Practical Recommendations for the Use of Angiotensin Receptor-Neprilysin Inhibitors (ARNI) in Heart Failure: Insights from Indian Cardiologists.

Heart failure is a significant public health concern characterized by notable rates of morbidity and mortality. Despite the presence of guideline-directed medical therapy (GDMT), its utilization remains inadequate. This practical recommendation paper focuses on the utilization of angiotensin receptor-neprilysin inhibitor (ARNI) as a pivotal treatment for heart failure with reduced ejection fraction (HFrEF), heart failure with preserved ejection fraction (HFpEF), and heart failure with improved ejection fraction (HFimpEF). The recommendations presented in this paper have been developed by a group of cardiologists in India who convened six advisory board meetings to discuss the utilization of ARNI in the management of heart failure. The paper emphasizes the importance of accurate biomarkers for diagnosing heart failure, particularly N-terminal pro-B-type natriuretic peptide (NT-proBNP) and B-type natriuretic peptide (BNP), which are commonly used. Additionally, the paper advocates the use of imaging, specifically echocardiography, in diagnosing and monitoring heart failure patients. Moreover, the paper highlights the role of ARNI in heart failure management, with numerous clinical trials that have demonstrated its effectiveness in reducing cardiovascular death or heart failure hospitalization, enhancing quality of life, and diminishing the risk of ventricular arrhythmias. This practical recommendation paper offers valuable insights into the utilization of ARNI in the management of heart failure, aiming to enhance the implementation of GDMT and ultimately alleviate the burden of heart failure on society.

A Retrospective, Observational, EMR-Based Real-World Evidence Study to Assess the Incidence of Pedal Edema in Essential Hypertensive Patients on Amlodipine or Cilnidipine.

INTRODUCTION: Calcium channel blockers have pedal edema as one of the confining factors of treatment. A real-world study may help evident reality of the situation in regular Indian clinical practice. The aim of the study is to assess effectiveness and incidence of pedal edema in essential hypertensive patients treated with amlodipine or cilnidipine monotherapy. METHODS: Retrospective EMR data of adult essential hypertensive patients, prescribed amlodipine (n = 800) or cilnidipine (n = 800) as monotherapy, were analyzed. Incidence of pedal edema from baseline visit was analyzed in terms of dose and duration of treatment. The changes in systolic (SBP) and diastolic blood pressure (DBP) from baseline and proportion of patients achieving target BP goals were assessed. RESULTS: In amlodipine and cilnidipine groups, mean changes in SBP and DBP from baseline to end of the study period were 28.4 and 15.1 mmHg and 24.3 and 13.5 mmHg, respectively (p value <0.05). More than 50% of patients in both groups achieved BP goal at the end of the study (p value 0.266). In amlodipine group, total 23.9% reported pedal edema, while in cilnidipine, 27.6% (p value 0.0863). At the end of the study, 3.5% and 8.2% of patients remain with pedal edema, respectively, in both groups (pvalue <0.005). CONCLUSION: Amlodipine demonstrated greater BP reduction at a lower average dose, better efficacy, and tolerability in terms of pedal edema count as a lesser number of patients reported edema at the end of the study and a higher percentage of patients continued the prescribed baseline dosage regimen as compared to cilnidipine. Thus, the study established amlodipine as an effective and well-tolerated antihypertensive for Indians.

Hypertension in Young Adults in India: Perspectives and Therapeutic Options amongst Clinician's in a Cross Sectional Observational Study.

