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Objectives: The prevalence of atherosclerosis and acute coronary syndrome (ACS) is increasing in young Indians (18-50 years of age). However, the characteristics of atherosclerotic plaques in such individuals are poorly understood, presenting distinct challenges for the management of ACS. This study aims to analyze plaque characteristics in young Indian patients with ACS who underwent percutaneous coronary intervention (PCI) using optical coherence tomography (OCT) imaging., Methods: This was a prospective, multicentric, non-interventional study on patients aged 18-50 years presenting with ST-elevation myocardial infarction (STEMI), non-ST elevation myocardial infarction, or unstable angina, and were scheduled to undergo OCT-guided PCI. Major adverse cardiac events (MACE) were assessed post-procedure and at the 6-month and 12-month follow-ups., Results: The study included 100 ACS patients (mean age = 43.6 ± 5.2 years), with 51% presenting with STEMI. Pre-PCI OCT assessment showed that fibrous plaques (75%) were most common followed by plaques containing macrophages (27%), microchannels (20%), and calcified nodules (14%). In addition, plaque rupture, plaque erosion, and lipid-rich plaques, along with red, white, and mixed thrombi, were observed in 31%, 25%, 24%, 21%, 14%, and 17% (total thrombus occurrence = 52%) of the patients, respectively. At 12 months, the MACE (coronary artery bypass graft) rate was 1%., Conclusions: Young Indian patients with ACS displayed a range of plaque morphologies identified through pre-PCI OCT. Among these, fibrous plaques were the most prominent type, followed by plaques containing macrophages. Additionally, plaque rupture, plaque erosion, and lipid-rich plaques were also observed in this population., Competing Interests: Conflict of interest All authors declare that they do not have any conflict of interest. MN is an employee of Abbott Healthcare Pvt Ltd., (Copyright © 2024 Cardiological Society of India. Published by Elsevier, a division of RELX India, Pvt. Ltd. All rights reserved.)

Introduction: Levels of lipoprotein (LP) (a) are useful marker for risk stratification of cardiovascular disease. This genetic biomarker is suggestive of patient predisposition to acute coronary event. The present study was to study correlation of LP(a) levels and plaque morphology in very young patients (<35 years) with acute coronary syndrome (ACS)., Methods: A prospective, single-center, observational study consisting of very young patients with ACS and fit for optical coherence tomography (OCT) guided invasive coronary angiography was conducted at tertiary-care centre. LP(a) levels were compared between healthy controls and very young ACS patients. Correlation of LP(a) levels and plaque characteristics in very young ACS patients was done using OCT imaging., Results: Out of enrolled 80 subjects, 40 were very young ACS and 40 were matched healthy controls. In very young patients, plaque rupture and erosion were mechanism of ACS in 67.5% and 32.5% patients, respectively. Mean levels of LP(a) were 28.10 ± 13.96 nmol/l in healthy controls and 47.19 ± 29.85 nmol/l in very young patients with ACS (p = 0.022). Among very young ACS patients, patients with LP(a) levels<75 nmol/l and ≥75 nmol/l had mean thin cap fibroatheroma thickness of 117.08 ± 52.542 μm and 95.00 ± 36.286 μm, respectively (p = 0.2355)., Conclusion: Higher levels of LP(a) were seen in younger patients with ACS compared with matched healthy individuals. Plaque rupture was the commonest mechanism of ACS in very young ACS patients. Patients with high LP(a) levels had lesser thickness of fibrous cap in OCT imaging compared with low levels of LP(a)., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 Cardiological Society of India. Published by Elsevier, a division of RELX India, Pvt. Ltd. All rights reserved.)

