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   Table of Contents - Current issue
Coverpage
May-August 2021
Volume 7 | Issue 2
Page Nos. 89-177

Online since Tuesday, August 31, 2021

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REVIEW ARTICLES  

Outcome of pulmonary hypertension in pregnancy in contemporary era: A case-based narrative review p. 89
Mohsin Raj Mantoo, Nayani Makkar, J Mahidhar, Uma Devi Karuru, Devesh Kumar, Sandeep Seth
DOI:10.4103/jpcs.jpcs_49_21  
A 35-year-old female presented to us with a history of exertional dyspnea from the last 20 years and low oxygen saturation noticed from last 1 month during her COVID-19-related illness. The patient did not seek medical attention over these years as the degree of limitation of physical activity was modest. She had a bad obstetric history: five second trimester pregnancy losses and one early neonatal death. Her symptoms were worse during pregnancy and improved thereafter. Physical examination was notable of cyanosis and features of pulmonary hypertension (PH). Echocardiography was suggestive of double outlet right ventricle, large subaortic ventricular septal defect with bidirectional shunt, and severe PH. This case highlights a variable clinical outcome of Eisenmenger syndrome in pregnancy. We did a literature review for studies reporting the outcomes of PH in pregnancy. The overall mortality rates seem to have declined dramatically from as high as 56% reported in studies in the 1990s to < 5% in more contemporary studies. The common adverse obstetric outcomes include prematurity and growth restriction.
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COVID-19 and cardiovascular disease: Clinical implications of biochemical pathways p. 97
Shivani G Varmani, Rimpy Kaur Chowhan, Ishani Sharma, Rajiv Narang
DOI:10.4103/jpcs.jpcs_21_21  
Coronavirus disease of 2019 (COVID-19) is a viral pandemic which has taken away more than over 4 million lives all over the world as of July 9, 2021, with the USA, India, and Brazil being the most affected countries. Apart from the respiratory tract, the cardiovascular (CV) system is one of the important organ systems affected by this complex multisystem disease. Various studies have confirmed that COVID-19 predisposes an individual to increased risk of CV complications. In fact, hospitalized patients have been consistently reported to have modulated levels of biomarkers demonstrating coagulation and acute cardiac injury. Understanding of molecular mechanisms underlying CV involvement is strongly believed to be the foundation for developing strategies for early diagnosis and management of COVID-19-affected individuals. We review here various molecular mechanisms underlying CV involvement in COVID-19 and discuss several biochemical prognostic markers, as they have evidently revealed their importance in predicting severe prognosis such as mortality, mechanical ventilation, and ICU admission among severe acute respiratory syndrome coronavirus 2-infected patients with or without previous history of myocardial injury. The therapeutic strategies that could be employed to treat and manage CV manifestations in COVID-19-positive individuals are also discussed.
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COVID-19, hypertension, and diabetes – Hunt for the link! p. 108
Kaustav Saha, Shatavisa Mukherjee
DOI:10.4103/jpcs.jpcs_40_20  
The recent pandemic outbreak of coronavirus disease 2019 (COVID-19) has left everyone baffled. The exponential rise in deaths worldwide, with such an extensive rapid spread, has made it a public health emergency. While the scientists at the frontier are untiringly putting their utmost efforts to come up with evidence-based pharmacological interventions, attempts have also been made to demystify the disease link with associated comorbidities and further risk prognostication. The presence of comorbidities has been documented to be associated with increased risk of developing acute respiratory diseases. Older hypertensives have been posed to be at greater risk of being affected, with associated complications and severity in grade. Diabetic and obese individuals have also been shown to be in increased risk of infections and other complications. Cytokine storm, a major complication of this disease, has also led to adverse renal outcomes. The present review aimed to probe the possible link between COVID-19 and various comorbidities.
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ORIGINAL ARTICLES Top

