Impact of long duration wearing of N95 masks on cardiorespiratory system and subjective sensations of health-care workers during COVID-19 era.

Background and Aims: N95 mask being an essential element of personal protective equipment to be worn by health-care workers (HCWs) may lead to adverse effects and physiological stress as HCWs have to wear it for prolonged hours. Therefore, we planned to conduct a study in our intensive care unit staff to look for the effects of N95 masks on their health as well as to plan recommendations to ease them. Material and Methods: We conducted this study on our intensive care unit nursing staff and HCWs. We noted their oxygen saturation and heart rate at baseline as well as after 1 h, 2 h, 3 h, and 6 h of duty along with their subjective sensations. Institutional ethical clearance for the same was taken. Collected data were entered in MS Excel database and analyzed using SPSS version 20.0. Fisher's Z test was applied for comparing proportion and analysis of variance for comparing two means. Results: One hundred and nine HCWs participated in this, out of which 93 (85.3%) were females and 16 (14.7%) were males. Eighty-four (77.1%) participants were below 40 years. Twenty-three participants (21.1%) were overweight and 37 (33.9%) were obese. There was no significant drop in saturation and rise in heart rate during these hours. Conclusions: On comparing subjective sensations of HCWs, our study found that feeling of uneasiness was found more in less than 40 years age group as compared to more than 40 years. N95 masks were found to have no impact on cardiovascular system and do not lead to hypoxia while working routinely even for prolonged hours.

Admission Serum Chloride Levels as Predictor of Stay Duration in Acute Decompensated Heart Failure.

OBJECTIVE: Recent studies have shown that lower serum chloride is associated with diuretic resistance and increased mortality in heart failure. Impact of lower admission chloride on duration of stay in acute decompensated heart failure (ADHF) has not been studied previously. METHODS: In this retrospective analysis, we studied the effect of admission serum chloride on the duration of hospital stay in patients admitted with ADHF. A total of 167 patients were studied. Serum chloride levels were divided into tertiles - <96 meq/L (tertile 1), 96-101 meq/L (tertile 2), and >101 meq/L (tertile 3) based on the distribution of serum chloride levels in our patients. RESULTS: The median lengths of hospital stay in tertiles 1, 2, and 3 were 8(Interquartile range :6 -11), 7 (Interquartile range :5 -10.50), and 6 days(Interquartile range :4.25 - 8), respectively (p = 0.011). Admission serum chloride levels were inversely associated with duration of stay (R2 linear = 0.074, p = 0.001). On multiple linear regression analysis, serum chloride remained independent predictor of increased hospital stay (p=0.003) while association with serum sodium was not significant (p=0.07). 1 unit increase in chloride level was associated with 1.3% (p=0.003) decrease in hospital stay (95% CI: 2.2% to 0.5%). CONCLUSION: This retrospective analysis suggests that admission serum chloride levels are independently and inversely associated with increased duration of stay. This is independent of admission sodium levels. Thus serum chloride, rather than sodium, is an important poor prognostic marker in heart failure patients.

Association of obesity with heart failure outcomes in 11 Asian regions: A cohort study.

