Syndrome 'Z': A Predictor of Angiographic Severity of Coronary Artery Disease in Patients of Acute Coronary Syndrome.

BACKGROUND: Owing to the growing evidence that the pathophysiology of obstructive sleep apnoea (OSA) and metabolic syndrome (MS) overlap considerably and both adversely impact cardiovascular health, we hypothesised that the presence of OSA with MS additively and adversely affect the severity of coronary artery disease (CAD). Exploration and understanding of this may have direct implications for the development of targeted, preventive strategies for CAD. Thus, this prospective study was aimed to determine the prevalence of 'Syndrome Z' in patients of MS who present with an acute coronary event and to correlate it with the angiographic severity of CAD in these patients. METHODS: The present study was a single centre, cross sectional study conducted in a university teaching hospital. In a span of 6 months, 922 patients with acute coronary syndromes (ACS) were screened for the study. Among these, 861 patients had no evidence of MS. The remaining 61 patients who were diagnosed to have MS were then subjected to an overnight sleep study. Only 58 had good sleep data so were included for further analysis. Angiographic parameters in terms of number of vessels involved and culprit lesions were noted and correlated with presence and absence of OSA and also with its severity based on the Apnoea/Hypopnoea Index (AHI). RESULTS: The prevalence of OSA positivity in patients with MS who presented with ACS was 34.5% (n=20). Most of the patients in the OSA negative group (78.9%, n=30) had disease limited to only one vessel while in the OSA positive group only a minority (15%, n=3) of patients had their disease limited to a single vessel (p=0.001). The number of lesions in the culprit vessel was also significantly less in the OSA negative group compared to the OSA positive group. While in the OSA negative group 68.4% (n=26) patients had a solitary lesion, followed by two and three lesions in 15.8% (n=6) of the patients each, multiple lesions were more common in OSA positive patients, involving 80% of cases (45.0%, n=9 with two lesions; 35.0%, n=7 with three lesions; only 20%, n=4 had a solitary lesion). CONCLUSIONS: Prevalence of 'Syndrome Z' is high in patients having MS presenting with ACS and it correlates with the angiographic severity of CAD.

Simultaneous quantitation of acetylsalicylic acid and clopidogrel along with their metabolites in human plasma using liquid chromatography tandem mass spectrometry.

The interest in therapeutic drug monitoring has increased over the last few years. Inter- and intra-patient variability in pharmacokinetics, plasma concentration related toxicity and success of therapy have stressed the need of frequent therapeutic drug monitoring of the drugs. A sensitive, selective and rapid liquid chromatography coupled with tandem mass spectrometry (LC-MS/MS) method was developed for the simultaneous quantification of acetylsalicylic acid (aspirin), salicylic acid, clopidogrel and carboxylic acid metabolite of clopidogrel in human plasma. The chromatographic separations were achieved on Waters Symmetry Shield(TM) C18 column (150 × 4.6 mm, 5 µm) using 3.5 mm ammonium acetate (pH 3.5)-acetonitrile (10:90, v/v) as mobile phase at a flow rate of 0.75 mL/min. The present method was successfully applied for therapeutic drug monitoring of aspirin and clopidogrel in 67 patients with coronary artery disease.

Prognostic value of Angiographic Perfusion Score (APS) following percutaneous interventions in acute coronary syndromes.

INTRODUCTION: Identifying reperfusion and predicting post procedure risk is important following Percutaneous Coronary Interventions (PCI). An Angiographic Perfusion Score (APS) combining TIMI flow (TFG) and myocardial perfusion (TMPG) grades before and after PCI can accurately measure both epicardial and myocardial perfusion and predict Major Adverse Cardiac Events (MACE). PATIENTS AND METHODS: APS was calculated in 226 (88 ST elevation Myocardial Infarction (STEMI) and 138 Non STEMI) patients. Maximum score being 12, reperfusion was defined as failed: 0-3, partial: 4-9, and full APS: 10-12. Thirty day MACE were observed. RESULTS: APS identified reperfusion significantly more than TMPG alone (STEMI: 50.6% vs 11.8% (p < 0.001); Non STEMI, early reperfusion: 69.4% vs 52.8% (p < 0.01) and Non STEMI late reperfusion: 38.2% vs 7.8%; (p ≤ 0.001) respectively. A significantly lower incidence of MACE was observed in the full as compared to the failed APS group (1.8% vs 22.5%) (p < 0.001). No differences were noted between TMPG 0-2 (9.8%, 9.4%, 7.3%, respectively) (p = NS). CONCLUSION: Compared to MPG alone APS detects more low risk reperfused patients, post PCI.

