Role of Empagliflozin in heart failure with severe aortic stenosis before valve replacement: EASTER-HF study.

We evaluated empagliflozin in severe DAS patients with HF before AVR. HF patients with LVEF 30-80 % and NYHA functional class II-IV symptoms got empagliflozin 10 mg or not within 6 months before AVR, along with SOC. Adding empagliflozin to the SOC before AVR reduced HF death or HHF by 73 % after 6-months in a group of 20 patients (RR 0.27; p = 0.022). Improving LVEF (+3.48 %, p < 0.001) and NT-proBNP levels (-3974.6 pg/mL) with empagliflozin in SOC before AVR significantly reduced in-hospital and 6-month mortality in this patient group. In severe DAS and HF patients, empagliflozin improved symptoms and prognosis.

The clinical experience of macitentan in pulmonary hypertension in Indian cohort: 12-month follow-up.

BACKGROUND: The effectiveness and safety of macitentan, an endothelin-receptor antagonist (ERA) in the treatment of pulmonary arterial hypertension (PAH), has been demonstrated in numerous randomized clinical trials including SERAPHIN, focused on the reduction of morbidity and mortality. OBJECTIVES: Our aim was to demonstrate the clinical and echocardiographic progression using macitentan in Indian patients with PAH. SETTINGS AND DESIGN: It was a retrospective study of 20 patients with multiple etiologies of PAH who had begun macitentan in routine clinical practice from a single center. There were 55% of patients with existing PAH therapies. SUBJECTS AND METHODS: The World Health Organization functional class (WHO-FC), 6-min walking distance, N-terminal prohormone of brain natriuretic peptide level (NT-pro-BNP), and echocardiographic data such as tricuspid annular plane systolic excursion (TAPSE), systolic pulmonary artery pressure (sPAP), and the occurrence of pericardial effusion were collected at baseline and 12-month follow-up. The statistical analysis was performed using SPSS software. RESULTS: Of the 20 PAH patients, 70% were women. The majority were in WHO FC II (50%), while 35% were in FC III and 15% were in FC IV. The mean age was 43.4 years at the start of the therapy with macitentan. After 6 months of macitentan therapy, 85% showed substantial improvement in their FC, each increased its 6-min walking distance test (P < 0.0001), and there was a significant reduction in plasma levels of NT-pro BNP (P < 0.0001). There has also been an improvement in echocardiographic parameters such as TAPSE and sPAP (P < 0.0001). CONCLUSIONS: Our findings indicate that macitentan has been well tolerated and beneficial in Indian patients with PAH and further, future research is required to verify these results.

ADDition of DAPAgliflozin, Sodium-Glucose Cotransporter-2 Inhibitor to Angiotensin Receptor Blocker-Neprilysin Inhibitors Non-Responders in Patient with Refractory Heart Failure with Reduced Ejection Fraction (ADD DAPA trial).

OBJECTIVES: We evaluated the efficacy and safety of dapagliflozin, a SGLT2i along with ARNI in refractory HFrEF irrespective of their diabetic status. METHODS: We performed a retrospective analysis of 104 symptomatic patients of HFrEF despite of optimal medical management with ARNI between January-June 2020. Despite the optimal GDMT, dapagliflozin, SGLT2i was added inpatients withrefractory heart failure. At 6-months follow-up, the primary outcome was change in left ventricular ejection fraction, and secondary outcomes included changes in NYHA functional class, vital parameters, renal function, potassium levels, and NT-pro BNP levels. RESULTS: The primary outcomeat 6-months follow-up was a mean change in left ventricular ejection fraction (LVEF) +9.00 ± 0.62 (p < 0.001). The secondary outcome was a significant improvement (69%) in median NYHA functional class by 2.3 (95% Confidence interval 2.245-2.355) with 92.6% of patients were in NYHA class I and 7.4% were in NYHA class II.Diabetic subgroup reached the HbA1C goal of <7%. None of them had either symptomatic hypotension, hypoglycaemia, dyselectrolaemia, and decline in renal function. The drug was well received by most of the patients. CONCLUSIONS: Dapagliflozin, an SGLT2i, should be used in symptomatic, refractory HFrEF patients despite the use of ARNI. The combination of ARNI and SGLT2i is well tolerated, but large, randomized trials are needed to prove this hypothesis.

A clinical experience of Indian patients with heart failure with reduced left ventricular ejection fraction using an angiotensin receptor-neprilysin inhibitor [ARNI] on an outpatient basis.

