The atrial fibrillation prevalence is found between 0.1% and 4% in community-based research and b... more The atrial fibrillation prevalence is found between 0.1% and 4% in community-based research and between 2.8% and 14% in studies conducted in hospitals; nevertheless, a large portion of AF is still misdiagnosed. Smartphone applications for diagnosing AF have been proposed given that a big portion of Indians own smartphones, although it is unknown how accurate these programs would be. The study's objectives were as follows: a) To evaluate the diagnostic efficacy of the Spandan ECG in detecting AF in a single center trial that took place in SMIH Dehradun under the supervision of the cardiologist, and b) to investigate arrhythmia detection through a smartphone-based and monitoring. This single-blinded, cross-sectional, single-center study was conducted at Shri Mahant Indresh Hospital (SMIH), Dehradun, Uttarakhand, India from August 2022 to December 2022. Patients (n=32) undergoing the electrocardiogram (ECG) at the Department of Cardiology of the SMIH, Dehradun during the study peri...
International Journal of Community Medicine and Public Health, Mar 29, 2023
The pathogenesis of ST-elevation myocardial infarction (STEMI), which can result from thrombus or... more The pathogenesis of ST-elevation myocardial infarction (STEMI), which can result from thrombus or other mediating factors, is connected to sudden complete blockage of the coronary artery lumen in acute coronary syndrome. 1-4 For the best clinical outcome in STEMI patients, quick catheter-based or pharmacologic reperfusion therapy is required. According to reports, nonreperfused STEMI victims lose one-third of their lives during the first 24 hours following the event. Most STEMI fatalities take place in the prehospital environment within ABSTRACT Background: When a severe heart attack called a ST segment elevation myocardial infarction (STEMI) is not treated, heart muscle is killed per minute. Hence, early detection and treatment are essential for patient survival. The objectives of this study were to evaluate the accuracy for detection of (a) the ST elevation myocardial infarction of smartphone 12 lead ECG system in comparison to 12 lead gold standard hospital ECG machine; and (b) classification of STEMI in smartphone ECG and hospital ECG. Methods: This prospective, cross sectional study, non-randomised, single blinded and single-center study was carried out at Shri Mahant Indresh Hospital (SMIH), Dehradun, Uttarakhand, India from 30 May 2022 to 17 January 2023. All patients (n=154) with chest pain, shortness of breath, palpitation under the observations before and after the Percutaneous coronary intervention (PCI) like Coronary angioplasty, bypass surgery were enrolled from Critical care unit (CCU) and intensive critical care unit (ICCU). Results: Mean age (SD) was 53.90±11.7 years. The male gender (83.12%) shows the maximum frequency than female gender. True positive cases derived from confusion matrix for 12 lead standard ECG and smartphone ECG in comparison to cardiologist diagnosis was 113 as compared to 129 from 12 lead Gold standard. Sensitivity of smartphone Spandan ECG (87.5%) was comparable to gold standard 12 lead ECG (98.4%). And, specificity and PPV of smartphone Spandan ECG was recorded to be better than gold standard 12 Lead ECG. STEMI was detected correctly in 132 (86.3%) cases and 141 (80.85%) cases by smartphone ECG and 12 lead Gold standard, respectively. Conclusions: Spandan ECG device scored a high accuracy and sensitivity. The overall accuracy of smartphone ECG in detecting the STEMI increased by 5.45%, i.e. the significance rise in accuracy of computer interpretation when compared to the cardiologists' diagnosis.
Background: Reliable and early detection of myocardial ischemia using computer-aided analysis of ... more Background: Reliable and early detection of myocardial ischemia using computer-aided analysis of electrocardiograms (ECG) provides an important reference for early diagnosis of CVD. We developed a 12-lead smartphone-based electrocardiogram (ECG) acquisition and monitoring system (called “Spandan”), and an application to assess underlying ischemia from analysis of electrocardiographic (ECG) signals only. Objectives of this study were to validate the Spandan 12 lead ECG interpretation for accuracy in the detection of Ischemia in comparison to cardiologists’ diagnosis and to evaluate the accuracy of ischemia in comparison to the interpretation of standard 12 lead ECG. Methods: In this multi-center study all patients (n=597) visiting the ECG room at the department of cardiology were enrolled in the study by taking their written consent and explaining the purpose of the study. Results: Mean age was 52.85 years. The male gender (n=344, 57.62%) shows the maximum frequency than female gende...
