Session 02 : Coronary Artery Disease

Session 2: Coronary Artery Disease
Chairpersons: Roopa Salwan and Neeraj Pandit

8:45-9:15 Balram Bhargava

9:15-9:35 Manikandan Subramanian 
9:35-9:55 Ajit Mullasari 
Creating STEMI Program in India
9:55-10:15 Nitish Naik 
10:15-10:35 Rishi Sethi 

Current Management of Chronic Stable Angina

posted Jan 25, 2017, 11:14 PM by sourav ghosh

Balram Bhargava
Professor, Senior Resident, Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India 

Chronic stable angina (CSA) is defined as chest discomfort which occurs predictably and reproducibly at a certain level of exertion and is relieved with either rest or nitroglycerin. The management of CSA has three major aspects which are preventive therapy, pharmacological therapy for angina and revascularization.
Preventive therapy includes low dose aspirin, risk factor reduction such as treatment of hypertension, diabetes and cessation of smoking. All patient should be on at least moderate intensity statins. ACE inhibitors have a major role in patients who are having hypertension, diabetes and chronic kidney disease.
Beta blockers, nitrates and calcium channel blockers are three first line class of anti-anginal drugs. Ranolazine and Nikorandil are newer drugs which may be used as combination therapy with the above.
All patients who continue to be having angina despite maximal tolerable doses of anti-anginals should be considered for coronary angiography followed by revascularization as deemed appropriate either by percutaneous coronary intervention or coronary artery bypass surgery. Other indications of angiography are intermediate or high risk criteria on non invasive stress testing irrespective of severity of angina.The choice of initial stress test such as treadmill test, nuclear imaging, or pharmacologic stress testing with imaging depends on patients baseline ECG and ability to perform exercise.
The management of CSA has improved tremendously over the past few years and is more evidence based now. Consequently, the outcome seems to have been improving.

Promoting Inflammation Resolution Response as a Therapeutic Strategy in Atherosclerosis

posted Jan 25, 2017, 11:11 PM by sourav ghosh

Manikandan Subramanian 
MBBS, PhD, Senior Scientist and Ramalingaswami Fellow, CSIR-Institute of Genomics & Integrative Biology, New Delhi, India

Atherosclerosis is a non-resolving chronic inflammatory disease triggered by the sub-endothelial retention of lipoproteins in large and medium-sized arteries. A small proportion of these atherosclerotic plaques display a “vulnerable phenotype” characterized by large necrotic cores and thin fibrous cap, which are harbingers of plaque rupture and acute luminal thrombosis leading to clinical conditions such myocardial infarction and stroke. Our studies have established that the dominant cellular processes that lead to vulnerable plaque development are 1) increased atherosclerotic lesional cell apoptosis, 2) defective phagocytic clearance of apoptotic cells (efferocytosis), and 3) failed inflammation resolution. Over the past few years, our research has focused on unraveling the mechanistic basis of these molecular events with a particular emphasis on the role of innate-adaptive immune cell interactions and inflammatory cytokine cross-talk in shaping these processes. Most recently, using a nanomedicine approach, we have demonstrated the possibility of enhancing efferocytosis efficiency within the atherosclerotic plaque to promote inflammation resolution and stabilization of advanced plaques.

Creating STEMI Program in India

posted Jan 25, 2017, 11:10 PM by sourav ghosh   [ updated Jan 26, 2017, 5:36 AM ]

Ajit Mullasari 
Director, Cardiology, The Madras Medical Mission, Chennai, India

The burden of cardiovascular disease is increasing at an unprecedented rate in the low and middle income countries (LMICs) because of ageing population, widespread exposure to increasing levels of risk factors such as unhealthy diet, physical inactivity, obesity, tobacco use, diabetes, raised blood pressure and abnormal blood lipids.The consequences of globalization and urbanization are also contributory factors.
There are no accurate estimates of STEMI in the LMIC, but it is possible that there could be upwards of 3 million cases per year.The almost universal use of Primary PCI as the reperfusion therapy of choice in ST-Elevation Myocardial Infarction (STEMI) and utilization of other evidence based medications, has dramatically improved the results of STEMI management in the United States and Western Europe.
The challenges for LMIC in Asia and Africa are entirely different.Regional Systems of care for STEMI care are virtually non-existent. Cardiac catheterisation laboratories are inadequate in number to serve the large numbers of patients with STEMI and are almost always clustered in urban locations.Poor transportation infrastructure, lack of adequately trained and equipped paramedics and ambulances, make access to these invasive centres difficult.Added to this is the financial constraints and lack of insurance coverage for the large majority of the population that limit these expensive procedures and costly medications to a small proportion of the patients.
In an environment of resource constraints with a burgeoning population of patients in LMIC with STEMI who require emergency care, the challenge is to address these issues in an effective and equitable manner.For this, innovation, particularly the use of technology can help deliver reperfusion for all.
This TNSTEMI project tries to address the management of STEMI and to utilize algorithms of STEMI management that may be more appropriate and easier to implement in LMIC.

Acute Coronary Syndrome in India: Observations and Opportunities

posted Jan 25, 2017, 11:08 PM by sourav ghosh

Nitish Naik
Professor, Department of Cardiology, Cardiothoracic and Neurosciences Centre

All India Institute of Medical Sciences, New Delhi, India
Coronary artery disease (CAD) is the leading cause of death amongst the non-communicable diseases in India. Acute coronary syndromes often herald the clinical presentation of CAD. While immediate assessment and percutaneous intervention is the standard of care for ST elevation myocardial infarction, most patients are unable to access such care even in urban areas due to a variety of reasons including late recognition, absence of adequate infrastructure and socio-economic factors. Significant health care delivery reforms and public education and awareness are required to improve patient 

Sleep Apnea and Coronary Artery Disease: Current Concepts

posted Jan 25, 2017, 11:05 PM by sourav ghosh   [ updated Jan 25, 2017, 11:06 PM ]

Rishi Sethi
Professor of Cardiology, KG's Medical University, Lucknow, India

Obstructive sleep apnoea (OSA) is a prevalent but under recognised form of sleep-disorder of breathing and is an emerging risk factor for acute coronary syndrome (ACS). 46–66% of the OSA patients end up with ACS. We sought to determine the effects of ethnicity on the prevalence of OSA which may differ not only between Western and Asian countries, but also within Asia itself.
A pooled analysis using patient-level data from the ISAACC Trial and Sleep and Stent Study was performed. Using the same portable diagnostic device, OSA was defined as an apnoea-hypopnoea index of ≥15 events per hour.
A total of 1961 patients were analysed, including Spanish (n=1050), Chinese (n=500), Indian (n=235), Malay (n=119), Brazilian (n=34) and Burmese (n=23) populations. BMI was significantly different among the various ethnic groups. The prevalence of OSA was highest in the Spanish (63.1%), followed by the Chinese (50.2%), Malay (47.9%), Burmese (43.5%), Brazilian (41.2%), and Indian (36.1%) patients. The estimated odds ratio of BMI on OSA was highest in the Chinese population (1.17; 95% confidence interval: 1.10–1.24). The area under the curve (AUC) for the Asian patients (ranging from 0.6365 to 0.6692) was higher than that for the Spanish patients (0.5161).
There was significant variation in the prevalence of OSA in patients with ACS in different ethnic group. However the effect of BMI onOSA was greater in the Chinese population as compared to other groups.

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