Does left atrial appendage morphology and dimension differ amongst etiological stroke subtypes in patients without known atrial fibrillation? Results from the left atrial appendage morphology and dimension assessment by TEE in patients with stroke without known atrial fibrillation (LAMDA-STROKE) study.

CONTEXT: Complex left atrial appendage (LAA) morphology is increasingly associated with cryptogenic ischemic stroke as compared to cardioembolic stroke due to atrial fibrillation (AF). However, data on such an association in patients with other etiological stroke subtypes in the absence of AF is limited. AIM: The study aimed to assess the LAA morphology, dimension and other echocardiographic parameters by transesophageal echocardiography (TEE) in patients with embolic stroke of undetermined source (ESUS) and compare it with other etiological stroke subtypes without known AF. METHODS: This was a single-Centre, observational study involving comparison of echocardiographic parameters including LAA morphology and dimension in ESUS patients (group A; n = 30) with other etiological stroke subtypes i.e., TOAST (Trial of Org 10172 in Acute Stroke Treatment) class I-IV without AF (group B; n = 30). RESULTS: Complex LAA morphology was predominant in group A (18 patients in group A versus 5 patients in group B, p-Value = 0.001). Mean LAA orifice diameter (15.3 + 3.5 mm in group A versus 17 + 2.0 mm in group B, p-Value = 0.027) and LAA depth were significantly lower in group A (28.4 + 6.6 mm in group A versus 31.7 + 4.3 mm in group B, p-Value = 0.026). Out of these three parameters only complex LAA morphology was found to be independently associated with ESUS [OR = 6.003, 95% CI {1.225-29.417}, p = 0.027]. CONCLUSION: Complex LAA morphology is a predominant feature in ischemic stroke patients with ESUS and may contribute to an increased risk of stroke in these patients.

Using a national level cross-sectional study to develop a Hospital Preparedness Index (HOSPI) for Covid-19 management: A case study from India.

BACKGROUND: We developed a composite index-hospital preparedness index (HOSPI)-to gauge preparedness of hospitals in India to deal with COVID-19 pandemic. METHODS: We developed and validated a comprehensive survey questionnaire containing 63 questions, out of which 16 critical items were identified and classified under 5 domains: staff preparedness, effects of COVID-19, protective gears, infrastructure, and future planning. Hospitals empaneled under Ayushman Bharat Yojana (ABY) were invited to the survey. The responses were analyzed using weighted negative log likelihood scores for the options. The preparedness of hospitals was ranked after averaging the scores state-wise and district-wise in select states. HOSPI scores for states were classified using K-means clustering. FINDINGS: Out of 20,202 hospitals empaneled in ABY included in the study, a total of 954 hospitals responded to the questionnaire by July 2020. Domains 1, 2, and 4 contributed the most to the index. The overall preparedness was identified as the best in Goa, and 12 states/ UTs had scores above the national average score. Among the states which experienced high COVID-19 cases during the first pandemic wave, we identified a cluster of states with high HOSPI scores indicating better preparedness (Maharashtra, Tamil Nadu, Karnataka, Uttar Pradesh and Andhra Pradesh), and a cluster with low HOSPI scores indicating poor preparedness (Chhattisgarh, Delhi, Uttarakhand). INTERPRETATION: Using this index, it is possible to identify areas for targeted improvement of hospital and staff preparedness to deal with the COVID-19 crisis.

The effects of dual antiplatelet therapy (DAPT) adherence on survival in patients undergoing revascularization and the determinants of DAPT adherence.

