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   Table of Contents - Current issue
July-September 2019
Volume 9 | Issue 3
Page Nos. 119-180

Online since Tuesday, December 3, 2019

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Effect of ischemic reversal program on high-Sensitivity C-reactive protein in patients of coronary heart disease: An observational study p. 119
Rohit Sane, Gurudatta Amin, Snehal Dongre, Rahul Mandole
Background: Chronic inflammation leads to rupture of atherosclerotic plaque, ultimately causing acute coronary syndromes. High-sensitivity C-reactive protein (hsCRP) is an inflammatory biomarker which is known to predict cardiovascular events in ischemic heart disease (IHD) patients. Ischemic reversal program (IRP) has been found to improve exercise capacity of IHD patients but action on hsCRP is unknown.Methodology: This retrospective study was conducted between July 2018 and December 2018, for evaluating the effect of IRP on hsCRP levels in IHD patients. The data of only those patients were considered who had been given the IRP-based treatment for a minimum of five sittings. The mean serum hsCRP at day 30 of treatment initiation was compared with day 1 values. The association between the comorbidities with decrease in the hsCRP levels was assessed by calculating odds ratio (OR) using regression analysis. Results: Of the 78 enrolled IHD patients, 54 were male with a mean age of 59.94 ± 9.46 years. The mean hsCRP levels at day 30 of the treatment initiation were significantly lower than day 1 values (2.01 ± 2.15 vs. 2.83 ± 3.07 mg/L, P < 0.05). The OR for the decrease in the hsCRP levels in IRP-treated IHD patients having comorbidities such as hypertension and myocardial infarction were insignificant; however, the OR with diabetes was significantly < 1 (OR: 0.35, P < 0.05). Conclusion: IRP treatment leads to a significant decrease in the serum hsCRP levels in majority of the IHD patients, indicating an additional anti-inflammatory action.
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Predictors for coronary artery ectasia p. 123
Ahmed Shawky Shereef, Nader Talat Kandeel
Background: Coronary artery ectasia (CAE) is characterized by dilation of an arterial segment to a diameter ≥1.5 times that of the adjacent normal coronary artery, 10%–20% of CAE have been described in association with inflammatory or connective tissue diseases. The underlying mechanisms of ectasia formation are not yet entirely known, so the aim is to assess the validity of the high-sensitivity C-reactive proteins (Hs-CRP) and the hematological parameters (platelet to lymphocyte ratio [PLR], mean platelet volume [MPV], and neutrophil-to-lymphocyte ratio [NLR]) to predict CAE. Patients and Methods: 60 patients with chronic stable angina were classified into three groups as follows: Group 1: CAE without coexisting atherosclerotic coronary arteries (20 patients), Group 2: CAE with coexisting atherosclerotic coronary arteries (20 patients), and Group 3: Normal coronary angiography (20 patients) as control group. Our patients were submitted to: (1) complete history taking, (2) thorough clinical examination, (3) electrocardiography, (4) laboratory investigation with special interest in complete blood picture and Hs-CRP, (5) transthoracic echocardiography, and (6) coronary angiography. Markis classification was used for classification of CAE. Results:(1) NLR ≥2.65 can predict CAE with sensitivity 52.5% and specificity 100% (P < 0.001). (2) PLR ≥110.5 can predict CAE with sensitivity 82.5% and specificity 60% (P = 0.001). (3) MPV ≥8.25 can predict CAE with sensitivity 72.5% and specificity 55% (P = 0.007). (4) Hs-CRP ≥2.35 mg/dl can predict CAE with sensitivity 95% and specificity 85% (P < 0.001). Conclusion: NLR, MPV, PLR, and Hs-CRP can predict CAE. They are available, cheap, and easily calculated.
