Prevalence of cardiac abnormalities and heart failure in unselected out-patients with type 2 diabetes mellitus and associated clinical factors: Real-world evidence from an Indian registry

OBJECTIVE

Type 2 diabetes mellitus (T2DM) is known to be associated with development of left ventricular (LV) dysfunction and heart failure (HF). The study aimed to determine the prevalence of LV dysfunction and HF in unselected out-patients with T2DM with no previous cardiac history and to correlate LV dysfunction and HF with demographic and comorbid characteristics.

METHODS

This cross-sectional study conducted at 27 centers in India captured demographic and clinical data through electronic case record forms. B-type natriuretic peptide of >105 pg/mL was used to diagnose HF and two-dimensional echocardiography was used to assess LV dysfunction.

RESULTS

Of the 615 patients, 54.3 % (n = 334) were males; mean age was 57.4 ± 10.48 years. More than one-third of the patients had T2DM duration of >10 years (n = 238; 38.7 %), with hypertension as the most prevalent comorbidity (n = 372, 78.6 %). Approximately 61.3 % of the patients had LV hypertrophy. The mean LV mass was 135.0 ± 56.16 g (95 % CI 130.28, 139.70). The prevalence of any type of LV dysfunction, including systolic or diastolic dysfunction and HF was 55 % (95 % CI 51.0, 59.0) and 10 % (95 % CI 7.0, 12.0), respectively. A negligible but statistically significant correlation was observed between LV dysfunction and T2DM duration (p = 0.011), alongside HF and age (p < 0.0001).

CONCLUSION

Real-world data from this registry from India demonstrates a substantial burden of LV dysfunction and HF in individuals with T2DM in India. It is imperative to formulate strategies for early identification of LV dysfunction in individuals with T2DM for prevention and consequent management of HF.

Bempedoic Acid for Lipid Management in the Indian Population: An Expert Opinion

Lipid-lowering is a central theme in the management of patients with atherosclerotic cardiovascular disease (ASCVD) and heterozygous familial hypercholesterolemia (HeFH), with statins being currently used as the first-line lipid-lowering agent (LLAs). Bempedoic acid (BA) has been recently approved for lipid management in ASCVD/HeFH patients. This expert opinion paper brings out the essential concept to assess the current place of BA in the Indian population. Here we highlight that the majority of the patients with clinical ASCVD may not be receiving the optimal dose of statin, thereby failing to achieve their lipid targets. The addition of BA to statin results in a significant reduction in low-density lipoprotein cholesterol (LDL-C) along with substantial reductions in non-high-density lipoprotein cholesterol (non-HDL-C), apolipoprotein B (ApoB), and high-sensitivity C-reactive protein (hsCRP) levels. For patients who do not achieve LDL-C targets, BA can be an effective add-on alternative to choose among non-statin LLAs. BA is a good choice for statin-intolerant cases, especially in combination with ezetimibe. Given the lack of effect of worsening hyperglycemia or any increase in the occurrence of new-onset diabetes, BA can be used without hesitation in patients with diabetes. The small risk of hyperuricemia could be mitigated with appropriate patient selection and monitoring of serum uric acid levels in patients at high risk of hyperuricemia. We believe BA is an excellent non-statin therapy that is efficacious, well-tolerated, and cost-effective for lipid management in ASCVD, HeFH, and statin-intolerant patients in India.

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

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

Clinical relevance of double-arm blood pressure measurement and prevalence of clinically important inter-arm blood pressure differences in Indian Primary Care

