ISSN 0019-4832

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Nizam’s Institute of Medical SciencesPanjagutta, Hyderabad - 500082Tel. No: 040-23302426, Mobile: 09848804212e-mail: saratkoduganti@yahoo.co.in

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ISSN 0019-4832

(ISSN 0019-4832)

Suman Bhandari

V Jacob Jose

Peeyush Jain, Sameer Shrivastava,

S Radhakrishnan, A Saxena

K Subramanyam

Dr. Pankaj Manoria

Param Puneet Singh

91-9911113738

Room No. 212

Department of Cardiology

Escorts Heart Institute and

Research Centre

Okhla Road, New Delhi – 110025

Tel: 26825000, 26825001

Telefax: 91-11-26825013

e-mail: sumanbhandari@yahoo.com

Sanjay K Singh

Elsevier

A division of Reed Elsevier

India Pvt Ltd

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New Delhi – 110065

Thomson Press (I) Ltd

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RN 2857/57

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Children’s Heart Care Centre, Sri Jayadeva Institute of Cardiology, Bangalore, India

Recent developments in the field of Pediatric cardiac surgery and Pediatric Cardiology especially non surgical transcather interventions have changed the pre-operative or pre-procedure diagnostic workup of the cardiac malformations. In many centres, this is achieved and based exclusively on Echo findings in some patients. In our centre too, pattern of children taken up for cath study has changed in the last 2 decades. The aim of this study was to determine the impact of changing trends due to advancement in Echo and interventions in children and to know the changing pattern of cath study in CHD. 2329 cases who underwent cardiac catherization between Jan 1998 and July 2007 formed the material for the study. The percentage of various heart diseases are given below and it was compared with the earlier data of 3790 cases of consecutive catheterizations done from 1981 to 1994 in the same centre.

Congenital April 1981–April 1994 Jan 1998–July 2007 heart disease (No. 5 3790) (No. 5 2329)Atrial septal defect 1479 (39%) 225* (9.8%)Ventricular septal defect 730 (19.3%) 5691 (24.8%)Pulmonary stenosis 377 (9.9%) 198§ (8.6%)PDA 177 (4.7%) 328† (14.4%)TOF 334 (8.8%) 533 (23.3%)TAPVC/PAPVC 71 (1.9%) 80 (3.5%)COA 62 (1.6%) 47 (2.2%)CTGV 56 (1.5%) 27 (1.3%)RSOV 50 (1.3%) 7 (0.3%)Miscellaneous 388 (10.2%) 270 (11.8%)

Children’s Heart Care Centre, Sri Jayadeva Institute of Cardiology, Bangalore, India

Transcatheter percutaneous device closure of ASD, VSD, PDA, PFO and other unusual shunts like AP window and RSOV is a safe, effective, and attractive alternative to surgery. Successful closure rate is very high and complication rate is very low. The aim is to know the incidence of very rare and unusual complications of Amplatzer device closure and their management. Out of total 136 cases; 42 were males, 94 were females. The youngest was 4 months old, case of PDA weighing 3.9 kgs and the oldest was a 65 years old case of ASD. Device closure was done in 97 cases of PDA, 33 cases of ASD, 5 cases of VSD and one case of ALVT. Thrombus on the device occurred in 2 cases (1.6%). The patient who developed acute thrombus soon after deployment, developed convulsions, occulogyric crisis, and died of shower of emboli to the brain within 18 hours after the procedure. Another one presented with headache and persistent vomiting, 3 weeks after device closure, made complete recovery with antiplatelet and anticoagulants. One patient with multiple VSD closed with single large 14 mm Amplatzer septal occluder, through Jugular approach,; developed transverse sinus thrombosis (0.8%). CT angio showed complete recovery with medical management. Severe intravascular hemolysis after transcatheter closure of a large PDA using the ADO is reported in literature. But none of our PDA patients had this complication. However, severe hemolysis occurred in a case of Aortico ventricular tunnel closed with 16 3 14 ADO (0.8%). Hemolysis subsided after 5 days. Device embolisation into aorta is very rare, as aortic pressure is higher than pulmonary artery. In a case of PDA, severe PH, as soon as the screw was released the device shot into the aorta. Device was pushed into left common iliac artery, screw fastened into device and retrieved in a novel way. Though kinking of the sheath occurs often it is overcome easily but multiple acute kinking of introducer sheath making the device closure impossible (0.8%). Kinking problem was overcome by using Cook’s sheath over the Mullin’s dilator. The device was negotiated by side of guide wire. The wire was withdrawn just before the deployment of the device. To conclude, success rate of Amplatzer device closure in usual and unusual shunts is very high and the complications are extremely rare. Timely detection of unusual complications and management is crucial in further reducing morbidity and mortality.

Department of Cardiology, Nizam’s Institute of Medical Sciences, Hyderabad

Efficiency of various aerosolized nitric oxide donor drugs (nitroglycerin and sodium nitroprusside) in selectively reducing pulmonary artery pressure and pulmonary vascular resistance has been demonstrated in various animal studies, but human studies on the role of inhaled nitric oxide donor drugs in the treatment of pulmonary arterial hypertension (PAH) are limited. Therefore, we studied the acute effects of inhaled nitroglycerin on pulmonary and systemic vascular haemodynamics in children with PAH associated with congenital heart disease. Fifteen children with acyanotic congenital heart disease and a left to right shunt with severe PAH, undergoing cardiac catheterization were included in this study. Systolic, diastolic and mean systemic as well as pulmonary artery pressures, right atrial pressure and pulmonary capillary wedge pressure (PCWP) were recorded and systemic vascular resistance index (SVRI) and pulmonary vascular resistance index (PVRI) were calculated at room air, following 100% oxygen as well as after nitroglycerin inhalation in all patients.

Seven patients responded to both oxygen and nitroglycerine. Eleven responded to nitroglycerine alone and four did not respond to both. There

Indian Heart J 2007; 58: 391–393

Clinical Base Post Post Pparameters Line (a) O2 (b) NTG (c) value

Systemic MAP 78.7 6 9.1 77.9 6 9.2 73.9 6 8.4 NS

Pulmonary MAP 71.1 6 11.7 65.0 6 15.4 53.8 6 15.8 , 0.01 (a-c)

MAP RATIO 0.9 6 0.1 0.8 6 0.2 0.7 6 0.2 , 0.05 (a-c)

QP 5.1 6 2.2 1 2.8 6 12.6 13.9 6 11.8 , 0.05 (a-c)

QP/QS 1.5 6 0.6 3.5 6 3.2 4.0 6 3.0 NS

SVRI 25.7 6 4.1 25.7 6 4.3 25.2 6 3.3 NS

PVRI 17.0 6 6.1 12.3 6 9.4 8.6 6 8.1 , 0.05 (a-c)

PVRI/SVRI 0.7 6 0.2 0.5 6 0.4 0.3 6 0.3 , 0.05 (a-c)

% Change PVRI 238.4 6 39.0 256.8 6 33.4 , 0.05 (b-c)

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was no patient who responded to 100% oxygen and did not respond to nitroglycerine inhalation. To conclude, inhaled nitroglycerin significantly decreased pulmonary systolic, diastolic and mean artery pressure as well as PVRI without affecting systemic haemodynamics, and thus can be used as a therapeutic modality for acute reduction of PAH in children with congenital heart disease. Surgical outcome of cardiac patients with shunt lesions with severe PAH who show decreased indices of pulmonary vascular resistance with nitroglycerine inhalation needs to be studied.

Department of Cardiology, Srichitra Tirunal Institute of Medical Sciences & Technology, Trivandrum, Kerala, India

The aim of this study was to determine the predictors of short and long term outcome of patient who had undergone surgery for Atrial septal defect (ASD) and mitral valve disease. Seventy-one consecutive patients who were operated in our institution from January 1991 to January 2007 with ASD and mitral valve disease (Rheumatic/mitral valve prolapse) were retrospectively studied. Patients with ostium Primum ASD and cleft AML were excluded from the study. The cohort was divided in to ASD-Mitral stenosis (ASD-MS) (20 patients) and ASD-Mitral regurgitation (ASD-MR) (51 patients). The basal NYHA functional class, rhythm, electrocardiographic and echocardiographic parameters, cardiac catheterization data (done in 35) and operative outcomes (death, need for prolonged inotropic support, duration of ventilation, bleeding, arrhythmias, stroke) of both groups were compared. The long-term follow up data were also compared. Patients in the ASD-MR group had worse functional status, more severe pulmonary arterial hypertension and features of congestive heart failure as compared to the ASD-MS group (p , 0.05). The indexed left ventricular end systolic diameter (iLVESD) was significantly higher in the ASD–MR (18.74 6 5.7 v/s 20.31 6 8.5) and higher number of patients had tricuspid valve regurgitation in the ASD-MR (37 v/s 32) group. There was no other significant difference in both the groups in other parameters. Patient in the ASD-MR group required surgery at a younger age (p , 0.002). However, patients in the ASD-MS group had worse immediate post operative outcome in the form of death (2 v/s 0), need for prolonged inotropic support (7 v/s 3). The prolonged inotropic support in the ASD-MS group was related to the lower iLVESD. Both the groups had similar outcome after the immediate post operative period and on long term (6 years). To conclude, even though ASD and MS or MR has similar hemodynamics the ASD-MR group is more at presentation. But this group fare better then the ASD-MS group because of the larger LV size. After the immediate post operative period however, both the groups had similar long term results.

