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i n d i a n h e a r t j o u rn a l 6 4 ( 2 0 1 2 ) S 1 2 8eS 1 3 1
Available online at w
journal homepage: www.elsevier .com/locate / ih j
64th Annual CSI Conference and SAARC Cardiac CongressDECEMBER 06e09, 2012, NEW DELHI, INDIA
Cardiovascular Pharmacology
Poster Presentation
Thrombolysis in massive pulmonary embolism:Our clinical experience
Brijesh Agrawal, Snehil Mishra, Irfan Khan, Pranjal Patil, Rajendra
Chavan, Dhirender Singh, Vinay Kumar, Pritesh Punjabi, Sohan
Sharma, Sachin M. Mukhedkar, Madhusudan A. Yemul, Sandeep
N. Patil, Jaywant M. Nawale, Ajay S. Chaurasia
TNMC and BYL Nair Ch. Hospital, Mumbai, India
Aim: To evaluate the efficacy of thrombolysis in massive pulmo-
nary embolism.
Materials & Methods: The hospital course of 24 patients treated
for massive pulmonary embolism demonstrated by CT-
pulmonary angiography, 2D ECHO & ECG findings, over a period
of 2 years, was reviewed. The embolism was termed massive in
the presence of hemodynamic instability &/or RV dysfunction on
2D ECHO &/or CT findings of significant main pulmonary or
proximal right or left pulmonary artery obstruction. The average
age of patients was 47 years with a range of 23 to 84 years. All
patients with no contraindications were thrombolysed with
Streptokinase followed by the course of anticoagulation. Echo-
cardiography was performed before & after therapy & presence of
thrombus in pulmonary artery, Pulmonary Artery Systolic Pres-
sure (PASP) as well as evidence of Right ventricular dysfunction
were noted.
Results: Of the 24 patients, 20 patients were thrombolysed, while 4
had contraindications to thrombolysis. In the thrombolytic arm, 4
patients died with 1 of these 4 dying as a result of intracranial
haemorrhage. In the group of patients not thrombolysed, 3 out of 4
patients died. The echocardiographic features such as PASP &
ventricular dysfunction improved in 12 of the 20 patients throm-
bolysed & the improvement persisted on follow up. None of the
patients whowere not thrombolysed showed any improvement in
Echocardiographic features.
Conclusion: Mortality due to massive pulmonary embolism was
remarkably high (75%) in patients who were not thrombolysed,
while patients who could be thrombolysed had 20% mortality.
Thrombolysis also led to improvement in echocardiographic
parameters, which was sustained on follow up. Incidence of
The author underlined is the Presenting author.
http://dx.doi.org/10.1016/j.ihj.2012.10.031
life threatening bleeding following thrombolysis was low (5%).
Thus our study confirmed the efficacy of thrombolysis in
patients with hemodynamic compromise & a likely benefit
even in those only with RV dysfunction &/or CT features of
massive embolism.
Name of Corresponding Author: Brijesh Agrawal; Designation: Senior
Resident, Department of Cardiology; Address for Correspondence:
Topiwala National Medical College & BYLNair Charitable Hospital,
Mumbai 400008l; Telephone 022 23081758; Fax 022 23542540;
Mobile 8767586093; Email: [email protected].
Safety and efficacy of eptifibatide asantithrombotic agent in pharmacoinvasivetherapy
D.P. Sinha, S. Sau, C.M. Zumder, C. Misra, J. Ghosh
Department of Cardiology, IPGME&R and SSKM Hospital, Kolkata, India
Introduction: Primary PCI is the preferred method of revascular-
isation in STEMI if it can be performed in time. However in our
country negligible percent of patient can achieve the scheduled
door to balloon time of <90 minutes. Use of gp2b3a inhibitor as
antithrombotic agent is class1 indication in primary PCI. But their
use in pharmaco invasive arm is shaded by increase risk of
bleeding. Abciximab is effective but very costly. In our country,
considering the socio-economic status of the population a cheap
though effective antithrombotic agent is required for successful
procedure.
