Impact of Cardiac Rehabilitation Programs Post Primary Percutaneous Coronary Intervention on Functional Capacity and Metabolic Profile Through Different Age Groups.

INTRODUCTION: Modern cardiac rehabilitation (CR) is a thorough approach including multiple arms that aim at improving quality of life and functional capacity. AIM: To study the impact of age on the benefits of cardiac rehabilitation program post-successful primary percutaneous coronary intervention (PCI). METHODS: This retrospective study includes 250 patients post primary percutaneous coronary intervention (PCI) who underwent a complete 12-week cardiac rehabilitation program. Functional capacity, metabolic profile, and parameters of diastolic function were assessed and compared at baseline and after completing the program. Four age strata were compared in terms of improvement of the various parameters studied. RESULTS: In the whole patient group, the workload achieved in metabolic equivalents (METS) and maximum exercise time significantly increased. Regarding metabolic profile, body mass index (BMI), total cholesterol, low-density lipoprotein (LDL), and Triglycerides significantly decreased. While high-density lipoproteins (HDL) increased but didn't reach significance. Echo data reflecting diastolic dysfunction also improved significantly. We found that the magnitude of improvement in all the earlier-mentioned parameters showed no statistically significant difference among the four age groups studied. CONCLUSION: Cardiac rehabilitation program post primary percutaneous coronary intervention (PCI) significantly improves functional capacity, metabolic profile, and diastolic function. It is never too old or too young to join the CR program. Different age groups benefit equally from rehabilitation.

Effect of a 6-week and 12-week cardiac rehabilitation program on heart rate recovery.

BACKGROUND: Cardiac rehabilitation has been shown to reduce cardiac mortality, improve quality of life, and reduce hospitalizations. Cardiac rehabilitation programs are usually performed over a 12-week period. Studies have shown that similar benefits could be achieved with shorter programs. Abnormal heart rate recovery after exercise has been associated with an increased risk of cardiovascular events and mortality. The main aim of this study was to compare the effect of a 6-week phase 2 cardiac rehabilitation program on heart rate recovery to a 12-week one in patients who had recovered from an anterior wall ST segment elevation myocardial infarction. RESULTS: This prospective study included 60 patients enrolled in cardiac rehabilitation programs randomized into two equal groups: a 6-week and a 12-week program. Baseline patient demographics, lipid profile, and left ventricular ejection fraction (LVEF) were assessed. METs achieved, total exercise time, resting heart rate, peak heart rate, and heart rate recovery at 1 min were examined. These were re-assessed at the end of each program. Results showed no difference between both groups at the end of each program regarding lipid profile and LVEF. Patients enrolled in the 12-week cardiac rehabilitation program were able to achieve more METs, had a longer exercise time, a higher peak heart rate, and had a lower resting heart rate at the end of the program. Heart rate recovery was slightly higher in patients enrolled in the 6-week program 26.5 ± 6.78 versus 23.17 ± 6.12 bpm (p = 0.051). On comparing the magnitude of change between both programs, those in the 12-week program had more increase in HDL-C levels, METs achieved, and exercise time. Additionally, they had more reduction of resting heart rate. Heart rate recovery was more increased for those in the 6-week program. CONCLUSION: Although heart rate recovery increases after completion of each of a 6-week and 12-week cardiac rehabilitation program compared to their baseline, there is no difference on comparing heart rate recovery between both programs at their end. Patients enrolled in a standard 12-week cardiac rehabilitation program achieve more METs, have a longer exercise time, a higher peak HR, and a lower resting HR at the end of the program compared to those in the 6-week program.

Prevalence of lower extremities peripheral arterial disease among Egyptian ischemic patients attending cardiac rehabilitation unit.

