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   Table of Contents - Current issue
Coverpage
July-September 2019
Volume 8 | Issue 3
Page Nos. 115-152

Online since Wednesday, July 31, 2019

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EDITORíS PAGE  

Editor's Page July 2019 p. 115
Ravi R Kasliwal
DOI:10.4103/2250-3528.263844  
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ORIGINAL ARTICLES Top

Ultrasonographic assessment of subclinical atherosclerosis in smokers aged <40 years p. 117
Taruna Singh, Ritu Karoli, Sachin Khanduri, Nikhil Gupta, Prem Shanker Singh
DOI:10.4103/JCPC.JCPC_51_18  
Introduction: Cigarette smoking is a well-known risk factor for developing coronary artery disease. Ultrasonography is an excellent tool which is noninvasive and cheap, might be utilized as a cost effective method to screen the high risk population. There are many surrogate markers of atherosclerosis which can be assessed with the help of ultrasonography such as carotid intima media thickness (CIMT), Flow mediated vasodilatation (FMD) and Ankle brachial index (ABI). Aim of our study was to assess atherosclerotic risk markers non invasively using ultrasonography as a tool in smokers less than forty years. Materials and Methods: All subjects amongst patient's attendants or hospital staff aged more than 18 years and less than 40 years with history of smoking were enrolled as cases and age, gender and BMI matched non smokers were defined as controls. Anthropometric and biochemical parameters were recorded and CIMT, FMD and ABI were assessed. Results: Amongst smokers, average duration of smoking was 8.5±2.5 years. They had higher systolic and diastolic blood pressures than controls. The smokers had higher total cholesterol, triglycerides and LDL. Smokers presented with higher values of CIMT and lower values of FMD and ABI than non-smoker controls. Conclusion: Subclinical markers are present even in young smokers who are less than forty years. Ultrasonography is a good modality to assess the surrogate markers of subclinical atherosclerosis.
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Skin manifestations of peripheral artery disease: Prevalence and diagnostic utility p. 121
Ejiroghene Martha Umuerri
DOI:10.4103/JCPC.JCPC_11_19  
Introduction: Peripheral artery disease (PAD) is a common but underdiagnosed arm of the cardiovascular triad. Reliance on the presence of skin manifestations of chronic lower limb ischemia may result in clinical inertia in the diagnosis of PAD. Objective: Literature on the skin manifestations of PAD is limited. This paper aims to determine the prevalence and diagnostic value of skin manifestations of PAD. Methods: This was a cross-sectional descriptive study of consecutive adults with hypertension and diabetes attending the consultant medical outpatient department, University of Benin Teaching Hospital, Benin-city, Nigeria. Physical examination of the skin of the lower limbs for features suggestive of PAD and ankle-brachial index (ABI) were performed. A diagnosis of PAD was made if ABI < 0.9. Results: Of the 541 participants, 115 (21.3%) had skin changes suggestive of PAD, and 182 (33.6%) had low ABI < 0.9. Among participants with PAD, 65 (35.7%) had skin manifestations suggestive of PAD. The association between PAD and skin manifestations suggestive of PAD was significant (χ2 = 34.248,P < 0.001). The sensitivity, specificity, positive, and negative predictive values of the presence of skin manifestations as a diagnostic tool for PAD compared with low ABI was 35.7%, 86.1%, 56.5%, and 72.5%, respectively. Conclusion: Among participants with PAD, the prevalence of skin manifestations of suggestive of PAD was 35.7%. Reliance on the presence of skin changes for diagnosis of PAD may result in missed or delayed diagnosis because of its low sensitivity and positive predictive value.
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Two-dimensional speckle tracking echocardiography as a predictor of significant coronary artery stenosis in female patients with effort angina who are treadmill test positive: An angiographic correlation p. 126
Suresh Madhavan, Jayaprasad Narayanapillai, Jose Sebastian Paikada, K Jayaprakash, VL Jayaprakash
DOI:10.4103/JCPC.JCPC_6_19  
Aim: This study aims to determine the diagnostic accuracy of two-dimensional speckle tracking echocardiography (2DSTE) in predicting the angiographic severity of coronary artery disease (CAD) in female patients with effort angina who are treadmill test (TMT) positive and for risk stratification, to decide on the need for invasive management. Materials and Methods: A total of 1000 female patients with effort angina who are TMT positive and are recommended for coronary angiogram based on standard treatment guidelines are subjected to 2DSTE and global longitudinal strain (GLS) score is obtained. Angiographic correlation was sought between lesion severity and GLS score. Results: The average age of patients included in the study is 55 years. Average Duke Score is −2. Average GLS score −15. 56% of patients had a significant coronary lesion of >70% in at least one of the coronary arteries. The optimum cutoff GLS score to predict significant coronary lesion is −17.5. Conclusion: GLS by 2DSTE correlates well with angiographic severity of CAD and can predict significant coronary lesion with a sensitivity of 94% and specificity of 76% in female patients with effort angina. Thus, GLS by 2DSTE can be used as a noninvasive screening test in predicting significant coronary artery stenosis and can complement TMT in risk stratification and in selecting patients for coronary angiogram.
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Clinical profile, complications, and quality of life in patients undergoing automatic implantable cardioverter-defibrillator implantation in a tertiary care hospital of North India p. 131
Suraj Khanal, Piyush Pathak, Ajay Bahl
DOI:10.4103/JCPC.JCPC_17_19  
Background: Despite better understanding of various aspects of Sudden Cardiac Death (SCD), mortality from the disease still remains very high. Coronary artery disease (CAD) is the most common cause of SCD in all parts of India. The American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society (ACC/AHA/HRS) guidelines recommend the use of implantable cardioverter-defibrillator (ICD) therapy as a primary prevention. Aim: The aim of our study was to assess the clinical and demographic profile, complications and quality of life (QOL) of patients undergoing ICD implantation as compared to controls at a tertiary care center of north India. Method: A total of 64 patients with mean age 54.39± 11.54 years were implanted ICD during a period of one year. During the same period, 51 patients in which ICD could not be implanted due to financial reasons were included as controls. Of the 64 patients, 43 (67.19%) patients received ICD for primary prevention whereas 21 (32.81%) patients received it for secondary prevention. Result: At a follow up of 6 months, mortality was 4 (7.84%) in ICD group as compared to 8 (15.69%) in control group. Mortality from SCD in ICD and control group was 2 and 5 respectively (P = 0.23). ICD interrogation data was collected for 37 cases of which 19 (51.35%) patients had records of ventricular tachycardia (VT) and 3 (8.1%) patients had records of ventricular fibrillation (VF) respectively. Total VT/VF episodes recorded in primary prevention group were 10, whereas 12 in secondary prevention group. Success rate of ATP and ICD shocks were 30.23% and 95.92% respectively. All 47 VT/VF episodes were terminated by shocks. Conclusion: The QOL of patients undergoing ICD implant was better in the domains of social relationship and environment though the difference was not significant statistically. Overall, there was a significant reduction in SCD mortality and no deterioration in QOL.
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CASE REPORTS Top

