Annual CSI Delhi Proceedings

12:38 pm Health Care

Take Home Messages

1.            Col C P Roy: Stains are safe. The concern about them causing diabetes is of no concern.

2.            Dr Rakesh Yadav: Venous grafts will lose 10% in the first month, another 10% in the firth year and then 2% every year. Bare stents are good enough for graft stenosis.

3.            Dr Sanjiv Sharma: For coronaries angiogram: look for anatomy (origin, course, termination); luminal abnormality; lesion and consequences on LV.

4.            Dr Sanjiv Sharma: all views are not required in coronary angiogram. LA caudal view gives maximum radiation.

5.            Dr Sanjiv Sharma: Never use le than 30 ml contrast in LV angiogram

6.            Dr R Juneja: Lead 2 is the best lead to study electro physiology

7.            Dr R Juneja: Left axis deviation with RBBB has to be ventricular tachycardia

8.            Dr R Juneja: MI with RVOT tachycardia is not due to MI

9.            Dr R Juneja: Do not send cases with bradycardia for EP studies.

10.          Dr S S Kothari: BP of 130 mm Hg rues out constrictive Pericarditis is not true

11.          Dr S S Kothari: BP of > 15 mm Hg systolic rules out AS is not true

12.          Dr S S Kothari: Any amount of gradient in mitral valve is abnormal

13.          Dr Rajnish Sardanna: Dronedarone is a class III antiarrhythmic agent that may be considered for the maintenance of sinus rhythm in patients with atrial fibrillation (AF).

14.          Dr Rajnish Sardanna: Dronedarone has many electrophysiological properties in common with amiodarone, including its antiadrenergic (ie, beta blocking) properties and the ability to inhibit multiple transmembrane potassium, sodium, and calcium currents.

15.          Dr Rajnish Sardanna: In contrast to amiodarone, which has an effective half-life of up to 50 days, dronedarone has a half-life of approximately 24 hours.

16.          Dr Rajnish Sardanna: Because of its hepatic metabolism, there are numerous potential drug interactions with dronedarone. Concomitant use of dronedarone with some medications (eg, ketoconazole, class I antiarrhythmic drugs) is contraindicated, while its use with other medications (eg, digoxin,warfarin, statins) may require dose adjustment.

17.          Dr Rajnish Sardanna: Trials have shown that dronedarone is more effective than placebo but less effective than amiodarone for the maintenance of sinus rhythm in patients with AF. However, dronedarone may be preferred in certain patient populations.

18.          Dr Rajnish Sardanna: Dronedarone (400 mg twice daily) is used for the maintenance of sinus rhythm in patients with paroxysmal or persistent AF or atrial flutter and no evidence of heart failure or left ventricular systolic function who have spontaneously reverted to sinus rhythm or in whom cardioversion is planned.

19.          Dr Rajnish Sardanna: Dronedarone should NOT be prescribed exclusively as a rate control medication and the results of the PALLAS trial, which demonstrated an increase in cardiovascular mortality when dronedarone was used solely as a rate controlling agent.

20.          Dr Rajnish Sardanna: Dronedarone is only rarely effective for the chemical cardioversion of AF or atrial flutter to sinus rhythm (less than 10 percent of patients). As such, dronedarone should NOT be used for this purpose.

21.          Dr Rajnish Sardanna: FDA warning has been issued in 14.1.11 and 21.7 11

22.          Dr A K Omar: Early initiation of dual antiplatelet therapy with aspirin and either a P2Y12 receptor blocker or GP IIb/IIIa inhibitor helps in all patients with non-ST elevation ACS, whether they are managed by a conservative or an invasive strategy.

23.          Dr A K Omar: For all patients with non-ST elevation ACS, give dual anti platelet therapy with aspirin 300mg and a P2Y12 receptor blocker.

24.          Dr A K Omar: The loading dose for ticagrelor is 180 mg, for prasugrel 60 mg, and for clopidogrel 300-600 mg.

