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   Table of Contents - Current issue
July-December 2020
Volume 2 | Issue 2
Page Nos. 49-106

Online since Friday, November 6, 2020

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COVID vaccines; the search continues!!! p. 49
G Vijayaraghavan
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Remdesivir and Favipiravir for COVID-19: An update Highly accessed article p. 51
Suman Omana Soman, AV Raveendran
COVID-19 pandemic due to SARS-CoV-2 infection has already resulted in more than 6 lakhs death worldwide. Various drugs like hydroxychloroquine, lopinavir/ritonavir, dexamethasone, ivermectin etc are examples of drugs currently used to treat COVID-19 with varying results. Remdesivir is a broad spectrum anti-viral agent, which is active against Middle East respiratory syndrome coronavirus (MERS-CoV), SARS-CoV-1, Ebola virus etc. Favipiravir had been widely used for treating influenza pandemics in Japan in 2014 .Studies showed that it was effective for treating many RNA viruses like arenavirus, bunyavirus, flavivirus, and filoviruses causing hemorrhagic fever and Ebola virus. Remdesivir and favipiravir are anti-viral agents tried in patients with COVID-19 with varying results. Currently Remdesivir is recommended in hospitalized patients with COVID-19 requiring supplemental oxygen and favipiravir in patients with mild to moderate disease. In this article we are reviewing the pharmacological features and clinical use of Remdesivir and favipiravir in COVID-19.
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Considerations for the use of statin therapy in Coronavirus Disease 2019 Era p. 55
Priyanka Thakur, Kunal Mahajan, Prakash Chand Negi, Neeraj Ganju, Sanjeev Asotra, Arvind Kandoria
Background: Patients with cardiovascular disease (CVD) are at an increased risk of developing severe disease and mortality associated with coronavirus disease 2019 (COVID-19). Statins form the cornerstone of therapy for primary and secondary prevention of CVD. Objective: This review aims at exploring the possible advantages and the risks associated with the use of statins in patients with COVID-19. Methods: We searched the PubMed and Google Scholar databases until June 5, 2020, and reviewed the available literature on this topic. Results: Statins have been shown to improve outcomes in acute respiratory distress syndrome, which is one of the major causes of death in COVID-19. Statins exert many pleiotropic effects (anti-inflammatory, immunomodulatory effect, nitric oxide release, and effects on coagulation cascade), which would theoretically appear beneficial in COVID-19. Statins also increase angiotensin-converting enzyme 2 levels in animal models and can potentially reduce lung injury related to viral infections. Besides, the cardioprotective effects of statins can be beneficial in cardiovascular complications (e.g., acute myocardial infarction) of COVID-19. Nonetheless, there are concerns regarding the adverse effects associated with the use of statins in the setting of COVID-19, which can be simply avoided by dose modification and clinical monitoring. Conclusions: Statins appear to be beneficial in COVID-19 and may improve the outcome, but future-focused studies are needed before recommending their de novo use in COVID-19.
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Pulmonary dysfunction: A predictor of postoperative outcome in severe mitral stenosis p. 60
Usha T Parvathy, Rajesh Rajan, AG Faybushevich, Kobalava D Zhanna
Background: Pulmonary function (PF) derangements in mitral stenosis (MS) can have an impact on the postmitral valve-replacement (MVR) period, which is not well studied. Objectives: The objectives were (1) to study the impact of the preoperative PF derangements intrinsic to MS on the early postoperative outcome and (2) to assess the prognostic relevance of spirometric tests as to the postoperative complications and morbidity. Methods: Prospective observational study: The spirometric pulmonary function tests (PFTs) performed in 25 patients with isolated MS (nonrandomized sampling) and arterial blood gas (ABG) were correlated to postoperative (post-MVR) variables: duration of ventilation, intensive care unit (ICU) stay, hospital stay, ABG, pulmonary complications, and outcome. Data were analyzed and compared under types, grades, and risk-based groups using nonparametric (Spearman's correlation, Kruskal–Wallis, and Mann–Whitney) tests. Results: The significant correlations were forced vital capacity (FVC)%, forced expiratory volume in 1 s (FEV1), FEV1%, peak expiratory flow rate (PEFR), and oxygen status to ventilation duration (P < 0.05); FEV1, PEFR, forced expiratory flow (FEF)-50, and oxygenation with ICU duration (P < 0.05); FVC, PEFR, and FEF-50 with hospital stay (P < 0.05); FVC, FEV1, and oxygenation to postoperative oxygen status (P = 0.02); FVC and FEV1 to pulmonary complications (P < 0.05); and FVC, PEFR, and FEF-50 with ventilation modification (P < 0.05). The morbidity and respiratory events showed a higher incidence with the mixed and severe categories (though not significant) and also with high-risk group in terms of postoperative pulmonary complications (P = 0.044) and prolonged ventilation. Mild trend toward hypercarbia needed ventilation optimization. Conclusions: PFT derangements in MS play an impact on the postoperative course to varying degrees. The advanced (severe and mixed) derangements and the high-risk group associate with greater morbidity and complications, calling for precautionary care, but on the whole do not contraindicate surgery. Spirometric evaluation can to a certain extent predict the postoperative morbidity risk.
