100 Clinical Questions in Cardiology
Today, cardiac care has become a specialty in India, where various institutions in our country have the capability of providing comprehensive cardiac care ranging from basic facilities in preventive cardiology to the most sophisticated technology, including that of minimally invasive and robotic surgery.
When we have a wealth of experience and expertise in our country, why look to the West for guidance? It is time that we built up our own database and developed our own recommendations and guidelines as it has become evident that ethnic differences are a very valid parameter, which cannot, and indeed should not, be ignored. This handbook is a move in the right direction as it presents in a comprehensive fashion, the wide and varied experiences of our cardiologists of our country who, based on their vast knowledge and personal experiences have developed the best possible way to approach the Indian patient.
It is, therefore, with a sense of great satisfaction that I write the preface to this novel venture by IJCP Publications to bring together the expertise of our immensely capable and knowledgeable team of cardiologists from different parts of the country. This would not only provide information and guidance on the latest in the field of cardiology but also provide invaluable help to doctors who want to practice rational therapeutics.
I take this opportunity to not only congratulate IJCP Publications for thinking of this unique unifying academic effort but also to appreciate the effort all the contributors who generously gave time in spite of their busy schedules to enable this book to see the light of day. Looking forward to many such joint ventures in the future, I wish you all a very happy and informative reading.

Dr. Ashok Seth Director, MAX Healthcare, New Delhi

Questions in Glaucoma
From the Desk of Group Editor-in-Chief
Glaucoma is a group of eye diseases that gradually cause vision loss without warning. In the early stages of the disease, there may be no symptoms. Experts estimate that half of the people affected by glaucoma may not know they have it. Vision loss is caused by damage to the optic nerve and loss of vision is losing one of the sense organs. Just blindfold yourself and try to move in your clinic for sometime. This is the state likely to occur about a glaucoma patient who does not receive timely medication or surgical treatment. There is no cure for glaucoma—yet. However, medication or surgery can slow or prevent further vision loss. The appropriate treatment depends upon the type of glaucoma among other factors. Early detection is vital to stopping the progress of the disease. Glaucoma is the second leading cause of blindness in the world, according to the World Health Organization. This book gives an insight to various diagnostic and treatment approaches to Glaucoma. It is a helpful guide for ophthalmologists as a shelf book for immediate reference regarding glaucoma.

From the Editor’s Desk
I am very happy to present to you this collection of questions and their answers by eminent glaucoma specialists of our country. I have prepared these questions based on my interactions with many of you during small clinical CME meets over the last couple of years. As newer research and better instrumentation keep appearing on the horizon of glaucoma care, we need answers to several questions to guide us in our day-to-day practice and this has been the guiding principle while preparing this publication. I hope that it serves to be useful and helps you take decisions in your daily clinical practice. For further clarifications you may contact me or any of the contributing authors and we will try to do our best to help you. I would like to express my heartfelt gratitude to all the specialists who have contributed to this work for their co-operation and the editorial staff of IJCP publication for their support to bring this work to you.

