Background: Management of such patients with inferior wall myocardial infarction (IWMI) complicated by right ventricular myocardial infarction (RVMI) requires volume replacement along with the standard therapy. However, the optimum amount of fluid needed to maintain systolic blood pressure (SBP) ≥90 mmHg in such patients has not been reported yet. This study evaluates the role of graded fluid infusion in improving the hemodynamic parameters in patients of IWMI with RVMI in hypotension or shock and also optimizes the amount of fluid needed to maintain SBP ≥ 90 mmHg. Materials and Methods: In this single-center, prospective observational study, patients with first episode of acute coronary syndrome diagnosed as IWMI complicated by RVMI and SBP <90 mmHg were included. The hemodynamic parameters such as heart rate, SBP, cardiac output, cardiac index, and pulmonary capillary wedge pressure (PCWP) were measured at the baseline and after each 500 ml normal saline over 15 min until SBP ≥ 90 mmHg was attained. The primary objective was to study the change in cardiac output, cardiac index, and PCWP with response to fluid. The amount of fluid needed for ≥ 10 rise in cardiac output and to maintain SBP ≥ 90 mmHg was also evaluated. The secondary objectives were to study the need for inotropic support, complications such as inhospital mortality, acute pulmonary edema, and local site bleeding. Further, the predictors of early responders (<2 L of fluid) were also evaluated. Results: Among all 16 patients, 3 (18.7%) were excluded and the rest received graded fluid therapy. Invasively monitored and graded fluid therapy resulted a significant rise in cardiac output (2.1 ± 0.7 L/min vs. 3.7 ± 0.7 L/min), cardiac index (1.3 ± 0.3 L/min/m^{2 vs.} 2.4 ± 0.76 L/min/m²), and PCWP (8.4 ± 3.0 mmHg vs. 17.6 ± 1.5 mmHg) in comparison to baseline parameters. On an average, 865 ± 462 mL fluid infusion was required for 10% improvement in CO from baseline. However, 2192 ± 560 mL fluid was needed for consistent maintenance of SBP ≥ 90 mmHg. The effect of fluid therapy was not significantly correlated with baseline clinical and hemodynamic parameters. There were no procedure- and therapy-related complications reported during the study. Conclusions: Early response to fluid therapy within 2 L of normal saline occurred independently of baseline hemodynamic parameters. However, more studies with larger number of patients would be needed to confirm the same.

Background: With the introduction of a huge armamentarium of invasive and noninvasive therapeutic strategies, the mortality related to acute coronary syndrome (ACS) has decreased across the world over the past 20 years, but the mortality remains high among Indian patients due to limited resource settings. Even in India, there is significant difference in health infrastructure in different part of country. This study was performed to evaluate the presentation, management and outcomes of ACS patients admitted in a high volume tertiary center of north India. Enrolment of the study done prior to covid pandemic. Materials and Methods: 3511 ACS patients >18 year of age were included for this prospective observational study. All patients were evaluated with detailed clinical history and examination, ECG, Troponin, and detailed echocardiography. Patients were treated as per current guideline recommendation which included primary percutaneous coronary intervention (PCI), pharmacoinvasive therapy, thrombolysis or medical management only. Data was analysed for age, sex, risk factors, type of ACS, treatment given and complications if any. Those patients who underwent invasive approach also evaluated for coronary anatomy pattern and variables. Results: Study population had younger mean age of 57.2 years, male preponderance (67%) and very high tobacco intake (46%). Out of all ACS patients 39% were STEMI (55% anterior wall myocardial infarction, 43% inferior wall myocardial infarction) and 61% were NSTEMI/USA. In STEMI subgroup, only 18% had primary PCI, while 42% received thrombolytic therapy as primary management. Nearly half of the patients who received thrombolytic therapy underwent pharmacoinvasive treatment (47.5%). A large number of late presenters (32% of all STEMI) did not receive any reperfusion therapy in index admission while few of them (6%) underwent invasive revascularization. Coronary anatomy evaluation showed multivessel disease in 53.1%. Left anterior descending artery was most common vessel involved (69.3%) among all ACS patients underwent coronary angiography. Most of the STEMI patients who underwent invasive route received PCI while very low rate for referral for CABG (2.1%). Major complications noted in study included left ventricular failure/cardiogenic shock (11.7%), advance AV blocks (8.2%), VT/VF (2.8%), Ventricular septal rupture (0.7%) and stent thrombosis (0.5%). In hospital mortality remained high (11.5%) mainly due to late presenters. Conclusion: ACS management specially STEMI care is still needs a boost in north India. With primary PCI rate of only 18% and more than one third being late presenters not receiving any reperfusion therapy, there is urgent need of robust primary and referral health care system. As compared to other part of India, tobacco intake is alarmingly high (46%) and needs widespread health awareness in community of tobacco ill effects.

