Hypertension: Chockalingam A

Padwal RS, Hemmelgarn BR, Khan NA, Grover S, McKay DW, Wilson T, Penner B, Burgess E, McAlister FA, Bolli P, Hill MD, Mahon J, Myers MG, Abbott C, Schiffrin EL, Honos G, Mann K, Tremblay G, Milot A, Cloutier L, Chockalingam A, Rabkin SW, Dawes M, Touyz RM, Bell C, Burns KD, Ruzicka M, Campbell NR, Vallée M, Prasad R, Lebel M, Tobe SW, Anonymous00149. · Division of General Internal Medicine, University of Alberta, Edmonton, Canada. · Can J Cardiol. · Pubmed #19417858 No free full text.

Abstract: OBJECTIVE: To provide updated, evidence-based recommendations for the diagnosis and assessment of adults with hypertension. OPTIONS AND OUTCOMES: The diagnosis of hypertension is dependent on appropriate blood pressure measurement, the timely assessment of serially elevated readings, the degree of blood pressure elevation, the method of measurement (office, ambulatory, home) and associated comorbidities. The presence of cardiovascular risk factors and target organ damage should be ascertained to assess global cardiovascular risk and determine the urgency, intensity and type of treatment required. EVIDENCE: MEDLINE searches were conducted from November 2007 to October 2008 with the aid of a medical librarian. Reference lists were scanned, experts were contacted, and the personal files of authors and subgroup members were used to identify additional studies. Content and methodological experts assessed studies using prespecified, standardized evidence-based algorithms. Recommendations were based on evidence from peer-reviewed full-text articles only. RECOMMENDATIONS: Recommendations for blood pressure measurement, criteria for hypertension diagnosis and follow-up, assessment of global cardiovascular risk, diagnostic testing, diagnosis of renovascular and endocrine causes of hypertension, home and ambulatory monitoring, and the use of echocardiography in hypertensive individuals are outlined. Key messages include continued emphasis on the expedited, accurate diagnosis of hypertension, the importance of global risk assessment and the need for ongoing monitoring of hypertensive patients to identify incident type 2 diabetes. VALIDATION: All recommendations were graded according to strength of the evidence and voted on by the 57 members of the Canadian Hypertension Education Program Evidence-Based Recommendations Task Force. All recommendations were required to be supported by at least 70% of task force members. These guidelines will continue to be updated annually.

Padwal RS, Hemmelgarn BR, McAlister FA, McKay DW, Grover S, Wilson T, Penner B, Burgess E, Bolli P, Hill M, Mahon J, Myers MG, Abbott C, Schiffrin EL, Honos G, Mann K, Tremblay G, Milot A, Cloutier L, Chockalingam A, Khan NA, Rabkin SW, Dawes M, Touyz RM, Tobe SW, Anonymous00038. · Division of General Internal Medicine, University of Alberta, Edmonton, Alberta. · Can J Cardiol. · Pubmed #17534459 links to  free full text

Abstract: OBJECTIVE: To provide updated, evidence-based recommendations for the diagnosis and assessment of adults with hypertension. OPTIONS AND OUTCOMES: The diagnosis of hypertension is dependent on the appropriate measurement of blood pressure, the timely assessment of serially elevated readings, the degree of blood pressure elevation, the method of measurement (office, ambulatory, home) and any associated comorbidities. The presence of cardiovascular risk factors and target organ damage should be ascertained to assess global cardiovascular risk, and to determine the urgency, intensity and type of treatment required. EVIDENCE: MEDLINE searches were conducted from November 2005 to October 2006 with the aid of a medical librarian. Reference lists were scanned, experts were contacted, and the personal files of authors and subgroup members were used to identify additional studies. Content and methodological experts assessed studies using prespecified, standardized evidence-based algorithms. Recommendations were based on evidence from peer-reviewed, full-text articles only. RECOMMENDATIONS: Recommendations for blood pressure measurement, criteria for hypertension diagnosis and follow-up, assessment of global cardiovascular risk, diagnostic testing, diagnosis of renovascular and endocrine causes of hypertension, home and ambulatory monitoring, and the use of echocardiography in hypertensive individuals are outlined. Key messages in 2007 include continued emphasis on the expedited, accurate diagnosis of hypertension, the importance of assessing the risk of cerebrovascular events as part of global risk assessment, the need for ongoing reassessment of patients with high normal blood pressure, and reviews of recent studies involving laboratory testing and home monitoring. VALIDATION: All recommendations were graded according to strength of the evidence and were voted on by the 57 members of the Canadian Hypertension Education Program Evidence-Based Recommendations Task Force. All recommendations reported here received at least 70% consensus. These guidelines will continue to be updated annually.

