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Biomedical subjects

Ramesh M Gowda

Publications and source records attributed to Ramesh M Gowda.

At least 19 recordsLinked to original sources
PubMed2006

Thoracoabdominal aortic aneurysm: diagnosis and management.

Thoracoabdominal aortic aneurysm is defined as a focal and localized dilatation of the aorta 1.5 to 2 times the diameter of the normal adjacent aorta and containing all three layers of the arterial wall. Conventional open surgical repair remains the gold standard for the majority of the patients with thoracoabdominal aortic aneurysm. Endovascular stent-graft aortic repair is a promising emerging therapy, which at present is considered an alternative to surgery in the elderly and in those with significant comorbid conditions. Adjunctive beta-blocker therapy should be used in all patients to reduce the shear force on the aortic wall.

Journal Article↗
PubMed2005

Clinical perspectives of the primary spontaneous coronary artery dissection.

Spontaneous coronary artery dissection is a rare cause of acute coronary syndrome or sudden death. Typically it affects young women during the peripartum period and those using oral contraceptives. The pathophysiology remains unclear, but an eosinophilic periadventitial inflammation has been commonly observed in such cases. Unlike atherosclerotic intimal dissection, the dissection plane in the spontaneous dissection lies within the media or between the media and adventitia. Due to the rarity of the condition, the optimal management of the spontaneous coronary artery dissection has not been established and it may range from conservative medical treatment to percutaneous or surgical interventions depending upon the anatomy of the dissection, compromise of the vessel lumen and the clinical circumstances. The reported prognosis varies widely. Spontaneous coronary artery dissection should be considered in the differential diagnosis in young persons with precordial chest pain, especially women in the peripartum state and those using oral contraceptives. The clinical perspectives of the primary spontaneous coronary artery dissection are elaborated.

Aortic Dissection↗
PubMed2005

Left main coronary artery aneurysm.

Left main coronary artery aneurysm is rare finding at coronary angiography. We report a case of a large left main coronary artery aneurysm in a 59-year-old male who had cardiac catheterization for effort angina and inducible myocardial ischemia.

Cardiac Catheterization↗
PubMed2005

Coronary artery fistulas: clinical and therapeutic considerations.

Coronary artery fistulas vary widely in their morphological appearance and presentation. These fistulas are congenital or acquired coronary artery abnormalities in which blood is shunted into a cardiac chamber, great vessel, or other structure, bypassing the myocardial capillary network. The majority of these fistulas arise from the right coronary artery and the left anterior descending coronary artery; the circumflex coronary artery is rarely involved. Clinical manifestations vary considerably and the long-term outcome is not fully known. The patients with coronary fistulas may present with dyspnea, congestive heart failure, angina, endocarditis, arrhythmias, or myocardial infarction. A continuous murmur is often present and is highly suggestive of a coronary artery fistula. Differential diagnosis includes persistent ductus arteriosus, pulmonary arteriovenous fistula, ruptured sinus of Valsalva aneurysm, aortopulmonary window, prolapse of the right aortic cusp with a supracristal ventricular septal defect, internal mammary artery to pulmonary artery fistula, and systemic arteriovenous fistula. Although noninvasive imaging may facilitate the diagnosis and identification of the origin and insertion of coronary artery fistulas, cardiac catheterization and coronary angiography is necessary for the precise delineation of coronary anatomy, for assessment of hemodynamics, and to show the presence of concomitant atherosclerosis and other structural anomalies. Treatment is advocated for symptomatic patients and for those asymptomatic patients who are at risk for future complications. Possible therapeutic options include surgical correction and transcatheter embolization. Historical perspectives, demographics, clinical presentations, diagnostic evaluation, and management of coronary artery fistula are elaborated.

Arterio-Arterial Fistula↗
PubMed2005

Firsts in cardiology: milestones and vital discoveries.

The modern day cardiology practice thrives on the extraordinary discoveries made in the understanding of the cardiovascular science and in the development of diagnostic and therapeutic methods. In this paper, the milestones and vital discoveries in the field of cardiology are described in chronologic order.

Cardiology↗
PubMed2005

Role of electrocardiography in identifying right ventricular dysfunction in acute pulmonary embolism.