BACKGROUND: Atherosclerosis is progressive and diffuse pathological disorders which can simultaneously affect multiple vascular beds. Diagnosing Lower extremities peripheral arterial disease (PAD) in patients with Coronary artery disease (CAD) admitted to cardiac rehabilitation program can help to tailor exercise regimen to fit these patients, in addition, early treatment and/or intervention may help to control progression of the disease. AIM: The study is to search for the prevalence of undiagnosed PAD using ankle brachial index (ABI) in Egyptian patients with documented CAD undergoing cardiac rehabilitation program. PATIENTS AND METHODS: The study included 200 patients with documented CAD scheduled for cardiac rehabilitation in Cardiology department, Ain Shams University, with exclusion of patients with known (diagnosed) PAD. All patients underwent ABI using Doppler ultrasonography. The patients were divided into two groups; Study group with positive ABI (≤ 0.9) and Control group with negative ABI (> 0.9). RESULTS: We found that the prevalence of undiagnosed PAD in those patients was 14.5% (29 patients). The incidence of PAD is increased in patients above 60 years (p = 0.001) and in presence of hypertension/uncontrolled systolic blood pressure (p = 0.002), Dyslipidemia (p = 0.005), or family history of ischemic heart disease (p = 0.035). PAD is associated also with impaired left ventricular systolic function and presence of segmental wall motion abnormalities at rest. Impaired eGFR increased the risk of development of PAD (p = 0.016). PAD was associated more with patients presented by multivessel lesions by coronary angiography and in presence of ischemic ECG changes. CONCLUSION: This study shows that significant PAD is present in almost 15% of ischemic Egyptian patients. We recommend ABI to be done routinely in patients with significant CAD for exclusion or diagnosis of PAD to help in treatment and improving quality of life in addition to modification of cardiac rehabilitation program in presence of PAD according to its severity.

Effect of cardiac rehabilitation on cardiovascular risk factors in chronic heart failure patients.

INTRODUCTION: Cardiac rehabilitation improves disease-related symptoms, quality of life, and clinical outcomes. This study was done to evaluate the effect of cardiac rehabilitation program on cardiovascular risk factors in chronic heart failure patients as well as functional capacity and health related quality of life. METHODS: The study was conducted on 80 Patients with chronic stable heart failure. All patients had full history and thorough physical examination. Body mass index (BMI), waist circumference, glycated hemoglobin (HbA1c), lipid profile, and echocardiography, all of which were done before and after recruitment in a 2 months cardiac rehabilitation program (through prescribed exercise training, 2 sessions/week for 2 months). The changes in functional capacity were evaluated by 6-min walk test (6MWT) and the changes in the health related quality of life were measured by Minnesota living with heart failure questionnaire (MLHFQ), both were done before and after the rehabilitation program. RESULTS: There was a highly significant reduction in the blood pressure, heart rate, BMI, waist circumference, the smokers' number and the glycated hemoglobin (HbA1c) (P < 0.01). However, there was no statistically significant reductions in low density lipoproteins (LDL), Triglycerides (P > 0.05). Highly significant improvements were noted in the functional capacity and the health related quality of life as evidenced by improvement in the 6MWT and the MLHFQ scores (total score, physical and psychological domains, P < 0.01). CONCLUSION: Cardiac rehabilitation had a significant improvement of cardiovascular risk factors, functional capacity and Health related quality of life in patients with chronic heart failure.

Antithrombotic Therapy for Transcatheter Valvular Interventions: A Revisit.

BACKGROUND: The optimal antithrombotic therapies for transcatheter aortic valve implantation (TAVI) and MitraClip implantation have not been well established. We conducted a narrative review from currently available studies between January 2002 and May 2016 to highlight the advantages and disadvantages of antithrombotic therapy use in cardiac catheter-based therapeutic techniques. Recently, these techniques have dramatically altered the approach towards valvular heart diseases management. The introduction into clinical practice, of TAVI for severe aortic stenosis and MitraClip for mitral regurgitation, has revolutionized interventional cardiology. However, TAVI is associated with a risk of cerebral embolization and ischaemic vascular events leading to neurological impairment and even death. These ischaemic complications might occur perioperatively or much later, although the estimated rate of occurrence is variable. CONCLUSION: We will discuss prior experience with MitraClip for antithrombotic use. It is imperative for patients undergoing transcatheter valvular interventions to have optimal antithrombotic therapy that balances between ischaemic and haemorrhagic complications. The appropriate timing, combination, and duration of antithrombotic medications need consensus to weigh between the efficacy, efficiency and adverse effects in patients with transcatheter valvular interventions.

Diffusion tensor imaging of mild-moderate carpal tunnel syndrome: correlation with nerve conduction study and clinical tests.

