The collateral damage of COVID-19 to cardiovascular services: a meta-analysis.

AIMS: The effect of the COVID-19 pandemic on care and outcomes across non-COVID-19 cardiovascular (CV) diseases is unknown. A systematic review and meta-analysis was performed to quantify the effect and investigate for variation by CV disease, geographic region, country income classification and the time course of the pandemic. METHODS AND RESULTS: From January 2019 to December 2021, Medline and Embase databases were searched for observational studies comparing a pandemic and pre-pandemic period with relation to CV disease hospitalisations, diagnostic and interventional procedures, outpatient consultations, and mortality. Observational data were synthesised by incidence rate ratios (IRR) and risk ratios (RR) for binary outcomes and weighted mean differences for continuous outcomes with 95% confidence intervals. The study was registered with PROSPERO (CRD42021265930). A total of 158 studies, covering 49 countries and 6 continents, were used for quantitative synthesis. Most studies (80%) reported information for high-income countries (HICs). Across all CV disease and geographies there were fewer hospitalisations, diagnostic and interventional procedures, and outpatient consultations during the pandemic. By meta-regression, in low-middle income countries (LMICs) compared to HICs the decline in ST-segment elevation myocardial infarction (STEMI) hospitalisations (RR 0.79, 95% confidence interval [CI] 0.66-0.94) and revascularisation (RR 0.73, 95% CI 0.62-0.87) was more severe. In LMICs, but not HICs, in-hospital mortality increased for STEMI (RR 1.22, 95% CI 1.10-1.37) and heart failure (RR 1.08, 95% CI 1.04-1.12). The magnitude of decline in hospitalisations for CV diseases did not differ between the first and second wave. CONCLUSIONS: There was substantial global collateral CV damage during the COVID-19 pandemic with disparity in severity by country income classification.

Chlorthalidone vs Hydrochlorothiazide for Hypertension-CV Events: Did the Design Influence the Outcome?

The Diuretic Comparison Project (DCP)1 was a real world study planned to evaluate in a pragmatic manner whether Chlorthalidone (CTD), as compared with Hydrochlorothiazide (HCTZ), would reduce the risk of major nonfatal cardiovascular disease outcomes in elderly hypertensive participants (≥65 years) who were receiving HCTZ (25 or 50 mg) at baseline. This study being a real world study lacks the robustness of a randomized controlled trial. The principle limitation being unequal exposure of the two diuretics, prolonged unknown duration of exposure to HCTZ vs a short exposure to CTD (Median 2.4 years). In the high risk population with history of MI/Stroke, CTD conferred a lower risk of primary outcome as compared to low risk population where no significant difference in outcome was seen in both diuretics. Other factors included, lack of established dose equivalency of the two diuretics and absence of use of 12.5 mg HCTZ in older hypertensives. How to cite this article: Pareek A, Messerli FH, Ram CVS. Chlorthalidone vs Hydrochlorothiazide for Hypertension-CV Events: Did the Design Influence the Outcome? J Assoc Physicians India 2023;71(10):93-93.

Multifaceted highly targeted sequential multidrug treatment of early ambulatory high-risk SARS-CoV-2 infection (COVID-19).

The SARS-CoV-2 virus spreading across the world has led to surges of COVID-19 illness, hospitalizations, and death. The complex and multifaceted pathophysiology of life-threatening COVID-19 illness including viral mediated organ damage, cytokine storm, and thrombosis warrants early interventions to address all components of the devastating illness. In countries where therapeutic nihilism is prevalent, patients endure escalating symptoms and without early treatment can succumb to delayed in-hospital care and death. Prompt early initiation of sequenced multidrug therapy (SMDT) is a widely and currently available solution to stem the tide of hospitalizations and death. A multipronged therapeutic approach includes 1) adjuvant nutraceuticals, 2) combination intracellular anti-infective therapy, 3) inhaled/oral corticosteroids, 4) antiplatelet agents/anticoagulants, 5) supportive care including supplemental oxygen, monitoring, and telemedicine. Randomized trials of individual, novel oral therapies have not delivered tools for physicians to combat the pandemic in practice. No single therapeutic option thus far has been entirely effective and therefore a combination is required at this time. An urgent immediate pivot from single drug to SMDT regimens should be employed as a critical strategy to deal with the large numbers of acute COVID-19 patients with the aim of reducing the intensity and duration of symptoms and avoiding hospitalization and death.

