The Promise of Cilnidipine in Hypertension with Comorbidities: National Consensus Statement: National Consensus Group Comprises Cardiologists, Nephrologists, and Diabetologists from India in a National Meet at New Delhi held on 22nd May 2022.

The rapidly increasing burden of hypertension is responsible for premature deaths from cardiovascular disease (CVD), renal disease, and stroke, with a tremendous public health and financial burden. Hypertension detection, treatment, and control vary worldwide; it is still low, particularly in low- and middle-income countries (LMICs). High blood pressure (BP) and CVD risk have a strong, linear, and independent association. They contribute to alarming numbers of all-cause and CVD deaths. A major culprit for increased hypertension is sympathetic activity, and further complications of hypertension are heart failure, ischemic heart disease (IHD), stroke, and renal failure. Now, antihypertensive interventions have emerged as a global public health priority to reduce BP-related morbidity and mortality. Calcium channel blockers (CCB) are highly effective vasodilators. and the most common drugs used for managing hypertension and CVD. Cilnidipine, with both L- and N-type calcium channel blocking activity, is a promising 4th generation CCB. It causes vasodilation via L-type calcium channel blockade and inhibits the sympathetic nervous system (SNS) via N-type calcium channel blockade. Cilnidipine, which acts as a dual L/N-type CCB, is linked to a reduced occurrence of pedal edema compared to amlodipine, which solely blocks L-type calcium channels. The antihypertensive properties of cilnidipine are very substantial, with low BP variability and long-acting properties. It is beneficial for hypertensive patients to deal with morning hypertension and for patients with abnormal nocturnal BP due to exaggerated sympathetic nerve activation. Besides its BP-lowering effect, it also exhibits organ protection via sympathetic nerve inhibition and renin-angiotensin-aldosterone system inhibition; it controls heart rate and proteinuria. Reno-protective, neuroprotective, and cardioprotective effects of cilnidipine have been well-documented and demonstrated.

The Power and Promise of Angiotensin Receptor Neprilysin Inhibitor (ARNI) in Heart Failure Management: National Consensus Statement.

;Heart failure (HF) is a huge global public health task due to morbidity, mortality, disturbed quality of life, and major economic burden. It is an area of active research and newer treatment strategies are evolving. Recently angiotensin receptor-neprilysin inhibitor (ARNI), a class of drugs (the first agent in this class, Sacubitril-Valsartan), reduces cardiovascular mortality and morbidity in chronic HF patients with reduced left ventricular ejection fraction (LVEF). Positive therapeutic effects have led to a decrease in cardiovascular mortality and HF hospitalizations (HFH), with a favorable safety profile, and have been documented in several clinical studies with an unquestionable survival benefit with ARNI, Sacubitril-Valsartan. This consensus statement of the Indian group of experts in cardiology, nephrology, and diabetes provides a comprehensive review of the power and promise of ARNI in HF management and an evidence-based appraisal of the use of ARNI as an essential treatment strategy for HF patients in clinical practice. Consensus in this review favors an early utility of Sacubitril-Valsartan in patients with HF with reduced EF (HFrEF), regardless of the previous therapy being given. A lower rate of hospitalizations for HF with Sacubitril-Valsartan in HF patients with preserved EF who are phenotypically heterogeneous suggests possible benefits of ARNI in patients having 40-50% of LVEF, frequent subtle systolic dysfunction, and higher hospitalization risk.

Unmet Need for Further LDL-C Lowering in India despite Statin Therapy: Lipid Association of India Recommendations for the Use of Bempedoic Acid.

