Dabigatran is indicated for stroke prevention for nonvalvular atrial fibrillation. Dabigatran is a double-edged sword as myocardial infarctions (MIs) were found increased and even cessation can result in MIs. The present report documents MI following stoppage, highlighting the importance of bridging with heparins, particularly for those with high CHADS 2 scores.

There are a number of guidelines on how to manage obesity, but inconsistencies in healthcare access, varying infrastructure, resource constraints and diverse local practices restrict their global applicability. This underscores the need for universal recommendations that address the unique challenges faced by patients and healthcare providers worldwide. Our Global Guidelines emphasize the incorporation of novel therapies, while integrating standards of care with the most up-to-date evidence to enable clinicians to optimize obesity management. Context-specific recommendations tailored to individual patient needs are highlighted, providing a thorough evaluation of the risks, benefits, and overall value of each therapy, aiming to establish a standard of care that improves patient outcomes and reduces the burden of hospitalization in this susceptible population. These Global Guidelines provide evidence-based recommendations that represent a group consensus considering the many other published guidelines that have reviewed many of the issues discussed here, but they also make new recommendations where new evidence has recently emerged, and – most importantly – also provide recommendations on several issues where resource limitations may put constraints on the care provided to patients living with obesity. Such “economic adjustment” recommendations aim to guide situations when “Resources are somewhat limited” or when “Resources are severely limited”. Hence, this document presents a comprehensive update to obesity management guidelines, thereby aiming to provide a unified strategy for the pharmacological, non-pharmacological, and invasive management of this significant global health challenge that is applicable to the needs of healthcare around the globe.

Diabetic kidney disease (DKD) is becoming an increasingly common consequence of diabetes in India, where the number of affected individuals is rising at an alarming pace. The illness is often silent in its early stages, and many patients are diagnosed only when kidney damage is advanced, leading to high rates of kidney failure and cardiovascular complications. This consensus document was developed by a broad group of experts to provide practical, evidence-based recommendations tailored for Indian healthcare settings. It stresses the importance of timely screening using the urine albumin-to-creatinine ratio and estimated glomerular filtration rate, along with routine evaluation of cardiovascular risks. The guidance covers key management areas such as blood pressure and glycemic control, the use of renin-angiotensin system blockers, newer agents such as sodium-glucose cotransporter 2 inhibitors (SGLT2) inhibitors and finerenone, as well as lifestyle and dietary measures. Equal attention is given to affordability, patient education, and integrating care into national health programs. By adapting international standards to local realities, this document aims to improve early detection, reduce inequalities in treatment, and support better long-term outcomes for people living with DKD in India.

Obesity is increasingly recognized as a chronic, relapsing, and progressive disease that acts as a major upstream driver of cardiovascular, kidney, and metabolic disorders, with South Asians experiencing heightened vulnerability at lower adiposity thresholds. Despite this, effective metabolic therapies remain underutilized in cardiology practice. Semaglutide, a GLP-1 receptor agonist, has emerged as a multisystem, disease-modifying agent with benefits that extend well beyond glycemic control. Accumulating evidence from the STEP (Semaglutide Treatment Effect in People with Obesity) program, the SELECT cardiovascular outcomes trial, the SOUL trial, heart failure with preserved ejection fraction (HFpEF) studies, and real-world cohorts underscores its relevance for cardiometabolic risk reduction and symptom improvement. Recognizing the need for India-specific guidance, a panel of cardiologists from across the country reviewed pivotal randomized trials, including STEP 1-8, STEP-HFpEF, STEP-HFpEF DM, STEP TEENS, SELECT, SOUL, SUSTAIN-6, and PIONEER-6, along with meta-analyses, observational data, and international recommendations to formulate practical, context-appropriate guidance for cardiology practice. Across diverse studies, semaglutide consistently produces substantial reductions in body weight and visceral fat, accompanied by improvements in blood pressure, glycemic control, inflammatory markers, and hepatic steatosis. SELECT demonstrated a significant reduction in major adverse cardiovascular events in adults with overweight or obesity and established atherosclerotic cardiovascular disease (ASCVD), independent of diabetes status. Benefits of obesity-related HFpEF include meaningful gains in symptoms, exercise tolerance, and quality of life. Emerging data also support renal and hepatic protection across CKM domains. Findings from high-dose 7.2 mg studies highlight a dose-response continuum but call for careful assessment of tolerability. As international guidelines increasingly position GLP-1 receptor agonists as cardiometabolic therapies, Indian data emphasize the importance of early, phenotype-driven intervention. Semaglutide represents a practice-changing therapy that addresses core pathophysiological drivers of ASCVD and HFpEF through integrated modulation of adiposity and metabolic dysfunction. Its cardiovascular efficacy, multisystem benefits, and suitability for South Asian phenotypes support broader incorporation into contemporary cardiology. This consensus offers a framework for evidence-based patient selection, contraindications, monitoring, maintenance strategies, and coordinated multidisciplinary implementation to ensure safe and effective use in Indian clinical practice.

