Awareness of lipid guideline recommendations for high-risk patients amongst primary care physicians in Canada

Background

Lipid guidelines for cardiovascular (CV) risk reduction have evolved in recent years, particularly since the introduction of PCSK9 inhibitors. In many jurisdictions, CV risk management is provided by primary care physicians (PCPs). We surveyed Canadian PCPs regarding their awareness and implementation of the 2021 Canadian Cardiovascular Society (CCS) lipid guideline recommendations for patients following an acute coronary syndrome (ACS) or for those with diabetes but without CV disease.

Methods and results

From a national database of PCPs with interest and/or experience in CV medicine, we invited PCPs to complete a survey regarding lipid management in high-risk patients. A committee of PCPs and specialists with lipid expertise including several co-authors of the 2021 CCS lipid guidelines had designed the survey to probe awareness and practice patterns. A total of 203 PCPs from across Canada completed the survey between January and March 2022. 23.6% of respondents had previously prescribed a PCSK9 inhibitor. Almost all (96.5%) PCPs concurred that a post-ACS patient should be seen by their PCP within 4 weeks of hospital discharge (79.3% within 2 weeks). Almost half (45.3%) responded that discharge summaries provided inadequate information relevant for PCPs, and 43% felt that lipid management post-ACS was the primary responsibility of specialists. More than half (56%) articulated challenges when seeing a post-ACS patient, related to inadequate discharge information, complexities of polypharmacy and duration of therapies, and managing perceived or real statin intolerance. 62% correctly identified the LDL-C intensification threshold of 1.8 mmol/L in post-ACS patients, while 79% considered that PCSK9 inhibitors were indicated only for those patients who were already receiving statins plus ezetimibe or had substantially elevated LDL-C levels. 55.2% were able to correctly identify clinical features associated with greatest absolute benefit of PCSK9 inhibitors in post-ACS patients. For patients with diabetes but without ASCVD, 80% of PCPs incorrectly believed that PCSK9 inhibitors were indicated for LDL-C levels above threshold despite statin therapy, and only 42% correctly identified the LDL-C threshold for treatment intensification of 2.0 mmol/L.

Conclusion

While PCPs are aware of the urgency regarding lipid management in post-ACS patients, many encounter challenges after hospital discharge, frequently deferring lipid management to specialists. Thus, almost one year following publication of the 2021 CCS lipid guidelines, substantial knowledge gaps remain regarding intensification thresholds and treatment options for patients post-ACS or for those with diabetes. Innovative and effective knowledge translation programs are urgently required.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Amgen Canada

Synthesis, Molecular Docking and In Vivo Biological Evaluation of Iminostilbene Linked 1,2,3-Triazole Pharmacophores as Promising AntiAnxiety and Anti-Inflammatory Agents

BACKGROUND

Iminostilbene and 1,2,3-triazole ring containing compounds are considered as beneficial substrates in drug design.

OBJECTIVES

This study was aimed at the synthesis of novel series of iminostilbene linked 1,2,3- triazole pharmacophores (7c-n) by Cu(I) catalyzed 1,3 dipolar cycloaddition reaction between 5- (Prop-2-yn-1-yl)-5H-dibenzo[b,f]azepine (7b) and various substituted azidobenzene derivatives (3cn).

METHODS

The chemical structures of compounds were confirmed by 1 H NMR, 13C NMR, LC-MS and molecular docking studies were carried out through HEX docking software.

RESULTS

The in vivo anti anxiety capacity of the compounds was evaluated by using "elevated plus maze" (EPM), anxiety model. The results exhibited that compounds (7d, 7e, 7j and 7k) have a higher anti anxiety effect close to diazepam. The anti-inflammatory activities of the synthesized compounds were evaluated by "Carrageenan-induced rat paw edema" model, compounds (7b, 7c, 7d, 7f, and 7j) demonstrated statistically significant inflammatory activity. Molecular docking analysis revealed that compounds (7d, 7e and 7j) bound to GABA(A) proteins show more efficiency when compared to the other analogues in the series.

