Relationship between P Wave Dispersion and Left Ventricular Diastolic Dysfunction in Hypertensive and Ischemic Heart Disease Patients.

Background: There is growing recognition that congestive heart failure caused by a predominant abnormality in left ventricular diastolic function is common and causes significant morbidity and mortality. Diastolic function usually declines before systolic function, and this precedes clinical signs. 12-lead electrocardiogram is a commonly used tool to assess left atrial enlargement, which is a marker of left ventricular diastolic dysfunction. We investigated the relationship between P wave dispersion, which is easily measured on the surface electrocardiogram and left ventricular diastolic function. Methods: There were 100 patients: 50 with diastolic dysfunction and 50 without. P wave dispersions were calculated by measuring minimum and maximum P wave duration values on the surface electrocardiogram. The relationships between P wave dispersion and echocardiographic measurements of diastolic dysfunction were assessed. Results: Maximum P wave duration was observed significantly (p=0.001) in patients with left ventricular diastolic dysfunction (119.60±8.2 ms vs 114.0±6.4 ms). Minimum P wave duration was observed significantly (p=0.001) higher in patients without diastolic dysfunction (72.6±7.5 ms vs 62.70±7.4 ms). P wave dispersion was observed significantly (p=0.001) higher in patients with left ventricular diastolic dysfunction (56.6±6.3 ms vs 41.5±5.2 ms). When patients were grouped according to grades of diastolic dysfunction, P wave dispersion was observed sequentially increased among 3 grades of left ventricular diastolic dysfunction (55.8±5.2 ms vs 55.9±7.0 ms vs 61.4±4.7) but the differences were not statistically significant (p=0.09). Conclusion: We conclude that P wave dispersion increases in diastolic dysfunction of LV. When clinical and echocardiographic variables are taken into account, there is a weak but significant correlation between P wave dispersion and left ventricular ejection fraction.

Effect of Subvalvular Changes on Mitral Valve Leaflets Excursion after Percutaneous Transvenous Mitral Commissurotomy.

Background: Aim of our study was to predict the effect of subvalvular changes on mitral valve leaflets excursion in a patient with mitral stenosis following percutaneous trans-venous mitral commissurotomy. Methods: Total of 60 patients of severe mitral stenosis were enrolled in the study. Transthoracic echocardiography was done on the day before percutaneous trans-venous mitral commissurotomy and 24-48 hours after percutaneous trans-venous mitral commissurotomy. Subvalvular area, anterior and posterior leaflets excursion were recorded. Results: Following percutaneous trans-venous mitral commissurotomy there were significant increase in anterior leaflet excursion from 1.8 ± 0.2 to 2.2 ± 0.2cm (p=<0.001), posterior leaflet excursion from 1.5±0.2to1.8 ± 0.2cm (p<0.001) . Subvalvular splitting areas was from 0.8 ± 0.2 to1.2 ± 0.2cm²(p=<0.001). Pulmonary arterial systolic pressure and left atrial diameter were significantly reduced respectively 55.6 ± 19.5 vs. 31.6 ± 9.5 mmHg,(p < 0.001) and 4.3 ± 0.6 cm vs. 3.8 ± 0.6 cm (p < 0.001). Post percutaneous trans-venous mitral commissurotomy subvalvular splitting area was found to be the predictor of increased excursion of both anterior and posterior mitral leaflets. Conclusion: percutaneous trans-venous mitral commissurotomy is associated with immediate significant changes in mitral valve morphology in terms of splitting of fused mitral commissures, increased valve leaflets excursion and splitting of the subvalvular structures. Post percutaneous trans-venous mitral commissurotomy subvalvular splitting area was found to be the predictor of increased excursion of both anterior and posterior mitral leaflets.

Association of Left Atrial Spontaneous Echocardiographic Contrast with Inflammatory Markers in Mitral Stenosis Patients.

