RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, …



"STUDY OF LEFT VENTRICULAR DIASTOLIC DYSFUNCTION IN PRIMARY HYPERTENSION AND ISCHEMIC HEART DISEASE-EVALUATION BY DOPPLER ECHOCARDIOGRAPHY AT AIMS RURAL HOSPITAL"

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SYNOPSIS OF DISSERTATION SUBMITTED TO

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

BANGALORE, KARNATAKA

In partial fulfillment of regulations for the award of

M.D. Degree in General Medicine

Submitted by

Dr. G. VIKAS NAIK M.B.B.S.

POST GRADUATE STUDENT IN

GENERAL MEDICINE (M.D.)

Under the guidance of

Dr. VASUDEVA NAIK. H. M.B.B.S., M.D.,

PROFESSOR AND HEAD,

DEPARTMENT OF GENERAL MEDICINE,

A.I.M.S., B.G.NAGARA-571448.

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DEPARTMENT OF GENERAL MEDICINE

ADICHUNCHANAGIRI INSTITUTE OF MEDICAL SCIENCES,

B.G.NAGARA-571448

2012

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE, KARNATAKA

ANNEXURE II

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

| | | |

|1 |NAME OF THE CANDIDATE |Dr. G VIKAS NAIK |

| |AND ADDRESS |P.G. IN GENERAL MEDICINE, |

| |(in block letters) |A.I.M.S., B.G. NAGARA, |

| | |MANDYA DISTRICT -571448 |

|2. |NAME OF THE INSTITUTION |ADICHUNCHANAGIRI INSTITUTE OF |

| | |MEDICAL SCIENCES, B.G.NAGARA. |

|3. |COURSE OF STUDY AND SUBJECT |M.D. IN GENERAL MEDICINE |

|4. |DATE OF ADMISSION TO COURSE |4th JUNE 2012 |

| | |"STUDY OF LEFT VENTRICULAR DIASTOLIC DYSFUNCTION IN PRIMARY HYPERTENSION |

|5. |TITLE OF THE TOPIC |AND ISCHEMIC HEART DISEASE-EVALUATION BY DOPPLER ECHOCARDIOGRAPHY AT AIMS |

| | |RURAL HOSPITAL" |

| | | |

|6. |BRIEF RESUME OF INTENDED WORK |APPENDIX-I |

| |NEED FOR THE STUDY |APPENDIX-IA |

| |6.2 REVIEW OF LITERATURE |APPENDIX-IB |

| |6.3 OBJECTIVES OF THE STUDYs |APPENDIX-IC |

| | | |

|7 |MATERIALS AND METHODS |APPENDIX-II |

| | | |

| |SOURCE OF DATA |APPENDIX-IIA |

| | | |

| |7.2 METHOD OF COLLECTION OF DATA : (INCLUDING SAMPLING PROCEDURE IF | |

| |ANY) |APPENDIX-IIB |

| | | |

| |7.3 DOES THE STUDY REQUIRE ANY INVESTIGATION OR INTERVENTIONS TO BE | |

| |CONDUCTED ON PATIENTS OR OTHER ANIMALS, IF SO PLEASE DESCRIBE | |

| |BRIEFLY. |YES |

| | |APPENDIX-IIC |

| |7.4 HAS ETHICAL CLEARENCE BEEN OBTAINED FROM YOUR INSTITUTION IN CASE| |

| |OF 7.3 | |

| | | |

| | |YES |

| | |APPENDIX-IID |

|8. |LIST OF REFERENCES | APPENDIX - III |

| | | |

|9. |SIGNATURE OF THE CANDIDATE | |

| | |The proposed study is being done to determine left ventricular dysfunction|

|10. |REMARKS OF THE GUIDE |among patients presenting with primary hypertension and acute myocardial |

