Impact of capacity building and tele ECG based decision support on change in thrombolysis rate and inhospital and one year mortality in patients with STEMI, using hub and spoke model; multi-phasic intervention trial.

BACKGROUND: We report the impact of capacity building and teleconsultation on change in the thrombolysis rates and one-year mortality in patients with STEMI using a hub and the spoke model of STEMI care. METHODS: Twenty secondary care public hospitals were linked with a teaching hospital as a hub centre and the impact of the intervention on change in ischemic time, thrombolysis rates and all-cause in-hospital and one-year mortality was compared. RESULTS: 29 patients with STEMI were treated during pre-intervention from April 2020 to June 2020 and 255 patients during the post-intervention period from July 2020 to Oct 2021 in spoke centres. 245 patients were reported to a hub centre during the study period. The thrombolysis rate was significantly higher in the spoke centres after intervention (65.5%vs. 27.5% p<0.001) and was also significantly higher than in patients treated in a hub centre (65.5% vs. 45.7 % p<0.01). The in-hospital mortality was significantly lower in patients treated at spoke centres compared to those treated at the hub centre (7.8% vs. 15.5% <0.003). The significant difference in mortality rate continued at one year (11.0% vs.18.4% p<0.01). The median time from symptoms to thrombolytic therapy was significantly lower in STEMI patients treated in spoke centres compared to a hub centre (230 minutes vs. 356 minutes p<0.001). CONCLUSION: The hub and spoke model of STEMI care is effective in increasing thrombolysis rate, and decreasing in-hospital and one-year mortality rate.

A Comprehensive Insight and Mechanistic Understanding of the Lipidomic Alterations Associated With DCM.

Dilated cardiomyopathy (DCM) is one of the major causes of heart failure characterized by the enlargement of the left ventricular cavity and contractile dysfunction of the myocardium. Lipids are the major sources of energy for the myocardium. Impairment of lipid homeostasis has a potential role in the pathogenesis of DCM. In this review, we have summarized the role of different lipids in the progression of DCM that can be considered as potential biomarkers. Further, we have also explained the mechanistic pathways followed by the lipid molecules in disease progression along with the cardioprotective role of certain lipids. As the global epidemiological status of DCM is alarming, it is high time to define some disease-specific biomarkers with greater prognostic value. We are proposing an adaptation of a system lipidomics-based approach to profile DCM patients in order to achieve a better diagnosis and prognosis of the disease.

Clinical characteristics, etiological profile, treatment and long term outcomes in patients with non ischemic systolic heart failure; Himachal Pradesh heart failure registry (HP-HF registry).

BACKGROUND: The data on clinical characteristics, treatment practices and out comes in patients with Non- ischemic Systolic Heart Failure (NISHF) is limited. We report clinical characteristics, treatment and outcomes in patients with NISHF. METHODS: 1004 patients with NISHF were prospectively enrolled and their demographics, clinical characteristics, and treatment were recorded systematically. Patients were followed annually for a median of 3 years (1 year to 8 years) for allcause death, major adverse cardiovascular events (MACE); composite of all-cause death, hospitalization of heart failure, and or for stroke. RESULTS: Patients of NISHF were middle-aged (58.8±16.2 years) population with severely depressed left ventricular ejection fraction (29.3±7.02%) and 31.1% had symptoms of advanced Heart failure. Hypertension (43.6%), obesity and or overweight (28.0%), Diabetes (15.0%), and valvular heart disease (11.8%) were the common risk factors. The guideline directed medical treatment was prescribed in more than 80% of the study cohort. Incidence of all cause death and MACE was 7 (6.8, 8.8) per 100 person years and 11(10, 13) per 100 person years respectively. The cumulative incidence of deaths and MACE was 35% (30%, 40%) and 49% (44%, 53%) at 8 years of follow-up. CONCLUSIONS: Patients of NISHF were middle-aged population with severely depressed LV systolic function with significant incident morbidity and mortality. Early detection of risk factors and their risk management and enhancing the use of guideline directed treatment may improve the outcomes.

Incidence, determinants, and outcomes of recovered left ventricular ejection fraction (LVEF) in patients with non-ischemic systolic heart failure; a hospital-based cohort study.

