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BACKGROUND: Quality of chronic care for cardiovascular disease (CVD) remains suboptimal worldwide. The Collaborative Quality ImProvement (C-QIP) trial aims to develop and test the feasibility and clinical effect of a multicomponent strategy among patients with prevalent CVD in India. METHODS: The C-QIP is a clinic-based, open randomized trial of a multicomponent intervention vs usual care that was locally developed and adapted for use in Indian settings through rigorous formative research guided by Consolidated Framework for Implementation Research (CFIR). The C-QIP intervention consisted of 5 components: 1) electronic health records and decision support system for clinicians, 2) trained nonphysician health workers (NPHW), 3) text-message based lifestyle reminders, 4) patient education materials, 5) quarterly audit and feedback reports. Patients with CVD (ischemic heart disease, ischemic stroke, or heart failure) attending outpatient CVD clinics were recruited from September 2022 to September 2023 and were randomized to the intervention or usual care arm for at least 12 months follow-up. The co-primary outcomes are implementation feasibility, fidelity (ie, dose delivered and dose received), acceptability, adoption and appropriateness, measured at multiple levels: patient, provider and clinic site-level, The secondary outcomes include prescription of guideline directed medical therapy (GDMT) (provider-level), and adherence to prescribed therapy, change in mean blood pressure (BP) and LDL-cholesterol between the intervention and control groups (patient-level). In addition, a trial-based process and economic evaluations will be performed using standard guidelines. RESULTS: We recruited 410 socio-demographically diverse patients with CVD from 4 hospitals in India. Mean (SD) age was 57.5 (11.7) years, and 73.0% were males. Self-reported history of hypertension (48.5%) and diabetes (41.5%) was common. At baseline, mean (SD) BP was 127.9 (18.2) /76.2 (11.6) mm Hg, mean (SD) LDLc: 80.3 (37.3) mg/dl and mean (SD) HbA1c: 6.8% (1.6%). At baseline, the GDMT varied from 62.4% for patients with ischemic heart disease, 48.6% for ischemic stroke and 36.1% for heart failure. CONCLUSION: This study will establish the feasibility of delivering contextually relevant, and evidence-based C-QIP strategy and assess whether it is acceptable to the target populations. The study results will inform a larger scale confirmatory trial of a comprehensive CVD care model in low-resource settings. TRIAL REGISTRATION: Clinical Trials Registry India: CTRI/2022/04/041847; Clinicaltrials.gov number: NCT05196659.
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Enfermedades Cardiovasculares , Mejoramiento de la Calidad , Humanos , India , Masculino , Femenino , Enfermedades Cardiovasculares/terapia , Persona de Mediana Edad , Registros Electrónicos de Salud , Envío de Mensajes de Texto , Educación del Paciente como Asunto/métodos , Sistemas de Apoyo a Decisiones Clínicas , Anciano , Insuficiencia Cardíaca/terapiaRESUMEN
Heart failure (HF) is a global health concern that is prevalent in India as well. HF is reported at a younger age in Indian patients with comorbidity of type 2 diabetes (T2DM) in approximately 50% of patients. Sodium-glucose cotransporter-2 inhibitors (SGLT2i), originally approved for T2DM, are new guideline-recommended and approved treatment strategies for HF. Extensive evidence highlights that SGLT2i exhibits profound cardiovascular (CV) benefits beyond glycemic control. SGLT2i, in conjunction with other guideline-directed medical therapies (GMDT), has additive effects in improving heart function and reducing adverse HF outcomes. The benefits of SGLT2i are across a spectrum of patients, with and without diabetes, suggesting their potential place in broader HF populations irrespective of ejection fraction (EF). This consensus builds on the updated evidence of the efficacy and safety of SGLT2i in HF and recommends its place in therapy with a focus on Indian patients with HF.
