CSI Chennai 2016 Highlights PDF

H I G H L I G H T S
67
th Annual Conference of
Cardiological Society of India
1013th February 2016, Chennai Trade Centre, Chennai

Editor
Prof. Santanu Guha
President Elect CSI
Chairman - Scientific Committee 67th Annual Conference of CSI
Highlights | 67th Annual Conference of Cardiological Society of India, February 10th13th, Chennai
Foreword
Dear Friends,
The 67th Annual Conference of the CSI took place in Chennai from
10th to 13th February 2016.
This time I kept a Conference Highlight Session on the last day. In
continuation of the same endeavor, this booklet and CD/DVD are being
published highlighting the major points each speaker emphasized in their
respective talks during the course of the conference. Almost all major
sessions have been covered. The oral and poster paper presentations
have been excluded as those have already been published in Indian Heart
Journal abstract issue.
I believe that this effort may be of some help for those who could not
attend all the sessions as well as for those who attended just to keep the
memory alive.
I would like to thank all professional attendees for bringing their expertise
and knowledge to the fore, Sun Pharmaceuticals for supporting us in
disseminating this prestigious knowledge initiative and knowledge
Partners M/s Klub Class for managing this important publication
With seasonal greetings,
Professor Dr. Santanu Guha

President, CSI
Foreword
It is a pleasant privilege to write a foreword to this endeavour of bringing
out a Highlights book on the proceedings of Cardiological Society of
India (CSI) 67th annual conference of CSI held at Chennai, from 10th to
13th February 2016. The conference being such a massive meeting held
simultaneously in five halls on four days, it is difficult for anybody to
know about the entire scientific deliberations of the meeting. Therefore,
this important publication would help participants gain good insight
about the scientific deliberations held during the meeting. Additionally,
this publication would be all the more useful for those who could not
participate in the conference and also act as a permanent resource
material for the academicians and the cardiology practitioners alike.
With the thoughtful designing of the scientific programme by
Dr Santanu Guha, an excellent gesture of Sun Pharma who have
agreed to disseminate this publication and also the well coordinated
compilation effort of important presentations by our knowledge partner
M/s Klub Class, I have no doubt that this will be a useful resource material
for all the esteemed members of the CSI.
Dr. S. Shanmugasundaram
Secretary, Organizing Committee, CSI
Contents
1.
Ambulatory Blood Pressure Monitoring: Expanding Indications ...................................... 1

Dr. George Koshy A
2.
Controversies on HDL Modulation: Likely Explanations .................................................... 2

Dr. S S Iyengar
3.
ARNI: The New Blockbuster for Heart Failure with Reduced Ejection Fraction ....................... 3
Dr. P C Manoria
4.
Acute Decompensated Heart Failure: An Internists Approach .......................................... 4

Dr. Soumitra Kumar
5.
Status of Non-Statin Anti-Lipidemic Therapy ...................................................................... 5

Dr. Ramesh Babu Byrapaneni
6.
Heart Failure in the Elderly ................................................................................................... 6

Dr. Suvro Banerjee
7.
Biomarkers in Heart Failure: Many Shots in the Arm ......................................................... 7

Dr. Amal Kumar Banerjee
8.
Anti-diabetics and Cardiac Vascular Safety issues .............................................................. 8

Prof. G Justin Paul
9.
Aids to HIV and Heart ........................................................................................................... 9

Dr. Debabrata Roy
10.
Ivabradine in CVD: What is New? ....................................................................................... 10

Dr. A K Pancholia
11.
Azilsartan Medoxomil- a New Kid in the Horizon of Hypertension ................................ 11

Dr. Mrinal Kanti Das
12.
Calcium Channel Blockers- Newer Perspectives ................................................................ 12

Dr. Geevar Zachariah
13.
Chronic Constrictive Pericarditis: An Outline of Diagnosis And Management ............... 13

Dr. Ranjit Nath
14.
Refractory Angina- Any Silver Lining? ............................................................................... 14

Dr. Santhosh Satheesh
15.
SCAD: When Intervention is Justified? .............................................................................. 15

Dr. Shirish Hiremath
16.
Thrombolytic Therapy in ACS ............................................................................................. 16

Dr. Sunil Sathe
17.
Heart Failure with Preserved Ejection Fraction (HF-PEF):

Current Concepts and Treatment ....................................................................................... 17
Dr. B P Singh
18.
Newer Oral Anticoagulants ................................................................................................ 18

Dr. Sandeep Bansal
19.
Granulomatous Diseases of Heart: A Bumpy Road .......................................................... 19

Dr. Satyendra Tewari
20.
Triglyceride: The End of Road? ........................................................................................... 20

Prof. K K Mitra
21.
Statins: How to Choose Among the Members? ................................................................ 21

Prof. Dr. T Govindan Unni
22.
Lipid guidelines in Indian context ...................................................................................... 22

Dr. K Sarat Chandra
23.
A Guide for the Hypertension Guidelines ......................................................................... 23

Prof. H C Kalita
24.
Uncomplicated Hypertension: Really That Simple? .......................................................... 24

Dr. Asha Mahilmaran
25.
Present Status of Anti Rheumatic Vaccine ......................................................................... 25

Dr. Cibu Mathew
26.
Resistant Hypertension: Causes, Consequences and Care ................................................ 26

Dr. Ajay K Sinha
27.
Obstructive Sleep Apnea and CVD ..................................................................................... 27

Dr. Jabir A
28.
The Future of Anti-Arrhythmic Therapy in AF ................................................................... 29

Dr. Rakesh Yadav
29.
Pulmonary Hypertension: a Management Approach ....................................................... 30

Dr. Praveen Jain
30.
Management of Hypertension in Acute Stroke ................................................................ 31

Dr. Ambuj Roy
31.
Detection of Asymptomatic Atherosclerosis: Whom, When and How? .......................... 32

Dr. James K J
32.
Device Therapy in HF: How Much is the Dividend? .......................................................... 33

Prof. Dr. Rabin Chakraborty
33.
High Gradient across Mitral Prosthesis: My Check List ..................................................... 34

Dr. Aniruddha De
34.
3D Echo is the Standard-of-Care ......................................................................................... 35

Dr. Amuthan V
35.
Stress Echocardiography for Clinical Decision Making ..................................................... 36

Dr. Manish Bansal
36.
Rare Cases of Cardiac Masses .............................................................................................. 37

Dr. (Lt Col) Nitin Bajaj
37.
Chest Pain in ER Echo in Triage ........................................................................................ 38

Dr. K Raghu
38.
Acute Aortic Syndrome ....................................................................................................... 39

Dr. Natesa G Pandian
39.
Evaluation of Inducible Ischemia by Nuclear scan ............................................................ 40

Prof. Dr. G N Mahapatra
40.
PET Perfusion Imaging is Better ......................................................................................... 41

Dr. Mythri Shankar
41.
Non-Invasive FFRCT: Will it Become a Clinical Reality? ..................................................... 42

Dr. Ravi Bathina
42.
Use of Contrast in Ischemic Heart Disease ........................................................................ 43

Dr. Nitin J Burkule
43.
An Overview of Advanced Cardiac Imaging ..................................................................... 44

Dr. Ansuman Saha
44.
Introduction to Cardiac Imaging ........................................................................................ 45

Dr. Johann Christopher
45.
Imaging LA Is it a Crystal Ball of CV Events? .................................................................. 46

Dr. K Chandrasekaran
46.
Can Routine Echo Predict Future CV Events? .................................................................... 47

Dr. Nitin Burkule
47.
Can Ultrasound Reclassify ASCVD Risk? ............................................................................ 48

Dr. Shishu Shankar Mishra
48.
Echocardiographic Evaluation of the Mitral Valve ............................................................ 49

Dr. Srikanth Sola
49.
Case Studies ......................................................................................................................... 50

Dr. Satish Parashar
50.
Vitamin D in the Prevention of Atherosclerosis ................................................................ 51

Dr. Soumitra Kumar
51.
Newer Anti-Diabetic Drugs : Role in Cardiac Patients ....................................................... 52

Dr. S B Gupta
52.
Benefit of Yoga in Heart Diseases: Do We Have Evidence? ............................................. 53

Dr. S C Manchanda
53.
Acute Rheumatic Fever: Treatment Controversies ............................................................ 54

Dr. Geetha Subramanian
54.
Establishing STEMI Care Systems in India ......................................................................... 56

Dr. S Ramakrishnan
55.
High Intensity Intermittent Exercise and

Moderate Intensity Continuous Exercise ........................................................................... 57
Dr. Sunitha Viswanathan
56.
Ideal Cardiac Rehabilitation Program ................................................................................ 58

Prof. Dr. Vijay Garg
57.
Risk Stratification Algorithm for Primary Prevention in Indian Population .................... 59

Dr. Biswakesh Majumdar
58.
Emerging Drugs for Obesity: At Last Some Viable Options? ........................................... 60

Dr. Dipak Sarma
59.
Dietary Approach to Health: Lessons from the PREDIMED Study .................................... 61

Dr. Anup Banerji
60.
Edible Oil .............................................................................................................................. 62

Dr. Soura Mookerjee
61.
Fruits and Vegetables for Cardiovascular Protection ........................................................ 63

Dr. Uday M Jadhav
62.
Metabolic Syndrome: Indian Scenario ............................................................................... 64

Prof. Apurba Kumar Mukherjee
63.
Pathogenesis and Laboratory Diagnosis of Underlying Rheumatic Fever:

Do We Finally Understand the Process? ............................................................................ 65
Dr. Thangam Menon
64.
Clinical Profile of Rheumatic Heart Disease ....................................................................... 66

Dr. Nagamani A C
65.
Secondary Prophylaxis in RHD: For Whom and For How long? ...................................... 67
Dr. G Karthikeyan
66.
Management of Atrial Fibrillation in Valvular Heart Disease .......................................... 68

Dr. Panchanan Sahoo
67.
Approach to a Patient with Sick Sinus Disease ................................................................ 69

Dr. Ulhas M Pandurangi
68.
Pulmonary Arterial Hypertension in Pregnancy ................................................................ 70

Dr. Milind S Phadke
69.
An Evidence-Based Review of Drug Eluting Stents .......................................................... 71

Dr. Asok Venkataraman
70.
NOACs Should Only Be Used in Non-Valvular AF ............................................................. 73

Dr. Dhiman Kahali
71.
Lessons Learned from Recent Clinical Trials and Various Guidelines

for Lipid Lowering Therapy ................................................................................................ 74
Dr. Prakash C Deedwania
72.
Will Transcatheter Aortic Valve Implantation (TAVI) Replace Surgery? .......................... 76

Dr. B D Prendergast
73.
Chronica Ischaemia in 2015 a European View Point ......................................................... 77

Dr. Roberto Ferrari
74.
Insulin Resistance in Ischemic Heart Disease .................................................................... 78

Dr. Udayan Ray
75.
Preventive Cardiology: Challenge for the Cardiologist ................................................... 80

Prof. David A Wood
76.
Remodelling of the Ventricle Pathophysiology and Treatment ....................................... 82

Dr. Roberto Ferrari
77.
Is Revascularization Mainstay Therapy for Chronic Stable Angina? ............................... 83

Dr. V K Bahl
78.
Heart Failure with Reduced Ejection Fraction in 2015: An Indian Viewpoint ................ 84
79.
Heart Failure with Reduced Ejection Fraction in 2015 ...................................................... 85

Dr. Roberto Ferrari
80.
Avoidance of Fluoroscopy during Radiofrequency Ablation ............................................86

Dr. Anitha G, et al.
81.
Prospective Observational Longitudinal Registry of Patients with

Stable Coronary Artery Disease (CLARIFY) - Global vs. Indian Cohort ............................ 88
Dr. Upendra Kaul
82.
Ulnars VInTEC Score as Clinical Predictor of Successful Ulnar Cannulation:

Subgroup Analysis of AJULAR (AJmer ULnar ARtery intervention) Cohort .................... 89
Dr. Bhanwar Lal Ranwa
83.
Detection and Location of Obstructive Coronary Artery Disease in

Patients of Chronic Stable Angina by Strain and Strain Rate
(Myocardial Deformation Parameters) In the Resting Echocardiogram .......................... 90
Dr. Deep Chandh Raja
84.
Epicardial Ablation of Ventricular Arrhythmia .................................................................. 92

85.
Valve Conservation Surgery: Current Status ..................................................................... 93

Dr. O P Yadava
86.
Wide QRS Tachycardia Separating Myths from Reality .................................................... 94

Dr. Mohan Nair
87.
Prosthetic Valve Endocarditis ............................................................................................. 95

Dr. K S Ravindranath
88.
TAVR VS SAVR Present Scenario ...................................................................................... 96

Dr. Brian Pinto
89.
Valve Conservation Surgery: Current status ..................................................................... 97

Dr. Atanu Saha
90.
Current Approach to a Patient with Functional Tricuspid Regurgitation ........................ 98

Dr. Mrinalendu Das
91.
Atrial Fibrillation: Rate Control Modalities ........................................................................ 99

Dr. A K Chauhan
92.
Stroke Prevention in Atrial Fibrillation ............................................................................. 100

Dr. Anurag Arora
93.
Cardioversion in Atrial Fibrillation .................................................................................... 101

Dr. R N Karmakar
94.
Atrial Fibrillation: Classification ........................................................................................ 102

Dr. Ashish Nabar
95.
Role of Ablation in Atrial Fibrillation ............................................................................... 103

Dr. A M Karthigesan
96.
Surgical AF ablation .......................................................................................................... 104

Dr. S. Thiagarajamurthy
97.
Dedicated Bifurcation Stents ............................................................................................ 105

Dr. Dharmendra Jain
98.
LV Assist Device .................................................................................................................. 106

Dr. Rupesh George
99.
Pharmacotherapy in Chronic Systolic Heart Failure: What is New? ............................... 107

Dr. U C Samal
100. Atrial Fibrillation: Case-Based Discussion ........................................................................ 108

Dr. M N Krishnan
101. Classification of Pulmonary Hypertension ....................................................................... 109
Dr. P Chandrasekhar
102. Pathogenesis and Pathology of Pulmonary Hypertension ............................................. 111

Dr. Sourangsu Chatterjee
103. Home Based Oxygen Therapy for Severe Pulmonary Hypertension ............................. 112
Dr. Hetan C Shah
104. Pharmacotherapy of Pulmonary Arterial Hypertension ................................................. 113

Dr. Dipak Ranjan Das
105. Iron Therapy in Heart Failure: Current Understanding ................................................... 114

Prof. Dr. Kajal Ganguly
106. Surgery for End-Stage Heart Disease .............................................................................. 115

Dr. A G K Gokhale
107. Bioresorbable Vascular Scaffold ....................................................................................... 116

Dr. C G Bahuleyan
108. Impella Device ................................................................................................................... 117

Dr. Manish Kapoor
109. Aspiration Thrombectomy ................................................................................................ 118

Dr. Saroj Mandal
110. The S-ICDTM System: Subcutaneous Implantable Defibrillator ..................................... 119

Dr. Soumik Basu
111. IRA/Multivessel Stenting in STEMI ................................................................................... 120

Dr. Goutam Dutta
112. Management of NSTE-ACS: Indian Scenario ................................................................... 121

Dr. Sundeep Mishra
113. MRI and Cardiac Devices .................................................................................................. 122

Dr. R K Saran
114. Management of Acute Pulmonary Embolism ................................................................. 123

Dr. P K Gupta
115. Management of STEMI- Indian Scenario ......................................................................... 124

Dr. C N Manjunath
116. A Strange Portrait of Therapeutic Anticoagulation ........................................................ 126

Dr. P K Deb
117. Takotsubo Cardiomyopathy .............................................................................................. 127

Dr. Pawan K Sharma
118. A Journey of 82 years of Thrombolysis in STEMI: Challenges of

STEMI Care in India and the Real World .......................................................................... 128
Dr. H K Chopra
119. Stents or CABG in 2016: Practice and Politics .................................................................. 129

Dr. David P Taggart
120. Future Improvements in the Interventional Treatment of Patients with STEMI ........... 130
Dr. Simone Biscaglia
121. Intervention: How and to What Extent is Technology Helping Us? .............................. 131
122. Contemporary Perspectives on ST Segment Elevation Acute
Coronary Syndromes The Good, The Bad and The Ugly........................................... 132
Dr. Gautam Kumar
123. Advanced Imaging in the Cath Lab: New Ideas and Applications ................................. 133
Dr. Y Chandrashekhar
124. NSTE-ACS: Conservative Treatment for Whom and When? ........................................... 134
Dr. Deepak Kumar Gupta
125. Hypertension and Diabetes Mellitus: Partners in Crime ................................................ 135

Dr. Charan Lanjewar
126. Intervention in Aortaarteritis: Largest Experience in India ............................................ 136

Dr. Monotosh Panja
127. Biomarkers in ACS ............................................................................................................. 137

Dr. Milan Chag
128. Percutaneous Intervention: For Whom and When? ........................................................ 138

Dr. Sanjay Chugh
129. Pre-Hospital Thrombolysis: Its Scope in India ................................................................. 139

Dr. Sanjay Tyagi
130. Ischemia and Viability Driven Revascularization: Is It the Answer? .............................. 140
Dr. Praveen Chandra
131. Antiplatelet Therapy in STEMI .......................................................................................... 142

Dr. Debdatta Bhattacharyya
132. Risk Stratification after STEMI .......................................................................................... 143

Dr. K Jayanthi
133. Hypertension Targets: Should They Differ? ..................................................................... 144

Dr. P Ramachandran
134. Implications of Central Aortic Blood Pressure in Management of Hypertension ......... 145
Dr. Devanu Ghosh Roy
135. First-Line Anti-Hypertensive Therapy .............................................................................. 146

Dr. Vidyut Jain
136. Acute Coronary Syndrome Surgery : For Whom and When? ........................................ 147
Dr. Arunkumar Krishnasamy
137. Classification and Diagnosis of Acute Coronary Syndrome (ACS) ................................. 148
Dr. Bhuban Majhi
138. Risk Stratification in Acute Coronary Syndrome ............................................................. 149

Dr. Pankaj Singh
139. Management of Valvular Heart Disease during Pregnancy ........................................... 150

Dr. A N Patnaik
140. Polypills: Hit or Flop? ......................................................................................................... 151

Col (Dr) R Girish
141. Revised Jones Criteria for Diagnosis of Acute Rheumatic fever .................................... 152
Dr. Chhabi Satpathi
142. Combination Diuretic Therapy in Heart Failure with Reduced EF: When and How? .... 153
Dr. Mriganka S Chaliha
143. Non-Invasive Testing in Stable Coronary Artery Disease (SCAD): Order of Preference ....... 154
Dr. D Rajasekhar
144. Stable CAD in Women ....................................................................................................... 155

Dr. Harendra Kumar
145. The Conduit Confusion ...................................................................................................... 156

Dr. Kunal Sarkar
146. Allopurinol and Chelation Therapy in Stable Angina ..................................................... 157

Dr. Aziz Khan
147. Stable Coronary Artery Disease: A Forerunner for

Ischemic Cardiomyopathy, Myth or Reality? ................................................................... 158
Dr. Rajeshwari Nayak
148. Stable Angina with Normal Coronaries: Management Protocol .................................... 159
Dr. Sunandan Sikdar
149. An Update on MINOCA ..................................................................................................... 161

Dr. Kadiyala Meenakshi
150. Is the Concept of Metabolic Syndrome Still Relevant? ................................................... 162

Dr. Bino Benjamin
151. All Nonvalvular AF Should be treated with NOAC certainly NO ................................... 163
Dr. K Venugopal
152. Unusual Case of Cardiomyopathy .................................................................................... 165

Dr. Uday Kiran A
153. Cardiac MR Ischemia Evaluation .................................................................................... 166

Dr. Mahesha B M
154. Cardiac MRI in CHD ............................................................................................................ 167

Dr. R Rajeshkannan
155. Emerging Trends in Non-Coronary CTA ............................................................................ 168

Dr. D Karthi Keyan
156. Coming off Bypass in OR Mishaps: TEE for the Rescue ................................................... 169
Dr. Raj Janardhanan
157. An Approach to a Patient with VT with Structurally Normal Heart .............................. 170
Dr. Rakesh Yadav
158. NSTEACS Conservative Treatment: For Whom and When? ............................................ 171
Dr. Deepak Gupta
159. The Heart Team Concept .................................................................................................... 172

Dr. Naresh Trehan
160. Obesity Paradox ................................................................................................................. 174

Dr. S K Dwivedi
Ambulatory Blood Pressure Monitoring:

Expanding Indications
Dr. George Koshy A
MD, DM, FRCP, FACC, FESC
Professsor and Head
Department of Cardiology, Government Medical College, Thiruvananthapuram, Kerala
Despite advances in the understanding of mechanisms of systemic hypertension, and increased

drug therapies, hypertension still remains an important risk factor for cardiovascular diseases.
Hypertension is responsible for 54% of stroke and 47% of ischemic heart disease cases worldwide.
The asymptomatic nature of the disease with a consequent delay in diagnosis, non-adherence to
therapy, suboptimal therapy, lack of regular follow-up, and side-effects of drugs remain significant
obstacles to the effective control of hypertension.
Ambulatory blood pressure monitoring (ABPM) has established itself as an important technique in
the diagnosis and management of hypertension. Apart from its usefulness in detecting white coat
effect, identifying masked hypertension, and evaluating nocturnal hypertension, the utility of ABPM
has been reported in various contexts as outlined in Table 1.
Table 1: Newer Clinical Applications of ABPM: Lessons From Clinical Studies.
CLINICAL SETTING
ABPM CORRELATES
Left ventricular
hypertrophy (LVH)
In hypertensive patients with LVH followed up for 1 year, treatment induced changes in ABP correlated better with
regression of LVH than clinic BP.
Diabetes mellitus
Non-dipping and masked hypertension is common among diabetic patients. Routine office BP measurements may
therefore underestimate the real CVD risk. Because of the potentially devastating synergistic effects of diabetes and
hypertension on target organ damage (TOD), ABPM might be considered in diabetic patients with high-normal BP
levels and in diabetic patients with TOD that is out of proportion to the severity and duration of diabetes.
Atherosclerosis
Systolic ambulatory BP variables are significantly associated with aortic arch atherosclerosis.
Metabolic syndrome
(MS) and Obesity
Patients with MS (especially in those with increased waist circumference) have higher rates of nocturnal non-dipping.
Smoking
An increased daytime but normal office BP may be related to smoking.
Cerebrovascular
disease
Increased ambulatory systolic BP has superior correlation with microvascular brain disease as detected by white
matter hyperintensity on brain MRI, as well as with neurocognitive decline.
Chronic Kidney
Disease (CKD)
CKD patients have higher rates of non-dipping and reverse dipping; these factors are correlated with higher stages
of nephropathy.
Elderly
Isolated ambulatory hypertension is associated with a 3-fold increased risk of CVD morbidity.
Gender
Males have more ABPM abnormalities and also show a greater increase in ABPM parameters with age.
Ethnic differences
African Americans have been found to have higher ABPM recordings when compared to European Americans on
longitudinal follow-up at 15 years in a population aged 7-30 years.
In conclusion, ABPM is a useful tool in the evaluation and management of selected patient subsets in
hypertension. At present, there is insufficient evidence to consider it as an essential part of standard
clinical practice in hypertension. However, with an increasing body of evidence, ABPM may constitute
an integral if not an essential part of hypertension management.
1
Controversies on HDL Modulation:

Likely Explanations
Dr. S S Iyengar
MBBS, MD
Interventional Cardiologist
Manipal Hospital, Bangalore
Dyslipidemia is one of the major risk factors for atherosclerotic vascular disease (ASCVD) and the
primary anti-dyslipidemia target is LDL-cholesterol. However, presence of residual risk despite achieving
the LDL-C goals necessitates the search for another therapeutic target. Dr. Iyengar discussed the role
of HDL in the treatment of dyslipidemia.
Epidemiological and observational studies strongly support the HDL hypothesis; HDL-C has an inverse
relationship with ASCVD events. Many potential beneficial actions have been attributed to HDL-C,
some of them being cholesterol efflux, anti-inflammatory, antiapoptotic, antioxidative, antiinfective,
antithrombotic, and vasodilatory effects. However, randomized control trials involving drugs like
niacin, fibrates and CETP inhibitors failed to demonstrate positive benefits of HDL-C increase in
ASCVD alleviation. In addition, genetic studies have cast a doubt on the HDL hypothesis. On the
contrary, higher HDL-C continues to be viewed as a negative risk factor in assessing ASCVD risk in
various guidelines.
HDL is highly heterogenous in structure and function. One should be cognizant that HDL-C is not
synonymous with HDL. Besides cholesterol, HDL is now known to carry more than 100 different types
of lipids, many of which are potent bioactive signaling molecules. Besides apolipoprotein A-I, its main
structural protein, approximately 80 different proteins have been described to be associated with
HDL. Studies have sought to identify the component of HDL that is clinically relevant, therefore, to
explain the beneficial effects of HDL. Further studies would clarify whether HDL is merely a biomarker
or a risk factor.
Some studies have shown the ratio of HDL-C to HDL to be a better indicator of ASCVD risk. Other
studies have recorded HDL-3C to have an association with long term ASCVD clinical events. In one
study, cholesterol efflux capacity was found to be a better biomarker.
Under certain situations, HDL-C becomes dysfunctional. It remains speculative how HDL acquires
its proinflammatory and proatherogenic effects. Coronary artery disease, chronic kidney disease,
senility, diabetes and smoking have been shown to be associated with dysfunctional HDL-C. It is
interesting that low fat, high fibre diet in combination with exercise converts HDL-C from being
proinflammatory to anti-inflammatory.
It remains largely unknown whether HDL functions are linked to HDL size, concentration, ApoA-I
composition, density, mobility, or any combination of these properties. Also, it remains unclear if
interventions should target the transformation of native HDL to dysfunctional HDL.
More data regarding the effect of HDL-targeted therapies on coronary heart disease events need to
emerge.
ARNI: The New Blockbuster for Heart Failure

with Reduced Ejection Fraction
Dr. P C Manoria
MBBS, MD
Cardiologist
Manoria Heart and Critical Care Hospital, Bhopal
Based on the PARADIGM HF trial results, angiotension receptor neprilysin inhibitor (ARNI) has
emerged as a new blockbuster in improving the survival of patients of chronic heart failure with
reduced ejection fraction (HFrEF) receiving standard evidence-based therapies. The drug has been
already approved by US FDA for clinical use and likely to be launched in India in June 2016.
The PARADIGM trial was a double-blind randomized study involving 8442 patients with class II, III, or
IV HF and an EF of 40% or less. The study interventions included either ARNI (at a dose of 200 mg
twice daily, each tablet containing sacubitril 97 mg and valsartan equivalent to 180 mg) or enalapril
(at a dose of 10 mg twice daily), in addition to recommended therapy. ARNI exhibits a dual action of
blocking the maladaptive RAAS and potentiating the vasoactive natriuretic peptide system. The trial
was prematurely terminated after a median follow up of 27 months because of substantial benefit
in ARNI arm.
The PARADIGM trial showed a very impressive reduction in the primary composite end point of CV
death and hospitalization for HF by 20% with a very significant P value = 0.0000002. The benefit
was seen very early and it was sustained and consistent across all sub-groups. The CV death was
reduced by 20% and hospitalization for HF by 21%. The all-cause mortality was reduced by 16%.
The drug was well tolerated and had lower withdrawal rate compared to enalapril.
Based on the above findings, Dr. Manoria concluded that ARNI is poised to supersede ACEI/ARBs,
thus heralding a new age of multisystem modulation that will revolutionize the way we understand
and treat cardiovascular disease.
Acute Decompensated Heart Failure:

An Internists Approach
Dr. Soumitra Kumar
MD, DM, FCSI, FACC, FESC, FSCAI, FICC, FICP, FIAE
Consultant Cardiologist
Fortis Hospital, Kolkata
Despite significant advances in the management of chronic heart failure (CHF), understanding of
acute decompensated heart failure (ADHF) has remained relatively stagnant. Therefore, Dr. Soumitra
Kumar provided a systematic approach to the management of ADHF. The initial management of
ADHF should comprise of diagnostic confirmation, haemodynamic and severity assessment followed
by institution of appropriate treatment. This should be carried out in a time-bound fashion akin to
management of acute coronary syndrome.
Treatment goals for patients admitted for ADHF are:
a. Improving symptoms, especially congestion and low-output symptoms
b. Identifying etiology and precipitating factors
c. Optimizing chronic oral therapy
d. Minimizing side effects
e. Identifying patients who might benefit from revascularization
f. Identifying patients requiring device support/transplantation
Diagnosis of ADHF includes biomarker (NTProBNP) and/or Echo-based approaches besides routine ECG
and Chest X-ray. Clinical severity assessment involves categorization of the patient into Warm/Dry,
Cold/Dry, Warm/Wet, Cold/Wet categories. Based on the severity and haemodynamic assessments,
primary treatment comprising of diuretics, vasodilators and inotropes should be instituted in various
combinations. Oxygen therapy and ventilator support (non-invasive/invasive) constitute essential
support systems. Renal replacement therapy (Ultrafiltration) may be essential in specific situations
of diuretic resistance/failure. Optimization of ongoing chronic therapy when presenting with acute
on chronic heart failure should be done on the basis of prevailing haemodynamic and renal status.
Etiology of ADHF should be interrogated at the earliest opportunity following stabilization and acute
coronary syndrome (ACS) should be investigated in particular for any scope of revascularization. Few
patients with refractory failure will require short-term left ventricular assist devices and may turn out
to be candidates for cardiac transplantation ultimately.
Status of Non-Statin Anti-Lipidemic Therapy

Dr. Ramesh Babu Byrapaneni
MBBS, MD, DM
Medwin Hospital, Hyderabad
LDL-C lowering has classically been the therapeutic target for reducing adverse cardiac events. Despite
evidence in favor of statins lowering LDL-C, mortality and morbidity, residual risk for CVD remains
intangible to intervention. Addition of lipid modifying agents such as fibrates, niacin, CETP inhibitors
does not increase the cumulative effect of statins. Therefore, there is an impending need for therapies
that address the residual risk despite statin therapy. Dr. Ramesh Babu discussed the role of PCSK9, a
novel target for dyslipidemia treatment that has gained much scientific interest in the recent times.
PCSK9 is a lysosomal protease, which facilitates catalytic breakdown of LDL-C receptors in hepatic
cells and thus blocks the hepatic breakdown of LDL-C; in consequence, circulating LDL-C levels
increase. Potential therapeutic targets in the PCSK9 pathway are depicted in Figure 1.
3
ARH
Endosome
1. Reduction of PCSK9 protein production
2. Reduction of PCSK9 mRNA expression
Lysosome
Golgi apparatus
1 PCSK9 mRNA
2
Endoplasmi reticulum
Nucleus
3. Inhibition of PCSK9 binding to the

LDL-R
Pro-PCSK9
Mature PCSK9
LDL receptor
4. Inhibition of PCSK9-mediated
degradation of the LDL-R
ARH Autosomal recessive

hypercholesterolemia
adaptor protein
Figure 1: Potential targets in the

PCSK9 pathway.
The first PCSK9 inhibitors to be approved the US FDA are alirocumab (July 2015) and evolocumab (August
2015). It is recommended for use in adult patients with hetreozygous familial hypercholesterolemia
(HeFH), homozygous familial hypercholesterolemia (HoFH) or clinical atherosclerotic cardiovascular
disease such as heart attacks or strokes who require additional lowering of LDL cholesterol.
ALN-PCSsc, an RNAi investigational drug that inhibits PCSK9 synthesis inhibitor based on interim
results is found to be a well-tolerated drug with all adverse events being mild or moderate in
severity. LDL-C reduction is comparable to that observed with anti-PCSK9 Mabs in patients with or
without statin co-medication. In addition, substantial reductions in LP(a), total cholesterol, non-HDL
cholesterol, with no change in HDL have been recorded.
5
Heart Failure in the Elderly

Dr. Suvro Banerjee
MD, FRCP, FRCP, FICC, FESC, FACC, FSCAI
Senior Consultant Interventional Cardiologist
Apollo Gleneagles Hospital, Kolkata
The prevalence of heart failure (HF) sharply increases in the elderly population; in people aged below
45 years, the prevalence is 1% and is increased by ten-fold in population aged above 70 years.
Dr. Suvro Banerjee notes an accumulation of adverse cardiac events and the cardiotoxic effects of
ageing to be the fundamental factors underlying increased prevalence in the elderly.
Although, people aged 70 years and above may be considered as the elderly, criteria for the Frail
elderly (Table 1) as prosposed by Martinez Martin et al. may be more meaningful.
Table 1: Frail Elderly Criteria.
1. Clinical criteria
Multiple comorbidities
Polymedication
Frequent hospitalizations
Repeat falls
Sensory deficit
Urinary incontinence
2. Functional criteria
Dependency in the basic

activities of daily life
Dependency in the
instrumental activities of
daily life
3. Socioeconomic
criteria
Lives alone
Recently widowed
Institutionalization
Age >80 y
Low economic status
4. Cognitive-affective
criteria
Depression
Cognitive deterioration
Diagnosis of HF may be challenging in the elderly because

of: atypical symptoms such as anorexia, nausea, irritability,
and confusion; symptoms being masked by frailty (shortness
of breath being unnoticeable due to inactivity); symptoms
being attributed to normal aging processes (shortness
of breath on exertion mistaken as part of ageing); and
symptoms being considered to be due to co-morbid diseases
(shortness of breath may be considered to be due to chronic
obstructive airways disease). In addition, specificity and
predictive value of natriuretic peptides decline with age.
Prognosis would depend on the degree of frailty and
associated comorbid conditions. The traditional HF
mortality predictive scores such as ADHERE and EFFECT are
not dependable in the elderly. Multidimensional Prognostic
Index may be effective.
Treatment challenges include exacerbation of comorbid conditions on treatment of HF and vice

versa. Underlying psychosocial factors, including anxiety, depression, lack of emotional support,
and social isolation may compound HF outcomes; therefore, these factors need clinical attention.
General principles of treatment in elderly are similar to that in young adults. Precipitating factors
(anemia, infection, arrhythmia, drug non-compliance) should be identified early and treated. Drugdrug interactions and drug-disease interaction are frequent, and these factors should be adequately
addressed.
In conclusion, early diagnosis and multidisciplinary care, education of patient and family, improving
social support and close monitoring of high risk patients in the community, are essential in improving
outcomes of HF in the elderly.
6
Biomarkers in Heart Failure:

Many Shots in the Arm
MD, DM, FACC, FESC, FACP, FAPSC, FICC, FCSI, FICP
Invoking the National Institute of Health (NIH) definition of biomarkers as a characteristic that is
objectively measured and evaluated as an indicator of normal physiologic processes, pathogenic
processes or the response to a therapeutic intervention, Dr. Banerjee presented an informative
update on the role of biomarkers in the diagnosis and management of heart failure. Specifically, the
presentation highlighted the importance of natriuretic peptides in the management of heart failure.
B-Type Natriuretic Peptide (pg/ml)
B-type natriuretic peptide (BNP) at a cut off level of >100 pg/ml improves the diagnostic accuracy
of heart failure (Figure 1) and also correlates with in NYHA functional class (Figure 2). Similarly,
N-terminal pro-B-type (NT-PROBNP) levels are reliable biomarkers for differentiating acute and nonacute congestive heart failure, and assessing the severity of heart failure. Furthermore, NT-PROBNP
levels are reliable predictors of survival in patients with acute heart failure.
Diagnostic Accuracy (%)
p < 0.0001 for BNP or Both vs Clinical Judgement

84.0
82.0
80.0
78.0
76.0
74.0
72.0
70.0
81.2
81.5
74.0
Clinical
Judgement
BNP >100
pg/ml
1400
1200
1000
800
600
400
200
0
I
(N = 18)
Both
Figure 1: Improvements in diagnostic

accuracy with BNP.
II
III
IV
(N = 152)
(N = 351)
(N = 276)
New York Heart Association Class
Figure 2: BNP levels and NYHA class.
Thus, measurement of BNP or NT-PROBNP levels is useful in ambulatory/ outpatients and hospitalized/
acute settings for decision making in the setting of clinical uncertainty and establishing prognosis or
disease severity in chronic heart failure. Along with this, biomarkers of myocardial injury or fibrosis
may be considered for additional risk stratification in patients with acutely decompensated heart
failure. Other biomarkers of clinical relevance include troponin, interleukin 6, galectin, copeptin and
serum Neutrophil gelatinase-associated lipocalin (NGAL).
Based on these discussions, the presentation highlighted and reiterated the crucial importance of
biomarkers (especially natriuretic peptides) in the management of heart failure. Biomarkers provide
important insights into physiologic mechanisms. Dr. Banerjee closed the presentation by stressing
that integration of biomarkers into disease management programs would perhaps lead to better
therapies and ultimately to improved patient outcomes.
7
Anti-Diabetics and Cardiac Vascular

Safety issues
Prof. G Justin Paul
MD, DNB [Medicine], DM, DNB [Cardio], FACC,
Professor of Cardiology
Madras Medical College, Chennai
Type 2 diabetes mellitus is a known risk factor for cardiovascular disease. Prof. Paul in his presentation
explained this risk in greater detail and also drew the attention of the audience towards the off-target
effects of antidiabetic agents that may increase the risk of cardiovascular disorders. Discussing data
from landmark clinical studies such as UKPDS, DCCT, ACCORD, ADVANCE and VADT, the speaker
highlighted that the outcome data from diabetic patients with proven coronary artery disease may
not apply to a diabetic patient without CAD. Prof. Paul presented an extensive and interesting
discussion on data from recent clinical studies on the cardiovascular risks and benefits of antidiabetic
agents (see Box 1).
Metformin
Safe for the heart
Sulfonylureas
Safety not clearly proven
Increased CV risk- conflicting evidence
Meglitinides
Not been proven safe
TZDs
Rosiglitazone increases ACS and HF
Pioglotazone at high does increase HF
Alpha glucosidase inhibitors
Weight neutral
No hypoglycemia
Safety is an issue
GLP analogues:
Lixisenatide is safe
Others -CVOT results are awaited
DPP4 inhibitors [Gliptins]
Safety is established
Do not cause weight gain/hypoglycemia
Saxagliptin is associated with increased
risk of HF
SGLT2 inhibitors
Weight neutral (may reduce weight)
Empagliflozin is safe and reduces CV risk
Canaglifozin and Dapagliflozin- CVOT
results awaited
Class effect assumed till such time
Box 1: An overview of cardiovascular safety of antidiabetic agents.
Concluding remarks of this presentation placed an emphasis on mitigation of other risk factors such
as cholesterol and blood pressure along with reductions in plasma glucose for cardiovascular risk
reduction in diabetes. The speaker also stressed the need for individualizing the treatment of every
patient by choosing a drug that does not compromise cardiovascular safety.
Aids to HIV and Heart

Dr. Debabrata Roy
MD, DM, FACC
Academic Co-ordinator and Senior Consultant Interventional Cardiologist
NH-RTIICS, Kolkata
Patients with an infection of human immunodeficiency virus (HIV) have an increased risk of developing
cardiovascular disorders (CVD). Dr. Roy highlighted that this association could be explained by the high
prevalence of CVD risk factors in patients with HIV infections. Furthermore, ART-induced metabolic
changes and systemic immune activation that promote endothelial inflammation and atherosclerosis
may also contribute to the burden of cardiovascular disorders in patients with HIV infections.
The presentation discussed the findings of studies that noted a high prevalence of smoking,
hypertension, diabetes and dyslipidemia in HIV-infected patients. Discussing the role of these
cardiovascular risk factors, Dr. Roy indicated that elevated triglycerides (TG), total cholesterol and
low-density lipoproteins, and lower high-density lipoproteins seen following the initiation of antiretroviral therapies (ART) are possibly due to IL6-mediated increases in lipolysis and hepatic synthesis
along with IL6-mediated suppression of insulin-mediated lipolysis and peripheral FFA trapping.
Furthermore, lipodystrophy seen in about 50% patients on long-term ART (particularly 1st generation)
increases the Framingham risk scores and mortality. The incidence of insulin resistance and diabetes
mellitus is high in patients and HIV and those on 1st generation ARTs such as thymidine-containing
analogue reverse transcriptase inhibitors. However, newer ARTs do not elevate these risks. A number
of clinical studies also report an increased risk of myocardial infarctions with drugs such as abacavir,
indinavir, lopinavir, and didanosine.
1.
Offer early ART by balancing the efficacy against the risk of long-term side effects
2.
Undertake CVD risk prediction.

a. D:A:D risk calculator may be marginally better
b. Framingham Risk Score may over and underestimate the risk in women, and ex-smokers
3.
Undertake measures to modify risk factors such as

a. Smoking,
b. Dyslipidemia
c. Hypertension
4.
Offer statin therapy along with ART to suppress endothelial inflammation.

Box 1: Providing aids to manage cardiovascular risks in patients with HIV infections.
With these observations, the presentation offered a few aids to manage cardiovascular risks in
patients with HIV infections (Box 1). Although HIV is associated with an increased risk of cardiovascular
disease due ART-induced metabolic changes and systemic immune activation, timely initiation of ART
is first priority considering the massive HIV-related benefit of these drugs. Routine assessment of
CVD risk and treatment of hypertension and dyslipidemia is the second priority. Dr. Roy concluded
the presentation by indicating that although ART can induce dyslipidemia, the risk should be put into
perspective with the massive HIV-related benefit associated with ART.
9
Ivabradine in CVD: What is new?

Dr. A K Pancholia
MD, FACC, FESC, FCSI, MAMS, FIMSA
Arihant Hospital and Research Center, Indore
Dr. Pancholia started his presentation by drawing the attention of the audience to the fact that
heart rate is inversely proportional to life expectancy (Figure 1). Elevated heart rate is associated
with a number of detrimental effects such as atherosclerosis, ischemia, remodeling and chronic
heart failure. The presenter discussed data from a number of clinical studies that indicate elevated
risk of myocardial infarction and coronary revascularization. Furthermore, heart rate >70 beats per
minute (BPM) is a significant predictor of cardiovascular death and hospitalization for heart failure.
The presenter also discussed and presented data from clinical studies that indicate a reduction in
relative risk of coronary revascularization, sudden death, and cardiovascular death with each 10 BPM
reduction in resting heart rate.
1000
Heart rate (bpm)
500
300
100
50
Mouse
Hamster
Rat
Monkey
Marmot
Cat
Dog
Giraffe
Tiger
Ass
Horse
Lion
Whale Whale
20
Exclusive HR reduction
Proven anti-anginal and anti-ischaemic effects
Preservation of left ventricular relaxation
No negative inotropic effects
Man
Absence of coronary vasoconstriction

Maintenance of blood pressure
Absence of bronchospasm linked with -blockers
No effect on intra-atrial, atrioventricular or
intraventricular conduction times.
10 15 20 25 30 35 40 80 100
Life expectancy (years)
Figure 1: Inverse relationship between

heart rate and life-expectancy.
Box 1: Advantages of ivabradine.
While beta blockers can reduce heart rate, their side-effects, negative inotropic actions and intolerance
at doses needed to reduce heart rate are a disadvantage. Ivabradine, a novel and pure heart rate
reducing agent acts through If inhibition, which reduces the diastolic depolarization slope. Discussing
data from a number of clinical trials such as INITIATIVE, BEAUTIFUL, and REDUCTION and along with
data from ASSOCIATE, ADDITION, SHIFT and SIGNIFY studies, Dr. Pancholi explained that ivabradine
improves coronary flow velocity, coronary flow reserve and increases coronary collateral circulation.
He also summarized the advantages of ivabradine (Box 1) and explained its utility in the treatment of
coronary artery disease, congestive heart failure and inappropriate sinus tachycardia. Closing remarks
of this presentation reiterated and emphasized that heart rate is the new target for management of
cardiovascular disease.
10
Azilsartan Medoxomil- a New Kid in the Horizon

of Hypertension
Dr. Mrinal Kanti Das
MD, DM, FICC, FCSI
Consultant and Senior Interventional Cardiologist
B.M. Birla Heart Research Centre, Kolkata
Hypertension is a critical and foremost risk factor for CHD, stroke, heart failure and PAD. In India, only
about one-tenth of rural and one-fifth of urban Indian hypertensive population have their BP under
control. Among patients with hypertension, non-compliance is a persisting problem and 50% stop
therapy within 2 years. Discussing these aspects, Dr. Das also pointed out that pre-hypertension is
associated with CVD mortality, especially with stroke mortality, but not with all-cause mortality. The
risk for CVD mortality is largely driven by high-range pre-hypertension.
Tight blood pressure control as opposed to tight glucose control results in a better risk reduction of
cardiovascular outcomes. Data from SPRINT study indicates that target systolic blood pressure of 120
mm Hg is superior to a target of 140 mm Hg. This change reduced the risk of death by almost 25% and
reduced the rate of overall cardiovascular problems, including heart attacks, strokes, and heart failure,
by almost a third. While a number of angiotensin receptor blockers have emerged and can address
the issue of hypertension control, azilsartan is a novel drug on the horizon. In the case of the AT1
K199A receptor, the unique structure of azilsartan might maintain the ability to block Ang II-induced IP
production and ERK activation after wash-out. This effect may prolong the effect of azilsartan.
Azilsartan induces the insurmountable antagonism of Ang II-induced vascular contractions against
AT1 receptor. Azilsartan induces stronger inverse agonism independent of Ang II stimulation than
candesartan, and this ability of azilsartan may be associated with its unique moiety. Hierarchical analysis
demonstrate that azilsartan medoxomil at its maximal dose has superior efficacy to both olmesartan
and valsartan at their maximal approved doses (Figures 1 and 2) without increasing adverse events.
Thus, azilsartan medoxomil could provide higher rates of hypertension control within the ARB class.
24-Hour Mean Systolic BP by ABPM
Change from Baseline to Week 6
24-Hour Mean Diastolic BP by ABPM

Change from Baseline to Week 6
(LS meanSE, mm Hg)
0
-3
-6
-9
-12
-15
(LS meanSE, mm Hg)
Placebo
AZL-M 40 mg
AZL-M 80 mg
VAL 320 mg
OLM-M 40 mg
-0.3
-10.2
-13.4
-2
Placebo
AZL-M 40 mg
AZL-M 80 mg
VAL 320 mg
OLM-M 40 mg
-0.1
-6
-12.0
-10
-14.5
Figure 1: Effects of azilsartan on 24-hour

mean systolic BP.
-7.1
-8.7
-7.7
-9.4
Figure 2: Effects of azilsartan on 24-hour

mean diastolic BP.
Dr. Das concluded his presentation by highlighting that the molecular findings on azilsartan should
open up newer thoughts on management of hypertension. However, he stressed the need for
outcomes data before adopting this potent drug widely in clinical practice.
11
Calcium Channel Blockers- Newer Perspectives

Dr. Geevar Zachariah
MD, DM
Chairman, Mother Heart Care
Thrissur, Kerala
Dr. Zachariah presented his perspectives on calcium channel blockers by starting off his presentation
with a discussion on physiology of voltage gated calcium channels. Describing the various types of
calcium channels and the evolution of calcium channel blockers, he highlighted that L-type blockers
have problems associated with baroreflex-mediated activation of sympathetic nervous system and thus
peripheral oedema. Furthermore, these drugs have a weak renoprotective and anti-albuminuric effects.
180
160
Amlodipine
Cilnidipine
Systolic BP
30
Number of patients
Blood pressure (mm Hg)
In contrast, cilnidipine is a blocker of L and N type calcium channels. Cilnidipine is effective and at
once daily dosing, with a BP lowering effect similar to amlodipine (Figure 1). However, cilnidipine
by virtue of presence of N type of calcium channels in the venules, dilate post capillary venules and
prevent capillary hypertension and edema formation (Figure 2). Furthermore, available clinical data
indicate that cilnidipine reduces heart rate, morning hypertension and renoprotective actions are
similar to benazepril. Furthermore, cilnidipine might improve insulin resistance and lower fasting
serum immunoreactive insulin (F-IRI), and HOMA-R in patients with obesity. Currently, cilnidipine
is seen as a calcium channel blocker with antihypertensive effect comparable to other agents in
the class along with a potential reduce peripheral edema, offer renal protection and avoid reflex
sympathetic activity. Dr. Zachariah indicated that the usefulness of cilnidipine at present is limited to
hypertensive patients requiring CCB and show intolerance to amlodipine-related edema.
140
120
100
80
60
40
Diastolic BP
25
With edema
Without edema
20
15
10
05
0
Pre
Amlodipine
12 months
Figure 1: BP lowering effects of cilnidipine.
Cilnidipine
Figure 2: Comparison of cilnidipine and

amlodipine for their effects on edema.
Dr. Zachariah also discussed other Dual L and T type CCBs such as manidipine, nilvadipine, benidipine
and efonidipine. He concluded his presentation by highlighting that drugs blocking both L and N
type calcium channels as well as L and T channels may have several advantages, like reduction of
edema, less or no reflex tachycardia and better renoprotection. Blockers of L and N or L and T calcium
channels are promising novel therapeutic agents for not only hypertension, but also heart failure,
arrhythmias, disorders of microcirculation and chronic pain.
12
Chronic Constrictive Pericarditis: An Outline of

Diagnosis And Management
Dr. Ranjit Nath
MD, DM
Professor of Cardiology,
RML Hospital and PGIMER, New Delhi
Constrictive pericarditis is a condition in which a thickened, scarred, and often calcified pericardium
limits diastolic filling of the ventricles. Although it is commonly thought that a normal pericardial
thickness excludes the diagnosis of constrictive pericarditis, 28% of surgically confirmed cases
have normal pericardial thickness on CT scan, and 18% have normal thickness on histopathologic
examination.
Dr. Ranjit Nath discussed the utility of various diagnostic methods for diagnosing constrictive
pericarditis. The presentation included a discussion on ECG, chest radiograph, CT, MRI and B typenatriuretic peptides for the diagnosis of constrictive pericarditis. Small studies have shown promising
value of BNP in differentiating constrictive pericarditis and restrictive cardiomyopathy. The discussion
also presented the diagnostic aspects of Doppler echocardiography and catheterization criteria for
the diagnosis of constrictive pericarditis.
Overall, the presentation indicated that no single approach should be used to diagnose all cases of
constrictive pericarditis. The diagnostic approach taken should be individualized for each patient. The
most important diagnostic tool is the clinical suspicion of constrictive pericarditis in a patient with
signs and symptoms of right sided heart failure that are disproportionate to pulmonary or left sided
heart disease.
Dr. Ranjit Nath concluded the presentation by emphasizing that no one finding will be 100% accurate
and that a final diagnosis should be based on a combination of clinical and echocardiographic
findings.
13
Refractory Angina- Any Silver Lining?