25.          Dr A K Omar: For those patients with a history of gastrointestinal bleeding, drugs which reduce the risk of recurrent bleeding (eg, proton pump inhibitors) should be given.

26.          Dr A K Omar: For those patients scheduled for an early invasive approach, we recommend giving either ticagrelor (at presentation) or prasugrel (with definition of coronary anatomy), as opposed to clopidogrel

27.          Dr A K Omar: For those patients who are managed with a delayed invasive approach (coronary angiography after four hours), start ticagrelor (at presentation) instead of clopidogrel and suggest ticagrelor instead of prasugrel (with definition of coronary anatomy)

28.          Dr A K Omar: For those patients managed without an invasive approach (conservative approach), start ticagrelor as opposed to clopidogrel

29.          Dr A K Omar: Give indefinite aspirin for all patients with non-ST elevation acute coronary syndromes

30.          Dr A K Omar: Give clopidogrel (75 mg/day) or prasugrel (10 mg for patients ≥60 kg) or ticagrelor 90 mg twice daily for at least one year in all patients with non-ST elevation ACS

31.          Dr Subhash Chandra: Apixaban or rivaroxaban in atrial fibrillation — Apixaban and rivaroxaban are two newer oral anticoagulants that do not require laboratory monitoring. In two randomized trials in patients with atrial fibrillation that compared one of these drugs to warfarin, ARISTOTLE and ROCKET-AF, apixaban and rivaroxaban (respectively) met the criteria for non-inferiority for the lowering of the risk of stroke and systemic embolization. Based on these two trials, and the results of the older RE-LY trial of dabigatran, one should sue a direct thrombin inhibitor or a factor Xa inhibitor rather than warfarin in patients with atrial fibrillation who require anticoagulation.

32.          Dr Sandeep Bansal: The World Health Organization (WHO) classifies patients with pulmonary hypertension (PH) into five groups based upon etiology. Patients in the first group are considered to have pulmonary arterial hypertension (PAH), whereas patients in the remaining four groups are considered to have PH

33.          Dr Sandeep Bansal: Vasoreactivity test — It is recommended that patients with group 1 PAH undergo a vasoreactivity test. This involves the administration of a short-acting vasodilator and then measurement of the hemodynamic response using a right heart catheter. Agents commonly used for vasoreactivity testing include epoprostenol, adenosine, and inhaled nitric oxide:

Epoprostenol is infused at a starting rate of 1 to 2 ng/kg per min and increased by 2 ng/kg per min every 5 to 10 minutes until a clinically significant fall in blood pressure, an increase in heart rate, or adverse symptoms (nausea, vomiting, headache) develop.

Adenosine is administered intravenously in doses of 50 mcg/kg per min and increased every two minutes until uncomfortable symptoms develop or a maximal dose of 200 to 350 mcg/kg per min is reached

Inhaled nitric oxide administered at 10 to 20 ppm is selective for the pulmonary vasculature.

An acute vasoreactivity test is considered positive if mean pulmonary artery pressure decreases at least 10 mmHg and to a value less than 40 mmHg, with an increased or unchanged cardiac output, and a minimally reduced or unchanged systemic blood pressure. Patients with a positive vasoreactivity test are candidates for a trial of CCB therapy with a dihydropyridine or diltiazem.

34.          Dr Praveen Chandra: A number of newer medical and invasive therapies have been evaluated for use in patients with stable angina. Of these, only ranolazine, a late sodium channel blocker, has been approved for clinical use and its role is evolving

35.          Dr Praveen Chandra: Ranolazine can be used as an option for angina patients who have failed all other anti anginal therapies. The initial dose of ranolazine is 500 mg twice daily. For patients who remain symptomatic, 1000 mg twice daily may be used.

