT) positive COVID-19 infection [odds ratio (OR) 1.08, 95% confidence interval (CI) 0.54-2.14] in the two groups, but the BCG arm showed a statistically significant decrease in clinically diagnosed (symptomatic) probable COVID-19 infections (OR 0.38, 95% CI 0.20-0.72). Compared with the BCG arm, significantly more patients developed severe COVID-19 pneumonia (CB-NAAT positive) and required hospitalisation and oxygen in the placebo arm (six versus none; p = 0.03). One patient belonging to the placebo arm required intensive care unit (ICU) stay and died. BCG had a protective efficacy of 62% (95% CI 28-80%) for likely symptomatic COVID-19 infection. CONCLUSIONS: BCG is protective in reducing the incidence of acute respiratory illness (probable symptomatic COVID-19 infection) and severity of the disease, including hospitalisation, in patients belonging to the high-risk group of COVID-19 infection, and the antibody response persists for quite a long time. A multi-centre study with a larger sample size will help to confirm the findings in this study. CLINICAL TRIALS REGISTRY: Clinical Trials Registry India (CTRI/2020/07/026668).

The Bacillus Calmette­Guérin (BCG) vaccine has been studied previously in several settings, including reducing childhood mortalities due to viral infections and induction of trained immunity and reducing upper respiratory tract infections and pneumonia in older adults. This multi-centre trial has tried to evaluate the efficacy of BCG revaccination in reducing the incidence and severity of COVID-19 infections in adults between 18 and 60 years of age belonging to the high-risk group owing to the presence of comorbidities including diabetes, chronic kidney disease, chronic liver disease and chronic lung diseases. A single dose of BCG vaccine produced significantly high titres of BCG antibodies lasting for six months. While there was no significant reduction in the incidence of COVID-19 infection, there was an 8.4% reduction in the incidence of symptomatic COVID-19 disease at the end of 9 months of follow-up. In addition, there were significantly fewer severe COVID-19 infections requiring hospital stay and oxygen support. However, the overall numbers of severe COVID-19 infections were low. Thus, the study shows that BCG can protect against symptomatic and severe COVID-19 disease. However, it might not reduce the incidence of new infections. The study results are significant for low- and middle-income countries without adequate coverage of primary doses of COVID-19 vaccination, let alone the booster doses. Future studies should evaluate the BCG vaccine's efficacy as a booster compared with routine COVID-19 vaccine boosters.

Delayed presentation of aorto-pulmonary window, double outlet right ventricle with pulmonary arterial hypertension: Illustration of uncommon association on dual-energy CT.

We present a case of a 26-year-old female with double outlet right ventricle and proximal aorto-pulmonary window (APW). The case highlights the role of computed tomography angiography in the diagnosis and characterization of APW defects, which are difficult to be diagnosed on transthoracic echocardiography.

Signature transcriptome analysis of stage specific atherosclerotic plaques of patients.

BACKGROUND: Inflammation plays an important role in all the stages of atherosclerotic plaque development. The current study aimed at assessing the altered expression of genes functioning in inflammation within the early stage (ES) and advanced stage (AS) atherosclerotic plaques obtained from patients undergoing coronary artery bypass grafting (CABG) surgery and identifying biomarker panel/s that may detect the status of plaque stages using peripheral blood samples. METHODS: A section of ES and AS plaques and normal left internal mammary arteries (LIMA) were obtained from 8 patients undergoing the CABG surgery. Total RNA isolated was analyzed for mRNA and miRNA expression profile by Affymetrix arrays. A significant number of mRNAs was found to be differentially expressed in ES and AS plaque tissues relative to LIMA. The pathway analysis of differentially expressed mRNAs in the two plaque stages was also performed using DAVID Bioinformatics Database. RESULTS: The mRNAs were found to be involved in critical inflammatory processes such as the toll-like receptor signaling pathway and cytokine-cytokine receptor interaction. Few miRNAs targeting these mRNAs were also altered in the two plaque conditions. QRT-PCR results showed a similar expression pattern of a few of the mRNAs and miRNAs in peripheral blood of the same patients relative to healthy controls. CONCLUSION: Changes in mRNA and miRNA expression associated with various inflammatory processes occur in different atherosclerotic stage plaques as well as peripheral blood. Detection of such variations in patients' blood can be used as a possible prognostic tool to detect and/or predict the risk and stage of atherosclerosis.

