An 85-Year-Old Man with Fever, Dyspnea, and Dry Cough Diagnosed with Idiopathic Hypereosinophilic Syndrome, Successfully Treated with High-Dose Corticosteroids

BACKGROUND Idiopathic hypereosinophilic syndrome (I-HES) is a rare disease diagnosed as absolute eosinophil count >1500 cells/µl and end-organ involvement attributable to tissue eosinophilia with no secondary cause of underlying eosinophilia. The mean age of presentation for I-HES is 44 years. The skin, lungs, and gastrointestinal (GI) system are most common sites of presenting manifestations, including fatigue, cough, dyspnea, myalgias, angioedema, rash, fever, nausea, and diarrhea. Although cardiac and neurologic symptoms are less common at presentation, they can be life-threatening. CASE REPORT We report the case of an 85-year-old man who presented with fever, malaise, and loss of appetite for 3 weeks, followed by dyspnea and dry cough for 2 weeks. His absolute eosinophil count was 9000 cells/µl, which was not responding to empirical antibiotic therapy, with worsening of symptoms, suggesting a non-infective origin. He was then extensively evaluated to establish underlying an etiology for specific treatment, which was negative for common causes like atypical infections, malignancy, and autoimmune disorders. He was then started on corticosteroid therapy to overcome an exaggerated immune response and reduce inflammation-related injury, to which he responded well. On follow-up, hypereosinophilia was fully cured, with reversal of end-organ involvement including myocarditis and pneumonitis. CONCLUSIONS This report shows that idiopathic HES can present with various clinical features and that accurate diagnosis, excluding known causes of eosinophilia, and early management are essential to prevent long-term organ damage. Our patient responded to prompt treatment with high-dose corticosteroids.

Role of two-dimensional strain echocardiographic parameters in suspected acute coronary syndrome patients with initial non-diagnostic electrocardiogram and troponins: An observational study

INTRODUCTION

Diagnosis of acute coronary syndrome (ACS) is often challenging especially in presence of initial normal troponins and non-specific electrocardiogram. The index study aimed at determining the diagnostic value of strain echocardiography in patients with suspected ACS but with non-diagnostic electrocardiogram and echocardiography findings.

METHODS

The study was conducted on 42 patients with suspected ACS and non-diagnostic electrocardiograms, normal quantitative troponin-T levels, and left ventricular function. All patients underwent conventional and 2D-strain echocardiography followed by coronary angiography, within 24 h of admission. Patients with regional wall motion abnormalities (RWMA), valvular heart disease, suspected myocarditis, and past coronary artery disease (CAD) were excluded.

RESULTS

Amongst the global strains, the global circumferential strain (GCS) was significantly reduced (p = .014) amongst those with significant CAD on angiography as opposed to global longitudinal strain (GLS) which was similar in the two groups (p = .33). The GCS/GLS ratio was also significantly reduced in patients with significant CAD compared to those with normal/mild disease on coronary angiography (p = .025). Both the parameters had good accuracy in predicting significant CAD. GCS displayed a sensitivity of 80% and a specificity of 86% at an optimal cut-off 31.5% (AUROC: .93, 95% CI: .601-1.000; p = .03), and likewise GCS/GLS ratio had a sensitivity of 80% and a specificity and 86% at a cut-off of 1.89% (AUROC: .86, 95% CI: .592-1.000; p = .049). GLS and peak atrial longitudinal strain (PALS) did not differ significantly in patients with/without significant CAD (p = .32 and .58, respectively).

CONCLUSION

GCS and GCS/GLS ratio provides incremental value in comparison to GLS, PALS, and tissue Doppler indices (E/e') in patients with suspected ACS and non-diagnostic electrocardiogram and troponins. GCS at cut-off of >31.5% and GCS/GLS ratio >1.89 can reliably exclude patients with significant CAD in this setting.

Prevalence and predictors of lower extremity atherosclerotic disease amongst high-risk patients using ankle brachial index

INTRODUCTION

The prevalence of lower extremity artery disease (LEAD) continues to increase worldwide. This is expected to translate into logarithmic rise in lower-limb amputations especially in the developing world. Majority of patients suffering from LEAD remain asymptomatic until late and are vulnerable to limb-threatening complications unless actively screened and treated.

METHODS

This was a prospective, single-center, observational study to determine the prevalence and predictors of LEAD. Patients with known atherosclerotic vascular disease (but not known LEAD) or those at risk were enrolled. All underwent ABI measurement as per the standard protocol. A threshold of ABI ≤ 0.90 was taken to diagnose LEAD.

RESULTS

A total of 1000 patients were enrolled. The mean age of the group was 61.4±10.0 years and the prevalence of LEAD was 10.2%. Amongst those who had LEAD, the majority of patients (69.6%) had no symptoms. The prevalence of LEAD in diabetic population in our study was 13.2% and in coronary artery disease patients it was 30.9%. Factors independently linked to LEAD on regression analysis included advanced age, presence of diabetes, smoking history, lower serum HDL and a lower ejection fraction.

CONCLUSIONS

The vast majority of patients suffering from LEAD are asymptomatic. Early diagnoses and institution of appropriate medical and physical therapy can prevent excess morbidity and mortality due to LEAD. Factors independently linked to LEAD are advanced age, presence of diabetes, smoking history, lower serum HDL and a lower ejection fraction. The presence of either of these should signal undertaking of appropriate steps to unmask underlying LEAD.

Outpatient Attendance in COVID Pandemic Lockdown: An Observational Study

Objectives:

The objectives of this study were to analyze the profile of outpatient department (OPD) attendance of a tertiary care hospital during pre- and post-pandemic lockdown period.

