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Peer Review Journal

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Volume 14, Number 2, June 2011, Pages 37-72

Dr KK Aggarwal Group Editor-in-Chief

Dr Praveen Chandra Guest Editor


Head Office: E - 219, Greater Kailash, Part I, 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 Dear Colleague,

22 June 2011, Wednesday

Don’t discard diabetic drug Pioglitazone even after the FDA’s Safety Announcement The U.S. Food and Drug Administration has announced that the use of the popular diabetic drug pioglitazone for more than one year may be associated with an increased risk of bladder cancer. According to the FDA’s Safety Announcement, information about this risk will be added to the Warnings and Precautions section of the label for pioglitazone-containing medicines. However the Endocrine Society, American Association of Clinical Endocrinologists and American Diabetes Association inspite of the FDA announcement have urged diabetes patients not to panic and stop the drug without their doctor’s advice. Stopping diabetic drug can result in higher levels of blood glucose that may cause serious short term health problems and could increase the risk of diabetes-related complications in the long term. As per the advice all diabetics should adhere to the following guidance provided by the FDA: 1. All diabetics should be told that there may be an increased chance of having bladder cancer when taking pioglitazone. 2. One should not take pioglitazone if receiving treatment for bladder cancer; 3. One should consult right away if one has any of the symptoms of bladder cancer including blood or red color in urine; urgent need to urinate or pain while urinating; pain in back or lower abdomen. According to the FDA Safety Announcement, the five-year interim analysis of an ongoing ten-year study showed that although there was no overall increased risk of bladder cancer with pioglitazone use, an increased risk of bladder cancer was noted among patients who had been on pioglitazone the longest and had been on higher doses over time. Large number of diabetics are on pioglitazone, which reduces insulin resistance and is useful in metabolic syndrome. The drug is already in criticism for gaining weight and possible heart failure. Dr KK Aggarwal Editor-in-Chief IIT medical courses: Institute to submit report to HRD ministry KOLKATA: After churning out successful technocrats, the Indian Institute of Technology, Kharagpur, is in the process of starting MBBS, MS and MD courses on its campus. The institution will submit a detailed project report to the Union human resource development (MHRD) ministry next month in this regard. “We believe that the ministry is all set to table a bill to amend the existing statute of the IITs to allow them to introduce medical studies as well as to allow us set up a hospital. Till now, we had churned out efficient engineers. Now, we will also be committed to producing world-class doctors,” said IIT Kharagpur’s deputy director AN Mazumdar. If Parliament passes the bill in the monsoon session, IIT Kharagpur will be the first among the six IITs to set up a medical school. The draft proposal submitted to MHRD speaks about introducing postgraduate courses in technology oriented medical education. (Source: TOI, Jun 20, 2011). Sunscreen labels can claim to protect against cancer Sunscreens that are at least 15 SPF and offer protection from UVA and UVB rays can carry new labels stating they protect against sunburn, early signs of aging, and skin cancer, the FDA has announced. Sunscreens that don’t provide sun protection that meets the FDA’s new standards will have to carry a warning about the product’s shortcomings so consumers don’t think they’re getting greater sun protection than they are. And the term sunblock - a misnomer according to an FDA official who said no lotion or spray can totally protect skin from the sun’s harmful rays -- will become a thing of the past. Also off sunscreen labels will be the words “waterproof” or “sweatproof” - claims that the FDA says overstate a suncreen’s abilities. (Source: Medpage Today). Fitness Update Running outside vs. the treadmill - which is better? The debate continues! Much research shows that more intense exercise is beneficial for weight loss and greater health benefits, which favors the treadmill. However, a large body of research also points to the idea that a positive response to exercise increases adherence; these findings favor running outside as it is often rated as more enjoyable. A new study published in the journal Medicine & Science in Sports & Exercise further addresses this question by examining the psychological and physical effects of running inside on a treadmill versus running outdoors at a self-selected pace. This study is unique as it is the first study to evaluate running in an outdoor setting instead of a laboratory.

Researchers from Brazil, Italy and the University of Pittsburg collaborated to conduct this study. Thirty-four individuals (17 men and 17 women) between 18 and 30 years old volunteered to participate. Each study subject had an initial screening with weight and BMI measurements before undergoing a maximal treadmill test to measure physical fitness. Afterwards, participants performed 20-min bouts of treadmill and outdoor walking - both at a self-selected pace. Each 20-minute bout was separated by 48 hours. Researchers measured intensity, perceived exhaustion and mood. While they found that the outdoor walking improved mood, the treadmill exercise lead to the highest intensity workout.T —Contributed by Rajat Bhatnagar, International Sports & Fitness Distribution, LLC, http://www.isfdistribution.com

Spiritual Update Science behind Hanuman Chalisa By doing spiritual rituals one can acquire many spiritual powers. The Hindu text has mentioned these powers either in Yoga Sutras Patanjali, Primary Ashta Siddhi in Hanumana Chalisa, 5 Siddhis in Bhagwat Puran and 10 secondary Siddhis by Lord Krishna again in Bhagwat Puran. Pediatric Update How do we diagnose galactosemia? Diagnosis is made by demonstration of reduced or absent activity of the enzyme galactose–1–phosphate uridyl transferase (GAL–1–PUT), which is central to galactose metabolism. This test is invalid if the child has received a blood transfusion within previous 2 months. Parents’ samples should be sent instead for carrier testing. —Dr Neelam Mohan, Director Pediatric Gastroenterology, Hepatology and Liver Transplantation, Medanta – The Medicity

Medi Finance Update What is Alpha? It is a mathematical measure of price volatility that attempts to isolate the price movements of a stock from those of the market. A stock with a high alpha is expected to perform well regardless of what happens to the market as a whole. —Dr GM Singh


Online Submission

Volume 14, Number 2, June 2011

An IJCP Group Publication

Contents From the Desk of Group Editor-in-Chief

Unilateral versus Bilateral IMA Grafts 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 Joint MD & Group Executive Editor

IJCP Editorial Board Dr Alka Kriplani, Asian Journal of Obs & Gynae Practice Dr VP Sood, Asian Journal of Ear, Nose and Throat Dr Praveen Chandra, Asian Journal of Clinical Cardiology

41

KK Aggarwal

review article

Evaluation of Cardiac Status of Patients with Sickle Cell Disease by 2-D Echo with Specific Reference to PH

43

Jaya Pathak, M Vadivelan, Cinosh Mathew

Clinical study

Study of Patients with Metabolic Syndrome and Its Association with End-organ Damage

48

Archana U Gandhi, P Shrivastava, SV Patel, G Madan

Case report

Peristent Left Superior Vena Cava in Holt-Oram Syndrome: A Rare Presentation

52

Monika Maheshwari, Tarachand Saini

Idiopathic Dilated Cardiomyopathy Complicating 54 in a Pregnancy with Uterine Fibroid Debasmita Mandal, Pradip Kumar Saha, Chaitali Dattaray, Saroj Mandal

Clinical algorithm

Diagnosis of PE in Pregnancy

57

Dr Swati Y Bhave, Asian Journal of Paediatric Practice Dr Vijay Viswanathan, The Asian Journal of Diabetology

Expert opinion

Dr KMK Masthan, Indian Journal of Multidisciplinary Dentistry Dr M Paul Anand, Dr SK Parashar, Cardiology Dr CR Anand Moses, Dr Sidhartha Das, Dr Ramachandran, Dr Samith A Shetty, Diabetology Dr Ajay Kumar, Gastroenterology Dr Koushik Lahiri, Dermatology Dr Georgi Abraham, Nephrology Dr Sidharth Kumar Das, Rheumatology Dr V Nagarajan, Neurology Dr Thankam Verma, Dr Kamala Selvaraj, Obs and Gyne

Advisory Bodies Heart Care Foundation of India Overseas Indian Peoples Foundation

What is the Relationship between Kidneys and Hypertension?

58

Ashok L Kirpalani

Research Review

From the Journals ...

60

Conference Calendar

Conference Calendar

62


Volume 14, Number 2, June 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

Emedinews Section

From eMedinewS

63

lighter reading

Printed at IG Printers Pvt. Ltd., New Delhi E-mail: igprinter@rediffmail.com

Lighter Reading

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.

67

Dr. Good and Dr. Bad Situation: A patient of CAD developed dengue.

Editorial Policies

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.

Start paracetamol and also stop lowdose aspirin

Start paracetamol

Š IJCP Academy

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: In dengue, low-dose aspirin should be discontinued. Dr KK Aggarwal

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From the Desk of Group Editor-in-Chief xxxxxxxxxxx

Unilateral versus Bilateral IMA Grafts

B

ilateral internal mammary artery (IMA) grafting uses both left and right IMAs.1-4 Many studies have shown better long-term patency with one arterial conduit, usually the left IMA, than with vein grafts in patients undergoing coronary artery bypass grafting. This raises the possibility that bilateral IMA grafting may be beneficial. A short-term result from 10-year Arterial Revascularization Trial (ART) of 3,102 patients randomly assigned to single or bilateral IMA grafting has shown5 that mortality at 30 days and at one year was similar in both groups (1.2 and 2.3 vs 2.5%, respectively). There was a small but significant increase in the rate of sternal wound reconstruction in those who received bilateral IMA grafts (1.9 vs 0.6%). Observational studies support the use of bilateral IMA grafting: 

Two retrospective reports2,3 have assessed the in-hospital outcome of bilateral compared to single IMA grafts, with or without additional SVG grafts and showed no differences in in-hospital mortality, the number of complications or the length of hospitalization. One of them showed that long-term survival was better with bilateral IMA grafting at 10 and 20 years.6 In another prospective study4 at 6-7 years, patients receiving bilateral IMA grafts had significant increases in graft patency and a trend toward a lower incidence of new MI. A meta-analysis of 15,962 patients showed that patient survival was better with bilateral grafts.7

Current View  At present, the main setting in which bilateral IMA grafting should be considered is in young patients in whom long-term graft survival and freedom from reintervention is particularly important. However, this approach may increase the risk of poor mediastinal healing, possibly leading to mediastinitis, especially in patients with diabetes, chronic obstructive pulmonary disease or obesity. 

Bilateral skeletonized IMA grafting is the alternative in which both IMA are dissected from their neurovascular bundles. The procedure preserves sternal collateral blood supply, thereby enabling rapid sternal healing with less risk of deep sternal infection.5 This technique is associated with low perioperative morbidity and comparable long-term survival relative to patients who receive a single IMA graft.8,9

References 1. Galbut DL, Traad EA, Dorman MJ, DeWitt PL, Larsen PB, Kurlansky PA, et al. Seventeen-year experience with bilateral internal mammary artery grafts. Ann Thorac Surg 1990;49(2):195-201. 2. Lytle BW, Blackstone EH, Loop FD, Houghtaling PL, Arnold JH, Akhrass R, et al. Two internal thoracic artery grafts are better than one. J Thorac Cardiovasc Surg 1999;117(5):855-72. 3. Ioannidis JP, Galanos O, Katritsis D, Connery CP, Drossos GE, Swistel DG, et al. Early mortality and morbidity of bilateral versus single internal thoracic artery revascularization: propensity and risk modeling. J Am Coll Cardiol 2001;37(2): 521-8. 4. Endo M, Nishida H, Tomizawa Y, Kasanuki H. Benefit of bilateral over single internal mammary artery grafts for multiple coronary artery bypass grafting. Circulation 2001;104(18):2164-70. 5. Taggart DP, Altman DG, Gray AM, Lees B, Nugara F, Yu LM, et al. Randomized trial to compare bilateral vs. single internal mammary coronary artery bypass grafting: 1-year results of the Arterial Revascularisation Trial (ART). Eur Heart J 2010;31(20):2470-81. Asian Journal of Clinical Cardiology, Vol. 14, No. 2, June 2011

41


From the desk of group edior-in-chief 6. Lytle BW, Blackstone EH, Sabik JF, Houghtating P, Loop FD, Cosgrore DM. The effect of bilateral internal thoracic artery grafting on survival during 20 postoperative years. Ann Thorac Surg 2004;78(6):2005-12; discussion 2012-4. 7. Taggart DP, D’Amico R, Altman DG. Effect of arterial revascularisation on survival: a systematic review of studies comparing bilateral and single internal mammary arteries. Lancet 2001;358:870-5. 8. Pevni D, Mohr R, Lev-Run O, Locer C, Paz Y, Kramer A, et al. Influence of bilateral skeletonized harvesting on occurrence of deep sternal wound infection in 1,000 consecutive patients undergoing bilateral internal thoracic artery grafting. Ann Surg 2003;237(2):277-80. 9. Pevni D, Uretzky G, Mohr A, Braunstein R, Kramer A, Paz Y, et al. Routine use of bilateral skeletonized internal thoracic artery grafting: long-term results. Circulation 2008;118(7):705-12.

