Impact of Mineralocorticoid Receptor Antagonists in the Treatment of Heart Failure: Targeting the Heart Failure Cascade

Epidemiological data from the Indian subcontinent on the burden of Heart failure (HF) is scarce. Mineralocorticoid receptor antagonists (MRAs) are usually used in the management of HF and hypertension. A consortium of experts reviewed and opined on the pathophysiological role of aldosterone in HF and its cascading effects on the heart in terms of cardiac fibrosis, cardiac hypertrophy, and remodeling, increased propensity to cause arrhythmias in addition to its effect on sodium and water retention. This expert opinion document highlights the various mechanisms of action of MRAs. It provides clinical experience and practice-based expert opinion on the use of spironolactone and eplerenone in patients with HF. The role of MRAs in diabetic patients with HF has also been profiled.

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.

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 .

Efficacy and safety of bisoprolol compared to other selective beta-1 blockers in the treatment of hypertension: a systematic review and meta-analysis of randomized parallel clinical trials

Background

Bisoprolol, a highly cardioselective beta-1 blocker (s-BB) has theoretical advantage over other cardio selective betablockers by way of better potency and tolerability in treating hypertension (HT). Individual published trials comparing s-BB are typically small. Meta-analysis of such trials clarifies the issue and position of bisoprolol in HT therapy.

Purpose

This meta-analysis compares bisoprolol with other s-BBs (Atenolol, Betaxolol, Esmolol, Acebutolol, Metoprolol, Nebivolol) for their efficacy and safety in patients with HT.

Methods

Literature databases PubMed, Embase, Cochrane Library, Clinicaltrials.gov, Surveillance, Epidemiology and End Results Program and 12 PV databases were searched systematically to identify randomized, parallel clinical trials published from inception to October 2019. Studies which compared bisoprolol with other s-BBs in HT patients were evaluated in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Random effects meta-analyses were conducted to assess mean difference (MD) and 95% confidence interval (95% CI) for blood pressure (BP), heart rate (HR) and lipid profile.

Results

13 studies compared bisoprolol with other s-BBs (metoprolol, atenolol) were included in this meta-analysis. Bisoprolol reported significant reduction in aortic systolic BP [MD: −8.00; 95% CI: −11.57, −4.43; P<0.01] and diastolic BP [MD: −2.90; 95% CI: −4.98, −0.82; P<0.01] during 8 weeks (w) treatment compared to other s-BBs. Bisoprolol treatment for 12w showed significant change in ambulatory heart rate (AHR) [MD: −5.22; 95% CI: −8.37, −2.07; P<0.01], daytime AHR [MD: −5.75; 95% CI: −9.16, 2.34; P<0.01] and nighttime AHR [MD: −3.22; 95% CI: −6.18, −0.26; P=0.03] in comparison to other s-BBs. Significant increase in low frequency HR variability [MD: 100.79; 95% CI: 16.66, 184.91; P=0.02] was reported with bisoprolol treated for 8w compared to other s-BBs. Baroreflex sensitivity significantly favored bisoprolol treated for 8w [MD: 1.01; 95% CI: 0.03, 1.98; P=0.04] in comparison to other s-BBs. HDL-C significantly increased with bisoprolol treated for 52w [MD: 6.80; 95% CI: 3.01, 10.60; P<0.01], 104w [MD: 12.00; 95% CI: 5.04, 18.96; P<0.01] and 156w [MD: 8.00; 95% CI: 0.58, 15.42; P=0.03]. There were no significant changes in total cholesterol [MD: −3.06; P=0.38], LDL-C [MD: −3.60; P=0.18] and triglyceride [MD: −21.00; P=0.26] on treatment with bisoprolol. Serious adverse events did not differ significantly on treatment with bisoprolol compared to other s-BBs.

Conclusion

The results of this meta-analysis reveal that bisoprolol showed a significant reduction of BP, HR, baroreflex sensitivity and improved HDL cholesterol levels compared to other s-BBs. Our results highlight the heterogeneity amongst the s-BBs and highlights the benefit of choosing bisoprolol in comparison to other s-BB in the management of HT.

