Publications by authors named "Bishav Mohan"

73 Publications

Do anti-platelet drugs improve duration of continuous renal replacement therapy? A retrospective cohort study in cardiac ICU patients.

Int J Artif Organs 2021 Jul 9:3913988211031253. Epub 2021 Jul 9.

Department of Cardiology, Hero DMC Heart Institute, Ludhiana, Punjab, India.

Objective: The objective of this study was to investigate the impact of anti-platelet drug/s on duration of continuous renal replacement therapy (CRRT) in those patients where anti-coagulants were not used due to certain contraindications and in cases where patients were on anti-platelet drugs and were given anti-coagulant during CRRT.

Method: This single-center, retrospective cohort study was conducted using the medical records patients treated with CRRT in the cardiac ICU of the inpatient urban facility, located in North India. Data was collected from only those patients who received CRRT for the duration of at least 12 h. Patient's in NAC group were not on any anti-platelet/s and did not receive anti-coagulant during CRRT. AC and AP group patients received anti-coagulant alone or were already on anti-platelet/s and did not receive anti-coagulant respectively while ACAP group patients were on anti-platelet drug/s and also received anti-coagulant during CRRT.

Result: Patients in AC, AP, or ACAP group showed significantly ( < 0.001) higher CRRT filter life compared to NAC group. The median CRRT filter life was significantly higher in the ACAP group compared to AC ( < 0.05) and AP ( < 0.001) groups.

Conclusion: This study indicates that systemic anti-platelet therapy can provide additional support in critical patients undergoing CRRT even with or without anti-coagulant therapy. However, the increase in CRRT filter life was more profound in patients who were on anti-platelet/s and also received anti-coagulant drug/s during CRRT.
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http://dx.doi.org/10.1177/03913988211031253DOI Listing
July 2021

Pulsatile neck veins and hepatomegaly, and icterus in an elderly female.

Eur J Intern Med 2021 Jun 29. Epub 2021 Jun 29.

Department of cardiology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India.

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http://dx.doi.org/10.1016/j.ejim.2021.06.006DOI Listing
June 2021

Real world data on clinical profile, management and outcomes of venous thromboembolism from a tertiary care centre in India.

Indian Heart J 2021 May-Jun;73(3):336-341. Epub 2021 Feb 17.

Department of Cardiology, Dayanand Medical College and Hospital, Unit Hero DMC Heart Institute, Ludhiana, India. Electronic address:

Objectives: Venous thromboembolism (VTE) is a major cause of mortality and morbidity worldwide. This study describes a real-world scenario of VTE presenting to a tertiary care hospital in India.

Methods: All patients presenting with acute VTE or associated complications from January 2017 to January 2020 were included in the study.

Results: A total of 330 patient admissions related to VTE were included over 3 years, of which 303 had an acute episode of VTE. The median age was 50 years (IQR 38-64); 30% of patients were younger than 40 years of age. Only 24% of patients had provoked VTE with recent surgery (56%) and malignancy (16%) being the commonest risk factors. VTE manifested as isolated DVT (56%), isolated pulmonary embolism (PE; 19.1%), combined DVT/PE (22.4%), and upper limb DVT (2.3%). Patients with PE (n = 126) were classified as low-risk (15%), intermediate-risk (55%) and high-risk (29%). Reperfusion therapy was performed for 15.7% of patients with intermediate-risk and 75.6% with high-risk PE. In-hospital mortality for the entire cohort was 8.9%; 35% for high-risk PE and 11% for intermediate-risk PE. On multivariate analysis, the presence of active malignancy (OR = 5.8; 95% CI: 1.1-30.8, p = 0.038) and high-risk PE (OR = 4.8; 95% CI: 1.6-14.9, p = 0.006) were found to be independent predictors of mortality.

Conclusion: Our data provides real-world perspectives on the demographic sand management of patients presenting with acute VTE in a referral hospital setting. We observed relatively high mortality for intermediate-risk PE, necessitating better subclassification of this group to identify candidates for more aggressive approaches.
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http://dx.doi.org/10.1016/j.ihj.2021.02.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8322750PMC
February 2021

Image of the month: An unusual cause of cough, stridor and dyspnoea: A giant aortic arch aneurysm.

Clin Med (Lond) 2021 05;21(3):e313-e314

Dayanand Medical College and Hospital, Ludhiana, India.

A 78-year-old man with hypertension presented with dry cough and gradually progressive dyspnoea for 3 months. The patient had an audible stridor. Cardiovascular examination was unremarkable. Respiratory system examination revealed both inspiratory and expiratory grunting sound. Laboratory investigations were normal. Electrocardiography showed sinus rhythm with left ventricular hypertrophy (LVH). Chest X-ray showed superior mediastinal widening. Transthoracic echocardiography showed preserved LV functions and dilated aortic arch. Contrast-enhanced computed tomography of the thorax showed a huge aortic arch aneurysm compressing the adjacent trachea. The patient was planned for hybrid aortic arch repair but the patient refused and was discharged on antihypertensive, antiplatelet and statin therapy. The patient continued to have limiting cough, dyspnoea and stridor for 4 months of follow-up until he suddenly died while at home. This case highlights an unusual presentation of a potentially lethal disease. Evaluation of patients presenting with cough and dyspnoea should not be restricted to respiratory diseases. The critical observations made from history.
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http://dx.doi.org/10.7861/clinmed.2021-0095DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8140711PMC
May 2021

Novel approach to engage left main coronary artery in aneurysmally dilated aortic root.

BMJ Case Rep 2021 Feb 18;14(2). Epub 2021 Feb 18.

Department of Cardiology, Dayanand Medical College and Hospital, Ludhiana, India.