CONCLUSION

These results suggest that compounds (7b, 7c, 7d, 7e, 7f, and 7j) can be considered as novel candidates for anti-anxiety and anti-inflammatory agents. Moreover, docking method was used to elucidate anti-anxiety effect of compounds. This study furnished insight into the molecular interactions of synthesized compounds with their physiological targets, and the potential to develop bioactive heterocyclic compounds.

Practical consensus recommendations for gestational breast cancer

This manuscript provides a practical and easy to use consensus recommendation to community oncologists on how to manage gestational breast cancer.

Cardiological society of India document on safety measure during echo evaluation of cardiovascular disease in the time of COVID-19

An echocardiographic investigation is one of the key modalities of diagnosis in cardiology. There has been a rising presence of cardiological comorbidities in patients positive for COVID-19. Hence, it is becoming extremely essential to look into the correct safety precautions, healthcare professionals must take while conducting an echo investigation. The decision matrix formulated for conducting an echocardiographic evaluation is based on presence or absence of cardiological comorbidity vis-à-vis positive, suspected or negative for COVID-19. The safety measures have been constructed keeping in mind the current safety precautions by WHO, CDC and MoHFW, India.

Cardiological Society of India: Document on acute MI care during COVID-19

The unprecedented and rapidly spreading Coronavirus Disease-19 (COVID-19) pandemic has challenged public health care systems globally. Based on worldwide experience, India has initiated a nationwide lockdown to prevent the exponential surge of cases. During COVID-19, management of cardiovascular emergencies like acute Myocardial Infarction (MI) may be compromised. Cardiological Society of India (CSI) has ventured in this moment of crisis to evolve a consensus document for care of acute MI. However, this care should be individualized, based on local expertise and governmental advisories.

Clinical and angiographic profiles and six months outcomes of smokers with acute ST segment elevation myocardial infarction undergoing primary percutaneous coronary angioplasty

Background

Outcomes of primary percutaneous coronary intervention (PCI) for acute STEMI (ST-segment elevation myocardial infarction) in smokers are expected to be better than non-smokers as for patients of acute STEMI with or without fibrinolytic therapy.

Objectives

This comparative study was designed to evaluate the outcomes of primary PCI in patients with acute STEMI in smokers and non-smokers. Clinical and angiographic profile of the two groups was also compared.

Methods

Over duration of two year, a total of 150 consecutive patients of acute STEMI eligible for primary PCI were enrolled and constituted the two groups [Smokers (n = 90), Non-smokers (n = 60)] of the study population. There was no difference in procedure in two groups.

Results

In the present study of acute STEMI, current smokers were about a decade younger than non-smokers (p value = 0.0002), majority were male (98.9% vs 56.6%) were male with a higher prevalence of hypertension and diabetes mellitus (61.67% vs 32.28% and 46.67% vs 14.44%, p = 0.001) respectively. Smokers tended to have higher thrombus burden (p = 0.06) but less multi vessel disease (p = 0.028). Thirty day and six month mortality was non-significantly higher in smokers 4.66% vs 1.33% (p = 0.261) and 5.33% vs 2.66% (p = NS) respectively. Rate of quitting smoking among smokers was 80.90% at 6 months.

Conclusion

The study documents that smokers with acute STEMI have similar outcomes as compared to non smokers with higher thrombus burden and lesser non culprit artery involvement. Smokers present at much younger age emphasizing the role of smoking cessation for prevention of myocardial infarction.