Materials and Methods:

All consecutive patients presenting to OPD from August 1, 2019 to November 23, 2020 were included in the study. The sample was divided into Zone R (Regular domain) and Zone L (Lockdown domain). Zone L was divided into three groups A, B, and C; representing attendance to be <30%, 30–60%, and >60% of previous (i.e., Zone R), respectively. The patient gender, intradepartmental, and inter departmental OPD attendance data were collected and analyzed.

Results:

n = 428,322 patients attended the OPD in the study period. 301,586 patients presented in Zone R and 126,736 presented in Zone L (P = 0.000). Zone L recorded an OPD attendance drop to 42% of Zone R. The least attended an OPD (Group A) was ophthalmology, ENT, dermatology, surgery, and orthopedics versus highest attendance (Group C) was noticed in emergency OPD and oncology with a moderate decline in the rest (P = −0.00, 0.00, and 0.00, respectively). Both male and female attendance in the OPD showed a decline; however, the gender divide was apparent with significantly low women attendance in all the departments (P = 0.00).

Conclusion:

OPD attendance showed a significant reduction in COVID lockdown era hitting the non-emergent medical branches the most. The gender divide significantly widened with less female attendance recorded in most OPDs in pandemic lockdown. Apt administrative measures could prove fruitful by an improved OPD attendance and its psychosocial implications to a society with less disease burden.

Clinical profile and outcome of cardiac manifestations in patients presenting with multisystem inflammatory syndrome in children associated with SARS-CoV-2 infection

Multisystem inflammatory syndrome in children (MIS-C) can cause significant morbidity and mortality in children. This study was conducted to assess the pattern and outcome of cardiac abnormalities in MIS-C. This retrospective study was conducted in children with MIS-C between 1 month and 18 years. We enrolled 53 children with a mean age of 7.78 ± 4.62 years. Overall, 35.8% of children with MIS-C had cardiac manifestations in the form of coronary artery abnormalities (CAAs) or left ventricular (LV) dysfunction. Younger age (P 0.009) and high C-reactive protein at admission (P = 0.001) were significant predictors of cardiac involvement. CAAs were seen in 11.3% of children. On follow-up, 67% and 83% of children showed regression of CAA at 1 and 6 months, respectively. 24.5% of patients had presented with LV dysfunction. LV ejection fraction improved significantly at 1 month (P = 0.002) and 6 months (P = 0.001). Cardiac outcomes in MIS-C were favorable with timely identification and treatment.

Hypertension in Women: The Current Understanding and Future Goals

Hypertension is one of the major contributing risk factor of cardiovascular diseases. Despite enormous advances in the preventive cardiology, hypertension remains the leading cause of death and disability in women. The article aims to focus on the gender specific differences in hypertension, and existing gaps in the current understanding of high blood pressure (BP) in women. Apart from epidemiological differences, hypertension in men and women has distinct pathophysiological mechanisms, impact on cardiovascular system, awareness and control. Prevalence of hypertension is higher in men than women till menopause; following this the prevalence rises steeply in women, and exceeds that of men above 75 years of age. Women with their estrogenic environment are relatively protected from high BP as their hormonal/chromosomal profile govern expression of alternate renin angiotensin axis (RAS) pathway and anti-inflammatory, vasodilatory, anti-proliferative immune cells whereas in males, classical RAS driven inflammatory, pro-hypertensive and proliferative milieu confers higher risk of hypertension. Thus, immunotherapy can have a potential therapeutic role in the treatment of hypertension in future. Cardiovascular consequences of high BP are worse in women than men in majority of trials. Women are now getting more aware of hypertension but the control of BP still remains poorer than men, especially in older age group. There are some noteworthy pharmacokinetic and pharmacogenomics gender differences in response to various antihypertensive drugs, which can be taken into consideration while choosing a particular class of drugs in female population. Standard treatment guidelines recommend same BP targets and management strategies in both the genders, but the trials so far have not been designed in a way to draw women specific conclusions on optimal cut-offs for diagnosis and treatment of BP due to under representation of women in majority of trials. More women centered analysis in future hypertension research projects can provide better scientific insights in various clinical aspects of hypertension.

Autoimmune polyendocrine syndrome II presenting paradoxically as Takotsubo cardiomyopathy: A case report and reappraisal of pathophysiology.. [DOI: 10.21203/rs.3.rs-1900621/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

BackgroundTakotsubo cardiomyopathy (TCM) is a rare disease entity characterized by acute, non-ischemic, reversible myocardial dysfunction that mimics acute myocardial infarction. Activation and excessive outflow of sympathetic nervous system is believed to be central to the figure in the disease pathogenesis. Adrenocortical hormones potentiate the systemic actions of sympathetic nervous system and accordingly are essential for regulation of myocardial function. We present an unusual case of a middle-aged woman with primary adrenal insufficiency who presented paradoxically with TCM. Case presentation A 50-year-old woman with past history of hypothyroidism presented to emergency department with history of acute chest pain and syncope. There was no significant drug history or history of an emotional or physical stimulus prior to admission. Prominent pigmentation over the tongue and skin creases of hands were noted. On presentation she was in shock and had ventricular tachycardia which required electrical cardioversion. The subsequent electrocardiogram demonstrated diffuse T-wave inversions with prolonged QTC. There was apical hypokinesia on echocardiogram and cardiac biomarkers were elevated. There was persistent inotropic requirement. She had marked postural symptoms and a postural blood pressure drop of 50mm Hg was present. Initial laboratory parameters were significant for hyperkalemia (7.8mEq/L) and hyponatremia (128mEq/L). These findings prompted evaluation for adrenal insufficiency which was confirmed with appropriate tests. Autoimmune polyendocrine syndrome II was thus diagnosed based on the above findings. Coronary angiography revealed normal coronaries. The diagnoses of TCM was established in accordance with the International takotsubo diagnostic criteria. She was started on stress dose steroid replacement therapy and improved dramatically. At one month of follow-up, the patient is asymptomatic and there was normalization of her left ventricular function. ConclusionsIntricate relationship and interplay exist between the steroid hormones and catecholamines in the pathogenesis of TCM. Steroid hormones not only potentiate the actions of catecholamines, they also regulate and channelize catecholaminergic actions preventing their deleterious effects on the cardiac tissue. Hence, both steroid deficiency and exogenous steroid replacement may precipitate TCM. Evidence from more such cases and larger perspective studies in the future will further improve our understanding of this complex disease process and its myriad associations.

