Publications by authors named "Ambuj Roy"

105 Publications

Imaging of Coronavirus Disease 2019 Infection From Head to Toe: A Primer for the Radiologist.

Curr Probl Diagn Radiol 2021 Nov-Dec;50(6):842-855. Epub 2021 Jul 5.

Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India. Electronic address:

Coronavirus Disease 2019 (COVID-19) disease has rapidly spread around the world after initial identification in Wuhan, China, in December 2019. Most common presentation is mild or asymptomatic disease, followed by pneumonia, and rarely- multiorgan failure and Acute Respiratory Distress Syndrome (ARDS). Knowledge about the pathophysiology, imaging and treatment of this novel virus is rapidly evolving due to ongoing worldwide research. Most common imaging modalities utilized during this pandemic are chest radiography and HRCT with findings of bilateral peripheral, mid and lower zone GGO and/or consolidation, vascular enlargement and crazy paving. HRCT is also useful for prognostication and follow-up of severely ill COVID-19 patients. Portable radiography allows follow-up of ICU patients & obviates the need of shifting critically ill patients and disinfection of CT room. As the pandemic has progressed, numerous neurologic manifestations have been described in COVID-19 including stroke, white matter hyperintensities and demyelination on MRI. Varying abdominal presentations have been described, which on imaging either show evidence of COVID-19 pneumonia in lung bases or show abdominal findings including bowel thickening and vascular thrombosis. Numerous thrombo-embolic and cardiovascular complications have also been described in COVID-19 including arterial and venous thrombosis, pulmonary embolism and myocarditis. It is imperative for radiologists to be aware of all the varied faces of this disease on imaging, as they may well be the first physician to suspect the disease. This article aims to review the multimodality imaging manifestations of COVID-19 disease in various organ systems from head to toe.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1067/j.cpradiol.2021.06.015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8256677PMC
October 2021

'Routine' versus 'Smart Phone Application Based - Intense' follow up of patients with acute coronary syndrome undergoing percutaneous coronary intervention: Impact on clinical outcomes and patient satisfaction.

Int J Cardiol Heart Vasc 2021 Aug 25;35:100832. Epub 2021 Jun 25.

Department of Cardiology, AIIMS, New Delhi, India.

Background: Acute coronary syndrome (ACS) refers to the spectrum of clinical presentation of coronary artery disease (CAD). As a routine practice at our institute, following PCI, ACS patients are called for the first follow up after two weeks. This period of two weeks can be full of anxieties, concerns and medical issues. In this study, we planned to assess the feasibility/acceptability of smart phone application (app) based system for patient follow-up and its comparison to routine practice among patients with ACS who have undergone a PCI.

Methods: A randomized controlled trial (RCT) was conducted over a period of one year from January to December 2017. After the PCI was deemed successful, patients were recruited and enrolled based on the understanding of basic English language and operation of a smart phone. Those who consented to be part of study were then randomly allocated either the conventional follow up group or the intense follow up (routine + smart phone app based follow up) group. First co- primary outcome was composite of clinical outcomes (mortality, myocardial infarction, stroke, target vessel revascularisation, heart failure admission and emergency visit). Second co- primary outcome was patient satisfaction. The overall patient satisfaction was assessed by the patients using a five-point patient satisfaction survey instrument containing five questions with 5 marks each, in which higher scores meant more satisfaction. Secondary outcome was controlled hypertension in hypertensive patients. It was defined as systolic BP less than 130 and diastolic BP less than 80 mmHg.

Results: A cohort of 228 patients (109 in intense app-based arm; 119 in routine follow up arm) were analyzed. The result showed significant improvement in blood pressure control in hypertensive population in intense app based follow up group (76.2%) when compared to routine follow up group (45%) with p value 0.0062. The satisfaction score was significantly higher in the intense app based follow up (20.7 ± 1.29) as compared to routine follow up (16.5 ± 2.68); p value 0.0001. In the intense app based follow up 72.5% patient felt it was excellent tool (score 21-25) while 27.5% categorized it as good (score 16-20). While the routine follows up was perceived as good by most (91.6%) of the patients. Only 4.2% graded it as excellent and an equal number (4.2%) graded it as a poor way of follow up.

Conclusions: App based system shows higher satisfaction rate and comparable clinical outcome when compared to traditional hospital based follow up protocol alone. It has a high acceptance rate and thus this system should be explored further to optimize long term patient care.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ijcha.2021.100832DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8250165PMC
August 2021

Exploring Barriers to Medication Adherence Using COM-B Model of Behaviour Among Patients with Cardiovascular Diseases in Low- and Middle-Income Countries: A Qualitative Study.

Patient Prefer Adherence 2021 23;15:1359-1371. Epub 2021 Jun 23.

Saw Swee Hock School of Public Health, National University of Singapore, Singapore.

Introduction: In 2016, cardiovascular diseases (CVDs) led to 17.9 million deaths worldwide, representing 31% of all global deaths. CVDs are the leading cause of mortality worldwide and significant barriers to achieving the sustainable development goals. Modern medicines have been significant in improving health outcomes. However, non-adherence to medication is one of the reasons behind adverse health-related outcomes among patients suffering from atherosclerotic cardiovascular disease in low- and middle-income countries.

Patients And Methods: This qualitative study was conducted at two tertiary care hospitals in India and Ghana. A total of 35 in-depth interviews were conducted with atherosclerosis cardiovascular disease (ASCVD) patients. The data were analysed thematically using the Capability Opportunity and Motivation (COM-B) framework.

Findings: The findings were summarised under three important broad themes of the COM-B framework: capability, opportunity and behaviour. Under capability, comprehension of disease, medication schedule, and unplanned travel affected adherence among patients. Cost of medication, insurance and access were the critical factors under opportunity, which negatively influenced medication adherence. Mood, beliefs about treatment and outcome expectations under motivation led to non-adherence among patients. Apart from these factors, some important health system factors such as health care experience and trust in the facilities and reliance on alternative medication also affected adherence in both countries.