Institute of Cardiovascular science, IPGME&R, Kolkata

Percutaneous closure of PDA is done usually by coils or the duct occluder. We have been using Amplatzer duct occluder (ADO) for a long time and its safety and effectiveness have already stood the test of time. Its main problem is its cost constrain which precludes its use in many cases in the economically challenged country like India. Another duct occluder, Blockaid is now available. Its design and deployment technique are similar to ADO but is more economical. We have enrolled last 30 patients for this study where we have used this device to asses its safety, efficacy, and ease of deployment. Mean age of the patients was 5 years (7 months to 58 years). Mean narrowest diameter of the ductus was 6 mm (4 mm to 12 mm). Mean pulmonary artery pressure was 40 mm of Hg (30 mm to 62 mm of Hg). The device was deployed in the usual anterograde route. Average reusability of the delivery cable was 15 times and the long sheath was 5 times for further cost containment. We did not face any technical problems during deployment. There was no mortality or any major complications. Loss of femoral pulse was found in 1 patient. All the patients had immediate complete closure of the shunt. During the follow-up (3 months to 2 years), there were no complications like late embolization, recanalization or obstruction across the descending aorta or pulmonary artery. We found this device for transcatheter PDA closure, to be safe and effective.

Department of Cardiology, Sri Sathya Sai Institute of Higher Medical Sciences, Bangalore

In patients of left to right shunt lesions with severe PAH who have "borderline" hemodynamics, decision about surgery is difficult. Temporary balloon occlusion of the ASD, VSD or PDA, with subsequent measurement of left and right heart filling pressures and pulmonary and systemic haemodynamics, has been performed as a more physiological method to assess operability and to predict post operative haemodynamics. We here present the data on 8 patients who showed good response to balloon occlusion of shunt lesion and were successfully operated. In all 8 cases; 4 PDAs, 2 VSDs (both perimembranous), and 2 OS ASDs with severe PAH were studied. Detailed clinical examination, ECG, Chest X ray, Echo, and colour doppler studies were performed. Cardiac catheterisation studies were performed in all patients with assessment of pulmonary and systemic haemodynamics and oximetry performed in the basal state, post oxygen inhalation and post balloon occlusion of the shunt. Assessment of patients post operatively on day 0, at discharge and 3 to 6 months after discharge by clinical examination and echo was done. Balloons used were Pulmonary wedge catheter (Arrow™) balloon for PDA, Accura (Vascular concepts™) mitral commisurotomy balloon for ASD and 1 case of VSD and Tyshak balloon for 1 case of PDA and 1 case of VSD.

Parameter PDA VSD ASD

AGE (years) 2, 11, 20 & 29 4 & 12 20 & 27

– mean systemic BP (mm Hg) 94.75 93.5 90

– mean PAP (mm Hg) 81.75 80.5 53

– mean PVRI (units) 11.87 13.85 9

– mean Qp:Qs 1.3 1.4 1.4

– mean systemic BP 96 93.5 86

– mean PAP (mm Hg) 79.7 73.5 45

– mean PVRI (units) 7.1 7.2 6.8

– mean Qp:Qs 3 2.5 2.3

– mean systemic BP 93 94.5 85

– mean PAP (mm Hg) 64 34.5 31

– mean PVRI (units) 5.1 4.9 3.9

– mean Qp:Qs 1.4 1.15 1.4

All patients underwent surgical closure of the shunt and had uneventful immediate post operative period and on 3 and 6 month follow up showed complete regression of pulmonary artery hypertension and good biventricular function. To conclude, reversibility of severe pulmonary

392 Congenital Heart Disease Indian Heart J 2007; 58: 391–393

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artery hypertension in congenital left to right shunt lesions can be reliably and effectively assessed by temporary balloon occlusion study during cardiac catheterisation with additive value to oxygen inhalation. Studies have shown that temporary balloon occlusion reproduces the post operative haemodynamics in a more physiological manner than oxygen or nitric oxide inhalation or other vasodilators. Temporary balloon occlusion is a safe, inexpensive, reliable procedure that can be performed with ease in most of these patients in most catheterisation labs with basic facilities.

Govt Medical College/GND Hospital, Amritsar, India

Familial dextrocardia is a rare entity. We present a family of 7 members (5 brothers and 2 sisters) with 3 brothers (no sister) having dextrocardia with situs inversus and other associations. Two brothers aged (32 and 40 years) presented to us with shortness of breath/palpitation and cyanosis. Both had a history of sinusitis, wheezing chest and purulent expectoration. Both were found to be having dextrocardia with situs inversus with features of frontal sinusitis and bronciectasis with cor pulmonale (Kartagener’s syndrome). Detailed echo did not reveal any congenital heart abnormality. On screening of other family members, the elder brother (57 years old) was also found to be having dextrocardia with situs inversus. He had moderate systolic hypertension. On IVP he was found to have both the kidneys on the right side although functionally they were normal. His detailed color Doppler Echocardiography also did not reveal any congenital heart abnormality. To conclude, three cases of dextrocardia with situs inversus occurring in the same family and presenting with Kartagener’s syndrome in two and moderate hypertension with ectopic kidney in the third one with no associated congenital heart abnormality in any of them are being presented because of the rarity of this type of familial dextrocardia.

Department of Cardiology, Nizam’s Institute of Medical Sciences, Hyderabad

Many factors have been recognized to be causally related to Endothelial dysfunction (ED). Hypoxia has also been related to ED through laboratory studies. Children with cyanotic congenital heart disease (CCHD) provide a unique opportunity to study the effect of chronic hypoxia on endothelial function in vivo in the absence of other confounding factors such as hypertension, smoking etc. The study population consisted of 24 children aged between two years and twelve years, 14 of whom had CCHD and 10 had acyanotic congenital heart disease (ACHD) without pulmonary arterial hypertension. Systemic oxygen saturation was assessed noninvasively with a pulse oximeter. Echocardiography was done in all children for confirmation of the diagnosis and assessment of pulmonary artery pressure. Endothelial function was assessed by measuring flow mediated dilataton (FMD) in the right superficial femoral artery (SFA) using ultra sound imaging. Statistical analysis was carried out using unpaired t-test. The mean baseline SFA diameter was 0.34 cm and 0.33 cm in the cyanotic and acyanotic group respectively, with a nonsignificant p-value. The mean baseline flows were 12.5 and 12.15 ml/min and the post release flows were 59.4 and 100.66 ml/min in cyanotic and acyanotic groups respectively with non significant p-values. FMD was significantly lower in the cyanotic group compared to the acyanotic group (9.5% and 15.6% respectively) with the p-value being , 0.005. To conclude, the study demonstrates that there is significant endothelial dysfunction in children with cyanotic congenital heart disease. In the absence of other common confounding variables, the endothelial dysfunction in these children is most probably related to chronic hypoxia. Hence, hypoxia may have a cause and effect relationship with endothelial dysfunction. Finally the role of endothelial dysfunction in the increased incidence of cerebrovascular events in CCHD patients needs to be further studied to open new avenues of treatment in order to reduce the incidence of these unfortunate events.

Department of Cardiology, Nizam’s Institute of Medical Sciences, Hyderabad

Tetralogy of Fallot (TOF) is known to be associated with anomalies in the origin and/or course of coronary arteries.which can add significantly to morbidity and mortality during surgical repair and need to be clearly delineated. We studied the incidence and pattern of coronary anomalies in patients with TOF who has undergone cardiac catherization in our centre. From Jan 2006–April 2007, 133 patients with TOF who underwent cardiac catheterization and angiography were included in this study. All patients underwent aortic root angiography in the left anterior oblique view. In patients in whom coronary anatomy could not be clearly delineated by the aortogram, selective coronary angiography in multiple views was performed. The noted coronary anomalies are shown below:

Table 1 Distribution of different coronary anomalies (n 5 26)

Type of anomaly Number (26)

High origin of right coronary artery from right sinus 9 (34.6%)

Single coronary artery from left coronary sinus 8 (30.7%)

Anterior descending artery from right coronary artery/sinus 4 (15.3%)

Single coronary artery from right coronary sinus 4 (15.3%)

Accessory anterior descending artery from right 1 (3.8%) coronary artery/sinus

To conclude, we noted from our study that the coronary artery anomalies are commonly associated with TOF. Most common anomaly was high origin of right coronary artery from right sinus followed by single coronary artery from left coronary sinus.

Institute of cardiovascular science, IPGME&R, Kolkata

Cerebrovascular accident (CVA) is a rare but ominous complication of congenital cyanotic heart disease (CCHD). It affects not only the natural history by mortality or morbidity, but also cause psychological handicap. In this retrospective study, we included 63 CCHD children (6 months–6 years), among 314 (3 months–42 years) children with CCHD admitted to our tertiary care center in Kolkata, between 2001 and 2006. Among the total series, we found 18 cerebrovascular accident affected children all of whom were in this specified age range (6 months–4 years). Four children, who had concomitant Infective endocarditis, were excluded from study as there was a possible embolic source for CVA. Hemogram of remaining 14 cerebrvascular affected patients (Hemoglobin(g/dl) 16.9 6 1.8, packed cell volume(%) 57.5 6 4.9, MCV(fl) 72 6 8, MCH(g) 23.7 6 7.6, MCHC(g/dl) 30.1 6 1.2, Ferritin(μg/l) 7 6 .8, Transferrin(g/l) 3.4 6 0.6). Among the remaining 49 non-affected children of the same age range, only 15 were iron deficient (Hemoglobin(g/dl) 17.8 6 1.7, packed cell volume(%) 60.2 6 5.1, MCV(fl) 70 6 9, MCH(g)

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23.9 6 7.7, MCHC(g/dl) 30.2 6 1.1, Ferritin(μg/l) 6.9 6 .9, Transferrin(g/l) 3.3 6 .5). Higher PCV is noted among non-affected (60.2 6 5.1) versus affected children (57.5 6 4.9), which is statically significant.