Dual antiplatelet therapy (DAPT) has remained the cornerstone for management of acute coronary syndrome (ACS) over the years. Clopidogrel has been the quintessential P2Y12 receptor (platelet receptor for Adenosine 5' diphosphate) inhibitor for the past two decades. With the demonstration of unequivocal superior efficacy of prasugrel/ticagrelor over clopidogrel, guidelines now recommend these agents in priority over clopidogrel in current management of ACS. Cangrelor has revived the interest in injectable antiplatelet therapy too. Albeit the increased efficacy of these newer agents comes at the cost of increased bleeding and this becomes more of a concern when combined with aspirin. Which P2Y12i is superior over another has been intensely debated over last few years after the ISAR-REACT 5 study with inconclusive data. Three novel antiplatelet agents are already in the pipeline for ACS with all of them succeeding in phase II studies. The search for an ideal antiplatelet remains a need of the hour for optimal reduction of ischemic events in ACS.

Objective: The concept of managing patients on the basis of culprit lesion characteristics is emerging. Atherosclerotic plaques are reported to be rare in young patients presenting with acute coronary syndrome (ACS). We aimed to assess culprit lesion characteristics in very young patients presenting with ACS by optical coherence tomography (OCT)., Methods: This was a prospective, single-center, open-label, observational study. Patients aged 35 years or less with ACS who underwent invasive coronary angiography and OCT were studied., Results: Of the 43 patients, 22 (51.2%) had plaque rupture, 16 (37.2%) had plaque erosion, and five (11.6%) had no specific lesion character. Plaque was fibroatheromatous in 34 (79.1%) patients and fibrous in seven (16.3%). Plaque was not found in two (4.7%) patients; of these, one (2.3%) had left anterior descending coronary artery bridging, and one (2.3%) had intimal dissection without any plaque. Plaque rupture was more commonly associated with fibroatheromatous plaques, whereas plaque erosion was more commonly associated with fibrous plaque (p=0.010)., Conclusion: Although plaque rupture and plaque erosion occurred at the same rate as seen in patients of all ages, calcified nodule as a culprit lesion was not found in young patients. Majority of the patients had plaque rupture and plaque erosion with fibroatheromatous plaque, signifying the occurrence of established coronary artery disease in very young patients of Southeast Asia.

Background: Owing to the growing evidence that the pathophysiology of obstructive sleep apnoea (OSA) and metabolic syndrome (MS) overlap considerably and both adversely impact cardiovascular health, we hypothesised that the presence of OSA with MS additively and adversely affect the severity of coronary artery disease (CAD). Exploration and understanding of this may have direct implications for the development of targeted, preventive strategies for CAD. Thus, this prospective study was aimed to determine the prevalence of 'Syndrome Z' in patients of MS who present with an acute coronary event and to correlate it with the angiographic severity of CAD in these patients., Methods: The present study was a single centre, cross sectional study conducted in a university teaching hospital. In a span of 6 months, 922 patients with acute coronary syndromes (ACS) were screened for the study. Among these, 861 patients had no evidence of MS. The remaining 61 patients who were diagnosed to have MS were then subjected to an overnight sleep study. Only 58 had good sleep data so were included for further analysis. Angiographic parameters in terms of number of vessels involved and culprit lesions were noted and correlated with presence and absence of OSA and also with its severity based on the Apnoea/Hypopnoea Index (AHI)., Results: The prevalence of OSA positivity in patients with MS who presented with ACS was 34.5% (n=20). Most of the patients in the OSA negative group (78.9%, n=30) had disease limited to only one vessel while in the OSA positive group only a minority (15%, n=3) of patients had their disease limited to a single vessel (p=0.001). The number of lesions in the culprit vessel was also significantly less in the OSA negative group compared to the OSA positive group. While in the OSA negative group 68.4% (n=26) patients had a solitary lesion, followed by two and three lesions in 15.8% (n=6) of the patients each, multiple lesions were more common in OSA positive patients, involving 80% of cases (45.0%, n=9 with two lesions; 35.0%, n=7 with three lesions; only 20%, n=4 had a solitary lesion)., Conclusions: Prevalence of 'Syndrome Z' is high in patients having MS presenting with ACS and it correlates with the angiographic severity of CAD., (Copyright © 2018. Published by Elsevier B.V.)

