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.

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.

Reattachment of complex fractures; a reality by advances in self-etch bonding systems

An 18-year-old female patient reported to the Department of Conservative and Endodontics with the chief complaint of fractured tooth with respect to 21 and increased pain and mobility tooth with respect to 22. Intraoral periapical radiograph of 21 revealed coronal loss of tooth structure involving enamel, dentin, and pulp, suggestive of split tooth with respect to 21. Intraoral examination revealed a fracture of coronal structure of 22 and increased mobility in the coronal aspect, suggestive of horizontal crown–root fracture. For management of 21, after endodontic phase, placement of fiberpost, and coronal buildup, intentional reimplantation was done to expose and reattach the vertically fractured root fragment. For management of 22, after endodontic phase, crown lengthening was done, and the fractured fragment was reattached by making it a Natural Richmond's Crown. Radiographs revealed a complete sealing of the fractured fragment and proper positioning of the tooth.

Characterization of an eye prosthesis using monopoly syrup.

The eye is a vital organ and an important component of facial expression. Loss of an eye has a crippling effect on the psychology of the patient. Maxillofacial prostheses restore and replace stomatognathic and associated facial structures with artificial substitutes. The objectives of eye prosthesis is to improve the patient esthetics, restore and maintain the health of the remaining associated structures, consequently provide physical and mental well-being. The primary purpose of an ocular prosthesis is to maintain the volume of eye socket and create the illusion of a healthy eye and surrounding tissue. A custom ocular prosthesis is a good option when reconstruction is done by plastic surgery, and osseointegrated implants are either not possible or not desired. A case of a custom-made ocular acrylic prosthesis is presented with acceptable fit, good retention, and esthetics.

Anaesthetic Considerations in a Patient with Klippelfeil Syndrome Undergoing Occipito Cervical Fixation

A rare case with Klippel-Feil syndrome with a classic triad having short neck, low posterior hair line and restricted motion of neck because of fused cervical vertebrae was scheduled for occipito cervical fixation, foramen magnum decompression, fusion with local bones and cervical traction. We present the anaesthetic management of this patient highlighting the various anomalies associated with Klippel-Feil syndrome and the presence of a difficult airway.

Safety and efficacy of indigenously developed and manufactured bivalirudin in moderate/high-risk Indian patients undergoing percutaneous coronary intervention: the Bivaflo Registry.

BACKGROUND: Current treatment strategies for percutaneous coronary intervention (PCI) and acute coronary syndrome (ACS) include concomitant use of glycoprotein IIb/IIIa inhibitors (GPI) and antithrombotic therapy such as aspirin, clopidogrel, and unfractionated or low-molecular-weight heparin. The "direct thrombin inhibitor" bivalirudin has been associated with better efficacy and safety than heparin. OBJECTIVE: The present study is performed to evaluate the safety and efficacy of an indigenously developed and manufactured bivalirudin (Bivaflo; Sun Pharmaceutical Industries Ltd., Mumbai) as the primary anticoagulation strategy during PCI in moderate-high risk patients with only provisional use of GPI. METHODS: This prospective multicentered registry enrolled 439 patients in 11 tertiary care centers across India. Patients who had ACS or other clinical/angiographic characteristics, which increase risk during PCI, were enrolled in the registry. Bivaflo was administered as a bolus dose of 0.75 mg/kg, followed by infusion at a rate of 1.75 mg/kg/h during the procedure and optionally 0.25 mg/kg/h for 4 hours after the procedure at investigator's discretion. GPI use was discouraged except as bailout. The primary endpoints were composite and individual incidences of death, myocardial infarction (MI), urgent revascularization, subacute stent thrombosis (SAT), or bleeding at day 7/hospital discharge, whichever was earlier. The secondary endpoints were 30-day composite and individual incidences of death, MI, urgent revascularization, and SAT. RESULTS: The mean age of the group was 58 +/- 10 years and 83% were males. Bivaflo was administered for a mean duration of 102 +/- 79 minutes, and 65% patients received Bivaflo infusion post-PCI. ACT values measured at 10 minutes after bolus and at the end of the PCI were found to be 339 +/- 110 and 336 +/- 104 seconds, respectively. GPI was provisionally used in only 4% (16) patients mostly due to new or suspected thrombus and obstructive dissection with decreased flow. At day 7/hospital discharge, there were no incidences of major adverse cardiac events or major bleeding. Minor bleeding occurred in only 4 patients (0.9%). The 30-day composite major adverse cardiac event rate was 0.68%. One death and two subacute thrombosis occurred during the 30-day follow-up. CONCLUSION: Bivaflo is safe and effective sole anticoagulation strategy during PCI of moderate-high risk patients. Bivaflo administration was associated with no major bleeding events and extremely low in hospital and 30-day MACE rate. These rates were lower than expected MACE rates for such a subgroup of patients based on historical controls.

Use of PercuSurge in primary angioplasty.

Thrombus load and its subsequent distal embolization causing slow flow makes primary angioplasty a challenging task. Although data is scanty, these complications may be potentially mitigated by use of distal protection devices. We report 6 cases of PercuSurge distal protection device-assisted primary angioplasty. All lesions were stented with patients achieving brisk TIMI 3 flow; none of the patients had in-hospital major adverse cardiac events. The strategy of PercuSurge Guardwire-assisted primary angioplasty seems encouraging in improving successful outcome in this subset of patients.