Assessment of posterior capsule integrity in posterior polar cataracts using anterior segment OCT

BACKGROUND

Posterior polar cataracts (PPC) pose a great surgical challenge to ophthalmic surgeons. Main intraoperative surgical concerns are increased risk of posterior capsular rupture (PCR), vitreous loss, and nuclear drop. Traditional assessment of posterior capsule integrity utilizing anterior segment- optical coherence tomography (AS-OCT) requires training, and it is a time-consuming process. Recent techniques of posterior capsule assessment need additional software installation, raising the cost of investigation for the patient. This video demonstrates a time-saving method to assess posterior capsular integrity using regular AS-OCT, which can be learnt and practiced easily in outpatient department (OPD).

PURPOSE

Ultrasound and 20 D lens mounted on posterior segment optical coherence tomography (OCT) are some of the popular methods to assess the posterior capsule. Such techniques need training and are laborious. Our technique used to assess posterior capsule integrity in PPC using AS-OCT is simple, time saving, and can be easily practiced.

SYNOPSIS

The technique described requires AS-OCT lens to be mounted on the lens aperture. The console panel is set to scan on scleral mode. AS-OCT is advanced to capture the cornea, anterior capsule, and posterior capsule. Intact posterior capsule is visualized as a continuous well-defined hyper-reflective layer, and any break in the continuity of this hyper-reflective layer suggests posterior capsule dehiscence, which can further be studied based on literature classifications.

HIGHLIGHTS

(1) Importance of proper preoperative assessment in cases of PPC. (2) Detailed technique of using anterior segment OCT module in acquiring scans of posterior capsule in PPC. (3) How to find whether the posterior capsule is intact versus dehiscent. (4) Clinical cases showing utility of this technique. (5) Uses and benefits.

VIDEO LINK

https://youtu.be/AohMG4jT13M.

Safety and Efficacy of OPN Balloon in Patients With Calcified Coronary Artery Disease

BACKGROUND

Patients with symptomatic calcified coronary lesions have poor outcomes. Such lesions require additional atherectomy devices for bed preparation.

AIM

To assess the safety and efficacy of OPN balloon in patients with calcified coronary lesions.

METHODS

This is an investigator-initiated, prospective, observational study. The primary outcome of the study was a procedural success.

RESULTS

We studied 71 patients (133 lesions). Maximum lesions were located in LAD [46.6 %]. The OPN balloon was used for pre-dilatation alone in 28.6 % (Pre-stent OPN group), post-dilatation alone in 63.2 % of lesions (Post-stent OPN group), and in both situations in 8.3 % of lesions with procedural success in 98.5 % of patients. Further dilatation with different NC balloons was required in both groups (30 %). The median (IQR) OPN balloon diameter in the pre- and post-stent OPN group were 2.5 (2.5, 3.0) and 3.0 (3.0,3.0) mm (p = 0.001), respectively. The difference between the diameter of the stent and OPN balloon used in pre-stent OPN group was 0.5 (0.2, 0.5) mm while it was 0.0 (0.0,0.2) mm in the post-stent OPN group (p < 0.001). Eight complications and two deaths occured. Distal shaft rupture was also noticed.

CONCLUSION

OPN balloon is safe, and effective in treating calcified coronary lesions. We propose to undersize the balloon by 0.5 mm for pre-dilatation followed by 0.25 mm larger NC balloon if needed. In the post-dilatation group, use a 1:1 size balloon in a non-tortuous straight segment. Use imaging especially when (1) the pressure taken more than the rated burst pressure, (2) an OPN balloon size is ≥3 mm (3) using 1:1 size OPN balloon in a tortuous segment.

Improved Diagnosis through Diastolic Hyperemia-Free Ratio (DFR) over Fractional Flow Reserve (FFR) in Intermediate Coronary Lesions

OBJECTIVES

To compare the fractional flow reserve (FFR) and diastolic hyperemia-free ratio (DFR) measurements in a population with intermediate coronary artery stenosis and improve the diagnosis.

BACKGROUND

Visual assessment of coronary artery stenosis severity, particularly in intermediate lesions, is prone to errors in decision-making. FFR provides a reliable assessment of functional severity in these cases but requires hyperemia induction by adenosine, which has side effects and increased cost. DFR is a novel hyperemia-independent index, which could be used as an alternative to adenosine-based hyperemia induction.

METHODS AND RESULTS

Between September 2019 to March 2020, 25 patients with 38 intermediate coronary stenotic lesions were included in the study. All patients underwent assessment of whole cycle Pd/Pa (ratio of distal coronary pressure to proximal aortic pressure), DFR and FFR. Mean whole cycle Pd/Pa, DFR and FFR were 0.93±0.06, 0.88±0.09, and 0.85±0.08, respectively. A significant positive correlation between DFR and FFR [r = 0.74; p<0.001] was observed. Receiver operating characteristic analysis showed an area under the curve of 0.90. DFR-only strategy with a treatment cut-off of ≤0.89 showed a diagnostic agreement with the FFR-only strategy in 74% of lesions, with a sensitivity of 54%, specificity of 82%, a positive predictive value of 60%, and a negative predictive value of 79%.

CONCLUSIONS

Real-time DFR measurements show a clinically reliable correlation with FFR. Hence, using DFR is likely to avoid adenosine administration as well as reduce the cost and procedural time. Further studies with a larger sample size would be ideal to evaluate specific cut-off values and endpoints.

Trans-radial approach versus trans-femoral approach in patients with acute coronary syndrome undergoing percutaneous coronary intervention: An updated meta-analysis of randomized controlled trials

Introduction

Trans-radial approach (TRA) is recommended over trans-femoral approach (TFA) in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI). We intended to study the effect of access on all-cause mortality.

Methods and results

We searched PubMed and EMBASE for randomized studies on patients with ACS undergoing PCI. The primary outcome was all-cause mortality at 30-days. The secondary outcomes included in-hospital mortality, major adverse cardiac or cerebrovascular event (MACE) as defined by the study, net adverse clinical event (NACE), non-fatal myocardial infarction, non-fatal stroke, stent thrombosis, study-defined major bleeding, and minor bleeding, vascular complications, hematoma, pseudoaneurysm, non-access site bleeding, need for transfusion, access site cross-over, contrast volume, procedure duration, and hospital stay duration. We studied 20,122 ACS patients, including 10,037 and 10,085 patients undergoing trans-radial and trans-femoral approaches, respectively. We found mortality benefit in patients with ACS for the trans-radial approach [(1.7% vs. 2.3%; RR: 0.75; 95% CI: 0.62–0.91; P = 0.004; I2 = 0%). Out of 10,465 patients with STEMI, 5,189 patients had TRA and 5,276 had TFA procedures. A similar benefit was observed in patients with STEMI alone [(2.3% vs. 3.3%; RR: 0.71; 95% CI: 0.56–0.90; P = 0.004; I2 = 0%). We observed reduced MACE, NACE, major bleeding, vascular complications, and pseudoaneurysms. No difference in re-infarction, stroke, and serious bleeding requiring blood transfusions were noted. We noticed a small decrease in contrast volume(ml) {mean difference (95% CI): −4.6 [−8.5 to −0.7]}, small but significantly increase in procedural time {mean difference (95% CI) 1.2 [0.1 to 2.3]}and fluoroscopy time {mean difference (95% CI) 0.8 [0.3 to1.4] min} in the trans-radial group.

