In This Issue — Myocardial Infarction: Management of the Subacute Period — Prevalence of Metabolic Syndrome in Patients with Essential Hypertension — Double-Chambered Right Ventricle with Transient 2:1 Atrioventricular Block: A Rare Presentation — Right-Sided Cardiophrenic Mass in an Older Woman — Diagnosis of Stable Ischemic Heart Disease: Recommendations from the ACP — Medicolegal Cases in Injury Patients and Indian Law
Volume 16, Number 10, February 2014 Pages 357-392
Asian
Journal of
IJCP Group of Publications
CLINICAL CARDIOLOGY
Dr Sanjiv Chopra Prof. of Medicine & Faculty Dean Harvard Medical School Group Consultant Editor
Volume 16, Number 10, February 2014
Dr Deepak Chopra Chief Editorial Advisor
Padma Shri and Dr BC Roy National Awardee Dr KK Aggarwal Group Editor-in-Chief Dr Veena Aggarwal MD, Group Executive Editor
from the desk of the group editor-in-chief 361 Predicting Sudden Cardiac Death
KK Aggarwal
Dr Praveen Chandra Guest Editor, AJCC praveen.chandra@medanta.org Assistant Editors: Dr Nagendra Chouhan, Dr Dharmendar Jain
REVIEW ARTICLE
AJCC Specialty Panel 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
Advisory Board Dr PK Jain Dr PK Gupta Dr Naresh Trehan Dr Sameer Shrivastava Dr Deepak Khurana Dr Ganesh K Mani Dr K S Rathor Dr Rajesh Kaushish Dr Sandeep Singh Dr Yugal Mishra Faculty Dr GK Aneja Dr Ramesh Thakur Dr Balram Bhargava Dr HK Bali Dr HM Mardikar
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IJCP Editorial Board
Obstetrics and Gynaecology Dr Alka Kriplani, Dr Thankam Verma, Dr Kamala Selvaraj Cardiology Dr Praveen Chandra, Dr SK Parashar Paediatrics Dr Swati Y Bhave Diabetology Dr CR Anand Moses, Dr Sidhartha Das, Dr A Ramachandran, Dr Samith A Shetty ENT Dr Jasveer Singh, Dr Chanchal Pal Dentistry Dr KMK Masthan, Dr Rajesh Chandna Gastroenterology Dr Ajay Kumar, Dr Rajiv Khosla Dermatology Dr Hasmukh J Shroff, Dr Pasricha, Dr Koushik Lahiri Nephrology Dr Georgi Abraham Neurology Dr V Nagarajan, Dr Vineet Suri Journal of Applied Medicine & Surgery Dr SM Rajendran, Dr Jayakar Thomas Orthopedics Dr J Maheshwari Anand Gopal Bhatnagar Editorial Anchor Advisory Bodies Heart Care Foundation of India Non-Resident Indians Chamber of Commerce & Industry World Fellowship of Religions
362 Myocardial Infarction: Management of the Subacute Period
Michael G. Mercado, Dustin K. Smith, Michael L. McConnon
CLINICAL STUDY 370 Prevalence of Metabolic Syndrome in Patients with Essential Hypertension
D Makwana, S Bagga, M Nandal
CASE REPORT 374 Double-Chambered Right Ventricle with Transient 2:1 Atrioventricular Block: A Rare Presentation
Monika Maheshwari, SK Kaushik
photo quiz 376 Right-Sided Cardiophrenic Mass in an Older Woman
PRACTICE GUIDELINES Published, Printed and Edited by Dr KK Aggarwal, on behalf of IJCP Publications Ltd. and Published at E - 219, Greater Kailash, Part - 1 New Delhi - 110 048 E-mail: editorial@ijcp.com
378 Diagnosis of Stable Ischemic Heart Disease: Recommendations from the ACP
Printed at New Edge Communications Pvt. Ltd, New Delhi E-mail: edgecommunication@gmail.com Š Copyright 2014 IJCP Publications 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 Ltd. No part of this publication may be published in any form whatsoever without the prior written permission of the publisher.
Medilaw 380 Medicolegal Cases in Injury Patients and Indian Law KK Aggarwal
Editorial Policies The purpose of IJCP Academy of CME is to serve the medical profession and provide print continuing medical education as a part of their social commitment. The information and opinions presented in IJCP group publications reflect the views of the authors, not those of the journal, unless so stated. Advertising is accepted only if judged to be in harmony with the purpose of the journal; however, IJCP group reserves the right to reject any advertising at its sole discretion. Neither acceptance nor rejection constitutes an endorsement by IJCP group of a particular policy, product or procedure. We believe that readers need to be aware of any affiliation or financial relationship (employment, consultancies, stock ownership, honoraria, etc.) between an author and any organization or entity that has a direct financial interest in the subject matter or materials the author is writing about. We inform the reader of any pertinent relationships disclosed. A disclosure statement, where appropriate, is published at the end of the relevant article. 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.
Around the Globe 382 News and Views
lighter reading 386 Lighter Side of Medicine
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Predicting Sudden Cardiac Death ÂÂ
Normally people can walk a distance of 400-700 meters in 6 minutes.
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People who can walk 500 meters in 6 minutes can safely go for Amarnath Yatra.
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A 6-minute walking distance of less than 300 meter is simple and useful predictors of sudden cardiac death in patient with mild-to-moderate heart failure.
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Patient with interstitial lung disease who can cover less than 200 meters during 6-minute walk test are 4 times more likely to die than those who can walk greater distance.
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People who can cover a distance of 200-300 meters need further evaluation.
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A fall of SpO2 of more than 4% ending below 93% suggests significant desaturation.
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An improvement of more than 70 meters or 10% in distance walk can make all the difference.
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An improvement of 30 meters in any distance walked is the minimally important difference in any treatment.
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Sudden cardiac death is linked to 15% of total urban mortality.
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Risk factors for sudden cardiac death include abnormal lipid levels, high blood pressure, cigarette smoking physical inactivity, diabetes, obesity, family history of pre-mature heart disease or heart attack.
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Binge drinking can cause sudden cardiac death (6 or more drinks per day or 5 drinks in one session).
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Risk of sudden cardiac arrest is transiently increased for up to 30 minutes after strenuous exercise (1/1.5 million of episode of exercise).
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If you are at low-risk for having a heart problem, you do not need a regular treadmill test. ■■■■
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Review article
Myocardial Infarction: Management of the Subacute Period MICHAEL G. MERCADO, DUSTIN K. SMITH, MICHAEL L. MCCONNON
Abstract Optimal management of myocardial infarction in the subacute period focuses on improving the discharge planning process, implementing therapies early to prevent recurrent myocardial infarction, and avoiding hospital readmission. Evidence-based guidelines for the care of patients with acute coronary syndrome are not followed up to 25% of the time. Antiplatelet therapy, renin-angiotensin-aldosterone system inhibitors, beta blockers, and statins constitute the foundation of medical therapy. Early noninvasive stress testing is an important risk assessment tool, especially in patients who do not undergo revascularization. Discharge preparation should include a review of medications, referral for exercise-based cardiac rehabilitation, activity recommendations, education about lifestyle modification and recognition of cardiac symptoms, and a clear follow-up plan. Because nonadherence to medications is common in patients after a myocardial infarction and is associated with increased mortality risk, modifiable factors associated with medication self-discontinuation should be addressed before discharge. Structured discharge processes should be used to enhance communication and facilitate the transition from the hospital to the family physician’s care.
Keywords: Myocardial infarction, subacute period, antiplatelet therapy, renin-angiotensin-aldosterone system inhibitors, beta blockers, statins, cardiac rehabilitation
C
ardiovascular disease causes one in six deaths in the United States annually.1 In 2008, medical costs of heart disease were an estimated $190 billion, and are projected to triple over the next 20 years.1 A myocardial infarction (MI), defined as clinical evidence of myo cardial necrosis consistent with myocardial ischemia, is diagnosed every 34 seconds in the United States.1,2 Acute coronary syndrome (ACS), which encompasses non–ST elevation MI and ST elevation MI, resulted in 1.2 million hospital admissions in 2009.1 Studies show that care consistent with established guidelines results in decreased mortality during hospitalization and at six months postdischarge, but up to 25% of opportunities to provide guidelinerecommended care are missed.3,4 Preventing
readmissions is also a concern; in a study of 16,000 patients with ACS, 20% were rehospitalized within one year, highlighting a need for more effective discharge planning and care transitions.5 Family physicians, in partnership with a cardiovascular subspecialist, have a vital role in the management of MI during the subacute period. This period begins after a revascularization procedure has been performed or after the decision to not revascularize is made, and lasts for one to three months.6 This article focuses on the management of MI during this critical period, and emphasizes the importance of the care transition from the hospital to the outpatient setting. Early Hospital Care
MICHAEL G. MERCADO, MD, is a staff faculty physician at the Naval Hospital Camp Pendleton (Calif.) Family Medicine Residency Program. At the time this article was written, he was head of the Department of Family Medicine at the U.S. Naval Hospital Guam in Agana Heights.
Irrespective of the timing or nature of the decision to revascularize, several therapies have proven benefit in reducing adverse cardiovascular events during the subacute period. Figure 1 provides an overview of the subacute management of MI.6-10
DUSTIN K. SMITH, DO, is a staff physician in the Department of Family Medicine at the U.S. Naval Hospital Guam.
Antiplatelet Therapy
MICHAEL L. MCCONNON, MD, is a staff faculty physician at the Naval Hospital Pensacola (Fla.) Family Medicine Residency Program. At the time this article was written, he was a staff physician in the Department of Family Medicine at the U.S. Naval Hospital Guam. Source: Adapted from Am Fam Physician. 2013;88(9):581-588.
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Aspirin An inhibitor of platelet aggregation, aspirin should be given to all patients with suspected ACS. A systematic
Review article review of 15 trials showed that aspirin therapy in patients who had experienced an MI reduced stroke, repeat MI, and death (absolute risk reduction [ARR] = 3.8%; number needed to treat [NNT] = 26).11 An adequate dosage in the acute period is 162 to 325 mg per day; the dosage should be reduced to 75 to 162 mg per day upon discharge and continued indefinitely for prevention of recurrent MI.6-11 P2Y12 Inhibitors P2Y12 inhibitors, includ ing clopidogrel, prasugrel, and ticagrelor, represent a class of antiplatelet agents that, when used in combination with aspirin therapy, decrease major cardiovascular events in patients with ACS who are undergoing percutaneous coro nary intervention.12-14 Guidelines suggest that this combination, known as dual anti platelet therapy, continue for a minimum of 12 months in patients receiving drug-eluting stents and for up to 12 months in those receiving bare metal stents, but the optimal duration is unknown.8,9 The benefits of dual antiplatelet therapy in decreasing the combined end points of cardiovascular mortality, subsequent MI, and stroke were noted at 30 days through 12 months for clopidogrel when compared with placebo (ARR = 2.1%; NNT = 48), and at 15 months and 12 months with prasugrel and ticagrelor, respectively, when compared with clopidogrel.14-16 Of the three P2Y12 inhibitors, only ticagrelor has been shown to improve all-cause mortality.12-14 Guidelines from the American College of Cardiology (ACC) and the American Heart Association (AHA) advocate dual antiplatelet therapy using clopidogrel and ticagrelor for up to 12 months in conservatively treated patients after an MI, but the optimal length of treatment is unclear.9 Proton pump inhibitors are recommended for patients receiving dual antiplatelet therapy who have a history of or risk factors for gastrointestinal bleeding.8,17 Clopidogrel is recommended for patients with aspirin intolerance or allergy, regardless of the initial management strategy.8,18
Beta Blockers Several systematic reviews have established the long-term mortality benefits of beta-blocker therapy in patients who have had an MI.19,20 The AHA recommends that oral beta-blocker therapy be initiated in all patients without contraindications within 24 hours after an MI, and continued at discharge.6,7,10 However, a Cochrane review that investigated antihypertensive agents initiated within 24 hours of
Management of Myocardial Infarction Acute management: aspirin or clopidogrel, anticoagulation, fibrinolysis (if appropriate), selection of management strategy
No coronary angiography
Pursue coronary angiography
Initiate clopidogrel or ticagrelor
Initiate P2Y12 inhibitor or glycoprotein IIb/IIIa inhibitor
Evaluate LVEF
LVEF > 40%
LVEF ≤ 40%
Pursue noninvasive testing Low risk of cardiac ischemia
High risk of cardiac ischemia
Perform coronary angiography
Coronary artery Revascularization Percutaneous coronary intervention bypass grafting not performed
Discontinue anticoagulant therapy Continue dual antiplatelet therapy for 12 months
Continue dual antiplatelet therapy Bare metal stents (up to 12 months) Drug-eluting stents (at least 12 months)
Discharge medications: aspirin, dual antiplatelet therapy if indicated, angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, aldosterone blocker if indicated, beta blocker, nitroglycerin, proton pump inhibitor in patients with an increased risk of gastrointestinal bleeding, and statin Discharge preparation: use a high-quality discharge process, perform a detailed medication review, initiate smoking cessation counseling and dietary education, provide exercisebased cardiac rehabilitation referral, review steps to manage ischemic symptoms, arrange for follow-up with a primary care physician and cardiologist
Figure 1. Overview of the subacute management of myocardial infarction. (LVEF = Left ventricular ejection fraction.) Information from references 6 through 10.
