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Volume 14, Number 8, December 2011, Pages 217-252

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eMedinewS is now available online on or From the Desk of Editor-in-Chief Padma Shri and Dr BC Roy National Awardee

Dr KK Aggarwal

President, Heart Care Foundation of India; Sr Consultant and Dean Medical Education, Moolchand Medcity; Member, Delhi Medical Council; Past President, Delhi Medical Association; Past President, IMA New Delhi Branch; Past Hony Director. IMA AKN Sinha Institute, Chairman IMA Academy of Medical Specialities & Hony Finance Secretary National IMA; Editor-in-Chief IJCP Group of Publications & Hony Visiting Professor (Clinical Research) DIPSAR

19 November 2011, Saturday Dear Colleague, WCIR: World Congress on Insulin Resistance, Diabetes & Cardiovascular Disease Meeting (WCIR update, Source: Medpage Today) Biologics in diabetes ‘Doctors are excited about the prospects for a monoclonal antibody for type 2 diabetes. In vitro and murine studies of the compound, XMetA, have shown that it selectively targets an allosteric insulin receptor-offering all the glucoregulatory benefits, but none of the mitogenic effects, according to Yehuda Handelsman, MD president WCIR Diabetics with OSA more at risk Diabetes patients with obstructive sleep apnea may have more autonomic dysfunction and also may be at greater risk of hypoglycemia. Those with the sleep disorder who also had poor autonomic function had significantly more hypoglycemia than those with more normal function (p <0.05) as per Dr Jennifer Cheng, of Rosalind Franklin University of Medicine and Science in Chicago. Renal hyperfiltration linked to stroke Renal hyperfiltration is associated with a greater risk of stroke, especially in patients with the metabolic syndrome or type 2 diabetes. In a single-center study, 22% of patients with either condition who also had renal hyperfiltration had a stroke, Harold Pretorius, MD, PhD, of the Cincinnati Cognitive Collaborative in Ohio. Hidden diabetes is common About 25% of healthy people have either dysglycemia or undiagnosed type 2 diabetes as per Mona Boaz, PhD, of E. Wolfson Medical Center in Holon. More than 20% of people screened had impaired glucose tolerance, and that another 4% had (type 2) diabetes but they did not know it. Weight loss the key for diabetics In a survey, patients who reported weight loss had significantly greater improvements in several markers of quality of life, especially self-esteem and physical health, than those who gained weight (p <0.001), Kathleen Fox, PhD, of Strategic Healthcare Solutions in Monkton, Md reported. Monoclonal antibodies for diabetes A monoclonal antibody selectively stimulated insulin signaling in vitro and improved fasting blood sugar in a mouse model, but its effects on humans remain to be seen. The fully human monoclonal antibody (XMetA) mimicked only the glucoregulatory action of insulin- not its growth factor pathway- and improved glycated hemoglobin (HbA1c) after six weeks of treatment in mice, according to John Corbin, PhD, of XOMA in Berkeley, Calif., a developer and manufacturer of therapeutic antibodies. Dr KK Aggarwal Group Editor-in-Chief of cystic fibrosis liver disease includes supplementation of fat– soluble vitamins.

Fitness Update Exercise and depression: An update Many studies show that exercise can remedy anxiety and depression in elderly populations. However, no studies have been conducted over a long period of time, and there is no research showing whether regular exercise is needed to maintain an antidepressant effect. Swedish researchers conducted a study to find out whether change in physical activity is associated with change in depression over time, and their results were published in the journal Health Psychology. Researchers studied a group of 17,500 elderly people with an average age of 64 years from 11 different European countries. The subjects were followed over a period of two and a half years, so researchers could track changes in their levels of physical activity and depression. People who were active were much less likely to feel depressed, however the results of the study show that regular exercise is key in maintaining mental and emotional well–being. Subjects who were active, but engaged in physical activity less regularly, were also more prone to depressive episodes. Interestingly, the authors also found that, for a small number of subjects, their depressive symptoms stopped people from being active in the first place. (Contributed by Rajat Bhatnagar, International Sports & Fitness Distribution, LLC, Medicine Update What are the treatment options in cystic fibrosis liver disease?  In addition to UDCA (ursodeoxycholic acid) treatment, treatment

Treatment of complications of portal hypertension and associated hypersplenism include variceal banding, portosystemic shunting, transjugular portosystemic shunt (TIPS), splenectomy, and liver transplant. Given that respiratory disease is the main contributor to CF mortality; however, liver transplantation is rarely required and is generally not indicated unless there are additional features of liver decompensation. —Dr Neelam Mohan, Director Pediatric Gastroenterology, Hepatology and Liver Transplantation, Medanta – The Medicity)

Legal Question of the Day Will a non–allopathic medical practitioner be guilty of committing the illegality of “cross pathy” in terms of Poonam Verma Vs. Ashwin Patel and Others, decided by the Supreme Court on 10.05.1996, reported as 4 SCC 332, if he prescribes OTC (Over the counter drugs)? Ans. Yes. He will be guilty. There is nothing in the judgment to exempt the use of OTC drugs. —Dr M C Gupta

Healthy Driving If you have to drive, the only way to be safe is to drink nothing. Even half a pint affects your reactions. (Conceptualized by Heart Care Foundation of India and Supported by Transport Department; Govt. of NCT of Delhi)

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Dr. Good and Dr. Bad Situation: A patient with diabetes of 10 years duration

came with atypical chest pain.


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take nSAIDS

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Lesson: Patients with type 2 diabetes for >10 years and type 1 diabetes for >15 years duration are at high risk for underlying cardiovascular disease.

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Dr KK Aggarwal Padma Shri and Dr BC Roy National Awardee Sr. Physician and Cardiologist Moolchand Medcity, New Delhi President, Heart Care Foundation of India Group Editor-in-Chief, IJCP Group and eMedinewS Chairman Ethical Committee, Delhi Medical Council Director, IMA AKN Sinha Institute (08-09) Hony. Finance Secretary, IMA (07-08) Chairman, IMA AMS (06-07) President, Delhi Medical Association (05-06) Krishan Kumar Aggarwal (Facebook)

Target Dose of Angiotensin II Receptor Antagonists in Patients with Heart Failure  When using losartan or valsartan for the treatment of heart failure (HF), it is recommended that patients be titrated to target doses (i.e., losartan 150 mg daily; valsartan 160 mg twice daily), whenever possible.  In an analysis of HF registry data of 5139 patients in Sweden, those treated with candesartan, had improved survival compared to patients who received losartan: 1 year survival 90% vs. 83%, 5 year survival 61% vs. 44%, respectively; hazard ratio [HR] 1.43 95% CI 1.23 to 1.65; P<0.001). (1)  However, at the time of establishing the registry, the target dose of losartan was 50 mg daily whereas the current target dose in HF is 150 mg daily. The target dose for candesartan was 32 mg daily, similar to the current recommendation.  Very few patients (18%) were at more than 50% of the currently recommended target dose for losartan (i.e., 150 mg daily) whereas about a third reached a similar level for candesartan. (1)  The losartan target dose of 150 mg daily in patients with HF is based on results of the Heart Failure endpoint Evaluation with the Angiotensin II Antagonist Losartan (HEAAL) study. This study compared losartan 50 mg with losartan 150 mg daily, with the primary endpoint of all-cause mortality and HF hospitalizations in 3846 patients with HF and a left ventricular ejection fraction (LVEF) < 40% who were intolerant to an angiotensin-converting enzyme inhibitor (ACEI) (86% reported intolerance due to cough). Seventy-two percent of patients received concomitant treatment with a beta-adrenergic blocker. After a median of 4.7 years of follow-up, treatment with losartan 150 mg (mean 129+39 mg) resulted in a 10% decrease in the risk for death or HF hospitalization compared to patients on losartan 50 mg (mean 46+11 mg) (losartan 150 mg 43.0% vs. losartan 50 mg 46.3%; HR 0.90 95% CI 0.82-0.99; P=0.027). Hyperkalemia, hypotension,

Asian Journal of Clinical Cardiology, Vol. 14, No. 8, December 2011


review article

 

kidney impairment, and angioedema all occurred more frequently in the losartan 150 mg treatment group compared to the 50 mg dose, with no difference in discontinuations due to these adverse events. (2) Review of the above data prompted an evaluation of data in VA patients with HF to identify if there was a potential gap in the recommended target dose and the prescribed dose of angiotensin II receptor antagonists used in the management of HF. According to VA data from 1/1/2011 to 3/31/2011, approximately 14,500 patients with a diagnosis of systolic HF were being treated with losartan, with 44% prescribed > 50% of the target dose of 150 mg, and an average daily dose of 66 mg. During this same timeframe, approximately 10,600 patients with HF were treated with valsartan, with 51% prescribed > 50% of the target dose of 320 mg (recommended 160 mg twice daily), and an average daily dose of 156 mg. Data with candesartan are not provided due to low utilization in VA. Losartan is not currently FDA approved for use in HF, and the target dose of 150 mg that was studied in the HEAAL trial is higher than the maximum recommended dose used for other indications (e.g., hypertension). Losartan is available in 25 mg, 50 mg and 100 mg tablets. Of the other available angiotensin II receptor antagonists, valsartan and candesartan are FDA approved for the treatment of HF. Patients with systolic HF should receive an ACEI, beta-adrenergic blocker, diuretic, and aldosterone antagonist, as indicated. In some patients (e.g., African-Americans) hydralazine/nitrates may be appropriate as well. An angiotensin II receptor antagonist may be considered in patients with systolic HF who are intolerant to an ACEI. Recommendation: When using losartan or valsartan for the treatment of HF, it is recommended that patients be titrated to target doses (i.e., losartan 150 mg daily; valsartan 160 mg twice daily), whenever possible.