Hypertension epidemiology in India: emerging aspects.

PURPOSE OF REVIEW: Hypertension is the most important noncommunicable disease risk factor in India with an estimated burden of 200 million persons. Nationwide studies and meta-analyses have reported increasing prevalence. We summarize unique features of hypertension in India. RECENT FINDINGS: Two recent nationwide studies to determine hypertension prevalence have been performed-Fourth National Family Health Survey and Fourth District Level Health Survey/Annual Health Survey. Age-adjusted hypertension was more in men (24.5%) than women (20.0%). Hypertension is more common in developed states of the country, urban populations and better socioeconomic status individuals. Urban-rural convergence and greater hypertension in younger men and women are unique findings. There is low status of its awareness, treatment and control. Diabetes prevalence is high in hypertension suggesting importance of insulin resistance. Prevalence of resistant hypertension is high. Pharmacoepidemiology studies have reported widespread use of all classes of antihypertensive drugs with increasing use of renin-angiotensin system blockers. There are limited studies focused on genetic epidemiology. SUMMARY: Hypertension is widely prevalent in India with large regional variation, greater prevalence in urban areas and the young. Treatment and control status are low. Diabetes is important comorbidity and resistant hypertension is frequent. There is widespread use of newer antihypertensive drugs.

Fixed-dose triple-combination treatments in the management of hypertension.

Hypertension remains uncontrolled in approximately 50% of patients with hypertension, which increases the risk of cardiovascular morbidity and mortality in these individuals. A key factor contributing to poor blood pressure (BP) control is nonadherence to prescribed antihypertensive medications. Improving patient adherence to antihypertensive therapy is the key to improving BP goal attainment. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) recommend a stepwise treatment algorithm for patients with stage 1 hypertension, with initial treatment consisting of a single antihypertensive drug. For most patients, however, combinations of 2 or more antihypertensive agents are necessary for adequate BP control. Antihypertensive regimens that combine agents from different antihypertensive drug classes can facilitate attainment of BP goals and improve cardiovascular outcomes at lower drug doses compared with monotherapy. Patient adherence to antihypertensive therapy decreases with increasing number of pills in multiple pill regimens, but fixed-dose triple-combination treatments for hypertension provide a tool for addressing patient nonadherence associated with pill burden. For patients whose antihypertensive therapy includes multiple medications, the use of a single-pill, fixed-dose combination therapy can significantly improve compliance and thereby help patients achieve BP goals. In addition, single-pill combinations may reduce health care utilization and medical costs compared with multiple single-pill therapies. The purpose of this article is to review the role of novel single-pill, fixed-dose, triple-combination treatments for modern hypertension management.

Therapeutic Usefulness of a Novel Calcium Channel Blocker Azelnidipine in the Treatment of Hypertension: A Narrative Review.

The prevalence of hypertension and comorbidities such as metabolic syndrome, diabetes mellitus, and chronic kidney disease in India is alarmingly high. Amlodipine, an older-generation calcium channel blocker (CCB), is currently the gold standard for hypertension management in India. However, it has several disadvantages, including reflex tachycardia and pedal edema. Therefore, an effective antihypertensive agent that does not cause these adverse effects and provides end-organ protection is required for the holistic management of hypertension in the country. Azelnidipine is a new-generation CCB that has recently been approved for the treatment of hypertension in India. This review provides an overview of the utility of azelnidipine for hypertension control, including comparisons with traditional CCBs such as amlodipine. It discusses the key antihypertensive effects of azelnidipine as well as its advantages in the prevention of tachycardia and associated complications. In addition, this review highlights the extensive cardio- and renoprotective activities of azelnidipine, including its effects on systolic and diastolic function and urinary albumin excretion. Overall, this substantial body of evidence supports the use of azelnidipine for the treatment of hypertension, especially in India. It suggests that the adoption of azelnidipine as the new gold standard CCB could help India battle its hypertension epidemic.

Achieving the Latest American Heart Association and American College of Cardiology Therapeutic Goals for Hypertension With Combination Therapy and Its Effects on Blood Pressure and Central Hemodynamic Parameters.

