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.

Coronary thrombo-embolic events after Covid-19 vaccination- a single centre study.

Thrombo-embolic complications after Corona virus disease-19 (COVID-19) vaccination have been previously reported. We aimed to study the coronary thrombo-embolic complications (CTE) after COVID-19 vaccination in a single centre during the initial 3 months of vaccination drive in India. All patients admitted to our hospital between 1st March 2021 and 31st May 2021 with Acute coronary syndrome (ACS) were included. Of the 89 patients [Age 55 (47-64)y, 13f] with ACS and angiographic evidence of coronary thrombus, 37 (42%) had prior vaccination history. The timing from last vaccination dose to index event was <1, 1-2, 2-4 and >4 weeks in 9(24%), 4(11%), 15(41%) and 9 (24%) respectively. ChAdOx1 nCoV-19/AZD1222 (Covishield) was the most used vaccine- 28 (76%), while 9 (24%) had BBV152 (Covaxin). Baseline characteristics were similar in both vaccinated (VG) and non-vaccinated group (NVG), except for symptom to door time [8.5 (5.75-14) vs 14.5 (7.25-24) hrs, p = 0.003]. Thrombocytopenia was not noted in any of the VG patients, while 2 (3.8%) of NVG patient had thrombocytopenia (p = 0.51). The pre- Percutaneous Coronary Intervention (PCI) Thrombolysis in Myocardial Infarction (TIMI) flow was significantly lower [1 (0-3) vs2 (1-3), p = 0.03) and thrombus grade were significantly higher [4 (2.5-5) vs 2 (1-3), p = 0.0005] in VG. The in-hospital (2.7% vs 1.9%, p = 1.0) and 30-day mortality were also similar (5.4% vs 5.8%, p = 1.0). This is the first report of CTE after COVID-19 vaccination during the first 3 months of vaccination drive in India. We need further reports to identify the incidence of this rare but serious adverse events following COVID-19 vaccination.

Acute Coronary Syndrome admissions and outcome during COVID-19 Pandemic-Report from large tertiary centre in India.

Few studies from various countries have reported decline in Acute Coronary Syndrome (ACS) admissions to hospital during COVID-19 pandemic. We studied the impact of COVID-19 strict lockdown on ACS admission in a tertiary referral hospital in India. This showed 43% decline in admissions (n = 104 vs mean n = 183) and even in those who got admitted, there was a delay in presentation compared to previous year, which was reflected in the outcome of patients. Government and health organizations should educate the public early-on during the pandemic about the consequences of ignoring other acute medical problems such as ACS.

Risk factors, comorbiditiEs and Atherogenic dysLipidaemia in Indian YOUNG patients with dyslipidaemia attending hospital/clinic: REAL YOUNG (dyslipidaemia) study.

OBJECTIVE: To evaluate the pattern of dyslipidaemia, risk factors, and comorbidities in young Indian adults with dyslipidaemia. METHODS: A retrospective, multi-centric real-world study included individuals with dyslipidaemia, aged 18 - 45 years, attending to 623 hospitals/clinics across India. Data were collected retrospectively from medical records to note demographics, risk factors (smoking, alcohol consumption, sedentary lifestyle, family history of dyslipidaemia, diabetes mellitus, and hypertension), and clinical details (height, weight, waist circumference, body mass index (BMI), blood pressure, blood sugar, glycated hemoglobin (HbA1c), triglycerides (TG), total cholesterol (TC), low-density lipoproteins (LDL-C), and high-density lipoprotein (HDL-C)).A descriptive analysis and comparative analysis (Mann-Whitney U test and Chi-square test) were done. RESULTS: Of the total 8135 patients, the majority were men (65.0%). Overall, 87.1% of population had one or multiple comorbidities which included the presence of dyslipidaemia alone (12.9%), dyslipidaemia with diabetes and hypertension (39.1%), dyslipidaemia with diabetes (33.6%), and dyslipidaemia with hypertension (14.4%). Sedentary lifestyle was prevalent observation in >50% of the population. Youngest age (18 - 25) group had higher prevalence of hypertriglyceridemia (63.2%), high LDL-C levels (56.8%), and low HDL-C levels (64.6%), while patients from the age group >25 to ≤35 years had the highest incidence of hypercholesterolemia (66.6%). Atherogenic dyslipidaemia was observed in 41.9%, 25.5%, and 23.2% of patients from age groups of ≥18 to ≤25, >25 to ≤35, and >35 to ≤45 years, respectively. Patients with HbA1c ≥6.5% had significantly higher levels of TG, TC, LDL-C, and lower HDL-C compared to those with HbA1c <6.5%. CONCLUSION: Hypertriglyceridemia, high LDL-C, low HDL-C, and atherogenic dyslipidaemia were prevalent in the young Indian cohort and sedentary lifestyle, and HbA1c ≥ 6.5% were the predominant risk factors of dyslipidaemia.

