Current Place of SGLT2i in the Management of Heart Failure: An Expert Opinion from India

Heart failure (HF) is a global health concern that is prevalent in India as well. HF is reported at a younger age in Indian patients with comorbidity of type 2 diabetes (T2DM) in approximately 50% of patients. Sodium-glucose cotransporter-2 inhibitors (SGLT2i), originally approved for T2DM, are new guideline-recommended and approved treatment strategies for HF. Extensive evidence highlights that SGLT2i exhibits profound cardiovascular (CV) benefits beyond glycemic control. SGLT2i, in conjunction with other guideline-directed medical therapies (GMDT), has additive effects in improving heart function and reducing adverse HF outcomes. The benefits of SGLT2i are across a spectrum of patients, with and without diabetes, suggesting their potential place in broader HF populations irrespective of ejection fraction (EF). This consensus builds on the updated evidence of the efficacy and safety of SGLT2i in HF and recommends its place in therapy with a focus on Indian patients with HF.

Role of Bisoprolol in Heart Failure Management: A Consensus Statement from India

In India, heart failure (HF) is an important health concern affecting younger age groups than the western population. A limited number of Indian patients receive guideline-directed medical therapy (GDMT). Selective β-1 blockers (BB) are one of the GDMTs in HF and play an important role by decreasing the sympathetic overdrive. The BB reduces heart rate (HR) reverse the adverse cardiac (both ventricular and atrial), vascular, and renovascular remodeling seen in HF. Bisoprolol, a β-1 blocker, has several advantages and can be used across a wide spectrum of HF presentations and in patients with HF and comorbid conditions such as coronary artery disease (CAD), atrial fibrillation (AF), post-myocardial infarction (MI), uncontrolled diabetes, uncontrolled hypertension, and renal impairment. Despite its advantages, bisoprolol is not optimally utilized for managing HF in India. This consensus builds on updated evidence on the efficacy and safety of bisoprolol in HF and recommends its place in therapy with a focus on Indian patients with HF.

The Power and Promise of Angiotensin Receptor Neprilysin Inhibitor (ARNI) in Heart Failure Management: National Consensus Statement

;Heart failure (HF) is a huge global public health task due to morbidity, mortality, disturbed quality of life, and major economic burden. It is an area of active research and newer treatment strategies are evolving. Recently angiotensin receptor-neprilysin inhibitor (ARNI), a class of drugs (the first agent in this class, Sacubitril-Valsartan), reduces cardiovascular mortality and morbidity in chronic HF patients with reduced left ventricular ejection fraction (LVEF). Positive therapeutic effects have led to a decrease in cardiovascular mortality and HF hospitalizations (HFH), with a favorable safety profile, and have been documented in several clinical studies with an unquestionable survival benefit with ARNI, Sacubitril-Valsartan. This consensus statement of the Indian group of experts in cardiology, nephrology, and diabetes provides a comprehensive review of the power and promise of ARNI in HF management and an evidence-based appraisal of the use of ARNI as an essential treatment strategy for HF patients in clinical practice. Consensus in this review favors an early utility of Sacubitril-Valsartan in patients with HF with reduced EF (HFrEF), regardless of the previous therapy being given. A lower rate of hospitalizations for HF with Sacubitril-Valsartan in HF patients with preserved EF who are phenotypically heterogeneous suggests possible benefits of ARNI in patients having 40-50% of LVEF, frequent subtle systolic dysfunction, and higher hospitalization risk.

Safety of Prasugrel in Indian patients - multicentric registry of 1000 cases

BACKGROUND

Clopidogrel has been the only available antiplatelet drug used along with aspirin in patients of ACS. In recent years 2 new antiplatelet drugs (Prasugrel and Ticagrelor) have become available. Prasugrel in the dose of 10 mg OD has been found to be more efficacious but with increased risk of major bleeding. For this reason it has not gained widespread usage in ACS patients undergoing PCI. There are no systematic data on the use of Prasugrel in Indian population.

