Association of angiotensin-converting enzyme, methylene tetrahydrofolate reductase and paraoxonase gene polymorphism and coronary artery disease in an Indian population

Background: Coronary artery disease (CAD) and cancer remain the leading causes of death in most developed countries. Elucidating the genetic components that contribute to their pathogenesis is challenging. In this case-control association study, we examine the association of single nucleotide polymorphisms (SNPs) in paraoxonase 573 A/G genes, methylene tetrahydrofolate reductase (MTHFR) 677 C/T and angiotensin-converting enzyme (ACE) gene insertion/deletion (I/D) polymorphism with CAD independently, as well as synergistically, in a north Indian population. Methods and results: Patients with at least 50% stenosis of at least one major coronary artery were classified as cases. The controls had no myocardial infarction. Polymerase chain reactions (PCR) followed by restriction fragment length polymorphism (RFLP) analyses were carried out to determine the SNPs. No significant association of the polymorphisms of the ACE or MTHFR genes with the risk of CAD was observed. However, the allele frequencies of the 573 A/G polymorphism of the paraoxonase gene differed significantly among cases and controls before and after controlling for confounding factors. The frequencies of AG vs AA genotypes and GG+AG vs AA genotypes also differed significantly in the two groups (p = 0.0002). The interaction of paraoxanase with both MTHFR and ACE independently showed significant positive associations Conclusions: The identification of ‘at risk’ individuals by genetic mapping of susceptible genes for effective control of other host factors will be a very effective and practical approach for prevention, as well as the development of improved therapy for patients. (Cardiol J 2011; 18, 4: 385–394

"Modified No-touch technique using floating wire"- a novel technique of Unprotected Carotid Artery Stenting for aorto-ostial lesion.

Takayasu arteritis (TA) is chronic inflammatory large vessel vasculitis where aorta and its main branches bear the maximum burden. Here, we report a case of 23-yr-old hypertensive male that had an episode of transient ischemic attack (TIA) three months back. He was diagnosed with type I Takayasu’s arteritis (TA) showing long segment osteo-proximal lesion of right common carotid artery (RCC) with near total occlusion, along with lesion involving bifurcation and proximal part of internal carotid artery having similar degree of severity on computed tomographic angiography of aorta. It was successfully stented with two overlapping 6x19, and 6x18 mm Herculink stent (Abott Vascular, USA) distally at 12 atm pressure while aorto-ostial lesion was stented using 7x19, and 7x18 mm overlapping Herculink stents at 14 atm pressure achieving excellent results with no residual stenosis. Carotid artery stenting (CAS) was unprotected as no embolic protection device was used, and aorto-ostial lesion was stented keeping a floating wire in subclavian artery as a modification of no touch technique. At 4-year follow up, computed tomographic imaging revealed well apposed stents with excellent patency

Trifurcation Stenting of left anterior descending artery by “Kurdistan” Technique using Two Guide Catheters

Percutaneous coronary intervention of trifurcating lesion is a challenging and complex procedure. This has been reported for left main trifurcation disease but little is known about such substrate in left anterior descending artery. We herein report a case of 68-year-old male with chronic stable angina who was successfully treated with percutaneous coronary stent implantation for trifurcation lesion of left anterior descending artery. Bifurcation lesion was treated using culottes’ technique with 6F guide catheter. Balloon angioplasty of third side branch of the trifurcation lesion was performed with another 6F guide catheter. Here, first 6F catheter was pulled to dehook the left main when left main was being hooked with second 6F catheter. Fine tuning of both guide catheters needs to be exercised to make them stable, and to avoid injury of left main artery. This is the first case report to highlight the feasibility and efficacy of dual guiding catheter to treat a trifurcation lesion of left anterior descending artery by "Kurdistan” Technique

Ostry zespół wieńcowy u 16-letniego chłopca — opis przypadku

Spontaneous coronary artery dissection is a rare but important cause of acute coronary syndromes in young patients.16-year-old boy presented as acute anterior wall myocardial infarction for which he was thrombolysed. Coronary angiogramshowed spiral luminal filling defects, with extensive contrast staining of proximal left anterior descending arteryand its branches. The patient refused angioplasty, which was advised, and was managed conservatively. Three weekslater he presented with acute coronary syndrome with unstable angina. Repeated angiogram showed complete healingof dissection. The hospital course of the patient was uncomplicated. This shows, that sometimes higher grade dissectionbeside intervention, can respond to conservative management as well.Samoistne rozwarstwienie tętnicy wieńcowej jest rzadką, lecz ważną, przyczyną ostrych zespołów wieńcowych u młodych pacjentów. W niniejszej pracy przedstawiono przypadek 16-letniego chłopca, u którego wystąpił ostry zawał ściany przedniej. Zastosowano leczenie trombolityczne. W koronarografii stwierdzono ubytki wypełnienia w kształcie spiralnym z silnym zakontrastowaniem proksymalnego odcinka gałęzi międzykomorowej przedniej i jej gałęzi. Zalecono wykonanie angioplastyki wieńcowej, jednak chory nie wyraził zgody na zabieg i w związku z tym zastosowano leczenie zachowawcze. Po 3 tygodniach u pacjenta wystąpił ostry zespół wieńcowy w postaci niestabilnej dławicy piersiowej. W wykonanym powtórnie angiogramie stwierdzono całkowite wygojenie rozwarstwienia. Hospitalizacja chorego przebiegała bez powikłań. Opisany przypadek pokazuje, że w niektórych rozwarstwieniach znacznego stopnia można uzyskać dobrą odpowiedź na leczenie zachowawcze bez zabiegów interwencyjnych