“Art at its Heart” “The Golden Art of History and Clinical Examination” p. 113
Tammiraju Iragavarapu, Gautham Sunkarapalli, Sushma Vutukuru, Aniket Vasanth Kataria
DOI:10.4103/jpcs.jpcs_38_21  
Background: History taking and physical examination have been rendered as the most valuable, cost effective reliable skills taught during medical education which reward the clinicians, the satisfaction of making a diagnosis, while building a natural bond of human touch with the patient. Aims and Objectives: A proper and judicious choice of investigations guided by logical reasoning which was made after integrating the history and physical exam is crucial for timely diagnosis and appropriate management. Materials and Methods: We report a series of 11 cases which were mismanaged in the early stages due to lack of proper history and physical examination. Results: Though these cases appear to be simple, they highlight the proper methodical and systematic way of approach to the patient care which helps in preventing unnecessary investigations and improper management. Conclusions: Excessive worshipping of newer diagnostic modalities will lead to a more “computer oriented” approach rather than a patient centered one.
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Cardiac amyloidosis in India: A clinicopathological study p. 121
Harsh Agarwal, Tamoghna Ghosh, Sudheer Arava, Ruma Ray, Sandeep Seth
DOI:10.4103/jpcs.jpcs_35_21  
Background: Cardiac amyloidosis (CA) has been rarely reported from India. We aim to describe the experience of diagnosing and treating cardiac amyloid over three decades from a tertiary care center in India. Materials and Methods: Medical records were screened starting from 1987 up to 2019 and patients with histopathological diagnosis of CA were identified. The demographics, clinical presentation, investigations available, prognosis, and outcomes were retrospectively reviewed and analyzed. Results: A total of 40 patients were enrolled, out of which 26 (65%) were males. Median age at presentation was 51 years with a range of 33–65 years. Fatigue, weakness, and shortness of breath were the most common presenting symptoms. Clinical features of systemic amyloidosis including periorbital ecchymosis and macroglossia were present in 7.5% and 10% patients, respectively. Median survival from diagnosis was 2.1 years. Conclusions: Cardiac amyloid is a rarely diagnosed cause of restrictive cardiomyopathy in India and usually fatal. The patients in India are younger than the West. Endomyocardial biopsy is usually required to make a diagnosis of cardiac involvement though magnetic resonance imaging and nuclear imaging may raise a suspicion of cardiac amyloid.
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One-year outcome of treating bifurcation coronary artery disease with newer generation drug-eluting stents: A single-center experience p. 128
Danny Kumar, Sundeep Mishra
DOI:10.4103/jpcs.jpcs_27_21  
Objectives: Bifurcation percutaneous coronary interventions (PCIs) remain a challenging subset with tussle between provisional versus dedicated (i.e. two-stent) stenting. Besides technical issues, many other factors such as cost, operator skill, and availability of surgery affect the practice which is followed in a particular region. Because of paucity of data in Indian settings, as also information with later generation stents; this study was planned. Methodology: Patients with bifurcation lesion undergoing elective PCI during 1-year period were prospectively enrolled. Decision of strategy (provisional or dedicated two-stent) and drug-eluting stent type (second or third generation) were operator's choice. Patients were followed telephonically and/or clinically (on routine visits) for 1-year postprocedure for any major adverse cardiac event. Results: One hundred and seven cases (28 in dedicated and 79 in provisional group) with a mean age of 56.2 ± 10.2 years were enrolled. All cases of dedicated arm were true bifurcation compared to 63.2% in provisional group (P < 0.001). In dedicated arm, 75% of patients had stenosis ≥5 mm in side branch (SB), in provisional group, 74.7% had <5 mm stenosis in SB (P < 0.001). T-TAP was most common strategy followed by DK crush and final kissing inflation was done in 96.4% cases of dedicated arm. Nearly 84.1% of patients could be followed up till the end of year. In hospital, events were few in either arm, one patient in the dedicated arm developed acute stent thrombosis and three patients in provisional arm developed in-hospital myocardial infarction. One-year major adverse cardiovascular event (MACE) was not significantly different (9.5% provisional vs. 7.4% dedicated; P = 0.65). Conclusions: One-year MACE did not differ in either 1 or 2-stent strategy in suitable patients with bifurcation lesions.
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Clinical course and outcomes of heart transplant patients with COVID infection p. 135
Manoj Kumar Sahu, Seshagiribabu Yagani, Prateek Vaswani, Prashant Sirohiya, Sarvesh Pal Singh, Milind Padmakar Hote, Sandeep Seth
DOI:10.4103/jpcs.jpcs_24_21  
Objective: The objective is to assess the clinical course and outcomes of heart transplant (HTx) recipients affected by COVID-19 disease in a tertiary care health care institution. Background: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) is a contagious illness with alarming morbidity and mortality. The HTx recipients are chronically immunosuppressed and thus COVID-19 infection in them may result in an unpredictable clinical course. Materials and Methods: HTx recipients in a tertiary care transplant center in North India were retrospectively reviewed from January 2020 to January 2021. Case records of 28 patients of HTx were reviewed, and four (14%) were found to have developed Covid-19 infection. Clinical parameters and outcomes of these four HTx recipients with confirmed SARS-CoV-2 infection are described. Results: Fourteen percent of our HTx patients (4 out of 28 patients under follow-up) developed COVID-19 in the first infection wave. The study population consisted of 3 males and 1 female patient with a median age of 28 years (range 15–39). The most common presenting symptoms were fever (100%), myalgia (100%) and cough (75%). There was no mortality observed in this study. None required intensive care admission or mechanical ventilatory support. Three were managed with hospital admission while one was subjected to home isolation. The mean hospital stay was 13.5 days (12–17 days). Immunosuppressants were modified by reducing tacrolimus and mycophenolate, however, corticosteroids were continued. Conclusion: The dose modification rather than discontinuation of immunomodulatory agents should be established as standard of care for transplant recipients. Steroids may provide added benefit and should be continued. The morbidity and mortality in such cases may be lower than anticipated; however, this needs to be substantiated with larger multicentric studies.