Hypertension guidelines recommend measuring blood pressure (BP) in both arms at least once. However, this is seldom done due to uncertainties regarding measurement procedure and the implications of finding a clinically important inter-arm BP difference (IAD). This study aimed to provide insight into the prevalence of clinically important IADs in a large Indian primary care cohort. A number of 134678 (37% female) unselected Indian primary care participants, mean age 45.2 (SD 11.9) years, had BP measured in both arms using a standardized, triplicate, automated simultaneous measurement method (Microlife WatchBP Office Afib). On average, there were clinically minor differences in right and left arm BP values: systolic BP 134.4 vs. 134.2 mmHg (p<0.01) and diastolic BP 82.7 vs. 82.6 mmHg (p<0.01), respectively. Prevalence of significant mean systolic IAD between 10 and 15 mmHg was 7813 (5.8%). Systolic IAD ≥ 15 mmHg 2980 (2.2%) and diastolic IAD ≥ 10 mmHg 7151 (5.3%). In total, there were 7595 (5.6%) and 8548 (6.3%) participants with BP above the 140/90 mmHg threshold in only the left or right arm, respectively. Prevalence of participants with elevated BP on one arm only was highest in patients with a systolic IAD ≥ 15 mmHg; 19.1% and 13.7%, for left and right arm, respectively. This study shows that a substantial prevalence of IAD exist in Indian primary care patients. BP is above the diagnostic threshold for hypertension in one arm only for 6% of participants. These findings emphasise the importance of undertaking bilateral BP measurement in routine clinical practice. This article is protected by copyright. All rights reserved.

Clinical relevance of double-arm blood pressure measurement and prevalence of clinically important inter-arm blood pressure differences in Indian primary care

Hypertension guidelines recommend measuring blood pressure (BP) in both arms at least once. However, this is seldom done due to uncertainties regarding measurement procedure and the implications of finding a clinically important inter‐arm BP difference (IAD). This study aimed to provide insight into the prevalence of clinically important IADs in a large Indian primary care cohort.

A number of 134 678 (37% female) unselected Indian primary care participants, mean age 45.2 (SD 11.9) years, had BP measured in both arms using a standardized, triplicate, automated simultaneous measurement method (Microlife WatchBP Office Afib).

On average, there were clinically minor differences in right and left arm BP values: systolic BP 134.4 vs 134.2 mmHg (p < .01) and diastolic BP 82.7 vs 82.6 mmHg (p < .01), respectively.

Prevalence of significant mean systolic IAD between 10 and 15 mmHg was 7,813 (5.8%). Systolic IAD ≥ 15 mmHg 2,980 (2.2%) and diastolic IAD ≥ 10 mmHg 7,151 (5.3%). In total, there were 7,595 (5.6%) and 8,548 (6.3%) participants with BP above the 140/90 mmHg threshold in only the left or right arm, respectively. Prevalence of participants with elevated BP on one arm only was highest in patients with a systolic IAD ≥ 15 mmHg; 19.1% and 13.7%, for left and right arm, respectively.

This study shows that a substantial prevalence of IAD exists in Indian primary care patients. BP is above the diagnostic threshold for hypertension in one arm only for 6% of participants. These findings emphasize the importance of undertaking bilateral BP measurement in routine clinical practice.

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.

Blood pressure and heart rate related to sex in untreated subjects: the India ABPM study

Women are underrepresented in groups of patients seeking hypertension care in India. The present paper reports trends in office and ambulatory blood pressure measurement (OBPM, ABPM) and 24-h heart rate (HR) with sex in 14,977 subjects untreated for hypertension (aged 47.3 ± 13.9 years, males 69.4%) visiting primary care physicians. Results showed that, for systolic blood pressure (SBP), females had lower daytime ABPM (131 ± 16 vs. 133 ± 14 mm Hg, P < .001) but higher nighttime ABPM (122 ± 18 vs. 121 ± 16 mm Hg, P < .001) than males. Females had higher HR than men at daytime (80 ± 11 vs 79 ± 11.5 bpm) and nighttime (71 ± 11 vs 69 ± 11), respectively (all P < .001). Dipping percentages for SBP (7.4 ± 7.3 vs 9.3 ± 7.4%), DBP (10.1 ± 8.6 vs. 12.3 ± 8.9%), and HR (10.7 ± 7.9 vs. 12.8 ± 9.2%) were lower (P < .001) for females than for males, respectively. Females more often had isolated nighttime hypertension as compared to males (14.9%, n = 684% vs 10.6%, n = 1105; P < .001). BP patterns and HR showed clear differences in sex, particularly at nighttime. As females were more often affected by non-dipping and elevated nighttime SBP and HR than males, they should receive ABPM, at least, as frequently as men to document higher risk necessitating treatment.

