Study of pattern & distribution of adverse drug reactions in acute coronary syndrome patients in a tertiary care hospital.

Background & objectives: With the availability of a wide range of drugs to treat patients with acute coronary syndrome (ACS), adverse drug reactions (ADRs) have become inevitable in clinical practice. Thorough knowledge of such reactions is essential for the treating physician for optimal treatment and better outcomes. There are many scales to define, measure and assess the ADRs, but there is a dearth of data available on such drug reactions among ACS patients. Hence, this study attempted to analyze the pattern, causality, severity, predictability and preventability of ADRs in ACS patients. All the ADRs reported during the study period were analyzed for causality by the World Health Organization-Uppsala Monitoring Centre (WHO-UMC), Naranjo's and Karch and Lasagna scales; severity by modified Hartwig and Siegel scale; predictability by Rawlins and Thompson criterion and preventability by Schumock and Thornton scale. Methods: A single-centre, record-based analysis for the occurrence of ADRs was done among ACS patients admitted to the department of Cardiology between January and October 2017. Demographic data, comorbid conditions, reported ADRs and ADR assessment details were noted from the hospital case records and ADR monitoring centre (AMC) records. The data were analyzed and presented in a descriptive manner using percentages, mean and standard deviation. The Pearson's chi-squared test was used to ascertain the significance of the association between different groups. Results: Out of 324 patients under evaluation, 67 had developed one or more ADRs. There were 30 different types of ADRs reported, headache being the most common. Among the drugs, heparin was the most common factor, causing 27 per cent of ADRs. Definite causality of a suspected drug causing ADRs was seen in 11.9 (n=8), nine (n=6) and 7.5 (n=5) per cent cases as per WHO-UMC, Naranjo (Naranjo algorithm) and Karch and Lasagna scales, respectively. In the severity of ADRs, the most severe reactions according to the modified Hartwig-Siegel scale (level 4a in our study) were seen in 17.5 (n=12) per cent of patients, and the rest were either level 2 or 3 reactions. Nearly 92.5 (n=62) per cent of reactions were predictable according to the Rawlins and Thompson criterion. Application of the modified Schumock-Thornton scale showed that 22.4 per cent of ACS patients had preventable reactions, and the rest were not preventable. Interpretation & conclusions: The study results suggest that ADRs are relatively common among ACS patients. Most of these can be identified and assessed for causality, severity, predictability and preventability using various available scales. Diligent pharmacovigilance for identifying and assessing ADRs may help manage and mitigate morbidity associated with these in high-risk ACS patients.

Achieving the Latest American Heart Association and American College of Cardiology Therapeutic Goals for Hypertension With Combination Therapy and Its Effects on Blood Pressure and Central Hemodynamic Parameters.

The present United States and European treatment guidelines recommend that antihypertensive therapy be initiated with a combination of agents from different classes to facilitate the achievement of control of blood pressure (BP). This prospective, randomized, open-label study was conducted at 3 tertiary hospitals in India to evaluate the effects of combination therapy with an angiotensin receptor blocker and a calcium antagonist on office BP and central hemodynamic parameters in patients with untreated hypertension or uncontrolled BP (>130/>80 mm Hg) during treatment with antihypertensive monotherapy. Patients were randomized to treatment with telmisartan 40 mg/day + amlodipine 5 mg/day or telmisartan 40 mg/day + cilnidipine 10 mg/day. Change from baseline to 8 weeks of treatment was assessed for seated office BP, ambulatory BP monitoring, and seated central hemodynamics (central BP, aortic augmentation index, central aortic augmentation pressure, and pulse wave velocity). A total of 94 of 96 enrolled patients completed the study. From baseline to 8 weeks a significant decrease was observed in both telmisartan + amlodipine and telmisartan + cilnidipine groups for mean BP (148.0 ± 12.80 to 124.0 ± 10.4 and 144.5 ± 10.2 to 123.0 ± 10.0 mm Hg, respectively; both p <0.001); in only telmisartan + amlodipine group for mean central aortic systolic and diastolic BP (131.1 ± 19.1 to 119.7 ± 14.9 mm Hg [p <0.001] and 93.3 ± 12.0 to 89.2 ± 14.6 mm Hg [p = 0.0008], respectively) and for central aortic pulse wave velocity (7.6 ± 1.4 to 7.2 ± 1.3 m/s, p = 0.0011); in only telmisartan + cilnidipine group for aortic augmentation index (27.5 ± 14.6 to 22.3 ± 12.2; p = 0.0178). Heart rate was unchanged in both treatment groups. Combination therapy with an angiotensin receptor blocker and a calcium antagonist effectively reduced BP to below the new <130/80 mm Hg target and had favorable effects on central hemodynamics.