Impact of a nurse-led teleconsultation strategy for cardiovascular disease management during COVID-19 pandemic in India: a pyramid model feasibility study

OBJECTIVE

The COVID-19 pandemic necessitated the use of telemedicine to maintain continuity of care for patients with cardiovascular diseases (CVDs). This study aimed to demonstrate the feasibility of implementing a nurse-led teleconsultation strategy for CVD management during the COVID-19 pandemic in India and evaluated the impact of nurse-led teleconsultations on patient treatment satisfaction.

DESIGN, SETTING AND PARTICIPANTS

We developed a two-stage teleconsultation strategy and tested the feasibility of implementing a nurse-led teleconsultation strategy to manage CVD in a northern state (Punjab) in India. A multidisciplinary team of experts developed the treatment protocol used for teleconsultations to manage CVD. Nurses were trained to provide teleconsultation, triaging of patients and referrals to the physicians. Patients with CVD who had an outpatient visit or hospitalisation between September 2019 and March 2020 at the Dayanand Medical College Hospital, Ludhiana, India, were contacted by phone and offered teleconsultations. Telemedicine strategy comprised: stage 1 nurse-led teleconsultations and stage 2 physician-led teleconsultations. Descriptive analysis was performed to report the proportion of patients triaged by the two-stage telemedicine strategy, and patient's clinical characteristics, and treatment satisfaction between the nurse-led versus physician-led teleconsultations.

RESULTS

Overall, nurse-led stage 1 teleconsultations were provided to 12 042 patients with CVD. The mean (SD) age of the participants was 58.9 years (12.8), and men were 65.4%. A relatively small proportion of patients (6.3%) were referred for the stage-2 physician-led teleconsultations and of these only 8.4% required hospitalisations. During stage 1 nurse-led teleconsultations, patients were referred to the physicians due to uncontrolled diabetes (24.9%), uncontrolled hypertension (18.7%) and congestive heart failure (16.2%). The patient's treatment satisfaction was similar between the nurse-led versus physician-led teleconsultations (p=0.07).

CONCLUSION

This study showed that a nurse-led telemedicine strategy is feasible to implement in a resource-constraint setting for triaging patients with CVD and reduces physician's burden.

Changing microbiological profile and antimicrobial susceptibility of the isolates obtained from patients with infective endocarditis - The time to relook into the therapeutic guidelines

The microbiological profile, associated risk factors and demographic characteristics of patients with IE has changed in the recent times. In the present study, the antibiotic susceptibility profile of 66 isolates (40 from IDU and 26 from non IDU) recovered over a period of three years from the patients with definitive diagnosis of IE along with their absolute minimum inhibitory concentrations (MIC-μg/ml) was determined as per CLSI, 2017 guidelines. Staphylococcus aureus was found to be the predominant pathogen associated with IE out of which 90.2% isolates were MRSA, although none of the isolates were found resistant to vancomycin, teicoplanin, daptomycin and linezolid. Pseudomonas aeruginosa isolates were 100% susceptible to carbapenams, however variable resistance was observed against other antimicrobials. All Enterococci were found to be 100% susceptible to linezolid and daptomycin, whereas vancomycin resistant enterococci phenotype was observed in 25% of the Enterococcal isolates. A noticeable difference in the antimicrobial susceptibility profile and their MICs were observed in the present study, as compared to published literature across the globe and within the country. However, no statistically significant difference (λ ² test, p > 0.01)in the AST pattern of isolates from IDU vs. Non IDU was observed. After reviewing the local antibiogram it seems that we need to have our own regional guidelines, which may partially replace the currently prevailing AHA/ESC guidelines.

Managing patients of shock and acute kidney injury in tertiary care cardiac ICU: Experience with continuous renal replacement therapy

Background

Clinical experience on details of CRRT initiation and outcomes in cardiac intensive care unit (CICU) patients is not available from developing countries like India. This study shares the 5-year clinical experience of managing CICU patients requiring CRRT in a tertiary care cardiac center of North India.

Materials and methods

Medical records of all CICU patients with acute kidney injury (AKI) managed by CRRT from October 2011 to September 2016 at tertiary referral center in North India were retrospectively reviewed. Multiple logistic regression analysis was used to identify predictors of post-CRRT mortality.

Results

A total of 630 patients received CRRT during the study period. Most commonly AKI developed in patients with acute coronary syndrome (30.2 %) with cardiogenic shock. 55.9 % of the CRRT patients were >60 years of age, and/or on multiple supports in ICU including, mechanical ventilation, high doses of inotropes & vasopressors and other cardiovascular support. Of those on CRRT, 130 (20.6 %) patients had died, 215 (34.1 %) were discharged and 285 (45.2 %) could not complete the desired course. Multivariate regression analysis showed independent association of mortality with high vasoactive-inotropic score, single CRRT cycle and low mean arterial pressure in CRRT patients.