BACKGROUND: The data on incidence of recovered Left Ventricular Ejection Fraction (LVEF) and outcome in patients with non ischemic systolic heart failure is limited. We report the incidence, determinants and mortality in patients with recovered LVEF. METHODS: The 369 patients with HFrEF with LVEF of less than 40% of non ischemic etiology with available follow up echocardiography study at one year were enrolled. The baseline data of clinical characteristics and treatment was recorded prospectively and were followed up annually for mean of 3.6 years (range 2 to 5 years) to record all cause death and LVEF measured echocardiographically. The recovered, partially recovered and no recovery of LVEF was defined based on increase in LVEF to 50% and more, 41% to 49% and to persistently depressed LVEF to 40% or lower respectively. RESULTS: The LVEF recovered in 36.5%% of the cohort at 5 years. The rate of recovery of LVEF was slower in patients with no recovery of LVEF at one year compared to cohort with partially recovered LVEF (18% vs.53%) at five year. The Baseline LVEF was significantly associated with recovered LVEF, odd ratio (95% C.I.) 1.09(1.04, 1.14). The cumulative mortality at five years was significantly lower in cohort with recovered LVEF (18.1% vs. 57.1%). CONCLUSIONS: One third of the patients had recovered LVEF and was significantly associated with baseline LVEF and lower mortality rate.

Structured Lifestyle Modification Interventions Involving Frontline Health Workers for Population-Level Blood Pressure Reduction: Results of a Cluster Randomized Controlled Trial in India (DISHA Study).

Background Population-wide reduction in mean blood pressure is proposed as a key strategy for primary prevention of cardiovascular disease. We evaluated the effectiveness of a task-sharing strategy involving frontline health workers in the primary prevention of elevated blood pressure. Methods and Results We conducted DISHA (Diet and lifestyle Interventions for Hypertension Risk reduction through Anganwadi Workers and Accredited Social Health Activists) study, a cluster randomized controlled trial involving 12 villages each from 4 states in India. Frontline health workers delivered a custom-made and structured lifestyle modification intervention in the selected villages. A baseline survey was conducted in 23 and 24 clusters in the control (n=6663) and intervention (n=7150) groups, respectively. The baseline characteristics were similar between control and intervention clusters. In total 5616 participants from 23 clusters in the control area and 5699 participants from 24 clusters in the intervention area participated in a repeat cross-sectional survey conducted immediately after the intervention phase of 18-months. The mean (SD) systolic blood pressure increased from 125.7 (18.1) mm Hg to 126.1 (16.8) mm Hg in the control clusters, and it increased from 124.4 (17.8) mm Hg to 126.7 (17.5) mm Hg in the intervention clusters. The population average adjusted mean difference in difference in systolic blood pressure was 1.75 mm Hg (95% CI, -0.21 to 3.70). Conclusions Task-sharing interventions involving minimally trained nonphysician health workers are not effective in reducing population average blood pressure in India. Expanding the scope of task sharing and intensive training of health workers such as nurses, nutritionists, or health counselors in management of cardiovascular risk at the population level may be more effective in primary prevention of cardiovascular disease. Registration URL: https://www.ctri.nic.in; Unique identifier: CTRI/2013/10/004049.

Role of omega 3 and omega 6 poly unsaturated fatty acids (PUFA) and vitamin D deficiency as risk determinants of metabolic syndrome in obesity: Worksite based case-control observational study.

BACKGROUND AND AIMS: Risk factors for metabolic syndrome among obese population are not clear. The role of Eicosapentaenoic acid (EPA), Arachidonic acid (AA) Poly Unsaturated Fatty Acids (PUFA), their ratio and vitamin D deficiency as risk factors of metabolic syndrome (MS) was explored in obese worksite workers. METHODS: The 145 obese worksite workers were enrolled and MS was diagnosed using adult treatment panel III criteria. The levels of EPA, AA PUFA were estimated using liquid chromatography-Mass Spectrometer and vitamin D levels with ELISA method. The association of MS with the tertiles of EPA, AA PUFAs, their ratio and vitamin D was estimated by calculating odds ratio and 95% C.I., taking lowest tertiles as the reference group using logistic regression model adjusted for age and gender. RESULTS: 105 out of 145 obese worksite workers; 72.4%, 95% C.I. (64.5%, 79.5%) had metabolic syndrome. The odd of MS was significantly lower in the group having highest tertiles of EPA 0.24 (0.09, 0.71) and was higher 2.0 (1.02, 3.89) in subjects with highest tertiles of AA: EPA ratio. The AA PUFA and vitamin D levels had no significant association with MS. CONCLUSION: The low levels of omega 3 PUFA (EPA) and elevated ratio of AA: EPA PUFA was significantly associated with MS in obese works site workers.

