Management of Heart Failure in a Resource-Limited Setting: Expert Opinion from India.

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.

Strain imaging as an early predictor in acute myocardial infarction - An augmented cross-sectional study.

INTRODUCTION: Cardiac fibres are affected invariably in myocardial infarction, with longitudinal strain being the earliest to be detected in the ischaemic cascade. The present study aims to assess strain imaging in acute myocardial infarction (AMI) patients admitted to the cardiology department at our institute and correlate GLS and DESL findings with other markers for myocardial function. METHODS AND MATERIAL: This augmented cross-sectional study was conducted amongst the patients admitted with diagnosis of AMI. During the study period, 157 subjects were sampled through convenience sampling, and examined as well as tested with routine investigations at baseline. The subjects were then followed through at first, third and six months, and findings noted. Chi-square was used to assess the crude association between sample characteristics. Pearson correlation and student t-test were used to find association between continuous variables. RESULTS: After screening 564 patients, 157 patients were included in the study after fulfilment of inclusion and exclusion criteria. A significant difference was found in baseline GLS scores and NTproBNP levels at 6 months in alive patients with STEMI, t (21.728) = -5.717, p < .001. Out of the 50 NSTEMI patients, 35 (70 %) were positive for ESL, similarly out of 43 STEMI patients without any RWMA, ESL was positive in 39 (90.02 %) patients. CONCLUSIONS: GLS by STE has good correlation with LVEF, WMSI and NT pro-BNP and it is an independent predictor of mortality and heart failure among patients with AMI.

Coronary artery disease in patients with rheumatic valvular heart disease- An analysis from eastern India.

INTRODUCTION: There is insufficient information on the angiographic characteristics of individuals with rheumatic valvular heart disease (VHD) from eastern India. The objective of this research is to gather important data in this area to aid the best surgical outcomes for patients with rheumatic VHD. MATERIALS AND METHODS: 978 consecutive patients with rheumatic VHD, scheduled for surgical intervention, were recruited. RESULT AND CONCLUSION: Mitral valve involvement was observed in 66.1 %, aortic valve in 7.3 % and both valves in 26.6 %. Patients with CAD had significantly higher proportions of severe aortic stenosis (AS). Therefore, addressing the risk factors for CAD is crucial in patients with rheumatic VHD.

Development and validation of a predictive model for the diagnosis of rheumatic heart disease in low-income countries based on two cross-sectional studies.

Objectives: We developed a questionnaire-based risk-scoring system to identify children at risk for rheumatic heart disease (RHD) in rural India. The resulting predictive model was validated in Nepal, in a population with a similar demographic profile to rural India. Methods: The study involved 8646 students (mean age 13.0 years, 46% boys) from 20 middle and high schools in the West Midnapore district of India. The survey asked questions about the presence of different signs and symptoms of RHD. Students with possible RHD who experienced sore throat and joint pain were offered an echocardiogram to screen for RHD. Their findings were compared with randomly selected students without these symptoms. The data were analyzed to develop a predictive model for identifying RHD. Results: Based on our univariate analyses, seven variables were used for building a predictive model. A four-variable model (joint pain plus sore throat, female sex, shortness of breath, and palpitations) best predicted the risk of RHD with a C-statistic of 0.854. A six-point scoring system developed from the model was validated among similarly aged children in Nepal. Conclusions: A simple questionnaire-based predictive instrument could identify children at higher risk for this disease in low-income countries where RHD remains prevalent. Echocardiography could then be used in these high-risk children to detect RHD in its early stages. This may support a strategy for more effective secondary prophylaxis of RHD.

Effectiveness of Amlodipine in the Control of 24-Hour Blood Pressure in Mild-to-Moderate Essential Hypertension: A Prospective, Multicenter, Observational Real-World Study from India.