Background: Spontaneous echocardiographic contrast (SEC) is a risk factor for left atrial thrombus formation and an important indicator of potential systemic embolism originated from heart. An established relation exists between the inflammatory status and the prothrombotic state. The present study was conducted to evaluate the association between left atrial spontaneous echocardiographic contrast with inflammatory markers in mitral stenosis patients. Methods: This observational analytical study was undertaken in the department of Cardiology, National Institute of Cardiovascular diseases (NICVD), Dhaka. A total of 70 patients with mitral stenosis were categorized into two groups: group I with left atrial SEC and group II without left atrial SEC. All patients underwent transthoracic as well as transoesophageal echocardiography. Complete blood count with ESR was done and neutrophil lymphocyte ratio was calculated. The high sensitive C-reactive protein (hs-CRP) was assayed. Results: The hs-CRP levels were significantly greater in the SEC-positive group (5.6±2.1vs 1.5±0.7, p=0.001). The mean ESR level was significantly greater in the SEC-positive group (32.6±15.5 mmvs15.8±4.7 mm).The neutrophil levels ((76.1±1.9 vs 63.7±3.3) were significantly greater in the SEC-positive group, and the lymphocyte levels (33.3±3.0 vs 21.5±1.3) were significantly greater in the SEC-negative group (p=0.001 for each). The neutrophil/lymphocyte (N/L) ratio was also significantly greater in the SEC-positive group (3.4±0.4 vs2.1±0.6, p=0.001).On multivariate analysis hs-CRP, neutrophil/lymphocyte ratio, raised ESR, mitral valve area and left atrial diameter were independent risk factors for SEC in patients with mitral stenosis. Conclusion: From this study it may be concluded that left atrial SEC is associated with raised inflammatory markers in majority of patients with mitral stenosis. So, SEC may be considered as a reflection of ongoing inflammatory process in patients with mitral stenosis.

Impaired Renal Function is Associated with Severe Coronary Artery Disease in Chronic Stable Angina Patients.

Background: Cardiovascular disease is the leading cause of morbidity and mortality in renal impaired patients. Many of the patients of chronic kidney disease die of cardiovascular disease before requiring dialysis. Cardiovascular disease in renal impaired patient is potentially preventable and treatable. The aim of this study was to evaluate the association between renal impairment and coronary artery disease severity in chronic stable angina patients. Methods: 110 patients with chronic stable angina who got admitted for coronary angiography were included in the study. They were divided into impaired renal function group (with estimated glomerular filtration rate [eGFR] <90 ml/min/1.73m2) and normal renal function group (eGFR e” 90 ml/min/1.73m2) on the basis of eGFR. The severity of the CAD was assessed by angiographic Vessel score and Gensini score. Results: Mean Gensini score was significantly high in impaired renal function group (42.30±24.9 vs 25.65±17.9, p <0.05). There was significant negative correlation between eGFR and vessel score (r=-0.30, p <0.05) and between eGFR and Gensini score (r =-0.65, P <0.05). In multivariate logistic regression analysis, after adjustment of factors eGFR remain independent predictors of severe CAD (P=0.002, OR -5.73). Conclusion: Impaired renal function, assessed by eGFR is associated with angiographic severe coronary artery disease in chronic stable angina patients and this association is independent of conventional cardiovascular risk factors.

Bioabsorbable Vascular Scaffold: A Revolution in Coronary Intervention.

Since the advent of percutaneous coronary angioplasty in 1977, immense experiment has been done to improve the outcome of the patients with coronary artery disease. Lot of trials have been done with angioplasty, bare metal stents, drug eluting stents, drug eluting balloons and other devices. Bioabsorbable vascular stents are relatively newcomers in this field with a lot of hope. We tried to update the latest status of Bioabsorbable vascular stents in this review, specially the short and midterm safety and efficacy and some of their limitations.

Recent Advancement in Non-surgical Interventional Treatment in Congenital Heart Disease at National Institute of Cardiovascular Disease (NICVD)-a Tertiary Care Hospital of Bangladesh.

