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.

Cerebral gigantism with West syndrome.

A case of cerebral gigantism (Sotos syndrome) with West syndrome in a one-year-old male child is reported. The case had a large stature, typical facies and neurodevelopmental delay along with infantile spasms, which were refractory to treatment with valproate and clonazepam.

Protein energey malnutrition and skeletal muscle wasting in childhood acute lymphoblastic lukemia.

OBJECTIVE: To determine the nutritional status and the extent of skeletal muscle wasting in children with acute lymphoblastic leukemia (ALL) at the time of diagnosis and after induction chemotherapy. DESIGN: Prospective observational study. SETTING: Tertiary care teaching hospital. METHODS: 25 new cases of ALL underwent somatometric measurements and ultrasonographic evaluation of skeletal muscle and subcutaneous fat at initial presentation and after completion of induction therapy. RESULTS: Malnutrition (weight for age < 80percnt) was evident in 13 cases (52percnt), but cumulative incidence of malnutrition (weight for age < 80percnt, weight for height < 90percnt, height for age < 95percnt, skin fold thickness < 5th centile, midarm muscle circumference < 5th centile) was 88percnt. Nine children lost weight during induction (range: 0.2 to 5.8 kg; means +/- SD: 1.9 plusmn 1.8 kg). All these cases had a complicated course during induction chemotherapy. Fourteen children (56percnt) had skeletal muscle wasting during induction chemotherapy. All those children who had lost weight also had skeletal muscle wasting. Subcutaneous fat, in contrast increased in 24 cases (96percnt). CONCLUSION: Malnutrition exists in a significant proportion of children with ALL. If induction chemotherapy is complicated, children lose significant weight and have significant muscle wasting. Increase in subcutaneous fat occurs in almost all children, which is probably a consequence of therapy with oral steroids

Assessment of malnutrition in alcoholic and non alcoholic cirrhotics.

OBJECTIVE: To study the nutritional status in patients with chronic liver disease using anthropometric techniques. METHODS: A total of 60 cirrhotic patients (30 Alcoholic (AC), 30 Non-alcoholic (NAC) and 30 control (CO) subjects were studied. Nutritional status was assessed using anthropometric measurements such as stature, body weight, body mass index, (BMI), skinfold thickness measurements and mid upper arm muscle circumference. Serum protein, serum albumin and globulin were measured. RESULTS: The skinfold thicknesses were significantly lower in NAC group of patients. In contrast the AC group of patients showed significantly lower mid upper arm muscle circumference values. Both groups of cirrhotic patients showed significantly lower total serum protein and serum albumin levels. CONCLUSION: Body fat is relatively more affected in NAC group of patients and muscle mass is more affected in AC group of patients.

Retro-peritoneal cystic lymphangioma in association with fetal hydantoin syndrome.

Antiepileptic drugs are known to be teratogenic. Use of phenytoin during pregnancy can cause various congenital malformations leading to 'fetal hydantoin syndrome'. One such case reported is unique in the sense that it occurred with retroperitoneal cystic lymphangioma, itself a rare condition. Such an association is not described elsewhere.

Longitudinal growth of arm circumference in Punjabi infants.

OBJECTIVE:To study distance and velocity growth pattern of mid-upper-arm-circumference in Punjabi infants. DESIGN: Longitudinal, monthly follow up. SETTING: Growth clinic and homes of subjects. SAMPLE: One hundred and fifty four (Male 86, Female 68) Punjabi infants weighing more than 2.5 kg at birth with gestation over 37 weeks. METHODS: Every subject was measured for mid-upper-arm circumference between 1 to 12 months of age at one monthly intervals by the same investigator with a time tolerance of 3 days on the day of measurement. RESULTS: Mid upper arm circumference showed rapid increase between 1 to 6 months whereafter, gain became slower during second half of infancy. It had grown by 34.9% in male and 40.2% in female infants between 1 to 12 months. Sex differences favoring male infants were statistically significant between 1 to 4 months. Monthly growth rates for arm-circumference depicted vascillatory pattern. CONCLUSION: The values presented for arm circumference may be used as reference base to monitor growth of children during infancy.

Percentile curves for body-mass index of Punjabi infants.

