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  Access statistics : Table of Contents
   2020| January-April  | Volume 6 | Issue 1  
    Online since April 17, 2020

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Types of variables in medical research
Shivam Pandey
January-April 2020, 6(1):4-6
Formulation of a research question is the initial and important step in any research work. Depending on the research questions to be answered, the researchers decide the statistical methods to be used for the analysis. Researchers have to be acquainted with a variety of variables involved in their study to choose appropriate diagrams/graphs and summary measures for presentation and to valid statistical tests for the analysis of data. The type of variable also decides the type of statistical analyses to be performed, whether parametric or nonparametric. Parametric methods, such as t-tests, ANOVA, Pearson correlation, and regression, require that the data follow a normal distribution. Frequently used nonparametric methods such as Mann–Whitney or Wilcoxon rank-sum test and rank correlation make no assumptions on the distribution of the data. Failure to pay attention to assumptions may lead to increase in type I or type II error rates.
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Principles of correlation and regression analysis
Shivam Pandey
January-April 2020, 6(1):7-11
In statistics, the correlation analysis quantifies the strength of the association between two quantitative variables. In the present article, we discuss how to establish a relationship or an association between two quantitative variables. While the correlation provides a quantitative way of measuring the degree or strength of a relation between two variables, regression analysis describes this relationship. Correlation and agreement are also distinguished, and pitfalls of correlation are discussed.
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Corona virus disease and the heart
Satyavir Yadav, Shivani Vashista, Pooja Bhardwaj
January-April 2020, 6(1):2-3
The world is in the midst of a corona virus disease (COVID-19) pandemic. We review a case of COVID-19 myocarditis which was successfully managed and reported and also comment on the connection of COVID-19 and the heart.
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Cardiology update 2020 first quarter
Satyavir Yadav
January-April 2020, 6(1):12-15
This review covers the end of 2019 and the beginning of 2020 and includes treatment of asymptomatic aortic stenosis, role of antisense oligonucleotides, rivaroxaban in transcatheter aortic valve implantation (TAVI), complete revascularization after myocardial infarction (MI) proving superior, study of colchicine in MI, and update of NOBLE trial showing that percutaneous coronary intervention in left main interventions is inferior to coronary artery bypass graft. There were also a number of trials highlighting various aspects of the outcomes of TAVI implants.
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Evolution of ventricular interdependence concept: Bernheim, reverse-bernheim effect and beyond!
Rohan Magoon, Souvik Dey, ItiShri , Ramesh Kashav
January-April 2020, 6(1):90-91
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Corona, the heart, and hope
Sandeep Seth, Shyamal K Goswami
January-April 2020, 6(1):1-1
  1,265 227 -
Quantitative analysis, cost comparison, physician, and patient perceptions on generic versus branded clopidogrel bisulfate tablets marketed in Kerala, India
Varghese George, Krishnamohan Mullavelil, Ancy Thannikkal Joseph, Cheriyan Koshy, Krishnan Nair Venugopal
January-April 2020, 6(1):40-46
Background: Clopidogrel bisulfate is sold in more than 60 advertised brand names (trade names) in the Indian market. Government health sector in India emphasizes on prescribing clopidogrel in its generic form, which refers to the chemical makeup of the drug, rather than to the advertised brand name, to reduce the economic burden. Preference for branded drugs and cost difference with generics are already well established, however physicians are apprehensive regarding the quality of generic drugs and have concerns about their reliability. Objective: We studied perspective of physicians and patients regarding generic versus branded medicines among hospitals in our locality. Cost difference incurred while prescribing various brands and generic clopidogrel tablets were calculated. Percentage purity of generic and branded clopidogrel tablets were analyzed to find if any difference really exists between them. Methodology: Perspective of 150 physicians and patients were studied using questionnaire method. Using ultraviolet spectrophotometer, generic and most commonly prescribed brands of clopidogrel were analyzed for percentage purity. Once analyzed, their costs were compared. Results: Eighty- six percent (n = 129) of physicians and 81% (n = 122) of patients surveyed, preferred branded medicines over generic ones. Among 10 branded clopidogrel tablets, only three complied with the Indian Pharmacopoeia standards of drug percentage purity. Pricing pattern of various brands of clopidogrel ranged from $1.4 to $3.13 per month. Generic clopidogrel tablets are available free of cost for patients from government-run hospitals but did not meet recommended percentage purity standards. Conclusion: Both branded and generic versions of clopidogrel have their merits and demerits. The general notion and doubt regarding difference in quality of generic versus branded version of medicines as evidenced by our perspective evaluation of physician and patients is appropriate in the present scenario. More large scale studies of different cardiovascular drugs are required to ensure their quality. Improved quality of generic medicines has to be ensured prior to marketing in India.
