Search

Background Given the shortage of cardiac rehabilitation (CR) programs in India and poor uptake worldwide, there is an urgent need to find alternative models of CR that are inexpensive and may offer choice to subgroups with poor uptake (e.g., women and elderly). Objectives This study sought to evaluate the effects of yoga-based CR (Yoga-CaRe) on major cardiovascular events and self-rated health in a multicenter randomized controlled trial. Methods The trial was conducted in 24 medical centers across India. This study recruited 3,959 patients with acute myocardial infarction with a median and minimum follow-up of 22 and 6 months. Patients were individually randomized to receive either a Yoga-CaRe program (n = 1,970) or enhanced standard care involving educational advice (n = 1,989). The co-primary outcomes were: 1) first occurrence of major adverse cardiovascular events (MACE) (composite of all-cause mortality, myocardial infarction, stroke, or emergency cardiovascular hospitalization); and 2) self-rated health on the European Quality of Life–5 Dimensions–5 Level visual analogue scale at 12 weeks. Results MACE occurred in 131 (6.7%) patients in the Yoga-CaRe group and 146 (7.4%) patients in the enhanced standard care group (hazard ratio with Yoga-CaRe: 0.90; 95% confidence interval [CI]: 0.71 to 1.15; p = 0.41). Self-rated health was 77 in Yoga-CaRe and 75.7 in the enhanced standard care group (baseline-adjusted mean difference in favor of Yoga-CaRe: 1.5; 95% CI: 0.5 to 2.5; p = 0.002). The Yoga-CaRe group had greater return to pre-infarct activities, but there was no difference in tobacco cessation or medication adherence between the treatment groups (secondary outcomes). Conclusions Yoga-CaRe improved self-rated health and return to pre-infarct activities after acute myocardial infarction, but the trial lacked statistical power to show a difference in MACE. Yoga-CaRe may be an option when conventional CR is unavailable or unacceptable to individuals. (A study on effectiveness of YOGA based cardiac rehabilitation programme in India and United Kingdom; CTRI/2012/02/002408)., Central Illustration

Aims: The prevalence of premature coronary artery disease (CAD) in India is two to three times more than other ethnic groups. Untreated heterozygous familial hypercholesterolemia (FH) is one of the important causes for premature CAD. As the age advances, these patients without treatment have 100 times increased risk of cardiovascular (CV) mortality resulting from myocardial infarction (MI). Recent evidence suggests that one in 250 individuals may be affected by FH (nearly 40 million people globally). It is indicated that the true global prevalence of FH is underestimated. The true prevalence of FH in India remains unknown. Methods: A total of 635 patients with premature CAD were assessed for FH using the Dutch Lipid Clinical Network (DLCN) criteria. Based on scores, patients were diagnosed as definite, probable, possible, or no FH. Other CV risk factors known to cause CAD such as smoking, diabetes mellitus, and hypertension were also recorded. Results: Of total 635 patients, 25 (4%) were diagnosed as definite, 70 (11%) as probable, 238 (37%) as possible, and 302 (48%) without FH, suggesting the prevalence of potential (definite + probable) FH of about 15% in the North Indian population. FH is more common in younger patients, and they have lesser incidence of common CV risk factors such as diabetes, hypertension, and smoking than the younger MI patients without FH (26.32% vs.42.59%; 17.89% vs.29.44%; 22.11% vs.40.74%). Conclusion: FH prevalence is high among patients with premature CAD admitted to a cardiac unit. To detect patients with FH, routine screening with simple criteria such as family history of premature CAD combined with hypercholesterolemia, and a DLCN criteria score >5 may be effectively used. Keywords: Familial hypercholesterolemia, Premature coronary artery disease, Dutch Lipid Clinic Network Criteria, Correction factor, Arcus cornealis

Objective: Primary objective was to compare the effects of atorvastatin 40 mg vs 80 mg on LDL-C in Indian patients with atherosclerotic dyslipidemia. Secondary objectives were to compare the effects of atorvastatin 40 mg vs 80 mg on HDL-C and triglycerides and also comparing of side effects (myopathy, hepatotoxicity and new onset diabetes mellitus) of both doses. Method: This Study is A Prospective, randomized, open-label, comparative study. This study was conducted on 240 patients of dyslipidemia (as per ACC/AHA 2013 lipid guidelines) attending the OPD/wards/CCU of department of cardiology, Sir Ganga Ram Hospital. They were randomly divided into 2 groups of 120 each. Group A consisted patients who received Atorvastatin 40 mg daily and Group B Atorvastatin 80 mg daily. The follow up period was 6 months. Results: At 3 and 6 month follow up, Atorvastatin 40 mg leads to mean LDL cholesterol reduction of 47.18 ± 20.81 & 50.03 ± 18.06 respectively. While Atorvastatin 80 mg results in LDL reduction as 50.11 ± 15.85 & 52.30 ± 13.72. The comparison between two doses revealed a non-significant difference (p = .118 & p = .149 respectively).At 6 months of follow up, few patients reported myalgia (2 in group A and 7 in Group B). The difference between groups was significant (p = .045). Although none of our patient had significant elevation of CPK. Conclusion: This study concluded that both doses of atorvastatin (40 & 80 mg) are equally efficacious in improving dyslipidemia but higher dose leads to more incidence of myalgia. Keywords: Atherosclerosis, Atorvastatin, Dyslipidemia, Myalgia

