Background: Intracoronary vasodilators are used in various stages of primary angioplasty, either to treat no reflow or prophylactically to prevent no reflow. Vasodilators were ineffective during primary angioplasty to treat no reflow likely because the drug was used after plaque modification. We evaluated the intracoronary use of sodium nitroprusside (SNP) before plaque modification and microembolization. Materials and Methods: We conducted a retrospective case–control study of all primary angioplasty cases done at Lourdes Hospital, Kerala, India, from March 2016 to May 2018 by two operators at the hospital. We retrospectively collected the data for primary angioplasty at the hospital and analyzed the data into two groups: one operator routinely used prophylactic intracoronary SNP in stable primary percutaneous coronary intervention (PCI) patients, whereas the other used it only if there was no reflow. The drug was delivered prophylactically through guiding catheter once at least TIMI I flow was present. We compared the effect of prophylactic vs. therapeutic use of intracoronary SNP on no reflow during primary percutaneous transluminal coronary angioplasty (PTCA). Results: Incidence of no reflow was significantly less in the group in which SNP was used at the onset of primary PTCA when compared with those patients in whom it was not used at the onset (6.5% vs. 28.4%, P < 0.001). The TIMI frame count (21.7 vs. 24, P = 0.22) and low TIMI myocardial perfusion grade (<2) (14% vs. 20%, P = 0.272) did not reach statistical significance. Conclusion: Prophylactic intracoronary use of SNP, before plaque modification, reduces the incidence of no reflow phenomenon after primary angioplasty.

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Lipomatous atrial septal hypertrophy (LASH) is a benign lesion characterized by massive accumulation of fat in the interatrial septum. Multimodality imaging, with echocardiography being the first technique, complemented by multislice computed tomography or magnetic resonance imaging help to make accurate diagnosis. Here, we report a case with a LASH with epicardial fat extension causing aneurysmal dilatation of left superior pulmonary vein with thrombus formation and pericardial effusion.

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Chronic kidney disease (CKD), diabetes mellitus, older age, acute coronary syndrome, and cardiogenic shock are the common predisposing factors for contrast-induced acute kidney injury (CI-AKI) after percutaneous coronary intervention (PCI). Apart from intravenous normal saline administration, other measures to prevent CI-AKI have not been consistently beneficial. More recently, intravascular ultrasound (IVUS)-guided zero-contrast PCI has emerged as an important method to prevent CI-AKI in experienced centers. Technical expertise in complex PCI and meticulous analysis of IVUS are required for this procedure. In this review, the authors have described the basic details of the steps involved in this technique. The authors believe that clinical implementation of this technique has the potential for mortality benefit in patients who are at high risk of CI-AKI.

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Background and Objectives: Severe acute respiratory syndrome due to coronavirus (SARS-COVID-19) was declared as pandemic on March 12, 2020. Government of India declared a total lockdown from March 25, 2020. We report the trends in heart failure (HF) admissions to cardiac care units (CCU) of Ernakulam district of Kerala during lockdown period in comparison with the equivalent period of 2019. Materials and Methods: We conducted a retrospective multicenter observational survey to collect data on admissions for HF at CCUs of Ernakulam district in Kerala from January to May 15, 2020. Records were analyzed for admissions during the equivalent period of 2019. Trends in admissions during lockdown phases were analyzed separately. Results: We observed a reducing trend in the number of admissions with a diagnosis of HF from February 2020. During lockdown phase, a 25.4% reduction in the number of HF admissions was recorded as compared to the equivalent period of 2019. The decrease was evident during all three phases of lockdown. Hospitals located within Kochi Corporation Limits recorded 36.2%, 22%, and 22.9% decrease, respectively, during phases 1, 2, and 3 of lockdown period. There was no decrease in the number of HF admissions to centers located at the periphery during this period. Conclusion: This study confirms a reduction in the number of HF admissions during lockdown period. The decrease was more evident in centers located within metropolitan city limits.

