Importance of Imaging in Work up of Cardiovascular Diseases by Using Telemedicine in Rural India.

BACKGROUND: Cardiovascular diseases have emerged as an epidemic in India. Telemedicine is a useful tool for sending ECG, x-ray and ultrasound images to telemedicine centre for diagnosis and management of cardiovascular diseases in rural areas as it overcomes the distance barrier. METHODS: National Heart Institute collaborated with Hospital Guide Foundation (HGF) Jewar, Greater Noida for conducting telemedicine sessions. Two hundred patients were analysed during time span of June 2018 to August 2019. Imaging tools like ECG, Chest X- ray and ultrasound were studied besides usual laboratory parameters. RESULTS: Important ECG abnormalities included LVH (10.9%), ischemia (10.1%), LBBB (2.4%), RBBB (3.9%), p- mitrale (1.5%), hyperkalaemia (2.3%) besides normal ECGs (56.2%). Chest x- ray revealed features of COPD (8.3%), cardiomegaly (6.9%), hilar shadows (6.9%), bronchitis (2.7%) and prominent broncho -vascular markings (6.9%). Ultrasound abdomen showed hepatomegaly (23.2%), fatty liver (15.1%), gallstones (2%). bilateral renal stone / left or right renal stone (42.4 %). CONCLUSION: Telecardiology/ Teleradiology are important and useful imaging tools in the diagnosis and treatment of cardiovascular diseases in rural India.

Effect of Cichorium intybus seeds supplementation on the markers of glycemic control, oxidative stress, inflammation, and lipid profile in type 2 diabetes mellitus: A randomized, double-blind placebo study.

Diabetes mellitus is associated with increased levels of inflammation and oxidative stress in patients. The aim of the present study was to test the hypothesis that aqueous extract of Cichorium intybus seeds (AECIS) would have add-on beneficial effect in type 2 diabetes mellitus (T2DM). In this double-blind randomized clinical study, 150 subjects were enrolled to assess the add-on efficacy and safety of AECIS in T2DM patients. The subjects were randomized (1:1) to the AECIS (n = 51) and placebo (n = 49) groups. The subjects in both groups continued to take prescribed doses of metformin. The standardization of AECIS was carried out by liquid chromatography-mass spectrometry and phytochemical analysis. The mean hemoglobin A1c (HbA1c) level in the AECIS and placebo groups at baseline was 8.6% and 8.5%, respectively. Mean values of HbA1c at the end of 12 weeks of intervention were 7.42% in the AECIS group (a reduction of 1.18% from baseline) and 8.4% in the placebo group (mean reduction of 0.1% from baseline). Besides, significant reduction in inflammation, oxidative stress, and hypertriglyceridemia was seen in the AECIS group (p < .05). The study shows for the first time that AECIS supplementation ameliorates the disease progression and it is beneficial as a potential adjunct dietary supplement for the management of T2DM.

Study of adverse drug reactions in patients with diabetes attending a tertiary care hospital in New Delhi, India.

The present prospective observational study was carried out in a tertiary care hospital in New Delhi, India from May 2014 to June 2015 to report adverse drug reactions (ADRs) in patients with type 2 diabetes mellitus (T2DM) using antidiabetic drugs. A total of 220 patients (121 males, 99 females) were enrolled. ADRs were recorded on the prescribed form. Causality and severity assessment was done using Naranjo's probability scale and modified Hartwig and Siegel's severity scale, respectively. Commonly prescribed drugs were biguanides, peptide hormone and sulphonylurea. A total of 26 ADRs were recorded (16 in males and 10 in females). Most commonly observed ADRs were related to endocrine and gastrointestinal system. Severity assessment of ADRs showed seven (26.9%) ADRs as moderate, and 19 (73.1%) as mild. No severe reactions were observed. ADRs were mostly related to endocrine and gastrointestinal system. More information on prescribed drugs and their side effects is required for ensuring patient safety.

Insulin Resistance in Young Obese Subjects and Its Relation to Smoking (A Pilot Study).