Background: Treatment of Congenital Heart Disease (CHD) is either Surgical or Interventional. Medical management is mainly symptomatic / palliative. Although surgery is the main mode of treatment but in the recent past non-surgical Interventional method is replacing it because of its multiple advantages over surgical procedures. Since 2005, we started our journey in National Institute of Cardiovascular Diseases with a PDA device closure. In this article we tried to review the success rate of the interventional procedures in this hospital. Methods: The aim of this retrospective study is to review the short term & Intermediate outcome of the non surgical interventional treatment of congenital heart diseases. We included all the interventional rocedures done in this Institute since 2005 upto December 2013. Results: During this period, we performed total 150 cases of patent ductus arteriosus (PDA) device, 20 cases of PDA Coil closure, 60 cases of atrial septal defect (ASD) device, 90 cases of Balloon Pulmonary Valvuloplasty (BPV), 20 cases of Balloon Aortic Valvuloplasty (BAV), 22 cases of Coarctation Balloon Angioplasty, 35 cases of Mitral Valvuloplasty (PTMC), 15 cases of Balloon Atrial Septostomy. Almost all of our intervention procedures were successful except one case of mortality related to procedure of PDA device closure, 4 device embolization (2 ASD & 2 PDA) and one case of PDA coil with persistent Intravascular hemolysis. All the embolized devices were subsequently retrieved surgically with repair. All other patients of interventional treatment are enjoying new life without any morbidity. Conclusion: Thus, we concluded that interventional methods of suitably selected case of congenital heart disease may be an alternative lucrative safe & effective option of remedy for many of the congenital heart diseases.

Association of Aortic Pulse Wave Velocity with the Severity of Coronary Artery Disease in Patients with Acute ST Elevation Myocardial Infarction.

Background: Arterial stiffness assessed noninvasively with aortic pulse wave velocity (PWV) has been associated with atherosclerosis in the coronary arteries and also cardiovascular mortality. The aim of this study was to evaluate the association between aortic PWV and severity of coronary artery disease (CAD) in patients with acute ST elevation myocardial infarction (STEMI). Methods: This cross sectional analytical study was conducted over 200 acute STEMI patients who were purposively selected and agreed to do coronary angiogram during index hospital admission. Assessment of aortic PWV was performed noninvasively with the commercially available SphygmoCor system using applanation tonometry with high fidelity micromanometer on the day before angiogram. Study subjects were subdivided into two groups on the basis of PWV. In group I: aortic PWV was d” 10 m/sec and in group II: aortic PWV was> 10 m/sec. One hundred patients were included in each group. Angiographic severity of CAD was assessed by vessel score, Friesinger score and Leaman score. Results: Vessel score 0 and 1 were significantly higher in group I (p<0.05) where vessel score 2 and 3 were significantly higher in group II (p<0.05).The mean PWV in the group with normal angiographic result was 8.10±2.9 m/sec, and in patients with single vessel disease it was 11.65±3.46m/sec. In those with double and triple vessel disease the mean value of PWV was found 13.85±3.80 and 15.70±4.66 m/sec respectively. The mean value of PWV increased in proportion with the number of vessel involved by CAD and the differences were statistically significant(p=0.001).The mean value of PWV was observed 8.5±2.3 and 12.5±3.7m/sec in insignificant and significant CAD respectively using Friesinger score and the difference was statistically significant (p<0.05).There was statistically significant positive linear relation between the values of PWV and vessel score(r=.62, p=0.01), Friesinger score(r=.64, p=0.01) and Leaman score(r=.45, p=0.01). Conclusion: Aortic PWV is associated with the extent and severity of CAD. This noninvasive, cheap, radiation free method may be considered as risk stratification tool beyond other investigations.

Prevalence of Rheumatic Fever and Rheumatic Heart Disease in School Children of Bharateswari Homes of Bangladesh.

Background: Rheumatic fever (RF) and rheumatic heart disease (RHD) continue to affect millions of people around the world, including Bangladesh. Children and adolescents are especially susceptible to this disease. Classical risk factors, i.e. poverty, overcrowding, ignorance and insufficient health care services are responsible for the high incidence and prevalence of these diseases. To assess the prevalence of RF and RHD among children, a school survey was conducted in Bharateswari Homes, in the district of Tangail, Bangladesh. Methods: A total of 947 students were examined. Revised Jones’ criteria (1992), and clinical examination were used for the diagnosis of RF and RHD. Results: Four cases of RF/RHD were found giving the prevalence of 4.22/1000. This is lower than the prevalence reported in eighties, but is consistent with those found in nineties. Conclusion: Among the school children, there is a declining trend in the prevalence of RF/RHD.