OBJECTIVE: To study percentile distance growth pattern of Body Mass Index (BMI) of Punjabi male and female infants. DESIGN: Longitudinal. SETTING: Growth Clinic. SUBJECTS: 154 Punjabi infants (Male 86; Female 68), aged birth-12 months. FOLLOW-UP: Nude body weight and crownheel length of all babies at birth and whereafter, were measured at monthly age intervals with time tolerance to +/-3 days by the same investigator upto 12 months of life. RESULTS: Mean (+/- SD) values for BMI measured 12.2 +/- 1.40 kg/m2 and 16.5 +/- 1.40 kg/m2 at birth and 12 months, respectively in male infants. The corresponding figures for female infants were 12.5 +/- 1.60 kg/ m2 and 16.5 +/- 1.50 kg/m2. A rapid increase in BMI values amongst infants of both sexes between birth to about six months followed by flattening of curves upto 12 months of age indicates an age dependent nature of BMI during first half of infancy in comparison to latter half during which these demonstrated stable trend. These findings are in contrast to those of the western infants who showed a regular increase in BMI throughout the first year of life. Sex differences were not significant at majority of the age levels. CONCLUSIONS: Percentile grids presented for BMI represent a normal, healthy and well-nourished infant population which can be used to assess the adiposity status of infants of the two sexes during the first year of life.

Co-existence of oblique pinnae and congenital heart disease.

The paper reports a syndrome in which oblique placement of one or both the pinnae on face was found to co-exist with congenital anomalies of heart like VSD, PDA and Tetralogy of Fallot, etc. Although clinically discernible in 90% of the subjects, objective evidence of obliquity of pinna was documented by photogrammetry. The values for the ear inclination in subjects categorized clinically as normally placed pinna were 7.9 degrees +/- 3.39 degrees with range 2 degrees-17 degrees. In contrast, subject where the pinna was clinically categorized as oblique had mean AEI 16.5 degrees +/- 5.81 degrees with a range 5 degrees-33 degrees. Eighteen of the 20 subjects with oblique pinna were demonstrated to have some congenital anomaly of heart as indicated by clinical and echocardiographic examination. In contrast, in subjects with normally placed pinna only 3 out of 34 possessed clinical heart defects. Presence of oblique pinna indicates a thorough search for undetected heart defects.

Percentile growth charts for head circumference in Punjabi infants.

Percentile growth charts for head circumference of Punjabi infants (male 86 and female 68) measured serially at monthly intervals during the first year of life are presented. Besides, constancy of sample size and strict adherence to time tolerance limit of +/- 3 days, on the day of monthly measurements other factors considered responsible for the natural smooth course of the percentile grids are highlighted. The presented data would enable easy detection of infants with abnormal course of head growth.

Reliability of skinfold calipers as a tool for measuring body fat in human beings.

Triceps skinfold thickness measured in ten adults aged 19 to 50 yr by a Holtain skinfold caliper, was compared with subcutaneous fat thickness obtained on cross-sections of the left upper arm by computerized axial tomography (CAT). The thickness of subcutaneous fat was measured on CAT scan film directly with the inbuilt computer graphic technique. The measurements taken on CAT scan film were found to be significantly higher (by 21-45%; P less than 0.001) than those by the skinfold calipers. Our findings suggest that skinfold calipers may not be very accurate tools for the assessment of body fat in human beings. Therefore, its use in the determination of body composition, for which great precision is required calls for re-thinking.

Ultrasonographic localization for renal biopsy.

One hundred and fifty consecutive percutaneous renal biopsies were performed using ultrasonography to localise the site and depth of the lower pole of the left kidney. Renal tissue was obtained in 95% of cases and an accurate histopathological diagnosis was reached in 89% of patients. Gross haematuria following the procedure occurred in 6%, but was usually transient. No other complications were encountered. Ultrasonographic marking of the biopsy site and depth is a quick, simple, accurate and safe method of localizing the kidney for the purpose of a biopsy.

Palpebral fissure length in normal infants.

Somatometric data on the size of palpebral fissure have been presented on 211 normal infants. The palpebral fissure length was derived from the inner canthal and outer canthal distances measured at different age levels. The size of palpebral fissure at birth (1.79 +/- 0.17 cm) is 76.8% of the value attained by it at 4-6 months age (2.33 +/- 0.09 cm), and 76.2% of the size at 10-12 months age (2.35 +/- 0.10 cm). Values for inner canthal and outer canthal distances measured at birth are also presented. The data provided are expected to assist objective evaluation of disorders affecting the size of palpebral fissure during infancy.