Cardiac rehabilitation (CR) after myocardial infarction is highly effective. It is unavailable in public hospitals in India due to limited resources. Our objective was to develop a scalable model of CR for India based on yoga, which could also appeal to some groups with low uptake of CR (e.g., ethnic minorities, women, and older people) globally. The intervention was developed using a structured process. A literature review and consultations with yoga experts, CR experts, and postmyocardial infarction patients were conducted to systematically identify and shortlist appropriate yoga exercises and postures, breathing exercises, meditation and relaxation practices, and lifestyle changes, which were incorporated into a conventional CR framework. The draft intervention was further refined based on the feedback from an internal stakeholder group and an external panel of international experts, before being piloted with yoga instructors and patients with myocardial infarction. A four-phase yoga-based CR (Yoga-CaRe) programme was developed for delivery by a single yoga instructor with basic training. The programme consists of a total of 13 instructor-led sessions (2 individual and 11 group) over a 3-month period. Group sessions include guided practice of yoga exercises and postures, breathing exercises, and meditation and relaxation practices, and support for the lifestyle change and coping through a moderated discussion. Patients are encouraged to self-practice daily at home and continue long-term with the help of a booklet and digital video disc (DVD). Family members/carers are encouraged to join throughout. In conclusion, a novel yoga-based CR programme has been developed, which promises to provide a scalable CR solution for India and an alternative choice for CR globally. It is currently being evaluated in a large multicentre randomised controlled trial across India.

Background Cardiac rehabilitation (CR) is a standard treatment for secondary prevention of acute myocardial infarction (AMI) in high income countries (HICs), but it is inaccessible to most patients in India due to high costs and skills required for multidisciplinary CR teams. We developed a low-cost and scalable CR program based on culturally-acceptable practice of yoga (Yoga-CaRe). In this paper, we report the rationale and design for evaluation of its effectiveness and cost-effectiveness. Methods This is a multi-center, single-blind, two-arm parallel-group randomized controlled trial across 22 cardiac care hospitals in India. Four thousand patients aged 18–80 years with AMI will be recruited and randomized 1:1 to receive Yoga-CaRe program (13 sessions supervised by an instructor and encouragement to self-practice daily) or enhanced standard care (3 sessions of health education) delivered over a period of three months. Participants will be followed 3-monthly till the end of the trial. The co-primary outcomes are a) time to occurrence of first cardiovascular event (composite of all-cause mortality, non-fatal myocardial infarction, non-fatal stroke and emergency cardiovascular hospitalization), and b) quality of life (Euro-QoL-5L) at 12 weeks. Secondary outcomes include need for revascularization procedures, return to pre-infarct activities, tobacco cessation, medication adherence, and cost-effectiveness of the intervention. Conclusion This trial will alone contribute >20% participants to existing meta-analyses of randomized trials of CR worldwide. If Yoga-CaRe is found to be effective, it has the potential to save millions of lives and transform care of AMI patients in India and other low and middle income country settings.

Diabetes mellitus (DM) is a known independent predictor of mortality following acute myocardial infarction (AMI). In addition, patients with DM may have other risk factors for AMI such as hypertension (HTN), tobacco use, physical inactivity. This study aimed to explore the distribution of cardiovascular (CV) risk factors among patients of AMI with and without DM. Yoga-CaRe, a multicenter randomized controlled trial, included patients of AMI (first or consequent AMI) with DM (n=856) and without DM (n=2330), aged 18-80 years from 24 cardiac centers across India. The baseline socio-demographics, clinical and behavioral characteristics of those with and without DM were analyzed using multivariable logistic/linear regression models, sequentially adjusted for age, gender, education and physical inactivity. Patients of AMI with DM were older as compared to those without DM (mean age 56.4± 9.4 vs. 51.9 ± 11.2). Patients with DM had higher odds of having hypertension, being physically inactive and had lower odds of self-reported ever tobacco use. Patients with DM had higher mean waist circumference, systolic and diastolic blood pressure (Table). No differences were found in body mass index between diabetes and nondiabetes groups.The observed differential distribution of CV risk factors in AMI patients with DM calls for a tailored rehabilitation plan. Cardiovascular risk factors among AMI patients with diabetes vs. without diabetesVariableDiabetes (n=856)Without diabetes (n=2330)Adjusted OR/Regression coefficient* [95% CI]Ever tobacco use (%)34.2%49.2%0.73 [0.60-0.88]Physical inactivity (%)57.8%49.2%1.38 [1.18-1.62]Body Mass Index ≥25Kg/m2 (%)57.6%50.8%1.13 [0.95-1.34]Waist circumference (cm) (mean)99.3±20.792.3±17.94.7 [3.1-6.3]*Systolic blood pressure (mmHg) (mean)123.4±17.2118.8±16.13.6 [2.3-4.9]*Diastolic blood pressure (mmHg) (mean)76.7±10.774.9±10.31.9 [1.02-2.7] *Hypertension (%)53.1%18.6%3.8 [2.9-5.1] Disclosure D. Soni: None. C.M. Ambalam: None. V.S. Ajay: None. K. Singh: None. K. Singh: None. P.A. Praveen: None. A. Roy: None. S.C. Manchanda: None. B. Mohan: None. P.C. Negi: None. P. Bhat: None. K.S. Sadananda: None. P.M. R.: None. P. Sarma: None. S. Natarajan: None. C. Narasimhan: None. N. Desai: None. S. Patil: None. D.S. Chadha: None. S. Chandra: None. S. Kinra: None. D. Prabhakaran: None.

Cardiovascular diseases (CVD) are the leading cause of death and disability worldwide. The main reason for increase of CVD is considered to be unhealthy lifestyle consistent of high fat, refined diet, psychosocial stress, lack of exercise and tobacco. In spite of several recent advances in the management of CVD the incidence is rapidly increasing specially in the developing countries and their economic burden is huge. There is a need for new cost effective and safe strategy to control this growing epidemic of CVD. Yoga may be such an alternative for controlling CVD. Several research studies suggest that yoga may be promising technique for primary and secondary prevention of CVD and these will be reviewed briefly in this chapter.