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Mortality and morbidity associated with type 2 myocardial infarction: A single-center study p. 70
Hoang H Truong, Maiskov V Victor, Meray A Imad, Zhanna D Kobalava, Usha T Parvathy, Ibrahim Al-Zakwani
Background: The incidence of Type 1 (T1) and Type 2 (T2) myocardial infarction (MI) varies according to the definition used. In clinical practice, approximately one third of T2MI underwent coronary angiography. It may be difficult to accurately diagnose this entity based only on clinical evidence of imbalance between oxygen supply and demand without angiographic data. Objective: The objective of this study was to assess the correlation between angiographic and clinical definitions of Type-2 versus Type-1 myocardial infarction (T2MI vs. T1MI) and prognosis. Methods: A total of 450 consecutive patients with a diagnosis of acute MI were prospectively recruited and underwent coronary angiography <24 h after the onset of symptoms. The mean follow-up was 1.9 years. Results: Atherothrombotic events were found in 275 (61.1%) patients, whereas clinical triggers were identified in 244 (54.2%) cases. T2MI was diagnosed in 175 (28.9%) patients. Rates of in-hospital (7.4% vs. 10.6%; P = 0.268) and long-term (16.6% vs. 17.1%; P = 0.886) mortality were comparable between T2MI and T1MI patients. Those with T2MI had a higher cardiac rehospitalization rate during follow-up (33.3% vs. 19.5%; P = 0.030). Reduced left ventricular ejection fraction (LVEF) was associated with increased long-term mortality (odds ratio 5.2; 95% confidence interval: 1.1–23.5; P = 0.030). GRACE score had a comparable predictive power for in-hospital mortality in both T1 and T2MI subtypes, but was poor in predicting all-cause long-term mortality in patients with T2MI (area under the receiver operating curve 0.663 vs. 0.847; P = 0.009). Conclusions: There was a discrepancy between angiographic and clinical definitions of MI types in a substantial proportion of our patient population. Reduced LVEF was a strong predictor for worse outcomes in T2MI patients. The GRACE score predicted in-hospital mortality well, but not long-term mortality in patients with T2MI.
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Visit-to-visit blood pressure variability in patients with chronic heart failure with reduced ejection fraction p. 80
Zhanna Kobalava, Yulia Kotovskaya, Elena Troitskaya, Lala Babaeva, Usha T Parvathy, Peter A Brady, Ibrahim Al-Zakwani
Background: There is a growing evidence of the prognostic significance of visit-to-visit blood pressure variation in different groups of patients but for heart failure with reduced ejection fractions remains a matter of controversy. Objective: The objective of the study was to evaluate the impact of visit-to-visit blood pressure variability (BPV) on the prognosis in patients with stable heart failure (HF) with reduced ejection fraction (EF). Methods: The retrospective analysis included 100 pts (80 men, age 64.4 ± 9.3 years, baseline BP 127.6 ± 15.1/77.9 ± 8.3 mmHg) with chronic heart failure II-IV NYHA functional class with mean EF 32.3 ± 4.3%. All patients received optimal medical therapy for HF. BP was measured with a validated oscillometric device. Visit-to-visit BPV was calculated as standard deviation, and the coefficient of variation of average BP for seven visits during 18 months. The endpoints were death, myocardial infarction, stroke, and hospitalization for HF. Results: Visit-to-visit systolic BPV (SBPV) ranged between 2.3 and 20.0 mmHg. A total of 47 endpoints in 37 patients were recorded. The patients with endpoints had higher visit-to-visit SBPV (11.2 ± 4.0 vs. 9.5 ± 3.5 mmHg, P < 0.05). Logistic regression analysis revealed that the risk of all negative outcomes was independently associated with lower EF (adjusted odds ratio (aOR) 0.84; 95% confidence interval (CI): 0.73-0.97; P = 0.02) and SBPV > 10.9 mmHg (aOR 3.0; 95% CI: 1.27–7.06; P = 0.01). Conclusions: Visit-to-visit SBPV >10.9 mmHg as well as lower EF were independently associated with negative outcomes in patients with stable HF with reduced EF.
