Facilitators and barriers of heart failure care in Kerala, India: A qualitative analysis of health-care providers and administrators

Objective Heart failure is a leading cause of death worldwide and in India, yet the qualitative data regarding heart failure care are limited. To fill this gap, we studied the facilitators and barriers of heart failure care in Kerala, India. Methods and results During January 2018, we conducted a qualitative study using in-depth, semi-structured interviews with 21 health-care providers and quality administrators from 8 hospitals in Kerala to understand the context, facilitators, and barriers of heart failure care. We developed a theoretical framework using iteratively developed codes from these data to identify 6 key themes of heart failure care in Kerala: (1) need for comprehensive patient and family education on heart failure; (2) gaps between guideline-directed clinical care for heart failure and clinical practice; (3) national hospital accreditation contributing to a culture of systematically improving quality and safety of in-hospital care; (4) limited system-level attention toward improving heart failure care compared with other cardiovascular conditions; (5) application of existing personnel and technology to improve heart failure care; and (6) longitudinal and recurrent costs as barriers for optimal heart failure care. Conclusions Key themes emerged regarding heart failure care in Kerala in the context of a health system that is increasingly emphasizing health-care quality and safety. Targeted in-hospital quality improvement interventions for heart failure should account for these themes to improve cardiovascular outcomes in the region.

Prevalence of vitamin B12 deficiency among individuals with type 2 diabetes mellitus in a South Indian rural community

Background: To estimate the prevalence of vitamin B12 deficiency in a rural south Indian community and to evaluate the association between metformin use and prevalent vitamin B12 deficiency in people with T2DM stratified by oral vitamin B12 supplementation.Methods: Using a cross sectional study design, a random sample of people with T2DM (N=438) was recruited from a rural community. Vitamin B12 deficiency was defined as serum B12 ?200pg/ml. Data on metformin dose, duration of use, oral vitamin B12 supplementation, and diet were collected. Laboratory measurements included complete blood count, tests for hepatic, renal, and thyroid function, as well as serum vitamin B12 levels and HbA1c.Results: The prevalence of vitamin B12 deficiency in people with T2DM was 11.2% (95% Confidence Interval (CI) 8.2%-14.1%). The odds of vitamin B12 deficiency in patients receiving a metformin dose of 2 grams/day were 4 times higher compared to those receiving ?1 gram/day, after adjusting for oral B12 supplementation (odds ratio 4.2;95% CI 1.5-11.8). The odds of vitamin B12 deficiency in those taking metformin and receiving oral vitamin B12 supplementation were lower compared to those on metformin and not receiving vitamin B12 supplementation (adjusted odds ratio 0.20; 95% CI 0.06-0.70).Conclusions: Vitamin B12 deficiency affects 1 in 10 people with T2DM, is associated with higher dose metformin use, and oral vitamin B12 supplementation mitigates B12 deficiency in this group.

Association between anthropometry, cardiometabolic risk factors, & early life factors & adult measures of endothelial function: Results from the New Delhi Birth Cohort.

Background & objectives: Abnormal endothelial function represents a preclinical marker of atherosclerosis. This study was conducted to evaluate associations between anthropometry, cardiometabolic risk factors, and early life factors and adult measures of endothelial function in a young urban Indian cohort free of clinical cardiovascular disease. Methods: Absolute changes in brachial artery diameter following cuff inflation and sublingual nitroglycerin (400 μg) were recorded to evaluate endothelium-dependent and -independent measures of endothelial function in 600 participants (362 men; 238 women) from the New Delhi Birth Cohort (2006-2009). Data on anthropometry, cardiometabolic risk factors, medical history, socio-economic position, and lifestyle habits were collected. Height and weight were recorded at birth, two and 11 yr of age. Age- and sex-adjusted linear regression models were developed to evaluate these associations. Results: The mean age of participants was 36±1 yr. Twenty two per cent men and 29 per cent women were obese (BMI > 30 kg/m2). Mean systolic blood pressure (SBP) was 131±14 and 119±13 mmHg, and diabetes prevalence was 12 and 8 per cent for men and women, respectively. Brachial artery diameter was higher for men compared with women both before (3.48±0.37 and 2.95±0.35 cm) and after hyperaemia (3.87±0.37 vs. 3.37±0.35 cm). A similar difference was seen before and after nitroglycerin. Markers of increased adiposity, smoking, SBP, and metabolic syndrome, but not early life anthropometry, were inversely associated with endothelial function after adjustment for age and sex. Interpretation & conclusions: The analysis of the current prospective data from a young urban Indian cohort showed that cardiometabolic risk factors, but not early life anthropometry, were associated with worse endothelial function.

