Abstract Background Atrial fibrillation (AF) is a common cardiac arrhythmia that affects around three million people worldwide. Thromboembolic stroke, myocardial ischemia and congestive heart failure with significant financial burden are bad outcomes of AF. It is associated with significant morbidity and is also an independent risk factor for mortality. The treatment of AF and its associated complications increases healthcare resource utilization and contributes to increasing costs of healthcare, particularly costs associated with recurrent hospitalization. Methods 538 patients of atrial fibrillation are enrolled in our multicentric study from 2012 to 2017 that brought to light the therapeutic impact a noninvasive, medication-free intervention has on a costly disease.The unique approach of this study involved patients serving as their own controls; for the first 12 weeks, patients continued standard AF medical or catheter ablation therapy, followed by 16 weeks of 30-min alternate day yoga sessions (Savasana / Sun Salution Yoga Posture, Ujjayi Breath and Anulom –Vilom Pranayam). Patients were also encouraged to practice yoga at home on a daily basis.We divided into two group Yoga and Non Yoga and compared the data after 16 weeks of training. Results Yoga training reduced symptomatic AF episodes (14.8±4 vs. 8.2±3.2, p<0.005), symptomatic non-AF episodes (12.8±2.8 vs. 9.2±2.2; p<0.004), asymptomatic AF episodes (2.4±0.4 vs. 1.3±0.20; p<0.005), and depression and anxiety (p<0.005) used Goldberg anxiety score 2.5 fold improved as compared to non yoga group while improving, QoL parameters including physical functioning, vitality, social functioning, and mental health as assessed using the SF-36 (p=0.017, p<0.001, p<0.001, p=0.019, and p<0.003, respectively). There were significant decreases in heart rate and systolic (11±3 mmhg) and diastolic (6±2 mmhg) blood pressure after yoga training (p<0.002). This may directly result in decreased hospitalization (38% in yoga vs 16% in non yoga group) and healthcare costs reduction in yoga group. Yoga is also an intervention free from medication-related side effects or the complications observed with cardiac ablation. Conclusions The primary outcome was a composite of the reductions in symptomatic AF, symptomatic non-AF, and asymptomatic AF episodes as recorded by a diary and correlated with a non-looping event monitor with low cost. Strikingly, the results validate the ability of yoga practice to reduce patient-reported AF symptoms. It also demonstrated a statistically significant impact on quality of life (QoL), mental health, physical functioning, depression, and anxiety with avoid of side effects of medication or ablation. Funding Acknowledgement Type of funding source: None

Abstract Background Chronic restrictive pulmonary disease may alter right and left ventricular function by changing intrathoracic pressure. Pulmonary hyperinflation may increase right atrial pressure, leading to reduced venous return and subsequent reductions in RV pre-load. In CRPD patients, hyperinflation has been directly correlated with reduced atrial chamber size, global RV dysfunction, and reduced LV filling. Accurate assessment of global and regional right ventricular (RV) systolic function is challenging. Purpose The aims of this study were to confirm the reliability and feasibility of a three-dimensional (3D) speckle-tracking echocardiography (STE) system, using comparison with cardiac magnetic resonance imaging (CMR), and to assess the contribution of regional RV function to global function. Methods In a retrospective, cross-sectional study setting, RV volumetric data were studied in 200 patients who were referred for both CMR and 3D echocardiography within 1 month. Three-dimensional STE-derived area strain, longitudinal strain, and circumferential strain were assessed as global, inlet, outflow, apical, and septal segments. Results 136 patients (68%) had adequate 3D echocardiographic data. RV measurements derived from 3D STE and CMR were closely related (RV end-diastolic volume, R2=0.89; RV end-systolic volume, R2=0.82; RV ejection fraction [RVEF], R2=0.68; P<0.003 for all). RVEF and RV end-diastolic volume from 3D STE were slightly but significantly smaller than CMR values (mean differences, −3% and −8 mL for RVEF and RV end-diastolic volume, respectively). Among conventional echocardiographic parameters for RV function (tricuspid annular plane systolic excursion, fractional area change, S' of the tricuspid annulus, RV free wall two-dimensional longitudinal strain), only fractional area change was significantly related to RVEF (r=0.30, P=0.005). Among segmental 3D strain variables, inlet area strain (r=−0.49, P<0.004) and outflow circumferential strain (r=−0.39, P<0.005) were independent factors associated with CMR-derived RVEF. Conclusions Severity of restrictive pulmonary disease influences RV systolic dysfunction, which is reflected in speckle tracking 3D echocardiographic parameters. Regional RV wall motion showed that heterogeneous segmental deformations affect global RV function differently; specifically, inlet area strain and outflow circumferential strain.RV volume and RVEF determined by STE were comparable with CMR measurements.

