A journal club on the Practice of Indian Physicians Towards Use of Calcium Channel Blockers in the Management of
Hypertension A Paper Based Questionnaire Survey, research.
journal club is one of the important academic activity during MD/MS courses. Present PPT is a journal club presented on an article that compare two antihypertensives and the presentation also includes critical analysis of the article.
Pesit trial New England Journal of MedicineDr fakhir Raza
first episode of syncope, should we do workup for Pulmonary embolism well simplified criteria D dimer level CT angiogram ventilation perfusion scanning
journal club is one of the important academic activity during MD/MS courses. Present PPT is a journal club presented on an article that compare two antihypertensives and the presentation also includes critical analysis of the article.
Pesit trial New England Journal of MedicineDr fakhir Raza
first episode of syncope, should we do workup for Pulmonary embolism well simplified criteria D dimer level CT angiogram ventilation perfusion scanning
Risk factors for medical complications of acute hemorrhagic strokePavan Lomati
Our study has assessed that hypertension followed by diabetes mellitus are the major risk factors for medical complications of hemorrhagic stroke. Female mortality
rate was more when compared to males.
COMPARES OPTIMAL MEDICAL THERAPY WITH INVASIVE THERAPY IN A PATIENT WITH STABLE ISCHEMIC HEART DISEASE WITH MODERATE TO SEVERE MYOCARDIAL ISCHEMIA ON NON INVASIVE STRESS TESTING
Primary PCI with stenting immediately after coronary reperfusion salvage procedures jeopardizes myocardium, improves prognosis, and is the current standard of care for acute STEMI .
No-reflow is defined as an acute reduction in myocardial blood flow despite a patent epicardial coronary artery .
The pathophysiology of no-reflow involves microvascular obstruction secondary to distal embolization of clot, microvascular spasm, and thrombosis .
No-reflow occurs in ~10% of cases of primary PCI and is associated with patient characteristics such as advanced age and delayed presentation and coronary characteristics such as a completely occluded culprit artery and heavy thrombus burden .
Inflammation plays a crucial role in the initiation and progression of atherosclerotic disease.
Monocyte chemoattractant protein-1 (MCP-1) is a member of the C-C chemokine family that is produced by monocytes or macrophages, smooth muscle cells, and endothelial cells within atherosclerotic plaques.
In addition to its established role in the pathogenesis of atherosclerotic disease progression and plaque rupture, MCP-1 is also involved in the reparative response, such as arteriolar remodeling and restenosis after an acute coronary event.
Risk factors for medical complications of acute hemorrhagic strokePavan Lomati
Our study has assessed that hypertension followed by diabetes mellitus are the major risk factors for medical complications of hemorrhagic stroke. Female mortality
rate was more when compared to males.
COMPARES OPTIMAL MEDICAL THERAPY WITH INVASIVE THERAPY IN A PATIENT WITH STABLE ISCHEMIC HEART DISEASE WITH MODERATE TO SEVERE MYOCARDIAL ISCHEMIA ON NON INVASIVE STRESS TESTING
Primary PCI with stenting immediately after coronary reperfusion salvage procedures jeopardizes myocardium, improves prognosis, and is the current standard of care for acute STEMI .
No-reflow is defined as an acute reduction in myocardial blood flow despite a patent epicardial coronary artery .
The pathophysiology of no-reflow involves microvascular obstruction secondary to distal embolization of clot, microvascular spasm, and thrombosis .
No-reflow occurs in ~10% of cases of primary PCI and is associated with patient characteristics such as advanced age and delayed presentation and coronary characteristics such as a completely occluded culprit artery and heavy thrombus burden .
Inflammation plays a crucial role in the initiation and progression of atherosclerotic disease.
Monocyte chemoattractant protein-1 (MCP-1) is a member of the C-C chemokine family that is produced by monocytes or macrophages, smooth muscle cells, and endothelial cells within atherosclerotic plaques.
In addition to its established role in the pathogenesis of atherosclerotic disease progression and plaque rupture, MCP-1 is also involved in the reparative response, such as arteriolar remodeling and restenosis after an acute coronary event.
Comparison Of Frequency Of Successful Treatment In Hypertensive Patients Trea...MazharIqbal393276
Hypertension is the most common modifiable risk factor for cardiovascular diseases, stroke and renal failure with a reported prevalence of less than 10% in 18-19 years to greater than 60% in over 70 years old Pakistani adults.