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Fragmented QRS complex in acute coronary syndrome, does it have significance in the emergency room? A study from Egypt p. 131
Ibtesam Ibrahim El-Dosouky, Hala Gouda Abomandour
Background: Fragmented QRS (fQRS) is derived from regional myocardial fibrosis/scar and ischemia, which cause heterogeneous myocardial electrical activation. We aimed to detect if the presence of fQRS can predict the presence of coronary artery disease (CAD) and to which extent in Egyptian patients with acute coronary syndrome (ACS). Materials and Methods: Seventy-four patients with ACS were divided into two groups according to the presence of fQRS in the initial and follow-up electrocardiography (ECG), they underwent clinical examination, full history for CAD risks, echocardiographic study, cardiac enzymes, lipid profile estimation, and coronary angiographic study. Results: FQRS, when compared with pathological Q wave and ST-segment depression for diagnosis CAD; it has higher sensitivity (49.0% vs. 36.7% and 17.3%) for left anterior descending artery (LAD), (66.7% vs. 14.3% and 9.5%) for left circumflex (LCX), (67.5% vs. 27.5% and 12.5%) for right coronary artery (RCA), more specific (92.00% vs. 78.2% and 80%) for LAD, higher positive predictive value (45% vs. 39.2% and 35.9%) for LAD, (77% vs. 50% and 22%) for LCX, (90% vs. 73.3% and 38.5%) for RCA, more accuracy (63.5% vs. 51.4% and 41.9%) for LAD, (85.1% vs. 71.6% and 64.8%) for LCX, and (78.4% vs. 55.4% and 41.9%) for RCA with a statistically significant differences (P < 0.05). Conclusions: Presence of fQRS in ECG is a good, simple, applicable positive test to predict the presence of significant CAD in the Egyptian patients with ACS in the emergency room, even in those without enzyme elevation but have “fQRS.”
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Fragmented QRS complex is independently associated with coronary microvascular function in asymptomatic patients with diabetes mellitus p. 136
Ragab A Mahfouz, Mohamed A Arab, Ibetsam I El-Dosoky
Aim: We aimed to investigate the relation between fragmented QRS (fQRS), coronary flow reserve (CFR), and cardiac dysfunction in asymptomatic patients with type 2 diabetes mellitus (DM). Subjects and Methods: Prospectively, 129 participants with DM (83 males; mean age: 49 ± 12 years). Surface electrocardiograms of all participates were analyzed for the presence of fQRS. Furthermore, individuals were evaluated for CFR, using transthoracic echocardiography with adenosine (0.14 μg/kg). They underwent both conventional and tissue Doppler imaging to evaluate cardiac functions. Lipid profile and fasting blood glucose were obtained. Results: CFR <2.0 was found in 74 (57%), while fQRS was detected in 80 (62%). Individuals with reduced CFR had a higher prevalence of fQRS compared with those with preserve CFR (96% vs. 16%, P < 0.001). Patients with fQRS had a lower CFR compared with those without fQRS (1.6 ± 0.3 vs. 2.7 ± 0.5, P < 0.001). The number of fQRS was inversely correlated with CFR (P < 0.001), S' wave (P < 0.01), and positively correlated with E/e' (P < 0.01), left atrial volume index (P < 0.02), triglycerides/high-density lipoprotein-cholesterol ratio (P < 0.01), and fasting blood sugar (P < 0.05). In addition, reduced CFR was closely correlated with increased E/e' ratio (P < 0.01) and lower S-wave (P < 0.03). On multivariate analysis, fQRS and CFR were independently associated (P < 0.001). ROC revealed that the number of QRS ≥3 was the optimal number (area under the curve = 0.92) to predict microvascular dysfunction. Conclusions: fQRS in asymptomatic patents with DM is associated with subclinical microvascular and left ventricular diastolic dysfunction. These findings revealed that the fQRS in the surface electrocardiography could be considered a simple marker for microvascular dysfunction in patients with DM.
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Determinants of microvascular dysfunction in normotensive offsprings of hypertensive parents p. 141
Ragab A Mahfouz, Mohamed Arab, Mohamed S Ghareb
Objective: Microvascular dysfunction usually precedes the onset of hypertension. We hypothesized that offspring of offsprings of hypertensive parents (OHP) would have coronary microvascular dysfunction. Yet, the determinants of microvascular dysfunction in OHP are not fully determined. We, therefore, studied coronary flow reserve (CFR) in OHP in relation to ambulatory blood pressure and lipid profiles. Subjects and Methods: One hundred and twenty-five healthy normotensive offsprings with family history of hypertension and 40 age- and sex-matched healthy normotensive offsprings without family history of hypertension (ONP) were enrolled for the study. All participates underwent transthoracic color Doppler echocardiography at rest and during adenosine (0.14 mg/kg) infusion. CFR was calculated as the ratio between hyperemic diastolic coronary flow to the resting diastolic coronary flow. All participates had ambulatory blood pressure monitoring. In addition, lipid profile was obtained, and triglycerides (TGs)/high-density lipoprotein cholesterol (HDL-C) was calculated. Results: CFR was significantly reduced among OHP compared with ONP (P < 0.001). Moreover, 61 of the OHP (49%) had CFR <2.0. OHP had an exaggerated morning blood pressure surge (MBPS) compared with ONP (P < 0.001). TG/HDL-C was significantly higher in OHP with reduced CFR compared with both OHP without reduced CFR and ONP (P < 0.001). TG/HDL-C was negatively correlated with CFR (P < 0.001). Furthermore, TG/HDL-C ratio was positively correlated with MBPS (P < 0.001). Multivariate analysis showed that BPMS and TG/HDL-C were independent predictors for reduced CFR in OHP (P < 0.001). Receiver-operating characteristic analysis showed that TG/HDL-c ratio ≥3.8 and MBPS ≥49 mmHg were the optimal cutoff values to predict reduced CFR among OHP, with (area under the curve = 0.91 and 0.92, respectively; P < 0.001). Conclusion: Our study suggests that microvascular function is significantly impaired in OHP. TG/HDL-C ratio and MBPS are independently associated with reduced CFR. These relationships could potentially reflect a subclinical precursor of cardiovascular risks and future hypertension, a premise that warrants close follow-up.
