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Janet Prameela Dsouza,1 Jyothi Chakrabarty,1 Padmakumar Ramachandran,2 Vasudeva Guddattu,3 Baby S Nayak,4 Anice George4 1Department of Medical-Surgical Nursing, Manipal College of Nursing, Manipal Academy of Higher Education, Manipal, Karnataka, India; 2Department of Cardiology, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India; 3Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, Karnataka, India; 4Department of Child Health Nursing, Manipal College of Nursing, Manipal Academy of Higher Education, Manipal, Karnataka, IndiaCorrespondence: Jyothi Chakrabarty, Professor and Head, Department of Medical-Surgical Nursing, Manipal College of Nursing Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India, Tel +91 9880078542, Email jyothi.r@manipal.edu Padmakumar Ramachandran, Professor and Unit Head, Department of Cardiology, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India, Tel +91 9900921428, Email padma.kumar@manipal.eduBackground: Cardiovascular diseases are one of the major causes of mortality at the global level. They account for approximately 17.9 million deaths per year. Warfarin and acenocoumarol are the commonly used oral anticoagulants to treat and prevent thromboembolic disorders in patients with cardiovascular diseases. In India, approximately 2– 2.5 million patients with rheumatic heart disease are receiving oral anticoagulation therapy. Additionally, this therapy is provided for stroke prevention in the case of atrial fibrillation and the treatment of valvular heart disease, stroke, and deep vein thrombosis. As the therapeutic range of these drugs is narrow and is affected by many factors, their use is challenging. This study aims to evaluate the effectiveness of a nursing intervention module in terms of adherence to therapy, knowledge, quality of life, and complications among patients receiving oral anticoagulation therapy. Furthermore, this study will address factors that affect adherence and the risk for bleeding by using a randomized controlled trial design.Methods: This single-blind, single-center, randomized controlled trial will focus on adherence to oral anticoagulation therapy. A total of 320 patients who are on oral anticoagulation therapy will be randomized into blocks and allocated to either the intervention or standard care group. The intervention will comprise the use of a nursing intervention module that includes a booklet, log sheet, and decision aid on oral anticoagulation therapy adherence. Outcome measures, that is, knowledge regarding oral anticoagulation therapy, adherence, complications, and quality of life, will be assessed at the baseline and during follow-ups.Discussion: Patient safety can be best achieved through patients’ adherence to medication dose and monitoring of blood test values. Thromboembolic and bleeding complications are likely to occur when either the patient does not adhere to the treatment or the therapeutic range of the international normalized ratio is not maintained. This study will assess the nonadherence behavior and the effectiveness of a nursing intervention module toward adherence behavior.Trial Registration: This research project is registered under the Clinical Trial Registry of India (CTRI/2019/06/019610).Keywords: nonadherence, warfarin, efficacy, awareness, well-being

Introduction: Some pacemaker implanted patients have an atherosclerotic disease which promotes conduction system ischemia and conduction disturbances. The aim of this study was to determine prevalence of coronary artery disease (CAD) and its risk factors in patients undergoing permanent pacemaker implantation (PPI). Methods: This prospective, single-center hospital based study examined patients older than 40 years who required PPI. Presence of atherosclerotic risk factors and CAD was examined. Results: Of 258 patients undergoing PPI, CAD was present in 50 (19.37 %) patients. CAD was more common among middle age and elderly patients (P = 0.03). Patients older than or equal 76.5 years had specificity of 78.8% for an association with CAD. Multivariate analysis showed that age (odds ratio: 1.042; 95% confidence interval: 1.009–1.075; P = 0.01) and diabetes (odds ratio: 3.437; 95% confidence interval: 1.618–7.303; P = 0.001) had a statistically significant association with CAD. Of 169 patients with involvement of the atrioventricular (AV) node, 28 (16.6 %) had associated left anterior descending artery (LAD) involvement with P = 0.01, suggesting an association between LAD disease and chronic degenerative changes in the AV node. Conclusion: CAD was present in 19.4% of patients undergoing PPI. Age and diabetes had a strong association with CAD. LAD stenosis was significantly more prevalent in AV nodal/ infra-hisian disease compared with sinus nodal disease.

Aim: The relationship between QT prolongation and myocardial ischemia is well known, however not many studies have correlated corrected QT interval and heart rate recovery with the severity of coronary artery disease (CAD). Methods: This was a single-center, prospective, observational study which included 127 patients with CAD and 124 patients without CAD. Results: Corrected QT variability from peak to recovery correlated well with CAD with a p value of 0.03. Receiver operative characteristic analysis did not show any significant diagnostic accuracy with any heart rate or QT parameters for predicting the presence or severity of CAD. Conclusion: Coronary artery disease is predicted by reduced ability of the heart rate to rise from rest to peak exercise and reduced recovery of heart rate and corrected QT from peak exercise to recovery at 1 min.