Background: Obstructive sleep apnoea (OSA) is an emerging risk factor for acute coronary syndrome (ACS). We sought to determine the effects of ethnicity on the prevalence of OSA in patients presenting with ACS who participated in an overnight sleep study., Methods: A pooled analysis using patient-level data from the ISAACC Trial and Sleep and Stent Study was performed. Using the same portable diagnostic device, OSA was defined as an apnoea-hypopnoea index of ≥15 events per hour., Results: A total of 1961 patients were analysed, including Spanish (53.6%, n=1050), Chinese (25.5%, n=500), Indian (12.0%, n=235), Malay (6.1%, n=119), Brazilian (1.7%, n=34) and Burmese (1.2%, n=23) populations. Significant differences in body mass index (BMI) were found among the various ethnic groups, averaging from 25.3kg/m 2 for Indians and 25.4kg/m 2 for Chinese to 28.6kg/m 2 for Spaniards. The prevalence of OSA was highest in the Spanish (63.1%), followed by the Chinese (50.2%), Malay (47.9%), Burmese (43.5%), Brazilian (41.2%), and Indian (36.1%) patients. The estimated odds ratio of BMI on OSA was highest in the Chinese population (1.17; 95% confidence interval: 1.10-1.24), but was not significant in the Spanish, Burmese or Brazilian populations. The area under the curve (AUC) for the Asian patients (ranging from 0.6365 to 0.6692) was higher than that for the Spanish patients (0.5161)., Conclusion: There was significant ethnic variation in the prevalence of OSA in patients with ACS. The magnitude of the effect of BMI on OSA was greater in the Chinese population than in the Spanish patients., (Copyright © 2016 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.)

Objectives: To compare the safety and diagnostic efficacy of coronary computed tomography angiography (CTA) with exercise electrocardiography (XECG) in triaging patients of low risk acute chest pain., Background: Noninvasive assessment of coronary stenosis by CTA may improve early and accurate triage of patients presenting with acute chest pain to the emergency department (ED)., Methods: Low risk patients of possible acute coronary syndrome (ACS) were included in the study. The patients in CTA arm with significant stenosis (≥ 50%) underwent catheterization, while those with no or intermediate stenosis (<50%) were discharged from ED and followed up periodically for six months for major adverse cardiovascular events (MACE). The same protocol was applied for XECG arm. Outcomes included: safety and diagnostic efficacy., Results: A total of 81 (41 CTA and 40 XECG) patients were enrolled. In this study CTA was observed to be 100% sensitive and 95.7% specific in diagnosing MACE in low risk patients of chest pain presenting to the ED, with a PPV of 94.7% and an NPV of 100%.The overall diagnostic efficacy was 97.6%. XECG was observed to be 72.7% sensitive and 96.6% specific in diagnosing MACE with a PPV of 88.9% and NPV of 90.3% in low risk chest pain patients presenting to the ED. The overall diagnostic accuracy was 90%., Conclusion: CTA is an excellent diagnostic tool in ED patients with low risk of ACS, with minimum time delay as compared to XECG, and also is safe for triaging such patients., (Copyright © 2014 Cardiological Society of India. Published by Elsevier B.V. All rights reserved.)

