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ABSTRACTS
Year : 2003  |  Volume : 4  |  Issue : 4  |  Page : 4 Table of Contents     

Abstracts


Date of Web Publication22-Jun-2010

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How to cite this article:
. Abstracts. Heart Views 2003;4:4

How to cite this URL:
. Abstracts. Heart Views [serial online] 2003 [cited 2020 Feb 19];4:4. Available from: http://www.heartviews.org/text.asp?2003/4/4/4/64426

Atrial Septal Defect Closure: Comparison of Amplatzer Septal Occluder and Surgery

Subramanyan R, Narayan R, Venkatraman M, Mukheini M, Riyami AM

Royal Hospital, Muscat, Oman

This study compares the results of Amplatzer Septal Occluder (ASO) with surgery for closure of secundum atrial septal defects (ASD).

Methods: 23 patients (age 6-52 years; 17 female, 6 male) underwent cardiac catheterisation for ASD closure by ASO. This group was compared with 44 consecutive patients (age 2-54 years; 32 female, 11 male) who underwent surgical ASD closure in the same time period. The procedural success, complications, early and medium term results, and length of hospital stay were compared.

Results: ASO device was successfully deployed in 18/23 patients (78%) in whom it was attempted. Failure of deployment was due to excessively large size of the ASD (> 30 mm, N=2), multiple defects (N=1), floppy inadequate rims (N=2) and inability to get a stable position (N=1). One patient had partial collapse of the right lower lobe, which recovered with physiotherapy. Other minor complications included transient hypotension and thrombophlebitis (1 patient each). There was no incidence of migration of ASO, thrombosis, embolism, infection or death. Complete abolition of the shunt was achieved in all 18 patients by ASO. Surgery was successful in completely abolishing the shunt in all 44 cases (100%). Early complications in the surgical group included pericardial effusion (1 patient), transient atrial fibrillation (2 patients), right atrial thrombus (1 patient) and wound complications (2 patients). The duration of hospital stay was significantly longer in the surgical group than in the ASO group. At late follow-up, results were similar for efficacy of closure and regression of right ventricular enlargement.

Conclusions: ASO is a safe and effective means of closing secundum ASD's, although the likelihood of success with a single procedure was greater with surgery. The incidence of complications was also slightly higher in the surgical group, but most events were transient and treatable. Medium-term results on follow-up were similar in the two groups. With experience, the success rate for ASO would be expected to improve, due to better case selection.

The Influence of Alteration in Preload on the Pattern of Left Ventricle Diastolic Filling by Pulsed Doppler Echocardiogram in Patients on Regular Hemodialysis

Taysir Garadah and A. Hai Al Awadi

Bahrain

The pattern of the left ventricle (LV) varies in patients with end stage renal disease. It is affected by preload, after load and the contractility. In this study, we evaluate the impact of preload on the pulsed Doppler indices of the LV.

Methods: Forty-five patients on regular dialysis were evaluated clinically and with pulsed Doppler echo before and after a dialysis session. Blood pressure, heart rate, and pulsed Doppler indices were recorded. The mean age of patients in the study group was 58 ± 20 years with 21 males. Thirty patients had a history of hypertension, and 11 had diabetes mellitus. Twenty-four patients had LV hypertrophy on ECG, but 29, on M mode echo. Seven patients had coronary artery disease. The mean duration of dialysis was 2.5 ± 1.67 hours. The mean hemoglobin level was 10.8 ± 2.06 gm/dl. Diastolic patterns of LV filling were type I in 17 patients; type II, in 12; and type III in 17. Patients were divided into 2 groups. Group I (n=21) had a net fluid loss of less than 2 liters, and group II (n = 24), a fluid loss of more than 2 liters. The age and risk factors were the same in both groups.

Results:

[Additional file 1]

Abbreviations: DT = deceleration time, LVEDD = left ventricle end diastolic dimension, EF = ejection fraction, SBP = systolic blood pressure, VI = aortic velocity integral, Before = before dialysis, After = after dialysis

Conclusions: Reduction of preload by more than 2 liters during dialysis leads to significant reduction in the E and A wave amplitudes of LV diastolic filling as well as the aortic flow integral. Thus preload needs to be taken into consideration when the status of diastolic function is investigated.

Total Anomalous Pulmonary Venous Connection: The Royal Hospital Experience

Ibrahim S. Al Ghaithi, R. Narayan, R . Subramanyan, Taha Al Delamie, V. John, S. Zacharias

Departments of Pediatric Cardiology and Cardiothoracic Surgery, Royal Hospital, Muscat, Oman.

Total anomalous pulmonary venous connection (TAPVC) is a condition in which all the pulmonary veins drain into the right atrium, either directly or indirectly. The age of presentation is variable, and open-heart surgery is required for the survival of these sick infants and children.

Methods: We reviewed a series of 25 children with isolated TAPVC who were operated in Royal Hospital, Muscat between 1995-2003. The ages of the children ranged from 6 days to 7 years (median 60 days). The type of anomalous connection was supracardiac in 11(44%), cardiac in 10(40%), infracardiac in 2 (8%) and mixed in 2(8%). Fifteen cases (60%) were sent for cardiac surgery on the basis of echocardiographic diagnosis alone. The remaining 10 (40%) underwent echocardiography followed by cardiac catheterization. 17 cases (68%) were operated when less than 1 year of age. There were 4 hospital deaths (16%). Two were intraoperative deaths and 2 occurred in the postoperative period. Two of the deaths were in neonates. One succumbed to septicemia following prolonged ventilation and the other was due to heart failure. Follow up has ranged from 6 months to 8 years. Conclusions: TAPVC, a cyanotic heart disease with heart failure, is eminently correctable by open-heart surgery with acceptable mortality. Many infants and children can be sent for surgery on echocardiographic diagnosis alone. Early diagnosis and early stabilization of this group of sick children has contributed to a better outcome.

The Role of Vitamin E in Prevention of Coronary Events and Stroke: Meta-Analysis of Randomized Controlled Trials

Abdullah Alkhenizan and Mohammed Al-Omran

King Faisal Specialist Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia

To assess the role of vitamin E supplements in the prevention of coronary events and stroke in adults, we reviewed randomized controlled trials (RCTs) in which outcomes associated with vitamin E supplement alone or in combination with other supplements were compared to a control group.

Methods: Primary outcomes were total myocardial infarctions (MI), fatal MI, and non-fatal MI. Secondary outcomes include total stroke, hemorrhagic stroke, ischemic stroke, total mortality, and cardiovascular mortality. Relative risk (RR) and risk difference (RD) with 95% confidence intervals (CI's) were reported. If there was a statistically significant RD, the number needed to treat (NNT) or number needed to harm (NNH) were calculated.

Results: Nine studies, including around 80,645 participants, met inclusion criteria. There were no statistically significant differences for total mortality or CVD mortality among the different interventions and the different groups of patients, nor was there any statistically significant reduction in all outcomes that were available for assessment in primary prevention studies. Statistically significant reductions were found in the secondary prevention of nonfatal MI (RR 0.51; 95% CI = 0.38 -.70, RD= -0.03, NNT=33) and in the incidence of non-fatal MI among patients receiving high dose vitamin E (RR 0.52; 95% CI = 0.35-0.77,RD=-0.01, NNT=10). Both of these results had significant between-study heterogeneity for the outcome (P=0.085 and p=0.02 for RR, respectively), and, using the random effects model, the RR's were 0.46 (95% CI = 0.25-0.84) and 0.51 (95% CI= 0.21-1.25), respectively. Natural vitamin E showed a statistically significant reduction of non-fatal MI (RR 0.32; 95% CI=0.19 - 0.56, RD= -0.03, NNT=33). No major adverse effects of vitamin E were reported in any of the studies.

Conclusions: Vitamin E supplementation reduces nonfatal MI in patients with pre-existing coronary artery disease but not total or CVD mortality. Higher doses (>300 IU) and natural vitamin E are most beneficial, and doses ranging between 50-800 IU were not associated with increased side effects.

