Healthy Heart (Vol-5, Issue-57) August, 2014 - Dr. …under certain conditions. This is known as...

Volume-5 | Issue-57 | August 5, 2014

Price : 5/-`

Healthy HeartHonorary Editor :

Dr. Vineet Sankhla

From the desk of Hon. Editor:

Dear Friends,

During the last few decades, acute ST-

elevation on an ECG in the proper

clinical context has been a reliable

surrogate marker of acute coronary

occlusion requiring urgent reperfusion.

In 2004, the ACC/AHA STEMI guidelines

specified ECG criteria that warrant

i m m e d i a t e r e v a s c u l a r i z a t i o n

(thrombolysis or PCI) but new findings

have emerged that suggest a

reappraisal is warranted. Although

STEMI criteria are well established,

interest is emerging in other cardiac

conditions that also benefit from

timely intervention, specifically “STEMI

Equivalents,” which warrant similarly

aggressive and definitive intervention.

ECG changes consistent with cardiac

ischemia & lacking ST elevation include

(1) ST elevation in lead aVR, (2) Wellens

Sign, (3) the de Winter ST/T complex (4)

pathologic ST changes in the presence

of left bundle branch block (4) Isolated

PWMI. Increased awareness about the

ST E M I e q u i v a l e nt s fa c i l i ta te s

communication between emergency

physicians and cardiologists.

- Dr. Vineet Sankhla

Novel ECG Patterns Of Ischemia In Acute Coronary Syndrome

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Dr. Ajay Naik (M) +91-98250 82666

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Dr. Dhiren Shah (M) +91-98255 75933

Dr. Hiren Dholakia (M) +91-95863 75818Dr. Chintan Sheth (M) +91-91732 04454Dr. Niren Bhavsar (M) +91-98795 71917

Dr. Kashyap Sheth (M) +91-99246 12288 Dr. Milan Chag (M) +91-98240 22107

Dr. Amit Chitaliya (M) +91-90999 87400

Dr. Ajay Naik (M)

Dr. Vineet Sankhla (M) +91-99250 15056

+91-98250 82666

Dr. Shaunak Shah (M) +91-98250 44502

Dr. Milan Chag (M) +91-98240 22107

Dr. Urmil Shah (M) +91-98250 66939

Dr. Hemang Baxi (M) +91-98250 30111

Dr. Anish Chandarana (M) +91-98250 96922

Cardiologists Cardiothoracic & Vascular Surgeons Cardiac Anaesthetists

Neonatologist and Pediatric IntensivistPediatric & Structural Heart Surgeons

Congenital & Structural Heart Disease SpecialistCardiac Electrophysiologist

The ECG criteria of ST Elevation MI (STEMI)

according to third universal definition of

MI by AHA/ESC 2012 are:

New ST Elevation (STE) of “J” Point in at

least two Contiguous leads :

in leads V2 – V3

≥ 2.5 mm (0.25mV) in men < 40 years

≥ 2.0 mm (0.20mV) in men ≥ 40 years

≥ 1.5 mm (0.15 mV) in women

and/or ≥ 1mm (0.1 mV) in other

contiguous chest leads or limb leads

(other than V2 – V3)

The axiom of “Time is Muscle” affects

nearly every medical professional

involved in emergency cardiac care. The

advantage of early revascularization and

the importance of “golden hour” in the

management of STEMI are extensively

highlighted. At the same time, a

conservative strategy with medical

management is often prescribed in

patients presenting with an unstable

Dr. Pranav Modi +91-99240 84700(M)

Cardiovascular, Thoracic &Thoracoscopic Surgeon

angina and NSTEMI which lack ST

elevation in ECG. Although the ECG

criteria of STEMI are well established,

interest is emerging in certain other ECG

changes of coronary ischemia which also

benefit from timely intervention and

warrant similar aggressive & definitive

intervention. These are called as “STEMI

Equivalents”. They are defined as any

ECG pattern potentially associated with

an acute coronary occlusion but lacking

“classic” ST-elevation.

