Greater COVID-19 Severity and Mortality in Hospitalized Patients in the Delta-phase Compared to the Others: A Single Center Prospective Registry.

BACKGROUND AND OBJECTIVE: To compare clinical and laboratory features, and outcomes in the second COVID-19 phase (delta variant) with the first and third phases in India we performed a registry-based study. METHODS: Patients with confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection were recruited over the study period from March 2020 to July 2022. In the first phase (wild type, March-December 2020) of the 7,476 suspected, 1,395 (18.7%) were positive and 863 (61.8%) were hospitalized, in the second phase (delta, January-July 2021) out of 8,680 suspected, 1,641 (19.4%) tested positive and 388 (23.6%) were hospitalized, and in the third phase (omicron, January-July 2022) out of 5,188 suspected patients, 886 (17.1%) tested positive and 94 (10.6%) were hospitalized. We compared details of admission clinical and laboratory features and in-hospital management and outcomes in the three phases. RESULTS: A total of 2,352 patients were recruited. The majority of the patients were men, aged <45 years were 20% and about 20% of patients had hypertension, diabetes, and cardiovascular diseases. Patients in the second phase had significantly more cough, fever, shortness of breath, and lower oxygen saturation (SpO2) at admission and also had more lymphopenia, C-reactive proteins (CRPs), interleukin-6, ferritin, lactic dehydrogenase, and transaminases than patients in the other two phases. In the second vs the first and third phases, the requirement of supplementary oxygen (47.9 vs 33.1 and 23.4%), proning (89.2 vs 37.1 and 5.3%), high flow nasal oxygen (15.7 vs 8.71 and 5.3%), noninvasive ventilation (14.4 vs 9.1 and 11.7%), invasive ventilation (16.2 vs 9.1 and 9.6%), steroids (94.1 vs 83.4 and 37.2%), remdesivir (91.2 vs 73.8 and 39.4%), and anticoagulants (94.3 vs 83.0 and 61.7%) was significantly more (p < 0.001). The median length of stay in days [interquartile range (IQR)] was longer in the second phase [8 (6-10)] vs the first [7 (5-10)] and the third phase [4 (3-6) days]. The intensive care unit (ICU) stay in the second phase [9 (5-13) days] was also significantly more than the first [6 (2-10)] and third [0 (0-3)] phases (p <0.001). Overall, in-hospital deaths occurred in 176 patients (12.8%). Deaths were significantly higher in the second phase (19.3%), compared to the first (11.0%) and the third (3.3%) phases (p <0.01). We also observed that greater disease severity at presentation was associated with higher mortality in all the phases. CONCLUSION: This study shows that COVID-19 patients that were hospitalized in the second (delta) phase of the epidemic had more severe disease compared to the first and third phases. In the second phase of patients, there was a significantly higher duration of hospitalization, ICU hospitalization, greater oxygen requirement, noninvasive and invasive ventilatory support, and more deaths.

Statins in Patients with Uncomplicated Hypertension: A Prescription Audit.

OBJECTIVE: Guidelines recommend prescription of statins in all high-risk patients with hypertension irrespective of their cholesterol levels. We performed a prescription audit in India to determine the application of recommendations. METHODS: A registry-based audit of patients with primary diagnosis of hypertension (n=3073) was performed. Details of co-morbidities and medications were obtained. Patients with known vascular disease were excluded. Patients were classified into subgroups based on risk factors and type of therapy. A multivariate model of risk was developed using clinical data and patients were classified into low, moderate and high risk. Statin prescriptions were divided into low, medium and high intensity based on US guidelines. Descriptive statistics are reported. RESULTS: Mean age of patients was 59±13 years, 47 % were women and 26 % were less than 50 years age. Diabetes was noted in 31.1 %, current smoking in 1.3 %, obesity in 14.7 % and hypothyroidism in 7.9 %. Statins were prescribed in 41.2 % (95% CI 39.4-42.9%), more in men compared to women (47.7% vs 33.7%, p<0.001). Most of the patients received moderate intensity statins (83.9%). In age-groups >40, 40-59, 60-79 and 80+ years, statins were prescribed in 18.7%, 36.5%, 49.5% and 49.4% respectively (ptrend <0.001). Statins were prescribed in 52.0% diabetics, 60.9% obese, 52.5% smokers and 34.8% hypothyroid. In the multivariate model statins use in low, medium and high risk patients was 28.4%, 46.6% and 55.1% respectively (ptrend <0.001). CONCLUSION: In an Indian secondary care practice only half of patients with moderate to high risk uncomplicated hypertension receive statins.

