Impact of capacity building and tele ECG based decision support on change in thrombolysis rate and inhospital and one year mortality in patients with STEMI, using hub and spoke model; multi-phasic intervention trial.

BACKGROUND: We report the impact of capacity building and teleconsultation on change in the thrombolysis rates and one-year mortality in patients with STEMI using a hub and the spoke model of STEMI care. METHODS: Twenty secondary care public hospitals were linked with a teaching hospital as a hub centre and the impact of the intervention on change in ischemic time, thrombolysis rates and all-cause in-hospital and one-year mortality was compared. RESULTS: 29 patients with STEMI were treated during pre-intervention from April 2020 to June 2020 and 255 patients during the post-intervention period from July 2020 to Oct 2021 in spoke centres. 245 patients were reported to a hub centre during the study period. The thrombolysis rate was significantly higher in the spoke centres after intervention (65.5%vs. 27.5 % p < 0.001) and was also significantly higher than in patients treated in a hub centre (65.5 % vs. 45.7 % p < 0.01). The in-hospital mortality was significantly lower in patients treated at spoke centres compared to those treated at the hub centre (7.8 % vs. 15.5 % < 0.003). The significant difference in mortality rate continued at one year (11.0 % vs.18.4 % p < 0.01). The median time from symptoms to thrombolytic therapy was significantly lower in STEMI patients treated in spoke centres compared to a hub centre (230 min vs. 356 min p < 0.001). CONCLUSION: The hub and spoke model of STEMI care is effective in increasing thrombolysis rate, and decreasing in-hospital and one-year mortality rate.

Clinical characteristics, etiological profile, treatment and long term outcomes in patients with non ischemic systolic heart failure; Himachal Pradesh heart failure registry (HP-HF registry).

BACKGROUND: The data on clinical characteristics, treatment practices and out comes in patients with Non- ischemic Systolic Heart Failure (NISHF) is limited. We report clinical characteristics, treatment and outcomes in patients with NISHF. METHODS: 1004 patients with NISHF were prospectively enrolled and their demographics, clinical characteristics, and treatment were recorded systematically. Patients were followed annually for a median of 3 years (1 year to 8 years) for allcause death, major adverse cardiovascular events (MACE); composite of all-cause death, hospitalization of heart failure, and or for stroke. RESULTS: Patients of NISHF were middle-aged (58.8±16.2 years) population with severely depressed left ventricular ejection fraction (29.3±7.02%) and 31.1% had symptoms of advanced Heart failure. Hypertension (43.6%), obesity and or overweight (28.0%), Diabetes (15.0%), and valvular heart disease (11.8%) were the common risk factors. The guideline directed medical treatment was prescribed in more than 80% of the study cohort. Incidence of all cause death and MACE was 7 (6.8, 8.8) per 100 person years and 11(10, 13) per 100 person years respectively. The cumulative incidence of deaths and MACE was 35% (30%, 40%) and 49% (44%, 53%) at 8 years of follow-up. CONCLUSIONS: Patients of NISHF were middle-aged population with severely depressed LV systolic function with significant incident morbidity and mortality. Early detection of risk factors and their risk management and enhancing the use of guideline directed treatment may improve the outcomes.

Incidence, determinants, and outcomes of recovered left ventricular ejection fraction (LVEF) in patients with non-ischemic systolic heart failure; a hospital-based cohort study.

BACKGROUND: The data on incidence of recovered Left Ventricular Ejection Fraction (LVEF) and outcome in patients with non ischemic systolic heart failure is limited. We report the incidence, determinants and mortality in patients with recovered LVEF. METHODS: The 369 patients with HFrEF with LVEF of less than 40% of non ischemic etiology with available follow up echocardiography study at one year were enrolled. The baseline data of clinical characteristics and treatment was recorded prospectively and were followed up annually for mean of 3.6 years (range 2 to 5 years) to record all cause death and LVEF measured echocardiographically. The recovered, partially recovered and no recovery of LVEF was defined based on increase in LVEF to 50% and more, 41% to 49% and to persistently depressed LVEF to 40% or lower respectively. RESULTS: The LVEF recovered in 36.5%% of the cohort at 5 years. The rate of recovery of LVEF was slower in patients with no recovery of LVEF at one year compared to cohort with partially recovered LVEF (18% vs.53%) at five year. The Baseline LVEF was significantly associated with recovered LVEF, odd ratio (95% C.I.) 1.09(1.04, 1.14). The cumulative mortality at five years was significantly lower in cohort with recovered LVEF (18.1% vs. 57.1%). CONCLUSIONS: One third of the patients had recovered LVEF and was significantly associated with baseline LVEF and lower mortality rate.