Hypertension is a leading cause of cardiovascular morbidity and mortality globally, with particularly low control rates in India. Beyond controlling blood pressure (BP), effective management must address associated comorbidities such as cardiovascular disease (CVD), chronic kidney disease (CKD), and type 2 diabetes mellitus (T2DM). A multidisciplinary panel of experts, including cardiologists, nephrologists, and physicians, developed this consensus through six advisory board meetings. A comprehensive literature review of randomized controlled trials and systematic reviews published between 2019 and 2025 was conducted via PubMed and Google Scholar. Key topics included pharmacological and non-pharmacological management of hypertension, combination therapy, and comorbidity-focused treatment strategies. Early screening for hypertension-mediated organ damage and the use of combination therapy, specifically telmisartan and cilnidipine for their complementary benefits, were emphasized. Evidence showed improved BP control, reduced proteinuria, and organ protection in individuals with CVD, CKD, and T2DM. Non-pharmacological interventions such as dietary modification, physical activity, smoking cessation, stress management, and adherence to therapy through fixed-dose combinations were also endorsed. This expert consensus supports a comprehensive, patient-centered approach to hypertension management in India. Available evidence suggests that cilnidipine and telmisartan may offer potential benefits beyond BP reduction, largely based on pharmacologic properties and surrogate outcomes. Future large-scale, randomized, comparative outcome trials are needed to better define the relative clinical benefits of this combination.

Introduction Individuals with chronic cardiac conditions are at increased risk for developing pneumococcal diseases. In this study, we aim to develop an evidence-based consensus document on the use of pneumococcal vaccines in individuals with cardiac conditions. Methods Modified Delphi consensus methodology was used to establish consensus. A committee of seven cardiologists from India formed the panel. Questions were drafted across three domains: (a) the risk of pneumococcal disease in patients with cardiac conditions, (b) evidence and optimal timing of pneumococcal vaccination, and (c) barriers to vaccination in cardiology settings. The consensus level was categorized into three groups: (a) low (<60%), (b) moderate (60%-79%), and (c) high (≥80%). Results Experts agreed that immunocompetent individuals with cardiac conditions, adults with a medical history of myocardial infarction/coronary artery disease, heart failure, individuals who fall under the coronary artery disease spectrum, older adults (>50 years of age) with chronic hypertension, and adults with chronic hypertension or a history of acute coronary syndrome/myocardial infarction, with multiple comorbidities, can benefit from pneumococcal vaccination. Conclusion This document will guide clinicians on the optimal timing for pneumococcal vaccination in patients with cardiac conditions and highlight specific patient subgroups that can benefit from it.

Heart failure with reduced ejection fraction (HFrEF) is a significant contributor to impaired quality of life, hospitalizations and mortality, globally as well as in India. Early and rapid initiation of the 4 pillars of guideline-directed medical therapy (GDMT) has been shown to significantly improve the morbidity and mortality rates associated with HFrEF. However, despite robust clinical evidence and proven benefits, GDMT is significantly underused in clinical practice. Lack of simplified, yet patient-profile-tailored treatment protocols, concerns regarding the safety or tolerability of medications, and therapeutic inertia commonly contribute to underuse. An Indian expert consensus was developed by using the modified Delphi technique to address the GDMT underuse. This expert consensus provides guidance on the use of GDMT based on the patient profiles encountered commonly in clinical practice with the objective of aiding optimal GDMT use and, thereby, improving the clinical outcomes in patients with HFrEF.

