Clinical and Preventive Cardiology

EDITOR'S PAGE
	Editor's page january 2019	p. 1
	Ravi R Kasliwal DOI:10.4103/2250-3528.252009
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ORIGINAL ARTICLES
	Clinical characteristics of peripartum cardiomyopathy patients admitted in tertiary hospital	p. 2
	Jishu Deb Nath, Anannya Das, Rajat Sanker Roy Biswas DOI:10.4103/JCPC.JCPC_21_18   Background: Peripartum cardiomyopathy (PPCM) is a potentially life-threatening condition marked by left ventricular (LV) dysfunction and heart failure. The disease incidence is rising and most of the cases are identified now due to availability of widespread echocardiography and possible suspicion by cardiologist. Materials and Methods: This was hospital-based study conducted in the department of medicine of a tertiary hospital, Bangladesh. The study population consisted of postpartum patients admitted to medicine ward for evaluating dyspnea from January 2012 to January 2017. Totally 31 patients were diagnosed as PPCM and taken as a sample after exclusion of all criteria. Results: Most of the patients belonged to 20–24 years of age group (51.6%, n = 16) and most patients developed PPCM in primigravida (51.6%). About 67.7% admitted from rural area and 32.3% from urban area. Exertional breathlessness (45.1%, n = 14) and orthopnea (32.2%, n = 10) are the predominant symptoms in all age groups, while exertional breathlessness was 50% presentations from early age group and 14.3% from elder group, while orthopnea was Observed 70% from early age group. Nearly 9.3% of participants in the study had twin pregnancy. Association of gestational hypertension and diabetes mellitus was found in this study group as 12.9%, n = 4, and 16.1%, n = 5. Majority of the patients (35.5%, n = 11) had no specific electrocardiography changes; sinus tachycardia and ST-T changes were found equally (22.5%, n = 7). About one-third of the patients (29%, n = 9) were found to have severe LV systolic dysfunction (ejection fraction [EF] <30%) and more than half of the patients had moderate LV systolic dysfunction (EF: 31%–40%). Conclusion: As PPCM is rising worldwide, so proper suspicion, early referral, early intervention, and prevention can overcome the misdiagnosis of PPCM which often leads to clinical deterioration and in some instances death.
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	Clinical and angiographic profile of young patients with ischemic heart disease: A central India study	p. 6
	Sunita Dinkar Kumbhalkar, Vikas V Bisne DOI:10.4103/JCPC.JCPC_22_18   Objective: The present study was undertaken in young patients of ischemic heart disease (IHD) to assess clinical, biochemical and angiographic profile, conventional and newer risk factors, and correlation of risk factors with significant and nonsignificant coronary artery disease (CAD). Materials and Methods: This was a hospital-based cross-sectional study conducted in 70 cases of young IHD (male ≤35 years and females ≤40 years). Patients were evaluated for clinical, biochemical and angiographic profiles, and conventional risk factors such as dyslipidemia, hypertension (HT), diabetes mellitus (DM), and family history of premature CAD (PCAD). Newer risk factors such as lipoprotein (a) (Lp [a]), homocysteine, and plasma fibrinogen were also assessed in some (n = 44) cases. Results: Mean age of patients was 32.97 ± 3.93 years; 11 (15.7%) were women. Various risk factors such as tobacco/gutka chewing, HT, smoking, DM, and family history of PCAD were observed in 35.7%, 22.8%, 17.1%, 11.5%, and 8.6% of patients, respectively. Nearly 77.6% of patients presented with anterior wall myocardial infarction and 61.4% were having moderate left ventricular dysfunction on echocardiography. Total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), triglycerides (TGs), and TC/high-density lipoprotein cholesterol (TC/HDL-C) were increased in 38.6%, 41.4%, 32.9%, and 25.7% patients, respectively. Newer risk factors such as Lp (a), homocysteine, and plasma fibrinogen were elevated in 61.4%, 77.3%, and 18.2% of patients, respectively. On coronary angiography, single-vessel disease was found in more than half of the patients (57.1%) followed by double-vessel disease (11.5%) and triple-vessel disease (7.1%). Coronary angiogram was normal in 24.3% of patients. Positive family history of PCAD, serum TGs, TC/HDL-C, and LDL-C/HDL-C were significantly (P < 0.05) associated with significant CAD as compared to nonsignificant CAD, whereas no such correlation was found in relation to newer risk factors. Conclusion: Indian males in South Asian population appear more prone to develop CAD; therefore, screening for risk factors should start at an earlier age. Smoking and tobacco chewing cessation, promotion of physical activities, and healthy dietary pattern have to be strongly encouraged in this vulnerable group.
