Expert eValuation of Efficacy and Rationality of Vildagliptin "EVER-Vilda": An Indian Perspective.

Vildagliptin, a dipeptidyl peptidase-4 (DPP-4) inhibitor is effective in reducing HbA1c levels in patients with type 2 diabetes (T2DM) when administered as monotherapy, dual or triple combination therapy. In India, Vildagliptin is commonly prescribed in T2DM patients because it reduces mean amplitude of glycemic excursion (MAGE), has lower risk of hypoglycemia and is weight neutral. Early combination therapy with vildagliptin and metformin is effective and well-tolerated in patients with T2DM, regardless of age or ethnicity. In view of already existing data on vildagliptin and the latest emerging clinical evidence, a group of endocrinologists, diabetologists and cardiologists convened for an expert group meeting to discuss the role and various combinations of vildagliptin in T2DM management. This practical document aims to guide Physicians and Specialists regarding the different available strengths and formulations of vildagliptin for the initiation and intensification of T2DM therapy.

Prevalence and correlates of metabolic syndrome among women living in urban slums, Mysore, India.

Metabolic Syndrome (MetSyn) is a predictor of cardiovascular disease (CVD). About a third of urban Indians suffer from MetSyn. This study examined the prevalence of MetSyn among women living in urban slums. A cross-sectional survey was carried out between October 2017 and May 2018 among a non-probability sample of slum-dwelling women, 40-64 years of age, in six government-designated slums in Mysore, India. Data were collected on demographics, diet, behavioral risks, anthropometry, blood pressure, serum glucose, hemoglobin A1c, and serum lipids. The study used a definition of MetSyn from the International Diabetes Federation Task Force on Epidemiology and Prevention with an HbA1c measure for average blood glucose. About two-fifths of the 607 participants had MetSyn (41.5%; 95% CI: 37.7-45.5). Of those, 40.9% met three criteria, 38.1% four, and 25.0%, all five criteria. Elevated BP was the most prevalent MetSyn factor (79.6%), followed by increased waist circumference (54.5%), low HDL (50.1%), elevated Hb A1c (37.1%), and elevated triglycerides (36.1%). Odds for MetSyn were 1.52 times greater for those who were 50-59 years of age compared with those 40-49 years of age (adjusted odds ratio[AOR]:1.52; 95% CI:0.96-2.40). Women with mobility issues had 1.29 times higher odds of MetSyn than those without it (AOR: 0.76, 95% CI: 0.96, 1.75). Housewives had 1.29 times greater odds of MetSyn (AOR: 1.29, 95% CI: 1.00, 1.67). There is a high prevalence of MetSyn among urban slum-dwelling women in Mysore. There is a need for interventions aimed at reducing CVD risk factors in this population.

Parity and later life risk for coronary heart disease among slum-dwelling women in Mysore, India.

BACKGROUND: To examine the role of parity in coronary heart disease (CHD) among middle-aged Indian women living in government-designated slums in Mysore, India. METHODS: Between October 2017 and May 2018, a cross-sectional study was carried out among women, 40-64 years of age, residing in government-designated slums in Mysore, India. In addition to socio-demographics, data were collected on CVD risk factors including use of tobacco and alcohol, diet, physical activity, sleep, quality of life, and personal and family history of chronic disease. Patients underwent a medical examination and a venous blood sample was taken for fasting lipid measurement. Resting electrocardiography was carried out by a trained medical technician. Multivariable logistic regression with associated 95% confidence intervals was used to examine the relationship between parity and coronary heart disease. RESULTS: The prevalence of CHD in this sample of middle-aged women was 6.4%. Nulliparous women were at heightened risk for CHD compared to parous women with up to five live births. In the adjusted model, women who had 1-2 and 3-5 live births had 0.24 times lower odds (95% Confidence Interval [CI]: 0.05-1.29) and 0.38 times lower odds (95%CI: 0.178-0.87) of CHD, respectively, as compared to nulliparous women. CONCLUSION: Among a fairly homogenous population of slum-dwelling women reporting almost universal breastfeeding for three or more months following birth, parity up to five births appeared protective against CHD. Further studies are needed to evaluate whether near universal breastfeeding rates in this population mediated the relationship of parity and CHD.

Prevalence and correlates of metabolic syndrome among rural women in Mysore, India.

AIMS: Metabolic Syndrome (MetS) is a strong predictor of Coronary Heart Disease (CHD). Studies in urban India have found about one-third of Indians suffer from MetS. Less is known about the prevalence of MetS in rural areas, where 70% of the population reside. This study examined the prevalence of Metabolic Syndrome in a population of rural women in India. METHODS: Data were gathered in a community-based study of 500 rural and tribal women residing in the Mysore district, between the age of 30-59 years. The study used the WHO STEPS approach, in which information on demographics and behavioral risk factors were collected. Along with anthropometric measurements, blood pressure, blood glucose, lipids were measured. A harmonized definition of MetS recommended by International Diabetes Federation Task Force on Epidemiology and Prevention was used in this study. RESULTS: Three out of five study participants were found to have MetS (47.1%, n = 223). Of those, 56.5% met 3 of the 5 criteria, 32.2% met 4 criteria, and 11.2% met all 5 criteria. Among the entire sample, low HDL was the most prevalent criterion (88.4%), followed by elevated glucose (57.9%), elevated triglycerides (49.3%), elevated BP (41.5%), and increased waist circumference (15.3%). In this sample, women with METS were generally older (p < 0.001), housewives (p = 0.001), that consumed salty highly processed foods (p = 0.020) and had low physical activity (p = 0.015). CONCLUSIONS: This study showed a high prevalence of MetS in rural women. There is a compelling need for interventions aimed at reducing CHD risk factors in this population.

