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  Citation statistics : Table of Contents
   2021| September-December  | Volume 7 | Issue 3  
    Online since December 14, 2021

 
 
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CASE REPORTS
A detailed review of management of coronary perforations by gelfoam closure
Debasish Das, Debasis Acharya, Jogendra Singh, Subhas Pramanik
September-December 2021, 7(3):230-235
DOI:10.4103/jpcs.jpcs_45_21  
We report a rare case of inadvertent distal small diagonal branch perforation noted postleft anterior descending coronary artery revascularization, rescued by Gelfoam closure in a 43-year diabetic male presenting with acute anterior wall ST elevated myocardial infarction. Intermittent balloon inflation for 30 min was not able to seal off the perforation; because of impending late (3–6 h) cardiac tamponade, we closed the perforation with Gelfoam embolization through Caravel microcatheter. Although rarely practiced, this armamentarium should be there in the interventional cardiology laboratory to deal with small vessel perforation (<2 mm), for which traditionally covered stents are not available in size.
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Hepatobiliary malignancy presenting as deranged coagulogram in postoperative mechanical valve replacement patients
Yatin Arora, Tanushree Kar, Velayoudam Devagourou
September-December 2021, 7(3):236-238
DOI:10.4103/jpcs.jpcs_20_21  
Valve replacement still defines a major proportion of valvular cases in cardiothoracic surgery in a developing country like India. With most patients getting a mechanical prosthetic heart valve and dependent on lifelong anticoagulation, regular international normalized ratio (INR) monitoring is warranted to maintain the optimum range while evaluating for any adverse effects in follow-up. We describe two postoperative patients of mechanical valve replacement on anticoagulant and antiplatelet, presenting with complaints of jaundice, bleeding, and deranged INR diagnosed with hepatobiliary–pancreatic malignancies. Although deranged coagulogram is mostly resulting from dosage modification of anticoagulants and dietary modifications, it should be sought out carefully, particularly in patients with a previously stabilized profile on a similar dosage and not be dismissed on account of anticoagulant therapy, especially if the patient is icteric.
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EDITORIAL
Cleansing the augean stables - Time to reclassify coronary artery disease
George Thomas
September-December 2021, 7(3):179-181
DOI:10.4103/jpcs.jpcs_61_21  
Although there have been spectacular developments in the diagnosis and treatment of coronary artery disease (CAD), the diagnostic terminology has not evolved accordingly. The present diagnostic terms are symptom, complication, and electrocardiogram based instead of the causative pathology. In the present era of excellent therapies, angina and infarction need not occur. When our efforts are directed at preventing these ill effects of CAD, the present diagnostic terms seem anachronistic. This article presents a simple, logical, and practical approach to CAD terminology.
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ORIGINAL ARTICLES
A causal model for the control of risk factors for cardiovascular diseases using a new temperamental personality theory in the general population of Western Iran: The mediating role of self-regulation
Ali Zakiei, Habibolah Khazaie, Mohammadreza Alimoradi, Amirmehdi Kadivarian, Nader Rajabi-Gilan, Saeid Komasi
September-December 2021, 7(3):190-197
DOI:10.4103/jpcs.jpcs_62_21  
Objective: Given the need for further studies on health-promoting behaviors, the present study aimed to investigate the antecedents of controlling risk factors for cardiovascular diseases (CVDs) according to the affective and emotional composite temperament (AFECT) model and the mediating role of self-regulation. Materials and Methods: The samples of this cross-sectional study included 776 people resident in Kermanshah in Western Iran in 2019. The participants were selected using a cluster sampling method. Data were collected using the controlling the risk factors for cardiovascular disease questionnaire (CRC), the short form self-regulation questionnaire, and the AFECT scale. The structural equation modeling was used to analyze the data. Results: The analysis results indicated that there was a significant correlation between dimensions of AFECT and self-regulation with the control of risk factors for CVDs. The results also indicated that the dimensions of AFECT did not directly affect the control of risk factors for CVDs, but the mediating role of self-regulation was confirmed in this regard. Conclusion: According to the results, the dimensions of AFECT could affect the control of risk factors for CVDs through self-regulation; hence, the role of self-regulation in controlling CVDs should be taken into account.