Systemic thrombolysis with tenecteplase in stent thrombosis patients as a life saving measure in odd situations: an observational study from tertiary care hospital

Background: Coronary artery stent thrombosis specifically acute stent thrombosis is always a nightmare for interventionist. Stent thrombosis is one of a severe and catastrophic complication of percutaneous coronary intervention (PCI). Repeat PCI is commonly considered the preferred strategy to manage patients with stent thrombosis. Thrombolytic therapy is considered only partially effective.Methods: This was a single centre largest ever observational study on this topic comprising of total 110 patients with history of previous stent implantation and now presented with an acute ST segment elevation myocardial infarction due to a probable stent thrombosis successfully treated with systemic thrombolysis with tenecteplase were studied over the period of 2 years (April 2017 to March 2019).Results: On analyzing data clinical success was reported in 92 (83.6%) patients, electrocardiographic success is seen in 102 (92.7%) patients while angiographic success was reported in 80(72.7%) patients. Cerebrovascular accident were reported in 2 (1.8%) patients which died later on.Conclusions: This study which is the first ever largest observational study on this topic demonstrates that, in patients with probable stent thrombosis and a short time to reperfusion in some specific extraordinary situations where timely percutaneous coronary intervention is not possible, systemic thrombolysis by fibrin specific Tenecteplase can be done as a life saving procedure which is associated with good immediate results

Porównanie stymulacji koniuszkowej i przegrodowej prawej komory: wpływ na wskaźniki echokardiograficzne, czynność lewej komory i efekty kliniczne w obserwacji krótko- i średniookresowej

