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   Table of Contents - Current issue
Coverpage
July-September 2019
Volume 5 | Issue 3
Page Nos. 75-108

Online since Monday, July 22, 2019

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REVIEW ARTICLE  

Where will non-Vitamin K oral anticoagulants stand beyond being standard of care in anticoagulation therapy? p. 75
Oktay Ergene
DOI:10.4103/IJCA.IJCA_14_19  
Objective: Atrial fibrillation (AF) is the most common arrhythmia that increases risk of stroke by 4–5 fold. AF prevalence is approximately 1%–3% in the general population and increases with age. Until 2010, the standard of care (SoC) for prophylaxis of ischemic stroke was Vitamin K antagonists. Phase III randomized controlled trials (RCTs) of non-Vitamin K oral anticoagulants (NOACs) showed that NOACs have comparable or lower risk of stroke, systemic embolism, major bleeding, and death with warfarin in populations with nonvalvular AF (NVAF). Since then, results of these pivotal RCTs were confirmed by postmarketing studies and real-world data. In the last 8 years, they have been replacing warfarin as the SoC not only for preventing stroke in NVAF patients but also for patients with deep vein thrombosis, pulmonary embolism, and those who undergo hip or knee surgery. In recent years, there are emerging data on new clinical areas such as coronary and peripheral artery disease. In this article, it is attempted to review what has changed in the last 8–10 years in the management and prevention of stroke associated with NVAF and other thromboembolic situations and to foresee whether NOACs will be SoC and stand beyond being SoC in anticoagulation therapy. Methods: IMS data were obtained from IQVIA with a permission letter on request of Dr. Ergene. IQVIA grants permission to use the statements for the specified purpose (NOACs share in the total anticoagulation market and role of NOACs as the SoC in the near future) of peer-review publication by Dr. Ergene. Conclusion: NOACs are breakthrough in stroke prevention, and they will prevail eventually. It will take a few years; anticoagulation market will grow in favor of NOACs, and most probably, NOACs will reach over 50% standard unit market share. It is even more exciting to hear about new therapeutic areas and indications for these agents.
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ORIGINAL ARTICLES Top

