Administrative Positions

  • 2016 2018

    Secretary

    Eye Bank association of India

  • 1994 2018

    Treasurer

    SAARC Academy of Ophthalmology

  • 1994 2018

    Chairperson scientific Committee

    ISCKRS

  • 1994 2018

    General Secretary

    Ophthalmic Research Association, R P Centre

Education & Training

  • Fellowship 2005

    Cornea Fellowship

    Moor fields Eye Hospital, London

  • MNAMS 2000

    Member of the national Academy of Medical Sciences

    AIIMS, New Delhi

  • MD 1995

    Doctor of Medicine - ophthalmology

    AIIMS, New Delhi

Honors and Awards

  • 2013
    Senior Achievement Award by American Academy of Ophthalmology
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  • 2013
    Achievement Award by Asia Pacific Academy of Ophthalmology
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  • 2012
    Video award by European Society of Cataract & Refractive Surgery
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  • 2012
    AIIMS Excellence award for research and certificate for notable contribution
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  • 2008
    International Ophthalmologist education award by American Academy of Ophthalmology
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Research Projects

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    1. Collagen cross linking for mycotic keratitis

    In the study of evaluation of corneal collagen cross-linking as an additional therapy in mycotic keratitis: Collagen cross-linking in mycotic keratitis, additional CXL treatment did not have any advantage over medical management.

    To know more Click here

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    2. DALK for Keratoconus

    In the study of Diamond knife-assisted deep anterior lamellar keratoplasty to manage keratoconus, DALK was effective and predictable as a surgical technique for management of keratoconus cases. This technique has the potential to offer visual and refractive outcomes comparable to those of big-bubble DALK.

    To know more Click here

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    3. Harvesting thin DSAEK Lenticules

    In the study of Thin lenticule Descemet's Stripping Automated Endothelial Keratoplasty: Single, Slow Pass Technique, they can be safely harvested using a single pass technique with 400 microns microkeratome head and can be used for a successful DSAEK surgery.

    To know more Click here

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Ophthalmology Clinics for Postgraduates

Book Jaypee Brothers Medical Publishers; 1 edition | 1 June 2017 | ISBN-10: 9386322897
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This book is practical revision guide for trainees in ophthalmology to assist in preparation for examinations. Six sections are each dedicated to a specific part of the eye, providing both long and short cases, with emphasis on topics commonly asked in examinations. Cases describe basic techniques, investigation and treatment options, with in depth detail on differential diagnosis. The final section discusses instruments for ophthalmic surgery. The text explains the latest surgical and medical management techniques and is further enhanced by clinical photographs and tables to assist learning. Key points : Practical revision guide for ophthalmology trainees preparing for examinations .Presented as long and short cases with emphasis on topics commonly covered in exams . Covers disorders in all sections of the eye.Highly illustrated with clinical photographs and tables.

Ocular Infections: Prophylaxis and Management

Namrata Sharma (Author), Atul Kumar (Author)
Book Jaypee Brothers Medical Publishers | 30 June 2017 | ISBN-10: 9386322889
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This book is a concise guide to the prevention and management of post-surgical ocular infections covering both common and serious conditions. Divided into 24 chapters, the text begins with discussion on preventive aspects including an introduction to the operating theatre, air flow and water requirements, and patient and personnel preparation. The following sections describe the diagnosis, treatment and prevention of infections resulting from different ocular surgeries. This practical guide is highly illustrated with clinical photographs and flow charts highlighting significant aspects of prevention and management. Key points - Concise guide to prevention and management of post-surgical ocular infections.Covers both common and serious conditions resulting from different types of surgery .Explains basic preventive measures relating to the operating theatre and personnel .Highly illustrated with clinical photographs and flow charts.

Corneal transplantation

Rasik B. Vajpayee (Author), Namrata Sharma (Author), Geoffrey C. Tab (Author)
BookJaypee Highlights Medical Publishers, Inc.; 2/E edition| January 1, 2010 | ISBN-10: 8184488599
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This book provides a comprehensive knowledge and information about the various aspects of Corneal grafting surgery. The new edition includes a detailed description of all new techniques of lamellar corneal transplantation surgeries including some very innovative techniques like Tuck in lamellar keratoplasty, Suture less DSAEK Triple surgery, DMEK and Double Bubble Deep Anterior lamellar keratoplasty. It also explains the various acronyms that seem to have populated modern corneal surgery. The book carries a very wide range of and sound practical advice based on the experience of the world's leader in this field who have described their surgical techniques and other aspects of corneal transplantation surgery in a lucid and well structured manner.

Step by Step LASIK Surgery

Namrata Sharma (Author), Rasik B. Vajpayee (Author), Laurence Sullivan (Author)
Book CRC Press; 1 edition | 12 August 2005 | ISBN-10: 1841844691
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A decade after the introduction of the LASIK technique in refractive surgery, the technique has reached its maturity. Thoroughly researched and easy to read, Step by Step LASIK Surgery provides practical information regarding the various aspects of LASIK surgery. Expert LASIK surgeons share their experiences with this state-of-the-art surgical technique. The book is organized in a simple and effective style that presents a step-by-step approach to LASIK surgery. It includes information about the latest microkertomes and excimer laser machines and specific surgical techniques like LASEK, LASIK for post-penetrating keratoplasty, ametropias, and wavefront guided LASIK.

Prevalence and risk factors of dry eye disease in North India: Ocular surface disease index-based cross-sectional hospital study

Jeewan S Titiyal, Ruchita Falera, Manpreet Kaur, Namrata Sharma
Journal Papers Article in Indian Journal of Ophthalmology 66(2) . January 2018 with 48 Reads

Abstract

Purpose: This study aims to study the prevalence of DED and analyze risk factors in North Indian population. Methods: This was a cross-section hospital-based, observational study. Cases enrolled over 2 years (systematic random sampling) were administered ocular surface disease index questionnaire to evaluate the prevalence and risk factors of DED. Schirmer's test and tear break-up time were performed only in the subset of patients giving consent. Categorical data were assessed with Chi-square/Fisher's Exact test, and odds ratio was analyzed using bivariate and multivariate logistic regression. P < 0.05 was statistically significant. Results: A total of 15,625 patients were screened. The prevalence of DED was 32% (5000/15625); 9.9% (496/5000) had mild DED; 61.2% (3060/5000) had moderate DED; and 28.9% (1444/5000) had severe DED. Age group of 21-40 years, male sex, urban region, and desk job were associated with increased risk of DED. Hours of visual display terminal (VDT) usage significantly correlated with DED (P < 0.001), and 89.98% of patients with 4 h or more of VDT use had severe dry eye. Cigarette smoking and contact lens usage had increased odds of developing severe DED (P < 0.001). Objective tests were undertaken in 552 patients; of these, 81.3% (449/552) had severe DED. Conclusions: The prevalence of DED in North India is 32%, with the age group of 21-40 years affected most commonly. VDT use, smoking, and contact lens use were associated with increased odds of developing DED.

Chlamydia trachomatis Antigen Positivity in Patients with Different Ocular Manifestations over 8 Years

NishatHussain Ahmed, Anjana Sharma, Gita Satpathy, Namrata Sharma
Journal PapersArticle in Journal of global infectious diseases 10(1):16 . January 2018 with 23 Reads

Abstract

Laboratory confirmation of chlamydial antigen in clinically suspected cases of chlamydial eye infections is important, as similar clinical picture can be presented by different infective or noninfective causes. We retrospectively analyzed the presence of Chlamydia trachomatis antigen in 690 clinically suspected patients over the last 8 years (2009-2016). The chlamydial antigen was detected using direct immunofluorescence assay. Overall, Chlamydia-specific antigen positivity was 45.5%. The highest positivity was seen in 2014 (68.6%) and the least in 2016 (9.4%). The antigen positivity in years 2015 (13.4%) and 2016 (9.4%) was significantly less than in all the previous study years (P < 0.0001). Antigen positivity in patients having clinical diagnosis of trachoma was significantly higher than those having other eye manifestations suggestive of chlamydial infections (P = 0.0274). Stringent surveillance both at community level and in hospital attendees is required to know the actual load of this pathogen.