Effect of Yoga on Clinical Outcomes and Quality of Life in Patients With Vasovagal Syncope (LIVE-Yoga).

OBJECTIVES: This study aims to determine the impact of yoga as an adjunct to standard therapy versus standard therapy alone on the symptomatic burden in patients with recurrent vasovagal syncope (VVS). BACKGROUND: There is a significant reduction in the quality of life (QoL) of patients with recurrent VVS. Existing management therapies have been largely ineffective. Recent trials have demonstrated the efficacy of yoga in diseases with autonomic imbalance, suggesting its possible utility in VVS. METHODS: Patients with recurrent VVS were randomized to receive either a specialized yoga training program in addition to current guideline-based therapy (intervention arm, group 1) or current guideline-based therapy alone (control arm, group 2). The primary outcome was a composite of the number of episodes of syncope and presyncope at 12 months. Secondary outcomes included QoL assessment by World Health Organization Quality of Life Brief Field questionnaire (WHOQoL-BREF) scores and Syncope Functional Status Questionnaire scores at 12 months, head up tilt test, and heart rate variability at 6 weeks. RESULTS: A total of 55 patients underwent randomization. The mean number of syncopal or presyncopal events at 12 months was 0.7 ± 0.7 in the intervention arm compared to 2.52 ± 1.93 in the control arm (P < 0.01). In the intervention arm, 13 (43.3%) patients remained free of events versus 4 (16.0%) patients in the control arm (P = 0.02). QoL at 12 months showed significant improvement of all Syncope Functional Status Questionnaire scores and 2 domains of WHOQoL-BREF scores (P < 0.05). CONCLUSIONS: Yoga as adjunctive therapy is superior to standard therapy alone in reducing the symptomatic burden and improving QoL in patients with recurrent VVS.

Cost analysis of treating cardiovascular diseases in a super-specialty hospital.

Cardiovascular care is expensive; hence, economic evaluation is required to estimate resources being consumed and to ensure their optimal utilization. There is dearth of data regarding cost analysis of treating various diseases including cardiac diseases from developing countries. The study aimed to analyze resource consumption in treating cardio-vascular disease patients in a super-specialty hospital. An observational and descriptive study was carried out from April 2017 to June 2018 in the Department of Cardiology, Cardio-Thoracic (CT) Centre of All India Institute of Medical Sciences, New Delhi, India. As per World Health Organization, common cardiovascular diseases i.e. Coronary Artery Disease (CAD), Rheumatic Heart Disease (RHD), Cardiomyopathy, Congenital heart diseases, Cardiac Arrhythmias etc. were considered for cost analysis. Medical records of 100 admitted patients (Ward & Cardiac Care Unit) of cardiovascular diseases were studied till discharge and number of patient records for a particular CVD was identified using prevalence-based ratio of admitted CVD patient data. Traditional Costing and Time Driven Activity Based Costing (TDABC) methods were used for cost computation. Per bed per day cost incurred by the hospital for admitted patients in Cardiac Care Unit, adult and pediatric cardiology ward was calculated to be Indian Rupee (INR) 28,144 (US$ 434), INR 22,210 (US$ 342) and INR 18,774 (US$ 289), respectively. Inpatient cost constituted almost 70% of the total cost and equipment cost accounted for more than 50% of the inpatient cost followed by human resource cost (28%). Per patient cost of treating any CVD was computed to be INR 2,47,822 (US $ 3842). Cost of treating Rheumatic Heart Disease was the highest among all CVDs followed by Cardiomyopathy and other CVDs. Cost of treating cardiovascular diseases in India is less than what has been reported in developed countries. Findings of this study would aid policy makers considering recent radical changes and massive policy reforms ushered in by the Government of India in healthcare delivery.

Determinants of Waist-to-Height Ratio and Its Relation to Hypertension among School Children in India: A Multicenter Study.

