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   Table of Contents - Current issue
January-April 2021
Volume 7 | Issue 1
Page Nos. 1-87

Online since Saturday, April 24, 2021

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25-Year history of heart transplant in India: Lessons learned Highly accessed article p. 1
UM Nagamalesh
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Implications of the use of hydroxychloroquine on cardioactive drugs Highly accessed article p. 3
Soumitra Ghosh, Ashutosh Yadav, Cliojis Francis, Anunay Gupta, Preeti Gupta, Sourabh Agstam
Hydroxychloroquine (HCQ) is a relatively safe drug, and has been emerged as one of the treatment options for the management of COVID-19. This review is from the viewpoint of cardiologists, and it covers the pharmacokinetics, pharmacodynamics, and mechanism of drug interaction of HCQ with the commonly used cardioactive drugs.
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Pulmonary artery hypertension: A bedside review Highly accessed article p. 8
Mohit Bhagwati, Rahul Mehrotra
Pulmonary artery hypertension (PAH) is a rare progressive disease affecting pulmonary arterial vasculature and the right side of the heart. The disease is notorious for its ominous course and high accelerated rates of mortality. Due to its varied etiology, it requires stepwise evaluation to differentiate various causes of PAH. With the advent of new drugs and improved registry-based data, there has been a global effort to reduce the morbidity and mortality of this disease. Therefore, all efforts should be made for quick diagnosis and uniform workup to reach the etiologic and hemodynamic diagnosis. There is a need of specialized PAH clinics and PAH specialists to cater to the needs of these patients who require multidisciplinary clinical care. This review aims to discuss the important aspects of the disease and its management in a ward round scenario as a case-based discussion format to put emphasis on the recent guidelines and classification.
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Critical care preparedness and conduct in COVID-2019 crisis p. 16
Manoj Kumar Sahu, Prateek Vaswani
Background: COVID-19 pandemic has stirred an unexpected turmoil in health care worldwide. The strategic conduct of critical care would warrant an effective preparedness plan, thorough knowledge of the disease manifestations, and relevant therapeutic strategy to sail through this crisis. Methods: English medical literature with MeSh database was searched using the key words such as “COVID-19 pandemic,” “ICU preparedness,” “COVID-19 management,” “COVID-19 therapy,” and “COVID-19 systemic effects.” The relevant studies were included with significant inputs from interdepartmental meetings for the formulation of a plan. Results: The analysis of the respective studies highlighted the requirements of COVID-19 designated intensive care units (ICUs) with special provisions and the therapeutic agents being used in critical patients with emphasis on Remdesivir, Dexamethasone, Convalescent Plasma, and insight into newer agents. The systemic manifestations of COVID-19 requiring ICU care such as acute respiratory distress syndrome, myocardial injury, arrhythmias, hypercoagulable state, and acute renal dysfunction have been highlighted. The need of updating records with research protocols cannot be disregarded. The care of patients should not compromise the health-care personnel requirements. Conclusion: The evidence-based preparedness strategy can curtail the critical care crunch in COVID-19 management; however, institutional specific approach should be formulated.
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COVID-19 and cardiac health: A review p. 24
Avinash Mani, Vineeta Ojha, Manoj Kumar Dubey
The ongoing novel coronavirus pandemic has caused a serious impact on patients suffering from cardiovascular disorders as they are predisposed to COVID infection as well as to exacerbation of their preexisting conditions which can prove to be fatal. Novel coronavirus disease-2019 (nCOVID-19) has a varied effect on the cardiac system ranging from myocardial injury to thromboembolic complications. A significant proportion of patients are noted to have comorbidities. Human angiotensin-converting enzyme 2 (ACE 2) receptor is considered the target of the severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2). SARS-Cov-2 leads to imbalance in RAAS activity which is responsible for target organ damage. Recombinant ACE 2 has been shown to restore ACE 2 levels in explanted hearts and restore balanced RAAS activity. nCOVID-19 can have varied cardiac manifestations ranging from acute coronary syndrome to heart failure, arrhythmias, pulmonary thromboembolism, and pericarditis. The current nCOVID-19 pandemic has led to changes in management strategies for cardiovascular diseases. Patients with ST-elevation myocardial infarction can be fibrinolysed when a primary percutaneous coronary intervention facility with adequate protection is not available. Angiotensin-converting enzyme inhibitor/angiotensin receptor blocker needs to be continued in patients with hypertension. Continuity of care for patients with chronic cardiovascular illness needs to be maintained. Management of cardiovascular emergencies needs to be done in a way which ensures the safety of health-care professionals and prevents infection transmission. Strict prevention of infection and health control measures will help to prevent spread of infection and reduce disease incidence.
