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AIM: Mitral stenosis (MS) is found to produce left ventricular (LV) dysfunction in some studies. We sought to study the left ventricular function in patients with rheumatic MS undergoing balloon mitral valvotomy (BMV). Ours is the first study to analyze effect of BMV on mitral annular plane systolic excursion (MAPSE), and to quantify prevalence of longitudinal left ventricular dysfunction in rheumatic MS. METHODS: In this prospective cohort study, we included 43 patients with severe rheumatic mitral stenosis undergoing BMV. They were compared to twenty controls whose distribution of age and gender were similar to that of patients. The parameters compared were LV ejection fraction (EF) by modified Simpson's method, mitral annular systolic velocity (MASV), MAPSE, mitral annular early diastolic velocity (E'), and myocardial performance index (MPI). These parameters were reassessed immediately following BMV and after 3 months of procedure. RESULTS: MASV, MAPSE, E', and EF were significantly lower and MPI was higher in mitral stenosis group compared to controls. Impaired longitudinal LV function was present in 77% of study group. MAPSE and EF did not show significant change after BMV while MPI, MASV, and E' improved significantly. MASV and E' showed improvement immediately after BMV, while MPI decreased only at 3 months follow-up. CONCLUSIONS: There were significantly lower mitral annular motion parameters including MAPSE in patients with rheumatic mitral stenosis. Those with atrial fibrillation had higher MPI. Immediately after BMV, there was improvement in LV long axis function with a gradual improvement in global LV function. There was no significant change of MAPSE after BMV.

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OBJECTIVE: High levels of mean platelet volume (MPV) may be associated with adverse outcomes in patients with myocardial infarction (MI). We examined the association between MPV and the risk of death and adverse cardiovascular outcomes in patients with MI. METHODS: We studied consecutive patients with MI admitted to a tertiary-care hospital during a period of 1 year. MPV was measured at admission and at third month. Patients were followed up for 1-year primary composite outcome of cardiovascular death, stroke, fatal or non-fatal MI and cardiac failure. Patients were classified according to tertile of baseline MPV. RESULTS: A total of 1206 patients with MI, including 934 men (77.4%) and 272 women (22.6%) were studied. The mean age of the study population was 56 years. At 1-year follow-up, 292 (28.57%) primary outcome occurred: cardiovascular mortality 78 (7.6%), fatal or non-fatal MI 153 (15.0%), stroke 30 (2.9%) and cardiac failure 128 (12.52%). Patients with the highest tertile MPV had higher primary outcome as compared with those with MPV in the lowest tertile (adjusted OR=2.31; 95% CI 1.60 to 3.35; p<0.001). Total mortality was also more in high-MPV group (adjusted OR 2.62; 95% CI 1.47 to 4.70; p<0.001). There were no significant changes in mean MPV values at admission from those at third month interval (9.15, (SD 0.99) vs 9.19 (SD 0.94); p=0.2). CONCLUSIONS: Elevated MPV was associated with worse outcome in patients with acute MI. Elevated MPV in these patients may be due to inherently large platelets. TRIAL REGISTRATION NUMBER: http://ctri.nic.in/Clinicaltrials/rmaindet.php?trialid=5485&EncHid=98036.61144&modid=1&compid=19; CTRI/2012/12/003222.

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BACKGROUND: Obese patients with established coronary artery disease have reduced mortality compared to normal or low body mass index (BMI) patients. The reason for the relation is not yet clearly understood. We sought to evaluate the association of BMI and waist circumference (WC) at the time of presentation in patients with myocardial infarction (MI) with one-year adverse cardiac events. METHODS: In this prospective cohort study, we included consecutive patients with acute MI admitted to a tertiary care hospital during a period of one year. Upon admission, BMI and WC were measured. Patients were followed-up for a period of one year and the primary composite outcome of death or non-fatal MI was correlated with BMI and WC categories. RESULTS: There were 703 patients (males 559 (79.5%)). Combined non-fatal MI and death at one year was 128 (18.2%). Incidence of primary outcome was 25.0% in low BMI group, 19.9% in normal BMI group, 13.1% in overweight group, 13.4% in class I obese, and 11.1% in class II obese groups. In univariate analysis, the inverse correlation was significant (p value=0.007). In one-year follow-up period, 12.8% in high and 20.8% in normal WC groups had primary outcome (p value=0.01). Both BMI and WC lost their predictive value in multivariate analysis. CONCLUSIONS: Low BMI and normal WC were associated with a worse short-term outcome in patients with acute MI. Neither BMI nor WC independently predicted cardiac events or death after acute MI.

