Background: Reproductive factors in women may predispose to coronary artery disease (CAD) in later life. However, the evidence is meager and varying in response. If the appropriate factors are identified, it would enable much earlier and more aggressive risk factor modification as reproductive factors can be ascertained much earlier than traditional risk factors for CAD. The study aims to evaluate the reproductive factors in women which contribute to CAD in later life. Materials and Method: This is a retrospective study of 500 women. Reproductive factors including pregnancy details and lactation were assessed. The study population was divided into two groups depending on the presence and absence of CAD and reproductive factors compared using MINITAB version 17. Results: The CAD group was a decade older with a significant history of hypertension (P = 0.003) and diabetes (P = 0.02). Age of menarche was earlier in the CAD group (12.74 ± 1.29 years vs. 13.18 ± 1.43 years; P = 0.00) with statistically significant occurrence of early menarche, i.e., ≤12 years (46.8% vs. 33.6%; P = 0.002; risk ratio [RR] = 1.31; odds ratio [OR] = 1.74; 95% confidence interval = 1.1–1.56). Age at first pregnancy was significantly earlier in the CAD group (18.74 ± 2.94 years vs. 19.41 ± 3.36 years; P = 0.018), but early pregnancy (≤18 years) was not statistically significant (34.8% vs. 30.8%; P = 0.34). The CAD group had a higher order of parity (3.12 ± 1.49 vs. 2.67 ± 1.21; P = 0.000), but multiparity (>3 paras) was not significant. History of pregnancy complication (54% vs. 20.8%; P = 0.00; RR = 5.38, OR = 7.67) and pregnancy loss (44.4% vs. 16.4%; P = 0.00; RR = 2.71; OR = 4.07) were significantly higher in the CAD group. The average age of menopause was significantly earlier in CAD (44.25 ± 7.35 years vs. 46.16 ± 6.32 years; P = 0.006), and early menopause (≤45 years) was of borderline significance (P = 0.06; RR = 1.93; OR = 5.08). Breastfeeding did not have any impact. Conclusion: Early menarche, pregnancy complication, and pregnancy loss are associated with CAD in later life. Early menopause irrespective of whether natural or surgical also predisposed to CAD. Age of first pregnancy was earlier and order of parity was higher in the CAD group, but no definite relation between early pregnancy and multiparity with CAD could be established. Intake of hormonal therapy for menstrual irregularity, late menarche and breast feeding did not predispose to CAD.

Context: Coronary artery disease (CAD) occurs as a consequence of dyslipidemia and chronic inflammation. Cardiovascular disease mortality is on the rise in India. Aims: Explore the utility of simple markers such as neutrophil-to-lymphocyte ratio (NLR) and triglyceride/high-density lipoprotein cholesterol (TG/HDLc) ratio, to study the extent of coronary lesions as seen on angiography. Settings and Design: Observational study in a tertiary-care hospital in North-India. Methodology: Coronary angiograms of 126 outpatients were graded as per Friesinger Index. Lipid profile was analyzed for each patient, along with complete blood count parameters, including total leukocyte count (TLC), absolute neutrophil, and lymphocyte counts and mean platelet volume (MPV). Statistical Analysis Used:Comparison of groups was done using a Mann–Whitney U test, of continuous variables using a correlation coefficient, and of categorical variables using a Chi-square test, and odds ratios were estimated. Receiver operator characteristic curves were constructed, and cutoffs were obtained. Results: TG/HDLc-ratio was associated with severe coronary lesions (Friesinger-Index ≥5) [odds ratio (OR): 3.46; 95% confidence interval (CI): 1.32–9.10], which was stronger than the association of TG [OR: 3.15; 95%CI: 1.33–7.42] or HDLc [OR: 1.86; 95%CI: 0.81–3.82] alone. No association existed for total or low-density lipoprotein cholesterol. NLR was significantly higher among patients with severe lesions. NLR and MPV were significantly correlated with TG/HDLc ratio. Area under curve for TG/HDLc ratio and NLR was 73.7 and 60.8. Cutoff values were 2.53 (Sensitivity (SN) = 83.1%, Specificity (SP) = 56.7%) and 1.84 (SN = 61.0%, SP = 49.3%), respectively. Conclusions: TG/HDLc ratio and NLR are associated with CAD severity, more so than TG or HDLc alone, or TLC. They are easily accessible and inexpensive markers that may be utilized in identifying patients at risk for heart disease.