Reuse of Cardiac Rhythm Control Devices: A Review.

Cardiac rhythm control devices i.e. pacemakers, implantable cardioverter-defibrillators (ICDs) and biventricular pacemakers are at times lifesaving treatment and prevention of arrhythmia. But, despite definite indications, many people in the developing countries cannot afford these devices due to high cost, and succumb to premature death. On the other hand, after implantation, pacemakers and ICDs are sometimes underutilized because of premature explantation due to death of the recipient, device infection, or upgradation, leaving a considerable extent of serviceable battery life unused. Majority of these explanted devices are simply thrown away. Though made for single use, a growing body of evidence indicates the safety, efficacy and feasibility of reimplantation of the prematurely explanted devices in patient in need who is otherwise unable to afford a new one. Patients, physicians, morticians, and even the general public support the idea of device donation and recycling. A number of organizations around the world have engaged themselves in this benevolent effort, and t he feasibility of device reutilization programme has already been established. However, some logistic, legal and ethical concerns are yet to be solved. The statutory bodies and professional organizations should address the issue of device recycling to solve the unsolved issues and formulate standard practice guidelines. In that case, such medical wastes may turn into invaluable resources, and help ensuring equitable medical care throughout the world.

Effect of Statin Therapy In Ventricular Arrhythmias In Patient With Acute Anterior Myocardial Infarction.

Background: Though statins are widely used in acute coronary syndrome (ACS), there is a paucity of information on the efficacy of high dose statin therapy in reducing the incidence of ventricular arrhythmias after acute myocardial infarction. Arrhythmias are relatively common in acute myocardial infarction (AMI) anterior, and sometimes progress to cardiac arrest. This study was planned to evaluate the role of high dose atorvastatin therapy in prevention of ventricular arrhythmias after acute anterior myocardial infarction. Methods: This study was conducted in NICVD from December 2010 to October 2011. Total 200 patients with newly diagnosed acute anterior myocardial infarction who received thrombolytic therapy were included in the study. They were divided into two groups. Group I (n=100) was selected for high dose atorvastatin therapy and group II (n=100) was selected for conventional doses of atorvastatin therapy. 24 hours Holter monitoring was performed 48 hours after hospital admission to evaluate arrhythmia. Results: Majority of the patients belonged to age range of 40 to 59 years with a male predominance. Patient characteristics regarding age, sex, drug use, risk factors for ventricular arrhythmia, body mass index, left ventricular ejection fraction were similar in two study groups. There was no electrolyte imbalance or renal impairment in any patient in either group. A significant difference in frequency of ventricular arrhythmias was found between the two groups. Ventricular premature beats were found in 66% patients in group I and 97% patients in group II (p=0.001) whereas non sustained ventricular tachycardia were observed in 0% and 4% in group I and group II respectively. Conclusion: High dose atorvastatin therapy is associated with lower frequency of ventricular arrhythmias after acute anterior myocardial infarction.

Impact of Blood Glucose Levels on Contrast Induced Nephropathy after Percutaneous Coronary Intervention in Patients not known to be Diabetic with Acute Coronary Syndrome.