Isolated pulmonary valve endocarditis with pulmonary annular abscess in a patient of Noonan syndrome.

Right-sided endocarditis is a rare entity, with various series reporting an incidence of 5%-10%. Pulmonary valve (PV) is not only the least commonly involved valve in infective endocarditis (IE), with an incidence of 1.5%-2%, but 'isolated' pulmonic valve endocarditis (PVE) without tricuspid valve involvement is even rarer with limited published data. We report a middle-aged man with Noonan syndrome and a dysplastic PV with severe pulmonary stenosis. He presented with a large isolated mobile PV vegetation with moderate pulmonary regurgitation (PR). Initially, he was managed conservatively, but due to persistent fever, pulmonary regurgitation and evidence of pulmonary annular abscess extending into the right ventricular outflow tract, he required surgical intervention. Considering the low incidence of isolated PVE, it poses a challenge for physicians in prompt diagnosis and timely management of the infection.

Impact of School-Based Health Behavioral Intervention on Awareness, Practice Pattern of Healthy Lifestyle, and Cardiometabolic Risk Factors among School Children of Shimla: A Cluster-Randomized, Intervention Study.

OBJECTIVES: To assess the impact of multicomponent intervention on knowledge and practice of health behaviors among school children. The secondary objective was to assess mean change in cardiometabolic risk factors such as anthropometric measurements and biochemical profile. METHODS: A cluster-randomized, controlled trial was conducted among adolescents aged 13-18 y from government and private senior secondary schools in Shimla city. Multicomponent health behavioral intervention was delivered through teachers. Subjective and objective measures of knowledge and health behaviors were the primary outcomes. RESULTS: There was no significant effect of intervention on nutrition knowledge adjusted mean difference (aMD) 2.4 (95% CI: -3.7 to 8.7; p = 0.43), and the dietary habits adjusted mean difference 2.9 (95% CI: -0.3 to 6.2; p = 0.08) between the intervention and control group. However, significant improvement in odds of dietary practices 2.4 (95% CI: 1.1 to 5.0; p = 0.03) and decreased odds of consumption of junk food 3.8 (95% CI: 1.6 to 9.3; p = 0.003) was observed. There was no effect on physical activity odds 2.9 (95% CI: 0.8 to 11.6; p = 0.12) or screen time with aMD 0.9 (95% CI: 0.7 to 1.2; p = 0.52). Anthropometric measurements and biochemical profile also did not differ except low-density lipoprotein cholesterol which had significantly lower aMD: -7.2 (95% CI: -13.6 to -1.0; p = 0.02). There was no change in alcohol and tobacco consumption with odds 0.8 (95% CI: 0.6 to 1.2; p = 0.33) and 1.0 (95% CI: 0.7 to 1.5; p = 0.87), respectively after intervention. CONCLUSIONS: Multipronged interventions targeting lifestyle behaviors of adolescents at multilevels are vital to curb rising trends of noncommunicable diseases. This quintessentially calls for wider support across multiple sectors and creation of sustained enabling macro- and micro-environment. The trial is registered in the Clinical Trial Registry of India under the registration number CTRI/2018/01/011312 dated 12/01/2018 Registered, retrospectively.

Assessment of the impact of heart failure on household economic well-being: a protocol.

Background: Heart failure (HF), which is an emerging public health issue, adversely affects the strained health system in India. The adverse impact of HF on the economic well-being has been narrated in various anecdotal reports from India, with affected individuals and their dependents pushed into the vicious cycle of poverty. There is limited research quantifying how HF impacts the economic well-being of households from low- and middle-income countries. Methods: We describe the methods of a detailed economic impact assessment of HF at the household level in India. The study will be initiated across 20 hospitals in India, which are part of the National heart Failure Registry (NHFR). The selected centres represent different regions in India, stratified based on the prevailing stages of epidemiological transition levels (ETLs). We will collect data from 1800 patients with acute decompensated HF and within 6-15 months follow-up from the time of initial admission. The data that we intend to collect will consist of a) household healthcare expenditure including out-of-pocket expenditure, b) financing mechanisms used by households and (c) the impoverishing effects of health expenditures including distress financing and catastrophic health expenditure. Trained staff at each centre will collect data by using a validated and structured interview schedule. The study will have 80% power to detect an 8% difference in the proportion of households experiencing catastrophic health expenditures between two ETL groups.  After considering a non-response rate of 5%, the target sample size is approximately 600 patients from each group and the total sample size is 1800 patients. Potential Impact: Our study will provide information on catastrophic health spending, distress financing and household expenditure in heart failure patients. Our findings will help policy makers in understanding the micro-economic impact of HF in India and aid in allocation of appropriate resources for prevention and control of HF.