It is estimated that more than one billion adults are hypertensive worldwide and this figure is projected to increase to 1.56 billion by the year 2025, which is an increase of 60% from year 2000
Clinical evidence suggests that lowering blood pressure with antihypertensive drugs reduces the risk of myocardial infarction, stroke, heart failure , revascularization procedures and end stage renal diseases in hypertensive patients.
Various classes of antihypertensive drugs like diuretics, beta blockers, calcium channel blockers and inhibitors of renin angiotensin system have been shown to reduce hypertension complications.
Among calcium channel blockers, amlodipine is a commonly prescribed antihypertensive with proven efficacy. However, the troublesome adverse reactions of amlodipine are development of pedal edema and other vasodilation related side effects like headache, dizziness, flushing, palpitation etc.
Lercanidipine is a third generation CCB claimed to have sustained blood pressure lowering with single daily dosing and CCBs related side effects are claimed to be low.
Cardiovascular disease (CVD) reduces the quality of life in patients and remains the leading cause of mortality globally.
Despite a number of preventive strategies for CVD, recommended by multiple scientific societies, there is a clear barrier to their effective implementation.2 In this regard, regular evaluation of the implementation of the CVD prevention guidelines may find the gaps in effective implementation of the guidelines that may help in reducing premature mortality and improving the quality of life in coronary heart patients.
Single Unit Transfusion policy Academic Detailing - Towards a more restrictive blood prescribing culture in the health care setting
Similar to Practice of Indian Physicians Towards Use of Calcium Channel Blockers in the Management of Hypertension A Paper Based Questionnaire Survey (20)
TDM is increasingly being used in clinical practice in order to improve the therapeutic outcome and reducing the toxicity in HIV infection.
The use of TDM requires certain criteria in order to interpret the plasma concentrations appropriately.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
2. Practice of Indian Physicians Towards Use of
Calcium Channel Blockers in the Management of
Hypertension : A Paper Based Questionnaire
Survey
Kalpesh Dalvi, Medical Advisor,
Abhijit Trailokya, Chief Manager, Medical Affairs,
Kamlesh Patel, General Manager, Medical Affairs
— Abbott Healthcare, Mumbai, Maharashtra, India.
ARCH INTERN MED/VOL 172 (NO. 2), JAN 23, 2012
Indian Medical Gazette — JANUARY 2015 2
3. ABSTRACT
Background: Hypertension is a prevalent condition. Improving blood pressure
control would depend on understanding concerns and limitations of physicians.
Objective: Understanding practice of calcium channel blockers use among
physicians.
Material and methods: A cross-sectional, observational paper based questionnaire
survey among 218 Indian physicians.
Results: According to 55.83% of physicians (n=218), prevalence of hypertension
ranges between 21-40%. Sixty percent physicians get referred cases mostly from
the general physicians (69.48%). More than 20% patients have concomitant illness
according to 33.81% physicians, most common being diabetes (33.44%).According
to 96.30% physicians, due to asymptomatic nature, hypertension remains
undiagnosed, untreated and uncontrolled. Stress (32.35%), obesity (23.13%),
physical inactivity (22.78%) and smoking (20.52%) are responsible for sympathetic
over activity. Calcium channel blockers (CCBs) (37.19%), beta blockers (30.43%),
angiotensin receptor blocker (ARB) (12.14%) and angiotensin converting enzyme
(ACE) inhibitors (4.02%) are used as first choice in patients with sympathetic over
activity. Ischemic event, stroke, heart failure and renal failure occur due to ignoring
sympathetic over activity according to 30.91%, 25.39%, 20.97% and 22.30%
physicians respectively. 3
4. • According to 51.63% of physicians, patient compliance to
antihypertensive therapy is > 70%. Lack of awareness (40.5%) and
dosage frequency (24%) are two most common reasons for
noncompliance. According to 89.72% of physicians, the current CCBs
primarily inhibit L-type calcium channels but cause sympathetic over
activity. A total of 48.34% physicians, >10% patients complain of pedal
edema with amlodipine. In physicians opinion, blockage of L and N type
of calcium channels (56.47%), unique mode of action (11.76%),
arteriolar and venous dilation (9.41%) and inhibition of
reninangiotensin- aldosterone (RAS) system (7.06%) are responsible for
less pedal edema with cilnidipine. A total of 98.7% and 99.54%
physicians rated efficacy and safety of cilnidipine as “good-very good”
compared to other CCB respectively.