Hypertension is a major public health problem and is an impor tant risk factor for stroke, coronary heart disease and renal failure. The blood pressure is not well controlled with drug therapy in large number of individuals, especially in the developing countries. There is a need for less expensive nonpharmacological alternative methods to control blood pressure. Yoga may be such cost-effective alternative. Several uncon trolled and ran do mized control trials have evaluated short- and long-term effects of yoga/meditation-based techniques in prehypertension and mild hypertension. Though, the results are mixed and there are several methodological limitations in reported studies, majority of studies demonstrate a modest decrease in both systolic and diastolic blood pressure. This modest decrease may significantly decrease the stroke mortality and coronary heart disease in general population. A recent scientific statement of American Heart Association also suggests that it is reasonable for all individuals with blood pressure levels more than 120/80 mm Hg to consider alternative approaches like transcendental medication as adjunct method to lower blood pressure.

Blood pressure (BP), even in healthy normotensive individuals, is dynamic, varies with a circadian periodicity, and is influenced by physiological and environmental factors. Abnormal 24-h BP patterns have been observed in many patients with hypertension (HTN), which may be overlooked if evaluations are based only on office BP measurements. Out of office BP measurements, such as Ambulatory Blood Pressure Monitoring and Home Blood Pressure Monitoring (ABPM and HBPM) is important for optimal BP management and are better predictors of adverse outcomes. However, HTN diagnosis and management are often based on relatively few clinic BP measurements, and there are no recommendations to guide clinicians managing patients with abnormal 24-h BP patterns in India. Thus, the present consensus statement aims to provide uniform evidence-based recommendations for the diagnosis and management of abnormal 24-h BP patterns. Strategies for screening for HTN based on the current prevalence trends in India have been suggested. Further, recommendations on the appropriate use of ABPM and HBPM in diagnosis and management of HTN are provided.

Objectives:The association between clinical profile such as electrocardiographic changes and angiographic changes without and with comorbid hypertension among acute myocardial infarction (AMI) patients is not explored in Indian population. To examine the clinical profile among AMI patients with and

We are describing a case of repeated interventions performed during long-term follow-up. To the best of our knowledge, this is the only case report of 1 closed mitral valvotomy followed by 3 time balloon mitral valvotomy culminating ultimately to mitral valve replacement in 41 year follow-up.

Yoga is a holistic mind–body intervention aimed at physical, mental, emotional and spiritual well being. Several studies have shown that yoga and/or meditation can control risk factors for cardiovascular disease like hypertension, type II diabetes and insulin resistance, obesity, lipid profile, psychosocial stress and smoking. Some randomized studies suggest that yoga/meditation could retard or even regress early and advanced coronary atherosclerosis. A recent study suggests that transcendental meditation may be extremely useful in secondary prevention of coronary heart disease and may reduce cardiovascular events by 48 % over a 5-year period. Another small study suggests that yoga may be helpful in prevention of atrial fibrillation. However, most studies have several limitations like lack of adequate controls, small sample size, inconsistencies in baseline and different methodologies, etc. and therefore large trials with improved methodologies are required to confirm these findings. However, in view of the existing knowledge and yoga being a cost-effective technique without side effects, it appears appropriate to incorporate yoga/meditation for primary and secondary prevention of cardiovascular disease.

Various population studies have reported the association of rare S2 allele of apolipoprotein C3 (APOC3) SstI polymorphism with hypertriglyceridemia (HTG) and coronary artery disease (CAD). We were the first to report an association of S2 allele with high triglyceride (TG) levels in healthy volunteers from Northern India. Since HTG is suggested to be a predominant risk factor for CAD among Indians, we have elucidated the relationship of APOC3 SstI polymorphism with the lipid profile and CAD. A total of 158 patients with ≥ 70% stenosis in one or more coronary artery (angiographically proven CAD patients), 35 subjects with < 70% stenosis (NCAD) and 151 normal controls (free of heart disease) from Northern plains of India were recruited in the study. DNA samples were analyzed by polymerase chain reaction (PCR) followed by SstI digestion. Lipid profile was estimated by enzymatic kit. We found a strong association of S2 allele with high TG levels, which was more significant in patients. Prevalence of S2 allele in normal controls and CAD patients were comparable, despite the fact that mean TG level was significantly higher in patients. A greater insight into this observation revealed that the prevalence of high TG, if not coupled with other risk factors (like high total cholesterol, low HDL), was comparable in patients and controls. Thus, our study reveals that rare S2 allele may be employed as a susceptibility marker for high TG. However, high TG or S2 allele alone may not contribute to the etiology of CAD.

The effect of icatibant (Hoe-140), a selective bradykinin receptor (B 2 ) antagonist on myocardial ischemic-reperfusion injury was studied in open chest barbiturate anaesthetized cats. The left anterior descending coronary artery was occluded for 15 min, followed by 60 min of reperfusion. Saline or icatibant (200 μg/kg) was administered intravenously slowly over 2 min, 5 min before reperfusion. In the saline-treated group, myocardial ischemic-reperfusion injury was evidenced by depressed MAP, depressed peak positive and negative d P /d t and elevated left ventricular end-diastolic pressure and enhanced oxidative stress [elevated plasma thiobarbituric acid reactive substances (TBARS; a marker for lipid peroxidation), depressed myocardial GSH (reduced glutathione), superoxide dismutase (SOD), catalase] and depletion of adenosine triphosphate (ATP) along with rise in plasma creatine phosphokinase (CPK). Administration of icatibant resulted in complete hemodynamic recovery together with repletion of ATP and reduction in plasma TBARS without any significant change in myocardial SOD, catalase and GSH. The results of the present study suggest a protective role of icatibant in myocardial ischemic-reperfusion injury.

