Endothelial nitric oxide synthase (eNOS) gene polymorphism (Glu298asp) and nitric oxide (NO) levels in patients with ST-segment elevation myocardial infarction (STEMI)

BACKGROUND

Genetic polymorphism in endothelial Nitric Oxide Synthase (eNOS) are associated with occurrence of multiple cardiovascular diseases (CVDs).

METHODS

This study included 300 young ST-segment elevation myocardial infarction (STEMI) patients and 300 healthy controls. STEMI patients were divided into two groups: premature coronary artery disease [CAD] (STEMI<40 years of age) and older STEMI (>40 years of age). Genetic polymorphisms in the eNOS gene (894G/T) was evaluated in both subjects and controls. Plasma levels of nitric oxide (NO) were estimated for both patients as well as controls.

RESULTS

Mean age of the study population was 49.7 ± 9.2 years with premature CAD being present in 58 (19.3 %) patients. No significant difference at genotypic (P = 0.589, odds ratio (OR) = 0.9, 95 % CI = 0.6-1.6) and allelic level (P = 0.173, OR = 1.2, 95 % CI = 0.9-1.4) was observed between STEMI patients and healthy controls. Genotype 894 TT had significantly higher frequency in STEMI patients >40 years (P = 0.047, OR: 2.5; 95 % CI = 1.0-6.0). No significant difference at genotypic (P = 0.279) and allelic level (P = 0.493) was observed between premature CAD (STEMI age <40 years) and healthy controls. NO levels (131 ± 59.6 μM vs 118.11 ± 49.96 μM; P = 0.001) was significantly higher in healthy controls as compared to STEMI patients >40 years of age (P= 0.001).

CONCLUSION

There was significant association of eNOS gene polymorphism Glu298Asp with STEMI patients > 40 years. However, this association was not observed in premature CAD patients. Lower levels of NO in STEMI patients >40 years suggests its potential role as a marker of CVD.

COVID-19 infected ST-Elevation myocardial infarction in India (COSTA INDIA)

OBJECTIVE

To find out differences in the presentation, management and outcomes of COVID-19 infected STEMI patients compared to age and sex-matched non-infected STEMI patients treated during the same period.

METHODS

This was a retrospective multicentre observational registry in which we collected data of COVID-19 positive STEMI patients from selected tertiary care hospitals across India. For every COVID-19 positive STEMI patient, two age and sex-matched COVID-19 negative STEMI patients were enrolled as control. The primary endpoint was a composite of in-hospital mortality, re-infarction, heart failure, and stroke.

RESULTS

410 COVID-19 positive STEMI cases were compared with 799 COVID-19 negative STEMI cases. The composite of death/reinfarction/stroke/heart failure was significantly higher among the COVID-19 positive STEMI patients compared with COVID-19 negative STEMI cases (27.1% vs 20.7% p value = 0.01); though mortality rate did not differ significantly (8.0% vs 5.8% p value = 0.13). Significantly lower proportion of COVID-19 positive STEMI patients received reperfusion treatment and primary PCI (60.7% vs 71.1% p value=< 0.001 and 15.4% vs 23.4% p value = 0.001 respectively). Rate of systematic early PCI (pharmaco-invasive treatment) was significantly lower in the COVID-19 positive group compared with COVID-19 negative group. There was no difference in the prevalence of high thrombus burden (14.5% and 12.0% p value = 0.55 among COVID-19 positive and negative patients respectively) CONCLUSIONS: In this large registry of STEMI patients, we did not find significant excess in in-hospital mortality among COVID-19 co-infected patients compared with non-infected patients despite lower rate of primary PCI and reperfusion treatment, though composite of in-hospital mortality, re-infarction, stroke and heart failure was higher.

Left ventricular function assessment after aortic and renal intervention in Takayasu arteritis by speckle tracking echocardiography: a pilot study

Background

Overt left ventricular (LV) dysfunction and congestive heart failure are known entities in Takayasu arteritis (TA). Subclinical LV dysfunction may develop in these patients despite normal LV ejection fraction (LVEF). Moreover, effect of treatment of aortic or renal artery narrowing in such patients is unknown.

