Ivabradine is a novel selective If current inhibitor with anti-ischemic and antianginal activity.
To assess the effect of the selective If current inhibitor ivabradine on heart rate, angina pectoris, and functional capacity in stable patients with chronic coronary artery disease on maximally tolerated medical therapy.
Materials and Methods:
Consecutive patients from the out-patient cardiology clinic with stable coronary artery disease documented by coronary angiography were included. Patients had to be on maximally tolerated medical therapy with β-blockers, angiotensin-converting enzyme inhibitors or receptor blockers (ACE-I or ARB), antiplatelets, statins, nitrates, and anti-metabolics with a baseline heart rate of at least 70 beats per minute. All patients underwent assessment of angina (Canadian Cardiovascular Society Angina Class: CCS I to IV) and functional capacity (using a validated self-administered questionnaire), at baseline and after 4 months of ivabradine therapy.
Twenty patients were enrolled (mean age 47 ± 7 years, all male, 60% with hypertension, 30% with diabetes mellitus). Patients were on optimal medical regimen of aspirin (100%), β-blocker (100%), statins (100%), clopidogrel (90%), nitrates (35%), anti-metabolics (90%), and ACE-I or ARB (95%). At baseline, the majority of patients (90%) were in CCS class II-IV. All patients were started on ivabradine 5 mg twice daily, and in 12 patients the dose was increased to 7.5 mg twice daily. After 4 months of treatment, the heart rate was significantly reduced from an average of 82 ± 8 to 68 ± 6 bpm (P < 0.001). The reduction in heart rate was accompanied by a significant improvement in functional capacity (score 3.5 ± 0.9 to 4.7 ± 0.7, P < 0.001) and angina classification; at baseline 10% of the patients were in CCS class I compared to 50% after 4 months of therapy (P = 0.01). No symptomatic bradycardia was reported with ivabradine.
The addition of ivabradine to optimal medical therapy in patients with stable coronary artery disease is associated with significant improvement in anginal symptoms and functional capacity.
Heart rate; ischemic heart disease; ivabradine
Percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) of the left anterior descending (LAD) specifically is associated with improved long-term 5 year survival as compared to PCI failure. The procedure is associated with usage of different types of dedicated guidewires by simple or complex techniques aiming to reopen the occluded artery.
To describe types and outcome of guidewires used in LAD-CTO utilizing a first intentional single wiring simple strategy.
A single center prospective registry for all consecutive patients with a PCI attempt to a native LAD CTO. The initial strategy for lesion crossing was Single wiring.
A total of 30 patients with LAD CTO lesions (100%), were recorded. Mean age was 71.6 + 15 years, 77% were Males, risk factors Hypertension in 63%, Diabetes 27%, Dyslipidemia 57%, smoking 40%, hereditary in 13% of patients. Isolated guidewire (GW) success rate was very high 93%. Single wiring was the prevailing technique used in 97% of successfull lesions (83% of total cases) while only 3% were by multiple wiring techniques. Successful single antegrade wiring represented 63% with a GW success rate of 92% of cases. Successful single retrograde wiring represented 13% with a GW success rate of 67%. Successful Crossing GW types in our patients were 44% Soft Tapered GWs; fielder XT (44%), 36% were Soft Non Tapered Pilot 50 (28%), whisper (8%), while 16% were Stiff Non tapered GWs; Miracle 12 (8%), Miracle 6 (4%), Miracle 3 (4%), and 4% were Stiff Tapered GWs; Progress 200 (4%).
Single wiring as an initial strategy in PCI for LAD-CTO lesions has a high success rate and is associated with a 44% majority of Soft Tapered GWs, 36% Soft Non Tapered, 16% Stiff Non tapered GWs, and 4% Stiff Tapered GWs.
Chronic total occlusion; first intention; guidewires; left anterior descending; single wiring
In patients with acute myocardial infarction or unstable angina undergoing coronary angioplasty, abciximab reduces major adverse cardiac events (MACE). Most clinical trials have studied mainly intravenous administration. Intracoronary (IC) bolus application of abciximab causes very high local drug concentrations and may be more effective in reducing acute and sub-acute stent thrombosis (ST). We studied whether IC bolus administration of abciximab is associated with a reduced ST and target vessels revascularization (TVR); therefore, less MACE rate compared with the standard intravenous IV bolus and infusion application.