Several studies including a small case-control (hypertriglyceridemic/normotriglyceridemic individuals) study by us revealed close association between rare S2 allele ofAPOC3 Sstl polymorphism and hypertriglyceridemia. With the understanding that Asian Indians are highly vulnerable to the adverse effects of hypertriglyceridemia, we extended the investigation and studied the frequency distribution of this polymorphism in 216 healthy volunteers from Northern plains of India. We found that more than 50% of the study population had one or two S2 allele. This may suggest that a larger fraction of this population is genetically predisposed to hypertriglyceridemia.

The risk/benefit of moderate to high doses of calcium antagonists in stable angina is uncertain. This study investigates the efficacy and acceptability of low dose diltiazem in combination with trimetazidine for the treatment of stable angina.In a 28-day, randomized, double blind study, treatment with 90 mg diltiazem in combination with 60 mg trimetazidine or placebo per day was compared in 50 patients with stable angina. The primary outcomes were time to 1-mm ST segment depression and the Duke treadmill score.Of the 25 patients in each treatment group, the number (%) of patients responding to trimetazidine compared to placebo was, in time to 1-mm ST segment depression, 13 (52) versus 5 (20), P0.05; in the Duke treadmill score, 18 (72) versus 8 (32), P0.01; and in angina 17 (68) versus 3 (12), P0.01. Compared to placebo there was an improvement with trimetazidine in mean exercise time to 1-mm ST segment depression of 128 s (95% confidence interval 45.0-208.5; P0.01); in the mean Duke treadmill score of 57.4% (95% confidence interval 9.9-100; P0.02); and in mean anginal attacks of 5.1 per week (95% confidence interval, 3.1-7.3, P0.01).The combination of low dose diltiazem with trimetazidine is effective with few side-effects in the symptomatic control of patients with stable angina.

The objective of this study was to prospectively investigate various clinical and echocardiographic variables to predict the left atrial and left atrial appendage clot and spontaneous echo contrast in patients with severe rheumatic mitral stenosis. We studied 200 consecutive patients (112 males and 88 females; mean age 29.6+/-9.6 years). Left atrial clot and spontaneous echo contrast were present in 26 and 53.5% of cases, respectively. There were no significant differences in the mitral valve area, mean transmitral diastolic gradient and left ventricular ejection fraction between patients with and without clot. Patients with clot were older (34.4+/-11.4 vs. 28.2+/-8.5 years, P0.001), had longer duration of symptoms (41. 4+/-36.0 vs. 28.8+/-22.9 months, P0.001), more frequent atrial fibrillation and spontaneous echo contrast (69.2 vs. 16.9%, P0. 00001 and 76.9 vs. 45.3%, P0.00001, respectively) and larger left atrial area and diameter (41.0+/-12.7 vs. 29.9+/-7.4 cm(2), P0.00001 and 53.9+/-8.3 vs. 47.6+/-7.4 mm, P0.0001, respectively) as compared to patients without clot. Similarly patients with spontaneous echo contrast were older (31+/-10.4 vs. 27.8+/-8.3 years, P0.01), had more frequent atrial fibrillation (48.6 vs. 9.7%, P0.0001), left atrial clot (37.4 vs. 12.9%, P0.0001), larger left atrial area and diameter (37.6+/-11.2 vs. 28.1+/-6.7 cm(2), P0.00001 and 52.2+/-8.3 vs. 45.9+/-6.5 mm, P0.00001, respectively) and smaller mitral valve area (0.77+/-0.14 vs. 0.84+/-0.13 cm(2), P0.01) as compared to patients without spontaneous echo contrast. There were no significant differences in the mean transmitral diastolic gradient and left ventricular ejection fraction. On multiple regression and discriminant function analysis, atrial fibrillation and left atrial area were independent predictors of left atrial clot formation. In a subgroup of patients with sinus rhythm, larger left atrial area and presence of spontaneous echo contrast were significantly associated with the presence of clot in left atrium and appendage. We conclude that in patients with severe mitral stenosis, the presence of atrial fibrillation and in the subgroup of the patients with sinus rhythm the presence of large left atrium (or =40 cm(2)) and spontaneous echo contrast were associated with higher risk of clot formation in the left atrium and might be benefited by prophylactic anticoagulation.

To determine whether the mitral valve morphology influences the results of percutaneous balloon mitral valvuloplasty for mitral stenosis, two-dimensional echocardiography was performed before valvuloplasty in 126 patients (mean age 25.5+/-9.4 years) and in 30 normal controls. The 2D echocardiographic features of mitral valve leaflets: thickness, length and motion; diastolic mitral valvular excursion; chordal length; mitral annular diameter; subvalvular distance ratio; distance between mid mitral annulus to left ventricular apex, base and tip of papillary muscle and effective balloon dilating area, effective balloon dilating area/body surface area and effective balloon dilating diameter/mitral annular diameter were then correlated to the immediate post-valvuloplasty mitral valve area. For the total patients population, post-valvuloplasty valve area increased from 0.67+/-0.17 to 2.1+/-0.86 cm2 (P0.0001), mean transmitral diastolic gradient decreased from 24.5+/-9.0 to 6.0+/-3.0 mm Hg (P0.0001), mean left atrial pressure decreased from 29.7+/-6.2 to 12.7+/-4.8 mm Hg (P0.0001), mean pulmonary artery pressure decreased from 44.8+/-14.2 to 25.4+/-9.5 mm Hg (P0.0001) and cardiac index increased from 2.7+/-0.38 to 3.1+/-0.55 l/min/m2 (P0.0001). The patients were divided into three groups on the basis of post-valvuloplasty mitral valve area. Group I had valve area1.5 cm2, group II had valve area from 1.5 to 1.9 cm2 and group III had valve areaor =2.0 cm2. On comparison, no statistically significant difference was found in any of the echocardiographic variables in the three groups. On univariate, multivariate, multiple regression and discriminate function analysis, none of the variables were found to have significant influence on immediate result of valvuloplasty. There was no significant difference in the incidence of mitral regurgitation in any of the three groups. We conclude that the extent of mitral valvular and subvalvular deformity do not have a significant effect on the immediate outcome of mitral valvuloplasty using the Inoue balloon and it can be successfully performed in patients with severe subvalvular fibrosis. Unique balloon geometry and stepwise balloon sizing may explain these acceptable immediate results in severely deformed valves.

