Statement from the Asia Summit: Current state of arrhythmia care in Asia.

On May 27, 2022, the Asia Pacific Heart Rhythm Society and the Heart Rhythm Society convened a meeting of leaders from different professional societies of healthcare providers committed to arrhythmia care from the Asia Pacific region. The overriding goals of the meeting were to discuss clinical and health policy issues that face each country for providing care for patients with electrophysiologic issues, share experiences and best practices, and discuss potential future solutions. Participants were asked to address a series of questions in preparation for the meeting. The format of the meeting was a series of individual country reports presented by the leaders from each of the professional societies followed by open discussion. The recorded presentations from the Asia Summit can be accessed at https://www.heartrhythm365.org/URL/asiasummit-22. Three major themes arose from the discussion. First, the major clinical problems faced by different countries vary. Although atrial fibrillation is common throughout the region, the most important issues also include more general issues such as hypertension, rheumatic heart disease, tobacco abuse, and management of potentially life-threatening problems such as sudden cardiac arrest or profound bradycardia. Second, there is significant variability in the access to advanced arrhythmia care throughout the region due to differences in workforce availability, resources, drug availability, and national health policies. Third, collaboration in the area already occurs between individual countries, but no systematic regional method for working together is present.

Home-based cardiac rehabilitation: development, implementation and outcome evaluation in patients with coronary artery diseases in Lahore, Pakistan - a mixed-methods study protocol.

INTRODUCTION: Cardiac rehabilitation (CR) is an important strategy to bring cardiac patients back to a normal life after a cardiac event. The benefits of CR as part of secondary prevention are widely known among people who have undergone myocardial infarction or revascularisation. As evidenced by several systematic reviews and meta-analyses, home-based CR (HBCR) has similar or greater effects on health-related quality of life, health outcomes, physical activity, anxiety and unplanned visits to the emergency department as compared with centre-based CR. The purpose of this study is to develop a contextual HBCR intervention and evaluate its effects on quality of life, health behaviours, bio-physiological parameters and emergency hospital visits of patients with coronary artery diseases in Lahore, Pakistan. METHODS AND ANALYSIS: This study will employ a mixed-method exploratory sequential research design. The researchers will invite 15-20 cardiac patients and 12-15 healthcare providers for semi-structured interviews in the qualitative phase of the study. Once the intervention is developed and validated through the qualitative phase, the outcomes will be evaluated through a single-blinded randomised control trial in the quantitative phase. A total of 118 patients with acute coronary syndrome will be recruited through a screening checklist and randomly allocated into the control and intervention groups (59 patients in each group). The inductive coding approach will be used for the thematic analysis of qualitative data, whereas the quantitative data will be analysed through descriptive and inferential statistics using SPSS to see the difference within the groups, between groups and between three intervals. ETHICS AND DISSEMINATION: The Ethical Review Committee of Aga Khan University and Mayo Hospital Lahore under the registration number 2023-8282-24191 and No/75749MH have approved this study protocol, respectively. The results of this study will be disseminated to participating patients (in the Urdu language), healthcare professionals and the public by publishing the manuscript in an open-access peer-reviewed journal and presenting it at different conferences. TRIAL REGISTRATION NUMBER: Australian New Zealand Clinical Trial Registry (ACTRN12623000049673p).

Challenges of managing hypertension in Pakistan - a review.

BACKGROUND: This review aims to describe existing evidence on the state of hypertension in Pakistan, including the prevalence, associated risk factors, preventive strategies, and challenges in the management of hypertension. METHODS: A comprehensive literature search was conducted electronically using PubMed and Google Scholar. Using specific screening methodology, 55 articles were selected to be included. RESULTS: We found from this extensive review that several small studies report high prevalence of hypertension but there is a lack of population based prevalence of hypertension in Pakistan. Lifestyle risk factors such as obesity, unhealthy diet, decreased physical activity, low socioeconomic status, and lack of access to care were the main associated factors with hypertension. Lack of blood pressure monitoring practices and medication non-adherence were also linked to uncontrolled hypertension in Pakistan and were more evident in primary care setups. The evidence presented is essential for delineating the burden of the disease, hence allowing for better management of this underserved population. CONCLUSION: There is a need for updated surveys to depict the true prevalence and management of hypertension in Pakistan. Cost-effective implementation strategies and policies at the national level are needed for both prevention and control of hypertension.

