Coronary Artery Disease


Angiographic Comparison Of Thrombus Load In Young Patients With
STEMI Lysed With Tenecteplase Versus Streptokinase

Krishna Kumar Dhoot, Rajat Gandhi, Anurag Rawat, Jojy Boben, Bino Benjamin, B.K Mahala, P.K.Shetty, George Cherian,
Narayana Hrudayalaya, Bangalore.

Young patients with myocardial infarction tends to have high thrombus burden in relation to plaque burden.

Aim: This study was done to evaluate thrombus burden in young patients who presented with ST elevation MI who were thrombolysed with either tenecteplase or streptokinase.

Methods: We included 24 patients in this study who were enrolled between June 2008 till june 2009 .Patients ranged between   age   21 and  40 years( mean age-30.6 years).  There were 20 males and 4 females.16 patients were smokers, diabetes was present in 8 patients and 4 had  family history of CAD. Patients were assigned to thrombolysis with streptokinase or tenecteplase after taking informed consent.14 patients underwent thrombolysis with tenecteplase while others opted for streptokinase.After stabilization they were taken for elective coronary angiogram on the 3 rd day.

Results: 12 (86%).patients who were thrombolysed with tenecteplase had recanalised artery, while in patients who were thrombolysed with streptokinase, 5(50%) had recanalised artery.

Conclusion: Thrombolysis with tencteplase is more effective and is associated with less thrombus burden compared to streptokinase especially in young patients due to high thrombus burden in this subgroup

KEYWORDS: Thrombus Load, Tenecteplase, Streptokinase.

Myocardial Perfusion Asseessed by Dual Energy Computed Tomography
Dr. Christopher J,Dr. Bathina R, Dr.Raju PK, Dr. Raju BS.
Care Hospital, Hyderabad, Andhra Pradesh

Introduction: Dual Energy Imaging has been in use for tissue differentiation exploiting the fact that the tissues in the human body show different absorption characteristics when penetrated with different X-ray spectra. We have used this property to image myocardial perfusion at rest.

Methods: We have used a dual source CT scanner (Definition, Siemens, Forchheim, Germany) in dual energy mode for performing coronary CT angiography in 10 patients. The CT scan was acquired with retrospective ECG-gating and the following scan parameters: 330-ms gantry rotation, pitch 0.2, and 32-2-0.6 mm collimation. One tube of the dual-source system was operated with 150 mAs/rot at 140 kv and the second tube with 165 mAs/rot at 80 kv. The scan was contrast medium-enhanced (70 ml Ultavist, 370 mg iodine/ml). From the dual-energy scan, 3 different image reconstructions with 0.75 mm section width and 0.4 mm increment were performed using the routine dual-energy CT reconstruction algorithm. The first set of transverse gray-scale images was obtained by merging 70% of the 140 kv spectrum and 30% of the 80 kv spectrum. All patients underwent 2D echo to look for regional wall motion abnormalities.

Results: 10 patients underwent perfusion study. 3 patients had normal coronaries and normal perfusion studies. 4 patients had mild CAD with normal perfusion studies. 3 patients had significant CAD with wall motion abnormalities and abnormal perfusion studies.

Conclusion: Preliminary data showes that Dual Energy coronary CT imaging is able to comprehensively assess coronary artery anatomy, wall motion abnormalities and myocardial perfusion at rest with a single contrast enhanced multislice CT scan.

Keywords: Mycardial Perfusion, dual Energy Computed Tomography, Wall Motion Abnormality.


Impact of intramyocardial hemorrhage detected by MRI on
left ventricular function in patients with reperfused acute anterior wall myocardial infarction
Jayakumar P, Arun Srinivas, Keshavamurthy CB, Guruprasad HP Rajagopal J,
Mahesh BM, Guruprasad BV, Maimoona Arshi, Shariff KR,

Vikram Hospital and Heart Care, Mysore, India


Introduction: Intramyocardial hemorrhage is a known common complication following reperfusion in ST elevated myocardial infarction. Although its presence is clearly related to infarct size, at present it is unknown whether post reperfusion hemorrhage affects long term left ventricular function.

Methods: 24 patients of acute Anterior wall myocardial infarction (AWMI) who were reperfused with thrombolysis and/or PCI along with standard protocol treatment were enrolled for this study. Baseline left ventricular function was calculated. All patients underwent angiogram and revascularization, if required, within 12-48 h of index event. 3 patients underwent primary PCI and 21 patients underwent rescue angioplasty. All patients underwent cardiac MRI, which showed the presence of infracted zone, regional wall motion abnormality with LV dimension, LV function and presence or absence of intramyocardial hemorrhage. All patients were followed upto 3 months. LV function was reassessed at 3 months with Echo.

Results: Out of 24 patients, 7 patients had MRI evidence of intramyocardial hemorrhage (All 7 were male patients). Smoking and diabetes mellitus were more common among patients with intramyocardial hemorrhage. Baseline LVEF was better in non-myocardial haemorrhage patients (38.5% v/s 35%) . At 3 months of followup, patients with nonhemorrhage myocardial fared better in terms of LV function (42% v/s 37.5% p= .03) and functional class compared to those with hemorrhage in myocardium.

Conclusion: Myocardial hemorrhage can be easily detected by cardiac MRI and is a frequent complication after successful myocardial reperfusion. It seems to be an independent predictor of adverse LV remodeling.

KEYWORDS: Intramyocardial Hemorrhage, Left Ventricular Function, Acute Anterior Wall Myocardial Infarction.

Category:                               Coronary Artery Disease    

Corresponding Author:        Dr.Jayakumar P

Designation:                           Registrar, Dept. of Cardiology

Address:                                 Dept. of Cardiology, Vikram Hospital Pvt.Ltd.,
No.46, Vivekananda Road, Yadavgiri, Mysore,
PIN - 570020, Karnataka State

Phone:                                    09986139909

Efficacy and safety of Tenecteplase in Indian Elderly STEMI
patients (Registry Data)

I.Sathyamurthy, K.Jayanthi&K.N.Srinivasan, Apollo Hospitals, Chernnai. Dayanand Kumble,
Jay Anand Hospital, Thane.Tiny Nair, PRS Hospital, Thiruvananthapuram. Thomas Alexander,

Kovai Medical Centre&Hospital, Coimbatore


Aim: To assess safety and efficacy of Tenecteplase in Indian elderly STEMI patients in clinical settings

Method: Retrospective prescription event monitoring on data from the Elaxim Indian Registry



Elderly(>60 Yrs)

Non-Elderly(<60 Yrs)




Age (Mean)



Coexisting Hypertension



Coexisting Diabetes



Chest pain till TNK-tPA time



Time for > 50% St resolution



Thrombolysis clinically successful (> 50% ST resolution)



Any bleeding(Excluding ICH)






Myocardial Reinfarction






Conclusions: Tenecteplase was an effective thrombolytic in 84.5% of  elderly STEMI patients with a mortality of 5.86%. Morbidity events were  not significantly different and within values reported in ASSENT-II Study 

Tenecteplase, ST Elevation Myocardial Infarction, Indian Registry.



Background and Aim: Presence of high thrombus burden has a serious negative impact on the immediate and delayed outcome of percutaneous interventions. Thrombus burden can be high in one of the following clinical situations viz. primary PCI, stent thrombosis and ectatic coronary arteries. Data on 100 consecutive coronary interventions with a high thrombus burden is being highlighted.

Result: The mean age of patients was 48.7 years (Range 22 – 81 years) with an M: F ratio of 2.5:1. 60% of them were diabetics. The clinical subsets included recent myocardial infarction (n=62), post stent deployment (n=18) and ectatic coronary arteries (n=20). Patients with recent acute myocardial infarction usually had single vessel disease (n=44). Most of these patients had totally occluded infarct related artery which was addressed with conventional angioplasty with stenting. Clot suction catheters were used prior to the PCI in 38 cases. Slow flow was noted post stent deployment in 28 cases which was usually managed with pharmacotherapy with nitrates, nikorandil and GpIIbIIIa inhibitors. 2 patients had persistent slow flow despite a satisfactory angiography result and 01 had a fatal outcome due to ongoing ischemia. Among the subset with stent thrombosis - 16 patients had sub-acute stent thrombosis whereas 2 patients had acute stent thrombosis. Clear history of non compliance with anti-platelet therapy was available in 14 patients with SAT. These patients were managed with repeat interventions. 2 patients in the SAT group died within 72 hours of the repeat procedure. Ectatic coronaries with coronary thrombus were seen in 20 patients. 8 patients had a single vessel ectasia where was in others it involved multiple coronary arteries. 16 patients were prescribed dual antiplatelet therapy for the condition and 4 patients s received long term anticoagulation for the same..

Conclusion: The paper will highlight the clinical implication and appropriate management of high thrombus burden in coronary arteries.

Coronary Artery Thrombus, Percutaneous Coronary Interventions Sub-Acute Stent Thrombosis.

Effect of Hyponatremia on in-hospital adverse outcome in patients with
Acute Coronary Syndrome-an extended follow up

CSM Medical Univercity, Lucknow, Uttar Pradesh


Background and Aim- Hyponatremia is common in hospitalized patients and often signifies poor prognosis. Hyponatremia is an established predictor of mortality in heart failure patients. The aim of this study was to assess the impact of hyponatremia on in hospital adverse outcome such as cardiogenic shock and mortality in acute coronary syndrome (STEMI & NSTEMI) patients.

Methods- Patients of ACS admitted in ICCU of department of cardiology from Jan 2008 to June 2009 were studied.  We measured the serum sodium at the time of admission and 24 hour after admission.  We divided the patient in to two groups and one group of patients with serum sodium more than 135 and another group with serum sodium less than 135.We noted the occurrence of cardiogenic shock and mortality during hospitalization as the marker of adverse event.

A total of 564 patients were studied. The average age of our study was 54.4+_ 6.2 years .Out of 564 patients, 154 (27.3%) were hypertensive and 128 (22.6%) were diabetics. Out of 564, 136 (24.11%) were hyponatremic at the time of admission. The incidence of adverse events (Table-1) in hyponatremic group was 31 (22.79%), whereas in non-hyponatremic group was 66 (15.4% (p <.001).



Total number of patients

Adverse events

Hyponatremia (<135 meq/l)


 31 (22.79%)

Non-hyonatremic group


 66 (15.4%)

Conclusion- Hyponatremia is associated with adverse in-hospital outcome in acute coronary syndrome patients. As this study is observational in nature, further randomized large studies needed to confirm this.

Keywords: Hyponatremia, Acute Coronary Syndrome, Cardiogenic Shock.


Nilesh M, Balaji P, Anandkumar G, Rajendra D, Ezhilan J, Latchumandhas K, Mullasari Ajit S,
ICVD, Madras Medical Mission, Chennai, India

Methods: All patients younger than 40 years of age presenting with acute myocardial infarction who underwent PCI from January 2006 to Jan 2009 were selected.

: There were total 1217 patients presented with acute myocardial infarction, out of which 153 patients (12.57%) patients were below 40 years of age. Out of that 43 patients (28.1%) underwent primary PCI. Out of 43 patients, 40 patients (93%) were male while 3 patients (07%) were female. There were 11 patients (25.6%%) with hypertension, 15 patients(34.9%) with Diabetes, 15 patients(34.9%) and 26 (60.4%) had positive family history of coronary artery disease. Out of 40 males, 31 (77.5%) were smoker while none of the female was smoker. 23 patients (53.5%) suffered anterior wall myocardial infarction (AWMI) while 20 patients (46.5%) suffered  inferior wall myocardial infarction (IWMI).  Out of them 32 patients (74.4%) had single vessel disease while others had two or three vessel disease. Out of 20 patients with IWMI, 13 patients had RCA as an infarct related artery while 7 had LCx as an infarct related artery. All the patients who underwent PCI had presented in the first 24 hours of the acute MI. 3 patients (7%) presented with cardiogenic shock. 5 patients (11.6%) had primary VF while one patient (2.32%) had secondary VT/VF. Average hospital admission period was 5.6 days. Out of 43 patients 2 patients died with mortality rate of 4.65%. One of the patients who died had presented with Cardiogenic shock while other patient died because of incessant VT/VF. Both the patients who died were males.  Both the patients who died had suffered AWMI.

Conclusion: Myocardial infarction in Young patients is more common in male patients who are smokers and who have strong family history. Young males who present with AWMI or Cardiogenic shock have high mortality while females have lower mortality as compared to males.