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Effectiveness of a structured heart failure clinical pathway on nurses' knowledge and patient care outcomes
Jerlin Joseph, L Gopichandran, Sandeep Seth, Milan Tirwa
January-April 2020, 6(1):53-60
Background: The global burden of heart failure (HF) is affecting at least 26 million people worldwide, and its incidence and prevalence are increasing. Management of patients suffering from HF requires a multidisciplinary management tool which is based on evidence-based practices. A clinical pathway (CP) has emerged as an essential strategy for knowledge transition, which helps in promoting effective health care in all disciplines of health care. The Objectives of the Study: The objectives of the study are to assess the effectiveness of a structured HF CP on nurses' knowledge and patient care outcomes in the Cardiology Department, AIIMS, New Delhi. Materials and Methods: This quasi-experimental study was conducted among 71 nurses working in the cardiac care unit (CCU) and cardiology (CT3) ward and 60 admitted acute decompensated HF patients. The study had three phases: preimplementation phase, implementation phase, and postimplementation phase. The implementation of the structured HF CP was made through an education session for nurses. Results: The nurses' knowledge and the patients' outcomes were assessed and compared before and after implementation of the CP. The knowledge score of the nurses had improved statistically significantly from 11.38 ± 2.9 to 16.85 ± 2.4 (P < 0.0001), after the implementation of the structured HF CP. With regard to patient outcomes, the postimplementation group had significant improvement when compared with the preimplementation group in terms of administration of beta-blockers (P = 0.028) and vaccination (P = 0.037). There was a clinically significant reduction in the length of intensive care unit stay, length of hospital stays, in-hospital mortality, and 30-day readmission and mortality in the postimplementation group than that in the preimplementation group.Conclusion: The implementation of the structured HF CP has improved the knowledge of the nurses working in CCU and CT3 ward and has also enhanced the outcomes of patients admitted in the Cardiology Department, AIIMS, New Delhi.
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Multivalvular heart disease: Case discussion
Ram Manohar Talupula, R A Benin Rajesh
January-April 2020, 6(1):18-22
Here we report a bedside case discussion of a young patient with multivalvular heart disease who presented with dyspnea, palpitations, abdomen distension, yellow eyes, and pedal edema. There were an irregular pulse, engorged neck veins, systolic murmurs in the apex and parasternal areas, and a diastolic parasternal murmur. The diagnosis of multivalvular disease is discussed based on the history and clinical findings. The help of the electrocardiogram, X-ray, and echocardiography in arriving at the diagnosis is also discussed in this bedside case discussion for students.
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Correlation of epicardial adipose tissue thickness by echocardiography with waist circumference, lipid profile, and severity of lesion by coronary angiography in patients with acute coronary syndrome
Gattu Pruthvi, Otikunta Adikesava Naidu, Nagula Praveen, Ravi Srinivas, Parvathareddy Krishna Malakonda Reddy
January-April 2020, 6(1):61-67
Context: Epicardial adipose tissue (EAT) thickness on echocardiography can be a promising marker for risk stratification in patients with coronary artery disease (CAD). Aim: To correlate EAT with waist circumference (WC), lipid profile, severity of coronary artery disease on angiography in patients with acute coronary syndrome(ACS). Subjects and Methods: Patients with acute coronary syndrome (ACS) with age >18 years were studied. Their demographic, clinical, biochemical, and angiographic profile was assessed. The correlation of EAT with WC, lipid profile, and the severity of lesion by coronary angiography was assessed. Results: A total of 120 consecutive patients with ACS were studied. The male: female ratio was 4:1. The mean age of presentation was 56.43 ± 11.39 years. Dyslipidemia was seen in 70 (58.33%) patients, whereas hypertension was seen in 58 (48.3%) patients. The syntax score (SS) was low in 34 (28.3%) and high in 50 (41.67%) patients. Mean EAT was high in patients with high SS compared to those with intermediate and low SS (9.66 ± 0.33 vs. 6.08 ± 0.10 vs. 5.90 ± 0.24 mm, P < 0.001). A significant correlation of EAT was seen with WC r = 0.749, total cholesterol r = 0.934, and high-density cholesterol r = 0.674, P < 0.001. The cutoff value of EAT on echocardiography to diagnose significant CAD (SS >23) was 6.23 mm on receiver operating characteristic curve analysis with an area under the curve being 0.953 and sensitivity of 100% and specificity of 70%. Conclusions: EAT thickness, can be a reliable, easy, noninvasive marker in risk stratification of patients at risk of CAD.