Aneurysmally dilated aortic route pose a considerable challenge in invasive coronary angiography (CAG) using routine workhorse catheters. Often one has to resort to either CT CAG which is not possible in all cases or use other techniques described in literature which may be technically challenging. We report a novel technique using multipurpose-1 (MPA-1) catheter. By applying gentle pressure, MPA-1 can be shaped to conform to aortic root anatomy by forming a primary and secondary loop. This makes engagement of left main ostium easy and atraumatic.
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http://dx.doi.org/10.1136/bcr-2020-239804DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7896588PMC
February 2021

Initial experiences regarding COVID19 mortality in Punjab-A mixed method analysis.

J Family Med Prim Care 2020 Nov 30;9(11):5689-5694. Epub 2020 Nov 30.

Department of Community Medicine, Dayanand Medical College and Hospital, Ludhiana, Punjab, India.

Context: The spread of COVID-19 pandemic poses a great challenge to health care organizations and unprecedented need for information. This study aims to identify possible factors causing delay and losing precious time during diagnosis and treatment of COVID-19 at home and health facility level. It also aims to highlight perceptions and experiences of family members of deceased regarding diagnosis and treatment of COVID-19 infection in hospital.

Methods: A retrospective study was done to review COVID-19 deaths from 18 March to 5 June 2020 in Punjab, India. A total of 48 laboratory confirmed (RT-PCR) COVID-19 deaths were reported during this period. Socio demographic profile, sequence of events including clinical symptoms, medical aid taken, time of confirmation of diagnosis and treatment before death were noted from the records on a predesigned proforma. Family members of deceased were also interviewed and asked open-ended questions regarding their experiences at various health facilities. Descriptive statistics was presented in percentages, mean, and median.

Results: Mean age of subjects was 56.3 ± 18.3 years. Majority (82.2%) had three or more than three comorbidities. Median time from appearance of first symptom to first medical contact and confirmation of diagnosis was 1 and 5 days, respectively. On the basis of interview with deceased's relative, various themes like delay in diagnosis and treatment, dissatisfied with hospital system and lack of communication between relative and patient were generated.

Conclusion: Presence of comorbidities was the most important risk factor. Health seeking behavior of patients immediately after appearance of symptoms was found to be satisfactory.
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http://dx.doi.org/10.4103/jfmpc.jfmpc_1411_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7842459PMC
November 2020

A rational approach to manage surgical procedures in COVID Era - A perspective based on experience in a private referral hospital.

J Anaesthesiol Clin Pharmacol 2020 Jul-Sep;36(3):325-330. Epub 2020 Sep 15.

Department of Medicine, Dayanand Medical College and Hospital, Ludhiana, Punjab, India.

Background And Aims: COVID-19 disease has imposed challenges in caring for non-Covid elective surgical patients. As elective surgeries become essential, we propose to evaluate our approach and outcomes of surgical procedures performed during the initial period of COVID-19 pandemic so as to provide a road-map for safer approach.

Material And Methods: We retrospectively evaluated outcomes in patients who underwent essential elective and emergency surgeries during the 5-week period between April 18, 2020 and May 28, 2020. All patients were screened at the front desk on their arrival to identify possible exposure to SARS- CoV-2. Nasopharyngeal swab of patients requiring hospital admission was tested for COVID-19 by quantitative RT-PCR. Patients needing essential elective surgery were taken up for surgery if they tested negative for COVID-19. Emergency procedures were undertaken in a demarcated theatre for COVID after taking level-3 protection without delay. The clinical data was reviewed and analysed.

Results: A total of 764 surgical procedures were conducted, of which 70.7% were elective essential surgeries, with 95.4% of these patients being discharged in stable healthy condition. Approximately 23% of the elective and 26% of the emergency surgeries was categorised in the surgical difficulty category III and majority of these were performed under general anesthesia. Postoperative mortality was 1.04%, but the overall mortality rate was approximately 2.5%. Only two patients (0.3%) tested positive for COVID-19 in our series.

Conclusion: A robust preoperative screening and testing can enable safe scheduling of essential elective surgeries.
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http://dx.doi.org/10.4103/joacp.JOACP_420_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7812968PMC
September 2020

Prognostic Role of B-Type Natriuretic Peptide in Adults with Acute Dyspnea Requiring Emergency Admission.

Int J Appl Basic Med Res 2020 Oct-Dec;10(4):265-269. Epub 2020 Oct 7.

Department of Cardiology, Dayanand Medical College and Hospital Unit Hero DMC Heart Institute, Ludhiana, Punjab, India.

Objective: The aim of the study was to evaluate the role of B-type natriuretic peptide (BNP) in patients presenting with acute dyspnea admitted in emergency services.

Materials And Methods: A prospective observational study was conducted on 100 patients presenting to the emergency of Dayanand Medical College and Hospital and Hero DMC Heart Institute with acute dyspnea of <48 h duration, in which BNP levels were done on arrival to emergency.

Results: BNP levels were significantly higher in patients having left ventricular dysfunction, both systolic and diastolic. Patients with systolic dysfunction had slightly higher BNP (1251.50 ±950.14 pg/mL) compared to patients with diastolic dysfunction (905.62±618.10 pg/mL) though statistically insignificant ( = 0.055). BNP levels were also inversely related to ejection fraction. Mean BNP levels in patients with EF <31%, 31%-45%, 46%-59%, and ≥60% were 1464.63 ± 1058.29, 968.24 ± 751.59, 841.64 ± 503.41 and 781.67 ± 504.21 ( = 0.009), respectively. Patients having higher BNP levels had significantly prolonged duration of stay compared to patients with lower BNP. Patients who expired had slightly higher levels of BNP though statistically nonsignificant. BNP had no significant statistical relation with age, heart rate, creatine phosphokinase-MB, Trop-T levels, systolic blood pressure.

Conclusion: We conclude that high BNP levels are a marker of cardiac dysfunction and increased duration of hospital stay in patients presenting to the emergency with acute dyspnea. Hence, BNP can be used as a screening test for the evaluation and management of dyspnea.
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http://dx.doi.org/10.4103/ijabmr.IJABMR_56_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7758801PMC
October 2020

Clinical characteristics and outcome of infective endocarditis among intravenous drug abusers in India.

