S Ramakrishnan

Heart failure in India: The INDUS (INDia Ukieri Study) study

Introduction: There are few data on heart failure (HF) burden and none available on the community prevalence of HF in India. We conducted a study aimed at determining the HF prevalence in a rural community as well as tertiary hospital care setting in North India. We also reviewed the existing literature regarding the estimated and projected prevalence of HF in India. Methodology: All adults (>20 years) with chronic breathlessness in six villages under a primary health care center in Northern India were identified and evaluated with standardized questionnaire and physical examination by trained health care workers. HF was diagnosed by standardized criteria and a transthoracic echocardiogram was performed in all subjects. In the hospital study, 500 consecutive patients presenting to our tertiary referral hospital were evaluated for the diagnosis of HF. For the systematic review, all published studies addressing HF or the burden of risk factors in India were identified. Projections for the absolute HF burden were made using local data and global studies of HF incidence, morbidity, and mortality. Results: Among the surveyed rural adult population of 10,163 patients, chronic breathlessness was present in 128 (1.3%). HF was present in 9% (n = 12), of which 67% (n = 8) had preserved left ventricular (LV) systolic function and 33% (n = 4) had LV systolic dysfunction. Therefore, the prevalence of HF in this general community was 1.2/1000. All patients with HF and preserved ejection fraction had poorly controlled hypertension. In the hospital study, of 500 consecutive patients, 20.4% had HF. Rheumatic heart disease (52%) was the most common cause followed by ischemic heart disease (17%). The mean age of presentation was 39 ± 16 years. The prevalence of HF in the outpatient department patients was 22.5% below 30 years and 14.9% above 50 years, reflecting the young population of HF. For the estimates concerning HF burden in India, projections were made using both age-specific extrapolations from developing countries and data regarding development of HF in the presence of risk factors. The estimated prevalence of HF is about 1% of the total population or about 8–10 million individuals. The estimated mortality attributable to HF is about 0.1–0.16 million individuals per year. Conclusions: While our hospital data are consistent with the HF burden and etiology expected in a government tertiary hospital setting, our community-based study is the first of its kind reported from India. The community study demonstrates a surprisingly low prevalence of symptomatic HF in the surveyed villages. This could be partially explained by the rural farming-based community setting but is also likely due to under-reporting of symptoms. Our review of the projected national estimates suggests an alarming burden of HF in India despite a younger population than the developed nations. A significant proportion of this burden may be preventable with better screening and early and adequate treatment of the risk factors.

Trans-septal closure of a right pulmonary artery to left atrial communication.

Right pulmonary artery–left atrial communication is a rare anomaly and is characterized by significant cyanosis and normal auscultation of the heart. Interventional closure of the fistula using occluder devices and coils have been rarely reported. We report an easy method of closure of the communication through trans‐septal approach using an Amplatzer duct occluder.

Management algorithms for acute ST elevation myocardial infarction in less industrialized world

AIIMS, New Delhi, India Department of Physiotherapy, School of Allied Health Sciences, Manipal University, Manipal 576104, Karnataka, India Department of Cardiology, AIIMS, New Delhi, India d PES-IMSR Superspeciality Hospital, Kuppam, District Chittoor, Andhra Pradesh, India e Interventional Cardiology & HOD Cardiology, The Mission Hospital, Durgapur, India f Sengupta Hospital and Research Institute, Nagpur, Maharashtra, India Clinical Research, Fortis Health Care, Fortis Escorts Heart Institute, Okhla Road, New Delhi 110025, India Apollo Speciality Hospitals, Vanagram, Chennai, India Medical College Vadodara, Vadodara, India Department of Cardiology, MGM New Bombay Hospital, New Mumbai 400702, India k Christian Medical College Hospital Vellore, Vellore 632004, India Dept of Medicine, Kishori Ram Hospital & Diabetes Care Centre, Kishori Ram Road, Basant Vihar, Bhatinda, India Moolchand Medicity, New Delhi, India Cardiology Department, LTMGH Sion, Mumbai, India CARE Hospitals, Hyderabad, India Dept of Cardiology, BHU, Varanasi, India

Epidemiology of acute decompensated heart failure in India : The AFAR study (Acute failure registry study)

Objectives: There is a paucity of data on acute decompensated heart failure (ADHF) in Indian patients. We herein report the in-hospital and 6-month outcome of Indian patients admitted with ADHF. Methods: We prospectively enrolled consecutive patients with ADHF due to systolic dysfunction in the acute failure registry and followed them up for at least 6 months. We analyzed the data on death and hospitalization of the first 90 patients on death and hospitalization over 6-months. Results: A total of 90 patients were enrolled with a mean age of 53.5 ± 17. 7 years and the majority were male (63%). The mean left ventricular ejection fraction was 29.2± 11.9%. The in hospital mortality was 30.8%. Postdischarge 6-month major adverse event (re-hospitalization/mortality combined) and mortality rates were 39.5% and 26.3%, respectively. Conclusions: These data from a single referral center provide insights into the current status of acute HF care in India. We report a higher in-hospital and follow-up mortality rates in ADHF patients who present at younger ages than reported in Western literature.