The role of electrocardiography in identifying right ventricular (RV) dysfunction in acute pulmonary embolism (APE) was evaluated in 81 patients with APE. The electrocardiographic markers studied were T-wave inversion in leads V1 to V3, the S1Q3T3 pattern, right bundle branch block, and sinus tachycardia. T-wave inversion in leads V1 to V3 had the greatest sensitivity and diagnostic accuracy for identifying RV dysfunction in patients with APE. The S1Q3T3 pattern and right bundle branch block had good specificity but moderate accuracy.

Acute Disease↗
PubMed2005

Treatment of refractory angina pectoris.

Refractory angina pectoris is defined as Canadian Cardiovascular Society class III or IV angina, where there is marked limitation of ordinary physical activity or inability to perform ordinary physical activity without discomfort, with an objective evidence of myocardial ischemia and persistence of symptoms despite optimal medical therapy, life style modification treatments, and revascularization therapies. The patients with refractory angina pectoris may have diffuse coronary artery disease, multiple distal coronary stenoses, and or small coronary arteries. In addition, a substantial portion of these patients cannot achieve complete revascularization and continue to experience residual anginal symptoms that may impair quality of their life and increase morbidity. This represents an end-stage coronary artery disease characterized by a severe myocardial insufficiency usually with impaired left ventricular function. As the life expectancy is increasing, patients with angina pectoris refractory to conventional antianginal therapeutics are a challenging problem. We review the nonconventional therapies to treat the refractory angina pectoris, including pharmacotherapy, therapeutic angiogenesis, transcutaneus electrical nerve and spinal cord stimulation, enhanced external counterpulsation, surgical transmyocardial laser revascularization, percutaneous transmyocardial laser revascularization, percutaneous in situ coronary venous arterializations, and percutaneous in situ coronary artery bypass. These therapies are not supported by a large body of data and have only a complementary role; therefore, the aggressive traditional and proven treatment of angina pectoris should be continued along with these therapies, used on an individual basis.

Angina Pectoris↗
PubMed2005

Acute pulmonary embolism in elderly: clinical characteristics and outcome.

OBJECTIVE: To evaluate the clinical characteristics and outcome of acute pulmonary embolism in elderly in comparison to the younger patients. METHODS: Study population consisted of 136 patients with a confirmed diagnosis of acute pulmonary embolism. Clinical characteristics and thromboembolic risk factors were analyzed between the elderly (> or =65 years of age) and the younger (<65 years of age) patients. In-hospital mortality was used as a measure of outcome. RESULTS: Elderly group consisted of 70 patients (age 76.4+/-8.3 years, range 65-96 years; females 58%) and younger group of 66 patients (age 48.5+/-12 years, range 18-64 years, females 59%). Syncope was more frequent in elderly group (19% vs. 6%, P=0.03) but the symptoms of shortness of breath and pleuritic chest pain were not significantly different between groups. Malignancy was the most common risk factor for thrombo-embolism, but immobilization predominated among patients in elderly group (21% vs. 6%, P=0.01). Tachycardia was common in younger patients compared to the elderly. Ventilation-perfusion scan was used more commonly in younger patients (76% vs. 57%, P=0.02), whereas, helical computed-tomography scan was used equally in both groups. Most of the patients had lower extremity duplex study (97% in each group). Inferior vena cava filter placement was common and thrombolytic therapy rare among elderly patients. Patients in elderly group had higher in-hospital mortality (17% vs. 5%, P=0.02). CONCLUSIONS: Syncope is a more frequent presenting symptom and immobilization a common risk factor in elderly patients with acute pulmonary embolism. In addition, they have higher in-hospital mortality.

Acute Disease↗
PubMed2005

Cardiac troponin I release in acute pulmonary embolism in relation to the duration of symptoms.

