Research (Cardiology)

Original Articles

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Impact of Pentaglobin in severe COVID 19 pneumonia- A prospective study
Dinesh Joshi, Kamal Sharma, Senthilraj Thangasamic, Rahul Patel, Iva Patel,
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Background: The current COVID-19 pandemic has become a global public health crisis and presents a serious challenge in treatment of severe COVID pneumonia patients. With an imperative need for an effective treatment, we aimed to study the effectiveness of Pentaglobin, an intravenous immunoglobin in the treatment of severe Covid-19 pneumonia patients.

Methods: This is an open-label non-randomised controlled study. Patients in the study group (n = 17) received Pentaglobin in addition to standard therapy and the control group (n = 19) received only the standard of care treatment. Severity of illness were quantified by severity scores and inflammatory laboratory parameters were compared between the two groups.

Results: The average length of hospital stay in pentaglobin group were 12.35 ± 6.98 days compared to 10.94 ± 4.62 days in standard treatment group with mean difference of 1.4 days (p value = 0.4). Pentaglobin did not provide an added advantage in terms of reducing the duration of hospital stay. There was no significant difference between both the groups in terms of requirement of invasive ventilation (p = 0.56) and mortality (p = 0.86). CT Severity score (OR = 1.39 95% CI = 1.09-1.77, P = 0.01), APACHE II score (OR = 1.16 95% CI = 0.99-1.35, P = 0.05) and the SOFA score (OR = 2.11 95% CI = 1.13-3.93, P = 0.02) were independent predictors of mortality.

Conclusion: The administration of pentaglobin in COVID -19 patients has no significant effect in reducing the risk of mechanical ventilation or death, in disease worsening or in reduction of inflammation.

Keywords: COVID-19; Immunomodulation; Pentaglobin; SAR-COV-2.

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Association of Structure and Function of left Atrial appendage with Left atrial appendage Thrombus formation in patients with Rheumatic Heart Disease: ASFALT-RHD study
Dr.Karthik Natarajan, Dr. Zeeshan Mansuri, Dr. Dinesh Joshi, Dr. Anand Shukla , Dr. Vishal Sharma, Dr. Benny Jose Panakkal , Dr. Vimlesh Pandey, Dr. Sanjeev Bhatia , Ms. Krutika Patel
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Context: In patients with rheumatic heart disease (RHD), left atrial appendage (LAA) dilation and thrombus formation is widely known. LAA thrombus formation is a risk factor for stroke even in patients with sinus rhythm. The aim of this study was to determine an association between LAA structure and function with respect to thrombus formation and differences in LAA size and velocity between patients with sinus rhythm and those with atrial fibrillation (AF).


Materials and Methods: We prospectively studied LAA structure and function in 120 patients with RHD by transthoracic echocardiography and/or transesophageal echocardiography by measuring left atrial (LA) dimension, LA area, LAAmax/min, LAA ejection fraction (EF), and LAA emptying velocity.

Results: Four out of 48 patients with sinus rhythm had LAA thrombus. In 72 patients with AF, 32 had LAA thrombus. Patients with LAA thrombus had lower mean LAA EF and emptying velocity both variables P-value is same (P<0.0001 and P<0.0001) Patients with LAA thrombus had increased mean LAA max and LAA min as compared to LAA max and LAA min in patients without LAA thrombus (P 0.008 for mean LAA max and P<0.0001 for LAA min respectively). Patients with AF with LAA thrombus had greater LAAmax compared to that in patients with AF without LAA thrombus (P < 0.0001). Doppler demonstrated a recognizable sawtooth LAA outflow velocity pattern in 32 of 36 (88.9%) patients with LAA thrombus versus 32 of 84 (38.1%) patients without LAA thrombus.
Conclusions: We conclude that LAA contractility is reduced in RHD with LAA thrombus, and loss of both contractility and LAA dilation is associated with increased risk of thrombus formation and hence the risk of stroke.

Keywords: Atrial fibrillation, left atrial appendage, rheumatic heart disease

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Clinical profile, risk stratification of patients with acute pulmonary embolism
Dr.Keyur Patel, Dr. Sanjeev Bhatia, Dr. Jit Bhrahmbhatt, Dr. Vishal Sharma, Dr. Zeeshan Mansuri, Dr. Kamal Sharma; Dr. Sharad Jain, Ms. Krutika Patel, Dr. Dignesh Vasava , Dr. Pinkesh Parmar
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Context: To study the demographics and clinical profile of patients with acute pulmonary embolism (PE) and impact of management as per risk stratification on outcome of patients with acute PE.


Materials and Methods: Prospective observational study of demographics, clinical profile, risk stratification, management, and outcome of patients presenting with acute PE from August 2016 to July 2017.


Results: One hundred and fifty patients who were detected to have acute pulmonary thromboembolism with a mean age of 45.08 years, with 70% being males, were included in the study. There were 6 (4%) patients in high-risk group, 69 (46%) patients in intermediate-high subgroup, 39 (26%) patients in intermediate-low subgroup and 36 (24%) patients in low-risk group as per the ESC 2019 guidelines using sPESI score, shock/hypotension, right ventricle (RV) dysfunction and cardiac marker elevation. 72 patients (52%) had antecedent deep vein thrombosis (DVT) of which 60 patients has proximal, whereas 12 patients had distal DVT. One hundred and forty-seven patients (98%) had moderate-to-severe TR, 117 patients (78%) had evidence of right atrium/RV dysfunction and 27 patients (18%) had evidence of thrombus in the heart. Computed tomography pulmonary angiogram showed middle pulmonary artery thrombus/dilatation in 63 patients (42%), saddle thrombus in 18 patients (12%), partial thrombus in the left pulmonary artery (LPA) and right pulmonary artery (RPA) in 84 (56%) and 75 (50%) patients, respectively. Majority (86%) of patients with tenecteplase; 9 (10.3%) patients with streptokinase and 3 (3.4%) was thrmobolysed with alteplase.


Conclusion: PE can present with unexplained dyspnea and atypical chest pain, among other signs and symptoms. Early diagnosis, risk stratification, and guideline-directed prompt management can lead to favorable outcome.

Keywords: Pulmonary embolism, risk stratification, simplified PESI score

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Do extent of collaterals influence severity of the myocardial injury as assessed by elevation in biomarkers?’
Gajendra Dubey, Kamal Sharma, Iva Patel, Zeeshan Mansuri, Vishal Sharma
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Introduction: Quantitative analysis of cardiac biomarkers, troponin I and CPK-MB, estimates the extent of myocardial injury while extent of benefit from coronary collateral circulation (CCC) to protect myocardium during acute myocardial infarction (AMI) needs validation. We analysed if the extent of collaterals had impact on baseline biomarkers at the time of coronary angiogram.

Methods: We analysed 3616 consecutive patients who presented with AMI and underwent invasive coronary angiography (CAG) with intent to revascularisation with biomarkers assessment at the time of CAG. CCC to Infarct related artery (IRA) were graded as per Rentrop grading viz. poorly-developed CCC (Grade 0/1 as Group A) and well-developed CCC (Grade 2/3 as Group B).

Results: Both groups (A and B) were matched for demographics, traditional risk factors, SYNTAX 1 Score, time to CAG from onset of angina and eGFR. 36.59% of patients had Non-ST segment elevation myocardial infarction (NSTEMI) as compared to 63.41% ST -segment elevation infarction (STEMI). Overall Troponin I (P=0.01, P=0.01) and CPK MB (P=0.00, P=0.002) values were lower in group B in both NSTEMI and STEMI groups respectively. Troponin I and CPK-MB were significantly lower in group B [with NSTEMI for SVD (Single vessel disease) (P=0.05) and DVD (Double vessel disease) (P=0.04),but not for TVD (Triple vessel disease) and with STEMI in SVD (P=0.01), DVD (P=0.01) and TVD (P=0.001)].

Conclusion: Patients with well-developed coronary collaterals had a lower rise in biomarkers in AMI as compared to those with poor collaterals amongst both NSTEMI and STEMI groups

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Acute and short term outcomes of balloon aortic valvuloplasty in patients with significant aortic stenosis- A single center experience
Jayesh Prajapati, Parminder Singh, Pooja Vyas, Iva Patel
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Background: The optimal treatment for congenital aortic stenosis (AS) remains in debate over the past three decades of practice with both balloon aortic valvuloplasty (BAV) and surgical aortic valvotomy. BAV has been the palliative therapy with AS in most centers. The present study aimed to provide role and short-term outcomes of BAV in AS patients.


Methods: We enrolled 58 patients aged ≤20 years of AS from July 2017 to November 2019. All patients were evaluated by echocardiography at 1, 3, and 6 months.

Results: From the total of 58 patients, there were 38 male and 20 female patients. BAV could be successfully completed in 56 patients (96.5%). Pre-BAV mean left ventricle systolic pressure (LVSP) was 187.85 ± 53.75 mmHg and transaortic gradient (TAG) was 90.67 ± 42.77 mmHg. LVSP and TAG were reduced significantly (P = 0.0001) post procedure (133.85 ± 41.33 mmHg and 28.11 ± 23.22 mmHg, respectively). Echocardiographic parameters such as V max, aortic valve (AV) G max, and AV G mean were significantly decreased post procedure and AVA was increased significantly post procedure. Ten (17.86%) patients had developed significant (more than or equal to moderate) aortic regurgitation post procedure (17.24%). About 66% of our patients had no complication post procedure. At 1, 3, and 6-month follow–up, AV G max and G mean and V max increased but were not statistically significant.


Conclusion: BAV via transarterial route in pediatric population with significant AS is safe, effective palliation with good immediate and midterm follow-up results with minimum complications. We did not face any major complications except for development of variable degrees of aortic regurgitation and access site complications.

Keywords: Aortic stenosis, balloon aortic valvuloplasty, surgical aortic intervention

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A study of spectrum of Rheumatic Heart Disease in children in a tertiary care hospital in western India
Pooja Vyas, Hasit Joshi , Radhakisan Dake Iva Patel, Krutika Patel
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Context: Rheumatic heart disease (RHD) predominantly affects adults. However, in developing countries like India, it is the most common acquired heart disease in children. The prevalence of RHD also varies from the region to region in the same country due to the differences in educational, economic, and social status as well as health-care facilities of the region. 

Aim: The aim of the study is to establish and discuss the spectrum of RHD in children from Western India and to explore the relationship between severity of valvular lesion by the age and sex of the children with RHD. 

Methods: Echocardiographic findings of children (N = 820) ≤18 years with RHD seen at our institute from January 2018 to December 2018 were retrospectively analyzed. RHD was screened by echocardiography. All the echocardiogram were analyzed for the pattern and severity of various valve lesions and associated abnormalities.

Results: Eight hundred and twenty children had a diagnosis of RHD. Maximum patients [476 (57.1%)] were from the age group of 13–18 years without any gender difference (418 male and 402 female). Mitral regurgitation (MR) was the most common lesion found in 81.46% children. Aortic regurgitation (AR) was seen in 29.76%, mitral stenosis (MS) was found in 20.48%, tricuspid regurgitation was seen in 66.83%, and aortic stenosis (AS) was found in 0.73% children. AR was found more common in males as compared to females (P = 0.0004). Majority of patients (69.5%) had single mitral valve involvement. Four hundred and eight patients (49.8%) had severe MR, 122 patients (14.9%) had severe MS, 62 patients (7.6%) had severe aortic regurgitation, and 2 (0.2%) patients had severe AS at the time of first presentation. Pulmonary hypertension was found in 69% of children. Children with MS and AS were older than those without MS and AS (P = 0.0001). 

Conclusion: Majority of children had severe valvular lesion and pulmonary hypertension at the time of first presentation. RHD is the leading cause of heart failure in children with requirement of surgical/catheter intervention and long-term medical management.

Keywords: Echocardiography, pediatric cardiology, rheumatic heart disease

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Clinical and angiographic predictors of in hospital mortality in patients with ventricular tachycardia in ST-elevation myocardial infarction amongst Asian Indians: CLAIRVOYANCE STUDY
Dr.MandipTilara, Dr.Vishal Sharma ,Dr. Kamal Sharma ,Dr.Zeeshan Mansuri, Dr. Jit Brahmbhatt, Dr. Dinesh Joshi , Dr. Roopesh Singhal ;Dr. Sharad Jain , Ms. Krutika Patel
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Objective: The study aimed to evaluate clinical and angiographic profile of Asian Indians presenting withsustained ventricular tachycardia (VT) in STEMI to derive predictors of in hospital mortality and outcomes.

Methods: This was a prospective, open label, all comersstudy of 200 consecutive patients who presented with sustained VT in the setting of STEMI in a tertiary care center of western India from January 2016 to December 2018.Clinical and the angiographic profile of all patients were analyzed and correlated with outcomes especially with in hospital mortality.

Results: Of 200 patients, 156(78%) were male and 44(22%) were female. Mean age of patients was 55.63±11.68years.Among the traditional risk factors, smoking and hypertension (63% and 63.5%) was the most prevalent and had the highest odds ratio of 1.41(95% CI 0.61 to 3.26; P 0.42 and 2.67 (95% CI 1.04 to 6.87; P0.04) consecutively. 48.5% of the patients had LAD as culprit artery, 38.5% of the patients had RCA as culprit artery. Hence Non- LCX culprit vessel had an OR of 1.41(95% CI 0.40 to 5.02; P 0.6).79% patients were hemodynamically unstable1.51(95% CI 0.62 to 3.7; P 0.37)at the time of VT, 21% patients were hemodynamically stable. In hospital mortality was 15% (30/200) and all these patients hadhemodynamically unstable at VT (p value< 0.0001).Prolonged QTc interval was significantly (p value <0.001) higher in mortality patients (470.13±36.76 msec) ascompared to the discharged patients(444.53±18.58 msec) with OR of 2.16(95% CI 0.83 to 0.98; P <0.0001)

Conclusion: The predictors of in hospital mortality due to VT in STEMI amongst Asian Indians were smoking and hypertension with lowest OR 0.69 and 0.37.Hemodynamically unstable VT, non-LCX culprit vessel and prolonged QTc with highest OR 2.16 for prolonged QTc.

Key words: Mortality in Patients; Angiographic Predictors; St-Elevation Myocardial Infarction.

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Is 3-Dimensional Echocardiography superior to 2D echocardiography in assessment of mitral regurgitation and anatomic variables in patients undergoing percutaneous balloon mitral valvuloplasty?”
Dr.Sandarbh Patel ,Dr.Vishal Sharma, Dr.Zeeshan Mansuri, Dr. Roopesh Singhal ;Dr. Kamal Sharma , Dr. JitBrahmbhatt ,Dr. Dinesh Joshi , Dr. Sharad Jain, Ms.Krutika Patel , Dr. Hemal Thakkar, Dr. Amit Soni
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Context: Percutaneous balloon mitral valvuloplasty (PBMV) is often used to treat suitable Mitral stenosis (MS) of rheumatic etiology. This study evaluated the efficacy of measurement of mitral valve regurgitation by 2D echocardiography (2DE). The study also evaluated 3D echocardiography as compared to 2DE for assessment of Mitral valve anatomy and geometry both pre-PBMV and post-PBMV.

Materials and Methods: This was prospective, observational single Centre study in which 60 patients of severe mitral stenosis suitable for PBMV were enrolled. The data collection of each patient included demographics, pre-PTBMV and postPTBMV functional class, electrocardiogram (ECG), 2DE & RT3DE both pre and post-PTBMV with special focus on real time 2DE and 3DE assessment of MV anatomy and MV Regurgitation. Post-PBMV, MV Regurgitation and anatomy were assessed in catheterization laboratory using 2DE and RT3DE.

Results: There were 32 (53%) females and 28 (47%) males. The mean Pre-PBMV LA Area by 2D Echo (31.38±7.66) and 3D Echo (29.38±7.93) were concordant (p=0.16). Majority patients 24(40%) had mild mitral regurgitation (MR) and only 2(3.3%) had moderate MR before PTBMV. Values of mobility, calcification and subvalvular pathology detected by 2D and 3D Echocardiography showed statistically significant difference (P=0.04 and <0.0001). No significant difference was found in thickness of valve (P=0.29). Higher grades of MR were picked by RT3DE as compared to 2DE.

Conclusions: Transthoracic and transesophageal real-time 3D echocardiography (RT3DE) were better in assessing subvalvular pathology, mobility calcification of MV and post-PBMV MR. There was no difference between 2DE and RT3DE for assessment of MV thickness.

Key words: Real-time 3D Echocardiography; Rheumatic mitral valve stenosis; Balloon mitral valvuloplasty.

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Assessing the Hemodynamic impact of various inotropes combinations in patients with Cardiogenic shock with Non-ST elevation Myocardial Infarction –The ANAPHOR study
Kamal Sharma, Riyaz Charaniya, Bhavik Champaneri, Sanjeev Bhatia, Vishal Sharma, Zeeshan Mansuri, Benny Jose Panakkal, Hemal Thakkar, Krutika Patel
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Background

Various inotropic agents/vasopressors combinations are used in patients of cardiogenic shock. We performed this study to observe hemodynamic effects of various inotrope/vasopressor combinations in patients with NSTEMI cardiogenic shock (CS) at tertiary cardiac centre

Methods and materials

Of 3832 NSTEMI, we studied 59 consecutive such patients with CS who hadn't undergone revascularization in the first 24 h in a prospective, open label, observational study. Group 1 comprised of background Dopamine with Noradrenaline titration(N = 38), Group 2 had background Dobutamine and Noradrenaline titration(N = 15) and Group 3 comprised of triple combination of Dopamine, Noradrenaline & Adrenaline(N = 6).

Results

The mean change in hemodynamic parameters between these groups from baseline to 24 h showed no statistical difference. Cardiac output(CO), mean arterial pressure(MAP), central venous pressure(CVP) and cardiac power output(CPO) in group 2 were favorable at 6 and 24 h compared to baseline but mean change was insignificant as compared to others. In group 3, the increase in MAP was significant. IABP use did not change CO, CPO or SVR in any group except lower dosages of Dobutamine (49%) in IABP group. Lower in-hospital mortality in group 2 compared to others (P = 0.004) may be reflective of sicker patients in group 1 and 3.

Conclusion

The mean changes in hemodynamic parameters were not significant between all groups. All regimes of inotropes when selected as per clinical indication in CS with ACS resulted in similar hemodynamic effects. The mortality difference may not truly be reflective of regimes rather reflect sicker patients in the higher mortality group.

Keywords
NSTEMI Cardiogenic shock In-hospital mortality

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Urinary NGAL as early prediction marker for severe coronary artery disease in ST-elevation myocardial infarction
Pooja Vyas , Roopesh Singhal , Hasit Joshi, Amit Chaudhri, Krutika Patel, Sunil Bobade, Nikul Panchal
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Background: Neutrophil gelatinase associated lipocalin (NGAL), an acute phase protein expressed in endothelial cells and macrophages in atherosclerotic plaques, may be involved in development of atherosclerosis via endothelial dysfunction, inflammatory processes and matrix degradation leading to atherosclerotic plaque instability by modulating the activity of metalloproteinase 9. Our aim was to correlate urine NGAL with complexity and severity of angiographic lesions in patients of STEMI.

Methods and Materials: We prospectively included 50 STEMI patients who underwent primary angioplasty. Urine NGAL, other inflammatory markers and biochemical parameters were measured on admission. According to SYNTAX score the STEMI patients were divided into two groups: Low SYNTAX score (≤ 22), intermediate- high SYNTAX score (>22).

Results: In our study, majority of STEMI patients (76%) had lower NGAL level (<50 ng/ml). Urine NGAL level showed significant increased trend as duration of angina increases (p=0.011). NGAL was significantly reversely correlated with LVEF (p= 0.04). Patients with deranged renal function (creatinine ≥ 1.5 mg/dl) had significantly higher NGAL values (≥50 ng/ml p=0.011). Although in STEMI, NGAL was not significantly correlated with number of vessels involved, but patients with high SYNTAX score (>22) had significant higher NGAL values (≥50 ng/ml p=0.012).

Conclusion: NGAL is a novel biomarker which predicts severity and complexity of angiographic lesions in patients of STEMI.

Key words: Atherosclerosis; biomarker; coronary artery disease; Neutrophil gelatinase associated lipocalin.

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Coexistent coronary artery disease in Indian patients undergoing permanent pacemaker implantation (PPI) for symptomatic bradyarrhythmia
Vyas Pooja, Meghnathi Himanshu, Joshi Hasit, Brahmbhatt Jit, Dake Radhakishan, Satpute Arjun, Patel Krutika
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Background

The cause-effect of conduction disturbance in chronic lesion of coronary arteries is complicated. This study was designed to evaluate coexistent CAD in patients with symptomatic bradyarrhythmia to find common anatomic basis for conduction disturbances and its relationship to conventional coronary risk factors.

Methods

In this prospective observational study, 929 patients who admitted for symptomatic bradyarrhythmia requiring permanent pacemaker implantation were included. All included patients underwent coronary angiography and were divided into groups based on angiographic findings. Association between conduction disturbances and these groups were analyzed.

Results

A total of 929 patients with mean age of 63.1 years were included in our study. We found age ≥50 years, male sex, presence of diabetes and hypertension as statistically significant predictors of abnormal coronary angiography. Obstructive CAD (≥50% stenosis) was found in 34.4% patients. Prevalence of single vessel disease, double vessel disease and triple vessel disease was 15.3%, 10.2% and 8.9% respectively. Severe coronary obstruction (≥90% obstruction) was found in 16.25% patients. Revascularization was advised in three fourth of cases of obstructive CAD. Approximately two third of patients didn’t have significant obstruction in coronaries supplying the conduction system. Type 4 was the commonest anatomy in obstructive CAD. SA Nodal artery was found more diseased in patients of SSS with p value of 0.01.

Conclusion

Obstructive CAD was found in one third of patients undergoing PPI. Age ≥50 years, male sex, diabetes and hypertension were found significantly correlated with presence of CAD and may act as important markers for the judgment of further coronary evaluation.

Keywords
Atrioventricular block
Coronary artery disease
Sick sinus syndrome
Permanent pacemaker implantation

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Two-year safety and efficacy of Indigenous Abluminally Sirolimus eluting stent. Does it differ amongst Diabetics? – Data from en-ABL-eregistry"
Kamal Sharma, Sameer Dani, Devang Desai, Prathap Kumar, Nirav Bhalani, Apurva Vasavda, Rutvik Trivedi
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Introduction: To evaluate the efficacy/safety profile of the Abluminus DES+ over 2-years follow-up in the “real-world” scenario in diabetics as compared to non-diabetics.

Methods: In prospective, all-comers, open-label registry conducted at 31 sites, patients were analyzed for 1 & 2-year outcomes with the primary endpoint defined as 3P-MACE of CV death, target vesselrelated myocardial infarction (TV-MI), ischemia-driven target lesion revascularization (TLR)/target vessel revascularization (TVR) apart from Stent thrombosis (ST).

Results: Of 2500 patients of PCI with 3286 Abluminus-DES+, 1641 (65.64%) were non-diabetics while 859 (34.36%) were diabetics. The 3-P MACE for the cohort at 1 & 2 years were 2.9%, and 3.16%; TLR/ TVR - 1.4% at both the intervals for 2493 patients at 2 years. follow-up. TV-MI & ST were 0.36% and 0.56% at 1st and 2nd year respectively. The 3P-MACE was lower in non-diabetics at 1 & 2 years (2.3% vs 4.2%; 2.4% vs 4.7% respectively). For components of MACE, CV mortality (0.9 vs 1.9% at 1 yr ; 1.0 vs 2.1% at 2 years) was significant (P<0.05) while TLR (1.1 vs 1.9% at 1 yr. & 1.1 vs 2.1% at 2 yrs.) and TV-MI (0.9 vs 1.9% at 1 yr. & 1 vs 2.1% at 2 years) were similar for diabetics and non-diabetics so was ST (P>0.05).

Conclusion: Abluminus-DES+ showed excellent 2-year safety and efficacy with low 3-P MACE which was higher in diabetics driven by higher CV death but similar TLR, TV-MI and ST.

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How do patients with Chronic Kidney Disease undergoing percutaneous coronary intervention differ clinically according to the severity of CKD? – CHANNEL Study
Meniya Jayesh, Sharma Kamal, Charaniya Riyaz, Jhameria Jevin, Bhatia Sanjeev, Patel Krutika, Jain Sharad, Panwar Jasraj, Patel Iva
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Background

Chronic kidney disease (CKD) is an independent risk factor for the development of coronary artery disease. We evaluated outcomes amongst patients of CKD undergoing percutaneous coronary intervention (PCI) as assessed on severity of CKD based on estimated glomerular filtration rate (eGFR) at the time of PCI.

Method and materials

We analyzed 100 consecutive CKD patients who underwent PCI and were followed up for 1 year; an observational, prospective, open-label study. Multivariate and Receiver operator characteristics (ROC) analysis was used to determine the cut point ofeGFR for predicting 4-P major adverse cardiac events (MACE) outcomes defined as the composite of Cardiovascular (CV) mortality, heart failure hospitalization (HHF), repeat revascularization and non-fatal MI over 1 year follow up.

Results

According to eGFR cut-off value derived from ROC, patients were divided in to two groups based on eGFR cut-off of 36.25 mL/min/1.73 m2. Majority of patients (79%) were in Group 1 (eGFR >36.25 mL/min/1.73 m2). Group 2 had Lower HbA1C, hemoglobin and elevated level of urea as compared to group:1 (p=0.002,<0.0001 respectively). All-cause mortality had trend forbeing higher (6.3 vs. 19%) in group:2, but statistically non-significant (p = 0.17). Lower baseline LVEF (39 ± 10.08%) across the cohort was independent predictor of higher risk for HHF. eGFR <36.25 mL/mim/1.73 m2 was the most robust predictor of MACE, carrying a 3-fold increase in risk of 4-P MACE with significant association (0.69, CI 0.59 to 0.78, p = 0.0009).