Funding Acknowledgement

Type of funding sources: None.

Effectiveness of bisoprolol versus selective beta-1 blockers in the management of hypertension: a systematic review and meta-analysis of randomized cross-over trials

Background

Cross-over trials carry a higher weightage in choosing a therapeutic agent in clinical practice. A meta-analysis of cross-over trials involving the use of bisoprolol in hypertension (HT) would bring about clarity in positioning this drug.

Purpose

The present study aimed to clarify the underlying benefits of bisoprolol in the reduction of blood pressure (BP) in HT patients when compared to selective beta-1 blockers (s-BBs - Atenolol, Betaxolol hydrochloride, Esmolol, Acebutolol hydrochloride, Metoprolol succinate, Nebivolol) by performing a meta-analysis of “cross-over” trials published in literature.

Methods

Systematic search was undertaken in PubMed, Embase, Cochrane Library, Clinicaltrials.gov registry, Surveillance, Epidemiology and End Results Program and 12 pharmacovigilance databases. Randomized, cross-over studies published up to October 2019 which compared bisoprolol with other s-BBs in HT patients were evaluated in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A meta-analysis was performed using random effects model in terms of mean difference (MD) and 95% confidence intervals (95% CI) for BP, heart rate (HR) and lipid profile.

Results

Nine randomized cross-over studies which compared bisoprolol with other s-BBs (atenolol and nebivolol) were included in this meta-analysis. Bisoprolol reported significant reduction of sitting BP [MD: −3.35, 95% CI: −6.75, 0.05; P=0.05] and reduction of diastolic BP [MD: −2.00; 95% CI: −8.04, 4.04; P=0.52, non-significant] among patients with HT when compared to other s-BBs. Heart rate (HR) decreased significantly among HT patients in bisoprolol group treated for 2 w [MD: −6.00; 95% CI: −11.30, −0.70; P=0.03] when compared to those treated with other s-BBs. Analysis of lipid profile showed non-significant reduction of serum cholesterol [MD: −7.74; 95% CI: −17.18, 1.70; P=0.11] and triglyceride [MD: −26.57; 95% CI: −64.34, 11.20; P=0.17] levels in the bisoprolol group compared to other s-BBs. Bisoprolol treatment for 8 w resulted in a slight but statistically significant change in potassium levels [MD: −0.10; 95% CI: −0.16, −0.04; P<0.01] among HT patients.

Conclusion

The results of this meta-analysis reported significant efficacy of bisoprolol on BP and HR in comparison to other s-BBs in a meta-analysis of cross-over trials. Our findings show that use of bisoprolol as a therapeutic option is efficacious and safe compared to other s-BBs in this patient population.

Funding Acknowledgement

Type of funding sources: None.

Validation of the OPtimal Treatment of Angina (OPTA) Questionnaire in Indian Patients with Chronic Stable Angina

BACKGROUND

A rising burden of coronary artery disease (CAD) in India is a major cause of concern, with angina being the leading manifestation. Hence a questionnaire to sensitize the clinicians about stable angina management and to assist in risk stratification is imperative.

OBJECTIVE

To evaluate the content and face validity of a modified questionnaire adapted from the 7-item Seattle Angina Questionnaire (SAQ).

MATERIALS AND METHODS

A panel of six experts in the field of evidence-based practice reviewed and rated the modified instrument for content clarity and relevance based on the 4-point ordinal scale. Face validity was assessed based on the trichotomous rating of "disagreed", "agree" or "neutral". Items on which ≥75% of patients "disagreed" were subjected to further review and revision.

RESULTS

A total of six experts and 51 patients participated in the content and face validity, respectively. As no question received a score ≤2 by two or more experts for either content clarity or relevance, no modification in the questionnaire was required post content validation. During face validation, all patients agreed that the questions correctly measured the specific area of cardiovascular health status and response options correctly captured the answers provided. Demographic and baseline data of the patients were collected.

