Search

A number of guidelines are available for the management of congenital heart diseases (CHD) from infancy to adult life. However, these guidelines are for patients living in high-income countries. Separate guidelines, applicable to Indian children, are required when recommending an intervention for CHD, as often these patients present late in the course of the disease and may have coexisting morbidities and malnutrition. Guidelines emerged following expert deliberations at the National Consensus Meeting on Management of Congenital Heart Diseases in India, held on August 10 and 11, 2018, at the All India Institute of Medical Sciences. The meeting was supported by Children's HeartLink, a nongovernmental organization based in Minnesota, USA. The aim of the study was to frame evidence-based guidelines for (i) indications and optimal timing of intervention in common CHD; (ii) follow-up protocols for patients who have undergone cardiac surgery/catheter interventions for CHD; and (iii) indications for use of pacemakers in children. Evidence-based recommendations are provided for indications and timing of intervention in common CHD, including left-to-right shunts (atrial septal defect, ventricular septal defect, atrioventricular septal defect, patent ductus arteriosus, and others), obstructive lesions (pulmonary stenosis, aortic stenosis, and coarctation of aorta), and cyanotic CHD (tetralogy of Fallot, transposition of great arteries, univentricular hearts, total anomalous pulmonary venous connection, Ebstein's anomaly, and others). In addition, protocols for follow-up of postsurgical patients are also described, disease wise. Guidelines are also given on indications for implantation of permanent pacemakers in children.

Studies have shown better graft function and reduced acute rejection rates among renal transplant recipients who were on Tacrolimus (Tac)-based immunosuppression regimens as compared to cyclosporine (CsA)-based regimens in the first year. However, the long-term follow-up data did not reveal better outcomes in the Tac-based regimens. In view of the short term benefits, the trend has been to change to Tac-based regimens off late. Data from the Indian subcontinent are, however, sparse. We, therefore, looked at our data to ascertain if Tac-based regimen does have better outcomes in our population. We studied a total of 108 individuals who underwent renal transplantation between January 2007 and June 2013, with a mean follow-up of 38.22 months (comparable to both groups). In our group, males constituted 77.8%,; and among the 108 individuals, 16.7% were diabetics. New-onset diabetes after renal transplantation was more common in the Tac group (21 vs. 12 and was statistically significant [P = 0.03]). At the last follow-up, serum creatinine was higher in the CsA group (1.77 mg/dl vs. 1.35 mg/dl) and was statistically significant (P = 0.03). Individuals requiring hemodialysis were also significantly higher in the CsA group (9 vs. 2; P = 0.05). The patient survival was similar in both groups (1-year and 5-year follow-up); however, graft survival was better in Tac group as compared to CsA group (0.94 vs. 0.88 at 1 year and 0.85 vs. 0.72 at 5 years).

Introduction: Nurse-led clinics are a model of care indicated where there are service gaps due to high demand or workforce shortages. Objective: The objective of this study was to evaluate the feasibility of a nurse-led follow-up clinic among postmyocardial infarction (MI) patients by inter-rater agreement of selected clinical variables with cardiologist clinic and to assess the satisfaction among post-MI patients related to assessment and recommendations done in a nurse-led follow-up clinic. Materials and Methods: Quasi-experimental evaluation design – only posttest using a comparison group was used. Convenience sampling was done. From three follow-up clinics, 79 participants were included, and the interventions were post-MI patients' assessment, documentation, and recommendations, which were done in both nurse-led and cardiologist follow-up clinics using post-MI clinical pro forma. Results: The overall inter-rater agreement ranges from 87.34% to 99.8%. The kappa score obtained was found to be highly significant (P = 0.0001). 86% of patients were highly satisfied and only 14% were moderately satisfied, and the total mean score was 34.47 ± 6.15. Conclusion: The nurse-led clinic was feasible among post-MI patients after proper training of nurse.

Diastolic dysfunction is common in cardiac disease and an important finding independent of systolic function as it contributes to the signs and symptoms of heart failure. Tissue Doppler mitral early diastolic velocity (Ea) combined with peak transmitral early diastolic velocity (E) to obtain E/Ea ratio provides an estimate of the left ventricular (LV) filling pressure. However, E/Ea has a significant gray zone and less reliable in patients with preserved ejection fraction (>50%). Two-dimensional echocardiographic speckle tracking measure myocardial strain and strain rate (Sr) avoiding the Doppler-associated angulation errors and tethering artifacts. Global myocardial peak diastolic strain (Ds) and diastolic Sr (DSr) at the time of E and isovolumic relaxation combined with E (E/Ds and E/10 DSr) have been recently proposed as novel indices to determine LV filling pressure. The present article elucidates the methodology of studying diastology with strain echocardiography along with the advantages and limitations of the novel technique in light of the available literature.