Materials and Methods:
This was a single-center observational study conducted between June 2007 and 2009. We studied a total of 447 patients admitted with either acute coronary intervention (PCI) and stenting. Patients with bleeding disorder, recent major surgery and high blood pressure were excluded. Patients were divided into two groups: Group I (n = 199) patient received IC bolus of abciximab (reopro) 0.25 μg/kg during the PCI in cath lab. Group II (n = 248) received the standard dose of reopro-a bolus intravenous 0.25 μg/kg and maintenance dose of 0.125 μg/kg over 12 h.
There were no differences between the groups with regard to diabetes mellitus, group I (56%) vs. group II (58%), P = 0.613; ACS, group I (38%) vs. group II (44%), P = 0.175; Dietthylstilbestrol Drug eluted stent (DES) in group I (66.5%) vs. (57.6%) group II, P = 0.056; Bare Metal Stent (BMS) in group I (33%) vs. (40.7%) group II, P=0.093; target vessel revascularization (TRV) was seen in 9 patients (4%) in group I vs. 16 patients (6%) in group II. ST elevation was seen in 4 patients (2%) in group I vs. 7 patients (2.8%) in group II, all presented with STEMI.
In this study, there was a trend toward less ST and TVR in patients who received IC reopro vs. intravenous route both in ACS and stable CAD. The percentage of DM was high in both groups (56%), especially in Saudi patients. In-stent restenosis (ISR) was less in group I than in group II, this was mainly associated with BMS usage. The percentage of BMS was more than 30% in both groups, either due to STEMI cases or large vessel size. Randomized controlled trials are warranted to further assess IC application of abciximab in reducing ST.
Abciximab; acute coronary artery disease; intracoronary; intravenous; stent thrombosis; tirofiban
Right ventricle (RV) dysfunction may be secondary to left ventricle (LV) dysfunction in patients of isolated left ventricle anterior myocardial infarction as a consequence of “Ventricular Interdependence”. As RV dysfunction is associated with high in-hospital morbidity and mortality, early recognization of RV dysfunction is warranted; but until today it remains a challenging task because of complex structure and asymmetric shape of RV.
Aims and Objectives:
Our aim in the present study was to compare Simpson's right ventricle ejection fraction (RVEF) with right ventricle myocardial performance index (RV-MPI) to predict RV function in patients with isolated left ventricle anterior myocardial infarction (LV-AMI).
Materials and Methods:
We conducted the present study at the Department of Cardiology of Jawahar Lal Nehru Medical College and Associate Group of Hospitals, Ajmer. The control group comprised of twenty five. Age, sex, BMI, pulse and blood pressure matched healthy subjects without history of heart disease, systemic hypertension, diabetes, any other systemic illness and with normal findings in resting and exercise ECG, Echocardiography and Coronary Angiography. Sub-group-1 consisted of 25 patients with hemodynamically significant stenosis of proximal left anterior descending artery (LAD) with patent first septal perforator (S1). Sub-group-2 was composed of s5 patients with hemodynamically significant stenosis of both LAD and left circumflex artery (LCx.). Both subgroups had fully patent right coronary artery (RCA) from proximal to distal end.
RV-MPI value determined using pulsed doppler echocardiography was 0.40 ± 0.19 in healthy subjects. However RV-MPI was increased in both subgroups of LV-AMI with significant increase in subgroup-2 (P < 0.005) as compared to subgroup-1 patients (P < 0.01). Simpson's RVEF was not significantly different between the groups (P > 0.05).
The findings in this study demonstrate that RV-MPI is a more sensitive, non-geometric echocardiographic parameter than Simpson's RVEF in detecting early RV dysfunction. Early detection of RV dysfunction is important to reduce morbidity and mortality in these patients.
Isolated left ventricle anterior myocardial infarction; right ventricle myocardial performance index; Simpson's right ventricle ejection fraction
In spite of there being several case reports, coronary stent fracture is not a well-recognized entity and incidence rates are likely to be underestimated. In this article, we review different aspects of stent fracture, including incidence, classification, predictors, outcome, diagnosis, and management.
Complication of percutaneous coronary intervention (PCI); instent restenosis; stent fracture; stent thrombosis
Coronary-subclavian steal syndrome results from atherosclerotic disease of the proximal subclavian artery, causing reversal of flow in an internal mammary artery used as conduit for coronary artery bypass. In the present case, we discussed the diagnosis and the treatment of coronary steal syndrome in a patient hospitalized due to decompensated cardiac insufficiency.
