Cardiological Society of India: Document on acute MI care during COVID-19.

The unprecedented and rapidly spreading Coronavirus Disease-19 (COVID-19) pandemic has challenged public health care systems globally. Based on worldwide experience, India has initiated a nationwide lockdown to prevent the exponential surge of cases. During COVID-19, management of cardiovascular emergencies like acute Myocardial Infarction (MI) may be compromised. Cardiological Society of India (CSI) has ventured in this moment of crisis to evolve a consensus document for care of acute MI. However, this care should be individualized, based on local expertise and governmental advisories.

Prevalence of hypertension among Indian adults: Results from the great India blood pressure survey.

OBJECTIVE: Hypertension is the most important risk factor for cardiovascular morbidity and mortality. There is limited data on hypertension prevalence in India. This study was conducted to estimate the prevalence of hypertension among Indian adults. METHODS: A national level survey was conducted with fixed one-day blood pressure measurement camps across 24 states and union territories of India. Hypertension was defined as systolic blood pressure (BP) ≥140 mmHg or a diastolic BP ≥90 mmHg or on treatment for hypertension. The prevalence was age- and gender-standardized according to the 2011 census population of India. RESULTS: Blood pressure was recorded for 180,335 participants (33.2% women; mean age 40.6 ± 14.9 years). Among them, 8,898 (4.9%), 99,791 (55.3%), 35,694 (11.9%), 23,084 (12.8%), 9,989 (5.5%), and 2,878 (1.6%) participants were of the age group 18-19, 20-44, 45-54, 55-64, 65-74, and ≥ 75 years, respectively. Overall prevalence of hypertension was 30.7% (95% confidence interval [CI]: 30.5, 30.9) and the prevalence among women was 23.7% (95% CI: 23.3, 24). Prevalence adjusted for 2011 census population and the WHO reference population was 29.7% and 32.8%, respectively. CONCLUSION: There is a high prevalence of hypertension, with almost one in every three Indian adult affected.

Clinical and angiographic profiles and six months outcomes of smokers with acute ST segment elevation myocardial infarction undergoing primary percutaneous coronary angioplasty.

BACKGROUND: Outcomes of primary percutaneous coronary intervention (PCI) for acute STEMI (ST-segment elevation myocardial infarction) in smokers are expected to be better than non-smokers as for patients of acute STEMI with or without fibrinolytic therapy. OBJECTIVES: This comparative study was designed to evaluate the outcomes of primary PCI in patients with acute STEMI in smokers and non-smokers. Clinical and angiographic profile of the two groups was also compared. METHODS: Over duration of two year, a total of 150 consecutive patients of acute STEMI eligible for primary PCI were enrolled and constituted the two groups [Smokers (n=90), Non-smokers (n=60)] of the study population. There was no difference in procedure in two groups. RESULTS: In the present study of acute STEMI, current smokers were about a decade younger than non-smokers (p value=0.0002), majority were male (98.9% vs 56.6%) were male with a higher prevalence of hypertension and diabetes mellitus (61.67% vs 32.28% and 46.67% vs 14.44%, p=0.001) respectively. Smokers tended to have higher thrombus burden (p=0.06) but less multi vessel disease (p=0.028). Thirty day and six month mortality was non-significantly higher in smokers 4.66% vs 1.33% (p=0.261) and 5.33% vs 2.66% (p=NS) respectively. Rate of quitting smoking among smokers was 80.90% at 6 months. CONCLUSION: The study documents that smokers with acute STEMI have similar outcomes as compared to non smokers with higher thrombus burden and lesser non culprit artery involvement. Smokers present at much younger age emphasizing the role of smoking cessation for prevention of myocardial infarction.

Management protocols for chronic heart failure in India.

Heart failure is a common clinical syndrome and a global health priority. The burden of heart failure is increasing at an alarming rate worldwide as well as in India. Heart failure not only increases the risk of mortality, morbidity and worsens the patient's quality of life, but also puts a huge burden on the overall healthcare system. The management of heart failure has evolved over the years with the advent of new drugs and devices. This document has been developed with an objective to provide standard management guidance and simple heart failure algorithms to aid Indian clinicians in their daily practice. It would also inform the clinicians on the latest evidence in heart failure and provide guidance to recognize and diagnose chronic heart failure early and optimize management.

Inadequacy of fluoroscopy and electrocardiogram in predicting septal position in RVOT pacing - Validation with cardiac computed tomography.

BACKGROUND: Electrocardiographic (ECG) and fluoroscopic criteria, which are the only available guides to achieve a true septal position during right ventricular outflow tract (RVOT) pacing, have been infrequently validated. We sought to validate these using cardiac computed tomographic angiography (CTA) to confirm lead position within the RVOT septum. METHODS: Forty-four patients with permanent pacemaker leads in the RVOT position underwent CTA. Lead positions in RVOT were classified as anterior, free wall, or septal location. Fluoroscopic images were obtained in 4 standard views. RESULTS: Only 19 (43%) patients had lead in true septal position within the RVOT in CTA while 25 patients (57%) were found to have an anterior lead location. Mean QRS axis, QRS duration, negative QRS in lead I, and notching in inferior leads were not significantly different between the two groups. The standard fluoroscopic LAO view showed a rightward-directed lead not only in all 19 patients with septal location, but also in 14/25 patients in the anterior location (p=0.22), and thus had a sensitivity of 100% but specificity of only 16% in predicting true septal position. The posteriorly directed lead in left lateral view was more accurate in predicting true septal position with good sensitivity (73.7%) and excellent specificity (80%). CONCLUSIONS: This study, using validation with CTA, showed that conventional ECG criteria and fluoroscopy are inaccurate in differentiating septal from anterior RVOT pacing. The fluoroscopic lateral view, as corroborated by CTA, is more reliable than the LAO view in predicting septal lead placement.