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Review article a cardiovascular event found no mortality benefit from beta-blocker therapy within the first month.21 In patients with a left ventricular ejection fraction (LVEF) of 40% or less, beta-blocker therapy should be titrated gradually and continued indefinitely.6,7 Bisoprolol, carvedilol, and metoprolol have exhibited a mortality benefit in patients with a reduced LVEF after an MI.22 Guidelines suggest using beta block ers for at least three years in patients with preserved systolic function, but this recommendation is based on limited data.7 One prospective cohort study of 14,043 patients with a remote history of MI concluded that beta-blocker use may not improve cardiovascular outcomes.23
Renin-Angiotensin-Aldosterone System Inhibitors Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers Angiotensin-converting enzyme (ACE) inhibitors are strongly recommended after an MI in patients with hypertension, diabetes mellitus, an LVEF of 40% or less, or chronic kidney disease.6,10 Randomized controlled trials (RCTs) have established that ACE inhibi tors reduce mortality in patients who have had an MI.24-26 One review of 22 RCTs concluded that early (within 48 hours) administration of ACE inhibitors after an MI reduced mortality in as early as one month (NNT = 167), and the benefits were greater at one year for early and late administration, with an ARR of 3.7% (NNT = 27) and 2.2% (NNT = 45), respectively.26 A Cochrane review con cluded that ACE inhibitors administered within 24 hours of a cardiovascular event can prevent three to five deaths per 1,000 patients at 10 days.21 Unless contraindicated, ACE inhibitors should be continued indefinitely for prevention of recurrent cardiovascular events.8 Angiotensin receptor blockers are recommended in patients who have indications for, but cannot tolerate, ACE inhibitors.6,8,10 Compared with monotherapy, com bination therapy with ACE inhibitors and angiotensin receptor blockers leads to increased adverse events with no mortality benefit in patients after an MI, and is not recommended.27 ACE inhibitors and angiotensin receptor blockers should be avoided in patients with hyperkalemia, hypotension, and acute renal failure until these conditions resolve.10 Aldosterone Blockers Based on the Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival Study, aldosterone blockers initiated as early as three days
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after an MI reduced all-cause mortality and cardiac death (ARR = 1.4%; NNT = 71) compared with placebo in patients with a low LVEF and signs of heart failure.28 Guidelines from the ACC/AHA recommend the use of aldosterone blockers in patients who have heart fail ure or diabetes, have an LVEF of 40% or less, are receiv ing ACE inhibitors and beta blockers, and have a serum potassium level less than 5.0 mEq per L (5.0 mmol per L) and a creatinine clearance greater than 30 mL per minute per 1.73 m2 (0.50 mL per second per m2).6,8,10
Statin Therapy The role of statins in reducing mortality and ACS in patients with cardiovascular disease is well established.8,29 Consequently, current guidelines advocate initiating these agents before discharge, despite questionable mortality benefit in the subacute period, and continuing therapy indefinitely.6,8,10,29 A Cochrane review found that early initiation of statins in patients with ACS reduced episodes of unstable angina within four months without decreasing mortality or recurrent MI.29 A meta-analysis of 21 trials concluded that statins initiated as early as one day before percutaneous coronary intervention reduced the risk of postprocedural MI (ARR = 6%; NNT = 17) and reduced atrial fibrillation after coronary artery bypass grafting.30 Although the choice of statin does not matter, higher doses may yield more benefits. An RCT of 4,162 patients hospitalized for ACS found a 29% reduction in recurrent unstable angina and a 14% reduction in revascularization in patients receiving 80 mg per day of atorvastatin compared with those receiving 40 mg per day of pravastatin.31 Consequently, high-dose atorvastatin may be considered in patients with ACS who are already receiving a lower dose or a less potent statin. The ACC and AHA recommend obtaining lowdensity lipo protein cholesterol measurements within 24 hours of hospitalization as part of a cardiac risk assessment and guide to initiating lipid-lowering therapy.6,10 Noninvasive Testing Noninvasive testing, with or without imaging, is an important risk-assessment tool in patients who have had an MI but are not undergoing angiography. LVEF assessment is essential and should guide decisions about care (Figure 1).6-10 The testing modality is based on exercise tolerance, baseline electrocardiography, and test availability. Intermediate- to low-risk patients who have been stable for 48 to 72 hours are candidates for
Review article symptom-limited stress testing.6,10 Guidelines from the ACC/AHA recommend submaximal exercise stress test ing at four to six days, or symptom-limited stress test ing at two to three weeks if predischarge testing was not performed.32 One study found early symptom-limited stress testing (three to seven days after MI) compara ble to late testing (one month postdischarge) for diag nostic and prognostic evaluation, but noted that 50% of cardiovascular events within one year of follow-up occurred within the first month, making earlier testing the preferred option.33 However, data addressing the relative safety of early symptom-limited stress testing are scant.10 Preparing for Discharge A multidisciplinary approach before discharge includes medication review, referral for cardiac rehabilitation, activity recommendations, education about lifestyle modifications and recognition of cardiac symptoms, and a clear follow-up plan. Inadequate communication can hamper transitions of care; a review of 73 studies found that discharging physicians directly communicated with the patient’s primary care physician only 3% to 20% of the time.34 Project RED (Re-Engineered Discharge) is a standardized, patient-centered discharge process that can be applied to patients with MI. An RCT of 749 adults with multiple medical conditions who were hospitalized in an urban medical center showed a 30% decrease in combined readmission rates and emergency department visits within 30 days of discharge when
Project RED was implemented.35 Table 1 summarizes the components of this quality-focused discharge process.35,36
Medication Review Therapy with a combination of antiplatelets, statins, beta blockers, and ACE inhibitors has been shown to decrease mortality at six months in patients with ACS, with incremental benefit as more agents are used.37 Table 2 summarizes the most pertinent medications for post-MI care.6-10 Nonadherence to therapy is common and is associated with increased mortality risk; in a prospective cohort study, patients who discontinued use of medications by one month after an MI were nearly four times as likely to die by one year as those who adhered to therapy.38 Modifiable factors associated with medication self-discontinuation are highlighted in Table 3 and should be addressed before discharge.39
Lifestyle Modification Counseling Crucial elements of lifestyle modification that should be discussed at discharge include diet, exercise, and smoking cessation. One study found that patients with ACS who did not adhere to dietary recommendations, remained sedentary, and continued to smoke at the 30-day follow-up had a fourfold increase in mortality within six months compared with those who adhered to all three components.40 Dietary counseling should include information about the Mediterranean diet, which has been shown to improve cardiovascular and all-cause
Table 1. Components of a Standardized, Patient-Centered Discharge Process Assess the patient’s understanding of the discharge plan; ask the patient to explain in his or her own words; identify and resolve barriers to understanding. Educate the patient about problem-solving strategies, including contacting the primary care physician. Educate the patient about the diagnosis and plan of care during hospitalization. Expedite transmission of the discharge summary to clinicians and services who will care for the patient after discharge. Make appointments for outpatient follow-up and postdischarge testing; stress the importance of follow-up care and ensure that transportation arrangements are in place. Organize postdischarge services; arrange appointments and address barriers to receiving the recommended services. Provide a written summary detailing the indication for admission, clinical course, follow-up, and medication indications and instructions. Provide the patient with steps to take if a concern about his or her condition arises, and explain which symptoms warrant an emergency. Reconcile the discharge plan of care with nationally accepted evidence-based guidelines. Review the patient’s medications; discuss any changes and potential adverse effects. Talk to the patient about tests performed in the hospital and how to follow-up on the results. Telephone the patient two to three days after discharge to address concerns. Information from references 35 and 36.
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Review article Table 2. Summary of Medications for the Subacute Management of Myocardial Infarction Medication
Recommendations
Antiplatelet agents
Aspirin therapy (162 to 325 mg daily in the acute period, 75 to 162 mg daily for long-term prevention) should be initiated early and continued indefinitely in all patients without contraindications. Clopidogrel (75 mg daily) is recommended in patients with aspirin allergy or intolerance. Clopidogrel (75 mg daily) or ticagrelor (90 mg twice daily) should be prescribed for up to 12 months as part of dual antiplatelet therapy with aspirin in patients treated medically. Clopidogrel (75 mg daily), ticagrelor (90 mg twice daily), or prasugrel (10 mg daily) should be prescribed for at least 12 months in patients receiving drug-eluting stents, and for up to 12 months in patients receiving bare metal stents.
Beta blockers
Beta blockers should be initiated early, titrated gradually, and continued indefinitely in all patients with an LVEF ≤ 40% who do not have contraindications. Beta blockers should be continued for at least three years in patients with preserved systolic function; use beyond three years is reasonable.
Lipid-lowering agents
Statins should be initiated early in all patients without contraindications.
Nitroglycerin
Patients should be instructed to use nitroglycerin sublingually (0.3 to 0.6 mg every five minutes for up to three doses) or as a spray (one or two sprays onto or under the tongue every five minutes for up to three doses) for management of acute cardiac symptoms.
Statins should be continued at discharge and titrated to achieve an LDL cholesterol level < 100 mg per dL (2.59 mmol per L) and a 30% reduction in the LDL cholesterol level; a goal LDL cholesterol level < 70 mg per dL (1.81 mmol per L) may be considered in high-risk patients.*
Patients should be instructed to discontinue physical activity or any stressful event if anginal discomfort occurs for more than two minutes. If the pain does not subside immediately, one dose of nitroglycerin should be taken sublingually. If the pain does not improve or worsens within five minutes of taking nitroglycerin, emergency medical services should be called, and two additional doses of nitroglycerin should be taken five minutes apart while the patient is lying down or sitting. Nitroglycerin should not be administered within 24 hours of a phosphodiesterase inhibitor. Renin-angiotensinaldosterone system inhibitors
ACE inhibitors should be initiated early and continued indefinitely in all patients without contraindications who have concomitant chronic kidney disease, diabetes mellitus, heart failure, hypertension, or an LVEF ≤ 40%. In all other patients without contraindications, it is reasonable to initiate ACE inhibitors early and continue therapy indefinitely. An ARB should be prescribed for patients who cannot tolerate ACE inhibitors. Combination therapy with an ACE inhibitor and ARB is not recommended. Aldosterone blockers should be initiated in patients who are already receiving therapeutic doses of an ACE inhibitor, have an LVEF ≤ 40%, and have symptomatic heart failure or diabetes. Candidates for aldosterone blockers should have a creatinine clearance > 30 mL per minute per 1.73 m2 (0.50 mL per second per m2) and a serum potassium level < 5.0 mEq per L (5.0 mmol per L).