BACKGROUND: Asians are predisposed to a lean heart failure (HF) phenotype. Data on the 'obesity paradox', reported in Western populations, are scarce in Asia and have only utilised the traditional classification of body mass index (BMI). We aimed to investigate the association between obesity (defined by BMI and abdominal measures) and HF outcomes in Asia. METHODS AND FINDINGS: Utilising the Asian Sudden Cardiac Death in Heart Failure (ASIAN-HF) registry (11 Asian regions including Taiwan, Hong Kong, China, India, Malaysia, Thailand, Singapore, Indonesia, Philippines, Japan, and Korea; 46 centres with enrolment between 1 October 2012 and 6 October 2016), we prospectively examined 5,964 patients with symptomatic HF (mean age 61.3 ± 13.3 years, 26% women, mean BMI 25.3 ± 5.3 kg/m2, 16% with HF with preserved ejection fraction [HFpEF; ejection fraction ≥ 50%]), among whom 2,051 also had waist-to-height ratio (WHtR) measurements (mean age 60.8 ± 12.9 years, 24% women, mean BMI 25.0 ± 5.2 kg/m2, 7% HFpEF). Patients were categorised by BMI quartiles or WHtR quartiles or 4 combined groups of BMI (low, <24.5 kg/m2 [lean], or high, ≥24.5 kg/m2 [obese]) and WHtR (low, <0.55 [thin], or high, ≥0.55 [fat]). Cox proportional hazards models were used to examine a 1-year composite outcome (HF hospitalisation or mortality). Across BMI quartiles, higher BMI was associated with lower risk of the composite outcome (ptrend < 0.001). Contrastingly, higher WHtR was associated with higher risk of the composite outcome. Individuals in the lean-fat group, with low BMI and high WHtR (13.9%), were more likely to be women (35.4%) and to be from low-income countries (47.7%) (predominantly in South/Southeast Asia), and had higher prevalence of diabetes (46%), worse quality of life scores (63.3 ± 24.2), and a higher rate of the composite outcome (51/232; 22%), compared to the other groups (p < 0.05 for all). Following multivariable adjustment, the lean-fat group had higher adjusted risk of the composite outcome (hazard ratio 1.93, 95% CI 1.17-3.18, p = 0.01), compared to the obese-thin group, with high BMI and low WHtR. Results were consistent across both HF subtypes (HFpEF and HF with reduced ejection fraction [HFrEF]; pinteraction = 0.355). Selection bias and residual confounding are potential limitations of such multinational observational registries. CONCLUSIONS: In this cohort of Asian patients with HF, the 'obesity paradox' is observed only when defined using BMI, with WHtR showing the opposite association with the composite outcome. Lean-fat patients, with high WHtR and low BMI, have the worst outcomes. A direct correlation between high WHtR and the composite outcome is apparent in both HFpEF and HFrEF. TRIAL REGISTRATION: Asian Sudden Cardiac Death in HF (ASIAN-HF) Registry ClinicalTrials.gov Identifier: NCT01633398.

Hypocalcemia Presenting as Life Threatening Torsades de Pointes with Prolongation of QTc Interval.

Torsades de pointes with prolonged QTc interval is a form of ventricular tachycardia. Many predisposing factors have been identified and hypocalcemia is among the rare ones. Our case illustrates that though rare, hypocalcemia might manifest as torsades de pointes with prolongation of QTc interval. Early diagnosis and management of dyselectrolytemia can prevent these patients from catastrophic torsades de pointes.

Role of Extracorporeal Membrane Oxygenation in Aluminum Phosphide Poisoning-Induced Reversible Myocardial Dysfunction: A Novel Therapeutic Modality.

BACKGROUND: Aluminum phosphide (AlP) poisoning carries a high rate of mortality despite intensive care management, primarily because of refractory myocardial depression, resistant hypotension, and severe metabolic acidosis as well as acute respiratory distress syndrome. Extracorporeal membrane oxygenation (ECMO) is a modified "heart-lung" machine to provide temporary cardiorespiratory support. We studied the novel use of ECMO in the management of a subset of patients with AlP poisoning. CASE REPORT: In this case series, seven patients with AlP poisoning suffering from severe metabolic acidosis and refractory cardiogenic shock with a reduced left ventricular ejection fraction (<35%) received ECMO treatment. The acidosis and hemodynamic status improved within 6-12 h and 12-24 h, respectively, in five patients. Two patients did not survive because of a long delay in presentation after ingestion. The majority of the patients developed dysrhythmias, ECMO cannulation site bleeding, and thrombocytopenia. Two patients required surgical exploration of the femoral artery. At 9 months of follow-up, all five surviving patients were doing well, with the near normalization of ventricular function. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: We have found that timely intervention with ECMO in patients with AlP poisoning-induced severe metabolic acidosis and refractory cardiogenic shock may lead to a significant improvement in overall survival. Therefore, ECMO might be considered as a bridge therapy for patients with intractable cardiorespiratory failure caused by AlP poisoning who are not responding to conventional treatment. ECMO, however, also is associated with significant complication rates, which must be incorporated into the risk-benefit analysis while considering treatment options.

Plasma and erythrocyte zinc in pre-eclampsia and its correlation with foetal outcome.

