Search

Lipid disorders play a major pathogenic role in the development of coronary artery disease, which is the major cause of mortality worldwide. In this review, the authors discuss the role of various lipid abnormalities in the causation of coronary artery disease and also highlight the ways to manage them. The roles of a healthy lifestyle and dietary patterns have been emphasized in this regard besides the significant role of drug treatment, which mostly revolves around the statin therapy.

Acute coronary syndromes form the most important diagnosis of any cardiac ICU, closely followed by acute decompensated heart failure. Anti-platelet therapy is the backbone of treatment for acute coronary syndromes. In addition to aspirin, P2Y12 receptor inhibitors play a significant role in the management of these critically ill patients. Several studies have been published over the years giving us insights on how and when to use these drugs. Intravenous anti-platelet therapy has taken a back seat after the new generation P2Y12 inhibitors have come into vogue. However, cangrelor, which acts within minutes, has made a niche for itself especially in patients going for urgent PCI. This chapter aims to discuss all these aspects.

Primary angioplasty has become the standard of care for the treatment of acute myocardial infarction (AMI) in the last three decades. However, there remain contentious issues that are constantly being reviewed and discussed. This chapter deals with some of these by summarising evidence and offering a perspective on some of these issues.

Coronavirus disease 2019 (COVID-19) has caused a devastating global pandemic and continues to overwhelm the health-care facilities and shatter the economies of countries worldwide. Although it primarily affects the lungs, it shares a strong interplay with the cardiovascular system. The presence of underlying cardiovascular disease and its risk factors (diabetes, hypertension) predispose the patients to increased severity and mortality associated with COVID-19. On the other hand, COVID-19 itself leads to various cardiovascular complications, which increase its associated morbidity and mortality in affected patients. It is, therefore, prudent to review the rapidly evolving data in this field and understand the mechanisms behind the cardiovascular involvement of this lethal disease.

The burden of atherosclerotic cardiovascular (CV) disease is alarmingly high and increasing in our country. Dyslipidemia is one of the major modifiable risk factors, and INTERHEART study showed that dyslipidemia had the highest population attributable risk for myocardial infarction. In the management of dyslipidemia, low-density lipoprotein cholesterol (LDL-C) is the primary therapeutic target. In addition to therapeutic lifestyle changes, statins and ezetimibe effectively lower LDL-C and consequently improve CV outcomes. However, there are situations where these drugs fall short of achieving the target or they may not be well tolerated.

Heart failure is a common clinical syndrome and a global health priority. The burden of heart failure is increasing at an alarming rate worldwide as well as in India. Heart failure not only increases the risk of mortality, morbidity and worsens the patient's quality of life, but also puts a huge burden on the overall healthcare system. The management of heart failure has evolved over the years with the advent of new drugs and devices. This document has been developed with an objective to provide standard management guidance and simple heart failure algorithms to aid Indian clinicians in their daily practice. It would also inform the clinicians on the latest evidence in heart failure and provide guidance to recognize and diagnose chronic heart failure early and optimize management.

Several classes of antihypertensive agents have been in clinical use, including diuretics, α-blockers, β-blockers, angiotensin converting enzyme (ACE) inhibitors, angiotensin II type 1 receptor blockers (ARB), and organic calcium channel blockers (CCBs). All these drugs are being currently used in the treatment of Hypertension & various disease conditions of the heart either alone or in combination. Cilnidipine is a new antihypertensive drug distinguished from other L-type Ca2+ channel blockers or even other antihypertensives, which will be useful for selection of antihypertensive drugs according to the pathophysiological condition of a patient.

Platelets play central role in thrombotic events in acute coronary syndromes (ACS) and during percutaneous coronary interventions (PCI). Platelet activation occurs through various mechanisms and all culminate in expression of the surface GP IIb-IIIa receptors which mediate their aggregation and thrombosis. Glycoprotein IIb-IIIa inhibitors (GPI) remain the most powerful antiplatelet agents by inhibiting this final common pathway of platelet activation. The role of GPI in the treatment of coronary ischemic events has evolved through the past 20 years. Given their potent antiplatelet activity and consistent anti-ischemic benefit in major trials, they were an integral part of antiplatelet – antithrombin portfolio in the treatment of ACS and during PCI over a decade. However, the advent of stents and thienopyridine ticlopidine and later clopidogrel made periprocedural ischemic complications less common and GPI had slowly lost its importance in routine low-risk PCI. Though GPI reduced periprocedural ischemic complications, increased bleeding events continued to be a major problem. In the recent years, bleeding has increasingly been recognized as a major determinant of clinical outcomes both with ACS and PCI. Recently, the availability of bivalirudin as an equally effective and safer periprocedural anticoagulant, heparin and GPI have slowly been pushed to second place over the entire spectrum of coronary interventions. The newer antiplatelets which provide rapid and more consistent antiplatelet action further reduced the role of GPI to a very small subset of patients where ischemic risk far exceeds the thrombotic risk.1–3 This editorial briefly evaluates the current role of GPI in the background of recent major studies with newer antiplatelets and bivalirudin.

Although, there have been significant advances in the management of heart failure (HF), one of the important problems faced by the clinician treating these patients is the significant recurrence of HF with consequent need for readmission. In this article, a discussion is made about the role of natriuretic peptides for monitoring long-term treatment of these patients and different trials done in this regard.