Keywords: Young, Myocardial Infarction, Primary Percutaneous intervention.

Periyanarkunan Ramaiya Murugesan, Krishnan.E., Ganesan.C,
U.Arun kumar, M.S.Murugan., Devanand, Dhanabalan

Department of Cardiothoracic Surgery and Radio diagnosis
PSG Institute of Medical Science and Research, Coimbatore, India.


Information of CAD in young Indians, their risk profile, safety and efficacy of PCI in them is inadequate. We performed retrospective analysis of young Indian patients who underwent percutaneous coronary interventions (PCI) in our cath lab. Data were collected from the cath lab register and medical records. Clinical demography and details of angiogram were noted. In patients where PCI was performed; lesion characteristics, stent details and follow up records were collected. Post-procedure all patients underwent life style counseling. Over a period of 40 months 6240 patients underwent coronary angiogram. 4864 were of Indian nationality. 472 out of 4864 were below 40 years. 54 were female. Mean age was 327 years. Youngest patient was a 19 year old boy. 116 patients underwent PCI. 12 of them were female. 80 out of 116 presented with acute myocardial infarction (AMI) [64 ST elevation AMI, 16 non-ST elevation AMI]. None of AMI patients had previous ischaemic symptom. 46 of 116 AMI patients were critical. 84% were smokers and 46% were diabetic. 32% were young professional working in high-pressure jobs. Among young women 12% were smokers and 68% were diabetics. Of all, 38% had family history of CAD; while 18% had dyslipidaemia. 6% were obese and 22% had hypertension. Coronary angiogram showed that 58% had single, 34% had double and 8% had triple vessel disease. Left anterior descending was the commonest vessel affected (46%) followed by right coronary artery (34%). Left main was involved in 2. Out of 80 patients with AMI, 56 had primary angioplasty. Drug eluting stents were used in 94%. 4 out of 116 died during hospital stay of which 2 died during PCI. All had good therapeutic compliance towards life style counseling. After discharge all were back to work in 4-6 weeks time.
In young Indians CAD is an important cardiac illness. Smoking and diabetes are 2 most important risk factors. In young Indian females diabetes tops the risk profile. AMI is the commonest presentation without any previous symptom. Primary angioplasty can be safely performed in young AMI. Use of drug eluting stent does not have any additional risk. Life style counseling is important with good therapeutic outcome.

Keywords: Percutaneous Coronary Intervention, acute myocardial infarction, Young.


Dr. T. De, Dr. A. Mishra, Dr. J.C. Sharma, Dr. K.K.H. Siddiqui, City – Kolkata.
B. M. Birla Heart Research Centre


Objective: - With myocardial stretching or increased wall tension, the peptide hormone B-type natriuretic peptide (BNP) is released from the cardiac ventricles. Patients who have ST elevation M.I. (STEMI) and elevated BNP levels tend to have a larger infarct, progressive left ventricular modeling and a greater mortality rate than those with lower BNP levels Elevated BNP levels have also been linked to adverse outcomes in patients with unstable angina and non ST elevation M.I. (UA/NSTEMI). Whether patients with UA/NSTEMI and elevated BNP levels would have more severe coronary vascular disease and more significant abnormalities of coronary blood flow was determined.

Methods: - 200 patients with UA/NSTEMI were included. For each patient baseline BNP levels and angiographic data were available. Patient groups were identified as those having baseline BNP levels of 80pg/ml or less (150 patients, 75%) and those having levels more than 80 pg/ml (50 patients, 25%).

Results: - Coronary angiography revealed tighter culprit vessel stenosis (75%) in the group of patients whose BNP levels were more than 80 pg/ml In contrast, the group with lower BNP levels had a median stenosis rate of 65%. When the culprit lesion was located in the left anterior descending coronary artery (LAD), the median BNP level was higher (40pg/ml) than when the lesion was not in the LAD location (22pg/ml). Patients with higher BNP levels were more likely to have the culprit lesion in the LAD location (45%) than were patients whose BNP levels were lower (30%). An elevated BNP level was significantly correlated with the severity of stenosis, and a culprit lesion in the LAD location.

Conclusion: - Elevated BNP levels were associated with a tighter culprit lesion diameter stenosis and culprit lesion in the LAD and proximal location. Thus, more severe disease and a greater extent or myocardial infarction was predicted by elevated BNP levels.

Keywords: B-type natriuretic peptide, Unstable Angina, NSTEMI.

Outcome of AMI patients in diabetics and non diabetics
Dr Vimal Bharti, Dr Rajeev Bhardwaj, Dr Surinder Thakur
IGMC Shimla Himachal Predesh


Aims and objectives: To study the short term outcome in AMI, in hospital and within one month in diabetics and non diabetics in a territiary care hospital.
Material and methods: Study was conducted in 50 consecutive AMI patients and 50 diabetic patients admitted with AMI in IGMC Shimla. In hospital outcome and complications were recorded. Echocardiography was done in all. All patients were reviewed after one month/ earlier if complication occurred.

Mean age of diabetic Patients(DP) was 64.4±yrs and that of non diabetic(ND) was 58.1±10.9 yrs. 68% of DP were male and 32% were female. In ND, 72% were male and 28% were female.70% DP presented with chest pain where as 96% ND presented with chest pain. 44 % DP patients were in heart failure, where as 10% ND had heart failure. In hospital mortality was 22% in DP and 14% in ND. 12.8% DP and 4.5% ND had readmission for heart failure within one month and there was one death in each group during this perind. In DP, random blood sugar(RBS) was 346.4±135.4 in those who died compared to 264.5±94.1 in survivors. HBA1c > 7% was seen in 21 DP, out of which 8(38.1%) died. Compared 3 deaths(10.3%) in those with <7%. In ND,15 patients had stress hyperglycemia out of 5(33%) died compared to 35 with normal RBS and mortality in them was 5.7%.

Chest pain was less common presentation in DP compared to ND. Most significant predictor of mortality was hyperglycemia, higher the RBS, more the mortality. GP with poor control of diabeted had 3,7 times higher mortality. Even in ND, patients with stress hyperglycemia had 5.8 times higher mortality.

Keywords: AMI Diabetes mellitus, HbA1c.

Relationship Of NT–PRO-BNP With Angiographic Coronary Artery Disease
Severity In STEMI In The Absence Of Significant Lv Dysfunction

Dr.satbir singh, Dr.JPS Sawhney, Dr. SC Manchanda, Dr.PK Khanna, Dr.S Dhawan, Dr.RR Mantri,
Dr.R Jain, Dr. R passey,Dr. A Mehta, Dr. B Kandpal, Dr.A Mohanty,
Dr. BS Vivek, Dr. A Makhija

SGRH, New Delhi


The purpose of study was to find out comparative assessment of N-terminal pro-brain natriuretic peptide (NT–pro-BNP) for angiographic coronary artery disease in ST elevation Myocardial infarction (STEMI). This study examined 60 patients (47 males & 13 females). The mean age was 57.23+13.42 years. NT–pro-BNP concentrations were measured using Point of care System by Roche Diagnostics followed by an angiographic procedure. Patients with LVEF<50%, >TYPE 2 diastolic dysfunction or STEMI > Killip class 2 were excluded. Angiographic severity was divided into Normal coronaries, insignificant coronary artery disease (<50% stenosis), single, double, triple, multi vessel coronary artery disease. Gensini score of angiographic severity was also calculated. Seventy three percent of patients were in Killip Class 1. Mean value (95% CI) of NT–pro-BNP in patients was 482.1 pg/ml (320.4 and 643.8). Mean values were not having any statistically significant difference for  patients with high mean BMI, mean arterial pressure or elderly age group. Thirty nine (60%) patients have NT–pro-BNP concentrations more than mean value. Patients were divided into 3 tertiles of increasing level of NT-pro-BNP. Mean (95%CI) of NT-pro-BNP in 3 tertiles of 20 patients each were 190 pg/ml (105.5 and 274.5), 416.0 pg/ml (393.8 and 438.2), and 883 pg/ml (469.6 and 1,271). With increasing  mean value of tertiles the severity of CAD increased as follows.





































The Gensini score 49.1 mean (95% CI of 40-58) which increased with inceeasing tertile severity from 33.7(21-46.3) for Tertile1, 46(36.7-65.8) for tertile 2 & 64.2(50.3- 78.1) for tertile3. This study thus shows that NT–pro-BNP concentrations are increases across the entire spectrum of patients with STEMI severity and parallel the angiographic severity despite normal LV functions.

Keywords: AMI Diabetes mellitus, HbA1c.


           Designation: DNB student
           Address for Correspondence: H no.3308 (F.F), C/O Mrs. D.M.Kalra,
                                 Ranjeet Nagar, Opp.South Patel Nagar, New Delhi, 110008

           Telephone 09818418251   Email:
Arun Prasath.P, Karthikeyan.B, Binaya BB, Gobu.P, Amirtha Ganesh.B,
Ajith.A, Santhosh Satheesh, Balachander J

Department of Cardiology, JIPMER, Pondicherry


Background: Non atherosclerotic coronary artery disease is a rare entity and usually affects young patients. We describe five patients with unusual etiologies of CAD

Methods: Patients who presented with Ischemic heart disease from August 2004 to June 2009 were evaluated. Four unusual causes of CAD were found

Case 1 – A twenty two year old female patient of Takayasus  arteritis presented with multiple episodes of angina .Coronary Angiogram ( CAG) revealed normal left main coronary artery, dissection of mid portion of Left anterior descending (LAD) artery, 75% lesion of proximal left circumflex artery(LCX) and total occlusion of proximal segment of the right coronary artery (RCA).

Case 2 – A twenty nine year old male patient of Hodgkin’s lymphoma who received mantle field radio therapy presented with chronic stable angina. CAG revealed 90% ostial stenosis of LAD. Right coronary system was normal

Case 3 – A twenty six year old male patient presented with recent anterior wall myocardial infarction. Examination revealed a soft systolic murmur in the left sternal border. CAG revealed anomalous origin of LAD from pulmonary artery and LCX originating from the RCA. Right coronary system was normal

Case 4 – A thirty seven year old female patient presented with multiple episodes of angina. She was a known case of Systemic sclerosis. CAG revealed 50% ostial stenosis and 70% distal stenosis of the left main, 90% stenosis of proximal LAD, 70% stenosis of mid LCX and total occlusion of mid RCA

Case 5 – A 43 year old male, diabetic presented with exertional angina. He was also admitted twice for unstable angina. CAG revealed normal left main, LCX and RCA. A coronary Arterio Venous malformation with a feeder artery originating from mid LAD and draining into pulmonary artery was present causing a steal phenomenon.

Conclusion: Young patients with symptoms of CAD need to be evaluated carefully to rule out coronary artery anomalies or rare coronary artery involvement in systemic disease.

Keywords: Systemic sclerosis, Arterio Venous malformation,Hodgkin's Iymphoma, Takayasus arteritis.

Role of procoagulant factors in young patients with acute coronary syndrome.
P.N.S.Haritha, Hima Bindu T.Pramod kmar rao,Niranjan reddy, Vinod kumar,V.Vanaja,G.Subramanyam,SVIMS,Tirupati.
NIMS, Hyderabad, Andhra Pradesh

BACKGROUND: One of the  important pathological factors of acute coronary syndromes is thrombosis. In this study we evaluated the procoagulant factors in young patients with acute coronary syndromes.

METHODS:50 patients with acute coronary syndrome and 50 controls under the age of  40 yrs. were enrolled in the study. All patients  were diagnosed as having acute coronary syndrome on the basis of  chest pain, ECG changes and troponin T levels. Immediately after admission samples for protein C, protein S, anticardiolipin antibody, lipoprotein (a) and fibrinogen were taken. Routine investigations were performed for all patients.

RESULTS: Mean age of the total study group was 32 +/- 5yrs.  Percentage of males in the study group were 68%.Mean values of  protein C, protein S, fibrinogen, Lp(a) and anti phospholipids antibody level in patients were 96.8 + 21.03,97.3+ 24.6,371+177.98, 13.8+11.3 and 2.71+3.86 respectively. Mean values of  protein C, protein S, Fibrinogen, Lp(a) and antiphospholipid antibody syndrome  were 84+18.6, 108+20.3, 14.8+9.1 and 1.6+0.8 respectively. There was significant difference in the protein C level between patients and controls(P value =0.001)There was no significant difference between protein S, fibrinogen anticardiolipin antibody and Lp(a) levels(P Value 0.36,0.22,0.18,0.4 respectively. There was significant difference in the antiphospho lipid antibody levels between males and females in the patient group and not in the control group P value = 0.008 and 0.54 respectively. There was no such difference in other parameters.

