Effectiveness and safety of optical coherence tomography-guided PCI in Indian patients with complex lesions: A multicenter, prospective registry.

BACKGROUND: Optical coherence tomography (OCT) is reported to be a feasible and safe imaging modality for the guidance of percutaneous coronary intervention (PCI) of complex lesions. METHODS: This multicenter, prospective registry assessed the minimum stent area (MSA) achieved under OCT guidance. A performance goal of 24% improvement in MSA over and above the recommendation set by the European Association of Percutaneous Cardiovascular Interventions Consensus 2018 (4.5 mm2 MSA for non-left main and 3.5 mm2 for small vessels). The incidence of contrast-induced nephropathy was also assessed. Core lab analysis was conducted. RESULTS: Five hundred patients (average age: 59.4 ± 10.1 years; 83% males) with unstable angina (36.8%), NSTEMI (26.4%), and STEMI (22%) were enrolled. The primary endpoint was achieved in 93% of lesions with stent diameter ≥2.75 mm (average MSA: 6.44 mm2) and 87% of lesions with stent diameter ≤2.5 mm (average MSA: 4.56 mm2). The average MSA (with expansion ≥80% cutoff) was 6.63 mm2 and 4.74 mm2 with a stent diameter ≥2.75 mm and ≤2.5 mm, respectively. According to the core lab analysis, the average MSA achieved with a stent diameter ≥2.75 mm and ≤2.5 mm was 6.23 mm2 and 3.95 mm2, respectively (with expansion ≥80% cutoff). Clinically significant serum creatinine was noted in two patients (0.45%). Major adverse cardiac events at 1 year were noted in 1.2% (n = 6) of the patients; all were cardiac deaths. CONCLUSION: PCI under OCT guidance improves procedural and long-term clinical outcomes in patients with complex lesions not just in a controlled trial environment but also in routine clinical practice.

Exploring the Need and Benefits of Digital Therapeutics (DTx) for the Management of Heart Failure in India.

Indian heart failure (HF) registries consistently indicate high hospital readmissions and increased mortality rates after HF diagnosis. The challenges of Indian cardiologists in HF management include limited longitudinal data, frequent readmissions, low medication adherence, inadequate monitoring and follow-up, insufficient patient education, and lack of standard guidelines on cardiac rehabilitation. This article outlines the adoption of digital therapeutics (DTx) in HF management as a potential solution to address these challenges. DTx services offer improved medication adherence, early symptom identification, remote vital monitoring, timely intervention, patient education on symptoms, self-awareness, and lifestyle. Overall, DTx for HF comprises a dedicated team of cardiologists, health coaches, care managers, and globally certified connected devices to provide comprehensive and proactive monitoring, personalized coaching and support, behavioral engagement to improve adherence, emergency response system, delivery of medications and diagnostic tests at home, and a dedicated application for caregivers. DTx has the potential to enhance HF management in India.

Examining the role of soft dimensions on the implementation of ISO 14000 environmental management systems: a graph-theoretic approach.

Organizations worldwide are now embracing different standards while approaching environmental management systems (EMS) to be environmentally and economically sustainable. The ISO 14001 EMS has captured much attention by offering efficient environmental practices organization-wide and throughout the supply chain. Human factors (HFs) are crucial behind implementing ISO 14001 EMS since research articles about ISO 14001 strongly emphasize different HFs. This study proposes a framework that solely focuses on those HFs. Influential HFs are extracted through content analysis of related literature and categorized into 5 main HFs. Opinions from experts in the relevant field about interrelationships and inheritances of the HFs are collected and converted into quantitative data. Incorporating the graph theoretic and matrix approach (GTMA), the data delivered permanent values corresponding to the main HFs and their best and worst possible values. Among the main HFs, EMS Training has been found to have the most scopes for improvement, followed by Employee Empowerment and EMS Teamwork. This study demonstrates a framework about how to assess the role of HFs behind internalizing ISO 14001 EMS and enables organizations to go for competitive benchmarking and to define and adjust goals for environmental management.

Guiding Principles for the Clinical Use and Selection of Microcatheters in Complex Coronary Interventions.

The use of microcatheters as a coronary interventional tool for a therapeutic approach to complex coronary interventions like bifurcation lesions, ostial location, tortuous anatomy, angled takeoffs, coronary calcification, and chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is growing among cardiologists across the country. During the treatment of such complex lesions, microcatheters play an essential part of the tool kit with both single-lumen and double-lumen microcatheters (DLMs) having their specific niche areas. The selection of microcatheters involves a detailed understanding of the microcatheter specification, lesion anatomy, lesion location, vessel tortuosity and trajectory, and crossing techniques. The selection of appropriate crossing techniques with different microcatheters increases success rates of PCI, reduces procedural time and contrast use, and lowers the radiation. However, the use of microcatheters and their technicalities have not yet fully realized by many operators and their true scope has not been fully explored. This article discusses and summarizes the thoughts and key opinions of experts in this field.