Screening for Atrial Fibrillation

Approximately 10% of ischemic strokes are associated with atrial fibrillation (AF) first diagnosed at the time of stroke. Detecting asymptomatic AF would provide an opportunity to prevent these strokes by instituting appropriate anticoagulation. The AF-SCREEN international collaboration was formed in September 2015 to promote discussion and research about AF screening as a strategy to reduce stroke and death and to provide advocacy for implementation of country-specific AF screening programs. During 2016, 60 expert members of AF-SCREEN, including physicians, nurses, allied health professionals, health economists, and patient advocates, were invited to prepare sections of a draft document. In August 2016, 51 members met in Rome to discuss the draft document and consider the key points arising from it using a Delphi process. These key points emphasize that screen-detected AF found at a single timepoint or by intermittent ECG recordings over 2 weeks is not a benign condition and, with additional stroke factors, carries sufficient risk of stroke to justify consideration of anticoagulation. With regard to the methods of mass screening, handheld ECG devices have the advantage of providing a verifiable ECG trace that guidelines require for AF diagnosis and would therefore be preferred as screening tools. Certain patient groups, such as those with recent embolic stroke of uncertain source (ESUS), require more intensive monitoring for AF. Settings for screening include various venues in both the community and the clinic, but they must be linked to a pathway for appropriate diagnosis and management for screening to be effective. It is recognized that health resources vary widely between countries and health systems, so the setting for AF screening should be both country- and health system-specific. Based on current knowledge, this white paper provides a strong case for AF screening now while recognizing that large randomized outcomes studies would be helpful to strengthen the evidence base.

DNA binding, anti-inflammatory and analgesic evaluation of metal complexes of N/S/O donor ligands; synthesis, spectral characterization

Transition metal complexes containing tri-dentate NSN donor ligands i.e., 5-((1(aminomethyl)cyclohexyl)methyl)-1,3,4-thiadiazol-2-amine (AMTA) (2) and 5-(2-aminophenyl)-1,3,4-thiadiazol-2-amine (ATA) (4i-ii) have been synthesized. The newly synthesized ligands and their respective complexes were characterized by elemental analysis, molar conductance measurement and various spectral studies [infrared (IR), electronic, and NMR (for ligands only)]. Metal complexes are like [M(AMTA)2], [M(ATA)2] type, where M=Mn(II), Co(II) and Cu(II). The proposed geometries of the complexes are octahedral in nature. The synthesized ligands and their complexes were exhibits effective anti-inflammatory, analgesic and DNA binding activities. All the tested compounds exhibited significant analgesic activity, whereas the compound 4i, 4(ia) and 4(iib) is equipotent with Diclofenac sodium.

Metal complexes of ONO donor Schiff base ligand as a new class of bioactive compounds: synthesis, characterization and biological evolution

Present work reviews that, the synthesis of (E)-N'-((7-hydroxy-4-methyl-2-oxo-2H-chromen-8-yl)methylene)benzohydrazide [L] ligand and their metal complexes. The colored complexes were prepared of type [M(2+)L]X2, where M(2+)=Mn, Co, Ni, Cu, Sr and Cd, L=(7-hydroxy-4-methyl-2-oxo-2H-chromen-8-yl)methylene)benzohydrazide, X=Cl(-). Ligand derived from the condensation of 8-formyl-7-hydroxy-4-methylcoumarin and benzohydrazide in the molar ratio 1:1 and in the molar ratio 1:2 for metal complexes have been prepared. The chelation of the ligand to metal ions occurs through the both oxygen groups, as well as the nitrogen atoms of the azomethine group of the ligand. Reactions of the Schiff base ligand with Manganese(II), Cobalt(II), Nickel(II), Copper(II), Strontium(II), and Cadmium(II) afforded the corresponding metal complexes. The structures of the obtained ligand and their respective metal complexes were elucidated by infra-red, elemental analysis, Double beam UV-visible spectra, conductometric measurements, magnetic susceptibility measurements and also thermochemical studies. The metal complex exhibits octahedral coordination geometrical arrangement. Schiff base ligand and their metal complexes were tested against antioxidants, antidiabetic and antimicrobial activities have been studied. The Schiff base metal complexes emerges effective α-glucosidase inhibitory activity than free Schiff base ligand.

