Acute Coronary Syndrome with Comorbidities: A Therapeutic Challenge Gurunath Parale
Abciximab administration, safety of 19
Activated clotting time 52
Activated partial thromboplastin time 20
Acute antiplatelet treatment 53
Acute coronary syndrome 2, 3, 9, 11, 29, 49, 52, 58, 60, 68, 72, 8183, 85, 90, 91, 105, 116, 127
treatment of 111
Acute myocardial infarction 1, 7, 16, 36, 59, 76, 82, 84, 86
diagnosis of 60
management of 60
Adenosine diphosphate 18
Advanced cardiac life support guidelines 126
Alberta Kidney Disease Network 32, 33
Alteplase 12
American Association for Study of Liver Diseases 77
American College of Cardiology 30, 92, 124
American Heart Association 10, 30, 92
American Stroke Association 10
Anemia 123, 124
autoimmune hemolytic 84, 85
Anesthesia 123
Angina, treatment of 111
Angiography 125
coronary 18, 36, 82, 125
coronary 61
primary 16
stroke after primary 16
Angiotensin-converting enzyme 61
inhibitor 4, 34, 63
therapy 40
Antibody reaction 82
Anticoagulation 20
agents 18
periprocedural 52
therapy 18
antibodies 83
syndrome, primary 112
Antiplatelet 64
therapy 18, 35
timing of resumption of 21
treatment 20, 75
Antiretroviral therapy 117
management of 117
Antirheumatic drugs, disease-modifying 109
Antithrombotic therapy 40
Anxiety 97
Aorta, ascending 22
Aortic valve
replacement 101
stenosis 101
symptomatic 101
Arrhythmias, cardiac 9
Arterial blood gas 126
Arterial disease, peripheral 30, 72
Aspirin 4, 20, 62
low-dose 108, 109
prophylactic use of 107
Atelectasis 97
Atherogenic lipid profile 116
Atherosclerosis 22, 30
accelerated 108
premature 108
Bare-metal stent 55
Beta-blockers 62, 76
Bivalirudin 52
Bleeding 123
risk 53
Blood pressure 107, 118
control of 34, 109
Body mass index 70
Bone mineral metabolism, disorders of 33
Brain 43
tissue 14
Breast cancer 99
British National Lymphoma Investigation Database 86
Calcium channel antagonists 34
Cancer 90, 94, 95
Cardiac disease 90, 95, 108
Cardiocerebral infarction 8, 9
hyperacute simultaneous 10
synchronous 8
Cardiopulmonary bypass 75
Cardiovascular disease 1, 30, 101, 105, 116
risk 117
Cardiovascular morbidity 106
Carotid artery
stenosis 22
stenting 23
Carotid endarterectomy 23
Carotid intima-media thickness 71
Carotid stenosis 22
symptomatic 22
Carotid stenting 23
Cerebral artery
anterior 14
middle 11, 14
Cerebrovascular disease 1, 4
Charlson comorbidity index 1
Chemotherapy 98
drugs 91
Child-Turcotte-Pugh classification 74
Cholesterol plaque formation 91
Chronic obstructive pulmonary disease 1, 58, 59, 61, 63, 64
Cigarette smoking, cessation of 118
Cirrhosis 71, 76
Clopidogrel 19, 5355, 95
plus aspirin 54, 55
Colon carcinoma 96
Combined combination antiretroviral therapy 116
Complete blood count 126
Connective tissue disease 1, 105
Conventional therapy 119
Coronary artery
bypass grafting 42, 51, 61, 93, 96, 119
surgery 18, 22, 23, 74
calcification score 31
disease 9, 30, 53, 59, 64, 69, 71, 72, 76, 82, 105, 108, 116, 123
management of 119
mechanisms of 91
risk of 118
stenosis, distribution of 70
thrombosis 85
Coronary computed tomography angiography 69, 70
Coronary flow velocity reserve 31
Coronary heart disease 32
atherosclerotic 85
treatment of 35
Coronary perfusion pressure 126
Coronary reperfusion strategies 38
Coronary revascularization 61
Corticosteroids 113
Creatine kinase, isoenzymes of 43
Cyclooxygenase-2 selective inhibitors 108
Dabigatran 54, 55
Danazol 82
Deep vein thrombosis 12, 20
Dementia 1
Dermatomyositis 113
Diabetes 30, 33, 116
mellitus 2, 71
Digestive tract tumors 95
Digital subtraction angiogram 15
Direct oral anticoagulant 53, 55
Disseminated intravascular coagulation 74
Dobutamine stress echocardiography 77
Drug-eluting stent 55, 93, 119
Dual antiplatelet therapy 22, 54, 73
Dyslipidemia 30, 33, 116, 118
Echocardiography, transesophageal 125
Emboli, chemical composition of 14
Endothelial dysfunction 30
Endothelial surface 83
Enzymes, cardiac 9
Epicardial adipose tissue 31
Esophageal varices 74
Estimated glomerular filtration rate 29
Exercise 109
Extracorporeal membrane oxygenation 127
Extubation 123