Sex disparity in left ventricular hypertrophy in South Asians with hypertension: influence of central obesity and high blood pressure.

Women have been reported to be at greater risk of left ventricular hypertrophy (LVH) than men in South Asia, but whether the sex disparity is affected by central obesity and blood pressure has not been well studied. We examined prospectively the interaction of sex with waist circumference and systolic blood pressure at baseline on LVH measured after a median of 8-year follow-up among 539 individuals with hypertension in Karachi, Pakistan, and found that the risk of LVH for women vs men increased with higher baseline waist circumference and systolic blood pressure. Our results underscore the urgency for public health programs to prevent obesity and control hypertension in women in South Asia.

Takotsubo Like Cardiomyopathy with Concomitant Pheochromocytoma: A Rare Presentation.

Pheochromocytoma classically presents with headache, diaphoresis, palpitations and, raised blood pressure. Rarely, it manifests as cardiomyopathy. Herein, we present a case of a 42-year woman who presented with heart failure and on work-up was found to have pheochromocytoma leading to Takotsubo-like cardiomyopathy. The biochemical profile revealed raised serum metanephrines and normetanephrines. CT abdomen showed a left adrenal mass. Within two weeks of presentation and before surgical excision of the mass, she recovered from cardiomyopathy. After medical optimisation, the patient underwent elective adrenalectomy, which on histological evaluation revealed pheochromocytoma. Key Words: Cardiomyopathy, Pheochromocytoma, Adrenal mass.

Clinical characteristics and prognostic factors of atrial fibrillation at a tertiary center of Pakistan - From a South-Asian perspective - A cross-sectional study.

BACKGROUND: There is lack of large data from South-Asian region on atrial fibrillation and it is imperative that clinical presentation, prognostic factors, management pursued, and outcomes are known for this part of the world. Once collective evidence for the region is known, region-specific guidelines can be laid forward. OBJECTIVES: To evaluate clinical characteristics and prognostic factors of atrial fibrillation at a tertiary care center of Pakistan. METHODS: This was a retrospective study conducted at a tertiary care center of Pakistan. Period of study ranged from July-December 2018. All hospitalized patients who were admitted with atrial fibrillation as a primary or associated diagnosis were enrolled. RESULTS: A total of 636 patients were enrolled. The mean age was 68.5 ± 12 years and 49.5% (315) were male. 90.6% of the patients were admitted via emergency room. Majority (59.9%) had previously known AF and 40% developed new-onset AF during the hospital stay. Hypertension was the most common co-morbid condition (85.4%) followed by Diabetes Mellitus (40.1%). At least 9% had rheumatic heart disease. The median CHA2DS2VASc and HASBLED scores were 4 and 2 respectively. More than one-third of patients had sepsis as a primary diagnosis (36.8%). The in-hospital mortality of patients with atrial fibrillation was 6.7%. Patients with new-onset AF had higher mortality. Sepsis and stroke were independently associated with a higher mortality. There was no significant difference in median CHA2DS2VASc and HASBLED scores for patients with new-onset and previously known AF. On discharge, 83% of the eligible patients received oral anticoagulation. CONCLUSION: There was higher prevalence of chronic co-morbid conditions in the studied population leading to a higher CHA2DS2VASC Score. Sepsis and stroke were independently associated with higher in-hospital mortality.

COVID-19 BBIBP-CorV vaccine and transient heart block - A phenomenon by chance or a possible correlation - A case report.

IMPORTANCE: Bradyarrhythmia during COVID19 illness carries prognostic significance. Electrophysiological side effects of COVID19 vaccine remain largely unknown. It is imperative to report nature of cardiovascular side effects of the vaccine. CASE PRESENTATION: An 80 years-old-man presented with complains of dizziness, trepidation and shortness of breath following his first shot of COVID-19 BBIBP-CorV (Sino-pharm). ECG on arrival showed 2:1 atrioventricular block with an underlying old left bundle branch block. The AV block changed into Mobitz type-I over the course of next 2 days and into a sinus 1:1 conduction on fourth day of presentation. However, our patient underwent permanent pacemaker implantation due to the underlying conduction tissue disease and intermittent 2:1 AV block during the hospital stay. CLINICAL DISCUSSION: It is likely that patients with an already diseased conduction system are at an increased risk of worsening of AV block following inoculation of the vaccine. Vaccine associated AV blocks are likely to be reversible. Presence of prior coronary artery disease and electrical abnormalities are important considerations. CONCLUSION: COVID-19 vaccine may have added side effects in subjects with known heart disease. Humoral response towards the vaccine might interfere with the conduction system of the heart and more so in patients with diseased and scarred myocardium.

