South African dyslipidaemia guideline consensus statement: 2018 update A joint statement from the South African Heart Association (SA Heart) and the Lipid and Atherosclerosis Society of Southern Africa (LASSA).

South Africa (SA) is home to a heterogeneous population with a wide range of cardiovascular risk factors. Cholesterol reduction in combination with aggressive management of modifiable risk factors, including nutrition, physical activity, blood pressure and smoking, can help to reduce and prevent morbidity and mortality in individuals who are at increased risk of cardiovascular events. This updated consensus guide to management of dyslipidaemia in SA is based on the updated European Society of Cardiology and European Atherosclerosis Society dyslipidaemia guidelines published in 2016. For individuals who are not considered to be at high or very high cardiovascular risk, the decision whether to treat and which interventional strategy to use is based on a cardiovascular risk score calculated using total cholesterol, high-density lipoprotein cholesterol (HDL-C), gender, age and smoking status. The cardiovascular risk score refers to the 10-year risk of any cardiovascular event and includes 4 categories of risk (low, moderate, high and very high). People with established cardiovascular disease, diabetes mellitus, chronic kidney disease and genetic or severe dyslipidaemias are considered to already be at high or very high risk and do not require risk scoring. Therapeutic lifestyle change is the mainstay of management for all patients. The need for and intensity of drug therapy is determined according to baseline low-density lipoprotein (LDL-C) levels and the target LDL-C concentration appropriate to the individual. LDL-C treatment targets are based on pre-treatment risk and are as follows: <3 mmol/L in low- and moderate risk cases; <2.5 mmol/L and a reduction of at least 50% if the baseline concentration is 2.5 - 5.2 mmol/L in high-risk cases; and <1.8 mmol/L and a reduction of at least 50% if the baseline concentration is 1.8 - 3.5 mmol/L in very high-risk cases. A statin is usually recommended first-line; the specific agent is based on the required degree of cholesterol reduction, comorbidities and co-prescribed medication. Special attention should be paid to children with a family history of genetic or severe dyslipidaemia, who should be screened for dyslipidaemia from 8 years of age. In SA, HIV infection is not considered to be a significant cardiovascular risk factor and treatment recommendations for HIV-positive individuals are the same as for the general population, with careful choice of pharmacotherapy to avoid potential adverse drug-drug interactions. The benefit of statins in individuals older than 70 years is uncertain and clinical judgement should be used to guide treatment decisions and to avoid side-effects and overmedication in this group.

Adverse effects of the 'Noakes' diet on dyslipidaemia.

There has been much hype and controversy over the so-called 'Noakes' diet. This diet advocates a low-cardohydrate, high-fat and high-protein intake. As previously reported in the Journal, Noakes has expressed the view that this diet coupled with exercise could have a favourable impact on lipid levels and potentially avoid the need for drug therapy. In that same report, it was noted that this has not been subjected to scientific validation. More recently the ability of the Noakes diet to give better weight-control results than a 'balanced diet' has been questioned.

The perils of pharmacological treatment for obesity: a case of sibutramine-associated cardiomyopathy and malignant arrhythmias.

A 58-year-old woman presented with severe left ventricular dysfunction and malignant arrhythmias after taking combination drug treatment for weight loss. The combination treatment included sibutramine, liothyronine, hydrochlorothiazide diuretic, metformin and fucus. The effect of these drugs individually and in combination is discussed, with particular reference to it being a malignant combination. The patient showed reversability of the left ventricular dysfunction and negative ventricular stimulation studies after cessation of the drug concoction.

CEPHEUS SA: a South African survey on the undertreatment of hypercholesterolaemia.

