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Satheesh G, Dhurjati R, Balagopalan JP, Mohanan PP, Salam A. Comparison of Indian clinical practice guidelines for the management of hypertension with the World Health Organization, International Society of Hypertension, American, and European guidelines. Indian Heart J 2024; 76:6-9. [PMID: 38171390 PMCID: PMC10943557 DOI: 10.1016/j.ihj.2023.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 12/28/2023] [Indexed: 01/05/2024] Open
Abstract
Hypertension is the leading risk factor for preventable cardiovascular diseases and all-cause mortality globally, with majority of the hypertension-attributed deaths occurring in low- and middle-income countries like India. Several international and national clinical practice guidelines (CPGs) provide evidence-informed recommendations to achieve optimal control. CPGs produced by the World Health Organization, International Society for Hypertension, American (AHA/ACC-2017), and European (ESC/ESH-2018) are "major" as they are widely used and are highly cited. We compared the main recommendations for the pharmacological management of hypertension among the major CPGs and the two existing Indian CPGs for similarities and shortcomings. Several deviations from the major CPGs were observed among Indian CPGs. Important shortcomings pertain to Indian CPGs' low priority for initial combination therapy and the use of single pill combinations. Having multiple CPGs providing conflicting recommendations might discourage the adoption of evidence-based practices. There is a need for updating Indian CPGs based on up-to-date evidence.
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Affiliation(s)
- Gautam Satheesh
- The George Institute for Global Health, Hyderabad, Telangana, India
| | - Rupasvi Dhurjati
- The George Institute for Global Health, Hyderabad, Telangana, India
| | | | - Padinhare P Mohanan
- Department of Cardiology, West Fort Hi-Tech Hospital, Thrissur, Kerala, India
| | - Abdul Salam
- The George Institute for Global Health, Hyderabad, Telangana, India; The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia; Prasanna School of Public Health, Manipal Academy of Higher Education, India.
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Chopra VK, Mohanan PP, Kher V, Mantri RR, Isaacs R, Jadhav U, Zalte N, Sugumaran A, Mohanasundaram S. The Potential Role of Torsemide in Optimizing Loop Diuretic Therapy for Heart Failure Patients. Cureus 2023; 15:e41957. [PMID: 37588313 PMCID: PMC10426810 DOI: 10.7759/cureus.41957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2023] [Indexed: 08/18/2023] Open
Abstract
Heart failure is associated with an increased frequency of hospitalization, reduced life span, and greater risk to public health, thus posing a challenge. In India, torsemide is one of the commonly used loop diuretics for decongestion in heart failure. However, this use of torsemide, including its dosing, and up/down titration, is based on practical experience. Loop diuretic therapy for heart failure patients poses several dilemmas due to the lack of robust evidence based on which treatment decisions can be made. To guide physicians on the optimal use of torsemide in heart failure patients with or without renal impairment, a panel of expert cardiologists and nephrologists from India convened to develop this expert opinion document for the use of torsemide. This expert opinion on torsemide will pave the way for optimal management with loop diuretic therapy in real-world heart failure patients.
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Affiliation(s)
- V K Chopra
- Clinical Cardiology Heart Failure and Research, Max Super Speciality Hospital, New Delhi, IND
| | - P P Mohanan
- Cardiology, Westfort Hi-Tech Hospital, Thrissur, IND
| | - Vijay Kher
- Nephrology, Medanta Kidney and Urology Institute, Gurugram, IND
| | | | - Rajan Isaacs
- Nephrology, Deep Kidney Care Centre, Ludhiana, IND
| | - Uday Jadhav
- Cardiology, Mahatma Gandhi Mission (MGM) New Bombay Hospital, Navi Mumbai, IND
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3
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Arora A, Kumar A, Anand AC, Kumar A, Yadav A, Bhagwat A, Mullasari AS, Satwik A, Saraya A, Mehta A, Roy D, Reddy DN, Makharia G, Murthy JMK, Roy J, Sawhney JPS, Prasad K, Goenka M, Philip M, Umaiorubahan M, Sinha N, Mohanan PP, Sylaja PN, Ramakrishna P, Kerkar P, Rai P, Kochhar R, Yadav R, Nijhawan S, Sinha SK, Hastak SM, Viswanathan S, Ghoshal UC, Madathipat U, Thakore V, Dhir V, Saraswat VA, Nabi Z. Position statement from the Indian Society of Gastroenterology, Cardiological Society of India, Indian Academy of Neurology and Vascular Society of India on gastrointestinal bleeding and endoscopic procedures in patients on antiplatelet and/or anticoagulant therapy. Indian J Gastroenterol 2023; 42:332-346. [PMID: 37273146 PMCID: PMC10240467 DOI: 10.1007/s12664-022-01324-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 12/12/2022] [Indexed: 06/06/2023]
Abstract
Antiplatelet and/or anticoagulant agents (collectively known as antithrombotic agents) are used to reduce the risk of thromboembolic events in patients with conditions such as atrial fibrillation, acute coronary syndrome, recurrent stroke prevention, deep vein thrombosis, hypercoagulable states and endoprostheses. Antithrombotic-associated gastrointestinal (GI) bleeding is an increasing burden due to the growing population of advanced age with multiple comorbidities and the expanding indications for the use of antiplatelet agents and anticoagulants. GI bleeding in antithrombotic users is associated with an increase in short-term and long-term mortality. In addition, in recent decades, there has been an exponential increase in the use of diagnostic and therapeutic GI endoscopic procedures. Since endoscopic procedures hold an inherent risk of bleeding that depends on the type of endoscopy and patients' comorbidities, in patients already on antithrombotic therapies, the risk of procedure-related bleeding is further increased. Interrupting or modifying doses of these agents prior to any invasive procedures put these patients at increased risk of thromboembolic events. Although many international GI societies have published guidelines for the management of antithrombotic agents during an event of GI bleeding and during urgent and elective endoscopic procedures, no Indian guidelines exist that cater to Indian gastroenterologists and their patients. In this regard, the Indian Society of Gastroenterology (ISG), in association with the Cardiological Society of India (CSI), Indian Academy of Neurology (IAN) and Vascular Society of India (VSI), have developed a "Guidance Document" for the management of antithrombotic agents during an event of GI bleeding and during urgent and elective endoscopic procedures.
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Affiliation(s)
- Anil Arora
- Institute of Liver, Gastroenterology, and Pancreatico-Biliary Sciences, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, 110 060, India.
| | - Ashish Kumar
- Institute of Liver, Gastroenterology, and Pancreatico-Biliary Sciences, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, 110 060, India
| | - Anil C Anand
- Department of Gastroenterology and Hepatology, Kalinga Institute of Medical Sciences, Kushabhadra Campus, 5, KIIT Road, Bhubaneswar, 751 024, India
| | - Ajay Kumar
- Department of Gastroenterology and Hepatology, BLK Max Multispeciality Hospital, Pusa Road, Radha Soami Satsang, Rajendra Place, New Delhi, 110 005, India
| | - Ajay Yadav
- Department of Vascular and Endovascular Surgery, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, 110 060, India
| | - Ajit Bhagwat
- Department of Cardiology, Kamalnayan Bajaj Hospital, Gut No 43 Bajaj Marg, Beed Bypass Road, Satara Deolai Parisar, Aurangabad, 431 010, India
| | - Ajit S Mullasari
- Department of Adult Cardiology, Madras Medical Mission, 4-A, Dr. J. Jayalalitha Nagar, Chennai, 600 037, India
| | - Ambarish Satwik
- Department of Vascular and Endovascular Surgery, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, 110 060, India
| | - Anoop Saraya
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, Sri Aurobindo Marg, Ansari Nagar, New Delhi, 110 029, India
| | - Ashwani Mehta
- Department of Cardiology, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, 110 060, India
| | - Debabrata Roy
- Department of Cardiology, Narayana Hrudayalaya Rabindranath Tagore International Institute of Cardiac Sciences, 124, Eastern Metropolitan Bypass, Mukundapur, Kolkata, 700 099, India
| | - Duvvur Nageshwar Reddy
- Department of Medical Gastroenterology, AIG Hospitals, Mindspace Road, Gachibowli, Hyderabad, 500 032, India
| | - Govind Makharia
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, Sri Aurobindo Marg, Ansari Nagar, New Delhi, 110 029, India
| | - Jagarapudi M K Murthy
- Department of Neurology, CARE Hospitals, Road No.1, Banjara Hills, Hyderabad, 500 034, India
| | - Jayanta Roy
- Department of Neurology, Institute of Neurosciences, 185/1, Acharya Jagadish Chandra Bose Road, Kolkata, 700 017, India
| | - Jitendra P S Sawhney
- Department of Cardiology, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, 110 060, India
| | - Kameshwar Prasad
- Rajendra Institute of Medical Sciences, Bariatu, Ranchi, 834 009, India
| | - Mahesh Goenka
- Institute of Gastrosciences, Apollo Multispeciality Hospitals, 58, Canal Circular Road, Kadapara, Phool Bagan, Kankurgachi, Kolkata, 700 054, India
| | - Mathew Philip
- Department of Medical Gastroenterology, Lisie Hospital, Lisie Hospital Road, North Kaloor, Kaloor, Ernakulam, 682 018, India
| | - Meenakshisundaram Umaiorubahan
- Department of Neuro Science, SIMS Hospital, No.1, Jawaharlal Nehru Salai (100 Feet Road), Vadapalani, Chennai, 600 026, India
| | - Nakul Sinha
- Department of Cardiac Sciences, Medanta Super Speciality Hospital, Sector - A, Pocket - 1, Amar Shaheed Path, Golf City, Lucknow, 226 030, India
| | - Padinhare P Mohanan
- Department of Cardiology and Cardiothoracic Surgery, Westfort High-Tech Hospital, Guruayoor Road, Punkunnam, Thrissur, 680 002, India
| | - Padmavathy N Sylaja
- Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Jai Nagar W Road, Chalakkuzhi, Thiruvananthapuram, 695 011, India
| | - Pinjala Ramakrishna
- Department of Vascular Surgery, Apollo Hospital Jubilee Hills, Road No 72, Opp. Bharatiya Vidya Bhavan School Film Nagar, Jubilee Hills, Hyderabad, 500 033, India
| | - Prafulla Kerkar
- Department of Cardiology, KEM Hospital and Seth G. S. Medical College, Acharya Donde Marg, Parel East, Parel, Mumbai, 400 012, India
| | - Praveer Rai
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow, 226 014, India
| | - Rakesh Kochhar
- Department of Gastroenterology, Fortis Hospital, Sector 62, Phase - VIII, Mohali, 160 062, India
| | - Rakesh Yadav
- Department of Cardiology, All India Institute of Medical Sciences, Sri Aurobindo Marg, Ansari Nagar, New Delhi, 110 029, India
| | - Sandeep Nijhawan
- Department of Medical Gastroenterology, SMS Medical College and Hospitals, J.L.N. Marg, Jaipur, 302 004, India
| | - Saroj K Sinha
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Madhya Marg, Sector 12, Chandigarh, 160 012, India
| | - Shirish M Hastak
- Department of Neurology, Global Hospitals, 35, Dr. E Borges Road, Hospital Avenue, Opposite Shirodkar High School, Parel, Mumbai, 400 012, India
| | - Sidharth Viswanathan
- Department of Vascular and Endovascular Surgery, Amrita Institute of Medical Sciences, Ponekkara, AIMS (P.O.), Kochi, 682 041, India
| | - Uday C Ghoshal
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow, 226 014, India
| | - Unnikrishnan Madathipat
- Department of Vascular and Endovascular Surgery, SUT Pattom Multi Super Specialty Hospitals, Pattom, Thiruvananthapuram, 695 004, India
| | - Vijay Thakore
- Department of Vascular and Endovascular Surgery, Aadicura Superspeciality Hospital, Winward Business Park, Jetalpur Road, Vadodara, 390 020, India
| | - Vinay Dhir
- Institute of Digestive and Liver Care, SL Raheja Hospital, Raheja Rugnalaya Marg, Mahim West, Mahim, Mumbai, 400 016, India
| | - Vivek A Saraswat
- Department of Gastroenterology and Hepatology, Mahatma Gandhi Medical College and Hospital, RIICO Institutional Area, Sitapura, Tonk Road, Jaipur, 302 022, India
| | - Zaheer Nabi
- Department of Medical Gastroenterology, AIG Hospitals, Mindspace Road, Gachibowli, Hyderabad, 500 032, India
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Mohanan PP, Jariwala P. HOW did GLP-1RAs bring about a paradigm shift in the guidelines of managing T2DM: A path to gluco-cardio Centricity. Indian Heart J 2023; 75:1-8. [PMID: 36435205 PMCID: PMC9986737 DOI: 10.1016/j.ihj.2022.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 11/18/2022] [Accepted: 11/21/2022] [Indexed: 11/25/2022] Open
Abstract
Diabetes is a common condition with a dismal prognosis. According to the International Diabetes Federation, 537 million people worldwide have diabetes. Cardiovascular disorders (CVD) are the major cause of death globally. Diabetes mellitus type 2 (T2DM) increases the risk of CVD. Since 2008, the FDA has required all new antihyperglycemic treatments to show no increased CV risk. Years of glucocentric diabetic therapy have left many patients on medicines with no known CV benefit. GLP-1 receptor agonists (GLP-1RAs) are excellent glucose-lowering medicines with little risk of hypoglycaemia, CVD and weight loss. GLP-1RAs may also delay renal disease development. As an adjunct to metformin or ongoing therapy, GLP1RAs or sodium-glucose cotransporter-2 inhibitors are recommended by the American Diabetes Association and the European Association for the Study of Diabetes (EASD). Thus, this review summarises GLP-1RA and their significance in the paradigm shift in diabetes care recommendations from glucocentric to gluco-cardiocentric.
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Affiliation(s)
- P P Mohanan
- Department of Cardiology, Westfort Hi-Tech Hospital, Ltd., Thrissur, India
| | - Pankaj Jariwala
- Department of Cardiology, Yashoda Hospitals, Somajiguda, Raj Bhavan Road, Hyderabad, 500 082, Telangana, India.
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Dhurjati R, Sagar V, Kanukula R, Rehana N, Mohanan PP, Huffman MD, Bhaumik S, Salam A. Quality of the Indian clinical practice guidelines for the management of cardiovascular conditions. JRSM Open 2022; 13:20542704221127178. [PMID: 36506268 PMCID: PMC9730011 DOI: 10.1177/20542704221127178] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
To assess the quality of Indian clinical practice guidelines (CPG)s for the management of cardiovascular conditions, MEDLINE, Embase, Google Scholar and websites of relevant medical associations and government organisations were searched, from inception until August 2020, to identify Indian CPGs for the management of cardiovascular disease (CVD) conditions, produced in or between 2010 and 2019. Excluded were CPGs that were not specific to India, focused on alternative systems of medicine, of non-CVD conditions (even if they included a component of CVD), and those related to the electronic devices, cardiac biomarkers, or diagnostic procedures. Quality of the each included CPG was assessed using the AGREE II tool by four reviewers in duplicate, independently. Each AGREE II domain score and overall quality score was considered low (≤40%), moderate (40.1%-59.9%), and high (≥60%). Of the 23 CPGs included, six (26%) were reported to be adapted from other CPGs. Fourteen (61%) CPGs were produced by medical associations, six (26%) by individual authors and three (13%) by government agencies. Based on the AGREE II overall quality score, two (9%) CPGs were of high quality, four (17%) and seventeen (74%) CPGs were of moderate and low quality, respectively. Except for scope and purpose, and clarity of presentation all other domains were rated low. The quality of most Indian CPGs for managing CVD conditions assessed using the AGREE II tool was moderate-to-low. Combined efforts from different stakeholders are needed to develop, disseminate and implement high-quality CPGs while identifying and addressing barriers to their uptake to optimize patient care and improve outcomes.