Consensus statement on management of chronic heart failure in India

Summary of the Consensus Statement: This statement has been prepared keeping Indian heart failure patients in mind. Optimal management of CHF improves quality of life, reduces hospitalization rates and prolongs survival for people with this condition. Echocardiography is the single most useful test in the evaluation of heart failure, and is necessary to confirm the diagnosis. Plasma B-natriuretic peptide (BNP) measurements may be useful in excluding CHF but not mandatory in India. Educate people with CHF about lifestyle changes (e.g., increase physical activity levels, reduce salt intake and manage weight). Educate people with CHF about CHF symptoms and how to manage fluid load. Avoid prescribing drugs that exacerbate CHF. Prescribe angiotensin-converting enzyme inhibitors (ACEI) at effective doses for people with all grades of systolic heart failure, and titrate to the highest recommended dose tolerated. Angiotensin II receptor antagonists (ARA) may be used as alternatives in people who cannot tolerate ACEIs. Mineralocorticoid receptor antagonists (MRAs) should also be used. For people with stabilised systolic heart failure, prescribe beta-blockers that have been shown to improve outcome in heart failure (e.g., bisoprolol, carvedilol, extended release metoprolol or nebivolol). Titrate to the highest recommended dose tolerated. Prescribe diuretics, digoxin and nitrates for people already using ACEIs and beta-blockers to manage symptoms as indicated. For people who have systolic heart failure (New York Heart Association (NYHA) Class II-IV) despite appropriate doses of ACEIs and diuretics, consider prescribing spironolactone. Eplerenone can be considered in certain setting especially post myocardial infarction though it is more expensive. Consider direct sinus node inhibition with ivabradine for people with CHF who have impaired systolic function, have had a recent heart failure hospitalisation and are in sinus rhythm with a heart rate >70 bpm despite beta blockers or where beta blockers are contraindicated Check for, and treat, iron deficiency in people with CHF to improve their symptoms, exercise tolerance and quality of life Consider assessing people with CHF for biventricular pacemakers and implantable defibrillators. Patients with end stage heart failure have an option for heart transplant and ventricular assist devices which is now available in select centers.

Rescue alcohol septal ablation in sepsis with multiorgan failure.

A 55 year old male patient with a diagnosis of hypertrophic cardiomyopathy was admitted with features of sepsis related to cholangitis. Initial management with intravenous (i.v.) fluids and antibiotics did not cause any change in his general condition mandating an emergency endoscopic retrograde cholangio-pancreatography (ERCP). After successful retrieval of CBD stone on ERCP, patient had massive upper gastrointestinal bleed leading to hypotension and shock. Addition of inotropes had led to further deterioration in his clinical status with a mean arterial BP falling to 44 mm of Hg. His echocardiography showed a resting left ventricular outflow tract (LVOT) gradient of 90 mm of Hg and thus was taken up for emergency alcohol septal ablation (ASA). Immediately after ASA, patient had significant decrease in LVOT obstruction and rise of systemic arterial pressures. After 10 days of antibiotic therapy patient was discharged with a residual LVOT obstruction of 28 mm of Hg.

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.

Algorithms for cardiovascular disease prevention

Prevention of coronary artery disease requires control of risk factors. It is not enough to take out guidelines, it is necessary to implement the guidelines. There are a number of studies which have shown that quite often guidelines are not followed.In this article, we have abstracted the essence of the guidelines into simple to follow algorithms so that they are easy to remember and also teach. For Cardiovascular risk reduction, general measures include stopping smoking, perform 150 minutes of moderate activity per week and take a low fat and low salt diet. For hypertension: All classes of drugs are suitable but generally (NICE 2011) Angiotensin receptor blockers or Angiotensin converting enzyme inhibitors for young (<55 years), Beta blockers ( only if other compelling indications). In elderly (>55 years, many with isolated systolic hypertension) Calcium channel blockers, diuretics if needed , are prefered. Combinations are used if monotherapy does not work. For dyslipidemia: Statin benefit groups are defined and manifest coronary artery disease and Diabetics above 40 years should get high dose statins. Lipid levels are only tested to look for compliance or further intensification of regime. Diabetes: Metformin is the drug of choice, Sulfonylureas can be used in combination. Glyptins are also safe and can be used. Other drugs should be used with the help of the endocrinologist.

A Case of pulmonary artery hypertension

A patient presented with dyspnea, chest pain, and hemoptysis. Clinical findings revealed evidence of severe pulmonary hypertension and cyanosis with clubbing and a wide split second sound. Investigations including cardiac catheterization and oxygen study were performed, and the patient was referred for surgical repair. This article discusses various aspects of history, clinical examination, and cardiac catheterization that were utilized to decide the management.

Case of cyanotic congenital heart disease

A adult patient presented with cyanosis since early childhood. The clinical approach to such a patient, including review of the ecg, chest xray and echocardiogram is presented. Various aspects of the bedside approach to adult cyanotic heart disease are discussed