Introduction: Angiotensin receptor blockers (ARBs) are emerging as an attractive first choice antihypertensive as recommended by various guidelines. However, choice among the first-line antihypertensive classes and among ARBs differs between practicing physicians. Aims: This survey aimed to understand the usage preferences of ARBs and its place in for treating hypertension (HTN) among physicians from various clinical settings in India. Methods: A cross-sectional survey was conducted with a prevalidated survey questionnaire consisting of 25 questions for HTN management. Practicing general physicians and cardiologists were approached for seeking their perception, opinions, and prescribing behavior. Results: Responses of 594 physicians and cardiologists were received. As opined by 90.1% of physicians, newly diagnosed HTN represented more than 10% of their overall patient load. As a monotherapy, 59.9% of the physicians preferred ARB as the first choice in newly diagnosed HTN patients, followed by calcium channel blocker (12.3%) and angiotensin-converting-enzyme inhibitor (8.1%). Of all ARBs, telmisartan is preferred by 73% of physicians. Most physicians prefer telmisartan among all ARBs for 24 h blood pressure (BP) control, including morning BP surge (76.4%) and for prevention of cardiovascular morbidity and mortality (78.8%) followed by olmesartan and losartan. Predominantly, majority of physicians (89.1%) agreed for the beneficial role of telmisartan in preventing onset of microalbuminuria and nephropathy. Conclusion: Indian physicians prefer ARBs as the first choice in most hypertensive patients, which shows agreement with the guideline recommendations followed globally. Telmisartan has emerged as the most preferred ARB among all, for most of the HTN patients including those with comorbidities.

Heart failure (HF) is a major health problem in India with a postadmission mortality of 20%–30%. Medication adherence ranges from 25% to 50%, and the tolerance of guideline-based medication is low for Indian patients. We took out guidelines on HF in 2015, and this update covers the changes which have occurred in HF management in the past 2 years. As a number of new drugs such as angiotensin receptor-neprilysin inhibitor and ivabradine have been approved for use in India, devices such as implantable cardioverter-defibrillators and cardiac resynchronization therapy are becoming more accessible and more left ventricular assist devices and transplants are being done in India, there is need for clear guidelines for the use of each which are practical for India.

Introduction: There are few data on heart failure (HF) burden and none available on the community prevalence of HF in India. We conducted a study aimed at determining the HF prevalence in a rural community as well as tertiary hospital care setting in North India. We also reviewed the existing literature regarding the estimated and projected prevalence of HF in India. Methodology: All adults (>20 years) with chronic breathlessness in six villages under a primary health care center in Northern India were identified and evaluated with standardized questionnaire and physical examination by trained health care workers. HF was diagnosed by standardized criteria and a transthoracic echocardiogram was performed in all subjects. In the hospital study, 500 consecutive patients presenting to our tertiary referral hospital were evaluated for the diagnosis of HF. For the systematic review, all published studies addressing HF or the burden of risk factors in India were identified. Projections for the absolute HF burden were made using local data and global studies of HF incidence, morbidity, and mortality. Results: Among the surveyed rural adult population of 10,163 patients, chronic breathlessness was present in 128 (1.3%). HF was present in 9% (n = 12), of which 67% (n = 8) had preserved left ventricular (LV) systolic function and 33% (n = 4) had LV systolic dysfunction. Therefore, the prevalence of HF in this general community was 1.2/1000. All patients with HF and preserved ejection fraction had poorly controlled hypertension. In the hospital study, of 500 consecutive patients, 20.4% had HF. Rheumatic heart disease (52%) was the most common cause followed by ischemic heart disease (17%). The mean age of presentation was 39 ± 16 years. The prevalence of HF in the outpatient department patients was 22.5% below 30 years and 14.9% above 50 years, reflecting the young population of HF. For the estimates concerning HF burden in India, projections were made using both age-specific extrapolations from developing countries and data regarding development of HF in the presence of risk factors. The estimated prevalence of HF is about 1% of the total population or about 8–10 million individuals. The estimated mortality attributable to HF is about 0.1–0.16 million individuals per year. Conclusions: While our hospital data are consistent with the HF burden and etiology expected in a government tertiary hospital setting, our community-based study is the first of its kind reported from India. The community study demonstrates a surprisingly low prevalence of symptomatic HF in the surveyed villages. This could be partially explained by the rural farming-based community setting but is also likely due to under-reporting of symptoms. Our review of the projected national estimates suggests an alarming burden of HF in India despite a younger population than the developed nations. A significant proportion of this burden may be preventable with better screening and early and adequate treatment of the risk factors.