Implementation and Evaluation of Virtual Anticoagulation Clinic Care to Provide Incessant Care During COVID-19 Times in an Indian Tertiary Care Teaching Hospital.

Background: COVID-19 caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-II) has become a global pandemic disrupting public health services. Telemedicine has emerged as an important tool to deliver care during these situations. Patients receiving Vitamin K antagonists (VKA) require structured monitoring which has posed a challenge during this pandemic. We aimed to evaluate the impact of Virtual anticoagulation clinic (VAC), a Telehealth model on the quality of anticoagulation, adverse events, and patient satisfaction vis-a-vis standard Anticoagulation clinic (ACC) care. Materials and methods: A bidirectional cohort study was conducted in the Department of Cardiology, JSS Hospital, Mysore. Two hundred and twenty-eight patients in the VAC and 274 patients in the ACC fulfilling inclusion criteria were the subjects of the study. Telehealth tools like WhatsApp and telephone were used. Time in therapeutic range (TTR), Percentage of International normalized ratio in range (PINRR), and adverse events were analyzed and compared between the VAC group and the ACC group, between pre-COVID and COVID ACC groups, and between the VAC group and the same pre-COVID cohort. Patient satisfaction was assessed by a questionnaire at the end of 8 months. Descriptive statistics were used for the patient characteristics and inferential statistics for the comparisons between pre-VAC and VAC care. Results: The mean TTR was 75.4 ± 8.9% and 71.2 ± 13.4% in the VAC group and ACC group, respectively (p < 0.001). The mean PINRR was 66.7 ± 9.4% and 62.4 ± 10.9% in the VAC group and ACC group respectively, (p < 0.001). There was no significant difference in TTR between the VAC group and the same pre-COVID cohort. The TTR differential between the pre-COVID and COVID ACC groups was significant. In either group, no major adverse events were seen. The most common tools used for data exchange were WhatsApp (83%) and SMS (17%). Seventy-four percent of patients were extremely satisfied with the overall VAC care. Conclusions: Virtual anticoagulation clinic, a telehealth model can be used as an alternative option to deliver uninterrupted anticoagulation care during pandemic times.

Risk Factors and Comorbidities in Young Indian Patients with Hypertension: REAL YOUNG (Hypertension) Study.

PURPOSE: To analyze the risk factors and comorbidities among the young Indian adults with hypertension. PATIENTS AND METHODS: This was a retrospective, multicentric real-world study which included patients diagnosed with and receiving treatment for hypertension. Data were collected from the medical records of clinics/hospitals across 623 study sites in India. Patients of either sex and aged 18-45 years were included. Demographic details (age, sex, anthropometric measurement), medical and family history, sedentary lifestyle, smoking status and alcohol consumption data were extracted. Descriptive and comparative analysis (Mann-Whitney U and chi-squared test) was done. RESULTS: Out of 15,006 young patients diagnosed with hypertension (men=63.6%), 65.7% belonged to the age group of >35-45 years. The median body mass index was 27.0 kg/m2. Patients diagnosed with only hypertension were 29.1% while other predominant comorbidities with hypertension were diabetes mellitus (42.4%) and dyslipidemia (7.8%). Hypertension with diabetes mellitus were prevalent in the age group of >35-45 years (43.8%). More than half of the patients with hypertension (n=7656) had a sedentary lifestyle. Overall, 35.6%, 47.3%, and 56.7% of the patients were alcoholic, smokers (present and former), and had a family history of hypertension, respectively. CONCLUSION: The results showed that among the young population, hypertension was common in the age group of >35-45 years and diabetes mellitus and dyslipidemia were common comorbidities. Family history, sedentary lifestyle, smoking, alcohol consumption, and body mass index may also contribute to hypertension.

Impact of Updated 2016 ASE/EACVI VIS-À-VIS 2009 ASE Recommendation on the Prevalence of Diastolic Dysfunction and LV Filling Pressures in Patients with Preserved Ejection Fraction.