Angina pectoris; carotico-subclavian bypass; coronary subclavian steal
A case of a 70-year-old female with a history of hypertension, atrial fibrillation, pacer implantation for symptomatic bradycardia, and a prior cerebrovascular accident, and had developed persistent methicillin-sensitive Staphylococcus aureus bacteremia is reported here. As part of her evaluation, a transesophageal echocardiogram was performed, and even though no vegetations were seen on either pacer wires or cardiac valves, a massive homogeneous thickening of the superior portion of the interatrial septum extending to the posterior and roof portions of the right atrial wall as well as to the superior vena cava causing proximal compression of this vessel was noted. Computed tomographic examination of the chest helped to determine that this mass density was not a tumor but in fact intrapericardial fat. Imaging findings and existing literature on this topic are reviewed.
Computed tomography; echocardiography; fossa ovalis; interatrial septum; lipomatous hypertrophy; right atria; superior vena cava
Interatrial septal aneurysm (IASA) consists of redundant atrial septal tissue, which bulges into either the left or the right atrium. The clinical implications of this entity are not entirely clear; however, if it is associated with other cardiac abnormalities such as patent foramen ovale and atrial septal defects. It may assume significance by increasing the risk of cardioembolic events such as stroke. We present a case of an individual with giant IASA detected by transesophageal echocardiography, which was mimicking a left atrial mass on transthoracic echocardiography. This case emphasizes the superiority of transesophageal imaging over transthoracic echocardiography for this clinical entity.
Atrial mass; interatrial septal aneurysm; transesophageal echocardiography
Background and Purpose:
Elderly Diabetics (DM) who present with Acute Coronary Syndrome (ACS) constitute a very high risk group. We present the pattern of management of elderly patients (>65 years) in the Kingdom of Saudi Arabia (KSA) in comparison to the international data extrapolated from a Multicenter International Diabetes-Acute Coronary Syndromes (MIDAS).
Materials and Methods:
DM patients presenting with unstable angina or non-ST-segment elevation myocardial infarction (MI) at the time of admission to the hospital were collectively enrolled into the MIDAS study. A total of 3624 patients were enrolled; 142 were from Saudi Arabia. Primary clinical outcome measure was in-hospital death or MI. We present the data of KSA based on the age of the patients in comparison to the international registry.
Baseline characteristics were typical for DM presenting with ACS, with mean age of 67 ± 15 years, males, constituted 36% of patients while 94% of patients were DM type 2. There was marked underutilization of glycoprotein IIb/IIIa inhibitors in those aged over 65 years with a decrease from 22.5 to 12.7 in KSA (Odds ratio 0.56) patients. The percentage of early coronary angiography approach in KSA was less than that of the international data with further reduction of the percentage in Saudi elderly population (from 49.3% to 25.5% with Odds ratio 0.52).
In elderly Saudi diabetic patients admitted with ACS, there is tendency for underutilization of GP IIb/IIIa, early coronary angiography, and revascularization that needs to be addressed.
Acute Coronary Syndrome; diabetics; elderly; GP IIb/IIIa; Multicenter International Diabetes-Acute Coronary Syndromes; NSTEMI; Saudi
Heart failure is an important cause of morbidity and mortality in developing nations like Nigeria. Sleep apnea and snoring has recently been recognized to be a cardiovascular risk factor. Sleep apnea is yet to be well studied among Africans with heart failure. We aimed to determine the prevalence of snoring and high risk for obstructive sleep apnea among Nigerians with stable heart failure.
Materials and Methods:
We studied 103 subjects that included 62 patients with heart failure and 41 control subjects. Demographic parameters and clinical examination were performed on the participants. The Berlin score and the Epworth Sleepiness Scale were administered for each participant. Echocardiography was done on all participants. Statistical analysis was done using Statistical Package for Social Sciences (SPSS) 17.0.
Snoring was reported in 48.4% of subjects with heart failure compared to 22.0% of control subjects ( P < 0.005). High risk for obstructive sleep apnea using the Berlin score was documented in 51.6% of heart failure subjects compared to 7.31% of controls. Excessive daytime somnolence occurred more in heart failure patients (51.6% vs. 9.8%, P < 0.05). Snorers tended to be older and were more likely to be obese than nonsnorers. Systolic blood pressure and fasting blood sugar were significantly higher among heart failure subjects with snoring than those without snoring (131.9 ± 19.2 vs. 119.2 ± 15.7 and 6.0 ± 0.8 vs. 5.4 ± 2.7, P < 0.005).
Heart failure seems to be associated with snoring and a high risk for obstructive sleep apnea among Africans with heart failure. Assessment for sleep disordered breathing should be incorporated into their routine clinical workup.