Insulin resistance is a condition in which cells fail to respond to the normal actions of insulin. Dietary fat, obesity and smoking have been attributed to increase insulin resistance. However, the prevalence of insulin resistance in young obese subjects and its relation to smoking is not well established. This study comprising seventy-five healthy young adults was undertaken to find insulin resistance in obese smokers and non smokers both. Present study showed an overall prevalence of raised homeostatic model assessment of insulin resistance in 14.7 % otherwise healthy young subjects (20-30 years age group). Non-smokers did not show any significant correlation between insulin resistance and body mass index at either stage (normal, pre-obese as well as obese). Smokers also did not show any significant difference of insulin resistance in normal and pre-obese stages. However, marked increase in homeostatic model assessment of insulin resistance was observed in obese smokers. Homeostatic model assessment of insulin resistance showed a linear trend in relation to body mass index and its values were found to be higher in smokers. Obesity combined with smoking demonstrated statistically significant increase in homeostatic model assessment of insulin resistance.

Terminalia arjuna (Roxb.) Wight & Arn. augments cardioprotection via antioxidant and antiapoptotic cascade in isoproterenol induced cardiotoxicity in rats.

Worldwide, Ischemic heart disease (IHD) affects a large population. Implication of myocardial infarction (MI) and its multiple pathophysiology in cardiac function is well known. Further, isoproterenol (ISP) is known to induce MI. Today, there is an urgent need for effective drug that could limit the myocardial injury. Therapeutic intervention with antioxidants has been shown useful in preventing the deleterious changes produced by ISP. Here, we investigated the protective effects of oral pre-treatment of hydroalcoholic extract of bark of Terminalia arjuna (HETA) on biochemical and apoptotic changes during cardiotoxicity induced by isoproterenol (ISP) in rats. HETA was orally administered at a dose of 100, 200 and 400 mg/kg body wt., for 30 days with concurrent administration of ISP (85 mg/kg body wt.) on days 28th and 29th at an interval of 24 h. ISP caused deleterious changes in the myocardium and significantly increased (P < 0.05) malondialdehyde, serum glutamate oxaloacitate transaminase, creatine kinase-MB, lactate dehydrogenase and troponin-I. However, it significantly decreased (P < 0.05) glutathione and superoxide dismutase compared to healthy control. Oral pre-treatment of HETA for 30 days significantly decreased (P < 0.05) the biochemical parameters of oxidative stress and cardiac markers as compared to ISP control. Histopathological findings also revealed that architecture of the myocardium was restored towards normal in HETA pre-treated group. Overall, the present study has shown that the hydroalcoholic extract of bark of T. arjuna (HETA) attenuates oxidative stress, apoptosis and improves antioxidant status in ISP-induced cardiotoxicity in rats.

A Systematic Review of Economic Evidence of Cardiovascular Interventions in India.

BACKGROUND: Cardiovascular diseases (CVDs) continue to be the primary cause of mortality globally and invariably in India as well. The rapid upsurge in the prevalence of CVDs in India has created a pressing need to promote contemporary, sustainable, and cost-effective interventions to tackle the CVD burden. This systematic review integrates the research-based evidence of the cost-effectiveness of various interventions that can be adapted to control CVDs in India. METHODS: Databases, namely, PubMed, Cochrane Library, Embase, and Google Scholar, were searched for data on the economic evaluation of interventions targeting CVD based on the Indian population for a period of 30 years (1991-2021). Two reviewers assessed the articles for eligibility, and data were extracted from the shortlisted articles as per a predefined template, including the quantification of methodological aspects. RESULTS: In total, 1249 studies were examined, out of which 23 completely met the inclusion criteria for full-text review. A total of 16 studies were based solely on the Indian population, while the rest (7) included South Asia/Asia for the intervention, of which India was a participant nation. Most of the economic evaluations targeted treatment-based or pharmacological interventions (14) for CVDs. The evaluations were based on Decision-based models (10), Randomized controlled Trials (RCTs) (9), and Observational studies (4). The cost-effectiveness ratio for the included studies exhibited a diverse range due to variations in methodological approaches, such as differences in study settings, populations, and inconsistencies in study design. The mean ICER (Incremental Cost-effectiveness ratio) for primordial and primary preventions was found to be 3073.8 (US $2022) and 17489.9 (US $2022), respectively. Moreover, the combined mean value for secondary and tertiary prevention was 2029.6 (US$2022). CONCLUSION: The economic evidence of public health interventions are expanding, but their focus is restricted towards pharmacological interventions. There is an urgency to emphasize primordial and primary prevention for better outcomes in health economics decision-making. Technology- based avenues for intervention need more exploration in order to cater to a large population like India.

