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64th Annual CSI Conference and SAARC Cardiac CongressDECEMBER 06e09, 2012, NEW DELHI, INDIA

Cardiovascular Pharmacology

Poster Presentation

Thrombolysis in massive pulmonary embolism:Our clinical experience

Brijesh Agrawal, Snehil Mishra, Irfan Khan, Pranjal Patil, Rajendra

Chavan, Dhirender Singh, Vinay Kumar, Pritesh Punjabi, Sohan

Sharma, Sachin M. Mukhedkar, Madhusudan A. Yemul, Sandeep

N. Patil, Jaywant M. Nawale, Ajay S. Chaurasia

TNMC and BYL Nair Ch. Hospital, Mumbai, India

Aim: To evaluate the efficacy of thrombolysis in massive pulmo-

nary embolism.

Materials & Methods: The hospital course of 24 patients treated

for massive pulmonary embolism demonstrated by CT-

pulmonary angiography, 2D ECHO & ECG findings, over a period

of 2 years, was reviewed. The embolism was termed massive in

the presence of hemodynamic instability &/or RV dysfunction on

2D ECHO &/or CT findings of significant main pulmonary or

proximal right or left pulmonary artery obstruction. The average

age of patients was 47 years with a range of 23 to 84 years. All

patients with no contraindications were thrombolysed with

Streptokinase followed by the course of anticoagulation. Echo-

cardiography was performed before & after therapy & presence of

thrombus in pulmonary artery, Pulmonary Artery Systolic Pres-

sure (PASP) as well as evidence of Right ventricular dysfunction

were noted.

Results: Of the 24 patients, 20 patients were thrombolysed, while 4

had contraindications to thrombolysis. In the thrombolytic arm, 4

patients died with 1 of these 4 dying as a result of intracranial

haemorrhage. In the group of patients not thrombolysed, 3 out of 4

patients died. The echocardiographic features such as PASP &

ventricular dysfunction improved in 12 of the 20 patients throm-

bolysed & the improvement persisted on follow up. None of the

patients whowere not thrombolysed showed any improvement in

Echocardiographic features.

Conclusion: Mortality due to massive pulmonary embolism was

remarkably high (75%) in patients who were not thrombolysed,

while patients who could be thrombolysed had 20% mortality.

Thrombolysis also led to improvement in echocardiographic

parameters, which was sustained on follow up. Incidence of

The author underlined is the Presenting author.

http://dx.doi.org/10.1016/j.ihj.2012.10.031

life threatening bleeding following thrombolysis was low (5%).

Thus our study confirmed the efficacy of thrombolysis in

patients with hemodynamic compromise & a likely benefit

even in those only with RV dysfunction &/or CT features of

massive embolism.

Name of Corresponding Author: Brijesh Agrawal; Designation: Senior

Resident, Department of Cardiology; Address for Correspondence:

Topiwala National Medical College & BYLNair Charitable Hospital,

Mumbai 400008l; Telephone 022 23081758; Fax 022 23542540;

Mobile 8767586093; Email: drbrijesh23@gmail.com.

Safety and efficacy of eptifibatide asantithrombotic agent in pharmacoinvasivetherapy

D.P. Sinha, S. Sau, C.M. Zumder, C. Misra, J. Ghosh

Department of Cardiology, IPGME&R and SSKM Hospital, Kolkata, India

Introduction: Primary PCI is the preferred method of revascular-

isation in STEMI if it can be performed in time. However in our

country negligible percent of patient can achieve the scheduled

door to balloon time of <90 minutes. Use of gp2b3a inhibitor as

antithrombotic agent is class1 indication in primary PCI. But their

use in pharmaco invasive arm is shaded by increase risk of

bleeding. Abciximab is effective but very costly. In our country,

considering the socio-economic status of the population a cheap

though effective antithrombotic agent is required for successful

procedure.

Aims and objectives: To determine the safety and efficacy of

pharmaco-invasive reperfusion strategy utilising full dose of

thrombolytics combined with PCI and intra and postoperative

eptifibatide use as sole antithrombotic agent in STEMI, presenting

in our hospital or referred from outside.

Materials and methods: Prospective data obtained from patient

attending in our hospital with AMI thrombolysed outside or in our

hospital within the schedule time period of 24 hrs of acute event.

Streptokinase was used as thrombolytic agent. They all received

the loading dose of aspirin 325 mg, either Clopidrogrel 600 mg

/prasugrel 60 mg, no heparin, intra & post procedural bolus &

maintenance dose of eptifibatide according to weight adjusted

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dose. Wide range of age from 32-83 yrs, both high and low risk

STEMI, both diabetic and nondiabetic patient included in the

study. All of the patients present within two to twelve hrs of AMI.

