Showing papers in "Indian heart journal in 2008"

Recent trends in coronary heart disease epidemiology in India.

Abstract: Coronary heart disease (CHD) is epidemic in India and one of the major causes of disease-burden and deaths. Mortality data from the Registrar General of India shows that cardiovascular diseases are a major cause of death in India now. Studies to determine the precise causes of death in urban Chennai and rural areas of Andhra Pradesh have revealed that cardiovascular diseases cause about 40% of the deaths in urban areas and 30% in rural areas. Analysis of cross-sectional CHD epidemiological studies performed over the past 50 years reveals that this condition is increasing in both urban and rural areas. The adult prevalence has increased in urban areas from about 2% in 1960 to 6.5% in 1970, 7.0% in 1980, 9.7% in 1990 and 10.5% in 2000; while in rural areas, it increased from 2% in 1970, to 2.5% in 1980, 4% in 1990, and 4.5% in 2000. In terms of absolute numbers this translates into 30 million CHD patients in the country. The disease occurs at a much younger age in Indians as compared to those in North America and Western Europe. Rural-urban differences reveal that risk factors like obesity, truncal obesity, hypertension, high cholesterol, low HDL cholesterol and diabetes are more in urban areas. Case-control studies also confirm the importance of these risk factors. The INTERHEART-South Asia study identified that eight established coronary risk factors--abnormal lipids, smoking, hypertension, diabetes, abdominal obesity, psychosocial factors, low fruit and vegetable consumption, and lack of physical activity--accounted for 89% of the cases of acute myocardial infarction in Indians. There is epidemiological evidence that all these risk factors are increasing. Over the past fifty years prevalence of obesity, hypertension, hypercholesterolemia, and diabetes have increased significantly in urban (R2 0.45-0.74) and slowly in rural areas (R2 0.19-0.29). There is an urgent need for development and implementation of suitable primordial, primary, and secondary prevention approaches for control of this epidemic. An urgent and sincere bureaucratic, political, and social will to initiate steps in this direction is required.

Reducing the burden of coronary artery disease in India: challenges and opportunities.

Abstract: Asian Indians—living both in India and abroad—have one of the highest rates of coronary artery disease (CAD) in the world, three times higher than the rates among Caucasians in the United States. The CAD among Indians is usually more aggressive at the time of presentation compared with whites or East Asians. The overall impact is much greater because the CAD in Asian Indians affects the “younger” working population. This kind of disproportionate epidemic among the young Indians is causing tremendous number of work days lost at a time when India is experiencing a dizzying economic boom and needs a healthy populace to sustain this boom. While the mortality and morbidity from CAD has been falling in the western world, it has been climbing to epidemic proportions among the Indian population. Various factors that are thought to contribute to this rising epidemic include urbanization of rural areas, large-scale migration of rural population to urban areas, increase in sedentary lifestyle, abdominal obesity, metabolic syndrome, diabetes, inadequate consumption of fruits and vegetables, increased use of fried, processed and fast foods, tobacco abuse, poor awareness and control of CAD risk factors, unique dyslipidemia (high triglycerides, low HDL-cholesterol levels), and possible genetic predisposition due to lipoprotein (a) [Lp(a)] excess. The effect of established, as well as novel, risk factors is multiplicative, not just additive (total effect > sum of parts). The management would require aggressive individual, societal, and governmental (policy and regulatory) interventions. Indians will require specific lower cut-offs and stricter goals for treatment of various risk factors than is currently recommended for western populations. To this end, the First Indo-US Healthcare Summit was held in New Delhi, India on December 14 and 15, 2007. The participants included representatives from several professional entities including the American Association of Physicians of Indian origin (AAPI), Indian Medical Association (IMA), Medical Council of India (MCI), and Government of India (GOI) with their main objective to address specific issues and provide precise recommendations to implement the prevention of CAD among Indians. The summary of the deliberations by the committee on “CAD among Asian Indians” and the recommendations are presented in this document. OBJECTIVES  Discussion of demographics of CAD in Indians—both in India and abroad, current treatment strategies, primordial, primary, and secondary prevention.  Development of specific recommendations for screening, evaluation and management for the prevention of CAD disease epidemic

Cardiovascular disease risk management in a primary health care setting of north India.

