Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Bhanu K Bhakhri

"The Journal of Clinical and Diagnostic Research (JCDR) has been in operation since almost a decade. It has contributed a huge number of peer reviewed articles, across a spectrum of medical disciplines, to the medical literature.
Its wide based indexing and open access publications attracts many authors as well as readers
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Dr Bhanu K Bhakhri
Faculty, Pediatric Medicine
Super Speciality Paediatric Hospital and Post Graduate Teaching Institute, Noida
On Sep 2018




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Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
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Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




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MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




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Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011

Important Notice

Original article / research
Year : 2009 | Month : June | Volume : 3 | Issue : 3 | Page : 1529 - 1536

Comparative Study Of Systolic And Diastolic Cardiac Failure In Elderly Hospitalized Patients In A Tertiary Care Hospital In Southwest India

DOCHERLA .M, HANDE MANJUNATH .H*, KAVITHA S**, SHASTRY B.A***, BHATIA S****,

* Professor, Head of Medicine, Department of Medicine o.p.d, Dr.T.M.A.Pai Hospital,** Asso. Prof, ***Prof, Head of Medicine,**** (M.D)Asst. Prof., [Dept. of Medicine, O.P.D, Kasturba Medical College, Manipal - 576104, Karnataka,(India)].

Correspondence Address :
Dr. Docherla Mahesh,
Asst. Prof., Dept. of Medicine,
Kasturba Medical College,
Manipal – 576104. Karnataka,(India).
Email address:-docherla@gmail.com
Ph No. - 9342748863 Fax No. : +91-0820-2571934

Abstract

Aims:To study and compare the clinical, echocardiographic and the aetiological features of systolic and diastolic cardiac failure in elderly patients.
Methods:This is a prospective observational study done from November 2003 to October 2005. Ninety four patients aged > 60 years who satisfied the Framingham’s Criteria for cardiac failure, admitted in the Medicine and Cardiology wards of Kasturba Hospital, Manipal, were included. All patients underwent echocardiographic study and the necessary evaluation to identify the aetiology of the cardiac failure.
Statistical Analysis:The results thus attained, were then charted and analyzed using the SPSS 11.0 statistical software package for Windows. The comparative analysis between Group 1 and Group 2 was done using the Chi-Square test for categorical variables. Continuous variables were also categorized and analyzed using the Chi-Square test.
Results:The mean age of the study group was 68.9 years ± 6.01 years. It consisted of 57 (60.63%) males and 37 (39.36%) females. Twenty eight (29.78%) patients had isolated systolic failure (Group 1) and 22 (23%) had isolated diastolic failure (Group 2). Tachycardia (p value = 0.017), cardiomegaly (p value = 0.039) and pulmonary rales (p value = 0.003) were more common in Group 1. The most common aetiology in both groups was coronary artery disease (CAD). Hypertension was more common in diastolic failure (p value = 0.010).
Conclusions:This study proves that isolated diastolic failure is a significant presentation among the elderly patients presenting to our hospital. Tachycardia, cardiomegaly and pulmonary rales were more common in systolic failure as compared to diastolic failure. These result from hypertension, which can be easily screened and treated.

Keywords

Congestive cardiac failure, Diastolic heart failure, Elderly, Hypertension, Ischaemic heart disease

Introduction
Heart failure is one of the commonest conditions that the cardiologist, physician or general practitioner comes across in their practice in hospital care. Recent developments in the management of diabetes, hypertension, dyslipidaemia and coronary artery disease have prolonged survival in clinical conditions resulting from acute cardiovascular events all over the world (1). Recent research in the field of cardiology has led to the realization that heart failure can occur with preserved systolic function, termed as Diastolic heart failure (2),(3),(4). Awareness of such a condition and the accurate diagnosis for it is necessary, since the treatment varies from systolic failure and holds a better prognosis (3),[ 5],[ 6],[ 7],[ 8].

In India, the latest 2001 Census figures show that the age group > 60 years presently constitutes 7.5% of the population (compared to 6.7% of total population in the 1991 census, 6.32% in 1981 and 5.97% in 1971), while the working population between 15-59 years constitutes 56.9% of the population (9). Life expectancy at birth for India has increased from 48.9 for males and 49.3 for females in 1971, to 61.6 years for males and 62.2 years for females respectively, by 1996 (10),(11).

Material and Methods

Patients And Settings
This was a prospective observational study conducted over a 2 year period from November 2003 to October 2005. It included 94 elderly patients who were admitted in the medicine and cardiology wards of Kasturba Hospital, Manipal, with a primary diagnosis of cardiac failure. To define the elderly population group, the World Health Organization (WHO) criteria of > 60 years was taken. All patients aged > 60 years who satisfied Framingham’s Criteria for cardiac failure after detailed history taking and physical examination, were included in the study. Patients < 60 years who did not satisfy Framingham’s criteria and the Echocardiographical criteria for systolic or diastolic dysfunction and with pre-existing lung, renal or liver disease, were excluded from the study. In those patients with recurrent decompensation, only the first admission was included.