Lipid-lowering therapy plays a crucial role in reducing adverse cardiovascular (CV) events in patients with established atherosclerotic cardiovascular disease (ASCVD) and familial hypercholesterolemia. Lifestyle interventions along with high-intensity statin therapy are the first-line management strategy followed by ezetimibe. Only about 20-30% of patients who are on maximally tolerated statins reach recommended low-density lipoprotein cholesterol (LDL-C) goals. Several factors contribute to the problem, including adherence issues, prescription of less than high-intensity statin therapy, and de-escalation of statin dosages, but in patients with very high baseline LDL-C levels, including those with familial hypercholesterolemia and those who are intolerant to statins, it is critical to expand our arsenal of LDL-C-lowering medications. Moreover, in the extreme risk group of patients with an LDL-C goal of ≤30 mg/dL according to the Lipid Association of India (LAI) risk stratification algorithm, there is a significant residual risk requiring the addition of non-statin drugs to achieve LAI recommended targets. This makes bempedoic acid a welcome addition to the existing non-statin therapies such as ezetimibe, bile acid sequestrants, and PCSK9 inhibitors. A low frequency of muscle-related side effects, minimal drug interactions, a significant reduction in high-sensitivity C-reactive protein (hsCRP), and a lower incidence of new-onset or worsening diabetes make it a useful adjunct for LDL-C lowering. However, the CV outcomes trial results are still pending. In this LAI consensus document, we discuss the pharmacology, indications, contraindications, advantages, and evidence-based recommendations for the use of bempedoic acid in clinical practice.

Incidence of Coronary Artery Disease After Permanent Pacemaker Implantation: A Hospital-based Study from East India.

Bradyarrhythmias, characterized by heart rates of <60 bpm due to conduction issues, carry risks of sudden cardiac death and falls. Pacemaker implantation is a standard treatment, but the interplay between bradyarrhythmias, coronary artery disease (CAD), and patient attributes requires further exploration. This study was a retrospective hospital record-based study that analyzed data from 699 patients who underwent pacemaker implantation for symptomatic bradyarrhythmias between February 2019 and February 2022. Clinical parameters, coronary angiography (CAG) findings, ejection fraction, and indications for pacemaker implantation were documented. The relationship between CAD severity, specific bradyarrhythmias, and ejection fraction was explored. Statistical analysis included chi-squared tests and t tests. The mean age of the study population (n = 699) was 66.75 years (male:female ratio, 70:30), with 77.2% having type 2 diabetes and 61.6% being hypertensive. The majority of patients had minor or non-obstructive CAD (61.8%), followed by normal CAG findings (25.75%) and obstructive CAD (12.45%). Complete heart block (CHB) was the primary indication for pacemaker implantation (55.2%), followed by sick sinus syndrome (22.3%). The results did not show any association between ejection fraction and CAG findings. Patients who presented with CHB had a higher incidence of obstructive CAD, indicating greater severity. This study sheds light on the intricate interplay between severe bradyarrhythmias, CAD, and patient characteristics. Our analysis revealed no statistical significance between obstructive CAD and the need for a permanent pacemaker. This makes us question our practice of maintaining a low threshold for coronary angiography during pacemaker implantation. The observed low yield and anticoagulation protocol reassure us of the choice to delay this diagnostic intervention. These insights can guide tailored management strategies, enhancing clinical care approaches for patients with severe bradyarrhythmias necessitating pacemaker implantation.

Nicorandil, Novel Potassium Adenosine Triphosphate Channel (K+ ATP) Opener in Ischemia With Non-Obstructive Coronary Arteries (INOCA) and Atherosclerotic Cardiovascular Disease (ASCVD): Delphi Consensus Statement.

BACKGROUND: Coronary artery disease (CAD) is a significant health concern today that has assumed epidemic proportions worldwide and in India. OBJECTIVE: The pathobiology of CAD or ischemia with non-obstructive coronary arteries disease (INOCA) in most cases involves coronary microvascular dysfunction (CMD) that often requires personalized pheno-approach based on the risk stratification and diagnostic yield, especially in patients with recurrent angina episodes. Chronic therapy with anti-anginal is often fraught with challenges of unipolar action, tolerance, and oxidative stress that precludes consistent benefits in clinical cases of CMD represented by microvascular angina (MVA). To further elucidate the clinical role and relevance of long-term vasodilator therapy, including nicorandil, a Knowledge, Attitude, and Perception (KAP) survey was planned to be conducted. METHODS: Based on responses to the KAP survey questionnaire, Delphi-mediated graded recommendations were developed by a specialist panel as per Agency of Health Care and Quality Systems (AHRQ) criteria. RESULTS: Management of INOCA with MVA requires a multidisciplinary approach involving non- or invasive procedures that may be relevant for persistent or refractory angina before instituting symptomatic and long-term use of nicorandil for beta-blocker intolerant and associated clinical phenotypes. CONCLUSION: The analyses provide a real-life approach to the management of INOCA and angina non-obstructive coronary artery disease (ANOCA) with underlying CMD that may be relevant in outpatient settings in India.