ACE = Angiotensin-converting enzyme; ARB = Angiotensin receptor blocker; LDL = Low-density lipoprotein; LVEF = Left ventricular ejection fraction. *High-risk patients include those with established coronary disease plus multiple major coronary risk factors, poorly controlled risk factors, or acute coronary syndrome. Information from references 6 through 10.
mortality rates.41,42 Guidelines encourage setting a goal of at least 150 minutes per week of moderate-intensity aerobic activity, such as brisk walking.8 Smoking
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cessation rates improve in patients with cardiovascular disease when behavioral interventions are initiated in the hospital setting and are coupled with one month of
Review article Table 3. Strategies to Prevent Medication Discontinuation Within 90 Days of an Acute Coronary Syndrome Avoid prescribing expensive medications when less expensive and equally effective alternatives are available. Enroll the patient in a diet and exercise program. Enroll the patient in a postdischarge comprehensive cardiac rehabilitation program. Help the patient find programs that help pay for medications. Minimize the number of medications given at discharge. Schedule a follow-up appointment with a cardiologist. Use a system of medication tracking (e.g., pillbox, calendar, alarm). Information from reference 39.
supportive contact.43 The addition of nicotine replace ment therapy increases the likelihood of cessation and is safe in patients with ACS.43,44 Postdischarge Interventions
Cardiac Rehabilitation The ACC and AHA recommend cardiac rehabilitation for patients with non–ST elevation MI or ST elevation MI.6,10 A Cochrane review found a 13% reduction in allcause mortality and a 26% reduction in cardiovascular mortality in patients who underwent an exercise-based rehabilitation program, with similar results in those who underwent comprehensive (exercise and dietary management) programs.45 Specifically, reductions were noted in all-cause and cardiovascular mortality in patients who had follow-up at or beyond 12 months. In addition to their mortality benefit, these programs improve fitness, symptoms, lipid profiles, stress level, and overall well-being.46 Although benefits are clear, cardiac rehabilitation remains an underutilized resource. A Medicare claims data analysis found that it was used in only 14% of patients hospitalized for MI, emphasizing the need for its inclusion in a comprehensive discharge plan.47
Activity Recommendations Guidelines from the ACC/AHA for management of non–ST elevation MI advise that patients may begin walking soon after discharge, resume sexual activity in as early as one week, and drive within three weeks after symptom resolution, although recovery times will vary depend ing on individual circumstances.6 Air travel
should be avoided for two weeks unless the patient is symptom free, possesses nitroglycerin, has a traveling partner, and avoids situations requiring increased physical demands.6 After ST elevation MI, patients are encouraged to return to physical activity as tolerated, ideally with guidance after an exercise stress test.10
Recognition of Cardiac Symptoms Patients who have had an MI and their families should be taught to recognize cardiac symptoms, initiate the emergency response system, and use prescribed nitro glycerin. Resources for cardiopulmonary resuscitation training programs should be readily available.10 FOLLOW-UP VISITS Patients who have had an MI should have follow-up appointments prescheduled with their cardiologist and primary care physician, and these appointments should be included in the discharge summary. Components of an effective follow-up visit include a review of symp toms, medication reconciliation, cardiovascular risk assessment, psychosocial status (including screening for depression), activity limitations, and referrals to cardiac rehabilitation if not already done.10 REFERENCES 1. Roger VL, Go AS, Lloyd-Jones DM, et al.; American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics—2012 update: a report from the American Heart Association [published correction appears in Circulation. 2012;125(22):e1002]. Circulation. 2012;125(1):e2-e220. 2. Thygesen K, Alpert JS, White HD, et al.; Joint ESC/ACCF/ AHA/WHF Task Force for the Redefinition of Myocardial Infarction. Universal definition of myocardial infarction. Circulation. 2007;116(22):2634-2653. 3. Fox KA, Steg PG, Eagle KA, et al.; GRACE Investigators. Decline in rates of death and heart failure in acute coronary syndromes, 1999-2006. JAMA. 2007;297(17):1892-1900. 4. Peterson ED, Roe MT, Mulgund J, et al. Association between hospital process performance and outcomes among patients with acute coronary syndromes. JAMA. 2006;295(16):1912-1920. 5. Menzin J, Wygant G, Hauch O, Jackel J, Friedman M. One-year costs of ischemic heart disease among patients with acute coronary syndromes: findings from a multi-employer claims database. Curr Med Res Opin. 2008;24(2):461-468. 6. Anderson JL, Adams CD, Antman EM, et al.; American College of Cardiology; American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise
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Review article the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarc tion); American College of Emergency Physicians; Society for Cardio vascular Angiography and Interventions; Society of Thoracic Surgeons; American Association of Cardiovascular and Pulmonary Rehabilitation; Society for Academic Emergency Medicine. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction [published correction appears in J Am Coll Cardiol. 2008;51(9):974]. J Am Coll Cardiol. 2007;50(7):e1-e157. 7. Smith SC Jr, Benjamin EJ, Bonow RO, et al.; World Heart Federation and the Preventive Cardiovascular Nurses Association. AHA/ACCF secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular disease: 2011 update. Circulation. 2011;124(22):2458-2473. 8. Levine GN, Bates ER, Blankenship JC, et al. 2011 ACCF/ AHA/SCAI guideline for percutaneous coronary intervention: executive summary [published correction appears in Circulation. 2012;125(8):e411]. Circulation. 2011;124(23):2574-2609. 9. Jneid H, Anderson JL, Wright RS, et al. 2012 ACCF/AHA focused update of the guideline for the management of patients with unstable angina/non-ST-elevation myocardial infarction (updating the 2007 guideline and replacing the 2011 focused update). J Am Coll Cardiol. 2012;60(7):645-681. 10. O’Gara PT, Kushner FG, Ascheim DD, et al.; American College of Emer gency Physicians; Society for Cardiovascular Angiography and Interven tions. 2013 ACCF/AHA guideline for the management of STelevation myocardial infarction. J Am Coll Cardiol. 2013;61(4):e78-e140. 11. Antithrombotic Trialists’ Collaboration. Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients [published correction appears in BMJ. 2002;324(7330):141]. BMJ. 2002;324(7329):71-86. 12. Mehta SR, Yusuf S, Peters RJ, et al.; Clopidogrel in Unstable Angina to Prevent Recurrent Events Trial (CURE) Investigators. Effects of pretreatment with clopidogrel and aspirin followed by long-term therapy in patients undergoing percutaneous coronary intervention: the PCI-CURE study. Lancet. 2001;358(9281):527-533. 13. Wiviott SD, Braunwald E, McCabe CH, et al.; TRITONTIMI 38 Investigators. Prasugrel versus clopidogrel in patients with acute coronary syndromes. N Engl J Med. 2007;357(20):2001-2015. 14. Wallentin L, Becker RC, Budaj A, et al.; PLATO Investigators. Ticagrelor versus clopidogrel in patients with acute coronary syndromes. N Engl J Med. 2009;361(11):1045-1057.
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15. Yusuf S, Zhao F, Mehta SR, Chrolavicius S, Tognoni G, Fox KK; Clopidogrel in Unstable Angina to Prevent Recurrent Events Trial Investigators. Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation [published correc tions appear in N Engl J Med. 2001;345(20):1506 and N Engl J Med. 2001;345(23):1716]. N Engl J Med. 2001;345(7): 494-502. 16. James SK, Roe MT, Cannon CP, et al.; PLATO Study Group. Ticagre lor versus clopidogrel in patients with acute coronary syndromes intended for non-invasive management: substudy from prospective randomised PLATelet inhibition and patient Outcomes (PLATO) trial. BMJ. 2011;342:d3527. 17. Abraham NS, Hlatky MA, Antman EM, et al. ACCF/ACG/ AHA 2010 expert consensus document on the concomitant use of proton pump inhibitors and thienopyridines: a focused update of the ACCF/ACG/AHA 2008 expert consensus document on reducing the gastro intestinal risks of antiplatelet therapy and NSAID use. Circulation. 2010;122(24):2619-2633. 18. Hillis LD, Smith PK, Anderson JL, et al. 2011 ACCF/ AHA guideline for coronary artery bypass graft surgery: executive summary [published corrections appear in Circulation. 2011;124(25):e956 and Circulation. 2012;126(7):e105]. Circulation. 2011;124(23):2610-2642. 19. Yusuf S, Peto R, Lewis J, Collins R, Sleight P. Beta blockade during and after myocardial infarction: an overview of the randomized trials. Prog Cardiovasc Dis. 1985;27(5): 335-371. 20. Freemantle N, Cleland J, Young P, Mason J, Harrison J. Beta blockade after myocardial infarction: systematic review and meta regression analysis. BMJ. 1999;318(7200): 1730-1737. 21. Perez MI, Musini VM, Wright JM. Effect of early treatment with anti-hypertensive drugs on short and long-term mortality in patients with an acute cardiovascular event. Cochrane Database Syst Rev. 2009;(4):CD006743. 22. Domanski MJ, Krause-Steinrauf H, Massie BM, et al.; BEST Investigators. A comparative analysis of the results from 4 trials of beta-blocker therapy for heart failure: BEST, CIBIS-II, MERIT-HF, and COPERNICUS. J Card Fail. 2003;9(5):354-363. 23. Bangalore S, Steg G, Deedwania P, et al.; REACH Registry Investigators. β-Blocker use and clinical outcomes in stable outpatients with and with out coronary artery disease. JAMA. 2012;308(13):1340-1349. 24. Latini R, Maggioni AP, Flather M, Sleight P, Tognoni G. ACE inhibitor use in patients with myocardial infarction. Summary of evidence from clinical trials. Circulation. 1995;92(10):3132-3137. 25. ACE Inhibitor Myocardial Infarction Collaborative Group. Indications for ACE inhibitors in the early treatment of
Review article acute myocardial infarction: systematic overview of individual data from 100,000 patients in random ized trials. Circulation. 1998;97(22):2202-2212.
36. Clancy CM. Reengineering hospital discharge: a protocol to improve patient safety, reduce costs, and boost patient satisfaction. Am J Med Qual. 2009;24(4):344-346.
26. Rodrigues EJ, Eisenberg MJ, Pilote L. Effects of early and late adminis tration of angiotensin-converting enzyme inhibitors on mortality after myocardial infarction. Am J Med. 2003;115(6):473-479.
37. Mukherjee D, Fang J, Chetcuti S, Moscucci M, KlineRogers E, Eagle KA. Impact of combination evidencebased medical therapy on mortality in patients with acute coronary syndromes. Circulation. 2004;109(6):745-749.
27. Pfeffer MA, McMurray JJ, Velazquez EJ, et al.; Valsartan in Acute Myocardial Infarction Trial Investigators. Valsartan, captopril, or both in myocardial infarction complicated by heart failure, left ventricular dysfunction, or both [published correction appears in N Engl J Med. 2004;350(2):203]. N Engl J Med. 2003;349(20):1893-1906.
38. Ho PM, Spertus JA, Masoudi FA, et al. Impact of medication therapy discontinuation on mortality after myocardial infarction. Arch Intern Med. 2006;166(17):1842-1847.
28. Pitt B, White H, Nicolau J, et al.; EPHESUS Investigators. Eplerenone reduces mortality 30 days after randomization following acute myocardial infarction in patients with left ventricular systolic dysfunction and heart failure. J Am Coll Cardiol. 2005;46(3):425-431. 29. Vale N, Nordmann AJ, Schwartz GG, et al. Statins for acute coronary syndrome. Cochrane Database Syst Rev. 2011;(6):CD006870. 30. Winchester DE, Wen X, Xie L, Bavry AA. Evidence of preprocedural statin therapy: a meta-analysis of randomized trials. J Am Coll Cardiol. 2010;56(14):1099-1109. 31. Cannon CP, Braunwald E, McCabe CH, et al.; Pravastatin or Atorvastatin Evaluation and Infection TherapyThrombolysis in Myocardial Infarction 22 Investigators. Intensive versus moderate lipid lowering with statins after acute coronary syndromes [published correction appears in N Engl J Med. 2006;354(7):778]. N Engl J Med. 2004;350(15):1495-1504. 32. Gibbons RJ, Balady GJ, Bricker JT, et al.; American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Committee to Update the 1997 Exercise Testing Guidelines. ACC/AHA 2002 guideline update for exercise testing: summary article [published correction appears in J Am Coll Cardiol. 2006;48(8):1731]. J Am Coll Cardiol. 2002;40(8):1531-1540. 33. Larsson H, Areskog M, Areskog NH, et al. Should the exercise test (ET) be performed at discharge or one month later after an episode of unstable angina or nonQ-wave myocardial infarction? Int J Card Imaging. 1991;7(1):7-14. 34. Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P,Baker DW. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA. 2007;297(8):831-841. 35. Jack BW, Chetty VK, Anthony D, et al. A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. Ann Intern Med. 2009;150(3):178-187.
