Frailty and outcomes in heart failure patients from high-, middle-, and low-income countries.

BACKGROUND AND AIMS: There is little information on the incremental prognostic importance of frailty beyond conventional prognostic variables in heart failure (HF) populations from different country income levels. METHODS: A total of 3429 adults with HF (age 61 ± 14 years, 33% women) from 27 high-, middle- and low-income countries were prospectively studied. Baseline frailty was evaluated by the Fried index, incorporating handgrip strength, gait speed, physical activity, unintended weight loss, and self-reported exhaustion. Mean left ventricular ejection fraction was 39 ± 14% and 26% had New York Heart Association Class III/IV symptoms. Participants were followed for a median (25th to 75th percentile) of 3.1 (2.0-4.3) years. Cox proportional hazard models for death and HF hospitalization adjusted for country income level; age; sex; education; HF aetiology; left ventricular ejection fraction; diabetes; tobacco and alcohol use; New York Heart Association functional class; HF medication use; blood pressure; and haemoglobin, sodium, and creatinine concentrations were performed. The incremental discriminatory value of frailty over and above the MAGGIC risk score was evaluated by the area under the receiver-operating characteristic curve. RESULTS: At baseline, 18% of participants were robust, 61% pre-frail, and 21% frail. During follow-up, 565 (16%) participants died and 471 (14%) were hospitalized for HF. Respective adjusted hazard ratios (95% confidence interval) for death among the pre-frail and frail were 1.59 (1.12-2.26) and 2.92 (1.99-4.27). Respective adjusted hazard ratios (95% confidence interval) for HF hospitalization were 1.32 (0.93-1.87) and 1.97 (1.33-2.91). Findings were consistent among different country income levels and by most subgroups. Adding frailty to the MAGGIC risk score improved the discrimination of future death and HF hospitalization. CONCLUSIONS: Frailty confers substantial incremental prognostic information to prognostic variables for predicting death and HF hospitalization. The relationship between frailty and these outcomes is consistent across countries at all income levels.

Prevalence and predictors of lower extremity atherosclerotic disease amongst high-risk patients using ankle brachial index.

INTRODUCTION: The prevalence of lower extremity artery disease (LEAD) continues to increase worldwide. This is expected to translate into logarithmic rise in lower-limb amputations especially in the developing world. Majority of patients suffering from LEAD remain asymptomatic until late and are vulnerable to limb-threatening complications unless actively screened and treated. METHODS: This was a prospective, single-center, observational study to determine the prevalence and predictors of LEAD. Patients with known atherosclerotic vascular disease (but not known LEAD) or those at risk were enrolled. All underwent ankle brachial index (ABI) measurement as per the standard protocol. A threshold of ABI ≤0.90 was taken to diagnose LEAD. RESULTS: A total of 1000 patients were enrolled. The mean age of the group was 61.4 ± 10.0 years and the prevalence of LEAD was 10.2%. Amongst those who had LEAD, the majority of patients (69.6%) had no symptoms. The prevalence of LEAD in diabetic population in our study was 13.2% and it was 30.9% in coronary artery disease patients . Factors independently linked to LEAD on regression analysis included advanced age, presence of diabetes, smoking history, lower serum HDL and a lower ejection fraction. CONCLUSIONS: The vast majority of patients suffering from LEAD are asymptomatic. Early diagnoses and institution of appropriate medical and physical therapy can prevent excess morbidity and mortality due to LEAD. Factors independently linked to LEAD are advanced age, presence of diabetes, smoking history, lower serum HDL and a lower ejection fraction. The presence of either of these should signal undertaking of appropriate steps to unmask underlying LEAD.

Clinical profile of patients with cardiac amyloidosis in India.

Limited data exists on patients with cardiac amyloidosis (CA) in India, due to underdiagnosis and late presentation. We present single centre data from 13 patients over a 4 year period with a median age of 65 years. A majority presented with symptomatic heart failure (69%) and eight patients had confirmed AL amyloidosis. At the end of the follow up period, 46% patients died, with 30% of the overall cohort dead within six months. Among the survivors, 71% continue to have NYHA grade III/IV symptoms. A suggested algorithm for earlier diagnosis in resource constrained settings is also presented.