A patient presented with dyspnea, chest pain, and hemoptysis. Clinical findings revealed evidence of severe pulmonary hypertension and cyanosis with clubbing and a wide split second sound. Investigations including cardiac catheterization and oxygen study were performed, and the patient was referred for surgical repair. This article discusses various aspects of history, clinical examination, and cardiac catheterization that were utilized to decide the management.

Autosomal dominant polycystic kidney disease (ADPKD) presenting in adults is well documented, but the presentation in children is uncommon and is unclear why the disease presents early. Cases in children are identified usually while screening those with a strong family history and less commonly when symptomatic. We present here two children with ADPKD.

A adult patient presented with cyanosis since early childhood. The clinical approach to such a patient, including review of the ecg, chest xray and echocardiogram is presented. Various aspects of the bedside approach to adult cyanotic heart disease are discussed

Prevention of coronary artery disease requires control of risk factors. It is not enough to take out guidelines, it is necessary to implement the guidelines. There are a number of studies which have shown that quite often guidelines are not followed.In this article, we have abstracted the essence of the guidelines into simple to follow algorithms so that they are easy to remember and also teach. For Cardiovascular risk reduction, general measures include stopping smoking, perform 150 minutes of moderate activity per week and take a low fat and low salt diet. For hypertension: All classes of drugs are suitable but generally (NICE 2011) Angiotensin receptor blockers or Angiotensin converting enzyme inhibitors for young (55 years, many with isolated systolic hypertension) Calcium channel blockers, diuretics if needed , are prefered. Combinations are used if monotherapy does not work. For dyslipidemia: Statin benefit groups are defined and manifest coronary artery disease and Diabetics above 40 years should get high dose statins. Lipid levels are only tested to look for compliance or further intensification of regime. Diabetes: Metformin is the drug of choice, Sulfonylureas can be used in combination. Glyptins are also safe and can be used. Other drugs should be used with the help of the endocrinologist.

A 29-year-old female had presented with dyspnea on exertion since she was 10 years old, with sudden worsening for 5 months along with palpitations on exertion for the past 5 months. The examination findings, electrocardiogram, chest X-ray, and echocardiogram are discussed in a stepwise manner to arrive at a diagnosis and plan the management of a patient with rheumatic heart disease with multivalvular lesions. Relevant literature is also reviewed.

Summary of the Consensus Statement: This statement has been prepared keeping Indian heart failure patients in mind. Optimal management of CHF improves quality of life, reduces hospitalization rates and prolongs survival for people with this condition. Echocardiography is the single most useful test in the evaluation of heart failure, and is necessary to confirm the diagnosis. Plasma B-natriuretic peptide (BNP) measurements may be useful in excluding CHF but not mandatory in India. Educate people with CHF about lifestyle changes (e.g., increase physical activity levels, reduce salt intake and manage weight). Educate people with CHF about CHF symptoms and how to manage fluid load. Avoid prescribing drugs that exacerbate CHF. Prescribe angiotensin-converting enzyme inhibitors (ACEI) at effective doses for people with all grades of systolic heart failure, and titrate to the highest recommended dose tolerated. Angiotensin II receptor antagonists (ARA) may be used as alternatives in people who cannot tolerate ACEIs. Mineralocorticoid receptor antagonists (MRAs) should also be used. For people with stabilised systolic heart failure, prescribe beta-blockers that have been shown to improve outcome in heart failure (e.g., bisoprolol, carvedilol, extended release metoprolol or nebivolol). Titrate to the highest recommended dose tolerated. Prescribe diuretics, digoxin and nitrates for people already using ACEIs and beta-blockers to manage symptoms as indicated. For people who have systolic heart failure (New York Heart Association (NYHA) Class II-IV) despite appropriate doses of ACEIs and diuretics, consider prescribing spironolactone. Eplerenone can be considered in certain setting especially post myocardial infarction though it is more expensive. Consider direct sinus node inhibition with ivabradine for people with CHF who have impaired systolic function, have had a recent heart failure hospitalisation and are in sinus rhythm with a heart rate >70 bpm despite beta blockers or where beta blockers are contraindicated Check for, and treat, iron deficiency in people with CHF to improve their symptoms, exercise tolerance and quality of life Consider assessing people with CHF for biventricular pacemakers and implantable defibrillators. Patients with end stage heart failure have an option for heart transplant and ventricular assist devices which is now available in select centers.