39. Melloni C, Alexander KP, Ou FS, et al. Predictors of early discontinuation of evidence-based medicine after acute coronary syndrome. Am J Cardiol. 2009;104(2):175-181. 40. Chow CK, Jolly S, Rao-Melacini P, Fox KA, Anand SS, Yusuf S. Association of diet, exercise, and smoking modification with risk of early cardiovascular events after acute coronary syndromes. Circulation. 2010;121(6): 750-758. 41. Mitrou PN, Kipnis V, Thiébaut AC, et al. Mediterranean dietary pattern and prediction of all-cause mortality in a US population: results from the NIH-AARP Diet and Health Study. Arch Intern Med. 2007;167(22):2461-2468. 42. Lichtenstein AH, Appel LJ, Brands M, et al. Diet and lifestyle recommendations revision 2006: a scientific statement from the American Heart Association Nutrition Committee [published corrections appear in Circulation. 2006;114(23):e629 and Circulation. 2006;114(1):e27]. Circulation. 2006;114(1):82-96. 43. Rigotti NA, Clair C, Munafò MR, Stead LF. Interventions for smoking cessation in hospitalised patients. Cochrane Database Syst Rev. 2012;(5):CD001837. 44. Meine TJ, Patel MR, Washam JB, Pappas PA, Jollis JG. Safety and effectiveness of transdermal nicotine patch in smokers admitted with acute coronary syndromes. Am J Cardiol. 2005;95(8):976-978. 45. Jolliffe JA, Rees K, Taylor RS, Thompson D, Oldridge N, Ebrahim S. Exercise-based rehabilitation for coronary heart disease. Cochrane Database Syst Rev. 2011;(7):CD001800. 46. Balady GJ, Ades PA, Comoss P, et al. Core components of cardiac rehabilitation/secondary prevention programs: a statement for healthcare professionals from the American Heart Association and the American Association of Cardiovascular and Pulmonary Rehabilitation Writing Group. Circulation. 2000;102(9):1069-1073. 47. Suaya JA, Shepard DS, Normand SL, Ades PA, Prottas J, Stason WB. Use of cardiac rehabilitation by Medicare beneficiaries after myocardial infarction or coronary bypass surgery. Circulation. 2007;116(15):1653-1662.
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Clinical Study
Prevalence of Metabolic Syndrome in Patients with Essential Hypertension D Makwana, S Bagga, M Nandal
Abstract The objective of this study was to study the prevalence of metabolic syndrome among patients with essential hypertension and to correlate metabolic parameters. It was a noninterventional, observational study in which 172 patients having essential hypertension who fulfilled the inclusion criteria were included and all were subjected to a uniform questionnaire, medical examination and investigations. Prevalence of metabolic syndrome was 55.23% in patients with essential hypertension in this study, more common in females and most common in age group between 40 and 50 years (39.60%). Low high-density lipoprotein cholesterol (HDL-C) level was the most common metabolic abnormality detected in patients with metabolic syndrome followed by an abnormal fasting blood sugar (FBS), abnormal waist circumference and abnormal triglyceride (TG) level. The females had an abnormal HDL-C levels in 92.06% (z = 16.19, p < 0.05) followed by an abnormal waist circumference in 61.90% (z = 6.85, p < 0.05). The FBS and TG were abnormal in 60.3% (z = 3.34, p < 0.05) and 50.7% (z = 2.57, p < 0.05), of female patients, respectively, while in males, the most common abnormality was low HDL-C in 87.5% (z = 12.54, p < 0.05) followed by abnormal TG levels in 65.62% (z = 3.71, p < 0.05), abnormal FBS 62.5%, (z = 2.92, p < 0.05) and abnormal waist circumference 40.62% (z = 2.14, p < 0.05). TG/HDL-C ratio of ≥3 was the variable that had the best correlation (p = 0.534) with the presence of metabolic syndrome.
Keywords: Metabolic syndrome, essential hypertension, metabolic parameters, high-density lipoprotein, waist circumference, triglycerides
T
he definition of metabolic syndrome refers to a cluster of metabolic abnormalities that are thought to occur due to insulin resistance and are associated with the presence of abdominal obesity. This cluster of metabolic abnormalities is known to increase the risk of coronary heart disease (CHD) and type 2 diabetes. Various abnormalities have been associated with metabolic syndrome. Here is a list of these abnormalities and the various metabolic derangements that are associated with each one of them. ÂÂ
Abdominal obesity
ÂÂ
Atherogenic dyslipidemia
Hypertension
ÂÂ
Insulin resistance zz
Impaired fasting glucose
zz
Impaired glucose intolerance
ÂÂ
Prothrombotic effect
ÂÂ
Increased fibrinogen proinflammatory effect
ÂÂ
Abnormal uric acid metabolism
ÂÂ
Endothelial dysfunction
ÂÂ
Reproductive zz
zz
Increase in triglycerides (TGs)
zz
Decrease in high-density cholesterol (HDL-C)
zz
Increase in low-density lipoprotein (LDL) particle
zz
Postprandial lipidemia
lipoprotein
Dept. of Medicine, BJ Medical College, Ahmedabad, Gujarat Address for correspondence Dr D Makwana Dept. of Medicine BJ Medical College, Ahmedabad, Gujarat
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ÂÂ
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Polycystic ovarian syndrome.
There is an increasing evidence that nonalcoholic steatohepatitis and several forms of cancer are more likely to occur in insulin-resistant individuals. It is important to note that not all insulin-resistant individuals will develop the entire cluster of abnormalities listed above and the number of manifestations present in an insulin-resistant individual will vary with the cut point used to separate normal from abnormal. Thus, detection of presence of insulin resistance along with other risk factor is more important. Indians living in urban areas of the Indian subcontinent as well as those who have migrated to western countries have a high prevalence of CHD as compared to Caucasians.
Clinical Study Material and Methods To achieve the above-mentioned aims and objectives, we carried out a noninterventional, observational study in 172 patients having essential hypertension attending the medicine outdoor patients department (OPD) of the tertiary care center from May 2010 to April 2011. The study subjects were examined and their laboratory investigations were carried out in a fasting state.
Inclusion Criteria The study included patients between the age group of 25 and 70 years attending the medicine OPD having essential hypertension, that is, blood pressure (BP) >140/90 mmHg or on antihypertensive treatment.
Exclusion Criteria ÂÂ
Age > 70 years
ÂÂ
Age < 25 years
ÂÂ
Patient on medications like steroid treatment for any cause, decongestants, appetite suppressants, cyclosporine, tricyclic antidepressants, monoamine oxidase inhibitors, erythropoietin, nonsteroidal anti-inflammatory agents and cocaine.
ÂÂ
Renal failure
ÂÂ
Obstructive sleep apnea
ÂÂ
Hypothyroidism, hyperthyroidism, hypercalcemia and acromegaly
ÂÂ
Pre-eclampsia/eclampsia
The metabolic syndrome in these patients was defined by the Adult Treatment Panel III (ATP III) criteria as the presence of any three or more of the following parameters: ÂÂ
Fasting blood glucose of ≥100 mg/dL
ÂÂ
Serum TGs ≥ 150 mg/dL
ÂÂ
Serum HDL-C <40 mg/dL (men) and 50 mg/dL (women)
ÂÂ
BP of ≥130/85 mmHg (or on antihypertensive treatment)
ÂÂ
Waist circumference of >102 cm (men) and 88 cm (women)
Outcomes Measured The final outcome measured was prevalence of metabolic syndrome in patients with essential hypertension, using the above-mentioned criteria, attending the medicine OPD. The predisposing factors like the age and the sex of the patient, lifestyle and the family history and their correlation with the metabolic
syndrome were studied. The percentage of patients having only LDL-C and the total cholesterol raised was also measured. The various variables of the metabolic syndrome were also correlated. The information thus obtained was analyzed using percentages; chi-square test and the variables correlated using Spearman’s correlation coefficient. Observation and Analysis Overall prevalence of metabolic syndrome in our study population was 55.23%, out of which 31.97% patients were females (Table 1). The prevalence was found to be highest in the middle age group of 40-50 years and Table 1. Distribution of Metabolic Syndrome Among the Cases Metabolic syndrome Yes Male
Number
Percent (%)
40
23.26
55
31.97
Male
43
25
Female
34
19.76
Total
172
100
Female No
Table 2. Prevalence of Metabolic Syndrome Among Various Age Groups Age groups (years)
<30
30-40
40-50
50-60
60-70
>70
Syndrome present
1.10
4.40
39.60
36.30
16.50
2.20
Syndrome absent
4.10
11.00
31.60
28.80
15.10
9.60
Table 3. Association of Waist Circumference (cm) with Metabolic Syndrome Waist circumference (cm) Abnormal Normal Total Chi-square test applied Pearson chisquare
Metabolic syndrome Yes No
Number 57
% 60.0
Number 12
% 15.58
38
40.0
65
84.41
95 Value
55.23 df
77 p value
44.77 Significance
34.92
1
<0.000001
Significance
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Clinical Study Table 4. Association of FBS (mg/dL) with Metabolic Syndrome FBS (mg/dL)
Abnormal Normal Total Chi-square test applied Pearson chi-square
Metabolic syndrome Yes No Number % Number % 51 53.68 3 3.89 44 46.32 74 96.10 95 Value
55.23 df
48.94
1
77 p value
44.77 Significance
2.27E-11 Significance
FBS = Fasting blood sugar.
Table 5. Association of TG with Metabolic Syndrome Triglyceride
Metabolic syndrome Yes
No
Number
%
Number
%
Abnormal
54
Normal
41
56.84
9
14.29
43.16
68
62.39
Total
95
55.23
77
44.77
Chi-square test applied
Value
df
p value
Significance
Pearson chisquare
37.35
1
1.04E-09
Significant
Table 6. Association of HDL-C with Metabolic Syndrome HDL-C
Metabolic syndrome Yes
No
Number
%
Number
%
Abnormal
87
82.07
27
17.93
Normal
8
13.79
50
86.21
Total
95
55.23
77
44.77
Value
df
p value
Significance
1
1.90E-15
Significant
Chi-square test applied Pearson chisquare
60.77
the prevalence of metabolic syndrome did not increase with age (Table 2).
of metabolic syndrome among hypertensive patients is around 55.23%, out of which 31.97% patients were females. Thus, we concluded that the prevalence of metabolic syndrome is higher in patients with essential hypertension as compared to the normotensive patients. Overall, metabolic syndrome in patients with essential hypertension was more prevalent among women than in men. The prevalence of metabolic syndrome in our study did not increase with age and the prevalence was found to be highest in the middle age group of 40-50 years. The most common abnormal metabolic parameter detected was HDL-C (91.57%) among subjects with metabolic syndrome. This was also the most common abnormal parameter in males as well as in females. Another parameter TG/HDL-C ratio has been shown to be a good surrogate marker for hyperinsulinemia as is FBS and it also provides an independent risk estimate for coronary artery disease. Our study showed that patient with TG/HDL-C ratio > 3.0 have higher chances of associated metabolic syndrome. Patients with the syndrome had an almost double cardiovascular event rate than those without (3.23 vs 1.76/100 patient-years, p < 0.001). The ATP III too underlines this fact and recognizes the primary endpoint of metabolic syndrome as an increased risk of cardiovascular disease (CVD) and emphasizes the need of targeting metabolic syndrome and its individual components in preventing the CVD after targeting LDL-C. Conclusion It has been demonstrated in our study that all patients of essential hypertension should be screened for various parameters of metabolic syndrome, as it was found that this population is at a higher risk of developing metabolic syndrome and its associated complications. As the prevalence is more in younger age group, screening should start at an early age and further studies should be carried out in Indian population to support the same evidence. References
Discussion
1. McKeigue PM, Miller GJ, Marmot MG. Coronary heart disease in south Asians overseas: a review. J Clin Epidemiol 1989;42(7):597-609.
The findings of our study carried out in 172 patients with essential hypertension attending the Medicine OPD of tertiary care center indicate that the prevalence
2. Chadha SL, Radhakrishnan S, Ramachandran K, Kaul U, Gopinath N. Epidemiological study of coronary heart disease in urban population of Delhi. Indian J Med Res 1990;92:424-30.
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Clinical Study 3. Balarajan R. Ethnic differences in mortality from ischaemic heart disease and cerebrovascular disease in England and Wales. BMJ 1991;302(6776):560-4. 4. Beckles GL, Miller GJ, Kirkwood BR, Alexis SD, Carson DC, Byam NT. High total and cardiovascular disease mortality in adults of Indian descent in Trinidad, unexplained by major coronary risk factors. Lancet 1986;1(8493):1298-301.