The Pattern of reciprocal electrocardiography changes in St-segment elevation myocardial infarction patients presenting with single-vessel disease versus multi-vessel disease p. 80
Mohamed Elsayed Zahran
DOI:10.4103/IJCA.IJCA_2_19  
Introduction: The reciprocal ST-segment depression in the electrocardiography (ECG) leads overlying noninfarcting areas was studied previously in acute myocardial ischemia. Multi-vessel disease (MVD) subset of patients have more vague and confusing presentations on ECG; they usually show less ST-segment elevation and profound and diffuse ST-segment depression compared to ST-segment elevation myocardial infarction (STEMI) patients with single-vessel disease (SVD) involving occlusion of one coronary artery only, namely the infarct-related artery (IRA). Aim of the Work: The aim was to study and compare the pattern of reciprocal ECG changes in STEMI patients presenting with SVD versus MVD. Methods and Results: A total of 125 consecutive patients admitted from April 2014 to August 2015 from the emergency room with the diagnosis of acute STEMI and treated by primary percutaneous coronary intervention (PPCI) at our cath lab at Ainshams University Hospitals (a 24/7 tertiary referral center for PPCI) were included. ST-segment deviations were measured at the J-point. Reciprocal ST-segment changes were identified as per guidelines published by the European Society of Cardiology and the American College of Cardiology, i.e., ST-segment depression ≥0.1 mV in any ECG lead other than aVR, while the cutoff value is different for leads V2 and V3 being only 0.05 mV. Coronary angiographies were evaluated by two independent operators blinded to the clinical and electrocardiographic data. Regarding the left anterior descending (LAD) occlusion, the reciprocal ST-segment depression magnitudes in lead III and in lead arteriovenous fistula (aVF) were significantly less in the MVD group compared to the SVD group, i.e., lead III (−0.08 ± 0.10 mV vs. −0.19 ± 0.15, P = 0.015) and lead aVF (−0.07 ± 0.06 mV vs. −0.15 ± 0.11, P = 0.02); while regarding the left circumflex coronary artery (LCX) occlusion, the reciprocal ST-segment depression extended significantly in V4 chest lead in the MVD group compared to the SVD group (−0.16 ± 0.08 mV vs. −0.1 ± 0.04, P = 0.025); and finally regarding the right coronary artery (RCA) occlusion, the reciprocal ST-segment depression extended significantly in V3 chest lead in the MVD group compared to the SVD group (−0.18 ± 0.07 mV vs. −0.1 ± 0.06, P = 0.02). Conclusion: The pattern of reciprocal ST-segment depression was more profound when the LAD was the culprit artery causing the anterior STEMI compared to the same case if the LAD was a part of MVD; this does not apply to the LCX and RCA when they were the culprit in cases of inferior STEMI where the MVD group showed more reciprocal ST-segment depression.
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A Safe and rapid technique for pacemaker İmplantation: Roadmap-guided subclavian vein puncture p. 86
Hakan Gunes, Mahmut Tuna Katırcıbası, Akif Serhat Balcıoğlu, Ekrem Aksu, Abdullah Sokmen, Gulizar Sokmen, Murat Kerkutluoglu, Ahmet Çağrı Aykan, Sami Ozgul
DOI:10.4103/IJCA.IJCA_10_19  
Objective: Widely used method is blinded puncture of subclavian vein, but the complication rate is high in this method. In this study, we aimed to demonstrate the effect of roadmap use during implantation of permanent pacemaker on the success rate, speed of puncture and complications. Methods: The study was designed as a prospective randomized controlled study. Totally, 125 devices were implanted to the patients included in the study, and 518 punctures were performed for implantation of these devices. 186 punctures were performed in roadmap group and 332 punctures were performed in conventional group. Two groups were compared with regard to clinical and demographic features, speed and success of puncture and complications. Results: Baseline characteristics were similar between groups. Median duration of intervention for each puncture was 27 (15/46) s in roadmap group and 56 (30/100) s in conventional group. The number of attempts for a successful puncture was detected as 1 (1/2) in roadmap group and 2 (2/4) in conventional group. Arterial puncture incidence was 10.3% in roadmap group and 37% in conventional group (P < 0.001 for all). Considering complications, the incidence of pneumothorax and intramuscular puncture was seen lower significantly (P = 0.046 and P = 0.006, respectively). Conclusion: Number of attempts for successful puncture, time needed for successful puncture, number of arterial puncture and complication rate was significantly lower in patients undergoing pacemaker implantation by roadmap technique. Based on these data, roadmap technique may take the place of conventional method of puncture.
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Evaluation of cardiac arrhythmia incidence in patients treated with oral moxifloxacin p. 92
Casit Olgun Celik, Aylin Yıldırır, Kaan Okyay, İlyas Atar, Mehmet Bülent Özin, İbrahim Haldun Müderrisoğlu
DOI:10.4103/IJCA.IJCA_3_19  
Background: The effect of moxifloxacin on QT interval is reversible and dose related, mainly provided by weakly but rapidly activated rectifying potassium channel blockade, IKr or human ether-a-go-go-related gene potassium channels. Retrospective data suggested an increase in cardiac event rates with moxifloxacin use. Nevertheless, except for case reports and experimental trials about QT/QTc, there are insufficient data in the literature on the incidence of cardiac arrhythmias detected by electrocardiography (ECG) and Holter monitoring. In this trial, we sought to determine the effects of newly administrated oral moxifloxacin on the incidence of cardiac arrhythmias. Methods: Forty-four patients (mean age 34.0 ± 10.4 years) treated with oral moxifloxacin with the indications of upper airway infections, community-acquired pneumonia, and acute exaggerated bronchitis were enrolled. All patients were screened for cardiac arrhythmia before therapy (BT) (0th day), on the 3rd day (during therapy [DT]), and on the 10th day (after therapy [AT]) with ECG and on the 3rd and 10th day with Holter monitorization. Before starting of the therapy, structural heart diseases were excluded using echocardiography, and other exclusion criteria were based on the laboratory tests.Results: The mean heart rate (HR) assessed by Holter monitoring was not significantly different during and after antibiotic therapy, although the mean HR measured from surface ECG was significantly reduced during and after antibiotic therapy compared to baseline (BT: 80.3 ± 13.9 beats per minute [BPM] vs. DT: 76.3 ± 11.3 vs. BPM vs. AT: 75.9 ± 106.0 BPM; P = 0.007). The mean QT interval value was increased on the 3rd day when compared to 0th day and was similar with the value on the 10th day (BT: 353.1 ± 24.6 msn vs. DT: 363.3 ± 23.7 msn vs. AT: 361.8 ± 20.8 msn; P = 0.034). The mean QTc interval was significantly increased on the 3rd day; however, it was decreased to the baseline value AT (BT: 396.4 ± 20.2 msn vs. DT: 404.4 ± 19.3 msn vs. AT: 397.5 ± 21.0 msn; P = 0.011). When the Holter monitoring findings of our study were analyzed in terms of gender interaction, minimal and maximal HR and QT dispersion parameters as well as the frequencies of ventricular and supraventricular extrasystoles and other arrhythmia findings were not different between male and females. Conclusion: Oral moxifloxacin started on an outpatient basis with the indication of airway infections resulted in a temporary increase in QT interval DT. However, it does not affect QTc and is not related with serious cardiac arrhythmias during Holter monitoring.
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CASE REPORTS Top

