Aims Limited data on the uptake of guideline-directed medical therapies (GDMTs) and the mortality of acute decompensated HF (ADHF) patients are available from India. The National Heart Failure Registry (NHFR) aimed to assess clinical presentation, practice patterns, and the mortality of ADHF patients in India. Methods and resultsThe NHFR is a facility-based, multi-centre clinical registry of consecutive ADHF patients with prospective follow-up. Fifty three tertiary care hospitals in 21 states in India participated in the NHFR. All consecutive ADHF patients who satisfied the European Society of Cardiology criteria were enrolled in the registry. All-cause mortality at 90 days was the main outcome measure. In total, 10 851 consecutive patients were recruited (mean age: 59.9 years, 31% women). Ischaemic heart disease was the predominant aetiology for HF (72%), followed by dilated cardiomyopathy (18%). Isolated right HF was noted in 62 (0.6%) participants. In eligible HF patients, 47.5% received GDMT. The 90 day mortality was 14.2% (14.9% and 13.9% in women and men, respectively) with a re-admission rate of 8.4%. An inverse relationship between educational class based on years of education and 90 day mortality (high mortality in the lowest educational class) was observed in the study population. Patients with HF with reduced ejection fraction and HF with mildly reduced ejection fraction who did not receive GDMT experienced higher mortality (log-rank P < 0.001) than those who received GDMT. Baseline educational class, body mass index, New York Heart Association functional class, ejection fraction, dependent oedema, serum creatinine, QRS > 120 ms, atrial fibrillation, mitral regurgitation, haemoglobin levels, serum sodium, and GDMT independently predicted 90 day mortality. Conclusion One of seven ADHF patients in the NHFR died during the first 90 days of follow-up. One of two patients received GDMT. Adherence to GDMT improved survival in HF patients with reduced and mildly reduced ejection fractions. Our findings call for innovative quality improvement initiatives to improve the uptake of GDMT among HF patients in India.
Objective: To evaluate how well patients with non-valvar atrial fibrillation (NVAF) were maintained within the recommended international normalised ratio (INR) target of 2.0-3.0 and to explore the relation between achieved INR control and clinical outcomes. Design: Record linkage study of routine activity records and INR measurements. Setting: Cardiff and the Vale of Glamorgan, South Wales, UK. Participants: 2223 patients with NVAF, no history of heart valve replacement, and with at least five INR measurements. Main outcome measures: Mortality, ischaemic stroke, all thromboembolic events, bleeding events, hospitalisation, and patterns of INR monitoring. Results: Patients treated with warfarin were outside the INR target range 32.1% of the time, with 15.4% INR values . 3.0 and 16.7% INR values , 2.0. However, the quartile with worst control spent 71.6% of their time out of target range compared with only 16.3% out of range in the best controlled quartile. The median period between INR tests was 16 days. Time spent outside the target range decreased as the duration of INR monitoring increased, from 52% in the first three months of monitoring to 30% after two years. A multivariate logistic regression model showed that a 10% increase in time out of range was associated with an increased risk of mortality (odds ratio (OR) 1.29, p , 0.001) and of an ischaemic stroke (OR 1.10, p = 0.006) and other thromboembolic events (OR 1.12, p , 0.001). The rate of hospitalisation was higher when INR was outside the target range. Conclusions: Suboptimal anticoagulation was associated with poor clinical outcomes, even in a well controlled population. However, good control was difficult to achieve and maintain. New measures are needed to improve maintenance anticoagulation in patients with NVAF. I t has been estimated that 470 000 patients received oral anticoagulation in 2001 in the UK.1 This number is likely to increase as the number of people in the elderly population increases.2 Furthermore, there are plans to identify all patients with atrial fibrillation (AF) through primary care screening as part of a national stroke prevention strategy implemented in 2004. 3 Long term anticoagulation treatment of patients with non-valvar atrial fibrillation (NVAF) can reduce the annual risk of stroke by two thirds.4 5 Such treatment compares favourably with the alternative, aspirin treatment. 6 However, the pharmacokinetic profile of warfarin is complex, 7 and monitoring is required to avoid both thromboembolic events associated with low intensity anticoagulation and haemorrhagic complications associated with higher intensity. Target levels of oral anticoagulation are disease specific and measured with the international normalised ratio (INR). In the case of NVAF, the range is 2.0-3.0. To attain INR values within this range, patients are routinely monitored and their doses are adjusted when necessary. In practice, it is recognised that long term stability is difficult to achieve because of unexpected fluctuations of the INR values in pat...
Tropical endomyocardial fibrosis (EMF) is endemic in southern districts of Kerala state in India, and sporadic cases are reported from other parts of Kerala. Transthoracic echocardiogram (TTE) is the initial imaging tool and is diagnostic for this condition. The inherent limitation of TTE is its limited sensitivity in the detection of intracardiac thrombus. Transthoracic echocardiography, contrast-enhanced cardiac computed tomography, and cardiac magnetic resonance imaging (CMR) are the imaging modalities for the detection of intracardiac thrombus. This report describes a 46-year-old male with right ventricular EMF (RVEMF) who presented with right heart failure. The TTE diagnosed RVEMF but failed to demonstrate the right atrial thrombus which was clearly seen on CMR. The merits of different imaging modalities for the detection of intracardiac thrombus are discussed.
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