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Lymphohistiocytic myocarditis: A rare case with imaging and pathological finding
Manish Shaw, Tripti Nakra, Sudheer Kumar Arava, Priya Jagia, Ruma Ray, SH Chandrashekhara, Sandeep Seth
January-April 2020, 6(1):84-86
Lymphohistiocytic myocarditis (LCM) is a rare kind of inflammatory myocardial disease that presents with a wide variety of nonspecific clinical characteristics and requires a high index of suspicion for prompt diagnosis and treatment. The diagnosis of this rare entity is essential to start the immunosuppressive therapy to control the disease process at an early stage. Typical features of layered myocardial enhancement after gadolinium injection in cardiac magnetic resonance (CMR) can suggest the diagnosis of either granulomatous or lymphohistiocytic infiltration of the heart, and biopsy is often required to differentiate between these two rare entities. We present a case of middle-aged women with cardiac conduction block with typical features of LCM in CMR and biopsy.
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Use of judkins left as a multipurpose catheter for simultaneous transradial percutaneous coronary angioplasty of left and right coronary arteries: A time-saving and cost-effective innovation
Naresh Gaur, Kunal Mahajan, Neeraj Ganju, Rajesh Sharma, Rao Somendra, Vaishali Verma, Ashu Gupta
January-April 2020, 6(1):78-80
Proper hardware selection during percutaneous coronary angioplasty (PCI) remains the key to the successful procedure, especially in the setting of an acute coronary syndrome (ACS) where minimizing the procedure time and the amount of dye is of utmost importance. Recent studies have demonstrated the benefit of complete revascularization in cases of multivessel disease in the ACS setting. During transradial intervention in a case of multivessel PCI, guiding catheter-induced radial artery spasm is a major concern. People have used guiding catheters such as Ikari for simultaneous PCI of right and left coronary arteries. This minimizes the risk of radial spasm and saves precious time, especially in the setting of ACS where each second counts. Limited data exist regarding the use of Judkins left (JL) catheter for PCI of simultaneous right and left coronary artery. Here, we describe an interesting case of simultaneous PCI of left anterior descending – infarct-related artery and right coronary artery – chronic total occlusion through transradial route using JL guide catheter in the setting of ACS.
  796 74 -
Correlation of systolic and diastolic time intervals with demographic and anthropometric parameters in young adults
Sadiqua Sadaf, Mehnaaz Sameera Arifuddin, Mohammed Ziya ur Rahman, Mohammed Abdul Hannan Hazari, Syeda Bushra Quadri
January-April 2020, 6(1):23-32
Context: Dimensions of vasculature may vary with height, weight, and build of the individual. This may, in turn, influence the time intervals during cardiac cycle. Aims: The aim of this study was to correlate the systolic and diastolic time (DT) intervals (preejection period [PEP], ejection time [ET], upstroke time [UT], DT, pulse duration [PD], and ejection slope [ES]) of pulse waves recorded from all four limbs in relation to age, gender, weight, height, heart rate, and blood pressure and to compare these cardiac time intervals between individuals with or without parental history of hypertension. Settings and Design: Ninety-eight healthy MBBS students in the age group of 19–21 years were included. Subjects and Methods: Students' history and demographic data were noted. Anthropometric measurements were recorded. The measurement of peripheral arterial pressures (in all four limbs) and determination of cardiac intervals (PEP, ET, UT, DT, PD, and ES) was done by PeriScope. Statistical Analysis Used: Data were analyzed using SPSS version 17.0. Results: Independent sample t-test showed statistically significant differences between genders with weight, height, waist circumference, and waist–hip ratio. Statistically significant differences existed between right arm systolic blood pressure, left arm systolic blood pressure, and left arm pulse pressure among males and females. Significant differences among males and females were observed in some of the cardiac time intervals. Mean arterial blood pressure recorded in all four limbs showed a significant negative correlation with right arm ES in males and left arm ES in females. Conclusion: Since gender, anthropometric parameters, and blood pressure influence cardiac time intervals, these should be adjusted for when deriving inference on left ventricular performance.
