Preliminary results of whole exome sequencing in a clinical hypertrophic cardiomyopathy cohort in India

Funding Acknowledgements

Type of funding sources: None.

Background

Hypertrophic cardiomyopathy (HCM), characterized by unexplained left ventricular hypertrophy and outcomes ranging from normal life expectancy to heart failure and sudden cardiac death, has a global prevalence of about 1 in 500. Genetic testing helps to improve care of patients with HCM and their family members as children of carriers have a 50% chance of inheriting the disease. However, there is limited availability, awareness and application of genetic testing modalities, particularly whole exome sequencing (WES), in the management of HCM in India.

Purpose

This study aimed to analyze the results of WES in a clinical HCM cohort in India.

Methods

Patients with unexplained moderate to severe cardiomyopathy presenting to our centre from 2017 to 2022 and consenting for genetic testing were included in the study. Following a thorough clinical diagnostic process including 3-generational family history, electrocardiogram and echocardiogram in all patients and exercise stress test, Holter monitoring and cardiac magnetic resonance imaging where applicable, pre-test counseling was provided and WES performed using genomic DNA isolated from whole blood samples. A total of 33 affected individuals including 1 affected family member from 32 families were processed for genetic testing. A multidisciplinary team comprising of cardiologist, cardiothoracic surgeon, physician with expertise in cardiogenetics, geneticist and genetic counselor carried out the study in a tertiary cardiac centre.

Results

Age of the probands (n=32) at the time of the study was 47.8±15.9 years and 24 (75%) were males. There was concomitant hypertension in 11 (34%), type 2 diabetes mellitus in 6 (19%), arrhythmias in 6 (19%) and coronary artery disease in 2 (6%) probands. Obstructive HCM was present in 2 (6%) probands. Disease-causing significant variants (Pathogenic/Likely pathogenic) were detected in 8 (25%, Table), variants of uncertain significance in 17 (53%) and no significant variants were detected in 7 cases. Cascade genetic testing of significant variants among 7 family members of 4 probands showed segregation of the pathogenic variant in 4 asymptomatic carriers.

Conclusions

The yield of whole exome sequencing in a clinical HCM cohort in India was 25%. Of note the rare variants of uncertain significance in the cardiomyopathy genes makes genetic counseling and disease management challenging. However, large-scale studies in the context of Indian population are expected to bring clarity on the role of these variants in disease manifestation. A multidisciplinary team approach incorporating genetic testing modalities such as whole exome sequencing and cascade screening is the way forward in the comprehensive management of patients with HCM and their families.

Improving cardiovascular health behaviors through a comprehensive lifestyle intervention program during the pandemic in India

Funding Acknowledgements

Type of funding sources: None.

Background

We have witnessed a dramatic dip in adherence to cardiovascular health behaviors during the COVID-19 pandemic. Data from across the globe has shown that risk factors for cardiovascular disease (CVD) such as decreased physical activity, poor diet, and increased depression, loneliness, and stress have peaked during the pandemic. Having been badly affected by the pandemic and having had prolonged periods of countrywide lockdown, the at-risk and established CVD population has faced a major challenge in adhering to a healthy lifestyle in India.

Purpose

This study aimed to analyze the change in cardiovascular health behaviors brought about by a comprehensive lifestyle intervention program (CLIP) during the pandemic in India.

Methods

All at-risk and CVD patients who had participated in the CLIP from mid 2020 to mid 2022 and had completed the internally validated health behavior assessment questionnaire, pre and post-program, were included in this retrospective study. A multidisciplinary team consisting of Physician, Physiotherapist, Dietician, and Counseling Psychologist provided the sessions online and/or in-person for the home-based and hybrid programs respectively. When a combination of online and in-person sessions were provided for a subject, it was called a hybrid program. The core components of the CLIP were exercise training, education on relevant health topics, nutritional guidance and psychosocial counseling.

