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   Table of Contents - Current issue
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October-December 2020
Volume 21 | Issue 4
Page Nos. 239-317

Online since Thursday, January 14, 2021

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ORIGINAL ARTICLES  

Coronary computed tomographic angiography imaging as a prognostic indicator for coronary artery disease: Data from a lebanese tertiary center p. 239
Salwa A Koubaissi, Zeinab Kamar, Mahdi El Ankouni, Jad A Degheili, Antoine Haddad
DOI:10.4103/HEARTVIEWS.HEARTVIEWS_87_20  
Background: Coronary artery disease (CAD) is a major cause of death and disability worldwide. Coronary computed tomographic angiography (CCTA) is a noninvasive imaging technique with a high negative predictive value (NPV). Most studies were done in developed countries, where the prevalence of CAD does not reflect the actual disease burden in developing countries, such as Lebanon. Methods: We retrospectively evaluated the prognostic value of CCTA in predicting acute myocardial events (AMEs) in 200 Lebanese patients. We determined if specific medical and radiological characteristics are linked with AME and looked for any association between the patient's medical risk factors and the type/location of detected atheromatous plaques. Patients' records were reviewed, and the follow-up period of 5–8 years ensued. Chi-square/Fisher test and Student's t-test were used, in addition to multinomial logistic regression to adjust for the confounding variables. P<0.05 was considered statistically significant. Results: Our study showed that CCTA had a NPV that reaches 97.9% in asymptomatic patients, a positive predictive value (PPV) of 76.4% for symptomatic patients, a sensitivity of 88.9%, and a specificity of 52.5%. AMEs were significantly increased in patients with a mixed plaque type and/or a moderate-to-severe lumen reduction on CCTA. Conclusions: CCTA is a sensitive modality for plaque detection and is found to have a remarkably high NPV for asymptomatic patients. A CCTA, along with a low pretest clinical probability of CAD, can be sufficient to rule out an AME for up to 8 years.
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The effect of glycemic control on cardiac outcomes in Saudi diabetic patients who underwent coronary angiogram p. 245
Mohammed Ali Balghith, Ahmed Ammar Almutairi, Ibrahim Abdulelah Almohini, Abdullah Rasheed Albadah, Ahmed Ayed Almutairi, Abdulrahman Abdulaziz Alhamdan, Hamza Shakir Alshareef, Meshal Abdullah Alkheraiji
DOI:10.4103/HEARTVIEWS.HEARTVIEWS_28_20  
Background: Diabetes mellitus is a metabolic disorder that causes impaired insulin secretion or cellular dysfunction. Glycated hemoglobin (HbA1c) indicates the long-term level of glucose. Diabetes can lead to cardiovascular complications such as acute coronary syndrome , which might require coronary intervention. Objectives: The aim of this study was to estimate the effect of glycemic control measured by HbA1c levels on cardiac complications in Saudi diabetic patients who underwent percutaneous coronary intervention (PCI) or Coronary artery bypass graft (CABG). Methodology: It was a cohort retrospective study conducted at King Abdulaziz Cardiac Center with a total sample size of 379 patients. The charts of all those diabetic patients were reviewed and their HbA1c level, type of intervention were compared to determine their effect on cardiac outcomes and complications. Inclusion criteria involved the age group 50–70 years within follow-up period of 3 years. Any patient known to have renal failure, liver dysfunction, type one diabetes, and cancer were excluded. The HbA1c level was divided into two groups (<7.5%, ≥7.5%). Results: Total sample size was 379, and the mean age was (60.33 ± 5.98) with male being (66.5%). HbA1c levels at admission were (mean 9.15 ± 2.03), whereas the mean after 3 years was (8.629 ± 1.518). The uncontrolled group was more likely to have PCI (n = 302), in comparison to the controlled group (n = 77) with a P value of 0.04. However, the controlled group was more likely to undergo medical treatment P value of 0.001. Patients with uncontrolled Hba1c after the intervention had a higher readmission rate with a P value of 0.018. Conclusions: Patients with an elevated level of HbA1c were more likely to be managed with PCI. Furthermore, they are at a higher risk of multiple readmissions. Patients who had CABG were at a lower risk of cardiac complications. Further studies are required in our population to consider different approaches of diabetes control for preventing adverse outcomes.
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Primary percutaneous coronary intervention facility hospitals and easy access can affect the outcomes of ST.segment elevation myocardial infarction patients p. 251
Mohammed Ali Balghith
DOI:10.4103/HEARTVIEWS.HEARTVIEWS_70_20  