Estimating ground-level PM2.5 using subset regression model and machine learning algorithms in Asian megacity, Dhaka, Bangladesh.

Fine particulate matter (PM2.5) has become a prominent pollutant due to rapid economic development, urbanization, industrialization, and transport activities, which has serious adverse effects on human health and the environment. Many studies have employed traditional statistical models and remote-sensing technologies to estimate PM2.5 concentrations. However, statistical models have shown inconsistency in PM2.5 concentration predictions, while machine learning algorithms have excellent predictive capacity, but little research has been done on the complementary advantages of diverse approaches. The present study proposed the best subset regression model and machine learning approaches, including random tree, additive regression, reduced error pruning tree, and random subspace, to estimate the ground-level PM2.5 concentrations over Dhaka. This study used advanced machine learning algorithms to measure the effects of meteorological factors and air pollutants (NOX, SO2, CO, and O3) on the dynamics of PM2.5 in Dhaka from 2012 to 2020. Results showed that the best subset regression model was well-performed for forecasting PM2.5 concentrations for all sites based on the integration of precipitation, relative humidity, temperature, wind speed, SO2, NOX, and O3. Precipitation, relative humidity, and temperature have negative correlations with PM2.5. The concentration levels of pollutants are much higher at the beginning and end of the year. Random subspace is the optimal model for estimating PM2.5 because it has the least statistical error metrics compared to other models. This study suggests ensemble learning models to estimate PM2.5 concentrations. This study will help quantify ground-level PM2.5 concentration exposure and recommend regional government actions to prevent and regulate PM2.5 air pollution. Supplementary Information: The online version contains supplementary material available at 10.1007/s11869-023-01329-w.

Percutaneous coronary intervention with drug-eluting stent implantation vs. coronary artery bypass grafting for multivessel coronary artery disease in metabolic syndrome patients with acute myocardial infarction.

BACKGROUND: Coronary artery bypass grafting (CABG) has been the treatment of choice for management of multivessel coronary artery disease, but percutaneous coronary intervention (PCI) with drug-eluting stents (DES) is increasingly being preferred. The aim of the present study was to compare outcomes of PCI with DES implantation (PCI-DES) and CABG for treating multivessel disease in metabolic syndrome patients with acute myocardial infarction (AMI). METHODS AND RESULTS: A total of 1,839 consecutive metabolic syndrome patients with AMI who underwent PCI-DES (n=1,715) and CABG (n=124) for treatment of multivessel disease were selected from Korea Acute Myocardial Infarction Registry from November 2005 through December 2006. Primary endpoint was 12-month all-cause mortality. The mortality rate at 12 months was significantly lower in the PCI-DES group (4.8% vs. 12.2% in CABG, P=0.014) on univariate analysis. According to a Cox model, 12-month mortality was similar between the 2 groups (P=0.603), which remained the same despite propensity score adjustment (P=0.485). Rate of repeat revascularization was significantly higher in the PCI-DES group compared to the CABG group (P<0.001). At 12 months, major adverse cardiovascular and cerebrovascular event (MACCE)-free survival was higher in ST-elevation MI (STEMI) patients in the CABG group. CONCLUSIONS: PCI-DES had an equivalent 12-month mortality risk to CABG for the treatment of multivessel disease in metabolic syndrome patients with AMI. CABG is more favorable for STEMI patients in terms of MACCE.

Safety and efficacy of overlapping homogenous drug-eluting stents in patients with acute myocardial infarction: results from Korea Acute Myocardial Infarction Registry.

