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Objectives We aimed to measure the change in prevalence of Coronary Heart Disease (CHD) and Cardiovascular Diseases (CVDs) risk among those aged 35–64 years in urban and rural areas of National Capital Region (NCR) of Delhi, between 1991-1994 (survey 1) and 2010–2012 (survey 2). Methods Both surveys used similar sampling methodology and mean ages of participants were similar. A total of 3048 and 2052 subjects were studied in urban Delhi and 2487 and 1917 participants recruited from rural Ballabgarh in survey 1 and in survey 2 respectively. CHD was diagnosed based on a Minnesota coded ECG and Rose angina questionnaire. Data on behavioural, physical, clinical and biochemical parameters were collected using standard methods. CVD Risk of participants was calculated using the gender specific Framingham risk equation. Results The age and sex standardised prevalence of CHD in urban Delhi increased from 10.3% (95% CI: 9.2–11.4) to 14.1% (95% CI: 12.6–15.6) between the two surveys as compared to an increase from 6.0% (95% CI: 5.0–6.9) to 7.4% (95% CI: 6.3–8.6) in rural Ballabgarh. The highest increase in the prevalence of CHD was reported among urban women (10.1% to 16.6%).The proportion of population with high 10-year CVD risk increased to 4.1% from 1.2% in rural areas as compared to 4.8% from 2.5% in urban areas. Conclusions The CHD and CVD risk has increased over 20 years period in and around Delhi and the increase was more in rural population and women, traditionally considered to be at low risk.

Background Given the shortage of cardiac rehabilitation (CR) programs in India and poor uptake worldwide, there is an urgent need to find alternative models of CR that are inexpensive and may offer choice to subgroups with poor uptake (e.g., women and elderly). Objectives This study sought to evaluate the effects of yoga-based CR (Yoga-CaRe) on major cardiovascular events and self-rated health in a multicenter randomized controlled trial. Methods The trial was conducted in 24 medical centers across India. This study recruited 3,959 patients with acute myocardial infarction with a median and minimum follow-up of 22 and 6 months. Patients were individually randomized to receive either a Yoga-CaRe program (n = 1,970) or enhanced standard care involving educational advice (n = 1,989). The co-primary outcomes were: 1) first occurrence of major adverse cardiovascular events (MACE) (composite of all-cause mortality, myocardial infarction, stroke, or emergency cardiovascular hospitalization); and 2) self-rated health on the European Quality of Life–5 Dimensions–5 Level visual analogue scale at 12 weeks. Results MACE occurred in 131 (6.7%) patients in the Yoga-CaRe group and 146 (7.4%) patients in the enhanced standard care group (hazard ratio with Yoga-CaRe: 0.90; 95% confidence interval [CI]: 0.71 to 1.15; p = 0.41). Self-rated health was 77 in Yoga-CaRe and 75.7 in the enhanced standard care group (baseline-adjusted mean difference in favor of Yoga-CaRe: 1.5; 95% CI: 0.5 to 2.5; p = 0.002). The Yoga-CaRe group had greater return to pre-infarct activities, but there was no difference in tobacco cessation or medication adherence between the treatment groups (secondary outcomes). Conclusions Yoga-CaRe improved self-rated health and return to pre-infarct activities after acute myocardial infarction, but the trial lacked statistical power to show a difference in MACE. Yoga-CaRe may be an option when conventional CR is unavailable or unacceptable to individuals. (A study on effectiveness of YOGA based cardiac rehabilitation programme in India and United Kingdom; CTRI/2012/02/002408)., Central Illustration