7. Ramachandran A, Snehalatha C, Dharmaraj D, Viswanathan M. Prevalence of glucose intolerance in Asian Indians. Urban-rural difference and significance of upper body adiposity. Diabetes Care 1992;15(10):1348-55. 8. McKeigue PM, Pierpoint T, Ferrie JE, Marmot MG. Relationship of glucose intolerance and hyperinsulinaemia to body fat pattern in south Asians and Europeans. Diabetologia 1992;35(8):785-91.
5. McKeigue PM, Shah B, Marmot MG. Relation of central obesity and insulin resistance with high diabetes prevalence and cardiovascular risk in South Asians. Lancet 1991;337(8738):382-6.
9. Reaven GM. Banting lecture 1988. Role of insulin resistance in human disease. Diabetes 1988;37(12):1595-607.
6. Ramachandran A, Jali MV, Mohan V, Snehalatha C, Viswanathan M. High prevalence of diabetes in an urban population in south India. BMJ 1988;297(6648):587-90.
11. Chan JM, Rimm EB, Colditz GA, Stampfer MJ, Willett WC. Obesity, fat distribution, and weight gain as risk factors for clinical diabetes in men. Diabetes Care 1994;17(9):961-9.
10. Meigs JB. Epidemiology of the metabolic syndrome, 2002. Am J Manag Care 2002;8(11 Suppl):S283-92; quiz S293-6.
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Long-term Air Pollution Ups Risk of CVD: European Study A large meta-analysis of 11 cohorts in five European countries suggests that long-term exposure to air pollution is a cardiovascular risk factor.1 The findings, from the European Study of Cohorts for Air Pollution Effects (ESCAPE), were published online January 21, 2014 in BMJ. People who live in polluted areas for a long period have a greater risk of having a first heart attack, said Giulia Cesaroni at Lazio Regional Health Service, Rome, Italy. According to the recent report on the Global Burden of Disease, particulate air pollution is estimated to cause 3.1 million deaths each year worldwide, reports Medscape. In the European Union, the current annual limit for fine particulate matter with a diameter of <2.5 μm (PM 2.5) is 25 μg/m3, which is more than twice as high as the acceptable level in the US, at 12 μg/m3. ESCAPE included 1,00,166 participants who were enrolled in cohorts in Finland, Sweden, Denmark, Germany, and Italy from 1997 to 2007 and had no previous coronary events at baseline. During a mean follow-up of 11.5 years, 5,157 participants had an incident acute coronary event. The researchers found that a 5 μg/m3 increase in annual exposure to fine (PM 2.5) particulate matter was associated with a 13% increased risk of coronary events, and a 10 μg/m3 increase in annual exposure to coarse (PM 10) particulate matter was associated with a 12% increased risk of coronary events. Significant cardiac effects were also discernible for exposure levels only slightly above the 10 μg/m3 World Health Organization (WHO) air-quality guideline for fine particles.2 Nearly 90% of the world’s population is exposed to levels of air pollution that exceed this recommended maximum threshold. A study showed that in Beijing, levels of fine particles in the air were more than 10 times as high as this over a 5-year period.3 There is a need to call for more efforts to reduce other known cardiovascular risk factors, such as smoking, in highly polluted areas. In addition, “people with or at risk of cardiovascular disease who live in highly polluted areas also warrant more aggressive use of primary and secondary preventive therapies, including antiplatelet agents, lipid-lowering agents and treatments for hypertension or diabetes, all known to prevent cardiovascular events.
References 1. Cesaroni G, Forastiere F, Stafoggia M, et al. Long term exposure to ambient air pollution and incidence of acute coronary events: prospective cohort study and meta-analysis in 11 European cohorts from the ESCAPE Project. BMJ 2014:348:f7412. 2. Brauer M and Mancini GBJ. Where there’s smoke… BMJ 2014;348:g40. 3. Guo Y, Li S, Tian Z, et al. The burden of air pollution on years of life lost in Beijing, China, 2004-08: retrospective regression analysis of daily deaths. BMJ 2013;347:f7139.
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case report
Double-Chambered Right Ventricle with Transient 2:1 Atrioventricular Block: A Rare Presentation MONIKA MAHESHWARI*, SK KAUSHIKâ&#x20AC;
Abstract We report herein a case of 35-year-old male with a history of complex congenital heart disease, consisting of double-chambered right ventricle (DCRV) with ventricular septal defect and presenting with transient 2:1 atrioventricular (AV) block on electrocardiogram. This unique presentation has not yet been described in literature, hence it was worth describing this rare complication of DCRV.
Keywords: Double-chambered right ventricle, atrioventricular heart block, moderator band
D
ouble-chambered right ventricle (DCRV) is a rare congenital heart disease characterized by the division of the right ventricular (RV) cavity into two chambers by anomalous muscle bundle or a hypertrophied moderator band.1 Electrocardiogram (ECG) usually shows features of RV overload, in form of RV hypertrophy or right bundle branch block.2 We describe herein the first case of unrepaired DCRV complicated with transient 2:1 atrioventricular (AV) block in ECG. CASE REPORT A 35-year-old male who was a diagnosed case of DCRV with ventricular septal defect (VSD) presented in outdoor with complaint of episodes of syncope on mild exertion since 2 months. On examination, his vital parameters were stable. Cardiac auscultation revealed a harsh, Grade 4/6 systolic murmur at left lower sternal border. Transthoracic echocardiogram confirmed DCRV and showed a prominent muscle band transversing from the RV free wall to the interventricular septum and dividing RV into two parts (RV1, RV2) with an apical muscular VSD. Color Doppler demonstrated a turbulent jet of blood from RV2 to RV1 through perforation in the anomalous muscular bundle (Fig. 1). On doing ECG there was transient 2:1 AV block evident in lead V2 (Fig. 2).
*3rd Year Resident â&#x20AC; Senior Professor and Ex.-Head Dept. of Cardiology Jawaharlal Nehru Medical College, Ajmer, Rajasthan Address for correspondence Dr Monika Maheshwari Navin Niwas, 434/10, Bapu Nagar, Ajmer, Rajasthan - 305 001 E-mail: opm11@rediffmail.com
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Figure 1. Transthoracic echocardiogram showing DCRV with a prominent muscle band dividing RV into two parts and an apical muscular VSD. Color Doppler demonstrating a turbulent jet of blood from RV2 to RV1 through perforation in the anomalous muscular bundle.
Figure 2. Electrocardiogram with transient 2:1 AV block evident in lead V2.
case report DISCUSSION
REFERENCES
DCRV is rare with overall incidence of 0.5-2%.3 Treatment of choice is resection of anomalous muscle bundle and repair of associated lesions during childhood.4 The long-term prognosis for patients after the intracardiac repair of DCRV is excellent, but in some reported cases, AV block occurred during the postoperative period, which required insertion of a permanent pacemaker.5 However, in our case there was no past history of surgical correction of the congenital lesion and 2:1 AV block developed spontaneously as a complication of unrepaired DCRV.
1. Bashore TM. Adult congenital heart disease: right ventricular outflow tract lesions. Circulation 2007;115(14):1933-47.
Conclusion We hypothesize that structural anomalies involved in DCRV like muscular band hypertrophy and substitution of myocardium by fibrotic tissue with myofilaments disarray, would have lead to development of AV block in our patient.
2. Byrum CJ, Dick M 2nd, Behrendt DM, Hees P, Rosenthal A. Excitation of the double chamber right ventricle: electrophysiologic and anatomic correlation. Am J Cardiol 1982;49(5):1254-8. 3. Singh NK, Karn JP, Gupta A, Senthil S. Double-chambered right ventricle with ventricular septal defect presenting in adulthood. J Assoc Physician India 2011;59:451-3. 4. Penkoske PA, Duncan N, Collins-Nakai RL. Surgical repair of double-chambered right ventricle with or without ventriculotomy. J Thorac Cardiovasc Surg 1987;93(3):385-93. 5. Hachiro Y, Takagi N, Koyanagi T, Morikawa M, Abe T. Repair of double-chambered right ventricle: surgical results and long-term follow-up. Ann Thorac Surg 2001;72(5):1520-2.
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Eating High Fiber Diet ÂÂ ÂÂ ÂÂ ÂÂ ÂÂ ÂÂ ÂÂ ÂÂ ÂÂ ÂÂ ÂÂ ÂÂ ÂÂ ÂÂ ÂÂ ÂÂ ÂÂ ÂÂ ÂÂ ÂÂ ÂÂ
There are two types of fibers. One is soluble and the other is insoluble. Soluble fiber includes those that are made up of carbohydrates and absorb in water. Examples are oats, barley and legumes. Insoluble fiber comes from plant cells and does not dissolve in water. Examples are wheat, ragi and other grains. Traditionally, fiber is insoluble fiber. Dietary fiber is a combination of soluble and insoluble fiber. The recommended amount of dietary fiber is 20-35 g in a day. Eating a high-fiber diet both can prevent constipation, reduce cholesterol and help in reversing obesity and heart diseases in children and adults. A high-fiber diet should be a balanced diet with food from all food groups. The common sources of fiber are whole grain produce and cereals, legumes, fruits and vegetables. One should eat fruits with significance, such as prunes and peas, which are natural laxatives. Raw vegetables such as carrot, garlic or cherry tomatoes are rich in fiber. Salads with dark green lettuce provide high fiber content. Eating whole wheat bread or with added fiber is a rich source of fiber. Prefer brown rice over white rice. You can eat whole wheat carbohydrates, bran muffins, bran cereals or oat meals. Avoid eating refined white flour, cereals and other starches. If juices are to be taken, one should take 4-6 ozs. Fruits are better than juices Try to develop a taste for bran by starting with 2-4 table spoons every day. Mix a high fiber cereal with a regular cereal. Isabgol is a fiber supplement.
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photo quiz
Right-Sided Cardiophrenic Mass in an Older Woman
A
76-year-old, physically active woman presented for an annual physical examination. Chest radiography revealed a large right cardiophrenic mass (Figures 1 and 2). The patient had no remarkable medical history or physical examination findings. She had no history of tobacco use, fever, night sweats, anorexia, weight loss, shortness of breath, or dyspnea with exertion.
Question Based on the patientâ&#x20AC;&#x2122;s history, physical examination, and radiographs, which one of the following is the most likely diagnosis?
Figure 1.
A. Carcinoma. B. Diaphragmatic eventration. C. Morgagni hernia. D. Pericardial cyst. E. Pericardial fat pad.
Figure 2.
SEE THE FOLLOWING PAGE FOR DISCUSSION.
Source: Adapted from Am Fam Physician. 2010;82(8):971-972.