Acute decompensated heart failure in a North Indian community hospital: Demographics, clinical characteristics, comorbidities and adherence to therapy

Background

Acute decompensated heart failure (ADHF) is a growing public health problem in the community. Limited and often contradictory data are available from small studies published from India. Objective of this study was to report clinical characteristics, outcome, and discharge treatment strategies of these patients from a single community hospital.

Methods

In this observational prospective study from a multispeciality community hospital from North India, data were collected to include demographics, clinical characteristics, management strategies, and prognosis in 428 patients with ADHF admitted for more than two consecutive years (January 2017 through December 2018).

Results

The study included 428 patients (mean age 61 ± 14 years) of whom 59% were male. ADHF with reduced left ventricular ejection fraction (HFrEF) was present in 77% subjects; Preserved (≥50%) and midrange ejection fraction (41–49%) with ADHF was observed in 12% and 11% patients, respectively. Ischemic etiology was noticed in 69% of the population. Prior myocardial revascularisation was observed in 47% of all and in 71% of those with ischemic heart disease. Major comorbidities included type 2 diabetes mellitus (60.7%), arterial hypertension (51%), anemia (54%), chronic kidney disease (29%), atrial fibrillation (16%), and hypothyroidism (9%). Mean hospital stay was 4.5 ± 3.2 days (inter-quartile range: 2–9 days). In-hospital mortality was 8.4% (36 patients) and there were additional 17% deaths over 6 months after discharge. At-discharge medication in those with HFrEF included anti–renin–angiotensin agents (57%), beta-adrenergic receptor blocking agents in 53%, mineralocorticoid receptor antagonists in 34%, ivabradine in 21%, and digoxin in 5%. Angiotensin–neprilysin inhibitor was prescribed to 21% patients at discharge. Ferric carboxymaltose use was in 7.5% of all despite a high prevalence of anemia (54%). Vaccination status at discharge was not available in majority.

Conclusion

The commonest cause of ADHF presenting to this community hospital was HFrEF of ischemic etiology. It is associated with significant in-hospital mortality. There is substantial under-use of guideline-recommended chronic heart failure therapies at hospital discharge. These data provide useful information which can be used to improve patient care and formulate future strategies for management of ADHF.

Supporting the Management of Patients with Heart Failure within Asia-Pacific, Middle East, and African Countries: A Toolbox for Healthcare Providers

OBJECTIVES

The management of heart failure (HF) is most effective when established treatment guidelines and recommendations are followed. We aimed to develop a "Toolbox" of resources to facilitate the care of patients with acute HF and chronic HF with reduced ejection fraction delivered by healthcare professionals across Asia-Pacific, the Middle East and Africa (henceforth referred to as the "Region").

METHODS

We convened a group of cardiologists from across the Region to develop a set of checklists, algorithms, and other practical resources. These resources are based on our experiences, current evidence, and international guidelines.

RESULTS

The HF Toolbox comprises three simplified sets of resources for use in the Emergency Room (ER), hospital and outpatient settings. Resources include admission and discharge checklists, treatment algorithms, recommendations for forming a multidisciplinary team, patient education, and self-management materials, and key performance indicators to monitor whether standards of care are met or maintained, or should be improved.

CONCLUSIONS

The HF Toolbox provides practical resources to simplify the management of patients with HF and to support the formation of HF programs in the Region. The Toolbox is aligned with current guideline recommendations and can support the management of patients from presentation in the ER, through hospital admission to outpatient care.