Background Cardiac rehabilitation (CR) is a standard treatment for secondary prevention of acute myocardial infarction (AMI) in high income countries (HICs), but it is inaccessible to most patients in India due to high costs and skills required for multidisciplinary CR teams. We developed a low-cost and scalable CR program based on culturally-acceptable practice of yoga (Yoga-CaRe). In this paper, we report the rationale and design for evaluation of its effectiveness and cost-effectiveness. Methods This is a multi-center, single-blind, two-arm parallel-group randomized controlled trial across 22 cardiac care hospitals in India. Four thousand patients aged 18–80 years with AMI will be recruited and randomized 1:1 to receive Yoga-CaRe program (13 sessions supervised by an instructor and encouragement to self-practice daily) or enhanced standard care (3 sessions of health education) delivered over a period of three months. Participants will be followed 3-monthly till the end of the trial. The co-primary outcomes are a) time to occurrence of first cardiovascular event (composite of all-cause mortality, non-fatal myocardial infarction, non-fatal stroke and emergency cardiovascular hospitalization), and b) quality of life (Euro-QoL-5L) at 12 weeks. Secondary outcomes include need for revascularization procedures, return to pre-infarct activities, tobacco cessation, medication adherence, and cost-effectiveness of the intervention. Conclusion This trial will alone contribute >20% participants to existing meta-analyses of randomized trials of CR worldwide. If Yoga-CaRe is found to be effective, it has the potential to save millions of lives and transform care of AMI patients in India and other low and middle income country settings.

Background Despite high projected burden, hypertension incidence data are lacking in South Asian population. We measured hypertension prevalence and incidence in the Center for cArdio-metabolic Risk Reduction in South Asia (CARRS) adult cohort. Methods The CARRS Study recruited representative samples of Chennai, Delhi, and Karachi in 2010/11, and socio-demographic and risk factor data were obtained using a standard common protocol. Blood pressure (BP) was measured in the sitting position using electronic sphygmomanometer both at baseline and two year follow-up. Hypertension and control were defined by JNC 7 criteria. Results In total, 16,287 participants were recruited (response rate = 94.3%) and two year follow-up was completed in 12,504 (follow-up rate = 79.2%). Hypertension was present in 30.1% men (95% CI: 28.7–31.5) and 26.8% women (25.7–27.9) at baseline. BP was controlled in 1 in 7 subjects with hypertension. At two years, among non-hypertensive adults, average systolic BP increased 2.6 mm Hg (95% CI: 2.1–3.1), diastolic BP 0.7 mm Hg (95% CI: 0.4–1.0), and 1 in 6 developed hypertension (82.6 per 1000 person years, 95% CI: 80.8–84.4). Risk for developing hypertension was associated with age, low socio-economic status, current alcohol use, overweight, pre-hypertension, and dysglycemia. Risk of incident hypertension was highest (RR = 2.95, 95% CI: 2.53–3.45) in individuals with pre-hypertension compared to normal BP. Collectively, 4 modifiable risk factors (pre-hypertension, overweight, dysglycemia, and alcohol use) accounted for 78% of the population attributable risk of incident hypertension. Conclusion High prevalence and poor control of hypertension, along with high incidence, in South Asian adult population call for urgent preventive measures.

Background An international collaboration of investigators will assess the benefits and risks of fixed dose combination (FDC) based care compared with usual care in populations at high risk of cardiovascular disease (CVD). Several trials are being conducted, as the effectiveness and economic impact of a FDC-based strategy may vary substantially between countries, given the varying influence of the health-care system within which the intervention is delivered. Methods Individual patient data (IPD) will be provided by participating trials for combined IPD meta-analysis. Results Primary outcomes will include self-reported current use of antiplatelet, statin, and combination (≥2) blood pressure lowering therapies at 12months, and change in systolic blood pressure (SBP) and LDL cholesterol from baseline to 12months. Non-inferiority margins of 3mmHg for SBP and 0.3mmol/L for LDL cholesterol have been pre-specified. Secondary outcomes will include change in cholesterol fractions, diastolic blood pressure and creatinine from baseline to 12months, quality of life, new onset diabetes mellitus, mortality (cardiovascular, non-cardiovascular and all cause) and a composite outcome of cardiovascular events (including all coronary heart disease events, heart failure events leading to death or requiring hospital admission, cerebrovascular events and peripheral arterial events). Conclusion The SPACE group of trials will assess, in a variety of healthcare settings, whether a FDC strategy for delivery of preventive medication has the potential to significantly improve prevention of cardiovascular disease in patients at high risk.

India is in the middle of the epidemiological transition, with the burden of disease shifting towards chronic conditions, of which cardiovascular diseases (CVDs) form a major part. Findings from the Framingham Heart Study (FHS) have tremendous potential to circumvent the projected increase in CVD burden in India, as they highlight the importance of measuring risk in individuals and populations, and preventing future onset of disease. The findings of the FHS have stimulated several cross-sectional studies in India documenting a high and increasing burden of CVD risk factors. These have led to policy level changes in the country, in the form of Framework Convention on Tobacco Control ratification, and the National Program on Diabetes, CVD, and Stroke. There is now need for an Indian cohort study on the lines of the FHS, which can more closely evaluate the use of the FHS risk score among Indians and translate FHS findings into the Indian context.

