01 M016 18423

Document Sample
01 M016 18423 Powered By Docstoc
					                                                                              Place : Bellary
From:                                                                         Date : 18.11.2010.

        DR. ADITYA.G.HEGDE
        Post Graduate Student in M.D. (General Medicine)
        Department of General Medicine,
        Vijayanagar Institute of Medical Sciences, Bellary.
To
        The Principal,
        Vijayanagar Institute of Medical Sciences,
        Bellary.

                                THROUGH PROPER CHANNEL

Respected Sir,
        Subject: Acceptance of registration and forwarding of my dissertation topic.


        With reference to the above subject, I, the undersigned studying Post Graduate
Course in M.D. General Medicine has been allotted the dissertation topic “CARDIAC
EVALUATION IN PATIENTS WITH STROKE WITH SPECIAL REFERENCE

TO ECHOCARDIOGRAPHY                  AT VIMS COMBINED HOSPITAL”, under the
guidance of DR. SRIKANT.R.GADWALKAR Professor and HOD, Department of General
Medicine, VIMS, Bellary.
        I request you to kindly forward the dissertation topic in the prescribed form to the
University for approval.
        Thanking you,
                                                                      Yours sincerely,
Signature of the guide :


(DR. SRIKANT.R.GADWALKAR)
                                                              (DR.ADITYA.G.HEGDE)
Professor and HOD                                             P.G.in General Medicine
Department of General Medicine,                               VIMS, Bellary
VIMS, Bellary
From :                                                                         Date :18.11.2010.
         The Professor and Head of the Department,
         Department of General Medcine,
         Vijayanagar Institute of Medical Sciences, Bellary.
To
         The Registrar,
         Rajiv Gandhi University of Health Sciences,
         Bangalore.
                                    THROUGH PROPER CHANNEL
Respected Sir,
          As per the regulations of the University for registration of Dissertation topic, the
following Post Graduate Student in MD General Medicine has been alloted the dissertation
topic as follows by the Official Registration Committee of all qualified and eligible guides of
the Department of Medicine.
              NAME                                   TOPIC                            GUIDE

                                      CARDIAC EVALUATION
   DR.ADITYA.G.HEGDE                  OF PATIENTS WITH                               DR.
 Post Graduate Student in M.D.        STROKE WITH SPECIAL             SRIKANT.R.GADWALKAR
       General Medicine,              REFERENCE TO                          Professor and HOD,
        VIMS, Bellary.                ECHOCARDIOGRAPHY                    Department of General
                                                                        Medicine, VIMS, Bellary.
         Therefore, I kindly request you to communicate the acceptance of the dissertation
topic allotted to the PG student at an early date.
                          Thanking you,
                                                                Yours faithfully,


         Signature of the guide :                        ( DR.SRIKANT GADWALKAR)
         (DR. SRIKANT.R.GADWALKAR)                       Professor and HOD
         Professor and HOD,                              Department of General Medicine
         Department of General Medicine                 VIMS, Bellary
          VIMS, Bellary


         .
         RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,
                   BANGALORE, KARNATAKA.

                                ANNEXURE – II
    SYNOPSIS FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

                                       DR.ADITYA.G.HEGDE
                                       POST GRADUATE STUDENT IN
1    Name of the candidate and
                                        M.D.GENERAL MEDICINE
     Address
                                        VIMS, BELLARY – 583104.
     ( In Block letters )



                                      VIJAYANAGAR INSTITUTE OF
2    Name of the Institution          MEDICAL SCIENCES, BELLARY


                                        M.D.GENERAL MEDICINE
3    Course of study and subject




4    Date of admission to the               07– 05 – 2010
     course
5    Title of Topic:
     “CARDIAC EVALUATION IN PATIENTS WITH STROKE
     WITH SPECIAL REFERENCE TO ECHOCARDIOGRAHY”
6   Brief resume of the intended work:
    6.1 Need for the Study:

       Cerebrovascular accident (CVA) or stroke is the most common life
    threatening disorder. It is the third leading cause of death in the developed
    countries after cardiovascular disease and cancer.
           CVA or strokes are capable of causing crippling morbidity in young as
    well as elderly individuals. They also have marked social, psychological and
    economic implications. Due to its wide prevalence and its high cost in economic
    terms as well as human disability, cerebrovascular accidents have evoked much
    interest in medical fraternity.