Conclusion

About 34.1 % of patients receiving CRRT were alive at discharge, emphasizing the feasibility and utility of CRRT as a promising modality in this population for improving outcomes.

A simple effective method for frailty in Heart Failure with impact on clinical outcomes in north Indian population

Introduction and objectives

Frailty has been studied extensively in elderly population as a predictor and prognostic marker for morbidity and mortality. Frailty is being increasingly recognized as a distinct pathophysiological condition which plays a major role in outcomes of various disease states including heart failure. Our aim was to study the prevalence of frailty in heart failure and see its prognostic significance in such patients.

Methods

This was a prospective study conducted in an out-patient HF clinic. All consecutive patients with HF, ≥25 years age, with LVEF<40% were included. All patients were asked a simple frailty questionnaire. Hand-dynamometer was used to assess handgrip strength in kilograms and were classified as frail, pre-frail or non-frail. The primary end point was cardiovascular mortality and hospitalization, and secondary end-point was composite of all cause mortality, hospitalization, device implantation and documented arrythmia.

Results

210 patients were studied for clinical outcomes. Mean age was 60.59 ± 11.55 years with 15% patients aged less than 50 years. Mean LVEF was 30.24 ± 6.8%. Handgrip strength was poor in the frail vs non/pre-frail patients (p = 0.001) with a strength >16.95 kg having sensitivity of 72% and specificity of 63% for the prediction of survival. Frailty was an independent predictor of mortality with higher mortality and re-hospitalization in frail population (p = 0.001). Hazard for mortality or hospitalization was 4.7 fold in frail population.

Conclusion

Frailty is associated with a significant morbidity and mortality in heart failure. A simple bedside hand-dynamometer may aid as a frailty screening tool in these patients and help in planning treatment strategies.

Do anti-platelet drugs improve duration of continuous renal replacement therapy? A retrospective cohort study in cardiac ICU patients

OBJECTIVE

The objective of this study was to investigate the impact of anti-platelet drug/s on duration of continuous renal replacement therapy (CRRT) in those patients where anti-coagulants were not used due to certain contraindications and in cases where patients were on anti-platelet drugs and were given anti-coagulant during CRRT.

METHOD

This single-center, retrospective cohort study was conducted using the medical records patients treated with CRRT in the cardiac ICU of the inpatient urban facility, located in North India. Data was collected from only those patients who received CRRT for the duration of at least 12 h. Patient's in NAC group were not on any anti-platelet/s and did not receive anti-coagulant during CRRT. AC and AP group patients received anti-coagulant alone or were already on anti-platelet/s and did not receive anti-coagulant respectively while ACAP group patients were on anti-platelet drug/s and also received anti-coagulant during CRRT.

RESULT

Patients in AC, AP, or ACAP group showed significantly (p < 0.001) higher CRRT filter life compared to NAC group. The median CRRT filter life was significantly higher in the ACAP group compared to AC (p < 0.05) and AP (p < 0.001) groups.

CONCLUSION

This study indicates that systemic anti-platelet therapy can provide additional support in critical patients undergoing CRRT even with or without anti-coagulant therapy. However, the increase in CRRT filter life was more profound in patients who were on anti-platelet/s and also received anti-coagulant drug/s during CRRT.

Role of Sildenafil in Management of Pediatric Acute Respiratory Distress Syndrome

Acute respiratory distress syndrome (ARDS) has high mortality and multiple therapeutic strategies have been used to improve the outcome. Inhaled nitric oxide (INO), a pulmonary vasodilator, is used to improve oxygenation. This study was conducted to determine the role of sildenafil, an oral vasodilator, to improve oxygenation and mortality in pediatric ARDS (PARDS). The prevalence of pulmonary hypertension in PARDS was studied as well. Inclusion criteria included children (1–18 years) with ARDS requiring invasive ventilation admitted to the pediatric intensive care unit of a teaching hospital in Northern India over a 1-year period of time. Thirty-five patients met the inclusion criteria. Cardiologist performed a detailed echocardiogram to determine pulmonary arterial pressure (PAP). Patients with persistent hypoxemia were started on oral sildenafil. The majority (77%) patients had a primary pulmonary etiology of PARDS. Elevated PAP (>25 mm Hg) was detected in 54.3% patients at admission. Sildenafil was given to 20 patients who had severe and persistent hypoxemia. Oxygenation improved in most patients after the first dose with statistically significant improvement in PaO2/FiO2 ratios at both 12 and 24 hours following initiation of therapeutic dosing of sildenafil. Improvement in oxygenation occurred irrespective of initial PAP. Outcomes included a total of 57.1% patients discharged, 28.6% discharged against medical advice (DAMA), and a 14.3% mortality rate. Mortality was related to the severity of PARDS and not the use of sildenafil. This is the first study to determine the effect of sildenafil in PARDS. Sildenafil led to improvement in oxygenation in nearly all the cases without affecting mortality. Due to unavailability of INO in most centers of developing countries, sildenafil may be considered as an inexpensive alternative in cases of persistent hypoxemia in PARDS. We recommend additional randomized controlled trials to confirm the effect of sildenafil in PARDS as determined in this study.

Clinical characteristics and outcome of infective endocarditis among intravenous drug abusers in India

INTRODUCTION

Infective endocarditis (IE) is the most dreaded complication of intravenous drug abuse (IVDA). IVDA is present in significant proportions in India. Since there is scarcity of Indian data on IVDA associated IE, we report a study comparing IVDA to non IVDA associated IE. We compare differences in clinical profile, microbiology, echocardiography and clinical outcome from a tertiary care hospital.