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Comparison of demographics and outcomes of acute heart failure patients with reduced, mid-range, and preserved ejection fraction p. 86
Mohammed Al-Jarallah, Rajesh Rajan, Hussein Heshmat, 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
Background: Heart failure (HF) burden in the developing world is not well quantified. Objectives: The objective is to evaluate the demographics and outcomes of acute HF patients with reduced ejection fraction (EF) (<40%) (HFr EF), HF with midrange EF (40%–49%) (HFmr EF) and HF with preserved EF (≥50%) (HFp EF) in the Arabian Gulf. Methods: Gulf CARE registry analyzed 4577 HF patients admitted to 47 hospitals in seven Middle Eastern countries (Kuwait, Oman, Qatar, Saudi Arabia, United Arab Emirates, Bahrain, and Yemen.) Analyses were performed using multivariate statistical techniques. Results: The overall median age was 60 (50–70) years and 63% (n = 2887) were male. The most prominent comorbidities included hypertension (61%; n = 2783), coronary artery disease (60%; n = 2762), and diabetes mellitus (49%; n = 2258). A total of 59% (n = 2683) of the patients had HFr EF, 21% (n = 962) had HFmr EF and 20% (n = 932) had HFp EF. Compared to those with HFr EF, patients with HFmr EF and HFp EF were more likely to be associated with hypertension (57% vs. 67% vs. 64%; P < 0.001), diabetes mellitus (47% vs. 57% vs. 51%; P = 0.002), and higher systolic blood pressure (133 vs. 143 vs. 143 mmHg; P < 0.001). Multiple logistic regressions demonstrated that there were no significant differences among the groups with regards to the 3-month (overall adjusted P value; P = 0.188) and 12-month (P = 0.220) cumulative all-cause mortality. The results also indicated that there were no significant differences among the groups with regards to the 3-month (P = 0.117) and 12-month (P = 0.244) re-hospitalization rates for HF. Conclusions: No significant differences among the groups with regards to 3-month and 12-month all-cause mortality and re-hospitalization rates for HF were observed between the groups in the Arabian Gulf.
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Left sympathetic denervation as an effective therapy in a young patient with long QT syndrome p. 95
Aramalla Sunitha, Oruganti Sai Satish, Palanki Surya Satya Gopal, Malempati Amaresh Rao
Long QT syndrome (LQTS) is a rare inherited cardiac channelopathy with an abnormally prolonged QT interval with an increased predisposition for fatal ventricular arrhythmias in the presence of a structurally normal heart. Beta-blockers are the treatment of choice and are successful in 75%–80% of patients. Although beta-blocker therapy significantly reduces the risk of sudden cardiac death (SCD) in this population, it is not completely protective, and cardiac events still occur. Implantable cardioverter-defibrillator (ICD) therapy is highly successful in preventing SCD in high-risk LQTS patients. However, it is not without complications, especially in children and young adults, in whom the initial decision to implant an ICD carries long-term implications. In this subgroup of patients, the left cardiac sympathetic denervation showed promising evidence. Here, we describe a case of a 19-year-old female with refractory ventricular tachycardia due to LQTS, successfully managed by the left cardiac sympathetic denervation and beta-blockers alone.
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Professor Sivaramakrishna Iyer Padmavathi p. 98
G Vijayaraghavan
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Cath lab management protocol for Corona COVID-19 suspected or positive case: An institutional protocol p. 100
Kawather Humaid Al Ramadani, Jamila Humaid Al Saidi, Hatim Hamed Al Jamoodi, Prashanth Panduranga, Safiya Al Shehi, Hifa Abdullah Al Mukhaini, Mohammed Barakat Al Riyami
Currently, there is a rapid worldwide spread of coronavirus infection 2019 (COVID-19). Cardiac Catheterization Laboratory staff are involved in emergency management of acute coronary syndrome including ST-elevation myocardial infarction and other emergencies. There is a paucity of Catheterization Laboratory protocols during a suspected or confirmed COVID patient intervention. Hence, to minimize the risk of spreading the virus to cardiac team members from suspected or confirmed cases of COVID-19, we present our institutional protocol, especially during ST-elevation myocardial infarction or emergency intervention.
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Change in blood pressure and pulse rate in construction workers working in intense heat p. 105
Keshab Mukhopadhyay, Ritesh Singh
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