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photo quiz Discussion The answer is C: Morgagni hernia. A Morgagni hernia is a congenital diaphragmatic hernia and is not usually associated with other congenital anomalies.1 Morgagni hernias result from the failure of the sternal and costal components of the diaphragm to fuse during embryogenesis. The condition represents 3 percent of all diaphragmatic hernias and is more common in women.2 Most patients are asymptomatic, but the condition may be identified incidentally on chest radiographs. Occasionally, Morgagni hernias cause nonspecific cardiovascular, gastrointestinal, or respiratory symptoms.3 The hernias are always right-sided and located in the anterior cardiophrenic sulcus.2 More than 90 percent of cases have hernia sacs, which may involve the omentum, colon, stomach, and small intestine. Classic radiographic findings include a homogeneous, rounded soft tissue opacity in the right cardiophrenic angle. A lateral chest radiograph is needed to show the anterior location of the opacity. Although rare, an air-fluid level within the opacity is consid ered pathognomonic of a Morgagni hernia. Computed tomography can be diagnostic in more than 80 percent of patients by showing fat and omental vessels or
Summary Table Condition
Characteristics
Carcinoma
Irregular or spiculated mass with obscured lung markings; possibly associated atelectasis, lymphadenopathy, or pleural effusion
Diaphragmatic eventration
Elevation of the affected area of the diaphragm; smooth hump along the contour of the diaphragm
Morgagni hernia
Homogeneous, rounded mass in the right anterior cardiophrenic angle; airfluid level within the mass is considered pathognomonic
Pericardial cyst
Anomalous outpouching of parietal pericardium; smoothly marginated mass touching the heart
Pericardial fat pad
Associated with Cushing syndrome, corticosteroid therapy, and obesity; density not as great and margins not as sharply defined as those of Morgagni hernia or pericardial cysts
abdominal viscera within the soft tissue mass.4 Once the condi tion is diagnosed, patients should be referred for reduction of the herniated organs and surgical repair of the anatomic defect.5 Carcinoma of the lung usually obscures bronchovascular markings and appears on radiography as an irregular or spiculated mass. Atelectasis, lymphadenopathy, or pleural effusion may be an associated finding. Diaphragmatic eventration is nonpara lytic weakening of the hemidiaphragm. It is usually partial and involves the anterome dial portion of the right hemidiaphragm. Radiography shows elevation of the affected area of the diaphragm, and the common pattern is a smooth hump along the contour of the diaphragm.6 Pericardial cysts are anomalous outpouchings of parietal pericardium. On radi ography, the cysts are smoothly marginated masses touching the heart, particularly at the right anterior cardiophrenic angle. Peri cardial cysts are sometimes difficult to distinguish from Morgagni hernias. Computed tomography or ultrasonography can demon strate the cystic nature of the lesions.7 Enlarged pericardial fat pads are associated with Cushing syndrome, corticosteroid therapy, and obesity. They often occupy the right cardiophrenic angle. Although the fat pads may obliterate the angle, the cardiac and diaphragmatic borders are usually visible. The density of fat pads is not as great as that of Morgagni hernias, and their margins are not as sharply delineated. REFERENCES 1. Naunheim KS. Adult presentation of unusual diaphragmatic hernias. Chest Surg Clin N Am. 1998;8(2):359-369. 2. Comer TP, Clagett OT. Surgical treatment of hernia of the foramen of Morgagni. J Thorac Cardiovasc Surg. 1966;52(4):461-468. 3. Bhasin DK, Nagi B, Gupta NM, Singh K. Chronic inter mittent gastric volvulus within the foramen of Morgagni. Am J Gastroenterol. 1989;84(9):1106-1108. 4. Minneci PC, Deans KJ, Kim P, Mathisen DJ. Foramen of Morgagni hernia: changes in diagnosis and treatment. Ann Thorac Surg. 2004;77(6):1956-1959. 5. Huston JM, King H, Maresh A, et al. Hernia of Mor gagni: case report. J Thorac Cardiovasc Surg. 2008;135(1): 212-213. 6. Deslauriers J. Eventration of the diaphragm. Chest Surg Clin N Am. 1998;8(2):315-330. 7. Breen JF. Imaging of the pericardium. J Thorac Imaging. 2001;16(1):47-54.
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practice guidelineS
Diagnosis of Stable Ischemic Heart Disease: Recommendations from the ACP
T
he American College of Physicians (ACP), in collabora tion with the American College of Cardiology Founda tion, American Heart Association, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, and Society of Thoracic Surgeons, has devel oped a guideline that helps physicians diagnose known or suspected cases of stable ischemic heart disease (IHD). Recommendations address IHD and related issues, including initial diagnosis, cardiac stress testing, and coronary angiography.
Initial Cardiac Testing Patients with chest pain should undergo a thorough history and physical examination to determine the prob ability of IHD before undergoing additional testing. The patient and physician should participate in the decision-making process regarding diagnostic and therapeutic options, with the physician explaining information about risks, benefits, and costs of care to the patient. Patients who present with acute angina must be cate gorized as stable or unstable. Patients who have unstable angina should be further categorized as high, interme diate, or low risk (Table 1). In patients with an obvious noncardiac cause of chest pain, resting electrocardiogra phy (ECG) is recommended for risk assessment. In patients with an intermediate pretest probability of IHD who have interpretable ECG results and at least moderate physical functioning or no disabling comor bidity, standard exercise ECG is recommended for ini tial diagnosis. In patients with an intermediate to high pretest probability of IHD whose ECG results cannot be interpreted and who have at least moderate physical functioning or no disabling comorbidity, exercise stress testing with radionuclide myocardial perfusion imaging or echocardiography should be used. Pharmacologic stress testing with radionuclide myo cardial perfusion imaging, echocardiography, or cardiac Source: Adapted from Am Fam Physician. 2013;88(7):469-470.
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magnetic resonance imaging should not be used for patients who have interpretable ECG results and at least moderate physical functioning or no disabling comor bidity. Exercise stress testing with nuclear myocardial perfusion imaging should not be used as an initial test in low-risk patients who have these same criteria. Pharmacologic stress testing with radionuclide myo cardial perfusion imaging or echocardiography is recom mended in patients with an intermediate to high pretest probability of IHD who are incapable of at least moderate physical functioning or who have a disabling comorbidity. Standard exercise ECG testing should not be used for patients who have ECG results that cannot be interpreted, who are incapable of at least moderate physical functioning, or who have a disabling comorbidity. Assessing resting left ventricular systolic and diastolic function and evaluating for abnormalities of myo cardium, pericardium, or heart valves using Doppler echocardiography are recommended in patients who have known or suspected IHD and previous myocardial infarction, pathologic Q waves, signs or symptoms that suggest heart failure, complex ventricular arrhythmias, or an undiagnosed heart murmur. Cardiac computed tomography, cardiac magnetic res onance imaging, echocardiography, and radionuclide imaging should not be used for routine assessment of left ventricular function in patients who have normal ECG results, no history of myocardial infarction, no signs or symptoms that suggest heart failure, and no complex ven tricular arrhythmias. Routine reassessment (less than one year) of left ventricular function using these tests is inap propriate in patients who have no change in clinical status and for whom no change in therapy is contemplated. Cardiac Stress Testing in Known Stable IHD Standard exercise ECG testing for risk assessment is recommended in patients with known stable IHD who are able to exercise and have ECG results that can be interpreted during exercise. If patients can exercise but have unin terpretable ECG results not caused
practice guidelineS Table 1. Short-Term Risk of Death or Nonfatal Myocardial Infarction in Patients with Unstable Angina* High risk At least one of the following features must be present: Angina at rest with dynamic ST-segment changes ≥ 1 mm† Angina with hypotension Angina with new or worsening mitral regurgitation murmur Angina with S3 or new or worsening rales Prolonged, ongoing (more than 20 minutes) pain at rest Pulmonary edema, most likely related to ischemia Intermediate risk No high-risk features but must have any of the following: Age older than 65 years‡ Angina with dynamic T-wave changes New-onset CCSC III or IV angina in the past two weeks with moderate or high likelihood of coronary artery disease§ Nocturnal angina Pathologic Q waves or resting ST-segment depression ≤ 1 mm in multiple lead groups (e.g., anterior, inferior, lateral) Prolonged (more than 20 minutes) rest angina, now resolved, with moderate or high likelihood of coronary artery disease Rest angina (more than 20 minutes or relieved with sublingual nitroglycerin) Low risk No high- or intermediate-risk feature but may have any of the following: Angina provoked at a lower threshold Increased angina frequency, severity, or duration New-onset angina with onset two weeks to two months before presentation Normal or unchanged electrocardiography results Note: A modified version of this table is available at https://www. aacvpr.org/Portals/0/resources/professionals/2012%20Guidelines_ StableIschemicHeartDisease_11-20-12.pdf. Fihn SD, Gardin JM, Abrams J, et al. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease. J Am Coll Cardiol. 2012;60(24):e51. CCSC = Canadian Cardiovascular Society Classification. *Estimation of the short-term risks of death and nonfatal myocardial infarction in unstable angina is a complex multivariable problem that cannot be fully specified in a table such as this. Therefore, it is meant to offer general guidance and illustration rather than rigid algorithms. †In
the modified table, ST-segment changes are greater than 0.5 mm. the modified table, age is listed as older than 70 years. §CCSC III angina is defined by marked limitation of ordinary physical activity. CCSC IV angina is defined by the inability to carry out any physical activity without discomfort. ‡In
by left bundle branch block or ventricular pacing, adding radionuclide myocardial perfusion imaging or echocardiography to standard exercise ECG testing is recommended. Pharmacologic stress testing or cardiac computed tomographic angiography should not be used to assess risk in patients with stable IHD who are able to exercise and have interpretable ECG results. In patients with known stable IHD who are unable to exercise regardless of the ability to interpret the patient’s ECG results, pharmacologic stress testing with radio nu clide myocardial perfusion imaging or echocardiography is recommended. Regardless of the patient’s ability to exercise, pharmacologic stress testing with radionuclide myocardial perfusion imaging or echocardiography for risk assessment in patients with stable IHD who have left bundle branch block on ECG is recommended. In patients being considered for revascularization of known coronary stenosis of unclear physiologic significance, exercise or pharmacologic stress testing with imaging for risk assessment is recommended. More than one stress imaging study, or a stress imaging study and cardiac computed tomography angiography at the same time, should not be used for risk assessment in patients with stable IHD. Coronary Angiography Patients with stable IHD who have survived sudden cardiac death or potentially life-threatening ventricular arrhythmia should undergo coronary angiography to assess cardiac risk. Patients with stable IHD who develop signs and symptoms of heart failure should be evaluated to determine if coronary angiography should be performed. Patients with stable IHD and clinical features indicative of a high likelihood of severe IHD should have coronary angiography to determine cardiac risk. Coronary angiography should be used for risk assessment in patients with stable IHD whose clinical char acteristics and results of noninvasive testing indicate a high likelihood of severe IHD, and when the benefits of coronary angiography outweigh the risks. Coronary angiography should not be used to assess risk in patients with stable IHD who decline revascularization, or who are not candidates for revascularization based on comorbidities or individual preferences; to further assess risk in patients with stable IHD who have preserved left ventricular function and low-risk criteria on noninvasive testing; for risk assessment in patients who are at low risk based on clinical criteria and who have not undergone noninvasive risk testing; or in asymptomatic patients with no indication of ischemia on noninvasive testing.
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mediLAW
Medicolegal Cases in Injury Patients and Indian Law KK Aggarwal
Section 324 of IPC in Medical Practice
Grievous Hurt as per IPC
Section 324: Voluntarily causing hurt by dangerous weapons or means: “Whoever, except in the case provided for by Section 334, voluntarily causes hurt by means of any instrument for shooting, stabbing or cutting, or any instrument which, used as weapon of offence, is likely to cause death, or by means of fire or any heated substance, or by means of any poison or any corrosive substance, or by means of any explosive substance or by means of any substance which it is deleterious to the human body to inhale, to swallow, or to receive into the blood, or by means of any animal, shall be punished with imprisonment of either description for a term which may extend to 3 years, or with fine, or with both”.
S 320 IPC defines grievous hurt and lists eight kinds of hurt which it lables as “grievous”. These clauses are not mutually exclusive for there can be injuries which may fall in more than one clause. However, the list is exhaustive in the sense that, the framers of the Code have used the term “only”, while listing the type of hurts which they designated as “grievous”. This positively shows that the list is exhaustive and no hurt outside the list given in S. 320 can be termed as ‘grievous hurt’.
It is the duty of the attending doctor to record all injuries, their dimensions as much as possible, and the body parts where the injuries are located; the nature of injury, whether simple or grievous; whether caused by sharp/blunt object; age or duration of injury and vital parameters like blood pressure, pulse respiration along with the mental status of the patient. When an investing officer comes to the hospital he needs some specific answers for his legal investigation and to book a case under the law of land. ÂÂ
Are the injuries present, self-inflicted or fabricated? If yes, please mention the forensic justification.
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Are there any signs/symptoms or smell of alcohol or any drug intoxication? If yes, please opine about the mental status due the influence of intoxication. Also, preserve the sample of blood.
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Please opine if the injured or intoxicated patient is fit to give statement? If no, please give due reasons and an approximate time interval for medical reevaluation for his/her fitness for statement.
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Is the condition of patient critical, severe or serious? If so, the dying declaration must be recorded by attending doctor before one or two witnesses.