Dr KK Aggarwal

Padma Shri and Dr BC Roy National Awardee Sr. Physician and Cardiologist, Moolchand Medcity President, Heart Care Foundation of India Group Editor-in-Chief, IJCP Group Group Editor-in-Chief, 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)

42

Asian Journal of Clinical Cardiology, Vol. 14, No. 2, June 2011


review article

Evaluation of Cardiac Status of Patients with Sickle Cell Disease by 2-D Echo with Specific Reference to PH Jaya Pathak*, M Vadivelan**, Cinosh Mathew†

Abstract Aims: To evaluate the cardiac status in patients with sickle cell anemia and sickle cell trait by 2-D Echocardiography (2-D Echo) with specific reference to pulmonary hypertension and to assess prevalence and severity of pulmonary hypertension in this population. Study design: A prospective, cross-sectional study was done in 50 patients with sickle cell disease in whom 2-D Echo was performed which assessed their cardiac status with specific reference to pulmonary hypertension. Material and methods: The study was conducted on outdoor and indoor patients of the Dept. of Medicine at Shri Sayajirao General Hospital, Vadodara, Gujarat. The study was conducted over a period of 18 months in 50 patients with sickle cell anemia as well as sickle cell trait. Results: The present study revealed that pulmonary hypertension was present in one-third of patients with sickle cell disease. Conclusion: Pulmonary arterial hypertension is one of the leading causes of morbidity and increased mortality in adults with sickle cell disease. Key words: Sickle cell disease, pulmonary hypertension

H

emoglobinopathies are disorders affecting the structure, function or production of hemoglobin. The most common hemoglobinopathy is sickle cell disease. In India, the highest prevalence of this disease is seen in Odisha (1-44%) and Madhya Pradesh (1-40%) while the prevalence in Gujarat is 1-31.4% amongst tribes.1 Studies from tertiary care referral centers suggest a prevalence of pulmonary hypertension in sickle cell disease patients ranging from 20 to 40%. Pulmonary hypertension develops in most forms of hereditary and chronic hemolytic anemia suggesting that there is a clinical syndrome of hemolysis-associated pulmonary hypertension. This complication has been reported with increasing frequency in patients with sickle cell disease. Pulmonary arterial hypertension (PAH) is a silent complication of sickle cell disease. 2-D Echocardiography (2-D Echo) is a good noninvasive screening

*Associate Professor **Assistant Professor † Ex-Resident, Dept. of Medicine Medical College and SSG Hospital, Vadodara Address for correspondence Dr M Vadivelan B-290, Saurabh Park, Behind Samta Flats Subhanpura, Vadodara - 390 023, Gujarat E-mail: mevadivelan@hotmail.com

Asian Journal of Clinical Cardiology, Vol. 14, No. 2, June 2011

method to detect sickle cell patients with PAH so that therapy can be started at an earlier stage to reduce morbidity and mortality. Aims of Study  To evaluate the cardiac status in patients with sickle cell anemia and trait by 2-D Echo with specific reference to pulmonary hypertension.  To assess prevalence and severity of pulmonary hypertension in this population.  To correlate differences in severity of pulmonary hypertension between patients with sickle cell anemia and sickle cell trait.  To evaluate comorbidities associated with pulmonary hypertension in form of clinical and laboratory parameters in patients with sickle cell disease. Material and Methods In this prospective, cross-sectional study, 50 adult patients having sickle cell anemia and sickle cell trait attending outpatient medical department or admitted in indoor medical wards at Shri Sayajirao General Hospital, Vadodara, Gujarat were taken as the study group. 2-D Echo was performed in all patients to know the alteration in their cardiac status with specific reference to pulmonary hypertension. 43


Review Article Inclusion Criteria

Adults above the age of 14 years who were previously diagnosed to have sickle cell anemia or trait and freshly detected cases on the basis of clinical grounds, and positive sickling test that was later confirmed by hemoglobin electrophoresis. Exclusion Criteria

Patients with ischemic heart disease or any structural heart disease and those with history of any pulmonary disease were excluded from the study. Each patient on admission was evaluated with complete blood count with peripheral smear examination, sickling test and hemoglobin electrophoresis. Transthoracic Echo was performed in all patients using the ‘ALOKA’ Echocardiographic machine SSD 630 with CW and PW Doppler probe 3 mega vietz with single and dual elements. Later on, the patient was subjected to Doppler ultrasound examination on the same machine using appropriate modes. Tricuspid regurgitation was assessed in the parasternal right ventricular inflow, parasternal short-axis and apical four-chamber views and a minimum of three sequential complexes were recorded. Continuous-wave Doppler sampling of the peak regurgitant jet velocity was used to estimate the right ventricular-to-right atrial systolic pressure gradient with the use of the Modified Bernoulli equation. Pulmonary hypertension was defined as a peak tricuspid regurgitant jet velocity of at least 2.5 meter per second (m/sec). Pulmonary artery systolic pressure (PASP) was calculated from the tricuspid regurgitation velocity (TRV) and the estimated right atrial pressure (RAP) using the Modified Bernoulli Equation: PASP = 4 (TRV × TRV) + RAP The mean RAP was calculated according to the degree of collapse of the inferior vena cava with inspiration: 5 mmHg for a collapse of at least 50% and 15 mmHg for a collapse of <50%. Results Total 50 patients of sickle cell disease, admitted in medical wards and attending Medical OPD at SSG Hospital, Vadodara, who satisfied the inclusion criteria, were selected for the study. 44

The age of patients ranged from 14 to 50 years. Majority of patients were in the age group of 14-20 years (46%). Out of 50 patients in the study, 34 were males (68%) and 16 were females (32%) (Table 1). Of the 50 patients included in the study, 36 (72%) were having sickle cell anemia while 14 (28%) were having sickle cell trait (Table 2). Both the sickle cell disease and trait groups had nearly the same distribution of patients in mild, moderate and severe anemia groups (Table 3). In the present study, pulmonary hypertension was defined in patients with sickle cell anemia who were having TRV >2.5 m/sec. Doppler-defined pulmonary hypertension was found in 34% patients. Twenty-seven percent patients with sickle cell anemia had pulmonary hypertension while 50% of patients with sickle cell trait had pulmonary hypertension (Table 4). Table 5 shows that the incidence of pulmonary hypertension increased with the age of the patients in the study. Seventy-five percent of patients in the age group of 31-40 years had pulmonary hypertension while 80% Table 1. Age and Gender Distribution of Patients with Sickle Cell Disease Age (years)

Gender Male

Female

14-20 years

17

6

21-30 years

11

7

31-40 years

4

1

41-50 years

2

2

Table 2. Distribution of Patients with Sickle Cell Disease to Sickle Cell Anemia and Sickle Cell Trait Characteristic

No. of patients

% of patients (n = 50)

Sickle cell anemia

36

72

Sickle cell trait

14

28

Table 3. Analysis of Hematological Profile of Patients with Sickle Cell Disease Hemoglobin

Sickle cell anemia patients

Sickle cell trait patients

<5 g/dl

15

7

5.1-7 g/dl

14

5

>7.1 g/dl

7

2

Asian Journal of Clinical Cardiology, Vol. 14, No. 2, June 2011


Review Article Table 4. Analysis of Tricuspid Regurgitation Velocity of Patients with Sickle Cell Disease TRV (m/sec)

Sickle cell anemia

Sickle cell trait

No.

%

No.

<2.5

26

72.22

2.5-2.9

8

22.22

>2.9

2

5.55

Total

%

No.

%

7

50

33

66

5

35.71

13

26

2

14.28

4

8

Table 5. Analysis of Pulmonary Hypertension with Respect to Age Groups Age (years)

No. of patients in the age group

PHT present No.

%

14-20

23

4

17.39

21-30

18

6

33.33

31-40

5

4

75

>40

4

3

80

PHT = Pulmonary hypertension.

Table 6. Analysis of Pulmonary Hypertension with Respect to Gender, Genotype and Presence or Absence of Crisis No. of patients in the group

PHT present No.

%

Gender Male

34

11

32

Female

16

6

37

Sickle cell disease

36

12

33

Sickle cell trait

14

5

35

Crisis present

14

7

50

Crisis absent

36

9

25

Genotype

History

of patients in the above 40 years age group had pulmonary hypertension. From Table 6, no significant difference was found in the incidence of pulmonary hypertension with respect to gender or their hemoglobin genotypes i.e., sickle cell anemia or trait. Significant difference was noted in the incidence of pulmonary hypertension in the patients who presented with crisis and those who did not. Table 7 shows that the mean hemoglobin level was lower in the group with pulmonary hypertension. The level of fetal hemoglobin (Hb F) was lower in those with pulmonary hypertension. Table 8 shows that patients with pulmonary hypertension had a higher degree of hemolysis as evident from the level of lactate Asian Journal of Clinical Cardiology, Vol. 14, No. 2, June 2011

dehydrogenase (LDH) while there was no significant difference between the two groups in terms of the reticulocyte count. Discussion Sickle cell disease is a genetically inherited disorder resulting from structural hemoglobinopathy that manifests as a chronic congenital hemolytic anemia. The cardiovascular system in sickle cell disease is stressed by chronic anemia, recurrent small pulmonary artery occlusions and myocardial hemosiderosis.2 The shunting of blood through infarcted, nonaerated segments of the lung compromises arterial oxygen saturation and sludging of sickled erythrocytes in small pulmonary arteries may result in pulmonary hypertension.3 45


Review Article Table 7. Analysis of Pulmonary Hypertension with Respect to Hemoglobin Levels Hemoglobin

PHT present

PHT absent

4.49

6.35

Hb F (mean)

12.52%

22.02%

Hb S (mean)

57.87%

65.68%

Mean Hb (gm %)

Table 8. Analysis of Pulmonary Hypertension with Respect to Markers of Hemolysis - Lactate Dehydrogenase and Reticulocyte Count Parameter LDH (mean level µl) Reticulocyte count (mean %)

PHT present

PHT absent

466.19

283.87

2.94

2.73

The term ‘pulmonary hypertension’ denotes various conditions in which mean pulmonary arterial pressure is elevated above 25 mmHg at rest or above 30 mmHg with exercise with normal pressure being 15 mmHg.4 The most useful diagnostic modality used to detect and/or confirm pulmonary hypertension is echocardiography.5 Echocardiography is noninvasive, can evaluate both right and left heart anatomy and function, and is ideal for evaluating and excluding secondary causes of pulmonary hypertension. Echocardiography is used to determine pulmonary hypertension severity and is of prognostic utility. Doppler Echo is the cornerstone of screening for pulmonary hypertension and provides a quantitative assessment on pulmonary artery pressures.6 The risk factors for pulmonary hypertension in sickle cell disease include age, degree of hemolysis and iron overload. The risk for pulmonary hypertension is not related to the level of Hb F or the frequency of vasoocclusive crisis. Several mechanisms have been proposed for the pathogenesis of pulmonary hypertension in patients with sickle cell disease. They include: 

46

Intravascular hemolysis leading to nitric oxide (NO) deficiency.7 Progressive interstitial fibrosis secondary to acute chest syndrome. Vasculopathy secondary to platelet activation and intimal thickening. Hypoperfusion of the pulmonary vascular bed.

