Statin Usage in Peripheral Arterial Disease Patients.

OBJECTIVES: Atherosclerotic cardiovascular disease (ASCVD) events have been shown to occur at higher frequency in patients with peripheral arterial disease (PAD). In this study, our aim is to evaluate whether statin is being used appropriately in patients with PAD and also evaluate its usage with the number of vascular beds involved. MATERIALS AND METHODS: This retrospective cross-sectional study reviewed data of patients with a confirmed diagnosis of PAD based on invasive or noninvasive imaging. Demographic, clinical, laboratory, and treatment data collected were described using descriptive statistics. Multiple logistic regression analysis was conducted to determine the predictors for the prescription of statins (HIS). High-intensity statin therapy was defined as atorvastatin ≥40 mg per day, rosuvastatin ≥20 mg per day, or simvastatin ≥80 mg per day, according to American College of Cardiology (ACC)/American Heart Association (AHA) guidelines. RESULTS: We analyzed data from 166 patients who met the inclusion criteria. The mean age was 63.34 years. The most common comorbidity was diabetes mellitus (DM) (68.86%). Statins were used in 82% of patients, among whom only 39% were on high-intensity statins. Multiple logistic regression analysis revealed that patients with cerebrovascular disease (CVD) [odds ratio (OR) = 0.19, 95% confidence interval (CI) = 0.06-0.61, p = 0.005], on oral anticoagulants (OAC) (OR = 0.16, 95% CI = 0.04-0.62, p = 0.008) and on dual antiplatelet therapy (DAPT) (OR = 0.20, 95% CI = 0.08-0.47, p < 0.000) had lower odds of receiving lower extremity revascularization (LIS) therapy. CONCLUSION: Despite having a high risk of future adverse cardiac events, patients with PAD are less likely to receive appropriate statin therapy. Involvement of more vascular beds was associated with higher chances of initiating high-intensity statin.

Right heart catheterization in idiopathic pulmonary hypertension: An all-inclusive necessity.

The gold standard for diagnosis of pulmonary hypertension is right heart catheterization. This procedure requires considerable expertise and has its own procedure related complications. If not done properly, it can lead to misinterpretations of its findings. We have highlighted the procedural technique and major pitfalls in the diagnosis of pulmonary hypertension.

The Indian REgistry on Current Patient PrOfiles and TReatment TrenDs in Hypertension (RECORD): Final Outcomes of the Real-world Observational Study.

Objectives: The Indian Registry on Current Patient Profiles and Treatment Trends in Hypertension (Record) evaluated the current trends and outcomes related to hypertension (HTN) management at 3, 6, 12, and 24 months in India. This study highlights and evaluates the outcomes and trends noted at 24 months. Materials and methods: The detailed study methodology is provided in the earlier publication (interim analysis at 12 months). Aspects such as changes in the quality of life (QOL), percentage of patients reaching target blood pressure (BP), treatment pattern among patients with comorbid conditions, and difference in treatment patterns between public and private healthcare settings, at 24 months, were evaluated in the current study. Results: The study population included 2,000 patients (55.7% males) with a mean age of 54.45 years. Telmisartan (43.7%) and amlodipine + telmisartan (16.4%) were the most prescribed monotherapy and combination therapy among patients with newly diagnosed HTN. A significant decrease in both systolic BP (SBP) and diastolic BP (DBP) was noted in the overall patient population at 24 months (p < 0.001). The mean change in SBP and DBP was slightly higher at 24 months compared to 12 months. This was more evident among patients on combination therapy. A significant improvement in QOL was noted at 24 months. Conclusion: Treatment strategies in HTN management are changing and are associated with effective HTN control and improvements in QOL. However, there is a further need for improved awareness regarding the optimal usage of combination therapy for better management of uncontrolled HTN. How to cite this article: Rajadhyaksha GC, Reddy H, Singh AK, et al. The Indian REgistry on Current Patient PrOfiles and TReatment TrenDs in Hypertension (RECORD): Final Outcomes of the Real-World Observational Study. J Assoc Physicians India 2023;71(11):43-49.

Effect of left ventricular geometric remodeling on restrictive filling pattern and survival in ischemic cardiomyopathy.

