Treatment-resistant hypertension (RH) is defined as uncontrolled blood pressure (BP) despite use of at least three different antihypertensive agents (including angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, calcium channel blocker, and a diuretic) at their optimal doses. It is important to properly diagnose and treat RH because patients are at high risk of end-organ damage. Activated renin-angiotensin-aldosterone system, increased renal sympathetic nervous system activity (increase sodium and water reabsorption and thus increase in extracellular fluid volume), and increased arterial stiffness become the main reason for hypertension. Therefore, a controlled BP can be achieved by the use of mineralocorticoid receptor blockers as add-on treatment to the first-line triple-drug combination therapy. In this review, we provide evidences from various studies comparing spironolactone treatment with other comparators (diuretics or other mineralocorticoid receptor blockers) or placebo signifying spironolactone is beneficial for controlling BP in patients with RH. Furthermore, there is a greater need to increase the use of mineralocorticoid receptor blocker, spironolactone, as fourth-line medication add-on to three drug therapy in patients with RH.

Purpose: When tachyarrhythmias originates from atrioventricular (AV) node, AV junction or bundle of His complex, they are termed “junctional ectopic tachycardia” (JET). Cardiac surgeries especially involving crux of the heart are mainly responsible for JET. Amiodarone and other pharmaco-therapeutic agents are tried as antiarrhythmics for the treatment of postoperative JET. Aim of this review was to discuss about role of ivabradine in the treatment of postoperative JET. Materials and Methods: A search was carried out for this review article on the basis of literature available including scientific databases of PubMed, Embase, Scopus, Google Scholar, using keywords “Ivabradine,” “Postoperative junctional ectopic tachycardia,” “Arrhythmias,” “Funny currents,” from October 2011 to October 2020. Results: After initial screening of 377 articles, 9 studies were included and discussed in detail in the present review article. Conclusion: Treatment of choice of postoperative JET is still not well established. Although there are very few case reports and case series that have been reported on the use of ivabradine in JET, yet it seems to offer a promising use.

Background: Troponin I (Trop 1) and N-terminal pro–B-type natriuretic peptide (NT-ProBNP) can be a discerning marker for the patients presenting with symptoms of acute cardiac ischemia and risk of death. The present study was to find a correlation between NT-ProBNP, troponin 1, and left ventricular ejection fraction (LVEF) in acute coronary syndrome (ACS) patients with mortality. Methods: Ninety ACS patients >18 years of age were included for this prospective observational study. Each patient was subjected to detailed clinical history, clinical examination, Trop I, NT-ProBNP, and LVEF at the time of admission. The primary outcome measures were to study the correlation of NT-ProBNP and Trop I and LVEF at the time of admission with mortality, whereas the secondary outcome measure was to study LVEF after ACS up to 1 month. Medians of continuous variables of two groups and three groups were tested. Results: The median Trop 1 levels were 12.0, 378.0, and 2454.0 in patients of unstable angina (UA), non-ST-segment elevation myocardial infarction (NSTEMI), and ST-segment elevation myocardial infarction (STEMI), respectively (P = 0.001). The median NT-ProBNP levels were 1027.0, 1494.0, and 3728.5 in patients of UA, NSTEMI and STEMI, respectively (P = 0.002). The median Trop 1 levels were 5433.0, 627.5, and 92.0 in patients whose LVEF was <40%, 40%–50%, and >50%, respectively (P = 0.001). The median NT-ProBNP levels were 14,554.0, 2009.0, and 306.0 in patients whose LVEF was <40%, 40%–50%, and >50%, respectively (P = 0.001). The median Trop 1 levels were 11439.0 and 570.0 in patients who expired and survived, respectively (P = 0.001). The median NT-ProBNP levels were 21047.0 and 1869.5 in patients who expired and survived, respectively (P = 0.001). The median LVEF were 30.0 and 45.0 in patients who expired and survived, respectively (P = 0.001). Trop I showed a significant positive correlation (r = 0.636) with NT-ProBNP levels (P < 0.001). Conclusion: Trop I, NT-ProBNP, and LVEF at the time of admission are strong predictors of 1-month mortality in ACS.