CONCLUSION

The newly developed 5-item questionnaire demonstrated content and face validity, suggesting it to be a potential instrument to improve management decision and care of angina patients in India.

Demographic profile, clinical characteristics and medical management patterns of Indian coronary artery disease patients: a nationwide urban-based, real-world, retrospective, observational electronic medical record study- report of baseline data

Background: This is the first detailed Indian electronic medical record (EMR)-based real-world observational study to understand the clinical characteristics, associated comorbidities/risk factors and treatment(s) of CAD patients across India.Methods: EMR data of adult Indians (aged ≥ 18 years) diagnosed with CAD was retrospectively analyzed.Results: The majority of the participants had stable IHD (93%), were men (68.5% in ACS, 59.8% in stable IHD), most common age group was 40-64 years in ACS (56.6%) and stable IHD (51.4%). Both are common in metros (ACS 52%, 62% stable IHD). There is a high frequency of hypertension (38.2% in ACS, 59% in stable IHD) and diabetes mellitus (32.3% in ACS, 57.6% in stable IHD). Most common treatments are antiplatelet drugs and lipid-lowering drugs (96%).Conclusions: In India, stable IHD is the most prevalent form in vast majority of patients. The patients with CAD are mostly males, are mainly located in metros and majority fall between the age group of 40-64. The major comorbidities are hypertension and diabetes mellitus. Sociodemographic and clinical characteristics for CAD in India may not be similar to what is reported from the west. There is a significant difference in drug usage and adherence to guidelines in India for CAD.

Changing pattern of admissions for acute myocardial infarction in India during the COVID-19 pandemic

AIM

Studies on the changes in the presentation and management of acute myocardial infarction (AMI) during the COVID-19 pandemic from low- and middle-income countries are limited. We sought to determine the changes in the number of admissions, management practices, and outcomes of AMI during the pandemic period in India.

METHODS & RESULTS

In this two-timepoint cross-sectional study involving 187 hospitals across India, patients admitted with AMI between 15th March to 15th June in 2020 were compared with those admitted during the corresponding period of 2019. We included 41,832 consecutive adults with AMI. Admissions during the pandemic period (n = 16414) decreased by 35·4% as compared to the corresponding period in 2019 (n = 25418). We observed significant heterogeneity in this decline across India. The weekly average decrease in AMI admissions in 2020 correlated negatively with the number of COVID cases (r = -0·48; r2 = 0·2), but strongly correlated with the stringency of lockdown index (r = 0·95; r2 = 0·90). On a multi-level logistic regression, admissions were lower in 2020 with older age categories, tier 1 cities, and centers with high patient volume. Adjusted utilization rate of coronary angiography, and percutaneous coronary intervention decreased by 11·3%, and 5·9% respectively.

CONCLUSIONS

The magnitude of reduction in AMI admissions across India was not uniform. The nature, time course, and the patient demographics were different compared to reports from other countries, suggesting a significant impact due to the lockdown. These findings have important implications in managing AMI during the pandemic.

Effectiveness and Effect on Renal Parameters of Amlodipine vs. Other Dihydropyridine Calcium Channel Blockers in Patients with Essential Hypertension: Retrospective Observational Study Based on Real-World Evidence from Electronic Medical Records

Introduction

The renoprotective effects of dihydropyridine calcium channel blockers (CCBs) have been established as non-inferior to other classes of antihypertensive drugs. Studying their effect on renal outcome parameters, specifically for amlodipine as monotherapy, in real-world settings can further help in expanding its usage among Indian patients. This study was performed to assess the effects of amlodipine and other dihydropyridine CCBs (cilnidipine, benidipine and azelnidipine) on renal parameters and effectiveness in blood pressure reduction in Indian patients.