Corneal edema after phacoemulsification

Namrata Sharma, Deepali Singhal, SreelakshmiP Nair, PrafullaKumar Maharana
Journal papers Article in Indian Journal of Ophthalmology 65(12):1381 . December 2017 with 40 Reads

Abstract

Phacoemulsification is the most commonly performed cataract surgery in this era. With all the recent advances in investigations and management of cataract through phacoemulsification, most of the patients are able to achieve excellent visual outcome. Corneal edema after phacoemulsification in the immediate postoperative period often leads to patient dissatisfaction and worsening of outcome. Delayed onset corneal edema often warrants endothelial keratoplasty. This review highlights the etiopathogenesis, risk factors, and management of corneal edema in the acute phase including descemet's membrane detachment (DMD) and toxic anterior segment syndrome. Various investigative modalities such as pachymetry, specular microscopy, anterior segment optical coherence tomography, and confocal microscopy have been discussed briefly.

Component corneal surgery: An update

PrafullaK Maharana, Pranita Sahay, Deepali Singhal, Namrata Sharma
Conference PapersArticle in Indian Journal of Ophthalmology 65(8):658 . August 2017 with 40 Reads

Abstract

Several decades ago, penetrating keratoplasty was a challenge to corneal surgeons. Constant effort by the corneal surgeon to improve the outcomes as well as utilization of the available resources has led to a revolutionary change in the field of keratoplasty. All these efforts have led to the evolution of techniques that allow a corneal surgeon to disease-specific transplant of individual layers of corneal so-called component corneal surgery depending on the layer of cornea affected. This has led to an improvement in corneal graft survival as well as a better utilization of corneal tissues. This article reviews the currently available literature on component corneal surgeries and provides an update on the available techniques.

Comparative evaluation of femtosecond laser-assisted cataract surgery and conventional phacoemulsification in white cataract

Jeewan S Titiyal, Manpreet Kaur, Archita Singh, Namrata Sharma
Conference Papers Article in Clinical Ophthalmology Volume 10(Issue 1):1357-1364 . July 2016 with 34 Reads

Abstract

Purpose: To compare femtosecond laser-assisted capsulotomy with conventional manual capsulorhexis in cases of white cataract. Patients and methods: The prospective comparative study enrolled 80 eyes (80 patients) with white cataract that underwent either femtosecond laser-assisted cataract surgery (Group 1, n=40) or conventional manual phacoemulsification (Group 2, n=40) at a tertiary care ophthalmic institution. The groups were divided based on the patient's choice and affordability of the procedure. Capsulotomy/capsulorhexis was evaluated in terms of size, circularity index (4*Pi [area/perimeter2]), intraocular lens coverage, and continuity. Each group was further subdivided based on the release of white milky fluid on initiation of the capsulotomy/capsulorhexis, and the "fluid" cases were compared with the "no-fluid" cases. The primary outcome measure was capsulotomy/capsulorhexis characteristics in the two groups.The secondary outcome measures were intraoperative phacoemulsification parameters, intraoperative complications, and postoperative visual acuity. Results: The size of the capsulotomy/capsulorhexis was 4.9+/-0.1 mm in Group 1 and 5.3+/-0.4 mm in Group 2 (P<0.001). Mean circularity index was 0.996+/-0.003 and 0.909+/-0.047 in Groups 1 and 2, respectively (P<0.001). In Group 1, free-floating circular capsulotomies were obtained in 52.5% (21/40) eyes; 37.5% (15/40) eyes had microadhesions; and 10% (4/40) eyes had incomplete capsulotomy in 1-2 clock hours. The incidence of residual adhesions was more in cases with release of white milky fluid (P=0.003). In Group 2, a multistep capsulorhexis was performed in 70% (28/40) of the eyes. There was no difference in terms of visual outcomes and intraoperative complications. Conclusion: Femtosecond laser-assisted cataract surgery has the advantage of creating a circular and optimally sized capsulotomy in cases of white cataract. The release of white milky fluid during femtosecond laser delivery is the most important factor affecting the creation of a free-floating capsulotomy.

Currrent Teaching

  • Present 2000

    Cornea, Cataract & Refractive Surgery Services

    Dr RP Centre, AIIMS, New Delhi

  • Present 2003

    Instruction courses

    American Academy of Ophthalmology, USA

Teaching History

  • 2011 1995

    Corneal Transplantation

    AIIMS, New Delhi

  • 2012 1996

    LASIK Surgery

    AIIMS, New Delhi

  • 2015 2011

    Phacoemulsification Surgery

    AIIMS, New Delhi

  • 2016 2012

    DescemetsStripping Automated Endothelial Keratoplasty: Different Strokes

    AIIMS, New Delhi

  • 2017 2013

    Deep Anterior lamellar Keratoplasty : Different Strokes

    AIIMS, New Delhi

At My Office

At Dr RP Centre, AIIMS, New Delhi You can consult me at Dr. Rajendra Prasad Centre of Ophthalmic Science, AIIMS located at AIIMS Campus, Sri Aurobindo Marg, Ansari Nagar, New Delhi, Delhi 110029. Consultation timings Monday - Saturday 1.30 pm - 4pm You may consider a call to fix an appointment.

At My Work

At My Lab

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    CSIR Develops Environment-Friendly Firecrackers For A Safe And Green Diwali

    CSIR scientists have developed less-polluting firecrackers which are not only environment-friendly but 15-20 per cent cheaper than the conventional ones, Union Minister for Science and Technology Harsh Vardhan said at a conference here.

     

    In a bid to promote an environment-friendly Diwali, scientists at the Council of Scientific and Industrial Research (CSIR) have developed less-polluting firecrackers which are not only environment-friendly but also cheaper than the conventional ones. CSIR scientists have developed less-polluting firecrackers which are not only environment-friendly but15-20 per cent cheaper than the conventional ones, Union Minister for Science and Technology Harsh Vardhan said at a conference here.

    The crackers have been named Safe Water Releaser (SWAS), Safe Minimal Aluminium (SAFAL), and Safe Thermite Cracker (STAR), respectively.

    https://doctor.ndtv.com/living-healthy/diwali-is-round-the-corner-csir-develops-environment-friendly-firecrackers-for-a-safe-and-green-diwa-1939950

     

     

     

     

    As far as the crackers are concerned, they have a unique feature of releasing water vapour and air as a dust suppressant and diluent for gaseous emissions and matching performance compared with conventional crackers.

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    Type 2 diabetes: New guidelines lower blood sugar control levels

    Description

    The American College of Physicians have now published their new guidelines regarding the desired blood sugar control levels for people with type 2 diabetes. The recommendations aim to change current therapeutic practices, and doctors should aim for a moderate level of blood sugar when treating their patients.According to the most recent estimates, almost 30 million people in the United States have type 2 diabetes, which amounts to over 9 percent of the entire U.S. population.Once diagnosed with type 2 diabetes, patients are often advised to take what is known as a glycated hemoglobin (HbA1c) test in order to keep blood sugar levels under control.