The purpose of this study was to assess diffusion tensor imaging in the diagnosis of mild-moderate carpal tunnel syndrome (CTS) and to correlate fractional anisotropy (FA) and apparent diffusion coefficient (ADC) with nerve conduction study and clinical tests. This prospective study was conducted upon 39 patients (9 males, 30 females; mean age = 33 years) with early stage of CTS. Twenty age- and sex-matched healthy volunteers were included as a control group. All patients underwent clinical tests and nerve conduction studies with calculation of the distal motor latency (DML) and distal sensory latency (DSL). Patients with CTS and volunteers underwent diffusion tensor imaging of the median nerve. The cross-sectional area (CSA), FA, and ADC of the median nerve were calculated. There was significant difference in FA and ADC between patients and controls (P = 0.001 respectively) and between mild and moderate CTS (P = 0.001 respectively). The cutoff FA and ADC of the median nerve used for the diagnosis of CTS were 0.45 and 1.31 × 10-3 mm2/s with areas under the curve (AUC) of 0.985 and 0.954, respectively, and the values used to differentiate mild from moderate CTS were 0.42 and 1.35 × 10-3 mm2/s with AUC of 0.964 and 0.688, respectively. The FA and ADC of the median nerve were correlated with CSA (r = 0.894; -0.769), DML (r = -0.935; 0.781), DSL (r = -0.953; 0.781), Tinel's test (r = 0.742; 0.684), and Phalen's test (r = 0.862; 0.742). Diffusion tensor imaging can be used for the diagnosis of mild-moderate CTS and well correlated with nerve conduction studies and clinical tests.

Prolonged bradycardia, asystole and outcome of high spinal cord injury patients: Risk factors and management.

BACKGROUND: High spinal cord injury (HSCI) is one of the devastating traumatic injuries. 80% of these patients are young male, and 93% will have major neurological disabilities. There is a paucity of literature about prolonged bradycardia in HSCI patients. The aim of this study was to know the prevalence, risk factors, precipitating factors for prolonged bradycardia in the HSCI patients. MATERIALS AND METHODS: All patients who were admitted to the Intensive Care Unit (ICU) of a tertiary hospital, with spinal cord injury above level of dorsal (D4) were enrolled in this study prospectively. Patient's demographic data, mechanism, level and type of spinal injury, associated injuries, injury severity score (ISS), spinal shock, vasopressors used, time of occurrence of bradycardia, treatment for bradycardia, precipitating as well as risk factors and outcome were recorded. RESULTS: During the study period, a total of 138 patients were admitted to the ICU with HSCI. Majority of patients were male. The most frequently associated injury in these patients was skeletal fractures (38.4%). Most common complication was pneumonia 56 (41%). Forty-five (33%) of the total patients had prolonged bradycardia; 87% of these patients had pneumonia when bradycardia occurred. 53.4% had cardiac asystole. 29 (21%) patients had bradycardia at the time of endotracheal suctioning, whereas 27 (20%) patients developed bradycardia at the time of positioning. Majority of the patients were managed conservatively. Those HSCI patients who developed prolonged bradycardia, their ISS score was statistically higher, ICU and hospital stay was significantly higher compared with those HSCI patient who did not have prolonged bradycardia. Multivariate analysis revealed that hypotension on admission; pneumonia, and tracheostomy were risk factors for the development of prolonged bradycardia in HSCI patients. CONCLUSION: Prolonged bradycardia was associated with significantly higher incidence of asystole. Endotracheal suctioning and positioning of HSCI patients were significant provocative factors for prolonged bradycardia; hypotension on admission, pneumonia and tracheostomy were the risk factors for the development of prolonged bradycardia in these patients.

Congestive Heart Failure With Apparently Preserved Left Ventricular Systolic Function: A 10-Year Observational Study.

We analyzed the clinical presentation and outcomes (from 2003 to 2013) of heart failure (HF) with apparently normal systolic function (HFPEF). Based on the echocardiographic left ventricular ejection fraction (LVEF), patients were divided into 2 groups, group 1 (<50%) and group 2 (≥50%). Of 2212 patients with HF, 20% were in group 2. Patients in group 2 were more likely to be older, females, Arabs, hypertensive, and obese (P = .001). Patients in group 1 were mostly Asians and had more troponin-T positivity (P = .001). Inhospital cardiac arrest, shock, and deaths were significantly greater in group 1. On multivariate analysis, age, ST-segment elevation myocardial infarction, lack of on-admission ß-blockers, and angiotensin-converting enzyme inhibitors use were independent predictors of mortality. HFPEF is associated with less mortality compared to those who presented with reduced LVEF. On admission, use of evidence-based medications could in part predict this difference in the hospital outcome.

Cardiovascular complications in diabetic patients undergoing regular hemodialysis: a 5-year observational study.