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	Levels of physical inactivity in rural and urban Tamil Nadu, India: A cross-sectional study	p. 13
	Carol Susan Devamani, Anu Mary Oommen, GK Mini, Vinod Joseph Abraham, Kuryan George DOI:10.4103/JCPC.JCPC_32_18   Background and Objectives: Physical inactivity is an important cardiovascular risk factor. This study assessed the prevalence and factors associated with insufficient physical activity (PA) in urban and rural Vellore, Tamil Nadu, India, among adults aged 30–64 years. Methodology: A cross-sectional World Health Organization STEPS survey was carried out in 48 wards of Vellore Municipality and nine rural villages of Tamil Nadu in 2010–2012. Adults (n = 6164, men 43.9%) aged 30–64 years were interviewed using the Global PA Questionnaire (2390 urban and 3774 rural). Insufficient PA was defined as not meeting the recommendation of 150 min of moderate aerobic PA, or 75 min of vigorous aerobic PA, or an equivalent combination, achieving at least 600 metabolic equivalent-minutes per day. Results: The prevalence of insufficient PA was 63.3% (95% confidence interval [CI]: 61.3%–65.3%) in the urban area and 40.6% (95% CI: 39.0%–42.2%) in the rural area. Women had a higher prevalence of insufficient PA compared to men, in both urban (70.8% vs. 53.8%) and rural (44.5% vs. 35.6%) areas. Those with higher education (odds ratio [OR]: 1.36, 95% CI: 1.20–1.53) and who were unemployed (OR: 2.97, 95% CI: 2.59–3.39) reported insufficient PA which was significantly higher than their counterparts. While urban participants had higher leisure time PA, rural participants had higher work- and travel-related PA. Conclusions: The high prevalence of insufficient PA found in this study shows that targeted interventions are needed to reduce insufficient PA, especially for women and urban populations.
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	Distribution of conventional lipids in Indians with premature coronary artery disease: A substudy of the premature coronary artery disease registry	p. 18
	Rahul S Patil, TR Raghu, CN Manjunath, Santu Ghosh, Laxmi H Shetty DOI:10.4103/JCPC.JCPC_33_18   Context: Conventional lipids in young Indians with Coronary Artery Disease. Aims: To study distribution of conventional lipids and their quantification in demographic subgroups of Indians with Premature Coronary Artery Disease (PCAD). Settings and Design: PCAD Registry is a Prospective Multisite Descriptive Observational study of Indians aged below 40 years with Coronary Artery Disease. This Lipid sub study is based on preliminary data of first year of the PCAD registry. Methods and Material: Of 1380 patients registered in PCAD registry, 1061 satisfied entry criteria. Conventional lipids were estimated using commercially available kits. Each of risk factor subgroups were compared by statistical analysis of lipid values. Statistical significance was derived by independent t-test or one-way ANOVA wherever appropriate. The distribution of different lipid profile parameters was visualised by nonparametric density plot. The data was analysed by statistical software R version 3.5.0. Results: A total of 1380 patients were registered. of which 1061 patients satisfied the entry criteria and were enrolled for the lipid analysis study. The mean age of all patients registered was 34.27 (±4.30) years. Mean total cholesterol of entire study population was 171.95 ± 47.11, LDL was 116.39 ± 84.81 mg/dl, HDL was 34.50 ± 9.64, TG was 165.18 ± 87.11, non-HDL was 138.09 ± 46.18. Conclusions: Among all the conventional lipid parameters, low HDL-C along with high TGs seems to be more relevant for premature coronary artery in Indians. Primary cardiovascular disease prevention for Young Indians cannot be solely on the basis of LDL-C. All risk factors should be considered together. Larger sample population studies are needed to draw population specific cutoff values for risk factors and to discover novel risk factors (CTRI/2018/03/012544).