References 1. Eklind-Cervenka M, Benson L, Dahlström U, et al. Association of candesartan vs losartan with all-cause mortality in patients with heart failure. JAMA 2011;305:175-82. 2. Konstam MA, Neaton JD, Dickstein K, et al., for the HEAAL Investigators. Effects of high-dose versus low-dose losartan on clinical outcomes in patients with heart failure (HEAAL study): a randomized, double-blind trial. Lancet 2009; 374:1840-8. Source: [Department of Veterans Affairs Veteran Health Administration (Vha) Pharmacy Benefits Management Services (Pbm) and Medical Advisory Panel (Map) Va Center For Medication Safety (Vamedsafe): National Pbm Communication • October 31, 2011





Asian Journal of Clinical Cardiology, Vol. 14, No. 8, December 2011


Recommendations on Follow-up Care of Patients with Prosthetic Valves Rajiv Bajaj

Abstract Surgery and anesthesia in hypertensive patients with or without coronary artery disease (CAD) is among dangerous and stressful procedures and been graded ASA-III category. Most of the unsuccessful outcomes are not due to negligence but are expected risk of anesthesia and surgery. There is no strategy that can assure a good outcome but a careful preoperative evaluation and serious monitoring during intraoperative period one can expect satisfactory results. Key words: xxxxxxxxxxxx


pproximately 10 thousand patients undergo valve replacement in India every year. Patients with metallic valve prosthesis require lifelong follow-up and anticoagulant therapy. Unfortunately, a sizeable number of these patients are poor, or hail from remote locations. Shortcomings in follow-up care can lead to life threatening hemorrhagic and thrombotic complications. Major Issues The following are the most important issues in the management of prosthetic valve patients: Oral anticoagulant therapy, including PT/INR and coumadin dosages, home INR kits, genetic profiling of coumadin sensitivity, additional antithrombotics, additional cardiac medications, follow-up cardiac investigations, management of thrombosis and bleeding, management during pregnancy, intercurrent illnesses, and during noncardiac surgery evaluation of unexplained fever, diet, exercise, vocational advice. Anti-Vitamin K Therapy (Coumadin Therapy)

Coumadin and similar vitamin K antagonists remain the recommended therapy for patients with metallic prosthetic valves (anti-vitamin K therapy,). Available coumadin-type medications are warfarin and acecoumarol. Either agent may be used. Warfarin has **xxxxxxx Address for correspondence xxxxxxxxxx xxxxxxxxxxxxxxx xxxxxxxxx

Asian Journal of Clinical Cardiology, Vol. 14, No. 8, December 2011

a slightly lower potency per milligram, and a slightly longer half-life. Late evening doses have maximal efficacy, as hepatic protein synthesis is primarily nocturnal. Careful monitoring of coumadin therapy is mandatory for reducing risks of bleeding and thrombosis. Patients should be categorized as low-risk and high-risk (Table 1). Low thrombotic risk patients have annual risks of near 1% per year. Anticoagulant related complications are frequent in the initial six months after surgery, and this period should be very closely supervised. Hemorrhagic risk

Low-risk: Males and non-menstruating females aged between 18 and 65,withno episode of significant hemorrhage while on adequate anticoagulant doses, and no potential bleeding sources in CNS, GI or GU systems. Anti Vitamin K therapy Risk Profile

Low-risk: cooperative patient with stable INR values and no anticoagulant related events >1 year post surgery. Such patients >3 years beyond operation are very low-risk. High-risk: All other patients including: patient unable to take full care for any reasons, patients with unstable INRs, those who have had bleeding or thrombosis occurring beyond the first 12 months of the operation despite adequate care. Laboratory Facilities for INR and biochemical measurements 223

review article Table 1. (Risk-profiling of Prosthetic valve Patients) Thrombotic Risks Low thrombotic risk group, target INR 2.5 (range 2-3): aortic metallic valve in sinus rhythm, no history of thrombosis when on adequate treatment, absence of marked chamber dilatation, or CHF High-risk group, target INR 3.0 (range 2.6-3.5) A) Bioprosthesis less than 3 months since implant B) Metallic prosthesis less than one year since implant C) Mitral metallic prosthesis D) Aortic metallic prosthesis with atrial fibrillation, E) CHF Very high-risk group (target INR 3.5) a) History of thrombosis while on adequate treatment b) Patients recovering from recent prosthetic valve thrombosis.

The prothrombin time/INR test (PT/ INR) is used to monitor anti-vitamin K (AVK) therapy. Reliable testing requires high quality laboratory services, as each step in the process is critical. It is strongly recommended that INR and biochemical measurements should be done in facilities that are NABL accredited (www.nabl-india. org). The laboratory should process the sample onsite, as collection centre/central lab can cause unacceptable delays in sample processing. When INR is ordered from uncertified laboratories, ensure accuracy in each step of the process. Common sources of error are given in Box 1. A reliable INR facility should be available within 4 hours travel-time to the patient. Metallic prosthetic valves are not recommended when a reliable facility is unavailable to the patient (located more than 6 hours away). In such patients mechanical valves should be used only with home INR kits. BOX: Common Sources of Errors in INR

Sample collection: use light or no tourniquet; use Vacutainers (before expiry date) for accurate ratio of sample and citrate. Adjustment of blood sample or citrate when severe anemia or polycythemia exists. Processing: Early centrifuging of sample at 4000 rpm for 15 minutes; confirmation of platelet count <10,000 in plasma; early processing of sample. On sight laboratory facilities are recommended; if sample is collected at remote location, it should be centrifuged, and transported at room temperature (2024 degrees). The sample must be analysed within 4 hours of venesection. Thromboplastin reagent: There is variability between reagents. WHO introduced International Normalized Ratio for standardization 224

of prothrombintest.Locally prepared reagents are not recommended. Lyophilized and liquid stable thromboplastin reagents from internationally renowned manufacturers are easily available in India. Sensitive reagents with International Sensitivity Index (ISI) close to 1.0 should be used. Thromboplastin with ISI value specific for that thromboplastin, instrument and model is preferable.These reagents require a â&#x20AC;&#x2DC;cold chainâ&#x20AC;&#x2122;, and procurement from reliable suppliers is essential. Grade I pure water should be used for reconstituting lyophilized thromboplastin. Once reconstituted, store and preserve it as per the manufacturerâ&#x20AC;&#x2122;s instructions to maintain stability. Expired reagents must be avoided. In India, supply of quality reagents, control Plasma, certified Plasma, Coagulometer and other accessory are available from distributors of Siemens Diagnostics (previously Dade Behring), Germany; Stago of France, and Instrumentation Laboratory (HemosiL) of USA and Italy. Analysis: Automated coagulation analyzer is recommended. In case of manual or semi automated instruments, temperature (37 degrees), accurate prewarming of reagent and blood sample and accurate pipetting are crucial. Standardization: Use Mean Normal Prothrombin Time (MNPT), single control PT is unreliable. Standardization is required each time a brand of thromboplastin or a new lot is used, or the method is modified, or coagulometer is changed or a major repair has taken place or blood collection system has changed, including change of new brand of Vacutainers.INR value should be reported to the nearest tenth of a unit. INR Monitoring Schedule

INR is usually measured daily during the index hospitalization. The recommended schedule for monitoring after discharge from hospital is given in Table 2. Beyond the first 3 months, INR measurements are pre phoned whenever dose adjustments are needed during follow-up. For asymptomatic cases, pre phoning is generally to half the scheduled time. Eg: at one month on a patient on two monthly measurements. After major intercurrent illnesses including severe hepatitis, the full schedule should be re-initiated till Asian Journal of Clinical Cardiology, Vol. 14, No. 8, December 2011

review article Table 2. INR Monitoring Schedules

Table 3. Therapeutic Range of INR

Till 14th post operative day: every 3 days

Therapeutic range: an INR value within 15% of the target INR

From 3rd to 6th weeks: weekly From 6th to 12th weeks: 2 weekly 3 to 18 months: monthly 18 months and later: 2 monthly for low-risk patients in the first 3 years, and 3 monthly subsequently, 1-2 monthly for high-risk patients.

stabilization of INR and complete recovery from the illness. Patients requiring antiepileptics, antitubercular drug rifampicin, amiodarone and similar interfering medications should have 2-weekly INR monitoring for two months after starting the drug. The same 2-weekly monitoring is required for two months after discontinuation of the drug (4 months for amiodarone). Dosage adjustments

Therapeutic range and acceptable range are defined in Table 3. Frequent dose titrations may be required in the initial three months after valve replacement. In asymptomatic patients beyond the first year of operation, usual treatment is continued if the INR is within 30% of accepted range. Thus, when target INR is 3.0, any value between 2.1 and 3.9 is accepted. Adjustments of dose are indicated when two indications exist (when 2 consecutive readings are out of range, or the patient has bruising or bleeding and high INR is detected). If the INR is within 40% of target range, and no cause for fluctuation is apparent, the same dose may be continued, with pre phoning of the next INR measurement. Any INR above >5.2, or below 1.8 requires reconfirmation of the value and adjustment of dose on the same day, or within the next few days. In most asymptomatic fluctuations, dose adjustment should be approximately 10%. The weekly dose should be calculated, and adjusted upwards or downwards by 10%. For example, a patient with two low INR values on 2 mg daily requires a dose escalation from 14 mg/ week to 16 mg/week. A loading ‘catch-up dose’ equal to the escalation (2 mg in above example) should be given as a stat dose; and the dose escalated to 2 mg daily 5 days/week, and 3 mg on two days of the week. The 2 days of higher dose should not be consecutive days. Asian Journal of Clinical Cardiology, Vol. 14, No. 8, December 2011

Acceptable range: an INR upto 30% of target value is ‘acceptable range’ in stable patients, and upto 20% in high-risk patients. Moderately deranged INR: 20-30% of target range in high-risk and 30-40% in low-risk patients Severely deranged INR: above 5.2, or below 1.8

Till target values are obtained, the INR measurements should be pre phoned, usually to half the usual time. For asymptomatic increase in INR to >6, skip dose for one day. For minor bleeds and elevated INR, the dose is skipped for one day if INR is below 6, and for 2 days if INR is above 6, and then the reduced dose is instituted. Home INR Kits

Home INR kits are now available from a reputed manufacturer (Coaguchek, Roche). The performance of these is sufficiently accurate, and these kits should be offered to patients as an additional resource to be used in conjunction with conventional testing. Home monitoring maybe used for spot tests during bleeding. They can also be alternated with conventional tests to reduce the number of visits to the laboratory. This may be instituted after an initial period of familiarization; when ≥4 readings have demonstrated reasonable correlation with conventional assay. Genetic Profiling of Coumadin Sensitivity

The dose of coumadin varies 15-fold between individuals. Even larger variations occur when enzyme inducing medications are co-prescribed. Affordable tests are now available for determining the presence of genetic phenotypes that markedly alter coumadin dose. Although these tests show good correlation with maintenance dose, titration of dose is required in every individual, and these tests, as employed presently, are not recommended in management. Additional Antithrombotics