The study aimed to explore the association between type 2 diabetes (T2D) and heart failure (HF) using echocardiography and NT-proBNP. The study also derived an NT-proBNP cut-off for diagnosing HF by echo in Asian Indians with T2D. A retrospective study was performed using data from individuals with T2D, aged ≥ 18 years, who visited diabetes clinics in India between March 2019 and December 2023. NT-proBNP levels were quantified by chemiluminescence, and left ventricular ejection fraction (LVEF) was assessed from echo using two-dimensional (2D) echocardiography. Heart failure was classified based on the European Society of Cardiology (ESC) guidelines. Receiver operating characteristic (ROC) curve was performed to determine the optimal NT-proBNP cut-off for diagnosing HF by echo. Among the 1189 study individuals included in the study (714 men and 475 women), 5.9

BACKGROUND:Managing thrombotic and hemorrhagic risks associated with dual antiplatelet therapy (DAPT) in patients with a high bleeding risk (HBR) is challenging, especially in post-percutaneous coronary intervention (PCI) patients. Transitioning from DAPT to single antiplatelet therapy (SAPT) aims to reduce bleeding complications while ensuring sufficient ischemic protection. This study explored Indian interventional cardiologists' views on de-escalation strategies in HBR patients, considering bleeding risk factors, including Indian-specific risks, such as tropical diseases and other comorbidities. MATERIALS AND METHODS:A cross-sectional questionnaire-based survey was conducted from June 2024 to July 2024 among 400 interventional cardiologists in India. A structured, pre-validated questionnaire was used to gather data on the perceived prevalence of HBR in routine practice, key HBR factors specific to Indian patients (such as frailty, comorbidities, and tropical diseases), preferred SAPT agents after DAPT, perceived bleeding risk profiles of antiplatelet agents, and barriers to implementation of de-escalation. Participation was voluntary and anonymous. Responses were analyzed using descriptive statistics and reported as frequencies and proportions. RESULTS:Of the 375 interventional cardiologists, 193 (51.47%) reported an HBR prevalence of less than 10%, and 250 (66.67%) believed that gastrointestinal (GI) bleeding was the most common complication in patients receiving DAPT. The main HBR factors included frailty, reported by 326 (86.90%) cardiologists, chronic kidney disease (CKD) stage 3 or severe, reported by 319 (85.1%) cardiologists, and liver cirrhosis with portal hypertension, reported by 324 (86.4%) interventional cardiologists. After DAPT, 128 (34.13%) cardiologists preferred clopidogrel 75 mg, and 107 (28.53%) preferred aspirin 75 mg. Clopidogrel was seen as the least likely to cause bleeding by 179 (48.00%) interventional cardiologists, with 80 (21.33%) rating it as the best option for HBR patients de-escalating from DAPT to SAPT. CONCLUSIONS:This study presents Indian interventional cardiologists' perspectives on de-escalation strategies, including transitioning from DAPT to SAPT, to reduce bleeding complications, while ensuring adequate ischemic protection in patients with HBR post-PCI. Interventional cardiologists have outlined criteria for identifying critical HBR factors relevant to the Indian population. Clopidogrel was the most preferred medication for transitioning to SAPT in HBR patients. Simplified Indian bleeding risk scoring tools and tailored approaches are essential for improving DAPT management in patients with HBR.

Amyloidosis is caused by extracellular deposition of amyloid protein in various organs and tissues. Light-chain amyloidosis is the most common systemic amyloidosis, whereas transthyretin amyloid cardiomyopathy is emerging as the underdiagnosed variant, especially in the elderly. Cardiac MRI and technetium-99m-pyrophosphate scintigraphy are specific non-invasive modalities that have simplified the diagnostic accuracy of cardiac amyloidosis. Identifying the type of amyloidosis is of paramount importance, given the differences in management protocols. Increased left-ventricular wall thickness and diastolic dysfunction are the most easily detectable manifestations of cardiac amyloidosis. Atrial involvement is early in both light-chain and transthyretin amyloidosis and is associated with high risk of arrhythmias and thromboembolic events. We report a case of wild-type transthyretin amyloid cardiomyopathy with predominant involvement of the right atrium and patchy involvement of the right and left ventricles.