Cardiovascular Research Publications from Latin America between 1999 and 2008. A Bibliometric Study / Publicações de Pesquisas Cardiovasculares da América Latina entre 1999 e 2008. Um Estudo Bibliométrico

Background: Cardiovascular research publications seem to be increasing in Latin America overall. Objective: To analyze trends in cardiovascular publications and their citations from countries in Latin America between 1999 and 2008, and to compare them with those from the rest of the countries. Methods: We retrieved references of cardiovascular publications between 1999 and 2008 and their five-year post-publication citations from the Web of Knowledge database. For countries in Latin America, we calculated the total number of publications and their citation indices (total citations divided by number of publications) by year. We analyzed trends on publications and citation indices over time using Poisson regression models. The analysis was repeated for Latin America as a region, and compared with that for the rest of the countries grouped according to economic development. Results: Brazil (n = 6,132) had the highest number of publications in1999-2008, followed by Argentina (n = 1,686), Mexico (n = 1,368) and Chile (n = 874). Most countries showed an increase in publications over time, leaded by Guatemala (36.5% annually [95%CI: 16.7%-59.7%]), Colombia (22.1% [16.3%-28.2%]), Costa Rica (18.1% [8.1%-28.9%]) and Brazil (17.9% [16.9%-19.1%]). However, trends on citation indices varied widely (from -33.8% to 28.4%). From 1999 to 2008, cardiovascular publications of Latin America increased by 12.9% (12.1%-13.5%) annually. However, the citation indices of Latin America increased 1.5% (1.3%-1.7%) annually, a lower increase than those of all other country groups analyzed. Conclusions: Although the number of cardiovascular publications of Latin America increased from 1999 to 2008, trends on citation indices suggest they may have had a relatively low impact on the research field, stressing the importance of considering quality and dissemination on local research policies. .

Fundamento: As publicações sobre pesquisa cardiovascular parecem estar crescendo na América Latina em geral. Objetivo: Analisar as tendências nas publicações cardiovasculares e suas citações de países na América Latina entre 1999 e 2008, e compará-las àquelas dos demais países. Métodos: Recuperamos, a partir da base de dados Web of Knowledge, as referências de publicações cardiovasculares entre 1999 e 2008 e as suas citações cinco anos após publicação. Para os países da América Latina, calculamos o número total de publicações e seus índices de citação (número total de citações dividido pelo número de publicações) por ano. Analisamos as tendências das publicações e dos índices de citação ao longo do tempo usando modelos de regressão de Poisson. A análise foi repetida para a América Latina como região e comparada àquela para os demais países agrupados de acordo com o desenvolvimento econômico. Resultados: O Brasil (n = 6.132) apresentou o mais alto número de publicações no período 1999-2008, seguindo-se Argentina (n = 1.686), México (n = 1.368) e Chile (n = 874). A maioria dos países apresentou elevação do número de publicações ao longo do tempo, principalmente Guatemala (36,5% anual [IC 95%: 16,7%-59,7%]), Colômbia (22,1% [16,3%-28,2%]), Costa Rica (18,1% [8,1%-28,9%]) e Brasil (17,9% [16,9%-19,1%]). No entanto, as tendências dos índices de citação variaram muito, de -33,8% a 28,4%. De 1999 a 2008, as publicações cardiovasculares na América Latina aumentaram em 12,9% (12,1%-13,5%) por ano. Entretanto, os índices de citação da América Latina aumentaram 1,5% (1,3%-1,7%) por ano, um aumento menor do que aqueles dos demais grupos de países analisados. Conclusões: Embora o número de publicações cardiovasculares da América Latina tenha aumentado de 1999 a 2008, tendências nos índices de citação sugerem que elas possam ter tido um impacto relativamente baixo na área de pesquisa, reforçando a importância de se considerar a qualidade e a disseminação ...