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A clinical relevance of fossa ovalis and patent foramen ovale: A morphological study of human heart
Thittamaranahalli Muguregowda Honnegowda, Mansour A Alghamdi
September-December 2021, 7(3):198-201
DOI:10.4103/jpcs.jpcs_60_21  
Background: The anatomical characterization of foramen ovale (FO) along with annulus or limbus varies in size and shape from the heart to heart. Patent FO (PFO) has been implicated in the etiology of a number of diseases, PFO is not an uncommon condition; their prevalence rate is 15%–35% in the population. Hence, morphological study of FO serves importance to know the exact location of the fossa ovalis (FOv) and prevalence of PFO in the Indian population by the autopsy method. Materials and Methods: This study was conducted in 106 apparently normal hearts available in the Department of Anatomy and Forensic Medicine and Toxicology. After opening the right atrium, the shape of FOv was observed, and dimensions were measured with the digital Vernier caliper and thickness of anterior and posterior limbus was noted. Probe patency was confirmed. Results: Area of the FOv (160.20 ± 104.9 mm2), thickness anterior limbus (7.24 ± 1.83 mm), and thickness of posterior limbus (6.38 ± 2.46 mm). The shape of FOv was oval (83%) in majority; in 86.7%, the rim of the limbus was raised and 13.3% it was flat; in 20.75%, a recess was found deep to the margin of the limbus and 10.37% showed probe patency. A significant positive correlation was observed between cardiac weight and area of FOv. Conclusion: By autopsy method, we found the prevalence of PFO is 4.71%, which is lower than Western population, our study also provides the accurate measurements related with several morphometric variation such as shape of FOv and limbus FOv.
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Clinical and angiographic profile of patients with severe left ventricular systolic dysfunction without established coronary artery disease
Lokesh Khandelwal, Vijay Kumar Trehan, MP Girish, Mohit Dayal Gupta, Safal Safal
September-December 2021, 7(3):202-206
DOI:10.4103/jpcs.jpcs_51_21  
Objective: Coronary artery disease (CAD) is the most common etiology of heart failure with reduced ejection fraction (EF). Coronary angiography is usually not done in patients with severe left ventricular systolic dysfunction (LVSD) without a history of acute coronary syndrome or angina, due to fear of increased risk. Hence, the prevalence of CAD in such cases remains unknown. This study aimed at analyzing the clinical and angiographic profile of the patients with severe LVSD (EF ≤35%) without established CAD. Methods: This was a prospective, observational study conducted from January 2018 to July 2019. One hundred consecutive patients (≥18 years) with severe LVSD (EF ≤35%) without established CAD were assessed for underlying CAD by coronary angiography. Patients were divided into those with no CAD and CAD. Patients having CAD were further classified into those with significant CAD and severe CAD based on angiographic lesion severity. The risk factors contributing to significant CAD were analyzed. Results: Sixty-four patients had no CAD and 36 patients had CAD, of which 34 and 26 patients had significant CAD and severe CAD, respectively. 41.7% patients had double-vessel disease followed by 33.3% and 25% patients having triple-vessel disease and single-vessel disease, respectively. The risk factors for significant CAD were male >55 years/female >65 years, male gender, diabetes mellitus, smoking, and dyslipidemia. Multivariate logistic regression analysis showed diabetes and dyslipidemia to be the independent risk predictors for significant CAD. Conclusion: Occult CAD is present in high proportions in patients with severe LVSD without established CAD specially in presence of risk factors such as diabetes, male >55 years/female >65 years and dyslipidemia. Hence, coronary angiography should be considered strongly in such patients having one or more of these risk factors.
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Prevalence of asymptomatic silent myocardial ischemia among type 2 diabetes mellitus patients in Bangalore - A hospital-based cross-sectional study
Nagappa H Handargal, Shristi J Shetty
September-December 2021, 7(3):207-211
DOI:10.4103/jpcs.jpcs_33_21  
Background: Earlier diagnosis of asymptomatic coronary artery disease (CAD) in diabetics may prevent catastrophic cardiac events and hence warrants the need for detection of silent myocardial ischemia (SMI). Therefore, the study aimed to assess the role of treadmill test (TMT) in patients who were asymptomatic, to detect and estimate the occurrence of SMI (positive exercise TMT), and to find the association between presence of SMI and duration of diabetes mellitus (DM). Methodology: A cross-sectional study was undertaken among 162 DM cases (type 2) with a mean age of 55.32 ± 11.89 years, who had undergone a TMT without any CAD evidence clinically. All the subjects had normal 12 lead electrocardiography and underwent TMT. Results: Among 162 subjects, TMT was positive in 63 (38.9%) study subjects. TMT positivity for inducible ischemia in type 2 DM patients was associated with increasing age, higher body mass index (BMI), smoking, higher HbA1C, albuminuria, retinopathy, and atherosclerotic cardiovascular disease (ASCVD) risk score. Smoking, diabetic retinopathy, and urine albumin were associated with TMT significantly (P value < 0.005). A significant linear increasing trend in proportion of TMT positive over HbA1c was observed. Mean height of TMT-positive subjects (159.2 ± 7.47 cm) was more than TMT-negative subjects (P < 0.005). The mean BMI (29.69 ± 3.58 kg/m2) and triglycerides (173.87 ± 112.7 mg/dl) of TMT-positive subjects were more than TMT-negative subjects (P < 0.005). Conclusion: CAD prevalence is greater in asymptomatic cases of type 2 DM in this geographic region. A significant linear increasing trend was observed in TMT positive over HbA1c. Hence, TMT can be incorporated in routine screening for SMI in patients suffering from diabetes.