This study confirms previous observations that CVA is rare in late childhood and adult CCHD and that low iron level is a consistent risk factor associated with CVA. But the issue remains unsettled why the higher PCV which is often associated with hyperviscosity and sometimes with relative anaemia is not a consistent risk factor for CVA.

Department of Cardiology, Sri Sathya Sai Institute of Higher Medical Sciences, Prashantigram, AP

Aortopulmonary window is an uncommon condition and if it presents in adults it is usually inoperable due to irreversible pulmonary arterial hypertension. Our study aimed to give details of adult patients who had been successfully treated for aortopulmonary window. Retrospective study of consecutive adult cases of aortopulmonary window treated at our institute between 1996 and 2006. Six adult patients successfully underwent aortopulmonary window closure. Five of the 6 had been correctly diagnosed on echocardiography, while one was only diagnosed after cardiac catheterisation for unexplained severe pulmonary arterial hypertension. Four of the patients had large defects with pulmonary vascular resistance index (PVRI) ranging from 5.2–15.9 at baseline, but showing significant reversibility with oxygen administration, with PVRI falling to 0.6–2.2. These cases were successfully operated on cardiopulmonary bypass. The other two patients with smaller lesions underwent off-pump ligation. There was no peri- or post-operative mortality. All were in NYHA class I on follow-up, ranging from 3 months to 8 years. To conclude, the diagnosis of aortopulmonary window in adults can usually be made by careful echocardiography alone. Even in the presence of severe pulmonary arterial hypertension, if a significant reversibility in pulmonary vascular resistance is demonstrated the condition can be successfully corrected with good long-term outcomes.

394 Coronary Artery Disease Indian Heart J 2007; 58: 394–395

Sir Hurkisondas Nurrotumdas Medical Research Society, Sir Hurkisondas Nurrotumdas Hospital and Research Centre, Mumbai, India

Transplantation of autologous bone marrow cells (ABMCs) contributes to the regeneration of infarcted myocardium and enhances left ventricular (LV) function after acute anterior wall myocardial infarction (AWMI). The present study was designed to assess the safety and feasibility of the same with long-term clinical follow-up. Twenty-seven patients of uncomplicated AWMI were enrolled in phase-I clinical trial. Seventeen patients received intra-coronary unfractionated ABMCs (ABMC group) from 7–15 days after AWMI and ten patients acted as controls. All the procedures were uneventful. Two patients in control group required repeat hospitalization. Six month follow-up of ten patients of ABMC group demonstrated a significant rise of 7%–12% in LV ejection fraction (LVEF) by LV angiography and cardiac Magnetic Resonance Imaging with signficant fall in LV end systolic volume of 16%–28% and marginal fall in LV end diastolic volume. Similar trend was not reflected in control group of five patients although there was rise in LVEF of 1%–3.2%. To conclude, this study shows that intracoronary infusion of ABMSC is safe and feasible after AWMI and trend towards prevention of ventricular remodeling. Clinical follow-up of 6 months to two years did not show any deleterious effects on cardiac function or any other organ.

Out of a total of 600 consecutive patients who underwent exercise treadmill test (TMT) for known or suspected coronary artery disease between September 2005 to March 2006; 300 patients were randomly selected. Significant ST elevation in lead V1 and aVR was defined as . 0.5 mm of ST elevation 80 ms from J point. All of them underwent coronary angiography within 3 months of TMT. Out of 300 patients, 286 had . 50% narrowing of one or more coronary arteries, 78 patients had . 50% narrowing of proximal left anterior descending artery (LAD) of which 23 had involvement of proximal LAD alone. The sensitivity and specificity of ST elevation in lead V1 for proximal LAD lesion was 61% and 86% respectively. Out of 23 patients with isolated proximal LAD involvement, 15 had significant ST elevation in V1. The sensitivity and specificity of lead V1 for detection of isolated proximal LAD lesion was 65% and 90% respectively. Out of 78, 62 patients with proximal LAD involvement had significant ST elevation in aVR. The sensitivity and specificity of lead aVR for detection of proximal LAD lesion was 79% and 60% respectively and isolated proximal LAD involvement alone was 83% and specificity 63%. Our study shows that ST elevation in leads V1, and aVR is fairly sensitive and specific for localization of lesion in proximal LAD.

Department of Cardiology, Madras Medical College, Chennai

Recently, a new exercise test criterion for diagnosing CAD was proposed based on a composite of changes in Q, R and S waves; the QRS score. We compared this new criterion with conventional ST Segment depression and other compositions of Q, R and S wave changes in patients and normals and related QRS score to CAG. The Study consisted of 25 persons with 8 normals (Group I) and 17 patients with documented CAD (Group II). A symptom limited exercise protocol according to the modified Bruce protocol was used for the QRS score, Q, R and S wave amplitudes which could be recovered immediately were subtracted from pretest values DQ, DR, DS respectively. The score was calculated by the formula.(DR 2 DQ 2 DS) AVF 1 (DR 2 DQ 2 DS) V5.

Using a cut off point of . 5 as normal, QRS score resulted in a sensitivity of 88.2% a specificity of 84.8% and predictive accuracy of 87.1% for

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ST segment depression. These values were 54.9%, 83%, and 64.5% respectively (p , 0.001 compared to the QRS score).

1. In 10 patients with QRS Score 5–3, the CAG demonstrated that 8 patients had single vessel disease (sensitivity 80%) St Segment depression in these patients was found only in 6 patients (Sensitivity 60%). One patient with Single Vessel Disease had QRS score of 6, but, St segment depression was present in that case (Sensitivity for combined parameters is 90%).

2. In 5 patients with QRS score 0–3 the CAG demonstrated double vessel disease in 4 patients (Sensitivity 80%) ST segment depression in these patients was found only in 3 patients (Sensitivity 60%). One patient with double vessel disease had QRS score of 5.4, but ST segment depression was present in that case. Sensitivity for combined parameters is 100%.

3. In 2 patients with QRS score-1, the CAG demonstrated TVD in both (Sensitivity 100%) ST depression was found in 1 patient (sensitivity 50%).

To conclude, our data suggest that an abnormal QRS score reflects myocardial ischemia. Further more the combined analysis of ST segment and QRS score is of value for the prediction of the presence or absence of CAD.

Govt Medical College/GND Hospital, Amritsar, India

Transfatty acids are partially hydrogenated unsaturated solid fats in the form of Vanaspati ghee etc; and are often used in fast foods and bakery preparations. Their intake is associated with adverse cardiac effects which are 2½ times more than that caused by saturated fat intake. Every 2% addition of TFA in diet increases the risk of CAD by 25%.The incidence of adverse events of acute coronary syndromes like atherosclerotic plaque rupture, heart failure, arrhythmias and SCD is also increased. 156 cases of CAD (M/F 108/48, aged 27.4–82.6 with a mean of 55.6 years) and with a history of higher intake of solid vegetable ghee and of fast foods (TFA content $7%) formed Group I. 132 cases using vegetable oils with a low intake of fast foods (TFA content # 3%) formed Group II. The intake of saturated fat was comparable in the 2 groups.

GP I-(156 cases GP II-(132 casesCardiovascular with high with low Pevent TFA intake) TFA intake) value

In Hospital mortality 12/156 (7.7%) 8/132 (6.1%) Insignificant

The present study showed that higher TFAs in diet were not only associated with a higher incidence of lipid abnormalities and diabetes in CAD cases but also with more adverse cardiovascular events of CAD in the Indian population.

Department of Cardiology, Sri Venkateswara Institute of Medical sciences, Tirupati, AP, India

In acute myocardial infarction (MI), the outcome depends on the extent of myocardial necrosis. In anterior wall MI, determination of the exact site of left anterior descending (LAD) coronary artery occlusion is important because the more proximal the occlusion, the less favourable the prognosis. Likewise, in inferior wall MI, involvement of proximal right coronary artery (RCA) may be associated with cardiogenic shock due to right ventricular infarction. In this study we prospectively analyzed the sensitivity, specificity, positive and negative predictive value of various electrocardiogram (ECG) features reported in published studies in the localization of culprit vessel. From an ongoing study, during the period October 2006 to May 2007, 49 patients admitted with acute ST elevation MI to the intensive coronary care unit (ICCU), of our tertiary care teaching hospital were included. Patients with previous MI, prior revascularization, left ventricular hypertrophy (LVH), and left bundle branch block (LBBB) were excluded from the study. Coronary arteriography (CAG) was performed in multiple projections to visualize the infarct related artery within 15 days of the occurrence of MI and constituted the ‘gold standard’ for defining the site of the lesion. The ECG with the most pronounced ST segment deviation before the start of reperfusion therapy was evaluated and correlated with occlusion site as determined by CAG. Mean age was 51 6 8 years and there were 88% males. Anterior wall MI contributing to 55% of patients. ST segment elevation in lead aVR, ST segment depression in lead V5 and complete right bundle branch block (cRBBB) strongly predicted left anterior descending artery occlusion proximal to first septal branch (specificity was 100%, 100%, and 94% respectively), whereas abnormal Q wave in V4-6 was associated with occlusion distal to first septal branch (sensitivity, specificity, positive predictive value, negative predictive values were 53, 70, 75, and 46% respectively). Abnormal Q wave in lead aVL was associated with occlusion proximal to first diagonal, whereas ST depression in lead aVL was suggestive of occlusion distal to first diagonal branch. In patients with inferior wall acute MI, a higher ST-segment elevation in lead III than in lead II and/or a greater ST-segment depression in lead aVL than in lead I was a sensitive and specific marker for RCA. ST-segment depression in lead I was significantly less common with LCX-related AMI than with RCA related AMI. To conclude, in acute myocardial infarction electrocardiogram is very useful to predict the occlusion site and such localization has prognostic significance.

