|Year : 2006 | Volume
| Issue : 1 | Page : 2-14
|Date of Web Publication||17-Jun-2010|
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
. Abstracts. Heart Views 2006;7:2-14
Taxus liberte in the "Real World": Six-month outcomes from the transitional phase of the taxus olympia registry
Waqar H. Ahmed, Ibrahim Al-Rashdan, Abdullah Al Naeemi, and Fuad A.Saeed, Ali Ghamdi, Saad Kassab, Saudi Arabia
Objectives: TAXUS OLYMPIA is a multicenter, prospective, global registry with 5 phases designed to capture usage data and clinical outcomes in patients receiving the second-generation TAXUS LibertŲ-SR Paclitaxel-Eluting Stent System during routine clinical practice. The purpose of this presentation is to report 6-month outcomes from the Phase I of TAXUS OLYMPIA.
Methods: Phase I is a post-approval, web-based registry involving 16 centers in seven countries where TAXUS LibertŲ is commercially available. A total of 529 patients receiving at least one TAXUS Liberte stent were enrolled. Clinical follow-up evaluations were scheduled for 1, 6, and 12 months post-implantation. To insure integrity of data collection, records from 100% of patients during the 30-day follow-up, and from a random sample of 20% of patients during the 6- and 12-month follow-up will be reviewed against the patient's medical chart for verification. Records from 100% of patients with reported cardiac events will also be verified. The primary outcome of Phase I is the rate of TAXUS LibertŲ related cardiac events (cardiac death, myocardial infarction and re-intervention) at 30 days post-implantation.
Results: From February to June 2005, 529 patients were enrolled in Phase I. A large proportion of those patients were considered high-risk, with 51.0% diabetics and 49.0% with angiographic evidence of multi-vessel disease. Overall, 57% of enrolled patients represent expanded use over those patients typically studied during randomized, controlled trials. The 30-day TAXUS Liberte related cardiac event rate was 1.3% (n=7), with 1.0% (n=5) of patients requiring a re-intervention. Additionally, the rates of TAXUS LibertŲ related cardiac death and myocardial infarction were low at 30 days (0.4%, n=2, and 1.0%, n=5, respectively). Within the first 30 days, stent thrombosis occurred in 1.1% (n=6) of patients.
Conclusion: The TAXUS OLYMPIA Registry is collecting clinical outcomes and usage data from patients receiving the next generation TAXUS LibertŲ stent in a real world setting. The 30-day outcomes of Phase I demonstrate a low occurrence of cardiac events and excellent outcomes in high-risk patients.
Percutaneous coronary intervention without on site cardiac surgery in the United Arab Emirates
Azan S. Binbrek, FRCP (Edin.) FRCP (Lond), Sanjeev K. Agarwal MD, DM (Cardiology), Dr. B. Mittal, MD, Haitham Al-Hashimi, M.B. ChB, MRCP (UK)
Rashid Hospital, Dubai, United Arab Emirates
Objectives: The aim of the present study is to assess the feasibility, efficacy, and safety of percutaneous coronary intervention (PCI) in patients with stable coronary artery disease, acute coronary syndrome (ACS) and ST segment elevation myocardial infarction (STEMI) in a Gulf area hospital without on-site cardiac surgical facilities.
METHODS: We reviewed the data of a total of 468 patients who underwent PCI between November 2003 and October 2005 in Rashid Hospital, Dubai, United Arab Emirates. Surgical standby arrangements were agreed upon with a nearby centre. Periprocedural and immediate pre-discharge outcomes were documented.
Results: There were 318 elective PCI and 50 for STEMI. An initial success with Thrombolysis in Myocardial Infarction (TIMI) grade III flow was achieved in 93.97% patients. 1.71% had suboptimal results because of diffuse distal disease of the target artery. One patient was a rescue angioplasty after failed thrombolysis. (He was in pulmonary oedema and died 3 hours later). The procedure had to be abandoned in 4.31% of patients as the target lesion could not be crossed. One of these patients had acute myocardial infarction with successful thrombolysis. A few patients had minor complications like puncture site hematoma, and bleeding not requiring blood transfusion or peripheral vascular intervention. None of the patients required emergency coronary artery bypass graft (CABG) surgery.
Conclusion: This study demonstrates that PCI can be performed in a selected group of patients with safety and efficacy in a hospital without on-site cardiac surgical facilities. None of our patients required referral for emergency CABG surgery.
Comprehensive evaluation of anomalous origin of the coronary arteries by 64-Detector spiral computed tomography
Ahmed Alsaileek, MD; Lucia Alvarez, MD; Julia Alegria, MD; Jamil Tajik, MD, Jerome Breen, MD; Paul Julsrud, MD
Background: Contrast-enhanced 64-detector computed tomographic coronary angiography (CTA) has shown improved visualization of coronary arteries. We sought to determine the value of CTA for a comprehensive evaluation of anomalous origin coronary arteries.
