Prevalence, clinical profile, and stroke risk of atrial fibrillation in rural Andhra Pradesh, India (the AP-AF study).

The burden of atrial fibrillation (AF) is increasing worldwide. It is often asymptomatic, with stroke being the first manifestation in some. AF burden in the community and the practice of stroke prophylaxis has not been studied in India. The problem might be higher in rural regions due to poor health awareness and challenges to healthcare access. This study aimed to estimate the prevalence of AF, clinical profile and stroke risk in rural India. METHODS: This is a community-based cross-sectional study done in rural Andhra Pradesh (AP). Adults from 40 villages formed the study population. We did a door-to door survey to collect information on demographics, and medical history. Electrocardiogram was recorded using a smart phone based Alivecor device. Participants diagnosed with AF underwent echocardiogram. Study cardiologists assessed the cardiovascular risk profile and collected detailed medical history. RESULTS: Fourteen of the 4281 individuals screened had AF (0.3%). The mean age of the sampled population was 44 ± 16.5 years with 56% women. The mean age of participants with AF was 71 ±7.8 years; males were 71%. Except for one, all were non-valvular AF. Majority had a CHA2D2S2Vasc score of ≥2. Three had history of stroke. Two were on anticoagulant therapy but without INR monitoring. CONCLUSION: The prevalence of AF is lower in this study compared to studies from the developed countries. Non-rheumatic cardiovascular risk factors were primary causes for AF. Non-adherence to stroke prophylaxis is a major threat that needs to be addressed.

Prevalence, clinical profile, and stroke risk of atrial fibrillation in rural Andhra Pradesh, India (The AP-AF study) - Rationale and design.

INTRODUCTION: The epidemiology of atrial fibrillation (AF) in India has not been studied systematically in large scale population based surveys. Stroke is one of the leading causes of death and disability in India. As AF is a major contributor of stroke, it is important to know the burden of AF and stroke risk in the population. The Andhra Pradesh Atrial Fibrillation (AP-AF) study aims to assess the prevalence, etiology, risk factors and stroke risk among the rural population in Andhra Pradesh, India. METHODS: This is a cross-sectional survey done using a two-stage sampling process. Adults (≥18years) from villages in East and West Godavari districts were sampled. Field investigators used a structured questionnaire to collect information on basic demographics, cardiovascular risk factors and medical history. Anthropometric measurements were performed, blood pressure measured and fasting capillary blood glucose was assessed. Electrocardiogram was done using a hand-held mobile ECG device-KardioMobile. ECGs were interpreted by study cardiologists. Participants diagnosed to have AF were invited to participate in a camp conducted by cardiologists where echocardiogram was done and also a focused history related to AF was collected. Along with age and sex stratified prevalence of AF, descriptive statistics will be used to present demographics, clinical profile, and cardiovascular risk factors. Stroke risk will be calculated using CHA 2 DS 2 -Vasc score. CONCLUSION: The AP-AF study is expected to provide important information on AF epidemiology in rural India. The information may help improve health care policies in preventing stroke and other complications of AF.

Operational guidelines for diabetic retinopathy in India: Summary.

Diabetes mellitus (DM) is of increasing public health importance in India. The magnitude has been increasing over the past three decades. DM is associated with major microvascular complications among which diabetic retinopathy (DR) is emerging as one of the leading causes of visual impairment in low and middle income countries. Two-thirds of the Indian population resides in rural areas where access to modern medicine is limited mostly to the public health system. Operational guidelines are critical in delivering program components effectively. They provide the template to benchmark service delivery and help in improving quality of care. A pilot initiative to reduce visual impairment in people with diabetes was supported by an international nongovernmental funding organization over a 5-year period in India. This initiative facilitated the development of operational guidelines for DR. The guidelines were developed through consensus and primarily addressed the public health system in India.

Safety and efficacy of epicardial approach to catheter ablation of ventricular tachycardia - An institutional experience.

