Angiotensin Receptor-Neprilysin Inhibitor Therapy and Cardiac Remodeling in Heart Failure: Consensus Statement from India

Adverse cardiac remodeling refers to progressive structural and functional modifications in the heart because of increased wall stress in the myocardium, loss of viable myocardium, and neurohormonal stimulation. The guideline-directed medical therapy for Heart failure (HF) includes Angiotensin receptor-neprilysin inhibitor (ARNI) (sacubitril/valsartan), ?-blockers, sodium-glucose co-transporter 2 (SGLT2) inhibitors, and mineralocorticoid receptor antagonists (MRA). ARNI is under-prescribed in India despite its attractive safety and efficacy profile. Therefore, the consensus discusses objectives and topics related to ARNI in the management of cardiac remodeling, and experts shared their views on the early timely intervention of effective dosage of ARNI to improve the diagnosis and enhance mortality and morbidity benefits in cardiac reverse remodeling (CRR).

Role of Iron Therapy in Heart Failure: A Consensus Statement from India

Iron deficiency (ID) with or without anemia is frequently observed in patients with heart failure (HF). Uncorrected ID is associated with higher hospitalization and mortality in patients with acute HF (AHF) and chronic HF (CHF). Hence, in addition to chronic renal insufficiency, anemia, and diabetes, ID appears as a novel comorbidity and a treatment target of CHF. Intravenous (IV) ferric carboxymaltose (FCM) reduces the hospitalization risk due to HF worsening and improves functional capacity and quality of life (QOL) in HF patients. The current consensus document provides criteria, an expert opinion on the diagnosis of ID in HF, patient profiles for IV FCM, and correct administration and monitoring of such patients.

Low framingham risk score despite high prevalence of metabolic syndrome in asymptomatic north-Indian population.

Background : Conflicting data exists regarding relationship between the Framingham risk score (FRS) and presence of metabolic syndrome (MS). Strong influence of age on FRS may further modify this relationship as prevalence of MS at younger age increases in South-Asian countries including India. However, only limited information is available about the prevalence of MS and its relationship with FRS in such populations at present. Methods : Clinical examination and biochemical investigations were performed in 1905 asymptomatic office executives who underwent routine health check-up at a tertiary care centre in India during the year 2005. Diagnosis of MS and FRS were based on the modified National Cholesterol Education Program- Adult Treatment Panel III guidelines. Results : Mean age of the subjects was 45.2 ± 10.3 years and 71.8% were males. MS was present in 47.5% (905 of 1905) subjects. Overall, 76.8% patients with MS had 10-year cardiovascular (CV) risk <10%, 20.6% had 10-20% risk and only 2.7% had >20% risk according to FRS. In the lowest age-quartile, 95.9% patients had 10-year risk <10%, 4.1% patients had 10-20% risk and none had >20% risk. In contrast, in the highest age-quartile, less than half of the patients had 10-year risk <10% and nearly half had 10-20% risk of CV events. Conclusions : Although the prevalence of MS is markedly high in young asymptomatic Indians, majority have low 10-year risk of CV events as estimated by FRS. These findings necessitate continued emphasis on detection of MS in these populations as reliance on FRS alone may result in underestimation of CV risk in them. ©

Prevalence of cardiovascular risk factors in Indian patients undergoing coronary artery bypass surgery.