International Journal of Research in Medical Sciences
Background: For the identification of arrhythmia and abnormal instances, researchers are examinin... more Background: For the identification of arrhythmia and abnormal instances, researchers are examining the reliability of the interpretation offered by smartphone-based portable ECG monitors. The indicator of an unclear alteration in the electrical activity of the heart is a cardiac abnormality. As a result, its early and accurate identification can avoid myocardial infarction and even sudden cardiac death. Objectives of this study were to evaluate and validate the Spandan 12 lead ECG interpretation for accuracy in detection of the cardiac arrhythmias in comparison to the cardiologist diagnosis, and to evaluate the accuracy of the arrhythmia detection of Spandan ECG in comparison to the 12 lead ECG machine. Methods: This cross-sectional study, non-randomised, single blinded and single-center study was carried out at Shri Mahant Indresh Hospital (SMIH), Dehradun, Uttarakhand, India from 1st August 2022 to 31st January 2023. All patients (n=312) visiting the electrocardiogram (ECG) room a...
Background: In patients experiencing an ST-elevation myocardial infarction (STEMI), rapid diagnos... more Background: In patients experiencing an ST-elevation myocardial infarction (STEMI), rapid diagnosis leads to optimal clinical outcomes. Recent technology has provided access to a reliable means of obtaining an ECG reading through a smartphone application (app) that works with an attachment providing all 12-leads of a standard ECG system. We developed a 12-lead smartphone-based electrocardiogram (ECG) called “Spandan”, and an application to accurately assess the presence of STEMI in patients presenting with chest pain. Objectives of study was to perform clinical observation studies on the patients screened for STEMIs and evaluate the variation in the diagnosis of STEMIs detected in both 12-lead gold standard and Spandan 12 lead ECG. Methods: This single-center study was carried out at Shri Mahant Indresh hospital (SMIH), Dehradun, Uttarakhand, India from April-2022 to November-2022. All patients (n=278) visiting the ECG room with symptoms of chest pain, shortness of breath and past ...
BACKGROUND Electrocardiography is the most convenient and cost-effective method at the primary le... more BACKGROUND Electrocardiography is the most convenient and cost-effective method at the primary level of healthcare infrastructure to localize and diagnose Myocardial infarction, ischemic heart diseases, and numerous arrhythmias. The manufacturers of ECG machines provide computer-generated Interpretations. However, these machines have differences in implementing the algorithms, which causes a change in diagnostic accuracy. Hence, the occurrence of False positives is the most commonly observed error that occurs during computer interpretation. OBJECTIVE This study aims to evaluate the differences observed in the computerized interpretation of ECG reports regarding the Cardiologist's diagnosis. METHODS The 12-lead ECG reports were collected from a 12-lead gold standard machine and a smartphone-based 12 lead ECG machine. The data of the 294 subjects out of 300 subjects were accessed from both ECG machines. The reports were evaluated by a Cardiologist based on the observational change...
ABSTRACT Secondary hypertension, i.e. where a definite cause for hypertension can be found, is no... more ABSTRACT Secondary hypertension, i.e. where a definite cause for hypertension can be found, is not uncommon in clinical practice and accounts for about 5% cases of hypertension. Common causes of secondary hypertension include renal parenchymal disease, renovascular hypertension, Conn Syndrome and pheochromocytoma. In Asian countries, aortoarteritis is still a common cause of secondary hypertension among young patients, especially females. Early diagnosis and appropriate treatment may significantly alter the natural history of the disease with substantial improvement in prognosis. Whenever a patient is diagnosed with hypertension, every effort should be made to rule out any possible secondary cause for the hypertension. Suspicion of secondary hypertension should be high in early or late onset hypertension, resistant hypertension, accelerated hypertension and in patients with markedly elevated blood pressure with severe target organ damage. Reno-vascular hypertension can be evaluated by non-invasive modalities like Ultrasound Doppler, MR angiography and CT angiography. If primary aldosteronism is suspected, patients should undergo screening with plasma rennin/aldosterone ratio and MRI for the detection of morphological adrenal abnormalities. Patient suspected of pheochromocytoma shows an increase in plasma or urinary catecholamines, but CT and MRI are needed to localize the tumours. Targeted testing should be done in all these patients to rule out any possible cause for secondary hypertension. Careful and thorough clinical evaluation and simple algorithms are needed to avoid unnecessary tests in making the diagnosis of secondary forms of hypertensions more accurately and promptly. Correcting the cause of secondary hypertension can lead to cure, avoiding the need for long-term medical therapy.
