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Hepatic edema is caused by decreased hepatic protein synthesis, a consequence of decompensated liver cirrhosis. Fluid accumulation occurs when there is an increase in hydrostatic pressure in the hepatic sinusoids and splanchnic capillaries, as well as low albumin. The first-line treatment for cirrhosis-related ascites is an aldosterone antagonist (spironolactone); however, in severe and recurring ascites, a combination of aldosterone antagonists and loop diuretics (torsemide, furosemide, and bumetanide) is preferable. Torsemide outperformed furosemide in terms of natriuretic and diuretic effects at an equivalent dose. Pharmacological features of torsemide, such as lesser hypokalemia effect, longer duration of action, higher bioavailability, and extended half-life, make it a better alternative than furosemide. In clinical studies, it is considered a safer and more acceptable choice with fewer complications.

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BACKGROUND: There is limited data comparing two gliflozins on their effect on biomarkers in diabetic patients with chronic heart failure. METHODS: A prospective, multicenter, active controlled, double-arm, investigator-initiated, interventional study enrolled 250 adults with T2DM and comorbid CHF (LVEF<40%; NT-proBNP >600pg/ml). 125 patients were allocated each to Remogliflozin (R) and Empagliflozin (E) group and followed up for 24 weeks. The primary endpoint was the mean percentage change from baseline in NT-proBNP level after 24 weeks. RESULTS: There was significant improvement from baseline in mean NT-proBNP level in both groups after 24 weeks however there was no significant difference between the two groups (p= 0.214). The mean NT-proBNP level improved from 2078.15±1764.70 pg/ml at baseline to 1185.06±1164.21 pg/ml at 6 months in R-group (p≤0.001) and from 2283.98±1759.15 pg/ml at baseline to 1395.33±1304.18 pg/ml at 6 months in E-group (p= <0.001). Left ventricular ejection fraction (LVEF) and LV volumes improved in both the groups. The glycemic parameters (HbA1c, FPG and PPG) demonstrated a significant reduction from baseline to week 24 in both groups. Similar improvement was seen in heart rate, blood pressure and weight reduction over 6 months in both groups. There was no drug related serious adverse event in any group. CONCLUSION: Remogliflozin and Empagliflozin significantly improves glycemic parameters and NT-proBNP levels as the index of the therapeutic effects in T2DM patients with CHF. The positive effects are comparable in both groups.

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Objectives: To determine the prevalence of hyperuricemia (HU) in patients with hypertension (HTN) and type 2 diabetes mellitus (T2DM) in the Indian setting. Methods: A retrospective analysis of patients undergoing screening for HU in health clinics across India between April to May 2017 was carried out. Data regarding demographics, history of T2DM and HTN and uric acid levels (easy touch uric acid monitoring system) were recorded during the program. Results: Data from 3044 screening programs was analysed. The mean age of the study population was 47.9 years; about two-thirds of the subjects were males. Of the 29391 subjects screened, 25.8% were found to have HU. The proportion of diabetics, hypertensives and diabetic hypertensives who had HU was 33.6%, 35.1%, and 34.4% respectively. A trend towards increased prevalence of HU was seen with increasing age and increased duration of diseases like HTN and diabetes. Conclusion: High prevalence of HU was observed in T2DM and HTN and in patients with both co-morbidities. Age-wise analysis revealed an increasing trend of HU with age. Further, the prevalence of HU also increased with increasing duration of T2DM and HTN.

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OBJECTIVE: To describe the efficacy, superiority and safety profile of the first-in-class angiotensin receptor-neprilysin inhibitor "Sacubitril/Valsartan" as compared to angiotensin-converting enzyme inhibitors (ACEi) and angiotensin II receptor blocker (ARB) in heart failure (HF) patients, reviewing data available from both clinical and pre-clinical studies. Evidences on health care utilization outcomes such as hospitalizations and emergency department visits were also evaluated. MATERIAL (DATA SOURCE): Sources: Medical literature on 'Sacubitril/Valsartan' and 'Angiotensin Receptor-Neprilysin Inhibitor' was identified by searching databases (including, but not limited to, PubMed, Embase and HighWire) for articles published since 1991, bibliographies from published literature, clinical trial registries/databases and websites (including those of regional regulatory agencies and the manufacturer). Additional information (including contributory unpublished data) was also requested from the companies developing the drug. SEARCH STRATEGY: We conducted separate searches for each of the interventions of interest. The timeframe for both searches spanned the period from January 1991 to the most recently published data available and focused on PubMed, Embase and HighWire indexed articles. The search strategies included a combination of indexing terms as well as free-text terms included separately in 'Keywords' section. To supplement the above searches and ensure optimal and complete literature retrieval, we performed a manual check of the references of recent relevant reviews and meta-analysis. Searches were last updated on 12th July 2017. SELECTION: Studies in patients with hypertension who received sacubitril/valsartan combination drug were included. Inclusion of studies was based mainly on the methods section of the trials. When available, large, well-controlled trials with appropriate statistical methodology was preferred. Relevant pharmacodynamics and pharmacokinetics data was also included. DATA EVALUATION: Many clinical trials have been conducted comparing the efficacy of sacubitril/valsartan with other anti-hypertensives. The trials have shown sacubitril/valsartan to be more effective in improving symptoms and physical limitations, reducing the risk of cardiovascular (CV) death, HF hospitalization, and the overall mortality and morbidity compared to its counterparts. CONCLUSION: Effective reduction of blood pressure to accepted goals is the key to reduce the risk of CV events and stroke. Dual inhibition of neprilysin and the angiotensin receptor with sacubitril/valsartan may represent an attractive and serendipitous therapeutic approach for a range of CV diseases, including hypertension and HF, in which vasoconstriction, volume overload and neuro-hormonal activation play a part in pathophysiology. Sacubitril/Valsartan appears to be more efficacious in reducing blood pressure than currently available ACEi and ARBs with a similar safety and tolerability profile. Besides, pleiotropic benefits like HbA1c reduction, better eGFR progression and a greater decrease in blood pressure and serum creatinine levels make this drug a novel addition to the current hypertension armamentarium.