Introduction. Right ventricular apical pacing (RVAP) has a greater ‘desynchronizing effect’ than pacing from the interventricular septum (RVSP) and may translate into worse outcomes in the long run. The aim of the present study was to examine the short- and intermediate-term effects of RVAP versus RVSP on echocardiographic features, left ventricular function, and clinical outcome. Materials and methods. 467 patients between August 2014 and March 2018 without structural heart disease were prospectively randomised to RVAP (N = 226) or RVSP (N = 241) and were studied at baseline, six months, and 12 months by echocardiography, biochemically [N-terminal pro-B-type natriuretic peptide (NT-proBNP)], and clinically [six-minute walk test (6MWT)]. Left ventricular 2D strain and tissue velocity images were analysed to measure 18-segment time-to-peak longitudinal systolic strain and 12-segment time-to-peak systolic tissue velocity. Intraventricular dyssynchrony was calculated using tissue Doppler velocity data by comparing the time to systolic peak velocity between segments in multiple apical views by their respective standard deviations. Interventricular dyssynchrony was measured as the temporal difference of left ventricular pre-ejection period and right ventricular pre-ejection period by pulse-wave Doppler images. All the analysis was carried out using statistical package for social service version 17.0 (SPSS Inc., Chicago, IL, USA). A p-value < 0.05 was considered statistically significant. Results. The commonest indication for pacemaker implantation was atrioventricular block (N = 311, 66.6%), followed by sinus node dysfunction (N = 138, 29.5%) and chronic bifascicular and trifascicular block (N = 18, 3.9%), with all patients receiving a single chamber pacemaker (VVI: n = 107, 22.9% and VVIR: n = 360,77.1%). There were significant differences in NT-proBNP level (410 ± 254 pg/mL vs. 370 ± 168 pg/mL, p = 0.02), 6MWT (442 ± 19 m vs. 482 ± 21 m, p = 0.01), mean QRS duration (164 ± 8.3 ms vs. 148 ± 10.6 ms, p = 0.02), intraventricular dyssynchrony (septal to lateral wall delay: 88.6 ± 24.2 ms vs. 43.7 ± 11.2 ms, p = 0.04), interventricular dyssynchrony (31.2 ± 22.8 vs. 19.4 ± 11.2, 0 = 0.03), end diastolic volume (78.4 ± 15.6 mL vs. 72.8 ± 14.2 mL, p = 0.04), and end-systolic volume (30.2 ± 13.1 mL vs. 25.6 ± 11.7 mL, p = 0.05) at the end of 12 months between RVAP and RVSP respectively, though not significantly different at six months, favouring the RVS-paced group. However, no significant difference in ejection fraction (59 ± 5% vs. 61.5 ± 3.2%, p = 0.39) and New York Heart Association class (1.29 ± 0.3 vs. 1.28 ± 0.4, p = 0.3) at six and 12 months follow up were noted. Conclusion. Right ventricular septal pacing was associated with a better outcome in terms of echocardiographic indices, left ventricular function, and clinical outcome compared to patients with apical pacing over an intermediate-term follow up.Wstęp. Stymulacja koniuszkowa prawej komory ma większy „wpływ desynchronizacyjny” niż stymulacja przegrodowa prawej komory (RVSP) i w dłuższej perspektywie może prowadzić do poważniejszych skutków. Przedstawione badanie przeprowadzono w celu porównania krótko- i długookresowego wpływu RVAP i RVSP na parametry echokardiograficzne, czynność lewej komory i efekty kliniczne. Materiał i metody. Prospektywne badanie prowadzono od sierpnia 2014 roku do marca 2018 roku. Uczestniczyło w nim 467 chorych bez choroby strukturalnej serca, których przydzielono losowo do RVAP (N = 226) lub RVSP (N = 241). W czasie pierwszej wizyty wszystkich uczestników poddano badaniu echokardiograficznemu, badaniu biochemicznemu [stężenie N-końcowego fragmentu propeptydu natriuretycznego typu B (NT-proBNP)] i ocenie stanu klinicznego [test 6-minutowego marszu (6MWT)]. Badania te powtórzono po 6 i 12 miesiącach. Przeanalizowano lewokomorowe obrazy 2D z badania odkształcenia (strain) i prędkości ruchu miokardium (tissue velocity), aby zmierzyć czas do maksymalnego skurczowego odkształcenie podłużnego w 18 segmentach i czas do maksymalnej skurczowej prędkości ruchu miokardium w 12 segmentach. Dyssynchronię śródkomorową obliczano na podstawie danych uzyskanych w badaniu doplera tkankowego, porównując czas do maksymalnej prędkości skurczowej między segmentami w wielu projekcjach koniuszkowych na podstawie ich odchyleń standardowych. Dyssynchronię międzykomorową mierzono jako różnicę w czasie okresu przedwyrzutowego lewej i prawej komory w badaniu doplera fali pulsacyjnej. Wszystkie analizy statystyczne wykonano za pomocą pakietu oprogramowania SPSS, wersja 17.0 (SPSS Inc., Chicago, IL, USA). Wartości p wynoszące poniżej 0,05 uznano za statystycznie istotne. Wyniki. Najczęstszym wskazaniem do wszczepienia stymulatora był blok przedsionkowo-komorowy (n = 311; 66,6%), a w następnej kolejności dysfunkcja węzła zatokowego (n = 138; 29,5%) i przewlekły blok dwu- lub trójwiązkowy (n = 18; 3,9%). Wszystkim chorym wszczepiono stymulator jednokomorowy (VVI: n = 107; 22,9% lub VVIR: n = 360;77,1%). Stwierdzono istotne różnice między RVAP i RVSP na korzyść stymulacji RVS w wartościach NT-proBNP (odpowiednio 410 ± 254 pg/ml vs. 370 ± 168 pg/ml; p = 0,02), dystansu 6MWT (442 ± 19 m vs. 482 ± 21 m; p = 0,01), średniego czasu trwania zespołu QRS (164 ± 8,3 ms vs. 148 ± 10,6 ms; p = 0,02), dyssynchronii śródkomorowej (opóźnienie między przegrodą międzykomorową a ścianą boczną: 88,6 ± 24,2 ms vs. 43,7 ± 11,2 ms; p = 0,04), dyssynchronii międzykomorowej (31,2 ± 22,8 vs. 19,4 ± 11,2; 0 = 0,03) oraz objętości końcoworozkurczowej (78,4 ± 15,6 ml vs. 72,8 ± 14,2 ml; p = 0,04) i końcowoskurczowej (30,2 ± 13,1 ml vs. 25,6 ± 11,7 ml; p = 0,05) po 12 miesiącach, jednak różnice zaobserwowane po 6 miesiącach. W badaniach przeprowadzonych po 6 i 12 miesiącach nie stwierdzono natomiast istotnych różnic pod względem frakcji wyrzutowej (59 ± 5% vs. 61.5 ± 3.2%, p = 0.39) ani klasy według New York Heart Association (1,29 ± 0,3 vs. 1,28 ± 0,4; p = 0,3). Wnioski. W obserwacji średnioterminowej stymulacja przegrody prawej komory wiązała się z lepszymi efektami w odniesieniu do wskaźników echokardiograficznych, czynności lewej komory i efektu klinicznego niż stymulacja koniuszkowa