| | |infarction in rural population. |

| | | |

|11. |11.1 NAME OF THE GUIDE |Dr. VASUDEVA NAIK. H. M.B.B.S, M.D. |

| | |PROFESSOR AND HEAD, |

| | |DEPARTMENT OF GENERAL MEDICINE, |

| | |A.I.M.S, B.G.NAGARA. |

| | | |

| |11.2 SIGNATURE OF THE GUIDE | |

| | | |

| | | |

| | | |

| | | |

| | | |

| |11.3 CO-GUIDE (IF ANY) |- |

| |11.4 SIGNATURE |- |

| | | |

| |11.5 HEAD OF DEPARTMENT |Dr. VASUDEVA NAIK. H. M.B.B.S, M.D. |

| | |PROFESSOR AND HEAD, |

| | |DEPARTMENT OF GENERAL MEDICINE, |

| | |A.I.M.S, B.G.NAGARA. |

| | | |

| |11.6 SIGNATURE | |

| | | |

| | | |

| | | |

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|12 |12.1 REMARKS OF THE CHAIRMAN |The facilities required for the investigation will be made available by |

| |AND PRINCIPAL |the college |

| | | |

| | |Dr. M.G. SHIVARAMU, M.B.B.S, M.D. |

| | |PRINCIPAL, |

| | |AIMS, B.G. NAGARA. |

| | | |

| |12.2 SIGNATURE | |

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APPENDIX-I

6.BRIEF RESUME OF THE INTENDED WORK

APPENDIX –I A

6.1 NEED FOR THE STUDY

Cardiovascular diseases are the most prevalent cause of death and disability worldwide. This is true for developed countries as well as developing countries like India which are expected To face a phenomenal increase in the burden of chronic diseases in the near future. Hypertension is highly prevalent in India. Recent studies give an idea about its increasing Prevalence attributable to rapid alteration of lifestyle in developing countries like India and Nepal.1

Studies showed that more than a quarter of world’s population had Hypertension in 2000 and this proportion would increase to 29% by 2025. Men and Women had similar overall prevalence of hypertension and the prevalence increased with Age consistently all over the world. Studies also negate the impact of affluence and family Size and suggest that hypertension is equally prevalent in rich and poor.2

Till the recent past, all the importance was being given to the systolic function of the heart even in the genesis of congestive heart failure, the role of systolic ventricular has been well recognized and stressed upon, time and again. But it is in this last decade that clinicians and researchers have discovered that reversible and irreversible abnormalities of left ventricular diastolic function contribute significantly to symptoms in individuals with a variety of cardiac disorders, including those with normal or near normal systolic function. This has important therapeutic implications.

Thus Diastolic Dysfunction can be used as an early indicator, as it is a precursor to increased left ventricular mass, left ventricular hypertrophy and clinical left ventricular failure.3 Doppler echocardiography is a standard non invasive method for determining early diastolic dysfunction, hence this study.

APPENDIX –I B

1. REVIEW OF LITERATURE

History

• The English clergyman Stephen Hales made the first published measurement of blood pressure in 1733.4

• Among the first to describe and work on coronary arteries were Leonardo da Vinci (1452–1519) as well as Andreas Vesal (1514–1564). William Osler (1849–1919). He worked extensively with angina pectoris as reflected in the paper “Lectures on angina”.5

• The American cardiologist James B. Herrick (1861–1954) made an important contribution to the analysis of coronary sclerosis in the paper “Clinical features of certain obstructions of the coronary arteries”.5

• Interest in the diastolic properties of the left ventricle, the nature of myocardial relaxation, and diastolic filling of the ventricles was stimulated by the early work of Henderson (1),Wiggers & Katz (2), and Meek (3)—and by the recognition that normal diastolic “function” is an important ingredient in the coordinated pump function of the heart.6

• Echocardiography has come a long way since its invention by Dr. Edler and Hertz from Sweden in the early 1950s.

DIASTOLIC DYSFUNCTION

• DEFINITION OF DIASTOLIC DYSFUNCTION7

Conceptually, diastole encompasses the time period during which the myocardium loses its ability to generate force and shorten and returns to an unstressed length and force. By extension, Diastolic dysfunction occurs when these processes are prolonged, slowed, or incomplete.