Comparative assessment of platelet GpIIb/IIIa receptor occupancy ratio with Eptifibatide/Tirofiban in patients presenting with ACS and undergoing PCI.

BACKGROUND: The level of platelet inhibition by a Glycoprotein IIb/IIIa (GpIIb/IIIa) antagonist therapy necessary to minimize thrombotic complications in patients undergoing percutaneous coronary intervention (PCI) is a subject of debate. The degree of platelet inhibition obtained 10 min after start of GpIIb/IIIa antagonist therapy predicts adverse events after PCI. The aim of this study was to look at platelet inhibition and to compare platelet GpIIb/IIIa receptors occupancy ratio (GpRO) with Eptifibatide and Tirofiban using various dose regimens and correlate with 30-day clinical outcomes in patients presenting with high-risk acute coronary syndromes (ACS) and undergoing PCI. METHODS: The patients were divided into four sub groups: (1) Eptifibatide two intracoronary bolus (180 µg/kg) alone (E(B)); or (2) two intravenous bolus (180 µg/kg) followed by infusion at 2 µg/kg/min for 24 h (E(B + Inf)); and (3) Tirofiban standard bolus dose (0.4 µg/kg) over 30 min followed by infusion at 0.1 µg/kg/min (T(Std)); or (4) at ADVANCE dose bolus (25 µg/kg) over 3 min, followed by infusion at 0.1 µg/kg/min (T(Adv)). Number of GpIIb/IIIa receptors was assessed by flow cytometry at baseline and 10 min after the bolus and percentage of free receptors was determined to calculate the GpRO. Patients were followed for 30 days for any major adverse cardiac events (MACE). RESULTS: 200 consecutive patients (including 74% with ST-elevation ACS) were enrolled. GpRO in groups E(B) (n = 48) and E(B + Inf) (n = 44) were 62.7% ± 27.2% and 61.4% ± 6.1% respectively while in the groups T(Std) (n = 96) and T(Adv) (n = 12) groups were 35.1% ± 17.74% and 68.8% ± 27.3% respectively. The GpRO was similar in E(B), E(B + Inf) and T(Adv) groups and was significantly higher than T(Std) group (p < 0.0001). The 30-day MACE rates in E(B) (4.2%), E(B + Inf) (4.5%) and T(Adv) (4.2%) were significantly lower than T(Std) group (12.5%) (p < 0.01). CONCLUSIONS: Standard dose Tirofiban results in significantly lower rates of GpIIb/IIIa receptor occupancy ratio and this correlated with higher incidence of 30-day MACE in high-risk ACS patients undergoing PCI.

Effect of yogic intervention on the autonomic nervous system in the patients with coronary artery disease: a randomized controlled trial.

In this study 258 patients from the Department of Cardiology in Chhatrapati Shahuji Maharaj Medical University, Lucknow were selected to participate. All had been diagnosed with coronary artery disease. They were randomly divided into 2 groups, the yoga group and the non-yoga group, 129 in each group; 208 completed the study protocol. The yogic intervention consisted of 35-40 min/day, 5 days a week over a period of 18 months in the Department of Physiology. Autonomic function testing was done in both the groups at zero time and after 18 months. We observed a statistically significant reduction in body mass index, waist circumference, systolic and diastolic blood pressure, and heart rate (P < 0.05), i.e., a significant positive effect was observed when yoga therapy was used as an adjunct in patients with coronary artery disease.

Percutaneous balloon pericardiotomy for the treatment of recurrent malignant pericardial effusion.