Clinical Cardiovascular Assessment
Each patient who was thus presented, was assessed clinically using the Framingham’s criteria for cardiac failure by the attending physician or cardiologist (12). Details noted at the time of clinical examination included heart rate, blood pressure, neck vein distension, pedal oedema, presence of additional heart sounds, murmurs, presence of crackles, hepatojugular reflux, hepatomegaly, anaemia, features of renal failure, etc. The clinical features were finalized after agreement between at least 2 of the study authors following independent examinations.

Laboratory And Echocardiographic Evaluation
All subjects underwent a routine battery of investigations including Haemogram, chest radiograph, electrocardiograph, renal function tests and liver function tests. Each and every patient underwent an Echocardiogram within 24 hours of admission using a General Electric Wingmed System 5 Model 1999 by the same echocardiography technician, to avoid interobserver variation.

Clinical Criteria And Division Of Patients
Tachycardia was defined as heart rate with > 120 beats per minute. Cardiomegaly was defined by a radiographical cardiothoracic ratio > 0.55. Radiographs were used to aid in the diagnosis of pleural effusion, cardiomegaly and pulmonary oedema. Hepatomegaly was defined as a liver span > 14 cm. Vital capacity was not measured for any patient as these patients were acutely ill at presentation.

All such patients who satisfied Framingham’s criteria with no exclusion criteria were then classified into 3 groups based on Echocardiography findings. Echocardiography parameters utilized were left ventricular internal dimensions, fractional shortening, ejection fraction and Mitral Doppler Flow Velocity ratio (E/A). Patients with Ejection Fraction < 50% and normal Mitral Doppler Flow Velocity E/A (E = Early Left Ventricular Filling Velocity, A = Velocity of Left Ventricular Filling contributed by Atrial Contraction), were considered to have isolated systolic failure, herewith represented as Group 1. Patients with Ejection fraction > 50% with E/A suggestive of diastolic dysfunction, were considered to have isolated diastolic failure, herewith represented as Group 2. Patients with Ejection Fraction < 50% and an E/A ratio suggestive of diastolic dysfunction were the combined failure group, herewith represented as Group 3 (13),(14),(15). If indicated, Exercise testing, Troponin I, 24 hours Holter monitoring or coronary angiography were carried out to identify the aetiology of cardiac failure. These investigations were carried out with the consent of the patients.

Ischaemic heart disease is defined by the presence of functional ischaemic heart disease (as proven by the Treadmill test, the Dobutamine Stress Echo or the Holter monitoring), > 50% stenosis of at least one coronary artery (by Coronary Angiography), or by the history of angioplasty or Coronary Arterial Bypass Graft (CABG). Patients with previous myocardial infarction or presenting with myocardial infarction have been accounted for separately. Ischaemic dilated cardiomyopathy is defined as the presence of the above criteria for ischaemia or the evidence or history of myocardial infarction with elevated volumes and dilated chambers. Dilated cardiomyopathy describes heart muscle disease in which the predominant abnormality is dilatation of the left ventricle, with or without right ventricular dilatation. Idiopathic dilated cardiomyopathy is a diagnosis of exclusion. Hypertensive cardiomyopathy is diagnosed when myocardial systolic function is depressed out of proportion to the increase in wall stress. A subject presenting with heart failure with hypertensive crisis was thus diagnosed if ventricular dilation and depressed systolic function remained after correction of hypertension (16).

The assessment of the precipitating factors was done on the basis of the same criteria as used in the New York Heart Failure Study (17).

Statistical Analysis
The results thus attained were then charted and analyzed using the SPSS 11.0 statistical software package for Windows. The comparative analysis between Group 1 and Group 2 was done using the Chi-Square test. Categorical variables and continuous variables were also categorized and analyzed by using the Chi-Square test.

Adequate studies on heart failure in India, focusing on diastolic heart failure and the elderly in India, are lacking. Hence, we have taken up this study to shed light on the clinical, echocardiographic and the aetiological features of cardiac failure among the elderly and to compare the various characteristics between isolated systolic failure and isolated diastolic failure.



Results

General Findings
The mean age of the study group was 68.9 years ± 6.01 years, with 57 (60.63%) males and 37 (39.36%) females. The mean age among males was 69.01 ± 6.485 years and in females, it was 68.76 ± 5.46 years.

The demographic details of the study group and their risk factors are as shown in (Table/Fig 1). Forty eight (51.06%) were known hypertensives, 40 (42.55%) were known diabetics and 15 (15.95%) were smokers.