Results

Age of the subjects (n=50) at enrolment was 54±13 years and 40 (80%) were male. The time between pre-program and post-program assessments was 110 (IQR 47) days. Number of at-risk and CVD patients attending home-based and hybrid programs are shown in the Figure. There were 4 couples in the study cohort; 21 (50%) of the remaining 42 subjects had at least 1 other family member attend the majority of sessions. There was a significant improvement in all the cardiovascular health behaviors, namely adequate daily intake of fruits, vegetables and whole grains, choice of heart-healthy foods between meals, sufficient weekly exercise and a reduction in self-reported chronic stress, upon completion of the CLIP (Table).

Conclusions

A comprehensive lifestyle intervention program that incorporates a multipronged approach to behavior modification is effective in improving cardiovascular health behaviors in individuals at-risk as well as with established cardiovascular disease in India. The ripple effect of behavior modification in the accompanying family members needs to be studied systematically.

Efficacy of home-based versus centre-based cardiac rehabilitation in an Indian cardiovascular disease population

Funding Acknowledgements

Type of funding sources: None.

Background

Cardiac rehabilitation (CR), an integral component of cardiovascular disease (CVD) management in developed countries, is yet to become mainstream in India. With the prevailing gross mismatch between the need and the availability of CR services, an alternative model such as home-based CR may be the potential solution to challenges such as accessibility issues, transportation cost and lack of time.

Purpose

This study aimed to compare the efficacy of home-based versus centre-based CR in an Indian CVD population.

Methods

All CVD patients who participated in our centre-based and home-based CR programs between mid-2014 and mid-2022 were included in the study. Subjects who did not complete their post program evaluation (n=15) were excluded. Demographic data and data pertaining to CVD risk factors, nature of CVD, procedure undergone and details of CR program provided were documented for all subjects. A multidisciplinary team consisting of Physician, Physiotherapist, Dietician, and Counseling Psychologist provided the CR program in-person or using telehealth platforms for the centre-based and home-based programs respectively. Subjects who attended some in-person and some home-based sessions were categorized based on the nature of the majority sessions.

Results

Age of the subjects (n=106) was 60±13 years, 94 (89%) were male and 22 (21%) were residing outside Chennai. While the risk factor and disease profiles were comparable, the home-based group was younger, had more out of Chennai participants and attended more sessions over a longer duration compared to the centre-based group (Table 1). The higher number of hybrid revascularization procedures in the home-based group corroborates with this being the preferred modality for acute coronary syndrome management during the pandemic-led lockdown. There was a significant improvement in body mass index, systolic blood pressure, 6-minute walk distance and left ventricular ejection fraction in those who completed the centre-based as well as home-based CR programs (Table 2).

Conclusions

Home-based CR is as efficacious as centre-based CR, is easier to deploy and helps overcome challenges inherent to centre-based CR such as transportation and time constraints. Home-based CR has potential to become the main mode of CR delivery in low-resource settings in the future.

COVID-Inflicted Coagulopathy: Expert Consensus on Management with Novel Oral Anticoagulants in India

Coronavirus disease 2019 (COVID-19) is a highly hypercoagulable viral infection complicated as COVID-inflicted coagulopathy (CIC), that is associated with increased risk of morbidity and mortality. International guidelines recommend low molecular weight heparin (LMWH) to treat CIC in both in-hospital and in-home settings. However, in India, using subcutaneous LMWH may not be a feasible option for a vast majority of patients under home management. Additionally, while some evidence advocates the use of novel oral anticoagulants (NOACs), in hospitalized settings, most guidelines find no role of NOACs in hospital settings. On the other hand, the resource crunch faced in recent COVID-19 pandemic in India forced physicians to treat many patients in home settings. These patients had been usually prescribed NOACs for ease of administration and adherence. Therefore, there is a need to form a consensus on the use of NOACs to manage CIC in India.

