Pathophysiology, etiology, and recent advancement in the treatment of congenital heart disease Jyoti Upadhyay, Nidhi Tiwari, Mahendra Rana, Amita Rana, Sumit Durgapal, Satpal Singh Bisht JOURNAL OF INDIAN COLLEGE OF CARDIOLOGY 2019 9(2):67-77 The most common birth anomaly occurring in infants is the congenital heart disease (CHD). It is the important cause of mortality and morbidity among children. The aim of this review is to conduct searches for peer-reviewed research papers published since 1980, with keywords “congenital heart defects,” “incidences,” “pathophysiology,” and “congenital anomalies.” Recent advances in the treatment of CHD have allowed many children to survive, causing a growing population of adults with the congenital heart defect. Lesser information exists regarding survival, prevalence, comorbidities, and late outcomes in this emerging group and several barriers hampers research in congenital heart defect. Some investigating research of congenital heart defect offers good opportunity in understanding and identifying high-risk population. This review provides an overview of the etiology, prevalence, pathophysiology, and advances in the treatment of congenital heart defect. Future research is needed to understand congenital heart defects, by the health-care providers and families, who are taking care of these patients. Experimental and epidemiological studies will provide us important information related to the physiology of congenital heart defects and identifying the etiological hypothesis behind it.

Assessment of left ventricular filling pressure and its correlation with severity of chronic kidney disease Vijesh Anand, Arun Prasath Palamalai, Hemachandar Radakrishnan JOURNAL OF INDIAN COLLEGE OF CARDIOLOGY 2019 9(2):78-82 Aims: This study was aimed to assess the left ventricular filling pressure (LVFP) and its relationship with severity of chronic kidney disease (CKD). Methods: One hundred CKD patients were subjected to standard echocardiography and the new modality of tissue Doppler imaging. The LVFP is calculated with E/e' ratio (early diastolic mitral inflow velocity – E to early diastolic mitral annulus velocity – e'). All these patients were divided into five subgroups depending on their estimated glomerular filtration rate (eGFR: ml/min/body surface area). Results: The analysis of echocardiographic parameters (E and e') showed that in CKD patients, the stage of renal failure was associated with the significant increase in LVFP with P < 0.001. There was a significant correlation between LVFP and eGFR with r = −0.467 and P < 0.001. Conclusion: These data suggest that LVFP starts to raise early in the case of CKD. The increase in LVFP is directly proportional to the severity of renal failure.

The relation between retinopathy grade and coronary artery disease in acute coronary syndrome diabetics Ahmed Shawky Shereef, Nader T Kandeel JOURNAL OF INDIAN COLLEGE OF CARDIOLOGY 2019 9(2):83-87 Background: Diabetic retinopathy (DR) was found to be associated with an increased risk for coronary artery disease (CAD). However, there are less data about the relation between the degree of DR and the angiographic severity of CAD. Objective: The objective of the study is to examine the relation between the degree of DR and the angiographic severity of CAD in patients with acute coronary syndrome (ACS). Patients and Methods: Fifty diabetic patients with ACS were enrolled in this study. History, clinical examination, echocardiography, coronary angiography, and fundus examination were done to all patients. According to the degree of DR, patients were classified into two groups: Group I – patients with no or mild nonproliferative (NP) DR (n = 27) and Group II – patients with moderate or severe NP DR or with proliferative DR (n = 23). Results: Population characteristics, risk factors, diabetes duration, insulin use, and echocardiographic measures were comparable in the two groups. Patients in Group II had significantly more number of diseased vessels, more maximum stenosis, and higher Gensini score than those of Group I. There was a significant correlation between the degree of DR and the number of diseased vessels (r = 0.358, P =0.011) and highly significant correlation between the degree of DR and maximum stenosis (r = 0.452, P =0.001) and Gensini score (r = 0.706, P < 0.00001). Conclusion: There is an obvious relation between the degree of DR and angiographic severity of CAD in diabetic patients with ACS. Patients with a higher degree of DR had more severe CAD.

