Self-blood pressure measurement as compared to office blood pressure measurement in a large Indian population; the India Heart Study

GeogRaphic and socioecoNomic Distribution of real-world Indian data of home blood pressure monitoring (GRAND Study): Study protocol for an observational study in 18 medical centers across India

One-fourth of death in India is attributed to cardiovascular disease (CVD) and more than 80% is related to ischemic heart disease and stroke. The main risk factor for CVD is hypertension. Every third person in India suffers from hypertension and the prevalence increased drastically in the past 20 years, especially among the youngest age group of 20 and 44 years. Regardless of being under anti-hypertension medication, the blood pressure (BP) control rate in the country is still low ranging between 6% and 28% only. Assessing the "true BP control rate" should be performed using both clinic BP measurement and out-of-office BP measurement as the latter shows better prognosis for patients' hypertension and CVD outcomes. Home blood pressure monitoring (HBPM) shows superiority over ambulatory BP measurement as multiple measurements can be collected at the patient's convenience. Only limited evidence on HBPM in India is available and it's either lacking in hypertension participants or of a small sample size. This study will investigate the real BP control status among 2000 hypertensive patients from 18 centers in 12 states across Pan-India. The outcome of this study will emphasize the value of establishing BP control management practice guidelines suitable for physicians and help policymakers in building proper strategies for hypertension management to reduce the CVD burden on the health situation in India.

A comparative analysis of ambulatory blood pressure characteristics in acute stroke and non-stroke Indian patients

OBJECTIVE

The objective of this study is to identify 24-h blood pressure (BP) characteristics after acute stroke in Indian hospitalized patients.

METHODS

In total, 769 patients [284 women (36.9%)] admitted at a hospital in South India were analyzed. Of these, 364 patients (47.3%) had recently experienced stroke. All patients underwent ambulatory blood pressure measurement (ABPM) so that ABPM patterns and ABPM risk parameters of stroke and non-stroke patients could be compared. Additionally, to investigate the relationship between ABPM parameters and stroke, a stepwise logistic regression analysis was employed.

RESULTS

Stroke patients had significantly higher BP than non-stroke patients (24-h ABP: 145.0 ± 22.1 vs. 133.7 ± 20.5 mmHg, P < 0.001), with similar dipping status. ABPM parameters mostly associated with stroke (all P < 0.001) were: nighttime [odds ratios (OR): 1.587, 95% confidence interval (95% CI): 1.341-1.885], 24-h (1.584, 1.34-1.881), minimum nighttime (1.582, 1.339-1.879), daytime (1.540, 1.304-1.827), and morning SBP (1.517, 1.287-1.797). Non-dipping status was relatively more common in stroke patients (79% vs. 71%, P < 0.05) but dipping percentage did not show a significant linear relationship with stroke.

CONCLUSION

Several ABPM characteristics were strongly associated with stroke in Indian hospitalized patients. Specifically, minimum nighttime and average morning SBP may be considered as important and practical parameters for its relationship with stroke.

Expert Consensus on Ivabradine-based Therapy for Heart Rate Management in Chronic Coronary Syndrome and Heart Failure with Reduced Ejection Fraction in India

Heart rate is an important indicator of health and disease and the modulation of heart rate can help to improve cardiovascular outcomes. Besides β-blockers, Ivabradine is a wellestablished heart rate modulating drug that reduces heart rate without any hemodynamic effects. This consensus document was developed with the help of expert opinions from cardiologists across India on effective heart rate management in routine clinical practice and choosing an appropriate Ivabradine-based therapy considering the available scientific data and guideline recommendations. Based on the discussion during the meetings, increased heart rate was recognized as a significant predictor of adverse cardiovascular outcomes among patients with chronic coronary syndromes and heart failure with reduced ejection fraction making heart rate modulation important in these subsets. Ivabradine is indicated in the management of chronic coronary syndromes and heart failure with reduced ejection fraction for patients in whom heart rate targets cannot be achieved despite guideline-directed β-blocker dosing or having contraindication/intolerance to β-blockers. A prolonged release once-daily dosage of Ivabradine can be considered in patients already stabilized on Ivabradine twice-daily. Ivabradine/β-blocker fixed-dose combination can also be considered to reduce pill burden. Two consensus algorithms have been developed for further guidance on the appropriate usage of Ivabradine-based therapies. Ivabradine and β-blockers can provide more pronounced clinical improvement in most chronic coronary syndromes and heart failure with reduced ejection fraction patients with a fixed-dose combination providing an opportunity to improve adherence.