Malignant disease with pericardial metastasis is one of the most common causes of recurrent pericardial effusion (PE) with tamponade. While surgical pericardiotomy in these patients is very morbid and may not be a viable option, a palliative treatment percutaneously with percutaneous balloon pericardiotomy (PBP) can be a preferred treatment. We report herewith a case of PBP technique done using our day-to-day catheterisation laboratory equipment.

Giant right atrial aneurysm presenting as right heart failure.

Idiopathic aneurysmal dilatations of the right atrium are rare anomalies. We report one such case of a young man presenting with fatigue, abdominal distension, pedal oedema, unremarkable cardiac examination except for raised jugular venous pressure, an electrocardiogram showing normal sinus rhythm with right bundle-branch block, and an radiograph of the chest showing cardiomegaly. The echocardiographic examination revealed a giant right atrium with low pressure tricuspid regurgitation. The computed tomography confirmed the findings of two-dimensional echocardiography. He was put on medical treatment and remained symptomatically controlled on follow-up.

Patterns and determinants of dyslipidaemia in 'Young' versus 'Not so Young' patients of coronary artery disease: a multicentric, randomised observational study in northern India.

AIMS: The aims of the study were to ascertain difference in lipid levels of 'Young' onset of coronary artery disease (CAD) (≤ 45 years) vs. 'Not so Young' onset of CAD (≥ 55 years) among north Indians and also to investigate determinants of 'dyslipidaemia' in CAD patients. METHODS: This was a prospective, multicentric, randomised, observational study carried in eight centres of UP, India. All blood investigations were performed employing a central laboratory. RESULTS: Out of a total 435 patients studied, 218 were in the 'young group' (YG) and 235 were in the 'Not so Young Group' (NSYG). Dyslipidaemia was more common in YG as evident by significantly higher levels of total cholesterol, triglycerides, low- and very low-density lipoprotein cholesterol as compared to NSYG. Diabetes, hypertension, urban lifestyle, and family history of CAD were found to be important determinants of dyslipidaemia in YG. CONCLUSION: We conclude that lipid levels among north Indians are significantly higher in younger patients with CAD when compared with elderly.

Demographic, clinical and etiological profile of pericardial effusion in India: A single centre experience.

INTRODUCTION: Pericardial effusion (PE) is a life-threatening condition. However, there are very few Indian studies which determined etiological distribution. The current retrospective observational study was carried out to assess etiological factors responsible for PE in a tertiary care centre in India. METHODS: The study enrolled consecutive 55 patients with the diagnosis of moderate to large PE as established by echocardiography between January 2018 and December 2018. The echocardiography guided percutaneous pericardiocentesis was performed by the standard procedure. RESULTS: Amongst the enrolled PE patients in the study, 30 (54.55%) were males and 25 (45.45%) were females, with the average age of 43.00 ± 15.54 years. In clinical assessment, tamponade was found in 52 (94.54%) patients. Tuberculosis was the most common etiology for PE (n=35, 63.64%) followed by hypothyroidism (n = 6, 10.9%), and malignancies (n = 4, 7.27%). Among 12.72% patients, the PE was of recurrent type. Additionally, no death or any complication was encountered during pericardiocentesis. CONCLUSION: Pericardial disease and effusion is a major cause of morbidity in India. Despite developments in the healthcare facilities, tuberculosis was the most common etiology for PE. Additionally, the raised number of hypothyroid and malignant PE cases demonstrates the changing etiological trends, similar to western countries.

Safety and feasibility of same-day discharge after elective percutaneous balloon mitral valvotomy: a prospective, single-center registry in India.