Patients with biological prosthetic valves can discontinue coumadin after three months unless indicated for coexisting conditions like atrial fibrillation. They must be treated with aspirin long-term, starting soon after 225

review article surgery. The risks of embolism are 5% in the first three months after bioprosthetic valve placement and closely monitored full therapy is essential in this period. Aspirin: Some patients with metallic aortic prosthesis are low-risk and may be managed with coumadin alone. For most prosthetic valve patients, aspirin 75-150 mg/day is indicated e.g. metallic mitral or tricuspid prosthesis, patients with marked LV dilatation and tendency to CHF, patients in AF, and patients with history of valve thrombosis/ symptomatic embolic episode despite adequate coumadin therapy. Clopidogrel (75 mgs od) and dipyramidole. (25 mg b.i.d.) are alternatives to aspirin. Orally-active antithrombins are now being developed as an alternative to AVK therapy. They may offer significant advantages over AVK therapy, but are currently not recommended for patients with metallic prosthesis, till data showing superiority/equivalence including data from large randomized trials become available. Bridging Therapy

â&#x20AC;&#x2DC;Bridging therapyâ&#x20AC;&#x2122; with heparin or low molecular weight heparins (LMWH) may be required when AVK therapy is temporarily discontinued for elective surgery, when patient is kept nil orally for any intercurrent illness, etc. It can be omitted in stable patients. It is best used sparingly, mostly for patients at very high thrombotic risk. Pre-op, warfarin should be stopped 84 hours before surgery, and acetrom 60 hours before. The INR is checked on morning of surgery. A value <1.5 is acceptable. Very high-risk cases should receive heparin, or low molecular heparin from 36 hours after the last coumadindose. The heparin dose maybe half of usual at 60 hours, and full dose from next day. It should be stopped 8 hours before surgery, and LMW should be stopped 16 hours before surgery. Post surgery, half dose heparin may be started after 12 hours or whenever hemostasis is secure, and full-dose heparin can be given from Day 3 with good hemostasis. AVK therapy is restarted on post op Day 1 or 2 or whenever oral medication is allowed. Bridging therapy with heparin or LMWH is continued till therapeutic INR is achieved on two consecutive days (INR ratio >2). 226

Additional Cardiac Medicines Congestive Heart Failure

Prosthetic valve patients have significant cardiac compromise and should be assumed to be highrisk for congestive heart failure. Cardiac medicines like diuretics, ACE inhibitors, and digoxin are often prescribed at the time of discharge from hospital. The ACC/AHA staging of heart failure is useful for prosthetic valve patients. Stage A and B of heart failure are preclinical stages. Valve patients frequently have overt congestive heart failure before surgery, stage C or D. Post op, most patients should be treated as stage B or C. Stage A: Patients with minimal structural heart disease undergoing aortic valve surgery after endocarditis or dissection; those undergoing very timely surgery for congenital aortic stenosis; isolated tricuspid valve replacements. Stage A patients may be treated with anti-thrombotics alone although addition of ACE inhibitors and betablockers is recommended especially after age 40. Stage B and C: Patients undergoing mitral valve replacement for predominant mitral stenosis; aortic stenosis with timely valve replacement correspond to stage B. The vast majority of patients with left-sided prosthetic valve should be assumed to be stage C, even when doing well after surgery, especially when aged over 40. The treatment of stage B and C patients includes full doses of ACE and ď ˘-blockers; with additional spirinolactone and digoxin if congestive failure supervenes despite regular medications. Arrhythmias

Atrial fibrillation is a frequent problem in valve patients, especially in mitral valve disease. In patients who are in sinus rhythm at any time in 12 weeks preceding surgery, the cardiologist should try to achieve sinus rhythm before discharge, and closely monitor the rhythm after discharge. If atrial fibrillation occurred transiently periop, the patient should receive antiarrhythmic therapy with amiodarone 100-200 mgs for three months. Patients who have pre- and post-operative atrial fibrillation may be managed with rate control or rhythm control. Patients below age 30 and with reasonable atrial size (<5cm), and patients below age 45 and left Asian Journal of Clinical Cardiology, Vol. 14, No. 8, December 2011

review article atrial size less than 4.0 should be labelled ‘persistent AF’ and considered for trial of rhythm control with amiodarone. Patients with significant sinus node disease are unsuitable for rhythm control. Rhythm control should be with 100-300 mg of amiodarone daily. The dose is titrated upwards during breakthroughs, and downwards by 50 mgs every six month if they remain arrhythmia free for 2 years. Rhythm control should be abandoned if a dose of 300 mg is ineffective, with recurrent breakthrough AF requiring cardioversion; or if patient desires to avoid cardioversions. Approximately 2-3 years in sinus rhythm can be expected by this approach before permanent AF supervenes. Atypical atrial flutters, usually left-sided are very common in mitral valve patients, especially in those on rhythm control with amiodarone. The atrial rate varies from 150-250. Episodes of atypical flutter are treated as breakthrough of AF. Prosthetic valve patients are at higher risk of many other arrhythmias including isthmus- dependent ‘typical’ flutter; sinus node dysfunction, VT, LBBB with CHF and are at increased risk of sudden death. These require standard care as in other cardiac patients. Follow-up cardiac investigations

Prosthetic valve patients require monitoring for overt and occult bleeding. Patients with audible paravalvular leaks are prone to hemolysis, and may require folate supplement. Anemia, diabetes, hypertension and renal dysfunction may supervene. All patients require 6-monthly hemoglobin, sugar and creatinine, Na and K estimations if they are stage B or C, annually if stage A and 3 monthly if stage D. The patient should undergo an echocardiogram for a) Unexplained cardiac symptoms b) Annually in patients with CHF c) Once in three years even if doing well. Echocardiography is indicated whenever there is an episode of thromboembolism. Thrombosis

Thrombosis may be obstructive (prosthetic valve thrombosis) or non obstructive (embolism). Significant embolism and obstruction occur equally frequently Asian Journal of Clinical Cardiology, Vol. 14, No. 8, December 2011

with metallic disc valves. In ball and cage valves thrombosis is less frequent, most episodes are embolic. Embolism should be classified as minor, major, and massive. Minor embolisms are TIAs and mildly symptomatic embolisms to spleen, kidney, and limbs. These should be treated with dose adjustments if INR is low. Raising the target INR by 0.5 and addition of aspirin is indicated if the event occurs when INR is adequate. Strokes, occlusion of brachial, or femoral, popliteal artery with limb ischemia are moderately large embolism. In patients presenting within first three hours of significant neurological deficit, and clear cut history of discontinuing coumadin in the absence of bleeding, INR sample should be drawn. Bleeding and hepatitis should be excluded by history and examination, and immediate treatment with tPA or full dose intravenous heparin can be started without delays for laboratory confirmation or CT scan. Embolism causing severe limb ischemia requires hospitalization and embolectomy. Fogarty technique is effective for upto two weeks after the embolism. Massive embolism presents as saddle embolism in abdominal aorta with absent femoral pulsations and abdominal pain. It may occur after starting thrombolysis for prosthetic valve thrombosis. CNS is usually spared, and history of underdosing is almost always present. The presentation is acute, and rapid transfer to cath lab facility is mandatory. The patient should receive IV heparin and be transferred to cath lab. Thrombolysis may be given before transfer if more than two hours is anticipated. Mechanical clot fragmentation with catheter is necessary. Brisk flow in celiac, superior mesenteric, both renals, and popliteals should be ensured by mechanical thrombus fragmentation, and the patient should be kept NPO till adequate GI recovery. Prosthetic valve thrombosis is diagnosed by symptoms and high echo gradients. Low INR, very high gradients (mean mitral flow velocity above 2m/sec or peak aortic velocity >4.5 m/sec), and corroborative 2-D findings of obstruction or thrombus are usually obvious. Severe anemia or atrial fibrillation with fast ventricular rate can lead to tachycardia, higher mitral gradients, and pulmonary congestion and should be excluded as the cause of worsening. If valve thrombosis seems likely after echo, patients with class 4 symptoms, or mean mitral gradients over 16 mm should receive 227

review article thrombolysis without delay. A 10% risk of embolism during thrombolysis is expected, and occurs within the first 8 hours. Streptokinase, urokinase and tPA are all effective. The standard thrombolytic dose should be infused over 10 hours. About 20-30% of the dose is given as a loading dose, the remaining dose is infused over 10 hours. With streptokinase, an acceptable dose is about 3 lakhs over 2-10 minutes followed by 1 lakh per hour. The gradient should be checked 2-4 hourly, and just before the end of infusion. If the clinical status and gradient are acceptable (mean mitral gradient <10 mm, peak aortic velocity <4.0 ), additional thrombolysis is not required. If the mean gradient remains above 15, a second and even a third half-dose can be infused over 8 hours each, without loading doses. An Echo shortly before the end of each infusion should be used to decide about need for further thrombolysis. Patients with acceptable improvement should undergo aggressive anticoagulation for 16 weeks, further reduction of gradient is usual. In the absence of bleeding, an INR of 4-4.5 should be maintained during this period, along with one or two antiplatelet agents. Surgical treatment is seldom needed. It should be considered for patients with recurrent thrombosis and bleeding despite adequate therapy, which occurs in 1% of cases. Such patients often have genetic abnormalities of coagulant protiens like protein C, and are unsuited for coumadin therapy, and should be considered for change over to heparin, or to a redo surgery and bioprosthesis. A trial of direct oral thrombin inhibitor is acceptable before resorting to surgery. Surgery is still indicated, but very rarely, when gradients are unacceptably high (>15 mm mean gradient in mitral, >4.5 velocity in aortic prosthesis) despite thrombolysis. Management of Bleeding