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Erratum: Cardiology department of all india institute of medical sciences, Rishikesh: Roads walked and roads aheadcardiology department of AIIMS, Rishikesh: Roads walked and roads ahead

January-April 2020, 6(1):92-92
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Noninvasive detection of cardiac transplant rejection using cardiovascular magnetic resonance: Correlation with endomyocardial biopsy
Vineeta Ojha, Tripti Nakra, Anubhav Narwal, Kartik P Ganga, Sudheer Arava, Ruma Ray, Sandeep Seth, Priya Jagia
January-April 2020, 6(1):87-89
A heart transplant patient came for her routine annual surveillance. She received cardiac transplant in April 2017. The patient did not have any cardiovascular symptoms. Her coronary angiogram did not reveal any significant coronary artery disease. The endomyocardial biopsy showed diagnosis of acute cellular rejection, Grade 1R with antibody mediated rejection, Grade 2 and Quilty effect was made. Subsequently, panel-reactive antibody assay was performed, and it was 0% for human leukocyte antigen (HLA) Class I and 43% for HLA Class II. A noncontrast cardiac magnetic resonance imaging (MRI) (mapping sequence) was done to rule out any rejection. Cine images revealed normal biventricular function. However, mapping sequences showed diffuse abnormal increase in native T1 (average ~1200 ms) and native T2 (average ~62 ms) values in the entire myocardium. MRI T1 and T2 mapping sequences may help in early non invasive detection of rejection.
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Antiphospholipid antibody syndrome presenting as pulmonary embolism in a young male
Vikas Gupta, Tanvi Singla, Bhupinder Singh, Bishav Mohan
January-April 2020, 6(1):75-77
Antiphospholipid syndrome (APS) is a prothrombotic condition seen more commonly in females. APS may be primary or secondary to an underlying connective tissue disease like systemic lupus erythematosus (SLE), which is also more common in females. We report an 18-year-old male who presented with deep venous thrombosis (DVT) and pulmonary embolism and was later diagnosed as SLE with secondary APS. This case highlights a rare presentation of DVT with pulmonary embolism as the presenting manifestation of SLE with secondary APS in a young male. It also highlights the importance of recognizing this hypercoagulable state as the cause of pulmonary embolism since it has important therapeutic implications.
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Fibular aplasia-tibial campomelia-oligodactyly syndrome phenotype wclar septal defect in an African Child
Igoche David Peter, Habila Umaru
January-April 2020, 6(1):68-70
This is a report of a 3yearold girl with findings of FATCO (fibular aplasia-tibial campomelia-oligodactyly) syndrome associated with ventricular septal defect. This is the first ever FATCO syndrome report in an African child to the best of the authors' knowledge. Association of the rare FATCO syndrome with cardiac defects is a rather rarer finding in medical literature. Does this combination of rarities suggest an emerging genetic syndrome?
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Significance of aortic propagation velocity in patients with coronary artery disease – A novel echocardiographic parameter of atherosclerosis
Marakkagari Vamsikrishna, Otikunta Adikesava Naidu, Nagula Praveen, Ravi Srinivas, Parvathareddy Krishna Malakonda Reddy
January-April 2020, 6(1):33-39
Background: Optimal risk stratification of patients with coronary artery disease (CAD) is of paramount importance to deliver appropriate care. As the age increases and with an increase in risk factors for CAD, the stiffness of the vascular system increases. The aortic propagation velocity (APV) may decrease with an increase in the stiffness and decrease in the strain and distensibility. Aim: To correlate the Aortic Propagation Velocity (APV) with the presence and severity of CAD. Subjects and Methods: Patients with diagnosis of Acute coronary syndrome (ACS) have been enrolled. APV, Aortic strain (AS) and aortic distensbility (AD) have been assessed in them. The correlation of the parameters with severity of CAD was assessed. Results: A total of 100 consecutive patients were studied. The patients were divided into two groups after coronary angiography (Group A – with CAD and Group B – normal coronaries). The male-to-female ratio in the whole cohort was 2.3:1. The mean age of presentation for Group A was 54 ± 10.8 years and for Group B was 51.1 ± 7.37 years (t = 1.56, P = 0.122). The AS, AD, and APV were significantly decreased in patients with CAD (P < 0.0001). There was significant decrease in APV as there is increase in syntax score (SS) (SS <22 [20] – 65.15 ± 9.25 vs. SS 22–32 [16] – 55.88 ± 10.14 vs. SS >32 [14] – 37.09 ± 8.02, respectively, P < 0.0001). On receiver operating characteristic curve analysis, the cutoff of APV for the prediction of CAD was 60 cm/sec (area under the curve: 0.813) with a sensitivity of 72.5% and specificity of 62%. Conclusion: APV is a reliable, simple echocardiographic parameter of aortic stiffness which is feasible for noninvasive cardiovascular risk stratification during the evaluation of CAD.