BACKGROUND: To evaluate the effects of Left ventricular remodeling patterns in patients with left ventricular restrictive filling pattern (RFP; E/A>2) in ischemic cardiomyopathy (ICM) on prognosis. METHODS: Patient data was retrospectively analyzed over a period of 4.5 years to determine the effect of LV geometry by Echocardiographic parameterson survival and re-admission for heart failure. All patients with previous history of transmural myocardial infarction were studied and all were on guideline directed medical therapy. None underwent device therapy or surgery. The stored 2D Echocardiograms were studied. Left ventricular dimensions were noted, including the relative wall thickness (RWT). The patients were grouped based on RWT<0.34 and ≥ 0.34 and were compared for clinical outcomes of mortality and re-admissions for heart failure, over a period of 54 months. RESULTS: There were 102 ICM patients who had baseline RFP. We identified two sub-groups based on geometric phenotypes of left ventricular eccentric remodeling and dilated remodeling based on the relative wall thickness (RWT >0.34 or <0.34). The patients with preserved RWT had significantly more dilated ventricles (LVIDd and LVIDs), greater pulmonary artery systolic pressures (PASP), greater diatolic dysfunction (E/A) and less left ventricular ejection fraction (LVEF); p < 0.001. The number of deaths was higher in the reduced RWT patients, as were the number of re-admissions, although the time to survival and time to re-admission was not significant. CONCLUSIONS: In this pilot study on ICM patients in advanced heart failure with baseline RFP, the presence of preserved RWT indicative of eccentric remodelling demonstrated a better clinical outcome.

Left ventricular function and survival in ischemic cardiomyopathy: Implications for surgical ventricular restoration.

Objectives: This pilot study evaluates the association of relative wall thickness (RWT) on survival in patients with ischemic cardiomyopathy (ICM). We hypothesized that patients with preserved RWT may be better candidates for surgical ventricular restoration than those with thinner RWT. Methods: Echocardiography was performed in 165 consecutive patients (aged 58.2 ± 14.7 years) divided into 2 groups based on RWT values. Group 1 had patients with preserved RWT and group 2 had patients with reduced RWT. Results: There were 120 (72.7%) patients with hypertension and 112 (67.8%) patients had diabetes mellitus. The patients with preserved RWT (group 1) had significantly more hypertension and diabetes. The patients with decreased RWT (group 2) were in a higher New York Heart Association functional class and had significantly greater incidence of anterior wall myocardial infarction. The entire cohort was followed over 24 months (group 1: n = 117 and group 2: n = 48). The overall all-cause mortality in group 1 (preserved RWT) was 7 (5.9%) and in group 2 (reduced RWT) was 35 (72.9%) (P < .0001). When readmission for congestive heart failure was analyzed, group 2 patients with lower RWT (P < .0001) had an increased rate of readmissions for heart failure. Conclusions: In patients with ischemic cardiomyopathy, a lower RWT indicative of dilated LV remodeling was associated with increased mortality and readmission for heart failure. The RWT may be a simple benchmark of viable or contractile myocardium in ICM. It can be hypothesized that patients with preserved RWT may benefit from surgical ventricular restoration.

Non-transplant Options in Advanced Heart Failure: Emergent Need for Guidelines ?

Advances in revascularization techniques along with its timeliness has significantly prolonged survival in Coronary Artery Disease. Progressive heart failure is one of the complications which persists in a large scale. The challenges of surgical revascularization in such patients with left ventricular dysfunction are daunting, necessitating short cross-clamp and cardio-pulmonary bypass times. Associated co-morbidities like renal dysfunction, low cardiac output state and pulmonary vascular obstructive disease are additional significant deterrents to surgical success. In the situation where transplant options are limited, viability of high-risk surgical revascularization may need radical re-thinking.

Image-Based Simulative Training for Myectomy in Hypertrophic Cardiomyopathy: An Emerging Necessity.

Surgical myectomy was initially advocated only for patients with symptoms refractory to maximal tolerated medical therapy. These were mainly symptoms of cardiac failure. In recent times, there has been a call for revision of guidelines to include patients earlier. As the disease progression cannot be reversed by most currently used drugs which become ineffective with time, this need for earlier myectomy seems mandatory. Presently, surgical expertise in myectomy is limited to specialized centers. The complexity of surgical myectomy is enhanced by the complex and variable anatomic substrate. With the need for earlier myectomy, a vast population of patients with hypertrophic cardiomyopathy will need surgery, predicating a requirement for more skilled cardiac surgeons. Mentoring programs in specialized centers may not be the solution, as is training surgeons using image-guided simulation techniques. Here, we discuss the existing simulative techniques and novel image-based preoperative planning techniques which may help guide myectomy.

Use of coronary hardware in peripheral vascular interventions: Necessity fostered ingenuity-Is it solution enough?