Context: Approximately half of the patients with heart failure have preserved ejection fraction (HFpEF). Epidemiologic studies and randomized trials provide somewhat conflicting data regarding outcomes of HFpEF. Aims: The objective is to study the clinical and echocardiographic profile of patients admitted with HFpEF and estimate outcomes. Settings and Design: This is a prospective observational study on patients with new-onset HF requiring hospitalization and normal EF and evidence of diastolic dysfunction in echocardiography. Subjects and Methods: Risk factors for HFpEF, clinical features, and echocardiographic parameters were recorded. The primary outcome studied was mortality at 1 year and the secondary outcome was rehospitalization at 1 year. Statistical Analysis Used: Variables were analyzed using Student's t-test and Chi-square test. Univariate and multivariate analysis were done to find out predictors of outcomes. Results: A total of 104 patients admitted with the first episode of HF were found to have left ventricular ejection fraction ≥ 50% and diastolic dysfunction. Associated cardiac conditions were hypertension in 77.8%, diabetes in 38.5%, ischemic heart disease in 30.7%, and atrial fibrillation in 32.7%. In our study, 42 patients (40.1%) had rehospitalization within 1 year. The mortality rate at 1 year was 15.4% (16 patients). The parameters found to be significantly correlated with mortality in the univariate analysis included age, high BP, anemia, hyponatremia, low isovolumetric relaxation time, and higher E/e' ratio. Multivariate analysis showed advanced age, hyponatremia, and high E/e' to be independent predictors of mortality. Conclusions: Among hospitalized patients with new-onset HFpEF annual mortality rate is as high as 15.4%. Advanced age, hyponatremia, and high E/e' were found to be independent predictors of mortality.

Context: In this COVID-19 pandemic, most of the healthcare infrastructure including healthcare officials has now been allocated toward COVID management. It is not even feasible for regular patients to visit hospital as they are susceptible to get infected. Aim: The aim is to study the impact of COVID-19 lockdown on the postoperative follow-up of patients with valvular heart diseases by international normalized ratio monitoring in a tertiary health care center. Subjects and Methods: This is an observational study on patients with prosthetic valve conducted at a tertiary healthcare center. Sixty postoperative patients were surveyed with a prevalidated questionnaire designed for them. The questionnaire included questions about the availability of testing centers, communication facility with doctors, and a list of complications such as skin color change, nose bleeds, abdominal fullness, dyspnea, fever, numbness, swelling of limbs, and headache. Results: The study comprised 60 patients with valve replacement surgery. 80% of patients faced difficulty in reaching the hospital during the lockdown; however, almost 86% of patients had telephonic conversation with the doctor. Almost 73% of patients did not have the testing facility in their locality. 34% of patients mentioned that they had history of prolonged fever, 14% presented with history of fullness of abdomen, 10% presented with episode of headache and unconsciousness, and 9% noticed a change in skin color. Conclusions: COVID-19 is still on rise, and there is a long way before herd immunity is developed or everyone is vaccinated. We need to find alternatives so that patient care is not affected. Point-of-care testing should be encouraged as it will reduce hospital visits and exposure to hospital-acquired infections.