The aim of this study was to compare safety and efficacy of 4 homogenous overlapping drug-eluting stents (DES) in acute myocardial infarction (AMI) patients. We selected 1,349 consecutive patients (62.1 ± 14.9 yr, 69.4% male) who received homogenous overlapping DESs in diffuse de novo coronary lesions from Korea Acute Myocardial Infarction Registry from April 2006 through September 2010. They were divided into 4 groups based on type of DES implanted - Paclitaxel (PES), Sirolimus (SES), Zotarolimus (ZES) and Everolimus (EES)-eluting stents. Primary endpoint was 12-month MACE. We also studied EES versus other DESs (PES + SES + ZES). Mean stent length was 26.2 ± 7.5 mm and mean stent diameter was 3.1 ± 0.4 mm. Average number of stents used per vessel was 2.2 ± 0.5. Incidence of major adverse cardiac events (MACE) in PES, SES, ZES, and EES groups were 9.5%, 9.2%, 7.5%, and 3.8%, respectively (P = 0.013). In EES group, overall MACE and repeat revascularization were lowest, and no incidence of stent thrombosis was observed. Non-fatal MI was highest in PES, almost similar in SES and EES with no incidence in ZES group (P = 0.044). Cox proportional hazard analysis revealed no differences in the incidence of primary endpoint (P = 0.409). This study shows no significant differences in 12-month MACE among 4 groups.

Clinical characteristics and 30-day outcomes in patients with acute decompensated heart failure: Results from Indian College of Cardiology National Heart Failure Registry (ICCNHFR).

BACKGROUND: Acute decompensated heart failure (ADHF) is a challenging medical emergency with high mortality and its prevalence is increasing in India. There is paucity of data on ADHF in the country. METHODS: Indian College of Cardiology National Heart Failure Registry (ICCNHFR) is an on-going observational registry on ADHF contributed by 22 hospitals across India; and we present the in-hospital and 30-day outcomes of ADHF patients enrolled from August 2018 to July 2019. Major objective included capturing demographics, comorbid conditions, aetiology, prescription patterns and assessing clinical outcomes. RESULTS: Of 5269 patients (mean age: 61.90 ± 13.85 years) enrolled in this study, males were predominant (67.09%). Mean duration of hospitalization was 5.74 ± 4.74 days. Ischemic heart disease was the most common (75.44%) aetiology. Abnormal electrocardiogram readings were found in most patients (89.86%). LVEF of ˂40% was found in 68.29% of patients. In-hospital mortality rates were 6.98%. The 30-day cumulative mortality was 12.35% and 30-day rehospitalization rate was 7.98%. At discharge, all guideline-based medical therapy (GDMT) were prescribed only to 24.99% of patients and 23.72% adhered to the prescription until 30 days. Older age, high serum creatinine levels and poor LVEF contributed to high mortality and rehospitalization. CONCLUSION: Patients with ADHF were younger and predominantly males. Usage of GDMT in ADHF patients was low (24.99%) and the in-hospital mortality was high. Older age, high serum creatinine levels, poor LVEF contributed for 30-day mortality and rehospitalization. This data on ADHF, could help in developing strategies to improve outcomes for HF patients in India.

Percutaneous coronary intervention in chronic total occlusion of anomalous right coronary artery: an onerous journey.

Chronic total occlusion (CTO) of coronary artery is a subset where cardiologists confront technical challenges most of the time during percutaneous coronary intervention (PCI). They experience an additional impediment when CTO intervention is performed in presence of anomalous coronary artery. Here we report a 58 years old gentleman with Diabetes mellitus and hypertension who admitted with Canadian Cardiovascular Society class III angina for 5 months. Coronary angiography revealed dual vessel coronary artery disease with CTO of right coronary artery (RCA) originating from left sinus of Valsalva. PCI with stenting has been done successfully to RCA lesion. Patient got relieved of angina after PCI and remains stable clinically since then.

The emerging role of gut microbiota in cardiovascular diseases.

There is mounting evidence which suggests the involvement of gut microbiota dysbiosis in the pathogenesis of various cardiovascular diseases (CVD) and associated risk states such as hypertension, type 2 diabetes, obesity and dyslipidaemia, atherosclerosis, heart failure and atrial fibrillation. The current review comprehensively summarizes the various pathogenetic mechanisms of dysbiosis in these conditions and discusses the key therapeutic implications. Further deeper understanding of the pathogenetic links between CVD and gut microbiota dysbiosis can aid in the development of novel microbiota-based targets for the management of CVDs.

Left bundle branch pacing in hypertrophic cardiomyopathy-a novel approach.