OBJECTIVES: To determine the plasma and erythrocyte zinc levels in women with preeclampsia and eclampsia after 28 weeks of gestation and compare with normal pregnancy and to correlate with the foetal outcome. MATERIAL AND METHODS: 150 antenatal women were divided into Study group A (75 women with preeclampsia or eclampsia); Control group B (75 women with normal pregnancy). Plasma and erythrocyte zinc levels were estimated in both the groups and correlated with the foetal outcome. RESULTS: The plasma zinc levels were significantly low (p < 0.01) in women with severe pre-eclampsia (9.28 +/- 1.63 micromol/l) and eclampsia (9.28 +/- 2.61 micromol/l) as compared to controls (10.63 +/- 1.82 micromol/l). The difference in the erythrocyte zinc levels was not statistically significant in the two groups. There were 4 (5.33%) stillbirths and 8 (10.66%) neonatal deaths in the study group as compared to 2 (2.6%) neonatal deaths in the control group. There was no statistically significant difference in the plasma and erythrocyte zinc levels in infants weighing less than 2500 gm in both the groups.The maternal mortality rate was 1.33% and the overall perinatal mortality rate in the study group was 17.3% as compared to 2.6% in the control group. CONCLUSIONS: Plasma zinc levels were significantly lowered in severe preeclampsia and eclampsia while the erythrocyte zinc levels did not show any significant change. There was no correlation between plasma or erythrocyte zinc levels and intrauterine growth restriction in pre-eclampsia.

Lipid Association of India 2023 update on cardiovascular risk assessment and lipid management in Indian patients: Consensus statement IV.

OBJECTIVE: In 2016, the Lipid Association of India (LAI) developed a cardiovascular risk assessment algorithm and defined low-density lipoprotein cholesterol (LDL-C) goals for prevention of atherosclerotic cardiovascular disease (ASCVD) in Indians. The recent refinements in the role of various risk factors and subclinical atherosclerosis in prediction of ASCVD risk necessitated updating the risk algorithm and treatment goals. METHODS: The LAI core committee held twenty-one meetings and webinars from June 2022 to July 2023 with experts across India and critically reviewed the latest evidence regarding the strategies for ASCVD risk prediction and the benefits and modalities for intensive lipid lowering. Based on the expert consensus and extensive review of published data, consensus statement IV was commissioned. RESULTS: The young age of onset and a more aggressive nature of ASCVD in Indians necessitates emphasis on lifetime ASCVD risk instead of the conventional 10-year risk. It also demands early institution of aggressive preventive measures to protect the young population prior to development of ASCVD events. Wide availability and low cost of statins in India enable implementation of effective LDL-C-lowering therapy in individuals at high risk of ASCVD. Subjects with any evidence of subclinical atherosclerosis are likely to benefit the most from early aggressive interventions. CONCLUSIONS: This document presents the updated risk stratification and treatment algorithm and describes the rationale for each modification. The intent of these updated recommendations is to modernize management of dyslipidemia in Indian patients with the goal of reducing the epidemic of ASCVD among Indians in Asia and worldwide.

Awareness and recommendation of home blood pressure measurement among physicians in India: Results from Asia HBPM survey 2020.

BACKGROUND: Awareness of hypertension and blood pressure (BP) control rates are still low in India. Home blood pressure monitoring (HBPM) is recognized as a valuable tool to diagnose and support hypertension treatment including the prevention of cardiovascular diseases(CVD) and target organ damage. We explored the prevailing knowledge and current recommendation of HBPM in daily practice by physicians in India. MATERIALS AND METHODS: As part of Asia HBPM Survey 2020, a cross-sectional survey was conducted among healthcare providers from India between June 2020 to June 2021. The questionnaire consisted of 37 questions and sub-questions related to HBPM awareness and recommendations to patients. RESULTS: A total of 832 physicians participated in the survey. Almost 83% were male, whereas age, specialty and workplace were well distributed. 31.3% of physicians instruct their patients to measure their BP before taking antihypertensive drugs, while around 30% of physicians gave no instructions. The reference value of hypertension diagnosis amongst the physicians was substantially low based on clinic BP (34.4%) and home BP (15.1%). Among physicians who manage hypertensive patients, nearly 88% recommend HBPM to their patients, however, only 34.9% of their patients own HBPM device and 30.4% of the patients measure their own BP at home. CONCLUSION: The survey reveals that HBPM instructions to the patients are either lacking or not well aligned with the local hypertension guidelines which may have led to the low HBPM use among patients. Clear and practical educational material and sessions are needed to improve the understanding of HBPM amongst physicians.

Similar Events but Contrasting Impact: Appraising the Global Digital Reach of World Heart Day and Atrial Fibrillation Awareness Month.

