Systems of care for ST-elevation myocardial infarction in India

The prevalence of coronary artery disease and ST-elevation myocardial infarction (STEMI) are increasing in India. Although recent publications have focused on improving preventive measures in developing countries, less attention has been placed on the acute management of STEMI. Recent policy changes in India have provided new opportunities to address existing barriers but require greater investment and support in the coming years.     

Sudden cardiac death and tuberculosis – How much do we know?

Tuberculosis (TB), caused by Mycobacterium tuberculosis, is a major killer in the world and pulmonary infections are well characterised. It is not widely known that TB myocarditis leads to sudden cardiac deaths (SCD), especially in young people. Unlike other causes of SCD, risk factors such as family history are absent and patients are asymptomatic. This makes risk stratification and interventions with implantable cardiac defibrillators extremely difficult. Only a few cases of TB myocarditis SCD have been reported since 1977 and all of which were diagnosed at autopsy. The majority of reports showed extensive TB infiltration of the myocardium with no systemic symptoms. Concurrent miliary or systemic TB was postulated to be the source of TB myocarditis. The mechanism of death has been hypothesized to be ventricular tachyarrhythmia. Pulmonary TB has also been reported to cause sudden death. However, ventricular arrhythmias have not been recorded, suggesting a different mechanism to TB myocarditis SCD, which centres upon cardiopulmonary collapse leading to bradycardia. Although anti-tuberculous chemotherapy is efficacious in the treatment of TB myocarditis, there is no evidence to suggest that it is effective in the prevention of SCD. It remains to be seen whether better global control of TB disease burden will result in reductions in SCD. Furthermore, no experimental data exist on the link between TB myocarditis SCD and arrhythmias. We propose a unifying diagnostic system for TB myocarditis based on the current data and molecular techniques. This is likely to require updates as more evidence becomes available.     

Repeat percutaneous coronary revascularization: Indications and outcomes in a “Real World” cohort

Objectives : To investigate rates of and reasons for second and subsequent stent procedures in an unselected, “real‐world” population. Background : Repeat stenting is the primary difference reported in clinical trials of alternative revascularization strategies. The incidence, indication, and outcome for repeat stenting in contemporary practice outside the more selective populations of trials and registries has not been described. Method : All patients undergoing a first percutaneous coronary intervention (PCI) procedure with stenting from January 2001 to August 2009 (10,509) from a large UK tertiary referral and district general hospital were identified. Mortality and the incidence, timing, and indication for repeat revascularization in this population were investigated from patient records. Results : Of 10,509 patients undergoing a first PCI and stent implant 23.5% underwent repeat angiography of which 11.2% required repeat PCI and 2% coronary artery bypass grafting (median follow‐up of 3.8 years). A total of 1.3% went on to a third PCI. The commonest indication for repeat stenting was disease progression remote from the original stent (46%) and planned staged PCI (23%); 21% had a stent‐related indication. Functional assessment before repeat stenting was used in one‐third of stable patients. Mortality was 2.5% per annum. Conclusions : In contemporary practice, patients undergoing a first stenting procedure have a low subsequent mortality, and the substantial majority (86.4%) requires no further revascularization over a median 3.8 year follow‐up. For those who do require repeat stenting, this is most commonly at a site remote from the first stent. © 2012 Wiley Periodicals, Inc.