Abstract: Objective This study was primarily carried out to assess the feasibility of an adapted WHO CVD risk management package in a primary care setting. Methods A community intervention trial was conducted in eight health posts located in rural, urban, and slum areas of northern India. After a 4 day training, eight health workers implemented the package among 1010 adults > or =30 years of age from a randomly chosen cluster of households. Locally adapted scenario 1 WHO protocol was used for the assessment of CVD risks. The health workers inquired about smoking, alcohol, diet, physical activity, symptoms of angina, and transient ischaemic attacks; and measured systolic blood pressure (SBP7), height, and weight. Those with a risk were counseled and referred to a physician. Hypertensives were followed at 1, 3, and 5-month interval to reinforce risk prevention and adherence to treatment. In a 20% random sub sample, in the study and control area before and after the intervention, WHO STEPS instrument was used to evaluate effectiveness of the package. Findings After training, the knowledge of health workers regarding risk factors and symptoms of CVDs increased from 47% to 92.5%, and their performance in detection of risks was comparable to the investigator. All health workers could pay scheduled home visits regularly. They referred 279 (27.6%) individuals having raised systolic blood pressure (SBP), and 74.5% contacted the doctor. Significant decrease in mean SBP (8.8 mm Hg) was observed during follow-up. Significantly higher reports of intention to quit tobacco (60.3% vs 25.5%) and regular intake of anti-hypertensive medication (58.3% vs 34.8%) were observed in the intervention area compared to the control area. Conclusion Adapted WHO CVD risk management package can be implemented through primary care system.

Obesity is major determinant of coronary risk factors in India: Jaipur Heart Watch studies.

Abstract: OBJECTIVE The impact of rising population-wide obesity on cardiovascular risk factors has not been well studied in low-income countries To correlate the prevalence of obesity with risk factors we performed epidemiological studies in India METHODS Multiple cross-sectional epidemiological studies, Jaipur Heart Watch (JHW), were performed in India in rural and urban locations From these cohorts, subjects aged 20-59 years (men 4102, women 2872) were included Prevalence of various risk factors: smoking/tobacco use, overweight/obesity (body mass index > or = 25 kg/m2) truncal obesity (waist:hip > or = 095 men, > or = 085 women), hypertension, dyslipidemias, metabolic syndrome and diabetes was determined Trends were examined using least squares regression RESULTS Smoking/tobacco use was more in rural men (500% vs 406%) and urban women (89% vs 45%, p < 001) Obesity, truncal obesity, hypertension, hypercholesterolemia, diabetes, and metabolic syndrome were more in urban cohorts (p < 0001) Age-adjusted prevalence (%) of obesity in various cohorts, rural JHW, and urban JHW-1, JHW-2, JHW-3, and JHW-4 respectively, in men was 94, 211, 356, 540, and 509 (r2 = 092, p = 0009) and in women 89, 157, 451, 615, and 577 (r2 = 088, p = 0018) Prevalence of truncal obesity in men was 32, 196, 396, 414, and 311 (r2 = 060, p = 0124) and in women 101, 495, 421, 517, and 505 (r2 = 056, p = 01467) In successive cohorts increasing trends were observed in the prevalence of hypertension (r2 = 093, p = 0008) and metabolic syndrome (r2 = 099, p = 0005) with weaker trends for hypercholesterolemia (r2 = 041, p = 0241) and diabetes (r2 = 079, p = 0299) in men In women, significant trends were observed for hypertension (r2 = 098, p = 0001) and weaker trends for others Increase in generalized obesity correlated significantly with hypertension (two-line regression r2, men 091, women 088), hypercholesterolemia (053, 044), metabolic syndrome (087, 094) and diabetes (084, 093) Truncal obesity correlated less strongly with the risk factors like hypertension (050, 057), hypercholesterolemia (088, 061), metabolic syndrome (076, 033), and diabetes (075, 033) CONCLUSIONS In Asian Indian subjects, escalating population-wide generalized obesity correlates strongly with increasing cardiovascular risk factors

Risk factors for non-communicable disease in urban Haryana: a study using the STEPS approach.

Abstract: Background India is in the midst of an epidemiological transition with non-communicable diseases increasing in importance. Targeting the risk factors for non-communicable diseases is recognized as an essential preventive strategy. There is lack of good quality data on prevalence of risk factors. The present study addresses this challenge in urban population of Ballabgarh town in Faridabad district of Haryana. Methods A total of 1263 male and 1326 female respondents were selected using multistage systematic random sampling, in 5 age groups of 10 years (15-24, 25-34, 35-44, 45-54 and 55-64). The World Health Organization's STEPS approach entails stepwise collection of the risk factor data based on standardized questionnaires (step 1), basic physical measures in step 2 and finally in 3rd step, basic biochemical investigations such as blood sugar and cholesterol. The prevalence was adjusted to the age and sex strata of urban Faridabad as per census 2001. Results The prevalence of current daily use of smoked tobacco was 22.2% (95% CI7colon; 20.0-24.6) for males and 1.4% (95% CI: 0.9-2.2) for females. In males the prevalence of current alcohol consumption was 28.9% (95% CI: 26.4-31.5). Physical inactivity was reported by 23.2% (95% CI: 20.9-25.6) of males and 52.4% (95% CI: 49.7-55.1) of female respondents. Only 8.6% of males and 4.4% of females were consuming adequate portions of the fruits and vegetables. 23.1% (95% CI: 20.8-25.5) males and 15.7% (95% CI: 13.87ndash;17.8) females were either in Stage 1 and 2 hypertension (JNC VII) or were taking anti-hypertensives. Among males, 25.4% (95% CI: 23.0-27.9) and, among females 34.9% (95% CI: 32.3-37.6) were overweight. Conclusion The prevalence of tobacco and alcohol use among males and physical inactivity among females was high. Low consumption of fruits and vegetables, hypertension and overweight was equally common among both the sexes in the population studied. Thus there is an urgent need for initiating measures at the risk factor level to counter this modern day epidemic of non-communicable disorders, within this urban community.