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OBJECTIVE: To describe the efficacy and safety profile of the new angiotensin receptor blocker (ARB), "Azilsartan Medoxomil", reviewing data available from both clinical and pre-clinical studies. MATERIAL: We completed a review of the English literature from PubMed using the keywords- azilsartan medoxomil, angiotensin receptor blockers (ARB), angiotensin converting enzyme inhibitors (ACEi) and hypertension. DATA EVALUATION: Many clinical trials have been conducted comparing the efficacy of azilsartan with other ARB's and also with the ACEi ramipril. The trials have shown azilsartan to be more effective in reducing the mean 24-hour systolic blood pressure compared to its counterparts. CONCLUSIONS: Azilsartan is a recently approved ARB and appears to be more efficacious in reducing blood pressure (BP) than the other ARBs with a similar safety and tolerability profile. Azilsartan's very high affinity to and slow dissociation from the angiotensin 1 receptor (AT1R) along with its inverse agonistic properties make it a very good candidate for clinical effects beyond simple BP control, potentially counteracting cardiac hypertrophy, cardiac fibrosis and insulin resistance, together with improved reno-protection and atherosclerotic plaque stabilization.

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Acromegaly is a rare condition with an approximate incidence of 3-4 new cases per million per year and occurs as a result of excess secretion of growth hormone (GH). It is associated with several cardiovascular manifestations of which dilated cardiomyopathy with systolic and diastolic dysfunction is relatively rare but associated with increased mortality. There are very few documented cases of acromegaly with dilated cardiomyopathy in Indian female patients in literature, thus justifying the uniqueness of our case. We report a case of acromegaly in a 41 year old female patient who remained undiagnosed for 6 years and presented to us for the first time with symptoms of heart failure. The symptoms were attributed to dilated cardiomyopathy resulting from a prolonged and excessive exposure of the myocardium to a GH secreting pituitary tumor. Subsequently she underwent trans-sphenoidal resection of the pituitary macroadenoma.

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OBJECTIVE: To study the practice pattern in the management of patients with stable angina (SA) in India. METHODS: The Stable Angina obseRvational Registry (STAR) prospectively enrolled patients provisionally diagnosed with SA by non-interventional practicing internists in India. Patients were followed for 3 months after enrollment to assess medical treatment, diagnostic management, and interventional treatment of coronary artery disease (CAD). At the study conclusion, a statistical analysis retrospectively categorized patients not at risk of CAD by the Morise-Jalisi scale though this was not part of the study protocol. RESULTS: Between January and May 2012, 2079 patients were enrolled at 131 centres. Mean age was 57 ± 11 years, 62% were men, and 40% had a history of diabetes. Over 90% of patients completed follow-up visit, >85% received statins and antiplatelet medications, >70% received beta blockers, and >60% received angiotensin-converting-enzyme inhibitors or angiotensin receptor blockers. Diagnostic testing rates were low: 93% for electrocardiogram, 44% echocardiogram, 42% chest radiography, 12% stress test, and 8% underwent noninvasive CT or invasive coronary angiography, of which, 86% had abnormal results. After the study, the Morise-Jalisi probability of CAD was intermediate in 42% and high in 51% of patients. Only 3.4% of all patients had coronary revascularization. CONCLUSIONS: In a large cohort of Indian patients with SA, disease severity and probability of CAD were high. Clinicians used evidence-based care for medical management, but underutilized diagnostic testing. Patients with SA in India need to be risk-stratified for probability and severity of CAD and, if indicated, receive additional diagnostic testing.

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Globally, antimicrobial resistance is alarming concern especially in commonly reported disease entities like respiratory tract infection, enteric fever and infections associated with gram-negative bacilli (GNB). Rational use of antimicrobial drugs reported significant decrease in bacterial burden and may also reduce the risk of disease progression. However, at times in particular indication, certain patient and pathogen factor limits the selection and use of specific antibiotic therapy while in some case, due to presence of additional risk factor, aggressive therapy is required to achieve clinical reemission and prevent complications. Delay in start of suitable antibiotic therapy is another imperative factor for treatment failure and rise of drug resistance. With rapidly increasing antibiotic resistance and decline in new antibiotic drug development, the toughest challenge remains to maintain and preserve the efficacy of currently available antibiotics. Therefore, the best rational approach to fight these infections is to 'hit early and hit hard' and kills drug-susceptible bacteria before they become resistant. The preferred approach is to deploy two antibiotics that produce a stronger effect in combination than if either drug were used alone. Various society guidelines in particular indications also justify and recommend the use of combination of antimicrobial therapy. Combination therapies have distinct advantage over monotherapy in terms of broad coverage, synergistic effect and prevention of emergence of drug resistance.