Background: The reperfusion therapy using primary percutaneous coronary intervention (PPCI) in ST-segment elevation myocardial infarction (STEMI) is known to give a better result than fibrinolytic therapy. The fast access to PPCI will improve hospital outcome. We believe that patient access to PPCI facility would have improved due to enhanced public awareness and expanding evidenced-based health provision. Methods: This is a single-center retrospective study to analyze and compare data for STEMI patients. Patients were transferred to our hospital during the year 2010. Group l comprised 223 patients. Group 2 comprised 288 patients. Group 2 patients were those treated between August 2014 and August 2015. We compared their demographic and baseline characteristics, patients' access to the hospital, reasons for no access, and hospital mortality for the two groups. Results: Among the 288 patients in Group 2, 247 patients (85%) were males with an average age of 57 years, 49% were diabetics, 48% were hypertensive, 48% were smokers, and 27% were obese. These were not different in Group 1. In Group 2, 164 patients (57%) only had access to PPCI compared to 56% in Group 1 (P = 0.536-NS). In G2, the main reasons for no PPCI were late presentation in 47% versus 53% in Group 1; P = 0.34 NS. In Group 2, 27% were due to thrombolysis versus 17% in Group 1 (P = 0.11 NS). Hospital mortality in Group 2 was 4% in those treated with PPCI compared to 2.3% in Group 1 (P = 0.522-NS). Mortality in patients who did not receive PPCI in Group 2 was 8% compared to 11.3% in Group 1 (P = 0.49-NS). Females in Group 2 have about 3 times higher mortality. Patients treated for STEMI in the last 12 months at King Abdulaziz Cardiac Center still have relatively low access to PPCI due mainly to persistent pattern of late presentation and prior thrombolysis, which reflect apparent lack of direct access to hospitals with PPCI facilities. Conclusion: Comparing the two periods, there was no change in cardiology practice. The low access to PPCI was mainly due to late presentation and prior thrombolysis. Hospital mortality rate for patients treated with PPCI remained low during the two era. This seemingly relates to both lack of public awareness and health provision factors in PPCI organizations.
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Clinical review: Management of patients with acute ST-elevation myocardial infarction p. 256
Fatema Ahmed Ali, Hasan Altahoo, Mary Lynch
DOI:10.4103/HEARTVIEWS.HEARTVIEWS_41_20  
Aims: The aim was to assess the quality of practice provided to acute ST-elevation myocardial infarction (STEMI) patients at the cardiac center, within a specified time frame and identify possible areas of improvement. Settings and Design: This is a retrospective standards-based clinical review, including adults diagnosed with acute STEMI between January 1, 2016 and January 1, 2017 of cases admitted and managed at the respective cardiac center. Subjects and Methods: The study was designed according to recommendations provided by the National Institute for Health and Care Excellence guidelines: “The acute management of myocardial infarction with ST-segment elevation;” alongside, the local standard: door-to-balloon time ≤90 min, adopted from the American Heart Association. Statistical Analysis Used: Data analysis was done through excel and SPSS for advanced statistical calculations. P < 0.05 was considered to be statically significant. Results: In total, 277 patients were included in the study. About 72% underwent primary percutaneous coronary intervention with 62 min as median door-to-balloon time. Door-to-balloon time >90 min was significantly higher when patients presented outside official hospital hours (P = 0.039). Transradial route was chosen in 77.7% of the cases. Conclusions: Practice at the cardiac center was found to show good compliance with the guidelines. However, door-to-balloon time for procedures performed out of official hospital working hours was slightly outside the recommended limit.
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Assessment of pulmonary artery pressures by various doppler echocardiographic parameters and its correlation with cardiac catheterization in patients with pulmonary hypertension p. 263
Arumugam Aashish, Srinivasan Giridharan, Selvaraj Karthikeyan, Balasubramaniyan Amirtha Ganesh, Palamalai Arun Prasath
DOI:10.4103/HEARTVIEWS.HEARTVIEWS_133_20  
Background: Measuring pulmonary artery pressures is a routine index in Doppler echocardiography to diagnose, risk stratify, and prognosticate patients with pulmonary hypertension (PH). There are numerous methods in use to measure it in routine clinical practice. Objective: The objective of this study was to assess the correlation between the commonly used Doppler-derived parameters such as tricuspid regurgitation (TR)-derived systolic pulmonary artery pressure (SPAP), pulmonary regurgitation (PR)-derived mean pulmonary artery pressure (MPAP), and right ventricular outflow tract acceleration time (RVOT AcT) with right heart catheterization (RHC) data which are the gold standard. Materials and Methods: In this analytical study, we prospectively measured echo and angiogram parameters such as TR-derived SPAP, PR-derived MPAP, and RVOT AcT and studied its association with RHC data of thirty patients for a span of 2 years. Right ventricular AcT was also included in the study. Their relationship was displayed using Bland–Altman scatter plots. P < 0.05 was considered as statistically significant. Results: Although both TR-derived SPAP and PR-derived MPAP had a moderate correlation with RHC-acquired data, the agreement between them was poor. RVOT AcT showed a strong inverse correlation with invasive MPAP. Conclusion: Among the three Doppler methods that were assessed to measure pulmonary pressures, RVOT AcT had a strong correlation with MPAP. RVOT AcT of <80 ms had a high sensitivity to detect severe PH (defined as MPAP >45 mmHg). Hence, it is recommended to include AcT as a routine measure in the armamentarium of echocardiographic parameters used in patients with PH.
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REVIEW ARTICLE Top