Background: The level of platelet inhibition by a Glycoprotein IIb/IIIa (GpIIb/IIIa) antagonist therapy necessary to minimize thrombotic complications in patients undergoing percutaneous coronary intervention (PCI) is a subject of debate. The degree of platelet inhibition obtained 10 min after start of GpIIb/IIIa antagonist therapy predicts adverse events after PCI. The aim of this study was to look at platelet inhibition and to compare platelet GpIIb/IIIa receptors occupancy ratio (GpRO) with Eptifibatide and Tirofiban using various dose regimens and correlate with 30-day clinical outcomes in patients presenting with high-risk acute coronary syndromes (ACS) and undergoing PCI., Methods: The patients were divided into four sub groups: (1) Eptifibatide two intracoronary bolus (180 μg/kg) alone (E(B)); or (2) two intravenous bolus (180 μg/kg) followed by infusion at 2 μg/kg/min for 24 h (E(B + Inf)); and (3) Tirofiban standard bolus dose (0.4 μg/kg) over 30 min followed by infusion at 0.1 μg/kg/min (T(Std)); or (4) at ADVANCE dose bolus (25 μg/kg) over 3 min, followed by infusion at 0.1 μg/kg/min (T(Adv)). Number of GpIIb/IIIa receptors was assessed by flow cytometry at baseline and 10 min after the bolus and percentage of free receptors was determined to calculate the GpRO. Patients were followed for 30 days for any major adverse cardiac events (MACE)., Results: 200 consecutive patients (including 74% with ST-elevation ACS) were enrolled. GpRO in groups E(B) (n = 48) and E(B + Inf) (n = 44) were 62.7% ± 27.2% and 61.4% ± 6.1% respectively while in the groups T(Std) (n = 96) and T(Adv) (n = 12) groups were 35.1% ± 17.74% and 68.8% ± 27.3% respectively. The GpRO was similar in E(B), E(B + Inf) and T(Adv) groups and was significantly higher than T(Std) group (p < 0.0001). The 30-day MACE rates in E(B) (4.2%), E(B + Inf) (4.5%) and T(Adv) (4.2%) were significantly lower than T(Std) group (12.5%) (p < 0.01)., Conclusions: Standard dose Tirofiban results in significantly lower rates of GpIIb/IIIa receptor occupancy ratio and this correlated with higher incidence of 30-day MACE in high-risk ACS patients undergoing PCI., (Copyright © 2012 Cardiological Society of India. Published by Elsevier B.V. All rights reserved.)

Introduction: Identifying reperfusion and predicting post procedure risk is important following Percutaneous Coronary Interventions (PCI). An Angiographic Perfusion Score (APS) combining TIMI flow (TFG) and myocardial perfusion (TMPG) grades before and after PCI can accurately measure both epicardial and myocardial perfusion and predict Major Adverse Cardiac Events (MACE)., Patients and Methods: APS was calculated in 226 (88 ST elevation Myocardial Infarction (STEMI) and 138 Non STEMI) patients. Maximum score being 12, reperfusion was defined as failed: 0-3, partial: 4-9, and full APS: 10-12. Thirty day MACE were observed., Results: APS identified reperfusion significantly more than TMPG alone (STEMI: 50.6% vs 11.8% (p < 0.001); Non STEMI, early reperfusion: 69.4% vs 52.8% (p < 0.01) and Non STEMI late reperfusion: 38.2% vs 7.8%; (p ≤ 0.001) respectively. A significantly lower incidence of MACE was observed in the full as compared to the failed APS group (1.8% vs 22.5%) (p < 0.001). No differences were noted between TMPG 0-2 (9.8%, 9.4%, 7.3%, respectively) (p = NS)., Conclusion: Compared to MPG alone APS detects more low risk reperfused patients, post PCI., (Copyright © 2012. Published by Elsevier B.V.)