Non-physician health workers for improving adherence to medications and healthy lifestyle following acute coronary syndrome: 24-month follow-up study.

OBJECTIVE: To evaluate usefulness of non-physician health workers (NPHW) to improve adherence to medications and lifestyles following acute coronary syndrome (ACS). METHODS: We randomized 100 patients at hospital discharge following ACS to NPHW intervention (n=50) or standard care (n=50) in an open label study. NPHW was trained for interventions to improve adherence to medicines - antiplatelets, ß-blockers, renin-angiotensin system (RAS) blockers and statins and healthy lifestyles. Intervention lasted 12 months with passive follow-up for another 12. Both groups were assessed for adherence using a standardized questionnaire. RESULTS: ST elevation myocardial infarction (STEMI) was in 49 and non-STEMI in 51, mean age was 59.0±11 years. 57% STEMI were thrombolyzed. On admission majority were physically inactive (71%), consumed unhealthy diets (high fat 77%, high salt 58%, low fiber 57%) and 21% were smokers/tobacco users. Coronary revascularization was performed in 90% (percutaneous intervention 79%, bypass surgery 11%). Drugs at discharge were antiplatelets 100%, ß-blockers 71%, RAS blockers 71% and statins 99%. Intervention and control groups had similar characteristics. At 12 and 24 months, respectively, in intervention vs control groups adherence (>80%) was: anti platelets 92.0% vs 77.1% and 83.3% vs 40.9%, ß blockers 97.2% vs 90.3% and 84.8% vs 45.0%), RAS blockers 95.1% vs 82.3% and 89.5% vs 46.1%, and statins 94.0% vs 70.8% and 87.5% vs 29.5%; smoking rates were 0.0% vs 12.5% and 4.2% vs 20.5%, regular physical activity 96.0% vs 50.0%, and 37.5% vs 34.1%, and healthy diet score 5.0 vs 3.0, and 4.0 vs 2.0 (p<0.01 for all). Intervention vs standard group at 12 months had significantly lower mean systolic BP, heart rate, body mass index, waist:hip ratio, total cholesterol, triglyceride, and LDL cholesterol (p<0.01). CONCLUSIONS: NPHW-led educational intervention for 12 months improved adherence to evidence based medicines and healthy lifestyles. Efficacy continued for 24 months with attrition.

Role of CT Coronary Angiography in Recanalization of Chronic Total Occlusion

Chronic total occlusion (CTO) is considered as the most challenging frontier in interventional cardiology and the last one to be conquered. With availability of state of the art hardware, wires and catheters in particular and increased skills of the operators, the success rate for recanalization of CTO by percutaneous catheter intervention (PCI) has improved. Yet the complications rate and longterm adverse events are high, mostly due to failure in tracking or navigation of hardware through the occluded CTO segment, prolonged exposure to radiation and high doses of contrast used. Therefore, proper selection of patient is of utmost importance. One of the major challenges for successful CTO recanalization is satisfactory visualization of the occluded CTO segment. Conventional invasive catheterization fails to fill the gap and the shortcomings and handicaps of such invasive imaging can be resolved with the use of non-invasive CT coronary angiography (CTCA). CTCA helps to better define the morphological features of the occluded CTO segment, which are established predictors of success, like the actual length of the occluded segment and any calcification or tortuosity in its course. Integration of reconstructed three-dimensional CT coronary images with twodimensional fluoroscopic images, offers directional guide to select the best angiographic plane for visualization of angiographically "missing segment". With advances in CT technology, CTCA has now become an established technology for pre-procedure evaluation of CTO segment, thereby help in planning and execution of successful PCI.

Safety of Prasugrel in Indian patients - multicentric registry of 1000 cases.

BACKGROUND: Clopidogrel has been the only available antiplatelet drug used along with aspirin in patients of ACS. In recent years 2 new antiplatelet drugs (Prasugrel and Ticagrelor) have become available. Prasugrel in the dose of 10 mg OD has been found to be more efficacious but with increased risk of major bleeding. For this reason it has not gained widespread usage in ACS patients undergoing PCI. There are no systematic data on the use of Prasugrel in Indian population. METHOD: This is a prospective, multicentric, hospital registry of 1000 patients with ACS undergoing PCI who were administered Prasugrel. The primary safety endpoint of this study was major and minor bleeding while the efficacy endpoint is the composite of CV death, nonfatal MI, nonfatal stroke up to 30 days after PCI. Patients with high bleeding risk were excluded. RESULTS: Most patients (91%) received loading dose of Prasugrel along with the maintenance dose getting according to the defined protocol. Patients were followed up to 30 days post procedure. Primary efficacy end point was reached in 3 patients only with two of them dying due to possible stent thrombosis and the third requiring revascularization of the target vessel for stent thrombosis. One major and 19 minor bleeding complications were recorded, with access site bleeding in 0.7% & non-access site bleeding in 1.2% of the subjects. CONCLUSION: Prasugrel was found to be effective & not associated with a high incidence of bleeding in the high risk ACS patients when those at a high bleeding risk were excluded.