Personality, Stress and First Nonfatal Acute Myocardial Infarction

Alaa Yasin Hasan

Ministry of Health, Oman

Personality behavior pattern A (PA) was postulated as an independent risk factor for acute myocardial infarction (AMI) in different races. The aim of this study was to assess if PA and exposure to stress contribute to the occurrence of a first, nonfatal AMI.

Methods: 78 patients with first nonfatal AMI and 78 controls matched for age, sex, hypertension, diabetes mellitus and smoking were assessed by Wail's scale for personality behavior at the Medical City Teaching Hospital in Baghdad, Iraq. History of acute stress was also noted.

Results: Personality behavior pattern A was more prevalent in patients with AMI than in controls (P< 0.05, RR 3.5). History of acute stress was more prevalent in PA patients than in pattern B patients (P< 0.05). Mean age of PA patients at the time of myocardial infarction (52.3 ± 11.49 years) was significantly less than that of B patients (56.9 ± 11.3 years) (P<0.05).

Conclusions: Personality behavior pattern A may be an independent risk factor for AMI. Persons with PA react pathologically to stress and they may their first AMI earlier.

Lipid Profiles in Young South Asian Males Residing in Different Countries

V Andrews1, M Gangola2, AV Kasbekar, R Swaminathan1

Department of Chemical Pathology, St Thomas' Hospital1 and The East London and City Health Authority2, London, UK

Cardiovascular mortality is high among Asians in the UK (Balarajan R. Br Med J 1991; 302:560-4).

Methods: In order to understand some of the risk factors for cardiovascular disease, we have compared serum cholesterol, triglyceride, HDL cholesterol, Apo B, Lipoprotein (a), Apo A1 and serum angiotensin converting enzyme (Serum ACE) in young males (20-25 years) in the following groups: Caucasians in UK, South Asians in UK, Indians living in India, Bangladeshis in Bangladesh and Sri Lankans in Sri Lanka. Fasting blood samples were taken and serum lipids and lipoproteins were measured by standard methodology in one laboratory in a London teaching hospital. Results were analysed by ANOVA and, Scheffes comparison was done between groups.

Results: These are shown as means + SD, except for Lipoprotein (a) where it is given as median and range, and summarised in the table below. Serum concentrations of cholesterol, ApoB and Lipoprotein (a) were highest in Sri Lankans residing in Sri Lanka and lowest amongst Indians living in India.

Conclusions: There is considerable variation in lipid profiles among different populations of South Asians.

[Additional file 2]

Risk Factors for Ischaemic Heart Disease in Young South Asian and European Males in the UK

V Andrews1, M Gangola2, AV Kasbekar, R Swaminathan1

Department of Chemical Pathology, St Thomas' Hospital, London1, East London and City Health Authority2, London, UK

While cardiovascular mortality among South Asian migrants is high (Khattar RS et al., Heart 2000; 83: 267-71), little is known about the reasons for this or the risk to second generation South Asians in the UK.

Methods: We undertook a prospective study comparing fasting lipid and biophysical profiles among second generation South Asian and European medical students in the UK. Results were analyzed by unpaired t tests or Mann-Whitney U tests where appropriate.

Results: Second generation South Asians have significant differences in cholesterol, LDL, ApoB, HDL and Apo A1 when compared with their European counterparts. These results are summarized in the table as mean +/- SD, with the exception of median and range for Lipoprotein (a).

[Additional file 3]

Conclusions: This study suggests abnormalities in lipid profiles may put second generation migrants at high risk for cardiovascular events.

Lipid Profile Differences of Young Men in the UK and Turkey

AV Kasbekar, V Andrews1, K Erbil2, R Swaminathan1

Departments of Chemical Pathology, St Thomas' Hospital, London, UK1 and Ankara, Turkey2

Cardiovascular mortality among Turkish migrants living in Germany has been reported to be lower than their host populations (Razum O et al., Ann Epidemiol 1998; 8:334-41). Little work has been done, however, to compare lipid and biophysical profiles of young Turkish men in Turkey with a UK Caucasian population.

Methods: In this study we compared fasting serum lipids from Turkish men in Turkey (aged 18.1 +/- 1.1 years) with age matched Caucasian men in London (19.8 + 0.8 years). Results were analysed by unpaired t tests or Mann-Whitney U tests where appropriate.

Results: The Turkish group had significantly lower serum cholesterol, triglyceride and Lipoprotein (a), as well as statistically lower HDL cholesterol and Apo A1 concentrations. Results are given as mean +/- SD, except for Lipoprotein (a), which is median and range.

[Additional file 4]

Conclusions: This study suggests that the cardiovascular risk factor profile for Turks in Turkey is different from that of Caucasian men resident in the UK. Further research is needed to ascertain the significance of these findings.

Are There Differences in Lipid Profiles Among Chinese Males Residing in the UK, Chinese Males Residing in Hong Kong and Caucasians in the UK?

AV Kasbekar, V Andrews1, M Gangola2, C.W.K.Lam3, R Swaminathan1

Department of Chemical Pathology, St Thomas' Hospital, London1, East London and City Health Authority2, Department of Chemical Pathology, Chinese University of Hong Kong, Hong Kong3

Rates of cardiovascular mortality are known to be different among the ethnic Chinese residing in different countries. The mortality from ischaemic heart disease in male Singaporeans is 2.98 times higher than that of men in Hong Kong (Zhang J et al., Euro J of Epid 2001; 17(5): 469-477). Little is known about the risk factors for ischaemic heart disease among ethnic Chinese in the UK.

Methods: A prospective study of cardiovascular risk factors among young male subjects (age 20-25) compared serum fasting lipid profiles on Caucasians in UK with ethnic Chinese residing in the UK and in Hong Kong. All samples were analysed in one London laboratory by standard techniques. Results were analysed by ANOVA and Scheffes comparisons were done between groups.

Results: Serum cholesterol was significantly higher in ethnic Chinese in both the UK and Hong Kong compared to Caucasians. Lipoprotein (a) results were significantly higher in the Chinese population in the UK than for the Chinese in Hong Kong and Caucasians in the UK.

[Additional file 5]

Results are given as mean +/- SD except for Lipoprotein (a) where it is given as median and range.

Conclusions: The profile of risk factors differs in these groups and more studies are needed to evaluate their relevance for cardiovascular disease among ethnic Chinese who reside in the UK.

Insulin Resistance in Caucasians and South Asians Residing in the UK and in India

AV Kasbekar, V Andrews1, S Vaja1, J Pickup1, R Swaminathan1

Department of Chemical Pathology, St Thomas' Hospital1, London, UK

Insulin resistance has been implicated in the increased risk of cardiovascular disease and non-insulin dependent diabetes mellitus (NIDDM) in South Asians (Stern MP et al., Diabetes 1995; 44: 369-74). Studies in the UK have suggested that South Asians are insulin resistant (Whincup PH et al., BMJ 2002; 324: 635). It has been suggested that the insulin resistance may be present in South Asians living in India, which would imply that it might be an inherited trait (Williams B. Lancet 1995; 345:401-2).

Methods: In order to further investigate this theory, we performed a prospective study measuring fasting insulin and glucose concentrations. Young male subjects of European origin were compared with second generation South Asians in the UK and Indians living in India. Insulin resistance was calculated using the HOMA method model.

Results: The body mass index (BMI) of Indians residing in India was significantly lower (19.8 +/- 4.48) than that of Europeans (23.9 +/- 3.23) and South Asians in the UK (23.2 +/- 3.67). Insulin resistance was also significantly lower among Indians in India (1.42 +/- 0.81) compared to Europeans (3.04 +/- 2.99) and South Asians in the UK (2.38 +/- 1.13) (p<0.001 by ANOVA). There was a significant correlation between body mass index and insulin resistance (r=0.382, p<0.001). Insulin resistance among Indians residing in India remained significantly lower than the other groups, even after correcting for the body mass index.

[Additional file 6]

Results given as mean +/- standard deviation

Conclusions: Insulin resistance may not be present in all groups of South Asians.

