Armed Forces Institute of Cardiology

Premature coronary artery disease (PCAD) is a growing public health concern, especially in South Asia, where traditional risk factors fail to fully explain the increasing incidence of early-onset myocardial infarction. To explore its molecular underpinnings, we conducted a pilot study analyzing plasma proteins and lipids to identify potential biomarkers and dysregulated pathways associated with PCAD. Label-free quantitative proteomics revealed distinct molecular signatures separating PCAD patients from age- and sex-matched healthy controls. Key alterations included upregulation of GALE, immunoglobulin genes, and KIF20B, suggesting enhanced inflammatory responses and proliferative activity associated with post-myocardial infarction cellular repair. Similarly, down regulations of various proteins linked to multiple functions, such as myocardial infarction, hemoglobinopathy, complement and coagulation cascade, and fatty acid and lipoprotein transport in hepatocytes, were observed. Untargeted lipidomics further revealed significant elevations in several phosphatidylcholine species (PC 42:5, PC 40:3, and PC 42:7), highlighting disruption of highly unsaturated phospholipid metabolism. Overall, these findings indicate that PCAD is a multifactorial disorder involving metabolic, immune, and vascular dysfunction beyond conventional lipid abnormalities, underscoring the need for larger cohort studies to validate these biomarkers and uncover novel therapeutic targets.

Background/Objectives: Coronary artery disease (CAD) remains the leading cause of mortality worldwide, with South Asia bearing a disproportionately high and rising burden, particularly at younger ages. The present study aimed to investigate genetic variants associated with premature coronary artery disease (PCAD) using whole-genome sequencing (WGS). Methods: WGS was conducted on 12 people (five PCAD cases, seven matched controls) to assess feasibility and methodology for future large-scale research. High-quality genomic DNA was sequenced at a minimum read depth of 10 & times; with a quality threshold of Q30. Variant calling with stringent quality control identified single-nucleotide polymorphisms (SNPs), followed by annotation against gnomAD for allele frequencies and ClinVar for pathogenicity. Protein-coding variants were filtered, and candidate genes were prioritized for comparative analysis between cases and controls. Results: An average of over 8.8 million SNPs per individual was identified, with comparable overall variant distributions between cases and controls. Initial analyses revealed 120 SNPs exclusively present in PCAD cases. All protein-coding variants were rare (allele frequency < 0.0001), and none were previously classified as pathogenic in ClinVar. After filtration, 87 candidate genes were prioritized. Enriched or unique variants in PCAD cases are mapped to genes involved in lipid metabolism, endothelial dysfunction, inflammatory signaling, immune regulation, thrombosis, vascular remodeling, and metabolic processes. Additional variants were identified in genes related to smooth muscle proliferation, oxidative stress, and other biological pathways. Conclusions: This WGS pilot study provides an initial overview of the genomic landscape of PCAD in a South Asian cohort, highlighting rare variants across multiple biological pathways implicated in atherosclerosis that need validation in a large-scale study.

Introduction: Foreign body aspiration is a rare yet life threatening event in adults[1]. Here, we present a case of an incidentally found pistachio shell in a patient with a history of recurrent pneumonia complicated by empyema. Case Presentation:44 y/o M with PMHx of asthma, and polysubstance use disorder presented with shortness of breath. On admission, his CXR showed right pleural effusion for which a subsequent CT Chest was done showing loculated right sided effusion concerning for empyema. A chest tube was placed, and patient was started on tPA Dornase. Pleural fluid was exudative and Cx grew Strep Viridans for which patient was treated with appropriate antibiotics and subsequent improvement in his SHOB. Incidentally, his CT Chest showed an ovoid 1.8 cm endobronchial structure concerning for a mucus plug vs foreign body. Inspection bronchoscopy showed an endoluminal body at the bronchus intermedius. Biopsy forceps were used to grasp the foreign body which appeared to be a nutshell. Removal was attempted through ET tube; however, foreign body was too large to pass through the tube. Attempt was also made to secure the foreign body with Cryo probe. Due to inability to pass the foreign body through the ET tube, the tube was removed en bloc with the bronchoscope with the cryoprobe in place holding the foreign body. Patient was extubated with successful removal of foreign body held with the cryoprobe. Patient was immediately reintubated by anesthesia present at bedside. Pt tolerated the procedure well and was safely extubated later. The foreign body was later found to be a pistachio shell. On further history, pt admitted passing out after binge drinking episodes and concurrent use of pistachios while drinking. Pt was educated to cut down on drinking and avoid eating nuts as well as other food items which would put him at an increased risk of spiration. Discussion: The incidence of foreign body aspiration is low in adults as compared to children; however, this must be on differentials in case of recurrent unresolving pneumonias. A high degree of suspicion for occult aspiration should be maintained in adult patients with unresolving pneumonia and history of polysubstance use disorder. Bronchoscopy remains the main therapeutic options for foreign body removal. Rigid Bronchoscopy has higher success rate (99%) than flexible bronchoscopy (86-91%)[2]; however, FB is used as the first approach for foreign body removal with RB being used only for difficult cases[3]. References: Available on request