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Affiliation(s)
| | - Vidya Sagar
- The George Institute for Global Health, New Delhi, Delhi, India
| | - Raju Kanukula
- The George Institute for Global Health, New Delhi, Delhi, India
| | - Nusrath Rehana
- The George Institute for Global Health, New Delhi, Delhi, India
| | | | - Mark D. Huffman
- Washington University in St. Louis, St Louis, MO, USA,The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Soumyadeep Bhaumik
- The George Institute for Global Health, New Delhi, Delhi, India,Meta-research & Evidence Synthesis Unit, The George Institute for Global Health, New Delhi, Delhi, India
| | - Abdul Salam
- The George Institute for Global Health, New Delhi, Delhi, India,Manipal Academy of Higher Education, Manipal, Karnataka, India,The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia,Abdul Salam.
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S H, Oomman A, Jadhav UM, Raghuraman B, Mohanan PP, Tiwaskar M, Wander GS, Chopra VK. Heart Failure with Preserved Ejection Fraction: Management Guidelines (From Heart Failure Association of India, Endorsed by Association of Physicians of India). J Assoc Physicians India 2022; 70:11-12. [PMID: 36082729 DOI: 10.5005/japi-11001-0077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Heart failure with preserved ejection fraction (HFpEF) accounts for 15-20% of patients with heart failure (HF) in India. Diagnosis is by clinical features supported by biomarkers and echocardiography. Lifestyle modifications, control of risk factors to optimum levels, and treatment of comorbidities are essential in the management of HFpEF. Spironolactone and sacubitril-valsartan [angiotensin receptor neprilysin inhibitor (ARNI)] are beneficial in subsets of HFpEF, especially with lower range of ejection fraction (EF). Sodium-glucose co-transporter-2 inhibitors (SGLT2i)-empagliflozin and dapagliflozin and probably sotagliflozin are the only currently available drugs which have shown benefits in HFpEF, mostly by reducing hospitalizations. The benefit of SGLT2i is evident in both diabetic and nondiabetic subsets.
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Affiliation(s)
- Harikrishnan S
- Professor, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerela; Corresponding Author
| | - Abraham Oomman
- Senior Consultant Cardiologist, Apollo Hospital Chennai, Chennai, Tamil Nadu
| | - Uday M Jadhav
- Consultant Cardiology, MGM New Bombay Hospital, Navi Mumbai, Maharashtra
| | - Bagirath Raghuraman
- Senior Consultant Cardiologist, Narayana Institute of Cardiac Sciences, Bengaluru, Karnataka
| | - P P Mohanan
- Director and HOD, Department of Cardiology, Westfort Hi-Tech Hospital Ltd., Thrissur, Kerala
| | - Mangesh Tiwaskar
- Consultant Physician and Diabetologist, Karuna Hospital, Mumbai, Maharashtra
| | - G S Wander
- Professor and Head of Cardiology, Dayanand Medical College & Hospital, Unit-Hero DMC Heart Institute, Ludhiana, Punjab
| | - V K Chopra
- Senior Director Clinical Cardiology, Max Super Speciality Hospital, New Delhi, Delhi, India
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Koshy L, Vb R, M M, Ben MP, Kishor P, Sudhakaran PR, Abdullakutty J, Venugopal K, Zachariah G, Mohanan PP, Harikrishnan S, G S. Pharmacogenetic variants influence vitamin K anticoagulant dosing in patients with mechanical prosthetic heart valves. Pharmacogenomics 2022; 23:475-485. [PMID: 35608144 DOI: 10.2217/pgs-2022-0014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background: Vitamin K antagonists (VKAs) are class I oral anticoagulants that are widely prescribed following surgical heart valve implantation. The objective of this study was to quantify the relative effects of VKORC1, CYP2C9 and CYP4F2 genotypes in predicting VKA dosing. Materials & methods: A total of 506 South Indian patients with mechanical prosthetic heart valves who were prescribed oral VKAs, such as warfarin or acenocoumarol, were genotyped. The discriminatory ability of mutant genotypes to predict dose categories and bleeding events was assessed using regression analysis. Results: The VKORC1 rs9923231, CYP2C9*3 and CYP4F2*3 mutant genotypes significantly influenced VKA-dose requirements and explained 27.47% of the observed dose variation. Conclusion: These results support pharmacogenetic screening for initial VKA dosing among South Indian patients with mechanical prosthetic heart valves.
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Affiliation(s)
- Linda Koshy
- Centre for Advanced Research & Excellence in Heart Failure, Sree Chitra Tirunal Institute for Medical Sciences & Technology, Trivandrum, Kerala, 695011, India
| | - Raghu Vb
- Inter-University Centre for Genomics & Gene Technology, Department of Biotechnology, University of Kerala, Trivandrum, Kerala, 695581, India
| | - Madhuma M
- Centre for Advanced Research & Excellence in Heart Failure, Sree Chitra Tirunal Institute for Medical Sciences & Technology, Trivandrum, Kerala, 695011, India
| | - Midhuna P Ben
- Inter-University Centre for Genomics & Gene Technology, Department of Biotechnology, University of Kerala, Trivandrum, Kerala, 695581, India
| | - Pritam Kishor
- Integrated Science Education & Research Centre, Visva-Bharati, Santineketan, West Bengal, 731235, India
| | - P R Sudhakaran
- Inter-University Centre for Genomics & Gene Technology, Department of Biotechnology, University of Kerala, Trivandrum, Kerala, 695581, India
| | | | - K Venugopal
- Department of Cardiology, Pushpagiri Hospital, Thiruvalla, Pathanamthitta, Kerala, 689101, India
| | - Geevar Zachariah
- Department of Cardiology, Mother Hospital, Thrissur, Kerala, 680012, India
| | - P P Mohanan
- Department of Cardiology, Westfort Hi-Tech Hospital, Thrissur, Kerala, 680002, India
| | - S Harikrishnan
- Department of Cardiology, Sree Chitra Tirunal Institute for Medical Sciences & Technology, Trivandrum, Kerala, 695011, India
| | - Sanjay G
- Department of Cardiology, Sree Chitra Tirunal Institute for Medical Sciences & Technology, Trivandrum, Kerala, 695011, India
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Vijay A, Mohanan PP, Kondal D, Baldridge A, Davies D, Devarajan R, Unni G, Abdullakutty J, Natesan S, Joseph J, Jayagopal PB, Joseph S, Gopinath R, Prabhakaran D, Huffman MD, Agarwal A. Polypill Eligibility for Patients with Heart Failure With Reduced Ejection Fraction in South India: A Secondary Analysis of a Prospective, Interrupted Time Series Study. J Am Heart Assoc 2021; 10:e021676. [PMID: 34612082 PMCID: PMC8751873 DOI: 10.1161/jaha.121.021676] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Affiliation(s)
- Aishwarya Vijay
- Department of Medicine Northwestern University Feinberg School of Medicine Chicago IL
| | | | - Dimple Kondal
- Centre for Chronic Disease Control New Delhi Delhi India
| | - Abigail Baldridge
- Department of Preventive Medicine Northwestern University Feinberg School of Medicine Chicago IL
| | | | - Raji Devarajan
- Centre for Chronic Disease Control New Delhi Delhi India
| | - Govindan Unni
- Jubilee Mission Medical College and Hospital Thrissur Kerala India
| | | | | | | | | | - Stigi Joseph
- Little Flower Hospital and Research Centre Angamaly Kerala India
| | | | - Dorairaj Prabhakaran
- Centre for Chronic Disease Control New Delhi Delhi India.,The Public Health Foundation of India Gurugram Haryana India
| | - Mark D Huffman
- Department of Medicine Northwestern University Feinberg School of Medicine Chicago IL.,Department of Preventive Medicine Northwestern University Feinberg School of Medicine Chicago IL.,The George Institute for Global Health University of New South Wales Sydney New South Wales Australia
| | - Anubha Agarwal
- Department of Medicine Northwestern University Feinberg School of Medicine Chicago IL
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Agarwal A, Mohanan PP, Kondal D, Chopra A, Baldridge AS, Davies D, Devarajan R, Unni G, Abdullakutty J, Natesan S, Joseph J, Jayagopal PB, Joseph S, Gopinath R, Prabhakaran D, Huffman MD. Presentation, Management, and In-Hospital Outcomes of Patients with Acute Heart Failure in South India by Sex: A Secondary Analysis of a Prospective, Interrupted Time Series Study. Glob Heart 2021; 16:63. [PMID: 34692388 PMCID: PMC8485866 DOI: 10.5334/gh.1043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 08/25/2021] [Indexed: 11/20/2022] Open
Abstract
Background Sex differences in presentation, management, and outcomes of heart failure (HF) have been observed, but it is uncertain whether these differences exist in South India. Objective We describe sex differences in presentation, management, and in-hospital outcomes in patients hospitalized with HF in South India and explore sex-based differences in the effect of the quality improvement intervention in a secondary analysis of a prospective, interrupted time series study. Methods The Heart Failure Quality Improvement in Kerala (HF QUIK) study evaluated the effect of a quality improvement toolkit on process of care measures and clinical outcomes in patients hospitalized with HF in eight hospitals in Kerala using an interrupted time series design from February 2018 to August 2018. The primary outcome was guideline-directed medical therapy (GDMT) at hospital discharge for patients with HF with reduced ejection fraction (HFrEF). We performed sex-stratified analyses using mixed effect logistic regression models. Results Among 1,400 patients, 536 (38.3%) were female. Female patients were older (69.6 vs. 65 years, p < 0.001), were less likely to have an ischemic etiology of HF (control period: 78.2% vs. 87.5%; intervention period: 83.6% vs. 91.5%; p < 0.05 for both) and were less likely to undergo coronary angiography or percutaneous coronary intervention. The quality improvement intervention had similar effects on the odds of GDMT at discharge in females with HFrEF (adjusted OR 1.79, 95% CI 0.92, 3.47) and males with HFrEF (adjusted OR 1.68, 95% CI 1.07, 2.64, pinteraction = 0.69). Conclusions We observed sex-specific differences in presentation and procedural management of patients with HF but no differences in the effect of the quality improvement intervention on discharge GDMT rates. Both male and female patients with HFrEF remained undertreated in the study intervention period, demonstrating the need for implementation strategies to close the HFrEF treatment gap in South India.
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Affiliation(s)
- Anubha Agarwal
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, US
| | | | - Dimple Kondal
- Centre for Chronic Disease Control, New Delhi, Delhi, IN
| | - Aashima Chopra
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, US
| | - Abigail S. Baldridge
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, US
| | | | - Raji Devarajan
- Centre for Chronic Disease Control, New Delhi, Delhi, IN
| | - Govindan Unni
- Jubilee Mission Medical College and Hospital, Thrissur, Kerala, IN
| | | | | | | | | | - Stigi Joseph
- Little Flower Hospital and Research Centre, Angamaly, Kerala, IN
| | | | - Dorairaj Prabhakaran
- Centre for Chronic Disease Control, New Delhi, Delhi, IN
- The Public Health Foundation of India, Gurugram, Haryana, IN
| | - Mark D. Huffman
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, US
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, US
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, AU
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10
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Gupta K, Ramakrishnan S, Zachariah G, Rao JS, Mohanan PP, Venugopal K, Sateesh S, Sethi R, Jain D, Bardolei N, Mani K, Kakar TS, Jain V, Gupta P, Gupta R, Bansal S, Nath RK, Tyagi S, Wander GS, Gupta S, Mandal S, Senguttuvan NB, Subramanyam G, Roy D, Datta S, Ganguly K, Routray SN, Mishra SS, Singh BP, Bharti BB, Das MK, Deb PK, Deedwania P, Seth A. Impact of the 2017 ACC/AHA guidelines on the prevalence of hypertension among Indian adults: Results from a cross-sectional survey. Int J Cardiol Hypertens 2021; 7:100055. [PMID: 33465185 PMCID: PMC7803035 DOI: 10.1016/j.ijchy.2020.100055] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 09/27/2020] [Accepted: 09/30/2020] [Indexed: 01/19/2023] Open
Abstract
Background The impact of the 2017 American College of Cardiology (ACC)/American Heart Association (AHA) guidelines for diagnosis and management of hypertension on the prevalence of hypertension in India is unknown. Methods We analyzed data from the Cardiac Prevent 2015 survey to estimate the change in the prevalence of hypertension. The JNC8 guidelines defined hypertension as a systolic blood pressure of ≥140 mmHg or diastolic blood pressure of ≥90 mmHg. The 2017 ACC/AHA guidelines define hypertension as a systolic blood pressure of ≥130 mmHg or diastolic blood pressure of ≥80 mmHg. We standardized the prevalence as per the 2011 census population of India. We also calculated the prevalence as per the World Health Organization (WHO) World Standard Population (2000–2025). Results Among 180,335 participants (33.2% women), the mean age was 40.6 ± 14.9 years (41.1 ± 15.0 and 39.7 ± 14.7 years in men and women, respectively). 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 belonged to age group 18–19, 20–44, 45–54, 55–64, 65–74 and ≥ 75 years respectively. The prevalence of hypertension according to the JNC8 and 2017 ACC/AHA guidelines was 29.7% and 63.8%, respectively- an increase of 115%. With the 2011 census population of India, this suggests that currently, 486 million Indian adults have hypertension according to the 2017 ACC/AHA guidelines, an addition of 260 million as compared to the JNC8 guidelines. Conclusion According to the 2017 ACC/AHA guidelines, 3 in every 5 Indian adults have hypertension.
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Affiliation(s)
- Kartik Gupta
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India.,Department of Medicine, Henry Ford Hospital, Detroit, MI, USA
| | - Sivasubramanian Ramakrishnan
- Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India.,Cardiology Society of India, India
| | | | | | | | | | | | | | | | | | - Kalaivani Mani
- Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India
| | | | - Vardhmaan Jain
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Prakash Gupta
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - P K Deb
- Cardiology Society of India, India
| | - Prakash Deedwania
- School of Medicine, University of California, San Francisco Fresno, CA, USA
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11
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Agarwal A, Mohanan PP, Kondal D, Baldridge A, Davies D, Devarajan R, Unni G, Abdullakutty J, Natesan S, Joseph J, Jayagopal PB, Joseph S, Gopinath R, Huffman MD, Prabhakaran D. Effect of a quality improvement intervention for acute heart failure in South India: An interrupted time series study. Int J Cardiol 2020; 329:123-129. [PMID: 33358838 DOI: 10.1016/j.ijcard.2020.12.048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 11/16/2020] [Accepted: 12/11/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND Although quality improvement interventions for acute heart failure have been studied in high-income countries, none have been studied in low- or middle-income country settings where quality of care can be lower. We evaluated the effect of a quality improvement toolkit on process of care measures and clinical outcomes in patients hospitalized for acute heart failure in 8 hospitals in Kerala, India utilizing an interrupted time series design from February 2018 to August 2018. METHODS The quality improvement toolkit included checklists, audit-and-feedback reports, and patient education materials. The primary outcome was rate of discharge guideline-directed medical therapy for patients with heart failure with reduced ejection fraction. We used mixed effect logistic regression and interrupted time series models for analysis. RESULTS Among 1400 participants, mean (SD) age was 66.6 (12.2) years, and 38% were female. Mean (SD) left ventricular ejection fraction was 35.2% (9.7%). The primary outcome was observed in 41.3% of participants in the intervention period and 28.1% of participants in the control period (difference 13.2%; 95% CI 6.8, 19.0; adjusted OR = 1.70; 95% CI 1.17, 2.48). Interrupted time series model demonstrated highest rate of guideline-directed medical therapy at discharge in the initial weeks following intervention delivery with a concomitant decline over time. Improvements were observed in discharge process of care measures, including diet counseling, weight monitoring instructions, and scheduling of outpatient clinic follow-up but not hospital length of stay nor inpatient mortality. CONCLUSIONS Higher rates of guideline-directed medical therapy at discharge were observed in Kerala. Broader implementation of this quality improvement intervention may improve heart failure care in low- and middle-income countries.