The ideal management of stable patients who present late after acute ST-elevation myocardial infa... more The ideal management of stable patients who present late after acute ST-elevation myocardial infarction (STEMI) is still a matter of conjecture. We hypothesized that the extent of improvement in left ventricular function after successful revascularization in this subset was related to the magnitude of viability in the infarct-related artery territory. However, few studies correlate the improvement of left ventricular function with the magnitude of residual viability in patients who undergo percutaneous coronary intervention in this setting. In 68 patients who presented later than 24 hours after a confirmed first STEMI, we performed resting, nitroglycerin-enhanced, technetium-99m sestamibi single-photon emission computed tomography–myocardial perfusion imaging (SPECT–MPI) before percutaneous coronary intervention, and again 6 months afterwards. Patients whose baseline viable myocardium in the infarct-related artery territory was more than 50%, 20% to 50%, and less than 20% were divid...
ABSTRACT Where at one hand, the vast majority of hypertensive patients succumb to the complicatio... more ABSTRACT Where at one hand, the vast majority of hypertensive patients succumb to the complications of hypertension like atherosclerosis, cerebrovascular diseases and congestive heart failure, a subset of these have an exacerbation in this gradual course that needs acute management in the blood pressure control and plays a role in short term outcomes. These hypertensive crises are now encountered more frequently, in more diverse and aging population than in earlier times.Despite the recognized unmet need of timely evaluation and management, fewer than 10% receive the recommended investigations and appropriate treatment often gets delayed. This review emphasizes the therapeutic implications of correct diagnosis, various treatment options and targets in different clinical circumstances.Nicardipine, clevidipine, esmolol and fenoldopam have emerged as potentially superior drugs in most hypertensive emergencies as compared to other conventional drugs. For hypertensive urgencies, blood pressure lowering at a gradual pace with oral drugs & adequate follow up are two important facets of management, making sure that the blood pressure has been lowered out of a potentially dangerous range.Impact of optimal management of hypertensive crisis should translate into lesser target organ damage and eventually fewer complications of stroke, myocardial infarction, or congestive heart failure.
ABSTRACT Amongst patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD), t... more ABSTRACT Amongst patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD), the leading cause of recurrent hospitalizations and death is cardiovascular diseases. Patients with CKD are more likely to die from cardiovascular causes than due to kidney related manifestations. Irrespective of the baseline renal function, even overt proteinuria and microalbuminuria are independent predictors of cardiovascular morbidity and mortality. Most current guidelines hence recommend that patients with CKD be considered to belong to the highest risk group for the development of cardiovascular diseases. However there is a significant “therapeutic inertia” and consequent sub-optimal management of patients with ESRD and associated cardiovascular diseases, owing to the fact that many such patients are often excluded in most large trials of cardiovascular morbidity and mortality. Moreover, due to the high incidence of associated coronary artery disease in patients with ESRD, it is important to appropriately risk stratify such patients awaiting renal transplantation. Though optimal screening protocols and frequency of testing have not been well defined, this paper discusses guidelines based practical approaches to cardiovascular risk in these high-risk patients.
Bronchoscopy is widely performed and generally considered safe. Cardiac complications during bron... more Bronchoscopy is widely performed and generally considered safe. Cardiac complications during bronchoscopy are uncommon, and usually occur in elderly patients with coexistent coronary artery disease, hypertension, or severely impaired pulmonary function and resting hypoxemia. We report a patient who developed sudden onset restlessness, chest discomfort, hypotension, global ST elevation in multiple electrocardiogram leads, and acute severe left ventricular systolic dysfunction during a bronchoscopic transbronchial lymph node biopsy. Differential diagnosis included a massive myocardial infarction, apical ballooning (Tako-tsubo syndrome), or coronary vasospasm. The electrocardiogram changes resolved spontaneously, and a coronary angiogram 48 hours later revealed normal coronary artery anatomy and normal LV function. The patient made an uneventful recovery. It is important for physicians to be aware of such unusual complications to be able to appropriately manage these patients in clinical practice.