Dr. Santhosh Satheesh
MBBS, MD, DM
Additional Professor and Head of Cardiology
Jawaharlal Institute of Post graduate Medical Education and Research
Chronic refractory angina is characterized by clinical diagnosis of stable angina, and does not respond to
risk factor modifications and medications. Furthermore, revascularization is not feasible. Neurological,
psychogenic and mitochondrial dysfunctions along with an untreatable angina significantly affect
quality of life. Chronic refractory angina is seen in about 53% patients post angioplasty and 12%
patients post CABG.
Box 1 indicates the list of conditions important in the diagnosis of refractory angina. Ranolazine
(inhibitor of late Na+ current) is the only FDA approved drug for refractory angina. EECP is the most
widely used and is an FDA approved non pharmacological therapy. Other classical non-pharmacologic
options for refractory angina pectoris are listed in Box 2. Discussing these aspects, Dr. Santhosh
Satheesh described Coronary Sinus Reducer, Extracorporeal Shockwave Myocardial Revascularizatio
(ESMR) and lipoprotein apheresis as silver linings in the management of chronic refractory angina.

Aortic stenosis
Anemia
Cardiac syndrome X
Costochondritis
Dilated cardiomyopathy
Gallbladder disease
Hypertrophic cardiomyopathy
Intercostal neuralgia
Pancreatitis
Peptic ulcer
Pericarditis/pleuritis
Pneumonia
Pneumothorax
Pulmonary embolism
Pulmonary hypertension
Esophageal spasm
Reflux esophagitis
Thyrotoxicosis
Box 1: Causes of chest pain to be ruled out in the differential

diagnosis of chronic refractory angina.
Enhanced external counterpulsation (EECP)
Spinal cord stimulation (SCS)
Percutaneous in situ coronary venous arterialization
Transmyocardial revascularization (surgical and percutaneous)
Stem Cell Therapy
Heart transplantation
Chelation therapy
Gene therapy
Box 2: Non-pharmacologic options for refractory

angina pectoris.
The reducer is an Hourglass shaped stainless steel balloon expandable stent. Results of the COSIRA
study indicates that 35% (18/52) of the patients in the Reducer group vs.15% (8/52) of patients
in the sham-control group improved by 2 CCS classes (p=0.024). Other observations indicate
that successful device implantation can be accomplished in about 96% of the participants. CT
angiography six months after device implantation indicates no device migration or occlusion. ESMR
uses a special generator that produces low intensity shockwaves and stimulates the formation of
new blood vessels. Three 20-minute sessions per week over nine weeks may be optimal. Lipoprotein
apheresis is another strategy currently under investigation. Describing Coronary Sinus Reducer, ESMR
and lipoprotein apheresis as promising future therapies, Dr. Santhosh Satheesh also stressed the
importance of psychological assessment and antidepressant use in a subset of patients with refractory
angina, a difficult to treat condition.
14
SCAD: When Intervention is Justified?

Dr. Shirish Hiremath
MD, DM
Heart Care Clinic, Pune
Dr. Shirish Hiremath started off his presentation by discussing the goals of treatment in SCAD, which
includes measures to: improve quality of life (symptoms), reduce mortality/morbidity and disease
progression. Describing data from meta-analyses, Dr. Hiremath highlighted data that indicate a
not-significant difference between PCI and optimal medical therapy in prevention of mortality,
revascularization and non-fatal MI in patients with stable CAD.
Describing the results of the Courage study,
Dr. Hiremath summarized a number of points,
which indicate that PCI was inadequately studied
in the Courage study (Box 1). The presenter
indicated that although the data from Courage
study did a great job in emphasizing medication
compliance, efforts to ensure optimal PCI was
sub-optimal.
Discussing these aspects in greater details, Dr.
Hiremath indicated that stenting of non ischemic
stenosis has no benefit as compared to medical
therapy. However, stenting of ischemia related
stenosis improves symptoms and outcome. The
presenter also indicated that fractional flow
reserve (FFR) is a useful index to indicate ischemia
from a particular stenosis. With incomplete
and unreliable non-invasive diagnostic workup (Figure 1), FFR guidance of revascularization
improves symptoms and outcome. In summary,
the presentation highlighted a possibility that
growing risks and advent of new drugs may end
angioplastys golden era.
15
1.
No - all cause death is the wrong endpoint (it should have

been cardiac death)
2.
No - MI is the wrong endpoint (it should have been large MI)
3.
No - the trial was underpowered to address all cause death

or any MI
4. No - angioplasty was suboptimal

5.
No - many/most patients who could have benefited from PCI

were likely excluded
Box 1: Was PCI adequately tested in the Courage Study?
29%
Exercise Test
Performed
Before
Angioplasty
71%
No Exercise Test Performed
Before Angioplasty
Figure 1: Proportions of patients undergoing non-invasive

stress testing prior to PCI.
Thrombolytic Therapy in ACS

Dr. Sunil Sathe
MD, DM
Cardiologist
Cardiac Care and Counseling Center, Pune
Dr. Sunil Sathe presented informative insights on thrombolytic therapy in acute coronary syndrome
(ACS). He stressed the need for a geographic strategy in the management of ACS, which involves
specific hospitals assuming responsibility for a given population with referrals based on location
and processes for monitoring of quality. The presentation highlighted that median time for medical
attention is about 6 hrs with high 30 day mortality. In Indian settings, most patients reach hospital by
private/public transportation and about 70% receive thrombolysis. Furthermore, most patients pay
directly for treatment.
Discussing the limitations of thrombolytic therapies, the presenter indicated that 20 to 60% do not
achieve tissue-level reperfusion. Furthermore, meta-analysis favors angioplasty. However STEMI in
patients with prior CABG, cost constraints for PAMI and time are important factors in assessing the
usefulness of thrombolysis in the era of PAMI. Therefore, time to reperfusion and not the type of
reperfusion was advocated as an acceptable line of thought. Time duration, clinical judgment and
logistics must be the criteria for decisions on PAMI and thrombolysis.
Although, fibrin specific bolus thrombolytics may be preferred, it is not mandatory. Dr. Sathe also
discussed the importance of pre-hospital thrombolysis in a well-equipped ambulance or nearest
health centre as soon as possible after symptom onset. He also discussed the need for well equipped
cardiac ambulances with 12 lead ECG, trained personnel to interpret ECG and ECG transmission
facility in getting patients quickly to medical settings.
16
Heart Failure with Preserved Ejection Fraction

(HF-PEF): Current Concepts and Treatment
Dr. B P Singh
Professor and Head
Department of Cardiology
IGIMS, Patna
HFPEF is defined by heart failure symptoms with a normal or near-normal ejection fraction (>0.50 or
0.45). The prevalence of HFPEF is high (Figure 1) and is seen among patients with conditions shown
in Figure 2. Along with abnormal diastolic function and subtle abnormalities of systolic function, the
pathophysiological underpinnings of HFPEF include ventricular-arterial coupling, decreased arterial
distensibility, and chronotropic incompetence.
Characteristics of Patients with Reduced and Preserved LVEF
13 Community Based Studies

1997-2006
Baseline Variables
100
HF-PEF Prevalence (%)
Median = 52% Mean = 55%

80
P-value
Reduced EF
Preserved EF
(<40%, n=1570) (>50%, n=880)
Mean LVEF%
25.9
62.4
<0.001
Age-years
71.8 12
75.4 11.51
<0.001
Female (%)
37.4
65.7
<0.001
Coronary artery disease%
48.7
35.5
<0.001
60
Angina (%)
28.0
22.8
<0.005
Prior myocardial infarction (%)
39
16.6
<0.001
Prior CABG (%)
12.9
5.8
<0.001
40
Hypertension (%)
84
91
<0.001
Diabetes (%)
38.9
31.7
<0.001
20
Atrial Fibrillation (%)
23.6
31.8
<0.001
Figure 1: Prevalence of HFPEF.
COPD (%)
13.2
17.7
<0.002
Hemoglobin <10 g/dl (%)
9.9
21.1
<0.001
Systolic blood pressure-mm Hg
146
156
<0.001
Figure 2: Patient Characteristics.
Diagnosis of HFPEF involves assessments of the symptoms and clinical signs of HF and ruling out comorbid conditions such as CKD, COPD, anemia, which mimics a HF presentation. Echocardiographic
abnormalities include increased LV mass, LA size, and Doppler parameters of diastolic dysfunction.
Elevated natriuretic peptides are extremely important in an accurate diagnosis. The prognosis of
HFPEF is just as bad as systolic heart failure and treatments include diuretics, verapamil, digoxin and
beta blockers along with other agents such as hydralazine/ISDN and ACE inhibitors/ ARBs.
Dr. Singh presenting and explaining these facts concluded that HFPEF is a pleomorphic condition
with a high risk of sudden death. Prevention of HFPEF can be achieved through control of blood
pressure and volume. However, the presenter noted that there is no proven evidence-based therapy
by quoting we have no knowledge of a therapy that has improved outcomes in HFPEF.
17
Newer Oral Anticoagulants

Dr. Sandeep Bansal
MD, DM, DNB, MNAMS, FIMSA, FISC, FAPSIC, FSCAI
Professor and Head of the Department
Vardhaman Mahavir Medical College and Safdarjang Hospital, New Delhi
Since the late 1980s, oral anticoagulants (OACs) have steadily evolved and a number of drugs
including dabigatran, rivaroxaban, apixaban, and edoxaban have come into clinical practice. OACs are
useful in orthopedic surgeries, venous thrombosis, in atrial fibrillation and acute coronary syndromes.
Although warfarin is the most common vitamin
C Myocardial infarction
NOAC
VKA
K antagonist (VKA), it has several limitations that
Event/Total Event/Total
OR (95%CI)
Asian
make it difficult to use in clinical practice. It has a
RE-LY, 150mg
9/933
10/926
0.89 (0.36-2.21)
ROCKET AF
8/468
8/464
0.99 (0.37-2.66)
narrow therapeutic window and an unpredictable
ARISTOTLE
8/988
7/1005
1.16 (0.42-3.22)
7/646
8/644
ENGAGE AF, 60mg
0.87 (0.31-2.42)
response which requires routine coagulation
Overall Effect
0.97 (0.59-1.58)
Q= 0.2 (P=0.978)
monitoring and frequent dose adjustments.
P= 0.0%
Though effective in stroke prevention, it
0.0
0.5
1.0
1.5
2.0
increases the risk of intracranial bleeding. Dr.
Favors NOAC
Favors VKA
Bansal presenting these facts also indicated that
Figure 1: Newer OACs in Myocardial
infarction.
poorly controlled warfarin might be worse than
no treatment.
Major bleeding
A
The presenter also discussed the efficacy results
of newer OACs in Asians, which indicate that
they may be beneficial in stroke and MI (Figure
1). Furthermore, safety results in terms of major
bleeding and intracranial bleeding favor the
newer OACs (Figures 2 and 3)
Dr. Bansal discussing the data on the efficacy
and safety of newer OACs indicated that
treatment switch to newer OACs may be done
in all patients except for those with valvular atrial
fibrillation, renal failure, those that have a stable
INR without a history of thromboembolism or
hemorrhage and patients not willing to change.
The presentation concluded by highlighting that
newer OACs can tackle the double burden of
rheumatic AF and NVAF. Although these drugs
are costlier, they show clear benefits.
18
Asian
RE-LY, 150mg
ROCKET AF
ARISTOTLE
ENGAGE AF, 60mg
Overall Effect
Q= 0.4 (P=0.949)
P= 0.0%
NOAC
VKA
39/933
23/466
33/961
42/642
OR (95%CI)
66/926
35/462
63/1002
68/641
0.0
0.57 (0.38-0.85)
0.63 (0.37-1.09)
0.52 (0.34-0.80)
0.59 (0.39-0.88)
0.57 (0.44-0.74)
0.5
1.0
Favors NOAC
1.5
2.0
Favors VKA
Figure 2: Safety of newer OACs with

respect to major bleeding.
B
Intracranial hemorrhage
Asian
RE-LY, 150mg
ROCKET AF
ARISTOTLE
ENGAGE AF, 60mg
Overall Effect
Q= 0.8 (P=0.851)
P= 0.0%
NOAC
VKA
8/933
4/466
11/961
9/642
OR (95%CI)
19/926
17/462
31/1002
28/641
0.0
0.41 (0.18-0.95)
0.23 (0.08-0.68)
0.36 (0.18-0.71)
0.31 (0.15-0.67)
0.33 (0.22-0.50)
0.5
Favors NOAC
1.0
1.5
2.0
Favors VKA
Figure 3: Safety of newer OACs with

respect to intracranial bleeding.
Granulomatous Diseases of Heart:

A Bumpy Road
Dr. Satyendra Tewari
MD, DM, FACC, FSCAI, FCAPSC, FESC, FCSI, FICC
Professor,
Department of Cardiology, SGPGIMS, Lucknow
Granuloma, an immune reaction leading to collection of macrophages at one particular place leads
to macrophage fusion and formation of giant cells. The condition results secondary to infections,
foreign bodies or autoimmune reaction. Granulomatous disease of the heart is an umbrella term used
to represent many diseases leading to formation of granulomas in the heart. Of them, rheumatic
heart diseases are more common in India. Although rheumatic heart diseases is a well known entity
in India, the realization that rheumatic heart diseases can lead to formation of granulomas in the
heart is not widely appreciated.
Granulomatous myocarditis can present as sarcoidosis or giant cell myocarditis. Cardiac sarcoidosis
is infrequent and hence is an easily missed diagnosis. Clinically, cardiac involvement is seen in only
2% cases of sarcoidosis. However, autopsy reports a 25% involvement. This condition is common in
the age group of 30-45 years. Clinical clues to cardiac sarcoidosis include disproportionate dyspnoea
in patients of pulmonary sarcoidosis. Furthermore, history of extracardiac sarcoidosis along with
syncope/ features of heart failure/ unexplained ventricular tachyarrrhythmias/ sudden cardiac death
are important clues for suspecting cardiac sarcoidosis. Definitive diagnostic test include PET scan,
cardiac MRI, thallium/ technetium 97 scans and gallium 67 scans. Treatments include optimal medical
therapy for congestive heart failure, corticosteroids, pacemakers for symptomatic high grade AV
blocks, AICD for documented VT/Vf CRT-D if appropriate indications are met and heart transplantation
for refractory heart failure.
Giant cell myocarditis is a rare and idiopathic cause of granulomatous myocarditis. Clinical suspicion
of this condition is warranted by acute onset of severe heart failure, progressive arrhythmias- VT,
heart blocks, and echocardiographic picture of normal or increased wall thickness (due to myocardial
edema) with poor LVEF. Cardiac MRI and EMB (Biopsy) are useful diagnostic tools. Treatments include
cyclosporine and steroids, LV assist devices and ECMO. Heart transplantation may also be needed in
select cases. CD3 Muromonad is a latest treatment modality for this condition. Metabolic diseases,
chronic granulomatous disease and infections are other causes of granulomatous diseases of heart.
Dr. Satyendra Tewari presenting this informative update described the condition as a bumpy road.
He explained that the bumpiness lies in fact that these conditions are under diagnosed and are
difficult to diagnose. Treatment modalities are disease specific with steroids playing a major role.
However, there is a paucity of randomized controlled trials to proving treatment benefits.
19
Triglyceride: The End of Road?

Prof. K K Mitra
MBBS, DM
HOD, Department of Cardiology
RGKMCH, Kolkata
High cholesterol, especially LDL- C is the best established modifiable risk factor for MI and CV Death.
Thus, lipid intervention is an effective way to reduce coronary artery disease. However, along with
targeting LDL- C, it is important to address triglycerides (TG) and low HDL-C as well. Based on this
premise, Dr. Mitra indicated that only about 25-30% relative risk reduction is noted even with high
intensity statin therapy. In the contexts of residual CVD risk even after LDL-C reduction with statin
treatment, the presenter discussed the implications of TG remodeling, and raising HDL levels.
While triglycerides are an excellent barometer of metabolic health, its status as a risk factor for
CAD in Indians remains controversial. Triglycerides are not significant after adjusting for HDL-C and
non HDL-C. Furthermore, exploration of postprandial TG in future studies may clarify the causal
relationships. In the contexts of raising HDL levels, studies with nicotinic acid, CETP inhibitors,
EL inhibitors have failed to show favourable outcomes. Thus, elevated HDL levels may not be as
important as is the mechanism that raises it.
Non HDL-C includes all apo B containing lipoproteins (VLDL, IDL, LDL, Lpa). Although, statin
effectively reduces all components of non HDL-C, add on therapy is often required with ezetemide,
BAS, niacin, fibrate and omega-3 fatty acids. Thus, there is a need for LDL lowering medications.
In this regard, the presenter discussed the possible roles of CETP inhibitors, PCSK9 inhibitors, oral
lomitapide (microsomal TG Transfer protein inhibitor), mipomersen (antisense oligonucleotide to
apoB and AapoC3 inhibitors.)
The presented concluded his presentation by explaining that focusing solely on LDL-C to reduce
the CVD risk will be an oversimplification of the problem. The atherogenic lipid molecules present
within the blood such as VLDL, IDL, chylomicrons, chylomicron remnants and lipoprotein(a) provides
a more accurate estimate of CV risk than LDL-C alone. He concluded the session by pointing out that
continued accumulation of high-quality trial data will inform future cholesterol treatment guidelines.
In summary, the presentation seemed to indicate that triglyceride targeting is not the end of the road
in dyslipidemia management and that we may need to look beyond statins.
20
Statins: How to Choose Among the Members?

Prof. Dr. T Govindan Unni
MD, DM
Jubilee Mission Medical College and Research Institute
Thrissur, Kerala
Medicine is concerned with choosing the right treatment. Cardiologists in recent years have
made their choices on the premise of good evidence. However, the greatest choice often starts
where the evidence finishes, namely, between drugs of the same class. While, pharmacodynamics,
pharmacokinetics, tolerability and costs are the premise for rational choice among drugs, the choice
of drugs belonging to the same class depends on superior efficacy versus better tolerability, cost
effectiveness and frequency of administration along with marketing and promotional influences.
Drugs of the same class are rarely compared in head on trials and it becomes difficult to identify to
extrapolate the effect one drug to other in the same class. Another factor is the cost, when drug
goes generic. Due to cost factors, the most economical drug will be employed on the premise of
class effects. While, statins have a similar mechanism of action, they differ with respect to chemistry,
pharmacokinetics and time of administration. Lipid management guidelines do not specify the specific
statins to be used. LDL is one of the most important factors in the causation of atherosclerosis and
all statins reduce LDL. In using statins for patients with ACS, lipid lowering effects of statins can be
considered as class effects, but their pleitropic actions may not be class effects and are difficult to
measure.
Presenting these data in greater detail, Dr. Govindan Unni highlighted three unanswered questions:
1. Lipid level or statin dose?
2. Pleotropic effects
a. Are they dose related?
b. Are they class related?
3. Which statin to be used and at what dose?
Along with this, the presenter also discussed the risk of new-onset diabetes with statin treatments and
pointed out at data, which indicates that this risk may be a class effect. High-dose statin therapy has
a higher chance of new-onset diabetes than low or moderate intensity statin therapy. The presenter
concluded his session by stating that the choice among statins be made after due consideration to
cost of equi-efficient dose, and on an understanding of benefits and side effects as class or dose
effects. The presenter indicated rosuvastatin for primary prevention and high-dose atrovastatin for
managing ACS.
21
Lipid Guidelines in Indian Context

Dr. K Sarat Chandra
MBBS, MD, DM
Cardiologist
Nizams Institute of Medical Sciences, Hyderabad
Dr. K. Sarat Chandra presented an overview of a consensus statement on the management of

dyslipidemia in Indian Patients. The need for these guidelines is summarized in Figure 1.
Vastly different CVD
epidemiology
Higher incidence of CVD
Younger onset of CVD
More severe disease
Clustering of CV risk
factors at younger age
Genetic contribution
Difference in lipid
abnormalities
Socio-economic and
cultural differences
Atherogenic dyslipidemia
more common
Exaggerated statin
response
? risk of side-effects
with statins
Lack of knowledge,
awareness
Issues related to
affordability, accessibility
for both diagnostic workup as well as therapy
Figure 1: Need for India-specific guidelines.

Explaining the guidelines in greater details, the presenter summarized the following as key messages
of these guidelines:
1. Measurement of lipids
What to measure: LDL-C or nonHDL-C?
When to measure?
2. CV risk stratification
Which risk score to use?
Definition for high CV risk
Threshold for starting statin therapy
3. Therapy
Whom to prescribe statins?
Risk groups or lipid-level based?
Dose
Any differences in statin dose?
How to follow-up?
Fixed targets or magnitude of LDL-C
reduction?
Role of non-statin drugs
The presentation indicated the higher prevalence of dyslipidemia in Indians to be due to their typical
lipid profile. Furthermore, there is a higher burden of diabetes in India and diabetic dyslipidemias
are a risk for CAD. The Indian guidelines presented herein recommended the use of lipid lowering
therapy for diabetic patients. The presentation further indicated that benefits of rosuvastatin is well
confirmed in Indian diabetic patients and is an Ideal choice of drug for Indians as it helps to achieve
guideline recommended goals as well as reduces CV risk markers.
22
A Guide for the Hypertension Guidelines

Prof. H C Kalita
DM, FACC
Assam Medical College, Dibrugarh
Close to one-third of adult population have

hypertension, which is a major risk factor for
cardiovascular events, stroke and chronic kidney
disease. Treatment of hypertension reduces
the risk of these diseases. About four major
treatment guidelines (NICE guidelines-2011,
ESC/ESH guidelines-2013, ASH/ISH guidelines
(2014), JNC-8 panel report-2014) exist for
guiding hypertension management. While some
components of the guidelines are in agreement
(Box 1), several points of discord exist between
them.
Dr. Kalita presenting these facts, indicated that the
discord among guidelines causes needless confusion,
disagreement and discontent. The presenter
indicated that guidelines become problematic
when the result is confusion and not clarity. In
a clarifying tone, Dr. Kalita indicated that BP
threshold of 140/90 in patients < 80 years and
150/90 in patients aged >80 years is optimal
in Indian conditions. He further indicated that
hypertension should be treated aggressively to
prevent increased morbidity and mortality from
CVD. Before concluding, the presenter stressed
the need for policy and focus on awareness,
detection, and control along with ensuring the
availability of economical and safe drugs.
23
BP Goal <140/90
Threshold for treatment >140/90 for
patients aged < 60yrs
BP threshold to start treatment >150/90
for patients aged in >80yrs
Target on treatment: < 150/90 in
fragile patients
Target on treatment: < 140/90 in fit
patients or those with CKD, DM
Less aggressive than earlier in goal BP
with DM and CKD <140/90
Beta-blocker is not a front runner in
treatment of uncomplicated hypertension
Box 1: Common meeting points of
hypertension guidelines.
Goal BP for patients aged between

60-79 yrs
BP goals for CKD patients
Drug selection
Box 2: Points of discord between
guidelines.
Uncomplicated Hypertension:
Really That Simple?
Dr. Asha Mahilmaran
MD, DNB, DM
Apollol Hospitals, Chennai
Audience gathered a connotation that uncomplicated hypertension is not uncomplicated at all.

Defining uncomplicated hypertension as Hypertension with no evidence of diabetes, cardiovascular
disease, or target organ damage, Dr. Asha Mahilmaran presented important insights on the
treatment and management of uncomplicated hypertension. The presenter indicated that solely
relying on manual office pressures misses out on white coat and masked hypertension.
The presentation highlighted the conclusions of the SPRINT study, which indicates that targeting
a systolic blood pressure of less than 120 mm Hg, as compared with less than 140 mm Hg, in
patients at high risk for cardiovascular events but without diabetes resulted in lower rates of fatal
and nonfatal major cardiovascular events and death from any cause. In these contexts, early blood
pressure control may be important.
In terms of treatment, monotherapy is Inadequate in 40%60% of hypertensive patients. ACE/ARB,
thiazide, or thiazide-like diuretic, CCB are the drugs of choice. Beta-blockers are not indicated as
first line drugs in uncomplicated hypertension. While combination of hypertension may be needed
in many patients, it is better to avoid ACEI with ARB. Nocturnal dosing of one or more drugs has
been shown to have better 24 hour control. Furthermore, converting nondippers to dippers may
prevent early morning surge. Ensuring treatment adherence is an important part of hypertension
management and statins are indicated in patients with hypertension and high CV risk.
Reiterating the findings of the SPRINT trial that targeting a BP goal of <120/80 lessens the CV risk
substantially, Dr. Asha Mahilmaran concluded the presentation stating that this target BP goal of
<120/80 would be the most challenging task in the pharmacotherapy of uncomplicated hypertension.
24
Present Status of AntiRheumatic Vaccine

Dr. Cibu Mathew
MBBS, MD, DM
Head of Department, Cardiology
Government Medical College, Thrissur
Rheumatic fever, an immunologic sequel of Group A Streptococcus (GAS) infection affects about
34.2 million people worldwide with an estimated DALY of 10.1 million. While primary and secondary
prevention of GAS infection with antibiotics is in practice, its applicability is limited by poor compliance,
resistance and the need for extensive resources. This lends premise for a vaccine against GAS. With
this introduction, Dr. Cibu Mathew presented an update of the vaccine against GAS.
Vaccines are mostly M-protein-based and the initial clinical trials were done with heat killed GAS
strain and later on with whole M protein. Trials were halted in 1979 due to safety issues and were
restarted in 2006. Issues with the vaccine are that they provide antibodies against the homologous
emm-type and not against heterologous types. To be effective, the vaccine ideally must incorporate
all the strains present in the community.
Discussing the various vaccine types, Dr, Mathew indicated that absence of disease animal models,
lack of standardization of immuno-assays, absence of correlate of immunity or protection in clinical
studies along with a lack of consensus on clinical development plans impede the development of
GAS vaccine. This along with safety issues and limited commercial and NGO interest in funding the
initiative are challenges.
The presenter concluded the presentation by noting that no vaccine is currently available
and the target of an effective and safe vaccine that would help abandoning the practice of culturing
throats, empirically treating pharyngitis with antibiotics, and/or recommending secondary antibiotic
prophylaxis in individuals with acute rheumatic fever seems distant at the moment.
25
Resistant Hypertension:
Causes, Consequences and Care
Dr. Ajay K Sinha
MD, FESC, FCSI, FICC, FAPCC, FACC
Senior Consultant, Cardiology
Paras HMRI Hospital and Cardiac Care, Patna
Prevalence of resistant hypertension is about 5% in general practice and about 50% in nephrology
clinics. Through an illustrative case study, Dr. Sinha described the nature of resistant hypertension.
Stressing the need for confirming treatment resistance, the presenter indicated the need for
automated office BP (average of 5 readings), regular review of home BP log and ambulatory blood
pressure management. Furthermore, monitoring treatment compliance is vital.
White Coat hypertension (not without risk)
Drugs such as NSAIDS
TOD is minimal in White Coat hypertension
Dietary supplements
Excessive alcohol consumption
Uncompressible arteries of old age (Oslers Pseudo HT)
Volume overload
Measurement issues small cuff (< 80% of arm)
Diabetes mellitus
BP recorded without 5-10 minutes of rest
Old age
Non-compliance with drug treatment
Renal parenchymal disease

Renovascular disease
40% patients discontinue treatment in the first year
Primary aldosteronism
No life-style modification practiced
Obstructive sleep apnea
Be cautious in labeling a patient with pseudo-hypertension
Pheochromocytoma
Cushings syndrome
Thyroid diseases
Aortic coarctation
Intracranial tumors
Box 1: Pseudo-resistant hypertension.
Box 2: Factors contributing to resistant hypertension.
Subsequently, it is important to identify and reverse factors contributing to true resistance and
exclude pseudo resistance (Box 1). Furthermore, identification and mitigation of contributing lifestyle
factors along with discontinuation or minimization of interfering substances (Box 2) are important
in the management of resistant hypertension. Treatment includes increasing the dose of diuretics.
Vasodilating beta-blocker (carvedilol), clonidine or guanfacine is also indicated. Switching calcium
channel blocker from the alternate class (non-dihydropyridine to a dihydropyridine or vice versa)
is also recommended. The presenter also stressed the need for testing primary aldosteronism and
obstructive sleep apnea along with reducing dietary sodium. The presenter also indicated the need
for eplerenone and epironolactone in patients whose blood pressure remains elevated after treatment
with a 3-drug regimen to maximal or near maximal doses.
26
Obstructive Sleep Apnea and CVD

Dr. Jabir A
MD, DM, FACC, FSCAI, FESC
Senior consultant cardiologist
Lisie hospital, Cochin
Prevalence estimates show 13.7% of the general

population to be affected by obstructive sleep
Hypertension------------------------- 50%
apnea (OSA) in the Northern part of India.
CAD------------------------------------ 33%
Another study conducted in Western part of India
revealed 19.5% of hospitalized population to be
ACS------------------------------------- 50%
affected by OSA. Dr. Jabir pointed to the fact that
OSA is linked to higher rates of cardiovascular
HFrEF----------------------------------- 30%
complications. Clinical trials have reported a
Acute Stroke ------------------------- 50%
direct correlative relationship between OSA and
cardiovascular complications such as systemic
AF requiring cardioversion--------- 50%
hypertension, congestive heart failure, coronary
artery disease, pulmonary artery hypertension,
Lone AF-------------------------------- 33%
arrhythmia, and stroke (Figure 1). The Wisconsin
Sleep Cohort study reported an increased number
of adverse cardiac events with OSA; severe OSA Figure 1: Prevalence of OSA in patients with
had pronounced adverse effects (Figure 2).
cardiovascular disorders.
35
35
Cumulative incidence of
fatal CVS events (%)
30
25
Cumulative incidence of
non-fatal CVS events (%)
Controls
Snorers
Mild OSAH
Severe OSAH
OSAH with CPAP
20
15
Controls
Snorers
Mild OSAH
Severe OSAH
OSAH with CPAP
30
25
20
15
10
10
5
0
0
0
36
72
108
144
36
72
108
Months
Figure 2: Effect of sleep disordered breathing on cardiovascular events.

27
144
Obstructive Sleep Apnea
PNA
Arousal
SNA
Catechols
HR
BP
Intrathoracic
pressure
PO2 PCO2
Myocardial
O2 delivery
Oxidative
stress
Dysglycemia
Infammation
Endothelial
dysfunction
Hypertension
Atherosclerosis
Myocardial Ischemia
LV hypertrophy and failure
Cardiac Arrhythmias
Sudden death
Cerebrovascular disease
LV wall tension
Cardiac O2 demand
Figure 3: Cardiovascular response to apnea.

In conclusion, Dr. Jabir presented a plausible explanation to the cardiovascular response to apnea as
shown in Figure 3. Additionally, he noted that although there is a paucity of data from randomized
controlled trials on treatment benefits, observational data indicate a trend towards better outcomes
with OSA treatment.
28
The Future of Anti-Arrhythmic Therapy in AF

Dr. Rakesh Yadav
MBBS, MD
Professor, Department of Cardiology
AIIMS, New Delhi
Atrial fibrillation (AF), the most common sustained cardiac arrhythmia, accounts for one-third of all
patient discharges with arrhythmia as principal diagnosis. The estimated prevalence of AF is 0.4% to
1% in the general population. Outlining the clinical outcomes affected by atrial fibrillation (Box 1)
and the classification of atrial fibrillation (Box 2), Dr. Yadav explained the treatment of various classes
of AF with pharmacological and non-pharmacological strategies.
Outcome parameter
Relative change in AF
patients
1. Death
Death rate doubled.
2. Stroke (includes
haemorrhagic stroke and
cerebral bleeds)
Stroke risk increased; AF is

associated with more severe
stroke.
3. Hospitalizations
Hospitalizations are frequent in

AF patients and may contribute
to reduced quality of life.
4. Quality of life and exercise

capacity
5. Left ventricular function
First episode
Symptomatic or asymptomatic
self limited or persistent
Recurrent AF
2 or more episodes lasting >30 seconds
Paroxysmal AF
Recurrent AF that ends spontaneously
Persistent AF
Wide variation, from no effect

to major reduction.
AF can cause marked distress
through palpitations and other
AF-related symptoms.
AF that requires pharmacotherapy or cardioversion for

termination (may be 1st episode or recurrent)
Permanent AF
Longstanding AF in which cardioversion has failed or
not been indicated
Wide variation, from no change

to tachycardiomyopathy with
acute heart failure.
Box 1: Clinical events (outcomes)

affected by AF.
Box 2: Classification of AF.
Dr. Yadav concluded his presentation by stating that the treatment of AF depends on disease, duration
and mechanism. Improvements in understanding the mechanisms of atrial fibrillation have greatly
enhanced its treatment. However, an ideal drug for rhythm control is still awaited and if found may
be the most important discovery in cardiology.
29
Pulmonary Hypertension:
aManagement Approach
Dr. Praveen Jain
MD, DM
Executive Director
Lifeline Hospital and Heart Centre, Jhansi
Describing pulmonary hypertension as a progressive increase in blood pressure in the pulmonary

vascular bed that results in heart failure and death, Dr. Jain presented important insights on the
management of pulmonary hypertension. The WHO classification categorizes pulmonary hypertension
into five types (Box 1). Explaining of the features of these types of pulmonary hypertension, Dr. Jain
indicated that they should be managed differently.
1. Pulmonary arterial hypertension
Unexplained dyspnea despite multiple

diagnostic tests
2. Pulmonary hypertension owing to left

heart disease
Typical symptoms (look for Raynauds)

Comorbid conditons:
3. PH secondary to chronic hypoxemia
CREST, liver disease, HIV, sickle cell,

OSA
4. Chronic thrombo-embolic pulmonary

hypertension (CTEPH)
Family history of PAH
5. Miscellaneous (usually extrinsic

compression of pulmonary arteries)
History of stimulant/anorexigen use
Box 1: Classification of pulmonary

hypertension.
Box 2: Reasons to suspect.
He presented the goals of therapy to include steps to alleviate symptoms and improve quality of life,
cardiopulmonary hemodynamics and prevention of right heart failure along with steps to delay time
to clinical worsening and reduce morbidity and mortality. He explained that the treatment plan for
pulmonary hypertension includes treatment of any underlying disease, along with treatments for
cardiac disease (left sided), lung disease, hypoxemia, obstructive sleep apnea and thromboembolic
disease.
Further, the presentation included discussions on medical therapies involving diuretics, anti coagulants
(IPAH), digoxin, oxygen and PAH specific therapy. He also discussed surgical options such as atrial
septostomy and lung transplantation. Dr. Jain concluded the presentation by stating that lung
transplantation, despite other therapies, is the only curative treatment for PAH.
30
Management of Hypertension in Acute Stroke

Dr. Ambuj Roy
MBBS, MD, DM
Additional Professor of Cardiology
AIIMS, New Delhi
Stroke is a major cause of disability and death in India and greater than 50% of strokes are attributable
to high blood pressure. While management of high blood pressure in prevention of stroke is well
established, the management of hypertension in acute stroke is debatable. Furthermore, management
of hypertension varies for ischemic and hemorrhagic strokes.
By highlighting these facts, Dr. Roy pointed out that blood pressure typically decreases spontaneously
during the acute phase of ischemic stroke, starting within 90 minutes after onset of stroke symptoms
to upto 10 days. Although clinical studies have shown a positive association between high BP and
poor outcomes in acute stroke, the causality is not conclusive.
He discussed and summarized the management protocols in acute ischemic stroke (Box 1).
Whom to treat?
High blood pressure should not be treated in initial 24 hours of

stroke if not for thrombolysis unless blood pressure is extreme (SBP
>220 mmHg or DBP >120 mmHg), or patient has concomitant
need of treatment
How much and how fast?
1. In patients eligible for thrombolytic therapy, reduce BP below

185/110 mm Hg.
2. In extreme hypertension, reduce BP approximately 15 percent
during 24 hours after stroke
When to start?
Not established, initiate 24 hours later (long-term antihypertensive

treatment)
Which drugs to be used?
Labetalol or nicardipine is used commonly

No class of oral antihypertensive has shown superiority over other.
Box 1: Summary of hypertension management in acute ischemic stroke.

Dr. Roy concluded his presentation with a famous quote from Joseph Joubert, It is better to debate
a question without settling it than to settle a question without debating it. This closing remark sums
up the debatable nature of hypertension management in acute stroke.
31
Detection of Asymptomatic Atherosclerosis:

Whom, When and How?
Dr. James K J
MBBS, MD, DM
Mother Hospital, Thrissur
Cardiovascular disease (CVD) is the leading cause of mortality worldwide, with coronary artery
disease (CAD), accounting for nearly half of all CVD deaths. Atherosclerosis, an anatomic substrate
for myocardial infarction, begins in childhood and progresses over decades. However, atherosclerosis
can be asymptomatic in a number of individuals. Highlighting data from a clinical study in North
India and the Thiruvananthapuram Autopsy Study, Dr. James pointed out a high prevalence of
atherosclerotic risk in the general population, especially in young patients aged <40 years of age.
Results of the Thiruvananthapuram Autopsy Study indicated significant atherosclerotic luminal
stenosis in 22.6% of study population. Further, the results revealed significant atheroma (Grade 4
by AHA grading) in 61% of cases.
While aggressive management of traditional risk factors and the use of population risk score are
important in the prevention of cardiovascular disease, risk scores such as the Framingham risk
score and the ACC/AHA -Pooled Cohort Equations -2013 have limitations in women and younger
population, who fall into the low-risk category. However, a significant number of cardiovascular
events occur in low-risk and intermediate-risk categories. Explaining these contexts, the presenter
discussed the need for screening subclinical atherosclerosis to ascertain the incremental risk prediction
for CV events over global risk assessment.
Indicating that these screening tests are suitable for intermediate risk subjects, the presenter discussed
the techniques and modalities for assessing subclinical atherosclerosis. The presentation elaborated
on noninvasive imaging modalities such as the 2D vascular ultrasound for assessing carotid intimamedia thickness (IMT) and presence of plaque. Discussing the utility of ankle brachial index (ABI),
Dr. James highlighted that addition of ABI scores to Framingham risk score can reclassify individuals in
their risk scores. Furthermore, non-contrast CT measures coronary calcification and provide superior
information compared with coronary angiography, which only assesses coronary artery lumen.
Assessments of calcified area and the calcium density using the coronary artery calcium score (CACS)
is another useful and important tool in these contexts. While, zero / low CACS is associated with a
low probability of a CV event, CACS >1,000 is associated with an annual risk of 25%. Using these
techniques the PESA study indicated subclinical atherosclerosis was present in 63% of participants.
Plaques were most common in the ilio-femorals (44%), followed by carotids (31%) and aorta (25%),
while CAC was present in 18%. The presenter also pointed out that contrast-enhanced computed
tomography is not recommended for screening subclinical atherosclerosis for reasons of contrast
allergies and renal insufficiency. Considering that carotid IMT is no longer recommended for routine
risk assessment of a first atherosclerotic cardiovascular event, CAC is likely to be the most useful
approach for improving risk assessment among individuals at intermediate risk.
32
Device Therapy in HF: How Much is the

Dividend?
Prof. Dr. Rabin Chakraborty
MD, DNB, MRCP, FRCP, FRCP, FRCP, FACC, FICC, FCSI, FISE, DM
Interventional Cardiologist and Electrophysiologist
Apollo Gleneagles Hospitals, Kolkata
Heart failure (HF) is a symptom complex and not just a disease or a diagnosis. Drawing the attention
of the audience to the fact that HF may be more like malignant cancer, Dr. Chakraborty pointed out
that 78% of HF patients have at least two hospital admissions per year and about 50% of them
are rehospitalized (Figure 1). Furthermore, HF-related mortality is high (Figure 2). Thus, the goals
of treatment in HF are to: to improve symptoms and quality of life, decrease likelihood of disease
progression, and reduce the risk of death and need for hospitalization.
100
100
Hospital Readmissions
75
75
50%
50
25
0
Mortality
20%
30 days
50%
50
25
0
6 mo
33%
12%
30 days
12 mo
5 yr
Median hospital LOS: 6 days
Figure 1: Re-hospitalization rates in

heart failure.
Figure 2: Mortality rates in heart failure.
Along with the health-related outcomes, a number of financial challenges also impede optimal
management of HF. A HF patient has on average 1.3 admissions the year after their HF destabilization.
On average, an HF admission costs a hospital about $8,112. In these contexts, results of the CAREHF study indicate that Cardiac Resynchronisation Therapy (CRT) is effective in reducing mortality and
major morbidity, and improving quality of life. In terms of cost-efficacy, long-term treatment with
CRT-P appears highly cost-effective compared to medical therapy for any starting age. Furthermore,
results of the CARE-HF study demonstrated that the cost effectiveness of CRT-ICD compared to CRT-P
is conditional on patient life expectancy and device longevity.
The presentation also included a discussion of clinical studies such as the COMPANION, MIRACLE,
MIRACLE ICD, REVERSE, RAFT, and MADIT CRT. Furthermore, results of the REVERSE study support
expanded use of CRT-D in mildly symptomatic heart failure. Explaining these data in greater detail,
Dr. Chakraborty concluded the session by highlighting the cost effectiveness of CRT therapy for
patients with heart failure (NYHA Class II IV, ambulatory) with QRS >120 msec, complete LBBB and
ejection fraction < 35%. Furthermore, CRT-D may be a cost effective option for patients with ischemic
cardiomyopathy (EF <30%), dilated cardiomyopathy and for those with expected life>1 year.
33
High Gradient across Mitral Prosthesis:

My Check List
Dr. Aniruddha De
MBBS, MD
Apollo Gleneagle Hospital, Kolkata
Dr. Aniruddha De discussed the various techniques for the evaluation of the prosthetic valve function
and explained that high gradient should prompt the search for mechanical obstruction; however,
high gradient in normally functioning valves may be possible too. Mechanical obstruction may be
due to thrombus, pannus, paravalvular regurgitation, and stuck valve. High gradient in a normally
functioning valve may be attributed to localized pressure gradients in bi-leaflet valve, increased
flow through the valve in anemia, pregnancy, tachycardia, first-degree AV block or due to patient
prosthesis mismatch.
As noted by the presenter, a comprehensive evaluation of the prosthetic valve function should involve
the recording of: peak early velocity, mean pressure gradient, heart rate, pressure half-time (PHT), the
presence of regurgitation, Doppler velocity index (DVI) and/or effective orifice area (EOA) as needed,
LV/RV size and function, LA size if possible, and PA systolic pressure.
Echocardiography should record multiple views, with attention to: opening and closing motion of
the moving parts, presence of leaflet calcification or abnormal echo density attached to the sewing
ring, occluder, leaflets, stents, or cage.
Peak early velocity is easy to measure and provides a simple screening estimate of prosthetic valve
dysfunction and can be elevated in: hyper dynamic states, tachycardia, small valve size, stenosis, or
regurgitation. In normal bi-leaflet mechanical valves, peak velocity is usually < 1.9 m/s but can be up
to 2.4 m/s.
Significant increase in PHT on serial studies or a markedly prolonged single measurement (>200 ms)
may be a clue to the presence of obstruction and PHT rarely exceeds 130 ms across normal prosthetic
valve. PHT should not be obtained in tachycardic rhythms or first degree blocks when the E and A
velocities are merged or the diastolic filling period is short.
DVI (VTIPrMV/VTILVO) can be elevated due to stenosis or regurgitation. For mechanical valves, a DVI<
2.2 is most often normal and higher values should prompt consideration of prosthesis dysfunction.
Indirect signs suggestive of significant MR include: hyper dynamic LV with low systemic output,
elevated mitral E velocity, elevated DVI, dense CW regurgitant jet with early systolic maximal velocity.
34
3D Echo is the Standard-of-Care

Dr. Amuthan V
MBBS, MD, DM (Cardiology)
Vandamalayan Hospital, Madurai
The advent of matrix transducers, together with significant improvements in semi-automated

volumetric analysis, have allowed 3D echocardiography to evolve from a complicated and timeconsuming imaging technique into a simple and quick imaging modality that is useful in everyday
clinical use. Additionally, 4D echocardiography (Real-time 3D echo) has been extensively demonstrated
to be more time-saving, reproducible and accurate than conventional 2D echocardiography in the
determination of left ventricular ejection fraction and is recommended by the current American
Society of Echocardiography guidelines as the standard-of-care.
Dr. Amuthan noted that regional wall motion analysis including 12 segment tomographic analysis
(Figure 1) and strain analysis (Automated Functional Imaging) has simplified the echo evaluation of
coronary artery disease for cardiologists in emergency settings.
In addition, he pointed that 3D evaluation of the cardiac valves have evolved to be the best comparable
methods in relation to Gorlin method for mitral valve area; CT/CMR correlation for the aortic valve
area; and selection of the valves for TAVR procedures. Of particular importance is the role of 3D transesophageal echocardiography in the detection of aortic para valvular leaks in the catheterization lab.
Figure 1: 12 segment tomographic slicing of left ventricle.