The present United States and European treatment guidelines recommend that antihypertensive therapy be initiated with a combination of agents from different classes to facilitate the achievement of control of blood pressure (BP). This prospective, randomized, open-label study was conducted at 3 tertiary hospitals in India to evaluate the effects of combination therapy with an angiotensin receptor blocker and a calcium antagonist on office BP and central hemodynamic parameters in patients with untreated hypertension or uncontrolled BP (>130/>80 mm Hg) during treatment with antihypertensive monotherapy. Patients were randomized to treatment with telmisartan 40 mg/day + amlodipine 5 mg/day or telmisartan 40 mg/day + cilnidipine 10 mg/day. Change from baseline to 8 weeks of treatment was assessed for seated office BP, ambulatory BP monitoring, and seated central hemodynamics (central BP, aortic augmentation index, central aortic augmentation pressure, and pulse wave velocity). A total of 94 of 96 enrolled patients completed the study. From baseline to 8 weeks a significant decrease was observed in both telmisartan + amlodipine and telmisartan + cilnidipine groups for mean BP (148.0 ± 12.80 to 124.0 ± 10.4 and 144.5 ± 10.2 to 123.0 ± 10.0 mm Hg, respectively; both p <0.001); in only telmisartan + amlodipine group for mean central aortic systolic and diastolic BP (131.1 ± 19.1 to 119.7 ± 14.9 mm Hg [p <0.001] and 93.3 ± 12.0 to 89.2 ± 14.6 mm Hg [p = 0.0008], respectively) and for central aortic pulse wave velocity (7.6 ± 1.4 to 7.2 ± 1.3 m/s, p = 0.0011); in only telmisartan + cilnidipine group for aortic augmentation index (27.5 ± 14.6 to 22.3 ± 12.2; p = 0.0178). Heart rate was unchanged in both treatment groups. Combination therapy with an angiotensin receptor blocker and a calcium antagonist effectively reduced BP to below the new <130/80 mm Hg target and had favorable effects on central hemodynamics.

Management of American Heart Association/American College of Cardiology-Defined Stage 2 Hypertension by Cardiologists in India.

Uncontrolled hypertension is an important cardiovascular risk factor and therefore requires effective approaches to patient management. This study assessed approaches to the management of patients with Stage 2 hypertension by cardiologists in India. This was a retrospective, multicenter, observational, case-based questionnaire study. Data on demographic characteristics, risk factors associated with Stage 2 hypertension, use of antihypertensive medications, side effects, and approaches to education for 2,540 patients were extracted from questionnaire responses provided by 508 cardiologists. The study population of patients with Stage 2 hypertension had a mean age of 55.0 years. Most of the patients (62.6%) were aged 30 to 60 years and diabetes mellitus was the most prevalent comorbidity (48.9%). Triple antihypertensive therapy was being used by 760 patients, and 634 and 1,146 patients were receiving 4 and 5 different antihypertensive medications, respectively. Telmisartan, amlodipine, chlorthalidone, hydrochlorothiazide, spironolactone, metoprolol, and prazosin were the commonly prescribed drugs. Ankle edema (27.7%) was the most frequent side effect of therapy. Pharmacotherapy was supported by patient education and lifestyle modifications for better blood pressure control. The standardized approach to the collection and assessment of these contemporary data provides useful insights into the characteristics and treatment of patients with Stage 2 hypertension in India.

Correlation Between Ambulatory Blood Pressure Monitoring and Office Blood Pressure Measurement in Patients with Hypertension: A Community Study.