Background: With over 18.6 million deaths annually, cardiovascular diseases (CVDs) are the leading cause of mortality worldwide. One such complication of CVDs that can result in stroke is atrial fibrillation (Afib). As part of global outreach and awareness, World Heart Day and Atrial Fibrillation Awareness Month are celebrated annually on 29 September and the month of September, respectively. Both of these events are important cardiovascular awareness initiatives to assist public education and develop awareness strategies, and they have received considerable support from leading international organizations. Objective: We studied the global digital impact of these campaigns via Google Trends and Twitter. Methods: We evaluated the overall number of tweets, impressions, popularity and top keywords/hashtags, and interest by region to determine the digital impact using various analytical tools. Hashtag network analysis was done using ForceAtlas2 model. Beyond social media, Google Trends web search analysis was carried out for both awareness campaigns to examine 'interest by region' over the past five years by analyzing relative search volume. Results: #WorldHeartDay and #UseHeart (dedicated social media hashtags for World Heart Day by the World Heart Federation) alone amassed over 1.005 billion and 41.89 million impressions as compared with the 1.62 million and 4.42 million impressions of #AfibMonth and #AfibAwarenessMonth, respectively. On Google Trends web search analysis, the impact of Afib awareness month was limited to the USA, but World Heart Day had a comparatively global reach with limited digital involvement in the African continent. Conclusions: World Heart Day and Afib awareness month present a compelling case study of vast digital impact and the effectiveness of targeted campaigning using specific themes and keywords. Though the efforts of the backing organizations are commended, planning and collaboration are needed to further widen the reach of Afib awareness month.

Cardiovascular implications of inflammatory bowel disease: An updated review.

Emerging data highlights the heightened risk of atherosclerotic cardiovascular diseases (ASCVD) in patients with chronic inflammatory disorders, particularly those afflicted with inflammatory bowel disease (IBD). This review delves into the epidemiological connections between IBD and ASCVD, elucidating potential underlying mechanisms. Furthermore, it discusses the impact of current IBD treatments on cardiovascular risk. Additionally, the cardiovascular adverse effects of novel small molecule drugs used in moderate-to-severe IBD are investigated, drawing parallels with observations in patients with rheumatoid arthritis. This article aims to comprehensively evaluate the existing evidence supporting these associations. To achieve this, we conducted a meticulous search of PubMed, spanning from inception to August 2023, using a carefully selected set of keywords. The search encompassed topics related to IBD, such as Crohn's disease and ulcerative colitis, as well as ASCVD, including coronary artery disease, cardiovascular disease, atrial fibrillation, heart failure, conduction abnormalities, heart blocks, and premature coronary artery disease. This review encompasses various types of literature, including retrospective and prospective cohort studies, clinical trials, meta-analyses, and relevant guidelines, with the objective of providing a comprehensive overview of this critical intersection of inflammatory bowel disease and cardiovascular health.

Clinical profile and outcome of cardiac manifestations in patients presenting with multisystem inflammatory syndrome in children associated with SARS-CoV-2 infection.

Multisystem inflammatory syndrome in children (MIS-C) can cause significant morbidity and mortality in children. This study was conducted to assess the pattern and outcome of cardiac abnormalities in MIS-C. This retrospective study was conducted in children with MIS-C between 1 month and 18 years. We enrolled 53 children with a mean age of 7.78 ± 4.62 years. Overall, 35.8% of children with MIS-C had cardiac manifestations in the form of coronary artery abnormalities (CAAs) or left ventricular (LV) dysfunction. Younger age (P 0.009) and high C-reactive protein at admission (P = 0.001) were significant predictors of cardiac involvement. CAAs were seen in 11.3% of children. On follow-up, 67% and 83% of children showed regression of CAA at 1 and 6 months, respectively. 24.5% of patients had presented with LV dysfunction. LV ejection fraction improved significantly at 1 month (P = 0.002) and 6 months (P = 0.001). Cardiac outcomes in MIS-C were favorable with timely identification and treatment.

Association Between Diabetes, Chronic Kidney Disease, and Outcomes in People With Heart Failure From Asia.