Methods

The retrospective data of adult patients (> 18 years) with essential hypertensive who were prescribed amlodipine (n = 92), cilnidipine (n = 91), benidipine (n = 70) or azelnidipine (n = 71) as monotherapy were analyzed. The renal outcomes, serum creatinine, estimated glomerular filtration rate (eGFR), blood urea nitrogen (BUN), microalbumin, urine albumin-to-creatinine ratio (UACR), sodium and potassium levels, and mean changes in BP were analyzed from baseline to 12 months. Appropriate statistical methods were used to determine the significance (p value < 0.05).

Results

From baseline to the end of the study, mean serum creatinine changed from 0.98 ± 0.17 to 1.07 ± 0.28 mg/dL with amlodipine, 0.97 ± 0.18 to 1.13 ± 0.50 mg/dL with cilnidipine, 0.98 ± 0.30 to 0.97 ± 0.27 mg/dL wi th benidipine, and 0.99 ± 0.23 to 0.98 ± 0.25 mg/dL with azelnidipine (p = 0.01). The mean microalbumin and UACR were reduced from baseline to the end of the study (p = 0.06 and p > 0.05). No significant changes were observed in BUN, sodium or potassium levels. Overall, for all CCBs, the mean systolic blood pressure (SBP) and diastolic blood pressure (DBP) values were reduced from baseline to the end of the study (p = 0.002). At the end of the study, the average dose of amlodipine was 7.25 mg, and the average reduction in SBP and DBP per mg dose was 1.54 and 0.57 mmHg. The corresponding numbers for the other CCBs were as follows: cilnidipine, 14.28 mg, 0.26 and 0.01; benidipine, 5.71 mg, 0.41 and 0.11; azelnidipine, 15.88 mg, 0.13 and 0.06.

Conclusion

Amlodipine and other CCBs demonstrated good efficacy and similar effects on renal parameters from baseline to end of study. Amlodipine also showed higher potency by demonstrating greater BP reduction at a lower dose. Thus, amlodipine can remain a preferred choice among CCBs, even with the advent of the newer CCBs.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40119-021-00224-8.

SGLT2-inhibition and Vascular Euphoria a Reconciliation of Vascular Health and Disease Homeostasis

The concept of SGLT2-inhibition, once regarded as a non-physiological approach to glycemia control, now finds a foundational relevance in risk-modification for cardiovascular, kidney, and metabolic outcomes, spanning beyond type-2 diabetes. Major studies have proven meaningful improvements in various clinical outcomes, with different SGLT2-i agents. Apart from glycosuria, SGLT2-inhibition is associated with several patho-physiological effects, which may contribute to the clinical benefits seen with these agents. This narrative review is an attempt to appraise the different patho-physiological effects mediated by SGLT2-inhibition, based on contemporary evidence. The review classifies these effects in the acronym of EUPHORIA, and grades the possible relevance of each effect, in improving clinical outcomes.

Progastrin production transitions from Bmi1+/Prox1+ to Lgr5high cells during early intestinal tumorigenesis

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Secretion of progastrin is a signature event of early malignant transformation in the colon.

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In the healthy epithelium, progastrin is produced by a subset of enteroendocrine cells expressing both Bmi1 and Prox1.

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LGR5-high intestinal stem cells are a primary source of progastrin production in early mouse and human intestinal adenomas.

Progastrin is an unprocessed soluble peptide precursor with a well-described tumor-promoting role in colorectal cancer. It is expressed at small levels in the healthy intestinal mucosa, and its expression is enhanced at early stages of intestinal tumor development, with high levels of this peptide in hyperplastic intestinal polyps being associated with poor neoplasm-free survival in patients. Yet, the precise type of progastrin-producing cells in the healthy intestinal mucosa and in early adenomas remains unclear. Here, we used a combination of immunostaining, RNAscope labelling and retrospective analysis of single cell RNAseq results to demonstrate that progastrin is produced within intestinal crypts by a subset of Bmi1⁺/Prox1⁺/LGR5^low endocrine cells, previously shown to act as replacement stem cells in case of mucosal injury. In contrast, our findings indicate that intestinal stem cells, specified by expression of the Wnt signaling target LGR5, become the main source of progastrin production in early mouse and human intestinal adenomas. Collectively our results suggest that the previously identified feed-forward mechanisms between progastrin and Wnt signaling is a hallmark of early neoplastic transformation in mouse and human colonic adenomas.