Background: The incidence of heart failure (HF) is likely to increase in future in India. As a result, India's health-care system has to care for an increased number of patients with advanced HF (AHF) in future. The objectives of this survey were as follows: (a) to assess cardiology trainees' approach toward treating HF patients and end-of-life (EOL) care, and (b) to review cardiology training curricula and HF management guidelines regarding the approach to EOL care issues in AHF. Methods: We surveyed cardiology fellows undergoing training. The survey questions aimed to assess cardiology fellows' approach in treating patients with different severities of HF and at EOL. We reviewed the cardiology training curricula of various Indian institutions and HF management guidelines from Indian professional bodies. Results: Ninety-nine fellows took part in the survey. 93%–100% reported that they were likely to prescribe recommended drug therapy and Cardiac resynchronization therapy-D implantation to all the patients. The number of likely responses for various EOL interventions was consistently lower when fellows had to rate interventions for themselves as patients. Sixty-four percent of fellows were unfamiliar or uncertain about the idea of hospice care. Eighty-four percent of fellows reported that their training was inadequate, or they were uncertain about the adequacy of their training regarding EOL care issues. None of the training curricula has mentioned “EOL care,” “palliative care,” or “hospice care,” and none of the HF management guidelines discussed such topics. Conclusion: There is an urgent need for sensitizing and training Indian cardiology fellows regarding different aspects of AHF and EOL care.

Background: Speckle tracking echocardiography (STE) may be useful in early detection of contractile dysfunction in severe aortic stenosis (AS) patients. Aims and Objectives: The present study aims to evaluate the global longitudinal strain (GLS), global circumferential strain (GCS), and strain rates in patients with severe AS and the role of STE in predicting the development of symptoms or left ventricular (LV) dysfunction in them. Methods and Results: This was a single-centered, prospective, observational study, done at a tertiary care hospital in north India. The study recruited 30 patients with severe AS and 10 healthy controls. Patients underwent two-dimensional echocardiography and STE at baseline and 6 months. Baseline characteristics were similar between the cases and controls. Majority of severe AS patients were symptomatic (n = 24; 80%). LV ejection fraction (LVEF) was similar between cases and controls at baseline and 6 months. Cases had a significantly worse GLS (−-19.3 ± 5.66 vs. -30.4 ± 3.63), GCS (−-29.6 ± 8.48 vs. −-33.6 ± 2.55), and strain rate parameters than the controls at baseline and had a significant decline in these parameters at 6 months. Among 6 asymptomatic patients, 3 developed symptoms and these patients had a significantly greater decline in GLS at 6 months as compared to asymptomatic patients. Conclusions: The present study revealed that patients with severe AS had an abnormal GLS and GCS to begin with, which was not picked by LVEF. Further, there was a significant worsening of these STE parameters at 6 months and those who had a greater decline were more likely to develop new symptoms.

Background: Acute pulmonary embolism remains a significant cause of morbidity and mortality. This study aimed to determine the clinical profile, management, and outcomes of patients with acute pulmonary embolism. Methods: This was a retrospective, single-center, and observational study. All consecutive patients with proven diagnosis of pulmonary embolism and treated at a tertiary care center were included in the study based on inclusion and exclusion criteria. Results: From January 2012 to May 2018, a total of 304 patients diagnosed with pulmonary embolism were included in the study. Majority of the patients (n = 195; 64.14%) were male. Among included patients, 92 (30.66%) were smokers, and 81 (26.6%) were obese. Dyspnea (98.03%) was the most commonly observed symptom. Of patients who underwent bilateral lower limb venous Doppler, deep vein thrombosis was noted in 172 (56.57%). Electrocardiography confirmed the presence of sinus tachycardia and classical S1Q3T3 pattern in 284 (93.42%) and 79 (25.99%) patients, respectively. Chest X-ray showed dilated main and right pulmonary arteries in 170 (55.92%) patients. Right ventricular dysfunction as detected by echocardiography was observed in 241 (79.28%) patients. Thrombolytic therapy was administered in 158 (51.97%) patients (n = 86 (28.29%) were treated with tenecteplase; n = 72 (23.68%) were treated with streptokinase). Conclusions: This study gives an insight into the clinical profile of patients hospitalized with a confirmed diagnosis of acute pulmonary embolism along with treatment and diagnostic approaches adopted by the physician in the Indian scenario.

