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Peripheral artery (PAD) disease in association with renal artery stenosis is an important association which predicts the severity of the disease. An increase in the number of vessels affected by peripheral artery disease increases the chances of renal artery stenosis. In our case, the patient had primarily presented with anginal chest pain with complaints of claudication which on further investigation was diagnosed to be a triple vessel coronary artery disease along with bilateral subclavian and bilateral renal stenosis. On detailed history taking, risk factors like hypertension and chronic smoking was found to be present in our case which predisposed to peripheral artery disease secondary to atherosclerosis which was diagnosed on further investigations. Although the association of renal artery stenosis is not very rare in cases of severe peripheral vascular diseases, the presence of a triple vessel coronary artery disease in synchrony is what makes it unique. Take away lesson from this case report is importance of early diagnosis of dyslipidemia causing atherosclerosis and its complications. Multiple atherosclerotic lesions in synchrony i.e, bilateral renal artery stenosis with bilateral subclavian artery stenosis with coronary artery triple vessel atherosclerotic disease like in our case and its severity should create awareness among health care individuals and early treatment measures including lifestyle modifications should be considered to avoid such drastic events.

Peripheral artery (PAD) disease in association with renal artery stenosis is an important association which predicts the severity of the disease. An increase in the number of vessels affected by peripheral artery disease increases the chances of renal artery stenosis. In our case, the patient had primarily presented with anginal chest pain with complaints of claudication which on further investigation was diagnosed to be a triple vessel coronary artery disease along with bilateral subclavian and bilateral renal stenosis. On detailed history taking, risk factors like hypertension and chronic smoking was found to be present in our case which predisposed to peripheral artery disease secondary to atherosclerosis which was diagnosed on further investigations. Although the association of renal artery stenosis is not very rare in cases of severe peripheral vascular diseases, the presence of a triple vessel coronary artery disease in synchrony is what makes it unique. Take away lesson from this case report is importance of early diagnosis of dyslipidemia causing atherosclerosis and its complications. Multiple atherosclerotic lesions in synchrony i.e, bilateral renal artery stenosis with bilateral subclavian artery stenosis with coronary artery triple vessel atherosclerotic disease like in our case and its severity should create awareness among health care individuals and early treatment measures including lifestyle modifications should be considered to avoid such drastic events.

The top cause of death around the world, cardiovascular disease is also the primary cause of death in India. In 2016, India anticipates a total of 62.5 million premature deaths due to cardiovascular disease. Aim: This research was conducted with the goals of (1) determining whether resting global longitudinal strain (GLS) correlates with angiographic severity in patients with coronary artery disease by using the GENSINI and SYNTAX scores; (2) evaluating the validity of using GLS to diagnose severe coronary artery disease; and (3) determining whether or not GLS can be used to diagnose severe coronary artery disease. It was anticipated that the study's findings would provide solutions to both problems." Materials & methods: To participate in the experiment, participants were required to either have coronary artery disease or a clinically comparable diagnosis. The study was conducted at the SCB Medical College and Hospital in Cuttack, which served as the location. Patients who had unstable angina, chronic stable angina, or myocardial infarction that did not involve ST-elevation were recruited to take part in the trial if they satisfied the inclusion criteria. The observational research method, known as cross-sectional research, was used for this study. One hundred and ten patients were evaluated for coronary artery disease as a potential diagnosis. Patients eligible to take part in the trial, defined as those who satisfied the inclusion criteria and made an appointment with a cardiologist at SCB Medical College and Hospital between August 2020 and December 2021, were allowed to do so. Conclusion: When evaluated during rest using 2D speckle tracking echocardiography, GLS reliably predicts the prevalence, severity, and degree of CAD. This test has a very high sensitivity and specificity. GLS has an early detection rate of 88.89% specificity and 84.62% sensitivity for severe CAD. The well-known SYNTAX and GENSINI scores show a linear but negative relationship between CAD complexity and GLS. 2-D-STE can improve echocardiography for the diagnosis of CAD by identifying high-risk individuals and providing the treating physician with more information. When the pretest chance of coronary artery disease is low, strain imaging can reveal significant illness in the heart's arteries. This is especially true during the entirety of the examination. [ABSTRACT FROM AUTHOR]