Background Calcium-channel blockers (CCB) are a mainstay in the management of hypertension (HTN), and amlodipine is the preferred CCB due to its longer half-life and better safety. Patients and methods This practice-based, observational, real-world evidence study assessed the 24-hour ambulatory blood pressure (ABP) control in mild-to-moderate essential hypertensive patients (treatment naïve receiving amlodipine monotherapy, or as add-on therapy) in inadequately controlled blood pressure (BP goal not met after one month of existing therapy). One hundred four (62M/42F) patients between 18 and 65 years of age who received amlodipine 5/10 mg/day for >8 weeks were included after obtaining informed written consent. The primary outcome was a change from baseline in the mean 24-h SBP and DBP on ABP monitoring at eight (±1) weeks. Secondary outcomes were different from baseline in the mean morning, day-time, night-time, and last six-hour dosing interval period. Other outcomes assessed BP variability (dippers and non-dippers), and responder rates based on ABP monitoring and in-clinic trough cuff measurements. Safety outcomes included adverse effects reported, electrocardiogram, and laboratory abnormalities (hepatic and renal function). Changes in BP parameters in different sub-groups (age, gender, BMI, physical activity, occupation, duration of hypertension, the total daily dose of amlodipine, type of amlodipine therapy, and hypertension severity at baseline) were estimated. Results Of the 104 patients, 49 patients (completed eight weeks) were included in the per-protocol (PP) data for efficacy analysis. Safety analysis was done on the intent-to-treat (ITT) dataset. Significant reductions (p<0.0001) from baseline in all BP measurements on ABPM were observed at the end of eight weeks. Similar improvements were observed in office BP recordings. There was a marginal but non-significant (p>0.05) increase in the proportion of dippers and extreme dippers with amlodipine at the end of the eight-week treatment period. Conclusions Amlodipine 5/10 mg/day therapy used as monotherapy or adjuvant therapy provided significant reductions in both office BP and ambulatory BP over eight weeks.

Telmisartan Plus Amlodipine as the Preferred Initial Combination in Newly Diagnosed Indian Patients with Hypertension: An Expert Consensus Statements.

INTRODUCTION: Hypertension (HTN) remains one of the most important risk factors for cardiovascular (CV) diseases and a leading cause of mortality worldwide. Despite improvement in detection and treatment, poor blood pressure (BP) control rates are observed globally. The situation in India is alarming with only 22.5% of patients maintaining their BP under control. Initiating early and effective treatment for HTN helps control BP within normal limits and reduces associated health risks. In India, currently, there are no guidelines on the choice of dual combination treatment that can be considered an initial treatment for newly diagnosed HTN patients to achieve effective BP control and reduce CV risks. OBJECTIVE: To provide consensus recommendations for preferred initial combinations in newly diagnosed Indian patients with HTN. METHODOLOGY: A core group of 100 experts with HTN expertise conceptualized and formulated the four key questions based on answerability, effectiveness, potential for translation to clinical practice, novelty, and potential impact on the healthcare burden. A mix of Delphi and Child Health and Nutrition Research Initiative (CHNRI) methods was adopted for acceptance or refusal of recommendations. Likert scale 1-9 was used for scoring. A score of ≥7 was considered "statement accepted," >6.50 "near to acceptance" and <6.50 "not accepted." A vote of ≥7 by at least two-thirds of the experts (66.66%) was mandatory for acceptance of the recommendation. CONCLUSION: Combination therapy could be necessary for a majority of newly diagnosed Indian patients for effective BP control. It can manage HTN with better clinical outcomes. Based on mean rating scores from experts, telmisartan plus amlodipine can be considered the preferred initial combination in the management of newly diagnosed Indian patients with HTN to achieve better BP control and improve CV outcomes.

Clinical profile and 90 day outcomes of 10 851 heart failure patients across India: National Heart Failure Registry.

AIMS: Limited data on the uptake of guideline-directed medical therapies (GDMTs) and the mortality of acute decompensated HF (ADHF) patients are available from India. The National Heart Failure Registry (NHFR) aimed to assess clinical presentation, practice patterns, and the mortality of ADHF patients in India. METHODS AND RESULTS: The NHFR is a facility-based, multi-centre clinical registry of consecutive ADHF patients with prospective follow-up. Fifty three tertiary care hospitals in 21 states in India participated in the NHFR. All consecutive ADHF patients who satisfied the European Society of Cardiology criteria were enrolled in the registry. All-cause mortality at 90 days was the main outcome measure. In total, 10 851 consecutive patients were recruited (mean age: 59.9 years, 31% women). Ischaemic heart disease was the predominant aetiology for HF (72%), followed by dilated cardiomyopathy (18%). Isolated right HF was noted in 62 (0.6%) participants. In eligible HF patients, 47.5% received GDMT. The 90 day mortality was 14.2% (14.9% and 13.9% in women and men, respectively) with a re-admission rate of 8.4%. An inverse relationship between educational class based on years of education and 90 day mortality (high mortality in the lowest educational class) was observed in the study population. Patients with HF with reduced ejection fraction and HF with mildly reduced ejection fraction who did not receive GDMT experienced higher mortality (log-rank P < 0.001) than those who received GDMT. Baseline educational class, body mass index, New York Heart Association functional class, ejection fraction, dependent oedema, serum creatinine, QRS > 120 ms, atrial fibrillation, mitral regurgitation, haemoglobin levels, serum sodium, and GDMT independently predicted 90 day mortality. CONCLUSION: One of seven ADHF patients in the NHFR died during the first 90 days of follow-up. One of two patients received GDMT. Adherence to GDMT improved survival in HF patients with reduced and mildly reduced ejection fractions. Our findings call for innovative quality improvement initiatives to improve the uptake of GDMT among HF patients in India.