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Diabetes Mellitus Tipo 2 , Insuficiencia Cardíaca , Inhibidores del Cotransportador de Sodio-Glucosa 2 , Humanos , Inhibidores del Cotransportador de Sodio-Glucosa 2/uso terapéutico , Insuficiencia Cardíaca/tratamiento farmacológico , India , Diabetes Mellitus Tipo 2/tratamiento farmacológico , Diabetes Mellitus Tipo 2/complicacionesRESUMEN
In India, heart failure (HF) is an important health concern affecting younger age groups than the western population. A limited number of Indian patients receive guideline-directed medical therapy (GDMT). Selective ß-1 blockers (BB) are one of the GDMTs in HF and play an important role by decreasing the sympathetic overdrive. The BB reduces heart rate (HR) reverse the adverse cardiac (both ventricular and atrial), vascular, and renovascular remodeling seen in HF. Bisoprolol, a ß-1 blocker, has several advantages and can be used across a wide spectrum of HF presentations and in patients with HF and comorbid conditions such as coronary artery disease (CAD), atrial fibrillation (AF), post-myocardial infarction (MI), uncontrolled diabetes, uncontrolled hypertension, and renal impairment. Despite its advantages, bisoprolol is not optimally utilized for managing HF in India. This consensus builds on updated evidence on the efficacy and safety of bisoprolol in HF and recommends its place in therapy with a focus on Indian patients with HF.
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Antagonistas de Receptores Adrenérgicos beta 1 , Bisoprolol , Insuficiencia Cardíaca , Humanos , Bisoprolol/uso terapéutico , Insuficiencia Cardíaca/tratamiento farmacológico , India , Antagonistas de Receptores Adrenérgicos beta 1/uso terapéutico , ConsensoRESUMEN
Rule-out of acute myocardial infarction (AMI) in patients presenting with acute chest pain at the emergency department (ED) is a major challenge across the globe. Patients presenting very early with chest pain may provide a diagnostic challenge even when using a cardiac necrosis specific biomarker, high sensitivity troponin (hs-Tn) as they are elevated at 3-6 h after the symptom onset. Copeptin is a marker of acute hemodynamic stress which is released within few minutes of the occurrence of MI and is elevated immediately at the presentation of patients with AMI. This indicates a complementary pathophysiology and kinetics of these two biomarkers. Hence, we evaluated whether or not a protocol with combined testing of copeptin and hs-TnI at admission in patients presenting with chest pain within 6 h in low to intermediate risk and suspected ACS leads to an earlier diagnosis of AMI and thereby, aids to prevent a higher proportion of major adverse cardiac events than the current standard protocol followed in ED. A total of 148 patients as per the inclusion criterion were recruited for the study. The dual biomarker copeptin and hs-TnI allows a rule-out of AMI at presentation with a sensitivity of 100% and NPV of 99.8%. Hence, the use of dual biomarker in conjunction with clinical assessment may obviate the need for a prolonged stay in the ED and retesting hs-TnI after 2 h (for delta check) in more than two-thirds of the patients. The inclusion of these tests could have an impact on the economic burden of the ED without jeopardizing the outcome for the patient.
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Acute myocardial infarction (AMI) causes significant mortality and morbidity. Timely diagnosis allows clinicians to risk stratify their patients and select appropriate treatment. Biomarkers have been used to diagnose or rule out AMI. An increasing number of novel biomarkers have been identified to predict the outcome following AMI or acute coronary syndrome (ACS). This may facilitate tailoring of appropriate therapy to high-risk patients. This review focuses on a variety of promising biomarkers which provide diagnostic and prognostic information.
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Síndrome Coronario Agudo/diagnóstico , Síndrome Coronario Agudo/metabolismo , Biomarcadores/metabolismo , Síndrome Coronario Agudo/terapia , HumanosRESUMEN
Familial hypercholesterolemia is a common genetic disorder of autosomal inheritance associated with elevated LDL-cholesterol. It is estimated to affect 1:250 individuals in general population roughly estimated to be 5 million in India. The prevalence of FH is higher in young CAD patients (<55 years in men; <60 years in women). FH is underdiagnosed and undertreated. Screening during childhood and Cascade screening of family members of known FH patients is of utmost importance in order to prevent the burden of CAD. Early identification of FH patients and early initiation of the lifelong lipid lowering therapy is the most effective strategy for managing FH. FH management includes pharmaceutical agents (statins and non statin drugs) and lifestyle modification. Inspite of maximum dose of statin with or without Ezetimibe, if target levels of LDL-C are not achieved, Bempedoic acid, proprotein convertase subtilisin/kexin type 9 (PCSK9) Inhibitors/Inclisiran can be added.