The 1 μg cosyntropin test in normal individuals: A reappraisal

BACKGROUND

The 1μg cosyntropin test has some advantages over the 250μg test as a test of adrenal function. One of the concerns regarding the 1 μg test includes stability of the cosyntropin when reconstituted and stored. Classically the 5(th) percentile responses to cosyntropin in normal individuals have been used to define a normal response. Recent studies have shown that these normative values should be determined for individual assays.

MATERIALS AND METHODS

We performed a 1μg cosyntropin test using reconstituted and refrigerated (4-8(°) C) cosyntropin in saline solution in 49 non pregnant adults who were apparently healthy and had no exposure to exogenous glucocorticoids. The cosyntropin solution was stored for up to 60 days following reconstitution. We analysed the data for any association between duration of cosyntropin solution storage and the cortisol responses to cosyntropin administration.

RESULTS

The mean ± SD cortisol level at baseline, 30 and 60 min were-12.19 ± 3 μg/dl, 20.72 ± 2.63 μg/dl, 16.86 ± 3.33 μg/dl. The 5(th) percentile cortisol response at 30 min was 16.5 μg/dl (16.33 μg/dl rounded off). The correlation coefficients between number of days of cosyntropin solution storage and the cortisol responses at 30 and 60 min were (Spear mans rho = 0.06,-0.24 respectively) (P = 0.69 and 0.41). There were no differences in cortisol values whether the storage was for less than 30 days or more than 30 days (mean difference 0.25 μg/dl P = 0.44).

CONCLUSION

The 5(th) percentile normative values determined for our assay is lower than what is currently being used clinically and in research publications. Prolonged refrigerated storage of cosyntropin solution does not affect the validity of the 1 μg cosyntropin test.

Congenital adrenal hyperplasia - experience from a tertiary centre in South India

Congenital adrenal hyperplasia is a group of autosomal recessive disorders caused by enzyme deficiency which leads to defects in biosynthesis of steroid precursors. Most common is 21 hydroxylase deficiency. Clinical spectrum varies from non-classical CAH to classic CAH, and it may be simple virilising form or salt-wastinfg type. 29 patients were included in our study from January 2012 to October 2012. 76% were females. Male babies typically presented with adrenal crisis between 3(rd) to 6(th) week of life. Around 20% of females were identified and appropriately treated only after late adolescence. Short stature was seen in 1/3(rd) of patients. 1/3(rd) of patients had suppressed 17 OHP levels suggestive of over-replacement therapy which may contribute to final reduction in adult height.

Megaduodenum in a patient with acromegaly

INTRODUCTION

Acromegaly is associated with enlargement of all organs including the gastro intestinal system. However, there are no previous reports of occurrence of megaduodenum in patients with acromegaly.

DISCUSSION

We present the case of a 47 year old male who was diagnosed to have acromegaly 13 years ago and had undergone transsphenoidal surgery twice with incomplete removal of the pituitary macro-adenoma and received radiotherapy following the second surgery. Patient has been on replacement therapy for hypocortisolism, hypothyroidism and hypogonadism since 10 years. Post glucose growth hormone level continued to remain unsuppressed; however, patient never received any medical therapy for acromegaly. He was evaluated with esophago-gastro-duodenoscopy for recurrent abdominal pain and distension, which showed an elongated and tortuous megaduodenum. These findings were verified with a barium study which revealed dilated stomach, first and second part of duodenum with no evidence of a distal obstruction.

CONCLUSIONS

We report this finding in view of the rare association.

A pilot study on the effect of telmisartan & ramipril on 24 h blood pressure profile & dipping pattern in type 1 diabetes patients with nephropathy

Background & objectives:

Angiotensin converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) have been used to normalize the blood pressure and the dipping pattern in patients with type 1 diabetes mellitus (T1DM) and nephropathy. However, there are no data on the effect of the dual blockade on the dipping pattern in these subjects. We therefore, carried out this study to evaluate the effect of administrating an ACEI followed by ARB in the optimum doses in T1DM patients with nephropathy on 24 h blood pressure (BP) profile and nocturnal dipping pattern.