Methods

This study included 15 angiographically confirmed TA patients undergoing aortic and/or renal intervention. A comprehensive clinical, biochemical and echocardiographic (2-dimensional, speckle tracking and tissue doppler imaging) evaluation were done at baseline, 72 h, and six months post intervention.

Results

Six patients (40%) had reduced LVEF (<50%) at baseline while rest 9 (60%) patients had reduced global longitudinal strain (GLS) but normal EF. Diastolic filling pattern was abnormal in all the patients. In patients with baseline reduced EF, mean EF improved from 24.62 ± 12.14% to 45.6 ± 9.45% (p = 0.001), E/e’ ratio decreased from 15.15 ± 3.19 to 10.8 ± 2.56 (p = 0.005) and median NT pro BNP decreased from 1673 pg/ml (970–2401 pg/ml) to 80 pg/ml (40–354 pg/ml) (p = 0.001) at 6 months after interventional procedure. In patients with baseline normal EF, median NT pro BNP decreased from 512 pg/ml (80–898.5 pg/ml) to 34 pg/ml (29–70.8 pg/ml) (p < 0.01), mean GLS improved from −8.80 ± 0.77% to −16.3 ± 0.78% (p < 0.001) and mean E/e’ decreased from 12.93 ± 2.63 to 7.8 ± 2.73 (p = 0.005) at 6 months follow up.

Conclusion

LV dysfunction is common in patients with TA and obstructive lesions in aorta or renal arteries. GLS can be used to assess subclinical systolic dysfunction in these patients. Timely intervention can improve LV dysfunction and can even reverse the subclinical changes.

Heart rate variability as a marker of cardiovascular dysautonomia in post-COVID-19 syndrome using artificial intelligence

Introduction

Cardiovascular dysautonomia comprising postural orthostatic tachycardia syndrome (POTS) and orthostatic hypotension (OH) is one of the presentations in COVID-19 recovered subjects. We aim to determine the prevalence of cardiovascular dysautonomia in post COVID-19 patients and to evaluate an Artificial Intelligence (AI) model to identify time domain heart rate variability (HRV) measures most suitable for short term ECG in these subjects.

Methods

This observational study enrolled 92 recently COVID-19 recovered subjects who underwent measurement of heart rate and blood pressure response to standing up from supine position and a 12-lead ECG recording for 60 s period during supine paced breathing. Using feature extraction, ECG features including those of HRV (RMSSD and SDNN) were obtained. An AI model was constructed with ShAP AI interpretability to determine time domain HRV features representing post COVID-19 recovered state. In addition, 120 healthy volunteers were enrolled as controls.

Results

Cardiovascular dysautonomia was present in 15.21% (OH:13.04%; POTS:2.17%). Patients with OH had significantly lower HRV and higher inflammatory markers. HRV (RMSSD) was significantly lower in post COVID-19 patients compared to healthy controls (13.9 ± 11.8 ms vs 19.9 ± 19.5 ms; P = 0.01) with inverse correlation between HRV and inflammatory markers. Multiple perceptron was best performing AI model with HRV(RMSSD) being the top time domain HRV feature distinguishing between COVID-19 recovered patients and healthy controls.

Conclusion

Present study showed that cardiovascular dysautonomia is common in COVID-19 recovered subjects with a significantly lower HRV compared to healthy controls. The AI model was able to distinguish between COVID-19 recovered patients and healthy controls.

Matrix metalloproteinases and their gene polymorphism in young ST-segment elevation myocardial infarction

BACKGROUND

Genetic polymorphism in MMPs are associated with multiple adverse CV events. There is little evidence regarding role of MMPs and their genetic polymorphisms in young (<50 years) ST-segment elevation myocardial infarction (STEMI) patients.