Introduction: Coronary heart disease (CAD) is the leading cause of morbidity and mortality worldwide, with India being the top cause. The Asian subcontinent accounts for 20% of the world's population, but 60% of the cardiovascular disease burden is due to genetic predisposition and environmental factors. Arterial stiffness increases with aging, accelerated by cardiovascular risk factors like hypertension and diabetes. Endothelial dysfunction in coronary arteries affects arterial stiffness and potentially reversible in atherogenesis. Pressure wave velocity (PWV) is a useful index for assessing endothelial status and large artery stiffness. Large artery stiffening can increase systolic blood pressure, left ventricular afterload, and left ventricular hypertrophy, potentially limiting coronary perfusion. Material and Methods: A prospective cross-sectional study was conducted at Sri Jayadeva Institute of Cardiovascular Sciences and Research Centre in Bangalore, India, from 1/6/2018 to 31/01/2019. Thirty patients with triple vessel disease and 30 age-matched controls underwent angiography at the institute. Echocardiography and Doppler evaluation assessed heart carotid pulse wave velocity and transit time. The study included patients with triple vessel disease and normal epicardial coronary arteries. The study excluded patients over 70 years old, having a heart rate above 100, having severe LV dysfunction below 30%, having chronic kidney disease, or having coronary artery stenosis. Demographic details, family history, medical history, clinical presentation, diagnostic tests, and blood tests were collected from patients. The study used descriptive and inferential statistical analysis, with continuous measurements presented as Mean ± SD and categorical measurements as Number (%). Results: The study involved 30 cases and 30 controls, with the majority of patients aged 50-70 years and controls aged 40-60 years. The gender distribution was predominantly males. Diagnosis distribution was similar between the two groups, with patients with EA, UA, or TMT positive being more likely to undergo angiography. BMI (kg/m2) distribution was similar between the two groups, with the majority of patients still overweight or obese but having normal BMIs. Pulse transit time (PTT) was significantly lower in the triple vessel disease case group compared to the control group with normal coronary angiography. Pulse wave velocity (PWV) increased in the case group compared to the control group. In contrast to the control group, 66% of the patients in the case group showed some kind of LV dysfunction due to more patients with myocardial infarction. Pulse wave velocity was significantly lower in the case group, with 20% and 63% shorter. LMCA distribution was also similar between the two groups, with patients with LMCA having lower pulse transit time (20%) and (63% shorter) compared to the control group. The study highlights the importance of assessing patients' angiography and LMCA distribution in determining the appropriate treatment for patients with LV dysfunction. Conclusion: Aortic PWV predicts future cardiovascular risk by accounting for known risk variables. It could be a valuable biomarker for intermediate risk, but randomized controlled studies are needed to prove its therapeutic utility before implementation. [ABSTRACT FROM AUTHOR]

Peripheral artery (PAD) disease in association with renal artery stenosis is an important association which predicts the severity of the disease. An increase in the number of vessels affected by peripheral artery disease increases the chances of renal artery stenosis. In our case, the patient had primarily presented with anginal chest pain with complaints of claudication which on further investigation was diagnosed to be a triple vessel coronary artery disease along with bilateral subclavian and bilateral renal stenosis. On detailed history taking, risk factors like hypertension and chronic smoking was found to be present in our case which predisposed to peripheral artery disease secondary to atherosclerosis which was diagnosed on further investigations. Although the association of renal artery stenosis is not very rare in cases of severe peripheral vascular diseases, the presence of a triple vessel coronary artery disease in synchrony is what makes it unique. Take away lesson from this case report is importance of early diagnosis of dyslipidemia causing atherosclerosis and its complications. Multiple atherosclerotic lesions in synchrony i.e, bilateral renal artery stenosis with bilateral subclavian artery stenosis with coronary artery triple vessel atherosclerotic disease like in our case and its severity should create awareness among health care individuals and early treatment measures including lifestyle modifications should be considered to avoid such drastic events.