Endothelial dysfunction is the postulated link between coronary artery disease (CAD) and erectile... more Endothelial dysfunction is the postulated link between coronary artery disease (CAD) and erectile dysfunction (ED). Brachial artery flow-mediated vasodilatation (FMD) is a non-invasive surrogate marker for endothelial function assessment. Despite Asian Indians representing a considerable global CAD burden, data on FMD and ED in these patients are lacking. Of the 225 patients undergoing coronary angiography, 72% had ED (assessed using the International Index of Erectile Function (IIEF-5) questionnaire); ED was moderate to severe in 61% of the patients. ED patients had a higher incidence of severe and diffuse angiographic CAD, a greater number of coronary vessels involved and a lower mean brachial artery FMD (6.40%64.60% vs. 9.10%64.87%, P,0.001) compared to non-ED patients. A progressive reduction in FMD was noted with increasing severity of ED. Impaired FMD (f5.5%) was twice as common in ED patients (52% vs. 24% without ED). Patients with impaired FMD had higher ED prevalence (85% vs. 62%) and lower mean IIEF-5 scores compared to those with normal FMD. Impaired FMD was a significant ED predictor independent of other risk factors (odds ratio, 2.33; 95% confidence interval: 0.59-9.23; P50.03). An inverse correlation between FMD and ED severity was observed (r520.22; P50.004). ED is common among Asian Indians with angiographically documented CAD. Patients with ED have impaired FMD independent of other risk factors, suggesting that endothelial dysfunction is the underlying pathophysiology. Urologists and cardiologists need to be aware of the association between ED, CAD and endothelial dysfunction.
Erectile dysfunction (ED) and coronary artery disease (CAD) often share common risk factors, and ... more Erectile dysfunction (ED) and coronary artery disease (CAD) often share common risk factors, and there is growing evidence that ED might serve as a clinical marker for cardiovascular disease. Despite rising trends of CAD in Asian Indians, limited data are available on the prevalence of ED and its correlation with CAD severity in such patients. To study the prevalence of ED in Asian Indian patients undergoing coronary angiography and to assess if the severity of ED correlates with angiographic severity of CAD. In all patients undergoing coronary angiography, ED was assessed using the International Index of Erectile Function-5 questionnaire. Among 175 male patients, ED was present in 70%; patients with ED had a higher incidence of multivessel CAD (80% vs. 36%, P 0.001), diffuse CAD (81% vs. 34%, P 0.001), and higher number of mean coronary vessels involved compared with those without ED. Those with severe ED had higher prevalence of multivessel CAD and higher number of mean coronary vessels involved compared with those with milder grades of ED. Onset of symptoms of ED preceded symptoms of CAD by a mean of 24.6 months in 84% of patients. The presence of severe ED was associated with a 21-fold higher risk of having triple-vessel disease (odds ratio [OR] 21.94, 95% confidence interval [CI] 3.41-141.09, P = 0.001) and an 18-fold higher risk of having diffuse angiographic CAD (OR 17.91, 95% CI 3.11-111.09, P = 0.001). Asian Indians with angiographic CAD frequently have ED; symptoms of ED precede that of CAD in most patients. Incidence of multivessel and diffuse CAD is significantly more common in patients with ED. It is important for physicians to be aware of the close relationship between the two conditions so that patients with ED can have optimal risk stratification for concomitant CAD whenever required.
Background:Erectile dysfunction in type-2 diabetes may be an independent marker for coronary arte... more Background:Erectile dysfunction in type-2 diabetes may be an independent marker for coronary artery disease. Present study was undertaken to investigate whether type-2 diabetic patients with erectile dysfunction without having overt cardiovascular disease had increased cardiovascular risk.Aim:To find out correlation between ED and cardiovascular risk in diabetic patients.Methods:Fifty type-2 diabetic patients were assessed for erectile dysfunction using international index of erectile dysfunction (IIEF-5), which include questionnaire and cardiovascular risk assessment by multiparameter cardiovascular analysis device (periscope).Results:The prevalence of erectile dysfunction in type-2 diabetics was very high (78%), mild, moderate and severe ED was present in 6, 36 and 36%, respectively. The total cardiovascular risk was more in patients with ED in comparison to patients without ED (34.87 ± 18.82 vs 20.91 ± 11.03 p = 0.002). The mean 10-years coronary risk and cardiac risk was 12.00 + 9.60 and 22.23 + 14.14 (p = 0.029) and 13.36 ± 1.22 and 28.85 ± 4.13 (p 0.002) in patients without ED and with ED respectively. The mean vascular and atherosclerosis risk was 28.73 ± 13.94 and 39.38 ± 19.51 (p > 0.05) and 26.18 ± 10.31 and 33.92 ± 13.40 (p > 0.05) in patients without ED and with ED, respectively. Total cardiovascular risk was found to increase with age, duration of diabetes and HbA1c levels.Conclusion:The total cardiovascular risk increases with increasing severity of erectile dysfunction in type-2 diabetic patients without having overt cardiovascular disease.