Long term outcomes in patients with RF/RHD: Eight-year follow-up of HP-RF/RHD (Himachal Pradesh Rheumatic Fever/Rheumatic Heart Disease) registry in a Northern Indian state.

BACKGROUND: The long-term outcome data in patients with rheumatic fever/rheumatic heart disease (RF/RHD) is limited. We report the cumulative incidence of adverse outcomes in a cohort of RHD patients from a northern state of India at a median follow-up of 5.4 years. METHODS: 1714 patients with RF/RHD diagnosed using clinical and echocardiographic criteria were registered from 2011 to 2018, and their baseline clinical characteristics and treatment practices were recorded. Patients were followed up annually for a median of 5.4 years (range 1-8 years) for incident adverse outcomes. The cumulative incidence of adverse composite outcomes, all-cause mortality, hospitalization for heart failure, stroke, and/or peripheral embolism was estimated. The baseline clinical characteristics were explored to identify the potential risk predictors using a multivariate cox proportional hazard model. RESULTS: The cumulative incidence of adverse composite outcomes was 17.1% (15.3%-19.0%) at a median follow-up of 5.4 years. The predictors for the adverse composite outcomes (hazard ratio, 95% confidence interval) were age (1.03, 1.02-1.04), education status below primary level (1.60, 1.23-2.05), severe valvular heart disease (1.74, 1.36-2.23), NYHA class III/IV at enrollment (1.56, 1.18-2.07), right heart failure (4.48, 2.85-6.95), history of stroke and/or peripheral embolism (3.7, 1.5-9.2) and mitral balloon valvuloplasty (0.62, 0.40-0.96). CONCLUSIONS: The incidence of adverse outcomes is substantial in patients with RF/RHD. Thus, early detection of high-risk patients and their risk management is needed to improve outcomes.

Nasal Polyposis and Its Association with Cardiac Functions.

OBJECTIVE: The aim of the study was to ascertain the effect of nasal polyposis on cardiac functions. MATERIAL AND METHODS: A prospective randomized interventional open-label endpoint-controlled study was conducted in an academic tertiary care hospital. Thirty-one patients with chronic rhinosinusitis with nasal polyposis were enrolled and administered fluticasone furoate nasal spray for 3 weeks before randomly segregation into surgical or medical group. The treatment continued for 3 months in both groups. The SNOT-22 (Sino-Nasal Outcome Test-22) score, polyp grade, and right ventricular and pulmonary arterial functions were recorded in both groups before and after 3 months of the intervention. RESULTS: Both groups had significant improvement in SNOT-22 scores after 3 months of intervention. Both groups showed improvement in cardiac functions, but statistical significance was found only in subjects who underwent surgery. CONCLUSION: Nasal polyp affects cardiac functions, and this needs further evaluation and research through studies on large samples.

Gender differences in the epidemiology of Rheumatic Fever/Rheumatic heart disease (RF/RHD) patient population of hill state of northern India; 9 years prospective hospital based, HP-RHD registry.

OBJECTIVES: We report the gender-based differences in the prevalence, severity, pattern of valvular involvement, and complications in patients with Rheumatic Fever/Rheumatic heart disease (RF/RHD). METHODS: The 2475 consecutive patients with RF/RHD diagnosed using clinical and echocardiographic criteria were registered prospectively from January 2011 till December 2019. The association of gender with the pattern of valvular involvement, nature, and severity of valvular dysfunction and cardiovascular complications was analyzed using a logistic regression model, and odds ratios with 95% CI were estimated. RESULTS: The mitral and tricuspid valve involvement was significantly lower in the male gender, odds ratio with 95% CI of 0.55 (0.44-0.61), and 0.69 (0.58-0.83) respectively, while the aortic valve was affected more frequently than females, odds ratio 1.36 (1.14-1.62). The severity of valvular disease had no significant association with gender, 0.99 (0.82-1.20). The association between gender and cardiovascular complications, heart failure, stroke, and atrial fibrillations were not statistically significant. The prevalence of RF/RHD was more than two-fold higher in female gender than male (71.4% vs. 29.6%, p < 0.0001). CONCLUSIONS: RF/RHD is more prevalent in females. Gender has a significant association with the pattern of valvular involvement. The severity of valvular dysfunction and cardiovascular complications had no significant association with gender.

Renin-Angiotensin System Inhibitors in COVID-19: Current Concepts.