METHODS

A total of 133 patients admitted from 1st January 2017 to 31st December 2019 who met the Modified Duke ''definitive'' criteria for IE were included. Detailed Information was collected regarding demography, clinical data and laboratory investigations. All patients underwent transthoracic echocardiography and trans-esophageal echocardiogram wherever necessary.

RESULTS

Among a total of 133 patients, 54 patients (40.6%) were iv drug abusers. Patients in IVDA-group were younger, mostly males, more likely to have concomitant HCV and HIV infections compared to non IVDA-group. Chronic comorbidities such as DM and CKD were more common in non IVDA-group. Rate of positive blood culture was higher in IVDA-group compared to non IVDA-group (74.1%v/s 32.9%,p < 0.001) with different microbiological profile. Percentage of Methicillin resistant staphylococcus aureus (42.6%v/s17.7%,p = 0.003) and pseudomonas related IE (18.5%v/s2.5%,p = 0.003) was significantly higher among IVDA-group. IVDA-group most commonly had tricuspid valve involvement Whereas mitral and aortic valve were most commonly involved valve in non IVDA-group. Mortality was slightly higher among IVDA-group compared to non IVDA-group, though statistically non-significant. Left sided valve involvement and Congestive heart failure were independent predictors of mortality.

CONCLUSION

IVDA-IE is a significant problem in India. Demographic, microbiological and echocardiographic profile is quite different in IVDA and non IVDA-group. There is urgent need to conduct larger studies.

Active surveillance with telemedicine in patients on anticoagulants during the national lockdown (COVID-19 phase) and comparison with pre-COVID-19 phase

BACKGROUND

The COVID-19 pandemic brought restriction to the movement of people due to the implementation of lockdown across various regions around the world. In India, most of the patients belong to rural areas and hence were unable to come for a follow-up visit. Hence, we reached out to patients on oral anticoagulation using telemedicine with aim of communicating with the patient concerning drug compliance, titration of dose of anticoagulation, health education, and identification of high-risk patients needing referral to the nearest health facility/our institute. This study was conducted at the Hero DMC heart institute (a tertiary care center for cardiac diseases). The study design is cross-sectional and involves a comparison of the pre-COVID-19 phase with the COVID-19 phase. We asked a five-component (Likert scale) questionnaire from patients for satisfaction after the consult. All symptoms, need for hospitalization and clinical events were recorded. The events were compared in both groups.

RESULTS

We contacted 628 patients through telemedicine and 600 patients gave consent for participation in the study. For comparison, we analyzed data of 614 patients in the pre-COVID-19 phase. The mean age during the pre-COVID-19 phase was 55.27 + 17.09 years and the COVID-19 phase was 56.97 + 15.09 years with males more than females in both groups. There was no significant difference in the number of patients on oral anticoagulants and novel oral anticoagulants (NOAC). However, there were higher number of  patients on antiplatelets in the pre-COVID phase (p value0.01). 37% in the pre-COVID-19 phase and 40.31 % in the COVID-19 phase were noted to have out of target range INR (International normalized ratio). There was no difference in the number of bleeding or thromboembolic events seen. Patient response as assessed by a questionnaire (Likert scale) showed that >75% of patients were satisfied.

CONCLUSION

Through telemedicine, we were able to approach our patients on oral anticoagulation and achieved titration of anti-coagulation, and health education similar to pre-COVID-19 times. During pandemics, telemedicine offers a promising option for patient management with chronic cardiac conditions. It also provides us an opportunity for the management of patients on oral anticoagulation involving titration of drug dosages (anti-coagulation), identification of high-risk patients, and health education.

Admission Serum Chloride Levels as Predictor of Stay Duration in Acute Decompensated Heart Failure

OBJECTIVE

Recent studies have shown that lower serum chloride is associated with diuretic resistance and increased mortality in heart failure. Impact of lower admission chloride on duration of stay in acute decompensated heart failure (ADHF) has not been studied previously.

METHODS

In this retrospective analysis, we studied the effect of admission serum chloride on the duration of hospital stay in patients admitted with ADHF. A total of 167 patients were studied. Serum chloride levels were divided into tertiles - <96 meq/L (tertile 1), 96-101 meq/L (tertile 2), and >101 meq/L (tertile 3) based on the distribution of serum chloride levels in our patients.

RESULTS

The median lengths of hospital stay in tertiles 1, 2, and 3 were 8(Interquartile range :6 -11), 7 (Interquartile range :5 -10.50), and 6 days(Interquartile range :4.25 - 8), respectively (p = 0.011). Admission serum chloride levels were inversely associated with duration of stay (R2 linear = 0.074, p = 0.001). On multiple linear regression analysis, serum chloride remained independent predictor of increased hospital stay (p=0.003) while association with serum sodium was not significant (p=0.07). 1 unit increase in chloride level was associated with 1.3% (p=0.003) decrease in hospital stay (95% CI: 2.2% to 0.5%).

CONCLUSION

This retrospective analysis suggests that admission serum chloride levels are independently and inversely associated with increased duration of stay. This is independent of admission sodium levels. Thus serum chloride, rather than sodium, is an important poor prognostic marker in heart failure patients.

Prevalence of sustained hypertension and obesity among urban and rural adolescents: a school-based, cross-sectional study in North India

OBJECTIVE

Recent data on sustained hypertension and obesity among school-going children and adolescents in India are limited. This study evaluates the prevalence of sustained hypertension and obesity and their risk factors among urban and rural adolescents in northern India.

SETTING

A school-based, cross-sectional survey was conducted in the urban and rural areas of Ludhiana, Punjab, India using standardised measurement tools.

PARTICIPANTS

A total of 1959 participants aged 11-17 years (urban: 849; rural: 1110) were included in this school-based survey.