Conclusions

Lower baseline eGFR was associated with higher incidence of 4 P MACE with best cut-off being eGFR <36.25 mL/min/1.73 m2. Lower Baseline LVEF was independent predictor from HHF across the cohort.

Keywords
ACS
Chronic kidney disease
MACE
Percutaneous coronary angioplasty

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Clinicobiochemical Parameters and Predictors of Liver Disease in Hospitalized Asian Indian Pregnant Women in a Tertiary Care Center in Northern India.
Bhandari, Vishal & Sharma, Kamal & Pannu, H & Chhina, Rajoo & Taneja, Ashima & Desai, Hardik & Patel, Neel & Patel, Khushboo & Bhalla, Sukriti & Patel, Hardik.
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Introduction During pregnancy, liver dysfunction is more frequent than expected and may require specialized care. For the early diagnosis, it is important to determine if changes in liver physiology may develop into liver disease. Liver disease during pregnancy may require intervention from a hepatologist for adequate monitoring of mother-fetus health outcomes. This study was aimed to evaluate the clinical profile and predictors of maternal mortality in patients with liver diseases among Asian-Indian-females.

Methods We conducted a prospective, open-label, consecutive all-comers study of 2,663 pregnant Asian Indian women admitted in the hospital, which included 92 with liver dysfunction. The medical aspects of the pregnancy were then followed prospectively with laboratory and clinical data during the hospital stay and analyzed. The current study was approved by the Institutional Ethical Committee.

Results We found that 92 out of 2,663 patients had liver dysfunction with a prevalence of 3.45%. Fifty-four (58.7%) patients had icterus followed by fever in 23 (25.0%), hypertension in 22 (23.9%), central nervous system manifestations in 21 (22.8%), abdominal pain in 19 (20.6%), vomiting in 19 (20.6%), and pruritus in six (6.5%). Predictors of maternal mortality were icterus (p = 0.04), hepatomegaly (p = 0.04), presenting serumbilirubin greater than 10 milligram% (mg%) (p = 0.008). The most common etiology was acute viral hepatitis (45.6%), followed by a hypertensive disorder of pregnancy (29.3%), acute fatty liver of pregnancy (1.1%), cholestatic jaundice (9.8%), hyperemesis gravidarum (2.2%), septicemic hepatitis (3.3%), dengue immunoglobulin M (IgM), and plasmodium vivax malaria antigen positive in (2.2%) each. Four patients (4.3%) were leptospira IgM reactive and had co-infection with hepatitis E virus. There was one patient (1.1%) with underlying chronic liver disease. Idiopathic liver disease was present in 5.4% of patients.

Conclusion Liver disease is relatively common in Indian pregnant women. It is associated with high maternal and perinatal mortality, even in a tertiary referral center. When managing pregnancy in a tertiary care center, for adequate follow-up of the disease and to prevent adverse consequences for mother and child, it is important to discard liver alterations early. For this purpose, liver disease during pregnancy needs early diagnosis for proper management. Furthermore, it is difficult to manage patients with preexisting liver disease, and it may require specialized intervention from a hepatologist and a gastroenterologist.

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Predictors of Mortality Amongst Tocilizumab Administered COVID-19 Asian Indians: A Predictive Study From a Tertiary Care Centre.
Hardik D. Desai, Kamal Sharma, Atul Parikh, Karan Patel, Jayesh Trivedi, Rupak Desai, Parth P. Patel, Zeel Patel, Smeet Patel, Saurav Kini
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Demographic and clinico-radiological profile on High-Resolution Computerized Tomography (HRCT) thorax in mild or asymptomatic clinically suspected COVID-19 patients in high-endemicity area of India—Can HRCT be the first screening tool?—The DECRYPTION study.
Sharma K, Gupta A, Vadgama K, Desai HD, Sharma N, Shah K, Jadeja DM. 
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Background: With COVID‑19 cases rising, despite CT chest being of value in diagnosis and prognostication in COVID‑19, its role in mild or asymptomatic suspected COVID‑19, before RT‑PCR test is lacking.

Method: This is a retrospective observational study involving asymptomatic or mildly symptomatic clinically suspected COVID‑19 infection in a high endemicity area. Of 2532 HRCT chest database, 376 eligible cases were analyzed for clinico‑radiological correlation for CT findings based CORADS and CT severity score between positive vs negative group.

Results: Of 376, 186 (48.46%) had COVID‑19 features on HRCT in mild and asymptomatic suspected patients. 98 (26.06%) had CO‑RARDS ‑ 5, 88 (23.40%) had CO‑RADS ‑ 4. 48 (12.76%), 128 (34.04%), 14 (3.72%) had CO‑RADS score of 3,2,1, respectively. Positive CT findings were more likely beyond 3 days of symptoms compared to those presenting earlier {days: (Mean) 4.2 vs 2.76} Positive CT was significantly associated with patients with anosmia and dyspnea. The common presenting symptoms were Fever 196 (52.12%) and followed by sore throat in 173 (46.01%). The common HRCT findings were Ground glass opacity (GGO) (74.60%), followed by Lymphadenopathy (LN) (27.92%). LN which was more prevalent in symptomatic patients {99/343 (28.86%) vs {6/33 (18.18%)} asymptomatics (P: 0.04)}. Consolidation was significantly more in asymptomatics with COPD (P: 0.004). 6 (3.22%) patients had CT score >17/25.

Conclusion: Chest HRCT picked 48.46% positive cases in mildly symptomatic and asymptomatic patients of which 3.22% had severe involvement (>17). Being a noninvasive, rapid, sensitive, low risk of cross infection with high reproducibility, chest CT is worth evaluating as screening modality even in asymptomatic and mildly symptomatic clinically suspected COVID‑19. Key words: COVID‑19; high resolution CT; sars‑cov‑2; screening

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Prevalence and cross states comparison of case fatality rate and recovery rate of COVID 19/SARS‑COV‑2 in India
Ansari AA, Desai HD, Sharma K, Jadeja DM, Patel R, Patel Y, Desai HM.
Full Text

Background and aim: CFR and RR are important indicator of disease pandemic. As of now no data is available about cross-states analysis of these. We aimed to evaluate CFR and RR of COVID-19 across majorly affected States in India. 

Method: We observed and compared data of confirmed COVID-19 cases, number of deaths, number of recovered/discharged cases and calculated CFR and RR across majorly affected States/UT in India from official database of Government of India, State Government official bulletin, accurate database worldometer. 

Results: The data showed that Gujarat, Madhya Pradesh, West Bengal reported highest CFR on 8th April, 22nd April, 6th May, 1st June 2020 (95% CI 4.91 – 6.99). Kerala showed encouraging recovery rates 24.32%, 70.31%, 93.24%, 45.81% on 8th and 22nd April, 6th May and 1st June 2020 respectively. India had an average estimated weekly Recovery rate of newly discharged/recovered cases was 32.68% from 19th March to 1st June 2020. (95% CI 20- 45.4%). (The Recovery rate across India was 80.83% as on 22nd September 2020.). 

Conclusion: The CFR of a disease varies greatly in different regions of the same Country and is influenced by numerous factors such as health control policies, medical standards, and detection efficiency and protocols apart from number of screening tests done. This comparison discusses need of evaluating policies with optimal reporting of medical history of affected persons when comparing COVID-19 case and fatality rates in different regions of the Country.

Keywords: Case fatality rate (CFR), COVID-19, India, recovery rate (RR), prevalence, SARS-COV-2

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Characteristics of ST-elevation myocardial infarction with failed thrombolysis
Ashish Mishra DM, Jayesh Prajapati DM, Gajendra Dubey DM, Iva Patel M.Sc, Mukesh Mahla MD, Suresh Bishnoi MD, Vimlesh Pandey MD
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Abstract

Background:

Fibrinolytic therapy is an important reperfusion strategy, especially when primary percutaneous coronary interventions cannot be offered to ST-elevation myocardial infarction patients. Given that failed reperfusion after fibrinolytic therapy is common, it is pragmatic that the predictors, outcomes, and angiographic profiles of patients with failed thrombolysis are carefully scrutinized.

Methods: We prospectively studied clinical variables and outcomes over 30 months in 243 ST-elevation myocardial infarction patients who received fibrinolytics as primary treatment. Logistic regression analysis was used to identify predictors of failed thrombolysis.

Results: Failed thrombolysis occurred in 38.68% of patients with a mean window period of 6.58  1.42 h, and 55.32% of patients with failed thrombolysis had Killip class >I on presentation. Risk factors such as diabetes mellitus (55.32%), dyslipidemia (60.64%) and obesity (77.66%) were frequently associated with failed thrombolysis; 73.40% of patients with failed thrombolysis had Thrombolysis in Myocardial Infarction flow grade 0/1 in the infarct-related artery, and 58.51% of such patients needed a rescue percutaneous coronary intervention. The mean Thrombolysis in Myocardial Infarction risk score was 5.46  2.77 in failed thrombolysis patients, with mortality of 4.25% at the 6-month follow-up.

Conclusion: Non-resolution of presenting symptoms and ST changes on electrocardiography at 90 min served as the earliest indicators of failed thrombolysis, with a significant angiographic correlation. Clinical variables such as delayed presentation (>6 h), dyspnea, Killip class >I, cardiogenic shock, Thrombolysis in Myocardial Infarction score, and conventional risk factors including diabetes mellitus, dyslipidemia, and obesity represented cluster of predictors of failed thrombolysis.

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Transcatheter Device Closure of Perimembranous Ventricular Septal Defect in Pediatric Patients: Long‑Term Outcomes
Jayal Hasmukhbhai Shah, Sanket Pravinchandra Saraiya, Tushar Sudhakarrao Nikam, Mukesh Jitendra Jha
Full Text

Aims: The aim of this study is to evaluate the safety and efficacy of transcatheter device closure of perimembranous ventricular septal defects in pediatric patients at long-term follow-up.


Materials and Methods: We prospectively studied 376 patients with perimembranous VSDs between September 2008 and December 2015 who underwent percutaneous closure at our center. Transthoracic echocardiography (TTE) and electrocardiogram were done before and after the procedure in all the patients. All patients were subjected to follow-up evaluation at 1, 3, 6, 12 months, and annually thereafter with TTE and electrocardiogram.


Results: A total of 376 patients (210 males and 166 females) underwent transcatheter closure of perimembranous VSD. Mean age of patients was 8.67 ± 3.02 (range 3–18 years) and mean weight was 21.15 ± 8.31 (range 8–65 kg). The procedure was carried out successfully in 98.93% of patients with no reported mortality. Rhythm disturbances occurred in 8.5% of patients after the procedure which included three cases of complete atrioventricular block.


Conclusion: This study shows that in experienced hands transcatheter closure of perimembrnous VSD is safe and effective at long-term follow-up. With minimal morbidity and no mortality, the transcatheter is an effective alternative to surgical closure in selected patients.

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Long-Term Results of Transcatheter Closure of Large Patent Ductus Arteriosus with Severe Pulmonary Arterial Hypertension in Pediatric Patients
Jayal Hasmukhbhai Shah, Dharmin Khimjibhai Bhalodiya, Abhishek Pravinchandra Rawal, and Tushar Sudhakarrao Nikam
Full Text

Aims: Patent ductus arteriosus (PDA) is one of the most commonly seen congenital heart diseases prevalent today. The aim of this study is to evaluate the safety and efficacy of transcatheter closure of hypertensive ductus at long-term follow-up. 

Materials and Methods: Transcatheter closure was attempted in 52 patients with hypertensive ductus arteriosus. A lateral or right anterior oblique view aortogram was done to locate and delineate PDA. All the patients underwent clinical examination, electrocardiography, chest X-rays, and echocardiography before discharge and at 1, 6, and 12 months after the procedure and yearly thereafter. 

Results: The mean age of patients at procedure was 7.98 ± 4.79 (11 months–17 years), and the mean weight was 17.72 ± 10.81 (4–47) kg. Transcatheter closure of hypertensive ductus was successful in 50 (96.15%) patients. The mean preprocedural pulmonary artery pressure was 81.38 ± 17.31 (range: 55–113) mmHg which decreased to 29.65±8.63 (19-38) mmHg at follow up. The most commonly used device was Amplatzer duct occluder in 63% of the patients followed by Amplatzer muscular ventricular septal defect occluder in 37% of the patients. There were two procedural failures, namely aortic obstruction and left pulmonary artery stenosis, which were managed uneventfully. There were no procedural deaths or device embolization. At median follow-up of 86 months, all the patients are well with no complications. 

Conclusion: The long-term results suggested that transcatheter closure of PDA with severe pulmonary hypertension in pediatric patients is safe and effective with minimal complications.

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Outcomes of Percutaneous Coronary Intervention in Patients with Crohn's Disease and Ulcerative Colitis (from a nationwide cohort)
Kobo O, Mohamed MO, Farmer AD, Alraies MC, Patel T, Sharma K, Nolan J, Bagur R, Roguin A, MamasMamas A.
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Patients with inflammatory bowel disease (IBD) are at an increased risk of ischemic heart disease. However, there is limited evidence on how their outcomes after percutaneous coronary intervention (PCI) compare with those without IBD. All PCI-related hospitalizations from the National Inpatient Sample from 2004 to 2015 were included, stratified into 3 groups: no-IBD, Crohn's disease (CD), and ulcerative colitis (UC). We assessed the association between IBD subtypes and in-hospital outcomes. A total of 6,689,292 PCI procedures were analyzed, of which 0.3% (n = 18,910) had an IBD diagnosis. The prevalence of IBD increased from 0.2% (2004) to 0.4% (2015). Patients with IBD were less likely to have conventional cardiovascular risk factors and more likely to undergo PCI for an acute indication, and to receive bare metal stents. In comparison to patients without IBD, those with IBD had reduced or similar adjusted odds ratios (OR) of major adverse cardiovascular and cerebrovascular events (CD OR 0.69, 95% confidence interval (CI) 0.62 to 0.78; UC OR 0.75, 95% CI 0.66 to 0.85), mortality (CD: OR 0.94, 95% CI 0.79 to 1.11; UC OR 0.35, 95% CI 0.27 to 0.45) or acute cerebrovascular accident (CD: OR 0.73, 95% CI 0.60 to 0.89; UC: OR 0.94, 95% CI 0.77 to 1.15). However, IBD patients had an increased odds for major bleeding (CD: OR 1.42 95% CI 1.23 to 1.63, and UC: OR 1.35 95% CI 1.16 to 1.58). In summary, IBD is associated with a decreased risk of in-hospital post-PCI complications other than major bleeding that was significantly higher in this group. Long term follow-up is required to evaluate the safety of PCI in IBD patients from both bleeding and ischemic perspectives.

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Comparison of morphologic profile of congenital heart defects associated with right isomerism and left isomerism in Western Indian population
Bhavik Champaneri, Prashant Agrawal, Mayank Jain, Tarun Parmar, Krutika Patel
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Context: Heterotaxy syndrome is a disorder that involves abnormal lateralization of the abdominal viscera, thoracic organs, and cardiac atria. The objective was to compare the frequency of morphologic profile of congenital heart defects associated with right isomerism and left isomerism in the Western Indian population.


Materials and Methods: This cross-sectional observational study was conducted by the Department of Pediatric Cardiology, U N Mehta Institute of Cardiology and Research Centre, Ahmedabad, Gujarat, India, from January 2016 to April 2018. All children presenting to the hospital with suspected congenital heart defect were included in the study. Echocardiography-based sequential segmental analysis was used; various cardiac defects were noted for patients with right isomerism (RAI) and left isomerism (LAI).


Results: Occurrence of heterotaxy in our screening population is 0.12%. A total of 93 children had atrial heterotaxy (M: F; 1.06:1), with 65 (69.89%) having RAI and 28 (30.11%) having LAI. Most common lesions associated with RAI included complete atrioventricular septal defect (n = 43, 66.2%), and pulmonary outflow tract obstruction (n = 35, 53.84%). LAI was associated with atrial septal defect (n = 24, 85.7%) ventricular septal defect (n = 23, 82.1%).


Conclusion: Heterotaxy encompasses a wide spectrum of congenital cardiac defects. The frequency of various defects associated with RAI and LAI in Western India is compared here to those as reported in the Western world.

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DoEs NTproBNP predict NO flow phenomenon IN patients undergoing Coronary Angioplasty in IHD amongst Asian Indians? (DENOMINATE Study)
Bhatia Sanjeev, Sharma Kamal, Narain V, Sethi Rishi, Jain Sharad, Meniya Jayesh , Jhameria Jevin, Panwar Jasraj, Patel Krutika
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Context: No-flow phenomenon during percutaneous coronary intervention (PCI) is a complex and multifactorial phenomenon with often devastating complications during PCI, especially in acute coronary syndrome (ACS) settings. There is paucity of data on serological predictors of the same.


Materials and Methods: This was an open-label, all-comers, observational, prospective study done on 175 patients covering the whole spectrum of coronary artery disease, undergoing PCI at the center. On admission detailed clinical history , general and systemic examination and laboratory investigations in form of hemoglobin, blood urea, serum creatinine, serum sodium, serum potassium, random blood sugar, electrocardiogram(ECG) and tropinin T were also done. Post procedure creatinine protein kinase MB (CPK MB) was done after 24 hrs, and thrombolysis in myocardial infarction (TIMI) flow was assessed during PCI in all patients by the operating interventional cardiologist.

Results: The mean value of NT-proBNP among patients with TIMI flow <3 was 3384.43 ± 1837.48 pg/ml, whereas among patients with TIMI flow 3, it was 894.64 ± 580.90 pg/ml. The difference between the two groups was statistically significant (P < 0.001), with TIMI flow 3 Group showing significantly lower mean NT-proBNP values as compared to the TIMI flow <3 category. There was no significant correlation between the mean NT-proBNP levels in various TIMI flow, that is, 0 and 2. In each quartile of NT-proBNP, there was a marked difference in the quartile value of the two TIMI <3 and TIMI 3 categories. Presence of angiographic thrombus was significantly associated with no-flow phenomenon.


Conclusion: Our study shows that higher NT-proBNP levels in patients with ACS who undergo PCI have higher likelihood of developing no-flow phenomenon during PCI.

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Multiple unplanned readmissions after discharge for an admission with percutaneous coronary intervention
Kwok, Chun Shing & Chatterjee, Saurav & Bagur, Rodrigo & Sharma, Kamal & Alraies, M Chadi & Fischman, David & Savage, Michael & Mohamed, Mohamed & Shoaib, Ahmad & Patel, Tejas & Mamas, Mamas.
Full Text

 

Abstract

Objective: This study aims to describe temporal trends, characteristics, and clinical outcomes of patients with more than one unplanned readmission within 30 and 180 days after admission with percutaneous coronary intervention (PCI). 

Background: There is limited understanding of multiple readmissions after PCI. 

Methods: Patients undergoing PCI between 2010 and 2014 in the U.S. Nationwide Readmission Database were evaluated for unplanned readmissions at 30 and 180 days after discharge. Trends in multiple readmissions, characteristics of patients, and causes of first readmissions are described. 

Results: A total of 2,324,194 patients were included in the analysis of 30-day unplanned readmissions and 1,327,799 patients in the analysis of 180-day unplanned readmission. The proportions of patients with a single readmission and multiple readmissions within 30 days were 8.5 and 1.0% and at 180 days were 15.4 and 9.1%, respectively. Common reasons for first readmission among patients with multiple readmissions were coronary artery disease, including angina, heart failure, and acute myocardial infarction. Factors associated with multiple readmissions were discharge against medical advice, discharge to care home, renal failure, and liver failure. The total cost of multiple readmissions is significant, with an increase from ~$20,000 for no readmission to over $60,000 at 30-day follow up and $86,000 at 180-day follow up. 

Conclusions: Multiple readmissions are rare within 30 days after PCI but increase to nearly 1 in 10 patients at 180 days, and 20–25% of patients who have multiple readmissions are readmitted for the same cause as for the first and second readmissions.

 

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Usefulness of ambulatory blood pressure measurement for hypertension management in India: the India ABPM study
Upendra Kaul, Priyadarshini Arambam, Srinivas Rao, Sunil Kapoor, J. P. S. Swahney, Kamal Sharma, Tiny Nair, Manoj Chopda, Jagdish Hiremath, C. K. Ponde, Abraham Oomman, B. C. Srinivas, Viraj Suvarna, Sanjiv Jasuja, Eric Borges & Willem J. Verberk
Full Text

Abstract The present paper reports differences between office blood pressure (BP) measurement (OBPM) and ambulatory blood pressure measurement (ABPM) in a large multi-centre Indian all comers’ population visiting primary care physicians. ABPM and OBPM data from 27,472 subjects (aged 51 ± 14 years, males 68.2%, treated 45.5%) were analysed and compared. Patients were classified based on the following hypertension thresholds: systolic BP (SBP) ≥ 140 and/or diastolic BP (DBP) ≥90 mmHg for OBPM, and SBP ≥ 130 and/or DBP ≥ 80 mmHg for 24-h ABPM, and SBP ≥ 120 and/or DBP ≥ 70 mmHg for night-time ABPM and SBP ≥ 135 and/or DBP ≥ 85 mmHg for daytime ABPM, all together. White coat hypertension (WCH) was seen in 12.0% (n = 3304), masked hypertension (MH) in 19.3% (n = 5293) and 55.5% (n = 15,246) had sustained hypertension. Isolated night-time hypertension (INH) was diagnosed in 11.9% (n = 3256). Untreated subjects had MH relatively more often than treated subjects (23.0% vs. 14.8%, p < 0.0001; respectively). Females had higher relative risk (RR) of having WCH than males (RR 1.16 [CI 95, 1.07–1.25], p < 0.0001). Whereas, males had higher RR of MH than females (RR 1.09 [CI 95, 1.02–1.17] p < 0.01). INH subjects had lower average systolic and diastolic dipping percentages (0.7 ± 6.6/ 2.2 ± 7.9 vs. 9.0 ± 7.3/11.9 ± 8.5, p < 0.001) than those without INH. In conclusion, for diagnosis of hypertension there was a contradiction between OBPM and ABPM in approximately one-third of all patients, and a substantial number of patients had INH. Using ABPM in routine hypertension management can lead to a reduction in burden and associated costs for Indian healthcare.

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One year clinical outcomes of drug-eluting stents versus bare-metal stents in large coronary arteries
Roopesh Singhal, Jayesh Prajapati, Iva Patel, Sibasis Sahoo, Chirag Patel
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Background: Drug-eluting stents (DESs) have been shown to reduce the risk of restenosis and other adverse cardiac events after percutaneous coronary intervention (PCI) as compared with bare-metal stents (BMSs). However, the superiority of DES over BMS has been questioned in large vessels. We evaluated the risks and benefits of the use of DES versus BMS in patients who undergo stenting of large coronary arteries (≥3.5 mm) up to 1-year follow-up. 

Materials and Methods: This was a prospective study carried out in all-comer patients enrolled between January 2015 and December 2015. The patients with the variable indication for PCI, multivessel involvement, prior revascularization, and adjuvant drugs such as GP IIb–IIIa inhibitors were included in the study. However, patients who did not provide written informed consent and received both DES and BMS were excluded from the study. The clinical outcomes were evaluated at 1 year. 

Results: A total of 266 lesions (240 patients) in the large coronary arteries were stented, of which 130 lesions were treated with BMS and 136 lesions were treated with DES. At 1-year follow-up, target lesion revascularization/target vessel revascularization (P = 0.6492) and all-cause death (P = 0.7098) did not differ significantly between the two groups. In addition, no significant difference was found in patients requiring medical management (P = 0.3937) as well as number of asymptomatic patients (P = 0.2027). 

Conclusions: At 1-year follow-up, BMSs and DESs showed similar clinical outcomes in large coronary arteries. Hence, the use of BMS in large coronary arteries (≥3.5 mm) should not be discouraged unless clinically indicated.

Keywords: Bare-metal stent, drug-eluting stent, large coronary artery, percutaneous coronary intervention

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Clinical profile of prosthetic heart valve thrombosis and outcome analysis of fibrinolytic therapy versus surgical management: A Single Centre Experience
Dr. Zeeshan Mansuri , Dr. Vishal Sharma, Dr. Sharad Jain, Dr. Jayesh Prajapati, Dr. Sanjeev Bhatia , Ms. Krutika Patel
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Context: The main aim of the study is to find out efficacy, outcomes, and complications of thrombolytic therapy and surgery for obstructive prosthetic heart valve thrombosis (PHVT).
Materials and Methods: This was a prospective, observational study done on 130 patients with PHVT, from January 2016 to December 2017. Baseline details, clinical investigations, echocardiography, and fluoroscopy were done. In fibrinolytic therapy, group agents used were streptokinase and urokinase. Out of 130, 115 patients were followed for up to 6 months after the discharge.

Results: Majority of the patients were females (66.9%). Sixty-five (50%) patients were in the New York Heart Association Class III, whereas 55 (42.3%) and 10 (7.7%) patients were in Class IV and II, respectively. Nearly 34.6% patients had AF, and remaining 63.1% had sinus rhythm. Out of 130 patients, 26 (20%) patients had single-leaflet valve and 103 (79.2%) patients had bileaflet valve, and only one patient had ball and cage type of the valve. Out of 130 patients, 81 (62.3%) patients received fibrinolytic therapy as the first-line therapy and 49 (37.7%) patients underwent surgery initially. In fibrinolytic therapy group, three patients underwent surgery due to failed fibrinolytic therapy. Fifty-three patients (65.5%) had complete hemodynamic and clinical success without any complications; 28 patients (34.5%) had failure. Of 130 patients, 49 patients underwent surgery as the initial treatment. In the surgical group, three patients died out of 52 patients; mortality rate was 5.80%.
Conclusion: Surgery should be offered to patients with contraindications for fibrinolytic therapy as in case of recurrent PHVT surgery offers better outcome with lesser recurrences when compared with fibrinolytic therapy.