The cardiovascular continuum is the developmental process of cardiovascular diseases (CVDs) leading to heart failure (HF) and sudden cardiac death. Beta-blockers (BBs) are at the forefront of managing conditions along this continuum, ranging from cardiovascular (CV) risk factors to heart failure. In particular, bisoprolol proved to be a highly cardio-selective BB with a favourable pharmacokinetic profile, demonstrating long-term safety, good tolerability, and proven efficacy in reducing cardiac events, including arrhythmias and mortality in patients with heart failure with reduced ejection fraction (HFrEF). This evidence-based perspective showcased numerous clinical studies revealing the utility of bisoprolol in managing patients with CVDs, particularly HFrEF and stable angina. It also included safety evidence for bisoprolol in patients with renal and hepatic dysfunction, etc. Expert opinions from leading cardiologists across India further reinforce the role of bisoprolol as a first-line therapy in managing HFrEF and stable angina, making its usage suitable for HFrEF and angina patients with special emphasis on comorbidities, such as chronic kidney disease (CKD), chronic obstructive pulmonary disease (COPD), and diabetes.

OBJECTIVES:Cardiovascular diseases (CVDs) have become a major cause of mortality in India and abroad. Various risk scores have been formulated to estimate CVD risk. The preferred biomarker for the detection of myocardial cell necrosis is cardiac troponin. Highly sensitive troponin assays are now available. Computed tomography coronary angiogram (CT-CAG) is the standard noninvasive modality to identify as well as exclude coronary artery disease (CAD). Our study aims to correlate high-sensitivity troponin I (hs-cTnI) and the QRESEARCH cardiovascular (CV) risk algorithm (QRISK3) score against CT-CAG and determine whether, by using these data, we can detect or rule out CAD accurately by noninvasive means alone. MATERIALS AND METHODS:We evaluated 100 subjects who presented with chest pain (primary prevention population) to the cardiology outpatient department. A detailed history was obtained, and blood investigations, including hs-cTnI, were conducted. The QRISK3 score was calculated, and CT-CAG was performed for all. Hs-cTnI >6 was considered significant. Those who had >50% diameter stenotic lesion(s) were deemed to have significant CAD. RESULTS:In our study with 100 subjects, 80 had hs-cTnI <6, and 20 subjects had hs-cTnI >6. The QRISK3 score did not show any statistical correlation with hs-cTnI. The hs-cTnI levels were compared with CT-CAG results and found that 80% of subjects with elevated hs-cTnI had CAD. CONCLUSION:A strong correlation between elevated hs-cTnI levels and CAD by CT-CAG was established by our study. The early detection of CAD will prompt early management and delay further progression of the disease.

Background Significant gains have been made in the management of heart failure (HF), but real world implementation remains unclear. We aimed to understand the present scenario of adherence to guideline directed medical therapy (GDMT) for HF in the developing country of India. Methods and Results Clinical implementation of HF guidelines and practice patterns of HF management were investigated in a nationwide open-access online survey of the Heart Failure Association of India. Participants (5012 respondents from 29 states, 86% males) from private hospitals (60%), tertiary hospitals (16%), public hospitals (14%) were represented. 53% were physicians, 44% were cardiologists and 2% were endocrinologists. 61% of respondents used NTproBNP as a choice of biomarker for HF management. 38% of respondents used European Society of Cardiology HF guidelines, while 35% used American College of Cardiology consensus statement on HF. 54% respondents believed that ¼th of their HF patients received guideline directed medical treatment (GDMT), while only 15% respondents believed that more than ¾th of their patients received GDMT. The greatest barriers perceived for providing GDMT for HF were poor drug compliance seen in 58% patients followed by treatment cost in 54% patients (figure 1). Conclusion This survey based assessment of understanding the challenges involved in having GDMT to HF patients will act as a springboard to rectify current barriers involved in management of HF patients

