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.

High Fibrinogen Level is An Independent Predictor of Presence and Severity of Coronary Artery Disease.

Background: Fibrinogen has been identified as an independent risk factor for cardiovascular disease and associated with traditional cardiovascular risk factors. Few reports have so far investigated the relationship between fibrinogen levels and the extent of coronary artery disease (CAD) as evaluated by coronary angiography. Therefore the current study was carried out to evaluate the relationship between fibrinogen levels and the extent of CAD as evidenced by coronary angiography. Method: A total of 210 patients having ischemic heart disease including chronic stable angina, unstable angina, non-ST elevated myocardial infarction & ST elevated myocardial infarction were evaluated in National Institute of Cardiovascular Disease (NICVD), Dhaka with a view to find out the relationship between fibrinogen levels and the extent of CAD undergoing coronary angiography. Patients were divided in 3 groups according to fibrinogen levels: Group I = fibrinogen levels <400 mg/dl, Group II = fibrinogen levels (400-600) mg/dl, Group III = fibrinogen levels > 600 mg/dl. In this study, angiographic severity was assessed by vessel score, stenosis score and lesion morphology and tries to find out their relationship with angiographic severity and fibrinogen level. Result: Using a prospective analytic design we studied 210 patients who were divided into 3 groups : Vessel score in Group I, Group II & Group III were 1.14 ± 0.56, 2.24 ± 0.58, & 3.00 ± 0.65 respectively which was statistically significant (p < 0.01) and Stenosis score in group- I, group- II & group- III were 6.00 ± 4.19, 18.72 ± 4.94, & 32.41 ± 15.75 respectively which was statistically significant (p < 0.01). Regarding morphology of the lesions, complex lesions in group I, group II & group III were 21%, 32% & 39% respectively (statistically significant; p < 0.01). Conclusion: High fibrinogen level is independently and significantly associated with more severe coronary artery disease. Serum fibrinogen can be used as a new and even simpler tool for risk stratification in acute coronary syndrome.

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.

Assessment of Acute Kidney Injury in Patients Undergoing Elective Coronary Angiography and Percutaneous Coronary Intervention.

Background: CIN has gained increased attention in the clinical setting, particularly during cardiac intervention but also in many other radiological procedures in which iodinated contrast media are used. There is at present good clinical evidence from well-controlled randomized studies that CIN is a common cause of acute renal dysfunction. Methodology: This was a prospective study conducted among the patients who underwent coronary angiography and percutaneous coronary intervention in the Department of Cardiology, Dhaka Medical College Hospital during January 2010 to December 2010. A total of 111 patients age range from 25 to 75 years were included in the study. Serum creatinine level at baseline and at the end of 48 hours was done in all these patients. Study population was divided into two groups according to development of acute kidney injury (AKI). Group-I = AKI, Group II = Not developed AKI. Results: AKI developed 11.7% of the study patient. DM and Preexisting renal insufficiency were significantly higher in group I patients. HTN was (61.5% Vs 44.9%) higher in group I but not significantly. History of ACE inhibitor/ARB, NSAID intake and LVEF <40% were significantly higher in group I patients. The mean±SD volume of CM (Contrast Media) were 156.9±44.8 ml and 115.4±30.0 ml in group I and group II respectively, which was significant. The mean±SD of serum creatinine after 48-72 hours of CAG/PCI was 1.4±0.37 mg/dl and 1.1±0.2 mg/dl in group I and group II respectively. The serum creatinine level increased significantly (p<0.05) after 48-72 hours of CAG/PCI in group I. In group II, S. creatinine level increased but not significant (p>0.05). Impaired renal function was found 76.9% and 2.0% in group I and group II respectively. DM, HTN, preexisting renal insufficiency, ACE inhibitor/ARB, NSAIDs, contrast volume (>150 ml), eGFR (<60 ml/min/ 1.73m2) and LVEF (<40%) are significantly (p0.05) associated for CIN development, Conclusion: CIN is an iatrogenic but preventable disorder results from the administration of contract media. Although rare in the general population, CIN occurs frequently in patients with underlying renal dysfunction and diabetes. In patients with pre angiographic normal renal function, the prevalence is low but in pre-existing renal impairment it may pose a serious threat. Thus risk factors are synergistic in their ability to predispose to the development of CIN. A careful risk-benefit analysis must always be performed prior to the administration of contrast media to patients at risk for CIN.

