Summary of the Consensus Statement: This statement has been prepared keeping Indian heart failure patients in mind. Optimal management of CHF improves quality of life, reduces hospitalization rates and prolongs survival for people with this condition. Echocardiography is the single most useful test in the evaluation of heart failure, and is necessary to confirm the diagnosis. Plasma B-natriuretic peptide (BNP) measurements may be useful in excluding CHF but not mandatory in India. Educate people with CHF about lifestyle changes (e.g., increase physical activity levels, reduce salt intake and manage weight). Educate people with CHF about CHF symptoms and how to manage fluid load. Avoid prescribing drugs that exacerbate CHF. Prescribe angiotensin-converting enzyme inhibitors (ACEI) at effective doses for people with all grades of systolic heart failure, and titrate to the highest recommended dose tolerated. Angiotensin II receptor antagonists (ARA) may be used as alternatives in people who cannot tolerate ACEIs. Mineralocorticoid receptor antagonists (MRAs) should also be used. For people with stabilised systolic heart failure, prescribe beta-blockers that have been shown to improve outcome in heart failure (e.g., bisoprolol, carvedilol, extended release metoprolol or nebivolol). Titrate to the highest recommended dose tolerated. Prescribe diuretics, digoxin and nitrates for people already using ACEIs and beta-blockers to manage symptoms as indicated. For people who have systolic heart failure (New York Heart Association (NYHA) Class II-IV) despite appropriate doses of ACEIs and diuretics, consider prescribing spironolactone. Eplerenone can be considered in certain setting especially post myocardial infarction though it is more expensive. Consider direct sinus node inhibition with ivabradine for people with CHF who have impaired systolic function, have had a recent heart failure hospitalisation and are in sinus rhythm with a heart rate >70 bpm despite beta blockers or where beta blockers are contraindicated Check for, and treat, iron deficiency in people with CHF to improve their symptoms, exercise tolerance and quality of life Consider assessing people with CHF for biventricular pacemakers and implantable defibrillators. Patients with end stage heart failure have an option for heart transplant and ventricular assist devices which is now available in select centers.

Sudden cardiac death is one of the most common cause of mortality worldwide. Despite significant advances in the medical science, there is little improvement in the sudden cardiac death related mortality. Coronary artery disease is the most common etiology behind sudden cardiac death, in the above 40 years population. Even in the apparently healthy population, there is a small percentage of patients dying from sudden cardiac death. Given the large denominator, this small percentage contributes to the largest burden of sudden cardiac death. Identification of this at risk group among the apparently healthy individual is a great challenge for the medical fraternity. This article looks into the causes and methods of preventing SCD and at some of the Indian data. Details of Brugada syndrome, Long QT syndrome, Genetics of SCD are discussed. Recent guidelines on many of these causes are summarised.

Cardiomyopathies are a major cause of heart disease. Not only the patients, but also their families are severely burdened by these illnesses. In the past decade, studies revealed the heterogeneity of these diseases in terms of clinical presentation, as well as their genetics. Studies done in the last few decades revealed a new concept of complex manifestation of cardiomyopathies with different heterogeneity level, penetration, and inheritance. The incomplete penetrance, genetic heterogeneity, and variable expression in cardiomyopathies paradoxically raise hopes that the development of novel disease modifying therapies may be achievable.

Kussmaul's has provided us with three important signs: Pulses paradoxus, Kussmaul's sign and Kussmaul Breathing. This article discusses Kussmaul's sign, its discovery, first description, pathophyiology and exceptions.

A patient of dominant right sided heart failure for 7 years is presented and discussed, starting from the history and examination findings and going on to all the investigations. The clinical findings, along with the electrocardiogram, chest X-ray, echocardiogram, and cardiac computed tomography are used to arrive at a diagnosis of chronic constrictive pericarditis. The differential diagnosis at each stage of presentation are presented and discussed.

