BACKGROUND Among patients with stable coronary disease and moderate or severe ischemia, whether clinical outcomes are better in those who receive an invasive intervention plus medical therapy than in those who receive medical therapy alone is uncertain. METHODS We randomly assigned 5179 patients with moderate or severe ischemia to an initial invasive strategy (angiography and revascularization when feasible) and medical therapy or to an initial conservative strategy of medical therapy alone and angiography if medical therapy failed. The primary outcome was a composite of death from cardiovascular causes, myocardial infarction, or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest. A key secondary outcome was death from cardiovascular causes or myocardial infarction. RESULTS Over a median of 3.2 years, 318 primary outcome events occurred in the invasivestrategy group and 352 occurred in the conservative-strategy group. At 6 months, the cumulative event rate was 5.3% in the invasive-strategy group and 3.4% in the conservative-strategy group (difference, 1.9 percentage points; 95% confidence interval [CI], 0.8 to 3.0); at 5 years, the cumulative event rate was 16.4% and 18.2%, respectively (difference, −1.8 percentage points; 95% CI, −4.7 to 1.0). Results were similar with respect to the key secondary outcome. The incidence of the primary outcome was sensitive to the definition of myocardial infarction; a secondary analysis yielded more procedural myocardial infarctions of uncertain clinical importance. There were 145 deaths in the invasive-strategy group and 144 deaths in the conservative-strategy group (hazard ratio, 1.05; 95% CI, 0.83 to 1.32). CONCLUSIONS Among patients with stable coronary disease and moderate or severe ischemia, we did not find evidence that an initial invasive strategy, as compared with an initial conservative strategy, reduced the risk of ischemic cardiovascular events or death from any cause over a median of 3.2 years. The trial findings were sensitive to the definition of myocardial infarction that was used.

Heart failure (HF) is a major cause of morbidity and mortality in high income countries. Shortage of population based HF studies from Low and Middle Income countries (LMIC) make global prevalence estimates difficult. In this editorial we discuss the possibility of generating HF data in LMICs by initiating HF surveillance systems integrated into the existing health surveillance system..

Background Coronavirus disease 2019 personal protective equipment has been reported to affect communication in healthcare settings. This study sought to identify those challenges experimentally. Method Bamford–Kowal–Bench speech discrimination in noise performance of healthcare workers was tested under simulated background noise conditions from a variety of hospital environments. Candidates were assessed for ability to interpret speech with and without personal protective equipment, with both normal speech and raised voice. Results There was a significant difference in speech discrimination scores between normal and personal protective equipment wearing subjects in operating theatre simulated background noise levels (70 dB). Conclusion Wearing personal protective equipment can impact communication in healthcare environments. Efforts should be made to remind staff about this burden and to seek alternative communication paradigms, particularly in operating theatre environments.

BackgroundThere are no recent data on prevalence of coronary artery disease (CAD) in Indians. The last community based study from Kerala, the most advanced Indian state in epidemiological transition, was in 1993 that reported 1.4 % definite CAD prevalence. We studied the prevalence of CAD and its risk factors among adults in Kerala.MethodsIn a community-based cross sectional study, we selected 5167 adults (mean age 51 years, men 40.1 %) using a multistage cluster sampling method. Information on socio-demographics, smoking, alcohol use, physical activity, dietary habits and personal history of hypertension, diabetes, and CAD was collected using a structured interview schedule. Anthropometry, blood pressure, electrocardiogram, and biochemical investigations were done using standard protocols. CAD and its risk factors were defined using standard criteria. Comparisons of age adjusted prevalence were done using two tailed proportion tests.ResultsThe overall age-adjusted prevalence of definite CAD was 3.5 %: men 4.8 %, women 2.6 % (p < 0.001). Prevalence of any CAD was 12.5 %: men 9.8 %, women 14.3 % (p < 0.001). There was no difference in definite CAD between urban and rural population. Physical inactivity was reported by 17.5 and 18 % reported family history of CAD. Other CAD risk factors detected in the study were: overweight or obese 59 %, abdominal obesity 57 %, hypertension 28 %, diabetes 15 %, high total cholesterol 52 % and low level of high density lipoprotein cholesterol 39 %. Current smoking was reported only be men (28 %).ConclusionThe prevalence of definite CAD in Kerala increased nearly three times since 1993 without any difference in urban and rural areas. Most risk factors of CAD were highly prevalent in the state. Both population and individual level approaches are warranted to address the high level of CAD risk factors to reduce the increasing prevalence of CAD in this population.

Coronary heart disease (CHD) is a major cause of mortality and morbidity all over the world. According to a report of World Health Organization (WHO) in 2005, cardiovascular disease (CVD) caused 17.5 million (30%) of the 58 million deaths that occurred worldwide. 1 While the prevalence and mortality due to CHD is declining in the developed nations 2 the same cannot be held true for developing countries. There has been an alarming increase over the past two decades in the prevalence of CHD and cardiovascular mortality in India and other south Asian countries. India is going through an epidemiologic transition whereby the burden of communicable diseases have declined slowly, but that of non-communicable diseases (NCD) has risen rapidly, thus leading to a dual burden. There has been a 4-fold rise of CHD prevalence in India during the past 40 years. Current estimates from epidemiologic studies from various parts of the country indicate a prevalence of CHD to be between 7% and 13% in urban 3e5 and 2% and 7% in rural 6,7 populations. Epidemiologic studies have shown that there are at present over 30 million cases of CHD in this country. A study by Gajalakshmi et al during 1995e1997 showed that CVD deaths are the highest (38.6%) in urban Chennai. 8 Similar data are published by Joshi et al from Andhra Pradesh. 9 The Global Burden of Diseases Study reported that the disabilityadjusted life years lost by CHD in India during 1990 was 5.6 million in men and 4.5 million in women; the projected figures for 2020 were 14.4 million and 7.7 million in men and women respectively. 10 The burgeoning burden of CHD in India can be explained by the alarming rise in the prevalence of coronary risk factors like diabetes, hypertension, atherogenic dyslipidemia, smoking, central obesity and physical inactivity. Rapid urbanization and change in lifestyle that occurred during the past two decades have led to the growing burden of coronary risk factors in India. Previous studies conducted in migrant Indians were misinterpreted to indicate that conventional risk factors do not account for the high prevalence and premature occurrence of CHD among Indians 11 ; they were thought to be genetically preordained to develop the disease. However, the large INTERHEART study which recruited significant number of Indian subjects found that the conventional risk factors accounted for most of the CHD burden. 12 The INTERHEART study was a large cross-sectional study of around 30,000 participants from 52 countries representing every inhabited continent. The specific aim was to assess the strength of association between various risk factors to myocardial infarction and to ascertain if this varies with geographic regions, age, sex or ethnicity. The secondary objective was to estimate the Population Attributable Risk (PAR) for risk factors and their combinations in the overall population and in various subgroups. The relation of smoking, history of hypertension or diabetes, waist/hip ratio, dietary patterns, physical activity, consumption of alcohol, blood apoli...