Department of Cardiology and Surgery, Indira Gandhi Medical College, Shimla

CAD in Indians occurs almost a decade earlier than in Western countries. We studied the risk factors and pattern of coronary artery involvement in patients with acute myocardial infarction. 51 consecutive patients who developed myocardial infarction below the age of 40 years of age were studied. Risk factors like lipid profile, homocystine (HC) and lipoprotein a (Lpa) were estimated. All patients were subjected to coronary angiography. Total patients studied were 51. Mean age was 36.07 6 3.92 years. 50 were males and one was female. 32 (62.7%) were smokers, 6 (11.7%) were hypertensive, and 2 were diabetic. Family history of CAD was present in 2 patients. Total cholesterol was raised in 15 (29.4%), LDL in 11 patients (21.5%) and triglycerides (TG) in 13 patients (25.5%). Low HDL was present in

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22 (43.1%). Homocystine was raised in 10 patients and Lp(a) in 10 patients. Cad was present in 36 (70.6%) patients and in 15 (29.4%) there was no significant CAD. Of the patients with CAD, single vessel disease was present in 31 (86.1%), 2 vessel disease in 3 patients and three vessel disease in 2 patients. 29 patients (80.6%) had LAD involvement, 6 had left circumflex disease and 6 had right coronary artery disease. To conclude, Young MI is almost exclusively seen in males. Most patients have single vessel disease and . 3/4 of the patients have LAD disease.

Dept of Cardiology, ICVS, IPGME&R, Kolkata

We sought to assess whether C – reactive protein levels correlated with extent and severity of angiographically documented coronary artery stenosis in cases of high risk acute coronary syndrome. We studied 60 patients of high risk acute coronary syndrome. Patients were classified on the basis of TIMI and ACC/AHA score. All the patients underwent detailed clinical examination, routine biochemical parameters, quantitative CRP level estimation and coronary angiography. Patients were stratified by levels of CRP as less than 1 mg/L, 1–3 mg/L and .3 mg/L. On coronary angiography, severity of CAD was assessed and scored according to Sullivan et al, which included vessel score, stenosis score and extension score. The study design was a prospective cohort study. We found that in patients with ACS, significantly greater number of patients with hsCRP greater than 3 mg/L had significant disease as well as thrombus burden (p , 0.05). Also, patients with multiple complex stenosis had a higher neutrophil count (p , 0.05). Thus, neutrophil count and CRP levels correlated with the extent of disease as documented on angiography. To conclude, Acute inflammatory markers correlated with the extent of CAD and hsCRP levels are a marker of CAD activity. HsCRP can thus be taken as a non invasive simple biochemical correlate of the inflammatory process in CAD.

Jawaharlal Nehru Medical College, KLES & MRC Nehru Nagar, Belgaum

The aim is to study the entry site complications and catheterisation complications in transradial and transfemoral interventions—A comparative non-randomised study. All patients undergoing transradial and transfemoral coronary angiography and coronary angioplasty between 1st November 2006 and 30th June 2007. Major complications peri- or post-procedurally related to transradial procedures (n 5 406) were uncommon. The total major and minor complications were seen in 16 patients (3.9%), 14 (3.4%) patients had minor local haematoma which were treated conservatively. There were 2 (0.04%) cases of a major forearm haematoma that occurred just after the completion of PTCA with stenting procedure. During the same period 1544 transfemoral procedures were done. The total complications were seen in 79 patients (5.1%), 68 (4.4%) had a minor haematoma while 10 (0.06%) had a major haematoma. The complication rates were 3.9% v/s 5.1% in transradial and transfemoral groups and were statistically significant (p , 0.001). To conclude, the incidence of access site vascular complications and catheterisation complications are greatly reduced in transradial group as compared to transfemoral group. Our own experience demonstrates transradial access for coronary angiography or angioplasty to be a safe, effective, and elegant alternative to transfemoral access, and is suitable for a wide variety of patients.

Department of Cardiology, St. Stephen’s Hospital, Tis Hazari Delhi

Several studies have shown that 20% to 35% angiographically successful recanalisation of an infarct related artery fail to salvage ischaemic myocardium (incomplete recovery of myocardial function). Intravenous nicorandil has been reported to improve early functional outcomes in patients with AMI. However, its effects on clinical end points have not been well studied. The aim is to assess the effects of single intravenous dose of nicorandil on functional improvement, in-hospital complications, and clinical end points in patients with acute STEMI undergoing pharmacological or catheter based reperfusion. The study was a double blind, placebo controlled, randomized clinical trial. 50 patients (25 each in nicorandil and placebo group) presenting with first STEMI formed the study group. Those with Hypotension (SBP , 90 mmHg), old MI or previous CABG/PTCA were excluded. Intravenous nicorandil was given as a total dose of 12 mg dissolved in 100 ml of 0.9% saline over 20–30 minute. period before reperfusion. The decision about PCI v/s thrombolysis was left to the discretion of the physician and choice of the patient. In addition to pharmacological or catheter based reperfusion of the infarct related artery; all patients received standard treatment with aspirin, clopidogrel, beta-blockers, statins, ACE inhibitors, and anticoagulants. Primary end-point was a composite of cardiovascular death, or hospitalization for CHF at 30 days. Secondary endpoints were: resolution of ST segment elevation on ECG after reperfusion at 90 min ECG, maximum serum CK levels, occurrence of malignant arrhythmias: ventricular tachycardia or ventricular fibrillation, TIMI flow grade after PCI, and ejection fraction at hospital discharge and at 1 month follow up. 80% of the patients in the nicorandil group received PCI v/s 84% in the placebo group (p 5 NS). Primary end point was reached in 4% in the Nicorandil group v/s 12% in the placebo group (p 5 0.05). ST-segment resolution .50% was observed in 84% and 72% of the nicorandil and placebo groups, respectively (p , 0.05). Postprocedural TIMI 3 flow was obtained in 95% of the nicorandil group and in 81% of the placebo group (p , 0.05). Peak CK-MB levels were significantly more in the placebo group as compared to nicorandil group (1660 6 820 v/s 1380 6 750 IU/ml respectively; p , 0.05). Nicorandil group had a higher LVEF at 30 days as compared to the placebo (52.3% v/s 48.3%; p 5 0.07). To conclude, single intravenous administration of Nicorandil given before reperfusion in patients with ST segment elevation myocardial infarction results in improved myocardial salvage and clinical outcomes at 30 days.

Fortis Flt. Lt. Rajan Dhall Hospital, New Delhi

Genous™ (Orbus Neich) bioengineered stent is a new approach designed to promote natural healing and prevent restenosis by early

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endothelialization. These stainless steel biocompatible matrix coated stents are covered with murine monoclonal, anti-human CD34 antibodies against endothelial progenitor cells (EPCs). After deployment, the circulating EPCs attach, differentiate and mature to form a functional endothelial layer. The clinical data with the stent is very limited and safety and efficacy of this stent in the setting of acute coronary syndrome is not known. We report the initial result of GENAMI study—a prospective, nonrandomized open labeled 2 centers study.

AMI was diagnosed by conventional criteria. All patients were treated with aspirin, clopidogrel (600 mg loading), heparin 5000 units I.V. bolus and high dose atorvastatin (40–80 mg). All the patients received Genous™ stent of appropriate length and diameter. The selection of the stent was at the discretion of the operator. All patients also received Gp IIb/IIIa inhibitors. Stents were deployed at high pressure ($ 12 atmospheres). A primary end point was major adverse cardiac events (death, MI, urgent TVR) at 6 months. Secondary end point is angiographic restenosis at 8 months.

Between May 2006 and February 2007, 20 patients of AMI were treated. One patient had cardiogenic shock at presentation. The mean age was 55.75 6 12.08 years and 16 (80%) were male. Coronary risk factors were hypertension in 10 (50%), diabetes mellitus in 8 (40%), smoking in 10 (50%), dyslipidaemia in 6 (30%) and family history of coronary artery disease in 2 (10%) patients.

The vessels treated were LAD in 11, RCA in 6, OM in 2 and LCX in 1 patient. Twenty-three stents were deployed in 21 lesions. The mean stent diameter was 3.08 6 0.31 mm and the mean stent length was 19.52 6 6.88 mm. Procedural success (defined as TIMI III flow with , 10% residual stenosis) was achieved in 19 (95%) cases. One patient with cardiogenic shock (TIMI II flow) died after 12 hours of the procedure due to arrhythmic storm. There was no further MACE at the end of 6 months. At the mean duration of follow up of 8.25 6 3.09 months, all patients were asymptomatic. The angiography study is in progress.