7-Meth-oxy-3,4-dihydro-naphthalen-1(2H)-one

In the title compound, C(11)H(12)O(2), the six-membered ketone ring fused to the 7-meth-oxy benzene ring adopts a slightly distorted envelope configuration with the central methyl-ene C atom being the flap. The crystal packing is stabilized by weak inter-molecular C-H⋯O and C-H⋯π inter-actions, which lead to supra-molecular layers in the bc plane.

Synthesis and antioxidant properties of some novel 5H-dibenz[b,f]azepine derivatives in different in vitro model systems

A series of 5H-dibenz[b,f]azepine containing different aminophenols and substituted aminophenols were synthesized. 3-chloro-1-(5H-dibenz[b,f]azepine-5yl)propan-1-one (2) was obtained by N-acylation of 5H-dibenz[b,f]azepine (1) with 3-chloro propionyl chloride. Further base condensation with different aminophenols and substituted aminophenols to produce series of 5H-dibenz[b,f]azepine containing aminophenol and substituted aminophenol (2a-e). The structures of newly synthesized compounds were characterized by spectral and elemental analysis. Their antioxidant properties were evaluated by using several methods: scavenging effects on 2,2-diphenyl-1-picrylhydrazyl (DPPH) radical, inhibition of lipid peroxidation using beta-carotene linoleate system, inhibition of human low-density lipoprotein (LDL) oxidation and reducing power. Butylated Hydroxy Anisole (BHA) and Ascorbic acid (AA) were used as the reference antioxidant compounds and also the comparative study with the synthesized compounds was done. Under our experimental conditions, Compound (2) showed negligible activity over all the antioxidant assays but 5H-dibenz[b,f]azepine containing different aminophenols and substituted aminophenols (2a-e) showed good antioxidant activities over all the methods and compounds containing substituted aminophenols 2e and 2d showed predominant antioxidant activities among the synthesized analogues.

1-Acryloyl-2,6-bis-(4-chloro-phen-yl)-3,5-dimethyl-piperidin-4-one

In the crystal structure of the title compound, C(22)H(21)Cl(2)NO(2), the piperidinone ring is in a boat conformation.

Correlation Between Inflammation and Oxidative Stress in Normocholesterolemic Coronary Artery Disease Patients ‘on’ and ‘off’ Atorvastatin for Short Time Intervals

AIM OF THE STUDY

To assess whether variations in antioxidant and anti-inflammatory parameters occur with short term administration and discontinuation of atorvastatin in normocholesterolemic coronary artery disease (CAD) patients.

METHODS

Forty CAD patients with near normal serum cholesterol levels (total cholesterol <240 mg/dl, LDL cholesterol <130 mg/dl) were continuously enrolled and randomized to groups A and B (20 patients taking atorvastatin) and groups C and D (20 patients not taking atorvastatin). Atorvastatin (10 mg/day) was continued in group A, withdrawn in group B and started in groups C and D for 6 weeks. Thereafter atorvastatin was withdrawn in group A and C, restarted in group B, and continued in group D for further 6 weeks. CRP, FRAP and TBARS were assessed at baseline, 6 weeks and 12 weeks in all the groups.