METHODS

This study included 100 young (18-50 years) STEMI patients and 100 healthy controls. Serum levels of MMP-3, MMP-9 and TIMP were estimated for both patients as well as controls. Additionally, genetic polymorphisms in the MMP-9 gene (-1562 C/T and R279Q) & MMP-3 gene (5A/6A-1612) was evaluated. All these patients were followed up for one year and major adverse cardiac events (MACE) were determined.

RESULTS

Serum levels of MMP-3 (128.16 ± 115.81 vs 102.3 ± 57.28 ng/mL; P = 0.04), MMP-9 (469.63 ± 238.4 vs 188.88 ± 94.08 pg/mL; P < 0.0001) and TIMP (5.84 ± 1.93 vs 2.28 ± 1.42 ng/mL; P < 0.0001) were significantly higher in patients as compared to controls. Additionally, patients with genetic polymorphisms in the MMP genes (5A/5A, 6A/6A and the AG genotypes) had an increased risk of STEMI. Patients with MACE had significantly higher levels of MMP-9 (581.73 ± 260.93 vs 438.01 ± 223.38 pg/mL; P = 0.012). A cutoff value of 375.5 pg/mL of MMP-9 was best able to discriminate patients with STEMI and MACE with sensitivity of 77.3% and specificity of 57%.

CONCLUSION

Novel biomarkers such as MMP-3, MMP-9 and TIMP and their genetic polymorphism are associated with the susceptibility for STEMI in young individuals. Higher MMP-9 levels in STEMI patients with MACE suggests its potential role in predicting cardiac remodeling and left ventricular dysfunction.

The deleterious impact of a non-synonymous SNP on protein structure and function is apparent in hypertension

Essential hypertension (EH) is a significant health issue around the globe. The indifferent therapy regimen suggests varied physiological functions due to the lifestyle and genetic presentations of an individual. The endothelial nitric oxide synthase (NOS3) gene is a crucial vascular system marker in EH that contributes significantly to the phenotype. Hence, the present study aimed to employ the candidate gene approach and investigate the association between NOS3 single nucleotide polymorphism (SNP) E298D (G894T/rs1799983) by applying several in silico tools and validation through human samples screening. We corroborated computational findings through a case-control study comprising 294 controls and 299 patients; the 894T allele emerged significantly as the risk allele (odds ratio=2.07; P=6.38E-05). The in silico analyses highlighted the significance of E298D on the native structure and function of NOS3. The dynamics simulation study revealed that the variant type 298D caused structural destabilization of the protein to alter its function. Plasma nitrite levels were reduced in patients (P=0.0002), and the same correlated with the 894T allele. Furthermore, correlations were apparent between clinical, genotype, and routine biochemical parameters. To conclude, the study demonstrated a perceptible association between the SNP E298D and NOS3 protein structure stability that appears to have a bearing on the enzyme's function with a deleterious role in EH.

Changing pattern of admissions for acute myocardial infarction in India during the COVID-19 pandemic

AIM

Studies on the changes in the presentation and management of acute myocardial infarction (AMI) during the COVID-19 pandemic from low- and middle-income countries are limited. We sought to determine the changes in the number of admissions, management practices, and outcomes of AMI during the pandemic period in India.

METHODS & RESULTS

In this two-timepoint cross-sectional study involving 187 hospitals across India, patients admitted with AMI between 15th March to 15th June in 2020 were compared with those admitted during the corresponding period of 2019. We included 41,832 consecutive adults with AMI. Admissions during the pandemic period (n = 16414) decreased by 35·4% as compared to the corresponding period in 2019 (n = 25418). We observed significant heterogeneity in this decline across India. The weekly average decrease in AMI admissions in 2020 correlated negatively with the number of COVID cases (r = -0·48; r2 = 0·2), but strongly correlated with the stringency of lockdown index (r = 0·95; r2 = 0·90). On a multi-level logistic regression, admissions were lower in 2020 with older age categories, tier 1 cities, and centers with high patient volume. Adjusted utilization rate of coronary angiography, and percutaneous coronary intervention decreased by 11·3%, and 5·9% respectively.

CONCLUSIONS

The magnitude of reduction in AMI admissions across India was not uniform. The nature, time course, and the patient demographics were different compared to reports from other countries, suggesting a significant impact due to the lockdown. These findings have important implications in managing AMI during the pandemic.