Moderate alcohol consumption is known to be protective against coronary heart disease (CHD). However, the INTERHEART study, a case-control study of acute myocardial infarction (MI) patients, revealed that alcohol consumption in South Asians was not protective against CHD. We therefore planned to study cardiovascular risk factor and CHD prevalence among male alcohol users as compared to age matched lifetime abstainers.The subjects for this study were recruited from a cross-sectional survey carried out among employees and their family members aged 20-69 years in 10 medium-to-large industries from diverse sites in India, using a stratified random sampling technique. Information on education, behavioral, clinical and biochemical risk factors of CHD and alcohol use was obtained through standardized instruments. CHD diagnosis was based on Rose Questionnaire or a prior physician diagnosed CHD.A total of 4465 subjects were present or past alcohol users. The mean age of alcohol users and lifetime abstainers was 42.8+/-11.0 years and 42.8+/-11.1 years, respectively (p=0.90). Systolic blood pressure and diastolic blood pressure were significantly higher in alcohol users (128.7+/-17.6 mmHg/80.1+/-11.3 mmHg) as compared to lifetime abstainers (126.9+/-15.9 mmHg/79.5+/-10.3 mmHg, p0.01). Fasting blood sugar in alcohol users (98.7+/-30.5 mg%) was also significantly higher than lifetime abstainers (96.6+/-26.0 mg%, p0.01). Total cholesterol was lower in alcohol users (179.1+/-41.1 mg%) as compared to lifetime abstainers (182.7+/-38.2 mg%, p0.01). HDL cholesterol was higher in alcohol users (42.9+/-10.8 mg%) as compared to lifetime abstainers (41.3+/-10.0 mg%, p0.01). Body mass index (BMI) was lower in alcohol users as compared to lifetime abstainers (22.7+/-4.1 kg/m2 vs. 24.0+/-3.3 kg/m2, p0.001). Tobacco use was significantly higher in alcohol users (63.1% vs. 20.7%). The odds ratio (OR) of having CHD after adjusting for tobacco use, BMI and education was 1.4 (95%CI 1.0-1.9) in alcohol users as compared to controls. The OR was 1.2 (95%CI 0.8-1.6) in occasional alcohol users, 1.6 (95%CI 1.0-2.2) in regular alcohol users and 2.1 (95% CI 1.1-3.0) in past alcohol users as compared to controls.We did not observe an inverse (protective) association between alcohol intake and the prevalence of CHD. In contrast, our study indicated an association in the reverse direction, suggesting possible harm of alcohol for coronary risk in Indian men. This relationship needs to be further examined in large, prospective study.

INTRODUCTION: Coronary heart disease (CHD) is exceptionally prevalent amongst globally dispersed migrant groups originating from the Indian subcontinent, but the contribution of dyslipidaemia to their increased risk remains poorly defined. METHODS: Fasting lipids and lipoproteins, apolipoproteins (Apo), low density lipoprotein (LDL) diameter and oxidised LDL were measured amongst rural Indians in India (n=294) and their migrant contemporaries in the UK (n=242). The performance of qualitative and quantitative measures of lipid metabolism were compared in the discrimination of WHO defined metabolic risk and raised Framingham CHD risk scores (>15%) using Receiver Operating Characteristic (ROC) curves. RESULTS: LDL diameter was correlated with triglycerides (R(2)=0.12, P