Background: Long-term adverse cardiovascular effects of smokeless tobacco are well established, however, the effect of chewing tobacco on coronary microcirculation and hemodynamic have not been studied. We intended to analyze the acute effect of chewing tobacco on coronary microcirculation and hemodynamics in habitual tobacco chewers with stable coronary artery disease undergoing elective percutaneous coronary intervention (PCI). Materials and Methods: We prospectively enrolled seven habitual tobacco chewers with stable coronary artery disease with single vessel disease or double vessel disease satisfying the criteria for elective PCI. Patients were instructed to keep 1 g of crushed dried tobacco leaves in the mouth after a successful PCI. Lesion in last stented vessels was evaluated for fractional flow reserve (FFR), coronary flow reserve (CFR), and index of microcirculatory resistance (IMR) post-PCI, after 15 min and 30 min of tobacco chewing along with the measurement of serum cotinine levels. Results: Oral tobacco led to high levels of cotinine in the majority of patients. There was an insignificant rise in heart rate, systolic and diastolic blood pressure following tobacco consumption. Baseline CFR (median 1.6, range 1.1–5.5) was low in tobacco chewers after PCI even after optimum FFR (0.9 ± 0.05) in the majority of patients suggesting abnormal microvascular hemodynamics (high IMR in 3 patients, overall median 14.2, range 7–36.2). However, there was no significant change in the estimated CFR or IMR values following tobacco chewing. One patient had bradycardia and hypotension which may be related to vagal reaction or acute nicotine poisoning. Conclusion: Tobacco chewers have abnormal coronary microcirculation hemodynamics even following a successful PCI. However, the coronary micocirculation and hemodynamics do not change acutely following tobacco chewing despite high serum cotinine concentrations.

Background: Hypertrophic cardiomyopathy (HCM) is a genetic disorder with the prevalence of 1 in 500 globally. HCM is clinically characterized by thickening of the wall of the heart, predominantly left ventricle (LV), and interventricular septum (IVS). Our study aims to report the demographical, clinical and genetic profile of Indian HCM patients. Methods: HCM patients were recruited on the basis of WHO criteria. The clinical phenotypes were analyzed using electrocardiography, two-dimensional electrocardiography, and hotspot region of the MYH7 gene was sequenced for all patients as well as for controls. Results: There were 59 patients with a clinical diagnosis of HCM with a preponderance of disease in males with a ratio (men, women) of 5.5:1. Average age of onset of the disease was late 30 s (39.2 ± 14.5) with familial HCM accounting for 18% (n = 9) for total HCM families (n = 50). Nonobstructive kind of HCM was more prevalent as compared to obstructive HCM (66.1% vs. 33.9%). Average posterior wall LV thickness of the HCM patients was 16 ± 4.8 mm and IVS thickness was 21 ± 8.3 mm with familial patients having greater wall thickness as compared to sporadic patients. Sequencing of hotspot region of MYH7 identified three mutations in three different patients. Two mutations were found to be segregating in familial cases. Conclusion: HCM is more prevalent in males with a predominance of hypertrophic nonobstructive cardiomyopathy form. Eighteen percent of cases were familial and showed an early onset of the disease and worse prognosis as compared to sporadic cases. Hotspot sequencing of MYH7 only explains 6% of its genetic basis. More of the candidate genes need to be screened through advanced techniques like next generation sequencing to identify the causal genes which could make us understand the mechanistic pathways.

Background: Mesenchymal stem cells (MSCs) are multipotent and can be easily cultured and expanded. Therefore, these are considered to be an attractive therapeutic tool for cardiac repair. These have been found to have tremendous potential to transdifferentiate to cardiac lineage both in vitro and in vivo. A number of chemicals and growth factors have been explored for the same. However, the effect of the paracrine factors released by cardiac tissue has not been studied much. Materials and Methods: In the present study, we have examined the differentiation capacity of conditioned media (CM) derived from human cardiac tissue on human bone marrow-derived MSCs (BM-MSCs). BM-MSCs after characterization were induced by culture supernatant collected from human cardiac tissue (21 days). Parallel cultures treated with 5-azacytidine (AZA) (30 days), were taken as controls. Results: MSCs treated with CM formed “muscle island” like structure and were found to be positive for cardiac-specific markers - myosin light chain-2v and cardiac troponin I proteins. However, uninduced BM-MSCs did not show positivity for any of these markers and maintained fibroblastic morphology. Conclusion: These findings demonstrate that cardiac CM is capable of effective induction of morphological and molecular changes in MSCs toward cardiac features. However, differentiation efficiency is less than that of 5-AZA and the mode of action and the components of CM are still to be known.