They include:

1. STE in aVR

2. Wellens Syndrome

3. De Winter ST/T wave complex

4. Pathological STE in LBBB

5. PWMI

In a patient presenting with symptoms of

ischemia, the ECG signs suggesting LMCA

occlusion are STE in aVR with STD (ST

depression) in multiple leads (> 6 leads).

1. ST ELEVATION IN AVR

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Healthy Heart

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d) No pathological precordial Q waves

or loss of R waves

e) ST segment in V2 and V3 that is

isoelectic or minimally elevated,

concave or straight

f) Symmetric and deep T inversion

(Wellens type 1) or biphasic T waves

in V2-V5 (Wellens type 2) in pain free

periods

g) Tight Proximal LAD stenosis

Wellens sign may reveal as subtle ST T

waves changes, but it is important to

recognize this sign as most of the

pat ients do not do wel l wi th

conservative Rx. This sign is mainly seen

during chest pain free intervals, unlikely

to be diagnosed by computer analysis

and most important – “ TMT is

contraindicated in such patients”. (Fig 2)

Figure-1 : STE in aVR with STD in multiple leads. Note the STE in aVR > STE in V1 s/o LMCA occlusion

Figure-2 : Wellens Syndrome (Type 2) - Biphasic T waves in V2-V4 with normal

R wave height. Note no or minimal STE in V2-V4

STE in aVR is not entirely specific for

LMCA occlusion and can also be seen in

TVD or Proximal LAD disease. However

STE in aVR > STE in V1 is specific for

LMCA occlusion and not seen in

Proximal LAD disease. (Figure 1)

Wellens' syndrome is a pattern of ECG T-

wave changes associated with critical,

proximal LAD stenosis, also referred to

as LAD coronary T-wave syndrome. This

sign in ECG was described by Prof. H

Wellens in 1982. It suggests a pre-

infarction stage and 75% will progress to

extensive MI in 2-3 weeks if untreated.

Wellens' Syndrome Criteria are:

a) Prior h/o of Chest Pain

b) Chest pain with near normal ECG

c) Normal or minimally elevated

cardiac enzymes

2. WELLENS' SYNDROME

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Healthy HeartVolume-5 | Issue-57 | August 5, 2014

Figure-3 : De Winter Sign - Upsloping J point depression with persistent tall

T waves in precordial leads

Figure-3 : Sgarbossa Criteria for diagnosing MI in presence of LBBB

associated with IWMI or Lateral wall MI.

In spite of absence of STE in ECG, an

isolated PWMI is an indication for

thrombolysis and diagnosis is often

missed.

applied in Ventricular Paced Rhythm

patients presenting with chest pain.

Isolated PWMI is uncommon. It is mostly

5. POSTERIOR WALL MI

3. DE WINTER SIGN

4. SGARBOSSA CRITERIA

De Winter et al published in NEJM 2008

about a novel ECG sign of Acute

Proximal LAD occlusion. De Winter sign

is 1-3 mm of ST depression that is up-

sloping at the J point in leads V1 through

V6 and associated with persistently tall,

upright, and symmetric precordial T-

waves. It is relatively uncommon (~2%)

but highly specific sign of acute Proximal

LAD occlusion. It is different from

Hyperacute phase of acute MI showing

tall ischemic T waves; rather than

evolution of tall, peaked (hyperacute) T

waves into frank STEMI, the De Winter T

wave pattern remain static over the next

few hours. None of the patients with De

Winter sign had acute LMCA occlusion

(Fig 3)

A new or presumed new onset LBBB is a

criterion for thrombolysis. However

studies have shown that more than 90%

of patients with LBBB in ER do not have

coronary occlusion. Hence this criterion

is likely to be demoted in future

guidelines. The caveat is SGARBOSSA

criteria (Fig 4)

Any score of ≥ 3 is consistent with Acute

MI and can be considered for

thrombolysis. The same criteria can be


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The ECG criteria of PWMI are

n

with

n STD in leads V1, V2

n Upright T waves in V1, V2, V3

A 15 lead ECG with posterior leads (V7

V8 V9) increases the sensitivity for

diagnosing Posterior wall ischemia by

90%. However only 0.5mm elevation in

posterior leads is required to diagnose a

PWMI. Hence avoid diagnosing STD in

the early precordial leads as a NSTEMI.