Epidemiology of cardioprotective pharmacological agent use in stable coronary heart disease.

OBJECTIVE: To determine use of class and type of cardioprotective pharmacological agents in patients with stable coronary heart disease (CHD) we performed a prescription audit. METHODS: A cross sectional survey was conducted in major districts of Rajasthan in years 2008-09. We evaluated prescription for classes (anti-platelets, ß-blockers, angiotensin converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARB), calcium channel blockers (CCB) and statins) and specific pharmacological agents at clinics of physicians in tertiary (n = 18), secondary (n = 69) and primary care (n = 43). Descriptive statistics are reported. RESULTS: Prescriptions of 2290 stable CHD patients were audited. Anti-platelet use was in 2031 (88.7%), ß-blockers 1494 (65.2%), ACE inhibitors 1196 (52.2%), ARBs 712 (31.1%), ACE inhibitors - ARB combinations 19 (0.8%), either ACE inhibitors or ARBs 1908 (83.3%), CCBs 1023 (44.7%), statins 1457 (63.6%) and other lipid lowering agents in 170 (7.4%). Among anti-platelets aspirin-clopidogrel combination was used in 88.5%. Top three molecules in ß-blockers were atenolol (37.8%), metoprolol (26.4%) and carvedilol (11.9%); ACE inhibitors ramipril (42.1%), lisinopril (20.3%) and perindopril (10.9%); ARB's losartan (47.7%), valsartan (22.3%) and telmisartan (14.9%); CCBs amlodipine (46.7%), diltiazem (29.1%) and verapamil (9.5%) and statins were atorvastatin (49.8%), simvastatin (28.9%) and rosuvastatin (18.3%). Use of metoprolol, ramipril, valsartan, diltiazem and atorvastatin was more at tertiary care, and atenolol, lisinopril, losartan, amlodipine and simvasatin in primary care (p < 0.01). CONCLUSIONS: There is low use of ß-blockers, ACE inhibitors, ARBs and statins in stable CHD patients among physicians in Rajasthan. Significant differences in use of specific molecules at primary, secondary and tertiary healthcare are observed.

Left main coronary artery bifurcation angioplasty and stenting after aortic valve replacement: a case report.

A 43-year-old young lady had closed mitral valvotomy (CMV) in 1994 and aortic valve replacement (AVR) in June 2007. Shortly thereafter, she presented with unstable angina in October 2007 with on-going pain and haemodynamic instability. Coronary angiogram showed tight left main bifurcation stenosis in a left dominant system. Having had open heart surgery (AVR) recently, and being on oral anticoagulation, with on-going ischaemia and unstable haemodynamics, percutaneous coronary intervention (PCI) was considered the most suitable option. She underwent successful PCI with two drug-eluting stents (T-stenting) to left main bifurcation through transradial approach and intra-aortic balloon support. Clinically she remained symptom free and coronary angiogram after 5 months and 15 months of follow-up showed patent stents. This case demonstrates the acute effectiveness of PCI for the treatment of critical left main disease following open heart surgery in patients who are not appropriate surgical candidates.

Low use of statins and other coronary secondary prevention therapies in primary and secondary care in India.

OBJECTIVE: To determine the frequency of use of pharmacotherapy with aspirin, beta blocker, statin, and angiotensin-converting enzyme (ACE) inhibitor in patients with stable coronary heart disease (CHD) among physicians at different levels of health care in Rajasthan state, India. METHODS: Physicians practicing at tertiary hospitals and clinics at tertiary, secondary and primary levels were contacted. Prescriptions of CHD patients were audited and descriptive statistics reported. RESULTS: We evaluated 2,993 prescriptions (tertiary hospital discharge 711, tertiary 688, secondary 1,306, and primary 288). Use of aspirin was in 2,713 (91%) of prescriptions, beta blockers 2,057 (69%), ACE inhibitors or angiotensin receptor blockers (ARBs) 2,471 (82%), and statins 2,059 (69%). Any one of these drugs was prescribed in 2,991 (100%), any two in 2,880 (96%), any three in 1,740 (58%), and all four in 1,062 (35.5%) (P < 0.001). As compared to tertiary hospital, prescriptions at tertiary, secondary, and primary levels were lower: aspirin (96% vs 95%, 91%, 67%), beta blockers (80% vs 62%, 66%, 70%), statins (87% vs 82%, 62%, 21%): two drugs (98% vs 96%, 98%, 85%), three drugs (75% vs 58%, 55%, 28%), or four drugs (54% vs 44%, 28%, 7%) (P < 0.01). Use of ACE inhibitors/ARBs was similar while nitrates (43% vs 23%, 43%, 70%), dihydropyridine calcium channel blockers (12% vs 15%, 30%, 47%), and multivitamins (6% vs 26%, 37%, 47%) use was more in secondary and primary care. CONCLUSIONS: There is suboptimal use of various evidence-based drugs (aspirin, beta blockers, ACE inhibitors, and statins) for secondary prevention of CHD in India.