Out of 94 patients, 28 (29.78%) of patients had isolated systolic failure (Group 1), 22 (23.40%) had isolated diastolic failure (Group 2) and 44 (46.80%) had combined failure (Group 3).

Eighteen (81.8%) patients in Group 2 and only 13 (44.8%) in Group 1 were known hypertensives, which was significant (p value = 0.010). Ten (34.5%) patients in Group 1 and 8 (36.4%) patients in Group 2 were known diabetics, which was not significant (p value = 0.962).

Findings In Cardiac Failure
Among all the 94 elderly patients, the most common symptom was exertional dyspnoea in 84 (89.36%) patients and the most common clinical sign was pulmonary rales in 78 patients (82.97%). The most common aetiology was coronary artery disease (CAD) in 52 (55.31%) patients, followed by valvular heart disease (VHD) in 12 (12.76%) patients. Ten (10.36%) had idiopathic dilated cardiomyopathy (IDC), 6 (6.38%) had hypertensive cardiomyopathy and 3 (3.19%) patients had both CAD and valvular heart disease. Twenty one (22.34%) of the total 94 patients had a previous history of myocardial infarction and were included under the category of coronary artery disease. The most common valvular heart disease was Aortic stenosis (AS) in 6 patients. Eleven (11.70%) patients had cardiac failure of unknown aetiology.

The most common precipitating factor identified, was severe functional Mitral Regurgitation in 16 (17.02%) patients, while the next most common factor was arrhythmias in 15 (15.97%) of patients. The most common arrhythmias precipitating cardiac failure were atrial fibrillation (AF) and Complete heart block (CHB) in 5 (5%) patients each. Eleven (11.70%) patients had pneumonia and 12 (12.76%) had other sources of infection. Six (6.38%) patients presented with accelerated hypertension and 4 (4.25%) had anaemia. No precipitating cause could be identified in 44 (46.80%) patients.

The comparison of the incidence of signs and symptoms between Group 1 and Group 2 is represented in (Table/Fig 2). Twenty seven (93%) patients in Group 1 and 13 (59%) patients in Group 2 had pulmonary rales, which was statistically significant (p value = 0.001). Thirteen (45%) patients in Group 1 and 3 (14%) patients in Group 2 had tachycardia, which was statistically significant (p value = 0.014). Nineteen (65.5%) patients in Group 1 and 8 (36.4%) in Group 2 had cardiomegaly, which was statistically significant (p value = 0.027).

The comparison of the aetiology between Group 1 and Group 2 is represented in (Table/Fig 3). One (4%) patient in Group 1 and 8 (36%) patients in Group 2 had valvular heart disease, which was significant (p value = 0.026). Among the 8 patients in Group 2 with Valvular heart disease (VHD), 4 had Aortic stenosis (AS) and 1 had Mitral stenosis (MS) with no proven associated ischaemic aetiology. There were 4 patients in Group 2 who were identified with hypertensive cardiomyopathy, while there were none in Group 1. No aetiology could be identified among 11 (11.70%) of the total number of patients, 9 of which belonged to these 2 groups.


Discussion

Studies on diastolic heart failure have been gaining popularity in recent times. Therapeutic research is also in high gear. The reasons for these activities are numerous. They include the increasing proportions of elderly populations in many countries, the confusion regarding clinical criteria to distinguish between the common systolic failure and the obscure diastolic failure, and finally, the better prognosis attributed to the management of diastolic heart failure. Differentiating between the two forms of cardiac failure becomes even more significant, since the treatment differs between the two conditions, with Digoxin remaining a controversial drug presently in diastolic failure. Despite all this interest on the subject, there are very few studies that have been carried out on this topic in the Indian population. Hence, we have taken up this study to characterize the forms of cardiac failure and to compare their features.

In comparison to other studies carried out on this topic, there is some strength to this study. The clinical assessment of all the patients was done by the same set of clinicians, thus enabling uniformity of assessment. Vasan and Levy have proposed that the diagnosis of diastolic heart failure might be strengthened by shortening the interval between the heart failure event and the documentation of a normal left ventricular ejection fraction (4), (13). All the echocardiographic and Doppler assessments in these subjects have been carried out within 24 hours of presentation at the hospital. Inter operator variability was minimized by using the same operator to note the echocardiographic findings. The machine used on all the patients was the same, unlike other studies referred here, where patients have been gathered from different centres, clinically assessed by different doctors, and have undergone echocardiographic evaluation by different machines and operators.

The average age of the study group was 68.9 ± 6.01 years and 32% were in the age group of > 70 years. Fifty seven (60.63%) were males. In comparison, The French national survey of heart failure consisted of 73% patients above 70 years of age, with 55% males (21). The Spanish study at Santiago de Compostela consisted of 40% patients in the age group of > 75 years and 61% were males (22). Thus, the age profile in this study was younger, reflecting the relatively younger population of India.