BACKGROUND AND AIM: Epicardial approach to VT ablation increases the success rate of ablation but is not without complications. We studied the safety and efficacy of epicardial VT ablations performed at our institute. METHODS: All patients who underwent epicardial VT ablation at our institute were studied retrospectively. The outcome of VT ablation was among three groups: ischaemic cardiomyopathy (ICM), non-ischaemic cardiomyopathy (NICM) and granulomatous myocarditis (GM). Safety outcomes assessed included all complications considered to be due to pericardial access or epicardial mapping/ablation. RESULTS: A total of 54 patients (total 119 VTs, mean 2.2 (0.9)) were taken up for ablation procedure through epicardial access. Mean age: 47 (10) years, males: 83%. All patients had drug resistant recurrent VTs. The epicardial procedure was abandoned in three patients due to access issues; percutaneous sub-xiphoid access was employed in 48 and surgical approach in four patients. Complete success was achieved in 59% and partial success in 76%. The outcomes were poor in ICM patients as compared to those with GM and NICM. Overall success rates for all clinical VTs were 89% in GM, 90% in NICM and 67% in ICM. Success rates for epicardial VT ablation were 94%, 85% and 78% respectively for GM, NICM and ICM. Procedure related complications occurred in six patients. CONCLUSION: Epicardial ablation for VT offers good immediate outcomes with acceptable safety profile.

Prevalence of atrial fibrillation in an urban population in India: the Nagpur pilot study.

OBJECTIVES: Atrial fibrillation (AF) is the most common sustained arrhythmia encountered in clinical practice with major public health impact mainly due to the increased risk of stroke. The recent Global Burden of Disease Study reported a lack of prevalence data from India. Our goal was to conduct a pilot study to evaluate the feasibility of assessing AF prevalence and stroke prophylaxis in an urban Indian community. METHODS: A screening camp was conducted in Nagpur, India, that evaluated adults aged ≥18 years. We collected demographics, recorded blood pressure, height, weight and the 12-lead electrocardiogram (ECG). The presence of diabetes and hypertension was recorded by self-reported history. Patients diagnosed with AF were evaluated further to assess aetiology and management. RESULTS: Of the total 4077 randomly selected, community-dwelling adults studied, 0.196% (eight patients) were found to have AF. Mean age of the population was 43.9±14.8, and 44.5% were female. The mean age of the patients with AF was 60.5±15.8 years (five females). Rheumatic heart disease was found in five patients with AF. Three patients had history of stroke (37.5%) and one had peripheral arterial thrombosis. Three patients were on warfarin, but without routine international normalised ratio (INR) monitoring. One patient was on aspirin. Five patients were on ß-blockers and one on both ß-blocker and digoxin. CONCLUSIONS: The prevalence of AF was low compared with other regions of the world and stroke prophylaxis was underused. A larger study is needed to confirm these findings. This study demonstrates that larger evaluations would be feasible using the community-based techniques employed here.

Pleomorphism during Ventricular Tachycardia: A Distinguishing Feature between Cardiac Sarcoidosis and Idiopathic VT.

BACKGROUND: Ventricular tachycardia (VT), a common manifestation of cardiac sarcoidosis (CS), is associated with high morbidity and mortality. It could be mistaken for idiopathic VT (IVT) in the absence of systemic manifestations and overt cardiac structural abnormality. We studied the electrocardiogram (ECG) characteristics of VT in CS that may distinguish from IVT and also explored the relationship of the ECG characteristics with imaging findings in patients with CS. METHODS AND RESULTS: Twelve-lead ECG characteristics of VT in CS patients (Group I = 37) were compared with IVT (Group II = 49). QRS duration, axis, morphology, VT cycle length, and cycle length variation (CLV) were analyzed. In Group I, 18 (49%) had pleomorphic VT (PLVT) and none in Group II. CLV was seen only in Group I (24%). Mean QRS duration (milliseconds) and cycle length (milliseconds) were greater in Group I (QRSd 152.49 [39.3] vs 140.9 [19.2]) and (332.2 [136.5] vs 312.9 [56.2]), the differences not statistically significant. In Group I, myocardial scar was present in 22 of 25 patients and myocardial inflammation in 28 of 29 patients as assessed by cardiac magnetic resonance imaging (delayed enhancement) and 18-fluorodeoxyglucose positron emission computed tomography, respectively. PLVT was seen more commonly in patients with involvement of >1 myocardial region than focal involvement (58% and 30%, respectively, with myocardial scar and 50% and 40%, respectively, with myocardial inflammation). CONCLUSION: Pleomorphism and CLV during VT may be distinguishing features between IVT and VTs of CS origin.