Hemmelgarn BR, McAlister FA, Grover S, Myers MG, McKay DW, Bolli P, Abbott C, Schiffrin EL, Honos G, Burgess E, Mann K, Wilson T, Penner B, Tremblay G, Milot A, Chockalingam A, Touyz RM, Tobe SW, Anonymous00011. · Division of Nephrology, University of Calgary, and Foothills Hospital, 1403 29th Street Northwest, Calgary, Alberta, Canada. · Can J Cardiol. · Pubmed #16755312 links to  free full text

Abstract: OBJECTIVE: To provide updated, evidence-based recommendations for the diagnosis and assessment of adults with high blood pressure. OPTIONS AND OUTCOMES: For persons in whom a high blood pressure value is recorded, a diagnosis of hypertension is dependent on the appropriate measurement of blood pressure, the level of the blood pressure elevation, the approach used to monitor blood pressure (office, ambulatory or home/self), and the duration of follow-up. In addition, the presence of cardiovascular risk factors and target organ damage should be assessed to determine the urgency, intensity and type of treatment. For persons diagnosed as having hypertension, estimating the overall risk of adverse cardiovascular outcomes requires an assessment for other vascular risk factors and hypertensive target organ damage. EVIDENCE: MEDLINE searches were conducted from November 2004 to October 2005 to update the 2005 recommendations. Reference lists were scanned, experts were polled, and the personal files of the authors and subgroup members were used to identify other studies. Identified articles were reviewed and appraised using prespecified levels of evidence by content and methodological experts. As per previous years, the authors only included studies that had been published in the peer-reviewed literature and did not include evidence from abstracts, conference presentations or unpublished personal communications. RECOMMENDATIONS: The present document contains recommendations for blood pressure measurement, diagnosis of hypertension, and assessment of cardiovascular risk for adults with high blood pressure. These include the accurate measurement of blood pressure, criteria for the diagnosis of hypertension and recommendations for follow-up, assessment of overall cardiovascular risk, routine and optional laboratory testing, assessment for renovascular and endocrine causes, home and ambulatory blood pressure monitoring, and the role of echocardiography for those with hypertension. Key features of the 2006 recommendations include continued emphasis on an expedited diagnosis of hypertension, an in-depth review of the role of global risk assessment in hypertension therapy, and the use of home/self blood pressure monitoring for patients with masked hypertension (subjects with hypertension who have a blood pressure that is normal in clinic but elevated on home/self measurement). VALIDATION: All recommendations were graded according to the strength of the evidence and were voted on by the 45 members of the Canadian Hypertension Education Program Evidence-Based Recommendations Task Force. All recommendations reported herein received at least 95% consensus. These guidelines will continue to be updated annually.

Campbell NR, Fodor JG, Chockalingam A. · No affiliation provided · Can J Public Health. · Pubmed #11962105 No free full text.

This publication has no abstract.

Campbell NR, Leiter LA, Larochelle P, Tobe S, Chockalingam A, Ward R, Morris D, Tsuyuki R. · Department of Medicine, University of Calgary, Calgary, Canada. · Can J Cardiol. · Pubmed #19417860 No free full text.

Abstract: The Canadian Hypertension Education Program, Blood Pressure Canada, Canadian Hypertension Society, Heart and Stroke Foundation of Canada, Canadian Diabetes Association, College of Family Physicians of Canada, Canadian Pharmacists Association and the Canadian Council of Cardiovascular Nurses call on Canadian health care professionals to redouble efforts to help patients achieve treatment targets (blood pressure less than 130 mmHg systolic and less than 80 mmHg diastolic) in people with diabetes. Treatment of high blood pressure in people with diabetes results in large reductions in death and disability within a short period of time and needs to be a therapeutic priority. Achieving blood pressure targets requires sustained lifestyle modification, and three or more drugs including a diuretic are often required. Antihypertensive treatment in people with diabetes is one of the few medical treatments estimated to reduce overall health costs. The cost of treatment is less than the cost of complications prevented. Blood pressure needs to be assessed at all visits and home blood pressure assessment is encouraged. Management strategies need to include assessment and management of cardiovascular risks including smoking, unhealthy eating, physical inactivity, abdominal obesity, dyslipidemia as well as dysglycemia. The risks and benefits of acetylsalicylic acid in primary prevention of cardiovascular disease are uncertain in people with hypertension and diabetes. Intensive individualized lifestyle modification is recommended to prevent and treat hypertension, dyslipidemia, dysglycemia and other vascular risks in people with diabetes.