Abstract Background Coronary revascularization is fruitful management to relieve angina and reduce mortality as compare to medical management in significant coronary artery stenosis. Although measurement of left ventricular ejection fraction (LVEF) after acute myocardial infarction (MI) is a performance measure, little is known about the relationship between EF and post-discharge mortality among MI patients in contemporary clinical practice. Objectives To assessment of mortality according to left ventricular ejection fraction and compare between yoga group and non yoga group, so that we can evaluate the importance of yoga and pranayam. Methods 2,470 patients (25 to 68 years of age) with STEMI were registered and managed with percutaneous coronary intervention at three centres from 2010 to 2012. Method was used to assess the association between left ventricular ejection fraction (LVEF) measured during the index hospitalization and 5-year mortality from date of registry. The relationship was examined with EF as a categorical variable, utilizing four clinically relevant categories (EF ≤34%, 35 to 45%, 46 to 54%, and ≥55%), and also with EF as a continuous variable. We divided two groups, group A was yoga with pranayam (n=1470) and group B was normal group (n=1000). Results Among STEMI patients we found a graded inverse association between EF category and mortality. For patients relevant categories (EF ≤34%, 35 to 45%, 46 to 54%, and ≥55%) mortality after 5 years was assessed by 21%, 14.3%, 12.2% and 11% in yoga, pranayam group (p<0.004). For patients relevant categories (EF ≤34%, 35 to 45%, 46 to 54%, and ≥55%) mortality after 5 years was assessed by 25%, 17.5%, 14.4% and 13% in normal group (p<0.004). LVEF was increased in yoga & pranayam group by 11±3% versus 4±1% non yoga group. Conclusion Yoga and Pranayam; breathing exercise may help to reduce metabolic stress, reduce oxygen demand and prevent ventricular remodeling. Low LVEF after STEMI remains an important risk factor for post-discharge mortality, even after extensive adjustment for patient and hospital characteristics. Routine yoga and pranayam; breathing exercise may reduce the mortality after myocardial infarction.

Abstract Background Chronic obstructive pulmonary disease may alter right and left ventricular function by changing intrathoracic pressure. Pulmonary hyperinflation may increase right atrial pressure, leading to reduced venous return and subsequent reductions in RV pre-load. In COPD patients, hyperinflation has been directly correlated with reduced atrial chamber size, global RV dysfunction, and reduced LV filling. Accurate assessment of global and regional right ventricular (RV) systolic function is challenging. Purpose The aims of this study were to confirm the reliability and feasibility of a three-dimensional (3D) speckle-tracking echocardiography (STE) system, using comparison with cardiac magnetic resonance imaging (CMR), and to assess the contribution of regional RV function to global function. Methods In a retrospective, cross-sectional study setting, RV volumetric data were studied in 302 patients who were referred for both CMR and 3D echocardiography within 1 month. Three-dimensional STE-derived area strain, longitudinal strain, and circumferential strain were assessed as global, inlet, outflow, apical, and septal segments. Results 208 patients (69%) had adequate 3D echocardiographic data. RV measurements derived from 3D STE and CMR were closely related (RV end-diastolic volume, R2=0.88; RV end-systolic volume, R2=0.81; RV ejection fraction [RVEF], R2=0.69; P<0.004 for all). RVEF and RV end-diastolic volume from 3D STE were slightly but significantly smaller than CMR values (mean differences, −2.8% and −7.8 mL for RVEF and RV end-diastolic volume, respectively). Among conventional echocardiographic parameters for RV function (tricuspid annular plane systolic excursion, fractional area change, S' of the tricuspid annulus, RV free wall two-dimensional longitudinal strain), only fractional area change was significantly related to RVEF (r=0.29, P=0.003). Among segmental 3D strain variables, inlet area strain (r=−0.48, P<0.002) and outflow circumferential strain (r=−0.37, P<0.003) were independent factors associated with CMR-derived RVEF. Conclusions Regional RV wall motion showed that heterogeneous segmental deformations affect global RV function differently; specifically, inlet area strain and outflow circumferential strain.RV volume and RVEF determined by STE were comparable with CMR measurements. Severity of COPD influences RV systolic dysfunction, which is reflected in speckle tracking 3D echocardiographic parameters.

