Current Place of SGLT2i in the Management of Heart Failure: An Expert Opinion from India.

Heart failure (HF) is a global health concern that is prevalent in India as well. HF is reported at a younger age in Indian patients with comorbidity of type 2 diabetes (T2DM) in approximately 50% of patients. Sodium-glucose cotransporter-2 inhibitors (SGLT2i), originally approved for T2DM, are new guideline-recommended and approved treatment strategies for HF. Extensive evidence highlights that SGLT2i exhibits profound cardiovascular (CV) benefits beyond glycemic control. SGLT2i, in conjunction with other guideline-directed medical therapies (GMDT), has additive effects in improving heart function and reducing adverse HF outcomes. The benefits of SGLT2i are across a spectrum of patients, with and without diabetes, suggesting their potential place in broader HF populations irrespective of ejection fraction (EF). This consensus builds on the updated evidence of the efficacy and safety of SGLT2i in HF and recommends its place in therapy with a focus on Indian patients with HF.

Consensus Statement from India on the Renal Benefits of ARNi, SGLT-2i, and Bisoprolol in Chronic Kidney Disease.

Chronic kidney disease (CKD) is a major contributor to morbidity and mortality in India. CKD often coexists with heart failure (HF), diabetes, and hypertension. All these comorbidities are risk factors for renal impairment. HF and CKD are pathophysiologically intertwined, and the deterioration of one can worsen the prognosis of the other. There is a need for safe renal pharmacological therapies that target both CKD and HF and are also useful in hypertension and diabetes. Neurohormonal activation achieved through the activation of the sympathetic nervous system (SNS), the renin-angiotensin-aldosterone system (RAAS), and the natriuretic peptide system (NPS) is fundamental in the pathogenesis and progression of CKD and HF. Angiotensin receptor neprilysin inhibitor (ARNi), sodium-glucose cotransporter 2 inhibitors (SGLT-2i), and selective ß1-blocker (B1B) bisoprolol suppress this neurohormonal activation. They also have many other cardiorenal benefits across a wide range of CKD patients with or without concomitant HF, diabetes, or hypertension. This consensus statement from India explores the place of ARNi, SGLT-2i, and bisoprolol in the management of CKD patients with or without HF and other comorbidities.

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.

Role of Iron Therapy in Heart Failure: A Consensus Statement from India.

Iron deficiency (ID) with or without anemia is frequently observed in patients with heart failure (HF). Uncorrected ID is associated with higher hospitalization and mortality in patients with acute HF (AHF) and chronic HF (CHF). Hence, in addition to chronic renal insufficiency, anemia, and diabetes, ID appears as a novel comorbidity and a treatment target of CHF. Intravenous (IV) ferric carboxymaltose (FCM) reduces the hospitalization risk due to HF worsening and improves functional capacity and quality of life (QOL) in HF patients. The current consensus document provides criteria, an expert opinion on the diagnosis of ID in HF, patient profiles for IV FCM, and correct administration and monitoring of such patients.

Angiotensin Receptor-Neprilysin Inhibitor Therapy and Cardiac Remodeling in Heart Failure: Consensus Statement from India.

Adverse cardiac remodeling refers to progressive structural and functional modifications in the heart because of increased wall stress in the myocardium, loss of viable myocardium, and neurohormonal stimulation. The guideline-directed medical therapy for Heart failure (HF) includes Angiotensin receptor-neprilysin inhibitor (ARNI) (sacubitril/valsartan), ß-blockers, sodium-glucose co-transporter 2 (SGLT2) inhibitors, and mineralocorticoid receptor antagonists (MRA). ARNI is under-prescribed in India despite its attractive safety and efficacy profile. Therefore, the consensus discusses objectives and topics related to ARNI in the management of cardiac remodeling, and experts shared their views on the early timely intervention of effective dosage of ARNI to improve the diagnosis and enhance mortality and morbidity benefits in cardiac reverse remodeling (CRR).

Role of Bisoprolol in Heart Failure Management: A Consensus Statement from India.