Chockalingam A, Chalmers J, Whitworth J, Erdine S, Mancia G, Mendis S, Heagerty A. · Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada. · J Hypertens. · Pubmed #19008700 No free full text.

This publication has no abstract.

Padwal RJ, Hemmelgarn BR, Khan NA, Grover S, McAlister FA, McKay DW, Wilson T, Penner B, Burgess E, Bolli P, Hill MD, Mahon J, Myers MG, Abbott C, Schiffrin EL, Honos G, Mann K, Tremblay G, Milot A, Cloutier L, Chockalingam A, Rabkin SW, Dawes MD, Touyz RM, Bell C, Burns KD, Ruzicka M, Campbell NR, Lebel M, Tobe SW, Anonymous00045. · Division of General Internal Medicine, University of Alberta, Edmonton, Canada. · Can J Cardiol. · Pubmed #18548142 links to  free full text

Abstract: OBJECTIVE: To provide updated, evidence-based recommendations for the diagnosis and assessment of adults with hypertension. OPTIONS AND OUTCOMES: The diagnosis of hypertension is dependent on appropriate blood pressure measurement, the timely assessment of serially elevated readings, degree of blood pressure elevation, method of measurement (office, ambulatory, home) and associated comorbidities. The presence of cardiovascular risk factors and target organ damage should be ascertained to assess global cardiovascular risk and determine the urgency, intensity and type of treatment required. EVIDENCE: MEDLINE searches were conducted from November 2006 to October 2007 with the aid of a medical librarian. Reference lists were scanned, experts were contacted, and the personal files of authors and subgroup members were used to identify additional studies. Content and methodological experts assessed studies using prespecified, standardized evidence-based algorithms. Recommendations were based on evidence from peer-reviewed, full-text articles only. RECOMMENDATIONS: Recommendations for blood pressure measurement, criteria for hypertension diagnosis and follow-up, assessment of global cardiovascular risk, diagnostic testing, diagnosis of renovascular and endocrine causes of hypertension, home and ambulatory monitoring, and the use of echocardiography in hypertensive individuals are outlined. Key messages in 2008 include continued emphasis on the expedited, accurate diagnosis of hypertension, the importance of global risk assessment and the need for ongoing monitoring of hypertensive patients to identify incident type 2 diabetes. VALIDATION: All recommendations were graded according to strength of the evidence and voted on by the 57 members of the Canadian Hypertension Education Program Evidence-Based Recommendations Task Force. All recommendations reported here received at least 70% consensus. These guidelines will continue to be updated annually.

Chockalingam A. · Simon Fraser University, Burnaby, Canada. · Can J Cardiol. · Pubmed #18548140 links to  free full text

Abstract: The World Health Organization attributes hypertension, or high blood pressure, as the leading cause of cardiovascular mortality. The World Hypertension League (WHL), an umbrella organization of 85 national hypertension societies and leagues, recognized that more than 50% of the hypertensive population worldwide are unaware of their condition. To address this problem, the WHL initiated a global awareness campaign on hypertension in 2005 and dedicated May 17 of each year as World Hypertension Day (WHD). Over the past three years, more national societies have been engaging in WHD and have been innovative in their activities to get the message to the public. In 2007, there was record participation from 47 member countries of the WHL. During the week of WHD, all these countries -- in partnership with their local governments, professional societies, nongovernmental organizations and private industries -- promoted hypertension awareness among the public through several media and public rallies. Using mass media such as Internet and television, the message reached more than 250 million people. As the momentum picks up year after year, the WHL is confident that almost all the estimated 1.5 billion people affected by elevated blood pressure can be reached. The success of WHD is due to the enthusiasm and voluntary action of multiple stakeholders from every member country.