Long term outcomes in patients with RF/RHD: Eight-year follow-up of HP-RF/RHD (Himachal Pradesh Rheumatic Fever/Rheumatic Heart Disease) registry in a Northern Indian state.

BACKGROUND: The long-term outcome data in patients with rheumatic fever/rheumatic heart disease (RF/RHD) is limited. We report the cumulative incidence of adverse outcomes in a cohort of RHD patients from a northern state of India at a median follow-up of 5.4 years. METHODS: 1714 patients with RF/RHD diagnosed using clinical and echocardiographic criteria were registered from 2011 to 2018, and their baseline clinical characteristics and treatment practices were recorded. Patients were followed up annually for a median of 5.4 years (range 1-8 years) for incident adverse outcomes. The cumulative incidence of adverse composite outcomes, all-cause mortality, hospitalization for heart failure, stroke, and/or peripheral embolism was estimated. The baseline clinical characteristics were explored to identify the potential risk predictors using a multivariate cox proportional hazard model. RESULTS: The cumulative incidence of adverse composite outcomes was 17.1% (15.3%-19.0%) at a median follow-up of 5.4 years. The predictors for the adverse composite outcomes (hazard ratio, 95% confidence interval) were age (1.03, 1.02-1.04), education status below primary level (1.60, 1.23-2.05), severe valvular heart disease (1.74, 1.36-2.23), NYHA class III/IV at enrollment (1.56, 1.18-2.07), right heart failure (4.48, 2.85-6.95), history of stroke and/or peripheral embolism (3.7, 1.5-9.2) and mitral balloon valvuloplasty (0.62, 0.40-0.96). CONCLUSIONS: The incidence of adverse outcomes is substantial in patients with RF/RHD. Thus, early detection of high-risk patients and their risk management is needed to improve outcomes.

Gender differences in the epidemiology of Rheumatic Fever/Rheumatic heart disease (RF/RHD) patient population of hill state of northern India; 9 years prospective hospital based, HP-RHD registry.

OBJECTIVES: We report the gender-based differences in the prevalence, severity, pattern of valvular involvement, and complications in patients with Rheumatic Fever/Rheumatic heart disease (RF/RHD). METHODS: The 2475 consecutive patients with RF/RHD diagnosed using clinical and echocardiographic criteria were registered prospectively from January 2011 till December 2019. The association of gender with the pattern of valvular involvement, nature, and severity of valvular dysfunction and cardiovascular complications was analyzed using a logistic regression model, and odds ratios with 95% CI were estimated. RESULTS: The mitral and tricuspid valve involvement was significantly lower in the male gender, odds ratio with 95% CI of 0.55 (0.44-0.61), and 0.69 (0.58-0.83) respectively, while the aortic valve was affected more frequently than females, odds ratio 1.36 (1.14-1.62). The severity of valvular disease had no significant association with gender, 0.99 (0.82-1.20). The association between gender and cardiovascular complications, heart failure, stroke, and atrial fibrillations were not statistically significant. The prevalence of RF/RHD was more than two-fold higher in female gender than male (71.4% vs. 29.6%, p < 0.0001). CONCLUSIONS: RF/RHD is more prevalent in females. Gender has a significant association with the pattern of valvular involvement. The severity of valvular dysfunction and cardiovascular complications had no significant association with gender.

Clinical Characteristics, Complications, and Treatment Practices in Patients With RHD: 6-Year Results From HP-RHD Registry.