Symptomatic bradycardia attributed by sick sinus syndrome in hypertrophic cardiomyopathy (HCM) is not commonly seen. Dual chamber pacing with right ventricular apical lead placement is conventional strategy in such scenario. Now physiological pacing which includes left bundle branch (LBB) pacing emerging as new technology for pacemaker implantation. Use of this technique is difficult in HCM due to septal hypertrophy. There is no such case reported so far in the literature where LBB pacing was performed in adult HCM for sick sinus syndrome. Here we present a novel approach of treating irreversible, symptomatic sinus node dysfunction in non-obstructive HCM with implementation of left bundle pacing strategy. Pacing parameters remain stable after 3 months of follow-up.

Long-term clinical outcomes of thrombus aspiration in STEMI patients undergoing primary percutaneous coronary intervention.

BACKGROUND: Clinical trials that evaluated long-term clinical outcomes of thrombus aspiration before primary percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI) have shown different results. Thus, this study was designed to evaluate the long-term clinical outcomes and trends in present usage of thrombosuction in STEMI patients undergoing primary PCI. METHODS: This was a single-center, retrospective study conducted at a tertiary-care center in India between January 2016 and December 2018. A total of 241 patients with STEMI who underwent primary PCI were differentiated into thrombus aspiration or standard primary PCI group. Primary endpoint was major adverse cardiac events (MACE) at 1-year. The other safety outcome measured at 1-year follow-up was stent thrombosis. RESULTS: Among 241 patients, 119 patients were included in the thrombus aspiration group and 122 patients were included in the standard primary PCI group. All patients underwent 1-year follow-up. MACE rate was found to be 4.2% and 4.9% in thrombus aspiration and standard primary PCI group (P=0.79), respectively. Death from any cause was found to be higher in thrombus aspiration 7 (5.9%) compared to standard primary PCI group 5 (4.1%). Of which, cardiac death has occurred in 5 (4.2%) patients of thrombus aspiration group and 4 (3.3%) patients of standard primary PCI group (P=0.747). Definite stent thrombosis was observed in 1 (0.8%) patient of both the groups (P=1.00). CONCLUSION: The study concludes that there was no significant benefit of thrombus aspiration concerning mortality rate or any other clinical outcomes at 1-year in STEMI patients.

Procedural safety and outcome of ultrathin strut stents (<60 µm) in the management of very long coronary artery stenosis (>30 mm) - A retrospective real world study.

BACKGROUND: The ultrathin strut stents (<60 µm) are new in the current stents technology. This technology has assured to have less stent thrombosis, restenosis and better deliverability. Still there is lacking data of using long ultrathin strut stents in very long segment coronary artery disease (>30 mm). AIM: The aim of this retrospective study was to assess the procedural safety and outcome of using ultrathin strut stents in very long segment coronary artery lesion. METHODS: In this retrospective analysis, we have enrolled those patients who had an implant of more than 30 mm length of ultrathin strut stents (Evermine 50TM and Tetrilimus stents) in real world patients as per physician discretion. Here, we enrolled 156 patients which included both acute coronary syndrome (ACS) and stable ischemic heart disease (SIHD). The endpoint of this study was to evaluate the immediate procedural success and short to intermediate term follow-up of all-cause mortality and clinically driven target lesion revascularization. RESULTS: Out of these 156 patients (mean age- 61.2 +/- 10.4 years; male: 114), in 12 patients, these long stents couldn't be delivered. In rest 144 patients, 147 ultrathin strut stents were implanted. In about 56% patients were hypertensive and 48% patients were diabetic. About 63% patients had ACS and rest 37% patients had SIHD. The mean duration of follow up was 8.4 +/- 13.9 months. Average stent length and diameter were 39.5 +/- 5.9 mm and 3.03 +/- 0.4 mm, respectively. There was no acute or sub-acute stent thrombosis and no procedural complication. Five patients died during follow-up (all-cause mortality) and rest are all symptoms free. There were no statistical significant differences seen among the stent types. CONCLUSION: Ultrathin strut stents can be considered for stenting in long segment coronary artery stenosis with reasonably good procedural success rate and have good clinical outcome, but needs further large randomized trial before using in this particular clinical condition. Both the stent designs have similar clinical outcome and procedural success.

Blunt traumatic dissection of right coronary artery presenting with acute inferior wall myocardial infarction: Dilemma in management.

