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In acute coronary syndrome (ACS) patients the focus is on major conventional risk factors - CRF [diabetes, hypertension, elevated low-density cholesterol (LDL-C) and smoking] whereas others - specific metabolic risk factors - MRF [high-density lipoprotein cholesterol (HDL-C), body-mass index (BMI), waist-hip ratio (WHR), and triglycerides, and HbA1c get less attention.This is a prospective case-control observational study from 15 tertiary care hospitals in India. CRF and MRF in patients presenting with first incidence of ACS (n = 2153) were compared with matched controls (n = 1210).Propensity score matching (PSM) yielded 1193 cases and matched 1210 controls. Risk factor prevalence in cases vs. controls were CRF: hypertension - 39.4% vs 16.4% (p 0.0001), diabetes - 42.6% vs 12.7% (p 0.0001), smoking - 28.3% vs 9.3% (p 0.0001) and elevated LDL-C - 70.2% vs 57.9% (p 0.0001). MRF: High BMI - 54.7% vs 55.1% (p = 0.84), increased waist: hip ratio 79.5% vs 63.6% (p 0.0001), high HbA1c - 37.8% vs 14.9% (p 0.0001), low HDL-C - 56.2% vs 42.8% (p 0.0001) and elevated triglycerides - 49.7% vs 44.2% (p = 0.007). Adjusted Odds ratios by multivariate analysis were CRF: hypertension - 2.3 (p 0.001), diabetes - 4.7 (p 0.001), high LDL-C - 3.3 (p 0.001) and smoking- 6.3 (p 0.001). MRF: High waist: hip ratio - 2.4 (p 0.001) high HbA1c - 3.2 (p 0.001), low HDL-C 2.2 (p 0.001) and elevated triglycerides - 0.878 p = 0.17.In India, the risk of ACS conferred by specific metabolic risk factors (High waist: hip ratio, Low HDL-C and High HbA1c) is comparable to that caused by CRF.

Objective: This is a prospective study of patients with LVEF ≤40%, with the objective of correlating CV events to LGE detected and quantified by CMRI. Methods: Heart Failure (HF) patients with LVEF 30% the corresponding figures were 9 (22.5%) vs 1 (2.8%) and 15 vs 1 respectively (p = 0.02). Conclusion: Demonstration of significant LGE by CMRI indicates high risk occurrence of CV events (CV hospitalization, appropriate shocks and total mortality) in NIDCM & ICM patients with LVEF

Electrical storm (ES) is a life threatening clinical situation. Though a few clinical pointers exist, the occurrence of ES in a patient with remote myocardial infarction (MI) is generally unpredictable. Genetic markers for this entity have not been studied. In the present study, we carried out genetic screening in patients with remote myocardial infarction presenting with ES by next generation sequencing and identified 25 rare variants in 19 genes predominantly in RYR2, SCN5A, KCNJ11, KCNE1 and KCNH2, CACNA1B, CACNA1C, CACNA1D and desmosomal genes - DSP and DSG2 that could potentially be implicated in electrical storm. These genes have been previously reported to be associated with inherited syndromes of Sudden Cardiac Death. The present study suggests that the genetic architecture in patients with remote MI and ES of unstable ventricular tachycardia may be similar to that of Ion channelopathies. Identification of these variants may identify post MI patients who are predisposed to develop electrical storm and help in risk stratification.

Introduction: There is high incidence of SCD in the early period following STEMI. We compared the temporal patterns and predictors of SCD amongst patients with LVEF ≤35% and LVEF >35%. Methods: Data from STEMI patients was prospectively collected. SCD cases formed the study cohort and were categorized into 2 groups based on their LV function. Results: There were 929 patients (mean age 55 ± 17 years) with a follow up of 41 ± 16 months. 154 pts (16.6%) had LVEF ≤35% (Group A, LVEF-29.9% ± 6%) and 775 pts had LVEF >35% (Group B, LVEF – 49% ± 14%). The two groups were similar with respect to sex distribution, age, prevalence of hypertension, and mean period of presentation. They differed in incidence of anterior wall MI (77.2% vs 55%), reperfusion (69% vs. 75%), prevalence of diabetes (50.6% vs 42%), and medication non-compliance (34% vs. 13%). The total SCD was 78 [Gp A, 25 (16.2%); Gp B, 53 (6.8%); p