PRIMARY AND SECONDARY OUTCOME MEASURES

To measure sustained hypertension among school children, two distinct blood pressure (BP) measurements were recorded at an interval of 1 week. High BP was defined and classified into three groups as recommended by international guidelines: (1) normal BP: <90th percentile compared with age, sex and height percentile in each age group; (2) prehypertension: BP=90th-95th percentile; and (3) hypertension: BP >95th percentile. The Indian Academy of Pediatrics classification was used to define underweight, normal, overweight and obesity as per the body mass index (BMI) for specific age groups.

RESULTS

The prevalence of sustained hypertension among rural and urban areas was 5.7% and 8.4%, respectively. The prevalence of obesity in rural and urban school children was 2.7% and 11.0%, respectively. The adjusted multiple regression model found that urban area (relative risk ratio (RRR): 1.7, 95% CI 1.01 to 2.93), hypertension (RRR: 7.4, 95% CI 4.21 to 13.16) and high socioeconomic status (RRR: 38.6, 95% CI 16.54 to 90.22) were significantly associated with an increased risk of obesity. However, self-reported regular physical activity had a protective effect on the risk of obesity among adolescents (RRR: 0.4, 95% CI 0.25 to 0.62). Adolescents who were overweight (RRR: 2.66, 95% CI 1.49 to 4.40) or obese (RRR: 7.21, 95% CI 4.09 to 12.70) and reported added salt intake in their diet (RRR: 4.90, 95% CI 2.83 to 8.48) were at higher risk of hypertension.

CONCLUSION

High prevalence of sustained hypertension and obesity was found among urban school children and adolescents in a northern state in India. Hypertension among adolescents was positively associated with overweight and obesity (high BMI). Prevention and early detection of childhood obesity and high BP should be strengthened to prevent the risk of cardiovascular diseases in adults.

Unusual case of intraoperative acute cor pulmonale during spine surgery

Perioperative complications of prolonged surgery and prone positioning are well known. Changing the position from prone to supine in an anesthetized patient can result in aspiration and airway obstruction. The drop-in oxygen saturation and hemodynamic changes are warning signs and can cause acute cardiac decompensation leading to diagnostic dilemma. We present a case where the patient had these changes after changing the position after spine surgery in prone position. A quick response from the treating anesthesiologist and active involvement of cardiologist helped in reaching the diagnosis and successful management of aspiration pneumonitis in this patient. We conclude that a quick response in investigations and multimodality approach helps in the management of such perioperative complications.

Determinants of in-hospital clinical outcome in patients with sub-massive pulmonary embolism

Introduction

There is limited data regarding in hospital determinants of clinical deterioration and outcome in sub massive pulmonary embolism (PE). We aimed to evaluate these determinants by comparing biomarkers, CT pulmonary angiogram echocardiography, electrocardiography variables.

Methods

57 patients of sub massive PE diagnosed on CT pulmonary angiogram were included. All patients received UFH on admission and were divided into two groups based on their clinical course. Group 1 comprised of patients who remained stable, group 2 of patients who showed signs of clinical deterioration.

Results

There were 34(59.6%) patients in group 1 and 23(40.4%) patients in group 2. No significant difference in age, gender, BMI. 59.37% had sub massive PE, 5.26% had mortality and 40.4% had clinical deterioration. Intravenous UFH infusion given to 59.6%, systemic thrombolysis 22.8%, catheter directed mechanical breakdown 14%, surgical embolectomy in 3.5% patients. S1Q3T3, new onset RBBB, T wave inversion > 1.63 mm, Basal RV size > 40 mm, RV: LV ratio > 1.2, Global RV longitudinal strain <−10.75% and RVSP > 39 mmHg profiled high risk group. Serum BNP and CT pulmonary angiogram derived scores didn’t differ significantly although CT findings helped to exclude low risk patients (specificity 88%, sensitivity 95%).

Conclusions

Physicians should be aware that patients who have ECG and Echocardiography changes suggestive of right ventricular strain and dysfunction above the cut off values and have documented thrombus in Proximal branches (RPA/LPA) or in distal portion of main pulmonary artery may require aggressive management with systemic/catheter based thrombolysis besides routine anticoagulation with heparin to prevent clinical deterioration.

Coronary Vasospasm Abutting the Stent: A Rare Though Important Cause of Recurrent Angina

Angiogram of the right coronary artery was used to reveal a subtotal occlusion abutting the proximal end of the stent with TIMI I flow that responded quickly to intracoronary nitrates. The patient was diagnosed with vasospastic angina.

Trend in prevalence of coronary artery disease and risk factors over two decades in rural Punjab

OBJECTIVES

The burden of coronary artery disease (CAD) has increased in the last three decades in low-income and middle-income countries including India. CAD is responsible for 20% deaths in India. The burden of CAD has increased due to a higher prevalence of risk factors related to the changing lifestyle. We studied the change in prevalence of CAD and risk factors over 20 years in a rural area.

METHODS

A rural population of adults over the age of 30 years from three villages of Punjab was surveyed for the prevalence of CAD and its risk factors in 1994 and 2014 using similar research methodology. CAD was diagnosed by Epstein and clinical criteria. Blood pressure, anthropometry, ECG and biochemical analysis were carried out. The findings of two surveys were compared with a look at the change in the prevalence of CAD and its risk factors over 20 years.