BACKGROUND: Despite the high prevalence of rheumatic heart disease (RHD) in developing countries such as India, data on characteristics, complications, and treatment practices are lacking. The HP-RHD (Himachal Pradesh Rheumatic Heart Disease) registry aimed at reporting these parameters in patients with RHD from a northern state of India. METHODS: A total of 2,005 consecutive patients of RHD were enrolled over a period of 6 years (2011 to 2016) in the present study. The clinical characteristics, complications, and treatment practices were systematically recorded. RESULTS: The mean age for patients with RHD was 40.3 ± 14.3 (range 5 to 83 years). RHD predominantly affected females (72.3%) and population from rural background (92%). Multivalvular involvement was frequent (43.2%), mitral valve was the commonest affected valve (83.3%). The majority of the patients had moderate-to-severe valvular dysfunction (69.3%). Mitral and tricuspid valve involvement was more frequent in female subjects compared with more frequent aortic valve involvement in male subjects (p < 0.001). The major adverse cardiovascular events were recorded in 23.4% patients at the time of registry and comprised mainly advanced heart failure (15.6%), peripheral embolism (4.1%), and stroke (3.9%). The independent risk determinants of major adverse cardiovascular events (were advanced age (odds ratio [OR]: 1.01; 95% confidence interval [CI]: 1.00-1.02), severe mitral stenosis (OR: 1.73; 95% CI: 1.34-2.20), severe tricuspid regurgitation (OR: 2.11; 95% CI: 1.48-3.02), presence of pulmonary artery hypertension (OR: 1.33; 95% CI: 1.04-1.69), and atrial fibrillation (OR: 1.64; 95% CI: 1.28-2.11). Evidence-based use of oral anticoagulant therapy was documented in 77.7% of high-risk patients. Only 28.5% of study population was receiving secondary prophylaxis. CONCLUSIONS: Complications in patients with RHD increase with age and worsening valvular dysfunction. Programs focused on early detection and evidence-based management will assist in improving outcomes.

Acute renal artery embolisation: role of local catheter-based intra-arterial thrombolysis.

A 45-year-old man without previous comorbidity presented to us with acute onset right-sided flank pain for last 14 hours. His general physical and systemic examination was unremarkable, and there were no clinical signs of peritonitis. The ultrasonography did not reveal any evidence of nephrolithiasis or hydronephrosis. His contrast-enhanced CT scan revealed hypoattenuated areas of right kidney and evidence of right renal artery thrombosis. He was immediately shifted to cardiac catheterisation lab, and his renal angiography showed thrombotic occlusion of right renal artery. The bolus dose of streptokinase (250 000 IU) was given locally in renal artery by right judkins catheter followed by systemic infusion of streptokinase (100 000 IU/hour) for 24 hours. After that he was started on low molecular weight heparin. Repeat renal angiography done after 5 days showed completely normal right renal artery. His cardiac and thrombophilia work up was negative, and he was discharged on antiplatelets, oral anticoagulants and statins.

Prevalence, risk determinants and consequences of atrial fibrillation in rheumatic heart disease: 6 years hospital based-Himachal Pradesh- Rheumatic Fever/Rheumatic Heart Disease (HP-RF/RHD) Registry.

OBJECTIVE: To report the prevalence, risk factors and consequences of atrial fibrillation (AF) in patients of rheumatic heart disease (RHD). METHODS: The Himachal Pradesh- Rheumatic Fever/Rheumatic Heart Disease (HP-RF/RHD) Registry database of 1918 patients was analyzed. AF was diagnosed with 12-lead ECG recording at entry in to the registry. The association of AF with nature and severity of valvular dysfunction was analyzed, adjusted for age, left atrial (LA) dimension and pulmonary arterial hypertension using multivariable logistic regression model and strength of association was reported as odds ratio (OR) with 95% confidence intervals (C. I.). RESULTS: The study population consisted of young (40.2 ±â€¯14.3 years), predominantly females (72.3%) from rural area (94.1%). Prevalence of AF was 23.9% (95% C. I. 22.1%-25.8%). The independent determinants AF were age (OR 1.04, 95% C.I. 1.03-1.06), LA size (OR 1.10, 95% C.I. 1.08-1.11). The association of AF with age, New York Heart Association functional class, mitral stenosis severity and tricuspid regurgitation was statistically significant and graded. Mitral regurgitation and aortic valve disease had no significant independent association with AF. The prevalence of heart failure, stroke, peripheral embolism and mortality was significantly higher among patients with AF (p < .01). CONCLUSION: AF is common in RHD patients and is significantly associated with heart failure and systemic thromboembolism. Age, mitral stenosis severity, tricuspid regurgitation and LA size were independently associated with AF.

Prevalence, risk factors, and significance of iron deficiency and anemia in nonischemic heart failure patients with reduced ejection fraction from a Himachal Pradesh heart failure registry.

