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   Table of Contents - Current issue
Coverpage
May-August 2019
Volume 5 | Issue 2
Page Nos. 67-134

Online since Monday, August 19, 2019

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EDITORIAL  

From receptors to the knife's edge p. 67
Sandeep Seth, Shyamal K Goswami
DOI:10.4103/jpcs.jpcs_47_19  
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REVIEW ARTICLES Top

G protein-coupled receptor signaling in cardiovascular system: Specificity versus diversity p. 68
Shyamal K Goswami
DOI:10.4103/jpcs.jpcs_37_19  
In metazoan organisms, communication of the constituent cells to its exterior is an essential component of tissue homeostasis and organ function. A plethora of growth factors, cytokines, hormones, regulatory small molecules, etc., interact with the cells surface receptors to initiate the signaling process that is transduced to the cell interior, regulating its functions. Over the years, thousands of such receptors have been identified and characterized. This number has substantially gone up in the postgenome era. Although the mechanisms of signal transduction by cell surface receptors is of immense interest for both clinicians and basic biologists, certain group of receptors have drawn equal attention of both the communities. One such group is the G protein-coupled receptors (GPCRs). Over the past half a century, this group of receptors has been extensively investigated, and a volume of information regarding their complexity as well as diversities has been revealed. Another interesting aspect of the GPCR study is their predominant roles in drug discovery and development. A substantial number of commonly used drugs are targeted toward the GPCR family, and several more are expected to be coming to the market in near future. Taking into consideration of the importance of these receptors, the following review summarizes certain fundamental aspects of its signaling mechanisms. Considering the vast information available on GPCRs and their importance in human health and diseases, following review provides a broad outline on the mechanisms of their functional diversity.
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Pseudo-resistant, resistant, and refractory hypertension: The good, the bad, and the ugly p. 76
Dibbendhu Khanra, Bhanu Duggal
DOI:10.4103/jpcs.jpcs_31_19  
Resistant Hypertension (RH) not uncommon in daily clinical practice but is often loosely coined. Accuracy of BP measurement, Adherence to prescribed medications and Adequacy of prescribed dosages are to be ensured before diagnosing RH. Ambulatory blood pressure monitoring and home blood pressure monitoring are becoming standard of care in evaluation of RH patients. Management of RH in recent years has been evolved and spiranolactone has become the fourth drug when combination of Renin-Angiotensin system blockers, calcium channel blockers and long acting thiazide like diuretics fail. Scores like PFK comprising of Urinary pH>7, Female Sex, K<3.5 mg/dl has been handy in decision making to start spiranolactone. However, Refractory Hypertension (RfH) has been defined when five anti-hypertensive drugs including spiranolactone fail and has been emerging to be a novel phenotype. RH patients are known to be volume dependent whereas RfH patients are known to have sympathetic overdrive. Management strategy of RfH is challenging and beta-blockers or alpha-blockers may be of role in these subset. Renal artery denervation is being resurrected with newer evidence and definitely an option for RfH patients. Novel therapies like Barroreceptor Activation Techniques and Central iliac arteriovenous anastomosis are being evaluated in resistant and refractory hypertension patients.
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Cardiology update 2nd quarter p. 81
Satyavir Yadav
DOI:10.4103/jpcs.jpcs_44_19  
This update includes some landmark trials which were published in the last 3 months. Myocardial perfusion cardiovascular magnetic resonance imaging has shown some initial promise in trials, rivaroxaban reduced thromboembolic events in heart failure with coronary artery disease, drug-coated balloons show superiority to bare metal stents in patients with high bleeding risk, and various studies are also published to improve cardiac resynchronization therapy pacemaker response.
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ORIGINAL ARTICLES Top