Methods: Out of 295 consecutive CTAs, 17 pts (5.8 %) were identified with anomalous origin of the coronary arteries. 53 % were men and the mean age was 55.1 years, [range 18.3 to 77.8].). All procedures were performed with ECG-gated 64-detector scanner (Sensation, Siemens, Germany). Oral beta-blocker was given to pts with heart rate more than 60 beats per minute 1 hour and sublingual NTG was also given to most pts 1-2 minutes before the procedure.
Results: In all pts CTA was considered adequate for evaluation of the origin and course of coronary arteries. Of 17 pts, the origin of the left main coronary artery (LMCA) was anomalous in 5 pts; 3 from the right sinus of Valsalva (RSV) and 2 from main pulmonary artery (PA). Separate origin of the LAD and LCX was found in 9 pts. Of these, LAD originated from left sinus of Valsalva (LSV) in 6 pts, RSV or right coronary artery (RCA) in 3 pts. The left circumflex artery (LCX) originated from RSV or RCA in 6, LSV in 2 pts and from the distal RCA in 1 patient. When originated from the right side, the LAD passed anterior to the pulmonary artery (PA) in 2 (out of 3) pts and between the aortic root and PA in one pt [Figure 2], and LCX passed retro-aortic in 5 (out of 6) pts and inferior heart in one patient. RCA origin was abnormal in 3 patients, all originated from the LSV and passed between aortic root and main PA.
Invasive coronary angiography (ICA) was performed in 11 pts, 7 before and 4 after the CTA. Compared to ICA, CTA was equally accurate and adequately characterized the origin and the course of the anomalous coronary artery. CTA was able to detect the presence of other anomalies: myocardial bridging of long segment of LAD in 3 pts, intra-mural course and compression of RCA between the great vessels in two patients and VSD in one patient. Furthermore, anomalous LCX from RCA could not be visualized by ICA in one pt.
Conclusion: 64-detector CTA provides high resolution non-invasive imaging that permits comprehensive evaluation of the origin of anomalous coronary artery with exact 3-dimentional delineation of the its course. CTA also helped to detect other associated abnormalities such as VSD, myocardial bridging or intramural course of coronary artery.
Anomalous origin of the three coronary arteries from the right aortic sinus of valsalva: Role of MDCT coronary angiography
Ayman A El Menyar, K.M Das, Jassim Al Suwaidi,
Department of Cardiology and Cardiovascular Surgery and Department of Radiology, Hamad Medical Corporation, Doha, Qatar.
Background: Monocuspal origin of all three coronary arteries through separate ostia from the right aortic sinus (RCS) is a rare occurrence. To date, the use of multidetector computed tomography (MDCT) for imaging of congenitally abnormal coronary arteries has been discussed only in a few individual case reports.
Objective: To describe the role of MDCT coronary angiography in the evaluation of two rare cases of monocuspal origin of all three coronary arteries from RCS.
Patients and Methods: We reviewed the clinical information and imaging studies of two patients who presented with chest pain. Both patients underwent conventional coronary angiography followed by noninvasive imaging with MDCT.
Results: Both patients had anomalous origin of the all three coronary arteries from the RCS. In one case the LAD took an intramural course in between the aorta and the right ventricular outflow tract (RVOT) while it passed anterior to the RVOT in the other patient. In the first patient, there was also associated coronary fistula to the right ventricle along with right coronary artery (RCA) and left anterior descending coronary artery (LAD) narrowing. Both the stenosed segments were successfully stented and were demonstrated to be patent in the subsequent MDCT.
Conclusion: Monocuspal origin of all three coronary arteries from the RCS is a rare anomaly and can be reliably diagnosed by MDCT. CT angiogram is a convenient complementary tool for coronary arteriography.
Experience with infinnium paclitaxel des in Saudi Arabia
Layth Mimish, Mohammad Anwar, Taher Hassan, Adil Mazin, Vitek Reznicek Abdul-Latif Khoja,
Objective: To evaluate the safety and efficacy of the Infinnium“ stent (A Paclitaxel coronary stent system from India) in patients from daily practice.
Methods: The study was designed as open label, non-randomized, multi-center study. The study included 109 non-randomized patients, with a total 176 Infinnium“ stents implanted (1.64 Infinnium“ / patient).
The first Infinnium Paclitaxel DES deployed in Saudi Arabia was on the 25th of July 2004. Until the 15th of September 2005, 176 stents were deployed in 109 patients. The procedure was successful in 173/176 stents (98.3%).