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Anticolesterolemiantes , Inhibidores de Hidroximetilglutaril-CoA Reductasas , Hiperlipoproteinemia Tipo II , Masculino , Humanos , Femenino , Proproteína Convertasa 9/uso terapéutico , Anticolesterolemiantes/uso terapéutico , LDL-Colesterol , Hiperlipoproteinemia Tipo II/diagnóstico , Hiperlipoproteinemia Tipo II/epidemiología , Hiperlipoproteinemia Tipo II/genética , Inhibidores de Hidroximetilglutaril-CoA Reductasas/uso terapéuticoRESUMEN
Evidence from the existing literature suggests that exercise has positive effects for prevention and treatment of cardiovascular diseases by reducing risk factors such as elevated blood lipids. Based on clinical and observational clinical trials, it is well established that increased physical activity and regular exercise has a favourable impact on blood lipids and lipoprotein profiles. Exercise training significantly decreases blood triglycerides concentration and increases high density lipoprotein cholesterol levels. Though the Indian data depicting the effect of exercise on lipids is scarce, exercise directly improves "atherogenic dyslipidaemia" which is frequently present among Indians i.e. HDL-C is increased, TG is reduced and LDL-C particle size is improved. While drug therapy is key to the treatment of dyslipidaemia, lifestyle alterations such as exercise should continue to be actively promoted and encouraged by clinicians. Exercise is a low cost, non pharmacological therapeutic lifestyle change that is of value to lipid metabolism and cardiovascular fitness.
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Dislipidemias , Ejercicio Físico , Humanos , HDL-Colesterol , Dislipidemias/terapia , Lípidos , Lipoproteínas , Triglicéridos , Ensayos Clínicos como Asunto , Estudios Observacionales como AsuntoRESUMEN
Heart failure poses a global health challenge affecting millions of individuals, and access to guideline-directed medical therapy is often limited. This limitation is frequently attributed to factors such as drug availability, slow adoption, clinical inertia, and delayed diagnosis. Despite international recommendations promoting the use of guideline-directed medical therapy for heart failure management, personalized approaches are essential in settings with resource constraints. In India, crucial treatments like angiotensin II receptor blocker neprilysin inhibitors and sodium-glucose co-transporter 2 inhibitors are not fully utilized despite their established safety and efficacy. To address this issue, an expert consensus involving 150 specialists, including cardiologists, nephrologists, and endocrinologists, was convened. They deliberated on patient profiles, monitoring, and adverse side effects and provided tailored recommendations for guideline-directed medical therapy in heart failure management. Stressing the significance of early initiation of guideline-directed medical therapy in patients with heart failure, especially with sodium-glucose co-transporter 2 inhibitors, the consensus also explored innovative therapies like vericiguat. To improve heart failure outcomes in resource-limited settings, the experts proposed several measures, including enhanced patient education, cardiac rehabilitation, improved drug access, and reforms in healthcare policies.
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BACKGROUND: The extent to which differences in results from Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation (ARISTOTLE) and Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition Compared with Vitamin K Antagonism for Prevention of Stroke and Embolism Trial (ROCKET) atrial fibrillation (AF)-the landmark trials for the approval of apixaban and rivaroxaban, respectively, for non-valvular AF-were influenced by differences in their protocols is debated. The potential influence of selection criteria on trial results was assessed by emulating these trials in data from the Global Anticoagulant Registry in the Field (GARFIELD)-AF registry. METHODS: Vitamin K antagonist (VKA) and non-vitamin K oral antagonist (NOAC) users from GARFIELD-AF were selected according to eligibility for the original ARISTOTLE or ROCKET AF trials. A propensity score overlap weighted Cox model was used to emulate trial randomisation between treatment groups. Adjusted HRs for stroke or systemic embolism (SE) within 2 years of enrolment were calculated for each NOAC versus VKA. RESULTS: Among patients on apixaban, rivaroxaban and VKA, 2570, 3560 and 8005 were eligible for ARISTOTLE, respectively, and 1612, 2005 and 4368, respectively, for ROCKET AF. When selecting for ARISTOTLE criteria, apixaban users had significantly lower stroke/SE risk versus VKA (HR 0.57; 95% CI 0.34 to 0.94) while no reduction was observed with rivaroxaban (HR 0.98; 95% CI 0.68 to 1.40). When selecting for ROCKET AF criteria, safety and efficacy versus VKA were similar across the NOACs. CONCLUSION: Apixaban and rivaroxaban showed similar results versus VKA in high-risk patients selected according to ROCKET AF criteria, whereas differences emerged when selecting for the more inclusive ARISTOTLE criteria. Our results highlight the importance of trial selection criteria in interpreting trial results and underline the problems faced in comparing treatments across rather than within clinical trials.