Methods:

An open label interventional pilot study was done during a one year period involving 30 consecutive patients who were treated with telmisartan 80 mg (0800-1000 h) for eight weeks followed by addition of ramipril 10 mg (1200-1400 h) for the next eight weeks. Ambulatory BP, dipping pattern and albumin excretion rate were studied after each phase. Twenty patients were hypertensive and 10 patients had macro- and 20 patients had microalbuminuria.

Results:

Telmisartan produced a fall in the clinic BP by 4/1.3 mm Hg (P<0.05 and P<0.362, respectively), 2/1.9 mm Hg in the mean 24 h BP, 1.4/1.1 mm Hg in the day BP and 3.7/3 mm Hg in the trough BP. Addition of ramipril to telmisartan produced a further reduction of 6.3/5.9 mm Hg in the clinic BP (P<0.001 for both), 4.3/4.2 mm Hg in the mean 24 h BP (P<0.01 and P<0.0001, respectively), 5.8/3.9 mm Hg in the day BP (P<0.01 for both), 4.2/2.5 mm Hg in the trough BP, with a reduction of clinic SBP and DBP of 10.3/7.2 mm Hg from the baseline. Telmisartan restored normal systolic dipping pattern in 33.3 per cent of the nondippers (P<0.01) but addition of ramipril was not complimentary. Hyperkalamia (>5.5 mmol/l) was observed only in 2 patients towards the end of the study.

Interpretation & conclusions:

The dual blockade with telmisartan and ramipril had complimentary effect on lowering of the BP, however, similar beneficial effect on the nocturnal dipping was not observed. Further studies with large number of subjects with longer duration of follow-up are required to validate these observations.

Validation of bedside methods in evaluation of diabetic peripheral neuropathy

BACKGROUND & OBJECTIVES

Vibration perception threshold (VPT) is considered as a gold standard for diagnosis of diabetic peripheral neuropathy. However, the data are sparse comparing the VPT with commonly used bedside modalities. This study was carried out to evaluate the usefulness of simple bed side screening modalities for peripheral neuropathy in patients with diabetes mellitus.

METHODS

A total of 1044 patients with diabetes mellitus attending the Diabetes clinic from January 2007 to May 2008, were included in this study. All subjects had a detailed clinical assessment including Diabetic Neuropathy Symptom (DNS) score, Diabetic Neuropathy Examination (DNE) score, ankle reflex, vibration sensation with a 128 Hz tuning fork, 10 g Semmes-Weinstein monofilament and vibration perception threshold (VPT).

RESULTS

The prevalence of peripheral neuropathy was 34.9 per cent with VPT. Foot care practices were followed by only 214 (20.5%) of the study population. When compared with VPT, ankle reflex was the most sensitive (90.7%) but least specific (37.3%). The tuning fork and monofilament tests respectively had lower sensitivity (62.5 and 62.8%) but better specificity (95.3 and 92.9%) and accuracy (78.9 and 77.9%). Significant correlations were observed between the VPT score and the DNE (r = 0.532, P<0.001) and DNS (r = 0.546, P<0.001) scores and absent tuning fork sensation (r = 0.590; P<0.001), monofilament sensation (r = 0.573; P<0.001) and ankle reflex (r = 0.377, P = 0.01).

INTERPRETATION & CONCLUSIONS

The present findings show that simple bed side tests are useful for assessing peripheral diabetic neuropathy, even in those subjects in whom foot care practices are not followed.

Anti-albuminuric efficacy of a combination of angiotensin converting enzyme inhibitor & angiotensin receptor blocker in type 1 DM with nephropathy

BACKGROUND & OBJECTIVES

The efficacy of the combination of angiotensin receptor blockers (ARBs) and angiotensin converting enzyme (ACE) inhibitors in patients of type 1 diabetes mellitus (DM) with nephropathy is debatable. The antialbuminuric efficacy of dual blockade in patients of type 1 DM with micro- or macroabuminuria were evaluated.