Resistant Hypertension in Clinical Practice in India: Jaipur Heart Watch.

BACKGROUND: Hypertension is highly prevalent in India but frequency of resistant hypertension has not been well studied. METHODS: We performed a registry-based study at a single center in patients with primary diagnosis of hypertension (n=3073). Details of co-morbidities, medications and blood pressure (BP) control were obtained. Patients with coronary heart disease, cerebrovascular disease and chronic kidney disease were excluded. Resistant hypertension was defined as uncontrolled hypertension (BP ≥140/90) with use of 3 drugs of which one was a diuretic, or any 4 drugs. RESULTS: Mean age of patients was 59±13 years, 47% were women and 26% <50y age. Diabetes was in 31.1%, hypothyroidism in 7.9% and chronic obstructive lung disease in 4.3%. The drugs prescribed were angiotensin converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARB) in 61.5%, beta blockers in 49.8%, dihydropyridine calcium channel blockers (CCB) in 46.8%, ARB in 44.4%, diuretics in 32.1% ACEi in 13.4%, other CCBs in 2.6% and mineralocorticoid receptor antagonists (MRA) in 1.1%. One antihypertensive drug was prescribed in 27.4%, two in 41.2%, three in 18.6% and four or more in 5.4%. Prevalence of resistant hypertension using standard definition was 19.4% (95% confidence interval, CI, 18.0-20.8%). It was more in women (23.5%) vs men (15.7%) (p<0.001). Using the alternate definition the prevalence was 6.3% (95% CI 5.3-7.0%) and also more in women (6.9%) vs men (5.4%). Resistant hypertension was more common in patients >60 years (odds ratio 1.36, 95% CI 1.18-1.58) and women (odds ratio 1.64, 95% CI 1.37-1.97). CONCLUSION: Prevalence of resistant hypertension is high in a secondary-care practice in India. It is significantly greater among older patients and women.

Urbanization, Human Development and Literacy and Syndemics of Obesity, Hypertension and Hyperglycemia in Rajasthan: National Family Health Survey-4.

OBJECTIVE: Non-communicable diseases (NCDs) are the new epidemic in India. District-specific prevalence of various NCD risk factors and their macrolevel determinants is unknown. We used National Family Health Survey-4 (NFHS-4) data to map the syndemics of obesity, hypertension and hyperglycemia in Rajasthan, the largest state of the country, and correlated their prevalence with selected social determinants of health- urbanization, human development index (HDI) and literacy. METHODOLOGY: Data on location-adjusted prevalence of various NCD risk factors among women (15-49y) and men (15-54y) were obtained from NFHS-4 data sheets. Heat maps were created to determine geographic distribution of obesity (body mass index, BMI ≥25 kg/m2), hypertension (known and/or BP ≥140/≥90 mmHg) and hyperglycemia (random glucose >140 mg/dl) in all the districts (n=33). We determined correlation of various social determinants with NCD risk factors. RESULTS: Significant geographic variation was observed in prevalence of obesity, hypertension and hyperglycemia in women and men. High prevalence of obesity and hypertension was observed in central and northwestern districts of the state. In women and men respectively, there was a significant positive correlation of obesity with urbanization (r=0.68, 0.51), HDI (r=0.70, 0.66) and female literacy (r=0.46, 0.34). Prevalence of hypertension also showed significant correlation with urbanization (r=0.18, 0.33), HDI (r=0.38, 0.52) and literacy (r=0.32, 0.21) while no correlation was observed with hyperglycemia. CONCLUSION: There is significant geographic variation in prevalence of obesity, hypertension and hyperglycemia in Rajasthan. Significant correlation of obesity and hypertension with urbanization, human development and female literacy is observed..

Smartphone-enabled retinal arteriovenous imaging and correlation with coronary SYNTAX score.