Cardiovascular fellow-in-training feedback on virtual and simulator-based learning experience during Covid-19 pandemic in a low to middle income country - A cross-sectional study.

BACKGROUND: COVID-19 pandemic has introduced us to a greater need of virtual learning platforms and has resulted in less clinical exposure for fellows-in-training. Virtual and simulator-based learning is not widely available in LMIC. It is imperative to analyze feedback of CV fellow-in-training regarding this mode of learning before large scale implementation. METHODOLOGY: This was an observational study conducted between July-August 2020. A multicentered survey was conducted. Survey questionnaire was disseminated to FIT (fellow-in-training) via Google Forms. The questionnaire contained a total of 24 questions about virtual and simulator-based learning during the pandemic. RESULTS: A total of 68 FIT responded to the survey. The mean age was 29.9 years. There were 37% females and 63% males. Majority (75%) agreed that it was easier for them to reach for online sessions than physical sessions. 60% FIT were confident in asking questions or giving comments during the online sessions. 57.4% FIT felt it easier to go through cardiovascular imaging/illustrations via online platforms. 50% (34) were confident that if online sessions had to continue, they would have enough academic learning before they graduated from the program and 54.4% (37) wanted online sessions to continue even beyond the pandemic days. 37.5% (18 out of 48) agreed that the simulator-based teaching was helping them practice skills in times of less clinical exposure. CONCLUSION: COVID-19 pandemic has significantly impacted cardiovascular FIT learning curve because of less hands-on and lack of physical teaching sessions. LMIC have lack of robust e-learning platforms. Virtual learning is convenient for academic learning with growing acceptance amongst fellows. FIT from LMIC are less acquaint to simulator-based teaching and there is a need to invest in simulator-based cardiovascular teaching in LMIC.

Perfecting temporary pacemakers in a developing country.

INTRODUCTION: Transvenous pacemakers are used to temporarily pace heart in emergent situations. This study was conducted to analyze the current success rate of temporary pacemaker insertion in our institution and discover causes for failure to improve the technique. METHODOLOGY: A retrospective cohort study was conducted of 263 patients from 2006 to 2016 who underwent TPM insertion at Aga Khan University Hospital, Karachi. RESULTS: The success rate for the procedure was 97.7%, with one mortality caused by the pacemaker. No significant risk factor was found for the failure of TPM. CONCLUSION: There was no significant effect of anatomical site or technique on the failure of TPM insertion. However, with better training and higher experience of the residents, the complications and rate of failures can be reduced.

Reverse Takotsubo Cardiomyopathy Following A Case Of Suspected Meningoencephalitis And Literature Review.

Reverse Takotsubo cardiomyopathy is a rare variant of stress cardiomyopathy. A 22-year-old male presented with altered mentation and fever. He was intubated due to low Glasgow Coma Scale. CT head plain showed diffuse cerebral oedema. Patient had raised troponin-I and echocardiogram revealed reduced ejection fraction with hyperdynamic apical segments and akinetic basal to mid segments suggestive of reverse Takotsubo cardiomyopathy (rTCM). Association of rTCM with neuropsychiatric disorders such as intracranial/epidural haemorrhages and anorexia nervosa has been defined. However, it is rare to have rTCM with meningoencephalitis.

Frequency of Peri-operative Hypertension in a tertiary care hospital in Karachi, Pakistan.

This study aims to determine the frequency of perioperative hypertension and its types (pre, intra and post-operative) hypertension in patients admitted for surgical procedures. This was a cross-sectional study conducted between the years 2012-2013 at the Aga Khan University Hospital, Karachi. Patients admitted for any surgical procedure during this time were included. Perioperative hypertension has been defined as systolic blood pressure of >140 mm Hg or a diastolic blood pressure of >90 mm Hg or whose blood pressure increased by 20% during surgery. A total of 428 surgical procedures were reviewed for the study. Overall perioperative hypertension was present in 231 (54%) of the patients. In the sample, 91 (21.7%) had pre-operative hypertension, 126(29.4%) reported pre-surgery hypertension, 24(5.6%) had intra-operative hypertension and 63(14.7%) had post-operative hypertension. Mean pain score was 1.43(1.4) v 1.25(1.2) in those with postoperative hypertension v no post-operative hypertension (p value 0.009).