    The test averages a person's blood sugar levels over the past 2 or 3 months, with an HbA1c score of 6.5 percent indicating diabetes.
    Patients who score over 6.5 percent would then be prescribed a daily insulin based treatment which they can inject themselves. Rapid-acting injections take effect within 5 to 15 minutes but last for a shorter time of 3 to 5 hours. Long-acting injections take effect after 1 or 2 hours and last for between 14 and 24 hours.But some studies have pointed out that the HbA1c test may currently be overused in the U.S., and they have suggested that such over-testing may lead to over-treating patients with hypoglycemic drugs.These drugs often have a range of side effects, such as gastrointestinal problems, excessively low blood sugar, weight gain, and even congestive heart failure.

    Additionally, as some researchers have pointed out, "Excessive testing contributes to the growing problem of waste in healthcare and increased patient burden in diabetes management."In this context, the American College of Physicians (ACP) set out to examine the existing guidelines from several organizations and the evidence available in an effort to help physicians make better, more informed decisions about treating people with type 2 diabetes.

    An A1C of 7 to 8 percent is recommended

    As the ACP explain, the current rationale behind the existing recommendations of a score of 6.5 percent — or below 7 percent — is that keeping blood sugar this low would decrease the risk of microvascular complications over time. However, the ACP found that the evidence for such a reduction is "inconsistent."

    As Dr. Jack Ende — the president of ACP — puts it, "[Our] analysis of the evidence behind existing guidelines found that treatment with drugs to targets of 7 percent or less compared to targets of about 8 percent did not reduce deaths or macrovascular complications such as heart attack or stroke but did result in substantial harms."

    He continues, saying, "The evidence shows that for most people with type 2 diabetes, achieving an A1C between 7 percent and 8 percent will best balance long-term benefits with harms such as low blood sugar, medication burden, and costs."

    Additionally, the ACP recommend that patients who are 80 years old and above, or who live with chronic illnesses such as dementia, cancer, or congestive heart failure, receive a treatment that focuses on reducing high blood sugar-related symptoms instead of lowering HbA1c levels.

    The reason for this is that for patients in this category, the potential side effects of hypoglycemic drugs outweigh the advantages.

    "Results from studies included in all the guidelines demonstrate that health outcomes are not improved by treating to A1C levels below 6.5 percent," Dr. Ende explains.

    "However, reducing drug interventions for patients with A1C levels persistently below 6.5 percent," he continues, "will reduce unnecessary medication harms, burdens, and costs without negatively impacting the risk of death, heart attacks, strokes, kidney failure, amputations, visual impairment, or painful neuropathy."

    "Although ACP's guidance statement focuses on drug therapy to control blood sugar, a lower treatment target is appropriate if it can be achieved with diet and lifestyle modifications such as exercise, dietary changes, and weight loss."

    Source :https://www.medicalnewstoday.com/articles/321123.php

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    Alternative Medicines May Aid in the Treatment of Psoriasis

    Description

    Most studies evaluated fish oil, acupuncture, indigo naturalis, curcumin, meditation.

    TUESDAY, Oct. 2, 2018 (HealthDay News) -- Some complementary and alternative medicines (CAMs) may be helpful in the treatment of psoriasis, according to a review published online Sept. 5 in JAMA Dermatology.

    A. Caresse Gamret, from the University of Miami, and colleagues conducted a systematic literature review to identify studies evaluating all documented CAM psoriasis interventions. Included interventions had more than one randomized clinical trial (RCT) supporting their use.

    The researchers identified 44 RCTs (17 double-blind, 13 single-blind, and 14 nonblind), 10 uncontrolled trials, two open-label nonrandomized controlled trials, one prospective controlled trial, and three meta-analyses. Compared with placebo, topical indigo naturalis (studied in five RCTs with 215 participants) showed significant improvements in psoriasis. Curcumin (evaluated in five studies with 118 participants) showed statistically and clinically significant improvements in psoriasis plaques. Twenty studies evaluated fish oil treatment, with most RCTs showing no significant improvement in psoriasis; however, most uncontrolled studies showed benefit with daily use. There was modest efficacy associated with meditation and guided imagery therapies (three single-blind RCTs with 112 patients). Acupuncture showed significant improvement in one meta-analysis of 13 RCTs versus placebo.

    "This review will aid practitioners in advising patients seeking unconventional approaches for treatment of psoriasis," the authors write.

    Source: https://www.physiciansbriefing.com/Article.asp?AID=738126

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    Long-term risk of recurrent stroke under-recognized

    Description

    Survivors of stroke or mini-stroke who do not experience early complications are usually discharged from secondary stroke prevention services. However, new research shows that these people remain at a long-term increased risk of stroke, heart attack, and death for at least 5 years after the initial event.

    Senior author Dr. Richard Swartz, a neurologist at Sunnybrook Health Sciences Centre in Ontario, Canada, and colleagues conducted the study. Their findingd were published in CMAJ.

    Stroke is the fifth leading cause of death in the United States, responsible for more than 130,000 deaths each year. More than 795,000 U.S. adults have a stroke each year, and around 185,000 of these affect individuals who have had a previous stroke.

    According to some research, the risk of recurrent stroke accumulates early after an initial stroke or mini stroke or Transient Ischemic Attck (TIA), and this is typically within the first 90 days. For this reason, the 90-day period after a stroke or TIA has been the focus of secondary prevention strategies in both research and clinical practice.

    Population-based studies have shown that in addition to having high short-term risks, the risk of recurrent strokes and death remain elevated in the long-term, with an 18 percent and 44 percent estimated risk over the course of 5 and 10 years, respectively, after an initial stroke or TIA.

    "There is a real need to maintain risk reduction strategies, medical support, and healthy lifestyle choices over the long-term, even years after a mild initial event," says Dr. Swartz.

    While data are available for risk estimates of adverse outcomes during the early high-risk period, little data are available to characterize long-term risk in individuals who experience no early complications after stroke or TIA.

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    WHAT IS DIABESITY?

    ObesityInsulin ResistanceMetabolic Syndrome and Type 2 Diabeteshave unfortunately grown to epidemic proportions. And the more doctors study these conditions, the more they seem to have in common. So much so that the term ‘Diabesity’ (Diabetes + Obesity) was coined to encompass them all.

    Simply put, Diabesity refers to any illness that ranges from mild insulin resistance to full-blown diabetes.

    These days, calories are so easy to come by, but that hasn’t always been the case. Storing fat from excess calories is a survival mechanism our bodies developed to survive hard times. Food is readily available for most of us – including food that isn’t always good for us (like junk food). And we live sedentary lifestyles compared to our ancestors. No need to go out and hunt and gather for every meal!

    All of these things put together are a recipe for disaster!

    What Causes Diabesity?

    Every medical complication of Diabesity, including diabetes, elevated blood sugar, insulin resistance, blood pressure, and many more, boils down to difficulties with diet and lifestyle.

    Dietary and Lifestyle Factors Lead to Diabesity!

    Most people believe Type 2 Diabetes is the result of too much insulin. But actually is the lack of insulin that ultimately causes problems.

    Foods that have a lot of easily absorbed sugars (like sodas and candy bars), and simple carbohydrates like pastas and bread and rice, and even potatoes, cause wide fluctuations in blood sugar, which makes it hard for your body to do its job of regulating insulin. Over time, your body’s cells can become more and more resistant to the effects of insulin, which means it can cause cravings of more bad foods in order to try and get extra sugar so it can even out your glycemic index.
    Insulin Resistance Begins

    First, you may see high insulin levels. The more they rise, the more your body resists insulin. This causes premature aging and deteriorating health. So a person could start to see early signs of heart disease, dementia, and all kinds of other things we’d all rather avoid.

    You may notice an out-of-control appetitemore fat around your bellysymptoms of inflammation or swelling, which if unchecked, can lead to a multitude of other health issues like depression, high blood pressure, bad cholesterol levels, even more weight gain, and lowered autoimmune system.