Hemostatic phenotype of thrombi derived from STEMI patients on cardiovascular prevention therapy p. 86
Jeske J. K van Diemen, Bernard J Smilde, Wessel W Fuijkschot, P Stefan Biesbroek, Yolande E Appelman, Paul A. J Krijnen, Yvo M Smulders, Hans W. M Niessen, Abel Thijs
DOI:10.4103/jpcs.jpcs_30_19  
Introduction: Aspirin and statin therapy are the basis of cardiovascular disease (CVD) prevention therapy. Recent data have suggested new additional preventive mechanisms: both aspirin and statin exhibit anti-inflammatory effects within intracoronary thrombi. As inflammation, aggregation, and thrombosis are closely intertwined, aspirin and subsequent statin therapy might influence the hemostatic content within intracoronary thrombi. Aim: The aim of the study is to explore the spectrum of CVD prevention therapy on intracoronary thrombus composition by analyzing main hemostasis components in patients with ST-segment elevation myocardial infarction (STEMI). Materials and Methods: We performed a cross-sectional histological pilot study with intracoronary thrombi derived from STEMI patients on CVD prevention therapy without usage of another anticoagulant agent other than aspirin. They were actively matched with intracoronary thrombi in a control group derived from STEMI patients not on any therapy – without a previous CVD history – based on thrombus age (fresh), sex, and age of the participant. Immunohistochemistry was performed with primary antibodies of factor XII (F-XII), tissue plasminogen activator (tPA), and factor VII (F-VII). Results: Four of the 13 thrombi derived from patients on CVD prevention therapy were not characterized as fresh and subsequently excluded. Moreover, one participant in the patient group had to be excluded post hoc. The thrombi in the patient group had a significantly more F-XII (27.7%) and tPA (10.1%) positive area versus the controls (17.5%; 4.5%), respectively. The F-VII-positive thrombus area was similar in both groups. Conclusion: These exploratory data demonstrate an increased procoagulant F-XII and fibrinolytic tPA content within intracoronary thrombi derived from patients on CVD prevention therapy compared with controls.
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Heart transplant in India: Gleneagles global experience p. 91
Ravi Kumar Ratnagiri, Prabhat Dutta, Sandeep Attawar
DOI:10.4103/jpcs.jpcs_19_19  
Introduction: Heart transplant in India was started in 1994. The Indian transplant program differs from the West. In this study, we report the heart transplant experience from Gleneagles Global, Chennai. Materials and Methods: There were 55 patients who underwent a heart transplant during this period. Patients were induced with basiliximab, and the maintenance therapy was with tacrolimus, mycophenolate, and steroids. Results: Fifty patients underwent a heart transplant between 2017 and 2018. The age ranged from 21 to 66 years, and there were 45 males and 10 females. All patients were Class III and IV. Induction for transplant was with basiliximab 10 mg–20 mg. In 54 patients, tacrolimus was used, and low-dose tacrolimus plus everolimus 0.25 mg twice a day was given in five patients. Mycophenolate mofetil was given to all patients. Steroids were given to all patients. In 38 patients, renal function normalized by day 5, and in 12 patients, the renal recovery was delayed to day 10. Two patients needed postoperative dialysis. Three patients died of severe renal failure and sepsis. Fifteen patients had new-onset diarrhea in the 1st year with four having CMV[CE2] [CE2] antigen positivity, one with Clostridium difficile, and seven patients with diarrhea resolving with termination of mycophenolate. Four had Escherichia coli or Salmonella diarrhea which responded to oral antibiotics. One patient developed herpes zoster and another developed hepatic mucormycosis. Twelve patients developed sustained tremors and ten had severe headaches needing tricyclic antidepressants. Ten patients had episodes of leukopenia, eight of which resolved after temporary stoppage of valganciclovir and reduced dose of mycophenolate and two patients needed Granulocyte-colony stimulating factor therapy. Conclusions: This report covers the experience of 2 years and 55 patients. Mild side effects were noted in 30 patients after heart transplant. Side effects such as diarrhea, tremors, and headache were easily treated by clinical manipulation of drugs. Overall, 14 patients had significant bacterial or fungal or viral infections. Three patients died of sepsis ( first 15 days after transplant in 2 patients and 3–6 months in another).
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Three dimensional echocardiography in non ST elevation acute coronary syndrome in North India (3D-EINSTEIN) - A single centre prospective study p. 94
Dibbendhu Khanra, SK Sinha, Pradyot Tiwari, MM Razi, Puneet Aggrawal, Shishir Soni, CM Verma, Ramesh Thakur, Bhanu Duggal
DOI:10.4103/jpcs.jpcs_18_19  
Background: In non ST elevated acute coronary syndrome (NSTEACS) significant coronary artery disease cannot be predicted by biological markers, electrocardiogram (ECG) or formal two dimensional echocardiography (2DE). Recent studies have demonstrated role of strain 2DE in determination of significant coronary artery disease but no studies on three dimensional echocardiography (3DE) is available in literature. Our objective was to evaluate role of 3DE in predicting SCAD among NSTEACS patients and compare 3DE viz-a-viz 2DE. Methods and Materials: Three dimensional echocardiography in non ST elevation acute coronary syndrome in North India (3D-EINSTEIN) study is a hospital based prospective study where 324 NSTEACS patients were evaluated by Troponin I levels, ECG, laboratory parameters. Global Registry of Acute Coronary Events (GRACE) risk score were calculated. 2DE and 3DE (4 beat full volume) loop were recorded in Philips iE33 xMATRIX, global ejection fraction (EF) and parametric images were analysed using QLAB9 3DQAdv software. Coronoary angiograms were undertaken and significant coronary artery disease was defined as luminal narrowing >70% in any epicardial coronary artery. Results: Unstable angina comprises only 15% of NSTEACS and clinical profile of them are similar to NSTEMI. Two third of NSTEACS patients had >70% stenosis in at least one coronary artery. 70% of them have single vessel disease (SVD). One third of NSTEACS patients had no significant ECG changes and 50% of them had lesions in left circumflex artery (LCX). Severe MR was present in 10% of total NSTEACS patients. Half of them had concomitant lesion in right coronary artery (RCA). Elevated Troponin I & 3DE changes are significantly more to be associated with significant coronary artery disease whereas ECG changes, 2DE changes & GRACE risk scores are not. Conclusion: In NSTEACS patients, 3DE is found to have more sensitivity and specificity than 2DE in predicting significant coronary artery disease and localising culprit arteries, which can be missed by 2DE in 23% cases. Large multi-centric studies exploring the role of 3DE in assessment of NSTEACS patients are needed.
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CURRICULUM IN CARDIOLOGY - IMAGES Top

