Efficacy and Safety of Azilsartan Medoxomil and Telmisartan in Hypertensive Patients: A Randomized, Assessor-Blinded Study.

BACKGROUND: Few studies have compared the safety and efficacy of azilsartan medoxomil (AZL-M) and telmisartan in hypertensive patients, especially using ambulatory blood pressure monitoring (ABPM). OBJECTIVE: The objective of this study was to compare the efficacy and safety profile of AZL-M and telmisartan in hypertensive patients using ABPM and clinic blood pressure (BP) monitoring. MATERIALS AND METHODS: This prospective, randomized, open-label, blinded endpoint, parallel-arm study included 700 patients, aged 18-70 years, with clinic and 24-h mean ambulatory systolic BP (SBP) of 150-180 mmHg and 130-170 mmHg, respectively. They were randomized equally into two groups: Group A received AZL-M 40 mg and Group T received telmisartan 40 mg; the dose was force titrated to 80 mg after 2 weeks if the response rate was not achieved. BP (clinical and ambulatory) was measured after 12 weeks and compared with baseline measurements. RESULTS: AZL-M significantly reduced the 24-h mean ambulatory SBP (Group A: 112.74 ± 7.58 mmHg; Group T: 113.96 ± 8.52 mmHg; P < 0.0001) and diastolic BP (Group A: 71.39 ± 5.89 mmHg; Group T: 67.29 ± 6.79 mmHg; P < 0.0001) compared with telmisartan at week 12. The clinic SBP significantly decreased in Group A at weeks 4 (-30.69± -0.33 mmHg) and 12 (-39.69± -1.09 mmHg) (for both, P = 0.0001). Dose titration was done in 99 and 128 patients from Group A and Group T, respectively (P = 0.012). Headache was the most common adverse drug reaction (Group A: 21; Group T: 27) and fatigue the least. CONCLUSION: This study found that AZL-M has greater antihypertensive efficacy than telmisartan, with comparable side effects. In addition, ABPM was shown to be a feasible method for such studies.

Management of electrical storm of unstable ventricular tachycardia in post myocardial infarction patients: A single centre experience.

OBJECTIVE: This is a case series of consecutive patients with past myocardial infarction presenting with Electrical Storm (ES) of unstable ventricular tachycardia (VT) treated by a protocol directed algorithm. METHODS: Management protocol involved treatment of reversible causes, ventilatory & hemodynamic support, administration of antiarrhythmic drugs (AAD) & maximally tolerated doses of beta-blockers, stellate ganglionectomy and Radiofrequency ablation (RFA) guided by Electro Anatomic Mapping (EAM). Patients were followed up periodically with review of device data logs. RESULTS: There were 12 patients (mean age=61.38±6.48years & mean LVEF=31.92±4.23%). Presentation was recurrent ICD shocks (n=5) or VT (n=7). All were mechanically ventilated. Reversible causes were identified in 4 patients and appropriately addressed. Totally 8 patients underwent endocardial substrate modification by EAM & RFA. Endocardial LV Voltage mapping demonstrated a mean scar area of 70.04±17.63 sq.cm (27.04±6.20% of mapped area). The electrograms targeted for ablation included late potentials, fractionated electrograms, double potentials and channels within the scar. Two patients had stellate ganglionectomy in addition. Ten patients (83.3%) survived to discharge, all of whom are alive at a follow up of 30.12±19months free of ES. VT free survival at end of follow up was 80%. No patient had hospitalization related to VT. Single episode of VT recurrence was seen in 2 patients at 7 months and 1year of follow up respectively. CONCLUSION: In post myocardial infarction patients presenting with ES and unstable VT, a protocol driven approach involving substrate modification targeting abnormal electrograms improves outcomes.

Large Submitral Aneurysm Compressing Left Main Coronary Artery: Rare Presentation of a Rare Disease.

