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   Table of Contents - Current issue
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January-June 2020
Volume 2 | Issue 1
Page Nos. 1-48

Online since Tuesday, June 16, 2020

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EDITORIAL  

COVID-19 and Cardiovascular diseases p. 1
Govindan Vijayaraghavan
DOI:10.4103/ACCJ.ACCJ_9_20  
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OPINION Top

Atherosclerosis and oncology: Shared mechanisms, shared treatment principles p. 3
Sorin C Danciu, Enrique Padilla Campos
DOI:10.4103/ACCJ.ACCJ_8_20  
Atherosclerosis and cancer are two chronic, progressive entities with major global disease burden that shares several mechanistic features. Despite these similarities, treatment strategies for malignancy and atherosclerosis differ significantly from each other. We propose that cardiovascular therapies can be optimized with the implementation of established cancer treatment principles.
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REVIEW ARTICLES Top

Chloroquine/hydroxychloroquine in the treatment and prophylaxis of COVID-19 disease p. 5
Deepthi Nair
DOI:10.4103/ACCJ.ACCJ_5_20  
COVID-19 is a zoonotic viral infection caused by severe acute respiratory syndrome coronavirus-2. Although the management of COVID-19 infection is mainly supportive, the arena of infective therapy now also includes drugs such as chloroquine and its substitute, hydroxychloroquine, which are believed to have antiviral properties in addition to their antimalarial and immunomodulating effects. The objective of this review article is to focus on the antiviral effect of chloroquine/hydroxychloroquine in the treatment and prophylaxis of COVID-19 disease.
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Computed tomography as an alternative to transesophageal echocardiography: A review of the literature in light of COVID-19 p. 8
Michael J Accavitti, Sorin Danciu
DOI:10.4103/ACCJ.ACCJ_10_20  
During the outbreak of coronavirus disease 2019 (COVID-19) in the spring of 2020, the CDC recommended health-care providers limit performing aerosol-producing procedures when possible. Transesophageal echocardiography (TEE) is a procedure used frequently for both procedural and nonprocedural cardiac imaging. The performance of a TEE requires not only for physicians and staff to be physically close to the mouths of potentially infected patients, but also involves aerosol generating activities such as airway suctioning. In addition, intubation with TEE probe can cause coughing. Cardiac computed tomography (CT) is an imaging modality that does not increase COVID-19 exposure risk to cardiology staff and physicians. In this article, we review the most common indications for TEE and discuss the data supporting the viability of using cardiac CT as an alternative to TEE.
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ORIGINAL ARTICLES Top