We conclude that the use of Genous™ bioengineered stent is safe in the setting of AMI at short-term follow up.

Isolated noncompaction of the ventricular myocardium (INVM) is a rare form of unclassified cardiomyopathy, which has three major clinical presentations—systolic heart failure, arrhythmia and embolic events. We encountered three patients of INVM who had varying clinicalpresentation.

Fortis Flt. Lt. Rajan Dhall Hospital, New Delhi

Drug-eluting stents (DES) have come under increased scrutiny after the European Society of Congress meeting in Barcelona in 2006 where two studies highlighted the risk for late thrombosis and death with drug eluting stents.

We did a retroseptive analysis comparing drug eluting and bare metal stent (BMS) usage pre- and post-september 2006. All the patients undergoing stent implantaion from July 2005 to July 2007 in our hospital were analysed. They were divided into two groups – Group 1 (July 2005 to September 2006) and Group 2 (October 2006 to July 2007). The two groups were compared with regards to relative drug eluting stent usage as compared to bare metal stent and other variables like stent diameter and length. One thousand forty four patients underwent stent implantation from July 2005 to July 2007, out of which 609 patients (mean age 57.7 6 11 years, 87.4% males) were in group 1 and 635 patients (mean age 58.7 6 10.8 years, 83.8% males) in Group 2.

Group 1 (before Sept. 2006) Group 2 (after Sept. 2006)

DES BMS DES BMS

No. of patients 418 (68.6%) 191 (31.4%) 400 (63%) 235 (37%)

Age (yrs) 57.2 6 10.1 58.7 6 11.2 59.1 6 10.7 58.0 6 11.0

Sex (male) 86.8% 89.0% 83.0% 84.0%

Mean stent 22.0 18.6 21.9 20.8 length (mm)

Mean stent 2.9 3.1 2.9 3.1 diameter (mm)

From this analysis we conclude that knowledge about late thrombosis has modified our stent usage pattern. Drug eluting stents usage has shown a declining trend and even longer bare metal stents are currently being used.

SCB Medical College, Cuttack, Orissa

The opening of occluded IRA late, after MI, remains controversial till today. However, there is a stray bias towards PCI by which, revascularization could benefit by reduction of LV remodeling, electrical stability but could also be harmful by distal embolization, and loss of recruitable collateral flow. To test the hypothesis of a strategy of routine PCI after a delay of 72 hours of MI and whether this would reduce composite end points of death, reinfarction and CHF; 200 consecutive patients of STEMI were enrolled and angiography was performed after a delay of 72 hours and were randomly assigned to PCI/Medical Therapy. Composite end points of Non-fatal MI and death were similar in PCI and Medical groups at 30 days, 6 months and 1 year i.e. 1% v/s 1%, 3.2% v/s 3.8% and 3.56% v/s 4.01% respectively. At 6 months, angina was more prevalent in Medical group (10% v/s 2%), death and HF were similar in both groups (3% v/s 4.8%) and (3.2% v/s 4.2%) respectively. At 1 year end point of HF (3% v/s 4.8%), reinfarction (3% v/s 5%) and death (2% v/s 3.6%), were similar and non-significant in both PCI and Medical group respectively. Thus, routine late PCI of IRA beyond 72 hours of AMI (STEMI) showed no reduction in major cardiovascular clinical events in comparison to medical therapy.

SCB Medical College, Cuttack, Orissa

Small vessel stenting has emerged as another milestone for intervention in the never ending quest for excellence. It constitutes about 30% to 50% of coronary catheter based procedures performed world wide each year. Recent different studies showed promising result of small vessel stenting with drug eluting stents. Our study compared the early (, 30 days) and late (6 months follow up) outcomes of small vessel stenting with BMS and DES.

In the present study we analysed 150 patients (50 BMS and 100 DES) between October, 2004 and October, 2005. The early (, 30 days) and late (, 6 months) outcomes were analysed in both the groups. Most of the patients in our study were between 50 and 60 years and a majory were male. There were no significant differences in the prevalence of HTN, DM, Dyslipidemia, and smoking in the two groups. Majority of the patients in both the groups were STEMI [35 (70%) in BMS and 65 (65%) in DES]. LAD was the

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predominant vessel [26 (52%) in BMS and 53 (53%) in DES] addressed followed by RCA and LCX. Majority of the patients in both the groups had DVD; 23 (46%) in BMS and 42 (42%) in DES followed by SVD; 17 (34%) in BMS and 30 (30%) in DES group. Proximal and Mid segment was addressed in 90% cases of BMS and 88% cases of DES group. All patients had either type A or type B lesion and type B was predominant lesion in both the groups.

Early outcomes in our study showed DES had better outcome than BMS and the total MACE rate was 5 (10%) in BMS and 3 (3%) in DES (p , 0.001). SAT occurred in 4 (8%) in BMS and 2 (2%) in DES group (p , 0.001). Nonfatal MI was found in 3 (6%) in BMS and 2 (2%) in the DES group.

The late outcome (6 months) in our study showed a higher MACE rate in BMS than the DES group (16% v/s 5%) (p , 0.001). ISR and TLR in our study showed a higher incidence in BMS group than DES (p , 0.001).

To conclude our study demonstrated that use of DES was superior to BMS in small vessel CAD and it appears to be safe and feasible.

Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India

Though Drug Eluting Stents (DES) have been used with good results in short, discrete lesions there is need to look at more data regarding their usage in a real world scenario.

From November 2005 to July 2007, 432 patients (mean age 57 6 10 years, 83.71% males) underwent coronary angioplasty with Endeavor (ABT-578 Drug eluting stent) implantation. Diabetes was present in 31.42%, hypertension in 42.88%, while 19.03% were smokers. The mean levels of total cholesterol, HDL-C, LDL-C, and triglyceride were 147 6 38.41, 32 6 16.3, 87 6 32.32, and 140 6 68.07 mg/dL respectively. Indication of angioplasty was stable angina in 139 (31.88%), unstable angina in 128 (29.35%), prior MI with inducible ischemia in 154 (35.32%), and acute MI in 15 (3.44%) cases.

A total of 452 vessels were treated, with an average of 1.37 stents/vessel. Vessel treated was LAD in 53.68%, RCA in 23.15%, LCX in 22.37% and Diagonal/Ramus in 0.8%. There were 6% Type A lesions, 18% Type B1, 47% Type B2 and 29% Type C lesions. Average lesion length was 18.86 6 6.56 mm while average reference vessel diameter was 2.6 6 0.4 mm. 2.5 mm stents were implanted in 3.6% patients, 2.75 mm in 26.5%, 3.0 mm in 49.4% patients, and 3.5 mm in 20.5% patients. One hundred sixty seven (34.5%) stents were more than 24 mm in length. Concomitant Gp IIbIIIa antagonists were used in 115 (26.37%) patients. All of our patients received 150 mg/day aspirin and 75mg/day of clopidogrel for at least 6 months. During a mean follow-up of 3.9 6 6.7 months (range , 1 months–19 months), 8 (1.83%) patients died, and 3 (1.55%) of our patients had target lesion revascularization. There has been one instances of documented subacute instent thrombosis, which was successfully dilated. To conclude ABT-578 Drug eluting Endeavor stents are safe when implanted in a wide variety of patients and have a good, short, and intermediate term follow-up results in a real world scenario.

Lari Cardiology, KGMU, Lucknow

GpIIb/IIIa antagonists have been shown to prevent thrombotic complications associated with coronary artery disease (CAD) in patients undergoing percutaneous coronary intervention (PCI). Flow cytometry method is used to determine GpIIb/IIIa receptor occupancy using monoclonal antibodies, with this background we proposed to determine percentage blockage of GpIIb/IIIa receptors with eptifibatide to minimise thrombotic as well as bleeding complications in patients undergoing (PCI). In this study, percentage of GpIIb/IIIa receptors blocked after eptifibatide bolus alone or bolus followed by infusion using flow cytometry was studied.

Forty-five patients with acute coronary syndrome admitted in ICU during March 2007 to July 2007 undergoing (PCI) were included in the study. The mean age of the patients was 54.9 years. Among 45 patients, 11 were non-ST elevation myocardial infarction (NSTEMI), 23 had anterior wall myocardial infarction, and 11 had inferior wall myocardial infarction. All patients were given aspirin, 300 mg loading dose of clopidogrel and low molecular weight heparin. Out of 45 patients, 27 patients were given 2 intra-coronary bolus of eptifibatide in dose of 180 g/kg 10 minutes apart alone and 18 patients were given 2 intracoronary bolus of eptifibatide in same dose followed by infusion at 2g/kg/mt for 12 hours. Percentage of GpIIb/IIIa receptors blocked was determined by taking blood sample in 3.8% sodium citrate vial 10 minutes after giving eptifibatide irrespective of bolus alone or bolus followed by infusion regimen. Percentage of free receptors at baseline and after eptifibatide was determined using flow cytometry. At baseline percentage of receptors blocked were 4 6 12.8 and after eptifibatide 66.3 6 16.86 (p 5 0.001). Percentage of receptors blocked with bolus alone 78 6 20.47 was found to be equivalent to bolus followed by infusion 65 6 9.68 regimen (p 5 NS). At 30 days none of the patients among both groups had recurrent myocardial infarction, target vessel revascularization, or heart failure. To conclude, in this study we found that bolus alone eptifibatide was able to block about 78% of GpIIb/IIIa receptors and this strategy may be useful in (PCI) procedures in preventing acute as well as short term clinical outcomes.