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Fibrilación Atrial , Inhibidores del Factor Xa , Selección de Paciente , Pirazoles , Piridonas , Rivaroxabán , Accidente Cerebrovascular , Humanos , Fibrilación Atrial/tratamiento farmacológico , Fibrilación Atrial/complicaciones , Inhibidores del Factor Xa/uso terapéutico , Inhibidores del Factor Xa/administración & dosificación , Accidente Cerebrovascular/prevención & control , Accidente Cerebrovascular/etiología , Pirazoles/uso terapéutico , Piridonas/uso terapéutico , Piridonas/efectos adversos , Piridonas/administración & dosificación , Rivaroxabán/administración & dosificación , Rivaroxabán/uso terapéutico , Masculino , Femenino , Anciano , Resultado del Tratamiento , Sistema de Registros , Administración Oral , Factores de Riesgo , Ensayos Clínicos Controlados Aleatorios como Asunto/métodos , Medición de Riesgo/métodos , Anticoagulantes/uso terapéutico , Vitamina K/antagonistas & inhibidoresRESUMEN
OBJECTIVE: Type 2 diabetes mellitus (T2DM) is known to be associated with development of left ventricular (LV) dysfunction and heart failure (HF). The study aimed to determine the prevalence of LV dysfunction and HF in unselected out-patients with T2DM with no previous cardiac history and to correlate LV dysfunction and HF with demographic and comorbid characteristics. METHODS: This cross-sectional study conducted at 27 centers in India captured demographic and clinical data through electronic case record forms. B-type natriuretic peptide of >105 pg/mL was used to diagnose HF and two-dimensional echocardiography was used to assess LV dysfunction. RESULTS: Of the 615 patients, 54.3 % (n = 334) were males; mean age was 57.4 ± 10.48 years. More than one-third of the patients had T2DM duration of >10 years (n = 238; 38.7 %), with hypertension as the most prevalent comorbidity (n = 372, 78.6 %). Approximately 61.3 % of the patients had LV hypertrophy. The mean LV mass was 135.0 ± 56.16 g (95 % CI 130.28, 139.70). The prevalence of any type of LV dysfunction, including systolic or diastolic dysfunction and HF was 55 % (95 % CI 51.0, 59.0) and 10 % (95 % CI 7.0, 12.0), respectively. A negligible but statistically significant correlation was observed between LV dysfunction and T2DM duration (p = 0.011), alongside HF and age (p < 0.0001). CONCLUSION: Real-world data from this registry from India demonstrates a substantial burden of LV dysfunction and HF in individuals with T2DM in India. It is imperative to formulate strategies for early identification of LV dysfunction in individuals with T2DM for prevention and consequent management of HF.
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Diabetes Mellitus Tipo 2 , Insuficiencia Cardíaca , Disfunción Ventricular Izquierda , Masculino , Humanos , Persona de Mediana Edad , Anciano , Femenino , Diabetes Mellitus Tipo 2/complicaciones , Diabetes Mellitus Tipo 2/epidemiología , Diabetes Mellitus Tipo 2/diagnóstico , Pacientes Ambulatorios , Prevalencia , Estudios Transversales , Insuficiencia Cardíaca/diagnóstico , Insuficiencia Cardíaca/epidemiología , Insuficiencia Cardíaca/tratamiento farmacológico , Disfunción Ventricular Izquierda/diagnóstico , Disfunción Ventricular Izquierda/epidemiología , Disfunción Ventricular Izquierda/etiología , Función Ventricular IzquierdaRESUMEN
INTRODUCTION: Sudden cardiac death (SCD) is the most lethal manifestation of heart disease. In an Indian study the SCDs contribute about 10% of the total mortality and SCD post ST elevation myocardial infarction (MI) constitutes for about half of total deaths. OBJECTIVE: Given the limitations of existing therapy there is a need for an effective, easy to use, broadly applicable and affordable intervention to prevent SCD post MI. Leading cardiologists from all over India came together to discuss the potential role of n-3 acid ethyl esters (90%) of eicosapentaenoic acid (EPA) 460 mg & docosahexaenoic acid (DHA) 380 mg in the management of post MI patients and those with hypertriglyceridemia. RECOMMENDATIONS: Highly purified & concentrated omega-3 ethyl esters (90%) of EPA (460 mg) & DHA (380 mg) has clinically proven benefits in improving post MI outcomes (significant 15% risk reduction for all-cause mortality, 20% risk reduction for CVD and 45% risk reduction in SCD in GISSI-Prevenzione trial) and in reducing hypertriglyceridemia, and hence, represent an interesting option adding to the treatment armamentarium in the secondary prevention after MI based on its anti-arrhythmogenic effects and also in reducing hypertriglyceridemia.
