Framework for a National STEMI Program: consensus document developed by STEMI INDIA, Cardiological Society of India and Association Physicians of India.

The health care burden of ST elevation myocardial infarction (STEMI) in India is enormous. Yet, many patients with STEMI can seldom avail timely and evidence based reperfusion treatments. This gap in care is a result of financial barriers, limited healthcare infrastructure, poor knowledge and accessibility of acute medical services for a majority of the population. Addressing some of these issues, STEMI India, a not-for-profit organization, Cardiological Society of India (CSI) and Association Physicians of India (API) have developed a protocol of "systems of care" for efficient management of STEMI, with integrated networks of facilities. Leveraging newly-developed ambulance and emergency medical services, incorporating recent state insurance schemes for vulnerable populations to broaden access, and combining innovative, "state-of-the-art" information technology platforms with existing hospital infrastructure, are the crucial aspects of this system. A pilot program was successfully employed in the state of Tamilnadu. The purpose of this article is to describe the framework and methods associated with this programme with an aim to improve delivery of reperfusion therapy for STEMI in India. This programme can serve as model STEMI systems of care for other low-and-middle income countries.

Menstrual and Gonadal Function Alterations in Women with Systemic Lupus Erythematosus.

PURPOSE: Systemic lupus erythematosus (SLE) is an autoimmune disorder and may affect the reproductive health status of the women. Objective is to analyze the types, incidence of various menstrual disturbances in these women, to identify risk factors and to assess the gonadal function. METHODS: The prospective cohort study was conducted in the SLE clinic of the Rheumatology Department of IPGMEandR, Kolkata from April 2010 to April 2011. Out of 152 females attending clinic, 110 patients fulfilling criteria were included in the study. RESULTS: Mean age of the study population was 27.25±3.4 years. Sixty six cases had menstrual abnormalities (12.72% amenorrhea, 44.45% oligomenorrhea, 2.7% premature ovarian failure, 10.9% menorrhogia). When comparative analysis of demographic, hormonal, ovarian Doppler and therapeutic variables of normal and abnormal cycles was carried out, following parameters were significantly more related to patients with abnormal cycle ; SLEDAI score (12.48±5.53 vs 8.69±4.9; p=0.00), disease duration (6.46±3.08 vs 4.3±1.36; p< 0.05), TSH (7.73±8.64 vs 3.07±2.06; p=0.00.), LH (6.55±4.38 vs 4.56±3.29; p=0.02), a high normal prolactin (12.57±7.75 vs 8.73±3.07; p=0.02), peak systolic velocity (6.53±2.17 vs 9.12±2.1; p=0.00), end-diastolic volume (4.21±2.9 vs 9.35±2.32; p=0.00) and cumulative dose of steroid (24.02±41.44 vs 9.32±9.96; p=0.01).Cyclophosphamide with cumulative dose ≥10 gm was related to amenorrhea and affected gonadal function. Gonadal insufficiency was evident in 33.63% and 2.72% had ovarian failure. CONCLUSIONS: Reduced menstruation is a major health concern in women with SLE as it is frequent and can result in depressed and failed gonadal function later. Doppler study of ovaries is a novel way of depiction of gonadal status in these women. Certain risk factors and revolving treatment part can be preventable.

Various coronary artery complications of Kawasaki disease: Series of 5 cases and review of literature.

Kawasaki disease is a generalized systemic vasculitis of unknown etiology involving medium and small size blood vessels throughout the body, virtually always involving the coronaries. In many part of this world, it is more common than rheumatic fever and viral myocarditis. Here, we are reporting 5 cases with history suggestive of Kawasaki disease in the early life, presenting with different coronary artery abnormalities. One of the patients had left main coronary artery cut-off, and the remaining 4 had some form of coronary artery aneurysms. 3 patients were given medical management, 1 patient had coronary bypass grafting, and the remaining 1 was planned for surgical correction. All the patients were stable on subsequent follow-ups.

Permanent pacemaker-related upper extremity deep vein thrombosis: a series of 20 cases.

BACKGROUND: Upper extremity deep vein thrombosis (DVT) has become a common occurrence nowadays due to emergence of multiple newer risk factors, such as implantation of permanent pacemaker (PPM) and implantable cardioverter-defibrillators. We are reporting 20 cases of upper extremity DVT related to PPM implantation. METHODS AND RESULT: All the patients presented within 6 months, with unilateral upper extremity swelling (90%), pain (45%), erythema (15%), and other less frequent features. Venography established the diagnosis in all the cases. Considering the distribution of possible risk factors of venous thrombosis among our patients, diabetes was the most frequent (present in 45%) followed by smoking (35%), hypertension (30%), obesity with body mass index ≥30 (30%), history of acute myocardial infarction (25%), chronic obstructive pulmonary disease (20%), and history of congestive cardiac failure (15%). Antiplatelets were not found protective against the development of this situation. There was no statistically significant difference in respect to venous access, number of leads, use of previous temporary pacing lead, or poor left ventricular systolic function (ejection fraction ≤40%) among the six patients who presented with complete occlusion of subclavian vein compared to the rest of the 14 patients who had partial occlusion. There were complete resolutions of symptom in 85% of patients after 6 months of anticoagulation therapy in the form of initial intravenous unfractinated heparin followed by oral warfarin. CONCLUSION: Anticoagulation with warfarin for 6 months with initial intravenous unfractionated heparin was a safe and effective mode of therapy in most of the patients with PPM related upper extremity DVT.

