Supporting the Management of Patients with Heart Failure within Asia-Pacific, Middle East, and African Countries: A Toolbox for Healthcare Providers.

OBJECTIVES: The management of heart failure (HF) is most effective when established treatment guidelines and recommendations are followed. We aimed to develop a "Toolbox" of resources to facilitate the care of patients with acute HF and chronic HF with reduced ejection fraction delivered by healthcare professionals across Asia-Pacific, the Middle East and Africa (henceforth referred to as the "Region"). METHODS: We convened a group of cardiologists from across the Region to develop a set of checklists, algorithms, and other practical resources. These resources are based on our experiences, current evidence, and international guidelines. RESULTS: The HF Toolbox comprises three simplified sets of resources for use in the Emergency Room (ER), hospital and outpatient settings. Resources include admission and discharge checklists, treatment algorithms, recommendations for forming a multidisciplinary team, patient education, and self-management materials, and key performance indicators to monitor whether standards of care are met or maintained, or should be improved. CONCLUSIONS: The HF Toolbox provides practical resources to simplify the management of patients with HF and to support the formation of HF programs in the Region. The Toolbox is aligned with current guideline recommendations and can support the management of patients from presentation in the ER, through hospital admission to outpatient care.

Rediscovering Chirality - Role of S-Metoprolol in Cardiovascular Disease Management.

BACKGROUND: The process of drug discovery and development today encompass a myriad of paths for bringing a new therapeutic molecule that has minimal adverse effects and of optimal use to the patient. Chirality was proposed in the direction of providing a purer and safer form of drug [Ex- cetrizine and levocetrizine]. Decades have passed since the introduction of this concept and numerous chiral molecules are in existence in therapeutics, yet somehow this concept has been ignored. This review aims to rediscover the ignored facts about chirality, its benefits and clear some common myths considering the example of S-Metoprolol in the management of Hypertension and other cardiovascular diseases. METHODS: Relevant articles from Pubmed, Embase, Medline and Google Scholar were searched using the terms "Chiral", "Chirality", "Enantiomers", "Isomers", "Isomerism", "Stereo-chemistry", and "S-Metoprolol". Out of 103 articles found 17 articles mentioning in general about the concept of chirality and articles on study of S-metoprolol in various cardiovascular diseases were then reviewed. RESULTS: Many articles mention about the importance of chirality yet the concept has not been highlighted much. Clear benefits with chiral molecules have been documented for various drug molecules few amongst them being anaesthetics, antihypertensives, antidepressants. Benefits of S-metoprolol over racemate are also clear in terms of responder rates, dose of administration and adverse effects profile in various cardiovascular diseases. CONCLUSIONS: Chirality is a good way forward in providing a new drug molecule which is safe with lesser pharmacokinetic and pharmacodynamics variability, lesser side effects and more potent action. S-metoprolol is chirally pure form of racemate metoprolol and has lesser side effects, is safer in patients of COPD and Diabetes who also have hypertension and comparable responder rates at half the doses when compared to racemate.

Parachute tricuspid valve in an asymptomatic adult.

Parachute tricuspid valve is a rare anomaly usually reported in small children. This report describes transthoracic and trans-oesophageal echocardiographic (TEE) features of parachute mitral valve in an adult patient.

Normative values of cardiac chamber dimensions and global longitudinal strain in Indians: the Indian Normative Data of Echocardiography Analyzed (INDEA) study.

Ethnic-specific normal reference ranges for various echocardiographic measurements are essential for accurate diagnostic interpretation and clinical decision-making. Unfortunately, such normative data for Indians is lacking. A total of 880 healthy volunteers (mean age 39.7 ± 12.3 years, 63.8% men) from six centers across different regions of India were enrolled in this study. Comprehensive transthoracic echocardiographic study was performed in all subjects, in accordance with the existing guideline recommendations. Cardiac chamber dimensions [Left ventricular (LV) end-diastolic diameter and volume; right ventricular (RV) basal diameter, left atrial volume] were obtained and indexed to body surface area. LV ejection fraction, LV global longitudinal strain (LVGLS) and measures of RV systolic function were also obtained. The subjects were divided into 3 age groups (35 years or less, 36-55 years and 56 years or above) for analysis. Age- and gender-specific reference values for various clinically relevant echocardiographic parameters were derived. Compared with women, men had larger cardiac chamber dimensions and volumes, but not when indexed. In contrast, the women had higher LV systolic function, but right ventricular systolic function was not different. The indexed LV volumes in our study were much smaller than those recommended in the American Society of Echocardiography (ASE)/European Association of Cardiovascular Imaging (EACVI) 2015 chamber quantification guidelines but were similar to those reported in the Indian patients included in the recent World Alliance Societies of Echocardiography (WASE) Normal Values Study. LVGLS was also comparable with the WASE data. INDEA study is the first, multi-centric study to provide normal echocardiographic references values for Indian adults. Our findings underscore the need to follow India-specific reference values, instead of those recommended by the ASE/EACVI, which are largely applicable to the western populations.