Keywords: Prosthetic heart valve thrombosis, surgery, thrombolytic therapy, treatment

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Safety and efficacy of Transcatheter device closure of patent ductus arteriosus in pediatric patients: Long Term Outcomes
Jayal Hasmukhbhai Shah, Dharmin Khimjibhai Bhalodiya, Abhishek Pravinchandra Rawal, Sanket P. Saraiya
Full Text

Aims: Patent ductus arteriosus (PDA) is among the most prevalent congenital heart diseases in current times. The aim of this study is to evaluate contemporarily the safety and efficacy of transcatheter device closure of PDA at long-term follow-up.

Materials and Methods: Transcatheter closure of PDA was attempted in 205 children between 2008 and 2015 using the Amplatzer duct occlude (ADO). Ductal anatomy was accurately delineated on lateral and right anterior oblique view on aortic angiogram. All children underwent complete clinical evaluation, electrocardiography, chest X-rays, and echocardiography prior to discharge and at 1-month, 6-month, and annual follow-up thereafter.

Results: Of a total of 205 cases, 64% were females; the mean age was 7.92 ± 3.61 years (1–17 years), while the mean weight was 16.68 ± 10.82 (5–41 kg). ADOs-I were used in all the cases. The procedure was successful in 99.03% of patients with excellent results. Two patients required surgical closure due to device-induced aortic obstruction and left pulmonary stenosis. There were no cases of procedural deaths, device embolization, device infection, and infective endocarditis. All children fared well at a median follow-up of 94 months with no complications.


Conclusion: The long-term data showed that percutaneous transcatheter closure of PDA using ADO was safe and effective in pediatric population with minimal complications.

Keywords: Long-term follow-up, patent ductus arteriosus, pediatric patients, transcatheter device closure

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Does angiographic profile and outcome of diabetic patients amongst Asian Indians correlate with presenting HbA1c during acute ST-elevation myocardial infarction? -DECIPHER study
Sharma Vishal, Sharma Kamal , Mansuri Zeeshan, Jain Sharad , Bhatia Sanjeev , Patel Krutika
Full Text

Background: The risk of myocardial infarction (MI) is high in patients with diabetes mellitus. The study aimed to evaluate the risk factors focusing on presenting glycated hemoglobin (HBA1C) and the angiographic profile of diabetic patients with ST elevation myocardial infarction (STEMI) and in-hospital 3-point major adverse cardiac event (MACE). 

Materials and Methods: Two hundred consecutive diabetic patients presenting with STEMI were enrolled for prospective observational study. Each patient underwent investigations including HbA1C, electrocardiogram, echocardiography, and coronary angiography with SYNTAX 1 SCORE (SS1) with intent to early revascularization. Continuous variables were compared using the unpaired Student's t-test. A receiver operator characteristic analysis was performed to determine a cutoff point for HbA1c value for predicting disease severity and prognosticate in-hospital 3-point MACE using multivariate analysis after normalizing the confounders. 

Results: Of the total 200 patients, 70 (35%) had single-vessel disease, 58 (29%) had the double-vessel disease, while 72 (36%) had triple-vessel disease. Among these patients, left main coronary artery was involved in 22 (11%) of patients. Hypertension (73.8% vs. 60%), obesity (35.4% vs. 18.4%), and left ventricular (LV) dysfunction (13.7% vs. 2.9%) were risk factors associated with disease severity with an odds ratio of 1.88 (95% confidence interval [CI]: 1.01–3.49; P = 0.04), 2.4 (95% CI: 1.19–4.84; P = 0.01), and 5.46 (95% CI: 1.23–24.29; P = 0.03), respectively. Receiver operating characteristic analysis of HbA1c with respect to 3P-MACE of in-hospital death, recurrent MI, and CV stroke revealed HBA1C <8.9 g% as cutoff for lower MACE as compared to those with >8.9 g% (95% CI: 0.66–0.79; P = 0.0004) with 65% sensitivity and 76.7% specificity. HbA1c >7.9 g% were more likely to have multivessel disease and SS1 >33. Patients with surgical site infection >33 were more likely to be hypertensive and had severe LV dysfunction and higher 3P MACE. 

Conclusion: Diabetic Asian Indian patients with STEMI with HbA1c >7.9 g% were more likely to have a multivessel disease and SYNTAX 1 Score >33. There was a significant association between presenting HbA1c >7.9 g% and disease severity and higher 3-P MACE among presenting with HbA1c >8.9 g%.

Keywords: Glycated hemoglobin A, major adverse cardiac event, ST-elevation myocardial infarction, SYNTAX score

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Clinical profile of patients with prosthetic heart valve thrombosis undergoing fibrinolytic therapy and NYHA class as a predictor of outcome
Dr. Sanjeev Bhatia, Sharad Jain, Vishal Sharma, Zeeshan Mansuri, Krutika Patel, Pragya Jain, Mithilesh Kulkarni, Tanmay Agrawal, Kamal Sharma
Full Text

Background: Prosthetic heart valve thrombosis (PHVT) is a potentially fatal complication of heart valve replacement with mechanical prostheses mainly due to thrombosis.

Aim: The study aimed to evaluate the clinical profile of the patients presenting with PHVT undergoing fibrinolytic therapy and analyzing patients with respect to New York Heart Association (NYHA) functional class on presentation and its association with outcome of fibrinolytic therapy.

Settings & design: This was prospective, observational study conducted from June, 2016 to April, 2017. Total 133 patients with prosthetic heart valve thrombosis were included.

Materials and methods: Routine blood investigations included complete hemogram, liver and renal function tests. Prothrombin time with INR was done on admission. The diagnosis of PHVT was assessed by fluoroscopy and/or echocardiography (transthoracic/transesophageal). Follow-up at 6 months was scheduled for all patients.

Statistical analysis: Parametric values between two groups were performed using the independent sample t-test or chi-square test, as appropriate. Univariate and multivariate logistic regression was used to find out factors associated with outcome.

Results: All patients received fibrinolytic therapy in which 108 (81.2%) were treated with streptokinase and 25 (18.8%) were treated with urokinase. On presentation, 48.9% patients were in NYHA class III, 41.4% in NYHA class IV and 9.77% in NYHA class II. Fibrinolytic therapy was successful in 105 patients (78.9%) and it failed in 28 patients (21.1%). Mortality in NYHA class II was 0%, NYHA class III was 4.6% and in NYHA class IV was 23.6%. During 6 months follow up prosthetic heart valve thrombosis recurred in 12 (11.43%) patients.

Conclusion: From our single centre experience, fibrinolytic therapy is fairly effective first line therapy for prosthetic heart valve thrombosis and NYHA functional class on presentation can predict the outcome of fibrinolytic therapy.

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A study of narrow QRS tachycardia with emphasis on the clinical features, ECG, electrophysiology/radiofrequency ablation
Vishal Poptani , Ashwal Adamane Jayaram, Sharad Jain, Jyothi Samanth
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Aim: Atrioventricular nodal reentrant tachycardia (AVNRT) and atrioventricular reentrant tachycardia (AVRT) are the most common forms of paroxysmal regular supraventricular tachycardias. 

Materials & methods: The clinical, ECG and electrophysiological findings of 121 patients with narrow QRS tachycardia were evaluated prospectively. 

Results: A total of 75 (62%) of the patients had AVNRT while 46 (38%) had AVRT. Pounding sensation in the neck (40 vs 15.2%; p = 0.004), presynope (26.7 vs 56.5%; p = 0.001) identifiable P wave after QRS complex (25.3 vs 73.9%; p = 0.001), pseudo r′/s waves (45.3 vs 4.3%; p = 0.001), limb leads ST-T changes (34.7 vs 60.9%; p = 0.004) were the significant changes observed. A total of 94.7% of AVNRT and 87% of AVRT could be diagnosed correctly considering both clinical and ECG criteria. Conclusion: Pounding sensation in the neck and presyncope along with ECG features like identifiable P wave after QRS complex, pseudo r′/s waves and limb lead ST-T changes very accurately differentiate AVNRT and AVRT.

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Prevalence and Patterns of Obstructive Sleep Apnea in Asian Indians With Congestive Heart Failure
Sukriti Bhalla , Kamal Sharma , R D. Yadave , Hardik D. Desai , Tanisha Vora , Erum Khan , Purva Shah , Dhigishaba Jadeja , Vishal Bhandari
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Prevalence and predictors of coronary slow flow in patients with angina and normal epicardial coronaries on invasive angiography amongst Asian Indians – PAPYRUS STUDY ”
Abhimanyu Kothari , Kamal Sharma , Sharad Jain, Sanjeev Bhatia, Vishal Sharma, Benny Panakkal , Krutika Patel
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Abstract

Background: The Coronary Slow Flow Phenomenon (CSFP) is sometimes seen amongst patients presenting with ACS, in particular unstable angina and rarely with Normal Epicardial Coronaries (NECA). The study attempts to identify predictors of CSFP in patients with classical angina and normal epicardial coronaries in Asian Indians.

Materials and Methods: This was a prospective, open label, observational study of 3000 consecutive patients undergoing invasive coronary angiography that was carried out a tertiary level cardiac care center between August 2016 to December 2018. After identifying the prevalence of CSFP using the corrected TFC method in allcomers, equal numbers of controls were analyzed for detailed evaluation for traditional risk factors, history, clinical examination, and laboratory investigation.

Results: CSFP was more prevalent in men than in women (P=0.007). Histories of smoking and hypertension were more prevalent in CSFP patients than in NECA patients statistically significant (50% vs 20%; p 0.02) and (66.7% vs 33.3%, P 0.009) with Odds Ratio (OR) of 4(95% CI 1.27 to 12.58; P 0.02) for smoking and 4(95% CI 1.37 to 11.7; P0.01) for hypertension. Presence of LV dysfunction (16.7% versus 10%, P 0.45) with OR 0.56(95% CI 0.12 to 2.57; P 0.45), high level of hemoglobin in CSFP group (14.17±1.45 vs 11.95±1.38 mg/dl; p <0.0001), high level of LDL-c (153.77±13.02 vs 92.37±11.45 mg/dl; p <0.0001) and low HDL-C (33.93±6.71 vs 55.60±5.78mg/dl; p <0.0001) were also independent predictors of CSFP. Amongst single vessel CSFP, LAD was most common vessel (40.4%). Conclusion: Prevalence of CSFP amongst Asian Indians is 1%. High LDL-c, Low HDL-c level, Smoking, elevated hemoglobin and Hypertension are independent predictors of CSFP.

Keywords: Coronary Artery Disease; Coronary Slow Flow Phenomenon; Risk factors.

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Predictors of Arterial Stiffness Amongst the 24-Hour Ambulatory Blood Pressure Variables in Hypertensive Patients
Vishal Bhandari, Kamal Sharma, Purva Shah, Erum Khan, Hardik D. Desai, Tanisha Vora, Sukriti Bhalla, Dhruvkumar Gadhiya, Manish Bansal, Ravi R. Kasliwal
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Trends of repeat revascularization choice in patients with prior coronary artery bypass surgery
Mohamed O Mohamed , Ahmad Shoaib , Bill Gogas , Tejas Patel , M Chadi Alraies , Poonam Velagapudi , Sanjay Chugh , Kamal Sharma , Walid Mohamed , Gavin J Murphy , Chun Shing Kwok , Muhammad Rashid , Rodrigo Bagur , Mamas A Mamas
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Objective

To examine rates and predictors repeat revascularization strategies (percutaneous coronary intervention [PCI] and coronary artery bypass grafting [CABG]) in patients with prior CABG.

Methods

Using the National Inpatient Sample, patients with a history of CABG hospitalized for revascularization by PCI or CABG from January 2004 to September 2015 were included. Regression analyses were performed to examine predictors of receipt of either revascularization strategy as well as in-hospital outcomes.

Results

The rate of redo CABG doubled between 2004 (5.3%) and 2015 (10.3%). Patients who underwent redo CABG were more comorbid and experienced significantly worse major adverse cardiovascular and cerebrovascular events (odds ratio [OR]: 5.36 95% CI 5.11–5.61), mortality (OR 2.84 95% CI 2.60,−3.11), bleeding (OR 5.97 95% CI 5.44–6.55) and stroke (OR 2.15 95% CI 1.92–2.41), but there was no difference in cardiac complications between groups. Thoracic complications were high in patients undergoing redo CABG (8%), especially in females. Factors favoring receipt of redo CABG compared to PCI included male sex, age < 80 years, and absence of diabetes and renal failure.

Conclusion

Reoperation in patients with prior CABG has doubled in the United States over a 12-year period. Patients undergoing redo CABG are more complex and associated with worse clinical outcomes than those receiving PCI.

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Baseline NT-proBNP and responsiveness to autonomic regulation therapy in patients with heart failure and reduced ejection fraction
Inder Anand , Jeffrey L. Ardell, Doug Gregory, Imad Libbus, Lorenzo DiCarlo, Rajendra K. Premchand, Kamal Sharma, Sanjay Mittal, Rufino Monteiro
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Background

Recent heart failure studies have associated lower baseline natriuretic peptide levels with improved morbidity/mortality outcomes during pharmaceutical treatment, and better clinical outcomes during neuromodulation (NM) with carotid nerve plexus stimulation for HFrEF when NT-proBNP < 1600 pg/ml. Whether baseline NT-proBNP is associated with HFrEF responsiveness to NM using vagus nerve stimulation (VNS) has not been examined. Hence, we evaluated the interaction of baseline NT-proBNP with changes in symptoms and function that occurred during chronic VNS in the ANTHEM-HF study.

Methods

A repeated measures, generalized-estimating, equations model evaluated the relationship of baseline NT-proBNP values above and below 1600 pg/ml to symptomatic and functional responses in ANTHEM-HF.

Results

Median (interquartile range; maximum) NT-proBNP was 868 (322, 1875; 14,656) pg/ml (N = 58). Heart rate (HR), HR variability (SDNN), 6-minute walk distance, MLWHF mean score, and NYHA improved significantly, independent of baseline NT-proBNP. While there was a statistical interaction between baseline NT-proBNP and better LVEF improvement during VNS, LVEF improved overall in the study cohort (N = 60; 32 ± 7 to 37 ± 10%; p = 0.0042), and in those patients whose baseline NT-proBNP was below the median baseline NT-proBNP value (n = 29; 36 ± 6 to 42 ± 10%; p < 0.0025)] or above this value (n = 29; 29 ± 7 to 32 ± 9%; p < 0.05).

Conclusions

In ANTHEM-HF, overall symptomatic and functional improvement during chronic VNS was independent of baseline NTproBNP. These are preliminary and hypothesis-generating findings, and the reason for a differing interaction between baseline NT-proBNP and response to CNPS and VNS remains unclear. It is anticipated that the ongoing ANTHEM-HFrEF Pivotal Study of VNS will provide additional insight.

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Comparative evaluation of safety and efficacy of radial arterial cannulation using conventional blind palpation technique with ultrasound guided Technique perioperatively - Raccuet study.
Sharma A, Pawar D, Modi M, Sonavane H, Sharma K.J Clin Anaesth 2019;6(3):382-5.
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Abstract
Introduction: Radial cannulation is needed in perioperative management of many patients requiring invasive hemodynamic monitoring during surgery and may be not only time consuming and at times difficult to attain in untrained centers.

Objectives: Comparative evaluation of safety and efficacy of Radial Arterial Cannulation using Conventional blind palpation technique with Ultrasound guided Technique perioperatively –Raccuet Study.


Materials and Methods: This randomized controlled, prospective, single blind comparative study was conducted on 142 adult ASA I to IV patients of either sex, scheduled for elective major surgery requiring general anesthesia of which 71 patients underwent radial cannulation by classical palpatory method (group P) and the other 71 underwent radial cannulation under ultrasound guidance (Group U). All procedures were evaluated using Siemens Acuson X500 ultrasound machine with 5-13Hz linear array transducer. All patients were evaluated for efficacy
by measuring time to cannulation (TTC), mean time to first attempt cannulation (mTFA), and number of attempts for cannulation (NA). Safety was assessed by evaluating incidence of hematoma and spasm in both the groups. Statistical analysis was done using (SPSS) Version 22.0. Independent t test and Mann Whitney test have been used for carrying out significant P value.


Results: Patients were demographically similar in both the groups. TTC in group U (37.97±18.14sec) was significantly less than that in Group P (58.38±21.45sec) (P =0.007).mTFA was 34.81±15.77 seconds in group U compared with 55.58±19.29 seconds with group P (P=0.01). There was trend towards lower NA in group U as compared to group P (P=0.06).Incidence of hematoma formation and vasospasm were similar amongst both groups but study was underpowered to evaluate the same. 

Conclusion: Ultrasound guided radial artery cannulation improves the success rate of cannulation in lesser time with similar complication rates as compared to classical palpatory method of cannulation.

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Blood Pressure Related to Age: The India ABPM Study
Upendra Kaul, Stefano Omboni Priyadarshini Arambam, Srinivas Rao, Sunil Kapoor, Jitendra P S Swahney, Kamal Sharma, Tiny Nair, Manoj Chopda, Jagdish Hiremath, Chandrashekhar K Ponde, Abraham Oomman, Budanur C Srinivas, Viraj Suvarna, Sanjiv Jasuja, Eric
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Abstract

The present paper reports trends in office blood pressure (BP) measurement (OBPM) and ambulatory blood pressure measurement (ABPM) with age in a large multi-center Indian all comers’ population visiting primary care physicians. ABPM and OBPM data from 27 472 subjects (aged 51 ± 14 years, males 68.2%, treated 45.5%) were analyzed and compared. Individual differences between OBPM and ABPM patterns were compared for patients according to 10-year age categories. Results showed that systolic (S) BP values started to increase with age from the age of 40, BP variability (SD) increased from the age of 30 years. Diastolic (D) BP values started to decrease from the age of 50 years. Mean OBPM values were higher than daytime ABPM values (all P < .001) in all age-groups. The prevalence of white coat hypertension (WCH) and masked hypertension (MH) was based on OBPM and daytime, 24-hour, and night time average BPs together. WCH decreased with age from 15.1% and 12.4% in treated and untreated subjects at the youngest age to 7.2% and 6.9% in the oldest age, respectively. MH prevalence was higher for untreated than for treated subjects but remained similar for all age-groups (range of 18.6%-21.3%). The prevalence of reverse dippers increased with age from the youngest to oldest group with 7.3%-34.2% (P < .001 for trend). Dippers prevalence decreased from 42.5% to 17.9% from the youngest to oldest age-groups, respectively (P < .001 for trend). These findings confirm that BP patterns show clear differences in trends with age, particularly regarding night time BP.

 

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Can decreased heart rate variability be a marker of autonomic dysfunction, metabolic syndrome and diabetes?
Gunjan Y Trivedi, Banshi Saboo, Ram B Singh, Anuj Maheshwari, Kamal Sharma, Narsingh Verma
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National Heart Failure Registry, India: Design and methods
Harikrishnan S, Bahl A, Roy A, Mishra A, Prajapati J, Nanjappa MC, Sethi R, Guha S, Satheesh S, Chacko M, Ganapathi S.
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Abstract

Objective

Heart failure (HF) has emerged as a global public health problem that affects both low and high-income countries. The high HF burden and the need for resource-intensive treatments often lead to health system crisis in resource-poor settings. Data on prevailing practice patterns and long-term clinical outcomes of HF are scarce from the low and middle-income countries. Nationally representative HF data from India are not available.

Methods

The National Heart Failure Registry (NHFR) is a multicentric, hospital-based registry of HF patients from 53 centers across India. Consecutive patients admitted with the diagnosis of acute decompensated HF satisfying the European Society of Cardiology (ESC) 2016 criteria will be enrolled into the registry from January 2019 to December 2019. Each participating center is expected to contribute 200 patients into the registry (i.e., more than 10,000 HF patients from India). We are collecting demographics, clinical, laboratory, imaging, and other diagnostic data at baseline from all registered patients in the registry by using a structured document. Additionally, we are collecting the details of treatment practices and the usage of guideline-directed therapy from all participants. We intend to obtain the in-hospital, 3-months, 6-months and one-year outcome data on mortality, cause of death, and repeated hospitalization events.

Conclusions

In summary, NFHR will be the first nationally representative HF registry aimed at providing crucial information on prevailing etiology, distribution and current practices in the management of HF.

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Is There an Association of Intracardiac Mass with High Urate Level? AIM-HUL Study
"Kamal Sharma, Dhammdeep Humane1, Jevin Jhamaria, Sharad Jain, Krutika Patel, Sachin Patil, Sanjeev Bhatia, Jasraj Panwar, J Pract Cardiovasc Sci 2019; 5:26-9. DOI:10.4103/jpcs.jpcs_3_19"
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The Young Myocardial Infarction Study of the Western Indians
Anand N. Shukla, Ashwal A. Jayaramy , Dhaval Doshi, Priyanka Patel , Komal Shahz , Alok Shinde, Harsh Ghoniya, Karthik Natarajan, Tarun Bansal Global Heart, Vol. 14, No. 1, 2019 27 March 2019: 27-33
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Abstract

Background

Myocardial infarction is among the leading causes of morbidity and mortality in young adults around the world.

Objectives

In the YOUTH (Young Myocardial Infarction Study of the Western Indians) registry, we aimed to evaluate risk factor profile and angiographic outcomes of reperfusion therapies of infarct-related artery in young western Indians (≤40 years) having ST-segment elevation myocardial infarction.

Methods

A total of 1,179 consecutive patients aged ≤40 years who presented with ischemic heart disease from June 2012 to December 2014 were enrolled in the YOUTH registry. A total of 787 patients with ST-segment elevation myocardial infarction were further evaluated. Categorical data was assessed using chi-square test, whereas continuous data was assessed using Student's t test. Regression analysis was performed to investigate the strength of association.

Results

In the YOUTH registry, the study population was predominantly male (93%) with tobacco consumption as major prevalent risk factor (49.7%). Of 787 patients, 451 (57.31%) were thrombolyzed, 326 (41.42%) did not receive any reperfusion therapy, and 10 patients (1.27%) underwent primary angioplasty. Younger age, window period <6 h, and lower lipoprotein (a) level were observed in patients with a recanalized infarct-related artery. Regression analysis showed window period of thrombolysis as strongest predictor (odds ratio: 1.790, 95% confidence interval: 1.144–2.802; p < 0.011) of successful reperfusion. Patients (n = 235) being thrombolyzed in a window period of <6 h, had higher rate of infarct-related artery recanalization (77%) as compared to those with ≥6 h window period (23%). In-hospital mortality was 0.38% (n = 3), whereas bleeding complication was noted only in 1 patient.

Conclusions

We herewith conclude that acute short-term outcome is favorable in young ST-segment elevation myocardial infarction patients, particularly in those who had received timely thrombolytic therapy. Though tobacco consumption was a major contributor of risk in young adults, prevalence of other risk factors was low in young Western Indians.

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Efficacy and superiority of an innovative method (IM) of intravenous (IV) fluid drip drop rate calculation using IV set and its comparison with conventional methods (CM).
Dhruvkumar M. Patel, Mukundkumar V. Patel, Kamal H. Sharma, Jignesh C. Kaklotar, Greshaben R. Patel, Maitri M. Patel International Journal of Research in Medical Sciences 2019 Feb;7(2):334-340
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ABSTRACT

Background:

Almost every indoor patient requires some form of intravenous (IV) fluids and its infusion rate should be proper as recommended for best treatment outcomes. To overcome the same, a simple, quick and easily applicable new method for drip drop rate calculation is proposed, which is user-friendly at bedside and doesn’t require mathematical skills or help.

Methods:

Author compared this novel innovative method (IM) of IV fluid drip drop rate method for both regular macro and micro drop infusion set against conventional mathematical calculation method (MC) of infusion in various IV fluid indoor orders and assessed for time-to-initiation of treatment (TI) required and its accuracy. Ten resident doctors and ten nursing staff participated to grade both conventional and novel methods by using pre-printed forms of various parameters like time consumption, comfort level, accuracy and applicability in ward and these both methods were scored on a scale of 1 to 10.

Results:

Conventional method (CM) required 14.23±1.10seconds, while novel method (IM) required average 3.63±0.73seconds for calculation of drop rate. Average grading for conventional method was 3.63±0.49 and for novel method was 7.84±0.6 out of 10.

Conclusions:

Novel method of IV fluid drip drop rate formula is easy, quick and superior in comparison to conventional method and it doesn’t require any additional instrumental help. It is good alternative to conventional formula for IV drip drop rate calculation in absence of infusion pump.

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Evaluation of Serum Vitamin D Level as a Prognostic Marker in the Clinical Manifestation of Acute Coronary Syndrome Patients
Hiren Anghan, Jayesh Prajapati, Iva Vipul Patel, Senthilraj Thangasami, Nikunj Patel
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Introduction: Epidemiologic studies have shown a strong association between Vitamin D deficiency and cardiovascular risk factors, myocardial infarction, and all-cause cardiovascular mortality. The purpose of this study was to determine the clinical implications of serum Vitamin D levels in an unselected cohort of acute coronary syndrome (ACS) patients at the time of hospital admission. 

Methods: This was a prospective observational study which enrolled a total of 310 patients from December 2015 to March 2018. The consecutive in-hospital patients with ACS diagnosed by the typical history of angina, electrocardiography changes, with or without cardiac enzymes were included in the study. The primary endpoint of the study was all-cause death during hospitalization. The secondary endpoint was the in-hospital incidence of major adverse cardiac events (MACEs). 

Results: The number of patients with diabetes and dyslipidemia was significantly higher in the Vitamin D-deficient group (46.7%, P = 0.04 and 45.4%, P = <0.001, respectively). The blood glucose, hemoglobin A1C, low-density lipoprotein, and total cholesterol were significantly higher in Vitamin D-deficient group (P = 0.045, 0.048, 0.013, and 0.024, respectively). There was no any relation of mortality and MACE between normal Vitamin D and Vitamin D deficiency patients. 