Surat

Outcomes of primary angioplasty can be improved by achieving better pre/post PCI TIMI flows. Earlier administration of antithrombotic and antiplatelet agents may help in achieving better TIMI flows. We evaluated the safety & efficacy of intravenous bolus of eptifibatide administered immediately after diagnosis of (ST elevation myocardial infarction) STEMI in centers without PCI prior to transfer fro PCI in comparison to usage of eptifibatide during primary PCI after transfer. Patients diagnosed to have STEMI (within 12 hours from pain onset) at centers without PCI facility and intended to be transferred for primary PCI were randomized to receiving bolus dose of eptifibatide before transfer and conventional usage of eptifibatide during primary PCI after transfer. All patients received 325 mg Aspirin, 300 mg Clopidogrel immediately after diagnosis of STEMI and patients in upstream eptifibatide arm (group A) received 10 ml bolus of eptifibatide. All patients were transferred immediately for primary PCI. All patients received intravenous enoxaparin after arrival at PCI facility. Patients in group B (no upstream eptifibatide) received eptifibatide bolus prior to primary PCI in the cath lab. Patients in both groups were started on infusion of eptifibatide in standard dose during PCI which was continued for 12 hours. TIMI flows on pre/post PCI angiograms were studied. Clinical end points included death and MACE rates at 30 days and bleeding complications. A total of 70 patients were randomized out of which 2 patients were excluded due to failure to adhere to protocol. Final analysis included 68 patients with 34 patients in each group. Both groups were demographically similar. Pre PCI TIMI 2/3 flow was better in group A 38.2 Vs 29.4% (p 5 0.61) as was pre PCI TIMI 3 flow 26.4 Vs 17.6% (p 5 0.56). Post PCI TIMI 3 flow was similar in both groups 97.1 Vs 94.1% (p 5 0.975). There was no significant difference in mortality and MACE rates at 30 days (Gr A 2.9% V Gr B 0; p 5 0.98). There was no major bleeding in either group and the incidence of minor bleeding was similar (5.8% in each group). To conclude, eptifibatide administered prior to transfer for PCI after diagnosis of STEMI showed trends towards improvement in pre and post PCI TIMI 3 flows although this was not statistically significant. There was no significant

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difference in MACE rate at 30 days in the two groups. There was no difference in bleeding complications and no complications were encountered prior or during transfer in the group receiving epifibatide in non-PCI center. This study demonstrates feasibility and safety of pre transfer administration of eptifibatide prior to primary PCI and warrants further larger studies to evaluate clinical benefits of this novel strategy.

Rabindranath Tagore International Institute of Cardiac Sciences, Mukundapur, Kolkata

Patients (n 5 20) developing no reflow during PCI were followed up (3 months). Thirteen patient developed no reflow following PCI for NSTEMI, and 7 patients for STEMI. In NSTEMI, group 3 received GpIIb/IIIa inhibitor before PCI and 10 during PCI. Four of the STEMI subjects were thrombolysed 12–24 hours after chest pain whereas 3 patients within 12 hours.

All had TIMI II flow following stent deployment, mean fall in SBP of 20 mmHg, no ST-T change, conduction disturbance or chest pain. Twelve patients received predilatation, 8 had direct stenting. Distal protection device or IABP not required in any. Intracoronary adenosine used in 8 patients and TIMI III flow achieved after mean of 16 minutes whereas nitroprusside used in 12 cases and TIMI III flow restored after mean of 10 minutes. At 3 months, patients receiving intracoronary nitroprusside showed neither deterioration in LVEF nor increase in LVIDD. Seven patients receiving adenosine showed 3–5% decrease in LVEF and 6–8 mm increase in LVIDD at 3 months of follow up, 1 patient died after 1 month of index procedure following reinfarction. To conclude, no reflow was more common in patients receiving predilatation. Early restoration of TIMI III flow noted in patients receiving intracoronary nitroprusside compared to adenosine. At 3 months follow-up patients in the former group fared better than later group.

Rabindranath Tagore International Institute of Cardiac Sciences, Mukundapur, Kolkata

From January 2005 to June 2007 we have done 994 diagnostic and therapeutic procedures through radial artery

2005 (Jan–Dec) 2006 (Jan–Dec) 2007 (Jan–Jun)

Total cases 187 477 330

Female pt 25 (13.36%) 85 (17.81%) 57 (17.27%)

Mean fluoro time 10.5 6 2.2 min 6.3 6 1.5 min 4.6 6 1.1 min

No of PCI done through 13 LCA 9 27 LCA 20 24 LCA 18 radial route RCA 4 RCA 7 RCA 6

Ulnar access Nil 7 11

Switch to femoral route 10 (5.34%) 7 (1.46%) 2 (0.6%)

Difficult puncture 20 (10.69%) 15 (3.15%) 9 (2.72%)

Radial artery spasm 25 (13.37%) 22 (4.62%) 7 (2.12%)

Ulnar artery spasm NA Nil Nil

Difficult engagement 20 (10.69%) 18 (3.77%) 7 (2.12%) (.2 catheter change)

Mean compression time 18 6 2 min 17 6 2 min 17 6 2 min during sheath removal

Local complication 1 Nil Nil

With time we have achieved reduced fluoroscopy time, absent local complication, quick mobilization, early discharge, and an alternative route for doing PCI. Spasm in ulnar artery was nil and was an alternative route in radial artery spasm. Slight prolongation in compression time during sheath removal is seen compared to femoral route (17 min v/s 12 min). To conclude, radial route is a feasible option for doing diagnostic and therapeutic procedures. It is associated with negligible local complication, early patient mobilization, decreased hospital stay and hence lowered cost.

Department of Cardiology, Bombay Hospital Institute of Medical Sciences

The aim was to study the feasibility, safety, efficacy, and medium term follow-up of DES use in instent restenosis of BMS. A prospective study in patients who underwent PTCA in BHIMS (1806 patients) between January 2004–Nov 2005 was done and 30 patients were evaluated. Inclusion Criteria were 1) instent restenosis of a BMS 2) target vessel revascularization restricted to a single vessel 3) clinical symptoms warranting a repeat PCI. Exclusion criteria 1) Presence of Leftmain stenosis 2) revascularization involving more than one stent in a single vessel 3) acute or subacute stent thrombosis. Three DES platforms used were CypherTM, TaxusTM, and EndeavorTM. Patients were followed up clinically at 30 days and telephonically at 180 days with further workup if required. Only 30 of 1806 patients who underwent PTCA in the study period fulfilled the study criteria. The pattern of restenosis was Type I (n 5 11), Type II (n 5 10), Type III (n 5 5), and Type IV (n 5 4). On followup, only one patient had documented instent restenosis in a DES. To conclude, DES is feasible, safe and effective in medium term followup of instent restenosis of BMS.

Institute of Cardiovascular Diseases, Madras Medical Mission, Chennai, India

The scenario of stent overlap necessitated by long target lesion, stent marginal dissection, incomplete target lesion coverage may complicate coronary artery procedures. Stent overlap can be associated with neo intimal proliferation and thrombosis/restenosis. The purpose of this study was to determine the outcome of patients who had undergone overlap stenting for coronary artery lesions in our institute between January 2003 and November 2006. A total of 40 patients had undergone overlap coronary stenting (36 TAXUS, 2 CYPHER, and 2 ENDEAVOR). The reason for overlapping was categorized as long lesion (65%), residual disease (25%) and edge dissection (10%). The target lesion was LAD (45%), RCA (35%), and LCX (20%). The total stent length ranged from 25 mm to 62 mm (44.2 6 8.39 mm). Post procedure, all patients had TIMI III flow. There were no major events in the immediate post procedure period. Our patients were followed up at 30 days and 6 months. The mean follow up period was 11 6 6.12 months. There was no incidence of stent loss or MACE at the end of 30 days and 6 months. In one patient, a aneurysm of LAD in the region of the overlapped segment was incidentally detected at the end of one month while undergoing elective angioplasty for the lesion in obtuse marginal. In our study, there was no incidence of stent thrombosis, death, MI or emergency CABG surgery after overlap stent deployment. One patient had aneurysm at the site of overlap segment at the end of one month which

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was managed conservatively. No MACE noted in the short term follow up period. Hence, we recommend the use of overlap stent implantation for long lesions and dissections, without complications and not compromising the post procedural blood flow. However, longer and larger studies are required to determine the long term outcome.

Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India

Stent thrombosis and instent restenosis are still unwanted events after coronary stenting. In-stent restenosis (ISR) due to neointimal hyperplasia is the Achilles heel of PCI with stenting. ISR is due to controlled intimal tear at the time of balloon expansion leading to proliferation of soft tissue within the stent. Cilostazol, a phosphodiesterase–III inhibitor has been shown to have antiplatelet and antiproliferative effects. The latter effect has the potential to reduce restenosis rate after stent implantation. Because of the higher cost of drug eluting stents (DES) and concerns of stent thrombosis, other cost effective strategies need evaluation. We studied patients with acute coronary syndromes on tirofiban infusion undergoing PCI with stenting and compared DES with bare metal stent (BMS) and long-term oral Cilostazol. We evaluated MACE rates in patients on tirofiban infusion undergoing PCI with drug eluting stent and compared them with patients receiving bare metal stent followed by oral cilostazol therapy. Total 42 patients of coronary artery disease, treated with coronary stenting were randomazied in 2 groups. Twenty-one in group A, who received bare metal stent were given tirofiban infusion during PCI and followed by oral cilostazol 100 mg twice daily for 6 months. Twenty-one patients in another group B were treated with drug eluting stent and were not given oral cilostazol on follow-up. Follow-up was done at 1 month, 3 months and 6 months. Primary end point was a composite of death, MI, and clinically driven revascularization in the target vessel. Both groups received standard therapy after PTCA i.e. aspirin, clopidogrel, statin, ACE inhibitor, and beta blocker in addition to assigned treatment. Primary end points were compared between group A and B. One patient in group B had angina at one month. Coronary angiography in this patient revealed insignificant in-stent restenosis and symptoms were attributed to anemia. One patient in group A had exertional dyspnea but angiography at six month revealed a patent stent and progression of CAD in other vessel. Composite primary endpoints of acute infarction, death, need for PCI and CABG was not seen in either group. No side effects of drug such as skin rash and bleeding requiring stoppage of Cilostazol, were seen. To conclude, tirofiban infusion during PCI in patients with CAD in whom bare metal stent is used, followed by long term oral treatment with cilostazol is safe and effective and short-term clinical outcome is comparable to costly therapy using drug eluting stent in PCI.

Krishna Heart Institute, Ahmedabad, India

There have been studies to suggest the effectiveness of Stent Design to affect Platelet activation and also showing the effect of retenosis rates comparing thin struts to thick struts. A lot is also talked about with the advent of DES in terms of uniform drug delivery. However, this papers aims at bringing out the long term effect of the stent design on Clinical TLRs (Primary End Point) converted into PCI or CABG and subsequently MACE (Secondary End Point). We did a 2 years clinical follow-up of 68 patients who underwent PTCA with stenting, between June 2004 and June 2005, with one or more BMS in one or more artery, with Open or closed cell design. These patients did not have DES in any of the artery. We excluded patients with calcification; however, the inclusion was AMI, Proximal LAD and RCA, diabetics, and routine lesions, making it a relatively high risk population. The risk of restenosis with BMS was clearly explained to the patient v/s a DES. The choice of stent "Closed" or "Open" cell was not discussed with the patients at the time of index procedure and was based on economic capability. We did direct stenting in all patients, except AMI, to reduce balloon related injury.

N 68

Male 48 71%

Female 20 29%

NIDDM 14 21%

IDDM 12 18%

Hypertension 16 24%

Smokers 20 29%

Tobacco 15 22%

Total Stents 75

Stents 38 37

N 34 34

RVD – Pre 3.11 6 0.28 3.14 6 0.29

MLD – Pre 0.52 6 0.21 0.53 6 0.20

Direct Stenting 94% 93%

Stented Diameter 3.14 6 0.24 3.15 6 0.27

Stented Length 16.78 6 3.89 16.75 6 3.94

MLD – Post 3.22 6 0.26 3.22 6 0.26

Diameter Stenosis 0.8 mm2 1.5 mm2

Inflation Pressure 13.86 6 0.99 13.86 6 1.03

GPIIbIIIa 33 32

TLR – PCI 3% 9%

TLR – CABG 3% 3%

Re-MI 0% 0%

Death 0% 3%

MACE 6% 15%

To conclude, our study, though a small population, indicates that Stent Design seems to affect the long term results. We also feel that probably the inability of Open Cell Design to hold on the plaque at the time of index procedure also leads to excess proliferation and thereby leading to clinical TLR.

Krishna Heart Institute, Ahmedabad, India

The aim of the study was to reduce the incidence of No-Reflow Phenomenon. Literature has shown that there is a risk of No-Reflow Phenomenon in close to 30% of patients undergoing PAMI with Stenting. The optimal method to treat a No-Reflow is yet to be

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established. This is one of the attempts to reduce the same. Hundred consecutive patients with Acute Myocardial Infarction underwent PAMI. Angiography revealed Thrombotic Total Occlusion of the vessel. POBA was performed in these patients with GPIIbIIIa inhibitors and/or extraction device as a first stage of intervention. This allowed to reduce the thrombus burden. These patients were put on the infusion of GPIIbIIIa and Nicorandil for nearly 12 hours. Then these patients were taken for Stenting (DES or BMS) of the culprit lesion. The stenting was done between 1 to 12 hours with or without IABP Support depending on the TIMI Flow.

No. of patients 100

Male 83 83%

Female 17 17%

Diabetes 37 37%

Hypertensive 40 40%

Tobacco 30 30%

LAD Stenting 84 76.67%

RCA Stenting 18 16.67%

LCx Stenting 8 6.67%

Extraction Device Use 11 11.00%

70% 30%

AMI , 6 hours 38 8

AMI 6 to 12 hours 25 10

AMI . 12 hours 7 12

Gp IIb/IIIa 100%

Abciximab 50 10

Tirofiban 20 20

Mean Stent Diameter 3.03 6 0.34 mm 3.15 6 0.36 mm

Mean Stent Length 22.8 6 5.99 mm 15.5 6 2.11 mm

Ave LVEF Pre Procedure 24% 22%

Complications during procedure 0% 0%

Clinical f/u @ 1 year 100%

Ave LVEF follow up 45% 41%

Death 2% 4%

TLR 2% 5%

Stent Thrombosis (ARC) 1% 3%

Other Clinical Event 0% *1%

* 1 Patient in the BMS arm developed Congestive Heart Failure. This was nothing related to the device or procedure. The patient died at 8 months included in Death.

To conclude, PAMI with delayed Stenting in Thrombotic Lesion with a DES/BMS, with GPIIb/IIIa support with or without extraction device has shown to prevent No-Reflow Phenomenon with a better clinical outcome at the end of 12 months. There is also a marked improvement in the LVEF at follow-up.

The Strategy:

1. If TIMI 0 after POBA: Allow GpIIb/IIIa/Nicorandil infusion with IABP support and stent the lesion within 12 hours.

2. If TIMI 1 or 2 after POBA: Allow GpIIb/IIIa/Nicorandil infusion and stent the lesion within 2 to 3 hours.

3. If TIMI 3 after POBA: Stent the lesion within 1 hour.

Department of Cardiology, Army Hospital Research & Referral, New Delhi

The drug-eluting stent has struck a blow against the spectre of restenosis- the Achilles heel of percutaneous intervention! However, it does not come without caveats of which a proper preparation of the bed prior to DES implantation is an important one. Rotablation is a technique that ensures a smooth passage for even the stiffest stent and and a fairly even bed for stent deployment. This technique extends the technique of angioplasty to patients with long lesions, calcified lesions, bifurcation lesions, and complex lesions who would otherwise be considered candidates for surgery. However, there is a significant learning curve and some experience is required before optimal results are achieved. Our experience with rotablation is summarized. Eleven patients underwent rotablation for calcified obstructive coronary artery disease. All underwent DES implantation. The age ranged from 44 years to 69 years and all were males. The vessel most commonly intervened was LAD followed by LCx and RCA. Two patients underwent intervention to a different vessel at a second sitting. All procedures were successful. One patient had a flow-limiting dissection in the mid-LAD after rotablation that required a second stent. A check angiogram at the angioplasty of the RCA a week later that was also diseased, revealed TIMI-3 flow in the LAD. Rotablation in experienced hands is a safe and effective technique to extend the benefits of angioplasty to complicated, calcified, and long lesions with special significance in the DES era.

1Institute of Cardiovascular Sciences, R.G. Kar Medical College and Hospitals, Kolkata2B.M. Birla Heart Research Centre, Kolkata

Cardiovascular disease accounts for the majority of hospital admission and deaths in diabetic patients. Restenosis is the major long-term limitation of percutaneous coronary revascularisation (PCR). The introduction of stents has improved outcomes after intervention in diabetic patients, but these patients continue to be at a greater risk for restenosis than are non-diabetic patients. The association between glycaemic control determined by preprocedural haemoglobin A1C (HbA1C) and the incidence of target vessel revascularisation was examined in diabetic patients undergoing elective percutaneous coronary intervention. In all 200 patients (50 without diabetes mellitus and 150 with diabetes mellitus) were included in the study. Optimal glycemic control was defined as preprocedural HbA1C of 7% or less and suboptimal control was defined as HbA1C of greater than 7%. Follow-up was done at 6 and 12 months after the intervention. The rate of 12 months target vessel revascularisation in diabetic patients with optimal glycemic control was similar to the rate for non diabetic patients (15% and 16% respectively). Diabetic patients with HbA1C greater than 7% had a significantly higher rate of target vessel revascularisation than those with HbA1C less than 7% optimal glycemic control was associated with a lower rate of cardiac rehospitalisation and recurrent angina at 12 months follow-up. (p 5 0.005). To conclude, optimal glycemic control was associated with a lower rate of target vessel revascularisation cardiac rehospitalisation and recurrent angina. Hence, aggressive treatment of diabetes mellitus to achieve HbA1C of 7% or less is beneficial in improving the clinical outcome after elective percutaneous coronary intervention.