We describe the use of the Inoue balloon to dilate the aortic valve by the physiologic antegrade route during pregnancy. A 27-year-old pregnant woman with severe aortic stenosis presented with progressive dyspnea and presyncope at 26 weeks of pregnancy. She subsequently underwent percutaneous valvuloplasty by the antegrade route utilizing the transseptal puncture. We conclude that percutaneous antegrade balloon valvuloplasty by the Inoue balloon (venous approach) is a safe and effective procedure. It markedly reduces fluoroscopy and is a palliative procedure that allows pregnancy to continue.

Coronary angioplasty of total occlusions is technically difficult and is associated with limited success rates. The procedural outcome is mainly determined by the underlying pathological process. Recanalization of total occlusions is aimed at finding the passage with least resistance, without causing dissection or perforation. Several techniques have been advocated to improve the overall success rate. Recently, a new 0.014" Nitinol wire (Crosswire, Terumo) has been introduced as a tool, to achieve higher success rates for total occlusion angioplasty. The wire consists of an extremely flexible Nitinol-core, a platinum/iridium coil at the distal tip, and a hydrophilic polymer coating. Balloon angioplasty was attempted in 30 totally occluded coronary arteries with mean age of occlusion being 5 +/- 4 months (range 2-14 months). The initial five procedures were performed following failure of the conventional angioplasty guidewires. Subsequently, Cross-wire was used electively in all the cases. The lesion was crossed successfully in 90% (27/30) cases. Dissection of the coronary artery with subintimal entry was seen in two (7%) cases, and the rest (three cases) could not be crossed. Balloon angioplasty and stenting (n = 21) were performed with good immediate angiographic results. There were no myocardial infarctions or deaths. Fourteen of 16 patients, who had completed 6 months follow-up, were asymptomatic. Angiographic evidence of in-stent restenosis was demonstrable in one case. Successful recanalization of total coronary occlusions by using Cross-wire can be expected in 83% cases, with reasonable safety.

Transvenous, transseptal, antegrade balloon aortic valvuloplasty (BAV) was successfully performed in 16 consecutive young adults with noncalcific aortic stenosis using Inoue balloon catheter. There were 13 males and three females, with a mean age of 20.4 ± 5.8 years (range 14–30 years). All the patients had normal left ventricular systolic function. All procedures were performed electively by the antegrade technique, except the initial index case in whom, the stenosed aortic valve could not be crossed retrogradely. Dilatation was performed using stepwise technique keeping the balloon:annulus ratio ≤100% in all the cases. Transaortic peak systolic gradient decreased from 113.4 ± 42.6 (range 70–210) mm Hg to 11.2 ± 9.2 (range 4–32) mm Hg; P = 0.0005. Following BAV, three patients developed grade 2+ aortic regurgitation, who were managed medically. None of the patients developed tamponade, vascular complications, excessive bleeding, or thromboembolism. Significant left to right atrial shunt (Qp/Qs ≥ 1.5:1) was observed in one case. The average procedure time was 20 ± 8 min (range 18–35 min). On follow-up (n = 11 patients) at 4 ± 1.5 months (range 2–7 months) all the patients were asymptomatic. Doppler transaortic peak systolic gradient was found to be 15 ± 10.3 mm Hg (range 4–36 mm Hg). Antegrade BAV technique using Inoue balloon for noncalcific aortic stenosis in young adults is safe, effective and may be technically advantageous. Cathet. Cardiovasc. Diagn. 44:297–301, 1998. © 1998 Wiley-Liss, Inc.

Many studies have attempted to validate the echocardiographic automated border detection (ABD) method for assessing left ventricular ejection fraction (LVEF) by comparing it with various echocardiographic and non-echocardiographic standards. The main basis of assessing its accuracy has been the coefficient of correlation. The fallacy of using coefficient of correlation for assessing agreement between two methods of measurement has been well emphasized in the literature. In the present study we used the Bland and Altman test for testing the accuracy of the ABD method. We compared the ABD method for LVEF assessment with the manual edge detection technique on echocardiography and with radionuclide ventriculography in 34 patients. The majority of patients (76%) had regional wall motion abnormality. The ABD method could be adequately performed in 25 (74%) patients. LVEF was significantly underestimated by the ABD method with very wide limits of agreement when compared with radionuclide ventriculography and the manual edge detection technique (−9.2±21.7 and −2.7±18.4 respectively, mean error±2 standard deviations). Stated simply, the ABD method could overestimate LVEF by 12.5 and 15.7 or underestimate by 30.9 and 21.1 when compared with radionuclide ventriculography and manual edge detection technique, respectively. This large error is by no means acceptable for clinical purposes. It is concluded that at the present stage, the ABD method cannot replace radionuclide ventriculography and manual edge detection technique for assessing LVEF.

