Stable angina is managed primarily through lifestyle advice, medication therapy, and coronary revascularization procedures. Some patients with refractory angina exhibit symptoms that are not optimally controlled with the optimal medication and revascularization options available. Enhanced external counterpulsation (EECP) is a technique that can be used to improve symptoms in chronic stable angina. However, the role of EECP has also been investigated following positive outcomes in patients with both angina and heart failure in multicenter studies. We performed a systematic review of the evidence of the clinical effectiveness of EECP. EECP has been approved by the United States Food and Drug Administration (FDA) for the management of refractory angina (Class IIb). About 200 hospitals across India have adopted this technique. EECP uses three sets of pneumatic cuffs that sequentially contract during diastole, increasing aortic diastolic pressure, augmenting coronary blood flow, and central venous return. EECP improves anginal symptoms and exercise tolerance, and reduces nitroglycerin use in patients with chronic, stable angina. EECP has also been shown to be safe and beneficial in patients with symptomatic stable congestive heart failure. It has been postulated that cardiac benefits of EECP are mediated through vascular endothelial growth factor, and nitric oxide-mediated vasodilatation and angiogenesis. In June 2002, the FDA also approved EECP therapy for heart failure patients. EECP is cost-effective if the observed quality of life benefits are assumed to continue throughout a patient's lifetime. However, there remain uncertainties around the long-term effects of the intervention.

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Complete heart block is a medical emergency managed by insertion of cardiac pacemakers. Most common reversible causes of AV (atrioventricular block) are drug induced, metabolic and endocrine causes. The metabolic causes of AV blocks are hyperkalemia and hypermagnesemia. Hyponatraemia is the commonest electrolyte disturbance seen in intensive care patients, but it causing cardiac conduction defects is very rare and here we present a 60 year old female with third degree (complete) AV block caused by hyponatraemia who reverted to sinus rythm after correction of hyponatraemia.

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Hypereosinophilic syndrome (HES) is a heterogeneous group of disorders with peripheral blood hypereosinophilia and eosinophil-mediated organ involvement. It may be primary, secondary, or idiopathic. In very rare cases, HES can be familial occurring as an autosomal dominant disorder. Cardiac involvement usually presents as heart failure, intracardiac thrombus, arrhythmias, and rarely as acute coronary syndrome (ACS) and is a major cause of morbidity and mortality. Cardiac magnetic resonance imaging has emerged as a diagnostic modality in diagnosis of eosinophilic endomyocardial disease. We report a case of a young male with familial HES presenting as ACS and discuss diagnostic and therapeutic clinical management.

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We report a case of hyperacute bilateral parotitis, where the patient developed bilateral parotid swelling within minutes, following administration of low-osmolar iodinated contrast agent. The condition, often called “iodide mumps” usually has a late onset ranging from hours to days. Recognition of early onset of the condition is important to avoid unnecessary investigations as the condition usually follows a benign course.

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Objective: No clinical study compares outcomes of left ventricular assist device (LVAD) implantation in patients with end-stage heart failure secondary to ischemic cardiomyopathy (ICM) and non-ICM (NICM). The purpose of this study is to analyze the outcome of LVAD therapy in these 2 cohorts of patients. Materials and Methods: Forty-four patients had HeartMate II LVAD implantation between September 2012 and August 2014. Charts were retrospectively reviewed and data accumulated were statistically analyzed. Results: A total of 23 (52%) patients were presented with ICM. Average age in ICM was 63.7 ± 6.8 years as opposed to 53.9 ± 16.3 in NICM (P = 0.017). About 78% of ICM and 67% of NICM group were male (P = 0.388). 43.5% of ICM had undergone previous cardiac operation versus 9.5% of NICM (P = 0.012). Implant strategy was bridge to transplant in 78% of ICM and 67% of NICM (P = NS) and destination therapy in 22% of ICM and 33% of NICM (P = NS). A thirty-day mortality rate was 17% in the ICM and 0% in the NICM (P = 0.06). One-year mortality was 39% for ICM and 19% for NICM (P = 0.14). On multivariate analysis, ICM emerged as an independent predictor of mortality (odds ratio: 3.19). Variables such as serum creatinine, inotropic or vasopressor requirement, intraaortic balloon pump use, or complex operations involving aortic or tricuspid valves at the time of LVAD placement did not impact mortality. Conclusions: This report, based on a nonmatched cohort of 44 patients, demonstrates that in an era of selective criteria for LVAD implantation, ICM emerges as an independent predictor of mortality. These patients tend to be older and are more likely to be undergoing reoperative sternotomy. These results should form the basis for a larger scale investigation of LVAD implantation in ICM patients.