Role of handgrip strength testing in pre-anaesthetic check-up: A prospective cross-sectional study.

Background and Aims: Frailty has been known to be associated with postoperative adverse events and longer hospital length of stay (LOS). Hand grip strength (HGS) is one of the parameters of measuring frailty. The aim of the study was to correlate preoperative handgrip strength and 30-day outcome of patients undergoing major abdominal surgery. It also aimed to evaluate the role of the standard preoperative variables like metabolic equivalents, revised cardiac risk index (RCRI), serum albumin, and serum creatinine along with their association with HGS testing in determining the postoperative outcome in surgical patients. Material and Methods: This prospective observational study included 149 American Society of Anesthesiologists class III/IV patients presenting for major abdominal surgery. A mean of three measurements of dominant HGS using Camry hand dynamometer was measured. The patients were divided into groups: weak, normal, and strong depending on grip strength. Patients were followed for 30 days and postoperative outcome in terms of ventilatory support, admission to intensive care unit, cardiac complications, in-hospital mortality, and LOS were recorded. Observational data obtained were reported as mean value and analyzed using Student's t-test or Wilcoxon/Mann-Whitney Rank test. Associations between RCRI, serum albumin, and LOS with HGS were evaluated using logistic regression. Results: The hospital LOS was significantly longer in patients with weak HGS (15.11 ± 11.03 days versus 10 ± 5.71 days, P = 0.001). Patients with weak HGS had significantly lower mean serum albumin levels compared to normal HGS (P = 0.0001) and a statistically significant RCRI score (P = 0.013). Conclusion: HGS can be used as a preoperative test in predicting hospital LOS after major surgery.

Effect of anti-platelet therapy on peri-operative blood loss in patients undergoing off-pump coronary artery bypass grafting.

Purpose: The purpose of this study was to review the effect of the pre-operative use of clopidogrel and aspirin on peri-operative bleeding, blood product transfusion, and resource utilization after coronary artery bypass grafting (CABG). Materials and Methods: A total of 1200 patients who underwent off-pump CABG (OPCABG) between 2010 and 2012 were retrospectively studied. Patients were divided into three groups: group 1: discontinued aspirin and clopidogrel 6 days prior to surgery (n = 468), group 2: discontinued both drugs 3 to 5 days prior to surgery (n = 621), and group 3: discontinued both drugs 2 days prior to surgery (n = 111). The bleeding pattern and blood product transfusion were studied and compared between the groups. Patients having history of other drugs affecting the coagulation profile, other organ dysfunction, on-pump CABG, and the combined procedure were excluded from the study. Results: Group 2 patients had a higher rate of bleeding and a reduced mean value of hemoglobin (Hb) as compared to other groups. The same results were seen in blood and blood product transfusion. Patients of group 2 and group 3 were associated with higher blood loss in terms of drainage at 12 and 24 hours. Post-operatively, this was statistically significant. Re-exploration was statisitically significant in group 3 patients (9.01%) than in group 2 (2.58%) and group 1 (1.07%) patients. Conclusion: The pre-operative use of clopidogrel and aspirin in patients undergoing OPCABG showed limited clinical benefits; however, its use significantly increased the risk of bleeding and blood transfusion, thus increasing morbidity and resource utilization. Hence, clopidogrel and aspirin should be stopped at least 6 days prior to surgery.

Assessment of Bleeding in Patients on Antiplatelets Undergoing Dental Implants.

Introduction: Antiplatelet drugs are used for the secondary prevention of cardiac and cerebrovascular diseases. Clopidogrel and Aspirin are the most commonly prescribed drugs for these patients. Physicians and dentists have to weigh bleeding risks versus thrombotic risks in interrupting antiplatelet regimen. The balance of these risks for an individual patient is the primary consideration in management of dental patients who are taking antiplatelet drugs and require dental implants. The study was undertaken to assess the risk of bleeding in patients on single and dual antiplatelets undergoing dental implants. Materials and method: 65 patients were assessed for bleeding after placement of dental implants. They were divided into 2 groups: group I included 48 patients on single antiplatelets (Aspirin) and group II included 17 patients on dual antiplatelets (Aspirin and Clopidogrel) based upon the timing of coronary intervention. Bleeding was evaluated intra-operatively and post-operatively. Results: Significant difference in bleeding was noted between group I and group II based on the Visual Analog Scale (VAS) for bleeding severity after implant placement both intra-operatively (P = 0.000) and post-operatively (P = 0.004) within 24 h. However, post-operative complication after 24 h was non-significant (P = 0.277). Conclusion: Dental implants can be safely placed in patients on single antiplatelet drugs without discontinuing them. In patients on dual antiplatelets, risk of bleeding is mild to moderate if the drugs are continued. Consultation with treating cardiologist is a must before any kind of dental invasive surgery in patients on antiplatelets.