CONCLUSIONS: Protein C may play important role in etiology of with acute coronary syndrome in young patients. There seems to be no role of fibrinogen Lp(a) and antiphospholipid antibody. Young females with acute coronary syndrome had higher levels of antiphospholipid antibody.

Keywords: Myocardial Infarction, Nephrotic Syndrome, Hypercholesterolemia.

Myocardial Infarction in children : Two interesting cases.
SP Suryawanshi, B Das, A Nitin, N Rama Kumari, B Srinivas, AN Patnaik, D Seshagiri Rao
NIMS, Hyderabad, Andhra Pradesh


Myocardial infarction in children is extremely rare and can have various etiologies. The following two are illustrative cases.  Case 1 : A 12 year boy, known case of Nephrotic Syndrome from the age of 7 years, on steroids , presented with dyspnea & PND episodes. He was in LVF and incidently detected to have right hemiplegia  with aphasia. ECG showed evolved extensive anterior wall MI .His Chest X-Ray revealed cardiomegaly. A 2-D Echocardiogram showed dilated LA & LV ,severe LV systolic dysfunction,hypokinesia of LAD territory & moderate PAH. Troponin-T was positive. CT scan brain showed infarct in left  fronto-temporo-parietal lobe. His angiogram showed insignificant CAD -LAD mid mild plaque and normal  innominate and bilateral carotid and subclavian arteries.His other investigations revealed  significant  albuminuria, serum hypoalbuminemia and thrombocytosis. His LVF and CVA improved over 1 week with medical management.  Case 2: A  16  year boy, non HT , non DM, having Hypercholesterolemia and family history of Hypercholesterolemia presented with dyspnea  and  palpitation for one month duration. His physical examination revealed cardiomegaly, tendinous and tuberous xanthomas and stria palmaris. His ECG showed decapitation of `r’ wave in lead V1 to V4. His CXR showed cardiomegaly. A 2D ECHO showed dilated LV, severe LV systolic dysfunction, akinetic  LAD territory, moderate MR and moderate PAH. His lipid profile was as follows : Total cholesterol – 440mg/dl, LDL- 398 , HDL-30,TG-60, VLDL-12mg/dl. His coronary angiogram showed LMCA- Ostial 90% stenosis and LAD -proximal 90% stenosis. He underwent CABG on next day uneventfully with IABP support.  

The first case suggests Nephrotic Syndrome as a possible cause of MI and CVA in children and the second case suggests Familial Hypercholesterolemia as a possible cause of MI and severe CAD in childhood.

Keywords: Protein C, Acute Coronary Syndrome, Lipoprotein (a), Antiphospholipid Anitbody.

Platelet volume indices in patients with Acute Coronary Syndrome
and their relationship with Metabolic syndrome
R. Mathur, B. Tiwari, V. Jain, R. Thakur, CM Varma, M Ahmad, RPS Bhardwaj, RK Bansal,
LPS Institute of Cardiology, Kanpur.


Background: Metabolic syndrome is a prothrombotic state and leads to development of coronary artery diseases. Mean platelet volume (MPV) and Platelet distribution width (PDW) are indicators of platelet activation which is central process in the pathogenesis of thrombotic vascular diseases. The present study therefore was designed to investigate MPV and PDW in patients with acute coronary syndromes and their correlation with occurrence of metabolic syndrome, if any.

Methods: We evaluated 144 consecutive patients who presented to us as a case of acute coronary syndrome and measured MPV and PDW in them. Out of them, 56(38.8%) had metabolic syndrome. Mean age was comparable between the two groups (58 years in those with metabolic syndrome Vs 57.13 years in those without metabolic syndrome, p=NS).

Observations:  The MPV was significantly higher in those patients with metabolic syndrome then in those without metabolic syndrome (7.58 fL Vs 6.66 fL, p<0.05). Likewise PDW was also significantly more in those with metabolic syndrome then in those without (18.96 fL Vs 18.45 fL, p<0.05). This signifies that platelets of the patients with metabolic syndrome are larger and also vary more in size then in those without metabolic syndrome.

Conclusion:  The platelets of patients with metabolic syndrome are larger and hence stickier.  This may predispose them to more thrombotic vascular events then those without metabolic syndrome. Thus measurement of MPV and PDW may be used for risk stratification of patients with metabolic syndrome.

Keywords: Platelet Volume Indices, Acute Coronary Syndrome, Metabolic Syndrome.

Intravenous Tenecteplase in ST elevation Myocardial Infarction:
A new era of medical intervention.
S khandelwal, V jain, R Thakur, C M Varma, M Ahmad, RPS Bhardwaj. , R K Bansal,
LPS Institute of Cardiology, Kanpur, Uttar Pradesh


Aim :  To assess the efficacy and safety of third-generation thrombolytic (tenecteplase) in acute STEMI patients.

Methods and Materials :  A total of 43 consecutive patients with acute STEMI (male : female 34:9), age varying between 38 and 75 years, who received weight adjusted dose of tenecteplase were analyzed.All of these patients, received low molecular weight heparin along with tenecteplase. All patients received anticoagulant and antiplatelets following lysis, and concomitant medications like statin, ACEI, beta-blocker. Efficacy of lysis was assessed by ST segment resolution (STR) in ECG, relief of chest pain at 90 minutes and culprit vessel TIMI flow by coronary angiogram. Safety of lysis`(including major and minor bleeding ) and recurrence of ischemia  MI and death  were also assessed.

Results :  Out of 43 STEMI patients who received tenecteplase, the reperfusion rate as indicated by > 50% STR at 90 minutes was 90.7% (39/43). Pain relief was 92.68% (38/41) (2 patients had no chest pain at presentation). Coronary angiogram was done on 31 patients (72%); of whom, 87.09% 27/31) had TIMI II-III flow, 12.91% had 0-I TIMI flow. Mortality was 2.32%(1 patient )  which was died due to ventricular fibrillation and cardiac arrest .There was no reinfraction or intracerebral hemorrhage in any patient .

Conclusion :  Tenecteplase is a safe and effective thrombolytic agent in acute STEMI in our population.

Keywords: Tenecteplase, Thrombolysis, ST elevation Myocardial Infarction.

Carotid Intima-Media Thickness Predicts Severity of Coronary
Artery Disease in Patients Undergoing Coronary Angiography
Pushpa BT MD, CK Reddy MD, N Desai MS McH, K Gupta MD, S Sola MD
Sri Sathya Sai Institute of Higher Medical Sciences, Bangalore and
Sri Sathya Sai Institute of Higher Medical Sciences, Prashanti Gram


Aims and Objectives: Carotid intima-media thickness (CIMT) is a known predictor of atherosclerotic events in asymptomatic healthy individuals. We hypothesized that increasing CIMT is associated with increasing coronary artery disease (CAD) severity in patients undergoing coronary angiography (CAG).

Methods: We prospectively enrolled patients who were undergoing CAG for evaluation of suspected CAD. Patients were excluded if they had known cerebrovascular disease or prior carotid artery procedures. CIMT was measured using high-resolution B-mode ultrasonography by an investigator who was blinded to the patients’ clinical status.

Results: We enrolled a total of 100 subjects (50±9 years; 83% females), of whom 75% had CAD (≥ 70% stenosis of at least 1 epicardial coronary artery). CIMT was normal (<0.1 cm) in 37/75 (49%) of the patients with CAD and was increased in the remaining 38/75 patients. However, all patients in the no-CAD group had a normal CIMT. Increasing CIMT was a predictor of increasing CAD severity, as identified by number of diseased vessels involved (p = 0.0001). On multivariate logistic regression analysis, CIMT remained an independent predictor of CAD severity after correcting for other conventional risk factors for CAD.

Conclusions: In patients undergoing CAG, increasing carotid intima-media thickness is associated with the presence of coronary artery disease. This association is independent of other conventional cardiovascular risk factors.

Keywords: Carotid Intima-Media Thickness, Coronary Artery Disease Coronary Angiography.

Carotid Intima-Media Thickness Predicts Severity of Coronary
Artery Disease in Patients Undergoing Coronary Angiography
Pushpa BT MD, CK Reddy MD, N Desai MS McH, K Gupta MD, S Sola MD
Sri Sathya Sai Institute of Higher Medical Sciences, Bangalore and
Sri Sathya Sai Institute of Higher Medical Sciences, Prashanti Gram


Background : True spontaneous coronary artery dissection (SCAD) is an extremely rare event and 80% of cases occur in young women. Sudden death has been reported commonly and nearly 69% of cases are diagnosed postmortum.

Objective : To study the clinical & angiographic features of 22 male patients of spontaneous coronary artery dissection.

Methods : Retrospective analysis of coronary angiogram in 22 patients who were found to have coronary artery dissection. The number and site of vessels involved, risk factors and LV dysfunction were studied.

Results : All 22 cases of coronary artery dissection occurred in men aged 32-58 years (mean 46.5 yrs). The dissection was seen in a single coronary vessel in 16, in two coronary vessels in 5 and in all three coronary vessels in 1 patient.  The dissection involved LAD-13, Circumflex-5 &  RCA-9. The clinical setting was MI / post MI angina in 17, unstable angina with TMT positive in 4, acute coronary syndrome in 3.  Diabetes mellitus was present in 5 patients and hypertension in 5 patient. Of these 22 patients 9 were chronic smoker and 4 were alcoholic. LV dysfunction was present in 14 of the 22 patients.  One patient with triple vessel SCAD had documented proximal LAD dissection 5 years ago.  2 patients received stent implantation to proximal LAD and LCX arteries and 19 patients were managed medically.

Conclusion : Spontaneous Coronary Artery Dissection is a rare cause of acute coronary syndrome and sudden cardiac death. Early diagnosis by angiogram and proper treatment strategy may help in preventing sudden cardiac death.

Keywords: Spontaneous Coronary Artery Dissection, MI, acute Coronary Syndrome, Sudden Cardiac Death.

Spontaneous Coronary Artery Dissection – Clinical Review
Dr.C.S.Reddy, Dr.J.Rajagopal, Dr.H.P.Guru Prasad, Dr.C.B.Keshavamurthy, Dr.A.Srinivas,
Vikram Hospital & Heart Care, Mysore


Background : True spontaneous coronary artery dissection (SCAD) is an extremely rare event and 80% of cases occur in young women. Sudden death has been reported commonly and nearly 69% of cases are diagnosed postmortum.

Objective : To study the clinical & angiographic features of 22 male patients of spontaneous coronary artery dissection.

Methods : Retrospective analysis of coronary angiogram in 22 patients who were found to have coronary artery dissection. The number and site of vessels involved, risk factors and LV dysfunction were studied.

Results : All 22 cases of coronary artery dissection occurred in men aged 32-58 years (mean 46.5 yrs). The dissection was seen in a single coronary vessel in 16, in two coronary vessels in 5 and in all three coronary vessels in 1 patient.  The dissection involved LAD-13, Circumflex-5 &  RCA-9. The clinical setting was MI / post MI angina in 17, unstable angina with TMT positive in 4, acute coronary syndrome in 3.  Diabetes mellitus was present in 5 patients and hypertension in 5 patient. Of these 22 patients 9 were chronic smoker and 4 were alcoholic. LV dysfunction was present in 14 of the 22 patients.  One patient with triple vessel SCAD had documented proximal LAD dissection 5 years ago.  2 patients received stent implantation to proximal LAD and LCX arteries and 19 patients were managed medically.

Conclusion : Spontaneous Coronary Artery Dissection is a rare cause of acute coronary syndrome and sudden cardiac death. Early diagnosis by angiogram and proper treatment strategy may help in preventing sudden cardiac death.

Keywords: Spontaneous Coronary Artery Dissection, MI, acute Coronary Syndrome, Sudden Cardiac Death.

Door- to -Balloon Time: Single Centre Experience
Suma. M. Victor, Anand Gnanaraj, Archana. C, Deepa. V, Sushanth, Mullasari Ajit S.
Madras Medical Mission, Chennai


Objective: To evaluate whether the recommended door-to-balloon (DTB) time of 90 minutes (min) for primary percutaneous coronary intervention (PPCI) can be achieved and to assess the factors that cause delay.

