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Hypertrophic cardiomyopathy (HCM) is characterized by abnormal thickening of the left ventricular myocardium. Apical HCM is a less common variant of HCM where the hypertrophy is limited to the apical segments and can be challenging to diagnose based on traditional echocardiography alone. Patients with HCM can present with exertional angina. We present a series of four different cases, where patients were advised computed tomography (CT) coronary angiography for the evaluation of coronary artery disease. While CT coronary angiography excluded obstructive coronary artery disease, a detailed evaluation of the retrospective electrocardiogram-gated CT coronary angiography data helped in establishing the diagnosis of apical HCM in these patients. We discuss the importance of a systematic analysis of cardiac CT for diagnosing HCM variants and highlight the utility of reconstructed static and cine CT images which are readily available from the data obtained during retrospective gated CT coronary angiography for diagnosing HCM.

Abstract Background Acute kidney injury (AKI) occurs frequently in ST-elevation myocardial infarction with cardiogenic shock (CS-STEMI) and is a strong independent prognostic marker for short and intermediate-term outcomes. Owing to the delayed presentation and limited facilities for primary percutaneous coronary intervention in low- and middle-income countries, the incidence, predictors, and outcome of AKI are likely to be different compared to the developed countries. We performed a post hoc analysis of patients presenting with CS-STEMI over 7 years (2016–2022) at a tertiary referral center in North India. The primary outcome assessed was AKI and the secondary outcome was in-hospital mortality. Results Of the 426 patients, 194 (45.5%) patients developed AKI, as defined by the Kidney Disease Improving Global Outcomes criteria. Left ventricular (LV) pump failure with pulmonary edema [Odds ratio (OR) 1.67; 95% confidence interval (CI) 1.04–2.67], LV ejection fraction (OR 1.35 per 10% decrease in ejection fraction; CI 1.04–1.73), complete heart block (OR 2.06; CI 1.2–3.53), right ventricular infarction (OR 2.76; CI 1.39–5.49), mechanical complications (OR 3.89; CI 1.85–8.21), ventricular tachycardia (OR 2.80; CI 1.57–4.99), and non-revascularization (OR 2.2; CI 1.33–3.67) were independent predictors of AKI in multivariate logistic regression analysis. Additionally, AKI was a strong predictor of in-hospital mortality (univariate OR 30.61, CI 17.37–53.95). Conclusions There is a higher incidence of AKI in CS-STEMI in resource-limited settings and is associated with adverse short-term outcomes. Additional studies are needed to address the optimal strategies for the prevention and management of AKI in such settings.

Background: COVID-19 can cause severe pneumonia that can progress to multiple organ failure. It is believed that dysregulation of inflammation and cytokine storm, contributes to severe COVID-19. As inflammatory mediators play an important role in the pathogenesis of the severe disease, inflammatory markers like fever, leucocytosis, and C-reactive protein are known to predict severe disease. Various other biomarkers have been known to have prognostic value in patients with COVID-19 infection. Inflammation, both local and systemic plays an important role in the pathogenesis of acute coronary syndrome (ACS). Thus in this study, we aimed to compare and describe the various biomarkers, and mortality between patients admitted with COVID-19 infection and ACS patients without COVID-19 infection. Methods: In a retrospective observational case-control study, a total of 108 patients admitted to our hospital during the month of May 2021 with COVID-19 were enrolled. Patients of the acute coronary syndrome (tested negative for COVID-19 infection) admitted during the same month were enrolled (including both the intensive care unit and ward) as controls. Results: The median age of patients with COVID was significantly lower than that of patients with acute coronary syndrome [49 years (IQR, 36-62 years) and 60 years (IQR, 52-66 years)]. Left ventricular ejection fraction was significantly higher among patients with COVID infection (58.5 ± 6.3% versus 36.9 ± 9.3%). The total leukocyte count was significantly higher among patients with COVID-19 compared to those with acute coronary syndrome [13200 per microliter (8625-17500) vs 9800 per microliter (8150-12150), P < 0.001]. The blood urea level was significantly higher among patients with COVID infection [52.5 (IQR, 34.7-81.5) versus 20 (IQR, 16-31)]. Levels of C-reactive protein were significantly higher among patients with COVID [39 (IQR, 7.7-100) versus 2 (1.4-3.5)]. The mortality of patients hospitalized with COVID was 4 times higher than those with acute coronary syndrome [25.9% (28) versus 6.1% (6)]. Survivors of COVID-19 had higher hemoglobin levels than those who did not [12.5 g/dLvs 11.5 g/dL, P = 0.03]. Conclusions: Elevated total leukocyte counts reflect underlying secondary bacterial infection among patients with COVID-19 and help initiate appropriate antibiotics. Depletion of intravascular volume reflected by an increased urea/creatinine ratio increases the risk of mortality and warrants aggressive measures of rehydration and albumin infusion.