Prolapsing giant right atrial myxoma in a young male presenting as pulmonary embolism.

A 22-year male presented with complaints of dyspnea. Multimodality imaging revealed a polypoidal right atrial mass with submassive pulmonary embolism. The patient underwent urgent surgery. The pathological examination confirmed it as cardiac myxoma. Cardiac myxoma, a most common primary cardiac tumor, is commonly found in the left atrium. The right atrium is an uncommon site and the usual mode of presentation is the tumor or thrombus embolization to the pulmonary circulation.

Real world data on clinical profile, management and outcomes of venous thromboembolism from a tertiary care centre in India.

OBJECTIVES: Venous thromboembolism (VTE) is a major cause of mortality and morbidity worldwide. This study describes a real-world scenario of VTE presenting to a tertiary care hospital in India. METHODS: All patients presenting with acute VTE or associated complications from January 2017 to January 2020 were included in the study. RESULTS: A total of 330 patient admissions related to VTE were included over 3 years, of which 303 had an acute episode of VTE. The median age was 50 years (IQR 38-64); 30% of patients were younger than 40 years of age. Only 24% of patients had provoked VTE with recent surgery (56%) and malignancy (16%) being the commonest risk factors. VTE manifested as isolated DVT (56%), isolated pulmonary embolism (PE; 19.1%), combined DVT/PE (22.4%), and upper limb DVT (2.3%). Patients with PE (n = 126) were classified as low-risk (15%), intermediate-risk (55%) and high-risk (29%). Reperfusion therapy was performed for 15.7% of patients with intermediate-risk and 75.6% with high-risk PE. In-hospital mortality for the entire cohort was 8.9%; 35% for high-risk PE and 11% for intermediate-risk PE. On multivariate analysis, the presence of active malignancy (OR = 5.8; 95% CI: 1.1-30.8, p = 0.038) and high-risk PE (OR = 4.8; 95% CI: 1.6-14.9, p = 0.006) were found to be independent predictors of mortality. CONCLUSION: Our data provides real-world perspectives on the demographic sand management of patients presenting with acute VTE in a referral hospital setting. We observed relatively high mortality for intermediate-risk PE, necessitating better subclassification of this group to identify candidates for more aggressive approaches.

Cardiothoracic surgery during COVID-19: Our experience with different strategies.

Background: An acute respiratory disease (COVID-19), caused by a novel coronavirus (SARS-CoV-2,), has been declared a pandemic by WHO. A surgery on COVID-19 patients not only involves a risk of spread of the disease but also there is a serious concern for the patient's surgical outcomes and resources requirement. Aim: The retrospective study is aimed to provide a protocol for pre-operative testing of SARS CoV-2 using RT-PCR in the patient undergoing cardio-thoracic surgeries. Material and Methods: To analyze the impact of pre-operative testing of SARS- CoV-2 using RT-PCR in the patient undergoing elective cardio-thoracic surgeries. The patient who underwent surgical interventions during the COVID-19 lockdown period was divided into two phases. Phase I (without COVID-19 RT-PCR testing) and Phase II (with pre-operative COVID-19 RT-PCR testing). The retrospective comparison between the two study groups was done using Student t-test, Mann-Whitney U, and Chi square (χ2) test depending upon the clinical variable to be analyzed. Results: During the early phase (phase I), 26 patients underwent cardio-thoracic surgery without COVID-19 RT-PCR test. Whereas, during phase II, all patients were tested for COVID-19 using RT-PCR, preoperatively and a total of 64 surgeries were performed during this phase. One patient planned for CABG was positive on RT-PCR for COVID-19 and was sent to the quarantine ward. The difference in the pre-operative hospital stay between two groups was found to be statistically significant and a significant decrease in the number of PPE kits used, during the phase I. Conclusion: All asymptomatic patients should be tested for COVID-19 using RT-PCR prior to cardio-thoracic surgeries not only to contain the disease but to avoid potential implications of COVID-19 on the perioperative course, without added financial implications.