Conclusion

TRA has significantly reduced 30-day all-cause mortality among patients undergoing PCI for ACS. TRA should be the preferred vascular access in patients with ACS.

Procedural Safety and Long-Term Clinical Outcomes in Patients Receiving Ultra-Long Everolimus-Eluting Stent: A Single-Center Real-World Experience

Background

Diffuse long coronary lesions are difficult to treat percutaneously. The aim of the present study was to assess the procedural safety and long-term efficacy of the ultra-long (48-mm) drug-eluting stent Xience Xpedition.

Methods

This was an investigator-initiated, observational, all-comers study. A total of 92 patients with 93 lesions were enrolled in the study from October 2016 to October 2020. The primary outcome of the study was major adverse cardiac events (MACEs). Secondary outcomes were individual components of the primary outcome and procedural success.

Results

The mean (standard deviation (SD)) age of the participants was 58.8 (10.8) years. More than half of the patients had ST-segment elevation myocardial infarction (STEMI) at presentation (55.4%). Ten patients were in cardiogenic shock (CGS; 10.8%). Most of the lesions were located in the left anterior descending artery (48.3%). American College of Cardiology/American Heart Association (ACC/AHA) type C was the most common lesion type amongst the intervened vessels (46.74%), with a mean syntax score (SD) of 16.99 (8.89). The mean stent diameter used was 2.77 mm (0.25). MACE was observed in 7.6% of patients studied at a median follow-up of 24 months. MACE was significantly lower in the population without CGS, occurring in only 2.4% of the patients; a significant difference in MACE was observed in patients with and without CGS (P < 0.001). Procedural success was obtained in 89.2% of total population; however, 96.3% of patients without CGS had procedural success.

Conclusions

The deployment of the ultra-long 48-mm Xience Xpedition stent is feasible, safe, and effective; and it was associated with a good intermediate-term clinical outcome.

Burden of Type 2 Diabetes and Associated Cardiometabolic Traits and Their Heritability Estimates in Endogamous Ethnic Groups of India: Findings From the INDIGENIUS Consortium

To assess the burden of type 2 diabetes (T2D) and its genetic profile in endogamous populations of India given the paucity of data, we aimed to determine the prevalence of T2D and estimate its heritability using family-based cohorts from three distinct Endogamous Ethnic Groups (EEGs) representing Northern (Rajasthan [Agarwals: AG]) and Southern (Tamil Nadu [Chettiars: CH] and Andhra Pradesh [Reddys: RE]) states of India. For comparison, family-based data collected previously from another North Indian Punjabi Sikh (SI) EEG was used. In addition, we examined various T2D-related cardiometabolic traits and determined their heritabilities. These studies were conducted as part of the Indian Diabetes Genetic Studies in collaboration with US (INDIGENIUS) Consortium. The pedigree, demographic, phenotypic, covariate data and samples were collected from the CH, AG, and RE EEGs. The status of T2D was defined by ADA guidelines (fasting glucose ≥ 126 mg/dl or HbA1c ≥ 6.5% and/or use of diabetes medication/history). The prevalence of T2D in CH (N = 517, families = 21, mean age = 47y, mean BMI = 27), AG (N = 530, Families = 25, mean age = 43y, mean BMI = 27), and RE (N = 500, Families = 22, mean age = 46y, mean BMI = 27) was found to be 33%, 37%, and 36%, respectively, Also, the study participants from these EEGs were found to be at increased cardiometabolic risk (e.g., obesity and prediabetes). Similar characteristics for the SI EEG (N = 1,260, Families = 324, Age = 51y, BMI = 27, T2D = 75%) were obtained previously. We used the variance components approach to carry out genetic analyses after adjusting for covariate effects. The heritability (h²) estimates of T2D in the CH, RE, SI, and AG were found to be 30%, 46%, 54%, and 82% respectively, and statistically significant (P ≤ 0.05). Other T2D related traits (e.g., BMI, lipids, blood pressure) in AG, CH, and RE EEGs exhibited strong additive genetic influences (h² range: 17% [triglycerides/AG and hs-CRP/RE] - 86% [glucose/non-T2D/AG]). Our findings highlight the high burden of T2D in Indian EEGs with significant and differential additive genetic influences on T2D and related traits.

Quantitative analysis of retinal microvascular changes in prediabetic and diabetic patients

Purpose:

To evaluate and correlate retinal microvascular changes in prediabetic and diabetic patients with functional and systemic parameters.

Methods:

Optical coherence tomography angiography (OCTA) was performed on all subjects after medical evaluation and laboratory investigations for blood sugar, glycosylated hemoglobin, and others. Automated quantification of vascular indices of the superficial plexus were analyzed.

Results:

Hundred and eleven persons (222 eyes) were grouped into prediabetic (PDM) (60 eyes), diabetic without retinopathy (NDR) (56 eyes), diabetic with retinopathy (DR) (66 eyes), and healthy controls (CTR) (40 eyes). The superficial retinal capillary plexus showed no significant changes in the prediabetic and NDR groups; however, central foveal thickness (CFT) was significantly reduced in PDM (P = 0.04). The circularity of the foveal avascular zone (FAZ) (P = 0.03) and the vessel density (VD) (P = 0.01) showed significant reduction from PDM to NDR. All vascular parameters were significantly reduced in DR and correlated with disease severity. The CFT correlated significantly with FAZ area. The VD and perfusion density were seen to correlate significantly with HbA1c and contrast sensitivity. The visual acuity was significantly correlated with the FAZ. Logistic regression revealed VD [OR 20.42 (7.9–53)] and FAZ perimeter [OR 9.8 (4.2–23.2)] as the strongest predictors of DR.

Conclusion:

The changes in OCTA can help predict onset of DR. FAZ changes are seen in early stages and are correlated well with systemic parameters, making it an easy target to monitor and screen for severity of DR. Significant reduction in the CFT in PDM suggests that neuronal damage precedes vascular changes.

Association of incremental pulse wave velocity with cardiometabolic risk factors

We investigate the association of incremental pulse wave velocity (ΔC; the change in pulse wave velocity over a cardiac cycle) with cardiometabolic risk factors and report the first and (currently) the largest population-level data. In a cross-sectional study performed in a cohort of 1373 general population participants, ΔC was measured using clinically validated ARTSENS devices. There were 455 participants in the metabolic syndrome (MetS) group whose average ΔC was ~ 28.4% higher than that of the non-metabolic syndrome (Non-MetS) group. Females with MetS showed ~ 10.9% elevated average ΔC compared to males of the Non-MetS group. As the number of risk factors increased from 0 to 5, the average ΔC escalated by ~ 55% (1.50 ± 0.52 m/s to 2.33 ± 0.91 m/s). A gradual increase in average ΔC was observed across each decade from the younger (ΔC = 1.53 ± 0.54 m/s) to geriatric (ΔC = 2.34 ± 0.59 m/s) populations. There was also a significant difference in ΔC among the blood pressure categories. Most importantly, ΔC ≥ 1.81 m/s predicted a constellation of ≥ 3 risks with AUC = 0.615, OR = 2.309, and RR = 1.703. All statistical trends remained significant, even after adjusting for covariates. The study provides initial evidence for the potential use of ΔC as a tool for the early detection and screening of vascular dysfunction, which opens up avenues for active clinical and epidemiological studies. Further investigations are encouraged to confirm and establish the causative mechanism for the reported associations.