Like thrombosis, bleeding is most likely in the first year of therapy and when medicines that affect INR are changed; or when the diet is drastically altered. Acute viral hepatitis is an important cause of major bleeding. Spontaneous bleeds due to overdosage should be divided into major, moderate, and minor. Major bleeds are intracranial bleeds and massive GI bleeds requiring multiple transfusions. Moderate bleeds are major 228

hemarthrosis, symptomatic serous cavity bleeds, bleeds requiring hospitalization, and any bleeding leading to <2 gm fall in hemoglobin concentration. Painful ecchymosis, oral and nasal bleeds, and persistent positive stool occult blood without significant anemia are classified as minor. Increased menstrual bleeding is frequent, and should be classified as major or minor. INR should be checked promptly whenever bleeding is reported. If there is a 1-2 day delay in obtaining INR, the patient should omit one dayâ&#x20AC;&#x2122;s dose. Spontaneous bleedings should be treated with fresh frozen plasma, or fresh whole blood, after drawing sample for INR measurement. Use of intravenous vitamin K should generally be avoided, it may be used if there is active bleeding and an INR which is >10. Intravenous vitamin K is effective in normalizing PT, but leads to prolonged resistance to coumadin therapy. It should be given for major bleeding, if FFP or fresh blood is not available. Patients treated with intravenous vitamin K may become coumadin-resistant for 2-6 weeks, requiring treatment with heparin till they regain coumadin response. Precipitating causes like addition of interfering drugs, mistakes in dosing, hepatitis, drastic change in diet should be identified. Menstrual bleeding: In the first year, minor bleeding without fall in hemoglobin levels should be managed without reduction in doses. In stable patients after the first year, the patient is encouraged to continue coumadin although skipping drug for one day, followed by half dose on day 2 of menses can be allowed in very stable patients (event-free for over 3 years). Heavy menstrual bleeding in the first year should be controlled with progesterones. 21 day cycles of 5-15 mg daily, or monthly injections of depot preparations. In very stable patients after the first 3 years, skipping Coumadin for two days is an alternative. Care During Noncardiac Admissions MRI Scans

All metallic prosthesis and sternal wires are safe for 1.5 and 3 tesla scanning. Patients with endocarditis at risk of valve dehiscence may be unsafe. Cath Lab Procedures

Emergency cath can be done without correcting INR, with careful hemostasis. For elective procedures Asian Journal of Clinical Cardiology, Vol. 14, No. 8, December 2011

review article stopping, coumadin for 1-2 days is adequate. In highrisk patients, omitting one nightâ&#x20AC;&#x2122;s dose is recommended. Pacemaker implants require stopping coumadin for 2-3 days and an INR of < 1.5 on morning of implant. Coumadin may be resumed within 24 hours, if hemostasis is satisfactory. Elective Surgery

Elective operations should be deferred in the first 12 months of valve surgery whenever possible. Very stable patients should discontinue coumadin for 3 days before major elective surgery, INR should be checked on morning of operation; a value of <1.5 is acceptable. It should be re-started after surgery on after 24 hours if hemostasis is satisfactory, without a loading dose. Bridging therapy with heparin is not recommended for very stable patients. For minor operations in accessible sites (tooth extraction, superficial procedures, banding of haemorrhoids) the dose should be omitted for two days, and Coumadin may be restarted on the same night if postop hemostasis is satisfactory. There is a hypercoagulable state for 24 hours after starting Coumadin, and there is very little risk of increased bleeding when restart of medications is timely in patients with satisfactory hemostasis, as is advised here. Emergency Surgery

Coumadin should be discontinued for 72 hours before semiurgent surgery. In emergencies, the patient should receive fresh frozen plasma to correct the INR, and postop coumadin therapy is administered as for elective surgery. Pregnancy

Bioprosthesis is preferable in women in childbearing age. In women with metallic prosthesis, pregnancy should generally be avoided, although, with good perinatal care, stable patients can undergo pregnancy with less than 10% risk of serious morbidity, and 1% risk of maternal mortality. Switch-over to heparin from before conception, or from 6th week is generally recommended, but it is not always needed. Patients with high daily AVK dose (>4 mg Acetrom, >5 mg warfarin) should be considered for heparin therapy, but patients requiring smaller doses may be managed with oral anticoagulant. In stable patients, the target Asian Journal of Clinical Cardiology, Vol. 14, No. 8, December 2011

INR should be lower for the first trimester and at term. (0.5 lower than usual INR). INR should be measured every month throughout pregnancy, at 10 days post delivery, and monthly till three months post-delivery. If cesarean section is planned, coumadin can be discontinued three days before section as for elective surgery. If vaginal delivery is expected, coumadin should be discontinued when labor starts and platelet poor plasma or FFP should be administered to normalize PT through labor. After delivery, oral coumadin is re-started on Day 2 in usual maintenance dose when postop course is smooth. Loading dose, and bridging therapy is indicated only in patients with previous history of thrombotic and hemorrhagic events. When bridging therapy is needed, it should be given as detailed for elective surgery. Unexplained Fever

Early Fever: Early after operation, endocarditis occurs due to periop contamination. History of troublesome fever immediate postop is often present in patients with early endocarditis. Early endocarditis manifests in the first six months after surgery. Patients must be aware of the significance of fever occurring in the first 6 months, and casual antibiotic therapy should be avoided. Fever appearing 1-6 weeks after discharge from hospital (and 1 week after stopping of post op antiobiotics): Causes include endocarditis, post-pericardiotomy syndrome, pleural effusion, malaria, urinary infection and wound infection. Unless the cause is obvious, blood cultures must be drawn. Post pericardiotomy patients have milder systemic symptoms, and preserved apatite. If endocarditis seems unlikely, NSAIDs are effective for post-pericardiotomy fever, and should be instituted while culture reports are awaited. Fever occurring beyond 6 weeks of operation: Unexplained fevers require exclusion of endocarditis. Patients must be aware of the need for drawing blood cultures before starting antibiotics whenever there is unexplained fever. When fever is unexplained and lasts >1 week, blood cultures must be drawn. In fever due to endocarditis occurring beyond six weeks of hospital discharge, other corroborative evidence such as splenomegaly, clubbing, high ESR and active urinary sediment, are usually present. 229

review article Their absence suggests that the cause is unlikely to be endocarditis. SBE Prophylaxis

After the initial period, endocarditis in uncommon in metallic prosthetic valves, usually occurring when there are predisposing comorbidities like very old age, diabetes, malignancy. Bioprostheses are prone to late endocarditis when degeneration and regurgitation supervene. In view of the serious nature of prosthetic valve endocarditis, antibiotic prophylaxis is still recommended for gingival, infected GI and urogenital tract procedures. It is not required for TEE. Dental procedures of gingival or periapical (root) and procedures with perforation of mucosa. Single oral dose of amoxicillin (2 gram), or cephalexin (2 gram) or azithromycin (500 mg). If oral medications not possible, ampicillin (2 gram) or ceftriaxone (1 gram). Patients allergic to penicillins and cephalosporins should be given clindamycin (p.o. 600 mg, IV dose is 300 mg). Other dental procedures like polishing, braces, superficial drilling, filling, tooth loss, minor oral injuries do not require prophylaxis. GI and genitourinary procedures, bronchoscopy, TEE do not require prophylaxis. Patients requiring these procedures for infective diseases should receive additional antibiotic dose just before the procedure. Similarly, all significant bacterial infections requiring antibiotics should have additional intravenous bolus antibiotic before surgical procedure on infected area. Diet, Exercise, Vocational Advice 4Patient Education

Every prosthetic valve patient requires counselling and education about care of the prosthetic valve. Information booklets or printouts should be given to the patient, and verbally explained to the patient before discharge. Include advice on: a) Not stopping coumadin b) Scheduled INR tests c) A list of vitamin K rich foods that should be restricted initially d) The patient should be taught to monitor prosthetic valve sounds, dull sounds and exertionaldysponea may be warning symptoms of obstruction. e) Instructions about bleeding and its management with cold compresses, pressure, and need for INR check. f ) Instructions on fever include use of paracetamol or ibuprofen. Unexplained fevers should be treated with antipyretics 230

alone, with need for blood cultures before starting antibiotics if the fever is prolonged beyond one week. g) Instructions on effect of hepatitis on INR. The patient should be aware of the symptoms of hepatitis. When suggestive symptoms occur, immediate review by physician is required, and anticoagulant dose may be skipped overnight if needed. Diet

INR varies with diet, and any drastic change in diet requires pre phoning INR monitoring. Patients should be advised a diet low in green leafy vegetables like spinach, and mustard greens for the first year. Some websites provide additional details. (eg: www.ods. In stable patients, normal diet can be taken after the first year. A diet low in fats and cholesterol is generally recommended for cardiac patients. Such advice should be specifically avoided. Exercise

Although various benefits of exercise are well-known, patients with prosthetic valves should be advised ample rest, not regular exercise. As a general rule, the patient should do less than what can be done comfortably, not more. Vocational Advice

Prosthetic valve patients are unsuited for jobs requiring high levels of physical fitness. Sedentary jobs should be advised. Women with metallic prosthesis should avoid pregnancies. Accelerated degeneration of bioprosthesis occurs during pregnancies. Counselling and information should be provided by the physician to help the family reach an informed decision. References 1. Salem DN, Stein PD, Al-Ahmad A, et al. Antithrombotic therapy in valvular heart disease-native and prosthetic: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004;126(3 Suppl):457S-


2. Douketis JD, Berger PB, Dunn AS, et al. The perioperative management of antithrombotic therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). American College of Chest Physicians McMaster University, Hamilton, Ontario, Canada. Chest 2008;133(6 Suppl):


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Clinical Study 3. Wong CS, Batchelor K, Bua J, et al. Safety and efficacy of warfarin in paediatric patients with prosthetic cardiac valves: a retrospective audit. Department of Nursing, The University of Melbourne. Thrombosis Research 2011 May 26. Paediatric Cardiology 2011 Apr 17. [Epub ahead of print] 4. Mahle WT, Simpson SA, Fye P, et al. Management of Warfarin in Children With Heart Disease. Childrenâ&#x20AC;&#x2122;s Healthcare of Atlanta, Emory University School of Medicine, 1405 Clifton Rd. NE, Atlanta, GA, 30322, USA, 5. Leiria TL, Lopes RD, Williams JB, et al. Antithrombotic therapies in patients with prostheticheart valves: guidelines translated for the clinician. J Thromb Thrombolysis 2011;31(4):514-22. 6. Chan WS, Anand S, Ginsberg JS. Anticoagulation of pregnant women with mechanical heart valves: a systematic review of the literature. Archi Int Med 2000;160(2):191-6. 7. Colli A, Dâ&#x20AC;&#x2122;Amico R, Mestres CA, et al. Is early antithrombotic therapy necessary after tissue mitral valve replacement? J HeartValve Dis 2010;19(4):405-11. 8. ElBardissi AW, DiBardino DJ, Chen FY, et al. Is early antithrombotic therapy necessary in patients with bioprosthetic aortic valves in normal sinus rhythm? J ThoracCardiovasc Surg 2010;139(5):1137-45. 9. Hage FG, Nanda NC. Guidelines for the Evaluation of Prosthetic Valves with Echocardiography and Doppler