Background Cardiovascular disease (CVD) remains the primary cause of mortality worldwide, with higher fatality rates in India. Multi-modal diagnostics integrating electrocardiogram (ECG) analysis, cardiac biomarkers, and region-specific insights can enhance early detection and clinical triage. Methods In this cross-sectional study, ECGs along with clinico-epidemiological data were collected from two regions- North and South Indian cohorts. ECGs were clinically annotated and were analyzed using Earth Movers Distance (EMD) and Support Vector Machine (SVM). A 2 ml blood sample from both cohorts was also collected for molecular analysis. Age and sex matched serum samples were curated to detect four novel cardiac biomarkers. ROC curve analysis was used to assess the relationship between the biomarker index and the probability of ECG abnormality. GraphPad 10.5 and Stata version 17.0 was used for statistical analysis. Results A total of 774 clinically annotated ECGs were collected (498 from North and 276 from South Indian cohort). For the molecular analysis, 34 serum samples were curated the North Indian cohort and 54 from the South Indian cohort. The proposed SVM algorithm reported combined accuracy of 90% for non-biomarker analyzed ECGs and 94% accuracy for biomarker analyzed ECGs. South Indian cohort with abnormal ECGs reported significantly higher GDF-15 level (1145.8 pg/ml) (p<0.001) as compared to North Indian cohort. GDF-15 also exhibited potential prediction ability for detecting abnormal ECG findings (AUC-0.8853). Conclusion Our study demonstrates GDF-15 as a potential biomarker for detecting region-specific abnormal ECG patterns. The proposed multimodal platform's high diagnostic accuracy reinforces the efficacy of the artificial intelligence-driven approach in early screening and triaging CVD cases across a diverse Indian population. Funding This study was funded by the Indian Council of Medical Research (ICMR) under its Ad-hoc Research Grant Scheme (Proposal ID: 2020-3500). ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This study was funded by the Indian Council of Medical Research (ICMR) under its Ad-hoc Research Grant Scheme (Proposal ID: 2020-3500) ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: 1. Ethics Committee BioMedical Research (BMR) (North Indian Cohort)- Institutional Ethics Committee Biomedical Research, Indraprastha Apollo Hospitals, New Delhi, Registration No.- EC/NEW/INST/2020/567 2. Ethics Committee Bio Medical Research (BMR) (South Indian cohort)- Institutional Ethics Committee Biomedical Research, Apollo Hospitals, Chennai, Registration No.- EC/NEW/INST/2020/527 3. Institutional ethics committee (site of experiment)- Institutional Ethics Committee, Amity University Uttar Pradesh, Noida (Ref. No. IBSC/AUUP/2020-1 /6) I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data produced in the present study are available upon reasonable request to the authors

Patients with heart failure with reduced ejection fraction (HFrEF) experience higher rates of in-hospital and all-cause mortality. On the basis of the VERINA trial, vericiguat is indicated for patients who have had a worsening heart failure (WHF) event despite optimal heart failure (HF) therapy, or for those with tolerability concerns. This multicenter, prospective, single-arm, non-randomized, real-world, descriptive study assessed the efficacy and safety of vericiguat in Indian patients aged ≥18 years with chronic HFrEF who were vericiguat-naïve and started treatment as per the local label. This analysis is based on interim data and the final results may differ. The main endpoint was a composite of cardiovascular (CV) death or first HF hospitalization. Secondary endpoints included each component of the primary outcome, all-cause death, and safety. Dose-titration parameters, including time to reach and duration at various dose levels, were also assessed. A total of 205 patients were enrolled (58.0 ± 13.27 years; 73.7

Background Significant gains have been made in the management of heart failure (HF), but real world implementation remains unclear. We aimed to explore the current practice pattern of management of HF in India which is a Low-middle income country. Methods and Results The Heart Failure Association of India distributed an electronic survey to understand the practice patterns of heart failure management. Clinical implementation of HF guidelines and practice patterns of HF management were investigated in a nationwide open-access online survey of. Participants (5012 respondents from 29 states, 86% males) from private hospitals (60%), tertiary hospitals (16%), public hospitals (14%) were represented. 53% were physicians, 44% were cardiologists and 2% were endocrinologists. 61% of respondents used NTproBNP as a choice of biomarker for HF management. 38% of respondents used ESC HF guidelines, while 35% used ACC consensus statement on HF. HFrEF was the commonest HF type encountered. (figure1). Only 25% of respondents assessed quality of life (QoL) by Minnesota living with heart failure questionnaire for their HF patients. 66% of respondents reported that sarcopenia was seen in 1/4thof their HF patients, while 68% thought that atrial fibrillation is seen in 1/4th of HF patients. 50% of respondents reported that 1/4th of their HF patients had renal dysfunction. Conclusion This large survey provides for the first time in-depth insights about practice patterns of HF management in a developing country like India and will provide us ideas about better HF managment in this part of the world.