Recurrent thromboembolic disease and in situ thrombosis.

The standard therapy for sickle cell disease complicated by pulmonary hypertension remains to optimize disease treatment with hydroxyurea and to use hydration and transfusions while employing standard pulmonary hypertension therapy (oxygen, anticoagulation and pulmonary vasodilator therapy). Survival is decreased among patients whose sickle cell disease is complicated by pulmonary hypertension.8 Limitations  This cross-sectional, comparative study was conducted with only 50 patients inclusive of sickle cell anemia and trait and hence, could not derive proper boundaries for cardiac parameters. A larger sample strength would be needed to accurately decide the cut off points.  Long-term follow-up studies are needed to establish definitive implications of pulmonary hypertension on mortality as implicated in international studies could not be carried out due to poor patient compliance.  Quantification of certain important parameters like cardiac catheterization for accurate measurement of pulmonary hypertension was not done due to lack of resources. Conclusion Advances in healthcare of patients with sickle cell disease have led to an increase in the life expectancy of these individuals. As this population grows older, chronic complications of this disease tend to develop. One of these complications, pulmonary hypertension, has become one of the leading causes of morbidity and mortality in adults with sickle cell disease. Pulmonary hypertension is seen in about one-third patients with sickle cell disease and is associated with increased mortality. Pulmonary hypertension in sickle cell disease is found to be associated with increasing age, the presence of crisis, anemia and the level of LDH. It is not found to be associated with gender, sickle cell anemia or trait and the reticulocyte count. It can be easily detected by 2-D Echo and remedial measures taken in the early stages of the disease helps to decrease morbidity and mortality in these patients. Asian Journal of Clinical Cardiology, Vol. 14, No. 2, June 2011


Review Article References 1. Lehman H, Cutbush MC. Sickle cell disease in India. BMJ 1952;(1):404-7. 2. Lindsay J Jr, Meshel JC, Patterson RH. The cardiovascular manifestations of sickle cell disease. Arch Intern Med 1974;133(4):643-51. 3. Gerry JL, Bulkley BH, Hutchins GM. Clinicopathologic analysis of cardiac dysfunction in 52 patients with sickle cell anemia. Am J Cardiol 1978;42(2):211-6. 4. Simonneau G, Galie N, Rubin LJ, Seeger W, Domenighetti G, Gibbs S, et al. Clinical classification of pulmonary hypertension. J Am Coll Cardiol 2004;43(12 Suppl S):5S-12S. 5. Yeo TC, Dujardin KS, Tei C, Mahoney DW, McGoon

MD, Seward JB. Value of a Doppler-derived index combining systolic and diastolic time intervals in predicting outcome in primary pulmonary hypertension. Am J Cardiol 1998;81(9):1157-61. 6. Raymond RJ, Hinderliter AL, Willis PW, Ralph D, Caldwell EJ, Williams W, et al. Echocardiographic predictors of adverse outcomes in primary pulmonary hypertension. J Am Coll Cardiol 2002;39(7):1214-9. 7. Alaga KI, Sood N, De Gent G, Kelly E, Henderson AG, Jones S. Pulmonary hypertension in sickle cell disease. Am J Med 2004;117(9):665-9. 8. Mark T. Gladwin, Vandana Sachdev. Pulmonary hypertension as a risk factor for death in patients with sickle cell disease. N Engl J Med 2004;350:2521-2.

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Clinical study

Study of Patients with Metabolic Syndrome and Its Association with End-organ Damage Archana U Gandhi*, P Shrivastava**, SV Patel†, G Madan‡

Abstract Objectives: To study profile of patients suffering from metabolic syndrome, to study correlation of metabolic syndrome with ischemic heart disease (IHD), chronic kidney disease (CKD), cerebrovascular (CV) stroke and retinopathy and to study correlation between increasing waist circumference and increased risk of end-organ affection. Method: Present study was carried with 75 patients having metabolic syndrome according to ATP III criteria (2005) at SSG Hospital, Baroda. After taking detailed patient history, examination and investigations, correlation between metabolic syndrome and end-organ dysfunction was explored. Results: Prevalence of metabolic syndrome was observed to increase with age and prevalence was found to be higher in males (53%) as compared to females (47%). Waist circumference was the most prevalent parameter in the criteria for metabolic syndrome (98.42%). Prevalence of IHD, CKD, CV stroke and retinopathy was 38.57%, 42.56%, 3.99% and 69%, respectively. Linear increase in the prevalence of end-organ disease was noted with increasing waist circumference. Conclusion: Prevalence of metabolic syndrome advances with increase in age. IHD, CKD and retinopathy are commonly associated with metabolic syndrome. Increased waist circumference is the most prevalent metabolic trait and increasing waist circumference has strong correlation with development of IHD, CKD and CV stroke. Key words: Metabolic syndrome, end-organ damage

M

etabolic syndrome is a combination of medical disorders that increases one’s predisposition for cardiovascular disease (CVD) and other end-organ affection.1,2 Components of metabolic syndrome include impaired plasma glucose, hypertension, central obesity and atherogenic dyslipidemia (ATP III criteria, 2005).3-5 Obesity especially truncal obesity is associated with resistance to the effect of insulin on glucose and fatty acid utilization in the liver and peripheral tissue. This is the cornerstone of the pathophysiology of metabolic syndrome.5,6 Insulin resistance leads to hyperinsulinemia, hyperglycemia and increased secretion of cytokines. This results in vascular endothelial dysfunction, inflammation and atherogenic lipid profile, all of which predispose to atherosclerosis, CVD, cerebrovascular disease and chronic kidney disease (CKD).6 *Associate Professor **Resident Dept. of Medicine † Associate Professor ‡ Junior Lecturer Dept. of PSM SSG Hospital, Medical College Baroda Address for correspondence Dr Archana U Gandhi Associate Professor, Dept. of Medicine, Medical College Baroda Raopura, Vadodara - 390 001 E-mail: draug20@gmail.com

48

Thus metabolic syndrome is an important risk factor for subsequent development of type 2 diabetes mellitus, CVD, renal disease and other clinical syndromes.6 Primary prevention, early detection and aggressive management are known to reduce morbidity and mortality associated with metabolic syndrome. Material and Methods A cross-sectional study was carried out with 75 patients having metabolic syndrome. ATP III criteria (2005) for metabolic syndrome were used for diagnosis of metabolic syndrome in patients who were admitted or were attending medical OPD at SSG Hospital, Baroda between May 2005 to June 2007. Current ATP III (2005) criteria define the metabolic syndrome as the presence of any three of the following five traits:  Abdominal obesity, defined as a waist circumference in men >102 cm (40") and in women >88 cm (35");  Serum triglycerides ≥150 mg/dl (1.7 mmol/l) or drug treatment for elevated triglycerides;  Serum high-density lipoprotein (HDL) cholesterol <40 mg/dl (1 mmol/l) in men and <50 mg/dl (1.3 mmol/l) in women or drug treatment for low HDL cholesterol;  Blood pressure ≥130/85 mmHg or drug treatment for elevated blood pressure; Asian Journal of Clinical Cardiology, Vol. 14, No. 2, June 2011


Clinical Study Fasting plasma glucose (FPG) â&#x2030;Ľ100 mg/dl (5.6 mmol/l) or drug treatment for elevated blood glucose.

A detailed history was taken regarding presenting complaints. Past history and family history suggestive of diabetes, hypertension, dyslipidemia, ischemic heart disease (IHD), congestive cardiac failure, cerebrovascular (CV) stroke, ophthalmic complaints and chronic renal failure was also asked for. Anthropometric examination including height, weight, body mass index, hip circumference, waist hip ratio and waist circumference was measured. Waist circumference was measured as per National Health and Nutrition Examination Survey (NHANES) Protocol: In upright position the right iliac crest of the patient was palpated and a horizontal mark was drawn just above the lateral border of it. It was crossed with a vertical mark in the midaxillary line. The measuring tape was placed around the abdomen at this level parallel to the floor and measurement of waist circumference was taken at normal minimal inspiration without compressing skin. Peripheral signs of atherosclerosis were looked for and other relevant examination, vital data and detailed systemic examination was done. Routine blood and urine investigations including complete blood count, urine examination, fasting and postprandial blood sugar level, renal function test, lipid profile were done. Chest X-ray and ECG were done to diagnose IHD, cardiomegaly and cardiac failure. Echocardiograhy, treadmill test, USG abdomen, CT head were also done as and when indicated. From history, physical and systemic examination and investigations, a profile of metabolic syndrome and correlation between metabolic syndrome and end-organ dysfunction including IHD, CKD, CV accidents and retinopathy was studied. The data was entered and analyzed in Epi-info software. Results In our study, maximum numbers of patients (40%) were in 51-60 years of age group. Most of the patients manifested metabolic syndrome in later part of their life (Table 1). Prevalence of metabolic syndrome was higher in males (53%) as compared to females (47%). Among females 71.42% were postmenopausal which Asian Journal of Clinical Cardiology, Vol. 14, No. 2, June 2011

suggests that prevalence of metabolic syndrome rises briskly in postmenopausal females. Waist circumference was the most prevalent parameter amongst those used in the criteria for metabolic syndrome. This was followed by high blood pressure, raised fasting blood glucose, raised triglyceride levels and finally decreased HDL level (Table 2). Figure 1 shows that in patients suffering from metabolic syndrome, prevalence of IHD was 38.57%, Table 1. Age and Sex-wise Distribution Age

Males

Females

Total

No.

%

No.

%

No.

%

30-40

1

2.5

2

5.7

3

4

41-50

8

20

9

25.7

17

22.6

51-60

18

45

12

34.2

30

40

61-70

8

20

10

28.5

18

24

71-80

5

12.5

2

5.7

7

9.33

Total

40

53

35

47

75

100

Table 2. Proportion of Metabolic Traits Metabolic traits

No. of patients

Percentage (%)

Blood pressure: Systolic >130 mmHg and diastolic >85 mmHg

70

93.1

Fasting blood glucose levels >110 mg/dl

65

86.45

Waist circumference males >40" and females >35"

74

98.42

Serum HDL cholesterol: Females <50 mg/dl and males <40 mg/dl

54

71.82

Serum triglycerides >150 mg/dl

62

82.46

CV stroke

Retinopathy

80 70 60 Percentage (%)

ď Ź

50 40 30 20 10 0

IHD

CKD

Figure 1. Metabolic syndrome and end-organ disease.