BACKGROUND: Assessment of diastolic dysfunction (DD) and left ventricular filling pressures (LVFP) by echocardiography is complex in patients with preserved ejection fraction (EF). The American Society of Echocardiography and the European Association of Cardiovascular Imaging (ASE/EACVI) jointly published recommendations in 2016 to simplify the diagnosis and classification of DD and the assessment of LVFP. We aimed to study the impact of the updated 2016 ASE/EACVI guidelines vis-à-vis the 2009 ASE recommendations on prevalence of DD and LVFP in patients with preserved EF. METHODS: Five hundred patients referred to the echocardiography laboratory from March 2020 to May 2020 were analyzed. Patients with left ventricular ejection fraction (LVEF) < 50% were excluded. All patients underwent comprehensive transthoracic echocardiography. DD and LVFP were assessed by the 2016 ASE/EACVI and 2009 ASE recommendations. The concordance between the guidelines was analyzed by kappa coefficient and overall proportion of agreement. RESULTS: Mean age was 53 ± 13 years and 63.4% were men. Prevalence of DD and abnormal LVFP were significantly lower with the 2016 recommendations than with the 2009 recommendations (9.4% vs. 16.8%, p < 0.001 and 8.4% vs. 12.8%, p < 0.05). Patients with Grade 1 DD (100%) and Grade 2 DD (46.4%) were reclassified by the 2016 recommendations. Indeterminate diastolic function (9.8%) was strikingly high according to the 2016 recommendations. The concordance between the two recommendations was moderate (kappa = 0.569). The overall proportion of agreement was 85.4%. CONCLUSIONS: Prevalence of DD and abnormal LV filling pressures were lower with application of the 2016 ASE/EACVI recommendations in patients with preserved EF. There was moderate agreement between the 2009 and 2016 recommendations.

Study of correlation between epicardial fat thickness and severity of coronary artery disease.

Epicardial fat thickness (EFT) reflects visceral adiposity and is associated with coronary artery disease (CAD). This study aimed to assess the correlation of echocardiographic EFT with the severity of CAD and to determine the EFT cut-off to predict CAD. EFT was measured in 503 patients undergoing coronary angiogram. Mean EFT was significantly higher in the CAD group than control group (5.55 ± 1.21 mm vs 3.25 ± 1.15 mm, p < 0.0001). EFT correlated with Gensini score (r = 0.906, p < 0.001). EFT cut-off ≥ 4.75 mm had 87% sensitivity and 63% specificity for prediction of significant CAD (AUC: 0.831, p < 0.001).

Appropriate use of PCSK9 Inhibitors in India.

The burden of atherosclerotic cardiovascular (CV) disease is alarmingly high and increasing in our country. Dyslipidemia is one of the major modifiable risk factors, and INTERHEART study showed that dyslipidemia had the highest population attributable risk for myocardial infarction. In the management of dyslipidemia, low-density lipoprotein cholesterol (LDL-C) is the primary therapeutic target. In addition to therapeutic lifestyle changes, statins and ezetimibe effectively lower LDL-C and consequently improve CV outcomes. However, there are situations where these drugs fall short of achieving the target or they may not be well tolerated.

Incidence and predictors of perioperative myocardial infarction in patients undergoing non-cardiac surgery in a tertiary care hospital.

BACKGROUND: The stress in the perioperative period is compounded by unpredictable and un-physiological changes in sympathetic tone, cardiovascular performance, coagulation and inflammatory responses, all of which in turn lead to alterations in plaque morphology predisposing to perioperative myocardial infarction (PMI). PMI has a considerable morbidity and mortality in patients undergoing not only high risk surgery, but also even with minor surgical interventions. OBJECTIVE: To study the incidence of PMI and its predictors in patients undergoing non-cardiac surgery in a tertiary care hospital. MATERIALS AND METHODS: Patients undergoing non-cardiac surgery were included in this prospective single-center observational study. The revised cardiac risk index (RCRI) was used for risk stratification. ECG monitoring was done for all patients. For patients suggestive of acute myocardial ischemia, echocardiography and serum troponin were evaluated. The patient was labeled as having a PMI if there was raised troponin level along with any one evidence of myocardial ischemia (symptoms, ECG changes or imaging results) and in these patients the factors predisposing to PMI were evaluated. All patients in the study were followed up to 30 days. RESULTS: Of the 525 patients analyzed, 33 patients (6.28%) had a PMI. Twelve out of the 33 (36.36%) PMI patients died within 30 days following surgery. Patients undergoing high risk surgery, smokers and patients with a past history of ischemic heart disease (IHD) were found to be at higher risk of developing PMI. The ASA physical status classification and the RCRI proved to be good predictors of PMI. Most of the PMI events (72.7%) occurred within 48 hours of surgery. CONCLUSION: PMI is a dreaded complication associated with a very high mortality. High risk surgery, smoking and past history of ischemic heart disease were independent predictors of PMI. The RCRI is a useful tool in pre-operative risk stratification of patients.