We performed a lesion matched comparison of AVE Microstent and Palmaz-Schatz stent implants with 6 month follow-up angiography to compare the occurrence of restenosis. Thirty-three pairs of lesions were matched for lesion location, ACC/AHA lesion type, reference diameter, lesion length, and angiographic descriptors. Age, sex, clinical profile, and indication for stenting were comparable. Quantitative coronary analysis before and after the procedure was comparable in the two groups but minimum lumen diameter (MLD) at follow-up was less with Microstent--2.01 +/- 1.01 mm than Palmaz-Schatz stent--2.43 +/- 0.96 mm (P = 0.05). Binary restenosis was present in 33% and 21% and was diffuse in 55% and 29% of the two groups, respectively. Typical angina at follow-up was more frequent with Microstent (36%) than Palmaz-Schatz stent (15%; P = 0.038). When implanted in lesions of similar complexity, Microstent yields similar post procedure angiographic results but smaller MLD at follow-up and more frequent angina than Palmaz-Schatz stent.

We reviewed our clinical and echocardiographic experience in 70 consecutive patients with 73 cardiac myxomas, diagnosed over an 11 year period. There were 21 males and 49 females, ages ranged from 18 to 80 years. Only in 5.7% cases was the diagnosis of myxomas made clinically. 88.6% cases were initially diagnosed as having: mitral valve disease (70%), tricuspid valve disease (10%), ischemic heart disease (5.7%), cardiomyopathy (2.9%), and the remaining 5.7% were detected during family screening and follow-up. The mean duration of symptoms was 10.6 months. The commonest symptom was dyspnoea (80%), followed by constitutional symptoms (45.7%), embolization (30%), palpitation (25.7%), syncope (15.7%), pedal oedema (15.7%) and pain chest (12.9%). The sites of myxomas were as follows: left atrium, 58; right atrium, 9; and, biatrium, 3. All myxomas except 3 were attached to the interatrial septum. The site, size, shape, attachment, mobility, prolapse into ventricle, and surface characteristic of myxomas were accurately assessed by 2D-echocardiography and confirmed in all (65 of 70) who underwent surgery. When the morphological characteristic of myxomas were studied and correlated with clinical features large left atrial myxoma size was closely related with constitutional symptoms, congestive heart failure, with syncope and auscultatory findings suggestive of mitral valve disease, whereas smaller myxoma size and irregular surface were associated with embolization. Constitutional symptoms were only present in left atrial myxoma. Post-operative mean echocardiographic follow-up of 60 months showed no recurrence except in 2 with familial myxoma. We conclude that the majority of myxomas mimic many cardiovascular diseases and were detected in symptomatic patients, so a high index of clinical suspicion is important for its early and correct diagnosis. The size and appearance of the myxomas correlated with the presenting symptoms.

We postulated that the sensitivity of transthoracic echocardiography in detection of left atrial cavity or appendage thrombi is better in south-east asian patients with rheumatic mitral stenosis. This was considering that these patients are generally younger, have lesser body weight and thinner chest walls resulting in better transthoracic echogenecity than their western counterparts. We prospectively performed transthoracic and transoesophageal echocardiography in 150 consecutive Indian patients (mean age 28.8±7.2 years; 78 men) being evaluated for percutaneous transvenous mitral commissurotomy. The overall sensitivity of transthoracic echocardiography was 74% (95% C.I. 59–88%). This was significantly higher than the pooled estimate from five western reports which evaluated similar patients (overall sensitivity 12%; 95% C.I. 0–25%; P

The effect of BW755C (a dual inhibitor of cyclo- and lipoxygenase enzymes) alone and in combination with iloprost (a PGI2 analogue) on myocardial reperfusion injury was investigated in anaesthetised open-chest dogs. The left anterior descending coronary artery was occluded for a period of 40 min followed by reperfusion for 3 h. Dogs were administered either saline, BW755C (10 mg kg-1 slow bolus) or BW755C plus iloprost (100 ng kg-1 min-1 for 75 min) just prior to reperfusion. The haemodynamic data showed significant reduction in MAP and both LV peak-positive and peak-negative dP/dt following reperfusion in the saline-treated group, along with a delayed recovery of LVEDP. These changes were accompanied by significant depletion of myocardial ATP and glycogen stores. Administration of BW755C prevented the haemodynamic changes and replenished the HEP stores. Although coadministration of iloprost with BW755C afforded early normalisation of LVEDP and LV peak positive dP/dt, but MAP and LV peak negative dP/dt remained significantly depressed. Therefore, it might be concluded from this study that supplementation of BW755C with iloprost may have deleterious haemodynamic effects on the reperfused myocardium, particularly in the doses used.

The effects of iloprost infusion (100 ng/kg/min for 75 min) alone and in combination with aspirin (3 mg/kg IV bolus) were compared in a canine model of myocardial reperfusion injury. Regional ischemia of 40 min was produced by temporary occlusion of the left anterior descending coronary artery, after which the myocardium was reperfused for a period of 3 hours. Mean arterial pressure (MAP), heart rate (HR), left ventricular end diastolic pressure (LVEDP), positive (+) LVdP/dtmax and negative (-) LVdP/dtmax were monitored. Rate pressure product and (-) dP/dt/Pmax were also derived from the above. Myocardial tissue levels of adenosine triphosphate (ATP), creatine phosphate (CP), glycogen and lactate were estimated. Following reperfusion in the saline treated group, there was a significant fall in (i) MAP, (ii) (+) LVdP/dtmax and (iii) (-) LVdP/dtmax. LVEDP was corrected about 2 hours after reperfusion. Despite correction of lactate accumulation, ATP and glycogen were not restored although the CP store was replenished. The hemodynamic profiles in both iloprost and in combination treated groups were similar; (i) depressed MAP (particularly during iloprost infusion) without any significant change in HR (ii) no significant depression in (+) LVdP/dtmax (iii) depression in (-) LVdP/dtmax but not when corrected for lower Pmax and (iv) a significant reduction in the incidence of reperfusion arrhythmias. Similarly, in both the drug/s treated groups, ATP, CP and lactate were normalised although glycogen store was not restored. The results of this study indicate (i) cardioprotective effect of iloprost even when administered prior to reperfusion and (ii) no additional protective effect of combining iloprost and aspirin.