Defining the hemodynamic response of hypertensive and normotensive subjects through serial timed blood pressure readings in the clinic.

BACKGROUND: Every third patient in the clinic is misdiagnosed due to white-coat phenomenon, necessitating needless and costly treatment. We aimed to study the hemodynamic response of the physician's visit on hypertensive and normotensive patients by investigating the trend of blood pressure (BP) before, during and 15 min after the physician-patient encounter. METHODS: A descriptive, cross-sectional study was conducted over a period of 8 months in the cardiology clinics at the Aga Khan University Hospital, Karachi. Both hypertensive and normotensive patients, aged ≥18 years, were recruited. Pregnant females or those with a history of volume loss were excluded. BP readings were taken using an automated, validated device (Omron-HEM7221-E) at three points: pre-clinic BP by the assessment nurse, in-clinic BP by the attending physician and post-clinic BP 15-min after the physician-patient encounter by a research assistant. Independent samples t-test was used to calculate the statistical difference between hypertensive and normotensive BP values. RESULTS: Of 180 participants, 71% (n = 128) were hypertensive and 57% (n = 103) of all were males. The mean age of the participants was 57 ± 15 years. The mean and standard deviation(±SD) systolic BP (SBP) taken pre-clinic, in-clinic and 15-min post-clinic for hypertensive population was 128.7 ± 20 mmHg, 137.1 ± 21 mmHg and 127.9 ± 19 mmHg. The mean and standard deviation(±SD) SBP taken pre-clinic, in-clinic and 15 min post-clinic for normotensive population was 112 ± 16 mmHg, 115.8 ± 20 mmHg and 111.8 ± 15 mmHg. The hypertensive SBP values showed statistically significant difference from the normotensive values (difference in pre-clinic SBP: 16.7 mmHg, p-value < 0.001; in-clinic SBP: 21.3 mmHg, p-value < 0.001; and 15 min post-clinic: 16.1 mmHg, p-value < 0.001). CONCLUSIONS: Hypertensive and normotensive patients display congruent hemodynamics upon visiting the physician, the alert response being accentuated amongst the hypertensive group. In-clinic BP readings are higher for both hypertensive and normotensive patients making them unreliable for screening and management of hypertension amongst both the groups.

The Post Clinic Ambulatory Blood Pressure (PC-ABP) study correlates Post Clinic Blood Pressure (PCBP) with the gold standard Ambulatory Blood Pressure.

OBJECTIVE: Our previous study showed that post-clinic blood pressure (BP) taken 15 min after a physician-patient encounter was the lowest reading in a routine clinic. We aimed to validate this reading with 24 h Ambulatory Blood Pressure Monitoring (ABPM) readings. A cross-sectional study was conducted in the cardiology clinics at the Aga Khan University, Pakistan. Hypertensive patients aged ≥ 18 years, or those referred for the diagnosis of hypertension were included. RESULTS: Of 150 participants, 49% were males. 76% of all participants were hypertensive. Pre-clinic BP reading was measured by a nurse, in-clinic by a physician and 15 min post-clinic by a research assistant using a validated, automated BP device (Omron-HEM7221-E). All patients were referred for 24 h ABPM. Among the three readings taken during a clinic visit, mean (± SD) systolic BP (SBP) pre-clinic, in-clinic, and 15 min post-clinic were 153.2 ± 23, 152.3 ± 21, and 140.0 ± 18 mmHg, respectively. Mean (± SD) diastolic BP (DBP) taken pre-clinic, in-clinic and 15 min post-clinic were 83.5 ± 12, 90.9 ± 12, and 86.4 ± 11 mmHg respectively. Mean (± SD) daytime ambulatory SBP, DBP and pulse readings were 134.7 ± 15, 78.7 ± 15 mmHg, and 72.6 ± 12/min, respectively. Pearson correlation coefficients of pre-clinic, in-clinic and post-clinic SBP with daytime ambulatory-SBP were 0.4 (p value: < 0.001), 0.5 (p value: < 0.001) and 0.6 (p value: < 0.001), respectively. Post-clinic BP has a good correlation with ambulatory BP and may be considered a more reliable reading in the clinic setting.

Infection of a Ventricular Septal Defect Patch with Acremonium Species.