Acute decompensated heart failure in a North Indian community hospital: Demographics, clinical characteristics, comorbidities and adherence to therapy.

BACKGROUND: Acute decompensated heart failure (ADHF) is a growing public health problem in the community. Limited and often contradictory data are available from small studies published from India. Objective of this study was to report clinical characteristics, outcome, and discharge treatment strategies of these patients from a single community hospital. METHODS: In this observational prospective study from a multispeciality community hospital from North India, data were collected to include demographics, clinical characteristics, management strategies, and prognosis in 428 patients with ADHF admitted for more than two consecutive years (January 2017 through December 2018). RESULTS: The study included 428 patients (mean age 61 ± 14 years) of whom 59% were male. ADHF with reduced left ventricular ejection fraction (HFrEF) was present in 77% subjects; Preserved (≥50%) and midrange ejection fraction (41-49%) with ADHF was observed in 12% and 11% patients, respectively. Ischemic etiology was noticed in 69% of the population. Prior myocardial revascularisation was observed in 47% of all and in 71% of those with ischemic heart disease. Major comorbidities included type 2 diabetes mellitus (60.7%), arterial hypertension (51%), anemia (54%), chronic kidney disease (29%), atrial fibrillation (16%), and hypothyroidism (9%). Mean hospital stay was 4.5 ± 3.2 days (inter-quartile range: 2-9 days). In-hospital mortality was 8.4% (36 patients) and there were additional 17% deaths over 6 months after discharge. At-discharge medication in those with HFrEF included anti-renin-angiotensin agents (57%), beta-adrenergic receptor blocking agents in 53%, mineralocorticoid receptor antagonists in 34%, ivabradine in 21%, and digoxin in 5%. Angiotensin-neprilysin inhibitor was prescribed to 21% patients at discharge. Ferric carboxymaltose use was in 7.5% of all despite a high prevalence of anemia (54%). Vaccination status at discharge was not available in majority. CONCLUSION: The commonest cause of ADHF presenting to this community hospital was HFrEF of ischemic etiology. It is associated with significant in-hospital mortality. There is substantial under-use of guideline-recommended chronic heart failure therapies at hospital discharge. These data provide useful information which can be used to improve patient care and formulate future strategies for management of ADHF.

Blood pressure and heart rate related to sex in untreated subjects: the India ABPM study.

Women are underrepresented in groups of patients seeking hypertension care in India. The present paper reports trends in office and ambulatory blood pressure measurement (OBPM, ABPM) and 24-h heart rate (HR) with sex in 14,977 subjects untreated for hypertension (aged 47.3 ± 13.9 years, males 69.4%) visiting primary care physicians. Results showed that, for systolic blood pressure (SBP), females had lower daytime ABPM (131 ± 16 vs. 133 ± 14 mm Hg, P < .001) but higher nighttime ABPM (122 ± 18 vs. 121 ± 16 mm Hg, P < .001) than males. Females had higher HR than men at daytime (80 ± 11 vs 79 ± 11.5 bpm) and nighttime (71 ± 11 vs 69 ± 11), respectively (all P < .001). Dipping percentages for SBP (7.4 ± 7.3 vs 9.3 ± 7.4%), DBP (10.1 ± 8.6 vs. 12.3 ± 8.9%), and HR (10.7 ± 7.9 vs. 12.8 ± 9.2%) were lower (P < .001) for females than for males, respectively. Females more often had isolated nighttime hypertension as compared to males (14.9%, n = 684% vs 10.6%, n = 1105; P < .001). BP patterns and HR showed clear differences in sex, particularly at nighttime. As females were more often affected by non-dipping and elevated nighttime SBP and HR than males, they should receive ABPM, at least, as frequently as men to document higher risk necessitating treatment.

Self-blood pressure measurement as compared to office blood pressure measurement in a large Indian population; the India Heart Study.