Pattern of acute MI admissions in India during COVID-19 era: A Cardiological Society of India study - Rationale and design

Background

COVID-19 pandemic has affected around 20million patients worldwide and 2.0 million cases from India. The lockdown was employed to delay the pandemic. However, it had an unintentional impact on acute cardiovascular care, especially acute myocardial infarction (AMI). Observational studies have shown a decrease in hospital admissions for AMI in several developed countries during the pandemic period. We aimed to evaluate the impact of COVID-19 on the AMI admissions patterns across India.

Methods

In this multicentric, retrospective, cross-sectional study, we included all AMI cases admitted to participating hospitals during the study period 15th March to 15th June 2020 and compared them using a historical control of all cases of AMI admitted during the corresponding period in the year 2019. Major objective of the study is to analyze the changes inthe number of hospital admissions for AMI in hospitals across India. In addition, we intend to evaluate the impact of COVID-19 on the weekly AMI admission rates, and other performance measures like rates of thrombolysis/primary percutaneous interventions (PCI), window period, door to balloon time, and door to needle time. Other objectives include evaluation of changes in the major complications and mortality rates of AMI and its predictors during COVID-19 pandemic.

Conclusions

This CSI-AMI study will provide scientific evidence about the impact of COVID-19 on AMI care in India. Based on this study, we may be able to suggest appropriate changes to the existing MI guidelines and to educate the public regarding emergency care for AMI during COVID-19 pandemic.

Tumor necrosis factor-alpha -308G/A gene polymorphism and novel biomarker profiles in patients with Takayasu arteritis

Background

Takayasu arteritis (TA) is an idiopathic chronic inflammatory disease of the aorta and its branches, leading to stenosis, occlusion, and aneurysmal dilatation. Tumor necrosis factor-alpha (TNF-α) is a cytokine with pleomorphic actions and plays a pivotal role in inflammation; the serum level of TNF-α is genetically determined. However, the literature lacks adequate information on the association of TNF-α polymorphisms with TA. Hence, the present study investigates the contribution of TNF-α polymorphism toward the complex etiology of TA.

Methods

A cross-sectional study was performed in 87 patients with TA and 90 controls. A promoter region polymorphism of TNF-α, rs1800629 G/A, or −308G/A was genotyped in all the study subjects followed by a case–control association study. Furthermore, to understand the biomarker profile, levels of specific markers such as erythrocyte sedimentation rate, serum high-sensitivity C-reactive protein, interleukin-18, interleukin-6, and TNF-α were measured in all the study subjects.

Results

All the inflammatory markers were significantly higher in the TA patients than in the controls. The genetic study (available for 57 TA patients and 36 controls) revealed that the TNF-α −308A allele was overrepresented in the TA patients (12% vs 7%). The TNF-α −308A allele correlated with the increased TNF-α levels, but it could not attain significance because of a small sample size.

Conclusion

The TNF-α −308G/A polymorphism is associated with TNF-α levels in Indian population, which might have implications for clinical risk stratification and treatment. The different TNF-α gene promoter polymorphism might contribute to the molecular pathogenesis of TA. However, further study of the underlying mechanism is warranted.

Phosphodiesterase-5 Inhibitor in Eisenmenger Syndrome

Background— Phosphodiesterase-5 inhibitors produce a significant decrease in pulmonary vascular resistance in patients with idiopathic pulmonary arterial hypertension. We studied the effects of tadalafil, a phosphodiesterase-5 inhibitor, on short-term hemodynamics, tolerability, and efficacy over a 12-week period in patients of Eisenmenger syndrome having a pulmonary vascular pathology similar to idiopathic pulmonary arterial hypertension.