Peripheral vascular disease in association with renal artery stenosis is an important association which predicts the severity of the disease. An increase in the number of vessels affected by peripheral vascular disease increases the chances of renal artery stenosis. In our case, the patient had primarily presented with anginal chest pain with complaints of claudication which on further investigation was diagnosed to be a triple vessel coronary artery disease along with bilateral subclavian and bilateral renal stenosis. On detailed history taking, risk factors like hypertension and chronic smoking was found to be present in our case which predisposed to peripheral artery disease secondary to atherosclerosis which was diagnosed on further investigations. Although the association of renal artery stenosis is not very rare in cases of severe peripheral vascular diseases, the presence of a triple vessel coronary artery disease in synchrony is what makes it unique. Take away lesson from this case report is importance of early diagnosis of dyslipidemia causing atherosclerosis and its complications. Multiple atherosclerotic lesions in synchrony i.e, bilateral renal artery stenosis with bilateral subclavian artery stenosis with coronary artery triple vessel atherosclerotic disease like in our case and its severity should create awareness among health care individuals and early treatment measures including lifestyle modifications should be considered to avoid such drastic events.

Introduction: Duration of Type 2 Diabetes Mellitus (T2DM) and degree of glycaemic control play a pivotal role in the development of macrovascular complications of T2DM, including Coronary Artery Disease (CAD). However, association of the duration of T2DM and Glycosylated Haemoglobin (HbA1c) level with the severity of CAD is still an ongoing matter of debate in the diabetic patient subset. Aim: To investigate the association of duration of T2DM and HbA1c level with severity of CAD in patients presenting with T2DM suspected of CAD. Materials and Methods: This prospective, cross-sectional, observational study was conducted on 500 T2DM patients at GNRC Medical, Guwahati, Assam, India from June 2017 to June 2019. The T2DM patients with suspected CAD were studied and stratified according to the duration of T2DM (<10 and >10 years) and HbA1c level (<7% or ≥7%). All patients underwent coronary angiography to assess number of diseased vessels i.e., insignificant CAD (defined as <50% diameter stenosis in left main and <70% diameter stenosis in other branches), Single Vessel Disease (SVD), Double Vessel Disease (DVD), Triple Vessel Disease (TVD), and Left Main Coronary Artery (LMCA) disease. Chi square test was used to assess the correlation of the duration of T2DM and HbA1c level with angiographic severity of CAD. The data were analysed using the Statistical Package for Social Sciences (SPSS) version 16.0, (Chicago, IL, USA). Results: A total of 500 patients were studied, of which, 295 (59%) and 205 (41%) patients had <10 and ≥10 year duration of T2DM, respectively. Overall, 264 (52.8%) patients had HbA1c <7%, and 236 (47.2%) had ≥7%. Normal coronary artery (42.4% vs. 5.9%; p=0.00001), insignificant CAD (9.8% vs. 2.4%; p=0.00124), SVD (21% vs. 6.8%; p=0.00001), and LMCA disease (2.4% vs. 13.2%; p=0.00001) were significantly higher in patients with <10 year duration of T2DM than ≥10 year. On the other hand, DVD (12.9% vs. 28.8%; p=0.00001), and TVD (11.5% vs. 42.9%; p=0.00001) were significantly higher in patients with ≥10 year duration of T2DM as compared to <10 year. Normal coronary artery (34.8% vs. 19.1%; p=0.0001), and insignificant CAD (10.2% vs. 2.9%; p=0.0013) was higher in patients with HbA1c level <7% than ≥7%. The prevalence of TVD (18.6% vs. 30.9%; p=0.0013), and LMCA disease (3.8% vs. 10.2%; p=0.0047) were significantly lower in patients with HbA1c level <7 than ≥7%. Conclusion: The T2DM patients with suspected CAD, longer duration of T2DM and poor glycaemic control were associated with more severe CAD. [ABSTRACT FROM AUTHOR]

We report 8‐year follow‐up of a home‐based exercise rehabilitation program combined traditional Chinese medicine for a patient with triple vessel disease patient complicated with heart failure without invasive intervention. Improvements were observed in all outcomes. For this patient with triple vessel disease patient complicated heart failure, we did not perform percutaneous coronary intervention, after applying home‐based cardiac rehabilitation combined with traditional Chinese medicine, the long‐term follow‐up. [ABSTRACT FROM AUTHOR]