Cardiac MRI viability study and its role in revascularization- Excerpts from a tertiary care cardiac centre

Funding Acknowledgements

Type of funding sources: None.

Background

Assessment of cardiac viability based revascularization has not convincingly demonstrated, to improve patient outcomes statistically even by large trials like STITCH and PPAR-2 using SPECT and PET analysis. Here we used cardiac viability by cardiac MRI to guide us for revascularization and also found out problems arising in the statistical analysis for the same

Methods

It is a retrospective observational longitudinal follow up study whereby patients who had ischemic cardiomyopathy (confirmed with coronary angiogram) and who were admitted with features of heart failure or with acute coronary syndrome and who subsequently underwent cardiac MRI viability testing during the period from 1/02/2017 to 31/01/2020 were included. Patients were excluded who had non ischemic cardiomyopathy. Using cardiac MRI- LVEF, RVEF, Wall motion severity Index and Total viability percentage were additionally computed and analyzed. Patients were deemed having viable myocardium on ≤50% LGE in cardiac MRI and final treatment of CABG, PCI or only medical management was analyzed for the Primary end points of CV mortality, non-fatal CVA and non-fatal AMI 

Results

Based on the criteria total of 94 patients were selected for the study, 53 patients kept on only medical management, 19 patients underwent PCI and 22 patients had CABG. The baseline characteristics of the study population were an average age of 60years, male (76%) with Diabetes Mellitus(69%) and Hypertension (41.5%) in them. Coronary Angiogram showed that 10.6% patients had LM involvement, 92% had LAD disease, 72% patients had LCX lesion and 74% had RCA disease. While average Echo LVEF was 35.82%, Cardiac MRI based mean LVEF was 30.78%. It was found that patients who were kept only on medical management had higher Wall motion Severity Index (2.05) over patients who  were treated with PCI (1.94) or CABG (1.80) (p = 0.006). Also it was found that the Total viability percentage was less in patients kept only on medical management (74%) vs patients who were treated with PCI (78%) or CABG (77.8%)(p = 0.08) .It was found by cardiac MRI that patients with significant LAD lesions with viable LAD territory, those who underwent CABG or PCI based therapy had lesser mortality(7.69%,10%) over patients kept only on medical management (23%) (p = 0.407). Among patients with significant LAD lesions with non-viable LAD territory, those who underwent CABG or only medical management had lesser mortality (11.5%) than patients who underwent PCI (50%) (p = 0.137).

Conclusion(s)

Cardiac MRI based viability testing may guide the physician for optimal treatment but it does not reach statistical significance. The reasons maybe different arterial segments having different viability and anatomical hazards acting as cofounding factors. Viability being a continuum process does not follow a strict cut off of 50% LGE and 100% acute occluded vessel may not allow LGE.

Interchangeability of retinal perfusion indices in different-sized angiocubes: An optical coherence tomography angiography study in diabetic retinopathy

Purpose

To evaluate the differences in vascular indices in different scan sizes of optical coherence tomography angiography (OCTA) images in normal persons versus persons with diabetic retinopathy.

Methods

OCTA scans of diabetic patients and age-matched controls were performed by a single operator. Automated quantification of vascular indices of the superficial plexus was analyzed in two angiocubes of 3 × 3 mm and 6 × 6 mm, respectively. The agreement was analyzed with the intraclass correlation coefficient (ICC) and Bland-Altman plots.

Results

Forty-eight eyes with DR, 36 eyes with no diabetic retinopathy (No DR), and 26 eyes of age-matched normals were scanned. The foveal avascular zone (FAZ) area and perimeter were highly reliable and interchangeable in both angiocubes of the healthy eyes (ICC 0.94, 0.75), No DR (ICC 0.92, 0.85), and DR eyes (ICC 0.97, 0.89). The vessel density (VD) and perfusion density (PD) showed excellent agreement in normal (ICC 0.89, 0.80) and No DR eyes (ICC 0.92, 0.81). But, only fair ICC was observed in DR eyes (0.56, 0.42).

Conclusion

The FAZ area and perimeter showed excellent reproducibility. The macular perfusion parameters are not interchangeable despite automated estimation. The variability is more with changes in the vascular network like DR. This variability should be considered while comparing different scans.

Clinical profile and management of patients with acute pulmonary thromboembolism - a single centre, large observational study from India

Acute pulmonary thromboembolism is associated with high mortality, similar to that of myocardial infarction and stroke. We studied the clinical presentation and management of pulmonary thromboembolism in the Indian population. An analysis of 140 patients who presented with acute pulmonary thromboembolism at a large volume center in India from June 2015 through December 2018 was performed. The mean age of our study population was 50 years with 59% being male. Comorbidities including deep vein thrombosis, diabetes mellitus, hypertension, and chronic obstructive pulmonary disease were present in 52.9%, 40%, 35.7% and 7.14% of patients, respectively. Out of 140 patients, 40 (28.6%) patients had massive pulmonary thromboembolism, 36 (25.7%) sub-massive pulmonary thromboembolism, and 64 (45.7%) had low-risk pulmonary thromboembolism. Overall, in-hospital mortality was 25.7%. Multivariate regression analysis found chronic kidney disease and pulmonary thromboembolism severity to be the only independent risk factors. Thrombolysis was performed in 62.5% of patients with a massive pulmonary thromboembolism and 63.9% of patients with a sub-massive pulmonary thromboembolism. In the massive pulmonary thromboembolism group, patients receiving thrombolytic therapy had lower mortality compared with patients who did not receive therapy (p=0.022), whereas this difference was not observed in patients in the sub-massive pulmonary thromboembolism group. We conclude that patients with acute pulmonary thromboembolism in India presented more than a decade earlier than our western counterparts, and it was associated with poor clinical outcomes. Thrombolysis was associated with significantly reduced in-hospital mortality in patients with massive pulmonary thromboembolism.

Comparison of the effect of Morphine and Fentanyl in patients with acute coronary syndrome receiving Ticagrelor - The COMET (Comparison Morphine, Fentayl and Ticagrelor) randomized controlled trial

INTRODUCTION

Dual antiplatelet therapy (DAPT) remains the cornerstone of acute coronary syndrome (ACS) management, and ticagrelor is one of the commonly used second antiplatelet agents. There is some evidence to suggest that morphine may reduce the antiplatelet effect of ticagrelor.