Conclusion: Vitamin D deficiency and insufficiency were common in patients with the ACS. In the current study, ACS patients with diabetes and dyslipidemia were strongly associated with Vitamin D deficiency, but there was no correlation between Vitamin D deficiency and ACS outcomes.

Keywords: Acute coronary syndrome, diabetes, dyslipidemia, Vitamin D deficiency

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Comparison of Limus- Eluting stents vs. Paclitaxel Eluting Stents in Diabetic & Non-Diabetic Patients: Short Term Results
Jayesh Prajapati, Ranjeet, Pooja Vyas, Iva Patel, Journal of Cardiovascular Medicine and Surgery. Volume 4, Issue 1, January - March 2018, Pages 33-39.
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Abstract

Background: Diabetes mellitus has been regarded as an independent risk factor for the progression of coronary artery disease. Even with DES, however patients with diabetes had increased rates of restenosis compared with patients who did not have diabetes. This study aimed to examine individual safety and efficacy endpoints. Methods: A total of 287 patients having chronic stable coronary artery disease or ACS were enrolled. To compare PES and LES in the Diabetic and Non-diabetic population, we separated patients in two groups. Results: In present study, there were 287 patients undergoing PTCA in whom 371 lesions were treated using either PES or LES. Out of 371, 169 lesions were treated with PES and 202 were treated with LES. In those treated with PES, 51 were diabetic while those treated with LES, 66 were diabetic. In present study, among all patients cardiac death, MI, ST, ISR and TLR noted in 2.95%, 4.14%, 2.95%, 5.91% and 4.14% patients respectively in those treated with PES. While those treated with LES cardiac death, MI, ST, ISR and TLR noted in 0.99%, 1.48%, 1.48%, 0.49% and 0.99% patients respectively. ISR and overall MACE observed were statistically significant between two groups. Conclusion: Although diabetes remains a significant predictor of adverse clinical outcomes after percutaneous coronary intervention with DES; in present study there was no statistically significant difference for occurrence of MACE among diabetic and nondiabetic patients. The principle end points of interest occurred with statistically significant lower incidence in patients treated with LES as compared to PES.

Keywords: Diabetes; Non-Diabetes; Limus Eluting Stent; Paclitaxel Eluting Stent. 

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Reappraisal and new observations on atrial tachycardia ablated from the non-coronary aortic sinus of Valsalva
Shomu Bohora, Yash Lokhandwala, Eduardo Back Sternick, Robert H. Anderson, Hein J.J. Wellens, Europace. 2018 Jan 1; 20(1):124-133. doi: 10.1093/europace/euw324.
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Aims

The clinical characteristics of atrial tachycardias (AT) ablated from the non-coronary aortic sinus (NCS) are thus far described only in small series. We aimed to outline, in a large cohort of patients, the clinical, electrocardiographic, electrophysiological characteristics of this tachycardia.

Methods and results

We analysed data pertaining to clinical, electrocardiographic, and electrophysiological characteristics of 43 consecutive patients from an overall cohort of 441 with AT who were successfully ablated from the NCS. The tachycardias ablated from the NCS were paroxysmal (98%) and adenosine sensitive (35/35). The patients were aged 54.6 ± 12.4 years, showing female preponderance (74%). No P wave pattern was predictive of the location of ablation. Electrophysiological findings suggested a possible micro-reentrant mechanism. During tachycardia, atrial electrograms recorded in the NCS preceded the A in the His region by 10.9 ± 7.4 ms. Fractionated atrial electrograms were noted at the site of ablation in 42 patients during the tachycardia. Radiofrequency ablation terminated the tachycardia within 5 s in 88%, with thermal automaticity seen only in 3 patients. The site of ablation at the base of the NCS was adjacent to the presumed site of the retroaortic node, a remnant of the initial atrio-ventricular canal musculature.

Conclusions

AT ablated from the NCS is a paroxysmal arrhythmia in middle-aged women, with distinct electrocardiographic and electrophysiological characteristics. We suspect the retroaortic node to be involved in the tachycardia circuit.

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Therapeutic Addressal of Post-Myocardial Infarction Ventricular Tachycardia: Implantable Cardiac Defibrillator Versus Medical Therapy
Dr. Nikhila Pachani, Dr. Praveen G. Pai, Journal of Cardiovascular Medicine and Surgery. Volume 4, Issue 1, January - March 2018, Pages 13-19.
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Objective: Sudden death due to the occurrence of sustained ventricular arrhythmia (VA) is the main contributor to total mortality in these highrisk postMyocardial infarction (MI) patients, accounting for about 40% of all deaths. We aimed to assess long term follow up of patients with prior MI and Left Ventricular dysfunction (LVD) undergoing automatic implantable cardioverterdefibrillator (AICD) insertion for primary and secondary prophylaxis. Methods: All patients who had prior MI and LVD with symptomatic Ventricular Tachycardia (VT) or patients who underwent electrophysiological studies for inducing VT during 2000 to August 2013 were included for the retrospective analysis. Age, gender, clinical features, addictions, LVEF, survival, recurrence of arrhythmia, recurrence of symptoms and hospitalization for congestive heart failure (CHF), device therapy, were considered for the analysis. Results: In our study we had age matched patients with male predominant patient population. We found that Holter study was less predictive than electrophysiological study in detecting VT in patients with MI and LVD. It was found to have 15% survival benefit in AICD group. There was increased hospitalization in AICD group compared to NonAICD group. Recurrence of arrhythmia and syncope was lower in AICD group whereas hospitalization due to CHF was higher in AICD patients. Conclusions: Our study shows that the implantation of a defibrillator in patients with a prior MI and LVD, with symptomatic or inducible VA on electrophysiological study has survival benefit, with increased incidence of hospitalization which can be attributed to Device therapy, CHF and morbidity due to longer life.

Keywords: Post MI; Ventricular Tachycardia; LV Dysfunction; Syncope; AICD. 

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Evaluation of prosthetic valve dysfunction by three‑dimensional echocardiography
Subhash Chaudhari, Jayesh Prajapati, Naman Shastri, Iva Patel, Sharad Jain, Sibasis Sahoo, Vijay Gupta
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ABSTRACT Background: Three‑dimensional (3D) echocardiography (echo) and transesophageal echo images enable visualization of valvular anatomy from unique orientations with improved spatial relationships not previously seen with two‑dimensional (2D) echo.

Materials and Methods: Patients who fulfilled the criteria had undergone detailed evaluation of prosthetic valve dysfunction. Prosthetic valve dysfunction patients with stable hemodynamic were included and 3D echo findings were compared with 2D echo.

Results: A total of 10 males and 25 females were evaluated in the study. Two females and one male had bioprosthetic, three males and two females had tilting disc valve, while 21 females and six males had bileaflet mechanical valve. 3D echo had shown abnormal motion of leaflets in seven male and 21 female patients compared to 2D echo. Abnormal valvular calcification was demonstrated in a total of 23 patients on 3D echo. Valve sewing‑ring integrity and motion were found abnormal in two male and two female patients in 3D echo. Prosthetic valve dehiscence and thrombus were better seen in five and 15 patients, respectively, on 3D echo. On 3D echo, pannus was better seen in one male and two females. 3D echo defined exact site and size of vegetation better than 2D echo in two female patients.

Conclusions: Real‑time 3D imaging allows clinically useful visualization of prosthetic valve components such as leaflets, rings, and struts of all prosthetic valves, irrespective of position. “En face” view of the valve has proven useful in the assessment of prosthetic valve endocarditis, paravalvular regurgitation, and prosthesis dysfunction. 3D echo imaging plays an important role in device closure.

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Burden of congenital heart diseases in a tertiary cardiac care institute in Western India: Need for a national registry
Pooja Vyas, Nilesh Oswal, Iva Patel
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ABSTRACT

Objective: Congenital heart disease (CHD) is very common disease, and it is the major cause of childhood mortality and morbidity. Not much of Indian data are available particularly from the western part of the country. There are needs to further explicate the spectrum and epidemiology of the CHD.

Materials and Methods: This retrospective study collected data of the paediatric patients received in our institute from January 2016 to June 2017. All simple and complex congenital anomalies diagnosed on echocardiography were included in our study.

Results: Of total 22,275 cases, CHDs were diagnosed in 9728 cases with a male‑to‑female ratio of 1:0.6. Most CHDs (62.77%) were diagnosed between 1month and 6 years of age. Incidence of cyanotic CHD was 27.14% and acyanotic CHDs was 72.86% with a ratio of cyanotic‑to‑acyanotic CHD being 1:2.7. Ventricular septal defect (26.24%) was the most common acyanotic CHD found followed by 2089 patients of atrial septal defect. Tetralogy of Fallot (13.57%) was the most common cyanotic CHD found followed by double‑outlet right ventricle in 276 patients (2.84%).

Conclusions: Ours is the largest Indian study till date in this spectrum which yielded new data on the epidemiology, incidence, and prevalence of CHD. Majority of the patients with CHD had acyanotic CHD with most common anomaly being ventricular septal defect. Tetralogy of Fallot was the most common cyanotic defect. This study will increase awareness in the people with a family history of CHD and health‑care providers and will assist in early diagnosis.

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Etiology, Management & Outcome of Ventricular Tachycardia in Structural Heart Disease Patients in Indian Context
Tushar Nikam, Jayesh Prajapati, Shomu Bohora, Iva Patel
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Abstract

Introduction: Ventricular tachycardia (VT) encompasses all the tachycardia’s originating in the ventricular myocardium or the specialized conductive tissue distal to the atrioventricular node. Structural heart disease (SHD) plays a major role in risk stratification, initial management, risk stratification, and treatment of ventricular arrhythmias.

Aim: The aim of the study was to study the clinical profile, various treatment modalities offered to patients and patient’s acceptance for same and the outcome following various treatment modalities in patients of ventricular tachycardia in structural heart disease patients in Indian context.

Materials and methods: 106 patients of ventricular tachycardia with underlying structural heart disease fulfilling the study criteria were enrolled in the study. All patients underwent detailed evaluation including history, clinical examination and laboratory investigations. Patients were managed according to standard guidelines. All patients were followed at 1 month, 3 months,and 6 months.

Results: Mean age was 53.6 years, 77.36% of patients were males. Monomorphic VT was commonest presentation and found in 93.39% of patients. Most common etiology for VT was coronary artery disease in 52.84% of patients. Mean LVEF in our study was 26.46±10.82%.Patients who had LVEF of <30% had maximum mortality of 48.05%. 23 (21.69%) patients in our study had opted for AICD and underwent the procedure accordingly. The main reason behind patients not opting for AICD was the economic issue. There were 2 (8.6%) deaths in AICD group and 12 (14.81%) in non­AICD group on follow­up.

Conclusion: In our study, the most common etiology of VT was coronary artery disease. Monomorphic VT is common in patients with underlying structural heart disease. Patients of VT with associated comorbidities and left ventricular dysfunction has higher mortality. Our study shows that the implantation of a defibrillator in patients with a prior myocardial infarction and left ventricular dysfunction, with symptomatic ventricular tachyarrhythmia have a trend towards survival benefit, compared to similar group of patients on medical follow up. But the main reason in Indian context behind not undergoing AICD implantation is economic issue.

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Diagnostic accuracy of a novel ‘winking coronary angiographic sign’ in patients presenting with ventricular septal rupture complicating acute myocardial infarction
Kamal Sharma, Komal Shah, ,Sachin Patil, , Riyaz Charaniya, Hussain Bhatia, Jayesh Meniya,
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Abstract 

Ventricular septal rupture (VSR) is an uncommon but potentially lethal complication of acute myocardial infarction (MI). Its prompt recognition is essential to permit timely institution of corrective measures. The present study was undertaken to assess the diagnostic accuracy of a novel and unique angiographic sign, the ‘winking coronary sign (WCS)’, for recognizing post-MI VSR. The WCS is defined as partial transient occlusion of the infarct-related culprit artery overlying the site of VSR during ventricular systole with near normal filling in the diastole. A total of 56 patients with post-MI VSR (mean age 60.9 ± 9.9 years, 75% male) were compared with 73 age- and sex-matched acute MI patients without VSR. The extent of coronary artery disease was not different between the two groups, but higher number of patients in the VSR group had thrombolysis in MI grade 3 flow (57.1% vs 34.5%, P 0.01). The WCS was observed in 67.9% of the patients with VSR but in none of the patients without VSR (p < 0.0001), yielding a sensitivity of 67.9% and specificity of 100% for this sign for diagnosing underlying VSR. This demonstrates the potential utility of the WCS for diagnosing VSR in patients in whom the VSR has developed in the time frame between the echocardiography and angiography or has been missed during the initial clinical and/or echocardiographic evaluation. 

Keywords 

Acute myocardial infarctionVentricular septal ruptureInfarct related arteryCoronary angiography

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Skipping breakfast and the risk of coronary artery disease
Sharma Kamal & Shah Komal & Brahmbhatt, Poonam & Kandre Yogini
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Background/Introduction

Nutritional studies have indicated a critical role of dietary habits in development of cardiovascular diseases (CVD).

Aim

We aimed to compare the risk of coronary artery disease (CAD) in habitual ‘breakfast skippers’ with those of ‘habitual breakfast eaters’ in Western part of India. We also planned to compare the cardiometabolic profiles of both the groups.

Design

In this prospective, case–control study of 1607 individuals; 980 were patients of CAD (cases) undergoing various cardiac interventions for revascularisation and other 627 were healthy individuals (controls) who were free from CAD.

Methods

Details of demographics and classical risk factors were collected for all the participants. Subjects were categorized as ‘breakfast eater’ or ‘breakfast skippers’ according to their response to the questionnaire. Logistic regression and correlation analysis were performed to assess the independent risk of all the factors and their inter-variable association.

Results

Significantly (P < 0.05) high prevalence of classical risk factors and breakfast skipping habit was found in cases when compared with controls. Diabetes showed the highest odds ratio (7.296; 95% confidence interval (CI) 4.825–11.030; P < 0.0001) for CAD, followed by hypertension (3.756; 95% CI 2.891–4.881; P < 0.0001) and habits of smoking/tobacco/alcohol consumption (1.914; 95% CI 1.528–2.398; P < 0.0001) and breakfast skipping 1.348 (95% CI 1.076–1.689; P < 0.0001). Breakfast skipping emerged as stronger risk factor than obesity and sedentary life style in Indians and showed close association with presence of hypertension.

Discussion/Conclusion

Habitual breakfast skippers are at increased risk for development of CAD and hypertension in Western India.

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Evaluation of SERENE-CAG score for assessing suitability for coronary angiography preoperatively in patients undergoing valve replacement surgery
Sharma Kamal & Singhal Roopesh & Jadhav Nikhil & Shah Komal & Patil Sachin
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Abstract

Aims

The aim of this study was to identify better selection criteria for subjecting patients of rheumatic heart disease (RHD) to preoperative coronary angiography (CAG) based on indigenous scoring system (SERENE-CAG [Selecting Patients Of Rheumatic Heart Disease Undergoing Valve Surgery For Presurgical Coronary Angiography]).

Methods

This prospective study included all consecutive 798 patients of RHD patients undergoing preoperative CAG from January 2016 to December 2017 over a duration of 2 years. Multivariate logistic regression analysis was performed with the presence of significant CAD [coronary artery disease] as the dependent variable with traditional risk factors of CAD. An additive score was developed using coefficient derived logistic regression for those variables that were significant. Receiver-operator curve analysis was performed to assess the ability of this score to predict diseased vs normal CAG.

Results

A total of 798 patients had a mean age of 51.7 ± 12.5 years. Significant CAD requiring revascularization along with valve surgery was identified in 50 (6.26%) patients. Male gender was found as significant predictors of CAD with odds ratio 2.6. A SERENE CAG SCORE of >2.8 resulted in sensitivity of 80% and specificity of 36.9% of predicting CAD in RHD patients with positive and negative predictive value of 7.8% and 96.5%, respectively.

Conclusion

The prevalence of CAD in RHD patients is low. Patient risk can be minimized by exploring noninvasive modalities for screening of CAD and by more appropriate selection of patients for invasive coronary angiogram. Using threshold SERENE-CAG score of >2.8 would result in deferring 34.6% of normal angiograms.

Keywords

Valvular heart diseaseCoronary artery diseaseCoronary angiography

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Predictors of the extent and severity of coronary artery disease for prognosis of patients with non-ST-segment elevation acute coronary syndromes
"Chirag Patel, Jayesh Prajapati, Iva V Patel, Roopesh Singhal, Ashish Mishra, Gaurav Singh, International Journal of cardiovascular practice, October 2018, Volume 3, Issue 4,Pages 75-79 "
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Introduction:

The proportion of patients visiting emergency department with chest pain indicative of non‐ST‐segment elevation acute coronary syndrome (NSTE-ACS) is increasing. The current risk assessment of patients with NSTE-ACS may calculate patients risk for recurrent events but may fail to identify patients with severe coronary artery disease (CAD). The present study aimed to identify predictors of the extent and severity of CAD for prognosis of NSTE-ACS patients undergoing early angiography.

Methods:

A total of 215 patients with NSTE-ACS were enrolled randomly and followed up between April-2015 and February-2017 at a tertiary healthcare center. The coronary angiography was performed. Patients were divided into two groups: high-risk coronary anatomy (HRCA) and low-risk coronary anatomy (LRCA). Patients were analyzed for baseline, demographic, clinical characteristics, and cardiovascular risk factors, during hospitalization and 30 days post discharge.

Results:

Among 215 enrolled patients, 90 (mean age: 52.22 ± 10.24 year) and 125 (mean age: 57.78 ± 8.83 year) patients were in the LRCA and HRCA group, respectively. The presence of previous heart failure [Odds Ratio (OR): 3.95, 95% confidence interval (CI): 1.11-14.10; P = 0.03], chronic renal failure [OR: 5.11, 95% CI: 1.12-23.22; P = 0.03] and peripheral vascular disease [OR: 3.38, 95% CI: 1.09- 10.42; P = 0.03] were significant independent predictors of HRCA. Additionally, Grace score >140 was the significant predictor of 30 days mortality [OR: 5.85; P = 0.02] and major adverse cardiac and cerebral events [MACCE; OR: 6.23, 95% CI: 2.22-17.50; P = 0.001].

Conclusions:

The extent and severity of CAD in NSTE-ACS patients can be predicted by assessing HRCA through clinical parameters. However, the correlation of HRCA with 30 days MACCE and mortality was modest.

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"Study of Clinico-etiological profile of patients with In-stent restenosis in population of western India "
"Sharad Jain ,RakeshTirmale, Krutika Patel , Keyur Patel , Kamal Sharma , Vishal Sharma, MandipTilara, ZeeshanMansuri Journal of Cardiovascular Medicine and Surgery Volume 4 Number 3, July - September 2018 DOI: http://dx.doi.org/10.21088/jcms.2454.7123.
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Abstract

Background: Drug-eluting stents (DES) represent a significant improvement in the treatment of coronary artery disease as they decrease restenosis rates by approximately 50% compared with bare-metal stents. The study aimed to evaluate clinical, etiological factors and angiographic characteristics associated with occurrence of In-stent restenosis in of Bare metal (BMS) vs. Drug eluting stents. Methods and Results: The study included 200 patients of percutaneous coronary angioplasty during October 2014 to June 2016.Mean age of patients was 58.06±8.79 years with 140 (70%) were males and 60 (30%) were females. BMSand DES ISR (44.1% vs 56.3%) were diabetic (DM), (61% vs 84.4%) were hypertensive, (77.9% vs 56.3%) were dyslipidemic, (46.3% vs 21.9%) were smokers consecutively. Amongst the above risk factors, Diabetes (p-value 0.01) and smoking (p-value 0.028) were the two factors which had statistically significant correlation with severity of In-stent restenosis(ISR). Patients with BMS had more Non Focal ISR 98 (79.03%) than focal ISR 38 (50%) and the difference was statistically significant (p value <0.001). There was statistically significant difference (p =<0.05) between the stent diameter and the severity of ISR with less than 2.5 mm Diameter stents associated with more Non focal ISR. Conclusion: ES appears to reduce restenosis and clinical end points and to be more cost effective than BMS. Patientrelated factors (i.e. sex, Diabetes, smoking) are important variables that affect restenosis and, hence, the appropriate selection of devices and patients is crucial.

Keywords: Bare Metal Stent; Drug Eluting Stent; Restenosis; Risk Factor

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Cardiovascular Disease Risk Factors and Socioeconomic Status: A Cross Sectional Study of Children and Adolescents from Western India
Nikhila Pachani, Gajendra Dubey, Komal H. Shah, Dhaval Doshi Journal of Cardiovascular Medicine and Surgery Volume 4, Issue 1, January - March 2018, Pages 13-19
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Abstract

Background: Socio-economic status isknown to possess an inverse relationship with cardiovascular disease risk. Aims: We aimed to investigate the prevalence of cardiovascular disease risk factors in children and adolescents of Western India and examine its association with the socio-economic status of the population. Materials and Methods: In this cross sectional, observational study, 3543 children and adolescents of 4-18 years of age were enrolled. Blood pressure (BP), body mass index (BMI) and anthropometric parameters were recorded according to the standardized protocols. Details of socio-economic status (SES), physical activity and stress were obtained from a questionnaire for each individual. Based on the SES, study population was divided into– group I (low-middle SES) and group II (high SES). Results: Overall, the prevalence of prehypertension, hypertension, sedentary life style and type A personality was 14.6%, 33.9%, 58.2%, 53.7% respectively. Obesity was observed in 13.4% and 22.3% of the individuals were malnourished. Prevalence of hypertension (35.21 vs 28.53%), obesity (7.44% vs 2.1%), high waist circumference (WC-58.82±20.34 vs 53.78±15.74) andhigh mid-arm circumference (MAC-21.87±5.3 vs 20.11±5.77) weresignificantly higher in group II as compared to group Ipopulation. Conclusion: The study observation suggests deadly coexistence of hypertension, obesity, sedentary life style and stress in Gujarati Asian Indian children and adolescents. These risk factor prevalence was more in population from high socio-economic class.These observations would contribute in development of appropriate preventive public health policy to efficiently manage these health and social issues early in life.

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Clinical outcome of novel long tapered Sirolimus-eluting coronary stent system in real world patients with long diffuse De novo coronary lesions.
Patted SV, Jain , Jiwani ,  Suryavanshi S, Raghu , Raveesh H, Rajalakshmi S, Thakkar , Turiya , Desai , Patted , Sharma K Cardiol Res. 2018 Dec;9(6):350-357. doi: 10.14740/cr795. Epub 2018 Dec 7
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Abstract

Background:

When coronary lesions involve segments > 48 mm, the only treatment possibility is stent overlapping which is associated with higher neointimal proliferation that lead to more restenosis. Furthermore, tapering of coronary arteries is a major challenge observed with long diffuse coronary lesions. This study attempted to assess the safety and performance of world’s first commercialised long-tapered (60 mm) sirolimus-eluting coronary stent (SES) system for the treatment of long diffused de novo coronary lesions in real world scenario.

Methods:

This was a retrospective, non-randomised, multicentre study which included 362 consecutive patients implanted with longtapered BioMime™ Morph SES system for the treatment of long diffused de novo coronary lesions. Safety endpoint was major adverse cardiac events (MACE), which was defined as composite of cardiac death, myocardial infarction (MI) and ischemic-driven target lesion revascularization (ID-TLR), at 12-month follow-up.

Results:

Out of 362 patients included, 170 (47.0%) were diabetic and 159 (43.9%) were hypertensive. The mean age of all patients was 61.09 ± 9.04 years. A total of 625 lesions were identified; out of which 402 lesions were intervened successfully using BioMime Morph. The cumulative incidence of MACE was 7 (2.0%) at 12-month follow-up which included four (1.1%) cardiac deaths, one (0.3%) case of MI and two (0.6%) ID-TLR. Acute stent thrombosis was reported in one (0.3%) patient.

Conclusions:

The present study confirms the safety and performance of BioMime Morph, and hence, can be considered as a treatment of choice for long diffused tapered de novo coronary lesions in routine clinical practice.

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Modifiable Life Style Risk Factors for CAD in Young Dyslipidemic Gujarati’s
Dhaval Doshi, Kartik, Priyanka Patel, Komal Shah, Volume 3, Issue 2, Jul-Dec 2017, Pages 95-101
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Abstract

Background and Objective: Earlier reports have mentioned a fourfold rise in coronary artery diseases (CAD) in the last four decades in India. Dyslipidemia is amongst the major modifiable risk factors for cardiovascular diseases. A particular dyslipidemic pattern has been observed in South Asians, borderline or normal low density lipoproteins and high triglycerides with low high density lipoproteins. There are evidences mentioning predisposition for CAD in young Gujarati population. In this study, we aim to analyze the prevalence of modifiable risk factors in young asymptomatic dyslipidemic Gujaratis for timely prognosis, management and delaying of the onset of CAD. Material and Methods: This cross sectional study was carried out at U.N. Mehta Institute of Cardiology and Research Centre, Ahmedabad, Gujarat, India in September 2015. Total 426 young asymptomatic dyslipidemic participants between 18 – 40 years of age, apparently healthy and disease free were enrolled for the study. Data analysis was carried out by SPSS version 22.0 (Chicago, IL, USA). Comparison between the groups was done using MannWhitney U test and the cut off value of p<0.05 was considered to be statistically significant. Results: The study population was male dominant (69.2%). Decreased consumption of fruits was major risk factor observed and diabetes was the least prevalent. Most common dietary habit was the consumption of vegetables. Apolipoprotein B/ Apolipoprotein A1 ratio was found abnormal in majority of study participants. Amongst 61.7% of the population following a sedentary lifestyle, majority were males (86.4%). Conclusion: On the basis of our observations, we would like to suggest physically active life style, decreased junk food consumption and increased consumption of fruits and nuts in young dyslipidemic individuals of Gujarati origin to lower their risk for coronary artery diseases.