Indian Heart J 2020 Nov-Dec;72(6):547-551. Epub 2020 Sep 18.

Department of Cardiology, Dayanand Medical College and Hospital, Unit Hero DMC Heart Institute, Ludhiana, India.

Introduction: Infective endocarditis (IE) is the most dreaded complication of intravenous drug abuse (IVDA). IVDA is present in significant proportions in India. Since there is scarcity of Indian data on IVDA associated IE, we report a study comparing IVDA to non IVDA associated IE. We compare differences in clinical profile, microbiology, echocardiography and clinical outcome from a tertiary care hospital.

Methods: A total of 133 patients admitted from 1st January 2017 to 31st December 2019 who met the Modified Duke ''definitive'' criteria for IE were included. Detailed Information was collected regarding demography, clinical data and laboratory investigations. All patients underwent transthoracic echocardiography and trans-esophageal echocardiogram wherever necessary.

Results: Among a total of 133 patients, 54 patients (40.6%) were iv drug abusers. Patients in IVDA-group were younger, mostly males, more likely to have concomitant HCV and HIV infections compared to non IVDA-group. Chronic comorbidities such as DM and CKD were more common in non IVDA-group. Rate of positive blood culture was higher in IVDA-group compared to non IVDA-group (74.1%v/s 32.9%,p < 0.001) with different microbiological profile. Percentage of Methicillin resistant staphylococcus aureus (42.6%v/s17.7%,p = 0.003) and pseudomonas related IE (18.5%v/s2.5%,p = 0.003) was significantly higher among IVDA-group. IVDA-group most commonly had tricuspid valve involvement Whereas mitral and aortic valve were most commonly involved valve in non IVDA-group. Mortality was slightly higher among IVDA-group compared to non IVDA-group, though statistically non-significant. Left sided valve involvement and Congestive heart failure were independent predictors of mortality.

Conclusion: IVDA-IE is a significant problem in India. Demographic, microbiological and echocardiographic profile is quite different in IVDA and non IVDA-group. There is urgent need to conduct larger studies.
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http://dx.doi.org/10.1016/j.ihj.2020.09.014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7772606PMC
June 2021

Cardiothoracic surgery during COVID-19: Our experience with different strategies.

Ann Card Anaesth 2020 Oct-Dec;23(4):485-492

Department of Cardiology, Hero DMC Heart Institute, Ludhiana, Punjab, India.

Background: An acute respiratory disease (COVID-19), caused by a novel coronavirus (SARS-CoV-2,), has been declared a pandemic by WHO. A surgery on COVID-19 patients not only involves a risk of spread of the disease but also there is a serious concern for the patient's surgical outcomes and resources requirement.

Aim: The retrospective study is aimed to provide a protocol for pre-operative testing of SARS CoV-2 using RT-PCR in the patient undergoing cardio-thoracic surgeries.

Material And Methods: To analyze the impact of pre-operative testing of SARS- CoV-2 using RT-PCR in the patient undergoing elective cardio-thoracic surgeries. The patient who underwent surgical interventions during the COVID-19 lockdown period was divided into two phases. Phase I (without COVID-19 RT-PCR testing) and Phase II (with pre-operative COVID-19 RT-PCR testing). The retrospective comparison between the two study groups was done using Student t-test, Mann-Whitney U, and Chi square (χ) test depending upon the clinical variable to be analyzed.

Results: During the early phase (phase I), 26 patients underwent cardio-thoracic surgery without COVID-19 RT-PCR test. Whereas, during phase II, all patients were tested for COVID-19 using RT-PCR, preoperatively and a total of 64 surgeries were performed during this phase. One patient planned for CABG was positive on RT-PCR for COVID-19 and was sent to the quarantine ward. The difference in the pre-operative hospital stay between two groups was found to be statistically significant and a significant decrease in the number of PPE kits used, during the phase I.

Conclusion: All asymptomatic patients should be tested for COVID-19 using RT-PCR prior to cardio-thoracic surgeries not only to contain the disease but to avoid potential implications of COVID-19 on the perioperative course, without added financial implications.
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http://dx.doi.org/10.4103/aca.ACA_166_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7879916PMC
November 2020

Negative pressure aerosol containment box: An innovation to reduce COVID-19 infection risk in healthcare workers.

J Anaesthesiol Clin Pharmacol 2020 Aug 24;36(Suppl 1):S144-S147. Epub 2020 Jul 24.

Department of Cardiology, Hero DMC Heart Institute, Ludhiana, Punjab, India.

Healthcare workers (HCW's) are at increased risk of corona virus disease (COVID-19) infection during aerosol generating activities. The aerosol box has been used during intubation and extubation to prevent transmission of infection to HCWs. Isolation room with negative pressure has been advocated for COVID-19 patients. The described containment box has been designed to be useful in COVID intensive care unit (ICU) as a multipurpose box which is a cost effective and readily available resource. This innovation combines the containment box with negative pressure generation using central vacuum.
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http://dx.doi.org/10.4103/joacp.JOACP_217_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7574021PMC
August 2020

Active surveillance with telemedicine in patients on anticoagulants during the national lockdown (COVID-19 phase) and comparison with pre-COVID-19 phase.

Egypt Heart J 2020 Oct 16;72(1):70. Epub 2020 Oct 16.

Department of Cardiology, Hero DMC Heart Institute, Unit of Dayanand Medical College and Hospital, Ludhiana, India.

Background: The COVID-19 pandemic brought restriction to the movement of people due to the implementation of lockdown across various regions around the world. In India, most of the patients belong to rural areas and hence were unable to come for a follow-up visit. Hence, we reached out to patients on oral anticoagulation using telemedicine with aim of communicating with the patient concerning drug compliance, titration of dose of anticoagulation, health education, and identification of high-risk patients needing referral to the nearest health facility/our institute. This study was conducted at the Hero DMC heart institute (a tertiary care center for cardiac diseases). The study design is cross-sectional and involves a comparison of the pre-COVID-19 phase with the COVID-19 phase. We asked a five-component (Likert scale) questionnaire from patients for satisfaction after the consult. All symptoms, need for hospitalization and clinical events were recorded. The events were compared in both groups.