Serum cystatin c and renal dysfunction in transradial versus transfemoral approaches in primary percutaneous coronary intervention Wael Ali Khalil, Mohammad Gouda Abdelhameed, Mahmmoud Diaa Elmenshawy, Ahmad Elhelaly JOURNAL OF INDIAN COLLEGE OF CARDIOLOGY 2019 9(2):88-94 Objectives: Contrast-induced nephropathy is one of the most common adverse side effects in ST-segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI). Serum cystatin C level is a biomarker of the renal function test. We aimed to compare the degree of renal dysfunction in transradial primary PCI versus transfemoral primary PCI and to use of serum cystatin C as a predictor of contrast-induced nephropathy. Methods: This study included 90 patients who were admitted to the hospital with STEMI and who underwent a primary PCI and they were divided into Group I (45 patients): a primary PCI via femoral approach and Group II (45 patients): a primary PCI via radial approach. We estimated both serum cystatin C and serum creatinine after 72 h of primary PCI. Results: Serum cystatin C level post-PCI had high sensitivity results in correlation with CIN and non-CIN groups. Further, the significant effects were found in all patients in association with serum cystatin C before and after PCI. The cutoff value of serum cystatin C with receiver operating characteristic curve analysis before PCI was 1.1 mg/dL and after PCI was 1.3 mg/dL. Conclusion: The transradial approach for a primary PCI is an effective and safe approach alternative to the femoral approach. Serum cystatin C is a biomarker and a predictor of the occurrence of contrast-induced nephropathy in STEMI patients who underwent a primary PCI and is one of the most sensitive renal markers regarding CIN in comparison to serum creatinine level.

Role of Vitamin D deficiency among patients with acute coronary syndrome Ahmed Shawky Shereef, Nader Talat Kandeel JOURNAL OF INDIAN COLLEGE OF CARDIOLOGY 2019 9(2):95-99 Background: Previous studies demonstrated that low Vitamin D levels are associated with hypertension, obesity, dyslipidemia, and diabetes mellitus, reflecting an increased cardiovascular (CV) risk burden. However, high levels can be associated with increased total and CV mortality. Hence, we aimed to evaluate the prevalence of Vitamin D deficiency and if it has a role in the occurrence of acute coronary syndrome (ACS). Patients and Methods: This study was carried out on 71 patients presented with ACS, undergoing coronary angiography at the cardiology department, Zagazig university hospitals. Exclusion Criteria: Disorders causing Vitamin D deficiency. Methods: All our patients were subjected to (1) careful history-taking; (2) thorough clinical examination; (3) resting electrocardiogram; (4) routine laboratory investigations beside thyroid, parathyroid hormone, Mg, Ph, and Vitamin D levels; (5) echocardiography; and (6) coronary angiography. Results: In the present study, receiver-operating characteristic curve analysis shows that the serum Vitamin D has a cutoff value ≤41.5 nm/L to predict ACS with 94.4% sensitivity and 83% specificity, a cutoff value ≤41.5 nm/L to predict unstable angina with 97.3% sensitivity and 83% specificity a cutoff value ≤52.625 nm/L to predict ST-elevation myocardial infarction (STEMI) with 100% sensitivity and 76.6% specificity, and a cutoff value ≤41 nm/L to predict non-STEMI with 100% sensitivity and 83% specificity. Conclusion and Recommendations: Vitamin D deficiency and insufficiency are common in patients with ACS. Further, larger multicenter studies are needed to assess Vitamin D level in ACS patients and to investigate its relationship with long term prognosis.

The relation between insulin resistance and left ventricular mass in hypertensive nondiabetic patients Ahmed Shawky Shereef, Nader Talat Kandeel JOURNAL OF INDIAN COLLEGE OF CARDIOLOGY 2019 9(2):100-104 Background: Patients with essential hypertension (EH) are often associated with left ventricular (LV) hypertrophy (LVH) and insulin resistance (IR). Insulin may have a direct growth-promoting effect on cardiomyocytes. Hence, the aim of this work was to study the effect of IR on LV geometry in newly diagnosed arterial hypertensive nondiabetic patients not taking any antihypertensive medication. Methods: One hundred and eight patients were included in our study including 88 newly diagnosed hypertensive nondiabetic patients and 20 healthy controls. Fasting glucose, insulin levels, total cholesterol, high-density lipoprotein-cholesterol (HDL-C), low-density lipoprotein-cholesterol, and triglyceride levels were measured. Homeostasis Model Assessment (HOMA) index was calculated for the assessment of IR. Echocardiography measurements of LV dimensions such as LV mass (LVM) and LVM index (LVMI) were calculated. Results: Fasting blood insulin and HOMA index were significantly higher in patients with LVH than patients with normal LV dimensions and controls. We found highly significant positive correlations between insulin levels, LVM, and LVMI. In addition, we found highly significant positive correlations between HOMA index, LVM, and LVMI. Conclusion: We conclude that cardiac changes in hypertensive patients including those with increased wall thickness, LVM, and LVMI are mediated, at least in part, by increased insulin levels and the HOMA index.