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.

Pattern of acute MI admissions in India during COVID-19 era: A Cardiological Society of India study - Rationale and design

Background

COVID-19 pandemic has affected around 20million patients worldwide and 2.0 million cases from India. The lockdown was employed to delay the pandemic. However, it had an unintentional impact on acute cardiovascular care, especially acute myocardial infarction (AMI). Observational studies have shown a decrease in hospital admissions for AMI in several developed countries during the pandemic period. We aimed to evaluate the impact of COVID-19 on the AMI admissions patterns across India.

Methods

In this multicentric, retrospective, cross-sectional study, we included all AMI cases admitted to participating hospitals during the study period 15th March to 15th June 2020 and compared them using a historical control of all cases of AMI admitted during the corresponding period in the year 2019. Major objective of the study is to analyze the changes inthe number of hospital admissions for AMI in hospitals across India. In addition, we intend to evaluate the impact of COVID-19 on the weekly AMI admission rates, and other performance measures like rates of thrombolysis/primary percutaneous interventions (PCI), window period, door to balloon time, and door to needle time. Other objectives include evaluation of changes in the major complications and mortality rates of AMI and its predictors during COVID-19 pandemic.

Conclusions

This CSI-AMI study will provide scientific evidence about the impact of COVID-19 on AMI care in India. Based on this study, we may be able to suggest appropriate changes to the existing MI guidelines and to educate the public regarding emergency care for AMI during COVID-19 pandemic.

ACEI-induced cough: A review of current evidence and its practical implications for optimal CV risk reduction

Cough is one of the common adverse effects in patients receiving angiotensin-converting enzyme inhibitors (ACEIs). This review presents the current evidence on incidence and mechanisms of cough associated with ACEIs use, and proposes a practical approach for managing the same for optimal cardiovascular (CV) risk reduction. The incidence of dry cough in patients receiving ACEIs vary among individual ACEIs, and is the lowest with perindopril. Cough is thought to originate from multiple mechanisms, bradykinin theory is the most commonly appealed hypothesis. The strategies for optimal management could be temporarily discontinuation of ACEI upon a reported incidence of cough and reintroduction after its remission. However, studies have reported disappearance of cough despite continuing treatment. Another important approach could be adding calcium channel blockers to ACEIs. Switching to alternative drugs such as angiotensin receptor blockers should be suggested in case intolerable symptoms recur and after exclusion of all other possible causes of cough.

Assessment of healthcare measures, healthcare resource use, and cost of care among severe hemophilia A patients in Mumbai region of India

Background

In India, the low public health priority given to rare disorders such as hemophilia hinders their management and optimal care, leading to relatively poor health outcomes. This study aims to profile the multidimensional health status of patients with severe hemophilia A, and its association with the use of healthcare resources and the cost of care in Mumbai region of India.

Subjects and Methods

A cross-sectional, single-center study was conducted during January-May 2011, among 160 patients diagnosed with severe hemophilia A in Mumbai region of India. Their health status was documented using the Hemophilia Utilization Group Study's validated instrument of Functional Health Status Measure (FHS) and a single item of Self-care Measure.

Results

Of 160 patients, 55% (n = 88) scored on the lower side on the FHS, with an average score of 6.65 ± 2.85. The use of healthcare resources and cost of treatment were considerable for patients with a lower mean rank score on the FHS and a higher mean rank score on the self-care measure. The consumption of clotting factor concentrates (CFCs), number of visits to a health facility and incidence of inpatient episodes were significantly associated with a relatively low score on the FHS. Similarly, a higher cost of treatment, in terms of the cost of CFCs, direct cost, emergency room cost, and indirect cost, were significantly associated with a lower score on the FHS.