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Antiarrítmicos/uso terapéutico , Muerte Súbita Cardíaca/prevención & control , Ácidos Docosahexaenoicos/uso terapéutico , Ácido Eicosapentaenoico/uso terapéutico , Hipertrigliceridemia/tratamiento farmacológico , Hipolipemiantes/uso terapéutico , Infarto del Miocardio/prevención & control , Servicios Preventivos de Salud , Consenso , Muerte Súbita Cardíaca/etiología , Combinación de Medicamentos , Humanos , Hipertrigliceridemia/complicaciones , Hipertrigliceridemia/mortalidad , India/epidemiología , Infarto del Miocardio/etiología , Infarto del Miocardio/mortalidad , Medición de Riesgo , Factores de Riesgo , Resultado del TratamientoRESUMEN
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.
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Cardiología , Hipertensión , American Heart Association , Amlodipino/farmacología , Amlodipino/uso terapéutico , Antagonistas de Receptores de Angiotensina/farmacología , Antagonistas de Receptores de Angiotensina/uso terapéutico , Antihipertensivos/uso terapéutico , Presión Sanguínea , Calcio/uso terapéutico , Bloqueadores de los Canales de Calcio , Quimioterapia Combinada , Objetivos , Humanos , Hipertensión/tratamiento farmacológico , Estudios Prospectivos , Análisis de la Onda del Pulso , Telmisartán/farmacología , Telmisartán/uso terapéutico , Resultado del Tratamiento , Estados Unidos/epidemiologíaRESUMEN
Aim: To study genetic variants in patients of familial dilated cardiomyopathy. Methodology: Patients with reduced ejection fraction of less than 45% and dilated left ventricle are considered to have dilated cardiomyopathy. Clinical history was taken and possible secondary causes of dilated cardiomyopathy were excluded. Family history of ≥2 affected relatives or sudden cardiac death in a relative with age less than 35 years were included. Such patients blood sample were sent for next generation sequencing and analysed for presence of genetic variants. Results: As part of pilot study 20 patients (44% were female and 66% were male) were included. There was presence of 16 different pathogenic variants in 14 patients. Two patients had more than one variants in them. Most common of which were sarcomeric mutations constituting 32%. Titin followed by Filamin, Lamin and Desmosomal where the most commonly repeated mutations. Discussion: In our patients of familial dilated cardiomyopathy, 70% were detected to have pathogenic variants in them. Most common variations were seen on Titin gene. Thus those with familial dilated cardiomyopathy should be considered for next generation sequencing. First degree relatives of those with pathogenic variants should be screened using cascade testing for earlier detection and disease monitoring in them.