METHODS AND RESULTS

In a single-center, randomized controlled trial, we compared the effect of morphine and fentanyl on platelet aggregation (PA) among patients with ACS treated with ticagrelor. Platelet aggregation was studied by automated light transmittance aggregometry (LTA) at baseline, and at 2 h after ticagrelor loading. The primary outcome was the difference in the maximal inhibition of platelet aggregation [IPA(%)] between the groups at 2 h. Pain relief, and drug-related adverse events were secondary outcomes. Of 136 patients randomized, 70 received fentanyl and 66 received morphine. At baseline, the median (IQR) platelet aggregation [61.35% (54.6 to 70) Vs. 58.8% (52.7 to 72.9)] were comparable between the groups. There was no statistically significant difference between the fentanyl and the morphine groups in IPA at 2-h [85.88%(64.65-98.16) and 81.93%(44.2-98.03), p = 0.09]. However, morphine use was independently associated with a PA of >30% at 2 h (p < 0.009). There was no difference in adverse events.

CONCLUSION

In patients with ACS, there was no significant difference between the use of fentanyl or morphine on the effect of ticagrelor on PA. (CTRI/2018/04/013423).

Urban environment as an independent predictor of insulin resistance in a South Asian population

Background

Developing countries, such as India, are experiencing rapid urbanization, which may have a major impact on the environment: including worsening air and water quality, noise and the problems of waste disposal. We used health data from an ongoing cohort study based in southern India to examine the relationship between the urban environment and homeostasis model assessment of insulin resistance (HOMA-IR).

Methods

We utilized three metrics of urbanization: distance from urban center; population density in the India Census; and satellite-based land cover. Restricted to participants without diabetes (N = 6350); we built logistic regression models adjusted for traditional risk factors to test the association between urban environment and HOMA-IR.

Results

In adjusted models, residing within 0–20 km of the urban center was associated with an odds ratio for HOMA-IR of 1.79 (95% CI 1.39, 2.29) for females and 2.30 (95% CI 1.64, 3.22) for males compared to residing in the furthest 61–80 km distance group. Similar statistically significant results were identified using the other metrics.

Conclusions

We identified associations between urban environment and HOMA-IR in a cohort of adults. These associations were robust using various metrics of urbanization and adjustment for individual predictors. Our results are of public health concern due to the global movement of large numbers of people from rural to urban areas and the already large burden of diabetes.

Electronic supplementary material

The online version of this article (10.1186/s12942-019-0169-9) contains supplementary material, which is available to authorized users.

Urbanization as a risk factor for aortic stiffness in a cohort in India

Urbanization is associated with higher prevalence of cardiovascular disease worldwide. Aortic stiffness, as measured by carotid-femoral pulse wave velocity is a validated predictor of cardiovascular disease. Our objective was to determine the association between urbanization and carotid-femoral pulse wave velocity. The analysis included 6166 participants enrolled in an ongoing population-based study (mean age 42 years; 58% female) who live in an 80 × 80 km region of southern India. Multiple measures of urbanization were used and compared: 1) census designations, 2) satellite derived land cover (crops, grass, shrubs or trees as rural; built-up areas as urban), and 3) distance categories based on proximity to an urban center. The association between urbanization and carotid-femoral pulse wave velocity was tested in sex-stratified linear regression models. People residing in urban areas had significantly (p < 0.05) elevated mean carotid-femoral pulse wave velocity compared to non-urban populations after adjustment for other risk factors. There was also an inverse association between distance from the urban center and mean carotid-femoral pulse wave velocity: each 10 km increase in distance was associated with a decrease in mean carotid-femoral pulse wave velocity of 0.07 m/s (95% CI: -0.09, -0.06 m/s). The association was stronger among older participants, among smokers, and among those with other cardiovascular risk factors. Further research is needed to determine which components in the urban environment are associated with higher carotid-femoral pulse wave velocity.

Mexican American and South Asian population-based cohorts reveal high prevalence of type 2 diabetes and crucial differences in metabolic phenotypes

OBJECTIVE

Prevalence of type 2 diabetes varies by region and ancestry. However, most guidelines for the prevention of diabetes mellitus (DM) are based on European or non-Hispanic white populations. Two ethnic minority populations-Mexican Americans (MAs) in Texas, USA, and South Indians (SIs) in Tamil Nadu, India-have an increasing prevalence of DM. We aimed to understand the metabolic correlates of DM in these populations to improve risk stratification and DM prevention.

RESEARCH DESIGN AND METHODS

The Cameron County Hispanic Cohort (CCHC; n=3023) served as the MA sample, and the Population Study of Urban, Rural, and Semi-Urban Regions for the Detection of Endovascular Disease (PURSE; n=8080) served as the SI sample. Using design-based methods, we calculated the prevalence of DM and metabolic comorbidities in each cohort. We determined the association of DM with metabolic phenotypes to evaluate the relative contributions of obesity and metabolic health to the prevalence of DM.

RESULTS

In the CCHC (overall DM prevalence 26.2%), good metabolic health was associated with lower prevalence of DM, across age groups, regardless of obesity. In PURSE (overall prevalence 27.6%), probability of DM was not strongly associated with metabolic phenotypes, although DM prevalence was high in older age groups irrespective of metabolic health.

CONCLUSION

Our study provides robust, population-based data to estimate the prevalence of DM and its associations with metabolic health. Our results demonstrate differences in metabolic phenotypes in DM, which should inform DM prevention guidelines in non-European populations.

Associations between Greenness, Impervious Surface Area, and Nighttime Lights on Biomarkers of Vascular Aging in Chennai, India

BACKGROUND

India is undergoing rapid urbanization with simultaneous increases in the prevalence of cardiovascular disease (CVD). As urban areas become home to an increasing share of the world's population, it is important to understand relationships between the built environment and progression towards CVD.

OBJECTIVE

We assessed associations between multiple measures of the built environment and biomarkers of early vascular aging (EVA) in the Population Study of Urban, Rural and Semiurban Regions for the Detection of Endovascular Disease and Prevalence of Risk Factors and Holistic Intervention Study (PURSE-HIS) in Chennai, India.

METHODS

We performed a cross-sectional analysis of 3,150 study participants. EVA biomarkers included systolic and diastolic blood pressure (SBP and DBP), central pulse pressure (cPP) and flow-mediated dilatation (FMD). Multiple approaches were used to assign residential exposure to factors of the built environment: Moderate Resolution Imaging Spectroradiometer (MODIS)-derived normalized difference vegetation index (NDVI), a measure of vegetation health and greenness; Landsat-derived impervious surface area (ISA); and Visible Infrared Imaging Radiometer Suite (VIIRS)-derived nighttime lights (NTL). Multivariable regression models were used to assess associations between each built environment measure and biomarkers of EVA, adjusting for age, body mass index (BMI), cooking fuel type, energy intake, sex, physical activity, smoking, socioeconomic status, and stress.