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Affiliation(s)
- Anubha Agarwal
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | | | - Dimple Kondal
- Centre for Chronic Disease Control, New Delhi, Delhi, India
| | - Abigail Baldridge
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Divin Davies
- WestFort Hi-Tech Hospital, Thrissur, Kerala, India
| | - Raji Devarajan
- Centre for Chronic Disease Control, New Delhi, Delhi, India
| | - Govindan Unni
- Jubilee Mission Medical College and Hospital, Thrissur, Kerala, India
| | | | | | | | | | - Stigi Joseph
- Little Flower Hospital and Research Centre, Angamaly, Kerala, India
| | - Rajesh Gopinath
- Amala Institute of Medical Sciences, Thrissur, Kerala, India
| | - Mark D Huffman
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Dorairaj Prabhakaran
- Centre for Chronic Disease Control, New Delhi, Delhi, India; The Public Health Foundation of India, Gurugram, Haryana, India
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12
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Bahuleyan CG, Namboodiri N, Jabir A, Lip GYH, Koshy A G, Shifas BM, Viswanathan S K, Zachariah G, Venugopal K, Punnose E, Natarajan KU, Mini GK, Joseph J, Nambiar C A, Jayagopal PB, Mohanan PP, George R, Unni G, Sajeev CG, Muhammed S, Syam N, Roby A, Daniel R, Krishnakumar VV, Pillai AM, Joseph S, Jinbert Lordson A. One-year clinical outcome of patients with nonvalvular atrial fibrillation: Insights from KERALA-AF registry. Indian Heart J 2020; 73:56-62. [PMID: 33714410 PMCID: PMC7961260 DOI: 10.1016/j.ihj.2020.11.152] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 11/04/2020] [Accepted: 11/29/2020] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND We report patient characteristics, treatment pattern and one-year clinical outcome of nonvalvular atrial fibrillation (NVAF) from Kerala, India. This cohort forms part of Kerala Atrial Fibrillation (KERALA-AF) registry which is an ongoing large prospective study. METHODS KERALA-AF registry collected data of adults with previously or newly diagnosed atrial fibrillation (AF) during April 2016 to April 2017. A total of 3421 patients were recruited from 53 hospitals across Kerala state. We analysed one-year follow-up outcome of 2507 patients with NVAF. RESULTS Mean age at recruitment was 67.2 years (range 18-98) and 54.8% were males. Main co-morbidities were hypertension (61.2%), hyperlipidaemia (46.2%) and diabetes mellitus (37.2%). Major co-existing diseases were chronic kidney disease (42.1%), coronary artery disease (41.6%), and chronic heart failure (26.4%). Mean CHA2DS2-VASc score was 3.18 (SD ± 1.7) and HAS-BLED score, 1.84 (SD ± 1.3). At baseline, use of oral anticoagulants (OAC) was 38.6% and antiplatelets 32.7%. On one-month follow-up use of OAC increased to 65.8% and antiplatelets to 48.3%. One-year all-cause mortality was 16.48 and hospitalization 20.65 per 100 person years. The main causes of death were cardiovascular (75.0%), stroke (13.1%) and others (11.9%). The major causes of hospitalizations were acute coronary syndrome (35.0%), followed by arrhythmia (29.5%) and heart failure (8.4%). CONCLUSIONS Despite high risk profile of patients in this registry, use of OAC was suboptimal, whereas antiplatelets were used in nearly half of patients. A relatively high rate of annual mortality and hospitalization was observed in patients with NVAF in Kerala AF Registry.
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Affiliation(s)
- C G Bahuleyan
- Cardiovascular Centre, Ananthapuri Hospitals and Research Institute, Trivandrum, India.
| | - Narayanan Namboodiri
- Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
| | - A Jabir
- Lisie Heart Institute, Ernakulam, India
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, United Kingdom; Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - George Koshy A
- Medical College Hospital, Trivandrum, India 8Global Institute of Public Health, 6. Cardiovascular Centre, Ananthapuri Hospitals and Research Institute, Trivandrum, India
| | - Babu M Shifas
- Cardiovascular Centre, Ananthapuri Hospitals and Research Institute, Trivandrum, India
| | - Kartik Viswanathan S
- Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
| | | | - K Venugopal
- Pushpagiri Medical College, Thiruvalla, India
| | | | - K U Natarajan
- Amrita Institute of Medical Sciences, Ernakulam, India
| | - G K Mini
- Global Institute of Public Health, Trivandrum, Kerala, India
| | | | | | | | - P P Mohanan
- West Fort Hi-Tech Hospital, Ponkunam, Thrissur, India
| | - Raju George
- Government Medical College Hospital, Kottayam, India
| | | | - C G Sajeev
- Government Medical College Hospital, Calicut, India
| | | | - N Syam
- General Hospital, Kollam, India
| | - Anil Roby
- Dr Damodaran Memorial Hospital, Kollam, India
| | - Rachel Daniel
- N S Memorial Institute of Medical Sciences, Kollam, India
| | - V V Krishnakumar
- Cardiovascular Centre, Ananthapuri Hospitals and Research Institute, Trivandrum, India
| | - Anand M Pillai
- Cardiovascular Centre, Ananthapuri Hospitals and Research Institute, Trivandrum, India
| | - Stigi Joseph
- Little Flower Hospital, M C Road, Angamali, India
| | - A Jinbert Lordson
- Cardiovascular Centre, Ananthapuri Hospitals and Research Institute, Trivandrum, India; Global Institute of Public Health, Trivandrum, Kerala, India
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13
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Gupta R, Das MK, Mohanan PP, Deb PK, Parashar SK, Chopra HK, Shrivastava S, Guha S, Goswami KC, Yadav R, Alagesan R, Amuthan V, Bansal M, Chakraborty RN, Chakraborti N, Chandra S, Chatterjee A, Chatterjee D, Chatterjee SS, Dutta AL, De A, Garg A, Garg VK, Goyal A, Goyal NK, Govind SC, Gupta VK, Hasija PK, Jabir A, Jain P, Jain V, Jayagopal PB, Kasliwal RR, Katyal VK, Kerkar PG, Khan AK, Khanna NN, Mandal M, Majumder B, Mishra SS, Meena CB, Naik N, Narain VS, Pancholia AK, Pathak LA, Ponde CK, Raghu K, Ray S, Roy D, Sarma D, Shanmugasundarum S, Singh BP, Tyagi S, Vijayaraghavan G, Wander GS, Wardhan H, Nanda NC. Cardiological society of India document on safety measure during echo evaluation of cardiovascular disease in the time of COVID-19. Indian Heart J 2020; 72:145-150. [PMID: 32768012 PMCID: PMC7250084 DOI: 10.1016/j.ihj.2020.05.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 05/15/2020] [Accepted: 05/19/2020] [Indexed: 01/08/2023] Open
Abstract
An echocardiographic investigation is one of the key modalities of diagnosis in cardiology. There has been a rising presence of cardiological comorbidities in patients positive for COVID-19. Hence, it is becoming extremely essential to look into the correct safety precautions, healthcare professionals must take while conducting an echo investigation. The decision matrix formulated for conducting an echocardiographic evaluation is based on presence or absence of cardiological comorbidity vis-à-vis positive, suspected or negative for COVID-19. The safety measures have been constructed keeping in mind the current safety precautions by WHO, CDC and MoHFW, India.
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Affiliation(s)
- Rakesh Gupta
- JROP Institute of Echocardiography, Ultrasound & Vascular Doppler, JROP Healthcare Pvt. Ltd., C-1/16, Ashok Vihar-II, Delhi, 110052, India; JROP Charak Heart City, MD City Hospital, Model Town Northex, Delhi, 110009, India.
| | - Mrinal Kanti Das
- C K Birla Group of Hospitals (BMB and CMRI), Kolkata, West Bengal, India
| | - P P Mohanan
- Westfort Hi-Tech Hospital, Thrissur, Kerala, India
| | | | - S K Parashar
- Metro Heart Hospital, Lajpat Nagar, New Delhi, India
| | | | | | - Santanu Guha
- Calcutta Medical College Hospital, Kolkata, West Bengal, India
| | | | - Rakesh Yadav
- All India Institute of Medical Sciences, New Delhi, India
| | | | - V Amuthan
- Jeyalakshmi Heart Center, Madurai, Tamilnadu, India
| | - M Bansal
- Medanta, The Medicity, New Delhi, India
| | - R N Chakraborty
- Medica Group of Superspeciality Hospitals, Kolkata, West Bengal, India
| | - N Chakraborti
- Medica Group of Superspeciality Hospitals, Kolkata, West Bengal, India
| | - S Chandra
- King George's Medical University, Lucknow, India
| | | | - D Chatterjee
- Rabindranath Tagore International Institute of Cardiac Sciences, Kolkata, India
| | | | | | - A De
- Apollo Gleneagles Hospital, Kolkata, India
| | - A Garg
- Jaipur Heart Institute, Jaipur, India
| | - V K Garg
- R D Gardi Medical College, Ujjain, India
| | - A Goyal
- Bani Park Hospital, Jaipur, India
| | - N K Goyal
- BLK Superspeciality Hospital, New Delhi, India
| | | | - V K Gupta
- Kishori Ram Hospital & Diabetes Care Centre, Bhatinda, India
| | | | - A Jabir
- Lisie Hospital Kochi, Kerala, India
| | - P Jain
- Lifeline Superspeciality Hospital, Jhansi, India
| | - V Jain
- Choithram Hospital &R.C., Indore, India
| | | | | | | | | | | | | | - M Mandal
- NRS Medical College, Kolkata, India
| | - B Majumder
- R.G. Kar Medical College & Hospital, Kolkata, India
| | - S S Mishra
- Hi-Tech Medical College and Hospital, Bhubaneshwar, India
| | - C B Meena
- SMS Medical College, Jaipur, Rajasthan
| | | | - V S Narain
- King George's Medical University, Lucknow, India
| | | | - L A Pathak
- Nanavati Heart Institute, Nanavati Superspeciality Hospital, Mumbai, India
| | - C K Ponde
- PD Hinduja National Hospital & RC, Mumbai, India
| | - K Raghu
- Care Hospital, Hyderabad, India
| | - S Ray
- Vivekananda Institute of Medical Sciences, Kolkata, India
| | - D Roy
- Rabindranath Tagore International Institute of Cardiac Sciences, Kolkata, India
| | - D Sarma
- Jorhat Christian Medical Centre Hospital, Jorhat, Assam, India
| | | | | | - S Tyagi
- GB Pant Institute of Post Graduate Medical Education and Research, New Delhi, India
| | | | - G S Wander
- Hero DMC Heart Institute, Ludhiana, India
| | - Harsh Wardhan
- Mahatma Gandhi Medical College and Hospital, Jaipur, India
| | - N C Nanda
- University of Alabama at Birmingham, Birmingham, AL, USA
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14
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Yoo SGK, Davies D, Mohanan PP, Baldridge AS, Charles PM, Schumacher M, Bhalla S, Devarajan R, Hirschhorn LR, Prabhakaran D, Huffman MD. Hospital-Level Cardiovascular Management Practices in Kerala, India. Circ Cardiovasc Qual Outcomes 2020; 12:e005251. [PMID: 31092020 DOI: 10.1161/circoutcomes.118.005251] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Background Hospital management practices are associated with cardiovascular process of care measures and patient outcomes. However, management practices related to acute cardiac care in India has not been studied. Methods and Results We measured management practices through semistructured, in-person interviews with hospital administrators, physician managers, and nurse managers in Kerala, India between October and November 2017 using the adapted World Management Survey. Trained interviewers independently scored management interview responses (range: 1-5) to capture management practices ranging from performance data tracking to setting targets. We performed univariate regression analyses to assess the relationship between hospital-level factors and management practices. Using Pearson correlation coefficients and mixed-effect logistic regression models, we explored the relationship between management practices and 30-day major adverse cardiovascular events defined as all-cause mortality, reinfarction, stroke, or major bleeding. Ninety managers from 37 hospitals participated. We found suboptimal management practices across 3 management levels (mean [SD]: 2.1 [0.5], 2.0 [0.3], and 1.9 [0.3] for hospital administrators, physician managers, and nurse managers, respectively [ P=0.08]) with lowest scores related to setting organizational targets. Hospitals with existing healthcare quality accreditation, more cardiologists, and private ownership were associated with higher management scores. In our exploratory analysis, higher physician management practice scores related to operation, performance, and target management were correlated with lower 30-day major adverse cardiovascular event. Conclusions Management practices related to acute cardiac care in participating Kerala hospitals were suboptimal but were correlated with clinical outcomes. We identified opportunities to strengthen nonclinical practices to improve patient care.
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Affiliation(s)
- Sang Gune K Yoo
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.G.K.Y., A.S.B., M.D.H.)
| | - Divin Davies
- WestFort Hi-Tech Hospital Ltd, Thrissur, India (D.D., P.P.M.)
| | | | - Abigail S Baldridge
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.G.K.Y., A.S.B., M.D.H.)
| | | | - Mark Schumacher
- Northwestern Memorial Healthcare, Chicago, IL (P.M.C., M.S.)
| | - Sandeep Bhalla
- Public Health Foundation of India, Gurgaon, India (S.B., D.P.)
| | - Raji Devarajan
- Centre for Chronic Disease Control, New Delhi, India (R.D., D.P.)
| | - Lisa R Hirschhorn
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL (L.R.H.)
| | - Dorairaj Prabhakaran
- Public Health Foundation of India, Gurgaon, India (S.B., D.P.).,Centre for Chronic Disease Control, New Delhi, India (R.D., D.P.).,London School of Hygiene and Tropical Medicine, London, United Kingdom (D.P.)
| | - Mark D Huffman
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.G.K.Y., A.S.B., M.D.H.)
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15
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Kerkar PG, Naik N, Alexander T, Bahl VK, Chakraborty RN, Chatterjee SS, Chopra HK, Dani SI, Deb PK, Goswami KC, Guha S, Gupta R, Gupta V, Hasija PK, Jayagopal PB, Justin Paul G, Kahali D, Katyal VK, Khanna NN, Mandal M, Mishra SS, Mohanan PP, Mullasari A, Mehta S, Pancholia AK, Ray S, Roy D, Shanmugasundarm S, Sharma S, Singh BP, Tewari S, Tyagi SK, Venugopal KN, Wander GS, Yadav R, Das MK. Cardiological Society of India: Document on acute MI care during COVID-19. Indian Heart J 2020; 72:70-74. [PMID: 32534693 PMCID: PMC7201231 DOI: 10.1016/j.ihj.2020.04.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 04/29/2020] [Indexed: 12/20/2022] Open
Abstract
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.