Left ventricular systolic and diastolic dysfunction and their relationship with microvascular complications in normotensive, asymptomatic patients with type 2 diabetes mellitus.

Abstract: OBJECTIVE: Diabetes mellitus is an established risk factor for cardiovascular events. Aims of the study were to assess left ventricular systolic and diastolic function in asymptomatic patients with type 2 diabetes and evaluate the relations among left ventricular function and specific diabetic complications. METHODS: Seventy-three normotensive patients with type 2 diabetes and no clinical evidence of cardiac disease were studied. Thirty-four healthy subjects served as control group. Echocardiographic studies were performed to assess left ventricular systolic and diastolic function. Microangiopathy was assessed by fundoscopy. Autonomic function was evaluated by standing blood pressure and heart rate response to Valsalva maneuver. RESULTS: Patients with type 2 diabetes had a lower ejection fraction (54 +/- 10.8 vs. 67 +/- 6.1%, p < or = 0.001), E-velocity (50.1 +/- 10.6 vs. 58.4 +/- 6.3 cm/s, p < or = 0.001), and E/A ratio of <1 (54.8 vs. 5.8%, p < or = 0.01) of the mitral diastolic flow compared with the control subjects, respectively. Patients with ejection fraction <50% had higher prevalence of retinopathy (52.9 vs. 26.7%, p < or = 0.05), abnormal blood pressure response to standing (52.9 vs. 7.1%, p < or = 0.001), and proteinuria (70.5 vs. 14.2%, p < or = 0.05). An inverse correlation was found between duration of diabetes and both ejection fraction (r = -0.53, p = 0.05) and E/A ratio (r = 0.36, p = 0.003). E/A ratio of <1 was associated with higher prevalence of retinopathy (45 vs. 18.1%, p < or = 0.05) and abnormal blood pressure response to standing (25 vs. 9%, p < or = 0.05). Multiple logistic regression model showed that diabetes was the strongest independent correlate of diastolic dysfunction (odds ratio 8.91, 95% CI: 4.18-18.52, p < or = 0.001). CONCLUSION: Asymptomatic diabetic patients have reduced left ventricular systolic and diastolic function as compared with healthy subjects. Left ventricular systolic and diastolic abnormalities are correlated with the duration of diabetes and with diabetic microangiopathies, like retinopathy and neuropathy. Diabetes mellitus is the strongest independent correlate of left ventricular diastolic dysfunction.

Clinical and angiographic profile of patients presenting with first acute myocardial infarction in a tertiary care center in northern India.

Abstract: Objective Acute myocardial infarction (AMI) is one of the presentation of coronary artery disease (CAD) and is thought to occur in younger age group in this region. The objective of this study was to evaluate clinical, biochemical and angiographic profile of patients with first acute myocardial infarction. Methods Eight hundred and forty-six consecutive patients who underwent coronary angiography within 4 weeks of MI were included. Results Males (n = 705, 83.3%) outnumbered females (n = 141, 16.7%) in each age group. Mean age of presentation was lower in females (58.25 +/- 9.69: 55.74 +/- 10.63). Three hundred and forty-two (40.8%) patients were thrombolyzed. Most common type of MI was anterior wall MI (n = 485, 57.32%). Three hundred and forty (40.4%) were diabetic with females outnumbering males proportionately (females = 63, 44.68%: males = 277, 39.29%). More females were hypertensive (females = 81, 57.45%: males = 306, 43.40%). Prevalence of smoking was quite low (n = 140, 16.50%) and mean age of smokers was less by 7 years than non-smokers. One hundred and forty-two (16.7%) were obese with mean age of presentation less by 7 years than non-obese. Single vessel disease (SVD) was more prevalent (361/846; 42.67%) and was more common in younger, non-diabetics and smokers. Diabetics were more likely to have triple vessel disease (TVD) (n = 112, 32.95%). Conclusions The study reveals that age of first AMI was comparable to that in western world. Females tend to be more hypertensive and diabetics. Younger, non-diabetics and smokers tend to have single-vessel disease. Diabetics and older population were more likely to have diffuse disease (TVD).