Mechanical circulatory assist devices: Available modalities and review of literature p. 269
Mohammed Faluk, Syed Mustajab Hasan, Tianyu Jiang, Ramy Abdelmaseih, Jigar Patel
DOI:10.4103/HEARTVIEWS.HEARTVIEWS_92_20  
Despite advancements in the field interventional cardiology, the prognosis in patients who suffer from cardiogenic shock is poor. Over the years, the use of percutaneous mechanical circulatory support (MCS) devices has increased with the aim to improve short- and long-term outcomes. In this article, we aim to review the different modalities available for MCS devices and current literature comparing their uses.
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VIEWPOINT Top

Social media use and community-based cardiovascular health-care professionals: Perception versus reality Highly accessed article p. 276
Muhammad Abubakar Shakir, Amarjit Singh, Patricia Levy, David A Cohen, Shaun Moran, Catherine Hanly Mikelson, Roberto Rodriguez, William A Gray, Riti Patel
DOI:10.4103/HEARTVIEWS.HEARTVIEWS_60_20  
Social media use has dramatically increased in the past two decades. This growth has been seen in the health-care field as well. Social media is being used for a variety of activities including networking, education, public health, and marketing. Health-care professionals in cardiology participate in social media to varying degrees and in different ways. Current studies have focused primarily on physicians who have an established presence on social media. To learn more about the social media habits of community-based cardiology providers, we queried attendants at a cardiovascular conference held by our health-care system. The purpose of this article is to:
  1. Highlight the social media habits of a range of community-based cardiology providers and distinguish between producing and consuming social media. There is a predominance of social media content consumers compared to producers
  2. Outline important considerations when assessing the risks and benefits of social media use and the perceived concerns of cardiology health-care professionals
  3. Emphasize the need to incorporate guidelines for social media use into institutional policies and provide training on social media use to the health-care community.
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HEMODYNAMIC CORNER Top

