Performance of the Achutha Menon Centre Diabetes Risk Score in Identifying Prevalent Diabetes in Tamil Nadu, India.

BACKGROUND: The Achutha Menon Centre Diabetes Risk Score (AMCDRS), which was developed in rural Kerala State, South India, had not previously been externally validated. We examined the performance of the AMCDRS in urban and rural areas in the district of Vellore in the South Indian state of Tamil Nadu, and compared it with other diabetes risk scores developed from India. METHODS: We used the data from 4,896 participants (30 to 64 years) of a cross-sectional study conducted in Vellore (2010 to 2012), to calculate the AMCDRS scores using age, family history, and waist circumference. Sensitivity, specificity, positive predictive value (PPV), and negative predictive values (NPV), and the area under the receiver operating characteristic curve (AROC) were calculated for undiagnosed and total diabetes. RESULTS: Of the 4,896 individuals surveyed, 274 (5.6%) had undiagnosed diabetes and 759 (15.5%) had total diabetes. The AMCDRS, with an optimum cut-point of ≥4, identified 45.0% for further testing with 59.5% sensitivity, 60.5% specificity, 9.1% PPV, 95.8% NPV, and an AROC of 0.639 (95% confidence interval [CI], 0.608 to 0.670) for undiagnosed diabetes. The corresponding figures for total diabetes were 75.1%, 60.5%, 25.9%, 93.0%, and 0.731 (95% CI, 0.713 to 0.750), respectively. The AROC for the AMCDRS was not significantly different from that of the Indian Diabetes Risk Score, the Ramachandran or the Chaturvedi risk scores for total diabetes, but was significantly lower than the AROC of the Chaturvedi score for undiagnosed diabetes. CONCLUSION: The AMCDRS is a simple diabetes risk score that can be used to screen for undiagnosed and total diabetes in low-resource primary care settings in India. However, it probably requires recalibration to improve its performance for undiagnosed diabetes.

Prevalence of statin use among high-risk patients in urban and rural Vellore, Tamil Nadu: A population-based cross-sectional study.

OBJECTIVES: This study assessed statin use among diabetics and those with coronary heart disease (CHD) in Vellore, Tamil Nadu. METHODS: A cross-sectional survey was conducted in rural and urban Vellore, among 6196 participants (30-64 years), in 2010-2012. Statin use among those with known CHD and diabetes (on diabetic medication) was recorded. A randomly selected sample of rural diabetics was resurveyed in 2016 to reassess statin use. RESULTS: Among 61 with CHD, 23 (37.7%) were on statins. Statin use among 422 diabetics aged ≥40 years with low-density lipoprotein ≥70 mg/dl was 13.4% in urban and 7.6% among rural. Statin usage among rural diabetics aged ≥40 years increased from 7.7% in 2010-2012 to 16.6% in 2016. CONCLUSIONS: Statin use for CHD was below 50% although higher than the use among diabetics, indicating the need to address this low rate of usage among these high-risk groups.

Prevalence of coronary heart disease in rural and urban Vellore: A repeat cross-sectional survey.

BACKGROUND: With the increase of cardiovascular risk factors in India, the prevalence of coronary heart disease (CHD) is also expected to rise. A cross-sectional study in 2010-2012 assessed the prevalence and risk factors for CHD in urban and rural Vellore, Tamil Nadu. The secondary objectives were to compare the current prevalence with the prevalence of CHD in the same areas in 1991-1994. METHODS: A cross-sectional survey was carried out among adults aged 30-64 years to determine the prevalence of CHD (previously diagnosed disease, symptoms detected using Rose angina questionnaire, or ischemic changes on electrocardiography). The study used the WHO STEPS method in addition to the Rose angina questionnaire and resting electrocardiography and was conducted in nine clusters of a rural block in Vellore district and 48 wards of Vellore town. The results were compared with a similar study in the same area in 1991-1994. RESULTS: The prevalence of CHD was 3.4% (95% CI: 1.6-5.2%) among rural men, 7.4% (95% CI: 4.7-10.1%) among rural women, 7.3% (95% CI: 5.7-8.9%) among urban men, and 13.4% (95% CI: 11.2-15.6%) among urban women in 2010-2012. The age-adjusted prevalence in rural women tripled and in urban women doubled, with only a slight increase among males, between 1991-1994 and 2010-2012. CONCLUSIONS: The large increase in prevalence of CHD, among both pre- and post-menopausal females, suggests the need for further confirmatory studies and interventions for prevention in both rural and urban areas.