In India, heart failure (HF) is an important health concern affecting younger age groups than the western population. A limited number of Indian patients receive guideline-directed medical therapy (GDMT). Selective ß-1 blockers (BB) are one of the GDMTs in HF and play an important role by decreasing the sympathetic overdrive. The BB reduces heart rate (HR) reverse the adverse cardiac (both ventricular and atrial), vascular, and renovascular remodeling seen in HF. Bisoprolol, a ß-1 blocker, has several advantages and can be used across a wide spectrum of HF presentations and in patients with HF and comorbid conditions such as coronary artery disease (CAD), atrial fibrillation (AF), post-myocardial infarction (MI), uncontrolled diabetes, uncontrolled hypertension, and renal impairment. Despite its advantages, bisoprolol is not optimally utilized for managing HF in India. This consensus builds on updated evidence on the efficacy and safety of bisoprolol in HF and recommends its place in therapy with a focus on Indian patients with HF.

Rheumatic Heart Disease in India in 2020: Advances in Diagnostic and Therapeutic Options.

Rheumatic Fever (RF)/ Rheumatic Heart Disease (RHD) is the result of autoimmune response triggered by group A Beta-haemolytic streptococcal pharyngitis leading to immune-inflammatory injury to cardiac valves. It is practically disappeared in developed countries. However, it continues to be a major cause of disease burden among children, adolescents, and young adults in low-income countries and even in high-income countries with socioeconomic inequalities. For decades, many cases of Acute Rheumatic Fever (ARF) and RHD were missed and were denied the secondary prophylaxis, as a result these patients used to end up with complications and untimely death. Advanced understanding of the echocardiography can prevent both under diagnosis and over diagnosis and thus help in management strategy. Another new advancement in recent past is the mitral valve repair, which is technically demanding, and the results are acceptable in experienced cardiac surgical units. Whenever feasible, valve repair should be preferred over valve replacement since it precludes the need for anticoagulation and future risks of prosthesis dysfunction.

COVID-Inflicted Coagulopathy: Expert Consensus on Management with Novel Oral Anticoagulants in India.

Coronavirus disease 2019 (COVID-19) is a highly hypercoagulable viral infection complicated as COVID-inflicted coagulopathy (CIC), that is associated with increased risk of morbidity and mortality. International guidelines recommend low molecular weight heparin (LMWH) to treat CIC in both in-hospital and in-home settings. However, in India, using subcutaneous LMWH may not be a feasible option for a vast majority of patients under home management. Additionally, while some evidence advocates the use of novel oral anticoagulants (NOACs), in hospitalized settings, most guidelines find no role of NOACs in hospital settings. On the other hand, the resource crunch faced in recent COVID-19 pandemic in India forced physicians to treat many patients in home settings. These patients had been usually prescribed NOACs for ease of administration and adherence. Therefore, there is a need to form a consensus on the use of NOACs to manage CIC in India.

Comparative study on conventional, ultrasonication and microwave assisted extraction of γ-oryzanol from rice bran.

In present study, conventional, ultrasonic and microwave assisted extraction methods were compared with the aim of optimizing best fitting solvent and method, solvent concentration and digestion time for high yield of γ-oryzanol from rice bran. Petroleum ether, hexane and methanol were used to prepare extracts. Extraction yield were evaluated for giving high crude oil yield, total phenolic content (TPC) and γ-oryzanol content. Gas chromatography-mass spectrophotometry was used for the determination of γ-oryzanol concentration. The highest concentration of γ-oryzanol was detected in methanolic extracts of microwave treatment (85.0 ppm) followed by ultrasonication (82.0 ppm) and conventional extraction method (73.5 ppm). Concentration of γ-oryzanol present in the extracts was found to be directly proportional to the total phenolic content. A combination of 80 % methanolic concentration and 55 minutes digestion time of microwave treatment yielded the best extraction method for TPC and thus γ-oryzanol (105 ppm).

Techniques to assess myocardial viability.

Assessment of myocardial viability in patients with chronic coronary artery disease or acute and sub-acute myocardial infarction is clinically important for distinguishing stunned and hibernating myocardium from irreversibly injured myocardium. Patients may benefit from revascularization when viable tissue is present in the dysfunctional area of the myocardium. Several clinical imaging modalities exist for assessment of viable myocardium which have proven useful for chronic chronic coronary artery disease are available but a reliable technique for the assessment of myocardial viability in the sub-acute situation does not exist.