Abstract Background Previous data showed the adrenal sex hormone dehydroepiandrosterone (DHEA) which is present in serum mainly as the sulfate DHEA-S is the most abundant steroid hormone and another hormones like testosterone, estradiol are related to cardiovascular risk in men. Literatures revealed vascular and metabolic actions of DHEA/-S, evidence for an association between DHEA/-S levels and cardiovascular events is controversy. Objectives Our aim is to review and clear the contradictory point regarding cardiovascular risk and correlation of testeosterone/ estradiol ratio, DHEA-S level with coronary inflammatory markers in men. Methods Large population based cohort study done at multi centre of cardiology from 2013- 2018 in India. We enrolled total 23631 normal healthy male population age between 40 to 60 years and divided into two groups based on testosterone/estradiol ratio (Group A (n=2450) lower value of T/E ratio and Group B (n=21181) normal or higher T/E ratio. We did cohort analysis for 5 years and evaluated DHEA-S level and correlated it with coronary inflammatory markers and cardiovascular risk. Results In group A (low T/E ratio) we found low level of DHEA-S (98% of individual) and higher value of interleukins IL-1 (68%),IL-6 (74%) and tumor necrosis factor TNF-1 (71%) and high sensitive C-reactive protein (hsCRP) (73% of individual). Data revealed two fold increase of high blood pressure and LDL cholesterol level as compared to group B (normal or high T/E ratio and normal or high value of DHEA-S). 2.5 fold higher rate of coronary heart disease (CHD) found in group A versus in group B. We did not found as much significant difference in stroke, carotid and peripheral artery disease. T/E ratio and DHEA-S levels were inversely associated with the age-adjusted risk of a CHD event; the hazard ratios and 95% confidence intervals per standard deviation (SD) increase were 0.76 (0.66 to 0.91) and 0.82 (0.72 to 0.93), respectively. Conclusions Decrease ratio of testosterone/estradiol levels correlate decreased levels of DHEA-S which may increase the risk of CHD in men. For future aspect, correction of T/E ratio, DHEA-S and increase its awareness should be at mass level for prevention of CHD.

Abstract Background Major cause of death across the world is coronary artery disease. The choice of treatment strategy should be primarily based on the hemodynamic significance of coronary artery stenosis. Two-dimensional speckle tracking provides valuable information for regional wall motion abnormalities. The purpose of this study was to determine the diagnostic value of left ventricular longitudinal strain and torsion to diagnose coronary artery disease during dobutamine stress echocardiography. Purpose The purpose of this study was to evaluate the diagnostic value of speckle tracking imaging-derived myocardial deformation parameters at rest and during dobutamine stress to determine the hemodynamic significance of coronary artery stenosis in patients with moderate and high probability of CAD. Methods We studied 204 patients (mean age 54.2±9.8 years, 128 male and 76 female) with known or suspected coronary artery disease, excluding those with prior history of transmural infarction. All of them underwent dobutamine stress echo and coronary angiography within one month. Wall-motion score index, left ventricular global longitudinal strain and torsion were measured at rest and peak stress. Optimal cut-offs were derived from receiver operating characteristic curves for strain and torsion values. Additionally, the respective differences between rest and stress were also calculated. Results During dobutamine stress echocardiography we revealed mean left ventricular ejection fraction was 53±6.2%. Coronary angiography revealed significant stenotic lesions in 124 patients (60.7%). Values regarding sensitivity, and specificity for wall motion score index difference were 76% and 84% respectively (area under curve 0.84). Global longitudinal strain difference (median 0.6%) illustrated 83% sensitivity and 74% specificity for disease detection (area under curve 0.82, cut-off value ≤0.5%). The respective values for torsion difference (median 5.1°) were 84% and 79% (area under curve 0.80, cut-off value ≤5.9°). Combination of wall motion score index difference and torsion difference for disease detection showed 89% sensitivity and 77% specificity (area under curve 0.84). Conclusions Left ventricular strain and strain rate analyses during DSE can be used in the assessment of hemodynamic significance of coronary artery stenosis in patients with moderate and high risk for CAD. The implementation of speckle tracking during dobutamine stress echo could serve as an adjunct method for coronary artery disease assessment, providing quantitative diagnostic information.