Takayasu arteritis in pregnancy: an analysis from eastern India.

OBJECTIVE: Takayasu's Arteritis (TA) is a rare inflammatory disease of medium and large size arteries that affects women of reproductive age. This study aims to highlight the antenatal management and analyze the obstetric outcome in women with TA. METHODS: This retrospective study was carried out in the Department of O&G, Cardiology and Rheumatology--IPGME&R, Kolkata from June 2002 to July 2010. Sixteen patients with 29 pregnancy events were compared with 60 matched controls. RESULTS: Clinical presentation of study population at admission included unequal or absent pulse, hypertension, congestive cardiac failure, retinopathy, aortic regurgitation and cerebrovascular accident (CVA). Mode of delivery was cesarean in 20 pregnancies (71.49%) and vaginal in nine pregnancies (31.03%). Significant maternal complications included pregnancy induced hypertension (100 vs. 1.66%; P < 0.001), preeclampsia (92.85 vs. 0%; P < 0.001), postpartum hemorrhage (17.24 vs. 1.66%; P < 0.001) and preterm labor (17.24 vs. 3.33%; P < 0.001). One maternal mortality was present due to CVA. Neonatal outcome showed 26 live births with increased incidence of intrauterine growth restriction (51.72 vs. 1.66%; P < 0.001) and neonates requiring NICU admissions (58.62 vs. 5.0%; P < 0.001). CONCLUSION: Although conception was spontaneous in all these pregnancies, antenatal and intrapartum control of blood pressure played a pivotal role in pregnancy outcome. High rate of operative interference was present. All subsequent pregnancies had similar outcome due to slow progression of the disease. Although pregnancy was complicated by hypertension and its sequelae, successful outcome could be achieved with timely admission, judicious medication and multidisciplinary approach.

Pregnancy and subsequent pregnancy outcomes in peripartum cardiomyopathy.

AIM: To study the clinical profile and management of peripartum cardiomyopathy, and to analyze the pregnancy outcomes of pregnant women with this disorder as well as its effect on subsequent pregnancies. METHODS: All patients admitted with peripartum cardiomyopathy from July 2006 to June 2009 by the Departments of Cardiology and Obstetrics and Gynecology from the Institute of Post Graduate Medical Education and Research, Kolkata, India, were considered for this observational study. Thirty-six women with 42 pregnancies (36 first pregnancies and six second pregnancies in the same patients) were evaluated. RESULTS: Primiparas constituted 39% (14/36) of the total study population. Twenty-six women (72%) were clinically improved and in 17 (48%) the left ventricular functional status returned to normal. Five cases (14%) developed persistent cardiomyopathy (persistent left ventricular dysfunction beyond six months of presentation), and five women (14%) presented with thromboembolic events and anticoagulation was used as secondary prophylaxis. Maternal mortality was 14% (5/36). Among all live babies two had intrauterine growth restriction (IUGR) and another two died during the neonatal period. Of the six women with subsequent pregnancies, the patient with persistent cardiomyopathy died after delivering a stillborn baby. The remaining five cases with normal left ventricular functional status had favorable fetal outcomes; however, the mothers experienced morbidities such as symptoms of heart failure (two cases) and one of them progressed to persistent cardiomyopathy. CONCLUSIONS: Subsequent pregnancies should be discouraged as it increases the risk of recurrence of left ventricular dysfunction. Anticoagulation may be considered as a primary prevention of thromboembolism in pregnant mothers with peripartum cardiomyopathy.

Tadalafil in the management of severe pulmonary artery hypertension.

Severe oyknibart arterial hypertension is a life-threatening disease with a poor prognosis. Continuous intravenous infusion of prostacyclin has proved effective in this condition. However, it carries the risk of serious complications arising from the complex delivery system along with a high cost. Prostacyclin analogs, endothelin antagonists, and the phophodiesterase-5 inhibitor sildenafil are emerging and promisinge therapies. Tadalafil, like sildenafil, is a selective phosphodiesterase-5 inhibitor with a longer duration of action. We repport the use of tadalafil in two patients of severe pulmonary arterial hypertension who could not afford expensive treatment.

Evaluation of routine functional testing after percutaneous coronary intervention.

Following percutaneous coronary intervention, 348 patients were randomized to either routine or selective functional testing strategies. For the primary end point of maximal exercise endurance on a treadmill at 9 months, achievement was similar in the routine and selective groups. For the secondary end points measuring functional status and quality of life, scores were also similar. There was little difference in the rates of invasive cardiac procedures for the 2 groups at 9 months.