Acute coronary syndrome is a manifestation of coronary artery disease caused by decreased blood flow to the heart musculature resulting in ischaemia and infarction of the heart. The Lewis (Le) blood group system comprise mainly Lewis a & b antigens which are secreted in plasma and are expressed on red cells, platelets and endothelium. This study assesses the risk of multivessel disease in acute coronary patients with lewis negative (a− b−) phenotype. The study included 183 patients diagnosed with acute coronary syndrome and who underwent coronary angiography to detect stenosis of the coronary vessels. The severity of the disease was classified based upon the number of vessels stenosed and their blood sample was phenotyped for Lewis antigens. The patients' risk factors, GRACE score and management were included for the study and multivariate logistic regression was carried out for analysis. The prevalence of Lewis (a− b−) was 27.4% and there was a significant association with multivessel disease (P < 0.05). However, there was no association of lewis (a− b−) with any of the risk factors causing coronary disease. The adjusted odds ratio of triple vessel disease in lewis (a− b−) was 2.6, female gender was 0.6 and patients with diabetes mellitus was 3.1, respectively. The GRACE score showed a significant association with ABO blood group (P < 0.05) but not with lewis (a− b−). Lewis negative patients are more likely to develop triple vessel disease compared to other lewis blood groups. This warrants further studies to investigate the link between lewis system and atherothrombosis. [ABSTRACT FROM AUTHOR]

Abstract We report 8‐year follow‐up of a home‐based exercise rehabilitation program combined traditional Chinese medicine for a patient with triple vessel disease patient complicated with heart failure without invasive intervention. Improvements were observed in all outcomes.

Introduction: Duration of Type 2 Diabetes Mellitus (T2DM) and degree of glycaemic control play a pivotal role in the development of macrovascular complications of T2DM, including Coronary Artery Disease (CAD). However, association of the duration of T2DM and Glycosylated Haemoglobin (HbA1c) level with the severity of CAD is still an ongoing matter of debate in the diabetic patient subset. Aim: To investigate the association of duration of T2DM and HbA1c level with severity of CAD in patients presenting with T2DM suspected of CAD. Materials and Methods: This prospective, cross-sectional, observational study was conducted on 500 T2DM patients at GNRC Medical, Guwahati, Assam, India from June 2017 to June 2019. The T2DM patients with suspected CAD were studied and stratified according to the duration of T2DM (10 years) and HbA1c level (

Vijay Yadav, Sunil Chandra Jha, Ratna Mani Gajurel, Chandra Mani Poudel, Ravi Sahi, Manju Sharma, Suman Adhikari Department of Cardiology, Manmohan Cardiothoracic Vascular and Transplant Centre, Kathmandu, NepalCorrespondence: Vijay YadavDepartment of Cardiology, Manmohan Cardiothoracic Vascular and Transplant Centre, Kathmandu, NepalTel +977-9851201126Email vjmedicine451@gmail.comBackground: Studies emphasizing the prevalence of coronary artery disease (CAD) and the diversity of coronary lesions among asymptomatic renal transplant recipients (RTRs) are few and far between in Nepal.Methods: In this cross-sectional observational study, a cohort of potential RTRs who were subjected to coronary angiography (CAG) as a part of both routine pre-op evaluation and therapeutic modality were enrolled and the spectrum of coronary angiographic lesions was reported. Significant CAD was defined by angiography as ≥ 70% stenosis. Percutaneous coronary intervention (PCI) was done for significant lesions.Results: A total of 60 patients (mean age: 53.7 ± 7.2 years, 43 males and 17 females) formed the subjects of the study. Diabetes was the commonest cause of ESRD (61.7%) with the mean duration of ESRD being 4.3 ± 2.2 years. Of the patients, 86.7% were routinely subjected to CAG and the remaining 13.3% presented with acute coronary syndrome. The right femoral artery was the most common access vessel (81.7%). CAD was present in 30/60 patients (50%). The left anterior descending artery was the most common culprit vessel (46.7%), followed by the left circumflex artery (38.3%). Among the routine CAG group, 42.3% had some form of CAD, the highest proportion of which was triple vessel disease (23.3%). Both double vessel disease and triple vessel disease were found to be highly prevalent in patients with hyperlipidemia, diabetes, and in smokers. The angiographic lesions were predominantly of discrete (41%), diffuse (35.9%), and eccentric (46.2%) types, had tandem arrangement (58.9%) with moderate angulation (56.4%), and were irregular (58.9%) in contour. A total of 3 ostial (7.7%) and 9 calcified (23.1%) lesions were found to be present. Chronic total occlusion and bifurcation lesions were observed in 4 (10.3%) and 5 (12.8%) cases, respectively. Six (15.4%) patients had well-developed collaterals. Twenty-one (53.8%) patients underwent PCI and 3 (7.7%) patients underwent coronary artery bypass surgery. Type B2 was the most common lesion (46.2%).Conclusion: Asymptomatic ESRD patients on the renal transplant list were found to have a high prevalence of CAD. CAG can be an efficient screening alternative for the detection of significant CAD among these patients.Keywords: coronary angiography, coronary artery disease, triple vessel disease, end-stage renal disease, kidney transplant