Relationship between Baseline White Blood Cell count and C-reactive protein with Angiographic severity of Coronary Artery Disease in Patients with Acute Coronary Syndrome.

Inflammation has been shown to play a role in atherosclerosis and acute coronary syndrome. This study was carried out to evaluate the relationship between baseline white blood cell (WBC) count and C-reactive protein (CRP) with angiographic severity of coronary artery disease in patients with acute coronary syndrome and to identify those subsets of patients with acute coronary syndrome who may need to undergo invasive or conservative strategies. Method: A total of 100 patients with acute coronary syndrome including unstable angina, non-ST elevated myocardial infarction & ST elevated myocardial infarction were evaluated in National Institute of Cardiovascular Disease (NICVD), Dhaka with a view to correlate angiographic findings, C-reactive protein and WBC count. Results: This study observed that either raised WBC count or raised CRP independently and combination of both WBC count and CRP elevation were significantly associated with more severe coronary artery disease. Either raised WBC count or raised CRP or combination of raised WBC count and CRP were significant predictor of multivessel disease and high stenosis score. Conclusion: Elevation of WBC count and CRP in patients with acute coronary syndrome are associated with severe coronary disease. WBC count and CRP can be used as a new and even simpler tool for risk stratification in acute coronary syndrome.

Consecutive bites on two persons by the same cobra: a case report

In tropical countries like Bangladesh, persons are bitten by snakes every day and a considerable number of patients die en route to the hospital. An event of consecutive neurotoxic bites on two men by a single snake was observed in the Snake Bite Study Clinic (SBSC) of the Chittagong Medical College Hospital (CMCH). Two brothers, working in their semi-pucca restaurant, were successively bitten by the same cobra on their lower limbs. Within an hour, they were taken to the CMCH. Few minutes after admission, both developed symptoms of neurotoxicity: ptosis, nasal voice, dysphagia, broken neck sign, etc. They received polyvalent antivenom (Haffkine Bio-Pharmaceuticals Company, India) and other auxiliary treatment immediately. Within few hours, neurotoxic features were completely absent. Later, the snake was captured in the restaurant kitchen and identified as monocellate cobra (Naja kauthia) by the SBSC. The elder brother developed significant antivenom reactions and both presented necrosis and ulceration at the bite sites. In these cases, immediate arrival to the hospital and early administration of antivenom resulted in successful recoveries.(AU)

Molecular comparison of toxigenic clinical & non-toxigenic environmental strains of Vibrio cholerae O1 Ogawa isolated during an outbreak of cholera in south India.

BACKGROUND & OBJECTIVES: While investigating a cholera outbreak in south India, toxigenic and nontoxigenic strains of Vibrio cholerae O1 were isolated from patients and from the environment, respectively. This study was performed to compare the genetic relatedness of the patient and environmental strains to determine clonal relationships among these strains and thereby determine the source of the cholera outbreak. METHODS: The 16 strains of V. cholerae isolated from hospitalized patients and 8 environmental V. cholerae strains isolated from the environment were phenotypically and genotypically characterized using a variety of standard techniques. RESULTS: Sixteen toxigenic clinical strains and 2 nontoxigenic environmental strains belonged to O1 serogroup, Ogawa serotype and El Tor biotype. The remaining 6 nontoxigenic environmental strains were classified as non-O1, non-O139 V. cholerae. The drug resistance pattern of the clinical and environmental strains of V. cholerae showed marked differences with the patient strains being resistant to more number of drugs as compared to the environmental strains. DNA fingerprinting of the strains showed considerable diversity between toxigenic clinical and nontoxigenic environmental O1 Ogawa isolates and between the O1 and non-O1, non-O139 isolates. INTERPRETATION & CONCLUSION: In this outbreak of cholera, the O1 strains of V. cholerae from clinical and environmental sources belonged to two different clones and the environmental strains could perhaps be the future cholera outbreak causing clones.