Ultrasound: Value and Limitations. Echocardiography: 2010;27(1)91-3. 10. Wilson W, Taubert KA, Gewitz M, et al. AHA Guideline, Prevention of Infective Endocarditis. Guidelines From the American Heart Association: A Guideline From the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation 2007;116:1736-54 11. Meschengieser SS, Fondevila CG, Frontroth J, et al. Lowintensity oral anticoagulation plus low-dose aspirin versus high-intensity oral anticoagulation alone: a randomized trial in patients with mechanical prosthetic heart valves. J ThoracCardiovasc Surg 1997;113(5):910-6. 12. Turpie AG, Gent M, Laupacis A, et al. A comparison of aspirin with placebo in patients treated with warfarin after heart-valve replacement.N Engl J Med 1993;329(8):524-9. 13. Vora A, Karnad D, Goyal V, et al. Control of rate versus rhythm in rheumaticatrial fibrillation: a randomized study. Indian Heart J 2004;56(2):110-6. 14. Bereznicki LR, Jackson SL, Peterson JM, et al. Accuracy and clinical utility of the CoaguChek XS portable international normalised ratio monitor in a pilot study of warfarin home-monitoring. J Clin Pathol 2007; 60:311-4.


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Non Cardiac Manifestations of Tetralogy of Fallot Apurv Pandey, Sanjiv Gupta, Neha Gupta, Dharmendra Jain

Abstract Tetralogy of Fallot is one of the commonest congenital cyanotic heart disease affecting children older than one year of age. Apart from its classical features it is associated with certain extra-cardiac manifestations which occur in varying frequency. They include CATCH22 monosomy, Down’s Syndrome, Velocardiofacial abnormalities, CHARGE Syndrome, Goldenhar Syndrome (Occulo-auriculo-vertebral), Poland Syndrome, Syndactyly, Brachydactyly and Hypoplasia of Ipsilatral hand. Key words: Tetralogy of Fallot (ToF), Down’s Syndrome, Velocardiofacial abnormalities, CHARGE Syndrome, Goldenhar Syndrome, Poland Syndrome.

Tetralogy of Fallot Fallot’s tetralogy is the commonest congenital cyanotic heart disease in children above the age of one year.

Consists of:  VentriclularSeptal Defects (infracristal type).  Right ventricular outflow tract obstructionInfundibular Pulmonary stenosis.  Overriding of Aorta.  Right Ventricular Hypertrophy

The basic abnormality contributing to each of these features is anterior and cephalad deviation of the outlet septum, which is malaligned with respect to the trabecular septum. The various extracardiac manifestations associated with ToF are:1  CATCH 22 Monosomy  Down’s Syndrome  CHARGE  Goldenhar Syndrome (Occulo-auriculo-vertebral)  Poland Syndrome

*Jrii Medicine Subharti Medical College **Senior Orthodontics, GTB Hospital † Associate Consultant, Max Hospital ‡ Assistant Professor Cardiology, Bhubaneswar Address for correspondence xxxxxxxxxx xxxxxxxxxxxxxxx xxxxxxxxx


Syndactyly Brachydactyly Velocardiofacial Abnormalities Hypoplasia of Ipsilatral hand

CATCH 22 Monosomy

CATCH 22 is a medical acronym for cardiac defects, abnormal facies, thymic hypoplasia, cleft palate, and hypocalcemia, and a variable deletion on chromosome 22q11. The deletion within the chromosome region of 22q11 may occur in patients with dysmorphologic and cardiological syndromes.2 Down’s Syndrome

Down syndrome,trisomy 21, is a chromosomal condition caused by the presence of all or part of an extra 21st chromosome. Often Down syndrome is associated with some impairment of cognitive ability and physical growth, and a particular set of facial characteristics. Many of the common physical features of Down syndrome may also appear in people with a standard set of chromosomes, including microgenia (an abnormally small chin)3, an unusually round face, macroglossia (protruding or oversized tongue)4, an almond shape to the eyes caused by an epicanthic fold of the eyelid, upslanting palpebral fissures (the separation between the upper and lower eyelids), shorter limbs, a single transverse palmar crease (a single instead of a double crease across one or both palms), poor muscle tone, and a larger than normal space between the big and Asian Journal of Clinical Cardiology, Vol. 14, No. 8, December 2011

Clinical Study second toes. Individuals with Down syndrome have a high risk of development of congenital heart defects (endocardial cushion defects,ToF), gastroesophageal reflux disease, recurrent ear infections, obstructive sleep apnea, and thyroid dysfunctions. CHARGE Syndrome

CHARGE is an acronym used for: C - Coloboma of the eye, central nervous system anomalies H - Heart defects A - Atresia of the choanae R - Retardation of growth and/or development G - Genital and/or urinary defects (Hypogonadism) E - Ear anomalies and/or deafness CHARGE syndrome was formerly referred to as CHARGE association, which indicates a non-random pattern of congenital anomalies that occurs together more frequently than one would expect on the basis of chance.5Very few people with CHARGE will have 100% of its known features.6Association with ToF has been reported in some cases. Goldenhar Syndrome ( Occulo-AuriculoVertebral )

Goldenhar syndrome (also known as Oculo-AuriculoVertebral (OAV) syndrome) is a rare congenital defect characterized by anomalous development of the first and second branchial arch7 leading to incomplete development of the ear, nose, soft palate, lip, and mandible..Common clinical manifestations include li mbaldermoids,preauricular skin tags, and strabismus.8 The characteristic features of Goldenhar syndrome like the incompletely developed ear, nose, soft palate, lip, and mandible are usually present ipsilaterally. Some patients might have growing tissues with internal organs, especially heart, kidneys, and lungs.9Association with ToF is known in some cases. Poland Syndrome

Poland syndrome was first described in 1841 by Sir Alfred Poland in the Guy’s Hospital Gazette while still a medical student based on findings of one cadaver Asian Journal of Clinical Cardiology, Vol. 14, No. 8, December 2011

dissection.10,11The syndrome is characterised by congenital aplasia of the sternocostal head of the pectoralis major muscle associated with ipsilateral hand deformities12.This rare entity is referred to as Poland’s syndrome or Poland’s syndactyly. 13,14,15In a few cases of Poland’s syndrome features like absence of digits, brachidactyly, hypoplasia of wrist and/or hand, hypoplasia of forearm, hypoplasia of arm, thoracic cage defects, herniation of lung, axillary web or band, absence of nipple and some genitourinary abnormalities have been reported.12,15The absence of the sternal head of the pectoralis major muscle is considered the minimal expression of this syndrome. Skin of the area is hypoplastic with a thinned subcutaneous layer, and the axillary hair may be absent. Skeletal deformities may involve absence of portions of the ribs or costal cartilages anteriorly. In severe cases, anterior lung herniation may be present. The scapula may be smaller with winging; this is termed Sprengel deformity.12The upper extremity also may be hypoplastic. The upper arm, forearm, and fingers may be shortened, which is termed brachysymphalangism. Simple, complete, or incomplete syndactyly can also be found in patients with Poland syndrome. Temtamy and McKusick [1969] reported a child with Poland defect and ipsilateral renal hypoplasia.16Subs equently, Mace et al [1972] found renal agenesis in one of their seven cases of Poland anomaly. This was also found by Miller and Miller [1975] in a child with absent pectoralis major muscle, without digital abnormality, who developed acute lymphoblastic leukemia. This reflects that a newborn who is suspected as a case of Poland’s syndrome must undergo a renal ultrasound and urographic studies to rule out any kidney involvement. Syndactyly

It is a condition where two or more digits are fused together. It occurs normally in some mammals, such as the siamang and kangaroo, but is an unusual condition in humans. Isolated syndactyly is one of the most common congenital malformations of the hands and feet. On the basis of an anatomic approach, isolated syndactyly has been subdivided into five types (Tentamy and McKusick 1978).16 Syndactyly type 1 (SD1 [MIM 185900]), also named “zygodactyly,” is inherited as an autosomal dominant trait and accounts 233

Clinical Study for the majority of isolated syndactylies, with an incidence of »2–3/10,000 in newborns (Castilla et al. 1980; Tentamy 1990). 17 In this common type of syndactyly, there is usually complete or partial webbing between the third and fourth fingers and the second and third toes, with occasional involvement of other digits. Syndactyly can be classified aseither simple or complex and as complete or incomplete.  In simple syndactyly, adjacent fingers or toes are joined by soft tissue.  In complex syndactyly, the bones of adjacent digits are fused. The kangaroo exhibits complex syndactyly.  In complete syndactyly, the skin is joined all the way to the tip of the finger.  In incomplete syndactyly, the skin is only joined part of the distance to the fingertip. Simple syndactyly can be full or partial, and is present at birth (congenital). In early human fetal development, webbing (syndactyly) of the toes and fingers is normal. At about 16 weeks of gestation, apoptosis takes place and an enzyme dissolves the tissue between the fingers and toes, and the webbing disappears. In some fetuses, this process does not occur completely between all fingers or toes and some residual webbing remains. Complex syndactyly occurs as part of a syndrome (such as Apert’s syndrome) and typically involves more digits and with complex syndactyly. Fenestrated syndactyly means the skin is joined for most of the digit but in a proximal area there is gap in the syndactyly with normal skin. This type of syndactyly is found in amniotic band syndrome. Brachydactyly

The term brachydactyly is derived from the ancient Greek (brachy-: short; dactylos: digit) meaning shortening of digits.Itoccours due to abnormal development of phalanges or metacarpals or both. Brachydactyly is one of the ten categories of hand malformations classified by Temtamy& McKusick16.The shortness is relative to the length of other long bones and other parts of the body. Brachydactyly is an inherited, either as an autosomal dominant or autosomal recessive trait. It can occur either as an isolated malformation or as a part of a complex malformation syndrome.18 234

Figure 1. Syndactyly (Source = Leslie G Biesecker. The Greigcephalopolysyndactyly syndrome.Orphanet Journal of Rare Diseases.3,10.2008.)

