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April-June 2020
Volume 21 | Issue 2
Page Nos. 57-124

Online since Monday, June 29, 2020

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CARDIOVASCULAR NEWS  

Cardiovascular News p. 57
Uma Velupandian
DOI:10.4103/HEARTVIEWS.HEARTVIEWS_25_20  
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ORIGINAL ARTICLES Top

Ventricular dysfunction in patients with coronary slow-flow phenomenon: A single-center case–control study p. 60
Mir Hossein Seyyed-Mohammadzad, Sanam Rashtchizadeh, Kamal Khademvatani, Roghaiyeh Afsargharehbagh, Aliakbar Nasiri, Nariman Sepehrvand
DOI:10.4103/HEARTVIEWS.HEARTVIEWS_119_18  
Background: Coronary slow-flow phenomenon (CSFP), characterized by delayed distal vessel opacification of contrast, in the absence of significant epicardial coronary stenosis, has effects on exercise capacity and clinical outcomes. The aim of this study was to explore the systolic and diastolic function of patients with CSFP and to compare it with a group of controls with normal coronary anatomy and flow. Materials and Methods: In this case–control study, 45 consecutive CSFP patients and 45 age-, body mass index-, and presentation season-matched controls with normal coronary arteries and normal coronary flows were enrolled from Seyyedoshohada Heart Center from March 2015 to March 2016. A transthoracic echocardiography was done by a blinded echocardiographer using both conventional and tissue Doppler imaging techniques. Results: Patients with CSFP were more likely to be male (P = 0.006) and smoker (P = 0.02) compared to controls. Other risk factors were not different between the two groups. There were no differences between groups in terms of the peak early (E) and late (A) diastolic velocities, deceleration time, early (E') and late (A') peak diastolic velocities at the mitral annulus, and the systolic mitral annular velocity (S'). Global longitudinal strain and peak systolic strain rates was lower in patients with CSFP compared to controls (−16.7% ±2.4% vs. −18.9% ±1.6%, P < 0.001 and 1.10 ± 0.1 vs. 1.24 ± 0.3, P = 0.008, respectively). Conclusion: Patients with CSFP showed signs of the left ventricular systolic dysfunction in tissue Doppler echocardiography, which underlines the importance of close follow-up in these patients. Patients with CSFP should be screened for ventricular function preferably by tissue Doppler echocardiography.
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Endovascular interventions to superficial femoral artery occlusion: Different approaches, technique, and follow-up p. 65
Santhosh Krishnappa, Jayasheelan Mambally Rachaiah, Harsha Mullusoge Mariappa, Chaitra Doddamadaiah, Manjunath Cholenahally Nanjappa
DOI:10.4103/HEARTVIEWS.HEARTVIEWS_34_19  
Background: Superficial femoral artery lesion is one of the main causes for intermittent claudication or critical limb ischemia. Percutaneous transluminal angioplasty is one of the approved therapies for this medical entity. Anatomical factors should be considered in choosing the right approach and puncture. The purpose of this study is to discuss the anatomical, radiological, and technical factors which determine the preference of various approaches and to determine its safety, efficacy, and mid-term clinical and radiological outcome. Methods: Retrospectively, data were collected from patients who underwent angioplasty to superficial femoral arteries for total occlusion from January 2015 and June 2018 in our center, we performed angioplasty to 59 occluded superficial femoral artery patients at our center. The ipsilateral femoral artery, ipsilateral popliteal artery, contralateral femoral artery, or upper limb approaches were used depending on the various anatomical factors determined by radiological imaging before the procedure. Results: Acute success rate was 91.52%. There were no significant periprocedural complications. At the latest clinical follow-up of mean 25.8 months (10–51), a restenosis rate of 16.67% in infrainguinal arteries and 5.88% in suprainguinal arteries were noted. Conclusions: Percutaneous transluminal angioplasty of superficial femoral artery is a proven, viable, safer, and effective option, with good mid-term clinical results and patency rates. Different approaches to be chosen depends on the anatomical and technical factors to get the best possible outcome.
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Effect of vasodilatory medications on blood pressure in patients undergoing transradial coronary angiography: A comparative study p. 75
Abdulla Shehab, Akshaya Srikanth Bhagavathula, Al Anee Kaes, Hany Ragy, Rajeev Gupta, Ibrahim Mahmoud El Mansour, Eman Eman Said Elkeshk
DOI:10.4103/HEARTVIEWS.HEARTVIEWS_114_19  
Background: In patients undergoing coronary intervention, different vasodilators are used to prevent the radial artery spasm (RAS). To date, no studies investigated the effect of these vasodilators in blood pressure (BP) reduction. Aim: The study aimed to investigate and compare the effect of vasodilatory medications on BP reduction in patients undergoing transradial coronary angiography procedure. Methods: We consecutively included 300 patients undergoing transradial coronary angiography procedures and randomly assigned them into three equal groups to compare the effect of verapamil (2.5 mg), nitroglycerin (200 μg), and combination (verapamil 2.5 mg with nitroglycerin 200 (μg) was diluted in 5 ml of normal saline and given through radial sheath. Changes in the BP, heart rate (HR), and other clinical parameters were assessed and presented as standardized mean differences (SMD) with 95% confidence intervals (CIs). ANOVA test was performed to analyze the differences in the BP and other clinical parameters between the three groups. Results: Overall, the mean age of the study population was 53.26 years (standard deviation: 9.27), male patients (84%), with dyslipidemia (62.6%), and diabetes (45%). At baseline, the mean systolic BP (SBP) was 150.91 ± 31.66 mmHg, HR (72.34 ± 12.71 beats/min). After the administration of vasodilators, the combination group reduced SBP significantly (SMD: −33.35 [95% CI]: −40.27–−26.42, P < 0.001). There was a statistically significant difference between groups for the SBP (F[2,296] =3.38, P = 0.035). Verapamil alone showed a significant decrease in the SBP by −27.23 mmHg and diastolic BP by −4.980 mmHg. Conclusion: Intra-arterial administration of verapamil alone showed lower BP reduction compared to the combination of vasodilators. Verapamil could be a safer and effective alternative to prevent RAS with no deleterious effect on BP and HR in patients undergoing transradial coronary angiography.
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Statin therapy and low-density lipoprotein cholesterol reduction after acute coronary syndrome: Insights from the United Arab Emirates p. 80
Abdulla Shehab, Akshaya Srikanth Bhagavathula
DOI:10.4103/HEARTVIEWS.HEARTVIEWS_115_19  
Background and Aims: Attaining guideline-recommended low-density lipoprotein cholesterol (LDL-C) goals (<70 mg/dl or ≥ 50% reduction) with statin therapy remains suboptimal after an acute coronary syndrome (ACS). This study aimed to assess the level of lipid-lowering therapy (LLT) utilization and achievement of LDL-C targets after ACS hospitalization in the United Arab Emirates (UAE). Methods: A retrospective, observational, longitudinal database analysis of Emirati patients with ACS or stable coronary heart disease was evaluated from January 2015 to June 2018. Patients were divided based on whether or not they were treated with LLT at index hospitalization with ACS. LDL-C target level achievement was assessed according to the 2013 American College of Cardiology/American Heart Association and European Society of Cardiology/European Atherosclerosis Society guidelines. Results: A total of 3,066 patients (mean age 65.5 ± 14 years) met the inclusion criteria. Overall, 58.1% (n = 1782) of the patients in the cohort were on LLT during the ACS hospitalization. At discharge, the mean LDL-C level was 84.8 ± 39.0 mg/dl, and 28%, 21%, and 9% received high-, moderate-, and low-intensity statins, respectively. At 6 months (n = 2046; 66.7%), 27.7% and 16.7% achieved an LDL-C of <70 mg/dl and 70–100 mg/dl, respectively. The highest level of LDL-C reduction by 50% within 6 months was observed among patients using moderate-intensity statin (37.2%). Conclusion: A large proportion of Emirati patients were not on LLT after ACS, and the rate of LDL-C target value attainment was extremely poor (27.7%). Optimal statin utilization by closely implementing the guidelines in the UAE is recommended.
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REVIEW ARTICLE Top