OBJECTIVE: India Heart Study (IHS) is aimed at investigating the agreement between office blood pressure measurement (OBPM) and self (S)BPM in a hypertension-naive population. METHODS: A total of 18 918 individuals (aged 42.6 ±â€Š11.7 years, 62.7% men), visiting 1237 primary care physicians across India, underwent OBPM. They performed SBPM for a period of 1 week using a validated oscillometric BP monitor that was preprogrammed to adhere to a guideline-based SBPM-schedule and blinded to the results. Thereafter, individuals underwent a second OBPM. Available laboratory results were obtained. Thresholds for elevated OBPM and SBPM were 140/90 and 135/85 mmHg, respectively. RESULTS: On the basis of first-visit OBPM and SBPM, there were 5787 (30.6%) individuals with normotension; 5208 (27.5%) with hypertension; 4485 (23.7%) with white-coat hypertension (WCH) and 3438 (18.2%) with masked hypertension. Thus, a diagnosis contradiction between SBPM and first-visit OBPM was seen in 9870 (41.9%) individuals. On the basis of second-visit OBPM, the normotension, hypertension, WCH and masked hypertension prevalence values were 7875 (41.6%); 4857 (25.7%); 2397 (12.7%) and 3789 (20.0%). There was poor agreement (kappa value 0.37) between OBPM of visit 1 and 2 with a diagnosis difference in 6027 (31.8%) individuals. The majority of masked hypertension and WCH individuals had BP values close to thresholds. CONCLUSION: There was a poor agreement between OBPM of visit1 and visit 2. Likewise, the agreement between OBPM at both visits and SBPM was poor. SBPM being considered to have a better correlation with patient prognosis should be the preferred method for diagnosing hypertension.

Congenitally unguarded tricuspid valve orifice with multiple other defects in a child with refractory heart failure.

Congenitally unguarded tricuspid valve orifice, a variant of tricuspid valve dysplasia, is a rare malformation with protean manifestations. This report describes a 5-year old child with refractory heart failure who, on echocardiography, was found to have unguarded tricuspid valve orifice with severe tricuspid regurgitation, pulmonary valve dysplasia with severe pulmonary regurgitation , cor triatriatum dexter , myxomatous mitral valve , perimembranous ventricular septal defect and a diverticulum of the right ventricular outflow tract. The management options for this child are discussed.

Management of hypertension in heart failure: striking lack of evidence for a common problem.

Arterial hypertension is common either as a concomitant or pathogenetic entity in patients with systolic heart failure and in those with heart failure and normal ejection fraction. In free-living communities, more than half of the patients of heart failure with normal ejection fraction (HFnEF) have hypertension somewhat more than that occurring in presence of systolic heart failure. In acute heart failure, co-existent hypertension is much more frequent. Separate guidelines exist for management of hypertension and systolic heart failure. There are no published guidelines for management of HFnEF. There are contradictory recommendations with regard to drug management of hypertension and systolic heart failure. This review examines the available literature on this common co-existing combination and suggests some new recommendations.

Prime time use of tissue Doppler echocardiography: what have we gained?

In daily practice, Tissue Doppler Echocardiography (TDI) is used to estimate left ventricular filling pressures, categorize diastolic dysfunction, identify patients with heart failure (HF) with normal ejection fraction, differentiate constrictive pericarditis from restrictive cardiomyopathy, to prognosticate acute coronary syndrome, valvular heart disease syndrome of HF etc, correlate exercise capacity and symptoms, differentiate physiological versus pathological hypertrophy, assessment of intraventricular dyssynchrony, regional and global systolic and diastolic properties, detection of right ventricular function and possible carriers of genetic cardiomyopathies like Fabry's disease and hypertrophic cardiomyopathy, etc. Its role in adding incremental value to stress echocardiography, subclinical dysfunction evaluation, cardiac transplant rejection, cardiotoxicity of anti-cancer drugs, predicting occurrence and reversion of atrial fibrillation, predicting aortic catastrophies etc, although very encouraging has not found many users. It was intuitively considered invaluable in detecting subclinical myocarditis, acute rheumatic fever, Chaga's disease and localization of atrioventricular accessory pathways with manifest conduction, but could not find prime time readiness. In a similar manner, tissue-velocity derived deformation parameters have not found prime time use, despite making great inroads into the mysteries of muscle mechanics. Part of the problem lies in their emphasis on unidirectional information of a structure which is essentially multidimensional. The other problems have been angle-dependency and low signal-to-noise ratio in deformation imaging which has restricted its use to highly experienced operators rather than more democratic use. Validation studies did indicate its great potential. TDI-derived imaging paved the way for non-Doppler multidimensional deformation imaging which is slowly gaining ground.

