SGLT-2 inhibitors are a novel class of anti-diabetic agents which act by inhibiting glucose reabsorption in proximal convoluted tubules of kidney. Apart from maintaining glucose homeostasis they exert a number of positive effects on the cardiovascular system like weight loss, decreasing blood pressure, preserving renal function, reducing triglycerides, natriuresis and improving endothelial dysfunction. In large clinical trials, all the three prototype agents – Empaglifozin, Canaglifozin and dapaglifozin have shown reductions in major adverse cardiovascular events including cardiovascular deaths, non fatal MI, stroke and heart failure (HF) hospitalizations. The reduction in heart failure hospitalization is a surprising finding and trials of these drug are now underway for HF also. More surprising is the fact that the benefits are comparable or even better that achieved by recently approved novel drugs for HF. In this review, we briefly discuss the pathophysiology of HF in diabetes, describe the prototype SGLT-2 molecules available, their data from large cardiovascular outcome trials till date and their role in current practice of diabetes management.
A BSTRACT Conventionally, rennin–angiotensin–aldosterone system (RAAS) inhibition has focused on angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers and angiotensin receptor-neprilysin inhibitors (ARNI) are the latest addition to this armamentarium. However, mineralocorticoid receptor antagonists (MRAs) also constitute an integral part of this anti-RAAS brigade, which are perceived more often as diuretics and are often under prescribed in heart failure (HF) despite being universally advocated by all major guidelines. Apart from HF, they have also shown promise in the management of hypertension, post-myocardial infarction, and hyperaldosteronism. Eplerenone, Food and Drug Administration (FDA) approved in 2002, is an acceptable alternative to spironolactone due to its sparing androgenic effects. In two big pivotal trials in heart failure (EMPHASIS -HF) and post-myocardial infarction (EPHESUS), the drug has firmly shown a reduction in adverse cardiovascular events. It has an established place in the management of resistant hypertension too. In this article, we will discuss the role of RAAS and its pathophysiology, pitfalls of spironolactone, which led to success of its congener, eplerenone, major studies conducted on eplerenone, current role of eplerenone, and comparison of the two MRAs.
Rampantly spreading around the globe and taking thousands of lives each day, coronavirus disease 2019 (COVID-19) may present with varied cardiovascular manifestations. Those with evidence of myocardial injury have a worse prognosis too. Patients with preexisting cardiovascular diseases or risk factors are at greater risk of adverse outcomes and mortality by this infection. Being highly contagious, measures to prevent cross-infection are of paramount importance. In this article, the authors summarize the various cardiovascular manifestations of COVID-19 and precautions needed while handling them and the long-term consequences of COVID-19 infection.
A 30‐year‐old woman presented with low‐grade dyspnea on exertion. Chest X‐ray demonstrated enlarged cardiac silhouette but was insufficient to delineate the cause. Echocardiogram revealed the cause to be the giant left atrium from mitral stenosis.
Hypertension, the commonest noncommunicable disease globally, is an important risk factor for cardiovascular disease and renal failure. Theoretically, while it is easy to diagnose and manage by simple measures, practically it has been observed that not only treatment but also diagnosis and its preventive measures are inadequate in developing as well as developed nations. Several guidelines by various international organizations are available to guide clinicians for hypertension management. Though the basic principles of hypertension management are similar in all the guidelines, subtle differences are there. In this article, we compare the two most widely accepted guidelines for hypertension, that is, American College of Cardiology/American Heart Association 2017 Hypertension Guidelines and 2018 European Society of Cardiology and European Society of Hypertension Guidelines on Hypertension. Both the differences and similarities between these two widely followed guidelines are presented.
SummaryWe report a rare case of primary hyperparathyroidism in a young female who presented with recurrent diabetic ketoacidosis. The patient had suffered an episode of acute pancreatitis in the past. On evaluation patient was found to have primary hyperparathyroidism and after removal of left inferior parathyroid adenoma her insulin requirement decreased by twelve units.KEY WORDS: primary hyperparathyroidism; acute pancreatitis; diabetic ketoacidosis. Case report19-years-old female presented to accident and emergency department with complaints of abdominal pain and vomiting from last one day. Her previous medical records revealed that patient suffered from similar episode of pain abdomen and vomiting in 2014 and serum amylase (603IU/ml, N 39 -117 U/L) and contrast enhanced computed tomography (CECT) of abdomen was suggestive of acute pancreatitis at that point of time. On the 4 th day during recovery, patient suffered from an episode of diabetic ketoacidosis (DKA) for which she was managed with intravenous insulin therapy and subsequently was discharged on premix insulin therapy. Patient remained all right until June 2015 when developed second episode of pain abdomen and vomiting and was found to have diabetes ketoacidosis, which occurred because patient missed 2 doses of insulin. Again, treatment for DKA was given and was discharged on twice a day premix subcutaneous insulin therapy. Now this was her third episode of admission with pain abdomen and vomiting. Patient is non-alcoholic, was not having gallstones in the past and there was no family history of diabetes. On examination, she was dehydrated with pulse rate of 120/min and blood pressure of 110/70. Systemic examination including cardiovascular, neurological, respiratory and gastrointestinal system were normal. On evaluation, patient was again found to be in DKA with a plasma glucose of 500 mg/dl, strongly positive urine ketones and arterial blood gas analysis with serum electrolyte suggestive of high anion gap metabolic acidosis and she was shifted to the department of endocrinology for management. In the next 24 hours, she improved with fluids and intravenous insulin therapy. Serum lipase level, renal function and liver function test were normal. Serum calcium was 12.30 mg/dl (N: 8.5-10.5 mg/dl), serum phosphate was 2.8 mg/dl (N: 3.5-5.5mg/dl) and serum alkaline phosphatase level was 1832units/l (N: 39-117 U/L). In view of hypercalcemia and hypophosphatemia detected incidentally on biochemical reports, the past medical records of patient was reviewed and it was found that during the previous episode of pancreatitis serum calcium was 10.4mg/dl that is contradictory to expected hypocalcaemia usually observed during acute pancreatitis. However, she never underwent any further investigation for this observation during any of her past admissions. In view of recurrent DKA, history of acute pancreatitis and hypercalcemia with hypophosphatemia, a presumptive diagnosis of hyperparathyroidism was made and blood sample for serum 25(OH) vitamin D and serum parathy...
Eisenmenger syndrome (ES) is defined as the process in which a long-standing left-to-right cardiac shunt caused by a congenital heart defect is eventually reversed into a cyanotic right-to-left shunt. It is crucial to recognize this grave pathology at the earliest because once it develops, treatment by medical or surgical means becomes even more challenging. In past decades, various therapeutic options have been developed that address the specific pathophysiological aspects of the disease and have shown to improve functional capacity and quality of life. There are three major therapeutic pathways in pulmonary hypertension treatment - endothelin receptor antagonists, phosphodiesterase type-5 inhibitors, and prostacyclin derivatives. These therapies not only improve hemodynamic parameters and exercise capacity but they also improve prognosis with various form of Pulmonary hypertension including ES. We report a case of a 35-year-old female of ostium secundum atrial septal defect with ES, started on upfront combination therapy of ambrisentan and tadalafil who demonstrated marked improvement after 3 months of medical therapy.
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