Systolic aortic regurgitation in rheumatic carditis: Mechanistic insight by Doppler echocardiography

Background

Aortic regurgitation (AR) usually occurs in diastole in presence of an incompetent aortic valve. Systolic AR is a rare phenomenon occurring in patients with reduced left ventricular systolic pressure and atrial fibrillation or premature ventricular contractions. Its occurrence is a Doppler peculiarity and adds to the hemodynamic burden.

Aim

Rheumatic carditis is often characterised by acute or subacute severe mitral regurgitation (MR) due to flail anterior mitral leaflet and elongated chords. In patients with acute or subacute MR, developed left ventricular systolic pressure may fall in mid and late systole due to reduced afterload and end-systolic volume and may be lower than the aortic systolic pressure, causing flow reversal in aorta and systolic AR.

Material and methods

17 patients with acute rheumatic fever were studied in the echocardiography lab during the period 2005–2015. Five patients had severe MR of which two had no AR and hence were excluded from the study. Three young male patients (age 8–24 years) who met modified Jones’ criteria for rheumatic fever with mitral and aortic valve involvement were studied for the presence of systolic AR.

Results

In presence of acute or subacute severe MR, flail anterior mitral valve and heart failure, all three showed both diastolic and late systolic AR by continuous-wave and color Doppler echocardiography.

Conclusion

Systolic AR is a unique hemodynamic phenomenon in patients with acute rheumatic carditis involving both mitral and aortic valves and occurs in presence of severe MR.

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.

Rediscovering Chirality - Role of S-Metoprolol in Cardiovascular Disease Management

BACKGROUND

The process of drug discovery and development today encompass a myriad of paths for bringing a new therapeutic molecule that has minimal adverse effects and of optimal use to the patient. Chirality was proposed in the direction of providing a purer and safer form of drug [Ex- cetrizine and levocetrizine]. Decades have passed since the introduction of this concept and numerous chiral molecules are in existence in therapeutics, yet somehow this concept has been ignored. This review aims to rediscover the ignored facts about chirality, its benefits and clear some common myths considering the example of S-Metoprolol in the management of Hypertension and other cardiovascular diseases.

METHODS

Relevant articles from Pubmed, Embase, Medline and Google Scholar were searched using the terms "Chiral", "Chirality", "Enantiomers", "Isomers", "Isomerism", "Stereo-chemistry", and "S-Metoprolol". Out of 103 articles found 17 articles mentioning in general about the concept of chirality and articles on study of S-metoprolol in various cardiovascular diseases were then reviewed.

RESULTS

Many articles mention about the importance of chirality yet the concept has not been highlighted much. Clear benefits with chiral molecules have been documented for various drug molecules few amongst them being anaesthetics, antihypertensives, antidepressants. Benefits of S-metoprolol over racemate are also clear in terms of responder rates, dose of administration and adverse effects profile in various cardiovascular diseases.

CONCLUSIONS

Chirality is a good way forward in providing a new drug molecule which is safe with lesser pharmacokinetic and pharmacodynamics variability, lesser side effects and more potent action. S-metoprolol is chirally pure form of racemate metoprolol and has lesser side effects, is safer in patients of COPD and Diabetes who also have hypertension and comparable responder rates at half the doses when compared to racemate.

Significant intra-valvular pressure loss across EPIC SUPRA and perimount magna supra-annular designed aortic bioprostheses in patients with normal aortic size

Doppler-derived trans-prosthetic gradients are higher and the estimated effective valve area is smaller than the catheter-derived and directly measured hemodynamic values, mostly due to pressure recovery phenomenon. Pressure recovery to a varying extent is common to all prosthetic heart valves including bioprostheses. Pressure recovery-related differences are usually small except in patients with bileaflet metallic prosthesis, wherein high-pressure local jets across central orifice have been documented since long back and also in patients with narrow aortic root. We describe two patients with normally functioning stented aortic bioprostheses with supra-annular design (EPIC SUPRA and PERIMOUNT MAGNA), wherein very high trans-prosthetic gradients and critically reduced estimated effective valve orifice areas in presence of normal aortic size were consistently recorded over long periods of follow-up. The valve leaflets, however had normal excursion, were thin, opened with a triangular or oblong shape and had expected geometric valve area (1.7 and 1.6 cm² respectively) measured by 3D trans-oesophageal echocardiographic planimetry. Pressure recovery upstream the valves accounted for 20% and 12% of total pressure gradients respectively. Dominant site for pressure drop was intra-valvular (75–85%). Such a phenomenon has not been reported in vivo for these two valve designs.

