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Volume 14, Number 7, November 2011, Pages 217-252

Dr KK Aggarwal Group Editor-in-Chief

Dr Praveen Chandra Guest Editor

Head Office: E - 219, Greater Kailash, Part 1, New Delhi - 48, India. e-Mail: emedinews@gmail.com, Website: www.ijcpgroup.com

eMedinewS is now available online on www.emedinews.in or www.emedinews.org 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, http://www.isfdistribution.com) 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)

Online Submission

Volume 14, Number 7, November 2011

An IJCP Group Publication

Contents From the Desk of Group Editor-in-Chief

Dr KK Aggarwal Group Editor-in-Chief IJCP Group emedinews@gmail.com

Dr Praveen Chandra Guest Editor, AJCC praveen.chandra@ medanta.org

Assistant Editor: Dr Nagendra Chouhan

AJCC Speciality Panel Advisory Board International Dr Fayoz Shanl Dr Alain Cribier Dr Kohtian Hai Dr Tanhuay Cheem Dr Ayman Megde Dr Alan Young Dr Gaddy Grimes Dr Jung bo Geg Dr Rosli Mohd. Ali Dr S Saito National Dr Mansoor Hassan

Dr RK Saran Dr SS Singhal Dr Mohd. Ahmed Dr PK Jain Dr PK Gupta Dr Naresh Trehan Faculty Dr GK Aneja Dr Ramesh Thakur Dr Balram Bhargava Dr HK Bali Dr HM Mardikar Dr Sanjay Mehrotra Dr Vivek Menon

Dr Sanjiv Chopra Prof. of Medicine & Faculty Dean Harvard Medical School Group Consultant Editor Dr Deepak Chopra Chief Editorial Advisor Anand Gopal Bhatnagar Editorial Anchor

Dr Keyur Parikh Dr Ajit Mullasari Dr Kirti Punamiya Dr MS Hiramath Dr VS Narain Dr SK Dwivedi Dr Raja Baru Panwar Dr Vijay Trehan Dr Rakesh Verma Dr Suman Bhandari Dr Ravi Kasliwal Dr Atul Abhyankar Dr Tejas Patel Dr Samir Dani

Dr KK Aggarwal CMD, Publisher and Group Editor-in-Chief Dr Veena Aggarwal MD & Group Executive Editor

Do not Take Painkillers If You are a Heart Patient KK Aggarwal

Review Article

Cardiovascular Monitoring of Hypertensive Patients with or without Coronary Artery Disease Undergoing Noncardiac Surgery

Dr VP Sood, Asian Journal of Ear, Nose and Throat Dr Praveen Chandra, Asian Journal of Clinical Cardiology Dr Swati Y Bhave, Asian Journal of Paediatric Practice Dr Vijay Viswanathan, The Asian Journal of Diabetology

case report

Emergency Percutaneous Balloon Mitral Valvuloplasty in a Critically Ill Patient with Severe Mitral Stenosis

227

Praloy Chakraborty, Sandeep Seth

Clinical Study

The Prevalence and Pattern of Dyslipidemia Among Type II Diabetic Patients at Rural Based Hospital in Gujarat, India

229

Pandya H, Lakhani JD, Dadhania J, Trivedi A

clinical practice

Role of Thrombectomy and Embolic Protection Devices in Acute ST Elevation Myocardial Infarction

236

Anupam Goel

Dr KMK Masthan, Indian Journal of Multidisciplinary Dentistry

Expert Opinion

Dr M Paul Anand, Dr SK Parashar, Cardiology Dr CR Anand Moses, Dr Sidhartha Das, Dr Ramachandran, Dr Samith A Shetty, Diabetology

222

Ajit Gupta, BP Singh

IJCP Editorial Board Dr Alka Kriplani, Asian Journal of Obs & Gynae Practice

221

Dr Ajay Kumar, Gastroenterology

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

Dr Hasmukh J Shroff, Dermatology

Sunil Prakash

239

Dr Georgi Abraham, Nephrology Dr V Nagarajan, Neurology Dr Thankam Verma, Dr Kamala Selvaraj, Obs and Gyne

Advisory Bodies Heart Care Foundation of India Overseas Indian Peoples Foundation

practice guidelines

International Consensus Group Issues Recommendations for Management of Upper GI Bleeding

240

Volume 14, Number 7, November 2011

Published, Printed and Edited by Dr KK Aggarwal, on behalf of IJCP Publications Pvt. Ltd. and Published at E - 219, Greater Kailash, Part - I, New Delhi - 110 048 E-mail: editorial@ijcp.com

Research Review

From the Journals ...

243

Emedinews Section

From eMedinewS

Printed at IG Printers Pvt. Ltd., New Delhi E-mail: igprinter@rediffmail.com Š Copyright 2011 IJCP Publications Pvt. Ltd. All rights reserved. The copyright for all the editorial material contained in this journal, in the form of layout, content including images and design, is held by IJCP Publications Pvt. Ltd. No part of this publication may be published in any form whatsoever without the prior written permission of the publisher.

244

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

came with atypical chest pain.

GET A TMT DONE

Š IJCP Academy

take nSAIDS

Editorial Policies The purpose of IJCP Academy of CME is to serve the medical profession and provide print continuing medical education as a part of their social commitment. The information and opinions presented in IJCP group publications reflect the views of the authors, not those of the journal, unless so stated. Advertising is accepted only if judged to be in harmony with the purpose of the journal; however, IJCP group reserves the right to reject any advertising at its sole discretion. Neither acceptance nor rejection constitutes an endorsement by IJCP group of a particular policy, product or procedure. We believe that readers need to be aware of any affiliation or financial relationship (employment, consultancies, stock ownership, honoraria, etc.) between an author and any organization or entity that has a direct financial interest in the subject matter or materials the author is writing about. We inform the reader of any pertinent relationships disclosed. A disclosure statement, where appropriate, is published at the end of the relevant article.

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.

Note: Asian Journal of Clinical Cardiology does not guarantee, directly or indirectly, the quality or efficacy of any product or service described in the advertisements or other material which is commercial in nature in this issue.

Dr KK Aggarwal

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From the Desk of Group Editor-in-Chief

Do not Take Painkillers If You are a Heart Patient

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) emedinews@gmail.com http://twitter.com/DrKKAggarwal Krishan Kumar Aggarwal (Facebook)

T

here is no safe duration for use of NSAID painkillers in patients with a history of heart attack according to an analysis of data from more than 83,000 patients and published in Circulation, Journal of the American Heart Association. NSAID use after heart attack increased the relative risk of death or second heart attack by as much as 45%. NSAID treatment was associated with a statistically significantly increased risk of death at the beginning of the treatment, and the risk persisted throughout the course of treatment. We must limit NSAID use to the absolute minimum in patients with established cardiovascular disease.  All NSAIDs increased risk of death or recurrent heart attack by 45% after a week.  Naproxen increase the risk of death or recurrent heat attack by 76% after a week but for treatments lasting 30 to 90 days the risk increased risk was 15%  Ibuprofen had the lowest initial risk, just a 4% increase for treatments lasting seven days or less. n

Asian Journal of Clinical Cardiology, Vol. 14, No. 7, November 2011

n

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review article

Cardiovascular Monitoring of Hypertensive Patients with or without Coronary Artery Disease Undergoing Noncardiac Surgery Ajit Gupta*, BP Singh**

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: Hypertensive, coronary artery disease, monitoring, ECG, TEE, CVP, PCWP

U

nexpected morbidity and mortality during surgery and anesthesia is not only distressing to the patients but to the whole institution. Inspite of recent improvement in preoperative prophylaxis/therapy and perioperative (pre-, intra- and postoperative) monitoring, the morbidity and mortality after non cardiac surgery has not lessened. It is also established fact that patients who develop myocardial ischemia during perioperative period have nine-fold higher risk of adverse outcome during hospital stay and two times greater risk of premature death in first six month of postoperative period, regardless of disease state or type of surgery. Similarly, patients who come out without myocardial ischemia do not develop cardiological dysfunction in postoperative period.1 The problem is substantial, chiefly due to hypertension and prevalence of CAD in this group. It has been estimated that in USA, one patient in three of general surgical population has CAD or has risk factor of coronary disease.2 And as such the perioperative myocardial ischemia is a silent and the single greatest cause of death following noncardiac surgery.3 Hypertension is considered as an useful marker for coronary inadequacy and perioperative control has **Additional Professor, Dept. of Anesthesiology and Critical Care **Dept. of Cardiology Indira Gandhi Institute of Medical Sciences, Patna Address for correspondence Dr Ajit Gupta Additional Professor Dept. of Anesthesiology and Critical Care Indira Gandhi Institute of Medical Sciences, Patna, Bihar E-mail: ajpta_igims@ yahoo.co.uk

222

shown reduced incidence of stroke and untoward cardiovascular problems. In surgical setup, exaggerated intraoperative blood pressure (BP) fluctuation with associated evidence of myocardial ischemia is more in hypertensive population and postoperative cardiac morbidity can be minimized, if perioperative monitoring with control of hypertension and perioperative risk is calculated and is taken care of. It is assumed that a hypertensive patient with or without CAD has been well-assessed and laboratory evaluation done, cause of hypertension (primary i.e. essential or secondary) has been settled and treatment of cause has been instituted. Some of the causes like phaeochromocytoma, renal artery stenosis or aldosteronism not responding to general antihypertensive treatment have been ruled out. Discussion Considering the risk involved the ultimate aim is well being of patient during the perioperative period and as such, care during pre-, intra- and postoperative period is necessary. Studies suggest that preoperative assessment and identification of high risk patient helps in monitoring and prevention of irreversible bad outcome.4 Till 1970, preoperative risk was assessed using Dripps American Surgical Association classification. In 1977, Goldmah et al5 published multifactorial index of cardiac risk, updated by Detsky et al in 1986.6 Perioperative risk assessment is not a static science. In 1996, American College of Cardiology and American Heart Association Joint Guidelines set cardiovascular Asian Journal of Clinical Cardiology, Vol. 14, No. 7, November 2011

review article evaluation guidelines;4 later American College of Physicians issued guidelines for assessing and management strategy for perioperative risks for non cardiac surgeries.5 Some of the evaluation of grade or severity of hypertension needs to be established, as this serves as base line. Various studies shows that Stage I and Stage II hypertension (Syst BP <180 mmHg and Diast BP <110 mmHg) are not independent risk of cardiac complication, but Stage III (Syst. BP >180 mmHg and Diast. BP >110 mmHg) are established risk factors of untoward perioperative complication.7 Hence, preoperative expectation in hypertensive patients with or without CAD is: Control of BP to a suitable baseline Stable cardiac parameters like:  Heart rate  Rhythm  Stroke volume  Pre- and afterload  PCWP  RAP and LAP  LVEDP History of drugs like b-blockers, clonidine, ACE inhibitors etc. A successful outcome will depend on how carefully evaluation and control of cardiac parameters have been achieved. During the intraoperative period, a protocol needs to be followed for good outcome in this group of patients. Some of the methods are old, time-tested but have their limitations. It has been well-said that the best and most reliable monitor in the operative setup is an anesthesiologist. A simple palpation of pulse, recording of BP, examination of mucosa and skin can give enough information to observer but in the modern era of electronics and legal implications, minimum monitoring guideline is to be followed. The minimum monitoring guideline varies country-to-country but it is wise to have basic as well as advanced monitoring facility during intraoperative period for acceptable outcome. One can introduce very sophisticated monitoring tools, subject to availability and familiarity to use them. Asian Journal of Clinical Cardiology, Vol. 14, No. 7, November 2011