Brugada syndrome: Clinical features, risk stratification, and management p. 88
Balal Rasheed Malik, Ahmed Mohamed Ali Rudwan, Mohamed Salah Abdelghani, Mohammed Mohsen, Shahul Hameed A. Khan, Nora Aljefairi, Elsayed Mahmoud, Nidal Asaad, Sajad Ahmed Hayat
DOI:10.4103/HEARTVIEWS.HEARTVIEWS_44_20  
In 1992, the Brugada brothers published a patient series of aborted sudden death, who were successfully resuscitated from ventricular fibrillation (VF). These patients had a characteristic coved ST-segment elevation in the right precordial leads on their 12-lead electrocardiogram with no apparent structural heart abnormality. This disease was referred to as “right bundle branch block, persistent ST-segment elevation, and sudden death syndrome.” The term Brugada syndrome (BrS) was first coined for this new arrhythmogenic entity in 1996. BrS is more prevalent in Southeast Asian ethnic groups and was considered a familial disease due to the presence of syncope and/or sudden deaths in several members of the same family, however, the genetic alteration was only noted in 1998. The genetic characterization of BrS has proven to be challenging. The most common and well-established BrS genotype involves loss-of-function mutations in the SCN5A gene, but only represents between 15% and 30% of the diagnosed patients. Patients with BrS can present with a range of symptoms which can include syncope, seizures, and nocturnal agonal breathing due to polymorphic ventricular tachycardia or VF. If these arrhythmias are sustained, sudden cardiac death may result. Despite the significant progress on the understanding of BrS over the last two decades, there remain a number of uncertainties and challenges; we present an update review on the subject.
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DRUG THERAPY Top