Fatty liver disease, nonalcoholic 70, 72
Fibrinolysis therapy 14
Fibrinolytic agents 12
Forced expiratory volume 63
Gammaglobulin, intravenous infusion of 87
Gastrointestinal tract 73, 110
Global Registry of Acute Coronary Events 12, 51
Glomerular filtration rate 107
Glucocorticoids 109
dose, minimizing 107
supraphysiologic dose of 111
Glucose intolerance 106
Glycoprotein 35, 52
Heart disease 95, 98
risk equivalence for 32
stable 3
Heart failure 99
congestive 1, 16, 22, 82
Heart valves 55
Helicobacter pylori 73
Hematological disorders 81
Hematoma expansion 20
Hemiplegia 2
Hemodialysis 31
Hemolysis, intravascular 85
Hemophilia 83
Hemorrhage 73
intracerebral 12, 20
intracranial 19, 20
retroperitoneal 15, 94
Henoch-Schonlein purpura 112
Heparin 19, 52
unfractionated 40
C virus 71
infection 71
viral replication 74
Hodgkin's disease 99
Hodgkin's lymphoma 86, 99
Human immunodeficiency virus 118
infection 116, 118
Hydroxychloroquine 107
Hydroxyurea 86
Hyperleukocytosis 85
Hypertension 30, 33, 106, 107
arterial 123
control of 107
Hypertrophy, myocardial 85
Hypotension 35, 123, 124
intraoperative 124
Hypothermia 123
Hypovolemia 123
Immune thrombocytopenic purpura 82
Inflammation, chronic 108
Inspired oxygen, fraction of 126
Insulin resistance 118
Intensive care unit 15, 97
Intravascular thrombi, formation of 85
Intravenous thrombolytic therapy 10
Intubation 123
Ischemia, myocardial 122, 125
Ivabradine 64
Kawasaki disease 112
disease 35
chronic 1, 29, 38
injury, acute 36
Leflunomide 109
Left bundle branch block 125
Left ventricular
ejection fraction 22, 96
mural thrombus 17
Leukemia 2
acute 85
chronic lymphocytic 98
Lipid-lowering therapy 118
high-density 118
low-density 106
cirrhosis 1, 4, 69, 72, 74, 76
disease 2, 75
chronic 68
end-stage 72, 74
disorders, common 72
function 74
Low-cholesterol paradox 41
Low-molecular weight heparin 20, 40
Low-platelet count 82
Lung disease, obstructive 59
Lymphoma, malignant 2
Major adverse cardiovascular event 3, 13
Malnutrition, inflammation, atherosclerosis, calcification syndrome 31
Metabolic syndrome 72, 118
Metastatic solid tumor 2
Mitral regurgitation, acute 127
Monckeberg's sclerosis 31
Monoclonal gammopathy 86
Multiple myeloma 86
Muscle 43
Myocardial infarction 1, 9, 16, 22, 29, 59, 62, 106
coexistence of 76
perioperative 122, 125
stroke after 17
Myocardial injury 122
Myocardial Ischemia National Audit Project 60
Myocardial ischemia, intraoperative 124
Myocarditis, inflammatory 113
Myocytolysis 9
Myositis, adult inflammatory 113
N-acetylcysteine 44
National Health Insurance Research Database 76
National Kidney Foundation 30
Nephropathy, contrast-induced 43
Nifedipine 107
Non-Hodgkin's lymphoma 86, 99
Non-nucleoside reverse transcriptase inhibitors 117
Non-ST elevation
acute coronary syndromes 10
myocardial infarction 11, 83
Non-ST segment elevation myocardial infarction 60, 61, 122
Nonsteroidal anti-inflammatory drugs 44, 73, 108, 110, 111
Nucleoside reverse transcriptase inhibitors 117
Obesity, central 106
Obstructive coronary artery disease 70
Optical coherence tomography 94
Oral anticoagulant 54, 55
Orthotopic liver transplantation 76
Oxygen saturation 124
Pain, postoperative 97
Paroxysmal nocturnal hemoglobinuria 85
Peptic ulcer disease 2
Percutaneous coronary intervention 10, 13, 19, 22, 30, 54, 72, 73, 82, 93, 119
stroke after 13
Pericarditis 92
Peritoneal dialysis 31
Pexelizumab, assessment of 16
excessive production of 84
microparticles, release of 82
Polycythemia vera 84
Polymyositis 113
Prasugrel 95
Proatherogenic lipid profile 112
Protease inhibitors 117
Pulmonary embolism 12
prophylaxis 20
Radiotherapy 99
Recombinant tissue plasminogen activator 10
Renal disease
end-stage 30
reduce progression of 34
Renal dysfunction, chronic 107
Renal failure, acute 36
Renal transplant 42
Reperfusion therapy 4
Respiratory system 86
Resuscitation, cardiopulmonary 126
Reteplase 12
Rheumatoid arthritis 105, 108, 111
Sickle cell
anemia 85
disease 85
Sickness, dominant cause of 1
Single antiplatelet therapy 54, 55
Sjögren's syndrome 112
Solid tumor 2
Splenectomy 82