Psychiatric comorbidities in acute coronary syndromes: Six-month follow-up study.

INTRODUCTION: Acute coronary syndrome (ACS) caused by coronary atherosclerosis include ST-segment elevation myocardial infarction (STEMI), non-STEMI, and unstable angina. The relation between psychiatric disorders and coronary artery disease is a complex one which includes the effect of the psychosocial factors on heart and vice versa. Point prevalence studies have been reported, but there is paucity of follow-up studies from India. MATERIALS AND METHODS: The study is a follow-up evaluation at discharge of 248 consecutive patients presented with ACS at JSS Hospital, Mysuru, Karnataka, over a period of 6 months to assess the psychiatric comorbidities. The patients were assessed on a structured and validated pro forma before discharge, at 3 months, and at 6 months. Screening of psychiatric disorders was done using Mini International Neuropsychiatric Interview PLUS 5.0.0 and assessment of depression was done using Hamilton Depression Rating Scale. ANOVA, Student's t-test, and SPSS 21 were used for statistical analysis. RESULTS: The most common psychiatric comorbidities include major depressive disorder (44%), it persisted at the end of 3 (P < 0.001) and 6 (P < 0.001) months. A spectrum of anxiety disorders including panic disorder (12.10%), dysthymia (3.60%), agoraphobia (2.40%), social phobia (2%), obsessive-compulsive disorder (1.6%), specific phobia (1.2%), and posttraumatic stress disorder (0.8%) in descending order at the end of 6 months were found. Significant reduction in substance use of nicotine (66.1%) and alcohol (56.0%) was reported on follow-up. CONCLUSION: Depression, anxiety, and substance use occur in patients with ACS which persist on follow-up. Early recognition at discharge and appropriate counseling on follow-up improve the clinical outcomes.

Evaluation for airway obstruction in adult patients with stable ischemic heart disease.

BACKGROUND: Ischemic heart disease (IHD) and chronic airway disease (COPD and Asthma) are major epidemics accounting for significant mortality and morbidity. The combination presents many diagnostic challenges. Clinical symptoms and signs frequently overlap. There is a need for airway evaluation in these patients to plan appropriate management. METHODS: Consecutive stable IHD patients attending the cardiology OPD in a tertiary care centre were interviewed for collecting basic demographic information, brief medical, occupational, personal history and risk factors for coronary artery disease and airway disease, modified medical research centre (MMRC) grade for dyspnea, quality of life-St. George respiratory questionnaire (SGRQ), spirometry and six-min walk tests. Patients with chronic airway obstruction were treated as per guidelines and were followed up at 3rd month with spirometry, six-minute walk test and SGRQ. RESULTS: One hundred fourteen consecutive patients with stable cardiac disease were included (Males-88, Females-26). Mean age was 58.89±12.24years, 53.50% were smokers, 31.56% were alcoholics, 40.35% diabetics, 47.36% hypertensive. Twenty five patients had airway obstruction on spirometry (COPD-13 and Asthma-12) and none were on treatment. Thirty-one patients had cough and 48 patients had dyspnea. Patients with abnormal spirometry had higher symptoms, lower exercise tolerance and quality of life. Treatment with appropriate respiratory medications resulted in increase in lung function, quality of life and exercise tolerance at 3rd month. CONCLUSION: Chronic respiratory disease in patients with stable IHD is frequent but often missed due to overlap of symptoms. Spirometry is a simple tool to recognize the underlying pulmonary condition and patients respond favorably with appropriate treatment.

A Study to derive distribution of carotid intima media thickness and to determine its COrrelation with cardiovascular Risk factors in asymptomatic nationwidE Indian population (SCORE-India).

