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RGUHS nocturnal dyspnea

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					            RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,
                      KARNATAKA, BANGALORE


      PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

1     NAME OF THE CANDIDATE                 DR MAYANK SARAWAG
      AND ADDRESS                           DEPARTMENT OF GENERAL
                                            MEDICINE
                                            K.S.HEGDE MEDICAL ACADEMY
                                            DERALAKATTE, MANGALORE-
                                            575108.

2     NAME OF THE INSTITUTION               K.S.HEGDE MEDICAL ACADEMY
                                            DERALAKATTE, MANGALORE-575108

3     COURSE OF STUDY AND                   M.D. (GENERAL MEDICINE)
      SUBJECT
4     YEAR OF JOINING THE                   13th MAY 2008
      COURSE
5     TITLE OF THE TOPIC                    STUDY OF CAROTID INTIMA MEDIA
                                            THICKNESS IN PATIENTS WITH
                                            CORONARY ARTERY DISEASE AND
                                            STROKE.

6      BRIEF RESUME OF INTENDED WORK

6.1                               NEED FOR THE STUDY

       Patients with established coronary artery disease (CAD) and stroke have
       relatively thick carotid intima media compared to normal population. There are
       several studies stating the role of intima media thickness of common carotid and
       internal carotid arteries as an independent risk factor for CAD and stroke. It
       shows diffuse ongoing atherosclerosis process affecting coronary and carotid as
       well as other arteries of the body.

       There have been only few research reports from India. GUPTA H. AND
       COLLEAGUES1 results indicate that raised values of average and maximum
       carotid intima media thickness are significantly associated with the presence of
       CAD and this association is independent of the presence of other conventional
       cardiovascular risk factors.
6.2   REVIEW OF LITERATURE

      Role of carotid artery intima media thickness as a risk factor for CAD and stroke
      have been studied by many researchers. BOTS M.L. AND COLLEAGUES2
      study shows that an increased common carotid intima media thickness relates to
      future cardiovascular and cerebrovascular events. Their study provides
      supportive evidence for the use of intima media thickness measurements as an
      intermediate or proxy end point in observational studies and trials.

      O'LEARY D.H. AND COLLEAGUES3 study concluded that common carotid
      artery (CCA) intima media thickness is associated with major risk factors for
      atherosclerosis and existing CAD and atherosclerotic disease in older adults.
      This association is not as strong as that for internal carotid artery intima media
      thickness. The combination of these measures relates more strongly to existing
      coronary heart disease and atherosclerotic disease and cerebrovascular disease
      risk factors than either taken alone.

      GRANER M. AND COLLEAGUES4 study concluded association of carotid
      intima media thickness (IMT) with severity and extent of CAD as assessed by
      quantitative coronary angiography. Carotid IMT seems to be a stronger predictor
      of coronary atherosclerosis in the mid and distal parts of the coronary tree than
      in the proximal part.

      TSIVGOULIS G. AND COLLEAGUES5 study concluded that increased CCA-
      IMT values are associated with a higher risk of long term stroke recurrence.

      KABLAK-ZIEMBICKA A. AND COLLEAGUES6 study shows that IMT
      increases with advancing CAD. Patient with mean IMT over 1.15mm have a
      94% likelihood of having CAD. Coexistence of CAD with severe stenosis of
      aortic arch arteries (like CCA and ICA) is relatively high and found in 16.6% of
      patients with three vessel CAD.


                               OBJECTIVES OF THE STUDY

      1.Carotid artery IMT thickness(by B-mode USG scan) - Its association with
6.3     CAD and stroke.

      2.Quantitative correlation of carotid artery IMT with severity of occlusive
        coronary artery disease as evidenced by coronary angiography.

      3.Comparison of carotid artery IMT with conventional risk factors for
        atherosclerosis.
7                            SUBJECTS AND METHODS

7.1   SOURCE OF DATA

      CASES - Patients admitted in Medical Wards of K.S. HEGDE CHARITABLE
      HOSPITAL under Medicine, Cardiology and Neurology and patients in
      M.I.C.U.(Medical Intensive Care Unit) and C.C.U.(Cardiac Care Unit) diagnosed
      as having stroke and / or CAD.

      CONTROLS - Patients attending outpatient department in Medicine, Cardiology
      and Neurology.

      Duration of study – From November 2008 to june 2010

      50 cases of CAD
      50 cases of stroke (both ischaemic and haemorrhagic)
      50 controls

      Controls - Healthy adults more than 30 years of age without present and past
      history of CAD, stroke and no risk factors for atherosclerotic disease like diabetes
      mellitus, hypertension, dyslipidemia, obesity.
7.2   INCLUSION CRITERIA

         1. Age more than 30 years (both male and female).
         2. Present or past diagnosis of CAD.
         3. Present or past diagnosis of stroke.