McKay DW, Godwin M, Chockalingam A. · Division of BioMedical Sciences, Faculty of Medicine, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador. · Can J Cardiol. · Pubmed #17534466 links to  free full text

Abstract: Early diagnosis of hypertension is one benefit of home blood pressure monitoring. Home measurement may also be used for the detection of masked hypertension. Home blood pressure readings have a strong correlation with risk, and the method has many advantages over office measurement in the management of hypertension, especially in patients with chronic kidney disease or diabetes. The present article provides practical advice on incorporating home blood pressure monitoring into practice. Patient education and training are discussed, as are tips to aid in the selection of devices for blood pressure measurement at home.

Penner SB, Campbell NR, Chockalingam A, Zarnke K, Van Vliet B. · Department of Medicine, Faculty of Medicine, University of Manitoba, Winnipeg, Manitoba. · Can J Cardiol. · Pubmed #17534464 links to  free full text

Abstract: Hypertension, the leading risk factor for mortality in the world, affects nearly one in four Canadians. There is substantive evidence that high dietary sodium contributes to hypertension. Animal studies consistently demonstrate increased blood pressure and cardiovascular morbidity and mortality with high dietary sodium intake. Evidence of the adverse health effects in humans associated with increased sodium intake is accumulating rapidly. Previously, limitations on sodium consumption were recommended only for those identifiable groups of people shown to be at higher risk. With the lifetime risk of developing hypertension being more than 90% in an average lifespan, the need for a population-based approach to reducing hypertension is clear. The present paper reviews the evidence of sodium and cardiovascular disease, resulting in the 2007 Canadian Hypertension Education Program recommendation of daily intake of less than 100 mmol of sodium in both normotensive and hypertensive adults.

McKay DW, Myers MG, Bolli P, Chockalingam A. · Division of Basic Medical Sciences, Faculty of Medicine, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada. · Can J Cardiol. · Pubmed #16755318 links to  free full text

Abstract: A patient has masked hypertension when his office blood pressure is less than 140/90 mmHg but his ambulatory or home blood pressure readings are in the hypertensive range. Several recent studies have demonstrated that cardiovascular risk is similar between those with masked hypertension and those with sustained hypertension. The prevalence of masked hypertension in Canada is not known, but data from other countries suggest rates greater than 8%. Physicians need to use careful clinical judgment to identify and treat subjects with masked hypertension. The present review discusses masked hypertension, its importance to clinical practice and some aspects of patient management.

Campbell N, Chockalingam A. · Department of Medicine, University of Calgary, Canada. · Indian Heart J. · Pubmed #16521630 No free full text.

This publication has no abstract.

Chockalingam A, Campbell N. · Faculty of Health Sciences, Simon Fraser University, BC, Canada. · Indian Heart J. · Pubmed #16521629 No free full text.

This publication has no abstract.

Chockalingam A, Gnanavelu G, Venkatesan S, Elangovan S, Jagannathan V, Subramaniam T, Alagesan R, Dorairajan S. · Department of Cardiology, Madras Medical College and Research Institute, Chennai 600 003, India. · Int J Cardiol. · Pubmed #15721505 No free full text.

Abstract: PURPOSE: We aimed to assess the effects of sildenafil and evaluate optimal dosing in primary pulmonary hypertension (PPH). Sildenafil selectively inhibits phosphodiesterase 5 (PDE5), which is abundant in pulmonary and penile tissue. This results in increasing nitric oxide (NO) at tissue level leading to pulmonary vasodilatation. SUBJECTS AND METHODS: Our study was a prospective study of sildenafil in 15 consecutive patients with severe symptomatic PPH of NYHA class III-IV. All patients were stabilized for a minimum period of 5 days with antifailure medications. Sildenafil was started at 50 mg twice daily for 4 weeks and increased to 100 mg bid for 4 more weeks in a step-up protocol. Primary end-points were change in Borg dyspnea index, NYHA class and 6-min walk distance, estimated at baseline 1, 2, 4 and 8 weeks. RESULTS: NYHA class (baseline 3.8 +/- 0.4 vs. 4 weeks 2.4 +/- 0.5, p = 0.002), Borg dyspnea index (8.1 +/- 1.7 vs. 4.4 +/- 1.9, p = 0.0007), 6-min walk distance (234 +/- 44 vs. 377 +/- 128 m, p = 0.001) and Pulmonary artery pressure (125 +/- 15 vs. 113 +/- 18 mm Hg p = 0.05) are significantly improved with sildenafil 50 mg bid at 4 weeks. Increasing the dose to 100 mg bid did not produce further benefit. Echocardiography parameters of right heart dimensions and functions did not change markedly in the study period. CONCLUSION: Sildenafil is well tolerated with no adverse effects in severe pulmonary hypertension. It reduces symptoms, improves effort tolerance and controls refractory heart failure significantly by 2 weeks in 70% of patients at 50 mg twice daily. Three patients (20%) failed to respond with sildenafil.