Incidence, predictors, and mortality of in-hospital stroke after acute coronary syndrome in the Middle East p. 13
Wadhha AlSaeed, Ibrahim Al-Zakwani, Prashanth Panduranga, Mohammad Zubaid, Wafa Rashed, Peter A Brady
DOI:10.4103/ACCJ.ACCJ_4_20  
Background and Objectives: The aim of this study is to determine the incidence, predictors, and outcomes of patients that developed in-hospital stroke in acute coronary syndrome (ACS) in the Middle East region. Methods: Data were analyzed from 4044 patients with a diagnosis of ACS admitted to 29 hospitals in 4 Arabian Gulf countries (Bahrain, Kuwait, Oman, and United Arab Emirates) from January 2012 to January 2013. Stroke was defined as a loss of neurological function caused by an ischemic or hemorrhagic event with residual symptoms at least 24 h after onset or leading to death. Analyses were performed using univariate and multivariate statistics. Results: Mean age of the cohort was 60 ± 13 years and 66% (n = 2686) were male. A total of 0.89% (n = 36) developed acute stroke during the index hospital admission. Of these, 25 (69%) were diagnosed with thrombotic, 9 (25%) hemorrhagic, and 2 (6%) unknown. Those patients that developed in-hospital stroke were more likely to suffer in-hospital death (31 vs. 4.0%; P < 0.001), cardiogenic shock (25 vs. 5.1%; P < 0.001), major bleeding (8.3 vs. 1.6%; P = 0.022), heart failure (39 vs. 13%; P < 0.001), and cardiac arrest (17 vs. 3.2%; P < 0.001). At 1 year, the cumulative all-cause mortality was 53% (n = 19) in those that developed in-hospital stroke. In hospital stroke was also associated with more prolonged hospital stay (7.5 vs. 4.0 days; P < 0.001). Adjusting for other factors in the model, the multivariate logistic regression model demonstrated that prior stroke (adjusted odds ratio [aOR], 4.61; 95% confidence interval [CI]: 1.97–10.8; P < 0.001) and left ventricular ejection fraction (LVEF) of <40% (aOR, 2.26; 95% CI: 1.05–4.87; P = 0.038) were associated with the development of in-hospital stroke. Conclusions: The incidence of in-hospital stroke in patients with ACS in the Middle East is low, but, when it occurs is associated with high all-cause in-hospital and 1-year mortality. Prior stroke and LVEF <40% were associated with the development of in-hospital stroke in this population.
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Prognostic value of endothelin-1 level in diabetic patients with coronary artery disease p. 19
Mostafa Attia Eldegwi, Waleed Abdou Ibrahim, Ibrahim Shehata Elmadbouh, Ahmed Abdullah Mostafa, Abdullah Mostafa Kamal
DOI:10.4103/ACCJ.ACCJ_2_20  
Background and Objectives: ET-1 has been demonstrated to play a role in endothelial dysfunction and inflammation, both of which are actively involved in the pathophysiology of the onset and progression of CAD. Diabetes mellitus (DM) increases the risk of CAD and has unfavorable effects on the vascular endothelium, hence, the importance of assessing this plasma marker and its relation to the severity of CAD in diabetic patients. The aim of this work is to study the prognostic value of the plasma level of the new marker, endothelin-1 (ET-1), in diabetic patients with coronary artery disease (CAD). Methods: Seventy patients with coronary artery lesions of not < 50% in at least one main coronary artery were randomized into 35 diabetics (Group I) and 35 nondiabetics (Group II). Twenty patients with normal coronaries as a control group (Group III) were also enrolled. The severity of coronary artery lesions was assessed by GINSINI score (GS) and SYNTAX score, and then, the relationship between them and ET-1 level was evaluated. Results: The ET-1 levels were significantly higher in Group I with higher GS values of 34.29 ± 11.7 points and SYNTAX scores of 18.4 ± 11.17 points than in Group II with lower GS values of 23.23 ± 8.14 points and SYNTAX of scores 12.06 ± 12.11 points (ET-1 was 187.93 ± 146.61 ng/L in Group I vs. 76.30 ± 91.83 ng/L in Group II, P = 0.001). ET-1 levels were significantly higher in Group I than in Group III (187.93 ± 146.61 ng/L vs. 26.16 ± 7.32 ng/L, P = 0.001). ET-1 levels were significantly higher in Group II than in Group III (76.30 ± 91.83 ng/L vs. 26.16 ± 7.32 ng/L, P = 0.001). Conclusion: There is a positive correlation between DM and both ET-1 levels and the severity of coronary artery lesions, P = 0.001.
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Limitations in using angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers in the management of heart failure due to comorbidities: An Indian scenario p. 24
Suman Omana Soman, G Vijayaraghavan, AR Muneer, AM Mujeeb, AS Ankudinov, AN Kalyagin
DOI:10.4103/ACCJ.ACCJ_1_18  
Background and Objectives: The essential drugs used in heart failure are angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers. Many trials had shown that these are the group of drugs with maximum benefits for the patients with heart failure. However, most of the patients were not receiving these drugs due to the negative impact of the comorbidities. Our study aims at identifying the limitations in giving ACE/angiotensin receptor blockers (ARBs) in chronic heart failure patients in our population. Methods: This is a prospective observational study conducted in a tertiary care center, over a period of 2 years from 2012. We selected 310 consecutive patients with the New York Heart Association (NYHA) Class 3 or 4 with various etiologies of heart failure. The patients with new-onset myocardial infarction, acute inflammatory conditions, septicemia, and end-stage renal disease with glomerular filtration rate (GFR) <30 were excluded from the study. Results: In our study population of 310 patients with various etiologies of heart failure, only 60.3% (187) of the patients received ACE/ARBs, in which 34.5% (107) received ACE inhibitors and 16.4% (n-51) received ARB s. Hence, we noticed that 39.7% (n-123) of the patients with heart failure could not receive these drugs due to renal failure (10.3%), hyperkalemia (13.5%), and hypotension (15.8%). Conclusion: We noticed that many of the patients (39.7%) with heart failure did not receive these drugs due to comorbidities. We found that many patients had moderate renal failure with a significant reduction in GFR. Hypotension may be due to reduced ejection fraction because of the patient selection of Class NYHA 3 or 4. Hypotension may reduce the GFR and hence the progressive rise of serum creatinine. Careful patient selection and detailed evaluation alone can improve the number of subjects to whom the above drugs can be given.
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Impact of digoxin on all-cause mortality and re-hospitalizations in acute heart failure patients Highly accessed article p. 29
Mohammed Al-Jarallah, Rajesh Rajan, Ibrahim Al-Zakwani, Raja Dashti, Bassam Bulbanat, Mustafa Ridha, Kadhim Sulaiman, Alawi A Alsheikh-Ali, Prashanth Panduranga, Khalid F AlHabib, Jassim Al Suwaidi, Wael Al-Mahmeed, Hussam AlFaleh, Abdelfatah Elasfar, Ahmed Al-Motarreb, Nooshin Bazargani, Nidal Asaad, Haitham Amin
DOI:10.4103/ACCJ.ACCJ_1_20  
Background and Objectives: The use of digoxin in acute heart failure (AHF) is not without controversy. The aim of this study was to examine the impact of digoxin therapy on all-cause mortality and re-hospitalizations for heart failure (HF) at 3 months and 12 months in AHF patients in the Arabian Gulf stratified by left ventricular ejection fraction (EF). Methods: Data were analyzed from 4577 consecutive patients admitted to 47 hospitals in seven Middle Eastern countries with AHF from February to November, 2012. Analyses were performed using univariate and multivariate statistical techniques. Results: The overall mean age of the cohort was 59 ± 15 years, and 63% (n = 2887) were males. At hospital discharge, digoxin was prescribed to 25% (n = 1156) of the patients. Nearly 59% (n = 2683) of the patients had HF with reduced EF (HFr EF) (<40%), 21% (n = 962) had HF with mid-range EF (HFmr EF) (40%–49%), and 20% (n = 932) had HF with preserved EF (HFp EF) (≥50%). The most prominent comorbidities included hypertension (61%; n = 2783), coronary artery disease (60%; n = 2762), and diabetes mellitus (49%; n = 2258). Multivariate logistic regression analysis demonstrated that digoxin use was associated with lower cumulative all-cause mortality at 3-month (adjusted odds ratio [aOR]: 0.57; 95% confidence interval [CI]: 0.41–0.79; P = 0.001) and at 12-month (aOR: 0.74; 95% CI: 0.58–0.96; P = 0.021) follow-up post hospital discharge in patients with HFr EF. There was, however, no survival advantage conferred by digoxin use in those with HFmr EF or HFp EF, at either the 3-month or 12-month follow-up (all P > 0.05). Digoxin use was also not associated with any benefits regarding re-hospitalization for HF at either 3 months or at 12 months in any type of HF (all P > 0.05). Conclusions: Digoxin was associated with lower cumulative all-cause mortality at both 3-month and 12-month follow-ups in AHF patients with reduced EF in the Arabian Gulf. However, digoxin use did not offer any survival advantages in those with HFmr EF and HFp EF after either 3 months or 12 months. Digoxin use was also not associated with any benefits toward re-hospitalizations for HF at a 3-month or 12-month follow-up in AHF patients.
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Antiplatelet drug resistance in Indians p. 36
Sadath A Pareed, G Vijayaraghavan, CC Kartha, MT Manoj
DOI:10.4103/ACCJ.ACCJ_6_20  
Background and Objectives: Resistance to the antiplatelet drugs aspirin and clopidogrel is well recognized, and its prevalence has been reported from many countries. There is, however, a paucity of reports on the prevalence of resistance to these drugs in Indian patients. This information is important as resistance to one or both of these drugs may play a role in-stent thrombosis and post angioplasty complications while using drug-eluting stents. The present study was conducted in 200 consecutive patients with myocardial infarction (MI) who underwent elective percutaneous coronary intervention in a single center and who gave consent for the study. The objective of the study was to determine the prevalence of aspirin and clopidogrel resistance in Indian patients who were administrated either of the drugs after PCI, using the VerifyNow P2Y12 assay. Methods: All patients were evaluated on day 7 after the procedure, and blood was collected in the laboratory and immediately analyzed. Platelete resistance to aspirin and clopidogrel was determined by verifying now RPFT point of the care system. Asprin resistance was measured as Aspirin Reaction Unit (ARU); >550 ARU was considered as aspirin resistance. Clopidogrel resistance was considered when Platelet Reaction Unit (PRU) was >213. Results: Among the 200 patients with MI, 87% were males and 13% were female. Their age group varied from 35 to 83 years. Among the study participants, 22% were resistant to an aspirin dose of 150 mg orally and the remaining 78% had normal platelet aggregation. About 68% were sensitive to clopidogrel, and 32% were resistant. About 58% of females were resistant to aspirin as against 29% of male patients, and 38% of females were resistant to clopidogrel as against 18% of male patients. Further, aspirin and clopidogrel were not associated with age and diabetes mellitus (P ≥ 0.05). Conclusions: The prevalence of aspirin and clopidogrel resistance in India is similar to those reported from the United States of America and Europe. The resistance pattern was also found to be similar.
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CASE REPORT Top