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Clinical profile of patients of ASD device closure with special reference to short and intermediate term complications
Pramesh Gaidhane, Jayesh Prajapati, Iva Vipul Patel, Bhagyashri Bhutada, Chandrashekhar Yadav, Krishan Yadav, Benny Jose Panakkal
September-December 2021, 7(3):212-218
DOI:10.4103/jpcs.jpcs_30_21  
Background: Device closure of atrial septal defect (ASD) is a treatment of choice in selected patients with a suitable defect. We aimed to evaluate short- and intermediate-term outcomes with device closure in special reference to complications in Western Indian population. Materials and Methods: The present prospective observational study enrolled 184 patients with ASD who underwent Device closure. All patients were followed at 15–30 days (short) and 3–12 months (intermediate). Results: Device closure of ASD was done successfully in 180 (97.83%) patients. Systolic (P = 0.02), diastolic (P = 0.007), and mean PA (P = 0.0001) pressure were significantly decreased at postprocedure. Residual defect was resolved in 94.2% of patients by 6 months. Preprocedural Pulmonary artery hypertension was found in 36 (19.56%) patients and was reduced in 15 (8.15%) patients postprocedure and in 10 (5.43%) patients at 1 year. Residual shunt was reported in 34% of patients which was resolved in all by 6 months. At postprocedure and follow–up, patients were developed minor complications included (0.5%) moderate MR, 1 (0.5%) lower respiratory tract infection, and 3 (1.6%) local site hematoma. Eleven (5.98%) major complications involved arrythmia (2.17%), infective endocarditis (0.54%), LAA perforation (0.54%), cardioembolic shock (0.54%), device embolization (0.54%), sudden cardiac arrest (0.54%), intraprocedural acute coronary syndrome (0.54%), and cardiac tamponade (0.54%). Conclusion: Device closure appears to be best available option at the present time. Careful attention to the details of the technique is mandatory to achieve a successful outcome in order to avoid complication related to procedure. Patients of all ages experience reduction in pulmonary artery pressure after percutaneous device closure of ASD.
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COVID-19 and its impact on the management of patients with acute coronary syndrome during the first COVID wave – A questionnaire-based survey among interventional cardiologists from Southern India
Thoddi Ramamurthy Muralidharan, Balakrishnan Vinod Kumar, Preetam Krishnamurthy, Nagendra Boopathy Senguttuvan, Jayanthy Venkata Balasubramaniyan, Shanmugasundaram Sadhanandham, Jebaraj Rathinasamy, Ramesh Sankaran, Manokar Panchanatham, Jayanthy Sathyanarayana Murthy, Thanikachalam Sadagopan
September-December 2021, 7(3):219-224
DOI:10.4103/jpcs.jpcs_43_21  
Background: The COVID-19 pandemic has transformed the medical society in many ways. With significant drain on the resources and altered healthcare priorities, there is a greater need for redeployment of the resources from noncommunicable diseases to COVID-19-related healthcare services. To understand the impact of the COVID-19 pandemic on the management of acute coronary syndrome (ACS) in Tamil Nadu, a survey was administered across cardiologists in Tamil Nadu. Methods: A survey was done using an electronic questionnaire administered regarding the change of patterns of acute coronary syndromes during the COVID through Google Forms with responses collected in excel format. Results: Among 256 cardiologists contacted, 101 responded to the survey. Among cardiologists who responded, all were interventional cardiologists– with most of them performing primary percutaneous coronary intervention (PCI) (95%) regularly during pre-COVID times. Most of them have noticed a significant reduction in the number of patients with ACS seeking health care (94%) and another 61% of respondents felt that there was a reduction in the number of patients with acute coronary syndrome. There was a significant delay in ST-segment elevation myocardial infarction presentation to the hospital (88%) and significant reduction in the number of primary PCI (47%). Only 19% of respondents did primary PCI for COVID-positive patients. Conclusions: COVID pandemic has emerged as a big challenge to the global health care system. Optimal acute coronary care could not be delivered in a timely manner due to multiple social, patient, and physician-related factors. The emerging techniques in rapid diagnosis of COVID-19 and protective measures of COVID infection are expected to improve the situation. Trial Registration: Clinical Trials Registry – India (CTRI), CTRI/2020/09/027517, Registered September 1, 2020 http://CTRI. nic. In/Clinicaltrials/pmaindet2. php? trialid = 47025 and EncHid = and user Name =.