Monitoring

Some of the vital monitoring norms and their importance are as follows: Blood Pressure

The body’s homeostatic mechanism is not only systemic or organ blood flow for adequate tissue oxygen delivery but maintenance of BP also. There is always a critical systemic arterial pressure below which vital organ perfusion can be compromised. So, it is very important to maintain normal level of BP during perioperative period. There are different methods, both invasive and noninvasive for assessment of BP. Sphygmomanometer   

Mercury Aneroid Electronic

Every one uses these monitoring devices and benefits and shortcomings are well-known. Oscillometer

Oscillometers are automated devices and quite common in use. They gives erroneous reading when BP has fallen below critical level or when the patient is being perfused on heart-lung machine. Continuous Noninvasive Finger BP Monitoring

This is a beat-to-beat arterial noninvasive BP monitoring device. BP in finger varies in clinical fashion with each cycle and the finger cuff receives the intra-arterial pressure which is converted to wave form, to be analyzed through consol into systolic, diastolic and mean BP. It is an advancement in BP monitoring and considered gold standard and replaces invasive intra-arterial BP monitoring. Invasive Intra-arterial BP Monitoring

It provides beat-to-beat measurement of BP and a waveform that can also be utilized for information like myocardial contractility. Severe changes in BP associated with arrhythmia such as premature ventricular contractions give an instant visual knowledge of hemodynamic consequences of rhythm disturbance. Arterial pressure waveform is 223

review article measured in ascending aorta which is different from the pressure measured in most of the peripheral arteries. Arterial waveform progressively gets distorted, as signal is transmitted down the arterial tree; components like dicrotic notch disappear, systolic peak increases, diastolic trough decreases and there is transmission delay as we move from aorta to dorsalis pedis, due to decreasing compliance in peripheral tree. This effect can be seen in dorsalis pedis where systolic BP may be 10-20 mmHg higher and diastolic BP may be 10-20 mmHg lower than the aorta. Pressure waves in artery or vein signify force generated in cardiac chambers and measurement of force is transmitted to a device that converts mechanical energy into electronic signal. The systemic BP is dependent upon two factors like pre- and afterload. Preload: Can be defined as end diastolic stress on the ventricles. Blood volume, venous tone, ventricular compliance, ventricular afterload, heart rate all constitute preload. The degree of stress on ventricular fibers determine the work done by the heart and thereby any increase of preload increases the work done, oxygen consumption by myocardium and susceptibility to cardiac ischemia. Afterload: It is the wall stress or tension of myocardium during ventricular ejection, which is dependent upon radius of ventricle, myocardial thickening, arterial compliance and systemic vascular resistance. Any change in above parameter will lead to cardiovascular compromise in hypertensive patient and potentials for myocardial ischemia. Central Venous Pressure Monitoring

Central venous catheter is used to monitor filling pressure of right ventricle, intravascular volume and right ventricular function. Water manometer is used routinely to measure central venous pressure (CVP) but electronic system is preferred to observe right atrial waveform which provides useful information. CVP monitoring does not provide any direct information of the left heart pressure but can be used as crude estimate of left ventricular function. Right atrial waveform has three upward and two downward complexes:

Upward a wave: Produced by atrial complexes After p-wave of ECG 224

contraction

Before first heart sound

c wave: Caused when tricuspid valve closes and bulges in right atrium v wave: Caused by rapid late systolic ventricular filling before tricuspid opens up at end of systole Downward x wave: During ventricular systole, complexes tricuspid valve is pulled away from right atrium causing x wave y wave: Caused by tricuspid opening, myocardial relaxation and ventricular filling Pulmonary Artery Pressure Monitoring

Flow directed pulmonary artery catheter (PAC) is a major advancement in cardiac assessment during the intraoperative period and immediate postoperative period as it gives most of the vital informations. PAC gives: Pulmonary artery systolic pressure  Pulmonary artery diastolic pressure  Mean pulmonary artery pressure  Pulmonary capillary wedge pressure (PCWP)  Cardiac output by thermodilution method Measurement of PCWP reflects the left atrial pressure which in turn is an estimate of left ventricular end diastolic pressure. It may not be very accurate but very close to it in normal circumstances. Information received from PCWP helps in estimation of cardiac index, systemic vascular resistance and ventricular function. In this way cardiac function as a whole can be assessed in a hypertensive patient. ECG Monitoring

ECG has become a routine monitoring tool during intraoperative period in all surgeries whether the patient is hypertensive or has CAD or not, irrespective of type of anesthesia. Every country has this device as minimum monitoring protocol, as it gives information regarding heart rate, myocardial ischemia, arrhythmia, altered physiological response and checks the placement of catheters. Myocardial Ischemia

In cases of hypertensives with or without CAD, ECG is vital in assessment although it has no standard Asian Journal of Clinical Cardiology, Vol. 14, No. 7, November 2011

review article criteria for detecting myocardial ischemia, ST-segment abnormality, T wave inversion, QRS and T wave changes all are considered for analysis. The standard approved by American College of Cardiologists (ACC) accepts the criteria suggested by Ellestad and colleagues8 for ST segment changes i.e. downward sloping of ST segment depression of >1 mm at 60 m. seconds from J point for 60 seconds, as ischemia. Digitalis toxicity, electrolyte disturbance, hyperventilation, WPW syndrome are certain nonischemic causes of ST changes.9 For ischemia monitoring, best lead is V5, but V4, II, V3 and V6 leads can also be used in decreasing order of sensitivity. Chances of diagnosing ischemia in combined leads: V5 and II in 80%, V4 and V5 in 90% and II and V2-V5 in 100%.10 Arrhythmia

Dysrrhythmia, during intraoperative period especially in hypertensive patients is very common during surgery and anesthesia. Hypertensive spikes are very common during surgery, when hollow organs or ligament gets stretched while analgesia may not be adequate. The incidence of arrhythmia during various types of anesthesia and surgery has been reported as:11,12 General anesthesia Regional anesthesia Intubated patients Nonintubated patient Thoracic surgery Peripheral surgery

66% 42% 72% 44% 93% 56%

Conduction Defect

May develop in patients with or without CAD and can be of various degree. ECG is the most vital mode of assessment and helps in instituting suitable measures in due time. Altered Physiological Changes

Few physiological changes may manifest in ECG tracing from which certain interference can be drawn:  Hypokalemia  Hyperkalemia  Hypocalcemia Asian Journal of Clinical Cardiology, Vol. 14, No. 7, November 2011

  

Hypocalcemia Digitalis toxicity Raised intracranial tension

Transesophageal Echocardiography

Transesophageal echocardiography (TEE) is an useful tool in the hands of cardiologists and anesthesiologist. It is the biggest leap in hemodynamic monitoring and clinician can study physiological and anatomical cardiac status, institute treatment and can assess the response of such treatment in real time. Modern TEE probes use 5-Mhz transducers and combines Doppler capability with 2D-imaging facility. Assessment by TEE can be utilized for more precise information to guide surgical interventions myocardial revascularization, valvular competence or repair of congenital heart disease), pharmacological support, fluid management in intraoperative period. Some of the important advantages: Cardiovascular Hemodynamics

Preload and LV filling: TEE gives precise information about left ventricular preload and direct information of ventricular volume. This is different from CVP and PCWP which give indirect estimate of volume status through pressure.13 It also give mean atrial pressure. LV contractility: By measuring LV fractional area at mid papillary muscle, one can assess contractility of left ventricle. Ejection fraction: Linear internal dimension of LV cavity at the end of diastole and systole and fractional shortening can be calculated. TEE in this way helps to calculate the ventricular volume and thereby ejection fraction. Cardiac output: TEE imaging of LV filling and ejection fraction helps immediate detection of changes in cardiac output. Myocardial Ischemia Monitoring

It is an established fact that acute myocardial ischemia causes thickening of myocardium and it’s abnormal inward motion. Thickening of myocardium takes some time to develop and there is sequential changes in functional status. It is also a fact that diastolic 225

review article dysfunction appears before systolic detectable by TEE immediately.14

dysfunction

Segmental wall motion abnormality (SWMA) develops within seconds of ischemia and depends upon degree of involvement. SWMA is suggested to be more sensitive index for ischemia diagnosis than changes in ECG or pulmonary artery catheter monitoring.15 As the oxygen demand/supply worsens, graded SWMA increases from hypokinesia to akinesia. Hypokinesia means reduced inward wall movement while akinesia means no wall movement and dyskinesia means paradoxical wall movement as well as outward movement during systole. TEE is a tool of real time assessment of myocardial ischemia leading to structural and physiological changes occurring during intraoperative period. Other Assessment Modalities

2. Mangano DT. Preoperative assessment of patients with cardiac disease. Curr Opin Cardiol 995;10:530-42. 3. Mangano DT. Perioperative Anesthesiology 1990;72:153-84.

cardiac

morbidity.

4. ACC/AHA Task force report. Guidelines for perioperative cardiovascular evaluation for non cardiac surgery. J Am Coll Cardiol 1996;27:910-48. 5. Palda VA, Detasky AS. Guidelines for assessing and managing the perioperative risk from coronary artery disease associated with major non cardiac surgery. Ann Intern Med 1997;127:309-28. 6. Fleisher LA. But is suppression of postoperative ST segment depression an important outcome? Anesth Analg 1997;84:709-11. 7. Goldman L. Multifactorial index of cardiac risk in noncardiac surgery: ten-year status report.. J Cardiothorac Anesth 1987;1(3):237-44. 8. Stuart R, Ellastad MH. Upsloping ST segment in exercise stress testing. Am J Cardiol 1976;37:19-22.

Pulse oxymetry: To asses tissue perfusion, assuring adequate oxygen delivery to tissue.

9. John G Muller, Paul G Barash. Automated ST segment monitoring. International Anesthesiology clinics. Little Brown and Company 1993;30(3):48-52.

Capnography: Any abnormal level of carbon dioxide is related to BP fluctuation and hence end-tidal CO2 (EtCO2) monitoring is helpful.

10. London MH, Hollenberg M, Wong MG, et al. Intraoperative myocardial ischemia; localization by continuous 12 lead electrocardiography. Anesthesiology 1998;9:232-41.

Arterial blood gas monitoring Core body temperature monitoring

Conclusion It can be concluded that in cases of hypertension, whether associated with CAD or not, a careful assessment is of prime importance. Hypertension is an important marker of perioperative disasters, any extreme of BP must be taken care of during perioperative period. With many weapons in armory, careful monitoring during pre-, intra- and postoperative periods helps in successful outcome. References 1. Badner NH, Knill RL, Brown JE, Novick TV, Gelb AW. Myocardial infarction after noncardiac surgery. Anesthesiology 1998;88(3):572-8.