    All of those things can occur due to insulin resistance and elevated insulin levels.

    Source: https://diabesitydoc.com/

    By Dr. T  [ Dr Frank Tortorice]

    Image: Representation purpose only

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    Could it be possible to eliminate clogged arteries?

    Could it be possible to eliminate clogged arteries?

    A new clinical trial to study a potential way of reducing the risk of early-onset atherosclerosis may be on the way.

    After evaluating previous research, a report published in the Journal of the American Heart Association concludes that a clinical trial might pave the way for a new treatment to help reduce the early onset of atherosclerosis.

    According to lead author Dr. Jennifer G. Robinson, a professor of epidemiology and director of the Prevention Intervention Center at the University of Iowa in Iowa City, the key may be targeting B lipoproteins in young and middle-aged adults.

    These blood proteins (also called apolipoprotein B) include low-density lipoprotein (LDL), or the "bad," cholesterol. Scientists think that LDL and other B lipoproteins are among the leading causes of atherosclerosis.

    Preventing atherosclerosis

    "Lowering them may have a big impact on making atherosclerosis go away," says Dr. Robinson. "If this works, you could completely eliminate heart attacks and stokes within a generation, because you can't have a heart attack or stroke unless you have atherosclerosis."

    The potential study aims to determine whether it is possible to reverse atherosclerosis in high-risk adults aged 25–55 using medications known as statins and PCSK9 inhibitors over a 3-year period. Both statins and PCSK9 inhibitors work to lower LDL cholesterol in the blood.

    "The idea is to get the cholesterol very low for a short period of time, let all the early cholesterol buildup dissolve, and let the arteries heal," says Dr. Robinson, confirming that this method has been successful in animal studies. "Then patients might need to be re-treated every decade or two if the atherosclerosis begins to develop again."

    "Once you know what causes something, you can come up with a hammer for it and eliminate it. We're not the first ones to think of this idea. This would be the culminating study of decades of research by thousands of people."

    Dr. Jennifer G. Robinson

    By Monica Beyer

    Source: https://www.medicalnewstoday.com/articles/323296.php

     

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    DR SHAH PUBLICATION

    Pulmonary hypertension (PH) is the end result of nearly all cardiac and some noncardiac conditions. It is an important marker of mortality and morbidity. It is also the deciding factor in the management of the etiological conditions, such as the timing of surgery in valvular heart disease, follow‑up of pulmonary arterial hypertension, diuretic therapy for diastolic dysfunction, and so on. To add to the problems, early signs and symptoms are nonspecific, and so the diagnosis is attained at a later and advanced stage. Although clinical evaluation is always essential, echocardiography is now the main tool for the evaluation of PH. The aims of echocardiography in PH are: (1) to identify the etiology, (2) assess the effects of PH on the right ventricle, (3) estimation of the severity of the PH, (4) monitoring the progression and therapeutic response in PH, and finally (5) predicting the prognosis. It is hence very important that one measures the pulmonary pressures accurately for proper patient management. The aim of this article is to provide a detailed information of the different parameters of PH in the different echocardiographic views and the technique of measuring these parameters.

     

    Keywords: Mean pulmonary artery pressure, pulmonary artery diastolic pressure, pulmonary artery systolic pressure, pulmonary hypertension, pulmonary vascular resistance

    Introduction

     

    Pulmonary hypertension (PH) is defined as a condition where there are hemodynamic and pathophysiologic changes, with increased mean pulmonary artery pressure (MPAP) of ≥25 mmHg at rest, at sea level, as measured by right heart catheterization (RHC).[1] The normal or increased pulmonary capillary wedge pressure (PCWP) decides whether it is precapillary, where the PCWP is ≤15 mmHg. or postcapillary, where in the PCWP is >15 mmHg. The increase in the pulmonary vascular resistance (PVR) is seen in precapillary PH, the cut‑off value being >2 wood units.[2] Shortly, combining various echo techniques, may make echocardiography the gold standard for the evaluation of PH, having a high sensitivity and accuracy. This will reduce the need for repeated invasive assessments in these patients.[3]

     

    RHC is considered the “gold standard” for the measurement of the systolic pulmonary artery pressure (SPAP). However, as it is invasive in nature, and sometimes has fatal complications,[4] it is utilized less frequently. RHC may be required for measurement of cardiac output, evaluation of intracardiac shunts, valve dysfunction, and finally in conditions where the cause of the PH is uncertain.[5]

    Transthoracic echocardiography is a promising method for

     

    the evaluation of PH, the right‑sided heart structure, and right

     

    ventricular function.[6,7] It provides us with direct and indirect

     

    signs of elevated pulmonary pressures. Thus, echocardiography has become a more preferred investigation for evaluation of SPAP and detecting the cause of PH.[1] Echocardiography is highly utilized as it is noninvasive, economical, convenient, bedside procedure, giving an instant diagnosis and can be repeated as many times as required. It has been demonstrated that SPAP and MPAP measured during RHC are similar to measurements obtained by echocardiography.[8] In some studies, it is observed that the SPAP by echo correlates well with SPAP by RHC, in patients with left‑sided heart diseases, while the correlation is not as accurate in right‑sided heart diseases.[9]

    Shah: Echocardiographic evaluation of pulmonary hypertension

     

     

    of the lungs, various congenital, valvular and left heart conditions, and certain systemic diseases.[10,11] One of the conditions that can be overlooked as a cause of PH is the left ventricular (LV) diastolic dysfunction. One should keep in mind that grade I diastolic dysfunction of the LV is commonly seen in precapillary PH and it should not be considered as a cause of pulmonary venous hypertension leading to PH.[12] The most recent WHO clinical classification of PH is the Dana Point 2008, which is based on the etiology of PH. It is classified into five groups [Figure 1].

     

    Echocardiographic Evaluation of Pulmonary Hypertension

     

    No single echocardiographic parameter is pathognomonic of

     

    PH, and as PH is such an important entity, the echocardiographic

     

    evaluation has to be meticulous and all the parameters systematically evaluated for its diagnosis. A thorough assessment of the PH should include three main entities, namely,

     

    1. Estimation of pulmonary arterial hypertension (PAH) (pulmonary artery systolic pressure, MPAP and diastolic pulmonary artery pressure [DPAP])

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

    Figure 1: The Dana point classification of pulmonary hypertension.

     

    CTD: Connective tissue disorders, CHD: Congenital heart disease, PAH:Pulmonary ar terial hyper tension, PVOD: Pulmonary veno occlusive disease, PCH:Pulmonary capillary haemangiomatosis, PH:Pulmonary hypertension, COPD:Chronic obstructive pulmonary disease, ILD:Interstitial lung disease, CTEPH:Chronic thromboembolism pulmonary hypertension

     

     

    1. Evaluation of the right ventricle (RV) function

     

    (systolic and diastolic)

     

    1. The measurement of the PVR.

     

    The RV systolic function could be global or regional [Table 1]. The different parameters for their evaluation are as shown in Table 1. Another peculiarity of the RV is that it has only two layers of muscle the longitudinal and the circumferential; hence the wringing motion is not present in RV contraction. Here also, the longitudinal action is dominant. This is opposed to the three types of contractions seen in LV, namely longitudinal, circumferential and rotational. In healthy individuals, as opposed to the LV and the systemic circulation, the pulmonary circulation is a low‑resistance system, accommodating the whole cardiac output.[13] The RV is more compliant than the LV and adapts better to volume loading than to pressure loading.