Background: The World Health Organization and the Government of India have set targets to reduce burden of noncommunicable diseases. Information on population level trend of risk factors would provide insights regarding the possibility of achieving them.Objective: This study aimed to determine the population trends of cardiovascular disease risk factors in the National Capital Region of Delhi over 2 decades.Methods: Two representative cross-sectional surveys were conducted among men and women ages 35 to 64 years, residing in the urban and rural areas (survey 1 [1991 to 1994] and survey 2 [2010 to 2012]) using similar methodology. The urban sample was collected from the Municipal Corporation of Delhi, and the rural sample was from the Ballabgarh block of the adjoining state of Haryana. A total of 3,048 and 2,052 subjects of urban areas and 2,487 and 1,917 subjects of rural areas were surveyed in surveys 1 and 2, respectively. Behavioral (smoking and alcohol use), physical (overweight, abdominal obesity, and raised blood pressure), and biochemical risk factors (raised fasting blood glucose and raised total cholesterol) were measured using standard tools.Results: Urban and rural prevalence of overweight, alcohol use, raised blood pressure, and blood glucose increased with increases in age-standardized mean body mass index (urban: 24.4 to 26.0 kg/m2; rural: 20.2 to 23.0 kg/m2), systolic blood pressure (urban: 121.2 to 129.8 mm Hg; rural: 114.9 to 123.1 mm Hg), diastolic blood pressure (urban: 74.3 to 83.9 mm Hg; rural: 73.1 to 82.3 mm Hg), and fasting glucose (urban: 101.2 to 115.3 mg/dl; rural: 83.9 to 103.2 mg/dl). The smoking prevalence increased in the rural male population. Raised total cholesterol declined in urban and increased significantly in rural populations.Conclusions: The study indicates an overall worsening of population levels of all cardiovascular disease risk factors in National Capital Region over past 20 years, though some signs of stabilization and reversal are seen in urban Delhi.HighlightsThis is the first repeat cross-sectional study from India that measures CVD risk factors in a representative sample in urban and rural populations using the same methodology to assess secular trends in the prevalence of CVD risk factors.The study reports a rapid rise in the burden of risk factors such as overweight, raised blood pressure, and raised blood glucose in urban and rural populations.The study emphasizes the need for active CVD surveillance systems and the relevance of combined population and high-risk approach to reduce population risk burden.

Background The decreased number and senescence of circulating endothelial progenitor cells (EPCs) are considered markers of vascular senescence associated with aging, atherosclerosis, and coronary artery disease (CAD) in elderly. In this study, we explore the role of vascular senescence in premature CAD (PCAD) in a developing country by comparing the numerical status and senescence of circulating EPCs in PCAD patients to controls. Methods EPCs were measured by flow cytometry in 57 patients with angiographically documented CAD, and 57 controls without evidence of CAD, recruited from random patients ≤ 50 years of age at All India Institute of Medical Sciences. EPC senescence as determined by telomere length (EPC-TL) and telomerase activity (EPC-TA) was studied by real time polymerase chain reaction (q PCR) and PCR– ELISA respectively. Result The number of EPCs (0.18% Vs. 0.039% of total WBCs, p Conclusions We observed an association between increased vascular cell senescence with PCAD in a sample of young patients from India. This suggests that early accelerated vascular cell senescence may play an important mechanistic role in CAD epidemic in developing countries like India where PCAD burden is markedly higher compared to developed countries.

Effectively tackling the growing noncommunicable disease (NCD) burden in low- and middle-income countries (LMIC) is a major challenge. To address research needs in this setting for NCDs, in 2009, National Heart, Lung, and Blood Institute (NHLBI) and UnitedHealth Group (UHG) engaged in a public-private partnership that supported a network of 11 LMIC-based research centers and created the NHLBI-UnitedHealth Global Health Centers of Excellence (COE) Program. The Program’s overall goal was to contribute to reducing the cardiovascular and lung disease burdens by catalyzing in-country research institutions to develop a global network of biomedical research centers. Key elements of the Program included team science and collaborative approaches, developing research and training platforms for future investigators, and creating a data commons. This Program embraced a strategic approach for tackling NCDs in LMICs and will provide capacity for locally driven research efforts that can identify and address priority health issues in specific countries’ settings.HighlightsA public-private partnership created the Program.Forming the Program captured all the elements of team science.The Program used best practices of collaborative science.Research training for future investigators was a high priority.