11. Bertrand CA, Steiner NV, Jameson AG, Lopez M. Disturbances of cardiac rhythm during anesthesia and surgery. JAMA 1971;216(10):1615-7. 12. Kuner J, Enescu V, Utsu F, Boszormenyi E, Bernstein H, Corday E. Cardiac arrhythmias during anesthesia. Dis Chest 1967;52(5):580-7. 13. Beaupre PN, Kremer PF, Cahalan MK, Lurz FW, Schiller NB, Hamilton WK. Intraoperative detection of changes in left ventricular segmental wall motion by transesophageal two-dimensional echocardiography. Am Heart J 1984;107(5 Pt 1):1021-3. 14. Tennant R, Wiggers C. The effect of coronary occlusion on myocardial contraction. Am J Physiol 1995; 112:351足-61. 15. Smith JS, Cahalan MK, Benefiel DJ, Byrd BF, Lurz FW, Shapiro WA, et al. Intraoperative detection of myocardial ischemia in high-risk patients: electrocardiography versus two-dimensional transesophageal echocardiography. Circulation 1985;72(5):1015-21.

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Asian Journal of Clinical Cardiology, Vol. 14, No. 7, November 2011

case report

Emergency Percutaneous Balloon Mitral Valvuloplasty in a Critically Ill Patient with Severe Mitral Stenosis Praloy Chakraborty*, Sandeep Seth*

Abstract Severe rheumatic mitral stenosis can present acutely with fulminant pulmonary edema. Despite aggressive medical therapy, if the underlying mechanical cause is not corrected, mortality is high. Percutaneous balloon mitral valvuloplasty is a well established elective treatment for hemodynamically significant mitral stenosis in selected patients but its role in the critically ill patient is less clear. We describe a case of fulminant pulmonary edema secondary to severe mitral stenosis, successfully treated by balloon mitral valvuloplasty. Key words: Mitral stenosis, balloon mitral valvuloplasty, Inoue balloon

Case Report A 32-year-old female presented to the emergency department with a 24-hour history of progressive dyspnea. She is a known case of rheumatic heart disease with severe mitral stenosis (mitral valve area on 2D echo was 0.8 cm2) and was not on regular medication. On examination the patient was in frank pulmonary edema with production of pink frothy sputum, tachycardia (117 bpm), with a blood pressure of 110/80 mmHg. Auscultation of her chest revealed bilateral widespread inspiratory crackles. An electrocardiogram confirmed atrial fibrillation with fast ventricular rate. Arterial blood gases at presentation demonstrated hypoxic respiratory failure and a metabolic acidosis. The patient was intubated due to severe hypoxia. Pulmonary artery catheterization revealed severe pulmonary venous hypertension (mean PCWP = 51) in the context of systemic pressure of 110/80. Transthoracic echocardiography (TTE) demonstrated changes consistent with severe rheumatic mitral stenosis. The left atrium was grossly enlarged. The mitral valve opening was severely restricted with an estimated valve area of 0.6 cm2 (by planimetry). Trans-septal catheterization was performed using a Brockenbrough needle. Balloon mitral valvuloplasty *Dept. of Cardiology All India Institute of Medical Sciences, New Delhi Address for correspondence Dr Praloy Chakraborty Dept. of Cardiology All India Institute of Medical Sciences, New Delhi

Asian Journal of Clinical Cardiology, Vol. 14, No. 7, November 2011

Figure 1. Catheter picture of balloon inflated across mitral valve.

was performed, using of a 26 mm Inoue balloon, chosen according height of patient. Two inflations were performed using 23.5 mm and 24.5 mm the mean PCWP was reduced to 24 with rapid improvement of systemic arterial oxygen saturation (Fig. 1). TTE demonstrated no increase in mitral regurgitation. Rapid hemodynamic improvement ensued; she continued to improve, and ventilatory support was withdrawn within 12 hours of the procedure. Repeat TTE performed one week after the procedure showed an increase in valve area to 1.5 cm2, and mild mitral regurgitation was noted and at one year follow-up patient is asymptomatic. 227

Case Report Discussion Although there is a vast body of literature concerning balloon mitral valvuloplasty,2-5 there is very little published data concerning the use of this procedure in patients with acute pulmonary edema secondary to severe mitral stenosis.6-7 Emergency mitral valve replacement was not an option in our patient in view of persisting pulmonary edema. Furthermore, either open or closed mitral valvotomy was considered to be too risky in such a sick patient. Percutaneous balloon valvuloplasty was therefore the only available treatment option, and the valve appearances were considered to be favorable for this procedure. Further data are needed to assess the suitability of balloon mitral valvuloplasty for similar patients, but it can be concluded that balloon mitral valvuloplasty should be considered for critically ill patients with acute pulmonary edema where there is no surgical alternative.

2. Cohen JM, Glower DD, Harrison JK, Bashore TM, White WD, Smith LR, et al. Comparison of balloon valvuloplasty with operative treatment for mitral stenosis. Ann Thorac Surg 1993;56:1254-62. 3. Cohen DJ, Kuntz RE, Gordon SP, Piana RN, Safian RD, McKay RG, et al. Predictors of long-term outcome after percutaneous balloon mitral valvuloplasty. N Engl J Med 1992;327:1329-35. 4. Chen CR, Cheng TO. Percutaneous balloon mitral valvuloplasty by the Inoue technique: A multicenter study of 4832 patients in China. Am Heart J 1995;129:11971203. 5. Lau KW, Hung JS, Ding ZP, Johan A. Controversies in balloon mitral valvuloplasty: The when (timing for intervention), what (choice of valve), and how (selection of technique). Cathet Cardiovasc Diagn 1995;35:91100.

References

6. Goldman JH, Slade A, Clague J. Cardiogenic shock secondary to mitral stenosis treated by balloon mitral valvuloplasty. Cathet Cardiovasc Diagn 1998;43:195-7.

1. Reyes VP, Raju BS, Wynne J, Stephenson LW, Raju R, Fromm BS, et al. Percutaneous balloon valvuloplasty compared with open surgical commissurotomy for mitral stenosis. N Engl J Med 1994;331:961-7.

7. Ward DE, Tanner MA. Percutaneous mitral commissurotomy using the metallic valvulotome technique in a critically ill adult. Clin Cardiol 2004;27:369-70.

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clinical study

The Prevalence and Pattern of Dyslipidemia Among Type II Diabetic Patients at Rural Based Hospital in Gujarat, India Pandya H*, Lakhani JD**, Dadhania Jâ&#x20AC; , Trivedi Aâ&#x20AC; 

Abstract Only proper control of diabetes has shown statistically significant difference (p <0.001) on prevalence and severity of dyslipidemia, consolidating the fact that the proper treatment and strict control of diabetes is the most important step in prevention and treatment of complications of diabetes. Key words: Dyslipidemia, Atherogenic lipid profile, Elevated triglycerides, HDL cholesterol, LDL cholesterol, Obesity, Metabolic syndrome, Diabetes

I

t is currently estimated that diabetes prevalence by 2030 will include 439 million adults world-wide.1 South East Asian countries bear the highest burden of diabetes, including India which may have up to 33 million cases.2 CAD accounts for the primary cause of death in almost all patients with diabetes. Despite major advances in primary and secondary prevention of CAD in the past 50 years, patients with diabetes still are relatively at an increased risk of CAD as compared to those without diabetes.3 Even as the causes of increased cardiovascular risk in type 2 diabetes are multi-factorial, an atherogenic lipid profile characterized by elevated triglycerides and low levels of high-density lipoprotein (HDL) cholesterol are few major modifiable factors contributing progressively in cardiovascular risk.4,5 Although three recent clinical trials of cholesterol lowering have shown that lowering LDL cholesterol in diabetic persons does reduce the incidence of CAD6-8 the relative importance of LDL cholesterol, compared with the characteristic dyslipidemia, in determining CAD risk in diabetic individuals is still a subject of debate. A question of particular importance is the relative role of various

*Associate Professor **Head and Professor â&#x20AC;  Jr Resident Dept. of Medicine, SBKS Medical Institute and Research Centre At and Piparia, Waghodia Vadodara, Gujarat Address for correspondence Dr Hetal Pandya Associate Professor Dept. of Medicine, SBKS MIRC E-mail: drhetalpandya@gmail.com

Asian Journal of Clinical Cardiology, Vol. 14, No. 7, November 2011

lipoprotein abnormalities in determining CAD risk in diabetic individuals in context to the ethnicity and region where they live. India has diverse lifestyle pattern and ethnic variations, thus epidemiological profile of diabetes mellitus may be different in different geographical areas. Gujarat is considered as one of the rich and developed States of India. A diet rich in oil and sugar content has pushed Gujarat to the forefront of contributors of diabetic patients in India. Ethnic Gujarati people are presumed to have high prevalence of CAD risk factors - obesity, metabolic syndrome, diabetes, hypertension, dyslipidemia because of traditional Gujarati food and less physically active life style. In our previous study on Diabesity in Gujarati population, even rural underdeveloped areas of Gujarat State were showing increasing trend of lifestyle disorders like diabetes and obesity.9 Another study had also shown increasing prevalence of another lifestyle disorder-hypertension and obesity in Gujarati population.10 Though burden of diabetes and dyslipidemia in India is mainly contributed by urban population, the increasing trend of diabetes and even dyslipidemia is observed in rural population too, because of urbanization and changing life style and food habits. There are very few data available for prevalence of dyslipidemia and diabetes from Indian continent, which are mainly from South Indian urban population and few from North Indian urban population.11-14 We were unable to find studies on prevalence and pattern of dyslipidemia in diabetic Gujarati population. The present study aims to bridge the gap by studying prevalence, pattern and 229