Hemodynamic Corner p. 281
Manar Fawaz Fallouh, Abdulrahman Arabi
DOI:10.4103/HEARTVIEWS.HEARTVIEWS_37_20  
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CASE REPORTS Top

Myopericarditis presenting as acute ST-elevation myocardial infarction with atrioventricular dissociation p. 284
Fateen Ata, Hammad Shabir Chaudhry, Ammara Bint I Bilal, Maria delas Nieves Montoro Lopez
DOI:10.4103/HEARTVIEWS.HEARTVIEWS_82_20  
Myopericarditis, which is an inflammatory process involving the myocardium and pericardium, is not a rare condition encountered in cardiac emergencies. Rarely though, it can give an acute myocardial infarction picture on electrocardiogram (ECG), leading to urgent angiography. More rarely, it can be associated with atrioventricular (AV) dissociation, which is a condition of dyssynchrony of electrical activity between atria and ventricles. We present the case of a young female, who presented with severe chest pain, associated with ST elevation in anterior leads of ECG and raised troponins, necessitating urgent coronary angiography. Normal coronaries led to further evaluation, including cardiac magnetic resonance imaging, which established the diagnosis of myopericarditis. The patient had AV dissociation secondary to myopericarditis. With the treatment of myopericarditis and transvenous pacing, the patient stabilized and was subsequently discharged asymptomatic.
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Giant negative T-waves as cardiac memory phenomenon following ablation of right-sided posteroseptal accessory pathway p. 289
Giacomo Mugnai, Stefano Cavedon, Cosimo Perrone, Claudio Bilato
DOI:10.4103/HEARTVIEWS.HEARTVIEWS_33_20  
We present a paradigmatic example of “cardiac memory,” characterized by deep, giant, and negative T-waves in the inferior leads, after a successful ablation of a right-sided posteroseptal accessory pathway.
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The use of low-dose intermittent levosimendan infusion therapy as bridge-to-left ventricular assist device in advanced chronic heart failure secondary to isolated cardiac sarcoidosis p. 291
Kamla Al-Wahaibi, Osman Mohamed Elfadil
DOI:10.4103/HEARTVIEWS.HEARTVIEWS_85_20  
Heart failure (HF) is a progressive condition that usually involves a debilitating late course with poor health-related quality of life and increasing mortality rate. In this report, we demonstrate the efficacy and safety of intermittent levosimendan infusion as a bridging therapy to left ventricular assist device use in a patient suffering from cardiac sarcoidosis who failed to respond to optimized medical therapy. Levosimendan was administered in an outpatient infusion-therapy facility every 2 weeks as a single intravenous infusion over 6 h at dose and rate of 0.2 μg/kg/min not proceeded by a bolus. The primary observation we are reporting is the efficacy of this approach reflected on serum concentrations of N-terminal brain natriuretic propeptide and creatinine levels. Secondary observation comprised patient-reported outcomes and clinical events including hospitalization (s).
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Severe right-sided heart failure and pulmonary hypertension with carfilzomib treatment in multiple myeloma p. 296
Pankaj Mathur, Sharmilan Thanendrarajan, Angel Lopez-Candales
DOI:10.4103/HEARTVIEWS.HEARTVIEWS_107_20  
Carfilzomib, a second-generation irreversible proteasome inhibitor, is currently considered the preferred therapy for relapsed and refractory multiple myeloma. There are several cardiovascular adverse effects described with carfilzomib chemotherapy most commonly being hypertension, dyspnea and decreased cardiac ejection fraction. We report a case of newonset pulmonary hypertension with right ventricular (RV) heart failure in a patient receiving carfilzomib. Awareness of this rare side effect of this drug is essential for prompt diagnosis and management. We also propose close monitoring of RV and pulmonary artery pressures along with left ventricular function in echocardiographic assessment in patients with carfilzomib chemotherapy.
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Recurrent infective endocarditis with mycotic aneurysm – Imaging modalities for the detection of an infective focus p. 300
Jennie Han, Kenneth Okonkwo, Nadeem Attar
DOI:10.4103/HEARTVIEWS.HEARTVIEWS_69_20  
Staphylococcus aureus bacteremia (SAB) and infective endocarditis (IE) are infections associated with considerable morbidity, requiring prompt accurate diagnosis and treatment. We present a case of a 58-year-old male patient with four episodes of recurrent symptomatic SAB treated for IE, but without positive findings on transthoracic echocardiography, transesophageal echocardiography, and fluorodeoxyglucose-positron emission tomography (FDG-PET). On the last admission, FDG-PET showed increased uptake in the right atrial appendage, and white blood cell single-photon emission computerized tomography (WBC-SPECT) was able to identify the infective focus as IE of the aortic valve. CT of the thorax also identified an associated mycotic aneurysm of the right coronary sinus. He was subsequently treated with mechanical aortic prosthesis and right coronary sinus plasty, and his symptoms did not recur till 2 years postcardiothoracic surgery. This case report demonstrates the emergence of nuclear cardiovascular imaging modalities in the diagnostic workup of IE and the utility of FDG-PET and WBC-SPECT in the identification of the infective focus. Patients with possible IE from the modified Duke criteria should be considered for FDG-PET or WBC-SPECT to enhance sensitivity. Peripheral mycotic aneurysms are a common complication of left-sided IE, which can present late into the disease process, and aortic imaging should be considered in patients with recurrent endocarditis to identify this.
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Unusual case of spontaneous postcoital type a aortic dissection p. 305
Iyad Farouji, Omar Al-Radideh, Theodore Dacosta, Hamid Shaaban, Abbas Shehadeh, Addi Suleiman
DOI:10.4103/HEARTVIEWS.HEARTVIEWS_165_20  
Aortic dissection is a life-threatening condition that may present as severe acute chest or abdominal pain, especially in high-risk patients, and should raise a high index of suspicion for aortic dissection when occurring after moderate-to-high-intensity activities, such as sexual intercourse. Sexual intercourse leads to physiological stress on the body causing an abrupt elevation in blood pressure and shearing force against the vessel wall. This shearing force increases the risk of vessel wall dissection. Below, we discuss a rare case of type A aortic dissection after sexual intercourse and highly recommend physicians to evaluate and educate their high-risk patients regarding aortic dissection with such activities.
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A PICTURE IS WORTH A THOUSAND WORDS Top