        Many studies have shown CVA associated with ECG changes and wall
    motion abnormalities on 2D echo         Changes occurring in ecg include T-wave, U-
    wave, ST-segment, QT-interval changes and various arrhythmias, these ECG changes
    may resemble those of myocardial ischemia or sometime myocardial infarction.


        Echocardiography is useful for detecting abnormalities of cardiac morphology or
    function that can lead to embolic stroke, including atrial myxoma, mitral stenosis and
    regurgitation, valvular vegetations, left ventricular or left atrial thrombus,
    cardiomyopathy, atrial septal aneurysm, and patent foramen ovale or atrial septal defect.


       Currently, the American College of Cardiology and the American Heart Association
    recommend echocardiography for patients with embolic stroke and clinical evidence
    of cardiac disease, as well as in patients with stroke who are less than 45 years old.


        Hence, study was undertaken to know the ECG and 2D echocardiographic
     changes (wall motion abnormalities) in different types of cerebrovascular
      accidents to know whether such changes have any diagnostic or prognostic
      significance.
 6.2 Review of Literature:

   Stroke ranks first in frequency and importance among all neurologic diseases of adult life. 1It is

the third leading cause of death in the developed countries after cardiovascular disease and cancer2

Cerebrovascular disease has been defined by WHO as ‘A neurological dysfunction with symptoms

lasting more than 24 hours or resulting in death before 24 hours and in which after adequate

investigations symptoms are presumed to be of a non-traumatic vascular origin (Hatono3, 1976).



    Cardioembolism is responsible for ~20% of all ischemic strokes..The most significant causes

of cardioembolic stroke in most of the world are nonrheumatic (often called nonvalvular) atrial

fibrillation, MI, prosthetic valves, rheumatic heart disease, and ischemic cardiomyopathy.4

Many studies have shown CVA associated with ECG changes and wall motion abnormalities on

2D echo.



   The changes of ECG in CVA were reported in many studies. (Bayers et al5, 1947; Burch et al6,

1954; Dimant J et al7, 1977). Changes occurring in ECG following stroke were T-wave, U-wave,

ST-segment, QT-interval and various arrhythmias, these ECG changes may resemble those of

myocardial ischemia or sometimes myocardial linfarction.



       Along with ECG changes many studies have shown wall motion abnormalities on

2D echo following stroke, especially with subarachnoid hemorrhage (Davies KR et al8, 1991;

Sakka SH et al9, 1999).
       Ramani A et al10 (1990) reported ECG abnormalities present in 100 patients with

acute cerebrovascular disease and previously normal heart, the abnormalities were more often

seen in patients with intracerebral and subarachnoid hemorrhages. The most common changes

were QTc prolonged and ST segment and T-wave abnormality.

       Echocardiographically determined LVM-to-height ratio offers prognostic information

beyond that provided by traditional cerebrovascular disease risk factors. Echocardiography

provides information that facilitates identification of individuals at high risk for stroke and

transient ischemic attack.11

      Echocardiography is useful for detecting abnormalities of cardiac morphology or function

that can lead to embolic stroke, including atrial myxoma, mitral stenosis and regurgitation,

valvular vegetations, left ventricular or left atrial thrombus, cardiomyopathy, atrial septal

aneurysm, and patent foramen ovale or atrial septal defect.12

      Currently, the American College of Cardiology and the American Heart Association

recommend echocardiography for patients with embolic stroke and clinical evidence of cardiac

disease, as well as in patients with stroke who are less than 45 years old.13



     Hence, study will be undertaken to know the ECG and 2D echocardiographic

changes     (wall     motion      abnormalities)     in     different    types   of cerebrovascular

accidents and to know whether such changes have any diagnostic or prognostic significance.
6.3 Objectives of the study

       • To study the different changes in ECG and Echocardiographic patterns in the

         cases of cerebrovascular accidents.

       • To assess the different changes have got any diagnostic or prognostic

         significance in these cases.




Materials And Methods:
7.1 Source Of Data:
                    The Study Will Be Conducted For Patients Admitted In VIMS
Combined Hospital From December 2010- June 2012. All The Patients With
Cerebrovascular accidents Will Be Taken For The Study.