The atrial fibrillation prevalence is found between 0.1% and 4% in community-based research and b... more The atrial fibrillation prevalence is found between 0.1% and 4% in community-based research and between 2.8% and 14% in studies conducted in hospitals; nevertheless, a large portion of AF is still misdiagnosed. Smartphone applications for diagnosing AF have been proposed given that a big portion of Indians own smartphones, although it is unknown how accurate these programs would be. The study's objectives were as follows: a) To evaluate the diagnostic efficacy of the Spandan ECG in detecting AF in a single center trial that took place in SMIH Dehradun under the supervision of the cardiologist, and b) to investigate arrhythmia detection through a smartphone-based and monitoring. This single-blinded, cross-sectional, single-center study was conducted at Shri Mahant Indresh Hospital (SMIH), Dehradun, Uttarakhand, India from August 2022 to December 2022. Patients (n=32) undergoing the electrocardiogram (ECG) at the Department of Cardiology of the SMIH, Dehradun during the study peri...
International Journal of Community Medicine and Public Health, Mar 29, 2023
The pathogenesis of ST-elevation myocardial infarction (STEMI), which can result from thrombus or... more The pathogenesis of ST-elevation myocardial infarction (STEMI), which can result from thrombus or other mediating factors, is connected to sudden complete blockage of the coronary artery lumen in acute coronary syndrome. 1-4 For the best clinical outcome in STEMI patients, quick catheter-based or pharmacologic reperfusion therapy is required. According to reports, nonreperfused STEMI victims lose one-third of their lives during the first 24 hours following the event. Most STEMI fatalities take place in the prehospital environment within ABSTRACT Background: When a severe heart attack called a ST segment elevation myocardial infarction (STEMI) is not treated, heart muscle is killed per minute. Hence, early detection and treatment are essential for patient survival. The objectives of this study were to evaluate the accuracy for detection of (a) the ST elevation myocardial infarction of smartphone 12 lead ECG system in comparison to 12 lead gold standard hospital ECG machine; and (b) classification of STEMI in smartphone ECG and hospital ECG. Methods: This prospective, cross sectional study, non-randomised, single blinded and single-center study was carried out at Shri Mahant Indresh Hospital (SMIH), Dehradun, Uttarakhand, India from 30 May 2022 to 17 January 2023. All patients (n=154) with chest pain, shortness of breath, palpitation under the observations before and after the Percutaneous coronary intervention (PCI) like Coronary angioplasty, bypass surgery were enrolled from Critical care unit (CCU) and intensive critical care unit (ICCU). Results: Mean age (SD) was 53.90±11.7 years. The male gender (83.12%) shows the maximum frequency than female gender. True positive cases derived from confusion matrix for 12 lead standard ECG and smartphone ECG in comparison to cardiologist diagnosis was 113 as compared to 129 from 12 lead Gold standard. Sensitivity of smartphone Spandan ECG (87.5%) was comparable to gold standard 12 lead ECG (98.4%). And, specificity and PPV of smartphone Spandan ECG was recorded to be better than gold standard 12 Lead ECG. STEMI was detected correctly in 132 (86.3%) cases and 141 (80.85%) cases by smartphone ECG and 12 lead Gold standard, respectively. Conclusions: Spandan ECG device scored a high accuracy and sensitivity. The overall accuracy of smartphone ECG in detecting the STEMI increased by 5.45%, i.e. the significance rise in accuracy of computer interpretation when compared to the cardiologists' diagnosis.
Background: Reliable and early detection of myocardial ischemia using computer-aided analysis of ... more Background: Reliable and early detection of myocardial ischemia using computer-aided analysis of electrocardiograms (ECG) provides an important reference for early diagnosis of CVD. We developed a 12-lead smartphone-based electrocardiogram (ECG) acquisition and monitoring system (called “Spandan”), and an application to assess underlying ischemia from analysis of electrocardiographic (ECG) signals only. Objectives of this study were to validate the Spandan 12 lead ECG interpretation for accuracy in the detection of Ischemia in comparison to cardiologists’ diagnosis and to evaluate the accuracy of ischemia in comparison to the interpretation of standard 12 lead ECG. Methods: In this multi-center study all patients (n=597) visiting the ECG room at the department of cardiology were enrolled in the study by taking their written consent and explaining the purpose of the study. Results: Mean age was 52.85 years. The male gender (n=344, 57.62%) shows the maximum frequency than female gende...