Negative hemodynamic impact of left bundle branch block in chronic systolic heart failure p. 309
Hira Pervez, Muhammad Rizwan Sardar
DOI:10.4103/HEARTVIEWS.HEARTVIEWS_181_20  
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HISTORY OF MEDICINE Top

Historical overview of pulse examination and easy interpretation of pulse (Nabz) through unani metaphysics p. 310
Adnan Mastan
DOI:10.4103/HEARTVIEWS.HEARTVIEWS_156_20  
Ancient science of pulse reading had existed from antiquity and still being practiced in some traditional medicine systems like Unani, Ayurveda and Chinese medicine etc. Examination of pulse still remains an integral part of these systems of medicine in disease diagnosis and monitoring the disease treatment. An experienced Unani physician can easily differentiate between normal and deranged temperament pulse through Unani metaphysics. As whole concept of disease and its management is based on temperament and its deviation under Unani system of medicine, therefore this unique and simple technique of pulse examination makes it easier to diagnose and treat any disease. In this article, it was tried to explore ancient history regarding knowledge base and practice of pulse reading and present various aspects of pulse examination described in Unani system of medicine and its interpretation through Unani metaphysics. This paper will be useful in generalizing the concept of pulse for better understanding.
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STUDENTíS PERSPECTIVE Top

What matters to patients matters to me Highly accessed article p. 317
Maryam Arabi
DOI:10.4103/HEARTVIEWS.HEARTVIEWS_205_20  
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