Methods: A total number of 85 consecutive patients that underwent PPCI in our institution from August 2008 to July 2009 were studied prospectively. From door to balloon, time was divided into 5 stages; any delay and the reason for delay were studied. Data was analyzed using SPSS version10.0.

Results: In our hospital, the average DTB time was 80.56min (SD= 34.37). DTB time <90 min was achieved in 76.5 %( 65), and DTB time >90 min occurred in 23.5 %( 20). Average Door to ECG time was 6.52 min (SD= 2.74), average time taken for decision of PCI by the CCU team was 7.51 min (SD= 10.5), average time taken for the patient’s consent was 19.6 min (SD= 17.6), average time taken for cath team to be activated was 6.7 min (SD= 7.6), average time taken for shifting to cath lab (financial clearance) was 39.15 min (SD= 22.9). Average time taken for sheath to balloon was 5.2 min (SD= 1.7). Out of the DTB >90 min group, hospital related delay occurred in 5% (1), patient related delay was responsible in 80% (16), both together in 15% (3). 89.5% (17) of patient related delay was due to financial clearance. There was no statistically significant delay for patients presented at morning or night and during the week or week end. Total mortality: 4.7%. Mortality among <90 min was 3.1%, mortality among >90 min was 10% (OR=1.07, 95% C.I, .92 -1.2).

Conclusions: With effective hospital strategies, the DTB time of 90 min can be achieved in majority of patients. The chief delay in DTB time in this study was due to financial constraints. Reduction in DTB time is associated with lesser mortality.

Keywords: Door-To-Balloon, Primary Percutaneous Coronary Intervention, Coronary Artery Disease.

Association between plasma adiponectin levels and acute
coronary syndrome and its relationship to corornary lesion severity.
Sunil K verma , Amit Mittal, MP Girish, MD Gupta, R Saijpaul, V Trehan, S Tyagi, Dept of Cardiology.
GB pant Hospital, New Delhi


Aims: Adiponectin is a recently discovered adipocyte specific cytokine which, in contrast to other adipokines, has been described to have anti-inflammatory, anti-thrombotic, and anti-atherogenic properties. This study evaluates the association between plasma adiponectin levels with acute coronary syndrome and its relationship to angiographic coronary lesion severity.

Methods and results: Adiponectin was measured in ninety patients undergoing coronary angiography. These ninety patients were divided into two subgroups – with (n=45) and without ACS (n=45). Patients without ACS were found to have higher adiponectin (16.47+7.88µg/ml) levels than patients with ACS (9.03+3.13µg/ml) and the difference was statistically significant (p <0.001). In multiple regression analysis adjusted for all  covariates, higher adiponectin levels remains positively associated with a lower risk of ACS(p value=0.002). The greatest increase in risk for ACS was seen at adiponectin levels < 12.20 µg/ml in study subjects. Moreover in the present study adiponectin levels shows a significantly progressive decrease as the angiographic severity of coronary artery stenosis increases (p valve=0.02).

Conclusions: Higher adiponectin levels are independently associated with lower risk of ACS and lower levels of adiponectin were associated with more severe coronary artery disease.

Keywords: Plasma Adiponectin, Acute Coronary Syndrome, Corornary Lesion Severity.

N Chaturvedi,D Kumar, R Thakur, C M Varma, M Ahmad RPS Bhardwaj. R K Bansal.
LPS Institute of Cardiology, Kanpur


Objective:. The objective of this study was to assess the relationship between plasma BNP levels and the extent of obstructive lesions on coronary angiography in refractory stable coronary artery patients.

Methods: Plasma BNP concentrations were measured in 126 patients (108 males and 18 females) with a diagnosis of refractory stable angina pectoris(symptomatic despite maximum medical therapy) who had a left ventricular ejection fraction (LVEF) >=45% on echocardiographic evaluation. Coronary angiography was performed in all patients, who were then divided into two groups according to the results of the angiography. Group 1 consisted of the patients who had a lesion leading to an obstruction of the lumen in any coronary artery by less than 50% or those who had normal coronary arteries.Rest other patients constituted group 2.

Results: In group 1 (n=18), the mean plasma BNP level was 17.54+/-5.99 pg/ml. In group 2 (n=108), it was 46.2+/-37.81 pg/ml. BNP was significantly higher in group 2 (P<0.001) than group 1. The BNP concentration of the patients with one-vessel disease (n=48), two-vessel disease (n=44), and three-vessel disease (n=16) were 36.23+/-35.95 pg/ml, 51.74+/-38.61 pg/ml, 60.88+/-37.67pg/ml consecutively. In this respect, the plasma BNP levels increased with increasing number of vessels involved although the difference was not statistically significant. Comparing  the patients in Group 2, according to involvement of left anterior descending artery (LAD), BNP levels were significantly higher in the patients with LAD involvement (53.45+/-39.67pg/ml) than patients without LAD involvement( 20.83+/-10.89 pg/ml) ( P<0.001).

Conclusion: Plasma levels of BNP were higher in patients who have stable coronary artery disease with preserved left ventricular systolic function. The level of increase in plasma BNP concentration was positively correlated with the extent of the lesion and LAD involvement on coronary angiography.

Keywords: Stable Coronary Artery Disease, left ventricular ejection fraction, B-Type Natriuretic Peptide.

S.Venkatesan C.Krishnakumar .G.Gnanavelu .R.Subramanian.Geetha Subramanian B.Ramamurthy.P.Arunachalam.M.Somsundram.V.E.Thandapani.M.A.Rajasekaran.
S.Murugan , Madupraphu doss ,P.Pachiappan.
Madras Medical College. Chennai


Unstable angina( UA /NSTEMI ) constitute a  heterogeneous  group of  patients with  lesions ranging from  normal coronary  artery  to severe multi vessel  disease. Even  though  multiple active plaques are documented ,  one  critical  lesion  would be   responsible  for  the  index  episode  of  angina..  Contrary to STEMI  there is no standard methodology   to identify  the  Angina  related artery.(ARA) in UA .We under took this  analysis  to find  whether  admission  ECG  with the help of echocardiography   could  predict  the ARA  in patients with UA

26  patients with  UA  admitted in  our  CCU  were  the  subjects of  study. Patients with   post  infarction angina,  CABG ,  PCI , old  MI , left ventricular  dysfunction  were  excluded. All patients  were treated  as per institutional protocol. .Echocardiogrphic analysis   of  wall motion defects (WMD)  were  documented  between  2hrs  and  24hours of admission  .CAG  was  done  between  24 hrs and  7  days. The  coronary  lesion was considered angina related  if  the  WMD  detected   by  echocardiography matched with  the  myocardial  segments supplied by the  arterial territory  containing the lesion . After locating the ARA , the patient’s  admission ECG   was  compared  retrospectively   with  CAG  finding  to study  whether  it has  any  predictive  value  for identifying  ARA.  6 patients  who  had single vessel disease the ARA  localization  was straight forward. (LAD -4 , LCX -1 RCA-1 ). In 2  patients  there was  obvious  eccentric thrombus containing plaque indicating the culprit lesion . 18 had DVD or TVD with no clearcut culprit lesion.

The following ECG findings were helpful in localizing ARA.ST depression in V3- V5 correlated  with  LAD  angina .Global ST depression was highly correlated with proximal LAD or Left main disease ( 6/6 patients). ST depression in V1 –V3 was associated more commonly with dominant LCX/OM disease. ST depression in 2 ,3 , AVF , or I, AVL  had  no significant correlation with either RCA or LAD  system.

It  is  concluded  ARA  can be  identified  with  fair  degree  of accuracy   by admission  ST segment  profile. This  observation  differs with  the existing literature which  suggest little role for ECG to localize arterial lesion in UA. In patients with multivessel CAD  with  more than one  critical lesion  a  combination of ECG  and echo features  help  us to  fix the angina related artery and possibly the lesion. This has  important  therapeutic implication.

Keywords: Angina Related Artery, Unstable Angina/NSTEMI, ECG, Echocardiography.

S.Venkatesan C.Krishnakumar .G.Gnanavelu .R.Subramanian.Geetha Subramanian B.Ramamurthy.P.Arunachalam.M.Somsundram.V.E.Thandapani.M.A.Rajasekaran.
S.Murugan , Madupraphu doss ,P.Pachiappan.
Madras Medical College. Chennai


CAG is the gold standard for assessing the severity  and extent of CAD. 64 SLICE CT angiograph is a recent innovation . In patients with suspected ischaemic cardiomyopathy  or  post infarct severe LV dysfunction,CAG carries higher risk. 45 consecutive patients (M36 F9) in age group 36 -67 with mean age of 57 yrs who presented with severe LV dysfunction with angina .64SLICE CT angiography was suggested in these patients as it needs only peripheral  venous access & patient needs to be in the lying posture for very less time compared to conventionaL angiography.After assessing the renal function and adequate heart rate control   patients underwent CT angio.In 12 patientcoronary were normal suggesting  dilated cardiomyopathy.Remaining 33 patients have 60% TVD 40% DVD) None had single vessel disease suggesting that more severe the LV dysfunctionmore severe the extent of CADIn 33 patients 13   had  ischaemic LV dysfunction 20 had post infarct failure. Of which 1 had moderate to severe Mitral regurgitation due topapillay muscle dysfunction.ThoughCABG could not be taken based on CT ANGIO findings at present still it is a very goodtool & a boon to di-fferentiate accurately Non ischaemic DCM from Ischaemic DCM. In th-ese patients it is possible to correct failure & suggest conventional CAG at a later date  and plan revascularusation  procedures.Thus 64 SLICE CT helps us to define dignosis & buy time to control failure & improve the outcome after revascularization & to avoid unnecessary CAG in patients with normal coronaries

Keywords: Post Infarct Servere LV Dysfunction, Ischaemic Cardiomyopathy, CT Angiography, Cardiomyopathy.



AIM: In premenopausal women with myocardial infarction, the following were studied
1. To study the novel risk factors
2. To study the angiographic profile

Methods: A total of 156 premenopausal women and 252 postmenopausal women (55–65 years old) who underwent coronary angiography for the first time from June 2008 to April 2009 were included and following parameters were studied. Age , occupation ,socioeconomic status, diabetes mellitus, hypertension, prior myocardial infarction, dyslipedemia, homocysteine, lipoprotein(a), hs CRP(High sensitivity c–reactive protein) level, prior cerebrovascular & peripheral vascular disease, smoking & alcohol intake, and coronary angiographic characteristics (presence, localization, length and severity) were compared between the premenopausal and postmenopausal coronary artery disease (CAD) groups.

Results: Premenopausal CAD patients presented with hypertension, diabetes mellitus and dyslipedemia less frequently when compared with postmenopausal CAD patients (52.0% vs. 62.0%, 17.0% vs. 37.5%, 27.9% vs. 39.4%, respectively; all P <0.05).Premenopausal CAD patients presented more frequently with high hs-CRP, homocysteine, and lipoprotein (a) levels when compared with postmenopausal CAD patients (68.9% vs. 23.7 %, 57.3 % vs. 36.9%, 48.6% vs. 28.8 % respectively; all P <0.05).Single vessel disease is seen more commonly in premenopausal CAD (53.2% vs. 25.9 %,< 0.05), And triple vessel disease in postmenopausal CAD patients (43.8% vs. 19.4%, P<0.05).But Premenopausal CAD group had more severe lesions (≥90%) at left main (3.9% vs. 1.6%, P <0.05) and proximal left anterior descending artery (LAD) (38.2% vs. 17.6%,P <0.05) than postmenopausal CAD patients.

1.Premenopausal CAD patients presented less frequently with conventional risk factors like diabetes mellitus, hypertension, dyslipedemia, than     postmenopausal CAD patients.
2. Premenopausal CAD patients had more commonly novel risk factors like homocysteine, lipoprotein (a), hs CRP, than postmenopausal CAD.
3. Single vessel disease is more common in Premenopausal CAD patients and triple vessel disease is more common in postmenopausal CAD patients.
4. Premenopausal CAD patients had severe left main & proximal LAD disease than postmenopausal CAD patients
5. In Premenopausal women with absent conventional risk factor, raised  Lipoprotein (a) acts as a single most risk factor that can be considered as “smoking      Equivalent ” in women,

Keywords: High Sensitivity C-Reactive Protein, Coronary Artery Disease, Premenopausal women.

