Atheroscerlotic heart disease in Bangladeshi immigrants: risk factors and angiographic findings.

BACKGROUND: The prevalence of coronary artery disease (CAD) among Bangladeshis greatly exceeds that of Caucasians. Bangladeshis also suffer from premature onset, clinically aggressive and angiographically extensive disease. The role of conventional CAD risk factors (CCRFs) has been questioned. We therefore sought to determine if the CCRFs of Bangladeshis differed from non-Bangladeshis. We also sought to determine whether CAD was more extensive in Bangladeshis and if Bangladeshi ethnicity was independently predictive of extensive i.e., 3-vessel CAD at angiography. METHODS: We reviewed the coronary angiograms and medical records of 75 Bangladeshis and 57 non-Bangladeshis presenting with myocardial infarction or angina pectoris. RESULTS: Bangladeshis were younger (56.1 vs. 62.4 years, p=.001), had a lower body-mass index (25.2 vs. 27.2 kg/m(2), p=.017) and were less likely to be current or recent smokers (40% vs. 58%, p=.041) than non-Bangladeshis. There were no statistically significant differences in the proportion of subjects in the 2 groups with respect to diabetes mellitus, dyslipidemia, hypertension or family history of CAD. Bangladeshis had twice the rate of 3-vessel CAD of non-Bangladeshis (53% vs. 26%, p=.002). Bangladeshi ethnicity was independently associated with >3X the likelihood of having 3-vessel CAD at angiography (p=.011). CONCLUSIONS: This study demonstrated that the CCRF burden of Bangladeshis with CAD is not excessive compared to that of non-Bangladeshis and is therefore unlikely to account for the excessive CAD risk found in this cohort. We also conclude that Bangladeshis have more angiographically extensive CAD than non-Bangladeshis and that Bangladeshi ethnicity is independently predictive of 3-vessel disease.

Diagnosis of ventricular aneurysm and other severe segmental left ventricular dysfunction consequent to a myocardial infarction in the presence of right bundle branch block: ECG correlates of a positive diagnosis made via echocardiography and/or contrast ventriculography.

BACKGROUND: A diagnostic ECG sign of a ventricular aneurysm (VA) consequent to a myocardial infarction (MI) in the presence of complete left bundle branch block was recently described, and consists of the presence of ST-segment elevation (+ST), instead of the expected ST-segment depression (-ST), in leads V4-6. Generally, complete right bundle branch block (RBBB) is associated with -ST in ECG leads V1-3. We hypothesized that stable +ST, instead of the expected -ST in leads V1-3 in patients with RBBB could be also diagnostic of a VA and other severe segmental left ventricular dysfunction (VA/SSD). Thus, this study was performed to explore the feasibility of using the ECG to diagnose a VA/SSD in the presence of RBBB, and to evaluate the determinants of such diagnosis. METHODS: The frequency of +ST > or =1 mm in leads V1-3 was assessed in patients with RBBB, prior MI, and a VA/SSD diagnosed by echocardiography and/or contrast left cine-ventriculography. The ECG correlates for a positive or negative diagnosis of a VA/SSD were explored. RESULTS: Out of 4197 files of our cohort of the Cardiology Clinic, RBBB was detected in 175 patients. Of these, 28 had an old MI, and had a VA/SSD diagnosed by > or =1 of noninvasive and/or invasive non-ECG tests. Twenty-one of these 28 patients had stable +ST in > or =1 of leads V1-3 (Group 1), and 7 did not (Group 2). Thus, the sensitivity of this ECG criterion for the diagnosis of VA/SSD was 75%, and the specificity was 100% in this highly selective group. VA/SSD in the septal and anterior myocardial regions was more frequent in the patients of Group 1, than in the patients of Group 2 (P = 0.03 and 0.02, correspondingly). The number of myocardial territories involved with the VA/SSD, or the ejection fraction were not different in the two groups (P = 0.65 and 0.55, correspondingly). CONCLUSION: VA/SSD can be diagnosed in the presence of RBBB by the concordant to the QRS repolarization changes (+ST) in leads V1-3. Positivity of this ECG marker for VA/SSD correlates with involvement of the septal or anterior myocardial regions, and represents mechanistically a superimposition of primary repolarization alterations, overcoming the secondary such changes.

Stability of the ECG features of complete right bundle branch block over time: a methodological study for implementation in research and clinical practice.

Since research is concentrated to a large extent on patients with left bundle branch block, we aimed at evaluating the hypothesis that measurements of certain intervals and other characteristics of the ECG may change over time in patients with right bundle branch block (RBBB), and to design a model, which could be implemented in research and clinical practice, irrespective of the specific ECG features present. The duration of the QRS complex, QT, QTc, and PR intervals, the frontal QRS axis, the heart rate and the presence of hemiblocks, atrioventricular blocks, and atrial fibrillation were compared in the 1st and last of all available ECGs for each patient. Also, a subgroup of patients who had a ventricular aneurysm (VA) was compared with the remaining patients, with respect to the above variables. This longitudinal analysis included all of the patients with RBBB followed in our Cardiology Clinic. There were no significant changes in the ECG variables from the two ECGs recorded 487.6 +/- 410.1 (range 0-1,476) days apart, in the two comparisons carried out in 151 patients with RBBB. Comparison of the above-described ECG intervals and characteristics of patients with RBBB were found to be stable over the time course of the investigation. This methodological study is presented as a model to be used serially and prospectively in research and clinical practice for the follow-up of patients with bundle branch block, VA, dilated cardiomyopathy, congestive heart failure, or those considered for cardiac resynchronization therapy.

Results of repeat balloon valvuloplasty for treatment of aortic stenosis in patients aged 59 to 104 years.

Balloon aortic valvuloplasty (BAV) may be considered a palliative procedure that is performed in patients who have severely symptomatic aortic stenosis and a prohibitive surgical risk. However, due to poor early survival rates, most previous studies have involved a single BAV procedure. We analyzed long-term outcomes in patients who had severe aortic stenosis and BAV that incorporated repeat procedures to maintain symptom relief and increase survival rate. We retrospectively analyzed 212 consecutive nonsurgical patients (59 to 104 years old) who had severe calcific aortic stenosis and underwent 282 cumulative BAV procedures. Demographic, procedural, and follow-up mortality data were collected. BAV was performed with single or incremental balloon dilatation to obtain a postprocedural transaortic gradient close to 1/3 of the baseline gradient. Peak transaortic gradient after BAV decreased from 55 +/- 22 to 20 +/- 11 mm Hg and aortic valve area increased from 0.6 +/- 0.2 to 1.2 +/- 0.3 cm(2). Mean follow-up duration was 32 +/- 18 months. During follow-up, 24% of patients underwent a second BAV and 9% of patients underwent a third BAV. Duration of symptom alleviation after the first, second, and third BAV procedures were 18 +/- 3, 15 +/- 4, and 10 +/- 3 months, respectively. Median survival rate after BAV was 35 months. Survival rates 1, 3, and 5 years after the procedure were 64%, 28%, and 14% respectively. Patients who underwent repeat BAV had higher 3-year survival rates than did patients who underwent 1 BAV (p = 0.01). Therefore, repeat BAV is a viable treatment strategy in nonsurgical patients who have severe calcific aortic stenosis, because it provides a median survival rate of approximately 3 years and maintains clinical improvement.