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Affiliation(s)
- P G Kerkar
- Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - N Naik
- All India Institute of Medical Sciences, New Delhi, India
| | - T Alexander
- Kovai Medical Center and Hospital, Coimbatore, Tamil Nadu, India
| | - V K Bahl
- All India Institute of Medical Sciences, New Delhi, India
| | - R N Chakraborty
- Medica Group of Superspeciality Hospitals, Kolkata, West Bengal, India
| | - S S Chatterjee
- Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India
| | | | - S I Dani
- Apollo Hospital, Ahmedabad, Gujarat, India
| | - P K Deb
- Daffodil Hospital, Kolkata, West Bengal, India
| | - K C Goswami
- All India Institute of Medical Sciences, New Delhi, India
| | - S Guha
- Calcutta Medical College Hospital, Kolkata, West Bengal, India
| | - R Gupta
- JROP Healthcare, New Delhi, India
| | - V Gupta
- Kishori Ram Hospital & Diabetes Care Centre, India
| | - P K Hasija
- Armed Forces Medical College, Pune, Maharashtra, India
| | | | | | - D Kahali
- BM Birla Heart Research Center, Kolkata, West Bengal, India
| | - V K Katyal
- Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India
| | - N N Khanna
- Indraprastha Apollo Hospital, New Delhi, India
| | - M Mandal
- NRS Medical College and Hospital, Kolkata, West Bengal, India
| | - S S Mishra
- Hi-Tech Medical College and Hospital, Bhubaneshwar, Odisha, India
| | - P P Mohanan
- Westfort Hi-Tech Hospital, Thrissur, Kerala, India
| | - A Mullasari
- Madras Medical Mission Hospital, Chennai, Tamil Nadu, India
| | - S Mehta
- University of Miami, Florida, USA
| | | | - S Ray
- Vivekanand Institute of Medical Sciences, Kolkata, West Bengal, India
| | - D Roy
- Rabindranath Tagore International Institute of Medical Sciences, Kolkata, West Bengal, India
| | | | | | - B P Singh
- Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India
| | - S Tewari
- Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | | | - K N Venugopal
- Pushpagiri Institute of Medical Sciences, Tiruvalla, Kerala, India
| | - G S Wander
- Dayanand Medical College, Ludhiana, Punjab, India
| | - R Yadav
- All India Institute of Medical Sciences, New Delhi, India
| | - M K Das
- C K Birla Group of Hospitals (BMB and CMRI), Kolkata, West Bengal, India.
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16
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Harikrishnan S, Mohanan PP, Chopra VK, Ambuj R, Sanjay G, Bansal M, Chakraborty RN, Chandra S, Chattarjee SS, Chopra HK, Mathew C, Deb PK, Goyal A, Goswami KC, Gupta R, Guha S, Gupta V, Hasija PK, Wardhan H, Jabir A, Jayagopal PB, Kahali D, Katyal VK, Kerkar PG, Khanna NN, Majumder B, Mandal M, Meena CB, Naik N, Narain VK, Pathak LA, Ray S, Roy D, Routray SN, Sarma D, Shanmugasundaram S, Singh BP, Tyagi SK, Venugopal K, Wander GS, Yadav R, Das MK. Cardiological society of India position statement on COVID-19 and heart failure. Indian Heart J 2020; 72:75-81. [PMID: 32405088 PMCID: PMC7219407 DOI: 10.1016/j.ihj.2020.04.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 04/29/2020] [Indexed: 02/06/2023] Open
Affiliation(s)
- S Harikrishnan
- Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India.
| | | | | | | | - G Sanjay
- Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
| | | | | | | | | | | | | | - P K Deb
- Daffodil Hospitals, Kolkata, India
| | - A Goyal
- Bani Park Hospital, D-9, Kabir Marg, Bani Park, JAIPUR, 302016, Rajasthan, India
| | | | - R Gupta
- JROP Institute of Echocardiography, New Delhi, India
| | - S Guha
- Medical College, Kolkata, India
| | - V Gupta
- Kishori Ram Hospital & Diabetes Care Centre, Bhatinda, Punjab, India
| | - P K Hasija
- MH Chennai, Armed Forces Medical Services, India
| | - Harsh Wardhan
- Mahatma Gandhi Medical College and Hospital, Jaipur, India
| | | | | | - D Kahali
- C.K.Birla Group of Hospitals (BMB), Kolkata, India
| | | | | | - N N Khanna
- Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi, India
| | - B Majumder
- R.G. Kar Medical College, Kolkata, India
| | - M Mandal
- NRS Medical College, Kolkata, India
| | - C B Meena
- SMS Medical College, Jaipur, Rajasthan, India
| | | | - V K Narain
- King George's Medical University, Lucknow, India
| | - L A Pathak
- Nanavati Superspeciality Hospital, Mumbai, India
| | - S Ray
- Vivekananda Institute of Medical Sciences, Kolkata, India
| | - D Roy
- Rabindranath Tagore International Institute of Cardiac Sciences, Kolkata, India
| | | | - D Sarma
- Jorhat Christian Medical Centre Hospital, Jorhat, Assam, India
| | | | | | - S K Tyagi
- GB Pant Institute of Post Graduate Medical Education and Research, New Delhi, India
| | | | | | | | - M K Das
- C.K. Birla Group of Hospitals (BMB/CMRI), Kolkata, India
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Agarwal A, Davies D, Goenka S, Prabhakaran D, Huffman MD, Mohanan PP. Facilitators and barriers of heart failure care in Kerala, India: A qualitative analysis of health-care providers and administrators. Indian Heart J 2019; 71:235-241. [PMID: 31543196 PMCID: PMC6796633 DOI: 10.1016/j.ihj.2019.04.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 03/13/2019] [Accepted: 04/26/2019] [Indexed: 12/30/2022] Open
Abstract
Objective Heart failure is a leading cause of death worldwide and in India, yet the qualitative data regarding heart failure care are limited. To fill this gap, we studied the facilitators and barriers of heart failure care in Kerala, India. Methods and results During January 2018, we conducted a qualitative study using in-depth, semi-structured interviews with 21 health-care providers and quality administrators from 8 hospitals in Kerala to understand the context, facilitators, and barriers of heart failure care. We developed a theoretical framework using iteratively developed codes from these data to identify 6 key themes of heart failure care in Kerala: (1) need for comprehensive patient and family education on heart failure; (2) gaps between guideline-directed clinical care for heart failure and clinical practice; (3) national hospital accreditation contributing to a culture of systematically improving quality and safety of in-hospital care; (4) limited system-level attention toward improving heart failure care compared with other cardiovascular conditions; (5) application of existing personnel and technology to improve heart failure care; and (6) longitudinal and recurrent costs as barriers for optimal heart failure care. Conclusions Key themes emerged regarding heart failure care in Kerala in the context of a health system that is increasingly emphasizing health-care quality and safety. Targeted in-hospital quality improvement interventions for heart failure should account for these themes to improve cardiovascular outcomes in the region.
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Affiliation(s)
- Anubha Agarwal
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | - Divin Davies
- WestFort Hi-Tech Hospital Ltd, Thrissur, Kerala, India
| | - Shifalika Goenka
- Centre for Chronic Disease Control, New Delhi, Delhi, India; Public Health Foundation of India, Gurugram, Haryana, India
| | - Dorairaj Prabhakaran
- Centre for Chronic Disease Control, New Delhi, Delhi, India; Public Health Foundation of India, Gurugram, Haryana, India
| | - Mark D Huffman
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; The George Institute for Global Health, Sydney, Australia
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18
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Mohanan PP, Huffman MD, Baldridge AS, Devarajan R, Kondal D, Zhao L, Ali M, Joseph J, Eapen K, Krishnan MN, Menon J, Thomas M, Lloyd-Jones DM, Harikrishnan S, Prabhakaran D. Microeconomic Costs, Insurance, and Catastrophic Health Spending Among Patients With Acute Myocardial Infarction in India: Substudy of a Randomized Clinical Trial. JAMA Netw Open 2019; 2:e193831. [PMID: 31099866 PMCID: PMC6537817 DOI: 10.1001/jamanetworkopen.2019.3831] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
IMPORTANCE Ischemic heart disease is the leading cause of death in India, and treatment can be costly. OBJECTIVE To evaluate individual- and household-level costs and impoverishing effects of acute myocardial infarction among patients in Kerala, India. DESIGN, SETTING, AND PARTICIPANTS This investigation was a prespecified substudy of the Acute Coronary Syndrome Quality Improvement in Kerala study, a stepped-wedge, cluster randomized clinical trial conducted between November 2014 and November 2016 across 63 hospitals in Kerala, India. In this cross-sectional substudy, individual- and household-level cost data were collected 30 days after hospital discharge from a sample of 2114 respondents from November 2014 to July 2016. Data were analyzed from July through October 2018 and in March 2019. EXPOSURES Health insurance status. MAIN OUTCOMES AND MEASURES The primary outcomes were detailed direct and indirect cost data associated with acute myocardial infarction and respondent ability to pay as well as catastrophic health spending and distress financing. Catastrophic health spending was defined as 40% or more of household expenditures minus food costs spent on health, and distress financing was defined as borrowing money or selling assets to cover health costs. Hierarchical regression models were used to evaluate the association between health insurance and measures of financial risk. Costs were converted from Indian rupees to international dollars (represented herein as "$"). RESULTS Among 2114 respondents, the mean (SD) age was 62.3 (12.7) years, 1521 (71.9%) were men, 1144 (54.1%) presented with an ST-segment elevation myocardial infarction, and 1600 (75.7%) had no health insurance. The median (interquartile range) expenditure among respondents was $480.4 ($112.5-$1733.0) per acute myocardial infarction encounter, largely driven by in-hospital expenditures. There was greater than 15-fold variability between the 25th and 75th percentiles. Individuals with or without health insurance had similar monthly incomes and annual household expenditures, yet individuals without health insurance had approximately $400 higher out-of-pocket cardiovascular health care costs (median [interquartile range] total cardiovascular expenditures among uninsured, $560.3 [$134.1-$1733.6] vs insured, $161.4 [$23.2-$1726.9]; P < .001). Individuals without health insurance also had a 24% higher risk of catastrophic health spending (adjusted risk ratio, 1.24; 95% CI, 1.07-1.43) and 3-fold higher risk of distress financing (adjusted risk ratio; 3.05; 95% CI, 1.45-6.44). CONCLUSIONS AND RELEVANCE The results of this study indicate that acute myocardial infarction carries substantial financial risk for patients in Kerala. Expansion of health insurance may be an important strategy for financial risk protection to disrupt the poverty cycle associated with cardiovascular diseases in India.
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Affiliation(s)
| | - Mark D. Huffman
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Raji Devarajan
- Centre for Chronic Disease Control, Gurgaon, India
- Public Health Foundation of India, Gurgaon, India
| | - Dimple Kondal
- Centre for Chronic Disease Control, Gurgaon, India
- Public Health Foundation of India, Gurgaon, India
| | - Lihui Zhao
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Mumtaj Ali
- Centre for Chronic Disease Control, Gurgaon, India
- Public Health Foundation of India, Gurgaon, India
| | - Johny Joseph
- Department of Cardiology, Caritas Hospital, Kottyam, India
| | - Koshy Eapen
- Department of Cardiology, Samaritan Hospital, Pazhangad, India
| | | | - Jaideep Menon
- Department of Cardiology, Sree Narayana Institute of Medical Sciences, Ernakulam, India
| | - Manoj Thomas
- Department of Cardiology, St Joseph’s Hospital, Dharmagiri, India
| | | | | | - Dorairaj Prabhakaran
- Centre for Chronic Disease Control, Gurgaon, India
- Public Health Foundation of India, Gurgaon, India
- London School of Hygiene and Tropical Medicine, London, United Kingdom
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19
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Huffman MD, Mohanan PP, Devarajan R, Baldridge AS, Kondal D, Zhao L, Ali M, Spertus JA, Chan PS, Natesan S, Abdullakutty J, Krishnan MN, Tp A, Renga S, Punnoose E, Unni G, Prabhakaran D, Lloyd-Jones DM. Health-Related Quality of Life at 30 Days Among Indian Patients With Acute Myocardial Infarction. Circ Cardiovasc Qual Outcomes 2019; 12:e004980. [PMID: 30755027 DOI: 10.1161/circoutcomes.118.004980] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Despite a high cardiovascular disease burden, data on patient-reported health status outcomes among individuals with cardiovascular disease in India are limited. METHODS AND RESULTS Between November 2014 and November 2016, we collected health-related quality of life data among 1261 participants in the ACS QUIK trial (Acute Coronary Syndrome Quality Improvement in Kerala). We used a translated, validated version of the Seattle Angina Questionnaire administered 30 days after discharge for acute myocardial infarction, wherein higher scores represent better health status. We compared results across sex, myocardial infarction type, and randomization status using regression models that account for clustering and temporal trends. Mean (SD) age was 60.8 (13.7) years, 62% were men, and 63% presented with ST-segment-elevation myocardial infarction. More than 2 out of 5 respondents (44%) experienced angina 30 days after hospitalization, but most (68% of respondents with angina; 27% of the total sample) experienced it less than once per week (Seattle Angina Questionnaire angina frequency score 60). Respondents rated high median (interquartile range [IQR]) scores for angina frequency (100.0 [80.0-100.0]) overall with similar unadjusted scores by sex, but between-hospitality variability was high. Median (IQR) physical limitation scale response was 58.3 (41.7-77.8), which is consistent with limitations in moderate- and high-intensity activities at 30-day follow-up. Older respondents had more angina frequency and physical limitations and lower treatment satisfaction and quality of life. Women had greater physical limitations (median [IQR], 52.8 [38.9-72.2] for women versus median [IQR], 61.1 [44.4-80.6] for men; P<0.01). Overall treatment satisfaction was high with median (IQR) score, 81.3 (75.0-93.8), but overall quality of life was lower with median (IQR) score, 66.7 (50.0-83.3). Allocation to the quality improvement intervention group had the strongest direct association with higher quality of life (difference, 4.2; P=0.03), but overall effects were modest. CONCLUSIONS This study represents the largest report of quality of life among myocardial infarction survivors in India with variability across age, sex, and quality improvement intervention status. Wide variability demonstrated across hospitals warrants further study. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov . Unique identifier: NCT02256657.
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Affiliation(s)
- Mark D Huffman
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (M.D.H., A.S.B., L.Z., D.M.L.-J.)
| | - Padinhare P Mohanan
- Department of Cardiology, WestFort Hi-Tech Hospital, Ltd, Thrissur, India (P.P.M.)
| | - Raji Devarajan
- Centre for Chronic Disease Control, New Delhi, India (R.D., D.K., M.A., D.P.).,Public Health Foundation of India, Gurgaon (R.D., D.K., M.A., D.P.)
| | - Abigail S Baldridge
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (M.D.H., A.S.B., L.Z., D.M.L.-J.)
| | - Dimple Kondal
- Centre for Chronic Disease Control, New Delhi, India (R.D., D.K., M.A., D.P.).,Public Health Foundation of India, Gurgaon (R.D., D.K., M.A., D.P.)
| | - Lihui Zhao
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (M.D.H., A.S.B., L.Z., D.M.L.-J.)
| | - Mumtaj Ali
- Centre for Chronic Disease Control, New Delhi, India (R.D., D.K., M.A., D.P.).,Public Health Foundation of India, Gurgaon (R.D., D.K., M.A., D.P.)
| | - John A Spertus
- Saint Luke's Mid America Heart Institute, Kansas City, MO (J.A.S., P.S.C.).,University of Missouri-Kansas City (J.A.S., P.S.C.)
| | - Paul S Chan
- Saint Luke's Mid America Heart Institute, Kansas City, MO (J.A.S., P.S.C.).,University of Missouri-Kansas City (J.A.S., P.S.C.)
| | | | | | | | - Abhilash Tp
- Sree Gokulam Medical College and Research Foundation, Thiruvananthapuram, India (A.T.P.)
| | - Sujay Renga
- Bishop Benziger Hospital, Kollam, India (S.R.)
| | - Eapen Punnoose
- Malankara Orthodox Syrian Church Medical College, Ernakulam, India (E.P.)
| | | | - Dorairaj Prabhakaran
- Centre for Chronic Disease Control, New Delhi, India (R.D., D.K., M.A., D.P.).,Public Health Foundation of India, Gurgaon (R.D., D.K., M.A., D.P.).,London School of Hygiene and Tropical Medicine, United Kingdom (D.P.)
| | - Donald M Lloyd-Jones
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (M.D.H., A.S.B., L.Z., D.M.L.-J.)
