Low use of statins and other coronary secondary prevention therapies in primary and secondary care in India.

ObjectiveTo determine the frequency of use of pharmacotherapy with aspirin, beta blocker, statin, and angiotensin-converting enzyme (ACE) inhibitor in patients with stable coronary heart disease (CHD) among physicians at different levels of health care in Rajasthan state, India.MethodsPhysicians practicing at tertiary hospitals and clinics at tertiary, secondary and primary levels were contacted. Prescriptions of CHD patients were audited and descriptive statistics reported.ResultsWe evaluated 2,993 prescriptions (tertiary hospital discharge 711, tertiary 688, secondary 1,306, and primary 288). Use of aspirin was in 2,713 (91%) of prescriptions, beta blockers 2,057 (69%), ACE inhibitors or angiotensin receptor blockers (ARBs) 2,471 (82%), and statins 2,059 (69%). Any one of these drugs was prescribed in 2,991 (100%), any two in 2,880 (96%), any three in 1,740 (58%), and all four in 1,062 (35.5%) (P < 0.001). As compared to tertiary hospital, prescriptions at tertiary, secondary, and primary levels were lower: aspirin (96% vs 95%, 91%, 67%), beta blockers (80% vs 62%, 66%, 70%), statins (87% vs 82%, 62%, 21%): two drugs (98% vs 96%, 98%, 85%), three drugs (75% vs 58%, 55%, 28%), or four drugs (54% vs 44%, 28%, 7%) (P < 0.01). Use of ACE inhibitors/ARBs was similar while nitrates (43% vs 23%, 43%, 70%), dihydropyridine calcium channel blockers (12% vs 15%, 30%, 47%), and multivitamins (6% vs 26%, 37%, 47%) use was more in secondary and primary care.ConclusionsThere is suboptimal use of various evidence-based drugs (aspirin, beta blockers, ACE inhibitors, and statins) for secondary prevention of CHD in India

Real-world clinical experience of ticagrelor in Indian patients with acute coronary syndrome after discharge from a tertiary setting

Background: To understand the usage pattern of ticagrelor in real-life clinical experience in Indian patients with the acute coronary syndrome (ACS) after discharge from a tertiary care setting. Methods: A retrospective multicentric observational study conducted across Indian healthcare centers having medical records of adult patients with ACS. Patients prescribed with ticagrelor post-discharge for at least 1 month were included. The study endpoints were to determine the clinical effectiveness of ticagrelor in post-ACS patients and adverse events reported during the study period. Results: A total of 1910 patients with ACS with a mean (SD) age of 58.2 (11.3) years were enrolled in this study. The median (IQR) duration of treatment was 30.0 (30.0-90.0) days. More than half of the patients (n=1115, 58.4%) were managed with interventional therapy. The most common comorbid conditions were type-2 diabetes mellitus (46.9%), followed by hypertension (36.8%). A total of 9.7% of patients reported complaints after treatment with ticagrelor. Among them, weakness, giddiness, and body pain were the most common (3.2%). Conclusions: This real-world study revealed that ticagrelor had been used widely in patients who underwent different management strategies. History of diabetes and hypertension were the most common risk factors. There were no major adverse events reported during the follow-up, indicating ticagrelor is well-tolerated in Indian patients with ACS

Epidemiology of cardioprotective pharmacological agent use in stable coronary heart disease

AbstractObjectiveTo determine use of class and type of cardioprotective pharmacological agents in patients with stable coronary heart disease (CHD) we performed a prescription audit.MethodsA cross sectional survey was conducted in major districts of Rajasthan in years 2008–09. We evaluated prescription for classes (anti-platelets, β-blockers, angiotensin converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARB), calcium channel blockers (CCB) and statins) and specific pharmacological agents at clinics of physicians in tertiary (n = 18), secondary (n = 69) and primary care (n = 43). Descriptive statistics are reported.ResultsPrescriptions of 2290 stable CHD patients were audited. Anti-platelet use was in 2031 (88.7%), β-blockers 1494 (65.2%), ACE inhibitors 1196 (52.2%), ARBs 712 (31.1%), ACE inhibitors – ARB combinations 19 (0.8%), either ACE inhibitors or ARBs 1908 (83.3%), CCBs 1023 (44.7%), statins 1457 (63.6%) and other lipid lowering agents in 170 (7.4%). Among anti-platelets aspirin–clopidogrel combination was used in 88.5%. Top three molecules in β-blockers were atenolol (37.8%), metoprolol (26.4%) and carvedilol (11.9%); ACE inhibitors ramipril (42.1%), lisinopril (20.3%) and perindopril (10.9%); ARB's losartan (47.7%), valsartan (22.3%) and telmisartan (14.9%); CCBs amlodipine (46.7%), diltiazem (29.1%) and verapamil (9.5%) and statins were atorvastatin (49.8%), simvastatin (28.9%) and rosuvastatin (18.3%). Use of metoprolol, ramipril, valsartan, diltiazem and atorvastatin was more at tertiary care, and atenolol, lisinopril, losartan, amlodipine and simvasatin in primary care (p < 0.01).ConclusionsThere is low use of β-blockers, ACE inhibitors, ARBs and statins in stable CHD patients among physicians in Rajasthan. Significant differences in use of specific molecules at primary, secondary and tertiary healthcare are observed

