Management of Hypertension in Patients with Type 2 Diabetes Mellitus: Indian Guideline 2024 by Association of Physicians of India and Indian College of Physicians.

In India and the Southeast Asian population, hypertension and type 2 diabetes mellitus (T2DM) are the leading lifestyle-related diseases, responsible for a majority burden of morbidity and mortality. Multiple population-spanning studies have revealed the staggering prevalence of both diseases in India, and the prevalence of both will only increase further due to factors such as an aging population, rapid urbanization, increased obesity, and sedentary lifestyles. More than 50 percent of hypertensive patients in India are also diagnosed with T2DM, and a detailed management protocol for the same is required, especially when a major portion of the disease is managed at the primary care level. The Association of Physicians of India (API) guidelines for the management of hypertension in patients with T2DM have been formulated based on consultation with leading physicians, cardiologists, diabetologists, and endocrinologists of India and Southeast Asia, keeping in mind the challenges faced by the patients in these countries and the appropriate management protocols that will be beneficial. While standard office-based blood pressure (BP) measurement forms the cornerstone of hypertension diagnosis and demands a uniform methodology to be followed, home blood pressure monitoring (HBPM) is recommended for long-term follow-up with validated devices. Ambulatory blood pressure monitoring (ABPM) offers comprehensive insights crucial for cardiovascular (CV) risk stratification. The complications of diabetic hypertension can span from increased CV risk, heart failure (HF), and renal dysfunction, and nonpharmacological and pharmacological management should be aimed toward not only control of the BP values but also protecting the end organs. While nonpharmacological measures include a focus on nutrition and diet, they also focus on approaches to weight loss, including a novel section covering the benefits of yoga. The guideline also focuses on a novel section of factors influencing CV risk, especially in the Indian population. For the pharmacological management, the guidelines address each of the categories of antihypertensive drugs, emphasizing the significance of combination therapies in the management of diabetic hypertension. In line with leading global guidelines for the management of hypertension in T2DM, for diabetic patients who often struggle with BP management and carry a high CV risk, the recommended dual combination antihypertensive therapy is particularly crucial and should be considered as first-line management therapy. While angiotensin-converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARBs) play a highly beneficial role in the management of diabetic hypertension, a combination of ACEi or ARB with dihydropyridine calcium channel blockers (DHP-CCBs) is recommended to reduce the risk of complications and enhance patient adherence. To achieve the target of effective BP control and end-organ protection, it is beneficial and recommended to include newer CCBs (e.g., cilnidipine) in the management protocol in combination with ACEi/ARBs. Combination therapy including ARBs and DHP-CCBs should be preferred over ß-blockers and thiazides. Among the CCBs, cilnidipine, a novel molecule, is a more effective and safer option for diabetic hypertensive patients in India. ß-blockers should be used if there is a history of myocardial infarction (MI), HF, coronary artery disease (CAD), or stable angina along with the initial hypertensive regimen. The guideline also focuses on the novel reno- and cardioprotective molecules such as finerenone and sodium-glucose cotransporter 2 inhibitors (SGLT2i) and their benefits in the management of diabetic hypertension.

Edema India: Executive Summary of Screening, Diagnosis, and Management of Edema.

The management of edema requires a systematic approach to screening, diagnosis, and treatment, with an essential initial assessment to differentiate between generalized and localized edema. The Association of Physicians of India (API) aimed to develop the first Indian Edema Consensus (Edema India), offering tailored recommendations for screening, diagnosing, and managing edema based on the insights from the expert panel. The panel suggested when evaluating edema symptoms, important factors to consider include the patient's current illness, medical history, risk factors, family history, and medications. Key diagnostic investigations for edema include complete blood count, cardiovascular imaging and markers, deep vein thrombosis (DVT) assessment, along with renal, hepatic, and thyroid function tests. Edema management involves a combination of pharmacologic and nonpharmacologic interventions, including limb elevation, physiotherapy, compression therapy, fluid removal, diuretics (loop diuretics: first-line therapy), and a sodium-restricted diet. The panel believed that educating patients could foster a preventive mindset, helping to prevent the worsening of edema.

Chest Computed Tomography (CT) Severity Score Assessment to Explore Association between Tuberculosis and COVID-19 Pneumonia for Assessing the TB Bulwark against Moderate to Severe COVID-19 Infection.

Importance Objective: First case of Covid-19 pneumonia was reported in Wuhan and soon it became pandemic.1 Pulmonary tuberculosis (TB) is mainly a disease of tropical and poor countries like India.9 Initially, it wasn't clear how these two diseases will interact with each other. We tried to determine if TB has any impact on course and prognosis of Covid-19 pneumonia. DESIGN SETTING: In this retrospective analytical study, data of 7774 patients were collected from various state government owned hospitals of India. Chest CT scans were reviewed for present or past stigmata of pulmonary TB, CORADS and CT severity score. Statistical analysis was done for class wise frequency distribution and association of attributes were calculated. RESULTS: 95.01% Patients with Covid-19 pneumonia didn't have CT signs of history of active or old healed pulmonary TB, while 4.99% had it. In first group 44.85 % mild, 36.17 % moderate and 13.98 % had severe disease, while in second group figure is 3.39 % 1.21 % and 0.40 % respectively. Probability of TB providing immunity against developing moderate or severe form of Covid-19 pneumonia is 0.6778. CONCLUSIONS: Patients with active or past history of TB are less prone to develop moderate or severe form of Covid-19 pneumonia. It may be the reason for less mortality in health resource poor India as compared to Europe or America.