Background: Contrast-Induced Nephropathy (CIN) is an iatrogenic disorder, resulting from exposure to contrast media. The association between pre-procedural blood glucose levels and CI-AKI risk (regardless of pre-existing diabetes) is unknown. The present study was conducted to evaluate the incidence of CI-AKI in patients with admission hyperglycemia in non-diabetic ACS patients. Methods: This is Prospective, observational study done in the department of Cardiology, National Institute of Cardiovascular Diseases (NICVD), Dhaka. Considering inclusion and exclusion criteria, 50 patients were non diabetic with ACS with normal blood glucose (d”7.8 mmol/l or d”140 mg/dl) in (Group I) and 50 patients were non diabetic with ACS with high blood glucose (>7.8 mmol/l or >140 mg/dl) undergoing percutaneous coronary intervention in (Group II). On admission random blood glucose was measured. Non- ionic low osmolar contrast agents (lopamidol) was used in all patients. Serum creatinine, serum electrolytes was measured and creatinine clearance rate was determined within 24 hours before PCI and day 1 and 2 after PCI. Results: The incidence of CIN was 24% in high blood glucose group and 4% in normal blood glucose group (p=0.004). It was also observed that gradual incremental increase in risk of CIN associated with higher admission blood glucose level. There was positive correlation between s. creatinine and admission blood glucose but it showed negative correlation between CCr and admission blood glucose after PCI in ACS patients not known to be diabetic. Conclusion: The present study reveals that index admission high blood glucose in acute coronary syndrome patients not known to be diabetic is associated with increased incidence of contrast induced nephropathy after percutaneous coronary intervention.

Mitral Annular Calcification is Associated with Severe Coronary Artery Disease in Patients Under 65 Years Old.

Background: Mitral annular calcification (MAC) is degenerative, fibrous calcification of the mitral valve annulus. It is more common in people over 70 years old. It is a marker of increased cardiovascular risk which occurs in a graded fashion by MAC severity. The aim of this study was to evaluate the association of Mitral annular calcification with severity of coronary artery disease (CAD) in patients under 65 years old. Methods: A total of 140 patients with IHD were enrolled by purposive sampling. Study populations were divided into MAC group and non MAC group. MAC was detected by Trans-thoracic echocardiography as an intense echo-producing structure located at the junction of the atrio-ventricular groove and posterior mitral leaflet in parasternal long axis view. MAC is measured in millimeters from the leading anterior to the trailing posterior edge and quantified as mild to moderate (1 to 4 mm) and severe (>4 mm) considering its thickness. Assessment of angiographic severity of CAD was done in the same hospital stay by Vessel score, Friesinger score and Leaman score. Results: Patients of MAC and non MAC groups were similar in terms of age and sex. Smoking (p=0.001) and family history of IHD (p=0.03) were significantly higher in MAC group. Anterior MI was significantly higher in MAC group (p=0.03). Left main and TVD were significantly higher in MAC group (p=0.001, p=0.01) whereas normal vessels were more in non MAC group (p=0.001). Intermediate and high Friesinger score (e”5) were significantly higher in MAC group whereas low Friesinger score (<5) were more in non MAC group. There was significant (p=0.01) positive correlation between MAC and CAD severity in terms of vessel score (r=0.76) Friesinger score (r=0.75) and Leaman score(r=0.42). Multivariate logistic regression analysis showed that MAC was independent predictors of significant CAD (p=0.02, OR= 2.84). Conclusion: Echocardiographically detected mitral annual calcification (MAC) can be an independent predictor of significant coronary artery disease. There is positive correlation between severity of MAC and severity of CAD. Cheap, available and radiation free nature of the echocardiographic detection of MAC may be a marker of significant CAD.

Angiographic Comparison of Coronary Artery Disease between Diabetic Men and Women.