Clinical correlates; heart failure; Nigeria; prevalence; sleep apnea; snoring
Coronary artery anomalies are uncommon disorders. According to the literature, ≈1% of the general population is affected by a coronary artery abnormality. Coronary artery anomalies are often not associated with clinical signs, symptoms, or complications; nevertheless, they can be associated with congenital heart diseases and lead to sudden death. However, these anomalies are more often discovered as incidental findings at the time of coronary angiography or autopsy. The clinical relevance of coronary artery anomalies is closely related to the functional ability to provide adequate blood supply to the myocardial tissue. We describe a complex left coronary artery anomaly, not previously reported in medical literature, involving origin, course, and distribution of this vessel.
Coronary artery anatomy; coronary artery anomaly; dual LAD
To assess the periodontal status among the patients suffering from acute myocardial infarction (AMI) and to investigate whether periodontitis is a risk factor for AMI or not.
Materials and Methods:
A cross-sectional study of 60 subjects, 30 subjects in each AMI group and control group was conducted. Details of risk factors like age, sex, smoking, and alcohol consumption were obtained through a personal interview. Medical history was retrieved from the medical file. The oral hygiene status was assessed by using a simplified oral hygiene index (OHI-S) and the periodontal status was assessed by community periodontal index (CPI) and loss of attachment (LOA) as per World Health Organization (WHO) methodology 1997. Chi-square test was used to analyze qualitative data whereas t-test and one way analysis of variance (ANOVA) test was used for quantitative data. Multiple regression model was applied to check the risk factors for AMI.
The mean OHI-S score for case and control group was 3.98 ± 0.70 and 3.11 ± 0.68, respectively, which was statistically highly significant ( P < 0.001). There was high severity of periodontitis (for both in terms of CPI and LOA) in the case group as compared with control group, that was found to be statistically highly significant ( P < 0.001). There was a significant result for OHI-S and LOA score with odds ratio of 0.13 and 0.79, respectively, when the multiple logistic regression model was applied.
The results of the present study show evidence that those patients who have experienced myocardial infarction exhibit poor periodontal conditions in comparison to healthy subjects and suggest an association between chronic oral infections and myocardial infarction.
Acute myocardial infarction; oral hygiene; periodontal disease; risk factors
Lipoprotein (a) [Lp (a)] is an established risk marker of coronary artery disease which is independent from other risk factors.
The aim was to address the association between Lp (a) and CAD risk in North Indians. To evaluate whether high levels of lipoprotein (a) [Lp (a)] is a predictor of risk and is related to the severity of CAD.
Materials and Methods:
This was a cross-sectional study done on 360 patients presenting with chest pain. Coronary angiography revealed CAD in 270 patients and 90 patients without CAD. Lipoprotein (a) level, lipid profile, fasting blood glucose, anthropometric and clinical parameters were analyzed.
Lipoprotein (a) 21.0 mg/dL is associated with the presence of coronary lesions (P = 0.0001). A highly significant difference in Lp (a) levels was observed between normal coronaries vs. single-vessel disease, double-and triple-vessel disease ( P < 0.0001). Body mass index (BMI) was significantly raised in CAD group compared to normal coronary.
Multivariate analysis found that Lp (a) was considered an independent predictor for severity of CAD and Lp (a) levels 21.0 mg/dL are associated with severe patterns of coronary atherosclerosis.
Angiography; atherosclerosis; lipoprotein (a); triglyceride
Though many studies have been conducted on the effect of chronic smoking on pulmonary function test (PFT) and heart rate variability (HRV), no study has found a correlation between the pulmonary function test and heart rate variability parameters so far.
The aim was to study if there was a correlation, if any, between PFT and HRV.
Settings and Design:
Thirty male subjects who were chronic smokers of at least 10 pack years and another 30 nonsmoking healthy males were included in the study and were matched for age, height, weight, and body surface area.
Materials and Methods:
PFT and HRV were performed on these subjects and a correlation was statistically derived.
Statistical Analysis Used:
Spearman′s correlation coefficient was used for the analysis of HRV and PFT. Multiple stepwise regression analysis was used subsequently.
HF and LF showed correlation coefficients of 0.378 and-0.383 with forced expiratory volume in the first second (FEV
1) and peak expiratory flow rate (PEFR), respectively. It was found that only FEV
1/FVC was having a statistically significant regression coefficient with HF the R-value was found to be 0.425 while with other parameters, it was not significant.