PURPOSE: To evaluate the release of cardiac troponin I in normotensive patients with acute pulmonary embolism in relation to the duration of symptoms. METHODS: Fifty-seven normotensive patients with acute pulmonary embolism were included in the study. Patients were divided into two groups based on the duration of symptoms at presentation: symptoms of < or =72 h, group A; symptoms of >72 h, group B. Serum cardiac troponin I levels were measured at presentation. RESULTS: Mean age was 63+/-18 years and 23 (40%) patients were males. Thirty-three (58%) patients had symptoms of < or =72 h (group A) and 24 (42%) had symptoms of >72 h (group B). Both groups had similar prevalence of right ventricular dysfunction on echocardiography (55% [n=18] in group A vs. 42% [n=10] in group B, p=NS). Sixteen patients had elevated serum cardiac troponin I (mean+/-S.D. 3.3+/-2.3 ng/ml, range 0.6-8.3 ng/ml). Elevated serum cardiac troponin I was strongly associated with right ventricular dysfunction (p=0.015). All patients with elevated serum cardiac troponin I (n=16) were in group A (p<0.0001). Twelve of 18 (67%) patients with (p=0.0005) and 4 of 15 (27%) patients without (p=NS) right ventricular dysfunction had elevated serum cardiac troponin I. Thirteen of 16 (81%) patients with elevated serum cardiac troponin I had duration of symptoms < or =24 h at presentation. CONCLUSIONS: The dynamics of cardiac troponin I release in acute pulmonary embolism in patients who present with symptoms of < or =72 h duration could be different from those who present with longer duration of symptoms. Therefore, the use of cardiac troponin I in risk stratification of acute pulmonary embolism might be limited to the patients presenting within 72 h of the onset of symptoms.

Acute Disease↗
PubMed2005

Evolution of the theory of circulation.

The first known descriptions regarding the basic aspects of circulation was probably in 500 B.C., by the Greek thinker Alcmaeon of Croton who observed arteries and veins to be dissimilar in animal dissection, and this was followed by the description of the human heart as a three chambered organ by Aristotle in 350 B.C. Herophilus of Chalcedon, a Greek anatomist, confirmed the findings of dissimilarity between arteries and veins in human cadaver dissections in 300 B.C., and determines that arteries were thicker than veins and contained blood. The advancement by far in the learning of human circulation was made possible first by significant contribution of Galen followed by observations of Ibn al-Nafis, Servetus, Colombo, Cesalpino, Vesalius and Fabricius. In 17th century William Harvey, an English physician, made important advancements into the understanding of this important area of medicine, advancements that continued with the observations of Malpighi.

Blood Circulation↗
PubMed2004

Role of N-acetylcysteine in prevention of contrast-induced nephropathy after cardiovascular procedures: a meta-analysis.

BACKGROUND: Contrast-induced nephropathy is one of the common causes of acute renal insufficiency after cardiovascular procedures. HYPOTHESIS: The objective of this paper was to analyze the published data on the usefulness of N-acetylcysteine in the prevention of contrast-induced nephropathy after these procedures. METHODS: Trials were selected if they were prospective, randomized, controlled, had selected patients with impaired renal function, used low-osmolality, nonionic contrast media intra-arterially, administered a total of four doses of N-acetylcysteine in addition to intravenous saline hydration, and had contrast-induced nephropathy as their primary outcome. Contrast-induced nephropathy was defined as an increase in serum creatinine concentration by >0.5 mg/dl or a 25% increase above baseline at or within 48 h post procedure. Meta-analysis was performed using the Fisher's Combined Test with a measure of effect size. The magnitude of the N-acetylcysteine effect was estimated using random-effects models. Homogeneity was evaluated using the chi-square test of homogeneity and standard Q statistic. Reporting bias was explored by the Rosenthal method. RESULTS: The Fisher's Combined Test was significant at p < 0.005 in favor of N-acetylcysteine. The size of the N-acetylcysteine effect was to reduce contrast-induced nephropathy by 20%. There was a 62% relative risk reduction in contrast-induced nephropathy with N-acetylcysteine using a fixed-effects model, and a 70% relative risk reduction using the random-effects model. In addition, we found that 27 unpublished trials showing no effects of N-acetylcysteine would exist to overturn the combined significance of p < 0.005 of the five trials in our meta-analysis. CONCLUSION: Oral administration of N-acetylcysteine in addition to intravenous saline hydration has a beneficial effect in the prevention of contrast-induced nephropathy after cardiovascular procedures in patients with impaired renal function.

Acetylcysteine↗
PubMed2004

Cardiac troponin I predicts myocardial dysfunction and adverse outcome in septic shock.