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Clinical and angiographic outcomes of coronary bifurcation lesions treated by TAP- stenting as an initial two stent strategy p. 31
Krishna Malakonda Reddy Parvathareddy, Naga Chaitanya Karella, Srinivas Ravi, Praveen Nagula, Jagadeesh Reddy Kolli, Syed Imamuddin
Context: The T-stenting with small protrusion (TAP) technique is a relatively new strategy among the bifurcation lesion interventions. Apart from being technically easy, there is complete coverage of the side-branch ostium and minimal overlap of the stent struts. Aims: We sought to report the outcomes of TAP technique in the management of the bifurcation lesions. Settings and Design: Prospective observational study between December 2017 and December 2019. Subjects and Methods: Patients with a diagnosis of coronary artery disease and bifurcation lesion on angiography were included in the study. Patients who underwent intervention with TAP technique were analyzed at baseline and followed up for a period of 1 year. The measured endpoints include major adverse cardiac events (MACE), target vessel revascularization (TVR), stent thrombosis (ST), and binary restenosis at 1-year follow-up. Results: During the study period, 152 bifurcation lesions in 148 patients were treated by percutaneous coronary intervention using drug-eluting stents. Of these, 15 patients (10.13%) underwent TAP stenting. The median age was 60 years. The procedural success was 100% in all the patients. At 1-year follow-up, MACE was seen in 13.3%, TVR in 6.66%, and binary stenosis in 6.66%. Conclusion: The TAP stenting as an initial two-stent strategy is associated with acceptable clinical outcomes (MACE and in-stent restenosis). There was no case of definite ST.
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Assessment of thirst intensity and thirst distress and the practices for its management among heart failure patients admitted to the cardiology unit p. 36
Karuna Thapa, Smita Das, Pragya Pathak, Sandeep Singh
Background: Thirst is reported as a troublesome symptom in patients with heart failure (HF), and very few studies have been done to assess thirst in these patients. Therefore, this study aims to assess thirst intensity, thirst distress, and practices of HF patients to manage thirst. Methods: A descriptive, cross-sectional study was conducted on 75 HF patients admitted to the cardiology department. Purposive sampling technique was used for collecting data from July 2019 to November 2019. Visual analog scale (0–100 mm) was used to assess thirst intensity, and 8-item thirst distress scale was used to assess thirst distress. The practices of the participants were assessed using a self-developed questionnaire. Results: The mean age of the participants was 44.83 ± 15.51 years and the majority (72%) was male. The majority of the participants (82.7%) had fluid restriction, and almost 97.3% of all of the participants were receiving diuretics. The median (interquartile range) thirst intensity was 33 (16–50) mm. About 66.7% of the participants had moderate-to-severe thirst distress. Both thirst intensity and thirst distress were associated with fluid restriction, New York Heart Association functional class, and serum urea level. The participants reported that they drink a small amount of water frequently, gargle with water, eat cucumber, drink buttermilk, lemon juice, and coconut water. Very few participants had made changes in their food habits and lifestyle. Conclusion: Two-thirds of the participants had moderate-to-severe thirst distress. Fluid restriction was associated with both thirst intensity and thirst distress. Thus, nurses are responsible to assess thirst among HF patients and help them to manage their thirst effectively.
