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), ?-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 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.

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.

Intracardiac mass lesions: experience of 14 cases.

Mass lesions within the heart are often encountered during routine echocardiography. The nature of such masses can generally be suspected depending upon clinical setting. During 13 years of our experience in echo lab, we came across 14 patients with large intracardiac masses (some of them, rare type). Clinical features, echocardiographic findings and histopathological confirmation which was possible in majority of them, are described. Five of our patients had cardiac tumour (myxoma), four had large intracavitary thrombus, while pieces from two patients were demonstrated to have large vegetations and hydatid cyst(s). One patient, suspected to have vegetation on mitral valve, turned out to have thick myxomatous tissue deposits on histopathology. Two-dimensional echocardiographic features of intracardiac mass lesion are generally dependable in deciding nature of such lesions. However, very large thrombus and vegetation mimicking cardiac tumour are rarely encountered.

Cardiac arrhythmias in aluminium phosphide poisoning studied by on continuous holter and cardioscopic monitoring.

Variable incidences of cardiac arrhythmias (based on isolated 12 lead ECG records) have been reported in patients of aluminium phosphide (ALP) poisoning. We did continuous holter and cardioscopic monitoring in ICU in 30 patients of acute ALP poisoning. Supraventricular and ventricular ectopics were recorded in each and every patient. Life threatening ventricular tachycardia was recorded in 40% cases and ventricular fibrillation in 23.3% cases. Supraventricular tachycardia and atrial flutter/fibrillation occurred in 46.7% and 20% patients, respectively. ST-T changes simulating myocardial ischaemia were also present in all patients (S-T depression in 90%, S-T elevation in 10%). One-third of the patients developed variable degrees of heart block, IV amiodarone/xylocard could revert dangerous ventricular arrhythmias to sinus rhythm in 4 cases. Toxic myocarditis produced by phosphine seems to be responsible for the development of these arrhythmias.

Profile of young acute myocardial infarction in Harayana.

Profile of acute myocardial infarction (AMI) in young patients (below 40 years) was studied in a rural/semi-urban population. Out of the total 338 patients who were admitted to ICCU over a period of one year, 65 (19.2%) were aged 40 years or below (Range 14-40 years). Male:female ratio was 20:1. Majority of these young patients were thinly built, engaged in heavy physical work and belonged to lower socio-economic group. Smoking was the most common risk factor (87%); other risk factors were few. Majority of these young patients ignored chest pain and reported late to the hospital. However, despite this, incidence of complications/mortality was less in comparison to their older counterparts. The overall mortality was only 6% as compared to 21% in older age group. The study focuses our attention to the rising incidence of AMI in young individuals even in populations least prone to ischaemic heart disease. Smoking was the only modifiable risk factor which needs to be curbed with full force.

The changing profile of Plasmodium falciparum malaria.

Resurgence of malaria has been noted in the Rohtak district (Haryana, India) after the recent floods. The profile of 66 patients of P. falciparum infection who were admitted to our hospital over one month in October 1995 is reported. While only a minority of cases (< 15%) presented with an uncomplicated course, all others developed one or more complication(s), some of them very rare. The usual manifestations viz, cerebral malaria, black water fever and algid malaria seen in the past were observed in less than half the patients. The remaining presented with unusual complications like haemolytic anaemia (46.2%), severe anaemia (37.9%), thrombocytopaenia (18.2%), pancytopaenia (6%), adult respiratory distress syndrome (4.5%) often not seen in sporadic cases of falciparum malaria which occurred in the past in this district. Similarly all deaths (15.1%) were noted in patients with rarer manifestations and only one patient died of cerebral malaria. This study confirms the occurrence of severe and complicated falciparum malaria in this part of the country.

Interpretation of treadmill stress test in patients with coronary artery disease receiving beta blocker therapy.

Graded maximal treadmill exercise responses were studied before and after beta blockade (atenolol 100 mg once daily for 2 weeks) in 20 male patients with chronic stable angina. Beta-blocking effect consisted of significant reduction of resting heart rate (HR) by 21%, systolic blood pressure (SBP) by 12% and rate pressure product (RPP) by 30%. While the maximum exercise capacity was marginally increased by mean 1.7 min +/- 1.6 SD (P less than 0.001) under the influence of therapy, peak HR, SBP and maximum RPP were significantly lower (P less than 0.001) than in preatenolol exercise tests. Similarly, while the configuration and magnitude of ST segment depression did not differ materially between the pre and post atenolol tests, onset time of ST change was delayed and offset time shortened significantly. These parameters cannot be relied upon to assess the extent and severity of coronary artery disease (CAD) if stress test is carried out while the patient is on a beta-blocking drug. The overall sensitivity of the stress test to detect coronary disease is, however, not likely to be compromised because of negligible influence of beta-blockers upon ST segment depression provided maximally tolerated (not submaximal) exercise is performed. ST/HR slope, an exercise test variable known to correlate well with the extent of CAD, was shown to be uninfluenced by beta-blockade. Its measurement is therefore recommended in interpreting stress tests performed in patients receiving beta-blocker therapy. This, however, requires a meticulously prepared protocol of recording computer averaged QRST complexes and multilead ECG tracings at very frequent intervals throughout the exercise.(ABSTRACT TRUNCATED AT 250 WORDS)

DC cardioversion and coronary artery spasm.

Marked ST segment elevation which occurred following DC shock given for conversion of lone atrial fibrillation in a 55 years old male is reported. This was possibly coronary artery spasm induced by direct current and adds one more complication to the many already described.

Comparative efficacy of atenolol and labetalol in essential hypertension--a double blind cross over trial.

In a double blind cross-over drug trial, antihypertensive effects (resting and after dynamic exercise) of atenolol and of labetalol were studied in 20 patients of mild to moderate essential hypertension. Both drugs exhibited almost equal antihypertensive response, and were well tolerated. Haemodynamic variables (HR, SBP, DBP and RPP), both at rest and after maximal tread mill exercise, were significantly altered (P less than 0.001) by both drugs. Exercise capacity was observed to be marginally improved by atenolol. Although the antihypertensive effect, when compared between the two drugs, was not statistically significant, individual suitability or comparison revealed a preference for atenolol in 17 patients and for labetalol in 3 patients.