Indian Journal of Clinical Cardiology

This expert opinion addresses the prevalence of cardiovascular diseases (CVDs) among Indian women, suggesting strategies for screening and risk assessment. A panel of expert cardiologists (n = 99) developed a questionnaire for screening CVD and risk stratification, analyzing discussion points and opinions to formulate recommendations. Experts strongly agreed that ischemic heart diseases remain underdiagnosed and undertreated among Indian women. Women should be screened for future risk of atherosclerotic CVD at the age of 45–50 years if they have diabetes or other CV risk factors. Experts strongly recommended targeted screening for CVD among women during and post-pregnancy period. Women should be screened for peripartum cardiomyopathy (PPCM) risks during pregnancy and post-delivery, with dyspnea, edema, and tachycardia being the most common red flags in the diagnosis of PPCM among Indian women. This expert opinion report provides a comprehensive overview of expert cardiologists’ recommendations for screening heart diseases and risk stratification in Indian women.

Transcatheter aortic valve implantation has taken the world by storm. The past decade saw expanding indications of Transcatheter aortic valve implantation to include patients at low surgical risk for surgical aortic valve replacement, patients with degenerated aortic bioprosthesis, and repurposing existing transcatheter aortic valves to treat pathology involving other valves. Also around the same time, various iterations of existing transcatheter heart valves and newly launched valves were made available for human use in India. This article highlights salient features of all the commercially available transcatheter heart valves in India. The article also provides a narrative to help a cardiologist choose a particular valve that would best suit the patient taking into account the valve design characteristics and features.

Epidemiological studies have shown that acute coronary events, heart failure, atrial fibrillation with fast ventricular rate and brain stroke events have increased prevalence in winter season. Infections have a pivotal role in triggering such events. Vaccination against influenza and pneumococcus has been documented to prevent such events in large epidemiological studies. Majority of the deaths during Corona virus-19 (COVID-19) pandemic were related to cardiovascular event apart from serious lung condition. Vaccination has been proven to reduce risk of recurrent hospitalizations and death especially in sick and frail patients with heart failure, chronic obstructive lung diseases, renal failure and acute coronary syndromes. It becomes more relevant in countries like India where patient has to pay huge amounts for hospitalization from the pocket. On the other hand, it reduces unnecessary strain on the healthcare manpower and resources. Practice of vaccination in addition to guidelines based pharmacological, device or surgical therapy, is to help both the patients and physicians.

Heart disease is a leading cause of mortality and morbidity globally. Sedentary lifestyle, bad eating habits, and little to no exercise have led to an alarming rise of lifestyle-mediated diseases in recent times. Table salt is one of the staples of all our kitchens and dining tables. Salt contains almost 98% sodium chloride. The unregulated amount of salt in our diet has led to adverse cardiovascular consequences. Fast foods such as salted French fries and Chinese cuisine may contain as much as 7,000 mg of sodium in a single meal! The American Heart Association (AHA) recommends a daily intake of not more than 2.3 g of salt per day (roughly one teaspoon). For patients with hypertension, heart failure, or kidney disease, a lower daily cut-off of 1.5 g of salt has been proposed but is still under debate. There is conflicting evidence of going too low with salt restriction as recent studies have shown increased adverse events when salt was restricted to beyond the recommended per-day threshold. The DASH (dietary approaches to stop hypertension) diet is a novel dietary pattern that is recommended for patients with hypertension. The DASH diet is not a restrictive or short-term diet but rather a sustainable and balanced approach to eating. It promotes a wide variety of foods, focusing on whole, unprocessed options, and encourages portion control. Adhering to a DASH eating pattern by itself can lower the systolic blood pressure by 6–11 mm Hg. Reducing salt intake can be challenging, as salt is present in many processed and packaged foods, restaurant meals, and fast food. More than 70% of the salt we eat, according to the AHA, comes from processed, prepackaged, and restaurant foods.

“Salt Lite” is often marketed as a healthier alternative for individuals looking to lower their sodium intake. It typically contains a blend of potassium chloride with sodium chloride and is hence not totally “sodium free.” Individuals considering the use of “Salt Lite” should be aware of its higher potassium content and should not use it if they have a kidney disease or are on drugs that can cause hyperkalemia. There is a common misconception that pink Himalayan salt is lower in sodium than regular table salt. However, both types consist of approximately 98% sodium chloride. Research has not shown that Himalayan salt has any unique health benefits compared to other dietary salts.

It is hence imperative for all individuals to restrict dietary salt intake to the recommended levels—as a measure toward a healthy lifestyle as well as a therapeutic modality for those with established cardiovascular diseases.