Aims and objectives: To determine the safety and efficacy of
pharmaco-invasive reperfusion strategy utilising full dose of
thrombolytics combined with PCI and intra and postoperative
eptifibatide use as sole antithrombotic agent in STEMI, presenting
in our hospital or referred from outside.
Materials and methods: Prospective data obtained from patient
attending in our hospital with AMI thrombolysed outside or in our
hospital within the schedule time period of 24 hrs of acute event.
Streptokinase was used as thrombolytic agent. They all received
the loading dose of aspirin 325 mg, either Clopidrogrel 600 mg
/prasugrel 60 mg, no heparin, intra & post procedural bolus &
maintenance dose of eptifibatide according to weight adjusted
i n d i a n h e a r t j o u r n a l 6 4 ( 2 0 1 2 ) S 1 2 8eS 1 3 1 S129
dose. Wide range of age from 32-83 yrs, both high and low risk
STEMI, both diabetic and nondiabetic patient included in the
study. All of the patients present within two to twelve hrs of AMI.
Procedures were done at mean six hrs of thrombolysis. End point
event monitored were stroke, major bleeding, reinfarction, stent
thrombosis, SCD due to other complication within one month,
rescue PCI
Results and observations: 62 patients were studied from month
May 2011 till date.49 weremale and 13 were female. Majority were
in 50-59 yrs age group in both male and female (25 and 7respec-
tively). All patients received 1st bolus of eptifibatide after PTCA
wire crossed the lesion.7 patients had no reflow and among them
3 had TIMI 2 flow at the of the procedure. Post procedure 3 (4.8%)
had minor bleed and 1 (1.6%) had major bleed requiring blood
transfusion. 2 (3.2%) patients had subacute stent thrombosis who
died during hospital stay. No Stroke, procedural AMIwas reported.
Conclusion: There was no excess bleeding, ischaemic complica-
tions or mortality in this group although heparin was not used.
Thus it can be concluded that Use of eptifibatide as sole antith-
rombotic agent in patient undergoing pharmacoinvasive therapy
is safe and effective
Abbrebiations: AMI-Acute myocardial infarction. STEMI-ST
Elevation Myocardial Infarction. PCI-Percutaneous coronary
intervention, SCD-Sudden Cardiac Death
Name of Corresponding Author: Prof. D.P. Sinha; Designation:
Professor of Cardiology; Address for Correspondence: Department of
Cardiology, ICVS, IPGME&R and SSKM Hospital, KOLKATA-20;
Mobile 9433018443; Email: [email protected].
Role of platelets in thrombosis; newerantiplatelet therapies: An overview
Gundu H. R. Rao, Professor
Lillehei Heart Institute, University of Minnesota, USA
Platelet hyper-function plays a very important role in the patho-
genesis of atherosclerosis, thrombosis and stroke. Hyperactive
platelets also are implicated in precipitating acute vascular events
in clinical complications associated with type-2 diabetes. Blood
platelets interact with a variety of soluble agonists such as
epinephrine, adenosine diphosphate (ADP), and many insoluble
cell matrix components, including collagen, fibronectin and
biomaterials used for medical devices and drug delivery. These
interactions stimulate specific receptors on the plasma
membrane and initiate the activation of intracellular enzymes.
Ionized calcium is the primary bio-regulator and varieties of
biochemical mechanisms modulate the level and availability of
free calcium. Elevation of cytosolic calcium stimulates phospho-
lipases and release arachidonic acid (AA) from platelet
membranes. Free AA is transformed to bioactive pro-aggregatory
metabolites like prostaglandin endoperoxides and thrombox-
anes. Aspirin inhibits the formation of these active metabolites,
whereas Plavix (Clopidogrel) inhibits ADP mediated activation of
platelets. Aspirin, Plavix and their combinations are the choice of
anti-platelet drugs available for secondary prophylaxis at this
time. In spite of such prophylactic measures, significant numbers
of patients on these therapies are at risk for acute vascular events,
indicating the limitations of these therapeutic modalities. In this
overview, I will discuss platelet physiology, pharmacology, risk
assessment, risk management, anti-platelet therapies,
expectations and limitations of anti-platelet therapies and some
aspects of prevention strategies.