International Journal of Research in Medical Sciences
Background: For the identification of arrhythmia and abnormal instances, researchers are examinin... more Background: For the identification of arrhythmia and abnormal instances, researchers are examining the reliability of the interpretation offered by smartphone-based portable ECG monitors. The indicator of an unclear alteration in the electrical activity of the heart is a cardiac abnormality. As a result, its early and accurate identification can avoid myocardial infarction and even sudden cardiac death. Objectives of this study were to evaluate and validate the Spandan 12 lead ECG interpretation for accuracy in detection of the cardiac arrhythmias in comparison to the cardiologist diagnosis, and to evaluate the accuracy of the arrhythmia detection of Spandan ECG in comparison to the 12 lead ECG machine. Methods: This cross-sectional study, non-randomised, single blinded and single-center study was carried out at Shri Mahant Indresh Hospital (SMIH), Dehradun, Uttarakhand, India from 1st August 2022 to 31st January 2023. All patients (n=312) visiting the electrocardiogram (ECG) room a...
Background: In patients experiencing an ST-elevation myocardial infarction (STEMI), rapid diagnos... more Background: In patients experiencing an ST-elevation myocardial infarction (STEMI), rapid diagnosis leads to optimal clinical outcomes. Recent technology has provided access to a reliable means of obtaining an ECG reading through a smartphone application (app) that works with an attachment providing all 12-leads of a standard ECG system. We developed a 12-lead smartphone-based electrocardiogram (ECG) called “Spandan”, and an application to accurately assess the presence of STEMI in patients presenting with chest pain. Objectives of study was to perform clinical observation studies on the patients screened for STEMIs and evaluate the variation in the diagnosis of STEMIs detected in both 12-lead gold standard and Spandan 12 lead ECG. Methods: This single-center study was carried out at Shri Mahant Indresh hospital (SMIH), Dehradun, Uttarakhand, India from April-2022 to November-2022. All patients (n=278) visiting the ECG room with symptoms of chest pain, shortness of breath and past ...
BACKGROUND Electrocardiography is the most convenient and cost-effective method at the primary le... more BACKGROUND Electrocardiography is the most convenient and cost-effective method at the primary level of healthcare infrastructure to localize and diagnose Myocardial infarction, ischemic heart diseases, and numerous arrhythmias. The manufacturers of ECG machines provide computer-generated Interpretations. However, these machines have differences in implementing the algorithms, which causes a change in diagnostic accuracy. Hence, the occurrence of False positives is the most commonly observed error that occurs during computer interpretation. OBJECTIVE This study aims to evaluate the differences observed in the computerized interpretation of ECG reports regarding the Cardiologist's diagnosis. METHODS The 12-lead ECG reports were collected from a 12-lead gold standard machine and a smartphone-based 12 lead ECG machine. The data of the 294 subjects out of 300 subjects were accessed from both ECG machines. The reports were evaluated by a Cardiologist based on the observational change...
ABSTRACT Secondary hypertension, i.e. where a definite cause for hypertension can be found, is no... more ABSTRACT Secondary hypertension, i.e. where a definite cause for hypertension can be found, is not uncommon in clinical practice and accounts for about 5% cases of hypertension. Common causes of secondary hypertension include renal parenchymal disease, renovascular hypertension, Conn Syndrome and pheochromocytoma. In Asian countries, aortoarteritis is still a common cause of secondary hypertension among young patients, especially females. Early diagnosis and appropriate treatment may significantly alter the natural history of the disease with substantial improvement in prognosis. Whenever a patient is diagnosed with hypertension, every effort should be made to rule out any possible secondary cause for the hypertension. Suspicion of secondary hypertension should be high in early or late onset hypertension, resistant hypertension, accelerated hypertension and in patients with markedly elevated blood pressure with severe target organ damage. Reno-vascular hypertension can be evaluated by non-invasive modalities like Ultrasound Doppler, MR angiography and CT angiography. If primary aldosteronism is suspected, patients should undergo screening with plasma rennin/aldosterone ratio and MRI for the detection of morphological adrenal abnormalities. Patient suspected of pheochromocytoma shows an increase in plasma or urinary catecholamines, but CT and MRI are needed to localize the tumours. Targeted testing should be done in all these patients to rule out any possible cause for secondary hypertension. Careful and thorough clinical evaluation and simple algorithms are needed to avoid unnecessary tests in making the diagnosis of secondary forms of hypertensions more accurately and promptly. Correcting the cause of secondary hypertension can lead to cure, avoiding the need for long-term medical therapy.