Yoga-Based Cardiac Rehabilitation After Acute Myocardial Infarction: A Randomized Trial.

BACKGROUND: Given the shortage of cardiac rehabilitation (CR) programs in India and poor uptake worldwide, there is an urgent need to find alternative models of CR that are inexpensive and may offer choice to subgroups with poor uptake (e.g., women and elderly). OBJECTIVES: This study sought to evaluate the effects of yoga-based CR (Yoga-CaRe) on major cardiovascular events and self-rated health in a multicenter randomized controlled trial. METHODS: The trial was conducted in 24 medical centers across India. This study recruited 3,959 patients with acute myocardial infarction with a median and minimum follow-up of 22 and 6 months. Patients were individually randomized to receive either a Yoga-CaRe program (n = 1,970) or enhanced standard care involving educational advice (n = 1,989). The co-primary outcomes were: 1) first occurrence of major adverse cardiovascular events (MACE) (composite of all-cause mortality, myocardial infarction, stroke, or emergency cardiovascular hospitalization); and 2) self-rated health on the European Quality of Life-5 Dimensions-5 Level visual analogue scale at 12 weeks. RESULTS: MACE occurred in 131 (6.7%) patients in the Yoga-CaRe group and 146 (7.4%) patients in the enhanced standard care group (hazard ratio with Yoga-CaRe: 0.90; 95% confidence interval [CI]: 0.71 to 1.15; p = 0.41). Self-rated health was 77 in Yoga-CaRe and 75.7 in the enhanced standard care group (baseline-adjusted mean difference in favor of Yoga-CaRe: 1.5; 95% CI: 0.5 to 2.5; p = 0.002). The Yoga-CaRe group had greater return to pre-infarct activities, but there was no difference in tobacco cessation or medication adherence between the treatment groups (secondary outcomes). CONCLUSIONS: Yoga-CaRe improved self-rated health and return to pre-infarct activities after acute myocardial infarction, but the trial lacked statistical power to show a difference in MACE. Yoga-CaRe may be an option when conventional CR is unavailable or unacceptable to individuals. (A study on effectiveness of YOGA based cardiac rehabilitation programme in India and United Kingdom; CTRI/2012/02/002408).

A rational approach to manage surgical procedures in COVID Era - A perspective based on experience in a private referral hospital.

BACKGROUND AND AIMS: COVID-19 disease has imposed challenges in caring for non-Covid elective surgical patients. As elective surgeries become essential, we propose to evaluate our approach and outcomes of surgical procedures performed during the initial period of COVID-19 pandemic so as to provide a road-map for safer approach. MATERIAL AND METHODS: We retrospectively evaluated outcomes in patients who underwent essential elective and emergency surgeries during the 5-week period between April 18, 2020 and May 28, 2020. All patients were screened at the front desk on their arrival to identify possible exposure to SARS- CoV-2. Nasopharyngeal swab of patients requiring hospital admission was tested for COVID-19 by quantitative RT-PCR. Patients needing essential elective surgery were taken up for surgery if they tested negative for COVID-19. Emergency procedures were undertaken in a demarcated theatre for COVID after taking level-3 protection without delay. The clinical data was reviewed and analysed. RESULTS: A total of 764 surgical procedures were conducted, of which 70.7% were elective essential surgeries, with 95.4% of these patients being discharged in stable healthy condition. Approximately 23% of the elective and 26% of the emergency surgeries was categorised in the surgical difficulty category III and majority of these were performed under general anesthesia. Postoperative mortality was 1.04%, but the overall mortality rate was approximately 2.5%. Only two patients (0.3%) tested positive for COVID-19 in our series. CONCLUSION: A robust preoperative screening and testing can enable safe scheduling of essential elective surgeries.

Unusual case of intraoperative acute cor pulmonale during spine surgery.