Single Vessel Stenting Of left Circumflex artery – In The Presence
Of InSignificant LAD Disease –certain Interesting Observation


Introduction &Aims: Stenting is the only option for revascularization in significant symptomatic LCX lesion in the presence of insignificant LAD disease. 30 consecutive patients (M25 F5 )age 45 -65 yrs admitted in our centre with significant LCX disease who underwent stenting were analysedreference to demographic characteristics,risk factors ,type of LAD and

the ECG changes pre & post stenting period . Indication for stenting was recurrent angina in 20 patients (M18 F2)& EST positive in 10 patients.CAG revealed 90% lesion in proximal LCX in 15 patients (M13 F2)Distal LCX in lesion in 15 patients (M12 F3) Non Dominant LCX in 27 patients (M23 F 4)dominant LCX in 3(M2 F1) All had insignificant LAD disease.(Type III LAD in 20 patients (M18 F2) Type II LAD 7 patients (M5 F2 ),type I LAD 3 pts (M2F1).Pre stent  ECG showed resting high lateral T wave changes in 20 patients.(M17 F3).10 pts resting ECG were normalNIDDM 23 pts(M20 F3 )SHT (M20 F1) Dyslipidemia (M24 F4). In the imm-ediate poststent period  ECG showed anterior lead ST-T changes in 20 patients persisting for upto 3 days and resolved completely(M17 F3)In the remaining 10  patients AW STEMI occured.theanalysis of second group of patients showed that they multiple risk factors . All the patients with post stent STEMI showed had proximal LCX lesion 3 ofthem had dominant   LCX (M2F1).Though LAD lesion was insignificant ,it was long lesion in all 10 patients  with 5 having proximal lesion ,5 having distal LAD lesion.It shows in pts having Dominant LCX, proximal   insignificant LAD lesion precipitated STEMI LAD territory which could be explained possibly by sudden post tent alteration ih the coronary flow hemodynamics with probable “steal phenomenon” like mechanism that could explain the ischemia in LAD territory .STEMI occurred in the age group of 45- 55 10 patients than in

 the older age group suggesting the role of better developed collaterals  in the older patients  that  possibly havea protective role in preventing transmural ischemia and limiting it to transient short lived ST-T changes . The possible Question arising out of this observation is should we have more stringent criterion to decide stenting of LCX lesion. Is there a role for Metabolism modying drugs like Trimatazidine , Ranolazine  before stenting?  In the presence of 2 proximallesion which one to be stented first?

Keywords: Left Circumflex artery, Percutaneous Coronary Intervention, Left Aanterior Descending artery.

Study of single dose Rosuvastatin versus Rosuvastatin plus Ezetimibe
combination to reduce inflammatory response in patients undergoing PTCA with stenting.

Parag Admane, R Pratiti, NV Deshpande, HM Mardikar

Mumbai, Maharastra


Aim: Coronary angioplasty evokes inflammatory response due to plaque disruption during. High sensitivity C - reactive protein (hs CRP) is used to measure vascular inflammation. Statins have been shown to modulate the hs CRP levels. We sought to evaluate the inflammatory response after PTCA using either Rosuvastatin alone or in combination of Ezetimibe in a short term study.

Materials and Method
: We enrolled 70 patients of stable angina undergoing PTCA with hs CRP level < 10 mg/L with coronary stenting between 1st March 2009 and 31st May 2009 and were randomized in 1:1 fashion The PTCA was done as per standard hospital protocol. The baseline hsCRP, CRP and lipid profile samples were collected. They were randomly divided into two groups, either Rosuvastatin 20mg Monotherapy (Group A) or Rosuvastatin10mg with Ezetimibe 10mg Therapy (Group B), given once a day as a single tablet. In this way Group A and B consisted of 35 patients each . All patients received standard care of treatment after PTCA.  The lipid profile and hs-CRP was measured on Cobas 111.

Baseline hs CRP was similar in the groups (2.36 ± 1.55 in group A and 2.13 ± 2.03mg/L in group B, p= 0.67). hs CRP levels increased significantly at 24 hours after PTCA both groups but the difference was not significant statistically. A significant decrease in hs CRP levels was observed in both treatment groups well below the baseline levels but the difference in the groups was not significant. The lipid profile improved in terms of reduction in LDL and increase in HDL cholesterol at one month, however the difference between the groups was not significant.

Both the strategies, Rosuvastatin 20 mg  vs Rosuvastatin plus Ezetemibe combination ( 10 mg + 10 mg) reduced equally  the inflammatory response after PTCA , irrespective of their effect on LDL cholesterol level at the end of one month.  

Keywords: Rosuvastatin, Ezetimibe, PTCA, High sensitivity C-reactive protein.

Prevalence of coronary risk factors in patients with Chronic Kidney Disease (CKD).
Dr Navjot Singh, Dr Robert James, Dr Timothy Rajamanickem,
Dr Gurpreet Singh,Dr Aroma Oberai, Dr Anna Mani.

Christian Medical College & Hospital, Ludhiana.


Aims & Objectives- To find out prevalence of various coronary risk factors in patients with CKD from North India.

Methods- This is a prospective study done on 140 patients who attended medical/nephrology OPD at CMC Ludhiana, with a diagnosis of CKD. All patients underwent physical examination and lab investigations included serum albumin, electrolytes & creatinine, blood sugars,urine analysis,HbA1C, lipid profile,uric acid, Lp(a), Homocysteine (Hcy) levels.The patients were classified in three groups, based on the values of creatinine clearance; group I >60ml/min, group II 30-60ml/min, group III <30ml/min.

Results- Out of 140 patients 78 were males & 62 females. Mean age at diagnosis of CKD was 56yr for males & 59yrs for females.The duration of CKD was 2.85yrs in males & 2.41yrs in females. 70%,75%& 85% of the patients were diabetic in group I,II&III respectively.76%,84% & 92% of the patients were hypertensive in the above groups.46%,38%& 28 % patients were found to be obese in group I, II, III respectively. Mean BMI were 34.66, 32.28 & 28.84 in the above groups (p=0.00). Mean HbA1C were 7.42,7.48 & 8.06 % in the above groups.(p=0.00). Hyperlipidemia was observed in 68%, 62%, 58% of patients in the above groups.Mean LDL C were 134mg/dl 122mg/dl & 114mg/dl in in three groups (p=0.00). Mean HDL& TG were 38.8mg/dl & 184mg/dl in group I as compared to 38.45mg/dl & 190mg/dl in group II & 38.12mg/dl & 188mg/dl in group III but the difference was statistically insignificant. Hyperuricemia was observed in 48%, 52% &70% patients in the respective groups(p=0.00). Raised Lp(a) was observed in 6%, 3% & 4% patients in the above groups & raised Hcy was observed in 12%, 9% & 12% of patients in above groups, but the difference  in Lp(a)  &  Hcy was statistically insignificant.

Conclusions-DM and Hypertension are the most common coronary risk factors associated with CKD & their poor control is associated with significant worsening of renal status.With the progression of renal disease there is fall in BMI as well as LDL cholesterol levels where as no significant change is noticed in HDL&TG levels.There is progressive increase in UA levels with deterioration in renal function, where as no significant change is observed in homocysteine & Lp(a) levels.

Keywords: Coronary Risk Factors, Chronic Kidney Disease, DM, Hypertension.

Glycoprotein IIb/IIIa inhibitor for failed thrombolysis in acute MI
V. Jan; Imran A; K. Aslam, N. Loan, H. Rather, S. Alai

Sher-i-Kashmir Institute of Medical Sciences, Srinagar


Failed thrombolysis is associated with a much higher chance of early death and greater left ventilator dysfunction. We studied the feasibility, safety, clinical benefit efficacy and 30 day outcome in 50 patients receiving GP IIb/IIIa receptor inhibitors (tirofiban) in patients with failed thrombolysis, in acute ST-elevation myocardial infarction, and compared with 50 patients for age, gender and infarct location, who did not receive rescue treatment for different reasons: GPIIb/IIIa administration resulted in an overall ST segment elevation, resolution, at 240 minutes in 44 patients. Incidence of major events during hospitalization was higher in control group. One patient (2%) died against 4(8%) in control while 4 patients had refractory angina needing early PCI as compared to 13 in control group. None reinfarcted as against 4 in control group. Two patients developed CCF against 8. However, minor bleeding events (mainly gum) were significantly higher, 9 against 0 in control. Coronary angiography revealed residual thrombus only in 4 patients treated with Tirofiban compared to 13 in controls. On 30 day follow up no death, CCF or repeat revascularization procedure was recorded in the study group, with significant improvement in LVEF.

Keywords: Glycoprotein IIb/IIIa, MI, Failed thrombolysis.

Factor V Leiden (FVL) by polymerase chain reaction and serum
fibrinogen levels in young patients with coronary artery disease

R Avasthi*, M Sherpa#, S Sharma#, U Rusia#

Department of Medicine* & Pathology#, UCMS (University of Delhi)
& GTB Hospital, Delhi


Background: Significance of thrombophilic molecular markers in the rising incidence of young CAD patients lacking conventional risk factors.

Aims and objectives: To study FVL by PCR and serum fibrinogen levels in young patients with CAD.

Methods: 30 diagnosed patients with CAD (documented as acute MI sustained at least 3 months prior to inclusion) of either sex under 40 years were included in the study. Thirty healthy age and sex matched control subjects without evidence of CAD or history of any vascular disease formed the control group. Detailed presentation, risk factors, family history, ECG features and angiographic findings (wherever available) were recorded. In addition to routine investigations, lipid profile, screening coagulation test and fibrinogen levels were done. DNA analysis by PCR for FVL was done in both CAD patients and controls.

Results: On assessment of conventional risk factors, there was only 1 patient without any risk factor. Three to four risk factors were present in 19/30 patients. Mean fibrinogen level was 252.1±114.8 mg/dl and 205.8±52.4 mg/dl in patients and controls respectively. The fibrinogen level was above the upper limit of normal range in 3 (10%) patients. Four patients (13.3%) showed mutation for FVL. Other characteristics of these 4 patients are shown in table below



+ve F/H






Fibrinogen level (mg/dl)

CRP >6

Total risk factors













































Conclusion: The contribution of FVL as thrombophilia marker in young patients with CAD may not be very significant, though it may be having amplifying effect on the presence of other risk factors. Conventional risk factors, contrary to belief may be of utmost importance in these young patients as prevention strategies to overcome disabling CAD.

Keywords: Factor V Leiden, Polymerase Chain Reaction, Coronary Artery Disease.

Hyperglycemia and Coronary Atherosclerosis in Non-Diabetic Patients
Rajeev Gupta, Aachu Agrawal, Sanjeeb Roy, Atul Kasliwal, JS Makkar,
Ajeet Bana, RK Tongia, Sailesh Lodha.

Fortis Escorts Hospital, Jaipur


Objectives: We assessed the association of blood glucose levels, within normal range, with degree of coronary atherosclerosis. 

Methods: Successive patients undergoing coronary angiography were evaluated for standard coronary risk factors (smoking/tobacco, hypertension, diabetes, and dyslipidemias. Association of coronary atherosclerosis (one, two, three or left main disease) at various blood glucose quintiles (<85, 85-99, 100-109, 110-125 and >126 mg/dl) was determined with using univariate statistics.

Results: Data of 956 cases that underwent coronary angiography at this centre were pooled, 278 (29%) had diabetes. In remaining 663 details of glucose status were available in 532. 152 (28.7%) had normal or <50% luminal narrowing, 125 (23.6%) had single vessel disease, 115 (21.7%) two vessel disease, 113 (21.3%) three vessel disease and 25 (4.7%) left main disease. Prevalence of smoking was in 21.5%, hypertension in 44.7%, high cholesterol in 26.9% and low HDL in 49.5%. Prevalence of atherosclerosis in different glycemia groups is shown in Table.

