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   Table of Contents - Current issue
Coverpage
July-September 2018
Volume 6 | Issue 3
Page Nos. 73-110

Online since Wednesday, September 12, 2018

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EDITORIAL  

Preface to the third issue of Heart India 2018 p. 73
Alok Kumar Singh
DOI:10.4103/heartindia.heartindia_36_18  
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REVIEW ARTICLE Top

Role of herpesviruses in coronary artery disease p. 75
Agam Bansal, Debasis Biswas
DOI:10.4103/heartindia.heartindia_18_18  
Coronary artery disease (CAD) is a huge global burden and is a leading cause of morbidity and mortality across the world. We have done this review to elucidate the pathogenesis of herpesviruses in causing CAD and to study an association between herpesviruses (cytomegalovirus [CMV] and herpes simplex virus [HSV-1 and -2]) and CAD. CMV can cause atherosclerosis directly through the activity of its gene products on endothelial cells, monocytes/macrophages, and smooth muscle cells and indirectly through production of pro-inflammatory cytokines at far off place. HSV infection causes atherosclerosis mainly by causing increased prothrombotic activity on endothelial cells, accumulation of cholesterol esters and triacylglycerols in vascular smooth muscle cells, and upregulating expression of Lectin like oxidized Low density lipoprotein receptor-1 (LOX-1) receptor on macrophages. The association between CMV and CAD is related to its seroprevalence with a positive association in developing countries (higher seroprevalence) and no significant association in developed countries (lower seroprevalence). However, the association between HSV infection and atherosclerosis is not related to its seroprevalence.
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ORIGINAL ARTICLES Top