The ideal management of stable patients who present late after acute ST-elevation myocardial infa... more The ideal management of stable patients who present late after acute ST-elevation myocardial infarction (STEMI) is still a matter of conjecture. We hypothesized that the extent of improvement in left ventricular function after successful revascularization in this subset was related to the magnitude of viability in the infarct-related artery territory. However, few studies correlate the improvement of left ventricular function with the magnitude of residual viability in patients who undergo percutaneous coronary intervention in this setting. In 68 patients who presented later than 24 hours after a confirmed first STEMI, we performed resting, nitroglycerin-enhanced, technetium-99m sestamibi single-photon emission computed tomography–myocardial perfusion imaging (SPECT–MPI) before percutaneous coronary intervention, and again 6 months afterwards. Patients whose baseline viable myocardium in the infarct-related artery territory was more than 50%, 20% to 50%, and less than 20% were divid...
ABSTRACT Where at one hand, the vast majority of hypertensive patients succumb to the complicatio... more ABSTRACT Where at one hand, the vast majority of hypertensive patients succumb to the complications of hypertension like atherosclerosis, cerebrovascular diseases and congestive heart failure, a subset of these have an exacerbation in this gradual course that needs acute management in the blood pressure control and plays a role in short term outcomes. These hypertensive crises are now encountered more frequently, in more diverse and aging population than in earlier times.Despite the recognized unmet need of timely evaluation and management, fewer than 10% receive the recommended investigations and appropriate treatment often gets delayed. This review emphasizes the therapeutic implications of correct diagnosis, various treatment options and targets in different clinical circumstances.Nicardipine, clevidipine, esmolol and fenoldopam have emerged as potentially superior drugs in most hypertensive emergencies as compared to other conventional drugs. For hypertensive urgencies, blood pressure lowering at a gradual pace with oral drugs & adequate follow up are two important facets of management, making sure that the blood pressure has been lowered out of a potentially dangerous range.Impact of optimal management of hypertensive crisis should translate into lesser target organ damage and eventually fewer complications of stroke, myocardial infarction, or congestive heart failure.
ABSTRACT Amongst patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD), t... more ABSTRACT Amongst patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD), the leading cause of recurrent hospitalizations and death is cardiovascular diseases. Patients with CKD are more likely to die from cardiovascular causes than due to kidney related manifestations. Irrespective of the baseline renal function, even overt proteinuria and microalbuminuria are independent predictors of cardiovascular morbidity and mortality. Most current guidelines hence recommend that patients with CKD be considered to belong to the highest risk group for the development of cardiovascular diseases. However there is a significant “therapeutic inertia” and consequent sub-optimal management of patients with ESRD and associated cardiovascular diseases, owing to the fact that many such patients are often excluded in most large trials of cardiovascular morbidity and mortality. Moreover, due to the high incidence of associated coronary artery disease in patients with ESRD, it is important to appropriately risk stratify such patients awaiting renal transplantation. Though optimal screening protocols and frequency of testing have not been well defined, this paper discusses guidelines based practical approaches to cardiovascular risk in these high-risk patients.
Bronchoscopy is widely performed and generally considered safe. Cardiac complications during bron... more Bronchoscopy is widely performed and generally considered safe. Cardiac complications during bronchoscopy are uncommon, and usually occur in elderly patients with coexistent coronary artery disease, hypertension, or severely impaired pulmonary function and resting hypoxemia. We report a patient who developed sudden onset restlessness, chest discomfort, hypotension, global ST elevation in multiple electrocardiogram leads, and acute severe left ventricular systolic dysfunction during a bronchoscopic transbronchial lymph node biopsy. Differential diagnosis included a massive myocardial infarction, apical ballooning (Tako-tsubo syndrome), or coronary vasospasm. The electrocardiogram changes resolved spontaneously, and a coronary angiogram 48 hours later revealed normal coronary artery anatomy and normal LV function. The patient made an uneventful recovery. It is important for physicians to be aware of such unusual complications to be able to appropriately manage these patients in clinical practice.