3D trans-esophageal echocardiography with fluoroscopy is assuming greater importance in various
interventions and procedures for structural heart diseases.
35
Stress Echocardiography for Clinical

Decision Making
Dr. Manish Bansal
MBBS, MD, DNB
Medanta: The Medacity, Gurgoan, Harayana
Since its introduction nearly 30 years ago, stress echocardiography has evolved in to one of the most
cost-effective tests for diagnostic and prognostic assessment of patients with suspected or known
CAD. Stress echocardiography is routinely employed for confirming the presence and severity of CAD
in a variety of clinical settings (in patients with chest pain, dyspnea or LV systolic dysfunction; and in
those undergoing pre-operative assessment among others), for assessing functional significance of
angiographically detected coronary lesions, and for the assessment of myocardial viability. Unlike all
other imaging modalities for the evaluation of CAD, stress echocardiography has the unique ability to
provide hemodynamic information, which has considerable diagnostic and prognostic significance. In
addition, stress echocardiography provides information about cardiac structure and function, which
is not amenable from most other imaging modalities. Apart from these, stress echocardiography has
several distinct advantages over other modalities used for the evaluation of CAD. Compared with
stress ECG, stress echocardiography is more accurate and feasible even in presence of baseline ECG
abnormalities or when the patient is not able to exercise; also, it provides lesion specific information
and permits simultaneous assessment of myocardial viability. When compared with stress nuclear
imaging, stress echocardiography is more specific (though less sensitive and has comparable overall
accuracy) and can be used in women and those with LVH or LBBB. Finally, when compared with CAG,
stress echocardiography provides functional significance of the coronary lesions, which is a more
important determinant of clinical outcomes than the anatomic significance of the lesions.
In addition to providing diagnostic information, stress echocardiography provides considerable
prognostic information. A normal stress echocardiogram indicates excellent prognosis with very low
risk of major adverse cardiac events, regardless of the angiographic extent of CAD, provided good
level of workload has been achieved. Conversely, an abnormal stress echocardiogram despite the
absence of hemodynamically significant CAD is associated with much worse outcome compared to
patients with normal stress echocardiogram.
Apart from evaluation of CAD, stress echocardiography is regularly used for the evaluation of patients
with valvular heart disease, for which it remains the only clinically relevant technique at present.
In summary, Dr. Manish Bansal notes that stress echocardiography is an operator dependent technique
and therefore, necessary expertise is required to ensure optimum diagnostic accuracy. In addition, it is
important to pay careful attention to all the technical details and to strictly follow the recommended
protocols during image acquisition and interpretation. The addition of newer techniques such as
strain imaging and three-dimensional echocardiography seems to be helpful in improving diagnostic
accuracy and minimizing operator dependence.
36
Rare Cases of Cardiac Masses

Dr. (Lt Col) Nitin Bajaj
Armed Forces Medical College
Pune
The presentation was of 2 cases of cardiac masses that presented a diagnostic dilemma becuase of
atypical histologic etiologies.
Case 1: A 21-year-old male presented with fever for 15 days and weight loss. He had no comorbid
conditions.
A work up for PUO was undertaken and a CT chest was done, which revealed multiple pulmonary
nodules and a mass lesion in right parahilar and para cardiac lesion in right upper lobe. Based on
clinical and radiological profile, ATT was started, but despite one-month of ATT, he continued to
be febrile, had weight loss, and investigation showed persistent eosinophilia. The PLAX view of his
echo showed a large mobile mass in the LVOT. It was an echogenic mass, which was homogenous
in appearance, freely mobile, the attachment was probably on the IVS though it was not very well
profiled. The LV function was normal. Colour flow interrogation across the LVOT showed some
turbulence across the aortic valve. On histopathaology, the findings were suggestive of invasive
aspergillosis involving the heart. Patient was started on voriconazole, patient improved and followup echo after 6 months was normal. This condition of invasive aspergillosis is an extremely rare
condition caused by Aspergillus fumigatus, which is more common in immunocompromised adults
and cardiac involvement is only 1-6%.
Case 2: A 33-year-old lady with complaint of RHD who underwent MVR with a SJM mechanical valve
along with a TV annuloplasty and a LA clot extraction in 2012 presented with worsening dyspnoea
of 2 months duration. Clinical examination revealed AF with controlled ventricular rate, clear chest
and normal prosthetic valve clicks. An echocardiography to assess valve function was asked for,
which showed a large round mobile mass lesion in the LA seeming to arise from the undersurface
of mitral valve. The lesion was mobile, with irregular margins, and seemed to arise from the junction
of IAS and mitral valve prosthesis. Significant obstruction to mitral inflow velocities was evident from
the increased gradients across the mitral valve. The patient had moderate PAH with estimated PASP
being 42 + RAP. Patient was subjected to surgical excision, wherein a 3cm x 3cm gelatenious mass
lesion was seen arising from post wall of LA. The MV prosthesis was normal, there was no pannus.
The mass lesion was excised and sent for histopathology, the findings of which were suggestive
of benign papillary fibroelastoma. Benign papillary fibroelastoma is a rare benign cardiac tumour,
arising most commonly from valvular endocardium. Though the etiology is not clear, is considered to
be associated with injury to the endocardial surface.
To conclude, the speaker stated that cardiac masses being rare in occurrence, they were easy to
be misdiagnosed, and infective causes for cardiac masses should also be considered in appropriate
clinical situation, like case 1, where fever was present. Surgery is generally required specially in large
lesions that pose an embolic risk. Histopathology is important as it can guide in additional medical
treatment as seen in the case of Aspergillosis.
37
Chest Pain In ER Echo in Triage

Dr. K Raghu
MBBS, MD, DM
Consultant Cardiologist and Electrophysiologist
Care Hospitals, Hyderabad
The greatest advantage of echocardiography in initial emergency department triage, the speaker
said, was when the clinical history and ECG findings were non-diagnostic. The goals of triage, he
said, was to identify patients with AMI, unstable angina, patients at high risk of cardiovascular
complications, and identify patients safe for ED release. The need to triage was underlined by the fact
that the missed AMI rate was inversely proportional to the admission rate for ED chest pain patients.
Unexplained
hemodynamic
deterioration
required immediate evaluation, and TTE and
TOE were complementary. Complications
could include ruptured ventricular septum, PM
rupture, free wall rupture, RV infarction, apical
aneurysm and thrombus, and Dressler syndrome.
Risk stratification was important for long term
clinical outcome, and echocardiography could
improve risk stratification. In ACS, effective risk
stratification could be achieved by simple echo
and chest ultrasound, which was comparable
with TIMI and GRACE score.
Algorithm of Chest Pain Assessment in ER

Chest pain
Non specific ECG changes normal cardia biomakers
Normal
Within 6 hrs
DSE
Resting TTE
Sensitivity 89.5%
Specificity 89%
NPP 98.5
Positive
Cardiac event 30%
Negative
Cardiac event 4%
Adapted from Otto C, 2012.
As evidences stated, the speaker said PSLS at rest

was significantly lower in patients with left main
or 3V CAD without RWMA and could be useful in identifying patients with a severe CAD. Also, SI
provided detailed mechanical characterisation of regions with myocardial ischemic insult and could
demonstrate post ischemic diastolic stunning despite complete systolic functional recovery after
reperfusion. Strain imaging had incremental value in the ability of echo to detect ischemia.
Other important tools to assess were diagnosis of coronary stenosis by coronary flow velocity reserve
measurement, and myocardial contrast echocardiography. Large studies were available which
showed that in ER, MCE provided additional diagnostic information over resting RWMA. Patients
with abnormal WMA and myoperfusion had worse prognosis compared to patients with RWMA
alone.
Echocardiography, the speaker said, was the cornerstone for diagnosis and management of chest pain
in the ER. Increasing use of echocardiography in triaging would reduce the number of misdiagnoses.
38
Acute Aortic Syndrome

Dr. Natesa G Pandian
MD
Professor, Tufts University School of Medicine
Boston, USA
If aortic dissection is not diagnosed and treated promptly, the speaker stated, the mortality escalates
every hour. But to identify acute aortic syndrome, the index of suspicion was critical. Sharing a few
case vignettes with the audience, the speaker noted that there was no single test to be done, and
the test to be performed depended on the place and facilities available to the doctor.
In aortic dissection, it was most essential to know the diagnosis and location. TEE was a very useful tool
in this regard. Intramural hematoma was common with 6-20% intramural hematoma accounting to
aortic dissection, and had to be borne in mind. Follow-up of aortic dissection also was very important
as up to 29% of late deaths after surgery were due to rupture of dissecting aneurysm or dissection
at remote site.
Penetrating aortic ulcer was another important acute aortic syndrome discussed by the speaker. It
is more common in descending aorta with elderly and hypertensive being more prone to it. Surgery
would be required if in descending PAU and in the presence of hemodynamic instability, pseudo
aneurysm, pericardial effusion, bloody pleural effusion and expanding intramural hematoma.
Another acute aortic syndrome with high mortality was aortic trauma, with a survival to hospital
chances of only 20%. Most common sites include the aortic isthmus tethered by ligamentum
arteriosum, ascending aorta above sinus of Valsalva and origin of the innominate artery. In acute
aortic syndrome, a doctor had to keep in mind the possibility of aortic dissection, aortic aneurysm,
penetrating ulcer, aortic trauma, and aortic atheroma. The common Echo findings in aortic trauma
were thick stripe due to deep laceration, pseudo aneurysm, fusiform dilation, intramural hematoma,
intraluminal thrombi, and mediastinal hematoma.
The speaker also spoke on the guidelines for aortic surgery in BAV (AHA/ACC guidelines). Surgery
was recommended in dilated aorta (>55 mm). In BAV, surgery to repair the aortic root or replace the
ascending aorta was indicated in patients with bicuspid aortic valves if the diameter of the aortic
root or ascending aorta was >5cm, or if the rate of increase in diameter was >0.5 cm per year. In
patients with bicuspid valves undergoing AVR because of severe AS or AR, repair of the aortic root
or replacement of the ascending aorta was indicated if the diameter of the aortic root or ascending
aorta was greater than 4.5 cm.
39
Evaluation of Inducible Ischemia

by Nuclear scan
Prof. Dr. G N Mahapatra
Associate Director, Medical Research
Lilavati Hospital and Research Center, Mumbai
Inducible ischemia was very useful to detect inducible ischemia prior to a heart attack as more than
one-third of the patients with CAD were not diagnosed until after an attack occurred. Stratification
of such patients further into various risk groups like high risk or low risk would lead to better
management options and outcomes, the speaker noted.
Various nuclear methods are available to detect inducible ischemia. Hardware designs included dual
head SPECT gamma camera and SPECT CT gamma camera. The speaker observed that evolution of
MPI over the years had occurred in parallel with advances in instrumentation, particularly with the
transformation from planar gamma camera imaging to tomographic images using SPECT technology.
However, MPI is still affected by several drawbacks that are inherent to any nuclear techniques, the
speaker observed. These included low photon flux, attenuation due to non-uniform tissues, motion
artefacts due to time consuming scan and radiation exposure.
The next tool discovered was the D-SPECT, which is similar to an S-SPECT gamma camera. The
advantages with this was lesser injection of radioisotope, reducing radiation dose without decreasing
imaging quality, and dedicated solid state cardiac camera. With newer innovations in imaging software,
it was easy to obtain the EDV, ESV, end systolic wall thickening and wall motion, LV global ejection
fraction to state a few. The correlations were excellent between these software for all parameters.
The development of multiple radioisotopes also gave more options to the doctor, like the TI-201,
TC99m MIBI, TC99m Tetrofosmin, Tubidium-82, F-18FDG, F-18 Fluripiridaz. Of these, Rubidium-82
was the most widely used PET MPI radiotracer in clinical practice. There were different protocols to
be followed for each radiotracer. New innovation in finding out myocardial perfusion agent has led
to newer agents like F-18 Fluripiridaz, F-18 FPTP, F-18 FFHTP, F-18FETP.
The advantages of PET over SPECT for the detection of inducible ischemia were many. PET scanners
have higher spatial resolution and count sensitivities than SPECT scanners. PET images can discriminate
more readily between areas of normal and abnormal perfusion, as a result leading to better diagnostic
accuracy with PET imaging. Also, PET agents can offer myocardial blood flow MBF/coronary flow
reserve (CFR) especially in the presence of inducible ischemia to reclassify the subset of patients.
Sensitivities for PET was 4%-5% higher and specificities 3-5% higher than for SPECT imaging.
In spite of these advantages, PET is not used more often for clinical MPI. Addressing this, the speaker
noted that cost was an important reason. Also, rb-82 was impractical for exercise stress perfusion
imaging because of its short 75 sec half-life and high G.I background activity even in fasting patients.
To conclude, he noted that nuclear scan was clearly superior to standard exercise testing in the
detection and evaluation of inducible ischemia. Quality control reforms and with rigorous training
standards, the use of nuclear scanning could go on to be the only modality for the detection of
inducible ischaemia.
40
PET Perfusion Imaging is Better

Dr. Mythri Shankar
MD
Nuclear Medicine Physician
Apollo Hospitals, Bangalore
Speaking on PET perfusion, the speaker noted that it had many advantages like lesser attenuation,
possible attenuation correction, increased diagnostic accuracy, better pictures and patient outcome
and also higher resolution, image uniformity, acquisition speed and quantification of CFR.
Again, different radioisotopes had different advantages and disadvantages, with different scenarios
requiring one or the other isotope. PET myocardial perfusion imaging with Rubidium-82 had the
advantage that it was generator produced with a half-life of 75 sec and has been used widely.
However, it had the most energetic positron, and poorer image quality compared to 13N ammonia and
needed a relatively fast tomograph. The economic pressure of generator also was to be considered.
With 13N Ammonia, it had the advantages of lowest positron range, physical half-life of 9.9 min,
complex uptake mechanisms, renal excretion, best image quality, and easy quantification of MBF and
CMS approval.
When different tests were compared in terms of finding true disease, it was noted that PET clearly
fared a lot better. SPECT had remarkably low specificity, with about 50% of an abnormal thallium
having a normal angiogram, which was not good at all. Cardiac PET on the other hand, had superior
sensitivity of 93% and specificity of 92%. PET allowed the doctor to detect the disease better. The
ROC (receiver operating curves) was also significantly better for PET than SPECT. The image quality
of PET was also superior to that of SPECT. All of these ensured that the confidence of interpretation
was higher in PET than SPECT. When SPECT was equivocal or indeterminate, PET was recommended.
The best advantage of PET was that it could quantify MBF. This could help detect MVCAD and
endothelial dysfunction. This, the speaker noted, was a compelling reason why it scores more over
SPECT. It could provide the CFR value to each region, which was suitable for evaluation of intermediate
lesions and follow up when treated medically. If CFR was reduced totally, there was a high likelihood
of significant lesion. Integrated PET/CTA studies were also something to look forward in the future,
the speaker noted.
41
Non-Invasive FFRCT:
Will it Become a Clinical Reality?
Dr. Ravi Bathina
MD
Cardiologist
Though coronary CTA is a very useful diagnostic tool, it cannot define the functional significance
of coronary lesions. The speaker shared data on how the current non-invasive tests do not measure
lesion specific ischemia and do not compare well to functional flow reserve (FFR). The DEFER, FAME
I and FAME II studies showed that FFR guided therapy provides a sustained clinical benefit over non
FFR guided therapy, and had a better event-free survival and reduced health care cost.
The functional significance of coronary lesions could be determined by FFR. He noted that in a study
(Kaul et al), 101 patients with 111 lesions were identified with 50-90% stenosis, providing a potential
for 111 stents. However, on the basis of FFR, only 30 required PCI, saving 81 lesions from unnecessary
stenting. FFR is the reference standard for defining the hemodynamic significance of coronary artery
stenosis, noted the speaker. Measurement of FFR requires invasive coronary angiography leading to
a need for non-invasive identification of ischemia-causing lesions.
This concept led to the development of FFRCT, which is non-invasive FFR computed from coronary
CT scans. Heartflow technology, a more advanced technique applies computational fluid dynamics
(CFD) to solve problems of human coronary blood flow.
DISCOVER-FLOW study compared FFRCT to invasively measure FFR, and concluded that FFRCT was a
novel non-invasive method that enabled physiologic determination of CAD from CCTA, without any
additional imaging or medications. FFRCT demonstrated excellent correlation with invasively measured
FFR. This non-invasive technology could reduce unnecessary invasive coronary angiography and
revascularization procedures. The DEFACTO trial compared FFRCT with CTA, and showed superiority
of FFRCT over the latter. The accuracy of FFRCT over CTA was shown by the Heart Flow NXT study. In
the RIPCORD study, from the original recommendation of PCI, 30% were reallocated to OMT alone
as no ischemic lesions were present. In 18% of the PCI group, FFRCT led to a change in the vessel or
vessels targeted. Overall, 72 recommendations were altered out of 200 cases.
To conclude, the non-invasive Heartflow analysis for functional significance of coronary stenoses
would be now possible using computationally derived FFR from anatomic coronary CT data. This new
technology provided a combined anatomic-functional assessment of coronary artery disease using a
single non-invasive test, which can help physicians appropriately select patients for medical therapy
or invasive angiography.
42
Use of Contrast in Ischemic Heart Disease

Dr. Nitin J Burkule
MD, DM, DNB, FASE, FACC
Rane Heart Hospital, Thane
The speaker noted that for contrast echocardiography, patients need IV access and it is generally the
main obstacle in most of the busy echo-labs. When the need for contrast arises, the availability of a
trained nurse was key for establishing a successful contrast echo program. The mechanical index (MI)
would be set at 0.3 to 0.6 for LVO, with the dynamic range kept modest. Larger bolus of contrast
and/or rapid flushing would lead to higher quantity of contrast in left ventricle (LV) cavity leading to
shadowing in lower half of the image and hence, one had to wait for partial destruction of contrast
till uniform LV opacification is seen. Less quantity of contrast could lead to swirling defect in LV
cavity. In this case, additional small bolus of IV contrast might be needed. The investigator needs
to look at all the 6 views carefully by looking at one segment at a time for endocardial excursion
and myocardial thickening. Though contrast echo could help in every stage of IHD, it is invaluable
to detect resting RWMA. The sustained and uniform opacification of LV cavity almost universally
enhanced the endocardial delineation of all LV wall segments, thereby increasing the diagnostic
information available to the clinician. The contrast LVO could clearly show stress induced regional wall
motion and thickening abnormality or stress induced regional thinning or LV dilatation. The ease of
appreciating LV segmental thickness and thickening is useful in early triage of patients presenting to
emergency dept with chest pain. The presence of RWMA could be confidently diagnosed by contrast
LVO. The presence of or absence of RWMA can help to rapidly risk stratify these patients, better than
TIMI score, while awaiting the troponin results. Contrast could also be used for myocardial perfusion
assessment. The presenter used many illustrative cases to support his words.
Talking about MCE, he observed that in an echolab with established contrast echo programme,
the need of MCE was not infrequent. MCE is the commonest and technically easy way to evaluate
for myocardial salvage in early period after primary PCI or thrombolysis in ST elevation myocardial
infarction (STEMI). Since myocardial thickness is preserved due to post reperfusion tissue oedema,
the myocardial perfusion would be easy to visualize. A salvaged myocardium would have reflow at
microvasculature level and MCE would show homogenous myocardial opacification in infarct territory.
Absence of MCE opacification in infarct territory would suggest myocardial necrosis, while uniform
MCE opacification suggests salvage of myocardium. The presence or absence of MCE opacification
could predict LV remodeling and adverse cardiac outcome post reperfusion in STEMI.
However, limitations were present for contrast too. For contrast LVO or MCE, the echo machines
were pre-set at low MI, which makes visualization of valves and atria difficult. No speckle tracking
imaging could be done on the same set of contrast images due to low frame rate and low MI
imaging. Shadowing is very common at basal segments and also due to rib or papillary muscles.
Artefactual attenuation in anterior wall due to lung shadowing or apical segments due to near field
destruction is also a common pitfall.
43
An Overview of Advanced Cardiac Imaging

Dr. Ansuman Saha
MBBS, MRCP
East Surrey Hospital, Surrey, UK
Because it provides an exciting and stunning picture in almost any imaging plane, the speaker
noted that cardiac MRI is a very important investigation for adult congenital heart diseases.
Perfusion MR could diagnose reversible ischemia, and aid in targeted PCI. Cardiac MRI could
also help in viability assessment by LGE. The advantages of MRI include better image quality,
multiplanar imaging, tissue characterization, safety and comprehensive evaluation.
The CE-MARC trial, which the speaker shared, is the largest, prospective, real world evaluation of
CMR and establishes the diagnostic accuracy in coronary heart disease and CMRs superiority over
SPECT, and observed that it should be adopted more widely than at present for the investigation
of coronary heart disease. Being non-invasive, no use of iodinated contrast agents, lack of
radiation exposure made it a very safe option for serial follow-up, and also in more vulnerable
patients who did not need unnecessary radiation like in the young and in females.
However, it is not suitable for all patients. It is not suitable for patients with metallic implants,
and those with external devices. In nephrogenic systemic fibrosis, if GFR<30, it could be used but
is contra-indicated in patients with GFR>30. Also, the cost made it not accessible everywhere,
and needed dedicated centres thereby limiting the availability and use. Also, being non-portable
is another limitation.
Cardiac CT is the newest imaging tool, which provides a basis for non-invasive CT coronary
angiography and evaluation of, anomalous coronary artery anatomy using much less radiation
dose; in addition, it gives out data on perfusion and scar volume. Cardiac CT has a sensitivity of
97%, specificity of 90% and negative predictive value of 99%.
To conclude, the speaker noted that cardiac MRI is an excellent non-invasive comprehensive
test for cardiac structure and function. CT coronary angiogram is a good non-invasive test to
check the coronary anatomy, and as its negative predictive value is 99%, it should be used as
gatekeeper for invasive coronary angiogram.
44
Introduction to Cardiac Imaging

Dr. Johann Christopher
MBBS, MD, DM, DNB
Addressing the audience, the speaker spoke on the changes in imaging in the Indian scenario before
CTA and after CTA. Before CTA, catheter angio was used to decide on intervention or MPS/SPECT,
but now CTA is being used to decide whether patient needs MPS PECT and further intervention or
catheter angiography before deciding on interventional procedures.
Cardiac evaluation is mainly dependent on Dobutamine Stress Echo, thallium scan, cardiac MR, cardiac
CT, and coronary angiogram. The speaker shared data from Indian studies regarding the correlation
of CAC with CTA and MACE in symptomatic patients, correlation of CIMT with CAC and SPECT in
symptomatic patients, correlation of FRS vs CAC vs TSS in symptomatic patients, correlation of lipids
vs CAC in symptomatic patients etc, but accepted that no test was perfect. Dynamic adenosine
stress myocardial perfusion CT could detect flow limiting coronary stenosis (FFR <0.75). Diagnostic
performance of CTCA FFR was also good to detect functional coronary lesion, with a sensitivity of
92% and specificity of 40%.
When it came to hybrid PET/CT
imaging, CT was the best in enabling
hybrid PET/CT imaging. 64 slice
CTCA has a negative predictive value
of 96.5%, which is reliable to rule
out significant CAD. ACS vulnerable
plaque also could be clearly defined
on CCTA. In addition, CCTA has an
important role to play before PCI of
chronic occlusions.
The question on cardiovascular
imaging ultimately came to how
it could change the practice of
cardiology, the speaker said, and
concluded with the suggestion of an
organisation of joint, multidisciplinary
diagnostic services as depicted in
Figure 1, with common diagnostic
protocols and pathways.
Cardiology
Nuclear
Medicine
Radiology
Joint Cardiac
Imaging Group
Patients requiring
Cardiovascular
Investigation
Common
diagnostic
protocols
and
pathways
{{
Ultrasound
SCINT./PET
CT
CMR
Angiography
Clinical
impact and
end-points
Suggested organisation of joint, multidisciplinary diagnistic services.

SCINT, nuclear scintigraphy; PET, positron emission tomography;
CT, X-ray compued tomography; CMR, cardiovascular magnetic resonance.
Figure 1: A systematic diagnostic pathway for cardiovascular investigation.
45
Imaging LA Is it a Crystal Ball of CV Events?

Dr. K Chandrasekaran
MD, FACC, FASE
Mayo Clinic, MN, USA
According to a study published in the Circulation, there was a relation between echocardiographically
determined left atrial (LA) size and atrial fibrillation (AF). In the study, it was observed that AF was
rare when LA dimension was less than 40 mm and was common when LA dimension was >40 mm.
Also, cardioversion while initially successful, was unlikely to result in SR lasting >6 months when LA
dimension was >45 mm. These findings underlined the need to measure the LA in such cases. The Bi
plane-length equation, which calculates the LA volume would be an important index in this regard.
The use of diastolic dysfunction and LA remodeling in the prediction of first AF showed that the age
adjusted cumulative survival free from NVAF decreased as the LAVI increased and was least in the
third tertile (LAVI >37 ml/m2 ; Figure 1).
Age-adjusted cumulative
Survival free from NYAF (%)
100
90
80
LAVI 27 mL/m2(tertile 1)
LAVI >27 to <37 mL/m2(tertile 2)
LAVI 37 mL/m2 (tertile 3)
70
P<0.001
60
0
Follow-up (yr)
Figure 1: Survival free rate from NYAF as a function if time.
The odds ratio also increased as the LAVI increased.

However, in spite of these results, the speaker urged the audience to be cautious and never to use
LAVI alone. He suggested its use along with diastolic function. Enlarged LAVI with normal diastolic
function was benign, while enlarged LAVI with abnormal diastolic function would be considered
malignant as it indicated pressure overload.
46
Can Routine Echo Predict Future CV

Events?
Dr. Nitin Burkule
MBBS, MD, DM, DNB, FACC, FASE
Rane Heart Hospital, Thane
Sharing the case history of a 60-year-old who was hypertensive and obese, with NSR and LVH, DOE
class III and presented after 17 months with AF, pulmonary edema and CVA, the speaker discussed
the role that routine echo would have in the prediction of future CV events.
The progression of patients with LA and LV subendocardial fibrosis, was usually exercise limitation
and diastolic dysfunction leading to HFNEF and to CHF or to paroxysmal/persistent AF and cardioembolic stroke. In SBHF, HF was more linked to abnormal GL strain and E/e, and therefore should be
added to current definition of SBHF. E/e and LVH are more predictive of exercise capacity than BNP.
Indices like LA volume index, minimal LAV, LA reservoir function, LA emptying fraction, LA booster
function are important in risk prediction in general population of AF, CHF, CBA and mortality. In
HFNEF, LA reservoir and contractile function during leg lifts were noted to be blunted. The global LAS
and global LAB of <31.2% and <15.2%, respectively, during leg lifts discriminate HFpEF from HT
controls with sensitivities of 90% and 89% and specificities of 83% and 94%. Diagnosis of HFNEF
is best when the doctor takes into account the age, gender, echocardiography, global LAs at rest and
global LAs with leg lifts.
The next scenario was in acute ischemia leading to subendocardial contractile dysfunction or
myocardial necrosis, wherein strain imaging and troponin were useful, respectively. The case was of
a 54-year-old male who was non-diabetic, non-hypertensive, and a non-smoker. CT CAG performed
2 years ago was normal with normal resting ECG. He had symptoms of new-onset chest pain on
exertion and sometimes while at rest, but was sent back from cardiologists office twice without a
diagnosis. The speaker noted that strain imaging would have been useful in this case. As shown in
experiments, ratio of SI-DI (strain imaging diastolic index) before and after exercise cutoff value of
0.39 (for >70% stenosis) had a sensitivity of 97% and specificity of 88%.
The use of routine echocardiography would be very useful to detect future CV events, the speaker
noted. However, the right knowledge and use of the appropriate indicators were very essential if it
had to become a powerful tool in preventing future CV events.
47
Can Ultrasound Reclassify ASCVD Risk?

Dr. Shishu Shankar Mishra
MBBS, MD, DM, DOCM, FAIMS, MCAM, FCCP, FIAE, FICC, FCSI
Cardiologist
Medicine and Heart Clinic, Cuttack
Many tests are available to diagnose and stratify patients with ASCVD risk, which aids in better
management of the patient. Stress echo test, TEE intimal thickening, echocardiography for aortic
sclerosis and aortic valve calcification are also used as markers of active atherosclerosis. A very
interesting tool for the same is CIMT (carotid intima media thickness) obtained through ultrasound.
IMT study for atherosclerosis was excellent, quick, reliable, reproducible and non-invasive. For every
0.19 mm increase in CIMT, the risk of death and MI increases by 36%. Carotid B mode ultrasonography
was done to measure intimal medial thickness, and was non-invasive, inexpensive and involved no
radiation. It is well-established as an indicator of cardiovascular risk from epidemiologic studies,
with lot of published clinical trials on utility of carotid IMT as measure of atherosclerosis and effects
of therapy. As per the ACCF/AHA 2010 and ESC 2012 guidelines, CIMT measurement could be
reasonable for CV risk assessment in asymptomatic adults at intermediate risk (Class IIa-B); however,
the 2013 ACC/AHA guideline did not recommend this for risk assessment.
Flow mediated vasodilatation (FMD) was another such tool. The normal values of FMD are 18.126.76% (Jadav et al), 16.1 25.3% (Mishra et al). Their utility was described by the TREND study
and BANFF study. Quantitative coronary angiography could be used to assess the reversibility of
atherosclerosis. IVUS was another powerful tool to assess the effect of high intensity statin therapy
on atherosclerosis in non-infarct related coronary arteries.
PROSPECT methodology, and American Heart Association classification and SHAPE criteria were few
criteria which could grade these conditions. Along with these, reclassification with CIMT added to
Framingham risk score was a new method of classification which could play more role in the future.
Classification of ASCVD by ultrasound could be the future, the speaker concluded. The classification
provided by the speaker was as follows:
Classificaion of ASCVD by Ultrasound
Clinically Advanced ASCVD
Sub-clinical ASCVD
Modality of Study
Echo
Stress Echo,
Contrast Echo, TEE
Vascular Study
Invasive
Non-Invasive
IVUS, TEE
CIMT, FMD, ABI, DA, Aorticarch,

descending aorta, Echo Study ABis
48
Echocardiographic Evaluation of
the Mitral Valve
Dr. Srikanth Sola
MD, FACC
Cardiologist
Sri Satya Sai Institute of Higher Medical Sciences
An echo done to assess the mitral valve, the speaker noted, had to tell four things. The grading
of MR severity, etiology of MR, MV anatomy (scallops involved, MV annulus diameter, tenting
height/volume, AML length, coaptation length, anterior leaftlet angle, interpapillary muscle
distance, chordal length etc) and also any associated pathology.
In mitral regurgitation (MR), severity grade (1+ to 4+ etc), vena contracta width, EROA, regurgitant
volume, regurgitant fraction were important to know, while the grading for ischemic MR would
be different. Based on the mechanism of MR, the Carpentiers functional classification was
charted. This was also an important classification as the probability of repair could be assessed
better.
MV annulus diameter of <35 mm would be considered normal, while >50 mm had a low
likelihood of repair. Mitral annular calcification was another prognostic factor. Predictors of
unsuccessful valve repair were coaptation height of >10mm, interpapillary muscle distance of
>20mm, tenting area>2.5 cm2, PLA>45, and TOE2-ch transgastric 90.
Other predictors of unsuccessful valve repair were organic MR, with large central regurgitant jet,
severe annular dilatation (>50mm), involvement of >3 scallops (esp if AML involved), extensive
valve calcification, and lack of valve tissue.
To summarise, the speaker noted that the factors that predict unlikely repair were remodeled
ventricle and deficient MV. Remodeled ventricle was characterized by dilated LV (LVED d>65mm;
LVEDs>51 mm), sphericity index >0.7, and dilated MV annulus (>50 mm), while deficient MV is
characterized by complex jets, poor leaflet tissue, 3 scallops involved, and tenting height >10
mm and area >2.5 cm2
49
Case Studies
Dr. Satish Parashar
MD, FACC, FCSI
Cardiologist
Metro Hospitals and Heart Institute, Delhi
The first case discussed was of a 9-year-old, with frequent chest infection, no dyspnoea, fairly normal
growth and history of frequent urination. On echo, it was observed that there was a large VSD with
inlet extension, restricted by septal leaflet of tricuspid valve. She had pulmonary atresia and the
ejection fraction as 60%. Post operatively, after 2 months, echo showed no residual VSD flow and
no mass. LV contractility was sluggish with EF 44%. Next echo after 5 months showed no VSD flow,
but global hypokinesia with EF 35%, PAP 28 mm Hg. The next echo after another 6 months showed
a mobile mass on RV side of patch closure; this was a large thrombus, which could have happened
due to low pressure state on RV side and post VSD closure endocarditis.
The next case was of a 44-year-old Nigerian female, whose only complaint was fatigue. She
was a known hypertensive since 5 years. BP on admission was 200/120 mm Hg, with grade 4/6
holosystolic murmur LSE. On echo, a double chambered right ventricle was noted. This condition
is a rare congenital disorder with 0.5% to 2% of all CHD, VSD being the commonest association
and most commonly misdiagnosed as VSD or PS. For diagnosing double chambered RV, awareness
of the condition, presence of RVH in absence of other obstructing lesions was important. Presence
of turbulence and systolic pressure gradient between inflow and outflow portions, RV angiography,
direct visualization during surgery and other associated lesions were important. The unusual features
of this condition being that it could remain undiagnosed upto this age, and was asymptomatic. No
evidence of RV failure was present and could be due to spontaneous closure of VSD.
The speaker concluded with a discussion on cardiac tamponade. He noted that the cardiac chamber
filling was sequentially impaired with low pressure atria affected first. The compressive effect on
a chamber occurs in cardiac cycle when its pressure decreased. Also, brief RA inversion may be
normal in small PE. Pleural effusion also may be added as an important D/d of cardiac tamponade.
In presence of small PE, it could lead to a misdirected diagnosis of tamponade. The pleural effusion
could lead to altered CV hemodynamics and contribute to dyspnoea with almost 18% cases ending
with RA collapse.
50
Vitamin D in the Prevention of Atherosclerosis

Dr. Soumitra Kumar
MD, DM, FCSI, FACC, FESC, FSCAI, FICC, FICP, FIAE
Vitamin D deficiency is prevalent in about 50% of the population worldwide. The fact that vitamin D
confers benefits beyond bone health was first suggested by ecologic studies showing lower incidence
of cancer and cardiovascular mortality in regions with greater exposure to UV-B radiation. Vitamin D
exerts a variety of direct favorable effects on endothelial dysfunction; the positive effects are exerted
on vascular smooth muscle cell (VSMC) proliferation, migration and calcification, as well as on the
inflammatory/immune processes of atherosclerosis. Additionally, it exerts indirect beneficial effects
against systemic factors that promote atherosclerosis, such as insulin resistance, dyslipidemia, RAAS
and consequent hypertension.
Dr. Soumitra Kumar noted that although observational studies are suggestive of vitamin D deficiency
to be linked to an increased risk of cardiovascular disease (CVD), data to contradict this correlation
exist too. While RECORD trial showed no effects of vitamin D3 supplementation on vascular disease,
mortality and all-cause mortality, the Womens Health Initiative (WHI) reported a nearly statistically
significant harmful effect with combined vitamin D3 and calcium supplementation in terms of nonfatal MI, CHD death or need for revascularization. However, it should be noted that randomized
controlled trials involving CVD and more specifically, atherosclerosis as primary predefined outcome
are lacking. The VITAL trial, which is a large, randomized, double-blind trial of Vitamin D3 (2000 IU/
day) and omega-3 fatty acid supplements in primary prevention of CVD in a multiethnic population
of 20000 US men 50 years of age and women 55 years of age is ongoing. More such large-scale
trials to test the effect of Vitamin D (D3 and D2) on atherosclerosis and CVD as primary outcome
are required to firmly establish the role of Vitamin D supplementation on CVD risk and mortality.
At present, prescribing Vitamin D supplementation with the goal of preventing CVD beyond
recommended daily needs is not preferred.
51
Newer Anti-Diabetic Drugs:

Role in Cardiac Patients
Dr. S B Gupta
MBBS, MD
Consultant Physician Cardiologist
Asian Heart Institute, Mumbai
Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in patients with diabetes.
Epidemiological data have shown that blood glucose levels are related to CVD; therefore, achieving
normoglycemia would be expected to reduce the incidence of CV events. However, large prospective
trials have shown conflicting results. The Epidemiology of Diabetes Interventions and Complications
(EDIC) trial and the United Kingdom Prospective Diabetes Study (UKPDS) showed better cardiovascular
outcomes, while Action in Diabetes and Vascular Disease (ADVANCE) and Veterans Affairs Diabetes
Trial (VADT) showed no macrovascular benefits and the Action to Control Cardiovascular Risk in
Diabetes (ACCORD) trial indicated increased all-cause and cardiovascular mortality. This could be
either because of the risk of unrecognized hypoglycaemic events or due to adverse effects of antidiabetic drugs affecting cardiovascular physiology.
Of the older anti-diabetic drugs, metformin is safe in the context of adverse CV status, including mild
degree of heart failure. Newer generation sulphonyl ureas (SUs) like glicazide and glimperide are
comparatively cardio-safe than older SUs. Among glitazones, pioglitazone has good cardiovascular
safety data; it is contraindicated in severe LV dysfunction and heart failure. Although dual peroxisome
proliferator-activated receptor (PPAR) modulators like glitazaars have a theoretical basis for use in
cardiac patients, real world scenario is contrary to it. -glucosidase inhibitors like acarbose have good
cardiac safety profile.
Newer anti-diabetics drugs have better cardiovascular safety profile. DPP-4 inhibitors like sitagliptin,
saxagliptin, vildagliptin, linagliptin or alogliptin possess significant cardiovascular safety. Teneligliptin,
approved in Japan in 2012 and recently launched in India is a cost-effective anti-diabetic drug.
However, it needs to be evaluated for cardiovascular safety.
Latest on the block are sodium glucose transport inhibitors (SGLT2i) like canagliflozin, dapagliflozin or
empagliflozin. SGLT2i seem to be promising in terms of cardiovascular safety. EMPA-REG OUTCOME
Clinical Trials reported 38% relative risk reduction in death from cardiovascular causes and 35%
relative risk reduction in hospitalizations from heart failure as compared to placebo.
The association of cardiovascular disease with diabetes remains a challenge, and the focus of diabetes
drug development seems to have shifted towards ensuring cardiovascular safety, rather than simply
addressing glucose homeostasis. Hence, it is important for the physicians that they shall weigh the
potential cardiovascular risk and the benefits before prescribing anti-diabetic drugs in cardiac patients.
52
Benefit of Yoga in Heart Disease:

Do We Have Evidence?
Dr. S C Manchanda
Senior Consultant Cardiologist
Sir Ganga Ram Hospital, New Delhi
The burden of heart diseases is rapidly increasing, especially in the developing countries. The primary
contributing factor is considered to be unhealthy life style; mental stress, high fat diet, lack of exercise
and smoking increase cardiovascular risk. Yoga tends to create a holistic lifestyle by mitigating
these risk factors. Several studies suggest yoga to be helpful in controlling the risk factors of heart
disease like hypertension, diabetes mellitus, dyslipidemia, obesity, metabolic syndrome, mental stress,
smoking, and oxidative stress. The American Heart Association has recently stated that meditation,
which is part of yoga, can be used as a non-pharmacological method to control blood pressure.
Other published studies have shown yoga to reverse early and advanced coronary atherosclerosis and
to be useful in the secondary prevention of coronary heart disease. In addition, cardiac arrhythmias
and heart failure have shown to be positively impacted by yoga. A summary of the beneficial effects
has been summarized in Figure 1.
YOGA
Myocardial Infarction
Coronary thrombosis
YOGA
Arrhythmias and loss

of muscle
Myocardial ischemia
Remodelling
Athersoclerosis
Oxidative stress, neurohormones
and Inflammation
Ventricular enlargement
YOGA
YOGA
Risk factors
Dyslipidemia
Hypertension
Diabetes
Smoking
Psychosocial stress
YOGA
End-stage heart
disease, death
Figure 1: Effect of yoga on the cardiovascular continuum.

Although there is an impending need for large multi-center trials to confirm the effectiveness of
yoga, Dr. Manchanda proposes yoga to be a simple, cost-effective, and a safe option that can be
recommended for primary and secondary prevention of heart disease.
53
Acute Rheumatic Fever: Treatment

Controversies
Dr. Geetha Subramanian
MD, DM, FIAE, FISE, FISC, FMMC, IACC
Professor and Head, Department of Cardiology
Benaras Hindu University
There is paucity of data from randomized clinical trials on the effectiveness of therapies for acute
rheumatic fever. Therefore, Dr. Geetha Subramanian sought to review the existing data and guidelines
for treatment of carditis in acute rheumatic fever; also, an appraisal on primary and secondary
prevention of rheumatic fever was provided.
For the treatment of moderate-to-severe carditis, regimens recommended by the Indian Academy
of Pediatrics may be used. Regimen I comprises of: prednisolone 2mg/kg/d escalated to a maximum
dose of 80mg/day until ESR normalizes. Then, the dose is tapered over a period of 2-4 weeks.
Simultaneously, aspirin at a dose of 50-75 mg/kg/d for a period of 12 weeks is recommended.
Regimen II comprises of prednisolone 2mg/kg/d escalated to a maximum dose of 80mg/day over a
period of 3-4 weeks. The dose is tapered over 10-12 weeks. However, the presenter pointed that
there is no conclusive evidence to indicate that the use of corticosteroids will prevent heart disease
in the long term.
Guidelines for primary and secondary prevention (Tables 1 and 2, respectively) have been presented
below.
Table 1: Primary Prevention of Rheumatic Fever.
Agent
Dose
Mode
Duration
Children: 250 mg 2 to 3 times daily for 27 kg (60 lb);

children >27 kg (60 lb), adolescents, and
adults: 500 mg 2 to 3 times daily
Oral
10 days
Oral
10 days
600 000 U for patients 27 kg (60 lb); 1 200 000 U for patients >27
kg (60 lb)
Intramuscular
Once
Variable
Oral
10 days
Oral
10 days
Oral
5 days
Oral
10 days
Penicillins
Penicillin V (phenoxymethyl penicillin)
or
Amoxicillin
50 mg/kg once daily (maximum 1 g)

or
Benzathine penicillin G
For individuals allergic to pencillin
Narrow-spectrum cephalosporin
(cephalexin, cefadroxil)
or
Clindamycin
20 mg/kg per day divided in 3 doses (maximum 1.8 g/d)

or
Azithromycin
12 mg/kg once daily (maximum 500 mg)

or
Clarithromycin
15 mg/kg per day divided BID (maximum 250 mg BID)
To be avoided in those with immediate (type 1) hypersensitivity to a penicillin.
54
Table 2: Secondary Prevention of Rheumatic Fever.

Agent
Dose
Mode
600 000 U for children 27 kg (60 lb),

1 200 000 U for those >27 kg (60 lb) every 4 wk*
Intramuscular
Penicillin V
250 mg twice daily
Oral
Sulfadiazine
0.5 g once daily for patients 27 kg (60 lb),

1.0 g once daily for patients >27 kg (60 lb)
Oral
Variable
Oral
Benzathine penicillin G
For individuals allergic to penicillin and sulfadiazine

Macrolide or azalide
*In high-risk situations, administration every 3 weeks is justified and recommended.
Valve replacement may be essential in patients with refractory heart failure due to severe carditis.
55
Establishing STEMI Care Systems in India

Dr. S Ramakrishnan
MBBS, MD
Additional Professor of Cardiology
AIIMS, New Delhi
Cardiovascular disease (CVD) burden is increasing substantially across the globe. This picture
corroborates well with the Indian scenario too; CVD affected 64 million people in 2015 and the
typical cause was found to be coronary artery disease. Reducing CVD burden is an important clinical
challenge facing the healthcare community. It is a well-known fact that myocardial salvage within
the critical period confers significant positive outcomes (Figure 1). The concept of pre-hospital
thrombolysis has been receiving a lot of interest in the recent times. Dr. Ramakrishna discussed some
of the pre-hospital thrombosis systems in India and the obstacles to its widespread use.
Mortality reduction
Pre-Hospital Thrombolysis Mission launched by

Critical time-dependent period
AIIMS, Delhi is one of the attempts by Indian
100%
Goal: myocardial salvage
60 min
hospitals to facilitate prehospital thrombolysis.
Time-independent period
D
80%
Goal: open IRA
The model involves recording ECG by a nurse
30%
60%
who attends to the patient at his/her residence
C
240 min
40%
and relaying th information to a cardiologist
10%
for diagnosis. Once STEMI is diagnosed, the
B
20% Extent of
A
myocardial
salvage
patient is taken in the ambulance to the hospital
0%
with thrombolysis (with IV tenecteplase) being
0
4
8
12
16
20
24
performed in the ambulance itself. Every
Time from symptom onset to reperfusion
ambulance is manned with two nurses and has
therapy (hours)
equipments such as ECG machine and defibrillator
with external pacing (Lifepak 15).
Figure 1: Tridimensional model of symptom
onset, time to treatment, and mortality.
Emergency Medical and Reseacrh Institute of
GVK has come up with a model that assists patients with getting their ECG transmitted to one of
the STEMI care coordiating centres and transporting them to one of the nearest network hospitals.
Average transportation time to hospital is less than 15 minutes in urban areas and about 25 minutes
in rural areas.
Dr. Ramakrishna noted that there is an impending need for government policies to encourage such
initiatives. Also, support by doctors and hospital admistrators are welcomed. Financial issues with
respect to the choice of thrombolytic and inconsistencies in insurance coverage were identfied to be
specific hindrances.
56
High Intensity Intermittent Exercise and

Moderate Intensity Continuous Exercise
Dr. Sunitha Viswanathan
MD, DM, FSCAI
GMC, Allepey
Moderate intensity continuous training (MICT) includes tread mill, running and slow endurance.
They are time consuming and are ineffective for weight loss. In contrast, high intensity intermittent
exercise (HIEE) refers to any workout that alternates between intense bursts of activity (e.g. sprinting
for a minute) and fixed periods of less intense activity (waking for a minute or 2) or even rest. While
both MICT and HIIE improve cardiovascular fitness, HIIE is associated with greater improvements in
VO2 max and body fat reductions. Furthermore, HIIE may produce twice as much improvement in
cardiovascular fitness of patients with hypertension, obesity, heart failure and metabolic syndrome
as compared to MICT.
Decreases in ATP stores
Epinephrine drives lipolysis
Decreases in phosphocreatine stores
Drives fat release from sub cutaneous and intramuscular

fat stores
Decreases in glycogen stores

At end of sprint, ATP resynthesis happens from PCr
degradation
More -adrenergic receptors in abdominal than

subcutaneous fat
Complete restoration of pH and lactate takes hours
More potential to lower abdominal fat
During recovery, O2 consumption is elevated to restore

metabolic processes to normal
Significant decreased in parasympathetic reactivation
Box 1: HIIE metabolic responses.
Box 2: Effects of increased catecholamines.
Explaining these contrasts, Dr. Sunitha Viswanathan presented an informative update on the
usefulness of HIEE in patients with cardiovascular diseases. The metabolic changes associated with
HIEE are listed in Box 1. HIEE increases norepinephrine levels by 6.3 fold and to 14.5 fold at end
of sprinting. Effects of this catecholamine increase are presented in Box 2. Furthermore, HIEE is
associated with marked growth hormone response in 30 seconds and remains elevated by 450%
up to 24 hours. These effects increase burning of calories and retards ageing. Along with this, HIEE
increases cortisol levels and plasma lactate levels. During recovery, removal of lactate and H+ is seen
along with increases in cardio-pulmonary functions. Further, excess post-exercise oxygen consumption
(EPOC) is noted during recovery. Explaining the beneficial effects of these on cardiac functions,
insulin resistance and glucose tolerance, the presenter noted that HIIE may be more effective than
MICT in improving mean VO2 in patients with CAD and provide a robust stimulus for exercise training
adaptations in patients with heart failure with preserved ejection fraction. After presenting evidences
from published literature on the safety of HIEE, Dr. Sunitha Viswanathan concluded the presentation
with a photograph of Usain Bolt and Justin Gatlin but indicated just before the conclusion slide that
HIEE is not just for Machos but also for patients on cardiac rehabilitation.
57
Ideal Cardiac Rehabilitation Program

Prof. Dr. Vijay Garg
MD, FCSI, FACP, FESC, FACC
R.D. Gardi Medical College
Ujjain
Cardiac rehabilitation is a multi-pronged approach designed to reduce mortality and morbidity of

CAD by optimizing a patients physical, psychological and social functioning along with mitigating
the risk of atherosclerosis. Available evidences from clinical studies and meta-analyses indicate that
cardiac rehabilitation reduces mortality and morbidity and may even prevent a recurrence of MI.
Explaining that it took a long time and effort to change the concept of bed rest after heart attack,
Dr. Garg presented the indications (Box 1) and contraindications (Box 2) of cardiac rehabilitation.
Absolute Acute myocardial infarction (within two days)
Unstable angina
Uncontrolled cardiac arrhythmias causing symptoms or
homodynamic compromise
Symptomatic severe aortic stenosis
Uncontrolled symptomatic heart failure
Acute pulmonary embolus or pulmonary infarction
Acute myocarditis or pericarditis
Active endocarditis
Acute aortic dissection
Acute noncardiac disorder that may affect exercise
performance or be aggravated by exercise
Inability to obtain consent
Acute myocardial infarction

Coronary artery bypass grafting
Percutaneous coronary vessel remodeling (i.e. angioplasty,
atherectomy, stenting)
Valve replacement or repair
Heart transplantation
Major pulmonary surgery
Great vessel surgery
Sustained ventricular tachycardia or fibrillation
Class III or IV congestive heart failure unresponsive to medical
therapy
Chronic stable angina pectoris unresponsive to medical
therapy
Box 1: Indications for cardiac rehabilitation.
Box 2: Contraindications for cardiac rehabilitation.
Explaining the effects of cardiac rehabilitation

on improvements in ejection fraction, heart
rate and event-free survival, the presenter
provided an informative update on the different
phases of a cardiac rehabilitation program
(Figure 1). The presenter reiterated that exercise
reduces cardiovascular risk by attenuating
endothelial dysfunction, inflammation, and
oxidative stress. The presentation also discussed
tele-rehabilitation, exer-gaming and Yoga
as a part of cardiac rehabilitation programs.
Dr. Garg concluded his presentation by stressing
that motivation is an important part of cardiac
rehabilitation programs. Coming from Ujjain,
Dr. Garg also invited members of the audience
for Simhasta 2016, a religious gathering held
every 12 years.
58
Phase 1
Inpatient
Rehabilitation
Phase 2
Phase 3
Multifaceted
Outpatient,
rehabilitation,
lasting 23 mo.
Exercise training
Healthing eating
and weight loss
Before Sessions
After Sessions
Unsupervised
exercise training
Maintenance,
idefinite
C
Risk factor
control
Smoking
Syptom-limited
exercise test
Exercise training
sessions
Phase 4
Supervised Non
EKG monitored
home exercise,
lasting 616 mo.
Low salt diet
Hypertension
LAFT
Lipids
Low calorie diet
Diabetes
Figure 1: Phases of cardiac rehabilitation.
Risk Stratification Algorithm for Primary

Prevention in Indian Population
Dr. Biswakesh Majumdar
MBBS, MD, DM, DIP (Cardio)
Professor and Head, Cardiology
BMCH, Burdwan
Assessing the seriousness of an illness to guide to therapeutic decisions and aggressiveness of therapy
are important clinical needs of risk-stratification. However, it is also important to incorporate factors
that reflect the specifics of geographical contexts. A number of risk-stratification algorithms exists
for estimating the risk of cardiovascular diseases (Box 1). It is well established that south Asians,
including Indians, have increased risk of CV disease as compared to other populations. Both the
genetic make-up and early onset of conventional CV risk factors are believed to contribute to this
excess risk. These components must be incorporated in the risk-stratification algorithms to avoid the
pitfalls of underestimating and overestimating the risks.
59
The Framingham risk score (FRS)