Results: We contacted 628 patients through telemedicine and 600 patients gave consent for participation in the study. For comparison, we analyzed data of 614 patients in the pre-COVID-19 phase. The mean age during the pre-COVID-19 phase was 55.27 + 17.09 years and the COVID-19 phase was 56.97 + 15.09 years with males more than females in both groups. There was no significant difference in the number of patients on oral anticoagulants and novel oral anticoagulants (NOAC). However, there were higher number of  patients on antiplatelets in the pre-COVID phase (p value0.01). 37% in the pre-COVID-19 phase and 40.31 % in the COVID-19 phase were noted to have out of target range INR (International normalized ratio). There was no difference in the number of bleeding or thromboembolic events seen. Patient response as assessed by a questionnaire (Likert scale) showed that >75% of patients were satisfied.

Conclusion: Through telemedicine, we were able to approach our patients on oral anticoagulation and achieved titration of anti-coagulation, and health education similar to pre-COVID-19 times. During pandemics, telemedicine offers a promising option for patient management with chronic cardiac conditions. It also provides us an opportunity for the management of patients on oral anticoagulation involving titration of drug dosages (anti-coagulation), identification of high-risk patients, and health education.
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http://dx.doi.org/10.1186/s43044-020-00105-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7562770PMC
October 2020

Admission Serum Chloride Levels as Predictor of Stay Duration in Acute Decompensated Heart Failure.

J Assoc Physicians India 2020 Oct;68(10):34-38

Professor and Head of Cardiology, Dayanand Medical College and Hospital, Unit Hero DMC Heart Institute, Ludhiana, Punjab.

Objective: Recent studies have shown that lower serum chloride is associated with diuretic resistance and increased mortality in heart failure. Impact of lower admission chloride on duration of stay in acute decompensated heart failure (ADHF) has not been studied previously.

Methods: In this retrospective analysis, we studied the effect of admission serum chloride on the duration of hospital stay in patients admitted with ADHF. A total of 167 patients were studied. Serum chloride levels were divided into tertiles - <96 meq/L (tertile 1), 96-101 meq/L (tertile 2), and >101 meq/L (tertile 3) based on the distribution of serum chloride levels in our patients.

Results: The median lengths of hospital stay in tertiles 1, 2, and 3 were 8(Interquartile range :6 -11), 7 (Interquartile range :5 -10.50), and 6 days(Interquartile range :4.25 - 8), respectively (p = 0.011). Admission serum chloride levels were inversely associated with duration of stay (R2 linear = 0.074, p = 0.001). On multiple linear regression analysis, serum chloride remained independent predictor of increased hospital stay (p=0.003) while association with serum sodium was not significant (p=0.07). 1 unit increase in chloride level was associated with 1.3% (p=0.003) decrease in hospital stay (95% CI: 2.2% to 0.5%).

Conclusion: This retrospective analysis suggests that admission serum chloride levels are independently and inversely associated with increased duration of stay. This is independent of admission sodium levels. Thus serum chloride, rather than sodium, is an important poor prognostic marker in heart failure patients.
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October 2020

Primary haemochromatosis resulting in dilated cardiomyopathy arising out of mutation in HJV gene in Indian patients: a rare scenario.

BMJ Case Rep 2020 Sep 16;13(9). Epub 2020 Sep 16.

Cardiology, Hero DMC heart institute, Dayanand Medical College and Hospital, Ludhiana, Punjab, India.

Primary haemochromatosis (PH) is a genetic disorder of iron metabolism with multiorgan involvement due to mutations in HFE or more rarely haemojuvelin (HJV) gene. Cardiac involvement results in dilated cardiomyopathy with reduced ejection fraction and progressive heart failure. PH is rarely reported from India and cardiomyopathy due to PH from HJV mutations is thought to be uncommon. We report two families with cardiomyopathy resulting from PH. Diagnosis was suspected on the basis of skin pigmentation, markedly elevated serum ferritin and transferring saturation. Genetic testing revealed a rare mutation in HJV gene in one family. Being a treatable condition, PH should be suspected and investigated in cardiomyopathy patients in Indian subcontinent. If HFE is negative, analysis of non-HFE mutation should always be considered.
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http://dx.doi.org/10.1136/bcr-2020-235650DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7497139PMC
September 2020

Yoga-Based Cardiac Rehabilitation After Acute Myocardial Infarction: A Randomized Trial.

J Am Coll Cardiol 2020 04;75(13):1551-1561

London School of Hygiene and Tropical Medicine, London, United Kingdom.

Background: Given the shortage of cardiac rehabilitation (CR) programs in India and poor uptake worldwide, there is an urgent need to find alternative models of CR that are inexpensive and may offer choice to subgroups with poor uptake (e.g., women and elderly).

Objectives: This study sought to evaluate the effects of yoga-based CR (Yoga-CaRe) on major cardiovascular events and self-rated health in a multicenter randomized controlled trial.

Methods: The trial was conducted in 24 medical centers across India. This study recruited 3,959 patients with acute myocardial infarction with a median and minimum follow-up of 22 and 6 months. Patients were individually randomized to receive either a Yoga-CaRe program (n = 1,970) or enhanced standard care involving educational advice (n = 1,989). The co-primary outcomes were: 1) first occurrence of major adverse cardiovascular events (MACE) (composite of all-cause mortality, myocardial infarction, stroke, or emergency cardiovascular hospitalization); and 2) self-rated health on the European Quality of Life-5 Dimensions-5 Level visual analogue scale at 12 weeks.