Objective: We report a case of a patient undergoing Open Coronary Artery Bypass Graft Surgery (CABG) with CytoSorb® under dual antiplatelet therapy (DAPT) with a broken guidewire in RCA ostium. Case Presentation: A 66-year-old male patient on doublet antiplatelet therapy of ticagrelor and ecospirin underwent percutaneous transluminal coronary angioplasty (PTCA) in lieu of Triple Vessel Disease (TVD). During withdrawal, guide wire was stuck in the right coronary artery ostium. Patient’s LVEF reduced to 40% with akinitic walls and early pulmonary edema. On-pump coronary artery bypass graft (CABG) surgery was performed using intraoperative CytoSorb®. Results: No post-operative bleeding was recorded. The patient demonstrated good pump function and sinus rhythm. The patient was discharged within 7 days of hospitalization including 3 days of ICU stay. Conclusions: Intra-operative usage of CytoSorb® during emergency cardiac surgery in-patient treated with anti-platelet agents is an effective option which reduces risk of bleeding complications, thereby improving outcomes, reducing cost and minimizing morbidity and mortality.

Amegakaryocytic thrombocytopenia is a rare haematologic disorder characterised by a profound reduction in platelet production due to the near absence of megakaryocytes, leading to severe thrombocytopenia. This report elucidates the diagnostic and therapeutic challenges encountered in managing such rare haematological conditions alongside significant cardiovascular disease. We detail the case of a patient who presented with chest pain and was diagnosed with non-ST elevation myocardial infarction (NSTEMI). Subsequent investigations revealed severe thrombocytopenia and underlying triple vessel disease, complicating immediate surgical intervention. Initial management strategies aimed at treating presumed immune thrombocytopenia proved ineffective. A definitive diagnosis of amegakaryocytic thrombocytopenia was established following a bone marrow biopsy. Despite treatment adjustments, including the administration of thrombopoietin agonists and immunosuppression, platelet counts improved but did not reach levels safe for coronary artery bypass grafting. This case underscores the importance of diagnosis and treatment of systemic disorders prior treatment of cardiac disease. It also demonstrates the importance of interdisciplinary cooperation in the treatment of a complex patient case., Learning Points: Amegakaryocytic thrombocytopenia is a rare cause of thrombocytopenia that can co-occur with cardiac conditions.The diagnosis of amegakaryocytic thrombocytopenia can be difficult as it can be mistaken for immune mediated thrombocytopenia, but distinction is critical as treatments differ.Modern patient care frequently requires collaboration between different subspecialities., Competing Interests: Conflicts of Interests: The Authors declare that there are no competing interests., (© EFIM 2024.)