Glucose (mg/dl)

Normal or insignificant (n=152)

Single vessel (n=125)

Two vessel (n=115)

Three vessel or left-main (n=158)

<85 (n=28)

10 (6.6)

7 (5.6)

4 (3.5)

7 (5.1)

85-99 (n=188)

57 (37.5)

37 (29.6)

42 (36.5)

52 (37.7)

100-109 (n=122)

42 (27.6)

27 (21.6)

29 (25.2)

24 (17.4)

110-125 (n=98)

23 (15.1)

26 (20.8)

19 (16.5)

30 (21.4)

>126  (n=94)

20 (13.2)

28 (22.4)

21 (18.3)

25 (18.1)

Conclusions: This study shows that blood glucose >85 mg/dl is associated with increased coronary atherosclerosis. Lower target for primary prevention programs is recommended.
Keywords: Hyperglycemia, Coronary Atherosclerosis, Primary Prevention,

Profile of Aorto-iliac Disease in Patients with Multi-vessel Coronary Artery Disease
P. Poddar, R. Vijayvergiya, A. Lal*, A. Behra**, S. Jain. Department
of Cardiology, Radiology* and Vascular Surgery**,

PGIMER, Chandigarh.


Introduction: Peripheral Arterial disease (PAD) of aorto-iliac vessels is common in patients with concomitant severe multi-vessel coronary artery disease (CAD). Angiography of these vessels at the time of coronary angiography may detect the occult stenosis, which has clinical implications. We studied the prevalence of symptomatic or asymptomatic aorto-iliac disease in patients with multi-vessel CAD.

Subjects and methods: From Jan - Sept 2008, 30 patients with multi-vessel CAD on coronary angiography were subjected to simultaneous abdominal aortogram and selective angiography of renal and mesenteric arteries.

Results: 30 consecutive patients including 20 males and 10 females of mean age 62.13 years were included. Atherosclerotic risk profile was like - Diabetes mellitus (n=14), hypertension (n=21), smoking (n=11), dyslipidemia (n=22). 6 patients had associated lower limb claudication, 5 patient each had abdominal bruit and absent lower limb pulses. Coronary angiography revealed left main with triple vessel disease in 11, severe triple vessel disease in 15, and double vessel disease in 4 patients. 13 patients had LVEF < 50%. Among 30 patients of CAD, 21 had significant PAD of abdomino-iliac vessels. Significant renal artery stenosis was present in 15 patients- 9 had bilateral and 6 had unilateral stenosis, none of them had impaired renal functions. Mesenteric artery and iliac artery stenosis was present in 12 and 6 patients respectively. 1 patient had abdominal aortic aneurysm.

Conclusion: Patients with multi-vessel CAD and PAD have more adverse risk profile for conventional atherosclerotic risk factors compared to CAD patients without PAD. Patients with severe multi-vessel CAD have very high prevalence of PAD of aorto-iliac vessels, hence a comprehensive evaluation for PAD is required in these patients.

Keywords: Aorto-iliac Disease, Profile of Aorto-iliac Disease,Multi-vessel Coronary Artery Disease.


More Arun , Gautam A, Yeriswamy MC, Varghese K, Santosh M J, Srilakshmi M A,
Shetty G G, Patil C B, Iyengar S S, Department of cardiology,

St John’s Medical College, Bangalore, India


Introduction: There is very little data on   prevalence   of angiographically proven coronary artery disease (CAD) in patients with peripheral arterial disease (PAD).

Aims: To study predictors and prevalence of CAD in patients with PAD.

Materials and Methods: We evaluated 345 consecutive patients with PAD who were referred for peripheral angiography. After obtaining informed consent all patients underwent coronary angiography in addition to peripheral angiography.

Results: The mean age   of   the   patients   was   54± 16 years.  87%   of patients were males. Smoking  was  the   most  common  risk  factor (n=179,52%),  followed  by hypertension (n=140,40%),  diabetes (n=138,40%)  and  dyslipidemia  (n=62,17%)Majority  of  patients  had  lower  limb  disease (n=244,71%) followed by aortic(n=52,16 %),upper limb (n=48,14%), renal(n=24,7%), and carotid disease (n=22,6%).Significant  CAD,  defined  as  50%  or  more  Stenosis of a major epicardial  coronary artery was seen in 175(50.72%) patients.  Associated CAD  was most    likely  to  be  present  in  patients  with  aortic (94%), followed  by  patients with renal artery stenosis (60%), lower limb (60%), carotid (46%), upper limb disease (25%).Patients  with  CAD were significantly older (59.1 years vs 49.6 years p<0.0001), more likely to be diabetic ( 29 % vs 10 % p<0.0001), hypertensive (26% vs 10% p<0.0001), and have higher triglyceride  levels (148 mg/dl vs. 128 mg/dl p<0.0001). There was no significant difference in the prevalence of other risk factors like gender, smoking, total HDL and LDL cholesterol.

Conclusion: CAD was common(50.72%)in patients with PAD and was more common in  patients  with  significant  stenosis  in  aorta, followed by  renal,lower limb,carotid and upper limb. In comparison CAD   was   least  common  in  patients with  upper limb disease. Increasing age, diabetes, hypertension and   high triglyceride levels also were significantly commoner in patients with concomitant CAD.

Keywords: Angiography, Coronary Artery Disease, Peripheral Arterial Disease.

Dual Source Multislice Computed Tomography in Myocardial Rupture.
Dr. Sayyed A, Dr. Christopher J, Dr. Bathina R, Dr . Raju BS.

CARE Hospital, Hyderabad, Andhara Pradesh


Introduction : Tentative diagnosis of myocardial rupture post MI has been made traditionally by clinical and echocardiographic criteria, the definitive diagnosis was made intraoperatively alone. With the advent of DSMSCT the diagnosis of rupture with its extent and location can be confirmed along with coronary anatomy accurately prior to surgery.

Method: Two patients with ? 2D echo suspicion of cardiac rupture were evaluated by a by dual source 64 slice Siemens -Definition using a gated low radiation protocol with weight-adjusted contrast. DSMSCT was performed with retrospective gating technique. All the phases of cardiac cycle were reconstructed at 10% intervals.

Results :
1. Scan revealed 1.5 x 1 cm perforation in the mid posterolateral wall with a serpiginous myocardial dissection communicating with the pericardial space, resulting in a moderate circumferential hemorrhagic pericardial effusion. The LCX stent was patent on imaging. The patient underwent surgical closure of the rupture.

2. Scan revealed a 0.5 x 0.3 cm perforation in the mid posterolateral wall with a serpiginous myocardial dissection communicating with the pericardial space, resulting in a moderate circumferential hemorrhagic pericardial effusion. CTA revealed total occlusion of the OMI with significant disease in LAD and D1. CABG with patch repair of the myocardial perforation was performed.

Conclusions :
Myocardial rupture is a surgical emergency. It is imperative to make an early and comprehensive diagnosis to enable early intervention. This study illustrates the ability for dual source multislice CT (DSMSCT) to comprehensively evaluate such patients.

Keywords: Dual Source Multislice Computed Tomography, Myocardial Rupture.


Dr. S.K. Mishra, Dr. T.K. Mishra, Dr. P.K. Rath

M.K.C.G. Medical College & Hospital, Berhampur-760004, Orissa


Lower high density lipoprotein cholesterol (HDL-C) has been shown to be associated with a high risk of cardiovascular events and a greater burden of atherosclerosis, even among patients with lower low density lipoprotein cholesterol (LDL-C) levels. Aim of the present study was to assess the prevalence and prognostic significance of low HDL-C levels in a cohort of patients with non ST-segment elevation ACS (NSTEACS).

In this prospective one year study, 153 patients having ECG changes and / or positive cardiac marker were included. The patients were divided in two groups having very low HDL-C levels (10-29 mg/dL), low HDL-C levels (30-39 mg/dL), normal HDL-C levels (40-59 mg/dL) and high HDL-C levels (³60 mg/dL), based upon classification of HDL-C levels by the adult treatment panel III from the National Cholesterol Education Programme.

Factors associated with very low HDL-C levels included male gender [Confidence Interval (CI) : 2.05 - 2.20, Odds ratio (OR) : 2.1], higher serum triglyceride values (CI : 1.03 - 1.05, OR : 1.04), current smoking (CI : 1.25 - 1.35, OR - 1.30), diabetes mellitus (CI : 1.15 - 1.23, OR - 1.20), hypertension (CI : 1.13 - 1.24, OR - 1.18), prior myocardial infarction (CI : 1.01 - 1.09, OR - 1.05), and body mass index (CI : 1.05 - 1.09, OR - 1.06). The continuous distribution of unadjusted in hospital mortality rates by HDL levels demonstrated that the highest mortality were seen among patients are lowest HDL values.

Thus, patients with low HDL-C levels are more likely to be male, diabetic, obese and smokers and have adverse prognosis. Guidelines should be laid down for management of very low HDL-C levels in patients with NSTE ACS.

Keywords: HDL-C Levels, Non-ST Segment Elevation, Acute Coronary Syndrome

Non Dominant RCA Lesion And Sick Sinus Syndrome
G.C Patri, G.C Patri (Jr.), S.Mohanty
Goodwill Hospital , Rourkela


Sick Sinus Syndrome(SSS) is often considered as a degenerative disease of sinoatrial region. Vascular etiology is often overlooked in these cases. We present 2 cases of sick sinus syndrome with nondominant  RCA occlusion in the absence of clinical or electrocardiographic evidence of inferior myocardial infarction.

CASE1 CA , 46 M presented with h/o giddiness for 15 days. The resting heart rate was 49/min.ECG revealed frequent SA blocks. Holter monitoring revealed a minimum HR of 45 bpm and intermittent SA blocks. ECHO did not reveal any RWMA.In view of his young age , a reversible cause needed to be excluded and a coronary angiography was planned. It revealed a normal left dominant LAD ,LCX coronary system. However his  nondominant RCA was occluded 90%. The artery to the sinus node was not visualised. In view of a nondominant  narrow calibre of RCA, intervention was deferred and the patient was managed medically. He has remained asymptomatic over the last 2 months now.

CASE2 CS,65 M presented with light headedness for 1 month with a  heart rate  48/min and BP of 180/105 mm of Hg.He was put on ACE  inhibitors and diuretic. His ECG and subsequent Holter monitoring revealed sinus bradycardia  and several episodes of SA block. ECHO was unremarkable. Subsequent coronary angio revealed mid LAD 70% obstruction, normal dominant LCX but total occlusion of RCA.
One needs to be aware of nondominant RCA lesion presenting as SSS in absence of ECG/ECHO evidence of inferior MI.

Keywords: Non dominant RCA, Sick Sinus Syndrome, Inferior Myocardial Infarction.

Clinical Outcome and Angiographic Profile of Acute Myocardial Infarction in Smokers
Jain T Kallarakkal, P B Jayagopal.
Lakshmi Hospital, Palakkad.


Aims and objectives: This study was undertaken to analyze the clinical and angiographic profile and their in hospital outcome of patients who are smokers admitted with acute myocardial infarction (MI).

Materials and methods: In this prospective study we enrolled 200 patients admitted with acute myocardial infarction of which 100 were smokers and 100 were non-smokers.

Observations and analysis: All smokers admitted with acute MI were males and their mean age was 48 ± 11.6 years. Chest pain was the presenting symptom in 78%; dyspnea in 15% and 7 % had both. 14 % of this patient population were diabetics and 27 % were detected to be diabetics at the time of MI with mean HbA1C 7.8 ± 1.9. 36 % of these patients were hypertensives and 26 % had a family history of CAD. 71% of smokers had low HDL (mean HDL 28 ± 11.6 mg/dl) and 36 % had high triglycerides (mean 241 ± 78.7 mg/dl). 61 % had anterior wall MI, 36 % had inferior wall MI and 3% had true posterior wall MI. 81% received thrombolytic therapy with a window period of 2.1 ± 1.9 hours. 19 % had delayed presentation. Among those patients who received thrombolytic therapy 59 % had normal LV systolic function and 22% had LV dysfunction (mean EF 42 ± 4 %). Among the patients with delayed presentation 14 % had LV dysfunction (mean EF 32 ± 17.6 %). All the patients were subjected to coronary angiogram. 42 % of the patients had single vessel disease and remaining 37 % had multi vessel disease. 21 % patients had recanalised coronary arteries with no significant flow limiting disease. Multi vessel disease was seen in patients with diabetes or newly detected diabetics. Comparing these variables with non diabetics conventional risk factors like diabetes (67 %), hypertension (72 %), high LDL (73%), family history of CAD (36 %) and high total cholesterol (79 %) were higher in non smokers. 39 % of non smokers had LV dysfunction (mean EF 41 ± 26 %). Multi vessel disease was higher in this group (68%) whereas recenalised coronaries after thrombolytic therapy was 9 %. 4% had in hospital mortality in this group whereas no death in the smokers group.

