Registry for Acute Coronary Events in Nigeria (RACE-Nigeria): Clinical Characterization, Management, and Outcome.

Background Coronary artery disease was hitherto a rarity in Africa. Acute coronary syndrome (ACS) accounts for coronary artery disease-related morbidity and mortality. Reports on ACS in Africa are few. Methods and Results We enrolled 1072 indigenous Nigerian people 59.2±12.4 years old (men, 66.8%) with ACS in an observational multicentered national registry (2013-2018). Outcome measures included incidence, intervention times, reperfusion rates, and 1-year mortality. The incidence of ACS was 59.1 people per 100 000 hospitalized adults per year, and comprised ST-segment-elevation myocardial infarction (48.7%), non-ST-segment-elevation myocardial infarction (24.5%), and unstable angina (26.8%). ACS frequency peaked 10 years earlier in men than women. Patients were predominantly from urban settings (87.3%). Median time from onset of symptoms to first medical contact (patients with ST-segment-elevation myocardial infarction) was 6 hours (interquartile range, 20.1 hours), and only 11.9% presented within a 12-hour time window. Traditional risk factors of coronary artery disease were observed. The coronary angiography rate was 42.4%. Reperfusion therapies included thrombolysis (17.1%), percutaneous coronary intervention (28.6%), and coronary artery bypass graft (11.2%). Guideline-based pharmacotherapy was adequate. Major adverse cardiac events were 30.8%, and in-hospital mortality was 8.1%. Mortality rates at 30 days, 3 months, 6 months, and 1 year were 8.7%, 9.9%, 10.9%, and 13.3%, respectively. Predictors of mortality included resuscitated cardiac arrest (odds ratio [OR], 50.0; 95% CI, 0.010-0.081), nonreperfusion (OR, 34.5; 95% CI, 0.004-0.221), pulmonary edema (OR, 11.1; 95% CI, 0.020-0.363), left ventricular diastolic dysfunction (OR, 4.1; 95% CI, 0.091-0.570), and left ventricular systolic dysfunction (OR, 2.1; 95% CI, 1.302-3.367). Conclusions ACS burden is rising in Nigeria, and patients are relatively young and from an urban setting. The system of care is evolving and is characterized by lack of capacity and low patient eligibility for reperfusion. We recommend preventive strategies and health care infrastructure-appropriate management guidelines.

Outcomes of transradial primary percutaneous intervention from a tertiary cardiac centre in Turkey.

OBJECTIVES: The aim was to study transradial approach (TRA) and transfemoral approach (TFA) in terms of feasibility, effectiveness, usefulness, and procedure characteristics in patients having ST-segment elevation myocardial infarction (STEMI) and undergoing primary percutaneous coronary intervention (PCI). Along with the said aim, major adverse cardiovascular events (MACE) at follow-up were also compared. METHODS: The present study was conducted on 344 consecutive patients having ST-segment elevation myocardial infarction and qualifying for PCI. Patients were classified into two groups according to radial and femoral approaches. Patients were followed-up for MACE. RESULTS: PCI was found to be successful in all patients. In TRA group the time between the end of the intervention to removal of the sheath, and duration of mobilization and hospitalization were significantly shorter when compared to TFA group (12 ± 2 minutes vs. 240 ± 12 minutes; P = 0.001, 13 ± 2 hours vs. 22 ± 2 hours; P = 0.001, and 96 ± 45 hours vs. 125 ± 55 hours; P = 0.001, respectively). In TRA group, two patients had hematomas greater than 2 cm while fourteen patients in TFA group had hematomas greater than 5 cm (1% vs. 8%; P = 0.002). TRA group had lower in-hospital MACE rates (5% vs. 11%; P = 0.036). The long terms MACE rates of the groups were similar (23% vs. 22%; P = 0.888). CONCLUSIONS: In patients with STEMI, PCI via TRA had the same effectiveness as TFA. Moreover, Time to ambulation and rates of bleeding complications were reduced by TRA, which allowed early rehabilitation. TRA reduced the incidence of in-hospital MACEs.

The association between thoracic periaortic fat and major adverse cardiovascular events.