Role of family milieu in tobacco addiction: a study in a tertiary-care institution in India.

Use of tobacco is singularly responsible for most cases of cancer and coronary artery disease (CAD). Efforts to stop tobacco-use need to be guided by social circumstances. It is believed that family milieu may play a role in tobacco addiction. We studied the prevalence and pattern of tobacco-use in families of 50 consecutive tobacco-user patients who presented to a tobacco-cessation clinic and compared with age- and gender-matched controls (non-users of tobacco). The tobacco-use rates were significantly higher in the family of patients with tobacco-use compared to the control group. We conclude that problems of tobacco-use are not related to individual phenomenon, and efforts for control of tobacco addiction must be focused on entire family.

All in the name of flavour, fragrance & freshness: commonly used smokeless tobacco preparations in & around a tertiary hospital in India.

BACKGROUND & OBJECTIVES: There is a general misconception that smokeless tobacco particularly sweetened and flavoured paan masala and gutkas are safe to use. The present study was undertaken with the objective of highlighting the deceptive and aggressive marketing techniques adopted by the manufacturers of smokeless tobacco preparations exploiting cultural, social and religious values. Another object was to highlight the lack of transparency in terms of content, weight, quality control and warning. METHODS: All empty pouches of the used paan masalas, gutka, khaini or surti in and around a tertiary care hospital at east Delhi were collected. Their constituents were studied as per written declaration by the manufacturers on each packet. Information on net weight, cost, presence and type of warning, and quality assurance on each brand provided on side of the packets was noted. RESULTS: A total of 1136 pouches of 33 brands/varieties were collected. Most of the gutka preparations contained tobacco, betel nut, unknown flavouring agents, undeclared spices and heavy metals. Warning regarding the harmful effect of tobacco was written in 90.9 per cent of brands with 81.8 per cent in English language only in minute font. Contents of the products were mentioned in 84.8 per cent of brands and only 27.3 per cent of those mentioned the net weight of the ingredients. INTERPRETATION & CONCLUSIONS: Seemingly 'innocuous' tobacco preparations in the form of paan masalas, gutka, khaini, surti or mouth fresheners contain various harmful substance like tobacco, betel nut, sugar coated fennel, saccharine, heavy metals like silver, unknown flavouring agents and undeclared spices in unknown quantities. Lack of transparency in terms of content, weight, quality control and warning is duping unsuspecting consumers.

Effects of Tobacco on Biochemical Parameters in Healthy and Type 2 Diabetic Subjects.

Diabetes and tobacco use are two of the largest public health challenges of our time. We aim to investigate the association between the two by comparing biochemical profiles of diabetic tobacco users (TUs) and tobacco nonus-ers (TNUs) to provide insight into the joint effect of tobacco and diabetes on body systems. This case-controlled study included 265 subjects, aged 18-60 yr, from the suburban population of Delhi, India. With the help of a questionnaire, participants are interviewed regarding their history of tobacco use. Results show association of tobacco use with elevated body-mass index, blood glucose levels, and insulin resistance in otherwise healthy and diabetic TUs. Even without previous history of coronary heart disease, total cholesterol and triglycerides are significantly further increased in TUs rather than in TNUs, indicative of initiation of lipid metabolism disorders. Tobacco use is also seen as a cause of oxidant/antioxidant imbalance in the body. Low serum albumin coupled with increased markers of inflammation and globulin levels is an indicator of generalized inflammation caused by tobacco's toxic effects. Creatinine levels are significantly higher in diabetic TUs, posing a threat to nephropathy progression. Evidence sufficiently infers that tobacco activates multiple biological pathways, through which the risk of metabolic disease increases. These factors may work in conjunction to increase risk of certain microvascular and macrovascular complications.

Right ventricular endomyocardial fibrosis presenting with ventricular tachycardia and apical thrombus--an interesting presentation.

