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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.

Several classes of antihypertensive agents have been in clinical use, including diuretics, α-blockers, β-blockers, angiotensin converting enzyme (ACE) inhibitors, angiotensin II type 1 receptor blockers (ARB), and organic calcium channel blockers (CCBs). All these drugs are being currently used in the treatment of Hypertension & various disease conditions of the heart either alone or in combination. Cilnidipine is a new antihypertensive drug distinguished from other L-type Ca2+ channel blockers or even other antihypertensives, which will be useful for selection of antihypertensive drugs according to the pathophysiological condition of a patient.

Platelets play central role in thrombotic events in acute coronary syndromes (ACS) and during percutaneous coronary interventions (PCI). Platelet activation occurs through various mechanisms and all culminate in expression of the surface GP IIb-IIIa receptors which mediate their aggregation and thrombosis. Glycoprotein IIb-IIIa inhibitors (GPI) remain the most powerful antiplatelet agents by inhibiting this final common pathway of platelet activation. The role of GPI in the treatment of coronary ischemic events has evolved through the past 20 years. Given their potent antiplatelet activity and consistent anti-ischemic benefit in major trials, they were an integral part of antiplatelet – antithrombin portfolio in the treatment of ACS and during PCI over a decade. However, the advent of stents and thienopyridine ticlopidine and later clopidogrel made periprocedural ischemic complications less common and GPI had slowly lost its importance in routine low-risk PCI. Though GPI reduced periprocedural ischemic complications, increased bleeding events continued to be a major problem. In the recent years, bleeding has increasingly been recognized as a major determinant of clinical outcomes both with ACS and PCI. Recently, the availability of bivalirudin as an equally effective and safer periprocedural anticoagulant, heparin and GPI have slowly been pushed to second place over the entire spectrum of coronary interventions. The newer antiplatelets which provide rapid and more consistent antiplatelet action further reduced the role of GPI to a very small subset of patients where ischemic risk far exceeds the thrombotic risk.1–3 This editorial briefly evaluates the current role of GPI in the background of recent major studies with newer antiplatelets and bivalirudin.

The American College of Cardiology (ACC) and American Heart Association (AHA), in collaboration with the National Heart, Lung and Blood Institute (NHLBI), have recently released a set of four important guideline documents that provide recommendations for blood cholesterol management in adults, management of overweight and obesity, life-style modifications to reduce cardiovascular (CV) risk and the approach to CV risk stratification.1–4 Of these, the cholesterol guidelines were perhaps the most awaited, given the significant improvements that have taken place in our understanding of lipid management over the past decade, since the previous NHLBI guidelines (adult treatment panel III) were last updated.5 However, the new recommendations depart heavily from the prevailing concepts in lipid management and in this process have sparked off an intense debate about their rationale and practicality. Therefore, a critical review of these guidelines, along with the related document on CV risk stratification, is warranted before we embark on the task to incorporate them in to our clinical practice.

A 7-month-old girl with failure to thrive, who, on clinical and diagnostic evaluation [echocardiography & CT angiography] to rule out congenital heart disease, revealed a rare vascular anomaly called systemic artery to pulmonary venous fistula. In our case, there was dual abnormal supply to the entire left lung as1 anomalous supply by normal systemic artery [internal mammary artery]2 and an aberrant feeder vessel from the abdominal aorta. Left Lung had normal bronchial connections and normal pulmonary vasculature. The fistula drained through the pulmonary veins to the left atrium leading to ‘left–left shunt’. Percutaneous intervention in two stages was performed using Amplatzer vascular plugs and coil embolization to close them successfully. The patient gained significant weight in follow up with other normal developmental and mental milestones.