Management of a patient with acute coronary syndrome after coronary artery bypass grafting (CABG) is challenging. Increasing age, associated co-morbidities, and progressive deterioration in left ventricular function make the scenario even worse. The escalation of ongoing medical treatment is usually the first step. Re-CABG is often not an option. Then, this becomes a compelling situation for an interventional cardiologist to perform an intervention to relieve the symptoms and sometimes repeated interventions. Conventionally, two types of interventions are described in this situation, either the intervention on native coronaries or intervention on graft vessels. Percutaneous revascularization is associated with higher rates of in-stent restenosis, target vessel revascularization, myocardial infarction, and death compared with native coronary arteries. Use of embolic protection devices is a Class I indication to decrease the risk of distal embolization. Nonetheless, these devices are underused. Most evidence supports treatment with drug-eluting stents. We illustrate the management with a case. This case used a thrombus aspiration device prior to stent deployment in saphenous vein graft to get optimal results without any "slow-flow" or "no-flow."

Congenitally corrected transposition of great arteries is a rare congenital anomaly. This case report describes a 30-year-old patient of congenitally corrected transposition of the great arteries with rheumatic involvement of systemic (tricuspid) atrio-ventricular valve.

The CSI Cardiac Prevent 2015 was held at Hotel Taj Palace, New Delhi, on September 25-27, 2015. The major challenge was to create interest among cardiologists and physicians on preventive cardiology, a neglected area. The theme of the conference was "Innovations in Heart Disease Prevention.′′ This conference included "CSI at WHF Roadmap Workshop, Inauguration Ceremony, scientific program, plenary sessions, Nursing/Dietician track, Industry Exhibition, Social Events," Great India blood pressure Survey, and CSI Smart Heart App. A total of 848 delegates/faculties attended this conference against a total of 1140 people registered for the meeting.

Abstract During the past 15 years, new treatment paradigms for neovascular age-related macular degeneration (nvAMD) have evolved due to the advent of intravitreal anti-vascular endothelial growth factor (VEGF) therapy and rapid advances in retinal imaging. Recent publications describe eyes with type 1 macular neovascularization (MNV) as showing more resistance to macular atrophy than eyes with other lesion types. We sought to explore whether the perfusion status of the native choriocapillaris (CC) surrounding type 1 MNV influences its pattern of growth. To evaluate this effect, we analyzed a case series of 22 eyes from 19 nvAMD patients with type 1 MNV exhibiting growth on swept-source optical coherence tomography angiography (SS-OCTA) over a minimum follow-up of 12 months. We observed an overall weak correlation between type 1 MNV growth and CC flow deficits (FDs) average size (τ = 0.17, 95% CI [− 0.20, 0.62]) and a moderate correlation with CC FD % (τ = 0.21, 95% CI [− 0.16, 0.68]). Type 1 MNV was located beneath the fovea in most of the eyes (86%) and median visual acuity was 20/35 Snellen equivalent. Our results support that type 1 MNV recapitulates areas of CC blood flow impairment while serving to preserve foveal function.

Immunoglobulin A (IgA) nephropathy is usually restricted to the kidneys in most cases, but associations with other immune and inflammatory diseases exist. Scleritis, however, is an unusual association. We present an observational case series of two patients who initially presented with recurrent episodes of scleritis. A thorough evaluation for recurrent scleritis did not reveal any secondary cause per se. They were further evaluated extensively for incidental proteinuria and microscopic hematuria. Renal function was normal. Renal biopsy was performed which revealed IgA nephropathy in both the patients. They were given oral prednisolone and telmisartan for six months and followed for nine and six months, respectively, after steroids were discontinued. Proteinuria remitted, renal function remained normal, and there were no further episodes of scleritis in these patients.

Elizabethkingia meningoseptica is a multidrug resistant gram-negative bacillus that is commonly associated with nosocomial infection in neonates. Prematurity and compromised immune system are a known risk factor for E. meningoseptica infection. It has been isolated in the hospital environment, water supplies, disinfectants and medical devices. We report 3 cases of neonatal infection by E. meningoseptica over a period of three years (2018-2020) in our Neonatal Intensive Care Unit (NICU). We encountered one case each of pneumonia, meningitis and septicemia. Infection associated with E. meningoseptica can be life-threatening if appropriate antibiotics are not prescribed. As this organism is multi drug-resistant, failure to identify this pathogen may lead to therapeutic failure. E. meningoseptica is intrinsically resistant to wide range of antibiotics used to treat other common pathogenic gram-negative bacteria; however, they are sensitive to fluoroquinolones and glycopeptides that are used for gram positives. In view of its multidrug resistant nature and ability to easily infect preterm and very low birth weight neonates, prompt diagnosis should be made and appropriate reinforcement of infection control measures should be considered to reduce morbidity and mortality.