This document summarizes the topics discussed at a journal club meeting led by Dr. Praveen Nagula. It includes discussions on valvular heart disease patterns in India, guidelines for ambulatory blood pressure monitoring, baroreflex activation therapy, electrocardiogram challenges, and the PREVAIL trial. It also reviews the incidence and characteristics of various valvular lesions seen on echocardiography at a large cardiac center in India, highlighting rheumatic heart disease as a major cause. Guidelines for the clinical use and interpretation of ambulatory blood pressure monitoring are summarized.

1. JOURNAL CLUB
DR.PRAVEEN NAGULA

2. Contents
 1.Valvular Heart Disease In India
 2.ESH PRACTICE GUIDELINES for ABPM
 3.BAT (BAROREFLEX ACTIVATION THERAPY)
 4.ECG Challenge
 5.PREVAIL Trial
 6.Update on PCSK9 Inhibitors
 7.Abstracts
2

3. Indian Heart Journal,July 2014 3

4. Background
 Diseases of the heart valves constitute a major cause of
cardiovascular morbidity and mortality worldwide with rheumatic
heart disease (RHD) being the dominant form of valvular heart
disease (VHD) in developing nations.
 The current study was undertaken at a tertiary care cardiac center with
the objective of establishing the incidence and patterns of VHD by
Echocardiography (Echo).
4

5.  Among the 136,098 first-time Echocardiograms performed
between January 2010 and December 2012, an exclusion
criterion of trivial and functional regurgitant lesions,yielded a
total of 13,289 cases of organic valvular heart disease as the
study cohort.
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6. 6

7.  In RHD, the order of involvement of valves was mitral (60.2%),
followed by aortic, tricuspid and pulmonary valves.
 Mitral stenosis, predominantly seen in females, was almost
exclusively of rheumatic etiology (97.4%).
 The predominant form of isolated MR was rheumatic (41.1%)
followed closely by myxomatous or mitral valve prolapse (40.8%).
 Isolated AS, more common in males, was the third most common
valve lesion seen in 7.3% of cases. Degenerative calcification was
the commonest cause of isolated AS (65.0%) followed by bicuspid
aortic valve (BAV) (33.9%) and RHD (1.1%).
7

8.  Multiple valves were involved in more than a third of all
cases (36.8%). The order of involvement was
MS  MR > MS  AR > MR  AR > AS  AR > MR  AS
> MS  AS.
 Overall, 9.7% of cases had organic tricuspid valve disease.
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9. 9

10. Age and sex distribution
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11. 11

12. Mitral stenosis
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13. Pul HTN among MS pts
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14. 14

15. 15

16.  Most common is MS+MR (AS +MR – Euro Heart Survey* )
 Least combination was that of MS +AS.
 Multivalvular disease was seen more in Females (1.2:1)
 Lesion combinations involving MS were common in females,
while all AS combinations were in males.
 MR+AR > MS + AR - paediatric age groups (reverse in Adults)
 In RHD,the combinations were ….
VALVE LESION
COMBINATION
PROPORTION OF
CASES
MS +MR (46.6%)
MS +AR (26.5%)
MR +AR (23.3%)
AS +AR (2.4%)
MR +AS (0.9%)
MS+AS (0.3%) 16

17. Isolated AS
17

18. 18

19. 19

20.  Roberts and Virmani et al – Tricuspid involvement is 12% - TS -
2% (seen in cases with MS and AS )(necropsy series)
 Hauck et al ,series of TR - RHD and Ebsteins anomaly (41 and
14% ) ,present study 70.2% and 15.4%
20

21. Conclusion
 RHD contributed most to the burden of VHD in the present
study with calcific degeneration, myxomatous disease and BAV
being the other major forms of VHD.
 Multiple valves were affected in more than a third of all cases.
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22. EUROPEAN SOCIETY OF HYPERTENSION
PRACTICE GUIDELINES FOR
AMBULATORY BLOOD PRESSURE
MONITORING
G.Parati et al,J Hypertension 2014,32:1359-1366
Consensus document 22