Singla A, Garg R, Garg N, Chockalingam A. · Division of Internal Medicine, University of Missouri-Columbia, MO 65212, USA. · Am J Med. · Pubmed #19486713 No free full text.

This publication has no abstract.

Mathavan A, Chockalingam A, Chockalingam S, Bilchik B, Saini V. · Apollo Hospital, Madurai, Tamilnadu, India. · Can J Cardiol. · Pubmed #19417861 No free full text.

Abstract: BACKGROUND: Studies have shown that South Asians are highly susceptible to cardiovascular diseases (CVDs). There is very little information available about the prevalence of risk factors for CVD in the physician population, a group that might be expected to be more aware of cardiovascular risk and health status. AIM: To evaluate the prevalence of cardiovascular risk factors - including metabolic, dietary and behavioural - among the physician population in southern India. METHODS: Approximately 4000 physicians of differing specialties from eight southern districts in Tamilnadu, India, in and around the city of Madurai were listed. Of these, 1600 were randomly selected to participate in a cross-sectional survey, of which 1514 physicians agreed to participate. The survey included demographic questionnaires, objective measurements of blood pressure, fasting blood sugar, fasting lipids and waist circumference, and questionnaires about their dietary and behavioural habits. RESULTS: Complete data were available for 1433 physicians. Using a blood pressure cut-off value of 130/85 mmHg or higher, the study recorded a prevalence of 41% among men and 23% among women. On applying the International Diabetes Federation criteria for the metabolic syndrome for the South Asian population, the present study identified 49% of female physicians and 41% of male physicians as having the metabolic syndrome. Only 17% were physically active. Less than one-half of them consumed vegetables. Nearly 31% of male physicians were smokers. CONCLUSION: Analysis of these data suggests that the risk for CVD and stroke is at epidemic proportions in a cohort of well-educated physicians who are in the highest quintile of income.

Chockalingam A, Dorairajan S, Bhalla M, Dellsperger KC. · Department of Internal Medicine, Division of Cardiovascular Medicine, University of Missouri School of Medicine, Columbia, MO, USA. · Crit Care Med. · Pubmed #19114882 No free full text.

Abstract: OBJECTIVE: To illustrate the clinical and hemodynamic abnormalities caused by dynamic left ventricular outflow tract obstruction (LVOTO) in critical care setting. DESIGN: We reviewed cases referred to Cardiology with echocardiographic evidence of LVOTO and their clinical presentations. We present those cases where LVOTO can transiently occur without hypertrophic cardiomyopathy when inotropic agents are used for hypotension. MEASUREMENTS AND MAIN RESULTS: Five women in the 50-70 age range and prior history of hypertension presented with various symptoms like chest discomfort, fatigue, dizziness, atrial fibrillation, and hypotension. An ejection systolic murmur was noted most often in the left third intercostal space and ECG revealed ST-T wave abnormalities. LVOTO caused by mitral systolic anterior motion was detected by echocardiography and catheterization excluded acute coronary disease. In critical care setting, LVOTO can occur due to apical ballooning syndrome, coronary disease, medications, volume depletion, and valvular abnormalities. Because this condition mimics acute coronary syndrome or other etiologies of hypotension in medical and surgical intensive care units, appropriate treatment can be delayed. Nonhypertrophic cardiomyopathy LVOTO usually responds well to fluid replacement, beta blockers, and medication changes. CONCLUSIONS: LVOTO should be suspected especially in women presenting with hypotension and systolic murmur in critical care settings. Clinical acumen and timely echocardiography are required to effectively counter this transient but potentially lethal problem.