Spontaneous bacterial peritonitis prophylaxis 74
Stable angina, pharmacological treatment of 42
Standard medical therapy 39
Statins 41, 63, 106
therapy 34
Steatohepatitis, nonalcoholic 72
ST-elevation myocardial infarction 8, 12, 37, 42, 83
bilateral asymptomatic 22
unilateral asymptomatic 22
Steroids 82
Streptokinase 12
Stress 97
Stroke 13, 19, 22, 53
acute 15
ischemic 7, 12
hemorrhagic 15
ischemic 9, 10
symptoms of 14
volume variation 127
ST-segment elevation myocardial infarction 4, 30, 60, 61, 122
Systemic lupus erythematosus 105, 107
Systemic vasculitis, primary 112
Tachycardia 123
Takayasu's arteritis 112
Takotsubo cardiomyopathy 92
Tenecteplase 12
Thrombocythemia, essential 84
Thrombocytopenia 82, 94
Thrombotic thrombocytopenic purpura 82
Ticagrelor 19
Tissue plasminogen activator 14
Transient ischemic attacks 9
Transjugular intrahepatic portosystemic shunts 74
Triglycerides 119
Tumor necrosis factor 30, 123
Unstable angina, pharmacological treatment of 42
Vascular disease, peripheral 1
Vasculitis, systemic 105
Vitamin K antagonist 55
von Willebrand disease 83
von Willebrand factor 40, 83
WOEST trial 53
Chapter Notes

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Author Gurunath Parale MD DM FACC FCSI FICP Professor Department of Medicine Ashwini Rural Medical College Chief Cardiologist Ashwini Cooperative Hospital Solapur, Maharashtra, India Editorial Assistance Virupaksha Joshi MBBS DMRD Radiologist Ashwini Cooperative Hospital Solapur, Maharashtra, India Forewords D Prabhakaran George Joseph Jagdish S HiremathCK Ponde
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Acute Coronary Syndrome with Comorbidities: A Therapeutic Challenge/ Gurunath Parale
First Edition: 2020
Printed at
I dedicate this book to my teachers at medical school who instilled in me, during those formative years, a sense of enquiry and inquisitiveness about everything. They gave me not just the fish, but also the fishing rod and moreover taught me how to use the rod.
D Prabhakaran MD DM (Cardiology) MSc FRCP FNASc
Vice President - Research and Policy, Public Health
Foundation of India (PHFI)
Professor, Department of Epidemiology
London School of Hygiene and Tropical Medicine, UK
Former Professor, Cardiology
All India Institute of Medical Sciences
Cardiovascular diseases have become the leading cause of death in India. According to the state level disease burden published recently they contribute nearly 20% of total mortality. Despite this they pose both a great challenge as well as an immense opportunity to healthcare providers in the world. While the survival has considerably improved, the biggest challenge in India is that the disease occurs at younger ages imposing an unaffordable financial burden to individuals and their families. In addition, comorbidities have emerged as a major determinant of survival among patients with coronary artery disease.
When I was asked to review the book titled “Acute Coronary Syndrome with Comorbidities: A Therapeutic Challenge“ by the well-known cardiologist Dr Gurunath Parale from Solapur, Maharashtra. I wondered as to the need for another book of cardiology given the profusion of textbooks that are currently available. However, ongoing through the book in detail, I am sure that this book will find a unique niche both for students and practicing cardiologists. One of the most ignored aspects in the management of coronary artery diseases is the presence of comorbidities and there is hardly any patient without involvement of another organ system which substantially influences outcomes and increases mortality. Dr Parale has had years of experience in handling such comorbidities and has shared his experiences through case studies. This format provides a real-life scenario and many of us can easily relate to such situations. In addition, he has provided several practical tips in handling patients with comorbidities. Further, the simple English makes it easily readable and I am sure this book will become a ready reckoner for the practicing cardiologist in handling complex situations.