PWMI is a condition benefiting from

acute reperfusion therapy and remain

vigilant for R wave and ST segment

pathology in leads in V1 through V3 in a

patient with ACS. (Fig 5).

Tall R waves, R/S ≥ 1 in V1, V2,V3

Figure-5 : PWMI - R/S ≥1 in V2-V3 with ST depression in V1-V3

MD, D.Sc.(Hon)FACC, FAHA, FISCU(D), FICA, FACA, FICP (Hon),

FIAE, FICMU (Hon), FACIP, FCSC (S), FIACS, FICC (Hon)

Organized by:


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At CIMS... we care

Dr. Navin NandaRecognized by International Society of Cardiovascular Ultrasound

Advanced Echocardiography Workshop

September 11-12, 2014 (9 am to 5 pm)

Venue : CIMS Hospital, Ahmedabad

Registration Fees :

Before August 31, 2014 ` 10,000/-

After August 31, 2014 & ` 15,000/-

Spot Registration

Text book of Echocardiography ` 7,000/-

by Dr Navin Nanda (Optional)

Lectures

Live Cases Demonstration

u Various advance Techniques in Echocardiography

u Indication of Contrast Echocardiography and its Clinical Application

u Tissue Doppler and its Application in Diastolic Dysfunction

u Trans Esophageal Echocardigraphy (TEE) - Indication and how to Approach

u Stress Echocardiography - Case Selection and Application

u 3D Echo & Strain imaging - applicationsu Interactive Session of interesting echo

u Contrast Echou Stress Echou Combined Contrast & Stress Echou Tissue Doppleru 3D Echo & Strain Imaging techniquesu Transesophageal Echocardiography

Mr. Nirav Patel : 090990 66528

Mr. Mahendra Desai : 090990 66527

For registration contact

Email: [email protected]

CIMS Hospital : Opp. Shukan Mall, Off Science City Road, Sola, Ahmedabad-60.

Phones : +91-79-3010 1059/60/61Website: www.cims.me


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Hypertrophic cardiomyopathy (HCM) is a primary disease of the myocardium in which a portion of the myocardium(the septal wall ) is thickened without any obvious cause. It is a leading cause of sudden cardiac death in young athletes and younger people are likely to have a more severe form of hypertrophic cardiomyopathy .With Hypertrophic Cardiomyopathy the cardiac myocytes increase in size, which results in the septal thickening . In addition, the normal alignment of muscle cells is disrupted (myocardial disarray).

HCM is most commonly due to a gene mutation in the primary component of the myocytes (the sarcomeres) and is inherited in an Autosomal dominant manner(50% of siblings inherit the disease from parents).HCM appears in all racial groups. The prevalence of HCM is about 0.2% to 0.5% of the general population. The clinical course of HCM is variable. Many patients are asymptomatic or mildly symptomatic. The patients may present with dysnea , angina, palpitations,lightheadedness, fatigue, syncope and sudden cardiac death. Major risk factors for sudden death include prior history of cardiac arrest or ventricular fibrillation, spontaneous sustained ventricular tachycardia, family history of premature sudden death, unexplained syncope, Left ventricular thickness greater than or equal to 30 mm, abnormal exercise blood pressure and nonsustained ventricular tachycardia.Presence of one of these risk factors may necessitate placement of Implantable Cardioveter Defibrillator device.

In as much as 70% of patients obstruction can be provoked under certain conditions. This is known as dynamic outflow obstruction Dynamic outflow obstruction (when present in HCM) is usually due to systolic anterior motion of the anterior leaflet of the mitral valve popularly known as SAM and is also the cause of mitral regurgitation in these patients.