RESULTS

Residing in areas with higher ISA or NTL, or lower greenness, was significantly associated with elevated SBP, DBP, and cPP, and with lower FMD, adjusting for age, BMI, sex, smoking status, and other CVD risk factors. An interquartile range decrease in greenness had the largest increase in SBP [4.3 mmHg (95% CI: 2.9, 5.6)], DBP [1.2 mmHg (95% CI: 0.4, 2.0)] and cPP [3.1 mmHg (95% CI: 2.0, 4.1)], and the largest decrease in FMD [-1.5% (95%CI: -2.2%, -0.9%].

CONCLUSION

Greenness, ISA, and NTL were associated with increased SBP, DBP, and cPP, and with reduced FMD, suggesting a possible additional EVA pathway for the relationship between urbanization and increased CVD prevalence in urban India. https://doi.org/10.1289/EHP541.

Prevalence, treatments and outcomes of coronary artery disease in Indians: A systematic review

AIM

To conduct a systematic review on the prevalence, risk factors, treatments and outcomes of Coronary Artery Disease (CAD) in Indians.

METHODS AND RESULTS

We conducted a systematic review of studies in Indians with CAD from Jan 1969 to Oct 2012. Initial search yielded 3885 studies and after review 288 observational studies were included. The prevalence of CAD in urban areas was 2.5%-12.6% and in rural areas, 1.4%-4.6%. The prevalence of risk factors was: smoking (8.9-40.5%), hypertension (13.1-36.9%) and diabetes mellitus (0.2-24.0%). The median time to reach hospital after an MI was 360 min. In hospital rates of drug use were: antiplatelets 68%-97.9%, beta blockers 47.3%-65.8% and ACEIs 27.8-56.8%.

CONCLUSIONS

In this first systematic review of CAD in India, prevalence of risk factors is high, treatments delayed and use of evidence based treatments variable.

Venthamarai chooranam, a polyherbal Siddha medicine, alleviates hypertension via AT₁R and eNOS signaling pathway in 2K1C hypertensive rats

The present study was aimed to scientifically demonstrate the anti-hypertensive action of Venthamarai chooranam (VMC) in renal hypertensive rats. Two Kidney One Clip (2K1C) Goldblatt model was adopted to induce hypertension in rats. Male Sprague Dawley rats (270-320 g) were randomized into sham (n = 6), vehicle-treated 2K1C (n = 9) and VMC-treated 2K1C (400 mg/kg, p.o; n = 8) and monitored for nine weeks. Systolic blood pressure (SBP), plasma nitrate/nitrite, carotid endothelial nitric oxide synthetase (eNOS), renal angiotensin type 1 receptor (AT₁R), angiotensin type 2 receptor (AT₂R), TNFα, IL-6, thioredoxin 1 (TRX1), and thioredoxin reductase 1 (TRXR1) mRNA expressions were studied. VMC upregulated eNOS expression which in turn improved plasma nitric oxide and decreased SBP in hypertensive rats. It down-regulated AT₁R and simultaneously upregulated AT₂R expression in comparison to vehicle-treated 2K1C rats. Further, renal TNFα and IL-6 expressions were down-regulated while TRX1 and TRXR1 were upregulated by VMC. VMC potentially interacts with renin-angiotensin components and endothelial functions, and thereby exerts its antihypertensive action. This is the first study to demonstrate the mechanism of anti-hypertensive action of VMC in an animal model of renovascular hypertension.

Population Study of Urban, Rural, and Semiurban Regions for the Detection of Endovascular Disease and Prevalence of Risk Factors and Holistic Intervention Study: Rationale, Study Design, and Baseline Characteristics of PURSE-HIS

We designed and implemented the PURSE-HIS (Population Study of Urban, Rural and Semiurban Regions for the Detection of Endovascular Disease and Prevalence of Risk Factors and Holistic Intervention Study) to understand the prevalence and progression of subclinical and overt endovascular disease (EVD) and its risk factors in urban, semiurban, and rural communities in South India. The study is also designed to generate clinical evidence for effective, affordable, and sustainable community-specific intervention strategies to control risks factors for EVD. As of June 2012, 8,080 (urban: 2,221; semiurban: 2,821; rural: 3,038) participants >20 years of age were recruited using 2-stage cluster sampling. Baseline measurements included standard cardiovascular disease risk factors, sociodemographic factors, lifestyle habits, psychosocial factors, and nutritional assessment. Fasting blood samples were assayed for putative biochemical risk factors and urine samples for microalbuminuria. All nondiabetic participants underwent oral glucose tolerance test with blood and urine samples collected every 30 min for 2 h. Additional baseline measurements included flow-mediated brachial artery endothelial vasodilation, assessment of carotid intimal medial wall thickness using ultrasonography, screening for peripheral vascular disease using ankle and brachial blood pressures, hemodynamic screening using a high-fidelity applanation tonometry to measure central blood pressure parameters, and aortic pulse wave velocity. To assess prevalence of coronary artery disease, all participants underwent surface electrocardiography and documentation of ventricular wall motion abnormality and function using echocardiography imaging. To detect subclinical lesions, all eligible participants completed an exercise treadmill test. Prospectively, the study will assess progression of subclinical and overt EVD, including risk factor-outcome relation differences across communities. The study will also evaluate community-specific EVD prevention using traditional Indian system of medicine versus recognized allopathic (mainstream) systems of medicine.

Abstract 410: High Sensitive C-Reactive Protein Independently Predicts Insulin Resistance in Women in a South Asian Population, With a Stronger Association in Urban Areas

Objectives: Insulin resistance (IR), which plays a fundamental role in the pathogenesis of metabolic syndrome and type 2 diabetes mellitus, is associated with serum levels of inflammatory markers and abdominal obesity. Whether the association of inflammation with IR is independent of obesity remains unresolved; moreover, whether this association varies with gender and urban living is not known. We therefore conducted a cross-sectional study to investigate the gender specific association between IR and high sensitive C-reactive protein (HsCRP), independent of abdominal obesity, in urban and rural communities in a South Asian population.

Methods: We conducted a population-based cross-sectional survey in 8,080 South Indians above the age of 20 years in both urban and rural environments. The study assessed of waist circumference (WC), blood pressure (BP), socioeconomic status, family history, anxiety and stress levels, and fasting blood for plasma glucose, insulin, total cholesterol (TC), triglyceride (TG), high density lipoprotein (HDL), low density lipoprotein (LDL) and HsCRP. IR was calculated using the homeostasis model assessment (HOMA-IR). After the exclusion of individuals with diabetics, 6,309 subjects (mean age 42 years; 58% women) were eligible and constituted the study sample.

Results: The HOMA-IR level (mean ± SD) was higher in women (1.98 ± 1.62), when compared to men (1.71 ± 1.38), and HsCRP levels were 4.00 ± 5.14 and 3.42 ± 7.22 mg/dl in women and men, respectively. There was stronger correlation of HsCRP with HOMA-IR in women (r= 0.371) when compared to men (r= 0.203). In a multiple regression analysis, after adjusting for WC and other co-variants such as, BP, TC, LDL, TG, socioeconomic status, physical activity and family history of diabetes, HsCRP continued to be a significant predictor only in women (p<0.001). In women with elevated HsCRP levels (≥ 3 mg/dl), after multivariate adjustments, the odds ratio of elevated HOMA-IR (≥ 2.86) was 2.13 [CI: 1.66, 2.74; p <0.001] in urban women, when compared to odds ratio of 1.41 [CI: 1.02, 1.96; p=0.037] in rural women.