The goal of this study is to portray an initial experience with the efficacy, safety, and, acceptance of ARNI in ambulatory cardiology practices in India. The research is a retrospective review of single-centre data who began therapy with ARNI in HFrEF between 2019 and 2020. The analysis included data for 454 symptomatic patients, aged 57 ± 20.8 years in NYHA class II-III. During follow-up, patients experienced significant improvement in HF symptoms determined by using Kansas City Cardiomyopathy Questionnaire (KCCQ) and a considerable reduction in NT-proBNP levels. ARNI is associated with substantial clinical benefit in an outpatient setting in HFrEF.

Prevalence of metabolic syndrome in women with polycystic ovary syndrome and the factors associated: A cross sectional study at a tertiary care center in Hyderabad, south-eastern India.

BACKGROUND AND AIMS: Metabolic syndrome (MetS) and polycystic ovary syndrome (PCOS) are two interrelated but distinct endocrine problems with several health consequences secondary to insulin resistance. This study aimed to determine the prevalence of MetS in women with PCOS. METHODS: This was a cross sectional study carried out from May 2017 to October 2017 at the gynecology outpatient clinic of a tertiary care private hospital in Hyderabad, India. Eligible women diagnosed with PCOS according to Rotterdam criteria were enrolled. The primary outcome was the prevalence of MetS diagnosed by the modified NCEP ATP III criteria. RESULTS: The study comprised 382 patients with a mean age of 26.8 ± 5.3 years. MetS was present in 147 (38.5%) women with PCOS. The most frequently observed individual components of MetS were increased waist circumference and decreased HDL cholesterol. When predictors for MetS were analyzed by multivariate regression, BMI (aOR 1.14; 1.06-1.23; p ≪0.001) and age (aOR 1.12; 1.06-1.17; p ≪0.001) were significantly associated with MetS; however, the effect size was modest. CONCLUSION: A high prevalence of MetS was observed in women with PCOS at this tertiary center in Hyderabad, with abdominal obesity and low HDL cholesterol as predominant components. We believe that universal screening of all PCOS women is a reasonable option.

Clinico-epidemiological profile of seven adults with spotted fever from a tertiary care hospital in South India.

Spotted fever (SF), a tick-borne rickettsial infection, is being increasingly reported from mainly northern Indian states. A lack of awareness and confirmatory laboratory tests underestimate the incidence of this infection which, in India, is predominantly seen during the rainy season. Many patients diagnosed with viral exanthematous illnesses may be suffering from SF, which is treatable if detected early. There is very little data on SF in adults in southern India. We present seven patients with SF treated between January 2007 and January 2008 in a tertiary care hospital in South India. All presented during the rainy season, with rash (100%) and generalized oedema (71%) being the most common features. There was one death due to type I respiratory failure. Renal failure, shock, aseptic meningitis and hepatitis were other significant abnormalities detected in these patients. Clinicians need to be aware of SF and suspect it in appropriate patients.

Central nervous system involvement in scrub typhus.

Scrub typhus is an emerging infectious disease in India. Among its protean clinical manifestations, central nervous system involvement is common. In this prospective observational study, altered sensorium, headache, seizures and aseptic meningitis were found to be common central nervous system manifestations. Prompt treatment with doxycycline reduces morbidity and mortality.

Acute kidney injury in tropical acute febrile illness in a tertiary care centre--RIFLE criteria validation.

BACKGROUND: Acute febrile illnesses are a common cause of tropical acute kidney injury (AKI). The incidence and severity of AKI in tropical febrile illnesses and validity of RIFLE classification are unclear. METHODS: Consecutive adult inpatients of a tertiary hospital in southern India with tropical acute febrile illness between January 2007 and January 2008 were prospectively studied for the incidence and severity of AKI based on RIFLE classification and its association with mortality and dialysis requirement. RESULTS: The 367 patients (mean age 39.7±16.9 years; 60% males) with tropical acute febrile illness due to scrub typhus (51.2%), falciparum malaria (10.4%), enteric fever (8.7%), dengue (7.6%), mixed malaria (6.5%), leptospirosis (3.3%), undifferentiated acute febrile illness (8.4%) and others (3.8%) (spotted fever, vivax malaria and Hantaan virus infection) had an overall mortality rate of 12.3%. The incidence of AKI was 41.1%; of which, 17.4%, 9.3% and 14.4% were in the Risk, Injury and Failure classes, respectively. Of the patients, 7.9% required dialysis. Among the Risk, Injury and Failure groups, there was an incremental risk of mortality (OR 6.9, 20.2 and 25.6; P<0.001) and dialysis requirement (OR 3.4, 28.8 and 178.8; P<0.001). CONCLUSIONS: The incidence of AKI in the common tropical acute febrile illnesses in our study such as scrub typhus, falciparum malaria, enteric fever, dengue and leptospirosis is 41.1%. RIFLE classification is valid and applicable in AKI related to tropical acute febrile illnesses, with an incremental risk of mortality and dialysis requirement.