A ventricular septal defect (VSD) patch infection with Acremonium species isolated from vegetation and blood culture is described. Antifungal treatment was discontinued after 3 months and patient developed relapse. Surgery with prolonged oral voriconazole was instituted with recovery. We emphasize importance of surgery and prolonged therapy to treat such infections.

Albuminuria and kidney function as prognostic marker of left ventricular mass among South Asians with hypertension.

We aimed to evaluate the association of albuminuria and estimated glomerular filtration rate (eGFR) at baseline and changes in these parameters with left ventricular mass index (LVMI) at 7 years in adults with hypertension from communities in Pakistan. A nested cohort of 539 hypertensives aged 40 years and older from a community-living population in Karachi, Pakistan, followed up for 7 years in the Control of Blood Pressure and Risk Attenuation trial. Urine spot albumin-to-creatinine ratio (UACR) and serum creatinine-based eGFR were assessed at baseline and 7 years, and echocardiography at 7 years. Mean age of participants was 50.9 ± 9.1 (standard deviation) years; 63% were female. Mean eGFR was 91.0 ± 15.9 (standard deviation) mL/min/1.73 m2 and median (interquartile range) UACR 6.2 (3.9, 11.3) mg/g. In multivariate analysis, although baseline eGFR was marginally associated with LVMI, a strong association was found between higher LVMI with greater rate of decline in eGFR (ß = -1.05; 95% confidence interval [CI]: [-1.94, -0.17]). Higher baseline UACR was significantly associated with higher follow-up LVMI (ß = 2.26; 95% CI: [0.87, 3.65]), as was rate of UACR increase of ≥1.07 mg/g/y versus of <0.14 mg/g/y. (ß = 4.19; 95% CI: [0.75, 7.63]). Associations with developing left ventricular hypertrophy were found for reduced baseline eGFR, higher baseline UACR, and greater rate of UACR increase, but not for rate of eGFR decline. Comparable results were observed for the outcomes of posterior wall thickness and septal wall thickness. Higher baseline albuminuria, lower baseline eGFR, and their longitudinal worsening were significantly associated with higher LVMI or the development of left ventricular hypertrophy among individuals with hypertension in Pakistan.

Level of knowledge among cardiac nurses regarding sexual counseling of post-MI patients in three tertiary care hospitals in Pakistan.

PURPOSE: The aim of this study is to measure the level of knowledge among cardiac nurses about sexual counseling of post-myocardial infarction (MI) patients. METHOD: This descriptive cross-sectional study was conducted among 153 nurses at three tertiary care hospitals of a large metropolitan city of Pakistan. RESULTS: The findings revealed that the majority nurses have moderate knowledge regarding post-MI sexual counseling. Additionally, nurses have lack of knowledge regarding effects of cardiac drugs on sexual life of post-MI patients. CONCLUSION: There is a need to improve nurses' knowledge in regard to sexual counseling among post-MI patients. Nurses should have knowledge to deal with such a sensitive issue as sexuality, in order to improve patients' quality of life. With respect to Pakistan, this was a baseline study and may provide insights for designing interventional or qualitative studies in the future.

Twiddlers syndrome presenting as life threatening electrical storm.

A 75-year-old man underwent implantation of a single chamber implantable cardioverter defibrillator (ICD) for primary prevention of his underlying severe non-ischaemic cardiomyopathy. Thirteen months later, he presented to the emergency room(ER) with inappropriate ICD shocks as a result of over sensing of the right ventricular lead and double counting of the right atrial signals. The chest X-ray (CXR) revealed a right ventricular ICD lead displaced into the right atrium with coiling in the pocket. The right ventricular shocking coil was noted at the tricuspid annulus. The lead was removed from the pocket and was replaced with a new lead. This case represents the classical Twiddler's syndrome in an ICD with potential lethal consequences.

Multicomponent intervention versus usual care for management of hypertension in rural Bangladesh, Pakistan and Sri Lanka: study protocol for a cluster randomized controlled trial.