Perm-Cath catheter-related atrial thrombus – Case series and management recommendations p. 42
Prashanth Panduranga, Kumail Al-Lawatiya, Issa Al-Salmi, Baher Hanna
DOI:10.4103/ACCJ.ACCJ_7_20  
Catheter-related atrial thrombus (CRAT) is frequent, with no clear guidelines available with regard to diagnosis and management. Here, we report five patients with Perm Cath related AT. We conclude and recommend that Perm Cath, when not needed or used needs to be removed as soon as possible. A majority of CRAT are detected incidentally. They commonly occur at inferior vena cava and right atrial junction and a transoesophageal echocardiogram is needed in most patients to clearly define the thrombus and see additional hidden thrombi. Differentiating CRAT versus vegetation is difficult and one needs to treat both if blood cultures are positive. Commonly these thrombi do not embolize and are fixed to atrial walls, but silent pulmonary embolism needs to be considered. All patients initially should be treated with intravenous or subcutaneous anticoagulation. Patients with “High Risk” features such as, “multiple thrombi > 2,” “mobile thrombi,” “extending or embolizing thrombi to pulmonary artery,” “infected thrombi,” and “failed anticoagulation” must be considered for thrombolysis followed by surgery if required.
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LETTER TO THE EDITOR Top

Chloroquine for coronavirus disease 2019 (COVID-19)? p. 47
Suman Omana Soman, Muneer Abdul Rahaman
DOI:10.4103/ACCJ.ACCJ_3_20  
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