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Acute electrocardiographic changes during smoking and tobacco chewing: A Cross-sectional study p. 41
Himanshu Gupta, Balram Bhargava, Sandeep Seth, CR Pruthvi, Sivasubramanian Ramakrishnan
Background: Smoking increases the risk of coronary artery disease. Very few studies have evaluated the temporal relationship of electrocardiographic changes with smoking. We sought to study and compare the electrocardiogram (ECG) changes during smoking and tobacco chewing in current smokers and tobacco chewers presenting with atypical chest pain with either negative or mild positive exercise ECG test (treadmill test [TMT]). Materials and Methods: We screened male smokers and tobacco chewers with atypical chest pain with TMT. A total of 60 patients, 30 in each group in whom TMT was either negative or mildly positive, underwent a 24-h Holter monitoring. We asked patients to note down their time of smoking and tobacco chewing along with the timing of symptoms if any. Results: All patients were male with an average age of 45 years in smokers and 42 years in the tobacco chewer group. The mean number of cigarettes consumed was 6 ± 2.8 and tobacco chewed was 5 ± 4.7 g/day. Heart rate (HR) in smokers increased from 82.5 ± 14.56/min 10 min before smoking to 90.63 ± 15.34/min, during smoking with peak HR achieved at the time of smoking (P < 0.0001). HR in the tobacco chewers peaked at 10 min after chewing from 80.62 ± 13.52/min 10 min before to 87.89 ± 13.86/min 10 min after chewing (P < 0.0001). Smoking was associated with a significant increase in supraventricular ectopics (VEs) from 3.98/h before smoking to 7.43/h during and 6.92/h after smoking (P < 0.0001). Two patients in the smoker subgroup had spontaneous smokeless tobacco -T changes lasting for 10–25 min. Smoking was associated with a significant decrease in HR variability (HRV) index than the controls (P = 0.023). Tobacco chewing was not associated with any significant changes in the HRV parameter. Conclusions: Smoking and tobacco chewing both significantly increase the HR acutely. Smoking leads to an increase in both supraventricular and VEs. We observed reduced HRV in patients who smoked cigarettes.
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One year outcomes following orthotopic heart transplantation at a tertiary care center in India p. 47
Syed Shamayal Rabbani, Sarvesh Pal Singh, Sandeep Seth, Anurag Goyal, Manoj Kumar Sahu, Milind P Hote
Introduction: Cardiac transplantation remains the gold standard for end stage heart failure. Even after 25 years, the progress of heart transplants in India has not been as expected, especially in the public sector. Till recently, ours was the only government hospital in India with a successfully running heart transplant program. This study's primary objective was to evaluate the 1-year survival of heart recipients in the past 5 years at our center and risk factors associated with early mortality. The secondary objective was to assess the correlation between per capita income and quality of life (QOL). Methodology: A retrospective analysis of records of 40 transplant patients, performed between June 2014 and June 2019 at our center, was done to calculate 1-year survival and evaluate risk factors for mortality. The following risk factors were analyzed for a significant correlation with mortality-infections, primary graft dysfunction (PGD), allograft rejection, ischemia time, and Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) score. Adults (>18 years of age) who are in the current follow-up (n = 21) were interviewed for the evaluation of their per capita income and QOL. A correlation was sought for between per capita income and QOL. Results: The mean age of patients was 31.2 ± 12.7 years. The 1-year survival of patients transplanted during 2014–2015 and 2016–2019 was 65% and 85%, respectively. None of the risk factors studied correlated with mortality. The most common cause of death in the 1st year following transplant was an infection. A total ischemia time of more than 240 min, higher preoperative PA pressures, and INTERMACS score ≤2 are significant risk factors for developing PGD. The mean monthly per capita income of the 21 patients, interviewed for QOL, is ₹7142 ± 3050. The cost of heart transplant for the first 2 years (including surgical expenses) is ₹997,760 ± 104,751 rupees at our institute, and the current mean monthly spending for medicines is ₹15,214 ± 5041. Conclusion: The 1-year survival of patients transplanted during 2014–2015 and 2016–2019 was 65% and 85%, respectively. There was no correlation between infections, PGD, allograft rejection, ischemia time, INTERMACS score, and mortality. The QOL of heart recipients, from economically weaker sections, is similar to that of India's general population. There is no correlation between per capita income and QOL after a heart transplant.
