Link between Periodontal Disease and Coronary Artery Disease: Bangladesh Perspective.

Coronary artery disease (CAD) is an increasingly important medical and public healthproblem, and is the leading cause of mortality in Bangladesh. Besides conventional risk factors and ethnicity, a number of emerging risk factors may explain the undue prevalence of CAD in this population. Periodontal disease (PD) is one of them, with prevalence of approximately 50%. As with many other diseases, PD is associated with CAD, and the association is independent of conventional risk factors. Low socioeconomic condition, illiteracy and ignorance, metabolic syndrome, nutritional deficiencies including hypovitaminosis D presumably contribute to the prevalence of PD in Bangladesh. In fact, PD and CAD share some cardiometabolic risk factors including diabetes mellitus, obesity and metabolic syndrome. Future research will hopefully explore different aspects of both public health problems, namely, PD and CAD in the country. The information gathered thereby, will help formulate policy to promote good oral health and tackle the deadly epidemic of CAD more efficiently.

Homozygous Familial Hypercholesterolaemia with Valvular Aortic Stenosis and Significant Coronary Artery Disease: A Case Report.

Homozygous Familial Hypercholesterolaemia is a genetic disorder which usually presents with early cardiovascular disease ranging from premature ischaemic disease, including myocardial infarction to aortic root stenosis. A 21 year old Bangladeshi male presented with exertional chest pain and breathlessness. He was diagnosed as a case of Homozygous Familial Hypercholesterolaemia. His angina symptoms were due to underlying valvular aortic stenosis which is a rare presentation of Homozygous Familial Hypercholesterolaemia.

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.

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.

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.

High-Density Lipoprotein as a Therapeutic Target: Treatment Strategies.

Coronary artery disease (CAD) is one of the most important causes of morbidity and mortality worldwide despite considerable therapeutic advances that control the risk factors. Numerous clinical trials have shown an inverse association between high density lipoprotein cholesterol levels and the risk of coronary artery disease. So, high density lipoprotein has become a new therapeutic target after low density lipoprotein in the management of risk factors of coronary artery disease. In this review, we explore existing and future treatment strategies along with their benefits and failures which will guide our management strategy. HDL raising therapies showed very promising results in many clinical trials but larger clinical trials are ongoing.

Correlation of Heart Rate Variability and 24- hour Mean Heart Rate with TIMI Risk Score in Acute ST-Segment Elevation Myocardial Infarction.

Background: Thrombolysis In Myocardial Infarction (TIMI) risk score, heart rate variability (HRV) and 24hour mean heart rate all are important predictor of prognosis after ST segment elevation myocardial infarction(STEMI). Correlation among these factors has not been studied thoroughly. Methods: This study was conducted in NICVD (National Institute of Cardiovascular Diseases), Dhaka, from July 2008 to June 2009. Total 105 STEMI patients were included in the study. TIMI risk score were calculated and each patient under went 24hour Holter monitoring. SDNN for HRV and mean RR interval for mean heart rate were recorded. Results : Ninety one patients (mean age 53.9 ± 10.8 years), 86.7% were males and 14( mean age 59.8 ± 8.8 years), 13.3% were female. Stratification of subjects by TIMI risk score shows that nearly 60% had risk score in the range of 3 – 7, 17. % between 0 – 2 and 24% 8 or more than 8.SDNN and RR interval stratified by TIMI risk score demonstrates that both the variables decreases significantly with the increase of TIMI risk score. Among the TIMI risk groups SDNN values were 120.0 ± 19, 871.0 ± 20.5 and 40.9 ± 6.4 msec in mild, moderate and high risk group respectively(p=<0.001). Mean RR were 836.8 ± 121.0, 776.7 ± 130.3 and 649.7 ± 75.5 msec in low, intermediate and high risk group respectively(p<0.001). There was a significant correlation between depressed SDNN and high TIMI risk score (r=.893, p=.001). High TIMI risk score also showed a negative correlation with mean RR interval (r=-574, p<0.001). Mean RR and SDNN show a perfect linear relationship (r = 0.657, p < 0.001). Conclusion: It was observed that depressed heart rate variability and increased 24-hours mean heart rate correlates with high TIMI risk score after acute ST-elevation myocardial infarction.

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.

Acute Myocardial Infarction after Dog Bite: A Case Report.

Acute myocardial infarction (AMI) after dog bite is rare. Capnocytophaga canimorsus , a Gramnegative, commensal organism of canine buccal cavity may cause bacterimia and sepsis. Hypotensioninduced stasis, septic emboli to the coronary artery, endothelial dysfunction and plaque vulnerability induced by acute inflammation may lead to acute coronary syndrome in this situation. Isolation of the bacteria may be challenging due to fastidious nature of the organism. Management is as per standard protocol. However, appropriate antibiotic therapy is crucial. Like many other parts of the world, dog bite is endemic in Bangladesh. The case presented here reminds us of the need for preparedness to deal with myocardial infarction associated with dog bite effectively.

Complementary and Alternative Medicine in Cardiovascular Care.

Complementary and alternative medicine (CAM) refers to a broad set of health care practices that are not part of a country’s own tradition and are not integrated into the dominant health care system. Herbal remedies, dietary supplements, acupuncture, homeopathy, ayurveda, unani, traditional Chinese medicine, prayer, yoga and meditation are the common examples. CAM therapies often represent an enormous area of unregulated and widely practised therapeutics with an inadequate scientific literature. However, there is emerging evidence that some of the CAM therapies are effective in certain clinical conditions. Presently, throughout the world, there is rampant growth of CAM industries, and increasing number of reputed pharmaceutical companies are producing herbals and dietary supplements. Herbal products used for cardiovascular purposes include garlic, hawthorn, ginkgo, horse chestnut and arjun. These substances are often popularly believed to be ‘natural’, hence safe. But adverse reactions including deaths have been reported with some of the CAM products. There is also growing concern for significant drug interaction among commonly used herbals, dietary supplements and cardiovascular drugs. At present, CAM therapies may best be regarded as an adjunct to standard medical care. More scientific research and strict regulation by standard national and international authorities are needed to ensure their efficacy and safety in cardiovascular care.