METHODS

In this open label observational study 30 patients (20 male 10 female) with type 1 DM were included who were initially treated with telmisartan 80 mg for eight weeks followed by addition of ramipril 10 mg for a further eight weeks. Albuminuria reduction was studied at the end of each phase.

RESULTS

Therapy with telmisartan for 8 wk resulted in a 39 per cent (P<0.01) reduction in albumin excretion rate (AER). Combination therapy with telmisartan and ramipril produced a further reduction in AER of 33.4 per cent (P<0.01), amounting to a total AER reduction of 59 per cent (P<0.001). Dual blockade was more effective in the group of macroalbuminuric as compared to microalbuminuric subjects (P<0.05). Telmisartan produced a significant reduction in SBP (P<0.05). The addition of ramipril produced a further reduction in BP, the total reduction being 10.3 in SBP and 7.2 mmHg in DBP (P<0.001 for both). There was an increase in mean serum potassium of 0.39 mmol/l (P<0.01) from baseline at the end of the study period and two patients had hyperkalemia>5.5 mmol/l with dual blockade.

INTERPRETATION & CONCLUSION

Dual blockade with ramipril enhanced the antialbuminuric efficacy of telmisartan and further reduced blood pressure. The effect of dual blockade was more pronounced in the macroalbuminuric subjects and it was well tolerated. However, careful monitoring of serum potassium is required.

Magnitude of foot problems in diabetes in the developing world: a study of 1044 patients

AIM

To gain insight into the prevalence of peripheral neuropathy, foot care practices, foot at risk and foot ulcers in patients with diabetes mellitus at a tertiary care centre.

METHODS

A prospective case study involving 1044 patients with diabetes mellitus attending the diabetes clinic of a tertiary care centre in north India from January 2007 to May 2008. All subjects underwent a detailed clinical assessment including vibration perception threshold (VPT) and ankle brachial pressure index (ABI), along with metabolic parameters, and were categorized into ulcer, foot at risk and patients with no risk factors. Foot care practices were assessed with a questionnaire. Peripheral neuropathy was defined as VPT score > or = 25 V. Peripheral vascular disease (PVD) was defined as ABI < 0.9. One hundred and forty-nine patients with foot at risk were followed up for 9.0 +/- 2.3 months (range 5-13 months).

RESULTS

The prevalence of peripheral neuropathy was 34.9% and of PVD 12.6%. Two thirds of the patients were at risk for foot ulceration; 9% had an ulcer and 20.2% of them required amputation. Correct foot care practices were followed by 214 (20.5%) subjects of the whole study population and by only 135 (19.3%) of the patients with foot at risk. Improvement in glycaemic control in the patients on follow-up was associated with improvement or stabilization of VPT score. Five (3.4%) patients developed new ulcers on follow-up.

CONCLUSION

The high prevalence of neuropathy and PVD, coexisting with poor adherence to foot care practices predisposes to foot problems in people with diabetes in our study population.

Hashimoto's encephalopathy: an under diagnosed entity

We describe a 60-year-old woman with Hashimoto's thyroiditis who presented with neuropsychiatric manifestations even on optimal and stable doses of levothyroxine replacement therapy. She had high anti-thyroid peroxidase antibody and responded to glucocorticoid treatment.

Hyperglycaemia in acute coronary syndromes: risk-marker or therapeutic target?

Patients with acute coronary syndrome (ACS) often have raised blood glucose concentrations when admitted to hospital; a marker for poorer prognosis. Interventions to rapidly normalise blood glucose inconsistently are applied and with uncertain utility. Here we review the association of hyperglycaemia with outcome, present evidence that this hyperglycaemia reflects more than a pre-existing diabetic state and discuss mechanisms by which glucose may adversely affect the course of acute myocardial infarction (AMI). Finally, we seek evidence that intensive insulin treatment improves outcome.