Procedures were done at mean six hrs of thrombolysis. End point

event monitored were stroke, major bleeding, reinfarction, stent

thrombosis, SCD due to other complication within one month,

rescue PCI

Results and observations: 62 patients were studied from month

May 2011 till date.49 weremale and 13 were female. Majority were

in 50-59 yrs age group in both male and female (25 and 7respec-

tively). All patients received 1st bolus of eptifibatide after PTCA

wire crossed the lesion.7 patients had no reflow and among them

3 had TIMI 2 flow at the of the procedure. Post procedure 3 (4.8%)

had minor bleed and 1 (1.6%) had major bleed requiring blood

transfusion. 2 (3.2%) patients had subacute stent thrombosis who

died during hospital stay. No Stroke, procedural AMIwas reported.

Conclusion: There was no excess bleeding, ischaemic complica-

tions or mortality in this group although heparin was not used.

Thus it can be concluded that Use of eptifibatide as sole antith-

rombotic agent in patient undergoing pharmacoinvasive therapy

is safe and effective

Abbrebiations: AMI-Acute myocardial infarction. STEMI-ST

Elevation Myocardial Infarction. PCI-Percutaneous coronary

intervention, SCD-Sudden Cardiac Death

Name of Corresponding Author: Prof. D.P. Sinha; Designation:

Professor of Cardiology; Address for Correspondence: Department of

Cardiology, ICVS, IPGME&R and SSKM Hospital, KOLKATA-20;

Mobile 9433018443; Email: drdpsinha@gmail.com.

Role of platelets in thrombosis; newerantiplatelet therapies: An overview

Gundu H. R. Rao, Professor

Lillehei Heart Institute, University of Minnesota, USA

Platelet hyper-function plays a very important role in the patho-

genesis of atherosclerosis, thrombosis and stroke. Hyperactive

platelets also are implicated in precipitating acute vascular events

in clinical complications associated with type-2 diabetes. Blood

platelets interact with a variety of soluble agonists such as

epinephrine, adenosine diphosphate (ADP), and many insoluble

cell matrix components, including collagen, fibronectin and

biomaterials used for medical devices and drug delivery. These

interactions stimulate specific receptors on the plasma

membrane and initiate the activation of intracellular enzymes.

Ionized calcium is the primary bio-regulator and varieties of

biochemical mechanisms modulate the level and availability of

free calcium. Elevation of cytosolic calcium stimulates phospho-

lipases and release arachidonic acid (AA) from platelet

membranes. Free AA is transformed to bioactive pro-aggregatory

metabolites like prostaglandin endoperoxides and thrombox-

anes. Aspirin inhibits the formation of these active metabolites,

whereas Plavix (Clopidogrel) inhibits ADP mediated activation of

platelets. Aspirin, Plavix and their combinations are the choice of

anti-platelet drugs available for secondary prophylaxis at this

time. In spite of such prophylactic measures, significant numbers

of patients on these therapies are at risk for acute vascular events,

indicating the limitations of these therapeutic modalities. In this

overview, I will discuss platelet physiology, pharmacology, risk

assessment, risk management, anti-platelet therapies,

expectations and limitations of anti-platelet therapies and some

aspects of prevention strategies.

Name of Corresponding Author: Gundu H. R. Rao Ph D; Designation:

Emeritus Professor; Address for Correspondence: Unit 306, North

Tower, 12500 Park Potomac Ave, Potomac, MD, USA 20854; Tele-

phone 301 444 4545; Mobile 952 594 5248; Email: gundurao9@gmail.

com

Cardiovascular manifestations of acuteorganophosphorus poisoning

S. Laudari and Patowary B.S.

DM Resident Cardiology, Professor of Medicine, College of Medical

Sciences, Bharatpur, Nepal, India

Aims and Objectives: This study is aimed to study the different

cardiovascular manifestations and complications of acute

organophosphorus (OP) poisoning.

Materials and Methods: This is a hospital based prospective study

of 115 acute OP poisoning patients presenting in casualty, inten-

sive care unit and medical wards of CMS-Teaching Hospital,

Bharatpur (Nepal) during November 2008 to October 2011. All the

data were entered into pre-structured proforma and then

analyzed by SPSS 15.00.