Background. Sleep-disordered breathing (SDB) is a common yet a largely underdiagnosed entity in developing countries. It is one treatable condition that is known to adversely affect the mortality and morbidity in heart failure (HF). This study is one of the first attempts aimed at studying SDB in chronic HF patients from an Indian subcontinent. Objectives. The aim of this study was to study the prevalence, type, and characteristics of SDB in chronic HF patients and their association with HF severity and left ventricular (LV) systolic function and also to determine the relevance of SDB symptoms and screening questionnaires such as the Epworth Sleepiness Scale (ESS), Berlins questionnaire, and STOP-BANG score in predicting SDB in chronic HF patients. Methods. We enrolled 103 chronic heart failure patients aged more than 18 years. Patients with a history of SDB and recent acute coronary syndrome within 3 months were excluded. Relevant clinical data, anthropometric measures, echocardiographic parameters, and sleep apnea questionnaires were collected, and all patients underwent the overnight type 3 sleep study. Results. The overall prevalence of SDB in our study was high at 81.55% (84/103), with a predominant type of SDB being obstructive sleep apnea (59.2%). The occurrence of SDB was significantly associated with the male gender ( p = 0.002 ) and higher body mass index (BMI) values ( p = 0.01 ). SDB symptoms and questionnaires like ESS, STOP-BANG, and Berlins also did not have a significant association with the occurrence of SDB in HF patients. Conclusions. Our study showed a high prevalence of occult SDB predominantly OSA, in chronic HF patients. We advocate routine screening for occult SDB in HF patients.

Polycythemia Vera (PV) is a chronic myeloproliferative disorder which is characterised by a high risk of developing arterial as well as venous thromboembolic complications like deep vein thrombosis, stroke, cortical vein thrombosis and rarely acute Myocardial Infarction (MI). PV has a risk rate of major thrombosis as high as 50%. Bleeding, thrombotic, and vascular complications are the major causes of morbidity and mortality, occurring in 40 to 60% of these patients. MI with heart failure is the most common cause of death in these patients. Congenital Protein S deficiency is an autosomal dominant disease. Venous thrombosis develops in 60- 80% of patients who are heterozygous for Protein S deficiency. Hereditary Protein S deficiency is a well known risk factor not only for venous thrombosis but also for arterial thrombosis including MI and stroke. However, association of Protein S deficiency with arterial thrombosis is less appreciated. Very rarely, we find all the varied thrombotic complications in one patient. We hereby present a case who had varied thrombotic presentations due to underlying polycythemia with Protein S deficiency.

Spine deformities have several associations with compromised cardiorespiratory function. Percutaneous coronary interventions rely on fluoroscopic anatomical landmarks to guide procedures, and distortion of the mediastinal soft tissue and skeletal anatomy in conditions like kyphoscoliosis can pose unique challenges for the interventional cardiologist. Here, we report a case of elderly kyphoscoliotic male patient with worsening angina, who underwent successful percutaneous coronary intervention via the radial route.

Sinus node dysfunction, as the sole manifestation of an acute coronary syndrome, is rare. We report a case of ischemic dysfunction of the sinus node in a patient who had previously undergone coronary artery bypass grafting for triple vessel disease. Intermittent rest angina with a junctional rhythm was noted in spite of patent grafts to all three vessels, which resolved after percutaneous revascularization of the right coronary artery.

Extrinsic compression of the Left Main Coronary Artery (LMCA) by a dilated pulmonary artery is a rare but a treatable cause of angina in patients with Pulmonary Artery Hypertension (PAH). In majority of these patients, angina is attributed to right ventricular or left ventricular demand ischemia and in the absence of cardiovascular risk factors for atherosclerosis, they rarely undergo a coronary angiogram. So this rare diagnosis may be missed in such patients and optimal management delayed. In this case report we describe a patient of PAH secondary to Patent Ductus Arteriosus (PDA), presenting with heart failure and complaining of persistent angina, due to extrinsic compression of the ostial LMCA by the dilated pulmonary artery, treated successfully by Percutaneous Coronary Intervention (PCI). This case reminds us that in all patients of pulmonary hypertension presenting with angina and left ventricular dysfunction, this rare but treatable cause should be identified by coronary angiography and treated with PCI.

