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Permanent catheters are widely used in haemodialysis of chronic kidney disease. Placement of these catheters is usually through the internal jugular vein or subclavian vein. Catheter placement is associated with risk of inadvertent puncture of the carotid artery, pleura and other nearby structures. These risks have been very much reduced with the use of point of care ultrasound. Even though ultrasound can guide proper puncture of the desired vessel, it cannot help in directing or following the course of the catheter after venepuncture [1]. We report a rare case of a malpositioned dialysis catheter which punctured the roof of the left atrium (LA) after going through the right pulmonary artery (RPA).

Background Current international guidelines on dyslipidemia are not concordant on various aspects of management. Also, there are no uniformly accepted Indian guidelines. We, therefore, performed a physician survey to understand lipid management practices in India. Methods An anonymous survey questionnaire was administered to gauge physicians’ self-reported behavior regarding lipid management aspects. Results were expressed in terms of percentages based on the number of responses obtained. Results A total of 404 physicians participated in the survey. Eighty-eight percent respondents ordered a lipid profile before starting statin therapy, and 80% preferred to set lipid targets, though the tools used for calculating cardiovascular risk varied. Atorvastatin was preferred over rosuvastatin in primary prevention (72.9 vs. 32.4%), secondary prevention (54.6 vs. 46.7%), diabetic patients (56.3 vs. 40.3%) and post-ACS (78.3 vs. 34%). High-intensity statins were preferred by 73.7% of respondents in post-ACS cases. Fifty percent doctors chose not to use a statin in diabetic patients, irrespective of their LDL-C levels. The most preferred drug option for managing atherogenic dyslipidemia and moderate hypertriglyceridemia was statin-fibrate combination (55.1%) and fibrates (35.4%), respectively. Sixty-three percent doctors preferred to prescribe statins in patients with moderately high LDL-C and normal triglycerides, without CHD or CHD risk equivalents. Around 28% of doctors preferred not to use pharmacotherapy for managing isolated low HDL. Of the participants, 73% used fibrates in ≤20% of their dyslipidemic patients, with fenofibrate being the most preferred (90.5%). Ezetimibe was mainly used in patients with uncontrolled LDL-C despite statin therapy (52.4% respondents). Most preferred approaches to manage statin intolerance included reducing statin dose (39%) and stopping and restarting statins at a lower dose (34.5%). Fifty-two percent of doctors chose not to alter pre-existing therapy in patients who had LDL-C levels at goal but elevated non-HDL-C levels. Conclusion This is the first survey in India that provides useful insights into Indian physicians’ self-reported perspectives on managing dyslipidemia in routine clinical practice. Despite concordance with the currently available guidelines in certain aspects, there is incongruence in managing specific dyslipidemia problems. Further continuing medical education and the development of evidence-based, India-specific lipid guidelines can help reduce some of these differences.

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

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.

Aneurysms of sinuses of Valsalva are rare aortic anomalies having an incidence of 1.4-4.94% in the Asian population. Spontaneous rupture is the most common complication and ruptured aneurysms usually present with congestive cardiac failure.INTRODUCTIONAneurysms of sinuses of Valsalva are rare aortic anomalies having an incidence of 1.4-4.94% in the Asian population. Spontaneous rupture is the most common complication and ruptured aneurysms usually present with congestive cardiac failure.Our study was aimed at evaluating the clinical profile of patients with ruptured sinus of Valsalva aneurysms (RSOVA) and their distribution, the surgical management and post-operative course.AIMOur study was aimed at evaluating the clinical profile of patients with ruptured sinus of Valsalva aneurysms (RSOVA) and their distribution, the surgical management and post-operative course.We retrospectively identified 21 patients who presented to us with RSOVA over a period of 7 years and underwent surgery for the same.MATERIAL AND METHODSWe retrospectively identified 21 patients who presented to us with RSOVA over a period of 7 years and underwent surgery for the same.RSOVA was more common in young males. Most cases involved the right coronary sinus (RCS) followed by the non-coronary sinus (NCS). The site of rupture was mostly the right ventricular outflow tract or the right atrium. All patients had a relatively asymptomatic post-operative course in the ward. On follow-up, most of the patients were symptom free.RESULTSRSOVA was more common in young males. Most cases involved the right coronary sinus (RCS) followed by the non-coronary sinus (NCS). The site of rupture was mostly the right ventricular outflow tract or the right atrium. All patients had a relatively asymptomatic post-operative course in the ward. On follow-up, most of the patients were symptom free.Surgery on cardiopulmonary bypass with moderate hypothermia with excision of windsock deformity and patching of the rupture site is a safe method of treating ruptured sinus of Valsalva aneurysms. Patients need to be followed up regularly to monitor for the development of aortic regurgitation.CONCLUSIONSSurgery on cardiopulmonary bypass with moderate hypothermia with excision of windsock deformity and patching of the rupture site is a safe method of treating ruptured sinus of Valsalva aneurysms. Patients need to be followed up regularly to monitor for the development of aortic regurgitation.