     

    Another change seen in the RV in PH is ventricular remodeling, which is a result of chronic progressive pressure loading. This is initially in the form of hypertrophy and later as dilation.[14]

     

    The different parameters to be evaluated in accordance with the different views are systematically discussed:

     

    Parasternal long axis view

    We all start our echocardiographic examination with this view, and the moment the probe is kept on the chest a fair idea as to the condition of the RV can be inferred. The following parameters can be evaluated from this view [Table 2].

    1. The proximal right ventricular outflow tract (RVOT) dimension can be measured. The normal value is

     

    Table 1: Parameters of RV Systolic Dysfunction

     

    Parameter

    Value

     

     

    Global

     

    RV Ejection Fraction

    <40%

    RV Fractional Area Change

    <35%

    dP/dt

    <1200 mm Hg/sec

    MPI by Doppler

    <0.43

    MPI by TDI

    <0.54

    Regional

     

    TAPSE

    <17mm

    ‘S’ Wave TDI Velocity in systole

    <9.5 Cm/sec

    Strain & Strain Imaging

    <‑20%

    Parasternal short axis view at aorta/left atrium level

     

    1. This view allows us to measure the proximal and distal RVOT. The cut off for the proximal RVOT is 28 mm ± 3.5 mm and distal RVOT is 22 mm ± 2.5 mm[15] [Figure 3]

     

    1. The size of the pulmonary artery which is usually less than the aortic diameter can also be measured in this view. Although there are no data to suggest that as an isolated parameter the dilatation of the pulmonary artery has any significance for the measurement of PH[16] [Table 3]

     

    1. MPAP and PADP can be measured in this view from the early and end diastolic pulmonary regurgitant (PR) velocities. It is discussed in detail in continuous wave (CW) Doppler evaluation [Figure 3 and Table 3]

     

    1. Interatrial septum (IAS), which bulges into the left atrium (LA), is an indirect indicator of PH and is seen in this view. This view also helps to identify the presence of any echo dropouts for the diagnosis of atrial septal defect (ASD). The diagnosis can be confirmed by colour flow imaging

     

    1. LV eccentricity index: Under normal circumstances, the higher pressures in the LV cavity Pushes the IVS into the lower pressure RV cavity. In patients with PH, initially the septum is pushed toward the LV, causing the IVS to flatten, but as the pulmonary pressure increases the septum may even bulge into the LV cavity in systole.[14] These changes in the motion of the IVS are evaluated by the LV eccentricity index. It is measured in the parasternal short axis (PSAX) view at the papillary muscle level and is equal to the ratio of the anteroposterior to septolateral

    LV diameter. The ratio is considered abnormal when it is >1 [Figure 4]. It also helps to differentiate between volume and pressure overload. If the RV is dilated and pushes the septum into the LV only in diastole, it indicates volume overload, but if the IVS is shifted into the LV both in systole and diastole, it will indicate RV pressure overload[16] [Video 2].

     

    Right ventricle inflow view

    This view is obtained by a medial and inferior angulation of the probe in the parasternal long‑axis (PLAX) view toward the Tricuspid Valve [Figure 4].

     

    1. The RV anterior and posterior wall can be evaluated to give a qualitative idea of the RV function. [Video 3]
    2. The anterior and posterior tricuspid leaflets are seen so that any primary valvular pathology can be ruled out

     

    1. The tricuspid regurgitation (TR) jet if it is eccentric can be interrogated in this view [Table 4].

     

    Right ventricle outflow view

    This view is obtained by the lateral and superior tilt of the probe towards the left shoulder in the PLAX view [Figure 4].

     

    1. In this view, the distal outflow tract can be fully evaluated with the pulmonary valve and the pulmonary artery

     

    1. The PR can also be addressed in a parallel fashion in this view

     

    1. The pulsed wave (PW) Doppler pulmonary flow can also be evaluated in this view [Video 4].

     

    Right ventricle focused view

    This view is obtained by the lateral placement of the probe in the apical four chamber view, so as to see the complete RV, with its free walls and the apex still being formed by the left ventricle [Figure 4 and Video 5].

     

    1. It allows us to visualize the RV free wall, and the basic three measurements are taken in this view:
      • basal (<42 mm), (b) mid‑RV (<34 mm) and (c) the longitudinal (<86 mm)[15] [Figure 5]. One thing that should be kept in mind is that sometimes the RV is obviously equal to or larger than the LV on visual appearance in the apical four chamber view, but the dimensions are normal. In this case, the RV should be reported to be visually dilated[15] [Table 5]

     

    1. RV fractional area change is another important parameter which is recommended by the American Society of Echocardiography (ASE) for the evaluation of the

     

    RV systolic function. It is shown to be an indicator of prognosis, and the response to treatment[1] and survival[18] in PH. The main limitation is the endocardial delineation [Figure 5 and Table 5].

     

    RV Fractional area change ( %)

    • ( End diastolic area End systolic area)

     

    End diastolic area

     

    The cut off for the normal value is >35% [Table 6].[15]

     

    Right ventricle modified apical view

    In this view, the probe is shifted medially in the apical four chamber view so that the apex is formed by the RV [Figure 4 and Video 6]. It is a useful view to evaluate the following parameters:

     

    1. The RV dilation and hypertrophy in PH can be evaluated in this view [Video 6]. One of the earliest structure to become hypertrophied is the moderator band[12] [Video 6]. In PH, it is also observed that the apex is frequently hypertrophied and akinetic, thereby favoring thrombus formation which has to be excluded in this view, by using the zoom and focus modalities[17]

     

    1. Sphericity index: it is the ratio of the short axis at the mid‑ventricular level of the RV divided by the RV long axis in end‑diastole, in the apical 4 chamber view. It is an indicator of RV remodeling and dilatation. The upper limit being 0.4 (35/86). The ratio is increased in RV remodeling. In patients with PAH, dilation of the RV is related to adverse clinical outcomes and also to the mortality[19] [Figure 5]

     

    1. The IAS can also be evaluated in this view as regards the direction of the bulging and for any echo dropouts in the ASD [Video 6]. In PH the IAS will bulge into the LA, and color flow imaging will help to diagnose ASD [Video 6]

     

    1. Right atrial linear dimensions can be measured in this view in end systole. These include the RA major and minor diameters. The cut off was >54 and >44, respectively [Figure 6]
    2. Right atrial volume index is usually recommended rather than the linear dimensions and can also calculated from this view. It is measured at end‑systole. The single plane area– length method recommended by the ASE is used and right atrial volume is measured using the area and the long‑axis dimension [Table 6].[15]

     

    Right atrium volume index = (0.85 A2/L)/BSA

     

    Where A is the right atrial area (cm2), L is the long‑axis RV dimension (cm) and BSA is body surface area [Figure 6].

     

    The normal range of the dimensions and volume  as shown in Table 5.[15] Due to the paucity of the standard RA volume data by two dimensional (2D) echocardiography, it is recommended to be done by three dimensional (3D) echocardiography.[15]

     

    Right ventricle subcostal view

    It is a very useful view in patients with a poor transthoracic view, such as in patients with corpulmonale, as the heart becomes vertical. Even in pediatric practice, it is the preferred view. The following parameters are evaluated in this view [Figure 7 and Table 7].

     

    1. The subcostal view allows the measurement of the RV free wall thickness and the RV systolic function. The recommended method of measurement of the RV wall thickness is at end diastole at the level of the tip of the tricuspid leaflet. The upper limit of thickness being

     

    5 mm [Figure 7 and Video 7]

     

    Due to the high‑frame rate and temporal resolution, M‑Mode

     

    is highly useful for the different measurements required for evaluation of the indirect signs of PH [Table 8].