Senior Physician and Cardiologist Moolchand Medcity, New Delhi
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The following kinds of hurt only are designated as “grievous”: First: Emasculation; Secondly: Permanent privation of the sight of either eye; Thirdly: Permanent privation of the hearing of either ear; Fourthly: Privation of any member or joint; Fifthly: Destruction or permanent impairing of the powers of any member or joint; Sixthly: Permanent disfiguration of the head or face; Seventhly: Fracture or dislocation of a bone or tooth; Eighthly: Any hurt which endangers life or which causes the sufferer to be during the space of twenty days in severe bodily pain or unable to follow his ordinary pursuits. Explanation: To make out the offence of causing grievous hurt, there must be a specific hurt, coming within any of the eight kinds enumerated in this section. A simple hurt cannot be designated as grievous simply because it was on a vital part of the body, unless the dimensions or the nature of the injury or its effects are such that (in the opinion of the doctor) it actually endangers life. For the courts to determine whether the hurt caused is grievous, the extent of the hurt and the intention of the offender have to be taken in to account. Further, it has to be proved that the offender intended to cause or had the knowledge that his act was likely to cause grievous hurt. Intention to cause grievous hurt is inferable from the circumstances of the case and the nature of the injury caused. The medical person, however, must confine himself to only opining whether a given hurt is grievous or otherwise, as per the 8 Clauses of S 320 IPC, and leave the “intention/ knowledge” part to the courts to decide. “Grievous bodily harm, which is defined in the book, is not
mediLAW necessarily either permanent or dangerous, but harm that seriously interferes with health or comfort. That is sufficient”. An injury is not grievous per se unless the nature, extent and effects of the said injury are such as to endanger the life of the victim, as per the opinion of the doctor, formed in good faith. Medical Testimony of Doctor in the Court of Law (Do not misrepresent documents/medical literature in the Court of Law) When evidence is read into the record of a trial, only that portion of the document, which validates the information being discussed needs to be read aloud. One paragraph or even one part of a paragraph may be all that is necessary to substantiate the point you are making. Documents must be presented in the words of the author. When you paraphrase evidence, you argue in a circle. Reading the remainder of the document, even if it establishes a context for the evidence, is unnecessary and time–consuming. When a document is cut in a manner, which lends the quoted passage a meaning other than what would be derived from a more complete reading, you are misrepresenting the document. This does not mean, however, that you are responsible for drawing the same conclusions from information as the author of the document. Drawing a contrary conclusion from passages accurately interpreted does not constitute misrepresentation. The fact that the author of the document reached a different conclusion from the information argues perhaps persuasively against your conclusion. However, you have not misused the evidence. Medicolegal cases and injury, assault and hurt in Indian law
voluntarily caused to any person in medicolegal cases. These would include abrasions, contusions, lacerations, stab wounds, electric shock, firearm, or ligatures, etc. resulting in injury to the human body. The doctor who is certifying an injury report should keep in mind the Penal provisions (as below) required by police to book the case. ÂÂ
Simple injury: IPC Section 323.
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Simple injury caused by dangerous weapons: IPC Section 324.
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Grievous injury: IPC Section 325.
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Grievous injury caused by dangerous weapons: IPC Section 326.
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Dangerous injury: IPC Section 307.
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Injury likely to cause death: IPC Section 304.
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Injury sufficient to cause death: IPC Section 302.
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Causing hurt by means of poison: IPC Section 328.
Preparation of MLC in injury cases by the attending doctor ÂÂ
Injuries produced by a blunt weapon on tense skin covering the bones, as on scalp, eyebrow, iliac crest, shin, perineum, knee or elbow look like incised wounds. During the preparation of medicolegal cases (MLC) report the doctors should keep in mind that he has to provide a clue about the weapon used, whether sharp-edged one or otherwise, the direction of the force, the duration of injury and the location of the wound, which may suggest mode of production i.e., suicide, accident, homicides along with whether the injury is fabricated or otherwise.
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Wounds produced by a blunt weapon or by a fall on the hard surface, object, on tense structures/skin covering the bones, such as the scalp, eyebrow, iliac crest, shin, perineum, knee or elbow when the limb is flexed look like incised wounds; but, they are lacerated wounds, also called split lacerations. These wounds may mislead the doctor and the investigating authorities about a sharp weapon.
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When incised-looking wounds are examined by doctor under magnifying lens, the edges of such wounds are found to be irregular with bruising and wounds are produced by blunt weapon.
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An incised wound, cut, slash and slice is a clean cut through the skin, it may or may not involve underlying tissues and structures. It is caused by a sharp-edged instrument, which is longer than the depth of wound. It is produced by infliction of an object having a sharp-cutting edge such as knife, razor, blade, scalpel, sword over the body.
The words injury, assault and hurt are invariably used by doctors in hospital practice and are used as synonyms. But all three have a different meaning as per law. It is defined by the Indian Penal Code as below: ÂÂ
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Injury: Section 44 of IPC defines injury as any harm whatever illegally caused to any person in body, mind, reputation or property. Assault: Section 351 of IPC defines assault as an offer or threat or attempt to apply force on body of another in a hostile manner. It may be a common/ simple assault or an intention to murder. Hurt: Section 319 of IPC defines hurt as whoever causes bodily pain, disease or infirmity to any person is said to cause hurt.
When we as doctors deal with cases of hurt/body injury, it means bodily pain, wound, disease or infirmity
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around the globe
News and Views Mild cOronary Artery disease in women similar to that in men
Herpes zoster independent risk factor for TIA and MI
Heart disease in women is typically viewed as different from men’s heart disease, in part because of women’s unique presenting symptomatology. But a study reported at the annual meeting of the Radiological Society of North America suggests that they may not really be all that different when it comes to mild coronary artery disease. A prospective, multinational registry analysis found that 1.2% of women and 1.1% of men with mild, nonobstructive coronary artery disease on coronary CT angiography experience a major adverse cardiovascular event, either heart attack or death, each year. For those free of coronary artery disease, the event rate was 0.3% for both sexes.
A new study in the journal Neurology has shown herpes zoster (shingles) to be an independent risk factor for transient ischemic attack (TIA) and myocardial infarction (MI) in all adults up to 24 years after an acute episode, and for stroke as well, although only among people whose HZ occurred when they were under 40 years of age. The authors suggest that people who are found to have risk factors for vascular disease should be vaccinated to prevent herpes zoster, which in itself is a severe disease, though it’s not clear yet whether the vaccine will prevent stroke.
Meaningful, long–term weight loss is possible
Women with high blood pressure (BP) are at higher risk than men for vascular disease, according to a study published in the journal Therapeutic Advances in Cardiovascular Disease. Results showed that compared with men who had the same level of high BP, the women in the study had 30-40% more vascular disease. Physiologic differences in the cardiovascular systems of women, such as the levels and types of hormones involved in regulating BP were also observed, which according to the researchers could affect the severity of heart disease.
The 8-year weight-loss results from the Look AHEAD: Action for Health in Diabetes study of overweight or obese patients with type 2 diabetes suggest it is possible to lose and keep weight off with a program of intensive lifestyle counseling. The findings are published online January 2 in Obesity. In Look AHEAD, at 1 year, 68.0% of participants who received intensive lifestyle counseling verses 13.3% of participants who received usual care lost at least 5% of their initial body weight. At 8 years, these percentages were 50.3% versus 35.7%, respectively. Positive EP test helps ID Post-MI patients for ICDs Post-myocardial infarction (MI) patients with severe left ventricular dysfunction who have a negative electrophysiologic study (EPS) showing no inducible ventricular tachycardia (VT) can do without the protection of an implantable cardioverter defibrillator (ICD), according to a new study in the journal Circulation. The patients in the series, all with a left ventricular ejection fraction (LVEF) lower than 30% or LVEF lower than 35% with heart failure, had low long-term rates of arrhythmia or death if VT could not be induced during electrophysiology testing.
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Women with high BP at higher risk for vascular disease than men
Risk of complications Associated with ICD Or CRT device higher than previously acknowledged The risk of a complication following the implantation of a cardiac device, such as an implantable cardioverter defibrillator (ICD), pacemaker or cardiac resynchronization therapy (CRT) device, is higher than previously acknowledged, according to the results of a new Danish analysis published December 17, 2013 in the European Heart Journal. Overall, one in 10 patients (9.6%) who received an implantable electronic device experienced a complication, a rate that is higher than the 5-6% published in previous studies. The rate of major complications was 5.6%, the most common being the need for a lead-related reintervention (2.4%).
around the globe Routine screening warranted for firstdegree relatives of patients with familial thoracic aortic aneurysm Routine screening is warranted for the first-degree relatives of patients who present with familial thoracic aortic aneurysm disease before age 60 years in the absence of predisposing conditions such as hypertension, Marfan syndrome or bicuspid aortic valve, according to a study presented at the American Heart Association scientific sessions. type 2 diabetes before age 50 associated with increased risk of microvascular complications A diagnosis of type 2 diabetes before age 50 was associated with an increased risk of microvascular complications, based on a secondary analysis of data from the international ADVANCE trial. The risk of microvascular complications, such as eye and kidney disease, increased with disease duration but not with patient age. The risk of macrovascular complications, such as myocardial infarction, stroke and cardiovascular events, as well as all-cause mortality, increased with both patient age and disease duration, according to findings presented at the World Diabetes Congress. Cer-001 does not reduce total atheroma volume in ACS A phase 2b trial of CER-001 (Cerenis Therapeutics), an engineered complex of recombinant human apolipoprotein A1 (apoA1) (the major structural protein of high-density lipoprotein [HDL], has failed to show that the agent can reduce total atheroma volume in patients with acute coronary syndrome (ACS). CER-001 is intended to mimic natural, nascent HDL (also known as pre-b-HDL) and to transiently increase apoA1 and the number of HDL particles to accelerate reverse lipid transport. MRI helps SEleCT stroke patients most likely to benefit from endovascular therapy According to a retrospective study, when considering patients with acute strokes for endovascular therapy, a magnetic resonance imaging (MRI) might help select those who will be most likely to benefit. A protocol that added MRI to the standard CT-based assessment was associated with a lower percentage of patients who underwent endovascular therapy (51.7% vs 96.6%,
p < 0.05), but a greater percentage who achieved a good clinical outcome at 30 days (23.6% vs 9.1%, p = 0.01) compared with a CT-based approach alone. The addition of MRI also was associated with a lower rate of 30-day mortality (25% vs 48.5%, p < 0.001). The findings are reported online in Stroke: Journal of the American Heart Association. Quitting moderate smoking by older people reduces CV risk earlier than expected Older people who quit their moderate smoking habit reduced their cigarette-associated cardiovascular risks to the level seen people who had never smoked in as little as 8 years, according to a prospective population study presented at the American Heart Associationâ&#x20AC;&#x2122;s annual scientific sessions. And this risk reversal occurred much sooner than the 15 years predicted in a 2004 report by the U.S. Surgeon General. ACE inhibitors and ARBs reduce risk of AF Results from a large retrospective study in the European Heart Journal suggest that controlling the activation of the renin-angiotensin system (RAS) with antihypertensive medications reduces the risk of atrial fibrillation (AF). Compared with b-blockers and diuretics, the use of angiotensin-converting enzyme (ACE) inhibitors and angiotensin-receptor blockers (ARBs) was associated with a significantly reduced risk of AF. Compared with these other agents, however, the use of ACE inhibitors and ARBs did not reduce the risk of stroke. Peripheral edema, jugular venous distension, a third heart sound and pulmonary rales associated with increased risk of MACE A retrospective study of patients in the Atrial Fibrillation and Congestive Heart Failure (AF-CHF) trial suggests that four signs of congestion on physical examination-peripheral edema, jugular venous distension, a third heart sound and pulmonary ralesâ&#x20AC;&#x201D;offer useful prognostic information beyond that obtained from standard clinical, ECG or echo parameters. Each sign of congestion was associated with an increased risk of cardiovascular mortality, all-cause mortality and heart failure-related death over a mean follow-up of 37 months. The study was published online January 8, 2014 in JACC: Heart Failure.