Objective: Biochemical markers are useful for the prediction of future cardiovascular events in patients with non-ST-segment elevation acute coronary syndrome (ACS). The independent as well as the combined prognostic value of elevated troponin-T, high-sensitivity C-reactive protein (hs-CRP), and N-terminal pro-brain natriuretic peptide (NT-pro-BNP) on the Thrombolysis In Myocardial Infarction (TIMI) risk score and on the short-term prognosis were evaluated in a cohort of ACS patients., Methods and Results: In an unselected, heterogeneous group of 80 patients with ACS (i.e., unstable angina [USA] or non-ST-elevation myocardial infarction [NSTEMI]), the levels of troponin-T, hs-CRP, and NT-pro-BNP were analyzed. The correlation between elevation of different biomarkers with TIMI risk score and their impact on 30-day major adverse cardiac events was sought. The levels of hs-CRP were significantly higher in patients who had angina as their predominant complaint (3.67 mg/dl vs. 1.67 mg/dl: p < 0.01), while levels of NT-pro-BNP was higher in those patients who had any element of heart failure at presentation (2616.39 pg/ml vs. 1068.3 pg/ml; p < 0.01). Troponin-T was highest in patients who had an element of both heart failure and angina at presentation (p < 0.01). The TIMI risk score expectedly had a positive and strong correlation with elevated troponin-T, but had no correlation with elevation of hs-CRP and NT-pro-BNP in isolation. However, when any two biomarkers were elevated, the patients were in the intermediate risk group as per TIMI risk score irrespective of troponin-T-elevation. When all the three biomarkers were elevated, the risk equaled the high-risk category of TIMI risk score. Elevated hs-CRP (3.40 mg/dl vs. 1.38 mg/dl; p < 0.001) and troponin-T (2.37 ng/ml vs. 1.23 ng/ml; p < 0.001) at baseline correlated independently with the occurrence of re-ischemia, while elevated NT-pro-BNP alone correlated significantly with the development of heart failure within 30 days of follow-up (4247.76 pg/ml vs. 1210.86 pg/ml; p < 0.01). The highest risk of death from any cardiovascular cause within 30 days of follow-up was significantly higher when all the three biomarkers were elevated., Conclusion: The use of NT-pro-BNP, hs-CRP, and troponin-T in combination appears to add critical prognostic insight to the assessment of patients with ACS.

Objective: Inflammation has been proposed as one of the factors responsible for the development of coronary artery disease (CAD) and high sensitivity C-reactive protein (hs CRP) at present is the strongest marker of inflammation. We did a study to assess the correlation of hs-CRP with socio-economic status (SES) in patients of CAD presenting as acute coronary syndrome (ACS)., Methods: Baseline hs-CRP of 490 patients of ACS was estimated by turbidimetric immunoassay. Patients were stratified by levels of hs-CRP into low (<1 mg/L); intermediate (1-3 mg/L) or high (>3 mg/L) groups and in tertiles of 0-0.39 mg/L, 0.4-1.1 mg/L and >1.1 mg/L, respectively. Classification of patient into upper (21.4%), middle (45.37 percent) and lower (33.3%) SES was based on Kuppuswami Index which includes education, income and profession. Presence or absence of traditional risk factors for CAD diabetes, hypertension, dyslipidemia and smoking was recorded in each patient., Results: Mean levels of hs-CRP in lower, middle and upper SES were 2.3 +/- 2.1 mg/L, 0.8 +/- 1.7 mg/L and 1.2 +/- 1.5 mg/L, respectively. hs-CRP levels were significantly higher in low SES compared with both upper SES (p = 0.033) and middle SES (p = 0.001). Prevalence of more than one traditional CAD risk factors was seen in 13.5%, 37.5% and 67.67 percent; in patient of lower, middle and upper SES. It was observed that multiple risk factors had a linear correlation with increasing SES. Of the four traditional risk factors of CAD, smoking was the only factor which was significantly higher in lower SES (73%) as compared to middle (51.67 percent;) and upper (39.4%) SES. We found that 62.3%, 20.8% and 26.5% patients of low, middle and upper SES had hs-CRP values in the highest tertile. Median value of the Framingham risk score in low, middle and upper SES as 11, 14 and 18, respectively. We observed that at each category of Framingham risk, low SES had higher hs-CRP., Conclusion: We conclude from our study that patient of lower SES have significantly higher levels of hs-CRP despite the fact that they have lesser traditional risk factors and lower Framingham risk. These findings add credit to our belief that inflammation may be an important link in the pathophysiology of atherosclerosis and its complications especially in patients of low SES who do not have traditional risk factors.