Broken coronary stent catheter retrieval percutaneously case report and literature review p. 99
Evliya Akdeniz, Baris Yaylak, Gönül Zeren, Ilhan Ilker Avci, Baris Simsek, Tolga Onuk, Can Yücel Karabay
DOI:10.4103/IJCA.IJCA_4_19  
We present a 73-year-old male patient with an unusual complication of a broken coronary stent catheter during percutaneous coronary angioplasty, which was successfully retrieved by balloon trapping and pulling-back method, along with literature review of similar cases.
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The de winter electrocardiographic pattern: What else do we need to learn? p. 103
Yalcin Velibey, Duygu Genç, Duygu Inan, Ozan Tezen
DOI:10.4103/IJCA.IJCA_9_19  
Electrocardiographic (ECG) abnormalities are often indicative of acute coronary artery occlusion. Early detection of these abnormalities is important for the identification of patients who may be candidates for emergent percutaneous coronary revascularization (PCR). In most cases, ST-segment elevation is the key factor in selecting patients for PCR. However, some cases with acute coronary artery occlusion do not have ST-segment elevation, resulting in delays in coronary reperfusion treatment. A 37-year-old male presented to the emergency department with typical chest pain. The patient indicated that he was a heavy marijuana user. Even though his admission ECG did not reveal ST-segment elevation, he was hemodynamically stable, and he did not develop life-threatening arrhythmias, he was immediately taken to the catheterization laboratory for urgent angiography with the diagnosis of acute myocardial infarction. The occluded left anterior descending artery seen in angiography was successfully revascularized with percutaneous coronary intervention. Herein, we present a case of a patient who was admitted to the emergency department with chest pain and ECG demonstrating the de Winter pattern. Based on this case, we present a detailed evaluation regarding the de Winter ECG pattern, which is equivalent to ST-segment elevation.
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Thrombus on the device early after the procedure of the left atrial appendage closure with the amplatzer cardiac plug: Is something wrong with the procedure or the device? p. 106
Baris Kilicaslan, Oner Ozdogan, Ali Kemal Cabuk, Inan Mutlu
DOI:10.4103/IJCA.IJCA_54_18  
Percutaneous left atrial appendage (LAA) closure is a currently utilized procedure for the prophylaxis of thromboembolic cerebrovascular events in selected patients with nonvalvular atrial fibrillation. The presence of thrombus on closure device was reported at 1st and 3rd months after the procedure, but as far as our knowledge, there are no data about early thrombus formation on the device during procedure. We present a case demonstrating thrombus on the atrial side of the Amplatzer Amulet LAA occluder device early after the implantation.
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