RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, …



RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA, BANGALORE

ANNEXURE II

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

|1. |NAME OF CANDIDATE AND ADDRESS |Dr. RAVI CHETHAN KUMAR A N |

| | |# 1, HOSTEL FOR PG & INTERNS BOYS, MMC & RI CAMPUS, MANDI |

| | |MOHALLA, |

| | |MYSORE – 570 001 |

|2. |NAME OF THE INSTITUTION |Mysore Medical College and Research Institute, Mysore. |

|3. |COURSE OF STUDY AND SUBJECT |M.D. (GENERAL MEDICINE) |

|4. |DATE OF ADMISSION TO COURSE |03-05-2010 |

|5. |TITLE OF TOPIC |“STUDY OF ACUTE MYOCARDIAL INFARCTION IN PATIENTS WITH CHRONIC |

| | |OBSTRUCTIVE PULMONARY DISEASE” |

6. BRIEF RESUME OF THE INTENDED WORK:

6.1 Need for Study:

Chronic obstructive pulmonary disease is characterized by airflow limitation that is not fully reversible. COPD is a major public health problem worldwide and is expanding throughout with a higher prevalence, morbidity and mortality. The World Health Report-2002 listed COPD as the 5th leading cause of death. It currently ranks No. 6 in global disease impact scale and is predicted to rise to No. 3 by 2020. The prevalence of COPD in India is 5% in males and 2.7% in females with male to female ratio of 1.6:1. It translates into approximately 12 million cases in India alone.

COPD is a preventable and treatable disease with significant extra pulmonary effect that contribute to the morbidity and mortality.

Systemic complication of COPD includes systemic inflammation, body weight loss, musculoskeletal effect, cardiovascular effects, hematological, neurological, psychiatric effect. The systemic complication reduces quality of life and increases mortality in COPD. Comorbid conditions are common in COPD and should be actively managed.

The patients with COPD are at increased risk for cardiovascular events. This is attributed to increased systemic inflammation, which increases the risk of atherosclerosis and ischaemic heart disease.

The decrease in cardiac reserve imposed by COPD may lead to greater hemodynamic compromise and greater risks of cardiovascular complication in acute myocardial infarction.

Though COPD and ischaemic heart disease are seen as comorbidity in elderly, not many studies have been done to study clinical profile and impact of MI in association with COPD and its complications with pulmonary hypertension and corpulmonale. Hence the need for the study.

6.2 Review of Literature:

1. Number of studies have shown an association between COPD and selected cardiovascular disease endpoints including total cardiac mortality, mortality from acute myocardial infarction, mortality after coronary artery bypass graft and pulmonary embolism. Low FEV1 is associated with all cause mortality, cardiovascular disease mortality, non-fatal and fatal myocardial infarction, non-fatal and fatal stroke and atrial fibrillation. There are several reasons for COPD-Cardiovascular Disease Association, including a major shared risk factor (smoking) and a number of factor that may lead to increased stress on cardiovascular system.1

COPD patient especially in case of more advanced disease may manifest hypoxemia, may contribute to episode of ischemic cardiovascular disease (eg: angina, myocardial infarction, transient ischemic attack or stroke).1

2. COPD causes 5% of death in UK and may contribute to more cardiovascular disease and cerebrovascular disease. These are the leading cause of morbidity and mortality in high income countries together accounting for 27% of all deaths. Patients with COPD are at a high risk of hospitalization and death from cerebrovascular disease and cardiovascular disease and increased risk of diabetes mellitus.2

3. Tobacco use is the most important etiologic factor behind development of COPD. Cigarette smoking induces a state of systemic inflammation characterized by the intense interaction and accumulation of all capable of creating a marked oxidant – antioxidant imbalance that result in cellular injury.3

Miller and Colleagues reported that number of circulating CD8+ T cells are increased and CD4+ T cells are decreased in heavy smokers. The abnormality was reversible often upon discontinuation of smoking. A low CD4+ / CD8+ ratio is characteristic of systemic inflammation in COPD.3