Name of Corresponding Author: Gundu H. R. Rao Ph D; Designation:
Emeritus Professor; Address for Correspondence: Unit 306, North
Tower, 12500 Park Potomac Ave, Potomac, MD, USA 20854; Tele-
phone 301 444 4545; Mobile 952 594 5248; Email: gundurao9@gmail.
com
Cardiovascular manifestations of acuteorganophosphorus poisoning
S. Laudari and Patowary B.S.
DM Resident Cardiology, Professor of Medicine, College of Medical
Sciences, Bharatpur, Nepal, India
Aims and Objectives: This study is aimed to study the different
cardiovascular manifestations and complications of acute
organophosphorus (OP) poisoning.
Materials and Methods: This is a hospital based prospective study
of 115 acute OP poisoning patients presenting in casualty, inten-
sive care unit and medical wards of CMS-Teaching Hospital,
Bharatpur (Nepal) during November 2008 to October 2011. All the
data were entered into pre-structured proforma and then
analyzed by SPSS 15.00.
Results:Majority of the patients had cardiac manifestations in the
form of sinus tachycardia (57/115¼49.57%). Sinus bradycardia was
observed in only 3 (2.61%) patients. The common complications
were: non-cardiogenic pulmonary edema in 23 (20%); electrocar-
diographic abnormalities including prolonged Q-Tc interval in 21
(18.26%); cardiac arrhythmias in 12 (10.43%); ST-T changes in 10
(8.70%) and atrioventricular conduction defects in 5 (4.35%).
Hypertension was detected in 23 (20%) patients and hypotension
in 6 (5.22%). Sixteen (13.91%) patients needed respiratory support
because of acute respiratory failure. Five patients had poly-
morphic ventricular tachycardia. Three patients died from
ventricular fibrillation. The overall mortality during this studywas
8 (6.95%) mainly contributed by WHO Class I compounds like
methylparathion and dichlorvos.
Conclusions: Cardiac complications are commonly encountered
after acute OP poisoning especially with WHO Class I compounds
during the first few hours. Hypoxia, respiratory failure, acid base
disturbances mainly metabolic/mixed acidosis, dyselectrolytemia
and over atropinisation were the major contributing factors.
Intensive supportive treatment and early specific therapy with
atropine and pralidoxime to counteract muscarinic and nicotinic
effects in intensive care unit will definitely help to reduce the
mortalities and morbidities.
Name of Corresponding Author: Dr Shankar Laudari, DM Resident,
Cardiology; Designation: College of Medical Sciences, Bharatpur,
Nepal; Address for Correspondence: Telephone 977 1 56523609; Fax
97756521527;Mobile 9779845112909; Email: [email protected]
Efficacy of high dose atorvastatin after PTCA andits tolerance in Indian patients
K.V. Pranav Kumar, K. Tamilarasu, P. Ramasamy, P. Arun Kumar,
G. Rajendiran, J.S. Bhuvaneswaran
PSG Institute of Medical Sciences and Research, Coimbatore, India
Prasugrel%(n)
Clopidogrel%(n)
Death from cardiovascular causes,
nonfatal MI, or nonfatal stroke
6.4 (12) 9.1 (17)
Nonfatal MI 5.4 (10) 8.1 (15)
Target vessel revascularisation 2.7 (5) 4.3 (8)
Stent thrombosis 1.08 (2) 3.2 (6)
Major or minor TIMI bleeding 5.4 (10) 3.2 (6)
Life threatening bleeding 2.1 (4) 1.6 (3)
Intracranial bleeding 1.08 (2) 0.5 (1)
Bleeding requiring transfusion 4.3 (8) 3.2 (6)
i n d i a n h e a r t j o u rn a l 6 4 ( 2 0 1 2 ) S 1 2 8eS 1 3 1S130
Aim & Objective: To study the efficacy of high dose atorvastatin in
reducing LDL levels after PTCA and to study its tolerance in Indian
patients.