The quality of sleep in coronary artery disease patients with and without anxiety and depressive symptoms.

Abstract: OBJECTIVE Although psychological problems, such as anxiety and depression, can affect the quality of sleep, there is scant research on the link between decreased sleep quality and mental health in coronary artery disease (CAD) patients. This study aimed to explore the quality of sleep in CAD patients with and without abnormal anxiety and depressive complaints. METHODS AND RESULTS In a cross-sectional setting, 163 CAD patients were consecutively selected. Using Hospital Anxiety Depression Scale (HADS), patients were divided into the following 4 groups: I(anx) (subjects with abnormal anxiety symptoms, n = 34), II(anx) (subjects without abnormal anxiety symptoms, n = 129), I(dep) (subjects with abnormal depressive symptoms, n = 34), and II(dep) (subjects without abnormal depressive symptoms, n = 129). Subsequently, sleep quality was compared between the study groups by means of Pittsburgh Sleep Quality Index were significantly (PSQI). Mean values of total PSQI score, subjective sleep quality, sleep latency and sleep disturbances in group I(anx) were significantly poorer than those in group II(anx). Also, mean values of total PSQI score and daytime dysfunction in group I(dep) were significantly poorer than those in group II(dep). CONCLUSIONS This study shows that there is a significant association between decreased quality of sleep and abnormal anxiety and depressive symptoms in CAD patients. Thus, we recommend that physicians check for the presence of the other related symptom when encountering patients with one of these complaints.

Use of slender catheters for transradial angiography and interventions.

Abstract: Currently the 0.014-inch guidewire is commonly used for coronary intervention and all devices are 0.014 inch-compatible. The size of common guiding catheters is 6-F or 7-F. However, PCI requires oral administration of antiplatelet agents, and punctured-site complications such as hemorrhage and hematoma occur more frequently with use of a 6-F or 7-F guiding catheter compared to a 5-F guiding catheter. Moreover, 6-F or larger guiding catheters may cause radial arterial occlusion, although the transradial approach causes less punctured-site complications compared to the transfemoral approach. Recently, 0.010-inch guidewires applicable for the Kissing Balloon Technique (KBT) using a 5-F guiding catheter and 0.010-inch guidewire-compatible balloons have been developed in Japan, and a 3-F angiography catheter has also been developed. We refer to these devices as the "Slender System", and we have used this system for active treatment of bifurcation lesions and chronic total occlusion (CTO). In this report, we describe angiography using a 3-F catheter, the KBT using a 5-F guiding catheter and 0.010-inch guidewires, and treatment of CTO using a 5-F catheter and 0.010-inch guidewires. For CTO treated using the Slender System at our facility, the transradial arterial approach was used in 96% of cases, treatment using the Slender System alone succeeded in 68%, and the overall success rate was 89%. Therefore, our results show that complex lesions may be treatable using the Slender System, and that not all complex lesions require a 6-F or larger guiding catheters, a femoral arterial approach, or bilateral guiding catheters.

Lack of association between Glu(298) asp polymorphism of endothelial nitric oxide synthase (eNOS) gene and coronary artery disease in Tamilian population.

Abstract: OBJECTIVE Glu298 Asp polymorphism of endothelial nitric oxide synthase (eNOS) gene has been recently implicated as a genetic marker for coronary artery disease (CAD) in some studies. There is no information on the prevalence of this polymorphism and its relationship with CAD in south Indian population. METHODS A case control study was performed for the determination of the influence of Glu298 Asp polymorphism of eNOS gene in Tamilian population of south India. The study subjects comprised of 100 angiographically proven CAD patients and 100 age- and sex-matched volunteers asymptomatic for CAD, with a low coronary risk score. Genotyping of the eNOS gene was done by the polymerase chain reaction-restriction fragment length polymorphism (PCR RFLP) method. RESULTS The genotype distribution was not significantly different between CAD (GG; 72, GT; 26, TT; 2) and control subjects (GG; 79, GT; 18, TT; 3). The corresponding allele frequencies were G 0.85, T 0.15 and G 0.88, T 0.12, respectively. The odds ratio for the association of CAD with the Asp variant failed to achieve statistical significance (OR = 0.66; 95% CI: 0.11-4.04, P = 1.0). CONCLUSION No significant association was observed between the Glu298 Asp polymorphism and CAD in this population group.