Conclusion: This study has highlighted that the health system factors have dominantly influenced adherence to medication in India and Ghana. In India, we found participants to be satisfied with their health care provided at the government hospitals. However, limited time for consultation, lack of well-stocked pharmacy and unclear prescription negatively influenced adherence among participants in India and Ghana. The study emphasises that the health system needs to be strengthened, and the patients' belief system needs to be explored to address the issue of medication adherence in LMICs.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.2147/PPA.S285442DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8236251PMC
June 2021

Changing Perspectives on HDL: From Simple Quantity Measurements to Functional Quality Assessment.

J Lipids 2021 26;2021:5585521. Epub 2021 Apr 26.

Department of Cardiology, All India Institute of Medical Sciences, New Delhi 110029, India.

High-density lipoprotein (HDL) comprises a heterogeneous group of particles differing in size, density, and composition. HDL cholesterol (HDL-C) levels have long been suggested to indicate cardiovascular risk, inferred from multiple epidemiological studies. The failure of HDL-C targeted interventions and genetic studies has raised doubts on the atheroprotective role of HDL-C. The current consensus is that HDL-C is neither a biomarker nor a causative agent of cardiovascular disorders. With better understanding of the complex nature of HDL which comprises a large number of proteins and lipids with unique functions, recent focus has shifted from HDL quantity to HDL quality in terms of atheroprotective functions. The current research is focused on developing laboratory assays to assess HDL functions for cardiovascular risk prediction. Also, HDL mimetics designed based on the key determinants of HDL functions are being investigated to modify cardiovascular risk. Improving HDL functions by altering its composition is the key area of future research in HDL biology to reduce cardiovascular risk.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1155/2021/5585521DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8096543PMC
April 2021

Crop Fires and Cardiovascular Health - A Study from North India.

SSM Popul Health 2021 Jun 27;14:100757. Epub 2021 Feb 27.

Centre for Atmospheric Sciences, Indian Institute of Technology Delhi, New Delhi, India & Centre of Excellence for Research on Clean Air (CERCA), Indian Institute of Technology Delhi, New Delhi, India.

We examine the impact of exposure to biomass burning events (primarily crop burning) on the prevalence of hypertension in four North Indian states. We use data from the National Family Health Survey-IV for 2015-16 and employ a multivariate logistic and linear model to estimate the effect of exposure to biomass burning on the prevalence of hypertension and blood pressure, respectively. The adjusted odds ratio of hypertension among individuals living in areas with high intensity of biomass (HIB) burning (defined as exposure to 100 fire-events during the past 30 days) is 1.15 [95% CI: 1.003-1.32]. The odds ratios further increase at a higher intensity of biomass burning and downwind fires are found to be responsible for the negative effect of fires on cardiovascular health. We also find that the systolic and diastolic blood pressure for older cohorts is significantly higher due to exposure to HIB. We estimate that elimination of HIB would prevent loss of 70-91 thousand DALYs every year and 1.73 to 2.24 Billion USD (in PPP terms) over 5 years by reducing the prevalence of hypertension. Therefore, curbing biomass burning will be associated with significant health and economic benefits in North India.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ssmph.2021.100757DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8040334PMC
June 2021

Role of CMR feature-tracking derived left ventricular strain in predicting myocardial iron overload and assessing myocardial contractile dysfunction in patients with thalassemia major.

Eur Radiol 2021 Aug 15;31(8):6184-6192. Epub 2021 Mar 15.

Department of Cardiovascular Radiology and Endovascular Interventions, All India Institute of Medical Sciences, New Delhi, 110029, India.

Objective: Myocardial iron overload (MIO) in thalassemia major (TM) may cause subclinical left ventricular (LV) dysfunction which manifests with abnormal strain parameters before a decrease in ejection fraction (EF). Early detection of MIO using cardiovascular magnetic resonance (CMR)-T2* is vital. Our aim was to assess if CMR feature-tracking (FT) strain correlates with T2*, and whether it can identify early contractile dysfunction in patients with MIO but normal EF.

Methods: One hundred and four consecutive TM patients with LVEF > 55% on echocardiography were prospectively enrolled. Those fulfilling the inclusion criteria underwent CMR, with T2* being the gold standard for detecting MIO. Group 1 included patients without significant MIO (T2* > 20 ms) and group 2 with significant MIO (T2* < 20 ms).

Results: Eighty-six patients (mean age, 17.32 years, 59 males) underwent CMR. There were 68 (79.1%) patients in group 1 and 18 (20.9%) in group 2. Fourteen patients (16.3%) had mild-moderate MIO, and four (4.6%) had severe MIO. Patients in group 2 had significantly lower global radial strain (GRS). Global longitudinal strain (GLS) and global circumferential strain (GCS) did not correlate with T2*. T1 mapping values were significantly lower in patients with T2* < 10 ms than those with T2* of 10-20 ms; however, FT-strain values were not significantly different between these two groups.

Conclusion: CMR-derived GRS, but not GLS and GCS, correlated with CMR T2*. GRS is significantly decreased in TM patients with MIO and normal EF when compared with those without. FT-strain may be a useful adjunct to CMR T2* and maybe an early marker of myocardial dysfunction in TM.

Key Points: • A global radial strain of < 29.3 derived from cardiac MRI could predict significant myocardial iron overload in patients with thalassemia, with a sensitivity of 76.5% and specificity of 66.7%. • Patients with any myocardial iron overload have significantly lower GRS, compared to those without, suggesting the ability of CMR strain to identify subtle myocardial contractile disturbances. • T1 and T2 mapping values are significantly lower in those with severe myocardial iron than those with mild-moderate iron, suggesting a potential role of T1 and T2 mapping in grading myocardial iron.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00330-020-07599-7DOI Listing
August 2021

Cardiac Magnetic Resonance Imaging in Coronavirus Disease 2019 (COVID-19): A Systematic Review of Cardiac Magnetic Resonance Imaging Findings in 199 Patients.

J Thorac Imaging 2021 Mar;36(2):73-83

Departments of Cardiovascular Radiology & Endovascular Interventions.

Objective: Cardiac magnetic resonance imaging (CMR) with its new quantitative mapping techniques has proved to be an essential diagnostic tool for detecting myocardial injury associated with coronavirus disease 2019 (COVID-19) infection. This systematic review sought to assess the important imaging features on CMR in patients diagnosed with COVID-19.

Materials And Methods: We performed a systematic literature review within the PubMed, Embase, Google Scholar, and WHO databases for articles describing the CMR findings in COVID-19 patients.