Chockalingam A. · Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia. · Can J Cardiol. · Pubmed #17534457 links to  free full text

Abstract: It is estimated that nearly one billion people are affected by hypertension worldwide, and this figure is predicted to increase to 1.5 billion by 2025. Nearly one-half of this population are unaware of their condition. Hypertension is the primary risk factor for heart disease and stroke. World Hypertension Day (WHD) has been an initiative of the World Hypertension League to raise hypertension awareness. In the past two years, many countries have taken an active part in promoting awareness through a number of initiatives in their respective countries. In Canada, WHD was a resounding success in 2005 and 2006, and major plans are underway for WHD 2007. The success of the Canadian WHD depends mainly on the partnership and shared values of all stakeholders, including professional societies, nongovernment organizations, government agencies and industry. Although it is too early to assess the impact of hypertension, it is evident that the countries involved are taking hypertension in the population seriously and are moving in the right direction. If the momentum continues, a drastic reduction in the prevalence of worldwide hypertension can be anticipated.

Chockalingam A, Campbell NR, Fodor JG. · Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada. · Can J Cardiol. · Pubmed #16755308 links to  free full text

Abstract: The World Health Report 2002 identified hypertension, or high blood pressure, as the third ranked factor for disability-adjusted life years. Hypertension is one of the primary risk factors for heart disease and stroke, the leading causes of death worldwide. Recent analyses have shown that as of the year 2000, there were 972 million people living with hypertension worldwide, and it is estimated that this number will escalate to more than 1.56 billion by the year 2025. Nearly two-thirds of hypertensives live in low- and middle-income countries, resulting in a huge economic burden. Awareness, prevention, treatment and control of hypertension is a significant public health measure. The World Hypertension League, through its national member societies, launched World Hypertension Day in 2005 and, due to its success throughout the world, it has been made an annual event. The 2006 World Hypertension Day was held on May 13; the theme of the day was "Treat to Goal", with a clear intent to ensure patient adherence and control of hypertension worldwide. In Canada, all stakeholders--professional societies, government, nongovernment organizations and industry--are working together to promote awareness of hypertension and to control it.

Chockalingam A, Ganesan N, Venkatesan S, Gnanavelu G, Subramaniam T, Jaganathan V, Elangovan S, Alagesan R, Dorairajan S, Subramaniam A, Rafeeq K, Elangovan C, Rajendran V. · American Board in Internal Medicine, National Board Cardiology, Department of Cardiology, Madras Medical College and Research Institute, Chennai, India. · Angiology. · Pubmed #16193194 No free full text.

Abstract: Cardiovascular disease is still on the increase in India owing to changing socioeconomic factors and unhealthy lifestyles. Better understanding of the role of hypertension (HTN) has led to new Joint National Committee (JNC-7) guidelines for its diagnosis and management. The authors aimed to evaluate the predictors and correlates of prehypertension (PreHTN) among adults in urban India. Study design is a cross-sectional survey among 2,007 adults in Chennai in July 2003; 1,505 men and 502 women over the age of 18 years were studied. Demographic data collected by direct interview were the following: age, smoking, alcohol intake, type of work, exercise patterns, and monthly income. Anthropometric data of height, weight, and waist and hip dimensions were measured. Blood pressure (BP) was recorded thrice, with at least 15 minutes between readings 2 and 3. The mean of readings 2 and 3 was taken for the study. Of the 2,007 people studied, 951 (47.4%) had PreHTN and 696 (34.7%) had HTN. PreHTN was found in 46.6% of the men and 49.8% of the women. PreHTN was prevalent in 47.4% of adults, and another 34.7% had hypertension (Stage I, 20%, and Stage II, 14.7%). In urban India less than 18% of adults have normal BP of less than 120/80. Multiple logistic regression analysis after age and sex correction identified obesity, diet, family history and middle-income group as correlating with PreHTN. The factors that predict HTN were age, sex, smoking, alcohol intake, sedentary lifestyle, and type of work.

Chockalingam A, Venkatesan S, Dorairajan S, Chockalingam V, Subramaniam T, Jaganathan V, Elangovan S, Alagesan R, Gnanavelu G, Arul AS. · Department of Cardiology, Madras Medical College and Research Institute, Chennai, India. · Angiology. · Pubmed #15793604 No free full text.