Impact of Thyroid Dysfunction on Insulin Resistance: A Study from a Tertiary Care Center in India.

INTRODUCTION: The thyroid hormones perpetuate a fine equilibrium of glucose metabolism. Abnormalities of thyroid function can disrupt this balance leading to glucose metabolism abnormalities and insulin resistance. OBJECTIVES: We studied the correlation between insulin resistance and thyroid status in hyperthyroid, euthyroid, and hypothyroid individuals. METHODS: In this observational comparative analysis conducted at a tertiary care center, the 3 study groups comprised of 35 patients each with newly detected hyperthyroidism, hypothyroidism and euthyroid individuals. Assays were conducted for serum insulin, thyroid profile, blood sugar and routine biochemistry in the fasting state. The homeostasis model assessment for insulin resistance (HOMA-IR) was used to evaluate insulin resistance. RESULTS: The mean HOMA-IR was highest in patients with hypothyroidism (3.22 ± 2.69) followed by the hyperthyroid group (2.25 ± 1.59). It was lowest in the euthyroid group (0.79 ± 0.58) with the intergroup difference being statistically significant (P<0.001). Hypothyroid patients showed a significant a positive correlation between TSH and HOMA-IR (r=0.945, P=<0.001) whereas hyperthyroid patients showed positive correlation between FT3 and insulin resistance (r=0.706, P<0.001). CONCLUSION: Thyroid dysfunction is associated with an increase in insulin resistance and glucose abnormalities validating the resultant higher risk of related cardiovascular and metabolic abnormalities observed in these patients.

To Evaluate the Association of Neck Circumference with Metabolic Syndrome and Cardiovascular Risk Factors.

BACKGROUND: It is accepted that metabolic syndrome increases the relative risk of cardiovascular disease and visceral adiposity lies at root of the cardio-metabolic risk. Upper body fat distribution has long been recognized as associated with metabolic syndrome and increased cardiovascular risk; hence the present study was conducted with the objective to evaluate the association of neck circumference with metabolic syndrome and cardiovascular risk factors. MATERIAL AND METHODS: The present study was a hospital based observational, Descriptive and comparative analysis, conducted at Department of General Medicine at a tertiary care centre of west India after Ethical clearance from the institute's ethical committee and written informed consent. A total of 405 subjects aged 18 - 60 years were selected consecutively after inclusion and exclusion criteria. Subjects were evaluated for metabolic syndrome components and cardiovascular risk factors. Neck circumference of ≥ 37 cm in males and ≥ 34 cm in females was considered abnormal. RESULTS: Metabolic syndrome was seen in 189 (46.7%) subjects. Raised triglyceride level was the most common (52.8%) component. Neck circumference was found to be statistically significant associated with metabolic syndrome (p<0.001) as well as cardiovascular risk factors like BMI, Waist circumference, Hypertension, Fasting blood sugar, TG and HDL were also found to be statistically significant associated with neck circumference. CONCLUSION: Neck Circumference can be used as a sensitive tool for metabolic syndrome and cardiovascular risk factors. Patients with abnormal Neck circumference should be screened for cardiovascular risk factors to detect abnormality for early and appropriate intervention.

Early Detection of Right Ventricular Dysfunction in Chronic Obstructive Pulmonary Disease by Echocardiography.

OBJECTIVE: This study is designed to investigate the effects of pulmonary arterial hypertension on RV systolic and diastolic functions in cases of COPD and to correlate RV systolic and diastolic functions with pulmonary arterial pressure. MATERIALS AND METHODS: 100 patients admitted in various medical wards of tertiary care Hospital and a primary care hospital with stable chronic obstructive pulmonary disease persons with age and sex-matched. 35 age and sex matched person without any associated and known disease were taken as control subjects. Selection of cases has been made on basis of detailed history, thorough clinical examination, electrocardiography, chest x-ray, pulmonary function tests. OBSERVATION: RV Systolic function (RVEF and RVWT) are significantly abnormal in patients of stable compensated COPD and they are significantly correlated with PAP(p< 0.002). RV diastolic function i.e., E/A ratio and PFR are altered in 60%(n-60) of patients of COPD studied against control subjects and significantly correlated with PAP(p< 0.002). CONCLUSION: Echocardiography is a non invasive method to detect changes of right ventricular dysfunctions in early stages with very good significant sensitivity and specificity.