The anomalous origin of the entire coronary system from the right coronary sinus is a very rare anomaly. Here a patient with this rare anomaly, who developed acute coronary syndrome, requiring revascularization, is presented and treated successfully. His coronary angiographic findings are also discussed. We would like to highlight the rarity of the origin of all 3 coronary arteries from a single coronary trunk. The case also highlights the importance of using Amplantzer AR1 guiding catheter for such anatomical variations arising in the right coronary cusp.

Objectives To evaluate, in the FLEX Registry, clinical outcomes of an ultrathin (60 µm) biodegradable polymer-coated Supraflex sirolimus-eluting stent (SES) for the treatment of coronary artery disease. Additionally, to determine the vascular response to the Supraflex SES through optical coherence tomography (OCT) analysis. Setting Multicentre, single-arm, all-comers, observational registry of patients who were treated with the Supraflex SES, between July 2013 and May 2014, at nine different centres in India. Participants 995 patients (1242 lesions) who were treated with the Supraflex SES, between July 2013 and May 2014, at nine different centres in India. A total of 47 participants underwent OCT analysis at 6 months’ follow-up. Interventions Percutaneous coronary intervention with Supraflex SES, Primary and secondary outcome measures The primary endpoint—the rate of major adverse cardiac events (defined as a composite of cardiac death, myocardial infarction (MI), target lesion revascularisation (TLR))—was analysed during 12 months. Results At 12 months, the primary endpoint occurred in 36 (3.7%) of 980 patients, consisting of 18 (1.8%) cardiac deaths, 16 (1.6%) MI, 7 (0.7%) TLR and 2 (0.2%) cases of non-target lesion target vessel revascularization. In a subset of 47 patients, 1227 cross-sections (9309 struts) were analysed at 6 months by OCT. Overall, a high percentage of struts was covered (98.1%), with a mean neointimal thickness of 0.13±0.06 µm. Conclusions The FLEX Registry evaluated clinical outcomes in real-world and more complex cohorts and thus provides evidence that the Supraflex SEX can be used safely and routinely in a broader percutaneous coronary intervention population. Also, the Supraflex SES showed high percentage of stent strut coverage and good stent apposition during OCT follow-up.

Drug-drug interactions (DDIs) are defined astwo ormoredrugs interacting in such a mannerthatthe effectiveness ortoxicity of one or more drugs is altered. DDI in patients receiving multidrug therapy is a major concern. The aim of the present study was to assess the incidence and riskfactors of DDIs in patients admitted in cardiology unit of a teaching hospital. A prospective, observational study was carried outfora period of 3 months (April-July 2009). During the study period, a total of 600 prescriptions were analyzed and it was found that 88 patients had at least one DDI. The percentage of DDIs was higher in females compared to maies (56.82% vs. 43.18%). DDIs were observed more in the age group of 60 years and above (57.96). Patients with more than 10 prescribed drugs developed DDIs more frequently [58 (65.91%)]. Heparin [55 (62.25%)] and aspirin [42 (47.72%)] were the most common drugs responsible for DDIs. Bleeding was the commonest clinical consequence [76 (86.63%)] found in this study population. On assessment of severity of DDIs, majority of the cases were classified as moderate in severity (61.36%). Aging, female gender and increase in concurrent medications were found to be associated with increased DDIs. Patients having these risk factors can be actively monitored during their stay in the cardiology department to identify DDIs.

A 55-year-old man with a history of coronary artery bypass graft surgery presented to us with unstable angina. Preliminary investigations showed new ST depressions in inferior leads and elevated cardiac enzymes (Trop T and CKMB). A coronary angiogram was performed showing an occluded venous graft to the right coronary artery (RCA), with a haemodynamically significant heavily calcified lesion in the proximal and mid RCA (figure 1A). Angioplasty and stenting to the native RCA was planned. After adequate predilation of the lesion, the RCA was stented with a 3.5×28 mm everolimus eluting stent. As there was a residual lesion distal to the stented segment, we planned to stent the distal segment …

Background Patient education is an important part of holistic care for patients with chronic diseases. With the success of the Heart Manual, it was felt there is a strong need to develop such a manual for those with pulmonary hypertension (PH) - the Pulmonary Hypertension Manual (PulHMan). This was developed through a qualitative methodology in order to ensure the needs of the patients were being met. The impact of the PulHMan on awareness about exercise-related benefits and PH are not known. Therefore the aim of this study was to assess the effects of the PulHMan on improving awareness among individuals with PH. Methods A repeat cross sectional study was carried out on 30 patients with PH to assess the effects of using the PulHMan on awareness of exercise-related benefits in PH. Awareness was assessed from a self-developed and validated questionnaire that included components of PH and exercise related components. Results Thirty patients with PH (mean right ventricular systolic pressure and six minute walk distance of 89.2±4.1mm Hg and 322.8±102m respectively) were included in the study. At baseline, it was seen that there was a low awareness regarding the benefits of exercise for PH. However, they were aware of the general health benefits of walking. After three months, it was seen that the PulHMan improved awareness on the benefits of exercising. Despite a low number willing to exercise (2/30) and participate in a home-based program (2/30), after using the PulHMan for three months, there was an improvement in those willing to exercise and participate in a home-based program (22/30 and 25/30 respectively). Conclusions The PulHMan was seen to improve awareness regarding the exercise-related benefits among patients with PH. More studies are needed to determine if this change in awareness translates into a behavioural change for those with PH.