     

    1. In the PLAX view the RV wall thickness and the proximal RVOT can be measured accurately utilizing the M‑Mode [Figure 8]
    2. In the PLAX view, the IVS motion can also be studied showing paradoxical IVS motion, the exact timing of the events can be done by M‑Mode examination [Figure 8]

     

    1. In the PSAX view, the pulmonary leaflet motion can be studied, showing the absence of the “a” wave and mid systolic anterior motion, corresponding to the mid‑systolic notching (closure) of the RVOT flow [Figure 8 and Video 11]

     

    1. The predominant muscles in the RV are the longitudinal one. Moreover, their function can be evaluated in the apical view. For this the M‑Mode can be used to record the movement of the lateral tricuspid annulus, known as the tricuspid annular plane excursion (TAPSE), The normal range is >17 mm, and reduced value indicates RV systolic [15] When measuring TAPSE, it is important to be parallel to the RV free wall and to see that that the entire RV is included in the view [Figure 8 and Video 12]. TAPSE is recommended as it is simple, reproducible and has prognostic value [Table 9]

     

    1. In the sub-costal view (SCV), M‑Mode can be used to measure the RV free wall thickness
    2. Most important is the evaluation of the size and degree of collapsibility of the IVC with respiration [Figure 9] which will estimate the RA pressure for SPAP calculation.

     

    The IVC is used for the estimation of the RA pressure for several reasons.

     

    1. The IVC is in direct communication with the RA

     

    1. It is highly compliant, so the RA pressure changes are reflected back into the IVC
    2. We can interrogate the IVC at right angles for exact measurement [Figure 10].

     

    If the IVC is dilated and noncollapsing, it is mandatory to check the collapsibility after a sniff, to rule out occasional noncompliant IVC. However, it should be kept in mind that the accuracy of the evaluation of the IVC diameter and the degree of collapse with inspiration is limited in conditions such as in athletes, patients on ventilators and in patients who are dyspnoeic [Table 9].[19]

     

    Continuous wave Doppler evaluation of pulmonary hypertension

     

    The CW Doppler is one of the important echocardiographic modality for the evaluation of certain parameters of PH [Table 10].

     

     

    Table 2: Summary of parameters evaluated in PLAX view

     

    Parameters

    Value

     

     

    Proximal RVOT

    >27

    RVH, wall thickness

    >5 mm

    IVS/LVPW ratio

    >1

    Paradoxical IVS motion

     

     

    Pericardial effusion

     

    MVP

     

    Dilated coronary sinus

     

    RVOT: Right ventricular outflow tract, RVH: Right ventricular hypertrophy,

     

    IVS: Interventricular septum, LVPW: Left ventricular posterior wall,

     

    MVP: Mitral valve prolapse

     

    Table 3: Summary of parameters evaluated in PSAX view

     

    Parameters

    Value

     

     

    Proximal RVOT

    > 31.5 MM

    Distal RVOT

    > 27.5 mm

    MPAP by PR jet

     

    DPAP by PR jet

     

     

    Shift of IAS to the left

     

    LV Eccentricity index

     

    RVOT: Right ventricular outflow tract, MPAP: Mean pulmonary artery

     

    pressure, PR: Pulmonary regurgitation, DPAP: Diastolic pulmonary artery

     

    pressure, IAS: Interatrial septum, LV: Left ventricle

     

    Table 4: Summary of parameters evaluated in RV Inflow view

     

    RV anterior and posterior walls

     

    RV systolic function

     

    TV primary pathology

     

    TR jet interrogation if eccentric

     

    RV: Right ventricle, TV: Tricuspid valve, TR: Tricuspid regurgitation

     

    1. The shape of the TR envelope is also guide to the severity.

     

    It is parabolic in mild PH and in severe TR there is an early equalization of the RA and RV pressures. Hence, the spectrum is triangular with an early systolic peaking.

     

    This is known as the “cut‑off” sign[15] [Figure 10]

     

    1. The severity of PH is evaluated by the tricuspid regurgitant velocity (TRV), according to the European Society of Cardiology (ESC) guidelines, as shown in Table 11. One very important fact that should be kept in mind while measuring the TR velocity is that the gain settings should be optimal, or we may underestimate the velocity, and the terminal hazy part should not be the end point, it should in the dark area (nodal velocity) up to which it should be measured. It is commonly referred to as measure “up to the chin, not the beard.”

     

    1. The calculation of the SPAP by CW Doppler was first reported by Yock and Popp 30 years ago.[20] Right ventricular systolic pressure (RVSP) is calculated from the maximal TRV which indicates the pressure difference between the RA and RV and adding the RA pressure to this. The RVSP is the same as the SPAP, provided there is no RVOT obstruction. The velocities are converted to gradients using the modified Bernoulli equation

     

     

    Table 5: Summary of parameters evaluated in RV special views

     

    RV Focused

    Basic RV

    Basal >42 mm, Mid >34 mm,

    view

    dimensions

    Longitudinal >86 mm

     

     

     

     

    RV FAC

    <35%

    RV modified

    Sphericity Index

    >0.4

    Apical

    RA dimensions

    Minor >44 mm, Major >54 mm

     

    RA volume index   Male >27 ml/m², Female >32 ml/m²

    RV: Right ventricle, RA: Right atrium, FAC: Fractional area change

     

    Table 6: RA dimensions

     

     

    Male

    Female

     

     

     

    RA minor axis dimensions (cm/m²)

    1.9±0.3

    1.9±0.3

    RA Major axis dimensions (cm/m²)

    2.5±0.3

    2.4±0.3

    2D right atrial volume (ml/m²)

    2.1±6

    2.5±07

    RA: Right atrium

     

     

     

    Table 7: Summary of parameters evaluated in Subcostal view

     

    RV Free wall thickness

     

    RV Systolic Function

     

    TR jet interrogation

     

    IVC evaluation for RA pressure estimation

     

    IAS evaluation

     

    RV: Right ventricle, TR:Tricuspid regurgitation, IVC: Inferior venacava, RA:Right atrium, IAS:Interatrial septum

     

    P = 4 × V2max

     

    Thus, we see that it is necessary to measure the TR jet accurately, as any mistake will be “squared.” The velocity has to be measured at end expiration otherwise it will be underestimated. Hence, to accurately measure the TR jet velocity it is necessary that we have adequate signals. If the signals are inadequate, they can be enhanced by injection of agitated saline, sonicated albumin or air‑blood saline mixture[21,22]

     

    It has to be kept in mind that the normal resting range of SPAP varies as per the age and the body mass index (BMI) and can be as high as 40 mmHg in the elderly, i.e. >50 years of age or obese, with a BMI of >30 kg/m2.[23]

     

    1. The PR flow velocities are higher in patients with PH. As the PR spectrum can be easily recorded, and so the MPAP and the PADP can be easily calculated. The MPAP can be calculated from the initial peak velocity of the PR spectrum,[24] and adding the RA pressure to it [Figure 11]

     

    1. While if we add the RA pressure to the end diastolic velocity, we will get the value of the PADP [Figure 11]. The normal value of the PR end‑diastolic pressure gradient is usually <5 mmHg. The rise in the PR end‑diastolic gradient has been shown to indicate systolic dysfunction, diastolic dysfunction, increased brain natriuretic peptide and decreased functional status[25]
    2. measuring the mean TR velocity by tracing the spectrum and adding the RA pressure [Figure 12]

       

      1. In shunts, such as ventricular septal defect (VSD) and patent ductus arteriosus (PDA), the SPAP can be estimated by the CW Doppler and the systolic blood pressure (BP). The gradient is calculated by the peak systolic velocity

       

      Table 8: Summary of parameters evaluated by M mode

       

      PLAX view

      RV wall thickness,

       

      Proximal RVOT

      PSAX view

      IVS motion (Paradoxical)

      Apical view

      TAPSE

      Sub costal view

      RV wall thickness

       

      IVC collapsibility

      PLAX: Parasternal long axis, PSAX: Parasternal short axis, RV:Right ventricle, RVOT:Right ventricle outflow tract, IVS:Interventricular septum, TAPSE: Tricuspid annular plane systolic excursion, IVC:Inferior venacava

       

      Table 9: IVC size, collapse and RA pressure

       

      IVC diameter

      Collapse

      RA pressure

       

       

       

      <12 mm

      Spontaneous

      Low volume status

      >17 mm

      > 50% collapse

      5‑10 mm Hg

      >17

      < 50% collapse

      10‑15 mm Hg.