Prevalence, awareness, treatment and control of hypertension among the elderly in a resettlement colony of Delhi.

Abstract: BACKGROUND With the increase of the elderly population in India, chronic diseases like hypertension are becoming an important public health problem. Thus, the present study was carried out to assess prevalence, awareness, treatment, and control of hypertension among elderly in a resettlement colony of Delhi. METHODS A community-based cross-sectional survey was carried out, using systematic random sampling technique. A total of 294 (119 male and 175 female) subjects aged 60 years or more were studied. Of the total subjects, 210 (71%) were in 60-69 years, 57 (19.47%) were in 70-79 years, and 27 (9.2%) were more than 80 years of age. Blood pressure of each subject was measured on two visits, 1 week apart and was graded according to World Health Organization-International Society of Hypertension/VI Joint National Committee on Prevention, Detection, Evaluation, and Treatment of high blood pressure guidelines. Anthropometric variables and other associated risk factors were also studied. RESULTS Hypertension was present in 116 subjects (39.5%), it was more among males 49 (41%) as compared to females 67 (38%). Among the hypertensive subjects, 60 (51.7%) were aware of their condition, 45 (39%) were on treatment, and 17 (14.67%) were controlled on treatment. Level of awareness and treatment were significantly higher among the females. Body mass index of 25 or more and alcohol consumption were found to be significantly associated with risk of having high blood pressure. CONCLUSION Prevalence of hypertension in the present study was 39.5%, while level of awareness, treatment, and control were 50%, 39%, and 14.6%, respectively.

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

Abstract: 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 (ie, 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 (367 mg/dl vs 167 mg/dl: p < 001), while levels of NT-pro-BNP was higher in those patients who had any element of heart failure at presentation (261639 pg/ml vs 10683 pg/ml; p < 001) Troponin-T was highest in patients who had an element of both heart failure and angina at presentation (p < 001) 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 (340 mg/dl vs 138 mg/dl; p < 0001) and troponin-T (237 ng/ml vs 123 ng/ml; p < 0001) 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 (424776 pg/ml vs 121086 pg/ml; p < 001) 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

In vitro cardiogenesis can be initiated in human CD34+ cells.

Abstract: BACKGROUND: The extensive damage that occurs in the cardiac tissue after myocardial infarct is the major concern in post infarct management. It is very well known that adult stem cells mobilized by administration of G-CSF result in homing of stem cells into the damaged myocardium. This is because of the fact that stem cells have the ability to proliferate and capacity to generate into multiple cell lineages. METHOD: A healthy donor was selected as per the guidelines given by the institutional ethical committee and Helsinki declaration. The donor was given G-CSF 5 microg/kg/day and stem cells were harvested from the peripheral blood using Fresenius ASTec204 cell separator. The PBSC were then evaluated by immunohistochemical staining using anti-human CD34 monoclonal antibodies. The cells were then cultured in DMEM with 10% FCS for 17 weeks and in vitro cardiogenesis was initiated by adding 4 microM/l 5'Azacytidine. RESULTS: In vitro cardiogenesis was initiated in pure CD34+ cells with 5' Azacytidine. The cells showed spontaneous beating after 24 hours of treatment and after 5 weeks, the cells connected with the adjoining cells by a myotube. In these cells, expression of myosin light chain (MLC2v) gene and GATA-4 transcription factor validated the development of cardiomyocytes. CONCLUSION: It is observed that the transplantation of autologous stem cells/fetal cardiomyocytes in the heart scar tissue developed due to infarct, limited the scar expansion, and prevented post infarct heart failures. Homing process due to the transplantation of autologous stem cells is time consuming; therefore, transplantation of cardiomyocytes developed from autologous stem cells could be the future method of correcting the infracted myocardium.

MSCT angiography diagnosis of thrombosis in external jugular venous aneurysm: case report and review of literature.

Abstract: True venous aneurysms are rarely-observed causes of neck swelling reported in children. We describe a 59-year-old female with a history of left-sided neck swelling due to external jugular venous aneurysm diagnosed by MSCT angiography. Thrombosis in external jugular venous aneurysm as in this case is extremely rare. Incidental note was made of the coexistent right internal jugular phlebectasia. A brief review of literature of this entity has been discussed.

Angiographic follow-up of genous bioengineered stent in acute myocardial infarction (GENAMI)-a pilot study.