METHOD

This is a prospective, multicentric, hospital registry of 1000 patients with ACS undergoing PCI who were administered Prasugrel. The primary safety endpoint of this study was major and minor bleeding while the efficacy endpoint is the composite of CV death, nonfatal MI, nonfatal stroke up to 30 days after PCI. Patients with high bleeding risk were excluded.

RESULTS

Most patients (91%) received loading dose of Prasugrel along with the maintenance dose getting according to the defined protocol. Patients were followed up to 30 days post procedure. Primary efficacy end point was reached in 3 patients only with two of them dying due to possible stent thrombosis and the third requiring revascularization of the target vessel for stent thrombosis. One major and 19 minor bleeding complications were recorded, with access site bleeding in 0.7% & non-access site bleeding in 1.2% of the subjects.

CONCLUSION

Prasugrel was found to be effective & not associated with a high incidence of bleeding in the high risk ACS patients when those at a high bleeding risk were excluded.

Aneurysm of sinus of Valsalva dissecting into interventricular septum with left ventricular communication

Septal dissection with left ventricular communication is a rare complication of aneurysm of sinus of Valsalva. This report describes a case of aneurysm of sinus of Valsalva with septal dissection, almost in its entirety with left ventricular communication--which is a very rare occurrence.

Increasing the fertilizer value of palm oil mill sludge: bioaugmentation in nitrification

Malaysia is essentially an agricultural country and her major polluting effluents have been from agro-based industries of which palm oil and rubber industries together contribute about 80% of the industrial pollution. Palm oil sludge, commonly referred to, as palm oil mill effluent (POME) is brown slurry composed of 4-5% solids, mainly organic, 0.5-1% residual oil, and about 95% water. The effluent also contains high concentrations of organic nitrogen. The technique for the treatment of POME is basically biological, consisting of pond systems, where the organic nitrogen is converted to ammonia, which is subsequently transformed to nitrate, in a process called nitrification. A 15-month monitoring program of a pond system (combined anaerobic, facultative, and aerobic ponds in series) confirmed studies by other authors and POME operators that nitrification in a pond system demands relatively long hydraulic retention time (HRT), which is not easily achieved, due to high production capacity of most factories. Bioaugmentation of POME with mixed culture of nitrifiers (ammonia and nitrite oxidizers) has been identified as an effective tool not only for enhancing nitrification of POME but also for improving quality of POME as source of liquid nitrogen fertilizer for use in the agricultural sector, especially in oil palm plantations. Nitrate is readily absorbable by most plants, although some plants are able to absorb nitrogen in the form of ammoniun. In this study, up to 60% reduction in HRT (or up to 20% reduction in potential land requirement) was achieved when bioaugmentation of POME was carried out with the aim of achieving full nitrification.

Empirical treatment of Shigella dysentery with trimethoprim: five-day course vs. single dose

Fifty-three adults hospitalized with Shigella dysentery were empirically treated with trimethoprim (200 mg) twice/day for 5 days, a single dose of trimethoprim (600 mg), or placebo in a randomized double-blind trial. During the first 24 hr of therapy, there was a reduction in the number of stools in 18/21 (86%) of patients treated with the 5-day regimen (trimethoprim-5) and 13/15 (87%) of patients treated with a single dose (trimethoprim-1), compared with 7/17 (41%) of the placebo group (P less than 0.025, both comparisons). The mean number of stools passed in the first 24 hr of therapy was 10.6, 10.8, and 21.3 stools in the trimethoprim-5, trimethoprim-1, and placebo groups, respectively. The mean (+/- SD) change in number of stools from baseline among treated patients during the first 24 hr was -4.9 (6.6) and -6.3 (6.3) for the trimethoprim-5 and trimethoprim-1 groups, respectively, compared with an increase of +2.4 (14.8) for the placebo group. There was a clinical failure at 48 hr in 9% of the trimethoprim-5 patients and 13% of trimethoprim-1 patients compared with 70% of placebo patients (P less than 0.005, both comparisons). Although we were unable to demonstrate a difference in efficacy between the two dosage schedules of trimethoprim, we conclude that both treatment regimens are effective for the treatment of Shigella dysentery.