Clinical Study severity of dyslipidemia in diabetic patients especially in rural areas of Gujarat. Material and Methods A prospective cross-sectional study was planned to analyse the pattern of dyslipidemia in diabetic patients attending the Diabetes Clinic and Outpatient Department of Dhiraj General Hospital attached with SBKS Medical Institute and Research Centre over a period of 6 months (July’ 2010 to December’ 2010). The study population consisted of already diagnosed, on treatment diabetic patients & newly diagnosed DM patients. The patients who were already having history of Coronary Artery Diseases (CAD) or Cerebro Vascular Accident (CVA) or diagnosed as having CAD or CVA on enrolment and patients already taking lipid lowering drugs were excluded from the study. Diabetic patients having other chronic systemic or metabolic disorder were not included in the study. Detailed history and clinical examination of all the enrolled patients was done. Anthropometric measurements (weight, height, waist circumference (WC) and hip circumference) were taken using standard methods. Fasting blood sample was collected for serum lipid profile investigation after 10 hours overnight fast. S. Cholesterol, S. Triglyceride, S. HDL, S. LDL, S. VLDL levels were measured using calibrated ERBACHEM 5 Plus, semi-automated machine. Cut off normal values for individual lipid levels were taken as per the National Cholesterol Education program (NCEP) Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III).15 Mixed dyslipidemia term is coined when two or more individual lipid levels were abnormal. The patients were categorized in different subgroups such as Male/Female, Urban/Rural, Controlled/ Uncontrolled, Obese/Non-obese, Hypertensive/ Non-hypertensive for subgroup analysis of diabetic dyslipidemia. All diabetic patients were categorized as urban if living in place with >1 lac population, obese or non-obese using BMI criteria of ≥23 proposed for South-Asian population (IDF -Modified ATP III criteria)15 and as hypertensive if their blood pressure is ≥130/85. ADA Criteria for treatment of diabetes (HbA1c <7 or fasting/preprandial plasma glucose <130 mg/dl and postprandial plasma glucose <180 mg/dl for two consecutive 230

visits) were used to divide the patients in controlled and uncontrolled groups.16 All the observations were tabulated and results were expressed as percentage and mean SD (Standard Deviation). Results Out of 171 diabetic patients enrolled in the study, 100 were male and 71 were female patients. The mean age of study population was 54.8 ± 10.12 (Male: 54.7 ± 10.65 and Female: 54.9 ± 9.42). The mean duration from the first diagnosis of diabetes for the study patients was 5.1 ± 4.64 years. Only 9.9% of patients were having DM since more than 10 years and 23.4% were diagnosed as diabetics in last 2 years only. Around, 33.9% were diabetics since 2 to 5 years and 32.7% were diabetics since 5 to 10 years. Further, 43.9% (n: 75) of patients were from urban area and 56.1% (n: 96) were from the rural area. The mean BMI of study population was 25.6 ± 5.81 (Male: 24.5 ± 4.71 and Female: 27.2 ± 6.81). Also, 68.4% (n: 117) of all diabetic patients participated in study were found to be obese by Modified ATP III criteria of BMI ≥23 for south-asian population. Only 19.3% of study patients were well controlled. Only 24% (n: 41) were hypertensive and 26.3% (n: 45) were smokers, all were males (Table 1). Individual serum lipid results were as follows. Mean S. Cholesterol level was 188.9 ± 43.70, mean S. Triglyceride was 174.6 ± 69.44, mean S. HDL was 46.2 ± 17.08, mean S. LDL was 105.9 ± 34.06 and mean S. VLDL level was 33.4 ± 11.08. (Table 2) Out of 171 DM patients, 36.3% (n: 62) patients were having high S. Cholesterol level, while almost similar no. of patients, 35.7% (n: 61) were having low S. HDL levels. About 56.1% (n: 96) were showing high S. Triglyceride level, while almost similar no. of patients, 57.3% (n: 98) were also having S. LDL levels above normal range. 49.7% (n: 85) were also showing high S. VLDL levels (Table 2, Chart 2). Discussion Patients with diabetes mellitus have a 2 to 4 fold increased risk of cardiovascular, peripheral vascular and cerebrovascular disease, which are the leading causes of morbidity and mortality in this population. Many western epidemiological studies have shown an association between diabetic dyslipidemia, which Asian Journal of Clinical Cardiology, Vol. 14, No. 7, November 2011

Clinical Study Table 1. Patient Characteristics and Prevalence of Dyslipidemia Characteristic

No of Patients [N: 171, (%)]

Dyslipidemia [n (%)]

P value

26(15.2%)

22(84.6%)

< 0.5

89(52%)

72(80.9%)

56(32.8%)

47(83.9%)

Age ( years) <45 46-60 >60 Sex Male

100(58.5%)

85(85%)

Female

71(41.5%)

56(78.9%)

< 0.5

Urban

75(43.9%)

61(81.3%)

Rural

96(56.1%)

80(83.3%)

Locality < 0.5

Control of DM Controlled

33(19.3%)

20(60.6%)

Uncontrolled

138(80.7%)

121(87.7%)

Obese (BMI≥ 23)

117(68.4%)

99(84.6%)

Non Obese (BMI <23)

54(31.6%)

42(77.8%)

Non-hypertensive (<130/85)

130(76%)

106(81.5%)

Hypertensive (≥130/85)

41(24%)

35(85.4%)

< 0.001

Obesity < 0.5

Hypertension < 0.5

Smoking Smoker

45(26.3%)

40(88.9%)

Non-smoker

126(73.7%)

101(80.2%)

<2 years

40(23.4%)

33(82.5%)

2-5 years

58(33.9%)

45(77.6%)

5-10 years

56(32.7%)

48(85.7%)

>10 years

17(9.9%)

15(88.2%)

< 0.5

Duration of DM < 0.5

Table 2. Serum Lipid Levels of Diabetic Patients Serum Lipid

Mean ± SD

Abnormal Value

Deranged Lipid Level n(%)

S.Cholesterol

188.9 ± 43.70

>200 mg/dl

62(36.3%)

S.Triglyceride

174.6 ± 69.44

>150 mg/dl

96(56.1%)

S.HDL

46.2 ± 17.08

<40 mg/dl

61(35.7%)

S.LDL

105.9 ± 34.06

>100 mg/dl

98(57.3%)

S.VLDL

33.4 ± 11.08

>32 mg/dl

85(49.7%)

is characterized by hypertriglyceridemia; low levels of high-density lipoprotein cholesterol; postprandial lipemia; and small, dense low density lipoprotein cholesterol (LDL-C) particles and the occurrence of cardiovascular disease.17-19 The analysis of data from our study provide an opportunity to examine major CAD risk factorAsian Journal of Clinical Cardiology, Vol. 14, No. 7, November 2011

dyslipidemia in population based sample of wellcharacterised type II diabetic individuals. The present study shows very high prevalence of dyslipidemia (82.5%) in ethnic Gujarati diabetic population which recommend the use of terminology - ‘diabetes lipidus’ for them. (Chart 1) Diabetic dyslipidemia is not only prevalent in urban Gujarat (81.3%) as assumed by 231

Clinical Study Deranged Lipid Level %

% Distribution of dyslipidemia in diabetic Patients S.VLDL S. Lipid

82.5%, 141

S.LDL S.HDL

S.Triglyceride S.Cholesterol

17.55%, 30

0.00%

Patients without dyslipidemia

Patients with dyslipidemia

10.00%

S. Cholesterol

Chart 1. Percentage Distribution of Dyslipidemia in Diabetic Patients.

20.00%

30.00% %

S. Triglyceride

40.00%

S. HDL

50.00%

60.00% 70.00%

S. LDL

S. VLDL

Chart 2. Prevalence of Individual Lipid Abnormalities in Diabetics.

Table 3. Age, Obesity, HT, U/R, Specific Prevalence of Dyslipidemia among Diabetic Males and Females Abnormal Lipid Level

S. Cholesterol (>150 mg/l)

S. Triglyceride (>150 mg/dl)

S. HDL (<40 mg/dl)

S. LDL

S. VLDL (>32 mg/dl)

M/F

Age Group

Control of DM

<45 years (n:26)

45-60 years (n:56)

>60 years (n:56)

Controlled Uncontrolled (n:33) (n:138)

Male

8

19

11

6

Female

3

10

11

Total

11(42.3%)

29(32.6%)

Male

13

Female

HT

BMI <23 (n:54)

BMI ≥23 (n:117)

<130/85 (n:126)

≥130/85 (n:41)

31

12

26

31

7

3

24

8

16

19

5

22(39.3%)

9(27.3%

55(39.9%

20(37.1%)

42(35.9%)

27

14

11

51

13

41

44

10

6

24

12

6

33

10

32

32

10

Total

19(50%)

51(57.3%)

84(61.6%)

23(42.6%)

73(62.4%)

Male

8

19

29

13

26

26(46.4%) 17(51.5%) 12

7

9

3

Female

4

9

Total

12(46.2%)

28(32.5%)

Male

10

30

16

Female

4

23

15

Total

14(53.8%)

53(59.6%)

Male

12

26

12

Female

6

18

11

Total

18(69.2%)

44(49.4%)

50(39.7%) 12(29.3%)

76(60.3%) 20(48.8%) 28

11

12

10

20

5

17

49(35.5%)

18(33.3%)

43(36.8%)

9

53

18

38

45

11

6

24

11

31

29

13

77(55.8%)

29(53.7%)

69(59%)

9

44

10

24

41

9

5

26

11

40

26

9

70(50.7%)

21(38.9%)

64(54.7%)

21(37.5)% 10(30.3%)

31(55.4%) 15(45.5%)

23(41.1%) 14(42.4%)

lavish lifestyle of fat and sugar rich food and lesser physical work but it is also increasingly witnessed in rural remote areas in similar proportion (83.3%); which is a worry some scenario. More so, males and females both were showing deranged lipid levels in almost similar numbers (M: 85% and F: 78.9%). So ‘diabetic dyslipidemia’/‘diabetes lipidus’ might become a synonym for diabetes in Gujarati population as a whole with its serious impact on rapidly rising prevalence of CAD in Gujarati’s. 232

Obesity

40(31.7%) 21(51.2%)

74(58.7%) 24(58.5%)

67(53.2%) 18(43.9%)

Another interesting finding observed is that diabetic patients having well controlled blood sugar level were having less prevalence of dyslipidemia. On enrolment most of the diabetic patients were having uncontrolled status (80.7%). 87.7% of these patients were also having dyslipidemia while only 60.6% of controlled or well treated diabetes group were having dyslipidemia (p <0.001). This finding consolidates the theory that strict control of diabetes itself is very necessary for favourable lipid profile. Asian Journal of Clinical Cardiology, Vol. 14, No. 7, November 2011

Clinical Study 80

80

60

60

40

40

20 0

20 <45 Cholesterol

45-60 Triglyceride

0

>60

HDL

LDL

VLDL

Chart 3a. Age specific prevalence of different lipid levels.

<23 Cholesterol

<23 Triglyceride

HDL

LDL

VLDL

Chart 3c. Obesity specific prevalence of different lipid levels.

70 60 50

80 60 40 20 0

40 30 20 10 0

Controlled (n:33) S. Cholesterol S. Triglyceride

Uncontrolled (n:138) S. HDL

S. LDL

S. VLDL

Chart 3b. Control od DM.