Endomyocardial fibrosis regression p. 102
Karishma Landge, Vineeta Ojha, Kartik P Ganga, Prateek Kaushik, Pooja Sharma, Priya Jagia, Sudheer Arava, Patel Chetan, Gurpreet Gulati, Ruma Ray, Sandeep Seth
DOI:10.4103/jpcs.jpcs_7_19  
Endomyocardial fibrosis usually is an end-stage cardiomyopathy. We present a case which was picked up early in a stage with active thrombosis and inflammation using magnetic resonance imaging and DOTANOC scans and treated leading to regression of inflammation and thrombus. We advocate aggressive investigation of all cardiomyopathies to look for treatable causes.
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CURRICULUM IN CARDIOLOGY - JOURNAL CLUB Top

Ventricular-arterial coupling: A novel echocardiographic risk factor for pediatric dilated cardiomyopathy p. 105
Sakshi Sachdeva
DOI:10.4103/jpcs.jpcs_34_19  
Ventricular-arterial coupling, earlier used for research and experimental purposes, is being used currently for bedside patient evaluation and decision making. Its use in adults with heart failure has been proven. In pediatric heart failure, due to dilated cardiomyopathy, its use as a prognostic tool has been first documented in this study, and cutoff values determining outcome, have been derived.
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CURRICULUM IN CARDIOLOGY - STATISTICS Top