Results: MACE occurred in 131 (6.7%) patients in the Yoga-CaRe group and 146 (7.4%) patients in the enhanced standard care group (hazard ratio with Yoga-CaRe: 0.90; 95% confidence interval [CI]: 0.71 to 1.15; p = 0.41). Self-rated health was 77 in Yoga-CaRe and 75.7 in the enhanced standard care group (baseline-adjusted mean difference in favor of Yoga-CaRe: 1.5; 95% CI: 0.5 to 2.5; p = 0.002). The Yoga-CaRe group had greater return to pre-infarct activities, but there was no difference in tobacco cessation or medication adherence between the treatment groups (secondary outcomes).

Conclusions: Yoga-CaRe improved self-rated health and return to pre-infarct activities after acute myocardial infarction, but the trial lacked statistical power to show a difference in MACE. Yoga-CaRe may be an option when conventional CR is unavailable or unacceptable to individuals. (A study on effectiveness of YOGA based cardiac rehabilitation programme in India and United Kingdom; CTRI/2012/02/002408).
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http://dx.doi.org/10.1016/j.jacc.2020.01.050DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7132532PMC
April 2020

Evaluation of intracoronary blood from obstructive vessel in patients of ST-elevation myocardial infarction undergoing PPCI.

Indian Heart J 2019 Jul - Aug;71(4):356-359. Epub 2019 Sep 26.

Department of Medicine, Guru Gobind Singh Medical College and Hospital, Faridkot, India.

Objective: Information available on acid-base imbalance in ST-elevation myocardial infarction (STEMI) submitted to primary percutaneous intervention is limited and no data were present on intracoronary blood analysis, extracted from obstructed artery.

Methods: This was a prospective study conducted over 12 months in which STEMI patients presenting in emergency and undergoing primary percutaneous coronary intervention were included. Blood gas analysis of intracoronary arterial blood from obstructed vessel and peripheral arterial blood was performed. Patients in whom adequate intracoronary sample could not be obtained were excluded. Intracoronary and peripheral arterial blood gas measurements were correlated and relationship of intracoronary parameters were compared with clinical parameters, investigational markers and short-term outcome.

Results: The mean age of study population was 54.8 years and average symptom onset to door time was 162 min. On comparing intracoronary blood with peripheral blood arterial obtained, pH (95% confidence interval [CI] -0.01 to 0.02;p = 0.44), lactate (95% CI 0.03-0.1;p = 0.28), bicarbonate (95% CI 0.6-1.5;p = 0.64), pCO (95% CI 1.1-2.4;p = 0.79) and pO (95% CI 3.2-47.5; p = 0.06) were all found to be statistically insignificant. Intracoronary hyperlactatemia was present in patients presenting with higher symptom onset to door time (p = 0.025). Systolic blood pressure (SBP) (p = 0.03) was also significantly lower in patients who had high intracoronary lactate levels.

Conclusion: The evaluation of intracoronary blood provides no additional information regarding the prognosis and short-term (30-day) outcome of the patients when compared with peripheral blood. However, there was a significant intracoronary hyperlactatemia in patients presenting late after symptom onset. SBP was also significantly less in patients with high intracoronary lactate, which signifies that predominant cause of hyperlactatemia was systemic hypoperfusion rather than local increase in lactate levels.
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http://dx.doi.org/10.1016/j.ihj.2019.09.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6890943PMC
May 2020

Prevalence of sustained hypertension and obesity among urban and rural adolescents: a school-based, cross-sectional study in North India.

BMJ Open 2019 09 8;9(9):e027134. Epub 2019 Sep 8.

Centre for Chronic Conditions and Injuries, Public Health Foundation of India, Gurgaon, Haryana, India.

Objective: Recent data on sustained hypertension and obesity among school-going children and adolescents in India are limited. This study evaluates the prevalence of sustained hypertension and obesity and their risk factors among urban and rural adolescents in northern India.

Setting: A school-based, cross-sectional survey was conducted in the urban and rural areas of Ludhiana, Punjab, India using standardised measurement tools.

Participants: A total of 1959 participants aged 11-17 years (urban: 849; rural: 1110) were included in this school-based survey.

Primary And Secondary Outcome Measures: To measure sustained hypertension among school children, two distinct blood pressure (BP) measurements were recorded at an interval of 1 week. High BP was defined and classified into three groups as recommended by international guidelines: (1) normal BP: <90th percentile compared with age, sex and height percentile in each age group; (2) prehypertension: BP=90th-95th percentile; and (3) hypertension: BP >95th percentile. The Indian Academy of Pediatrics classification was used to define underweight, normal, overweight and obesity as per the body mass index (BMI) for specific age groups.

Results: The prevalence of sustained hypertension among rural and urban areas was 5.7% and 8.4%, respectively. The prevalence of obesity in rural and urban school children was 2.7% and 11.0%, respectively. The adjusted multiple regression model found that urban area (relative risk ratio (RRR): 1.7, 95% CI 1.01 to 2.93), hypertension (RRR: 7.4, 95% CI 4.21 to 13.16) and high socioeconomic status (RRR: 38.6, 95% CI 16.54 to 90.22) were significantly associated with an increased risk of obesity. However, self-reported regular physical activity had a protective effect on the risk of obesity among adolescents (RRR: 0.4, 95% CI 0.25 to 0.62). Adolescents who were overweight (RRR: 2.66, 95% CI 1.49 to 4.40) or obese (RRR: 7.21, 95% CI 4.09 to 12.70) and reported added salt intake in their diet (RRR: 4.90, 95% CI 2.83 to 8.48) were at higher risk of hypertension.

Conclusion: High prevalence of sustained hypertension and obesity was found among urban school children and adolescents in a northern state in India. Hypertension among adolescents was positively associated with overweight and obesity (high BMI). Prevention and early detection of childhood obesity and high BP should be strengthened to prevent the risk of cardiovascular diseases in adults.
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http://dx.doi.org/10.1136/bmjopen-2018-027134DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6738741PMC
September 2019

Intra-operative uterine artery embolization with caesarean delivery in an adjoining operating theatre and catheter lab (OT/CL) complex vs. conventional management in patients with abnormally invasive placenta: a retrospective case control study.