Introduction: Junctional rhythm (JR) is a rescue rhythm where the upstream impulse generators fail to pace the heart and atrioventricular (AV) junction takes up that function. The presentation is variable ranging from totally asymptomatic cases, where it is a manifestation of heightened vagal tone, to life-threatening bradycardia, resulting from some serious underlying pathologies. JR results from diverse causes such as sick sinus syndrome, acute myocardial infarction (AMI), dyselectrolytemia, drugs, and toxins. Understanding the etiologic factor has immense implication in the management as the prognosis is related mainly to the primary pathology rather than JR itself. Subjects and Methods: In this observational study, we evaluated 100 hospitalized patients of JR over a period of 1 year regarding their symptoms, signs, and underlying pathology. Results: Among 100 patients, 38 had a history of syncope and 42 had angina. Twenty-four patients had hyperkalemia (22 of them had renal dysfunction). Thirty patients had elevated troponin-T and/or CK-MB. The most common etiology was AMI responsible in 28% patients followed by hyperkalemia (24%), sick sinus syndrome (20%), and medication drug use (16%) as the principal causes of JR. Myocarditis, toxin, and hypothyroidism were uncommon association. Accelerated JR and junctional tachycardia were associated with AV nodal ablation and postsurgical patients, respectively. Conclusion: JR is a manifestation of several diverse etiopathologies, and elucidation of them is extremely important for the patient management. We estimated the prevalence of various underlying etiologies which should be considered during the management of such patients.

Background: The optimal treatment for congenital aortic stenosis (AS) remains in debate over the past three decades of practice with both balloon aortic valvuloplasty (BAV) and surgical aortic valvotomy. BAV has been the palliative therapy with AS in most centers. The present study aimed to provide role and short-term outcomes of BAV in AS patients. Methods: We enrolled 58 patients aged ≤20 years of AS from July 2017 to November 2019. All patients were evaluated by echocardiography at 1, 3, and 6 months. Results: From the total of 58 patients, there were 38 male and 20 female patients. BAV could be successfully completed in 56 patients (96.5%). Pre-BAV mean left ventricle systolic pressure (LVSP) was 187.85 ± 53.75 mmHg and transaortic gradient (TAG) was 90.67 ± 42.77 mmHg. LVSP and TAG were reduced significantly (P = 0.0001) post procedure (133.85 ± 41.33 mmHg and 28.11 ± 23.22 mmHg, respectively). Echocardiographic parameters such as V max, aortic valve (AV) G max, and AV G mean were significantly decreased post procedure and AVA was increased significantly post procedure. Ten (17.86%) patients had developed significant (more than or equal to moderate) aortic regurgitation post procedure (17.24%). About 66% of our patients had no complication post procedure. At 1, 3, and 6-month follow–up, AV G max and G mean and V max increased but were not statistically significant. Conclusion: BAV via transarterial route in pediatric population with significant AS is safe, effective palliation with good immediate and midterm follow-up results with minimum complications. We did not face any major complications except for development of variable degrees of aortic regurgitation and access site complications.

Introduction: Cardiac perforation by pacemaker/automatic implantable cardioverter-defibrillator (AICD) lead can be a life-threatening emergency. Delayed cardiac perforation by pacemaker/AICD lead is defined as perforation occurring after a period of 1 month following pacemaker/AICD insertion. Delayed perforation is often difficult to identify at first and needs active intervention to prevent complications and death. Materials and Methods: Patients presenting with and operated upon for delayed cardiac perforation following pacemaker/AICD insertion were included in this study. The study was conducted between April 2019 and April 2020. Results: Three patients reported with delayed cardiac perforation after pacemaker insertion. All patients had syncopal episodes, and detection could be easily done using chest X-ray and trans-thoracic echocardiography (TTE). Two patients had active fixation leads used for anchoring the lead in the right ventricle (RV). Two patients were female, while one was a male, and all had perforation through the RV apex. Lead reposition was done in two cases, thereby preventing the need for placing additional leads, while a new lead was required in the third case. Conclusion: Early identification of cardiac perforation can be done easily with chest X-ray and TTE, but a high index of suspicion should be kept in mind. Surgical or fluoroscopic intervention may be planned depending on the available expertise and patient condition.