BACKGROUND: High blood pressure (BP) is the leading attributable risk for cardiovascular disease (CVD). In rural South Asia, hypertension continues to be a significant public health issue with sub-optimal BP control rates. The goal of the trial is to compare a multicomponent intervention (MCI) to usual care to evaluate the effectiveness and cost-effectiveness of the MCI for lowering BP among adults with hypertension in rural communities in Bangladesh, Pakistan and Sri Lanka. METHODS/DESIGN: This study is a stratified, cluster randomized controlled trial with a qualitative component for evaluation of processes and stakeholder feedback. The MCI has five components: (1) home health education by government community health workers (CHWs), (2) BP monitoring and stepped-up referral to a trained general practitioner using a checklist, (3) training public and private providers in management of hypertension and using a checklist, (4) designating hypertension triage counter and hypertension care coordinators in government clinics and (5) a financing model to compensate for additional health services and provide subsidies to low income individuals with poorly controlled hypertension. Usual care will comprise existing services in the community without any additional training. The trial will be conducted on 2550 individuals aged ≥40 years with hypertension (with systolic BP ≥140 mm Hg or diastolic BP ≥90 mm Hg, based on the mean of the last two of three measurements from two separate days, or on antihypertensive therapy) in 30 rural communities in Bangladesh, Pakistan and Sri Lanka. The primary outcome is change in systolic BP from baseline to follow-up at 24 months post-randomization. The incremental cost of MCI per CVD disability-adjusted life years averted will be computed. Stakeholders including policy makers, provincial- and district-level coordinators of relevant programmes, physicians, CHWs, key community leaders, hypertensive individuals and family members in the identified clusters will be interviewed. DISCUSSION: The study will provide evidence of the effectiveness and cost-effectiveness of MCI strategies for BP control compared to usual care in the rural public health infrastructure in South Asian countries. If shown to be successful, MCI may be a long-term sustainable strategy for tackling the rising rates of CVD in low resourced countries. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02657746 . Registered on 14 January 2016.

Biventricular thrombus in hypereosinophilic syndrome presenting with shortness of breath.

A 48 years old male presented to clinic with 12 months of low grade fever with shortness of breath which has progressively worsened with no associated weight loss, night sweats or loss of appetite. There was no prior history of chronic illness before the current illness. Laboratory workup revealed a high white blood cell count with predominant eosinophils. Chest X-ray was normal. Transthoracic echocardiography and Cardiac Magnetic Resonance showed biventricular thrombi. On further extensive workup the findings were consistent with hypereosinophilic syndrome. The patient was started on oral steroids, hydroxyurea, imatanib mesylate and oral anticoagulation. The patient responded to the treatment with complete resolution of his symptoms over the course of few months. The repeat Echocardiogram after a year showed normal left ventricular systolic and diastolic function with complete resolution of biventricular thrombi.

Control of blood pressure and risk attenuation: a public health intervention in rural Bangladesh, Pakistan, and Sri Lanka: feasibility trial results.

BACKGROUND: High blood pressure (BP) is the leading attributable risk for cardiovascular disease globally. There is little information on effective and sustainable public health system strategies for managing hypertension in South Asian countries. We conducted a feasibility study to gather preliminary data to optimize BP-lowering strategies for a public health intervention in rural communities in Bangladesh, Pakistan, and Sri Lanka. METHODS: A mixed method feasibility study comprised a 3-month pre and postevaluation of a multicomponent intervention (MCI), including BP screening and home health education by trained government community health worker (CHW); providers trained in hypertension management, and compensation of CHW for additional services. Checklists were used to document care. Stakeholder interviews were also conducted. Individuals aged 40 years and above with high BP (systolic ≥140 mmHg or diastolic ≥90 mmHg based on two readings from 2 separate days, or receiving antihypertensive medications) were enrolled from rural communities in Bangladesh, Pakistan, and Sri Lanka. BP was measured at baseline and 3 months postintervention. RESULTS: A total of 412 (90%) of the 454 eligible individuals were recruited. Of those recruited, 90% received home health education session by trained CHWs, 80% were referred to trained providers, of whom 83% completed the management checklist. A follow-up rate of 95.6% was achieved. The mean SBP declined significantly by 4.5 mmHg 95% confidence interval (2.3, 6.7) mmHg (P < 0.001) in the overall pooled analysis in three countries; however, it varied among countries. BP decline was 10.5 mmHg (8.1, 13.0 mmHg) (P < 0.001) in the pooled analysis of individuals with uncontrolled hypertension at baseline, and was also significant each of the three countries. All 98 stakeholders strongly supported upscaling the proposed MCI strategies. CONCLUSION: The proposed MCI is feasible for implementation and requires long-term, large-scale evaluation in the rural public health infrastructure in South Asian countries to determine sustainability of health system changes and BP control. If these long-term effects are confirmed, MCI may be a long-term strategy for tackling rising rates of cardiovascular disease in low-resourced countries.Clintrial.gov NCT02341651.