Telmisartan Plus Amlodipine as the Preferred Initial Combination in Newly Diagnosed Indian Patients with Hypertension: An Expert Consensus Statements.

INTRODUCTION: Hypertension (HTN) remains one of the most important risk factors for cardiovascular (CV) diseases and a leading cause of mortality worldwide. Despite improvement in detection and treatment, poor blood pressure (BP) control rates are observed globally. The situation in India is alarming with only 22.5% of patients maintaining their BP under control. Initiating early and effective treatment for HTN helps control BP within normal limits and reduces associated health risks. In India, currently, there are no guidelines on the choice of dual combination treatment that can be considered an initial treatment for newly diagnosed HTN patients to achieve effective BP control and reduce CV risks. OBJECTIVE: To provide consensus recommendations for preferred initial combinations in newly diagnosed Indian patients with HTN. METHODOLOGY: A core group of 100 experts with HTN expertise conceptualized and formulated the four key questions based on answerability, effectiveness, potential for translation to clinical practice, novelty, and potential impact on the healthcare burden. A mix of Delphi and Child Health and Nutrition Research Initiative (CHNRI) methods was adopted for acceptance or refusal of recommendations. Likert scale 1-9 was used for scoring. A score of ≥7 was considered "statement accepted," >6.50 "near to acceptance" and <6.50 "not accepted." A vote of ≥7 by at least two-thirds of the experts (66.66%) was mandatory for acceptance of the recommendation. CONCLUSION: Combination therapy could be necessary for a majority of newly diagnosed Indian patients for effective BP control. It can manage HTN with better clinical outcomes. Based on mean rating scores from experts, telmisartan plus amlodipine can be considered the preferred initial combination in the management of newly diagnosed Indian patients with HTN to achieve better BP control and improve CV outcomes.

Sarcomeric gene mutations in phenotypic positive hypertrophic cardiomyopathic patients in Indian population.

HCM is a monogenic cardiac disorder with a high risk of sudden cardiac death, heterogeneous phenotypic expression and genetic profile. HCM is expressed as autosomal dominant in fashion with the prevalence of 1:500 in the general population. The main objective of the current study was to unravel the mutation status in sarcomeric genes in urbanizing Pune population. HCM patients were recruited from Bharti hospital and Poona hospital and research centre, Pune after being screened by 2-D echocardiography. DNA was extracted from whole blood samples and PCR amplification was performed for selected exons from pre-selected genes, amplimers of >300 b.p were restriction digested and the SSCP technique was optimized for maximum result output. HCM patients shows the maximum prevalence of mitral regurgitation (23.3%) while the minimum prevalence was left auricular diameter (10%). Maximum variation spectrum was present in MYBPC3 genes as most of them were "benign" type as per Polyphen-2 tool status. Mutations in the MYH7 gene produce a prominent impact on splicing by the creation of a new SRP40 binding site (Exon Splicing Enhancer) as predicted by Human Splicing Finder 3.1. I736T mutation in the MYH7 gene results in replacement of ß-strand by α-helix upstream from mutation site which may have a profound impact on protein tertiary structure as predicted by Polyphen-2 tool (probably damaging-1.00). Also, two 'novel' mutations and one 'novel' variation were reported in the present study. Thus, the MYBPC3 gene shows maximum mutation load among other sarcomeric genes. Double gene mutations do not represent much severe pathophysiology as compared to single gene mutated and genotypic negative HCM patients.

Assessment of Prescription Adherence to Secondary Prevention Guideline Recommendations and Patient Adherence to Pharmacotherapy and Lifestyle Modifications in Acute Coronary Syndrome and Chronic Coronary Syndrome Patients.