Serum Homocysteine, Folate and Thermolabile Variant of MTHFR in Healthy Sri Lankans Living in the UK

AV Kasbekar, D Alagratnam1, V Andrews1, AS Wierzbicki1, R Swaminathan1

Department of Chemical Pathology, St. Thomas' Hospital1, London, UK

Homocysteine is an independent risk factor for coronary heart disease (Chambers JC et al., Lancet 2000; 355: 523-7). Indian Asians are reported to have a reduced intake of folate, a nutritional determinant of homocysteine (Abraham R et al., Hum Nutr Appl Nutr 1987; 41:164-73). Recent reports have suggested that some groups of South Asians have higher serum homocysteine and lower folate than Caucasians. Another predisposing factor to higher serum homocysteine is the thermolabile variant (677CΖT) of the MTHFR gene (Michie CA et al., Lancet 1998; 351: 1105).

Methods: We examined fasting levels of homocysteine, folate and MTHFR genotype in a group of 114 healthy, non-diabetic Sri Lankans (60 males and 54 females) living in London.

Results: Sex differences were found for serum homocysteine as previously reported. Four subjects (4%) had serum homocysteine concentrations of >14μmol/l, the upper limit of normal in folate replete people. Their serum folate was significantly lower (5.5 +/- 0.91 vs 8.9 +/- 0.34, P=0.038). The allele frequency of the thermolabile variant MTHFR gene (10%) was lower than the 34% frequency reported in various European populations. Folate intake in the Sri Lankan population was adequate to maintain a normal serum homocysteine concentration. The table summarises serum homocysteine, serum folate and red cell folate (+/- standard error of means) according to MTHFR status.

[Additional file 7]

Reference ranges for red cell and serum folate are given in brackets.

Conclusions: Abnormal homocysteine metabolism due either to the TT genotype or to inadequate folate intake is unlikely to be involved in the increased incidence of coronary heart disease in this population. Serum homocysteine concentration needs to be interpreted with genotype data for a specific ethnic group.

The Relationship of Serum Total Sialic Acid, A Reputed Cardiovascular Risk Factor with Plasma Fasting Insulin Concentration in Normal Individuals

AV Kasbekar, V Andrews1, P Lumb1, R Swaminathan1, M Crook1

Department of Chemical Pathology, St. Thomas' Hospital1, London, UK

There is interest in serum total sialic acid as a cardiovascular risk factor (Lindberg G et al. BMJ 1991; 302: 143-46).

Methods: The relationship between conventional cardiovascular risk factors and serum sialic acid was explored in a group of 100 healthy young subjects (54 females and 46 males; age 20.7 +/- 0.89 years) by measuring serum total sialic acid, fasting plasma insulin, fasting glucose concentration, serum cholesterol and triglyceride concentrations.

Results: In multiple regression analysis, serum total sialic acid correlated independently with serum cholesterol (0.113 p < 0.001) and fasting plasma insulin concentration (0.036 p < 0.04). In females, serum total sialic acid correlated independently with systolic blood pressure (0.181 p < 0.001), diastolic blood pressure (0.053 p < 0.04), serum cholesterol concentration (0.125 p < 0.002) and fasting plasma glucose concentration (0.056 p < 0.03). There was no significant independent correlation between serum total sialic acid and any of the other variables in males.

[Additional file 8]

Results are given as mean +/-SD

Conclusions: This is the first demonstration of a significant univariate correlation between serum total sialic acid and fasting insulin in normal healthy subjects. The association between insulin resistance and cardiovascular disease (Stout RW. Lancet 1987; 1: 1077-1079), may explain the association between serum total sialic acid and cardiovascular disease.

Ethnic Differences in Serum Total Sialic Acid: A Reputed Cadiovascular Risk Factor

AV Kasbekar, V Andrews1, P Lumb1, R Swaminathan1, M Crook1

Department of Chemical Pathology, St. Thomas' Hospital1, London, UK

Serum total sialic acid has been reported as a cardiovascular risk factor (Lindberg G et al., Int J Epidemiol 1992; 21: 253-57), but whether there are racial differences is unknown.

Methods: Healthy young subjects (62 females and 62 males; ages 20.0 +/- 0.9 years), 68 of whom were of South Asian origin (37 females and 31 males) and 56, Caucasians (25 females and 31 males) were studied. Fasting blood samples were used for measurement of serum sialic acid.

Results: Serum total sialic acid was significantly higher in the South Asian males than in age-matched Caucasian males (74.3 +/- 12.3 mg/dL vs 68.2 +/- 13.0 mg/dL, p < 0.02). However, in females, serum total sialic acid was significantly higher in the Caucasians as compared to the South Asians (76.0 +/- 13.1 mg/dl versus 68.2+/- 13.0 mg/dL, p < 0.01).

Conclusion: We conclude that serum total sialic acid levels may differ among racial groups and also may be useful to identify individuals at risk for cardiovascular disease. Large prospective studies may help to explain why serum total sialic acid is a reputed cardiovascular risk factor and shows racial differences.

The Incidence of Stroke Among Patients Admitted With Various Cardiovascular Disorders (1991 - 2001)

The incidence and outcome of stroke and are well defined in the developed world. However, in the developing world and particularly in the Gulf region, they are not well described.

Methods: The objective of this study was to investigate incidence and outcome of stroke in a geographically defined population admitted to Hamad Hospital with cardiovascular disorders between January 1991 and December 2001.

Results: Of the total of 20,856 patients treated during the ten year period, 8446 (40.5%) were Qataris. There were 53 Qatari patients and 46 Non-Qatari with stroke. Associated factors are summarized in the table below.

[Additional file 9]

There were no significant differences among groups in postmenopausal status, previous myocardial infarction or surgical revascularization (CABG).

Conclusions: The current population-based study of Qatari nationals residing in Qatar characterizes for the first time the incidence of stroke in the Gulf region, its associated conditions and the outcome among cardiac patients.

Electrocardiographic Diagnosis of Critical Stenosis of the Left Coronary Arterial System

Ayman Ahmed Elmenyar

Department of Cardiology, Hamad Medical Corporation, Doha, Qatar

Coronary angiography is undoubtedly the gold standard for diagnosis of coronary artery stenosis. If, however, a critical and proximal lesion in the left coronary system could be suspected from other investigations, earlier identification of such patients might salvage more myocardium and minimize morbidity and mortality. The large area of the ventricle at risk makes recognition of such ECG patterns critically important to prevent extensive anterior myocardial infarction and its complications.

Methods: Serial 12-lead electrocardiograms were recorded in the emergency room to identify certain T-wave changes in precordial leads on or shortly after admission in patients with typical angina fulfilling the criteria of Wellens. In atypical anginal pain, treadmill exercise ECG was done for evidence of more serious lesions in left main coronary artery. This was especially useful if it revealed ST-elevation during exercise with a normal resting ECG.

Results: According to those criteria one patient was diagnosed in the emergency room to have a tight lesion of the left anterior descending artery and sent directly for urgent revascularization. A second patient underwent urgent CABG for left main coronary artery disease.

Conclusions: Resting ECG and/or treadmill ECG can provide important information which complements coronary angiography and may shorten the door-to-treat time.

Clinical and Histologic Studies of a Qatari Family with Myofibrillar Myopathy and Review of the Literature

Ayman A.Elmenyar, Jassim Al-Suwaidi, A.A.Gehani, H.A.Hajar

Department of Cardiology, Hamad Medical Corporation, Doha, Qatar

The current study reports the first family with confirmed myofibrillar myopathy (MFM) in the Middle East and the third family worldwide.

Methods: A Qatari family consisting of one brother and three sisters was studied. This report focuses mainly on the clinical presentation and investigations done to diagnose "myofibrillar myopathy", including echocardiogram, cardiac catheterization, cardiac and skeletal muscle biopsy, electromyography and electrophysiology studies. It also reviews the current literature.

Results: The brother had restrictive cardiomyopathy and life threatening arrhythmia requiring permanent pacemaker placement at the age of 16 years. Three years later, he developed skeletal myopathy. One sister underwent heart transplantation for severe hypertrophic cradiomyopathy at the age of 15 years. The other sister had permanent pacemaker implantation for complete heart block at the age of 21 years, and, at the time of the study, she had nearly normal echocardiographic findings. Both sisters have no clinical myopathy.

Conclusions: This study highlights the importance of considering this disease in young patients presenting with idiopathic cardiomyopathy and/or AV block in the Gulf States. It is also the first report of two different types of cardiomyopathy and two different indications for permanent pacemaker placement in the same generation of a family with this disease.