J Obstet Gynaecol 2020 Apr 25;40(3):324-329. Epub 2019 Jul 25.

Department of Obstetrics and Gynaecology, Dayanand Medical College and Hospital, Ludhiana, India.

Patients of abnormally invasive placenta (AIP) undergoing caesarean delivery are at increased risk of haemorrhage. Conventional management includes piecemeal removal of placenta or placenta left . However, they often require hysterectomy after delivery. Post-delivery prophylactic uterine artery embolisation (UAE) can help reduce morbidity and preserve fertility. We created an adjoining operating theatre and catheter lab (OT/CL complex). This is a retrospective case control study in which 37 patients of AIP were evaluated. Sixteen subjects (cases) had UAE immediately after caesarean delivery, and 21 subjects (controls) had usual care with traditional methods of controlling postpartum haemorrhage and hysterectomy where required. The hysterectomy rate (18.7% vs. 85.7%), mean duration of hospital stay (6.8 ± 2.6 vs. 13.9 ± 8.1) and number of units of blood transfusion required were significantly less in the case group as compared with controls. UAE is an effective conservative treatment along with caesarean delivery in patients with AIP.Impact statement AIP is associated with high rates of PPH, maternal morbidity and mortality and need for hysterectomy after delivery. UAE has been advocated to preserve fertility and reduce PPH in these patients along with caesarean delivery. We created an adjoining operating theatre and catheter lab (OT/CL complex) in a tertiary care centre and managed these patients with prompt UAE after caesarean delivery with team approach. We have shown significant reduction in morbidity and hospital stay with this coordinated management. UAE with caesarean delivery is a preferred mode of delivery for patients of AIP. These patients should be diagnosed and referred to tertiary care centres with such facilities electively so as to provide optimal care to these patients. Cooperation between interventionist and obstetrician and adjoining availability of OT and catheter lab can further help in reducing the time to embolisation after delivery. A hybrid operating theatre with digital subtraction angiography (DSA) facilities would be ideal for the management of such patients.
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http://dx.doi.org/10.1080/01443615.2019.1621817DOI Listing
April 2020

Young male with a large round radio-opacity on chest X-ray.

Eur Heart J Case Rep 2018 Dec 14;2(4):yty121. Epub 2018 Nov 14.

Hero DMC Heart Institute, Dayanand Medical College and Hospital Unit, Ludhiana, Punjab, India.

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http://dx.doi.org/10.1093/ehjcr/yty121DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6426004PMC
December 2018

Unusual case of intraoperative acute cor pulmonale during spine surgery.

Ann Card Anaesth 2019 Apr-Jun;22(2):229-232

Department of Cardiology, DMCH, Ludhiana, Punjab, India.

Perioperative complications of prolonged surgery and prone positioning are well known. Changing the position from prone to supine in an anesthetized patient can result in aspiration and airway obstruction. The drop-in oxygen saturation and hemodynamic changes are warning signs and can cause acute cardiac decompensation leading to diagnostic dilemma. We present a case where the patient had these changes after changing the position after spine surgery in prone position. A quick response from the treating anesthesiologist and active involvement of cardiologist helped in reaching the diagnosis and successful management of aspiration pneumonitis in this patient. We conclude that a quick response in investigations and multimodality approach helps in the management of such perioperative complications.
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http://dx.doi.org/10.4103/aca.ACA_128_18DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6489396PMC
June 2020

Impact of extra-corporeal membrane oxygenation on outcome of aluminium phosphide poisoning complicated with myocardial dysfunction.

Clin Toxicol (Phila) 2019 Nov 11;57(11):1095-1102. Epub 2019 Mar 11.

Department of Cardiology, Dayanand Medical College and Hospital , Ludhiana , India.

Aluminium phosphide (AlP) poisoning is associated with a high mortality rate when patients are complicated with myocardial dysfunction and refractory shock or severe metabolic acidosis. We studied the role of veno-arterial extra-corporeal membrane oxygenation (VA-ECMO) in patients of AlP poisoning induced myocardial dysfunction. This is a tertiary care, single-centre, retrospective study. Between January 2011 and June 2016, total of 107 patients with AlP poisoning were identified and of those 67 were categorised in high-risk category as per the criteria. The in-hospital mortality of patients who received ECMO ( = 35) was compared to those who received conventional treatment ( = 32) only. The use of ECMO in addition to conventional treatment has reduced the in-hospital mortality from 84.4% to 40% (odds ratio: 0.47; 95% confidence interval 0.31-0.73). Among survivors, the ECMO group had a significantly lower baseline left ventricular ejection fraction (LVEF; median: 24%; IQR: 22-29 vs. median: 32%; IQR: 32-33.5;  < .003) but a non-significantly higher LVEF at the time of discharge (median: 52%; IQR: 48-60 vs. median: 48%; IQR: 47-49; : .064) than did the conventional group. On logistic regression analysis the higher sequential organ failure assessment (SOFA) score, lower pH and the non-usage of ECMO were found to be the independent predictors of mortality. The use of ECMO in high-risk patient of AlP poisoning has resulted in a significant reduction in the mortality. A high baseline SOFA score has been found to be the independent predictor of mortality.
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http://dx.doi.org/10.1080/15563650.2019.1584297DOI Listing
November 2019

Seasonal variation in 24 h blood pressure profile in healthy adults- A prospective observational study.

J Hum Hypertens 2019 08 12;33(8):626-633. Epub 2019 Feb 12.

Hero DMC Heart Institute, Dayanand Medical College & Hospital, Ludhiana, Punjab, India.