• Conclusion: In hypertension, sympathetic over activity may cause many
complications. As per the physicians opinion survey, cilnidipine because
of its unique mechanism of action offers multiple benefits in
hypertensive patients and can be preferred over amlodipine.
• Keywords:hypertension, sympathetic over activity, physicians based
questionnaire survey, calcium channel blocker, cilnidipine.
5. • Hypertension, a common chronic disease worldwide is a major risk factor
for cardiovascular disease. The problem of hypertension in India is soaring
with reported prevalence in urban and rural population about 25% and 15%
respectively. Treating this highly prevalent condition without significant
adverse events is very important. Though some hypertensive patients may
consult cardiologist, nephrologist or endocrinologist directly, but general
physicians also play a very important role in the management of
hypertension in India. Secondly, cooperation of patients also plays a critical
role in the management of hypertension. For the treatment of hypertension,
various classes of antihypertensive agents such as angiotensin converting
enzyme inhibitors (ACE inhibitors), angiotensin receptor blockers (ARBs),
calcium channel blockers (CCB), beta blockers, diuretics, and their
combinations are available in India. The selection of one drug over the
other may depend on various factors including patient profile, age,
associated comorbid conditions, cost of therapy, side effects etc. We
believed that improving control of increased blood pressure in clinical
practice would depend on understanding the concerns of physicians and
limitations in the management of hypertension mainly related to
pharmacotherapy and trying to provide solutions for these concerns and
limitations. 5
Introduction
6. • To understand the approach and practice of using calcium channel
blockers in the treatment of hypertension among physicians in India.
6
Objective
7. MATERIALS AND METHODS
A cross-sectional, observational questionnaire-based survey was
conducted among 218 physicians in India. The duration of this survey
was from June 2013 to December 2013. The physicians practicing
independently and in the hospitals in metro and tier I cities were
included in the survey. The study participants were provided a paper
based questionnaire survey format comprising of four sections;
epidemiology, approach to diagnosis and management of
hypertension, use of CCBs and cilnidipine 5 and 10 mg. The
physicians willing to fill the complete survey format were enrolled.
The overall information regarding the approach to the management of
hypertension while using antihypertensive agents with focus on CCBs
was collected.
The filled survey forms were returned by the physicians with the
medical representatives.
7
8. • Number of responses to each question was categorized
and percentages for all the responses were calculated.
Missing data was not considered for calculating
percentages.
Statistical Analysis
9. RESULT
9
•Total 218 physicians were enrolled in this survey. The results of the survey are
only subjective, recording opinion of physician based on their clinical
experience and practice. According to 55.83% of physicians, the prevalence of
hypertension in India ranges between 21-40%. Most of the physicians (80.18%)
see more than 20 hypertensive patients in a month. Only 6.14% physicians see
about 6-10 patients per month while 13.36% physicians see between 11-20
patients per month. The number of physicians treating hypertensive patients in
different age groups was almost similar. A total of 25.63% of physicians treat
patients between age group of 40-50 years and 50-60 years each.
The number of physician treating hypertensive patients between 60-70 years and
>70 years were 25.13% and 23.62% respectively. Most of the physicians
(73.92%) come across more than ten percent newly diagnosed patients in their
practice while remaining physicians treat less than ten percent of newly
diagnosed cases of hypertension. Sixty percentage of physicians get referred
cases of hypertension while others 39.37% physicians seen hypertensive patients
directly. Most of the cases are referred by general physicians (69.48%) or
consulting physicians (17.53%) while others are referred by the other specialties
e.g. gynecologists etc.
10. • The percentage of pre-hypertensive (32.10%), stage 1 (34.18%) and
stage 2 (33.72%) hypertension is approximately same among newly
diagnosed hypertensive cases (Fig. 1).
• Concomitant illness is often observed in patients with hypertension.
More than 20% patients have concomitant illness according to 33.81%
physicians. Less than 5% cases have concomitant illness according to
9.05% physicians while according to 28.57% physicians, 6-10% and 11-
20% of the patients have concomitant illness. In stage 1 hypertensive
patients, the most common illness is diabetes (33.44%) followed by
coronary heart disease (25.86%), chronic kidney disease (23.23%) and
heart failure (15.65%) (Fig. 2).