Sudden Cardiac death (SCD) is a major clinical event causing adverse impact on global economy. This review summarizes the available epidemiological data on SCD from different parts of the world. It contrasts the Indian and global perception on the issues influencing data collection, burden of SCD and sudden deaths occurring following Myocardial Infarction. The differences in data from India and rest of the world are highlighted.

Intra-cardiac extension of tumour thrombus of follicular carcinoma of thyroid is uncommon. We report a case of advanced thyroid carcinoma where tumour thrombus was well profiled with CT scan and transesophageal echo images and extension was noted from SVC into right atrium, with clinical features of superior vena cava syndrome. The clinical significance of the “ring sign” is discussed.

Radiofrequency ablation is a therapeutic option for recurrent ventricular tachycardia (VT) in both ischaemic and non-ischaemic subsets. Usually this is attempted by mapping endocardially; however, in some situations epicardial approach may be needed to access the VT circuit. We report two cases in which epicardial approach was used to successfully ablate the VT, when endocardial ablation was ineffective.

Atrial fibrillation (AF) is the most common of the serious cardiac rhythm disturbances and is responsible for substantial morbidity and mortality. Available drug therapy for AF has modest efficacy and is associated with the risk of life-threatening pro-arrhythmic complications. Dronedarone is a newer therapeutic agent with a structural resemblance to amiodarone and a better side effect profile. It is a multichannel blocker with antiadrenergic properties and has been evaluated in both rate and rhythm control strategies in the management of AF. In this review, we discuss the current role of dronedarone in the contemporary management of AF.

Introduction Epidemiology of sudden cardiac death (SCD) in India is understudied. Methods We assessed proportion of SCD among total mortality in a population in Southern India using a staged, questionnaire-based kindred-wide approach. Detailed questionnaires (DQs) were completed by medical trainees from 8 medical colleges. Preliminary questionnaires evaluated total deaths in the kindred of a respondent. Deaths due to obvious non-cardiac causes were excluded. DQs were completed for the remaining deaths and categorized using a three-member adjudication system. Results A total population of 22,724 was evaluated by 478 respondents, (278 M and 200 F). Out of a total of 2185 deaths, 1691 (77.4%) were recallable. A total of 173 (10.3%; 128 M and 45 F; mean age — 60.8±14years) deaths were adjudicated as SCD. Of these, 82 (47.3%) were ≤60years of age. Prior MI, LV dysfunction and prior aborted SCD were found in 33.5%, 22.5% and 5.7% respectively. Coronary artery disease (CAD) was observed in 66 (38%) and acute myocardial infarction documented in 30 (17%). At least 1 of 3 CAD risk factors — hypertension, diabetes, or smoking was observed in 80.6%. Proportion of subjects with at least one risk factor for CAD were similar in the age groups above and below 50years (67.6% vs. 81.7%, p=0.065). Conclusions SCD contributed to 10.3% of overall mortality in this population from Southern India. On an average, SCD cases were 5–8years younger compared to populations reported in the western hemisphere, with a high prevalence of major risk factors for CAD.

Successful Induction With Progesterone and Radiofrequency Ablation. Verapamil-sensitive idiopathic left ventricular tachycardia in pregnancy is a rare diagnosis. We report a case of a primigravida female with new onset fascicular ventricular tachycardia that was managed with oral verapamil. Post pregnancy, the tachycardia was not inducible in the electrophysioplogy lab. Progesterone, a hormone associated with pregnant state, was used to successfully induce the tachycardia, which was ablated. This is the first reported case of an idiopathic ventricular tachycardia associated with pregnancy that could be induced later by recreating the hormonal milieu associated with pregnant state.

