Implementation of clinical audit to improve adherence to guideline-recommended therapy in acute coronary syndrome.

BACKGROUND: Despite global consensus on the management of acute coronary syndrome (ACS), implementation of strategies to improve adherence of guideline-directed medical therapy (GDMT) remains sub-optimal, especially in developing countries. Thus, we aimed to assess the effect of clinical pharmacist-led clinical audit to improve the compliance of discharge prescriptions in patients admitted with ACS. It is a prospective clinical audit of ACS patients which was carried out for 12 months. The discharge prescriptions were audited by clinical pharmacists for the appropriateness in the usage of statins, dual antiplatelet therapy (DAPT), beta-blockers, and angiotensin-converting enzyme inhibitors (ACE-I)/angiotensin receptor blocker (ARB). A feedback report was presented every month to the cardiologists involved in the patient care, and the trend in the adherence to GDMT was analyzed over 12 months. RESULTS: The discharge prescriptions of 1072 ACS patients were audited for the justifiable and non-justifiable omissions of mandated drugs. The first-month audit revealed unreasonable omissions of DAPT, statin, ACE-I/ARB, and beta-blockers in 1%, 0%, 14%, and 11% respectively, which reduced to nil by the end of the 11th month of the audit-feedback program. This improvement remained unchanged until the end of the 12th month. CONCLUSIONS: The study revealed that periodic clinical audit significantly improves adherence to GDMT in patients admitted with ACS.

The genetics of cardiac failure: Role of a G protein-coupled receptor polymorphism in therapeutic response in an Indian population.

BACKGROUND AND AIM: The incidence of heart failure (HF) is rising to epidemic proportions in developing countries like India. A lack of adequate Indian studies underscores the importance of pursuing research into HF in an Indian population. G protein-coupled receptor kinase 5 (GRK5) Gln41>Leu (rs2230345) polymorphism was reported as a genetic modifier associated with survival in HF patients. A prospective study was conducted to investigate the association of GRK5 Gln41>Leu polymorphism with response to ß-blocker therapy in Indian HF patients. METHODS: HF patients (n=584) were recruited for the study. The patients were genotyped by tetra-primer based allele specific polymerase chain reaction and confirmed with Sanger sequencing. The HF patients were evaluated for GRK5 gene expression and followed up for ~3 years. Drug dosages, cardiac output and hospitalization-free survival were evaluated as study outcomes. HF subgroups (i.e. systolic or diastolic dysfunction, biventricular dysfunction and pulmonary artery hypertension) were also analyzed in association with hospital-free survival. RESULTS: HF patients showed genotype frequencies of AT (15%) and TT (1%). AT/TT genotype carriers showed downregulated GRK5 gene expression and significant reduction in carvedilol drug dosage (p=0.0001). Moreover, AT/TT genotype carriers on ß-blockers showed improved ejection fraction from 27% to 36% (p=0.0007) and increased hospitalization-free survival in comparison to other HF patients. HF patients with AA genotype showed an increased rate of hospital admission in comparison with patients with the AT/TT genotype. HF subgroups with the AT/TT genotype showed an increased hospitalization-free survival versus subgroups with the AA genotype. CONCLUSIONS: GRK5 Gln41>Leu polymorphism in response to ß-blocker therapy improved cardiac function in HF patients. RELEVANCE FOR PATIENTS: This study presents a comprehensive clinicofunctional pharmacogenetic characterization of GRK5 Gln41>Leu polymorphism in a cohort of Indian HF patients. GRK5 Gln41>Leu polymorphism can confer improved cardiac function and reduce hospitalization, thus improving the quality of life in HF patients.

Clinical characteristics and outcomes of patients admitted with acute heart failure: insights from a single-center heart failure registry in South India.