A case report of Mycobacterium abscessus infective endocarditis in rheumatic heart disease p. 136
Rakesh Sharma, Saurabh Mehrotra
DOI:10.4103/JCPC.JCPC_4_19  
Infective endocarditis owing to Mycobacterium abscessus infection is extremely rare and is usually seen as prosthetic valve endocarditis. A 34-year-old male with rheumatic heart disease presented to us with undiagnosed pyrexia. He had vegetation on anterior mitral leaflet, and his blood cultures grew M. abscessus. The patient responded transiently to amikacin, clarithromycin, and minocycline. His course was complicated by recurrent cardioembolic strokes. The patient was not willing for surgery and had downhill course with persistent fever and heart failure leading to death. Native valve M. abscessus endocarditis is extremely rare. Early surgical intervention is recommended along with intravenous antibiotics, but the course is usually fatal.
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Left atrial tumor, complete heart block, and triple-vessel coronary artery disease: A very rare case report p. 139
Suraj Khanal, CR Pruthvi, Kewal Kanabar, Dinakar Bootla, Krishna Prasad
DOI:10.4103/JCPC.JCPC_21_19  
Primary cardiac tumor (PCT) is a very rare clinical presentation, with myxoma representing the most common type. Majority of the myxomas are found in the left atrium along with a female dominance. This report describes a very rare case of a 67-year-old woman presenting with PCT, complete heart block, and triple-vessel coronary artery disease. The patient was planned to undergo a coronary artery bypass grafting (CABG) along with concomitant tumor excision and epicardial pacemaker insertion. Since the patient and her family did not consent for the CABG, transvenous permanent pacemaker insertion was performed with an advice to follow-up for CABG and tumor excision.
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LANDMARK TRIALS Top

The challenge of optimal evaluation of low and intermediate pretest probability stable chest pain: Insights from recent randomized clinical trials p. 142
Satyanarayana Upadhyayula, Ravi R Kasliwal
DOI:10.4103/JCPC.JCPC_25_19  
Given the wide knowledge gaps in the evaluation of patients with low and intermediate pretest probability stable chest pain and the ubiquity of noninvasive imaging the below mentioned largest, most comprehensive and timely randomized clinical trials (RCTs), provide valuable insights into risk stratification, diagnosis, management, prognostication, and outcomes. Rapid clinical assessment of patients with low/intermediate-risk stable chest pain can identify high-risk individuals. However, about 33% of patients labeled as noncardiac chest pain die from cardiovascular disease or develop acute coronary syndrome (ACS) during 5 years' follow-up. About 1.5% of patients with ACS are missed even after extensive testing leading to potential medical, legal, and psychological sequelae. As a result, clinicians have a low threshold to admit even low risk patients for prolonged expensive observation and testing leading to unnecessary admissions, false-positive test results, and unnecessary invasive downstream investigations. This scenario gives a clarion call for improving the diagnostic accuracy, risk stratification, and prognostication in low/intermediate-risk stable chest pain patients. The most common clinical scenario most of us come across is a middle-aged patient with new onset/recurrent low/intermediate-risk stable chest pain attending the emergency department (ED). Issues which are head scratching and mindboggling about this scenario is the ability of the clinician to optimally utilize the appropriate tests from the available armamentarium of functional, anatomical and biochemical diagnostic strategies (exercise electrocardiogram, stress echocardiogram, nuclear stress test, computed tomographic coronary angiography, and circulating biomarkers) to arrive at accurate diagnosis for flawless management. One of the main purposes of the article is to avoid underdiagnosis, overdiagnosis, and misdiagnosis in patients with stable chest pain. We have cherry-picked four large recent landmark RCTs to help the clinician to sharpen his clinical skills, maximize diagnostic accuracy, speed up emergent interventions, assist in surgical planning, and optimize medical therapies. Unfortunately, physical examination for determining the cause of low/intermediate-risk stable chest pain is neither sensitive nor specific to identify obstructive coronary artery disease (CAD). The four recent RCTs are as follows: (1) PROspective Multicenter Imaging Study for Evaluation of Chest Pain trial; (2) Scottish COmputed Tomography of the History, Electrocardiogram, Age, Risk factors, and initial Troponin Trial; (3) Impact on Management of the HEART Risk Score in Chest Pain Patients trial; and (4) Randomized Investigation of Chest Pain Diagnostic Strategies, Shared Decision-Making in the ED: Chest Pain Choice trial.
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