AIM: The study aimed to examine the association between thoracic periaortic fat tissue volume and the long-term incidence of major adverse cardiovascular events. METHODS: This retrospective cohort study included 433 consecutive patients (372 male and 61 female). Periaortic fat tissue volume was measured via electrocardiogram-gated 64-multidetector computed tomography. The patients were evaluated on an average 3 years of follow-up for major adverse cardiovascular events. The patients were divided into groups according to the presence of major adverse cardiovascular events. RESULTS: Major adverse cardiovascular events were noted in 44 (10.2 %) patients during follow-up. Periaortic fat tissue volume was significantly higher in the major adverse cardiovascular events (+) group (35.4 ± 26.1 cm(3) vs. 24.1 ± 14.9 cm(3), P = 0.001). The logistic regression model showed that periaortic fat tissue volume (hazard ratio: 1.03; 95 % CI: 1.01-1.05; P = 0.001), the glomerular filtration rate (hazard ratio: 0.98; 95 % CI: 0.96-0.99; P = 0.03), and male gender (hazard ratio: 4.76; 95 % CI: 1.08-20.90; P = 0.04) were independent predictors of major adverse cardiovascular events. CONCLUSION: Thoracic periaortic fat tissue volume may be considered a useful new parameter for predicting major adverse cardiovascular events.

The impact of central blood pressure levels on the relationship between oscillometric and central blood pressure measurements: a multicenter invasive study.

The aim of this study was to investigate impact of central blood pressure (BP) levels and sex on the difference between central and upper arm oscillometric BP values. Oscillometric arterial BP measurements of 675 patients were simultaneously compared with values measured from the ascending aorta. The patients were divided into 3 groups according to systolic BP levels. The upper arm oscillometric device overestimated systolic BP (SBP) at low and medium BP levels but it underestimated SBP at high BP level. As for the effect of sex on differences in central and oscillometric BP, SBP was overestimated to a lesser degree in women than in men at low BP levels, but it was more highly underestimated in women than in men at high BP levels. The difference between oscillometric upper arm BP and aortic BP was directly affected by the patient's central BP level. In addition, the difference between central and oscillometric BP was also affected by sex factor.

Mean platelet volume in predicting short- and long-term morbidity and mortality in patients with or without ST-segment elevation myocardial infarction.

Mean platelet volume (MPV) is a marker of platelet activation. An increased MPV is associated with acute myocardial infarction (AMI) and long-term mortality. The aim of this study was to compare MPV in patients with ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation myocardial infarction (NSTEMI). Also, we investigated the value of MPV on in-hospital mortality and long-term prognosis of patients with STEMI and NSTEMI. We studied 429 patients with AMI (70.4% male, 61.9 ± 12.4 years; 279 patients with STEMI, 150 patients with NSTEMI). MPV and platelet count were similar in both groups. Elevated MPV increased the risk of death by 3.1-fold (p < 0.001) in STEMI group during the hospitalization. However, increased MPV was not associated with in-hospital mortality in NSTEMI group. The area under the receiver operating characteristic curve of MPV was 0.868 (95% CI, 0.830-0.907) for predicting two-year mortality. A cut-off point of 11.1 fL showed a sensitivity of 81% and a specifity of 77% for prediction of two-year mortality. Kaplan-Meier survival curve showed two-year mortality rate of 12.5% in patients with MPV >11.1 fL versus 9.9% in patients with MPV <11.1 fL (p < 0.001). Cox regression analysis showed MPV to be an independent predictor of two-year mortality (Hazard ratio 1.7; 95% CI 1.5-1.9; p < 0.001). An increased MPV is an independent predictor of in-hospital mortality in patients with STEMI. However, elevated levels of MPV did not predict in hospital mortality in NSTEMI group. The increase in MPV values was independently correlated with two-year mortality in all study patients.

Plasma concentrations of soluble CD40 ligand in smokers with acute myocardial infarction: a pilot study.

Coronary artery disease (CAD) is believed to be the single leading cause of death in both men and women in the world. Smoking is the most important risk factor for CAD. Smoking increases platelet aggregation and thrombus formation. CD40 ligand (CD40L) is a transmembrane glycoprotein derived from activated platelets. It participates in thrombus formation during the acute phase of acute myocardial infarction (MI). Elevation of CD40L identifies the patients who are at highest risk for cardiac events and who are likely to benefit from treatment with the glycoprotein IIb/IIIa (GPIIb/IIIa) receptor antagonists. The purpose of this study was to evaluate levels of CD40L in smokers with acute MI. Fifty-seven patients with acute MI were enrolled in this study. Thirty-one smokers were compared with 26 non-smokers. Soluble CD40L level in the plasma was determined by a standard enzyme-linked immunosorbent assay. Circulating levels of CD40L were higher in the smokers' group. Smokers with acute MI may have increased risk for thrombotic complications during acute MI, and optimal antiaggregant therapy should be administered.

Association between exaggerated blood pressure response to exercise and serum asymmetric dimethylarginine levels.