Thirty-nine year male had a history of road traffic accident with polytrauma. At emergency room he started having chest pain with ventricular tachycardia. He was subsequentially diagnosed with right coronary artery dissection secondary to blunt trauma which is an extremely rare cause of inferior wall myocardial infarction. After some dilemmas, he was ultimately treated with intravascular ultrasound guided coronary angioplasty with stenting and had an uneventful recovery.

Outcome of everolimus eluting bioabsorbable vascular scaffold (BVS) compared to non BVS drug eluting stent in the management of ST-segment elevation myocardial infarction (STEMI) - A comparative study.

BACKGROUND: The safety and efficacy of everolimus eluting bioabsorbable vascular scaffold (BVS) in the management of "ST" segment elevation myocardial infarction (STEMI) are yet to be established. AIMS: To evaluate immediate and short term safety and efficacy of the everolimus-eluting ABSORB BVS compared with non BVS drug eluting stent (DES) in patients with STEMI. METHODS: From December 2013 to December 2014, 220 patients with STEMI were included in this study. Among them, 35 patients treated with BVS were compared with a control group composed of 180 patients who underwent non BVS DES implantation in the same time period. The incidence of major adverse cardiac events (MACE: stent thrombosis: death, non-fatal myocardial infarction, or target vessel/lesion revascularization) before discharge and up to six months was evaluated. RESULTS: 1 vessel disease was more frequent whereas, 2 and 3 vessel disease was less frequent in BVS group. Procedural characteristics were also similar between groups, except for the use of post dilation (p=0.04). Procedural success, in-hospital, and up to six-month MACE rates were similar between both groups. Definite or probable stent thrombosis did not occur (according to the ARC criteria) in BVS patients, though two patients during the index admission and another two patients in the first month after DES implantation had stent thrombosis. CONCLUSION: The use of the ABSORB BVS for STEMI is feasible and associated with good procedural safety, and angiographic success rate.

Device sizing for transcatheter closure of ruptured sinus of Valsalva as per echocardiography color Doppler turbulent flow jet diameter.

Rupture of sinus of Valsalva (SV) is a rare occurrence with a wide spectrum of presentation, ranging from an asymptomatic murmur to cardiogenic shock or even sudden cardiac death. We hereby report a case which was successfully closed by transcatheter technique. In this case, ruptured SV was entered from the aorta, an arteriovenous loop was created and device was implanted using a venous approach. The procedure was safe, effective and uncomplicated, obviating the need for surgery. In this case, the authors report for the first time the use of echo color Doppler turbulent flow jet diameter as a reference value for sizing the device.

Comparison of zotarolimus- and everolimus-eluting stents in patients with ST-elevation myocardial infarction and chronic kidney disease undergoing primary percutaneous coronary intervention.

BACKGROUND: Chronic kidney disease (CKD) is associated with poor outcomes after percutaneous coronary intervention (PCI). The aim of the study was to compare zotarolimus- and everolimus-eluting stents used during primary PCI in patients with acute myocardial infarction (AMI) and CKD. METHODS: We selected 854 consecutive ST-elevation MI patients with CKD (estimated glomerular filtration rate <60 mL/min/1.73 m(2)) undergoing primary PCI who were followed up for 12 months. They were divided into two groups based on type of stents implanted: (1) zotarolimus-eluting stent (ZES) and (2) everolimus-eluting stent (EES). The study end point was the 12-month major adverse cardiac events (MACE) which included all-cause death, non-fatal MI, target lesion revascularization (TLR), and target vessel revascularization (TVR). RESULTS: The average number of stents used per vessel was 1.4 ± 0.7. A total of 433 patients received ZES and 421 patients received EES. There was no significant difference in the incidence of 12-month MI, TLR, or TVR. All-cause death was found to be borderline significant between two groups (2.8% in ZES vs 0.9% in EES, p=0.05). The incidence of 12-month MACE in ZES and EES was 5.7% and 2.6% respectively, p=0.022. Stent thrombosis did not differ between groups (p=0.677). Kaplan-Meier analysis did not show significant difference for 12-month MACE-free survival between groups (log-rank p=0.158). It remained the same even after propensity adjustment for multiple confounders in Cox model (p=0.326). CONCLUSIONS: Implantation of ZES or EES provided comparable clinical outcomes with similar risk of 12-month MACE and death in STEMI patients with CKD undergoing primary PCI.