OBJECTIVE: The objectives of this study were to determine myocardial injury in patients with septic shock by measuring serum cardiac troponin I (cTnI), to evaluate relationship between elevated cTnI and myocardial dysfunction and to determine if cTnI is a predictor of outcome in these patients. METHODS: Thirty-seven consecutive patients with septic shock were included in the study. Serum cTnI was measured at study entry and after 24 and 48 h. Transthoracic echocardiogram, electrocardiogram and regular biochemical and hemodynamic assessments were performed. RESULTS: Sixteen (43%) patients had elevated serum cTnI. These patients had higher need for inotropic/vasopressor support (94% vs. 53%, p=0.018), higher APACHE II score (28 vs. 20, p=0.004), higher incidence of regional wall motion abnormalities on echocardiography (56% vs. 6%, p=0.002), lower ejection fraction (46% vs. 62%, p=0.04) and higher mortality (56% vs. 24%, p=0.04) compared to normal cTnI patients. By multiple logistic regression analysis, serum cTnI and APACHE II score were independent predictor of death and length of stay in intensive care unit. Serum cTnI, APACHE II score, anion gap and serum lactate were independent predictor of need for inotropic/vasopressor support. Receiver-operating characteristics of serum cTnI as a predictor of death in septic shock were significant. The elevated serum level of cTnI correlated with the lower left ventricular ejection fraction (p<0.001). CONCLUSIONS: Myocardial injury can be determined in patients with septic shock by serum cTnI. Serum cTnI concentration correlates with myocardial dysfunction in septic shock. High serum cTnI predicts increased severity of sepsis and higher mortality. A close monitoring of patients with septic shock and elevated levels cTnI is warranted.

Aged↗
PubMed2004

Novel therapeutics for treatment of long-QT syndrome and torsade de pointes.

Long-QT syndrome is a clinically and genetically heterogeneous syndrome characterized by lengthening of the QT interval and increased dispersion of the ventricular repolarization on surface electrocardiogram and a propensity to malignant ventricular arrhythmias, torsade de pointes and ventricular fibrillation, which may lead to sudden cardiac death. Long-QT syndrome mostly affects adolescents and young adults with structurally and functionally normal hearts and is caused by aberrations in potassium and sodium ion channels. Standard therapies for long-QT syndrome include correction of the underlying cause, alleviation of the precipitating factors, magnesium sulfate, isoproterenol, antiadrenergic therapy (beta-adrenergic receptor blockers, left cervicothoracic sympathectomy), cardiac pacing, and implantable cardioverter defibrillator. The potential therapies include sodium channel blockers (mexiletine, flecainide, lidocaine, pentisomide, phenytoin), potassium, potassium channel activators (nicorandil, pinacidil, cromakalim), alpha-adrenergic receptor blockers, calcium channel blockers, atropine, and protein kinase inhibitors. The purpose of this review is to outline the established therapies and update the recent advances and potential future strategies in the treatment of long-QT syndrome and torsade de pointes.

Humans↗
PubMed2004

Female preponderance in ibutilide-induced torsade de pointes.

OBJECTIVE: Ibutilide, a class III antiarrhythmic agent used for pharmacological cardioversion of atrial arrhythmias, has a potential to cause QT-interval prolongation and torsade de pointes. Purpose of this study was to determine whether women are more prone to develop ibutilide-induced torsade de pointes. METHODS: All clinical trials, cases, case series, and related articles in English-language in addition to 51 patients from our institution on the subject were examined. RESULTS: In a database derived from 23 reports in literature and from our institution, 1720 patients received ibutilide for cardioversion of atrial arrhythmias. Only in 87% (n=1492) patients, data were reported whether or not ibutilide caused torsade de pointes. The overall incidence of torsade de pointes was 3.9% (n=58) patients. Data on sex distribution of ibutilide-induced torsade de pointes was available in 73% (n=1096) patients. Torsade de pointes developed in 17 (5.6%) of 304 women and 24 (3%) of 792 men (P=0.05). It occurred during or within 45 min after completion of the infusion of ibutilide. Treatment instituted was with intravenous magnesium sulfate alone in 14% (n=8) patients, magnesium sulfate plus lidocaine in 5% (n=3) patients, magnesium sulfate with electrical cardioversion in 17% (n=10) patients, electrical cardioversion alone in 19% (n=11) patients, and precordial thump in 3% (n=2) patients. In 41% (n=24) of patients who developed torsade de pointes, it resolved without treatment. There were no reported deaths secondary to torsade de pointes associated with ibutilide infusion. CONCLUSION: Incidence of ibutilide-induced torsade de pointes is higher in women than in men. Greater caution must be observed while using ibutilide in women.

Anti-Arrhythmia Agents↗