OBJECTIVE: To study the factors associated with waist-to-height ratio (WHtR) among school children aged 5-15 y and its association with hypertension. METHODS: In this cross-sectional study, data on background characteristics, socioeconomic status (SES), anthropometric parameters, and blood pressure were obtained from school children from three states of India. WHtR ≥ 0.5 was defined as obesity and hypertensives were defined based on Fourth Report criteria. Descriptive statistics were applied and multiple linear regression was done to identify factors associated with WHtR. A receiver operating characteristics (ROC) analysis was used to evaluate the predictive ability of WHtR to predict hypertension RESULTS: The mean WHtR among the 12,068 students was 0.40 (± 0.05) and it showed a U-shaped distribution with age with trough at 10 y of age for both genders. Mean WHtR was higher among residents of Manipur, among boys and hypertensives. WHtR was positively associated with weight > 30 kg, male gender, schools with high SES, Manipur and Goa region, and negatively associated with age > 10 y. The area under the ROC curve of WHtR for diagnosis of hypertension was low 0.544 (95% CI 0.532, 0.556). CONCLUSION: There is a nonlinear relation between age, gender, and WHtR, which varies by geographical region and HT. This would need to be kept in mind while using it to identify obesity in children, though its discriminant value for hypertension is low.

An evidence-based scoring system to diagnose acute rheumatic fever with carditis in children.

BACKGOUND: Acute rheumatic fever (ARF) with carditis and chronic rheumatic heart disease (RHD) may be difficult to differentiate and may lead to missed diagnosis of carditis. We aimed to determine differences between these groups and to develop a new scoring system for this purpose. METHODS: Children (N = 514; mean age 11.6 ± 2.8, range 5-18 years; 65% males) enrolled in a RHD registry at a tertiary care centre were studied. Clinical, laboratory and echocardiographic features of acute rheumatic carditis group (N = 126) were compared with chronic RHD group (N = 388). We performed multiple regression analysis and then developed a new scoring system using independent predictors. Accuracy of this scoring system was assessed using receiver operating characteristic (ROC) curve analysis. RESULTS: Patients with ARF and carditis were younger, more commonly had history of fever, arthritis/arthralgias and had worse NYHA class. On echocardiography, severity of mitral regurgitation, presence of mitral leaflet nodules, mitral valve prolapse and pericardial effusion were more common in ARF group. On multiple regression analysis, following features were found to be independently predictive of ARF with carditis: age -negative association, NYHA class, severity of mitral regurgitation, mitral leaflet nodules, erythrocyte sedimentation rate and antistreptolysin titer. Based on these 6 variables, a new scoring system (0-13) was developed. A score of 5 or more was found to be best threshold for diagnosis of carditis (ROC AUC 0.87, sensitivity 76%, specificity 79%). CONCLUSION: A new scoring system based on independent statistical associations appears promising for differentiating ARF with carditis from chronic RHD.

Utility of HEART Pathway in Identifying Low-Risk Chest Pain in Emergency Department.

BACKGROUND: Chest pain is a common presenting symptom in the emergency department (ED). The HEART (history, electroencephalogram [ECG], age, risk factors, and troponin I) score, with addition of troponin at 3 h, helps to determine appropriate risk stratification of the patients. OBJECTIVE: This study evaluated the utility of the HEART pathway as a decision aid designed for risk stratification of patients with acute-onset chest pain for early and safe disposition. METHODS: This was a prospective observational study done in a tertiary care center. Focused history, 12-lead ECG, and baseline troponin I level on arrival and at hour 3 were recorded. Subjects were classified as low risk (HEART score 0-3) or high risk (HEART score ≥ 4). Patients with a HEART score of 0-3 with negative troponin I at 3 h were discharged and were followed up for major adverse cardiac events (MACEs) within 30 days of ED presentation. RESULTS: A total of 250 patients were screened for the study, of which 151 were included for the final analysis. One hundred and two patients (68%) were male and 54% of patients were younger than 45 years. HEART scores of 0 (n = 16), 1 (n = 43), 2 (n = 44), and 3 (n = 48) were observed. There was only 1 MACE (0.7%) in 30 days after ED discharge in the study population. The mean length of ED stay in the low-risk group was 4.5 h. CONCLUSIONS: Low-risk patients, as per the HEART pathway, can be discharged safely from the ED, which reduces ED stay and health care resource use.

Brachial Artery "Low-Flow Mediated Constriction" Is Associated with Myocardial Perfusion Defect Severity and Mediated by an Altered Flow Pattern during Occlusion.