Review of multinational human subjects research: experience from the PHFIEmory Center of Excellence partnership.

Public Health Foundation of India (PHFI), New Delhi, India and Emory University, Atlanta, USA, are lead partners in the National Heart, Lung and Blood Institute/UnitedHealth funded Center of Excellence (COE) in Cardio-metabolic Risk Reduction in South Asia which provides a vehicle for the development of collaborative research projects. With funding from the National Institutes of Health/ Fogarty International Center, a project was commenced to ensure seamless, thorough and efficient review of this collaborative research. The primary activities of the project are: 1) fact-finding activities which included conduct of a case study and review of policies and procedures of the involved ethics review committees (ERCs); 2) training workshops for COE ERC members and staff and 3) piloting of parallel review of continuing reviews and amendments. A process of parallel review of collaborative research has now been initiated and projects are now submitted simultaneously to the Emory institutional review board (IRB) and PHFI institutional ethics committee (IEC).

Integrating mental health into cardiovascular disease research in India.

Mental health refers to a diverse field where individuals can cope with daily stress, realize their potential and maintain a state of well-being. In recent years, there has been increasing recognition of the influence of mental health on general health, and in particular on cardiovascular diseases and their risk factors. Epidemiological research has focused on several psychosocial components including social determinants, comorbid psychiatric disorders, psychological stress, coping styles, social support, burden on the family, well-being, life satisfaction, personality and cognitive factors in connection with cardiovascular diseases. There is epidemiological research in India that integrates mental health with common cardiovascular diseases such as coronary health disease and stroke. Data from mental health research is sufficiently compelling to highlight the role of chronic stress, socioeconomic status and psychiatric disorders such as depression, substance use, social networks and support in relation to vulnerability to cardiovascular diseases. There are psychosocial consequences of cardiovascular diseases including deficits in the domains of life skills, coping skills and neurocognition, in addition to caregiver burden. The implications of bio-psychosocial models of assessments and interventions that target complex individual and contextual variables simultaneously on cardiovascular treatment outcomes have highlighted the importance of studying mental health in Indian settings. Integration of mental health into mainstream research is the need of the hour. A multidimensional approach to accomplish this is required including at the level of research conceptualization, discussions with key stakeholders, at the policy level, at the institutional level, and at the clinical and community level.

Impact of comprehensive cardiovascular risk reduction programme on risk factor clustering associated with elevated blood pressure in an Indian industrial population.

Background & objectives: Cardiovascular risk factors clustering associated with blood pressure (BP) has not been studied in the Indian population. This study was aimed at assessing the clustering effect of cardiovascular risk factors with suboptimal BP in Indian population as also the impact of risk reduction interventions. Methods: Data from 10543 individuals collected in a nation-wide surveillance programme in India were analysed. The burden of risk factors clustering with blood pressure and coronary heart disease (CHD) was assessed. The impact of a risk reduction programmme on risk factors clustering was prospectively studied in a sub-group. Results: Mean age of participants was 40.9 ± 11.0 yr. A significant linear increase in number of risk factors with increasing blood pressure, irrespective of stratifying using different risk factor thresholds was observed. While hypertension occurred in isolation in 2.6 per cent of the total population, co-existence of hypertension and >3 risk factors was observed in 12.3 per cent population. A comprehensive risk reduction programme significantly reduced the mean number of additional risk factors in the intervention population across the blood pressure groups, while it continued to be high in the control arm without interventions (both within group and between group P<0.001). The proportion of ‘low risk phenotype’ increased from 13.4 to 19.9 per cent in the intervention population and it was decreased from 27.8 to 10.6 per cent in the control population (P<0.001). The proportion of individuals with hypertension and three more risk factors decreased from 10.6 to 4.7 per cent in the intervention arm while it was increased from 13.3 to 17.8 per cent in the control arm (P<0.001). Interpretation & conclusions: Our findings showed that cardiovascular risk factors clustered together with elevated blood pressure and a risk reduction programme significantly reduced the risk factors burden.

Genomic approaches to coronary artery disease.