Advances in Cardiology Nursing in Doha, Qatar

Barbara De Fleliriot

Cardiology & Cardiovascular Department, Hamad Medical Corporation, Doha,Qatar

Qatar is a fast developing country with a population in excess of 700,000 from a variety of different countries and cultures. Hamad General Hospital is a state-run hospital with the only Cardiology Department in the country. The Cardiology in-patient areas have more than 60 beds and employ about 130 nurses.

Methods: The problem of standardization of nursing methods to provide ultimate and constant patient care was addressed by recognizing that nurses come from very different cultures and training centers. It was also acknowledged that culture plays a big part in the image of nursing and in the ability of the nurse to see herself / himself as a professional person and act accordingly. Nursing administration also underwent beneficial changes. Nurses were encouraged to follow their chosen career path and to become involved in patient satisfaction surveys, performance improvement issues and research.

Results: Great strides were made in the past few years to provide capable, up-to-date, well-informed and confident nurses in the Cardiology Units. This resulted in an ongoing process, which extended into the patient/family/ community teaching and rehabilitation areas as well.

Conclusions: With the high incidence of coronary, artery disease in Qatar, our cardiology nurses need to be able to work confidently with their patient and also be able to help in prevention of cardiac disease and promotion of a healthy heart.

Influence of the Mink Gene Polymorphism on the Development of Atrial Fibrillation in Patients with Sick Sinus Syndrome

Burova N.*, Berkovich O.*, Larionova V.**, Baranov D.**, Timoshin V.**, Shlyakhto E*

Pavlov State Medical University* and Laboratory of Molecular Diagnostics**,

State Pediatric Medical Academy, St. Petersburg, Russia

To study the influence of the minK gene polymorphism on the development of atrial fibrillation (AF) in the patients with sick sinus syndrome (SSS), two hundred eighteen patients with SSS were examined:

Methods: Patients were divided into three groups: Group I had 104 patients with the SSS but no paroxysmal AF (42 men, 62 women, mean age 68.17 ± 8.93 years). In Group II, 84 patients with the SSS had paroxysmal AF (21 men, 63 women, mean age 69.66 ± 7.77 years). Group III consisted of 30 patients with a long-term history of the SSS and chronic AF that developed less than 6 months before the enrollment into the study (14 men, 16 women, mean age 69.88 ± 7.81 years). The minK gene genotypes (GG, SS and GS) identification was carried out with use of polymerase chain reaction with subsequent restriction analysis. The Î2-test was used for the statistical analysis.

Results: In the patients of groups I and II, the 38GS-genotype of minK gene was found the most frequently (groups I - 56.7%, II - 55.9%, III - 36.7%). There was a significantly increased portion of the 38GG-genotype patients in the group III as compared other groups (groups I - 23.1%, II - 30.9%, III - 56.7%, p I-II >0.05, p I-III 0.0002, p II-III 0.006). At the same time, the 38SS-genotype was found in only 2 of the group III patients (6.7%). The odds ratio (OR) for chronic AF in the patients with 1 mink 38G allele was 2.87 (95% Cl 0.65 - 12.67) compared with the patients with no mink 38G allele. A higher OR of 3.61 (95% Cl 1.64 - 7.96) was obtained for patients with 2 minK 38G alleles.

Conclusions: Correlation between the minK 38G allele and the chronic AF in the patients with SSS was found, and an increased risk of chronic AF in the patients with 2 minK 38G alleles was shown.

Case Report of Idiopathic Pericardial Effusion with Nice ECG and ECHO Findings

Ihab Suliman

Department Of Cardiology, King Fahad National Guard Hospital, Riyadh, Kingdom of Saudi Arabia

Idiopathic pericardial effusion is uncommon.

Methods: We present an 18-year-old male with idiopathic pericardial effusion and a review of the literature.

Results: An eighteen-year-old male was hospitalized in September 2001 with a large pericardial effusion. This was discovered during routine medical examination for entry into military college. One week earlier, he had experienced flu like symptoms. Initial investigations during admission for observation included those for malignancy and tuberculosis as well as connective disorders. These were all negative. The patient was treated with multiple medications, steroids, colchicine, and NSAIDs, but without improvement. Eventually, he underwent creation of a pericardial window, but without a good response. In the end, the patient had sub total pericardiectomy, following which he remained asymptomatic. Echocardiography one and two years after the procedure showed no reaccumulation of fluid, although both this and the electrocardiogram showed biatrial enlargement throughout his period of observation.

Conclusions: Most cases of idiopathic pericardial effusion are probably of viral etiology.

Complications of Hypertension in the Gulf

Abdul hai Al Awadi, Hussain Sameer, Sathish Koshy

Al Salmaniya Medical Complex, Bahrain

Hypertension is among the most prevalent cardiovascular problems in public health. Although easily detectable on screening, untreated, it can lead to cardiovascular morbidity and mortality. Patients may be asymptomatic or mildly symptomatic, and once identified, should be treated regularly. In Bahrain, the number of patients with hypertension and its complication is comparatively high.

Methods: Three studies were done in Salmaniya Medical Complex in 1987,1994 and 2002 to investigate the incidence and complications of hypertension. Systolic pressure of more than 140/90 was the entry criteria for the study.

Results: Ages ranged from 26-89 years. A significant number of patients (21.5%) had hyperlipidemia. Comparative analysis showed increasing numbers of patients with hypertension over time, but a reduction of complications as summarized in the chart.

[Additional file 10]

Conclusions: As a result of awareness and educational programs by private and government health agencies and prompt treatment, the incidence of complications of hypertension has been reduced to 20% in Bahrain as well as world-wide.

Does Monitoring Sites Selection Improve Surgical Outcome in Neonatal Coarctation of the Aorta with Associated Transverse Arch Hypoplasia?

Madan Maddali, Jutta Fahr, John Valliattu, Taha Delamie

Royal Hospital, Oman

To evaluate if selection of monitoring sites would optimize anesthetic and surgical management of neonates with duct dependant circulation, we reviewed our experience with coarctation of the aorta and hypoplasia of the aortic arch.

Methods: 73 neonates (M: 32, F: 41) weighing between 900 and 3800 grams (mean = 2662) and aged 3 to 21 days (mean = 11.7) that were operated since September 1998 were analyzed retrospectively. Of these, 24 cases, 12 of whom had associated arch hypoplasia, were included in the study. All 24 patients received PGE1 infusions until PDA ligation. The right radial and a lower limb artery were cannulated in addition to standard monitoring techniques. Pre and post ductal pulse oxymetry probes were also placed. Until the time of PDA ligation, a Qp: Qs ratio around 1:1 was achieved by avoiding hyperoxia and hypercapnea, with uncorrected pH up to 7.25 and aiming for a preductal SaO2 of around 85%. Proximal aortic cross clamp (ACC) placement was guided by changes in waveforms in the right radial artery and the pre-ductal pulse oxymetry trace. Pulmonary artery (PA) banding was performed in 6 cases, guided by a reduction in SaO2, ETCO2, and PA pressures.

Results: Prior to PDA ligation, all patients were stabilized with PGE1 infusions and the maintenance of Qp: Qs ratios. The proximal ACC was adjusted on 12 occasions in the 12 patients with arch hypoplasia. Total ACC duration ranged from 13 to 35 minutes (mean=26). The repair was redone on 6 occasions at the time of initial operation, based on persisting pressure gradients between the right radial and the lower limb artery. One baby had a residual gradient post operatively.

Conclusions: Prior to PDA ligation, pre and post ductal SaO2 monitoring helped achieve hemodynamic stability and maintain good systemic perfusion through the PDA. The right radial artery pressure trace and the right upper limb SaO2 trace facilitated placement of the proximal ACC without compromise of carotid blood supply in patients with arch hypoplasia. The lower limb pressure trace contributed in the assessment of the coarctation repair and served as a portal for post ductal blood gas analysis. We conclude that proper selection of monitoring sites does improve the final out come of surgery for these complex congenital heart lesions.