Patterns of left ventricular hypertrophy in chronic kidney disease: an echocardiographic evaluation.

BACKGROUND: We evaluated the chronic kidney disease (CKD) patients having different degree of uremia for the prevalence of Left Ventricular Hypertrophy (LVH), different patterns of left Ventricular Hypertrophy by echocardiographic variables to define the most sensitive and powerful predictor of cardiovascular disease (CVD) and premature morbidity and mortality. METHODS: We used clinical and biochemical data from the prospective study done by us to evaluate "The Echocardiographic assessment of cardiac functions in patients with chronic kidney disease". The diagnosis of CKD was made on the basis of serum creatinine (sCr) concentration of more than 1.5 mg/dl, persistent and with no evidence of recovery over a period of 3 months. Glomerular filtration rate (GFR) was calculated by the Modification of Diet in Renal Disease (MDRD) equation and cut-off for CKD was taken to be < 60 ml/min/1.73 m2 as per existing guidelines. The study population consisted of a total of 75 subjects divided into three groups of 25 subjects each, all between the age of 20-65 yrs: GROUP A: Healthy normal controls (sCr < 1.5 mg/dl); GROUP B: Patients with mild to moderate CKD (sCr 1.5 - 6.0 mg/dl); GROUP C: Patients with severe CKD (sCr > 6.0 mg/dl). RESULTS: A progressive rise in prevalence of LVH was observed with the severity of kidney disease from 64% (mild/ moderate CKD group) to 96% (severe CKD group) and higher prevalence of LVH in females than males in the severe CKD group. The mean LVMI in both the groups of CKD was significantly higher than the healthy controls (76.62 +/- 10.97). Also, mean LVMI in severe CKD (139.23 +/- 17.47) patients was significantly higher than in mild/moderate CKD (114.91 +/- 15.20) patients. The prevalence of concentric remodeling in both the CKD groups was alike (20%). While that of concentric hypertrophy in severe CKD patients (68%) was significantly higher than in mild/moderate CKD group (40%) (p < 0.05), but no significant difference was observed for eccentric pattern of hypertrophy between the two CKD groups. This suggests that concentric hypertrophy is more prevalent in CKD patients. CONCLUSIONS: The mean left ventricular mass index (LVMI) showed a proportionate increase with the severity of renal failure and a progressive rise with increase in severity of disease. Patients of CKD groups revealed occurrence of concentric remodeling which is a predictor of high vulnerability for progressing into concentric and eccentric hypertrophy. Hence early medical intervention may reverse the concentric remodeling, thereby preventing the advancement to concentric or eccentric LVH.

Enhanced external counterpulsation and CVD protection: 3D echo validation: a promising approach.

UNLABELLED: AIMS & OBJECTIVE: To evaluate the impact of enhanced external counterpulsation (EECP) on various echo variables by 3D-Echocardiography. MATERIALS AND METHODS: 60 adult patients from indoor and outdoor patient department; consisting of 16 patients with heart failure (HF) with left ventricular systolic dysfunction, 20 patients with heart failure with normal ejection fraction (HFNEF), 4 patients with prior percutaneous coronary intervention (PCI), 3 patients with prior coronary artery bypass grafting (CABG) and 17 patients with syndrome X; were subjected to Echocardiographic evaluation. The various echo variables included were left ventricular myocardial performance index (LVMPI), left ventricular mass index (LVMi), left ventricular diastolic dysfunction (LVDD), left ventricular systolic function (LVEF) and left atrial volume index (LAVi). Once randomized, patients underwent 35 hrs EECP treatment sessions, each lasting 1 hour, could be given once or twice per day. RESULTS: There was a significant reduction in the overall prolonged mean LVMPI from baseline (0.54 +/- 0.2) to post ECP treatment (0.43 +/- 0.1) in the total study population (p < 0.001). EECP treatment significantly reduced baseline grade II or grade III diastolic dysfunction and E/E' ratio > 12, but not in patients with baseline E/E' < 12, baseline normal diastolic function or grade I diastolic dysfunction. Similiarly the mean LVEF in the subset of patients with HF treatment was 30.7 +/- 3.1; post ECP the mean LVEF was increased to 36.9 +/- 3.2 which was statistically significant (p < 0.001). In the remaining patients, who had mean LVEF within normal range, there was no significant difference pre and post EECP (p value- NS). Pre EECP the mean LAVi in the total population was increased up to 33.4 +/- 5.6 ml/m2. Post EECP the mean LAVi reduced to 24.8 +/- 4.2 ml/m2, which was also statistically significant (p < 0.001). Regarding mean LVMi as well as in the patterns of LVH, there were no significant changes seen as compared to baseline. CONCLUSION: Enhanced External counterpulsation is noninvasive, non-surgical method of choice for CVD & heart failure protection. It is very useful in Single vessel or multivessel disease, heart failure, HFNEF, Post PCI or post CABG and syndrome X. It reduces LVMPI and improves global cardiac function, increases LVEF in patients with ejection fraction of less than 50%, reduces grade II or grade III diastolic dysfunction and E/E' ratio more than 12, decreases LAVi by 25.7%; thereby reducing adverse clinical events in CAD and heart failure.