Conclusions: Thrombotic occlusions are more common among smokers and they present relatively at younger age. Low HDL and high triglycerides had strong association with this subset of patients. Recanalisation of coronary arteries was significantly high (P<0.0001) with smokers. LV dysfunction was more in patients with anterior MI who presented later. Multi vessel CAD was more seen in patients with other risk factors especially diabetes.

Keywords: Acute Myocardial Infarction, Coronary Artery Disease, Smoker.

‘ANTERIOR PUNCTURE ONLY’ for radial artery cannulation during
Coronary Angiography : ROTATORY PUNCTURE technique

M.Ramanathan . Y.Vijayachandra Reddy


Background : Modified Seldinger technique for femoral artery cannulation is an established and preferred method to reduce the incidence of vascular complications like hematoma. Transradial coronary angiography (CAG) has become very popular now. Conventional Radial artery puncture involves ‘through and through’ puncture of the artery and withdrawal of the cannula to enter the lumen back for wiring. “Only Anterior puncture” technique is theoretically superior and may result in even lesser complications. Since radial artery is of small caliber, it is technically demanding. We evolved a ‘rotatory puncture’ technique for ‘only anterior wall’ puncture using the usual ‘cannula over needle’ system.  

Aims and methods: We prospectively analysed the success rate, complications (immediate and at 1 month follow-up) in 100 consecutive patients who underwent transradial CAG from January to May 2009. The technique and video recording of ‘rotatory puncture technique’ will be highlighted.

Results : The age of the study group ranges from 28 to 76 years. 56 patients underwent CAG as outpatients (Daycare angio) and 44 as inpatients. 68 patients were male; 32 were female. 90 patients had good volume pulse (subjective impression); 10 had weak pulse. We could accomplish ‘anterior puncture only’ in 94 cases. All the 6 cases where inadvertent through and through puncture occurred belong to weak pulse group. Anterior puncture could be accomplished in 4 patients of the weak pulse group also. There was no hematoma or arteriovenous fistula or nodule formation in any of the 85 patients who came for follow up. None in the anterior puncture group had loss of pulse while 2 in the through and through group had.

Conclusion : “ANTERIOR PUNCTURE ONLY” technique for radial artery cannulation is feasible in majority of the patients undergoing transradial CAG and should be the preferred approach whenever possible.

Keywords: Anterior Puncture, Radial Artery Cannulation, coronary Angiography, Rotatary Puncture Technique.


Nizam's Institute of Medical Sciences, Hyderabad


ABSTRACT: Coronary artery disease is a major health problem affecting middle-aged population. To detect, evaluate and prognosticate CAD, stress testing is good non invasive procedure, whereas coronary arteriogram (CAG) is very important to define the coronary artery lesion anatomically and plan the management. The present study was conducted in patients with positive stress test (with moderate to high probability for stress inducible ischemia) .A total of 184 patients were enrolled from January 2009 to June 2009.120 patients were males, 64 were females. Mean age of 55.68years. 68 were hypertensive , 52 were diabetics , 72 were smokers. CAG findings were 62 were normal, 50 were single vessel disease (SVD), 37 had double disease (DVD) and 24 had triple vessel disease (TVD), with LMCA + TVD in 11patients. The sensitivity of stress test was 34% in diagnosing coronary disease as shown in this study

Keywords: Tetralogy of fallot, Atrial Septal Defect, Tricuspid Stenosis.

“Evaluation of the role of Stand Alone Intra Coronary administration of Eptifibatide on short term outcomes of Percutaneous Coronary Intervention for Acute Coronary Syndrome”
B.Singh, R.Vishnu, A.Jain, A.K.Singh, S. Chandra, R.Sethi, S.K. Dwivedi, V.S.Narain, R.K. Saran, V. K. Puri
CSM Medical College, Lucknow, Uttar Pradesh


Introduction & Background - Platelet Glycoprotein (Gp) IIb/IIIa inhibitors are important part of pharmacotherapy in Percutaneous Coronary Intervention (PCI) especially for acute coronary syndrome (ACS). However there is hardly any data on the intracoronary (IC) use of these agent. We studied the safety and efficacy of IC administration of Eptifibatide during PCI for ACS.

Methods – Consecutive patients undergoing PCI for ACS were included in the present study. Three different dosing schedule of Eptifibatede were studied. Group A had IC eptifibatide 2 bolus 10 minutes apart (180 µg/kg) only, group B had IC 2 bolus 10 minutes apart (180 µg/kg) and IV infusion at 2 µgm/kg/min for 18 to 24 hours, and group C had IV 2 bolus 10 minutes apart (180 µg/kg) and IV infusion at 2 µgm/kg/min for 18 to 24 hours. Short term outcomes were recorded in the form of death, CKMB elevation >3 times, major bleeding upto hospital discharge or 7 days, whichever was earlier.

Results – A total of 95 patients were enrolled in the study. There were 84.2 % (n = 80) males and 15.8 % (n = 15) females and mean age of patints was 54.7 ± 15.3 years. Total number of patients in Group A, B and C were 30 (31.5 %), 40 (42.1 %) and 25 (26.3 %) respectively. Short term adverse outcomes occurred in 3.4%, 5 % & 8 % in Group A, B & C respectively. Major bleeding was similar in Group B & C (12.5 % & 16 %), however in both these groups, it was singnificantly higher than group A (3.4 %; p < 0.001).

Conclusion – We conclude that stand alone IC bolus Eptifibatide is efficacious and safe for use in ACS during PCI.

Key words:   Acute Coronary Syndrome, Eptifibatide, Intracoronary

Incidence and pattern of Myocardial Infarction in patients with Clinical Syndrome X
M Shafiq, R Meera, G Vijayaraghavan
Kerala Institute of Medical Sciences, Trivandrum.


Background: Most investigators consider clinical Syndrome X to be an innocent disease affecting women. Recent reports have shown that they are prone to develop acute myocardial infarction and consequent myocardial damage.

Aims: Study of clinical profile of Indian patients admitted for acute coronary syndrome (ACS) with ECG changes of ischemia during pain or stress test or elevated cardiac markers, but had normal coronary angiogram.

Subjects and methods: During a 12 month period from January 2008 730 patients admitted for ACS had coronary angiogram. 70 of them had normal coronaries. They had abnormal ECG during pain or on TMT test. Detailed physical examination, cardiac markers, ECG, Echo Doppler Studies and risk factors for ischemic heart disease were analysed.

Results: 39 (55.72%) were females and 31 (44.28%) males. Hypertension was present in 44 (62.85%), Type 2 Diabetes Mellitus in 27 (38.57%), and Dyslipidemia in 38 (54.28%). Angina was present in 53 (75.71%) and dyspnea in 28 (40%). 37 (52.85) had abnormal ECG findings and T wave inversion was seen in 31(44.28%) patients. Significant elevation of Troponin T was seen in 7(10%) and CPK-MB in 4 (5.7%) patients. 2D Echocardiogram demonstrated normal Left Ventricular ejection fraction in 68 (97.14%) patients. Regional wall motion abnormalities correlated with changes in cardiac markers. Average hospital stay was 5 +/- 2 days.

Conclusion:  We found that patients with Clinical Syndrome X and ACS can develop acute myocardial infarction with significant myocardial injury and this disease should not be considered as an innocent disease.

Keywords: Acute Coronary Syndrome, Clinical Syndrome X, Acute Myocardial Infarction.

Angiographic Profile of significant Left main coronary artery ( LMCA)stenosis – Report of 118 cases.
Dr Malladi Srinivasa Rao, Dr B Adilakshmi , Dr D srinivasa Rao, Dr C Ravi Venkatachelam ,
Dr S Abbaiah, Dr G V Reddy, Dr P Ramana Rao, Dr A Suresh,
Dr KP Hemamalini , Dr Purnachandra Rao

Institution – Dept of Cardiology, Andhra Medical College, King George Hospital, Visakhapatnam.


Aim : To analyse the cases of significant LMCA obstruction( 50% of more diameter stenosis) who underwent angiography  at King George Hospital , Visakhapatnam from Jan 2007 to June 2009.

Methodology : We retrospectively analysed the data of patients who underwent angio at King George Hospital , Visakhapatnam.Of the 1911 cases of Signicicant coronary artery disease LMCA stenosis was seen in 118 cases ( 6.1%). Male /Female ratio – 93 / 25.Of them 68.4% were hypertensives, 41.5% were diabetics, 34.7% were smokers. Mean age of presentation was 59 yrs ( 23 – 80).. Isolated LMCA involvement seen in 4 ( 3.3%) , associated single vessel disease in 9 ( 7.6%) , double vessel disease in 12 ( 10.1%), triple vessel disease in 93 ( 78.8%).Proximal / ostial involvement is seen in 21 ( 17.8%), mid part in 13 ( 11 %), distal  in 83 ( 70.3%) and total occlusion in 1 case

Conclusions: Significant LMCA involvement is seen in 6.1% . In majority of cases it is associated with triple vessel disease and distal segment is the commonest site of involvement.    

Keywords: Coronary Angiography, Left Main Coronary Artery, Coronary Artery Disease.

Tenecteplase in acute STEMI –KIMS experience
Dr Rajendra Kumar Jain, Dr. Dayasagar Rao, Dr. T. N.C. Padmanabhan, Dr. Sachin, Dr. Vinay, Dr. Sudam Jare
Dept. Of Cardiology, KIMS, Secunderabad


Aim: Our experience with 3 rd generation thrombolytic (Tenecteplase) in acute STEMI in Indian population.

Methods: Retrospective analysis of 43 patients of acute STEMI who received weight adjusted dose of Tenecteplase was done. All patients received anticoagulants and antiplatelets along with thrombolysis and concomitant medications like ACE inhibitors, beta blockers, statins. Efficacy of lysis was assessed by >50% ST segment resolution in ECG, relief of chest pain at 90 minutes & culprit vessel TIMI flow by coronary angiogram. Recurrence of symptoms, MI, stroke, arrhythmias and mortality were also assessed.

Results: Out of 43 patients of STEMI who received tenecteplase,37  male,6 female. Age range 30-88yrs, (mean 57.5 yrs). Window period varied from 30 minutes to 12 hrs, mean 3hr 45 minutes. 44% patients diabetic, 35% hypertensive, 14%  smoker. Reperfusion rate as indicated by > 50% STR at 90 minute was 69%, pain relief was 81%.Coranary angiogram was performed in 26 patients of which 61% had TIMI 3 flow, 8% TIMI 0. Reinfarction was found in 9.3% patients. Mortality was 13.95%. One patient had upper GI bleed, no ICH noted. All 6 patients which died had severe LV dysfunction. No significant MR or VSD noted.

Conclusion:Tenecteplase is safe and effective thrombolytic agent in STEMI in our population. Symptom to needle time upto 3 hrs result in best response. Adjunctive anticoagulant is must. Prehospial thrombolysis is feasible

Keywords: Tenecteplase, ST Elevation Myocardial Infarction, Thrombolysis.

Door- to -Needle Time: Where do we lose time?
Suma. M. Victor, Sushanth, Anand Gnanaraj, Archana. C, Mullasari Ajit S.
Institute of Cardiovascular Diseases, Madras Medical Mission, Chennai


Objective: To assess and evaluate whether the recommended door-to-needle (DTN) time of 30 minutes (min) for thrombolytic administration in STEMI patients can be achieved, to identify reasons associated with a prolonged DTN time.
Methods: Our study was a prospective study of 46 consecutive patients who were thrombolyzed for STEMI at our hospital from August 2008 to July 2009. From door to needle, time was divided into 4 stages; any delay and the reason for delay were studied. Data was analyzed using SPSS version10.0.

Results: The average DTN time was 37.74 min (SD= 19.37). DTN time <30 min was achieved in 63 %( 29), >30 min occurred in 37 %( 17). Average Door to ECG time was 6.06 min (SD= 3.6), average time taken for decision of thrombolysis by the CCU team was 7.51 min (SD= 10.5), average time taken for the patient’s consent was 17.07 min (SD= 14.93), average time taken to start STK was 5.28 min (SD= 1.9). Out of the DTN time >30 min group, hospital related delay occurred in 11.7% (2), patient related delay was responsible in 88.3% (15). Out of the Patient related issues, 100% delay occurred due to the time taken to decide between Primary PCI or thrombolysis. (financial reasons). There was significant delay between the patients treated in the morning time and night time, and during the week days and week end, (OR 3.2, 95% C.I, .82-12.6, OR 1.47, 95% C.I, .33-6.4, respectively). Total mortality: 4.3%, all patients were in the >30 min group, (OR=1.133, 95% C.I, .953 -1.348).