Total Arterial Revascularization With or Without Cardiopulmonary Bypass

Anvay Mulay, Jaswant Patel

B D Mehta Mahavir Heart Institute, Surat, India

Material and Method: A total of 555 patients underwent total arterial revascularization with or without associated procedures between January 2000 and June 2003. Mean age of the patients was 56.6 yrs, ranging from 27 to 81 years. Of these 38% had Diabetes, and 100 had left main stem disease. Recent MI was present in 20 patients. In 310 patients LVEF was less than 0.35. The mean number of 3.2 distal anastomosis was performed using a combination of LIMA, RIMA, and Radial artery as a pedical or composite graft. 244 patients were done off-Pump.

Results: On the basis of electrocardiographic and enzyme changes, two had perioperative myocardial infarction. 23 patients had transient ST elevation. Seven patients had additional long saphenous vein graft. Incidence of re-exploration for bleeding was 1.9%. Neurological complications were nil and 3 had pulmonary complications. Sternal wound complications were present in two patients. In hospital mortality was 1.6%. All but two survivals were discharged from the hospital between 6-8 days. Those who underwent postoperative angiography showed string like LIMA in two and Radial in one.

Conclusion: Usage of total arterial coronary revascularization can be extended to a majority of subsets of coronary artery disease by judiciously using combinations of composite grafts. Beating heart total arterial revascularisation although technically demanding has its advantages.

New Technique for Non-Surgical Closure of Ventricular Septal Defect: The Largest Experience in the Arabian Gulf Countries

Mohammed T Numan, MD. Assad Al Haroob, MD. Ziyad Hijazi, MD.

Cardiology & Cardiovascular Surgery Department, Hamad Medical Corporation, Doha, Qatar.

Transcatheter Amplatzer device closure has been used to close muscular ventricular septal defects with satisfactory results. A new asymmetric Amplatzer perimembranous ventricular septal occluder has been specially designed for closure of perimembranous ventricular septal defects (VSD). We report our experience with VSD device closure from January 1, 2003 till December 1, 2003 using the new Amplatzer perimembranous and muscular ventricular septal occluders. During the 11 month period we closed 17 patients with VSD percutaneously, 13 perimembranous and 4 muscular VSDs. The mean age was 9 years (range 2.5 - 18 years), mean weight of 33 kg (range from 10.6 - 83 kg). The mean VSD size by transesophageal echocardiogram was 9.7 mm (range 6 -16 mm); Qp:Qs mean of 1.44:1 (range of 1.2:1 to 2.4:1). The mean device size was 10 mm (6 - 16 mm). Immediate and complete closure was achieved in 15 patients (~90%). One patient with perimembranous VSD had a small residual shunt around the device and one patient with apical VSD had a residual small shunt around the device. No major complication like death, CVA bleeding or perforation has occurred with our experience. Minor Complications included LBBB in one patient; two patients developed mild to moderate tricuspid regurgitation, two patients developed trivial aortic insufficiency. On follow up, the LVEDD improved from a mean of 4.4 cm (3.4 - 5.9) to a mean of 4.0 cm (3.2 - 5.5 cm) at three months follow up, p< 0.05.

We concluded that transcatheter occlusion of perimembranous and muscular VSDs is safe, feasible, effective with high success rate and low complications. We are still following these patients for longer time to look at their long term results.

Self Expandable Stent Usage in Children

Mohammed T Numan

Cardiology & Cardiovascular Surgery Department, Hamad Medical Corporation, Doha, Qatar

The use and placement of self-expandable stents in children reported are very limited in the literature. The improved wall stent of the radial power and flexibility make this category of stents more amenable to pediatric use.

Methods: We are reporting our experience in our institution, Hamad Medical Corporation, Qatar, of three children in whom we used improved version of wall stents. The sites of implantations are inferior vena cava, right branch of pulmonary artery and right ventricle to PA conduit. A total of three stents were used in these three patients. The age of these children was 10 to 15 years; two males and one female. The stenoses at these sites were relieved with reduction of gradient across them to less than 70%. We didn't observe any complication of vessel rupture, bleeding, migration of the stent, subsequent thrombosis or recurrence of stenosis.

Conclusion: Self-expandable stents are safe to use in children with very low complication rate. Larger cohorts are needed to confirm this pilot study.

Radio Frequency Ablation Therapy of Life Threatening Arrhyhtmias

Mohammed T. Numan

Department of Cardiology & Cardiovascular Surgery, Hamad Medical Corporation, Doha, Qatar

Huang first introduced radio frequency ablation of ectopic foci and accessory pathways in 1986. In the last 10 years this modality of therapy became the treatment of choice in several arrhythmias.

Methods: In our center (Hamad Medical Corp. Qatar) we treated a total of 22 patients diagnosed with supraventricular tachycardia and ventricular tachycardia. 10 patients were females and 12 were males. Age ranged from 4 to 56 years. 10 patients had AV node reentry tachycardia, 6 had Wolf Parkinson White, two had ectopic atrial tachycardia, 3 had atrio-ventricular tachycardia and one had ventricular tachycardia. Our success rate was 21 out of the 22 patients. No major complications of death, CVA or pericardial effusion were reported. No recurrence after successful ablation on follow up more than two months. In this abstract we present four patients who attended the emergency room with life threatening arrhythmia with symptoms of cardiogenic shock, requiring DC cardioversion. These four patients subsequently were taken to the Electrophysiology laboratory and treated by RF ablation of their arrhythmia substrate. All of them became arrhythmia free after the ablation treatment with no recurrence after a median follow up of four months.

Conclusion: RF energy catheter ablation is a life-saving therapy with high rate of success and very low mortality and complications.

Dobutamine Stress Echocardiography in the Assessment of Myocardial Ischemia

Mohammed Khamis Mukhaini, P. Prashanth

Department Of Cardiology, Royal Hospital, Muscat,Oman

Methods: 55 patients with suspected or known coronary artery disease (CAD) referred for evaluation of myocardial ischemia by dobutamine stress echocardiography (DSE) were prospectively studied between Jan 2002 to Oct 2003 at our Echolaboratory Department, Royal Hospital, Muscat, Oman. All these patients underwent coronary angiography at our Catheterization laboratory under standard protocol. Patients were excluded if they had significant valvular disease, evidence of heart failure at the time of testing, atrial fibrillation, sustained arrythmias, and pregnancy. All medications were continued except beta-blockers during the study.

DSE was performed by a standard protocol in all patients using dobutamine infusion starting at 10 mcg/kg/min increasing every 3 min up to 40 mcg/kg/min. Atropine up to 2 mg was added if target heart rate was not achieved. 2D echocardiography was performed in 4 standard views using ATL HDI 5000 CV system using single phased array transducer (P4-2) in fundamental and harmonic imaging on a quadscreen format, displayed in a cine loop and digitally recorded on optical disk. Regional wall motion abnormalities (WMA) analysis was performed as described on standards of the American Society of Echocardiography. A 16-segment model dividing the left ventricle was used. The following scoring system was used for each segment: 1=normal, 2=hypokinesia, 3=akinesia and 4=dyskinesia. The test was considered positive for ischemia if there is new or worsening of WMA or wall motion score greater 1 in a segment compared to baseline was seen or a biphasic response of a rest dysynergy was noted.

Results: Coronary angiography demonstrated significant (> 50% stenosis) CAD in 35 patients and no significant disease in 20. One-vessel disease was present in 21 patients, two-vessel disease in seven, three-vessel disease in six and left main in one. Stress induced wall motion abnormalities developed in 31/35 patients (89%) who had significant CAD. There were four false-negative studies and they occurred in patients with single-vessel disease resulting in a sensitivity of 81% (17/21) for those with one-vessel disease and sensitivity of 100% (14/14) for those with multivessel and left main disease. Stress induced wall motion abnormalities were absent in 17/20 patients (85% specificity) who had no significant CAD. There were 3 false positive cases all of whom had < 50% stenosis in a single vessel. The location of stress-induced wall motion abnormalities correlated with the distribution of angiographically diseased vessel in 16/17 (94%) who had echocardiographic abnormalities and one vessel disease. The location of stress-induced abnormalities correlated with the distribution of at least one significantly diseased vessel in 13/14 patients (93%) who had multivessel or left main disease. Stress echocardiography correctly predicted the presence of multivessel disease in 10/14 (71%) based on multiregional wall motion abnormalities. Mild side-effects were seen in 2% of patients with no serious complications.