Prospective Cardiovascular Munster Score (PROCAM)
World Health Organization/International Society of
Hypertension (WHO/ISH) CVD risk prediction charts
Systemic Coronary Risk Evaluation (SCORE)
QRISK
Reynolds score
New Zealand score
American College of Cardiology/ American Heart Association
(ACC/AHA) pooled cohort equations
The 3rd Joint British Societies (JBS3) risk calculator
Box 1: Traditional risk algorithms.
Asian Indians
Framingham Offspring Study
35
n = 414
30
20
15
10
5
et
es
ab
Di
50
35
>2
TG
HD
L<
60
40
>1
L
LD
>2
TC
rte
ns
io
sit
y*
pe
Hy
be
in
g*
0
ok
25
Sm
Results of the CADI study pointed out a high

prevalence of heart disease in the absence
of high prevalence of traditional risk factors
(Figure 1). Pointing out these important aspects,
Dr. Biswakesh Majumdar highlighted that the
FRS does not take into account many of the
non-conventional risk factors such as obesity,
sedentary life styles and family history of
premature CAD. Furthermore, FRS relies heavily
on age as a determinant of CV risk. Consequently,
in a young individual, the estimated 10-year CV
risk according to FRS is invariably low, despite the
presence of multiple CV risk factors. This leads
to underestimating risks in Indian population.
Discussing these issues and the other risk
algorithms, Dr. Biswakesh Majumdar indicated
that until a comprehensive risk stratification
model is developed for Indians, the WHO risk
score for south-eastern region or the ATP III
score, or European SCORE can help our
practicing cardiologists to stratify risk in our high
risk population.
*P=<0.0001
P=<0.008
P=NS
Figure 1: Prevalence of risk factors in CADI study

versus Framingham Offspring study.
Emerging Drugs for Obesity:

At Last Some Viable Options?
Dr. Dipak Sarma
MD, MRCP, FRCP
Senior consultant, Cardiology and Critical Care
Jorhat Christian Medical Centre, Jorhat
Obesity, the fifth leading cause of death affects close to 500 million people and is associated with
cardiovascular disease (CVD), diabetes mellitus and cancer. While lifestyle modification is very
important, it is often ineffective alone and necessitates adjunctive pharmacological therapies.
A number of drugs have been approved and subsequently withdrawn from the market on the
grounds of an unacceptable risk-benefit ratio. Orlisat, lorcaserin and phentaramine/ topiramate are
the three drugs currently in clinical practise with an approval from the US FDA.
Anti-obesity drugs include centrally-acting anorexiants and peripherally-acting GI fat blockers.
Orlistat inhibits gastric/pancreatic lipase and Phospholipase A and results in a modest weight loss
of 9-10%. Lorcaserin, a selective 5-HT2C receptor agonist decreases food intake by acting on the
pro-opiomelanocortin system of neurons and results in a placebo-subtracted weight loss of 3-3.6%.
Furthermore, phentaramine/ topiramate combination is associated with a placebo-subtracted weight
loss of 8.6 9.3%. The modest effects of currently available agents warrant newer agents.
Discussing these, Dr. Dipak Sarma presented an update on bupropion and naltrexone as agents
with a promising future for treating obesity. Bupropion acts on the pro-opiomelanocortin system of
neurons and reduces food intake along with increasing energy expenditure. Naltrexone blocks opioid
receptors in pro-opiomelanocortin system of neurons. A number of clinical trials are assessing the
safety and efficacy of bupropion and naltrexone combination. The ongoing LIGHT Study is assessing
cardiovascular outcomes of this combination. A number of other agents acting on angiogenesis and
novel targets such as leptin and amylin are currently in development.
Dr. Dipak Sarma concluded his presentation by reiterating that that several new drugs are in the
pipeline. Among them naltrexone + bupropion is the best hope in the near future. Until further data
emerges, lifestyle modification remains as the first and must option.
60
Dietary Approach to Health: Lessons from the

PREDIMED Study
Dr. Anup Banerji
Army Hospital (Research and Referral)
New Delhi
Cardiovascular disease, the main cause of premature mortality across the world necessitates
preventive strategies as a public health priority. In these contexts, a high-quality diet and a healthy
lifestyle are the most important factors. The diet-heart hypothesis has been a long-standing tenet in
CVD prevention and nutritional epidemiology. A weakness of the diet-heart hypothesis is that most
of the available evidences are not specific to clinical outcomes, but only intermediate risk biomarkers.
Furthermore, most of data have come from observational studies and not randomized controlled
trials. Explaining these aspects, Dr. Anup Banerji emphasized the need for randomized controlled
trials with cardiovascular end-points to investigate the diet-heart hypothesis.
Eat More:
Eat Less:
Fruits
Red/processed meats
Vegetables
Sugar and baked goods
Nuts
High fat dairy
Legumes
Sweets and soft drinks
Increased Longevity
Prevention of
Whole grain
Fish in place of red meat
Olive oil and other healthy fats
Cardiovascular Disease
Diabetes
Depression
Metabolic Syndrome
Dementia
Results from the PREDIMED study
If you choose to drink red

wine, do so moderately
(3-7 drinks/week)
reduced MI, strokes and associated deaths
Box 2: Advantages of a Mediterranean diet.
Box 1: The Mediterranean diet.
Since 2003, about 200 studies have investigated the Mediterranean diet (see Box 1) and evidences for
their usefulness in health in rapidly accruing (Box 2). Despite this, data from these studies are silent on
mortality as an outcome. These gaps are addressed in the PREDIMED trial, which randomized 7,500
Spaniards at a risk of cardiovascular disease. Volunteers in the study were randomized (counseled
to) to a Mediterranean diet (with 1L extra virgin Olive oil a week) or Mediterranean diet (with nuts)
or a low-fat diet (20-25 percent fat diet). The trial was stopped prematurely as the interim analyses
demonstrated significantly fewer heart attacks, strokes, and deaths from cardiovascular disease in
the Mediterranean groups than in the low-fat diet group. An important feature of this study is that it
was a randomized trial and provided data on the usefulness of the Mediterranean diet for reducing
adverse cardiovascular outcomes. Dr. Anup Banerji concluded the presentation by highlighting the
observation of Harvard Health Publication that, the Mediterranean diet is a diet of abundance and
not a diet of restriction. This diet, in addition to not smoking and daily physical activity is a blueprint
for protecting and perhaps improving health.
61
Edible Oil
Dr. Soura Mookerjee
MD, DM, FESC, FACC
Associate Professor of Cardiology
Medical College, Kolkata
It was a true myth buster! Dr. Soura Mookerjee indicated that plenty of long-term observational
studies find no link between saturated fat consumption and LDL levels. He pointed out that
saturated fats areexcellentfor cooking as they are resistant to heat-induced damage and further
stated that coconut oil, lard and butter are all excellent choices for cooking, especially for high-heat
cooking methods like frying. Polyunsaturated fats, on the other hand, easily oxidize when heated.
He further stated that diets high in saturated fats can lower LDL-p, whilelow-fat diets can have an
adverse effect and raise LDL-p. The presentation brought to notice that two recent studies have
found no association between saturated fatty acids and heart diseases. The presenter in no unclear
terms stated that the saturated fat myth was never proven, isnt proven and never will be proven,
as it is flatly wrong.
Speaking on coconut oil, the presenter indicated that lauric acid, comprises about half of the fatty acid
content incoconut oil. He pointed out the medium chain fatty acids (MCFA) are quickly converted
into energy by hepatic enzymes and the MCFAs are never stored as fat. Dr. Mookerjee also indicated
that palmitic acid contained in palm oil is a good source of antioxidants and highly suitable for
commercial cooking as it is stable at high temperatures and is economical. While a higher amount
of MUFA and PUFA distinguishes mustard oil from other types offats, it remains to be ascertained
whether erucic acid content in mustard oils are the reason for a higher incidence of heart block in
the Eastern regions of India. The presenter, however, pointed out that trans fats (used to prolong the
shelf life of food) are ugly fats with an adverse effect on lipid profiles.
The presenter opined that all liquid oils are about the same. He pointed out that unless you drink
your cooking oil, or deep-fry every day, your choice of cooking oil doesnt make a huge difference.
Indicating that the major source of oil in our diets is from packaged foods and fast-food meals and
not from home-cooked foods. Dr. Mookerjee concluded an extremely interesting presentation by
stating that no oil is, so unhealthy to be considered a poison; so healthy to be a medicine.
62
Fruits and Vegetables for Cardiovascular

Protection
Dr. Uday M Jadhav
MD, FACC (USA), FASH (USA), FESC, FAPSC, FICC, FCSI, FIAE, FISE, FICP
Cardiology Department
MGM New Bombay Hospital
American College of Cardiology/American Heart Association lifestyle guidelines recommend high

intake of fruits and vegetables as a Class 1-Grade A recommendation to lower cardiovascular risk.
Expanding on this recommendation, Dr. Jadhav indicated that the risk of all-cause mortality decreases
by 5% for each additional serving of fruit and vegetables per day. Furthermore, consumption of fruits
and vegetables reduce the risk of all-cause mortality by 6% and 5%, respectively. The risk of allcause mortality did not reduce further after a threshold around five servings of fruit and vegetables
a day. Mechanisms for the inverse association between consumption of fruit and vegetables and
cardiovascular mortality may be attributable to their antioxidant compounds and polyphenols that
prevent the oxidation of cholesterol and other lipids in the arteries.
Dr. Jadhav pointed out evidences from published literature which indicate that a higher intake of
fruits and vegetables is associated with:
Lower prevalence of coronary artery calcification, which correlates with total atherosclerotic
plaque burden, more so than luminal stenosis
Lower odds of prevalent CAC (on higher intake during young adulthood) after 20 years of
follow-up
The presentation concluded by pointing out the results of the INTERHEART study, which indicates
that exercise, moderation of alcohol intake and a high intake of fruits and vegetables lower the risk
of coronary heart disease.
63
Metabolic Syndrome: Indian Scenario

Prof. Apurba Kumar Mukherjee
MBBS, MD
Head, Department of Medicine
In-Charge, Division of Diabetes, R G Kar Medical College, Kolkata
Prof. Apurba Kumar Mukherjee started off his presentation by describing metabolic syndrome to
comprise of any three conditions listed in Box 1. Explaining the high prevalence of metabolic syndrome
in Indian contexts, the speaker discussed the findings of a study that estimated the prevalence of
metabolic syndrome amongst medical students of RG Kar Medical College. Box 2 describes the
baseline characteristics of this study.
Waist circumference >90 cm in
males and >80 cm in women
Triglycerides >150 mg/dL
HDL <40 mg/dL in males and
<50 mg/dL in females
BP >130/85 mmHg and/or
receiving drug treatment for
hypertension
FPG >100 mg/dL or drug
treatment for diabetes
Box 1: Criteria for metabolic syndrome.
Total No.
184
Mean Age
Total=21.83.8 yrs
Mets +ve = 026
Mets -ve = 158
Male
148
Female
036
Mets Prevalence
14% (26)
Urban
070
Rural
114
5 components Mets
0.54% (1)
Hindu
169
Muslim
015
4 components Mets
1.62% (3)
Non-veg
176
Veg
009
3 components Mets
12% (22)
Smoker
034
Non-Smoker
150
2 components Mets
15.2%
F/HDM/HT/DL
021
F/H-Negative
163
1 component Mets
36.9%
IFG-present
026
IFG-Absent
158
0 components Mets
33.7%
Raised BP
030
Normal BP
154
Raised TG
034
Normal Trigly
150
Raised WC
043
Normal WC
141
Low HDL
065
Normal HDL
119
Box 2: Baseline characteristics of the metabolic syndrome

study at RG Kar Medical College.
Results of the study indicated a high prevalence of metabolic syndrome in young MBBS students
(12% had at least 3 components required for diagnosis). About 15.2% and 36.9% had two and one
component of metabolic syndrome, respectively. Dr. Mukherjee indicated that these students had a
high risk of overt metabolic syndrome in a few years in absence of lifestyle modifications. The speaker
attributed the high prevalence of metabolic syndrome to demographic and economic transitions,
a thrifty phenotype genotype, physical inactivity along with socioeconomic and sociocultural factors.
Discussing other aspects of managing metabolic syndrome, the speaker concluded the presentation
by stressing on lifestyle management with diet and exercise. He pointed out that there is no single
pill for metabolic syndrome and reiterated the fact that individual components of the metabolic
syndrome have to be individually managed.
64
Pathogenesis and Laboratory Diagnosis of Underlying

Rheumatic Fever: Do We Finally Understand the Process?
Dr. Thangam Menon
Professor of Microbiology
University of Madras
Rheumatic fever, a non-suppurative inflammatory disease seen following an infection of upper

respiratory tract by GABHS (Streptococcus pyogenes) results in divergent manifestations that include
arthritis, carditis, and chorea along with erythema marginatum/subcutaneous nodules. Although the
incidence of acute rheumatic fever has declined in Europe and North America, it remains as one of
the most important causes of cardiovascular morbidity and mortality in the developing countries.
Pathogenesis of rheumatic fever is influenced by genetic predispositions and the molecular mimicry
between Streptococcus antigens and cardiac myosin. The molecular mimicry characterized by sharing
of epitopes between host antigens and streptococcal bacteria is a hallmark of the pathogenesis
of rheumatic fever. A streptococcal carbohydrate epitope, N-acetyl glucosamine, and the a-helical
coiled- streptococcal M protein structurally mimic cardiac myosin, tropomyosin, keratin and laminin
in the human host with identical and homologous amino acid sequences.
The pathogenic mechanisms proceed in a two-step process whereby antibodies initially damage and
inflame the endothelium of the valve making it susceptible to subsequent infiltration and attack
by T-cells. Streptococcal antigens trigger incorrect T-cell activation and B-cell activation results in
generation of auto-antibodies. Antibodies that recognize cardiac myosin in the myocardium also
recognize the valve endothelium and laminin. Rheumatic valves also display increased expression
ofVCAM-1, which is expressed on blood vessels after the cytokine stimulation of the endothelium.
With respect to genetic predisposition, HLA class II genes were potentially linked with the development
of rheumatic fever/rheumatic heart disease. HLA class II molecules play an important role in antigen
presentation to the T-cell receptor (TCR) and consequently in the triggering of cellular and humoral
immune responses. HLA-DR7 allele is most consistently associated with rheumatic heart disease.
HLA-DR53, another HLA class II molecule, is in linkage disequilibrium with HLA-DR4, DR7 and DR9. In
a cohort of south Indian patients, DRB3 showed a positive association with rheumatic heart disease.
DQB1 loci alleles did not bear a significant association.
Following a discussion on these aspects, Dr. Thangam Menon indicated that there is no single
or specific laboratory test to diagnose rheumatic fever. The Jones criteria remain as the primary
guideline for diagnosing acute rheumatic fever. The presentation further discussed the usefulness
of anti-streptolysin O (ASO) titer and the anti-DNase B (ADB) titer. The presentation concluded with
a discussion on D8/17, a non-HLA B-cell antigen and noted that D8/17 may be seen as a marker of
susceptibility to rheumatic fever.
65
Clinical Profile of Rheumatic Heart Disease

Dr. Nagamani A C
MD, DM
Sri Jayadeva Institute of Cardiovascular Sciences and Research
Bengaluru
Rheumatic heart disease (RHD) is a common acquired cardiovascular disease in children and young
adults. Accounting for 12- 65% of hospital admissions related to cardiovascular disease, it is a major
cause of morbidity and mortality in the developing countries. Describing rheumatic heart disease as
a disease of the children and young adults, Dr. Nagamani pointed out that it usually occurs 10 to
20 years after the original illness. The presenter explained that the mitral valve is more commonly
involved than the aortic valve. One third of mitral disease is associated with aortic lesion and that
isolated aortic valve lesions are less likely to be rheumatic.
The presenter further explained that tricuspid valve disease always coexists with mitral and aortic
disease. The pattern of valvular lesion commonly seen in India is presented in Box 1. Discussing the
topic of multivalvular lesions, the presenter explained data from an Indian study. With an elaborate
and informative update on the symptomology and clinical presentations of RHD, Dr. Nagamani
concluded the presentation by stating that majority of RHD patients present in later stages of the
disease. Furthermore, compliance to antibiotic prophylaxis is unsatisfactory. Dr. Nagamani asserted
that improvements in the socioeconomic condition and better screening and patient education are
the keys to reduce the burden of RHD in India.
Type of lesion
No.
Percentage
Mitral stenosis (MS)
10
28.6
Mitral regurgitation (MR)
17.1
MS, MR
15
42.9
MS, MR, Tricuspid regurgitation
5.7
Aortic regurgitation
5.7
Box 1: Patterns of valvular lesions reported

in a South Indian study.
MS + MR (46.6%)
MS + AR (26.5%)
MR + AR(23.3%)
MS + AS (2.4%)
MR + AS (0.9%)
AS + AR (0.3%).
Box 2: Combinations of multivalvular lesions in

RHD reported in a South Indian study.
66
Secondary Prophylaxis in RHD:

For Whom and For How Long?
Dr. G Karthikeyan
MD, DM, MSc
All India Institute of Medical Sciences, New Delhi
Dr. Karthikeyan presented two scenarios (Box 1) to explain the secondary prophylaxis in RHD. Current
guidelines indicate that all people with acute rheumatic fever or rheumatic heart disease should
continue secondary prophylaxis for a minimum of 10 years after the last episode of ARF or until
the age of 21 years (whichever is longer). Those with moderate or severe rheumatic heart disease
should continue secondary prophylaxis up to the age of 3540 years. The presentation discussed this
guideline in the context of data available on the recurrence rates of rheumatic fever (Figure 1) and
effect of recurrences (Figure 2). The presentation discussed the evidence that the use of secondary
prophylaxis was not independently associated with disease progression/ CHF/ death.
8
7
6
5
4
3
2
1
0
RF recurrence rates
Boston
1920-30
New york UK-US-Canada TAiwan

1950-60
1950s
1979-90
History or treated
recurrence, n/N
No history of
recurrence, n/N
p-value
No carditis
2/9
3/71
0.09
Grade I apical systolic murmur
4/5
4/22
0.02
Grade II, III apical systolic murmur

with or without other murmurs
6/13
39/120
0.36
Status at enrolment
(per 100 pt-yrs)
Brazil
1995-2005
NT Autralia
1997-2010
Figure 1: ARF recurrence rates.
Carditis with heart failure
7/10
12/18
1.0
Carditis with pre-existing RHD
14/17
39/62
0.14
Figure 2: Effect of recurrences.
With these discussions, the presentation concluded by stating that the strength of evidence for
secondary prophylaxis in preventing ARF recurrences and disease progression is weak. However,
patients with a tendency to carditis and a mild RHD after the first attack may benefit the most from
secondary prophylaxis. The presentation noted that the recurrence rates fall to near zero, 10 years
after the index ARF. The presentation started off with two clinical scenarios (Box 1). The resolution of
these scenarios as depicted in Box 2 summarizes the essence of this presentation.
1. 14 year old boy, incidentally detected to have definite RHD
with mild MR
a. Oral penicillin for 10 years
b. Benzathine penicillin 3-weekly for 10 years
c. Benzathine penicillin 3-weekly till age 40
d. Benzathine penicillin 3-weekly life-long
2. 28 year old woman with severe MS and moderate AR, post
successful PTMC
1. 14 year old boy, incidentally detected to have definite RHD

with mild MR
2. 28 year old woman with severe MS and moderate AR, post
successful PTMC
Box 1: Two clinical scenarios depicting the rationale for

secondary prophylaxis.
Box 2: Scenario resolution presented at the conclusion.
67
Management of Atrial Fibrillation in

Valvular Heart Disease
Dr. Panchanan Sahoo
MBBS, MD, DM
Chief Cardiologist
Kalinga Institute of Medical Sciences, Bhubaneswar
Atrial fibrillation (AF) is the most common type of arrhythmia encountered in clinical practice. The
prevalence of AF in general population varies from 0.4% to 1% and sharply increases to 8% in the
population aged over 80 years. Valvular heart disease (VHD), specifically the mitral valve disease is
the most common type of atrial fibrillation. The most clinically significant event in atrial fibrillation is
the high risk of thromboembolic complications.
Management of atrial fibrillation involves three dimensions, namely heart rate optimization, rhythm
control, and thromboembolism prophylaxis. Heart rate is regulated with the help of beta-blocker,
verapamil, digitalis, or amiodarone. Rhythm control is established with the help of antiarrhythmic
drugs belonging to 1A, 1C, and III; permanent pacemaker implantation after AV node ablation or
radiofrequency ablation; or surgical approach involving LA appendage closure. Rate and rhythm
establishment are accomplished by cardioversion (electrical or pharmacological) if LA thrombus is
excluded by transthoracic or transesophageal echocardiography.
The risk of major bleeding for patients on anticoagulation for atrial fibrillation may be determined
with the help of the HAS-BLED score for Major Bleeding Risk. CHA2DS2-VASc score is used for the
assessment of stroke risk in atrial fibrillation. History of congestive heart failure, hypertension, stroke/
TIA/thromboembolism, vascular disease, and diabetes mellitus are the determinants of risk score.
Patients at high-to-moderate risk require treatment with vitamin K antagonists (Warfarin or Acitron;
INR 2-3 or up to 2.5 to 3.5 in those with prosthetic heart valve). Low risk group can be managed with
antiplatelet drugs, including aspirin or clopidogrel.
Dr. Sahoo concluded that atrial fibrillation is rarely life-threatening, however is typically recurrent.
According to him, chief clinical goals should include reducing frequency, duration and severity of
recurrent episodes in order to reduce the risk of thromboembolism.
68
Approach to a Patient with Sick Sinus Disease

MBBS, MD, DM
Cardiologist
Madras Medical Mission
The key features of sick sinus disease are inappropriate sinus bradycardia and chronotropic
incompetence of sinus node. Common symptoms include easy fatigability and dyspnea on
exertion. The diagnosis is often missed in the elderly; paradoxically, they are commonly affected
by the disease most. Occasionally sinus bradycardia due to heightened vagal tone in young and
physically well-conditioned individuals is misinterpreted as sinus node dysfunction.
Pacemaker is indicated when the symptoms are unequivocally associated with documented
bradycardia. Single chamber atrial based pacing is ideal, however, risk of atrial lead malfunction
and possible AV blocks may necessitate dual chamber pacemaker.
Atrial tachyarrhythmias often coexist with sick sinus disease. Antiarrhythmic drugs may worsen
sinus dysfunction and hasten pacemaker requirement. Radiofrequency ablation for atrial
tachyarrhythmia in sick sinus disease is associated with high recurrence rates. Rarely AV node
ablation followed by pacemaker implantation is required. All the sick sinus disease patients need
to be monitored for atrial tachyarrhythmias and should be evaluated for risk for stroke and
anticoagulation requirement.
69
Pulmonary Arterial Hypertension in Pregnancy

Dr. Milind S Phadke
MD, DM
Associate Prof, Dept of Cardiology
LTM College and LTMG Hospital, Mumbai
Pulmonary arterial hypertension (PAH) is 3-4 times more common in women than men. Women
affected are often young and of childbearing age. Thus, PAH in pregnancy is an important consideration
in cardiovascular contexts. Pregnancy is contraindicated in PAH of any cause and is associated with
serious maternal and foetal outcomes (Box 1). Discussing these issues, Dr. Milind Phadke pointed
out that IPAH and CHD-PAH are the major causes of PAH in pregnancy (Figure 1). Indicating that
presenting symptoms not specific and that many symptoms overlap with that of normal pregnancy,
the presenter discussed the role echocardiography and cardiac catheterization.
Maternal
Mortality
Deterioration in NYHA class
Right heart failure
Increased hospitalization
Fetal
Abortions
Increased preterm delivery
Fetal demise
P=0.047
60
56
iPAH
CHD-PAH
oPH
50
40
28
% 30
20
33
36
30
17
10
0
Box 1: Issues associated with PAH in Pregnancy.
19972007
19781996
Figure 1: Aetiology-wise mortality.
The presentation emphasized the importance of contraceptive counseling in women with PAH. As
mutation in BMPR2 is found in about 80% of families affected by HPAH, routine genetic counseling
was discussed as an important part of PAH management in women. Furthermore, the presentation
highlighted that pregnancy termination should be offered regardless of WHO FC or other markers
of prognosis. The first trimester is the safest time for elective pregnancy termination, and uterine
dilatation and evacuation may be a safe procedure. Dr. Phadke also indicated that second trimester
up to the point of fetal viability may also be considered.
Discussing the issue of pregnancy and PAH in the era of targeted therapy, the presenter outlined
important tips for pregnancy management along with a discussion on anesthesia in pregnant PH
patients, PAH-directed therapies and anticoagulant usage. The presentation concluded with an
emphasis on careful attention to potential periods of deterioration and a multidisciplinary approach
in institutes accustomed to care of pregnant patients with heart disease.
70
An Evidence-Based Review of
Drug Eluting Stents
Dr. Asok Venkataraman
MD
Cardiac Surgeon
Loyala University Medical Center, Illinois, USA
The presenter addressed the gathering on Drug eluting stents- an evidence based review. Speaking
on how the number of PCI had seen an upstroke from 1997 to 2012, he noted that PCI was not
without complications. These included acute vessel closure, MI, restenosis, need for resuce CABG,
stroke, arrhythmias, and even death. Others were complications of vascular access, vascular damage
from the catheters, and complications from contrast usage.
Early angioplasties, though technically successful, were less effective than CABG mainly due to target
vessel revascularization, Dr. Asok said. Speaking on trials, he drew attention to the BENESTENT and
STRESS studies, which used the articulated Palmaz-Schatz stent. In Luasanne, a single center trial
limited to the right coronary artery lesions was done using the Wiktor stent. The speaker noted that
during the in-hospital phase, BENESTENT and STRESS showed the composite clinical end point to be
less in the stent than in the PTCA groups (p<0.05). In Luasanne, there was no difference between
the groups. The incidence of subacute closure was similar with both treatments in the three trials.
Speaking on restenosis with BMS, he shared with the audience the observations from the MUSIC
trial. The predictors were used to construct a reference chart that predicts the expected 6 month
QCA restenosis rate. Restenosis rate, the speaker noted, was significantly reduced if the stents were
post-dilated with a non-compliant balloon to 8 sq mm or more.
Other trials viz RAVEL, SIRIUS, ELUTES, ASPECT, TAXUS II were studies which compared bare stents
with drug eluting stents, and in each trial, restenosis with DES was significantly lesser than with
bare stents. In the SYNTAX trial, PCI was better than CABG in patients with SYNTAX score 0-22 and
in score 23-32, while SYNTAX score >33 CABG was noted to be better. Comparing the mortality
rates in patients using DES vs those using bare metal stents in primary PCI, it was observed that the
mortality rates were significantly lesser with DES. The few complications with DES included stent
thrombosis (acute, subacute, late or very late), restenosis, and positive remodeling.
The reasons for stent thrombosis, the speaker noted were many including: (1) stent expansion,
reduced TIMI flow, incomplete revascularization; (2) complex disease, small caliber vessel and diffuse
disease; or (3) acute coronary syndrome, reduced EF, high platelet reactivity on clopidogrel, renal
failure and DAPT discontinuation. Ways to prevent stent thrombosis include DAPT for 12 months or
more, full stent expansion and to consider platelet reactivity testing (with prasugrel, ticagrelor instead
of clopidogrel).
71
The first substantial concern of ST beyond 30 days occurred with the use of intracoronary
brachytherapy, the speaker noted. He continued that stent placement in the same setting as
intracoronary brachytherapy had been associated with persistent risk of ST beyond 30 days in 5% to
10% patients. A few causes for late stent thrombosis were strut malapposition, neoatherosclerosis,
uncovered struts, and stent underexpansion.
The speaker also put forth the dilemma on the use of dual antiplatelet therapy. The meta-analysis
which he shared also showed that the lesser events of stent thrombosis with DAPT could be offset
by the increase in major bleeding and death with DAPT.
Finally, the speaker touched upon the role of drug eluting balloon (DEB), which was introduced to
prevent restenosis after balloon angioplasty. However, clinically convincing results have not been
demonstrated and these difficulties favored the development of stent based drug delivery. The
speaker concluded with a note on bioabsorbable vascular scaffolds and polymer free stents and their
potential role in the future.
72
NOACs Should Only Be Used in Non-Valvular AF

Dr. Dhiman Kahali
MD, DM, FSCAI
Senior Consultant Interventional Cardiologist
B M Birla Heart Research Centre, Kolkata
This was an intresting presentation by Dr. Dhiman Kahali who spoke on using NOAC only in non
valvular AF. Though warfarin had been used as a gold standard since 1954, the speaker noted
that there were a few limitations for the same, like slow onset due to heparin bridging, food/drug
interactions, complex peri-procedural management, and narrow therapeutic window. Though NOAC
has been used in various conditions worldwide, in light of new evidence, it should be used only in
non valvular atrial fibrillation (AF).
The aim of selecting an appropriate antithrombotic therapy for a patient is always to reduce the risk
of thrombotic events with an acceptable increase in bleeding complications, he observed. The 2012
ESC guidelines, as the speaker puts it, recommends a practice shift towards identification of truly
low-risk patients who do not require antithrombotic therapy rather than focusing on identification
of high-risk patients. The guidelines also recommend that in case of valvular AF, oral warfarin is the
antithrombotic agent of choice, and not the NOAC. This has been supported by evidence from the
Engage AF , ROCKET AF, ARISTOTLE, RELY studies comparing the NOAC with warfarin.
In non valvular AF, NOACs were superior to warfarin. The number of events of stroke or systemic
embolism and major bleeding was less with NOAC as compared to warfarin. NOAC significantly
reduced stroke and mortality. In addition, the relative efficacy and safety of NOACs were consistent
across a wide spectrum of AF patients. Speaking on which NOAC to choose, the speaker observed
that from the data available, Dabigatran 150 mg BID was superior to rivaroxaban in some efficacy
endpoints, while major bleeding was significantly lower with Dabigatran 110 mg BID or apixaban.
However, head to head comparisons between these molecules would be needed before drawing
proper conclusions.
The speaker admitted that these were not all purpose drugs and there were downsides to NOACs
too. Cost, lack of reversibility, limited long-term data, and no evidence in valvular AF were a few
downsides which the speaker discussed about NOACs.
The use of NOAC is also made confusing with trespect to the dose, whether to use 110 mg BID
dabigatran or 75 mg BID, with the speaker sharing data on both these regimens. He also shared
protocols on how to shift a patient from vitamin K antagonists to NOACs.
To conclude, he stated that use of treatment had to be truly individualized in AF. There had to be
robust risk stratifying systems to estimate individual embolic risk, scoring systems to estimate bleeding
risk, wealth of trial data on therapeutic options, and also the need for more than one therapeutic
option. This in his opinion, was the way forward for anticoagulation in this year.
73
Lessons Learned from Recent Clinical Trials and

Various Guidelines for Lipid Lowering Therapy
Dr. Prakash C Deedwania
MD, FACC, FACP , FAHA
Prof of Medicine, UCSF School of Medicine,
San Francisco
Dr. Prakash C Deedwania addressed the audience on Lessons learned from recent clinical trials and
various guidelines for lipid lowering therapy.
Beginning with the observation that LDL cholesterol (LDL-C) is essential for the development and
progression of atherosclerotic cardiovascular disease (ASCVD), he went on to say that lowering LDL
cholesterol is a central tenet of clinical practice as studies have shown that LDL-C has a causative
role in ASCVD. Randomized trials, he noted, have shown that lowering LDL-C consistently reduces
ASCVD events. As the collaborators data published from 14 clinical trials observed, the major vascular
events reduced proportionally with the mean absolute reduction in LDL-C levels. Also, important was
the fact that event reduction was independent of baseline LDL-C.
The speaker suggested that we have entered a new era in the treatment of established coronary
heart disease (CHD). Treating patients with established CHD to an LDL of 77 mg/dL with 80 mg of
atorvastatin daily, from their starting LDL-C of 100 mg/dL, provided a highly significant reduction
in the risk of major cardiovascular events. He observed that there was a growing body of evidence
indicating that lowering LDL-C well below currently recommended levels can further reduce the
preventable healthcare burden associated with cardiovascular and cerebrovascular disability.
In the IMPROVE-IT trial, it was the first trial demonstrating incremental clinical benefit when adding a
non-statin (ezetimibe) agent to statin therapy. As the speaker said, it reaffirmed the LDL hypothesis,
that reducing LDL-C prevents cardiovascular events, and these results could be considered for future
guidelines.
The speaker next addressed the various guidelines for the use of statins. In the US, he observed that
high intensity statin therapy was used to decrease LDL-C by more than 50%, moderate intensity
statins for 30-50% reduction and low intensity statins for reductions of less than 30%. Important
points from the European guidelines included that statins had to be started in patients with noncardioembolic ischemic stroke and also that CKD stages 2-5 were CHD risk equivalent and the LDL-C
target in these patients should be adjusted to the degree of renal failure. As per the NICE guidelines,
the recommendation included the need to prescribe atorvastatin 20 mg for the primary prevention of
CVD and atorvastatin 80 mg for patients with established CVD or diabetes. But one thing common
to all guidelines was that the shift was from a target based approach to a drug and dose based
74
approach. As the speaker noted, this was beneficial to the patient as they would receive evidence
based high and moderate intensity statin therapy.
The speaker also added that if non HDL-C and LDL-C goals were not achieved with statin therapy,
then non-statin therapy should be considered, with ezetimibe being an important evidence based
treatment in this regard. Resins or niacin could be considered in selected patients.
Talking on how to treat dyslipidemias in south Asians, the speaker shared studies on comparison of
rosuvastatin and atorvastatin at doses 10 mg and 20 mg, and in both, rosuvastatin was a better drug
capable of higher LDL-C and non HDL-C reductions that atorvastatin.
The speaker summarized with take home messages on the topic including the need to reduce
cholesterol with statins as the most effective intervention to reduce the risk of CV events including
strokes, and although guidelines differ, they all recommend high intensity statins for secondary
intervention. The speaker also suggested that although there is a paucity of data in Indian patients,
moderate to high intensity statins were recommended for secondary prevention in Indian patients
due to inordinately high risk of CV events at a relatively younger age.
75
Will Transcatheter Aortic Valve Implantation

(TAVI) Replace Surgery?
Dr. B D Prendergast
DM, FRCP, FESC
St. Thomas Hospital, London
The question of whether transcutaneous aortic valve implantation (TAVI) would replace surgery was
the topic on which Dr. B D Prendergast addressed the audience.
Dr. Prendegast shared data on how over the past few years, the number of TAVI procedures in the
database had shown very rapid growth from 66 in 2007 to 1271 in 2012. More interventional
cardiologists were doing TAVI.
The speaker used an article from NEJM, on the effect of availability of TAVR on clinical practice, for
the trends in aortic valve intervention in Germany 2007-2013. The fall in mortality was from 13.2%
to 5.4 % in TAVI and in surgical aortic valve replacement (SAVR) it was 3.8% to 2.2%. There were
reductions in stroke, bleeding, PPM requirement, and AKI. In AS, TAVR is used in a patient if the
surgical risk is high and if there is hope of benefit from TAVI.
The TAVI devices have improved over the years, the speaker noted, with many more advanced devices
present which provided better results and reduction in mortality. The evolution of the Edwards
Balloon expandable transcatherter valves have evolved from 24F in 2002 to 14F in 2013 (Sapien 3).
The all-cause mortality at 30 days, all strokes at day 30 and moderate/severe PVL at 30 days were all
significantly reduced with the use of SAPIEN 3 device.
TAVI is no longer an experimental, new wave procedure and should be actively considered in all
intermediate/high risk patients with AS, the speaker noted. It needed more trials in intermediate and
low risk cohorts, more durability data, better cost effectiveness data, simplification of the procedure
and accelerated hospital discharge, reduced pacing rates, and avoidance of long term complications.
He also observed that presently in low risk patients surgery is used and in high risk and extremely
risky patients TAVR is used, and this could change in the ensuing years.
In the trial on transcatheter vs surgical aortic valve replacement involving patients with severe aortic valve
stenosis, it was observed that TAVI had more pacemakers, aortic regurgitation and higher functional
class, while in SAVR, there was more bleeding, shock, atrial fibrillation and acute kidney injury.
The speaker also noted that in AS, there were many perils in following a conservative approach
as noted by Taniguchi et al. in their trial of initial surgical vs conservative strategies in patients
with asymptomatic severe AS. Early valve replacement was followed by reduction in mortality and
hospitalization than with conservative treatment.
The speaker also touched upon the PARTNER III which is designed to assess TAVI with SAPIEN 3 valve
vs open surgical valve replacement. The trial would include upto 1300 patients and is a non-inferiority
study with a one-year composite end point that includes death, stroke and rehospitalisation. Having
addressed the audience on the role of TAVI and its applications, the speaker concluded with his
optimistic message that the future is bright, and the future would be TAVI.
76
Chronica Ischaemia in 2015

a European View Point
Dr. Roberto Ferrari
MD, PhD, FESC
Chair of Cardiology
University of Ferrara, Italy
Dr. Roberto Ferrari addressed the audience on the European view point on chronic ischemia in 2015.
Observing that CAD was still costing 2.6% of total health expenditure, even in this era of PCI, he
noted that the epidemiology was showing a shift. There was a decline in incidence in younger age
groups, and shift of the burden to elderly with the prevalence increasing with increasing age of the
population. Stating that there were different phases and approaches to treat chronic CAD, besides
lifestyle modification, the role of revascularisation and pharmacotherapy was touched upon by the
speaker.
Though the speaker accepts PCI is booming, he was cautious on the fact that it may not improve
prognosis always, as ischemia in humans was a rather personal entity, which allows hibernation,
preconditioning, and stunning and thus viability. An example quoted was of data from COURAGE,
wherein it was noted that in stable CAD, PCI guided by visual assessment did not provide additional
benefit over full medical therapy and lifestyle improvements. But the 2012 trial-FAME 2 showed
superiority of PCI guided by FFR<0.8, plus optimal therapy over best available therapy alone. In FAME
2, it was noted that cumulative events decreased over a 5-year follow up period with FFR guided PCI,
and therefore the speaker asked the audience to keep in mind that the needs of a patient and the
different behavior of ischemia in different patients before going for revascularization.
The next important point debated by the speaker was on the role of heart rate (HR) reduction in
angina treatment. He shared that HR reduction in chronic CAD with preserved EF was important
for symptom reduction but not for prognosis as noted with ivabradine in SIGNifY trials and others
studies with betablockers. Based on data from the 1980s, he observed that the beta blocker benefit
was related to the extent of HR reduction, but modern therapy for AMI had changed the phenotype
of the infarcted heart and arrhythmias and sudden death are rare. The 2014 meta-analysis on 26793
patients also inferred fewer deaths when HR was increased. As noted by the speaker, beta-blockers
reduced mortality in heart failure, but not if ventricular function was conserved as seen in angina.
In heart failure, beta blockers and invabradine paradoxically increased contractility by reducing
remodeling.
Another point raised was on the role of improving coronary microcirculation, as angina exists even
in the absence of obstructive disease. There was increasing role of coronary microcirculation in the
therapy of angina, and was an area to look in the future for treatment of angina.
To conclude, the speaker also raised the point on the role of coronary sinus narrowing. Sharing an
article published in NEJM, he observed that the reduction in CCS class was higher in patients who
underwent coronary sinus narrowing (from 3.2 baseline to 2.1) as against the control (3.1 to 2.6).
This was another area of interest, which the speaker was optimistic would have a big role to play in
the future.
77
Insulin Resistance in Ischemic Heart Disease

Dr. Udayan Ray
MD, PhD, MBA, FAACB, FACTM, FACB, FRCPA, M.Ed
Clinical Associate Professor and Director of Clinical Chemistry
Department of Pathology at the Royal Hobart Hospital, The University of Tasmania, Australia
Talking about how AMI or AIHD was the leading cause of morbidity and mortality globally, Dr.
Udayan Ray stated the presence of associated insulin resistance in a large number of these high risk
cases. In the diagnosis of AMI, he noted the requirement of presence of two of the following factors,
viz, a history of prolonged chest discomfort or angina equivalent, or ECG changes consistent with
ischemia or necrosis, or elevated cardiac enzymes (gold standard).
Bringing in the relation of insulin to AMI, he stated that ACS or acute ischemic disease is 2 to 3 times
more common in diabetics, and pre-diabetics (metabolic syndrome). Metabolic syndrome affected
20-30% of the young and 40-50% of the elderly population in the world, and could be called an
epidemic of modern civilisation.
The speaker reports that a high prevalence of hyperglycemia among acute myocardial infarction
patients without known diabetes mellitus was recognized as early as 1931 and insulin therapy
proposed as an adjunctive as early as 1960s.
In non diabetic Japanese ACS patients, in a trial, it was noted that they presented with hyperglycemia,
caused primarily by impaired initial insulin secretion, and insulin therapy on time improves the survival
as well as prognosis of the ACS patients. The study by Dr. Heinrich, the speaker observed that
functional disturbances of the coronary circulation could be associated with insulin resistance, and
the high mortality rate associated with insulin resistance was at least in part related to functional
disturbances of the vasculature. These primarily involved endothelium, and the dysfunctional
endothelium resulted in atherosclerosis and plaques. Quantifying insulin resistance by HOMA index
would be a pivotal factor for the development of metabolic syndrome, seeing how important insulin
resistance is in the prognosis of ACS.
The next point addressed by the speaker was on insulin resistance and adiponectin. In AIHD, the
adipocytes secreted less adipocytokines, and therefore adiponectin, a marker for insulin sensitivity
would be less in the presence of insulin resistance, which could assist in identifying insulin resistance
in AIHD patients.
The speaker also stated that more research was needed on insulin and insulin-induced nitric oxide
in normal and AIHD patients. Insulin-induced nitric oxide was reduced in AIHD patients and raising
these levels might be another target to improve outcomes in such patients. Another marker affecting
78
prognosis was dermicidin isoform 2, a stress induced protein that inhibited insulin synthesis in the
beta cells of islets of langerhan.
To summarise the studies, the speaker concluded that insulin-induced nitric oxide (NO) inhibited
platelet aggregation. In AIHD, anti IANOS-Ab impaire the activity of IANOS and thereby leading to a
decrease in NO levels. The lack of sufficient amount of NO during the evolving phase of AIHD caused
the formation of thrombus by the aggregating platelets in the coronary arteries. The speaker noted
that NO could be playing the saviour role in evolving phase of AIHD. Insulin had a thromboprotective
effect through NO, and therefore inhibiting the progression of an evolving thrombus in the setting of
AIHD, and preventing the culmination to AMI, and concluded that more research as needed to fully
tap the role of insulin and NO in treatment of AIHD and improve prognosis.
79
Preventive Cardiology: Challenge for the

Cardiologist
Prof. David A Wood
MD
Professor of Cardiovascular Medicine
National Heart and Lung Institute, Imperial College London
The presenter addressed the audience on how preventive cardiology was a challenge for a cardiologist.
Sharing some statistics, he pointed out that the global CV deaths had increased by 40% from 1990
to 2013. In this, 25% change was due to increased population, while 55% was due to aging. He
stated that the vision was to have a world free of avoidable burden of non-communicable diseases,
and proposed the global action plan in the subsequent years.
Talking about the formal meeting of member states in Geneva, 2012, he spoke about the set of 9
global non-communicable diseases targets for 2025. One was to reduce premature mortality from
non-communicable disease by 25% by 2025, which was aptly named 25 by 25. It would focus on
lifestyle targets, risk factor targets, and medicine targets. The World Heart Federation (WHF) has a
25 by 25 global target to achieve 25% relative reduction in overall mortality from CVD. In addition,
the federation has a goal of 25% reduction in premature mortality from cardiovascular disease by
2025.
To achieve this, the WHF had roadmaps for secondary prevention of CVD, for hypertension control
and for tobacco control as they were very important causes of major CVD.
The road to a healthy heart, he noted, needed few critical things in place. There had to be a health
care system accessible to patients, clinical guidelines recommending priority interventions should
be available, and these recommendations should be followed by the health care professionals.
Priority interventions should be available as well as affordable, and the health care system should
be organized to ensure adequate follow-up of patients with CVD. And more importantly, patients
should adhere to recommendations.
He shared that aspirin, ACE inhibitors, statins and beta blockers were the priority secondary prevention
medications and at least three of these had to be used for secondary prevention (aspirin, statin and
at least one blood pressure lowering drug).
But the speaker also accepted that the road to healthy heart was not without blocks. Patients with
known CVD not having access to health care system being the most important of them all. This, he
believed could be overcome by strengthening the role of PHC for cardiovascular secondary prevention,
integrating cardiovascular secondary prevention with management of other chronic conditions,
80
increasing opening times of clinics, and locating them close to communities in rural areas and finally,
to integrate secondary prevention interventions in single cardiac rehabilitation programme.
To conclude, the speaker stressed on the role of Cardiological Society of India had in making 25
by 25 mission a success. He called upon CSI to be a strong national advocate for cardiovascular
health and disease prevention in order to influence the India national action plan for prevention of
non-communicable diseases. He stated the need for promoting a national alliance for prevention of
cardiovascular disease, developing and delivering high quality prevention and rehabilitation services
for all patients, and to measure patient outcomes to demonstrate that all were delivering the best
clinical and cost effective preventive care.
81
Remodelling of the Ventricle Pathophysiology

and Treatment
Dr. Roberto Ferrari
MD, PhD, FESC
Chair of Cardiology,
University of Ferrari, Italy
In the year 1982, Hocman and Bulkley coined the term remodelling to describe changes at the site
of myoacardial infarct and later to describe changes distant to the infarct. However, the molecular,
cellular, interstitial and genomic changes that manifest clinically as changes in size, shape and
function of the heart are not easy to define. Presenting these facts and perspectives, Dr. Ferrari
noted that clinicians view remodeling as increases in ventricular volumes with geometrical changes.
While a biologist views remodelling as an up and down regulation of protein expression with
a switch towards the embryonic phenotype, a pathologist thinks of it as areas of fibrosis with
hypertrophic and/or apoptotic myocyte. The presenter noted that remodeling could be treated
with ACE inhibitors, beta-blockers, anti-aldosterone therapy, ranolazine, ivabradine and cardiac
resynchronization therapy.
Presenting interesting perspectives on the definition of remodelling, Dr. Ferrari discussed the concept
of cellular life-death cycle, apoptosis vs hypertrophy, switch forward embryonic phenotypes, tissue
vs. plasma alterations and neurohormonal and neuroumoral activation and also pointed out that
key lessons on the topic can be sourced from oncology. Displaying a number of colorful visuals of
meteors, leaves falling off a tree, the presenter explained that life and death are integrating parts of
the universe and they are programmed by the nucleus as reproduction and apoptosis, respectively.
While the genetic program of the embryonic myocyte is connected to the life/death cycle as it reproduces
and dies from apoptosis, the adult myocyte is not connected to the life/death cycle as it usually does
not reproduce or die from apoptosis (dies from necrosis). Equating hypertrophy and apoptosis to life
and death, respectively, he explained these events as resulting from neurohumoral and neuroendocrine
tissue activation following a myocyte stretch. Dr. Ferrari pointed out that the presence of embryonic
myofilaments, embryonic SERCA, ventricular ANP and ventricular if channels in the remodeling areas
suggests that embryonic genetic program of lifeToday
death is reinstated in these areas.
Extracellular
Explaining that the genetic program of life-death

is controlled by transcription factors in the nuclei
and highlighting that oncology research has
provided a lot of insights in to the modulation
of pathways that regulate the transcription
of growth factor genes, Dr. Ferrari concluded
the presentation by noting that the current
strategies against remodeling are targeting the
membrane bound receptors and the future may
incorporate the nuclear transcription factors.
Beta Blockers
ACEi
Intracellular
MRA
Neprilysin
Tomorrow
LIfe
Death
Promotors of life Suppressors of death
Figure 1: The present and future of treating remodeling.
82
Is Revascularization Mainstay Therapy for