AIM: The aim of the CEntralised Pan-South African survey on tHE Under-treatment of hypercholeSterolaemia (CEPHEUS SA) was to evaluate the current use and efficacy of lipidlowering drugs (LLDs), and to identify possible patient and physician characteristics associated with failure, if any, to achieve low-density lipoprotein cholesterol (LDL-C) targets. METHODS: The survey was conducted in 69 study centres in South Africa and recruited consecutive consenting patients who had been prescribed LLDs for at least three months. One visit was scheduled for data collection, including fasting plasma lipid and glucose levels. Physicians and patients completed questionnaires regarding their knowledge, awareness and perceptions of hypercholesterolaemia and the treatment thereof. RESULTS: Of the 3 001 patients recruited, 2 996 were included in the final analyses. The mean age was 59.4 years, and 47.5% were female. Only 60.5 and 52.3% of patients on LLDs for at least three months achieved the LDL-C target recommended by the NCEP ATP III/2004 updated NCEP ATP III and the Fourth JETF/South African guidelines, respectively. Being male, older than 40 years, falling into the lower-risk categories, compliance with the medication regimen, and patient knowledge that the LDL-C goal had been reached, were associated with the highest probability of attaining LDL-C goals. CONCLUSION: The results of this survey highlight the sub-optimal lipid control achieved in many South African patients taking lipid-lowering therapy.

A multicentre, open-label, observational local study to evaluate the low-density lipoprotein cholesterol-lowering effect of ezetimibe as prescribed in daily routine practice in the South African population.

OBJECTIVE: The study examined the efficacy, safety and tolerability of co-administering the cholesterol absorption inhibitor, ezetimibe 10 mg with ongoing statin therapy in hypercholesterolaemic patients. PATIENTS AND METHODS: I n this multicentre, open-label, observational study, hypercholesterolaemic patients (from 44 South African specialty practices) on statin therapy were screened and after meeting the inclusion criteria, all received ezetimibe (10 mg/day) in addition to their ongoing statin therapy for four weeks. RESULTS: In 358 patients, ezetimibe co-administered with ongoing statin therapy significantly reduced the low-density lipoprotein cholesterol (LDL-C) level by an additional 21.9% in the total population. In the secondary-prevention patients (category 1 cardiovascular risk according to ESC guidelines adopted for South Africa), an additional 20.4% reduction was observed, and a 25.5% additional reduction for the primary-prevention patients (category 2 cardiovascular risk according to ESC guidelines adopted for South Africa). These results were consistent across gender, race, age, statin brand and dose subgroups. Ezetimibe co-administered with ongoing statin therapy also increased the number of patients reaching their LDL-C goals according to their risk category (2.5 mmol/l for category 1 patients and 3.0 mmol/l for category 2 patients). Ezetimibe-plus-statin therapy was well tolerated, with a good safety profile. CONCLUSION: Ezetimibe co-administered with ongoing statin therapy consistently produced significant additional improvements in LDL-C levels and goal attainment. This was observed for the whole population as well as for the two risk categories. The addition of ezetimibe to ongoing statin therapy may be considered for patients not achieving their LDL-C goals on conventional statin therapy.

Aortocoronary saphenous vein bypass aneurysm--an unusual presentation.

Aneurysms of aortocoronary saphenous bypass grafts are an unusual and rare complication of coronary artery bypass surgery. Approximately 30 such cases have been reported in the literature. Atheromatous aneurysms usually appear late (more than 10 years after grafting). They are usually asymptomatic, but may manifest for investigation as a lesion altering the mediastinal contour. We report a further case of an atherosclerotic aortocoronary saphenous vein graft aneurysm in which the patient presented with angina due to aneurysmal compression of the host vessel.

Pulmonary arterial thrombosis in secundum atrial septal defect.

Nineteen adolescent or adult patients with secundum atrial septal defect (ASD) underwent pulmonary arteriography to evaluate the presence of proximal pulmonary arterial (PA) thrombosis. This procedure demonstrated proximal PA thrombosis in 8 patients (group 2). These patients had a distinctive hemodynamic profile, consisting primarily of significant PA hypertension. None of the 11 patients with normal angiograms (group 1) had severe PA hypertension (p less than 0.0001). Proximal PA thrombosis appears to be the major factor in the development and progression of PA hypertension in adult patients with ostium secundum ASD. Pulmonary angiography should be undertaken in all adult patients with ostium secundum ASD who have at least moderate PA hypertension. Long-term anticoagulation is advocated for patients with PA thrombosis irrespective of a decision for surgical intervention.

Torsade de pointes due to coxsackie B3 myocarditis.