Conclusion: Dobutamine stress echocardiography is a safe and accurate noninvasive method of detecting or ruling out coronary artery disease.

Pulmonary Embolism Series in Dubai Hospital

S. Ali, A. M. Yusufali

Cardiac Center, Dubai Hospital, UAE

Pulmonary embolism (PE) is a major international health problem and clinicians can miss it easily if they do not have good clinical suspicion as shown by the post-mortem studies. Among the 19 cases of pulmonary embolism seen in Dubai hospital, between 2000-2003 there were 10 (53%) males and 9 (47%) females, ages between 26-74 years. The commonest complaint was shortness of breath, which was found in 9(47%) patients, chest pain in 7(37%) patients and 2 (10%) patients presented with syncope. All the patients had normal blood pressure (> 90/60) and 9 (47%) patients had a heart rate above 100/minutes. All patients had a positive V/Q scan positive, suggestive of PE, apart from 1, which was not done. 7 (37%) patients had a PAP of >35mmHg assessed by echocardiography, and 5 (26%) of them had evidence of dilated RV. Echo was not done in 3(16%) patients. 5 (26%) patients had ECG changes of tall R in V1 and 1(5%) had S1Q3T3 pattern. 16(84%) patients were anticoagulated using heparin and Warfarin, and 3 (16%) patients were thrombolysed using r-TPA. An IVC filter was inserted in 1(5%) patient. History of DVT was found in 9(47%) patients, and 2(10%) patients had LSCS before PE was diagnosed. 1 (5%) patient had SLE, 1(5%) ischaemic dilated cardiomyopathy, and 1(5%) sickle cell anaemia.

Anti-Inflammatory Action of Statins as the Main Mechanism of their Cardioprotective and Metabolic Influence in Patients with Acute Myocardial Infarction

V.Shumakov

N.D.Straschesko Institute of Cardiology, Kiev. Ukraine

The character and mechanisms of simvastatin action on clinical course, function of the heart and coronary vascular system, activity of the systemic inflammation, lipid and glucose metabolism disturbances in patients with acute myocardial infarction in early and removed periods of recreation were explored. It was combined with the investigation of the interdependence between hypolipidemic, antiinflammatory and antioxidant activity of simvastatin and its influence on carbohydrate metabolism in rabbits with induced inflammation. Simvastatin in investigated patients had a moderate hypolipidemic action in association with significant lowering of the plasma atherogenic abilities which were tested by capture of modified lipoproteins with mouse macrophages. This effect of simvastatin was the reflection of its antiinflammatory, antioxidative action and glucose metabolism normalization. This action of simvastatin stipulated for the significant improvement of the myocardial contractile function and increasing of the physical tolerance during rehabilitation.

In the experimental part of the investigation the direct anti-inflammatory, antioxidant, and antiatherogenic actions of simvastatin was established and was found to be due to its ability to suppress the activity of inflammatory blood cells (macrophages, monocytes and neutrophils) and normalization of glucose metabolism. This led to the lowering of plasma lipoprotein atherogenity in association with the suppression of macrophages ability to absorb the modified lipoproteins.

CYP2C9 Genotypes Frequency Among Omani Patients Receiving Warfarin

M.O.M Tanira, K.A.Al Balushi, I.S. Ahmad, A.T. Al Hinai, M.K Al-Mukhaini

College of Medicine & Health Sciences, Sultan Qaboos University and Royal Hospial MOH, Muscat, Sultanate of Oman

Cytochrom P 450 2C9 isoenzyme (CYP2C9 ) metabolizes a wide range of drugs including S-Warfarin. Genetic variations in CYP2C9 gene may lead to significant differences in warfarin metabolism resulting in variable patient response to the drug. In addition to the wild type allele CYP2C9*1, CYP2C9 gene has two allelic variants viz CYP2C9*2 and CYP2C9*3, which may decrease enzymatic activity by 30% and 80% respectively. It has been reported that a strong association between CYP2C9 variant alleles and low dose warfarin requirement exists.

In this study, we determined the frequencies of CYP2C9 allele variants in Omani patients receiving warfarin. DNA was isolated and PCR-RELP method was used to study CYP2C9 gene polymorphism. Preliminary data after genotyping 37 out of 200 patients DNA samples showed that 10.8% and 13.5% of the sample were heterozygous for the CYP2C9*2 and CYP2C9*3 alleles, respectively. Besides 5.4% were homozygous for the CYP2C9* allele. No homozygous DNA samples were found for the CYP2C9*3 allele. The allele frequency of CYP2C9*3 in Omani subjects (0.068) was similar to that of Causcasian populations (0.060 - 0.100) and higher than of East Asian populations (0.011 - 0.026). The frequency of CYP2C9*2 allele (0.108) was also similar to that of Caucasian populations. These data imply that about 30% of Omanis are slow metabolizers of warfarin. The frequency of the two slow CYP2C9 allele variants in Omani subjects was similar to that of Caucasian populations.

Intermediate Followup After Repair of Complete AV Canal Defect: The Omani Experience

M.Venkatrman, Taha Al Delamie, V.John, Sunny Zacharias.

Departments of Pediatric Cardiology and Cardiothoracic Surgery, Royal Hospital, Muscat, Oman

Aim: To look at the surgical outcome and intermediate follow up after repair of complete AV Canal defect.

Material & Method: From June 1992 to December 2002, a total of 73 children (age range: 1 month to 84 months, median 10 months) underwent repair of complete AV canal defect at The Royal Hospital. The weight of these patients ranged from 2.5 kg to 15 kg (median 5.6 kg). 59 patients (80.9%) had Down's syndrome. Surgical repair was by a two patch technique in 68 patients. Associated lesions included Fallot's (6), DORV (1), Unroofed coronary sinus (4), Secundum ASD (8) and a large PDA (32).

Results: There were 11 (15.06%) early deaths. Seven of these patients were older than 6 months. There were three late deaths two months to three years after surgery. Of the 59 survivors 8 patients have been lost to follow up. 51 patients have been followed up from six months up to 120 months (median 55 months). 8 patients have undergone re-surgery for residual lesions. 31 patients are in class I without medications. The rest are in class I - II on medications.

Conclusion: Our results demonstrate that the intermediate outcome after repair of complete AV canal defect is quite satisfactory. Patients operated after six months of age are at a higher risk.

Seizure Related Cardiac Events

P. Venugopalan

Sultan Qaboos University Hospital, Muscat,Oman.

The incidence of seizure related non-fatal cardiac arrhythmias range from 1:525 to 1:2100 of episodes. Associated bradycardia and asystole, although rare, could be life threatening and occur mostly in older children. A close differential diagnosis is a primary cardiac arrhythmia that leads to cerebral hypoperfusion, as in patients with congenital long QT syndrome.

Five children who were primarily diagnosed to have seizures, but found subsequently to have an underlying cardiac arrhythmia are presented. Case 1 was a 6-month old infant girl with resistant seizure disorder. While in hospital, she developed generalized tonic clonic seizures, and during the episode of seizure, developed severe bradycardia and cardiac asystole. She required cardiac pacemaker implantation in addition to anticonvulsant therapy, but succumbed to the event subsequently. Case 2 was a 15-month-old infant boy, who developed febrile seizures and was hospitalized. On arrival in the hospital, he was noted to have ventricular tachycardia, and required therapy with amiodarone and flecainide in addition to anticonvulsants. This patient recovered subsequently. Case 3 was a 12-year-old girl who had repeated episodes of palpitations followed by generalized tonic clonic convulsions. The cardiac arrhythmia was identified as a reentry tachycardia, and treated. However, the episodes persisted and she responded to a course of carbamazepine. Case 4 was a 10-year old girl who was referred with history of unconsciousness followed by abnormal movements of acute onset. Examination revealed complete heart block with intermittent episodes of ventricular fibrillation. She required implantation of a permanent pacemaker, and has been asymptomatic subsequently. Case 5 was a 1-month old infant boy who had two episodes of loss of consciousness with generalized tonic clonic seizures associated with cyanosis. He had congenital long QT syndrome and was placed on beta-blocker therapy, with no recurrence of symptoms.