Conclusion: HsCRP is associated with IR independent of abdominal obesity in non-diabetic South Asian women, and at elevated HsCRP levels the association is stronger in urban women.

Abstract 215: Principal Components Analysis in a South Asian Population: Cardiovascular Risk Variable Clustering and Obesity

Aim: Western populations demonstrate a strong role of obesity in clustering of cardiovascular (CV) risk factors. We hypothesized that obesity would not have a dominant role in the clustering of CV risk factors in South Asians, who develop CV disease at young ages despite relatively low BMI.

Methods: We selected 6224 South Indians without diabetes from a population-based cross-sectional survey (mean age 42 years; 58% women) for analysis. We used gender-specific principal components analysis (PCA), a multivariate correlation technique, with orthogonal rotation (to produce interpretable factors) to test the hypothesis. The PCA was done using measures of fasting (FPG) and 2 h plasma glucose (2h PG), haemoglobin A1c (A1c), fasting insulin (FIns), triglycerides (TG) and high-density lipoprotein (HDL), diastolic (DBP) and systolic blood pressure (SBP), body mass index (BMI) and waist circumference (WC). We did separate subgroup analyses stratified by various potential modifiers.

Results: The obesity indices correlated positively with CV risk variables (except HDL), regardless of gender. PCA failed to demonstrate a single dominant underlying pathological role (one component was rejected at P < 0.0001), but suggested three non-overlapping factors (physiological domains) underlying the clustering of the risk variables, accounting for 60% of the total variance in the data [Fig]. Obesity indices had significant positive loading (95% confidence interval >0.8) only in Factor 1, which included FIns, TG, and HDL. The FPG, 2hPG and A1C were associated with Factor 2. The SBP and DBP were associated with Factor 3. The factor patterns were virtually identical among all the subgroups with coefficients of congruence close to 1.0.

Conclusions: These findings are consistent with the presence of three distinct physiological domains underlying CV risk variable clustering. Obesity did not have a dominant role in the clustering of CV risk factors in the South Asian population.

Abstract 551: In a South Asian Population, Urbanization is an Independent Predictor of Arterial Stiffness in Men

Background: Rapid urbanization is driving economies of South Asian countries. Here we use satellite based land cover data and distance to urban center (UC) to measure of the impact of urban environment on arterial stiffness (AS) in a population based study in South India.

Methods: In a cross-sectional analysis, after exclusion of people with previous history of diabetes and hypertension, 6746 subjects (mean age 42 years; 54% women) spread over 78 kms from the UC constituted the study sample. MODIS satellite derived land cover data at a 1 km x 1 km resolution was obtained and joined to each participant's geolocated residential position in ArcGIS to assign urban and rural designations. The study included carotid-femoral pulse wave velocity (PWV) measurement using a high-fidelity applanation tonometry, blood pressure (BP), anthropometric, psychosocial, high sensitive C-reactive protein (HsCRP) and other biomarkers assessments.

Results: Based on land cover analysis, participants in urban locations had a mean (SD) PWV (m/s) of 7.74 (1.65) compared to 7.6 (1.62) in rural locations (p= 0.002) [Fig 1], while there was no significant difference in HsCRP levels. In multiple regression analyses adjusting for age, smoking, BMI, BP, blood glucose, LDL, socioeconomic, anxiety and stress levels, distance from UC was independently associated with PWV in men (β = -0.007, p <0.001), but not in women. Standardized effect-estimates in the multi-linear regression model indicated that distance from UC had the third largest effect on PWV after age and BP. After multivariable adjustments, the largest effect of distance from UC on PWV was on non-smoking men age 46-75 years. Residing every 1 km further away from the UC corresponded with a -0.012 m/s (95%CI: -0.020, -0.003) decrease in PWV.

Conclusions: Urbanization is an independent predictor of AS in men, more so in non-smoking older men. Further research will elucidate components in the urban environment that may be contributing to higher AS.

Prevalence and risk indicators for attachment loss in an urban population of South India

AIM

To estimate the prevalence and severity of attachment loss in an urban population of South India and to determine related risk indicators.

MATERIALS AND METHODS

This population based cross sectional study used a subset of data from a large survey representative of urban population from Chennai city. The sample consisted of 900 subjects in the age range of 17 years to 87 years. Participants were interviewed using a structured proforma and subjected to a full mouth clinical examination of six sites per tooth. The prevalence of clinical attachment level (CAL) and association with various risk indicators was assessed.

RESULTS

Out of the 900 subjects examined, 868 (96.4%) had CAL <5 mm and 32 (3.6%) had CAL ≥ 5 mm. Age, smoking, poor oral hygiene were found to be independent risk indicators for CAL (p<0.05). Smoking (pack years) was found to exhibit a dose response effect with CAL (Kendall's Tau coefficient = 0.098) (p<0.05).

CONCLUSION

In this urban population, a low prevalence of CAL ≥ 5 mm was observed. Amongst the risk indicators evaluated, age, smoking and poor oral hygiene contribute significantly to attachment loss.

Abstract 412: Obesity is an Independent Predictor Of Arterial Stiffness

Background Arterial stiffness assessed by carotid-femoral pulse wave velocity (PWV) is an independent predictor of cardiovascular morbidity and mortality. We aimed to investigate how various measures of obesity affect arterial stiffness.

Methods We conducted a population-based cross-sectional survey in 8,042 South Indians above the age of 20 years. Following completion of a detailed medical history questionnaire, all participants underwent haemodynamic screening including brachial and central blood pressure, and PWV measurements using a high-fidelity applanation tonometry. The study included anthropometric measurements and fasting blood for total cholesterol (TC), triglyceride (TG), high density lipoprotein (HDL), low density lipoprotein (LDL) and blood glucose (BG) levels. After the exclusion of people with previous history of diabetes, hypertension and dyslipidemia on drug therapy, 5,841 subjects (mean age 41.6 years; 58% women) constituted the study sample

Results In an univariate analysis, PWV correlated positively with age, mean blood pressure (MAP), heart rate (HR), body mass index (BMI), waist circumference (WC), waist to hip ratio (WHR), body fat percent (BF%), TC, TG, LDL and BG levels (P <0.001) and negatively with HDL levels (P=0.005). In a multivariate regression analysis, majority of the PWV variability in the model was accounted for by MAP and age, (cumulative adjusted R2 change of 32.79% as compared to the total adjusted R2 change of 35.25%). However, BMI (β= 0.042; adjusted R2 change=2.83%; p<0.001) independently correlated with PWV and its contribution to the PWV variability was far more significant compared to LDL, BG and TG (cumulative adjusted R2 change=1.08%). Multivariate regression analysis using the WC, WHR, or BF% instead of the BMI continued to demonstrate a significant independent effect of obesity parameters on PWV.