Submitral left ventricular aneurysm is a rare cardiac anomaly that was first reported from African countries and initially termed as "annular left ventricular aneurysm". Submitral aneurysm (SMA) causes out-pouching of the left ventricular wall, adjacent to the posterior leaflet of the mitral valve. Generally, SMA opens into left ventricle (LV) with a wide mouth and not into left atrium (LA). We report a case of Submitral Aneurysm with two openings: one into LV and the other into LA. This case also highlights the compression of coronary arteries by the submitral aneurysm. Large SMA can cause compression of left main coronary artery rarely. Having a knowledge of this point can help the clinician. SMA generally have an opening in LV but in this case SMA has two openings (One in LV and another in LA). This knowledge can help in proper surgical management.

Percutaneous closure of post-myocardial infarction ventricular septal rupture - A single centre experience.

BACKGROUND: Post-infarction ventricular septal rupture (VSR) is a rare but lethal mechanical complication of an acute myocardial infarction (AMI). Survival to 1 month without intervention is 6%. Given high surgical mortality, transcatheter closure has emerged as a potential strategy in selected cases. Indian data on percutaneous device closure of post AMI-VSR is scarce hence we report our single-centre experience with ASD occluder device (Amplatzer and lifetech) for closure of post-AMI VSR. METHODS AND RESULTS: In this single-centre, retrospective, cohort study, patients who underwent transcatheter closure of post-MI VSR between 2005 and 2015 at KIMS Hospital were included. Primary outcome was mortality rate at 30 days. Seven patients were included in the study (mean age, 58.29±9.8 years). 5 patients had anterior wall myocardial infarction (AWMI) & 2 had inferior wall myocardial infarction (IWMI). None of the patients received thrombolytic therapy. Device was successfully placed in 5 patients (71.4%) with minimal residual shunt in 2 patients (40%). Out of 7 cases 2 patients survived (29% survival rate) and are doing well on follow up at 1 and 5 years respectively. Cardiogenic shock, IWMI and serpigenious form of VSR were associated with poor outcomes. Delayed revascularization (PCI) was associated with better outcomes. CONCLUSION: Percutaneous closure is a potential technique in a selected group of patients. The presence of cardiogenic shock, IWMI and serpigeneous form of VSR constitutes important risk factors for mortality. Device implantation is in general successful with few procedure-related complications and should be applied on a case-by-case basis.

Ruptured pseudo-aneurysm of the mitral-aortic intervalvular fibrosa - A 3D transesophageal echocardiographic depiction.

Pseudo-aneurysm of the mitral-aortic intervalvular fibrosa (MAIVF) is a rare complication of native or prosthetic valve endocarditis. Good imaging is the key to successful diagnosis of this rare entity. This report describes a pseudo - aneurysm of the MAIVF rupturing into left atrium in a patient with double valve replacement with special reference to 3-dimensional transesophageal echocardiographic imaging. .

Follicular thyroid carcinoma with tumour thrombus extending into superior vena cava and right atrium - A case report.

Intra-cardiac extension of tumour thrombus of follicular carcinoma of thyroid is uncommon. We report a case of advanced thyroid carcinoma where tumour thrombus was well profiled with CT scan and transesophageal echo images and extension was noted from SVC into right atrium, with clinical features of superior vena cava syndrome. The clinical significance of the "ring sign" is discussed.

Setting up a transcatheter aortic valve implantation program: Indian perspective.

Transcatheter aortic valve implantation (TAVI) has revolutionized the management of elderly patients with symptomatic severe aortic stenosis in the western world. It is a valuable alternative to surgical aortic valve replacement in patients, who are inoperable or at high surgical risk due to co-morbidities. The prevalence of aortic stenosis increases sharply with age after the sixth decade and is expected to have a significant impact on the geriatric health care system of India, given the rapid increase in life expectancy in recent years. Although a decade has passed since the first TAVI implantation, it is yet to penetrate most of the developing countries in a major way. This short review focuses on fundamentals of initiating a TAVI program based on the experience of a high volume TAVI center with a successful program in Germany.