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Stress among the nurses and their family involved in COVID-19 patient management p. 142
Pallavi Rai, Santoshi Kumari, Deblina Roy, Manoj Kumar Sahu
DOI:10.4103/jpcs.jpcs_19_21  
Background: COVID-19 pandemic has caused havoc and many deaths around the world. Coronavirus is highly contagious and spreads like wildfire in the community. The nurses and other frontline health-care workers (HCWs) bore the brunt of this pandemic with maximum effect because they all worked with infected patients. Direct exposure has caused stress, anxiety, and physical cum mental discomfort among them. Objective: This study aimed to assess stress among nurses and family members related to COVID-19 outbreak. Methodology: In this study, mixed method of prospective approach was used. The study was conducted virtually using social media platforms by online questionnaire. It included 150 participants and information was collected on demographic data, change in relationship with family, spouse, children, self-concept, and perceived stress among themselves and their family members. Results: All the nurses were involved in the direct care of COVID-infected patients. Many participants (47%) became anxious and worried about themselves. More than half (56.7%) respondents had no change in relationship, while 40.7% experienced change in relationship with their family. Majority of the participants (88%) had long travel hours and accommodation issues. Although the nurses working for COVID patients were stressed, frightened, and anxious, most of them took pride in their work as a contribution toward the nation during this current pandemic. Conclusion: This study demonstrated that frontline HCWs were at increased risk of mental health consequences such as stress, anxiety, and frustration. Their children developed behavioral changes such as agitation and aggressiveness. Many nurses got more family support than before for their contribution during COVID-19 pandemic.
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Multidetector computed tomographic evaluation of complications following lung transplantation with clinical correlation: A single center experience from India p. 149
Yvette Kirubha Jayakar David Livingstone, Thirugnanasambandan Sunder, Twinkle Dhanuka, Kapali Sunder, Paul Ramesh Thangaraj, Madhan Kumar Kuppuswamy
DOI:10.4103/jpcs.jpcs_17_21  
Context: Lung transplantation (LT) is now being performed for end-stage lung and heart-lung disease in a few centers in India. Experience in multidetector computed tomography (MDCT) evaluation of posttransplant complications is currently limited and evolving. Aims: This study analyses the early experience in our center regarding the imaging features of complications following LT with clinical outcome correlation and identify the role of MDCT. Methodology: A retrospective study of patients who underwent LT and had MDCT imaging from January 2017 to March 2019 was performed. There were 22 patients in this period whose clinical course and CT scans were studied. Results: The complications encountered include pleural effusions, atelectasis, bronchostenosis, and reperfusion injury. Rare complications included pulmonary thromboembolism and rejection. The accuracy of computed tomography (CT) imaging in airway evaluation was high but was limited in characterization of consolidation as either infective or noninfective. Conclusions: CT is the noninvasive imaging modality of choice in evaluating chronic rejection, airway complications such as bronchostenosis and pulmonary thromboembolism. Clinical, laboratory, and biopsy correlation are needed to diagnose infection or acute rejection, both of which can present with consolidation. Temporal evaluation of events is critical. Familiarity and awareness by the radiologist are crucial for good clinical outcome.
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Use and assessment of knowledge of Vitamin K antagonist therapy in cardiac patients: A Tertiary Care Hospital-based survey p. 158
Nandini Pattnaik, Anwar Hussain Ansari, Praloy Chakraborty, Niveditha Devasenapathy
DOI:10.4103/jpcs.jpcs_16_21  
Background: Safety and efficacy of Vitamin K antagonists (VKAs), the most widely used oral anticoagulant (OAC), is monitored by therapeutic international normalized ratio (INR). The current study was conducted to evaluate the proportion of patients achieving therapeutic range INR and assessment of the knowledge, and awareness among patients regarding OAC therapy, as well as identification of the challenges in the monitoring of INR. Materials and Methods: This hospital-based, single-center cross-sectional study was conducted at a tertiary care hospital in Delhi. Patients on anticoagulation with VKAs were interviewed and their records were reviewed. Information on sociodemographic characteristics, history of cardiac illness, INR range, knowledge, and awareness regarding VKA therapy were analyzed. Data management was done via CSPro and statistical analysis via STATA 13.0. Results: A total of 86 patients were evaluated. The mean age of the study participants was 49 ± 14.9 years. Only 29.1% of the study group achieved therapeutic INR. Overall awareness and knowledge regarding the need for VKA therapy, ideal INR range, complications of poor monitoring, and dietary restrictions were in the range of 31%–48%. Conclusion: Poor INR control is prevalent in Indian patients on VKAs therapy. Although the future practice may move toward newer anticoagulants, a substantial proportion of our population may still need VKAs. Hence, there is a need for improving the knowledge and awareness of patients on VKA therapy to improve therapeutic effectiveness.
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LETTER TO THE EDITOR Top