Results:Majority of the patients had cardiac manifestations in the

form of sinus tachycardia (57/115¼49.57%). Sinus bradycardia was

observed in only 3 (2.61%) patients. The common complications

were: non-cardiogenic pulmonary edema in 23 (20%); electrocar-

diographic abnormalities including prolonged Q-Tc interval in 21

(18.26%); cardiac arrhythmias in 12 (10.43%); ST-T changes in 10

(8.70%) and atrioventricular conduction defects in 5 (4.35%).

Hypertension was detected in 23 (20%) patients and hypotension

in 6 (5.22%). Sixteen (13.91%) patients needed respiratory support

because of acute respiratory failure. Five patients had poly-

morphic ventricular tachycardia. Three patients died from

ventricular fibrillation. The overall mortality during this studywas

8 (6.95%) mainly contributed by WHO Class I compounds like

methylparathion and dichlorvos.

Conclusions: Cardiac complications are commonly encountered

after acute OP poisoning especially with WHO Class I compounds

during the first few hours. Hypoxia, respiratory failure, acid base

disturbances mainly metabolic/mixed acidosis, dyselectrolytemia

and over atropinisation were the major contributing factors.

Intensive supportive treatment and early specific therapy with

atropine and pralidoxime to counteract muscarinic and nicotinic

effects in intensive care unit will definitely help to reduce the

mortalities and morbidities.

Name of Corresponding Author: Dr Shankar Laudari, DM Resident,

Cardiology; Designation: College of Medical Sciences, Bharatpur,

Nepal; Address for Correspondence: Telephone 977 1 56523609; Fax

97756521527;Mobile 9779845112909; Email: lshankar2@hotmail.com

Efficacy of high dose atorvastatin after PTCA andits tolerance in Indian patients

K.V. Pranav Kumar, K. Tamilarasu, P. Ramasamy, P. Arun Kumar,

G. Rajendiran, J.S. Bhuvaneswaran

PSG Institute of Medical Sciences and Research, Coimbatore, India

Prasugrel%(n)

Clopidogrel%(n)

Death from cardiovascular causes,

nonfatal MI, or nonfatal stroke

6.4 (12) 9.1 (17)

Nonfatal MI 5.4 (10) 8.1 (15)

Target vessel revascularisation 2.7 (5) 4.3 (8)

Stent thrombosis 1.08 (2) 3.2 (6)

Major or minor TIMI bleeding 5.4 (10) 3.2 (6)

Life threatening bleeding 2.1 (4) 1.6 (3)

Intracranial bleeding 1.08 (2) 0.5 (1)

Bleeding requiring transfusion 4.3 (8) 3.2 (6)

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Aim & Objective: To study the efficacy of high dose atorvastatin in

reducing LDL levels after PTCA and to study its tolerance in Indian

patients.

Methods: The study was done on 30 patients who underwent

PTCA in PSG hospitals, Coimbatore from June 2012 to July 2012.

Lipid levels were checked after 1 week of receiving 80mg of ator-

vastatin after undergoing PTCA. Outcome was measured in terms

of number of patients who reached LDL levels of 100 or lower.

Occurrence of any side effects of atorvastatin and SGOT/SGPT

levels were noted at one week.

Results: Out of 30 patients included in the study, at the end of 1

week of therapy with 80mg of atorvastatin, 66% (n¼20) of the

patients had LDL level of <70, 23% (n¼7) had levels of 71-100 and

only 10% (n¼3) had levels >100. Of the 3 patients with LDL levels

>100, the range was 101 to 102. There was no significant elevation

in SGPT and SGOT levels with average value being 29 and 22

respectively. 26% (n¼8) responded positively for adverse effects of

atorvastatin. Side effects reported were minor and included

muscle and joint pain and none of them were severe enough to

discontinue therapy.

Conclusion: High dose atorvastatin is very efficacious in reducing

LDL levels in a short period of time and is well tolerated in Indian

patients.

Name of Corresponding Author: Dr. Pranav Kumar K.V; Designation:

2nd year Resident ( DM Cardiology); Address for Correspondence: PSG

Hospital, Coimbatore; Tel./Fax: 0422 2365000 Mobile þ91

9003346211; Email: doctorpranav@gmail.com.

Comparative study of prasugrel and clopidogrelin patients undergoing PCI in Indian population.

Prabhu S., Inania R., Bansal N.O.

Sir J. J., Hospital, Mumbai, India

Aims and Objective: To compare the efficacy and safety of pra-

sugrel with clopidogrel in patients with acute coronary syndrome

under going PCI.