The functional receptor to SARS-CoV-2, the virus responsible for the coronavirus disease 2019 (COVID-19) pandemic, is angiotensin-converting enzyme-2 (ACE-2), the same enzyme that physiologically counters the renin-angiotensin system (RAS) activation. Some researchers have questioned RAS inhibitors' safety in COVID-19 patients since these drugs have demonstrated an increase in ACE-2 expression in preclinical studies; therefore, they may facilitate viral invasion. On the contrary, others have hypothesized a protective role of RAS inhibitors against COVID-19-associated lung injury. Overall, the data are grossly inadequate to reach any conclusion since no human trials have yet evaluated the effects of RAS inhibitors in COVID-19. We review the current data and pathophysiological mechanisms behind this intriguing interplay between the RAS inhibitors and the COVID-19.

Cardiac biomarker-based risk stratification algorithm in patients with severe COVID-19.

BACKGROUND AND AIMS: Cardiac biomarkers like cardiac troponins and natriuretic peptides are elevated in a substantial proportion of patients with coronavirus disease 2019 (COVID-19). We propose an algorithmic approach using cardiac biomarkers to triage, risk-stratify and prognosticate patients with severe COVID-19. METHODS: We systematically searched the PubMed and Google Scholar databases until May 31st, 2020, and accessed the available data on the role of cardiac biomarkers in patients with COVID-19. RESULTS: COVID-19 is associated with acute cardiac injury in around 7-28% of patients, significantly increasing its associated complications and mortality. Patients with underlying cardiovascular disease are more prone to develop acute cardiac injury as a result of COVID-19. The use of cardiac biomarkers may aid in differentiating the cardiac cause of dyspnea in patients with severe COVID-19. Cardiac biomarkers may also aid in triaging, risk-stratification, clinical decision-making, and prognostication of patients with COVID-19. However, there are concerns that routine testing in all patients with COVID-19 irrespective of severity, may result in unnecessary downstream investigations which may be misleading. In this brief review, using an algorithmic approach, we have tried to rationalize the use of cardiac biomarkers among patients with severe COVID-19. This approach is also likely to lessen the infection exposure risk to the cardiovascular team attending patients with severe COVID-19. CONCLUSION: It appears beneficial to triage, risk-stratify, and prognosticate patients with COVID-19 based on the evidence of myocardial injury and the presence of underlying cardiovascular disease. Future research studies are, however, needed to validate these proposed benefits.

The role of natriuretic peptide estimation in severe COVID-19.

Since its inception in Wuhan in December 2019, Coronavirus disease 2019 (COVID-19) has shattered the economies and health-care infrastructures worldwide. Even the best of health-care systems (United States, Italy) have been overwhelmed and collapsed because of this unprecedented pandemic. India is preparing itself for the onslaught of Coronavirus. After recording its first case on January 30th, 2020, the rise was slow until the last week of March. However, since then, the number of cases has increased exponentially, and as on April 14th, 2020, there have been more than 10,000 cases of coronavirus disease (COVID-19) in India, which has resulted in more than 350 deaths.

Yoga-Based Cardiac Rehabilitation After Acute Myocardial Infarction: A Randomized Trial.

BACKGROUND: Given the shortage of cardiac rehabilitation (CR) programs in India and poor uptake worldwide, there is an urgent need to find alternative models of CR that are inexpensive and may offer choice to subgroups with poor uptake (e.g., women and elderly). OBJECTIVES: This study sought to evaluate the effects of yoga-based CR (Yoga-CaRe) on major cardiovascular events and self-rated health in a multicenter randomized controlled trial. METHODS: The trial was conducted in 24 medical centers across India. This study recruited 3,959 patients with acute myocardial infarction with a median and minimum follow-up of 22 and 6 months. Patients were individually randomized to receive either a Yoga-CaRe program (n = 1,970) or enhanced standard care involving educational advice (n = 1,989). The co-primary outcomes were: 1) first occurrence of major adverse cardiovascular events (MACE) (composite of all-cause mortality, myocardial infarction, stroke, or emergency cardiovascular hospitalization); and 2) self-rated health on the European Quality of Life-5 Dimensions-5 Level visual analogue scale at 12 weeks. RESULTS: MACE occurred in 131 (6.7%) patients in the Yoga-CaRe group and 146 (7.4%) patients in the enhanced standard care group (hazard ratio with Yoga-CaRe: 0.90; 95% confidence interval [CI]: 0.71 to 1.15; p = 0.41). Self-rated health was 77 in Yoga-CaRe and 75.7 in the enhanced standard care group (baseline-adjusted mean difference in favor of Yoga-CaRe: 1.5; 95% CI: 0.5 to 2.5; p = 0.002). The Yoga-CaRe group had greater return to pre-infarct activities, but there was no difference in tobacco cessation or medication adherence between the treatment groups (secondary outcomes). CONCLUSIONS: Yoga-CaRe improved self-rated health and return to pre-infarct activities after acute myocardial infarction, but the trial lacked statistical power to show a difference in MACE. Yoga-CaRe may be an option when conventional CR is unavailable or unacceptable to individuals. (A study on effectiveness of YOGA based cardiac rehabilitation programme in India and United Kingdom; CTRI/2012/02/002408).