Hypoplastic right heart syndrome, absent pulmonary valve, and non-compacted left ventricle in an adult

Hypoplastic right heart syndrome is a rare cyanotic congenital heart disease with under-development of the right ventricle, tricuspid, and pulmonary valves leading to right-to-left shunting of the blood through inter-atrial septal defect. Perinatal mortality is high with very few patients surviving to adulthood without corrective surgery. This report describes a 26-year-old young woman, who had recurrent abortions and stillbirths and detected to have marked cyanosis with hypoplastic right heart, sub-arterial ventricular septal defect, absent pulmonary valve, non-compaction of the left ventricle, and bicuspid aortic valve with aortic regurgitation. The patient died owing to progressive heart failure 4 years after the diagnosis was made.

Congenitally unguarded tricuspid valve orifice with right ventricular apical isolation in an adult

Congenitally unguarded tricuspid valve (TV) orifice, a variant of TV dysplasia, is a rare malformation with protean manifestations. This report describes a symptomatic adult male with gross right heart failure and atrial fibrillation, who was found to have an unguarded TV orifice with isolation of the trabecular apical cavity of the right ventricle (RV) and muscular ridges separating outflow tract (forme-fruste of the double-chambered RV). The right ventricular outflow tract remained patent.

Normal echocardiographic measurements in Indian adults: How different are we from the western populations? A pilot study

This study sought to gain insights into the magnitude of error resulting in echocardiographic interpretations in Indian subjects by using western data as the reference. Standard transthoracic echocardiographic examination was performed in 100 healthy volunteers (mean age 34.0 ± 8.8 years, 59% males). Compared with the reference values published by the American Society of Echocardiography (ASE), our subjects had much smaller left ventricular (LV) end-diastolic dimension, end-systolic dimension, and end-diastolic volume (only 58%, 61%, and 61% of the subjects were having values within the ASE-defined normal ranges). Indexing to body surface area increased these proportions to 81%, 90%, and 68%, respectively. In contrast, LV ejection fraction and most of the measures of LV diastolic function coincided with the ASE-recommended age- and gender-specific values.

Acquired discrete subaortic stenosis late after mitral valve replacement

Although acquired left ventricular outflow obstruction has been reported in a variety of conditions, there are scant reports of its occurrence following mitral valve replacement (MVR). This study describes two female patients, who developed severe discrete subaortic stenosis, five years following MVR. In both cases, the mitral valve was replaced by a porcine Carpentier-Edwards 27-mm bioprosthesis with preservation of mitral valve leaflets. The risk of very late left ventricular outflow tract obstruction after bio-prosthetic MVR with preservation of subvalvular apparatus needs to be kept in mind in symptomatic patients.

Spontaneous dissecting aneurysm of the left atrium complicated by cerebral embolism: A report of two cases with review of literature

Left atrial dissection is a very uncommon complication of cardiac surgery and usually causes significant hemodynamic compromise. Little is known about spontaneous dissection of the left atrium. Two patients, one middle-aged man and another elderly woman were evaluated following stroke. Routine trans-thoracic echocardiogram showed vertical division of the left atrium with both chambers communicating with each other through an orifice. Detailed trans-oesophageal echocardiographic study revealed dissection of the left atrium producing an additional false chamber (pseudo-aneurysm) placed posterior to the left atrial appendage and above the postero-lateral aspect of mitral annulus. Spontaneous dissection of the left atrium is extremely rare, and there is no report of cerebral embolism associated with it. Review of literature reveals interesting facets of this rare entity.