PCSK9 monoclonal antibodies: An overview p. 97
Rasha Kaddoura, Bassant Orabi, Amar M Salam
DOI:10.4103/HEARTVIEWS.HEARTVIEWS_20_20  
PCSK9 monoclonal antibodies are novel lipid-lowering therapy that have been extensively studied in patients with hypercholesterolemia either as monotherapy or as an add-on to other LLTs. PCSK9 monoclonal antibodies have significantly reduced the low-density lipoprotein cholesterol (LDL-C) plasma level resulting in a better LDL-C goal attainment. The commercially available PCSK9 monoclonal antibodies, alirocumab and evolocumab, have demonstrated reductions in major adverse cardiovascular events such as myocardial infarction, stroke, unstable angina, and the need for coronary revascularization but not mortality. PCSK9 monoclonal antibodies have demonstrated a favorable safety profile. The most reported side effects are mild injection site with no causal relationship proven between the inhibition of PCSK9 and neurocognitive or glycemic adverse events. In this overview, the efficacy and safety of PCSK9 monoclonal antibodies in the treatment of primary and familial hypercholesterolemia will be discussed.
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CASE REPORTS Top

Right atrial pseudoaneurysm complicating epithelioid hemangioendothelioma p. 104
Muhammed Jameesh Moidy, Osama Ali M. Ibrahim, Enas Ali Ibrahim Ali Khalifa, Sherif Mahmoud Helmy
DOI:10.4103/HEARTVIEWS.HEARTVIEWS_96_19  
Cardiac pseudoaneurysm is uncommon among young adults with trauma. Infection, prior cardiac procedure, or cardiac operations are the most common reported causes. Right atrial pseudoaneurysm (RAPA) is extremely rare. Although often challenging to diagnose, advances in noninvasive imaging have improved the ability to diagnose cardiac pseudoaneurysms. We present a case of RAPA, highlighting the diagnostic accuracy of echocardiography in this rare entity.
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Intravascular imaging in acute coronary syndrome patients without significant stenosis on coronary angiography p. 109
Omnia Tajelsir Osman, Mohammed Ahmed Alhijji, Salaheddin Omran Arafa
DOI:10.4103/HEARTVIEWS.HEARTVIEWS_141_19  
Intravascular coronary imaging has facilitated the field of interventional cardiology with multiple studies showing the superiority of intravascular image-guided percutaneous coronary interventions for the reduction of lesion revascularization rates. It also aids in understanding the mechanism of myocardial infarction with nonobstructive coronary artery disease. Despite such results, there is a slow adaptation of intravascular imaging use in the real world. We present two cases where intravascular imaging helped in the rapid understanding of the etiology of acute coronary syndrome and facilitated the management of both patients.
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Epilepsy and brugada syndrome: Association or uncommon presentation? p. 114
Mohamed Salah Abdelghani, Ammar Chapra, Nidal Asaad, Sajad A Hayat
DOI:10.4103/HEARTVIEWS.HEARTVIEWS_34_20  
Brugada syndrome (BrS) is a rare genetic disease, of which its clinical manifestations include, but not limited to, syncope or sudden cardiac death. A 30-year-old Bangladeshi male patient with a past medical history of epilepsy was admitted following successful resuscitation from an out of hospital cardiac arrest secondary to ventricular fibrillation. Electrocardiogram (ECG) upon admission was suggestive of BrS type I. His old medical record showed similar ECG 2 months earlier when he had presented with syncope and was diagnosed with seizure. The correlation between BrS and epilepsy has been reported in the literature, discussing whether seizure is an uncommon presentation of BrS or whether epilepsy and BrS share similar genetic mutations that have the potential to cause both arrhythmia and seizures in some patients. Patients who present with seizure and ECG suggestive of Brugada pattern should be evaluated to rule out associated or underlying cardiac arrhythmia.
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Ortner's syndrome as a presenting feature of congenital heart disease in infants p. 118
Syed Ahmed Zaki, Dinesh Banur
DOI:10.4103/HEARTVIEWS.HEARTVIEWS_120_19  
Ortner's syndrome is a rare condition characterized by hoarseness of voice due to left recurrent laryngeal nerve (RLN) palsy in association with cardiovascular disease. We report two cases of congenital heart disease in infants presenting with Ortner's syndrome. We believe that the dilated pulmonary artery in the first case and the left atrial dilatation in the second case caused compression of the left RLN resulting in hoarseness of voice. After the corrective cardiac surgery, the voice of both the infants had normalized. Through this case report, we highlight that Ortner's syndrome is an important differential diagnosis of hoarseness of voice in infancy.
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A PICTURE IS WORTH A THOUSAND WORDS Top

A bouncing ball inside the heart p. 121
Gopal Chandra Ghosh, Paul V George
DOI:10.4103/HEARTVIEWS.HEARTVIEWS_27_18  
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ART AND MEDICINE Top

Susruta p. 122
Smitha Anilkumar
DOI:10.4103/HEARTVIEWS.HEARTVIEWS_14_20  
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HISTORY OF MEDICINE Top

Evolution of brugada syndrome p. 123
Rachel Hajar
DOI:10.4103/HEARTVIEWS.HEARTVIEWS_29_20  
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