Results: A total of 34 studies comprising 199 patients were included in the final qualitative synthesis. Of the CMRs 21% were normal. Myocarditis (40.2%) was the most prevalent diagnosis. T1 (109/150; 73%) and T2 (91/144; 63%) mapping abnormalities, edema on T2/STIR (46/90; 51%), and late gadolinium enhancement (LGE) (85/199; 43%) were the most common imaging findings. Perfusion deficits (18/21; 85%) and extracellular volume mapping abnormalities (21/40; 52%), pericardial effusion (43/175; 24%), and pericardial LGE (22/100; 22%) were also seen. LGE was most commonly seen in the subepicardial location (81%) and in the basal-mid part of the left ventricle in inferior segments. In most of the patients, ventricular functions were normal. Kawasaki-like involvement with myocardial edema without necrosis/LGE (4/6; 67%) was seen in children.

Conclusion: CMR is useful in assessing the prevalence, mechanism, and extent of myocardial injury in COVID-19 patients. Myocarditis is the most common imaging diagnosis, with the common imaging findings being mapping abnormalities and myocardial edema on T2, followed by LGE. As cardiovascular involvement is associated with poor prognosis, its detection warrants prompt attention and appropriate treatment.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/RTI.0000000000000574DOI Listing
March 2021

Change in prevalence of Coronary Heart Disease and its risk between 1991-94 to 2010-12 among rural and urban population of National Capital Region, Delhi.

Indian Heart J 2020 Sep - Oct;72(5):403-409. Epub 2020 Aug 9.

Public Health Foundation of India, Gurgaon, India.

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.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ihj.2020.08.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7670492PMC
May 2021

The Integrated Tracking, Referral, and Electronic Decision Support, and Care Coordination (I-TREC) program: scalable strategies for the management of hypertension and diabetes within the government healthcare system of India.

BMC Health Serv Res 2020 Nov 9;20(1):1022. Epub 2020 Nov 9.

Department of Endocrinology & Metabolism, All India Institute of Medical Sciences, New Delhi, India.

Background: Hypertension and diabetes are among the most common and deadly chronic conditions globally. In India, most adults with these conditions remain undiagnosed, untreated, or poorly treated and uncontrolled. Innovative and scalable approaches to deliver proven-effective strategies for medical and lifestyle management of these conditions are needed.

Methods: The overall goal of this implementation science study is to evaluate the Integrated Tracking, Referral, Electronic decision support, and Care coordination (I-TREC) program. I-TREC leverages information technology (IT) to manage hypertension and diabetes in adults aged ≥30 years across the hierarchy of Indian public healthcare facilities. The I-TREC program combines multiple evidence-based interventions: an electronic case record form (eCRF) to consolidate and track patient information and referrals across the publicly-funded healthcare system; an electronic clinical decision support system (CDSS) to assist clinicians to provide tailored guideline-based care to patients; a revised workflow to ensure coordinated care within and across facilities; and enhanced training for physicians and nurses regarding non-communicable disease (NCD) medical content and lifestyle management. The program will be implemented and evaluated in a predominantly rural district of Punjab, India. The evaluation will employ a quasi-experimental design with mixed methods data collection. Evaluation indicators assess changes in the continuum of care for hypertension and diabetes and are grounded in the Reach, Effectiveness, Adoption Implementation, and Maintenance (RE-AIM) framework. Data will be triangulated from multiple sources, including community surveys, health facility assessments, stakeholder interviews, and patient-level data from the I-TREC program's electronic database.

Discussion: I-TREC consolidates previously proven strategies for improved management of hypertension and diabetes at single-levels of the healthcare system into a scalable model for coordinated care delivery across all levels of the healthcare system hierarchy. Findings have the potential to inform best practices to ultimately deliver quality public-sector hypertension and diabetes care across India.

Trial Registration: The study is registered with Clinical Trials Registry of India (registration number CTRI/2020/01/022723 ). The study was registered prior to the launch of the intervention on 13 January 2020. The current version of protocol is version 2 dated 6 June 2018.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s12913-020-05851-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7652581PMC
November 2020

Atorvastatin and Aspirin as Adjuvant Therapy in Patients with SARS-CoV-2 Infection: A structured summary of a study protocol for a randomised controlled trial.

Trials 2020 Oct 30;21(1):902. Epub 2020 Oct 30.

Department of Cardiology, All India Institute of Medical Sciences (AIIMS), Ansari Nagar East, New Delhi, 110029, India.

Objectives: To assess the impact of adding statin (atorvastatin) and/or aspirin on clinical deterioration in patients infected with SARS-CoV-2 who require hospitalisation. The safety of these drugs in COVID-19 patients will also be evaluated.

Trial Design: This is a single-centre, prospective, four-arm parallel design, open-label, randomized control trial.

Participants: The study will be conducted at National Cancer Institute (NCI), Jhajjar, Haryana, which is a part of All India Institute of Medical Sciences (AIIMS), New Delhi, and has been converted into a dedicated COVID-19 management centre since the outbreak of the pandemic. All RT-PCR confirmed cases of SARS-CoV-2 infection with age ≥ 40 years and < 75 years requiring hospital admission (patients with WHO clinical improvement ordinal score 3 to 5) will be included in the trial. Written informed consent will be taken for all recruited patients. Patients with a critical illness (WHO clinical improvement ordinal score > 5), documented significant liver disease/dysfunction (aspartate transaminase [AST] / alanine aminotransferase [ALT] > 240), myopathy and rhabdomyolysis (creatine phosphokinase [CPK] > 5x normal), allergy or intolerance to statins or aspirin, prior statin or aspirin use within 30 days, history of active gastrointestinal bleeding in past three months, coagulopathy, thrombocytopenia (platelet count < 100000/ dl), pregnancy, active breastfeeding, or inability to take oral or nasogastric medications will be excluded. Patients refusing to give written consent and taking drugs that are known to have a significant drug interaction with statin or aspirin [including cyclosporine, HIV protease inhibitors, hepatitis C protease inhibitor, telaprevir, fibric acid derivatives (gemfibrozil), niacin, azole antifungals (itraconazole, ketoconazole), clarithromycin and colchicine] will also be excluded from the trial.