Snoring is associated with obesity among middle aged Slum-dwelling women in Mysore, India.

BACKGROUND: Globally, rates of obesity have trebled in the past four decades. India has more than 9.8 million men and 20 million women classified as obese. While poor diet and sedentary lifestyles are major causes, growing evidence suggests other factors like sleep-disordered-breathing may also be contributors. METHODS: A cross-sectional survey was carried out between October 2017 and May 2018 among a nonprobability sample of slum-dwelling women, 40-64 years of age, in government-designated slums in Mysore, India. After the informed consent process, data were collected on sociodemographics, tobacco and alcohol consumption, diet, physical activity, sleep, quality of life, and personal and family history of diagnosed cardiometabolic disorders. Body mass index (BMI) was calculated using anthropometry. The serum was tested for HbA1c and lipid profile. RESULTS: In this sample of slum-dwelling women, snoring was associated with obesity. Habitual snorers had more than double the odds (adjusted odds ratio [aOR] 2.05; 95% confidence interval [CI] 1.26-3.33;P < 0.004) of obesity I, and seven times the odds (aOR 7.71; CI: 3.58-16.62;P < 0.001) of being in the obesity II category compared to nonsnorers after adjustment for age, diabetes, hypertension, hypercholesterolemia, and daytime sleepiness. There was no difference in obesity status among participants reporting abnormal sleep duration, napping, daytime sleepiness, sleep apnea, insomnia, or the use of sleep medication. CONCLUSION: The relationship between snoring and obesity has not been well explored. This study among slum-dwelling Indian women found a significant relationship between snoring and obesity. Future research should explore the underlying mechanisms connecting snoring to BMI.

Cardiovascular Risk Factor Knowledge and Behaviors Among Low-Income Urban Women in Mysore, India.

BACKGROUND: Cardiovascular diseases (CVDs) are the leading causes of death among women globally. Cardiovascular disease-related events are more common in older women compared with men and are more likely to result in death. Although research in high-income countries suggests that women have unique sociobiological CVD risk factors, only a few study authors have examined risk factor knowledge among women from low- and middle-income countries. OBJECTIVE: The aim of this study was to assess CVD risk factor knowledge among low-income urban Indian women. METHODS: A cross-sectional study was conducted among a nonprobability sample of 607 slum-dwelling women, 40 to 64 years old, living in Mysore, India, between October 2017 and May 2018. Participants underwent an interviewer-administered questionnaire measuring demographics, CVD risk factor knowledge, and medical history. RESULTS: Cardiovascular disease risk factor knowledge was low in this population and was associated with age, education, income, and caste. Approximately half of the participants (47%) answered less than 50% of the questions correctly, and a third had knowledge scores greater than 70%, which we defined as "good knowledge." Only 4 of 7 traditional CVD risk factors (ie, physical activity, smoking, overweight, and high cholesterol) were recognized by greater than half of the participants. The lowest knowledge levels were among older single women with no education and monthly household incomes less than Rs 3000 (approximately US $42). CONCLUSIONS: Previous research among slum dwellers in India reported a high prevalence of modifiable CVD risk factors compared with more affluent urban peers. Interventions aimed at CVD risk factor knowledge may be an important first step in controlling heart disease in this vulnerable population.

A rare case of right ventricular myxoma causing recurrent stroke.

We present a 62-year-old lady admitted in our hospital with two episodes of acute ischemic stroke about 2 weeks apart. She was evaluated for acute ischemic stroke and was thrombolysed for recent stroke in right MCA territory first time. On further evaluation, she was found to have a RVOT mass. A transthoracic and transesophageal echocardiogram revealed a PFO and a large, 5.1cm×2.3cm, ovoid, well circumscribed, echogenic mass in the right ventricle outflow tract attached by small pedicle to the ventricular side of anterior tricuspid leaflet, partly obstructing the right ventricular outflow tract and protruding through the pulmonic valve during systole. She was scheduled for surgery (right ventricular mass excision and PFO closure) after 3 weeks due to the risk of secondary hemorrhage in the infarcted area following thrombolysis and anticoagulation and so was discharged with medications after full neurologic recovery after about a week of hospital stay. She was readmitted 7 days after discharge, before the scheduled date of surgery with history of weakness of right upper limb, slurred speech and mild breathing difficulty lasting for about 20min following which she improved slowly (transient ischemic attack). The tumor was completely removed with the stalk using cardiopulmonary bypass support. The histopathological findings confirmed the diagnosis of myxoma.