Rising trend of cardiovascular risk factors between 1991-1994 and 2010-2012: A repeat cross sectional survey in urban and rural Vellore.

BACKGROUND: Repeat cross sectional surveys document the trend of prevalence rates for non-communicable diseases and their risk factors. In this study, we compare the prevalence rates for risk factors for cardiovascular disease in urban and rural Vellore between 1991-1994 and 2010-2012. METHODS: Cross sectional survey was carried out in 1991-1994 in a rural block in Vellore district and in Vellore town, to study the prevalence of cardiovascular risk factors among adults aged 30-60 years. A repeat survey was done in 2010-2012 using the WHO STEPS method. In both surveys, socio-demographic and behavioral history, physical measurements, biochemical measurements, and medical history were obtained. Age adjusted rates were used to compare the rates in the two surveys. RESULTS: In the rural areas, there was a three times increase in diabetes and body mass index (BMI) ≥25kg/m(2) (overweight/obese) with a doubling of the prevalence of hypertension. In urban areas there was a tripling of diabetes, doubling of proportion with BMI≥25kg/m(2) and 50% increase in prevalence of hypertension. While the proportion of male current smokers reduced by 50% in both rural and urban Vellore, lifetime abstainers to alcohol decreased in the rural area from 46.8% to 37.5% (p<0.001). CONCLUSIONS: There has been an alarming rise in diabetes, hypertension, and overweight/obese with an even greater increase in rural areas. Alcohol use is increasing while smoking is on the decline. Primary prevention programs are required urgently to stem the rising incidence of non-communicable diseases in India.

Prevalence of risk factors for non-communicable diseases in rural & urban Tamil Nadu.

BACKGROUND & OBJECTIVES: Surveillance of risk factors is important to plan suitable control measures for non-communicable diseases (NCDs). The objective of this study was to assess the behavioural, physical and biochemical risk factors for NCDs in Vellore Corporation and Kaniyambadi, a rural block in Vellore district, Tamil Nadu, India. METHODS: This cross-sectional study was carried out among 6196 adults aged 30-64 yr, with 3799 participants from rural and 2397 from urban areas. The World Health Organization-STEPS method was used to record behavioural risk factors, anthropometry, blood pressure, fasting blood glucose and lipid profile. Multiple logistic regression was used to assess associations between risk factors. RESULTS: The proportion of tobacco users (current smoking or daily use of smokeless tobacco) was 23 per cent in the rural sample and 18 per cent in the urban, with rates of smoking being similar. Ever consumption of alcohol was 62 per cent among rural men and 42 per cent among urban men. Low physical activity was seen among 63 per cent of the urban and 43 per cent of the rural sample. Consumption of fruits and vegetables was equally poor in both. In the urban sample, 54 per cent were overweight, 29 per cent had hypertension and 24 per cent diabetes as compared to 31, 17 and 11 per cent, respectively, in the rural sample. Physical inactivity was associated with hypertension, body mass index (BMI) ≥25 kg/m[2], central obesity and dyslipidaemia after adjusting for other factors. Increasing age, male sex, BMI ≥25 kg/m[2] and central obesity were independently associated with both hypertension and diabetes. INTERPRETATION & CONCLUSIONS: Diabetes, hypertension, dyslipidaemia, physical inactivity and overweight were higher in the urban area as compared to the rural area which had higher rates of smokeless tobacco use and alcohol consumption. Smoking and inadequate consumption of fruits and vegetables were equally prevalent in both the urban and rural samples. There is an urgent need to address behavioural risk factors such as smoking, alcohol consumption, physical inactivity and inadequate intake of fruits and vegetables through primary prevention.

L wave in echo Doppler.

62-year-old female presented with progressive dyspnea NYHA class III for six months. Echocardiography showed normal left ventricular (LV) systolic function, mild biatrial enlargement, an L wave in pulse wave Doppler at mitral inflow and in M mode echocardiography across mitral valve. Tissue Doppler imaging at medial mitral annulus showed an L' wave in mid diastole in addition to E' and A' wave. An L wave in pulse wave Doppler and M mode echocardiography represents continued pulmonary vein mid diastolic flow through the left atrium in to LV across mitral valve after early rapid filling. Presence of an L' wave in these patients associated with higher E/E' is indicative of advance diastolic dysfunction with elevated filling pressures.

Assessment of right ventricular strain and strain rate in patients with severe mitral stenosis before and after balloon mitral valvuloplasty.