Objectives: To determine frequency of left main stem (LMS) and triple vessel coronary artery disease (3VCAD) in patients of Non-ST-elevation myocardial infarction (NSTEMI) and to compare the frequency of LMS and 3VCAD in patients with NSTEMI with or without ST elevation in lead aVR. Methodology: Total 346 patients with NSTEMI having age 30-70 years were included in this descriptive cross-sectional study. The data on demographic details was collected. All patients underwent electrocardiography (ECG) and cardiac specific troponin-I assessment. Patients were categorized as NSTEMI with or without ST-elevation in lead aVR. Coronary angiography was performed in all patients and angiographic findings were noted. Results: Mean age of patients was 51.87±10.03 years. There were 218 (63.01%) males and 128 (36.99%) female patients. 182 (52.60%) patients of NSTEMI had ST elevation in aVR. LMS disease was found in 53 (29.10%) patients with ST elevation in aVR. Sensitivity, specif icity, positive predive value and negative predictive value of ST elevation in aVR for LMS disease was 62.35%, 50.57%, 29.12% and 80.49% respectively. 3 VCAD was found in 54 (29.70%) with ST elevation in aVR. Sensitivity, specificity, positive predive value and negative predictive value of ST elevation in aVR for 3VCAD was 77.14%, 53.52%, 29.67% and 90.24% respectively. Conclusion: NSTEMI patients with ST elevation in aVR may have higher chances of having LMS disease or 3VCAD. There is high negative predict ive value for ST elevation in aVR to predict LMS disease or 3VCAD. [ABSTRACT FROM AUTHOR]

Acute coronary syndrome with cardiogenic shock is a life-threatening condition, but with planned staged treatment combined with coronary revascularization and mechanical circulatory supports its management is increasingly possible. Here, we present our successful life-saving case. A 76-year-old male patient was diagnosed with ST-elevation myocardial infarction with cardiogenic shock due to severe stenosis of the left main coronary artery based on the severe triple vessel disease. We initially introduced Impella CP and performed a percutaneous coronary intervention without stenting on the patient. We maintained hemodynamics with Impella CP and performed coronary artery bypass grafting after a week. Intraoperatively, Impella CP was left to function as a left ventricular vent. The patient required upgrading to Impella 5.5 plus veno-arterial extracorporeal membrane oxygenation postoperatively, but his condition gradually improved, all mechanical circulatory supports could be weaned off, and he eventually survived. [ABSTRACT FROM AUTHOR]

Hydatid cyst is an infection caused by the larval form of Echinococcus tapeworm. A cardiac presentation of the cyst is a rare scenario. This is a case of an elderly female who presented with dyspnoea, angina and heaviness of chest, and was found to have ischemic heart disease on electrocardiography. Her echocardiography showed global left ventricular hypokinesia and a pericardial cystic lesion. Cardiac magnetic resonance imaging revealed a loculated mass lesion along the free wall of the left ventricle and triple vessel disease was seen on coronary angiogram. Serum IgG antibodies against Echinococcus were positive. Anaphylaxis and cardiac tamponade due to cyst rupture were the main concerns. Since our patient had two life threatening conditions, a combined surgical and medical approach was opted. She underwent coronary artery bypass grafting along with cyst excision and albendazole therapy; and recovered uneventfully.

A 75-year-old, married man was diagnosed with coronary artery disease (CAD) [severe triple vessel disease (TVD)] in the 2nd week, June-2018. The physician advised him to undergo conventional medication and coronary artery bypass graft. Since the patient refused to undergo surgery he was admitted in our hospital and underwent yoga and naturopathy-based lifestyle modification (YNLM) along with conventional medicines for 16 weeks [12 weeks of intensive care at inpatient department and 4 weeks at outpatient department (OPD)]. After 16 weeks, the patient visited our OPD once/twice a month for 6 months. An increase in left ventricular ejection fraction from 35 to 48%; and a reduction in weight from 77.5 to 71-kg, and BMI from 26.60 to 24-kg/m2 were observed after 6 months of follow-up compared with baseline. Thus, YNLM might be considered as an adjuvant in reducing risk factor and in improving left ventricular systolic dysfunction in patients with CAD (severe-TVD). However, further studies are required to establish the efficacy of YNLM for CAD. [ABSTRACT FROM AUTHOR]