Spectrum of congenital mitral valve abnormalities associated with solitary undifferentiated papillary muscle in adults

BACKGROUND

Congenital anomaly wherein the mitral valve leaflets are directly attached to the papillary muscle(s) (PM) with or without short under-developed chords is rarely reported in adults. Patients with two PMs with an intervening fibrous bridge have also been included under this head in previous studies.

METHODS

Echocardiography enables accurate evaluation of the morphology and function of valve leaflets, chordae tendineae, and PM. This report describes a series of six patients aged 56-84 years who had abnormal mitral valve with a large solitary and anomalously inserted PM seen over a period of 3 years. Only those patients who had a single pillar or bridge-like PM and either absent tendinous chords or small under-developed chords were included in the analysis.

RESULTS

Among 9600 consecutive echocardiograms performed, six patients met the criteria of an abnormal mitral valve with solitary large PM. Two patients underwent mitral valve replacement with partial excision of the PM wherein echocardiographic observations were confirmed. The patients were previously followed with the diagnosis of hypertrophic cardiomyopathy (3) and rheumatic mitral valve disease (3). Multi-planar reconstruction of 3D echocardiographic images provided incremental value in assessing the detailed patho-anatomy of PMs in these cases.

CONCLUSION

In adult patients, a high index of suspicion is required to detect congenital mitral stenosis/regurgitation with large solitary PM (resembling a parachute mitral valve) which may masquerade as hypertrophic cardiomyopathy or rheumatic mitral valve disease.

Parachute deformity of both atrioventricular valves with congenitally corrected transposition in an adult

A 23-year-young female presented with mild exertional dyspnoea and palpitation since early childhood. By deploying 2D- and 3D echocardiography, she was detected to have situs solitus, atrioventricular and ventriculoarterial discordance with L-malposition of great vessels, valvular pulmonary stenosis, large secundum atrial septal defect, bicuspid aortic valve, right-sided aortic arch, and moderately severe mitral and tricuspid valve regurgitation. Typical parachute deformities of the morphologically mitral and tricuspid valves were observed. 3D echocardiography revealed a single papillary muscle in the morphologically left ventricle placed anteriorly and providing insertion to tendinous cords and only a moderator band with no other muscle bundles in the morphologically right ventricle placed posteriorly and providing attachment to two strings of cords. Considering the minimal symptoms, conservative treatment was pursued.

Parachute mitral valve and Pacman deformity of the ventricular septum in a middle-aged male

Parachute mitral valve and Pacman heart (incomplete muscular ventricular septal defect) are rare congenital deformities usually reported in infants and children. Very few adult patients with these anomalies are reported but the association of the two has not been described. This report describes a 56-year-old male with exertional dyspnea who was detected to have moderately severe mitral regurgitation and mitral stenosis. Typical parachute deformity of the mitral valve with a reduced opening and common attachment of all the chordae to a single posteromedial papillary muscle was evident. The chordae were elongated, lax, and redundant, which is atypical for this anomaly. Incidentally, detected aneurysm of the basal muscular interventricular septum (Pacman deformity or incomplete triangular septal defect) was also present.

Short Term Safety and Tolerability of a Fixed Dose Combination of Olmesartan, Amlodipine and Hydrochlorothiazide

OBJECTIVE

To assess the short term safety and tolerability of a fixed dose combination (FDC) of olmesartan, amlodipine and hydrochlorothiazide (OAH) in real-world clinical setting in India.

MATERIALS AND METHODS

Physicians were requested to provide eight weeks observational clinical event data of the patients prescribed with FDC of Olmesartan (20/40mg), Amlodipine (5mg) and hydrochlorothiazide (12.5mg) in the prescription event monitoring (PEM) forms. Data on patients' demographics, indication for FDC, concomitant medication and other relevant history was also collected and was analysed with descriptive statistics.