OBJECTIVE: Right ventricular (RV) dysfunction in isolated severe mitral stenosis (MS) patients have prognostic significance. Study aim was to assess RV function in these subjects by strain and strain rate analysis, pre and post-balloon mitral valvuloplasty (BMV). METHODS: Twenty five patients with isolated severe MS in sinus rhythm were assessed for RV function by two dimensional (2D) longitudinal strain & strain rate imaging before and after BMV and compared with that from twelve healthy age matched controls. RESULTS: Patients with severe MS had significantly lower global RV systolic strain; segmental strain at basal, mid, apical septum and basal RV free wall; but similar strain at mid and apical RV free wall as compared to controls. The systolic strain rate was significantly lower only at mid septum. In addition, they had higher estimated pulmonary artery systolic pressure and RV myocardial performance index; lower tricuspid annular plane systolic excursion (TAPSE), peak systolic velocity at lateral tricuspid annulus, isovolumic acceleration and fractional area change (FAC). Global RV systolic strain as well as, segmental strain at basal, mid and apical septum showed a statistically significant rise after BMV. TAPSE and FAC also increased significantly post BMV. CONCLUSIONS: RV systolic function is impaired in patients with severe MS and can be assessed by global and segmental RV strain before the appearance of clinical signs of systemic venous congestion. Impaired global and segmental RV strain values in these patients are primarily due to increased after load and improve after BMV with reduction in RV afterload.

Mitral leaflet separation index-a simple novel index to assess the severity of mitral stenosis.

BACKGROUND: Mitral leaflet separation (MLS) index is a recently recognized method to assess the severity of mitral stenosis. The aim of this study is to assess the severity of mitral stenosis (MS) using the MLS index. METHODS AND RESULTS: One hundred and fifty consecutive patients with MS who underwent 2D echo were studied. In each patient the severity of MS was assessed using 2D mitral valve area, pressure half time and MLS index. The mitral leaflet separation was measured in diastole, as the maximal separation at the tips in long axis and apical 4 chamber views. There were 34 (22.7%) patients with mild MS, 52 (34.7%) patients with moderate MS and 64 (42.7%) patients with severe MS. One hundred and ten (73.3%) patients were in sinus rhythm and 40 (26.7%) patients were in atrial fibrillation. The MLS index correlated very well with MVA by planimetry (r = 0.87, P < 0.0001) and pressure half time (r = 0.86, P < 0.0001). Good correlation was found even in atrial fibrillation (r = 0.87 and r = 0.87, respectively). ROC curve demonstrates that MLS index of 0.80cm or less identified severe MS with 92% sensitivity and 92% specificity. MLS index of >1.11 cm identified mild MS with 97% sensitivity and 97% specificity. CONCLUSION: The MLS index can be used as a screening method to semi quantify patients with mitral stenosis. This should be added into yet another method to assess the severity. This index will complement the other methods in our practice.

Serum leptin levels in acute myocardial infarction.

BACKGROUND: Several studies have shown an association of serum leptin levels with cardiovascular diseases. The present study was undertaken to assess levels of serum leptin in patients presenting with acute ST segment elevation myocardial infarction. METHODS AND RESULTS: Ninety-four consecutive patients presenting with acute ST segment elevation myocardial infarction were studied and 46 controls were taken from patients who presented with chest pain but had no history of myocardial infarction in the past. There were 59 patients with anterior wall infarction and 31 had inferior wall infarction and in 4 it was a combination of anterior and inferior wall infarction. The serum leptin levels in patients with myocardial infarction was 6.51 +/- 6.76 ng/ml versus 2.86 +/- 2.22 ng/ml in controls. In the multivariate analysis the odds ratio for serum leptin with myocardial infarction was 1.45 with a 95% confidence interval of 1.2 to 1.8. CONCLUSIONS: Our results suggest that serum leptin level is elevated in patients with acute ST segment elevation myocardial infarction.

Mortality and morbidity of acute ST segment elevation myocardial infarction in the current era.