Methods and Results— Sixteen symptomatic Eisenmenger syndrome patients (mean age, 25±8.9 years) were assessed hemodynamically at baseline and 90 minutes after a single dose of tadalafil (1 mg/kg body weight up to a maximum of 40 mg). The same dose was then continued daily for 12 weeks, and the patients were restudied. There was a significant decrease in mean pulmonary vascular resistance immediately (24.75±8.49 to 19.22±8.23 Woods units; P <0.005) and at 12 weeks (19.22±8.23 to 17.02±6.19 Woods units; P =0.03 versus 90 minutes). Thirteen of 16 patients (81.25%) showed a ≥20% decrease in pulmonary vascular resistance and were defined as responders. The mean systemic oxygen saturation improved significantly both immediately (84.34±5.47% to 87.39±4.34%; P <0.005) and at 12 weeks (87.39±4.34% to 89.16±3.8%; P <0.02 versus 90 minutes) without a significant change in systemic vascular resistance. None of the patients had a fall in systemic arterial pressure, worsening of systemic oxygen saturation, or any adverse reactions to the drug. The mean World Health Organization functional class improved from 2.31±0.47 to 1.25±0.44 ( P <0.0001), and the 6-minute walk distance improved from 344.56±119.06 to 387.56±117.18 m ( P <0.001).

Conclusions— Preliminary evaluation of tadalafil has shown efficacy and safety in selected patients with Eisenmenger syndrome, warranting further investigation in this subgroup of patients.

Mitral Valvuloplasty by Inoue Balloon Under Transthoracic Echocardiographic Guidance

BACKGROUND

Mitral valvuloplasty traditionally performed under fluoroscopic guidance has emerged as an effective nonsurgical technique for the treatment of symptomatic patients with mitral stenosis. We undertook a study to evaluate the feasibility of performing valvuloplasty by the Inoue balloon solely under transthoracic echocardiographic (TTE) guidance with the backup of transesophaeal echocardiography (TEE) and fluoroscopy.

METHODS

Between September 2003 and July 2004, mitral valvuloplasty using the Inoue balloon was performed solely under TTE guidance in the catheterization laboratory with backup of fluoroscopy and TEE in 75 patients (52 female patients, including 18 who were pregnant, and 23 male patients) with symptomatic mitral stenosis (New York Heart Association class II-IV) with satisfactory TTE window and valve morphology suitable for valvuloplasty.

RESULTS

The procedure was technically successful (no requirement of TEE or fluoroscopy) in 68 patients (89%). TEE was required for septal puncture in 3 patients whereas fluoroscopic assistance was required to complete the procedure in 4 patients. Procedural success after valvuloplasty (doubling of mitral valve area or mean gradient across mitral valve < 5 mm Hg in absence of complications like severe mitral regurgitation or tamponade) was achieved in 70 patients. There was an increase in mean mitral valve area as assessed echocardiographically from 0.84 +/- 0.16 cm2 to 1.7 +/- 0.27 cm2 with decrease in mean diastolic gradient from 27.2 +/- 8.4 mm Hg (18-36 mm Hg) to 5.2 +/- 4.1 mm Hg (3-14 mm Hg). The mean procedure time was 27.2 +/- 8.4 minutes (15-45 minutes). Mild mitral regurgitation appeared or increased in severity to moderate degree as assessed by color Doppler during the procedure in 11 patients (14.6%) but no patient developed severe mitral regurgitation. No patient had cardiac tamponade as puncture of the septum under TTE guidance prevents inadvertent puncture of the aorta, coronary sinus, inferior vena cava, and right atrial and left atrial wall that sometimes occurs during septal puncture under fluoroscopic guidance.

CONCLUSION

Balloon mitral valvuloplasty under sole TTE guidance is safe and feasible in experienced hands.

U wave: an important noninvasive electrocardiographic diagnostic marker

Study of U waves exemplifies important clinical role of noninvasive electrocardiography in modern cardiology. Present article highlights significance of U waves with a clinical case and also summarizes in brief the history of the same.

Transcatheter closure of coronary-to-pulmonary fistula by nonconventional coils in a patient with tetralogy of Fallot

We report a case in which a coronary-to-pulmonary fistula was successfully occluded in a patient with tetralogy of Fallot by employing the cut floppy tips of coronary angioplasty guidewires using a new technique.