OBJECTIVE: To assess the feasibility of measurement of retinal arteriovenous (AV) ratio using a smartphone, we performed a comparative evaluation with fundus camera imaging and coronary SYNTAX score. METHOD: Successive coronary artery disease (CAD) patients who underwent coronary angiography were recruited for smartphone retinal imaging. Following pupillary dilatation, fundus camera images and smartphone photography were performed. Video images were captured with a smartphone, edited and analysed. Retinal artery and vein size at 0.5 and 1 disc diameter (DD) were measured using DICOM software by two independent observers. Another observer calculated SYNTAX score. RESULTS: Analysable smartphone images were available in 91 (89.2%) of 102 patients. Tobacco use was found in 26%, hypertension in 54%, diabetes in 55%, and high LDL cholesterol in 50%. Median and 25-75 interquartile range (IQR) AV ratio at 0.5 and 1.0 DD, respectively, with smartphone were 0.48 (0.45-0.52) and 0.47 (0.45-0.52) and fundus camera were 0.48 (0.44-0.53) and 0.48 (0.45-0.53) (Spearman's correlation 0.80 and 0.79, p < 0.001). Coronary single vessel disease was in 21%, double vessel in 16%, triple vessel in 55%, normal angiogram in 8%, and median SYNTAX score was 18.0 (8.0-25.0). There was an inverse correlation of SYNTAX score with smartphone-derived AV ratio at 0.5 and 1.0 DD (rho -0.27,p = 0.007 and -0.26,p = 0.009) as well as with fundus camera (rho -0.37 and -0.38, p < 0.001). Trend-analysis showed an inverse association of smartphone AV ratio with increasing CAD (ptrend <0.001). CONCLUSIONS: Smartphone-based retinal AV imaging is feasible and comparable to fundus-camera imaging. There is a significant inverse correlation with coronary angiographic severity.

Association of health insurance status with coronary risk factors, coronary artery disease, interventions and outcomes in India.

Objective: Coronary artery disease (CAD) related hospitalization and interventions are associated with catastrophic out-of-pocket health expenditure in India. To evaluate differences in risk factors, disease severity, management and outcomes in uninsured vs insured CAD patients we performed a study. Methods: Successive CAD patients who underwent percutaneous intervention (PCI) at our centre were enrolled from January 2018 to June 2021. Clinical, angiographic and intervention data were periodically uploaded in the American College of Cardiology CathPCI platform. Descriptive statistics are reported. Results: 4672 CAD patients (men 3736, women 936) were included; uninsured were 2166 (46%), government insurance was in 1635 (36%) and private insurance in 871 (18%). Mean age was 60.1 ± 11 years, uninsured <50y were 21.6% vs 14.0% and 20.3% with government and private insurance. Among the uninsured prevalence of raised total and non-HDL cholesterol, any tobacco use, ST-elevation myocardial infarction (STEMI) and ejection fraction <30% were more (p < 0.01). In the STEMI group (n = 1985), rates of primary PCI were the highest in those with private insurance (38.7%) compared to others. Multivessel stenting (≥2 stents) was more among the insured patients. Median length of hospital stay was similar in the three groups. In-hospital mortality was slightly more in the uninsured (1.43%), compared to government (0.88) and privately insured (0.82) (p = 0.242). The cost of hospitalization and procedures was the highest among uninsured (US$ 2240, IQR 1877-2783) compared to government (US$ 1977, IQR 1653-2437) and privately insured (US$ 2013, IQR 1668-2633) (p < 0.001). Conclusions: Uninsured CAD patients in India are younger with more risk factors, acute coronary syndrome, STEMI, multivessel disease and coronary stenting compared to those with government or private insurance. The uninsured bear significantly greater direct costs with slightly greater mortality.

Macrolevel association of COVID-19 with non-communicable disease risk factors in India.