4. The neutrophilic inflammation of airway is an abnormal response to noxious particles and gases is the hallmark of COPD. The chronic inflammation involves airways, lung parenchyma, pulmonary vasculature activated inflammatory cells releases a variety of mediators including LTB4, IL8, TNFα, TGFβ and many others and these causes systemic inflammation and other effects in distant organs.4

COPD is an important risk factor for atherosclerosis. COPD increases the risk of cardiovascular disease 2-3 fold. Even modest decrease in FEV1 causes 2-3 fold of IHD, stroke and sudden cardiac death.4

Neutrophillic inflammation that is the hallmark of COPD destabilize the atherosclerotic plaque and leads to rupture and increases the risk of myocardial infarction. 4

Polycythemia is a major hematological complications in patients with COPD pre disposing to vascular events. Hypoxia, hypercapnia and polycythemia together or alone leads to ischaemic events. 4

5. The co-morbidity of COPD with atherosclerotic disease associated with common risk factor such as smoking. However, atherosclerosis in addition shares many of the inflammatory mechanism with those found in COPD. 5

|Mediators |Targets |COPD |Atherosclerosis |

|TGFβ |Smooth muscle cells |Peribronchial fibrosis |Intimal hyperplasia |

|LTB4 |Leukocytes |Leukocyte recruitment and |Leukocyte recruitment and |

| | |Activation |Activation |

|MMP9 |Extra cellular matrix |Emphysema |Plaque rupture |

6. The exacerbation of COPD increases the risk of myocardial infarction and stroke. This may have implication for therapy and exacerbation of COPD. 6

7. COPD confers 2-3 fold greater risk of cardiovascular deaths. Which inturn accounts for half of all COPD deaths. A recent large epidemiological study showed increased cardiovascular mortality particularly in patients < 65 years old with COPD affecting long term prognosis after myocardial infarction. 7

COPD is a very strong predictor of hemodynamic compromise resulting in death or cardiogenic shock in patient presented with ST segment elevated MI. This study suggests that hemodynamic and pulmonary consequence of COPD.

6.3 Objectives of the Study:

1. To study the clinical profile of Acute myocardial infarction in patients with chronic obstructive pulmonary disease.

2. To study the risk factors and comorbid conditions for acute myocardial infarction associated with COPD patients.

3. To study the inhospital outcome of acute phase of myocardial infarction in COPD patients.

7. MATERIALS AND METHODS:

7.1 Source of Data:

Patients of COPD with acute myocardial infarction, who are admitted in K.R. Hospital Mysore and SJIC Mysore during the study period of November 2010-May 2013.

7.2 Method of Collection of Data:

Sample size : Minimum of 30

Sampling method : Simple Random Sampling

7.3 Inclusion Criteria:

1. Known case of COPD patient with acute myocardial infarction.

2. Patients with clinically probable indicators of COPD with acute myocardial infarction.

3. Patient who meets the gold criteria for diagnosis of COPD with acute myocardial infarction.

7.4 Exclusion Criteria

• Patients with known case of asthma.

• COPD patients with old myocardial infarction.

• Patients with neuromuscular disease.

• Patients with restrictive lung disease.

Data will be collected using a pretested proforma meeting the objectives of the study. Detailed history, physical examination and necessary investigations will be undertaken. The purpose of the study will be explained to the patient and informed consent obtained.

The analysis of the data will be done using appropriate statistical methods. Ethical committee will be taken

7.5 Investigations:

1. Complete hemogram

2. RBS / FBS, PPBS

3. Lipid profile

4. Serum creatinine

5. Blood urea

6. ECG

7. 2-D echocardiography

8. Spirometry

9. Cardiac enzymes (trop-T)

7.6 Has Ethical Committee Clearance been obtained from your institution:

Yes. (copy enclosed)

8. LIST OF REFERENCES:

1. Sidney S. Soral M. Quesenberry et al. COPD and incident cardiovascular disease hospitalization and mortality: Kaiser permanent medical care program. Chest /128/4 / October 2006: 2068-2074.

2. Feary RJ. Reed Rigvs CL. Smith JC. et al. prevalence of major comorbidities in subject with COPD and incidence of myocardial infarction and stroke. A comprehensive analysis using data from primary care. Thorax 2010:65:956-962.