Abstract: OBJECTIVE GENAMI, an angiographic follow-up study was undertaken to evaluate the safety and efficacy of a new generation endothelial progenitor cell (EPC) capture stent, GENOUS during primary angioplasty for ST-elevation myocardial infarction (MI). METHODS Eleven consecutive patients with acute ST-elevation MI underwent primary percutaneous coronary intervention (PCI) using a bio-engineered GENOUS EPC stent. RESULTS Procedural success was 100%. Ten patients who survived underwent a follow-up angiography at 8 months. There was no instance of stent thrombosis during the follow-up period up to 12 months. The quantitative angiographic (quantitative coronary analysis [QCA]) follow-up data showed a late loss at 8 months of 0.97 +/- 0.94 mm and the late loss index was 44.35 +/- 40.47% with angiographic restenosis seen in 5 of 10 patients (50%). One of these patients with provocable ischemia underwent repeat PCI. CONCLUSIONS The QCA data of this study shows a high late loss with frequent angiographic restenosis during follow-up with this stent during primary PCI for acute STEMI. This observation, with important clinical implications, needs to be confirmed in larger studies.

Comparison between transcatheter closure and minimally invasive surgery for fossa ovalis atrial septal defect: a single institutional experience.

Abstract: Background Although, conventional surgical closure of atrial septal defect (ASD) provides excellent results with very low mortality and morbidity, it leaves the scar of incision and postoperative pain. Newer treatment modalities like minimal invasive surgery and percutaneous closure are being increasingly used nowadays where available. Aim To compare the patient population, success, safety, and efficacy of transcatheter closure of ASD (Group A) with that of minimally invasive surgery (Port Access) (Group B). Methods In this retrospective non-randomized study, a record of a total of 640 patients with diagnosis of ASD secundum between May 1997 and October 2006 were reviewed. A total of 470 out of 640 patients were selected for transcatheter closure (Group A) while 170 patients were taken for surgical closure by minimally invasive port access surgery (Group B). The safety and efficacy of two groups was evaluated on the basis of morbidity and mortality, duration of intensive care unit (ICU) stay, total duration of hospital stay, post-procedural complications, residual sequel at time of discharge, and residual flow across the ASD. Results Success rate in two groups was 97.1% and 99.4%, respectively and had no statistically significant difference. Similarly major complication rate also had no difference in statistical significance (1.8% and 2.9% for Group A and B, respectively). Group B patients had longer hospital stay. A small but significant number of patients were not found suitable for device closure. This number is likely to decrease as experience with technique increases. Port access surgery is currently not possible in small children (femoral artery diameter 35 mm) due to difficulty in cannulation. Conclusion Percutaneous device closure of ASD can be offered as a treatment option in suitable patients. Port access is minimally invasive and an equally safe and effective alternative choice in ASDs with deficient rim in patient with appropriate age and weight.

Aortic dissection: a rare presenting manifestation of Takayasu's aortitis.

Abstract: Aortic dissection is a rare manifestation of Takayasu's aortitis. We report a patient of Takayasu's aortitis who presented with severe intermittent claudication of the thigh and buttock region due to the dissection of abdominal aorta. Patient was managed by implantation of self expanding stents in the abdominal aorta. Patient continues to be asymptomatic on follow-up of eleven months.

Mitral leaflet separation index-a simple novel index to assess the severity of mitral stenosis.

Abstract: BACKGROUND Mitral leaflet separation (MLS) index is a recently recognized method to assess the severity of mitral stenosis. The aim of this study is to assess the severity of mitral stenosis (MS) using the MLS index. METHODS AND RESULTS One hundred and fifty consecutive patients with MS who underwent 2D echo were studied. In each patient the severity of MS was assessed using 2D mitral valve area, pressure half time and MLS index. The mitral leaflet separation was measured in diastole, as the maximal separation at the tips in long axis and apical 4 chamber views. There were 34 (22.7%) patients with mild MS, 52 (34.7%) patients with moderate MS and 64 (42.7%) patients with severe MS. One hundred and ten (73.3%) patients were in sinus rhythm and 40 (26.7%) patients were in atrial fibrillation. The MLS index correlated very well with MVA by planimetry (r = 0.87, P 1.11 cm identified mild MS with 97% sensitivity and 97% specificity. CONCLUSION The MLS index can be used as a screening method to semi quantify patients with mitral stenosis. This should be added into yet another method to assess the severity. This index will complement the other methods in our practice.

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

Abstract: 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 ( 3 mg/L) groups and in tertiles of 0-039 mg/L, 04-11 mg/L and >11 mg/L, respectively Classification of patient into upper (214%), middle (4537 percent) and lower (333%) 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 23 +/- 21 mg/L, 08 +/- 17 mg/L and 12 +/- 15 mg/L, respectively hs-CRP levels were significantly higher in low SES compared with both upper SES (p = 0033) and middle SES (p = 0001) Prevalence of more than one traditional CAD risk factors was seen in 135%, 375% and 6767 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 (5167 percent;) and upper (394%) SES We found that 623%, 208% and 265% 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

Double superior vena cava presenting with anomalous jugular and azygous venous systems.