Intervention And Comparator: In this study, the benefit and safety of atorvastatin (statin) and/or aspirin as adjuvant therapy will be compared with the control group receiving usual care for management of COVID-19. Atorvastatin will be prescribed as 40 mg oral tablets once daily for ten days or until discharge, whichever is earlier. The dose of aspirin will be 75 mg once daily for ten days or until discharge, whichever is earlier. All other therapies will be administered according to the institute's COVID-19 treatment protocol and the treating physician's clinical judgment.

Main Outcomes: All study participants will be prospectively followed up for ten days or until hospital discharge, whichever is longer for outcomes. The primary outcome will be clinical deterioration characterized by progression to WHO clinical improvement ordinal score ≥ 6 (i.e., endotracheal intubation, non-invasive mechanical ventilation, pressor agents, renal replacement therapy, ECMO requirement, and mortality). The secondary outcomes will be change in serum inflammatory markers (C-reactive protein and Interleukin-6), Troponin I, and creatine phosphokinase (CPK) from time zero to 5th day of study enrolment or 7th day after symptom onset, whichever is later. Other clinical outcomes that will be assessed include progression to Acute Respiratory Distress Syndrome (ARDS), shock, ICU admission, length of ICU admission, length of hospital admission, and in-hospital mortality. Adverse drug effects like myalgia, myopathy, rhabdomyolysis, hepatotoxicity, and bleeding will also be examined in the trial to assess the safety of the interventions.

Randomisation: The study will use a four-arm parallel-group design. A computer-generated permuted block randomization with mixed block size will be used to randomize the participants in a 1:1:1:1 ratio to group A (atorvastatin with conventional therapy), group B (aspirin with conventional therapy), group C (aspirin + atorvastatin with conventional therapy), and group D (control; only conventional therapy).

Blinding (masking): The study will be an open-label trial.

Numbers To Be Randomised (sample Size): As there is no existing study that has evaluated the role of aspirin and atorvastatin in COVID-19 patients, formal sample size calculation has not been done. Patients satisfying the inclusion and exclusion criteria will be recruited during six months of study period. Once the first 200 patients are included in each arm (i.e., total 800 patients), the final sample size calculation will be done on the basis of the interim analysis of the collected data.

Trial Status: The institutional ethical committee has approved the study protocol (Protocol version 3.0 [June 2020]). Participant recruitment starting date: 28 July 2020 Participant recruitment ending date: 27 January 2021 Trial duration: 6 months TRIAL REGISTRATION: The trial has been prospectively registered in Clinical Trial Registry - India (ICMR- NIMS): Reference no. CTRI/2020/07/026791 (registered on 25 July 2020)].

Full Protocol: The full protocol is attached as an additional file, accessible from the Trials website (Additional file 1). In the interest of expediting dissemination of this material, the familiar formatting has been eliminated; this Letter serves as a summary of the key elements of the full protocol.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s13063-020-04840-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7598224PMC
October 2020

Management of Cardiovascular Disease Patients With Confirmed or Suspected COVID-19 in Limited Resource Settings.

Glob Heart 2020 07 1;15(1):44. Epub 2020 Jul 1.

Division of Cardiology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Groote Schuur Hospital, Cape Town, ZA.

In this paper, we provide recommendations on the management of cardiovascular disease (CVD) among patients with confirmed or suspected coronavirus disease (COVID-19) to facilitate the decision making of healthcare professionals in low resource settings. The emergence of novel coronavirus disease, also known as Severe Acute Respiratory Syndrome-Coronavirus-2 (SARS-CoV-2), has presented an unprecedented global challenge for the healthcare community. The ability of SARS-CoV-2 to get transmitted during the asymptomatic phase and its high infectivity have led to the rapid transmission of COVID-19 beyond geographic regions, leading to a pandemic. There is concern that COVID-19 is cardiotropic, and it interacts with the cardiovascular system on multiple levels. Individuals with established CVD are more susceptible to severe COVID-19. Through a consensus approach involving an international group this WHF statement summarizes the links between cardiovascular disease and COVID-19 and present some practical recommendations for the management of hypertension and diabetes, acute coronary syndrome, heart failure, rheumatic heart disease, Chagas disease, and myocardial injury for patients with COVID-19 in low-resource settings. This document is not a clinical guideline and it is not intended to replace national clinical guidelines or recommendations. Given the rapidly growing burden posed by COVID-19 illness and the associated severe prognostic implication of CVD involvement, further research is required to understand the potential mechanisms linking COVID-19 and CVD, clinical presentation, and outcomes of various cardiovascular manifestations in COVID-19 patients.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.5334/gh.823DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7413193PMC
July 2020

A multinational registry to study the characteristics and outcomes of heart failure patients: The global congestive heart failure (G-CHF) registry.

Am Heart J 2020 09 6;227:56-63. Epub 2020 Jun 6.

Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada.

The goal of the global congestive heart failure (G-CHF) registry is to collect comparative international data on heart failure characteristics, management, and outcomes and to better understand the determinants that impact the clinical course of heart failure. METHODS: G-CHF is a multicenter, prospective cohort study of adult patients with a new or prior clinical diagnosis of heart failure. We have enrolled 23,047 participants from 257 centers in 40 countries from 8 major geographic regions of the world, with recruitment ongoing. Approximately 4,000 participants will also participate in substudies to assess frailty, comorbidity, diet, barriers to care, biomarkers, and planned detailed echocardiographic analyses. Follow-up is planned for a period of 5 years. The primary outcome is cause-specific mortality. Key secondary outcomes include hospitalizations, quality of life, and major cardiovascular and noncardiovascular outcomes. A total of 31.9% of participants were enrolled as inpatients. Thus far, mean age of the cohort at baseline is 63.1 years, and 60.8% are male. Participants most commonly have heart failure with reduced ejection fraction (53.6%) followed by preserved ejection fraction (24.2%) and midrange ejection fraction (20.6%). The most common causes of heart failure are ischemic (37.8%) followed by hypertensive (20.0%), idiopathic (15.1%), and valvular disease (8.8%). CONCLUSION: G-CHF will provide a greater understanding of the characteristics of the global heart failure population, variations in its management, clinical outcomes, and what continues to impact morbidity and mortality in this high-risk population.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ahj.2020.06.002DOI Listing
September 2020

Resource and Infrastructure-Appropriate Management of ST-Segment Elevation Myocardial Infarction in Low- and Middle-Income Countries.