Viral myocarditis may present with a variety of electrocardiologic aberrations. Torsade de pointes, a potentially malignant ventricular arrhythmia associated with prolongation of the QT interval has not been described in patients with acute viral myocarditis. This report details this finding in a patient with coxsackie B3 myocarditis in whom symptomatic torsade de pointes was documented.

Combined unilateral pulmonary artery agenesis and contralateral peripheral pulmonary artery stenosis.

Unilateral absence of a pulmonary artery is a rare congenital malformation. This report details the finding in two cases of this anomaly associated with peripheral stenosis of the contralateral pulmonary artery.

Contribution of echocardiography and immediate surgery to the management of severe aortic regurgitation from active infective endocarditis.

The timing of surgery in patients with severe aortic regurgitation and left ventricular (LV) failure, particularly when associated with active infective endocarditis (IE), is of the utmost importance. From July 1982 to May 1984, 34 patients, aged 15 to 60 years, with severe aortic regurgitation underwent immediate (within 24 hours of diagnosis) aortic valve surgery. All patients were in New York Heart Association class IV for LV failure. Eighteen patients had right-sided heart failure. Decision for immediate surgery was based on the echocardiographic demonstration of diastolic closure of the mitral valve or of vegetations on the aortic valve. Premature closure of the mitral valve was demonstrated echocardiographically in 17 patients, 13 of whom had diastolic crossover of LV and left atrial pressure tracings recorded at surgery. IE of the aortic valve was confirmed at surgery in 29 patients, 27 of whom had vegetations on echocardiography. Seven patients required replacement of both aortic and mitral valves. Antibiotic therapy for IE was started immediately after blood cultures were taken and continued for 4 to 6 weeks postoperatively. The mortality rate within 30 days of surgery was 6% for the group as a whole and 7% for those with IE. Mean follow-up period for the 32 survivors was 10.6 months. There were 2 late deaths. No patient had periprosthetic regurgitation or persistence of endocarditis. Procrastination in referral for surgery of these extremely ill patients is not justified and is likely to be associated with higher risks of morbidity and mortality.

Electrocardiographic differentiation of the causes of left ventricular diastolic overload.

Left ventricular hypertrophy due to diastolic overload is characterized by the following in lead V6: (a) tall R wave; (b) prominent initial Q wave; (c) minimally elevated concave-upward ST segment; and (d) relatively tall symmetrical T wave. Reciprocal deep S waves are seen in lead V1. This study reflects a further evaluation of these parameters in the four main causes of left ventricular diastolic overload: mitral incompetence, aortic incompetence, patent ductus arteriosus, and ventricular septal defect. An S wave in lead V1 which is equal to or greater than the R wave in lead V6 excludes the diagnosis of mitral incompetence.

Effects of atenolol on exercise capacity in patients with mitral stenosis with sinus rhythm.

Exercise capacity is frequently impaired in patients with mitral stenosis (MS) and sinus rhythm (SR). The resulting increased heart rate, which shortens the diastolic filling period, and the increased cardiac output lead to further elevations of left atrial pressure and subsequent pulmonary congestion. The effect of the beta-receptor blocking agent atenolol, 100 mg/day, was assessed in 13 patients with MS and SR. Exercise performance was assessed using a modified multistage Bruce protocol after 2 weeks of placebo and after 2 weeks therapy with atenolol in a single-blind, crossover, placebo-controlled, randomized study. Atenolol resulted in significant decreases in mean heart rates at rest and during exercise (p = 0.0015) and a significant increase in total exercise time (p = 0.0015). Maximal exercise capacity was also significantly improved (p = 0.0015). All patients were both objectively and subjectively improved by atenolol. Thus, beta-blockade with atenolol improves exercise capacity in patients with MS and SR and may be of benefit to most such patients. The improved effort tolerance is attributed to reduction of the exercise-associated sinus tachycardia by beta-blockade, allowing a longer diastolic filling period and better left atrial decompression.

Transudative ascites with a high protein content. Case reports.

The case reports of 2 patients with constrictive pericarditis and 1 patient with the Budd-Chiari syndrome are used to show that high-protein ascites may occur in the absence of disease of the peritoneum. Protein content should not be the only factor assessed in differentiating between transudative and exudative ascites.