• Differentiating Diastolic dysfunction from Diastolic Heart Failure:

• Heart failure is a clinical syndrome characterized by symptoms and signs of decreased tissue/organ perfusion. Standardized criteria to diagnose heart failure have Been developed, perhaps the best validated of which come from the Framingham Study. Diastolic dysfunction refers to a condition in which abnormalities in mechanical function are present during diastole. Abnormalities in diastolic function can occur in the presence or absence of a clinical syndrome of heart failure and with normal or abnormal systolic function. Therefore, whereas Diastolic dysfunction describes an abnormal mechanical property, diastolic heart failure describes a clinical syndrome.

PREVALENCE AND ETIOLOGY:

• On average, 40 percent of patients with heart failure have preserved systolic function.8 The incidence of diastolic heart failure increases with age, and it is more common in older women.9 Hypertension and cardiac ischemia are the most common causes of diastolic heart failure. Common precipitating factors include volume overload; tachycardia; exercise; hypertension; ischemia; systemic stressors (e.g., anemia, fever, infection, thyrotoxicosis); arrhythmia (e.g., atrial fibrillation, atrioventricular nodal block); increased salt intake; and use of nonsteroidal anti-inflammatory drugs.

MORTALITY:

The annual mortality rate for patients with diastolic heart failure ranges from 5 % to 8%. In patients with diastolic heart failure the prognosis is also affected by the pathological origin of the disease. Data suggests an increasing amount of mortality in patients > 70 years with systolic and diastolic dysfunction is almost equivalent.15, 16

MORBIDITY:

Morbidity from diastolic heart failure is quite high which requires frequent hospital admissions and outpatient visits. The 1- year re- admission rate approaches 50% in patients with diastolic heart failure15,16

ECHOCARDIOGRAPHY:

The term echocardiography refers to a group of tests that utilize ultrasound to examine the heart and record information in the form of echoes, i.e., reflected sonic waves. Today it is recognized one of the most important diagnostic techniques available in cardiovascular medicine.

TYPES OF ECHOCARDIOGRAM:

1) M- Mode: This provides unidimensional time motion image of the cardiac structures with great sensitivity. M stands for motion.

2) Two – dimensional: This provides two dimensional view of the cardiac structures. It can be static or real time.

3) Doppler echocardiography: M-mode and two dimensional echocardiography essentially create ultrasonic images of the heart. Doppler echocardiography utilizes to record the blood flow within the cardiovascular system.

• Mensura Asceric et al., postulated that Left ventricular diastolic dysfunction is frequent in case of essential hypertension, older people, ischemia, obese woman and diabetics. Diastolic heart weakness prevalence rises with age.10

• The study by Ren et al., 8 in 1994, in particular, evaluated measurements of diastolic function on Doppler echocardiography according to cardiac geometry and evidenced the presence of diastolic dysfunction in the prehypertrophy phases (cardiac remodeling)11

• Ahmad et al., Carried out a study over a large group of patients with ischaemic heart disease with previous myocardial infarction and postulated that left ventricular diastolic dysfunction is a common finding in patients with previous myocardial infarction and suggested as a major cause in the long term development of congestive cardiac failure in post myocardial infarction patients.12

• Nagueh et al., postulated the Guidelines and Standards for the determination of left ventricular dysfunction by 2D- Echocardiography.13

• An experimental study carried out by Grauss et. Al. Showed myocardial damage on tissue biopsy on various autopsies conducted on patients who had died due to ischaemic heart disease. They also conducted series of animal experiments on mice demonstrating the use of human mesenchymal stem cells derived from patients with ischaemic heart disease improve left ventricular function in myocardial infarction.14

• Akkoc et. al., carried out a study on a 118 hypertensive subjects and postulated the importance of Doppler echocardiography in determining early right ventricular diastolic dysfunction by correlating the indices of tricuspid flow parameters, right ventricular thickness and correlated the right ventricular and left ventricular filling parameters in patients with essential hypertension.17

• Verdeccehia et. al., presented a study which provides the first assessment of prevalence, determinants and prognosis of asymptomatic left ventricular diastolic dysfunction in a large population of subjects with essential hypertension. Prevalence of asymptomatic left ventricular diastolic dysfunction, defined by an echocardiography, and the subjects with asymptomatic left ventricular diastolic dysfunction showed a 9-fold higher risk of hospital admission for congestive heart failure over a mean follow-up period of 6 years compared with those with normal Ejection fraction.18