Atrial high rate episodes (AHRE) confers increased morbidity and mortality amongst patients with permanent pacemaker implantation (PPI). The incidence of AHREs and it's clinical predictors in Indian patients without prior history of atrial fibrillation (AF) are not well understood. A total of 100 dual-chamber PPI patients, who had no prior history of AF, underwent pacemaker interrogation starting from a minimum of 1 month after implantation to detect any AHREs. The incidence of AHREs was 17% at a mean follow up 15.2 ± 7.5 months. Only right ventricular apical lead position was found to have an independent association with AHREs (OR: 3.50, 95% CI: 1.02–12.03; p = 0.04).

Atrial fibrillation (AF) confers a 2-to-3-fold increased risk of developing cognitive dysfunction and dementia, independent of age and past stroke. The purpose of study was to identify risk factors for developing dementia amongst AF patients in India. This was a single-centre, prospective, observational study wherein recently diagnosed, treatment naïve, persistent non-valvular AF patients were enrolled. All patients were screened for dementia using the Mini-Mental state exam. Amongst a total of 108 patients enrolled, 40 (37%) had dementia. The most common cognitive deficits were in attention and calculation followed by memory deficits. Factors independently contributing to dementia were advanced age, female sex, presence of diabetes, elevated pulmonary artery pressures and a lower serum albumin.

Katz-Wachtel phenomenon is an electrocardiogram (ECG) sign demonstrating large equiphasic precordial QRS complexes indicative of biventricular hypertrophy. This sign is most commonly seen in children with congenital heart disease and is rarely described in adults. We report a case where this ECG sign was noted in an adult with dilated cardiomyopathy and discuss the possible mechanisms for this unusual finding.

Background: The relationship of atrial fibrillation (AF) with coronary artery disease (CAD) is well established, yet it is often missed. There is evidence of myocardial ischemia on stress imaging in AF patients in the absence of obstructive CAD. In this prospective cohort, we studied the angiographic profiles of non-valvular AF patients. Methods: The study was a nonrandomized, prospective, single-center observational study of consecutive patients of persistent non-valvular AF. Patients symptomatic for AF despite optimal medical therapy for 3 months were recruited and all underwent coronary angiograms (CAG). Patients with prior history of CAD were excluded. Results: A total of 70 patients were followed for a mean duration of 12 ± 1.4 months. The mean age of the study group was 66.07 (±11.49) years. Hypertension was the commonest comorbidity seen in 74% patients. Obstructive CAD was present in 32 (46%) patients, non-obstructive (

Aim: The purpose of this study was to assess the safety and performance of the domestically manufactured Charak DDDR 747R (Pacetronix Ltd, Indore, India) pacemaker device. Materials and Methods: This was a prospective, controlled, single-center study conducted between March 2016 and August 2017. Eligible patients were implanted with a Charak DDDR 747R pacemaker with parameters set as specified on the packaging material unless otherwise advised by the physician. Patients were evaluated before discharge and at the 18-month follow-up. Data such as patient age, gender, and medical history were collected to determine patient eligibility for study participation, monitoring of study progress, and data analysis. Results: A total of 35 patients were analyzed. Males comprised 45.7% and females comprised 54.3% of patients. The average pacing threshold was threshold (atrium) was 1.05 V and the average pacing threshold (ventricle) was 1.07 V. The average impedance (atrium) was 641.09 Ω and the average impedance (ventricle) was 719.31 Ω. No serious adverse events were documented during the follow-up. One death occurred; however, this was not device-related. Conclusions: As per study findings, the Charak DDDR 747R, an indigenous pacemaker, is safe and effective in the Indian population. Durable lead parameters were obtained during the study which remained stable over time referring the same. Future larger studies are needed to confirm the preliminary data obtained from our study.