In third world countries like India, where there is a paucity of dedicated interventional radiologists and training fellowships in peripheral interventions, it is the onus of the cardiologist to perform peripheral interventions. This coupled with logistic constraints of unavailability of medical insurance for majority of the population, makes it necessary to modify coronary hardware for use in peripheral interventions. Here, we discuss the modifications and simplifications performed to ensure optimal quality of clinical outcomes.

Redo quadruple-valve repair after Ross procedure: a viable option?

Quadruple-valve repair or replacement is associated with significant morbidity and mortality because the clinical situation of severe disease of all 4 valves implies incipient myocardial damage. We report a case of redo quadruple-valve repair in a patient with rheumatic heart disease who had undergone the Ross procedure 14 years earlier. He presented with heart failure. Cardiac evaluation revealed severe disease of all 4 valves, necessitating surgery. Because he was in advanced heart failure and all 4 valves were suitable for repair, a quadruple-valve repair was performed.

Tailoring therapy for ischemic cardiomyopathy: is Laplace's law enough?

The burden of heart failure has long plagued the productive years of the population, with therapeutic advances in the timely treatment of ischemic heart disease decreasing its associated mortality. Angiotensin-converting enzyme inhibitors and ß-blockers have impacted heart failure therapeutics in a revolutionary way. The importance of blockade of the renin-angiotensin system and adrenergic stimulation are fully accepted concepts that apply in young and old, symptomatic and asymptomatic, borderline low and very low Ejection Fraction (EF), left ventricular failure and biventricular failure. Despite several interventions, both pharmaceutical and device based for the treatment of ensuing heart failure, the incidence is increasing in large proportions. Newer molecules like sacubitril show more promise. Despite these novel therapies, several patients relentlessly progress to a stage of advanced heart failure. The use of left-ventricular-assist devices has variable clinical benefit, with some patients progressing to heart transplantation.

Improvements in left ventricular twist mechanics following myectomy for hypertrophic cardiomyopathy with mid-ventricular obstruction.

We aimed to evaluate left ventricle twist mechanics in mid-ventricular obstructive and apical type of hypertrophic cardiomyopathy and changes induced by myectomy. We studied 3 consecutive patients by cardiac magnetic resonance preoperatively and 6 weeks after myectomy. We calculated the apical and basal rotations at the base and apex respectively. All 3 patients underwent myectomy by the standard described technique. The basal rotations remained the same, while there was an improvement in the maximal apical rotation from 0.385 ± 0.3975° to 0.9086 ± 1.1751°. In hypertrophic cardiomyopathy with mid-ventricular obstruction and apical hypertrophy, there is decreased apical rotation, which improves after myectomy.

Stent Migration during Endovascular Treatment of Traumatic Arteriovenous Fistula following Lumbar Spine Surgery.

We report the endovascular treatment of an arteriovenous fistula involving the right common iliac artery (CIA) and left common iliac vein in a 48-year-old male patient who had previously undergone lumbar spine disc surgery. A balloon expandable covered stent was deployed in the CIA which got partially dislodged into the aorta during attempted postdilatation of the stent. The proximal end of the stent was secured in place with an inflated balloon in the aorta, introduced from the contralateral iliac artery, allowing successful retrieval and dilatation of the stent graft through the ipsilateral femoral vascular access. The stent migration was managed without complications, and the fistula was successfully occluded.

Improvements in Regional Left Ventricular Function Following Late Percutaneous Coronary Intervention for Anterior Myocardial Infarction.

BACKGROUND: Late revascularization following a myocardial infarction has questionable clinical benefit. METHODS: We studied 13 patients with anterior wall myocardial infarction who underwent percutaneous coronary intervention within 2 weeks of the primary event, by quantitative analysis of 2-dimensional echocardiographic images. Endocardial segmentations of the left ventricular (LV) endocardium from the 4-chamber views were studied over time to establish cumulative wall displacements (CWDs) throughout the cardiac cycle. RESULTS: Left ventricular end-systolic volume decreased to 42 ± 8 mL/body surface area (P = .034) and LV ejection fraction improved to 52% ± 7% (P = .04). Analysis of LV endocardial CWD demonstrated significant improvements in mid-systolic to late-systolic phases in the apical LV segments, from 3.5 ± 0.32 to 5.89 ± 0.43 mm (P = .019). Improvements in CWD were also observed in the late-diastolic phase of the cardiac cycle, from 1.50 ± 0.42 to 1.76 ± 0.52 mm (P = .04). CONCLUSIONS: In our pilot patient cohort, following late establishment of infarct-related artery patency following an anterior wall myocardial infarction, regional improvements were noted in the LV apical segments during systole and late diastole.