Conclusion

The health status of patients with severe hemophilia A is compromised and has a significant impact on the use of healthcare resources and the cost of treatment.

Abstract P107: Real-World Azilsartan efficacy Assessment Study in Indian Hypertensive patients (RAAS-India)

Background: Azilsartan, a potent angiotensin type 1 receptor blocker (ARB) has limited data on the efficacy and safety in hypertensive subjects in India.

Methods: Retrospective audit based on data from the prescribing physicians on efficacy of Azilsartan monotherapy or in combination with other antihypertensive drugs. Office blood pressure (BP) measurement prior to initiation of Azilsartan, at 1 st and 2nd follow-up visits were recorded. Two-tailed paired t -test and nonparametric Wilcoxon signed-rank test were used for statistical analysis.

Results: Data of 1397 patients was collected of which 844 patient were eligible for analysis at baseline. Mean age was 54.7 years. Azilsartan was started as monotherapy in 64.6% patients and as an add-on to antihypertensive therapy in 35.4% patients. Significant reduction of 19.6 mm Hg in mean Systolic BP (baseline: 162.6 + 15.6 mm Hg to visit 1: 143 + 13.7 mm Hg, p<0.001) and 30.2mm Hg in mean Systolic BP (baseline: 162.6 + 15.6 mm Hg to visit 2: 132.4 + 10.7, p<0.001) was observed. Significant reduction of 9.2 mmHg in mean diastolic BP (baseline: 95.4 + 10 mmHg to visit 1 at mean day 36 : 86.2 + 7.1 p<0.001) and 13.5mmHg in mean diastolic BP (baseline: 95.4 + 10 mmHg to visit 2 at mean day 71: 81.9 + 5.7 p<0.001) was observed. Azilsartan in the prescribed dose was well tolerated. Most common adverse event reported were Nausea 10 (1.2 %), metallic taste 10 (1.2 %) and giddiness 8 (0.9 %). No serious adverse events were reported.

Conclusion: Azilsartan alone or with other antihypertensive drugs significantly reduced BP in Indian hypertensive patients in a real world setting. Azilsartan was well tolerated without any major or serious adverse events.

Pharmacological Reperfusion Therapy with Tenecteplase in 7,668 Indian Patients with ST Elevation Myocardial Infarction - A Real World Indian Experience

OBJECTIVE

This real-world, observational, prescription event monitoring study was conducted to evaluate safety and efficacy of indigenous tenecteplase (TNK-tPA) in Indian patients presenting with ST elevation myocardial infarction (STEMI).

METHODS

This is a multi-centric, observational, prescription event monitoring study. Data was collected for 7,668 patients from 1,307 investigator sites across India from January 2011 to February 2016.

RESULTS

Overall, 76.71% patients were hypertensive, 47.97% patients were diabetic, 42.01% had dyslipidemia, 24.35% had ischemic heart disease and 40.82% patients were smokers. The overall rate for achieving clinically successful thrombolysis by TNK was 93.34%. Delayed administration of tenecteplase yielded lower success rate (84.66%) as against those patients who received tenecteplase within 3 hours of symptoms (94.34%). 93.2% patients had chest pain resolution after pharmacological fibrinolysis. Overall 91.1% patients had 50% resolution of ST elevation at 90 minutes and mean time for 50% ST resolution was 72.06 minutes. Overall 53 patients died (mortality of 0.69%) before discharge. The incidence of bleeding (excluding stroke) was 1.77%, any stroke without ICH was 0.18% and any ICH was 0.38%.

CONCLUSION

The findings of this study further reinforce the safety and efficacy of indigenous TNK-tPA in Indian patients presenting with STEMI, including high-risk sub-groups. The study also highlights the importance of early reperfusion therapy.