Methods: The study was done on 30 patients who underwent
PTCA in PSG hospitals, Coimbatore from June 2012 to July 2012.
Lipid levels were checked after 1 week of receiving 80mg of ator-
vastatin after undergoing PTCA. Outcome was measured in terms
of number of patients who reached LDL levels of 100 or lower.
Occurrence of any side effects of atorvastatin and SGOT/SGPT
levels were noted at one week.
Results: Out of 30 patients included in the study, at the end of 1
week of therapy with 80mg of atorvastatin, 66% (n¼20) of the
patients had LDL level of <70, 23% (n¼7) had levels of 71-100 and
only 10% (n¼3) had levels >100. Of the 3 patients with LDL levels
>100, the range was 101 to 102. There was no significant elevation
in SGPT and SGOT levels with average value being 29 and 22
respectively. 26% (n¼8) responded positively for adverse effects of
atorvastatin. Side effects reported were minor and included
muscle and joint pain and none of them were severe enough to
discontinue therapy.
Conclusion: High dose atorvastatin is very efficacious in reducing
LDL levels in a short period of time and is well tolerated in Indian
patients.
Name of Corresponding Author: Dr. Pranav Kumar K.V; Designation:
2nd year Resident ( DM Cardiology); Address for Correspondence: PSG
Hospital, Coimbatore; Tel./Fax: 0422 2365000 Mobile þ91
9003346211; Email: [email protected].
Comparative study of prasugrel and clopidogrelin patients undergoing PCI in Indian population.
Prabhu S., Inania R., Bansal N.O.
Sir J. J., Hospital, Mumbai, India
Aims and Objective: To compare the efficacy and safety of pra-
sugrel with clopidogrel in patients with acute coronary syndrome
under going PCI.
Methods: To compare prasugrel, a new thienopyridine, with clo-
pidogrel, we randomly assigned 370 patients (185 in each group)
with moderate to high risk acute coronary syndromes with age
less than 75 years with scheduled percutaneous coronary inter-
vention to receive prasugrel (a 60 mg loading dose and a 10 mg
daily maintenance dose) or clopidogrel (a 300mg loading dose and
a 75 mg daily maintenance dose). Mean body weight was 64 kg.
The primary efficacy endpoint was death from cardiovascular
causes, nonfatal myocardial infarction, or nonfatal stroke. The
key safety end point was major bleeding.
Results: The primary efficacy endpoint occurred in 9.1% of
patients receiving clopidogrel and 6.4% of patients receiving pra-
sugrel.We also found significant reductions in the prasugrel group
in the rates of myocardial infarction (8.1% for clopidogrel vs 5.4%
for prasugrel), urgent target vessel revasularisation (4.3% for clo-
pidogrel vs 2.7% for prasugrel). Major bleeding was observed in
2.1% of patients receiving prasugrel and 1.6% of patients receiving
clopidogrel. Also greater in the prasugrel group was the rate of life
threatening bleeding (2.1% vs 1.6%), bleeding requiring trans-
fusion, (4.3% vs 3.2%) and overall bleeding risk (5.4% with prasu-
grel and 3.2% with clopidogrel).