Abstract: OBJECTIVE Examination of the heart revealed the presence of both the right and left superior vena cava. The right superior vena cava terminated into the right atrium and received the right root of the azygous vein, and the left superior vena cava received the left root of the azygous vein before entering the dilated coronary sinus. The azygous vein ascended in the right chest, and at the level of the third thoracic vertebra, it divided into the right and left roots, which joined the respective superior vena cava. Observation of the left lung revealed the presence of both the oblique and horizontal fissures that demarcated the upper, middle, and lower lobes. Dissection of the neck revealed abnormal connection of the superficial veins. The left external and anterior jugular veins opened at the confluence of veins that was drained by the venous arch that passed to the right side of the neck to open into the right external jugular vein.

Elastic properties of aorta are impaired in patients with slow coronary flow phenomenon.

Abstract: BACKGROUND Increased stiffening and decreased distensibility of the large arteries are associated with the presence of coronary artery disease and has been related to increased cardiovascular mortality in different populations. AIM Aim of this present study was to investigate the elastic properties of the aortic wall in patients with slow coronary flow phenomenon. MATERIAL AND METHOD We studied 20 patients with slow coronary flow phenomenon (age: 40+/-12 years)and 15 normal control subjects by echocardiography. Aortic strain (%) and distensibility (10(-3) mmHg(-1)) were calculated from the echocardiographically-derived thoracic Ao diameters (mm). The measurement of pulse pressure was obtained by cuff sphygmomanometry. RESULTS There was no difference in the left ventricular ejection fraction, left ventricular end-diastolic and end-systolic diameters, left atrial diameters, left ventricular mass index between patients with slow coronary flow phenomenon and control groups. Maximal aortic diastolic diameter was increased in patients with slow coronary flow phenomenon compared with control group (p<0.05). Ao distensibility and Ao strain were lower in the patients with slow coronary flow phenomenon compared with control group (p<0.05). CONCLUSION Reduced thoracic aortic elastic properties in patients with slow coronary flow phenomenon,assessed by echocardiography, apart from demonstrating subclinical atherosclerosis may also contribute to the etiopathogenesis of the slow coronary flow phenomenon necessitating more aggressive primary preventive measure.

Efficacy and safety of combination of extended release niacin and atorvastatin in patients with low levels of high density lipoprotein cholesterol.

Abstract: OBJECTIVE We investigated the safety and efficacy of combination therapy of extended release (ER) niacin and atorvastatin in patients with low HDL-C and compared the results with atorvastatin monotherapy. METHODS This open label study recruited consecutive men and women who had coronary artery disease with HDL-C levels <35 mg/dL. These patients were already on atorvastatin therapy targeted to lower low density lipoprotein cholesterol (LDL-C), for a minimum period of 6 months. Group 1, n = 104 (mean age 52.7 years) received ER niacin in addition to atorvastatin and group 2 (n = 106) continued on atorvastatin (mean age 52.3 years). ER niacin dose was built up to a maximum of 1.5 g and atorvastatin dose titrated according to LDL levels in both the groups. The lipoprotein levels at baseline were similar (p = NS). RESULTS At 9 +/- 1.8 months of follow-up, the mean dose of ER niacin was 1.3 g and atorvastatin 13.2 mg in group 1. In comparison, group 2 patients had mean atorvastatin dose of 15.9 mg. Patients in group 1 had significant elevation in HDL-C cholesterol (39.5 +/- 5.5 vs 35.7 +/- 4.5 mg/dL), reduction in total cholesterol (156.4 +/- 31 vs 164.5 +/- 39.3 mg/dL) and also LDL-C (88.9 +/- 28.3 vs 99.8 +/- 35.4 mg/dL) compared to group 2 (all p < 0.05). The magnitude of reduction in triglyceride levels was not significant between the groups (140.1 +/- 40.4 vs 145.2 +/- 46.5 mg/dL) (p = NS). No major adverse events or clinical myopathy occurred in either groups. Four patients (4%) discontinued ER niacin (2 due to gastro-intestinal symptoms and 2 due to worsening of diabetes). Flushing occurred in 3% patients, but none felt it to be troublesome. CONCLUSION Adding ER niacin to atorvastatin exhibited beneficial effects on lipid profile with significant elevation of HDL-C cholesterol and further lowering of LDL-C compared to monotherapy. This treatment offered better targeted therapy and was well tolerated with proper monitoring in Indian patients.

Myocardial Bridge in association with fixed atherosclerotic lesions treated with drug-eluting stents: a follow-up report with quantitative coronary analysis.