Management of American Heart Association/American College of Cardiology-Defined Stage 2 Hypertension by Cardiologists in India.

Uncontrolled hypertension is an important cardiovascular risk factor and therefore requires effective approaches to patient management. This study assessed approaches to the management of patients with Stage 2 hypertension by cardiologists in India. This was a retrospective, multicenter, observational, case-based questionnaire study. Data on demographic characteristics, risk factors associated with Stage 2 hypertension, use of antihypertensive medications, side effects, and approaches to education for 2,540 patients were extracted from questionnaire responses provided by 508 cardiologists. The study population of patients with Stage 2 hypertension had a mean age of 55.0 years. Most of the patients (62.6%) were aged 30 to 60 years and diabetes mellitus was the most prevalent comorbidity (48.9%). Triple antihypertensive therapy was being used by 760 patients, and 634 and 1,146 patients were receiving 4 and 5 different antihypertensive medications, respectively. Telmisartan, amlodipine, chlorthalidone, hydrochlorothiazide, spironolactone, metoprolol, and prazosin were the commonly prescribed drugs. Ankle edema (27.7%) was the most frequent side effect of therapy. Pharmacotherapy was supported by patient education and lifestyle modifications for better blood pressure control. The standardized approach to the collection and assessment of these contemporary data provides useful insights into the characteristics and treatment of patients with Stage 2 hypertension in India.

Therapeutic adherence in hypertension: Current evidence and expert opinion from India.

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.

Cardiovascular disease risk factors among undergraduate medical students in a tertiary care centre of eastern India: a pilot study.

BACKGROUND: Handful studies report the prevalence of cardiovascular disease (CVD) risk factors among medical students from India and none from the eastern part of the country. AIM: To estimate the prevalence of risk factors of CVD and their correlation with CVD risk ratio among the MBBS students from eastern India. METHODS: 433 students were studied. International Physical Activity Questionnaire-long form was used for assessment of physical activity and Perceived Stress Scale (PSS) to elicit psychological stress levels. Waist-to-height ratio (WHtR) was calculated. Total cholesterol to high-density lipoprotein ratio was calculated as the CVD risk ratio. RESULTS: 39.3% were women and 68.6% of the subjects were in junior classes. 22.4% subjects had high PSS while 30% performed low physical activity. Tobacco and alcohol intake was prevalent in 29.3% and 21.0% respectively. High CVD risk ratio was found in 14.3%. Most risk factors were more prevalent among juniors except diabetes. Among the non-overweight and non-obese subjects there was a significant positive correlation between WHtR and CVD risk score (R = 0.33, p < 0.001). 82.7% of the variance in CVD risk ratio could be explained by WHtR, Body mass index, Triglycerides and Low-density lipoprotein (F(7, 425) = 296.085), of which LDL (ß = 0.755) contributed the most. CONCLUSIONS: High prevalence of different modifiable CVD risk factors revealed among the subjects in this study is concerning. WHtR appears promising as an independent early predictor of CVD risk in Indian population. A dedicated CVD risk assessment tool for the young population is necessary.

Demographic profile, clinical characteristics and medical management patterns of Indian coronary artery disease patients: a nationwide urban-based, real-world, retrospective, observational electronic medical record study- report of baseline data.

Background: This is the first detailed Indian electronic medical record (EMR)-based real-world observational study to understand the clinical characteristics, associated comorbidities/risk factors and treatment(s) of CAD patients across India.Methods: EMR data of adult Indians (aged ≥ 18 years) diagnosed with CAD was retrospectively analyzed.Results: The majority of the participants had stable IHD (93%), were men (68.5% in ACS, 59.8% in stable IHD), most common age group was 40-64 years in ACS (56.6%) and stable IHD (51.4%). Both are common in metros (ACS 52%, 62% stable IHD). There is a high frequency of hypertension (38.2% in ACS, 59% in stable IHD) and diabetes mellitus (32.3% in ACS, 57.6% in stable IHD). Most common treatments are antiplatelet drugs and lipid-lowering drugs (96%).Conclusions: In India, stable IHD is the most prevalent form in vast majority of patients. The patients with CAD are mostly males, are mainly located in metros and majority fall between the age group of 40-64. The major comorbidities are hypertension and diabetes mellitus. Sociodemographic and clinical characteristics for CAD in India may not be similar to what is reported from the west. There is a significant difference in drug usage and adherence to guidelines in India for CAD.