We conclude that smoking affects all the parameters of PFT and HRV. Since there is a correlation between PFT parameters (PEFR and FEV1) and HRV parameter (LF and HF), this can help us in predicting cardiac morbidity in chronic smokers. So HRV should be included as a routine test along with PFT in chronic smokers for early diagnosis of cardiac involvement.
Heart rate variability; parasympathetic; pulmonary function test; smoking
Peripartum cardiomyopathy (PPCM) is a rare cause of pregnancy-related heart failure, which affects a woman during the last months of pregnancy or first months of parturition. Its etiopathogenesis is still unclear. Coexistence of PPCM with human immunodeficiency virus (HIV) has been scarcely analyzed. A low CD4 count is proposed to be one of the predictors of dilated cardiomyopathy in HIV. Here, a pregnant woman with HIV presented with signs of congestive heart failure for the first time during her last trimester. Echocardiography revealed a dilated cardiomyopathy with ejection fraction of 34% which proved the diagnosis of PPCM. She underwent cesarean section for impending previous scar rupture. Her status deteriorated subsequently in spite of all efforts and she succumbed due to ventricular tachycardia. This case necessitates an awareness regarding coexistence of HIV with PPCM and dreaded clinical sequences. Patients suffering from HIV should be treated well and their CD4 count should be improved before conception to avoid such complications in pregnancy.
CD4 count; human immunodeficiency virus; peripartum cardiomyopathy; pregnancy
Congenital absence of the pericardium is a rare cardiac condition, which can be either isolated or associated with other cardiac and extracardiac anomalies. There are six different types, depending on the severity of the involvement. Most of the patients with this defect are asymptomatic, especially the ones with complete absence of the pericardium. However, some patients are symptomatic, reporting symptoms that include chest pain, palpitations, dyspnea, and syncope. Diagnosis is established by the characteristic features on chest X-ray, echocardiogram, chest computed tomography (CT), and/or cardiac magnetic resonance imging (MRI). We present here a case of a 23 year-old-male, who presented to our hospital with complaints of pleuritic chest pain and exertional dyspnea, of a two-week duration. He was physically active and his past history was otherwise insignificant. His chest CT with contrast was interpreted as showing evidence of multiple emboli, predominantly in the left lung, and he was started on a heparin and warfarin therapy. A repeat chest CT with contrast three weeks later showed no significant change from the previous CT scan. Both scans showed that the heart was abnormally rotated to the left side of the chest. An echocardiogram raised the suspicion of congenital absence of the pericardium, with a posteriorly displaced heart. In retrospect, motion artifact on the left lung, attributed to cardiac pulsations and the lack of pericardium, resulted in a CT chest appearance, mimicking findings of pulmonary embolism. The misdiagnosis of pulmonary embolism was attributed to the artifact caused by excessive cardiac motion artifact on the chest CT scan. In non-gated CT angiograms, excessive motion causes an artifact that blurs the pulmonary vessels, reminiscent of a ′seagull′ or a ′boomerang′. Physicians need to be aware of this phenomenon, as well as the characteristic radiological features of this congenital anomaly, to enable them to make a correct diagnosis.
Cardiology; congenital anomaly; radiology
The aim of the present study was to compare the short-term and 6-month clinical outcome, and survival in patients older than 60 years with ST-elevation myocardial infarction randomized to either primary percutaneous coronary intervention (PPCI) or thrombolysis.
Materials and Methods:
82 patients with STEMI older than 60 years were randomized to either primary PCI or thrombolysis from September 2006 to August 2008. Angiograms were reviewed by two interventionalists not involved in the study. Patients randomized to primary PCI received Aspirin and 600 mg Clopidogrel. Heparin was administered in conjunction with PCI. Patients randomized to thrombolysis received Aspirin followed by streptokinase infusion for one hour. Rescue PCI was considered if there was ongoing pain and ST-segment resolution was <50% at 90 min. after initiation of thrombolysis or chest pain recurred with ST-segment elevation within 24 hours. All patients were followed up for 6 months. End points were reinfarction and cardiac death using competing-risks regression estimation.
The mean time from hospital admission to start of streptokinase infusion was 31 ± 15 min and door to balloon time was 70 ± 25 min. There was no significant difference between the groups in the number of deaths and reinfarctions at 6 months. As expected, the fibrinolysis group had a higher rate of revascularization and heart failure.
The higher rates of heart failure and need for revascularization in the fibrinolysis group reinforces benefits of PPCI in patients older than 60 years. PPCI in those who are 60 years and above with AMI is safe and cost effective.
Acute myocardial infarction; fibrinolysis; primary percutaneous coronary intervention