BACKGROUND: The prevalence and burden of coronary heart disease (CHD) has increased substantially in India, accompanied with increasing need for percutaneous coronary interventions (PCI). Although a large government-funded insurance scheme in Maharashtra, India covered the cost of PCI for low-income patients, the high cost of post-PCI treatment, especially Dual Antiplatelet Therapy (DAPT), still caused many patients to prematurely discontinue the secondary prevention. Our study aimed to investigate the effectiveness of DAPT adherence on all-cause mortality among post-PCI patients and explore the potential determinants of DAPT adherence in India. METHOD: We collected clinical data of 4,595 patients undergoing PCI in 110 participating medical centers in Maharashtra, India from 2012 to 2015 by electronic medical records. We surveyed 2527 adult patients who were under the insurance scheme by telephone interview, usually between 6 to 12 months after their revascularization. Patients reporting DAPT continuation in the telephone survey were categorized as DAPT adherence. The outcome of the interest was all-cause mortality within 1 year after the index procedure. Multivariate Cox proportional hazard (PH) model with adjustment of potential confounders and standardization were used to explore the effects of DAPT adherence on all-cause mortality. We further used a multivariate logistic model to investigate the potential determinants of DAPT adherence. RESULTS: Out of the 2527 patients interviewed, 2064 patients were included in the analysis, of whom 470 (22.8%) discontinued DAPT prematurely within a year. After adjustment for baseline confounders, DAPT adherence was associated with lower one-year all-cause mortality compared to premature discontinuation (less than 6-month), with an adjusted hazard ratio (HR) of 0.52 (95% Confidence Interval (CI) = (0.36, 0.67)). We also found younger patients (OR per year was 0.99 (0.97, 1.00)) and male (vs. female, OR of 1.30 (0.99, 1.70)) had higher adherence to DAPT at one year as did patients taking antihypertensive medications (vs. non medication, OR of 1.57 (1.25, 1.95)). CONCLUSION: These findings suggest the protective effects of DAPT adherence on 1-year mortality among post-PCI patients in a low-income setting and indicate younger age, male sex and use of other preventive treatments were predictors of higher DAPT adherence.

Comparative study of acute coronary syndrome in postmenopausal women and age-matched men: A prospective cohort study in Southern India.

Background: Acute coronary syndrome (ACS) differs in women and men with respect to risk factors, clinical presentation, complications and outcome. The major reason for the differences has been the effect of estrogen which protects women from coronary artery disease (CAD) till menopause. Women develop CAD one decade later than men. Hence, we compared the profile of ACS in postmenopausal women with age-matched men to see, does the difference still exist. Materials and Methods: Comparative prospective study of 50 postmenopausal women as study group and fifty age-matched men as a control group diagnosed with ACS, who were admitted in a medical college hospital from December 2013 to September 2015. Chi-square test and Student's t-test have been used to find the significant association of study parameters between women and men. Results: Chest pain was the main complaint in the majority of the women (76%) and men (88%). Radiation of chest pain (60%) and sweating (72%) were significantly present in men compared to women (24% and 26%, respectively), whereas breathlessness was significantly present in women (40%) compared to men (16%). Women had later presentation to the hospital after symptom onset compared to men. Women had a higher respiratory rate (22.02 cycles/min) compared to men (20 cycles/min) and more crepitations compared to men. Men had more ventricular tachycardia (14%) and intracerebral hemorrhage (4%), whereas women had all other complications more than or same as men and higher in-hospital mortality (14%) compared to men (8%). Conclusion: Postmenopausal women with ACS had more atypical presentation of symptoms, later presentation to hospital, more tachypnea, more crepitations, more complications, and higher in-hospital mortality compared to men of the same age group. The difference in the profile of ACS continues to exist even after menopause and age matching.