Endothelial dysfunction is the postulated link between coronary artery disease (CAD) and erectile... more Endothelial dysfunction is the postulated link between coronary artery disease (CAD) and erectile dysfunction (ED). Brachial artery flow-mediated vasodilatation (FMD) is a non-invasive surrogate marker for endothelial function assessment. Despite Asian Indians representing a considerable global CAD burden, data on FMD and ED in these patients are lacking. Of the 225 patients undergoing coronary angiography, 72% had ED (assessed using the International Index of Erectile Function (IIEF-5) questionnaire); ED was moderate to severe in 61% of the patients. ED patients had a higher incidence of severe and diffuse angiographic CAD, a greater number of coronary vessels involved and a lower mean brachial artery FMD (6.40%64.60% vs. 9.10%64.87%, P,0.001) compared to non-ED patients. A progressive reduction in FMD was noted with increasing severity of ED. Impaired FMD (f5.5%) was twice as common in ED patients (52% vs. 24% without ED). Patients with impaired FMD had higher ED prevalence (85% vs. 62%) and lower mean IIEF-5 scores compared to those with normal FMD. Impaired FMD was a significant ED predictor independent of other risk factors (odds ratio, 2.33; 95% confidence interval: 0.59-9.23; P50.03). An inverse correlation between FMD and ED severity was observed (r520.22; P50.004). ED is common among Asian Indians with angiographically documented CAD. Patients with ED have impaired FMD independent of other risk factors, suggesting that endothelial dysfunction is the underlying pathophysiology. Urologists and cardiologists need to be aware of the association between ED, CAD and endothelial dysfunction.
Erectile dysfunction (ED) and coronary artery disease (CAD) often share common risk factors, and ... more Erectile dysfunction (ED) and coronary artery disease (CAD) often share common risk factors, and there is growing evidence that ED might serve as a clinical marker for cardiovascular disease. Despite rising trends of CAD in Asian Indians, limited data are available on the prevalence of ED and its correlation with CAD severity in such patients. To study the prevalence of ED in Asian Indian patients undergoing coronary angiography and to assess if the severity of ED correlates with angiographic severity of CAD. In all patients undergoing coronary angiography, ED was assessed using the International Index of Erectile Function-5 questionnaire. Among 175 male patients, ED was present in 70%; patients with ED had a higher incidence of multivessel CAD (80% vs. 36%, P 0.001), diffuse CAD (81% vs. 34%, P 0.001), and higher number of mean coronary vessels involved compared with those without ED. Those with severe ED had higher prevalence of multivessel CAD and higher number of mean coronary vessels involved compared with those with milder grades of ED. Onset of symptoms of ED preceded symptoms of CAD by a mean of 24.6 months in 84% of patients. The presence of severe ED was associated with a 21-fold higher risk of having triple-vessel disease (odds ratio [OR] 21.94, 95% confidence interval [CI] 3.41-141.09, P = 0.001) and an 18-fold higher risk of having diffuse angiographic CAD (OR 17.91, 95% CI 3.11-111.09, P = 0.001). Asian Indians with angiographic CAD frequently have ED; symptoms of ED precede that of CAD in most patients. Incidence of multivessel and diffuse CAD is significantly more common in patients with ED. It is important for physicians to be aware of the close relationship between the two conditions so that patients with ED can have optimal risk stratification for concomitant CAD whenever required.
Background:Erectile dysfunction in type-2 diabetes may be an independent marker for coronary arte... more Background:Erectile dysfunction in type-2 diabetes may be an independent marker for coronary artery disease. Present study was undertaken to investigate whether type-2 diabetic patients with erectile dysfunction without having overt cardiovascular disease had increased cardiovascular risk.Aim:To find out correlation between ED and cardiovascular risk in diabetic patients.Methods:Fifty type-2 diabetic patients were assessed for erectile dysfunction using international index of erectile dysfunction (IIEF-5), which include questionnaire and cardiovascular risk assessment by multiparameter cardiovascular analysis device (periscope).Results:The prevalence of erectile dysfunction in type-2 diabetics was very high (78%), mild, moderate and severe ED was present in 6, 36 and 36%, respectively. The total cardiovascular risk was more in patients with ED in comparison to patients without ED (34.87 ± 18.82 vs 20.91 ± 11.03 p = 0.002). The mean 10-years coronary risk and cardiac risk was 12.00 + 9.60 and 22.23 + 14.14 (p = 0.029) and 13.36 ± 1.22 and 28.85 ± 4.13 (p 0.002) in patients without ED and with ED respectively. The mean vascular and atherosclerosis risk was 28.73 ± 13.94 and 39.38 ± 19.51 (p > 0.05) and 26.18 ± 10.31 and 33.92 ± 13.40 (p > 0.05) in patients without ED and with ED, respectively. Total cardiovascular risk was found to increase with age, duration of diabetes and HbA1c levels.Conclusion:The total cardiovascular risk increases with increasing severity of erectile dysfunction in type-2 diabetic patients without having overt cardiovascular disease.
Uploads
Papers by Tanuj Bhatia