Acute undifferentiated febrile illness in adult hospitalized patients: the disease spectrum and diagnostic predictors - an experience from a tertiary care hospital in South India.

Local prevalences of individual diseases influence the prioritization of the differential diagnoses of a clinical syndrome of acute undifferentiated febrile illness (AFI). This study was conducted in order to delineate the aetiology of AFI that present to a tertiary hospital in southern India and to describe disease-specific clinical profiles. An 1-year prospective, observational study was conducted in adults (age >16 years) who presented with an undifferentiated febrile illness of duration 5-21 days, requiring hospitalization. Blood cultures, malarial parasites and febrile serology (acute and convalescent), in addition to clinical evaluations and basic investigations were performed. Comparisons were made between each disease and the other AFIs. A total of 398 AFI patients were diagnosed with: scrub typhus (47.5%); malaria (17.1%); enteric fever (8.0%); dengue (7.0%); leptospirosis (3.0%); spotted fever rickettsiosis (1.8%); Hantavirus (0.3%); alternate diagnosis (7.3%); and unclear diagnoses (8.0%). Leucocytosis, acute respiratory distress syndrome, aseptic meningitis, mild serum transaminase elevation and hypoalbuminaemia were independently associated with scrub typhus. Normal leukocyte counts, moderate to severe thrombocytopenia, renal failure, splenomegaly and hyperbilirubinaemia with mildly elevated serum transaminases were associated with malaria. Rash, overt bleeding manifestations, normal to low leukocyte counts, moderate to severe thrombocytopenia and significantly elevated hepatic transaminases were associated with dengue. Enteric fever was associated with loose stools, normal to low leukocyte counts and normal platelet counts. It is imperative to maintain a sound epidemiological database of AFIs so that evidence-based diagnostic criteria and treatment guidelines can be developed.

Scrub typhus associated macrophage activation syndrome.

Macrophage activation syndrome (MAS) is a rare phenomenon that occurs either primarily or secondary to a multitude of conditions, including juvenile rheumatoid arthritis most commonly, and other infections like enteric fever and tuberculosis. It has been reported as an extremely rare complication of scrub typhus with no cases presented from India. We report three cases of scrub typhus presenting with confirmed MAS between January 2007 and December 2007 to a tertiary care hospital in South India. All three patients had clinical and laboratory evidence for scrub typhus and MAS. All the patients responded promptly to antibiotics and made an uneventful recovery. These three patients are presented to highlight the importance of considering scrub typhus in patients with MAS following acute febrile illnesses.

Scrub typhus: an unrecognized threat in South India - clinical profile and predictors of mortality.

Scrub typhus is an important cause of acute undifferentiated febrile illnesses in the Indian subcontinent. Delay in diagnosis and in the initiation of appropriate treatment can result in severe complications such as acute respiratory distress syndrome (ARDS), septic shock and multisystem organ failure culminating in death. We conducted a prospective, observational study to delineate the clinical profile and predictors of mortality in scrub typhus in adults admitted to the medical wards of a tertiary care, referral hospital in South India over a one-year period. The case fatality rate in this study was 12.2%. Metabolic acidosis (odds ratio [OR] 6.1), ARDS (OR 3.6), altered sensorium (OR 3.6) and shock (OR 3.1) were independent predictors of mortality. It appears that scrub typhus has four possible overlapping clinical presentations: mild disease; respiratory predominant disease; central nervous system predominant disease (meningoencephalitis); or sepsis syndrome. Given the telltale presence of an eschar (evident in 45.5%), the characteristic clinical profile and the dramatic therapeutic response to a cheap, yet effective, drug such as doxycycline, medical practitioners in the region should have ample opportunity to reach an early diagnosis and initiate treatment which could, potentially, reduce the mortality and morbidity associated with scrub typhus.

Peduncular hallucinosis in 'top of the basilar syndrome': an unusual complication following coronary angiography.

Cerebral thromboembolism is a potential, although rare, complication of coronary angiography. An elderly woman presented with visual hallucinations, features of bilateral third nerve palsy, impaired vertical and horizontal gaze and mild motor weakness of the left upper limb, following diagnostic coronary catheterization. These findings suggested the anatomical location of the lesion to lie in the caudal midbrain, which was confirmed on computed tomography of the brain. Peduncular hallucinosis following cardiac catheterization, to the best of our knowledge, has only been described once in the literature. Awareness of this entity and its clinical presentation is essential for appropriate investigation and management.