Regression of coronary atherosclerosis through healthy lifestyle in coronary artery disease patients--Mount Abu Open Heart Trial.

AIMS: To evaluate the efficacy of a unique healthy and happy lifestyle (HLS) program in regression of coronary atherosclerosis and reduction in cardiac events in an open trial. METHODS: One hundred and twenty three angiographically documented moderate to severe coronary artery disease (CAD) patients were administered HLS comprising of low-fat, high-fiber vegetarian diet, moderate aerobic exercise and stress-management through Rajyoga meditation. Its most salient feature was training in self-responsibility (heal+thy) and self-empowerment through inner-self consciousness (swasth; swa=innerself, sth=consciousness) approach using Rajyoga meditation. Following a seven day in-house sojourn, patients were invited for six month follow-up for reassessment and advanced training. At the end of two years, all patients were asked to undergo repeat angiography. RESULTS: Three hundred and sixty coronary lesions were analysed by two independent angiographers. In CAD patients with most adherence, percent diameter stenosis regressed by 18.23 +/- 12.04 absolute percentage points. 91% patients showed a trend towards regression and 51.4% lesions regressed by more than 10 absolute percentage points. The cardiac events in coronary artery disease patients were: 11 in most adherence, and 38 in least adherence over a follow-up period of 6.48 yrs. (risk ratio; most vs least adherence: 4.32; 95% CI: 1.69-11.705; P < 0.002). CONCLUSION: Overall healthy changes in cardiovascular, metabolic and psychological parameters, decline in absolute percent diameter coronary stenosis and cardiac events in patients of CAD were closely related to HLS adherence. However, more than 50% adherence is essential to achieve a significant change.

Echocardiography in acute coronary syndromes.

Echocardiography including 2 Dimensional, Color Doppler, Tissue Doppler Imaging, Myocardial Contrast Echocardiography, Strain and Strain rate, etc are the most powerful modalities for the assessment of myocardial performance in patients with established orsuspected acute coronary syndrome and acute myocardial infarction with a high accuracy, sensitivity and specificity. Dobutamine Stress Echocardiography has tremendous potential of evaluating microcirculation impairment especially in diagnosing the extent of myocardial damage, reversibility component at rest and at the peak levels of stress with appropriate drugs, mechanical (percutaneous coronary intervention) or surgical intervention. Echocardiography and its newer modalities are therefore, promising and valuable tools for assessment of myocardial perfusion in the setting of myocardial infarction. This article provides an overview of clinical evidence supporting the efficacy of echocardiography and its newer modalities in assessment of myocardial function and performance. Timely effective evaluation of acute coronary syndrome and myocardial infarction by echocardiography and its newer modalities may help in early diagnosis,prognositification and warrant specific therapeutic intervention, thereby help in reducing morbidity and mortality.

Bisoprolol and heart failure: new frontiers.