The analysis of individual lipid levels shows that the mean levels of all lipids were in abnormal range except S. HDL level (Table 2), which is surprising as it is quite low in many studies on diabetic patients. There has been a recent focus on the characteristic dyslipidemia of type II diabetes, which includes elevated triglycerides, low HDL cholesterol, and a preponderance of small dense LDL particles. These characteristics were highly prevalent in diabetic participants in this cohort. Hypertriglyceridemia (56.1%) and high S.LDL level (57.3%) were noted in large number of patients in our study as observed in almost all studies done in diabetic patients but the prevalence of these abnormalities is quite high in Gujarati diabetic population in comparison to low S. HDL levels (35.7%) which is considered as one of the major component of diabetes dyslipidemia. Hypercholesterolemia (36.3%) and high level of S.VLDL (49.7%) were also found in large number of patients (Table 2). In our study, most of the diabetic patients had mixed dyslipidemia i.e. more than one lipid abnormality. The most common mixed abnormality detected was hypertriglyceridemia and high LDL level (39.1%) which is different from our western counterparts Asian Journal of Clinical Cardiology, Vol. 14, No. 7, November 2011

non HT Cholesterol

Triglyceride

HT HDL

LDL

VLDL

Chart 3d. Hypertension specific prevalence of different lipid levels.

showing hypertriglyceridemia and low S. HDL as major abnormality. The S. LDL levels were not found to be very high in most of these studies as they had used more relaxed cut of point of â&#x2030;Ľ130 for S. LDL.4,5 Individually also these two abnormalities (hypertriglyceridemia and high LDL level) are considered as major CAD risk factor, so both together in diabetic patients can be considered as very critical CAD risk factor and needs very prompt management for the prevention of CAD. The other types of mixed dyslipidemia observed in our study were (1) hypercholesterolemia with high LDL level (2) hypertriglyceridemia with hypercholesterolemia. All lipid levels were found to be deranged in 10.5% of the diabetic patients, suggesting very high rate of severe form of dyslipidemia in diabetic patients. So we suggest not to concentrate on any specific lipid level in Indian diabetic patients but to analyse the complete lipid profile as a whole and to start intensive therapy for the same as early as possible. We had also done subgroup analysis for dyslipidemia in these patients according to non modifiable and modifiable confounding factors that might affect 233

Clinical Study dyslipidemia. Young diabetic patients (<45 years of age) had similar prevalence of dyslipidemia (84.6%) as older group (83.9%), which is very dangerous trend correlating with higher rate of CAD in younger Indian population with statistically insignificant difference (p <0.5) (Table 1). Hypertriglyceridemia and high LDL levels were observed in all age groups. Obesity (BMI ≥23 as per IDF, Modified ATP III criteria for South Asian population) better termed as ‘Diabesity’ is seen in 68.4 % of diabetic patients which is similar to our previous study on prevalence of diabesity in Gujarati population.9 A very high rate of dyslipidemia (84.6%) was observed in patients with diabesity which suggests that obesity, diabetes and dyslipidemia - all major CAD risk factors go hand in hand in Gujarati population. As observed in all other subgroups, hypertriglyceridemia and high LDL levels were also noted in diabesity group. But more surprisingly even non obese diabetic patients were also having high prevalence of dyslipidemia (75.9%) with similar pattern as obese patients without any statistically significant difference (p <0.5). In diabetic hypertensive subgroup of patients, 82.9% of patients were having deranged lipid levels while non hypertensive DM group was also showing similar trend (81.5%) with similar type of dyslipidemia. Similarly urbanised life style was found to have little impact on prevalence and pattern of dyslipidemia in diabetic patients. Both urban and rural diabetic population were showing almost 82% prevalence of dyslipidemia. Other confounding factors like smoking and duration of diabetes also failed to show any statistically significant difference (p <0.5) on prevalence and type of dyslipidemia in diabetic patients. So from the subgroup analysis, it can be interpreted that diabetes itself is responsible for very high rate dyslipidemia as well as for particular pattern of dyslipidemia by mechanism of insulin resistance. Age, duration of diabetes, obesity, hypertension like confounding factors were not able to influence the prevalence and pattern of diabetic dyslipidemia in our study. Only proper control of diabetes has shown statistically significant difference (p <0.001) on prevalence and severity of dyslipidemia, consolidating the fact that the proper treatment and strict control of diabetes is the most important step in prevention and treatment of complications of diabetes. 234

As shown in our study, dyslipidemia in diabetes-very critical CAD risk factor is having a high prevalence in Gujarati population, but surprisingly only very few diabetic patients (14.3%) were investigated for their lipid profile in past. For this reason, we strongly recommend detailed lipid profile to be done for each and every diabetic patient at the time of diagnosis and regularly on follow up. Conclusion Our study highlighted the very high prevalence of dyslipidemia associated with diabetes as one of the highest ranked risk factor for CAD in Indians, especially Gujarati population. One or another lipid level is found to be abnormal in most of the diabetic patients, suggesting that whole of the lipid profile must be done and evaluated at regular intervals in these patients. Present study also highlights the importance of strict control of diabetes in prevention and treatment of dyslipidemia associated with diabetes as dyslipidemia is more frequent in uncontrolled diabetic patients than controlled ones. It is of paramount importance to aim for the stricter goals and specific thresholds for dyslipidemia in Indian diabetic patients to start early and prompt preventive measures to reverse the tide of the rising CAD epidemic in Asian Indians. References 1. Shaw JE, et al. Global estimates of the prevalence of diabetes for 2010 and 2030. Diabetes Res Clin Pract 2010;87:4-14. [PubMed: 19896746] 2. Health situation in the South East Asia Region 19982000. WHO Regional office for South East Asia 2002; New Delhi. 3. American Heart Association. Heart Disease and Stroke Statistics-2008 Update. Dallas, Texas: American Heart Association; 4. UK Prospective Diabetes Study 27: Plasma lipids and lipoproteins at diagnosis of NIDDM by age and sex. Diabetes Care 1997;20:1683-1687. 5. Cowie CC, Howard BV, Harris MI. Serum lipoproteins in African Americans and Whites with non-insulindependent diabetes in the US population. Circulation. 1994;90:1185-1193. 6. Pyorala K, Pedersen TR, Kjekshus J, Faergeman O, Olsson AG, Thorgeirsson G. Cholesterol lowering with simvastatin improves prognosis of diabetic patients with coronary heart disease. Diabetes Care 1997;20:614-­620. Asian Journal of Clinical Cardiology, Vol. 14, No. 7, November 2011

Clinical Study 7. Sacks FM, Pfeffer AM, Moye LA, Rouleau JL, Rutherford JD, Cole TG, Brown L, Warnica JW, Arnold JMO, Wun C-C, Davis BR, Braunwald E. The effect of pravastatin on coronary events after myocardial infarction in patients with average cholesterol levels. N Engl J Med. 1996;335:1001-1009. 8. Downs JR, Clearfield M, Weis S, Whitney E, Shapiro DR, Beere PA, Langendorfer A, Stein EA, Kruyer W, Gotto AM Jr. Primary prevention of acute coronary events with lovastatin in men and women with average cholesterol levels: results of AFCAPS/TexCAPS: Air Force/Texas Coronary Atherosclerosis Prevention Study. JAMA. 1998;279:1615-1622. 9. Pandya H, Lakhani JD, Patel N. Obesity is becoming synonym for diabetes in rural areas of India also â&#x20AC;&#x201C; an alarming situation. Int J Biol Med Res 2011;2(2):556-60. 10. Joshi A, Bhugra P, Lakhani J, Desai S. Body mass index and central obesity in Hypertensive patients. Guj

Med Jr 2004;61(03):33-36.

11. Misra A, Pandey RM, Devi J R, Khannav N, Sharma R. High prevalence of diabetes, obesity and dyslipidemia in urban slum population in northern India. Int obes Relat Metab Disord 2001;25:1722-9. 12. Mishra A. Khurana L. obesity and metabolic syndrome in developing countries. J Clin Endocriol Metab 2008; 93:59-30.

13. Ramachandran A, Snehalatha C, Satyavani K, Vijay V. Metabolic syndrome in urban Asian Indian adults â&#x20AC;&#x201C; A population study using modified ATP III criteria. Diab Res Clin Pract 2003;60:199-204. 14. Mohan V, Shanthirani S, Deepa R, Deepa M. Intra-urban differences in the prevalence of metabolic syndrome in southern India the Chennai Urban population study. Diabetic Medi 2005;18:280-7. 15. Expert panel on Defection, Evaluation and Treatment of High Blood Cholesterol in Adults. Executive Summary of the Third Report of the National Cholesterol Education program (NCEP) Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) JAMA 2001;285:2486-97. 16. American Diabetes Association: Clinical practice recommendations 2007 Diabetes Care 2007;30:S4. 17. Campos H, Moye LA, Glasser SP, Stampfer MJ, Sacks FM: Lowdensity lipoprotein size, pravastatin treatment, and coronary events. JAMA 2001;286:1468-74. 18. Sacks FM, Campos H: Low-density lipoprotein size and cardiovascular disease: a reappraisal. J Clin Endocrinol Metab 2003;88:4525-32. 19. Jungner I, Sniderman AD, Furberg C, Aastveit AH, Holme I, Walldius G: Does low-density lipoprotein size add to atherogenic particle number in predicting the risk of fatal myocardial infarction? Am J Cardiol 2006; 97:943-6.

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clinical practice

Role of Thrombectomy and Embolic Protection Devices in Acute ST Elevation Myocardial Infarction Anupam Goel

Abstract Primary angioplasty is the established and recommended treatment for acute ST elevation myocardial infarction (STEMI). Unfortunately macro-and microembolization during primary percutaneous coronary intervention (PCI) are frequent and may result in obstruction of microvascular network with subsequent reduction in reperfusion efficacy. Techniques that have been used to reduce these events in addition to multiple pharmacological measures include thrombectomy devices (aspirational or mechanical) and embolic protection devices. Key words: Thrombectomy devices, primary angioplasty, ST elevation myocardial infarction, percutaneous coronary intervention, embolic protection

P

rimary angioplasty is the established and recommended treatment for acute ST elevation myocardial infarction (STEMI). Unfortunately macro-and microembolization during primary percutaneous coronary intervention (PCI) are frequent and may result in obstruction of microvascular network with subsequent reduction in reperfusion efficacy. Out of the multiple factors postulated for slow flow, the presence and size of the thrombus in coronary artery bed is the most powerful predictor of slow flow or no flow. Techniques that have been used to reduce these events in addition to multiple pharmacological measures include thrombectomy devices (aspirational or mechanical) and embolic protection devices. Catheter thrombus aspiration is done by low profile catheter that is advanced to the thrombus and the aspiration is performed through the syringe suction. The devices available are:  Export thrombo suction device  Pronto  Diver  Rescue  TVAC Mechanical aspiration devices apply energy through saline jets or rotating catheter to facilitate breakup of the thrombus which is then aspirated these include: Consultant Interventional Cardiology Max Heart & Vascular Institute, Saket, New Delhi

236

 

Angiojet X-sizer

Embolic protection devices employ an occlusive balloon or filter that is advanced distal to the thrombus on it own guide wire and PCI is performed. Available embolic protection devices are: Percusurge guard wire (uses balloon occlusion)  Filter wire  SpideRX  Angioguard Despite the understandable benefits of reducing embolic showers during primary PCI, these adjunctive coronary devices have not been consistently shown to be useful. There have been large numbers of trials studying the role of these devices in primary PCI but unfortunately till now we do not have any set guidelines regarding their use. This is primarily because of small size of the trials and heterogenous inclusion criteria and use of surrogate markers of coronary perfusion like TIMI blush grade, LV systolic function and peri- procedural adverse events as a marker of better myocardial perfusion. In the AIMI multicentre trial,1 480 patients were randomized to thrombectomy with Angiojet versus conventional PCI. The primary end-point was infarct size estimated by technetium-99m sestamibi. This trial showed a paradoxically larger infarct size and higher mortality in patients treated with thrombectomy in comparison with conventional primary angioplasty. Asian Journal of Clinical Cardiology, Vol. 14, No. 7, November 2011