Background: Diabetes mellitus (DM), chronic kidney disease (CKD), and heart failure (HF) are pathophysiologically linked and increasing in prevalence in Asian populations, but little is known about the interplay of DM and CKD on outcomes in HF. Objectives: This study sought to investigate outcomes in patients with heart failure with preserved ejection fraction (HFpEF) vs heart failure with reduced ejection fraction (HFrEF) in relation to the presence of DM and CKD. Methods: Using the multinational ASIAN-HF registry, we investigated associations between DM only, CKD only, and DM+CKD with: 1) composite of 1-year mortality or HF hospitalization; and 2) Kansas City Cardiomyopathy Questionnaire scores, according to HF subtype. Results: In 5,239 patients with HF (74.6% HFrEF, 25.4% HFpEF; mean age 63 years; 29.1% female), 1,107 (21.1%) had DM only, 1,087 (20.7%) had CKD only, and 1,400 (26.7%) had DM+CKD. Compared with patients without DM nor CKD, DM+CKD was associated with 1-year all-cause mortality or HF hospitalization in HFrEF (adjusted HR: 2.07; 95% CI: 1.68-2.55) and HFpEF (HR: 2.37; 95% CI: 1.40-4.02). In HFrEF, DM only and CKD only were associated with 1-year all-cause mortality or HF hospitalization (both HRs: 1.43; 95% CI: 1.14-1.80), while in HFpEF, CKD only (HR: 2.54; 95% CI: 1.46-4.41) but not DM only (HR: 1.01; 95% CI: 0.52-1.95) was associated with increased risk (interaction P < 0.01). Adjusted Kansas City Cardiomyopathy Questionnaire scores were lower in patients with DM+CKD (HFrEF: mean 60.50, SEM 0.77, HFpEF: mean 70.10, SEM 1.06; P < 0.001) than with no DM or CKD (HFrEF: mean 66.00, SEM 0.65; and HFpEF: mean 75.80, SEM 0.99). Conclusions: Combined DM and CKD adversely effected outcomes independently of HF subtype, with CKD a consistent predictor of worse outcomes. Strategies to prevent and treat DM and CKD in HF are urgently required.

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.

Current realities of home blood pressure monitoring from physicians' perspectives: results from Asia HBPM survey 2020.

Uncontrolled hypertension is a significant problem in many parts of Asia. Effective management is essential to reduce the burden of hypertension. Home blood pressure monitoring (HBPM) is a promising tool that can aid in the diagnosis and management of hypertension. Experts from 11 countries/regions in Asia conceptualized a large-scale survey to examine the current realities of HBPM. A cross-sectional survey was conducted among health care professionals from China, India, Indonesia, Japan, Malaysia, the Philippines, Singapore, South Korea, Taiwan, Thailand, and Vietnam between November 2019 and June 2021. Physicians' responses were summarized using descriptive statistics. A total of 7945 physicians participated in the survey. Among all respondents, 50.3% and 33.5% viewed HBPM as highly recognized by physicians and patients in their country/region, respectively. Lack of understanding of HBPM and concern with the accuracy and reliability of HBPM devices were identified as key barriers to HBPM recognition. Nearly all physicians (95.9%) reported recommending HBPM to their patients; however, they reported less than 50% of their patients measured home blood pressure (HBP). Among physicians who recommended HBPM, only 22.4% and 54.1% cited HBP diagnostic threshold values and timing of taking antihypertensive drugs that were consistent with available guidelines, respectively. The survey reveals that the recognition of HBPM as a valuable tool to diagnose and manage hypertension is suboptimal in most parts of Asia. Despite high recommendation of HBPM to hypertensive patients by physicians, there are considerable discrepancies between guidelines recommendations and practice realities. The recognition of HBPM as a valuable tool for the diagnosis and management of hypertension is suboptimal among both physicians and patients in Asia. A clear and consistent guidance for proper HBPM practice and use of validated and calibrated HBP monitors are among the top priorities to support the integration of HBPM into daily patient care. HBPM: home blood pressure monitoring, HBP: home blood pressure.

Concept, hardware development, and clinical trials of a Galinstan based Mercury free sphygmomanometer: Merkfree.

The aim of this work is to develop Merkfree-a mercury-free sphygmomanometer that looks, feels, and operates just like a traditional mercury sphygmomanometer (MS). For this we use Galinstan as a substitute for mercury, which is a non-toxic alloy of Gallium, Indium and Tin. Galinstan is nearly half as dense as mercury and sticks to class. To work with the lower density, we designed an enclosure and scale that is nearly double the length of MS. The issue of stickiness with glass was resolved by maintaining a small meniscus of a reducing agent in the measuring tube and tank of Merkfree. Clinical trials to validate the accuracy of Merkfree against MS and oscillometric sphygmomanometer (OS) were conducted over 252 patients. The results show a good correlation of the systolic and diastolic BP measurements from Merkfree with respect to MS and the OS. The mean absolute percentage error is less than 10% for both SBP and DBP. We also found that Merkfree has lower rounding-off errors compared to MS. Merkfree can be a viable alternative to mercury sphygmomanometer that can help achieve the goal of WHO in eliminating mercury from healthcare, while simultaneously making sure that gold standard technique of sphygmomanometry continues to be available to the clinicians.