Coronary artery disease (CAD) is a leading cause of death and disability worldwide. In addition to lifestyle and environmental factors which are major aetiologic determinants, there is considerable familial clustering of the disease indicating a genetic component in its causation. Although the total genetic contribution to CAD risk can be quantified, the determination of the size and number of contributing effects is impossible without identifying all CAD susceptibility genes. However, despite extensive studies, strong evidence of a molecular genetic association with coronary artery disease or myocardial infarction remains elusive. Genome wide association studies have been successful in identifying robust associations of single nucleotide polymorphisms (SNP) with CAD. Identifying the causal variant and dissecting pathways linking these variants to disease process is a major challenge. Technologies from whole genome sequencing, proteomics, transcriptomics and metabolomics are now available to extend analysis to a more complete range of potential susceptibility variants, and to support more explicit modelling of the joint effects of genes and environment. The availability of these high throughput technologies does not diminish the importance of rigorous phenotyping and appropriate study designs in all the endeavours to understand the aetiopathogenesis of CAD. Combining classical epidemiology with modern genomics will require collaborative efforts within the cardiovascular disease community at both bench and bedside and this will have the potential to expand our understanding of CAD and translate discoveries into clinically useful applications that will have a major impact on public health.

Coronary heart disease in Indians: Implications of the INTERHEART study.

Coronary heart diseases (CHD) have reached epidemic proportions among Indians. The recently concluded INTWERHEART study emphasizes the role of behavioural and conventional risk factors in the prediction of CHD risk among Indians. These findings have implication for the health care providers and policy makers in the country due to the fact that all these conventional risk factors are potentially modifiable and are good starting points for prevention. The policy measures by means of legislation and regulatory approaches on agriculture and food industry or tobacco or physical activity will have large impact on CHD risk factor reduction in the population. In addition, the health system needs to focus on: (i) providing information for increasing awareness and an enabling environment for adoption of healthy living habits by the community; (ii) early detection of persons with risk factors and cost-effective interventions for reducing risk; and (iii) early detection of persons with clinical disease and cost-effective secondary prevention measures to prevent complications. The evidence from INTERHEART provides rationale for developing treatment algorithms and treatment guidelines for CHD at various levels of health care. In addition, INTERHEART provides answer for the quest for a single reliable biomarker, Apo B/ApoA 1 ratio that can predict the future CHD risk among individuals. Further to this, the INTERHEART study also opens up several unanswered questions on the pathobiology of the premature onset of myocardial infarction among Indians and calls for the need to developing capacity in clinical research in CHD in India.

Heart failure: Epidemiology and prevention in India.

Reliable estimates of heart failure are lacking in India because of the absence of a surveillance programme to track incidence, prevalence, outcomes and key causes of heart failure. Nevertheless, we propose that the incidence and prevalence rates of heart failure are rising due to population, epidemiological and health transitions. Based on disease-specific estimates of prevalence and incidence rates of heart failure, we conservatively estimate the prevalence of heart failure in India due to coronary heart disease, hypertension, obesity, diabetes and rheumatic heart disease to range from 1.3 to 4.6 million, with an annual incidence of 491 600–1.8 million. The double burden of rising cardiovascular risk factors and persistent ‘pretransition’ diseases such as rheumatic heart disease, limited healthcare infrastructure and social disparities contribute to these estimates. Staging of heart failure, introduced in 2005, provides a framework to target preventive strategies in patients at risk for heart failure (stage A), with structural disease alone (B), with heart failure symptoms (C) and with end-stage disease (D). Policy-level interventions, such as regulations to limit salt and tobacco consumption, are effective for primordial prevention and would have a wider impact on prevention of heart failure. Clinical preventive interventions and clinical quality improvement interventions, such as treatment of hypertension, atherosclerotic disease, diabetes and acute decompensated heart failure are effective for primary, secondary and even tertiary prevention.

Paraoxonase gene Q192R & L55M polymorphisms in Indians with acute myocardial infarction & association with oxidized low density lipoprotein.