RESULTS

The overall age standardised prevalence of CAD increased from 2.79% in 1994 to 4.06% (p<0.05) in 2014. There was a significant increase in the prevalence of several risk factors including sedentary lifestyle (8.2% vs 41.3%, p<0.001), hypertension (14.5% vs 26.5%, p<0.001), diabetes (4.7% vs 9.7%, p<0.001), obesity (16.6% vs 35.4, p<0.001) and hypercholesterolaemia (7% vs 9.6%, p 0.011). In contrast, cigarette smoking (8.9% vs 3%, p<0.001) and use of desi ghee (51.4% vs 28.5%, p<0.001) decreased.

CONCLUSIONS

In a rural population of Punjab, the prevalence of several CAD risk factors like sedentary lifestyle, hypertension, diabetes, obesity and hypercholesterolaemia increased over 20 years. These changes in risk factors were associated with a modest increase in prevalence of CAD.

Hypocalcemia Presenting as Life Threatening Torsades de Pointes with Prolongation of QTc Interval

Torsades de pointes with prolonged QTc interval is a form of ventricular tachycardia. Many predisposing factors have been identified and hypocalcemia is among the rare ones. Our case illustrates that though rare, hypocalcemia might manifest as torsades de pointes with prolongation of QTc interval. Early diagnosis and management of dyselectrolytemia can prevent these patients from catastrophic torsades de pointes.

Gender bias in cardiovascular healthcare of a tertiary care centre of North India

OBJECTIVES

To analyse the gender bias in paediatric patients referred for free cardiac treatment as part of School Health Programme at a tertiary care centre in North India.

METHODS

A total of 537 children were referred for further management of congenital heart disease or rheumatic heart disease. Of these, 519 underwent cardiac intervention, and the data from their records were analysed retrospectively to determine any gender disparity in the utilisation of cardiac surgery.

RESULTS

Of the 519 children studied, only 195 (37.6%) were girls, while the remaining 324 (62.4%) were boys (male-to-female ratio of 1.66:1, p<0.0001), indicating a large gender divide. Gender bias was found to be prevalent across all the age groups irrespective of the type of cardiac ailment. Moreover, no statistically significant difference was found between the urban and rural populations (male-to-female ratio of 1.64:1 in rural and 1.71:1 in urban populations; p=0.823) in terms of gender disparity.

CONCLUSIONS

Significant gender discrepancies exist in healthcare-seeking behaviour of patients in North India despite the provision of free cardiac treatment. An equal prevalence of gender bias in urban and rural communities points towards deep-rooted social norms beyond just the economic constraints. Healthcare policies ensuring equal treatment of male and female children should be promulgated to ensure a complete eradication of this social evil.

Clinical and echocardiographic diagnosis, follow up and management of right-sided cardiac thrombi

BACKGROUND

Right-sided cardiac masses are infrequent and have varied clinical presentation. The present study describes the clinical features, echocardiographic findings and management of 19 patients presenting with right-sided cardiac thrombi in a tertiary care center in north India.

METHODS

This is a retrospective, single center observational study of consecutive patients over the period January 2003-2008 admitted in our emergency intensive care unit (EICU). We identified 38 patients with right-sided cardiac masses admitted to EICU diagnosed by transthoracic echocardiography of which 19 patients had right-sided thrombus. The echocardiographic findings were reviewed by two cardiologists in all patients. Treatment was not standardized and choice of therapy was based on judgment of attending physician.

RESULTS

The mean age of patients with cardiac thrombus was 36.6 ± 11.8 years. Right atrial (n = 17) and right ventricle (n = 2) thrombi were associated with deep vein thrombosis (DVT) in 7 (36.8%) and pulmonary embolism in 3 (15%) patients. 13 (68.4%) patients appeared to have in situ mural thrombus. 12 patients were managed with oral anticoagulants, 3 patients underwent surgery and 4 patients were thrombolysed. All the survivors had a mean follow-up of 40 ± 6 months (range--18-50 months).

CONCLUSIONS

Prompt echocardiographic examination in an appropriate clinical setting facilitates faster diagnosis and management of patients with right-sided cardiac thrombi. High incidence of in situ mural thrombus and varied comorbidities predisposing to right-sided cardiac thrombi besides DVT and pulmonary embolism need to be recognized. Oral anticoagulation and thrombolysis appear to be the mainstay of treatment with surgery limited for selected patients.

Case report of isolated congenital absence of right pulmonary artery with collaterals from coronary circulation

Isolated unilateral absence of a proximal pulmonary main artery is a rare congenital lesion which is often associated with other cardiovascular abnormalities and a diverse clinical presentation. It is usually diagnosed in childhood. Patients who survive into adulthood is uncommon. We report a case of 46 year old hypertensive and obese female who presented with progressive dyspnea. She had features of pulmonary hypertension. The diagnosis was confirmed by CT pulmonary angiography which showed absence of right pulmonary artery and conventional pulmonary angiography which showed ipsilateral lung receiving collaterals from Right coronary artery and its branches. The purpose of this report is to highlight the fact that UAPA, although a rare entity, should be kept in mind in patients with unexplained PAH and prolonged respiratory symptoms unresponsive to routine treatment modalities.

Impact of catheter fragmentation followed by local intrapulmonary thrombolysis in acute high risk pulmonary embolism as primary therapy

BACKGROUND

Pulmonary embolism (PE) with more than 50% compromise of pulmonary circulation results significant right ventricular (RV) afterload leading to progressive RV failure, systemic hypotension and shock. Prompt restoration of thrombolysis, surgical embolectomy, or percutaneous mechanical thrombectomy (PMT) prevents progressive hemodynamic decline. We report our single center experience in high risk PE patients treated with standard pigtail catheter mechanical fragmentation followed by intrapulmonary thrombolysis as a primary therapy.