      >17

      No collapse with

      > 20 mm Hg.

       

      dilated hepatic veins

       

      IVC: Inferior venacava, RA: Right atrium

       

       

      Table 10: Parameters of PH evaluated by CW Doppler

       

      TR

       

      Intensity of TR spectrum

       

      Shape of the TR spectrum

       

      Velocity of the TR jet

       

      Mean TR velocity

       

      PR

       

      Mean pulmonary artery pressure

       

      Diastolic pulmonary artery pressure

       

      VSD

       

      RV systolic & diastolic pressure from BP

       

      PDA

       

      PASP & DPAP from BP

       

      PH:Pulmonary hypertension, CW: Continuous Doppler, TR: Tricuspid

       

      regurgitation, PR: Pulmonary regurgitation, VSD: Ventricular septal defect, RV: Right ventricle, BP:Blood pressure, PDA:Patent ductus arteriousus, PASP:Pulmonary artery systolic pressure. DPAP:Diastolic pulmonary artery pressure


      across the shunt and is subtracted from the systolic BP to give the RV systolic pressure, in VSD, which is equal to the SPAP in the absence of RVOT obstruction. In PDA, we directly get the SPAP [Figure 13]

       

      1. By similar method we can get the PADP, utilising the peak end diastolic velocity across the shunt and diastolic blood pressure [Figure 13]

       

      1. PVR may be estimated by dividing TRV (in meters per second) by the time‑velocity integral of the RV outflow tract (in centimeters).[13,24] The PVR helps us also to differentiate the PH due to high pulmonary flow, seen in anemia, hyperthyroidism, and obesity (normal PVR) from the PH seen in PAH (high PVR). The estimation of the PVR also helps us to identify the terminal patients with low MPAP, which is due to failing RV and not due to basically low PH [Table 11].

       

      PVR = 10 × TRV

      VTIRVOT

       

      Pulsed wave Doppler evaluation of pulmonary hypertension

       

      1. Pulmonary acceleration time (PAT) is another entity that is useful for the evaluation of PH. The PAT is measured on the

      PW spectrum of the RVOT flow obtained, by placing the sample volume at the center of the pulmonary annulus, in the short‑axis view. PAT is the time from the start to the peak of the pulmonary flow [Figure 14]. PAT can be very useful in the absence of recordable TR jet. The normal value being >120 m.seconds.[26] The time progressively shortens with rising in the pulmonary pressure [Table 12]. It is shown in many studies that PAT <70–90 m.sec. indicates pulmonary pressure of >70 mmHg.[15] PAT is the rate dependant parameter and has to be corrected for heart rate when it is either >100 or <70/min. This is done by multiplying the observed PAT by 75 and dividing the result by the heart rate[12]

       

      • PAT × 75

       

      Correction of PAT for heart rate

      HR

    3. Although this is not usually used in routine practice.[15] It should be kept in mind that PAT is also flow dependant and if the right‑sided flow is more as in ASD the PAT can be normal even with raised pulmonary pressure

       

      The MPAP can be derived from PAT. This is possible by using the Mahan’s equation

       

       

       

       

       

       

       

       

       

       

       

       

       

       

       

       

       

       

       

       

       

      Figure 12: Mean pulmonary artery pressure by mean tricuspid regurgitant

       

      velocity. PH: Pulmonary hypertension, PAP: Pulmonary artery pressure, TR: Tricuspid regurgitation, PAP: Pulmonary artery pressure, RAP: Right atrial pressure

       

       

       

       

       

       

       

       

       

       

       

       

       

       

       

      Figure 13: Systolic pulmonary artery pressure in shunts. VSD: Ventricular

       

      septal defect, PASP: Pulmonary artery systolic pressure, SBP: Systolic

       

      blood pressure, PS: Pulmonary stenosis


       

      Mahan’s equation ‑ MPAP = 90 − (0.62 × PAT)

       

      But the use of the TR jet velocity, for measuring the MPAP is said to be more reliable than PAT. For PW evaluation of the PH the position of the sample volume is very important. The velocity of the flow varies from the inner to the outer edge being higher on the inner edge of the pulmonary artery. Hence, it is recommended to put the sample volume in the center, just prior to the pulmonary valve leaflets. This will also avoid the turbulence in the spectrum, if the sample volume is placed beyond the valve [Table 13][26]

       

      1. Pattern of pulmonary flow spectrum can also be a guide as to the level of PH. In normal individuals, pulmonary flow tracing has a symmetric counter with a pea
    4. Shah: Echocardiographic evaluation of pulmonary hypertension


       

      velocity occurring at mid systole. As the pulmonary pressure increases, peak velocity occurs earlier in systole, the velocity time integral (VTI) decreases and a late systolic notching is often present [Figure 14]. This notch is analogous to the mid‑systolic notch seen in M‑Mode examination of the pulmonary valve[15] [Figure 8 and Video 13]. The Doppler pattern of the mid‑systolic notch is highly specific for PH.[27] It has been observed that a notched pattern of the RVOT flow spectrum is seen in 100% of the patients with raised PVR as in PAH. The absence of the notch pattern strongly suggests presence of pulmonary venous hypertension[28]

       

      1. PVR may be estimated by dividing TRV (in meters per second) by the time‑velocity integral of the RV outflow tract (in centimeters)[13,24]

       

      PVR = 10 × TRV

      VTI( RVOT)

       

      The PVR helps us to differentiate the PH due to high pulmonary flow as is seen in anaemia, hyperthyroidism and obesity, where the PVR will be normal, as against PH in PAH, where the PVR will be high. The PVR also helps us to identify the terminal patients with low MPAP, which is due to failing RV and not due to low normal pulmonary pressure[24]

       

      1. The evaluation of hepatic vein (HV) flow constitutes the cornerstone of Doppler assessment of RAP. The normal HV flow has two main components, a larger systolic “S” wave and a slightly smaller diastolic “D” The HV flow is dependent on the respiratory cycle with an increased flow in inspiration and decrease flow in expiration. Sometimes, at the end systole, a small retrograde flow may be seen, the systolic reversal ‘SR’ wave. With bradycardia we see a diastolic reversal “DR” wave also Thus, it is quite obvious that any condition that affects the RA pressure or filling will affect the HV flow.

       

      With increase in the RA pressure the gradient between the

       

      HV and the RA decreases thereby reducing the forward flow. Thus, the main findings in PH are the blunting or absence of the “D” wave with a large right atrial reversal. If the “A” wave is more than the forward systolic “S” wave it predicts increase RAP[29,30] [Figure 15]

       

      If there is RV systolic dysfunction, there will be decrease in the “S” velocity and increase in the “D” velocity

       

      1. The SVC can also be used for the evaluation of the flow patterns. It is visualized from the suprasternal notch as a blue colored flow just to the right of the aortic arch.