Objective This study was undertaken to determine the clinical profile of patients undergoing emergency surgery after balloon mitral valvotomy, to note operative findings and compare them with those of transthoracic echocardiography, to describe the mechanisms of complications, and to describe outcomes. Methods A retrospective study was undertaken of patients requiring emergency surgery after percutaneous mitral valvotomy with an Inoue balloon from January 1990 to December 2003. The data analyzed included demographic variables, causes and clinical presentations of complications, and outcome. In 14 consecutive cases of mitral regurgitation, an observational study comparing the operative findings with echocardiography was also undertaken. Results In 1388 cases of valvotomy, complications necessitating urgent surgery occurred in 31 cases (2.2%). Acute mitral regurgitation occurred in 23 cases (74.2 %), and cardiac tamponade occurred in 8 cases (25.8%). Mitral regurgitation was due to leaflet tearing in all cases: anterior leaflet in 20 cases and posterior leaflet in 3 cases. Hypotension, orthopnea, and pulmonary edema were the clinical presentation for mitral regurgitation. Transthoracic echocardiography underestimated the severity of mitral valve pathology. Bilateral severe commissural fusion and pliable leaflet with paracommissural calcium was seen in anterior leaflet tearing. Cardiac tamponade with hemodynamic compromise occurred as a result of left atrial perforation in 6 cases, right atrial perforation in 1 case, and left ventricular perforation in 1 case. High septal puncture led to atrial perforation. Operative mortality was 9.6%, and low cardiac output developed in 29%. Conclusion Acute mitral regurgitation and cardiac tamponade were the causes of emergency surgery after balloon valvotomy. Transthoracic echocardiography underestimated the severity of valve pathology.

Durable polymer-based drug-eluting stents have been reported to adversely affect the safety profile and are also suspected to cause serious long-term complications. It has been proposed that the biodegradable polymer coatings may reduce such late-stage adverse effects. The purpose of this registry

A 60-year-old lady with type 2 diabetes was diagnosed with tuberculous pericardial effusion, and initiated on antitubercular therapy with isoniazid (300 mg oral), rifampicin (600 mg oral), pyrazinamide (1250 mg oral) and ethambutol (800 mg oral) along with prednisolone (60 mg oral). On follow-up, transthoracic echocardiography confirmed resolution of pericardial effusion. A submitral aneurysm measuring 2.2×1.8 cm was visualised just below the posterior mitral leaflet, and confirmed by transesophageal echocardiography. As the patient was asymptomatic and there was no evidence of mitral regurgitation, it was …

Isolated single coronary artery in the presence of an atrial septal defect (ASD) is a rare congenital anomaly. There are no clear guidelines regarding the management of ASD in these patients. Transcatheter closure of the ASD in the presence of a single coronary artery that has a retro-aortic course is a matter of concern because of the possible risk of coronary impingement by the left atrial disc. Here we report the first case of an ASD device closure in a patient with a retro-aortic right coronary artery. The immediate results were good; however, long-term follow up is warranted to look for late complications.

A 53-year-old woman diagnosed with rheumatic mitral stenosis (at the age of 40 years) presented with worsening dyspnoea New York Heart Association class III of 1 month duration. She was on regular treatment with diuretics, β-blockers and warfarin (in view of valvular atrial fibrillation). However, 1 month prior to presentation, she was off all medications except warfarin, which she was compliant on. Blood investigations revealed the presence of subclinical hypothyroidism with an optimal international normalised ratio of 2.64. ECG …

Venous aneurysms arising from the mediastinal systemic veins are rare. There are only 27 reported cases of such aneurysms. Majority arise from the superior vena cava. We are reporting a saccular aneurysm of superior vena cava in a 58-year-old male. The chest radiogram suggested superior mediastinal mass and the computed tomogram was suggestive of aortic arch aneurysm. Aortography and venography confirmed the diagnosis as saccular aneurysm arising from the superior vena cava. A 7 cm saccular aneurysm arising from the distal half of superior vena cava was resected through median sternotomy. The surgery was done to prevent pulmonary thrombo-embolism.