BACKGROUND: The exaggerated blood pressure response to exercise (EBPR) is an independent predictor of hypertension. Asymmetric dimethylarginine (ADMA) is an endogenous nitric oxide inhibitor and higher plasma levels of ADMA are related to increased cardiovascular risk. The aim of this study is to identify the relationship between ADMA and EBPR. METHODS AND RESULTS: A total of 66 patients (36 with EBPR and 30 as controls) were enrolled in the study. EBPR is defined as blood pressure (BP) measurements > or =200/100 mmHg during the treadmill test. All the subjects underwent 24-h ambulatory BP monitoring. L-arginine and ADMA levels were measured using a high performance lipid chromatography technique. The serum ADMA levels were increased in the EBPR group compared to the healthy controls (4.0+/-1.4 vs 2.6+/-1.1 micromol/L respectively, P=0.001), but L-arginine levels were similar in the 2 groups (P=0.19). The serum ADMA levels were detected as an independent predictor of EBPR (odds ratio 2.28; 95% confidence interval 1.22-4.24; P=0.002). CONCLUSIONS: Serum ADMA levels might play a role in EBPR to exercise.

Congenitally corrected transposition of great arteries with severe rhythm disturbances.

Within recent years, much scientific attention has been devoted to adults with congenital heart disease (CHD) and probable complications. Congenitally corrected transposition of the great arteries (CCTGA) is a rare, complex form of congenital heart defects. CCTGA is characterized by atrioventricular (AV) and ventriculoarterial (VA) discordance and, hence, by a physiologically normal direction of blood flow. The development of complete AV block and global ventricular dysfunction has been identified as the cause of cardiac death. Although the development of arrhythmias represents a major cause of morbidity and mortality in patients with CHD, the account of all implantations of pacemakers and implantable cardioverter defibrillators (ICD) is less than one percent. This paper presents a case of CCTGA with severe rhythm disorders, discusses probable treatment options, and offers indications of ICD implantation in patients with CHD.

A comparison of blood pressure and pulse pressure values obtained by oscillometric and central measurements in hypertensive patients.

OBJECTIVE: Wide pulse pressure (PP) affects the accuracy of oscillometric blood pressure measurements (OBPM): however, the degree of this impact on different patient groups with wide PPs is unclear. This study will investigate the accuracy of OBPM in achieving target BP and PP in isolated systolic hypertension (ISH) group compared with mixed hypertension (MHT) group. METHOD: A total of 115 patients (70 with ISH and 45 with MHT) were enrolled in the study. Upper arm and wrist OBPM, obtained by OmronM3 and OmronR6 devices respectively, were compared with the simultaneously measured values from the ascending aorta. The ISH was defined as a systolic blood pressure (SBP) > or =140 mmHg and a diastolic blood pressure (DBP) <90 mmHg. MHT was defined as a SBP> or =140 mmHg and a DBP> or =90 mmHg. RESULTS: The mean central arterial blood pressure (BP) and central PP were higher in the ISH group than those in the MHT group. The upper arm OBPM underestimated the central SBP in two groups (-5 mmHg, -3 mmHg, p=0.5, respectively), but overestimated DBP in the ISH group compared with MHT patients (6.8 mmHg, 1 mmHg, p=0.04, respectively). Wrist OBPM similarly underestimated to the central SBP in each group (-16 mmHg, -19 mmHg, p=0.15), whereas the sum of overestimation of DBP was significantly higher in the ISH than in the MHT group (+6 mmHg, - 1 mmHg, p=0.001, respectively). Also, each of the devices underestimated the central PP in the ISH group (about 10 mmHg) as being higher than that of the MHT group. CONCLUSION: Oscillometric devices may be used for self-BP measurement in patients with ISH without clinically important disadvantages compared with the patients with MHT. For PP measurement in patients with ISH, there were substantial differences between intra-arterial and indirect arm BP measurements.

Completely asymptomatic proximal aortic dissection and massive bullous lung disease: coincidence or is there any etiologic link?

This case report focuses on a completely asymptomatic proximal aortic dissection in a middle-aged male smoker with bullous lung disease. The possibility of a relationship between A1-antitrypsin (A1AT) deficiency and aortic dissection is discussed in light of the recent data.

[Comparison between brachial blood pressures obtained by aneroid sphygmomanometer and central aortic pressures: factors affecting the measurements]. / Aneroid sfigmomanometreyle ölçülen brakiyal arter basincinin santral aortik basinçla karsilastirilmasi ve farka etki eden faktörler.