RESULTS

Baseline CRP, TBARS and FRAP levels were significantly different (p < 0.05) between groups A and B and C and D at the time of enrollment, indicating lower levels of oxidative stress (FRAP-172.40 +/- 23.41 nmol Fe(2+)/l vs 142.62 +/- 15.73 nmol Fe(2+)/l and TBARS-3.66 +/- 1.14 nmol/ml vs 6.11 +/- 1.85 nmol/ml) and low grade inflammation (CRP-1.38 +/- 0.69 mg/l vs 3.19 +/- 1.77 mg/l) in statin treated groups. In group B, discontinuation resulted in increase in CRP (2.87 +/- 0.98 mg/l) and TBARS (5.75 +/- 1.35 nmol/ml) and decrease in FRAP (133.132 +/- 13.32 nmol Fe(2+)/l) and whereas group A patients did not show significant variation in values compared to baseline (CRP-1.36 +/- 0.33 mg/l, FRAP-155.45 +/- 19.51 and TBARS-4.22 +/- 0.81). Administration of atorvastatin caused a marked reduction in oxidative stress and inflammation in groups C and D (CRP-1.13 +/- 0.99 mg/l and 1.73 +/- 1.60 mg/l, FRAP-166.54 +/- 34.11 and 177.44 +/- 13.31 nmol Fe(2+)/l, TBARS-4.66 +/- 2.33 and 3.55 +/- 1.25 nmol/ml respectively). The values returned to pretreatment levels on discontinuation of the drug in group C (CRP-2.61 +/- 1.28 mg/l, FRAP-138.49 +/- 19.62 nmol Fe(2+)/l, TBARS-6.13 +/- 0.74 nmol/ml) whereas the decline was maintained in group D (CRP-1.62 +/- 1.48 mg/l, FRAP-173.07 +/- 9.03 nmol Fe(2+)/l, TBARS-3.75 +/- 1.03 nmol/ml).

CONCLUSION

Administration and withdrawal of atorvastatin caused changes in markers of oxidative stress which closely correlated with changes in marker of inflammation. Further, the salutary effects were of quick onset, but were rapidly reversed on withdrawal of atorvastatin.

Lactose maldigestion in different age groups of north Indians

Lactase activity with age has been reported in a wide variety of population globally. However, most of these studies in human have ignored to assess age stratified lactose maldigestion. Therefore, the present study was planned to determine lactose maldigestion in different age groups of north Indians adults. Two hundred apparently healthy north Indians (age rage 10-80 years) were subjected to a 50g lactose hydrogen breath test by standard method using a Model 12 Microlyzer from Quintron, USA. The percentage of lactose maldigestion was calculated for different age groups with an interval of 10 years. The results of this study revealed that the frequency of lactose maldigestion did not differ significantly among the age groups. Thus, this study suggests that lactose maldigestion is not associated with age stratification among north Indians.

Necrotizing periorbital Fusarium infection--an emerging pathogen in immunocompetent individuals

Fungal infections of the skin and deeper tissues of the periorbital region are quite rare. We report a case of a localized, deep periorbital necrotizing Fusarium infection in an otherwise healthy, elderly lady. Since the clinical features and histopathological findings of Fusarium infection are by no means characteristic, the definitive diagnosis was achieved with the help of microbiological examination of cultured organisms. A combined medical and surgical therapy led to adequate control of infection. To conclude, localized, deep periorbital necrotizing soft tissue infection by Fusarium in an immunocompetent lady is not reported in literature. One should have a high index of suspicion for emerging fungal pathogens in the differential diagnosis of necrotizing orbital or adnexal conditions, even in an immunocompetent patient. The histologic findings of septate, branching hyphae and vascular invasion cannot distinguish Fusarium species from various other moulds such as Aspergillus species; microbiologic studies are essential for confirming the diagnosis.

Graded balloon atrial septostomy in severe pulmonary hypertension

BACKGROUND

The prognosis of patients with severe primary pulmonary hypertension is poor. The role of balloon atrial septostomy as a palliative procedure in these patients is not well defined. We retrospectively analyzed our data regarding the safety, clinical outcome and survival benefit of graded balloon atrial septostomy in patients with severe pulmonary hypertension.