The clinical and experimental data on seasonal variation in blood pressure is mainly from office and home blood pressure (BP) monitoring studies. There are few studies from temperate climates on seasonal changes with ambulatory blood pressure (ABP) monitoring and none from India. This is a prospective, observational study among healthy adults. ABP was measured in four different seasons in 28 subjects. Mean arterial pressure (MAP), ambulatory systolic blood pressure (SBP), and ambulatory diastolic blood pressure (DBP) were significantly higher in winter compared to summer season. 24-hour MAP was lowest in summer while highest MAP was recorded in winter (97.04 ± 8.30 and 103.89 ± 8.54, respectively). The mean difference was -6.86 mm Hg (95% CI: -10.74 to -2.97, p = 0.001). This difference was mainly due to increase in day time MAP. There was no difference in 24 h systolic and diastolic blood pressure between summer and winter. There was significant difference between summer and winter in the SBP (day time) [125.61 ± 11.44 and 131.93 ± 9.46, mean difference -6.32 (95% CI: -10.69 to -1.95, p = 0.005)] and DBP (day time) [79.57 ± 9.95 and 87.07 ± 9.9, mean difference -7.50 (95% CI: -12.49 to -2.51, p = 0.003)]. The night time systolic and diastolic BP was similar during winter and summer. Thus, BP increases significantly during winter compared to summer season. This change is primarily in the day time systolic, diastolic and mean blood pressures. Larger studies are required to further validate our findings.
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http://dx.doi.org/10.1038/s41371-019-0173-3DOI Listing
August 2019

Determinants of in-hospital clinical outcome in patients with sub-massive pulmonary embolism.

Indian Heart J 2018 Dec 22;70 Suppl 3:S90-S95. Epub 2018 Jun 22.

Department of Cardiology Dayanand Medical College & Hospital Unit Hero, DMC Heart Institute, Ludhiana 141001, Punjab, India.

Introduction: There is limited data regarding in hospital determinants of clinical deterioration and outcome in sub massive pulmonary embolism (PE). We aimed to evaluate these determinants by comparing biomarkers, CT pulmonary angiogram echocardiography, electrocardiography variables.

Methods: 57 patients of sub massive PE diagnosed on CT pulmonary angiogram were included. All patients received UFH on admission and were divided into two groups based on their clinical course. Group 1 comprised of patients who remained stable, group 2 of patients who showed signs of clinical deterioration.

Results: There were 34(59.6%) patients in group 1 and 23(40.4%) patients in group 2. No significant difference in age, gender, BMI. 59.37% had sub massive PE, 5.26% had mortality and 40.4% had clinical deterioration. Intravenous UFH infusion given to 59.6%, systemic thrombolysis 22.8%, catheter directed mechanical breakdown 14%, surgical embolectomy in 3.5% patients. S1Q3T3, new onset RBBB, T wave inversion > 1.63 mm, Basal RV size > 40 mm, RV: LV ratio > 1.2, Global RV longitudinal strain <-10.75% and RVSP > 39 mmHg profiled high risk group. Serum BNP and CT pulmonary angiogram derived scores didn't differ significantly although CT findings helped to exclude low risk patients (specificity 88%, sensitivity 95%).

Conclusions: Physicians should be aware that patients who have ECG and Echocardiography changes suggestive of right ventricular strain and dysfunction above the cut off values and have documented thrombus in Proximal branches (RPA/LPA) or in distal portion of main pulmonary artery may require aggressive management with systemic/catheter based thrombolysis besides routine anticoagulation with heparin to prevent clinical deterioration.
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http://dx.doi.org/10.1016/j.ihj.2018.06.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6310705PMC
December 2018

Factors influencing prehospital delay in patients presenting with ST-elevation myocardial infarction and the impact of prehospital electrocardiogram.

Indian Heart J 2018 Dec 14;70 Suppl 3:S194-S198. Epub 2018 Nov 14.

AIIMS, New Delhi.

Background: In ST-elevation myocardial infarction (STEMI), prehospital delay is a significant factor, decreasing likelihood of revascularization and increasing mortality. Prehospital delays are substantive in Indian patients with STEMI. Our study aimed to investigate factors associated with prehospital delay in patients with STEMI.

Methods: A multicentric prospective analysis was conducted at five major cardiac care referral centers in Punjab including a tertiary care teaching hospital over a period of 1 year from January 2015 to December 2015. Patients presenting with STEMI were included in the study. A structured questionnaire was used to gather patient characteristics and factors responsible for prehospital delay.

Results: Of the 619 patients included in the study, 42% presented with more than 6 h of prehospital delay. On univariate analysis, delay was significantly higher among elderly (p = 0.01), illiterate patients (p = 0.02), and patients residing in rural areas (p = 0.04). Recognizing symptoms as cardiac in origin (p < 0.001), hospital as initial medical contact, and availability of prehospital electrocardiogram (ECG) (p = 0.001) were associated with shorter delays. On multivariate analysis, prehospital delay was significant in elderly patients, initial point of care as outpatient clinic, and patients without access to prehospital ECG.

Conclusion: Our study concludes that demographic and socioeconomic barriers exist that impede rapid care seeking and highlights the need for utilization of prehospital ECG to decrease prehospital delay. Possibilities include, educating the public on the importance of early emergency medical services contact or creating emergency stations in rural areas with ECG capabilities. Our study also invites further research, regarding role of telemedicine to triage patients derived from prehospital ECGs to decrease prehospital delay.
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http://dx.doi.org/10.1016/j.ihj.2018.10.395DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6309871PMC
December 2018

Early onset ACS: An age based clinico-epidemiologic and angiographic comparison.

Atherosclerosis 2018 12 19;279:45-51. Epub 2018 Oct 19.

Department of Cardiology, Hero DMC Heart Institute, Ludhiana, India.

Background And Aims: Acute coronary syndrome (ACS) in the very young is a rare entity, with limited data. We aimed to study patterns and profile of ACS in patients aged 20-30 years in comparison with those above 30 years.