METHODS

50 consecutive patients with diagnosis of high risk PE defined as having shock index >1 with angiographic evidence of >50% pulmonary arterial occlusion are included in the present study. All patients underwent emergent cardiac catheterization. After ensuring flow across pulmonary artery with mechanical breakdown of embolus by rotating 5F pigtail catheter; bolus dose of urokinase (4400 IU/kg) followed by infusion for 24 h was given in the thrombus. Hemodynamic parameters were recorded and follow up pulmonary angiogram was done. Clinical and echo follow up was done for one year.

RESULTS

Pigtail rotational mechanical thrombectomy restored antegrade flow in all patients. The mean pulmonary artery pressure, Miller score, Shock index decreased significantly from 41 ± 8 mmHg, 20 ± 5, 1.32 ± 0.3 to 24.52 ± 6.89, 5.35 ± 2.16, 0.79 ± 0.21 respectively (p < 0.0001). In-hospital major complications were seen in 4 patients. There was a statistically significant reduction of PA pressures from 62 ± 11 mmHg to 23±6 mmHg on follow up.

CONCLUSIONS

Rapid reperfusion of pulmonary arteries with mechanical fragmentation by pigtail catheter followed by intrapulmonary thrombolysis results in excellent immediate and intermediate term outcomes in patients presenting with high risk pulmonary embolism.

A cost effective endovascular approach for management of post-catheterization profunda femoris artery pseudoaneurysm using thrombin

Post-catheterization PSA is one of the most commonly encountered vascular complications of cardiac and peripheral angiographic procedures. We report the case of patient who developed deep-seated profunda femoris artery pseudoaneurysm (PSA) following cardiac catheterization. Despite, repeated ultrasound guided compressions the PSA failed to close and instead produced local site pressure ulcers. The secondary infection followed which precluded use of percutaneous thrombin injection. The PSA was finally closed via a total endovascular technique combining intravascular thrombin injection and coil embolization, thus obviating the need for expensive measures like cover stents or invasive surgical repairs.

Clinical and echocardiographic predictors of cardiorenal syndrome type I in patients with acute ischemic right ventricular dysfunction

BACKGROUND

In current cardiology practice, the importance of acute cardiorenal syndrome (CRS) in determining the outcome of patients with acute coronary syndrome (ACS) is well recognized. Certain groups of ACS patients are at higher risk of developing CRS. Data on the association between right ventricular (RV) functions and CRS after acute myocardial infarction (AMI) are scarce. The purpose of the current study was to evaluate the relation between RV function and the development of CRS in patients presenting with inferior wall AMI and RV involvement.

PATIENTS AND METHODS

Patients with inferior wall AMI with RV involvement underwent echocardiography at admission to assess RV function. RV functions were quantified according to RV fractional area change (RVFAC), tricuspid annular plane systolic excursion (TAPSE), and RV outflow tract fractional shortening (RVOTFS). The patients were followed up until discharge from hospital. All patients who developed CRS were included in group I, all patients who did not develop CRS were included in group II (controls). Multivariate analysis was carried out to determine the significance of the echocardiographic and clinical parameters in predicting the development of CRS in these patients.

RESULTS

In our study, a history of diabetes mellitus, cardiogenic shock at admission, and RVFAC and TAPSE could significantly predict the development of CRS in patients presenting with inferior wall AMI and RV involvement.

CONCLUSIONS

RV functions provide strong prognostic information regarding the development of CRS in patients of inferior wall AMI with RV involvement.

Mechanical breakdown and thrombolysis in subacute massive pulmonary embolism: A prospective trial

AIM: To assess role of combined modality of mechanical fragmentation and intralesional thrombolysis in patients with massive pulmonary embolism presenting subacutely.

METHODS: Eight of 70 patients presenting in tertiary care centre of North India with massive pulmonary embolism within 4 years had subacute presentation (symptom onset more than 2 wk). These patients were subjected to pulmonary angiography with intention to treat basis via mechanical breakdown and intra lesional thrombolysis. Mechanical breakdown of embolus was accomplished with 5-F multipurpose catheter to re-establish flow, followed by intralesional infusion of urokinase (4400 IU/kg over 10 min followed by 4400 IU/kg per hour over 24 h).

RESULTS: Eight patients, mean age 47.77 ± 12.20 years presented with subacute pulmonary embolism (mean duration of symptoms 2.4 wk). At presentation, mean heart rate, shock index, miller score and mean pulmonary pressures were 101.5 ± 15.2/min, 0.995 ± 0.156, 23.87 ± 3.76 and 37.62 ± 6.67 mmHg which reduced to 91.5 ± 12.2/min (P = 0.0325), 0.789 ± 0.139 (P = 0.0019), 5.87 ± 1.73 (P = 0.0000004) and 27.75 ± 8.66 mmHg (P = 0.0003) post procedurally. Mean BP improved from 80.00 ± 3.09 mmHg to 90.58 ± 9.13 mmHg (P = 0.0100) post procedurally. Minor complications in the form of local hematoma-minor hematoma in 1 (12.5%), and pseudoaneurysm (due to femoral artery puncture) in 1 (12.5 %) patient were seen. At 30 d and 6 mo follow up survival rate was 100% and all the patients were asymptomatic and in New York Heart Association class 1.

CONCLUSION: Combined modality of mechanical fragmentation and intralesional thrombolysis appears to be a promising alternative to high risk surgical procedures in patients with subacute massive pulmonary embolism.

Cardiac amyloidosis--two case reports with variable presentation

Many cases of progressive heart failure due to cardiac amyloidosis remain undiagnosed due to the rarity and lack of suspicion on part of physician. Treatment options are limited and patients are also poor responders in later stages. Hence, early diagnosis by recognition of syndromic presentation and diagnostic modalities is helpful in retarding the disease process.