Association between the polymorphisms of matrix metalloproteinases 9 and 3 genes and risk of myocardial infarction in Egyptian patients

The present study investigated the relationship between the genetic polymorphisms in MMP-9 and MMP-3 genes and acute myocardial infarction [AMI]. We examined 40 patients with acute myocardial infarction and 40 age and sex matched controls for MMP-9 functional promoter polymorphism [-1562 C > T] and MMP-3 [5A/6A] deletion/insertion polymorphism using restriction fragment length polymorphism [RFLP] for amplified genomic DNA. The frequencies of the combined mutant genotypes CT and TT in the [-1562 C > T] MMP9 were significantly higher in AMI patients [20%] when compared to the controls [0%] [pvalue = 0.005] showing an association between these genotypes and AMI. Also there was a significant difference between 5A/5A genotype and 5A allele frequencies when both are compared in the patients [25% and 35%] and the controls [2.5% and 18.75%] [p = 0.009; OR = 13; CI = 1.576-107.233]; and [p = 0.02; OR = 2.333, CI = 1.130-4.820] respectively. In conclusion, the -1562C > T polymorphism of the MMP9 gene is strongly associated with acute myocardial infarction in the Egyptian population. Furthermore, our study supported the presence of the 5A/5A genotype of MMP3 gene promoter polymorphism as a risk factor of AMI in Egyptian patients. Meanwhile, the race selection should be paid more attention since the pathogenesis of a disease might have different bases in different racial population groups

Prevalence and outcome of bacterial endocarditis in patients with implantable cardiac devices infections

Cardiac device infection [CDI] is a devastating complication of permanent pacemakers [PPM] or implantable cardioverter-defibrillators [lCD]. The incidence and outcome of endocarditis among patients [Pts] with CDI is not well defined. Is to report the experience in the prevalence, clinical presentations and management of bacterial endocarditis [BE] among patients with CDI in a tertiary care cardiac center over 25 years. A total of 2630 cardiac devices implanted in a cohort of 2367 patients [pts] over 25 years were studied. Out of these, 117 [4.4%] Pts presented with CDI. Clinical, bacteriologic and both transthoracic [TTE] and transoesophageal Echocardiographic [TEE] assessments were done. Of the 117 Pts with CDI [90 males, age ranging 18-82 yrs, mean=63 +/- 6 ys], 87 [74%] had redo procedures [battery replacement in 50, repositioning of leads in 12, device extrusion in 15 or evacuation of significant haematoma in 10 pts]. Of these 87 pts, 65 had re-implants on the same day of explantation. In 30 pts [26%] no apparent cause of P1 was identified. Out of the 117 Pts with CDI, 30 pts [26% of CDI and 1.1% of total procedures] had device-related BE with vegetations appeared in all pts by TEE [15 DDD, 9 VVI, 3 CRT and 3 lCD]. The clinical presentations were prolonged fever in 25 pts [83%], significant pulmonary hypertension with thrombo-embolism in 3 pts [10%], severe sepsis and multi-organ failure in 2 pts [6%]. Twenty-eight pts [93%] had positive blood cultures Istaph.aureus in 23 [77%] and enterococci in 5]. There were only 2 Pt with negative blood cultures. Device lead vegetations were evident in 20 pts [>10mm diameter in 13 pts]. Ten pts presented with only right heart valves vegetations. Out of the 30 BE pts, 28 [93%] had P1 while 2 pts had no apparent cause but frequent intravenous injections [one drug addict and one on regular haemodialysis]. Out of the 20 pts with lead endocarditis 15 had their leads removed surgically with re-implantation of either epicardial [6 pts] or endocardial leads [9 pts]. Fifteen pts had only medical treatment with proper antibiotics [5 pts with lead BE and all 10 pts with valvular BE]. Four pts [13%] died; all had their devices implanted on same day of explanation. Conclusion: Cardiac devices Redo procedures are major risk factors for CDI specially re-implantation on same day. Device related BE carries a serious morbidity and mortality yet surgical removal of the whole system is the management of choice. Blood stream bactraemia is a potential risk factor in patients with cardiac devices and warrant prophylaxis against BE