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20
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Singh K, Devarajan R, Mohanan PP, Baldridge AS, Kondal D, Victorson DE, Karmali KN, Zhao L, Lloyd-Jones DM, Prabhakaran D, Goenka S, Huffman MD. Implementation and acceptability of a heart attack quality improvement intervention in India: a mixed methods analysis of the ACS QUIK trial. Implement Sci 2019; 14:12. [PMID: 30728053 PMCID: PMC6364470 DOI: 10.1186/s13012-019-0857-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 01/16/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The ACS QUIK trial showed that a multicomponent quality improvement toolkit intervention resulted in improvements in processes of care for patients with acute myocardial infarction in Kerala but did not improve clinical outcomes in the context of background improvements in care. We describe the development of the ACS QUIK intervention and evaluate its implementation, acceptability, and sustainability. METHODS We performed a mixed methods process evaluation alongside a cluster randomized, stepped-wedge trial in Kerala, India. The ACS QUIK intervention aimed to reduce the rate of major adverse cardiovascular events at 30 days compared with usual care across 63 hospitals (n = 21,374 patients). The ACS QUIK toolkit intervention, consisting of audit and feedback report, admission and discharge checklists, patient education materials, and guidelines for the development of code and rapid response teams, was developed based on formative qualitative research in Kerala and from systematic reviews. After four or more months of the center's participation in the toolkit intervention phase of the trial, an online survey and physician interviews were administered. Physician interviews focused on evaluating the implementation and acceptability of the toolkit intervention. A framework analysis of transcripts incorporated context and intervening mechanisms. RESULTS Among 63 participating hospitals, 22 physicians (35%) completed online surveys. Of these, 17 (77%) respondents reported that their hospital had a cardiovascular quality improvement team, 18 (82%) respondents reported having read an audit report, admission checklist, or discharge checklist, and 19 (86%) respondents reported using patient education materials. Among the 28 interviewees (44%), facilitators of toolkit intervention implementation were physicians' support and leadership, hospital administrators' support, ease-of-use of checklists and patient education materials, and availability of training opportunities for staff. Barriers that influenced the implementation or acceptability of the toolkit intervention for physicians included time and staff constraints, Internet access, patient volume, and inadequate understanding of the quality improvement toolkit intervention. CONCLUSIONS Implementation and acceptability of the ACS QUIK toolkit intervention were enhanced by hospital-level management support, physician and team support, and usefulness of checklists and patient education materials. Wider and longer-term use of the toolkit intervention and its expansion to potentially other cardiovascular conditions or other locations where the quality of care is not as high as in the ACS QUIK trial may be useful for improving acute cardiovascular care in Kerala and beyond. TRIAL REGISTRATION NCT02256657.
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Affiliation(s)
- Kavita Singh
- Centre for Chronic Disease Control, New Delhi, India
- Public Health Foundation of India, Gurgaon, India
| | - Raji Devarajan
- Centre for Chronic Disease Control, New Delhi, India
- Public Health Foundation of India, Gurgaon, India
| | - Padinhare P Mohanan
- Westfort Hi-Tech Hospital, Ltd, Thrissur, India
- Cardiological Society of India - Kerala Chapter, Kerala, India
| | - Abigail S Baldridge
- Department of Medicine, Northwestern University Feinberg School of Medicine, 680 N. Lake Shore Drive, Suite 1400, Chicago, IL, 60611, USA
| | - Dimple Kondal
- Centre for Chronic Disease Control, New Delhi, India
- Public Health Foundation of India, Gurgaon, India
| | - David E Victorson
- Department of Medicine, Northwestern University Feinberg School of Medicine, 680 N. Lake Shore Drive, Suite 1400, Chicago, IL, 60611, USA
| | - Kunal N Karmali
- Department of Medicine, Northwestern University Feinberg School of Medicine, 680 N. Lake Shore Drive, Suite 1400, Chicago, IL, 60611, USA
| | - Lihui Zhao
- Department of Medicine, Northwestern University Feinberg School of Medicine, 680 N. Lake Shore Drive, Suite 1400, Chicago, IL, 60611, USA
| | - Donald M Lloyd-Jones
- Department of Medicine, Northwestern University Feinberg School of Medicine, 680 N. Lake Shore Drive, Suite 1400, Chicago, IL, 60611, USA
| | - Dorairaj Prabhakaran
- Centre for Chronic Disease Control, New Delhi, India
- Public Health Foundation of India, Gurgaon, India
- London School of Hygiene and Tropical Medicine, London, UK
| | - Shifalika Goenka
- Centre for Chronic Disease Control, New Delhi, India
- Public Health Foundation of India, Gurgaon, India
- Indian Institute of Public Health-Delhi, New Delhi, India
| | - Mark D Huffman
- Department of Medicine, Northwestern University Feinberg School of Medicine, 680 N. Lake Shore Drive, Suite 1400, Chicago, IL, 60611, USA.
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21
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Huffman MD, Mohanan PP, Prabhakaran D. Evidence-based global cardiovascular disease control priority interventions. Indian J Med Res 2018; 148:247-250. [PMID: 30425212 PMCID: PMC6251275 DOI: 10.4103/ijmr.ijmr_1482_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Mark D Huffman
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, United States
| | - P P Mohanan
- Department of Cardiology, Westfort Hi-Tech Hospital, Ltd., Thrissur, India
| | - Dorairaj Prabhakaran
- Executive Director, Centre for Chronic Disease Control, New Delhi; Vice President, Research & Policy, Public Health Foundation of India, Gurugram, India; Department of Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
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Guha S, Harikrishnan S, Ray S, Sethi R, Ramakrishnan S, Banerjee S, Bahl VK, Goswami KC, Banerjee AK, Shanmugasundaram S, Kerkar PG, Seth S, Yadav R, Kapoor A, Mahajan AU, Mohanan PP, Mishra S, Deb PK, Narasimhan C, Pancholia AK, Sinha A, Pradhan A, Alagesan R, Roy A, Vora A, Saxena A, Dasbiswas A, Srinivas BC, Chattopadhyay BP, Singh BP, Balachandar J, Balakrishnan KR, Pinto B, Manjunath CN, Lanjewar CP, Jain D, Sarma D, Paul GJ, Zachariah GA, Chopra HK, Vijayalakshmi IB, Tharakan JA, Dalal JJ, Sawhney JPS, Saha J, Christopher J, Talwar KK, Chandra KS, Venugopal K, Ganguly K, Hiremath MS, Hot M, Das MK, Bardolui N, Deshpande NV, Yadava OP, Bhardwaj P, Vishwakarma P, Rajput RK, Gupta R, Somasundaram S, Routray SN, Iyengar SS, Sanjay G, Tewari S, Sengottuvelu G, Kumar S, Mookerjee S, Nair T, Mishra T, Samal UC, Kaul U, Chopra VK, Narain VS, Raj V, Lokhandwala Y. Corrigendum to "Cardiological Society of India position statement on management of heart failure in India" [Indian Heart J 70 (S1) (2018) S1-S72]. Indian Heart J 2018; 70:952-953. [PMID: 30580876 PMCID: PMC6306345 DOI: 10.1016/j.ihj.2018.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Affiliation(s)
- Santanu Guha
- Chairman, CSI Guidelines Committee; Medical College Kolkata, India
| | - S Harikrishnan
- Chief Coordinator, CSI HF Position Statement; Sree Chitra Tirunal Institute for Medical Sciences & Technology, Trivandrum, Kerala, India.
| | - Saumitra Ray
- Convenor, CSI Guidelines Committee; Vivekananda Institute of Medical Sciences, Kolkata, India
| | - Rishi Sethi
- Joint Coordinator, CSI HF Position Statement; KG Medical University, Lucknow, India
| | - S Ramakrishnan
- Joint Coordinator, CSI HF Position Statement; All India Institute of Medical Sciences, New Delhi, India
| | - Suvro Banerjee
- Joint Convenor, CSI Guidelines Committee; Apollo Hospitals, Kolkata, India
| | - V K Bahl
- Joint Coordinator, CSI HF Position Statement; All India Institute of Medical Sciences, New Delhi, India
| | - K C Goswami
- Joint Coordinator, CSI HF Position Statement; All India Institute of Medical Sciences, New Delhi, India
| | - Amal Kumar Banerjee
- Institute of Post Graduate Medical Education & Research, Kolkata, West Bengal, India
| | - S Shanmugasundaram
- Department of Cardiology, Tamil Nadu Medical University, Billroth Hospital, Chennai, Tamil Nadu, India
| | | | - Sandeep Seth
- Joint Coordinator, CSI HF Position Statement; All India Institute of Medical Sciences, New Delhi, India
| | - Rakesh Yadav
- Joint Coordinator, CSI HF Position Statement; All India Institute of Medical Sciences, New Delhi, India
| | - Aditya Kapoor
- Department of Cardiology, Sanjay Gandhi PGIMS, Lucknow, Uttar Pradesh, India
| | - Ajaykumar U Mahajan
- Department of Cardiology, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, Maharashtra, India
| | - P P Mohanan
- Department of Cardiology, Westfort Hi Tech Hospital, Thrissur, Kerala, India
| | - Sundeep Mishra
- Joint Coordinator, CSI HF Position Statement; All India Institute of Medical Sciences, New Delhi, India
| | - P K Deb
- Daffodil Hospitals, Kolkata, West Bengal, India
| | - C Narasimhan
- Department of Cardiology & Chief of Electro Physiology Department, Care Hospitals, Hyderabad, Telangana, India
| | - A K Pancholia
- Clinical & Preventive Cardiology, Arihant Hospital & Research Centre, Indore, Madhya Pradesh, India
| | | | - Akshyaya Pradhan
- Department of Cardiology, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - R Alagesan
- The Tamil Nadu Dr.M.G.R. Medical University, Tamil Nadu, India
| | - Ambuj Roy
- Joint Coordinator, CSI HF Position Statement; All India Institute of Medical Sciences, New Delhi, India
| | - Amit Vora
- Arrhythmia Associates, Mumbai, Maharashtra, India
| | - Anita Saxena
- Joint Coordinator, CSI HF Position Statement; All India Institute of Medical Sciences, New Delhi, India
| | | | | | | | - B P Singh
- Department of Cardiology, IGIMS, Patna, Bihar, India
| | | | - K R Balakrishnan
- Cardiac Sciences, Fortis Malar Hospital, Adyar, Chennai, Tamil Nadu, India
| | - Brian Pinto
- Holy Family Hospitals, Mumbai, Maharashtra, India
| | - C N Manjunath
- Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bangalore, Karnataka, India
| | | | - Dharmendra Jain
- Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Dipak Sarma
- Cardiology & Critical Care, Jorhat Christian Medical Centre Hospital, Jorhat, Assam, India
| | - G Justin Paul
- Department of Cardiology, Madras Medical College, Chennai, Tamil Nadu, India
| | | | | | - I B Vijayalakshmi
- Bengaluru Medical College and Research Institute, Bengaluru, Karnataka, India
| | - J A Tharakan
- Department of Cardiology, P.K. Das Institute of Medical Sciences, Vaniamkulam, Palakkad, Kerala, India
| | - J J Dalal
- Kokilaben Hospital, Mumbai, Maharashtra, India
| | - J P S Sawhney
- Department of Cardiology, Dharma Vira Heart Center, Sir Ganga Ram Hospital, New Delhi, India
| | - Jayanta Saha
- Chairman, CSI Guidelines Committee; Medical College Kolkata, India
| | | | - K K Talwar
- Max Healthcare, Max Super Speciality Hospital, Saket, New Delhi, India
| | - K Sarat Chandra
- Indo-US Super Speciality Hospital & Virinchi Hospital, Hyderabad, Telangana, India
| | - K Venugopal
- Pushpagiri Institute of Medical Sciences, Tiruvalla, Kerala, India
| | - Kajal Ganguly
- Department of Cardiology, N.R.S. Medical College, Kolkata, West Bengal, India
| | | | - Milind Hot
- Department of CTVS, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Mrinal Kanti Das
- B.M. Birla Heart Research Centre & CMRI, Kolkata, West Bengal, India
| | - Neil Bardolui
- Department of Cardiology, Excelcare Hospitals, Guwahati, Assam, India
| | - Niteen V Deshpande
- Cardiac Cath Lab, Spandan Heart Institute and Research Center, Nagpur, Maharashtra, India
| | - O P Yadava
- National Heart Institute, New Delhi, India
| | - Prashant Bhardwaj
- Department of Cardiology, Military Hospital (Cardio Thoracic Centre), Pune, Maharashtra, India
| | - Pravesh Vishwakarma
- Joint Coordinator, CSI HF Position Statement; KG Medical University, Lucknow, India
| | | | - Rakesh Gupta
- JROP Institute of Echocardiography, New Delhi, India
| | | | - S N Routray
- Department of Cardiology, SCB Medical College, Cuttack, Odisha, India
| | - S S Iyengar
- Manipal Hospitals, Bangalore, Karnataka, India
| | - G Sanjay
- Chief Coordinator, CSI HF Position Statement; Sree Chitra Tirunal Institute for Medical Sciences & Technology, Trivandrum, Kerala, India
| | - Satyendra Tewari
- Department of Cardiology, Sanjay Gandhi PGIMS, Lucknow, Uttar Pradesh, India
| | | | - Soumitra Kumar
- Convenor, CSI Guidelines Committee; Vivekananda Institute of Medical Sciences, Kolkata, India
| | - Soura Mookerjee
- Chairman, CSI Guidelines Committee; Medical College Kolkata, India
| | - Tiny Nair
- Department of Cardiology, P.R.S. Hospital, Trivandrum, Kerala, India
| | - Trinath Mishra
- Department of Cardiology, M.K.C.G. Medical College, Behrampur, Odisha, India
| | | | - U Kaul
- Batra Heart Center & Batra Hospital and Medical Research Center, New Delhi, India
| | - V K Chopra
- Heart Failure Programme, Department of Cardiology, Medanta Medicity, Gurugram, Haryana, India
| | - V S Narain
- Joint Coordinator, CSI HF Position Statement; KG Medical University, Lucknow, India
| | - Vimal Raj
- Narayana Hrudayalaya Hospital, Bangalore, Karnataka, India
| | - Yash Lokhandwala
- Mumbai & Visiting Faculty, Sion Hospital, Mumbai, Maharashtra, India
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Sarma S, Harikrishnan S, Baldridge AS, Devarajan R, Mehta A, Selvaraj S, Ali MK, Mohanan PP, Prabhakaran D, Huffman MD. Availability, Sales, and Affordability of Tobacco Cessation Medicines in Kerala, India. Circ Cardiovasc Qual Outcomes 2018; 10:CIRCOUTCOMES.117.004108. [PMID: 29150536 DOI: 10.1161/circoutcomes.117.004108] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Accepted: 10/23/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND India is the world's second largest consumer of tobacco, but tobacco cessation remains uncommon due, at least in part, to underutilization of cessation pharmacotherapy. We evaluated the availability, sales, and affordability of nicotine replacement therapy, bupropion, and varenicline in the South Indian state of Kerala to understand potential reasons for underutilization. METHODS AND RESULTS From November 2016 to April 2017, we collected data on availability, inventory, and pricing of cessation medication through a cross-sectional survey of 199 public, semiprivate (Karunya), and private pharmacies across 5 districts in Kerala using World Health Organization/Health Action International methodology. Revenue and sales data were obtained from the latest Pharmatrac medication database. We assessed affordability using individual- and household-level income and expenditure data collected from November 2014 to November 2016 through the Acute Coronary Syndrome Quality Improvement in Kerala randomized trial. Cessation medications were not available in public hospitals (0%, n=58) nor in public specialty centers (0%, n=10) including those designated to provide cessation services. At least 1 cessation medicine was available at 63% of private pharmacies (n=109) and 27% of Karunya (semiprivate) pharmacies (n=22). Among the 75 pharmacies that stocked cessation medications, 96% had nicotine replacement therapy, 28% had bupropion, and 1% had varenicline. No outlets had sufficient inventory for a patient to purchase a 12-week treatment regimen. There were an estimated 253 270 treatment regimens sold throughout India and 14 092 in Kerala in 2013 to 2014. Treatment regimens cost 1.9 to 13.0× the median amount spent on smoked tobacco and between 8% and 52% of nonsubsistence income. CONCLUSIONS Tobacco cessation medications are unavailable in the Kerala public sector and have limited availability in the private and semiprivate sectors. When available, medications are unaffordable for most patients. Addition of tobacco cessation medication onto national and state essential medicines lists may help increase access. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov. Unique identifier: NCT02256657.