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Background: There are limited data on the late outcome of the acute coronary syndrome (ACS) in India. We prospectively investigated the clinical characteristics, management, and 1-year outcomes of patients with ACS admitted to a tertiary care center of South India. Materials and Methods: In this prospective observational study, we enrolled 3149 adults hospitalized with a diagnosis of ACS between December 1, 2014 and March 31, 2017 at Government Medical College Kozhikode, Kerala. Patients were followed up at 30 days, 6 months, and 1 year. Primary outcome was all-cause mortality at 365 days. Secondary outcomes were 30-day mortality, sudden cardiac death (SCD), and major adverse cardiac events (MACEs) at 1 year after discharge. Results: A total of 3149 patients with ACS were admitted during the study period (48% with ST-elevation myocardial infarction [STEMI], 37% with non-ST-elevation MI [NSTEMI], and 15% unstable angina [UA]). The patients were of ages 58 ± 11.9 years. During hospitalization, the majority of the patients received guideline recommended drugs and percutaneous coronary intervention (PCI) was performed in 28%. Reperfusion therapy was performed in 88% of patients with STEMI (53% thrombolytic therapy and 45% including primary and rescue PCI). At 1 year, all-cause mortality and composite MACE after discharge were 14.4% and 17.6%, respectively. MACE included cardiovascular death (5.4%), re-infarction (15.7%), and non-fatal stroke (0.6%) after discharge. SCD at 1 year was 1.8%. The main factors associated with 1-year all-cause mortality and MACE were older age, prior history of ACS, ventricular tachycardia or ventricular fibrillation, right bundle branch block with Q wave, and left ventricular systolic dysfunction. Conclusion: One-year all-cause mortality after the admission of ACS was high, but post-discharge cardiovascular mortality was comparable to other developed countries. This highlights a better secondary prevention practices and risk stratification in our population.

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Background and Objectives: Severe respiratory syndrome caused by coronavirus 2 (SARS COVID-19) was declared a pandemic by the World Health Organization (WHO) on March 12, 2020. In India, the central government declared lockdown on March 25, 2020. We report the trends in admissions for acute coronary syndromes (ACS) at cardiac care units (CCUs) during lockdown and impact on reperfusion strategies adopted during this time period in comparison with the previous year. Materials and Methods: We conducted a multicenter retrospective observational survey on admissions for ACS at CCUs of Ernakulam district in Kerala from January to May 15, 2020. Records were analyzed for admissions during equivalent period of 2019. Trends in admissions during lockdown phases were analyzed separately. Results: We observed an 18.2% reduction in admissions for ACS during lockdown. A significant reduction in number of patients presenting with ST elevation myocardial infarction (STEMI) (186 vs. 169 and 130 vs. 82) was observed when compared to 2019 (P = 0.0047). Decrease in number of primary angioplasties was noted during lockdown phase (302 vs. 244. P = 0.049). There was an increase in adoption of thrombolysis as reperfusion modality at tertiary care centers during lockdown period (27.1% vs. 40.8%). We did not observe an increase in number of patients who presented late during this phase and there was no heterogenicity in admission pattern according to hospital location. Conclusion: Study confirms a significant reduction in admissions for ACS during lockdown period and change in reperfusion strategies adopted during lockdown.

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PROLOGUE: The “Executive Master Cardiac Health Checkup” (wonder who made that up the first time!) patient makes his entrance into the cardiologist’s outpatient (OP) chamber. It doesn’t require the deductive skills of our friend in Baker street to identify that he has recently returned from either the USA or its neighbor across the Niagara. He looks healthy as a fresh cucumber. And smells even better (Calvin Klein probably). I offer him a smile, a seat, and my hand. He mistakes the intention of my third gesture and hurriedly thrusts a package on to my unsuspecting hand—the colourful and fancy looking Investigation File (gloss finish for the extra effect). “Doctor, all the test reports are here. Blood tests, ECG, Echo are all done. They wouldn’t let me do the TMT without seeing you,” he complained. I thank the technician silently in my mind for having followed my standing instruction faithfully (I have had my share of trouble with unsolicited treadmill tests). I tell him calmly that I wish to talk to him first about his health, then proceed with a clinical examination, and would then give my full attention to the reports in the file. He is clearly not happy. He gives a few not-so-furtive glances at his oversized watch to indicate that he didn’t have much time to waste. POST SCRIPT: After the evaluation, I happily gave the gentleman a “clean chit” and congratulated him on the excellent condition of his heart. He didn’t look as happy as I wanted him to feel though. “Doctor, can I do the TMT now?,” he asked impatiently. One should know when a battle is lost. I smiled, and wrote “Routine check up, No risk factors” against the indication column on the TMT form. The patient proudly came back with the “Negative TMT.” This time, he was smiling from ear to ear, “Thank you Doc, I will be back next year around Christmas for the same check-up.” So much for evidence-based medicine!

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