An unusual presentation of acute pulmonary embolism secondary to upper extremity deep vein thrombosis Khadhar Mohamed Sarjun Basha, PB Jayagopal JOURNAL OF INDIAN COLLEGE OF CARDIOLOGY 2019 9(2):105-107 Acute pulmonary embolism (PE) secondary to congenital venous malformation of the upper limb is a rare clinical entity. Clinical manifestation may range from vague shoulder discomfort to features of superior vena cava or thoracic outlet syndrome. We report a case of a 43-year-old adult patient who was referred as acute coronary syndrome and on evaluation was diagnosed as acute PE secondary to upper extremity deep vein thrombosis. Magnetic resonance venogram of the right upper limb revealed congenital venous malformation with thrombus as the cause for deep vein thrombosis.

Kounis syndrome: Allergic myocardial infarction!! Deepak Kadeli, Deepthi Mangesh, R Keshava, A Gopi JOURNAL OF INDIAN COLLEGE OF CARDIOLOGY 2019 9(2):108-110 Anaphylaxis is a type 1 hypersensitivity reaction where the body reacts to an allergen within minutes. Free antigens cross-link the IgE on mast cells and basophils, which causes a release of vasoactive biomolecules which cause systemic vasospasm. A wide range of causes include insect bites and stings, foods, and medications. It can manifest with a constellation of symptoms, but common manifestations include urticaria, shortness of breath, vomiting, lightheadedness, and low blood pressure. Some unusual presentations include gastrointestinal symptoms such as loose stools and abdominal pain, but in rare cases, they may present as myocardial infarction. We present a case of a 49-year-old female who presented with effort angina and developed severe anaphylactic reaction to the dye used in angiogram, precipitating an inferior wall myocardial infarction.

Isolated acute right heart failure syndrome in a young male with severe sepsis: An unusual pathophysiology in a normal heart Raghuram Palaparti, Sudarshan Palaparthi, Gopala Krishna Koduru, PS S Chowdary, Hari Krishna Marri, Purnachandra Rao Kondru, Somasekhar Ghanta, Prasad Maganti, Sasidhar Yendapalli JOURNAL OF INDIAN COLLEGE OF CARDIOLOGY 2019 9(2):111-115 Acute right heart failure is being increasingly recognized in intensive care unit (ICU) and when severe, can contribute to hemodynamic instability. Sepsis-induced myocardial dysfunction is also a known entity in critical care ICU. However, isolated right ventricle (RV) dysfunction in patients with sepsis after excluding chronic heart and lung disease is underdiagnosed and reported uncommonly. Whether RV is a bystander or a major contributor to hemodynamic instability in that scenario has not been studied clearly. Here, we report a 42-year-old male patient with no major cardiovascular risk factors who presented to us in shock with a history of low-grade fever, generalized weakness, and decreased urine output for 3 days. On physical examination, he had pedal edema and neck vein distension. He was found to have neutrophilic leukocytosis, deranged renal function test, and liver function test. His chest X-ray posteroanterior view showed cardiomegaly with pulmonary congestion. His electrocardiography (ECG) showed right bundle branch block (RBBB). He was anuric and started on dialysis for severe acidosis. In view of shock, renal failure and RBBB on ECG, a transthoracic echocardiography was done which showed gross dilatation of right atrium, and RV with severe RV dysfunction with normal left ventricle function. Contrast-enhanced computerized tomography chest was negative for pulmonary thromboembolism. His blood culture has grown Escherichia coli. With intravascular (IV) fluids, ionotropic support, renal replacement therapy, IV antibiotics, and other supportive therapy, he gradually improved. His serial ECGs showed resolution of RBBB. Two-dimensional echo showed improved RV function. He was discharged on day 9 and his 2-week follow-up echo showed normalization of RV function. During follow-up, his coronary angiogram showed normal coronaries. This case illustrates the importance of identifying acute RV failure in patients with severe sepsis with shock. It also underscores the necessity for more studies and research on understanding the pathophysiology of RV dysfunction in critical care patients and its contribution to hemodynamic instability.

Acute myocardial infarction secondary to analgesic abuse: Should it be a novel risk factor for coronary artery disease! Pankaj Jariwala JOURNAL OF INDIAN COLLEGE OF CARDIOLOGY 2019 9(2):116-117