A 22-year-old male having cardiomegaly with prominent right atrium (RA) enlargement in his chest X-ray underwent echocardiography which revealed an anterior mediastinal cystic lesion. Contrast-enhanced computed tomography of the thorax showed saccular contrast filling outpouching from ostia of the right coronary artery (RCA) of size 5.9 × 6.4 cm in anterior atrioventricular groove compressing RA and right ventricle along the RCA course. The left main coronary artery also appeared to be dilated with a diameter of 1.1 cm proximally. The patient denied any prior angina, palpitation, and dyspnea on exertion. This case is reported for its rarity and the dilemma involving its appropriate medical and surgical management.

Takotsubo cardiomyopathy (TCMP), also called as stress cardiomyopathy, is a transient left ventricular (LV) dysfunction. TCMP’s association with endocrine and thyroid diseases has been recently described, but TCMP in a patient of Hashimoto’s thyroiditis with encephalopathy is rarely reported. ¹ Here, we present a recent case of TCMP in a patient with Hashimoto’s encephalopathy who was treated with steroids and responded well. Our case here highlights about having a lower threshold for screening of thyroid and other endocrine disorders in patients with TCMP.

Lutembacher’s syndrome is a rare condition and is most often treated surgically. Due to the advances in percutaneous procedures, this form of management is desired which has the advantage of decreased morbidity and is aesthetically superior. In this case report of percutaneous treatment for a Lutembacher’s patient the percutaneous transvenous mitral commissurotomy and atrial septal defect device closure was done with minimal technical difficulties and with excellent post-procedure results.

Submitral left ventricular aneurysm is a rare entity. It is mostly in Africans; the most prevalent etiology is congenital. It is also seen rarely in Caucasians and Asians due to varied etiologies. The diagnosis may be achieved by transthoracic echocardiography, transesophageal echocardiography, or even left ventricular angiography. We present a case where the former was misleading and the latter could not be performed due to cardiac failure, yet diagnosis was achieved by magnetic resonance imaging.

Percutaneous coronary intervention (PCI) is one of the most commonly performed cardiovascular interventions to treat significant coronary artery stenosis. Although a safe procedure, it carries the risk of complications like coronary artery perforation (CAP), bleeding, stroke, and acute kidney injury rarely resulting in death. The incidence of CAP is 0.84% of all PCI procedures and the incidence is increasing as cardiologists are accepting more and more challenging cases. CAP is caused by a guidewire (GW) or a vessel tear from balloon angioplasty, stenting, or rotational atherectomy. Though the majority of CAPs do not result in cardiac tamponade, some do lead to tamponade and death. The majority of distal wire perforations respond to prolonged balloon inflation, coils, glue, or fat embolization. Herein, we report a case of distal CAP in a 63-year-old woman occurring following left circumflex artery PCI caused by the exiting of coronary GW. The CAP was successfully sealed by the liquid embolization technique using ONYX. First described in 1990, Onyx is an elastic polymer composed of ethylene vinyl alcohol copolymer dissolved in dimethyl sulfoxide and mixed with micronized tantalum powder (Onyx). The Onyx is predominantly used by interventional radiologists while performing neurovascular and peripheral vascular interventions. There were only a few case reports of plugging of CAPs using Onyx. Our case highlights the safety and feasibility of closing distal CAPs using Onyx.

The echocardiographic markers that occur in sequence in cardiac tamponade are inferior vena cava plethora, right atrial diastolic collapse, exaggerated inspiratory variation in mitral and tricuspid velocities and finally right ventricular diastolic collapse. Contrary to popular belief, the degree of atrial inversion does not correlate with the presence or absence of tamponade physiology, however, the right atrial inversion time (exceeding one-third of the cardiac cycle) significantly improves the sensitivity of atrial collapse in predicting tamponade. We present here an important demonstration of fundamental physiology of respirophasic variation of right atrial collapse in cardiac tamponade.

We present a case of bigeminal rhythm where a critical evaluation of underlying rhythm abnormality is important to differentiate escape-capture bigeminy from escape-echo bigeminy, and to decide further management plans.

Coronary artery disease (CAD) stands as the prevailing global cause of death, and coronary artery bypass grafting (CABG) remains the optimal revascularization method for severe CAD. While surgical management has progressed significantly, the implementation of these advancements requires acceleration. The impetus for this acceleration can be bolstered through specialized coronary surgery societies, which can concentrate research efforts, synthesize evidence, and contribute to the formulation of practice guidelines. Cross-continental collaborations among national and international societies, such as the International Society for Coronary Artery Surgery, Japanese Association for Coronary Artery Surgery, and Society of Coronary Surgeons (India), can address knowledge gaps, drive innovation, standardize training, and improve adherence to practice guidelines. Dedicated coronary societies have the potential to revolutionize coronary surgery and enhance patient outcomes.

In this article, the late-breaking trials presented at TCT and AHA 2023 are briefly described. The trials are described under the headings according to the area of interest of the trial.

These 20 questions are meant for DM/DNB/Post SS-Fellow residents/associate consultants.