7.3   EXCLUSION CRITERIA

         1. Age less than 30 years of age.
         2. Cases / controls who are not giving consent.


7.4   DIAGNOSIS OF CAD-
         Clinical features, ECG changes, increased cardiac enzymes, ECHO changes
         and coronary angiography suggesting CAD.

      DIAGNOSIS OF STROKE-
         Clinical features, CT brain (plain or contrast) or MRI brain (plain or contrast)
         suggesting stroke.


7.5   METHODOLOGY---

      After selecting the cases, a detailed questionnaire which includes a detailed
      history, physical examination and relevant investigations are done for each case.
      Controls are also analysed with relevant investigations.
      After confirming the diagnosis of CAD and stroke, cases will undergo
      measurement of IMT of distal CCA at its posterior wall bilaterally. Cases of CAD
      will undergo coronary angiography to see the extent of the disease.
      Controls will also undergo measurements of IMT of distal CCA at its posterior
      wall bilaterally.
      For measurement of IMT - B-mode USG scan using 11MHz probe is used and
      whenever required to see plaques, plaque ulceration, lumen stenosis Colour
      Doppler scan is used.
      A written informed consent will be obtained from all CAD and stroke patients and
      from controls.


7.6   TYPE OF STUDY – Case control study

7.7   STATISTICS - Multivariate logistic regression analysis using SPSS software.

7.8   DOES THE STUDY REQUIRE ANY INVESTIGATIONS OR
      INTERVENTIONS
      TO BE CONDUCTED ON PATIENTS OR OTHER HUMANS OR ANIMALS ?
      IF SO, PLEASE DESCRIBE BRIEFLY ?

      Yes. Coronary angiography, B-mode USG scan / Colour Doppler scan.

7.9   HAS ETHICAL CLEARANCE BEEN OBTAINED FROM YOUR
      INSTITUTION IN CASE OF 7.8 ?

      Yes.

7.10 ABBREVIATIONS:

      IMT - Intima media thickness
      CAD - Coronary artery disease
      ICA - Internal carotid artery
      CCA - Common carotid artery
      TIA’s – Transient ischaemic attacks


8                              LIST OF REFERENCES

         1. GUPTA H., BHARGAVA K., BANSAL M., TANDON S., KASLIWAL
            R. R. Carotid Intima Media Thickness and Coronary Artery Disease : An
            Indian Perspective, Asian Cardiovascular Thoracic Annuals 2003;11:217-
            221
         2. BOTS M.L., HOES A.W., KOUDSTAAL P.J., HOFMAN A, GROBBEE
            D.E. Common Carotid Intima Media Thickness and Risk of Stroke and
            Myocardial Infarction - The Rotterdam Study Circulation 1997;96:1432-
            1437
         3. O'LEARY D.H.,POLAK J.F., KRONMAL R.A., SAVAGE P.J.,
            BORHANI N.O., KITTNER S.J., TRACY R. et al Thickening of Carotid
            wall - A marker for atherosclerosis in the elderly. Cardiovascular Health
            Study Collaberative Research Group Accepted October 11, 1995.
         4. GRANER M., VARPULA M., KAHRI J., SALONEN R.M.,
            NYYSSONEN K., NIEMINEN M.S. et al, Association of Carotid Intima
            media thickness with Angiographic Severity and Extent of coronary artery
            disease, American Journal of Cardiology 2006,97:624-629
         5. TSIVGOULIS G., VEMMOS K., PAPAMICHAEL C., SPENGOS K.,
            MANIOS E., STAMATELOPOULOS K. et al Common Carotid artery
            Intima Media thickness and the risk of stroke recurrence, Stroke
            2006;37:1913-1916
         6. KABLAK-ZIEMBICKA A., TRACZ W., PRZEWLOCKI T., PIENIAZEK
            P., SOKOLWSKI A., KONIECZYNSKA M. Association of Increased
            Carotid Intima media thickness with the Extent of Coronary artery disease.
            Heart 2004;90:1286-1290
9    SIGNATURE OF THE
     CANDIDATE:

10   REMARKS OF THE GUIDE :     Forwarded




11   NAME AND DESIGNATION OF    Dr. L.N.Samaga
     THE GUIDE:                 Professor
                                General Medicine


12   SIGNATURE OF THE GUIDE:


13   CO-GUIDE:

14   SIGNATURE OF CO-GUIDE:

15   HEAD OF THE DEPARTMENT:    Dr. P.S.Prakash
                                Professor and Head of the Department
                                General Medicine



16   SIGNATURE OF THE HEAD OF
     THE DEPARTMENT:

17   REMARKS OF CHAIRMAN AND PRINCIPAL:




18   SIGNATURE:
19.                                                 PROFORMA

Name              :

Age               :

Gender            :

Occupation        :

Hospital number :



RELEVENT HISTORY

A. History of CAD:

Chest pain        : Yes              No           Duration :                     Others:

Breathlessness    : Yes              No           Duration :                     Others:

Orthopnea         : Yes              No           Duration :

PND (Paroxysmal Nocturnal Dyspnea): Yes                     No          Duration :

Cough and expectoration: Yes                No             Duration :            Others:

Palpitation       : Yes              No           Duration :

Syncope           : Yes              No           Duration :


B. History of stroke:

Hemiparesis / Hemiplegia : Yes              No             Duration :

Facial weakness             : Yes           No             Duration :

Dysarthria                  : Yes           No             Duration :

Dysphasia                   : Yes           No             Duration :

Numbness, Tingling          : Yes           No             Duration :

Loss of Consciousness       : Yes           No             Duration :

Headache                    : Yes           No             Duration :

Vomiting                    : Yes           No             Duration :

Seizures                    : Yes           No             Duration :

Giddiness                   : Yes           No             Duration :
Vertigo                     : Yes             No           Duration :

Dysphagia, Choking, Nasal regurgitation: Yes                No               Duration :

Ataxia                      : Yes             No           Duration :

Bowel, Bladder incontinence: Yes                     No             Duration :

Diplopia                    : Yes             No           Duration :

TIA’s                       : Yes             No           Duration :

Fever                       : Yes             No           Duration :


PAST HISTORY:

Previous history of CAD, hospitalisation.

Previous history of stroke, hospitalisation.

Diabetes Mellitus

Hypertension

Intermittent Claudication (symptoms of Peripheral Vascular Disease)


HISTORY OF MEDICATIONS

Specify


HISTORY OF RELEVANT SURGERIES

CABG(coronary Artery Bypass Graft)

PCI(Percutaneous Coronary Intervention)


PERSONAL HISTORY

Smoking

Alcoholism

Diet (fatty diet)


FAMILY HISTORY

CAD

Stroke
GENERAL PHYSICAL EXAMINATION

Blood pressure (supine position)

Pulse

Peripheral pulses

Markers of hyperlipidemia

Carotid bruit

Significant postural drop in blood pressure (systolic blood pressure more than 20mm of Hg and diastolic
blood pressure more than 10mm of Hg)

Jugular venous pulse

Pedal edema


RELEVENT SYSTEMIC EXAMINATION

CENTRAL NERVOUS SYSTEM EXAMINATION:

Higher mental functions

Cranial nerve involvement (specify)

Motor system:
        Attitude             :           Right:                        Left:
        Bulk                 :           Right:                        Left:
        Tone                 :           Right:                        Left:
        Power                :           Right:                        Left:
        Reflexes
                    Pupillary reflex              :   Right:                            Left:
                    Corneal reflex                :   Right:                            Left:
                    Gag reflex                    :   Right:                            Left:
                    Jaw jerk                      :   Right:                            Left:
                    Abdominal reflex              :   Right:                            Left:
                    Cremasteric reflex            :   Right:                            Left:

                    Deep tendon reflexes:
                    Biceps jerk                   :   Right:                            Left:
                    Triceps jerk                  :   Right:                            Left:
                    Supinator jerk                :   Right:                            Left:
                    Knee jerk                     :   Right:                            Left:
                    Ankle jerk                    :   Right:                            Left:

                    Plantar reflex                :   Right:                            Left:

Sensory system:
        Touch
        Pain
        Temperature
        Vibration
          Joint position
          Cortical sensations

Cerebellar signs:



Signs of meningeal irritation:



Fundoscopy



CARDIOVASCULAR SYSTEM:

Cardiac dullness            :Normal        Obliterated 

Precordial bulge            : Yes          No 

Epigastric pulsation        : Yes          No 

Apical impulse (specify) :

Systolic thrill             : Yes          No             Area:

Palpable S1 (specify area) : Yes           No 

Palpable S2 (specify area) : Yes           No 

S1 characteristic (specify) :

S2 characteristic (specify) :

Presence of S3 or S4 (specify):

Systolic murmur (specify area and character) :     Area:            Characteristic:

Diastolic murmur (specify area and character) :    Area:            Characteristic:
RELEVENT INVESTIGATIONS

Haemoglobin

Total leukocyte count

Differential leukocyte count

Erythrocyte sedimentation rate

Platelet count

Bleeding time

Clotting time

Urine routine examination

Fasting blood sugar level

Postprandial blood sugar level

Glycosylated haemoglobin

Fasting lipid profile

Blood urea

Serum creatinine

Serum electrolyte levels

ECHO cardiogram

Electrocardiogram

Chest X-ray

Common carotid artery IMT measurement by B-mode USG scan

Colour Doppler scan to see evidence of-

        plaque

        plaque ulceration

       lumen stenosis

Coronary angiogram

CT (computed tomography) brain

MRI (magnetic resonance imaging) brain
20 RESULTS / DISCUSSION / ANALYSIS

				
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