Keywords: Dyslipidemia; Sedentary Lifestyle; Coronary Artery Disease.

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Androgenic alopecia, premature graying, and hair thinning as independent predictors of coronary artery disease in young Asian males
Kamal Sharma, Dhammdeep Humane, Komal Shah, Sachin Patil, Riyaz Charaniya, Jayesh Meniya, Cardiovascular endocrinology December 2017 - Volume 6 - Issue 4 - p 152–158.
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Introduction We herewith aimed to explore the association of premature graying, androgenic alopecia (AGA), and hair thinning with coronary artery disease (CAD) in young (≤40 years) male individuals from Western India.

Patients and methods In this prospective, case–control study, 1380 male individuals from a super speciality cardiac care center were enrolled, of which 468 were established cases of CAD and 912 were age-matched healthy male individuals not having history of any major illness including CAD. Details of demographics, cardiovascular risk factors, and cutaneous markers were collected for both the groups. 

Results Prevalence of hypertension (30.3 vs. 13.6%), obesity (28.8 vs. 12.2%), hair thinning (36.3 vs. 14.6%), premature graying (49.6 vs. 29.9%), AGA (49.1 vs. 27.4%), and lipid abnormalities (total cholesterol – 16.7 vs. 8.8%; low-density lipoprotein – 7.3 vs. 2.2%; and high-density lipoprotein – 92.5 vs. 88.7%) were higher in cases as compared with control. Multiple logistic regression analysis showed that AGA [5.619, 95% confidence interval (CI): 4.025–7.845, P<0.0001] is the strongest predictor of CAD among young Asian male individuals, closely followed by premature graying (5.267, 95% CI: 3.716–7.466, P<0.0001), obesity (4.133, 95% CI: 2.839–6.018, P<0.0001), and hair thinning (3.36, 95% CI: 2.452–4.621, P<0.0001). SYNTAX score, left ventricle ejection fraction, and degree of disease severity were also found to be independent associates of premature graying and AGA.

Conclusion Our findings support the hypothesis that cutaneous markers are independently associated with underlying CAD irrespective of other classical cardiovascular risk factors. This, in combination with classical markers, could be effectively used for early identification and risk stratification of young patients with occult or established CAD.

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Is Neutrophil-to-Lymphocyte Ratio a Predictor of Coronary Artery Disease in Western Indians?
Kamal Sharma, Alap K Patel,Komal H Shah, Ashwati Konat, International Journal of Inflammation – 2017; Volume 2017, Article ID 4136126, pp 1-8.
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Introduction. The current study was designed to evaluate the association of neutrophil-to-lymphocyte ratio (NLR) with coronary artery disease (CAD) presence. We also aimed to propose a suitable cut-off of NLR for diagnosis of CAD in Western Indians. Methods. Total 324 patients undergoing coronary angiography were enrolled and were subdivided into two groups: group 1 (n=99; population without CAD) and group 2 (n=225; population with CAD).

Results. The results indicated significant (p<0.05) positive association between elevated levels of WBC, neutrophil, monocyte, NLR, hs-CRP, CPK-MB, and troponin I and disease presence. According to subgroup analysis, the association was more profound in male and older population. Among all the markers NLR showed the strongest predictive potential for CAD with highest odds ratio (1.495; 95% CI: 0.942–2.371;p<0.048 ). Optimum cut-off of NLR for diagnosis of CAD was 2.13 (AUC-0.823;p<0.001 ; sensitivity: 83.64%; specificity: 63.46%). Association of NLR with other biochemical markers such as hs-CRP, CPK-MB, and troponin I was also observed in quartile analysis. Conclusion. NLR is a simple indicator that could be effectively used for the diagnosis of CAD with a cut-off of 2.13 in Western Indian population.

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Winking of an Infarct Related Artery Overlying Ventricular Septal Rupture Complicating Acute MI: An Angiographic “Winking Coronary” Sign
Kamal Sharma, Nilesh Oswal, Roopesh Singhal, Journal of Cardiovascular Medicine and Surgery Volume 3, Issue 2, Jul-Dec 2017, Pages 179-183.
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Abstract

Background: Post myocardial infarction -Ventricular septal rupture is a fatal condition needing immediate attention. Objectives: This study intends to report a unique angiographic finding – “Winking coronary” sign of infarct related artery (IRA) overlying the ventricular septal rupture (VSR) complicating acute myocardial infarction (AMI). Materials and Methods: Retrospective analysis of 15 patients (mean age - 62.43 ± 8.4 years) having VSR after AMI were included and coronary angiogram of all these patients were evaluated. Thirteen patients had anterior wall and 2 had inferior wall AMI. Results: Majority of the patients had LAD (n=13; 86.7%) and only 13.3% (n=2) had RCA as an involved IRA. None of the patient showed association of LCX as a culprit artery. Only 1 patient had completely occluded IRA, where as all other (n=14; 93.3%) patients showed winking coronary sign on coronary angiogram. In all 4 patients’ who had undergone surgical closure of VSR, the anatomic site of the “wink” was well correlated with the defect at the time of surgery. Conclusions: “Winking coronary” sign of the IRA is sensitive and specific feature of underlying VSR complicating a case of AMI on coronary angiogram.

Keywords: Acute Myocardial Infarction; Ventricular Septal Rupture; Infarct Related Artery; Coronary Angiography. 

 

 

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Study of Short and Intermediate Term Clinical Outcomes of Patients with Protected and Unprotected LMCA Stenting
Pooja Vyas, Jayesh Prajapati, Sibasis Sahoo, Iva Patel, Jagjeet Deshmukh, Chirag Patel, Roopesh Singhal, Journal of Clinical and Diagnostic Research - 2017; Volume 11; Issue 4: pp OC29-OC33
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Introduction: Significant unprotected Left Main Coronary Artery (LMCA) disease is detected in 5%-7% of cases undergoing Coronary Angiography (CAG). Present guidelines have revealed the significance of anatomical location in left main artery stenosis and syntax scores for determination of Major Adverse Cardiac Events (MACE). Debate still persists over the best treatment regarding outcomes of Coronary Artery Bypass Grafting (CABG) and LMCA stenting for patients with LMCA disease.
Aim: Aim of the study was to evaluate short and intermediate term clinical outcomes of Percutaneous Coronary Intervention (PCI) in LMCA disease in respect to mortality, Cerebrovascular Accidents (CVA), reinfarction, stent restenosis and need for repeat target lesion revascularization.
Materials and Methods: From July 2013 to February 2015, 50 patients underwent LMCA stenting. All patients underwent detailed clinical assessment, detailed 2D echocardiographic assessment. Syntax score was calculated in all patients. Clinical in hospital and outpatient follow up was obtained at one, three, six, nine months and one year.
Results: Mean age was 53.14±9.60 years. On CAG 16 (32%) patients had ostial LMCA lesion, 8 (16%) had mid LMCA lesion, distal LMCA was diseased in 6 (12%). In emergency situation, two bail out LMCA stenting were done for treatment of LMCA dissection. A total of 42 (84%) patients had low syntax score, 6 (12%) had intermediate and 2 (4%) had high syntax score. Only LMCA stenting was done in 22 (44%) patients, LMCA to Left Anterior Descending (LAD) stenting was done in 22 (44%) and LMCA to Left Circumflex (LCX) stenting was done in 6 (12%) patients. Drug-Eluting Stent (DES) was used in 35 (70%) cases while Bare-Metal Stent (BMS) was used in 15 (30%). An 8% mortality and 8% target lesion revascularization rate were observed in our study.
Conclusion: Our study revealed that LMCA stenting is a safe and feasible alternative mode of revascularization in selected patients. Patients most suitable for LMCA stenting in our study were those with isolated ostial/mid LMCA disease, with protected LMCA disease and those who underwent elective stenting procedure.

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Balloon dilatation of native coarctation of aorta in infants - short term clinical result
Oswal N, Doshi D, Jadhav N, Humane D, Sharma K, Shah K, Pediatric Review: International Journal of Pediatric Research - 2017; Volume 4; Issue 1: pp 53-58
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Background: Balloon dilatation with or without placement of stent in native coarctation offers a good alternative to surgery. Aim: To determine feasibility and safety of primary balloon angioplasty in infants with coarctation of aorta. Materials and Methods: This was a retrospective, observational study of 44 consecutive infants undergoing balloon dilatation of native coarctation of aorta during a 4 year period from July 2009 to July 2013. Demographic details, previous history and data of chest X-ray, electrocardiogram and sequential echocardiography were collected for all the patients. The patients were followed up at 1 months, 6 months and 1 year thereafter. Results: The reintervention rate was 20.45% after successful procedure. Two patients having hypoplastic arch had successful procedure with 1 requiring reintervention. Left ventricular dysfunction was observed in 15 patients, out of them 11 patients improved immediately after the procedure. Thirty five (79.55%) patients did not undergo reintervention in whom mean gradient was reduced from 48.05±15.26 mm Hg to 10.97±5.8 mm Hg after percutaneous reintervention (p<0.0001). Also, mean diameter in this group was improved (1.94±0.52 vs 6.07±1.84 mm; p <0.0001). Early age of presentation was identified as a contributor of reintervention in the study population (p=0.009). Conclusions: This study results show that BDC in infants is a safe and feasible technique that could be effectively used as an option of surgery in order to reduce mortality and morbidity.

Keywords: Coarctation of aorta, Balloon angioplasty, Infants
 

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Clinical study of incidence of significant major aorto pulmonary collateral arteries in patients of TOF and its correlation with pulmonary artery anatomy
Dhaval Doshi, Nilesh Oshwal, Anand Shukla, Priyanka Patel, Komal Shah, Pediatric Review: International Journal of Pediatric Research - 2017; Volume 4; Issue 2: pp 102-107
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Clinical study of incidence of significant major aorto pulmonary collateral arteries in patients of TOF and its correlation with pulmonary artery anatomy | Doshi | Pediatric Review: International Journal of Pediatric Research

Introduction: Tetralogy of Fallot (TOF) with hypoplastic pulmonary arteries and major aorto pulmonary collateral arteries (MAPCAs) is the most extreme variant of TOF. MAPCAs are frequently present and the main source of pulmonary flow in patients with TOF with hypoplastic arteries in the absence of patent ductus arteriosus (PDA). Objective: To study the incidence of significant MAPCAs in patients of TOF and its correlation with pulmonary artery anatomy. Patients and Methods: This prospective study has been conducted on a cohort of 100 consecutive TOF patients of 0-15 years of age. All the clinical and demographic parameters were collected. Two dimensional ECHO and CT pulmonary angiography was performed to define PA anatomy and MAPCAs morphology. Cardiac catheterization was performed as and when required. All the patients selected for the study, had PDA absent. Results: A total 56 patients had MAPCAs. Hypoplastic LPA was observed in 31 patients, of which 27 (87%) had significant MAPCAs, and hypoplastic RPA was found in 46 patients with 40 (87%) having significant MAPCAs. The mean diameter found was 5.78 ± 3.52 mm. Direct arborization pattern was observed in 45 patients. The mean oxygen saturation was 76.72 ± 7. Conclusion: Patients with TOF and hypoplastic pulmonary arteries had significant incidence of MAPCAs. The majority had MAPCAs with direct origin from descending aorta and larger diameter. A statistically significant difference was observed in the oxygen saturation levels in patients with and without MAPCAs.

 

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Impact of coronary artery disease on augmentation index as measured by estimated central blood pressure: A case control study in Asian Indians
Kamal H.Sharmaa,* Neha Sharma, Komal Shah , Sachin Patil Indian Heart Journal 70(2018)615–621, https://doi.org/10.1016/j.ihj.2017.12.001
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Aims:

We compared various components of blood pressure and arterial stiffness of healthy control with those of coronary artery disease (CAD) patients using BP+ machineTM.

Methods:

In this prospective, case-control study, total 585 individuals of both the genders were enrolled. The study population consisted of 277 controls (healthy siblings of diseased subjects not having CAD – group A) and 308 CAD patients (group B). Age and sex adjusted regression and receiver operative curve (ROC) analysis was performed to assess the strength of association of these parameters.

Results:

We found that mean systolic blood pressure (SBP) (137.14  22.49 vs. 129.26 19.86), central systolic blood pressure (CSBP) (130.78  21.89 vs. 117.53 17.98), augmentation index (AI) (108.55  44.98 vs. 49.38  21.03) and pulse rate variability (98.82  231.09 vs. 82.86  208.77) were significantly (p < 0.05) higher in CAD population as compared to healthy counterparts. Left ventricular contractibility as measured by dP/dt was significantly lower in CAD patients. All these parameters were significantly abnormal in CAD as compared to healthy control population irrespective of the gender of the patient except for SBP in females. Both – odds ratio (1.108; 95% CI: 1.081–1.135; p < 0.0001) and ROC analysis (AUC: 0.937; 95% CI: 0.919–0.956; p < 0.0001) showed AI as the strongest predictor of CAD, closely followed by CSBP.

Conclusion:

Central aortic blood pressure parameters such as AI and CSBP measured noninvasively with BP+ machine could be the effective predictors of CAD in Asian Indians.

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Therapeutic Addressal of post-Myocardial Infarction
Dr. Nikhila Pachani, Dr. Praveen G. Pai Journal of Cardiovascular Medicine and Surgery Volume 3, Issue 2, Jul-Dec 2017, Pages 132-138
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Objective: Sudden death due to the occurrence of sustained ventricular arrhythmia (VA) is the main contributor to total mortality in these highrisk post­ Myocardial infarction (MI) patients, accounting for about 40% of all deaths. We aimed to assess long term follow up of patients with prior MI and Left Ventricular dysfunction (LVD) undergoing automatic implantable cardioverter­defibrillator (AICD) insertion for primary and secondary prophylaxis. Methods: All patients who had prior MI and LVD with symptomatic Ventricular Tachycardia (VT) or patients who underwent electrophysiological studies for inducing VT during 2000 to August 2013 were included for the retrospective analysis. Age, gender, clinical features, addictions, LVEF, survival, recurrence of arrhythmia, recurrence of symptoms and hospitalization for congestive heart failure (CHF), device therapy, were considered for the analysis. Results: In our study we had age matched patients with male predominant patient population. We found that Holter study was less predictive than electrophysiological study in detecting VT in patients with MI and LVD. It was found to have 15% survival benefit in AICD group. There was increased hospitalization in AICD group compared to Non­AICD group. Recurrence of arrhythmia and syncope was lower in AICD group whereas hospitalization due to CHF was higher in AICD patients. Conclusions: Our study shows that the implantation of a defibrillator in patients with a prior MI and LVD, with symptomatic or inducible VA on electrophysiological study has survival benefit, with increased incidence of hospitalization which can be attributed to Device therapy, CHF and morbidity due to longer life.

Keywords: Post MI; Ventricular Tachycardia; LV Dysfunction; Syncope; AICD.

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Sinus Rhythm in Rheumatic Mitral Stenosis after Balloon Mitral Valvotomy: Is it Feasible?
Ashwal A Jayaram, Anand N Shukla, Saurin Shah, Vidya Nayak, Sridevi Prabhu, Umesh Pai Journal of Clinical and Diagnostic Research - 2017; Volume 11; Issue 2: pp OC01-OC05
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Introduction:

Atrial Fibrillation (AF) is largely present in patients with rheumatic valvular disease, leading to hospitalizations.

Aim:

We aimed to study the restoration and maintenance of Sinus Rhythm (SR) in rheumatic patients with Mitral Stenosis (MS) and AF after Balloon Mitral Valvotomy (BMV) and evaluated the factors which affect the maintenance of SR. Materials and

Methods:

A total of 50 patients who underwent BMV at U. N. Mehta Institute of Cardiology and Research Centre from 2010 November to 2013 January were included in the study. Subsequently, all patients were treated with amiodarone and electrical cardioversion was applied in patients in whom it was necessary. The patients were followed for six months for conversion and maintenance of SR.

Results:

Total 34 (68%) patients reverted to SR. Twelve patients reverted to SR with amiodarone and 22 patients with electrical cardioversion and amiodarone. Out of the total, 29 patients and 26 patients remained in SR at the end of follow up at 3 months and 6 months respectively.

Conclusion:

Smaller Left Atrial (LA) size and greater Mitral Valve Area (MVA) are the chief predictors of restoration and maintenance of SR. Combining BMV with an aggressive antiarrhythmic strategy offers the best prospect of rhythm control.

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TRANSVENOUS ARTERIAL DUCT STENTING IN CYANOTIC PATIENTS WITH PULMONARY ATRESIA AND VENTRICULAR SEPTAL DEFECT
Bhavesh Thakkar, Abhishek Raval, Tarun Madan, Nilesh Oswal, Rhshikesh Umalkar, Komal Shah, Bhumika Maheriya Progress in Pediatric Cardiology
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We aimed to study the feasibility and outcomes of transvenous approach for arterial duct stenting in patients with pulmonary atresia-ventricular septal defect. Duct-dependent hypoxic patients with pulmonary atresia-ventricular septal defect and the confluent pulmonary artery branches were enrolled for ductal stenting and followed-up regularly. Twenty-three patients, with median age of 25 days (1 to 545 days) and weight of 2.8 kg (2.1 to 7.2 kg) were enrolled. Mean baseline arterial oxygen saturation was 69.38 ± 8.04%. Median right pulmonary artery and left pulmonary artery Z-scores were − 1.53 (− 4.19 to 2.48) and − 1.08 (− 8.03 to 3.0) respectively. Mean narrowest ductal diameter was 1.81 ± 0.57 mm and length was 13.63 ± 3.52 mm. Total 26 stents with mean diameter of 4.23 ± 0.29 mm and length of 14.88 ± 3.65 mm were deployed. Post-stenting mean arterial oxygen saturation increased significantly from baseline-value to 89.44 ± 4.86% (p < 0001). One patient suffered pulmonary edema. At median follow-up of 8 months (3 to 10 months), mean arterial oxygen saturation (78.82 ± 8.49%) was significantly higher than baseline value of 69.38 ± 8.04% (p = 0.0004). Median right and left pulmonary artery Z-scores were 0.39 (− 2.76 to 2.88) and − 0.02 (− 2.06 to 3.86) respectively. Five patients required re-intervention (shunt in 2 and angioplasty in 3 patients). Three patients died, one due to sepsis and another two with worsened cyanosis. Transvenous ductal stenting is an effective palliation in patients with pulmonary atresia-ventricular septal defect obviating the limitations of arterial approach.

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HIGH DENSITY LIPOPROTEIN CHOLESTEROL AS A RISK FACTOR OF CORONARY ARTERY DISEASES IN YOUNG WESTERN INDIAN: A COMPARISON WITH OTHER LIPID MARKERS
Jagjeet K.Deshmukh, Jayesh S.Prajapati, Komal H.Shah, Krutika H.Patel, Subhash D. Chaudhari, Pooja M.Vyas, Alok Shinde, Saurabh R.Bagga (National Journal of Laboratory Medicine. 2016 Oct, Vol-5(4): IO01-IO05)
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Introduction: Dyslipidemia – a modifiable risk factor of coronary artery diseases (CAD) is often subjected to ethnic variations. Different communities are known topossess different pattern of lipid abnormalities and study of it is highly required in order to form various preventive strategies. Aim: To compare the prevalence of dyslipidemias in healthy control versus young CAD patients from Western India. We also seek to assess the strength of each associated dyslipidemia and propose a most suited risk factor for this community. Materials and Methods: In this single centric, prospective and case control study 200 subjects (100 patients with CAD & 100 healthy volunteer) were enrolled. Fasting blood sample were collected from the antecubital vein of the subjects under sterile conditions. Lipid profile parameterssuch as total cholesterol (TC), triglyceride (TG), total lipid (TL), low density lipoprotein (LDL), high density lipoprotein (HDL), and very low density lipoprotein cholesterol (V... the strength of association of an individual risk factor. Significance was taken as two tailed p<0.05. Results: There was equal number of patients divided in case and control group. In all 65 males and 35 females and, 59 males and 41 females in case and control group respectively (p=0.47). The distribution of cardiovascular risk factors was significantly (p<0.05; BMI: 23.96 ± 4.37 vs 22.65 ± 4.55; diabetes: 10% vs 2%; hypertension: 41% vs 11%; Smoking: 11% vs 1%) higher in CAD patients as compared to control population. The level of HDL was significantly lower in cases, whereas all other lipid parameters except LDL were higher in cases as compared to control (p<0.05). Odds ratio analysis showed that low HDL levels 11.76 (95% CI 4.69 to 29.49) is the strongest associate of CAD amongst all other lipids in Western Indian population. Conclusion: The study results conclude that in young CAD patients from western India the role of low HDL is significant as compared to other dyslipidemias.

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DIAGNOSTIC ACCURACY OF COMPUTED TOMOGRAPHY ANGIOGRAPHY AS COMPARED TO CONVENTIONAL ANGIOGRAPHY IN PATIENTS UNDERGOING NONCORONARY CARDIAC SURGERY.
Hasit Joshi, Ronak Shah, Jayesh Prajapati, Vipin Bhangdiya, Jayal Shah, Yogini Kandre, Komal Shah HEART VIEWS Jul-Sep 16 Issue 3 / Vol 17/ Page : 88-91
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To compare the diagnostic accuracy of multi‑slice computed tomography (MSCT) angiography with conventional angiography in patients undergoing major noncoronary cardiac surgeries. Materials and Methods: We studied fifty major noncoronary cardiac surgery patients scheduled for invasive coronary angiography,29 (58%) female and 21 (42%) male. Inclusion criteria of the study were age of the patients less than or equal to 40 years, having low or intermediate probability of coronary artery disease (CAD), left ventricular ejection fraction (LVEF) greater than 35%, and patient giving informed consent for undergoing MSCT and conventional coronary angiography. The patients with LVEF <35%, high pretest probability of CAD, and hemodynamically unstable were excluded from the study.Results: The diagnostic accuracy of CT coronary angiography was evaluated regarding true positive, true negative values. The overall sensitivity and specificity of CT angiography technique was 100% (95% confidence interval [CI]: 39.76%–100%) and91.30% (95% CI: 79.21%–97.58%). The positive (50%; 95% CI: 15.70%–84.30%) and negative predictive values (100%; 95% CI:91.59%–100%) of CT angiography were also fairly high in these patients. Conclusion: Our study suggests that this non-invasive technique may improve perioperative risk stratification in patients undegoing non-cardiac surgery

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APOLIPOPROTEIN B / APOLIPOPROTEIN A – I RATION A BETTER DIAGNOSTIC MARKER OF CORONARY HEART DISEASE THAN CONVENTIONAL LDL / HDL RATIO.
Jayesh S.Prajapati, Jagjeet K.Deshmukh, Krutika H. Patel, Komal H.Shah, Hasit J. Joshi, Ranajeet More, Sibasis S. Sahoo National Journal of Laboratory Medicine. 2016 Jul, Vol-5(3): BO01-BO05
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Introduction: Apolipoprotein B (Apo B) and apolipoprotein A-I (Apo-I) are cholesterol transporters playing an important role in lipid metabolism. Apo B and A-I represent the total atherogenic and non-atherogenic particles respectively. Hence, their ratio – Apo B/A-I has been strongly associated with various cardiovascular events. Aim: To compare the diagnostic efficacy of apolipoproteins with conventional lipids for coronary heart disease. Materials and Methods: There were 295 individuals with or without coronary heart disease were enrolled in the study. The demographic details along with clinical investigations of serum lipid parameters, Apo B and Apo A-I levels were obtained and recorded. Study Design: It was a single centre, prospective observational study of 295 individuals of both the genders (235 males and 60 females) with or without coronary artery disease. Statistical Analysis: A comparison of parametric values between two groups was performed using student’s t-test. Non-parametric analysis of the continuous data was performed using Mann-Whitney U test. Significance was taken as two tailed p less than 0.05. Results: In study population, 221(74.92%) had coronary heart disease (CHD) and 74(25.08%) were normal. Statistically significant differences were found in the levels of apo B/apo A-I ratio (p=0.009), and Apo A-I (p≤0.001) between two groups. The other lipid parameters and ratios such as cholesterol, triglyceride, HDL-C, LDL-C, nonHDL-C cholesterol, VLDL, Total lipid, Apo-B, LDL-C/HDL-C and TC/HDL-C were not found to be significant. Conclusion: The present study shows that Apo B/A-I possesses superior diagnostic efficacy for coronary heart disease as compared to conventional lipid parameters and could be effectively used in clinical practice

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NOVEL INDEXES FOR DIAGNOSING METABOLIC SYNDROME IN APPARENTLY HEALTHY GUJARATI ASIAN INDIANS: A CROSS – SECTIONAL STUDY.
Dr. Hasit Joshi, Dr. Komal Shah, Ms. Priyanka Patel, Dr Jayesh Prajapati, Dr. Meena Parmar, Dr. Dhaval Doshi, Dr. Shardul Chaurushia
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Background: We aimed to compare the diagnostic accuracy of four novel indexes—triglyceride/high-density lipoprotein cholesterol (TG/HDL-C) ratio, weight height ratio (WHtR), lipid accumulation product (LAP) and visceral adiposity index (VAI) with conventional components of metabolic syndrome (MetS) in order to identify a single index for the diagnosis of MetS in Gujarati Indian population.

Methods: This observational and cross sectional study involved a total of 3329 healthy adults of 18–79 years of age. Demographic and clinical data such as body mass index, waist circumference, blood pressure were measured along with the levels of lipids and fasting blood glucose.