BACKGROUND: The study aimed to estimate the prevalence, risk determinants, and its clinical significance of iron deficiency and anemia in patients of nonischemic heart failure with reduced ejection fraction (HFrEF). METHODS: Serum ferritin, transferrin saturation, and the hemoglobin (Hb) levels were measured in 226 consecutive patients with HFrEF diagnosed based on the left ventricular ejection fraction ≤ 45% and absence of coronary artery luminal narrowing of more than 50%, in a prospective tertiary care hospital-based heart failure registry. Patients with the New York Heart Association functional class III/IV were classified as patients with advanced heart failure. Multivariable logistic regression modeling was performed to assess the risk determinants of iron deficiency and anemia and their clinical significance as the risk factors for advanced heart failure. Odds ratio with 95% confidence interval (CI) was reported as the estimates of the strength of association between exposure and outcome variables. RESULTS: Iron deficiency and anemia were prevalent in 58.8% (52.2%-65.1%) and 35.8% (29.8%-42.3%) of patients, respectively. Female gender [OR 3.5 (95% CI 1.9-6.5)], history of bleeding [OR 11.7 (95% CI 1.4-101.2)], and vegetarian diet [OR 2.5 (95% CI 1.4-4.6)] were significantly associated with iron deficiency, while diabetes [OR 3.0 (95% CI 1.40-6.5)], estimated glomerular filtration rate [OR 0.98 (95% CI 0.97-0.99)], history of bleeding [OR 13.0 (95% CI 2.3-70.9)], and female gender [OR 2.9 (95% CI 1.5-5.7)] had significant association with anemia. The Hb level (OR 0.82 (95% CI 0.70-0.96) and transferrin saturation (OR 0.98 (95% CI 0.96-0.99)] had a significant inverse association with symptoms of advanced heart failure. CONCLUSION: Iron deficiency and anemia are common comorbidities associated with HFrEF. Low Hb and transferrin saturation are significantly associated with advanced heart failure. The findings have important implications in the management of heart failure.

A Constellation of Cardiac Anomalies: Beyond Shone's Complex.

Shone's anomaly is a very rare congenital cardiac malformation characterized by four serial obstructive lesions of the left side of the heart (i) Supravalvular mitral membrane (ii) parachute mitral valve (iii) muscular or membranous subaortic stenosis and (iv) coarctation of aorta. We report a unique presentation of Shone's complex in a 14-year-old adolescent male. In addition to the four characteristic lesions the patient had bicuspid aortic valve, aneurysm of sinus of valsalva, patent ductus arteriosus, ventricular septal defect, persistent left superior vena cava opening into coronary sinus and severe pulmonary artery hypertension. This case report highlights the importance of a strong clinical suspicion of the coexistence of multiple congenital cardiac anomalies in Shone's complex and the significance of a careful comprehensive echocardiography.

Takayasu arteritis presenting with total occlusion of the left main coronary artery ostium: an extremely rare occurrence.

A young 18-year-old female patient with exertional angina and claudication of the upper limbs was subjected to angiography. Bruits were auscultated over the bilateral renal arteries, right subclavian and right common carotid arteries. There was asymmetry of peripheral pulses. Laboratory parameters demonstrated a high erythrocyte sedimentation rate and C reactive protein. An aortic angiogram revealed a typical picture of Takayasu arteritis with bilateral subclavian, common carotid and renal involvement. A coronary angiogram was performed which showed total occlusion of the left main coronary artery. There was retrograde filling of the left coronary artery on right coronary artery injection up to the ostium of the left main coronary artery. Since the markers for disease activity were high, the patient was started on steroids and urgent coronary artery bypass grafting was planned. Unfortunately, the patient refused urgent intervention and was later lost to follow-up. This case describes an extremely rare occurrence of total occlusion of the left main coronary artery ostium in a patient with Takayasu arteritis.

Prevalence of congenital heart disease in rural population of Himachal - A population-based study.

AIM: There is no community-based study about the prevalence of congenital heart disease (CHD) in Himachal; hence, we undertook this study. METHODS AND RESULTS: A population-based survey was done in four villages of different districts of Himachal Pradesh. In total, 1882 persons were examined. 909 were male and 973 were female. There were 12 cases of CHD in the population (6.3/1000): four of these were male (33.3%) and 8 were female (66.6%). Mean age of these patients was 19.5±11.07 years. Atrial septal defect (ASD) was the commonest lesion followed by ventricular septal defect (VSD). CONCLUSION: Prevalence of CHD in general population was 6.3/1000. ASD was the commonest lesion. CHD was more common in female.