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Clinical and angiographic profile of acute coronary syndrome patients (<40 years) and short-term prognosis: A cross-sectional study
Nivargi Varun, Jadhav Ajitkumar
September-December 2021, 7(3):225-229
DOI:10.4103/jpcs.jpcs_58_21  
Background: The rapidly changing economic stature and lifestyle choices of young individuals have affected healthcare in India. An increased prevalence of acute coronary syndrome (ACS) in young individuals has been observed. Aims and Objectives: The present cross-sectional, observational study was designed to record the clinical and angiographic profiles of young individuals (<40 years) with ACS. Materials and Methods: This cross-sectional, observational study was also designed to analyze the associations of lifestyle risk factors such as obesity, smoking, and alcohol on the occurrence of ACS and short-term (1 month) prognosis (rehospitalization and mortality). The inclusion criteria were age between 18 and 40 years with angina pectoris or equivalent at presentation and later diagnosed ACS per the consensus paper from the European Society of Cardiology/American College of Cardiology/American Heart Association/World Heart Federation joint task force. Patients with a previous history of ACS/coronary revascularization, atypical chest pain, valvular heart disease, hypertrophic cardiomyopathy, and/or congenital heart disease were excluded. Results: Out of the 403 patients that were screened, 162 young patients (18–40 years, mean ± standard deviation: 31.5 ± 4.64) were enrolled from a single tertiary cardiac care center located at Pune, Maharashtra, from May 2014 to May 2016. Most of the patient population were males (n [%]:151 [93.2]) of which 50% had positive addiction status for alcohol and smoking, family history of coronary artery disease (CAD) and a quarter of the patients had comorbidities of diabetes mellitus, hypertension, and/or abnormal lipid profile. The majority of the young ACS patients had ST-elevated myocardial infarction (STEMI: 87%), wherein anterior wall myocardial infarction was the most common electrocardiogram presentation, and primary angioplasty in myocardial infarction (PAMI) was the preferred modality of treatment in most of the young patients (61.7% vs. 38.3% thrombolysis). Conclusion: The prevalent angiographic profile of this study participants included obstructive CAD, single vessel disease, left ventricular ejection fraction (LVEF) <45, Angina Class IV, New York Heart Association (NYHA) class I, and Killip class I. Low LVEF, NYHA class IV, and Killip class IV showed association with short-term outcomes (mortality). The present study adds to the pool of information related to the western Indian population. However, a larger cohort study with a long-term follow is warranted to analyze the detailed ACS progression status in young individuals.
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QUIZ TIME
A “Cutie” - Diagnosis using cute heuristics
HS Kiran
September-December 2021, 7(3):239-240
DOI:10.4103/jpcs.jpcs_55_21  
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REVIEW ARTICLE
Use of thrombolytic agents for ST-elevation myocardial infarction care in India: An expert consensus
Arun Chopra, Suresh V Patted, Mukesh Parikh, Rajeev Agarwal, K Jaishankar, Nitin Modi
September-December 2021, 7(3):182-189
DOI:10.4103/jpcs.jpcs_106_20  
In India, ST-elevation myocardial infarction (STEMI) is the predominant form of acute coronary syndrome. It is estimated to affect approximately 30 million people in India. The mainstay treatment approach for STEMI management is primary percutaneous coronary intervention (PCI) within 90 min after the first medical contact. However, due to existent clinical and practical barriers in performing timely PCI, optimal treatment is not offered on a timely basis. The challenges or barriers to timely PCI can be overcome by a pharmaco-invasive approach, in which thrombolysis is performed as soon as the patient is diagnosed with STEMI and transferred for PCI. Pharmaco-invasive approach is effective in shortening time to reperfusion therapy by allowing prompt initiation of thrombolysis followed by PCI as soon as possible. An experts' panel discussion was conducted involving 47 cardiologists all over India to review evidence-based concept of pharmaco-invasive treatment approach and to gain their expert opinion on emergency management of STEMI patients in the Indian setting. The experts highlighted that thrombolysis is the most implemented reperfusion strategy in India, especially when primary PCI is not available for STEMI patients. According to them, pharmaco-invasive approach would be appropriate to gain time to treatment in the event of expected treatment delays. Among thrombolytic agents, the experts recommended using third-generation thrombolytic agents because of their faster patency, more effectiveness, and ease of administration. They also emphasized on various clinical factors and practical considerations to be assessed before employing thrombolytic agents. In their opinion, bolus thrombolytic agents such as tenecteplase and reteplase offer effective, safer, easier, and faster administration for varied clinical profiles in all practical ways.
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