Results: The overall prevalence of MetS was 34.32%, which was almost double in older individuals (45.5% vs. 20.8%) and slightly higher in males (37% vs. 31.2%). In comparison to individual components of MetS, three novel indexes—VAI, LAP and TG/HDL-C ratio showed superior diagnostic efficacy yielding an area under curve of 0.856, 0.821 and 0.821 respectively. The optimal cut-offs for VAI, LAP and TG/HDL Ratios for male, females, young and old population are (79.71, 88.12, 75.42, 87.4), (35.62, 34.73, 35.88, 34.7) and (2.249, 3.16, 2.49, 2.79) respectively. The diagnostic effectiveness of novel markers was unaffected by the age and gender of an individual. However, the efficacy of WHtR was comparable with the other conventional markers.

Conclusion: Three novel markers—LAP, VAI and TG/HDL-C ratio could be effectively used as a single ‘Surrogate marker’ for screening of asymptomatic Gujarati Asian Indians with MetS.

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ACCURACY OF DIFFERENT IMAGING MODALITIES PRIOR TO BIVENTRICULAR REPAIR IN TETRALOGY OF FALLOT.
Abhishek Raval, Nilesh Oswal, Bhavesh Thakkar, Rajiv Garg, Komal Shah, Iva Patel Internet Journal of Medical Update. 2016 January;11(1):3-11
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The aim of the present study was to determine the diagnostic accuracy ofnon-invasive tests in patients with Tetralogy of Fallot prior to biventricular repair, and theneed of invasive angiocardiography in specific subgroups. A retrospective analysis wasperformed for paediatric patients with Tetralogy of Fallot who underwent biventricularrepair in three consecutive months. Patients were divided into two groups according totheir age: below and above 5 years. We compared the findings of different imagingmodalities (e.g. echocardiography, multi-detector Computed Tomography (CT) andinvasive angiocardiography) to intraoperative findings to determine their accuracies indifferent subgroups. Results showed that echocardiography is reliable for preoperativeimaging, especially in younger children (sensitivity=71.43%) and its findings are‘moderately’ concordant with intraoperative findings (kappa=0.439). For patients above 5years of age, its sensitivity (29.41%) declines and findings are ‘poorly’ concordant withintraoperative findings (kappa=0.093). With addition of multi-detector CT, the findings ofnon-invasive means are ‘perfectly’ concordant with the intraoperative findings (kappa=1)in children below 5 years and ‘moderately’ concordant with those (kappa=0.4) in childrenabove 5 years. The findings of CT are ‘moderately’ concordant with those of invasiveangiocardiography (kappa=0.4). Tetralogy of Fallot patients below 5 years can directly besubjected to surgery with work-up including detailed echocardiography only. If anatomy isnot clearly delineated, CT helps and invasive angiocardiography is not essential. In patientsabove 5 years, CT has an important role in defining anatomy. The need for catheterizationis limited to hemodynamic evaluation of prior shunt and embolization of aorto-...

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Distribution of Coronary Artery Anomalies and Their Evaluation with Different Imaging Modalities
Abhishek Raval, Nikhil Jadhav, Jayesh Prajapati, Jayesh Rawal, Rajiv Garg, Komal Shah, Iva Patel, International Journal of Medical Research and Review - 2016; Volume 4; Issue 10: pp 1807-1819
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Distribution of Coronary Artery Anomalies and Their Evaluation with Different Imaging Modalities | Raval | International Journal of Medical Research and Review

Introduction: Coronary artery anomalies (CAA) are diverse abnormalities. Methods: A retrospective review of coronary imaging of 17,245 patients over 2 years was performed. Patients with CAA detected on echocardiography, invasive coronary angiography (CAG) and multidetector computed tomographic angiography (MDCTA) were compared. Results: CAAs were detected in 257 patients (1.49%). Prevalence were: absent left main trunk- 0.319%, anomalous coronary artery from opposite sinus (ACAOS)- 0.516%, coronary fistulae- 0.203%, myocardial bridge- 0.093%, malignant anomalies- 0.3%. The commonest CAA was absent left main trunk. The yield of echocardiography negatively correlated with age (r=-0.6). CAG and MDCTA were equal (p=1) for detection of absent left main trunk. CAG had low sensitivity (58.3%) and MDCTA was better than it (p<0.01) for detection of abnormal high origin. For ACAOS, detection by both were not different (p=0.5) but the course was delineated better with MDCTA than with CAG (p=0.05). Both were equal for detection of intramyocardial course (p=0.5). However, MDCTA delineated its course better than CAG (p<0.01). Echocardiography had 93% sensitivity for fistula in those <12 years in age. Radiation exposure with CAG, 7.3 ± 2mSv, was lower than that with MDCTA, 14.5 ± 3mSv (p<0.01). It correlated with CAA score (r=0.3), with CAG but not with MDCTA. Contrast exposure correlated with CAA score (r=0.4) for adults with CAG but not with MDCTA. Conclusion: Echocardiography reliably detects CAAs in children. CAG and MDCTA are comparable for detection of most CAA. MDCTA delineates the course better than CAG. For MDCTA, radiation exposure is not correlated with complexity of CAA in contrast to that with CAG.

 

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Diagnostic accuracy of serum cystatin C for early recognition of contrast induced nephropathy in Western Indians undergoing cardiac catheterization
Anand N. Shukla, Manish Juneja, Himanshu Patel, Komal H Shah, Ashwati Konat, Bhavesh M Thakkar, Tarun Madan, Jayesh Prajapati, Indian Heart Journal - 2016 http://dx.doi.org/10.1016/j.ihj.2016.12.010
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Aims We aimed to compare the diagnostic efficacy of serum cystatin C (sCyC) for contrast induced nephropathy (CIN) in Western Indians undergoing cardiac catheterization. We also aimed to propose a clinically applicable cut-off of sCyC for early identification of CIN in this ethnic group.

Methods In this prospective study, 253 patients undergoing coronary angiography and/or percutaneous coronary intervention were enrolled. The demographic and risk factor details, levels of sCr at baseline, 24 and 48 h after the procedure, whereas baseline and 24 h levels of sCyC were noted. Increase of 0.5 mg/dl or ≥25% from baseline sCr was used to define CIN. Optimum cut off of sCyC for CIN diagnosis was obtained using Receiver Operating Characteristic (ROC) curve analysis.

 Results After 48 h of contrast media (CM) exposure, the incidence of CIN was 12.25% (31 patients) according to sCr definition, where only 3.9% (10 patients) had sCr rise in 24 h. Overall significant (p < 0.0001) rise in mean levels of sCr (48 h) and sCyC (24 h) was observed in CIN patients. However, the mean sCr rise at 24 h was non-significant. The optimum cut off of sCyC for diagnosing CIN was found to be a rise of ≥10% from baseline (AUC – 0.901; sensitivity – 100%, specificity – 77.89%). According to sCyC, 94 (37.15%) patients had CIN.

Conclusion We may conclude that a rise of ≥10% in sCyC at 24 h could be used as a reliable marker for identification of CIN in western Indians undergoing cardiac catheterization.

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Incidence and clinical profile of coronary artery disease in patients with rheumatic heart disease undergoing valvular intervention
Nikhil D Jadhav, Kamal H Sharma, Komal H Shah, Ashwati Konat, Dhammdeep Humane, Sachin Patil, International Journal of Medical Research and Review - 2016; Volume 4: Issue 10: pp 1915-1920
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Incidence and clinical profile of coronary artery disease in patients with rheumatic heart disease undergoing valvular intervention | Jadhav | International Journal of Medical Research and Review

Abstract

Background: We aimed to determine the overall prevalence of coronary artery disease (CAD), atherosclerotic risk factors and clinical profile of patients with rheumatic heart disease (RHD) undergoing valvular interventions in Asian Indians. Method: This was an all comers, observational, prospective study of 757 rheumatic patients, who underwent coronary angiography (CAG) prior to percutaneous balloon valvulotomy, surgical valvular repair or replacement from July 2011 to December 2013. Among them who had significant CAD (stenosis ≥50%) (Group A), were compared with similar number of age and sex matched patients of RHD without CAD (Group B). Result: The overall prevalence of CAD in the patients undergoing valvular intervention was 9.1% (66.7% males, 33.3% female; mean age 55.20±8.6). The CAD incidence in patients with mitral, aortic and both valve replacement were 24.1%, 10.8% and 6.1% respectively. The prevalence of smoking habit (33.3% vs. 20.9%), diabetes (24.6% vs. 3.1%), hypertension (21.7% vs. 6.8%), postmenopausal status (65.2% vs. 18.4%), family history of CAD (17.4% vs. 8.3%) and aortic valve disease (10.1%) was significantly higher in group A as compared to group B except for obesity (11.5% vs. 18.7%). Conclusion: Prevalence of CAD in patients with valvular heart disease in western population of Asian Indians is 9.1%. Coronary angiography should be performed in patients having CAD risk factors, irrespective of the valvular lesion involved.

Keywords: Rheumatic heart disease, Valvular Interventions, Coronary artery disease, Incidence, Risk factors

 

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Cardiac rhythm abnormalities after transcatheter device closure of perimembraneous ventricular septal defects in pediatric patients at intermediate term follow up
Jayal H. Shah, Bhavesh M. Thakkar, Pediatric Review: International Journal of Pediatric Research - 2016; Volume 3: Issue 10: pp 720-725.
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Cardiac rhythm abnormalities after transcatheter device closure of perimembraneous ventricular septal defects in pediatric patients at intermediate term follow up | Shah | Pediatric Review: International Journal of Pediatric Research

Abstract

Background: Transcatheter closure of perimembranous ventricular septal defects in pediatric patients poses special challenges owing to anatomical relationship between conduction system and perimembraneous ventricular septal defect. Aims: The study aims to assess and evaluate the conduction disturbances after transcatheter device closure of perimembranous ventricular septal defect using different occluders at mid-term follow-up. Methods: We studied 297 patients having PMVSD with clinical and/or echocardiographic evidence of a significant left-to-right shunt. All subjects underwent clinical examination, electrocardiogram (ECG), chest X-rays and transthoracic echocardiography before discharge and at 1, 6 and 12-months after the procedure and yearly thereafter. Platelet anti-aggregation therapy with aspirin 5 mg/kg/day orally and endocarditis prophylaxis was prescribed for six months.  Results: The mean age of the patients was 8.64±3.14 years (range 3-17.2 years). Majority (86.2%) had no residual shunt at follow-up. Total rhythm disturbances were seen in about 6% (18/297) of patients with transient complete atrioventricular block (CAVB) occurring in 3 patients. There was no mortality in our study which compares well with the surgical results in which it is between 0-3 percent. Conclusions: This study showed that transcatheter closure of PMVSD using symmetric PMVSD occluders and duct occluders is a safe and effective alternative to surgery. Oversizing of devices should be minimized and low profile devices appropriate to specific morphology of VSD should be used. It has excellent results in experienced hands with minimum morbidity and almost no mortality.

Keywords: Structural heart disease, Perimembraneous ventricular septal defect, Transcatheter closure, Pediatric cardiology

 

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Safety and efficacy of percutaneous device closure of large post tricuspid shunts in pediatric patients with severe PAH at short term and midterm follow up
Jayal H. Shah, Bhavesh M. Thakkar, International Journal of Medical Research and Review - 2016; Volume 4: Issue 10: pp 1724-1730.
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Safety and efficacy of percutaneous device closure of large post tricuspid shunts in pediatric patients with severe PAH at short term and midterm follow up | Shah | International Journal of Medical Research and Review

Abstract

Background: Transcatheter closure of large post-tricuspid shunts in patients with severe pulmonary arterial hypertension remains a challenging problem. Among this unique subset of patients there is an entire spectrum of severity of pulmonary vascular disease with variable pulmonary vascular resistance and reversibility especially in older children. Aims: The current study was done to assess the safety and efficacy of percutaneous device closure of large post tricuspid shunts in pediatric patients with severe PAH at short and mid term follow up. Methods: A total of 42 pediatric patients underwent transcatheter closure of large post tricuspid shunts with severe PAH. All subjects underwent clinical examination, electrocardiography, chest x-rays and echocardiography before discharge and at 1, 6 and 12 months after the procedure and yearly thereafter. Results: Most of the patients (64 %) were having patent ductus arteriosus followed by ventricular septal defect in 8 patients (19.04%), aorto-pulmonary window in 5 patients (12%) and coronary cameral fistula in 2 patients (5%). Cardi-O-Fix VSD occluder was the most commonly used device (45%), Cardi-O-Fix PDA occluder (21%) and Amplatzer duct occluder in 17% patients. Pre-procedural pulmonary artery systolic pressure decreased significantly from mean 81.12 mmHg to mean 43.17 mmHg post procedure over a mean follow-up of 18.5 months. Only two major complications viz; severe aortic obstruction and symptomatic complete heart block were noticed in two children. Conclusions: Our study showed that the transcatheter closure of large post tricuspid shunts in pediatric patients with severe PAH was safe, feasible and efficacious alternative to conventional surgery.

Keywords: Large post-tricuspid shunts, Pediatric Cardiology, Structural heart disease, Transcatheter closure

 

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Intra-aortic balloon pump insertion through the right subclavian artery in a patient of anterior wall myocardial infarction with ventricular septal rupture and severe peripheral artery obstruction disease.
Sharma KH, Shah BS, Jadhav ND. Catheter Cardiovasc Interv. 2016 Sep;88(3):E99-E102. doi: 10.1002/ccd.25425. Epub 2014 Feb 27.
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Intra-aortic balloon pump (IABP) is used in cardiogenic shock of different etiologies.
Routinely, it is inserted through the transfemoral access, but in the patients with severe
peripheral artery obstruction disease (PAOD), use of alternative approach is needed. In
this case report, IABP insertion through the right subclavian artery with the help of cardi-
othoracic surgeon in a patient of anterior wall myocardial infarction (AWMI) with severe
PAOD has been described. A 60-years-old male patient, with the history of chronic
smoking, presented with progressing chest pain for last 3 days. On the basis of clinical
examination and radiological findings, he was diagnosed with AWMI along with the ven-
tricular septal rupture and PAOD. The patient was advised to undergo coronary artery
bypass graft with VSR repair, but to stabilize the patient, it was necessary to put him on
IABP. Because of the severe PAOD, femoral access was not suitable to insert the IABP,
and hence, the right subclavian route was accessed. Then, the patient was operated and
no other complications were encountered. Subclavian arterial IABP insertion under local
anesthesia is easier and safer to perform and allows increased patient mobility. Other
routes, such as, ascending aorta and axillary artery have also been discussed in other
literatures, but subclavian arterial IABP insertion was found to be the best in the patients
with severe PAOD. Trans-subclavian route is an effective approach in extended IABP
utilization even in patients with severe PAOD

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A survey of cardiac implantable electronic device implantation in India: By Indian Society of Electrocardiology and Indian Heart Rhythm Society.
Shenthar J, Bohra S, Jetley V, Vora A, Lokhandwala Y, Nabar A, Naik A, Calambur N, Gupta SB. Indian Heart J. 2016 Jan-Feb;68(1):68-71. doi: 10.1016/j.ihj.2015.06.037. Epub 2016 Jan 18.
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Background:

There is limited data regarding the demographics and type of cardiac implantable electronic device (CIED) in India.

Aim:

The aim of this survey was to define trends in CIED implants, which included permanent pacemakers (PM), intracardiac defibrillators (ICD), and cardiac resynchronization therapy pacemakers and defibrillators (CRT-P/D) devices in India. Methods: The survey was the initiative of the Indian Society of Electrocardiology and the Indian Heart Rhythm Society. The type of CIED used, their indications, demographic characteristics, clinical status and co-morbidities were collected using a survey form over a period of 1 year.

Results:

2117 forms were analysed from 136 centers. PM for bradyarrhythmic indication constituted 80% of the devices implanted with ICD's and CRT-P/D forming approximately 10% each. The most common indication for PM implantation was complete atrio-ventricular block (76%). Single chamber (VVI) pacemakers formed 54% of implants, majority in males (64%). The indication for ICD implantation was almost equal for primary and secondary prevention. A single chamber ICD was most commonly implanted (65%). Coronary artery disease was the etiology in 58.5% of patients with ICD implants. CRT pacemakers were implanted mostly in patients with NYHA III/IV (82%), left ventricular ejection fraction ​

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AGE AND SEX SPECIFIC REFERENCE INTERVALS FOR MODIFIABLE RISK FACTORS OF CARDIOVASCULAR DISEASES FOR GUJARATI ASIAN INDIANS.
Sibasis Sahoo, Komal H. Shah, Ashwati R. Konat, Kamal H. Sharma, and Payal Tripathi International Journal of Chronic Diseases Volume 2015 (2015), Article ID 394798, 9 pages
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Objective. We aimed to establish age and sex specific percentile reference data for cardiovascular risk factors such as lipids, sugar, blood pressure, and BMI in apparently healthy and disease-free Gujarati population. Methods. In this cross-sectional study, we enrolled 3265 apparently healthy and disease-free individuals of both genders residing in Gujarat state. Fasting samples of blood were used for biochemical estimations of lipids and sugar. The measurement of BMI and blood pressure was also done according to the standard guidelines. Age and gender specific 5th, 25th, 50th, 75th, 90th, and 95th percentiles were obtained. Results. The mean values of lipids, sugar, blood pressure, and BMI were significantly () higher in males as compared to female population. Age-wise distribution trends showed increase in the risk factors from the 2nd decade until the 5th to 6th decade in most of the cases, where loss of premenopausal protection in females was also observed. Specific trends according to gender and age were observed in percentile values of various parameters. Conclusion. The outcome of current study will contribute significantly to proposing clinically important reference values of various lipids, sugar, blood pressure, and BMI that could be used to screen the asymptomatic Gujarati Indian population with a propensity of developing dyslipidemia, diabetes, blood pressure, and obesity.

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INCIDENCE AND ASSOCIATES OF RENAL ARTERY STENOSIS IN PATIENTS UNDERGOING PERIPHERAL AND CORONARY ANGIOGRAPHY.
Hasit Joshi, Jayesh Prajapati, Ronak Shah, Pavan Roy, Vipin Bhangdiya, Komal Shah and Priyanka Patel International Journal of Biomedical and Advance Research 2015; 6(08): 558-563.
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Objectives: Increasing prevalence of renal artery stenosis (RAS) in coronary artery disease (CAD) patients has been reported by many. We aimed to study the incidence and risk factors of renal artery disease in patients undergoing coronary angiography (CAG) and/or peripheral angiography (PAG). Methods: Data of 2209 consecutive patients undergoing CAG and/or PAG followed by renal angiography was collected from January-June 2013. Pervasiveness of risk factors such as hypertension, diabetes, dyslipidemia, smoking, family history and incidence of CAD were studied. Significant difference in profiles of patients with or without compelling atherosclerotic renal artery stenosis (ARAS) was tested by chi-square and unpaired t-test. Results and conclusion: Of 2209 patients, the prevalence of RAS in the study population was 6.11%. Mean age of the RAS patient group was 57.17 ± 10.82 years. Advancing age, hypertension, diabetes, smoking and dyslipidemia were found to be strongly associated with RAS. Patients with significant CAD had increased chances to develop ARAS. Ageing and presence of risk factors were closely associated with significant ARAS and hence they could be used in effectively predicting the presence of RAS in patients undergoing routine CAG and/or PAG.

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TRANSCATHETER DEVICE CLOSURE OF PERIMEMBRANOUS VENTRICULAR SEPTAL DEFECT IN CHILDREN TREATED WITH PROPHYLACTIC ORAL STEROIDS: ACUTE AND MID-TERM RESULTS OF A SINGLE CENTER, PROSPECTIVE, OBSERVATIONAL STUDY.
Bhavesh Thakkar, Nehal Patel, Shomu Bohora, Dharmin Bhalodiya, Tarandeep Singh, Tarun Madan, Saurin Shah, Vishal Poptani and Anand Shukla Cambridge University Press 2015
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Background and Objective: Although transcatheter closure of perimembranous ventricular septal defect is emerging as an accepted, viable alternative, conduction disturbances still remain a major concern. Although steroid treatment has shown encouraging results with complete recovery, efficacy of prophylactic use of steroids is still speculative. We aim to study the mid-term outcome of perimembranous ventricular septal defect closure in children who received prophylactic oral steroids. Materials and methods: A prospective study was designed and antegrade device closure was attempted in eligible children who met the following inclusion criteria: age 3–18 years and weight greater than 10 kg, defect diameter less than or equal to 12 mm, and symptomatic, haemodynamic changes or history of infective endocarditis. Prophylactic steroid protocol consisted of 2 weeks oral prednisolone (1 mg/kg/day) initiated immediately after the procedure, and in the event of bradyarrhythmia it was escalated to 2 mg/kg. Patients were regularly followed-up at 1, 6, and 12 months and then annually. Patients with post-procedure heart block underwent Holter monitoring after a minimum of 1 year interval. Results: Between May, 2007 and August, 2012, successful device closure was accomplished in 290/297 patients. Mean age and weight were 9±3.12 years and 21±8.27 kg, respectively. The defect measured 5±1.38 mm on echocardiography. Mean fluoroscopy time was 12.98±8.64 minutes. Eight patients with major complications included one each with device embolisation, haemolysis, severe aortic regurgitation, and five with bradyarrhythmias, including complete atrioventricular block in three, Mobitz II in one, and bifascicular block in one. Patients with complete atrioventricular block responded to high-dose ...

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PREVALENCE AND PREDICTORS OF METABOLIC SYNDROME IN YOUNG ASYMPTOMATIC GUJARATI POPULATION.
Sharad R. Jain, Komal H. Shah, Himanshu N. Acharya, Kaushik Barot and Kamal H. Sharma International Journal of Chronic Diseases Volume 2015 (2015), Article ID 365217
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Background. Metabolic syndrome is a cluster of risk factors leading to the development of atherosclerotic cardiovascular diseases. We aimed to evaluate the prevalence of metabolic syndrome (MS) and its predictors in young and apparently healthy Gujarati individuals. Methods. This population based cross-sectional study involved a total of 1500 healthy adults of 20–40 years of age. Demographic details and clinical data such as body mass index (BMI), waist circumference (WC), and blood pressure were measured along with the estimations of lipoprotein (a), total cholesterol (TC), triglyceride (TG), total lipid, LDL/HDL ratio, TC/HDL ratio, and fasting blood glucose (FBS). Results. Overall in young Gujarati population (20–40 years) prevalence rates of MS were 16.0% (male: 21.5%; female: 10.8%) where the metabolic abnormalities increased with advanced age as 9.56% of the young population (20–30 years) had MS, in contrast to the 24.57% in the old (31–40 years). Odds ratio analysis had indicated BMI (1.120; 95% CI: 1.077–1.163; ) as the strongest risk factor for MS closely followed by advancing age (1.100; 95% CI: 1.061–1.139; ) levels. Conclusion. Prevalence of metabolic syndrome in young Gujarati population reinforces the need for early life style intervention and awareness programs in this ethnic group.

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PREVALENCE AND PROFILES OF DYSLIPIDEMIA IN APPARENTLY HEALTHY ADULT GUJARATI POPULATION.
Sibasis S. Sahoo , Tarun Madan , Kamal H. Sharma , Sharad R. Jain , Komal H. Shah , Yogini A. Kandre Healthline Journal Volume 6 Issue 1 (January – June 2015)
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Introduction : Circulating lipids and lipoproteins are long being recognized as risk factors for developing cardiovascular diseases (CVD). Objective : To evaluate the prevalence and profiles of dyslipidemia in young and asymptomatic Gujarati population. Method : In this cross sectional study we had randomly selected 1440 individuals of the both the genders who were of 20- 40 years of age and disease free. Individuals having history of any medications for diabetes, hypertension and CVD were excluded from the study. The remaining healthy individuals underwent detained physical examinations and tests of lipid profiles. Results :  In the overall population, the prevalence of low HDL-C (36.53%) and high lipoprotein (a) (32.15%) were most common lipid abnormalities found. We have observed that except for lipoprotein (a) (28.4% Vs35.66%),the males were more dyslipidemic than females (p<0.001). Age-wise distribution showed that younger individuals (20-29 years) were having superior lipid profile as compared to their older counterparts (30-40 years) (p less than 0.001). In population having lipoprotein (a) abnormality (32.15%), the low HDL-C (33.7%) was highly prevalent. Conclusion : Thus it is concluded that the young Gujarati population is highly susceptible to develop lipoprotein (a) and HDL-C abnormalities and this information could be used to design the preventive polices for future CVD events.

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DO CIRCULATING BLOOD CELL TYPES CORRELATE WITH MODIFIABLE RISK FACTORS AND OUTCOMES IN PATIENTS WITH ACUTE CORONARY SYNDROME (ACS)?
Kamal H. Sharma, Komal H. Shah, Iva Patel, Alap K. Patel, Subhash Chaudhari Indian Heart Journal
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Aims: Atherosclerosis is an inflammatory process with different cardiovascular risk factors(CVRFs) contributing to its pathogenesis. We aimed to evaluate the specific relationshipbetween circulating blood leukocytes, troponin I and CVRFs.Methods: We prospectively enrolled 959 patients with evidence of acute coronary syndromeeither in form of unstable angina or STEMI or NSTEMI. Details demographic characteristics,CVRF and biochemical parameters such as total white blood cells (WBC), neutrophil,lymphocytes, platelet, neutrophil/lymphocyte ratio (NLR), platelet/lymphocyte ratio (PLR),and troponin I were collected.Results: The results indicated that patients having either hypertension, diabetes or smoking habit had significantly higher levels of total WBC ( p = 0.013), neutrophil ( p = 0.029), NLR ( p = 0.029) and PLR ( p = 0.009). The level of troponin I was unaffected by these risk factors. Significant association of hypertension was found with total WBC ( p = 0.0392), lymphocytes ( p = 0.0384) and PLR ( p = 0.0027), whereas in diabetes and females all other leukocyte subtypes were significantly altered except for platelet and troponin I. Smokers had higher level of total WBC count ( p = 0.0033) and PLR ( p = 0.0464). No relationship between CVRFs and leukocytes was observed in males. The age independent effect was observed with PLR, whereas association with total WBC, lymphocytes, NLR, platelet was specific in older population. In younger patients NLR ( p = 0.0453) is more likely to be elevated. Mortality was significantly associated with changes in the leukocytes but not with the CVRF presence.