Objective: Several studies have demonstrated a shift in the spectrum of infective endocarditis (IE) in the developed world. We aimed to investigate whether demographic and microbiologic characteristics of IE have changed in India. Design: A retrospective analysis of patients with in north India between 2010 and 2020. Methods: The clinical and laboratory profiles of 199 IE admitted to an academic hospital patients who met the modified Duke criteria for definite IE were analysed. Results: The mean age was 34 years, and 84% were males. The main predisposing conditions were injection drug use (IDU) (n = 71, 35.7%), congenital heart disease (n = 46, 21.6%), rheumatic heart disease (n = 25, 12.5%), and prosthetic device (n = 19, 9.5%). 17.1% of patients developed IE without identified predispositions. Among 64.3% culture-positive cases, the most prevalent causative pathogens were Staphylococcus aureus (46.1%), viridans streptococci (7.0%), enterococci (6.0%), coagulase-negative staphylococci (5.5%), gram negative bacilli (5.5%), polymicrobial (5.5%), and Candida (1.0%). The tricuspid (30.3%), mitral (25.6%), and aortic (21.6%) valves were the most common sites of infection, and 60.3% had large vegetations (>10 mm). Systemic embolization occurred in 55.3% of patients at presentation. Cardiac surgery was required for 13.1%. In-hospital mortality was 17.1% and was associated with prosthetic devices (p-value, 0.001), baseline leucocytosis (p-value, 0.036) or acute kidney injury (p-value, 0.001), and a microbial etiology of gram negative bacilli or enterococci (p-value, 0.005). Conclusion: IDU is now the most important predisposition for IE in India, and S. aureus has become the leading cause of native valve endocarditis with or without IDU.

HIV/AIDS is a multisystemic disorder and occurrence of cardiovascular disease is higher compared to non-HIV individuals. Spontaneous coronary artery dissection (SCAD) remains a rare and underdiagnosed cause of acute coronary syndrome (ACS), even in modern day era. SCAD is predominantly seen in young to middle aged females and present as a non-atherosclerotic cause of myocardial ischaemia, infarction or sudden cardiac death (SCD); with or without ventricular arrythmias. Ventricular tachycardia (VT) can sometimes be the initial presentation of SCAD. HIV associated arteriopathy can predispose to occurrence of SCAD. We report a case of a 38-year-old male suffering from HIV/AIDS, with no conventional risk factors presenting as VT. Coronary angiogram showed SCAD in right coronary artery without any flow limitation.

Abstract Background Anemia affects one-third of heart failure patients and is associated with increased morbidity and mortality. Despite being one of the commonest comorbidities associated with heart failure, there is a significant knowledge gap about management of anemia in the setting of heart failure due to conflicting evidence from recent trials. Main body The etiology of anemia in heart failure is multifactorial, with absolute and functional iron deficiency, decreased erythropoietin levels and erythropoietin resistance, inflammatory state and heart failure medications being the important causative factors. Anemia adversely affects the already compromised hemodynamics in heart failure, besides being commonly associated with more comorbidities and more severe disease. Though low hemoglobin levels are associated with poor outcomes, the correction of anemia has not been consistently associated with improved outcomes. Parenteral iron improves the functional capacity in iron deficient heart failure patients, the effects are independent of hemoglobin levels, and also the evidence on hard clinical outcomes is yet to be ascertained. Conclusion Despite all the research, anemia in heart failure remains an enigma. Perhaps, anemia is a marker of severe disease, rather than the cause of poor outcome in these patients. In this review, we discuss the current understanding of anemia in heart failure, its management and the newer therapies being studied.