The prediction of left main and/or triple-vessel coronary artery disease by tissue doppler-based longitudinal strain and strain-rate imaging p. 81
Akhil Kumar Sharma, Gaurav Kumar Chaudhary, Rajiv Bharat Kharwar, Mahim Saran, Sharad Chandra, Sudhanshu Kumar Dwivedi, Varun Shankar Narain
DOI:10.4103/heartindia.heartindia_30_18  
Background: In the absence of evident regional wall motion abnormality (RWMA) at rest, detection of severe coronary artery disease (CAD) usually requires a stress test. Ventricular strain is a more sensitive parameter of myocardial systolic function and may be abnormal in patients with severe CAD. Thus, this study aimed to evaluate the longitudinal strain and strain-rate imaging for prediction of left main (LM) and triple-vessel disease CAD with normal left ventricular ejection fraction (LVEF) and no RMWA. Materials and Methods: Patients included were of stable CAD, unstable angina, or non-ST segment elevation myocardial infarction with LVEF >50% and without RWMA. A thorough echocardiographic evaluation to assess peak systolic longitudinal strain (PSLS) and PSLS rate (PSLSR) in 16 segments of the left ventricle was done. The visual evaluation of percent diameter stenosis of the angiographic lesions was done according to the American Heart Association classification. Patients were grouped into high-risk group (LM or triple-vessel CAD), low-risk group (CAD other than high risk), and normal group (absence of CAD). Results: A total of 86 patients were studied. Of which, 60 were male and 26 were female. The global PSLS and PSLSR were lower in the high-risk group as compared to the other two groups (P < 0.001). The combined basal plus mid-PSLS and PSLSR were lower in the high-risk group (P < 0.001). Receiver operating characteristic curve analysis showed an optimal cutoff value of −17.3% (sensitivity 82% and specificity 80%) for global PSLS and −15.0% (sensitivity 75% and specificity 73%) for basal plus mid-PSLS for detection of high-risk CAD. Similarly, a cutoff value of −0.74 s−1 (sensitivity 82% and specificity 73.6%) for global PSLSR and −0.66 s−1 (sensitivity 85.7% and specificity 86.7%) for basal plus mid-PSLSR were calculated for the prediction of high-risk CAD. Conclusion: The PSLS and PSLSR were lower in patients having high-risk CAD that included LM and triple-vessel disease, even when resting wall motion and LVEF were normal. The study concluded that PSLS and PSLSR are sensitive and specific noninvasive modalities for predicting the possibility of high-risk CAD in the presence of normal LV systolic function and absence of resting RWMA.
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Comparison of left internal mammary harvesting techniques for coronary artery bypass grafting: A prospective study p. 90
Sarvesh Kumar, Vijayant Devenraj, Akshyaya Pradhan, Vivek Tewarson, Sushil Singh K, BB Kushwaha
DOI:10.4103/heartindia.heartindia_25_18  
Introduction: Left internal mammary artery (LIMA) is the most common arterial conduit used for patients undergoing coronary artery bypass grafting (CABG) surgery. Maintaining pleural integrity during harvesting has been documented to have better patient outcomes. Hence, we evaluated postoperative outcomes using two different LIMA harvesting techniques, one with intact pleura and other with pleura opened. Methods: In this prospective study, we recruited a total of 110 patients undergoing CABG. Based on the pleural being intact or opened, the patients were divided in two groups. In Group 1, LIMA was harvested with pleura intact (extra-pleural approach) while in Group 2, LIMA was harvested with pleura being opened (intrapleural / pleurotomy). The primary objective was to evaluate the impact on various post-operative parameters like total ventilatory time, mediastinal drainage, need for Blood transfusions, post operative deterioration of lung function , post operative pain scores and duration hospital stay. Results: Out of 110 patients undergoing CABG, LIMA was harvested by extra-pleural approach in sixty-six while in the rest forty-four pleurotomy was needed. The baseline demographic attributes of patients were similar in both groups. The post operative parameters such as ventilatory time, blood loss, need for blood transfusions, and prolonged hospital stay were found to be significantly higher in the group with intrapleural LIMA harvest technique (P <0.05). Pulmonary complications like pleural effusion, atelectasis were more frequent with in the intrapleural harvest as compared to extra-pleural harvest technique.(P <0.001). Post operative pain scores as evaluated by NRS scale were also significantly higher after intrapleural harvest (P <0.001). Conclusions: Harvesting of LIMA for CABG extrapleurally has significant post-operative benefits and faster recovery compared to pleurotomy and intraplueral approach.
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A comparative study of tirofiban plus enoxaparin versus enoxaparin alone along with dual antiplatelet blockade in the management of patients with non-ST elevation acute coronary syndrome p. 97
Monika Bhandari, Pravesh Vishwakarma, Mukul Misra, Varun Shankar Narain, Akshyaya Pradhan, Rishi Sethi
DOI:10.4103/heartindia.heartindia_32_18  
Introduction: Antithrombotic therapy in patients with non-ST elevation acute coronary syndrome (NSTE-ACS) includes dual antiplatelet therapy (DAPT) along with enoxaparin. However, resistance to antiplatelet action of aspirin and clopidogrel is well known and is about 27% (0-57%) and 30%, respectively. Hence the use of GPIIb/IIIa inhibitor appears to be a reasonable option as they act on the final common pathway of platelet aggregation. Though frequently used in patients undergoing percutaneous intervention (PC1), their use in patients not undergoing such procedure is not popular despite evidence in literature. Materials and Methods: This study was done on 44 patients of NSTE-ACS managed conservatively. The patients were randomized in a 1:1 fashion in two groups. The patients in group 1 received tirofiban(0.4μg/kg/min i.v for 30 min followed by 0.1μg/kg/min for 48 hours) in addition to aspirin (325 mg stat followed by 75 mg P.O. daily), clopidogrel (300 mg stat followed by 75 mg P.O. daily) and enoxaparin (1 mg/kg S.C bid for 5 days). The group 2 patients received DAPT and enoxaparin only, in similar doses. Both the groups received antianginal therapy as appropriate and statins. Results: The study showed the benefits of adding tirofiban to enoxaparin and DAPT irrespective of age, sex, presence or absence of diabetes and dyslipidemia, ECG changes, troponin positivity and TIMI score in patients with NSTE-ACS. There was a significant reduction {Risk reduction (RR) of 45.4% P <0.01} in composite of primary end points refractory ischemia myocardial infarction (MI) and death with Tirofiban. No major or minor bleeding episodes were seen in any patients. Conclusion: Thus, we conclude that tirofiban in addition to DAPT and enoxaparin reduces the risk of refractory ischemia, MI and death in patients with NSTE-ACS without any additional risk of major or minor bleeding. Therefore, we advocate this regimen in patients with NSTE-ACS managed conservatively. Large randomized study is needed to recommend this regimen.
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Central aortic pressure indices and cardiovascular risk factors: Demographic, clinical, and prognostic characterization p. 102
Rajesh Gopalan Nair, Shreetal Rajan Nair, Vinayakumar D, Kader Muneer, Haridasan V, Dolly Mathew, Biju George, Krishnan MN, Sajeev CG
DOI:10.4103/heartindia.heartindia_21_18  
Objectives: The primary objective of the study was to assess the association between central aortic blood pressure indices and coronary artery disease (CAD) in patients undergoing elective angiography and the secondary objective was to study whether any association exists between central aortic pressure indices and the incidence of major adverse cardiovascular events (MACE) in the same patients during a 6-month follow-up period. Methods: We conducted a prospective observational study in consecutive patients undergoing coronary angiography. Central and peripheral pressures were invasively recorded and CAD was classified into obstructive and nonobstructive group. CAD severity was graded using the Gensini score and patients were divided into tertiles. Patients were followed up, and the role of central aortic pressure indices in the prediction of cardiovascular events was analyzed. Results: A total of 623 patients were enrolled. Central pulsatility was found to be most closely associated with severity of CAD by univariate analysis, with age, sex, and smoking status being important predictors of pulsatility. A positive correlation was found between the central and peripheral mean and pulse pressures. No significant association was noted between the central aortic pressures and MACE on short-term follow-up. Conclusions: Of the various central aortic pressure indices studied, central pulsatility was found to be most closely associated with the severity of CAD.
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CASE REPORT Top

Moyamoya disease masquerading as recurrent headaches in a 4-year-old child p. 108
Ishtiyaq Qadri, Mohd Ashraf, Anil Kumar Parihar
DOI:10.4103/heartindia.heartindia_4_17  
Moyamoya disease can have varied clinical manifestations and the diagnosis is often made only on acute presentation. We present a case of 4 year old male child diagnosed with moyamoya disease who had a history of recurrent headaches in past.
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