BACKGROUND: Coronary artery diseases (CADs) contribute to the majority of deaths and disabilities worldwide. People who have suffered an acute myocardial infarction (AMI) are at a higher risk of having a further attack. Hence, prolonged secondary prevention is necessary following index myocardial infarction (MI) for long-term cardiovascular protection as it reduces the morbidity and mortality associated with reinfarction, improves the quality of life, and is cost-effective. METHODS: An observational, ambidirectional study was carried out in a tertiary care hospital for 6 months. A total of 200 patients above 18 years of age with a confirmed diagnosis of acute coronary syndrome (ACS) or chronic coronary syndrome (CCS) were included in the study. Prospective data were collected using a self-designed patient profile form and by interviewing patients in the cardiac outpatient department while retrospective data were collected from the medical records department of the hospital. RESULTS AND CONCLUSION: Sex-wise distribution showed that males and females constituted 79 and 21% of the study participants, respectively, while the age-wise distribution revealed that the majority of patients were in the age-group of 60 years and above (63.5%). Hypertension and diabetes mellitus were the most common comorbid conditions, while dyslipidemia was the least observed comorbidity. Prescription adherence to secondary prevention guideline recommendations was studied, which revealed that 26.5% of the prescriptions were adherent to all four guideline recommendations. On evaluating adherence to pharmacotherapy, the maximum proportion of patients demonstrated moderate adherence (45%).

Reversible left ventricular dysfunction due to endless loop tachycardia in patient with dual chamber pacemaker- A case report.

A 60 years male patient underwent permanent pacemaker [DDDR -with dual chamber pacing (D) with dual chamber sensing (D) with dual mode of response (D) with rate responsive pacing(R) -St Jude's medical (Abbott- Endurity 2160)] implantation for complete heart block (CHB). After 4 months patient was admitted for congestive heart failure. 12 Lead electrocardiograms (ECG) was suggestive of tachycardia at 130 beats per minute (regular rhythm), with ventricular complexes preceded by pacing spikes and maintenance of 1:1 atrio-ventricular relationship. Echocardiography showed global hypokinesia of left ventricular (LV) myocardium with reduced LV ejection fraction. LV dysfunction and heart failure were attributed to tachy-cardiomyopathy. Pacemaker telemetry data demonstrated that the tachycardia was likely to be pacemaker-mediated endless loop tachycardia (ELT). ELT in this case was perpetuated secondary to shortening of post ventricular atrial refractory period (PVARP), intact retrograde ventriculo-atrial (VA) conduction and addition of antiarrhythmic drugs prolonging retrograde VA conduction. Rate response (Dynamic) PVARP was reprogrammed allowing PVARP extension. Following this ELT was terminated. LV ejection fraction was normalized on subsequent follow up visit after seven days.

Indian College of Physicians (ICP) Position Statement on Pharmacovigilance.

Pharmacovigilance is the art and science of detection, understanding and prevention of adverse drug reactions and not merely a critical analysis of prescriptions and errors. This field starts with reporting by clinicians of a suspected adverse drug reaction (ADR) to the pharmacologist followed by joint causality analysis and ends at the application of new information by a clinician for benefit of patients. There are a number of ways, which can be utilised for reporting adverse effects using pen and paper format to software applications for smart phones. Varied types of activities spreading from systematic reviews to the mechanistic evaluation of ADR can be performed under the umbrella of pharmacovigilance. It is of utmost importance for clinicians to understand how to identify, communicate and understand adverse effects of drugs with an aim to prevent harm to patients.

Indian College of Physicians Position Statement: Addictive Disorders Among Persons with Diabetes Mellitus.

OBJECTIVES: Migraine, a common primary headache disorder which can be severely disabling, associated with poor health-related quality of life (HRQoL) amongst affected patients. The present study was performed to provide adequate clinical data on migraine and the management practices in India. MATERIAL AND METHODS: A cross-sectional study was designed to assess disease burden, HRQoL, symptom profile, management trends and comorbidities associated with migraine patients across ten centres in India. This study assessed HRQoL using Migraine Specific Quality of life (MSQ) and Migraine Disability Assessment Scores (MIDAS) questionnaire. Categorical variables were summarized as frequency, and percentage and continuous variables as mean and standard deviation respectively. RESULTS: A total of 705 patients were enrolled with a mean age of 35.2 years. Hypertension (7.0%) was the highest co-morbid illness associated with migraine. A higher MSQ score was observed in females as compared to males (39.3±12.4 and 37.4±11.6) while MIDAS showed a comparable score (27.7±47.6 and 27.2±35.4). Majority of migraine patients were unemployed (61.6%) and in profession, females had poor HRQoL than males by MIDAS and MSQ. Majority of patients had pulsating, bilateral attacks for the duration of 4h to 72 h. Paracetamol (47.1%) and propranolol (50.9%) was most commonly prescribed drugs for acute attack and prophylaxis, respectively. CONCLUSION: The quality of life was superior in males as compared to females amongst migraine patients in India. Hypertension was the commonest comorbidity associated with migraine. KEY MESSAGES: Migraine is associated with substantial disability with higher prevalence in females and older people (age >40 years). NSAIDs and propanol was widely prescribed drug in acute attacks and prophylaxis of migraine respectively. Cardiovascular diseases, diabetes mellitus and anxiety were common comorbidities associated with migraine.