Cluster-analysis & patterns of dissemination of multidrug resistance among clinical strains of Vibrio cholerae in Calcutta, India.

BACKGROUND & OBJECTIVES: Antimicrobial resistance among Vibrio cholerae has been monitored for several years in Calcutta. To investigate the changing trends in multidrug resistance (MDR) among different serogroups of V. cholerae and to perform software assisted cluster analysis the current study was undertaken. METHODS: Strains isolated from patients with cholera and "cholera-like" diarrhoea admitted in the Infectious Diseases Hospital, Calcutta were analysed. Eight hundred and forty V. cholerae strains isolated from 1992 through 1997 were tested for susceptibility to 11 antibiotics. Cluster analysis was done using SPSS software. RESULTS: Most of the strains exhibited MDR with fluctuating trends as the resistance profile diverged each year. A total of 119 different resistance profiles exhibited by V. cholerae O1, O139 and non-O1, non-O139 serogroups were analysed by cluster combination method. During 1993 and 1994, 53 per cent of V. cholerae O139 and 82 per cent of V. cholerae O1 serogroups, respectively, exhibited maximal number of new resistance patterns. The frequency of new resistance patterns among V. cholerae non-O1, non-O139 was constantly high (33-47%) during 1995 to 1997. INTERPRETATION & CONCLUSIONS: With a few exceptions, preponderance of the resistance profiles was generally not confined to any serogroup. The cluster analysis depicted dissemination of some of the resistance patterns commonly found among V. cholerae non-O1, non-O139 belonging to different serogroups to the O139 serogroup in the succeeding years. In this study we have shown that the V. cholerae strains are resistant to several antibiotics with constant change in the MDR profiles. It is imperative to define the susceptibility pattern of the strains to determine the effective drug of choice for the treatment of cholera.

Sero-epidemiological studies on Toxoplasma gondii infection in man and animals in Bangladesh.

Sera from randomly selected 49 professional blood donors, 617 pregnant women, 14 butchers, 528 slaughtered goats and 24 domestic cats in the district of Mymensingh were tested for the presence of T. gondii antibodies using a Latex agglutination test (LAT). Overall 12.4% blood donors, 11.18% pregnant women, 50.00% butchers, 12.88% slaughtered goats and 33.33% cats had diagnostically significant antibody titers (> or = 1:64) to T. gondii. Epidemiological studies on T. gondii infection with LAT were conducted in 25 family members with sero-positive cats and 9 family members with 2 sero-positive women without cats in the family. Significantly (p < 0.01) higher sero-positivity rate was recorded in the family members (24.00%) with positive cats in comparison to family members (11.11%) without cats. The epidemiologic study indicates that infected cats and goat meat might be significant sources of T. gondii infection for humans in Bangladesh.

Study of complications in hypertensive patients having irregular treatment.

One hundred cases of hypertensive complications due to irregular drug-therapy were studied in medicine units of Dhaka Medical College Hospital for the period of one year from February 7, 1989 to February 6, 1990. Among those stroke had headed the list (48%) manifesting in various ways e.g. cerebral haemorrhage with focal neurological signs--hemiplegia, hemiperesis, aphasia etc. Hypertension associated with varying degrees of cardiac ischaemias and heart failure was seen in 14% and 10% cases respectively. Highest incidence of complications was seen in 1-5 years after detection of hypertension with mean age of 55 +/- 18.70 years. Out of 48 cases of strokes, smoker were 41 (75.92%). Regarding reasons of noncompliance of drugs, personal carelessness was the prominent one (47%). Among the risk-factors for atherosclerosis family history tops the list (66%). Diabetes coexists with hypertension in 13% cases. Ocular complications were seen in 06% cases of malignant hypertension with variable retinal changes.