Background: Cardiovascular disease is the leading cause of death in India. Our aim is to study the clinical, epidemiological profile and in-hospital outcomes of patients presenting with acute coronary syndrome. Methods: We did a prospective single center observational study of the 1203 patients presenting with ACS to a tertiary referral center in North India over a period of one year (July 2018–June 2019). Results: The mean age of study population was 58.4 ± 12.5 years. STEMI and NSTE-ACS accounted for 69.9% and 31.1% respectively. 62.1% of our patients were from rural background. The median time to hospital admission was 600 min for STEMI patients, thrombolysis was performed in 52% of cases. Cardiogenic shock at presentation was noted in 18%. Coronary angiography and percutaneous coronary intervention were done in 1062 (88.3%) and 733 (60.9%) patients respectively. The overall in-hospital mortality was 7.6%. STEMI patients had higher mortality than NSTE-ACS (8.9% vs 4.5% p

Background: Coronary artery disease (CAD) is witnessing a demographic transition with increasing prevalence in younger individuals. Data is scarce comparing various characteristics of acute coronary syndrome (ACS) between young and old patients in an Indian setting. Hence, we evaluated the epidemiological, demographic, risk factor, and outcome profile of young and old ACS patients in Indian setting. Methods: This was a prospective observational study, which enrolled 50 consecutive ACS patients each into two groups: younger (≤45 years) and elderly (>45 years), respectively. Comparison of clinical presentation, electrocardiography, echocardiographic findings, conventional, nonconventional risk factors, and in-hospital outcomes including duration of hospital stay and major adverse cardiac events (MACE) were made between the two groups. Multivariate regression analysis of risk factors as determinants of MACE adjusting for other confounding factors was also performed. Results: Fifty patients in each group were compared. Mean age in the younger and elderly group was 36 ± 4.69 and 61.58 ± 10.69 years, respectively. Male sex, smoking, family history of CAD, hyperhomocysteinemia, and obesity were observed more in the younger population. While dyslipidemia, low physical activity, diabetes mellitus, and history of previous ACS was more in the older population. Single-vessel disease was more common in younger patients while multivessel involvement was more common in elderly patients. Older patients had longer hospital stays and more in-hospital MACE including deaths. By multivariate analysis, shock was found to be an independent predictor of MACE in both groups. Conclusion: Younger ACS patients have a different risk profile and better in-hospital outcomes compared to older patients.

Abstract Background Vascular spasm is well known to occur in the arterial system. Central venous spasm during pacemaker implantation is uncommon with only a few cases reported from time to time. Sometimes, the venous spasms may not respond to nitroglycerine injections which requires a change of access site and undue discomfort for the patient. Case presentation A 72-year-old female patient with no prior comorbidities presented to us with recurrent dizziness on exertion and at rest. The electrocardiogram showed complete heart block, likely to be of sclerodegenerative etiology as the patient did not have any ischemic symptoms, also the electrocardiogram and echocardiogram did not show any evidence of ischemia. As part of the hospital protocol, a venogram was performed by giving intravenous diluted contrast (iohexol) through the left brachial vein, which showed good-sized axillary and subclavian veins. We attempted to cannulate the left axillary vein with a 16G needle using Seldinger technique, but the axillary vein could not be cannulated despite multiple attempts. We gave incremental boluses of intravenous nitroglycerine, despite that the left axillary vein could not be cannulated. Repeat intravenous contrast injection showed severe spasm of axillary and subclavian veins. Finally, the axillary vein was cannulated from the right side using anatomical landmarks and a pacemaker was implanted. Conclusions Venous spasm during device implantation although uncommon, it should be anticipated in patients with difficult cannulation to prevent inadvertent complications like pneumothorax and arterial injuries. Mild venous spasm may relieve with time but severe venous spasm may require a change of access site