• Most of the physicians (96.30%) physicians agree that in many patients
due to asymptomatic nature, hypertension remains undiagnosed,
untreated and uncontrolled. Similarly, according to 97.71% physicians,
sympathetic over activity is one of the major causes for hypertension.
Stress (32.35%), obesity (23.13%), physical inactivity (22.78%) and
smoking (20.52%) are the major reasons for sympathetic over activity
(Fig. 3).
• According to 79.25% physicians sympathetic over activity is present in
up to 50% of the newly diagnosed patients with hypertension. A total of
18.40% and 2.36% of physician believe that sympathetic over activity is
present in about 51-75% and 76-100% newly diagnosed hypertensive
patients.
11.
12.
13. • Amongst antihypertensive drugs, ACE inhibitors, ARBs, CCBs and beta blockers are used
for the management of hypertension with sympathetic over activity by 23.72%, 24.54%,
24.74% and 24.54% physicians respectively. Calcium channel blockers (37.19%), beta
blockers (30.43%), ARBs (12.14%) and ACE inhibitors (4.02%) are first choice for the
management of hypertensive patients with sympathetic over activity amongst
antihypertensive drugs and Beta blockers (26.09%), CCBs (23.97%), ARBs
• (19.90%) and ACE inhibitors (19.4%) are used as second choice agent in the management
of hypertensive patients with sympathetic over activity. Ischemic events, stroke, heart
failure and renal failure are the consequences of ignoring sympathetic over activity in
patients with high blood pressure according to 30.91%, 25.39%, 20.97% and 22.30%
physicians respectively (Fig. 4).
• First three indications for the use of calcium channel blockers are elderly patients (36.27%),
isolated systolic blood pressure (23.53%) and diabetes (11.27%).
• According to 51.63% of physicians, the compliance rate in hypertensive patients is more
than 70% while remaining physicians feel, the compliance rate is less than 70%.
• The most common reason for non-compliance is lack of awareness (40.5%) while second
most common reason is dosage frequency (24%). The other causes of noncompliance in
hypertensive patients are lack of visible advantages of medicine to the patient (18%) and
precautions to be taken while taking medicines (12%) (Fig. 5).
• A total of 76.78% physicians preference use of CCB only in established cases of
hypertension with sympathetic over activity because of less side effects (46.67%), good
efficacy (26.67%), once daily dosage/long duration of action (11.11%) or cost (8.89%).
14.
15. • The four most common benefits considered by the physicians while prescribing
CCBs are safety/tolerability profile of the agent (30.24%), blood pressure control
(27.42%), compliance (6.05%) and cost (4.44%).
• According to most of the physicians (89.72%), the current CCBs primarily inhibit
L-type calcium channels and reduce blood pressure, but they stimulate sympathetic
nerve activity leading to reflex tachycardia.
• The five most common patients profiles where cilnidipine 5/10 mg is used in the
management of hypertension are elderly patients (>50 yrs) (12.03%), diabetic
hypertensive patients (10.79%), all hypertensive patients (10.37%), young
hypertensive (6.64%) and stage 1 hypertension (6.64%)
• The dose of cilnidipine used ranges between 5 to 40 mg per day mostly once daily
(73.21%) or twice daily (26.79%). Most of the physicians (62.64%) use cilnidipine
for one month to one year while 10.44% physicians believe that it needs to
continue for long time. A total of 8.79% physicians consider it needs to be given for
life long.
• A total of 48.34% physician mentioned that >10% patients complain of pedal
edema with amlodipine while 29.86% physicians said, pedal edema is seen in 5-
10% of patients. Almost all (99.52%) physicians feel that introduction of
cilnidipine would minimize the incidence of pedal edema.
16. • Blockage of L and N type of calcium channels (56.47%), unique mode of
action (11.76%), arteriolar and venous dilation (9.41%) and inhibition of
rennin-angiotensinaldosterone system (7.06%) are the four important
reasons recognized by the physicians responsible for less pedal edema with
cilnidipine.
