Updates in the management of Dyslipidaemia in the high and very high risk individual for CV risk reduction.

Cardiovascular disease (CVD) has been the main cause of mortality and an important cause of morbidity in Malaysia for several years. To reduce global cardiovascular (CV) risk in the population, primary preventive strategies need to be implemented. Hypercholesterolaemia is one of the major risk factors for CVD. This paper is an expert review on the management of hypercholesterolemia focusing on high and very high risk individuals. In low and Intermediate risk individuals, therapeutic lifestyle changes (TLC) and a healthy lifestyle alone may suffice. In high and very high risk individuals, drug therapy in conjunction with TLC are necessary to achieve the target LDL-C levels which have been shown to slow down progression and sometimes even result in regression of atherosclerotic plaques. Statins are first-line drugs because they have been shown in numerous randomized controlled trials to be effective in reducing CV events and to be safe. In some high risk individuals, despite maximally tolerated statin therapy, target Low Density Lipoprotein Cholesterol (LDL-C) levels are not achieved. These include those with familial hypercholesterolaemia and statin intolerance. This paper discusses non-statin therapies, such as ezetimibe and the newer Proprotein convertase subtilisin/kexin type 9 Inhibitors (PCSK9-i).

Calcium score of coronary artery stratifies the risk of obstructive coronary artery diseases.

BACKGROUND AND AIMS: Coronary heart disease is a major health problem in Malaysia with high morbidity and mortality. Common primary screening tool of cardiovascular risk stratification is exercise treadmill test (ETT). This communication is to determine the performance of coronary artery calcium score a new method to stratify the presence of obstructive coronary artery disease (CAD) in comparison to traditional ETT in patients having coronary artery diseases. MATERIALS AND METHODS: Patients between 30 to 60 years old attended the ETT to screen for ischemic heart disease were recruited for Agatston coronary artery calcium score (CACS) of multi-sliced computed tomography (MSCT). Subsequently all patients underwent a full MSCT coronary angiography. The major determinant was the state of CAD whether obstructive (50% stenosis or more) or non-obstructive (less than 50% stenosis). All patients diagnosed with obstructive CAD on MSCT coronary angiogram were subjected to invasive coronary angiogram (ICA) to confirm the findings and planned the need for revascularization. RESULTS: The CACS was 100% sensitivity and 97.5% specificity in detecting obstructive CAD at the optimal cut-off value of 106.5 and above. The positive predictive value (PPV) at CACS ≥ 106 was 71.4% and the negative predictive value (NPV) was consistent at 100%. Compare to ETT, the CACS discriminative value and diagnostic performance was much better (PPV 71.4% vs. 45.5%), respectively. CONCLUSION: CACS can be a good diagnostic screening tool in patients suspected of CAD, and particularly within the non-diagnostic ETT subgroup with low to moderate cardiovascular risks.

Myocardial ischaemic time and its relation with left ventricular ejection fraction after single valve replacement.

BACKGROUND AND AIMS: The effect of the duration of ischaemic myocardial time to left ventricular ejection fraction (LVEF) after valve replacement surgery has been attributed. This study aims to look at the correlation between myocardial ischaemic time and changes LVEF post valve replacement surgery up to 6 months period. PATIENTS AND METHODS: This is a single centre observational study. Forty-four patients were included in the study from total of 82 patients. Serial echocardiographic examinations were taken at baseline, early postoperative (2 weeks) and late (6 months) post operative. RESULTS: Seventeen males and 27 females, mean age of 46±14 years were studied. Mean NYHA Class was 1.7±0.8. Morbidity recorded in 14 patients (31.8). There were three mortalities (6.8%). Thirty eight (86.4%) patients had mitral valve replacement and 6 (13.6%) patients had aortic valve replacement. Mean cardiopulmonary bypass time (CPB) was 108±25 minutes. Mean time for aortic cross clamping time was 84±20 minutes. Left ventricular end diastolic diameters (LVEDD), left ventricular ejection systolic diameter (LVESD) were significantly reduced from 5.2±0.7 cm to 4.8±0.6 cm and from 3.5±0.7 cm to 3.1±0.5 cm at 6 months respectively. LVEF showed significant improvements from 59±10 cm to 63±10 cm at 6 months. There was no significant correlation between aortic cross clamping time with changes in LVEF at early postoperative (p=0.674) and late postoperative (p=0.798). CONCLUSION: This study showed that improvements in LVEF were seen at 6 months post operatively. We found that the duration of myocardial ischaemic time did not significantly affect post operative LVEF changes.

Severe left anterior descending artery stenosis with proximal arteriovenous malformation presenting as acute myocardial infarction.

Congenital coronary artery anomalies are rare, with an incidence of about 0.06-1.3 percent of all patients undergoing cardiac catheterisation. They are commonly asymptomatic, but potentially serious lesions may lead to myocardial ischaemia, infarction and/or sudden cardiac death. The occurrence of a concomitant stenotic lesion is exceedingly rare. We report an 80-year-old man who presented with acute anterior myocardial infarction. Coronary angiography revealed severe proximal left anterior descending (LAD) and arteriovenous malformation (AVM) from the first septal branch of the LAD. The LAD stenosis and the AVM were successfully treated with two Jomed covered stents.

Information Needs of Post Myocardial Infarction (MI) Patients: Nurse’s Perception in Universiti Kebangsaan Malaysia Medical Centre (UKMMC)

Patient education has been considered as an integral component of care for patient after myocardial infarction. Post myocardial infarction patients require information and knowledge related to their conditions to reduce anxiety and aid recovery. The objective of this study was to identify nurses’ perception on information needs of post MI patients of UKMMC. A cross sectional study using Cardiac Patient Learning Needs Inventory (CPLNI) adopted from Timmins and Kalizer (2002) was used. It comprises seven cate-gories: related to anatomy and physiology, psychological factor, life style factor, medi-cation information, dietary information, physical activity, and symptom management. This study was conducted in coronary care unit (CCU), coronary rehabilitation ward (CRW), medical ward 1 and medical ward 2 from January 2007 to March 2007. 56 res-pondents (96%) who fulfilled the inclusion criteria were recruited in this study. Results showed that CCU and CRW respondents ranked symptom management as their first ranking followed by medication, life style factor, anatomy and physiology, dietary in-formation, physical activity and psychological factor. However, respondents in Medical Ward 1 and 2 reported and ranked medication information as their top priorities fol-lowed by symptom management, psychological factors, dietary information, physical activity, anatomy and physiology and life style factor. There were significant differ-ences between ward nurses’ responses with their perception related to anatomy and physiology, psychology factor, life style factor, physical activity, and symptom man-agement with p value<0.05. This study concluded that the information needs are not always perceived in unison by nursing personnel as the CCU and CRW nurses ranked symptoms management as the cardinal factor whilst Medical Ward 1 and 2 nurses give paramount importance to medication. In order to improve this situation for post MI pa-tient, information need has to be tailored, individualized and prioritized based upon their needs.