BACKGROUND: The prevalence of hypertension in the young adult population is rising in India. Increased arterial stiffness due to RAAS activation and increased sympathetic overactivity due to stress have been implicated as primary factors for the same. This study was aimed to understand the Indian clinician's perspective on approach to management of hypertension in young adults. METHODS: A cross sectional observational survey using a structured questionnaire was conducted online with 2287clinicians (cardiologists, diabetologists, consultant physicians and family physicians). RESULTS: The prevalence of hypertension was 10-30% as per opinion of 64.8% clinicians. The top three risk factors for hypertension in young were perceived to be smoking, mental stress and obesity. Around 57.4% respondents opined that both increased heart rate and systolic blood pressure were markers of sympathetic overactivity. More than 60% respondents across specialities preferred ARBs to treat hypertension in young adults. Amongst the ARBs, telmisartan was the preferred ARB by >80% respondents. Metoprolol was the preferred beta blocker by almost 64% respondents. The objective of selection of beta-blocker by majority of clinicians due to sympathetic overactivity. Telmisartan and Metoprolol single pill combination achieved the BP goal in 40-60% of patients as reported by 41.3% of the physicians. The combination therapy was well tolerated in young hypertensive patients. CONCLUSIONS: Initiation of an early and appropriate antihypertensive treatment in young population may lower the burden of cardiovascular disease in this population. ARBs and beta -blockers were the preferred class of anti-hypertensive drugs in the cohort of young hypertensive patients .

White blood cell count in healthy Sierra Leoneans.

The lack of standard local values for use as reference values has been a problem facing our haematological units in Sierra Leone for a long time. As a preliminary step towards the establishment of standard local values, one hundred and sixty apparently healthy Sierra Leoneans between the ages of 10 years to 50 years and above living in Freetown were investigated for the determination of total and differential white blood cells counts. The total white cell count was done by using the neubeur counting chamber whilst the differential white cell count was done from a thin blood smear stained with leishman's stain. A mean white blood cell count of 5.0 x 10(9)/L was obtained for the study group with a range of 2.4-12.0 x 10(9)/L. The study did not show any significant difference in white blood cell count between males and females. A mean differential neutrophil count of 56% was obtained for the study group and a mean differential lymphocyte count of 37% were obtained for the study group. The leucopenia obtained for the study group is thought to be due to the neutropenia and is probably thought to be a genetically determined characteristic of the indigenous Africans.

Humoral antibody response in Leishmania tropica infection.

A small epidemic of Leishmania tropica infection was detected in Rajasthan, India. Most cases were in the 21-25 years age group and were possibly related to outdoor activity. Nearly one third of the patients had more than five lesions, the maximum number of lesions being confined to the face, neck and extremities. As determined by ELISA, 90% cases had leishmania antibodies with an OD range of 0.8-1.1. The serum of 60% of patients was positive by CIEP against L. tropica promastigote soluble antigen. By immunofluorescence, 96% persons were positive when L. tropica promastigotes were used as the substrate. The prevalence of infection with L. tropica appears to be much higher than that reported earlier.

HIV-I antibodies in health and disease.

Antibodies to human immune deficiency (HIV) virus were studied in 2000 individuals including cases of non-Hodgkin's lymphoma, systemic lupus erythematosus (SLE), leprosy, chronic renal failure on haemodialysis and patients attending STD clinics. A group of blood donors was also screened, ELISA kits provided by Wellcome Diagnostics were used. Results indicate that the ELISA values were far above the cut off figure in all except in a couple where the husband who had stayed in Uganda for several years, and had features of full blown AIDS died 4 months after the diagnosis. The spouse contacted AIDS within a relatively short incubation period and died within 6 months of diagnosis. The North Indian population thus appears to be free of this virus so far. This observation will be an important lead mark in the future epidemiology of HIV infection in India.

Human T cell receptors for monkey erythrocytes.

To test the specificity of T cell receptors, erythrocytes and lymphocytes of man and rhesus monkey (Macaca mulatta) and erythrocytes of sheep were mixed in four different combinations to observe the rosette formation. During the study, a major proportion of human T cells formed spontaneous rosettes with the erythrocytes of rhesus monkey. A small number of monkey lymphocytes formed rosettes with human group O Rh-negative cells while T cells both of man and rhesus monkey formed rosettes with sheep red blood cells.