The patients included 84 males (77%) and 25 females (33%), with a mean age of 57 - 11 yrs (32-85 yrs). Mean CCS anginal Class was 3 (-1) with U.A.P in 44 cases, 7 with NSTEMI, and 11 with STEMI, 2 in cardiogenic shock.
The patients had the following risk factors for coronary artery disease: smoking in 40/109 (37%), Diabetes in 57/109 (52%), hypertension 69/109 (63%), and hyperlipidemia in 75/109 (69%). 82/176 (46.6%) stents were deployed in LAD and diagonals, 31 (17.6%) in Circumflex and OM, 3 (1.8%) in Intermediate, 59 in RCA (33.5%), and 1 in LMCA.
Mean RVD was 2.92 - 0.4 (2.5 - 4mm), and mean lesion length was 18.2 - 7 (6-35mm). 75/176 (42%) stents were deployed in small vessels (less than 2.6mm), and 94/176 (53%) for long lesions (more than 25mm). 38/176(21.6%) lesions were calcified, and 24(13.6%) were restenotic.
Results: All stents except two were deployed successfully (98.4%) with acute stent thrombosis occurring in 2 patients, both of whom had sub-therapeutic anticoagulation (ACT less than 150 sec). One of these 2 patients died. (He had preoperative LVEF less than 20%, 3-vessel CAD, denied surgery, and was hemodynamically unstable).
All patients were followed up clinically at 1, 3, 6, and 12 months by clinic visit or over the phone. Symptomatic patients underwent coronary angiography.
There were 3 late thromboses (after 2 months), with two sudden deaths in the 1st year of follow-up, one of which is in a patient with LVEF of 25%. Two of the above stents were not fully expanded for different reasons on review of the initial intervention angiogram.
Conclusion: The stents were easily deployed despite the complexity of the lesions treated, which represent real world day-to-day cases, rather than selected ideal lesions. There was a high prevalence of Diabetes, small vessels, and long lesions in the treated cases compared to randomized trials.
To assess the long-term efficacy, larger number of patients with worldwide registry with long term follow up is required.
Surgical ventricular restoration (SVR): Early experience in Saudi Arabia
E. Ahmed MD, FRCSI, W.Abukhudair, MD, FRCSC; W. Ahmed,MD, FACC; K. Sheibi. MD, FACC; A. Ajam, MD, MRCP; A. Ashmeg., MD, FRCS Saudi Arabia
Objective: To evaluate our early experience with SVR as therapy for a subset of patients with ischemic cardiomyopathy.
Background: Ischemic cardiomyopathy poses a challenging problem to the cardiologist and cardiac surgeons. Following myocardial infraction, 20% of patients develop ventricular dilation and congestive heart failure (CHF) even with early reperfusion therapy. This is due to "ventricular remodeling" process that results in the loss of the normal elliptical shape of the ventricle and CHF. Ventricular volume reduction, and shape restoration surgery has recently become an available option for this subset of patients. We prospectively examined the early outcome of SVR in our institution.
Methods: Eight prospective post anterior myocardial infraction patients underwent SVR with concomitant CABG /or mitral valve repair are presented.
Results: The mean age was 50.6 (+ 5.1) years. All patients were males. The mean left ventricular fraction was 20-3.16. Six patients had SVR with concomitant CABG. Two patients had mitral valve repair as well. Two patients did not undergo the surgery due to the pre-op mortality of one and intra-operative change of decision to CABG alone for the other. The average number of grafts was 2 + 0.63. The NYHA class improved from 3.3 (+ 0.8) to 1.8 (+ 0.4). The left ventricular ejection fraction improved from 20% (+3.16) to 30.8% (+5.8). The post-op ventilation period was 40 hours (+1.9) and the mean length of stay was 12.8 (+ 4.7) days. Intra aortic balloon pump (IABP) and Levosimendan were used in all patients. The operative mortality for the six SVR cases was zero.
Conclusion: In our preliminary group, the SVR can be performed safely. SVR may afford significant improvement of symptoms and ejection fraction. Further studies are needed to define the patients best served with the procedure.
The impact of basal glucometabolic status on the short term prognosis in patients following acute myocardial infarction
Dr. Taysir Garadah, Dr. Hayat al Mahroos; Dr. A. Hai al Awadhi;
Salmaniya Medical Centre, Arabian Gulf University, Manama, Bahrain
Objective: Diabetes is associated with increased mortality following AMI compared to the general population. The aim of this retrospective study was to investigate the effect of high random blood sugar of >5.8 mmol/l and the level of glycosylated hemoglobin of >6 on short term mortality and cardiac event rates in 1420 patients with AMI admitted to the CCU.