A 26 year old lady with structurally normal heart underwent electrophysiological study (EPS) and radiofrequency ablation for recurrent supraventricular tachycardia (SVT). EPS revealed orthodromic atrioventricular reciprocating tachycardia (AVRT) involving a left sided concealed pathway. This report demonstrates the clues provided by spontaneous bundle branch aberrancy during SVT in predicting the mechanism of tachycardia.

Ventricular tachycardia arising from the right ventricular outflow tract is one of the common forms of idiopathic ventricular tachycardia. One of the major challenges in mapping and ablation of idiopathic right ventricular outflow tract ventricular tachycardia is noninducibility. Direct stimulation of sympathetic nerves innervating the right ventricular outflow may provide an alternative approach to induce arrhythmia. We report a case of idiopathic right ventricular outflow tract tachycardia in whom tachycardia was noninducible by aggressive conventional stimulation protocols, which was induced by high-frequency stimulation of proximal pulmonary artery and was successfully ablated.

With increasing population of coronary artery disease and even higher prevalence of risk factors fueling it, the enormity of the problem of sudden cardiac death (SCD) has begun to be perceived in the developing countries like India. The alarming increase in the sudden deaths in our country mandates focused attention of cardiologists and physicians towards this problem. It is imperative for the practicing clinician to have a clear understanding of the scope of this problem and be conversant with the available and evolving therapies in this area. The current issue of this journal has been conceptualized to achieve this objective. The presentation of this special supplement on SCD to the readers is a great moment for the editorial team of the IHJ. This endeavor intends to focus on the catastrophic clinical problem of SCD and serve as a useful resource for the cardiologists to access balanced scientific information for practice. This publication is a conglomeration of articles written by authors from different parts of the world, summarizing the current developments in this field and presenting their authoritative insights of the issues involved in the management of SCD. The content has been designed to present a holistic picture of the problem and at the same time allow a comprehensive elaboration of each component of the management. It is well recognized that despite being a global phenomenon, the issues involved in the management of SCD are not uniform and hence there can be no universal solutions. The first ICD implant in 1980 was a major landmark in the history of SCD and this therapy remains the only proven tool to influence survival outcomes of high risk patients. The ability of these devices in preventing sudden deaths is established beyond doubt and is the present standard of care, but clinical wisdom arising from experience of last 2 decades has taught us that defibrillators alone will not suffice in reducing the burden of SCD. There are numerous strategies that can influence the SCD figures but have not been utilized to their full potential. These exist in the realms of preventive cardiology, management of acute coronary syndromes, fine tuning of indications for ICD, appropriate device programming, genomics for risk stratification, ablation of ventricular arrhythmias and neural modification of the substrate. A conscious effort has been made to include the contribution of each of these components. This supplement is privileged to have Prof Mark E Josephson, the father of clinical electrophysiology as the special guest editor. His immense and passionate continued contribution since 1970's as a teacher, clinician and researcher has been a major factor in the evolution of this area. I gratefully acknowledge his involvement in the editorial process and his mentorship in bringing out this supplement. The authors and the editorial team who have worked diligently to bring out this issue in a given time frame deserve commendation. We are hopeful that this supplement would be a valuable resource in understanding and managing the problem of SCD, thus stimulating further research in this area.

Recently, a "hybrid therapy" strategy has been used for successful rhythm control in persistent and permanent atrial fibrillation (AF) patients. The impact of this strategy on arrhythmia recurrences and subsequent AF related hospitalizations are unknown.Forty-seven patients (66 +/- 10 years) with symptomatic persistent (N = 26) or permanent (N = 21) AF underwent "hybrid therapy" and were followed for 24 +/- 15 months. All patients underwent linear right atrial ablation and implantation of pacemaker or atrioventricular defibrillator (AVICD) capable of continuous right atrial pacing with previously ineffective antiarrhythmic drug therapy for AF prevention. Device data-logs were used to monitor AF recurrences.Freedom from permanent AF was 97, 90, and 83% at 6 months, 2 and 3 years, respectively. Sixteen patients (34%) had no recurrent AF after "hybrid therapy." Thirty-one patients (66%) had a total of 55 AF recurrences (mean 1.8 per patient). There was a significant reduction in the mean AF related hospitalizations (from 3.5 +/- 2.8 to 0.57 +/- 1.1 per patient), cardioversion hospitalizations (from 3.5 +/- 2.2 to 0.38 +/- 0.5 per patient) and DC cardioversions (from 3.1 +/- 3.9 to 0.7 +/- 0.5 per patient) after hybrid therapy compared to event rates before therapy (p0.05 for all).Rhythm control improves significantly with hybrid therapy in patients with persistent and permanent AF refractory to drugs and cardioversion therapy. This improvement is associated with a significant reduction in AF related hospitalizations and need for cardioversion therapy.