Pattern of acute MI admissions in India during COVID-19 era: A Cardiological Society of India study - Rationale and design.

BACKGROUND: COVID-19 pandemic has affected around 20million patients worldwide and 2.0 million cases from India. The lockdown was employed to delay the pandemic. However, it had an unintentional impact on acute cardiovascular care, especially acute myocardial infarction (AMI). Observational studies have shown a decrease in hospital admissions for AMI in several developed countries during the pandemic period. We aimed to evaluate the impact of COVID-19 on the AMI admissions patterns across India. METHODS: In this multicentric, retrospective, cross-sectional study, we included all AMI cases admitted to participating hospitals during the study period 15th March to 15th June 2020 and compared them using a historical control of all cases of AMI admitted during the corresponding period in the year 2019. Major objective of the study is to analyze the changes inthe number of hospital admissions for AMI in hospitals across India. In addition, we intend to evaluate the impact of COVID-19 on the weekly AMI admission rates, and other performance measures like rates of thrombolysis/primary percutaneous interventions (PCI), window period, door to balloon time, and door to needle time. Other objectives include evaluation of changes in the major complications and mortality rates of AMI and its predictors during COVID-19 pandemic. CONCLUSIONS: This CSI-AMI study will provide scientific evidence about the impact of COVID-19 on AMI care in India. Based on this study, we may be able to suggest appropriate changes to the existing MI guidelines and to educate the public regarding emergency care for AMI during COVID-19 pandemic.

A questionnaire survey for improving awareness of rheumatic heart disease among school-aged children in India.

OBJECTIVES: We examined the level of awareness about Rheumatic Heart Disease (RHD) among school-aged children in a rural district of India and evaluated the effects of a questionnaire-based survey in improving the level of awareness. METHODS: The study involved 8,646 students aged 10-16 years from 20 schools in West Midnapore, India which was conducted in August 2017. We examined changes in the level of awareness of RHD using a 29-point scoring system in seven domains. The baseline questionnaire survey assessed students' knowledge and was followed by a multimedia presentation about RHD and a post-intervention survey using the same questionnaire. The questionnaire included 9 questions on different aspects of RHD including prevalence, nature of disease, symptoms, determinants, treatment options, impact of the disease and diagnosis. RESULTS: The mean age of the study population was 13 years and 46% were boys. At baseline, the mean level of knowledge about RHD was 42% (12.2 out of 29 points). After the school-based presentation, the score improved to a mean of 55% (15.9 points on the 29-point scale), a 31% relative improvement. Improvement in students' knowledge was noted across all seven domains, individually and combined (p < 0.001). CONCLUSIONS: Awareness among children in rural India about RHD is modest. A school-based intervention could help in improving awareness about this chronic condition and may promote secondary prophylaxis to reduce the morbidity and mortality from RHD.

Cardiological society of India document on safety measure during echo evaluation of cardiovascular disease in the time of COVID-19.

An echocardiographic investigation is one of the key modalities of diagnosis in cardiology. There has been a rising presence of cardiological comorbidities in patients positive for COVID-19. Hence, it is becoming extremely essential to look into the correct safety precautions, healthcare professionals must take while conducting an echo investigation. The decision matrix formulated for conducting an echocardiographic evaluation is based on presence or absence of cardiological comorbidity vis-à-vis positive, suspected or negative for COVID-19. The safety measures have been constructed keeping in mind the current safety precautions by WHO, CDC and MoHFW, India.

Percutaneous coronary intervention provided better long term results than optimal medical therapy alone in patients with chronic total occlusion: A meta-analysis.