Conclusions: DTN time of <30 min could be achieved in majority of patients in our study. The delay in DTN time was mainly due to decision making between primary PCI or thrombolysis (financial reasons, which we also attribute to the delay of DTN time between morning and night, between week days and week ends). Prolonged DTN time is associated with significant mortality rise

Keywords: Door-TO-Neelde Time, ST Elevation Myocardial Infarction, PCI.

Role of endothelial function in coronary slow flow
phenomenon with angiographically normal coronaries.
S Nathani, S Mukhopadhayay, S. Tyagi, V Trehan, V Goyal,Girish MPl G. B. Pant Hospital, New Delhi, India
G. B. Pant Hospital, New Delhi, India


Background: Coronary slow flow phenomenon (CSFP) is not a benign phenomenon and has been associated with recurrent angina & sudden cardiac death but its etiopathogenesis remains unclear.

Aims and objectives: To evaluate the role of endothelial function in patients with coronary slow flow (CSF) and to compare them with patients with normal coronary flow.

Methods : Patients >18 years of age who present with history of angina, whose CAG reveals normal coronaries with slow flow were included in the study. 28 consecutive patients with angiographically proven CSF and angiographically normal coronary arteries (group 1) were compared with 28 patients who presented with chest pain & have normal coronary arteries (group 2). Patients with slow flow phenomenon were assessed for carotid intimal medial thickness (IMT), brachial artery hyperemic studies and hs- CRP levels.

Results: No significant difference was found in the hs-CRP levels between the two groups. CIMT was found to be significantly more in patients with CSF group that in patients with normal coronary arteries with normal coronary flow (NCF group). Percentage of endothelial dependent dilatation in patients with CSF group was significantly smaller than in NCF group. The percentage of nitroglycerine (NTG)-induced dilatation was not significantly different between patients with SCF and patients with NCF.

Conclusion: These findings suggest that endothelial function is impaired in patients with slow coronary flow.

Keywords: Endothelial function, Intimal Medial Thickness, Coronary Slow Flow Phenomenon Angiographycally

4b/4a polymorphism of eNOS associates with acute coronary syndrome
Amandeep Markan, MD Gupta, MP Girish, Ritankur Barkotoky, QA Pasha,Tyagi S. Department Of Cardiology,
G.B.Pant Hospital and Institute of genomic and Integrative Biology Mall Road , Delhi.


Aim : Objective: Endothelial nitric oxide synthase (NOS3) gene polymorphisms are considered potential genetic risk factors in cardiovascular diseases. The aim of this study was to investigate the contribution of the 4b/4a polymorphism in acute coronary syndrome (ACS).

Methods: In a case-control study, 450 consecutive ethnically-matched unrelated subjects comprising 320 controls and 130 patients were recruited at GB Pant hospital. The NOS3 4b/4a polymorphism was PCR amplified; genotyping was done by 15% PAGE to differentiate the three genotype-based products: 420bp for 4bb, 420bp & 393 bp for 4b/4a, and 393 bp for 4aa.

Results: Allele The genotype and allele frequencies of the 4b/4a polymorphisms were in HWE in both the groups. Genotype distribution differed significantly with 62% vs 73% for 4bb, 29% vs 21% for 4ba and 9% vs 6% for 4aa in patients and controls (χ2=5.9, df = 2, P<0.05), respectively. Further, the 4aa homozygotes showed the highest risk to ACS compared with 4bb homozygotes (OR = 2.2, Wald’s 95% CI = 1.1–4.8). Additionally, 4ba heterozygotes also showed 1.6 times higher risk of ACS than 4bb carriers (OR = 1.6, Wald’s 95% CI=1.0–2.6, P<0.03;). As a consequene, the alleles also differd significantly (χ2 = 6.7, P=0.009); the 4a allele being overrepresented in patients conferring greater risk of ACS (OR=1.6, 95% CI = 1.1–2.3).

Conclusion: The 4aa genotype and 4a allele of NOS3 4b/4a polymorphism confer risk by associating with ACS susceptibility.

Keywords: Endothelial Nitric Oxide Synthase, 4b/4a Polymorphism, Acute Coronary Syndrome.

Metabolic syndrome in patients of acute coronary syndrome :
revised anthropometric criteria in a north Indian
population subgroup. Are we any wiser?

V. Jain, R. Mathur, , R. Thakur, CM Varma, M Ahmad, RPS Bhardwaj, RK Bansal,
LPS Institute of Cardiology, Kanpur.


Objective: To evaluate the prevalence of metabolic syndrome in patients of acute coronary syndrome using old as well as revised anthropometric criteria for waist circumference  in a predominantly north Indian population.

Methods: We evaluated 239 indoor patients of acute coronary syndrome for the presence of metabolic syndrome using NCEP ATP III CRITERIA with two sets of criteria for waist circumference 1) males ≥ 102 cm & females ≥ 88 cm (old  NCEP ATP III criteria) 2) males ≥ 90 cm & females ≥ 80 cm ( revised IDF ethnic specific criteria ).
Observations:  A total  of 239 patients (males = 190, females = 49 ) of acute coronary syndrome admitted in the time period from feb 2008 to may 2009 were evaluated for the presence of metabolic syndrome. Using old criteria,  metabolic syndrome was diagnosed in 83 patients (34.73%) which included 49 males (20.5%) and 34 females ( 14.23 %). Using revised criteria for waist circumference, metabolic syndrome was uncovered in 119 patients ( 49.79 %) which included 80 males (33.47 %) and 39 females ( 16.32 %), thus uncovering a significantly higher number of cases at high risk of cardiovascular events which were not identified using older non ethnic specific criteria.

Conclusion:  Application  of revised ethnic specific anthropometric criteria for the diagnosis of metabolic syndrome results in better identification of north indian patients at high risk of cardiovascular events. These proposed alterations in criteria will help make metabolic syndrome a more accurate predictor of cardio- vascular disease risk in different population groups.

Keywords: Metabolic Syndrome, Acute Coronary Syndrome, Anthropometric criteria..

S.Venkatesan ,Krishnakumar,. Murugan, Madhuprabhudoss, G.Gnanvelu R..Subramanian,
Geetha Subramnainan, B.Ramamurthy , P.Arunachalam .M.Somsundram,

Madras Medical College. Chennai


The primary goal in management of STEMI is early restoration of myocardial perfusion . Ironically ,angiographic IRA patency is often taken as a surrogate marker for successful myocardial reperfusion in spite of poor correlation between the two. It is generally believed no reflow occurs mainly in cath lab following primary PCI . But it is a less appreciated fact , that it can also occur following thrombolysis. The aim of this study is to estimate the incidence of no reflow (Which is synonymous with failed reperfusion ) in STEMI following thrombolysis. 117 patients with AMI who were thrombolysed in our coronary care unit between 2008 and 2009 were the subjects of study. All received streptokinase as per protocol. Patients with history of old MI ,LV dysfunction were excluded. Patients who received late thrombolysis (> 12 hrs) were also excluded. Echocardiographic assessment of infarct segments were done between 24h to 1 week. Coronary angiogram was done between 72 hours to 1 week following AMI. Thrombolysis was considered to be successful only if the IRA was at least 70% patent with or without a plaque or luminal irregularity. Reperfusion was deemed to be failed if the patient showed any of the following 1. Persistent ST elevation 2.Presence of more than two akintic infarct segments 3. Wall motion index > 3, 4.Ejection fraction < 40% . 5. Less than TIMI 3 in IRA and blush in myocardium .Of the 74 patients who had successful thrombolysis 23(30%) patients fulfilled the criteria for failed myocardial reperfusion.It should be noted here the ECG criteria of regression of ST elevation predicted myocardial reperfusion better than CAG. The mechanism for failed reperfusion is attributed to 1.clogging of myocardial capillary circulation from the debri of dissolved thrombus .2.Interstitial myocardial edema.3.Micro vascular necrosis. These cause an epicardial myocardial dissociation and result in a paradox of “Open artery but closed myocardium”

We conclude successful thrombolysis per se cannot be considered as a positive outcome in STEMI. A significant subset of (30% in this study) patients with patent IRA failed to achieve myocardial reperfusion due to no reflow. This has great therapeutic implication and impacts the long term outcome .

Keywords: ST Elevation Myocardial Infarction, Thrombolysis, Angiography.

Predictors of Vascular Events after Carotid Artery Stenting: 6month follow up
Suma. M. Victor, Ida Mercelin Leo, Anand Gnanaraj, Anand Kumar, Rajendra Deshmukh, Mullasari Ajit.S.
Institute of Cardiovascular Diseases, Madras Medical Mission, Chennal, Tamil Nadu


Objectives: Cardiovascular events appear to complicate the post procedural period in carotid artery stenting. We sought to assess the predictors of these events at 6month follow up in patients who underwent carotid artery stenting.   

Methods: 32 patients who underwent carotid artery stenting from 2007 to 2008 were enrolled into the study. All patients underwent detailed historical as well as neurological and physical examination pre and post procedurally. All the various clinical, morphological, and procedural determinants were analyzed and the predictors of vascular events were identified using Odds Ratio.  

Results: The mean age of the patients was 63.7±10 years, 75% (24) were males, and 25% (8) were females. Only 9.3% had symptoms attributable to the lesion treated. 62.5% preexisting coronary artery disease, 21% had bilateral carotid disease. At 6 months, death occurred in 3.1% (1), 12.5% (4) were hospitalized with cardiac ischemia; neurological events were noted in 9.3% (3). Significant predictors of events at 6months were- preexisting neurological deficit, peri procedural hypotension, bilateral carotid disease, chronic kidney disease and LDL > 100.

Predictors of events at 6 months

Odds ratio


Preexisting neurological deficit



Periprocedural hypotension



Bilateral carotid disease



Chronic kidney Disease



LDL >100



Conclusions: At 6 months various factors predicted higher risk of cardiovascular events. Identifying these factors may help in proper patient selection in carotid artery stenting.

Keywords: Endothelial Nitric Oxide Synthase, 4b/4a Polymorphism, Acute Coronary Syndrome.

Intensive Antithrombotic Pharmacotherapy In High Risk Acute Myocardial Infarction
Sudhir Varma,Harpreet Singh Kalra, RPS Sibia, Balbir Singh, U Kaul.
Sadbhavna Medical and Heart Institute, Patiala


High risk acute MI (with cadiogenic shock, pulmonary edema, Echo LVEF <0.40, malignant ventricular arrhythmias , failed thrombolysis) carries very high mortality and morbidity.
                35 Consecutive high risk MI patients received within 12 hours of acute event have  been enrolled since October 2009. They have been divided into Group 1- Intensive therapy  (n=18; 13M, 5F; age 53±10 years), who received streptokinase , 1.5 million units I.V, clopidogrel 600 mg stat, 75 mg/day, Aspirin 325 mg stat and 150 mg/day, tirofiban I.V 0.4 mcg/kg/min for 30 min and later 0.10 mcg /kg/ min upto 48 hours and enoxaparin 60 mg s/c b.i.d. Group II-Usual therapy (n=17; 11M, 6F; age 50±11) received 1.5 million units of streptokinase , 300 mg clopidogrel stat, 75 mg/day, 325 mg aspirin stat & 150 mg/day, and enxoparin 60 mg s/c b.i.d. The 30 days results are depicted in table 1.

High Risk MI (n=35) Intensive drugs group 1 (n=18 Routine drugs Group II (n=17)
Death 4 6*
Recurrent MI 1 3*
Stroke - -
Revascularization 5* 3
Major Bleed 2* -
Assisted ventilation 6 8*
IABP 6 6

*p<0.05    Table 1:  Intensive Antithrombotic therapy in High Risk MI .
The strategy of aggressive antithrombotic drug therapy can result  in reduced morbidity and mortality with acceptable bleeding risk in high risk acute MI patients. 

Keywords: High risk, Acute MI, Cadiogenic Shock, Pulmonary Edema, Malignant Ventricular Arrhythmias, Failed Thrombolysis.