Study of Acidithiobacillus ferrooxidans and enzymatic bio-Fenton process-mediated corrosion of copper-nickel alloy

This study presents the corrosion behavior of the copper-nickel (Cu-Ni) alloy in the presence of Acidithiobacillus ferrooxidans (A. ferrooxidans) and glucose oxidase (GOx) enzyme. In both the cases ferric ions played an important role in weight loss and thereby to carry out the corrosion of the Cu-Ni alloy. A corrosion rate of 0.6 (±0.008), 2.11 (±0.05), 3.69 (±0.26), 0.7 (±0.006) and 0.08 (±0.002) mm/year was obtained in 72 h using 9K medium with ferrous sulfate, A. ferrooxidans culture supernatant, A. ferrooxidans cells, GOx enzyme and hydrogen peroxide (H2O2) solution respectively. The scanning electron microscopy (SEM) micrographs showed that a variable extent of corrosion was caused by 9K medium with ferrous sulfate, GOx and A. ferrooxidans cells. An arithmetic average surface roughness (Ra) of 174.78 nm was observed for the control work-piece using optical profilometer. The change in Ra was observed with the treatment of the Cu-Ni alloy using various systems. The Ra for 9K medium with ferrous sulfate, GOx and A. ferrooxidans cells was 374.54, 607.32 and 799.48 nm, respectively, after 24 h. These results suggest that A. ferrooxidans cells were responsible for more corrosion of the Cu-Ni alloy than other systems used.

Leaching of metals from printed circuit board powder by an Aspergillus niger culture supernatant and hydrogen peroxide

Removal of chemical coating of PCB powder using 0.1 M sodium hydroxide solution.

Blood pressure control with a single-pill combination of indapamide sustained-release and amlodipine in patients with hypertension: the EFFICIENT study

OBJECTIVE

Despite antihypertensive treatment, most hypertensive patients still have high blood pressure (BP), notably high systolic blood pressure (SBP). The EFFICIENT study examines the efficacy and acceptability of a single-pill combination of sustained-release (SR) indapamide, a thiazide-like diuretic, and amlodipine, a calcium channel blocker (CCB), in the management of hypertension.

METHODS

Patients who were previously uncontrolled on CCB monotherapy (BP≥140/90 mm Hg) or were previously untreated with grade 2 or 3 essential hypertension (BP≥160/100 mm Hg) received a single-pill combination tablet containing indapamide SR 1.5 mg and amlodipine 5 mg daily for 45 days, in this multicenter prospective phase 4 study. The primary outcome was mean change in BP from baseline; percentage of patients achieving BP control (BP<140/90 mm Hg) was a secondary endpoint. SBP reduction (ΔSBP) versus diastolic BP reduction (ΔDBP) was evaluated (ΔSBP/ΔDBP) from baseline to day 45. Safety and tolerability were also assessed.

RESULTS

Mean baseline BP of 196 patients (mean age 52.3 years) was 160.2/97.9 mm Hg. After 45 days, mean SBP decreased by 28.5 mm Hg (95% CI, 26.4 to 30.6), while diastolic BP decreased by 15.6 mm Hg (95% CI, 14.5 to 16.7). BP control (<140/90 mm Hg) was achieved in 85% patients. ΔSBP/ΔDBP was 1.82 in the overall population. Few patients (n = 3 [2%]) reported side effects, and most (n = 194 [99%]) adhered to treatment.

CONCLUSION

In patients who were previously uncontrolled on CCB monotherapy or untreated with grade 2 or 3 hypertension, single-pill combination indapamide SR/amlodipine reduced BP effectively--especially SBP--over 45 days, and was safe and well tolerated.

TRIAL REGISTRATION

Clinical Trial Registry-India CTRI/2010/091/000114.

Pharmacologic reperfusion therapy with indigenous tenecteplase in 15,222 patients with ST elevation myocardial infarction - the Indian Registry

OBJECTIVE

To study the efficacy and safety of single intravenous bolus administration of indigenously developed tenecteplase (TNK-tPA) in the management of patients with ST-elevation myocardial infarction (STEMI) in clinical practice.