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Clinical Study Table 3. Relationship of Waist Circumference with End-organ Disease Waist circumference

Total no. of patients

%

IHD

%

CKD

%

Stroke

%

<40

2

2.66

0

0

0

0

0

0

40-45

10

13.33

2

20

4

40

0

0

46-50

33

43.89

10

30

14

42

0

0

51-55

11

14.63

6

54

5

45

0

0

>56

19

25.27

11

57

9

47

3

15

Correlation: WC and IHD: r = 0.293, p = 0.011; WC and CKD: r = 0.156, p = 0.182; WC and Stroke: r = 0.282, p = 0.014.

CKD 42.56%, CV stroke 3.99% and that of retinopathy was 69%. Prevalence of end-organ diseases like IHD and stroke showed a significant increase with increasing waist circumference (p = 0.011 for correlation between waist circumference and IHD and p = 0.014 for that with stroke). CV stroke was seen in patients with waist circumference >56 inches only (Table 3). Discussion In our study most patients manifested metabolic syndrome in later period of their lives i.e. after 50 years of age. Ford et al in his analysis of the data of the third NHANES2,3 study, noted the same finding, i.e. as age advances, prevalence of metabolic syndrome increases. In present study prevalence of metabolic syndrome was higher in males (53%) as compared to females (47%). But studies done by Ramachandran et al7 and Gupta et al8 showed higher prevalence of metabolic syndrome in females as compared to males. In our study, within the female population, 71.42% females were postmenopausal suggesting that prevalence of metabolic syndrome rises briskly in postmenopausal female as compared to males of same age group. Whitcroft observed similar findings in his study.9 Waist circumference was the most prevalent parameter amongst the criteria used in our study for metabolic syndrome. This shows that central and abdominal obesity are the most significant predictors of metabolic syndrome amongst our population. Metabolic syndrome is a well-known risk factor for CVD risk factor and in our study also, 38.57% patients had IHD. Three meta-analyses, which included many similar studies, found that the metabolic syndrome increases the risk for incident CVD (RRs ranging from 1.53 to 2.18) and is hence associated with mortality 50

(RRs 1.27-1.60).10-12 In a study of the Framingham population, obese people with the metabolic syndrome had a 10-fold increased risk for diabetes and a twofold increased risk for CVD relative to normal weight people without the metabolic syndrome. Normal weight people meeting revised 2005 ATP III criteria for the metabolic syndrome had a four-fold increased risk for diabetes and a three-fold increased risk for CVD.13 The increased risk appears to be related to the risk factor clustering or insulin resistance associated with the metabolic syndrome rather than simply to obesity. In our study, prevalence of CKD was 42.56% in metabolic syndrome patients. In NHANES III survey1 cumulative prevalence of chronic kidney was 23.3% and Tanaka et al14 noted prevalence of CKD in metabolic syndrome patients as 13.7%. In our study prevalence of stroke was 3.99%. Koren-Morag et al in their study noted that patients with the metabolic syndrome without diabetes exhibited a 1.49-fold increased odds for ischemic stroke or transient ischemic attack, whereas those with frank diabetes had a 2.29fold increased odds.15 Prevalence of retinopathy in our patients was 69%. Wong16 noted that persons with metabolic syndrome were more likely to have retinopathy than persons without it. Table 3 shows that there is linear increase in prevalence of IHD, CKD and CV stroke with increasing waist circumference in patients with metabolic syndrome. Bogalusa Heart Study and Framingham Heart Study data analysis also suggested that increase in central fat antedates the development of coronary heart disease, atherosclerosis and related disorders.17 Primary prevention, early detection and aggressive management of risk factors can reduce morbidity and mortality associated with metabolic syndrome. The cornerstone of treatment is the Asian Journal of Clinical Cardiology, Vol. 14, No. 2, June 2011


Clinical Study management of weight and ensuring appropriate levels of physical activity. Recent studies demonstrate that dietary modification and enhanced physical activity may delay or prevent the transition from impaired glucose tolerance to type 2 diabetes mellitus and provide relevant treatment paradigms for patients with the metabolic syndrome. Proper management of the individual abnormalities of this syndrome can reduce morbidity and mortality.18 Conclusions This study shows that  As age advances prevalence of metabolic syndrome increases.  IHD, CKD and retinopathy are commonly associated with metabolic syndrome.  Increased waist circumference is the most prevalent metabolic trait among the parameters used to define metabolic syndrome and increasing waist circumference has strong association with development of IHD, CKD and CV stroke. References 1. Park YW, Zhu S, Palaniappan L, Heshka S, Carnethon MR, Heymsfield SB. The metabolic syndrome: prevalence and associated risk factor findings in the US population from the Third National Health and Nutrition Examination Survey, 1988-1994. Arch Intern Med 2003;163(4):427-36. 2. Isomaa B, Almgren P, Tuomi T, Forsén B, Lahti K, Nissén M, et al. Cardiovascular morbidity and mortality associated with the metabolic syndrome. Diabetes Care 2001;24(4):683-9. 3. Genuth S, Alberti KG, Bennett P, Buse J, Defronzo R, Kahn R, et al; Expert Committee on the diagnosis and Classification of Diabetes Mellitus. Follow-up report on the diagnosis of diabetes mellitus. Diabetes Care 2003;26(11):3160-7. 4. Grundy SM, Cleeman JI, Daniels SR, Donato KA, Eckel RH, Franklin BA, et al; American Heart Association; National Heart, Lung, and Blood Institute. Diagnosis and management of the metabolic syndrome: an American Heart Association/National Heart, Lung, and Blood Institute Scientific Statement. Circulation 2005;112(17):2735-52. 5. Reaven GM. Banting lecture 1988. Role of insulin resistance in human disease. Diabetes 1988;37(12): 1595-607. 6. DeFronzo RA, Ferrannini E. Insulin resistance. A multifaceted syndrome responsible for NIDDM, obesity, hypertension, dyslipidemia, and atherosclerotic

Asian Journal of Clinical Cardiology, Vol. 14, No. 2, June 2011

cardiovascular disease. Diabetes Care 1991;14(3): 173-94. 7. Ramachandran A, Snehalatha C, Satyavani K, Sivasankari S, Vijay V. Metabolic syndrome in urban Asian Indian adults - a population study using modified ATP III criteria. Diabetes Res Clin Pract 2003;60(3):199-204. 8. Gupta A, Gupta R, Sarna M, Rastogi S, Gupta VP, Kothari K. Prevalence of diabetes, impaired fasting glucose and insulin resistance syndrome in an urban Indian population. Diabetes Res Clin Pract 2003;61(1):69-76. 9. Whitcroft S, Herriot A. Insulin resistance and management of the menopause: a clinical hypothesis in practice. Menopause Int 2011;17(1):24-8. 10. Ford ES. Risks for all-cause mortality, cardiovascular disease, and diabetes associated with the metabolic syndrome: a summary of the evidence. Diabetes Care 2005;28(7):1769-78. 11. Galassi A, Reynolds K, He J. Metabolic syndrome and risk of cardiovascular disease: a meta-analysis. Am J Med 2006;119(10):812-9. 12. Gami AS, Witt BJ, Howard DE, Erwin PJ, Gami LA, Somers VK, et al. Metabolic syndrome and risk of incident cardiovascular events and death: a systematic review and meta-analysis of longitudinal studies. J Am Coll Cardiol 2007;49(4):403-14. 13. Meigs JB, Wilson PW, Fox CS, Vasan RS, Nathan DM, Sullivan LM, et al. Body mass index, metabolic syndrome, and risk of type 2 diabetes or cardiovascular disease. J Clin Endocrinol Metab 2006;91(8):2906-12. 14. Tanaka H, Shiohira Y, Uezu Y, Higa A, Iseki K. Metabolic syndrome and chronic kidney disease in Okinawa, Japan. Kidney Int 2006;69(2):369-74. 15. Koren-Morag N, Goldbourt U, Tanne D. Relation between the metabolic syndrome and ischemic stroke or transient ischemic sttack: a prospective cohort study in patients with atherosclerotic cardiovascular diseae. Stroke 2005;36(7):1366-71. 16. Wong TY, Duncan BB, Golden SH, Klein BE, Couper DJ, Klien BE, et al. Associations between the metabolic syndrome and retinal microvascular signs: the Atherosclerosis Risk In Communities study. Invest Ophthalmol Vis Sci 2004;45(9):2949-54. 17. Burke GL, Webber LS, Srinivasan SR, Radhakrishnamurthy B, Freedman DS, Berenson GS. Fasting plasma glucose and insulin levels and their relationship to cardiovascular risk factors in children. Bogalusa Heart Study. Metabolism 1986;35(5):441-6. 18. Eriksson K, Lindgärde F. Prevention of type 2 (noninsulin-dependent) diabetes mellitus by diet and physical exercise. The 6-year Malmö feasibility study. Diabetologia 1991;34(12):891-8.

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Case report

Persistent Left Superior Vena Cava in Holt-Oram Syndrome: A Rare Presentation Monika Maheshwari*, Tarachand Saini**

Abstract Holt-Oram syndrome (HOS) is an autosomal dominant condition characterized by congenital cardiac and forelimb anomalies. The most common reported cardiac defect is atrial septal defect. We report herein a rare association of persistent left superior vena cava in a patient with HOS. Key words: Congenital heart disease, atrial septal defect, forelimb anomalies

H

olt-Oram syndrome (HOS), also known as the â&#x20AC;&#x2DC;heart-hand syndrome,â&#x20AC;&#x2122; is a genetically determined disorder in which aplasia or hypoplasia of the digital rays and/or radius are associated with congenital heart disease. The overall prevalence of HOS is 1/1,00,000 live births.1 The deformity is due to mutations in the transcription factor TBX5 which plays a role in the development of the heart and upper limbs before birth.2 Ostium secundum atrial septal defect (ASD), followed by ventricular septal defect and ostium primum ASD are the most commonly reported cardiac defects. Association of persistent left superior vena cava with HOS is very uncommon and rarely been described in literature.2,3 Hence, it was worth reporting one such case recently encountered in our OPD. Case Report A 20-year-old girl presented with complaints of dyspnea on exertion, palpitation and growth retardation. On physical examination, she had hypoplastic thumbs with short forearms (Fig. 1). There was a pansystolic murmur of Grade 4/6 at left sternal border. Chest X-ray showed cardiomegaly. Electrocardiogram revealed P-mitrale with left ventricular diastolic overload. Echocardiogram demonstrated a muscular *dm (Cardiology), 1st Year Resident Dept. of Cardiology **MD (General Medicine), 1st Year Resident Dept. of Medicine Jawaharlal Nehru Medical College, Ajmer Address for correspondence Dr Monika Maheswari Navin Niwas, 434/10 Bapu Nagar, Ajmer, Rajsthan - 305 001 E-mail: opm11@rediffmail.com

52

Figure 1. Female with deformed hypoplastic thumb and short forearm.

ventricular septal defect in apical septum, 4 mm in size, with left to right shunt (Fig. 2). An additional characteristic anomaly was the presence of left superior vena cava draining into the left atrium (Fig. 3). Patient was then referred to a higher center for surgical correction of her musculoskeletal deformity and associated cardiac defects. Discussion Holt-Oram first described this syndrome in 1960 in a four-generation family with ASDs and congenital anomalies of thumbs.4 Since then, about 200 clinical papers have been published that further delineate the clinical features of HOS. Skeletal abnormalities affect the upper limbs exclusively; lower limb abnormalities Asian Journal of Clinical Cardiology, Vol. 14, No. 2, June 2011


Case Report

Figure 2. Echocardiogram (subcostal view) demonstrating an apical muscular ventricular septal defect.