Conclusion: In a large a population-based cross-sectional survey the study demonstrates a positive, independent association between obesity parameters and increased arterial stiffness.

Acute toxicity and the 28-day repeated dose study of a Siddha medicine Nuna Kadugu in rats

BACKGROUND

Nuna Kadugu (NK), a Siddha medicine prepared from leaves and fruits of Morinda Pubescens, used for the treatment of various skin diseases. Though NK has been widely used for several decades, no scientific report was available on its safety. Present study was undertaken to demonstrate the oral toxicity of NK in Sprague Dawley rats.

METHODS

Acute and 28-day repeated oral toxicity studies were performed following OECD test guidelines 423 and 407, respectively, with minor modifications. In acute oral toxicity study, NK was administered at 2000 mg/kg b.wt., p.o and animals were observed for toxic signs at 0, 0.5, 1, 4, 24 h and for next 14 days. Gross pathology was performed at the end of the study. In repeated dose, the 28- day oral toxicity study, NK was administered at 300, 600 and 900 mg/kg b.wt./p.o/day. Two satellite groups (control and high dose) were also maintained to determine the delayed onset toxicity of NK. Animals were observed for mortality, morbidity, body weight changes, feed and water intake. Haematology, clinical biochemistry, electrolytes, gross pathology, relative organ weight and histopathological examination were performed.

RESULTS

In acute toxicity study, no treatment related death or toxic signs were observed with NK administration. In the repeated dose study, no significant differences in body weight changes, food / water intake, haematology, clinical biochemistry and electrolytes content were observed between control and NK groups. No gross pathological findings and difference in relative organ weights were observed between control and NK treated rats. Histopathological examination revealed no abnormalities with NK treatment.

CONCLUSION

Acute study reveals that the LD50 of NK is greater than 2000 mg/kg, b.wt. in fasted female rats and can be classified as Category 5. 28-day repeated oral toxicity demonstrates that the No Observed Adverse Effect Level of NK is greater than 900 mg/kg b.wt./day, p.o in rats. There were no delayed effects in NK satellite group. In conclusion, NK was found to be non-toxic in the tested doses and experimental conditions.

Polyphenols in madhumega chooranam, a Siddha medicine, ameliorates carbohydrate metabolism and oxidative stress in type II diabetic rats

ETHNOPHARMACOLOGICAL RELEVANCE

Present study was undertaken to demonstrate the mode of anti-diabetic action of a polyherbal Siddha Medicine, Madhumega chooranam (MMC).

MATERIALS AND METHODS

MMC was fractionated into phenolic (PMMC) and non-phenolic (NPMMC) portions in order to identify bioactive fraction. Study was performed in type II diabetic rats. Role of PMMC and NPMMC on liver glucose-6-phosphatase, fructose-1,6-bisphosphatase, glucokinase and glycogen content were determined. Their role on superoxide dismutase, reduced glutathione and lipid peroxidation were investigated. In addition, their effects on GLUT4 and PPARγ gene expression were studied. Pancreas and liver histopathology was studied using hematoxylin and eosin stain.

RESULTS

PMMC improved carbohydrate metabolism by decreasing glucose-6-phosphatase and fructose-1,6-bisphosphatase and increasing glucokinase and glycogen contents in diabetic rats liver. It alleviated oxidative stress by increasing superoxide dismutase, glutathione and decreasing lipid peroxidation content. PMMC up-regulated liver GLUT4 and PPARγ mRNA expression in comparison to the vehicle or NPMMC rats.

CONCLUSION

Madhumega chooranam mediates its anti-diabetic action through the inhibition of gluconeogenesis and activation of glycolytic pathways in type II diabetic rats. Increased GLUT4 and PPARγ expressions provide additional information on its glucose uptake/sensitising and hypolipidemic potential. Phenolic components of MMC were found to be the bioactive principles.

Amniotic membrane transplantation for acute ocular chemical burns in a child

An ocular burn injury with calcium hydroxide with opaque cornea and limbal ischaemia of more than 270 degrees which was treated byamniotic membrane transplantation on the 6th day following injury is reported. Postoperatively the ocular surface remained stable with no inflammation, vascularisation or infection. Amniotic membrane restored conjunctival surface much earlier than corneal surface and prevented symblepharon formation. We believe that amniotic membrane transplantation may be considered in acute phase of severe chemical injury for a more favourable prognosis.

Evaluation of subjective and objective cyclodeviation following oblique muscle weakening procedures

Purpose:

To evaluate the subjective and objective cyclodeviational changes following different weakening procedures on superior and inferior oblique muscles

Design:

Comparative case series

Materials and Methods:

In a prospective institution based study, 16 cases of A pattern horizontal strabismus having superior oblique overaction were randomized to superior oblique weakening procedures: either silicon expander or translational-recession. Similarly, 20 cases of V pattern horizontal strabismus with inferior oblique overaction were randomized for inferior oblique weakening procedures: either 10 mm Fink′s recession or modified Elliot and Nankin′s anteropositioning. Cyclodeviation was assessed subjectively with the synoptophore and objectively using the fundus photograph before surgery and 3 months postoperatively. Change in cyclodeviation was measured by subjective and objective methods. The index of surgical effect (ISE) was defined as the net torsional change postoperatively.

Results:

The difference between the extorsional change induced by the two superior oblique procedures, silicone expander (-6°) and translational recession (-11.3°), was statistically significant (P=0.001). Translational recession caused more extorsional change (ISE=296%) than silicone expander surgery (ISE=107%). The two inferior oblique weakening procedures, Fink′s recession (+2.5°) and modified Elliot and Nankin′s anteropositioning (+4.7°) produced equitable amount of intorsional shift with no statistical difference (P=0.93). Objective measurements were significantly more than the subjective measurements.

Conclusions:

Different weakening procedures on oblique muscles produce different changes in cyclodeviation, which persists even up to 3 months. Subjective cyclodeviation is less than the objective measurements indicating partial compensation by sensorial adaptations.

Treatment and outcomes of acute coronary syndromes in India (CREATE): a prospective analysis of registry data

BACKGROUND

India has the highest burden of acute coronary syndromes in the world, yet little is known about the treatments and outcomes of these diseases. We aimed to document the characteristics, treatments, and outcomes of patients with acute coronary syndromes who were admitted to hospitals in India.

METHODS

We did a prospective registry study in 89 centres from 10 regions and 50 cities in India. Eligible patients had suspected acute myocardial infarction with definite electrocardiograph changes (whether elevated ST [STEMI] or non-STEMI or unstable angina), or had suspected myocardial infarction without ECG changes but with prior evidence of ischaemic heart disease. We recorded a range of clinical outcomes, and all-cause mortality at 30 days.