Objective Low density lipoprotein (LDL) particles are heterogeneous in terms of size, density, chemical composition and electric charge with certain particle of LDL being more atherogenic than the others. The present study aimed to look at the LDL particle heterogeneity, particle size and association with other cardiovascular disease (CVD) risk factors in young Indian industrial population. Methodology 600 employees of an industry of Delhi, aged 20-39 years were selected for the study. Data on demographics, individual characteristics associated with major risk factors of CVD, past medical history, clinical and anthropometric profile was collected. Fasting glucose, lipid profile, apolipoprotein (A1, B, and E), lipoprotein (a), high sensitive C-reactive protein (hsCRP) and insulin were estimated. LDL particle size was determined in ethylenediamminetetraacetate (EDTA) plasma by 3% polyacrylamide gel electrophoresis. Result We found a prevalence of small dense LDL phenotype (LDL size ≤ 26.3) in 27.4% of males and 24.0% of females. The mean waist circumference, blood pressure, triglycerides (TAG), cholesterol, hsCRP, apolipoprotein (A1, B and E) and insulin were higher in males whereas mean high density lipoprotein was higher in females. Females also had a significantly higher mean LDL particle diameter as compared to males. Conclusion TAG, physical activity and lipoprotein (a) correlated with small dense LDL in this young Indian population.

BACKGROUND Carditis is the only component of rheumatic fever that leads to permanent disability. The diagnosis of carditis is presently made by using composite clinical criteria based on the revised Jones' criteria. Since myocardial involvement is an important component of rheumatic carditis, right ventricular endomyocardial biopsies were performed in 54 patients with clinical acute rheumatic fever and quiescent rheumatic heart disease to evaluate the role of biopsy for the diagnosis of rheumatic carditis. METHODS AND RESULTS In 11 of the 54 patients, clinical consensus was certain about rheumatic fever and carditis based on the revised Jones' criteria (group 1). Histomorphological abnormalities in these patients were scarce. The diagnostic features of rheumatic myocarditis including Aschoff nodules or histiocytic aggregates were encountered in 3 patients (27%). Lymphocytic infiltration was sparse. A majority of patients demonstrated myocyte degeneration, interstitial degeneration, or occasional interstitial mononuclear cell infiltration, but since these histopathological lesions may occur in other conditions also, they were considered nondiagnostic. In 33 of the 54 patients with preexisting rheumatic heart disease, the diagnosis of carditis was suspected based on varied clinical presentations. Since previous cardiac findings were not available in these patients, the clinical diagnosis of carditis could not be made without equivocation (group 2). Twenty-three patients presented with unexplained acute onset of congestive heart failure and evidence of recent streptococcal infection (group 2A). While 13 of them had one or more other major manifestations, 10 patients had only minor manifestations. Mimetic carditis was suspected in the remaining 10 of 33 patients based on carditis having occurred in previous episodes of rheumatic fever (group 2B). The endomyocardial biopsy provided confirmatory evidence of rheumatic myocarditis in 9 patients of group 2A but in none of the 10 patients with suspected mimetic carditis. Nondiagnostic myocyte or interstitial alterations were frequently observed in group 2. Ten of the 54 patients had no clinical evidence of active carditis (group 3). No histological alterations diagnostic of rheumatic carditis were noted in these patients. Twenty-two follow-up biopsies were performed in the first 10 consecutive patients. Diagnostic histiocytic aggregates or Aschoff nodules were observed in initial biopsies in 4 of 10 patients, and nonspecific myocyte or interstitial alterations were observed in 9. All patients with diagnostic changes in initial biopsy demonstrated fibrohistiocytic nodules in 6- or 12-week biopsy samples. Nondiagnostic alterations, similar to those seen in acute cases, were present in 5 of 8 patients at 6 weeks, 5 of 8 patients at 12 weeks, and 3 of the 6 patients at 24 weeks despite the presumed adequate immunosuppressive therapy. No complications related to biopsy were encountered. CONCLUSIONS The present study highlights the low frequency of diagnostic features in the biopsy specimens of patients with definite clinical rheumatic carditis. Although such alterations are not observed in patients with chronic rheumatic heart disease, endomyocardial biopsy does not appear to provide additional diagnostic information where clinical consensus is certain about diagnosis of rheumatic carditis. Our study, however, substantiates the concept of carditis underlying unexplained congestive heart failure of acute onset in patients with preexisting rheumatic heart disease and elevated antistreptolysin-O titers.