• According to 48.08% of the physicians >36% patients who were
prescribed cilnidipine showed satisfactory control of blood pressure. Most
of the physicians (96.67%) agree that cilnidipine helps to increase the
compliance in hypertensive patients because of reduced ankle edema
(33.53%), no or less side effects (21.56%), once daily dosage (13.77%),
good blood pressure control (8.98%) and less or no reflex tachycardia
(7.19%).
• Most of the physicians 98.7% rated efficacy of cilnidipine as “good-very
good” compared to other CCB. Similarly, 99.54% physicians rated the
safety of cilnidipine as “good-very good” (Table 1).
• The dilatation of efferent and afferent arterioles, reduction of glomerular
pressure and rennin secretion and reduction of proteinuria were reported as
properties responsible for reno-protection with cilnidipine by 87.50% of
the physicians (Table 2).
17.
18. DISCUSSION
18
•More than 20% physicians use ACE inhibitors, ARB, calcium channel blocker (CCBs)
and beta blockers for the management of hypertension with sympathetic over activity.
CCBs are widely used in the treatment of hypertension6. CCBs are used more than beta
blockers, ARB and ACE inhibitors as first choice in hypertensive patients with
sympathetic over activity. However, it should be noted that because of complications of
increased sympathetic tone dihydropyridine type of calcium channel blockers with slow
onset of action without reflex activation of the sympathetic tone should be used5. L/N-
type calcium channel blockers have sympatholytic action7. Cilnidipine is a L/N-type
CCB, used in the treatment of essential hypertension 8 which has a slow onset but long-
lasting action.
•Chronically elevated sympathetic tone may cause adverse impact on heart, kidney and
blood vessels. The results of such sustained sympathetic over activation can lead to
ischemia, heart failure, hypertrophy, stroke and atherosclerosis. Large number of
physicians in this study agreed that ignoring sympathetic over activity may lead to
ischemic event, stroke, heart failure and renal failure.
•Non-adherence to medications is a major concern in the management of chronic disease
such as hypertension10,11. Close to half of the physicians in this study reported that
compliance rate in hypertensive patients is less than 70%.
•Patients’ levels of hypertension awareness is low1, which has been seen both in urban
and rural patients in India2. Lack of knowledge is associated with noncompliance12.
19. • In this study also, the most common reason for noncompliance reported is lack of
awareness followed by dosage frequency of antihypertensive agents. Lesser frequency of
administration may help to improve the patient compliance. Cilnidipine can be used once
or twice daily13. Education of patients about disease and its management also helps to
improve adherence which results in improved treatment outcomes14.
• Most of the physicians believe that the current calcium channel blockers primarily inhibit
L-type calcium channels, but cause reflex tachycardia because of the stimulation of
sympathetic nerve activity. In this regards, L/N-type calcium channel blockers such as
cilnidipine have an advantage because of the sympatholytic action7.
• Calcium channel blockers are associated with risk of peripheral edema as a side effect
which may reduce patient compliance 15. Amlodipine is an L-type calcium channel
blocker (CCB) which causes ankle edema as a common adverse effect 8. Many physicians
mentioned patients often complain of pedal edema with amlodipine. Use of cilnidipine
may minimize pedal edema, because of the unique mechanism of action such as blockage
of L and N type of calcium channels. L/N-type calcium channel blockers have reno-
protective effect because of the dilation of afferent and efferent arterioles of the renal
glomerulus. The L/N type calcium channel blockers provide better protection against
organ damage compared to L-type calcium channel blockers in hypertension7. In the
hypertension, protection against organ damage with L/N type calcium channel blockers is
better compared to L-type calcium channel blockers7. Cilnidipine inhibits renal RAS,
protects podocytes 6 and prevents development of proteinuria16. Renoprotective effects of
cilnidipine are induced via mechanisms independent of renal sympathetic nerve
inhibition6.
20. Limitations
• The study has some limitations:
• First, it was a cross sectional survey and the responses were
subjective.
• Secondly, the survey forms were provided through medical
representative and filled forms were also collected by the medical
representatives; hence the bias towards product benefits can-not be
ruled out.
21. Conclusion
• Hypertension is a common disease in Indian population. Elevated
sympathetic hyperactivity can lead to various complications in
hypertensive patients. Cilnidipine because of its unique mechanism
of action i.e. L/N calcium channel blockage offers multiple benefits
in hypertensive patients. Because of less pedal edema, reduced
reflex tachycardia and reno-protections cilnidipine may be preferred
over amlodipine.
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