Background: Cardiomyopathies are a heterogeneous group of diseases of the myocardium associated with varied pathology. Pathology data from India are scarce. Methods: A retrospective, descriptive study of autopsies, as well as endomyocardial biopsy specimens, was done of patients with cardiomyopathy. The clinical and pathological features are described. Results: There were 32 patients with dilated cardiomyopathy. Two were pediatric, and two had arrhythmogenic right ventricular cardiomyopathy. Myocarditis was seen in 12 cases. In our endomyocardial biopsy data of 32 patients with restrictive cardiomyopathy (RCM), we found amyloid in 13 and idiopathic RCM in the remainder. Our genetic studies in cardiomyopathies suggest that the same genetic mutation may lead to different phenotypic manifestations with restrictive or hypertrophic cardiomyopathies in different families. Conclusions: This study gives insight into the pathology and etiology of some of the cardiomyopathies seen in India. They differ from the west, and now with the availability of genotyping and magnetic resonance imaging, more data should soon be available from more centers.

Myocarditis is a challenging diagnosis for both clinician and pathologist due to the extreme diversity of clinical presentation and low sensitivity of detection of myocarditis in the endomyocardial samples. The exact incidence of myocarditis is still not known as endomyocardial biopsy (EMB) is not performed in all suspected cases of myocarditis in majority of the centers. Identification of Dallas criteria in EMB is still considered as a gold standard in the diagnosis of myocarditis. Viral myocarditis is one of the most common causes of myocarditis next to idiopathic or primary myocarditis. Virtually any type of virus can affect the heart. Idiopathic myocarditis should be categorized depending upon the histopathological findings and clinical features as fulminant, chronic active, eosinophilic, granulomatous, or giant cell myocarditis. Hence, a thorough basic set of all relevant investigations including molecular study should be carried out in the evaluation of clinically suspected viral myocarditis patients to identify the active phase of the viral disease process which ultimately helps in the determination of treatment protocol and prognosis.

Viral myocarditis is now acknowledged as a leading cause of morbidity as well as mortality in cardiovascular diseases. Its treatment is highly dependent on its proper diagnosis as its clinical features overlap with or mimic many other cardiovascular conditions. Histology by endomyocardial biopsy (EMB) confirms its diagnosis but given its own limitations and complications, the noninvasive imaging methods such as echocardiogram and magnetic resonance imaging as well as the molecular techniques like polymerase chain reaction (PCR) have redefined the entire scenario. Of these, PCR can detect the viral epitopes in peripheral blood samples, heart biopsy tissues samples, or urine/stool sample. Moreover, the best use of PCR is exemplified in the EMB samples where scarcity of the sample is not a limiting factor unlike histopathological examination. Detecting the subclinical infections, identifying different strains, and detecting pathogens which are otherwise difficult to grow gives PCR an edge. As it is said “time is money,” thus rapid detection of specific nucleic acid sequences from minute samples, and the overall cost-effectiveness makes PCR a technique of choice in the diagnostic armamentarium.

Raised right ventricular end-diastolic pressure and diastolic pressure equalization are accurate in only up to 85% causes in differentiating constrictive pericarditis from restrictive cardiomyopathy. Therefore imaging in the form of either computed tomography (CT) or magnetic resonance (MR) is important for clinching the diagnosis. In cases of diagnostic dilemma, cardiac MR (CMR) is the investigation of choice with its ability to show both morphological (increased pericardial thickness) and functional changes (constriction, septal bounce). CT for constrictive pericardium may be done if CMR is not available or when there is any contraindication to doing CMR.