INTRODUCTION: The relationship between low flow-mediated constriction (LFMC), a new proposed measure of endothelial function, with cardiovascular disease severity and its hypothesized stimulus, that is, low flow, has not been comprehensively evaluated. The study evaluated association between change in brachial artery diameter during constriction with severity of myocardial perfusion defect (PD) and alterations in different components of flow profile. METHODS: Brachial artery responses to occlusion were assessed in 91 patients and 30 healthy subjects. Change in anterograde and retrograde blood flow velocities (delta anterograde blood flow velocity and retrograde blood flow velocity), anterograde shear rate and retrograde shear rate (delta ASR and RSR, respectively), and oscillatory shear index (delta) during forearm occlusion at 50 mm Hg above systolic pressure, from baseline was calculated. Myocardial perfusion was evaluated in patients using exercise single positron emission computed tomography and % myocardial PD was calculated from summed stress score. RESULTS: LFMC emerged as independent predictor of defect severity after correcting for age and gender (p = 0.014). Sixty-seven patients (73.6%) and 15 healthy subjects (50%) showed constriction during occlusion. In stepwise backward regression analysis, RSR contributed 35.5% and ASR contributed 20.1% of the total 63.9% variability in artery diameter during occlusion. CONCLUSION: The results suggest that LFMC is independently associated with myocardial perfusion severity and is "mediated" by an altered flow profile during occlusion.

Impact of bariatric surgery on carotid intima-medial thickness and cardiovascular risk: results of a prospective study.

BACKGROUND: The impact of bariatric surgery on atherosclerosis is a relatively less studied subject. Obesity has been identified as an independent risk factor for cardiovascular disease (CVD). Carotid intima-media thickness (CIMT), a surrogate marker for atherosclerosis and risk of CVD, has been found to be associated with obesity. Recent literature has shown that there is significant reduction in CIMT following bariatric surgery. The aim of this study was to evaluate the impact of bariatric surgery on CIMT and risk of CVD in an Indian population. METHODS: This is a prospective study conducted in a tertiary referral centre in India. Patients undergoing bariatric surgery from December 2017 to September 2019 were included. CIMT measurements and American College of Cardiology/American Heart Association (ACC/AHA)-pooled cohort CVD risk scores were done before and at 6 months and 12 months after surgery. RESULTS: Fifty-four patients were enrolled, of which 70% were females. Mean age was 40.8 ± 10.7 years. Mean pre-operative weight and mean BMI were 115.2 ± 21.9 kg and 45.9 ± 6.5 kg/m2, respectively. Patients who completed 12-month follow-up were considered for analysis of outcomes. There was significant reduction in BMI to 33.1 ± 5.7 kg/m2 at 12 months after surgery (p < 0.0001). Mean CIMT reduced significantly from 0.58 ± 0.08 mm at baseline to 0.52 ± 0.10 mm at 12 months. Lipid profile, fasting blood sugar and HbA1C also improved, which resulted in reduction of lifetime and 10-year CVD risk from 42.3 to 26% and 4 to 1.5%, respectively, at 12 months after surgery. CONCLUSIONS: Bariatric surgery results in significant reduction in CIMT and CVD risk in patients with morbid obesity.

The impact of obstructive sleep apnoea severity on cardiac structure and injury.

BACKGROUND: Obstructive sleep apnoea (OSA) is an important factor in the development and progression of heart failure (HF). The prevalence of OSA is higher in patients with HF than in the general population. We sought to test the hypothesis that OSA severity was predictive of ventricular function and cardiac injury [as assessed by high-sensitivity cardiac troponin I(hs-cTnI)]. METHODS: A total of 60 patients were recruited after evaluation for sleep disturbances using the Jenkins Sleep Questionnaire (JSQ) and Epworth Sleepiness Scale (ESS). Subsequently, they underwent polysomnography thus confirming the diagnosis of OSA and were equally divided into three groups according to OSA severity grade. Following polysomnography, the next morning patients underwent venous blood sampling and echocardiography. RESULTS: We observed a statistically significant association (P = 0.009) between diastolic dysfunction grades and severity grades of OSA. All the three diastolic dysfunction variables E/A ratio, deceleration time and E/e' ratio had a significant association(P < 0.05) with severity grades of OSA. There was a marginally significant positive correlation (ρ = 0.3244, p = 0.04) between AHI events per hour and mitral E/e' ratio. There was a statistically significant association(P < 0.001) between hs-cTnI value among different severity grades of OSA. CONCLUSIONS: Here in our study, we found OSA a potential risk factor for development of myocardial injury and diastolic dysfunction. Severe grades of OSA are associated with higher grades of diastolic dysfunction and circulating levels of hs-cTnI. These data are consistent with the notion of a vicious cycle of frequent apnoea's or hypoxemia and recurrent myocardial injury, which could increase the risk of heart failure especially diastolic dysfunction in OSA.