      It is more readily evaluated using transoesophageal echocardiography[15]

      1. The tissue Doppler imaging (TDI) is another modality to evaluate the RV systolic function and the RAP by a single step method. It involves the PW Doppler evaluation of the lateral TV annulus in the TDI mode. The three waves studied are the systolic “S” wave, and the Diastolic E’ and A’ waves. The “S” wave provides the idea as to the RV

      function. The normal value being 14.1 ± 2.3 cm/sec. the cut off for poor RV function being <9.5 cm/s[15] [Figure 16]

       

      1. The Tei Index or the myocardial performance index (MPI) is another parameter which helps us to evaluate the RV function. MPI is a unit less entity calculated by the ratio of the sum of the iso‑volumic contraction time (ICT) and iso‑volumic relaxation time to the ejection time. It is obtained by the PW interrogation of the TV flow and the RVOT flow. The calculation is as shown.

       

      MPI = TCTO − ET

      ET

       

      TC: Tricuspid closure, TO: Tricuspid opening time,

       

      ET: Ejection time of PV

       

      The normal value is 0.28 ± 0.04,[15] An increase in the Tei or MPI is suggestive of RV dysfunction. An increased RV MPI is a sensitive and specific marker of PH.[15]

       

      1. The MPI can be calculated by the TDI as well. TDI is proposed to be less preload dependent compared to the traditional PW technique. PW TDI is simpler and more robust to use, with high temporal resolution.[15] It is recommended that the MPI should not be used as a sole criterion and also in patients with irregular heart rhythm

       

      The RAP can be estimated by the ratio of the early tricuspid inflow velocity to the tissue Doppler early tricuspid annular velocity

    Colour flow imaging

    A qualitative estimate of the PH can be made from the colour flow patterns of the severity of the TR and PR jets and the flow reversal in the HV [Figure 17].

     

    Transoesophageal echocardiography

    There are very few indications for transoesophageal echocardiography in patients who have PH, & they are namely (1) to confirm and assess congenital intracardiac shunts, (2) to assess the severity and contribution of left‑sided heart disease, (3) rarely in right‑sided masses and finally (4) to guide the invasive procedures like inter atrial septostomy.

     

    Strain imaging

    These days speckle tracking is used very frequently for the noninvasive evaluation of the global and regional RV function. Though the machines still do not have dedicated right sided speckle tracking software, one can measure the global longitudinal strain (GLS) of the RV by tracing the RV free wall in place of the LV, in the apical four chamber view as shown in [Figure 18 and Video 14]. It is easy, angle independent and less load dependent. In PH, the RV strain is reduced due to the increase in the afterload. This can be with or without RV dysfunction. Some echo cardiographers exclude the IVS from the speckle tracking to remove the LV component in its measurement [Figure 18]. With speckle tracking the segmental strain can also be inferred [Figure 18].The normal GLS is - 29 %+ 4.5 %” (> - 20 %).[15] These values are after excluding the IVS. Strain imaging is useful to identify the response to treatment, and also helps to detect early signs of RV

     

     

    dysfunction in PH.[31] The main disadvantage is the necessity of a good 2D image.

     

    Realtime threedimensional echocardiography

     

    Due to the complex shape of the RV, real‑time three‑dimensional echocardiography (RT3D) is the ideal modality of investigation for the measurement of the RV function and volumes. This allows the measurements without geometric assumptions, and foreshortened views. Good correlation was seen in the volumes and ejection fraction measured by RT3D echocardiography and other imaging modalities.[32]

     

    Conclusion

     

    Thus, we see that echocardiography is a convenient, portable, accurate, economical, and noninvasive method of evaluation of PH, which is an integral part of the echocardiographic examination of the heart. Doppler echocardiography provides a complementary, comprehensive method to assess the right‑sided hemodynamics in PH. It is recommended to use multiple parameters for the comprehensive evaluation of PH, to avoid common pitfalls and we should never forget to integrate the findings in a clinical context. Thus, combining various techniques may make echocardiography the standard

     

    for the evaluation of PH, having a high sensitivity and accuracy. This will reduce the need for repeated invasive assessments in these patients.[33]

     

    Financial support and sponsorship

    Nil.

     

    Conflicts of interest

    There are no conflicts of interest.

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    PUBLICATION BY DR RAJESH SHAH

    ECHOCARDIOGRAPHIC EVALUATION OF PULMONARY HYPERTENSION

     

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    Breast cancer: Omega-3-rich diet may stop tumors from spreading

    New research shows that a diet rich in marine omega-3 fatty acids slows the growth and spread of breast cancer cells in female mice. The diet enriched with omega-3 also improved the rodents' survival.

    A vast body of research hails the benefits of a diet rich in omega-3 fatty acids. These healthful fats are found in fish, seafood, nuts, and seeds, as well as in fish oil, plant oils, and some fortified foods.

    For example, an extensive study of almost half a million people, which lasted around 16 years, recently found that eating more fish and long-chain omega-3s reduces the risk of mortality and may prolong life.

    Omega-3s may improve cardiovascular and cognitive function, potentially stave off depression, and have a positive impact on a person's mental health, some studies maintain.

    Emerging research has explored the link between omega-3s and cancerObservational studieshave linked diets rich in marine omega-3 fatty acids with a lower risk of breast cancer. Some molecular studies have suggested that omega-3s may stop cancer by activating the body's natural pain-killers.

    Now, experiments in mice add to the mounting evidence that dietary omega-3s may have cancer-fighting properties.

    Fatty acids, such as the ones found in fish oil, could prevent breast cancer cells from growing and spreading, suggests a new paper published in the Journal of Mammary Gland Biology and Neoplasia.

    Saraswoti Khadge, a former doctoral researcher in the laboratory of James Talmadge, a professor of pathology and microbiology at the University of Nebraska Medical Center in Omaha, led the new research.

    Fish oil may reduce tumors, block metastasis

    Khadge and team fed two groups of adult female rodents nearly identical diets. However, the main difference was that one group ate a diet rich in olive oil-derived omega-6 polyunsaturated fats, whereas the other group received food containing omega-3-rich fish oil.

    Then, the researchers injected the mice with 4T1 breast cancer cells, which cause tumors to spread quickly to the breast glands. Furthermore, 4T1 cells can spontaneously migrate to other sites, such as bones, the lungs, and the liver.

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    Long-term risk of recurrent stroke under-recognized

    Survivors of stroke or mini-stroke who do not experience early complications are usually discharged from secondary stroke prevention services. However, new research shows that these people remain at a long-term increased risk of stroke, heart attack, and death for at least 5 years after the initial event.

    Senior author Dr. Richard Swartz, a neurologist at Sunnybrook Health Sciences Centre in Ontario, Canada, and colleagues conducted the study. Their findingd were published in CMAJ.

    Stroke is the fifth leading cause of death in the United States, responsible for more than 130,000 deaths each year. More than 795,000 U.S. adults have a stroke each year, and around 185,000 of these affect individuals who have had a previous stroke.

    According to some research, the risk of recurrent stroke accumulates early after an initial stroke or mini stroke or Transient Ischemic Attck (TIA), and this is typically within the first 90 days. For this reason, the 90-day period after a stroke or TIA has been the focus of secondary prevention strategies in both research and clinical practice.

    Population-based studies have shown that in addition to having high short-term risks, the risk of recurrent strokes and death remain elevated in the long-term, with an 18 percent and 44 percent estimated risk over the course of 5 and 10 years, respectively, after an initial stroke or TIA.

    "There is a real need to maintain risk reduction strategies, medical support, and healthy lifestyle choices over the long-term, even years after a mild initial event," says Dr. Swartz.

    While data are available for risk estimates of adverse outcomes during the early high-risk period, little data are available to characterize long-term risk in individuals who experience no early complications after stroke or TIA.