Unlabelled: Recently reports of a variable platelet response to aspirin and potential resistance to therapy have emerged with thienopyridines group of drugs. However the data available on clopidogrel resistance is scarce. The present study was initiated to prospectively evaluate the prevalence of clopidogrel resistance in patients of acute coronary syndrome(ACS) presently on dual anti platelet therapy by using an established method of optical platelet aggregation. We studied 39 patients of ACS, who were on clopidogrel 300 mg bolus followed by 75 mg per day for 3 days along with aspirin 325 mg per day. Fasting blood samples were assessed using optical platelet aggregation (Chronolog Corp, USA). Clopidogrel resistance was defined as <10% decrease from baseline in platelet aggregation. Clopidogrel semi-responders were defined as 10-29% ( <30%) decrease from baseline in platelet aggregation. Clopidogrel non-responders were defined as a composite of resistant and semi-responders. A baseline mean platelet aggregation obtained from 18 healthy subjects was 63.8 +/- 14.75% with 5 mu and 68.8 +/-13.91% with 10 mu of Adenosine Diphosphate. Hence, the definition of clopidogrel resistance was set as aggregation of >57% with 5 mu ADP and >61.9% with 10 mu ADP (< 10% decrease from baseline). The definition of clopidogrel semi-responder was set as aggregation of >or=45% with 5 mu ADP and >or=48% with 10 mu ADP (10-29% decrease from baseline). The mean platelet aggregation with 5 mu and 10 mu of Adenosine Diphosphate in the patient group was 30.77 +/- 17.19% and 35.71 +/- 17.0% respectively. Based on these criteria, 2.54% patients were found to be clopidogrel resistant, 12.7% were clopidogrel semi-responders and 84.7% were clopidogrel responders. On comparison of clopidogrel responders with non-responders, females ( p=0.07) and patients with higher serum triglyceride levels (p=0.08), had a trend to be more inclined towards clopidogrel non-responders. All other parameters tested namely age, smoking, diabetes, hypertension, obesity, cholesterol, hemoglobin, platelet count, ejection fraction and concurrent drug intake did not show any statistically significant difference among the groups., Conclusions: This study shows that clopidogrel resistant and clopidogrel semi-responders do occur in Indian patients with ACS and there are no reliable clinical predictors for this condition. The diagnosis therefore relies primarily on laboratory tests.

Patients with hypereosinophilia often present with symptoms and signs of other systemic disease.We present the case of a 30-year-old man who had hypereosinophilia presenting as acute coronary syndrome, while having normal coronaries. The history, clinical examination and laboratory investigations were consistent with a diagnosis of tropical eosinophilia, which responded promptly to diethyl carbamazine.

Background Guillain–Barré syndrome (GBS) is a monophasic disease characterized by acute polyradiculoneuropathy. Aim This study investigated cardiovascular complications in patients with GBS and their relationship with outcomes. Design and methods We included 96 patients, who were diagnosed with GBS according to Brighton case definitions. All enrolled patients were evaluated according to a predetermined algorithm, which included nerve conduction studies, cerebrospinal fluid analysis, electrocardiography, 2D echo, cardiac markers and autonomic function testing. Results We enrolled a total of 96 patients. The mean age of patients was 35.75 ± 17.66 years. Furthermore, 54.2% of patients developed cardiovascular complications, of which changes in electrocardiography (ECG) findings (50%), hypertension (28.12%), labile hypertension (12.5), tachycardia (26.04), bradycardia (13.54%) and a fluctuating heart rate (HR) (11.46) were common. Other cardiovascular complications seen in GBS patients were increased pro-BNP (26.04%), raised troponin T levels (3.12%), acute coronary syndrome (2.08%), heart failure (2.08%) and abnormal 2D echo findings (8.33%). The results of the univariate analysis revealed that a history of preceding infection, a Medical Research Council sum score, neck muscle weakness, facial nerve involvement, bulbar involvement, respiratory failure, cardiovascular complications, autonomic dysfunction, acute motor sensory axonal neuropathy subtype and baseline Hughes score were significantly (P  < 0.005) associated with poor outcomes. However, none of these factors were found to be independently associated with poor outcomes in the multivariate analysis. Conclusion A considerable number of patients with GBS developed cardiovascular complications and it needs attention. [ABSTRACT FROM AUTHOR]