23. Introduction
 Blood Pressure (BP) varies widely through a 24 hr period.
 Ambulatory blood pressure monitoring (ABPM) involves
measuring BP at regular intervals(usually every 20-30 min)over a
24 hr period while patients undergo normal daily activities
including sleep.
 Accuracy validated over all ages.
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24. How came the idea of ABPM??
 Blood pressure is a highly dynamic parameter with continuous
fluctuations having both short term and long term variability.
 Short term variability within 24 hrs can be readily assessed by
ABPM.
 Long term variability- BP measurements over days,weeks,or
months with repeated measurements of office,HBPM,ABPM.
 Short term variability can be considered for risk stratification.
Not a parameter for routine use in clinical practice.
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25. Advantages of ABPM
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26. Why these guidelines ???
 ESH 2013 ABPM position paper.
 Evidence from over 600 papers,34 international experts in
HTN.(Milan,2011)
 Reference source for ABPM.(obviously)
 Main conclusions that are directly relevant to clinical practice
are presented and updated.
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27. Questions addressed …
 Which patients should have ABPM?
 How to apply and interpret ABPM in daily practice?
 How to introduce an ABPM serivce in routine clinical
practice?
27

28. Indications
 1.white coat HTN in untreated patients (most well established
indication)
 2.identify varying 24 hr BP profiles.
 3.identify masked HTN
 4.assessment of treatment efficacy.
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29. 29

30. 30

31. Definition of white coat hypertension
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32. Masked HTN, Masked uncontrolled HTN
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33. 33

34. Fall of Nocturnal
SBP,DBP
Ratio of
night/day
SBP,DBP
Remarks
DIPPING >10% <20% >0.8 < 0.9 Normal
REDUCED
DIPPING
1-10% >0.9 < 1.0 Increased CV risk
NON DIPPING,
RAISING
Increase in BP ≥1 Increased CV risk
EXTREME
DIPPING
>20% <0.8 debatable
NOCTURNAL
HTN
>120/70mm Hg
34

35. Normal daytime and night time BP with preserved dipping.BP increase only in the
white coat windows at the beginning and the end of the ABP recording.
Dagnosis –WHITE COAT HYPERTENSION
35

36. ABPM in a 45 yr old driver,
clinic BP -138/88 mm Hg Diagnosis ?
Masked Hypertension
Increased day time BP particularly during working hours(bus
driver) and increased night time BP with preserved dipping.
Clinic BP at138/88 mm Hg 36

37. Clinic BP at 146/86mm Hg..diagnosis?
Daytime HYPERTENSION with preserved nocturnal BP dipping
BP constantly elevated during day time(awake) with low night time (asleep) BP 37

38. Clinic BP at 152/88 mm Hg..diagnosis?
 NON DIPPING HYPERTENSION
 Elevated 24 h ambulatory BP with reverse BP dipping at night(BP rising
pattern) in a patient with moderate form of OSA.
 Bad prognosis 38

39. 39

40. 40

41. 41

42. 42

43. 43

44. 44

45. 45

46. 46

47.  Welch Allyn ABPM 6100 Demonstration.mp4
 Wearing a 24 hour blood pressure
monitor[12].mp4
47

48. What would be an adequate cuff for Blood
pressure monitoring?
48

49. BP cuff sizes in children
49

50. 50

51. BAROREFLEX
ACTIVATION THERAPY

52. Baroreflex activation therapy
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53. 53

54. 54

55.  Barostim neo video.mp4
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56. 56

57. 57

58. 58

59. 59

60. ECG CHALLENGE

61. 61

62. 62

63.  Supraventricular tachycardia
 WPW syndrome,Left lateral pathway
 AVRT ,orthodromic
 QRS alternans.
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64. 64

65. 65

66. 66

67. 67

68.  Acute evolving anterior transmural MI
 Post Thrombolysis – AIVR.
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69. 69

70. 70

71. 71

72. 72

73. 73

74.  Acute inferior ST segment elevation myocardial
infarction.
 Second degree AV block(Mobitz type I)
74

75.  What is pardee’s sign ?
75

76. ST elevation as a sign of coronary
obstruction.
1920.
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77. 77