Conventional Vs non invasive ventilation in acute respiratory failure

Treatment of patients with acute respiratory failure [ARF] often involves mechanical ventilation via endotracheal intubation. Non-invasive positive pressure ventilation [NIV] using Bi-level positive airway pressure [BiPAP] can be a safe and effective means of improving gas exchange. 1] Assess non-invasive positive pressure ventilation [BiPAP] as an alternative way for ventilation in ARF, and to 2] Determine factors that can predict the successful use of BiPAP. Thirty patients with acute respiratory failure [both type I and II] were enrolled in the study and divided into two groups. Group I included 10 patients who were subjected to invasive mechanical ventilation. Group II included 20 patients were subjected to NIV using BiPAP. Both groups were compared regarding the following parameters: Arterial blood gases [ABG] on admission, 30 minutes after beginning of mechanical ventilation, 1[1/2] hour then once daily. Complications namely ventilator associated pneumonia [VAP], skin necrosis and CO[2] narcosis; static compliance and resistance were measured at day one and day two. Compared to group I, group II patients were associated with similar improvement in ABGs data at 30 minutes and at discontinuation of ventilation [Table A]. Group II patients showed significantly lower incidence in VAP [20% Vs 80%], shorter duration of mechanical ventilation [3 +/- 3 Vs 6 +/- 5 days, p=0.006], with shorter length of hospital stay [5.8 +/- 3.6 Vs 8.9 +/- 2.7 days, p=0.011] when compared to group I. Skin necrosis [50%] and CO[2] narcosis [20%] occurred in group II only. Group II patients showed significant difference change in compliance and change in resistance from day I to day II when compared to group I Table [B]. On univariate basis, parameters were analyzed to choose those who were associated with outcome in concern [successful NIV]. The following parameters were identified: Level of consciousness, pH [7.3 +/- 0.03 Vs 7.26 +/- 0.1, p=0.009] PCO[2] [69.16 +/- 13.14Vs 100.97 +/- 12.04] on admission, 1[1/2] hour after NIV, pH [7.37 +/- 0.03 Vs 7.31 +/- 0.17, p=0.005], PCO[2] [53.98 +/- 8.95 Vs 77.47 +/- 5.22, p=0.0001] in whom NIV succeeded and failed respectively. Then multivariate analysis utilizing two different techniques namely [multivariate logistic regression and discriminate analysis] was used. The variable identified was PCO[2] after 1[1/2] hour in the two models with specificity 100%. In patients with acute respiratory failure, non-invasive ventilation was as effective as conventional ventilation in improving gas exchange, associated with fewer serious complications and shorter stay in intensive care. One and half hour trial with NIV can predict success with BiPAP, as shown by an improvement in pH and PCO[2] and overall clinical picture. PCO[2] after 1[1/2] hour could be the sole predictor of successful NIV with 100% specificity

Sildenafil is as effective in secondary as in primary pulmonary hypertension: impact on acute and short term haemodynamics

Patients with pulmonary hypertension [PH] usually present with limited exercise tolerance, heart failure, and diminished life expectancy. Vasodilators might cause hypotension and deterioration in gas exchange. Sildenafil, a selective phosphodiestrase inhibitor [PDEI-type 5] has been used as an alternative to prostacyclin and nitric oxide in primary PH with reports of early success. Our aim was to assess the acute and short term effects of Sildenafil in patients [pts] with pulmonary hypertension due to different etiologies. Ten pts have been studied [7 females, 3 males, mean age 37 +/- 10 y, range=23-56ys.]. They included 4 pts with primary PH, 2 with Eisenmenger syndrome, 2 with thromboembolic and 2 with Bilharzial PH. Following clinical evaluation and functional class assessment [NYHA], all pts were subjected to Swan-Ganz catheterization whereby mean pulmonary artery pressure [mPAP], pulmonary vascular resistance [PVR] and mixed venous oxygen saturation [mVo2] were invasively measured. Echocardiography where right ventricular diameter [RVD] in short axis view, left ventricular stroke volume [SV] and cardiac output [COP] were evaluated. Readings were recorded before, 3 days and 3 months after start of oral Sildenafil therapy [25 mg 6 hourly] for all pts. Out of the 10 pts, 8 [including 3 with PPH] showed significant clinical, hemodynamic and echocardiographic improvement 3 days after therapy. Two pts failed to show improvement [one primary and one Eisenmenger PH]. The former 8 pts showed improvement of NYHA class [from IV to III], a substantial reduction of mPAP [95 to 76 mmHg, p<0.01] of mean PVR [1797 to 1128 dynes. sec cm-5, p<0.01] with insignificant rise in mVo2 [53 to 57 Torr]. All hemodynamic changes occurred without change of arterial BP or heart rate. Echocardiography showed insignificant mild reduction in mean RVD [6.6 to 6.4 cm] with marginally significant rise in SV [44 to 51 Ml, p<0.05], and COP [3.7 to 3.9 L/min, P < 0.01]. Follow up three months later showed sustained improvement in 7 out of the latter 8 pts [one Bilharzial pt died suddenly after discharge] clinically [NYHA-III to II], further reduction of mPAP [from 77 to 67 mmHg, p<0.05], mean PVR [from 1128 to 958 dynes sec. cm -5, p<0.01] with further rise in mVo2 [from 57 to 61 Torr, P<.01]. Echocardiography showed continued significant reduction of the RVD to 4.1 cm [P<0.01] with further rise in SV to 56 ml [P<0.05], and COP to 4.1 L/min [P < 0.01]. 1] Sildenafil proved to be effective in the acute and short term conditions both subjectively and objectively and in both primary and secondary PH. 2] In Bilharzial PH, sildenafil looks promising, however larger number of Bilharzial PH pts should be studied.3] Sildenafil and other selective PDE5 inhibitors with improved selectivity and longer half-lives merit further therapeutic studies in pulmonary hypertension