Circulation 2020 06 15;141(24):2004-2025. Epub 2020 Jun 15.

Public Health Foundation of India, New Delhi (K.S.R.).

The 143 low- and middle-income countries (LMICs) of the world constitute 80% of the world's population or roughly 5.86 billion people with much variation in geography, culture, literacy, financial resources, access to health care, insurance penetration, and healthcare regulation. Unfortunately, their burden of cardiovascular disease in general and acute ST-segment-elevation myocardial infarction (STEMI) in particular is increasing at an unprecedented rate. Compounding the problem, outcomes remain suboptimal because of a lack of awareness and a severe paucity of resources. Guideline-based treatment has dramatically improved the outcomes of STEMI in high-income countries. However, no such focused recommendations exist for LMICs, and the unique challenges in LMICs make directly implementing Western guidelines unfeasible. Thus, structured solutions tailored to their individual, local needs, and resources are a vital need. With this in mind, a multicountry collaboration of investigators interested in LMIC STEMI care have tried to create a consensus document that extracts transferable elements from Western guidelines and couples them with local realities gathered from expert experience. It outlines general operating principles for LMICs focused best practices and is intended to create the broad outlines of implementable, resource-appropriate paradigms for management of STEMI in LMICs. Although this document is focused primarily on governments and organizations involved with improvement in STEMI care in LMICs, it also provides some specific targeted information for the frontline clinicians to allow standardized care pathways and improved outcomes.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1161/CIRCULATIONAHA.119.041297DOI Listing
June 2020

Cardiovascular risk prediction in India: Comparison of the original and recalibrated Framingham prognostic models in urban populations.

Wellcome Open Res 2019 2;4:71. Epub 2019 Dec 2.

Centre for Global Chronic Conditions, London School of Hygiene & Tropical Medicine, London, UK.

Cardiovascular diseases (CVDs) are the leading cause of death in India. The CVD risk approach is a cost-effective way to identify those at high risk, especially in a low resource setting. As there is no validated prognostic model for an Indian urban population, we have re-calibrated the original Framingham model using data from two urban Indian studies. We have estimated three risk score equations using three different models. The first model was based on Framingham original model; the second and third are the recalibrated models using risk factor prevalence from CARRS (Centre for cArdiometabolic Risk Reduction in South-Asia) and ICMR (Indian Council of Medical Research) studies, and estimated survival from WHO 2012 data for India. We applied these three risk scores to the CARRS and ICMR participants and estimated the proportion of those at high-risk (>30% 10 years CVD risk) who would be eligible to receive preventive treatment such as statins. In the CARRS study, the proportion of men with 10 years CVD risk > 30% (and therefore eligible for statin treatment) was 13.3%, 21%, and 13.6% using Framingham, CARRS and ICMR risk models, respectively. The corresponding proportions of women were 3.5%, 16.4%, and 11.6%. In the ICMR study the corresponding proportions of men were 16.3%, 24.2%, and 16.5% and for women, these were 5.6%, 20.5%, and 15.3%. Although the recalibrated model based on local population can improve the validity of CVD risk scores our study exemplifies the variation between recalibrated models using different data from the same country. Considering the growing burden of cardiovascular diseases in India, and the impact that the risk approach has on influencing cardiovascular prevention treatment, such as statins, it is essential to develop high quality and well powered local cohorts (with outcome data) to develop local prognostic models.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.12688/wellcomeopenres.15137.2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7255911PMC
December 2019

Pectoral nerves block for periprocedural analgesia in patients undergoing CIED implantation.

Anaesth Crit Care Pain Med 2020 10 3;39(5):619-621. Epub 2020 Apr 3.

Department of Cardiology, AIIMS, New Delhi, India.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.accpm.2020.03.017DOI Listing
October 2020

Association of Maternal History of Neonatal Death With Subsequent Neonatal Death in India.

JAMA Netw Open 2020 04 1;3(4):e202887. Epub 2020 Apr 1.

Harvard Center for Population and Development Studies, Cambridge, Massachusetts.

Importance: Among the United Nations' Sustainable Development Goals is to reduce the neonatal mortality rate to 12 per 1000 live births by 2030. Identifying high-risk pregnancies can help achieve this target in low-resource countries, such as India, which accounts for one-fourth of global neonatal deaths.

Objective: To analyze the association of maternal history of neonatal death with subsequent neonatal mortality.

Design, Setting, And Participants: This cross-sectional study included a nationally representative sample of singleton live births from multiparous women. Data were obtained from the 2016 National Family Health Survey in India. Data were analyzed from November 2018 to January 2020.

Exposures: Maternal history of neonatal death and a comprehensive set of covariates, including socioeconomic environment, maternal anthropometry, and pregnancy care.

Main Outcomes And Measures: Subsequent neonatal mortality. Population-attributable risk associated with history of neonatal death was calculated, and sensitivity analyses were performed.

Results: The overall study population consisted of 127 336 singleton live births from multiparous women aged 15 to 49 (mean [SD] age, 28.8 [5.2] years) years when the survey was undertaken. In our analytic sample, 11 101 (8.7%) mothers had a history of neonatal death, and 506 of 2224 total neonatal deaths (22.8%) were attributed to women with history of neonatal death. The prevalence of history of neonatal death differed by selected covariates and across states or union territories. Maternal history of neonatal death was associated with significantly higher odds of neonatal mortality (adjusted odds ratio, 2.23; 95% CI, 1.96-2.55), and this remained consistent across different subgroups. The population-attributable risk associated with maternal history of neonatal death was 11.8%. Stronger associations were found for maternal history of multiple neonatal deaths (adjusted odds ratio, 3.50; 95% CI, 2.78-4.41) and in respect to the risk of mortality in early neonatal period (ie, 0-2 completed days) (adjusted odds ratio, 2.45; 95% CI, 2.09-2.86).

Conclusions And Relevance: These findings suggest that maternal history of neonatal death is a potentially useful risk factor to identify women and neonates who may need extended and enhanced pregnancy care.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1001/jamanetworkopen.2020.2887DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7163408PMC
April 2020

HDL functions and their interaction in patients with ST elevation myocardial infarction: a case control study.