History of present illness: An 80-year-old female with a history of Crohn’s disease presented to the emergency department with chest pain. She had two weeks of exertional chest pain that preceded an episode of chest pain immediately prior to arrival associated with diaphoresis. Her pain nearly completely resolved with sublingual nitroglycerin provided by pre-hospital personnel. She was hemodynamically stable with normal vital signs on arrival. An ECG was immediately obtained. Significant findings: The ECG shows ST-segment depressions in precordial leads V3 through V6, and limb leads I, II, and aVL, and 1 mm of ST-segment elevation in aVR. The initial troponin I was elevated at 1.37 ng/mL (upper limit of normal 0.40). Cardiology decided to delay catheterization until the next day when diffuse coronary disease was discovered (including 90% of the left circumflex stenosis, 60% proximal and 75% mid-left anterior descending stenosis, 75% third diagonal branch stenosis, and 90% posterior descending artery stenosis). The following day, the patient went to the operating room for coronary artery bypass grafting (CABG). Discussion: Traditionally, lead aVR has not received attention when interpreting acutely ischemic changes on ECG, leading some to refer to it as “the forgotten lead.”1 Current guidelines acknowledge the significance of multilead ST depression with coexistent ST elevation in aVR, and this pattern has been identified as the strongest predictor of severe left main coronary artery and/or 3-vessel disease (LM/3VD).2-3 When this ECG pattern is recognized in patients with ischemic symptoms, the emergency physician should involve cardiology early. When managing patients with suspected LM/3VD, it is important to withhold dual anti-platelet therapy as CABG is likely to be indicated,1,3 and guidelines recommend discontinuing P2Y12 inhibitors like clopidogrel or ticagrelor at least 24 hours prior to urgent CABG.2

Masquerading bundle branch block is a rare but important finding on the Electrocardiogram (ECG). It is an indication of severe and diffuse conduction system disease and usually indicates poor prognosis. The precordial leads show a Right Bundle Branch Block (RBBB) pattern while the limb leads resemble a Left Bundle Branch Block (LBBB). This finding on an ECG is almost invariably associated with severe underlying heart disease. It is extremely important to be aware of this finding as it is a marker of poor cardiac outcomes. We report the case of a 68-year-old gentleman, who presented with progressive dyspnoea on exertion over three months. ECG showed a broad QRS complex with a RBBB pattern on the precordial leads and a LBBB pattern on the limb leads (suggestive of masquerading bundle branch block). A coronary angiogram revealed severe Triple Vessel Disease (TVD). The patient was scheduled for an early Coronary Artery By-Pass Grafting Surgery. However, his clinical condition deteriorated and he died while awaiting the surgery.

Objectives: The objective of this study was to show coronary angioghraphic pattern in patients having high duke treadmill. th Methodology: This cross sectional study was conducted between 28th March 2015 to 27th Sepetember 2015 at Cardiology Department of Chaudhary Pervaiz Elahi Institute of Cardiology, Multan. Patients with stable angina having high Duke's score that is less than 11, between 35-60 years of age of both genders were selected. Patients with history of myocardial infarction, unstable angina, heart failure and pregnancy were excluded. After this coronary angiography was conducted in all these patients. Findings were noted as no stenosis, single vessel disease, double vessel disease, triple vessel disease and left main stem disease. Results: Mean age of patients was 52.42 ± 4.78 years. Out of total 220 patients, 126 (57.27) were females,with female to male ratio of 1.3:1. Triple vessel disease was most common angiographic finding and was seen in 82 (37.27%) patients followed by left main stem disease in 73 (33.18%) patients. Double vessel disease, single vessel disease and no stenosis in 39 (17.73),18 (8.18%) and 08 (3.64%) patients respectively. Conclusion: This study concluded that severity of angiographic patterns correlate significantly with high risk Duke's trade mill score on exercise testing in patients with stable angina. [ABSTRACT FROM AUTHOR]