Epidemiological trends of acute coronary syndrome in Shimla district of the hilly state of Northern India: Six-year data from the prospective Himachal Pradesh acute coronary syndrome registry.

OBJECTIVES: The epidemiological trends of incidence, treatment practices, and outcomes are reported from Shimla district of the northern state of India. METHODS: The data of clinical characteristics, treatment practices, and outcomes of patients with acute coronary syndrome (ACS) diagnosed using standard criteria were collected systematically from the defined hilly geographical region of the northern state of India from January 2013 to December 2018 as the part of Himachal Pradesh acute coronary syndrome (HP ACS) registry. The year-wise trends of incidence, demographic, clinical characteristics, treatment practices, and in-hospital mortality are reported. RESULTS: The incidence of ACS shows declining trends. The mean age at incident ACS is increasing without change in gender predilection. The prevalence of overweight/obesity and diabetes has increased significantly since 2013 but tobacco consumption has not changed. The reperfusion therapy has increased significantly (20.9% in 2013 to 42.1% in 2018, p < 0.01) primarily because of an increased use of percutaneous coronary angioplasty. There is a trend of increasing use of beta blockers. The use of other oral secondary preventive drugs remained more than 90% since 2013. The in-hospital mortality rate is declining (9.0% in 2013 to 6.0% in 2018, p < 0.01). CONCLUSIONS: Epidemiological characteristics of the ACS population in Shimla district are changing. The trends of use of reperfusion therapy in ST segment elevated myocardial infarction population has although increased but is still suboptimal, and there is a need for taking initiatives both at the system and population level to improve the reperfusion therapy.

Clinical Characteristics, Complications, and Treatment Practices in Patients With RHD: 6-Year Results From HP-RHD Registry.

BACKGROUND: Despite the high prevalence of rheumatic heart disease (RHD) in developing countries such as India, data on characteristics, complications, and treatment practices are lacking. The HP-RHD (Himachal Pradesh Rheumatic Heart Disease) registry aimed at reporting these parameters in patients with RHD from a northern state of India. METHODS: A total of 2,005 consecutive patients of RHD were enrolled over a period of 6 years (2011 to 2016) in the present study. The clinical characteristics, complications, and treatment practices were systematically recorded. RESULTS: The mean age for patients with RHD was 40.3 ± 14.3 (range 5 to 83 years). RHD predominantly affected females (72.3%) and population from rural background (92%). Multivalvular involvement was frequent (43.2%), mitral valve was the commonest affected valve (83.3%). The majority of the patients had moderate-to-severe valvular dysfunction (69.3%). Mitral and tricuspid valve involvement was more frequent in female subjects compared with more frequent aortic valve involvement in male subjects (p < 0.001). The major adverse cardiovascular events were recorded in 23.4% patients at the time of registry and comprised mainly advanced heart failure (15.6%), peripheral embolism (4.1%), and stroke (3.9%). The independent risk determinants of major adverse cardiovascular events (were advanced age (odds ratio [OR]: 1.01; 95% confidence interval [CI]: 1.00-1.02), severe mitral stenosis (OR: 1.73; 95% CI: 1.34-2.20), severe tricuspid regurgitation (OR: 2.11; 95% CI: 1.48-3.02), presence of pulmonary artery hypertension (OR: 1.33; 95% CI: 1.04-1.69), and atrial fibrillation (OR: 1.64; 95% CI: 1.28-2.11). Evidence-based use of oral anticoagulant therapy was documented in 77.7% of high-risk patients. Only 28.5% of study population was receiving secondary prophylaxis. CONCLUSIONS: Complications in patients with RHD increase with age and worsening valvular dysfunction. Programs focused on early detection and evidence-based management will assist in improving outcomes.