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around the globe Drinking green tea reduces BP-lowering effect of nadolol A preliminary study reports that drinking green tea reduced the plasma concentration and the systolic BP-lowering effect of the b-blocker nadolol in 10 healthy young volunteers. The researchers showed that the BP-lowering effect of a single dose of nadolol was weaker after the volunteers had been drinking about 2 cups a day of green tea for 2 weeks than after they had been drinking this amount of water for 2 weeks. Further, they showed that in cell-culture experiments, green tea appears to inhibit an organic anion-transporting polypeptide (OATP)—specifically OATP1A2—which is present in the intestinal epithelium and at least partly responsible for transporting nadolol into cells. The study is published January 13, 2014 in Clinical Pharmacology and Therapeutics. Reusing cleaned ECG lead wires safe A new study presented at the Society of Critical Care Medicine 43rd Critical Care Congress shows that reusing cleaned electrocardiography (ECG) lead wires does not increase toxicities in intensive care units (ICUs). CT angiography feasible at an ultra-low radiation dose of 0.2 millisievert Coronary computed tomography (CT) angiography with diagnostic image quality is feasible at an ultra-low radiation dose of 0.2 millisievert using model-based iterative reconstruction. This represents roughly an 80% reduction in radiation dose compared with standard coronary CT angiography, Dr Julia Stehli said at the annual meeting of the Radiological Society of North America. Low Vitamin D Levels Linked to Fatal CVD Vitamin D deficiency is much more strongly linked to fatal than nonfatal cardiovascular events (27% increased risk), results of a large prospective study by Drs Laura Perna and Ben Schottker, German Cancer Research Center (Heidelberg) suggests. The findings are published in the December issue of the Journal of Clinical Endocrinology and Metabolism. The population-based cohort study enrolled 9,949 adults aged 50-74 years recruited during regular health check-ups at primary-care practices in 2000-2002. There were more women than men (59% vs 41%); most participants (59%) had inadequate vitamin D levels (<50 nmol/L). Blood samples were collected at baseline, 5
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and 8 years, reports Medscape Cardiology. Mean follow-up was 9.2 years for mortality and 6.5 years for the endpoints of cardiovascular disease (CVD), coronary heart disease (CHD) and stroke. A total of 854 patients had a nonfatal CVD event, 176 had a fatal CVD event, 460 had a nonfatal CHD event, 79 had a fatal CHD event, 313 had a nonfatal stroke and 41 had a fatal stroke. Overall, the proportion of individuals who had no events was significantly lower among those with vitamin D deficiency. Even after adjustment for other potential confounders, including smoking and physical activity, vitamin D deficiency still conferred a significant 27% increased risk for total CVD, and a 62% increased risk for fatal CVD. There was no association between vitamin D deficiency and nonfatal CVD events. Individuals with low vitamin D levels also had a significant 36% increased risk of total CHD and a nonsignificant 33% increased risk of total stroke. longer dialysis duration improves ECG parameters associated with SCD New research suggests that longer dialysis duration may improve electrocardiographic (ECG) parameters associated with sudden cardiac arrest, which is the leading cause of death in hemodialysis patients. The ASAIO Journal study found frequent nocturnal hemodialysis was associated with an improvement in Tpeak to Tend within 365 days and past 365 days of dialysis initiation as well as improvement in QRS amplitude variation within 365 days and past 365 days of dialysis initiation. Atenolol more effective than lisinopril in Ht with LVH In a study that compared atenolol-based antihypertensive therapy with lisinopril-based therapy in 200 dialysis patients with hypertension (HT) and left ventricular hypertrophy (LVH), home blood pressure was consistently higher in the lisinopril group despite the need for more antihypertensive agents. The findings are reported in Nephrology Dialysis Transplantation. FDA recommends approval of antiplatelet vorapaxar An Food and Drug Administration (FDA) Advisory Committee voted with one dissenting voice−to recommend approval of the antiplatelet vorapaxar (proposed trade name Zontivity) for reducing atherothrombotic events in certain patients with a history of myocardial infarction (MI). By a vote of 10–1, the agency’s Cardiovascular and Renal Drugs Advisory
around the globe Committee affirmed that the benefits of the drug− which is being considered for reducing vascular events in patients with atherosclerotic disease but no history of stroke or transient ischemic attack−outweighed the risks, which were primarily focused on bleeding. Poor people more than twice as likely as the wealthy to become frail after MI As people get older, their bodies wear down and become less resilient. In old age, it’s common for people to become ‘clinically frail,’ and this ‘frailty syndrome’ is emerging in the field of public health as a powerful predictor of healthcare use and death. Vicki Myers and Prof. Yariv Gerber of the Dept. of Epidemiology and Preventive Medicine at the School of Public Health at Tel Aviv University’s Sackler Faculty of Medicine and colleagues have found that poor people are more than twice as likely as the wealthy to become frail after a heart attack. The findings are published in the International Journal of Cardiology. anatomic burden good predictor of outcomes with optimal medical therapy in patients with stable CAD Findings from a substudy of the COURAGE trial reveal that anatomic burden, but not ischemic burden, is a good predictor of outcomes in patients with stable coronary artery disease (CAD) treated with optimal medical therapy with or without revascularization. But neither risk stratification measure, used alone or in combination, helped identify patients who would benefit from percutaneous coronary intervention (PCI). In addition to medical therapy, according to the analysis, published online in the journal JACC: Cardiovascular Interventions. fDA approves corevalve prosthesis for TAVI The Food and Drug Administration (FDA) has approved Medtronic’s CoreValve prosthesis for transcatheter aortic valve implantation (TAVI) in patients with symptomatic severe aortic stenosis who are not candidates for surgical valve replacement. CoreValve now becomes the second TAVI device available for use in the U.S., along with the Edwards Sapien valve. AHA/ASA Issues statement on risk adjustment of ischemic stroke outcomes The American Heart Association/American Stroke Association (AHA/ASA) has issued a statement on risk adjustment of ischemic stroke outcomes for comparing hospital performance. Published online in Stroke on
January 23, the authors state that: “There are a number of important methodological challenges in undertaking risk-adjusted outcome comparisons to assess the quality of stroke care in different hospitals. It is important for stakeholders to recognize these challenges and for there to be a concerted approach to improving the methods for quality assessment and improvement.” rise in inappropriate catheterization for suspected CAD One in four patients who underwent recent diagnostic catheterizations in 18 New York state hospitals to detect suspected coronary artery disease (CAD) were not appropriate candidates for this procedure, based on new criteria. In a study, among the patients who had undergone inappropriate diagnostic catheterization, 57% had no chest pain, no previous stress test and a low to intermediate Framingham global CAD risk score. The study was published online January 28, 2014 in Circulation: Cardiovascular Interventions. excessive sugar intake carries greater risk of dying from CVD People who had excessive amounts of added sugar in their diet carried greater risks of dying from cardiovascular disease (CVD). Quanhe Yang, PhD, of the CDC’s Division for Heart Disease and Stroke Prevention in Atlanta, and colleagues report that through a median follow-up of nearly 15 years, those who had 10-24.9% of calories come from added sugar were 30% more likely to experience cardiovascular death than those with less than 10%. In addition, the risk of death during the follow-up period jumped greatly – to 175% – for those getting 25% or more of their calories from added sugar. The findings are reported online in JAMA Internal Medicine. cognitive decline in diabetic patients similar with both intensive and standard antihypertensive treatment Diabetic patients in late middle-age receiving intensive antihypertensive therapy in a randomized trial in JAMA Internal Medicine showed the same rates of cognitive decline as those assigned to standard treatment. Among some 3,000 participants in the ACCORD study with no clinical evidence of cognitive impairment or dementia, those randomized to intensive BP-lowering therapy showed a mean decrease in scores on the Digit Symbol Substitution Test (DSST) of 1.86 points after 40 months of follow-up, compared with a decline of 1.61 points in those receiving standard antihypertensive treatment.
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lighter reading
Sometimes your biggest weakness can become your biggest strength Take, for example, the story of one 10-year-old boy who decided to study judo despite the fact that he had lost his left arm in a devastating car accident. The boy began lessons with an old Japanese judo master. The boy was doing well, so he couldn’t understand why, after 3 months of training the master had taught him only one move.
laugh a while
An Inspirational Story
Lighter Side of Medicine
“Sensei,” the boy finally asked, “Shouldn’t I be learning more moves? This is the only move I know.”
Not quite understanding, but believing in his teacher, the boy kept training. Several months later, the sensei took the boy to his first tournament. Surprising himself, the boy easily won his first two matches. The third match proved to be more difficult, but after some time, his opponent became impatient and charged; the boy deftly used his one move to win the match. Still amazed by his success, the boy was now in the finals. This time, his opponent was bigger, stronger, and more experienced. For a while, the boy appeared to be overmatched. Concerned that the boy might get hurt, the referee called a time-out. He was about to stop the match when the sensei intervened. “No,” the sensei insisted, “Let him continue.” Soon after the match resumed, his opponent made a critical mistake: He dropped his guard. Instantly, the boy used his move to pin him. The boy had won the match and the tournament. He was the champion. On the way home, the boy and sensei reviewed every move in each and every match. Then the boy summoned the courage to ask what was really on his mind. “Sensei, how did I win the tournament with only one move?” “You won for two reasons,” the sensei answered.
QUOTE
“But this is the only move you’ll ever need to know,” the sensei replied.
History of Telecommunication After having dug to a depth of 10 feet last year, Italian scientists found traces of copper wire dating back 100 years and came to the conclusion, that their ancestors already had a telephone network more than 100 years ago. Not to be outdone by the Italians, in the weeks that followed, a Chinese archaeologist dug to a depth of 20 feet, and shortly after, a story in the China Daily read: ‘Chinese archaeologists, finding traces of 200 years old copper wire, have concluded their ancestors already had an advanced high-tech communications network a hundred years earlier than the Italian’s. One week later, the Punjab Times, a local newspaper in India, reported the following: After digging as deep as 30 feet in his pasture near Amritsar, in the Indian state of Punjab, Dugdeep Singh, a self-taught archaeologist, reported that he found absolutely nothing. Dugdeep has therefore concluded that 300 years ago, India had already gone wireless. “When your time is Good, your Mistakes are taken as a Joke! But when your time is Bad, even your Jokes are noticed as Mistakes!”
Dr. Good & Dr. Bad Situation : A heart patient died after drinking 200 mL of drink in one go.
It cannot be a cause of death
Binge drinking can cause sudden death
Lesson : Binge drinking means 5 or more drinks in one session. One US
The boy’s biggest weakness had become his biggest strength.
KK Aggarwal
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© IJCP GROUP
“First, you’ve almost mastered one of the most difficult throws in all of judo. And second, the only known defense for that move is for your opponent to grab your left arm.”
drink is 40 mL; therefore, 200 mL of whiskey in one session can precipitate sudden cardiac death.
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Manuscripts should be prepared in accordance with the ‘Uniform requirements for manuscripts submitted to biomedical journals’ compiled by the International Committee of Medical Journal Editors (Ann. Intern. Med. 1992;96: 766-767). Asian Journal of Clinical Cardiology strongly disapproves of the submission of the same articles simultaneously to different journals for consideration as well as duplicate publication and will decline to accept fresh manuscripts submitted by authors who have done so. The boxed checklist will help authors in preparing their manuscript according to our requirements. Improperly prepared manuscripts may be returned to the author without review. The checklist should accompany each manuscript. Authors may provide on the checklist, the names and addresses of experts from Asia and from other parts of the World who, in the authors’ opinion, are best qualified to review the paper. Covering letter -
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Paintal AS. Impulses in vagal afferent fibres from specific pulmonary deflation receptors. The response of those receptors to phenylguanide, potato S-hydroxytryptamine and their role in respiratory and cardiovascular reflexes. Q. J. Expt. Physiol. 1955;40:89-111.
2. Total number of pages ________________________
Books
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Stansfield AG. Lymph Node Biopsy Interpretation Churchill Livingstone, New York 1985.
Indian 1.____________Foreign 1.________________
2.____________ 2.________________
Articles in Books
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Strong MS. Recurrent respiratory papillomatosis. In: Scott Brown’s Otolaryngology. Paediatric Otolaryngology Evans JNG (Ed.), Butterworths, London 1987;6:466-470.
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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, emedinews@gmail.com Website: www.ijcpgroup.com
Dr KK Aggarwal Group Editor-in-Chief Dr Veena Aggarwal MD and Group Executive Editor Dr Alka Kriplani Dr Praveen Chandra Dr Swati Y Bhave Dr CR Anand Moses Dr Sidhartha Das Dr Wiqar Sheikh Dr Ajay Kumar Dr A Ramachandran Dr Samith A Shetty Dr SK Parashar Dr Kamala Selvaraj Dr Georgi Abraham Dr V Nagarajan Dr Thankam Verma Dr KMK Masthan Dr Hasmukh J Shroff Dr Rajesh Chandna Dr SM Rajendran
Volume 22, Number 11
April 2012, Pages 545-596
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