RésuméContexte: Le syndrome coronarien aigu (SCA) diffère chez les femmes et les hommes en ce qui concerne les facteurs de risque, la présentation clinique, les complications et les résultats. La principale raison des différences a été l'effet de l'œstrogène qui protège les femmes de la maladie coronarienne (CAD) jusqu'à la ménopause. Les femmes développent CAD une décennie plus tard que les hommes. Par conséquent, nous avons comparé le profil du SCA chez les femmes ménopausées avec des hommes du même âge pour voir si la différence existe toujours. Matériels et méthodes: Étude prospective comparative de 50 femmes ménopausées en tant que groupe d'étude et de cinquante hommes du même âge en tant que groupe témoin ayant reçu un diagnostic de SCA, qui ont été admises dans un hôpital universitaire de médecine de décembre 2013 à septembre 2015. Test du chi carré et test de Student. -test ont été utilisés pour trouver l'association significative des paramètres d'étude entre les femmes et les hommes. Résultats: La douleur thoracique était la principale plainte chez la majorité des femmes (76 %) et des hommes (88 %). L'irradiation de la douleur thoracique (60 %) et la transpiration (72 %) étaient significativement présentes chez les hommes par rapport aux femmes (24 % et 26 %, respectivement), tandis que l'essoufflement était significativement présent chez les femmes (40 %) par rapport aux hommes (16 %) . Les femmes se sont présentées plus tard à l'hôpital après l'apparition des symptômes par rapport aux hommes. Les femmes avaient une fréquence respiratoire plus élevée (22,02 cycles/min) par rapport aux hommes (20 cycles/min) et plus de crépitations par rapport aux hommes. Les hommes présentaient plus de tachycardie ventriculaire (14 %) et d'hémorragie intracérébrale (4 %), tandis que les femmes présentaient toutes les autres complications plus ou autant que les hommes et une mortalité hospitalière plus élevée (14 %) que les hommes (8 %). Conclusion: Les femmes ménopausées atteintes de SCA présentaient une présentation plus atypique des symptômes, une présentation plus tardive à l'hôpital, plus de tachypnée, plus de crépitations, plus de complications et une mortalité hospitalière plus élevée que les hommes du même groupe d'âge. La différence dans le profil du SCA continue d'exister même après la ménopause et l'appariement de l'âge. Mots-clés: Syndrome coronarien aigu, infarctus aigu du myocarde, hommes, ménopause, angor instable, femmes.

Heart Failure in Tetralogy of Fallot due to Associated Hypertrophic Obstructive Cardiomyopathy: A Lesson to Learn.

Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart disease. Heart failure (HF) in a case of uncomplicated TOF is uncommon but can occur under special circumstances. TOF associated with hypertrophic obstructive cardiomyopathy (HOCM) is a very rare combination of anomalies, and very few cases have been reported in the literature. Here, we report the case of a 2-month-old male infant who presented to us with central cyanosis and features of HF. He was worked up and found to have TOF with HOCM and advised surgical correction. Hence, we propose that HOCM is also one factor which can precipitate HF in a patient of TOF along with the classical causes mentioned in the literature. Furthermore, the left ventricular outflow tract obstruction of HOCM in a patient of TOF has an inverse relation with the degree of cyanosis.

Left ventricular tamponade- pathophysiology determines the therapeutic approach: a case series.

BACKGROUND: Left ventricular (LV) tamponade is rare. LV tamponade can occur in cases of a loculated pericardial effusion overlying the LV and in cases of circumferential pericardial effusions in patients with severe pulmonary arterial hypertension (PAH). Both causes of LV tamponade share the common feature of not presenting with the classical features of cardiac tamponade. However, the therapeutic approach of the two is different. CASE SUMMARY: Here, we report two cases of LV tamponade. The first patient was a case of post-mitral valve replacement who presented with loculated posterior pericardial effusion with LV tamponade. Due to the loculated and posterior nature of the effusion, his pericardial fluid was drained from the axilla by echocardiographic and fluoroscopic guidance. The second patient presented with features of severe PAH with a circumferential pericardial effusion and LV tamponade. Due to the circumferential nature of the effusion, the pericardiocentesis was performed from the subxiphoid route. DISCUSSION: The pathophysiology of LV tamponade must be determined accurately before performing pericardiocentesis. Left ventricular tamponade in patients with severe PAH and non-loculated circumferential effusion can be drained from the subxiphoid route, while LV tamponade due to loculated effusion overlying LV must be drained by echocardiographic and fluoroscopic guidance from the axilla.

The use of integrative therapy based on Yoga and Ayurveda in the treatment of a high-risk case of COVID-19/SARS-CoV-2 with multiple comorbidities: a case report.