Methods: To compare prasugrel, a new thienopyridine, with clo-

pidogrel, we randomly assigned 370 patients (185 in each group)

with moderate to high risk acute coronary syndromes with age

less than 75 years with scheduled percutaneous coronary inter-

vention to receive prasugrel (a 60 mg loading dose and a 10 mg

daily maintenance dose) or clopidogrel (a 300mg loading dose and

a 75 mg daily maintenance dose). Mean body weight was 64 kg.

The primary efficacy endpoint was death from cardiovascular

causes, nonfatal myocardial infarction, or nonfatal stroke. The

key safety end point was major bleeding.

Results: The primary efficacy endpoint occurred in 9.1% of

patients receiving clopidogrel and 6.4% of patients receiving pra-

sugrel.We also found significant reductions in the prasugrel group

in the rates of myocardial infarction (8.1% for clopidogrel vs 5.4%

for prasugrel), urgent target vessel revasularisation (4.3% for clo-

pidogrel vs 2.7% for prasugrel). Major bleeding was observed in

2.1% of patients receiving prasugrel and 1.6% of patients receiving

clopidogrel. Also greater in the prasugrel group was the rate of life

threatening bleeding (2.1% vs 1.6%), bleeding requiring trans-

fusion, (4.3% vs 3.2%) and overall bleeding risk (5.4% with prasu-

grel and 3.2% with clopidogrel).

Conclusion: Our data support the hypothesis that the greater

inhibition of adenosine diphosphate-induced platelet aggregation

by means of prasugrel, a potent oral P2Y12 inhibitor, is more

effective at preventing ischemic events than is the inhibition

conferred by a standard regimen of clopidogrel. However, this

beneficial effect is accompanied by a slight increase in the rate of

major bleeding. When considering the choice of antiplatelet

regimens for the treatment of patients with acute coronary

syndromes who are undergoing PCI, clinicians need to weigh the

benefits and risks of intensive inhibition of platelet aggregation.

Name of Corresponding Author: Sandesh Prabhu; Designation: Senior

Resident, DM Cardiology; Address for Correspondence: Department

of Cardiology, Sir J J hospital, Byculla, Mumbai; Telephone:

02223738947 Fax: 02223735599 Mobile: 9892654409; Email:

sandesh4u@yahoo.co.uk.

Pattern and prevalence of cardiovascular diseasein indoor psychiatric patients in an industrialcity of eastern India

Subodh Kumar and K. N. Thakur

Bokaro General Hospital, Bokaro Steel City, India

Various psychiatric conditions and stress related disorders have

been evaluated as risk factors for the development and expression

of cardiovascular disease. The issue of prevention of cardiac

problems in psychiatric patients has been poorly attended by the

clinicians in this part of the country.

Aims and objects: The present study aims to see the pattern and

prevalence of cardiovascular disease in adult psychiatric patients

admitted in the psychiatry ward of the Bokaro General Hospital in

4-month duration period.

Methods: In this study all the 122 adult psychiatric patients

admitted in the psychiatry ward of the hospital by the psychia-

trists were selected for the examination during a random 4-month

period, April to July, 2012. Pattern and prevalence of cardiovas-

cular disease in these patients were ascertained with the help of

a clinical psychologist (presenting author), the treating psychia-

trists, and the case record files. Sociodemographic and clinical

data-sheet and especially designed psychosocial risk factors

schedule of cardiovascular disease were applied to the subjects.

Results and conclusions: The obtained data are being analyzed.

Results and conclusions of the study and their implications for

prevention of cardiac risk factors in this clinical population will be

discussed at the time of presentation.

Name of Corresponding Author: Subodh Kumar; Designation: Senior

ClinicalPsychologist;Address forCorrespondence:Q.No.3039,Sector-5-

B, Bokaro Steel City, Jharkhand-827006; Ph. 08986873068 Mobile:

09798701542; Email: subodhkumar17@yahoo.com.

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A Comparative Evaluation of the Safety andTolerability of the combination of Aspirin andPrazugrel with Aspirin and Clopidogrel in PostPCI patients

Tom Devasia*, Supurna Dhar**, Swapna S.**, Thashma P.P.**,

Yeshwanth Rao**

* Dept of Cardiology, Kasturba Medical College Hospital, Manipal, Kar-

nataka **Faculty, Dept. Of Pharmacology, KMC-IC, Manipal, Karnataka

Background: Prasugrel, a new thienopyridine antiplatelet agent is

indicated for the reduction of thrombotic cardiovascular events

(including stent thrombosis) in patients with acute coronary

syndrome (ACS) who are to be managed with primary or delayed

percutaneous coronary intervention PCI . Prasugrel may be given

concurrently with aspirin for post PCI patients. A potential

concern of prazugrel therapy is its safety, particularly bleeding.