BACKGROUND: Percutaneous mitral balloon valvotomy (PBMV) is an alternative to surgery for patients with severe mitral valve (MV) stenosis. However, the safety and feasibility of same-day discharge (SDD) in patients undergoing elective PBMV for severe MV stenosis is yet to be investigated. This study aimed to assess safety and feasibility of SDD in patients undergoing elective PBMV because of severe MV stenosis in a tertiary-care hospital in India. METHODS: From January 2018 to November 2018, patients with a diagnosis of severe MV stenosis were treated with PBMV at our institution. Among these patients, those suitable for SDD were prospectively included in this registry. Vascular access was achieved in forearm arteries and femoral veins. Clinical, echocardiographic and hemodynamic features were collected before and after PBMV. The primary outcome was 30-day mortality. The secondary outcome was incidence of in-hospital complications. Other outcomes of interest were arterial spasm and forearm haematoma. RESULTS: A total of 98 patients scheduled for SDD after elective PBMV were included in the registry. Mean MV area increased from 0.8 ± 0.1 to 1.6 ± 0.2 cm2 (p < .001). Severe MV regurgitation after PBMV occurred in 3 patients, and 1 patient developed pericardial tamponade. Severe arterial spasm occurred in 2 patients. None of the included patients developed a clinically relevant haematoma of forearm. A total of 94 (96%) were discharged on the same day. No patient died up to 30-day follow-up. CONCLUSION: PBMV from the venous access site can reduce the hospital stay of patients to less than a day with less local site complications.

'Routine' versus 'Smart Phone Application Based - Intense' follow up of patients with acute coronary syndrome undergoing percutaneous coronary intervention: Impact on clinical outcomes and patient satisfaction.

BACKGROUND: Acute coronary syndrome (ACS) refers to the spectrum of clinical presentation of coronary artery disease (CAD). As a routine practice at our institute, following PCI, ACS patients are called for the first follow up after two weeks. This period of two weeks can be full of anxieties, concerns and medical issues. In this study, we planned to assess the feasibility/acceptability of smart phone application (app) based system for patient follow-up and its comparison to routine practice among patients with ACS who have undergone a PCI. METHODS: A randomized controlled trial (RCT) was conducted over a period of one year from January to December 2017. After the PCI was deemed successful, patients were recruited and enrolled based on the understanding of basic English language and operation of a smart phone. Those who consented to be part of study were then randomly allocated either the conventional follow up group or the intense follow up (routine + smart phone app based follow up) group. First co- primary outcome was composite of clinical outcomes (mortality, myocardial infarction, stroke, target vessel revascularisation, heart failure admission and emergency visit). Second co- primary outcome was patient satisfaction. The overall patient satisfaction was assessed by the patients using a five-point patient satisfaction survey instrument containing five questions with 5 marks each, in which higher scores meant more satisfaction. Secondary outcome was controlled hypertension in hypertensive patients. It was defined as systolic BP less than 130 and diastolic BP less than 80 mmHg. RESULTS: A cohort of 228 patients (109 in intense app-based arm; 119 in routine follow up arm) were analyzed. The result showed significant improvement in blood pressure control in hypertensive population in intense app based follow up group (76.2%) when compared to routine follow up group (45%) with p value 0.0062. The satisfaction score was significantly higher in the intense app based follow up (20.7 ± 1.29) as compared to routine follow up (16.5 ± 2.68); p value 0.0001. In the intense app based follow up 72.5% patient felt it was excellent tool (score 21-25) while 27.5% categorized it as good (score 16-20). While the routine follows up was perceived as good by most (91.6%) of the patients. Only 4.2% graded it as excellent and an equal number (4.2%) graded it as a poor way of follow up. CONCLUSIONS: App based system shows higher satisfaction rate and comparable clinical outcome when compared to traditional hospital based follow up protocol alone. It has a high acceptance rate and thus this system should be explored further to optimize long term patient care.

Cardiological society of India document on safety measure during echo evaluation of cardiovascular disease in the time of COVID-19.

An echocardiographic investigation is one of the key modalities of diagnosis in cardiology. There has been a rising presence of cardiological comorbidities in patients positive for COVID-19. Hence, it is becoming extremely essential to look into the correct safety precautions, healthcare professionals must take while conducting an echo investigation. The decision matrix formulated for conducting an echocardiographic evaluation is based on presence or absence of cardiological comorbidity vis-à-vis positive, suspected or negative for COVID-19. The safety measures have been constructed keeping in mind the current safety precautions by WHO, CDC and MoHFW, India.