Chronic Stable Angina
Dr. V K Bahl
Professor and Head
All India Institute of Medical Sciences, New Delhi
Dr. Bahl started his presentation by noting that the topic of revascularization vs. medical therapy is
a favorite topic among lay press and scientific debates. Dr. Bahl pointed out to a report from NEJM
(Figure 1), which indicates a lack of consensus among the medical fraternity for the best technique to
treat a patient with stable angina. He noted that stable CAD is a stable angina is a broad term with
significantly diverse presentations of symptoms as well as the prognosis. Describing seven types of
medical decision-making (Box 1), the presenter noted that it is best is to go by the evidence even if
it seems to be contrary to popular belief.
The presenter explained that the goal of revascularization includes soft end-points (relieve symptoms,
reduce ischemia and improve quality of life) and hard end-points (prevention of MI and death). The
presentation further discussed data from various clinical studies including the COURAGE trial, BARI
2D, FAME 2, and others with respect to these soft and hard endpoints.
Total number of votes: 7632
Treatment option 1: 3282
votes
Appropriate Medical
Management and Close followup for Adherence
votes
Appropriate Medical
Management and PCI
votes
Appropriate Medical
Management and CABG
100%
75%
50% 43.01
25%
40.17
16.82
Figure 1: Management Of Stable CAD.
Eminence based
White hair
Vehemence based
Level of stridency
Eloquence based
Smoothness of tongue
Providence based
Religious fervor
Nervousness based
Risk of litigation
Confidence based
Bravado (surgeons)
Evidence based
Statistically Valid
Box 1: Medical decision-making.
The presentation concluded by noting that revascularization and medical therapy are two very different
procedures. The essence of the presentation was well captured by concluding the presentation with
a quote from Mark Twain everyone is entitled to their own opinion, but not their own fact.
83
Heart Failure with Reduced Ejection Fraction

in 2015: An Indian Viewpoint
Past President, Cardiological Society of India
Association of Physicians of India
SAARC Cardiac Society
Heart failure in India has reached epidemic proportions. Prevalence of heart failure in India due to
CAD, hypertension, obesity, diabetes and rheumatic heart disease range from 1.3 to 4.6 million,
with an annual incidence of 491 6001.8 million. Discussing the various etiological factors (Figure 1)
and the prevalence of multifactorial etiologies (Table 1) in Indian patients, Dr. Banerjee highlighted
the need for early identification of the risk factors and initiation of appropriate therapy at early stages
prevents development of heart failure.
7.2
6.2 1
19.9
66.2
11
Sl. No.
Etiology
No. of patients
Percent (n=500)
DM + HTN + CAD
117
23.4
DM
HTN + CAD
75
15
Drugs
DM + HTN
52
10.4
Valvular Heart
Disease
DM + CAD
48
9.6
CArdiomyopathy
Isolated CAD
91
18.2
Corpulmonale
Isolated HTN
84
16.8
Isolated DM
12
2.4
CAD
HTN
45.8
65.6
Others
Figure 1: Etiology of heart failure in Indian

population.
Table 1: Prevalence of multifactorial etiology in

CHF patients.
The presentation discussed clinical diagnosis and diagnostic imaging and emphasized the role of
echocardiogram in identifying patients with heart failure. The presenter also discussed various
pharmacotherapeutic options for treatment of heart failure. Dr. Banerjee presented an elaborate
discussion on the findings of the SPANDAN Heart Failure Registry and ESC guidelines. The presentation
concluded by emphasizing that the optimum utilization of the available drugs, general measures and
surgical procedures appropriate to the condition improves the outcome of patients with heart failure.
84
Heart Failure with Reduced Ejection

Fraction in 2015
Dr. Roberto Ferrari
MD, PhD, FESC
Chair of Cardiology,
University of Ferrari, Italy
Dr. Ferrari presented an informative session that covered ESC 2012 guidelines, new findings since
the publication of ESC 2012 guidelines and the existing challenges, limitations and barriers. The
ESC 2012 guidelines confirmed the usefulness of diuretics and recommended a beta--blocker and
an ACE inhibitor as soon as possible for actions on remodelling and reduction of sudden deaths.
Furthermore, the ESC 2012 guidelines recommend an expanded indication for mineralocorticoid
receptor antagonists (MRAs) and a new indication for the sinus node inhibitor ivabradine. With
respect to devices, the ESC 2012 guidelines recommed an expanded indication for resynchronisation
(CRT), new role of coronary revascularisation and showed a recognition of the growing use of assist
devices (VADs).
24
914
LCZ696
(n=4187)
16
HR=0.80 (0.73-0.87)
P=0.0000002
Number needed to treat=21
8
0
1117
Enalapril
(n=4212)
32
32
Enalapril
HR=0.80 (0.71-0.89)
(n=4212)
P=0.00004
Number needed to treat=32
24
16
180 360 540 720 900 1080 1260

Days after Randomization
0
0
Box 1: PARADIGM-HF: Cardiovascular

Death or Heart Failure Hospitalization
(Primary Endpoint).
LCZ696
Enalapril
558
LCZ696
(n=4187)
Patients at Risk
693
4187
4212
180 360 540 720 900 1080 1260

4056
4051
3891
3860
3282
3231
2478
2410
1716
1726
1005
994
280
279
Box 2: PARADIGM-HF: Cardiovascular

Death.
Kaplan-Meler Estimate of
Cululative Rates (%)
40
The presentation discussed the new data since the 2012 guidelines by presenting the results of the
PARADIGM trial, along with the new data on the role of stem cell supplementation and remote
monitoring. Discussing the results of the PARADIGM trial (See Box 1 to 3), the presenter noted
that in patients with heart failure with reduced ejection fraction, LCZ696 when compared with
recommended doses of enalapril was less likely to cause cough, hyperkalemia, renal impairment or
treatment discontinuation.
32
Enalapril
(n=4212)
24
HR=0.84 (0.76-0.93)
P<0.0001
16
711
LCZ696
(n=4187)
8
0
0
Patients at Risk
LCZ696
Enalapril
835
4187
4212
180 360 540 720 900 1080 1260

4056
4051
3891
3860
3282
3231
2478
2410
1716
1726
1005
994
280
279
Box 3: PARADIGM-HF: All-Cause

Mortality.
The presenter noted that there is no consensus on how a stem cell is defined and accordingly the
definition of SC can be sometimes quite different from one paper to another, thus increasing the
possibility of confusion in the field. The presentation also discussed the role of remote monitoring and
the problems of target dose vs. target effect. The presentation concluded by noting that guidelines
are not perfect and that a number of physician and patient level barriers towards addressing heart
failure with reduced ejection fraction. Several unmet needs exist in prevention of HF, comorbidities,
correct use of drugs and devices and the value of remote monitoring.
85
Avoidance of Fluoroscopy during

Radiofrequency Ablation
Dr. Anitha G, et al.
Department of Cardiac Electrophysiology and Pacing,
The Madras Medical Mission, Chennai.
Only few electrophysiology laboratories have demonstrated the feasibility and safety of minimizing
fluoroscopy during catheter ablation procedures using 3dimensional electroanatomical mapping
system (3D Map). It is not known whether these results can be reproduced by other centers and also
if fluoroscopy can be completely avoided. Therefore, the prospective study by Anita et al. assessed
the safety and feasibility of non-fluoroscopic catheter ablation of tachyarrhythmias and whether the
simplified tagging only approach instead of creating 3-D chamber anatomy may suffice.
During the period from March 2012 to December 2014, 364 patients underwent radiofrequency
ablation procedure with the aid of 3-D map (The Ensite Velocity-Navx, St. Jude Medical). The
procedures were performed under conscious sedation using right and if required left femoral vessels
for access. The insertion and positioning of the catheters were performed under 3D Map guidance
using 2 simultaneous views, usually left anterior oblique and right anterior oblique, and one of the
external skin patches as reference. The catheters were placed making gentle movements of advance
until intracavitary electrograms were registered and were lodged in the desired position. Once the
coronary sinus catheter was cannulated, the reference for the 3-D Map was changed to its distal
tip. Two more 5F or 6F quadripolar diagnostic catheters were placed at the His bundle and the RV
apex. A 7F deflectable duodecapolar (St. Jude Medical) was inserted in the right atrium when the
clinical diagnosis was either atrial tachycardia or atrial flutter. A 6F decapolar catheter was inserted
in the left ventricle when the diagnosis was ventricular tachycardia. A 6F or a 7F deflectable ablation
catheter was used. No attempts were made to create 3-D chamber anatomy when the diagnosis was
other than atrial tachyarrhythmias (AT, AF or AFL) and VT (except idiopathic left ventricular fascicular
tachycardia). Instead, only the points of interest based on electrogram were tagged (tagging only
approach). Fluoroscopy was deliberately avoided unless absolutely necessary.The feasibility, efficacy,
safety and the procedural time of catheter positioningand ablation without fluoroscopy were
analyzed.
A total of 364 patients underwent radiofrequency ablation using 3-D map. Without fluoroscopy, the
entry of catheters into the right heart was achieved in 87% (N=317) patients with mean time of 1.7
0.3 min. The CS cannulation without fluoroscopy was possible in 84% (N=306) of patients with
the mean time of 1.9 0.6 min. The incidence of ablation without fluoroscopy and procedural time
for each arrhythmia are shown in Table 1. Fluoroscopy was resorted to only when resistance was
felt while advancing catheters to the desired position or when there was suspicion of tamponade
or failure to achieve non inducibility of tachycardia. There were no complications during catheter
86
advancement to the heart. However, four patients (1.2%) developed cardiac tamponade during
intracardiac catheter manipulation.
Table 1: Feasibility of Non-Fluoroscopic Ablation.
Total No. of
cases
Ablations without
fluoroscopy
Mean Procedure
time
(N)
(N)
(Min)
AVNRT
177
156 (88%)
36 7.5
Right sided
Accessory pathway
52
18 (34%)
40 7.8
ILVT*
12
4 (36%)
84 23
Mahaim pathway
2 (33%)
55 21.6
Arrhythmia
*ILVT Idiopathic left ventricular tachycardia
The above results reaffirm the feasibility, safety and efficacy of non-fluoroscopic ablation for some
of the tachyarrhythmias with the aid of 3-D map. The simplified tagging only method is adequate
for safer and effective ablation in AVNRT, right sided accessory pathways including Mahaim and ILVT.
87
Prospective Observational Longitudinal Registry of Patients with

Stable Coronary Artery Disease (CLARIFY) - Global vs. Indian Cohort
Dr. Upendra Kaul
MBBS, MD, DM
Executive Director- Academics and Research (Cardiology)
Fortis Hospital Vasant Kunj, New Delhi
Coronary artery disease continues to be the main cause of death worldwide. Data available
from clinical trials or registries does not adequately represent populations with stable CAD.
Kaul et al. identified the importance of data from longitudinal observational studies of a representative
large cohort of patients with stable CAD, spanning several geographic regions, focusing on stable
outpatients (as opposed to patients hospitalized or recently discharged from hospitals for acute
manifestations of the disease), and including both symptomatic and asymptomatic patients.
CLARIFY (The prospeCtive observational LongitudinAl RegIstry oF patients with stable coronary
arterY disease) is an international, prospective, observational, longitudinal registry of outpatients
with stable CAD, defined as prior myocardial infarction or revascularization procedure, evidence of
coronary stenosis of >50%, or chest pain associated with proven myocardial ischemia.
A total of 33,438 patients were enrolled from 45 countries in Africa, Asia, Australia, Europe, the
Middle East, and North, Central and South America. 809 patients were recruited from India, with
representation from various cities. The data was collected at baseline and there is an ongoing effort
to collect outcomes data annually for 5 years. An inter-rim report of 2-year outcomes has been
depicted in Table 1.
Table 1: Two-Year Outcomes Data from the CLARIFY
Outcome
All cause death
Cardiovascular death
Non-Cardiovascular death
Unknown cause of death
Myocardial infarction (Fatal or nonfatal)
Stroke (Fatal or Non-Fatal)
Cardiovascular death or non-fatal MI
Cardiovascular death, non-fatal MI or
non-fatal stroke
Level
1. Total CLARIFY population (excluding India)
2.India
1.Total CLARIFY population (excluding India)
2.India
2.India
2.India
2.India
2.India
2.India
2.India
N with event/N in
group (%)
952/31693 (3%)
28/805 (3.5%)
458/31692 (1.4%)
12/805 (1.5%)
308/31692 (1%)
10/805 (1.2%)
186/31693 (0.6%)
6/805 (0.7%)
543/31693 (1.7%)
5/805 (0.6%)
296/31689 (0.9%)
7/805
830/31689 (2.6%)
13/805 (1.6%)
1049/31689 (3.3%)
16/805 (2%)
HR (95% CI)
1.0 (-)
1.18 (0.81-1.72)
1.0 (-)
1.05 (0.59-1.86)
1.0 (-)
1.31 (0.7-2.45)
1.0 (-)
1.29 (0.57-2.91)
1.0 (-)
0.37 (0.15-0.88)
1.0 (-)
0.94 (0.45-1.99)
1.0 (-)
0.62 (0.36-1.08)
1.0 (-)
0.6 (0.37-0.99)
p-value
0.3930
0.8715
0.4048
0.5404
0.0256
0.873
0.0903
0.0458
Kaul et al. noted that Indian population differed from the global population in terms of having more
patients with history of diabetes (44.3% vs. 28.73%) and average heart rate (76.6 vs. 68.3 bpm) at
baseline. Results at study completion would provide a picture of the worldwide prevalence of stable
CAD and in Indian population as well.
88
Ulnars VInTEC Score as Clinical Predictor of Successful Ulnar Cannulation:

Subgroup Analysis of AJULAR (AJmer ULnar ARtery intervention) Cohort
Dr. Bhanwar Lal Ranwa
MBBS, MD
Jawaharlal Nehru Medical College and Hospital, Ajmer
Percutaneous cannulation of the radial and femoral artery has proven to be a useful approach
in diagnostic and interventional coronary procedures. However, need of radial artery as graft
vessel for coronary artery bypass surgery (CABG) in future and failure to access radial artery
due to anatomical variation, prompts one to switch for femoral route. Ulnar artery cannulation
provides a useful option to preserve radial artery; also, it serves to reduce complications
associated with the femoral route. Bhanwar Lal et al. provided a simple bedside clinical score
for prediction of success of ulnar artery cannulation.
Ulnar artery was cannulated for coronary angiography in 1187 patients from June 2011-April
2014 undergoing coronary angiography. Data collection included: number of attempts
needed to cannulate ulnar artery (3 attempts was considered failure), volume of pulse (good
volume: pulse pressure >40 mmHg), experience of the operator (>50 radial/ulnar cannulation
versus <50 cannulation), palpability of ulnar artery with ease (when compared to radial
artery), calcification of vessel present or not, tortuosity of vessel and sex category. Data
was collected with intention to construct a model for predicting successful outcome for ulnar
artery cannulation procedure.Outcomes were analyzed with the help of fit model on JMP SAS
software version 11.2.0.
Based on the study findings, the investigators concluded that Ulnars VImTEC(Volume,Inability
to palpate of pulse with ease, Tortuosity of vessel, Experience of operator, Calcification
of vessel) score 3 is a simple and easy bedside score that can predict the success of
cannulation of ulnar artery.
89
Detection and Location of Obstructive Coronary

Artery Disease in Patients of Chronic Stable
Angina by Strain and Strain Rate (Myocardial
Deformation Parameters) In the Resting
Echocardiogram
Dr. Deep Chandh Raja
MD, DM
Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow
Stress echocardiography identifies flow-limiting coronary artery disease (CAD) in clinical practice
with satisfactory accuracy. Deformation characteristics of longitudinally oriented myocardial fibers
are sensitive markers of early derangements of cardiac function caused bycoronaryarterydisease.
Therefore, Deep Chandh et al. evaluated the diagnostic power of Doppler Tissue Imaging (DTI)
longitudinalstrainandstrainrateindetectionof CAD andlocationof the culprit vessel in resting
echocardiogram inpatientspresenting with chest pain and correlation with coronary angiography, a
gold standard.
The study evaluated 104 consecutive patients undergoing coronary angiography who met the
following inclusion criteria: (i) presenting with chest pain on exertion, (ii) stable vital signs with
normal systolic function and wall motion at rest, (iii) normal sinus rhythm without left bundle branch
block, and (iv) no valvular stenosis or regurgitation of more than mild degree.Patientswith recent
or past history of acutecoronarysyndrome, raised cardiac biomarkers, uncontrolled hypertension,
cardiomyopathy, chronic renal failure were excluded. Conventional 2D echocardiographic
examinations were performed using a Vivid 7 system (GE Vingmed; Horten, Norway) with a 3.5 MHz
transducer. Echocardiography examination included measurements of cardiac dimensions, volumes,
and LV ejection fraction. Doppler tissue imagingstrainwas evaluated in 3 views (apical 4 chamber,
apical 2 chamber and APLAX view) analysing 16 segments of left ventricle. DTI regional longitudinal
systolicstrainandstrainrate, diastolicstrainandstrainrateand curved anatomical M mode (CAMM)
analysis fordetectionof onset of relaxation was done to detectlocationof CAD.
Mean age of the study group was 56.7+9.1 years with 81% were male. Diabetes, hypertension,
smoking were found in 29.8%, 67.3% and 46.2% respectively. The mean systolic and diastolic blood
pressures are 130.86 and 74.46.5 mmHg respectively.
Coronaryangiography showed single vessel, double vessel and triple vessel in 36.5%, 17.3% and
22.1% respectively. Angiographically normal coronaries were present in 24.1% of the study group.
The culprit vessel was LAD in 58.6% cases, LCX in 43.2% cases, RCA in 35.6% cases.
90
Longitudinalstrainanalysis in 16 segments of left ventricle was done with 5 variables-Systolicstrain,
Systolic strain rate, Diastolic strain rate, Time to onset of relaxation by CAMM analysis and Postsystolic index. The cut offs for the above variables used were -15%, -1.00 /s, +1.00/s, 0.50 msec and
0.35 respectively.
Systolic strain had the highest sensitivity to detect CAD in the region of LAD (positive predictive
value-78.4%, sensitivity-83.6%) followed by the RCA region (positive predictive value- 78.7%,
sensitivity-89.5% and LCX region (positive predictive value-78.4%, sensitivity-84.7%). Similar trends
were observed for the Systolicstrainrate, Diastolicstrainrateand CAMM analysis as well. Post-systolic
shortening was present in 54.8% cases. However, true posts-systolic shortening as determined by
Post-systolic index of more than 0.35, was found in 33.6% cases and was 100% percent specific in
localising CAD to a particular region.
CAMM analysis was superior to the other variables in localising CAD to the respective regional wall.
For detection of CAD in LAD territory, the sensitivity, specificity, positive and negative predictive
values of CAMM analysis were 90.1%, 81.3%, 87.3%, and 85.3%, respectively. Diastolic strain
ratewas the next variable with predictability higher than Systolicstrainrateor Systolicstrain. Similar
trends were noted for detection of regional wall motion abnormalities in RCA and LCX territory
as well. Similarly CAMM analysis had a high negative predictive value of 98.5% to rule out any
obstructiveCAD in a patient.
In conclusion, longitudinal myocardial deformation has a good predictive value for
diagnosingobstructiveCAD. Systolicstrainhas the highest sensitivity for detectingobstructiveCAD
in LAD followed by RCA and LCX. CAMM analysis had the highest negative predictive value to rule
out obstructiveCAD.
91
Epicardial Ablation of Ventricular Arrhythmia

MBBS, MD, DM
Cardiologist
Madras Medical Mission
Conventional endocardial radio frequency catheter ablation for ventricular tachycardia (VT) in
structurally normal heart with substrate being located either in the conduction system or in the subendocardium is known to yield long lasting and most often permanent cure in majority of cases.
However, the results of such an ablation technique when employed for VT in ischemic or nonischemic
cardiomyopathies are only modest. Even with the use of three-dimensional non-fluoroscopic
electroanatomic mapping to aid substrate guided ablation and irrigated ablation catheters to
access deeper lesions, the rate of recurrence remains high. The most likely explanation for such
consequences is the location of re-entry circuits deep in the subendocardium or in the epicardium,
making them inaccessible to current endocardial ablation techniques. Pericardial space provides
access to epicardial mapping and ablation of such substrates. Therefore, access to the epicardium is
obtained via pericardial puncture with the help of subxyphoid approach. Use of irrigated-tip ablation
catheter is mandatory and regular aspiration of epicardial fluid is required. Coronary angiography is
needed to define the proximity of ablation site to coronary arteries. The course of the phrenic nerve
is delineated with high-output pacing to avoid injury.
Epicardial ablation is more frequently employed for failed VT ablation by endocardial approach.
In patients with nonischemic cardiomyopathy and arrhythmogenic right ventricular dysplasia, endoand epicardial mapping and ablation are frequently performed in combination. Rarely, epicardial
ablation is performed without endocardial mapping when the ECG morphology of VT is highly
suggestive of epicardial origin. Very wide QRS (>180ms), pseudodelta wave and absence of Q waves
in inferior leads are among the many ECG signs, which indicate epicardial VT.
92
Valve Conservation Surgery: Current Status

Dr. O P Yadava
MBBS, MS, DNB (CTVS)
CEO and Chief Cardiac Surgeon
National Heart Institute, New Delhi
Despite being an effective and expedient procedure, valve replacement oftentimes necessitates lifelong anticoagulation, which can be significantly distressful. Harkens Ten Commandments for an ideal
valve remain challenging to achieve and this has the underpinnings of valve conservation surgery.
As noted by Dr. Yadava, repair techniques are better evolved for mitral valve (MV) as compared to
aortic valve (AV) (Table 1). MV repair is necessary in rheumatic patients and is the gold standard for
degenerative and functional MV pathologies (Table 2), as they improve both the short term and long
term survival and reduce valve related events. However, for ischemic MR, replacement may be a
better option as 32.6% of patients show moderate to severe recurrent MR at 12 months with repair
as against 2.3% with replacement (p<0.001; Acker et al, 2014).
Table 2: Mitral Valve Pathologies Amenable to MV Repair.
Table 1: MV Repair Techniques.

Resection
a) LEAFLET
MV Prolapse (Barlows/Floppy)
Myxo degen
Type II (P2)
Augmentation
Edge-to-edge (Alfieri)
Functional MR
Geo vent remodelling (Dil CM, Isch CM)
Elongation/Shortening
b) CHORDAE
Ischaemic MR
Type IIIb (P3)
Asymm distortion (Kwan, Circl 2003)
Transposition
Neo-chordae
c) PAP MUSCLE
d) ANNULUS
Rheumatic MR
Type IIIa
Plication
Misc
Endocarditis (Type I)
Traumatic
Translocation
Annuloplasty
Lately, percutaneous techniques are being used but the results are not comparable with surgical
outcomes. Minimally invasive and Robotic techniques represent other options, but they need
standardization
The various atrial valve (AV) repair techniques available include raphe release, cusp plication, cusp
resection and shaving, PTFE free margin shortening or augmentation, and patch repair. Reportedly,
AV repair is associated with 100% actuarial freedom from mortality at five years; however, up to
49% patients develop late onset aortic regurgitation (Svensson et al, 2014). Furthermore, technical
complexity and decision making involved in these procedures have limited their wide diffusion.
However, Dr. Yadava points that these techniques can be learned, albeit with persistence and
perseverance, and results close to the ones presented in reference centers can be achieved (Lamana
et al, 2015).
93
Wide QRS Tachycardia: Separating

Myths from Reality
Dr. Mohan Nair
MBBS, MD, DM
Cardiologist
GM Modi Hospital, Delhi
The speaker addressed many myths regarding wide QRS tachycardia in his discussion. The first point
he addressed was on the belief that wide QRS tachycardia could equally be VT or SVT. He shared
that VT was the most common cause of WCT with more than 80% of unselected populations and
more than 95% in-patients with structural heart disease. The belief that QRS morphology accurately
differentiates between VT and SVT and that it should be the most important diagnostic criterion
was also inaccurate, with the speaker accepting that though QRS morphology was important, it was
not fool-proof. A-V relation, capture beats and fusion were more important. A-V dissociation: atrial
activity that is independent of ventricular activity, occurred in 20 to 50% of VT and almost never
in SVT. When the atrial rate is slower than the ventricular rate, this would strongly suggest VT, he
stated. Atrial rate faster than the ventricular rate suggested a SVT, such as atrial flutter or AT w/2:1
AV conduction.
The next myth the speaker spoke on was that QRS duration is an important differentiator, and that
wider the QRS, the greater the likelihood of VT. In reality, he shared that QRS duration, in general, a
wider QRS favoured VT, but QRS duration less than 140 msec did not exclude VT. The speaker struck
down the belief that QRS concordance in precordial leads was diagnostic of VT. In reality, he said,
concordance was present when QRS complexes in all p6 precordial leads were monophasic with the
same polarity. Concordance was not present if any of the 6 leads had a biphasic QRS, and absence
of concordance was not diagnostically helpful.
The rate and regularity, he said, did not accurately differentiate VT from SVT with aberrancy. Rate had
limited use in distinguishing VT from SVT as there was too much overlap, while VT was generally regular,
and there could be a slight variation in the RR intervals. Hemodynamic compromise during broad
QRS tachycardia need not imply VT. While VT was more likely to cause hemodynamic deterioration,
hemodynamic status during tachycardia was dependent on a number of factors, including rate,
presence/absence of underlying heart disease etc.
Even ECG, he noted, could provide the probable diagnosis in many patients, but definitive diagnosis
is not always possible and could be time consuming. For adequate analysis, a 12 lead ecg and rhythm
strip would be needed. It was important to identify the P waves, and determine morphology, and
note the A to V relationship, the atrial activation sequence.
He concluded by suggesting that in all wide QRS complex tachycardia, it was necessary to assess the
His bundle electrogram, other electrograms such as AEGM, His-V relationship, P:QRS, spontaneous
shifts in activation, and atrial pace.
94
Prosthetic Valve Endocarditis

Dr. K S Ravindranath
MD, DM, DNB
Cardiologist
RK Heart Care Centre, Bangalore
PVE, one of the most severe form of IE, occurred in 1-6% of patients with valve prosthesis. The
incidence was 0.3 to 1.2% per patient year, and accounted for 10 to 30% of all cases of IE. Also, the
mechanical and bioprosthetic valves were affected equally.
The 1-year period after surgery was an important period as significant differences between the
microbiological profiles are observed before and after this time point. Early PVE (<1yr) involved the
junction between the sewing ring and the annulus, leading to perivalvular abscess, dehiscence,
pseudo-aneurysms and fistulae. Large vegetation could also cause valve obstruction. In late PVE,
perivalvular area was less affected due to endothelization. In bioprosthetic PVE, infections located on
the leaflets of the prosthesis usually lead to cusp rupture and perforation.
In early PVE, the microbiology showed predominance of Saureus, coagulase negative S aureus, gram
negative bacilli and fungi, while late PVE was more akin to native valve endocarditis, with streptococci,
S gallolyticus, enterococci, and community acquired staphylococci. In the TAVR associated prosthetic
valve infective endocarditis study, the most common causes were staphylocci and enterococci and
was noted in 50% of the patients; TAVR-PIE was associated with a very high mortality.
Diagnosis of PCE was more difficult than NVE, with symptoms of fever, new/changing murmurs, HF,
new ECG changes, emboli. Echo and blood culture were frequently negative. TEE was mandatory in
suspected PVE, and negative echo did not rule out PVE, while new peri prosthetic leak was a major
criterion. The Duke criteria of NVE had a sensitivity of 70-80%, but were less useful in PVE because
of their lower sensitivity in this setting. The addition of abnormal FDG uptake/CT/nuclear imaging as
a novel major criterion for PVE was very useful. 18F-FDG-PET/CT was noted to improve the diagnostic
accuracy of the modified DC in patients with suspected IE and prosthetic valves or cardiac devices.
PET/CTA yielded the highest diagnostic performance and provided additional diagnostic benefits.
PVE was associated with poor prognosis and factors like older age, diabetes, staph or fungal infection,
early PVE, HF, stoke and intracardiac abscess. The most common complications of PVE were abscess,
pseudoaneurysm, fistula, valvular dehiscence, paravalvular regurgiatation, and leaflet perforation.
While antibiotic standard therapy would take 2-6 weeks in NVE, PVE necessitates antibiotic therapy
for more than 6 weeks.
Surgery is indicated for prosthetic dysfunction and heart failure, but is done only in 50% of patients.
Early surgery led to lower mortality in subgroups with regurgitation, paravalvular abscess, fistula, and
vegetation. Surgery for PVE involved radical debridement with removal of all infected foreign material
from the original prosthesis. Homografts, stentless zenografts or autografts may be considered in
aortic PVE. However, late PVE without complications could be managed conservatively.
95
TAVR vs SAVR: Present Scenario

Dr. Brian Pinto
MD, DM, FACC, FESC
Chief of Cardiology and Director of Cardiac Catheterization Lab
Holy Family Hospital, Mumbai
Dr. Brian Pinto noted that there is a significant unmet need in the treatment of this severe aortic
stenosis. In adults with severe, symptomatic, calcific AS, AVR was the only effective treatment.
Though over 4 lac aortic stenosis patients are present in India, under 11000 aortic valve replacements
are done every year, with a large number of patients going untreated.
However, the results today were encouraging, as shown by the CoreValve US pivotal trial.
Echocardiographic findings showed TAVR had significantly better valve performance over SAVR at all
follow-up visits. The all-cause mortality was also significantly less with transcatheter post procedure.
The all-cause mortality at 5 years was also observed to be better with TAVR as shown by the PARTNER
A trial. These trials showed that the percutaneous transcatheter interventions were being increasingly
embraced.
Newer advancements like valve-in-valve, which were FDA approved (CoreValue and Sapien XT)
gave better results. These medtronics were leading the transformation of care for patients with
aortic stenosis through paradigm-shifting evidence, indication expansion, and innovation. These
advancements also made treatment options more bolder, with even extreme risk to high risk patients
being operated.
The expanding field of percutaneous interventions for valvular heart disease were benefitting more
and more patients. The CoreValve Evolut R system was one of the advanced intervention transcatheter
valves. For percutaneous interventions for valvular heart disease to be successful, the speaker noted
it was essential to appropriately select patient, use a heart team approach, share experience and
generate evidence, and ensure excellent follow-up care.
To conclude, the speaker noted that TAVR was increasing in popularity and in ease of procedure.
From inoperable to extreme risk and then to intermediate risk, the procedure was comparable or
even better than SAVR in the short and medium term. The procedure has been totally done by a
puncture technique in more than 90% of patients and under LA with sedation. The stroke rate and
incidence of paravalvular leak also had come down dramatically. The new devices were partially or
totally retrievable improving significantly the ease of implantation, with valve in valve and bicuspid
AV becoming indications.
96
Valve Conservation Surgery: Current status

Dr. Atanu Saha
MBBS, MS, DNB-CTVS, FRCS
Consultant Cardiac Surgeon
RTIICS NH, Kolkata
Since the first prosthetic mitral valve implantation in 1960, various valve substitutes have been
proposed, but the speaker shared that none were free from complications. As per the STS database,
the proportion of patients undergoing repair for MR rose from 51% in 2000 to 69% in 2007.
The speaker shared that there was a need to repair to preserve the ventricular function, to avoid
anticoagulation, to ensure lower cost, low morbidity and mortality, low risk of thromboembolism
and in pregnancy.
The aim of repair was to restore the function rather than the anatomy of the valve apparatus,
as this approach was to either limit or increase leaflet motion in addition to remodelling annulus
using prosthetic ring. The techniques of repair could be of 2 types, annular and valvular procedure.
Annular procedures included suture annuloplasty and ring annuloplasty, while valvular procedures
were leaflet procedures, chordal procedures or papillary muscle procedures. Other options available
include quandrangular excision of PML, triangular excision of AML, chordal shortening, chordal
transposition, chordal replacement or artificial PTFE chordae. The guidelines for mitral valve repair
were provided by the 2014 AHA/ACC valvular heart disease guidelines.
For tricuspid valve, the procedures available were suture annuloplasty (DeVagas procedure),
annulosplasty using pericardial tissue, ring annuloplasty with Carpentier-Edwards semi rigid ring or
Cosgrove-Edwards flexible band.
The other valve, aortic valve, was selected for repair only in a small proportion of cases, and was
mostly done for AR. The techniques were either patch repair of cusp perforation, cusp extension, or
cusp plication.
To conclude, the speaker noted that mitral valve repair for degenerative disease had undergone a
virtual revolution in the previous 30 years. What was once viewed skeptically was now well accepted
as the ideal treatment for mitral regurgitation based on improved physiology and lower valve related
morbidity than valve replacement.
97
Current Approach to a Patient with Functional

Tricuspid Regurgitation
Dr. Mrinalendu Das
MBBS, MS, MCh
Senior Consultant Cardiac Surgeon
RTIICS NH, Kolkata
Placing an emphasis on functional tricuspid regurgitation, the speaker noted that the initial belief
that mitral valve replacement alone led to the resolution of functional TR is a very conservative
approach. However, high mortality in patients who had residual/progressive TR lead to studies
proposing tricuspid repair concomitantly with mitral procedures and the current consensus was for a
more aggressive approach to the so-called functional TR.
He noted that up to one-third of patients with significant MS had moderate or greater TR, and was
probably related to high incidence of PAH with MS. There was less incidence of TR in MR patients.
The incidence of late TR after mitral valve surgery was more common in rheumatic valvular disease
than degenerative disease.
The assessment of functional TR would need assessment of severity of tricuspid regurgitation,
tricuspid annular diameter, and mode of leaflet coaptation. Severity of TR can be assessed by echo,
with venacontracta >6.5, effective regugitant orifice >40 mm2, regurgitant volume >45 ml, but was
more difficult, with 3D echo being a better modality. It was also noted that once the tricuspid annulus
dilated beyond 34 mm, TR usually ensued, with severity increasing as annular diameter increased.
Improvement without surgery was more frequent in patients with younger age, normal sinus rhythm,
no pulmonary hypertension, no annular dilation, and in mild functional TR. Rigid remodelling ring
annuloplasty and tricuspid leaflet augmentation were commonly followed approaches to surgery
with good results. Few reports even described percutaneous approach, which was still in research
phase but a promising technology.
Risk factors for recurrent TR included persistent or recurrent mitral valve disease, persistent pulmonary
hypertension, organic tricuspid valve disease, leaflet tethering, atrial fibrillation and older age. But,
most of the current literature, the speaker observed, suggested that tricuspid repair at the time of
mitral surgery could give a survival as well as symptomatic advantage.
To conclude, the speaker noted that the current management of functional TR needed a revision
of the present understanding. Severe TR needed to be corrected during left sided surgery, but less
severe TR needed more detailed analysis. Use of tricuspid annulus size as a trigger for repair rather
than just the severity of TR could help identify the patients who needed concomitant tricuspid repair.
Special attention was needed in cases with leaflet tethering. Overall, more aggressive stage specific
approach was recommended.
98
Atrial Fibrillation: Rate Control Modalities

Dr. A K Chauhan
MBBS, MD
Cardiologist
Chauhan Sanjeev Hospital, Bareilly
Despite the tremendous advances made in cardiovascular medicine during the last century, atrial
fibrillation (AF) has emerged as a global epidemic in this new millennium with enormous public health
and economic burden, the speaker noted. Atrial fibrillation (AF) is the most common arrhythmia
in clinical practice, accounting for one-third of hospitalizations for cardiac arrhythmia, and being
responsible for 36 % of all medical causes of admission in the emergency department.
The management goal in atrial fibrillation was to suppress complaints by giving symptomatic
treatment, and also to prevent CV complications. These goals needed to be pursued in parallel. For
this, the most important things to know were the type of AF as well as the symptoms due to AF. AF
could be paroxysmal, persistent, long standing persistent or permanent (accepted). The EHRA scores
I-IV were based on the AF-related symptoms.
In acute/unstable setting, significant variations in the management of acute sustained AF had been
identified in different countries. When a patient presented with symptomatic acute AF, the focus
of management was on effective rhythm and rate control. A tailored management approach was
essential after careful clinical evaluation of the different aspects. Different approaches were required
for hemodynamically stable AF, hemodynamically compromised AF and recurrent hemodynamically
stable AF. In a non-acute/stable setting, rhythm control was the focus.
The approach to selecting drug therapy for ventricular rate control was as follows:
Atrial Fibrillation
No other CV
disease
Hypertension or
HFpEF
LV
Dysfuction or HF
COPD
Beta blocker
Diltiazem
Verapamil
Beta blocker
Diltiazem
Verapamil
Beta blocker
Digoxin
Beta blocker
Diltiazem
Verapamil
Amiodarone
Speaking on treatment for rate control, the speaker noted that rate control should be continued
throughout a rhythm control approach to ensure adequate control of the ventricular rate during
recurrences of AF. If symptoms were more, then a more strict rate control was required, while no or
tolerable symptoms meant a lenient rate control could be accepted.
99
Stroke Prevention in AtrialFibrillation

Dr. Anurag Arora
MBBS, MD, CCEBDM, CCDE (WHO, FICM
Consultant Physician and Cardiologist
Tulip Hospital, Haryana
With one-third of all hospitalizations for cardiac rhythm disturbances being due to AF, AF has become
a very common disorder. AF in turn is associated with a five-fold higher risk of stroke. The speaker
noted that without prevention, approximately 1 in 20 patients would have a stroke in each year. AF
was the leading cause of embolic stroke. The worst thing about AF, he noted, was not AF in itself,
but rather was ischaemic stroke.
The priority in management was for optimal patient protection with the help of an excellent
anticoagulation treatment program. The first step in this was to assess stroke risk and bleeding risk
with CHA2DS2-VASc score and HAS-BLED score respectively, and subsequently based on the scores,
and based on patient values and preferences, NOAC or VKA anticoagulation therapy was started.
The VKAs are the most commonly used anticoagulation, but were with many limitations. These
limitations to a certain extent were being overcome by the NOAC (novel anticoagulants) or the non
Vit.K antagonist (NOAC).
The practical guideline to start OAC was shared by the speaker. It was essential to decide whether
anticoagulation was merited, based on risk/benefit analysis. The choice of VKA/NOAC had to be
made on the basis of approved indication by regulatory authorities and guidelines. KFT also was
extremely important, and the product characteristics, patient related clinical factors and patient
preferences needed to be taken into account before initiation.
In clinical trials, NOACs had demonstrated favourable safety and efficacy profiles compared with
warfarin, and were associated with a similar or reduced risk of major bleeding compared with
warfarin in phase III trials.
To conclude, the speaker noted that NOACs were the way forward. They could be used in all major
co-morbid conditions with NVAF like diabetes mellitus, hypertension, prior history of stroke, prior
history of MI, CHF, mild to moderate renal impairment, and senility. The ESC and AHA guidelines also
had endorsed NOAC for stroke prevention in atrial fibrillation.
100
Cardioversion in Atrial Fibrillation

Dr. R N Karmakar
MBBS, MD, DM
Associate Consultant Cardiologist
Narayana Health
Speaking on the role of cardioversion in AF, Dr. Karmakar underlined its utility in improving the
symptoms and QOL in AF, and in improving the short-term outcome. But he also noted that there
were pitfalls. The randomized trials had failed to show a superiority of rhythm control with AAD over
rate control on mortality. Also, rhythm control strategy had resulted in more hospitalizations.
The indication for cardioversion in AF was in hemodynamic instability, first episode of AF, long term
rhythm control if planned, symptomatic AF in persistent or infrequent episodes, and in potentially
reversible cause. Cardioversion was not to be planned in conditions where the risks might outweigh
the benefits and if there was a low likelihood of maintaining sinus rhythm. Risk outweighed benefits
in cases where patient was asymptomatic or minimally symptomatic, with multiple comorbidities, in
advanced age and with a poor overall prognosis.
A uniform protocol was to be maintained before cardioversion, with ventricular rate control to
improve the symptoms, anticoagulation with heparin if <48 hrs to procedure, and OAC if >48 hrs to
procedure. Also, the precipitating factor had to be addressed.
The two strategies for cardioversion were DCC and AAD. Though the two strategies had not been
compared to each other in controlled trials, the speaker noted that the evidence from studies
that compare ADD to placebo suggested significantly lower rates of successful conversion using a
pharmacological approach versus DC cardioversion. Electrical cardioversion was contraindicated in
digoxin toxicity and in severe hypokalemia or electrolyte imbalances. The risks associated with electrical
cardioversion were thromboembolism, ventricular tachycardia and fibrillation, bradyarrhythmias, skin
burn, muscle soreness, and related complications.
Antiarrhythmic drugs could be administered for attempted conversion of AF or to facilitate electrical
cardioversion. Pharmacological cardioversion was most likely to be effective when initiated within 7
days after onset of an episode of AF. The choice of drug was a tough question to answer. Though
several comparisons have been made between the different options, no clear conclusions could be
drawn regarding the difference in the effect on conversion of these drugs. The choice therefore, the
speaker suggested, should be made on the basis of contraindications, side effects, availability and
cost.
To conclude, the speaker noted that most patients with AF should have a trial of cardioversion. The
mode of cardioversion was to be individualized, guided by hemodynamic stability and duration, with
rate control and anticoagulation as essential accompaniers. The choice of antiarrhythmic agent could
be made on the basis of contraindications, side effects, availability and costs, and after cardioversion,
prophylaxis was to be started for appropriate candidates only.
101
Atrial Fibrillation: Classification

Dr. Ashish Nabar
MBBS, MD, DNB
Consultant - Interventional Cardiology
Jupiter Hospital, Thane
In AF, the muscle sleeve of pulmonary veins was the most common site of origin, with non-PV
triggers being the posterior wall of LA, SVC, IVC, crista terminalis, fossa ovalis, and coronary.
A focal trigger leading to initiation of re-entry was more frequent in the young, hypertensive, acute
infections, ADHF, ACS, and hyperthyroidism. Also, the speaker noted, that atrial fibrillation begets
atrial fibrillation. AF led to shortening and heterogenicity of refractory period, shortening of action
potentials, changes in channel expressions affecting cellular coupling and conductivity and finally
atrial fibrosis. It was more frequent to see substrate alterations, multiple wavelets in the elderly,
RHD:MV, CHF, CAD, CMP and LVDD.
The speaker observed that AF was a progressive disease, and the first diagnosed episode of AF could
be paroxysmal, persistent, long standing persistent or permanent (accepted). The therapeutic strategy
also changed with different presentations. Persistent AF favoured rate control, while paroxysmal or
newly detected AF favoured rhythm control.
The speaker also spoke on AF ablation, wherein he noted that it could be the first line therapy for
symptomatic paroxysmal AF. The factors to be considered were age, functional class, symptoms,
structural remodelling due to AF, and duration of AF, availability of effective drugs and also tolerability
of drugs. In paroxysmal, persistent (not long standing) AF, the ablation lesions were created in a
circumferential fashion around the right and left PVs, and the primary end point of this ablation
strategy was the electrical isolation of the PV musculature. Non PV foci could also be selectively
targeted. In long standing persistent, a roof line connecting the lesions encircling the left and/or
right PVs was present, and also a mitral isthmus line connecting the MV and the lesion encircling
the left PVs at the level of the left inferior PV. However, he observed, that when it came to antithrombotic strategy, it did not matter on the type of AF, and same protocol would be followed in
both.
102
Role of Ablation in Atrial Fibrillation

Dr. A M Karthigesan
MD, DNB, FHRS, CCDS, CEPS
Apollo Hospitals,
Chennai
The posterior left atrium and the pulmonary veins are the main triggers or drivers for atrial fibrillation.
The development of AF required both a trigger as well as a susceptible substrate. Speaking on the
role of ablation in AF, Dr. Karthigesan noted that the goal of AF ablation was to prevent AF by either
eliminating the trigger that initiated AF or altering the arrhythmogenic substrate. The most common
ablation strategy was electrical isolation of the PVs by creation of circumferential lesions around the
right and the left PV ostia, which probably would impact both the trigger and the substrate of AF.
The rationale for AF ablation was to improve the quality of life in symptomatic AF patients, while
other hypothetical reasons were to decrease the stroke risk, heart failure risk and also for improved
survival.
The AF ablation technologies included 3D electroanatomic mapping systems- CARTO and Ensite,
and robotic and magnetic navigation systems. The achievement of electrical isolation required,
at a minimum, assessment and demonstration of entrance block into the PV. Monitoring for PV
reconduction for 20 minutes following initial PV isolation was to be considered.
In a meta-analysis of randomized AF ablation trials, the overall success rate was 77.8% in the ablation
arm as compared with 23.3% in the control group. Catheter ablation decreased the recurrence of
AF by 71%. Success rate of AAD alone was 52% while multiple procedure success rate of AAD was
71%. The overall complication rate was 4.5%, with cardiac tamponade, TIA, and stroke being the
most common in them. Paroxysmal AF ablation with cryo balloon also showed similar success rate
with more persistent phrenic nerve injury.
Recurrence after ablation also could happen. The most common mechanism was the electrical
reconnection of one or more PVs, while other mechanisms were non-PV arrhythmogenic foci and
progressive electrical /structural remodelling of the atria as a result of aging, heart failure, inflammation
and diabetes. Long standing persistent AF, OSA with obesity, large LA diameter, low EF, elderly age,
HTN and AF by MRI were predictors of poor outcome with catheter ablation.
Technology advances like the ContactForce sensing technology were capable of real-time assessment
of the contact force (CF) applied at the catheter tip-tissue interface. The CF technology resulted in a
37% reduction in AF recurrence at a median follow-up of 12 months.
To summarise, the speaker reiterated that ablation therapy should be considered only for asymptomatic
patients, and may need more than one procedure to improve the long-term outcome. Also, the
newer contact force technology was more likely to improve the success rate of catheter ablation.
103
Surgical AF ablation
Dr. S Thiagarajamurthy
Chief Cardiothoracic Surgeon
Billroth Hospitals,
Chennai
The Cox-Maze IV is currently the gold standard for surgical treatment of atrial fibrillation, noted the
speaker. The indications for this was patients undergoing concomitant cardiac surgery and those not
undergoing a concomitant cardiac surgery. For those undergoing other cardiac surgical procedures,
all patients with symptomatic atrial fibrillation should be considered for surgical ablation, regardless
of whether antiarrhythmic medications were started.
The results from Ralph Damiano et al study shed more light on the role of ablation assisted Cox
maze procedure. After an ablation-assisted Cox-maze procedure, the freedom from atrial fibrillation
was 89%, 93% and 89% at 3, 6 and 12 months, respectively. The freedom from both AF and
antiarrhythmic drugs was 63%, 79% and 78% at 3, 6 and 12 months respectively. The risk factors
for atrial fibrillation recurrence at 1 year were enlarged left atrial diameter, failure to isolate the entire
posterior left atrium, and early atrial tachyarrhythmias.
An RCT on AF ablation in MV surgery was performed. A total of 3502 patients were screened and off
the 1082 who were eligible, 260 were randomized into the study. Statistically significant results were
obtained, with the freedom from AF post MVS+ablation being much more superior than surgery
alone.
To conclude, the speaker noted that AF ablation was performed at his centre as a concomitant
procedure, along with MVR or repair. Standard diathermy was used at 20 power settings, and maze
lesions performed. LA appendage was ligated, and RA appendage ligated. More than 80% had
sinus/regular rhythm, and the post-op management was easy.
104
Dedicated Bifurcation Stents

Dr. Dharmendra Jain
MD, DM, FNB
Assistant Professor of Cardiology
Benares Hindu University, Varanasi
Due to major cardiac events related to the side-branch (SB) compromise, the concept and practice of
dedicated bifurcation stenting is of significant clinical importance. However, there is lack of consensus
on the optimal bifurcation approach. Dr. Dharmendra Jain reviewed the existing evidence base to
clarify the best bifurcation percutaneous coronary intervention (PCI) approach between provisional
T-stenting of implanting only one-drug eluting stent (1 DES) in the main-branch (MB) and a two-DES
approach with routine stenting of both bifurcation branches (MB and SB).
The Randomised Study of the Crush Technique Versus Provisional Side-Branch Stenting in True
Coronary Bifurcations (CACTUS Study) was a prospective, randomised, multicentre study involving
350 patients that assessed whether elective stenting of both branches (by the use of Crush technique)
provides greater benefits than the simple approach of stenting only the MB (provisional T-stenting)
with additional stenting on the SB only in the case of unsatisfactory result at that site. This study has
demonstrated that in most true bifurcations, a provisional strategy is effective with the necessity to
implant a second stent in the SB in about one-third of cases.
More definitive data regarding the use of one stent or two stent strategy in bifurcation angioplasty
with DESs has come from the NORDIC study. In this study, a strategy of stenting both the main
vessel and the side branch (MV+SB) was compared with a strategy of stenting the main vessel only,
with optional stenting of the side branch (MV), with sirolimus-eluting stents. Results showed that a
2-DES strategy (Crush or Culotte) is associated with excellent clinical and angiographic results and
should be considered in the treatment of large SBs where suboptimal angiographic results could be
associated with subsequent clinical problems.
The various dedicated stents discussed by the presenter included Y-med Sidekick (Y-med Inc; San
Diego, CA, USA), Multilink Frontier (Abbott Vascular Devices, CA/Guidant Corporation; Santa Clara,
CA, USA), Nile Croco (Minvasys; Genevilliers, France) and the Axxess Plus (Devax; Irvine, California,
USA).
105
LV Assist Device
Dr. Rupesh George
MD, DM, DNB
Associate Professor and Consultant Interventional Cardiologist
Amala Cardiac Center, Ernakulam
Despite several advances in drug therapy, devices and surgical repairs, 5-10% of heart failure patients
continue to have persistent NYHA-IV symptoms. Advanced heart failure is associated with poor
survival rate; the 6-month mortality rate is as high as 50%. Once the typical interventions fail to
produce a beneficial response, replacement becomes inevitable. In fact, cardiac transplantation is
the gold standard treatment for advanced heart failure; it increases survival by a median period of
11 years and confers significant positive impact on quality of life. However, organ scarcity is a major
limitation in cardiac transplantation. The demand and supply ratio does not look rosy even in the
US where techniques for harvesting donor hearts are advanced; heart transplantation rate is 2500
patients per year, while 250,000 patients are diagnosed with advanced heart failure. This imbalance
has the underpinnings of the advancement of mechanical assist device therapy.
The earliest devices (Heartmate VE; Figure 1) were volume displacement, pulsatile pumps with a
number of mechanical bearings; these devices succumbed to wear and tear with time. Despite failure
of these devices at 2 years, the survival rate was increased nearly two-fold when compared to medical
therapy (REMATCH trial).
Aorta
External
battery
pack
Skin
entry
site
Left
ventricle
One-way outflow
valve (closed)
Pump
Bloodpumping housing
chamber
One-way inflow
valve (open)
Flexible
diaphragm
Blood
flow
External
system
controller
Pulsatile-flow
LVAD
Percutaneous
lead
Percutaneous
lead
Actuator
bearing
Motor
Pusher
plate
Replacement of pulsatile
pumps with pulsatile
continuous flow pumps
has
overcome
the
disadvantages associated
with pulsatile pumps and
continuous flow pumps.
In addition, mechanical
bearings
are
being
replaced by non-contact
magnetic levitation rotors.
These novel changes
make the device more
compact and durable.
Dr.
Rupesh
George
pointed to the fact that
mechanical assist devices
have conferred a two-fold survival benefit when compared to a decade ago. With the advent of
remote monitoring, he hopes that transcutanous energy transfer will enable LV assist devices in
becoming an alternative to cardiac transplantation. In the future, cardiac transplantation may be
reserved for device failure patients.
Figure 1: An Illustration of Heartmate VE.
106
Pharmacotherapy in ChronicSystolic Heart