Velocardiofacial Syndrome

Velocardiofacial syndrome (VCFS) is a genetic condition which results from abnormal pharyngeal arch development that causes defective development of the parathyroid glands, thymus, and conotruncal region of the heart. Shprintzen and colleagues first described the syndrome in 1978.19Velocardiofacial syndrome is associated with more than 180 different clinical features, with no single anomaly present in every patient. Individuals affected may present with structural or functional palatal abnormalities, cardiac defects, unique facial characteristics, hypernasal speech, hypotonia, and defective thymic development. An estimated 75% of patients with velocardiofacial syndrome have cardiac anomalies.20The cardiac defects are usually of the conotruncal type, which occur secondary to abnormal development of the outflow portion of the developing heart. The most common cardiac defects include interrupted aortic arch type B (50%), truncusarteriosus (34.5%) and tetralogy of Fallot (16%).Palatal abnormalities predispose to speech and feeding difficulties. The defective thymic development is associated with impaired immune function. This condition predisposes Asian Journal of Clinical Cardiology, Vol. 14, No. 8, December 2011

Clinical Study the patient to an increased risk of infection and in some leads to development of autoimmunity. Parathyroid and immune deficiencies can progress or resolve with time. Affected individuals may also present with learning disabilities, overt developmental delay, psychiatric disorders, and renal and musculoskeletal defects.This congenital disorder is caused by a deletion (microdeletion) at the q11.2 band, which is located on the long arm (q) of chromosome 22.In 90% of cases, the disorder occurs as the result of a new mutation in the form of a de-novo 3-megabase microdeletion or translocation. This 3-megabase microdeletion encompasses a region that contains 40 genes.21These genes have a role in organ development, including the heart and the CNS. These genes likely affect coronary artery development, given the number of coronary artery abnormalities associated with conotruncal defects.22 Hypoplasia of Ipsilatral hand

Hypoplasia of Ipsilateral hand has also been reported in certain cases in association with ToF. References 1. Perloff Congenital Heart Diseases in adults,5rd Edition, 2003. 2. Alikaşifoğlu M, Malkoç N, Ceviz N, Ozme S, Uludoğan S, Tunçbilek E. Department of Pediatrics, Hacettepe University Faculty of Medicine, Ankara, Turkey. Microdeletion of 22q11 (CATCH 22) in children with conotruncal heart defect and extracardiac malformations. Turk J Pediatr. 2000 Jul-Sep;42(3):215-8. 3. Meira Weiss (1994-02). Conditional love: parents’ attitudes toward handicapped children. p. 94. ISBN 9780897893244. 4. This discussion by Myron Belfer, MD, book by Gottfried Lemperie, MD, and DorinRadu, MD (1980). “Facial Plastic Surgery in Children with Down’s Syndrome (preview page, with link to full content on plasreconsurg. com)”. p. 343. 5. Blake KD, Davenport SLH, Hall B, Hefner MA, Pagon RA, Williams MS, Lin A, Graham JM: CHARGE Association - An update and review for the primary pediatrician. Clinical Pediatrics 37(3):159-73, 1998. 6. Pagon PA, Graham JM, Zonana J, Young SL: Congenital heart disease and choanal atresia with multiple anomalies. Journal of Pediatr 1981;99:223-227.

7. Touliatou V, Fryssira H, Mavrou A, Kanavakis E, KitsiouTzeli S (2006). “Clinical manifestations in 17 Greek patients with Goldenhar syndrome”. Genet. Couns. 17 (3): 359-70. PMID 17100205. 8. Temtamy SA, McKusick VA: The Genetics of Hand Malformations New York: Alan R Liss, INC; 1978. 9. Zaka-ur-Rab Z, Mittal S. “Optic Nerve Head Drusen in Goldenhar Syndrome”. JK Science 2007;9(1):33-34. 10. Poland A. Deficiency of the pectoral muscles. Guy’s Hosp Rep 1841;6:191. 11. Clarkson P. Poland’s syndactyly. Guy’s Hosp Rep 1962; 111:335. 12. David TJ. Nature and etiology of the Poland anomaly. NEJM 1972;287:487. 13. Bouvet JP, Leveque D, Bernetieres F, Gros JJ. Vascular origin of Poland syndrome. Eur J Pediatr 1978;128:17. 14. Briner V, Thiel G. Hereditäres Poland SyndrommitMegacalicose der rechtenNiere. Schweiz Med Wochenschr 1988;118:898. 15. Mace JW, Kaplan JM, Schanberger JE, Gotlin RW. Poland’s syndrome. ClinPediatr 1972;11:98. 16. Tentamy SA, McKusick VA. The genetics of hand malformations.Alan R. Liss, New York 1978;301-322. 17. Castilla EE, Paz JE, Orioli-Parreiras IM. Syndactyly: frequency of specific types. Am J Med Genet 1980; 5:357-364. 18. Samia A Temtamy and Mona S Aglan. Brachydactyly. Orphanet Journal of Rare Diseases 2008;3:15. 19. Shprintzen RJ, Goldberg RB, Lewin ML, et al. A new syndrome involving cleft palate, cardiac anomalies, typical facies, and learning disabilities: velo-cardio-facial syndrome. Cleft Palate J 1978;15(1):56-62. 20. Ryan AK, Goodship JA, Wilson DI, et al. Spectrum of clinical features associated with interstitial chromosome 22q11 deletions: a European collaborative study. J Med Genet 1997;34(10):798-804. 21. Shprintzen RJ. Velo-cardio-facial syndrome: 30 Years of study. Dev Disabil Res Rev 2008;14(1):3-10. 22. Theveniau-Ruissy M, Dandonneau M, Mesbah K, et al. The del22q11.2 candidate gene Tbx1 controls regional outflow tract identity and coronary artery patterning. Circ Res 2008;103(2):142-8.


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Common Coronary Trunk From the Right Sinus of Valsalva Giving Origin to Right and Left Coronary Arteries *Monika Maheshwari, **Chandra Prakash Tanwar

Abstract Introduction: Bank employees around Manipal, who volunteered were considered, as the work situation is found to have a bearing on health status of an individual. Patients & Methods: The consenting employees were selected after having given informed consent and detailed interview, examination and appropriate laboratory investigations were conducted. Data analysis was done on SAS 7.5 version. Discussion: 50% of the population had presence of more than, one coronary risk factors which strikes a chord of impending doom. The prevalence of various risk factors for bank employees paralleled the prevalence rates in Urban areas as per other studies and hence appropriate counselling and other interventional measures need to be instituted in this vulnerable population, to prevent cardiovascular disease, on account of occupation. Key words: xxxxxxxxxxxxx


oronary artery anomalies are rare entities. Overall incidence being 0.3-1.3% of patients undergoing coronary angiography1 and 0.17% of routine autopsy studies.2 The most commonly occurring congenital anomaly of coronary vessels, is the left circumflex artery originating from the right coronary artery. Other anomalies include - origin of left coronary artery from pulmonary artery, origin of right coronary artery from left sinus of valsalva presence of a single coronary artery, hypoplastic coronary vessels, coronary artery aneurysms and coronary artery fistula. We report here an interesting case report of single coronary trunk from the right sinus of valsalva giving origin to right and left coronary arteries. Case Report A 52-year-old male presented in emergency department with retrosternal chest pain since 2 months which was pressure like in nature sometimes precipitated by effort but often occurred at rest. On physical examination her blood pressure was 140/90 mmHg, pulse 82/ minute, respiratory rate 16/minute and temperature *Cardiology 2nd Year Resident Dept. of Cardiology **General Medicine 2nd Year Resident Dept. of Medicine Jawahar Lal Nehru Medical College, Ajmer Address for correspondence Navin Niwas, 434/10, Bapu Nagar, Ajmer - 305 001 E-mail:


98.4○F. There was no pallor, cyanosis, clubbing. icterus or lymphadenopathy . Jugular venous pressure was normal. Chest skiagram showed mild cardiomegaly . Electrocardiogram revealed shallow ‘T’ wave inversion in precordial leads (V1-V6) . Cardiac enzymes levels were within normal limits . 2 D echocardiogram showed normal left ventricular functions with some apical hypertrophy. A treadmill exercise test was planned to evaluate inducible ischaemia and functional capacity but the test was prematurely terminated at stage–2 because of exhaustion and dyspnoea. Diagnostic coronary angiography was therefore undertaken which revealed an anomalous coronary anatomy, with the origin of right coronary artery and left main stem from the right sinus of Valsalva as a common coronary trunk (Figure- 1). The coronary arteries were free of atherosclerotic disease. Discussion Lipton et al3 classified the coronary artery system as L when the single coronary artery originated from the left sinus of Valsalva and R when it originated from the right sinus of valsalva. An aberrant origin of the main stem from the right sinus of Valsalva represents one of the rarest forms of all coronary anomalies, seen in only 0.0024% to 0.044% of the population. In such cases with a common arterial trunk nourishing the entire heart , the main stem takes 1 of 4 aberrant pathways to reach its proper vascular territory. These pathways are Asian Journal of Clinical Cardiology, Vol. 14, No. 8, December 2011

Clinical Practice designated as type A (anterior to the right ventricular outflow tract), type B (between the aorta and pulmonary trunk), type C (cristal, coursing through the crista supraventricularis portion of the septum), and type D (dorsal or posterior to the aorta),4,5,6 These may be responsible for ischaemia, congestive heart failure and sudden death. All angiographers and cardiac surgeons need to be familiar with these anatomic variants because accurate identification and delination of the course and distribution of coronary vessels with nature of blood supply to the myocardium is integral for proper surgical revasularisation in presence of coronary artery disease. References

2. Alexander RW, Griggith GC. Anomalies of the coronary arteries and their clinical significance. Circulation 1956;14;800-5. 3. Lipton MJ, Barry WH, Obrez I et al .Isolated single coronary artery diagnosis ,angiographic classification andd clinical significance .Radiol 1979; 130: 39-47. 4. Liberthon RR, Dinsmore RE, Bharati S, et al. Aberrant coronary artery origin from the aorta: diagnosis and clinical significance Circulation 1974;50:774-779. 5. Desmet W, Vanhaecke J, Vrolix M, et al. Isolated single coronary artery: a review of 50,000 consecutive angiographies Eur Heart J 1992;13:1637-1640. 6. Mohan JC, Tomar D, Shekar C, Mohan V, Kaur B. Single coronary artery supplying the entire heart. Indian Heart J 2011;63:280.

