The Potential Role of Torsemide in Optimizing Loop Diuretic Therapy for Heart Failure Patients

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.

Heart Failure with Preserved Ejection Fraction: Management Guidelines (From Heart Failure Association of India, Endorsed by Association of Physicians of India)

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.

Hypertension in Young Adults in India: Perspectives and Therapeutic Options amongst Clinician's in a Cross Sectional Observational Study

BACKGROUND

The prevalence of hypertension in the young adult population is rising in India. Increased arterial stiffness due to RAAS activation and increased sympathetic overactivity due to stress have been implicated as primary factors for the same. This study was aimed to understand the Indian clinician's perspective on approach to management of hypertension in young adults.

METHODS

A cross sectional observational survey using a structured questionnaire was conducted online with 2287clinicians (cardiologists, diabetologists, consultant physicians and family physicians).

RESULTS

The prevalence of hypertension was 10-30% as per opinion of 64.8% clinicians. The top three risk factors for hypertension in young were perceived to be smoking, mental stress and obesity. Around 57.4% respondents opined that both increased heart rate and systolic blood pressure were markers of sympathetic overactivity. More than 60% respondents across specialities preferred ARBs to treat hypertension in young adults. Amongst the ARBs, telmisartan was the preferred ARB by >80% respondents. Metoprolol was the preferred beta blocker by almost 64% respondents. The objective of selection of beta-blocker by majority of clinicians due to sympathetic overactivity. Telmisartan and Metoprolol single pill combination achieved the BP goal in 40-60% of patients as reported by 41.3% of the physicians. The combination therapy was well tolerated in young hypertensive patients.

CONCLUSIONS

Initiation of an early and appropriate antihypertensive treatment in young population may lower the burden of cardiovascular disease in this population. ARBs and beta -blockers were the preferred class of anti-hypertensive drugs in the cohort of young hypertensive patients .

Acute decompensated heart failure (ADHF) during COVID-19 pandemic-insights from South India

AIM

This retrospective study compares admissions and outcomes due to acute decompensated heart failure (ADHF) during the COVID-19 pandemic from 25 March to 25 July 2020 with the historical patient control who were admitted during the same period in 2019.

METHODS AND RESULTS

Data of the participating hospitals was collected and analysed from the ICC NHFR (Indian College of Cardiology National Heart Failure Registry) for 2019 and 2020. Total number of ADHF admissions, demographics, aetiology, co-morbid conditions and in-hospital mortality was compared and analysed. A significant decrease in the number of hospital admissions due to ADHF from 2019 to 2020 (1056 vs. 526 respectively) was noted. Incidence of admissions with <40% ejection fraction (EF) reduced in 2020 (72.4% and 80.2% in2020 and 2019)and >40% (EF) increased (27.6% and 19.8% in 2019 and 2020 respectively, p = 0.0005). Ischemic heart disease (IHD) was the most common aetiology (78.59% in 2019 and 80.98% in 2020, p = 0.268). The in-hospital mortality was numerically higher in 2020 (10%) than in 2019 (8%), but not statistically significant (p = 0.161).

CONCLUSION

This study from the registry shows that the incidence of ADHF admissions during COVID-19 lockdown significantly reduced compared to the previous year. Demographic patterns remained similar but patients presenting with de-novo HF increased; IHD was the most common cause. The in-hospital mortality was numerically higher during the lockdown. The impact of lockdown perhaps led to fewer hospitalisations and this is to be factored in future strategies to address health care delivery during such crises.

Consensus and development of document for management of stabilized acute decompensated heart failure with reduced ejection fraction in India

Aim

Ensuring adherence to guideline-directed medical therapy (GDMT) is an effective strategy to reduce mortality and readmission rates for heart failure (HF). Use of a checklist is one of the best tools to ensure GDMT. The aim was to develop a consensus document with a robust checklist for stabilized acute decompensated HF patients with reduced ejection fraction. While there are multiple checklists available, an India-specific checklist that is easy to fill and validated by regional and national subject matter experts (SMEs) is required.

Methodology

A total of 25 Cardiology SMEs who consented to participate from India discussed data from literature, current evidence, international guidelines and practical experiences in two national and four regional meetings.

Results

Recommendations included HF management, treatment optimization, and patient education. The checklist should be filled at four time points- (a) transition from intensive care unit to ward, (b) at discharge, (c) 1st follow-up and (d) subsequent follow-up. The checklist is the responsibility of the consultant or the treating physician which can be delegated to a junior resident or a trained HF nurse.

Conclusion

This checklist will ensure GDMT, simplify transition of care and can be used by all doctors across India. Institutions, associations, and societies should recommend this checklist for adaptability in public and private hospital. Hospital administrations should roll out policy for adoption of checklist by ensuring patient files have the checklist at the time of discharge and encourage practice of filling it diligently during follow-up visits.

Management protocols for chronic heart failure in India

Heart failure is a common clinical syndrome and a global health priority. The burden of heart failure is increasing at an alarming rate worldwide as well as in India. Heart failure not only increases the risk of mortality, morbidity and worsens the patient's quality of life, but also puts a huge burden on the overall healthcare system. The management of heart failure has evolved over the years with the advent of new drugs and devices. This document has been developed with an objective to provide standard management guidance and simple heart failure algorithms to aid Indian clinicians in their daily practice. It would also inform the clinicians on the latest evidence in heart failure and provide guidance to recognize and diagnose chronic heart failure early and optimize management.