BACKGROUND & AIMS: Greater COVID-19 related mortality has been reported among persons with various non-communicable diseases (NCDs). We performed an ecological study to determine the association of state-level cases and deaths with NCD risk factors and healthcare and social indices. METHODS: We obtained cumulative national and state-level data on COVID-19 cases and deaths from publicly available database www.covid19india.org from February to end November 2020. To identify association with major NCD risk factors, NCDs, healthcare related and social variables we obtained data from public sources. Association was determined using univariate and multivariate statistics. RESULTS: More than 9.5 million COVID-19 cases and 135,000 deaths have been reported in India towards end of November 2020. There is significant positive correlation (Pearson r) of state-level COVID-19 cases and deaths per million, respectively, with NCD risk factors- obesity (0.64, 0.52), hypertension (0.28, 0.16), diabetes (0.66, 0.46), NCD epidemiological transition index (0.58, 0.54) and ischemic heart disease mortality (0.22, 0.33). Correlation is also observed with indices of healthcare access and quality (0.71, 0.61), urbanization (0.75, 0.73) and human (0.61, 0.56) and sociodemographic (0.70, 0.69) development. Multivariate adjusted analyses shows strong correlation of COVID-19 burden and deaths with NCD risk factors (r2 = 0.51, 0.43), NCDs (r2 = 0.32, 0.16) and healthcare (r2 = 0.52, 0.38). CONCLUSIONS: COVID-19 disease burden and mortality in India is ecologically associated with greater state-level burden of NCDs and risk factors, especially obesity and diabetes.

Low quality cardiovascular care is important coronary risk factor in India.

Global Burden of Disease study has reported that cardiovascular and ischemic heart disease (IHD) mortality has increased by 34% in last 25 years in India. It has also been reported that despite having lower coronary risk factors compared to developed countries, incident cardiovascular mortality, cardiovascular events and case-fatality are greater in India. Reasons for the increasing trends and high mortality have not been studied. There is evidence that social determinants of IHD risk factors are widely prevalent and increasing. Epidemiological studies have reported low control rates of hypertension, hypercholesterolemia, diabetes and smoking/tobacco. Registries have reported greater mortality of acute coronary syndrome in India compared to developed countries. Secondary prevention therapies have significant gaps. Low quality cardiovascular care is an important risk factor in India. Package of interventions focusing on fiscal, intersectoral and public health measures, improvement of health services at community, primary and secondary healthcare levels and appropriate referral systems to specialized hospitals is urgently required.

Evaluation of statin prescriptions in type 2 diabetes: India Heart Watch-2.

BACKGROUND: Contemporary treatment guidelines advise statin use in all patients with diabetes for reducing coronary risk. Use of statins in patients with type 2 diabetes has not been reported from India. METHODS: We performed a multisite (n=9) registry-based study among internists (n=3), diabetologists (n=3), and endocrinologists (n=3) across India to determine prescriptions of statins in patients with type 2 diabetes. Demographic and clinical details were obtained and prescriptions were audited for various medications with a focus on statins. Details of type of statin and dosage form (low, moderate, and high) were obtained. Patients were divided into categories based on presence of cardiovascular risk into low (no risk factors, n=1506), medium (≥1 risk factor, n=5425), and high (with vascular disease, n=1769). Descriptive statistics are presented. RESULTS: Prescription details were available in 8699 (men 5292, women 3407). Statins were prescribed in 55.2% and fibrates in 9.2%. Statin prescription was significantly greater among diabetologists (64.4%) compared with internists (n=53.3%) and endocrinologists (46.8%; p<0.001). Atorvastatin was prescribed in 74.1%, rosuvastatin in 29.2%, and others in 3.0%. Statin prescriptions were lower in women (52.1%) versus men (57.2%; p<0.001) and in patients aged <40 years (34.3%), versus those aged 40-49 (49.7%), 50-59 (60.1%), and ≥60 years (62.2%; p<0.001). Low-dose statins were prescribed in 1.9%, moderate dose in 85.4%, and high dose in 12.7%. Statin prescriptions were greater in the high-risk group (58.0%) compared with those in the medium-risk (53.8%) and low-risk (56.8%) groups (p <0.001). High-dose statin prescriptions were similar in the high-risk (14.5%), medium-risk (11.8%), and low-risk (13.5%) groups (p=0.31). CONCLUSIONS: Statins are prescribed in only half of the clinic-based patients in India with type 2 diabetes. Prescription of high-dose statins is very low.