How to read a forest plot p. 108
Ushmita Seth
DOI:10.4103/jpcs.jpcs_39_19  
When the data-based practice began to accumulate, forest plots were introduced to realize the collective power of the statistical data. It is a graphical representation of a meta-analysis, also known as blobbogram. It allows you to view and analyze the resulting sample individual statistics from multiple similar studies all in one place, along with summary statistics at the bottom. The plot includes the point value of the sample statistic as well as its confidence interval (usually taken as 95%).
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CURRICULUM IN CARDIOLOGY - CASE DISCUSSION Top

Constrictive pericarditis p. 111
Faraz Ahmed Farooqui
DOI:10.4103/jpcs.jpcs_45_19  
A patient presented with Ascites for 3 months. Clinical examination showed ascites , presence of atrial fibrillation and a raised JVP. Further evaluation helped make a diagnosis of constrictive pericarditis. The questions that arise at each step of evaluation of such a patient starting from the history to examination and investigation is discussed in this bedside case discussion.
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CURRICULUM IN CARDIOLOGY - BOOK REVIEW Top

The knife's edge: The heart and mind of a cardiac surgeon p. 116
Raghav Bhargava
DOI:10.4103/jpcs.jpcs_43_19  
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CURRICULUM IN CARDIOLOGY - HISTORY OF MEDICINE Top

The ‘man’ behind modern cardiac catheterization Highly accessed article p. 118
Subhajit Sahoo, Rohan Magoon, Arindam Choudhury
DOI:10.4103/jpcs.jpcs_41_19  
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CASE REPORTS Top

Cardiac myxoma with glandular elements: An unusual histologic variant with a brief review of the literature p. 119
Biswajit Dey, Vandana Raphael, Yookarin Khonglah, Prasad Kalita Jyoti
DOI:10.4103/jpcs.jpcs_29_19  
Cardiac myxoma with glandular elements is an unusual histologic variant of cardiac myxoma and constitutes 2%–5% of all cardiac myxomas. Here, we report a case of cardiac myxoma with glandular elements in a 34-year-old male, who presented with right-sided hemiparesis following a cardiovascular attack 2 months back. Echocardiography revealed a large right atrial mass measuring 3.5 cm × 3.5 cm × 2 cm. Under cardiopulmonary bypass, left atrial mass was excised. Histopathological and immunohistochemical examination of the mass confirmed the diagnosis of cardiac myxoma with glandular elements. It is important to recognize this variant to avoid misdiagnosis of metastatic adenocarcinoma due to its rarity as well as due to its unusual morphological features.
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Chronic painless stanford type a aortic dissection involving whole of the aorta in an elderly female p. 122
Kunal Mahajan, Rajeev Bhardwaj, Sachin Sondhi
DOI:10.4103/jpcs.jpcs_14_19  
Stanford type A aortic dissection (AD) is a rapidly progressive disease associated with a very high mortality rate, especially in the absence of emergent surgical repair. However, very rarely, few cases remain undiagnosed in acute phase because of atypical or absent symptoms. We present such an atypical case of a chronic painless type A AD in an elderly female, who is still surviving at 6 months follow-up without any surgical/catheter-based intervention. This case emphasizes that chronic type A ADs have different natural history and could potentially be managed differently from the acute lesions.
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Snowman heart p. 125
Sachin Sondhi, PC Negi, Sanjeev Asotra, Ayushi Mehta
DOI:10.4103/jpcs.jpcs_27_19  
Total anomalous pulmonary venous connection (TAPVC) consists of abnormality of blood flow in which all pulmonary veins drain into systemic veins or into right atrium with or without pulmonary venous obstruction. Systemic and pulmonary venous blood mix in right atrium. An atrial septal defect is required for survival. We report a case of supracardiac TAPVC and discussed about its diagnostic and management approach.
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LETTERS TO EDITOR Top

Cardiology department of all India institute of medical sciences, Rishikesh: Roads walked and roads ahead p. 128
Dibbendhu Khanra, Bhanu Duggal, Ravi Kant
DOI:10.4103/jpcs.jpcs_35_19  
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The rainbow p. 133
Bimal Kumar Das
DOI:10.4103/jpcs.jpcs_17_19  
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