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Coronary artery diseases (CADs) are preventable and controllable disorders, but they continue to be a major cause of morbidity and premature mortality across globe. India is projected to have 62 million CAD patients by 2015, with nearly 1/3rd of this burden shared by patients younger than 40 years. The renin-angiotensin-aldosterone system (RAAS) plays a pivotal role in blood pressure (BP) regulation and fluid and electrolyte homoeostasis. Activation of RAAS has long been implicated in the pathogenesis of acute myocardial infarction (AMI) and benefits of inhibition of RAAS as an effective way to intervene in the pathogenesis of AMI is well documented. In the setting of AMI, angiotensin-II plays a significant detrimental role, contributing to cardiac remodeling, a process that predisposes to subsequent arrhythmia and cardiac failure. Angiotensin converting enzyme inhibitors (ACEls) play a key role in the clinical management of several cardiovascular disease (CVD)s such as AMI, by inhibiting the actions of angiotensin-II, ACEIs would be expected to modify unwanted post-AMI events. ACEIs trials have tested AMI patients with two different approaches: selective (those with left ventricular dysfunction (LVD) treated over a long-term) and relatively unselective (those treated early over the course and for a short-period, up to 6 weeks). In general, results are consistent and beneficial as regards to reduction in both short-term & long-term mortality and heart failure. There are evidences that suggest yielding of an extra protection (reduced mortality and occurrence of severe LVD) with early introduction of ACEIs in the course of AMI. Trials have also shown ACEIs effective and consistent protection against re-infarction and management of arrhythmias after AMI. Large clinical trials have proven ACEIs to be superior to ARB, in preventing CV deaths in high-risk AMI subjects. They have proven to be safe & effective in diabetic & older population. With wealth of evidence available supporting use of ACEIs in patients with MI, The use of ACEIs in AMI has moved form experimental to standard therapy.
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Inhibidores de la Enzima Convertidora de Angiotensina/uso terapéutico , Infarto del Miocardio/tratamiento farmacológico , Humanos , Infarto del Miocardio/fisiopatología , Función Ventricular Izquierda/efectos de los fármacosRESUMEN
Hypertension (HTN) is a globally prevalent non-communicable disease contributing significantly to cardiovascular (CV) morbidity and mortality. In achieving control of HTN, therapeutic adherence plays a crucial role. Studies from India identify varying rates of adherence to antihypertensive medications. Multiple factors determine treatment adherence in HTN. In India, factors such as lower socioeconomic status, health literacy, asymptomatic nature of disease, forgetfulness, cost of medications, and duration of HTN determine the adherence. An excellent physician-patient relationship incorporating adequate counseling along with the use of other methods can identify poor adherence. Improving adherence necessitates incorporating a multipronged approach with strategies directed at physicians, patients, and health systems. With innovation in therapeutics, the pharmaceutical sector can contribute significantly to improve adherence. Furthermore, increasing adherence to lifestyle interventions can help achieve better HTN control and improve CV outcomes. In the Indian context, more emphasis is necessary on patient education, enhanced physician-patient relationship and communication, increased access to health care, and affordability in improving therapeutic adherence in HTN.
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Testimonio de Experto , Hipertensión , Antihipertensivos/uso terapéutico , Humanos , Hipertensión/tratamiento farmacológico , Hipertensión/epidemiología , India/epidemiología , Cumplimiento de la Medicación , Cumplimiento y Adherencia al TratamientoRESUMEN
Hypertension is a major public health problem and leading cause for diseases involving cardiovascular & renal system. It is fourth largest contributor for premature deaths in developed countries and seventh largest in developing world. The major pharmacological strategies currently utilized for hypertension management include volume control with diuretics, suppression of central and peripheral sympathetic nervous system activity, vasodilatation with ion channel manipulation and blockade of renin-angiotensin-aldosterone system. Activation of the renin-angiotensin-aldosterone system in the pathogenesis of cardiovascular diseases and renal disease is well established. It also has been established that inhibition of renin-angiotensin-aldosterone system, is an effective way to intervene with pathogenesis of these