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AGE RELATED DIFFERENCES OF NOVEL ATHEROSCLEROTIC RISK FACTORS AND ANGIOGRAPHIC PROFILE AMONG GUJARATI ACUTE CORONARY SYNDROME PATIENTS.
Jayesh Prajapati, Hasit Joshi, Sibasis Sahoo,Kapil Virpariya, Meena Parmar, Komal Shah Journal of Clinical and Diagnostic Research. 2015 Jun, Vol-9(6): OC05-OC09
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Context: Although numerous risk factors have been established to predict the development of acute coronary syndrome (ACS), the risk factor profile may be different between the younger and older individuals. Aim: To analyse the frequency and pattern of atherogenic risk factors and angiographic profiles in age-stratified Gujarati patients with ACS. Materials and Methods : ACS patients undergoing coronary angiography at U.N. Mehta Institute of Cardiology and Research, Gujarat, India between January 2008 and December 2012 were classified in to two age groups with 40y as cut-off. Patients were assessed for conventional risk factors (diabetes mellitus, dyslipidaemia, hypertension, smoking, obesity), novel risk factors (high sensitivity C-reactive protein, lipoprotein (a), homocysteine), and angiographic profiles.The statistical difference between two age groups was determined by Student’s t-test for continuous variables and Chi-square or Fisher’s exact test for categorical variables. Results: A total of 200 patients, 100 patients less than or equal to 40 y of age and 100 patients more than 40 y of age, were evaluated. Older patients had higher frequency of hypertension (32 vs. 16%, p=0.008), while family history of coronary artery disease was more common among younger patients (19 vs. 9%, p=0.041). The incidence of diabetes, dyslipidaemia, smoking and tobacco chewing did not vary significantly between the two groups. Total cholesterol and low-density lipoprotein cholesterol levels were significantly higher in the younger group (p less than 0.05). Lipoprotein (a), homocysteine and high-sensitivity C reactive protein levels were comparable between two age groups. Multi-vessel coronary artery disease was more common among older group. The most commonly affected coronary artery was the left ...

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TISSUE DOPPLER IMAGING IN RHEUMATIC MITRAL VALVE DISEASE PATIENTS FOR THE ASSESSMENT OF LEFT VENTRICULAR FUNCTION.
Mona S Jain, Kamal H Sharma, Nikhil D Jadhav, Komal H Shah, Ashwati Konat American Journal of Advanced Medical & Surgical Research, 2015;1(1):3-8.
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The aim of the study is to investigate whether the Tissue doppler imaging (TDI) technique is advantageous in evaluation of LV systolic function in patients with rheumatic mitral valve disease in comparison to Simpson’s method of conventional echocardiography. In this prospective, crosssectional study,60 age and sex matched individuals were enrolled into two groups (30 in each group) -healthy controls (Group 1) and the patients of rheumatic mitral valve disease (Group 2). In addition to the standard Echocardiographic assessment methods, both the groups underwent the tissue Doppler evaluation,in order to assess the LV function. Student’s t-test was used to compare continuous variable whereas chi-square test was used for the categorical variables. Myocardial performance index (MPI) assessed by conventional echocardiography and tissue doppler method were significantly (<0.001) lower in group 1 (0.39 ± 0.03) as compared to group 2 (0.46 ± 0.02) subjects. Peak systolic myocardial velocity (13.73 ± 2.51 vs 7.8 ± 1.42), early diastolic (16.4 ± 2.99 vs 8.03 ± 1.47) and late diastolic myocardial velocities (11.17 ± 2.04 vs 7.56 ± 1.38) were significantly higher in group 1 than in group 2. The strain and strain rate of base lateral, mid and apical LV free wall, apical-, mid- and base septal were significantly (p<0.05) lower in group 2 as compared to group 1. Tissue Doppler imaging (TDI) can be useful in the detection of subclinical LV dysfunction in patients of rheumatic mitral valve disease. Myocardial strain offers an objective mean to quantify global and regional LV function and to improve the accuracy and reproducibility of conventional echocardiographic studies.

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PREVALENCE AND PREDICTORS OF UNDIAGNOSED HYPERTENSION IN AN APPARENTLY HEALTHY WESTERN INDIAN POPULATION.
Anand N. Shukla, Tarun Madan, Bhavesh M. Thakkar, Meena M. Parmar, and Komal H. Shah Advances in Epidemiology Volume 2015 (2015), Article ID 649184, 5 pages
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This epidemiological study was designed to evaluate the prevalence of undetected hypertension in an apparently healthy western Indian population having no history of major illness. 3629 individuals of 18 years of age were included in the study. Hypertension (HTN) was defined as systolic blood pressure (SBP) 140 mmHg or diastolic blood pressure (DBP) ≥ 90 mmHg and prehypertension (PHTN) as SBP ≥ 120–139 mmHg or DBP ≥ 80–89 mmHg, but without HTN. The prevalence of undiagnosed HTN in the total population was 26% and was 11% and 40% in the young (40-year) and old (40-year) populations, respectively. The prevalence of PHTN, 40% in the overall population, was nearly the same in the young (39%) and the old population (42%). The risk factor most strongly associated with PHTN and HTN was obesity, showing the highest odds ratio in the overall (PHTN 2.14; 95% CI 1.20–3.81; HTN 2.72; 95% CI 1.53–4.85), the young (PHTN 2.29; 95% CI 1.25–4.21; HTN 2.92; 95% CI 1.59–5.35), and the old (PHTN 1.13; 95% CI 0.65–1.96; HTN 1.38; 95% CI 0.79–2.4) populations. Hypertension is a major risk factor for cardiovascular diseases which must not be ignored, especially in the western Indian population.

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ARE GUJARATI ASIAN INDIANS ‘OLDER’ FOR THEIR ‘VASCULAR AGE’ AS COMPARED TO THEIR ‘CHRONOLOGICAL AGE’?.
Kamal H Sharma, Sibasis Sahoo, Alap K Patel, Nikhil D Jadhav, Meena M Parmar, Komal H Shah, Krutika H Patel, QJM: An International Journal of Medicine - 2015; Volume 108: Issue 2: pp 105-12
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Background: South Asians are known to carry higher burden of cardiovascular diseases as compared to their Caucasian counterparts. Aim: The current study was designed to evaluate whether vascular age is advanced for Gujarati Asian Indians as matched to their chronological age in apparently healthy, asymptomatic population. We have also assessed the contributing risk factors for premature vascular ageing. Design : It was cross sectional study of 2483 individuals of Gujarat state in Western India having no past or present history of major illness including CVD. Methods : The vascular age of the population was calculated using Framingham vascular age calculator. A relationship between risk factor prevalence and vascular ageing was evaluated using univariate analysis of variance. Results : The mean chronological age of the study population was 46.8 (±10.35) years whereas mean vascular age was 53.34 (±16.05) years, and the difference (6.54±9.5) between both was statistically significant (p<0.0001). Contributory risk factors for advanced vascular age apart from chronological age (75.4%) and male gender (66.2%) were the presence of dyslipidemia (60.4%) hypertension (57.34%) and increased waist circumference (male 39.7%, female 29%). Results of regression analysis showed that vascular age progression was highly associated with blood pressure (19.9, 95% CI: 14.34-27.63), followed by smoking (15.23, 95% CI: 8.4-27.59), and blood sugar (12.97, 95% CI: 3.48-48.25). Conclusions: The Gujarati Asian Indians are subjected to premature vascular ageing and henceforth routine screening for vascular age and risk factors prevalence is strongly advocated in this ethnic group.

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Study of Effectiveness and Safety of Percutaneous Balloon Mitral Valvulotomy for Treatment of Pregnant Patients with Severe Mitral Stenosis
Hasit Sureshbhai Joshi, Jagjeet Kishanrao Deshmukh, Jayesh Somabhai Prajapati, Sibasis Shahsikant Sahoo, Pooja Maheshbhai Vyas, and Iva Vipul Patel, Journal of Clinical and Diagnostic Research - 2015; Volume 9: Issue 12: pp OC14–OC17.
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Introduction: In pregnant women mitral stenosis is the commonest cardiac valvular lesion. When it is present in majorly severe condition it leads to maternal and fetal morbidity and mortality. In mitral stenosis pregnancy can lead to development of heart failure.
Aim: To evaluate the safety and efficacy of balloon mitral valvulotomy (BMV) in pregnant females with severe mitral stenosis.
Materials and Methods: A total of 30 pregnant patients who underwent BMV were included in the study from July 2011 to November 2013. Clinical follow-up during pregnancy was done every 3 months until delivery and after delivery. The mean follow up time after BMV was 6.72±0.56 months.
Results: From the 30 pregnant females 14 (46.67%) and 16 (53.3%) patients underwent BMV during the third and second trimester of pregnancy respectively. The mean mitral valve area was 0.85+0.16 cm2 before BMV that increased to 1.60+0.27 cm2 (p<0.0001) immediately after BMV. Peak and mean diastolic gradients had decreased significantly within 48 hours after the procedure (p<0.001) but remained very much unchanged at 6.72 month period of follow-up. Two patients had an increase in mitral regurgitation by 2 grades.
Conclusion: During pregnancy BMV technique is safe and effective in patients with severe mitral stenosis.

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Clinical and angiographic follow-up of coronary artery fistula interventions in children: techniques and classification revisited.
Thakkar B, Patel N, Poptani V, Madan T, Saluja T, Shukla A1, Oswal N, Bisnoi A., Cardiol Young - 2015; Volume 25: Issue 4: pp 670-80
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Clinical and angiographic follow-up of coronary artery fistula interventions in children: techniques and classification revisited. - PubMed - NCBI

BACKGROUND:

Transcatheter closure of coronary artery fistula has emerged as a safe and effective alternative to surgery. However, follow-up angiographic data after closure of the coronary artery fistula is extremely limited. We report our clinical and angiographic follow-up of children who underwent either transcatheter or surgical closure.

METHOD:

Clinical profile, echocardiography parameters, and closure technique were retrospectively reviewed from the hospital charts. Since 2007, 15 children have been intervened and followed up with electrocardiography, echocardiography, and angiography.

RESULTS:

A total of 15 children (six girls), with mean age of 6.7±5.4 years and weighing 16.3±9.8 kg, underwent successful closure (transcatheter=13, surgical=2) without periprocedural complication. Coronary artery fistula arose from the right (n=7) and left coronary artery (n=8) and drained into the right atrium or the right ventricle. Transcatheter closure was carried out using a duct occluder. Of the patients, two underwent surgical closure of the fistula on a beating heart. At 31.8±18.7 months follow-up, all the children were asymptomatic and had no evidence of myocardial ischaemia or infarction. However, follow-up angiography revealed thrombotic occlusion of fistula with the patent parent coronary artery in those having branch coronary artery fistula, and five of seven patients with parent coronary artery fistula had near-complete occlusion of fistula extending into the native coronary artery.

CONCLUSION:

Follow-up angiography revealed a high incidence of parent artery occlusion when the fistula was arising from the native artery and not from one of its branches. Coronary artery fistula intervention of the parent coronary artery fistula always carries the potential risk of ischaemia, unless the distal-most exiting segment is the primary site of occlusion.

 

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ENCORE: Extension of the ANTHEM-HF Study Evaluating Autonomic Regulation Therapy in Reduced Ejection Fraction Heart Failure
Jain, Rajendra & Sharma, Kamal & Mittal, Sanjay & Monteiro, Rufino & Libbus, Imad & DiCarlo, Lorenzo & Ardell, Jeffrey & S. Rector, Thomas & Amurthur, Badri & Kenknight, Bruce & Anand, Inder. Journal of Cardiac Failure. 21. 940. 10.1016/j.cardfail.201
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Extended Follow-Up of Patients with Heart Failure Receiving Autonomic Regulation Therapy in the ANTHEM-HF Study. Journal of Cardiac Failure
Jain, Rajendra & Sharma, Kamal & Mittal, Sanjay & Monteiro, Rufino & Dixit, Satyajit & Libbus, Imad & A DiCarlo, Lorenzo & Ardell, Jeffrey & S Rector, Thomas & Amurthur, Badri & Kenknight, Bruce & Anand, Inder. J Card Fail. 2016 Aug;22(8):639-42. doi: 1
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Objective

Evaluate the effects of a novel autonomic regulation therapy (ART) via vagus nerve stimulation (VNS) in patients with chronic heart failure (HF) and reduced left ventricular ejection fraction during a 12-month follow-up period.

Methods

The Autonomic Regulation Therapy for the Improvement of Left Ventricular Function and Heart Failure Symptoms (ANTHEM-HF) study enrolled 60 subjects with New York Heart Association class II-III HF and low left ventricular ejection fraction (≤40%), who received open-loop ART using VNS randomized to left or right cervical vagus nerve placement and followed for 6 months after titration to a therapeutic output current (2.0 ± 0.6 mA). Patients received chronic stimulation at a frequency of 10 Hz and pulse duration of 250 µsec. Forty-nine subjects consented to participate in an extended follow-up study for an additional 6 months (12 months total posttitration) to determine whether the effects of therapy were maintained.

Results

During the 6-month extended follow-up period, there were no device malfunctions or device-related serious adverse effects. There were 7 serious adverse effects unrelated to the device, including 3 deaths (2 sudden cardiac deaths, 1 worsening HF death). There were 5 nonserious adverse events that were adjudicated to be device-related. Safety and tolerability were similar, and there were no significant differences in efficacy between left- and right-sided ART. Overall, mean efficacy measure values at 12 months were not significantly different from mean values at 6 months.

Conclusions

Chronic open-loop ART via left- or right-sided VNS continued to be feasible and well-tolerated in patients with HF with reduced EF. Improvements in cardiac function and HF symptoms seen after 6 months of ART were maintained at 12 months.

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CARDIOVASCULAR DISEASE RISK FACTOR ESTIMATION IN GUJARATI ASIAN INDIAN POPULATION USING FRAMINGHAM RISK EQUATION.
Sibasis Sahoo, Komal Shah, Anand Shukla, Jayesh Prajapati, Pratik Shah NATIONAL JOURNAL OF MEDICAL RESEARCH Volume 4│Issue 4│Oct – Dec 2014
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Introduction: Framingham 10 years risk estimation tools are potentially a cost-effective strategy for cardiovascular disease (CVD) prevention in developing countries. The current investigation was designed to predict CVD risk in healthy and asymptomatic Gujarati Asian Indians. Methods: It was observational study of 2483 individuals of Gujarat state having no past or present history of major illness including CVD. The study cohort was stratified into three groups of low-, intermediate- and high risk of CVD according to the Framingham 10 years risk calculator and the contributing factors for higher CVD risk were studied. Results : Out of 2483 individuals, (65.4%) had low risk of CVD event followed by 21.95% having intermediate and 12.65% showing high risk. The low level of HDL-C (85.03%), hypertension (63.69%) and elevated TC (60.83%) and LDL-C (60.83%) were found to be the main contributors for CVD risk. In high risk males the levels of TC (58.45%) and LDL-C (58.1%) were significantly elevated (p<0.0001), whereas levels of HDL-C (92.25%) markedly low in this subset of population, whereas in females hypertension (100%) and abnormalities of lipids (TC – 83.33%, LDL-C – 86.67%) were the contributors. The CVD risk increased with age in both the genders where maximum risk was found at the population being in the 60-69 years (male – 45.07%; female – 46.67%) of the age. Conclusion: Higher risk in Gujarati Asian Indian community is mainly attributed by dyslipidemias and hypertension. Both of them being modifiable risk factors, the life style modification is highly advocated in this ethnic group.

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PATIENT PROFILE AND RESULTS OF PER-CUTANEOUS TRANS-VENOUS MITRAL COMMISSUROTOMY IN MITRAL RESTENOSIS FOLLOWING PRIOR PER-CUTANEOUS TRANS-VENOUS MITRAL COMMISSUROTOMY VS SURGICAL COMMISSUROTOMY.
Kamal H. Sharma, Sharad Jain, Anand Shukla, Shomu Bohora, Bhavesh Roy, Gaurav D. Gandhi, A.J. Ashwal indian heart journal 66 (2014) 164-168
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Background: Patients with mitral restenosis who have undergone prior PTMC or surgical commissurotomy have increased. Predictors of outcome of repeat PTMC in either subgroup of patients may be different. Aims and objectives: Aim was to assess and compare the immediate results of PTMC in patients who had undergone a prior PTMC or surgical commissurotomy. Methods and results: This is a single center, prospective, open label study. Of 70 patients in study, 44 (62.85%) patients had prior history of PTMC and 26 (37.15%) had prior surgical commissurotomy (closed/open). Average time from the initial procedure was 8.88 +/- 5.36 years overall, 6.75 +/- 3.38 for patients with prior PTMC and 16.73 +/- 3.67 for patients with prior surgical commissurotomy. Prior PTMC group had 75% female, patients with prior surgical commissurotomy were older (44 +/- 7 vs 33.57 +/- 9.1 years, p = 0.001), had higher NYHA class (III/IV in 100% vs 86.36%, p = 0.006.), higher atrial fibrillation (73.1% vs 25% p less than 0.0001) and higher Wilkins’ score (greater than 8 in 88.46% vs 68.18%, p = 0.05). Successful PTMC was lower (65.4% vs 84.1%) in patients with prior surgical commissurotomy, though statistically not significant (p = 0.07). After PTMC, mitral valve area, PA systolic pressure, LA

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DOES THE CLINICAL PROFILE OF GUJARATI PATIENTS WITH TAKAYASU’S AORTOARTERITIS DIFFER FROM OTHER INDIANS?
Sharad R Jain, Kamal H Sharma, Rajiv Garg and Nikhil Jadhav Internet Journal of Medical Update. 2014 July;9(2):4-8
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Takayasu’s aortoarteritis is a well-known yet rare form of large vessel vasculitis. It is a chronic inflammatory diseas, which has remained an enigma since it was first described a century ago. The present study was done to document the demographic profile, clinical course, complications and survival of 30 consecutive patients with aortoarteritis in the Gujarati population of western India. The study used non-invasive (color doppler, CT and MR angiography) and invasive techniques (conventional angiography) to document the vessels involved. The study showed almost equal incidence of disease in males and females in the Gujarati population unlike in other studied populations. Incidence of type-III aortoarteritis was the most common and left renal involvement was found to be significantly more common than right renal involvement in the present study. There was no mortality during the study period.

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COST-EFFECTIVENESS ANALYSIS OF NEBIVOLOL AND METOPROLOL IN ESSENTIAL HYPERTENSION: A PHARMACOECONOMIC COMPARISION OF ANTIHYPERTENSIVE EFFICACY OF BETA BLOCKERS.
Rachna S. Patel, Kamal H. Sharma, Nitisha A. Kamath, Nirav H. Patel, Ankita M. Thakkar Indian J Pharmacol. 2014 Sep-Oct; 46(5): 485–489.
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Objective: To estimate and compare the cost-effectiveness and safety of nebivolol with sustained-release metoprolol in reducing blood pressure by 1 mm of Hg per day in hypertensive patients. Materials and Methods : This was a prospective, randomized, open label, observational analysis of cost-effectiveness, in a questionnaire-based fashion to compare the cost of nebivolol (2.5 mg, 5 mg, 10 mg) and sustained released metoprolol succinate (25 mg, 50 mg, 100 mg) in hypertensive patients using either of the two drugs. A total of 60 newly detected drug naïve hypertensive patients were considered for the comparison, of which 30 patients were prescribed nebivolol and the other 30 were prescribed metoprolol succinate as per the recommended dosage. Based on the data, statistical analysis was carried out using GraphPad Prism 5 and MS Excel Spreadsheet 2007. Results: The cost of reducing 1 mm of Hg blood pressure per day with nebivolol was 0.60, 0.70, and 1.06 INR, whereas that of metoprolol succinate was 0.93, 1.18, and 1.25 INR at their respective equivalent doses, hence significantly lower with the nebivolol group as compared to the metoprolol group (P < 0.05). Conclusions: This pharmacoeconomic analysis shows that nebivolol is more cost-effective as compared to metoprolol when the cost per reduction in blood pressure per day is considered. This may affect the patients economically during their long-term use of these molecules for the treatment of hypertension.

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ASSOCIATION OF HIGH DENSITY LIPOPROTEIN WITH PLATELET TO LYMPHOCYTE AND NEUTROPHIL TO LYMPHOCYTE RATIO IN CORONARY ARTERY DISEASE PATIENTS.
Jayesh H. Prajapati, Sibasis Sahoo, Tushar Nikam, Komal H. Shah, Bhumika Maheriya, and Meena Parmar Journal of Lipids Volume 2014 (2014), Article ID 686791, 8 pages
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Background : We aimed to evaluate a relationship between platelet-lymphocyte ratio (PLR) and neutrophil-lymphocyte ratio (NLR) with high density lipoprotein (HDL) cholesterol levels in coronary artery disease (CAD) patients. Methods : A total of 354 patients with angiographically confirmed coronary blockages were enrolled in the study. Hematological indices and lipid profiling data of all the patients were collected. Results: We have observed significant association between HDL and PLR (P=0.008) and NLR (P=0.009); however no significant relationship was obtained with HDL and isolated platelet (P=0.488), neutrophil (P=0.407), and lymphocyte (P=0.952) counts in CAD patients. The association was subjected to gender specific variation as in males PLR (P=0.024) and NLR (P=0.003) were highly elevated in low HDL patients, whereas in females the elevation could not reach the statistically significant level. The PLR (217.47 versus 190.3;P=0.001 ) and NLR (6.33 versus 5.10;P=0.001 ) were significantly higher among the patients with acute coronary syndrome. In young patients the PLR (P=0.007) and NLR (P=0.001) were inversely associated with HDL, whereas in older population only NLR (P=0.005) had showed a significant association. Conclusions: We conclude that PLR and NLR are significantly elevated in CAD patients having low HDL levels.

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CLINICAL AND ANGIOGRAPHIC FOLLOW-UP OF CORONARY ARTERY FISTULA INTERVENTIONS IN CHILDER: TECHNIQUES AND CLASSIFICATION REVISITED.
Bhavesh Thakkar, Nehal Patel, Vishal Poptani, Tarun Madan, Tarandip Saluja, Anand Shukla, Nilesh Oswal and Arvind Bisnoi Cardiology in the Young / FirstView Article pp 1-11
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Background : Transcatheter closure of coronary artery fistula has emerged as a safe and effective alternative to surgery. However, follow-up angiographic data after closure of the coronary artery fistula is extremely limited. We report our clinical and angiographic follow-up of children who underwent either transcatheter or surgical closure. Methods : Clinical profile, echocardiography parameters, and closure technique were retrospectively reviewed from the hospital charts. Since 2007, 15 children have been intervened and followed up with electrocardiography, echocardiography, and angiography. Results: A total of 15 children (six girls), with mean age of 6.7±5.4 years and weighing 16.3±9.8 kg, underwent successful closure (transcatheter=13, surgical=2) without periprocedural complication. Coronary artery fistula arose from the right (n=7) and left coronary artery (n=8) and drained into the right atrium or the right ventricle. Transcatheter closure was carried out using a duct occluder. Of the patients, two underwent surgical closure of the fistula on a beating heart. At 31.8±18.7 months follow-up, all the children were asymptomatic and had no evidence of myocardial ischaemia or infarction. However, follow-up angiography revealed thrombotic occlusion of fistula with the patent parent coronary artery in those having branch coronary artery fistula, and five of seven patients with parent coronary artery fistula had near-complete occlusion of fistula extending into the native coronary artery. Conclusions: Follow-up angiography revealed a high incidence of parent artery occlusion when the fistula was arising from the native artery and not from one of its branches. Coronary artery fistula intervention of the parent coronary artery fistula always carries the potential risk of ischaemia, unless ...

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THE OBESITY PARADOX IN THE DISTRIBUTION OF DYSLIPIDEMIA IN OBESE VERSUS NON-OBESE PATIENTS OF CAD IN GUJARATI POPULATION.
Kamal H Sharma, Sanjay J Vaghani, Gaurav D Gandhi, Nikhil D Jadav, Sandarbh P Patel, Meena M Parmar, Komal H Shah Indian Association of Preventive and Social Medicine, Health Line Journal, VOLUME: 5 ISSUE: 1 January-June 2014
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Background: Cardiovascular diseases (CVD) are the major cause of morbidity and mortality in developing countries. Risk factors for CVD like hypertension, diabetes, dyslipidemia and smoking contribute significantly to atherosclerosis and consequently to CVD. The aim of this study was to observe distribution of these risk factors in Gujarati coronary artery disease (CAD) patients over the entire spectrum of BMI and to look for existence of obesity paradox. Methods : This randomized and crosssectional study was done in September, 2010 on 818 subjects. Subjects of established CAD were evaluated by pretested proforma, physical examinations and, tests of lipid profiles, blood sugar levels. Results: The proportion of hypertension, was significantly higher in More than 30 BMI group than BMI less than 25 and 25-30 group (p value less than 0.0001). Diabetes and dyslipidemia were non-significantly higher in BMI 25-30 than BMI less than 25 and more than 30 showing possible effect of obesity paradox. In females, effect of obesity paradox was found in high cholesterol content which was statistically significant (p=0.0465) and low HDL was highest in BMI with less than 25 than those with BMI with 25-30 and more than 30 (p=0.1341). The same effect was observed with LDL also but in a non-significant (p=0.6556) fashion. The results found in male population were similar to the females in case of high cholesterol and LDL. Though statistically insignificant the age related dyslipidemia distribution also showed existence of obesity paradox. Conclusions: In females, high cholesterol was more in BMI less than 25 than BMI 25-30 and more than 30 group. Same effect was found in males also but did not reach statistically significant level.