Clinical correlation of multiple biomarkers for risk assessment in patients with acute coronary syndrome.

OBJECTIVE: Biochemical markers are useful for the prediction of future cardiovascular events in patients with non-ST-segment elevation acute coronary syndrome (ACS). The independent as well as the combined prognostic value of elevated troponin-T, high-sensitivity C-reactive protein (hs-CRP), and N-terminal pro-brain natriuretic peptide (NT-pro-BNP) on the Thrombolysis In Myocardial Infarction (TIMI) risk score and on the short-term prognosis were evaluated in a cohort of ACS patients. METHODS AND RESULTS: In an unselected, heterogeneous group of 80 patients with ACS (i.e., unstable angina [USA] or non-ST-elevation myocardial infarction [NSTEMI]), the levels of troponin-T, hs-CRP, and NT-pro-BNP were analyzed. The correlation between elevation of different biomarkers with TIMI risk score and their impact on 30-day major adverse cardiac events was sought. The levels of hs-CRP were significantly higher in patients who had angina as their predominant complaint (3.67 mg/dl vs. 1.67 mg/dl: p < 0.01), while levels of NT-pro-BNP was higher in those patients who had any element of heart failure at presentation (2616.39 pg/ml vs. 1068.3 pg/ml; p < 0.01). Troponin-T was highest in patients who had an element of both heart failure and angina at presentation (p < 0.01). The TIMI risk score expectedly had a positive and strong correlation with elevated troponin-T, but had no correlation with elevation of hs-CRP and NT-pro-BNP in isolation. However, when any two biomarkers were elevated, the patients were in the intermediate risk group as per TIMI risk score irrespective of troponin-T-elevation. When all the three biomarkers were elevated, the risk equaled the high-risk category of TIMI risk score. Elevated hs-CRP (3.40 mg/dl vs. 1.38 mg/dl; p < 0.001) and troponin-T (2.37 ng/ml vs. 1.23 ng/ml; p < 0.001) at baseline correlated independently with the occurrence of re-ischemia, while elevated NT-pro-BNP alone correlated significantly with the development of heart failure within 30 days of follow-up (4247.76 pg/ml vs. 1210.86 pg/ml; p < 0.01). The highest risk of death from any cardiovascular cause within 30 days of follow-up was significantly higher when all the three biomarkers were elevated. CONCLUSION: The use of NT-pro-BNP, hs-CRP, and troponin-T in combination appears to add critical prognostic insight to the assessment of patients with ACS.

"Poor man's risk factor": correlation between high sensitivity C-reactive protein and socio-economic class in patients of acute coronary syndrome.

OBJECTIVE: Inflammation has been proposed as one of the factors responsible for the development of coronary artery disease (CAD) and high sensitivity C-reactive protein (hs CRP) at present is the strongest marker of inflammation. We did a study to assess the correlation of hs-CRP with socio-economic status (SES) in patients of CAD presenting as acute coronary syndrome (ACS). METHODS: Baseline hs-CRP of 490 patients of ACS was estimated by turbidimetric immunoassay. Patients were stratified by levels of hs-CRP into low (<1 mg/L); intermediate (1-3 mg/L) or high (>3 mg/L) groups and in tertiles of 0-0.39 mg/L, 0.4-1.1 mg/L and >1.1 mg/L, respectively. Classification of patient into upper (21.4%), middle (45.37 percent) and lower (33.3%) SES was based on Kuppuswami Index which includes education, income and profession. Presence or absence of traditional risk factors for CAD diabetes, hypertension, dyslipidemia and smoking was recorded in each patient. RESULTS: Mean levels of hs-CRP in lower, middle and upper SES were 2.3 +/- 2.1 mg/L, 0.8 +/- 1.7 mg/L and 1.2 +/- 1.5 mg/L, respectively. hs-CRP levels were significantly higher in low SES compared with both upper SES (p = 0.033) and middle SES (p = 0.001). Prevalence of more than one traditional CAD risk factors was seen in 13.5%, 37.5% and 67.67 percent; in patient of lower, middle and upper SES. It was observed that multiple risk factors had a linear correlation with increasing SES. Of the four traditional risk factors of CAD, smoking was the only factor which was significantly higher in lower SES (73%) as compared to middle (51.67 percent;) and upper (39.4%) SES. We found that 62.3%, 20.8% and 26.5% patients of low, middle and upper SES had hs-CRP values in the highest tertile. Median value of the Framingham risk score in low, middle and upper SES as 11, 14 and 18, respectively. We observed that at each category of Framingham risk, low SES had higher hs-CRP. CONCLUSION: We conclude from our study that patient of lower SES have significantly higher levels of hs-CRP despite the fact that they have lesser traditional risk factors and lower Framingham risk. These findings add credit to our belief that inflammation may be an important link in the pathophysiology of atherosclerosis and its complications especially in patients of low SES who do not have traditional risk factors.