Figure 3. Echocardiogram (subcostal view) demonstrating left superior vena cava draining into the left atrium.

have not been reported. Abnormalities may be unilateral or bilateral and asymmetric and involve structures originating from embryonic radial ray such as radial, carpal and thenar bones. Aplasia, hypoplasia, fusion and abnormal development of these structures include a wide-spectrum of clinical disorders such as phocomelia, foreshortened arm, absence of first finger and triphalangia.5

both parents is recommended, including physical examination and radiographs of the upper extremities to detect subtle changes of the thumb and carpal bones, and examination of the heart, including electrocardiogram, echocardiogram and karyotyping and molecular studies.

Complex congenital cardiac malformations have been reported to occur in about 18% of the patients with HOS. Bruneau et al6 summarized the defects in 240 patients. Among these patients, 58% had ASD and 28% had ventricular septal defect. Less common anomalies, such as conduction defect, truncus arteriosus, mitral valve defect, patent ductus arteriosus, and tetralogy of Fallot, occur in 18, 8, 4, 4 and 3%, respectively. Cardiac rhythm disturbances include both tachyarrhythmia and bradyarrhythmia. Prominent among these are heart blocks (first-degree, second-degree or thirddegree), wandering atrial pacemaker, and sinus bradycardia. The severity of cardiac spectrum is not always proportional to that of upper limb deformity. Sudden death from heart block has been reported.3 Hence, genetic counseling should be provided to all patients with HOS. Evaluation of

Asian Journal of Clinical Cardiology, Vol. 14, No. 2, June 2011

References 1. Basson CT, Cowley GS, Solomon SD, Weissman B, Poznanski AK, Traill TA, et al. The clinical and genetic spectrum of Holt-Oram syndrome (heart-hand syndrome). N Eng J Med 1994;330(13):885-91. 2. Solit RW, Smullens SN, Templton JY 3rd. Congenital heart disease and upper extremity defects. A case report (Holt-Oram syndrome). J Cardiovasc Surg (Torino) 1973;14(1):76-80. 3. Cheng TO. Persistent left superior vena cava in HoltOram syndrome. Int J Cardiol 2000;76(1):83,81-2. 4. Holt M, Oram S. Familial heart disease with skeletal malformations. Br Heart J 1960;22:236-42. 5. Omer Ă&#x2021;, Mehmet N, Cumhur Ki. Holt-Oram syndrome (heart-hand syndrome): case report. Turkish J Thorac Cardiovasc Surg 2002;10:247-8. 6. Bruneau BG, Logan M, Davis N, Levi T, Tabin CJ, Seidman JG, et al. Chamber-specific cardiac expression of Tbx5 and heart defects in Holt-Oram syndrome. Dev Biol 1999;211(1):100-8.

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Case Report

Idiopathic Dilated Cardiomyopathy Complicating in a Pregnancy with Uterine Fibroid Debasmita Mandal*, Pradip Kumar Saha**, Chaitali Dattaray†, Saroj Mandal‡

Abstract Idiopathic dilated cardiomyopathy (DCM) during gestation is a rare coincidence. These patients can experience hazardous complications like; cardiac failure and even death during pregnancy due to physiologically increased in vascular volume and cardiac output. A previously diagnosed case of idiopathic DCM (ejection fraction (EF) - 32% and severe left ventricular systolic dysfunction in Echo Doppler, NYHA functional Class IV) who also had a big uterine fibroid was admitted to our antenatal ward at 33 weeks four days gestation with signs of left ventricular failure. She required intensive coronary care unit (ICCU) care and was treated with digoxin, inotrops and diuretics, etc. She was managed expectantly upto 36 weeks and terminated by cesarean section due to intrauterine growth restriction. Postpartum period was also eventful with another episode of cardiac failure which needed ventilator support as well as ICCU back-up. She was followed-up with regular echocardiography and ECG, and showed improvement at sixth month with EF of 42%. Adequate counseling prenatally and antenatally and good multidisciplinary support may lead to successful pregnancy outcome in patients with idiopathic DCM. Key words: Idiopathic dilated cardiomyopathy, pregnancy, fibroid, left ventricular failure

D

ilated cardiomyopathy (DCM) is defined as dilatation of one or both ventricles with reduced left ventricular ejection fraction (LVEF) in the absence of coronary, valvular, congenital or any systemic diseases known to cause myocardial dysfunction.1 The predominant features are evidenced by increased myocardial mass, cardiomegaly with dilatation enlargement of one or both ventricles with improper contractility, impairment of systolic function.2 It has been observed that young nonpregnant women with DCM have poor prognosis and survival than women with peripartum cardiomyopathy.3 It is only very rarely that DCM is well-documented before pregnancy.4 During gestation the physiologic hemodynamic alteration and procoagulant state of pregnancy can destabilize the cardiac disease as well as the pregnancy outcome itself. Authors have documented a negative impact of pregnancy on the clinical course of a woman

*Assistant Professor **rmo cum Clinical tutor † Associate Professor ‡ Final Year Post Doctoral Trainee (Cardiology) Dept. of Obstetrics and Gynecology and Dept. of Cardiology ipgmeR and sskm Hospital, Kolkata Address for correspondence Dr Debasmita Mandal Qr. No.: C/11, sskm Hospital Campus 242, ajc Bose Road, Kolkata - 700 020, West Bengal E-mail: drdebasmitamondal@yahoo.com debasmita_mandal@rediffmail.com

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with DCM and also shown an increased incidence of neonatal complications in mothers with DCM.5 Here, we present the clinical sequel of a young woman with DCM and a big fundal fibroid during her antenatal period and her subsequent successful pregnancy outcome at 36 weeks gestation. Case Report A 24-year-old primigravida at 33 weeks four days of gestation was referred with chief complaint of acute exacerbation of breathlessness and palpitation for four days. Previously she required admission, at eight weeks gestation, at a local health center for severe orthopnea. Ultrasonography (USG) was done which corroborated the gestational age and revealed a big fundal fibroid (14.2 × 13.6 × 13.2 cm3). Echo Doppler diagnosed DCM with severe left ventricular systolic dysfunction, ejection fraction (EF) of 32%, moderate mitral regurgitation and moderate pulmonary arterial hypertension. Later, on admission in our antenatal ward, she was moderately anemic, afebrile and normotensive. All other peripheral signs like cyanosis, jaundice, clubbing and edema were absent. Uterine height corresponded to 32 weeks gestation. She had dyspnea at rest (NYHA functional Class IV), tachycardia, raised jugular venous pressure and left ventricular failure Asian Journal of Clinical Cardiology, Vol. 14, No. 2, June 2011


Case Report Table 1. Overview of Literatures on Idiopathic Dilated Cardiomyopathy in Pregnancy (All Case Reports and Study that could be Found Searching Medline from 1980-2010) Authors

No. of pregnancies

Complications during pregnancy

Mode of termination

Gestational age at delivery

Neonatal outcome

Mazor et al2 1994

1

Slow progress of labor

LSCS

36 weeks

No morbidity

Chan et al9 1999

1

Thromboembolic stroke

LSCS

31 weeks

1.6 kg baby IUGR

Berstein et al7 2001

3

PIH

2 by forceps 1 therapeutic abortion

34 Âą 5.9 weeks

2 normal 1 (multiple cardiac anomalies)

Yacoub et al6 2002

1

LVF

Therapeutic abortion

20 weeks

Stillbirth

Avila et al8 2003

18

CCF, angina, arrhythmia, thromboembolism abortion, maternal death

Majority by NVD

Grewal et al5 2010

27

PPH, pre-eclampsia, LVF

Majority by NVD

Stillbirth, prematurity

38 weeks

Prematurity, fetal death, IUGR

LSCS = Lower segment cesarean section; PIH = Pregnancy-induced hypertension; LVF = Left ventricular failure; CCF = Congestive cardiac failure; NVD = Neonatal vulnerability database; PPH = Postpartum haemorrhage; IUGR = Intrauterine growth restriction

while investigations revealed hemoglobin level of 9.2 gm% with 29% packed cell volume; liver function tests, renal function tests and coagulation profile were within normal range. Previous USG showed adequate fetal growth and excluded the absence of congenital anomaly. Chest X-ray on admission revealed a dilated heart with pulmonary venous congestion. ECG revealed sinus tachycardia and echocardiography showed dilated left atrium and ventricle with global hypokinesia of left ventricle and LVEF was 24%. She was shifted to intensive coronary care unit (ICCU) for better management and treated conservatively with digoxin, diuretics, potassium supplements, heparin and inotrops. After stabilization of heart failure, regular echocardiographic monitoring was continued. EF of left ventricle was found to vary between 25% and 32% with medical treatment. Simultaneous USG fetal monitoring and iron and calcium supplementation were continued. At 36 weeks five days, pregnancy was terminated by elective lower segment cesarean section for intrauterine growth restriction (IUGR) and oligohydramnios under graded epidural anesthesia. A 2.49 kg girl baby was delivered with Apgar score of 9 and 8 at one and 5 minutes, respectively. Postoperatively patient again developed left ventricular failure and cardiogenic shock, which required ICCU admission and multidisciplinary support. She was Asian Journal of Clinical Cardiology, Vol. 14, No. 2, June 2011

discharged after two weeks and asked to be on followup. Neonate did not show any congenital affection. Follow-up echocardiography at sixth month showed relatively improved left ventricular systolic function with EF of 42%. For contraception she was advised progesterone only pill. Discussion While the incidence of DCM (idiopathic and secondary) is observed to be 5-8 cases/1,00,000 population/year,5 occurrence of idiopathic DCM during gestation is rare.2,4,6 Yacoub et al while reporting such case conducted a MEDLINE search from 1980 to 2000 and found only two pregnant cases with idiopathic or primary dilated cardiomyopathy.6 From 2001 to 2010 few authors shared their experience and total no of pregnancies reported were 48 (Table 1).5,7,8 Very limited supporting data are available for management guidelines during pregnancy. Pregnancy outcome of 51 pregnancies showed increased rate of therapeutic abortions and maternal complications included pregnancy-induced hypertension, preterm labor, low birth weight, intrauterine death and ventricular tachycardia, arrhythmia, thromboembolism, infective endocarditis and heart failure, etc. Grewal et al studied 36 pregnancies with DCM which included 27 women with idiopathic DCM and observed cesarean deliveries in seven pregnancies for obstetric indications only, no operative interference was present 55


Case Report for cardiac indications and preferred method of anesthesia was epidural.5 They observed poor neonatal outcome in women with severe DCM (moderate/ severe left ventricular systolic dysfunction and NYHA functional Class III/IV) if concomitant obstetric risk factors were present. The present case had severe left ventricular systolic dysfunction with EF of 32% (severe DCM) in first trimester adding to this presence of big fundal fibroid also increased the obstetric risk. The mode of delivery was cesarean section under graded epidural anesthesia for an obstetric indication not due to heart disease per se. Maternal morbidity included heart failure twice (33 weeks and immediate postpartum period), oligohydramnios and IUGR. We also have the same concern which other authors have, that pregnancy is a major determinant for deterioration of DCM cases.5,9 Many have advised against conception with DCM and poor left ventricular systolic function (EF <3050%).10 But there is minimal evidence-based data to recommend it. Simultaneously repeated pregnancies should be discouraged in these patients. Routine administration of anticoagulant is required throughout the pregnancy to avoid thromboembolism. Though the present case was managed successfully due to optimal obstetric, ICCU and neonatal intensive care unit (NICU) coordination, undertaking pregnancy in these woman is hazardous and becomes a cause of concern for the family and attending physicians. In our experience, counseling plays a vital role preconceptionally and antenatally. In DCM, prepregnant hemodynamically stable status with good left ventricular function may result in a successful outcome. To avoid such a potentially fatal situation of severe DCM in pregnancy like we observed, whenever an antenatal patient complains of effort intolerance, dyspnea and palpitation, ECG and Echo Doppler should ideally be recommended. In a properly monitored environment pregnancy