Abstract: Stenting of muscle bridge is still a controversial issue with concerns regarding high restenosis rates, plaque prolapse and stent fracture. We report a case with significant atherosclerotic disease of right coronary artery and left anterior descending artery associated with a muscle bridge, proximal to the diseased segment which became more prominent after stenting the fixed lesion. This was managed by implanting another drug eluting stent, covering the bridge. Angiographic follow-up at 9 months revealed no difference in quantitative coronary angiography parameters in the stented segment of the bridge, as compared to other stented segments.

A case-control study of risk factors for coronary heart disease in urban Indian middle-aged males.

Abstract: OBJECTIVE There are few case-control studies on native Indians to explore the reasons for the growing prevalence of coronary heart disease (CHD) in Indians. The present study was undertaken to identify the conventional coronary risk factors in angiographically proven CHD cases by comparing their prevalence in age-and gender-matched healthy controls. METHODOLOGY A hospital-based case-control study was performed on 197 middle-aged urban males (age 40-64 years) with angiographically proven CHD and 197 age (32 years) and gender-matched healthy controls in a tertiary cardiac care center of New Delhi. Prevalence of coronary risk factors with special emphasis on diet was determined by administration of a pre-tested questionnaire, physical examination, and biochemical estimation of blood lipids and glucose. Odds ratios (OR) and their 95% confidence intervals (CI) for the association of risk factors with CHD and their population attributable risks (PAR) were calculated. RESULTS Logistic regression analysis showed that history of diabetes mellitus (OR 4.934, 95% CI 2.320-10.494), low education (OR 2.410, 95% CI 1.261-4.608), full cream milk consumption (OR 2.113 95% CI 1.176-3.798), and family history of premature cardiovascular disease (CVD) (OR 1.810, 95% CI 1.064-3.079) were independent risk factors for CHD. High HDL-C (OR 1.055 95% CI 1.025-1.086) and fruit intake (OR 1.473, 95% CI 1.020-2.128) emerged as anti-risk factors. 44.1% of PAR was attributable to low HDL-C (.3%), low education status (6.6%), history of diabetes mellitus (6.0%), family history of premature CVD (4.4%), low fruit consumption (4.3%), tobacco abuse (4.2%), full cream milk consumption (3.6%) or milk intake (3.4%), high fasting blood glucose (2.3%), and history of hypertension (2.07 percent;). CONCLUSIONS Conventional risk factors are not enough to explain the high prevalence of CHD among native Indians. While efforts must go on to reduce the risk attributable to them, the role of emerging risk factors should be investigated.

Non-invasive evaluation of endothelial function, arterial mechanics and nitric oxide levels in children of hypertensive parents.

Abstract: OBJECTIVE To evaluate endothelial function, arterial mechanics and nitric oxide levels in apparently healthy children of hypertensive parents. DESIGN Analytical observational study. SETTING Tertiary Care hospital. MATERIAL The group comprised 40 non-obese normotensives (11-18 years). Out of these, 20 were children of parents (one or both) with hypertension (systolic >140 mm Hg, diastolic > 90 mm Hg) while the rest were children of normotensive parents (controls). High resolution ultrasonography was performed to measure flow mediated and glyceryltrinitrate induced dilatation in the brachial artery and arterial mechanics in the common carotid artery. Fasting blood was assayed for nitric oxide by the Griess method. RESULTS Flow mediated dilatation (FMD) was decreased in children of hypertensive parents as compared to controls (0.016 + 0.007 cm vs 0.075 vs 0.075 7plus; 0.130 cm, p < 0.05) the difference being statistically significant. But subsequently, the post glyceryl-trinitrate (GTN) dilation was comparable in both with no statistical significant difference being noted. Arterial mechanics (carotid intima-media thickness-C-IMT) were comparable in both the groups. Similarly nitric oxide levels estimated in platelet rich and platelet poor plasma were comparable in both the groups, with no statistical significance. CONCLUSIONS Flow mediated vasodilatation (FMD) in the brachial artery was decreased in children of hypertensive parents as compared to controls. Subsequent post GTN vasodilatation was comparable in both the groups because, GTN acts directly on vascular muscle and not on endothelium. Similarly, arterial mechanics (C-IMT) and nitric oxide estimation in platelet rich and platelet poor plasma were comparable in both the groups. It is, therefore, concluded that children of hypertensive parents have evidence of endothelial dysfunction, as shown by the decrease in flow mediated dilatation, which could be an early marker for the development of coronary artery disease.

Heart involvement in disseminated cysticercosis- a case report and review of literature.

Abstract: Heart involvement in cysticercosis is uncommon but is well described in literature. Most of the reports are in the form of autopsy studies. Here we describe a young female with asymptomatic involvement of the heart, diagnosed by echocardiography.