Endomyocardial fibrosis is a progressive disease of unknown origin affecting children and young adults. It involves inflow portion of right and/or left ventricle and apex. It may be associated with thrombus. Literature regarding right ventricular endomyocardial fibrosis with thrombus is scarce. Here we report a rare case of right ventricular endomyocardial fibrosis presenting as ventricular tachycardia and echocardiographic evidence of apical thrombus. Interestingly there was no pulmonary involvement or evidence of deep venous thrombosis. This case also underscores the importance of urgent echocardiography in diagnosis of obscure cases of ventricular tachycardia.

Role of Terminalia arjuna Wight and Arn. in the treatment of chronic coronary artery disease from pharmacovigilance point of view.

BACKGROUND AND OBJECTIVES: Terminalia arjuna Wight and Arn. (Arjuna) has been used in indigenous system for the treatment of cardiac ailments since 500 BC. However, there is a lack of vigilance studies during long-term therapy. The present clinical study was planned to examine the long-term safety of Arjuna as an adjunct drug in chronic coronary artery disease (CAD) patients. MATERIALS AND METHODS: During the study period, a total of 35 patients of chronic CAD were enrolled to receive Arjuna bark extract powder (500 mg three times daily) along with conventional drugs. The control group (35 patients) received conventional drugs alone. Hemogram, liver function tests and kidney function tests were done at baseline and then every 6 months until the end of the study. Electrocardiography was done every 6 months and echocardiography was done yearly for left ventricular ejection fraction and regional wall motion abnormalities. Any adverse drug reactions reported by the patients were also recorded. RESULTS: The mean age of patients in test and control groups was 60.88 ± 9.02 and 58.51 ± 12.64 years, respectively. There was a predominance of male patients in both the groups. The patients were observed for duration ranging from 9 months to 4 years and 9 months. Other than baring gastritis and constipation, no other noteworthy adverse effects were reported. No significant difference was found in laboratory value on baseline and end of therapy in both the groups. CONCLUSION: The results of the present study concluded that Arjuna is safe and effective in patients with chronic coronary artery disease.

Cichorium intybus attenuates streptozotocin induced diabetic cardiomyopathy via inhibition of oxidative stress and inflammatory response in rats.

The aim of the present study was to investigate the effects of Cichorium intybus on lipid peroxidation activities of both enzymatic and non-enzymatic antioxidants, inflammatory mediators, myocardial enzymes and histopathology of cardiac tissues in experimental diabetic cardiomyopathy (DCM). DCM was induced by single intraperitoneal injection of streptozotocin (STZ) (40 mg/kg) combined with high energy intake in rats. Seed extract of Cichorium intybus (CIE) (250 mg/kg & 500 mg/kg) was administered orally once a day for 3 weeks. Phytochemical investigations of seed extract revealed presence of some active ingredients such as alkaloids, tannins, saponin, phenols, glycosides, steroids, terpenoids and flavonoids. Seed extract of Cichorium intybus confirmed a significant potency towards restoring the blood glucose, an elevation of the levels of aspartate aminotransferase (AST), lactate dehydrogenase (LDH), superoxide dismutase (SOD), thiobarbituric acid reactive substances (TBARS), blood glutathione (GSH), TNF-α and IL-6 and a reduction in the levels of catalase (CAT) was observed following the STZ treatment. Oxidative stress was accompanied by myocardial degeneration as evidenced by histopathological examination of cardiac tissues. Administration of CIE reduced the lipid peroxides level in heart. Serum levels of AST, GSH, LDH and SOD were brought down to physiological levels by CIE in STZ induced DCM rats. CIE also markedly down-regulated serum TNF-α and IL-6 levels. Catalase that was reduced in serum was brought back to near normal level. The extensive necrotic changes of cardiac tissue by STZ was minimized to normal morphology upon CIE administration. The study demonstrates the cardioprotective effect of CIE via inhibition of oxidative stress and pro-inflammatory cytokines.

Terminalia arjuna Wight & Arn.--a useful drug for cardiovascular disorders.