Clinical Practice In a Danish single centre trial,2 215 STEMI patients were randomized to rescue catheter or conventional PCI. No benefit was observed in terms of ST segment resolution. In VAMPIRE3 trial presented in 2005 in annual meeting of AHA, 368 patients were randomized to TVAC or conventional angioplasty. Thrombectomy was associated with better myocardial perfusion and less distal embolization despite no impact on 30-day survival. In accordance with the VAMPIRE trial,4-6 several small randomized studies including the study by De Luca et al have shown that thrombectomy devices improved myocardial perfusion and reduced distal embolization. Luca and colleagues7 reported the results of their randomized trial to investigate the impact of adjunctive use of manual aspiration thrombectomy (Diver) on myocardial perfusion and left ventricular remodelling. A total of 78 patients with anterior STEMI and clear angiographic evidence of intracoronary thrombus were randomized to conventional primary PCI versus adjunctive aspiration thrombectomy. All patients were treated with stenting and glycoprotein IIb/IIIa inhibitors. The primary end point of the study was left ventricular remodeling. This trial showed significant benefits with adjunctive thrombectomy in terms of myocardial perfusion (evaluated by ST segment resolution and myocardial blush) and left ventricular remodeling, without benefits in clinical outcome. Interestingly, the use of thrombectomy largely favored a strategy of direct stenting (92.1% vs 5.3% in control group). Thrombus Aspiration with Export Catheter in ST Elevation Myocardial Infarction trial,8 published in 2007, studied the safety and efficacy of the EXPORT catheter for thrombus aspiration in patients with STEMI in 129 patients. It revealed significant improvement in TIMI frame count and myocardial perfusion and TIMI flow in these patients. Recently, Bavry et al9 published a meta-analysis involving a total of 30 studies with 6,415 patients in whom thrombectomy devices or embolic protection devices have been used. Over a mean follow-up of 5 months, mortality among all studies was 3.2% for the adjunctive device group versus 3.7% for PCI alone. Asian Journal of Clinical Cardiology, Vol. 14, No. 7, November 2011

Among thrombus aspiration studies, mortality was 2.7% for the adjunctive device group versus 4.4% for PCI alone, for mechanical thrombectomy, mortality was 5.3% for the adjunctive device group versus 2.8% for PCI alone, and for embolic protection, mortality was 3.1% for the adjunctive device group versus 3.4% PCI alone. In summary, not all adjunctive thrombectomy devices are similar. Specifically, catheter thrombus aspiration devices appear to be the most attractive group by significantly reducing mortality, compared with PCI alone. There is no obvious benefit or harm with embolic protection devices; therefore, the coronary utility of these devices remains in the revascularization of saphenous vein grafts in stable patients. TIMI blush grade and ST-segment resolution are limited in their ability to act as surrogate markers and therefore they should not be used solely in place of clinical outcomes in designing future acute myocardial infarction studies. Until data from additional larger randomized trials become available; the adjunctive use of thrombectomy devices in primary angioplasty for STEMI has to be individualized and should be used only in patients with evident large thrombus load. References 1. Ali A. Angiojet reolitic thrombectomy. Patients undergoing primary angioplasty for acute myocardial infarction â&#x20AC;&#x201C; The AIMI Study. www.tctmd.com (Accessed 28 May 2005). 2. Kaltoft A, Bottcher M, Nielsen SS, et al. Thrombectomy as an adjunct to percutaneous coronary intervention in ST-segment elevation myocardial infarction. A prospective randomized controlled trial. 3. Ikari Y, Kawano S, Sakurada M, et al. Thrombus aspiration prior to coronary intervention improves myocardial microcirculation in patients with ST elevation acute myocardial infarction: the VAMPIRE study. Circulation 2005;112(suppl II):659. 4. De Luca L, Sardella G, Davidson CJ, et al. Impact of intracoronary aspiration thrombectomy during primary angioplasty on left ventricular remodelling in patients with anterior ST elevation myocardial infarction. Heart 2006;92:951-7. 5. Dudek D, Mielecki W, Legutko J, et al. Percutaneous thrombectomy with the RESCUE system in acute myocardial infarction. Kardiol Pol 2004;61:523-33.

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Expert Opinion

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

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ietary salt has long been recognized as a major factor affecting blood pressure such that sodium intake is a component of lifestyle modification guidelines for control of high blood pressure.1 Almost all national and international organizations recommend moderate decrease in dietary salt intake as part of the nonpharmacologic approach to managing hypertension. The 2003 Seventh Joint National Committee (JNC-7) guidelines advocate cutting down on salt intake in diet from the customary 150-200 mEq/day down to 100 mEq/day (approximately 2.3 g of sodium or 6 g of sodium chloride).2 Likewise, the European Society of Hypertension (ESH) has also laid down cut-off values for dietary salt intake. The 2007 ESH guidelines recommend dietary salt intake of <85 mEq/ day (2.0 g of sodium).3 About 80% of the salt in diet is obtained from the salt that is added in food and drink processing. Therefore, reducing the amount of salt added by food processors is the most feasible method to obtain significant, population-wide decrease.4 A regulatory intervention to promote a populationwide decrease in intake of dietary salt by 3 g/day results in significant savings in quality-adjusted life years and in healthcare costs annually. Such an intervention would be cost-saving even if only a modest reduction of 1 g/day were achieved gradually between 2010 and 2019, and would be more cost-effective than using medications to lower blood pressure in all persons with hypertension.5 The projected benefits of reducing salt by 3 g/day in the US study were as follows: Decline in the number of new cases of myocardial infarctions by upto 99,000, coronary heart disease by upto 1,20,000 and stroke by upto 66,000 annually.

Fall in the number of deaths due to any cause by upto 92,000 annually. Healthcare cost saving of upto 24 billion annually. These projected cardiovascular benefits are similar to those of population-wide reductions in smoking, obesity and cholesterol. Hence, modest reductions in dietary salt could substantially reduce cardiovascular events and medical costs and should be a public health target.5 One gram of sodium = 44 mEq; 1 g of sodium chloride contains 17 mEq of sodium. References 1. Lackland DT, Egan BM. Dietary salt restriction and blood pressure in clinical trials. Curr Hypertens Rep 2007;9(4):314-9. 2. Chobanian AV, Bakris GL, Black HR, et al. National Heart, Lung, and Blood Institute JNC on Prevention, Detection, Evaluation, and Treatment of High BP; National High BP Education Program Coordinating Committee. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: The JNC 7 report. JAMA 2003;289(19):2560-72. 3. Mancia G, De Backer G, Dominiczak A, et al. 2007 Guidelines for the Management of Arterial Hypertension: The Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). J Hypertens 2007;25(6):1105-87. 4. Engstrom A, Tobelmann RC, Albertson AM. Sodium intake trends and food choices. Am J Clin Nutr 1997;65(2 Suppl):704S-707S. 5. Bibbins-Domingo K, Chertow GM, Coxson PG, et al. Projected effect of dietary salt reductions on future cardiovascular disease. N Engl J Med 2010;362(7):590-9.

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practice guidelines

International Consensus Group Issues Recommendations for Management of Upper GI Bleeding

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he clinical and economic burden of upper gastrointestinal (GI) bleeding is considerable, with the annual incidence ranging from 48 to 160 cases per 100,000 adults and mortality rates ranging from 10 to 14 percent. In response to new data that may lead to improved patient outcomes, the International Consensus Upper Gastrointestinal Bleeding Conference Group-a multidisciplinary group of 34 experts from 15 countries-developed international guidelines for managing nonvariceal upper GI bleeding. The guidelines include new recommendations, as well as updates to the 2002 guidelines from the British Society of Gastroenterology and the 2003 consensus guidelines from the Nonvariceal Upper GI Bleeding Consensus Conference Group. The evidence rating system implemented is defined as follows: 1A = strong recommendation, highquality evidence; 1B = strong recommendation, moderate-quality evidence; 1C = strong recommendation, low- or very low-quality evidence; 2A = weak recommendation, high-quality evidence; 2B = weak recommendation, moderate-quality evidence; 2C = weak recommendation, low- or very lowquality evidence. Grade 1 recommendations should be interpreted as “do it” or “do not do it”; grade 2 recommendations should be interpreted as “probably do it” or “probably do not do it.” Resuscitation, Risk Assessment, and Pre-endoscopy Management Revised recommendation: Prognostic scales are recommended for early stratification of patients into low- and high-risk categories for rebleeding and mortality. (Grade: 1C) Early identification of high-risk patients can facilitate appropriate intervention, which minimizes morbidity and mortality. Stratification should be based on clinical, laboratory, and endoscopic criteria. Predictors of increased risk of rebleeding include age older than 65 years; shock; poor overall health; comorbid illnesses; low initial hemoglobin (Hgb) levels; melena; transfusion requirement; fresh 240

red blood on rectal examination, in the emesis, or in the nasogastric aspirate; sepsis; and elevated urea, creatinine, or serum transaminase levels. New recommendation: Blood transfusions should be administered in patients with an Hgb level of 7 g per dL (70 g per L) or less. (Grade: 1C) Patients should be considered for transfusion based on their underlying condition, hemodynamic status, and markers of tissue hypoxia in acute situations. Red blood cell transfusion is rarely needed in patients with an Hgb level greater than 10 g per dL (100 g per L) and is usually needed when the Hgb level is less than 6 g per dL (60 g per L). New recommendation: In patients receiving anticoagulants, correction of coagulopathy is recommended, but should not delay endoscopy. (Grade: 2C) Available data suggest that it may not be necessary to delay endoscopy in patients with mild to moderate coagulopathy. One study of patients undergoing endoscopy found no difference in rebleeding, surgery, mortality, or complication rates between patients receiving warfarin (Coumadin) and those not receiving anticoagulants. New recommendation: Promotility agents should not be used routinely before endoscopy to increase the diagnostic yield. (Grade: 2B) Although promotility agents may be useful in selected patients with suspected blood in the stomach, they are not recommended for routine use in patients with upper GI bleeding. Revised recommendation: Selected patients with acute ulcer bleeding who are at low risk of rebleeding on the basis of clinical and endoscopic criteria may be discharged promptly after endoscopy. (Grade: 1A) One randomized controlled trial (RCT) assessing the role of early discharge in low-risk patients found no difference in rates of recurrent bleeding. None of the patients who were discharged early experienced serious adverse events, underwent surgery, or died during the 30-day follow-up. Asian Journal of Clinical Cardiology, Vol. 14, No. 7, November 2011

practice guidelines Revised recommendation: Pre-endoscopic proton pump inhibitor (PPI) therapy may be considered to downstage the endoscopic lesion and decrease the need for endoscopic intervention, but should not delay endoscopy. (Grade: 1B) PPI therapy may be useful, especially in patients suspected to have highrisk stigmata. However, it has not been shown to affect rebleeding, surgery, or mortality. Endoscopic Management Revised recommendation: Early endoscopy (within 24 hours of presentation) is recommended for most patients with acute upper GI bleeding. (Grade: 1B) Early endoscopy has been shown to be safe and effective in all risk groups, although it may need to be delayed or deferred in certain high-risk patients, such as those with active acute coronary syndrome or suspected perforation. Revised recommendation: The finding of a clot in an ulcer bed warrants targeted irrigation to attempt dislodgement, with appropriate treatment of the underlying lesion. (Grade: 2B) Revised recommendation: The role of endoscopic therapy for ulcers with adherent clots is controversial. Intensive PPI therapy alone may be sufficient. (Grade: 2B) Endoscopic therapy for adherent clots involves preinjecting with epinephrine before shaving, followed by applying combination treatment to the remaining stigmata of hemorrhage. A meta-analysis of five RCTs involving patients with adherent clots found no significant benefits for endoscopic therapy compared with no endoscopic therapy. Revised recommendation: Epinephrine injection alone provides suboptimal effectiveness and should be used in combination with another method. (Grade: 1B) Revised recommendation: Clips, thermocoagulation, or sclerosant injection should be used in patients with high-risk lesions, alone or in combination with epinephrine injection. (Grade: 1A) Meta-analyses showed that adding a second procedure (e.g., an injection of alcohol, thrombin, or fibrin glue; thermal contact; clips) to epinephrine injection is superior to epinephrine injection alone. Adding a second procedure for high-risk stigmata significantly reduced rebleeding, surgery, and mortality compared with epinephrine monotherapy. Asian Journal of Clinical Cardiology, Vol. 14, No. 7, November 2011