Folate Decorated Dual Drug Loaded Nanoparticle: Role of Curcumin in Enhancing Therapeutic Potential of Nutlin-3a by Reversing Multidrug Resistance

Retinoblastoma is the most common intraocular tumor in children. Malfunctioning of many signaling pathways regulating cell survival or apoptosis, make the disease more vulnerable. Notably, resistance to chemotherapy mediated by MRP-1, lung-resistance protein (LRP) is the most challenging aspect to treat this disease. Presently, much attention has been given to the recently developed anticancer drug nutlin-3a because of its non-genotoxic nature and potency to activate tumor suppressor protein p53. However, being a substrate of multidrug resistance protein MRP1 and Pgp its application has become limited. Currently, research has step towards reversing Multi drug resistance (MDR) by using curcumin, however its clinical relevance is restricted by plasma instability and poor bioavailability. In the present investigation we tried to encapsulate nutlin-3a and curcumin in PLGA nanoparticle (NPs) surface functionalized with folate to enhance therapeutic potential of nutlin-3a by modulating MDR. We document that curcumin can inhibit the expression of MRP-1 and LRP gene/protein in a concentration dependent manner in Y79 cells. In vitro cellular cytotoxicity, cell cycle analysis and apoptosis studies were done to compare the effectiveness of native drugs (single or combined) and single or dual drug loaded nanoparticles (unconjugated/folate conjugated). The result demonstrated an augmented therapeutic efficacy of targeted dual drug loaded NPs (Fol-Nut-Cur-NPs) over other formulation. Enhanced expression or down regulation of proapoptotic/antiapoptotic proteins respectively and down-regulation of bcl2 and NFκB gene/protein by Fol-Nut-Cur-NPs substantiate the above findings. This is the first investigation exploring the role of curcumin as MDR modulator to enhance the therapeutic potentiality of nutlin-3a, which may opens new direction for targeting cancer with multidrug resistance phenotype

Analyzing the effect of the density of medium on efficiency of hydrocyclone separator in sorting of PVC and PET using CFD

In plastic recycling, the precision with which a plastic component is separated during the recycling process from a combination determines the purity of the recycled plastic. In this study, polyethylene terephthalate (PET) particles and polyvinyl chloride (PVC) particles are separated using a hydrocyclone separator, a density-based sorting device that uses centrifugal force and a flow pattern generated by liquid pressure to separate particles. In hydrocyclonic sortation, the density of the medium is one of the crucial variables that affect sortation because an effective separation requires a suitable density difference between particles and medium. If the medium density is too close to the particle density, there won't be enough centrifugal force to separate the particles from the fluid, and the separation will be inefficient. And when the medium density and particle density differ too much, excessive turbulence disrupts the sorting process, making the sortation process less efficient. Therefore, using both theoretical and computational fluid dynamics (CFD) simulation approaches, the study analyzes the influence of medium density on separation efficiency and determines an optimal medium density at which separation efficiency is maximum. Theoretically, medium density should be 1374.07 kg/m3 for maximum efficiency, while 1380 kg/m3 has been determined to be optimal medium density for maximum efficiency in CFD simulation. The result of the CFD simulation is in good agreement with the outcome of the theoretical approach. In both scenarios, it turned out that the appropriate medium density for obtaining the best separation efficiency is closer to that of denser particles

Heart Failure Etiologies, Management and Short-term Outcomes in Hospitalized and Clinic-Based Patients in India

Introduction: Heart failure epidemiology has been very poorly studied in India. There are only limited studies that have evaluated etiologies and outcomes. The aim of this study was to determine etiologies and management of heart failure in hospital and clinic-based patients. Methodology: Successive patients presenting to a tertiary care hospital with acute decompensated heart failure (ADHF, n=102) and stable heart failure (SHF, n=179) were enrolled. Etiology of heart failure was diagnosed using clinical examination and echocardiography. Both the groups were followed for 90 days. Descriptive statistics are presented. Results: Etiologies of heart failure in ADHF vs SHF patients, respectively, was coronary heart disease 50.0 v/s 53.6%, hypertension 27.4 v/s 15.1%, dilated cardiomyopathy 16.7 v/s 7.3%, rheumatic heart disease 4.9 v/s 14.0%, and hypertrophic cardiomyopathy 1.0 v/s 7.3%. Heart failure with normal ejection fraction was in 23 ADHF (22.5%) and 2 SHF (1.1%) patients. In-hospital treatments included diuretics, nitrates, angiotensin converting enzyme inhibitors (ACEI), angiotensin receptor blockers (ARB), mineralocorticoid receptor antagonists (MRA), digoxin, anticoagulants, vasodilators and vasopressors. In-hospital mortality in ADHF was 10.3% (n=11). At discharge significantly greater numbers of patients with ADHF v/s SHF were on loop-diuretics (95.5 v/s 78.2%), antiplatelets (74.4 v/s 64.2%) and antiarrhythmics/ivabradine (23.3 v/s 6.1%) while lesser were on thiazides (1.5 v/s 9.5%), MRA (33.4 v/s 43.0%), ACEFARB (34.5 v/s 76.0%) and beta-blockers (33.4 v/s 45.8%) (p<0.05). 90-day mortality in ADHF was 26.7% (n=24) and in SHF 6.7% (n=7) (p<0.01). Conclusions: Coronary and hypertensive heart diseases are important causes of heart failure at a tertiary-care hospital in India. Rheumatic heart disease and primary cardiomyopathies are also present in significant proportion. In ADHF patients there is low use of evidence-based therapies (ACEI/ARBs, beta-blockers