The following tracings were obtained in the EP lab during a SVT study. Fig. 1 shows a 12 lead recording of ECG of a patient showing termination of supraventricular tachycardia (SVT). The first 8 beats are narrow QRS short RP tachycardia e with the differential diagnosis of AVNRT or AVRT or less commonly atrial tachycardia. This train is followed by a single ventricular premature beat (VPB) delivered from a catheter in right ventricle, which terminates the tachycardia. On the 12 lead ECG, the single paced beat is seen as a fusion beat as it has some resemblance to a paced ventricular beat and some to the SVT beat. The fusion can result only if both the paced and SVT beats have excited the HisePurkinje system and confirms that the paced beat is His refractory. Fig. 2 shows the corresponding intracardiac recordings of the same event. The first 3 complexes are the SVT beats, where the atrial activation of distal coronary sinus appears to precede that of theHis andproximal coronary sinus suggesting possible involvement of a left sided accessory pathway. The single VPB (4th beat) is delivered during the SVT coinciding with the His deflection on the His catheter and this terminates the tachycardia. Subsequent 2 beats are sinus. Delivering of a His synchronous or

Collateral damage to esophagus with ablative therapies for atrial fibrillation (AF) remains a major concern with percutaneous catheter based therapies. Endoscopically documented thermal injuries to the esophageal mucosa such as ulcerations or hemorrhages are seen in a significant percentage of patients undergoing AF ablation. [1,2] The reporting of occurrence of a fatal left atrio-oesophageal fistula (LAEF) with circumferential pulmonary vein isolation in 2004, led to an explosion of innovations and strategies to protect the esophagus during transmural posterior left atrial lesions. The use of low energy lesions in the posterior wall, introduction of a temperature probe in the esophagus, use of proton pump inhibitors, pre and intra procedure imaging and alternative sources of ablation have all contributed to this endeavor. Clinical applications of each of these strategies have shown that none of them are infallible in completely attenuating the vulnerability of esophagus during pulmonary vein isolation.

The arena of cardiovascular diseases in the world has consistently been associated with paucity of contribution of data from India. There are currently serious and focused attempts at acquiring and analyzing global data on heart rhythm disorders, particularly the problems of heart failure, atrial fibrillation and sudden death. The compilation of global statistics is bound to be incomplete without representation of figures and trends from a country of over a billion constituting 1/6th of the world population. The challenges associated with data collection are real and result from unique situations prevailing in this part of the world [1,2]. There is a serious impediment to assessment of mortality figures as there is a gross under registration of deaths with only a small percentage of them being medically certified. Even when certified there is uncertainty in the reliability of death certificates due to inconsistent physician attribution of causes, absence of uniform codes and standardization in the data entered in the certificates. The information obtained from first responders is limited as there are no systemwide emergency services and is accessible to small minority of the population in select urban communities and autopsies in non-medico legal cases are practically nonexistent. Furthermore, for the majority of the population including patients with cardiovascular diseases periodic physician visits are infrequent and out patient medical records are seldom available or feasible for analysis. Incidence and prevalence of episodic clinical events like atrial fibrillation are hence difficult to obtain. Absence of adoption of uniform and standardized coding by hospitals for classification of diseases imposes restriction on identification of morbidities like heart failure. Contact details of patients not infrequently are erroneous, not updated or incomplete making it difficult for investigators to collect follow up data.