BACKGROUND: There is presently no data to describe normal distribution of carotid intima-media thickness (CIMT), an established measure of subclinical atherosclerosis, in Indian subjects. METHODS: In this multi-centric study, 1229 subjects with age ≥30 years and no previous cardiovascular disease (CVD) underwent CVD risk factor assessment and CIMT measurement. Mean far wall common carotid artery IMT was measured on both sides and averaged. RESULTS: Mean age of the subjects was 48.0±12.0 years and 54.2% were men. CIMT measurement was feasible in 1157 subjects. Mean, median and 75th percentile values of CIMT for different age-groups were derived for men and women separately. There was a progressive increase in CIMT with increasing age (P<0.001) and men had higher CIMT values than women (0.608±0.12mm vs. 0.579±0.11mm, P<0.001). The CIMT values were also higher in diabetics (0.635±0.10mm) and hypertensives (0.624±0.10mm) as compared to non-diabetics (0.589±0.12mm, P<0.001) and non-hypertensives (0.592±0.12, P 0.02) respectively. Among continuous variables, age, systolic blood pressure and fasting blood glucose had strong to modest correlation with CIMT (Pearson's r 0.524, 0.282 and 0.192 respectively, all P values <0.001), whereas body mass index, diastolic blood pressure and serum triglycerides exhibited weak but still statistically significant relationship (Pearson's r 0.069, P 0.019; Pearson's r 0.065, P 0.026; and Pearson's r 0.094, P 0.001, respectively). CONCLUSIONS: This is the first study to provide age- and gender-specific distribution of CIMT in Indian subjects free from CVD. This information should help facilitate further research and clinical work involving CIMT in India.

Cardiac Biomarkers for Better Management of Acute Coronary Syndromes.

Acute myocardial infarction (AMI) causes significant mortality and morbidity. Timely diagnosis allows clinicians to risk stratify their patients and select appropriate treatment. Biomarkers have been used to diagnose or rule out AMI. An increasing number of novel biomarkers have been identified to predict the outcome following AMI or acute coronary syndrome (ACS). This may facilitate tailoring of appropriate therapy to high-risk patients. This review focuses on a variety of promising biomarkers which provide diagnostic and prognostic information.

QT prolongation and torsades de pointes with psychotropic agents.

The unexpected and catastrophic cardiovascular effects of psychotropic drugs are well described albeit uncommon. The list of drugs which have been associated with prolonging QT interval and hence potentially causing Torsades de pointes is exhaustive. The insight into the plausible mechanisms are largely unclear. However, the practical implications of anticipating and recognizing QT prolongation cannot be overemphasized.

The Indian Consensus Document on cardiac biomarker.

Despite recent advances, the diagnosis and management of heart failure evades the clinicians. The etiology of congestive heart failure (CHF) in the Indian scenario comprises of coronary artery disease, diabetes mellitus and hypertension. With better insights into the pathophysiology of CHF, biomarkers have evolved rapidly and received diagnostic and prognostic value. In CHF biomarkers prove as measures of the extent of pathophysiological derangement; examples include biomarkers of myocyte necrosis, myocardial remodeling, neurohormonal activation, etc. In CHF biomarkers act as indicators for the presence, degree of severity and prognosis of the disease, they may be employed in combination with the present conventional clinical assessments. These make the biomarkers feasible options against the present expensive measurements and may provide clinical benefits.

A serial echocardiographic study of myocardial abscess in a patient surviving staphylococcal septicemia.

2D echocardiography was performed on a 4-year-old child suffering from right thigh abscess due to MRSA infection following diagnosis of pericardial effusion by USG abdomen. It revealed myocardial abscess and pericardial effusion. This child underwent series of 2D echocardiographic studies which showed image appearance of myocardial abscess with its time course of healing.

Relationship between beat-to-beat variability of RT-peak and RT-end intervals in normal controls, patients with anxiety, and patients with cardiovascular disease.

BACKGROUND: Some studies suggest that it is important to take the end of "T" wave to quantify QT-interval variability, which signifies cardiac repolarization lability, as there is substantial and important information beyond the peak of the T wave on the surface electrocardiogram. METHODS: In this study, we examined the relationship between the variability of beat-to-beat RTe (beginning of R-peak to T-end) and the variability of RTp (R-peak to T-peak) in the following groups: normal controls (n = 26), patients with anxiety (n = 26), and patients with cardiovascular disease with or without diabetes (n = 63). We obtained ECG sampled at 1024 Hz in lead II configuration in supine posture to obtain beat-to-beat interbeat interval (R-R) and RT-interval variability for 256 seconds. RESULTS: We found significant positive correlations (r = 0.8; P < 0.00001) in normal controls and patients with anxiety between the variability of RTeVI and RTpVI (RTe and RTp variability indices, respectively, corrected for the mean of RTe and RTp and the mean and the variance of R-R). These correlations were also statistically significant in the medically ill group but the r values were much smaller (r = 0.45 in various groups). The slopes were also significantly different between the two groups (P < 0.001). Bland-Altman plots also showed better agreement between the two measures in the controls and patients with anxiety compared to the group with cardiovascular disease. CONCLUSIONS: These findings have methodological implications for studies comparing people with and without overt cardiovascular illness. While RTe or RTp variability index may be used interchangeably in normal controls and some patients with no overt cardiovascular problems, it may be more prudent to use both RTe and RTp variability indices in patients with cardiovascular illness. These indices, especially RTeVI, may provide different information about cardiac repolarization lability. Future studies should address the importance of the relative usefulness of these two measures especially in cardiac patients before and after successful treatment.