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may be allowed to extend to term provided patient is clinically and hemodynamically stable. This is one of the rare cases of severe DCM (severe left ventricular systolic dysfunction, EF - 32% and clinically NYHA Class IV) with big fundal fibroid to have a successful pregnancy outcome at term. References 1. Elliot P. Cardiomyopathy. Diagnosis and management of dilated cardiomyopathy. Heart 2000;84(1):106-12. 2. Mazor M, Levitas E, Gussarsky Y, Friedman S. Idiopathic dilated cardiomyopathy in pregnancy. Arch Gynecol Obstet 1994;255(1):51-3. 3. Van Hoeven KH, Kitsis RN, Katz SD, Factor SM. Peripartum versus idiopathic dilated cardiomyopathy in young women - a comparison of clinical, pathologic and prognostic features. Int J Cardiol 1993;40(1):57-65. 4. Task Force on the Management of Cardiovascular Diseases During Pregnancy of the European Society of Cardiology. Expert consensus document on management of cardiovascular diseases during pregnancy. Eur Heart J 2003;24(8):761-81. 5. Grewal J, Siu SC, Ross HJ, Mason J, Balint OH, Sermer M, et al. Pregnancy outcomes in women with dilated cardiomyopathy. JACC 2010;55:45-52. 6. Yacoub A, Martel MJ. Pregnancy with primary dilated cardiomyopathy. Obstet Gynecol 2002;99(5 Pt 2): 928-30. 7. Berstein PS, Magriples U. Cardiomyopathy in pregnancy: a retrospective study. Am J Perinatol 2001;18(3):163-8. 8. Avila WS, Rossi EG, Ramires JA, Grinberg M, Bortolotto MR, Zugaib M, et al. Pregnancy in patients with heart disease: experience with 1,000 cases. Clin Cardiol 2003;26(3):135-42. 9. Chan F, Kee WD. Idiopathic dilated cardiomyopathy presenting in pregnancy. Can J Anaesth 1999;46(12): 1146-9. 10. Thorne SA, Nelson-Piercy C, MacGregor A, Gibbs S, Crowhurst J, Panay N, et al. Pregnancy and contraception in heart disease and pulmonary arterial hypertension. J Fam Plann Reprod Health Care 2006; 32(2):75-81.

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Clinical algorithm

Diagnosis of PE in Pregnancy

Clinical suspicion of PE

Low

Intermediate or high

D-dimer (optional)

Negative

Positive

Multidetector-row (spiral) CT

PE excluded

Normal spiral CT

Spiral CT indeterminate

Spiral CT showing definite PE

Not available

PE excluded

Additional testing: V/Q scan; VCUS lower extremity; MRI; pulmonary angiography

PE diagnosed

V/Q scan

CT = Computed tomography; MRI = Magnetic resonance imaging; PE = Pulmonary embolism; VCUS = Venous compression ultrasonography; V/Q = Ventilation-perfusion.

Source: Adapted from Am Fam Physician. 2008;77(12):1709-1716.

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Expert opinion

What is the Relationship between Kidneys and Hypertension? Ashok L Kirpalani

The kidneys are the regulators of blood presure (BP) in the normal body. Role of Kidney in Essential HT Essential hypertension (HT) is the cause of HT in 95% of HT sufferers. It is yet unclear what causes essential HT, but a very large number of patients of essential HT are salt-sensitive i.e., when deprived of salt, the BP comes down in these patients. The mechanism that causes HT is in the kidneys, most likely at the level of the tubules. The daily amount of salt ingested by a person needs a certain minimum BP to excrete it from the kidneys. The level of BP required for this is adjusted by a â&#x20AC;&#x2DC;Natriostatâ&#x20AC;&#x2122;. In patients with essential HT, this natriostat is reset at an abnormally high setting. The exact anatomical location of this natriostat is the subject of much current research. Once the molecular/cellular mechanism that operates this natriostat is identified, these patients of salt-sensitive essential HT will no longer be classified as essential HT and their renal etiology will be established. Essential HT can Cause Renal Failure Patients of essential HT can suffer from acute renal failure (ARF) when the essential HT gets converted to malignant HT (probability 1-7%, highest in smokers). When essential HT becomes malignant, the BP shoots up above 120 mmHg diastolic, the ophthalmic fundus shows papilledema, patients become drowsy and can get convulsions (hypertensive encephalopathy). This is a life-threatening situation and can best be treated in the ICU using vigorous modes of BP control. The patient may need dialysis as the creatinine rises rapidly and urine output falls and uremia ensues. As the BP comes under control, renal function actually may deteriorate and patient may require dialysis for

Professor Dept. of Nephrology Bombay Hospital Institute of Medical Sciences, Mumbai

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some time. With good treatment, however, many patients recover renal function, which may not reach normal value but the patient can become dialysis independent with sufficient recovery of renal function. This disease is called malignant nephrosclerosis. Essential HT can also Lead to CRF This is a slow irreversible chronic organ damage, which causes shrinkage of kidneys over a long period of time. There is simultaneous damage seen in other target organs due to essential HT i.e., a) Brain: History of cerebral thrombosis, hemorrhage or other atherosclerotic events like embolic or lacunar infarcts. b) Heart: Evidence of left ventricular hypotrophy (heaving apex beat, enlarged left border of heart on percussion, increased left ventricular mass index (LVMI) and diastolic dysfunction, followed by more severe left ventricular hypotrophy and dilatation on echocardiography), ischemic heart disease (IHD) or congestive heart failure c) Eyes: Showing hypertensive retinopathy Stages I-IV. The urine in this disease is usually free of formed elements but may have small degree of non-nephrotic proteinuria. This disease is called benign nephrosclerosis, even though it ultimately leads to end-stage renal disease needing dialysis and transplantation. It is much more common in the black population. Kidney Diseases Produce HT HT of the renal variety i.e., HT due to renal blood vessels (renovascular HT) or HT due to disease of renal parenchyma (renoparenchymal HT) is secondary to renal disease. Those due to parenchymal disease, such as glomerulonephritis, interstitial nephritis, cysts of kidneys and hereditary diseases like Alport syndrome usually manifest with urinary abnormalities, such as proteinuria, hematuria, pyuria, cylinduria (casts in the urine) and can produce ARF or chronic renal failure (CRF). The urine of patients with renovascular HT is usually free from formed elements, but may have some non-nephrotic range proteinuria. There is clinical confusion when a patient arrives in renal failure and Asian Journal of Clinical Cardiology, Vol. 14, No. 2, June 2011


case report Expert Opinion has HT. What came first the chicken or the egg (i.e., the HT or the renal failure)?

to distinguish what came first - and it may not be necessary from the treatment point of view.

The situation is often clarified mostly by the patientâ&#x20AC;&#x2122;s history and the clinical examination. A long-standing history of HT, with history of IHD, cerebral vascular disease, with minimal proteinuria, little or no hematuria, heaving apex beat and left ventricular enlargement by percussion, with ECG/echocardiogram showing increased left ventricular hypertrophy, diastolic dysfunction, left ventricular hypertrophy and dilatation, or IHD, and with the eyes showing fundal changes of HT - all point towards nephrosclerosis. The absence of these findings are in favor of renal disease producing HT. Quite often however, it is impossible

Renal Parenchymal Disease and Nephrosclerosis can Coexist When a person has renal HT, from any etiology, that hypertensive state itself induces histopathological changes of nephrosclerosis due to the HT and not due to the original renal disease. This nephrosclerosis adds to the renal damage produced by the renal disease and accelerates the process of azotemia. As a therapeutic maneuver, tight control of BP helps to decelerate the process of azotemia and retards the progression of the renal failure towards end-stage. n

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Research Review

From the Journals ... Effect of Spironolactone on Patients with Atrial Fibrillation and Structural Heart Disease Background: Several studies have shown that the modulation of fibrotic scar in cardiac diseases has beneficial effects on cardiac arrhythmias. In addition, recent reports suggest a potential role of mineralocorticoid receptor upregulation in atrial fibrillation (AF). The role of spironolactone, a mineralocorticoid receptor blocker and a potent antifibrotic agent, in AF is as yet unexplored. The aim of this study was to determine if spironolactone, a mineralocorticoid receptor blocker with potent antifibrotic properties, has beneficial effects on AF. Hypothesis: Spironolactone therapy in patients with atrial fibrillation provides additional clinical benefits in addition to the current conventional pharmacological agents. Methods: A comprehensive retrospective analysis was performed on 83 patients with AF, including 23 who were treated with spironolactone for â&#x2030;Ľ3 months. The combined primary outcome of hospitalization for AF or direct current cardioversion (DCCV) was compared between patients treated with spironolactone in addition to the usual care for AF and those receiving conventional medical therapy alone.

Introduction: Leisure sport activity (LSA) is gaining in importance among middle-aged and senior men in the German population. There is a consensus that regular aerobic exercise at moderate intensities and increased physical fitness are associated with a reduced risk of fatal and nonfatal acute cardiac events (ACE) in middleaged individuals. However, vigorous exercise (VE) can acutely and transiently increase the risk of an ACE in susceptible individuals. There is an ongoing discussion as to whether preparticipation screening may prevent such events. This case study characterizes patients participating in LSA who had not been involved in preparticipation screening prior to their ACE. Methods: In the period between June 2003 and July 2009, all consecutive patients with an ACE presenting at the catheter laboratory were retrospectively screened for VE that had occurred during LSA. All 13 men with previously unknown coronary artery disease (CAD) had exercised regularly. All patients underwent coronary angiography. This study characterized clinical parameters, duration of LSA, coronary diagnostic procedure, as well as therapeutic intervention.

Conclusions: Spironolactone therapy is associated with a reduction in the burden of AF, as reflected by a combination of hospitalizations for AF and DCCV. Larger randomized controlled studies should be performed to evaluate the efficacy and safety of spironolactone as an adjunctive therapy for patients with AF.

Results: In seven patients, cardiovascular (CV) risk factors comprised arterial hypertension in seven, hyperlipidemia in seven, smoking or former smoking in two, family history of CV disease in four, and previous peripheral atherosclerotic disease in two. The culprit lesion was identified in seven patients in the left anterior descending artery, in four in the right coronary artery, and in two in the circumflex artery. The mean left ventricular ejection fraction was 65% (45-84). The mean complexity of the lesions using the syntax score was 17 (2-36). PCI was performed in 12 patients, while one patient was transferred for coronary artery bypass grafts. All patients survived their ACE.

Williams RS, Delemos JA, Dimas V, et al. Clin Cardiol 2011 June 14. [Epub ahead of print].

Conclusion: This case study supports the data indicating that ACE in men with previously unknown

Results: Patients receiving spironolactone had significantly fewer primary outcome events (AFrelated hospitalizations or DCCV) (22% vs 53%, p = 0.027).