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.

Purpose: The rising prevalence of heart failure (HF) in midlife years in Indians is posing an economic challenge. Sacubitril/valsartan demonstrated a significant risk reduction of cardiovascular deaths by 20% and HF rehospitalizations by 21% versus enalapril but has a higher drug cost. High cost is an impediment and poses a challenge for healthcare stakeholders to choose interventions that are more efficacious. We developed an intuitive evidence-based cost-consequence analysis (CCA) comparing sacubitril/valsartan with enalapril in chronic HF patients with reduced ejection fraction (HFrEF). Methodr. Authors adopted HF outcome probabilities for mortality and hospitalizations from the PARADIGM-HF trial. Economic (drug acquisition and hospitalization costs, earning potential) and clinical [length of stay (LOS), rates of mortality and hospitalizations] inputs were obtained from the published literature. The tool enables the user to input patient numbers, health setting (public/private), time horizon (6-27 months), number of hospitalizations (1.42-5), LOS (5.3-9 days), and wages per day €5.61-€28.03 (INR500-INR2,500). Results'. Hypothetical HF patient with a daily wages of €22.42 (INR 2,000) spent €420.31 (INR 37,490) for sacubitril/valsartan at a private set-up to realize an annual cost savings of €485.34 (INR 43,290). While the other patient with a lower daily wage of €11.21, at a public set-up had to spend €43.09 (INR 3,843) more to realize benefits of mortality, hospitalization, and productivity savings due to sacubitril/valsartan. Conclusion: Sacubitril/valsartan has the potential to improve clinical as well as economic outcomes by generating substantial cost-savings to minimize budget deficit. CCA could support healthcare stakeholders in selecting an appropriate treatment strategy for chronic HFrEF patients.

Background Current clinical guidelines recognize that the use of more than one agent is necessary to achieve target BP in the majority of patients. The ASCOT-BPLA trial demonstrated that the free combination of amlodipine and perindopril effectively controlled BP and was better than a β-adrenoceptor antagonist (β-blocker)/diuretic combination in reducing total mortality and cardiovascular outcomes. Objective To evaluate the efficacy and tolerability of a fixed combination of perindopril and amlodipine in the clinical setting. Study design The STRONG (SafeTy & efficacy analysis of coveRsyl amlodipine in uncOntrolled and Newly diaGnosed hypertension) study was a prospective, observational, multicenter trial. Setting This was a naturalistic, real-world, clinic-based, outpatient study involving 336 general practitioners/ primary care physicians in 65 cities in India. Patients Adults aged 40–70 years with newly diagnosed/untreated stage 2 hypertension (BP ≥ 160/100 mmHg), hypertension uncontrolled with monotherapy (BP > 140/90 mmHg), or hypertension inadequately managed with another combination therapy. Intervention Fixed combination perindopril 4 mg/amlodipine 5 mg once daily for 60 days. Main outcomes measure The primary outcomes were the mean change in BP from baseline and the proportion of patients achieving adequate BP control (≤ 140/90 mmHg, or ≤ 130/80 mmHg in patients with diabetes mellitus) in the intent-to-treat (ITT) population. Secondary analyses included incidence of adverse events (ITT) and treatment adherence rate (completers). Results In total, 1250 patients comprised the ITT population: 32.6% with newly diagnosed hypertension; 40.5% with hypertension uncontrolled with monotherapy; and 26.9% with hypertension inadequately managed with another combination therapy. Mean SBP/DBP decreased significantly from baseline (167.4±15.2/101.4±9.1 mmHg) over 60 days (−41.9 ± 34.8/−23.2 ± 21.8 mmHg; p<0.0001). Target BP was achieved in 66.1% of patients in the total population, 68.3% of untreated patients, 68.4% of patients uncontrolled with monotherapy, and 59.9% of patients inadequately managed with combination therapy. In 161 patients with SBP >180 mmHg at baseline (newly diagnosed: n = 50; uncontrolled on monotherapy: n = 53; inadequately managed on combination therapy: n = 58), BP was reduced by 63.2 ± 32.5/29.0 ± 21.9 mmHg (p<0.0001) at day 60. The fixed combination was safe and well tolerated. All 1175 patients completing the 60-day study (94%) adhered to their treatment regimen. Conclusion Fixed combination perindopril/amlodipine was found to be an effective and well tolerated antihypertensive treatment, with an excellent rate of treatment adherence in the clinical setting. Fixed combination perindopril/amlodipine is expected to be useful in the management of hypertension in primary healthcare, with a positive impact on treatment adherence.