The late rising pacing threshold is an alarming situation in which a possibility of lead dislodgement is usually considered first. This condition is usually picked up on routine follow-up interrogation; however, it can clinically manifest as syncope due to bradyarrhythmia. We report such a case in a 59-year-old male presenting to the emergency with syncope with a double chamber pacemaker in situ. He had a history of pacemaker implantation 16 years back and a pulse generator replacement (PGR) 6 years back with desirable parameters found immediately and up to 4 years after PGR. He was found to have a complete heart block on an electrocardiogram following the evaluation of presyncope and subsequently on his pacemaker interrogation high threshold was found which improved to acceptable levels after 4 weeks of steroid therapy.

We present an extremely rare case series of two short dual right coronary arteries (RCAs), causing coronary ischemia without the presence of obstructive coronary artery disease. We describe here the presence of short dual RCA in a 55-year-old nondiabetic, nonhypertensive, and nondyslipidemic male presenting with effort angina New York Heart Association Class II for the last 6 months with strongly positive stress test and another 40-year-old athlete (Central Reserve Police Force Army) without conventional risk factors with effort angina Class II for the last 3 months also with strongly positive stress test. Dual RCA, otherwise known as double RCA, duplicate RCA, or split RCA is extremely rare to encounter in routine clinical practice. The patient had a significant effort angina; in spite of nonatherosclerotic coronaries, small dual RCA terminating much earlier than the intended area of supply was the reason behind coronary ischemia with strongly positive provocative stress test. Short normal dual RCA can be a cause of coronary ischemia although mentioned in the literature; there has been no case report in the world literature till now about short dual nonatherosclerotic RCA causing coronary ischemia. Our case is unique and first to describe short dual RCA terminating much earlier than the intended area of supply can attribute to demand ischemia in the intended area of supply without the presence of obstructive coronary artery disease. We treated the patient with nicorandil to improve myocardial microvascular flow in ischemic region with symptomatic improvement of the patient.

The identification of ST-segment elevation on the electrocardiogram is an integral part of decision-making in patients who present with suspected ischemia. Unfortunately, ST-segment elevation is nonspecific and may be caused by noncardiac causes such as electrolyte abnormalities. We present a case of a 52-year-old male who presented with ST-segment elevation secondary to hypercalcemia in a patient with hypertension with osteoporotic vertebral collapse.

We present a rare case of left ventricular noncompaction (LVNC) in a 23-year-old female with recurrent syncope with electrocardiography documentation of apical septal ventricular tachycardia (VT). Abnormal embryological myocardial maturation presenting as LVNC with electrogenic heterogenity across the noncompacted spongiform segments result in recurrent VT and mandates automated intracardiac defibrillator implantation (AICD). These subsets of patients in spite of AICD implantation require life-long broad-spectrum antiarrythmic in the form of amiodarone and beta-blocker to prevent a crisis of VT storm or sudden cardiac death.

Transcatheter closure has become the standard treatment for patent ductus arteriosus (PDA) with excellent short- and long-term results. Left ventricular systolic dysfunction after closure is a known phenomenon rather than a complication with varied incidence documented in literature. Here, we report our experience of six cases who developed left ventricle (LV) dysfunction following percutaneous closure of PDA. Age, PDA size indexed to body surface area and pulmonary hypertension were the parameters noted to be associated with poorer LV function after closure. The LV dysfunction was transient and asymptomatic in most with delayed recovery noted with increasing age.

Libman-Sacks endocarditis is usually associated with systemic lupus erythematosus and malignancies. It usually presents between ages 40 and 70 years. Our case was a seven year old child who was initially suspected and treated on lines of rat bite fever endocarditis based on history of rat bite but on further investigations patient was diagnosed with libman sacks endocarditis. High index of suspicion should be there for Libman-Sacks endocarditis for early diagnosis and treatment in cases with positive family history.