Bipolar disorder associated with tuberous sclerosis: Chance association or aetiological relationship?

Tuberous sclerosis is a rare disorder. Mental retardation, epilepsy, autism and hyperactivity are commonly reported neuropsychiatric disorders associated with tuberous sclerosis. Rarely, other psychiatric disorders such as psychosis, depression and anxiety associated with this condition have been reported in the literature. A case of bipolar disorder associated with tuberous sclerosis with onset of the first manic episode at the age of 7 years is reported. The possibility of tuberous sclerosis as one of the causes of secondary mood disorder in very young children is also discussed.

Ect in mentally retarded subjects with psychiatric illness

The mentally retarded subjects show a much higher prevalence of full range of psychiatric disorders than the non-retarded population. Whereas the role of psychotropic drugs in such patients is well discussed, the reports on the use of ECT are scarce. Many psychiatrists dealing with the mentally retarded psychiatric patients are reluctant to consider ECT due to lack of adequate experience. We report five mentally retarded patients with different psychiatric disorders who were successfully treated with ECT after failing adequate trials of pharmacotherapy. No disproportionately higher adverse events on account of mental retardation were observed. ECT need to be favorably considered in mentally retarded persons with psychiatric morbidity especially when treatment with psychotropic drugs either fail or is intolerable.

Normal pressure hydrocephalus presenting as psychotic depression : moderately successful treatment with a course of ect & pharmacotherapy : a case report

The characteristic symptoms of normal pressure hydrocephalus are dementia, urinary incontinence and gait disturbance. Psychiatric symptoms make their appearance usually after the characteristic symptoms. In some cases, however, prominent psychiatric symptoms are the presenting picture even before the cognitive decline is evident. A case of NPH is discussed which presented with psychotic depression along with urinary incontinence. CT scan showed dilated supratentonal ventricular system and normal fourth ventricle. There was slight widening of cortical sulci. The cognitive impairment set in later during the course of illness. The psychiatric symptoms responded fairly well to a course of ECT and antidepressant drugs.

Basal thyroid functions in first episode depressive illness : a controlled study

Significant but subtle abnormalities in the thyroid functions in depressive patients, have been reported. Basal thyroid functions of 33 drug naive depressive patients having first episode of illness were compared with 31 healthy matched controls. The mean value of total thyroxin (T(3)) was significantly higher in depressives. Total triiodothyronine (T(3)) was lower in depressive patients but the difference was not significant. The mean value of thyroid stimulating hormone (TSH) was comparable in the two groups No significant difference was found with respect to total T(4) and total T(3) when depressive patients with various subtypes of depression were compared. But depressive patients with psychotic features had significantly higher mean value of TSH as compared to those without them. The findings are discussed in relation to the available literature.

Genomic imprinting in bipolar affective disorder

With recent advances in molecular genetics, a new mechanism proposed for the inheritance of Bipolar Disorder is Genomic Imprinting or Parent of Origin Affect. In this study of 79 consecutive first episode manic patients, predominantly male, we failed to establish the phenomenon of imprinting. With other proposed non-Mendelian patterns of inheritance, it may be that bipolar disorder is genetically heterogenous.

Transsexulism : onset after an acute psychotic episode

Transsexualism is a rare disorder with an uncertain aetiology. Recently, biological factors have been considered to be important in its occurrence. The relationship of transsexualism with psychosis is not known; in most cases no specific relationship exists, though few cases of symptomatic transsexualism have been reported. In the following case, cross dressing and homosexual orientation was present from an early age, but gender dysphoria became manifest only after the onset of an acute psychotic episode. The implications of such a finding are discussed.

Biological damage in spleen by iodine-125 in potassium perchlorate blocked thyroid of rats

Studies on spleen have been performed following administration of iodine-125 in perchlorate-treated rats. Although DNA levels did not change appreciably, there was a significant decrease in total RNA following incorporation of iodine-125. Associated with the changes in RNA, there was a significant rise in acid phosphatase and total as well as Mg-dependent ATPases. Increased activity of acid phosphatase seems to be related to the loss of lymphocytes, whereas the rise in ATPase appeared to be associated with cells of red pulp of spleen. It is suggested that damage to the spleen after administration of iodine-125 is due to the Auger effect.

Evaluation of a simpler technique for in-vivo labelling of red blood cells with 99mTc

The efficiency of labelling red blood cells with intravenously administered 99mTcO4, by prior oral administration of stannous chloride dihydrate, has been evaluated. Optimum labelling occurred 1 hr after the oral dose of 200 mg of SnCl2.2 H2O and 20 min after the intravenous injection of 99mTcO4. The mechanism of labelling has been shown to be diffusion of 99Tc through the cell membrane followed by binding to haemoglobin in the presence of reducing agent. The in-vivo labelling technique has been found to be useful for the diagnosis of an abdominal mass and for static perfusion studies.

Evaluation of a Simpler Technique for In-Vivo Labelling of Red Blood Cells with 99mTc

The efficiency of labelling red blood cells with intravenously administered 99mTc04, by prior oral administration of stannous chloride dihydrate, has been evaluated. Optimum labelling occured 1 hr after the oral dose of 200 mg of SnCl2 · 2 H20 and 20 min after the intravenous injection of 99mTc04. The mechanism of labelling has been shown to be diffusion of 99mTc through the cell membrane followed by binding to haemoglobin in the presence of reducing agent. The in-vivo labelling technique has been found to be useful for the diagnosis of an abdominal mass and for static perfusion studies.