Ancient Indian physicians used the powdered tree bark of Terminalia arjuna Wight & Arn. for alleviating "hritshool" (angina) and other cardiovascular conditions. Its stem bark possesses glycosides, large quantities of flavonoids, tannins and minerals. Flavonoids have been detected to exert antioxidant, anti-inflammatory and lipid lowering effects while glycosides are cardiotonic, thus making Terminalia arjuna unique amongst currently used medicinal plants. In this review an attempt has been made to discuss various aspects of its ethnomedical, pharmacognostical, phytochemical, pharmacological and clinical relevance to cardiovascular conditions. Experimental studies have revealed its bark exerting significant inotropic and hypotensive effect, increasing coronary artery flow and protecting myocardium against ischemic damage. It has also been detected to have mild diuretic, antithrombotic, prostaglandin E(2) enhancing and hypolipidaemic activity. There is ample clinical evidence of its beneficial effect in coronary artery disease alone and along with statin. However, toxicological studies in experimental animals are lacking. Considering its anti-ischemic activity and its potential to correct dyslipidemia, reduce left ventricular mass and increase left ventricular ejection fraction, it is essential to examine the molecular mechanism of its action and its core constituents. Proposition to administer Terminalia arjuna along with statins deserves to be explored in depth for defining its place in the over all management and prevention of coronary artery disease.

Beta-thalassemia, hyperlipoproteinemia(a), and metabolic syndrome: its low-cost holistic therapy.

Metabolic syndrome (MS) is an emerging global health problem. Although studies highlighting its genetic, lipid, and cardiometabolic associations have been described in detail, the exact cause for these associations is not clear. The authors describe, in this study, the case of a patient who, along with his family members, had clinical evidence of MS. In addition, this patient also exhibited beta-thalassemia minor and hyperlipoproteinemia(a). Lipoprotein [Lp(a)] levels diminished significantly following therapy with bark-stem powder of Terminalia arjuna, an ancient remedy recommended for angina pectoris. The co-existence of these conditions, reflecting both a genetic link and a significant reduction in Lp(a) levels amounting to 24.71% following the administration of T. arjuna, prompted the authors to report on this case.

Quality of Life in Patients with Coronary Artery Disease and Panic Disorder: A Comparative Study.

OBJECTIVES: The quality of life (QOL) of patients with coronary artery disease (CAD) is known to be impaired. Non-cardiac chest pain referrals are often under-diagnosed and untreated, and there are hardly any studies comparing the QOL of CAD and panic disorder related (non-cardiac) chest pain referrals (PDRC). METHODS: We assessed the psychiatric morbidity and QOL of patients newly diagnosed with CAD (n = 40) at baseline and six weeks post-treatment and compared their QOL with patients with PDRC (n = 40) and age- and gender-matched healthy controls (n = 57). Psychiatric morbidity in the CAD group was assessed using the General Health Questionnaire (GHQ12) item, Hamilton Anxiety Scores (HAM-A), and Hamilton Depression Scores (HAMD). QOL measures were determined by the World Health Organization QOL questionnaire (brief) and Seattle Angina Questionnaire. The CAD group was treated with anti-ischemic drugs (nitrates, betablockers), antiplatelet drugs (acetylsalicylsalicylic acid), anticoagulants (low molecular weight heparin, clopidogrel), and managed for risk factors. The PDRC group was treated with selective serotonin reuptake inhibitors and anxiolytics. RESULTS: Patients with panic disorder had a worse QOL than those with CAD and healthy controls in the physical domain and psychological domain (PDRC vs. CAD vs. healthy controls, p < 0.001). In the CAD group, smoking was associated with change in angina stability (p = 0.049) whereas other tobacco products were associated with change in angina frequency (p = 0.044). Psychiatric morbidity was present in 40.0% of patients with CAD. In the PDRC group, a significant correlation of HAM-A scores was noted in the physical (p = 0.000), psychological (p = 0.001), social (p = 0.006), and environment (p = 0.001) domains of QOL. Patients with panic disorder had a significant improvement in anxiety scores after treatment compared to baseline (HAM-A scores difference 21.0 [16.5-25.6]; p < 0.001). CONCLUSIONS: Patients in the PDRC group had a worse QOL than those in the CAD and healthy control groups. This highlights the need for careful diagnosis and prompt treatment of panic disorder in these patients to improve their QOL. Additionally, smoking, the use of other tobacco products, and hypercholesterolemia were associated with angina symptoms in patients with CAD.