BACKGROUND: Conventional cardiovascular risk factors (CVRFs) are known to influence short-term and long-term outcome following coronary artery bypass graft surgery (CABG). There has been recent increase in prevalence of CVRFs in general population in India. However no information is available regarding the prevalence of same in patients undergoing CABG. METHODS AND RESULTS: In this cross-sectional study, one thousand consecutive patients undergoing elective CABG were included and data on major CVRFs was obtained in them. Mean age of the patients was 59.73 +/- 9.5 years and 884/1000 (88.4%) patients were males. 505/994 (50.8%) patients had BMI > or = 25.0 kg/m2 and 747/994 (75.2%) had BMI > or = 23.0 kg/m2. Diabetes mellitus was present in 475/1000 (47.5%) patients (46.5% men and 55.2% women), hypertension in 709/1000 (70.9% overall; 70.8% men and 71.6% women) and dyslipidemia in 781/913 patients (85.6% overall; 84.5% men and 93.9% women). 213/913 (23.3%) patients had LDL > or = 100mg/dl, 662/913 (72.5%) patients had low HDL and 338/913 (37.0%) patients had elevated triglycerides. 199/1000 (19.9%) patients (18.7% men and 29.3% women) had family history of premature CAD and 545/1000 (54.5%) patients (53.4% men and 62.9% women) had at least one family member having CAD (irrespective of the age of onset). 94/1000 (9.4%) patients (10.4% men and 1.7% women) were current smokers and another 302/1000 (30.2% overall; 33.7% men and 3.4% women) had history of smoking in the preceding one year. 876/913 (95.9%) of all the patients had at least one of the five major CVRFs and only 37/ 913 (4.1%) patients (4.1% men and 4.3% women) were free of all these risk factors. Sixty-one of the 1000 patients (6.1%) were younger than 45.0 years of age. As compared to older patients, dyslipidemia, family history of premature CAD and smoking were commoner in patients less than 45 years of age. In contrast, diabetes and hypertension were more prevalent in the older individuals. CONCLUSIONS: The present study showed high prevalence of most of the conventional CVRFs, esp. diabetes, hypertension and dyslipidemia in Indian population undergoing CABG.

Dobutamine stress echocardiography--methodology, clinical applications and current perspectives.

Dobutamine stress echocardiography is often used as a non-invasive diagnostic modality for detection of coronary artery disease. In terms of accuracy it rivals SPECT scintigraphy. Application of non-coronary artery disease has made it an attractive diagnostic tool. However, like all diagnostic modalities it has its inherent limitations. Quantitation of stress echocardiography can resolve most of the problems surrounding its use.

Understanding systolic hypertension in the elderly.

Among the various causes of blood pressure in the elderly population, isolated systolic hypertension (ISH) is the commonest. Its prevalence increases with age. Age related rigidity of aorta is the primary cause of ISH. Systolic rise in blood pressure is at least as important as the diastolic blood pressure. Several non-pharmacological and pharmacological therapies are well-established for reduction of blood pressure in this age group. Among different groups of anti-hypertensive drugs, the preference depends primarily on co-morbidities and overall cardiovascular risk. Lifestyle modification should also be an integral part of therapy for each patient. Various studies suggest that control of blood pressure definitely decreases the incidence of mortality as well as coronary artery disease, stroke and other morbidities.

Endothelium-dependent brachial artery flow mediated vasodilatation in patients with diabetes mellitus with and without coronary artery disease.

AIM OF THE STUDY: Endothelial function as assessed by brachial artery flow mediated vasodilatation (FMD) has been shown to be impaired in patients with coronary artery disease (CAD). Since diabetes mellitus (DM) has been considered to be CAD risk-equivalent, we sought to determine whether endothelial dysfunction is present in patients with DM independent of presence of CAD. METHODOLOGY: One hundred and ninety eight individuals were included in the study and divided into four groups: Group 1--patients with risk factors for CAD, but no DM or CAD; Group 2--patients with DM but no CAD; Group 3--patients with CAD but no DM and Group 4--patients with both DM and CAD. Brachial artery FMD assessment was performed once in all subjects and FMD was calculated as percentage increase in brachial artery diameter in response to increase in brachial artery flow. RESULTS : Mean FMD was significantly higher in Group 1 (7.03 +/- 2.87%) compared to the other three groups. Mean FMD in Group 2 (5.51 +/- 2.12%) was similar to that in Group 3 (4.56 +/- 2.70%; p value 0.195) but significantly higher than that in Group 4 (4.26 +/- 1.93%; p value 0.038). There was no statistically significant difference in mean FMD in Group 3 and Group 4 (p value 0.65). CONCLUSION : Endothelial function as assessed by FMD is significantly impaired in diabetics compared to non-diabetics in absence of CAD. In addition, similar degree of impairment in endothelial function is seen in diabetics without CAD and non-diabetic patients having CAD, implying CAD risk-equivalence of diabetes.