Results: All patients with AMI as evidenced by ECG and raised cardiac enzymes (CK MB and troponin) were included over a duration of two years, 2004 and 2005. The results were as follows.
· Cardiac Events were: Atrial fibrillation, AV Block, V Tachy, Pulmonary oedema, Hypotension, Shock.
Among patients with high sugar, only 284 (50%) had high HBAIC >6 and 150 (26%) patients had no prior history of diabetes mellitus. The number of patients that were given thrombolytic therapy in the high sugar group was 477 (84%) and in the normal sugar group was 698 (82%).
[Additional file 1]
Conclusion: The high random blood sugar on admission of myocardial infarction patients, regardless of its etiology, carries a high short term morbidity and mortality. Furthermore, patients with normal HBAIC but high random blood sugar on admission also have a higher morbidity and mortality rate.
Intermediate Result of Intracoronary stand-alone bolus administration of eptifibatide during coronary intervention (ICE) study
Walid Hassan, MD, FACC; Naser ElKum, PhD*; Hani Al-Sergani, FACC; Jehad Al Buraiki; Nathem Akhras; PharmD**; Fawaz Al Turki; Suliman Kharabsheh, FACC, Mohamed E Fawzy, FACC, Amr Badr; Fayez El Shaer; Charles Canver, FACC.
King Faisal Heart Institute, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
Background: There have been several studies testing intravenous (IV) bolus and continuous administration of eptifibatide during percutaneous coronary intervention (PCI). There is no present data available considering giving this platelet inhibitor as intracoronary (IC) bolus only without further IV infusion during PCI.
Methods: We compared the clinical outcomes of 376 patients who received eptifibatide by 3 different routes during PCI and were followed up for over 24 months. Group A (119 patients) had IC eptifibatide bolus only; group B (119 patients) had IC bolus and continuous IV infusion and group C (138 patients) had IV bolus and continuous IV infusion. Patients who had stent(s) and received eptifibatide were included in the study. The standard systemic bolus doses of eptifibatide 180 mcg /kg was given either via IC or IV route and only groups B and C received continuous IV infusion at 2 mcg /kg/min for 18 hours.
Results: Patients, procedural characteristics, and outcomes are shown in the table below. The 6, 12, 24-month cumulative composite endpoint of death, myocardial infarction (MI) and target vessel revascularization (TVR) was lower in group A (9.3, 14.3, 14.3%) compared to group B (19.1, 24.1, 24.8%) and group C (27.5, 40.5, 44.2%) P<0.05. The frequency of major, minor bleeding and re-hospitalization was lowest in group A (2.4, 5.8, 10.9%) compared to group B (7.5, 11.7, 16.8%) and group C (9.5, 17, 28%) P<0.05.
[Additional file 2]
Conclusion: The IC bolus alone route of eptifibatide may be safer and superior to the IV route and continuous infusion may not be necessary. Large-scale prospective randomized trials are needed to validate these findings.
Anticoagulation in pregnant women with prosthetic heart valves
Dr. Taha Al Delamie
HOD Cardiothoracic Department, Royal Hospital, Oman
Objective: The aim of this study is to establish a uniform therapy of anticoagulation in pregnant women with prosthetic valves and to discuss and evaluate the incidence of anticoagulant related complications taking into account the socioeconomic background.
Methods: A retrospective study on 67 pregnancies in 24 women with mechanical prosthetic heart valves from 1983-2000 was performed. The age group ranged from 16 to 45 years (Mean age - 25 years). These pregnancies were divided into two groups: Group 1 (N=46) received oral anticoagulants (Warfarin) throughout pregnancy and Group 2 (N=21) received SC Heparin in the first trimester and oral anticoagulants for the rest of the pregnancy. Both groups received Heparin as an anticoagulant two weeks before the expected date of delivery. All babies were examined at the time of delivery by the pediatrician.
Results: There was no case of Warfarin embryopathy detected and no maternal death. Life threatening valve thrombosis occurred in 2 patients, both of whom were in Group 2. They required emergency open-heart surgery for the replacement of thrombosed valves. Surgery was successful and both had stillborn babies. Group 1 had higher incidence of spontaneous abortion than Group 2 although this was not statistically significant. The role of LMWH in patients with prosthetic valves is not yet established and is not recommended for thrombotic prophylaxis in patients with prosthetic heart valves by the FDA.
Conclusion: The incidence of Warfarin embryopathy has been overstated. We recommend the use of warfarin as an anticoagulant throughout pregnancy especially in countries with similar socioeconomic background to Oman.