Stent implantation in right-sided patent ductus arteriosus to relieve severe cyanosis in adult patient with pulmonary atresia and ventricular septal defect

Patients with unrepaired pulmonary atresia and ventricular septal defect may develop stenosis of collaterals or shunts to the pulmonary arteries leading to hypoperfusion of lungs and systemic hypoxemia. A 25-year-old female with pulmonary atresia and ventricular septal defect presented with progressively increasing cyanosis and exercise intolerance. A restrictive right-sided patent ductus arteriosus was identified as the main source of pulmonary blood flow. We report transcatheter implantation of a balloon-expandable stent across the stenosed duct to augment the pulmonary blood flow as a palliative management option. Patient had immediate improvement in arterial oxygen saturation from 66% to 85% with excellent clinical improvement and stable oxygen saturation on 8 months of follow-up.

Isolated extra-cranial internal carotid artery aneurysm in a young adult with Eale's disease

A young male patient, a known case of Eale's disease presented with a large isolated aneurysm of the extra-cranial part of internal carotid artery. Detailed investigation failed to establish the etiology of the aneurysm, and it is possible that the underlying pathology may be the same as that of Eale's disease. Eale's disease is an idiopathic vascular disease of the peripheral retina and we hypothesize that aneurysm in this patient may be associated with Eale's disease of the eye.

Barium carbonate poisoning mimicking Guillain-Barre syndrome

Areflexic quadriplegia due to barium carbonate (rat poison) poisoning is described in two young patients. These cases very closely resembled Guillain-Barre syndrome. The various effects of barium carbonate along with the pathogenesis of hypokalaemic paralysis are highlighted.

Occult primary adenocarcinoma causing pseudomyxoma peritonei with pleural and hepatic metastases

Pseudomyxoma peritonei is characterized by diffuse collections of gelatinous flux resulting from implantation of malignant tumors or irritation from ruptured benign cysts. We report a patient with pseudomyxoma peritonei caused by an occult primary adenocarcinoma, who had both pleural and hepatic metastases.

A rapid method for plasma ammonia estimation using an indigenously purified enzyme

Determination of ammonia level in blood is important, especially in the diagnosis of hepatic disorders. An indigenously purified enzyme was used in the standardisation of the assay. The assay is a two reagent system, requires five minutes for completion and can be performed at temperature between 25-27°C. Performance of the assay was assessed by linearity, imprecision, functional sensitivity and interference studies. Lyophilised reagent I and reagent II were found stable for at least one year. The plasma level of ammonia for the controls was 13.7±7.3 μMol/L, whereas for subjects of hepatic disorders, it was 69.1±32.4 μMol/L (P<0.001). The functional sensitivity was between 2-1000 μMol/L. Within-run coefficient of variation was between 1.1-2.0% and between-run coefficient of variation was between 1.9-3.7%. The mean recovery after dilution was 99.6%. The present method can estimate ammonia up to 1000 μMol/L without dilution of sample. Assay time of five minute may be shortened to one minute. This method is suited for routine clinical use in treatment of hepatic disorders.

Fertility decline in Punjab, India: parallels with historical Europe

Two interesting features emerge from this study of fertility behaviour in Punjab. First, it brings out the common features of peasant life and demographic behaviour found in this developing-country setting and in historical Europe. As in much of Europe, marriage was regulated to adjust to the availability of land and other resources. It is interesting to note that the operation of this 'nuptiality valve' was quite consistent with a system of joint families and partible inheritance. Secondly, the findings suggest that we need to re-define what we understand to be the features of socio-economic development which are crucial for fertility decline. Fertility began to decline steadily in this part of Punjab as early as 1940, at a time when the society was overwhelmingly agrarian, illiterate, and infant mortality was high with no access to modern contraceptive technology, as in historical Europe. The onset of the decline was brought about by development interventions which stabilized fluctuations in crop yields and mortality, thus radically improving stability of people's expectations. This study also points out the inapplicability of Mamdani's theories of fertility behaviour to the people he studies.