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Affiliation(s)
- Smitha Sarma
- From the Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL (S. Sarma, A.S.B., M.D.H.); Department of Cardiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India (S.H.); Public Health Foundation of India and Centre for Chronic Disease Control, Gurgaon, Haryana, India (R.D., D.P.); Public Health Foundation of India, Gurgaon, Haryana, India (A.M.); Public Health Foundation of India, Delhi, India (S. Selvaraj); Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA (M.K.A.); and Department of Cardiology, Westfort Hi-Tech Hospital Ltd, Thrissur, Kerala, India (P.P.M.)
| | - Sivadasanpillai Harikrishnan
- From the Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL (S. Sarma, A.S.B., M.D.H.); Department of Cardiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India (S.H.); Public Health Foundation of India and Centre for Chronic Disease Control, Gurgaon, Haryana, India (R.D., D.P.); Public Health Foundation of India, Gurgaon, Haryana, India (A.M.); Public Health Foundation of India, Delhi, India (S. Selvaraj); Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA (M.K.A.); and Department of Cardiology, Westfort Hi-Tech Hospital Ltd, Thrissur, Kerala, India (P.P.M.)
| | - Abigail S Baldridge
- From the Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL (S. Sarma, A.S.B., M.D.H.); Department of Cardiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India (S.H.); Public Health Foundation of India and Centre for Chronic Disease Control, Gurgaon, Haryana, India (R.D., D.P.); Public Health Foundation of India, Gurgaon, Haryana, India (A.M.); Public Health Foundation of India, Delhi, India (S. Selvaraj); Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA (M.K.A.); and Department of Cardiology, Westfort Hi-Tech Hospital Ltd, Thrissur, Kerala, India (P.P.M.)
| | - Raji Devarajan
- From the Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL (S. Sarma, A.S.B., M.D.H.); Department of Cardiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India (S.H.); Public Health Foundation of India and Centre for Chronic Disease Control, Gurgaon, Haryana, India (R.D., D.P.); Public Health Foundation of India, Gurgaon, Haryana, India (A.M.); Public Health Foundation of India, Delhi, India (S. Selvaraj); Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA (M.K.A.); and Department of Cardiology, Westfort Hi-Tech Hospital Ltd, Thrissur, Kerala, India (P.P.M.)
| | - Aashna Mehta
- From the Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL (S. Sarma, A.S.B., M.D.H.); Department of Cardiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India (S.H.); Public Health Foundation of India and Centre for Chronic Disease Control, Gurgaon, Haryana, India (R.D., D.P.); Public Health Foundation of India, Gurgaon, Haryana, India (A.M.); Public Health Foundation of India, Delhi, India (S. Selvaraj); Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA (M.K.A.); and Department of Cardiology, Westfort Hi-Tech Hospital Ltd, Thrissur, Kerala, India (P.P.M.)
| | - Sakhtivel Selvaraj
- From the Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL (S. Sarma, A.S.B., M.D.H.); Department of Cardiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India (S.H.); Public Health Foundation of India and Centre for Chronic Disease Control, Gurgaon, Haryana, India (R.D., D.P.); Public Health Foundation of India, Gurgaon, Haryana, India (A.M.); Public Health Foundation of India, Delhi, India (S. Selvaraj); Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA (M.K.A.); and Department of Cardiology, Westfort Hi-Tech Hospital Ltd, Thrissur, Kerala, India (P.P.M.)
| | - Mohammed K Ali
- From the Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL (S. Sarma, A.S.B., M.D.H.); Department of Cardiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India (S.H.); Public Health Foundation of India and Centre for Chronic Disease Control, Gurgaon, Haryana, India (R.D., D.P.); Public Health Foundation of India, Gurgaon, Haryana, India (A.M.); Public Health Foundation of India, Delhi, India (S. Selvaraj); Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA (M.K.A.); and Department of Cardiology, Westfort Hi-Tech Hospital Ltd, Thrissur, Kerala, India (P.P.M.)
| | - Padinhare P Mohanan
- From the Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL (S. Sarma, A.S.B., M.D.H.); Department of Cardiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India (S.H.); Public Health Foundation of India and Centre for Chronic Disease Control, Gurgaon, Haryana, India (R.D., D.P.); Public Health Foundation of India, Gurgaon, Haryana, India (A.M.); Public Health Foundation of India, Delhi, India (S. Selvaraj); Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA (M.K.A.); and Department of Cardiology, Westfort Hi-Tech Hospital Ltd, Thrissur, Kerala, India (P.P.M.)
| | - Dorairaj Prabhakaran
- From the Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL (S. Sarma, A.S.B., M.D.H.); Department of Cardiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India (S.H.); Public Health Foundation of India and Centre for Chronic Disease Control, Gurgaon, Haryana, India (R.D., D.P.); Public Health Foundation of India, Gurgaon, Haryana, India (A.M.); Public Health Foundation of India, Delhi, India (S. Selvaraj); Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA (M.K.A.); and Department of Cardiology, Westfort Hi-Tech Hospital Ltd, Thrissur, Kerala, India (P.P.M.)
| | - Mark D Huffman
- From the Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL (S. Sarma, A.S.B., M.D.H.); Department of Cardiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India (S.H.); Public Health Foundation of India and Centre for Chronic Disease Control, Gurgaon, Haryana, India (R.D., D.P.); Public Health Foundation of India, Gurgaon, Haryana, India (A.M.); Public Health Foundation of India, Delhi, India (S. Selvaraj); Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA (M.K.A.); and Department of Cardiology, Westfort Hi-Tech Hospital Ltd, Thrissur, Kerala, India (P.P.M.).
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Guha S, Harikrishnan S, Ray S, Sethi R, Ramakrishnan S, Banerjee S, Bahl VK, Goswami KC, Banerjee AK, Shanmugasundaram S, Kerkar PG, Seth S, Yadav R, Kapoor A, Mahajan AU, Mohanan PP, Mishra S, Deb PK, Narasimhan C, Pancholia AK, Sinha A, Pradhan A, Alagesan R, Roy A, Vora A, Saxena A, Dasbiswas A, Srinivas BC, Chattopadhyay BP, Singh BP, Balachandar J, Balakrishnan KR, Pinto B, Manjunath CN, Lanjewar CP, Jain D, Sarma D, Paul GJ, Zachariah GA, Chopra HK, Vijayalakshmi IB, Tharakan JA, Dalal JJ, Sawhney JPS, Saha J, Christopher J, Talwar KK, Chandra KS, Venugopal K, Ganguly K, Hiremath MS, Hot M, Das MK, Bardolui N, Deshpande NV, Yadava OP, Bhardwaj P, Vishwakarma P, Rajput RK, Gupta R, Somasundaram S, Routray SN, Iyengar SS, Sanjay G, Tewari S, G S, Kumar S, Mookerjee S, Nair T, Mishra T, Samal UC, Kaul U, Chopra VK, Narain VS, Raj V, Lokhandwala Y. CSI position statement on management of heart failure in India. Indian Heart J 2018; 70 Suppl 1:S1-S72. [PMID: 30122238 PMCID: PMC6097178 DOI: 10.1016/j.ihj.2018.05.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Affiliation(s)
- Santanu Guha
- Chairman, CSI Guidelines Committee; Medical College Kolkata, India
| | - S Harikrishnan
- Chief Coordinator, CSI HF Position Statement; Sree Chitra Tirunal Institute for Medical Sciences & Technology, Trivandrum, Kerala, India.
| | - Saumitra Ray
- Convenor, CSI Guidelines Committee; Vivekananda Institute of Medical Sciences, Kolkata
| | - Rishi Sethi
- Joint Coordinator, CSI HF Position Statement; KG Medical University, Lucknow
| | - S Ramakrishnan
- Joint Coordinator, CSI HF Position Statement; All India Institute of Medical Sciences, New Delhi, India
| | - Suvro Banerjee
- Joint Convenor, CSI Guidelines Committee; Apollo Hospitals, Kolkata
| | - V K Bahl
- Joint Coordinator, CSI HF Position Statement; All India Institute of Medical Sciences, New Delhi, India
| | - K C Goswami
- Joint Coordinator, CSI HF Position Statement; All India Institute of Medical Sciences, New Delhi, India
| | - Amal Kumar Banerjee
- Institute of Post Graduate Medical Education & Research, Kolkata, West Bengal, India
| | - S Shanmugasundaram
- Department of Cardiology, Tamil Nadu Medical University, Billroth Hospital, Chennai, Tamil Nadu, India
| | | | - Sandeep Seth
- Joint Coordinator, CSI HF Position Statement; All India Institute of Medical Sciences, New Delhi, India
| | - Rakesh Yadav
- Joint Coordinator, CSI HF Position Statement; All India Institute of Medical Sciences, New Delhi, India
| | - Aditya Kapoor
- Department of Cardiology, Sanjay Gandhi PGIMS, Lucknow, Uttar Pradesh, India
| | - Ajaykumar U Mahajan
- Department of Cardiology, LokmanyaTilak Municipal Medical College and General Hospital, Mumbai, Maharashtra, India
| | - P P Mohanan
- Department of Cardiology, Westfort Hi Tech Hospital, Thrissur, Kerala, India
| | - Sundeep Mishra
- Joint Coordinator, CSI HF Position Statement; All India Institute of Medical Sciences, New Delhi, India
| | - P K Deb
- Daffodil Hospitals, Kolkata, West Bengal, India
| | - C Narasimhan
- Department of Cardiology & Chief of Electro Physiology Department, Care Hospitals, Hyderabad, Telangana, India
| | - A K Pancholia
- Clinical & Preventive Cardiology, Arihant Hospital & Research Centre, Indore, Madhya Pradesh, India
| | | | - Akshyaya Pradhan
- Department of Cardiology, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - R Alagesan
- The Tamil Nadu Dr.M.G.R. Medical University, Tamil Nadu, India
| | - Ambuj Roy
- Joint Coordinator, CSI HF Position Statement; All India Institute of Medical Sciences, New Delhi, India
| | - Amit Vora
- Arrhythmia Associates, Mumbai, Maharashtra, India
| | - Anita Saxena
- Joint Coordinator, CSI HF Position Statement; All India Institute of Medical Sciences, New Delhi, India
| | | | | | | | - B P Singh
- Department of Cardiology, IGIMS, Patna, Bihar, India
| | | | - K R Balakrishnan
- Cardiac Sciences, Fortis Malar Hospital, Adyar, Chennai, Tamil Nadu, India
| | - Brian Pinto
- Holy Family Hospitals, Mumbai, Maharashtra, India
| | - C N Manjunath
- Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bangalore, Karnataka, India
| | | | - Dharmendra Jain
- Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Dipak Sarma
- Cardiology & Critical Care, Jorhat Christian Medical Centre Hospital, Jorhat, Assam, India
| | - G Justin Paul
- Department of Cardiology, Madras Medical College, Chennai, Tamil Nadu, India
| | | | | | - I B Vijayalakshmi
- Bengaluru Medical College and Research Institute, Bengaluru, Karnataka, India
| | - J A Tharakan
- Department of Cardiology, P.K. Das Institute of Medical Sciences, Vaniamkulam, Palakkad, Kerala, India
| | - J J Dalal
- Kokilaben Hospital, Mumbai, Maharshtra, India
| | - J P S Sawhney
- Department of Cardiology, Dharma Vira Heart Center, Sir Ganga Ram Hospital, New Delhi, India
| | - Jayanta Saha
- Chairman, CSI Guidelines Committee; Medical College Kolkata, India
| | | | - K K Talwar
- Max Healthcare, Max Super Speciality Hospital, Saket, New Delhi, India
| | - K Sarat Chandra
- Indo-US Super Speciality Hospital & Virinchi Hospital, Hyderabad, Telangana, India
| | - K Venugopal
- Pushpagiri Institute of Medical Sciences, Tiruvalla, Kerala, India
| | - Kajal Ganguly
- Department of Cardiology, N.R.S. Medical College, Kolkata, West Bengal, India
| | | | - Milind Hot
- Department of CTVS, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Mrinal Kanti Das
- B.M. Birla Heart Research Centre & CMRI, Kolkata, West Bengal, India
| | - Neil Bardolui
- Department of Cardiology, Excelcare Hospitals, Guwahati, Assam, India
| | - Niteen V Deshpande
- Cardiac Cath Lab, Spandan Heart Institute and Research Center, Nagpur, Maharashtra, India
| | - O P Yadava
- National Heart Institute, New Delhi, India
| | - Prashant Bhardwaj
- Department of Cardiology, Military Hospital (Cardio Thoracic Centre), Pune, Maharashtra, India
| | - Pravesh Vishwakarma
- Joint Coordinator, CSI HF Position Statement; KG Medical University, Lucknow
| | | | - Rakesh Gupta
- JROP Institute of Echocardiography, New Delhi, India
| | | | - S N Routray
- Department of Cardiology, SCB Medical College, Cuttack, Odisha, India
| | - S S Iyengar
- Manipal Hospitals, Bangalore, Karnataka, India
| | - G Sanjay
- Chief Coordinator, CSI HF Position Statement; Sree Chitra Tirunal Institute for Medical Sciences & Technology, Trivandrum, Kerala, India
| | - Satyendra Tewari
- Department of Cardiology, Sanjay Gandhi PGIMS, Lucknow, Uttar Pradesh, India
| | | | - Soumitra Kumar
- Convenor, CSI Guidelines Committee; Vivekananda Institute of Medical Sciences, Kolkata
| | - Soura Mookerjee
- Chairman, CSI Guidelines Committee; Medical College Kolkata, India
| | - Tiny Nair
- Department of Cardiology, P.R.S. Hospital, Trivandrum, Kerala, India
| | - Trinath Mishra
- Department of Cardiology, M.K.C.G. Medical College, Behrampur, Odisha, India
| | | | - U Kaul
- Batra Heart Center & Batra Hospital and Medical Research Center, New Delhi, India
| | - V K Chopra
- Heart Failure Programme, Department of Cardiology, Medanta Medicity, Gurugram, Haryana, India
| | - V S Narain
- Joint Coordinator, CSI HF Position Statement; KG Medical University, Lucknow
| | - Vimal Raj
- Narayana Hrudayalaya Hospital, Bangalore, Karnataka, India
| | - Yash Lokhandwala
- Mumbai & Visiting Faculty, Sion Hospital, Mumbai, Maharashtra, India
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Huffman MD, Mohanan PP, Devarajan R, Baldridge AS, Kondal D, Zhao L, Ali M, Krishnan MN, Natesan S, Gopinath R, Viswanathan S, Stigi J, Joseph J, Chozhakkat S, Lloyd-Jones DM, Prabhakaran D. Effect of a Quality Improvement Intervention on Clinical Outcomes in Patients in India With Acute Myocardial Infarction: The ACS QUIK Randomized Clinical Trial. JAMA 2018; 319:567-578. [PMID: 29450524 PMCID: PMC5838631 DOI: 10.1001/jama.2017.21906] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
IMPORTANCE Wide heterogeneity exists in acute myocardial infarction treatment and outcomes in India. OBJECTIVE To evaluate the effect of a locally adapted quality improvement tool kit on clinical outcomes and process measures in Kerala, a southern Indian state. DESIGN, SETTING, AND PARTICIPANTS Cluster randomized, stepped-wedge clinical trial conducted between November 10, 2014, and November 9, 2016, in 63 hospitals in Kerala, India, with a last date of follow-up of December 31, 2016. During 5 predefined steps over the study period, hospitals were randomly selected to move in a 1-way crossover from the control group to the intervention group. Consecutively presenting patients with acute myocardial infarction were offered participation. INTERVENTIONS Hospitals provided either usual care (control group; n = 10 066 participants [step 0: n = 2915; step 1: n = 2649; step 2: n = 2251; step 3: n = 1422; step 4; n = 829; step 5: n = 0]) or care using a quality improvement tool kit (intervention group; n = 11 308 participants [step 0: n = 0; step 1: n = 662; step 2: n = 1265; step 3: n = 2432; step 4: n = 3214; step 5: n = 3735]) that consisted of audit and feedback, checklists, patient education materials, and linkage to emergency cardiovascular care and quality improvement training. MAIN OUTCOMES AND MEASURES The primary outcome was the composite of all-cause death, reinfarction, stroke, or major bleeding using standardized definitions at 30 days. Secondary outcomes included the primary outcome's individual components, 30-day cardiovascular death, medication use, and tobacco cessation counseling. Mixed-effects logistic regression models were used to account for clustering and temporal trends. RESULTS Among 21 374 eligible randomized participants (mean age, 60.6 [SD, 12.0] years; n = 16 183 men [76%] ; n = 13 689 [64%] with ST-segment elevation myocardial infarction), 21 079 (99%) completed the trial. The primary composite outcome was observed in 5.3% of the intervention participants and 6.4% of the control participants. The observed difference in 30-day major adverse cardiovascular event rates between the groups was not statistically significant after adjustment (adjusted risk difference, -0.09% [95% CI, -1.32% to 1.14%]; adjusted odds ratio, 0.98 [95% CI, 0.80-1.21]). The intervention group had a higher rate of medication use including reperfusion but no effect on tobacco cessation counseling. There were no unexpected adverse events reported. CONCLUSIONS AND RELEVANCE Among patients with acute myocardial infarction in Kerala, India, use of a quality improvement intervention compared with usual care did not decrease a composite of 30-day major adverse cardiovascular events. Further research is needed to understand the lack of efficacy. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT02256657.