The effect of high plasma levels of angiotensin-converting enzyme (ACE) and plasminogen activator inhibitor (PAI-1) on reperfusion after thrombolytic therapy in patients presenting with acute myocardial infarction
Ayman A. El Menyar1; O. M. Altamimi1; Mohamed M.GomaaΉ; Zainab Fawzy2; M.O.Abdel Rahman2; Abdulbari Bener
1Department of Cardiology and Cardiovascular Surgery; 2Department of Laboratory Medicine and Pathology; 3Department of Medical Statistics & Epidemiology, Hamad Medical Corporation, Doha, Qatar
Objective: Resistance to thrombolytic agents and delays in reperfusion occur in more than 30% of patients after acute myocardial infarction. This may play an important role in unsuccessful recanalization after thrombolytic therapy. The aim of this study is to assess the clinical and biochemical markers of reperfusion after different types of thrombolytic therapy and to find out the relationship between PAI-1 and ACE serum levels and the short-term outcome.
Methods: Pretreatment ACE and PAI-1 plasma levels of patients with acute myocardial infarction, treated with thrombolytic therapy were determined. Failure of thrombolysis was considered when reperfusion was delayed as assessed by noninvasive reperfusion criteria, reinfarction, and impaired left ventricular function.
Results: A total 184 patients were recruited for the study of which males constituted 90.7% of the sample and Qataris were 9%. High plasma level of ACE (>50 U/L), PAI-1 (>43ng/ml) and both was found in 57, 108 and 32 patients respectively. High enzymes levels of PAI-1 or ACE were observed with old age and male gender. Subjects with high ACE plasma levels were characterized by impaired LV systolic function (79.0% vs. 75.0%), new Q-wave (88.4% vs. 74.2%), less repurfusion arrhythmia (19.3% vs. 22.8%) and prolonged hospitalization (70% vs. 66%)but no statistical significance was observed. High enzymes levels of PAI-1 were observed with higher incidence of anterior myocardial infarction (50.0% vs. 41.0%), lesser ST segment reduction (65.6% vs. 58.8%), reinfarction (6.3%vs. 5.9%), and impaired LV systolic function (90.6% vs. 76.0%), and prolonged hospitalization (70.4% vs. 63.4). There was a statistically significant difference between the three thrombolytic agents in the presence of high ACE regarding hospital overstay only (p=0.02). The presence of high PAI-1 significantly affected the percent of ST-segment resolution (p=0.03).
Conclusion: High plasma ACE and /or PAI-1 plays a considerable role in the higher incidence of unsuccessful reperfusion and impaired left ventricular function after thrombolytic therapy. A rapid diagnostic tool that enables physicians to detect these enzymes before giving thrombolytic therapy may change the strategy of treatment to offer another effective revascularization method.
Cytotoxin- associated gene - A -positive helicobacter pylori strains: Risk factor for ischemic stroke and coronary heart disease
Shereen Attia, MD; Ihab Hamdy, MD; Nasrat Ayad, MD; Nabeeh El Fadaly, MD Departments of Cardiology, Internal Medicine and Clinical Pathology, Faculty of Medicine, Tanta University, Kuwait
Background: It is uncertain whether helicobacter pylori (H pylori) is associated with ischemic syndromes and whether this association is mediated by the induction of atherosclerosis. In this study, we tested the hypothesis that cerebral, coronary, carotid and aortic atherosclerosis show a selective association with virulent H pylori strains.
Methods: The seroprevalence of infection by H pylori strains bearing the cytotoxin-associated gene- A (CagA), a strong virulence factor, was assessed by ELISA test in 118 patients and 59 controls. Patients were characterized into stroke subtypes based on pathognomic mechanisms. Carotid atheroma load was estimated using duplex scanning. We also tested the prevalence of CagA- positive H pylori in a subgroup of patients who subsequently had a coronary event or aortic atherosclerosis.
Results: CagA- H pylori strains seropositivity was more common in cases than controls (59.3% vs 37.2%, p=0.0056), and this remained significant after controlling for other risk factors including socioeconomic status. CagA-positive H pylori seropositivity was associated with large vessel disease (p=0.0007), lacunar stroke (p=0.05) but not stroke due to cardioembolism or unknown etiology (p=0.5 and 0.39 respectively). Also mean percentage carotid stenosis was significantly higher in patients seropositive for CagA H pylori (p<0.001). The prevalence of CagA-positive H pylori infection in the subgroup of patients with history of coronary heart disease was statistically significant (p=0.005). Abdominal aortic atherosclerosis showed higher prevalence of CagA - H pylori seropositivity (p=0.06).
Conclusion: Infection with virulent CagA- bearing H pylori strains is an independent risk factor for atherosclerotic stroke and coronary heart disease.