We aimed to study the vascular outcomes in hemodialysis (HD) patients based on their diabetic status. A cohort observational study was conducted among patients undergoing regular HD with a 5-year follow-up. Of the 252 consecutive HD patients, 60% were diabetic. Compared with nondiabetics, diabetics were 11 years older, 4 years lesser on HD, and more likely to have prior cerebrovascular and coronary artery disease (CAD). Overall 5-year follow-up showed that diabetic patients had higher rates of HD vascular accesses (57% vs 41%, P = .01), CAD (64% vs 33%, P = .001), major amputations (8.6% vs 0%, P = .003), and mortality (66% vs 23%, P = .001). On multivariate analysis, independent predictors of mortality included number of vascular accesses in nondiabetics and HD duration, CAD, and peripheral artery disease in diabetic patients. Diabetes mellitus is associated with a significant vascular burden and mortality among HD patients. Moreover, our finding highlights the vascular impact of renal failure and HD.

Initial heart rate and cardiovascular outcomes in patients presenting with acute coronary syndrome.

OBJECTIVES: To assess the impact of on-admission heart rate (HR) in patients presenting with acute coronary syndrome (ACS). METHODS: Data were collected retrospectively from the second Gulf Registry of Acute Coronary Events. Patients were divided according to their initial HR into: (I: < 60, II: 60-69, III: 70-79, IV: 80-89 and V: ≥ 90 bpm). Patients' characteristics and hospital and one- and 12-month outcomes were analyzed and compared. RESULTS: Among 7939 consecutive ACS patients, groups I to V represented 7%, 13%, 20%, 23.5%, and 37%, respectively. Mean age was higher in groups I and V. Group V were more likely males, diabetic and hypertensive. ST-elevation myocardial infarction was the main presentation in groups I and V. Reperfusion therapies were less likely given to group V. Beta blockers were more frequently prescribed to group III in comparison to groups with higher HR. Groups I and V were associated with worse hospital outcomes. Multivariate analysis showed initial tachycardia as an independent predictor for heart failure (OR 2.2; 95%CI: 1.39-3.32), while bradycardia was independently associated with higher one-month mortality (OR 2.0; 95%CI: 1.04-3.85) CONCLUSION: The majority of ACS patients present with tachycardia. However, low or high HR is a marker of high risk that needs more attention and management.

Incidental abdominal aneurysms: a retrospective study of 13,115 patients who underwent a computed tomography scan.

We evaluated the frequency and outcomes of abdominal aortic aneurysm (AAA) in Qatar. Data were collected retrospectively between 2004 and 2008 for all adult patients who underwent abdominal computed tomographic scanning for any reason. Patients with AAA were followed up for 3 years for aneurysmal rupture and mortality. Of the 13,115 patients screened, 61 (0.5%) patients had abdominal aneurysms. Most (82%) patients with AAA were male with mean age of 67 ± 12 years. The incidence of AAA substantially increased with age. Cardiovascular risk factors were prevalent among patients with AAA. The main location of AAA was infrarenal (67%), followed by thoracoabdominal (23%). The mean AAA diameter was 5.3 ± 2.5 cm. The rate of AAA rupture was 8% with a mortality rate of 60%; 80% of these were infrarenal, and 80% of them had a diameter of ≥5.5 cm. Overall mortality was 33%. This large study addressed the impact of screening for AAA in a population with high cardiovascular burden.

Epicardial coronary arteries in khat chewers presenting with myocardial infarction.

Background. Khat chewing is a common habit in Yemen despite increased evidence of its negative impact on the cardiovascular system. Aims. We aimed to study the epicardial coronary arteries in khat chewers presenting with myocardial infarction (AMI). Materials and Methods. A descriptive, cross-sectional study was conducted between November 2008 and May 2009 in Yemen. AMI patients who underwent coronary angiogram were enrolled and divided into groups (gp): gp1 (diabetic and khat chewers), gp2 (khat chewers and nondiabetic), and gp3 (diabetic and non-khat users). Results. Of 347 AMI patients 63%, 21%, and 16% were in gp 2, 3, and 1, respectively. Khat chewers were younger in comparison to non-khat users. Group 3 patients were more likely to have multivessel disease, severe left anterior descending (LAD), right coronary artery (RCA) stenosis and total RCA, and left circumflex (Lcx) occlusion compared to other groups. Group 1 patients were more likely to have total LAD occlusion and severe Lcx lesions. In multivariate analysis, age, diabetes mellitus, and smoking were significant independent predictors for significant coronary artery lesions; however, khat chewing did not show such association. Conclusions. Coronary spasm is the main mechanism of AMI in khat chewers. The impact of our finding for risk stratification and management warrants further studies.

