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.

Comparison of cardiac vagal activity between pre and postmenopausal women using heart rate recovery.

Ageing is associated with an increase in Heart Rate Recovery (HRR). HRR is a property of vagal activity. But there is little evidence regarding the extent to which age-related changes in HRR depend on simultaneous transition from pre-menopausal state to postmenopausal state. The purpose of this study was (i) to compare HRR between pre and postmenopausal women, (ii) to compare heart rate recovery between men of age group 40-45 years and 45-50years respectively (iii) and to determine whether difference in age, gender and body composition could account for the difference in HRR between pre- and post-menopausal groups. Methods: HRR was assessed using modified Bruce exercise protocol. The body mass index was assessed by measuring weight and height of the subject. Data was analyzed after adjusting for age and body composition. Results: It was found that the HRR were significantly higher (P <0.001) in postmenopausal women compared to that of premenopausal women. Analysis after adjusting for age and gender revealed that men of same age group didn’t undergo much change in HRR as compared to women. Conclusions: The study concludes that both ageing and declined oestrogen levels are associated with the increased Hear Rate Recovery (HRR) seen among postmenopausal women.

Efficacy of echocardiographic criteria for diagnosis of carditis in acute rheumatic fever.

Background: There is a great need forECHOcriteria for accurate diagnosis of carditis in acute rheumatic fever. Aim: To propose and test the efficacy of ECHO criteria for accurate diagnosis of carditis. Material and Methods: The 333 cases underwent detailed clinical examination, laboratory tests and meticulous Echocardiographic study.Vijay’s ECHO criteria for the diagnosis of carditis / subclinical valvulitis was used. 220 (66.06%) cases were both Jones’ positive and ECHO positive [True +ve], 52 cases (15.61%), probably had subclinical carditis as murmur was not heard (Jones’-ve) but ECHO was positive [False - ve]. Four cases, clinically diagnosed as carditis were Jones’+ve ,but ECHO showed congenital heart disease [False +ve]. 57 cases (17.11%) were clinically , echocardiographically and Jones’ negative were taken as control (True –ve). Sensitivity is81%and specificity is 93%. Conclusions: Precise diagnosis of both carditis /subclinical valvulitis is possible with Vijay’s ECHO criteria. ECHO should be included as a major criterion in Jones’criteria.

Evaluation of Neurophysiological Parameters: Autonomic Status and Acute Pain Perception in Migraneurs.

Introduction: Painful conditions are associated with autonomic dysfunction and altered pain perception. However, data regarding autonomic status in migraineurs is not conclusive and there are few studies regarding acute pain perception in these cases. Aims: This study was conducted to assess various neurophysiological parameters namely autonomic functions using the autonomic function tests and acute pain perception using the cold pressor test in migraneurs. Material and methods: 60 migraineurs and 30 age and gender matched control subjects were included in this study after screening for the exclusion criteria and following a written consent. Diagnosis of migraine was made according to the International Classification of Headache Disorders(ICHD) – 2 Criteria. In the pain free state of the subjects, autonomic function tests including basal heart rate variability, E:I ratio, 30:15 ratio, postural challenge test and sustained handgrip test were carried out together with the cold pressor test. Unpaired t-test was used for analysing the data. Result: Migraineurs showed a trend towards increased parasympathetic tone, as compared to the control subjects, though the p-values were not significant. The pain threshold was lower while the pain tolerance was significantly lower in migraineurs as compared to controls (p= 0.00).Conclusion: In our study we observed an increased vagal tone together with lower values of pain threshold and pain tolerance in migraineurs, indicating that certain neurophysiological parameters are affected in painful conditions like migraine.

Present scenario of device closure for congenital heart diseases.

There has been tremendous advances in the treatment of congenital heart diseases following the development of transcatheter closure devices in the last decade. Device-closures of patent ductus arteriosus, atrial septal defect and ventricular septal defects, as in use today, have been highlighted in this article along with a brief discussion in the subject.