Lipids Health Dis 2020 Apr 15;19(1):75. Epub 2020 Apr 15.

Department of Biochemistry, All India Institute of Medical Sciences, Room No. 3044, New Delhi, 110029, India.

Background: Recent studies emphasize the importance of HDL function over HDL cholesterol measurement, as an important risk for cardiovascular diseases (CVD). We compared the HDL function of patients with acute coronary syndrome (ACS) and healthy controls.

Methods: We measured cholesterol efflux capacity of HDL using THP-1 macrophages labelled with fluorescently tagged (BODIPY) cholesterol. PON1 activities toward paraoxon and phenyl acetate were assessed by spectrophotometric methods.

Results: We recruited 150 ACS patients and 110 controls. The HDL function of all patients during acute phase and at six month follow-up was measured. The mean age of the patients and controls was 51.7 and 43.6 years respectively. The mean HDL cholesterol/apolipoprotein A-I levels (ratio) of patients during acute phase, follow-up and of controls were 40.2 mg/dl/ 112.5 mg/dl (ratio = 0.36), 38.3 mg/dl/ 127.2 mg/dl (ratio = 0.30) and 45.4 mg/dl/ 142.1 mg/dl (ratio = 0.32) respectively. The cholesterol efflux capacity (CEC) of HDL was positively correlated with apolipoprotein A-I levels during acute phase (r = 0.19, p = 0.019), follow-up (r = 0.26, p = 0.007) and of controls (r = 0.3, p = 0.0012) but not with HDL-C levels (acute phase: r = 0.07, p = 0.47; follow-up: r = 0.1, p = 0.2; control: r = 0.02, p = 0.82). Higher levels of cholesterol efflux capacity, PON1 activity and apolipoprotein A-I were associated with lower odds of development of ACS. We also observed that low CEC is associated with higher odds of having ACS if PON1 activity of HDL is also low and vice versa.

Conclusion: ACS is associated with reduced HDL functions which improves at follow-up. The predicted probability of ACS depends upon individual HDL functions and the interactions between them.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s12944-020-01260-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7158160PMC
April 2020

Yoga-Based Cardiac Rehabilitation After Acute Myocardial Infarction: A Randomized Trial.

J Am Coll Cardiol 2020 04;75(13):1551-1561

London School of Hygiene and Tropical Medicine, London, United Kingdom.

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).
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jacc.2020.01.050DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7132532PMC
April 2020

Risk factors for myocardial infarction in very young South Asians.

Curr Opin Endocrinol Diabetes Obes 2020 04;27(2):87-94

Cardiovascular Division, New York University School of Medicine, New York, New York, USA.

Purpose Of Review: It is only over the last few decades that the impact of coronary artery disease (CAD) in very young South Asian population has been recognized. There has been a tremendous interest in elucidating the causes behind this phenomenon and these efforts have uncovered several mechanisms that might explain the early onset of CAD in this population. The complete risk profile of very young South Asians being affected by premature CAD still remains unknown.

Recent Findings: The existing data fail to completely explain the burden of premature occurrence of CAD in South Asians especially in very young individuals. Results from some studies identified nine risk factors, including low consumption of fruits and vegetables, smoking, alcohol, diabetes, psychosocial factors, sedentary lifestyle, abdominal obesity, hypertension and dyslipidemia as the cause of myocardial infarction in 90% of the patients in this population. Recent large genome-wide association studies have discovered the association of several novel genetic loci with CAD in South Asians. Nonetheless, continued scientific efforts are required to further our understanding of the causal risk factors of CAD in South Asians to address the rising burden of CVD in this vulnerable population.

Summary: In this review, we discuss established and emerging risk factors of CAD in this population.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/MED.0000000000000532DOI Listing
April 2020

Prevalence of hypertension among Indian adults: Results from the great India blood pressure survey.

Indian Heart J 2019 Jul - Aug;71(4):309-313. Epub 2019 Sep 18.

Objective: Hypertension is the most important risk factor for cardiovascular morbidity and mortality. There is limited data on hypertension prevalence in India. This study was conducted to estimate the prevalence of hypertension among Indian adults.

Methods: A national level survey was conducted with fixed one-day blood pressure measurement camps across 24 states and union territories of India. Hypertension was defined as systolic blood pressure (BP) ≥140 mmHg or a diastolic BP ≥90 mmHg or on treatment for hypertension. The prevalence was age- and gender-standardized according to the 2011 census population of India.

Results: Blood pressure was recorded for 180,335 participants (33.2% women; mean age 40.6 ± 14.9 years). Among them, 8,898 (4.9%), 99,791 (55.3%), 35,694 (11.9%), 23,084 (12.8%), 9,989 (5.5%), and 2,878 (1.6%) participants were of the age group 18-19, 20-44, 45-54, 55-64, 65-74, and ≥ 75 years, respectively. Overall prevalence of hypertension was 30.7% (95% confidence interval [CI]: 30.5, 30.9) and the prevalence among women was 23.7% (95% CI: 23.3, 24). Prevalence adjusted for 2011 census population and the WHO reference population was 29.7% and 32.8%, respectively.

Conclusion: There is a high prevalence of hypertension, with almost one in every three Indian adult affected.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ihj.2019.09.012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6890959PMC
May 2020

Coronary Artery Disease in Patients with Ischemic Stroke and TIA.

J Stroke Cerebrovasc Dis 2019 Dec 9;28(12):104400. Epub 2019 Oct 9.

Department of Neurology, All India Institute of Medical Sciences, New Delhi, India.

Background And Objectives: Ischemic stroke (IS) and coronary artery disease (CAD) share common risk factors and one may be the harbinger of the other. We aimed to study prevalence of symptomatic and asymptomatic CAD in a cohort of consecutive patients with IS and assess its relationship with intracranial and extracranial large artery cerebrovascular disease (LAD).

Methods: All consecutive eligible IS and Transient Ischemic Attack (TIA) patients were recruited into the study. Both clinically suspected and asymptomatic patients (N = 259) underwent myocardial Stress-rest Gated Technetium-99m (Tc99m) MIBI Myocardial Perfusion SPECT scan performed on a dual head SPECT-CT to estimate evidence of myocardial ischemia.