Sudden cardiac death in athletes: where do we stand.

We aimed to review the literature to explore the magnitude of sudden cardiac death (SCD) in young athletes. Although SCD in athletes is not a common event, it represents a tragedy of the apparently fit young population. SCD varies according to countries, age groups, and sex. In addition, it varies in the underlying causes and the screening tool. Therefore, we are in need for further research efforts. Guidelines, public and physician awareness, and education regarding the warning signs are integral part in the strategy to reduce SCD tragedy. However, all these requirements raise concern for cost-effectiveness in some countries for proper implementation.

Cardiovascular benefits of black cumin (Nigella sativa).

Black Cumin (Nigella sativa), which belongs to the botanical family of Ranunculaceae, commonly grows in Eastern Europe, the Middle East, and Western Asia. Its ripe fruit contains tiny black seeds, known as "Al-Habba Al-Sauda" and "Al-Habba Al-Barakah" in Arabic and black seed or black cumin in English. Seeds of Nigella sativa are frequently used in folk medicine in the Middle East and some Asian countries for the promotion of good health and the treatment of many ailments. However, data for the cardiovascular benefits of black cumin are not well-established. We reviewed the literature from 1960 to March 2012 by using the following key words: "Nigella sativa," "black seeds," and "thymoquinone." Herein, we discussed the most relevant articles to find out the role of Nigella sativa in the cardiovascular diseases spectrum especially when there is a paucity of information and need of further studies in human to establish the utility of Nigella sativa in cardiovascular system protection.

Myocardial viability: what we knew and what is new.

Some patients with chronic ischemic left ventricular dysfunction have shown significant improvements of contractility with favorable long-term prognosis after revascularization. Several imaging techniques are available for the assessment of viable myocardium, based on the detection of preserved perfusion, preserved glucose metabolism, intact cell membrane and mitochondria, and presence of contractile reserve. Nuclear cardiology techniques, dobutamine echocardiography and positron emission tomography are used to assess myocardial viability. In recent years, new advances have improved methods of detecting myocardial viability. This paper summarizes the pathophysiology, methods, and impact of detection of myocardial viability, concentrating on recent advances in such methods. We reviewed the literature using search engines MIDLINE, SCOUPS, and EMBASE from 1988 to February 2012. We used key words: myocardial viability, hibernation, stunning, and ischemic cardiomyopathy. Recent studies showed that the presence of viable myocardium was associated with a greater likelihood of survival in patients with coronary artery disease and LV dysfunction, but the assessment of myocardial viability did not identify patients with survival benefit from revascularization, as compared with medical therapy alone. This topic is still debatable and needs more evidence.

Anti-chromatin and anti-histone antibodies in Egyptian patients with systemic lupus erythematosus.

There has been a renewed interest in anti-chromatin and anti-histone antibodies in the last few years. To assess the prevalence of anti-chromatin and anti-histone antibodies in patients with systematic lupus erythematosus (SLE) and to correlate serum levels of these antibodies with clinical features of the disease, the presence of anti-chromatin and anti-histone antibodies in 38 patients with SLE was investigated by an enzyme-linked immunosorbent assay (ELISA). To determine the specificity of these antibodies, 15 patients with rheumatoid arthritis, 15 patients with systemic sclerosis, and 15 normal controls were also tested. Sensitivity of anti-chromatin antibodies in SLE patients was 89.5% and specificity was 80.0%, while sensitivity of anti-histone antibodies was 92.1% and specificity was 82.2%. Significant associations were found between the levels of anti-chromatin antibodies and arthritis, malar rash, oral ulcer, pulmonary affection (P < 0.05) also, lupus nephritis (P < 0.01), and disease activity score as measured by SLE disease activity index (SLEDAI; P < 0.001). Significant association was found between anti-histone antibodies and fatigue (P < 0.05). The incidence of positive anti-chromatin and anti-histone antibodies was significantly higher than that of anti-dsDNA antibodies in early stage of the disease. We conclude that anti-chromatin and anti-histone antibodies are both sensitive and specific for SLE and could be a useful addition to the laboratory tests that can help in the diagnosis of SLE. Anti-chromatin antibodies seem to be a promising marker useful in early diagnosis and assessment of disease activity in SLE patients especially in patients who are negative for anti-dsDNA antibodies.