Prevalence of atrial fibrillation in patients with cardiovascular disorders in Qatar
1Wafer Dabdoob; 1Dhabia Al-Mohannadi; 2Abdulbari Bener; 1Mohammad T Numan; 1Jassim Al Suwaidi, 1H.A. Hajar Albinali
1Department of Cardiology &Cardiovascular Surgery,
2Department of Epidemiology & Medical Statistics, Hamad Medical Corporation, Doha, Qatar
Background: The incidence of Atrial Fibrillation (AF), its causes and outcome are well-defined in the developed world. However in the developing world, especially in the Arabian Gulf region, the incidence of AF is not well defined. The main objective of this study is to determine the incidence of AF among Qatari patients admitted with various cardiovascular disorders in a geographically defined population in the Gulf region (January 1991 to December 2002) and study the various risk factors.
Methods and Results : A total of 20,856 patients were treated with various cardiovascular disorders over a ten-year period. 8446 patients (40.5%) were Qatari. Of those who developed AF 11.9% were Qataris while 8% were non-Qatari. Among Qatari patients, 971 patients had AF and 7059 had no AF. There was no significant difference found neither in the mean age of the two groups (patients with AF and without AF) (60.10-15.84 yrs vs. 58.29 -14.29 yrs respectively) or in the incidence of hypertension (40.5% vs.42.1%).
Patients with AF were less likely to have acute myocardial infarction (4.4% vs 20.7%, p<0.0001), diabetes mellitus (35.3% vs.48.8%, p<0.0001) and prior CABG (5.6% vs 7.5%,p=0.027). Patients with AF were more likely to have mitral stenosis (1.9% vs. 0.5%, p< 0.0001) and mitral regurgition (3.3% vs 1.5%, p<0.0001). As for principal valve pathology; there were no significant differences in the incidence of aortic stenosis (2.0% vs 2.6%, p<0.26), aortic regurgitation (1.3% vs.1.0%, p<0.3) or mitral valve prolapse (0.4% vs.0.3%, p< 0.3).
Conclusion: In the majority of patients long-standing AF is associated with organic heart disease. Predictive factors of AF include diabetes, hypertension, congestive heart failure, old myocardial infarction, increasing age and male gender.
Sex hormones and oxidant-antioxidant status in post-menopausal women with coronary artery disease
Dr.Mohamed A. Helaly Egypt
Background: The strikingly lower prevalence of acute coronary syndromes in premenopausal women than in men of similar age, then the progressive narrowing of that difference with age after menopause, suggests an important role for sex hormones and probably oxidative stress in the development of coronary artery disease. The aim of this study is to evaluate the sex hormones and oxidant-antioxidant status in postmenopausal women and their correlation with coronary artery disease.
Methods : This study was conducted on 40 non-hormone user postmenopausal women with coronary artery disease. They were divided into 3 groups: Group 1 (17 patients) had an acute myocardial infarction; Group 2 (10 patients) had unstable angina and Group 3 (13 patients) had stable angina. Control consisted of 20 apparently healthy postmenopausal women of similar age. All cases and control subjects were subjected to thorough history taking, full clinical examination, routine laboratory investigations, resting echocardiography and special laboratory investigations including assay of serum levels of total & free testosterone, total estradiol, morning & nocturnal cortisol, malondialdehyde which is a modified low density lipoprotein-cholesterol,- tocopherol and vitamin-C.
Results: We found a higher level of total and free testosterone in the three groups than control subjects (P=0.016 vs P=0.031 respectively). The free testosterone had a mild significant positive correlation with the severity of coronary artery disease (P=0.04). Moreover, the free testosterone was significantly higher in the group of acute myocardial infarction than in the group of stable angina (P=value 0.008). The serum level of total estradiol was significantly lower in cases than in the control group (P<0.0001), but it was not correlated with the severity of coronary artery disease (P<0.689). Malondialdehyde was significantly higher in cases than the control subjects (P<0.0001) and it had a mild positive correlation with the severity of coronary artery disease (P=0.01). Moreover, it was significantly higher in cases of acute myocardial infarction in comparison to stable angina cases (P=0.005). -tocopherol and vitamin C were significantly lower in cases than in control group (P<0.0001 vs 0.048 respectively), but they were not correlated with the severity of coronary artery disease (P= 0.66 vs 0.16 respectively).
Conclusion: There was no correlation between the severity of coronary artery disease and level of measured sex hormones such as testosterone, estradiol, and malondialdehyde.