My hearty congratulations to Dr Parale in writing this book which must have been a love of labor for him. I am sure this book will be widely read and used.
George Joseph DM FCSI
Professor of Cardiology
Christian Medical College
Vellore, Tamil Nadu, India
An outstanding masterpiece from a brilliant academician, this gem of a book is a must-read for any clinician dealing with coronary artery disease patients. Dr Gurunath Parale has a captivating style of presentation, starting each chapter by narrating related real-life dilemmas he encountered candidly and with endearing honesty. Having whetted the appetite to know more about the subject, Dr Parale then launches into a masterly review of the relevant literature, providing fascinating insights into the pathophysiology and management of acute coronary syndrome encountered in association with various comorbidities. The primary focus is on the practical difficulties one often faces when dealing with patients with acute coronary syndrome and specific comorbidities. Dr Parale provides clear solutions to each problem, based on a thorough but succinct review of the state-of-the-art and the latest guidelines. And if this was not enough to indelibly imprint these facts in one's memory, Dr Parale provides a deft finishing touch to each chapter with a precise summary of the key points. I am sure anyone fortunate enough to lay hands on a copy of this book will enjoy reading it as much as I did.
Jagdish S Hiremath DM (Card) DNB (Card) FACC
Cath Lab Ruby Hall Clinic
Pune, Maharashtra, India
I have been associated with Dr Gurunath Parale as a professional colleague for many decades. His astute clinical judgement supported with exceptional hand skill makes him one of the leading interventional cardiologist of the country. Present book of comorbid conditions with acute coronary syndrome, the subject of the book itself indicates a thinker in Dr Gurunath Parale. The chapters that you will read are real-world experiences. Dr Parale always follows guideline science, but also adds original experience in the narration. He is a master of science of medicine, but also introduces art of medicines which comes from the book of experience.
I find this book exceptionally useful for all interventional cardiologists. It is an excellent reference book in one's shelf and in one's computer. Every chapter can guide one when faced with “associated comorbid conditions with acute coronary syndrome”. I congratulate Dr Gurunath Parale for having thought of this unusual topic and passing the benefit of his own thought process to many of his colleagues like me and also thousands of junior budding cardiologist of the country.
Consultant Cardiologist
PD Hinduja National Hospital and Medical Research Centre
Mumbai, Maharashtra, India
It gives me great pleasure and pride to write a foreword for Dr Gurunath's venture. Postgraduate medicine is ever evolving and this is the era of evidence-based medicine. The textbook knowledge of the disease process forms the base of the pyramid and pyramid keeps on going taller when more and more data is added derived from randomized trials and registries. A clinician is supposed to have mandatory knowledge of clinical trials and registry data which help him in decision making in day-to-day clinical practice. Despite this knowledge, there are frequent occasions where a clinician is faced with a case where decision making is extremely difficult, complex and challenging.
I myself firmly believe that the use of clinical case discussions is one of the best method of teaching and learning medicine not only for the medical students, but also for experienced consultants.
Dr Gurunath Parale is known to the medical world for a very long time. He was the pioneer cardiologist in the district of Solapur and has practiced medicine and all the facets of cardiology including clinical cardiology, echocardiography and interventional cardiology in the most versatile manner. He has maintained his academic excellence even when having the busiest practice and that too in a place like Solapur. He has written books for patients, has published several articles in national and international journals and also has presented complex interventional cases in conferences like TCT and EuroPCR.
This compilation of challenging case scenarios and dilemmas in cardiovascular medicine comes as a breath of fresh air. He has beautifully discussed each case/topic, its complexity in a most lucid manner with extensive coverage of the relevant literature. What is most important is that the clinicians will get a very clear idea about how to deal with such dilemma when they face such a patient. The selection of cases and the topics explore those areas of cardiology which remains untouched in textbooks, journals and even conferences.
I am extremely impressed with this book because it bridges the gap between the established knowledge and the gray areas and this is so very important for a clinical cardiologist today, because he/she is invariably faced with patients with multiple comorbidities.
I and Dr Gurunath have a very long association of over 30 years, as we both have taken our postgraduate degrees in medicine from the same institute, VM Medical College, Solapur, Maharashtra. When I look back and see his growth it makes me immensely proud and ecstatic.