Conclusion: Our data support the hypothesis that the greater
inhibition of adenosine diphosphate-induced platelet aggregation
by means of prasugrel, a potent oral P2Y12 inhibitor, is more
effective at preventing ischemic events than is the inhibition
conferred by a standard regimen of clopidogrel. However, this
beneficial effect is accompanied by a slight increase in the rate of
major bleeding. When considering the choice of antiplatelet
regimens for the treatment of patients with acute coronary
syndromes who are undergoing PCI, clinicians need to weigh the
benefits and risks of intensive inhibition of platelet aggregation.
Name of Corresponding Author: Sandesh Prabhu; Designation: Senior
Resident, DM Cardiology; Address for Correspondence: Department
of Cardiology, Sir J J hospital, Byculla, Mumbai; Telephone:
02223738947 Fax: 02223735599 Mobile: 9892654409; Email:
Pattern and prevalence of cardiovascular diseasein indoor psychiatric patients in an industrialcity of eastern India
Subodh Kumar and K. N. Thakur
Bokaro General Hospital, Bokaro Steel City, India
Various psychiatric conditions and stress related disorders have
been evaluated as risk factors for the development and expression
of cardiovascular disease. The issue of prevention of cardiac
problems in psychiatric patients has been poorly attended by the
clinicians in this part of the country.
Aims and objects: The present study aims to see the pattern and
prevalence of cardiovascular disease in adult psychiatric patients
admitted in the psychiatry ward of the Bokaro General Hospital in
4-month duration period.
Methods: In this study all the 122 adult psychiatric patients
admitted in the psychiatry ward of the hospital by the psychia-
trists were selected for the examination during a random 4-month
period, April to July, 2012. Pattern and prevalence of cardiovas-
cular disease in these patients were ascertained with the help of
a clinical psychologist (presenting author), the treating psychia-
trists, and the case record files. Sociodemographic and clinical
data-sheet and especially designed psychosocial risk factors
schedule of cardiovascular disease were applied to the subjects.
Results and conclusions: The obtained data are being analyzed.
Results and conclusions of the study and their implications for
prevention of cardiac risk factors in this clinical population will be
discussed at the time of presentation.
Name of Corresponding Author: Subodh Kumar; Designation: Senior
ClinicalPsychologist;Address forCorrespondence:Q.No.3039,Sector-5-
B, Bokaro Steel City, Jharkhand-827006; Ph. 08986873068 Mobile:
09798701542; Email: [email protected].
i n d i a n h e a r t j o u r n a l 6 4 ( 2 0 1 2 ) S 1 2 8eS 1 3 1 S131
A Comparative Evaluation of the Safety andTolerability of the combination of Aspirin andPrazugrel with Aspirin and Clopidogrel in PostPCI patients
Tom Devasia*, Supurna Dhar**, Swapna S.**, Thashma P.P.**,
Yeshwanth Rao**
* Dept of Cardiology, Kasturba Medical College Hospital, Manipal, Kar-
nataka **Faculty, Dept. Of Pharmacology, KMC-IC, Manipal, Karnataka
Background: Prasugrel, a new thienopyridine antiplatelet agent is
indicated for the reduction of thrombotic cardiovascular events
(including stent thrombosis) in patients with acute coronary
syndrome (ACS) who are to be managed with primary or delayed
percutaneous coronary intervention PCI . Prasugrel may be given
concurrently with aspirin for post PCI patients. A potential
concern of prazugrel therapy is its safety, particularly bleeding.
The use of aspirin and clopidogrel in combination has become
part of the standard clinical care of patients with coronary artery
disease. The aim of this study is to compare the safety of 2 anti-
platelet combinations (prasugrel + aspirin vs clopidogrel + aspirin)
in post PCI patients.
Methodology: Seventy three eligible patients were enrolled in the
study and randomised based on the body weight (33 patients in
<60 kg category & 40 in >60kg category) into arms - prazugrel/
aspirin (17 in <60 kgs, 20 in >60kgs) & clopidogrel/aspirin (17 in
<60kgs & 20 in >60kgs). Haemoglobin levels were estimated
before (0 week) and after (12 weeks) the study. Any other adverse
effects were observed during the study.