• Miller et. al., in 2011 carried out a study postulating that Patients with Left ventricular systolic dysfunction commonly have secondary pulmonary hypertension, which is largely determined by the severity of Left ventricular diastolic dysfunction even with adjustment for Functional mitral regurgitation and low Left ventricular ejection fraction. Thus, measures of Left ventricular diastolic dysfunction in routine clinical practice where Pulmonary systemic pressure may not be estimated are important physiologic descriptors of hemodynamic status and are cumulatively linked in the prediction of pulmonary hypertension. 19

• Kane et. al., in 2011 carried out a population based cohort study in patients of elderly age group, hypertension and ischaemic heart disease, undergoing 4 years of follow-up, prevalence of diastolic dysfunction increased. Diastolic dysfunction was associated with development of heart failure during 6 years of subsequent follow-up.20

• Shah et. al., in 2011 has carried out successful phase ii trials in determining the importance of newer and non invasive imaging modalities such as Doppler echocardiography in patients with hypertension and ischaemic heart disease to determine different heart failures. 21

• Maurizio Galderisi carried out the most recent study in 2011 determining the progression of hypertensive involvement toward heart failure includes myocardial fibrosis and changes of left ventricular geometry. In the presence of these abnormalities, diastolic abnormalities occur and are defined as LV diastolic dysfunction. They include alterations of both relaxation and filling, which precede alterations of chamber systolic function and can induce symptoms of heart failure even when ejection fraction is normal. In this view, diagnosis, prognosis, and therapeutic management of Diastolic dysfunction in hypertensive patients is a growing public health problem. Diastolic dysfunction may be asymptomatic and identified occasionally during a Doppler-echocardiographic examination. This tool has gained, therefore, important clinical position for diagnosis of Diastolic dysfunction. This can be obtained by different ultrasound maneuvers/tools but the ratio between transmitral E velocity and pulsed tissue Doppler–derived early diastolic velocity (E/e′ ratio) is the most feasible and accurate. The identification of left atrial enlargement may be useful in uncertain cases. 22

• Gurpal et. al., carried out an study on indian population in a subset of 162 patients with primary hypertension and postulated with echocardiographic indices and revealed the importance of early treatment of early left ventricular diastolic dysfunction. 23

• Zaheer et. al., in 2012 carried out a study on indian population in a subset of 50 patients with ischaemic heart disease and ischaemic cardiomyopathy and detrmined the importance and presence of diastolic dysfunction using Doppler echocardiography, in correlation with risk factors, presentation of symptoms and prognosis. 24

APPENDIX –IC

AIMS AND OBJECTIVES

1. To evaluate application of doppler echocardiography in determining left ventricular diastolic dysfunction in ischemic heart disease and essential hypertension.

2. To evaluate significance of left ventricular diastolic dysfunction in ischemic heart disease and essential hypertension.

3. To find out early left ventricular diastolic dysfunction in ischemic heart disease and essential hypertension as a marker of impending major cardiac events and to promote the quality of life.

APPENDIX-II

7.0 MATERIALS AND METHODS

APPENDIX-IIA

7.1 SOURCE OF DATA:

Study will be carried out in Sri Adichunchanagiri Institute of Medical Sciences and Research Center. B.G. Nagar, which is a rural medical college, for over a period of 24 months.

APPENDIX-IIB

1. METHOD OF COLLECTION OF DATA

This study will be carried out on rural patients admitted to our rural hospital in ICCU under Medicine Department, From November 2012 to November 2014.

75 patients with primary hypertension and 60 patients presenting with ischemic heart disease (unstable angina, anterior wall myocardial infarction and inferior wall myocardial infarction). Admitted to Adichunchanagiri hospital under the department of general medicine will be studied.

Detailed history and physical examination will be done.

Control Groups:

Patients with hypertension without diastolic dysfunction and patients with ischaemic heart disease without diastolic dysfunction were taken as controls. Both the sets of patients were studied separately. All patients were subjected to color Doppler echocardiographic examination.

Statistical Methods: Continuous data are expressed as mean ± SD and between groups are compared with unpaired student ‘t’ test. P ................
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