RESULTS

Two hundred thirty eight physicians provided data of 4763 patients. Mean age of the population was 55±7 years and males were 59.3%. The commonest indication for the FDC was uncontrolled hypertension (60.7%). Diabetes and dyslipidemia were present in 37.9% and 35.1% respectively. Concomitant medications included statins (42.3%), oral anti-diabetic (33.7%) and antiplatelet agents (24.7%). Pedal oedema (0.29%) was the most common adverse event (AE) reported followed by headache (0.16%), giddiness (0.15%), light headedness (0.15) and stroke (0.15%). Other less common (0.04%) reported AEs were tiredness, dizziness, gastritis, hypersomnia, hypoglycaemia, lower respiratory tract infection (LRTI), weakness, diarrhea, labyrinthitis, urinary tract infection, hyponatremia and hypotension. Occurrence of AEs was more common in patients with uncontrolled hypertension (60.74%).

CONCLUSION

The FDC of olmesartan, amlodipine and hydrochlorothiazide prescribed most frequently for patients with uncontrolled hypertension and co-morbidities was found to be safe and well tolerated over a short period of observation.

The Indian Consensus Document on cardiac biomarker

Despite recent advances, the diagnosis and management of heart failure evades the clinicians. The etiology of congestive heart failure (CHF) in the Indian scenario comprises of coronary artery disease, diabetes mellitus and hypertension. With better insights into the pathophysiology of CHF, biomarkers have evolved rapidly and received diagnostic and prognostic value. In CHF biomarkers prove as measures of the extent of pathophysiological derangement; examples include biomarkers of myocyte necrosis, myocardial remodeling, neurohormonal activation, etc. In CHF biomarkers act as indicators for the presence, degree of severity and prognosis of the disease, they may be employed in combination with the present conventional clinical assessments. These make the biomarkers feasible options against the present expensive measurements and may provide clinical benefits.

Bilateral outflow obstructions without ventricular septal defect in an adult: Illustrated by real-time 3D echocardiography

Double-chambered right ventricle with discrete subaortic stenosis without ventricular septal defect is rare in adults. This report shows incremental value of 3D echocardiography in delineating the pathoanatomy of these lesions.

Cardiac Biomarkers for Better Management of Acute Coronary Syndromes

Acute myocardial infarction (AMI) causes significant mortality and morbidity. Timely diagnosis allows clinicians to risk stratify their patients and select appropriate treatment. Biomarkers have been used to diagnose or rule out AMI. An increasing number of novel biomarkers have been identified to predict the outcome following AMI or acute coronary syndrome (ACS). This may facilitate tailoring of appropriate therapy to high-risk patients. This review focuses on a variety of promising biomarkers which provide diagnostic and prognostic information.

Unique phenotypes of typical and inverted Takotsubo cardiomyopathy in young females

Takotsubo cardiomyopathy is an acute cardiac syndrome characterized by transient left ventricular regional wall motion abnormalities (with peculiar apical ballooning appearance), chest pain or dyspnea, electrocardiographic changes and minor elevations of cardiac enzyme level in the absence of coronary artery disease. We present 3 cases of a transient cardiomyopathy, noted in young women with associated emotional, physical or pharmacologic triggering events, that are distinct in that they all manifested initially with acute pulmonary edema with systolic akinesis involving different LV segments with rapid recovery. It is a reversible cardiac condition that should be differentiated from ischemic and peripartum cardiomyopathy.

Congenitally unguarded tricuspid valve orifice with multiple other defects in a child with refractory heart failure

Congenitally unguarded tricuspid valve orifice, a variant of tricuspid valve dysplasia, is a rare malformation with protean manifestations. This report describes a 5-year old child with refractory heart failure who, on echocardiography, was found to have unguarded tricuspid valve orifice with severe tricuspid regurgitation, pulmonary valve dysplasia with severe pulmonary regurgitation , cor triatriatum dexter , myxomatous mitral valve , perimembranous ventricular septal defect and a diverticulum of the right ventricular outflow tract. The management options for this child are discussed.