Background: Drug-eluting stents (DESs) have been shown to reduce the risk of restenosis and other adverse cardiac events after percutaneous coronary intervention (PCI) as compared with bare-metal stents (BMSs). However, the superiority of DES over BMS has been questioned in large vessels. We evaluated the risks and benefits of the use of DES versus BMS in patients who undergo stenting of large coronary arteries (≥3.5 mm) up to 1-year follow-up. Materials and Methods: This was a prospective study carried out in all-comer patients enrolled between January 2015 and December 2015. The patients with the variable indication for PCI, multivessel involvement, prior revascularization, and adjuvant drugs such as GP IIb–IIIa inhibitors were included in the study. However, patients who did not provide written informed consent and received both DES and BMS were excluded from the study. The clinical outcomes were evaluated at 1 year. Results: A total of 266 lesions (240 patients) in the large coronary arteries were stented, of which 130 lesions were treated with BMS and 136 lesions were treated with DES. At 1-year follow-up, target lesion revascularization/target vessel revascularization (P = 0.6492) and all-cause death (P = 0.7098) did not differ significantly between the two groups. In addition, no significant difference was found in patients requiring medical management (P = 0.3937) as well as number of asymptomatic patients (P = 0.2027). Conclusions: At 1-year follow-up, BMSs and DESs showed similar clinical outcomes in large coronary arteries. Hence, the use of BMS in large coronary arteries (≥3.5 mm) should not be discouraged unless clinically indicated.

Background: Noninvasively jugular venous pressure (JVP) is measured at bedside commonly by card and ruler. New tools have been developed for the measurement of JVP with the basis of this method. However, these tools have some limitations. Aim: The aim of this study was (1) to develop a JVP scale which would be devoid of common problems faced with currently available devices and (2) to test the provisional validity and reliability of the device in the estimation of JVP. Materials and Methods: We used two common plastic rulers – one as vertical and one as horizontal. The vertical ruler was cut at the level of 5 cm mark. A piece of aluminum sheet was used to make an adapter in which the vertical ruler can slide. This adapter was attached to the horizontal ruler. Both the rulers were equipped with spirit-level capsules. This device was used by 16 raters to measure JVP on five individuals twice. Inter-rater, intra-rater, and test–retest reliability were checked by the intraclass correlation coefficient (ICC) in IBM® SPSS® Statistics Version 20 software package. Results: For average measures, inter-rater ICC was 0.998 (P < 0.001), intra-rater ICC was 0.981 (P < 0.001), and test–retest ICC was 0.829 (P = 0.001). Inter- and intra-rater reliability was “excellent,” whereas test–retest reliability was “good.” Conclusions: Developed JVP scale is low cost and easy to build at any resource-limited settings. This would be an adjunct tool for bedside cardiovascular examination of patients with good to excellent reliability. This would also be used for teaching cardiovascular physiology for medical and allied science students.

Background: Earlobe crease (ELC) has been found to be associated with the presence of coronary artery disease (CAD) in many studies; however, studies from India are limited. The aim of this study was to determine the prevalence of CAD in those with ELC and to assess the correlation of ELC with severity of CAD. Materials and Methods: This was a cross-sectional, multicenter study; 1400 patients undergoing coronary angiogram were approached, but 1070 patients were analyzed after excluding patients with ear piercings and other ear diseases. Patients were classified into no ELC, mild ELC, and severe ELC according to Ishi et al. Results: Seven hundred and eighty patients had CAD proven by coronary angiography. Of these, 74% (580/780) had an ELC either mild or severe. The patients with ELC had a significantly higher incidence of hypertension, diabetes mellitus, and hypercholesterolemia. However, the prevalence of smoking and family history of premature cardiovascular death were similar in both the groups. The prevalence of CAD was found to be significantly higher (odds ratio [OR]: 4.22 [95% confidence interval (CI): 3.18–5.61], P < 0.0001) among the patients with ELC (580/698) in comparison to patients without ELC (200/372). The prevalence of multivessel disease (MVD) was found to be significantly higher among the ELC-positive patients than ELC-negative patients (OR: 5.03 [95% CI: 3.61–6.90], P < 0.0001). Moreover, MVD was significantly more prevalent in patients (OR: 6.27 [95% CI: 4.23–9.29], P < 0.0001) in the severe ELC group (150/190) in comparison to the mild ELC group (190/508). Conclusion: ELC is an important clinical sign which should be examined carefully for its presence as well as severity. Both presence and severity of crease were related to occurrence and severity of CAD, respectively, in our study. Long-term cohort studies involving multiple ethnicity populations are necessary to determine the role of ELC in development as well as prognosis of CAD.