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A comparative assessment of the severity of coronary artery disease in patients with low ankle–Brachial index and normal ankle–Brachial index: An angiography-based cross-sectional observational-analytical study (CADLABI study) p. 54
Awadhesh Kumar Sharma, Mohit P Kejriwal, Santosh Kumar Sinha, MM Razi, Umeshwar Pandey, Praveen Shukla, Ramesh Thakur, CM Verma, Vinay Krishna
Objectives: The ankle–brachial index (ABI) is an efficient tool and an indicator of generalized atherosclerosis. Still, there is uncertainty regarding the severity of coronary artery disease (CAD) in patients having low ABI. The uniqueness of this study is that it is the first largest study done with the aim to determine the severity of CAD in the form of a number of involvements of coronary vessel in patients with low ABI. Materials and Methods: It is a hospital-based cross-sectional observational-analytical study. A total of 500 patients of suspected CAD were recruited. ABI was measured first and then all patients were sent for coronary angiography. Based on ABI values, patients were divided into two groups, i.e., Group A (patients with low ABI or ABI ≤0.9) and Group B (patients with normal ABI or ABI >0.9). Results: Twenty-three, i.e., 4.6% of patients had ABI <0.9. All patients having low ABI had CAD. In assessing CAD severity, it was reported that in Group A, triple-vessel disease (TVD) was present in 65.2% (P = 0.0001), double-vessel disease in 21.7% (P = 0.72), single-vessel disease in 8.6% (P = 0.06), and noncritical CAD in 4.3% (P = 0.9) as compared to Group B. In patients with Group A, 52.1% were smoker (P = 0.01), 69.5% have increased body mass index (P = 0.71), 43.4% have a history of hypertension (P = 0.73), and 60.8% were diabetic (P = 0.0005). Conclusion: CAD is widely prevalent almost in all patients with low ABI and more than half of these patients have TVD on angiographic assessment.
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An unusual case report of two cases with coexisting type I aortopulmonary window with tetralogy of fallot with pulmonary atresia p. 60
Prateek Vaswani, Palleti Rajashekar, Velayoudam Devagourou
Aortopulmonary window is an uncommon truncal anomaly. Its coexistence with tetralogy of Fallot (TOF) with pulmonary atresia is rare. This rare complex association is always a surgical challenge due to lack of an established surgical approach. The association with TOF makes the interventional approach unlikely. In the two cases summarized below, we have addressed the investigation strategy reaching the final diagnosis. The surgical interventions and our decision-making in the final adopted technique have been highlighted. The relevant surgical outcome with postoperative follow-up has been discussed. The rarity of this association without a standard management algorithm mandates the relevance of this presentation.
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Severe hypertriglyceridemia with recurrent pancreatitis treated with therapeutic plasma exchange p. 63
Anshul Kumar Jain, Neha Bedi, Anurag Garg
Severe hypertriglyceridemia (HTG) is associated with an increased risk of cardiovascular disease and acute pancreatitis. We report the case of a 34-year-old female admitted with complaints of recurrent pancreatitis and triglyceride (TG) levels above 995 mg/dl. The patient was started on therapeutic plasma exchange (TPE) to achieve a rapid fall (78%) in serum TG levels. We conclude that TPE is a safe and quick therapeutic treatment modality for patients with HTG-induced recurrent acute pancreatitis who fail to respond to conventional therapy.
