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).

The Power and Promise of Angiotensin Receptor Neprilysin Inhibitor (ARNI) in Heart Failure Management: National Consensus Statement

Heart failure (HF) is a huge global public health task due to morbidity, mortality, disturbed quality of life, and major economic burden. It is an area of active research and newer treatment strategies are evolving. Recently angiotensin receptor-neprilysin inhibitor (ARNI), a class of drugs (the first agent in this class, Sacubitril–Valsartan), reduces cardiovascular mortality and morbidity in chronic HF patients with reduced left ventricular ejection fraction (LVEF). Positive therapeutic effects have led to a decrease in cardiovascular mortality and HF hospitalizations (HFH), with a favorable safety profile, and have been documented in several clinical studies with an unquestionable survival benefit with ARNI, Sacubitril–Valsartan. This consensus statement of the Indian group of experts in cardiology, nephrology, and diabetes provides a comprehensive review of the power and promise of ARNI in HF management and an evidence-based appraisal of the use of ARNI as an essential treatment strategy for HF patients in clinical practice. Consensus in this review favors an early utility of Sacubitril–Valsartan in patients with HF with reduced EF (HFrEF), regardless of the previous therapy being given. A lower rate of hospitalizations for HF with Sacubitril–Valsartan in HF patients with preserved EF who are phenotypically heterogeneous suggests possible benefits of ARNI in patients having 40–50% of LVEF, frequent subtle systolic dysfunction, and higher hospitalization risk.

The correlation of cardiovascular risk factors and angiographic findings with serum vitamin D levels in patients undergoing coronary angiography

Background: Studies regarding correlation of various conventional risks factors for Coronary Artery Disease (CAD) are many. Keeping in mind the scarcity of studies regarding Vit-D Deficiency (VDD), a new risk factor in CAD, present study was conducted to correlate Vit-D level with conventional risk factors and Coronary Angiography (CAG).Methods: Hundred adult patients admitted to Medicine and Cardiology undergoing CAG with suspected or established CAD were kept in study. Patients having renal, hepatic, parathyroid disease, osteomalacia and patients taking drugs interfering with Vitamin D (Vit-D) metabolism were excluded. After detailed history and thorough clinical examination, routine investigations and 25-(OH) D level was estimated. Subsequently patients underwent CAG. Statistical analysis by Mann Whitey test and Chi-square Test was done and inference was drawn.Results: 100 patients in different age groups had hypertension (HTN) in 53, diabetics mellitus (DM) 39, dyslipidemia 62, smokers 38 and family history of CAD 19. CAG showed normal coronaries in 4, Single Vessel Disease (SVD) in 30, double vessel diseases (DVD) 43 and triple vessel disease (TVD) 22. Vit-D level <20ng/ml i.e. Vit-D deficiency (VDD) in 68, 20-30ng/ml i.e. Vit-D insufficiency (VDI) in 22 and >30ng/ml (normal) in 10. VDD was profound in 51-60 and 61-70 years age groups. Statistical correlation of VDD was not significant with conventional risk factors, but statistically significant correlation of VDD was observed with dyslipidemia and CAG findings in our study.Conclusions: Like earlier studies we observed significant correlation of Vit-D levels with CAD. Though dyslipidemia was significantly correlated with VDD, correlation of other conventional risk factors like age, sex, HTN, DM, smoking and family history was not found. We conclude from this study presence of significant association of VDD with severe CAD. DVD and TVD by CAG were common with low Vit-D levels.

Left ventricular dysfunction in patients with subclinical hypothyroidism and its reversibility after hormone therapy.

AIM: To ascertain the presence of LV dysfunction in patients of subclinical hypothyroidism and its reversibility after hormone therapy. METHODS AND METERIAL: Thirty two patients with subclinical hypothyroidism (SH) were included in the study, along with thirty two age and sex matched individuals serving as controls. The patients with SH had normal serum T3 and T4 with an elevated TSH value. All patients and the controls were subjected to detailed echocardiographic examination for assessment of LV systolic and diastolic function before and one year after hormone (thyroxine) therapy. RESULTS: The systolic function of LV was normal in patients with SH. There was significant diastolic dysfunction in the SH patients as compared with controls. There was prolongation of deceleration above time (169 +/- 6.1 msec. vs. 148.1 +/- 5.4 msec in controls, p < 0.05), isovolumic relaxation time (89.1 +/- 7.3 msec vs. 79.4 +/- 5.9 msec., p<0.05), increased A wave (0.63 +/- 0.6 m/sec. vs. 0.54 +/- 0.05 m/sec) and reduced E/A ratio (0.7 +/- 0.09 vs. 1.4 +/- 0.3, p < 0.05). Echocardiography at the end of one year of hormone therapy revealed considerable improvement in diastolic function of the LV. There was significant improvement in DT (from 169 +/- 6.1 msec. to 151 +/- 5.2 msec, p < 0.05), IVRT (from 89.1 +/- 7.3 msec. to 80.2 +/- 6.5 msec, p < 0.05) and increased E/A ratio (from 0.7 +/- 0.09 to 1.3 +/- 0.1, p < 0.05). CONCLUSION: Hypothyroidism, even in subclinical stage, can cause diastolic dysfunction of the LV. These abnormalities in diastolic function can be reversed by thyroxine therapy.

