Pulmonary Hypertension Registry of Kerala, India (PRO-KERALA): One-year outcomes.

BACKGROUND: Short term outcomes of patients with pulmonary hypertension are not available from low and middle-income countries including India. METHODS: We conducted a prospective study of 2003 patients with pulmonary hypertension, from 50 centres (PROKERALA) in Kerala, who were followed up for one year. Pulmonary hypertension (PH) was mainly diagnosed on the basis of Doppler echocardiography. The primary outcome was a composite end-point of all-cause death and hospital admission for heart failure. All cause hospitalisation events constituted the secondary outcome. RESULTS: Mean age of study population was 56 ± 16 years. Group 1 and Group 2 PH categories constituted 21.2% and 59% of the study population, respectively. Nearly two-thirds (65%) of the study participants had functional class II symptoms. 31% of Group 1 PH patients were on specific vasodilator drugs.In total, 83 patients (4.1%) died during the one-year follow-up period. Further, 1235 re-hospitalisation events (61.7%) were reported. In the multivariate model, baseline NYHA class III/IV (OR 1.87, 95% C.I. 1.35-2.56), use of calcium channel blockers (OR 0.18, 95% C.I. 0.04-0.77), vasodilator therapy (OR 0.5, 95% C.I. 0.28-0.87) and antiplatelet agents (OR 1.80, 95% C.I. 1.29-2.51) were associated with primary composite outcome at one-year (p < 0.05). CONCLUSION: In the PROKERALA registry, annual mortality rate was 4%. More than half of the patients reported re-hospitalisation events on follow up. Uptake of guideline directed therapies were suboptimal in the study population. Quality improvement programmes to improve guideline directed therapy may improve clinical outcomes of PH patients in India.

Pulmonary hypertension registry of Kerala, India (PRO-KERALA) - Clinical characteristics and practice patterns.

BACKGROUND: Epidemiological data on pulmonary hypertension (PH) are scarce from developing countries including India. METHODS: We established a multi-center registry of PH, the PRO-KERALA registry, in Kerala, India. Fifty hospitals enrolled consecutive adult (>18 years) patients for one year. Echocardiographic criteria (right ventricular systolic pressure - RVSP > 50 mmHg) or invasively obtained mean pulmonary artery pressure > 25 mmHg was the criteria for entry. RESULTS: There were 2003 patients (52% Women, mean age 56 ±â€¯16.1 years) enrolled. The mean RVSP was 68.2 (SD = 17.9) mmHg. Majority of the study participants (59%) belonged to group 2 of the WHO Nice Classification 2013 (PH secondary to left heart disease). One-fifth (21.2%) belonged to group 1, while 13.3%, 3.8% and 2.4% of the study population belonged to groups 3, 4 and 5 respectively. More than a quarter (27%) reported PH due to left heart disease with valvular disease etiology; while 20.7% had coronary artery disease. The other common etiological factors were chronic obstructive pulmonary disease (10.6%), congenital heart disease (14.6%), idiopathic pulmonary hypertension (5.8%), and chronic thromboembolic pulmonary hypertension (3.8%). Only one of two patients with pulmonary artery hypertension was receiving PH specific therapies. The use of combination therapy was negligible and PH-specific therapies were prescribed off-label to a small proportion of patients too. CONCLUSION: PRO-KERALA is the first PH registry from South Asia and the second largest globally. Left heart diseases attribute to three fifths of patients with PH. Utilization rates of PH specific drug therapies are remarkably lower than the Western population.

Surveillance of noncommunicable diseases by community health workers in Kerala: the epidemiology of noncommunicable diseases in rural areas (ENDIRA) study.

BACKGROUND: India carries the greatest burden of noncommunicable disease (NCD) globally. However, there are few contemporary, community-based studies of prevalence in India. Given the physician shortages in rural areas, large-scale, region-specific studies of NCD using community health workers (CHW) may offer a feasible means of NCD surveillance. OBJECTIVES: This study sought to conduct a large-scale, population-based, CHW-led study of NCDs in Kerala, India. METHODS: In rural Kerala, India, a population of 113,462 individuals was defined geographically by 5 panchayats (village councils). The ENDIRA (Epidemiology of Noncommunicable Diseases in Rural Areas) study was conducted via accredited social health activists (ASHA), who are CHW employed by Kerala state government. After training of ASHA, standardized questionnaires were used during 2012 in household interviews of individuals ≥18 years of age to gather sociodemographic, lifestyle, and medical data. RESULTS: ASHA recruited 84,456 adults who were included in the analyses (25.4% were below the poverty line). The prevalence of NCD was comparable to contemporary studies in India: myocardial infarction (MI) 1.4%; stroke 0.3%; respiratory diseases 5.0%; and cancer 1.1%. The dietary habits were as follows: 84.1% of the population was vegetarian; 15.9% ate meat/fish ≥1 day per week; 4.2% had ≥1 alcoholic drink per week; and 8.1% smoked regularly. Compared with men, women were older, had lower body mass index, more likely to be hypertensive, less likely to smoke or drink alcohol, and have diabetes or dyslipidemia (p < 0.0001). NCD were more common in men than women: MI (1.9% vs. 0.9%); stroke (0.5% vs. 0.3%); cancer (1.2% vs. 0.9%); and respiratory diseases (5.9% vs. 4.0%) (p < 0.0001). Age ≥65 years, hypertension, diabetes mellitus, dyslipidemia, smoking, and male sex were strongly associated with MI and stroke. There were high levels of agreement between ASHA and physicians for diagnoses of MI, stroke, hypertension, and diabetes. CONCLUSIONS: CHW effectively conducted a large-scale prevalence study of NCD in Kerala, including prevalence of risk factors. In rural Kerala, traditional risk factors were strongly associated with MI and stroke.