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Aim Studies on the changes in the presentation and management of acute myocardial infarction (AMI) during the COVID-19 pandemic from low- and middle-income countries are limited. We sought to determine the changes in the number of admissions, management practices, and outcomes of AMI during the pandemic period in India. Methods & Results In this two-timepoint cross-sectional study involving 187 hospitals across India, patients admitted with AMI between 15th March to 15th June in 2020 were compared with those admitted during the corresponding period of 2019. We included 41,832 consecutive adults with AMI. Admissions during the pandemic period (n = 16414) decreased by 35·4% as compared to the corresponding period in 2019 (n = 25418). We observed significant heterogeneity in this decline across India. The weekly average decrease in AMI admissions in 2020 correlated negatively with the number of COVID cases (r = −0·48; r 2 = 0·2), but strongly correlated with the stringency of lockdown index (r = 0·95; r 2 = 0·90). On a multi-level logistic regression, admissions were lower in 2020 with older age categories, tier 1 cities, and centers with high patient volume. Adjusted utilization rate of coronary angiography, and percutaneous coronary intervention decreased by 11·3%, and 5·9% respectively. Conclusions The magnitude of reduction in AMI admissions across India was not uniform. The nature, time course, and the patient demographics were different compared to reports from other countries, suggesting a significant impact due to the lockdown. These findings have important implications in managing AMI during the pandemic.

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Cardiovascular abnormality is the most consistent finding and occur in almost 80 % of all Williams syndrome (WS). Although a number of cardiovascular defects are common to WS, the majority presents in some form of arterial stenosis whereas supravalvular aortic stenosis is the most common one. Here we describe a 12 year old boy with elfin facies, presenting with urinary incontinence and a systolic murmur in right upper parasternal region. Echocardiography showed presence of double chambered right ventricle (DCRV) along with supravalvular aortic stenosis (SVAS) and coronary artery aneurysms, left pulmonary artery stenosis and multiple bladder diverticula in CT abdomen. With the clinical suspicion the diagnosis of WS was made and confirmed by fluorescent in situ hybridisation (FISH) study showing deletion in 7q11.23. Though different forms of arterial stenosis at multiple sites have been demonstrated in WS, DCRV in Williams syndrome is not reported till date in medical literature.

Symmetrical peripheral gangrene is an ischemic necrosis simultaneously involving the distal portions of two or more extremities without any proximal arterial obstruction or vasculitis. It may occur as a result of a large number of infectious and non-infectious causes. A few cases of symmetrical peripheral gangrene associated with cardiac disease have been described in the literature. We describe a case of symmetrical peripheral gangrene complicating ventricular pseudoaneurysm, probably a hitherto unreported occurrence. In this report, we sought to emphasize the importance of cardiac evaluation while dealing with a case of symmetrical peripheral gangrene.

Background COVID-19 pandemic has affected around 20million patients worldwide and 2.0 million cases from India. The lockdown was employed to delay the pandemic. However, it had an unintentional impact on acute cardiovascular care, especially acute myocardial infarction (AMI). Observational studies have shown a decrease in hospital admissions for AMI in several developed countries during the pandemic period. We aimed to evaluate the impact of COVID-19 on the AMI admissions patterns across India. Methods In this multicentric, retrospective, cross-sectional study, we included all AMI cases admitted to participating hospitals during the study period 15th March to 15th June 2020 and compared them using a historical control of all cases of AMI admitted during the corresponding period in the year 2019. Major objective of the study is to analyze the changes inthe number of hospital admissions for AMI in hospitals across India. In addition, we intend to evaluate the impact of COVID-19 on the weekly AMI admission rates, and other performance measures like rates of thrombolysis/primary percutaneous interventions (PCI), window period, door to balloon time, and door to needle time. Other objectives include evaluation of changes in the major complications and mortality rates of AMI and its predictors during COVID-19 pandemic. Conclusions This CSI-AMI study will provide scientific evidence about the impact of COVID-19 on AMI care in India. Based on this study, we may be able to suggest appropriate changes to the existing MI guidelines and to educate the public regarding emergency care for AMI during COVID-19 pandemic.

Funding Acknowledgements Type of funding sources: None. Background Hypertension (HTN) has been found to increase the risk of Covid-19 mortality when compared with normotensives, and those discontinuing the antihypertensive treatment have an additional fatality risk. Objective The survey was carried out to seek the opinion of Indian healthcare practitioners (HCPs) on the risk factors, challenges and management of HTN during the ongoing Covid-19 pandemic. Method This was a structured web-based objective questionnaire survey involving 2545 HCPs PAN-India. The survey comprised questions related to the risk factors for HTN, home blood pressure monitoring (HBPM), BP control, treatment, complications and challenges of uncontrolled HTN during Covid-19. Results This study showed that tobacco use, obesity and comorbidities are top three modifiable risk factors for HTN followed by emotional stress, during Covid-19 pandemic. A majority of HCPs (44%) reported that <30% of their hypertensive patients check BP at home while 36% and 20% reported that 30-50% and >50% of their patients respectively, practice HBPM. 20%, 63%, and 17% of HCPs respectively, reported that <20%, 20-40% and >40% of their patients presented with BP > 150/100 mmHg during lockdown. Of all the HCPs, 53% and 33% respectively, reported BP increase in <20% and 20-40% of their patients on monotherapy while 14% of HCPs reported BP increase in >40% of their patients on monotherapy during the lockdown. As compared to high dose monotherapy, dual and triple combination therapies (TDC) were selected as most preferred for the management of uncontrolled BP opted by 56% and 34% of the HCPs, respectively. The dual combination antihypertensives were ranked as angiotensin receptor blockers (ARB) + diuretic (DU) > ARB + calcium channel blockers (CCB) > ARB + beta-blocker. The TDC with ARB + CCB + DU was the most favored TDC antihypertensive therapy during Covid-19 era. Acute coronary syndrome was anticipated as the most common complication of HTN in the Covid-19 pandemic, followed by renal dysfunction, cerebral ischemia and cerebral hemorrhage reported by 47%, 17%, 14% and 14% of HCPs, respectively. Multiple challenges in HTN care during Covid-19 as opined by HCPs included BP measurement while avoiding the risk of infection (57%), advising treatment via teleconsultation (48%), dose modification (41%), patient compliance (32%) and transport-related issues (30%). Most of the HCPs believed that self-monitoring of BP (32%) and economical medicines (24%) can improve medication adherence in patients with HTN. Conclusion The study underlined that the provision of economic medicines, single pill combinations, doctor-patient digital connect, and patient education can help in improving medication adherence leading to better outcomes in patients with HTN during Covid-19.  The study also suggested the need to enhance HBPM and the use of ARB-based dual and triple combination therapies to improve BP control in patients uncontrolled on monotherapy during Covid-19 pandemic.