Prime time use of tissue Doppler echocardiography: what have we gained?

In daily practice, Tissue Doppler Echocardiography (TDI) is used to estimate left ventricular filling pressures, categorize diastolic dysfunction, identify patients with heart failure (HF) with normal ejection fraction, differentiate constrictive pericarditis from restrictive cardiomyopathy, to prognosticate acute coronary syndrome, valvular heart disease syndrome of HF etc, correlate exercise capacity and symptoms, differentiate physiological versus pathological hypertrophy, assessment of intraventricular dyssynchrony, regional and global systolic and diastolic properties, detection of right ventricular function and possible carriers of genetic cardiomyopathies like Fabry's disease and hypertrophic cardiomyopathy, etc. Its role in adding incremental value to stress echocardiography, subclinical dysfunction evaluation, cardiac transplant rejection, cardiotoxicity of anti-cancer drugs, predicting occurrence and reversion of atrial fibrillation, predicting aortic catastrophies etc, although very encouraging has not found many users. It was intuitively considered invaluable in detecting subclinical myocarditis, acute rheumatic fever, Chaga's disease and localization of atrioventricular accessory pathways with manifest conduction, but could not find prime time readiness. In a similar manner, tissue-velocity derived deformation parameters have not found prime time use, despite making great inroads into the mysteries of muscle mechanics. Part of the problem lies in their emphasis on unidirectional information of a structure which is essentially multidimensional. The other problems have been angle-dependency and low signal-to-noise ratio in deformation imaging which has restricted its use to highly experienced operators rather than more democratic use. Validation studies did indicate its great potential. TDI-derived imaging paved the way for non-Doppler multidimensional deformation imaging which is slowly gaining ground.

Management of hypertension in heart failure: striking lack of evidence for a common problem

Arterial hypertension is common either as a concomitant or pathogenetic entity in patients with systolic heart failure and in those with heart failure and normal ejection fraction. In free-living communities, more than half of the patients of heart failure with normal ejection fraction (HFnEF) have hypertension somewhat more than that occurring in presence of systolic heart failure. In acute heart failure, co-existent hypertension is much more frequent. Separate guidelines exist for management of hypertension and systolic heart failure. There are no published guidelines for management of HFnEF. There are contradictory recommendations with regard to drug management of hypertension and systolic heart failure. This review examines the available literature on this common co-existing combination and suggests some new recommendations.

Quantification of Regional Nonuniformity and Paradoxical Intramural Mechanics in Hypertrophic Cardiomyopathy by High Frame Rate Ultrasound Myocardial Strain Mapping

This study tested the hypothesis that linear mapping of regional myocardial strain comprehensively assesses variations in regional myocardial function in hypertrophic cardiomyopathy. Hypertrophic cardiomyopathy is characterized by disorganized myocardial architecture that results in spatial and temporal nonuniformity of regional function. Left ventricular deformation was quantified in 20 patients with hypertrophic cardiomyopathy and compared with 25 age- and sex-matched control subjects. Abnormalities in subendocardial strain ranged from reduced longitudinal shortening to paradoxical systolic lengthening and delayed regional longitudinal contractions that were often located in small subsegmental areas. These variations were underestimated significantly by arbitrary measurements compared with linear mapping, in which a region of interest was moved across the longitudinal length of left ventricle (difference of peak and least strain, 10.7% +/- 5.1% vs 17% +/- 5.5%; P < .001). Echocardiographic assessment of variations in regional strain requires careful mapping and may be inappropriately assessed if left ventricular segments are sampled at arbitrary focal locations.

Aneurysmal deformity of the basal interventricular septum secondary to impinging turbulent transprosthetic eccentric flow jets

Cases of aneurysm of basal muscular interventricular septum are very uncommon. This report describes a rare case of a young man in which aneurysmal deformity was an incidental finding during follow-up after thrombolysis of the obstructed mitral prosthesis.