Systemic hemodynamic atherothrombotic syndrome in the young: An early phenotype of established cardiovascular disease? p. 168
Andrea Rendón-Ariza, María José Urueta-Gaviria, Jhon Jairo Contreras-Cabeza, Stephany Alejandra Carrera-Patiño, Ivan David Lozada-Martínez
DOI:10.4103/jpcs.jpcs_44_21  
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CROSSWORD Top

A cardiovascular crossword… p. 170
Armaanjeet Singh, Rohan Magoon, Ramesh Chand Kashav, Jasvinder Kaur Kohli
DOI:10.4103/jpcs.jpcs_42_21  
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CASE REPORT Top

Hypertrophic cardiomyopathy: Totally a ST-elevation myocardial infarction mimic p. 172
Debasish Das, Debasis Acharya, Tutan Das, Shashikant Singh, Jaideep Das Gupta, Subhas Pramanik
DOI:10.4103/jpcs.jpcs_26_21  
Hypertrophic cardiomyopathy (HCM) commonly presents with nonspecific ST-T changes in an electrocardiogram (EKG), and a paucity of literature description exists about index presentation of HCM totally as ST-elevation myocardial infarction (STEMI) in a very young age. The presence of convex ST elevation in surface EKG in HCM patients indicates disease progression, becomes evident in the fifth or sixth decade of life, and warrants further risk stratification for the need of automated intracardiac defibrillator therapy. We present a rare presentation of nonobstructive HCM totally mimicking acute anterior wall STEMI in a very young male in his third decade of life, which has not been described in the literature so far. Because of the presence of typical convex shaped ST elevation with biphasic terminal T wave inversion across anterior precordial leads with ongoing typical angina, the patient was subjected to right transradial coronary angiogram which revealed the presence of normal nonatherosclerotic coronaries.
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SHORT COMMUNICATION Top

Annual report of the Indian Heart and Lung Transplant Registry p. 175

DOI:10.4103/jpcs.jpcs_34_21  
The Indian Society of Heart and Lung Transplantation started building up a cloud-based registry of heart and lung transplantation from 2018 to 2019. As a first step, the hospitals involved in these procedures were enrolled in a Cloud-based Google Sheet Registry. Data have been updated till April 2021. This brief communication is the first publication from this registry and lists the 72 hospitals which participated in this voluntary registry. Starting in 1994 at AIIMS New Delhi, India as of now has completed 1113 heart transplants, 101 heart lung transplants, 338 lung transplants, and implanted 124 left ventricular assist devices.
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