A Clinical Study on the Pattern of Mitral Valvular Disease in a Peripheral Tertiary Hospital in Bangladesh.

Background: Rheumatic mitral valvular disease (MVD) is a common cause of cardiovascular morbidity and mortality in Bangladesh. Many patients are diagnosed late, get maltreated, and develop complications, which can be minimized if early diagnosis could be made. Objectives: The study was carried out to determine the common symptoms and signs of mitral valvular disease in our population, to find out the incidence and pattern of complications, to list the pattern of valve lesions, to identify the common findings in different investigations and to find out the causes of delay in diagnosis. Methods: Fifty consecutive cases of isolated MVD of rheumatic origin admitted in Rajshahi Medical College Hospital, Rajshahi, Bangladesh, from July, 2002 to March, 2003 were included. Detailed history was taken, and clinical examination was performed. Chest skiagram, 12-lead ECG and echocardiography were performed in all patients. Other investigations include complete blood counts, anti-streptolysin O (ASO) titre, C-reactive protein (CRP), blood sugar, serum creatinine and routine urinalysis. Results: The peak incidence of MVD was found in the third decade (34%), 14 (28%) patients were <20 years of age. Thirty two (64%) patients had poor socio-economic condition. A previous history suggestive of rheumatic fever was found in 28 (56%). Twenty six (52%) patients received treatment from the registered medical practitioners and/or from the hospitals, 11 (22%) consulted with the quacks only, 5 (10%) had treatment from both sources. Significant delay was found in 28 (56%) patients. Illiteracy and ignorance was found to be the cause in 14 (28%) cases, poverty in 12 (24%) and misdiagnosis in 7 (14%). Six (12%) patients adopted indigenous treatment. Forty three (86%) patients experienced moderate to severe limitation of day-to-day activities all had breathlessness. Palpitation, fatigue and cough were found in 49 (98%), 45 (90%) and 42 (84%) cases respectively. Nineteen (38%) patients had haemoptysis, 15 (30%) had dysphagia. Apex beat was normally situated in 32 (64%), and shifted in 16 (32%) cases. Forty two (84%) patients had left parasternal heave and palpable P2 was found in 41 (82%) patients. Diastolic thrill was palpable in 28 (56%) cases, systolic thrill in 8 (16%) patients. The first heart sound (S1) was loud in 34 (68%) and soft in 8 (16%) cases. Mid-diastolic murmur of MS was audible in 46 (92%) cases, pansystolic murmur of mitral regurgitation in 19 (38%) patients and pansystolic murmur of tricuspid regurgitation in 10 (20%). Opening snap was found in 30 (60%), and presystolic accentuation in 27 (54%) cases. Roentgenographic study revealed moderate to huge enlargement of cardiac shadow in 29 (58%), straightening of the left border of the heart with fullness or outward bulging of the pulmonary conus in 43 (86%), double contour of the right border in 35 (70%), upper lobe diversion of pulmonary vasculature in 31 (62%), Kerley B lines in 10 (20%) and pulmonary oedema in 16 (32%) patients. The ECG showed P-mitrale in 32 (64%), atrial fibrillation in 14 (28%) and atrial flutter in 2 (4%) cases. Echocardiography revealed thickening of mitral valve leaflets in all patients, changes in subvalvular apparatus in 28 (56%) and calcification in mitral valve apparatus in 3 (6%) cases. Mitral valve area was <1 cm2 in 33 (66%), 1.0 to 1.4 cm2 in 14 (28%) and e”1.5 cm2 in 1 (2%) patients. The left atrial size was 41 to 50 mm in 20 (40%) and >50 mm in 10 (20%) cases. Two patients had left atrial thrombus. Evidence of pulmonary hypertension was found in 34 (68%) patients. Conclusion: Rheumatic MVD and the accompanying complications can be detected with an appreciable degree of accuracy by skillful clinical assessment and judicial use of simple investigations like roentgenography, electrocardiography and echocardiography which are available in many parts of our country at affordable costs. So every effort should be made to utilize these invaluable resources to tackle this public health problem more efficientlly.