Failure: What is New?
Dr. U C Samal
MD, FICC, FACC, FIACM, FIAE, FISE, FISC, FAPVS
Permanent and Chief Trustee, ICC-Heart Failure Foundation
Patients with heart failure (HF) fall into two categoriesthose who are stable and ambulatory with a
relatively low event rate, and patients requiring hospitalization who are characterized by high postdischarge mortality and rates of rehospitalization. HF trials in 2010 contributed to the advancement
of outpatient management, whereas the development of novel therapies with a survival benefit
is impending. Therefore, Dr. Samal reviewed the existing evidence-base to suggest the possible
pharmacotherapeutic options for HF.
He noted that due to substantial evidence in favor of LCZ696 ARNI (Entresto), it is set to replace
conventional therapy with enalapril in chronic systolic heart failure (PARADIGM-HF trial).
Based on data from EMPHASISHF/EPHESUS trials, eplereonone may be considered useful in reducing
mortality in NYHA Class IIIV HF, in NYHA Class I, in post-MI cases, and in patients with ejection
fraction EF < 40%, and in patients with a history of diabetes.
Nonsteroidal mineralocorticoid receptor antagonists, like finerenone appear to be as effective as and
may replace both spironolactone and eplerenone as the mortality reducing drug. As observed in the
ARTS/ARTS-HF trials, finerenone at 2.5 mg/day and 20 mg/day, respectively, reduces albuminuria
and NT-proBNP, lowers hyperkalemia and worsening renal function, and positively impacts type-2
diabetes outcomes. In addition, he noted that zirconium cyclosiclicate ZS-9 is likely to emerge as an
important drug.
Aliskiren an important direct renin inhibitor (150mg/300 mg) is an effective option in stable chronic
HF (NYHA Class II to IV) as evident from the ATMOSHPHERE trial.
FAIR-HF, CONFIRM-HF, and IRONMAN have documented injectable iron therapy and oral iron
supplementation to be associated with comparable positive outcomes for the Patient Global
Assessment, EQ-5D, KCCQ, and 6-min walk test in patients with NYHA Class II or III; LVEF <45%;
hemoglobin level between 95 to 135g/dL; and iron deficiency anemia (ferritin: 100 to 299 g/L and
transferrin saturation: <20%).
The SHIFT trial recorded ivabradine (up to 7.5 mg twice a day) along with a beta-blocker to be
associated with 18% reduction in primary endpoint composite of cardiovascular death or HF
hospitalization in HF patients with LVEF < 35%.
Beta-blocker therapy remains imperative in HF patients with atrial fibrillation akin to the counterintuitive
conclusion of the meta-analysis on the use of beta-blockers in atrial fibrillation published in Lancet
in 2014.
107
Atrial Fibrillation: Case-Based Discussion

Dr. M N Krishnan
DM, FRCP, FACC, FESC, FICC
Professor and Head, Department of Cardiology
Government Medical College, Kozhikode
Dr. Krishnan presented two cases of atrial fibrillation that responded well to ablation techniques. In
the first case, a 42-year-old male executive presented with worsening fatigue, vague chest discomfort
and palpitation. The patient was on anti-hypertensive medications but no other significant past
events or illnesses were noted. Heart rate was 184 bpm and was irregular and the blood pressure was
96/64 mm Hg. Patient was admitted into CCU. Echocardiogram showed normal size and contraction
of left ventricles, mild LVH (IVSd/PWD 13/12), and normal left atrium, along with normal valves and
septa. There was no thrombus in LA/LAA and the renal, thyroid and hepatic functions were normal.
ECG on admission is shown in Box 1. Patient was electrically cardioverted under heparin cover and
was discharged with a prescription of vitamin K antagonists and beta-blockers for 4 weeks. No antiarrhythmic drugs were prescribed. The patient presented after 2 weeks with palpitation and reported
an episodic palpitation of 2 to 3 times a month. The patient was put on amiodarone but was not
able to tolerate and was expecting improvements in symptom control. Subsequently, the patient was
put on oral vitamin K antagonists with regular INR monitoring and underwent AF ablation. Following
this, the patient was free of symptoms at 6 months post- ablation.
In the second case, a 68-year-old retired teacher with a history of
diabetes and dyslipidemia presented with worsening effort dyspnoea
and distressing palpitation. Furthermore, patient had a history of
unstable angina and small vessel disease and underwent PTCA with
a drug eluting stent in P-LAD. Clinically, the patient showed signs of
atrial fibrillation and cardiomegaly. ECG on admission is shown in Box
2. Echocardiogram showed dilated LA, LV and severe LV dysfunction
with an ejection fraction of 24%. Furthermore, a moderate mitral
regurgitation was seen. There were no indications of regional wall
motion abnormalities (RWMA), thyroid dysfunction or electrolyte
imbalances. Creatinine values were 2.4 mg/dL and eGFR was 34mL/
min. Chest X-ray indicated signs of pulmonary venous hypertension
with interstitial edema. Initially, the patient was treated for heart failure
and rate control with digoxin, diuretics, ACEI and BB. While there
were marginal improvements in symptom control, and regression of
mitral regurgitation, left ventricular ejection fraction remained at 25
-30. Furthermore, HR continued to be in the range of 110-120 range
despite the maximum tolerated dose of beta-blockers and digoxin.
Following this, the patient underwent AV nodal ablation and VVI
pacing. In about 6 months, there was a complete resolution of mitral
regurgitation and LVEF rose to 42%. The patient was advised reduced
dose rivaroxaban indefinitely and was quite well at follow up.
108
Box 1: ECG on admission (Case 1).
Box 2: ECG on admission (Case 2).
Classification of Pulmonary Hypertension

Dr. P Chandrasekhar
MD, DM
Prof and HOD of Cardiology
Kurnool Medical College
The initial classification of pulmonary hypertension (PH) into primary pulmonary hypertension and
secondary pulmonary hypertension by the International Conference on Primary PH held in the year
1973 has undergone significant changes (Box 1 & 2).
Dr. Chandrasekhar explained these changes in an informative presentation. The Evian classification
attempted to create categories of PH that shared pathologic, clinical and therapeutic features. This
was a much broader and more encompassing classification with 5 major categories. In 2003, the 3rd
World Symposium on PAH held in Venice, Italy, reviewed and made modest changes to the impact
and usefulness of the Evian classification. The 4th World Symposium on PH held in Dana Point,
California, introduced major changes to the five groups.
1. Pulmonary arterial
hypertension
1.1 Idiopathic PAH
1.2 Heritable PAH
1.3 Associated with
connective tissue
disease, HIV infection,
portal hypertension,
congenital
heart diseases,
schistosomiasis
2. Pulmonary hypertension
due to left heart disease
due to lung diseases and/
or hypoxia
4. Chronic thromboembolic
pulmonary hypertension
(CTEPH)
with unclear multifactorial
mechanisms
Box 1: Snapshots of the modifications in classification of pulmonary hypertension.
109
Box 2: Summaries of the modifications in classification of pulmonary hypertension.
Explaining specific changes and modifications to the different groups and sub groups of pulmonary
hypertension, the presenter summarized the 2015 ESC/ERS Guidelines for the diagnosis and treatment
of pulmonary hypertension.
110
Pathogenesis and Pathology of Pulmonary

Arterial Hypertension
Dr. Sourangsu Chatterjee
MD, DM
Head of Department, Cardiology
North Bengal Medical College
Pulmonary arterial hypertension (PAH) is a proliferative pan vasculopathy characterized by

vasoconstriction, intimal hyperplasia and fibrosis, medial hypertrophy and in situ thrombosis of the
small pulmonary arteries and arterioles. Discussing the pathogenesis of PAH, Dr. Chatterjee explained
the Multiple Hit hypothesis. Along with an underlying genetic predisposition to pulmonary vascular
disease, secondary hits (Box 1) over time activate the disease process by causing vasoconstriction or
remodelling. The presentation described the impact of these modifiers on the pathogenesis of PAH.
Box 2 presents the list of genes whose mutations are involved in the pathogenesis of PAH.
Specific types of gene mutation
Second genetic mutation
Increased PBF ( left to right shunt)
Environmental factors: Drugs, HIV
infection
Altered structure/function of membrane
ion channel.
Inflammation: Cytokines
Increased endothelin
Decreased no and prostacyclin
Procoagulant factors
Anti-apoptotic factors
Autoimmune mediators
Cell- cell interaction
Cell-matrix interaction
Bone morphogenetic protein receptor

type2 (BMPR2)
Serine/ threonine- protein kinase receptor
R3 (also called activin-like kinase type 1
receptor ALK1)
5 OH tryptamine (serotonin) transporter
Endoglin (ENG)
Mothers against decapentaplegic
homologue9 (SMAD9)
Caveolin1 (CAV 1)
Potassium channel subfamily K member3
(KCNK3)
Box 1: Modifiers/secondary hits that activate the pathogenesis

of PAH.
Box 2: Genes involved in the pathogenesis of PAH.
Pathologic findings in patients with PAH include intimal hyperplasia and fibrosis (concentric/
eccentric), medial hypertrophy, adventitial thickening with moderate perivascular inflammatory
infiltrates. Furthermore, the presenter explained pathological findings such as in situ thrombosis of
small pulmonary arteries and arterioles (obstructive vasculopathy) and complex lesions (plexiform,
dilated lesions). The presentation also discussed the roles of perivascular inflammation and metabolic
plasticity in vascular cell proliferation (vascular remodelling). The presenter indicated that these events
are emerging paradigms in the pathobiology of PAH.
111
Home Based Oxygen Therapy for Severe

Pulmonary Hypertension
Dr. Hetan C Shah
MD, DM
Associate Professor, Department of Cardiology
King Edward Memorial Hospital and Seth GS Medical College, Mumbai
Beginning the discussion with a historical account of oxygen therapy in medicine, Dr. Hetan Shah,
discussed the clinical aspects of home based oxygen therapy in chronically hypoxaemic patients. The
presentation specifically focused on long-term oxygen therapy (LTOT), which is defined as oxygen
used for at least 15 h per day in chronically hypoxaemic patients (PaO2 7.3 kPa). Indicating that LTOT
improves the function of all hypoxia-sensitive cells, Dr. Shah explained the effects of LTOT on survival,
neuropsychiatric function, pulmonary circulation and erythropoietic system.
Cumulative survival,
percent
1. Document the need for LTOT in the

medical record
2. Select a qualified oxygen equipment
supplier
3. Complete certificate of medical
necessity form
4. Monitor use and environment
(with home oxygen supplier)
5. Reevaluate for possible changes in the
prescription
6. Renew LTOT, as required
100
Continuous oxygen
(nearly 18 hours/day)
80
60
40
Nocturnal oxygen
20
0
6
12
18
24
30
36
Months after randomization
Figure 1: Survival in patients of COPD on long-term oxygen

therapy (results of the NOTT trial).
Percent survival
100
Box 1: Responsibilities of physicians prescribing long-term

oxygen therapy (LTOT).
80
60
40
20
Oxygen
Control
0
The presenter discussed data from the NOTT trial
0
12
24
36
48
60
Months
and MRC trial, which demonstrated better survival
rates with LTOT as compared to nocturnal oxygen
Figure 2: Survival in patients of COPD on long-term oxygen
(Figure 1) and no oxygen (Figure 2), respectively.
therapy (results of the MRC trial).
Furthermore, LTOT improves cognitive function,
sleep quality and quality of life. The presenter highlited and discussed the recommendation that
LTOT should be ordered for patients with pulmonary hypertension, including idiopathic pulmonary
hypertension, when the PaO2 is 8 kPa (Grade D). Furthermore, the presenter discussed the evidences
and recommendations for hypercapnia during O2 treatment and flow titration. Following discussions
on the different equipments for home oxygen therapy, and the advantages of O2 conservation
devices, Dr. Hetan C Shah concluded the presentation by explaining the responsibilities of physicians
prescribing LTOT (Box 1).
112
Pharmacotherapy of Pulmonary Arterial

Hypertension
Dr. Dipak Ranjan Das
MD, DM, FESC, FICC
Institute of Cardiovascular Sciences
S. C. B. Medical College, Cuttack
Describing pulmonary hypertension to be a

result vascular remodeling arising out of an
imbalance of endogenous vasoconstrictors and
vasodilators, Dr. Das discussed and explained
the pharmacotherapy of pulmonary arterial
hypertension (PAH). Explaining that the treatment
algorithm of PAH may be divided into three focus
areas (Box 1), he discussed the improvements in
survival associated with therapies targeting the
prostacyclin, nitric oxide, and the endothelin-1
pathways. Discussing the pharmacotherapy with
bosentan and abrisentan, the presenter indicated
that abrisentan is safe with LFT abnormalities and
has no significant interactions with sildenafil. The
presentation also provided an update on riociguat
(a soluble guanylate cyclase stimulator), and
PDE-5 inhibitors such as sildenafil and tadalafil in
the management of PAH. The presentation also
included a discussion on the pharmacotherapy of
PAH with agents such as beraprost, epoprostenol,
Iloprost and treprostinil that act on the prostacyclin
pathway. The presentation concluded with a few
recommendations for the pharmacotherapy of
pulmonary arterial hypertension (Box 2).
Normal
Pulmonary hypertension
VIP
NO
Urotensin II
Urotensin II
Endothelin-1
PGI2
Endothelin-1 VIP
Angiotensin II
Angiotensin II NO
ANP
ANP
serotonin
Adrenomedullin serotonin
PGI2 Adrenomedullin
1. General measures, supportive therapy, referral strategy,

acute vasoreactivity testing and chronic treatment with
calcium channel blockers;
Vasoconstrictor = vasodilators
Vasoconstrictor > vasodilators
Minimal resting tone
Increased tone
Vascular remodelling
Figure 1: Imbalance of endogenous vasoconstrictors and

vasodilators in PAH.
Monotherapy with endothelin receptor antagonist (ETRA),

phosphodiesterase-5 (PDE5) inhibitor, or the soluble
guanylate cyclase stimulator riociguat for treatment naive
PAH patients with WHO FC II/ WHO FC III symptoms
A parenteral prostanoid for treatment naive PAH patients
with WHO FC III symptoms who have evidence of rapid
progression of their disease, or other markers of a poor
clinical prognosis.
Addition of a parenteral or inhaled prostanoid For PAH
patients in WHO FC III who have evidence of disease
progression and/or poor clinical prognosis with one or two
oral agents
Inhaled treprostinil or inhaled iloprost in patients with PAH
FC III who remain symptomatic on stable and appropriate
doses of an endothelin receptor antagonist (ETRA) or a
PDE5 inhibitor
Monotherapy with a parenteral prostanoid agent like IV
epoprostenol or IV / SC treprostinil for treatment-naive PAH
patients in WHO FC IV
2. Initiation of therapy with approved PAH drugs
Addition of a third class of PAH therapy for WHO FC III or

IV PAH patients with unacceptable or deteriorating clinical
status despite PAH-specific therapy
3. Clinical response to the initial therapy, combination therapy,

balloon atrial septostomy, and lung transplantation
Box 1:Three main focus areas of PAH treatment algorithm.
Box 2: Recommendations for the pharmacotherapy of

pulmonary arterial hypertension.
113
Iron Therapy in Heart Failure:

Current Understanding
Prof. Dr. Kajal Ganguly
MD, DM, FACC, FESC
Head: Department of Cardiology, Senior Consultant Interventional Cardiologist
N.R.S Medical College and Hospital, Kolkata
Iron is essential for cell growth and survival and plays a crucial role in electron-transfer reactions,
transport and storage of oxygen and oxidative phosphorylation. Heart failure is associated with
depletion in myocardial iron. Indicating that iron deficiency is seen in 50% patients with heart failure
Dr. Ganguly, pointed out to data that indicate that iron deficiency (beyond anemia) is associated with
an increased mortality and morbidity in systolic heart failure. Furthermore, available data indicate that
iron deficiency (not anemia) is associated with reduced exercise capacity in heart failure. Furthermore,
functional iron deficiency is associated with reduced rates of event-free survival in patients with heart
failure. Dr. Ganguly stressed the need for routinely assessments of serum iron, serum transferrin,
transferrin saturation and serum ferritin in patients with heart failure.
FCM improved 6MWT at week 24
FCM vs placebo: 33 11 m (least squares mean SE)
35
34
18
17
20 16
or
or
uc
h
w
ly
at
e
er
lit
M
od
2 3
De
ad
1 2
se
tle
ch
a
ng
or
ed
ed
tle
lit
Un
im
im
A
te
ly
im
M
od
er
a
uc
h
pr
ov
pr
ov
pr
ov
ed
ed
1 3
se
2 3
se
10
10
LSM change in 6MWT

distance from baseline (m)
28
26
30
Patients (%)
40
30
P=0.002
20
FCM (N=150)
Placebo (N=151)
10
0
-10
-20
-30
Week 24
Figure 1: FCM improved self-reported PGA scores at week 24

(Fair HF trial).
Figure 2: FCM improved 6MWT at week 24

(results of the CONFIRM HF).
Discussing the treatment options for iron deficiency in heart failure, Dr. Ganguly pointed out to the
American College of Physicians guideline on treatment of anemia in patients with heart disease,
which indicates no specific benefits with red blood cell transfusion and erythropoiesis stimulating
agents. On the other hand, intravenous iron increases exercise tolerance and improves quality of
life. In these contexts the presenter discussed the findings of the FAIR HF (Figure 1) and CONFIRM
HF (Figure 2) trials along with data from a meta-analysis, which indicates that ferric carboxymaltose
lowers the rate of CV hospitalisation and CV related death in patients with systolic CHF and iron
deficiencies. The presentation concluded by noting that the target hemoglobin for heart failure is
usually around 11.5 g/dL and emphasized that the treatment of heart failure with IV iron may prevent
the progression of the renal disease as well as heart disease.
114
Surgery for End-stage Heart Failure

Dr. A G K Gokhale
MBBS, MS, MCh, DNB
Cardiothoracic, Vascular and Transplant Surgeon
Apollo Hospitals, Jubilee hills, Secunderabad
Dr. Gokhale started off his presentation by stating that the goal of surgery in heart failure is to
increase cardiac output and longevity along with improving the symptomatic status. Surgery for
patients in advanced heart failure aims to correct or repair many of the pathophysiological changes
that occur in heart failure, which are not corrected by medical treatment alone.
The surgical techniques performed in contemporary practise include surgical revascularization of
hibernating myocardium, ventricular restoration surgery and mitral valve repair along with use of
ventricular assist devices, and heart transplantation. Discussing revascularization, Dr. Gokhale pointed
out to data that indicate the efficacy of the surgical technique as compared to medical therapies
(Figure 1).
Percent Survival
20
-79.6%
X2=147
P<0.0001
Death rate (%/yr)
16.0
23.0%
X2=1.43
P=0.23
15
10
5
0
7.7
6.2
3.2
1.00
0.90
0.80
0.70
0.60
0.50
0.40
0.30
0.20
0.10
0.00
p=0.0047
p=0.0091
0
Viable
Nonviable
Figure 1: Survival Benefit Medical vs.

revascularization.
VELVAS (n=68)
OMM (n=61)
12
18
24
30
Months Post Enrollment
36
42
Figure 2: Destination therapy (chronic VAD) compared to

maximum medical therapy: REMATCH study.
Speaking on valve surgery, the presenter indicated that mitral annulus, leaflets and subvalvular
apparatus are all amenable to surgical repair. Pointing to a post-hoc analysis of patients with moderate
or severe mitral regurgitation in the STICH trial, the presenter highlighted data that indicates better
survival in patients who underwent mitral valve surgery at the time of CABG as compared with
those undergoing CABG alone (adjusted HR 0.41, 95% CI 0.22-0.77). The presentation further
focused on ventricular assist devices and heart transplantation. Results of the REMATCH study are
presented in Figure 2. The presentation concluded by noting that surgery for heart failure and heart
transplantation are under-utilized, despite thier potential to improve the quality and longevity of life.
115
Bioresorbable Vascular Scaffold

Dr. C G Bahuleyan
MD, DM, FRCP, FSCAI
Former Professor and Head, Department of Cardiology, Medical College and Hospital, Trivandrum
Chairman - Cardiovascular Centre, Ananthapuri Hospitals and Research Institute, Trivandrum
New generation drug-eluting stents are associated with excellent outcomes, despite their limitations
of persistent inflammation, neoatherosclerosis, loss of normal vessel curvature and vasomotion.
Discussing the clinical need (Box 1) and the available biodegradable stents, Dr. Bahuleyan discussed
the available clinical data on Absorb, a bioresorbable vascular scaffold.
The presenter pointed to data that indicates an increase in mean lumen area, reduction in plaque
area, restored vasomotion and sustained low event rates at 5 years with Absorb (Figure 1).
The presentation also pointed out the limitations of BVS to include the following:
Not very complaint
Restore the vessel to a more natural state

Eliminate chronic sources of vessel
irritation and inflammation
Keeping the vessels free for future
treatment options
Reduce the need for prolonged DAPT2
Allows for use of non-invasive imaging
techniques (CCTA)
Improve patient quality of life
High strut thickness

Relative low radial force
Limited distensibility
Limited availability of sizes
Higher ST rate in the first 12- months
Lack of Statistically Significant differences
(DES vs BVS)
Serial IVUS Analysis
Vasomotion Testing* (N=53)
Solid Line=Cohort B1 (L=21)

Dotted Line=Cohort B2 (L=30)
9
Mean Plaque Area
8
7
Mean Lumen Area
6
5
Post6
1 yrs
PCI Months
2 yrs
3 yrs
5 yrs
100
90
80
70
60
50
40
30
20
10
0
-20.0 -10.0
Major Adverse Cardiac Events

(Cardiac Death, MI or ID-TLR)
24.0%
Absorb BVS*
XIENCE V**
20.0%
MACE
mm2
10
Box 1: Clinical needs for a bioresorbable vascular scaffold.
Distal
Scaffold
Prox
10.0
20.0 30.0
14.3%
43.3%
12.0%
8.0%
11.0%
4.0%
0.0%
12
24
36
48
60
Time Post Index Procedure (Months)
Number of patients at risk
Vasoditation
0.0
16.0%
40.0
*Relative changes in mean lumen diameter

before and after nitrate administration.
Time after index

Procedure (Days)
37
194 284 393 573 758 1123 1488 1853
Absorb BVS
101
99
96
XIENCE V
96
94
92
91
88
86
85
227 224 219 211 204 200 194 182 174 169
*Absorb BVS; ABSORB Cohort B (B1+B2)

**XIENCE V; 3.0 x 18mm subgroup from SPIRIT I + SPIRIT II + SPIRIT III
Figure 1: Results from the Absorb trials.
The presentation concluded by noting that data on bifurcation and LMCA stenting are unanswered
questions in the realm of bioresorbable vascular scaffold.
116
Impella Device
Dr. Manish Kapoor
Associate Professor
Dept. of Cardiology
NEIGRIHMS, Shillong
The Impella device consists of a catheter mounted axial blood flow device fitted onto a pigtail
catheter. It has a miniaturized micro axial rotary pump based on the concept of Archimedes screw.
When positioned across the aortic valve, it provides active forward support and simulates normal
physiology in unloading aspirated oxygenated blood from LV into ascending aorta. Figure 1 shows
the Impella catheter and the Impella console.
Figure 1: Impella Family of catheters and the console.

Change in Cardiac Index
IABP vs. Impella 2.5
0.5
0.4
0.3
0.2
0.1
0.0
1. Impella 2.5 is approved by FDA for partial circulatory

support for up to 6 hrs for high risk PCI.
2. Off label uses include:
MI complicated by Cardiogenic Shock.
0.49
Post cardiotomy failure
02
0
p=
Off pump CABG

0.11
IABP
Heart transplant Rejection
Bridge to definitive ventricular assistance.

Ablation of HD unstable VT
Impella
Figure 2: Results of the ISAR-SHOCK study.
Box 1: Indications for the Impella System.
Describing Impella as an ideal cardiac assist, Dr. Kapoor pointed out that impella is a safe and simple
device and provides optimal systemic hemodynamic support and myocardial protection (Figure 2).
Describing and explaining the methods for the placement of Impella, Dr. Kapoor discussed data from
clinical studies on the efficacy of Impella in a number of approved and off-label indications (Box 1).
117
Aspiration Thrombectomy
Dr. Saroj Mandal
MD, DM, FACC, FSCAI, FESC, FAPSIC, FICP
Asst. Prof. of Cardiology,
SSKM Hospital and IPGMER, Kolkata
Major limitation of primary PCI includes distal embolization and reduced flow aspiration. In these
contexts, aspiration thrombectomy may improve clinical outcomes and reduce embolization. Dr.
Mandal began his presentation on the topic by stating that aspiration thrombectomy is intuitive
and feels right. He explained the reasons for using thrombectomy during primary PCI (Box 1) and
also discussed its limitations (Box 2).
It may prevent distal embolization
May prolong PCI duration

Higher dependency on operator`s
technique
May not achieve complete thrombus
removal
Can cause distal embolization due to
device manipulation
Do not completely eliminate no reflow
Do not reduce the need for adjunctive
stenting
Increased cost
It allows the operator to have a better

visulization of the atherosclerotic lesion
It allows better evaluation of vessel size
It allows direct stenting (less distal

embolization and improved reperfusion)
It may prevent stent malapposition
Box 1: Why thrombectomy during primary PCI?
Box 2: Limitations of thrombectomy.
The presenter discussed data from studies such as the TAPAS trial, TASTE and TOTAL. The presenter
discussed the limitations of the study design as well as their results. Dr. Mandal indicated that the
experience of operators and the mortality
reductions (at 1 year) shown in a few studies
Lower SBP and worse Killip class on
could be related to ST resolution and lower
admission
reinfarction and stent thrombosis rate. He
Longer door-balloon time
summarized the usefulness of thrombectomy by
More frequent TIMI 0 or 1 before PPCI
noting that selective aspiration thrombectomy
Less frequent restoration of flow after
has a role in primary PCI, especially in sicker
indwelling the guide wire
patients (Box 3). However, he noted that routine
aspiration thrombectomy may not be an useful
Box 3: Conditions that require selective aspiration
option.
thrombectomy.
118
The S-ICDTM System

Subcutaneous Implantable Defibrillator
Dr. Soumik Basu
MD, DM
Medica Hospital, Kolkata
Dr. Basu presented an informative update on the S-ICD system, which is an entirely subcutaneous
system without a need for leads in the heart. This leaves the vasculature untouched. Furthermore, the
system is placed using anatomical landmarks, reducing the need for fluoroscopy during implantation.
In addition, sophisticated algorithms provide effective detection and treatment of VT/VF.
The presenter explained the design goals of the S-ICD system (Box 1) and pointed out to trade-offs
that include larger generator unit and resulting cosmetics and only a post-shock pacing without
brady pacing and ATP therapy. The presenter discussed various aspects of the system including its
technology, placement techniques and its use in various indications (Figure 1).

To avoid both the short- and longterm complications associated with
transvenous leads
7%
4%
37%

To defibrillate with more uniform voltage
gradients, reducing myocardial damage

To sense activation across the whole
heart, improving accuracy for arrhythmia
detection.
Ischemic CM
31%
Idiopathic VF
Channelopathy

To provide an option for patient subpopulations for which TV-ICD is not ideal
Non-ischemic CM
Congenital

To reduce risk of lead failure in young and
active patients
8%
13%
Box 1: Design Goals of Subcutaneous ICD Therapy

A new approach.
Other
Figure 1: Clinical Indications S-ICD system.
Following discussions on the clinical data, the presenter concluded by noting that the S-ICDTM
system has over 1300 patients in clinical studies. Data from these studies indicate that
6.8% of patients have received appropriate, life-saving shocks
The system has 99.8% sensitivity
Treatment times are comparable to TV-ICDs (~20 seconds)
119
IRA/Multivessel Stenting in STEMI

Dr. Goutam Datta
MD, DNB, DM, MRCP, FSCAI
Burdwan Medical College
West Bengal
About 30-50% of STEMI patients have additional stenoses other than the infarct related artery.
Current guidelines support targeting only the culprit vessel with PCI. However, contemporary studies
have suggested the usefulness of preventive revascularisation. Box 1 presents the arguments aganist
and in favor of preventive revascularisation.
Agreement
Disagreement
No subsequent hospitalization for

staged procedures
Prolongation of procedure
Reduced hospitalization expenses
Unnecessary risk and possible

procedure complications
Better quality of life
Increase RX dose and

contrast dose
Reduced medical therapy and

double antiplatelet therapy duration
Overestimation of stenosis
severity
Primary endpoint
No
HR 0.35 (95% CI 0.21-0.58)
events
53
60
p<0.001
40
21
20
0
Preventive PCI No Preventive PCI

Preventive vs no preventive PCI AP vs NP
HR (95% CI)
p-value
Cardiac death/MI
11 vs 27
0.36 (0.18-0.73)
0.004
Cardiac death
4 vs 10
0.34 (0.11-1.08)
0.07
Box 1: Views on preventive revascularisation.
Figure 1: Results of the PRAMI study.
1.0
82.5%
0.8
76.6%
0.6
0.4
0.2
Multi-Vessel PCI
p=0.02
Culprit-Only
0.0
0
3
4
Years
Event free from CV Death (%)
Event free from MACCE (%)
The presentation discussed data from clinical studies such as the PRAMI study (Figure 2), INTERSTELLAR
study (Figure 3), and others, which compared the complete revascularization with PCI of culprit
vessels. The presenter pointed out that no univocal data exists in the favor of one strategy over other
for non culprit lesion in MVD in primary PCI. However, the balance seems to hang towards complete
revascularization (not in the acute phase).
100
89.9%
80
85.3%
60
40
20
Multi-Vessel PCI
p=0.06
Culprit-Only
0
0
3
4
Years
Figure 2: Data from INTERSTELLAR cohort.
In conclusion, Dr. Datta indicated that although revascularisation of residual lesions should be
performed, clarity on optimal timing and methods to assess severity of non culprit lesion is lacking.
120
Management of NSTE-ACS: Indian Scenario

Dr. Sundeep Mishra
MMBS, DM
AIIMS, New Delhi
Acute coronary syndrome represents an important healthcare concern worldwide. However, Dr.
Sundeep Mishra notes that its presentation, distribution, and treatment responses could vary in Indian
patients as compared to the western population. The discrepancies are attributable to differences
in factors such as literacy, accessibility to healthcare, urban penetration levels, and economic status.
An analysis of data from four registries, namely the CREATE Registry (n=20937), Kerala ACS Registry
(n= 25748), Himachal Pradesh ACS Registry (n= 5180) and the North East ACS Registry (n= 704) was
conducted.
The distribution of NSTEMI versus STEMI was found to be dependent on the economic background
of the regions. In middle income areas (Kerala and Himachal Pradesh), NSTEMI was predominant;
this trend corroborates with that observed in the West. In economically backward regions, STEMI was
predominant; this leads us to believe that patients seek medical services only when severely affected.
NSTEMI patients were older, had more risk factors and present later during the course as compared
to those with STEMI.
The utilization of drug therapy was found to be variable; adherence to anti-platelet therapy was
highest (>90%) followed by beta blockers and statins (~70%). Low utilization was reported for ACEinhibitors and ARBs (~25%). Rates of reperfusion were typically low.
The 30-day in-hospital mortality was 3.8% in CREATE Registry, and 1.8% in the Kerala ACS Registry;
these figures compare well with data from the West (Global Registry of ACS). However, mortality rate
was higher in regions that faced inadequate access to healthcare; it was 5% and 6% as evident from
the Himachal Pradesh ACS, the North Eastern ACS, respectively.
In rural centers, inadequate access to healthcare services, difficulties in transportation and poor
socio-economic background are impediments to the care of patients with ACS. In urban centers,
out-of-pocket expenses remain challenging for patients.
121
MRI and Cardiac Devices

Dr. R K Saran
MD, DM, FACC, FRCP
King George Medical University, Lucknow
Use of MRI in patients with pacemaker devices has been associated with adverse effects such as
torque and dislodgement of the device, unpredictable Reed Switch behavior, and life-threatening
arrhythmias. However, not using MRI can be lead to missing out information that does not get
detected by CT scanning. Dr. RK Saran used the following three examples (Figures 1 to 3) to illustrate
the importance of MRI over CT.
CT scan
missed soft
tissue abscess
in a patient
with neck pain
and fever
CT scan
missed
infarction in a
CVA patient
Figure 1: Brain computed tomography
(CT) vs MRI in a patient with
weakness.
Figure 2: Cervical spine computed

tomography (CT) vs MRI in patient
with neck pain and fever.
Interruption of
SVC and IVC
Lead Artifact
CT scan
provided
only 50%
information
in a case of
cardiac tumor.
Figure 3: Cardiac computed tomography (CT) vs MRI in a patient with facial swelling.
The above mentioned discrepancies led to the development of devices that are MRI-safe. However,
the use of MRI in patients with old devices remains intriguing. Recommendations by the 2013
ESC guidelines clarify this dilemma. In patients with conventional cardiac devices, MRI at 1.5 T can
be performed with low risk of complications, if appropriate precautions are taken. On the other
hand, in patients with MRI Conditional Pacemakers, MRI at 1.5 T can be done safely by following
manufacturers instructions.
122
Management of Acute Pulmonary Embolism

Dr. P K Gupta
Saif and IBHO Hospital
Pulmonary embolism is an important clinical entity with considerable mortality despite advances
in diagnosis and treatment. Dr. Gupta offered a comprehensive review focused mainly on risk
stratification, management protocols and treatment based on risk assessment.
A summary of the risk-adjusted management algorithm is presented in Figure 1.
Clinical suspicion of PE
Shock / Hypotension?
Yes
No
Diagnostic algorithm as for

suspected high-risk PE
Diagnostic algorithm as for

suspected not high-risk PE
PE confirmed
Assess clinical risk
(PESI or sPESI)
PESI Class III-IV
or sPESI 1
PE confirmed
PESI Class I-II

or sPESI = 0
Intermediate risk
Consider further risk stratification
RV function (echo or CT)
Laboratory testing
One positive
or both negative
Both positive
High risk
Intermediate-high risk
Intermediate-low risk
low risk
Primary
reperfusion
A/C; monitoring:
consider rescue
reperfusion
A/C; hospitalization
A/C; consider early

discharge and home
treatment, if feasible
Figure 1: Risk-adjusted management algorithm.

In high and intermediate-high risk patients, systemic/catheter-based thrombolysis or surgical
embolectomy is the preferred treatment. In intermediate-low risk group, LMWH+VKA/NOACS may be
considered. In the low risk group, LMWH+VKA/NOACS is recommended along with early discharge.
Special patient groups, involving pregnant women (without shock or hypotension) and cancer
patients may be treated with weight-adjusted dose of LMWH and extended anticoagulation (beyond
3 to 6 months) for an indefinite period or until cancer is cured, respectively.
123
Management of STEMI- Indian Scenario

Dr. C N Manjunath
MD, DM
Professor and HOD of Cardiology.
Director, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bangalore
The speaker discussed the management of STEMI, a grave complication of the most common, noncommunicable disease in India, CAD. An interesting fact was that the clinical presentation of ACS
is different in India than globally. Globally UCAD was more predominant, while in India STEMI was
more predominant. The speaker noted that evidence suggests that prompt restoration of flow in the
obstructed infarct artery after the onset of symptoms in patients with STEMI is the key determinant
of long and short term outcomes regardless of whether reperfusion is achieved by fibrinolysis or PCI,
and therefore all attempts should be made to reduce the delays to reperfusion within the golden
hour, the first 60 minutes.
Based on the meta-analysis of 23 RCT comparing PCI vs lysis, it was observed that the rate of death,
reinfarction and stroke, all were higher in the lysis group than the PCI group. The third approach, the
pharmacoinvasive therapy was also discussed by the speaker. The benefits were minimizing infarct
size, clinical stabilization, prevention of early reinfarction and protection of microcirculation, whereas
the risk was of procedural MI, bleeding and renal damage.
The TRANSFER AMI trial, was a trial the speaker used to support his talk, where patients with STEMI
were treated with either pharmacoinvasive therapy or standard treatment after fibrinolysis. The trial
concluded that pharmacoinvasive approach was safe and efficacious compared to treatment with
thrombolytics and transfer for rescue PCI only.
The other approach was facilitated PCI, wherein the pharmacologic therapy was given just prior to
planned PCI for STEMI with an intent to improve coronary patency before arrival in the catheterization
lab.
Since prasugrel and ticagrelor have not been clinically evaluated in fibrinolysis, the speaker was of the
opinion that they should be avoided in fibrinolysis. Also, angiography and PCI should be performed
in later half of time window of 3-24 hrs, post-fibrinolysis with streptokinase. Pharmaco-invasive
approach and rescue PCI, radial approach should be preferred.
The reality check in India from the CREATE registry showed that only 58.5% and 8% patients receive
thrombolysis and PCI, respectively. The SJISCR data on STEMI interventions showed that primary PCI
was used in 14%, rescue PCI in 8%, and pharmacoinvasive approach in 78%.
124
SJICSR Institute Protocol

Diagnosis of STEMI
Treated outside
(Thrombolysed and referred)
Direct / Self-referral
Successful lysis
Failed lysis
First option: Primary PCI
PCI (3-48 hrs)
Rescue PCI
*Thrombolysis if the patient/

relative is unwilling for quick
decision/consent.
The key issues affecting STEMI care in India were something to be addressed, the speaker said. The
rising incidence of ACS and STEMI component, limited availability and access to emergency services,
insufficient cath lab services in rural sector, inadequate public funding and health insurance in most
Indian states, heterogeneity in care, limited public education, and social cultural impediments were
a few of them.
He noted that as time to reperfusion is a critical determinant of outcome in STEMI, every patient of
STEMI should receive reperfusion therapy without delay, depending on local logistics. Also, restoration
of early patency of IRA and normal microvascular perfusion directly correlates with better outcomes.
The speaker also noted the need for government sponsored health schemes to include fibrin specific
lytics. Primary PCI, he said still remains the gold standard reperfusion strategy in STEMI, but if
inaccessible, pharmacoinvasive approach should be considered. To conclude, the speaker noted that
for STEMI in india, the best solution in rural and semi urban India was to initiate early thrombolytic
therapy (prehospital/in hospital) followed by early routine angiography within 3-24 hours.
125
A Strange Portrait of Therapeutic

Anticoagulation
Dr. P K Deb
MD, DM, FCSI, FESC, FICC
Past President, Cardiological Society of India
In the Dr. K K Datey memorial oration, Dr. P K Deb took the audience through a portrait of therapeutic
anticoagulation over the past years. As he began, he aptly stated that the optimum fluidity of blood
is a delicate mechanism of nature and it must be judiciously disturbed. Many anticoagulants were
already available, and still we continue to search for newer anticoagulants. The speaker questioned
the validity of ongoing search for newer anticoagulants.
The speaker noted that it has been over 100 years of heparin use, ever since it was isolated in 1916.
Over the years the use of heparin has also noted the pleotropic effects like platelet inhibition, antiinflammatory action, anti-proliferative action, anti-lipid action. The strength of UFH, the speaker
noted, was the early onset of action, easy availability of antidote, easy coagulation monitoring in
cathlab and outside, freedom to use in renal dysfunction, long clinical experience, affordability, and
it was these facts that make the speaker believe that UHF will continue to survive beyond 100 years.
There were however, limitations like poor therapeutic window, ineffective fixed dose, inconsistency
between different coagulometers, and intravenous administration.
LMWH had convenient administration, predictable response, no need for monitoring, and anti Xa
assay in special situations being the advantage. But it had a major hurdle to cross. Procedural ACT
target during PCI with UFH is somewhat defined, but with LMWH, no such algorithm is available
yet, noted the speaker. In ACS, most of the available data supported the use of enoxaparin among
LMWH in PCI. But, bleeding risk together with its long half life, absence of specific antidote, and
absence of anticoagulation monitoring made sure to exercise caution while using LMWH in coronary
interventions and cardiac surgery.
Next came direct thrombin inhibitors, which could act upon circulating and clot bound thrombin.
Studies like OASIS 2 and ACUITY have shown low incidence of bleeding. However, the results of
HEAT-PPCI trial said that systemic use of heparin would reduce drug costs substantially, along with
no increase in bleeding complications.
For long term anticoagulation, the speaker said that oral medication was the treatment of choice. This
could be through vitamin K antagonists (VKA) or novel anticoagulants (NOAC). The trials like RELY,
REMEDY, RECOVER II, REMODEL, RENOVET, REMOBILISE, ROCKET, EINSTEIN, ARISTOTLE, ENGAGE
AF etc add to the existing knowledge on the role of NOAC and their benefits. NOAC was described by
the speaker as the emerging star in anticoagulant therapy, but it still had a few hurdles like bleeding,
lack of coagulation monitoring and lack of antidotes, along with its set of contraindications.
To conclude, the speaker noted that despite the advent of NOACs, they have not been able to
displace UFH and VKA, and he was optimistic that even with passing time, that might remain the
same in the future too.
126
Takotsubo Cardiomyopathy
Dr. Pawan K Sharma
MD, FACC, FSCAI
Medical Director, Cath Lab St Marks Hospital,
Salt Lake City, UTAH, USA
Dr. Pawan Sharma spoke to the audience on Takotsubo cardiomyopathy, which was first described
in Japan in 1990, also known as apical ballooning syndrome, ampulla cardiomyopathy, stress
cardiomyopathy, or broken heart syndrome. This condition was caused by intense emotional or physical
stress leading to rapid, severe, but reversible cardiac dysfunction, which mimics typical anterior MI
with ECG and echo changes without obstructive CAD, and mildly elevated cardiac enzymes.
The clinical features include chest discomfort, dyspnea or both during severe emotional stress/
anxiety, with middle aged or elderly women most commonly affected. The cause was unclear but is
associated with exaggerated sympathetic stimulation.
In the ECG, diffuse symmetric T wave inversion is most common. Precordial ST elevation, pronounced
QT prolongation, loss of R wave progression, prolonged PR interval, and pathologic Q waves in leads
V1, V2, V3 and aVL are commonly observed anomalies. In patients with TC and ST elevation, 4
phases are noted. Phase 1 is characterized by ST elevation during acute onset, phase 2 by T inversion
on days 1 to 3, phase 3 by transient improvement in T inversion on days 2 to 6, and phase 4 by giant
T wave inversion and QT prolongation until recovery.
Lab findings include mildly elevated troponins and CK-MB. In the echo, transient, regional akinesis
or dyskinesis of the entire LV apex and RV apex could be noted. Reduced LVEF and systemic
dysfunctioning, apical ballooning, and restoration of normal global and regional myocardial function
with serial examination with time are noted. Sestamibi myocardial perfusion gated SPECT shows
infarction of the apex and dyskinesis of apex, which normalizes after about 1 month.
The four diagnostic criteria proposed for this cardiomyopathy are:
Transient dyskinesis or akinesis of the mid and distal LV with wall motion abnormality beyond a
single major coronary artery
Non-obstructive CAD by cath within 24 hrs of symptom onset
New ECG change
Absence of recent significant head trauma, ICH, pheochromocytoma, HOCM, myocarditis.
Common complications include CHF, rarely LV wall rupture, LV thrombus, LVOT obstruction with
SAM, MR, ventricular arrhythmias and death.
Talking about the management, the speaker suggested that it be initially treated as acute MI with
urgent cath, and also with aspirin, LMWH, ACEI, beta blockers, and diuretics. Being benign, it
had less than 1% in-hospital mortality, and in all cases, LV function returns to normal within few
weeks. However, rare LV rupture causing sudden death in upto 3% of patients with Takotsubo
cardiomyopathy was also observed.
127
A Journey of 82 years of Thrombolysis in STEMI:

Challenges of STEMI Care in India and the Real World
Dr. H K Chopra
MBBS, MD
President, CSI
Taking the audience through the many years of thrombolysis in STEMI, Dr. Chopra laid bare the
present statistics of the CAD menace in India. Irrespective of whatever treatment is provided, he
reinforced the fact that ultimately it is the time to reperfusion that matters. In simple terms, time is
myocardium. Rapid diagnosis with early reperfusion was the pillar of reperfusion.
The speaker discussed the history of thrombolysis over the years, with historical milestones like IV STK
in evolving AMI, first time in 1984 and IV STK in AMI 6-36m FU in 1990. The stalwarts and pioneers
in this field were all credited and acknowledged with their contribution to this field.
Data that provided insight into the therapy with agents like STK, ATP and RTP in STEMI were shared
including GISSI trial, ISAM trial, GISSI 2 , GUSTO trial I, INJECT, RAPID 1 and RAPID 2, COBALT trial,
GUSTO III. WEST and CAPTIM were 2 trials comparing TLT vs PCI. Also, TNK was preferred over RTP
in STEMI as more data suggested the same as well as guidelines like ACCP Chest recommended TNK
as class IA recommendation and RTP as Class IB.
In the Italian registry, with a size of 27000, it preferred to use TNK compared to PCI, as it was
immediate, easily available everywhere and also was a real opportunity for timely reperfusion. The
efficacy was also enhanced by an adjunctive. Similarly the data on the TNK use in STEMI was shared
on the Indian population too. This was supported even in the French Fast registry, wherein again TNK
was preferred over PPCI in STEMI. As per the STREAM trial, TNK followed by PCI in 24 hrs was the
strongly recommended protocol. The fact that only 4% of transferred patients receive PPCI within 90
min from first medical contact reinforces the use of TNK over PPCI.
The speaker observed that TLT with TNK and RTP was the most promising therapy in golden hour.
CST with TNK was highly significant in first 3 hours of STEMI (robust evidence). Pre-hospital TLT was
the need of the hour, with reduced overall mortality rate and minor bleeding being minimal and
easily manageable. TLT + PCI (3 to 24 h) was the most practical as well as the only way, the speaker
said.
To conclude, the speaker noted that health of millions is at stake with rising menace of STEMI in
India, and early TNK/RTP administration in STEMI was the need of the hour. TNK/RTP being very safe
and effective method of emergency thrombolysis, TNK/RTP followed by PCI was the recommended
protocol (if PCI was not feasible within 90 min). The speaker called all the doctors to act locally, and
impact globally with the use of TNK/RTP.
128
Stents or CABG in 2016: Practice and Politics