BACKGROUND: The current gold standard for blood pressure (BP) measurements is based on office BP measurements (OBPMs) by a sphygmomanometer or a digital device. Ambulatory BP measurement (ABPM) is a noninvasive method for continuous monitoring of BP over a period during routine activities of the patient. Thus, ABPM offers multiple BP readings during the patients' daily routine as compared to the single reading by OBPM at rest. A good correlation exists between mean 24-hour BP readings and the prediction of cardiovascular events. The present multicenter observational study was aimed to assess the correlation between ABPM and OBPM in patients with newly diagnosed, controlled, or uncontrolled hypertension in the community setting. Our hypothesis was to test if ABPM provides any further value in those hypertensive patients in whom the office blood pressure levels are controlled. A supplementary hypothesis was whether obtaining ABPM in patients with newly diagnosed or uncontrolled hypertension yields any value over and beyond OBPM. Another objective was to find out the applicability of ABPM in the community setting where the medical care is provided by primary care family physicians and not by specialists. MATERIALS AND METHODS: Materials and Methods A total of 1000 patients were analysed for this study. Those with controlled hypertension were assigned to Group A, and those with newly diagnosed/untreated hypertension comprised Group B. Group A was followed up during Visit 2 and Group B was followed up during Visit 2 and either Visit 3 or Visit 4 to assess the BP measurements by ABPM and OBPM. RESULTS: The correlation between ABPM and OBPM showed minimal variation in the BP readings of Group A subjects at Visit 2. A variation in BP readings was observed in Group B at Visit 2. Furthermore, the correlation was established between ABPM and OBPM noted for Group B subjects during Visit 3, and minimal variation was noted during Visit 4. CONCLUSIONS: Conclusions A good correlation was observed between ABPM and OBPM during both visits in patients in Groups A and B. However, a notable variation was noted in the diastolic BP readings. Thus, large-scale clinical studies are required to detect the prevalence of hypertension, masked hypertension, and dipping patterns associated with hypertension and other related medical co-morbidities.

Risk factors predisposing to acute stroke in India: a prospective study.

BACKGROUND: Stroke is an important neurological disorder with significant morbidity and mortality. In India, the risk factors for stroke (obesity, diabetes mellitus, alcoholism, hypertension, and sedentary lifestyle) are mounting with economic growth and increasing the disease burden. OBJECTIVE: To assess the severity and risk factors of stroke in India and identify any new predisposing factors. METHODS: A multicentric (six tertiary care hospitals across India) prospective observational study (from September 2016 to July 2017) was conducted on 526 stroke patients, presenting within the first 24 h to examine the risk factors for ischemic and hemorrhagic strokes. Severity was determined using the National Institutes of Health Stroke Scale (NIHSS). RESULTS: Predominantly male (72.3%), 75% of the sample was >50 years old, with a mean body mass index (BMI) of 25.8 ±â€Š4.3 kg/m2 and 14.6% obese patients. Hypertension and diabetes mellitus were the commonest comorbidities, followed by a history of ischemic heart disease and familial history of stroke. 20.5% of patients had mild strokes, 57.4% had moderate, 8.4% experienced moderate-severe strokes, whereas 7.2% had severe strokes. Regarding the admission diagnoses, 56.8% were ischemic, 18.6% were hemorrhagic, 1.1% had a transient ischemic attack, 6.6% suffered recurrent strokes, and 17% were other forms. CONCLUSION: The foremost risk factors for stroke in India, hypertension and diabetes, need to be controlled and treated like other global high-risk populations for stroke prevention. The NIHSS scores highlight the relationship between risk factors and stroke severity.

The evolving definition of systemic arterial hypertension.

Systemic hypertension is an important risk factor for premature cardiovascular disease. Hypertension also contributes to excessive morbidity and mortality. Whereas excellent therapeutic options are available to treat hypertension, there is an unsettled issue about the very definition of hypertension. At what level of blood pressure should we treat hypertension? Does the definition of hypertension change in the presence of co-morbid conditions? This article covers in detail the evolving concepts in the diagnosis and management of hypertension.

Central aortic blood pressure assessment and cardiovascular risk.

Peripheral brachial blood pressure measurements may not provide an accurate representation of degenerative changes that characterize cardiovascular disease. Evidence is mounting that antihypertensive treatment strategies with apparently similar effects on brachial blood pressure may have different effects on central aortic pressure, which in turn may lead to overestimation or underestimation of therapeutic efficacy. The relative importance of central and brachial blood pressure for predicting cardiovascular risk and clinical outcomes has been examined in several clinical studies. These studies have reported that a large proportion of individuals considered to have normal blood pressure values based on brachial systolic pressures had high-normal blood pressure based on central aortic pressure measurements. As additional evidence suggesting the superiority of central aortic pressure over peripheral assessments becomes more abundant, measurement of central aortic pressure may be the next important advancement in the management of hypertension.