METHODS AND RESULTS

Eleven patients (7 males), aged 6 to 30 years (mean age 16.2+/-8.9 years), with severe pulmonary artery hypertension (mean pulmonary artery pressure of 76+/-16.9 mmHg) and refractory congestive heart failure and/or recurrent syncope underwent balloon atrial septostomy. Graded balloon dilatation under echocardiographic guidance and arterial oxygen saturation monitoring was done in all the patients. Procedure-related mortality was 18.2%. Significant acute hemodynamic improvement was seen in the survivors (pre-balloon atrial septostomy cardiac index 1.88+/-0.48 L/min/m2; post-balloon atrial septostomy cardiac index 2.18+/-0.37 L/min/m2, p<0.009). Patients were followed up for a mean period of 20.3 months after the procedure (range: 3 months-5 years). There was functional improvement and increased exercise tolerance in all the patients for a mean follow-up period of 14.6 months (NYHA functional class 3.62+/-0.69 to 2+/-0.50). The estimated probability of survival in this cohort at 1 year was only 48%; but 7 of 8 patients (87%) who survived the procedure were alive at 1 year.

CONCLUSION

We conclude that balloon atrial septostomy improves clinical status, hemodynamic variables and possibly also improves survival in selected patients with severe pulmonary artery hypertension. It remains a definite palliative option for refractory primary pulmonary hypertension. However, the procedure-related risks are high in very sick patients and, therefore, balloon atrial septostomy may be advocated early in the course of the disease.

Management of cardiomyopathy resulting from incessant supraventricular tachycardia in infants and children

BACKGROUND

Radiofrequency ablation is considered to be the treatment of choice in patients with ventricular dysfunction related to incessant supraventricular tachycardia. However, reservations regarding its use in infants and children prompted us to try alternative strategies for this group.

METHODS AND RESULTS

Eight children (age range: 1 day to 10 years) were diagnosed to have tachycardia-related ventricular dysfunction in the past 6 years. They presented with symptoms of palpitation, dyspnea and/or generalized swelling over the body of 3 months to 2 years'duration. The cardiothoracic ratio at presentation was 64% (52%-70%) and ejection fraction was 22.2% (15%-45%). In 7 patients tachycardia was diagnosed to be ectopic atrial and in 1 it was permanent junctional reciprocating tachycardia. Six of these children were managed with intravenous/oral amiodarone in combination with digoxin (3) and/or propranolol (2). In one child addition of amiodarone to digoxin and propranolol led to polymorphic ventricular tachycardia, and amiodarone was withdrawn. Only one child underwent radiofrequency ablation as the first choice because regular follow-up was not possible due to logistic reasons. Sinus rhythm with normalization of ventricular function was achieved in 6 of the 7 children treated medically. One child continued to have frequent episodes of tachycardia and underwent successful radiofrequency ablation of a high right atrial ectopic focus. Two out of the 6 patients on amiodarone could be managed with only digoxin and propranolol after their ventricular function had returned to normal. A third patient relapsed on stopping amiodarone and underwent successful radiofrequency ablation of a left atrial ectopic tachycardia.

CONCLUSIONS

Short-term amiodarone in combination with digoxin/propranolol is a safe and effective treatment strategy for infants/children with tachycardiomyopathy. Control of tachycardia is achieved in the majority, leading to recovery of ventricular function. This approach may avoid unnecessary ablations in children or at least postpone it till the procedure would be safer.

Are drugs and catheter ablation effective for treating ventricular arrhythmias in populations that cannot afford implantable cardioverter defibrillators?

Despite recent advances, ventricular arrhythmias continue to pose a therapeutic challenge, especially to the clinician in the developing world. Although the implantable cardioverter defibrillator (ICD) has improved survival in both primary and secondary prevention trials, it still remains a costly modality for the developing world. Even though certain subgroups stand to benefit unequivocally in survival from the ICD, there are others in whom this therapy may not offer a survival benefit over empiric antiarrhythmic drug therapy with amiodarone. The utility of optimized drug therapy (including either amiodarone or sotalol, b-blockers, and angiotensin-converting enzyme inhibitors) needs to be compared with the ICD in a randomized manner in these lower-risk patients with ventricular arrhythmias. The role of conventional catheter ablation techniques is mostly adjunctive to drugs and ICDs, although the newer mapping and ablation techniques may offer greater promise in the future.