Results: The mean and the standard deviation between Hb values
before and after antiplatelet combination therapy showed no
significant difference (p¼0.94 & 0.93 in <60 kg, p¼0.56 & 0.81 in
>60 kg resply) in both the groups. No other adverse effects were
observed.
Conclusion: The safety profile of the newer antiplatelet drug
prazugrel (in combination with aspirin) is similar to the current
standard combination of clopidogrel and aspirin.
Oral Presentation
Outcome of high dose tirofiban bolus only versusbolus plus infusion strategy during primary PCIin Acute Myocardial Infarction (AMI)
T. Ghose, R. Kachru, R. Gupta, A. Hussain, S.D. Karloopia,
K.K. Shahi, U. Kaul
Fortis Flt. Lt. Rajan Dhall Hospital, New Delhi, India
Single centre studies have shown that high dose tirofiban (25mcg/
kg) bolus only during elective percutaneous coronary intervention
(PCI) is safe, feasible and has comparable short and intermediate
term out come. Outcome data of such an approach in primary PCI
is rare.
In this retrospective analysis, we compared the in hospital and
30 days MACE amongst all the patients undergoing primary PCI
with tirofiban bolus (Group A) and bolus plus infusion (Group B)
usage between June 2006 to June 2012.
Standard antiplatelet protocol was followed. Inj. Tirofiban
bolus was administered as intravenous/intracoronary bolus (25
mcg/kg over 3 min) or bolus plus infusion (0.15 mcg/kg/min
over 16-18 hours). Inj. Heparin was administered to keep the
intraprocedural ACT between 250-300 seconds. Thrombo-
suction (Thrombuster II, Kaneka Corporation, Japan) was done.
Intracoronary NTG and/or Nicorandil were administered
routinely based on the haemodynamics. Either balloon dilata-
tion followed by stent implantation or direct stenting was
performed. In trans radial approach the sheaths (6F, Avanti,
Cordis) were removed in lab and pneumatic radial compression
device (TR band, Terumo, Japan) was applied. In transfemoral
approach the sheath (6F, 7F, Cordis) were removed at ACT < 160
sec.
Baseline demographic profile was comparable between two
groups. Post procedural TIMI III flow was achieved in 48 (94%) in
group A compared to 190 (95.4%) in group B (P¼NS).
Post procedural TMP flow was grade 1 in 1 (2%) vs 3 (1.5%), TMP
grade 2 flow was in 24 (47.05%) vs 76 (38.1%) and TMP grade 3 flow
was 26 (50.9%) vs 120 (60.3%) patients in group A and B respectively
(P¼NS). Mean left ventricular ejection fraction was 38þ12% vs
39þ14% in group A & B respectively (P¼NS). Death was recorded in
1 (1.9%) vs 2 (1.0%) in Group A & B respectively (P¼NS). Myocardial
infarction occurred in 5 (9.8%) vs 6 (3.0%) in Group A& B respective
(P¼NS). TVR occurred in 3 (5.9%) vs 2 (1.0%) in Group A & B
respectively. TIMI Major bleeding occurred in 6 (11.7%) vs 8 (4.02%)
in Group A & B respectively (P¼NS). TIMI Minor bleeding occurred
in 10 (11.7%) vs 12 (4.02%) in Group A & B respectively (P¼NS). Any
bleeding occurred in 16 (31.3%) vs 20 (10.05%) in Group A & B
respectively (P¼NS).
High dose tirofiban bolus only dose in the setting of primary PCI
is safe, useful and is associated with similar outcome when
compared with bolus plus infusion strategy. Large prospective
randomized controlled trial is warranted.
Name of Corresponding Author: Dr. Tapan Ghose; Address for
Correspondence: 6020/D-6 Vasant Kunj, New Delhi 110070 Mobile
9811695113; Email: [email protected].