Background: Immune checkpoint inhibitors (ICIs) are increasingly being used for cancer therapy. Cardiotoxicity from ICIs has largely been underestimated since cardiovascular monitoring is not routinely performed after initiating immunotherapy. Cardiotoxic side effects are uncommon but are serious complications of ICIs with a high morbidity and mortality. Aims and Objectives: To determine gender differences in the risk of CVEs in cancer patients that receive immunotherapy. To determine the risk of CVEs in males and females who received different number of ICI injections. To study other possible risk factors for adverse CVEs in patients who received immunotherapy with ICIs. Materials and Methods: In this observational, retrospective, pharmacovigilance study, we used MarketScan Databases to compare cardiovascular adverse events reported in patients who received ICIs. The data used in this study was fully integrated and de-identified data. The study included 16,574 patients who had cancer and underwent ICI therapy between January 1, 2011, and December 31, 2018. ICI drugs in this study included nivolumab, pembrolizumab, atezolizumab, avelumab, durvalumab, and ipilimumab. The time to an event and the end of follow-up was counted from the time of first ICI injection. Our primary exposure variable was gender. Results: This study demonstrated that time to adverse CVE in cancer patients that receive ICI therapy is affected by the gender. The hazard time to CVEs between the male and female gender varied by age. There was no difference in CVEs between males and females at a younger age. The hazard time to CVEs increased with age above 60 years in males when compared to females. The hazard of time to CVE in males was 1.18 times the hazard in females at the mean study age of 60.5 years. Adjusted Kaplan–Meier survival curves for males and females stratified by ICI injection categories showed that those with fewer number of ICI injections had a shorter time to CVE. Conclusions: The number of ICI injections and the gender both impact adverse cardiovascular events in cancer patients. Managing and reducing cardiotoxicity is vital for safe delivery of this effective therapy. Future studies should assess whether late onset chronic cardiotoxicity can occur with ICI therapy.

Objectives: There is a significant gap among hypertensive patients who are being treated and those who actually achieve blood pressure (BP) control. The main objective of this article is to determine if there are any differences in clinical outcomes and BP control with a combination treatment as compared to monotherapy as the initial treatment of hypertension. It also focuses on to compare the efficacy and compliance of fixed-dose combination (FDC) as compared to monotherapy and conventional multi-pill combination therapy as the initial treatment of hypertension. Methods: A search of literature was done using PubMed and Google scholar to prepare a review on this topic. Results: The main evidence supporting the use of combination therapy is focused on the use of combinations of renin–angiotensin System (RAS) blocker with calcium channel blockers (CCBs) and with thiazide diuretics. Several randomized clinical trials have proven the efficacy of combination therapy to be superior to monotherapy as initial treatment for timely and adequate BP control. Conclusion: Several benefits of achieving good BP control have been proven by several studies including the Systolic Blood Pressure Intervention Trial study, but only a few guidelines internationally recommend combination antihypertensives as a routine first-line treatment in all hypertensive patients. It is reasonable to go for aggressive management of hypertension involving the use of FDC antihypertensives from two different classes of drugs to achieve the recommended goals of BP of <140/90 mmHg for most patients and <130/80 mmHg for high-risk patients. The combination treatment that can be considered is the combination of RAS blockers with CCB or RAS blockers with thiazide diuretics.