Cardiorenal link in health and in disease states
Dr. Chandra Mauli Jha, MRCP (UK)
Department of Nephrology, Rustaq Regional Hospital, Oman
Physiological link between cardiac and renal function had been well understood but how the functional impairment of these two systems, either alone or if coexistent, affects long term outcome was not known until recently. Recent world-wide rise in incidence and prevalence of chronic renal impairment, increase in old age population and improved survival of patients of ischemic heart disease has led to increase in number of patients with coexistent cardiac and renal dysfunction. It is now recognized that impaired renal function is an independent strong risk factor for cardiovascular outcome. Though the pathophysiological mechanism is less than clear, there have certainly been interest generated and exploration made to some extent. I shall review in this presentation the extent of the problem, the recent researches made in the field and possible mechanism(s) visualized. The ill-effect of cardiac and renal dysfunction which has recently been referred by some workers in this field as "cardio-renal syndrome" is not simply additive but multiplicative. It has tremendous economical impact on the health care system.
This subject of "cardio-renal link in pathological state" is considered important to be discussed in such an important scientific meeting because the speaker have noticed that in practice there is not enough recognition & awareness among Internists, cardiologists and nephrologists of this clinical problem. This leads to inadequate & suboptimal management of patient from both renal and cardiac point of view. Author feels that spread of information on this subject among clinicians shall not only improve their care, but shall also lead to practice of preventive aspect of chronic renal & cardiac diseases. Moreover it may also stimulate clinicians to investigate further about this disease entity.
Frequency distribution of metabolic syndrome among diabetic patients referred to the diabetic center of Baghzereshk-Iran
Introduction: Metabolic syndrome is not a disease, but is a cluster of disorders of metabolism, including high blood pressure, high insulin levels, excess body weight and abnormal cholesterol levels that make the individual more susceptible to develop diabetes, heart disease or stroke. Each of these disorders is by itself a risk factor for other diseases. In combination, these disorders dramatically increase the chances of developing potentially life-threatening illnesses.
Method and Material: In this investigation we studied the frequency of metabolic syndrome in patients referred to the Esfahan Diabetic center over a 3 month period. Diagnosis of metabolic syndrome was made according to the NCEP-ATP 3 Guidelines. The study population consisted of 200 diabetic patients RESULTS: About 75 percent of the patients had metabolic syndrome. Patients were categorized according to different age groups, range f 34 to 84 years old. The syndrome was more prevalent in the age category between 55 - 64 years. We used Chi-Square test to study the association between metabolic syndrome and gender, hypertension, waist circumference, HDL and triglyceride level. The P value was <0.0001 indicating significant association between metabolic syndrome and hypertension , HDL , triglyceride and waist circumference.
Discussion: It seems that poor control and late diagnosis of metabolic syndrome and ignorance about the new NCEP protocol for treatment leads to increase in the prevalence of this syndrome and increases the risk of subsequent cardiovascular mortality.
Anesthetic drugs are the key to fast track recovery of coronary bypass patients
Mohammed A. El-Arief and Iman Khamis
Anesthesia Department Hamad Medical Corporation, Doha Qatar
Objective: Advances in anesthesia and surgery have been crucial in improving postoperative outcome. The objective of this study was to evaluate remifentanil-sevoflurane anesthesia for fast track tracheal extubation after coronary artery bypass graft surgery (CABG), regarding the time of ventilation and complication rate in the postoperative period.
Patients and Method: 60 patients scheduled for (CABG) were allocated into two groups; In group I (remifentanil-sevoflurane) 30 patients; anesthesia was induced using midazolam, propofol and a bolus dose of remifentanil over two minutes by continuous infusion, and endotracheal intubation was facilitated using cisatracurium. Anesthesia was maintained using sevoflurane in oxygen and air and continuous remifentanil infusion. In group II (fentanyl-isoflurane) anesthesia was induced using midazolam, propofol and fentanyl then endotracheal intubation was facilitated using cis-atracurium. Anesthesia was maintained by isoflurane in oxygen and air and fentanyl infusion. In both groups, muscle relaxation was achieved with cisatracurium infusion. Patient characteristics were similar in both groups.
Results: The mean ventilation times were significantly shorter in Group I (remi-sevo) group. 42% of patients in (remi-sevo) group were extubated on arrival at the ICU compared to 2% in Group II (fent-isof). Intraoperative hemodynamics, MPAP, CVP, PCWP, CI and PVR were not significantly different during operation in both groups. Complications were similar in both groups.
Conclusion: Early extubation (fast track) can be effective and safe upon using remifentanil and sevoflurane anesthesia as it reduces intubation and ventilation time without increasing postoperative complications.
Clinical approach of evidence based therapy for CVD
Mohammad A. Bajubair, MD; N. Jaber, MD and A. Alnono, MD
Faculty of Medicine and Health sciences, University of Sana'a, Yemen.