The use of aspirin and clopidogrel in combination has become

part of the standard clinical care of patients with coronary artery

disease. The aim of this study is to compare the safety of 2 anti-

platelet combinations (prasugrel + aspirin vs clopidogrel + aspirin)

in post PCI patients.

Methodology: Seventy three eligible patients were enrolled in the

study and randomised based on the body weight (33 patients in

<60 kg category & 40 in >60kg category) into arms - prazugrel/

aspirin (17 in <60 kgs, 20 in >60kgs) & clopidogrel/aspirin (17 in

<60kgs & 20 in >60kgs). Haemoglobin levels were estimated

before (0 week) and after (12 weeks) the study. Any other adverse

effects were observed during the study.

Results: The mean and the standard deviation between Hb values

before and after antiplatelet combination therapy showed no

significant difference (p¼0.94 & 0.93 in <60 kg, p¼0.56 & 0.81 in

>60 kg resply) in both the groups. No other adverse effects were

observed.

Conclusion: The safety profile of the newer antiplatelet drug

prazugrel (in combination with aspirin) is similar to the current

standard combination of clopidogrel and aspirin.

Oral Presentation

Outcome of high dose tirofiban bolus only versusbolus plus infusion strategy during primary PCIin Acute Myocardial Infarction (AMI)

T. Ghose, R. Kachru, R. Gupta, A. Hussain, S.D. Karloopia,

K.K. Shahi, U. Kaul

Fortis Flt. Lt. Rajan Dhall Hospital, New Delhi, India

Single centre studies have shown that high dose tirofiban (25mcg/

kg) bolus only during elective percutaneous coronary intervention

(PCI) is safe, feasible and has comparable short and intermediate

term out come. Outcome data of such an approach in primary PCI

is rare.

In this retrospective analysis, we compared the in hospital and

30 days MACE amongst all the patients undergoing primary PCI

with tirofiban bolus (Group A) and bolus plus infusion (Group B)

usage between June 2006 to June 2012.

Standard antiplatelet protocol was followed. Inj. Tirofiban

bolus was administered as intravenous/intracoronary bolus (25

mcg/kg over 3 min) or bolus plus infusion (0.15 mcg/kg/min

over 16-18 hours). Inj. Heparin was administered to keep the

intraprocedural ACT between 250-300 seconds. Thrombo-

suction (Thrombuster II, Kaneka Corporation, Japan) was done.

Intracoronary NTG and/or Nicorandil were administered

routinely based on the haemodynamics. Either balloon dilata-

tion followed by stent implantation or direct stenting was

performed. In trans radial approach the sheaths (6F, Avanti,

Cordis) were removed in lab and pneumatic radial compression

device (TR band, Terumo, Japan) was applied. In transfemoral

approach the sheath (6F, 7F, Cordis) were removed at ACT < 160

sec.

Baseline demographic profile was comparable between two

groups. Post procedural TIMI III flow was achieved in 48 (94%) in

group A compared to 190 (95.4%) in group B (P¼NS).

Post procedural TMP flow was grade 1 in 1 (2%) vs 3 (1.5%), TMP

grade 2 flow was in 24 (47.05%) vs 76 (38.1%) and TMP grade 3 flow

was 26 (50.9%) vs 120 (60.3%) patients in group A and B respectively

(P¼NS). Mean left ventricular ejection fraction was 38þ12% vs

39þ14% in group A & B respectively (P¼NS). Death was recorded in

1 (1.9%) vs 2 (1.0%) in Group A & B respectively (P¼NS). Myocardial

infarction occurred in 5 (9.8%) vs 6 (3.0%) in Group A& B respective

(P¼NS). TVR occurred in 3 (5.9%) vs 2 (1.0%) in Group A & B

respectively. TIMI Major bleeding occurred in 6 (11.7%) vs 8 (4.02%)

in Group A & B respectively (P¼NS). TIMI Minor bleeding occurred

in 10 (11.7%) vs 12 (4.02%) in Group A & B respectively (P¼NS). Any

bleeding occurred in 16 (31.3%) vs 20 (10.05%) in Group A & B

respectively (P¼NS).

High dose tirofiban bolus only dose in the setting of primary PCI

is safe, useful and is associated with similar outcome when

compared with bolus plus infusion strategy. Large prospective

randomized controlled trial is warranted.

Name of Corresponding Author: Dr. Tapan Ghose; Address for

Correspondence: 6020/D-6 Vasant Kunj, New Delhi 110070 Mobile

9811695113; Email: ghosetapan@yahoo.com.