The effects of thromboxane A2 (TXA2)/prostaglandin endoperoxide receptor blockade on myocardial infarct size and cardiac dynamics were determined in a canine model of 24 h acute myocardial infarction. Anesthetized open-chest dogs were subjected to left anterior descending (LAD) coronary artery occlusion. Twenty minutes post-occlusion the dogs were given i.v. saline (0.9% NaCl solution) (n = 12) or the TXA2 receptor antagonist SQ 29548 (0.2 mg/kg i.v. loading dose +0.2 mg/kg/h i.v. for 4 h) (n = 10). SQ 29548 treatment resulted in a significant (P < 0.01) reduction in infarct size. Heart rate (HR) and systolic blood pressure (SAP) were not markedly affected by the drug. The sharp rise in the left ventricular end diastolic pressure (LVEDP) in the saline-treated animals was significantly lowered by SQ 29548 treatment and the correction of this variable was maintained till 24 h post-occlusion. The lowered maximal rate of rise of left ventricular pressure (LVdP/dt max) in the saline-treated animals was corrected albeit non-significantly by the drug treatment. Thus, SQ 29548 treatment resulted in a significant salvage of myocardial tissue and marked alterations in left ventricular dynamics. The study suggests a deleterious role for thromboxane A2 in ischemia; indicating that TXA2 blockade may have potential as a mode of therapy for ischemic heart disease.

Lipoprotein Lp(a) excess has been identified as a powerful predictor of premature atherosclerotic vascular diseases. To evaluate this in a North-Indian population, 130 CAD patients and 130 controls were analyzed. The size of the apo(a) phenotypic isoforms was inversely proportional to Lp(a) concentrations. The mean concentration of Lp(a) in the CAD patients was 42±34 mg/dl whereas in the normal subjects it was much lower, 27±27 mg/dl. 157 subjects out of the total 260 subjects showed plasma levels of >20mg/dl. The frequency of high Lp(a) levels was much higher in patients(73%) than controls (43%). These data suggest (1) that there is heterogeneity of the Lp(a) polymorphism, (2) Higher Lp(a) levels were found in patients than in the controls, (3) Patients showed 1.5 fold increase in Lp(a) levels as compared to the controls. We conclude that low molecular weight apo(a) isoforms are significantly associated with increased risk of CAD in the North-Indian population.

An elevated level of plasma homocysteine, sulfur containing amino acid generated through demethylation of methionine has been widely accepted as a risk factor for cardiovascular disease (CVD). The increase can result from genetic and/or nutrient related disturbances in the remethylation or transsulfuration pathways for homocysteine metabolism. A common mutation (C677T) in the gene encoding for the enzyme 5, 10-methylenetetrahydrofolate reductase (MTHFR) or deficiency of the B vitamins namely folic acid, B(12), B(6) can lead to hyperhomocysteinemia.In the present study, we have investigated the incidence of the (C677T) MTHFR polymorphism in the North Indian males. 141 angiographically proven coronary artery disease (CAD) patients and 55 age and sex matched healthy volunteers were examined for the association between MTHFR gene polymorphism and CAD. The MTHFR genotyping was performed using polymerase chain reaction (PCR) followed by restriction-isotyping with Hinf 1 endonuclease. A trend for higher 'T' allele frequency (0.19) was observed in patients than in controls (0.16). However no significant association was found between C677T mutation and CAD severity. The lack of statistical significance could be due to the small sample size studied. Hence a larger study including various ethnic groups is warranted.

In 136 consecutive patients who underwent percutaneous transvenous mitral commissurotomy (PTMC) with use of the single rubber-nylon (Inoue) balloon Inoue balloon angiographically analyzed subvalvular fibrosis was assessed retrospectively with regard to results and complications. There were 53 males and 83 females, with a mean age of 22 +/- 11 years (range 10 to 48 years). For the entire group, mitral valve area increased from 0.7 +/- 0.3 to 2.1 +/- 0.6 cm2 (p0.001). Valve area increased from 0.7 +/- 0.12 to 1.8 +/- 0.14 cm2 in patients with severe subvalvular fibrosis (n = 55) and from 0.8 +/- 0.11 to 1.9 +/- 0.12 cm2 in cases with mild to moderate subvalvular fibrosis (n = 80; p = NS). The number of patients with 2+ or greater increase in mitral regurgitation was not different between the two groups (6% vs 5.5%, p = NS). None of the patients required mitral valve replacement immediately after PTMC. We conclude that, with use of the Inoue balloon, PTMC can be successfully performed in patients with severe subvalvular fibrosis.

The effects of i.v. prostaglandins (PGs) E2 and I2 on ouabain-induced cardiac arrhythmias were investigated in chloralose-anaesthetized cats. Bilateral vagotomy and guanethidine-pretreatment interventions were employed to elucidate the involvement of vagal and sympathetic neural influences in these effects. PGE2 (1 micrograms/kg/min i.v. infusion for 5 min) and PGI2 (4-16 microgram/kg i.v. bolus injections) effectively suppressed the ouabain-induced arrhythmias in a control group of cats. The bilateral vagotomy or guanethidine-pretreatment interventions did not significantly alter the antiarrhythmic effects of PGE2 and PGI2. It is concluded that the presence of functionally intact sympathetic and vagal nerve supply to the heart is not a prerequisite for the antiarrhythmic effects of i.v. administered PGE2 and PGI2. The possible role of direct action of these PGs on the myocardium is discussed.