The primary goal of medications is to relieve symptoms such as chest pain, shortness of breath, and palpitations. Beta-blockers are considered first-line agents, as they can slow down the heart rate. For patients who cannot tolerate beta blockers or do not have good control of symptoms with beta blockers, nondihydropyridine calcium channel blockers can be used. Dihydropyridine calcium channel blockers should be avoided in patients with evidence of obstruction. For patients who continue to have symptoms despite the above treatments, Patients who continue to have symptoms despite drug therapy can consider more invasive therapies

Surgical Septal Myectomy is an open heart operation done to relieve symptoms in patients who remain severely symptomatic despite medical therapy. In experienced centers surgery have mortality of less than 1% and success rate of 85%. It involves a median sternotomy (general anesthesia, opening the chest, and cardiopulmonary bypass) and removing a portion of the interventricular septum thus relieving the obstruction and improving SAM and mitral regurgitation.Complications of septal myectomy surgery include , arrhythmias, infection,incessant bleeding, septal perforation/defect and stroke. Complete heart block can occur in 2-5% of patients necessitating a Permanent pacemaker implantation.Some patients may need Mitral valve replacement if mitral regurgitation persists after myectomy.

Alcohol septal ablation is a percutaneous technique that involves injection of alcohol into one or more septal branches of the left anterior descending artery causing localize infarction and scarring ,thus reducing the LV outflow tract obstruction.The results from septal ablation are inferior to surgical myectomy ,thought it can be used prior to surgical myectomy in select group of patients with a large septal artery.

Hypertrophic Obstructive Cardiomyopathy (HOCM) - Untouched Catastrophic

CIMS Hospital Cardiothoracic Vascular Surgery Department & Gujarat Cardiothoracic Surgeons Club organized first of its kind in Gujarat a Live Workshop on Hypertrophic obstructive cardiomyopathy (HOCM) – Extended Septal Myectomy on Sunday, the 27th of July 2014 at CIMS Hospital Auditorium. Two patients were operated for this very rare anamoly with excellent results. This type of surgeries are rarely done in India.

Dr. Dhiren Shah & Dr. Milan Chag of CIMS hospital conducted the workshop. Visiting Faculty were Dr. Sujay Shad and Dr. Sumir Dubey from Ganga Ram Hospital, New Delhi.

Courtesy : CIMS Cardiac Surgery Team

Dr. Dhiren Shah+91-98255 75933

Dr. Dhaval Naik +91-90991 11133

Dr. Saurabh Jaiswal+91-95867 25827


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Indian Society of Electrocardiology (ISE)

& Ahmedabad Physician Association (APA)

Organizes

Advanced ECG Learning Course

Radisson Blu,Near Panchvati Cross Roads, Off C.G. Road, Ambawadi, Ahmedabad-380006.

Venue : Date & Time :

August 31, 2014

Sunday

10 am to 2 pm

10.00 AM Asymptomatic person with Arrhythmia Risk- How to

Manage (WPW/ Brugada / AF etc.)

- Dr. Yash Lokhandwala

10.20 AM ECG vs Holter vs ELR vs ILR - Dr. Hygriv Rao

10.40 AM Tachycardiomyopathy Cause & Management

- Dr. Kartikeya Bhargava

11.00 AM Tough Clinical scenarios in Arrhythmias - Dr. Ajay Naik

11.20 AM Discussion - All Faculty

11.30 AM Break

12.00 PM The J wave Spectrum from Early Repolarization to

Idiopathic VF - Dr. Kartikeya Bhargava

12.20 PM Wide QRS Tachycardia: Always a Conundrum

- Dr. Yash Lokhandwala

12.40 PM Novel Signs of Acute Ischemia / ECG Risk Stratification of

ACS - Dr. Vineet Sankhla

01.00 PM Scar related VT - Problem & Solution - Dr. Hygriv Rao

01.20 PM Discussion

01.30 PM Lunch

For registration contact : Mr. Mahendra Desai:+91-90990 66527, Mr. Nirav Patel:+91-90990 66528