The differential diagnosis and pathophysiology of arrhythmia-related seizures are discussed, and the need for regular cardiac monitoring during episodes of seizures or seizure like events emphasized.

Transradial Coronary Artery Intervention

Waqar Habib

Cardiology & Cardiovascular Surgery Department, Hamad Medical Corporation, Doha, Qatar

Objective: Radial access for coronary artery intervention promises fewer access site complications and improved patient comfort via immediate ambulation. However, this transradial coronary angioplasty technique appeared to be technically more demanding compared to the traditional femoral technique which has hindered its wider acceptance. The purpose of this study was to assess the applicability and learning curve of transradial intervention in the Saudi population for operators without prior experience in this approach.

Methods: After confirming a normal Allen's test, right radial artery cannulation was performed and a 6F sheath was inserted. Standard 6F guiding catheters were used for the coronary intervention. The anti-thrombotic therapy was at the discretion of the operator.

Results: Transradial coronary intervention was successful in 214 vessels in 188 patients. It was unsuccessful in 4 (2%) due to access failure (1), or inability to engage the ostium. 187 patients were men (99%); mean age was 54 years, mean weight was 80 kg, and 50% were diabetic. Abciximab was used in 12%, 7% were primary intervention for acute myocardial infarction and 27 patients (14%) underwent multivessel intervention. The mean procedure time was 53 minutes and the mean fluoroscopy time was 15 minutes. The Extra-backup 3.0 or JL3.5 guide catheter was used for 88% of the 143 LAD or circumflex interventions and the JR4 guide catheter was used for 80% of the 71 RCA interventions. There were no bleeding or ischemic complications in the 188 patients.

Conclusions: Transradial access for coronary intervention is successful in 98% of the procedures and is very safe even with relatively inexperienced operators.

A Registry of Acute Myocardial in Kuwait: Patient Characteristics and Practice Patterns

Mohammad Zubaid1, Wafa A Rashed1, Mohammad Husain2, Bader A Mohammad2, Mustafa Ridha3, Mahmood Basharuthulla3, Marwan Abu Rezq4, Jaroslav Smid5, Lukman Thalib6

1Division of Cardiology, Department of Medicine, Mubarak Al-Kabeer Hospital; Departments of Medicine 3Al-Farwaniya Hospital; 3Al-Adan Hospital; 4Al-Amiri Hospital, 5Al-Sabah Hospital; 6Department of Community Medicine and Biostatistics, Faculty of Medicine, Kuwait University, Kuwait

Background: Coronary artery disease (CAD) is the leading cause of death in Kuwait, yet data about patient characteristics and practice patterns is lacking.

Objectives: To establish a registry of all acute myocardial infarction (AMI) cases admitted to the general hospitals in Kuwait, so that the characteristics and management patterns of patients with AMI could be accurately determined.

Methods: For six consecutive months we prospectively included all AMI patients admitted to the coronary care units of the five participating hospitals.

Results: Of the 662 patients, 87% were men. The mean age was 55 years. History of diabetes, hypertension and current smoking was found in 41%, 35% and 49%, respectively. History of hypercholesterolemia or fasting cholesterol 5.2 mmol/l was found in 56% of the patients. Eighty percent suffered ST-segment elevation AMI. We identified 476 patients who were eligible for thrombolytic therapy, 12 of whom (3%) did not receive it. The median time from diagnostic electrocardiogram to thrombolytic therapy was 45 minutes. The rate of prescribing aspirin, beta-blockers, angiotensin converting enzyme inhibitors (ACEI) and statins at discharge among survivors was 98%, 86%, 51%, and 50%, respectively. The in-hospital mortality was 6.2%.

Conclusions: Our AMI population is characterized by young age and high rates of diabetes, smoking, and hypercholesterolemia. The majority had ST-segment elevation AMI. Thrombolytic therapy is appropriately utilized, but measures need to be introduced to decrease the time to treatment. The rate of use of aspirin and beta-blockers is appropriate, while the use of ACEI and statins needs improvement.

Diabetes Mellitus as a Contributor to the Hospital Mortality After Acute Myocardial Infarction in Kuwait

Lukman Thalib1, Mohammad Zubaid2, Cheriyil G Suresh2, Wafa Rashed2

Department of Community Medicine & Behavioral Sciences (Biostatistics)1 and Medicine2,

Faculty of Medicine, Kuwait University, Kuwait

Objectives: The aim of the study was: 1) to examine in-hospital mortality after acute myocardial infarction ( AMI ) in diabetic and non-diabetic patients and 2) to evaluate if this association remains the same across ethnicity and gender.

Methods and Results: We used a 1:1 individual matched retrospective case control study. All patients admitted to Mubarak Al-Kabeer Hospital in Kuwait with a diagnosis of AMI during August 1997 to July 2000 made up the study population. All 137 patients who died in hospital during this period made up the cases. Control subject to match each case was randomly chosen from survivors, after hospitalization with AMI. Cases and controls were matched for age, sex and ethnicity.

History of diabetes mellitus (DM) was found to be significantly associated with in-hospital mortality after AMI (odds ratio: 2.35, 95% CL: 1.39 - 3.97). None of the other cardiovascular related histories were associated with mortality. This association was prominent among Kuwaiti patients (odds ratio: 3.0, 95% Cl: 1.5-5.9), and not significant among non- Kuwaiti population 9 odds ratio: 1.5, 95% Cl: 0.7 - 3.6). The association was not found to be different between males and females.

Conclusions: Risk of in-hospital mortality after AMI is more than doubled among diabetic patients. This association was found to be significantly higher among Kuwaiti Arabs.

Incidence of Acute Myocardial Infarction During the Month of Ramadan and Eid Days

Mohammad Zubaid1, Cheriyil G Suresh1, Wafa Rashed1, Lukman Thalib2

Departments of Medicine1 and Community Medicine and Behavioral Sciences (Biostatistics)2, Faculty of Medicine, Kuwait University, Kuwait

Introduction: The Holy month of Ramadan and the Eid holiday that follows marking the end of fasting are considered a special time for millions of Muslims around the world. The month of Ramadan is associated with dramatic changes in eating habits, sleep and work pattern, and behavior. Hematological and biochemical changes in the body have been reported during Ramadan. However, there are no substantial studies regarding the influence of Ramadan and the Eid days that follow on patients' clinical conditions, especially as relates to the incidence of heart disease.

Aim: Our aim was to study: (1) the influence that Ramadan fasting might have on the incidence of acute myocardial infarction (AMI) and (2) the influence that Eid days might have on the incidence of AMI.

Methods: The source of this analysis is Mubarak Al-Kabeer Hospital Coronary Care Unit Registry. We identified the months of Ramadan in the last 5 years and systematically identified the incidence of AMI cases that were admitted during, before and after Ramdan. The incidence of AMI in the last 5 days immediately after Ramadan (Eid Days) was also studied.

Results: The table shows the number of AMI admissions during Ramadan, before and after in 5 consecutive years.

[Additional file 11]

Conclusion: There were no significant differences in AMI admissions during Ramadan months compared to one month prior to it.

Khat Chewing is a Risk Factor for Acute Myocardial Infarction

Al Motarreb1; S Briancon2, N Al-Jaber1; B Al Adhi1, F Al-Jailani1, S Salik3, KJ Broadley3

Al Thawrah Teaching Hospital1, Sana'a, Yemen, 2Clinical Epidemiology and Evaluation CHU, Nancy and School of Public Health, Nancy I Henri Poincare University, France and 3Department of Pharmocology, Welsh School of Pharmacy, Cardiff University, Cardiff, UK

Background: Khat chewing is a common habit in Yemen and East African countries. Millions of people chew khat leaves every day. The main effect of khat is increased energy, alertness and relaxed feeling. Cathinone is the main active substance in fresh khat leaves with sympathomimetic effect.

Aims: To determine if khat chewing is a potential risk factor for development of acute myocardial infarction (AMI).

Design: A hospital - based matched case control study

Method: 100 patients admitted with acute myocardial infarction to the ICU of Al Thawra Teaching Hospital, Sana'a Yemen enrolled between 1997 and 1999. 100 control subjects matched to cases for sex and age were recruited from the out patients clinics of the same hospital.