BACKGROUND: The epidemiology of HF in India is largely unexplored. Current resources are based on a few hospital-based and a community-based registry from North India. Thus, we present the data from a single hospital-based registry in South India. Patients admitted with acute heart failure over a period of 1 year were enrolled in the registry and were characterized based on their ejection fraction (EF) measured by echocardiogram. The clinical profile of the patients was assessed, including their in-hospital outcomes. One-way ANOVA and univariate analysis were performed for comparison between three EF-based groups and for the assessment of in-hospital outcomes. RESULTS: A total of 449 patients were enrolled in the registry, of which 296, 90, and 63 patients were categorized as, HFrEF, HFmrEF, and HFpEF, respectively. The prevalence of HFrEF was higher (65.99%). The mean age (SD) of the study cohort was 59.9±13.3. The majority of the patients presented with acute denovo HF (67%) and were more likely to be males (65.9%). The majority of patients presented with warm and wet clinical phenotype (86.4%). In hospital mortality was higher in HFmrEF (3.3%). CONCLUSION: Patients with HFrEF had high adherence to guideline-directed medical therapy (GDMT). HFrEF patients were also likely to have longer hospital stay along with a worsening of renal function. The in-hospital mortality was comparable between the EF-based groups. Additionally, the association of clinical phenotypes with outcome highlighted that patients in warm and wet phenotype had a longer length of hospital stay, whereas the mortality and worsening renal function rates were found to be significantly higher in the cold and wet group.

Impact of Clinical Audit on Adherence to the Guidelines Directed Medical Therapy in Patients Admitted with Heart Failure.

BACKGROUND: The adoption of guideline recommendations of pharmacotherapy to improve the clinical course of Heart Failure (HF) remains below par. Our objective is to evaluate the impact of clinical audit on adherence to the Guideline-Directed Medical Therapy (GDMT) in patients admitted with acute heart failure with reduced ejection fraction (EF). METHODS: A prospective interventional study was conducted over a period of 12 months from June 2018 to May 2019 in all patients admitted with acute heart failure with reduced ejection fraction. The discharge prescriptions of patients who met the inclusion criteria were audited for appropriateness in the usage of neurohormonal blockers and Ivabradine, by a clinical pharmacist on a monthly basis. Audit results were presented to the practicing physicians every month and feedback was given. RESULTS: Discharge prescriptions of 716 patients who presented with HF were audited for the reasonable or unreasonable omission of neurohormonal blocking drugs. The first-month audit revealed that the unreasonable omission of Angiotensin-Converting Enzyme Inhibitors/ Angiotensin Receptor Blockers/ Angiotensin Receptor Neprilisin Inhibitors ( ACEI/ARB/ARNI), Betablockers and Mineralocorticoid Receptor Antagonists (MRA) were 24.5%, 13.1%, and 9.09% respectively, which reduced to nil at the end of the study period (p=0.00). Initiation of Ivabradine before prescribing or achieving the target dose of Betablocker was noted in 38.18% of patients in the first month, which was also reduced to nil (p=0.00) at the end of the study. CONCLUSION: This study reveals that periodic clinical audit improves adherence to GDMT in patients admitted with heart failure with reduced ejection fraction.

Mechanism and Immediate Outcome of Significant Mitral Regurgitation Following Balloon Mitral Valvuloplasty with JOMIVA Balloon.

INTRODUCTION: Balloon Mitral Valvuloplasty (BMV) with inoue balloon is the most common technique being followed worldwide. Over the wire BMV is a modified technique with Joseph Mitral Valvuloplasty (JOMIVA) balloon and is being followed in certain centres. We hypothesized that, the incidence and mechanism of Mitral Regurgitation (MR) is likely to be different from that of inoue balloon. AIM: To assess the mechanism and immediate clinical outcome of significant MR following BMV with JOMIVA balloon retrospectively. MATERIALS AND METHODS: We retrospectively analyzed the outcome of 48 patients who developed moderate to severe MR out of 249 patients who underwent BMV in our institute. We analyzed the echocardiographic and clinical parameters of these patients. RESULTS: Nineteen (7.6%) patients developed severe MR and 29 (11.2%) patients developed moderate MR. Commisural separation resulting in MR was the most common cause which was contributing to 73.6 % and 85.7% of patients with moderate and severe MR respectively. Leaflet tear was the second most common cause which contributed to 15.7% and 14.2% of patients with severe and moderate MR respectively. Chordal rupture contributed to 10.5% of patients with severe MR. Six (31.6%) patients with severe MR developed worsening breathlessness among them one had to be referred for mitral valve replacement during index hospitalization and the rest could be managed medically. Patients with moderate MR remained asymptomatic and stable. CONCLUSION: Severe MR following JOMIVA BMV results most commonly due to wide separation of commisures. JOMIVA balloon is less likely to cause damage to subvalvular structures than inoue balloon. Most patients who develop severe MR will not require emergency mitral valve replacement. Moderate MR is well tolerated clinically.