1. Yamanaka O, Hobbs RE. Coronary artery anomalies in 126,595 patients undergoing coronary arteriography. Cathet Cardiovas Diagn 1990;21:28-40.

Asian Journal of Clinical Cardiology, Vol. 14, No. 8, December 2011


Back to Future


Asian Journal of Clinical Cardiology, Vol. 14, No. 8, December 2011

Expert Opinion

What are the Guidelines for Intake of Salt for Hypertensive Patients? Sunil Prakash





Senior Nephrologist Artemis Hospital Gurgaon

Asian Journal of Clinical Cardiology, Vol. 14, No. 8, December 2011


practice guidelines

Updated Dietary Guidelines from the USDA and HHS

The U.S. Department of Agriculture (USDA) and the U.S. Department of Health and Human Services (HHS) jointly created the updated version of the Dietary Guidelines for Americans, 2010. The Dietary Guidelines for Americans are reviewed every five years, by law. Previous versions of the guidelines stated that the recommendations were meant for healthy Americans older than two years, whereas the 2010 update changed this wording to specify that the recommendations apply not only to those who are healthy, but also to those who are at increased risk of chronic disease. The updated guidelines are based on two main concepts: focusing on balancing caloric intake over time to reach and maintain a healthy body weight; and consuming more nutrient-dense foods and beverages in place of those high in sodium, saturated fats, added sugars, and refined grains. The key recommendations from the guidelines specifically address how to balance caloric intake for weight management; reduce consumption of less healthy foods; increase overall intake of healthier foods and nutrients; and develop healthy eating patterns (Table 1). The guidelines emphasize that most personsâ&#x20AC;&#x2122; nutritional needs are best met solely by consuming foods, but that fortified foods and dietary supplements may be helpful in some cases. The guidelines cover additional dietary recommendations specific to certain population groups, including persons 50 years and older, and women who are pregnant or breastfeeding, or who are capable of becoming pregnant. For older persons, recommendations involve consuming foods fortified with vitamin B12 (e.g., fortified cereals) or taking dietary supplements to ensure adequate vitamin levels. Women who are pregnant or breastfeeding are advised to consume 8 to 12 oz of seafood per week, but to limit consumption of white (albacore) tuna to 6 oz per week and to avoid consuming tilefish, shark, swordfish, and king mackerel. Pregnant women are advised to take an iron supplement. For women capable of becoming pregnant, Source: Adapted from Am Fam Physician. 2011;84(3):332-334.


Table 1. Overview of Key Recommendations from the Dietary Guidelines for Americans, 2010 Balance caloric intake for weight management Control total caloric intake to manage body weight Increase physical activity and reduce time spent doing sedentary activities Maintain appropriate caloric balance during childhood, adolescence, adulthood, pregnancy and breastfeeding, and older age Prevent or reduce overweight and obesity by improving eating and physical activity behaviors Reduce intake of less healthy foods Get less than 10 percent of calories from saturated fatty acids; avoid consuming trans fatty acids Limit alcohol consumption to no more than one drink per day in women and two drinks per day in men Limit consumption of foods with refined grains Reduce daily sodium intake to < 2,300 mg; or < 1,500 mg in persons who are black, older than 50 years, or who have hypertension, diabetes mellitus, or chronic kidney disease Reduce intake of calories from solid fats and added sugars Increase intake of healthier foods and nutrients Choose a variety of protein foods; replace those higher in solid fats with proteins lower in solid fats Choose foods that provide more potassium, fiber, calcium, and vitamin D Consume at least one-half of grains as whole grains Increase intake of vegetables, fruits, and fat-free or low-fat dairy products; eat a variety of vegetables Increase the amount and variety of seafood in diet Use oils in place of solid fats, when possible Build healthy eating patterns Account for all foods and beverages consumed to assess overall healthy eating pattern goals Follow food safety recommendations Make sure eating pattern meets appropriate nutrient and caloric needs

the guidelines address iron intake by recommending that this population choose foods that include heme iron, provide additional iron sources, and are high in nutrients that enhance iron absorption (e.g., vitamin Asian Journal of Clinical Cardiology, Vol. 14, No. 8, December 2011

practice guidelines C). These women also are advised to consume 400 mcg of synthetic folic acid per day. Also included in the guidelines are basic food safety principles to help reduce the risk of foodborne illness, and a section about helping Americans make healthy

Asian Journal of Clinical Cardiology, Vol. 14, No. 8, December 2011

choices to improve overall nutrition and physical activity in the United States. The updated guidelines also noted and took into consideration that almost 15 percent of households recently have been unable to obtain sufficient food to meet dietary needs.


practice guidelines


Asian Journal of Clinical Cardiology, Vol. 14, No. 8, December 2011

Research Review

From the Journals ...





Source: Adapted from Am Fam Physician. 2010;81(3):333.

Asian Journal of Clinical Cardiology, Vol. 14, No. 8, December 2011


Emedinews Section

From eMedinewS

News and Views The natural remedy for superbugs? Coriander oil could be used to cure food poisoning and MRSA, say scientists Coriander oil could be used to cure a host of infections including food poisoning and the superbug MRSA, say researchers. The herb extract is resistant to a range of toxic bacteria which cause infections that are resistant to drugs, a study has found. Portuguese scientists tested samples of the oil – taken from the seeds of a coriander plant – against 12 lethal bacteria. All showed reduced growth and most were killed by a solution containing less than 1.6 per cent of the oil. The team from the University of Beira Interior found the oil attacks and kills the outer membrane of bacteria cells, including salmonella, E.coli and MRSA. Dr Fernanda Domingues, who co–authored the study, said coriander oil could help the millions who suffer from food–borne illnesses every year. ‘It could become a natural alternative to common antibiotics,’ she said. ‘We envisage the use of coriander in lotions, mouth rinses and even pills, to fight multidrug–resistant bacterial infections that otherwise could not be treated. (Source: http://www.–2029248/Coriander– oil–used–cure–food–poisoning–MRSA–say-scientists. html#ixzz1VvpOf8Qm Half of U.S. adults will be obese by 2030, report says Based on trends, half of the adults in the United States will be obese by 2030 unless the government makes changing the food environment a policy priority, according to a report released Thursday on the international obesity crisis in the British medical journal the Lancet. Those changes include making healthful foods cheaper and less–healthful foods more expensive largely through tax strategies, the report said. Changes in the way foods are marketed would also be called for, among many other measures. A team of international public health experts argued that the global obesity crisis will continue to grow worse and 244

add substantial burdens to health–care systems and economies unless governments, international agencies and other major institutions take action to monitor, prevent and control the problem. Changes over the past century in the way food is made and marketed have contributed to the creation of an “obesogenic” environment in which personal willpower and efforts to maintain a healthful weight are largely impossible, the report noted. (Source:–science/ half–of–us–adults–will–be–obese–by-2030–report–says/2011/08/25/ gIQAYthweJ_story.html, Aug 25, 2011)

Add homocysteine to improve CVD risk stratification Risk stratification for cardiovascular disease (CVD) improved significantly with the addition of homocysteine level to the Framingham Risk Score as per a study in the Journal of the American College of Cardiology. Homocysteine level >15 µmol/L predict a 172% increased risk of CVD. New target against type 2 diabetes and prediabetes identified Researchers at the Joslin Diabetes Center have identified a new drug target for treatment of type 2 diabetes and prediabetes. In their study, they have shown that an enzyme, Sirt3, found in the mitochondria – the power producers of cells that convert energy into usable forms – of cells is decreased in the skeletal muscle of those with diabetes, a finding that could lead to the development of drugs to boost the activity of this enzyme in an effort to fight the disease. “Ours is perhaps the first study to understand what is going wrong in the mitochondria of those with diabetes,” said senior author C. Ronald Kahn, M.D., Head of the Joslin Section on Integrative Physiology and Metabolism and the Mary K. Iacocca Professor of Medicine at Harvard Medical School. The goal for the future will be to find ways to restore levels of Sirt3 or increase the activity of the existing Sirt3, perhaps with a drug, in a bid to improve insulin resistance in the muscle and improve Asian Journal of Clinical Cardiology, Vol. 14, No. 8, December 2011

eMedinewS Section muscle metabolism, he said. “It is a new target,” he said. “Agents which increase Sirt3 activity could, therefore, potentially reverse at least some of the adverse effects of type 2 diabetes,” the paper concludes. The study was recently published in the Proceedings of the National Academy of Sciences. (Source: New target against type 2 diabetes and prediabetes identified, Aug 23, 2011) Fitness Update Please don’t stop the music

Do you listen to music while you exercise? New research published in the Journal of Clinical Sport Psychology suggests that you should, in order to reap maximum benefits from your workouts. Many researchers have found that music enhances exercise, and this study summarized all the relevant research on the benefits of listening to music during exercise. The authors of the article reviewed a total of 20 previous studies that examined the effects of adding music to exercise in different populations, and the results were clear: music benefits exercisers. Among the most prominent benefits of listening to music were increased motivation to exercise as well as improvement in exercise capacity and intensity. Some studies found that music was exceptionally helpful for patients undergoing cardiovascular or pulmonary rehabilitation or treatment for diseases such as Alzheimer’s and Parkinson’s. Other studies found that adding music to exercise increased elderly exercisers’ confidence and life satisfaction. The study concluded that music is most effective when it coincided with people’s own personal preferences. Now, you have a great excuse to buy some new music for your mp3 player! (Contributed by Rajat Bhatnagar, International Sports & Fitness Distribution, LLC,

Lab Update Prolactin 

This test is done when a person has symptoms of a prolactinoma, such as unexplained headaches, visual impairment, and/or galactorrhea. Testing may be ordered, along with other tests, when a woman is experiencing infertility or irregular menses or when a man has symptoms such as decreased libido, galactorrhea, or infertility.