AIMS: Studies comparing the outcome of percutaneous coronary intervention (PCI) along with optimal medical therapy (OMT) versus OMT alone in treatment of chronic total occlusion (CTO) are limited by observational design, variable follow-up period, diverse clinical outcomes, high drop-out and cross-over rates. This study aims to conduct a meta-analysis of published data of observational as well as randomized studies comparing long term outcomes of PCI+OMT versus OMT alone. METHODS AND RESULTS: PubMed, Embase and Cochrane databases were systematically reviewed. 15 studies meeting criteria were included in the meta-analysis. The New-castle Ottawa scale was used to appraise the overall quality of the studies. Random-effects model with inverse variance method was undertaken. Major adverse cardiovascular events (MACE) which comprises of cardiac death, myocardial infarction, stroke, and un-planned revascularization were significantly lower in the PCI+OMT group (RR:0.76; 95% CI:0.61 to 0.95; P=<0.00001; I2 = 85%). All-cause mortality and cardiac death were significantly lower in the PCI+OMT group (P=<0.00001 in both). Myocardial infarction and stroke rates were lower in the PCI+OMT group, however they did not reach statistical significance (P = 0.24, P = 0.15 respectively). Unplanned revascularizations (of any vessel) were also similar in both the groups (P = 0.78, I2 = 88%). CONCLUSION: PCI of CTO is rewarded with better long term outcome, in terms of MACE, all-cause mortality and cardiac death with similar rates of un-planned revascularization.

Screening for Hypertension in Asymptomatic Individuals in India: An Expert Consensus Statement.

INTRODUCTION: Hypertension (HTN) is a rapidly growing epidemic in India. It is no larger restricted to older adults as more young Indians are being diagnosed with HTN. Despite its significant prevalence, the awareness, treatment, and control of HTN remain low in India. Thus, early diagnosis is essential to control HTN and prevent future complications. Screening for HTN can help identify undiagnosed and asymptomatic HTN, and thereby the early use of interventions to control the blood pressure (BP). However, no comprehensive guidelines have been established for effective HTN screening in asymptomatic individuals in an Indian setting. OBJECTIVE: To provide consensus recommendations for hypertension screening in India. CONSENSUS RECOMMENDATIONS: Screening for HTN can provide more effective control of HTN and reduce the complications. Experts recommended that the initial age at screening should be 18 years. In individuals at a high risk of HTN, targeted screening can be undertaken. BP measurement using an electronic BP recorder (with at least two readings) are required for identifying HTN during screening. In asymptomatic adults with BP <130/85 mmHg and BP of 130-139/85- 89 mmHg, rescreening should be conducted every 3-5 years and at least every year, respectively. Screening for HTN can be cost effective even when universal screening of the entire population is undertaken. CONCLUSION: The consensus recommendations would increase the awareness of HTN screening. Screening for HTN can provide more effective control of HTN and reduce the complications.

Managing ACS during COVID-19 infection: Do not follow the traditional route.

COVID-19 pandemic is creating havoc in the world. It is also spreading in India creating a massive healthcare problem. Few major hospitals were closed down because of the spread among healthcare personnel. Management of several commonly occurring diseases needed modifications to a lesser or greater extent because of this pandemic. Management of acute coronary syndrome (ACS) also requires certain modifications. In this opinion paper an attempt has been made to give an outline of ACS management in this changed scenario.

Digital healthcare: The only solution for better healthcare during COVID-19 pandemic?

The huge impact of the COVID-19 pandemic on global healthcare systems has prompted search for novel tools to stem the tide. Attention has turned to the digital health community to provide possible health solutions in this time of unprecedented medical crisis to mitigate the impact of this pandemic. The paper shall focus on how digital solutions can impact healthcare during this pandemic.

Prevalence of hypertension among Indian adults: Results from the great India blood pressure survey.

OBJECTIVE: Hypertension is the most important risk factor for cardiovascular morbidity and mortality. There is limited data on hypertension prevalence in India. This study was conducted to estimate the prevalence of hypertension among Indian adults. METHODS: A national level survey was conducted with fixed one-day blood pressure measurement camps across 24 states and union territories of India. Hypertension was defined as systolic blood pressure (BP) ≥140 mmHg or a diastolic BP ≥90 mmHg or on treatment for hypertension. The prevalence was age- and gender-standardized according to the 2011 census population of India. RESULTS: Blood pressure was recorded for 180,335 participants (33.2% women; mean age 40.6 ± 14.9 years). Among them, 8,898 (4.9%), 99,791 (55.3%), 35,694 (11.9%), 23,084 (12.8%), 9,989 (5.5%), and 2,878 (1.6%) participants were of the age group 18-19, 20-44, 45-54, 55-64, 65-74, and ≥ 75 years, respectively. Overall prevalence of hypertension was 30.7% (95% confidence interval [CI]: 30.5, 30.9) and the prevalence among women was 23.7% (95% CI: 23.3, 24). Prevalence adjusted for 2011 census population and the WHO reference population was 29.7% and 32.8%, respectively. CONCLUSION: There is a high prevalence of hypertension, with almost one in every three Indian adult affected.