Clinical trials have consistently shown the benefits of beta-blocker treatment in patients with chronic heart failure (HF). As a result, bisoprolol, carvedilol, and metoprolol succinate are now indicated for the treatment of all patients with chronic HF who do not have major contraindications. In the Cardiac Insufficiency Bisoprolol Study II (CIBIS-II), all-cause mortality and sudden death were reduced in patients treated with bisoprolol when compared with those on placebo (11.8% vs. 17.3%; p < 0.0001 and 3.6% vs. 6.3%, p < 0.002; respectively) regardless of age, New York Heart Association (NYHA) functional class and co-morbidities. More recently, CIBIS-III has shown similar efficacy and safety of the initiation of HF treatment with either bisoprolol or enalapril, with a tendency to a survival advantage with bisoprolol. Nowadays, the role of bisoprolol, as well as that of carvedilol and metoprolol succinate, in HF treatment is firmly established and research is mainly focused on implementation of treatment and better dosing. This article will summarize evidence for the efficacy of bisoprolol in the treatment of HF.

Cardiological Society of India: Document on acute MI care during COVID-19.

The unprecedented and rapidly spreading Coronavirus Disease-19 (COVID-19) pandemic has challenged public health care systems globally. Based on worldwide experience, India has initiated a nationwide lockdown to prevent the exponential surge of cases. During COVID-19, management of cardiovascular emergencies like acute Myocardial Infarction (MI) may be compromised. Cardiological Society of India (CSI) has ventured in this moment of crisis to evolve a consensus document for care of acute MI. However, this care should be individualized, based on local expertise and governmental advisories.

Cardiological society of India document on safety measure during echo evaluation of cardiovascular disease in the time of COVID-19.

An echocardiographic investigation is one of the key modalities of diagnosis in cardiology. There has been a rising presence of cardiological comorbidities in patients positive for COVID-19. Hence, it is becoming extremely essential to look into the correct safety precautions, healthcare professionals must take while conducting an echo investigation. The decision matrix formulated for conducting an echocardiographic evaluation is based on presence or absence of cardiological comorbidity vis-à-vis positive, suspected or negative for COVID-19. The safety measures have been constructed keeping in mind the current safety precautions by WHO, CDC and MoHFW, India.

Diastolic heart failure: a clinical challenge early recognition & timely intervention is the need of the hour.

Diastolic Heart failure (DHF) is the major cause of morbidity and mortality all over the world. It is responsible for more than 50% of the heart failure cases. New onset of symptomatic DHF is a lethal disease with a 5-yr mortality of approximately 50%. DHF is also referred to as heart failure (HF) with normal left ventricular ejection fraction (LVEF)-HFNLVEF. The diagnosis of DHF requires the following criteria: (i) signs and symptoms of heart failure (ii) normal or mildly abnormal systolic left ventricular (LV) function (iii) evidence of LV diastolic dysfunction. Diagnostic evidence of LV diastolic dysfunction can be obtained invasively (LV end-diastolic pressure > 16 mmHg or mean pulmonary capillary wedge pressure > 12 mmHg) or non-invasively by tissue Doppler imaging (TDI) (E/E' > 15). If TDI yields an E/E' ratio suggestive of LV diastolic dysfunction (15 > E/E' > 8), then additional echo variables are required for diagnostic evidence of LV diastolic dysfunction, which include Doppler flow profile of mitral valve or pulmonary veins, measurement of LV mass index (LVMi) or left atrium volume index (LAVi), electrocardiographic evidence of atrial fibrillation or high levels of B-natreuretic peptide. Echo-Doppler techniques using LV filling pressures and tissue Doppler imaging of the mitral annulus help in identifying and classifying the degree of LV diastolic dysfunction. However, clinically this is more relevant to advanced overt disease. Therefore early recognition of DHF in relatively asymptomatic or less symptomatic patients with occult LV diastolic dysfunction is a real challenge. Recently it has been shown that reduction in left atrial strain and strain rate and increase in left atrial (LA) stiffness index has a high predictive value for detection of occult LV diastolic dysfunction. Thus early recognition of occult DHF and timely therapeutic intervention may help in prognostic stratification in DHF.