METHODS

Observational, prescription-event monitoring study.

RESULTS

Data of 15,222 patients who had STEMI and received weight adjusted TNK injection was analyzed. Overall 95.43% patients had clinically successful thrombolysis (CST). In the different subgroups, hypertensives, diabetics, smokers and hyperlipidemic patients had CST rates comparable to the general patient data. CST rates were significantly lower in the elderly patients (>70 years; 92.11%; p < 0.0001), in patients with history of Ischemic Heart Disease (IHD, 93.86%; p = 0.0004) and in patients receiving delayed treatment (>6 h after onset of chest pain; 85.38%; p < 0.0001). CST was significantly higher in patients who received an early thrombolysis (<3 h after onset of chest pain; 96.54%; p = 0.006). Overall mortality was 1.69%, while it was significantly higher in the elderly (4.42%), patients with history of IHD (2.67%), females (2.93%) and in those who received delayed treatment (4.98%). The overall incidences of intracranial hemorrhage (ICH), bleeding excluding ICH, stroke and ventricular tachyarrhythmia were 0.39%, 2.01%, 0.16% and 2.35% respectively. Age >70 years, diabetes, hyperlipidemia and history of IHD were associated with a higher incidence of heart failure, myocardial re-infarction or ventricular tachyarrhythmias. However, incidence of ICH and bleeding other than ICH was comparable amongst all patient subgroups.

CONCLUSION

This study confirms the safety and efficacy of indigenous tenecteplase in Indian patients with STEMI, including high risk subgroups. It also highlights the fact that delayed treatment denotes denial of benefits of pharmacologic reperfusion therapy.

Efficacy and safety of tenecteplase in ST elevation myocardial infarction patients from the Elaxim Indian Registry

OBJECTIVE

to study the efficacy and safety of indigenously developed tenecteplase injection in the management of Indian STEMI patients in clinical practice.

METHODS

post-licensure, observational, prescription event monitoring study.

RESULTS

2100 patients received weight-adjusted tenecteplase injection. More than 90% patients received aspirin, clopidogrel, and enoxaparin/heparin. Clinically successful thrombolysis was reported in 86.71%, in-hospital mortality was 3.48%. The adverse events recorded were comparable with previously published data. Any bleeding (excluding intra-cranial hemorrhage) was seen in 4.62% patients which was reported in 0.90% patients of which 47.34% patients had also received GpIIb/IIIa inhibitors.

CONCLUSION

This study confirms the efficacy and safety of indigenous tenecteplase in Indian STEMI patients.

Rheumatic mitral valve surgery in the fifth decade: our experience

AIM

Rheumatic mitral patients reach their fifth decade of life more often now than in the past. The purpose of this study is to provide insight into improving morbidity and mortality in these patients.

METHODS

This retrospective study included 105 patients aged 50 years or more. Seventy-five underwent mechanical valve replacement and 30 received a bioprosthetic valve. Data were collected from medical records and outpatient department (OPD) registers. Follow-up included transthoracic 2D echocardiography, supported by clinical parameters, and X-ray findings.

RESULTS

Mean age was 58.52+/-2.4 years. Follow-up period ranged from one to eleven years (mean 6.8+/-0.9 years). Immediate perioperative mortality included five patients (4.76%) and long term mortality included three patients (3%). 35 patients previously underwent closed and open commissurotomy and balloon valvotomy. Multivariate analysis showed age, repeat surgery, atrial fibrillation, tricuspid valve disease, and preoperative functional status to be incremental risk factors. Freedom from repeat operation at 3 and 6 years was 90% and 85% in group I (<60 years), respectively. Actuarial survival at 4 and 6 years of follow up was 94.24% and 88.52%, respectively.

CONCLUSION

With improving life expectancy and early interventions, the number of < or = 50-year old rheumatic valvular disease patients is increasing. The present study showed a marked improvement for this subset of patients, although age still remains the main risk factor along with atrial fibrillation, repeat surgery, stroke and tricuspid valve disease.