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Affiliation(s)
- Mark D. Huffman
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Raji Devarajan
- Centre for Chronic Disease Control, Gurgaon, India
- Public Health Foundation of India, Gurgaon, India
| | | | - Dimple Kondal
- Centre for Chronic Disease Control, Gurgaon, India
- Public Health Foundation of India, Gurgaon, India
| | - Lihui Zhao
- Centre for Chronic Disease Control, Gurgaon, India
- Public Health Foundation of India, Gurgaon, India
| | - Mumtaj Ali
- Centre for Chronic Disease Control, Gurgaon, India
- Public Health Foundation of India, Gurgaon, India
| | | | | | | | | | | | | | | | | | - Dorairaj Prabhakaran
- Centre for Chronic Disease Control, Gurgaon, India
- Public Health Foundation of India, Gurgaon, India
- London School of Hygiene and Tropical Medicine, London, England
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Guha S, Sethi R, Ray S, Bahl VK, Shanmugasundaram S, Kerkar P, Ramakrishnan S, Yadav R, Chaudhary G, Kapoor A, Mahajan A, Sinha AK, Mullasari A, Pradhan A, Banerjee AK, Singh BP, Balachander J, Pinto B, Manjunath CN, Makhale C, Roy D, Kahali D, Zachariah G, Wander GS, Kalita HC, Chopra HK, Jabir A, Tharakan J, Paul J, Venogopal K, Baksi KB, Ganguly K, Goswami KC, Somasundaram M, Chhetri MK, Hiremath MS, Ravi MS, Das MK, Khanna NN, Jayagopal PB, Asokan PK, Deb PK, Mohanan PP, Chandra P, Girish CR, Rabindra Nath O, Gupta R, Raghu C, Dani S, Bansal S, Tyagi S, Routray S, Tewari S, Chandra S, Mishra SS, Datta S, Chaterjee SS, Kumar S, Mookerjee S, Victor SM, Mishra S, Alexander T, Samal UC, Trehan V. Cardiological Society of India: Position statement for the management of ST elevation myocardial infarction in India. Indian Heart J 2017; 69 Suppl 1:S63-S97. [PMID: 28400042 PMCID: PMC5388060 DOI: 10.1016/j.ihj.2017.03.006] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Affiliation(s)
| | - Rishi Sethi
- King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Saumitra Ray
- Vivekananda Institute of Medical Sciences, Kolkata, West Bengal, India
| | - Vinay K Bahl
- All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | | | - Prafula Kerkar
- Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | | | - Rakesh Yadav
- All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | | | - Aditya Kapoor
- Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Ajay Mahajan
- Lokmanya Tilak Municipal Medical College & General Hospital, Mumbai, Maharashtra, India
| | | | | | | | - Amal Kumar Banerjee
- Institute of Post Graduate Medical Education & Research and Memorial Hospital, Kolkata, West Bengal, India
| | - B P Singh
- Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India
| | - J Balachander
- Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Puducherry, India
| | - Brian Pinto
- Holy family Hospital, Mumbai, Maharashtra, India
| | - C N Manjunath
- Sri Jaydeva Institute of Cardiovascular Sciences & Research, Bangaluru, Karnataka, India
| | | | | | - Dhiman Kahali
- BM Birla Heart Research Center, Kolkata, West Bengal, India
| | | | - G S Wander
- Hero DMC Heart Institute, Ludhiana, Punjab, India
| | - H C Kalita
- Assam Medical College, Dibrugarh, Assam, India
| | | | - A Jabir
- Lisie Hospital, Kochi, Kerala, India
| | - JagMohan Tharakan
- Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Justin Paul
- Madras Medical College, Chennai, Tamil Nadu, India
| | - K Venogopal
- Pushpagiri Institute of Medical Sciences, Tiruvalla, Kerala, India
| | - K B Baksi
- Belle Vue Clinic, Kolkata, West Bengal, India
| | | | - Kewal C Goswami
- All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | | | - M K Chhetri
- IPGMER & SSKM Hospital, Kolkata, West Bengal, India
| | | | - M S Ravi
- Madras Medical College, Chennai, Tamil Nadu, India
| | | | | | | | - P K Asokan
- The Fatima Hospital, Calicut, Kerala, India
| | - P K Deb
- ESI Hospital, Manicktala, Kolkata, West Bengal, India
| | - P P Mohanan
- Westfort Hi-Tech Hospital, Thrissur, Kerala, India
| | | | - Col R Girish
- Command Hospital, Central Command, Lucknow, India
| | - O Rabindra Nath
- Apollo Gleneagles Heart Institute, Kolkata, West Bengal, India
| | | | - C Raghu
- Prime Hospitals, Hyderabad, India
| | | | | | - Sanjay Tyagi
- GB Pant Institute of Post Graduate Medical Education & Research, New Delhi, India
| | | | - Satyendra Tewari
- Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | | | | | | | - S S Chaterjee
- Indra Gandhi Institute of Cardiology, Patna, Bihar, India
| | - Soumitra Kumar
- Vivekananda Institute of Medical Sciences, Kolkata, West Bengal, India
| | | | | | - Sundeep Mishra
- All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | | | | | - Vijay Trehan
- Indo-US Super Speciality Hospital, Hyderabad, India
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Mathew A, Abdullakutty J, Sebastian P, Viswanathan S, Mathew C, Nair V, Mohanan PP, George Koshy A. Population access to reperfusion services for ST-segment elevation myocardial infarction in Kerala, India. Indian Heart J 2017; 69 Suppl 1:S51-S56. [PMID: 28400039 PMCID: PMC5388050 DOI: 10.1016/j.ihj.2017.02.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Revised: 02/13/2017] [Accepted: 02/20/2017] [Indexed: 01/17/2023] Open
Abstract
Background Population access to timely reperfusion is a decisive factor in determining the success and acceptability of any regional system of ST-segment elevation myocardial infarction (STEMI) care. We sought to determine the proportion of population of the southern Indian state of Kerala having timely access to STEMI reperfusion. Methods We identified the STEMI reperfusion facilities available at all acute-care hospitals, in Kerala, by conducting a cross-sectional survey. We mapped the geographical catchment areas of these hospitals using historical travel speeds and appropriate Geospatial Information Systems (GIS) analyses. Subsequently, using block level population data, we estimated the proportion of the population residing within these geographies. Results We estimated that 23.33 million people, forming 69.84% of the state population, resided in the green zone (within half-hour travel distance of a percutaneous coronary intervention [PCI]-capable hospital), which covered 47.94% of the geographical area of the state. Outside this green zone, 21.87% of the state population resided within 1 hr travel distance of a thrombolysis-capable hospital. Finally, 8.28% of the state population resided in the red zone, where access to any reperfusion-capable hospital took >1 hr, which covered 22.15% of the geographical area of the state. Conclusions A majority of the population of Kerala had timely access to PCI-capable hospitals. GIS-based mapping of Indian states, in terms of access to STEMI reperfusion, may help devise protocols to achieve seamless transfer of patients to reperfusion-capable hospitals. Such regionalization of STEMI care would enhance organizational synergies to achieve better access to reperfusion, especially in remote areas.
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Affiliation(s)
- Anoop Mathew
- MOSC Medical College Hospital, Kolenchery, Kerala, India.
| | | | | | | | - Cibu Mathew
- Government Medical College Hospital, Thrissur, Kerala, India
| | | | | | - A George Koshy
- Government Medical College Hospital, Thiruvanathapuram, Kerala, India
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Patel A, Mohanan PP, Prabhakaran D, Huffman MD. Pre-hospital acute coronary syndrome care in Kerala, India: A qualitative analysis. Indian Heart J 2016; 69:93-100. [PMID: 28228314 PMCID: PMC5319123 DOI: 10.1016/j.ihj.2016.07.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Revised: 06/26/2016] [Accepted: 07/16/2016] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE Ischemic heart disease is the leading cause of death in India. Many of these deaths are due to acute coronary syndromes (ACS), which require prompt symptom recognition, care-seeking behavior, and transport to a treatment facility in the critical pre-hospital period. In India, little is known about pre-hospital management of individuals with ACS. We aim to understand the facilitators, barriers, and context of optimal pre-hospital ACS care to provide opportunities to reduce pre-hospital delays and improve acute cardiovascular care. METHODS AND RESULTS We conducted a qualitative study using in-depth interviews and focus group discussions with 27 ACS providers in Kerala, India to understand facilitators, barriers, and context to pre-hospital ACS care. Six themes emerged from these interviews and discussions: (1) individuals with ACS misperceive their symptoms as non-cardiac in origin; (2) emergency medical services are infrequently used; (3) insufficient pre-hospital healthcare infrastructure contributes to pre-hospital delay; (4) multiple stops are made before arriving at a facility that can provide definitive diagnosis and treatment; (5) relatively high costs of treatment and lack of widespread health insurance coverage limits care delivery; and (6) novel mobile technologies may allow for faster diagnosis and initiation of treatment in the pre-hospital setting. CONCLUSIONS Individualized patient-based factors (general knowledge of ACS symptoms, socioeconomic position) and broader systems-based factors (ambulance networks, coordination of transport) affect pre-hospital ACS care in Kerala. Improving public awareness of ACS symptoms, increasing appropriate use of emergency medical services, and building a infrastructure for rapid and coordinated transport may improve pre-hospital ACS care.
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Affiliation(s)
- Amisha Patel
- Departments of Preventive Medicine and Medicine-Cardiology, Northwestern University Feinberg School of Medicine, Chicago, USA.
| | | | - Dorairaj Prabhakaran
- Centre for Chronic Disease Control and Public Health Foundation of India, Gurgaon, NCR, India
| | - Mark D Huffman
- Departments of Preventive Medicine and Medicine-Cardiology, Northwestern University Feinberg School of Medicine, Chicago, USA
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Patel A, Prabhakaran D, Berendsen M, Mohanan PP, Huffman MD. Pre-hospital policies for the care of patients with acute coronary syndromes in India: A policy document analysis. Indian Heart J 2016; 69 Suppl 1:S12-S19. [PMID: 28400033 PMCID: PMC5388021 DOI: 10.1016/j.ihj.2016.06.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2016] [Revised: 06/19/2016] [Accepted: 06/22/2016] [Indexed: 11/28/2022] Open
Abstract
Background and objective Ischemic heart disease is the leading cause of death in India. In high-income countries, pre-hospital systems of care have been developed to manage acute manifestations of ischemic heart disease, such as acute coronary syndrome (ACS). However, it is unknown whether guidelines, policies, regulations, or laws exist to guide pre-hospital ACS care in India. We undertook a nation-wide document analysis to address this gap in knowledge. Methods and results From November 2014 to May 2016, we searched for publicly available emergency care guidelines and legislation addressing pre-hospital ACS care in all 29 Indian states and 7 Union Territories via Internet search and direct correspondence. We found two documents addressing pre-hospital ACS care. Conclusion Though India has legislation mandating acute care for emergencies such as trauma, regulations or laws to guide pre-hospital ACS care are largely absent. Policy makers urgently need to develop comprehensive, multi-stakeholder policies for pre-hospital emergency cardiovascular care in India.