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Leisure Sport Activity as a Trigger for Acute Coronary Events in Men without known Coronary Artery Disease: A Single-center Case Study

Asian Journal of Clinical Cardiology, Vol. 14, No. 2, June 2011


Research Review CAD is not uncommon during LSA. This patient cohort provides data on a group of patients who might benefit from preparticipation screening. Cuneo A, Oeckinghaus R, Tebbe U. Herz 2011 June 16. [Epub ahead of print]

Impact of Change in Serum Sodium Concentration on Mortality in Patients Hospitalized with Heart Failure and Hyponatremia Background: Hyponatremia is a common electrolyte abnormality among patients hospitalized with heart failure and it is a marker for increased short-term and long-term mortality. However, little is known about the time-course of hyponatremia and whether changes in serum sodium levels impact clinical outcomes. Method and Results: Three hundred twenty-two patients hospitalized with decompensated heart failure and serum sodium <135 mmol/l were evaluated. Following hospital discharge, the first sodium value obtained within a 60-270 day period was recorded, and patients were classified into 3 groups based on whether the serum sodium value increased (≥2 mmol/l), decreased (≤2 mmol/l) or remained unchanged (±1 mmol/l) relative to the baseline value. Kaplan-Meier survival curves were constructed to illustrate mortality as a function of change in sodium concentration over time, and a Cox-proportional hazards model was constructed to determine if change in serum sodium concentration predicted mortality after adjusting for relevant covariates. The mean age of the population was 66 years, 45% were women and 55% were Caucasian. The mean baseline sodium level was 131 mmol/l and the mean ejection fraction was 32.5%. Two hundred twenty-two patients (68.9%) exhibited an increase in sodium during follow-up; in 57 patients (17.7%) the level was unchanged and in 43 patients (13.4%) there was a decrease in sodium level. During a median follow-up of 610 days, there was a strong positive association between change in sodium level and survival (p for trend <0.001); i.e., increased sodium was associated with decreased mortality. In multivariable analysis, change in sodium concentration and higher blood urea nitrogen were the strongest predictors of mortality (both p < 0.0001). Conclusions: Among patients hospitalized with heart failure and hyponatremia, change in serum sodium Asian Journal of Clinical Cardiology, Vol. 14, No. 2, June 2011

concentration over time is a strong predictor of longterm survival. Madan VD, Novak E, Rich MW. Circ Heart Fail 2011 June 14. [Epub ahead of print]

Surgical Ablation of Refractory Ventricular Tachycardia in Patients with Nonischemic Cardiomyopathy Background: The surgical approach for the treatment of ventricular tachycardia (VT) has been largely replaced by percutaneous, catheter-based techniques. However, some VT circuits, particularly in patients with nonischemic cardiomyopathy (NICM), remain inaccessible to percutaneous ablation. Surgical therapy of these VTs is an alternative approach; however, its methodology has not been well-defined. The purpose of this study was to evaluate the efficacy of preoperative electroanatomic and electrophysiologic characterization of the VT substrate and circuit in order to guide surgical ablation. Method and Results: Eight patients with recurrent sustained VT refractory to antiarrhythmic drugs (AAD) underwent endocardial and/or epicardial ablation procedures. Electroanatomical mapping was performed, and the VT substrate, and circuit(s) were defined using voltage, activation, entrainment, and pace-mapping. All eight patients underwent detailed endocardial mapping; six patients also underwent epicardial mapping. Radiofrequency ablation was performed using an open irrigation catheter. Following the unsuccessful percutaneous approach, surgical cryoablation was applied to the sites, previously identified and targeted during the percutaneous procedure. There were no significant perioperative complications. During a mean follow-up period of 23 ± 6 months (Range: 15-34 months), six patients had significant reduction in VT burden as evident by a reduced number of ICD shocks after ablation (6.6 to 0.6 shocks per patient; p = 0.026). Two patients died, one from progressive heart failure and one from sepsis. Conclusions: VT circuits inaccessible to percutaneous ablation techniques are rare but can be encountered in patients with NICM. These VTs can be successfully targeted by surgical cryoablation guided by preoperative electroanatomic and electrophysiologic mapping. Anter E, Hutchinson MD, Deo R, et al. Circ Arrhythm Electrophysiol 2011 June 14. [Epub ahead of print]

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conference calendar

Conference Calendar 16th World Congress on Heart Disease: International Academy of Cardiology, Annual Scientific Sessions 2011

Website: www.iccsk.org

July 23-26, 2011

Worldcon 2011 (XVIth World Congress Cardiology, Echocardiography and Allied Imaging Techniques 2011)

Venue: Vancouver, BC, Canada Website: http://www.cardiologyonline.com/ ICC-Con 2011 (18th Annual Conference of The Indian College of Cardiology 2011) August 19-21, 2011 Venue: ITC, The Sonar, Kolkata Website: www.icc-con2011.org E-mail: rabinchak@yahoo.co.in

E-mail: icn2005@sancharnet.in

September 30, to October 02, 2011 Venue: The Leela Kempinski, Gurgaon, Delhi (NCR) Website: www.worldcon2011.org E-mail: echoacadindia@yahoo.co.in HSI-Con 2011 (20th National Annual Conference of the Hypertension Society of India 2011)

Echo Nagpur 2011 (6th Annual Live Meet on Cardiac Imaging and Clinical Cardiology)

October 29-30, 2011

August 19-21, 2011

Website: http://hsicon2011.com

Venue: Hotel Tuli Imperial, Ramdaspeth, Nagpur

E-mail: hsicon2011@gmail.com

Website: www.echonagpur.com

CSI 2011 (63rd Annual Conference Cardiology Society of India - 2011)

E-mail: admin@echonagpur.com

Venue: Kadavu Resort, Calicut

ICCD 2011 (6th International Congress on Cardiovascular Diseases 2011)

December 08-11, 2011

September 11-13, 2011

Website: www.csi.org.in

Venue: India Habitat Centre, New Delhi

Venue: Mumbai

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Emedinews Section

From eMedinewS SYNTAX Score Useful in Unstable Coronary Disease

Exercise During Pregnancy Improves Fetal Cardiovascular Function

SYNTAX scores, typically used to triage patients to percutaneous or surgical coronary intervention, may also be predictive of future events in patients with non-ST-segment elevation acute coronary syndromes undergoing percutaneous coronary intervention (PCI). The scoring system is based on results from the landmark SYNTAX (Synergy between PCI with Taxus and Cardiac Surgery) trial to help determine when surgery is a better option than stenting.

Many studies have also shown that mothers’ exercise and eating patterns can affect their children’s weight, their predisposition to exercise, and their overall health as adults. Now, a new study, Early Human Development, adds a category to that list by showing evidence that exercising during pregnancy can improve fetus’ cardiovascular health. Researchers at the Kansas City University of Medicine and Biosciences collected fetal heart measurements from 66 fetuses when their mothers reached 28, 32 and 36 weeks of pregnancy. The researchers divided mothers into two groups: One group engaged in moderate to vigorous aerobic activity for 30 minutes at least three times a week while the members of the other group didn’t exercise at all. At 32 weeks, researchers started to see changes in heart response in the fetuses of the exercising moms and at 36 weeks, they noted significant changes, including a lower heart rate and increased heart rate variability.

Source: Medpage Today

Waist Size is a Better Predictor of Health, Especially in Heart Patients Research studies and health experts have long predicted that waist size is a better way to estimate heart disease and mortality risk than body mass index (BMI). Now a new review article published in the Journal of the American College of Cardiology adds to the list of evidence in favor of measuring waist size. The article, which reviews and analyzes results from several major studies, declares that waist size provides a far more accurate way to predict a heart patient’s chances of dying at an early age from a heart attack or other causes. Researchers from the Mayo Clinic analyzed data from just under 16,000 heart patients who had participated in previous studies. More than one-third of the patients died during the studies, which lasted from six months to eight years. The researchers found that heart patients with a high ratio of waist-to-hip circumference or a large waist size (>35 inches for women or >40 inches for men) were 70% more likely to die during the study period than those with smaller waists. The combination of a large waist and a high BMI upped the risk of death even more, indicating that overall body weight does play a part, although it’s to a lesser extent. In order to keep your waistline down, aim to exercise or be active on most days of the week. —Rajat Bhatnagar, International Sports and Fitness Distribution, LLC

Asian Journal of Clinical Cardiology, Vol. 14, No. 2, June 2011

3,500-year Mummy is Oldest Heart Disease Case London: An Egyptian princess who lived 3,500 years ago is thought to be the first known person to have had heart disease, say experts. An international team, which analyzed the remains of 52 mummies, including that of the princess, claims that she would have needed a heart bypass surgery if she were living now, for scans show she had coronary artery disease. Princess AhmoseMeryet-Amon was from an illustrious Egyptian family. She lived in what is now Luxor from the year 1580 BC, and died in her 40s. Her mummified body has been kept at the National Museum of Antiquities, Cairo. According to the researchers, the princess, who lived on a diet rich in vegetables, fruit, limited meat and plenty of fish from Nile river, had extensive blockages in arteries leading to her heart, brain, stomach and legs. The researchers say her case shows heart disease pre-dates a modern lifestyle. Gregory Thomas of the University of California, who led the team, said, “There was no gas or electricity at that time, so presumably 63


eMedinewS Section she had an active lifestyle”. Her diet was significantly healthier than ours. She would have eaten fruit and vegetables and fish were plentiful in the Nile at that time. The food would have been organic - and there were no trans-fats or tobacco available then. “Yet, she had these blockages. This suggests to us that there’s a missing risk factor for heart disease - something that causes it that we don’t yet know enough about.” Source: TOI, May 19, 2011

Higher-salt Diet and Blood Pressure Higher sodium consumption was associated with increased systolic blood pressure, but not greater mortality or cardiovascular events in a new prospective analysis of Europeans’ sodium excretion. The study included 3,681 people without cardiovascular disease at the start of the trial who were followed for a median of 7.9 years. They were divided into tertiles by their 24-hour urinary sodium excretion, and cardiovascularrelated death rates were compared among the tertiles. The results were published in the May 4 Journal of the American Medical Association. Gout Enhances Risk of MI in Young According to a study reported at the Annual European Congress of Rheumatology, gout is an independent risk factor for acute myocardial infarction, even among younger patients and those without cardiovascular risk factors. ESHG: Lipid Genes Signal Diabetes, Heart Disease The genes that control lipid levels may be an early predictor of diabetes as well as atherosclerosis and heart disease, researchers reported in two separate studies. In one study, the lipid component dihydroceramide (dhCer) coded by a region on chromosome 3 appeared to be a diabetes risk factor independent of glucose and insulin levels, Joanne E Curran, PhD, of the Texas Biomedical Research Institute in San Antonio, and colleagues found. In another, a risk score pooling small effects of common genetic variants predicted carotid plaque and arterial wall thickness as well as coronary heart disease, reported Sara Willems, PhD, of Erasmus Medical Center in Rotterdam, the Netherlands, and colleagues. Both studies were presented at the European Society of Human Genetics meeting in Amsterdam. Source: Medpage Today