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Pedicled omental wrapping of ascending aortic graft following mediastinitis p. 66
Yatin Arora, Velayoudam Devagourou, Ratnesh Kumar
A 51-year-old male patient post-Aortic valve replacement (#25 SJM) underwent redo supra-coronary ascending aorta replacement for ascending aortic aneurysm developed a peri-graft purulent collection 2 months later post surgery. He was successfully treated by debridement of infected tissues, antiseptic irrigation with povidone, and omental wrapping of graft. The patient was discharged after full course of antibiotics. Quick diagnosis with debridement, irrigation, and omental wrapping can be effective in the treatment of mediastinitis following graft replacement of the ascending aorta for preventing catastrophic complications
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Left ventricular thrombus in patients with COVID-19 – A case series p. 69
Pankaj Jariwala, Arshad Punjani, Harikishan Boorugu, Mari Ajay Reddy
Scarred culprit vessel territory secondary to nonreperfused myocardial infarctions (MIs), nonischemic cardiomyopathy, left ventricular (LV) noncompaction, endomyocardial fibrosis, and long-standing arrythmias are usually causes of LV thrombus (LVT) formation. However, in the setting of MI, large infarctions, apical akinesia or dyskinesia, LV aneurysms are often predisposed t'o the formation of LVT. The hypercoagulable or inflammatory disorder can rarely predispose to the formation of LVT. In early prethrombolytic and thrombolytic periods, LVT was present in 20%–50% of patients in the context of acute MI, more commonly in acute anterior or apical MI. While the incidence of LVT has dropped in recent times, its identification is expected to rise during the COVID-19 pandemic. Patients with chest pain are more likely to delay initial hospitalization because of a fear of contracting COVID-19. Infection with COVID-19 was associated with the remarkably hypercoagulable state which increased the risk of the early development of LVT in the setting of MI or underlying prethrombotic conditions. We present a series of four cases in which COVID-19 and cardiovascular disease were characterized by various configurations of large LVT.
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Calcific severe rheumatic mitral valve stenosis disguising as a “pseudoprosthesis”: An imaging vignette p. 76
Akhlaque Ahmed, Ankit Kumar Sahu, Aditya Kapoor
We present an interesting cardiac fluoroscopic image representing a severe rheumatic mitral restenosis with heavily calcific mitral valve leaflets having a striking resembling to the valve leaflets of bileaflet mechanical valve on cineangiography with respect to size, shape, motion, and position.
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Hydroxychloroquine and azithromycin use in COVID-19 era and cardiovascular concerns: Current perspective p. 78
Aditya Kapoor, Ankit Kumar Sahu
In the present era of coronavirus disease 2019 (COVID-19) pandemic, lack of an established and effective targeted therapy sans a vaccine is proving to be a major hurdle in containing the contagion. Hydroxychloroquine (HCQ), a widely used antimalarial and anti-inflammatory drug, has been proposed for coronavirus infection management by various drug regulatory authorities for emergency use including Indian Council of Medical Research. However, clinical safety concerns primarily regarding cardiovascular issues have been raised against HCQ usage, especially in relatively higher dosage in conjunction with azithromycin (AZM) coprescription. HCQ and to some extent, AZM have proven to be effective against COVID-19. Barring a small at-risk population for cardiovascular adverse effects, their clinical use in the treatment and prevention of COVID-19 was deemed to be beneficial and even recommended by various national and international representative societies including the World Health Organization, especially in high-risk individuals such as health-care workers and exposed contacts of coronavirus positive patients under due medical supervision. Multiple studies evaluating the anticoronaviral efficacy for prevention as well as for treatment prospect were conducted, but none could convincingly demonstrate a beneficial effect of HCQ with or without AZM on alleviating symptoms, shortening hospitalization, improving survival, or preventing disease transmission.
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Double whammy: Rheumatic heart disease associated with left ventricular noncompaction p. 83
Antara Banerji, Pradyot Tiwari
We present a rare case of a 48 year old man, coming with Rheumatic heart disease, mitral regurgitation, aortic regurgitation and LV non compaction. This is a very rare combination of diseases.
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A neonatal echocardiographic Z-score nomogram for a developing Country p. 85
Mahmood Dhahir Al-Mendalawi
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Author's Reply p. 86
R Jain, C Mathew, J Rawal, T Shah, B Padhi, NA Saxena
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Emerging technologies for heart disease: A book review p. 87
Eli Gabbay
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