Dr. David P Taggart
MD, PhD, FRCS, FESC
Professor of Cardiovascular Surgery,
University of Oxford
Dr. Taggart addressed the aspect whether PCI or CABG was the way to go in 2016. Raising a question
on whether the relative efficacy results depicted by randomized controlled trials were to be taken
at face value, he said that with the exception of the SYNTAX trial, 19 other trials of PCI vs CABG
enrolled <10% of the eligible population i.e. those with low severity CAD, and the duration of follow
up was 5 years, which can be considered only an interim analysis. Even in the arms with optimal
medical therapy, patients received substantially inferior guideline medical therapy; this could have
increased mortality and MACE. A meta-analysis of CABG vs DES showed favourable results in CABG
group over the DES. Another study comparing DES with CABG in diabetics also showed superiority
of CABG with benefits of surgery increasing with time.
The speaker stated that CABG has more survival benefit due to three reasons. Firstly, since atheroma
is mainly located in proximal coronary arteries, the bypass graft to mid coronary vessel renders the
complexity of proximal culprit lesion irrelevant and also offers prophylaxis against future culprit
lesions. Secondly, IMA elutes NO into coronary circulation thus, reducing risk of further disease.
Thirdly, PCI had incomplete revascularisation. As a result, the speaker stated that PCI will never match
the results of CABG for LM/MVD.
Dr. Taggart shared how more PCI was done than what the guidelines stated, with undue importance
placed on PCI even though guidelines recommended CABG in those cases. As per the 2014 ESC/
EACTS guidelines, CABG was superior even though most grafts were veins and despite inferior
OMT. To summarise, the speaker called on for a more prominent role of heart team to ensure that
treatment is provided according to guidelines.
Speaking next on the facts of arterial grafts in 2015, the speaker noted that more vein grafts were
done (80%); artery grafts were more superior to the vein grafts. The results were better with BIMA as
observed with the systematic review comparing BIMA vs SIMA, where BIMA had better survival rates.
With composite arterial grafts based on in situ BIMA, OPCABG eliminated any aortic manipulation
(thereby minimizing the risk of stroke). This would be particularly beneficial in diseased aorta and
elderly. At eight years, radial artery graft had marked superiority over SVG in patency and functional
patency. The use of VEST external stent also gave better results with SVG, with lesser complications
and better patency. With stent, there was smaller smoother intima, smaller media and greater lumen
regularity. The stent also resulted in less turbulent flow.
To summarise, the speaker noted that there was significant underuse of arterial grafts. There was
strong evidence that with BIMA, there was superior angiographic patency to vein grafts and superior
long term survival and less risk of stroke but increased sternal wound reconstruction. With RA, there
was evidence that superior angiographic patency to vein grafts, could improve long term survival
vs SVG, and may be second artery of choice in obese IDDM, but it had inferior patency if used to
coronary with stenosis <70% and was more prone to spasm, leading to ponder over the role of
external stenting of SVG.
129
Future Improvements in the Interventional

Treatment of Patients with STEMI
MD
Cardiovascular Institute, Ferrara, Italy
Speaking on the open issues in STEMI, Dr. Biscaglia questioned whether there could be a shift
from transfemoral access to a transradial access. There was overwhelming evidence in the
form of RIFLE-STEACS study, STEMI-RADIAL trial and the RIVAL trial. Yet, radial access was still
underutilized, as per statistics. The recent MATRIX results reinforced previous evidences, the
speaker noted. The results were driven by a 33% reduction in major bleeding in the radial
access group. This in turn drove a mortality benefit, underlining the benefits of radial access
over femoral. The question of feasibility in clinical practice was another factor to be addressed
in this regard, the speaker observed. He noted that transradial access was feasible and safe
independently from Allen test results. It was feasible and safe in complex procedure needing 7F
sheath. Radial access was safer than the femoral one in STEMI patients, and it was feasible and
safe even in complex settings.
The second point raised by the speaker was on the evolution of devices in interventional
treatment of STEMI patients. Sharing an NEJM article, he noted that with stenting, a 2 fold
reduction in TVR at 6 ms was noted, with larger coronary lumen and lower coronary dissections.
With BMS + abciximab, there was a three-fold TVR reduction and significant survival benefit.
The second-generation DES, he noted are the current gold standard treatment in STEMI patients.
With BVS, DOCE were comparable at 1y with second-generation DES, but with a higher risk of
strut thickness, thrombogenecity and malapposition. Though there are few trials with BVS, the
mechanistic endpoint and low number of patients did not allow drawing any clinical conclusion.
Studies/registries to assess BVS safety in STEMI patients with contemporary implantation
technique was required to take this forward in future.
For proper BVS implantation, he noted 5 must dos. These were to prepare the lesion, properly
size the vessel, pay attention to expansion limits, post dilate with a non-compliant balloon, and
to prescribe adequate length of dual antiplatelet regimen.
To conclude, he stated that BVS was an attractive technology especially in STEMI setting, but
adequately powered studies on hard endpoints were needed to confirm BVS safety in STEMI
patients.
130
Intervention: How and to What Extent is

Technology Helping Us?
MD
Cardiovascular Institute, Ferrara, Italy
Functional flow reserve (FFR) , near infrared spectroscopy (NIRS), and bioresorbaable vascular scaffold
(BVS) and their impact in interventional management was discussed.
Talking on the usefulness of FFR in identifying patients in need of stenting, the speaker shared the
results of DEFER study which showed that oculostenotic reflex is not enough to identify ischemic
lesions. FAME I and II were 2 landmark studies which showed that the outcome after FFR-guided
PCI was superior to angio-guided PCI, and there was a positive FFR benefit from PCI as compared
to OMT. The five-year follow-up of FAME was done and it was noted that the FFR benefit was
consistent through the years. But this still had limitations, like that fact that it was not powered for
five-year follow up, 14% patients were lost to follow-up, first generation DES was used, and also it
was unknown whether events between 2 and 5 years were related to index stenosis. The PLATFORM
trial also showed that non-invasive FFR was safe. But, the author noted that FFR does not solve all
problems. Patients with negative FFR could still have AMI.
To address the limitation of FFR, the use of NIRS was proposed. The vulnerable/eroded plaque theories
were based on increased endothelial apoptosis and lipid core, and NIRS could identify chemical
composition of the plaque. For lipids, NIRS correlated with autopsy, as the speaker noted. STEMI
patients showed high lipid core burden index (LCBI) and the same could be used to prospectively
identify patients at risk in non-culprit arteries. The question here would be if we were ready for
routine use of NIRS alone or in combination with other tools, to which the speaker was of the
opinion that the future was in the use of multimodality imaging.
The third option, BVS was an attractive option, the speaker said. The rationale of BVS was in the
regression of plaque media, late lumen enlargement and remodelling, shielding and recapping
of plaque, restoration of coronary vasomotion and endothelial function, no chronic source of
inflammation and future possibility for CABG.
However, the speaker noted that even BVS was not concern-free, with the problem of overlapping in
complex lesions being present. The five prerequisites for proper BVS implantation were to prepare the
lesion, properly size the vessel, pay attention to expansion limits, post-dilate with a non-compliant
balloon, and to prescribe adequate length of dual antiplatelet regimen. Complex lesions could be
treated with BVS only with a careful implantation technique, or else more events would be noted.
To conclude, the speaker noted that we were moving from the angiographic evaluation of coronary
stenosis to a multimodal evaluation of coronary plaques (FFR, OCT, IVUS/NIRS). Disappearing scaffold
was a very attractive technology, but at present its safety was validated only in simple patients with
simple lesions, and we have to be careful before extrapolating the same over the population.
131
Contemporary Perspectives on ST Segment Elevation Acute

Coronary Syndromes The Good, The Bad and The Ugly.
Dr. Gautam Kumar
MD, FACC
Assistant Professor of Medicine, Division of Cardiology
Emory University, Atlanta
The focus of the talk was on 3 points, the STEMI system of care, thrombus aspiration, and the
hemodynamic support and non-culprit lesions.
Stating projections that by 2020, 60% of the global CAD burden would be in India, the speaker
noted that it took a median of 300 min to get to hospital, with a 30 day mortality of 9% in India.
Time was the most important factor in the management of AMI, and as was well known, time was
myocardium. Important metrics like the EMS time, door-to-ECG, Door in-Door out, first medical
contact to device all had to be improved in the indian setting if we had to reduce the mortality.
Sharing his vision of the ideal STEMI system, he noted that it could be possible only with excellent
integration of the public, system, EMS, and enhanced cooperation between STEMI referring hospitals,
and receiving hospitals along with support from health agencies and policymakers.
On manual thrombus aspiration, as noted in studies like INFUSE-AMI, TASTE, and TOTAL, aspiration
vs PCI alone showed no difference in mortality. But TAPAS and 1-year study showed that the mortality
was reduced with aspiration. Mechanical thrombus aspiration also had mixed results with AIMI and
SMART PCI having no difference, while JETSTENT and MUSTEL had improved STR and MACE.
The speaker concluded with a discussion on temporary mechanical support with IABP, Impella 2.5,
CP and 5.0, and Tandemheart. Data on non-cultprit lesions from PRAMI, DANAMI3-PRIMULTI and
CvLPRIT were shared. In PRAMI, decreased death, MI and angina freedom was noted. In DANAMI3PRIMULTI, decresed primary endpoint but driven by ischemia-driven revascularization was observed
while with CvLPRIT, decreased MACE and trend for components were noted.
132
Advanced Imaging in the Cath Lab:

New Ideas and Applications
Dr. Y Chandrashekhar
MD
Professor of Medicine
University of Minnesota Medical School, Minneapolis
Speaking on the multiple advancements in the imaging modalities in cath lab, the speaker noted
how the number of FFR procedures had risen steadily along with FFR guided PCI in the US, while the
number of PCI had fallen between 2008 and 2012.
Comparing the various techniques, the speaker noted that when it comes to imaging, though OCT
was more complex to perform than IVUS, the trade off was much better with OCT, making it the
king of the hill. Based on measures of plaque burden in the proximal edge as well as the distal edge,
OCT was found to be superior to IVUS.
Before selecting any imaging, it is important to know its usefulness in that context. For example,
necrotic cores could cause MI but would not be picked up by angiogram or FFR or a stress test. Lipid
cores with no TCFA would be picked up by NIR, but not by FFR. Fibrous cap could be picked up by
FFR. Necrotic core is an important indicator because it is more proportional to ischemia rather than
stenosis severity.
Imaging could also be used to assess reversal of a condition or improvement of a condition after a
therapy has been initiated. The thickness of fibrous cap could be assessed before and after therapy
or intervention to observe improvement. With the help of imaging, doctors could triage high risk
patients for prophylactic intervention. High amount of lipid core at the culprit site is a strong predictor
of MI, and intervention could be planned accordingly. It could also be used to predict outcomes of
intervention. Imaging of neo intima is another important tool that can be used by the doctors to
reduce complications.
In conclusion, Dr. Chandrashekar noted that although imaging may be used effectively in specific
subsets of patients, more evidence is welcomed.
133
NSTE-ACS:
Conservative Treatment for Whom and When?
Dr. Deepak Kumar Gupta
MBBS, DM
Cardiologist
Apollo Hospital, Ranchi
In the light of growing body of evidence, the controversy of conservative versus invasive treatment
in unstable angina and NSTEMI (NSTE-ACS) is being clarified. Dr. Gupta states that risk stratification
in NSTE-ACS is very important in the decision-making of an appropriate management protocol. The
low risk group necessitates ischemia-guided therapy (TIMI 0 or 1, GRACE <109). Patients in higher
risk groups require early invasive therapy; recommendations are as follows:
1.
Immediate (within 2 hours): Patients with refractory or recurrent angina with initial treatment,
signs/symptoms of heart failure, new/worsening mitral regurgitation, hemodynamic instability,
sustained ventricular tachycardia, or ventricular fibrillation
2.
Early (within 24 hours): None of the immediate characteristics but new ST-segment depression,
a GRACE risk score >140, or temporal change in troponin
3.
Delayed invasive: None of the immediate or early characteristics but renal insufficiency, left
ventricular ejection fraction (LVEF) < 40%, early post-infarct angina, history of percutaneous
coronary intervention (PCI) within the past 6 months, prior coronary artery bypass surgery
(CABG), GRACE risk score of 109-140, or TIMI score of 2 or higher.
Conservative treatment after coronary angioplasty is indicated in the presence of normal angiography,
including conditions such as Tako-Tsubo cardiomyopathy, coronary spasm and coronary microvascular
disease. It has been observed that about 9.6% of NSTEMI patients, including non-diabetic and
female patientshave non-obstructive CAD. A meta-analysis of 8 trials (3075 women and 7075 men)
found invasive treatment to have comparable benefit in men and high-risk women for reducing
the composite end point of death, MI, or rehospitalization with ACS. In contrast, data from this
meta-analysis provided evidence supporting the new guideline recommendation for a conservative
strategy in low-risk women. Additionally, invasive procedure may be withheld in the elderly, patients
with comorbidities like dementia, severe chronic renal insufficiency, cancer patients, and in patients
with a high risk of bleeding. In addition, CAD not amenable to revascularization may necessitate
conservative treatment.
134
Hypertension and Diabetes Mellitus:

Partners in Crime
Dr. Charan Lanjewar
MBBS, MD, DM (Cardiology)
Consultant- Interventional Cardiology
Global Hospital, Mumbai
Hypertension and diabetes mellitus synchronously elevate the risk of cardiovascular diseases. In
addition, both these risk factors predispose the occurrence of the each other. Hypertension is twice
as common in diabetes mellitus patients as compared to the general population. New-onset diabetes
is 2.5 times more common in the hypertensive population as compared to the non-hypertensive
population. About 258 million people have co-existing hypertension and diabetes mellitus; comorbid
presence increases the cardiovascular risk by three-fold.
Dr. Lanjewar noted a substantial overlap in hypertension and diabetes and mentioned the following
etiological factors: metabolic syndrome; overactive RAAS; nephropathy; recurrent pyelonephritis
leading to renal scarring; endocrine disturbances, including Cushings syndrome, pheochromocytoma,
and others; and certain drugs such as oral contraceptive pills, and steroids.
Furthermore, he provided guidelines for the management of hypertension in patients with
comorbid diabetes mellitus. Effective management necessitates both life style modification and
pharmacotherapy. Current recommendations favor a systolic blood pressure goal of < 140 mmHg.
Lower systolic targets, such as < 130 mmHg, may be appropriate for certain individuals, such as
younger patients. Diabetic patients with blood pressure >120/80 mmHg should be advised lifestyle
changes.
Lifestyle modifications alone can reduce blood pressure by 20-40 mmHg. HOPE, EUROPA, PEACE
and IMAGINE trials have confirmed the vascular protection effects of ACE-I/ARBs in preventing death,
stroke and myocardial infarction, heart failure, revascularization, development of diabetes, diabetic
microvascular complications and nephropathy. RAAS inhibitors are considered as initial therapy of
choice; ACE-I and thiazide diuretics represent first line therapy. ACCOMPLISH trial showed superiority
of amlodipine over hydrochlorothiazide when combined with an ACE-I. Though theoretically
attractive, combination of ACE-I and ARB is of limited utility.
In addition, diabetic patients are at an increased risk of developing atherosclerosis and worse
clinical outcomes following revascularization procedures. Primary prophylaxis with aspirin is not
recommended. Data to guide decision making are limited regarding the usefulness of CABG and PCI
using DES and newer antiplatelet agents in diabetic patients with multivessel coronary artery disease.
Although CABG remains the standard of care for most diabetic patients with multivessel CAD, the
paradigm may begin to shift.
135
Intervention in Aortaarteritis:
Largest Experience in India
Dr. Monotosh Panja
MD, DM, FACC, FICP, FCSI
Senior Interventional Cardiologist
BM Birla Heart and Research Center
Takayasu arteritis is a nonspecific inflammatory disease of unknown origin that leads to various types
of aortoarterial stenosis/occlusion or dilatation. Its clinical manifestations are varied and related to
the vessel that presents the stenotic or occlusive lesions, such as the aortic arch (pulseless disease),
descending thoracic or abdominal aorta (atypical coarctation), renal arteries, coronary arteries,
and pulmonary arteries. Aortic aneurysmhttp://circ.ahajournals.org/content/118/25/2738.full and
aortic valve regurgitation with ascending aortic dilatation may also develop in some instances.
While pharmacological management is suitable for some patients, especially those presenting with
early stages of the disease, surgical treatment is essential in others. Dr. Monotosh Panja explained
his experience with angioplasty in the treatment of aortaarteritis, a summary of which has been
presented below.
A total of 274 angioplasties were performed as an intervention in aortaarteritis. Carotid angioplasty
was attempted in 36 patients (40 lesions) and the success rate was found to be 70%. Of the 36
patients, 1 had major embolic event, while 3 patients had transient ischemic attack. Angiographic
restenosis of the carotid artery was seen in 7 cases (17.5%). Subclavian angioplasty was attempted
in 58 patients involving 64 lesions. Stenting was done in 14 cases. Aortic balloon angioplasty was
performed in 52 patients involving 58 lesions with stenting in 12 lesions. Success rate was 58%.
Restenosis rate was found to be: 25% (thoracic aorta), and 38% (abdominal aorta). Renal angioplasty
of 120 lesions with stenting in 96 lesions was done. Restenosis rate was found to be 18%. PTCA with
cutting balloon followed by DES (LMCA and Proximal LAD 10 cases, RCA 5 cases) was performed;
restenosis occurred in 3 cases over a period of 5 years.
Takayasus arteritis is associated with significant negative impact on mortality and morbidity. Medical
therapy does not represent an efficacious option in this context; this is particularly true in childhood
onset disease. Based on the above study results, Dr. Panja states that early angioplasty of the
stenosed vessel may be associated with symptomatic improvement, survival benefits, and quality of
life improvements.
136
Biomarkers in ACS
Dr. Milan Chag
MD, DM, DNB
Sterling Hospitals, Ahmedabad
Dr. Milan discussed the various biomarkers useful in the diagnosis of myocardial infarction (MI). He
pointed hs-cardiac troponins to be important biomarkers in this context. A dynamic elevation of
cardiac troponin above the 99th percentile in the normal distribution curve indicates MI. In patients
with MI, hs-troponin rises rapidly (usually within 1 h) and remains elevated for several days. Another
useful biomarker is the copeptin. Rapid rule-in and rule-out algorithms based on 0h/1h (Figure 1) and
0h/3h (Figure 2) testing of hs-cardiac troponin are useful in the early diagnosis and in the decision
making of the need for emergency room admission.
Acute Chest Pain
Suspected NSTEMI
hs-cTn <ULN
Pain >6h
hs-cTn >ULN
Pain <6h
Painfree,
GRACE <140,
differential diagnoses
excluded
Discharge/Stress
testing
changea
(I value >ULN)
+ clinical presentation
hs-cTn
no change
Highly abnormal hs-cTn
Re-test hs-cTn: 3h
0h <A ng/l
or
0h <B ng/l and
0-lh <C ng/l
Other
0h D ng/l
or
0-lh E ng/l
Rule-out
Observe
Rule-in
hs-cTn
no change
Work-up
differential
diagnoses
Invasive
management
GRACE=Global Registry of Acute Coronary Events score; hs-cTn=high sensitivity cardiac troponin;
ULN=upper limit of normal, 99th percentile of healthy controls. a change, dependent on assay.
Highly abnormal hsTn defines values beyond 5-fold the upper limit of normal.
Figure 1: 0h/3h algorithm for decision

making in MI.
hs-cTnT (Elecsys)
12
52
hs-cTnT (Architect)
52
hs-cTnT (Dimension
Vista)
0.5
107
19
Figure 2: 0h/1h algorithm for decision

making in MI.
Furthermore, copeptin aids in the rapid rule-out; low levels (<10 pmol/L) signals normalcy. TIMI risk
score and ECG may be useful too.
137
Percutaneous Intervention: For Whom

and When?
Dr. Sanjay Chugh
MD, DM, FACC, MRCP, FSCAI, FIMSA, FCSI
Arternis Health Institute, Gurgoan
In acute coronary syndrome patients, early percutaneous coronary intervention (PCI) should be done in
all except if they fall in the low risk category. Dr. Sanjay Chugh noted the usefulness of risk stratification
with TIMI and GRACE scores in this context. He presented the following recommendations:
1. Low risk patients are characterized by TIMI score 0 to 1, GRACE score <109, T-wave inversion, no
ST changes, negative troponin testing, absence of ongoing pain. This group of patients requires
stress test, ischemia guided coronary angiogram, and PCI.
2. Patients with GRACE score 109-140, LVEF <0.4, prior CABG/PCI (<6m), post-infarction angina,
raised serum creatinine are considered to be at intermediate risk. PCI should be performed after
2-3 days of stabilization.
3. Patients with GRACE score>140, ST depression >0.5mm, raised cardiac enzymes/ troponins
are at high risk. Coronary angiogram and revascularization should be performed within 24 h;
intervention in the first 2h is favorable as seen in STEMI.
4. Patients with ongoing or recurrent angina at rest, hemodynamic compromise, heart failure,
hypotension, sustained ventricular tachycardia or ventricular fibrillation, cardiac arrest, ischemic
mitral regurgitation are considered to be at very high risk and must be taken up immediately,
within 2 hours.
According to the conclusion of a recent meta-analysis of four randomized trials, transradial PCI as
compared to transfemoral PCI is associated with less bleeding and increased survival benefit. The
presenter pointed to a useful training program conducted by the Wellness and Radial Intervention
Society (www.waris.co.in) for training cardiologists in transradial PCI. Through fellowship programs
and conferences, the society catalyzes the learning curve of cardiologists in the context of transradial
intervention.
138
Pre-Hospital Thrombolysis: Its Scope in India

Dr. Sanjay Tyagi
MBBS, MD, DM
Director and Professor, Department of Cardiology,
Maulana Azad Medical College, New Delhi
Time to treatment is of critical importance in acute STEMI; with 30-minute delay in treatment, the
1-year mortality risk is increased by 7.5%. Prehospital thrombolysis represents a potentially important
reperfusion option in eligible STEMI candidates. The extent of penetration of primary PCI in Indian
settings is inadequate with only nearly 5% of patients undergoing PCI. The challenges include
delayed recognition of symptoms, lack of awareness, lower socioeconomic conditions, infrastructural
inadequacies, lack of ambulance services, and lack of widespread primary PCI programs. Therefore,
there is an imperative need to establish STEMI care systems in India.
Dr. Sanjay Tyagi elucidated the following factors to be essential in setting up a STEMI care system:
1. Increased public awareness to aid early recognition of symptoms of AMI
2. A dedicated 24h helpline and a cardiac ambulance facility equipped with defibrillator are essential.
Additionally, training paramedics to recognize symptoms and to manage early complications of
STEMI (pain, VT/VF and bradycardiac arrhythmias) is important.
3. 12 lead ECG for diagnosis
4. Facility for tele-transfer of ECG
5. IV thrombolytics (tenecteplase or reteplase)
6. Equipment for rhythm monitoring, defibrillator and advanced cardiovascular life support during
transportation
7. Mechanism to relay information to the hospital
8. Appropriate triaging services
9. Decision to pharmacoinvasive PCI or post-thrombolysis PCI
In conclusion, the presenter emphasized the importance of establishing a healthcare model that
delivers prehospital thrombolysis in India settings. Inadequate access to primary PCI underscores the
importance of prehospital thrombolysis. A good STEMI care program should be adapted to include
both rural and urban areas; longer transportation times due to remoteness of the location and traffic
congestion, respectively, need to be taken into account.
139
Ischemia and Viability Driven Revascularization:

Is It the Answer?
Dr. Praveen Chandra
MD, DM, FACC, FESC, FSCAI, FAPSIC
Chairman, Division of Interventional Cardiology
Medanta, The Medicity, Gurgaon
Dr. Praveen Chandra in his talk, raised some valid points on the use of viability driven revascularization
in ischemia. Drawing on the results of the COURAGE trial, he noted that this trial had a very fast
impact with the number of stenting procedures coming down quite fast.
He suggested though stenting was a good tool, decision making had to be excellent and doctors
had to use the tools available which include symptoms, clinical presentation, biomarkers and
angiography to make sound judgements. There were newer tools for decision making like FFR, IVUS,
PET CT, SPECT, EURO score, STS score for CABG, SYNTAX score for PTCA, and also the very important
dynamic of patient preference, which might be dependent on socioeconomic status and availability
of healthcare facility.
Speaking on the dilemma of many doctors, on whether to use CABG or stenting, he shared results of
the ARTS study and SYNTAX study. In the ARTS study, in multivessel disease, it was noted that CABG
and stenting were equally effective treatments to prevent death and AMI, but there were more
repeated revascularization and angina in stent group. This was reiterated even in the SYNTAX study.
The speaker suggested that in patients with similar degree of anatomic disease, the most important
predictor of outcome was the presence and extent of inducible ischemia.
Another important trial shared by the speaker was the FAME study, wherein it was concluded that
routine measurement of FFR during DES stenting in patients with multivessel disease was superior
to current angiography guided treatment, which improved the outcome of PCI significantly. Thus,
instead of treating all patients with multivessel disease alike, the speaker recommended a tailored
approach of splitting the population into two groups depending on the functional extent of disease
and then guiding stenting based on FFR, which was an easy and accurate index to distinguish nonculprit lesions from the culprit lesions.
By classifying patients with otherwise similar characteristics into 2 groups, according to functional
extent of disease (number of culprit lesions), and then using PCI and CABG accordingly, provided an
equally effective treatment, both in terms of adverse events, repeated revascularization and quality
of life.
140
Patient with 3 vessel disease
What is the periprocedural risk eg. Euroscore?

What is the lession complexity, e.g. Syntax score?/
What is the lesion functionality (FFR)
Suitable for
CABG
High risk for CABG

PCI
Most complex lesion

first? -e.g. CTO
Failure
Outcome
Stable
Success
What is the
patients clinical
status
Contrast volume?
Renal Status?
Unstable
PCI of culprit lesion
Evaluation of
other lesions
Acceptable
Surgery
Complete revascularization
Staged procedure
Sharing few case presentations, the speaker reinforced his opinion that angiography need not be the
decision maker. He spoke of the importance of FFR for physiology and PET scan to look at viability
before planning revascularization. Another important tool was the use of AUC score, where it was
appropriate to revascularise only if the scores were 7 to 9.The AUC scores use clinical presentation,
severity of angina, extent of ischemia, extent of medical therapy, and extent of anatomic disease to
arrive at the score.
To conclude, the speaker again reiterated the importance of acknowledging that angiography alone
need not be the tool to decide on revascularization, and also the fact that all occlusions need not be
opened all the time, and also the need to use AUC, PET scan and the heart team approach judiciously.
141
Antiplatelet Therapy in STEMI

Dr. Debdatta Bhattacharyya
MBBS, MD
Consultant - Cardiology
Rabindranath Tagore International Institute of Cardiac Sciences, Mukundapur
It is a widespread practice to treat post-PCI patients with anticoagulation therapy. However, the
speaker noted that studies showed that the chances of MI and of requiring repeated interventions
were higher with anticoagulation therapy. When compared with antiplatelet therapy, it was observed
that there was 82% lower risk of MI and 78% less chances of requiring repeated interventions with
antiplatelet therapy compared to anticoagulation.
These results were compounded further with the STARS trial, wherein the difference between
ASA+ticlopidine group was superior to the ASA+Coumadin group (p=<0.01) in reducing primary
endpoint event. However, ticlopidine use was limited due to many limitations. Compared to ticlopidine,
clopidogrel was a much more accepted molecule, with many trials confirming the additive effect
of clopidogrel with ASA in STEMI. However, the speaker noted that clopidogrel was limited by its
variability in the response. This limitation was overcome by prasugrel, which had a more rapid, and
consistent effect compared to clopidogrel. The two molecules were compared in the TRITON-TIMI
38: STEMI PCI trial. Prasugrel was superior to clopidogrel and also it was efficacious in diabetics. The
results from an Indian trial on patients undergoing PCI observed that both the drugs were found to
be well tolerated and had comparable safety profile.
The speaker noted that the early discontinuation of DAPT was identified as a risk factor for late stent
thrombosis due to delayed arterial healing in patients with a DES. However, prolonged DAPT was also
associated with higher severe bleeding rates compared to aspirin therapy alone. The guidelines were
to use DAPT consisting of aspirin + P2Y12 receptor antagonist after DES implantation for atleast 12
months by the ACC/AHA guidelines and for 6 to 12 months by European guidelines. Similarly, PLATO
STEMI study showed that ticagrelor was superior to clopidogrel, with similar bleeding episodes, while
the DISPERSE-2 study showed no significant difference in bleeding events at 4 and 12 weeks. The
guidelines to the use of antiplatelet therapy to support PCI or fibrinolysis were provided by the ACC/
AHA guidelines and the ESC guidelines.
Addressing whether there was a role for IV
antiplatelet inhibitors, the speaker noted that it
could be used in high risk patients with elevated
troponins, and high thrombus burden during PCI,
but there was no role in routine use, in high risk
patients not preloaded with P2Y12inhibitors and in
high risk patients with ongoing ischemia in addition
to DAPT. The speaker concluded with a graphical
representation of his preference of antiplatelet
drugs in different scenario, as follows.
142
Aspirin +
Prasugrel
PCI
or
Aspirin +
Ticagrelor
STEMI
Fibrinolysis
Aspirin +
Clopidogrel
Risk Stratification After STEMI

Dr. K Jayanthi
MBBS, MD, DNB
Senior Consultant - Interventional Cardiology
SIMS Hospitals, Chennai
Though all STEMI patients were at high risk, within the STEMI population, there is a spectrum of
higher and lower risk patients, noted the speaker, and stratification was very essential to provide the
best possible care with the most favourable prognosis.
There are two time-points for STEMi risk stratification: early (within 4-6 hours after presentation)
and late (during hospital course/prior to discharge). The risk factors could be before MI, at the time
of MI and in ECG findings. The risk factors before MI include number of CHD risk factors, CKD,
PVD, previous MI/CABG/stroke, while the factors at the time of MI include heart failure, Killip class,
hypotension, and tachycardia. ECG findings associated with worse prognosis are anterior compared
to inferior infarcts, the presence of Q waves, a greater number of leads showing ST elevation, lack of
ST segment resolution after fibrinolysis at 90-180 mins, AF and high grade ventricular arrhythmias.
Other risk factors were biomarkers like Hs Trop T, NT Pro BNP and also potassium, anaemia, elevated
WBC count, plasma aldosterone. Abnormal myocardial perfusion and age of aspirated thrombus also
have a say in the prognosis.
Different risk assessment tools are available. TIMI score based on data from 15000 patients with STEMI
eligible for fibrinolytic therapy, which was an arithmetic sum of 8 independent variables predicting
mortality was one of them. The GRACE risk model was based on the GRACE registry. A total GRACE
score of 100 meant low risk, 101-170 was medium risk, and 171 was high risk patients. Other
risk assessment tools were PAMI risk score, TIMI risk index (TRI), and Zwolle primary PCI index and
CADILLAC risk score.
Late risk stratification was another approach performed 3-7 days after MI to consider early discharge
for low risk patients, and to assess long term prognosis. The main components of this were
measurement of LVEF, stress testing and methods used for risk stratification of arrhythmic death.
CMR (cardiac magnetic resonance) was another tool with growing evidence of its additive value in
identifying patients at risk for SCD.
However, there were limitations for the use of LVEF as sole risk stratifier for SCD, noted the speaker.
The majority of SCD events occurred in MI survivors with LVEF>40%, and even in high risk group
with very low LVEF, only few patients benefitted from ICD. Reduced post MI EF was a risk for both
sudden as well as non-sudden death. Other non-invasive risk factors were MADIT II risk score model,
ventricular ectopy, QRS duration, SAECG, Microvolt T-wave alternans, and markers of autonomic
tone- BRS and HRV. But, none of the noninvasive risk factors demonstrated efficacy, had limited
sensitivity and also low specificity. They had high negative and low positive predictive values, with
no uniformity in the trial results. The speaker noted that any score developed should have details
on potential harm from PCI or thrombolysis, and the risk scores should help physician take decision
regarding particular mode of treatment with regard to treatment efficacy and, quality of life. More
importantly, it should be applicable to real world population.
143
Hypertension Targets: Should They Differ?

Dr. P Ramachandran
MD, DM
Cardiologist
Billroth Hospitals, Chennai
Acknowledging that high blood pressure is one of the most common conditions among middle aged
and older adults, and is a leading risk factor for stroke, heart disease, CKD and other conditions, the
speaker raised the point that there were numerous phenotypes in hypertension, and blood pressure
targets should differ in each of them.
Blood pressure control in human beings is controlled by many factors viz, brain, behaviour pattern,
extent of sympathetic system, RAAS system activation status, consumption pattern of salt, salted
snacks and pickles, alcohol, and compliance and adherence to BP lowering drugs. Blood Pressure
variability was also another important variable in hypertension. Noting this, the speaker also stated
that the hypertension treatment differed on many factors like baseline SBP and DBP, established
CVD-MI, CVA, CKD and aortic diseases, presence of diabetes, and extent of renal dysfunction.
The speaker stated that BP targets differed with respect to age pattern, diabetes, renal failure, CVA,
aortic dissection, mental status, and sodium levels. Reaching these BP targets could be achieved by
non drugs too, as was observed in USA and Europe when national level salt restriction had resulted in
less strokes and MI, while in Portugal, reducing salt from 20gm to 10 gm in breads resulted in 2500
less strokes in the year 2010.
Addressing the goals in the management of hypertension, he noted that it was essential to treat
more hypertensive patients, and then to reach the target of BP. This was to be followed up by
sustaining the target and finally, to down titrate the drug doses if the SBP fell <120 mm Hg in one or
more visits, as the BP lowering had to be gradual. The Sprint trial involving 9050 patients concluded
that 120 mm Hg was better than 140 mm Hg, but excluded diabetic and CKD patients. It also stated
that any BP lowering drug was better than no drug at all.
Speaking on the supportive measures to minimize bleeding in patients on NOACs, the speaker noted
that all the NOAC have relatively short half lives, and it was essential to assess for other concomitant
medications that may promote bleeding. Adequate blood pressure control was important.
To conclude, the speaker noted that the hypertension targets cannot be the same in all sugbroups;
factors such as age diabetes, chronic kidney diseases, aortic dissection, and aortic aneurysm should
be considered. In non-communicable disease management today, the speaker urged the audience
to treat the patient as a partner in NCD management contract and not as physician as a master and
the patient as a slave.
144
Implications of Central Aortic Blood Pressure

in Management of Hypertension
Dr. Devanu Ghosh Roy
MBBS, MD, DM, FRCP
Peerless Hospital, Kolkata
Speaking on the role of central aortic BP in the management of hypertension, the speaker noted that
the diastolic and mean pressures were very similar at the radial/brachial and central sites, but systolic
CBP was not the same as brachial or radial systolic BP. He noted that though brachial BP parameters
were reasonably predictive of CV morbidity and mortality, the brachial BP could not completely reflect
aortic degenerative changes. There was evolving evidence that different antihypertensive drugs with
similar effects on brachial BP could have diverse effects on central aortic pressure (CAP). CAP was
influenced considerably vascular endothelial function, and represented the BP actually perceived by
the heart and the brain.
Studying the pressure wave reflection at the heart, he noted the consequences of stiffening of arteries.
If the central systolic pressure increased, the central pulse pressure was increased. An increase in the
central pulse pressure that drives the cerebral blood flow increased the stroke risk. This change in
central systolic pressure could occur without any changes in the peripheral systolic pressure, noted
the speaker. Secondly, there was an increase in the left ventricular load, which increased risk of LV
hypertrophy. Thirdly, the pressure that was perfusing the coronary arteries during the critical diastole
period was reduced, increasing the risk of myocardial ischemia.
If the reflected wave travelled fast and arrived during systole, it created augmentation pressure
(Alx), with extra pressure work for the heart during systole. This could lead to LVH and cardiomyopathy,
and treatments that could lower the Alx could help the patient.
The Strong Heart study of 3050 high-risk adults showed that central pulse pressure was 50% better
than brachial pulse pressure in predicting cardiovascular events. Other studies over a range of ethnic
groups and diseases have shown that central pressure is an independent and more significant predictor
of risk than conventional brachial blood pressure measurements. The CAF study demonstrated
lower central BP with CCB/ACEI arm than the beta blocker arm. The different BP lowering drugs
in the study had different effects on central BP. A linear relationship was noted between central
pressure and CV outcomes, but not with peripheral pressure. The speaker shared another study
which showed that 4 months Rx with ACEI decreased CAP pressure and augmentation index, and 6
months of treatment with atorvastatin decreased CAP and Alx.
In conclusion, the speaker noted that increased arterial stiffness was associated with end-organ
damage and was an independent predictor of CV risk, and assessment of PWV in conjunction
with central PP provided additional useful information on efficacy of antihypertensives. The major
antihypertensive drug classes had differential effects on CAP despite having similar effects on brachial
pressure. Assessing CAP may be the next important advance in the future clinical management of
hypertension, he opined.
145
First-Line Anti-Hypertensive Therapy

Dr. Vidyut Jain
MBBS, MD, DM
Choithram Hospital, Indore
Acknowledging that hypertension probably was one of the major health concern in the present,
the speaker pondered on the first line therapy for the same in this talk. The critical questions in this
regards, he stated, was when to start therapy, how low should we go in BP target reduction, and
what drug to be used. The targets were different in diabetes patients, in high risk patients, low risk
patients, and in the very elderly. The treatment algorithm would change based on whether it was
for treatment of systolic/diastolic hypertension without other compelling indications, or treatment
of isolated systolic hypertension without other compelling indications, or treatment of hypertension
with compelling indications. The high risk groups were black persons, those with CVD including
stroke, diabetics, and multiple risk factors.
When combining drugs, he suggested to always using first-line therapies. Also, combination of an
ACEI with an ARB did not reduce cardiovascular events more than the ACEI alone, and had more
adverse effects, therefore they were not generally recommended.
In the general non-black population, including those with diabetes mellitus, the latest guidelines
from JNC 8, based on results from the ALLHAT trial and the LIFE study, the first line drugs were
thiazide diuretics, CCB, ACE inhibitor, ARB. In the black patients, including those with diabetes, the
first line was thiazides and CCB. Thiazides were more effective than ACEI in improving CVA and CHF.
The HYVET trial observed the outcomes of fatal and non-fatal endpoints in elderly population, and
it was observed that lowering the blood pressure in hypertension above 80 years with indapamide
was associated with reductions in total mortality and reduced rate of cardiovascular events. The
ONTARGET study observed the effect of ACEI and ARB in patients with established CAD. It concluded
that ACEI was definitely recommended for most patients with established CAD, while ARB was not
inferior to ACEI in IHD.
In hypertension associated with stroke, the target was to treat BP and lower it by 15-25% (if SBP>220
DBP>120) in the first 24 hour and then gradual reduction, while in TIA, the target BP was to be
<140/90. An ACEI/diuretic combination was the most preferred, while combinations of an ACEI
with ARB were not preferred. In hypertension with diabetes mellitus, ACE inhibitors, ARB, CCB and
thiazide were appropriate choices, while combinations of an ACEI with an ARB were specifically not
recommended in the absence of proteinuria. The target BP in CKD was <140/90 mm Hg.
To summarise, the speaker noted that first line anti-hypertension drug choice depends on pre-existing
status of patients. Simple looking drugs could offer equal benefit and safety comparable to newer
drugs. Newer agents could target endothelial dysfunction more selectively, which was the main
mechanism of HTN and thus offered better BP control and prevent target organ damage.
146
Acute coronary syndrome surgery for whom and when ?

Dr. Arunkumar Krishnasamy
MS, MCh, DNB
Cardiothoracic Surgeon, Billroth Hospitals
Chennai
In class I, NSTEACS, emergency CABG was recommended for patients in whom primary PCI had
failed or was not suitable, coronary anatomy was suitable for CABG, and with persistent ischemia
of a significant area of myocardium. It could also be done in postinfarction mechanical complication
of MI, in cardiogenic shock and in life threatening ventricular arrhythmias. In class IIa, CABG was
reasonably useful as a revascularization strategy in patients with MVD with recurrent angina or MI
within the first 48 hrs of ACS as an alternative to a more delayed strategy, and also in patients greater
than 75 years with LBB block who are suitable for revvascularisation irrespective of the time interval
from MI to onset of shock.
CABG in ACS could be done as an emergency as in failed PCI, mechanical complications, and in
cardiogenic shock in unsuitable coronary anatomy. It could also be elective, as in all other patients,
with CABG appearing to be the most beneficial when surgery was performed after several days of
medical stabilisation and discontinuation of DAPT. Elective could also be done in MVD and culprit PCI
after risk stratification. The ESC guidelines of myocardial revascularisation was as follows:
ESC guidelines of myocardial Revascularisation 2015
CABG in ACS
Emergency
Proceed to CABG
Semi elective
Elective
Case to case desicion

Risk of
Thrombosis
CABG delayed until dual

anti platelet effect goes off
Risk of
Bleeding
In surgical strategies, off pump, assisted beating and on pump were the various strategies. The off
pump approach carried the advantage in terms of bleeding complications. Time-consuming harvesting
of conduits should be discouraged in the presence of hemodynamic instability. The speaker noted
that LIMA should be given to LAD, while in all other vessels saphenous vein was equally good. The
perioperative strategy had to be detailed and the key was to avoid additional ischemia.
To conclude, the speaker noted that PCI was the procedure of choice for NSTEACS patients requiring
immediate myocardial revascularization, while CABG was complementary. CABG could be done with
aspirin, but discontinuation of clopidogrel, ticagrelor needed 5 days and prasugrel 7 days before
CABG unless in emergency. Off pump CABG with IABP support gave better results. Also, a heart team
approach to revascularization decisions, involving an interventional cardiologist and cardiothoracic
surgeon was used in patients with unprotected left main or complex CAD.
147
Classification and Diagnosis of Acute Coronary

Syndrome (ACS)
Dr. Bhuban Majhi
MD, DM
Assistant Professor
IPGMER, Kolkata
Patients presenting with acute typical chest pain and suspected as ACS are differentiated based
on ECG into STE-ACS or NSTE-ACS. NSTE-ACS was further differentiated based on the biomarkers
elevation into NSTE-MI or unstable angina. The speaker observed that the introduction of highsensitivity cardiac troponin measurements in place of standard troponin assays had resulted in an
increase in the detection of MI and a reciprocal decrease in the diagnosis of unstable angina.
The diagnosis of NSTE-ACS was arrived at with the help of history, ECG findings and the biomarkers.
If the standard leads in ECG were inconclusive and the patient had significant signs or symptoms of
ongoing MI, additional leads should be recorded, the speaker noted. In case of persistent or recurrent
symptoms or diagnostic uncertainty, an additional 12-lead ECG was to be obtained. Measurement of
a biomarker of cardiomyocyte injury, preferably hs-cardiac troponin was mandatory in all patients with
suspected NSTE-ACS within 60 minutes. Among the other biomarkers, only CK-MB and copeptin
had clinical relevance.
The use of rule-in and rule-out algorithms was very useful to increase diagnostic accuracy. The
recommendations were to use the 0h/3h algorithm. As an alternative, 0h/1h assessments were
recommended when high sensitivity cardiac troponin assays with a validated algorithm were
available. The negative predictive value for MI in patients assigned rule-out exceeded 98% in several
large validation cohorts, while the positive predictive value for MI in those patients meeting the
rule-in criteria was 75 to 80%. Alternatives to these two algorithms were the 2h rule-out protocol
combining the TIMI risk score with ECG and hs-cardiac troponin at presentation which allowed a safe
rule-out in up to 40% of patients, and a dual marker strategy for rule-out combining normal levels
of cardiac troponin together with low levels of copeptin (<10 pmol/L) at presentation which showed
a very high NPV for MI, obviating the need for serial testing in selected patients.
Transthoracic echocardiography (TTE) was useful to identify abnormalities suggestive of MI or necrosis,
to detect alternative pathologies associated with chest pain and in the evaluation of left ventricular
(LV) systolic function, which is important to estimate prognosis. MDCT was another tool which was
useful and allowed for visualization of the coronary arteries and a normal scan excluded CAD. If the
other imaging modalities like ECG and biomarker were inconclusive, then imaging modalities like
Echo, nuclear myocardial perfusion scan had an adjuvant role in diagnosis and management, the
speaker noted.
148
Risk Statification in Acute Coronary Syndrome

Dr. Pankaj Singh
MBBS, MD, DNB
Associate Consultant- Interventional Cardiologist
RTIICS NH, Kolkata
Risk stratification in any ACS case is essential to assess whether the symptoms are a manifestation
of ACS; also, the therapy/site of care depends on the diagnosis. It would also help to determine the
prognosis/short term survival, the speaker observed.
In unstable angina, a history of accelerating tempo of ischemic symptoms in the preceding 48 hrs,
and prolonged ongoing rest pain places the patient in high risk, while prior MI, peripheral or CVS/
CABG/aspirin use patient with prolonged rest angina, now resolved with rest or SL NTG characterizes
intermediate risk. New onset or progressive angina, without prolonged rest pain but with moderate
or high likelihood of CAD is placed in low risk category. Examination and ECG are also essential tools
to stratify the risk. Biochemical cardiac markers (BCM) are useful in both the diagnosis as well as
estimating prognosis. BCM used include cardiac troponins, CK-MB, myoglobin, and CRP. Elevated
TnT >0.1ng/ml correlates to high risk, while intermediate risk is characterized by levels >0.01 and
<0.1 ng/ml. Normal TnT levels meant low risk.
TIMI score of 5-7 is high risk, 3-4 is intermediate risk and score 0-2 is low risk. Other risk scores that
are used to stratify risk include the GRACE risk score and the PURSUIT score. Also, it was essential
to do a predischarge risk stratification with non-invasive evaluation of left ventricular function, tests
for ongoing myocardial ischemia (treadmill stress test, Holter ST monitoring), and tests for electrical
instability.
To summarise, the speaker noted that the risk stratification would be a very useful tool in the hands
of a physician who judiciously used it, to ensure optimal therapy of a patient with ACS, and in
ensuring the least chances of recurrences and best possible outcome in any given condition. Many
approaches were already available, and this field would see many more advances in the future.
149
Management of Valvular Heart Disease

during Pregnancy
Dr. A N Patnaik
MBBS, MD, DNB, DM, FSCAI
Cardiologist
Star Hospitals, Hyderabad
Majority of the valvular heart diseases in pregnant women are of rheumatic etiology. Most patients
are unaware of their heart problem and present with undue breathlessness at late pregnancy or
the condition is diagnosed for the first time by an obstetrician during one of the routine antenatal
visits. Dr. Patnaik discussed his concern regarding the inadequate penetration of preconception
counseling into patient-care services. Physicians caring for female patients of reproductive age that
have a history of valvular heart disease or prior cardiac valve surgery have largely underutilized
preconception counseling. From risk stratification, to contraception counseling and pursuit of the
appropriate therapeutic course prior to conception, preconception counseling has the potential to
simplify the clinical course for many of these patients at high risk. Therefore, he emphasized that
there is an impending need for measures that would reduce the morbidity and mortality associated
with valvular heart diseases during pregnancy.
The presenter opined that patients presenting with mitral stenosis may be managed with the help
of ballon dilatation of the valve, preferably in the second trimester. The interventions have to be
performed under appropriate radiation protection strategies so as to not harm the fetus and mother.
Valve surgeries involve high risk and are performed only after a careful risk-benefit assessment;
consent from the mother to undergo surgery should be obtained by thoroughly explaining the
risk of fetal loss. Patients with tissue valve may be treated without much difficulty; however, those
with mechanical valves pose a special challenge especially with respect to the management of
anti-coagulation. Problems like prosthetic valve thrombosis and infective endocarditis can be life
threatening.
In conclusion, management of valvular heart disease in pregnancy is multi-faceted and therefore
needs a team effort.
150
Polypills: Hit or Flop?