Myocarditis as an initial manifestation of systemic lupus erythematosus.

We report a case of systemic lupus erythematosus (SLE) whose initial presentation was in the form of myocarditis. The patient did not have arthritis, fever or butterfly rash. Presence of LE cell phenomenon, positive ANA, anti-DS DNA antibodies, leucopenia and high ESR with polyserositis indicated the diagnosis to be SLE. Therapy with steroid resulted in complete recovery. The patient developed atrial fibrillation during her course of acute illness which is being reported for the first time.

Amlodipine-induced gingival hyperplasia.

Gingival hyperplasia can occur during use of drugs such as diphenylhydantoin, cyclosporine and nifedipine. We report, three cases of gingival hyperplasia induced by amlodipine, a second generation calcium channel blocker. Exact cause of induction of thehyperplasia is not known. Individual variation in metabolism of the drug may be a factor.

Percutaneous balloon angioplasty of membranous obstruction of the inferior vena cava.

BACKGROUND: Membranous obstruction of the inferior vena cava is common in African and Asian countries. METHODS AND RESULTS: Between January 1999 and January 2002, 19 patients were prospectively studied. The mean age of the patients was 38+/-6.9 years. All of them had swelling of the abdomen and ankle edema. Five patients (26.3%) had jaundice, 9 (47.3%) had hepatomegaly, and 5 (26.3%) splenomegaly. Ultrasonography could detect the site of obstruction in 18 patients (94.7%). Vena cavography demonstrated obstruction of the inferior vena cava at the level of the diaphragm, with 2 patients (10.5%) having additional intrahepatic obstruction. The mean pressure gradient was 22+/-3.5 mmHg. Seventeen patients underwent balloon angioplasty using a Joseph balloon. The procedure was successful in 15 patients (88.2%). The post-angioplasty mean pressure gradient was 5+/-1.4 mmHg. On follow-up, 3 patients (20%) developed features of restenosis: out of them, 2 underwent successful redilatation. CONCLUSIONS: Balloon angioplasty of membranous obstruction of the inferior vena cava is feasible with a high success rate, without any rupture of the inferior vena cava.

Has the prevalence of rheumatic fever/rheumatic heart disease really changed? A hospital-based study.

BACKGROUND: Rheumatic fever and rheumatic heart disease still remain major public health problems. With a dramatic rise in the incidence of coronary artery disease cases, the focus of the physician seems to be shifting away from rheumatic fever and rheumatic heart disease. The aim of the present study was to assess the prevalence of rheumatic fever and rheumatic heart disease, and to ascertain if there was any decline in the prevalence of the disease. For the first time, data on the prevalence of rheumatic fever and rheumatic heart disease are reported from Orissa, an underdeveloped state in eastern India. METHODS AND RESULTS: We scrutinized the records of cardiac patients admitted to the medicine, pediatrics and cardiology wards of the SCB Medical College and Hospital, Cuttack from 1981 to 1990 and 1991 to 2000. During the period 1981-1990, out of 11,782 cardiac patients, 5537 (46.9%) were suffering from rheumatic fever and rheumatic heart disease. During 1991-2000, out of 14,803 cardiac patients, 6670 hospitalized patients (45%) were found to have rheumatic fever and rheumatic heart disease. During the first and second periods, the number of patients with rheumatic fever admitted was 1079 (9.2%) and 1330 (8.9%), respectively. The decline in the percentage of rheumatic fever cases was statistically not significant (p>0.05). During the two periods, the number of rheumatic heart disease patients admitted was 4458 (37.8%) and 5340 (36.1%), respectively. During both the periods studied, the decline in the percentage of rheumatic heart disease cases admitted was statistically not significant (p>0.05). We also compared rheumatic fever and rheumatic heart disease cases admitted during 1981-1985 with those admitted during 1996-2000. This analysis also did not show any demonstrable decline in the prevalence of the disease (2692 [46.2%] v. 3296 [44.4%], p>0.05). CONCLUSIONS: Our results show that rheumatic fever and rheumatic heart disease cases constitute a significant percentage of the admissions of total cardiac cases to our hospital. Over the past 20 years, there is no significant decline in the percentage of rheumatic fever and rheumatic heart disease cases being admitted to a major government hospital.