Abstract Background Diffuse long coronary lesions require long overlapping stents which produce less than optimal long-term results. Sizing of long stents becomes difficult owing to tapering of coronaries and overlapping with excessive metal which makes restenosis a nagging problem on long-term follow-up. The optimal stent sizing becomes even more important when left main (LM) needs to be treated along with left ascending artery (LAD) or left circumflex artery (Lcx). The chronic total occlusions (CTO) represent other complex diffuse coronary lesions which not only require higher expertise and better hardware but also usually long lengths of overlapping stents. The long-tapered sirolimus-eluting stent system (BioMime Morph) has been successfully used in long diffuse lesions in individual coronaries including CTO but the use of the same in LM-LAD/LM-Lcx diffuse lesions has not been explored well where its tapered design can really be favourable. Case presentation We here present a case of a 51-year-old hypertensive male presented with NSTEMI and angiography showing left main triple vessel disease with CTO of right coronary artery (RCA). We successfully stented the LM-LAD and RCA (staged) using a long-tapered BioMime Morph system. IVUS was used for optimising the LM-LAD stent. At 6 months follow-up, the patient was doing well on double anti-platelets. Conclusion Complex coronary disease, involving the left main and LAD diffusely and CTO of RCA, can be well managed by using a single long-tapered stents thereby avoiding multiple stenting strategy. The stents with decremental diameter will provide better adaptation to the vessel size and their natural tapering. The usage of intravascular imaging helps in better optimisation of stents

Although measurements of natriuretic peptides have a role in chronic heart failure and acute coronary syndrome, their role has not been studied in ST-elevation myocardial infarction complicated by cardiogenic shock (CS-STEMI). Sixty-four patients with CS-STEMI were prospectively recruited to assess the prognostic value of N-terminal pro-B-type natriuretic peptide (NT-proBNP) measurement after 24 h of the onset of angina or anginal equivalent. Patients who died within 24 h were excluded. The mean age was 56.9 ± 10.6 years and the median time to presentation was 22 h (Interquartile range 7–48 h). Thrombolysis was done in 51% and PCI in 31% of cases. The in-hospital mortality was 26.5%. The ROC analysis showed a strong relationship between elevated NT-proBNP and in-hospital mortality (AUC = 0.748; p = 0.003). An NT-proBNP value > 8582 pg/mL showed 76.5% sensitivity, 68% specificity, 46.4% positive predictive value, and 89% negative predictive value for in-hospital mortality. Acute kidney injury [Odds ratio (OR) 7.30; 95% confidence interval (CI) 1.42–37.37] and NT-proBNP (OR 1.12 per 1000 pg/mL; CI 1.012–1.25) were independent predictors of mortality in multivariate regression analysis. Although we found plasma NT-proBNP at 24 h to be an independent predictor of in-hospital mortality in CS-STEMI, additional studies with a larger sample are required to ascertain these findings and validate the appropriate cut-off values.

Traumatic injuries to subclavian artery are uncommon vascular injuries, seen in 2% of the patients presenting with trauma. However, they form an important cluster of cases since high mortality and morbidity is reported. Traditionally treated with surgical repair of the artery, emergence of endovascular therapy has provided a valuable alternative for their management. Although considered as a safer approach, endovascular stenting is not free from its own set of challenges. We report a case of subclavian artery injury with pseudoaneurysm and arteriovenous fistula, which was treated with endovascular graft stenting occluding the ipsilateral vertebral artery.