Concept, hardware development, and clinical trials of a Galinstan based Mercury free sphygmomanometer: Merkfree

The aim of this work is to develop Merkfree-a mercury-free sphygmomanometer that looks, feels, and operates just like a traditional mercury sphygmomanometer (MS). For this we use Galinstan as a substitute for mercury, which is a non-toxic alloy of Gallium, Indium and Tin. Galinstan is nearly half as dense as mercury and sticks to class. To work with the lower density, we designed an enclosure and scale that is nearly double the length of MS. The issue of stickiness with glass was resolved by maintaining a small meniscus of a reducing agent in the measuring tube and tank of Merkfree. Clinical trials to validate the accuracy of Merkfree against MS and oscillometric sphygmomanometer (OS) were conducted over 252 patients. The results show a good correlation of the systolic and diastolic BP measurements from Merkfree with respect to MS and the OS. The mean absolute percentage error is less than 10% for both SBP and DBP. We also found that Merkfree has lower rounding-off errors compared to MS. Merkfree can be a viable alternative to mercury sphygmomanometer that can help achieve the goal of WHO in eliminating mercury from healthcare, while simultaneously making sure that gold standard technique of sphygmomanometry continues to be available to the clinicians.

Beta-Adrenergic Blockade: Is It the Prudent Choice against Sympathetic Overdrive in Patients with Hypertension or Heart Failure?

The development of hypertension and heart failure is correlated with the hyperactivation of the sympathetic nervous system. Beta-blockers are often considered a good therapeutic option in such clinical scenarios. However, the choice of β-blocker is a concern because of certain aspects like associated metabolic disturbances with their usage. Metoprolol has been reported to have the potential to alleviate sympathetic overdrive in patients with hypertension and heart failure. S-Metoprolol is the chirally pure β-blocker with favorable pharmacological features, improved safety profile, and allied clinical advantages versus racemic metoprolol; given this, can it be an effective therapeutic option against sympathetic overdrive in patients with hypertension and/or heart failure is not fully recognized yet. In this review, we attempted to discuss the current facts around sympathetic overdrive linked with hypertension as well as heart failure and pertaining pharmacological intervention with a focus on β-blockers in these clinical situations with an emphasis on the likely beneficial role of S-metoprolol.

Auscl-D: a mercury-free digital auscultatory sphygmomanometer

More than quarter of world's population is consumed by hypertension, leading to premature death of thousands of people per year across the globe. One of the major reasons behind hypertension misdiagnosis is inaccurate blood pressure (BP) measurements, which can be attributed to various human or instrumentation errors. Currently used BP measuring sphygmomanometers, suffers from poor reliability, performance deterioration over time or are unable to meet environmental protection protocols. In this article, we propose a low-cost, highly portable, light-weight, easily manufacturable, battery operated, mercury free, auscultation based digital sphygmomanometer - Auscl-D, for easy and accurate BP measurements. The proposed device can be made from easily available components with cheap manufacturing processes available throughout globe, even in remote areas. The device demonstrated to have accuracy comparable to mercury sphygmomanometer, which is the gold-standard for BP measurements. The preliminary clinical trials were conducted at Dayanand Medical College & Hospital (DMCH) (Ludhiana, India), to compare the performance of proposed device with commonly used aneroid sphygmomanometers employing the auscultatory method and validated oscillometric sphygmomanometers from MicroLife. The test results show good agreement for systolic and diastolic BP measurements taken using Auscl-D device compared to the aneroid and oscillometric types. This shows the potential of proposed design to serve as low-cost, highly portable replacement for conventionally used sphygmomanometers, without the toxicity and reliability issues.

A survey to gauge confidence of Indian clinicians on three primary devices for blood pressure measurement

PURPOSE

As per its commitment at Minamata convention, and in line with other developed economies, the Indian government is set to ban the use of mercury sphygmomanometers by end of the year 2020. However, the Mercury sphygmomanometer is still widely used by clinicians in India. We conducted a survey to gauge the confidence of Indian clinicians on three primary devices of blood pressure (BP) measurement - mercury sphygmomanometer, aneroid sphygmomanometer and automatic digital BP monitor.

MATERIALS AND METHODS

We conducted an anonymous online survey through various clinician forums asking questions related to accuracy, reliability and expectations from BP monitors.

RESULTS

A total of 139 responses were received from clinicians across specialties. The results show that more than 80% of clinicians believe that mercury sphygmomanometers are the most accurate and nearly 50% find it most reliable. For most respondents, accuracy is the most important parameter and convenience of use and portability are secondary considerations. If a mercury-free sphygmomanometer is offered with the same accuracy and reliability, 88% of respondents said they are willing to buy it.

CONCLUSIONS

Mercury sphygmomanometer is still perceived favorably over other non-mercury alternatives by most Indian clinicians. Validated oscillometric devices should be promoted to bring about change in the perspectives of clinicians towards adopting non-mercury alternatives of BP measurement in India.