Cardiac Centre , Althawra Teaching Hospital, Sana'a
Background: Evidence-based drug therapy (EBT) is defined in a generally positive and individualistic way that emphasizes the importance of outcomes and states, more or less, that a doctor makes his decisions according to the best available knowledge. EBT narrowly defines "evidence" for effective, ethical therapy as "results" from double-blind research done with randomly controlled clinical trials (RCTs). Cardiovascular diseases and drug therapy is a rapidly changing field and we are always open to new evidence or evidence that we may have overlooked. Not all doctors want or need to learn how to practice all five steps of EBT. Indeed, most doctors consider themselves users of EBT. As the epidemiological view of EBT is available, the clinical practice requires more stable data in the literature and especially in the teaching and training textbooks. Practicing EBT is an advance in the drug therapy and is believed to help in relieving contradiction and confusion of the therapy.
Objective: Our aim was to explore the necessity of following new clinical evidence in the treatment of the CVD in clinical practice and the availability of RCTs in the textbooks and commonly used literature.
Methods: Cross-sectional interview survey of 20 physicians in the cardiac centre, Althawra teaching hospital, Sanaa, Yemen, to understand drug use in regard to the EBT (clinically evidenced, RCTs) or the mechanism of actions (non-clinical evidences) especially focused on ischemic heart disease and heart failure. The five commonly used textbooks were studied for the availability of RCTs.
Results: In chronic ischemic heart disease, ABC regimen (Aspirin, B-blockers, and angiotensin converting enzyme inhibitors, Captopril) as secondary prevention was selected by almost all physicians (92%), while nitrates put as first drug of choice for chronic ischemia only a small number of physicians (16%). In treatment of congestive heart failure (CHF), digoxin (36% vs 10%) was reported to be the first line therapy more by the newly graduated physicians. All new editions of the textbooks have included RCTs as the basis for therapy in clinical practice, especially in Braunwald Heart disease and Davidsons Medicine. EBT was used more often for long term drug therapy than acute drug therapy.
Conclusion: Results showed a necessity for correlation between basic evidence and clinical evidence (EBT). Including the RCTs in the commonly used textbooks may help in this regard by enabling physicians to find new evidence and will help to relieve some of the confusion about therapy in clinical practice.
15 years of pediatric valve experience
Dr. Raj Gopal Menon
Objective: Despite improving surgical techniques, treatment of heart valve disease in children remains controversial. Somatic growth and adequate anticoagulation are of concern when children undergo valve replacement. We conducted this study to evaluate the performance of valves in this age group.
Methods: 41 children under the age of 13 years who underwent valve replacement were included in this study. A total of 47 valves were implanted in 41 patients: 44 were mechanical prostheses, one bioprosthetic, one pulmonary autograft and one was a Contegra valved conduit. 33 (70.3%) valves were implanted in the mitral position, 11 (23.4%) in the aortic position, 1(2.1%) in tricuspid position and 2 (4.2%) in pulmonary position. Preoperatively, 14 (34.14 %) were in NYHA class IV, while 24 (58.53%) were in NYHA class III.
Results: There were 2 (4.87%) hospital deaths and 2 (4.87%) late deaths while 2 (4.87%) patients were lost to follow up. The mean follow up period was 9.4 yrs. 35 (85.36 %) patients were in NYHA Class I and free of all medications except warfarin. 3 (7.31%) patients have undergone 5 successful pregnancies. The median INR was 2.23. Major thrombo-embolic episode occurred in 1 (2.43%) patient.
Conclusion: In view of the problems of sizing, anticoagulation and need for re-operation at an early age, there is a reluctance to replace valves in children. This study shows that despite these problems, valve replacement can be undertaken safely and successfully in children, when repair has failed or not technically feasible.
Intermediate follow up after total correction of fallots tetralogy
Dr. Taha Delamie; Dr. M. Venkatraman; Dr. V. John;
Dr Z. Sunny; Dr.Menon Raj
Royal Hospital, Muscat, Oman.
Objective: To evaluate the surgical outcome and intermediate follow up after total correction of Fallots Tetralogy.
Material and Methods: From Jan.1992 to Dec.2004, 162 patients (age range 2months to 24 years) underwent intra cardiac repair of fallots tetralogy. The weight of these patients ranged form 4 kg to 44 kg.(mean wt: 13.2 kg). 35 patients had a previous BT shunt. 119 patients received a trans annular patch.
Results: Hospital Mortality was 5.5% ( 9/162 pts). Of the 153 survivors files of 17 patients were not available. 136 patients were followed up for 144 months (mean 5.2 years). 7 of these have undergone reoperations for residual lesions. 118 of these patients are in class 1 on no medications.
Conclusion: These results demonstrate that the intermediate outcome after repair of Fallots Tetralogy is very satisfactory. There is a need to establish a uniform clinical protocol to follow up these patients regularly.
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