Transcatheter aortic valve replacement in India-Early experience, challenges, and outcomes from a single center.

BACKGROUND: Despite the increasing popularity of transcatheter aortic valve replacement (TAVR), only about 10,000 TAVR cases have been performed in Asia to date. The procedure is still in a nascent stage in India with very few centers offering this state-of-art technique. Here, we present the early results of TAVR experience at our center. METHODS: Forty-nine patients with severe symptomatic aortic stenosis (AS) were referred to our center for TAVR from November 2015 to February 2018. Twenty-five patients underwent TAVR at our conventional cardiac catheterization laboratory under local or general anesthesia, with standby surgical team support. RESULTS: The mean age of the patients was 72.0 ± 8.1 years. The mean Society of Thoracic Surgeons score was 13.8 ± 10.2. Baseline mean ejection fraction was 50.3 ± 14.8%. Baseline mean aortic valve gradient was 55.8 ± 24.7 mmHg. There was one procedural-related death. Two of the patients required urgent surgery: one for contained annular rupture and one underwent vascular repair for femoral artery occlusion. Mild and moderate paravalvular leak was seen in 11 and 3 patients, respectively. Four patients (16%) required permanent pacemaker. Eighty percent were in New York Heart Association class I-II at discharge. One-year all-cause mortality was 8%, with no hospitalizations or major adverse cardiac event during the 1-year follow-up. CONCLUSION: Our early data clearly shows that in our country, TAVR is a good alternative for symptomatic severe AS for high surgical risk cases. Large-scale multicenter studies are required to study the real impact of TAVR in the Indian scenario. During initial years of implementation of a nationwide TAVR program, it may be prudent to focus on creating TAVR Centers of Excellence by developing an ideal hub and spokes model.

Relationship of left atrial appendage function to left ventricular function.

BACKGROUND: The study was conducted to evaluate the relationship of left atrial appendage function to left ventricular function and to analyze, if left ventricular dysfunction predisposed to left atrial appendage thrombus formation even in the presence of sinus rhythm. METHODS AND RESULTS: The study was conducted in 78 patients with a mean age of 53+/-8.5 years, all of whom were in sinus rhythm. Transesophageal echocardiography was performed to record the left atrial appendage emptying and filling velocity and to look for the presence of spontaneous echo contrast and thrombus. Patients with severe left ventricular dysfunction (Group I--left ventricular ejection fraction < 35%) and patients with moderate left ventricular dysfunction (Group II--left ventricular ejection fraction 35-45%) had lower left atrial appendage emptying velocity (33.6+/-16 and 39.7+/-19.5 cm/s, respectively) and filling velocity (41+/-14.7 and 41+/-17 cm/s, respectively) when compared to patients with preserved systolic function (Group II--left ventricular ejection fraction >45%), who had emptying and filling velocity of 55+/-16 and 56+/-15 cm/s, respectively (p <0.05). Twelve out of 32 (38%) patients with severe left ventricular dysfunction (Group I) and 7 out of 25 (28%) patients with moderate left ventricular dysfunction (Group II) had presence of left atrial appendage thrombus as compared to none of the patients with preserved left ventricular ejection fraction (Group III) (p <0.001). CONCLUSIONS: Patients with left ventricular dysfunction also had left atrial appendage dysfunction as evidenced by lower emptying and filling velocities and had increased incidence of thrombus formation.

Familial cardiac myxoma: Carney's complex.

We report a case of Carney's complex in a 12-year-old boy who had the characteristic features of multiple cutaneous tumors, pigmentation, and biatrial myxoma. His large right atrial myxoma almost occluded the tricuspid valve and presented a life-threatening emergency. Surgery saved his life, but recurrence of myxoma was noted on follow-up. The familial nature of the condition is highlighted by the case of the patient's 44-year-old mother, who also presented with features of Carney's complex: multiple cutaneous tumors and a tiny, asymptomatic, left atrial myxoma, which was detected during routine echocardiographic screening.

Left ventricular pseudoaneurysm caused by coronary spasm, myocardial infarction, and myocardial rupture.

We report a very rare case of a 47-year-old man who had coronary spasm that resulted in a silent myocardial infarction, a ruptured myocardial wall, and a nonruptured left ventricular pseudoaneurysm. The patient presented with a 6-month history of dyspnea on exertion, without evidence of fixed coronary artery stenosis. Coronary angiography showed severe coronary spasm of the left anterior descending and left circumflex arteries; the spasm was relieved promptly by nitroglycerin. Echocardiography and left ventricular angiography revealed the large left ventricular pseudoaneurysm posterolateral to the left ventricle. We performed surgical resection of the pseudoaneurysm and patch repair of the ruptured left ventricular wall, with excellent results. We present this case because of the highly unusual sequence of events. Early surgical intervention resulted in the patient's recovery.