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Problem of complete ostial coverage in short left main artery
Himanshu Gupta, Dinakar Bootla
January-April 2020, 6(1):71-74
A 58-year-old male presented with unstable angina and strongly positive myocardial perfusion imaging. Coronary angiogram revealed significant left main (LM) and multivessel disease. He underwent LM and bifurcation percutaneous intervention by provisional side-branch strategy after heart team discussion. After LM to proximal left anterior descending stenting, left circumflex wire was recrossed followed by kissing balloon inflation (KBI). Stent boost after KBI showed fractured stent in the LM artery. Why did this complication occur and how did we manage is described in detail in this case report.
  561 94 -
Early surgery or conservative care for asymptomatic aortic stenosis (The RECOVERY trial)
Nayani Makkar
January-April 2020, 6(1):16-17
The Early Surgery or Conservative Care for Asymptomatic Aortic Stenosis (The RECOVERY Trial) was an open-label, parallel-group trial that recruited 145 patients with very severe aortic stenosis with a mean gradient of 50 mmHg or greater across the aortic valve). It showed that early surgery should be considered the modality of choice in patients with asymptomatic severe aortic stenosis considering the high rate of progression of the disease to a symptomatic state and amelioration of the risk of sudden death with early surgery.
  558 97 -
Evaluation of baseline hemoglobin levels and creatinine clearance as independent prognostic factors for patients undergoing primary percutaneous coronary intervention
Sharad Chandra, Birendra Kumar, Pravesh Vishwakarma, Sudhanshu K Dwivedi, Rishi Sethi, Akshyaya Pradhan, Gaurav Chaudhary, Akhil Sharma, Monika Bhandari, Varun S Narain
January-April 2020, 6(1):47-52
Objective: The objective is to evaluate the impact of baseline hemoglobin (Hb) levels and creatinine clearance (CrCl) levels in acute ST-segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI). Methods: This was a single-center, prospective observational study conducted at a tertiary-care center in India. We enrolled 337 STEMI patients between November 2015 and December 2016. Patients were divided into four groups on the basis of baseline Hb and CrCl levels: Group-1: patients with normal Hb and normal CrCl (102 [30.2%]); Group-2: patients with low Hb and normal CrCl (78 [23.2%]); Group-3: patients with normal Hb and low CrCl (79 [23.4%]); and Group-4: patients with low Hb and low CrCl (78 [23.2%]). Results: The mean age group at presentation was 40–70 years. In-hospital complications were observed in 11 (10.8%) patients of Group-1, 11 (14.1%) patients of Group-2, 37 (46.8%) patients of Group-3, and 52 (66.7%) patients of Group-4, respectively (P = 0.03). Adverse events at 30-day follow-up were found to be higher in Group-4 (15 [19.2%] patients) followed by Group-3 (8 [10.1%] patients), Group-2 (4 [5.1%] patients), and Group-1 (2 [2%] patients), respectively (P = 0.01). Death was observed in one (1%) patient of Group-1, three (3.8%) patients of Group-2, five (6.3%) patients in Group-3, and eight (10.3%) patients of Group-4 (P = 0.03). Conclusion: Low Hb levels and CrCl levels in acute STEMI patients undergoing primary PCI were associated with increased risk of 30-day event rates.
  526 77 -
Whole coronary circulation originating from single ostia – Rare case report
Sunil Gurmukhani, Vivek Agrawal, Sunil Mittal, Pradyot Tiwari, Sanjay Shah, Tejas Patel
January-April 2020, 6(1):81-83
The prevalence of coronary artery anomalies is approximately 1% in individuals undergoing angiography. Most of the anomalies are benign, but some can lead to myocardial infarction, cardiomyopathy, and sudden cardiac death. It is very rare to have an entire coronary circulation that arises from the right coronary cusp. We present the case of a 55-year-old female who presented with the complaints of chest pain on exertion with positive stress test. An invasive angiogram revealed all the three coronary arteries originating from the right coronary cusp.
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