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Context: Diabetes mellitus is a recognized risk factor for heart failure. Dipeptidyl peptidase-4 inhibitors (DPP4i) are used in patients with diabetes largely due to its efficacy in glycated hemoglobin (HbA1c) reduction, neutral weight effect, and lower hypoglycemic events. New antidiabetic medications such as the glitazones have been linked with increasing mortality and heart failure exacerbations. The effect of DPP4i in heart failure has not been shown in a heterogenous Asian population. Aims: The aim of this study was to assess incidence of heart failure and cardiovascular (CV) events in patients with diabetes with known coronary artery disease (CAD) treated with DPP4i. Subjects and Methods: This was a single-center, retrospective analysis of patients with diabetes mellitus attending various specialist clinics in Universiti Teknologi MARA treated with available DPP4i agents from January 2013 to July 2015. Medical records were reviewed and data collected for demographic, anthropometric, laboratory, and treatment modalities. Endpoints include changes in body weight, body mass index, lipid, renal profile, and CV events during follow-up. Results: Three hundred and twenty-three patients with diabetes were screened and 307 fulfilled the inclusion criteria. Fifty-four were on linagliptin, 115 were on vildagliptin, and 154 were on saxagliptin. Majority of patients (87.6%) had uncontrolled diabetes at baseline (HbA1c, %) (8.9 ± 2.07). There was a significant reduction in HbA1c from baseline to visit 1 at 3 months (P = 0.000). Similarly, significant improvement in HbA1c seen from baseline to visit 1 (P = 0.000). A higher CV event rate was found between 20 and 30 weeks of therapy with DPP4i. The cumulative survival was 99.5% at 20 weeks and reduced to 98.75% at 30 weeks (P = 0.033). There were seven reported events (0.98%) due to heart failure or acute coronary syndrome. These participants had higher baseline HbA1c and creatinine compared to the overall cohort. Conclusions: Higher CV events were seen in diabetic patients with known CAD treated with DPP4i between 20 and 30 weeks of therapy and occurred earlier in patients with chronic kidney disease. This is later than published data and raises the need to monitor this group of patients for symptoms of heart failure beyond conventional monitoring.

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Spontaneous coronary artery dissection (SCAD) is a rare condition and uncommon cause of acute coronary syndrome which is associated with high acute phase mortality with an estimated prevalence of approximately 0.7%. SCAD is known to occur more commonly in young women during pregnancy or postpartum period, and in most cases, it involves a single coronary artery. It has also been reported in patients with atherosclerosis. SCAD is generally treated by percutaneous intervention and stenting. While stenting a segment of the right coronary artery (RCA) with dissection, opening the balloon in the false lumen or placing a stent in the false plane can lead to abrupt closure of the RCA leading to on table catastrophe, thereby confirming that we are in the true lumen is of pivotal importance. Simple maneuvers to prevent this error can be lifesaving. In this article, we have presented a few practical measures to deal with this dilemma in the background of a patient who was found to have spontaneous spiral dissection of the RCA while being evaluated for angina.

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Left atrial appendage aneurysm (LAAA) without involvement of mitral valve is a rare anomaly caused due to dysplasia of atrial muscles. Patients may be asymptomatic or may present with palpitations, dyspnea, atypical chest pain, or thromboembolic complications. Treatment usually consists of surgical resection of the aneurysm, and prognosis postsurgery is very good. We herein report a case of a 4-year-old child who presented with palpitations and found to be having LAAA.

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We report a case of acquired multiple coronary microfistulas between left anterior descending coronary artery and left ventricle following myocardial infarction (MI), revealed after coronary angioplasty. Acquired coronary cameral fistulas have been described following a variety of interventions including coronary artery bypass surgery, valve replacement, cardiac transplantation, endomyocardial biopsy, septal myectomy, and coronary angioplasty. In addition, prior MI and severe atherosclerosis can also open up the vessels of Wearn and establish a direct communication with the cardiac chambers. The fistulas appeared in our case were small, multiple, and distal and did not produce any symptoms. Immediate appearance of these fistulas following percutaneous revascularization might be alarming. Awareness of this delayed consequence of myocardial ischemia aids in appropriate management. Relevant reports in the literature are briefly discussed.

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Unilateral absence of a pulmonary artery (UAPA) is a rare defect. It may be associated with other congenital cardiovascular malformations which present at an early age. Isolated UAPA (IUAPA), i.e., without any other cardiovascular malformations, usually is asymptomatic and presents in adulthood. In infancy, IUAPA may be suspected by the presence of recurrent respiratory infections and pulmonary hypertension (PHT). Here, we present a child with IUAPA who presented with intermittent cyanosis which is unusual. Echocardiography done showed the presence of severe PHT with a patent foramen ovale (PFO) with a right to left shunt. Detailed echo revealed the absence of right pulmonary artery which was confirmed by a multislice detector computed tomography (MDCT). Infants with unexplained PHT should be screened for the possibility of IUAPA. MDCT scan and magnetic resonance imaging (MRI) can confirm the echocardiographic diagnosis. The treatment plan depends on the presence of symptoms, size of pulmonary artery, and collaterals. Early surgical or hybrid intervention may improve survival. Medical management includes treatment for congestive cardiac failure and pulmonary vasodilators for PHT. Infants with severe PHT are difficult to treat and have poor prognosis.

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Single coronary artery is a rare congenital anomaly of the coronary artery. The association ranges from predominantly asymptomatic to myocardial infarction, syncope being an uncommon presentation of Takayasu's arteritis. Given a limited literature of single coronary artery, we have made an attempt in our case report to relate an uncommon association of single coronary artery and Takayasu's arteritis.

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Anomalous origin of the left coronary artery from the pulmonary artery with bileaflet mitral valve prolapse is rare and seldom reported. We report a case of an elderly man who presented with typical angina symptom and a positive exercise stress test. Coronary angiogram failed to identify arterial course due to the presence of extensive collaterals. Images from cardiac computed tomography angiography provided the correct diagnosis and guided treatment. He was treated with medical therapy and remained asymptomatic on follow-up.

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A 51-year-old female was admitted with subarachnoid hemorrhage (SAH) secondary to aneurysmal rupture of the anterior communicating artery (ACoA). Initial echocardiogram was normal. She underwent aneurysmal clipping and the initial postoperative period was uneventful. On the 9^th postoperative day, she developed sudden-onset hypotension. Electrocardiogram (ECG) was performed suggestive of acute anterior wall myocardial infarction. Echocardiogram revealed apical ballooning with basal hypercontractility consistent with stress cardiomyopathy. To confirm the diagnosis, coronary angiography was performed, which was normal. She was treated conservatively; however, on the 11^th postoperative day she had a sudden cardiac arrest and succumbed to death.

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