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1Senior Resident, 2Assistant Professor, 3Professor Institute of Cardiovascular Sciences, RG Kar Medical College and Hospital, Kolkata

Young women represent a less common subset of coronary artery disease patients worldwide, with scarce epidemiologic data from eastern India. Retrospective record review, of patients admitted to Institute of Cardiovascular Sciences, RGKar Medical College, Kolkata, during the period from January to June 2007, was done, to include females less than 45 years diagnosed with acute coronary syndrome. History, clinical notes, investigation details and treatment outcomes were documented. In all 127 patients were included in the study. The mean age was 39.9 6 4.9 years and unstable angina (62.9%) was the commonest presentation. Positive family history (70.3%) and diabetes (48.1%) were the significant risk factors and showed positive correlation with angiographic findings. Single-vessel disease (44.4%) was most prevalent; followed by 3-vessel (22.2%) and 2-vessel (18.5%) which were limited to the diabetic subset. Obstruction to LAD (58.3%) prevailed over RCA (25%) or circumflex lesions (16%) among those with single-vessel-disease. We also documented normal coronary anatomy (7.4%) and congenital malformations (7.4%) in a significant minority. To conclude, young females with ACS are more likely to have single vessel disease, especially in the absence of risk factors. Congenital coronary anomalies should be considered during angiography.

Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India

Currently available DES have limitations of short and long term problems related to polymer coating used. We report our experience with Yukon stent that is having a polymer free on site stent coating, using 2% rapamycin solution. Between June 2004–June 2007, a total of 710 patients were stented with a total of 876 Yukon stents. Mean age was 55 6 10 years. Out of all patients, 608 (85.63%) were males. DM was present in 221 (31.12%) patients, hypertension in 330 (46.47%) patients, while 116 (16.3%) patients were smokers. The indications of angioplasty were CSA in 325 (45.77%) patients, USA in 343 (48.30%) patients and acute MI in 42 (5.91%) patients. LAD was stented in 412 (58.08%), LCx or major OM in 199 (28.02%), and RCA in 276 (38.87%) cases. The mean reference vessel diameter was 2.8 6 0.6 mm with a mean lesion length of 14.3 6 7.1 mm.The majority of treated lesions (67.7%) were complex (ACC/AHA Type B2 and C). The mean diameter and length of stent used was 3.0 6 0.5 mm and 19.5 6 8.1 mm. n 5 excellent acute results in all patients. At mean follow up period of 6.4 1 8.2 months (up to 18 months). 16 (2.25%) patients had MI, 4 patients were having sub acute thrombosis and 12 patients had late thrombosis. Only 3 patients died in hospital, and 18 (2.53%) patients have died within a follow up of 1 month .30 (4.22%) patients had target vessel revascularization. We conclude that in real world situation in a high risk population and complex lesions, placement of polymer free stents with onsite sirolimus coating is feasible, safe with excellent acute results and good outcomes on intermediate term follow-up.

Dept of Cardiology, ICVS, IPGME&R1, Kolkata, Cardiology Department, AMRI, Kolkata2

We sought to assess the safety and efficacy of DES in Primary angioplasty for acute myocardial infarct in our centres. We studied 120 patients, which was divided into three groups: 95 patients with sirolimus eluting stent group (SES including other congeners of sirolimus), and 25 patients with bare metal stents. Outcomes were assessed for 12 months for major adverse cardiac events (MACEs) including myocardial infarction, in-stent thrombosis, clinical restenosis, and death. Several trials have shown the effectiveness of drug-eluting stents (DES) in reducing restenosis. Acute ST-elevation myocardial infarction (STEMI) has been an exclusion criterion in most trials evaluating the safety and efficacy of DES. We studied the use of DES in Primary PCI in acute myocardial infarct patients in our centres. There were 3 in-stent thromboses in the sirolimus group (3.2%). The thromboses ranged from acute (within 24 hours) to as late as 8 months. Clinical restenosis was encountered in 4 patients (16%) in the bare metal stent group.One of the 25 patients with bare metal stents had stent thrombosis (4%). There were 4 total deaths, all related to complications from the index STEMI: 1 in the bare metal group, 3 in the sirolimus group. The post discharge MACE rate was 7% with no deaths. In conclusion, the use of DES in acute STEMI is associated with a low post discharge MACE rate and a 3.2% in-stent thrombosis (p-not significant) rate, which is similar to reported rates in earlier randomized trials.

Lalitha Super Speciality Hospital, Kothapet, Guntur, Andhra Pradesh

The aim was to demonstrate that left trans radial route coronary angiography is safe, very convenient, and minimal time taking with high success rate. From June 2004–June 2007, 4500 coronary angiograms were done through left trans radial route. Male female ratio 6.5:3.5. The youngest was 21 years, and the oldest was 85 years. DM 34%, Smoking 28%, F/H/O positive in 11%, and lipid abnormalities in 8%. Hardware used was like in right trans radial approach. Terumo exchange wire, tiger catheter 5F, and 6F terumo sheath. Premedication – Midazolam, Fantanyl intra venous; Diltiazem 5 mg, 100 micro grams Nitroglycerine, 5000 units Heparin intra arterial. After this modified Allen’s left radial puncture is done by modified seldinger’s technique. Using 0.32 exchange terumo wire and 5F tiger catheter, both right and left coronaries are done. Pigtail catheter is used for LV injection. The success rate was 98%, and Fluro time was 1.8 minutes. Average procedure time is 6.5 minutes. No major vascular complications were seen and the incidence of spasm is less than 1%. One patient developed small pseudoaneurysm. To conclude, left trans radial approach is safe and convenient. The added advantage is non selective left internal mammary (LIMA) imaging can be done.

Lalitha Super Speciality Hospital, Kothapet, Guntur, Andhra Pradesh

The aim of the study to establish the importance of non selective LIMA angiogram for patients going for bypass surgery. From Jan 2002–June 2007, 1100 cases of LIMA angiograms were done as a routine procedure for

402 Coronary Intervention Indian Heart J 2007; 58: 396–405

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patients where coronary angiograms indicated Bypass surgery. After completion, coronary angiogram non selective 8–10 ml dye injection was given in left 6 subclavian artery. In Femoral route RCA cathetar was used. Pigtail/tiger cather was used in left trans radial route. In 4 cases there was 100% block of left subclavian artery, one case had critical stenosis, one patient had very torturous ecstatic LIMA; one case had aberrant origin, one case had 100% mid segment LIMA block. In all these cases, LIMA is not suitable for grafting. To conclude, this procedure can be done safely without an extra cost, extra time or additional risk. Non selective LIMA angiograms give valuable information regarding the suitability of LIMA in patients undergoing Bypass surgery.

Sri Jayadeva Institute of Cardiology, Bannerghatta Road, 9th Block Jayanagar, Bangalore, India

At our Institute we progressively collected data on patients presenting with recurrence of symptoms following index PCI from January 2005 till the present date. 72 Patients in the age group of 41–79 yrs underwent follow up angiogram, 49% were diabetic, 90% of patients were on statins, on treatment LDL-c , 130 mg% was observed in 87% of patients, 69% of patients had low HDL (, 40 mg%).

Angiographic profile and re-intervention – 33 of 72 (46%) patients had patent stent and insgtinificant native vessel disease progression and managed medically. Twenty patients developed instent restenosis (28%). Among 20 patients with ISR 10 were managed with repeat PCI for ISR, 2 patients with focal ISR in DES were treated with POBA only, while 8 underwent CABG (ISR 5 4, ISR 1 Native vessel disease progression 5 4, native vessel disease progression 5 7)

A total of 78 stents were followed in 72 patients, 72% were BMS. In BMS group 21% underwent repeat PCI for ISR, while 39% continue to have patent distance and were managed medically in 40% CABG was advised due to progression of disease in other vessels associated with ISR.

A total of 17 DES were followed angiographically, in DES group 87% were diabetic, 53% of patients in DES group had patent vessels and advised medical management, Instent restenosis was diffuse with Endeavor and Pronova stents while Cypher stent group (n 5 9) had focal ISR in 2 patients and managed with POBA only. Five patients had both BMS and DES—2 of them had patent DES but significantly narrowed BMS, 1 had both stents patent, while 2 had both significantly narrowed.

It is important to note that our study included patients presenting with recurrence of angina after index PCI. Among this group of patients 49% were diabetics and 72% had bare metal stents, we observed that over a follow up period of 4 months to 3½ years 46% of patients can be managed medically, 30% needed repeat PCI (12 for ISR, 10 for native disease progression).

Among DES group, 87% were diabetic, restenosis was focal with Cypher stent while diffuse with other DES.

Sri Jayadeva Institute of Cardiology, Bangalore

The aim of the study was to find out the relation between aortic pulse pressure and the prevalence and extent of coronary artery disease undergoing diagnostic coronary angiography. Aortic pulse pressure is a significant marker of cardiovascular morbidity independently of mean blood pressure and 60 mmHg should be considered as the threshold at risk both in normotensives and hypertensives. Hundred patients were included in this study.We investigated the relation between aortic pulse pressure and the presence and extent of CAD in patients undergoing diagnostic coronay angiography of the 100 patients included in this study, 71 were males, 29 females. Of these, 38% were diabetics, 49% hypertensives, 58% smokers and 60% had dyslipidemia.Among them 41% had MI, 8% had unstable angina, 28% TMT positive, 17% effort angina, only 5% had undergone PTCA earlier (3 BMS and 2 DES).

The patients were classified into 3 groups according to the severity of CAD. Normal co