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VIEW POINT
	Cardiometabolic risks in India	p. 25
	Gundu H R Rao DOI:10.4103/JCPC.JCPC_39_18   In a recent article in this journal, we discussed diabetes and Cardiovascular disease (CVD) risks in Indians living abroad. The article was written to complement the information that was published by an elite group of the American Heart Association (AHA);-"the council members of the various subcommittees." In the journal Circulation, AHA published a scientific statement about the CVD risk of Indians living in the USA. In the June issue of the journal PLoS Medicine, The George Institute for Global Health (GIGH), Sydney, Australia, with collaborators from; Harvard T. H. Chan School of Public Health, USA; Department of Economics, University of Gottingen, Heidelberg University, Germany; School of Public Health Johannesburg, South Africa; King's College London, UK, Indian Institute of Public Health, and Public Health Foundation of India, have published a one of a kind article on, "Geographic and sociodemographic variation of CVD disease risk in India: A cross-sectional study of 797,540 adults." I am writing this article, as a complement to the topic reviewed by the George Institutes of Global Health and associates and other expert groups. The specific objectives of this academic exercise by the GIGH were, to determine how the CVD risk- and the factors that determine risk varies among states in India, by rural-urban location, and by individual-level sociodemographic characteristics. Rajeev Gupta and associates from Jaipur, under the aegis of South Asian Society on Atherosclerosis and Thrombosis, did a study in 2012, on "Regional variations in CVD risk in India: India heart watch." The researchers found a wide regional variation in CVD mortality. They concluded, "that although no nationwide study of risk factors exists, there were significant state-level and rural-urban level differences in major CVD risk factors such as smoking, obesity, central adiposity, hypertension, hypercholesterolemia, and diabetes. They also stressed the need for uniform protocols, to assess the regional differences. Whereas, the report by the GIGH Collaborators group, did pooled analysis of CVD risk for 797,540 adults across India, and identified important variation in risk among individuals living in different States. According to them, CVD risk was the highest in the northern (Himachal Pradesh, Uttarakhand), northeastern (West Bengal, Nagaland, Manipur, and Mizoram), and Southern States (Kerala, Andhra Pradesh) of India. CVD risk was found to be higher in urban areas, that too among males, while mean body mass index was higher among wealthy, blood glucose, high systolic blood pressure was common in poor people of middle and older age. We have access to data from three important studies, related to the variation of CVD risk in Indians living in India, as well as abroad. It is high time, that we use these data to develop guidelines, guidance statements, novel clinical studies for validating safety and efficacy of complementary therapies for early risk factors such as oxidative stress, inflammation, and endothelial dysfunction, put together integrated noninvasive diagnostic platforms for risk assessment, risk prediction, and reduction or reversal of metabolic diseases. Having said that, I would like to emphasize the need for a national platform, to address the issues related to this very important public health problem, and to coordinate the prevention strategies.
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CASE REPORT
	Homozygous familial hypercholesterolemia with valvulopathy	p. 34
	Ashokan Nambiar, Robin George Manappallil, VG Pradeep Kumar, Avinash Sarpamale DOI:10.4103/JCPC.JCPC_26_18   Familial hypercholesterolemia (FH) is an autosomal codominant genetic disorder of lipid metabolism. The occurrence of its homozygous form is rare. This is a case of a young girl who presented with syncope and was found to have multiple tuberous xanthomas and valvulopathy, along with deranged lipid profile, suggestive of homozygous FH.
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RECENT LANDMARK TRIALS
	Should aspirin be used for primary prevention?	p. 38
	Mohit Bhagwati, Rahul Mehrotra DOI:10.4103/JCPC.JCPC_54_18
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