Comparsion of central aortic pressure to brachial artery pressure in hypertensive patients on drug treatment: An observational study.

BACKGROUND: High brachial blood pressure (BP) is an important cardiovascular risk factor. However major differences in central systolic BP can occur among people with similar brachial systolic BP. It is known that central aortic pressure responses to antihypertensive therapy can differ substantially from brachial BP responses, such that true treatment effects cannot be gauged from conventional brachial BP. OBJECTIVE: The purpose of this study was to examine if adequate control of brachial BP was concordant with central BP control in treated hypertensive subjects. METHODS: Non-invasive acquisition of brachial and central pressures and wave forms was obtained from 100 subjects with systemic arterial hypertension on drug therapy and 50 healthy individuals. After all necessary precautions according to the guidelines, brachial and central pressures and wave forms were measured 3 times at 5 min intervals using an upper arm cuff (AGEDIO K900 HDP Stolberg, Germany). The mean of the last two measurements of each was recorded as representative of brachial and central aortic pressures and wave forms. RESULTS: In 45 of 50 healthy subjects with normotension (41 male, 9 female, mean age 38 years), central systolic BP was <120 mmHg. Five healthy subjects (10%) had falsely normal brachial systolic BP, but raised central systolic BP. Out of 100 patients with known hypertension and on various anti-hypertensive drug combinations, 9 had uncontrolled hypertension (defined as brachial BP of >140/90 mmHg and central systolic BP > 120 mmHg). Ninety-one patients had controlled hypertension as estimated by brachial BP of whom, 37 patients had uncontrolled central BP (systolic BP > 120 mmHg). Thus, brachial BP estimation over-estimated control of hypertension in 41% patients (p < 0.01). Central systolic BP control was inadequate in 9 out of 41 patients (22%) on angiotensin receptor blocking therapy versus 27 out of 31 (87%) patients on beta-blocking therapy (p < 0.05). Thus, there was a marked mismatch with regard to control of hypertension between central and peripheral measurements. CONCLUSION: Central BP measurement provides important information on true prevalence of uncontrolled hypertension in the outpatient setting which is higher than current estimates from brachial BP measurement. Optimal BP control by central BP is far less than observed from peripheral pressure measurement. Residual cardiovascular risk despite adequate control of brachial BP can also be explained by the substantial frequency of uncontrolled hypertension as determined by the central BP in patients with apparently controlled hypertension. Both these conclusions have significant impact on prevalence of uncontrolled hypertension and its proper management. Further studies are required to confirm the current data and to provide evidence that treatment decisions based on measurements of central BP result in better outcomes.

Systolic aortic regurgitation in rheumatic carditis: Mechanistic insight by Doppler echocardiography.

BACKGROUND: Aortic regurgitation (AR) usually occurs in diastole in presence of an incompetent aortic valve. Systolic AR is a rare phenomenon occurring in patients with reduced left ventricular systolic pressure and atrial fibrillation or premature ventricular contractions. Its occurrence is a Doppler peculiarity and adds to the hemodynamic burden. AIM: Rheumatic carditis is often characterised by acute or subacute severe mitral regurgitation (MR) due to flail anterior mitral leaflet and elongated chords. In patients with acute or subacute MR, developed left ventricular systolic pressure may fall in mid and late systole due to reduced afterload and end-systolic volume and may be lower than the aortic systolic pressure, causing flow reversal in aorta and systolic AR. MATERIAL AND METHODS: 17 patients with acute rheumatic fever were studied in the echocardiography lab during the period 2005-2015. Five patients had severe MR of which two had no AR and hence were excluded from the study. Three young male patients (age 8-24 years) who met modified Jones' criteria for rheumatic fever with mitral and aortic valve involvement were studied for the presence of systolic AR. RESULTS: In presence of acute or subacute severe MR, flail anterior mitral valve and heart failure, all three showed both diastolic and late systolic AR by continuous-wave and color Doppler echocardiography. CONCLUSION: Systolic AR is a unique hemodynamic phenomenon in patients with acute rheumatic carditis involving both mitral and aortic valves and occurs in presence of severe MR.

Significant intra-valvular pressure loss across EPIC SUPRA and perimount magna supra-annular designed aortic bioprostheses in patients with normal aortic size.