Introduction: Pneumomediastinum is a rare clinical entity and is defined as air within the mediastinum. Symptoms of pneumomediastinum include chest pain, dyspnea, subcutaneous emphysema, dysphagia and dysphonia. It is further divided into primary spontaneous pneumomediastinum and secondary pneumomediastinum. Here we present a case of Primary Spontaneous Mediastinum in a 28-year-old asthmatic patient after ae episode of upper respiratory tract infection. Case Report: A 28-year-old patient with past medical history of well controlled mild intermittent asthma presented to the hospital with chest pain and dyspnea. On further evaluation, he reported upper respiratory tract symptoms for last 3-4 days with heavy bouts of coughing. He reported that the chest pain started after the coughing spells. He also reported to have been in close contact with his wife and kid who were recently infected with common cold. On physical exam, he had subcutaneous emphysema. His CXR showed pneumomediastinum, with a subsequent CT Chest showing extensive pneumomediastinum with air tracking around his chest and upper neck, secondary to possible alveolar rupture aka Macklin effect. CT Chest didn't show any esophageal injury or tear. Pt also reported smoking marijuana recently. Pt was treated conservatively with analgesics and oxygen, and despite his impressive CT Chest, his symptoms improved dramatically within a day, and he was discharged home with directions to follow outpatient. Pt was also advised to avoid smoking to prevent recurrence of the pneumomediastinum. Discussion: Pneumomediastinum is a rare clinical diagnosis and usually has a good clinical outcome. Spontaneous pneumomediastinum usually occurs in healthy subjects but is associated with risk factors including smoking and polysubstance abuse. Secondary pneumomediastinum is due to an identifiable risk factor including iatrogenic, surgery, trauma, COPD, bronchiectasis, and malignancy. The pathophysiology of pneumomediastinum is termed as ‘Macklin effect’, defined as 3 step process: alveolar ruptures, air dissection along bronchovascular sheaths, and spreading of this pulmonary interstitial emphysema into the mediastinum. It's important to find the inciting event causing the pneumomediastinum as that guides the management. Treatment for primary spontaneous pneumomediastinum is usually conservative with analgesic and oxygen. Focus should be on treating symptoms rather than imaging which can look dramatic in some instances. Pneumomediastinum is self-resolving, and recurrence is usually rare. References: Available on request and on QR Code

Background: Temporary pacemakers (TPM) are often placed using femoral, jugular, or subclavian veins, but these approaches have risks like pneumothorax or lead dislodgement. The supraclavicular route may offer a safer alternative, but data is limited. Methods: In this retrospective observational study, we assessed 3,569 patients who got a TPM at a tertiary hospital (2020–2024). Of these, 1,644 had supraclavicular access, and 1,925 had infraclavicular access. We compared success rates, complications, and procedure times. Data came from medical records, and all analyses were performed using SPSS v26. Results: The study compared outcomes between supraclavicular (n=1,644) and infraclavicular (n=1,925) approaches for temporary pacemaker implantation in 3,569 patients. Baseline characteristics were well-matched between groups, with similar age (63.7 vs 64.1 years), sex distribution (56.3% vs 55.7% male), and comorbidity profiles (all p>0.05). The supraclavicular approach demonstrated superior safety outcomes, with significantly lower overall complication rates (9.3% vs 14.8%, p<0.001), including reduced arterial puncture (2.0% vs 4.2%), pneumothorax (0.3% vs 1.1%), lead dislodgement (4.5% vs 6.8%), and hematoma formation (1.5% vs 2.7%). Multivariate analysis identified supraclavicular access as independently protective against complications (OR 0.59, 95% CI 0.48-0.73), along with younger age and normal renal function. Procedural efficiency favored the supraclavicular approach, with shorter mean procedure times (24.6 vs 29.1 minutes, p<0.001) and higher first-attempt success rates (89.4% vs 83.2%, p<0.001). Predictive modeling showed excellent discrimination for complications (AUC 0.73), while survival analysis confirmed prolonged complication-free intervals with supraclavicular access (log-rank p=0.01). Conclusion: Supraclavicular access for TPM is safer, faster, and more successful than the traditional infraclavicular approach. It should be considered as a first-choice method, especially in emergencies.