Tuberculosis (TB) is responsible for approximately 70% of the cases of large pericardial effusion and the most cases of constrictive pericarditis in developing countries. Early diagnosis and institution of appropriate therapy are critical to prevent mortality. Treatment of TB pericardial effusion consists of 4-drug therapy (isoniazid, rifampicin, pyrazinamide, and ethambutol) for 2 months followed by 2 drugs (isoniazid and rifampicin) for 4 months. Systematic reviews and meta-analyses suggest that although overall corticosteroids are associated with a beneficial effect on the variables analyzed, the wide confidence interval and a small number of events make it impossible to draw firm conclusions. Pericardiectomy is the definitive treatment for constrictive pericarditis, but is unwarranted either in very early constriction where it could be transitory.

Student's t-test is a method of testing hypotheses about the mean of a small sample drawn from a normally distributed population when the population standard deviation is unknown. In 1908 William Sealy Gosset, an Englishman publishing under the pseudonym Student, developed the t-test. This article discusses the types of T test and shows a simple way of doing a T test.

In this era of Google search, it is easy for beginners to fancy literature review limited to this popular search engine. Unfortunately, this will miss a vast index of articles which exist within our reach. Some specialized search portals leading to their corresponding databases deal with the tremendous medical literature that has been generated over decades. This article deals with the “what?” and “how to?” of these available databases of the medical articles. This will make your literature review efficient and the confidence in collected evidence - accurate.

Stroke prevention is important in patients with atrial fibrillation. Dual antiplatelets are important after a drug coated stent implant in patients with coronary artery disease, while patients with atrial fibrillation need anticoagulation. When to give triple therapy with combination dual antiplatelets and anticoagulation and how to balance the risk and benefits is discussed in this article.

We report the successful implant of an external basal annuloplasty device (basal annuloplasty of the cardia externally), which is a dimethyl silicone band, slipped around the base of the heart at the atrioventricular groove and the sub-annular myocardium to provide external myocardial support and mitral annuloplasty. The patient had ischemic heart disease with moderate functional mitral regurgitation which was reduced to mild regurgitation. The patient underwent coronary artery bypass during the same surgery.

In India, the discipline of cardiology started in the late 1950s and at that time pediatric cardiology was practiced as a part of cardiology specialty. This article traces the history of pediatric cardiology in India. Dr. S. Padmawati and Dr. Kamala Vytilingam underwent training in pediatric cardiology at international centers in the early 1950s and early 1960s. Dr. N. Gopinath successfully closed a ventricular septal defect using a pump oxygenator at Christian Medical College, Vellore. Open heart surgery program kicked off in the 1960s with the tireless efforts of many other surgeons. Dr. Rajendra Tandon, trained for 2 years at Boston Children Hospital under Dr. Alexander Nadas, joined the Department of Cardiology at the All India Institute of Medical Sciences, New Delhi in 1963. This and many other stories are described.

Despite advancements in diagnosis and pharmacotherapy, heart failure (HF) remains as a major health problem. The prevalence in the general population is estimated to range from 0.3% to 2.0%, increases considerably with age, and approximately doubles with every additional decade of life. In the last two decades, hospital admission rates for HF have increased steadily. The prevalence of HF can be estimated at 1–2% in the Western world and the incidence approaches 5–10/1000 persons/year. Estimates of the occurrence of HF in the developing world are largely absent. In a recent US population-based study, the prevalence of HF was 2.2% (95 confidence interval 1.6–2.8%), increasing from 0.7% in persons aged 45 through 54 years to 8.4% for those aged 75 years or older. In this article, we look at the major papers published in HF in the past 1 year.

In this edition of conference news, we round up on conferences on heart failure in India. The Cardiology Society of India held its first conference on heart failure in Indore. The Heart Failure Association of India held its meeting in Delhi. AIIMS, JNU and the Journal of the Practice of Cardiovascular Sciences will conduct the Heart Failure Certification Program in October in JNU.

The Health Ministry's Screening Committee (Indian Council of Medical Research) takes decisions on the international research proposals in the field of health research, requiring foreign collaboration and assistance from foreign funding agencies.