Doppler-derived trans-prosthetic gradients are higher and the estimated effective valve area is smaller than the catheter-derived and directly measured hemodynamic values, mostly due to pressure recovery phenomenon. Pressure recovery to a varying extent is common to all prosthetic heart valves including bioprostheses. Pressure recovery-related differences are usually small except in patients with bileaflet metallic prosthesis, wherein high-pressure local jets across central orifice have been documented since long back and also in patients with narrow aortic root. We describe two patients with normally functioning stented aortic bioprostheses with supra-annular design (EPIC SUPRA and PERIMOUNT MAGNA), wherein very high trans-prosthetic gradients and critically reduced estimated effective valve orifice areas in presence of normal aortic size were consistently recorded over long periods of follow-up. The valve leaflets, however had normal excursion, were thin, opened with a triangular or oblong shape and had expected geometric valve area (1.7 and 1.6cm2 respectively) measured by 3D trans-oesophageal echocardiographic planimetry. Pressure recovery upstream the valves accounted for 20% and 12% of total pressure gradients respectively. Dominant site for pressure drop was intra-valvular (75-85%). Such a phenomenon has not been reported in vivo for these two valve designs.

Acquired discrete subaortic stenosis late after mitral valve replacement.

Although acquired left ventricular outflow obstruction has been reported in a variety of conditions, there are scant reports of its occurrence following mitral valve replacement (MVR). This study describes two female patients, who developed severe discrete subaortic stenosis, five years following MVR. In both cases, the mitral valve was replaced by a porcine Carpentier-Edwards 27-mm bioprosthesis with preservation of mitral valve leaflets. The risk of very late left ventricular outflow tract obstruction after bio-prosthetic MVR with preservation of subvalvular apparatus needs to be kept in mind in symptomatic patients.

Congenitally unguarded tricuspid valve orifice with right ventricular apical isolation in an adult.

Congenitally unguarded tricuspid valve (TV) orifice, a variant of TV dysplasia, is a rare malformation with protean manifestations. This report describes a symptomatic adult male with gross right heart failure and atrial fibrillation, who was found to have an unguarded TV orifice with isolation of the trabecular apical cavity of the right ventricle (RV) and muscular ridges separating outflow tract (forme-fruste of the double-chambered RV). The right ventricular outflow tract remained patent.

Parachute mitral valve and Pacman deformity of the ventricular septum in a middle-aged male.

Parachute mitral valve and Pacman heart (incomplete muscular ventricular septal defect) are rare congenital deformities usually reported in infants and children. Very few adult patients with these anomalies are reported but the association of the two has not been described. This report describes a 56-year-old male with exertional dyspnea who was detected to have moderately severe mitral regurgitation and mitral stenosis. Typical parachute deformity of the mitral valve with a reduced opening and common attachment of all the chordae to a single posteromedial papillary muscle was evident. The chordae were elongated, lax, and redundant, which is atypical for this anomaly. Incidentally, detected aneurysm of the basal muscular interventricular septum (Pacman deformity or incomplete triangular septal defect) was also present.

Mobile thrombus originating from densely calcified mitral annulus with cerebral embolism.

Mitral annular calcification (MAC) has been considered a predisposition and an association of thrombo-embolic disease. Superimposed thrombus on MAC is under-appreciated as a potential cause of systemic thrombo-embolism. This report describes an elderly gentleman, who had recurrent cerebral embolism and in one of the episodes, a large mobile thrombus was detected on the ventricular surface of calcified mitral annulus. The thrombus disappeared after initiation of anti-coagulation.

Spontaneous dissecting aneurysm of the left atrium complicated by cerebral embolism: A report of two cases with review of literature.

Left atrial dissection is a very uncommon complication of cardiac surgery and usually causes significant hemodynamic compromise. Little is known about spontaneous dissection of the left atrium. Two patients, one middle-aged man and another elderly woman were evaluated following stroke. Routine trans-thoracic echocardiogram showed vertical division of the left atrium with both chambers communicating with each other through an orifice. Detailed trans-oesophageal echocardiographic study revealed dissection of the left atrium producing an additional false chamber (pseudo-aneurysm) placed posterior to the left atrial appendage and above the postero-lateral aspect of mitral annulus. Spontaneous dissection of the left atrium is extremely rare, and there is no report of cerebral embolism associated with it. Review of literature reveals interesting facets of this rare entity.