Non-physician health workers for improving adherence to medications and healthy lifestyle following acute coronary syndrome: 24-month follow-up study

Objective: To evaluate usefulness of non-physician health workers (NPHW) to improve adherence to medications and lifestyles following acute coronary syndrome (ACS). Methods: We randomized 100 patients at hospital discharge following ACS to NPHW intervention (n = 50) or standard care (n = 50) in an open label study. NPHW was trained for interventions to improve adherence to medicines – antiplatelets, β-blockers, renin–angiotensin system (RAS) blockers and statins and healthy lifestyles. Intervention lasted 12 months with passive follow-up for another 12. Both groups were assessed for adherence using a standardized questionnaire. Results: ST elevation myocardial infarction (STEMI) was in 49 and non-STEMI in 51, mean age was 59.0 ± 11 years. 57% STEMI were thrombolyzed. On admission majority were physically inactive (71%), consumed unhealthy diets (high fat 77%, high salt 58%, low fiber 57%) and 21% were smokers/tobacco users. Coronary revascularization was performed in 90% (percutaneous intervention 79%, bypass surgery 11%). Drugs at discharge were antiplatelets 100%, β-blockers 71%, RAS blockers 71% and statins 99%. Intervention and control groups had similar characteristics. At 12 and 24 months, respectively, in intervention vs control groups adherence (>80%) was: anti platelets 92.0% vs 77.1% and 83.3% vs 40.9%, β blockers 97.2% vs 90.3% and 84.8% vs 45.0%), RAS blockers 95.1% vs 82.3% and 89.5% vs 46.1%, and statins 94.0% vs 70.8% and 87.5% vs 29.5%; smoking rates were 0.0% vs 12.5% and 4.2% vs 20.5%, regular physical activity 96.0% vs 50.0%, and 37.5% vs 34.1%, and healthy diet score 5.0 vs 3.0, and 4.0 vs 2.0 (p < 0.01 for all). Intervention vs standard group at 12 months had significantly lower mean systolic BP, heart rate, body mass index, waist:hip ratio, total cholesterol, triglyceride, and LDL cholesterol (p < 0.01). Conclusions: NPHW-led educational intervention for 12 months improved adherence to evidence based medicines and healthy lifestyles. Efficacy continued for 24 months with attrition

Low use of statins and other coronary secondary prevention therapies in primary and secondary care in India.

ObjectiveTo determine the frequency of use of pharmacotherapy with aspirin, beta blocker, statin, and angiotensin-converting enzyme (ACE) inhibitor in patients with stable coronary heart disease (CHD) among physicians at different levels of health care in Rajasthan state, India.MethodsPhysicians practicing at tertiary hospitals and clinics at tertiary, secondary and primary levels were contacted. Prescriptions of CHD patients were audited and descriptive statistics reported.ResultsWe evaluated 2,993 prescriptions (tertiary hospital discharge 711, tertiary 688, secondary 1,306, and primary 288). Use of aspirin was in 2,713 (91%) of prescriptions, beta blockers 2,057 (69%), ACE inhibitors or angiotensin receptor blockers (ARBs) 2,471 (82%), and statins 2,059 (69%). Any one of these drugs was prescribed in 2,991 (100%), any two in 2,880 (96%), any three in 1,740 (58%), and all four in 1,062 (35.5%) (P &lt; 0.001). As compared to tertiary hospital, prescriptions at tertiary, secondary, and primary levels were lower: aspirin (96% vs 95%, 91%, 67%), beta blockers (80% vs 62%, 66%, 70%), statins (87% vs 82%, 62%, 21%): two drugs (98% vs 96%, 98%, 85%), three drugs (75% vs 58%, 55%, 28%), or four drugs (54% vs 44%, 28%, 7%) (P &lt; 0.01). Use of ACE inhibitors/ARBs was similar while nitrates (43% vs 23%, 43%, 70%), dihydropyridine calcium channel blockers (12% vs 15%, 30%, 47%), and multivitamins (6% vs 26%, 37%, 47%) use was more in secondary and primary care.ConclusionsThere is suboptimal use of various evidence-based drugs (aspirin, beta blockers, ACE inhibitors, and statins) for secondary prevention of CHD in India