Objective: Delayed presentation after ST-elevation myocardial infarction (STEMI) and complicated by cardiogenic shock (CS-STEMI) is commonly encountered in developing countries and is a challenging scenario because of a delay in revascularization resulting in infarction of a large amount of the myocardium. We aimed to assess the clinical characteristics, angiographic profile, and predictors of outcome in patients with a delayed presentation after CS-STEMI. Methods: A total of 147 patients with CS-STEMI with time to appropriate medical care ≥12 h after symptom onset were prospectively recruited at a tertiary referral center. Results: The median time to appropriate care was 24 h (interquartile range 18–48 h). The mean age was 58.7 ± 11.1 years. Left ventricular pump failure was the leading cause of shock (67.3%), whereas mechanical complications accounted for 14.9% and right ventricular infarction for 13.6% of cases. The overall in-hospital mortality was 42.9%. Acute kidney injury [Odds ratio (OR) 8.04; 95% confidence intervals (CI) 3.08–20.92], ventricular tachycardia (OR 7.04; CI 2.09–23.63), mechanical complications (OR 6.46; CI 1.80–23.13), and anterior infarction (OR 3.18; CI 1.01–9.97) were independently associated with an increased risk of mortality. Coronary angiogram (56.5%) revealed single-vessel disease (45.8%) as the most common finding. Percutaneous coronary intervention was performed in 53 patients (36%), at a median of 36 h (interquartile range 30–72) after symptom onset. Conclusion: Patients with a delayed presentation after CS-STEMI were younger and more likely to have single-vessel disease. We found a high in-hospital mortality of 42.9%. Appropriate randomized studies are required to evaluate the optimal treatment strategies in these patients. Keywords: Cardiogenic shock, STEMI, Mortality, PCI, Medical stabilization, Late presentation

Introduction: Coronary Artery Disease (CAD) is a major global health problem. Recent studies demonstrated that lower vitamin D level (70%-90% and >90% stenosis respectively (p= 0.46) and 15.20ng/ml (±13.00), 15.50ng/ml (±11.30) and 11.80ng/ml (±7.00) in patients with CAD with single, double and triple vessels disease respectively (p= 0.14). The frequency of vitamin D deficiency were 66.70%, 83.20 % and 83.10% in patients with CAD with 50% -70%, >70%-90% and >90% stenosis respectively and 81.40%, 80.00% and 83.50% in patients with single, double and triple vessel disease respectively, as compared to 89.30% in patients with normal coronary artery (p= 0.41 and 0.075). So, all the study groups of CAD had low serum vitamin D level and high frequency of vitamin D deficiency, which was statistically insignificant. Conclusion: Prevalence of vitamin D deficiency is very high in CAD, but it does not correlate with the angiographic severity of CAD.

Two new species of genus Stenamma viz Stenamma wilsoni sp. nov. and Stenamma jhitingriense sp. nov. are described from Indian Himalaya. This adds two more species to the genus from Indian Himalaya, with only Stenamma kashmirense Baroni Urbani, 1977 described earlier. A revised key to 26 species from Palaearctic and Oriental is provided here with.

Human serum paraoxonase-1 (PON1) prevents oxidation of low density lipoprotein cholesterol (LDL-C) and hydrolyzes the oxidized form, therefore preventing the development of atherosclerosis. The polymorphisms of PON1 gene are known to affect the PON1 activity and thereby coronary artery disease (CAD) risk. As studies are lacking in North-West Indian Punjabi's, a distinct ethnic group with high incidence of CAD, we determined PON1 activity, genotypes and haplotypes in this population and correlated them with the risk of CAD.350 angiographically proven (≥ 70% stenosis) CAD patients and 300 healthy controls were investigated. PON1 activity was determined towards paraoxon (Paraoxonase; PONase) and phenylacetate (Arylesterase; AREase) substrates. In addition, genotyping was carried out by using multiplex PCR, allele specific oligonucleotide -PCR and PCR-RFLP methods and haplotyping was determined by PHASE software. The serum PONase and AREase activities were significantly lower in CAD patients as compared to the controls. All studied polymorphisms except L55M had significant effect on PONase activity. However AREase activity was not affected by them. In a logistic regression model, after adjustment for the conventional risk factors for CAD, QR (OR: 2.73 (1.57-4.72)) and RR (OR, 16.24 (6.41-41.14)) genotypes of Q192R polymorphism and GG (OR: 2.07 (1.02-4.21)) genotype of -162A/G polymorphism had significantly higher CAD risk. Haplotypes L-T-G-Q-C (OR: 3.25 (1.72-6.16)) and L-T-G-R-G (OR: 2.82 (1.01-7.80)) were also significantly associated with CAD.In conclusion this study shows that CAD patients had lower PONase and AREase activities as compared to the controls. The coding Q192R polymorphism, promoter -162A/G polymorphism and L-T-G-Q-C and L-T-G-R-G haplotypes are all independently associated with CAD.