Perioperative complications of prolonged surgery and prone positioning are well known. Changing the position from prone to supine in an anesthetized patient can result in aspiration and airway obstruction. The drop-in oxygen saturation and hemodynamic changes are warning signs and can cause acute cardiac decompensation leading to diagnostic dilemma. We present a case where the patient had these changes after changing the position after spine surgery in prone position. A quick response from the treating anesthesiologist and active involvement of cardiologist helped in reaching the diagnosis and successful management of aspiration pneumonitis in this patient. We conclude that a quick response in investigations and multimodality approach helps in the management of such perioperative complications.

The Prevalence, Clinical Spectrum and the Long Term Outcome of ST-segment Elevation Myocardial Infarction in Young - A Prospective Observational Study.

INTRODUCTION: Incidence of coronary artery disease at the younger age is rising. We studied the prevalence, clinical spectrum and long term outcome of ST-segment elevation myocardial infarction in young. MATERIAL AND METHODS: This is a prospective observational study, performed at a tertiary care center from January 2015 to June 2016. Of the total 977 consecutive patients with ST segment elevation myocardial infarction (STEMI), 130 patients aged ≤45 years were included. All patients were followed-up for at least 1-year from the index admission. RESULTS: The overall prevalence of STEMI among younger patients was 12.8%. There was male dominance (96.8%). Smoking (37.6%) was observed to be the most common risk factor for young STEMI, followed by diabetes mellitus (16.8%) and hypertension (16%). Younger patients with acute MI had preponderance to anterior wall (68.8%), single-vessel disease (50%) and left anterior descending artery being the culprit lesion (67.3%). Near normal/normal coronary arteries were observed in 12.9% of cases. The most commonly used management strategy was mechanical revascularisation (43.2%), followed by thrombolysis (28.8%) and medical management (28%). The overall mortality and combined MACCE rates at 1 year were 3.2% and 18.4% respectively. Outcome was better in patients who received mechanical revascularization/thrombolysis than those who received medical management only, with a lower MACCE rates (hazard ratio: 0.36; 95% CI: 0.16-0.8, p = 0.01. CONCLUSION: The young MI patients are unique in having male dominance, better outcome, more of single-vessel disease with significant number of normal coronaries, better response to mechanical as well as pharmacological revascularization.

Early onset ACS: An age based clinico-epidemiologic and angiographic comparison.

BACKGROUND AND AIMS: Acute coronary syndrome (ACS) in the very young is a rare entity, with limited data. We aimed to study patterns and profile of ACS in patients aged 20-30 years in comparison with those above 30 years. METHODS: In this retrospective record-based study, the demographic and clinical profile of all patients with ACS in the last 12 years (n = 35259) was analysed: group I (20-30 years) and group II (above 30 years). Patients in group II were selected by systematic sampling. Age, gender, domicile, body mass index (BMI), serum cholesterol, smoking, alcohol use, drug abuse, diabetes, hypertension, family history, type of ACS, angiographic findings and management strategies were recorded. Chi-square test and Fischer's exact test were used for data analysis. RESULTS: Of 35,259 patients, 0.32% (n = 114) were from the younger age group, with a rising trend of prevalence over 12 years. Obesity, overweight, urban living, smoking, alcohol and drug abuse were significantly higher in group I (p < 0.05). Diabetes mellitus and hypertension were more prevalent in group II (p = 0.001). STEMI in group I (76.3%) and NSTEMI in group II (47.1%) were the common modes of presentation (p = 0.001). 42.1% of group I patients had recanalized coronaries with conservative management in comparison to 3% in group II (p = 0.001). CONCLUSIONS: There is a rising trend in prevalence of ACS in very young patients. Overweight, obesity, urbanization and drug abuse are potential risk factors. The younger subset of ACS patients is different from the older population due to their thrombotic milieu, which could be more amenable to intensive pharmacologic management.

Trend in prevalence of coronary artery disease and risk factors over two decades in rural Punjab.