36.          Dr Praveen Chandra: Ivabridine  is a novel agent that acts specifically on the sinus node ionic channels to slow the heart rate. There is no effect on blood pressure, conduction, or cardiac contractility. This results in isolated slowing of the pulse and consequent improvement in angina threshold without the side effect of depression, cardiac function, or potentially increasing atrio-ventricular block

37.          Dr Praveen Chandra: Stable angina pectoris, or stable angina, refers to chest discomfort that occurs predictably and reproducibly at a certain level of exertion and is relieved with rest or nitroglycerin.

38.          Dr Praveen Chandra: The goals of treatment of stable angina involve therapies to prevent/minimize ischemia and to improve survival. These goals can be achieved with a variety of modalities including medical therapy, non pharmacologic and lifestyle measures, and revascularization with either percutaneous coronary intervention (PCI) or coronary artery bypass graft surgery (CABG).

39.          Dr Praveen Chandra: In chronic stable angina there are two primary indications for coronary angiography followed by revascularization of appropriate lesions: Angina that significantly interferes with a patient’s lifestyle despite maximal tolerable medical therapy and patients with high-risk criteria and selected patients with intermediate-risk criteria on noninvasive testing, regardless of anginal severity.

40.          Dr Praveen Chandra: Revascularization is performed in appropriate patients in whom angiography reveals anatomy for which revascularization has a proven benefit or in whom medical therapy has failed.

41.          Dr Praveen Chandra: The choice between PCI and CABG is based upon anatomy and other factors such as left ventricular function and the presence or absence of diabetes. With the availability of drug-eluting stents, PCI is increasingly performed for most lesions.

42.          Dr U Kaul: Prospective trials have demonstrated that fibrinolytic therapy is not beneficial in patients with a non-ST elevation ACS

43.          Dr U Kaul: TIMI risk score: Outcome in patients with unstable angina or an NSTEMI; a value of one was assigned when a factor was present and 0 when it was absent.

•             Age ≥65 years

•             Presence of at least three risk factors for CHD (hypertension, diabetes, dyslipidemia, smoking, or positive family history of early MI)

•             Prior coronary stenosis of ≥50 percent

•             Presence of ST segment deviation on admission ECG

•             At least two anginal episodes in prior 24 hours

•             Elevated serum cardiac biomarkers

•             Use of aspirin in prior seven days (which is probably a marker for more severe coronary disease)

Patients are considered to be at low risk with a score of 0 to 1; intermediate risk with a score of 2 to 3; and high risk with a score of 4 to 7.

44.          Dr U Kaul: Bad prognosis markers: St depression, positive troponin and low estimated GFR

45.          Dr U Kaul: In angina there are three presentations of angina that suggest an acute coronary syndrome (ACS):Rest angina, which is usually more than 20 minutes in duration; New onset angina that markedly limits physical activity and Increasing angina that is more frequent, longer in duration, or occurs with less exertion than previous angina

46.          Dr U Kaul: UA and NSTEMI differ primarily in whether the ischemia is severe enough to cause sufficient myocardial damage to release detectable quantities of a marker of myocardial injury (troponins): UA is considered to be present in patients with ischemic symptoms suggestive of an ACS and no elevation in troponins. NSTEMI is considered to be present in patients having the same manifestations as those in UA, but in whom an elevation in troponins is present

47.          Dr U kaul: Since an elevation in troponins may not be detectable for hours after presentation, UA and NSTEMI are frequently indistinguishable at initial evaluation. As a consequence, initial management is the same for these two syndromes.

48.          Dr U Kaul: The 2007 ACC/AHA guidelines has concluded that anticoagulant therapy should be added to anti platelet therapy in most patients with ACS

49.          Dr U Kaul: For patients managed with an invasive approach, UFH, enoxaparin, bivalirudin, and fondaparinux all have established efficacy.

50.          Dr U Kaul: For patients managed with a conservative strategy, enoxaparin, UFH, or fondaparinux are recommended. Fondaparinux is better.

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