At the end, I must say that if every clinician keeps on contributing such pearls of experience to help his colleagues and budding consultants the world will become a different place.
Gurunath Parale MD DM FACC FCSI FICP
Department of Medicine
Ashwini Rural Medical College
Chief Cardiologist
Ashwini Cooperative Hospital
Solapur, Maharashtra, India
It is almost 25 years since I embarked on my practice of cardiology in the ‘textile town’ of Solapur, Maharashtra, India. Since I was the only cardiologist with super-specialist qualification for a long time, it was not surprising that patients from all corners of this large district were referred to me for consultation on various heart ailments. The diagnosis and treatment of ischemic heart disease used to be a relatively simple affair with straight-forward approach as guided by the standard textbooks. Once the acute myocardial infarction (AMI) was diagnosed acute coronary syndrome (ACS) is a recent nomenclature, based on TMT and ECG findings, the treatment options were 2-fold, i.e. either intravenous thrombolysis, if the patient reached the hospital within the so-called ‘window’ period or a conservative line of management with bed-rest and medications. It was the era before the hi-tech cath labs and percutaneous re-perfusion techniques became the standard, first-line methods of treatment.
However, in the past decade or so, the scene of cardiology practice changed in significant ways. Firstly, I was no longer the only cardiologist and the hospital, where I worked was not the only hospital catering to the district inhabited by a million people. The so-called simple and uncomplicated cases of ACS were successfully treated in smaller nursing homes at the periphery of the district. Secondly, the not-so-simple cases were being referred to the tertiary care hospital where I work. Many of the patients referred to me with heart disease suffered from other comorbid conditions. Some of them had a long history of chronic obstructive airway disease, while some others had suffered a recent cerebrovascular accident. Many of these patients with heart disease had a hitherto undetected kidney disease or a hematological disorder or even a connective tissue disease. Some of the patients who were referred to me for cardiac evaluation were even treated and declared as cured from malignant disease such as breast carcinoma. At least two of the patients suffered from chronic liver disease and one of them was even wait-listed for a liver transplant. Therefore, the present scene was a far cry from the old days when I diagnosed AMI and treated it with thrombolysis or waited with crossed fingers for the patient to recover after prescribing medicines.
However, with the advent of primary angioplasty as the treatment of choice for AMI, a paradigm shift took place in the manner in which MI or ACS was treated. Introduction of drug-eluting stents was a path-breaking innovation and dual antiplatelet therapy became the mainstay of medication to prevent thrombosis within the stent. However, the changing demography of the patients referred to a tertiary care hospital had its own share of challenges. Apart from the cardiac disease, associated comorbid conditions in some of them threw up special challenge for the treating cardiologists like me. For instance:
These are some of the vexed issues troubling the cardiologist like me practicing in a tertiary care hospital. Moreover, there is scanty and sketchy material available in present day medical literature to guide the physician and help him practice evidence-based medicine. The book in your hand now is a culmination of my decade-long effort to find meaningful answers and dependable protocols to deal with the vexed problem of heart disease with comorbid conditions. It is my ardent hope that the reader will find answers in this book to the dilemma he/she must be facing in his/her daily practice.
I am indebted to my wife Dr Neha, without whose moral support this book would not have been possible. Silently but stoically, Dr Neha put up with my obsession to write this book and the manner in which this obsession intruded our ‘we’ time even during weekends and holidays. I am grateful to my elder son Dr Chinmay for his insightful comments and suggestions. I discovered during these interactions what a fine young man he has turned out to be. I also acknowledge my younger son Hrishikesh whose encouraging words have kept me steadfast on my path toward academic pursuit.
I am honoured and obligated to well acclaimed quartet of cardiologists Dr D Prabhakaran, New Delhi, Dr George Joseph, Vellore, Dr Jagdish S Hiremath, Pune, Dr CK Ponde, Mumbai. Each one of them not only set aside his precious time to read excerpts of this book but also readily agreed to write a foreword. Without the encouraging forewords from such accomplished cardiologists and prominent academicians, this book would not have acquired the legitimacy I hope it would.
I also acknowledge Dr Satyawan Sharma, the famous cardiologist at Bombay Hospital who gave me some useful suggestions.
Last but not the least, important is the invaluable help I got from my colleague radiologist Dr Virupaksha Joshi. Although his specialty is far different from the topics in this book, he put his mind, brain and most importantly heart into this project and helped me to complete it which at one point of time I thought was not possible.