BACKGROUND: The mortality rate of acute myocardial infarction has come down considerably in the past three decades. In view of paucity of literature on this issue, present study was done to find out the in-hospital mortality and 30-day event rate in patients with acute ST segment elevation myocardial infarction presenting to a tertiary care hospital in India. METHODS AND RESULTS: Consecutive patients (n=1320) with the diagnosis of acute ST segment elevation myocardial infarction admitted in our institution were included in this study. The in-hospital mortality and 30-day event rates (mortality, reinfarction, recurrent angina and heart failure) were analyzed. The mean age of study population was 56+/-13 years. There were 1106 (83.8%) males and 214 (16.2%) females; 569 (43.1%) patients were smokers, 504 (38.2%) patients had hypertension, 531 (40.2%) patients were diabetic and 154 (11.7%) patients had past history of myocardial infarction. Anterior wall infarction was present in 752 (57%) patients, 517 (39.1%) patients had inferior wall infarction, 324 (62.7%) patients had associated right ventricular or posterior wall infarction and 51 (3.9%) patients had antero-inferior infarction; 1093 patients (82.8%) received thrombolytic therapy while 227 patients were not thrombolyzed due to various reasons. Of the total 1320 patients, 223 (16.9%) patients died during in-hospital stay while 1097 patients were discharged from the hospital in stable condition after a mean stay of 5.3+/-3.4 days. Thirty-day event rates of death, reinfarction and recurrent angina following hospital discharge was 18.8% (134/715 patients) and 36 (5%) patients presented with heart failure. CONCLUSIONS: The in-hospital mortality rate of acute ST segment elevation myocardial infarction in a tertiary care hospital is 16.9%, which is higher compared to reports from the West.

Torsade de pointes in a case of pheochromocytoma--an unusual presentation of an uncommon disease.

We report the case of a middle aged lady with dilated cardiomyopathy, presenting with recurrent syncope due to torsade de pointes. Further evaluation revealed that she had a pheochromocytoma which caused the arrhythmia.

Prevalence of coronary artery disease in patients with rheumatic heart disease in the current era.

BACKGROUND: This study was undertaken to determine the prevalence of coronary artery disease in patients with rheumatic heart disease undergoing valve surgery. METHODS AND RESULTS: Consecutive patients with rheumatic heart disease (n=376) who were above the age of 40 years, and scheduled for valve surgery underwent diagnostic coronary angiogram to delineate coronary arteries. The patients were divided into three groups based on valve involvement (mitral valve, aortic valve, and combined aortic and mitral valve). Significant coronary artery disease was considered to be present if one or more coronaries showed 50% or more luminal stenosis. There were 287 (76.3%) males and 89 (23.7%) females. The mean age of the study population was 51.2+/-8.2 years. Eighty-nine (23.8%) patients had typical chest pain, 116 (30.6%) patients had atypical chest pain and 171 (45.5%) patients had no chest pain. Hypertension was noted in 88 (23.4%) patients, 65 (17.3%) patients had diabetes, 98 (26.1%) patients were smoker, and 66 (17.6%) patients had dyslipidemia, and 15 (4.0%) patients gave past history of myocardial infarction. Of the total 376 patients, 46 (12.2%) patients were found to have significant coronary artery disease. In patients with mitral vale disease the prevalence was 13.5% (13/96), while it was 15.3% (19/124) in patients with aortic valve disease and 9% (14/156) in those with combined mitral and aortic valve disease. CONCLUSIONS: Our results suggest that the overall prevalence of coronary artery disease in a group of patients with rheumatic heart disease undergoing valve surgery in the current era is 12.2%. This prevalence is much lower than the figures reported earlier in the Western literature.

Timing of surgery in regurgitant lesions.

For both aortic and mitral regurgitation if the patient has irreversible LV dysfunction, then they are at increased risk of postoperative LV dysfunction and death from heart failure. To justify the risk of surgery, the ideal timing for surgery is to do the same at the onset of LV dysfunction. There are several clinical and non-invasive indicators of the same.

Declining prevalence of rheumatic heart disease in rural schoolchildren in India: 2001-2002.

BACKGROUND: Rheumatic heart disease is still a major health problem in developing countries such as India and, for the health planners to allocate funds, the actual prevalence of the disease should be known. This study aimed to assess the prevalence of rheumatic heart disease in rural school children in India. METHODS AND RESULTS: A total of 229,829 children between 6 and 18 years of age were screened as part of a school health program. All children with a valvar heart disease detected by the screening doctor were referred to a tertiary care center for evaluation by a cardiologist. The presence of cardiac lesions was confirmed by color Doppler examination. All children with known congenital heart disease were excluded from this study. A total of 374 children were found to have heart disease. Of these, 157 children were found to have rheumatic heart disease, confirmed by echocardiogram. Thus, the current prevalence of rheumatic heart disease is 0.68 per 1000 children. CONCLUSIONS: In the largest school survey conducted to date in India, we report the prevalence of rheumatic heart disease to be 0.68 per 1000 children. Our study suggests that there may have been a dramatic decline in the prevalence of rheumatic heart disease in India.