disorders. Therapies like beta blockers, renin inhibitors, angiotensin converting enzyme inhibitors, angiotensin receptor blockers and aldosterone inhibitors, that inhibit renin-angiotensin-aldosterone system have proven to be highly successful for treatment of hypertension & related cardiovascular diseases. Renin inhibitors block the renin-angiotensin-aldosterone system at its origin, and thus offer a new approach to pharmacotherapy of Hypertension. Aliskiren is the first in a new class of orally active, non-peptide, low molecular weight direct renin inhibitor available for clinical use and potential new approach to the blockade of the renin-angiotensin-aldosterone system. Studies in humans demonstrate to an effectual blood Pressure lowering effect of aliskiren with placebo like tolerability, when used as monotherapy or in combination with other agents and has the potential to be useful in this wide spectrum of conditions
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Amidas/administración & dosificación , Antihipertensivos/administración & dosificación , Fumaratos/administración & dosificación , Hipertensión/tratamiento farmacológico , Renina/antagonistas & inhibidores , Administración Oral , Adolescente , Adulto , Anciano , Amidas/sangre , Amidas/farmacología , Fumaratos/sangre , Fumaratos/farmacología , Humanos , Persona de Mediana Edad , Farmacocinética , Ensayos Clínicos Controlados Aleatorios como Asunto , Sistema Renina-Angiotensina , Factores de TiempoRESUMEN
Being one of the most widely prevalent diseases throughout the world, hypertension has emerged as one of the leading causes of global premature morbidity and mortality. Hence, blood pressure (BP) measurements are essential for physicians in the diagnosis and management of hypertension. Current American College of Cardiology/American Heart Association (ACC/AHA) guidelines recommend initiating antihypertensive medications on the basis of office BP readings. However, office BP readings provide a snapshot evaluation of the patient's BP, which might not reflect patient's true BP, with the possibility of being falsely elevated or falsely low. Recently, there is ample evidence to show that ambulatory blood pressure monitoring (ABPM) is a better predictor of major cardiovascular events than BP measurements at clinic settings. ABPM helps in reducing the number of possible false readings, along with the added benefit of understanding the dynamic variability of BP. This article will focus on the significance of ambulatory BP, its advantages and limitations compared with the standard office BP measurement and a brief outlook on its use and interpretation to diagnose and treat hypertension.
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Algoritmos , Monitoreo Ambulatorio de la Presión Arterial/métodos , Presión Sanguínea/fisiología , Hipertensión/fisiopatología , Cooperación del Paciente , HumanosRESUMEN
OBJECTIVE: This observational study was designed to understand the usage pattern of ticagrelor in real-life clinical practice among a large number of acute coronary syndrome (ACS) patients undergoing percutaneous coronary intervention (PCI), coronary artery bypass graft (CABG), or medical management (MM). The study also recorded clinical events, i.e., bleeding, dyspnea, and cardiovascular (CV) events, reported by the investigator during the follow-up period. METHODS: The ACS patients aged ≥18 years hospitalized for ACS and were prescribed ticagrelor upon discharge or ≤1 month and patients who underwent PCI, CABG, or MM for ACS were enrolled. The subjects were followed up for a period of up to 12 months. The data were collected on a case report form. RESULT: The study recruited 2997 subjects from 49 sites in India. Approximately half of the ACS subjects had ST segment elevation myocardial infarction (48.9%), and PCI was used as management in 92.4% subjects. The mean (±SD) duration of use of ticagrelor was 314 (±110.2) days over a period of 12 months. Of 136 subjects (4.5%) who experienced any clinical events, CV deaths were reported in 20 (0.7%), myocardial infraction in 19 (0.6) subjects and ischemic stroke in 23 (0.8%) subjects, and severe dyspnea was reported in 68 (2.2%) subjects. Out of 33 bleeding cases, 25 (0.8%) subjects had thrombolysis in myocardial infarction (TIMI) minimal, seven (0.2%) had TIMI minor, and one TIMI major. Platelet inhibition and patient outcomes (PLATO) major was reported in two subjects and CABG bleed in one subject. The incidence of PLATO defined major and minimal bleeding were lower in subjects undergoing fibrinolysis than overall population. CONCLUSION: Ticagrelor has been used across ACS types and in different management strategies in real world settings in India. The incidence of clinical events was lower as compared with data in literature. ClinicalTrials.gov Identifier: NCT02408224.