Asian Journal of Clinical Cardiology, Vol. 14, No. 8, December 2011

Prolactin levels are also often ordered in men as a follow–up to a low testosterone level. (Dr Arpan Gandhi and Dr Navin Dang)

Medicolegal Update Embalming certificate of deceased is required by law in air/rail transportation

Embalming is the process of chemically treating a dead body developed by the ancient Egyptians of preserving a person’s body after death or to delay the decomposition of the body, restore it to an acceptable physical appearance and reduce the presence and growth of bacteria to prevent foul smell as well as perfume or add fragrance to corpse.  One of the most famous embalmed corpses today is that of the Russian communist leader Vladimir Lenin, whose embalmed corpse is on display at the Red Square mausoleum in Moscow. The corpse is very well–preserved, and should last for at least another 100 years.  The process of embalming has a very long history, dating back to the Egyptian process of mummification. Though their techniques were quite different from those used today, the effect was the same — to preserve an individual’s body after death. In case of the ancient Egyptians, they believed that the spirit would return to the body after death, so it must remain in good condition. To preserve the corpses, they covered bodies in a drying chemical called natron, and then wrapped them in linen sheets.  Today, embalming is done by injecting chemicals directly into the bloodstream to preserve the corpse’s appearance. The most commonly used chemicals for embalming are formaldehyde and ethanol. A combination of these two chemicals is sufficient to preserve the body for a short time means up to a week  To keep the corpse in good condition for a longer period means up to a month, you would use a solution made up almost entirely of formaldehyde.  There are several steps involved in modern embalming. First, the embalming fluid is injected directly into the deceased’s blood vessels, and pushed through the body with a mechanical pump. Next, the internal organs are hollowed of 245

eMedinewS Section their contents and filled with embalming fluid. The chemicals are then injected beneath the skin wherever necessary, followed by a final surface embalming on injured areas of the body. (Dr Sudhir Gupta, Additional Prof, Forensic Medicine & Toxicology, AIIMS)

Gyne Update Women lose knee cartilage faster than men do MRIs show women lose three to four times more knee cartilage annually. Women have higher risk for osteoarthritis than men do; moreover, women who have knee osteoarthritis sustain greater cartilage loss than do men with knee osteoarthritis. To determine whether differences in cartilage health distinguish men and women with no clinical evidence of knee osteoarthritis, researchers in


Australia compared magnetic resonance imaging (MRI) results in 169 women and 102 men (all white). All participants underwent MRI at baseline and at a mean of 2.3 years later to measure knee cartilage volume and to detect defects at tibiofemoral and patellar sites. Men were substantially older than women (mean age, 60 vs. 57). However, in analysis adjusted for age, height, weight, and baseline total bone area, women lost four times more tibial (1.6% vs. 0.4%; P=0.05) and three times more patellar cartilage (2.3% vs. 0.8%; P=0.02) annually than did men. Women also had substantially higher risk for progression of cartilage defects in the tibial area (odds ratio, 3.0) but not in the patellar area. (Dr Maninder Ahuja, Secretary General IMS) (Source: Published in Journal Watch Womenâ&#x20AC;&#x2122;s Health September 3, 2009)

Asian Journal of Clinical Cardiology, Vol. 14, No. 8, December 2011

eMedinewS Section


Asian Journal of Clinical Cardiology, Vol. 14, No. 8, December 2011




lighter reading

Lighter Reading

Laugh a While


Memory Test

That which is static and repetitive is boring. That which is dynamic and random is confusing. In between lies art.

Three elderly men visited the doctor for a memory test. The doctor asked the first one, “What’s three times three?”

—Albert Einstein

“285!” the man replied. Worried, the doctor turned to the second man. “How about you? What’s three times three?” “Uh, Monday!” the second man shouted. Even more concerned, the doctor motioned to the third man. “Well, what do you say? What’s three times three?”

make sure

DURING MEDICAL PRACTICE A 40–year–old male developed acute heart attack after playing squash.

“Nine!” the third man replied. “Excellent!” the doctor exclaimed. “How did you get that?”

my God! Why was a cardiac test not done?

“Oh, it’s pretty simple,” the man explained. “You just subtract the 285 from Monday!” —GM Singh

Idioms Excuse my French: Please forgive me for cussing. Everything but the Kitchen Sink: Almost everything and anything has been included. Ethnic Cleansing: Killing of a certain ethnic or religious group on a massive scale. © IJCP Academy

—Ritu Sinha

Spiritual Update Rome was not built in a Day

With ‘Abhyas’ or constant practice, one can conquer all the obstacles in life. The sutra “Rome was not built in a day” has a deep spiritual meaning. In the path for self–realization, regular practice is the principle behind all paths: Bhakti, Karma or the Gnana marg. Persistence is the key…


Make sure: that anybody taking up anaerobic games after the age of 40 should first get a cardiac clearance.

Asian Journal of Clinical Cardiology, Vol. 14, No. 8, December 2011

Information for Authors Manuscripts should be prepared in accordance with the ‘Uniform requirements for manuscripts submitted to biomedical journals’ compiled by the International Committee of Medical Journal Editors (Ann. Intern. Med. 1992;96: 766-767). Asian Journal of Clinical Cardiology strongly disapproves of the submission of the same articles simultaneously to different journals for consideration as well as duplicate publication and will decline to accept fresh manuscripts submitted by authors who have done so. The boxed checklist will help authors in preparing their manuscript according to our requirements. Improperly prepared manuscripts may be returned to the author without review. The checklist should accompany each manuscript. Authors may provide on the checklist, the names and addresses of experts from Asia and from other parts of the World who, in the authors’ opinion, are best qualified to review the paper. Covering letter -

- -

The covering letter should explain if there is any deviation from the standard IMRAD format (Introduction, Methods, Results and Discussion) and should outline the importance of the paper. Principal/Senior author must sign the covering letter indicating full responsibility for the paper submitted, preferably with signatures of all the authors. Articles must be accompanied by a declaration by all authors stating that the article has not been published in any other Journal/Book. Authors should mentioned complete designation and departments, etc. on the manuscript.

Manuscript - Three complete sets of the manuscript should be submitted and preferably with a CD; typed double spaced throughout (including references, tables and legends to figures). -

The manuscript should be arranged as follow: Covering letter, Checklist, Title page, Abstract, Keywords (for indexing, if required), Introduction, Methods, Results, Discussion, References, Tables, Legends to Figures and Figures.


All pages should be numbered consecutively beginning with the title page.

departments and institutions where the work was performed, name of the corresponding authors, acknowledgment of financial support and abbreviations used. - The title should be of no more than 80 characters and should represent the major theme of the manuscript. A subtitle can be added if necessary. - A short title of not more than 50 characters (including inter-word spaces) for use as a running head should be included. - The name, telephone and fax numbers, e-mail and postal addresses of the author to whom communications are to be sent should be typed in the lower right corner of the title page. - A list of abbreviations used in the paper should be included. In general, the use of abbreviations is discouraged unless they are essential for improving the readability of the text. Summary - The summary of not more than 200 words. It must convey the essential features of the paper. - It should not contain abbreviations, footnotes or references. Introduction - The introduction should state why the study was carried out and what were its specific aims/objectives. Methods - These should be described in sufficient detail to permit evaluation and duplication of the work by others. - Ethical guidelines followed by the investigations should be described. Statistics The following information should be given: - The statistical universe i.e., the population from which the sample for the study is selected. - Method of selecting the sample (cases, subjects, etc. from the statistical universe). - Method of allocating the subjects into different groups. - Statistical methods used for presentation and analysis of data i.e., in terms of mean and standard deviation values or percentages and statistical tests such as Student’s ‘t’ test, Chi-square test and analysis of variance or non-parametric tests and multivariate techniques.

Note: Please keep a copy of your manuscript as we are not responsible for its loss in the mail. Manuscripts will not be returned to authors.


Title page Should contain the title, short title, names of all the authors (without degrees or diplomas), names and full location of the


Asian Journal of Clinical Cardiology, Vol. 14, No. 8, December 2011

Confidence intervals for the measurements should be provided wherever appropriate.

Results These should be concise and include only the tables and figures necessary to enhance the understanding of the text.


Discussion -

This should consist of a review of the literature and relate the major findings of the article to other publications on the subject. The particular relevance of the results to healthcare in India should be stressed, e.g. practicality and cost.

References These should conform to the Vancouver style. References should be numbered in the order in which they appear in the texts and these numbers should be inserted above the lines on each occasion the author is cited (Sinha12 confirmed other reports13,14...). References cited only in tables or in legends to figures should be numbered in the text of the particular table or illustration. Include among the references papers accepted but not yet published; designate the journal and add ‘in press’ (in parentheses). Information from manuscripts submitted but not yet accepted should be cited in the text as ‘unpublished observations’ (in parentheses). At the end of the article the full list of references should include the names of all authors if there are fewer than seven or if there are more, the first six followed by et al., the full title of the journal article or book chapters; the title of journals abbreviated according to the style of the Index Medicus and the first and final page numbers of the article or chapter. The authors should check that the references are accurate. If they are not this may result in the rejection of an otherwise adequate contribution. Examples of common forms of references are: Articles


Do not use clips/staples on photographs and artwork.


Illustrations must be drawn neatly by an artist and photographs must be sent on glossy paper. No captions should be written directly on the photographs or illustration. Legends to all photographs and illustrations should be typed on a separate sheet of paper. All illustrations and figures must be referred to in the text and abbreviated as ‘Fig.’. Please complete the following checklist and attach to the manuscript: 1. Classification (e.g. original article, review, selected summary, etc.)_______________________________

Paintal AS. Impulses in vagal afferent fibres from specific pulmonary deflation receptors. The response of those receptors to phenylguanide, potato S-hydroxytryptamine and their role in respiratory and cardiovascular reflexes. Q. J. Expt. Physiol. 1955;40:89-111.

2. Total number of pages ________________________


6. Suggestions for reviewers (name and postal address)

Stansfield AG. Lymph Node Biopsy Interpretation Churchill Livingstone, New York 1985.

Indian 1.____________Foreign 1._ _______________


2._ _______________

Articles in Books


3._ _______________

Strong MS. Recurrent respiratory papillomatosis. In: Scott Brown’s Otolaryngology. Paediatric Otolaryngology Evans JNG (Ed.), Butterworths, London 1987;6:466-470.


4._ _______________

Tables -

These should be typed double spaced on separate sheets with the table number (in Roman Arabic numerals) and title above the table and explanatory notes below the table.

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The legend must include enough information to permit interpretation of the figure without reference to the text.

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