Objectives: India has the largest burden of diabetes in the world, much of which remains undiagnosed. This study aimed to develop a risk score to predict the likelihood of having undetected diabetes in individuals, based on identification of noninvasive risk factors for Type 2 diabetes.Methodology: The risk score was developed in urban and rural participants, aged 35– 64 years, from a representative cross-sectional population survey conducted in Delhi in 1991–1994. Multivariable logistic regression model coefficients were used to assign each categorical risk factor a score value with undiagnosed diabetes as the dependent variable. The validity of the composite risk score was tested in an independent multicentre cross-sectional survey conducted in 2001–2003 in a different population.Results: Complete baseline data were available for 4044 men and women in the first population, of whom, 440 had diabetes (199 cases undiagnosed). Age, waist circumference, blood pressure and family history of diabetes were significant (p < 0.01) non-invasive predictors of diabetes status in the multivariable model. The risk of having diabetes increased progressively as the risk score rose from 0 to 29. When tested in the independent population (n = 10566, of whom 1066 had diabetes and 375 were undiagnosed), a score value >16 predicted diabetes status with a sensitivity of 0.79 (95% CI:0.77–0.82), specificity of 0.56 (95% CI:0.55–0.57), and a positive likelihood ratio of 1.8 (95% CI:1.7–1.9) for all cases with diabetes, and a sensitivity of 73%, specificity of 56% and a positive likelihood ratio of 1.6 (95% CI: 1.5–1.7) for undiagnosed diabetes cases.Conclusion: Application of this risk score identified a substantial proportion of individuals with undiagnosed diabetes, using tools easily available in low-resource settings.

Cardiovascular diseases (CVDs) and diabetes are major public health problems worldwide. They accounted for 32% of the total deaths globally and contributed to 11% of the global burden of disability adjusted life years (DALYs) in the year 2005 ([1][1]). The fast-changing demographic profile in the

Manoj Joshi*, Sandeep Bhalla, Kolli S. Reddy, Viswanathan Mohan, Ranjit Unnikrishnan, Pratibha Karnad, Dorairaj Prabhakaran Training, President, Public Health Foundation of India (PHFI), New Delhi, Dr. Mohan’s Diabetes Specialities Centre, Dr. Mohan’s Diabetes Specialities Centre, Chennai, Johnson & Johnson Medical India, Mumbai, Centre for Chronic Disease ControlCCDC, Public Health Foundation of India (PHFI), New Delhi, India

Myocarditis constitutes an important component of rheumatic carditis. Antimyosin scintigraphy, which allows noninvasive assessment of myocyte damage, can be used for documentation of cardiac involvement in patients with rheumatic fever where clinical diagnosis is not unequivocal.

Clinical, echocardiographic, haemodynamic and angiographic features of a patient with rheumatic mitral stenosis, hypertrophic cardiomyopathy and anomalous muscle bundle in the right ventricle are presented. At the bedside, the presence of left ventricle type apex beat, left ventricle S4 gallop, ejection systolic murmur at the left mid sternal border and electrocardiographic evidence of left ventricular hypertrophy in a patient with classical findings of mitral stenosis in the absence of significant mitral regurgitation and aortic valve disease should suggest this extremely rare association of mitral stenosis with hypertrophic cardiomyopathy.

We assessed left ventricular systolic function by means of radionuclide ventriculography in 20 consecutive unselected patients with systemic lupus erythematosus. All patients had normal left ventricular systolic function (defined as ejection fraction greater than 45%) in a resting state. Regional wall motion abnormalities were, however, seen in 4 patients (20%). Of these 20 patients, 8 were able to exercise on a bicycle ergometer. These patients were subjected to exercise radionuclide ventriculography. Of these 8 patients, 3 (37.5%) had an abnormal ventriculographic response to exercise (as evidenced by a subnormal rise in ejection fraction or a fall, appearance of a new regional wall motion abnormality or worsening of a pre-existing one). This probably reflects subclinical left ventricular dysfunction unmasked by the stress of exercise. The clinical significance of these abnormalities on long-term myocardial function and their possible reversibility with remission of the disease needs to be assessed in future studies.

A 17-year-old girl was seen with acute anterior myocardial infarction resulting in congestive heart failure. Clinical examination followed by detailed investigation revealed diffuse nonspecific aorto-arteritis, with left coronary ostial stenosis, which is a very rare association. The relevant literature is reviewed.