Increased beat-to-beat QRS amplitude variability in patients with congestive cardiac failure.

In patients with ischemic heart disease, dobutamine provoked-stress increases beat-to-beat QRS amplitude variability, which may be due to an electrical instability of the myocardium. Our results in this pilot study showed that patients with congestive heart failure had significantly higher beat-to-beat QRS amplitude variability compared to controls in resting supine posture. This may partly be due to myocardial disease or irregular respiration in this patient group.

Regional differences in the reference blood pressure in young Indians.

This study compares the blood pressure (BP) in young population of North India and South India. Age, height and sex specific BP was estimated for 6320 North Indian subjects aged 7-18 years and compared with BP values of South Indian subjects. North Indian boys and girls had lower diastolic BP (DBP) with no difference in systolic BP (SBP) than South Indian boys and girls between 7-12 years. Between 13-18 years North Indian boys and girls had significantly higher SBP with no difference in DBP. The significant regional differences in BP distribution among young Indians suggest considering geographic location of the population in evaluating blood pressure.

Increased pulse-wave velocity in patients with anxiety: implications for autonomic dysfunction.

Decreased vagal function is associated with vascular dysfunction. In this study, we compared vascular indices and correlated heart rate and QT variability measures with vascular indices in patients with anxiety disorders and normal controls. We compared age- and sex-matched controls (n=23) and patients with anxiety (n=25) using the Vascular Profiler (VP-1000; Colin Medical Instruments, Japan), approved by the US Food and Drug Administration. Using this machine, we obtained ankle and brachial blood pressure (BP) in both arms (brachial), both legs (ankle), and carotid artery, and lead I electrocardiogram (ECG) and phonocardiogram. Using these signals, pulse-wave velocity (PWV), and arterial stiffness index % and preejection period can be calculated. We also obtained ECG sampled at 1000 Hz in lead II configuration in supine posture to obtain beat-to-beat interbeat interval (R-R) and QT interval variability for 256 s. Patients with anxiety had significantly higher carotid mean arterial pressure (MAP) %, brachial-ankle PWV (BAPWV), arterial stiffness index %, MAP, and diastolic BP of the extremities compared to controls. We found significant negative correlations (r values from .4 to .65; P<.05 to .007) between R-R interval high-frequency (0.15-0.5 Hz) power (which is an indicator of cardiac vagal function), and increased BAPWV and systolic BP of the extremities only in patients. We were unable to find such correlations in controls. We also found significant positive correlations between QT variability index (a probable indicator of cardiac sympathetic function) and MAP of the extremities and BAPWV only in the patient group. These findings suggest an important association between decreased vagal and increased sympathetic function, and decreased arterial compliance and possible atherosclerotic changes and increased BP in patients with anxiety.

Blood pressure reference tables for children and adolescents of Karnataka.

BACKGROUND: The blood pressure levels may vary in population because of genetic, ethnic and socio economic factors. Local reference values have to be established to understand the blood pressure variable. METHODS: Blood pressure data of 2278 boys and 2930 girls in the age group of 3-18 years were analysed to study the distribution pattern of systolic blood pressure and diastolic blood pressure and to develop reference values to define hypertension. Blood pressure was measured using standardised techniques in all. The first and fifth phases of Korotkoff sounds were taken as indicative of systolic blood pressure and diastolic blood pressure respectively. Height percentiles were computed for each one year age group. According to percentiles of height 50th, 90th, 95th and 99th percentiles of systolic blood pressure and diastolic blood pressure were estimated for every one year age. RESULTS: The blood pressure (both systolic and diastolic) tends to increase with age. The stepwise regression analysis revealed that the age and height but not gender, are important determinants of blood pressure. Age and height specific, 50th, 90th and 95th and 99th percentiles of systolic and diastolic blood pressure were derived and are presented in tabular form. CONCLUSION: The blood pressure of children and adolescents can be evaluated using the reference table according to body size. The table provided helps to classify blood pressure as normal or pre hypertension and to define different stages of hypertension.