Col (Dr) R Girish
MD, DNB, DM
Command Hospital, Lucknow
Cardiovascular disease (CVD) is a leading cause of mortality and morbidity worldwide. Risk factor
mitigation strategies applicable to large segments of the population, including wider use of proven,
safe, and inexpensive pharmacological therapies, are currently underutilized. The World Health
Organization has recognized the concept of polypill as a potential to bridge the treatment gap,
naming it best buy for cardiovascular disease prevention and control in the secondary prevention
(post-MI and stroke). Polypillis a medication that combines a fixed drug combination of a statin,
aspirin, folic acid and three blood pressure medications each at half dose. Evidence has shown onethird of the patients receiving a polypill to be conferred with 11 years of life free from coronary
events and strokes; however, 8%15% patients develop adverse events. A list of available polypills
is mentioned in Table 1.
Table 1: Available Polypills.
Company
Polypill
Active Components (mg)
Dr. Reddys laboratories

(India)
Red Heart Pill 1
TM
aspirin (75), lisinopril (10), simvastatin (20), atenolol (50)
Red Heart Pill 2TM
aspirin (75), lisinopril (10), simvastatin (20, 40), hydrochlorothiazide (12,5)
Zydus Cadila (India)
Zycad
aspirin (75), atorvastation (10), ramipril (5), metoprolol (50)
Zydus Cadila (India)
Ramitorva
Cadila (India)
Polycap,
PolycapDS
aspirin (100,200), simvastatin (20,40), ramipril (5,10), atenolol (50,100),

hydrochlorothiazide (12,5,25)
CNIC-FERRER (Spain)
Trinomia
aspirin (100), simvastatin (40), ramipril (2.5,5,or 10)
Alborz Darou (Iran)
PolyIran
asprin (81), atorvastation (20), enalapril (5) or valsartan (40),

hydrochlorothiazide (12,5)
TM
aspirin (75), ramipril (5), atorvastation (10)
In summary, Dr. Girish noted that the polypill idea reinforces the importance of aggressive multi
factorial intervention and hence should be considered as an integral part of a comprehensive CVD
prevention strategy. It could reduce the CVD risk by 80% -90% cost-effectively.
151
Revised Jones Criteria for Diagnosis of Acute

Rheumatic fever
Dr. Chhabi Satpathi
Associate Professor
SCB Medical College
In the absence of pathologic signs and laboratory investigations, Jones criteria (Box 1) are used to
diagnose acute rheumatic fever. However, high proportions of over-diagnosis, under-diagnosis and
missed diagnosis of rheumatic fever obstinately persist in clinical practice. The last revision of the
Jones criteria was done in the year 1992. During this two-decade period, echocardiographic and
Doppler (E and D) studies have become important tools in the diagnosis of rheumatic heart disease.
Incorporating latest findings and developments in E and D studies, American Heart Association put
forth revised Jones criteria in the year 2015.
Dr. Chhabi Satpathi discussed the need for this revision and impact it would have on improving the
diagnosis of rheumatic fever. He pointed out that the diagnosis of rheumatic fever is difficult when
carditis is the only manifestation and this difficulty becomes pronounced when carditis is subclinical.
The presenter highlighted data from Vijaylaxmi et al, which indicates that 50% of SC carditis cases
considered Jones negative and that 14-40% of clinically diagnosed cases dont have carditis on E and
D study. Furthermore, polyarthralgia considered as a minor criteria by many, shows echo evidence of
carditis in more than 50% of patients.
The presentation explained the recommendations on E and D studies in the 2015 version of the Jones
criteria (Box 2). Dr. Satpathi concluded the session by quoting EC Lasegues famous line that says RF
is a disease that licks the joints but bites the heart and indicated that E and D studies can fill the gray
areas in the diagnosis of a condition that can bite the heart. Furthermore, he added that the E and
D criteria may negate the age old teaching that 50% cases of rheumatic heart disease are without a
past history of acute rheumatic fever.
1. E and D should be done in all cases of
confirmed and suspected ARF (class I,B)
2. Serial E and D is reasonable in pts diagnosed
or suspected of ARF even if no carditis
diagnosed at presentation
(class IIa, C)
3. E and D should be done to assess subclinical
carditis in moderate to high risk population,
where ARF is considered likely (class I,B)
4. E and D finding not consistent with carditis
excludes the diagnosis even with a heart
murmur otherwise thought Rheumatic
carditis (class I,B)
Box 2: Recommendations on E and D studies
in the 2015 version of the Jones criteria.
Major Criteria

Carditis
Polyarthritis
Chorea
Erythema
marginatum
Subcutaneous
nodules
Minor Criteria
Clinical
Fever
Arthralgia
Laboratory findings
Acute phase reactants: ESR and C-reactive protein
Electrocardiogram: Prolonged PR interval
Plus supporting evidence of GABHS infection:

Increased anti-streptolysin O (ASO) or other anti-streptococcal antibodies (DNAse B)
Positive throat culture for GABHS
Positive rapid antigen detection test for GABHS
Box 1: The Jones Criteria for Acute Rheumatic Fever, Update 1992.
152
Combination Diuretic Therapy in Heart

Failure with Reduced EF: When and How?
Dr. Mriganka S Chaliha
Assam Medical College, Dibrugarh
Volume overload is an important clinical target in the management of heart failure with reduced
ejection fraction. The issue is typically addressed using loop diuretics. A challenging subset of heart
failure patients exhibit fluid overload despite significant doses of loop diuretics - a situation typically
described as diuretic resistance. Up to 30% (as reported in the ADHERE registry) of the patients
with decompensated heart failure present with loop-diuretic resistance. Several approaches to treat
diuretic-resistant HF are available. One such approach is the addition of a thiazide-type diuretic to
loop diuretics to produce diuretic synergy via sequential nephron blockade, which was first described
more than 40 years ago. Other combinations include loop diuretics with mineralocorticoid receptor
antagonist (MRA) and V2-vasopressin receptor blockers (Vaptans).
Rationale of Combination Diuretic Therapy
Diuretic effect tapers over time and this phenomenon is known as diuretic braking. When used for
the treatment of congestive heart failure, there is seen a rightward shift of the dose response curve;
this is due to the difference in the diuretic concentration in the tubular lumen and its natriuretic
effect. This rightward shift is known as the diuretic resistance.
Concurrent use of drugs acting upon different segments of the nephron and loop diuretics produces
an additive or synergistic effect by reducing diuretic resistance.
A trial involving 40 patients with NYHA functional class III/IV heart failure receiving thiazide diuretics
(bendroflumethiazide 10 mg daily versus metolazone 10 mg) in addition to loop diuretic therapy
recorded a clinical response rate of 92.5%; symptomatic improvement allowing hospital discharge
was found in 90% of patients.
Ideal Candidates for Combination Diuretic Therapy
1. Patients with gross fluid overload refractory to optimized doses of intravenous loop diuretic
(diuretic resistant), especially in patients with chronic decompensated systolic heart failure
with or without impaired renal function (Class I).
2. In acute decompensated heart failure, when diuresis is inadequate to relieve symptoms
(Class IIa).
Combination of loop diuretics with thiazide diuretics represents a low-cost, effective therapy for
the treatment of heart failure in patients showing diuretic resistance. Other combinations of loop
diuretics with mineralocorticoid receptor antagonist and Vaptans may be effective too. However, as
noted by Dr. Mriganka, there is an impending need for further randomized trials to substantiate the
role of combination diuretic therapy in heart failure with reduced ejection fraction.
153
Non-Invasive Testing in Stable Coronary

Artery Disease (SCAD): Order of Preference
Dr. D Rajasekhar
MD, DM, FACC, FESC, FSCAI, FCSI
Professor and Head
Department of Cardiology, SVIMS, Tirupati
When a patient presents with angina, stable coronary artery disease (SCAD) should be differentiated
from acute coronary syndrome (ACS). Once ACS is excluded, SCAD needs further investigation for
establishing diagnosis, prognostication and evaluation of treatment efficacy. Dr. Rajasekhar discussed
the various non-invasive testing modalities and a summary of his presentation is given herein.
The selection of a non-invasive test for SCAD diagnosis will depend on factors including:
1.
Ability of the patient to exercise adequately
2.
Interpretable or uninterpretable exercise ECG (LBBB, Pacing, LVH, digoxin, pre-excitation)
3.
Pre-test probability of SCAD (low/intermediate/high)
Exercise ECG remains the test of first choice for diagnosis of SCAD, if a patient is able to exercise
adequately, has an interpretable ECG and has at least an intermediate level of disease probability. If a
patient is able to exercise but has an uninterpretable ECG, then exercise test with echocardiography
or Nuclear Myocardial Perfusion Imaging (MPI) are the tests of choice. If MPI or echocardiography is
counterproductive, then pharmacological stress is indicated.
Besides being useful for diagnosis of SCAD, these tests are useful in risk assessment. In addition,
they can be used in follow-up care and in the assessment of efficacy of various treatment modalities,
including revascularization. In fact, outcomes in SCAD will depend on anatomical burden and
distribution of disease, the resultant ischemic burden and their effects on left ventricular ejection
fraction.
Nature of pain, precipitating factors and relieving factors are the three characteristic features of
angina. SCAD is likely if 2-3 anginal characteristics are present; further investigation for SCAD is
indicated. On the other hand, if only one anginal characteristic is present, then aggressive evaluation
may not be clinically useful.
As many as nine non invasive evaluation modalities for SCAD are available with varying degrees of
sensitivity and specificity. These include Exercise ECG, Stress Echo, Contrast Echo, SPECT imaging,
cardiac CT, PET and cardiac perfusion MRI. Sensitivity and specificity of exercise ECG is lowest (0.6
and 0.7 respectively). Cardiac CT has the highest sensitivity and PET has the highest specificity. When
both sensitivity and specificity are considered together PET is closest to ideal.
154
Stable CAD in Women

Dr. Harendra Kumar
MD, PhD (Med), FICP, FIAE, FICC, FCSI
Senior Consultant Cardiologist and Director
Indira Gandhi Institute of Cardiology, Patna
In recent years many clinical trials have provided evidence that there are substantial gender differences
in the pathophysiology, clinical presentation, diagnosis, and treatment of CAD. Although women
have a higher atherosclerotic burden, they are more symptomatic and have a lower prevalence of
obstructive CAD than men. Therefore, Dr. Harendra Kumar discussed the various differences in stable
CAD in women and men.
In women, the initial manifestation of CAD is typically stable angina; prevalence is 47% versus 26% in
women and men, respectively. Fewer women undergo diagnostic non-invasive testing and coronary
angioplasty. The presenter noted that although women have lower rates of previous myocardial
infarction, percutaneous coronary intervention, and coronary artery bypass grafting, they are at
an elevated risk of heart failure. Suboptimal treatment penetration, including inadequate medical
treatment and revascularization was noted in women. However, women generally have single-vessel
disease as compared to men who present with multi-vessel disease.
There is observed significant differences in the risk factors for SCAD in men and women. Women
with diabetes mellitus have a four-fold increase in the risk of death from cardiovascular disease as
compared with age and sex-matched control population. Depression being two-times more common
in women as compared to men increases the cardiac risk by 50%. Additionally, anxiety, martial stress
and early life adversities are important risk factors in women. Intervention to reduce stress has been
reported to reduce mortality by about 70% in women with CAD.
In conclusion, the need for women to be educated about the risk factors for CAD was identified in
order for reduced incidence of the use of coronary interventions to accrue.
155
The Conduit Confusion

Dr. Kunal Sarkar
MBBS, MD, DM
Past President, IACTS
Dr. Sarkar addressed the audience on the use of conduits. He noted that studies by Floyd Loop
and Lytle (1999) and Lytle (2001) that compared survival and reoperation hazard function curves
in propensity-matched patients showed increased IMA use over Y grafts. Another meta-analysis
comparing BIMA and LIMA confirmed survival advantage of BIMA. The Buxton study showed 97%
patency with LIMA, 89% with RIMA and 91% with radial. Survival was 86% with BIMA and 71%
with SIMA.
Sequential internal thoracic artery bypass, the speaker noted, was safe as per data, but survival
benefit was yet to be proven. The speaker noted that based on the evidences at hand, it was safe to
accept that LIMA improves survival, BIMA improves it further. Sternal infection occurs at a rate of 1%
to 2% and the speaker noted that it could be reduced by skletonization.
The use of radial artery was mentioned by the speaker, with long term patency superior with an OR
of 2.28. However, the speaker suggested to avoid this if stenosis<80%. It was superior to SVG in
high grade stenoses>80%. The 5 yr patency of >80% far exceeded the stent patency, which was
more commonly performed.
Extend arterial grafts was another option: adding a second arterial graft, specially to the left coronary
system increases the application by 10%. Radial artery was to be used in high grade stenosis/diabetics
and aortic manipulation to be avoided, if in doubt.
Estimates of ITA patency of left ITA to LAD and non-LAD coronary arteries at 10 years after CABG
was observed, according to degree of proximal coronary stenosis. It was observed that the patency
was higher in LAD territory.
A new standard of care was VEST, which is a kink resistant, in situ adjustable cobalt chrome scaffold,
which could be a 1 minute implantation procedure without affecting the grafting technique. It also
needed no sutures or glue to fixate the device to the vein graft.The prevention of post implantation
dilation was better with VEST than without. Skeletonization was another technique which could be
used to reduce the complications. It reduced the incidence of sternal infection by 60%.
156
Allopurinol and Chelation Therapy in

Stable Angina
Dr. Aziz Khan
MD, DM, FACC, FESC, FSCAI
Crescent Hospital and Heart Centre
Nagpur, India
Allopurinol, a xanthine oxidase inhibitor has been traditionally used in the treatment of gout. The
application of allopurinol in coronary artery disease is based on previous evidence that xanthine
oxidase is a potent mediator of oxidative stress. Early studies have shown the potential of allopurinol
to reduce vascular oxidative stress and thereby improve endothelial function. In experimental heart
failure, allopurinol improves mechano-energetic uncoupling in myocardium. Furthermore, allopurinol
decreases oxygen demand without changing cardiac output in pacing-induced heart failure in dogs.
Discussing these evidences, Dr. Khan noted that if such an effect also occurs in man, this drug
could become a new treatment for ischemia.
Dr. Khan also discussed data from various clinical studies including the one from Noman et al, which
indicated that high-dose allopurinol significantly prolongs the time to ST depression, the total exercise
time, and the time to chest pain in patients with chronic stable angina during a standard exercise test.
This suggests that endogenous xanthine oxidase activity contributes to exercise-induced myocardial
ischaemia. Furthermore, data from Rajendra et al. indicates that high-doseallopurinolprofoundly
reduces vascular tissue oxidative stress and improves measures of vascular/endothelial dysfunction.
Furthermore, high-doseallopurinolmight reduce future cardiovascular events and deaths in CAD.
Discussing the results of the TACT study, the presenter pointed out that in stable patients with
MI, the use of IV chelation regimen with disodium EDTA modestly reduces the risk of a composite
of adverse cardiovascular outcomes, many of which were revascularization procedures. Discussing
these aspects and highlighting that more research is needed in ascertaining the role of allopurinol
and chelation therapy in stable angina, Dr. Khan concluded his presentation by pointing towards the
American College ACC/AHA guidelines for the management of stable CAD, which gives chelation
therapy a Class III recommendation (not useful/effective and may be harmful).
157
Stable Coronary Artery Disease: A Forerunner

for Ischemic Cardiomyopathy, Myth or Reality?
Dr. Rajeshwari Nayak
MBBS, DNB, DNB
Senior Consultant Interventional Cardiologist, Apollo Hospitals, Chennai
Dr. Rajeshwari Nayak presented an informative update on the stable coronary artery disease as a
forerunner of ischemic cardiomyopathy. The prevalence of SCAD is 5-8% in the age group of 45 to
64 years and 12-15% between 65-84 years. The pathologies and clinical course of SCAD is depicted
in Box 1 and 2, respectively.

Plaque related obstruction

Focal or diffuse spasm, normal or
diseased vessel
Microvascular dysfunction
LV dysfunction leading to ischemic
cardiomyopathy
LV dysfunction: hibernation, stunning or
scarred myocardium
Box 1: Pathology in SCAD.
Continue to be stable
Phases of instability
MI
Ischemic cardiomyopathy
Heart failure
Box 2: Clinical Course of SCAD.
Discussing the risk stratification of SCAD, the presentation indicated that low risk, intermediate
risk and high risk are associated with an annual mortality of <1%, 1-3% and >3%, respectively.
Characteristics of the high risk group include: diabetes, hypertension, dyslipidemia, PVOD, CKD,
previous MI and heart failure. The presentation emphasized that prognostication of SCAD is very
important to identify high risk patients who benefit from revascularization and to avoid unwarranted
procedures in low risk patients.
Ischemic cardiomyopathy is characterized by LV systolic dysfunction (with an EF of 40%) occurring
as a result of coronary artery disease. Risk factor profile, response to OMT, proximity and proximity
and severity of the stenosis, number of vessels involved determine the development of Ischemic
cardiomyopathy. The presentation further discussed the pathology with myocardial hibernation,
stunning and multiple infarcts.
The presentation concluded by noting that SCAD is a forerunner for ischemic cardiomyopathy.
Periodic prognostic evaluation of SCAD patients to prevent development of cardiomyopathy was
recommended. The presentation indicated that high risk SCAD patients should be advised ICA and
revascularization to prevent ischemic cardiomyopathy.
158
Stable Angina with Normal Coronaries:

Management Protocol
Dr. Sunandan Sikdar
MBBS, MD, DM
Narayana Multispeciality Hospital
Barasat
Chest pain without obstructive CAD is a heterogeneous entity in which a subset of patients experiences
microvascular angina (Figure 1). Microvascular coronary dysfunction, defined as limited coronary flow
reserve and/or coronary endothelial dysfunction is the predominant etiologic mechanism of ischemia
in women with the triad of persistent chest pain, no obstructive coronary artery disease, and ischemia
evidenced by stress testing. The CART National Registry defined non-obstructive CAD as any stenosis
>20%, but <70% (any epicardial artery ) or >20%, but <50%, (in the left main artery). Discussing
these issues, Dr. Sikdar presented practical considerations for diagnosis (Figure 2). Dr. Sikdar pointed
out that the lack of standardized definitions has made the evaluation of treatment strategies for
microvascular angina challenging. Discussing the various treatment options, the presenter indicated
that there is little evidence to support current treatment strategies for objectively-defined CMD.
He indicated that ranolazine, statins and ACEI have more favourable data.
em
Pericardial
Pain
cN
Cardia
Inappropriate
Pain
Perception
Cardi
Chest Pain
Without
Obstructive
Coronary
Artery Disease
Sy
ac
nd
Coronary Spasm
rom
e
Mi
i na
crov
ascular Ang
Atherosclerosis
and
Inflammation
Gastrointestinal
Psychiatric
Smooth Muscle
Dysfunction
Sympathetic
Dysfunction
Endothelial
Dysfunction
Cardia
c Ischemic
Figure 1: Heterogeneity of chest pain without obstructive CAD.
159
ia c
Musculoskeletal
ard
ch
-C
-I s
on
on
Pulmonary
Angina
+ sings of myocardial ischemia
Coronary
angiography
Anomalous coronary origin
Myocardial bridge
Coronary aneurysm
Coronary
stenosis
Absent
Mild
DS <50%
Moderate
DS 50-70%
Acetylcholine
Test
FFR
0.80
no or <75% diameter reduction

no angina
no ischemic ECG changes
no or <75% diameter reduction

+ angina
+ ischemic ECG changes
Microvascular
Angina
Endothelial Dysfunction
Severe
DS >70%
0.80
75% diameter reduction

+ angina
+ ischemic ECG changes
Vasospastic
Angina
Significant
atherosclerotic CAD
Non-atherosclerotic
CAD
Adenosine Test
CFR 2.5
True Syndrome X
CFR <2.5
Microvascular Angina
Endothelial-Independent Dysfunction
Figure 2: Practical consideration for diagnosis.
The presentation concluded by noting that patients with the lowest CFR or MPR values have the
worse prognosis.
160
An Update on MINOCA
Dr. Kadiyala Meenakshi
MD, DM
Department of Cardiology, Madras Medical Collage,
Chennai
Presenting ECG and coronary angiography (Figures 1 and 2) findings of a patient, Dr. Kadiyala Meenakshi
discussed the prevalence of myocardial infarction and non-obstructive coronary arteries (MINOCA)
along with providing an update on the methods for an accurate diagnosis and treatment. Angiography
may not identify significantly diseased artery in some patients with myocardial infarction (MI).
Figure 1: ECG findings of a patient with

MINOCA.
Figure 2: Coronary angiography findings of

a patient with MINOCA.
The presenter discussed data from published meta-analyses and the CRUSADE registry. Presentations
also included a discussion of a retrospective analysis of 221 consecutive angiograms done on acute
MI patients. Results of this study indicated that 19% patients had MINOCA. In this study, 30%
patients with MINOCA had completely normal coronary arteries. A preponderance of MINOCA is
seen in young patients (median age was 40 yrs) and females (22% as compared to 15% males).
While patients with MINOCA are less likely to have hyperlipidemia, hypertension may be more likely.
Thrombosis due to occult plaque rupture, coronary spasm, endothelial and microvascular dysfunction
and thrombotic disorders are possibly some of the potential causes of MINOCA. About 75% patients
with MINOCA present with features of NSTEMI. CMRI is a useful tool in the differential diagnosis of
MINOCA from cardiac structural disorders and myocarditis, which often masquerade as MINOCA.
Localized areas of angiographic stenosis underestimate the extent of atherosclerotic involvement of the
coronary arteries by angiography. Thus, IVUS and OCT are more useful in identifying atherosclerosis.
All-cause in-hospital and 12-month mortality due to MINOCA is about 0.9% and 4.7%, respectively.
In terms of treatment, aspirin, clopidogrel, beta blockers are indicated. Life style modifications
are absolutely important in the management of MINOCA. Dr. Kadiyala Meenakshi concluded the
presentation by stressing the need for further investigations to identify best methods of quantifying
the extent of CAD and correlating it with subsequent MI and mortality rates.
161
Is the Concept of Metabolic Syndrome

Still Relevant?
Dr. Bino Benjamin
MBBS, MD, DM, DNB, FNB, FACC, FSCAI
Jubilee Mission Medical College
Thrissur
Metabolic syndrome (MetS) bearing the names of syndrome X, insulin resistance syndrome, the deadly
quartet and the obesity dyslipidemia syndrome, was suggested on the premise of the co-occurrence
of metabolic risk factors for both type 2 diabetes mellitus and cardiovascular disorders. Although,
several definitions for the metabolic syndrome exists the definition from National Cholesterol
Education Program (NCEP) Adult Treatment Panel III is the most widely used.
Metabolic syndrome is an important risk factor for future development of type 2 diabetes and/
or CAD. The key clinical implication of metabolic syndrome is to identify individuals who need
aggressive lifestyle modification. Major clinical studies (Box 2) and three meta-analyses reported that
MetS increases the risk for incident CVD and all-cause mortality. The ADA and EASD published a
joint statement raising questions on whether the components of the metabolic syndrome, warrant
classification as a true syndrome. This argument stems from the observation that CVD risk with
metabolic syndrome is not greater than the sum of its individual components. Furthermore, treatment
strategy of MetS varies depending on the components. Dr. Bino Benjamin explained that clustering
of risk factors for diabetes and CVD is a real phenomenon. The presence of one component of the
syndrome should lead to evaluation for other risk factors. There are a number of other advantages
of diagnosing metabolic syndrome (Box 2). The need to classify MetS as a true syndrome and
the issue of CVD risk of MetS beyond its individual components are academic questions. Dr. Bino
Benjamin concluded his presentation by asserting that As physicians, we should rise above these
academic arguments and combine forces to address the menace.

Framingham Study MetS alone predicted 25% of all

new onset CVD
MONICA-1 Health Study IR and MetS independently

predicted CVD
Diabetes Prevention Project (2002) MetS increased

type 2 diabetes mellitus
Danish Population Study (2007) insulin resistance (IR)

and MetS both independent predictors of incident CVD
Fits the profile of many presenting in primary care
Predict and prevent type-2 diabetes to a large extent
Encourages patients and physicians to adhere to lifestyle

modification
Helps to manage all components according to guidelines
UPPSALA Study (USLAM) MetS predicted 50% risk of

CVD (adjusted for Framingham score)
Box 1: Evidences for MetS as

risk factor for CVD.
In future, genetic screening for early diagnosis and

prevention will be facilitated
Box 2: Advantages of diagnosing metabolic

syndrome.
162
All Nonvalvular AF Should be treated with

NOAC certainly NO
Dr. K Venugopal
MD, DM, FCSI, FICC, FACC, FESC
Professor and Head, Cardiology
Pushpagiri Institute of Medical Sciences, Tiruvalla
Dr. K Venugopal, Prof and Head of Cardiology, PIMS, discussed the merits and demerits of using novel
anticoagulants in all cases of non valvular AF. Beginning on the backdrop of a clinical case presentation
of a 71 yr old diabetic CABG patient with a new onset AF who now needed oral anticoagulants, he
brought forth the two options to be used- Vitamin K antagonists or novel anticoagulants to be used
in this patient?
To address this, he presented the ground realities. Stroke prevention being central to the management
of AF, the past focus was to identify high risk patients and start them on oral warfarin, and maintain
the INR between 2 and 3. Novel anticoagulants were also considered a convenient alternative, but
were more expensive. The speaker noted the utility of CCHA2DS2 VASc score in assessing the risk of
stroke in patients with AF, and using to promptly start stroke prevention therapy, which could be in
the form of VKA (vitamin K antagonists ) or NOAC (Novel anticoagulants).
Sharing with the audience the results of a meta-analysis published in the Lancet, 2004 by Christian
T Ruff, et al, the speaker highlighted the main findings in the same. The meta-analysis had observed
that in patients of AF, if efficacy was compared between warfarin and NOAC, significantly fewer
systemic embolic or stoke events were noted with the NOACs than with warfarin. This benefit was
largely driven by the large reduction of hemorrhagic stroke with the NOAC. However, the NOAC
group had more number of gastro intestinal bleed as compared to warfarin. If the overall rates of
major bleeding was assessed, it was clear that there was significantly lesser risk of major bleeding
with NOAC than with oral warfarin.
Having shared the above trial, the speaker however noted that there were however cases or situations
where it might be more preferable to use VKA. In prosthetic heart valves, pregnancy, renal impairment,
compliance, gastro intestinal disease VKA was a good choice and also when the physician preferred
dosing convenience and cost to enhance compliance. VKA required monitoring, and had higher risk
of ICH but its risk of GI bleed was lower, dose adjusting was possible, it was cheaper and also it had
an antidote available. On the other hand, NOAC were expensive, were excreted by kidneys, had
higher risk of GI bleed, and did not yet have an antidote but they did not require monitoring and the
risk of ICH was lower.
While talking on the uses of home monitoring of INR, the speaker shared a large study done on
very old patients on VKA and noted that the rate of bleedings was very low and that age in itself
163
should not be considered a contraindication to treatment. Adequate management with VKA still
could provide old and frail patients to benefit from VKA thromboprophylaxis. The benefits of home
monitoring of INR was highlighted in another study, where it was observed that home monitoring
increases time in the therapeutic range, which would give better therapeutic efficacy.
Having presented these evidence on VKA as well as NOAC, Dr. Venugopal concluded by asking the
audience whether to go for a drug used more than 40 years or a drug which has been introduced
recently just for ease of administration and lack of monitoring with no specific antidotes, which
cannot be used in many situations, and called the audience to take the call themselves.
164
Unusual Case of Cardiomyopathy

Dr. Uday Kiran A
Post Graduate
Osmania General Hospital, Hyderabad
A 55-year-old male, an agricultural labourer presented with complaints of shortness of breath

class III, and intermittent palpitations and reeling sensation. He was a smoker and an alcoholic. On
examination, pulse was 60 bpm and BP was 120/80 mm Hg. S1 and S2 were normal, and there was
reduced air entry and coarse crepitations at both lung bases.
On investigation, ECG was normal but for LVH. CAG showed left dominant circulation and normal
epicardial coronaries. Deep trabeculations in the myocardium with flow was demonstrated in colour
Doppler. Mild LV systolic dysfunction, good RV function and sclerotic aortic valve were noted. Echo
showed a thick, inner layer of non-compacted myocardium subtending an outer, thin compacted
layer of myocardium with ratio of non-compacted myocardium during systole being greater than 2:1.
This was a case of left ventricular non-compaction cardiomyopathy (LVNC), which was first described
in 1984. The speaker noted that it was also known as hypertrabeculation of myocardium or spongy
myocardium, with an incidence of <0.3% and an annual incidence of 0.1 per lakh. The cause of LVNC
though not fully elucidated, the disease was thought to be a morphogenetic abnormality involving an
arrest of compaction of the loose myocardial meshwork during fetal ontogenesis, affecting the apical
segments most commonly. The common clinical features include CHF, arrthythmia, thromboembolic
events and could occur with other congenital heart lesions.
Echocardiography played an essential role in the diagnosis and the most commonly used diagnostic
criteria are those proposed by Jenni et al, which are more accurate echocardiographic criteria that
are available. Echocardiography was the traditional tool for diagnosis, but the apical region could not
be properly viewed by echo, and could lead to underestimation of the degree of the left ventricular
non-compaction. Thus, cardiac MRI was the method of choice to confirm or rule out the diagnosis of
NCC, because it provides a more detailed description of the cardiac morphology in any image plane.
MRI criteria in end diastole include the following:
Non compaction: compaction is >2.3
Non compaction LV mass >20% of global LV mass
Treatment was to be directed towards its most important clinical implications, which include heart
failure, arrhythmias and systemic embolic events, while definitive treatment was heart transplantation.
165
Cardiac MR Ischemia Evaluation

Dr. Mahesha B M
Chief Radiologist
Vikram Hospital, Mysore
The various approaches to assess cardiac ischemia was discussed by the speaker. Myocardial perfusion
reserve, which is an accurate measure of coronary circulation to deliver sufficient oxygen to the region
of heart muscle could be used as a surrogate marker for ischemia, he said. Among various available
diagnostic modalities, cardiac MR perfusion imaging was a reliable and robust tool with advantages
of accurate assessment of myocardial perfusion, high spatial resolution, non-invasive nature, and
absence of ionizing radiation.
Stress perfusion-CMR is another tool, which involves monitoring of the contrast medium wash-in
kinetics into the myocardium during hyperemic state (stressful state). In territories with stenosed
coronary arteries, the wash-in of CM would be delayed, and depicted as dark zones on perfusion
MR images.
Timeline of stress perfusion protocol
Rest
perfusion
Stress
perfusion
Loc
Break (10 min)

(Valves, coronary)
Function
(2CV, 4CV, LX, SX)
10
15
Late
Enhancement
Break
(5 min)
20
25
Copy references for slice position and

imaging parameters
Test
run
Stress
Func.
Stress
Perf.
HR
Rest
Func.
Rest
Perf.
Late
Enhancement
2:30 min
Adenosine@
140 g/kgBW/min
for 3 min
Gadolinium@
0.075 mmol/kg BW
4 ml/sec flow
Gadolinium@
0.075 mmol/kg BW
4 ml/sec flow
Many case presentations were provided in the talk to give illustrative examples. If there was no
perfusion defect, then it was interpreted as normal. If perfusion defect was present but no delayed
contrast enhancement, it was ischemia, while perfusion defect with delayed enhancement was
indicative of an infarct. Stress CMR could identify significant coronary arterial stenosis and also
analyse the coronary microcirculation. However, it was contraindicated in acute MI, severe AS and
CHB.
166
Cardiac MRI in CHD

Dr. R Rajeshkannan
MD, DNB, PDCC
Department of Radiology, AIIMS
The common indications for CMR in CHD, as the speaker discussed, were in follow-up after
surgical repair like TOF repair, atrial/arterial switch operation, pre/post fontan assessment,
complex repairs anatomic and pre-operative assessments.
The approach to CHD included assessment on three fronts: morphological, functional (TRICKS)
and tissue characterization. Morphological assessment involves evaluation of arteries and veins
for extra-cardiac involvement and cine stack for intra-cardiac involvement. For extra cardiac,
Cine stack for intra cardiac. Functional assessment involves SA cine and PC imaging (flow), while
tissue characterization involves MDE for scar and 3D modelling.
Qp/Qs could be easily measured by assessing flow in the main pulmonary artery, ascending aorta
and drawing contours in one slice and automated extrapolation to all slices. This could be
validated and confirmed within 5 min. In pulmonary regurgitation, there is prolonged ejection
time with delayed cessation of forward flow in the pulmonary artery. Additionally, a delay
between cessation of forward flow and tricuspid valve inflow indicates an increased IVRT; this
is suggestive of diastolic antegrade flow in the pulmonary artery indicating right ventricular
diastolic dysfunction.
Radio prototyping of congenital heart disease models is also a very useful technology, with the
aid of ink-jet technology. By segmenting a 3D SSFP of the fetus, the speaker noted that we could
measure the fetal volume and then index the flow measurements to fetal weight.
On the decision of whether to use CT or MR for CHD, the speaker observed that the decision was
to be made case-by-case based on the availability of the required technology, local expertise, the
type of data required, the risks of sedation or anaesthesia versus the risks of radiation exposure,
but he also observed that the ideal would be to try using CMR, whenever possible.
167
Emerging Trends in Non Coronary CTA

Dr. D Karthikeyan
DMRD, DNB
Cardiac Radiologist
Vivus Diagnostics, Bangalore
Advances in cardiac CT have brought its use in clinical routine to unprecedented levels, the speaker
noted. In a decade, CCTA could penetrate everyday work, in both specialized and non-specialized
centers, and would provide more functional information on the myocardium, by enabling evaluation
of whether a stenosis is reducing blood flow to the myocardium or not.
It could be very useful in assessing post thrombolysis distal reperfusion in IRA. There is a close
relationship between the presence and size of segmental myocardial hypoattenuation on initial scans
and the likelihood of follow-up segment dysfunction after acute MI in both patent and occluded
arteries. Early perfusion defect observed by using CT would reflect a decrease in the volume of the
vascular bed- that is, a decrease in the myocardial blood flow. When myocardial cells are damaged
and the cell number decreases after an acute MI, the volume of the interstitial space increases
causing myocardial enhancement.
In heart valve diseases, CCT make it possible to non-invasively rule out coronary disease before valve
surgery and to potentially avoid invasive heart catheterization in 66-75% of patients. The same
imaging test could provide abundant anatomic and functional information that complements the
information from echocardiography, making it possible to characterize the etiology of the valve
disease and its repercussions on the heart and aorta, as well as to quantify the severity of disease
affecting the valves of the left side of the heart. In patients with severe aortic stenosis, the speaker
noted that Transcatheter aortic valve implantation (TAVI) is becoming an accepted procedure. Accurate
evaluation of the native aortic valve annular dimensions is critical to optimize selection of the correct
bioprosthetic valve size. Incorrect valve sizing could lead to paravalvular aortic regurgitation, which
is a predictor of worse long-term outcome, valve embolization, patient prosthesis mismatch, and
catastrophic annular rupture.
Multi-phase CCT reconstruction could be used to visualize metallic prosthetic valve motion and
identify valve dysfunction, such as a stuck leaflet. CCT could also image pannus, has good sensitivity
and specificity for identifying large vegetation, and is emerging as a powerful tool in identifying
complications of endocarditis, particularly aortic root abscess. Additionally, mitral valve prolapse,
paradoxical septal bounce data can be obtained by multi-phase CCT. It could also provide knowledge
of cardiac anatomy, which is a prerequisite for successful electrophysiological procedure. And lastly,
the speaker noted that CT has emerged as a competitor to MRI and echocardiography and is being
increasingly used in recent years. The images of cardiac masses are acquired as an adjunct to cardiac
CT coronary angiography.
168
Coming Off Bypass in OR Mishaps:

TEE for the Rescue
Dr. Raj Janardhanan
MD, MRCP, FACC, FASE
Associate Professor, Medicine
Director of Non-Invasive Imaging, South Campus, University of Arizona
The condition of the patient in the OR is not always predictable, with variation in hemodynamics,
pressure, volume and rhythm complicating things, noted the speaker. The doctor always had to be
prepared for a mishap.
A few things to be borne in mind to take care of these things were discussed by the speaker. He
noted that ones needs to look at ventricle appearance, evaluate volume status, check LV underfilling,
and any new wall motion abnormalities. In addition, exact mitral leaflet pathology in MVP, aortic
dimensions in AVR, significance of aortic regurgitation in aorta repair, and any associated valvular AS
in septal myectomy for HOCM have to be determined. Also, thought had to be given on whether
to fix the MR in a case of severe AS, whether to do de-airing of the heart, and if there was any preexisting secondary problem. Being prepared for all these questions puts much more control in the
hands of the doctor in case of any mishap.
In the OR, the speaker noted the role of a TEE operator was very critical, and could function as the
second pair of eyes for the surgeon and the rest of the team. It was very important for the TEE
operator in the OR to be vigilant, efficient and anticipate complications. This could reduce/prevent
the occurrence of a majority of the complications and yield better post-procedural outcomes.
169
An Approach to a Patient with VT with

Structurally Normal Heart
Dr. Rakesh Yadav
MBBS, MD
Department of Cardiology, AIIMS
VT with structurally normal heart also called as idiopathic VT was the topic by the speaker. Speaking
on this condition, he said that the classification was based on the ventricle of origin, the response
to pharmacologic agents, evidence for catecholamine dependence, morphologic features of the
arrhythmia, whether repetitive, non-sustained or sustained.
The most common form of idiopathic ventricular tachycardia originated from the RVOT (60-80%). It
usually exhibited one of the two phenotypes, either non sustained, repetitive monomorphic ventricular
tachycardia or paroxysmal, exercise-induced sustained VT. But both forms were characterized by
adenosine sensitivity. It was more frequent in women and between the ages of 30 and 50 and the
ECG during sinus rhythm was usually unremarkable and normal echo noted.
Exercise testing reproduced the clinical VT only in less than 25 to 50%. Electrophysiologic diagnosis
would be better equipped to detect this. The decision to treat RVOT tachycardia depended on the
frequency and severity of symptoms. If symptoms were infrequent and relatively mild, treatment is not
mandated. If symptoms were severe, then radiofrequency catheter ablation of the arrhythmogenic
focus became the treatment of choice. The initial drug of choice was a beta blocker, and later CCB.
Class I and III drugs also were effective. Acute termination of RVOT tachy could be achieved by
several means like Valsalva, iv adenosine or even iv verapamil and lidocaine.
Although adenosine-sensitive ventricular tachycardia most commonly originates from the RVOT, in
approximately 10 to 15% pf patients, the site of origin was from the LVOT. The tachycardia was
initiated as well as terminated with programmed stimulation and cannot be entrained.
The other form was ILVT, idiopathic left ventricular tachycardia, which was a paroxysmal VT that
originated in the region of the left posterior septum, also known as exercise related VT. The age
group was between 15 to 40 and was predominantly in males, and could be occasionally incessant
in nature resulting in tachycardiomyopathy. The diagnostic triad with induction with atrial pacing,
RBBB with left axis and absence of structural heart disease would be very useful. i.v verapamil was
effective in terminating the tachycardia but radiofrequency has remained the procedure of choice.
The last form of idiopathic left ventricular tachycardia the speaker spoke on was idiopathic propranol
sensitive ventricular tachycardia, and the hallmark of this was that it is not inducible with PES,
but isoproterenol infusion usually induced this VT and beta-blockers were effective in completely
terminating the tachycardia.
170
NSTEACS Conservative Treatment:

For Whom and When?
Dr. Deepak Gupta
MBBS, MD, DM, FSCAI, FESC
Director, Medica Institute of Cardiac Sciences
Jharkand
Many trials like FRISC-II, TACTICS TIMI-18, and RITA -3 had shown that high risk patients of NSTEACS
benefitted from early vascularization. These trials also supported an early invasive approach in
intermediate risk patients. The speaker addressed the role of conservative treatment in NSTE-ACS
ie. optimal medical treatment without coronary angio or optimal medical treatment after coronary
angio.
The conservative strategy involved initial medical management followed by catheterization and
revascularization only if ischemia reoccurred despite vigorous medical therapy, either when the
patient was at rest or during a non-invasive stress test.
Conservative treatment in NSTEACS is for patients with a low risk score, and ischemia guided strategy
is recommended. In very elderly and frail patients with co-morbidities like dementia, severe chronic
renal insufficiency, cancer and high risk of bleeding, invasive procedure could be withheld. The third
option was in the absence of high risk features, when the patient or physician preference would be
taken into account.
In NSTEACs after coronary angiography, conservative treatment could be followed in patients with
normal coronary angiogram in Tako-tsubo cardiomyopathy, coronary thromboembolism, coronary
spasm, coronary microvascular disease.
In conservative treatment in NSTEACS, the duration of dual antiplatelet agents is for at least for 1
month, and a high dose statin can be used. However, as the speaker noted, there were few questions
which needed to be solved like whether high sensitive trop T could replace standard test in India.
Also, there was the question of how to implement CT coronary angio in routine practice of chest
pain triage.
To conclude, the speaker noted that the current risk stratification in NSTEACS was very important.
The invasive approach was useful for very high risk, and intermediate risk patients, while ischemia
guided approach was recommended for low risk patients. Conservative treatment could be offered
after coronary angiography.
171
The Heart Team Concept

Dr. Naresh Trehan
Chairman and Managing Director
Division of Cardio Thoracic and Vascular Surgery
Medanta-The Medicity, Gurgaon
There is paucity of data regarding the utility of coronary artery bypass grafting (CABG) versus
percutaneous coronary intervention (PCI) in patients with multi-vessel disease or left main coronary
artery disease. Dr. Naresh Trehan noted that an objective assessment of the need for PCI versus CABG
would need consideration of the factors illustrated in Figure 1. Furthermore, patient profiling with the
help of SYNTAX score may be useful. SYNTAX score provides guidance on optimal revascularization
strategies for patients with high risk lesions. Components of SYNTAX Score are depicted in Figure 2.
Coronary anatomy
Clinical setting
Co-existing conditions
SYNTAX score
Stable CAD
EUROSCORE
Targets adequate/not
adequate for CABG
Non-ST-ACS
STS score
Lesions can/cannot be
treated with PCI
Cardiogenic shock
STEMI
Ventricular function
Age
Ischaemic burden
Valvular heart disease

Renal insufficiency
Patient-related factors
Pulmonary disease
Frailty
Preference
Coagulation/bleeding disorders
Compliance to antiplatelet agents
Cerebrovascular disease
Tolerance of dual antiplatelet therapy
Peripheral vascular disease
Scheduled non-cardiac surgery
Life expectancy
Need for anticoagulation
Figure 1: Patient factors involved in decision-making.
Total occlusion
Tortuosity
Number of
diseased segments
Diffuse disease
Trifurcation
Bifurcation
SYNTAX score
(11 measures of
lesion complexity)
Aorto ostial
Dominance
Thrombus
Heavy
calcification
Length
Figure 2: SYNTAX score determinants.
172
For optimal outcomes to accrue the presenter underscored the importance of a heart team that
is multidisciplinary in nature comprising of cardiothoracic surgeon, anesthesiologist, interventional
cardiologist, echocardiographer, and operating room/cath lab staff. Figure 3 illustrates an algorithmic
approach to mutlivessel disease and left main stenosis.
Number of coronary arteries with relevant stenosis in proximal segment
1- or 2-vessel disease
Syntax score 22
Proximal LAD involvement
No
3-vessel disease
Syntax score 23
Yes
Low
surgical
risk*
Heart team discussion0
PCI
CABG
Figure 3: An algorithmic heart-team approach to multivessel disease.
Left main
Isolated 1
vessel disease
Ostium/
mid shaft
+ 2 or 3
vessel disease
Distal
bifurcation
Syntax
score 32
Syntax
score 32
High surgical risk
Yes
Heart Team
No
CABG
Figure 4: An algorithmic approach to left main coronary artery disease.
In conclusion, Dr. Naresh pointed to the need for establishing a heart-team approach because
it is an objective decision making process, while it accounts for patient preferences, guideline
recommendations and efficacy of the personnel involved.
173
Obesity Paradox
Dr. S K Dwivedi
MD, DM, FSCAI, FESC, FACC
King Georges Medical University, Lucknow
Obesity (BMI > 30 kg/m2) is associated with increased incidence of CV risk factors. Despite higher
incidence of CV risk factors, obesity is reported to be associated with better outcomes in patients
with CAD, hypertension and heart failure. Dr. Dwivedi discussed this paradox by presenting data that
showed improved survival with increased BMI (Figure 1). In addition, obesity is linked to improved
clinical outcomes following CABG (Table 1), improved survival in heart failure (Figure 3), reduced allcause and CV mortality together with reduced hospitalization in chronic heart failure (Table 2).
3.5
Unadjusted
Adjusted
3.0
2.5
RR
2.0
1.5
1.0
0.5
0.0
Low
weight
Normal
weight
Over
weight
Obese
Severely
obese
Figure 1: Association of bodyweight with cardiovascular mortality

(Romero-Corral, et al).
Table 1: Clinical outcomes at three-year follow-up
Death
Cerebrovascular accident
Myocardial infarction
Repeat revascularization
Repeat CABG
Repeat PCI
Major adverse cardiac and
cerebrovascular events
<25
(n=169)
4.7%
4%
7.7%
10%
2.4%
8.8%
24%
174
CABG (n=604)
BMI (kg/m2)
25-30
>30
(n=299)
(n=136)
5%
3.7%
3%
3%
4.7%
4.4%
6.3%
3%
1%
0%
6.0%
3%
16%
11%
p Value
0.8.
0.77
0.29
0.03
0.15
0.09
0.008
1.0
Cumulative Survival
0.8
0.6
0.4
Underweight (n=164)
Recommended Weight (n=692)
Overweight (n=168)
Obese (n=179)
0.2
0
0
12
18
24
30
36
42
48
54
60
Months
Figure 2: Risk-adjusted survival curves for the four BMI categories.
Table 2: Relation of BMI to Mortality and Hospitalization in Patients with

Chronic Heart Failure
BMI
CV Mortality
Hospitalization
Low
1.20 (1.01-1.43)
1.19 (1.09-1.30)
25-30
0.79 (0.70-0.90)
0.92 (0.86-0.97)
30-35
0.82 (0.64-1.05)
0.99 (0.92-1.07)
>35
0.71 (0.50-1.01)
1.28 (0.88-1.87)
As explained by the presenter, reasons that contribute to this paradox are discussed herein. Firstly,
lower BMI values have been related to low lean mass, a condition also known as sarcopenia. Raised
BMI can be due to preserved or increased lean mass, with better fitness and exercise capacity, and
improvement in metabolic profiles. Higher BMI groups are consistently associated with a higher
prevalence of established cardiovascular risk factors. Therefore, they were more likely to be a target
of effective secondary prevention therapies. Additionally, lower levels of atrial natriuretic peptide and
attenuated response to hormones of the renin-angiotensin-aldosterone system could be a protective
factor.
In conclusion, Dr. Dwivedi proposed the potential usefulness of factors such as abdominal obesity,
waist-hip ratio, % body fat as better predictors of fatness and thus cardiovascular complications. He
noted that basing our decisions on BMI solely could be futile.
175
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H I G H L I G H T S

Cardiological Society of India

1013th February 2016, Chennai Trade Centre, Chennai

With seasonal greetings,

Professor Dr. Santanu Guha

Secretary, Organizing Committee, CSI

Ambulatory Blood Pressure Monitoring: Expanding Indications ...................................... 1

Controversies on HDL Modulation: Likely Explanations .................................................... 2

Acute Decompensated Heart Failure: An Internists Approach .......................................... 4

Status of Non-Statin Anti-Lipidemic Therapy ...................................................................... 5

Heart Failure in the Elderly ................................................................................................... 6

Biomarkers in Heart Failure: Many Shots in the Arm ......................................................... 7

Anti-diabetics and Cardiac Vascular Safety issues .............................................................. 8

Aids to HIV and Heart ........................................................................................................... 9

Ivabradine in CVD: What is New? ....................................................................................... 10

Azilsartan Medoxomil- a New Kid in the Horizon of Hypertension ................................ 11

Calcium Channel Blockers- Newer Perspectives ................................................................ 12

Chronic Constrictive Pericarditis: An Outline of Diagnosis And Management ............... 13

Refractory Angina- Any Silver Lining? ............................................................................... 14

SCAD: When Intervention is Justified? .............................................................................. 15

Thrombolytic Therapy in ACS ............................................................................................. 16

Heart Failure with Preserved Ejection Fraction (HF-PEF):

Newer Oral Anticoagulants ................................................................................................ 18

Granulomatous Diseases of Heart: A Bumpy Road .......................................................... 19

Triglyceride: The End of Road? ........................................................................................... 20

Statins: How to Choose Among the Members? ................................................................ 21

Lipid guidelines in Indian context ...................................................................................... 22

A Guide for the Hypertension Guidelines ......................................................................... 23

Uncomplicated Hypertension: Really That Simple? .......................................................... 24

Present Status of Anti Rheumatic Vaccine ......................................................................... 25

Resistant Hypertension: Causes, Consequences and Care ................................................ 26

Obstructive Sleep Apnea and CVD ..................................................................................... 27

The Future of Anti-Arrhythmic Therapy in AF ................................................................... 29

Pulmonary Hypertension: a Management Approach ....................................................... 30

Management of Hypertension in Acute Stroke ................................................................ 31

Detection of Asymptomatic Atherosclerosis: Whom, When and How? .......................... 32

Device Therapy in HF: How Much is the Dividend? .......................................................... 33

High Gradient across Mitral Prosthesis: My Check List ..................................................... 34

3D Echo is the Standard-of-Care ......................................................................................... 35

Stress Echocardiography for Clinical Decision Making ..................................................... 36

Rare Cases of Cardiac Masses .............................................................................................. 37

Chest Pain in ER Echo in Triage ........................................................................................ 38

Acute Aortic Syndrome ....................................................................................................... 39

Evaluation of Inducible Ischemia by Nuclear scan ............................................................ 40

PET Perfusion Imaging is Better ......................................................................................... 41

Non-Invasive FFRCT: Will it Become a Clinical Reality? ..................................................... 42

Use of Contrast in Ischemic Heart Disease ........................................................................ 43

An Overview of Advanced Cardiac Imaging ..................................................................... 44

Introduction to Cardiac Imaging ........................................................................................ 45

Imaging LA Is it a Crystal Ball of CV Events? .................................................................. 46

Can Routine Echo Predict Future CV Events? .................................................................... 47

Can Ultrasound Reclassify ASCVD Risk? ............................................................................ 48

Echocardiographic Evaluation of the Mitral Valve ............................................................ 49

Case Studies ......................................................................................................................... 50

Vitamin D in the Prevention of Atherosclerosis ................................................................ 51

Newer Anti-Diabetic Drugs : Role in Cardiac Patients ....................................................... 52

Benefit of Yoga in Heart Diseases: Do We Have Evidence? ............................................. 53

Acute Rheumatic Fever: Treatment Controversies ............................................................ 54

Establishing STEMI Care Systems in India ......................................................................... 56

High Intensity Intermittent Exercise and

Ideal Cardiac Rehabilitation Program ................................................................................ 58

Risk Stratification Algorithm for Primary Prevention in Indian Population .................... 59

Emerging Drugs for Obesity: At Last Some Viable Options? ........................................... 60

Dietary Approach to Health: Lessons from the PREDIMED Study .................................... 61