Management standards for stable coronary artery disease in India.

Coronary artery disease (CAD) is one of the important causes of cardiovascular morbidity and mortality globally, giving rise to more than 7 million deaths annually. An increasing burden of CAD in India is a major cause of concern with angina being the leading manifestation. Stable coronary artery disease (SCAD) is characterised by episodes of transient central chest pain (angina pectoris), often triggered by exercise, emotion or other forms of stress, generally triggered by a reversible mismatch between myocardial oxygen demand and supply resulting in myocardial ischemia or hypoxia. A stabilised, frequently asymptomatic phase following an acute coronary syndrome (ACS) is also classified as SCAD. This definition of SCAD also encompasses vasospastic and microvascular angina under the common umbrella.

Aorto-ostial atherosclerotic coronary artery disease-Risk factor profiles, demographic & angiographic features.

BACKGROUND: The risk factors along with demographic and angiographic features associated with aorto-ostial atherosclerotic coronary artery disease usually differ from that of non-aorto-ostial atherosclerotic coronary artery disease. OBJECTIVES: This study was designed to evaluate etiology of aorto-ostial atherosclerotic coronary artery disease involving left main coronary artery (LMCA), right coronary artery or both with consideration of clinical risk factors, demographic and angiographic features. METHODS: A total of 7356 angiograms over 2 years in continuation were analyzed. RESULTS: 116 patients were found to have aorto-ostial coronary artery disease with prevalence of 1.5. A total of 95 patients who have complete data were analyzed. Mean age was 59 ± 10 years. Prevalence in males was 5.7 times greater than female. Isolated ostial LMCA was 2 times more prevalent than isolated ostial RCA. Hypertension, diabetes and smoking were the main risk factors. 34.7% of the patients had hypercholesterolemia (> 180 mg/dl) and 26.3% of the patients had hypertriglyceridemia (> 150 mg/dl). High TC/HDL (> 3.5) ratio was seen in 77.9% of the patients. When ostial LMCA group was compared with ostial RCA group hypertriglyceridemia (Odds ratio 9.8, 95% CI, 1.7-4.2, P < 0.001) and hypercholesterolemia (Odds ratio 7.05, 95% CI, 1.7-5.7, P < 0.001) emerged as independent risk factors for ostial LMCA disease. CONCLUSION: Overall there is 1.5% prevalence of atherosclerotic aorto-ostial disease of coronary arteries among patients of atherosclerotic coronary artery disease and higher proportions of patients are of male sex. Hypercholesterolemia, hypertriglyceridemia and high TC/HDL ratio can be considered as risk factors for aorto-ostial atherosclerotic coronary artery disease.

NT pro B type natriuretic peptide levels in constrictive pericarditis and restrictive cardiomyopathy.

BACKGROUND: The differentiation of constrictive pericarditis (CP) from restrictive cardiomyopathy (RCM) may be clinically difficult and may require multiple investigations. Even though brain natriuretic peptide (BNP) is shown to be higher in patients with RCM as compared to CP, the clinical utility is not fully established especially in Indian patients known to have advanced CP and myocardial involvement. METHODS AND RESULTS: We measured NT-pro-BNP levels in 49 patients suspected of having either CP or RCM, diagnosed on the basis of echocardiography, computed tomography, magnetic resonance imaging, endomyocardial biopsy and cardiac catheterization data as needed. Twenty nine patients (Mean age - 26 yrs, 24 males) had CP and 20 patients (Mean age - 39 yrs, 14 males) had RCM. The median plasma NT-pro-BNP levels were significantly higher in RCM as compared to CP [1775 (208-7500) pg/ml vs 124 (68-718) pg/ml, respectively; p = 0.001]. A cut off value of 459 pg/ml had sensitivity, specificity and overall accuracy of 90%, 86% and 88% respectively, for differentiating CP from RCM. CONCLUSIONS: The NT-pro-BNP levels are significantly elevated in RCM as compared to CP.

Clinical validation of a low-cost telemedicine equipment remote medical diagnostics kit at a tertiary care hospital.

BACKGROUND: The Remote Medical Diagnostics kit is an indigenous and low-cost technology that can measure and transmit via the internet 6 clinical parameters viz. Blood pressure (BP), pulse, temperature, oxygen saturation, 12-lead Electrocardiogram (ECG) and heart/breath sounds. Prior to commercial use, it needs clinical validation. METHODS: Fifty three patients (including 1 acute myocardial infarction) were evaluated for the above parameters using accepted standard methods and the Remote Medical Diagnostics kit. RESULTS: The intraclass correlation coefficient (ICC) for systolic BP (SBP), diastolic BP (DBP), saturation pulse, manual pulse and temperature was 0.927, 0.904, 0.989, 0.99 and 0.912 indicating a high degree of agreement between the two methods. For oxygen saturation, the ICC was 0.763 indicating a moderately high agreement. For heart sounds, the kappa coefficient (kappa) for inter-rater reliability was 0.48 (observed agreement of 96.1%). For breath sounds, the 'kappa' value was 0.48 indicating moderate agreement. For the breath sounds, the 'kappa' value was 0.38, indicating fair agreement (the observed agreement of 94.2%). For the ECG, the observed agreement was 94.4% by visual assessment. CONCLUSION: At the bedside, the Remote Medical Diagnostics kit was clinically validated for the above 6 parameters.