Results: Khat chewing was significantly higher among the AMI cases group than control group (OR - 5.0, 95% CI 1.9 - 13.1). A dose-response relationship was observed, the heavy khat chewers having 39 times increased risk of AMI.

Conclusion: This study indicates that khat chewing is associated with acute myocardial infarction and is an independent dose-related risk factor for the development of the myocardial infarction.

Patients with Hypertension and Advanced Renal Failure: A Case of Gludodorticoid Responsive Aldosteronism & Lessons Learned

Chandra Mauli Jha

Department of Nephrology, Rustaq Hospital, Oman

A 30-year-old male presented with advanced renal failure (serum creatinine 612 umol/l) with uncontrolled hypertension which was noted two years earlier. Detailed workup was pursued. Considering young age of the patient and a diagnosis of glucocorticoid responsive aldosteronism was established. Appropriate therapy could be achieve better Hypertensive control resulting in improvement of renal function (< 200 umol/l) which has retained stable over last three & half years. The case is considered worth reporting since author feels that this case exemplifies some common pitfalls in primary management of hypertension & great benefit incurred from good control of hypertension. In general & in specialist clinics too, hypertensive patients are not investigated adequately for secondary causes resulting in poor control of hypertension & early occurrences of end-organ damage; an associated grossly deranged renal function is considered more often a cause rather than the effect of hypertension, leading to error in management. Community physicians required to be stressed about the need & benefit of hypertension control in terms of cost-saving & improvement of quality of life by thoughtful management. The presentation discusses common pitfalls in primary management of hypertension & a simplified approach for work-up for suspected secondary useful for general practitioners & physician.

Outcome of Chest Pain in Young Adults Reporting to the Aga Khan University Hospital Emergency Department

Muhammad Shahid, Kamran Hameed

Section of Emergency Medicine, Department of Medicine, The Aga Khan University Hospital, Karachi Pakistan

Introduction: Approximately 14% of patients with chest pain are under the age of 40 years. The prevalence of coronary artery disease (CAD) in Pakistan is probably as high as in developed countries.

Study Objectives: 1) To assess the frequency of acute coronary syndrome (ACS) in less than 40 years of age patients; 2) To determine predictive factors for better identification of individuals with ACS.

Subjects: Hundred young patients of either sex with chest pain and in whom an ECG was done were included. Patients with pre-established cardiac diseases were excluded from the study. The study was conducted from June 2002 to February 2003.

Methods: A data collection form was completed that included data regarding demographics, cardiac risk factors, cardiac history, physical examination findings, final Emergency Department (ED) diagnosis and disposition.

Results: n = 77 were admitted in the hospital and n = 23 were discharged through ED. Final diagnosis of patients consisted of n = 16 with muscukoskeletal chest pain, n = 20 with MI, n = 7 with psychogenic, n = 4 with angina,

n = 47 with atypical chest pain, n = 2 with gastritis and n = 4 with others (left sided empyema, pneumonia, tuberculous pericarditis and takayasu arteritis).

Conclusion: It was found that young patients presenting to ED with chest pain had a greater likelihood of suffering from ACS if they are male and between 30 to 40 years of age. Most patients who suffered from MI had some evidence of abnormality on clinical examination like an elevated JVP, rales and S4. People of any age group presenting to ED with chest pain should not be disregarded and should be thoroughly evaluated with special attention in the presence of cardiac risk factors and physical findings.

Pediatric Valve Replacement

Raj G Menon, The Royal Hospital, Oman

Introduction: Despite improvement in surgical techniques, treatment of heart valve disease in children remains controversial. Somatic growth and adequate anticoagulation levels are of concern when children undergo valve replacement. This study was conducted to evaluate the performance of valve replacement in this age group.

Methods: A retrospective study of 34 children below thirteen tears who underwent valve replacement was conducted. 38 valves were implanted in 34 patients; 37 mechanical and one bioprosthetic valve. 26 underwent MVR, 2 AVR, 4 DVR, 1 had tricuspid valve replacement and 1 had pulmonary valve replacement. Preoperatively, 13 (38.2%) were in NYHA Class IV, while 21 ( 61.7%) were in NYHA Class III.

Results: There were 2 (5.8%) hospital deaths, 27 (79.4% ) patients were in NYHA Class I and free from all medication except warfarin. 3 (8.6%) patients have undergone 4 successful pregnancies.

Conclusion: In view of problems of sizing, anticoagulation and need for re-operation at an early age, there is reluctance for valve replacement in children. This study shows that despite this problem, replacement can be undertaken with good results, if repair is not technically feasible.

Acute Myocardial Infarction Among Qatari Women (1991-2001)

J Al Suwaidi, A Bener, HA Hajar

Cardiology & Cardiovascular Surgery Department, Hamad Medical Corporation, Doha, Qatar

Aim: To assess whether female sex is a factor independently related to in-hospital mortality in acute myocardial infarction in a geographically defined population in the developing world.

Methods: A total of 20,856 patients were treated with various cardiovascular disorders during the ten years (1991-2001), 8446(40.5%) of them were Qataris. Of 1598 consecutive patients (1147 males and 451 females) with acute myocardial infarction were studied. Clinical characteristics, medical therapy and in-hospital outcome were analyzed. Multivariate analysis was done to evaluate whether female gender was an independent predictor for poor outcome.

Results: Females were older (p<0.0001) and had a higher incidence of hypertension (p<0.0001), hypercholesterolmia (p=0.026), and diabetes mellitus (p<0.0001). Males were more frequently to be smokers (p<0.0001). Female patients were more likely to receive thrombolytic therapy and aspirin. The in-hospital mortality was significantly higher in women when compared top men (18.4% vs. 13.9%; P=0.025) and they were more likely to develop stroke (2.9% vs. 1.0%) and heart block (6.4% vs. 3.3%). However, after adjustment for all baseline variables, female gender was not an independent predictor of increased risk of in-hospital mortality (p=0.75).

Conclusion: Women with AMI have higher in-hospital mortality because of worse baseline clinical characteristics and less likely to receive appropriate therapy. When compared to men Regional and global measures to fight coronary artery disease and its risk factors in women are urgently needed.

Comparison of Diets Enriched by Hydrogenated Fat/Olive Oil on Lipid Peroxidation and Antioxidant Capacity in Rabbits

Paknahad Z, Mahdavi R, Asgari S, Bashardoost N, Naderi GH, Mahboob S, Rajabi P, Karimabadeh N.

Isfahan University of Medical Sciences, Iran

Many studies suggest that consumption of hydrogenated fat may increase the risk of coronary heart disease, while monosaturated fats may be associated with a lower coronary risk profile. Oxidative damages including those associated with lipid peroxidation are generally believed to be a significant factor in much pathological process. In the pathogenesis of atheroclerosis, there is evidence, that increasing the lipoprotein peroxidation may be involved. In Iran, about 22% of total calories is derived from fat, especially hydrogenated fat about 5-10 %. Olive oil is the usual diet in Mediterranean countries and is rich in monodaturated fatty acids especially oleic acids, and has an optimal linoleic / linoleic ratio and is rich in antooxidants.

Aim: To compare the effects of hydrogenated fat and olive oil in lipid peroxidation and probable modulating effect of substituting olive oil in diet.

Methods: Adult male rabbits were allocated in 4 groups, according to their dietary type. Collection of blood were made before the beginning of dietary treatment, and the end of period (12 weeks).

Results: Comparison of four groups after experimental period showed that mean of MDA was the highest in the hydrogenated fat group (P = 0.01) and anhtioxidant capacity was the highest in the hydrogenated fat + olive oil groups (N.S.) The comparison of olive oil and hydrogenated fat group showed that hydrogenated fat group had higher mean of MDA and antioxidanr capacity than the other group, but was significant only about MDA. The comparison of hydrogenated fat and combined group (hydrogenated fat+olive oil), showed that means of MDA were higher in hydrogenated fat group than the other group.

Conclusion: In conclusion, undesirable effects of hydrogenated fat on lipid peroxidation could be modulated by substituting olive oil in the diet.




 

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