Two-year follow-up data from the STEPP-AMI study: A prospective, observational, multicenter study comparing tenecteplase-facilitated PCI versus primary PCI in Indian patients with STEMI.

BACKGROUND: A pharmacoinvasive strategy may alleviate the logistical and geographical barriers in timely reperfusion of ST-segment elevation myocardial infarction (STEMI), especially in a developing country like India. AIM: To assess the safety and efficacy of pharmacoinvasive strategy versus primary PCI in STEMI patients at 2 years. METHODS: Patients enrolled in STEPP-AMI, an observational, multicenter, prospective study of 200 patients presenting with STEMI, were followed up for 2 years. Group 'A' comprised of patients with pharmacoinvasive strategy (n=45), and patients who underwent primary PCI (n=155) formed group 'B'. Primary endpoint was composite of death, cardiogenic shock, reinfarction, repeat revascularization of the culprit artery, or congestive heart failure at 30 days, with follow-up till 2 years. RESULTS: The primary endpoint occurred in 11.1% and 17.8% in group A and in 3.9% and 13.6% in group B, at 30 days and 2 years, respectively (p=0.07, RR=2.87; 95% CI: 0.92-8.97 at 30 days and p=0.47, RR=1.31; 95% CI: 0.62-2.76). There was no difference in bleeding risk between groups, 2.2% in group A and 0.6% in group B ('p'=0.4). The infarct-related artery patency varied at angiogram; it was 82.2% in arm A and 22.6% in arm B ('p'<0.001). In group A, failed fibrinolysis occurred in 12.1%. CONCLUSION: A pharmacoinvasive strategy resulted in outcomes that were comparable with primary PCI at 2 years, suggesting it might be a viable option in India. Larger studies are required to confirm these findings.

A prospective, observational, multicentre study comparing tenecteplase facilitated PCI versus primary PCI in Indian patients with STEMI (STEPP-AMI).

OBJECTIVE: To compare the efficacy of pharmacoinvasive strategy versus primary percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI). Primary PCI is the preferred treatment for STEMI, but it is not a feasible option for many. A pharmacoinvasive strategy might be a practical solution in the Indian context, although few empirical data exist to guide this approach. METHODS: This is a prospective, observational, multicentre pilot study. Two hundred consecutive patients with STEMI aged 18-75 years, presenting within 12 h of onset of symptoms and requiring a reperfusion strategy, were studied from five primary PCI capable centres in South India. Patients who opted for pharmacoinvasive strategy (n=45) formed group A. Group B consisted of patients treated with primary PCI (n=155). One patient was lost to follow-up at 1 year. The primary end point was a composite of death, cardiogenic shock, reinfarction, repeat revascularisation of a culprit artery and congestive heart failure at 30 days. RESULTS: The primary end point occurred in 11.1% in group A and in 3.9% in group B, p=0.07 (RR=2.87; 95% CI 0.92 to 8.97). The infarct-related artery patency at angiogram was 82.2% in group A and 22.6% in group B (p<0.001). PCI was performed in 73.3% in group A versus 100% in group B (p<0.001), and a thrombus was present in 26.7% in group A versus 63.2% in group B (p<0.001). Failed fibrinolysis occurred in 12.1% in group A. There was no difference in bleeding risk, 2.2% in group A versus 0.6% in group B, (p=0.4). CONCLUSIONS: This pilot study shows that a pharmacoinvasive strategy can be implemented in patients not selected for primary PCI in India and hints at the possibility of similar outcomes. Larger studies are required to confirm these findings. TRIAL REGISTRATION NUMBER: TRIAL IS REGISTERED WITH CLINICAL TRIAL REGISTRY OF INDIA, CTRI NUMBER: REF/2011/07/002556.

Efficacy and safety of tenecteplase in Indian elderly STEMI patients from the Elaxim Indian Registry.

OBJECTIVE: To analyze the efficacy and safety of indigenous Tenecteplase in Indian elderly STEMI patients in a clinical setting. METHODS: Post-licensure, observational, prescription event monitoring (PEM) study. RESULTS: 2162 patients received weight-adjusted Tenecteplase injection. The data for elderly (> 60 years) and non-elderly (< or = 60 years) was identified, segregated and compared. Out of 2162 patients, 805 were elderly patients and 1357 were non-elderly. Clinically successful thromolysis was seen in 83.98% of elderly and 86% of non-elderly group (p = 0.22). There was no significant difference in percentage of patients reporting bleeding, stroke, intracranial hemorrhage, myocardial reinfraction, ventricular tachyarrhythmia between the groups. Mortality was significantly (p = < 0.0001) more in elderly (6.21%) than non-elderly (2.06%) patients. CONCLUSION: The indigenously developed Tenecteplase shows high efficacy and safety in its in-hospital use in Indian elderly patients with STEMI.

Hydatid cyst of the right ventricle, liver and lungs.

Cardiac Echinococcosis is a rare and the most serious of all hydatid manifestations. We report here a case of 27 year old female who had hydatid cyst in the liver, lungs & right ventricle. The cardiac hydatid cyst was operated and numerous daughter cysts were removed. Diagnostic radiological illustrations and surgical specimen of daughter cysts has been provided in this article.