Hypertension
Why a Monograph on Hypertension?
Hypertension and high cholesterol levels have long been known to increase the risk of developing cardiovascular diseases (CVD). The higher the blood pressure and/or cholesterol level, the greater is the risk. Also, studies have proven that lowering blood pressure and cholesterol levels decreases the risk for CVD.
When the blood pressure or blood cholesterol levels of large groups of people are plotted on a graph against CVD mortality, it often results in a J-shaped curve. This curve shows that those with higher blood pressure and/or cholesterol levels, closer to the top of the curve, are more likely to die from CVD. The curve also shows that those at the lowest end of the curve (with very low blood pressure and/or cholesterol levels) also have increased CVD mortality, which accounts for the J shape. This is known as the J-curve phenomenon. Most evidence, however, indicates that the group at the bottom-left part of the curve (with very low blood pressure and cholesterol levels) tends to be different from the general population in other ways - and those differences may contribute to the apparent increase in mortality.
While treatment of high blood pressure or increased cholesterol levels with drugs may have some side effects, treatment doesn’t result in the markedly low values associated with increased CVD mortality. High blood pressure has been reported in children. Some diseases, usually heart or kidney disease, can cause high blood pressure in children. This is called secondary hypertension. The Cardiovascular Control Program of the Ministry of Health has recommended that all children (above age 4) should have yearly blood pressure measurements. This recommendation comes from the fact that early detection of high blood pressure has been shown to improve the healthcare of the children. If the disease is successfully treated, blood pressure usually returns to normal. Some medicines can cause high blood pressure, but when they’re discontinued, blood pressure usually returns to normal.
At one time, doctors thought that in most cases of high blood pressure in children it was a case of secondary hypertension (that is, caused by other disease). Now they know this isn’t so. Some children have higher blood pressure than others for unknown reasons. These children are said to have primary or essential hypertension. In one of a survey carried by Heart Care Foundation of India in association with Department of Science and Technology it was found that the incidence of high blood pressure in the school children was nearly 10%. Research scientists don’t know why some children have higher blood pressure than others. Children who are overweight usually have higher blood pressure. Some children inherit the tendency toward higher blood pressure from one or both parents.
The incidence of hypertension is high in our country. It is almost taking an epidemic shape. The extent of problem is evident from the following statistics.
International
In 1999-2002, 28.6% of the US population had hypertension and it is still increasing.
An estimated 972 million people in the world are suffering from hypertension.
Incidence rates of hypertension range between 3% and 18%, depending on the age, gender, ethnicity and body size of the population studied.
As many as 50 million Americans aged 6 and older have high blood pressure. (Based on NHANES III data.)
One in five Americans (and one in four adults) has high blood pressure.
Of those people with high blood pressure, 31.6% don’t know they have it.
Despite advances in hypertension treatment, control rates continue to be suboptimal. Only about one-third of all hypertensives are controlled in the United States.
The cause of 90-95% of the cases of high blood pressure isn’t known; however, high blood pressure is easily detected and usually controllable.
High blood pressure (hypertension) killed 42,565 Americans in 1997 and contributed to the deaths of about 210,000.
Non-Hispanic blacks and Mexican Americans are more likely to suffer from high blood pressure than are non-Hispanic whites.
People with lower educational and income levels also tend to have higher levels of blood pressure. National
In a meta-analysis of 34 epidemiological studies from rural and urban populations of India, it was concluded that hypertension is emerging as a major health problem in India and is more in urban than in rural subjects.
The prevalence of hypertension in recent studies was almost similar to those in USA.
Over 75% people are not even aware of the presence of blood pressure in them.
Most of the hypertensives are on inadequate treatment.
Over 50% change treatment from one pathy to other.
Hypertension is the commonest cause of end-stage renal disease. Some facts about hypertension
Antihypertensive therapy is associated with reductions in stroke incidence averaging 35-40%, myocardial infarction, 20-25%; and heart failure, more than 50%.
A 5 mm reduction in diastolic blood pressure can reduce heart disease risk by 21% (Magnus and Beaglehole, 2001).
If we were to eliminate prehypertension from the society, we could potentially about 47% of all heart attacks.
Framingham study found that a prehypertensive person is more than 3 times more likely to have a heart attack and 1.7 times more likely to have heart disease than a person with normal blood pressure.
For every fall of 20 in systolic and fall of 10 in diastolic blood pressure you need one intervention: Lifestyle modifictions treatment or one drug.
It is estimated that in patients with stage 1 hypertension (systolic blood pressure 140-159 mmHg and/or diastolic blood pressure 90-99 mmHg) and additional cardiovascular risk factors, achieving a sustained 12 mmHg reduction in systolic blood pressure over 10 years will prevent one death for every 11 patients treated. In the presence of CVD or target organ damage, only nine patients would require such blood pressure reduction to prevent a death. Recent clinical trials have demonstrated that effective blood pressure control can be achieved in most patients who are hypertensive.
A 1,600 mg sodium DASH eating plan has effects similar to single drug therapy. Combinations of two (or more) lifestyle modifications can achieve even better results. One can achieve a reduction of 5-20 mmHg of blood pressure for every 10 kg weight loss. Consume a diet rich in fruits, vegetables, and low fat dairy products with a reduced content of saturated and total fat. It can reduce a blood pressure of 8-14 mmHg. Reduce dietary sodium intake to no more than 100 mmol/day (2.4 g sodium or 6 g sodium chloride). It can alone reduce blood pressure by 2-8 mmHg. Engage in regular aerobic physical activity such as brisk walking (atleast 30 min/day, most days of the week). It can alone reduce blood pressure by 4-9 mmHg. Limit consumption to no more than two drinks (1 oz or 30 ml ethanol; e.g., 24 oz beer, 10 oz wine, or 3 oz 80-proof whiskey) per day in most men and to no more than one drink per day in women and lighter weight persons. It can alone reduce blood pressure by 2-4 mmHg. The irony of the situation is that the subject is of utmost importance to us yet the least discussed in day-to-day clinical postings in the MBBS course. Somebody said once - if you know how to treat hypertension, diabetes and asthma you can earn your livings. It looks simple but is a complicated issue to understand and practice. Dr Paul Anand, an international authority on this subject has done a wonderful job on this subject. He has been able to gather the top of the experts in this field to compile the third issue of this monograph. The monograph contains the latest updated information on the management of hypertension and other related issues which one comes across quite often in day-to-day practice.