OBJECTIVES: The burden of coronary artery disease (CAD) has increased in the last three decades in low-income and middle-income countries including India. CAD is responsible for 20% deaths in India. The burden of CAD has increased due to a higher prevalence of risk factors related to the changing lifestyle. We studied the change in prevalence of CAD and risk factors over 20 years in a rural area. METHODS: A rural population of adults over the age of 30 years from three villages of Punjab was surveyed for the prevalence of CAD and its risk factors in 1994 and 2014 using similar research methodology. CAD was diagnosed by Epstein and clinical criteria. Blood pressure, anthropometry, ECG and biochemical analysis were carried out. The findings of two surveys were compared with a look at the change in the prevalence of CAD and its risk factors over 20 years. RESULTS: The overall age standardised prevalence of CAD increased from 2.79% in 1994 to 4.06% (p<0.05) in 2014. There was a significant increase in the prevalence of several risk factors including sedentary lifestyle (8.2% vs 41.3%, p<0.001), hypertension (14.5% vs 26.5%, p<0.001), diabetes (4.7% vs 9.7%, p<0.001), obesity (16.6% vs 35.4, p<0.001) and hypercholesterolaemia (7% vs 9.6%, p 0.011). In contrast, cigarette smoking (8.9% vs 3%, p<0.001) and use of desi ghee (51.4% vs 28.5%, p<0.001) decreased. CONCLUSIONS: In a rural population of Punjab, the prevalence of several CAD risk factors like sedentary lifestyle, hypertension, diabetes, obesity and hypercholesterolaemia increased over 20 years. These changes in risk factors were associated with a modest increase in prevalence of CAD.

Outcome of patients supported by extracorporeal membrane oxygenation for aluminum phosphide poisoning: An observational study.

INTRODUCTION: Aluminum phosphide (AlP) poisoning has a high mortality rate despite intensive care management, primarily because it causes severe myocardial depression and severe acute respiratory distress syndrome. The purpose of this study was to evaluate the impact of the novel use of extracorporeal membrane oxygenation (ECMO), a modified "heart-lung" machine, in a specific subset of AlP poisoning patients who had profound myocardial dysfunction along with either severe metabolic acidosis and/or refractory cardiogenic shock. METHODS: Between January 2011 and September 2014, 83 patients with AlP poisoning were enrolled in this study; 45 patients were classified as high risk. The outcome of the patients who received ECMO (n=15) was compared with that of patients who received conventional treatment (n=30). RESULTS: In the high-risk group (n=45), the mortality rate was significantly (p<0.001) lower in patients who received ECMO (33.3%) compared to those who received conventional treatment (86.7%). Compared with the conventional group, the average hospital stay was longer in the ECMO group (p<0.0001). In the ECMO group, non-survivors had a significantly (p=0.01) lower baseline LV ejection fraction (EF) and a significantly longer delay in presentation (p=0.01). CONCLUSION: Veno-arterial ECMO has been shown to improve the short-term survival of patients with AlP poisoning having severe LV myocardial dysfunction. A low baseline LVEF and longer delay in hospital presentation were found to be predictors of mortality even after ECMO usage. Large, adequately controlled and standardized trials with long-term follow-up must be performed to confirm these findings.

Gender bias in cardiovascular healthcare of a tertiary care centre of North India.

OBJECTIVES: To analyse the gender bias in paediatric patients referred for free cardiac treatment as part of School Health Programme at a tertiary care centre in North India. METHODS: A total of 537 children were referred for further management of congenital heart disease or rheumatic heart disease. Of these, 519 underwent cardiac intervention, and the data from their records were analysed retrospectively to determine any gender disparity in the utilisation of cardiac surgery. RESULTS: Of the 519 children studied, only 195 (37.6%) were girls, while the remaining 324 (62.4%) were boys (male-to-female ratio of 1.66:1, p<0.0001), indicating a large gender divide. Gender bias was found to be prevalent across all the age groups irrespective of the type of cardiac ailment. Moreover, no statistically significant difference was found between the urban and rural populations (male-to-female ratio of 1.64:1 in rural and 1.71:1 in urban populations; p=0.823) in terms of gender disparity. CONCLUSIONS: Significant gender discrepancies exist in healthcare-seeking behaviour of patients in North India despite the provision of free cardiac treatment. An equal prevalence of gender bias in urban and rural communities points towards deep-rooted social norms beyond just the economic constraints. Healthcare policies ensuring equal treatment of male and female children should be promulgated to ensure a complete eradication of this social evil.