Methods: In this retrospective record-based study, the demographic and clinical profile of all patients with ACS in the last 12 years (n = 35259) was analysed: group I (20-30 years) and group II (above 30 years). Patients in group II were selected by systematic sampling. Age, gender, domicile, body mass index (BMI), serum cholesterol, smoking, alcohol use, drug abuse, diabetes, hypertension, family history, type of ACS, angiographic findings and management strategies were recorded. Chi-square test and Fischer's exact test were used for data analysis.

Results: Of 35,259 patients, 0.32% (n = 114) were from the younger age group, with a rising trend of prevalence over 12 years. Obesity, overweight, urban living, smoking, alcohol and drug abuse were significantly higher in group I (p < 0.05). Diabetes mellitus and hypertension were more prevalent in group II (p = 0.001). STEMI in group I (76.3%) and NSTEMI in group II (47.1%) were the common modes of presentation (p = 0.001). 42.1% of group I patients had recanalized coronaries with conservative management in comparison to 3% in group II (p = 0.001).

Conclusions: There is a rising trend in prevalence of ACS in very young patients. Overweight, obesity, urbanization and drug abuse are potential risk factors. The younger subset of ACS patients is different from the older population due to their thrombotic milieu, which could be more amenable to intensive pharmacologic management.
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http://dx.doi.org/10.1016/j.atherosclerosis.2018.10.017DOI Listing
December 2018

The Prevalence, Clinical Spectrum and the Long Term Outcome of ST-segment Elevation Myocardial Infarction in Young - A Prospective Observational Study.

Cardiovasc Revasc Med 2019 05 21;20(5):387-391. Epub 2018 Jul 21.

Department of Cardiology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India.

Introduction: Incidence of coronary artery disease at the younger age is rising. We studied the prevalence, clinical spectrum and long term outcome of ST-segment elevation myocardial infarction in young.

Material And Methods: This is a prospective observational study, performed at a tertiary care center from January 2015 to June 2016. Of the total 977 consecutive patients with ST segment elevation myocardial infarction (STEMI), 130 patients aged ≤45 years were included. All patients were followed-up for at least 1-year from the index admission.

Results: The overall prevalence of STEMI among younger patients was 12.8%. There was male dominance (96.8%). Smoking (37.6%) was observed to be the most common risk factor for young STEMI, followed by diabetes mellitus (16.8%) and hypertension (16%). Younger patients with acute MI had preponderance to anterior wall (68.8%), single-vessel disease (50%) and left anterior descending artery being the culprit lesion (67.3%). Near normal/normal coronary arteries were observed in 12.9% of cases. The most commonly used management strategy was mechanical revascularisation (43.2%), followed by thrombolysis (28.8%) and medical management (28%). The overall mortality and combined MACCE rates at 1 year were 3.2% and 18.4% respectively. Outcome was better in patients who received mechanical revascularization/thrombolysis than those who received medical management only, with a lower MACCE rates (hazard ratio: 0.36; 95% CI: 0.16-0.8, p = 0.01.

Conclusion: The young MI patients are unique in having male dominance, better outcome, more of single-vessel disease with significant number of normal coronaries, better response to mechanical as well as pharmacological revascularization.
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http://dx.doi.org/10.1016/j.carrev.2018.07.020DOI Listing
May 2019

Factors affecting seasonal changes in blood pressure in North India: A population based four-seasons study.

Indian Heart J 2018 May - Jun;70(3):360-367. Epub 2017 Sep 20.

Hero DMC Heart Institute, Dayanand Medical College & Hospital, Ludhiana, Punjab, India. Electronic address:

Objective: There are no community based, longitudinal, intra individual epidemiological studies on effect of weather and season on blood pressure (BP). We evaluated the effect of season and temperature on prevalence and epidemiology of BP in tropical climate.

Methods And Results: It was a longitudinal cross sectional survey of rural and urban subjects in their native surroundings. BP was measured in four different seasons in same subjects. A total of 978 subjects (452 rural and 521 urban) were included in the current analysis. Demographic characteristics such as age, gender, education, occupational based physical activity and body mass index (BMI) were recorded. Mean BP, both systolic and diastolic were significantly higher in winter season as compared to summer season. Mean difference between winter and summer was 9.01 (95% CI: 7.74-10.28, p<0.001) in systolic BP and 5.61 (95% CI: 4.75-6.47, p<0.001) in diastolic BP. This increase in BP was more marked in rural areas and elderly subjects. Prevalence of hypertension was significantly higher during winter (23.72%) than in summer (10.12%).

Conclusion: BP increases significantly during winter season as compared to summer season. Increase is more marked in rural areas and elderly subjects. Seasonal variation in BP should be taken into account while looking at prevalence of hypertension in epidemiological studies.
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http://dx.doi.org/10.1016/j.ihj.2017.09.012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6034019PMC
September 2018

Coronary Vasospasm Abutting the Stent: A Rare Though Important Cause of Recurrent Angina.

J Invasive Cardiol 2018 Jun;30(6):E46-E47

Dayanand Medical College and Hospital, Udham Singh Nagar, Ludhiana 560069, India.

Angiogram of the right coronary artery was used to reveal a subtotal occlusion abutting the proximal end of the stent with TIMI I flow that responded quickly to intracoronary nitrates. The patient was diagnosed with vasospastic angina.
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June 2018

Hypocalcemia Presenting as Life Threatening Torsades de Pointes with Prolongation of QTc Interval.

Indian J Clin Biochem 2018 Apr 1;33(2):235-238. Epub 2017 Aug 1.

1Present Address: Department of Cardiology, Dayanand Medical College and Hospital, Civil Lines, Tagore Nagar, Ludhiana, 141001 India.

Torsades de pointes with prolonged QTc interval is a form of ventricular tachycardia. Many predisposing factors have been identified and hypocalcemia is among the rare ones. Our case illustrates that though rare, hypocalcemia might manifest as torsades de pointes with prolongation of QTc interval. Early diagnosis and management of dyselectrolytemia can prevent these patients from catastrophic torsades de pointes.
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http://dx.doi.org/10.1007/s12291-017-0684-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5891463PMC
April 2018
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