   -    Inclusion Criteria
   -    Cases of CVA (CT scan proved) admitted within 72 hours after the onset of
        stroke will be selected for the study, patients admitted beyond 72 hours after
        onset of stroke will be excluded as the incidence of ECG changes beyond this
        period would be infrequent.


   -    Exclusion Criteria
   . Traumatic cases producing neurological deficits, infection, neoplastic
   cases producing CVA,CVA cases with known underlying cardiac diseases,
   which produce ECG and echocardiographic changes will be excluded.
7.2 Method of Collection of Data:
( Including the sampling procedure if any )
      Detailed history will be taken from patient and meticulous examination will

be done according to the prepared proforma.

      After admission a detailed history regarding the temporal profile of the

stroke including history of risk factors like hypertension, diabetes mellitus,

smoking, history of IHD and rheumatic heart disease will be obtained.

       Detailed       neurological     examination     including        fundoscopy     and

cardiovascular    examination        will   be   carried   out     in    all   the   cases.



The diagnosis of CVA will be made on the basis of following criteria:



1.Temporal profile of clinical syndrome

2. Clinical examination
3. CT scan of brain


A 12 lead ECG and 2D echocardiography will be done within 24 hours of
     admission.


7.3 Does the study requires any investigations or interventions to be
     conducted on patients or other humans or animals ? If so please describe
     briefly. YES
    1. Complete blood count
    2. Erythrocyte sedimentation rate
   3. Renal function test
   4. Serum electrolytes
   5. Lipid profile
   6. 12 lead ECG
  7. 2D echocardiography with colour Doppler
  8. CT scan of brain




7.4 Has ethical clearance been obtained from your Institution in case of 7.3 ?
    YES, Ethical clearance has been obtained from VIMS INSTITUTIONAL
ETHICS COMMITTEE, Bellary.
8                                    List of References:
     1. Adam’s and Victor’s principles of neurology-9th edition pg 146


     2. Dalal   PM.    Cerebrovascular    disorders.   API   Textbook      of   Medicine,    7th
         Edition: 796-809


     3. Ruth Bontia. Epidemiology of Stroke. Lancet 1992; Vol. 339; 343-4.

     4. Wade S Smith, Stephen L Hauser, Donald J Easton. Cerebrovascular
          disease, harrison’s Principles of Internal Medicine, 17th Edition, 2008; 2513-2514.


     5. Byer E, Ashman R, toth LA. Electrocardiograms with large upright T-
          waves and long QT intervals. American Heart Journal; 1947; 33: 796-806.




    6. Baruch GE, Meyers R, Abildskov JA. A new electrocardiographic pattern
         observed     in    cerebrovascular    accidents.    Circulation    1954;    9:     719-
         723.
    7. Dimant J, Grob D. Electrocardiographic changes and myocardial damage
         in patients with acute CVA. Stroke. 1977; 8: 448-455


     8. Davies KR, Gelb AW, Manninen PH, Boughner DR, Bisnaire D. Cardiac
         function in aneurysmal SAH – A study of electrocardiographic and
         echocardiographic abnormalities. British      Journal of Anesthesia
          1991 Jul; 67(1): 58-63.


    9.   Sakka SG, Haettemann E, Reinhart K. Acute left ventricular dysfunction
         and SAH. J. Neurosurg. Anesthesiol 1999 Jul; 11(3): 209-13.


    10. Ramani A, Shetty U, Kundaje GN. Electrocardiographic abnormalities in
          cerebrovascular accident. Angiology 1990 Sept; 41(9P+1): 681-6.
9   Signature of the candidate :
                                     RECOMMENDED AND
10 Remarks of the guide :            FORWARDED
11 Name and Designation of :       DR. SRIKANT.R.GADWALKAR
    ( In Block Letters)            Professor and HOD,
    11.1 Guide:                    Department of Medicine,
                                   VIMS, Bellary.
    11.2 Signature


    11.3 Co – Guide, if any


    11.4 Signature


                                   DR. SRIKANT .R.GADWALKAR
    11.5 Head of the Department Professor and Head of the Department,
                                   Department of Medicine,
                                   VIMS, Bellary.


    11.6 Signature


12 12.1 Remarks of Chairman
    and Principal


    12.2 Signature

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:15
posted:6/9/2012
language:
pages:11