Abstract: Angiotensin-converting enzyme inhibitors (ACEI) are often used in preventing and treating heart failure due to regurgitant valve disease. The majority of patients with symptomatic rheumatic heart disease (RHD) have significant mitral stenosis (MS) and are denied ACEI therapy, because of the fear of hypotension in the presence of fixed obstruction. The authors assessed the safety and efficacy of ACEI in 109 consecutive patients with RHD and with significant mitral stenosis (mitral valve orifice, MVO < 1.5 cm2)and with NYHA class III or IV heart failure symptoms. Mean age was 33.1+/-12 years, systolic blood pressure (BP) was 111+/-10, and diastolic BP was 73+/-8 mm Hg. MS was significant in 100 patients with mitral regurgitation in 46, aortic regurgitation in 19, and pulmonary hypertension in 60 patients. After initial stabilization, enalapril 2.5 mg bid was started in hospital and titrated up to 10 mg bid over 2 weeks. NYHA status, Borg score, and 6-minute walk test were assessed at baseline, and at 1, 2, and 4 weeks. Seventy-nine of the 100 patients who completed the study had severe MS (MVO < 1.0 cm2). Enalapril was well tolerated by all study patients without hypotension or worsening of symptoms. NYHA class (3.2+/-0.5 baseline vs 2.3+/-0.5 at 4 weeks, p < 0.01) Borg Dyspnea Index (7.6+/-1.3 vs 5.6+/-1.3, p < 0.01), and 6-minute walk distance (226+/-106 vs 299+/-127 m, p < 0.01) improved significantly with enalapril. Patients with associated regurgitant lesions showed more improvement in exercise capacity (120+/-93 vs 39+/-56 m, p < 0.001). Enalapril was well tolerated in patients with RHD with moderate and severe MS. Irrespective of the valve pathology, enalapril improved functional status and exercise capacity with maximum benefit in patients with concomitant regurgitant valvular heart disease.

Chockalingam A, Prabhakar D, Dorairajan S, Priya C, Gnanavelu G, Venkatesan S, Chockalingam V. · Institute of Cardiology, Madras Medical College and Research Institute, Chennai, India. · J Heart Valve Dis. · Pubmed #14765832 No free full text.

Abstract: BACKGROUND AND AIM OF THE STUDY: Rheumatic fever (RF) and chronic rheumatic heart disease (RHD) are common in developing countries. Two-thirds of RHD patients are school-children aged between 5 and 15 years. Pre-schoolers aged <5 years are not immune to RF however, and to date RHD patterns in this very young age group have not been studied systematically. METHODS: Records of all RHD patients seen at the authors' institution between January 1999 and December 2000 were retrospectively reviewed. A special analysis was conducted among pre-school children aged <5 years. RESULTS: Thirty-eight (6.8%) of the RF/RHD admissions were aged <5 years, and 28 of these patients (20 males, 8 females) presented with acute RF. The mean age of acute RF diagnosis was 4 years. All RF/RHD patients aged <5 years were in normal sinus rhythm. Joint pain and swelling (25 cases; characteristic migratory polyarthritis in six, monoarthritis in five) and fever (24 cases) were the most frequent symptoms. Arthritis, carditis and chorea occurred in 75%, 50% and 4% respectively, with no instances of erythema marginatum or subcutaneous nodules. Effort intolerance, chest discomfort and palpitations were reported by nine, five and three cases, respectively. Mitral regurgitation was the most common valvular lesion in RF. The youngest case of confirmed acute RF was an 18-month-old male. The only patient with mitral stenosis in the present series was a 4-year-old girl. None of the patients required surgical intervention, and there were no deaths. CONCLUSION: RHD is common in very young age groups of <5 years. Pre-schoolers account for a significant proportion of acute RF and chronic RHD admissions among children. Mitral regurgitation is the most common cardiac manifestation, but obstructive valve disease is distinctly rare in this age group. Aortic regurgitation, left ventricular dysfunction and pulmonary hypertension may complicate the course of RF in these very young children.

Chockalingam A, Gnanavelu G, Elangovan S, Chockalingam V. · Department of Cardiology, Madras Medical College and Research Institute, Chennai, India. · J Heart Valve Dis. · Pubmed #14565709 No free full text.