FINDINGS

We enrolled 20,937 patients. Of the 20,468 patients who were given a definite diagnosis, 12,405 (60.6%) had STEMI. The mean age of these patients was 57.5 (SD 12.1) years; patients with STEMI were younger (56.3 [12.1] years) than were those with non-STEMI or unstable angina (59.3 [11.8] years). Most patients were from lower middle 10,737 (52.5%) and poor 3999 (19.6%) social classes. The median time from symptoms to hospital was 360 (IQR 123-1317) min, with 50 (25-68) min from hospital to thrombolysis. 6226 (30.4%) patients had diabetes; 7720 (37.7%) had hypertension; and 8242 (40.2%) were smokers. Treatments for STEMI differed from those for non-STEMI or unstable angina. More patients with STEMI than with non-STEMI were given anti-platelet drugs (98.2%vs 97.4%); angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB) (60.5%vs 51.2%); and percutaneous coronary interventions (8.0%vs 6.7%, p<0.0001 for all comparisons). Thrombolytics (96.3% streptokinase) were used for 58.5% of patients with STEMI. Conversely, fewer patients with STEMI than those with non-STEMI or unstable angina were given beta blockers (57.5%vs 61.9%); lipid-lowering drugs (50.8%vs 53.9%); and coronary bypass graft surgery (1.9%vs 4.4%, p<0.0001 for all comparisons). The 30-day outcomes for patients with STEMI were death (8.6%), reinfarction (2.3%), and stroke (0.7%). Outcomes for those with non-STEMI or unstable angina were better: death (3.7%), reinfarction (1.2%), and stroke (0.3%, p<0.0001 for all comparisons). Use of key treatments also differed by socioeconomic status: more rich patients than poor patients were given thrombolytics (60.6%vs 52.3%), beta blockers (58.8%vs 49.6%), lipid-lowering drugs (61.2%vs 36.0%), ACE inhibitors or ARB (63.2%vs 54.1%), percutaneous coronary intervention (15.3%vs 2.0%), and coronary artery bypass graft surgery (7.5%vs 0.7%, p<0.0001 for all comparisons). Mortality was higher for poor patients than for rich patients (8.2%vs 5.5%, p<0.0001). Adjustment for treatments (but not risk factors and baseline characteristics) eliminated this difference in mortality.

INTERPRETATION

Patients in India who have acute coronary syndromes have a higher rate of STEMI than do patients in developed countries. Since most of these patients were poor, less likely to get evidence-based treatments, and had greater 30-day mortality, reduction of delays in access to hospital and provision of affordable treatments could reduce morbidity and mortality.

Treatment and outcomes of acute coronary syndromes in India (CREATE): a prospective analysis of registry data

BACKGROUND

India has the highest burden of acute coronary syndromes in the world, yet little is known about the treatments and outcomes of these diseases. We aimed to document the characteristics, treatments, and outcomes of patients with acute coronary syndromes who were admitted to hospitals in India.

METHODS

We did a prospective registry study in 89 centres from 10 regions and 50 cities in India. Eligible patients had suspected acute myocardial infarction with definite electrocardiograph changes (whether elevated ST [STEMI] or non-STEMI or unstable angina), or had suspected myocardial infarction without ECG changes but with prior evidence of ischaemic heart disease. We recorded a range of clinical outcomes, and all-cause mortality at 30 days.

FINDINGS

We enrolled 20,937 patients. Of the 20,468 patients who were given a definite diagnosis, 12,405 (60.6%) had STEMI. The mean age of these patients was 57.5 (SD 12.1) years; patients with STEMI were younger (56.3 [12.1] years) than were those with non-STEMI or unstable angina (59.3 [11.8] years). Most patients were from lower middle 10,737 (52.5%) and poor 3999 (19.6%) social classes. The median time from symptoms to hospital was 360 (IQR 123-1317) min, with 50 (25-68) min from hospital to thrombolysis. 6226 (30.4%) patients had diabetes; 7720 (37.7%) had hypertension; and 8242 (40.2%) were smokers. Treatments for STEMI differed from those for non-STEMI or unstable angina. More patients with STEMI than with non-STEMI were given anti-platelet drugs (98.2%vs 97.4%); angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB) (60.5%vs 51.2%); and percutaneous coronary interventions (8.0%vs 6.7%, p<0.0001 for all comparisons). Thrombolytics (96.3% streptokinase) were used for 58.5% of patients with STEMI. Conversely, fewer patients with STEMI than those with non-STEMI or unstable angina were given beta blockers (57.5%vs 61.9%); lipid-lowering drugs (50.8%vs 53.9%); and coronary bypass graft surgery (1.9%vs 4.4%, p<0.0001 for all comparisons). The 30-day outcomes for patients with STEMI were death (8.6%), reinfarction (2.3%), and stroke (0.7%). Outcomes for those with non-STEMI or unstable angina were better: death (3.7%), reinfarction (1.2%), and stroke (0.3%, p<0.0001 for all comparisons). Use of key treatments also differed by socioeconomic status: more rich patients than poor patients were given thrombolytics (60.6%vs 52.3%), beta blockers (58.8%vs 49.6%), lipid-lowering drugs (61.2%vs 36.0%), ACE inhibitors or ARB (63.2%vs 54.1%), percutaneous coronary intervention (15.3%vs 2.0%), and coronary artery bypass graft surgery (7.5%vs 0.7%, p<0.0001 for all comparisons). Mortality was higher for poor patients than for rich patients (8.2%vs 5.5%, p<0.0001). Adjustment for treatments (but not risk factors and baseline characteristics) eliminated this difference in mortality.

INTERPRETATION

Patients in India who have acute coronary syndromes have a higher rate of STEMI than do patients in developed countries. Since most of these patients were poor, less likely to get evidence-based treatments, and had greater 30-day mortality, reduction of delays in access to hospital and provision of affordable treatments could reduce morbidity and mortality.

Left ventricular systolic dysfunction identification by motion analysis

This paper presents a new technique for identification of regional dysfunctions in the left ventricle from 2-D echocardiography. It uses a novel left ventricular border tracking algorithm based on Fuzzy inference system. In this paper we show how the regional dysfunction present in the left ventricle can be identified by tracking the movement of centre of mass of left ventricle in a 2D space. The path pattern of that point traced over the cardiac cycles shows variation between the two groups. The main advantage of this proposed approach is the smaller date handling in regional dysfunction identifications unlike other existing methods. The method is illustrated on the real 2D echocardiograph dataset that includes patients having dysfunctions in the left ventricular wall. The diagnostic potential of this method is explained in detail.

Percutaneous transluminal coronary angioplasty by right transradial approach in a patient with arteria lusoria

Though the radial artery is an ideal site of access for coronary interventions, at times anatomical variations make this procedure complicated. We describe one such arterial aberrancy, the retroesophageal right subclavian artery or arteria lusoria, in which the right subclavian artery arises distal to the left subclavian artery. Therefore, approaching through the right radial artery, the catheter has to take a zigzag course through the right subclavian to the descending aorta, and then to the ascending aorta. This often makes it difficult to perform diagnostic angiography. Performing angioplasty by the right transradial approach also becomes a more difficult task and requires greater perseverance and skill. In the case described here, the patient with arteria lusoria had tandem 90% stenosis involving the proximal and mid left anterior descending artery. Percutaneous transluminal coronary angioplasty with stenting of the proximal and mid left anterior descending artery by the right transradial approach was performed, negotiating the loop with two paclitaxel-eluting stents.