To understand the current clinical practices followed by healthcare professionals (HCPs) among populations with hypertension and obesity with sympathetic overactivity and develop strategies to improve the management of hypertension. A standard questionnaire was formulated based on high sympathetic overactivity and/or obesity in young patients with hypertension to gather information on the perception and practices of HCPs toward the management of young patients with hypertension who have high sympathetic overactivity and/or obesity. HCPs throughout India were selected. The key insights and recommendations from the panel discussion were summarized in a report that helped to develop strategies to improve the management of young hypertension patients with high sympathetic overactivity/obesity. A total of 1170 HCPs participated in the survey and in panel discussion meetings. According to 53% of HCPs, patients with hypertension with increased sympathetic overactivity or stress are most commonly aged 41-60 years. These patients have a higher likelihood of developing stroke (60%), alcoholism (46%), and sleep apnea (41%). Moreover, these HCPs also opined that patients with hypertension and obesity are at greater risk of developing coronary artery disease and chronic kidney disease (69%) and often require multiple antihypertensive drugs (60%). For the management of hypertension in obese patients with sympathetic overactivity, a combination of telmisartan and cardio-selective beta-blockers is the preferred treatment (66%). Additionally, a combination of telmisartan and metoprolol is recommended to control sympathetic overactivity in obese patients with hypertension. Sympathetic overactivity is becoming more common in young adults with hypertension, and the combination of telmisartan and cardio-selective beta-blockers is the best treatment option for these patients. This approach may help to effectively manage hypertension and reduce the risk of complications associated with sympathetic overactivity. The limitation of the study is its reliance on self-reported data from HCPs, which may introduce bias.

The present United States and European treatment guidelines recommend that antihypertensive therapy be initiated with a combination of agents from different classes to facilitate the achievement of control of blood pressure (BP). This prospective, randomized, open-label study was conducted at 3 tertiary hospitals in India to evaluate the effects of combination therapy with an angiotensin receptor blocker and a calcium antagonist on office BP and central hemodynamic parameters in patients with untreated hypertension or uncontrolled BP (>130/>80 mm Hg) during treatment with antihypertensive monotherapy. Patients were randomized to treatment with telmisartan 40 mg/day + amlodipine 5 mg/day or telmisartan 40 mg/day + cilnidipine 10 mg/day. Change from baseline to 8 weeks of treatment was assessed for seated office BP, ambulatory BP monitoring, and seated central hemodynamics (central BP, aortic augmentation index, central aortic augmentation pressure, and pulse wave velocity). A total of 94 of 96 enrolled patients completed the study. From baseline to 8 weeks a significant decrease was observed in both telmisartan + amlodipine and telmisartan + cilnidipine groups for mean BP (148.0 ± 12.80 to 124.0 ± 10.4 and 144.5 ± 10.2 to 123.0 ± 10.0 mm Hg, respectively; both p <0.001); in only telmisartan + amlodipine group for mean central aortic systolic and diastolic BP (131.1 ± 19.1 to 119.7 ± 14.9 mm Hg [p <0.001] and 93.3 ± 12.0 to 89.2 ± 14.6 mm Hg [p = 0.0008], respectively) and for central aortic pulse wave velocity (7.6 ± 1.4 to 7.2 ± 1.3 m/s, p = 0.0011); in only telmisartan + cilnidipine group for aortic augmentation index (27.5 ± 14.6 to 22.3 ± 12.2; p = 0.0178). Heart rate was unchanged in both treatment groups. Combination therapy with an angiotensin receptor blocker and a calcium antagonist effectively reduced BP to below the new <130/80 mm Hg target and had favorable effects on central hemodynamics.