Abstract: BACKGROUND AND AIM OF THE STUDY: The study aim was to determine prevalence and patterns of chronic rheumatic heart disease (RHD) in developing countries, where it remains a major cause of mortality and morbidity. The incidence of different valvular lesions and complications in chronic RHD were analyzed. METHODS: The study design was a retrospective case series analysis in the setting of a tertiary care institution in southern India. Participants were consecutive patients registered under 'chronic RHD' in the cardiology department of the authors' institution over the past 20 years. Data are presented for 10,000 cases in two age groups: group I, aged < or = 18 years (n = 2,910); and group II, aged > 18 years (n = 7,090). RESULTS: Mitral regurgitation was the single most common lesion (n = 1,007) in group I, while the dominant lesion in group II was mitral stenosis (n = 2,943). Isolated aortic valve disease was seen in 130 (4.5%) and 195 (2.8%) cases in groups I and II, respectively. Tricuspid stenosis was seen in 45 cases, and rheumatic involvement of all four cardiac valves was documented in four cases. Pulmonary hypertension was present in 42.4% and 80.8% in groups I and II, respectively, and functional tricuspid regurgitation in 38.9% and 77.2%, respectively. Overall, 5.9% of patients had atrial fibrillation, 0.9% had left atrial thrombus (seen on transthoracic echocardiography) and 0.4% had embolic cerebrovascular events. Pericardial effusion was present in 0.7% cases, and infective endocarditis was noted at presentation in 0.6%. CONCLUSION: Chronic RHD in developing countries is associated with major complications and high mortality. The critical evaluation of individual lesions must be combined with frequent overall clinical evaluation in order to time appropriate medical and surgical interventions.

Khan N, Chockalingam A, Campbell NR. · The University of Calgary, Calgary, Canada. · Can J Cardiol. · Pubmed #12107423 links to  free full text

Abstract: BACKGROUND: Hypertension is a major risk factor for death that affects many Canadians, but only 16% of hypertensive Canadians are treated and have their hypertension controlled. While the control rate is very low, the 2001 Canadian Hypertension Recommendations do not recommend that low risk hypertensive patients be started on pharmacotherapy, and pharmacotherapy is not recommended for people for whom there is no demonstrable benefit from randomized, controlled trails. OBJECTIVES: To determine the proportion of hypertensive patients who are appropriately managed according to the 2001 Canadian Hypertension Recommendations. METHODS: Data from the Canadian Heart Health Survey, which surveyed a cross-sectional population (n=23,129) between 1986 and 1992, were used to determine the proportion of nondiabetic hypertensive patients who are managed according to the 2001 Canadian Hypertension Recommendations. Hypertensive patients not recommended to receive pharmacotherapy include those without risk factors and target organ damage, with a diastolic blood pressure of 90 to 99 mmHg and a systolic blood pressure of less than 160 mmHg. People with diastolic blood pressures of less than 90 mmHg who have systolic blood pressures of 140 to 159 mmHg are also not recommended to have pharmacotherapy. Patients prescribed antihypertensive therapy who had blood pressure controlled to less than 140/90 mmHg were assessed as having their hypertension managed appropriately, as were those who were not treated and were not recommended to be prescribed treatment. RESULTS: There were 58,813 (1.7%) hypertensive patients who did not have target organ damage or additional risk factors, and had a systolic blood pressure of less than 160 mmHg and a diastolic blood pressure between 90 and 99 mmHg. Twenty four per cent of hypertensive persons (831,787) had a systolic blood pressure of 140 to 160 mmHg and a diastolic blood pressure of less than 90 mmHg. About 25% (23.6%+1.7%) of hypertensive Canadians in the Canadian Heart Health Survey are not recommended to be prescribed antihypertensive therapy according to the 2001 Canadian Hypertension Recommendations. Sixteen per cent of hypertensive patients were treated and had their blood pressures controlled (blood pressure less than 140/90 mmHg). Therefore, about 41% (ie, 16%+25%) of hypertensive patients are appropriately managed according to the 2001 Canadian Hypertension Recommendations. CONCLUSIONS: The results of the Canadian Heart Health survey indicate that there are a striking number of Canadians with untreated high blood pressure (59%) who probably do not have their hypertension managed according to the 2001 Canadian Hypertension Recommendations. Greater efforts are required to identify people with hypertension, and to ensure that they are managed according to the best available evidence.