Evaluation of bachmann bundle pacing versus right atrial pacing in prevention of atrial fibrillation after coronary artery bypass surgery.

BACKGROUND: In patients undergoing coronary artery bypass surgery (CABGS), occurrence of atrial fibrillation (AF) is common in the postoperative period and is associated with increased morbidity with longer intensive unit care (ICU) and hospital stay. Prevention with antiarrhythmic drugs is of limited success and associated with significant side effects. Therefore alternative approaches, such as Bachmann Bundle pacing, are required. METHODS AND RESULTS: 154 consecutive patients, mean age 58±8.8 years, including 134 males and 20 females, were randomized to three groups; Group I : No pacing n= 54, Group II : RA pacing n= 52, Group III : Bachmann Bundle pacing n= 48. All the groups were well matched with regard to age, left atrial size, ejection fraction and use of beta blockers. Patients in Groups II and III were continually paced at a rate of 100 beats per minute (bpm) or at 10 bpm more than patients' intrinsic heart rate. All the patients were monitored for 72 hours by telemetry and occurrence of AF was noted. Incidence of AF was 0% (none of 48 patients) in Group III as compared to 16.6% in Group I (9 of 54 patients) (p 0.003) and 12.5% in Group II (5 of 52 patients) (p 0.03). There was a trend towards shorter ICU stay in Group III (3.9 days) as compared to Group II (4.5 days) and Group I (4.1 days). Among the three groups, the reduction in mean P wave duration also was greater in Bachmann bundle paced group. CONCLUSION: In patients undergoing CABGS, Bachmann bundle pacing is superior to right atrial / no pacing in the post operative period for preventing occurrence of AF and reducing ICU stay, commensurate with a reduction in mean P wave duration on surface ECG.

Ablation of incessant orthodromic reciprocating tachycardia in a child with congenitally corrected transposition of great arteries and ebsteinoid malformation of left atrioventricular valve.

We report about a patient with congenitally corrected transposition of the great arteries and ebsteinoid malformation of left atrioventricular (AV) valve who presented with incessant orthodromic atrioventricular reciprocating tachycardia due to a left posteroseptal accessory pathway. Radiofrequency catheter ablation using trans-septal approach successfully eliminated the posteroseptal pathway across the morphologic tricuspid valve. This report highlights the importance of delineating the anatomy of the interatrial septum in complex congenital heart diseases for performing safe trans-septal puncture during ablation of accessory pathways.

Diabetes and Anemia: International Diabetes Federation (IDF) - Southeast Asian Region (SEAR) position statement.

Anemia is often associated with diabetes mellitus and is known to intensify the risk of developing diabetes-related microvascular and macrovascular complications. There is paucity in understanding of co-existence of these conditions, especially in Southeast Asian countries. Iron and/or erythropoietin deficiencies are the major causes of anemia in diabetes, and diabetic kidney disease plays a key role. Patients with diabetes need to be screened for anemia along with other risk factors and anemia should be corrected appropriately to improve overall clinical outcomes. This position statement aims to provide a comprehensive overview and an algorithm for appropriate management of anemia in patients with diabetes.

Brugada syndrome unmasked by sodium channel blockade.

We report the case of a 29-year-old male suffering from recurrent syncope and palpitations. He had a structurally normal heart and his baseline electrocardiogram was normal. His electrophysiologic study revealed an inducible, nonsustained polymorphic ventricular tachycardia on programmed electrical stimulation. With the administration of intravenous Flecainide, there was typical ST-segment elevation in leads V2 and V3, indicative of the Brugada syndrome. He underwent an implantable cardioverter defibrillator implantation. The cardioverter defibrillator delivered an appropriate shock when the patient suffered ventricular fibrillation during follow-up one year later. This report illustrates the role of pharmacologic challenge in the diagnosis of the Brugada syndrome.