Results: Three hundred patients completed the study. Forty one patients were previously diagnosed cases of definitive CAD. Twelve patients were clinically suspected to have CAD and 247 patients were asymptomatic. Among these, 12 patients (4.81%) had a positive SPECT. The overall prevalence of CAD was 17.67% (n = 53). Presence of diabetes was an independent predictor of CAD (OR 1.98, 95% CI 1.07-3.67. P .02). No significant association was found between the presence of LAD and CAD in all subgroup comparisons. However, there was a suggestion of higher LAD among patients with known CAD compared with others.

Conclusions: CAD is prevalent in patients with ischemic stroke. No definitive relationship was found between CAD and intracranial or extracranial LAD. Population based stratification tools are needed to further assess the need to detect subclinical CAD in patients with stroke.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2019.104400DOI Listing
December 2019

CABG Improves Outcomes in Patients With Ischemic Cardiomyopathy: 10-Year Follow-Up of the STICH Trial.

JACC Heart Fail 2019 10 11;7(10):878-887. Epub 2019 Sep 11.

Duke Clinical Research Institute and Department of Biostatistics and Bioinformatics, Durham, North Carolina.

Objectives: The authors investigated the impact of coronary artery bypass grafting (CABG) on first and recurrent hospitalization in this population.

Background: In the STICH (Surgical Treatment for Ischemic Heart Failure) trial, CABG reduced all-cause death and hospitalization in patients with and ischemic cardiomyopathy and left ventricular ejection fraction <35%.

Methods: A total of 1,212 patients were randomized (610 to CABG + optimal medical therapy [CABG] and 602 to optimal medical therapy alone [MED] alone) and followed for a median of 9.8 years. All-cause and cause-specific hospitalizations were analyzed as time-to-first-event and as recurrent event analysis.

Results: Of the 1,212 patients, 757 died (62.4%) and 732 (60.4%) were hospitalized at least once, for a total of 2,549 total all-cause hospitalizations. Most hospitalizations (66.2%) were for cardiovascular causes, of which approximately one-half (907 or 52.9%) were for heart failure. More than 70% of all hospitalizations (1,817 or 71.3%) were recurrent events. The CABG group experienced fewer all-cause hospitalizations in the time-to-first-event (349 CABG vs. 383 MED, adjusted hazard ratio [HR]: 0.85; 95% confidence interval [CI]: 0.74 to 0.98; p = 0.03) and in recurrent event analyses (1,199 CABG vs. 1,350 MED, HR: 0.78, 95% CI: 0.65 to 0.94; p < 0.001). This was driven by fewer total cardiovascular (CV) hospitalizations (744 vs. 968; p < 0.001, adjusted HR: 0.66, 95% CI: 0.55 to 0.81; p = 0.001), the majority of which were due to HF (395 vs. 512; p < 0.001, adjusted HR: 0.68, 95% CI: 0.52-0.89; p = 0.005). We did not observe a difference in non-CV events.

Conclusions: CABG reduces all-cause, CV, and HF hospitalizations in time-to-first-event and recurrent event analyses. (Comparison of Surgical and Medical Treatment for Congestive Heart Failure and Coronary Artery Disease [STICH]; NCT00023595).
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jchf.2019.04.018DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7375257PMC
October 2019

Prevalence of sustained hypertension and obesity among urban and rural adolescents: a school-based, cross-sectional study in North India.

BMJ Open 2019 09 8;9(9):e027134. Epub 2019 Sep 8.

Centre for Chronic Conditions and Injuries, Public Health Foundation of India, Gurgaon, Haryana, India.

Objective: Recent data on sustained hypertension and obesity among school-going children and adolescents in India are limited. This study evaluates the prevalence of sustained hypertension and obesity and their risk factors among urban and rural adolescents in northern India.

Setting: A school-based, cross-sectional survey was conducted in the urban and rural areas of Ludhiana, Punjab, India using standardised measurement tools.

Participants: A total of 1959 participants aged 11-17 years (urban: 849; rural: 1110) were included in this school-based survey.

Primary And Secondary Outcome Measures: To measure sustained hypertension among school children, two distinct blood pressure (BP) measurements were recorded at an interval of 1 week. High BP was defined and classified into three groups as recommended by international guidelines: (1) normal BP: <90th percentile compared with age, sex and height percentile in each age group; (2) prehypertension: BP=90th-95th percentile; and (3) hypertension: BP >95th percentile. The Indian Academy of Pediatrics classification was used to define underweight, normal, overweight and obesity as per the body mass index (BMI) for specific age groups.

Results: The prevalence of sustained hypertension among rural and urban areas was 5.7% and 8.4%, respectively. The prevalence of obesity in rural and urban school children was 2.7% and 11.0%, respectively. The adjusted multiple regression model found that urban area (relative risk ratio (RRR): 1.7, 95% CI 1.01 to 2.93), hypertension (RRR: 7.4, 95% CI 4.21 to 13.16) and high socioeconomic status (RRR: 38.6, 95% CI 16.54 to 90.22) were significantly associated with an increased risk of obesity. However, self-reported regular physical activity had a protective effect on the risk of obesity among adolescents (RRR: 0.4, 95% CI 0.25 to 0.62). Adolescents who were overweight (RRR: 2.66, 95% CI 1.49 to 4.40) or obese (RRR: 7.21, 95% CI 4.09 to 12.70) and reported added salt intake in their diet (RRR: 4.90, 95% CI 2.83 to 8.48) were at higher risk of hypertension.

Conclusion: High prevalence of sustained hypertension and obesity was found among urban school children and adolescents in a northern state in India. Hypertension among adolescents was positively associated with overweight and obesity (high BMI). Prevention and early detection of childhood obesity and high BP should be strengthened to prevent the risk of cardiovascular diseases in adults.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1136/bmjopen-2018-027134DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6738741PMC
September 2019

Missing female patients: an observational analysis of sex ratio among outpatients in a referral tertiary care public hospital in India.

BMJ Open 2019 08 7;9(8):e026850. Epub 2019 Aug 7.

Pulmonary Medicine and Sleep Disorders, All India Institute of Medical Sciences, New Delhi, Delhi, India.