Revised recommendation: Routine second-look endoscopy is not recommended. (Grade: 2B) The most recent data do not show a benefit with second-look endoscopy (i.e., a preplanned systematic endoscopy performed 16 to 24 hours after initial endoscopy). When available, high-dose intravenous PPI therapy is the current standard. Patients with high-risk presentations may benefit from second-look endoscopy, but more research is needed. Pharmacologic Management Revised recommendation: An intravenous bolus followed by continuous-infusion PPI therapy should be used to decrease rebleeding and mortality in patients with high-risk stigmata who have undergone successful endoscopic therapy. (Grade: 1A) Strong evidence supports the use of high-dose intravenous PPI therapy following successful endoscopy. No conclusions may be made at this time regarding low-dose intravenous PPI therapy or high-dose oral PPI therapy. New recommendation: Patients should be discharged with a prescription for a single daily dose oral PPI; the duration should be dictated by the underlying etiology. (Grade: 1C) Once-daily PPI therapy has been shown to be effective in patients with peptic ulcer disease. However, some studies demonstrate relatively low healing rates for complicated or severe esophagitis, and twice-daily doses may be needed. Nonendoscopic and Nonpharmacologic In-Hospital Management New recommendation: Most patients who have undergone endoscopic hemostasis for high-risk stigmata should remain hospitalized for at least 72 hours. (Grade: 1C) Studies show that after endoscopic therapy, it takes 72 hours for most high-risk lesions to become low-risk lesions. More research is needed to determine whether selected high-risk patients may be treated in the outpatient setting. New recommendation: Where available, percutaneous embolization can be considered as an alternative to surgery in patients for whom endoscopic therapy has been unsuccessful. (Grade: 2C) Percutaneous or transcatheter arterial embolization may be considered as an alternative to surgery, especially in patients who are high-risk candidates for surgery. Although uncommon, possible complications include bowel 241

practice guidelines ischemia; secondary duodenal stenosis; and gastric, hepatic, and splenic infarction. Revised recommendation: Patients with bleeding peptic ulcers should be tested for Helicobacter pylori and receive eradication therapy if it is present, with confirmation of eradication. (Grade: 1A) New recommendation: Negative H. pylori diagnostic tests obtained in the acute setting should be repeated. (Grade: 1B) Diagnostic tests for H. pylori (e.g., serology, histology, urea breath test, rapid urease test, stool antigen, culture) may show increased false-negative rates in patients with acute bleeding; therefore, repeat testing after an initial negative result is needed. Postdischarge, Aspirin, and NSAIDs New recommendation: In patients with previous ulcer bleeding who require a nonsteroidal anti-inflammatory drug (NSAID), treatment with a traditional NSAID plus PPI or a cyclooxygenase-2 (COX-2) inhibitor alone is associated with a clinically important risk of recurrent bleeding. (Grade: 1B) New recommendation: In patients with previous ulcer bleeding who require an NSAID, the combination of a PPI and a COX-2 inhibitor is recommended to reduce the risk of recurrent bleeding compared with COX-2 inhibitors alone. (Grade: 1B) Adding a PPI to traditional NSAID therapy is recommended to

reduce the risk of upper GI complications, although the combination of a COX-2 inhibitor plus a PPI was associated with the greatest reduction in risk. Other studies found a decreased risk of endoscopic ulcers with a COX-2 inhibitor plus a PPI, compared with a COX-2 inhibitor alone. New recommendation: In patients who take lowdose aspirin and develop acute ulcer bleeding, aspirin therapy should be restarted as soon as the risk of cardiovascular complication is thought to outweigh the risk of bleeding. (Grade: 1B) Discontinuing aspirin therapy for an extended period increases thrombotic risk in patients who require cardio-protective aspirin therapy. One meta-analysis showed that nonadherence or withdrawal of aspirin therapy is associated with a threefold risk of major adverse cardiac events. According to the American Heart Association, the decision to discontinue aspirin therapy in patients with acute ulcer bleeding should be made on an individual basis. New recommendation: In patients with previous ulcer bleeding who require cardiovascular prophylaxis, clopidogrel (Plavix) alone has a higher risk of rebleeding than aspirin combined with a PPI. (Grade: 1B) Two RCTs showed a significant reduction in rebleeding in patients taking aspirin plus a PPI compared with those receiving clopidogrel alone, although there was no significant effect on mortality. n

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(...Contâ&#x20AC;&#x2122;d from page 237) 6. Antoniucci D, Valenti R, Migliorini A, et al. Comparison of rheolytic thrombectomy before direct infarct artery stenting versus direct stenting alone in patients undergoing percutaneous coronary intervention for acute myocardial infarction. Am J Cardiol 2004;93:1033-5.

for acute myocardial infarction: a meta-analysis of randomized trials. Am Heart J 2007;153(3):343-53. 8. Thrombus Aspiration with Export Catheter in ST Elevation Myocardial Infarction. Journal of Interventional Cardiology published online: 30 January 2007.

7. De Luca G, Suryapranata H, Stone GW, Antoniucci D, Neumann FJ, Chiariello M. Adjunctive mechanical devices to prevent distal embolization in patients undergoing mechanical revascularization

9. Bavry AA, Kumbhani DJ, Bhatt DL. Role of adjunctive thrombectomy and embolic protection devices in acute myocardial infarction: a comprehensive meta-analysis of randomize trials. Eur Heart J 2008;29:2989-3001.

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Research Review

From the Journals ...

Reducing Perioperative Events During Vascular Surgery Background: Patients undergoing noncardiac vascular surgery have a high risk of postoperative cardiac events attributed to underlying coronary artery disease and related inflammation. Other studies have shown that statins can reduce inflammation; therefore, it is possible that they could also prevent coronary plaque rupture, even in patients who have not required statin therapy for hyperlipidemia. The Study: For the DECREASE III (Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography III) study, Schouten and colleagues recruited patients older than 40 years who were not currently being treated with a statin and who were scheduled for non-emergent, noncardiac vascular surgery (e.g., abdominal aortic aneurysm repair, carotid endarterectomy, or aortoiliac or lower-limb arterial reconstruction). In addition to receiving perioperative beta blockers, patients were randomized to receive placebo or extended-release fluvastatin (Lescol) in a dosage of 80 mg per day. The study medication was

started at a median of 37 days before surgery and continued for at least 30 days after surgery. Patients were excluded if they had unstable coronary artery disease or had undergone surgery within the previous 30 days. The primary outcome was myocardial ischemia within 30 days after surgery. Results: Twenty-seven (10.8 percent) of the 250 patients in the fluvastatin group developed myocardial ischemia, compared with 47 (19.0 percent) of the 247 patients in the control group (hazard ratio [HR] = 0.55; number needed to treat [NNT] = 12). Patients taking fluvastatin were less likely to experience cardiovascular death or nonfatal myocardial infarction than those in the control group (4.8 versus 10.1 percent, respectively; HR = 0.47; NNT = 19). There were no significant differences in rates of creatine kinase or alanine transaminase elevation between groups. Conclusion: The authors conclude that perioperative fluvastatin therapy, in addition to beta-blocker therapy, leads to significant improvement in the rates of postoperative cardiac outcomes in patients undergoing noncardiac vascular surgery. n

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Emedinews Section

From eMedinewS

FDA Approves Device for Nonsurgical Aortic Valve Repair He FDA approved the Sapien Transcatheter Heart Valve for treatment of patients too sick to undergo open-heart surgery to repair calcified aortic valves. The Sapien valve, from Edwards Lifesciences, is a replacement valve that doesn’t require major surgery. The Sapien valve is approved for patients who are not eligible for open-heart surgery for replacement of their aortic valve and have a calcified aortic annulus. The product label advises that a heart surgeon should be involved in determining if the Sapien valve is an appropriate treatment for the patient. It is not approved for patients who can be treated by open-heart surgery. (Source: Medpage Today) Indian Foods that Cut Fat You don’t have to acquire a taste for olive oil, seaweed or soya to maintain a low-fat, healthy diet. Indian cuisine can be healthy too, if it’s cooked with oil and ingredients that take care of your heart and health. Ayurveda suggests you include all tastes - sweet, sour, salty, pungent, bitter and astringent in at least one meal each day, to help balance unnatural cravings. Turmeric

Curcumin, the active component of turmeric, is an object of research owing to its properties that suggest it may help to turn off certain genes that cause scarring and enlargement of the heart. Regular intake may help reduce low-density lipoprotein (LDL) or bad cholesterol and high blood pressure, increase blood circulation and prevent blood clotting, helping to prevent heart attack. Garlic

An effective fat-burning food, garlic contains the sulfur compound allicin, which has anti-bacterial effects and helps reduce cholesterol and unhealthy fats. 244

Cardamom

This is a thermogenic herb that increases metabolism and helps burn body fat. Cardamom is considered one of the best digestive aids and is believed to soothe the digestive system and help the body process other foods more efficiently. Chillies

Foods containing chillies are said to be foods that burn fat. Chillies contain capsaicin that helps in increasing the metabolism. Capsaicin is a thermogenic food, so it causes the body to burn calories for 20 minutes after you eat the chillies. Curry leaves

Incorporating curry leaves into your daily diet can help you lose weight. These leaves flush out fat and toxins, reducing fat deposits that are stored in the body, as well as reducing bad cholesterol levels. If you are overweight, incorporate eight to 10 curry leaves into your diet daily. Chop them finely and mix them into a drink, or sprinkle them over a meal. —Rajat Bhatnagar, International Sports and Fitness Distribution, LLC

Vitamin B1, Plasma Thiamine, or thiamin, sometimes called aneurin, is a water-soluble vitamin of the B complex (vitamin B1), whose phosphate derivatives are involved in many cellular processes. Thiamine deficiency can lead to myriad problems including neurodegeneration, wasting and death. 