This study investigated the differential effect of losartan, an AT1 receptor blocker, when administered in pre- and postischemic phases, on the biochemical, hemodynamic and oxidative stress associated with regional ischemic-reperfusion injury in cat. Losartan (5 microg/kg/min) or normal saline was administered intravenously in open chest barbiturate anesthetized cats, 15 min before and 10 min after the occlusion of the left anterior descending (LAD) coronary artery. The LAD was occluded for 15 min followed by 60 min reperfusion. In the saline treated group, there was significant depression of hemodynamic functions, i.e., mean arterial pressure (MAP), heart rate (HR), left ventricular end diastolic pressure (LVEDP) and left ventricular (LV) peak (+/-) dP/dt, along with depletion of adenosine triphosphate (ATP) of the affected myocardium. Oxidative stress during reperfusion injury was evidenced by significant increase in plasma thiobarbituric acid reactive substances (TBARS) accompanied by significant reduction in myocardial superoxide dismutase (SOD) activities. In both treatment groups, losartan caused recovery of all the hemodynamic parameters and repletion of ATP along with no significant change in plasma TBARS and myocardial SOD activity. There was no effect on catalase activity. Results from the study suggest that the effects of pre- and posttreatment of losartan are comparable in functional recovery of the heart from ischemic-reperfusion injury.

In practice, chronic heart failure is often not treated with angiotensin-converting enzyme inhibitors. One reason is the fear of first-dose hypotension. In the majority of patients, this condition is asymptomatic and the consequences are unexpected. Presently, little is known of its epidemiology.This was a prospective, 48-hour observational study of 160 patients with chronic heart failure due to systolic dysfunction, previously untreated with angiotensin-converting enzyme inhibitors, randomly drawn from the clinical practice of selected cardiologists across India. The primary outcome was a change in the mean arterial pressure during the first 24-hours after the first dose of an angiotensin-converting enzyme inhibitor. In 131/160 patients (81.9%) with no hypotensive symptoms, the incidence of first-dose hypotension (maximum 24-hour fall in mean arterial pressure greater than 10% from baseline) was 56/131 (42.7%). Pre-treatment diastolic pressure had a negative, independent association with 24-hour change in mean arterial pressure, accounting for 29% (R2=0.29, p0.01) of its variability, and its predictive value was greater with pro-drug angiotensin-converting enzyme inhibitors. The incidence of first-dose hypotension increased from 1 patient (4.8%) at a pre-treatment diastolic pressure of 50-70 mmHg to 35 patients (42.7%) at 71-90 mmHg, p0.01.The incidence of first-dose hypotension with angiotensin-converting enzyme inhibitors in outpatients with chronic heart failure due to systolic dysfunction is high. Pre-treatment diastolic pressure is an independent risk factor, and its predictive value increases with pro-drug angiotensin-converting enzyme inhibitors. This could help physicians to anticipate asymptomatic first-dose hypotension and increase the utilization of these agents in heart failure.

Yoga has potential for benefit for patients with coronary artery disease though objective, angiographic studies are lacking. We evaluated possible role of lifestyle modification incorporating yoga, on retardation of coronary atherosclerotic disease. In this prospective, randomized, controlled trial, 42 men with angiographically proven CAD were randomized to control (n = 21) and yoga intervention group (n = 21) and were followed for 1 year. The active group was treated with a user-friendly program consisting of yoga, control of risk factors, diet control and moderate aerobic exercise. The control group was managed by conventional methods i.e. risk factor control and American Heart Association step I diet.

The benefits from cardiac angiographic procedures are enormous. They can prove to be life saving in many situations. The utility of such angiographic procedures is unquestionable. What matters is, can the doses be reduced even if they are not alarming from the point of view of deterministic effects? In the authors' study they observed that the doses are not reaching the level of deterministic effects particularly for skin injuries. Keeping in mind the stochastic effects and associated ALARA principle, every attempt to reduce the dose is welcome. The maximum problem is encountered in convincing the cardiologists that they need training in radiation protection. While cardiologists are afraid of the small amount of radiation from a radioactive stent, they invariably they fail to pay heed to X-rays, which are taken hundreds of times, and have a higher radiation intensity than the radioactive substances used in stents. There does appear to be scope for dose reduction, and here training methodologies might be useful.

The association between Chlamydia pneumoniae infection and atherosclerosis has gained recognition. However, the nature of this association is controversial. The infective link may not be specific for atherosclerosis and may also exist in other nonatherosclerotic arterial diseases. We investigated patients with nonspecific aortoarteritis for serological evidence of prior Chlamydia pneumoniae infection.Fifty patients each of nonspecific aortoarteritis and coronary artery disease with angiographic evidence of significant (70%) coronary artery lesions were tested for the presence of IgG antibodies against Chlamydia pneumoniae by micro-immunofluorescence assay and compared with 50 age- and sex-matched normal healthy controls. The number of patients with nonspecific aortoarteritis who tested positive for Chlamydia pneumoniae antibodies (IgG) was not significantly different from controls (8 v. 7, p=ns). The mean titer amongst positive subjects in the two groups was also similar (1:40+/-40 v. 1:50+/-25; p=ns). Patients with coronary artery disease were significantly older than patients with nonspecific aortoarteritis and controls (53.2+/-5.8 v. 21.2+/-9.9 years and 24.5+/-5.2 years, p0.01 for both) and showed a higher seroprevalence of prior Chlamydia pneumoniae infection (18 v. 8 and 7, p0.05 for both). The mean IgG titers of patients with coronary artery disease who tested positive were also significantly higher than the other two groups (1:98+/-34 v. 1:40+/-40, p0.001 and 1:98+/-34 v. 1:50+/-25, p0.01, respectively).In patients with nonspecific aortoarteritis, the seroprevalence of prior Chlamydia pneumnoniae infection is not more than that in healthy individuals of the same age group, but is significantly lesser than that in patients with coronary artery disease. Thus Chlamydia pneumoniae infection may not be associated with all forms of chronic inflammatory arterial lesions.