Diastolic and systolic right ventricular dysfunction precedes left ventricular dysfunction in patients paced from right ventricular apex.

BACKGROUND: Cardiac dysfunction after right ventricular (RV) apical pacing is well known but its extent, time frame of appearance and individual effect on left ventricular (LV), RV systolic and diastolic parameters has not evaluated in a systematic fashion. METHODS: Patients with symptomatic bradycardia and ACC-AHA Class I indication for permanent pacemaker implantation (PPI) were implanted a single chamber (VVI) pacemaker. They were followed prospectively by echocardiographic examination which was done at baseline, 1 week, 1 month and 6 months after implantation. Parameters observed were chamber dimensions (M-line), chamber volumes, cardiac output (modified Simpson's method), systolic functions (ejection fraction, pre-ejection period, ejection time and ratio) and diastolic functions( isovolumic relaxation time & deceleration time) of left and right heart. RESULTS: Forty eight consecutive patients (mean age 65.6+/-11.8 yrs, 66.7% males, mean EF 61.82+/-10.36%) implanted a VVI pacemaker were enrolled in this study. The first significant change to appear in cardiac function after VVI pacing was in diastolic properties of RV as shown by increase in RV isovolumic relaxation time (IVRT) from 65.89+/-15.93 to 76.58+/-17.00 ms,(p<0.001) at 1week and RV deceleration time (DT) from 133.84+/-38.13 to 153.09+/-31.41 ms, (p=0.02) at 1 month. Increase in RV internal dimension (RVID) from 1.26+/-0.41 to 1.44+/-0.44, (p<0.05) was also noticed at 1 week. The LV diastolic parameters were significantly altered after 1 month with increase in LV-IVRT from 92.36+/-21.47 to 117.24+/-27.21ms, (p<0.001) and increase in LV DT from 147.56+/-31.84 to 189.27+/-28.49ms,(p<0.01). This was followed by LV systolic abnormality which appeared at 6 months with an increase in LVPEP from 100.33+/-14.43 to 118.41+/-21.34ms, (p<0.001) and increase in LVPEP/LVET ratio from 0.34+/-0.46 to 0.44+/-0.10, (p<0.001)]. The reduction in LV EF was manifested at 6 months falling from 61.82+/-10.36% to52.52+/-12.11%, (p<0.05) without any significant change in the resting cardiac output. CONCLUSION: The present study shows that dysfunction of right ventricle is the first abnormality that occurs in VVI paced patients, which manifests by 1 week followed by LV dysfunction which starts appearing by 1 month and the diastolic dysfunctions precede the systolic dysfunction in both ventricles.

Sialic acid in cardiovascular diseases.

Sialic acid, the acylated derivatives of 9-carbon sugar neuraminic acid, present as terminal component of oligosaccharide chains of many glycoproteins and glycolipids, has been recognized to be involved in the regulation of a great variety of biological phenomena. Studies have shown that serum sialic acid predicts both coronary heart disease and stroke mortality and reflects the existence or activity of an atherosclerotic process. Most of the studies have shown an elevation in serum sialic acid concentration in coronary heart disease and a positive correlation between the raised serum sialic acid and the severity of the coronary lesions is observed. However, a few contradictory reports are also available. Racial differences in serum sialic acid have also been reported and correlated with international differences in the prevalence of atherosclerosis. Reduced sialic acid content of platelets, erythrocytes and lipoproteins may play important role in the pathogenesis of atherosclerosis. Elucidation of the mechanism of alternation in sialic acid concentration may throw more light on its potential clinical utility. Hence more studies are needed to designates sialic acid as a cardiovascular risk factor/marker.