Background: Cardiovascular diseases are the leading cause of death and morbidity in diabetic patients and this group is two to four times as likely to develop cardiovascular disease than the nondiabetic group, women being specially involved in this situation. In women , diabetes appear to be a stronger risk factor for the development of coronary heart disease than in men regardless of age ,menopausal status and whether or not the patient is insulin or non-insulin dependent. Objective of this study was to compare the angiographic extent of coronary artery disease between diabetic men and diabetic women. Method: This observational study was undertaken on 100 diabetic patients ( 50 women and 50 men) admitted inNational Institute of Cardiovascular disease (NICVD) during the period of July, 2006 to April ,2007.Diabetic women with coronary artery disease constitute the study group-I and diabetic men with coronary artery disease matched for age (±5 years) and risk factors , the study group-II . Coronary angiography was done in all patients & findings were analyzed. Segmental distribution method for coronary artery lesions was used to describe the distribution of atherosclerotis in coronary artery. Results: The mean age of group I was 51.02 ±8.93 years and that of the group II was 50.99± 9.83 years. In this study it was found that Diabetic women with coronary artery disease (CAD) had a higher coronary artery score, CAS (11.02±5.034) as compared to the diabetic men with CAD ( 8.04±4.866) (p<0.001). Diabetic women had also higher number of diseased vessels ( 78.67% vs 67.34%; p<0.01) and higher number of vessel score 3 ( 58% vs 34%; p<0.001). As compared to the diabetic men, diabetic women had a higher total number of coronary artery lesions (183 vs 136; p<0.001), a higher number of lesions per patient (3.66/ patients vs 2.72/patients; p<0.001) and a higher number of diffuse vessels (13.56% vs 8.91%;p<0.05). Conclusion: Diabetic women with coronary artery disease have more severe disease on coronary angiography as compared to diabetic men with coronary artery disease. The diffuse coronary artery involvement was also significantly higher in diabetic women than men.

Fractional Flow Reserve - A Review.

Percutaneous coronary intervention is being performed over the last 35 years. In this time span a remarkable advancement occurred in this field regarding skill & hardware. Its spectrum has also been widened starting from chronic stable angina to Acute coronary syndrome, single vessel disease to multivessel disease, simple to complex lesions including left main disease. The incidence and prevalence of Ischaemic heart disease (IHD) is also increasing. Number of studies has been conducted to decide how far this modality of treatment can change the morbidity and mortality of the IHD. Cardiologists are trying to detect the culprit lesions, treatment of which will be beneficial for the patient. Number of noninvasive and invasive modalities has been introduced to determine the functional significance of a coronary artery stenosis. Fractional flow reserve (FFR) is one of the relatively new methods in this field. We will discuss some of the basic aspects of FFR and its implications in different subsets of coronary artery disease.

Increased Arterial Stiffness Correlates with the Severity of Coronary Artery Disease in Patients with acute ST Elevation MI.

Background: The aim of this study was to evaluate the association between arterial stiffness determined noninvasively by pulse wave analysis (PWA) and the severity of coronary artery disease in patients with acute ST elevation myocardial infarction (STEMI). Methods: This cross sectional study was conducted in the National Institute of Cardiovascular Disease, Dhaka over a period of ten months starting from July 2011 to April 2012. Patients were purposively selected from those who were admitted in NICVD with acute STEMI myocardial infarction agreed to do coronary angiography. Total 99 patients (male: 81, female: 18) were included in this study. Assessment of arterial stiffness was performed noninvasively with the commercially available SphygmoCor system using applanation tonometry with a high-fidelity micromanometer. Augmentation index (AIx), Augmentation pressure (AP) and Augmentation index corrected for heart rate 75beats/min (AIx@75) were derived from this with the technique of PWA. Coronary angiography was performed in those patients during the same hospital stay and severity was assessed by vessel score, Friesinger score and Leaman score. Results: It was found that 9 (9.1%) patients had score 0, 42 (42.4%) had score 1, 23 (23.2%) had score 2 and 25 (25.3%) had score 3. However higher the number of vessels is involved, the greater is the AIx @75. Mean score in single, double and triple vessel disease was 24.50, 33.57 and 34.60 respectively. The mean level of AIx @75 was observed 23.97±11.47 and 31.76±11.26 in insignificant and significant CAD respectively using Friesinger score. The difference was statistically significant (p<0.05). Spearman correlation analysis demonstrated a positive correlation between the AIx@75 and the severity of coronary artery disease (p= <0.05, r=0.40). Conclusion: In conclusion, the results presented herein indicate that augmentation pressure (AP), augmentation index (AIx), and augmentation index corrected for heart rate 75/minute (AIx@75), measures closely related to wave reflections and arterial stiffness, are predictors of severity of CAD. It may be considered as a recommended test for the evaluation of CV risk in addition to other routine investigations.