ANALYSIS OF PSYCHO-SOCIAL RISK FACTORS IN PATIENTS WITH RECENT ACUTE CORONARY SYNDROME: A CASE-CONTROL STUDY

ABSTRACTObjective: Although psycho-social factors are reported to be independently associated with myocardial ischemia in many studies, the majority ofthese were done in the western population. This was conducted in India to determine the impact of psycho-social factors in subjects with the recentacute coronary syndrome (ACS).Methods: Patients with the first episode of ACS within 4 weeks of onset at LPS Institute of Cardiology, Kanpur, India between 2013 and 2015 wereenrolled as cases. Control was community-based individuals without coronary artery disease. Both were compared for demographic variables,the psycho-social profile including annual income, education status, depression, stressful life events (using presumptive stressful life events scale,i.e. PSLES), and independent predictors were determined using multiple logistic regression analysis and were computed as odds ratio (OR).Results: Between 200 cases and 200 controls, respectively, statistically significant difference was observed in mean annual income (2.74±1.95 vs.2.23±1.22 lac rupees; p&lt;0.05), smoking exposure (13.93±16.17 vs. 4.88±3.10 pack years; p&lt;0.05), mean number of stressful life events (8.18±2.57 vs.4.14±1.63; p&lt;0.05). Depression (48% vs. 27%; p&lt;0.05) while education status was comparable. Further, odds of having myocardial infarction werehigher for subjects with mild-to-moderate depression (OR: 2.45), family history of heart disease (OR: 2.25), hypertensive males (OR: 1.43), anddiabetic females (OR: 1.22).Conclusion: Psycho-social factors, particularly depression may have a significant role in the prognosis of ACS. Further systematic studies arewarranted to provide more important insights regarding the magnitude of the association between psycho-social factors and the onset of ACS.Keywords: Coronary artery disease, Depression, Psycho-social factors, Presumptive stressful life events scale, Stressful life events

Prevalence of isolated diastolic hypertension and associated risk factors among adults in Kanpur, India

Background: Isolated diastolic hypertension (IDH) is a largely unrecognized subtype of hypertension, more commonly seen in the younger age group. Aims: (1) To determine the prevalence of IDH in the adult population of Kanpur district. (2) To study the associated risk factors of IDH. Methods: A community-based cross-sectional study was conducted in 801 subjects, aged 20 years and above, using multistage stratified random sampling technique. Results: The prevalence of IDH was 4.5%, which was 6.2% in men and 3.1% in women. A significant proportion of IDH was seen in the 40–49 years age group. Multivariate logistic regression analysis of the associated risk factors showed that gender, physical activity and BMI were significantly associated with IDH. Conclusion: Isolated diastolic hypertension is an emerging problem in developing countries. IDH is more common among men, sedentary individuals and those with a higher BMI

Genetic predisposition to oxcarbazepine induced Stevens-Johnson syndrome

Stevens-Johnson syndrome (SJS) is a rare immunologic reaction that may involve skin or various mucosal surfaces. The etiology may range from multiple pharmacologic agents to viral infections. Associated findings can range from minimal skin and mucosal involvement to extensive dermal exfoliation, nephritis, lymphadenopathy, hepatitis, and multiple serologic abnormalities. We report a female patient of 38 years with a history of drug allergy who was administered oxcarbazepine for the management of right partial bronchial seizure due to left parasagittal mass lesion following which she developed papular rashes all over the body and diagnosed as SJS. Although carbamazepine (CBZ) is the most common cause of SJS, a new anticonvulsant, oxcarbazepine, which is structurally related to CBZ, has been shown to induce SJS

Genetic predisposition to oxcarbazepine induced Stevens-Johnson syndrome

Stevens-Johnson syndrome (SJS) is a rare immunologic reaction that may involve skin or various mucosal surfaces. The etiology may range from multiple pharmacologic agents to viral infections. Associated findings can range from minimal skin and mucosal involvement to extensive dermal exfoliation, nephritis, lymphadenopathy, hepatitis, and multiple serologic abnormalities. We report a female patient of 38 years with a history of drug allergy who was administered oxcarbazepine for the management of right partial bronchial seizure due to left parasagittal mass lesion following which she developed papular rashes all over the body and diagnosed as SJS. Although carbamazepine (CBZ) is the most common cause of SJS, a new anticonvulsant, oxcarbazepine, which is structurally related to CBZ, has been shown to induce SJS