Intravenous streptokinase in the management of a subset of patients with unstable angina: a randomized controlled trial.

We report the results of a randomized controlled trial of intravenous streptokinase in a subset of patients with unstable angina. Seventy-six patients were admitted with prolonged (more than 20 minutes) angina at rest of less than 3 weeks onset. Fifty-two patients continued to have more than 3 episodes of prolonged angina in 48 hours on medical therapy with metoprolol, isosorbide dinitrate, nifedipine and intravenous nitroglycerin. Forty-eight patients consented to enter the study and were randomized into two groups. The first group, of 24 patients, received 1.5 million units of streptokinase infusion and the second group, also of 24 patients, received a placebo. Pain relief within 48 hours was achieved in 19/24 (79.1%) patients after streptokinase infusion as compared to 9/24 (37.5%) of the controls (P less than 0.05). Approximately 90% (17/19) of patients responding to streptokinase therapy were relieved of chest pain within the first six hours as against none in the controls. The incidence of acute myocardial infarction within six months was 12.5% (3/24) in those receiving streptokinase and 25% (6/24) in the controls. Mortality at six months stood at 8.33% (2/24) in the treated patients and 16.6% (4/24) in the controls. Intravenous streptokinase thus appears to be of benefit in patients with angina at rest of recent onset which does not respond to conventional medical therapy.

Left ventricular diastolic collapse in low-pressure cardiac tamponade.

A case of systemic hypotension with volume depletion not responding to intravenous fluids was found to have features of cardiac tamponade on two-dimensional (2-D) echocardiography. Intracardiac pressures were normal on cardiac catheterization. An interesting observation was the presence of left ventricular (LV) collapse on 2-D echocardiography. To the authors' best knowledge, such a case of low pressure cardiac tamponade with LV collapse has not been reported earlier.

Silent ischemic interval on exercise test is a predictor of response to drug therapy: a randomized crossover trial of metoprolol versus diltiazem in stable angina.

BACKGROUND AND HYPOTHESIS: There is no method available to predict the relative antianginal efficacy of beta blockers and calcium-channel antagonists. The present study was undertaken to assess the role of silent ischemic interval (SII) on exercise treadmill test (ETT) as a predictor of response to therapy with metoprolol and diltiazem in patients with stable angina. METHODS: Thirty-four patients with stable angina were divided into two groups depending upon the presence or absence of an SII gap of at least 1 min between onset of ST depression and appearance of angina on ETT. Metoprolol (50-100 mg twice daily) and diltiazem (60-120 mg three times daily) were randomly assigned for 6 weeks to patients in each group, and then patients were crossed over for further 6 weeks after a washout period of 2 weeks. Antianginal efficacy was assessed by clinical and exercise parameters. RESULTS: In patients with SII, the clinical responder rate was better with metoprolol than with diltiazem (90 vs. 60%, respectively), and on ETT, metoprolol produced significant improvement in the total exercise time (p< 0.01), time to 1 mm ST depression (p <0.01), time to angina (p <0.01), and a significant decrease in peak rate-pressure product (p<0.001), whereas diltiazem had no significant effect on exercise parameters. However, in patients without SII, metoprolol and diltiazem had a similar clinical responder rate (57%), and both produced a significant increase in total exercise time (p < 0.01), time to 1 mm ST depression (p < 0.01), and time to angina (p < 0.01). In addition, metoprolol had a significant effect on peak rate-pressure product (p < 0.001). CONCLUSION: Silent ischemic interval on ETT can be a predictor of response to antianginal therapy in stable angina, as patients with SII respond better to metoprolol and those without SII respond equally to both metoprolol and diltiazem.