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ASSOCIATION BETWEEN ANDROGENETIC ALOPECIA AND CORONARY ARTERY DISEASE IN YOUNG MALE PATIENTS.
Kamal H Sharma, Anchal Jindal International Journal of Trichology / Jan-Mar 2014 / Vol-6 / Issue-1
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Background : Several studies have demonstrated an association between androgenetic alopecia (AGA) and cardiovascular disease. Still controversies exist regarding the association.Are they truly associated? Objective< Strong> : The purpose of the present study was to assess the prevalence of AGA and establish its association in young (<45 years) Asian Indian Gujarati male patients having coronary artery disease (CAD). Materials and Methods : Case‑control prospective multicentric study was carried out on 424 men. Case group consisted of 212 male subjects having CAD (Group 1) and another 212, either sibling or first degree male relative of the case subjects (having no evidence of CAD) were considered as the control group (Group 2). Age, total cholesterol, incidence of diabetes mellitus, and hypertension were similar in both groups. The degree of alopecia was assessed using the Norwood‑Hamilton scale for men. Statistical analysis was performed using Chi‑square test. Results: AGA was found in 80 (37.73%) young CAD patients (Group 1), whereas 44 (20.7%) of patients had alopecia in the control group (Group 2). There was statistically significant association between male AGA and CAD (P = 0.001). Odds ratio was 2.70 (95% confidence interval [CI], 1.72 ± 4.26). Statistically significant association was found between high grade baldness (Grades IV‑VII) and CAD in young men (P < 0.05). Odds ratio = 2.36 (95% CI, 1.108 ± 5.033). There is statistically significant association of AGA in young Asian Gujarati male with CAD and the prevalence of AGA in young CAD patient is 37.73%. Conclusions: This study implies early onset AGA in male is independently associated with CAD, though mechanisms need to be investigated.

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NOVEL ATHEROSCLEROTIC RISK FACTORS AND ANGIOGRAPHIC PROFILE OF YOUNG GUJARATI PATIENTS WITH ACUTE CORONARY SYNDROME.
Jayesh Prajapati, Sharad Jain, Kapil Virpariya, Jayesh Rawal, Hasit Joshi,Kamal Sharma, Bhavesh Roy, Ashok Thakkar Journal of the association of physicians of india • vol 62 • published July, 2014
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Objectives: In this study we aimed to analyse the frequency of atherosclerotic risk factors with focus to novel risk factors for coronary artery disease and angiographic profile in young (≤ 40 years) acute coronary syndrome (ACS) patient with healthy controls in Gujarat, India. Methods : Between January 2008 and December 2012, 109 consecutive young patients aged ≤ 40 years old, diagnosed to have ACS were included in the study. All ACS patients underwent diagnostic coronary angiography. An equivalent age and sex matched population without coronary disease with similar risk factors without tobacco considered a control group. All angiographic patients were evaluated for conventional risk factors for coronary artery disease like diabetes mellitus, hypertension, smoking, obesity as well as novel atherogenic risk factors like high sensitivity C-reactive protein (Hs-CRP), Lipoprotein(a) [LP(a)], homocysteine, apolipoprotein A1 (ApoA1) and B (ApoB). Results: In a study group, out of 109 young patients, 90 (82.6%) patients were presented to our hospital as ST-segment elevation myocardial infarction (STEMI), 10 (9.2%) presented as known non- ST-elevation myocardial infarction (NSTEMI) and 9 (8.3%) presented as unstable angina (UA). Serum cholesterol, triglycerides, LDL, LP(a) and lipid tetrad index were significantly higher in the study group whereas the HDL levels significantly lower as compared to the control group. Conclusions: A quite common risk factors of premature CAD are smoking, high Hs-CRP, high LP(a), hyperhomocysteinaemia and positive family history in the young ACS. Most common presentation of ACS in young was STEMI. On angiography, single vessel involvement was the most common finding.

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CLINICAL PROFILE OF PEDIATRIC PATIENTS WITH LONG QT SYNDROME MASQUERADING AS SEIZURES.
Bhavesh Thakkar, Anand Shukla, Tarandeep Singh, Saurin Shah, Shomu Bohora, Jayal Shah, Tarun Madan The Indian Journal of Pediatrics January 2014
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Objective : To study the clinical profile of patients with long QT syndrome presenting as seizures. Methods : Retrospective analysis of six pediatric patients admitted at authors’ institute between October 2008 and January 2013 with seizures and a presumptive diagnosis of long QT syndrome (LQTS) was done. The diagnosis was made on the basis of updated Schwartz diagnostic criteria. Clinical data, investigation profile and follow up of patients was recorded in a standard format and analysed. Results: All the 6 patients in the study were boys with a mean age of 10.3 ± 2.8 y at the time of diagnosis. The lag period between symptom onset and diagnosis was 5.6 ± 3.14 y. All patients had history of seizures with a history of precipitating event in 4 patients. Average baseline QTc interval was 556 ± 41.31 ms. Mean Schwartz score was 6.66 ± 1.16. Polymorphic VT was documented in 4 patients. After initiating standard treatment with betablockers, nicorandil, spironolactone or pacemaker, all the six patients were asymptomatic at a mean follow up period of 17.5 mo, with no recurrence of seizures. Conclusions: LQTS can cause seizures due to prolonged ventricular arrhythmias in high risk subgroup. Children, who present with LQTS and seizures, generally have a precipitating event causing seizures, and they respond well to drug therapy.

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ONE YEAR CLINICAL OUTCOMES OF BIOMATRIX™-BIOLIMUS A9™ ELUTING STENT: THE E-BIOMATRIX MULTICENTER POST MARKETING SURVEILLANCE REGISTRY IN INDIA.
Ashwin B. Mehta, Praveen Chandra, Jamshed Dalal, Prabhakar Shetty, Devang Desai, K. Chocklingam, Jayesh Prajapati, pramod Kumar, Vilas Magarkar, Apurva Vasawada, B.K. Goyal, Viveka Kumar, V. Suryaprakash Rao, Ramesh Babu, Pritesh Parikh, Upendra Kaul, Ar
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Objectives: The e-BioMatrix is a post marketing multicenter registry with an objective to evaluate the 2 year clinical safety and efficacy outcomes in patients treated with BioMatrix™ – Biolimus A9™ (BA9™) drug eluting stents (DES). Background : Drug-eluting stents still have late-stage disadvantages that might be attributable to the permanent polymer. BioMatrix a new generation DES containing anti-proliferative drug Biolimus A9™ incorporating a biodegradable abluminal coating that leaves a polymer-free stent after drug release enhancing strut coverage while preventing neointimal hyperplasia.Methods : This interim analysis consists of a total of 1189 patients with 1418 lesions treated with BioMatrix stent who entered this multicenter registry in India. We analyzed the incidence of major adverse cardiac events (MACE) and stent thrombosis (ST) at 1, 6, and 12 months with an extended follow-up of 2 years. Recommended antiplatelet regimen included clopidogrel and aspirin for 12 months. Results: The mean age was 57.6 ± 10.9 years, 81.8% were males, comorbidity index was 1.20 ± 1.33, 68% presented with acute coronary syndrome, 49% had hypertension and 40.8% had diabetes mellitus. One-year clinical follow-up was completed in 987 patients at the time of interim analysis. The incidence of MACE is 0.45 for 1544 person-year follow-up. There were only 03 cases of ST (01 late ST) reported during this time. Conclusions: This registry demonstrates excellent one-year clinical safety and efficacy of BioMatrix stents. The 1-year result shows that BioMatrix stent may be a suitable alternative as compared to contemporary DESs which are currently available in the market for simple as well complex disease.

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RESPONSE OF BLOOD PRESSURE AFTER PERCUTANEOUS TRANSLUMINAL RENAL ARTERY ANGIOPLASTY AND STENTING.
Jayesh S Prajapati, Sharad R Jain, Hasit Joshi, Shaurin Shah, Kamal Sharma, Sibasis Sahoo, Kapil Virparia and Ashok Thakkar World J Cardiol. 2013 July 26; 5(7): 247-253
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Aim : To evaluate the short and intermediate term outcome of percutaneous transluminal renal artery angioplasty (PTRA) and stenting particularly on blood pressure (BP) control and renal function and to evaluate predictors of poor BP response after successful PTRA and stenting.Methods : We conducted a prospective analysis of all patients who underwent PTRA and stenting in our institute between August 2010 to September 2012. A total number of 86 patients were underwent PTRA and renal stenting. Selective angiography was done to confirm at least 70% angiographic stenosis. The predilatation done except few cases with critical stenosis, direct stenting was done in the rest of cases. All patients received aspirin 325 mg orally, and clopidogrel 300 mg orally within 24 h before the procedure. Heparin was used as the procedural anticoagulant agent. Optimal results with TIMI-III flow obtained in all cases. Following stent placement, aspirin 150 mg orally once daily was continued for a minimum of 12 mo and clopidogrel 75 mg orally once daily for at least 4 wk. The clinical, radiological, electrocardiography, echocardiography and treatment data of all patients were recorded. The BP measurement, serum creatinine and glomerular filtration rate (GFR) were recorded before the procedure and 1 and 6 mo after PTRA. Results: A total of 86 patients were included in the study. The mean age of study population was 55.87 ± 11.85 years old and 67 (77.9%) of patients were male. There was a significant reduction in both systolic and diastolic BP at 1 mo after the procedure: 170.15 ± 20.10 mmHg vs 146.60 ± 17.32 mmHg and 98.38 ± 10.55 mmHg vs 89.88 ± 9.22 mmHg respectively (P = 0.0000). The reduction in BP was constant throughout the follow-up period and was evident 6 mo after the procedure: ...

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EFFECTS OF IMPLICATION OF TIME MANAGEMENT PRINCIPLES ON EFFICIENCY PARAMETERS IN THE CARDIAC CATHETERIZATION LABORATORY.
Kamal Sharma, Anchal Jindal healthline pISSN 2239-337X/eISSN 2320-1525 Volume 4 Issue 1 January-June 2013
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Context : With the increasing incidence of Coronary Artery disease in developing countries and availability of fewer resources and manpower, optimal Operating Room management is the key factor for patient care.Aims: To evaluate the effect of time management principles on efficiency parameters in the cardiac cath-lab.Methods and Materials : Prospective interventional study was carried out on patients admitted for procedures at the cath lab amongst eight cardiologists during April 2009 to June 2009. The control period was from January 2009 to March 2009. Parameters like start time tardiness, case cancellation rate, turn over time, waiting time of the operator in the waiting area of the cath-lab and patients’ waiting since hospitalization for operative slot was evaluated after the implementation of time management steps and compared with control group. Unpaired t-test was used for statistical analysis. P< 0.05 was considered as statistically significant.Results: Total number of the patients were 430 (Mean + SD, 73.75+83.63) and 590 (75+52.59) for study group and for control group respectively. Implementation of operating room (OR) management principles resulted in improvement of OR efficiency parameters reaching statistically significant reduction in start-time tardiness (P=0.023), case cancellation rate (P=0.031), turnover time (P=0.0113) and patient waiting time (P=0.025) while reduction in cardiologist waiting time did not reach statistically significant level (P=0.15).Conclusions: Implementation of OR management principles in cath-lab resulted in improvement of most of the efficiency parameters in patient management.

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EFFICACY AND SAFETY OF TENECTEPLASE IN PULMONARY EMBOLISM.
Anand N. Shukla, Bhavesh Thakkar, Ashwal A. Jayaram, Tarun H. Madan, Gaurav D. Gandhi International Urology and Nephrology December 2013, Volume 45, Issue 6, pp 1629-1635
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Pulmonary embolism (PE) is a relatively common life-threatening cardiovascular condition associated with significant morbidity and mortality. We present the efficacy and safety data of weight-adjusted tenecteplase in 30 consecutive patients of acute PE. 30 patients (22 male, 8 female) with acute PE were included in the study and divided into three groups: (1) Acute PE complicated by shock stage and/or persistent hypotension (12 patients). (2) RV dilatation and/or dysfunction without hypotension (14 patients). (3) Severe hypoxemia without hypotension and RV dysfunction (4 patients). Predominant symptoms were dyspnoea, cough, chest pain, syncope and haemoptysis, noted in 100 % (30), 40 % (12), 54 % (16), 32 % (9) and 10 % (3) of patients respectively. RV dilatation and dyskinesia were present in 86 %, septal paradoxical movement in 73 % and inferior venacava collapse absent in 53 % of patients respectively. 12 patients presented with acute PE and cardiogenic shock, 14 patients showed RV dilatation and dysfunction with systolic BP more than 90 mmHg and four patients were having RV dilation without dysfunction but severe hypoxemia. There was significant reduction in right ventricular systolic pressure and improvement in right ventricular dysfunction. Our study shows that tenecteplase is very effective and safe in the treatment of PE with minimal risk of bleeding in high risk group and intermediate risk and even in selective low risk category group of patients. However, in view of small number of patients in study group, a large multicentre randomized study would be required to draw a firm conclusion regarding the thrombolysis in low risk category patient.

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PREVALENCE AND PREDICTORS OF RENAL ARTERY STENOSIS IN PATIENTS UNDERGOING PERIPHERAL AND CORONARY ANGIOGRAPHY.
Anand N. Shukla, Tarun H. Madan, Ashwal A. Jayaram, Vivek B. Kute, Jayesh R. Rawal, A. P. Manjunath, Satyam Udhreja International Urology and Nephrology December 2013, Volume 45, Issue 6, pp 1629-1635
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Background : Renal artery stenosis is a potential cause of secondary hypertension, ischemic nephropathy and end-stage renal disease. Atherosclerosis is by far the most common etiology of renal artery stenosis in elderly. We investigated whether the presence of significant atherosclerotic renal artery stenosis (ARAS) with luminal diameter narrowing ≥50 % could be predicted in patients undergoing peripheral and coronary angiography.Methods : The records of 3,500 consecutive patients undergoing simultaneous renal angiography along with peripheral and coronary angiography were reviewed. The patients with known renal artery disease were excluded.Results: Prevalence of ARAS was 5.7 %. Significant ARAS (luminal diameter narrowing ≥50 %) was present in 139 patients (3.9 %). Hypertension with altered serum creatinine and triple-vessel CAD were associated with significant renal artery stenosis in multivariate analysis. No significant relationship between the involved coronary arteries like left anterior descending, left circumflex, right coronary artery and ARAS was found. Only hypertension and altered serum creatinine were associated with bilateral ARAS. Extent of CAD or risk factors like diabetes, hyperlipidemia or smoking did not predict the unilateral or bilateral ARAS.Conclusions: Prevalence of ARAS among the patients in routine cardiac catheterization was 5.7 %. Hypertension is closely associated with significant ARAS. Significant CAD in the form of triple-vessel disease and altered renal function tests are closely associated with ARAS. They predict the presence of significant renal artery stenosis in patients undergoing routine peripheral and coronary angiography. Moreover, hypertension and altered renal functions predict bilateral ARAS.

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EVALUATION OF HYPONATREMIA IN HEART FAILURE PATIENTS ADMITTED IN CRITICAL CARE UNIT: SINGLE CENTRE EXPERIENCE.
Dr. J.R. Rawal, Dr. H.S. Joshi, Dr. S.R. Jain, Dr. B.H. Roy, Dr. R.V. Ainchwar, Dr. S.R. Shah, Dr. G.D. Gandhi, Dr. S.D. Chaudhri Indian Journal of Applied – Basic Medical Sciences (2013), Volume 15B (21) JULY-13
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Background and Objectives : Hyponatremia is a very common electrolyte disturbance in hospitalized patients of heart failure. Clinical profile of such patients with hyponatremia and common co-morbidities are subjects of current study where we made an attempt to evaluate severity, symptoms and in hospital outcome of such patients.Methods : All patients presented to intensive coronary care unit (ICCU) with decompensated congestive cardiac failure (CCF) during three months period in 2012 were included in the study.Results: Out of total 1184 ICCU admissions, 650 were presented with decompensated heart failure. Serum sodium levels less than 135 mmol/L was found in 334 patients while severe hyponatremia less than 110 mmol/L was seen in 5.3%. Symptomatology ranged from mild irritability and intractable vomiting to seizures and unresponsiveness on neurologic evaluation. Male preponderance (64.40%) was noted. Common co-morbidities were hypertension (64.22%), Diabetes mellitus (32.41%), Ischemic Heart Disease (67.42%) and valvular heart disease (10.5%). Two diuretic molecules were co-administered in (39.70%). Females tolerated different grades of hyponatremia better than males with fewer symptoms and less mortality.Conclusions: Hyponatremia is more common in male patients presenting with CCF however, female patients with CCF have less mortality and fewer symptoms. There is a direct relation of serum sodium concentration and in hospital mortality.

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EFFECT OF ORAL SILDENAFIL ON RESIDUAL PULMONARY ARTERIAL HYPERTENSION IN PATIENTS FOLLOWING SUCCESSFUL PERCUTANEOUS BALLOON MITRAL VALVULOPLASTY (PBMV): SHORT TERM RESULTS IN 12 PATIENTS.
Dr. J.R. Rawal, Dr. H.S. Joshi, Dr. B.H. Roy, Dr. R.V. Ainchwar, Dr. S.S. Sahoo, Dr. A.P. Rawal, Dr. R.A. Shah Indian Journal of Applied – Basic Medical Sciences (2013), Volume 15B (21) JULY-13
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Residual pulmonary arterial hypertension is frequently associated with continued symptoms and morbidities of right ventricular (RV) failure even after successful Percutaneous Balloon Mitral Valvuloplasty. (PBMV): Vasodilators and diuretics may further add to the agony of patients by causing systemic hypotension and hypoperfusion of other organs. Inhaled nitric oxide (NO) and oral sildenafil has been effective in ameliorating symptoms of primary pulmonary hypertension (PPH). Use of oral sildenafil in secondary pulmonary arterial hypertension (PAH) is still investigational. Few favorable reports are noted in recent literature. Our aim is to evaluate the effectiveness of oral sildenafil in patients symptomatic of residual pulmonary arterial hypertension (PAH) by decreasing (RV) after load with maintaining systemic perfusion pressure, oral sildenafil will reduce symptoms and improve effort tolerance in residual PAH patients.

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EARLY VASCULAR HEALING WITH BIODEGRADABLE POLYMER COATED SIROLIMUS-ELUTING CORONARY STENT IMPLANTATION:ASSESSED BY OPTICAL COHERENCE TOMOGRAPHY RESULTS AT 4-MONTH FOLLOW-UP.
Abhyankar A, Prajapati J, Reddy S. Minerva Cardioangiol. 2013 Jun;61(3):313-22.
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Aim: The aim of this study was to evaluate the strut apposition and neointimal coverage of Supralimus-Core stent struts at 4 months after implantation using optical coherence tomography (OCT).Methods: The Supralimus-Core OCT study is a retrospective, single-center study evaluating strut apposition and neointimal coverage with OCT at 4 months after stent implantation. A total of 12 patients, who had 15 stents implanted were included in the study. The OCT was obtained using a C7-XR FD-OCT (frequency-domain OCT) intravascular imaging system. Strut apposition, neointimal hyperplasia (NIH) thickness and stent coverage on each stent strut were evaluated.Results: A total of 2870 struts and 1950 frames were analyzed from 15 stents. Average stent length was 29.3 mm. Average reference vessel diameter was 2.64 mm. Among 12 patients, 3 (25.0%) patients were with diabetes, 4 (26.7%) type B2 and 10 (66.7%) type C lesions. The apposed and covered struts were 2787 (97.11%), whereas malapposed and covered struts were 3 (0.10%), apposed and uncovered 49 (1.71%) and malapposed and uncovered 31 (1.08%). Mean NIH thickness was 155.1±55.2 µm.Conclusions: The present study suggests that Supralimus-Core stent has a favorable vascular healing pattern at 4 months after stent implantation in terms of stent-strut coverage and strut apposition. This information indicates that the Supralimus-Core stent is a promising solution for decreasing late stent restenosis and preventing stent thrombosis.

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PERVENTRICULAR DEVICE CLOSURE OF ISOLATED MUSCULAR VENTRICULAR SEPTAL DEFECT IN INFANTS: A SINGLE CENTRE EXPERIENCE.
Bhavesh Thakkar, Nehal Patel, Shaunak Shah, Vishal Poptani, Tarun Madan, Chirag Shah, Anand Shukla, Vaishali Prajapati Indian Heart Journal Volume 64, Issue 6, November–December 2012, Pages 559–567
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Objectives: To evaluate prospective single centre experience of mid-term safety and efficacy of perventricular device closure of isolated large muscular ventricular septal defect (mVSD) in high-risk infants.Background : Surgical closures of large mVSD in infants represent a challenge with significant morbidity.Methods : Between August 2008–2010, perventricular closure was attempted in 24 infants of 6.01 ± 2.37 months age and 4.27 ± 0.56 kg weight under TEE guidance.Results: The device was successfully deployed in 21/24 infants. Size of mVSD was 8.42 ± 1.46 mm (6.1–12 mm). Mean procedure time was 28.8 ± 11.7 min. The closure rate was 84% immediately and 100% at 6 months. Four patients suffered major complications: 2-died, 1-esophageal perforation, 1-persistent CHB. At 26.23 ± 6.63 months follow-up two patients were symptomatic: 1-required device retrieval, 1-died of severe gastroenteritis.Conclusions: Perventricular device closure of isolated mVSD appears feasible option at mid-term follow-up and may either substitute or complement the conventional surgical technique in selected cases depending on institutional paediatric cardiac surgery performance.

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EVALUATION OF COMPLIANCE AND BLOOD PRESSURE REDUCTION IN PATIENTS TREATED WITH AMLODIPINE AND METOPROLOL SINGLE PILL COMBINATION VS. ITS INDIVIDUAL COMPONENTS.
Patel PB, Anand IS and Sharma K International journal of research in pharmacy and chemistry 1(3),579-586; 2011
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The objective of study is to compare the efficacy of single pill combination containing Metoprolol and Amlodipine (Metoprolol/Amlodipine 25/2.5) to its individual components in patients having hypertension in Gujarat region. We conducted this study at multicentre and this was open-label, and prospective in patient with Hypertension (140-180 mmHg/90-114 mmHg) in 3 centers from one city. Patients having hypertension were treated with one of three treatments (Metoprolol/Amlodipine 25/2.5, Amlodipine 5mg, Metoprolol 50mg) and treated for 12 weeks with three follow up visits to record BP and clinical status. At baseline, treatment groups were balanced; mean (standard deviation, SD) sitting BP was 159.7 (±5.35)/102.4 (±3.85) mmHg. The greatest reduction in BP from baseline to 12 weeks was seen in the SPC group (14.46/10.08mmHg; p<0.05). The remaining group demonstrated a significant decline from baseline (p<0.05): Amlodipine 5, -11.66/-8.72; Metoprolol 50, -9.18/-7.46. Reduction in BP by SPC however was not statistically superior to monotherapies. Responder rates (sitting DBP less than 90 mmHg or reduction more than or equal to 10 mmHg) were 92 % in SPC group. There were no reports of SAEs related to study medications. There were not any discontinuations reported in three groups due to adverse events. Blood pressure reduction from combining drugs from two different classes can be predicted on the basis of additive effects. SPC of Metoprolol and Amlodipine (25/2.5) is more effective as comparison with doubling dose of single individual drug in achieving target BP levels in patients with mild to moderate hypertension.

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EFFECT OF FIXED DOSE COMBINATIONS OF METOPROLOL AND AMLODIPINE IN ESSENTIAL HYPERTENSION: MARS – A RANDOMIZED CONTROLLED TRIAL.
Devi P, Xavier D, Sigamani A, Pandey S, Thomas T, Murthy S, Sharma K, Bosco B, Mehta K, Joshi S, Gupta R, Singh G, Hiremath J, Ds C, Nambiar A, Pais P. Blood Press Suppl. 2011 Dec;2:5-12.
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Aim : To compare two strengths of a fixed drug combination (FDC) containing metoprolol XL and amlodipine (metoprolol/amlodipine 50/5; and metoprolol/amlodipine 25/2.5) with its components in hypertension. Methods : We conducted this multicentre, randomized, open-label, trial in Indian patients with hypertension (140-180 mmHg/90-114 mmHg) in 11 centres from nine cities. Eligible patients (n = 402) were randomized into one of five treatment groups (metoprolol XL 50 mg + amlodipine 5 mg, metoprolol XL 25 mg + amlodipine 2.5 mg, metoprolol XL 50 mg, metoprolol XL 25 mg or amlodipine 5 mg) and treated for 8 weeks with five follow-up visits to record blood pressure (BP) and clinical status. Results: At baseline, treatment groups were well balanced; mean +/- SD BP was 154.87 +/- 11.91/96.63 +/- 6.97 mmHg. The greatest reduction in BP from baseline to 8 weeks was seen in the high-dose FDC group (23.61/14.91 mmHg; p<0.001). The remaining 4 groups too demonstrated a significant reduction (p< 0.001): low-dose FDC – 22.29/ – 14.66; metoprolol 50, – 23.17/ – 13.37; metoprolol 25,- 18.41/ 12.50 and amlodipine 5, – 23.01/- 13.08. BP reductions by FDCs, however, were not statistically superior to monotherapies. Responder rates (sitting diastolic BP< 90 mmHg or reduction > or =10 mmHg) were 93% in the high-dose FDC group and 97% in the low-dose FDC group, and control rates (sitting BP < 140/90 mmHg) were 66% and 58%, respectively. These rates were higher than that seen in individual components. There were no reports of serious adverse events related to study medications. One each from the low-dose FDC and metoprolol 25 mg group discontinued because of adverse events. Conclusions: FDCs of metoprolol and amlodipine are effective and safe in mild to moderate hypertension.