Fourteen patients underwent thrombectomy for thrombosis of implanted Bjork-Shiley valves (13 in the mitral and one in the aortic position) between January, 1975, and July, 1984. There was no operative mortality or perioperative embolism. Over a follow-up period of 1 to 96 months (average 23.5 months), there was no late mortality. Serial evaluation of valve function by cinefluoroscopy and echocardiography has shown no evidence of rethrombosis or valve dysfunction in any of the patients. Cardiac catheterization and angiocardiography done in 10 patients at various intervals (1 month to 6 years) postoperatively have shown normal valve function in all and normalization of elevated preoperative intracardiac pressures in the majority. Our experience suggests that thrombectomy of thrombosed Bjork-Shiley valves provides excellent early and long-term results in terms of patient survival and valve function.

D8/17, a B cell alloantigen, and its occurrence with DR/DQ antigens was examined in 54 patients with rheumatic heart disease and matched North Indian controls. Thirty-four patients (62.9%) carried D8/17 as compared with a frequency of 12.5% in controls (chi 2 by Yates', 18.75; p less than 0.0001). A marginally increased frequency of human leukocyte antigen (HLA)-DR3 (44.2% vs. 28.8%) and a significantly reduced frequency of HLA-DR2 (21.1% vs. 46.6%; p less than 0.005) was observed in patients as compared with controls. However, the most significant positive association was observed with HLA-DQw2 (63.4% in patients and 31.5% in controls; chi 2 by Yates', 9.85; p less than 0.005). The DQw2 association was significant only in the D8/17-positive patients. These observations suggest that the disease susceptibility gene in rheumatic heart disease may be nearer to the HLA-DQ locus than to the HLA-DR.

Thirty patients with acute rheumatic fever, and 20 with inactive rheumatic heart disease were studied in order to determine parameters which differentiate the two groups. Subcutaneous nodules developed following the subcutaneous injection of autologous blood in 16 of 26 patients with rheumatic fever but in none of the 20 with inactive rheumatic heart disease (P = 0.00001). Myocardial reactive antibodies were found in 14 of 30 patients with rheumatic fever, and in 4 of 20 with inactive rheumatic heart disease (P = 0.0505). Significantly higher values of IgG (P less than 0.001), IgA (P less than 0.01), C3 (P less than 0.001) and C4 (P less than 0.001) were observed in rheumatic fever patients. There was no significant difference in IgM levels. A combination of three variables (artificial subcutaneous nodules, IgA, and C3) had a sensitivity of 87% and a specificity of 100% for rheumatic fever. A combination of two variables (artificial subcutaneous nodules and IgA) had a sensitivity of 84% and a specificity of 100% for rheumatic fever.

Lymphocyte subsets in 53 patients with acute rheumatic fever and 78 patients with chronic rheumatic heart disease were compared with 20 normal control subjects and 39 patients suffering from uncomplicated streptococcal pharygitis to obtain information about the pathogenesis of the disease. Twenty patients with rheumatic fever were followed for 24 weeks to evaluate changes occuring over the course of the disease. Total leukocyte and lymphocyte counts were increased in patients with rheumatic fever and to a lesser extent in those with rheumatic heart disease, when compared with controls. The difference between the two groups was significant. Patients with acute rheumatic fever had an increased number of B cells and a smaller increase in total T and T-helper-inducer (CD-4) cells. The proportion of B cells increased, while that of T-suppressor-cytotoxic (CD-8) cells fell. An increased number and proportion of B cells was also seen in patients with rheumatic heart disease. Total T and T-helper lymphocyte percentages and numbers were significantly higher in patients with rheumatic fever compared with those of patients with rheumatic heart disease. Follow-up studies at 6, 12, and 24 weeks revealed no significant differences from the entry point studies, although there was a trend toward reduction in the degree of derangement from normal values. Patients with uncomplicated streptococcal pharyngitis, however, did not show perturbations in the T-cell and T-subset counts. Our study suggests that the immunoregulatory defect in acute rheumatic fever is characterized by a relative reduction of suppressor T cells with an absolute increase in helper T cells and B cells, resulting in an increased cellular as well as humoral immune response. The persistent alteration in B cells in the patients with chronic rheumatic heart disease suggests an ongoing immunoinflammatory process during the apparently quiescent phase.

A case who developed severe and potentially fatal reaction to an angiographic contrast medium despite adequate pretreatment with steroids for 2 weeks is reported. This is the second such case reported in the English literature.