Background: The magnitude of risk factor clustering for coronary artery disease (CAD), as well as the CAD, is increasing in developing countries, especially in the young. Objectives: The objective of this study was to study the sociodemographic, clinical, and angiographic profile of young patients (<45 years of age) presenting for coronary angiography at the Department of Cardiology, Goa Medical College, Bambolim. Materials and Methods: Ninety-four patients aged <45 years were interviewed using a semi-structured questionnaire between August 2018 and February 2019. The data were presented as proportions and means, and an appropriate test of statistical significance was applied toward drawing statistically sound conclusions. Results: There was a striking male preponderance with males contributing 97.9% of the patients. The proportion of patients with normal coronaries and single-, double-, and triple-vessel disease was, respectively, 21.3%, 56.8%, 18.9%, and 24.3%. Diabetes mellitus and use of tobacco were associated with CAD in a statistically significant manner (P < 0.05). Only around one-third of diabetics in the study group were subjected to fasting or random blood sugar estimation, and HbA1c was estimated in only 17%. Conclusion: Public awareness of the early-onset CAD and its risk factors, proper laboratory workup of patients to identify clustering of risk factors, and further research to dwell in to the sex bias among the reported patients is required.

Purpose: The present study was aimed to assess the prevalence, location, and patterns of late gadolinium enhancement (LGE) in idiopathic dilated cardiomyopathy (DCM) on cardiac magnetic resonance (CMR) imaging and to correlate the left ventricular (LV) functions obtained by cine CMR with the values obtained by echocardiography. Methods: This was a prospective single-center study covering a 2-year study period. The authors studied the prevalence, location, and patterns of LGE in idiopathic DCM on CMR and correlated the ventricular functions obtained by CMR with those obtained by echocardiography. Results: LGE was seen in 18/40 (45%) and was absent in 22/40 (55%) of patients. With regard to location, septal enhancement was the most common, seen in 8 (20%) followed by free-wall enhancement in 4 (10%) and a concomitant septal and free-wall enhancement in 6 (15%). In terms of pattern, midwall enhancement was observed in 10 (25%), subepicardial in 2 (5%), subendocardial in 4 (10%), and focal and transmural enhancement in 1 each. The maximum correlation for calculation of LV ejection fraction (EF) was obtained between CMR and two-dimensional echocardiography (P = 0.442). Conclusion: CMR is an accurate tool to determine the phenotype of DCM by identifying the presence, location, and pattern of LGE which has a prognostic value and is used to guide management. CMR is the most accurate assessment tool for the calculation of EF and other volumetric variables in DCM.

Purpose: The benefits of cardiac resynchronization therapy (CRT) depend on multiple factors including patient selection and left ventricular (LV) lead position in the coronary sinus. The ideal position for stimulation is the posterolateral region of the left ventricle, since this is the site where maximum contractile delay is seen. But this ideal site of LV lead placement is not possible in many patients due to anatomical limitations. Our study evaluated the feasibility of the middle cardiac vein (MCV) as an alternative target for LV lead placement with short-term outcomes result in a small cohort of patients. Methods: This is a single-center experience over a span of 2 years where in patients with anatomical limitations, we positioned our LV leads through MCV. In this period, we had implanted a total of 76 CRTs in our institution, out of which 6 cases we used MCV. We utilized collateral circulation to reach as close possible to the lateral surface of the left ventricle. Right ventricular (RV) leads were positioned to either outflow tract or upper septum to enhance the electrical gap in between two ventricular leads. Results: We achieved satisfactory periprocedural end results in all the cases as evident by appropriate threshold/impedances of all the leads, lack of diaphragmatic stimulation, etc. There were no procedural complications. Optimum short- and midterm improvement of symptomatic class and LV ejection fraction was observed. None of the patients had any lead dislodgement, abnormal change in lead threshold parameters, or need for hospitalizations for heart failure in follow-ups. Conclusion: We conclude that when usual posterolateral or lateral target veins cannot be accessed for LV lead placement, as an alternative approach utilizing MCV collateral circulation to reach as close possible to the lateral surface may be considered in CRT. RV leads to be positioned at the outflow tract or upper septum in those cases.