Objective: To investigate gender discrimination in access to healthcare and its relationship with the patient's age and distance from the healthcare facility.

Design And Setting: An observational study based on outpatient data from a large referral public hospital in Delhi, India.

Participants: Confirmed clinical appointments.

Primary And Secondary Outcome Measures: Estimates from the logistic regression are used to compute sex ratios (male/female) of patient visits with respect to distance from the hospital and age. Missing female patients for each state-a measure of the extent of gender discrimination-is computed as the difference in the actual number of female patients who came from each state and the number of female patients that should have visited the hospital had male and female patients come in the same proportion as the sex ratio of the overall population from the 2011 census.

Results: Of 2377028 outpatient visits, excluding obstetrics and gynaecology patients, the overall sex ratio was 1.69 male to one female visit. Sex ratios, adjusted for age and hospital department, increased with distance. The ratio was 1.41 for Delhi, where the facility is located; 1.70 for Haryana, an adjoining state; 1.98 for Uttar Pradesh, a state further away; and 2.37 for Bihar, the state furthest from Delhi. The sex ratios had a U-shaped relationship with age: 1.93 for 0-18 years, 2.01 for 19-30 years, and 1.75 for 60 years or over compared with 1.43 and 1.40 for the age groups 31-44 and 45-59 years, respectively. We estimate there were 402 722 missing female outpatient visits from these four states, which is 49% of the total female outpatient visits for these four states.

Conclusion: We found gender discrimination in access to healthcare, which was worse for female patients who were in the younger and older age groups, and for those who lived at increasing distances from the hospital.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1136/bmjopen-2018-026850DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6687005PMC
August 2019

Complete Heart Block.

Circulation 2019 08 5;140(6):516-519. Epub 2019 Aug 5.

Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1161/CIRCULATIONAHA.119.042001DOI Listing
August 2019

Incidence and predictors of pacemaker-induced cardiomyopathy with comparison between apical and non-apical right ventricular pacing sites.

J Interv Card Electrophysiol 2019 Oct 30;56(1):63-70. Epub 2019 Jul 30.

Department of Cardiology, All India Institute of Medical Sciences, 7th Floor, Cardiothoracic Sciences Centre, New Delhi, 110029, India.

Background: Asynchronous activation of left ventricle (LV) due to chronic right ventricular (RV) pacing has been known to predispose to LV dysfunction. The predictors of LV dysfunction remain to be prospectively studied. This study was designed to follow up patients with RV pacing to look for development of pacing-induced cardiomyopathy (PiCMP), identify its predictors and draw comparison between apical vs non-apical RV pacing sites.

Methods: Three hundred sixty-three patients undergoing dual-chamber and single-chamber ventricular implants were enrolled and followed up. Baseline clinical parameters; paced QRS duration and axis; RV lead position by fluoroscopy; LV ejection fraction (LVEF) by Simpson's method on transthoracic echocardiography (TTE); intraventricular dyssynchrony (septal-posterior wall contraction delay) and interventricular dyssynchrony (aortopulmonary ejection delay) on TTE were recorded. The patients were followed up at 6-12 monthly interval with estimation of LVEF and pacemaker interrogation at each visit. Pacemaker-induced cardiomyopathy (PiCMP) was defined as a fall in ejection fraction of 10% as compared to the baseline LVEF. Patients developing PiCMP were compared to other patients to identify predictors.

Results: The mean age of study population was 59.8 years, 68.3% being males. Fifty-one percent and 49% patients underwent VVIR and DDDR pacemaker implantation, respectively. After attrition, 254 patients were analysed. PiCMP developed in 35 patients (13.8%) over a mean follow-up of 14.5 months. After multivariate analysis, burden of ventricular pacing > 60% [HR 4.26, p = 0.004] and interventricular dyssynchrony (aortopulmonary ejection delay > 40 msec) [HR 3.15, p = 0.002] were identified as predictors for PiCMP in patients undergoing chronic RV pacing. There was no effect of RV pacing site (apical vs non-apical) on incidence of PiCMP [HR 1.44, p = 0.353).

Conclusions: Incidence of PiCMP with RV pacing was found to be 13.8% over a mean follow-up of 14.5 months. Burden of right ventricular pacing and interventricular dyssynchrony were identified as the most important predictors for the development of PiCMP. Non-apical RV pacing site did not offer any benefit in terms of incidence of PiCMP over apical lead position.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s10840-019-00602-2DOI Listing
October 2019

Strategies for Stakeholder Engagement and Uptake of New Intervention: Experience From State-Wide Implementation of mHealth Technology for NCD Care in Tripura, India.

Glob Heart 2019 06;14(2):165-172

Department of Endocrinology & Metabolism, All India Institute of Medical Sciences, New Delhi, India. Electronic address:

Background: Appropriate strategies and key stakeholder engagement are the keys to successful implementation of new health care interventions.

Objectives: The study sought to articulate the key strategies used for scaling up a research-based intervention, mPower Heart electronic Clinical Decision Support System (e-CDSS), for state-wide implementation at health facilities in Tripura.

Methods: Multiple strategies were used for statewide implementation of mPower Heart e-CDSS at noncommunicable diseases clinics across the government health facilities in Tripura: formation of a technical coordination-cum-support unit, change management, enabling environment, adapting the intervention with user focus, and strengthening the Health Information System.

Results: The effective delivery of a new health system intervention requires engagement at multiple levels including political leadership, health administrators, and health professionals, which can be achieved by forming a technical coordination-cum-support unit. It is important to specify the role and responsibilities of existing manpower and provide a structured training program. Enabling environment at health facilities (providing essential equipment, space and time, etc.) is also crucial. Successful implementation also requires that patients, health care providers, the health system, and leadership recognize the immediate and long-term benefits of the new intervention and have a buy-in in the intervention. With constant encouragement and nudge from administrative authorities and by using multiple strategies, 40 government health facilities adopted the mPower Heart e-CDSS. From its launch in May 2017 until November 20, 2018, a total of 100,810 eligible individuals were screened and enrolled, with 35,884 treated for hypertension, 9,698 for diabetes, and 5,527 for both hypertension and diabetes.

Conclusions: Multiple strategies, based on implementation principles, are required for successful scaling up of research-based interventions.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.gheart.2019.06.002DOI Listing
June 2019
-->