Discrete subvalvular aortic stenosis in adults.

Discrete subvalvular aortic stenosis is a relatively rare condition in adults. It is often diagnosed during first decade of life especially in association with other congenital malformations. Isolated form of discrete subvalvular aortic stenosis may however silently progress from innocent murmurs of childhood and adolescence to symptomatic left ventricular outflow tract obstruction in adults. Certain overt and subtle morphological abnormalities may underlie the initial expression as well as high recurrence rates after surgical resection of sub aortic membrane. Though surgical resection is the only treatment available, debate on the surgical technique and appropriate timing of surgery continues. Close followup with serial echocardiographic examinations in patients detected to have functional murmurs during childhood may be helpful in early detection of subvalvular aortic stertosis.

Discrete subvalvular aortic stenosis.

Discrete Subaortic Stenosis is one of the many lesions responsible for left ventricular outflow tract (LVOT) obstruction. It may present as in an isolated from as membranous or fibromuscular ring below the aortic valve or in association with other congenital anamolies such as VSD, PDA, coarctation of aorta, hypoplastic aortic annulus, double chamber right ventricle among others. The condition is rarely diagnosed antenataly or in infancy but often manifests in the first decade of life with features of progressive LVOT obstruction, LV hypertrophy and dysfunction aortic regurgitation due to damage to the aortic cusps because of the jet from the subaortic narrowing which may also render the aortic valve prone to infective endocarditis. Interaction of genetic predisposition and morphologically deformed long and narrow LVOT cause rheological abnormalities and increased shear stress in the region of subaortic stenosis and seem to be the main etiological factor alongwith poorly defined role of more extensive but subtle changes in the LV endocardium. Condition can be easily diagnosed by cross-sectional and Doppler echocardiography and confirmed by demonstrating a pressure gradient below aortic valve on cardiac catheterisation and LV angiography. Surgical membranectomy alongwith myotomy or myomectomy remain the mainstay of treatment but long term results are not satisfactory as there is a high rate of recurrences requiring reoperations. A close follow up with serial echocardiographic examinations is very helpful in early detection of subaortic obstruction in patients who have so called functional murmurs in the childhood.

Sequential external counterpulsation: an adjunctive therapy for patients with chronic coronary artery disease and left ventricular dysfunction.

We assessed the clinical and haemodynamic improvement with 3 weeks of sequential external counterpulsation (SECP) therapy in 23 patients with chronic coronary artery disease (CAD) and left ventricular (LV) dysfunction who were refractory to maximal tolerated doses of medical therapy and in whom intervention or surgery was not contemplated. All patients were subjected to one-hour duration of SECP for 3 weeks. SECP is a new noninvasive tool which increases coronary artery filling utilizing external pressure in a sequential manner from calf to thigh. A detailed clinical and echocardiographic evaluation was done before and after the completion of therapy to assess the utility of SECP. There were 18 males and 5 females with a mean age of 53 years. On coronary angiography, 39 percent patients had single, 8.7 percent had double and 48 percent had triple vessel disease. Four patients had coronary artery bypass graft (CABG) surgery in the past. Out of all patients, 48 percent had diffuse or distal coronary artery disease which was considered not suitable for CABG, 22 percent were not willing for intervention and 30 percent had other systemic diseases making them unfit for surgery. After 3 weeks of SECP, the anginal frequency reduced from 9 episodes/week to 1 episode/week. Before SECP, 74 percent patients were in NYHA class III, whereas only 8.7 percent were class III symptomatic after SECP. All patients claimed symptomatic improvement of a mean of 6.8 +/- 1.4 on a visual analog scale of 1-10. After SECP, the LV diastolic dimensions reduced from 54.6 +/- 7 to 51 +/- 7 mm, systolic dimensions reduced from 40 +/- 8 to 36 +/- 8 mm and LVEF increased from 32.7 +/- 9 to 37.4 +/- 8.5 percent. In conclusion, 3 weeks of therapy with SECP produces significant improvement in symptomatic status and cardiac function in patients with chronic CAD and LV dysfunction, refractory to medical therapy.