Background Non-traditional EKG parameters such as QRS pattern and QRS duration (QRSd) are being investigated in acute coronary syndrome as prognostic markers. Following an infarction, the heart attempts to compensate for myocardial loss through remodeling which eventually lowers the ejection fraction (LVEF). Our objective is to evaluate the relationship between the QRSd at the time of NSTEMI and extent of coronary artery disease (CAD) and changes in LVEF. Methods and results Patients admitted with NSTEMI between 08/01/2006 and 9/30/2012 were included. Patients were classified into high or low QRSd at cutoff value of 90 ms noted on initial EKG after excluding bundle-branch block. A total of 536 patients with mean age of 66 ± 14 years were included. 49% were male and majority were African American (73%). Patients within the higher QRSd group had a lower LVEF at the time of the NSTEMI compared to those with QRSd < 90 ms (47 ± 15% vs. 50 ± 13%; p < 0.038). The LVEF remained lower in the high QRS group on follow up to 12 months (47 ± 15% vs. 52 ± 11%; p < 0.001). The high QRSd group had a higher incidence of severe LV dysfunction at baseline (27% vs. 18%; p < 0.045). Logistic regression analysis revealed that a QRSd ≥ 90 ms was also independently associated with a severely reduced LVEF on follow-up (OR = 2.7; CI 1.55–4.69; p < 0.001). Conclusion QRSd ≥ 90 ms at the time of NSTEMI is predictive of three-vessel/left main coronary artery involvement and a lower LVEF. This depression in LVEF is maintained for up to 12 months. Thus, the QRSd at time of NSTEMI has additional prognostic significance. [ABSTRACT FROM AUTHOR]

Introduction: Atherosclerosis leading to ischemic heart disease (IHD) is the most common cause of cardiac deaths worldwide. To evaluate the prevalence of atherosclerosis, an autopsy-based study conducted on subjects who died of noncardiac causes can be a valuable tool. With this hypothesis, we conducted this study on the hearts of subjects who died of noncardiac causes. Materials and Methods: This study was conducted from August 2012 to February 2013 at Department of Pathology, BJ Medical College, Ahmedabad, Gujarat. The deceased patients who died of noncardiac causes and underwent autopsy at our hospital, their hearts were sent to our department for histopathological analysis. The hearts were fixed in 10% formalin, weighed, measured, and the three main coronary arteries were dissected out and carefully examined for any histological evidence of atherosclerotic plaques and associated pathological lesions and graded according to the classification given by American Heart Association. Results: A total of 250 autopsy cases were evaluated. Amongst them 113 were deaths due to noncardiac causes, of which 83 (73.45%) subjects had evidence of atherosclerosis. In the study, 68 (82%) were males and 15 (18%) were females. Left anterior descending artery (LADA; 69%) was the most commonly involved coronary artery. Triple vessel disease was found in 22% of subjects. Conclusion: The study showed alarmingly high prevalence of atherosclerosis. The pathogenesis of coronary atherosclerosis begins at a younger age in Indian population. Though the incidence of atherosclerosis is more common in males compared to females; coronary atherosclerosis is an important risk factor for IHDs in both sexes and screening for the same should begin at an early age. [ABSTRACT FROM AUTHOR]

Objective: To determine the frequency of carotid artery disease in patients under going coronary artery bypass graft (CABG) and to assess the association between carotid artery disease and coronary artery disease (CAD). Methodology: This cross sectional study was conducted at Rawalpindi Institute of Cardiology, Rawalpindi, Pakistan from October 2013 to April 2014. All participants underwent pre-operative carotid Doppler assessment for level of stenosis and site of carotid plaque. Using the criteria defined by the Society of Radiologists in the Ultrasound Consensus, the degree of stenosis was stratified into the categories of normal (no stenosis), 50% non-obstructive carotid disease, 50-69% significant stenosis, 70% critical stenosis to near occlusion, near occlusion, and total occlusion. Results: The total number of patients were 140 with the mean age of 59.6±7.1 years. Male to female ratio was 4:1. Normal carotid arteries were seen in 31 (22.2%) patients, while 79 (56.4%) had non-obstructive carotid disease, 15 (10.7%) had significant stenosis, 12 (8.5%) had critical stenosis, and 3 (2.1%) had near occlusion stenosis. Carotid bulb was the most common site of plaque while the left internal carotid artery was the commonest site of both significant and critical stenosis. Near occlusion was noted in left ICA in two patients and right external carotid artery in one patient. Out of 128 patients who underwent CABG,128 had TVD, DVD in 8 and 4 had SVD on coronary angiography.. Conclusion: We concluded that high number of patients(77.85%) have carotid artery disease on routine ultrasonic carotid assessment. Carotid bulb was the most common site of plaque while the left internal carotid artery was the commonest site of both significant and critical stenosis. [ABSTRACT FROM AUTHOR]