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Study Shows 19% of Young Adults have High Blood Pressure Roughly 19% of young adults may have high blood pressure, according to an analysis of the National Longitudinal Study of Adolescent Health (Add Health), which is supported by the National Institutes of Health. The researchers took blood pressure readings of more than 14,000 men and women between 24 and 32 years of age who were enrolled in the long-running study. The analysis was conducted by Kathleen Mullan Harris, PhD, principal investigator of the study, and colleagues at the University of North Carolina at Chapel Hill. The study’s first author was Quynh C Nguyen, of the University of North Carolina Gillings School of Public Health. The findings were published online in Epidemiology. Diabetes may be Less of a Heart Risk for Women In a study of asymptomatic patients with type 2 diabetes, women had a lower cardiac event rate than men, although screening for silent myocardial ischemia did not benefit either sex, a post-hoc analysis of the DIAD trial showed. NIH Stops Clinical Trial on Combination Cholesterol Treatment The National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health has stopped a clinical trial studying a blood lipid treatment 18 months earlier than planned. The trial found that adding high-dose, extended-release niacin to statin treatment in people with heart and vascular disease, did not reduce the risk of cardiovascular events, including heart attacks and stroke. Participants were selected for AIM-HIGH because they were at risk for cardiovascular events despite well-controlled low-density lipoprotein (LDL or bad cholesterol). Their increased risk was due to a history of cardiovascular disease and a combination of low highdensity lipoprotein (HDL or good cholesterol) and high triglycerides, another form of fat in the blood. Low HDL and elevated triglycerides are associated with an increased risk of cardiovascular events. While lowering LDL decreases the risk of cardiovascular events, it has not been shown that raising HDL similarly reduces the risk of cardiovascular events. During the study’s Asian Journal of Clinical Cardiology, Vol. 14, No. 2, June 2011


eMedinewS Section 32 months of follow-up, participants who took highdose, extended-release niacin and statin treatment had increased HDL cholesterol and lowered triglyceride levels compared to participants who took a statin alone. However, the combination treatment did not reduce fatal or nonfatal heart attacks, strokes, hospitalizations for acute coronary syndrome or revascularization procedures to improve blood flow in the arteries of the heart and brain. The AIM-HIGH trial, which stands for Atherothrombosis Intervention in Metabolic Syndrome with Low HDL/High Triglycerides: Impact on Global Health, enrolled 3,414 participants in the United States and Canada with a history of cardiovascular disease who were taking a statin drug to keep their LDL cholesterol low. Study participants also had low HDL cholesterol and high triglycerides, which meant that they were at significant risk of experiencing future cardiovascular events. Niacin, also known as Vitamin B3, has long been known to raise HDL and lower triglycerides. Eligible participants were randomly assigned to either high-dose, extended-release niacin (Niaspan) in gradually increasing doses upto 2,000 mg/day (1,718 people) or a placebo treatment (1,696 people). All participants were prescribed simvastatin (Zocor), and 515 participants were given a second LDL cholesterol-lowering drug, ezetimibe (Zetia), in order to maintain LDL cholesterol levels at the target range between 40-80 mg/dl. Researchers began recruiting participants in early 2006. The study was scheduled to finish in 2012. The average age of the participants was 64 years. Preexisting medical conditions included coronary artery disease (92%); metabolic syndrome, which is a cluster of risk factors for heart disease (81%); high blood pressure (71%); and diabetes (34%). More than half of participants reported having a heart attack prior to entering the study. The rationale for the AIM– HIGH study was based in part on a large number of observational studies that consistently showed that low HDL cholesterol increases the risk of cardiovascular events in men and women, independent of high LDL cholesterol. In addition, previous small clinical studies showed that relatively high residual cardiovascular risk exists among patients with cardiovascular disease, low HDL cholesterol and high triglycerides despite intensive management of LDL cholesterol. Asian Journal of Clinical Cardiology, Vol. 14, No. 2, June 2011

Higher Heart Rate Acts as Prognostic Marker A rapid heart rate in chronic heart failure patients carries a higher mortality risk regardless of ejection fraction status, but also predicts a modest survival benefit from candesartan, researcher Davide Castagno, MD, of Brigham and Women’s Hospital in Boston, and colleagues reported. Nearly One in Five Young Adults may have High Blood Pressure The number of young adults in the United States with high blood pressure may be much higher than previously reported, according to a new study by researchers at the University of North Carolina at Chapel Hill. Vitamins-Open Secrets revealed Folic Acid Helps Prevent Coronary Heart Disease

A high level of homocysteine in the blood has been clearly implicated in heart disease, stroke and peripheral vascular disease. Homocysteine is an amino acid that is not found in protein as such, but is involved in the metabolism of other amino acids (methionine and cysteine). The average blood level of total homocysteine in male adults is about 10 µmol/l. Researchers at the University of Washington confirm that people with a higher than normal level of homocysteine have a greater risk of developing vascular disease. The researchers evaluated 17 studies dealing with the link between homocysteine levels and the risk of coronary artery disease (CAD). They found that men with a level of 15 µmol/l had a 60% greater risk of developing CAD while the increased risk for women was 80%. The risk for cerebrovascular disease (stroke) was found to be almost twice as high in men and women with elevated (15 µmol/l) homocysteine levels. The risk of developing peripheral vascular disease (e.g. intermittent claudication) was found to be almost seven times higher among people with elevated homocysteine levels. The researchers conclude that a high homocysteine level is an independent risk factor for vascular disease and that a 5 µmol/l elevation results in the same increase in CAD risk as a cholesterol increase of 0.5 mmol/l (20 mg/dl). The researchers 65


eMedinewS Section also evaluated 12 studies concerning the connection between dietary intake of folic acid and homocysteine level. They found that folic acid is very effective in lowering homocysteine levels. An intake of 400 µg/ day (the level found in most supplements) lowers the homocysteine level by about 6 µmol/l. The researchers conclude that over 44,000 lives could be saved every year if just half the population of the United States were to supplement with 400 µg/day of folic acid. Unfortunately, recent surveys have shown that 88% of American adults have a daily intake of folic acid

<400 µg. The researchers warn that an increased intake of folic acid may mask a vitamin B12 deficiency and recommend that 1 mg of vitamin B12 be added to all supplements containing 400 µg of folic acid. They also recommend that consideration be given to fortifying grain products with 350 µg of folic acid per 100 g of grains. This strategy would have the added advantage of making it easier to prevent neural tube defects in newborn babies. JAMA 1995;274(13):1049-57.

Medicolegal Update How will a doctor judge/assess the decision-making capacity of a patient?

Competent and conscious patients have the exclusive right to refuse medical care. 

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The patient’s right to refuse care is determinative even in cases where the patient’s wishes may conflict with those of his or her family or legal agency. Decisions become more difficult when patients have some cognitive impairment, such as moderate Alzheimer’s disease, senile dementia. In such a situation, the first step is to try to determine if the patient is able to make decisions for him or herself. If not, the next step would be to determine whether they have made any previous instructions for their care. Mental Competence is a legal term and must be determined by a judge and not a doctor after a thorough medical examination report and relates to whether individuals have the legal right to make

their own decisions and whether others should respect the decisions they make. Mental Capacity is the clinical cousin to the legal term ‘competence’. A patient may have the capacity to express their values and preferences and make decisions regarding treatment even if they are unable to carry out other functions of higher reasoning such as balancing their money/property or living independently. On the other hand, a patient without capacity may seem intact in superficial conversation but be unable to make decisions regarding their medical care on their own preferences and values. Capacity does not require a formal legal determination or psychiatric/medical evaluation but can be done by clinicians. —Dr Sudhir Gupta, Additional Professor, Forensic Medicine and Toxicology, AIIMS

Medifinance Update

Spiritual Update

What is short selling?

Hanuman Chalisa

When an investor goes long on an investment, this means that he or she has bought a stock believing its price will rise in the future. Conversely, when an investor goes short he or she is anticipating a decrease in share price therefore “Short selling is the selling of a stock that the seller does not own.” More specifically, a short selling means the sale of a security or any individual stock that is not owned by the seller at that point of time, but he promises to deliver it at time of delivery.

Sadho Sant Ke Tum Rakhvare Asur Nikandan Ram Dulare Meaning: Oh Hanumanaji! You are the savior and the guardian angel of saints and sages and destroy all the Demons; you are the seraphic darling of Shri Ram. Spiritual significance: By regular pranayama, achieving parasympathetic state and meditating on the Anhata chakra one acquires the power of sages and destroys the demonic qualities in one self.

Asian Journal of Clinical Cardiology, Vol. 14, No. 2, June 2011


lighter reading

Lighter Reading

10 Commandments of Marriage Commandment 1: Marriages are made in heaven. But so are thunder and lightning. Commandment 2: If you want your wife to listen and pay strict attention to every word you say; talk in your sleep. Commandment 3: Marriage is grand - and divorce is at least 100 grand! Commandment 4: Married life is very frustrating. In the first year of marriage, the man speaks and the woman listens. In the second year, the woman speaks and the man listens. In the third year, they both speak and the neighbours listen. Commandment 5: When a man opens the door of his car for his wife, you can be sure of one thing: Either the car is new or the wife is. Commandment 6: Marriage is when a man and woman become as one. The trouble starts when they try to decide which one. Commandment 7: Before marriage, a man will lie awake all night thinking about something you say. After marriage, he will fall asleep before you finish. Commandment 8: Every man wants a wife who is beautiful, understanding, economical and a good cook. But the law allows only one wife. Commandment 9: Marriage and love are purely matter of chemistry. That is why wives treat husbands like toxic waste. Commandment 10: A man is incomplete until he is married. After that, he is finished

All things in life are temporary. If going well, enjoy it, they will not last forever. If going wrong, don’t worry, they can’t last forever either. Often when we lose hope and think this is the end, God smiles from above and says, “Relax, it’s just a bend, not the end! When God solves your problems, you have faith in His abilities; when God doesn’t solve your problems, He has faith in your abilities. Worrying does not take away tomorrow’s troubles, it takes away today’s peace. When you pray for others, God listens to you and blesses them and sometimes, when you are safe and happy, remember that someone has prayed for you. Laugh a While!

Traffic policeman: “Didn’t you hear my whistle, madam?” Woman driver: “Yes, but I don’t like flirting while I’m driving.”

make sure

During Medical Practice A 60-year-old male developed acute heart attack after consuming Viagra.

Oh my God! Why was cardiac clearance not taken before?

Pearls of Thought

Prayer is not a ‘spare wheel’ that you pull out when in trouble, but it is a ‘steering wheel’ that directs the right path throughout life. Do you know why a car’s windshield is so large and the rear view mirror is so small? Because our past is not as important as your future. Look ahead and move on. Friendship is like a book. It takes few seconds to burn, but it takes years to write.

Asian Journal of Clinical Cardiology, Vol. 14, No. 2, June 2011

© IJCP ACADEMY

Make sure that all older patients get a cardiac clearance before they are given Viagra group of drugs. Dr KK Aggarwal

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

- -

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

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

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-

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

-

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

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

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

-

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

-

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.

Asian Journal of Clinical Cardiology, Vol. 14, No. 2, June 2011


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 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.

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. -

Do not use clips/staples on photographs and artwork.

-

Illustrations must be drawn neatly by an artist and photographs must be sent on glossy paper. No captions should be written directly on the photographs or illustration. Legends to all photographs and illustrations should be typed on a separate sheet of paper. All illustrations and figures must be referred to in the text and abbreviated as ‘Fig.’. Please complete the following checklist and attach to the manuscript: 1. Classification (e.g. original article, review, selected summary, etc.)_______________________________ 2. Total number of pages ________________________ 3. Number of tables ____________________________ 4. Number of figures ___________________________ 5. Special requests _____________________________

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. -

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

Asian Journal of Clinical Cardiology, Vol. 14, No. 2, June 2011

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 Website: www.ijcpgroup.com

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One of the leading medical publication groups in Asia. A Pioneer in Medical Journalism with publications in various specialities that bring to you the latest happenings, technological developments, vision into the future and much more in the medical field. Since 18 years, IJCP Group has been providing viable and cost-effective media and communication solutions to the pharma and healthcare companies in getting their message across the target audiences. IJCP is the preferred media partner of leading pharmaceutical and healthcare companies in India as well as some Asian countries.

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