Multiplane transesophageal echocardiography: our initial experience.

We present our experience in the diagnostic assessment of a wide spectrum of cardiovascular disorders using multiplane transesophageal echocardiography (MP-TEE). Two hundred and seventeen patients in the age range of 11-71 years were subjected to MP-TEE from January to November 1993. The male:female ratio was 1.1:1. One hundred and ten patients had predominantly mitral valve disease of rheumatic origin, eleven had mitral valve prolapse, twenty patients had aortic valve disease and thirty seven patients had more than one valve involvement. Six patients with suspected prosthetic heart valve dysfunction and ten patients of hypertrophic cardiomyopathy were also studied. Two patients had unexplained pulmonary hypertension, three had pericardial disease and three had proximal aortic dissections. Twenty six patients with congenital heart disease were studied of which nineteen had atrial septal defects, one had corrected transposition of great vessels with pulmonic stenosis and one adult had Ebstein's anomaly of the tricuspid valve. In our experience, MP-TEE enhances the versatility of TEE by providing incremental diagnostic information and enhancing delineation of pathology. The procedure was well-tolerated and no complications occurred.

Nuclear imaging study of nifedipine induced modulations of central haemodynamics in severe hypertension with and without coronary artery disease.

Acute effects of Nifedipine, a calcium channel blocking agent (CCBA), on central haemodynamics in patients with severe hypertension and angiographically proved coronary artery disease (CAD) has been studied using Nuclear Ventriculography (MUGA). While peripheral vasodilatation leads to significant reduction of systemic blood pressure in all severe hypertensive patients (p < 0.0005 and p < 0.0001), the central haemodynamics did not improve significantly in patients without CAD (p = NS). However, in hypertensive subset of CAD, central haemodynamics significantly improves with rise of global ejection fraction (p < 0.001) and improvement of wall motion abnormalities (p < 0.001).

Percutaneous intraaortic balloon pulsation for management of life threatening emergencies in an intensive coronary care unit.

The indications for the outcome of use of intraaortic balloon pulsation (IABP) in 66 patients (65 males, 1 female), in addition to the usual conventional medical therapy, are reported here. IABP was used for treatment of cardiogenic shock (5 patients), acute myocardial infarction with rupture of interventricular septum (2 patients), acute myocardial infarction with refractory left ventricular failure (2 patients), resistant ventricular tachyarrhythmias (5 patients), refractory angina (50 patients) and for hypotension following high risk coronary angiography (2 patients). A Datascope 10.5 F percutaneous balloon was inserted in all, mostly using the left femoral artery. Either definitive treatment (coronary artery bypass surgery or coronary angioplasty) was offered when feasible or the balloon was weaned off. Twelve patients underwent coronary angiography on IABP; while 31 patients had undergone the angiography earlier. Surgery was possible in 33 patients with 90% survival rate. The non surgical group showed 30% survival rate. The complications of IABP encountered were: leg ischaemia (2 patients), septicemia (4 patients) and balloon rupture (2 patients). Our experience suggests that percutaneous IABP is a very useful management procedure for seriously sick high risk patients prior to definitive therapy. Patients who could have a definitive treatment while on IABP, especially the group with refractory angina, did best on a short term follow up. Vascular complications are minimal while on IABP.

An evaluation of cardiac function in malnourished children by non-invasive methods.

Forty-six malnourished children between 3-48 mo with varying grades of malnutrition (PEM) were evaluated for left ventricular function by echocardiography. None of these children had any pre-existing cardiac disease, chronic illness or significant anemia. Children with Grades III and IV PEM had significantly smaller cardiac chamber size and ventricular wall thickness as compared to normally nourished children. Cardiac output as well as other indices of left ventricular function (percentage fractional shortening, mean rate of circumferential fibre shortening and ejection fraction) were also significantly decreased in severe PEM. The atrophic PEM heart does appear to show left ventricular dysfunction in moderately severe malnutrition.