Immediate Outcome of Balloon Mitral Valvuloplasty with JOMIVA Balloon during Pregnancy.

INTRODUCTION: Rheumatic mitral stenosis is the most common Valvular Heart Disease encountered during pregnancy. Balloon Mitral Valvuloplasty (BMV) is one of the treatment option available if the symptoms are refractory to the medical management and the valve anatomy is suitable for balloon dilatation. BMV with Inoue balloon is the most common technique being followed worldwide. Over the wire BMV is a modified technique using Joseph Mitral Valvuloplasty (JOMIVA) balloon catheter which is being followed in certain centres. AIM: To assess the immediate post procedure outcome of over the wire BMV with JOMIVA balloon. MATERIALS AND METHODS: Clinical and echocardiographic parameters of pregnant women with significant mitral stenosis who underwent elective BMV with JOMIVA balloon in our institute from 2005 to 2015 were analysed retrospectively. Severity of breathlessness (New York Heart Association Functional Class), and duration of pregnancy was included in the analysis. Pre procedural echocardiographic parameters which included severity of mitral stenosis and Wilkin's scoring were analysed. Clinical, haemodynamic and echocardiographic outcomes immediately after the procedure were analysed. RESULTS: Among the patients who underwent BMV in our Institute 38 were pregnant women. Twenty four patients (63%) were in New York Heart Association (NYHA) Class III. All of them were in sinus rhythm except two (5%) who had atrial fibrillation. Thirty four patients (89.5%) were in second trimester of pregnancy at the time of presentation and four (10.5%) were in third trimester. Echocardiographic analysis of the mitral valve showed that the mean Wilkin's score was 7.3. Mean mitral valve area pre procedure was 0.8 cm2. Mean gradient across the valve was 18 mmHg. Ten patients (26.5%) had mild mitral regurgitation and none had more than mild mitral regurgitation. Thirty six patients had pulmonary hypertension as assessed by tricuspid regurgitation jet velocity. All of them underwent BMV with JOMIVA balloon. Post procedure mean mitral valve area was 1.7 cm2 as assessed by echocardiography. Post procedure mean gradient across the mitral valve as assessed by echocardiography was 5 mmHg. Two patients had moderate to severe mitral regurgitation after the procedure and the rest had either no mitral regurgitation or mild mitral regurgitation after the procedure. None of the patients warranted mitral valve replacement after BMV. No patients had any manifestations of systemic embolism like cerebrovascular accident or limb ischemia after the procedure. None of the patients had preterm delivery or adverse fetal outcome during index hospitalisation. CONCLUSION: Over the wire BMV is safe and effective method during pregnancy. The results are comparable to that of Inoue technique. BMV offers a good symptomatic improvement in pregnant women presenting with symptoms of pulmonary congestion because of Rheumatic mitral stenosis.

Beware of Venous Anomalies in Young Patients with Sick Sinus Syndrome: A Report of Two Cases of Sick Sinus Syndrome with Systemic Venous Anomalies.

We report two young patients with symptomatic sick sinus syndrome admitted for permanent pacemaker implantation (PPI). On evaluation with echocardiography, one of them was found to have persistent left superior vena cava and venography showed absent right superior vena cava also. He underwent PPI with leads inserted via left superior vena cava, coronary sinus, right atrium and right ventricle. The other patient was incidentally found to have interrupted inferior vena cava with azygos continuation while being planned for temporary pacemaker implantation. She underwent successful PPI. We would like to stress the importance of having a high suspicion for these systemic venous anomalies in patients presenting with sick sinus syndrome especially at young age. If we could diagnose preoperatively, we can avoid on table surprises.