BACKGROUND: We report a high-risk case of a coronavirus disease 19 (COVID-19)-positive patient with comorbidities including diabetes mellitus (DM), hypertension (HTN), hypothyroidism and chronic kidney disease (CKD), treated successfully using an integrative therapy plan based on Ayurveda and Yoga, along with government-mandated compulsory modern western medicine (MWM) treatment. Recently, some evidence has been emerging on the use of Ayurveda for treatment of COVID-19. The classical texts of Ayurvedic medicine such as Charaka Samhita and Sushruta Samhita contain descriptions of pandemics of similar proportions and describe them as Janapadoddhvansa, meaning the destruction of communities, along with their causes and treatment. CASE PRESENTATION: The case reported herein is a 55-year-old man from Delhi, India, with confirmed (tested) COVID-19, who first took MWM for 7 days before seeking integrative therapy. The patient has comorbidities including DM, HTN, hypothyroidism and CKD and had developed symptoms including fever (which was resolved by the time integrative therapy was started), sore throat, dry cough, body aches, weakness, bad taste and smell, and heaviness in the abdomen. Based on the patient's symptoms and comorbidities, a treatment plan including Ayurvedic medicines, Yoga protocol, dietary recommendations and lifestyle modifications was prescribed by a registered Ayurveda doctor and a Yoga consultant. The patient started experiencing improvement in all the symptoms within 2 days after starting the treatment; he reported approximately [Formula: see text] relief from the symptoms after 5 days, and almost complete relief within 9 days. Also, the blood sugar levels (both fasting blood sugar [FBS] and postprandial blood sugar [PPBS]) exhibited significant improvement after 5 days, and decreased to within the normal range within 12 days. Besides relief in symptoms, the patient's real-time reverse transcription polymerase chain reaction (RT-PCR) test done on the 19th day returned negative results. CONCLUSIONS: Integrative therapy was found to be effective in mitigating the symptoms of COVID-19 in this patient with multiple comorbidities. Moreover, a significant improvement in blood sugar levels (not under control with modern medicine) was also achieved. Integrative therapy based on the classical texts of Ayurveda and Yoga may offer a promising and scalable treatment option for COVID-19 patients. A case series or a suitably designed randomized controlled trial is needed to assess its efficacy.

Cardiac rehabilitation: Appraisal of current evidence and utility of technology aided home-based cardiac rehabilitation.

Cardiac rehabilitation (CR) is an evidence-based intervention that uses exercise training, health behaviour modification, medication adherence and psychological counselling to improve secondary prevention outcomes in patients with cardiovascular disease. CR programs reduce morbidity and mortality rates in adults with ischemic heart disease, following coronary intervention, heart failure, or cardiac surgery. These are significantly underused, with only a minority of eligible patients participating in CR in India. Novel delivery strategies and CR endorsement by healthcare organizations are urgently needed to improve participation. One potential strategy is home-based CR (HBCR). Differing from centre-based CR services, which are provided in a medically supervised facility, HBCR relies on remote coaching with indirect exercise supervision. It is provided mostly or entirely outside of the traditional centre-based setting and could be facilitated by the aid of technology and web based applications. The purpose of this appraisal is to identify the core components, efficacy, strengths, limitations, evidence gaps, and research necessary to guide the future delivery of HBCR. This appears to hold promise in expanding the use of CR to eligible patients. Additional research and demonstration projects are needed to clarify, strengthen, and extend the HBCR evidence base for key subgroups, including older adults, women, underrepresented minority groups, and people in remote and rural areas. HBCR may be a reasonable option for a selected group of patients and could be a game changer in low- and middle-income countries who are eligible for CR.

Percutaneous coronary intervention provided better long term results than optimal medical therapy alone in patients with chronic total occlusion: A meta-analysis.