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Glycemic variability as a predictor of major adverse cardiac events after percutaneous coronary intervention p. 148
Manar M Alzaky, Ahmed Said Eldamanhory, Nader Talat Kandeel, Mohammad Ibrahim Ameen
Background: The endothelial dysfunction was greater by glucose fluctuation than by chronic hyperglycemia. The glycemic variability (GV) may be an independent risk factor for atherosclerotic coronary artery disease in diabetic patients. The cardiovascular complications are higher following myocardial infarction in diabetic patients than nondiabetic individuals. Aim of the Work: Our aim is to prove that good controlling of acute shooting of blood glucose level up and down will improve the outcome in patient undergoing percutaneous coronary intervention (PCI). Subjects and Methods: GV is evaluated using intraday variability by fasting, preprandial, and postprandial blood glucose levels in 120 patients. Hemoglobin A1c was used to evaluate glycemic control. The relationship between GV and development of major adverse cardiac events (MACE) in patients undergoing PCI is studied. Results: There is a statistically significant difference between the relation of GV and MACE within 1 month after PCI in uncontrolled diabetes compared to controlled group. There is no statistically significant difference found between the two groups regarding age, gender, risk factors (hypertension, smoking and dyslipidemia), and laboratory parameters including triglycerides, total cholesterol, low-density lipoprotein, and high-density lipoprotein. Conclusions: Uncontrolled GV is associated with poor short-term outcome after PCI in controlled diabetic patients compared to nondiabetic individuals undergoing PCI. Greater GV is associated with composite MACE, especially for uncontrolled diabetic patients. After multivariable logistic analysis, GV remains an independent prognostic factor for composite MACE after 3 months in patients undergoing PCI.
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Diagnostic accuracy of 256 slices computed tomography coronary angiography in post coronary artery bypass graft Egyptian patients p. 154
Hanan Radwan, Nader Kandil, Mohamed Elshaer, Ahmed Abd-Elkader
Objective: Evaluate the diagnostic accuracy of 256 slices computed tomography (CT) coronary angiography (CA) (multidetector CT [MDCT]) in the assessment of native coronary arteries and grafts in post-coronary artery bypass graft (CABG) surgery Egyptian patients. Patients and Methods: It included 70 patients with a history of isolated CABG with recurrent chest pain. We excluded patients with a history of redo CABG or other open-heart surgeries, renal impairment, severe claustrophobia, chronic liver disease, dye allergy, tachycardia with contraindication to beta blockers (BB), pregnancy. All patients were subjected MDCT and CA. Both examinations were done within 3 months. Results: In our study, 161 grafts evaluated (63 left internal mammary artery [LIMA] in situ grafts, 5 right internal mammary artery (RIMA) and 2 radial grafts, and 91 venous grafts). CA failed to detect 3 LIMA and 7 venous grafts. All were seen only by MDCT. For grafts CT compared to CA has sensitivity (91.5%, 84.8%), specificity (98%, 100%), accuracy (95.65%, 96.9%), positive predictive value (PPV) (96.43%, 100%), and negative predictive value (NPV) (95.24%, 96.2%) in the assessment of significant stenosis and total occlusion of grafts, respectively. For grafted vessels CT has sensitivity (94%, 100%), specificity (98%, 100%), accuracy (96.94%, 100%), PPV (95.92%, 100%), and NPV (97%, 100%) in the assessment of significant stenosis and total occlusion of grafted vessel, respectively. For native vessels CT has sensitivity (100%, 97.7%), specificity (84.2%, 98.4%), accuracy (97.14%, 98.1%), PPV (96.6%, 97.7%), and NPV (100%, 98.37%) in the assessment of significant stenosis and total occlusion of native vessels, respectively. Conclusion: Our study demonstrated a high diagnostic accuracy of MDCT for the assessment of bypass grafts and grafted or native coronary arteries compared with CA. Detection of grafts or native vessels occlusion was better than detection of substantial stenosis. MDCT is a good negative test for native vessels as it has a high sensitivity since it tends to overestimate stenosis degree, so patients with negative MDCT angiographic results mostly have patent vessels.