Prevalence and awareness of cardiovascular disease including life styles in a lower middle class urban community in an Asian country

The emerging Cardiovascular Diseases are becoming leading cause of death in the developing countries. The incidence of coronary heart disease in Pakistan is not well established. The aim was to report the prevalence of coronary heart disease in an urban Pakistani Community and to evaluate the awareness of coronary heart disease and to determine life styles of the community. Metroville a suburb of Karachi was selected, it has 4296 household population. After open invitation 398 households agreed to participate in an intervention study. The data obtained at baseline is basis of this report. Subjects >/= 18 years age were 1078 while 382 males and 343 females were > 30 years age. Physical exam height, weight, BMI, ECG, waist circumference, blood pressure were determined. Questionnaire was administered to evaluate life styles and awareness in face to face interviews. Household data showed 1.24 families per household with 3.98 adults and 4.26 children. Uneducated were 27.5% while 26.3% had 10 years as more schooling. Most had job. By history the prevalence of heart attack was 8.2% in women and 4.5% in men, Over all 6.2%, Stroke 2.6, hypertension 26.7% and diabetes 9.5%. Abnormal ECG suggesting myocardial infarction or ishaemia prevalence rate was 4.4 percent, awareness that heart attack was major problem was reported in 40% men and 25% women who strongly agreed while 31% men and 35% agreed that heart attack can not be prevented. Food and its linkage to coronary heart disease showed majority were aware of organ meat, fat and obesity linkage to coronary heart disease. Physical activity was mostly confined to walking stairs at home and shopping trips. Tobacco was used by 34.3% men and 6.2% women. Coronary heart disease prevalence was significant in an urban Karachi community and the prevalence had increased over the past decades. Smoking, obesity were prevalent. The community had sedentary life style

Pattern of coronary arterial distribution and its relation to coronary artery diameter

This study was carried out to determine the pattern of coronary arterial distribution and its relation with coronary artery diameter in adult Pakistani population as demonstrated by selective coronary angiography. Consecutive series of 220 adult subjects who underwent diagnostic coronary angiography at National Institute of Cardiovascular Disease [NICVD] between May 2000 and December 2000 were studied. Patients whose age was more than 18 years, with no apparent disease in the proximal arterial segment, proximal artery and tip of the catheter in the middle of the frame and catheter of a No. 6 French size of same manufacturer used were included in this study. Patients who were given vasodilator before or during the procedure, angiograms showing complete proximal occlusions or ectatic arteries were excluded. Sixty% subjects had right dominance pattern of which 78.1% were male and 21.8% female. By contrast 15% had left coronary dominance, of which 78.7% were male and 21.2% female. Where as, 24% patients had co-dominant [balanced] circulation with 83.3% male and 16.6%, female. In patients with left dominant pattern, the mean diameter of the right coronary artery [RCA] was significantly smaller [p<0.00 I] as compared to dominant right or co-dominant pattern. Where as in patients with right dominant pattern, the mean diameter of the circumflex [CX] artery was significantly smaller [p<0.001] as compared to dominant left. The coronary arterial distribution in Pakistani population is not significantly different from that given in the literature and the diameter of the RCA and the CX artery are significantly affected by dominance pattern

Greek technique for type 4A coronary artery bifurcation lesions

In routine coronary angiography, bifurcation lesion is not uncommon. Current practice of dealing with type 4a coronary bifurcation lesions [lesions of main branch without significant lesions of the side branch] may lead to true bifurcation lesions after stenting due to axial plaque redistribution. This series describes an experience with Greek technique for treatment of type 4a bifurcation lesions in 18 patients for primary stenting of main vessel with simultaneous kissing balloon of side branch in an effort to avoid snow plough effect