AIMS: Studies comparing the outcome of percutaneous coronary intervention (PCI) along with optimal medical therapy (OMT) versus OMT alone in treatment of chronic total occlusion (CTO) are limited by observational design, variable follow-up period, diverse clinical outcomes, high drop-out and cross-over rates. This study aims to conduct a meta-analysis of published data of observational as well as randomized studies comparing long term outcomes of PCI+OMT versus OMT alone. METHODS AND RESULTS: PubMed, Embase and Cochrane databases were systematically reviewed. 15 studies meeting criteria were included in the meta-analysis. The New-castle Ottawa scale was used to appraise the overall quality of the studies. Random-effects model with inverse variance method was undertaken. Major adverse cardiovascular events (MACE) which comprises of cardiac death, myocardial infarction, stroke, and un-planned revascularization were significantly lower in the PCI+OMT group (RR:0.76; 95% CI:0.61 to 0.95; P=<0.00001; I2 = 85%). All-cause mortality and cardiac death were significantly lower in the PCI+OMT group (P=<0.00001 in both). Myocardial infarction and stroke rates were lower in the PCI+OMT group, however they did not reach statistical significance (P = 0.24, P = 0.15 respectively). Unplanned revascularizations (of any vessel) were also similar in both the groups (P = 0.78, I2 = 88%). CONCLUSION: PCI of CTO is rewarded with better long term outcome, in terms of MACE, all-cause mortality and cardiac death with similar rates of un-planned revascularization.

Acute adrenal insufficiency as a mysterious cause of shock following percutaneous coronary intervention: a cardiologist's nightmare.

The differential diagnosis of shock following percutaneous coronary intervention (PCI) is vast. Access site complications and bleeding can cause hypovolemic shock. Peri-procedural myocardial infarction, abrupt closure, stent thrombosis, coronary dissection and coronary perforation have a stormy presentation. Vasovagal shock is manifested by bradycardia and hypotension and quickly responds to atropine. Anaphylactic shock secondary to contrast administration can be stormy but usually responds to steroids or adrenaline. Septicemia due to unsterile techniques can cause a less dramatic shock. Acute adrenal insufficiency causing shock following PCI has not been described to the best of our knowledge. We report the case of a 54-year-old woman who underwent successful multivessel PCI. She had refractory unexplained shock following the PCI with no much response from inotropic or intra-aortic balloon pump. After ruling out all possible causes of shock and clinical suspicion of adrenal insufficiency, she was treated with steroids resulting in dramatic improvement in her hemodynamics.

Survival outcomes post percutaneous coronary intervention: Why the hype about stent type? Lessons from a healthcare system in India.

A prospective, multicenter study was initiated by the Government of Maharashtra, India, to determine predictors of long-term outcomes of percutaneous coronary intervention (PCI) for coronary artery disease, and to compare the effectiveness of drug-eluting stents (DESs) and bare-metal stents (BMSs) in patients undergoing PCI under government-funded insurance. The present analysis included 4595 patients managed between August 2012 and November 2016 at any of 110 participating centers. Using the classical multivariable regression and propensity-matching approach, we found age to be the most important predictor of 1-year mortality and target lesion revascularization at 1 year post-PCI. However, using machine learning methods to account for unmeasured confounders and bias in this large observational study, we determined total stent length and number of stents deployed as the most important predictors of 1-year survival, followed by age and employment status. The unadjusted death rates were 5.0% and 3.8% for the BMS and DES groups, respectively (p = 0.185, log-rank test). The rate of re-hospitalization (p<0.001) and recurrence of unstable angina (p = 0.08) was significantly lower for DESs than for BMSs. Increased use of DES after 2015 (following establishment of a price cap on DESs) was associated with a sharp decrease in adjusted hazard ratios of DESs versus BMSs (from 0.94 in 2013 to 0.58 in 2016), suggesting that high price was limiting DES use in some high-risk patients. Since stented length and stent number were the most important predictors of survival outcomes, adopting an ischemia-guided revascularization strategy is expected to help improve outcomes and reduce procedural costs. In the elderly, PCI should be reserved for cases where the benefits outweigh the higher risk of the procedure. As unemployed patients had poorer long-term outcomes, we expect that implementation of a post-PCI cardiovascular rehabilitation program may improve long-term outcomes.