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Affiliation(s)
- Amisha Patel
- Departments of Preventive Medicine and Medicine-Cardiology, Northwestern University Feinberg School of Medicine, Chicago, USA.
| | - Dorairaj Prabhakaran
- Centre for Chronic Disease Control, Gurgaon, India; Public Health Foundation of India, Gurgaon, India
| | - Mark Berendsen
- Galter Health Sciences Library, Northwestern University Feinberg School of Medicine, Chicago, USA
| | | | - Mark D Huffman
- Departments of Preventive Medicine and Medicine-Cardiology, Northwestern University Feinberg School of Medicine, Chicago, USA
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Bansal M, Sarat Chandra K, Nair T, Iyengar SS, Gupta R, Manchanda SC, Mohanan PP, Dayasagar Rao V, Manjunath CN, Sawhney JPS, Sinha N, Pancholia AK, Mishra S, Kasliwal RR, Kumar S, Krishnan U, Kalra S, Misra A, Shrivastava U, Gulati S. Consensus statement on the management of dyslipidemia in Indian subjects: Our perspective. Indian Heart J 2016; 68:238-41. [PMID: 27133351 PMCID: PMC4867022 DOI: 10.1016/j.ihj.2016.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2016] [Accepted: 02/02/2016] [Indexed: 11/29/2022] Open
Affiliation(s)
- Manish Bansal
- Senior Consultant Cardiology, Medanta The Medicity, Sector 38, Gurgaon, Haryana 122001, India
| | - K Sarat Chandra
- Sr. Cardiologist, Indo US Superspecialty Hospital, Ameerpet, Hyderabad 500016, India.
| | - Tiny Nair
- Head, Department of Cardiology, PRS Hospital, Trivandrum, Akashdeep, TC 17/881, Poojapura, Trivandrum, Kerala 695012, India
| | - S S Iyengar
- Sr. Consultant & HOD, Manipal Hospital, 133, JalaVayu Towers, NGEF Layout, Indira Nagar, Bangalore 560038, India
| | - Rajeev Gupta
- Head of Medicine and Director Research, Fortis Escorts Hospital, JLN Marg, Malviya Nagar, Jaipur 302017, India
| | | | - P P Mohanan
- Westfort H. Hospital, Poonkunnanm, Thrissur 680002, India
| | - V Dayasagar Rao
- Sr. Cardiologist, Krishna Institute of Medical Science, Minister Road, Secunderabad, India
| | - C N Manjunath
- Director, Prof & HOD, Sri Jayadeva Institute of Cardiovascular Sciences & Research, Bannerghatta Road, Bangalore 560069, India
| | - J P S Sawhney
- Chairman, Department of Cardiology, Sir Ganga Ram Hospital, New Delhi, India
| | - Nakul Sinha
- Sr. Consultant & Chief Interventional Cardiologist, Sahara India Medical Institute, VirajKhand, Gomti Nagar, Lucknow, Uttar Pradesh 226010, India
| | - A K Pancholia
- Head, Department of Clinical and Preventive Cardiology and Research Centre, Arihant Hospital, Indore, MP, India
| | - Sundeep Mishra
- Prof. Cardiology, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Ravi R Kasliwal
- Chairman, Clinical and Preventive Cardiology, Medanta The Medicity, Sector 38, Gurgaon, Haryana 122001, India
| | - Soumitra Kumar
- Professor, Vivekanada Institute of Medical Sciences, Kolkata, India; Chief Co-ordinator, Academic Services (Cardiology), Narayana Hrudayalay, RTIICS, Kolkata, India; Consultant Cardiologist, Fortis Hospital, Kolkata, India
| | - Unni Krishnan
- Chief Endocrinologist & CEO, Chellaram Diabetes Institute, Pune 411021, India
| | - Sanjay Kalra
- Consultant Endocrinology, Bharti Hospital & BRIDE, Karnal, Haryana, India
| | - Anoop Misra
- Chairman, Fortis-C-DOC Centre of Excellence for Diabetes, Metabolic Diseases and Endocrinology, Chirag Enclave, New Delhi, India
| | - Usha Shrivastava
- Head, Public Health, National Diabetes, Obesity and Cholesterol Foundation (N-DOC), Diabetes Foundation (India), New Delhi, India
| | - Seema Gulati
- Head, Nutrition Research Group, Centre for Nutrition & Metabolic Research (C-NET) & National Diabetes, Obesity and Cholesterol Foundation (N-DOC), New Delhi, India; Chief Project Officer, Diabetes Foundation (India), C-6/57, Safdarjung Development Area, New Delhi 110016, India
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Krishnan MN, Zachariah G, Venugopal K, Mohanan PP, Harikrishnan S, Sanjay G, Jeyaseelan L, Thankappan KR. Prevalence of coronary artery disease and its risk factors in Kerala, South India: a community-based cross-sectional study. BMC Cardiovasc Disord 2016; 16:12. [PMID: 26769341 PMCID: PMC4712491 DOI: 10.1186/s12872-016-0189-3] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Accepted: 01/08/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There are no recent data on prevalence of coronary artery disease (CAD) in Indians. The last community based study from Kerala, the most advanced Indian state in epidemiological transition, was in 1993 that reported 1.4% definite CAD prevalence. We studied the prevalence of CAD and its risk factors among adults in Kerala. METHODS In a community-based cross sectional study, we selected 5167 adults (mean age 51 years, men 40.1%) using a multistage cluster sampling method. Information on socio-demographics, smoking, alcohol use, physical activity, dietary habits and personal history of hypertension, diabetes, and CAD was collected using a structured interview schedule. Anthropometry, blood pressure, electrocardiogram, and biochemical investigations were done using standard protocols. CAD and its risk factors were defined using standard criteria. Comparisons of age adjusted prevalence were done using two tailed proportion tests. RESULTS The overall age-adjusted prevalence of definite CAD was 3.5%: men 4.8%, women 2.6% (p < 0.001). Prevalence of any CAD was 12.5%: men 9.8%, women 14.3% (p < 0.001). There was no difference in definite CAD between urban and rural population. Physical inactivity was reported by 17.5 and 18% reported family history of CAD. Other CAD risk factors detected in the study were: overweight or obese 59%, abdominal obesity 57%, hypertension 28%, diabetes 15%, high total cholesterol 52% and low level of high density lipoprotein cholesterol 39%. Current smoking was reported only be men (28%). CONCLUSION The prevalence of definite CAD in Kerala increased nearly three times since 1993 without any difference in urban and rural areas. Most risk factors of CAD were highly prevalent in the state. Both population and individual level approaches are warranted to address the high level of CAD risk factors to reduce the increasing prevalence of CAD in this population.
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Affiliation(s)
- M N Krishnan
- Govt. Medical College, Kozhikode, Kerala, India.
| | | | - K Venugopal
- Pushpagiri Hospital, Tiruvalla, Kottayam, Kerala, India.
| | - P P Mohanan
- Westfort High-tech Hospital, Thrissur, Kerala, India.
| | - S Harikrishnan
- Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India.
| | - G Sanjay
- Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India.
| | - L Jeyaseelan
- Department of Biostatistics, Christian Medical College, Vellore, Tamil Nadu, India.
| | - K R Thankappan
- Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum Medical College, P.O. 695011, Thiruvananthapuram, Kerala, India.
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Chan MY, Du X, Eccleston D, Ma C, Mohanan PP, Ogita M, Shyu KG, Yan BP, Jeong YH. Acute coronary syndrome in the Asia-Pacific region. Int J Cardiol 2016; 202:861-9. [DOI: 10.1016/j.ijcard.2015.04.073] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Revised: 03/26/2015] [Accepted: 04/09/2015] [Indexed: 11/28/2022]
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Chandra KS, Bansal M, Nair T, Iyengar SS, Gupta R, Manchanda SC, Mohanan PP, Rao VD, Manjunath CN, Sawhney JPS, Sinha N, Pancholia AK, Mishra S, Kasliwal RR, Kumar S, Krishnan U, Kalra S, Misra A, Shrivastava U, Gulati S. Consensus statement on management of dyslipidemia in Indian subjects. Indian Heart J 2014; 66 Suppl 3:S1-51. [PMID: 25595144 PMCID: PMC4297876 DOI: 10.1016/j.ihj.2014.12.001] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Affiliation(s)
- K Sarat Chandra
- Editor, Indian Heart Journal, Sr. Cardiologist, Indo US Superspeciality Hospital, Ameerpet, Hyderabad 500016, India
| | - Manish Bansal
- Senior Consultant e Cardiology, Medanta e The Medicity, Sector 38, Gurgaon, Haryana 122001, India
| | - Tiny Nair
- Head, Department of Cardiology, PRS Hospital, Trivandrum, Akashdeep, TC 17/881, Poojapura, Trivandrum, Kerala 695012, India
| | - S S Iyengar
- Sr. Consultant & HOD, Manipal Hospital, 133, JalaVayu Towers, NGEF Layout, Indira Nagar, Bangalore 560038, India
| | - Rajeev Gupta
- Head of Medicine and Director Research, Fortis Escorts Hospital, JLN Marg, Malviya Nagar, Jaipur 302017, India
| | | | - P P Mohanan
- Westfort H. Hospital, Poonkunnanm, Thrissur 680002, India
| | - V Dayasagar Rao
- Sr. Cardiologist, Krishna Institute of Medical Science, Minister Road, Secunderabad, India
| | - C N Manjunath
- Director, Prof & HOD, Sri Jayadeva Institute of Cardiovascular Sciences & Research, Bannerghatta Road, Bangalore 560 069, India
| | - J P S Sawhney
- MD DM FACC, Chairman Department of Cardiology, Sir Ganga Ram Hospital, New Delhi, India
| | - Nakul Sinha
- Sr. Consultant & Chief Interventional Cardiologist, Sahara India Medical Institute, VirajKhand, Gomti Nagar, Lucknow, Uttar Pradesh 226010, India
| | - A K Pancholia
- Head, Department of Clinical and Preventive Cardiology and Research Centre Arihant Hospital, Indore, MP, India
| | - Sundeep Mishra
- Prof. of Cardiology, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Ravi R Kasliwal
- Chairman, Clinical and Preventive Cardiology, Medanta e The Medicity, Sector 38, Gurgaon, Haryana 122001, India
| | - Saumitra Kumar
- Professor, Vivekanada Institute of Medical Sciences, Kolkata, India; Chief Co-ordinator, Academic Services (Cardiology), Narayana Hrudayalay, RTIICS, Kolkata, India; Consultant Cardiologist, Fortis Hospital, Kolkata, India
| | - Unni Krishnan
- Chief Endocrinologist & CEO, Chellaram Diabetes Institute, Pune 411021, India
| | - Sanjay Kalra
- Consultant Endocrinology, Bharti Hospital & BRIDE, Karnal, Haryana, India
| | - Anoop Misra
- Chairman, Fortis-C-DOC Centre of Excellence for Diabetes, Metabolic Diseases and Endocrinology, Chirag Enclave, New Delhi, India
| | - Usha Shrivastava
- Head, Public Health, National Diabetes, Obesity and Cholesterol Foundation (N-DOC), Diabetes Foundation (India), New Delhi, India
| | - Seema Gulati
- Head, Nutrition Research Group, Center for Nutrition & Metabolic Research (C-NET) & National Diabetes, Obesity and Cholesterol Foundation (N-DOC), New Delhi, India; Chief Project Officer, Diabetes Foundation (India), C-6/57, Safdarjung Development Area, New Delhi 110 016, India
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Zachariah G, Harikrishnan S, Krishnan MN, Mohanan PP, Sanjay G, Venugopal K, Thankappan KR. Prevalence of coronary artery disease and coronary risk factors in Kerala, South India: a population survey - design and methods. Indian Heart J 2013; 65:243-9. [PMID: 23809375 DOI: 10.1016/j.ihj.2013.04.008] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2012] [Revised: 03/18/2013] [Accepted: 04/03/2013] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND There is paucity of reliable contemporary data on prevalence of coronary artery disease (CAD) and risk factors in Indians. Only a few studies on prevalence of CAD have been conducted in Kerala, a Southern Indian state. The main objective of the Cardiological Society of India Kerala Chapter Coronary Artery Disease and Its Risk Factors Prevalence Study (CSI Kerala CRP Study) was to determine the prevalence of CAD and risk factors of CAD in men and women aged 20-79 years in urban and rural settings of three geographical areas of Kerala. METHODS The design of the study was cross-sectional population survey. We estimated the sample size based on an anticipated prevalence of 7.4% of CAD for rural and 11% for urban Kerala. The derived sample sizes for rural and urban areas were 3000 and 2400, respectively. The urban areas for sampling constituted one ward each from three municipal corporations at different parts of the state. The rural sample was drawn from two panchayats each in the same districts as the urban sample. One adult from each household in the age group of 20-59 years was selected using Kish method. All subjects between 60 and 79 years were included from each household. A detailed questionnaire was administered to assess the risk factors, history of CAD, family history, educational status, socioeconomic status, dietary habits, physical activity and treatment for CAD; anthropometric measurements, blood pressure, electrocardiogram and fasting blood levels of glucose and lipids were recorded.
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Bhandari S, Seth A, Sethi KK, Tyagi S, Gupta R, Tiwari SC, Mehrotra S, Seth A, Guha S, Deb PK, Dasbiswas A, Mohanan PP, Venugopal K, Sinha N, Pinto B, Banerjee A, Sengottuvelu G, Mehran R, Mc Collough P. Cardiological Society of India practice guidelines for angiography in patients with renal dysfunction. Indian Heart J 2012. [PMID: 23186627 DOI: 10.1016/j.ihj.2012.11.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
PREAMBLE: The potential risk of contrast-induced acute kidney injury (CI-AKI) has made utilization of coronary angiography in the work-up for the diagnosis of coronary artery disease in CKD quite low.(1) This is in contrast to increasing prevalence and severity of CAD as the serum creatinine rises.(2) In fact most CKD patients will succumb to CAD and not to ESRD.(3) Thus the judicious use of CAG/PCI in this setting is of prime importance but underused. The CSI began to develop guidelines for Indian context as most guidelines are those developed by ACC/AHA or ESC. The aim was to assist the physicians in selecting the best management strategy for an individual patient under his care based on an expert committee who would review the current data and write the guidelines with relevance to the Indian context. The guidelines were developed initially in June 2010 as an initiative of Delhi CSI. Three interventional cardiologist (SB, AS, KKS), one nephrologist (SCT) and two clinical cardiologists (ST, RG) along with Dr. Roxana Mehran (New York) and Dr. Peter McCullough (Missouri), U.S.A.; were involved in a three-way teleconference to discuss/debate the data. This was presented by SB, and over the next two hours each data subset was debated/agreed/deleted and this resulted in the "Guidelines for CAG in Renal Dysfunction Patients". These were then written and re- circulated to all for final comments. Further, these guidelines were updated and additional Task Force Members nominated by Central CSI were involved in the formation of the final CSI Guidelines. Both (Roxana Mehran and Peter McCullough) reviewed these updated Guidelines in October 2012 and after incorporating the views of all the Task Force members-the final format is as it is presented in this final document.
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Prabhakaran D, Jeemon P, Mohanan PP, Govindan U, Geevar Z, Chaturvedi V, Reddy KS. Management of acute coronary syndromes in secondary care settings in Kerala: impact of a quality improvement programme. Natl Med J India 2008; 21:107-111. [PMID: 19004139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
BACKGROUND Evidence-based therapies that have been shown to improve outcomes in acute coronary syndromes (ACS) are often underused in clinically eligible patients. We evaluated the impact, efficacy and acceptability of a quality improvement programme to manage ACS. METHODS A well-defined geographical area was identified and a situational analysis done. All physicians in the area, who were actively involved in the detection and management of ACS, were invited to participate in the quality improvement programme. The programme involved the use of a service delivery package which consisted of standard admission orders and patient-directed discharge instructions. Concurrently, health education in the community to promote self-detection, self-administration of aspirin and self-referral were carried out. All participating physicians were asked to register consecutive cases of ACS (20 each) presenting to their clinics before and after the intervention programme. The pre- and post-intervention data were compared. RESULTS The use of aspirin at discharge increased from 89.7% to 96.8% (p < 0.05) and that of heparin from 57.6% to 66.3% (p < 0.05). The use of beta-blockers increased from 48.6% to 63.4% (p < 0.05) and that of lipid-lowering therapy from 74.1% to 96.3% (p < 0.05). There was a significant reduction in the use of calcium channel blockers from 21.6% to 8.1% (p < 0.05). The time to thrombolysis decreased significantly (median difference of 54 minutes, p < 0.05) after the intervention programme. CONCLUSION Structured quality improvement programmes aimed at both patients and providers can be successful in secondary care settings of developing countries.
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Affiliation(s)
- D Prabhakaran
- Centre for Chronic Disease Control, New Delhi 110016, India
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Mohanan PP, Visweswaran RK. Sublingual nifedipine in severe hypertension with advanced renal failure. J Assoc Physicians India 1987; 35:222-3. [PMID: 3611006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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