Abstract Background Telemedicine has beneficiary aspect to manage health and reduce the burden of illness. It represent health promotion with support of many ways like tele (distance mode), e (electronic mode), audio visual mode and m (mobile or smart phones) mode etc. Objectives To evaluate the cardiovascular land economical outcomes of tele-cardiology, e-cardiology, audio-visual cardiology and m-cardiology in large population and to review with increase awareness and application of telemedicine. Methods We enrolled 12872 patients from different cardiac centres in india and registered in TEAM (Tele-cardiology, E-cardiology, Audio-visual cardiology and M-cardiology) registry from 2008 to 2018. We included tele diagnosis, tele assistance, tele monitoring, tele therapy, electronic remot media, audio visual media and mobile apps for management of different category of cardiovascular disease like coronary heart and structural heart disease, hypertension, heart failure and congenital heart disorders. We compared TEAM registry with usual group (n=13229) at the platform of beneficiary outcomes regarding diagnostic, therapeutic significance, economical burden, mortality and rate of hospitalization. Results Our data revealed that 34% more correction of the diagnosis of congenital heart diseases, 29% reduction of unnecessary transport of acute coronary syndrome and non cardiac chest pain from primary to higher cardiac centre. 38% patients of ST elevation of myocardial infarction were benefited by facilliated angioplasty and 50% mortality risk reduction in TEAM registry as compare usual group. In heart failure patients, 12 months clinical outcomes revealed that there was a significant reduction in rehospitalizations in the TEAM group compared with the usual-care group (19.6% versus 33.7%,) and also found 29% stroke reduction in TEAM group. Usual group showed 2.5 fold higher economical burden than TEAM registry. Conclusion Total approach of telemedicine in cardiology service may diagnose correctly at root level, prevent clinical instability, reduce rehospitalization and lower the cost of managing heart patients.

Abstract Background Chronic obstructive pulmonary disease may alter right and left ventricular function by changing intrathoracic pressure. Pulmonary hyperinflation may increase right atrial pressure, leading to reduced venous return and subsequent reductions in RV pre-load. In COPD patients, hyperinflation has been directly correlated with reduced atrial chamber size, global RV dysfunction, and reduced LV filling. Accurate assessment of global and regional right ventricular (RV) systolic function is challenging. Purpose The aims of this study were to confirm the reliability and feasibility of a three-dimensional (3D) speckle-tracking echocardiography (STE) system, using comparison with cardiac magnetic resonance imaging (CMR), and to assess the contribution of regional RV function to global function. Methods In a retrospective, cross-sectional study setting, RV volumetric data were studied in 302 patients who were referred for both CMR and 3D echocardiography within 1 month. Three-dimensional STE-derived area strain, longitudinal strain, and circumferential strain were assessed as global, inlet, outflow, apical, and septal segments. Results 208 patients (69%) had adequate 3D echocardiographic data. RV measurements derived from 3D STE and CMR were closely related (RV end-diastolic volume, R2=0.88; RV end-systolic volume, R2=0.81; RV ejection fraction [RVEF], R2=0.69; P<0.004 for all). RVEF and RV end-diastolic volume from 3D STE were slightly but significantly smaller than CMR values (mean differences, −2.8% and −7.8 mL for RVEF and RV end-diastolic volume, respectively). Among conventional echocardiographic parameters for RV function (tricuspid annular plane systolic excursion, fractional area change, S' of the tricuspid annulus, RV free wall two-dimensional longitudinal strain), only fractional area change was significantly related to RVEF (r=0.29, P=0.003). Among segmental 3D strain variables, inlet area strain (r=−0.48, P<0.002) and outflow circumferential strain (r=−0.37, P<0.003) were independent factors associated with CMR-derived RVEF. Conclusions Regional RV wall motion showed that heterogeneous segmental deformations affect global RV function differently; specifically, inlet area strain and outflow circumferential strain.RV volume and RVEF determined by STE were comparable with CMR measurements. Severity of COPD influences RV systolic dysfunction, which is reflected in speckle tracking 3D echocardiographic parameters.