The purpose of science and indeed of all our scientific endeavors should be to provide answers to the vexing problems facing humanity and come up with solutions to make our lives easier. Science was born out of the curiosity of man to plausibly explain the various happenings around him. The greatest scientist of our times, Albert Einstein, was by his own admission, not intelligent but possessed a very high degree of curiosity and it was his ability to stick to his query, with an all consuming passion, until he found a convincing solution that led him to propound some of the greatest scientific theories ever given. In medicine too, we have come a long way in our understanding of the human system and the various disease processes. As men of science practicing medicine, we are expected to continue our quest into the mysteries of the human body and unravel solutions to the raging scourges of our times-cancer and cardiovascular disease. As regards cardiovascular disease, a lot has been learnt in a short span of the last 50–60 years and thus an enormous hope has been pinned on us to come up with new information, safer and more effective drugs and techniques to contain the epidemic of cardiovascular disease, especially atherosclerotic coronary artery disease. Every New Year brings new expectations. The end of 2013 was marked by the release of several major guidelines and some very interesting studies in the field of cardiology. The ones that attracted most attention were the guidelines on hypertension (JNC-8, ISH, ESC, ADA) and on lipids (ACC/AHA). For most of us, who like to delve deep into the subject and look up for solutions to our raging problems, they have raised more questions than ever and have left us baffled. With the advancing years, we are expected to have improved our understanding of the disease processes and gained insights into the management based on new studies. Far from it, it is surprising how much the different guidelines on hypertension from different societies, differ from each other, each claiming to be based on the latest information! Not only do they differ on the threshold and goals for management in different subsets, they offer no direction on the use of ambulatory or home BP monitoring, on how low to go or whether the “J curve” exists. The question of different races and lack of data for us Indians further confuses us, divides us and leaves us on shaky ground when faced with our patients. A person above 60 years of age who was on antihypertensives may now be off medications if you go by the JNC-8 guidelines. It also depends on which guideline his physician believes in and which part of the world he lives in. What if he has migrated just a couple of years ago, or develops diabetes? As regards lipids, an altogether new paradigm has emerged. It all has boiled down to LDL and Statins. It is all so simple or is it? The HDL conundrum remains unexplained and the role of non-HDL cholesterol, small dense LDL has been pushed aside. For good? Not perhaps. The guidelines recommend the use of a global risk calculator for deciding about the 10 year and long term CVD risk. It means each physician should have a smart phone or a computer at hand always! What about the risk approaches we have been using so far? Forget about them and quickly adapt to the new approach but is it final? No. Sooner or later this too will change. Besides, we have no answer to the questions we all have about the right diet. We have seen the back of Atkin's diet, Ornish diet and are now told that even fresh fruit juices are loaded with sugars and may not be good at all. We are still debating about the role of aspirin in primary prevention of CVD and are trying to define “stress”, which, in the form of depression could join the ranks of hypertension and diabetes as a risk factor! Beta blockers have not found favor as antihypertensives while coronary stents continue to be recommended inspite of failing to show any mortality benefit in stable coronary artery disease. While, once an absolute no-no in heart failure, beta blockers are now the drugs of choice! What to make of these developments? All this shakes up, takes away from the enormous faith we have come to put on the spirit of scientific endeavor-something that characterizes this century. It compels one to think whether our foundations are sound and whether we have understood the pathophysiology of cardiovascular disease at all, whether we have understood the heart at all? Are we progressing in a direction trying to answer the right questions or are we floundering in the dark, building upon what is evident in terms of data while missing out on the subtle but unseen truths? Alternative schools of thought like Ayurveda and Homeopathy have existed for long enough periods to be without any basis. They may not have undergone rigorous scrutiny, the statistical evidence may not be there but they have stood the test of time. Similarly, the heart has long been believed to be the seat of the soul, of divinity itself, in the human body-a belief shared by all religions and systems. The heart is not merely an organ for pumping blood but also has the capability to feel and communicate, has been our innate knowledge all along. There is brain death but when the heart stops, it is death. When and why the heart stops cannot be predicted still. These are some of the fundamental questions which science has never been able to answer. Maybe, we have never thought for long on this perhaps, not evaluated this fundamental aspect broadly enough, with the open mindedness it deserves. The world still runs on theories of relativity, of uncertainty, of quantum physics and particle physics. All of these may become undone in future since they are theories after all! So is all medicine perhaps. The higher echelons of science have thus started to enquire into the real function of heart in the human body. There are studies showing beyond doubt that the heart has the ability to communicate with other hearts, with other organs of the body and indeed the ability to feel! Systematic researches into the patients of heart transplants have shown startling results on these aspects. Inanimate machines have been shown to be influenced by the feelings of their handlers. Human hearts with love have been shown to elicit positive reactions in the other hearts in the vicinity. The role of positive feelings, of love, brotherhood, unity, long preached by scriptures, is now being investigated for their impact on the human heart. The positive effect of meditation has been felt by its practitioners for ages but is now being studied systematically for measurable effects on cardiovascular health and overall well being. All this seems fantastic today, but who knows, half a century from now what turn cardiovascular science will take! We have already witnessed major shake-ups in the most fundamental of our theories in cardiology. Given the skepticism and confusion with the current understanding and lack of any answers to the vexing questions of life, and death, “the heart” yearns for truth-pure, unchanging truth which explains it all and brings solace, that which comes with true knowledge. Till such time, one is forced to unlearn all that has been learned so far and begin accepting the emerging evidence to treat patients effectively, safely but on shaky foundations and with a nagging voice in the “heart” telling us that all this may change too…