Background & objectives: Paraoxonase (PON) is an HDL associated ester hydrolase with an ability to retard LDL oxidation in vitro by preventing lipid peroxide generation. The population variability in enzyme activity is attributed to polymorphisms in paraoxonase gene. For example, polymorphism at codon 192 and 55 of the paraoxonase gene has been reported to be associated with coronary heart disease (CAD) and diabetes among different ethnic groups. The present study looks at PON192 and 55 polymorphism among hospitalized Asian Indian patients with myocardial infarction (MI) and their association with circulating oxidized LDL and antioxidant status. Methods: One hundred and twenty four consecutive patients of acute myocardial infarction and 221 age-matched controls were recruited for the study. Oxidized LDL was measured in serum by ELISA and total antioxidant levels by the 2,2’-azino-bis-(3 ethyl benzothiozoline-6-sulfonate) (ABTS) method. Other known cardiovascular risk factors, apolipoprotein B, apolipoproteinA1, lipoprotein(a), hsCRP and homocysteine were also measured. Paraoxonase gene polymorphism at codon 192 and 55 were analyzed by PCR-RFLP. Results: Patients with MI had significantly higher oxidized LDL (P<0.05) and lower total antioxidant capacity (P<0.001) as compared to controls. Oxidized LDL correlated with total cholesterol, LDL and Apo B in patients. B allele frequency of the codon 192 polymorphism in paraoxonase gene was higher in cases as compared to controls and odds ratio of developing the MI with BB genotype versus AA genotype was 2.37, (P=0.044). Codon 55 polymorphism in paraoxonase gene was not associated with CAD. There was no difference in oxidized LDL between the different genotypes of PON192 and PON55. Interpretation & conclusions: Although PON192 polymorphism was associated with CAD, no correlation of PON192 or 55 polymorphism was found with oxidized LDL suggesting that presence of other antioxidant factors may be of equal importance in preventing LDL oxidation.

Improved method of total antioxidant assay.

Commercially available analytical kits for the estimation of total antioxidant status are expensive and time-consuming. Most of the commercially available kits for total antioxidants estimation are based on the principle of suppression of ABTS radical cation formation by antioxidant in the serum sample. The method requires stringent assay conditions, like exact incubation time and the temperature (37 degrees C) of the reaction and on an average not more than 40 samples can be analyzed on a day. We have adapted the assay to a microplate, thereby allowing more number of samples to be analyzed per day. Further, the reagent volume required is one fourth than that for the original procedure thereby cutting cost. Thirty samples were analyzed by original method on spectrophotometer and our adapted microplate assay. The values of total antioxidant obtained by the two methods correlated well. Thus, total antioxidant can be estimated reliably using the microplate method.

Two-year outcomes in patients admitted with non-ST elevation acute coronary syndrome: results of the OASIS registry 1 and 2.

BACKGROUND: Acute coronary syndrome continues to have significant long-term morbidity and mortality. This study sought to compare baseline characteristics, practice patterns and clinical outcomes for patients with non-ST elevation acute coronary syndrome from a broad range of low-, middle- and high-income countries. METHODS AND RESULTS: We compared the data from a prospective registry of patients with non-ST elevation acute coronary syndrome involving 4615 patients from 65 centers in 8 low and middle income countries (OASIS registry 2) with those obtained from 7987 patients from 95 centers in 6 middle and high income countries (OASIS registry 1). Patients in the OASIS registry 2 were younger, were more often males and smokers, presented later to the hospital after symptom onset and had a lower prevalence of diabetes at admission [with the exception of India, which had the highest age-adjusted prevalence (39.1%)]. There were marked variations in the angiography and intervention rates during the hospital stay, but the uses of proven pharmacological therapies were comparable. The two-year mortality rates adjusted for baseline covariates ranged from 6.9% to 15%. Patients from China had the lowest two-year mortality rate (6.9%) and patients from India had the highest rate (15%). Combining the two registries, the covariate-adjusted rate of death or myocardial infarction did not differ across countries with in-hospital angiographic rates of > or = 50% (17.1%), 25-49% (16.7%) or < 25% (16.5%). However, the covariate-adjusted rates for subsequent myocardial infarction (7.6%, 9.2% and 10.8% respectively, p < 0.0001), refractory angina (21.3%, 27.7% and 35.4% respectively, p < 0.0001) and the composite of death, myocardial infarction or refractory angina (34.9%, 40.7% and 46.8% respectively, p < 0.0001) differed depending on the angiographic rates. CONCLUSIONS: Among the participating countries there was a marked heterogeneity in patient characteristics, coronary interventions, resulting in differences in the two-year composite rates of death, myocardial infarction and refractory angina among patients admitted with non-ST elevation acute coronary syndrome.