Fifty one percent patients were known hypertensives, which was the most common risk factor, followed by diabetes (42.55%). In the New York Heart Failure Registry, 78% were reported to have hypertension. The ADHERE registry had 70% hypertensives, while the French national survey had 46% known hypertensives and 19% diabetics (23),(24). Twenty (22.34%) of patients in the present study had a history of previous myocardial infarction. Similar findings were found in the French survey (22%)(21) also.

This study shows that isolated diastolic heart failure (23%) is definitely an important feature in cardiac failure among the elderly patients presenting to our hospital. The incidence of isolated diastolic failure as reported in the ADHERE registry was 46%, that in the Spanish study was 40% and that in the French survey was 38%(21), (22), (24). This difference can probably be accounted for by the older age profile in these studies, the higher proportion of hypertensive females and the earlier and more severe incidence of coronary artery disease in the Indian population, which has led to a greater proportion of combined failure (Group 3). Even though the comparison of ages between Group 1 and Group 2 did not show any statistically significant difference, isolated diastolic failure does account for a greater proportion of patients in the present study, as age advances. In contrast, both the Spanish and French studies have found significant differences (p < 0.0001)(21),(22). This probably would have been borne out more easily in the present study with larger samples and a higher proportion of patients in the higher age groups. Also, this study did not find any significant difference in the incidence of systolic or diastolic failure among the sexes (p value = 0.057), probably due to lesser proportion of females in the present study and in the higher age groups.

There was no significant difference in the occurrence of various symptoms between the groups. Tachycardia (p value = 0.014), cardiomegaly (p value = 0.027) and pulmonary rales (p value = 0.001) were significantly more common in Group 1. In comparison, the Spanish study found a significantly higher incidence of neck vein distension (p = 0.030), third heart sound (p < 0.0001), Cardiomegaly (p = 0.005) and pulmonary oedema (p < 0.0001) in the group with systolic failure(22). Thus, this study shows that pulmonary rales, tachycardia and cardiomegaly can be used to diagnose systolic cardiac failure with greater certainty.

Coronary artery disease was the most common aetiology of cardiac failure (55.31%). The ADHERE registry had reports of 57% cases and the New York Heart Failure Registry had reports of 43% cases attributed to coronary artery disease(23), (24). It was the most common aetiology for all three groups. Valvular heart disease (12.76%) was a more common aetiology in isolated diastolic failure (36%) dominated by degenerative valvular disease in the form of Aortic stenosis, the difference being statistically significant (p value = 0.013). Similar findings were stated by the Spanish study (21%).22 In the same study, valvular heart disease was found to be significantly more common in diastolic heart failure (33.1%) than in systolic heart failure (12.6%). Group 2 also had a higher number of hypertensives (p value = 0.010), which was similar to the Spanish (p value < 0.001) and French (p < 0.05) study results (21),[ 22].

Our study has also made an effort to identify the precipitating factors where possible, using similar criteria as reported in the New York Heart Failure Registry (23). The most common precipitating factor was found to be severe functional Mitral regurgitation (> Grade 3+) (17%), followed by arrhythmias (15.97%).

The findings of this study are shown in comparison to other studies carried out worldwide, albeit, with varying criteria and numbers as shown in (Table/Fig 4).

Limitations Of This Study
A larger sample size would have been probably more representative, especially in the higher age groups, since we had only 3 patients above 80 years, all of whom were male. The aim of this study was to study the characteristics between the different types of heart failure and to compare them. This study reflects the findings in patients presenting to this hospital only. Our findings cannot be used to project the incidence and prevalence of the different types of heart failure in the general population or even in the elderly in general. Pro-B type Natriuretic Peptide (Pro BNP) and B type Natriuretic Peptide (BNP) were not available in the hospital at the time of this study.

Conclusion

This study provides evidence that isolated diastolic failure is not an uncommon clinical presentation among the elderly presenting to our hospital. Many result from inadequately treated or undetected hypertension which can be easily screened and treated without the need for invasive, time consuming or costly investigations. The Indian population is also prone to suffer from coronary artery disease and diabetes at an earlier age as compared to their western counterparts. Early and aggressive recognition and management of these conditions would lead to lesser morbidity and a better quality of life. Hence, we recommend that a strong comprehensive screening program for hypertension, diabetes, dyslipidaemia and coronary artery disease should be implemented.

Key Message

• Diastolic failure is a significant presentation in India.
• Tachycardia, Cardiomegaly and Pulmonary rales are less common in diastolic heart failure as compared to systolic failure.
• Untreated hypertension contributes significantly to diastolic heart failure

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