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BACKGROUND: Beta-blockers are frequently used in patients with mitral stenosis to control the heart rate and alleviate exercise-related symptoms. The objective of our study was to examine whether ivabradine was superior to atenolol for achieving higher exercise capacity in patients with moderate mitral stenosis in sinus rhythm. We also evaluated their effects on left ventricular myocardial performance index (MPI). METHODS AND RESULTS: Eighty-two patients with moderate mitral stenosis in sinus rhythm were randomized to receive ivabradine (n=42) 5mg twice daily or atenolol (n=40) 50mg daily for 6 weeks. Transthoracic echocardiography and treadmill test were performed at baseline and after completion of 6 weeks of treatment. Mean total exercise duration in seconds markedly improved in both study groups at 6 weeks (298.57±99.05s vs. 349.12±103.53s; p=0.0001 in ivabradine group, 290.90±92.42s vs. 339.90±99.84s; p=0.0001 in atenolol group). On head-to-head comparison, there was no significant change in improvement of exercise time between ivabradine and atenolol group (p=0.847). Left ventricular MPI did not show any significant change from baseline and at 6 weeks in both drug groups (49.8%±8% vs. 48.3%±7% in ivabradine group, 52.9%±10% vs. 50.9%±10% in atenolol groups; p=0.602). CONCLUSION: Ivabradine or atenolol can be used for heart rate control in patients with moderate mitral stenosis in sinus rhythm. Ivabradine is not superior to atenolol for controlling heart rate or exercise capacity. Left ventricular MPI was unaffected by either of the drugs.

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AIMS: We sought to evaluate the correlation between PCWP and LAP and to compare transmitral gradients obtained with LAP and PCWP in MS, before and after balloon mitral valvotomy (BMV). METHODS: Consecutive patients with MS for BMV were included in this prospective cohort study. Simultaneous PCWP and LAP were recorded followed by simultaneous left atrium-left ventricular (LA-LV) and pulmonary capillary wedge pressure-left ventricular (PCWP-LV) gradients before and after BMV. RESULTS: There were 30 patients with a mean age of 41 yrs (males 10 (33.3%), females 20 (66.7%)). There was no significant difference between mean LAP and mean PCWP before BMV (21.3mmHg and 22.3mmHg, respectively) or after BMV (15.3mmHg and 17.3mmHg, respectively). There was excellent correlation between mean PCWP and mean LAP before BMV (r=0.95) (p<0.001) and after BMV (r=0.85) (p<0.001). The phasic components of the pressures (a and v waves) of LAP and PCWP also showed good correlation before and after BMV. Further, transmitral gradients assessed by LA-LV and PCWP-LV pressures showed excellent correlation before BMV (r=0.95) (p<0.001) and after BMV (r=0.95) (p<0.001). CONCLUSION: In patients with MS undergoing balloon valvotomy, PCWP shows good correlation with LAP. Transmitral gradients obtained with PCWP and LAP also correlate well after correction of phase lag in PCWP tracing. Hence, PCWP can be used for reliable measurement of transmitral gradient.

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BACKGROUND: Coronary sinus filling time (CSFT) has been proposed as a simple method for assessment of coronary microvascular function in patients with angina and normal coronaries. But its correlation with inducible ischemia and prognostic significance in predicting future cardiovascular events has not been studied. The present study assessed the prognostic significance of CSFT during one year of follow up. METHODS: We compared coronary sinus filling time of patients with angina and normal coronaries with that of control population. Control group was formed by those patients with supraventricular arrhythmia undergoing radiofrequency ablation and having normal coronaries. Baseline treadmill test (TMT) parameters like workload, duration and Duke Score were assessed. Patients were followed up for one year and a composite of cardiovascular mortality and non-fatal myocardial infarction was analyzed. Number of patients presenting to emergency or outpatient department with recurrent chest pain symptoms during one year follow up was considered for secondary outcome analysis. Coronary sinus filling time was analyzed with respect to cardiovascular events, repeat hospitalization for recurrent angina and TMT parameters. RESULTS: Total 72 patients and 16 controls were studied. Mean CSFT value in the study group was 5.31 ± 1.03 sec and in the control group was 4.16 ± 0.72 sec and the difference was significant (p value = 0.0001). No correlation was found between baseline and repeat TMT parameters with CSFT. There was no cardiovascular mortality or hospitalization for non-fatal MI during one year follow up. But patients with frequent emergency or outpatient department visits with chest pain had a high CSFT compared with asymptomatic patients (p value = 0.005). CONCLUSION: Coronary sinus filling time may be used as a simple marker of microvascular dysfunction in patients with angina and normal coronaries. Patients with recurrent chest pain symptoms after one year follow up were found to have high CSFT compared to asymptomatic patients.

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This paper highlights the use of information technology (IT) in disaster management and public health management of disasters. Effective health response to disasters will depend on three important lines of action: (1) disaster preparedness; (2) emergency relief; and (3) management of disasters. This is facilitated by the presence of modern communication and space technology, especially the Internet and remote sensing satellites. This has made the use of databases, knowledge bases, geographic information systems (GIS), management information systems (MIS), information transfer, and online connectivity possible in the area of disaster management and medicine. This paper suggests a conceptual model called, "The Model for Public Health Management of Disasters for South Asia". This Model visualizes the use of IT in the public health management of disasters by setting up the Health and Disaster Information Network and Internet Community Centers, which will facilitate cooperation among all those in the areas of disaster management and emergency medicine. The suggested infrastructure would benefit the governments, non-government organizations, and institutions working in the areas of disaster and emergency medicine, professionals, the community, and all others associated with disaster management and emergency medicine. The creation of such an infrastructure will enable the rapid transfer of information, data, knowledge, and online connectivity from top officials to the grassroots organizations, and also among these countries regionally. This Model may be debated, modified, and tested further in the field to suit the national and local conditions. It is hoped that this exercise will result in a viable and practical model for use in public health management of disasters by South Asian countries.

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