A lack of thiamine can be caused by malnutrition, a diet high in thiaminase-rich foods (raw freshwater fish, raw shellfish, ferns) and/or foods high in antithiamine factors (tea, coffee, betel nuts) and by grossly impaired nutritional status associated with chronic diseases, such as alcoholism, gastrointestinal diseases, HIV-AIDS, and persistent vomiting. Asian Journal of Clinical Cardiology, Vol. 14, No. 7, November 2011

eMedinewS Section 

It is thought that many people with diabetes have a deficiency of thiamine and that this may be linked to some of the complications that can occur. Well-known syndromes caused by thiamine deficiency include beriberi and Wernicke-Korsakoff syndrome, diseases also common with chronic alcoholism.

—Dr Arpan Gandhi and Dr Navin Dang

Legal Question I am an India citizen. I graduated in medicine from China. I have been offered a scholarship to pursue postgraduation in Orthopedics in China without paying any fees. The university is recognised by WHO but not by the MCI. Will I face any problem if I work in the private sector in India as an orthopedician? Can I get a diploma in orthopedics from India while I am working for my postgraduate degree in China? Please give me career guidance.

—Dr M C Gupta, Advocate

What is hide and die syndrome? 

Ans. 

The question of your practicing medicine in India does not arise unless you are registered with the medical council in India. If you want to work in India as a doctor, this is a must. You should get in touch with the MCI to find if there is a way to get registered. If you don’t get a licence to practice medicine in India, the only option to pursue medical career for you is to get your PG degree in China and work there or in some other country that may allow you to work there. If you get an Indian licence and, after getting it, you still want to get your PG degree from China because it is free, you may do so and, afterwards, do one of the two things:

EITHER come back and try to get D Orth, MS or DNB in India;

OR, go to USA, Canada, UK, Australia or New Zealand and get a degree in ortho from any of these 5 countries because it would be recognised in India if it is recognised by the medical council of the country concerned.

If you are not a registered medical practitioner in India on the basis of medical graduation, it is

Asian Journal of Clinical Cardiology, Vol. 14, No. 7, November 2011

doubtful that you would be permanently registered with the medical council in India on the basis of a PG degree from the 5 countries as mentioned above. It is possible that even if you do not get registered with the MCI and obtain a PG degree from any one of the 5 countries, and if you want to work in India as a medical teacher or researcher or a doctor working in a charitable institution, then, as per the MCI Act, 1956, you can be given temporary registration in India.

There is a peculiar aspect to some cases of hypothermic deaths in that it is associated with the victim undressing and hiding away from sight. The subject is usually an old person, man or woman. The person is usually found dead at home partly or even completely without clothing even in winter or in a cold environment. The victim may have burrowed his or her way into some corner or cupboard or alternatively pulled down furniture or household article into the body. The house may be in such a situation of disorder that when police break in and find a dead body among such a chaos, they may naturally suspect a case of robbery and murder. The sign of hypothermia is usually present during autopsy. There is variation in the adrenaline/noradrenaline ratio, a manifestation of stress induced by low temperature along with other biomedical markers of hypothermia. —Dr Sudhir Gupta, Additional Prof, Forensic Medicine and Toxicology, AIIMS Ref: Knight’s Forensic Pathology

What the National Drug Policy of India says How to Report Cases of Malaria?

Malaria is currently not a notifiable disease in India, but it important that private providers inform the Government malaria services about malaria cases seen every fortnight. Suitable formats for this can 245

eMedinewS Section be obtained from district medical officers. Whenever an increase in the number malaria cases, this should local health authorities.

malaria officers or block a private provider observes of suspected or confirmed be intimated urgently to

What are the criteria for referral to a Referral Hospital? 

Cerebral malaria patients not responding to initial anti-malarial treatment.

Severe anemia warranting blood transfusion

Bleeding and clotting disorder

Hemoglobinuria

Pulmonary edema

Cerebral malaria complicating pregnancy

Oliguria not responding after correction of fluid deficit and diuretics Fluid, electrolyte and acid-base disturbance

What are the symptoms for immediate referral of a malaria case to a higher level healthcare facility? The management of severe malaria requires immediate administration of life-saving drugs. Therefore essential requirements for management of severe malaria are as follows: 

Persistence of fever after 48 hours of initial treatment Continuous vomiting and inability to retain oral drugs

Headache continues to increase

Severe dehydration-dry, parched skin, sunken face

Too weak to walk in the absence of any other obvious reason Change in sensorium e.g. confusion, drowsiness, blurring of vision, photophobia, disorientation

Convulsions or muscle twitching

Bleeding and clotting disorders

Suspicion of severe anemia

Jaundice

Hypothermia AC Dhariwal, Hitendrasinh G Thakor, Directorate of NVBDCP, New Delhi

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How is a case of Hepatitis C diagnosed?  A screening antibody test such as an Enzyme immunoassay (EIA) or other immunoassay is initially performed and RT-PCR for RNA is used to confirm active infection. In HIV+ patients with a low CD4 count (<200 cells/mm3), the EIA may occasionally be negative and an RT-PCR may be needed for definitive diagnosis.  An antibody test may not become positive for three or more months after acute HCV infection but a test for HCV-RNA will be positive after only two weeks.  Chronic infection is confirmed if an HCV-RNA assay is positive six months after the first positive test. Patients with low-level viremia may require HCV-RNA levels testing on two or more occasions to confirm infection.  All patients being considered for therapy should have a viral RNA test to confirm viremia and be genotyped. A positive antibody test with persistently negative RNA test indicates resolved infection. How can asthmatic medications be delivered to a child?

In pediatric asthma, inhaled treatment is the cornerstone of asthma management. Inhaler devices currently used broadly fall into the following four categories:  Pressurized metered dose inhaler (pMDI): Propellant used to dispense medication when canister is pressed manually.  Dry powder inhaler (DPI): Does not require handbreath coordination to operate.  Breath-actuated pMDI: Propellant used to dispense medication when patient inhales.  Nebulized solution devices In pediatrics, the inhaler device must be chosen on the basis of age, cost, safety, convenience, and efficacy of drug delivery.  The preferred device for children younger than 4 years is a pMDI with spacer and age-appropriate mask.  Children aged 4-6 years should use a pMDI plus a valved holding chamber or spacer.  Children older than 6 years can use either a pMDI, a DPI, or a breath-actuated pMDI. Asian Journal of Clinical Cardiology, Vol. 14, No. 7, November 2011

eMedinewS Section For all three groups, a nebulizer with a valved holding chamber (and mask in children younger than 4 years) is recommended as alternate therapy. An Egg a Day Raises Risk of Diabetes

People who eat eggs every day may substantially increase their risk of type 2 diabetes, researchers here said. Men with the highest level of egg consumption -at seven or more per week - were 58% more likely to develop type 2 diabetes than those who did not eat eggs, and women were 77% more likely to become diabetic if they ate at least an egg a day, Luc Djoussé, MD., DSc., of Brigham and Women’s Hospital and Harvard, and colleagues reported online in Diabetes Care. Levels of egg intake above one a week also incrementally increased diabetes risk in both men and women (both p <0.0001 for trend), the researchers said. (Source: Medpage Today) Poor countries bear higher stroke burden

Low-income countries and those that spend little on healthcare have higher rates of stroke than wealthier nations and countries with higher

healthcare expenditures, a systematic review showed. (Source: Medpage Today) —Dr. Neelam Mohan, Director Pediatric Gastroenterology, Hepatology and Liver Transplantation, Medanta – The Medicity)

Family History of BRCA Mutation not Cancer Risk Factor Women who test negative for a BRCA mutation that runs in their family aren’t more likely to develop breast cancer than otherwise suggested by a family history alone, a study affirmed. Such women showed no significant difference in breast cancer risk compared with those in breast cancer-affected families without identified BRCA1 or BRCA2 mutations, Alice S. Whittemore, PhD, of Stanford University in Palo Alto, Calif., and colleagues found. (Source: Medpage Today) ACG: Tests help tell GERD from esophagitis

Two tests-major basic protein (MBP) and eotaxin 3- can help physicians distinguish between eosinophilic esophagitis and gastroesophageal reflux disease (GERD), a researcher said here. (Source: Medpage Today) n

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Lighter Reading

Clinical Tip

Quote

There is no absolute predictor of a ‘cardiovascular event’ such as heart attack or stroke, nor is there any 100% accurate predictor of cardiovascular disease (CVD). It is a matter of playing the odds. An apparently fit individual of a given age, weight and lifestyle has a given set of odds, he/she will or will not experience CVD and the odds go up with the presence of “risk factors.”

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

make sure

DURING MEDICAL PRACTICE

A Different Approach to Percussion

Legions of physicians have been taught the traditional technique of percussion used in physical examination: Strike the terminal phalanx of the middle finger of the non-dominant hand with the tip of the middle finger of the dominant hand. I have found that striking the non-dominant middle finger with a reflex hammer offers several advantages over the traditional method. It is easier to perform, is more easily reproduced, provides more audible notes (especially important in a noisy setting such as the emergency department), and is less painful to the struck phalanx. Physicians with long fingernails are the ones, who would appreciate this fact the most.

A 40-year-old hypertensive lady with a BP of 130/86 mmHg is complaining of giddiness due to antihypertensives. Oh My God! Why did you put her on antihypertensives. why didn’t you advise lifestyle modifications?

© IJCP Academy

Pearls

—Michael W Rich, Akron, Ohio

An Myth Episiotomy is safer for the baby and makes for a gentler birth.

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Make sure: To first advise lifestyle modifications like exercise, low salt diet, high fiber diet, decreasing stress, etc. before advising antihypertensive medications in hypertensives.

Asian Journal of Clinical Cardiology, Vol. 14, No. 7, November 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 -

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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.

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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.

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

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Asian Journal of Clinical Cardiology, Vol. 14, No. 7, November 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.

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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

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Do not use clips/staples on photographs and artwork.

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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 ________________________

Books

6. Suggestions for reviewers (name and postal address)

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

Indian 1.____________Foreign 1._ _______________

2.____________

2._ _______________

Articles in Books

3.____________

3._ _______________

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

4.____________

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.

Legends - These should be typed double spaces on a separate sheet and figure numbers (in Arabic numerals) corresponding with the order in which the figures are presented in the text. -

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Figures - Two complete sets of glossy prints of high quality should be submitted. The labelling must be clear and neat. - All photomicrographs should indicate the magnification of the print. - Special features should be indicated by arrows or letters which contrast with the background. - The back of each illustration should bear the first author’s last name, figure number and an arrow indicating the top. This should be written lightly in pencil only. Please do not use a hard pencil, ball point or felt pen. - Color illustrations will be accepted if they make a contribution to the understanding of the article.

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

3. Number of tables ____________________________ 4. Number of figures ___________________________ 5. Special requests _____________________________

7. All authors’ signatures________________________ 8. Corresponding author’s name, current postal and e-mail address and telephone and fax numbers __________________________________________

Online Submission Also e-issue @ www.ijcpgroup.com For Editorial Correspondence

Dr KK Aggarwal

Group Editor-in-Chief Asian Journal of Clinical Cardiology E - 219, Greater Kailash, Part - 1, New Delhi - 110 048. Phone: 011-40587513 E-mail: editorial@ijcp.com, emedinew@gmail.com Website: www.ijcpgroup.com

Asian Journal of Clinical Cardiology, Vol. 14, No. 7, November 2011

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AJCC-November-2011