Purpose Cellular cardiomyoplasty is a potential therapeutic approach to preventing left ventricular remodeling after myocardial infarction and has shown encouraging results such as induction of neoangiogenesis and functional improvement of diseased hearts. We report the results of a pilot study on progenitor cells in five patients with acute myocardial infarction (AMI). Materials and Methods Patients with single-vessel disease who had their first episode of myocardial infarction and underwent angioplasty after 48 h (an average of 17 days following myocardial infarction) were included in the study. Mononuclear cells (MNCs) (1×10 7 ) were isolated by Ficoll Hypaque method from 60 ml of bone marrow (BM) obtained from the iliac crest of 5 patients (aspiration was performed under local anesthesia). The mean CD34 count was 1–4%. After confirming the patency of the affected vessel postangioplasty, cellular concentrate was injected into the affected artery in 3-ml boluses (three to four injections), with intermittent occlusion. Results The mean age of all five male patients was 48.6+13.7 years. At 1 year, five patients were asymptomatic, and one had Class II dyspnea on exertion. The results of an echocardiogram performed at 6 months showed an improvement in ejection fraction (EF) from 35.3% to 43.13% and in fractional shortening from 24.75% to 28.33%. End-systolic volume decreased from 115.5 to 92.3 ml, end-diastolic volume decreased from 177.5 to 170 ml, and end-systolic dimensions also decreased from 4.26 to 4 mm, demonstrating positive left ventricular remodeling. Repeat echocardiogram at 1 year showed persistent improvement in EF. No adverse events were noted either before or after the procedure. Conclusion The injection of autologous BM MNCs is a safe and efficacious therapy following early revascularization in AMI patients.

The American College of Cardiology (ACC) and American Heart Association (AHA), in collaboration with the National Heart, Lung and Blood Institute (NHLBI), have recently released a set of four important guideline documents that provide recommendations for blood cholesterol management in adults, management of overweight and obesity, life-style modifications to reduce cardiovascular (CV) risk and the approach to CV risk stratification.1–4 Of these, the cholesterol guidelines were perhaps the most awaited, given the significant improvements that have taken place in our understanding of lipid management over the past decade, since the previous NHLBI guidelines (adult treatment panel III) were last updated.5 However, the new recommendations depart heavily from the prevailing concepts in lipid management and in this process have sparked off an intense debate about their rationale and practicality. Therefore, a critical review of these guidelines, along with the related document on CV risk stratification, is warranted before we embark on the task to incorporate them in to our clinical practice.

A 7-month-old girl with failure to thrive, who, on clinical and diagnostic evaluation [echocardiography & CT angiography] to rule out congenital heart disease, revealed a rare vascular anomaly called systemic artery to pulmonary venous fistula. In our case, there was dual abnormal supply to the entire left lung as1 anomalous supply by normal systemic artery [internal mammary artery]2 and an aberrant feeder vessel from the abdominal aorta. Left Lung had normal bronchial connections and normal pulmonary vasculature. The fistula drained through the pulmonary veins to the left atrium leading to ‘left–left shunt’. Percutaneous intervention in two stages was performed using Amplatzer vascular plugs and coil embolization to close them successfully. The patient gained significant weight in follow up with other normal developmental and mental milestones.

This report documents clinical and hemodynamic benefits of balloon mitral valvuloplasty (BMV) using a bifoil balloon catheter from a single center in 415 consecutive cases of rheumatic mitral stenosis (MS). The procedure was successful in 396 (95.2%) patients, with an increase in mitral valve area (MVA) from 0.82 ± 0.35 cm2 to 2.21 ± 0.24 cm2 (P < 0.001). There were 2 (0.48%) in-hospital deaths, and 6 (1.44%) patients developed acute mitral regurgitation. The procedural and fluroscopy time was reduced significantly from 52 ± 11 and 38 ± 6 min to 33 ± 7 and 19 ± 5 min, respectively, after modifications of technique in our last 326 cases. The bifoil balloon catheter technique is safe and effective, and provides excellent hemodynamic benefits which are sustained at long-term follow-up. This technique should be considered as an addition to the existing armamentarium of interventional cardiologists performing mitral balloon valvuloplasty. Cathet. Cardiovasc. Diagn. 43:43–47, 1998. © 1998 Wiley-Liss, Inc.

There have been considerable advances in the management of acute coronary syndromes in the recent past. There are three risk scoring systems used for prognosticating these patients. An attempt is made in this article to discuss the pros and cons of the different risk scoring systems and their clinical utility.

Hypoparathyroidism is associated with chronic hypocalcaemia which can have a variety of manifestations including cardiovascular changes. We describe here a case of primary hypoparathyroidism associated with systolic dysfunction of left ventricle presenting as a dilated cardiomyopathy in addition to other manifestations.

To study the safety and efficacy of covered stents in angioplasty of saphenous vein grafts a retrospective study was carried out among 12 consecutive cases admitted at the cardiology unit of Nizam's Institute of Medical Sciences during last 3 years. Angioplasty of saphenous vein grafts is a challenging task due to the different nature of the disease in vein grafts compared to the native coronary arteries. The lesions in vein grafts are more often diffuse and have considerable loose atherothrombotic material that is prone for distal embolisation, resulting in slow flow/no reflow and myocardial damage. Use of covered stents for saphenous vein grafts appears to be feasible and safe.