Atrial synchronous left ventricular only pacing with VDD pacemaker system - a cost effective alternative to conventional cardiac resynchronization therapy.

INTRODUCTION: Atrial synchronous left ventricular (LV) only pacing using two leads and VDD pacemaker could be a cost effective alternative to conventional cardiac resynchronization therapy (CRT). METHODS: We implanted right atrial (RA) and LV leads with VDD pulse generator (LV only pacing) in five carefully screened heart failure patients who could not afford conventional CRT. All had NYHA class III/IV symptoms despite maximal guideline directed medical therapy. The sensed atrioventricular delay was programmed to pre-excite the LV and achieve fusion beat. Response to treatment was assessed at 6 months. RESULTS: Four patients were males. The mean age was 58 ± 12 years. At follow up, there was improvement in electrocardiographic, and echocardiographic parameters: Mean QRS duration decreased from 174 ± 17 msec to 128 ± 10.9 msec (p = 0.009), LV end-diastolic diameter decreased from 73.2 ± 12 mm to 65.8 ± 9.6 mm (p = 0.026), LV end-systolic diameter decreased from 65 ± 12 mm to 54 ± 10 mm (p = 0.020). There was a trend towards reduction of LV end-systolic and end-diastolic volumes. LV ejection fraction improved from 25 ± 6% to 34 ± 6% (p = 0.013) and left atrial dimension reduced from 44 ± 4 mm to 39 ± 5 mm (p = 0.045). All patients improved clinically. CONCLUSION: RA-LV pacing using VDD pacemaker is a safe and effective technique of CRT. This may be a cost effective alternative to conventional CRT for patients in developing countries.

Renal sympathetic denervation for treatment of resistant hypertension - indigenous technique.

BACKGROUND: The endovascular approach of ablation of renal sympathetic nerves is found to be effective in the treatment of uncontrolled hypertension. We report here our experience with the procedure in eight patients with drug resistant hypertension. METHODS: We included patients in whom the blood pressure remained above 150/90 mmHg despite being on minimum three antihypertensive drugs. Radiofrequency ablation of the sympathetic nerves of both the renal arteries was done using conventional ablation catheters. The patients were followed at 1-month, 3 months and 6 months post procedure and blood pressure recorded. RESULTS: All patients underwent successful renal sympathetic denervation. The mean blood pressure of the patients was 181/102.5 mmHg before the procedure and the average requirement of antihypertensive drugs per day was 4. A significant reduction in both systolic and diastolic blood pressure was observed post procedure which sustained over the follow up period of six months. The mean blood pressure observed at 1-month, 3 and 6 months were 137.5/80 mmHg, 136/81 mmHg and 137.5/81 mmHg, respectively. The average requirement of the number of antihypertensives also was reduced to 2.5 at the end of 6 months. There were no procedural complications. CONCLUSION: Catheter based renal denervation causes substantial and sustained blood pressure reduction without serious adverse events in patients with resistant hypertension.

Physician assistant education in India.

The first PA program in India was established in 1992 with a focus on expanding cardiovascular surgery. Since then, eight additional programs have developed (in total seven baccalaureate and two master's level programs). Approximately 850 graduates are distributed throughout southern India with concentrations near their home universities. While all PAs are trained as generalists, most work in hospitals in specialized roles such as surgery. With service delivery a looming issue in India, there is an increased interest in the PA profession, and existing PA programs are beginning to work together to advance the field.