3. Cote GC. Celli BR. Predictors of mortality in COPD. Clin chest med. 2007; 28:515- 524.

4. Khader AKA. Systemic effects of COPD. Pulmon. 2008; 9:3:2-4.

5. Magnus back, atherosclerosis COPD and chronic inflammation. Respiratory medicine: COPD update. Vol.4, issue 2, May 2008; 60-65.

6. Donaldson GC. Harst RJ. Increased risk of myocardial infarction and stroke following exacerbation of COPD. Chest May 2010. Volume 137, 1091-1097.

7. Wakabayashi K. Gonzalez AM. Delhave C. et al. impact of COPD on acute phase outcome of myocardial infarction: Coronary Heart Disease; 18 January 2010.

8. Definition of COPD as in Global strategy for diagnosis, Management and prevention of Chronic Obstruction Pulmonary Disease. Updated 2009.

9. Definition of myocardial infarction as in joint ESC/ACC/AHA/WHF/WHO/ task force for redefinition of MI 2007.

9. Signature of the Candidate :

10. Remarks of the Guide :

11. Name and Designation of

11.1 Guide : DR. SHETTY SHIVAKUMAR M M.D.

Professor,

Department of Medicine,

Mysore Medical College &

Research Institute, Mysore.

11.2 Signature :

11.3 Head of the Department : DR. H VASUDEVA NAIK M.D.

Professor and Head,

Department of Medicine,

Mysore Medical College &

Research Institute, Mysore.

11.4 Signature :

12. 12.1 Remarks :

12.2 Remarks of the Dean

and Director :

12.2 Signature :

ETHICAL COMMITTEE CLEARANCE

1. Title of Dissertation : “STUDY OF ACUTE MYOCARDIAL

INFARCTION IN PATIENTS WITH CHRONIC OBSTRUCTIVE PULMONARY DISEASE"

2. Subject : M.D. GENERAL MEDICINE

3. Name of the Candidate : DR. RAVI CHETHAN KUMAR A N

4. Name of the Guide : DR. SHETTY SHIVAKUMAR M M.D.

Professor,

Department of Medicine,

K.R. Hospital,

Mysore Medical College &

Research Institute, Mysore.

5. Approved / not approved

(If not approved, suggestions) :

MEMBERS OF THE ETHICAL CLEARANCE COMMITTEE

PROFESSOR & HOD PROFESSOR & HOD

DEPARTMENT OF SURGERY DEPARTMENT OF MEDICINE,

MYSORE MEDICAL COLLEGE & MYSORE MEDICAL COLLEGE &

RESEARCH INSTITUTE, RESEARCH INSTITUTE,

MYSORE MYSORE

SUPERINTENDENT SUPERINTENDENT

K. R. HOSPITAL CHELUVAMBA HOSPITAL

MYSORE MYSORE

SUPERINTENDENT LAW EXPERT

PKTB HOSPITAL

MYSORE

DEAN AND DIRECTOR PRINCIPAL

MYSORE MEDICAL COLLEGE MYSORE MEDICAL COLLEGE

& RESEARCH INSTITUTE & RESEARCH INSTITUTE

MYSORE MYSORE

From,

Dr. RAVI CHETHAN KUMAR A N

Post-graduate in General Medicine

Department of General Medicine

K.R. Hospital

Mysore Medical College & Research Institute

Mysore.

To,

Registrar (Evaluation)

Rajiv Gandhi University of Health Sciences

Bangalore.

Through proper channel.

Respected Sir,

Subject: Submission of Synopsis titled “STUDY OF ACUTE MYOCARDIAL INFARCTION IN PATIENTS WITH CHRONIC OBSTRUCTIVE PULMONARY DISEASE"

I am hereby submitting the above titled synopsis (4 copies) as mentioned above, so kindly accept my application and do the needful.

Thanking you,

Yours faithfully,

(Dr. RAVI CHETHAN KUMAR A N)

Forwarded to Dean and Director, MMC & RI, Mysore for further needful action

Professor and Head,

Date: Department of Medicine,

Place: MMC & RI, Mysore

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