Mr. Ketan Acharya:+91-98251 08257

Course Director

Dr. Ajay Naik, MD, DM, DNB, FACC, FHRS

President, Indian Society of ElectrocardiologyMD Physicians,

Post graduates in Medicine

Who should attend :

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January 23-25, 2015

JIC 2015

Conference Secretariat

CIMS Hospital, Nr. Shukan Mall, Off Science City Road, Sola, Ahmedabad-380060

Phone : +91-79-3010 1059 / 1060 Fax: +91-79-2771 2770

Email : [email protected], www.jicindia.orgCIMSRE

Care Institute

Medical Society

for Research

and Education

GMERS

Medical College,

Sola, Ahmedabad

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For more information / download Registration Formwww.jicindia.org

Important

Announcement

JIC 2015 at a Glance

Last date of refundable registration for

MD Physicians is August 31, 2014.

Over 1000 registrations confirmed

January 23, 2015 - Main SessionDay - 1q

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q

Introduction Session

Coronary Artery Disease / Acute

Coronary Syndromes

Plenary Lectures by International

Speakers

January 23, 2015 - Satellite SessionsDay - 1

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q

Pharmaology & Therapeutics - 1 & 2

Cardiology Guidelines

January 24, 2015 - Main SessionDay - 2q

q

q

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Interactive ECGs/Arrhythmia

Atrial Fibrillation/ Arrhythmia

Plenary Lectures

CIMS-Oration

January 25, 2015 - Pulmonary and Critical Care Conference

January 25, 2015 - Certification CourseDay - 3

q Internal Medicine / Clinical Cardiology

q

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Peripheral/ Endovascular /Diabetic Foot

Stroke

q

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Congenital Heart Disease

Heart Failure

Live Case Session

/ Structural

q

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q

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Hypertension/Lipids & Cardiovascular Risk

Management

Medical Devices in Cardiology / Interventional

Cardiology

Debates

Special Topics

January 24-25, 2015 - JIC Onco Meet

Printed, Published and Edited by Dr. Keyur Parikh on behalf of the CIMS HospitalPrinted at Hari Om Printery, 15/1, Nagori Estate, Opp. E.S.I. Dispensary, Dudheshwar Road, Ahmedabad-380004.

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PATIENTS WHO ARE ELIGIBLE

Endovascular Workshop Peripheral August 21-22, 2014with Dr. Ashit Jain, USA

l l l

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Carotid Artery Stenosis Renal Artery Stenosis Acute Limb Ischemia

Critical Limb Ischemia Varicose Veins Dialysis Access Procedures

Pulmonary Embolism Thoracic Outlet Syndrome Uterine Fibroids

Vascular Malformations Venous Insufficiency and Venous Ulcers

Claudication Femoropopliteal Disease Brachiocephalic Arterial Disease

Venous Thromboembolic Disease Thoracic Abdominal Aortic Aneurysms

Mesenteric Disease Catheter-Based Interventions for Failing Hemodialysis Accesses

Infrapopliteal Peripheral Arterial Disease Intracranial Arterial Stenotic Disease

Vertebral Arterial Disease

Daily screening camp of the concerned patients is being held at CIMS Hospital. Time: 2.00 pm - 6.00 pm

PATIENTS WILL BE PROVIDED FOLLOWING FREE SERVICES:

1. Consultation 2. ABI 3. Doppler (Arterial or Varicose Veins - if indicated)

You may call any of our CIMS Cardiologists listed on the front page

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CIMS Hospital, Nr. Shukan Mall, Off Science City Road, Sola,Ahmedabad-380060. Phone : +91-79-2771 2771-75 (5 lines) For appointment call : +91-79-3010 1200, 3010 1008 (9 am-5 pm)Mobile : +91-98250 66661 or email onemail : web :

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Healthy Heart (Vol-5, Issue-57) August, 2014 - Dr. …under certain conditions. This is known as...

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