Objective: Cardiomyopathy is defined as a heterogeneous group of diseases of the myocardium, is a transient reversible, but potentially life-threatening condition. The natural history, management pattern, and outcome of cardiomyopathy are not clear in Indian scenario. This study was conducted to investigate the clinical features, prognostic predictors, and clinical outcomes of patients with cardiomyopathy. Materials and Methods: We retrospectively analyzed the data of 119 patients of cardiomyopathy admitted to tertiary care hospital from January 2016 to April 2019. Results: The mean age of analyzed patients was 55.08 ± 15.75 years. During admission, symptoms such as breathlessness (63.64%) and fever (40.17%) were reported more often than other symptoms. 38.66% of patients had dilated and stress cardiomyopathy while 15.97% had ischemic cardiomyopathy. Among the independent predictors of all cause death the respiratory failure, sepsis and renal dysfunction were identified. Reduced ejection fraction in 73%, moderate-to-severe mitral regurgitation in 20%, and global hypokinesia in 68.57% patients were observed. Of total admissions, 86% of patients recovered while 14% patients resulted in death. Conclusion: Our study shows that respiratory failure, sepsis, anemia, and renal failure are major contributing factors in poor prognosis, although most of the patients recovered from cardiomyopathy. Cardiomyopathy is the one of the important causes for heart failure with reduced ejection fraction.

Objectives: Congenital absence of pericardium (CAP) is a very rare condition, with an incidence of <1 in 10,000 and occurs in isolation or associated with various congenital cardiac or systemic disorders. We describe the two cases of incidentally diagnosed left-sided congenitally absent pericardium and evaluate the presentation, diagnosis, and management with recent work done in this area. Atrial septal defects have been associated with the absence of pericardium similar to one of our case. We also found this entity associated with aortic coarctation which has not previously been described. Materials and Methods: Using our database, we retrospectively went through the details of patients operated in our center between January 2015 and December 2019 to identify the cases with CAP. Results: Out of 2193 cardiac surgeries, 478 patients got operated for congenital heart disease out of which 2 were found with pericardial defects intraoperatively. No surgical intervention for the pericardial defects was done. Both patients did well after surgery for their primary disease. Conclusions: Congenital defects of the pericardium are very rare. Although there are characteristic radiology findings, yet without a suspicion, these can be easily missed and are discovered during surgery. The associations with many cardiac conditions have been seen; however, association with aortic coarctation is extremely rare as we could not find any such association in literature.

Background: Infective endocarditis (IE) is an infection affecting the endocardial lining and contributed to socioeconomic burden due to prolonged admission, invasive procedure, and expensive treatment. The high prevalence of intravenous drug user intravenous drug user (IVDU) shifts the paradigm of the disease, and thus, we aim to determine the clinical characteristics, outcome, and inhospital mortality of IE among IVDU patients. Materials and Methodology: This is a retrospective cohort by analyzing case records for IVDU patients admitted to Hospital Tengku Ampuan Afzan diagnosed with IE from January 2014 until June 2017. Results: A total of 32 patients were included, with a median age of 35 years old (standard deviation: 6.5). Only 56.3% presented with fever, whereas most of them complained of nonspecific symptoms such as reduced exercise tolerance (59.4%) and weight loss (56.3%). Seventy-five percent had concomitant hepatitis C, but only 6.3% of them were HIV positive. Valvular heart disease accounted for 46.9%, while chronic rheumatic heart diseases and previous IE infection accounted for 28.1% and 18.8%, respectively. For microbiological characteristics, Staphylococcus aureus accounted for 62.5%, followed by streptococci (15.4%) and others (2%). The most common valve affected in IVDU was tricuspid valve (62.5%), followed by mitral valve (21.9%) and pulmonary valve (9.4%). Furthermore, mortality was reported at 25%, while severe valvular complications (62.5%) were observed with elevated episodes of emboli (62.5%) and cardiogenic shock (40.6%). Conclusion: Hence, IVDU is an essential predictive factor and is associated with various severe complications and thus warranted for aggressive preventive measurement to reduce the morbidity.