We present the first reported case showing metastatic giant bone cell tumor being treated successfully with pembrolizumab after failing prior tyrosine kinase inhibitor therapy. Of note, the patient developed multiple systemic effects associated with checkpoint inhibitor use. One year after starting the checkpoint inhibitor (ICI), the patient also developed hepatitis that was confirmed by liver biopsy and pathology to be, in part, due to drug-mediated toxicity similar to prior ICI toxicity cases that have been reported. Additionally, although the patient had vascular risk factors (hypertension, diabetes and smoking), it was notable from a cardiology perspective that the patient developed 2 subsequent non–ST-elevation myocardial infarctions, with rapid progression of stenosis of the left circumflex artery 2 months apart. The first left heart catheterization showing minimal disease of the left circumflex, but 2 months later, presenting with chest pain, a repeat left heart catheterization showed significant stenosis of the left proximal circumflex, raising the possibilities that either ICI can promote plaque rupture and/or accelerated atherosclerosis; both phenomena have been shown to occur in animal models. The patient also developed thyroiditis with subsequent hypothyroidism, now on thyroid replacement from checkpoint inhibitor use. This case demonstrates the multiorgan adverse effects this new antioncologic agent can have and yet also its promising antitumor effects. Awareness of the side effects among primary care doctors and all specialists will be helpful in managing these potential side effects and research will help elucidate ways to prevent the adverse effects.

Over a third of critical illness survivors manifest significant psychocognitive impairments following discharge from the intensive care unit (ICU). It is not known which patient populations are at highest risk or if assessment at ICU discharge can guide outpatient treatment prioritization.Prospective single center study in an academic medical center encompassing six types of ICUs assessed prevalence of psychocognitive morbidity based on ICU type and associations between initial and 3 month follow-up evaluation. Adult patients with >48 h ICU stays completed the Hospital Anxiety and Depression Scale (HADS), Impact of Events Scale-Revised (IES-R), and Montreal Cognitive Assessment-Blind (MoCA-blind).Of 299 patients who underwent initial assessment, 174 (58%) completed follow-up. Length of stay, MoCA-Blind, HADS-A/D and IES-R scores were similar across ICUs. Most commonly observed impairment in-hospital was cognitive (58%) followed by anxiety (45%), acute stress (39%) and depression (37%). There were significant correlations between in-hospital and follow-up psychocognitive outcomes.There was no significant difference in impairment by ICU type. Significant correlation between the initial assessment and follow-up scores suggests that early screening of high risk patients may identify those at greatest risk of sustained morbidity and facilitate timely intervention.

The use of amphetamines is a global public health concern. We summarise global data on use of amphetamines and mental health outcomes.A systematic review and meta-analysis (CRD 42017081893). We searched Medline, EMBASE, PsycInfo for methamphetamine or amphetamine combined with psychosis, violence, suicidality, depression or anxiety. Included studies were human empirical cross-sectional surveys, case-control studies, cohort studies and randomised controlled trials that assessed the association between methamphetamine and one of the mental health outcomes. Random effects meta-analysis was used to pool results for any use of amphetamines and amphetamine use disorders.149 studies were eligible and 59 were included in meta-analyses. There was significant heterogeneity in effects. Evidence came mostly from cross-sectional studies. Any use of amphetamines was associated with higher odds of psychosis (odds ratio [OR] = 2.0, 95%CI 1.3–3.3), violence (OR = 2.2, 95%CI 1.2–4.1; adjusted OR [AOR] = 1.4, 95%CI 0.8–2.4), suicidality OR = 4.4, 95%CI 2.4–8.2; AOR = 1.7, 95%CI 1.0–2.9) and depression (OR = 1.6, 95%CI 1.1–2.2; AOR = 1.3, 95%CI 1.2–1.4). Having an amphetamine use disorder was associated with higher odds of psychosis (OR = 3.0, 95%CI 1.9–4.8; AOR = 2.4, 95%CI 1.6–3.5), violence (OR = 6.2, 95%CI 3.1–12.3), and suicidality (OR = 2.3, 95%CI 1.8–2.9; AOR = 1.5, 95%CI 1.3–1.8).Methamphetamine use is an important risk factor for poor mental health. High quality population-level studies are needed to more accurately quantify this risk. Clinical responses to methamphetamine use need to address mental health harms.