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Adverse effects of statins – Myths and facts Highly accessed article p. 165
D Prabhakar
Treatment with statins for dyslipidemia is confronted by both patient and doctor and social media-related myths. The common myths and the relevant facts in light of the recent ACC/AHA guidelines on the management of blood cholesterol 2018 are interesting. Most common side effects listed with statins are statin-associated muscular symptoms, new-onset type 2 diabetes mellitus, intracranial hemorrhage, and elevation of liver enzymes. The current article reviews the myths and the facts about the side effects associated with statins and how to tackle the side effects practically.
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Supraventricular tachycardia as presenting feature of Nevi, Atrial myxoma, Myxoid neurofibromatosis, and Ephelides Syndrome p. 169
Sonali Vadi, Milan Mehta
NAME composed of Nevi, Atrial myxoma, Myxoid neurofibromatosis, and Ephelides is a rare autosomal dominant syndrome with unknown prevalence. NAME syndrome has variable clinical manifestations, including skin pigmentation, neurofibromatosis, congestive cardiac failure, or even stroke as a result of tumor emboli. To the best of our knowledge, there are no prior published reports of supraventricular tachycardia as the initial presenting finding in a patient with NAME syndrome, a common arrhythmia signaling a rare syndrome. We describe a woman who presented with supraventricular tachycardia. Her thorough clinical examination with detailed workup revealed the features of NAME syndrome.
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A rare association of congenital mid-muscular ventricular septal defect with acute anterior wall myocardial infarction in the elderly: Clinical and hemodynamic implications p. 171
Pankaj Jariwala, Ajit Ekbote
We report a rare association of acute myocardial infarction (AMI) in an elderly patient who had undiagnosed mid-muscular ventricular septal defect (VSD). The patient underwent primary percutaneous coronary angioplasty of the left anterior descending artery. It is uncommon to survive with VSD at this age, and the association of it with AMI is still rare. Whether the presence of congenital heart disease poses them for the increased risk of coronary artery disease is a matter of further investigation. Furthermore, the presence of VSD while they incur myocardial infarction affects the prognosis of the patient is not clear.
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An unusual presentation of acute pulmonary embolism secondary to upper-extremity deep-vein thrombosis p. 174
S Khadhar Mohamed Sarjun Basha, Jayagopal Pathiyil Balagopalan
Acute pulmonary embolism (PE) secondary to congenital venous malformation of the upper limb is a rare clinical entity. Clinical manifestation may range from vague shoulder discomfort to features of superior vena cava or thoracic outlet syndrome. We report a case of a 43-year-old adult patient who presented with acute coronary syndrome and on evaluation was diagnosed with acute PE secondary to upper-extremity deep-vein thrombosis (DVT). Magnetic resonance venogram of the right upper limb revealed congenital venous malformation, with thrombus as the cause of DVT.
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Perioperative myocardial infarction in a case of mitral valve replacement: Rare complication of a common procedure p. 177
Muni Venkatesa Reddy, Shishir Kumar Roul, Saurabh Ajit Deshpande
A 56-year-old female underwent mitral valve replacement for severe symptomatic rheumatic mitral stenosis. There was perioperative myocardial infarction as evidenced by the regional echocardiogram (ECG) and echocardiographic changes (left anterior descending [LAD] territory) and hemodynamic instability. The patient was immediately taken up for coronary angiogram to find complete occlusion of mid-segment of the LAD artery. Thrombus aspiration and intracoronary nitrates were given to restore thrombolysis in myocardial infarction (TIMI) III flow in the vessel. The patient was discharged after 10 days without any other complications. On follow-up ECG, the regional wall motion abnormality persisted. Repeat coronary angiogram done for the same revealed no lesions in coronary vessels with TIMI III flow.
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