Context: In patients with rheumatic heart disease (RHD), left atrial appendage (LAA) dilation and thrombus formation is widely known. LAA thrombus formation is a risk factor for stroke even in patients with sinus rhythm. The aim of this study was to determine an association between LAA structure and function with respect to thrombus formation and differences in LAA size and velocity between patients with sinus rhythm and those with atrial fibrillation (AF). Materials and Methods: We prospectively studied LAA structure and function in 120 patients with RHD by transthoracic echocardiography and/or transesophageal echocardiography by measuring left atrial (LA) dimension, LA area, LAA_max/min, LAA ejection fraction (EF), and LAA emptying velocity. Results: Four out of 48 patients with sinus rhythm had LAA thrombus. In 72 patients with AF, 32 had LAA thrombus. Patients with LAA thrombus had lower mean LAA EF and emptying velocity both variables P-value is same (P<0.0001 and P<0.0001) Patients with LAA thrombus had increased mean LAA max and LAA min as compared to LAA max and LAA min in patients without LAA thrombus (P 0.008 for mean LAA max and P<0.0001 for LAA min respectively). Patients with AF with LAA thrombus had greater LAA_max compared to that in patients with AF without LAA thrombus (P < 0.0001). Doppler demonstrated a recognizable sawtooth LAA outflow velocity pattern in 32 of 36 (88.9%) patients with LAA thrombus versus 32 of 84 (38.1%) patients without LAA thrombus. Conclusions: We conclude that LAA contractility is reduced in RHD with LAA thrombus, and loss of both contractility and LAA dilation is associated with increased risk of thrombus formation and hence the risk of stroke.

Context: To study the demographics and clinical profile of patients with acute pulmonary embolism (PE) and impact of management as per risk stratification on outcome of patients with acute PE. Materials and Methods: Prospective observational study of demographics, clinical profile, risk stratification, management, and outcome of patients presenting with acute PE from August 2016 to July 2017. Results: One hundred and fifty patients who were detected to have acute pulmonary thromboembolism with a mean age of 45.08 years, with 70% being males, were included in the study. There were 6 (4%) patients in high-risk group, 69 (46%) patients in intermediate-high subgroup, 39 (26%) patients in intermediate-low subgroup and 36 (24%) patients in low-risk group as per the ESC 2019 guidelines using sPESI score, shock/hypotension, right ventricle (RV) dysfunction and cardiac marker elevation. 72 patients (52%) had antecedent deep vein thrombosis (DVT) of which 60 patients has proximal, whereas 12 patients had distal DVT. One hundred and forty-seven patients (98%) had moderate-to-severe TR, 117 patients (78%) had evidence of right atrium/RV dysfunction and 27 patients (18%) had evidence of thrombus in the heart. Computed tomography pulmonary angiogram showed middle pulmonary artery thrombus/dilatation in 63 patients (42%), saddle thrombus in 18 patients (12%), partial thrombus in the left pulmonary artery (LPA) and right pulmonary artery (RPA) in 84 (56%) and 75 (50%) patients, respectively. Majority (86%) of patients with tenecteplase; 9 (10.3%) patients with streptokinase and 3 (3.4%) was thrmobolysed with alteplase. Conclusion: PE can present with unexplained dyspnea and atypical chest pain, among other signs and symptoms. Early diagnosis, risk stratification, and guideline-directed prompt management can lead to favorable outcome.

An incidentally diagnosed patient with Brugada syndrome was found to have atrial flutter on baseline electrocardiogram. He was DC (Direct current) cardioverted which revealed sick sinus syndrome. The patient was implanted with VVIR(Ventricular rate modulated pacing) pacemaker. Underlying sinus node dysfunction can be present in cases of Brugada syndrome with atrial flutter. The patient may require pacemaker insertion postcardioversion.