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Síndrome Coronario Agudo/tratamiento farmacológico , Inhibidores de Agregación Plaquetaria/uso terapéutico , Ticagrelor/uso terapéutico , Síndrome Coronario Agudo/terapia , Anciano , Puente de Arteria Coronaria , Femenino , Humanos , India , Masculino , Intervención Coronaria Percutánea , Inhibidores de Agregación Plaquetaria/efectos adversos , Estudios Prospectivos , Ticagrelor/efectos adversosRESUMEN
BACKGROUND: Acute coronary syndrome (ACS) is associated with emergency hospitalizations, and there are limited real-world data on clinical outcomes in post-ACS Asian patients. This article presents data on the Indian subgroup from the Long-term Follow-up of Antithrombotic Management Patterns in Acute Coronary Syndrome Patients in Asia (EPICOR-Asia) study. METHODS: EPICOR included patients with ACS [ST-segment elevation myocardial infarction (STEMI), non-ST-segment elevation myocardial infarction (NSTEMI), or unstable angina (UA)]. The study had two phases: acute phase and follow-up phase. The primary objective was to describe short- and long-term antithrombotic management patterns. RESULTS: EPICOR-India enrolled 2468 patients (STEMI-1482; NSTEMI-562; and UA-424). Cardiovascular risk factors were present in 1362 (55.2%) patients. Prehospital care was received by 879 (35.6%) patients, and the median time from the symptom onset to the first medical attention was 3 h (0.08, 100.33). The most common drug regimen prescribed during the acute phase was ≥2 antiplatelet agents + anticoagulants with no glycoprotein IIb/IIIa inhibitors and at discharge were aspirin + clopidogrel. About 78.8% of patients were discharged on dual antiplatelet therapy (DAPT) and 16%, on single antiplatelet therapy (SAPT). At 23 months after discharge, 55.6% were on DAPT, while 16.4% were on SAPT. Postdischarge outcomes at 2 years included death in 165 (6.7%) patients, composite events of death, myocardial infarction (MI), or ischemic stroke in 182 (7.4%) patients, and bleeding events in seven (0.3%) patients. CONCLUSION: This study showed a gap between international recommendations and implementation for managing ACS in Indian patients. Most of the patients prefer to undergo invasive management instead of non-invasive therapy. At the end of the 2-year follow-up, more than half of the population was receiving DAPT, with most patients on receiving a combination of aspirin and clopidogrel. The mortality along with composite events of death, MI, or ischemic stroke was highest for patients with NSTEMI.
Asunto(s)
Síndrome Coronario Agudo/tratamiento farmacológico , Fibrinolíticos/uso terapéutico , Hospitalización/tendencias , Pacientes Internos , Medición de Riesgo/métodos , Terapia Trombolítica/métodos , Síndrome Coronario Agudo/epidemiología , Electrocardiografía , Femenino , Estudios de Seguimiento , Humanos , India/epidemiología , Masculino , Persona de Mediana Edad , Morbilidad/tendencias , Estudios Prospectivos , Tasa de Supervivencia/tendencias , Factores de Tiempo , Resultado del TratamientoRESUMEN
Heart rate (HR) is strongly associated with both peripheral and central blood pressures. This association has implications in hypertension (HTN) prognosis and management. Elevated HR in HTN further elevates the risk of adverse outcomes. Evidence suggests that HR is an independent risk factor for cardiovascular (CV) and total mortality in patients with HTN. With objective to engage physicians and researchers in India to identify and discuss the implications related to HR management in HTN, experts in the HTN management provided consensus recommendations. The key expert recommendations included the following. (i) Heart rate (HR) has inverse relationship with the central aortic pressure, whereby reduction in HR is associated with an increase in central aortic pressure. This counter-balances the benefit of HR reduction with the harmful effects of rising central aortic pressure. (ii) Increase in the resting HR is associated with increased risk of incident HTN. A linear association between the two is observed especially in individuals with HR >80 bpm. (iii) A reduced HR variability further adds to the propensity for the development of HTN, especially in men. (iv) Each 10 beats per minute increase in the resting HR can substantially increase the risk of adverse CV and mortality outcomes. On treatment HR provides a better prognostic guide. (v) Ambulatory HR with day-time and night-time HR evaluation may also suggest different impact on outcomes. (vi) Target HR in patients with HTN remains unclear. Generally, HR<70 bpm on beta blocker (BB) treatment is advised which may be further lowered in patients with comorbidities like heart failure and coronary artery disease. (vii) Adopting healthy lifestyle approaches to keep check on BP and HR is essential. (viii) Use selective beta-1 blocker in symptomatic cases with elevated HR beyond 80-85 mmHg. BBs are expected to benefit by lowering HR by nearly 10 bpm. Preference should be given to newer beta-blockers which reduce HR and both peripheral and central blood pressure to derive comprehensive advantage of this dual action. (ix) It still remains unclear whether reducing HR in HTN without comorbidities alters the CV and mortality outcomes.