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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

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.

Ventricular tachycardia (VT) occurring late after myocardial infarction is often due to reentry circuit in the peri-infarct zone. The circuit is usually located in the sub-endocardium, though subepicardial substrates are known. Activation mapping during VT to identify target regions for ablation can be difficult if VT is non inducible or poorly tolerated. In the latter, a substrate based approach of mapping during sinus rhythm in conjunction with pace mapping helps to define the reentry circuit and select target sites for ablation in majority of patients with hemodynamically unstable VT. Percutaneous epicardial catheter ablation has been attempted as an approach where ablation by a conventional endocardial access has been unsuccessful. We report a case of post myocardial infarction scar VT which could be successfully ablated with a substrate based approach from the epicardial aspect.

Drug refractory ventricular tachycardia (VT) occurring as a storm after acute myocardial infarction has grave prognosis. We report a case of a middle-aged lady who presented with drug refractory VT that lead to persistent electrical storm two weeks after an anterior wall myocardial infarction. She underwent a successful catheter ablation of VT followed a few days later by implantation of an AICD. Catheter ablation of the VT could control the persistent electrical storm and the patient was free from a recurrence of VT at three month follow up.

PURPOSE OF REVIEW Present generation implantable cardioverter-defibrillators (ICD) have become a proven primary therapeutic option in management of symptomatic ventricular arrhythmias and are now being increasingly used for primary prevention. The addition of biventricular pacing and atrial defibrillation to these devices has had an impact on the management of several new patient populations. The widespread application of these devices requires precise knowledge of their potential benefits and factors that could adversely affect device function. RECENT FINDINGS ICD therapy has improved the survival of coronary disease patients with left ventricular dysfunction by reducing sudden death rate. In congestive heart failure patients, ICD therapy and biventricular pacing improves heart failure status thus improving overall survival and quality of life. Atrial defibrillation can establish rhythm control in drug refractory atrial fibrillation usually in a "hybrid therapy" prescription. SUMMARY Implantable cardioverter defibrillators have proven to be invaluable in the primary and secondary prevention of sudden cardiac death. Incorporation of new technology in these devices has resulted in expanded indications that improve survival and quality of life of new patient populations.

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.

Uncontrolled Hypertension(HTN) accounts for significant morbidity and mortality. Despite newer drugs hypertension remains uncontrolled in approximately a third of the patients. The overall prevalence of hypertension in adults20 years was 30% in men and 34% in women in 2002. We report 2 patients with uncontrolled hypertension in whom Renal denervation therapy improved the control of blood pressure

Assessment of ventricular dyssynchrony by Tissue Doppler Imaging (TDI) is being increasingly used in patient selection for Cardiac Resynchronization Therapy (CRT). Regional distribution of dyssynchrony has been sparingly addressed in dyssynchrony studies in heart failure population.TDI was used to assess prevalence and regional distribution patterns of ventricular dyssynchrony in heart failure (HF) patients with systolic LVdysfunction (LVEF equal or less than 40%) in sinus rhythm. Inter-ventricular dyssynchrony (IVD) and left ventricular dyssynchrony (LVD) equal or greater than 40 msec were considered significant and LVD equal or greater than 65 m sec indicated severe dyssynchrony.100 HF patients (Wide QRS, Gp I, N =70Normal QRS Gp II, N=30, and 25 normal individuals with complete LBBB (n=14) or RBBB (n=11) underwent TDI. IVD was seen in 35 (35%) patients (74% LV delay26% RV delay) and LVD in 68 patients (68%). The relative prevalence of lVD and LVD respectively in Group land Group II HF patients was47% vs. 7% (p0.001) and 70% vs. 67%. (p=ns) while LVD in Groups A (LBBB, n=41)B (RBBB, n=26) was 76% and 58%, p=ns. The prevalence ofsevere LVD was similar in Gp III (37% and 57%, p=ns), and in Gp AB (46%26%, p=ns). Regional distribution patterns of LVD in normal individuals with bundle branch block showed septal delay in 20%, a prevalence of similar to heart failure population (23%, Gp I, and 21% Gp II, p=ns). Lateral wall delay was demonstrated only in the HF population seen in 33% of Gp I and 47% of Gp II patients, p=ns.LVD is distributed amongst HF patients with narrow or wide QRS and with LBBB or RBBB with a similar regional distribution. Dyssynchrony in normal individuals with bundle branch block is in the form of septal delay. These findings may have implications for patient selection for CRT and site of LV pacing.

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.

This report illustrates the case of a young lady evaluated for drug-refractory symptomatic paroxysmal atrial fibrillation. Successful isolation of left inferior pulmonary vein was achieved by segmental ostial ablation and circumferential Lasso mapping catheter. Patient is now free of symptoms and is off all anti-arrhythmic drugs.

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.