OBJECTIVES: We compared brachial artery blood pressures (BP) measured by aneroid sphygmomanometer with ascending aortic blood pressures and evaluated the factors affecting the differences between the two methods. STUDY DESIGN: The study included 463 patients (177 women, 286 men; mean age 60+/-11 years) undergoing routine coronary angiography. Simultaneously, ascending aortic pressures were measured using a pigtail catheter and brachial artery pressures were measured from the right arm with an aneroid sphygmomanometer. Pulse pressure, fractional pulse pressure, and pulsatility index were calculated from systolic and diastolic BP values. RESULTS: Overall, systolic (-3.1+/-10 mmHg) and diastolic (+3.0+/-7.1 mmHg) brachial pressures showed significant deviations from aortic pressures (p=0.001). Although systolic BP did not differ significantly in both methods for men and women, brachial diastolic BP was significantly different in women (+4.8 mmHg, p=0.0001). Brachial diastolic BP showed a greater deviation from the aortic diastolic pressure in patients > or =60 years of age (+4.5 mmHg and +1.1 mmHg, respectively; p=0.0001). Deviation of systolic BP in hypertensive patients (-4 mmHg) was greater than that in normotensives (-2.0 mmHg, p=0.04). Deviation of brachial systolic BP was highly correlated with increases in aortic systolic pressure (p=0.0001). Differences between the two methods in systolic (-5.8 mmHg, p=0.01) and diastolic (+4.2 mmHg, p=0.03) BP were significant in patients with coexisting diabetes and hypertension. Body mass index and arm circumference were not correlated with deviations between the two methods. CONCLUSION: The main factors (female gender, age, hypertension, diabetes) affecting BP differences between the two methods should be considered in clinical practice.

Complete atrioventricular block associated with rivastigmine therapy.

PURPOSE: A case of complete atrioventricular block associated with rivastigmine use is presented. SUMMARY: A 67-year-old Turkish woman with Alzheimer's disease was admitted to the hospital because of dizziness and syncope. Her medical history included diagnoses of hypertension (treated with amlodipine 5 mg daily) and diabetes mellitus (treated with nateglinide 120 mg daily). She had been taking both drugs for over five years. She had also been taking rivastigmine 6 mg p.o. daily for five months for the treatment of Alzheimer's disease. She had experienced dizziness since the onset of rivastigmine therapy but had not reported it to any health care provider. On admission, she had a blood pressure measurement of 90/60 mm Hg and a pulse rate of 34 beats/min. A 12-lead electrocardiogram revealed complete atrioventricular block. Echocardiography results, blood electrolyte levels, and cardiac biochemical markers were normal. After initial evaluation, a temporary transvenous pacemaker was implanted via the right femoral vein. Amlodipine and rivastigmine were discontinued. On the first day of hospitalization, a coronary angiogram revealed normal coronary anatomy. Two days later, the complete atrioventricular block resolved spontaneously to sinus rhythm. Rivastigmine 6 mg p.o. daily was reinitiated, and complete atrioventricular block recurred on the fourth day of therapy. A VVI permanent pacemaker was implanted on the fifth day of hospitalization. Amlodipine and rivastigmine were reinitiated. The patient continued rivastigmine 6 mg p.o. daily after permanent pacemaker implantation. A three-month follow-up appointment revealed that no further syncope episodes or dizziness had occurred. CONCLUSION: A 67-year-old woman developed complete atrioventricular block after receiving rivastigmine for the treatment of Alzheimer's disease.

Acute coronary embolism without valve thrombosis in a patient with a prosthetic mitral valve--successful percutaneous coronary intervention: a case report.

We present a 44-year-old female patient with anterior myocardial infarction caused by embolization from mitral valve prosthesis due to inadequate anticoagulation. The patient underwent a cardiac catheterization within the 1st hour of arrival. The angiography showed total occlusion of the left anterior descending coronary artery after the second diagonal branch. Percutaneous transluminal coronary angioplasty and stenting were performed, and coronary artery perfusion was restored. The pain disappeared completely immediately after this intervention. Transthoracic echocardiography shortly after this intervention showed normal prosthetic valve function and no thrombus. Transesophageal echocardiography performed 2 days later revealed no thrombus at the prosthetic valve. In conclusion, this case demonstrated that coronary embolism may occur even without prosthetic valve thrombus or dysfunction with suboptimal International Normalized Ratio levels, and can be successfully treated with percutaneous transluminal coronary angioplasty and stenting.

The effect of diabetes mellitus on the P-wave dispersion.

BACKGROUND: P-wave dispersion (PD), a measure of heterogeneity of atrial refractoriness, is defined as the difference between the minimum (P min) and maximum P-wave (P max) durations on standard 12-lead electrocardiography (ECG). Increase in PD shows the intra-atrial and inter-atrial non-uniform conduction. In the present study the evaluation of the effect of diabetes mellitus (DM) on PD in patients without coronary artery disease and hypertension was carried out. METHODS AND RESULTS: Seventy-six diabetic patients who had no coronary artery disease or hypertension (group 1; mean age 48+/-9) and 40 healthy volunteer individuals (group 2; mean age 46+/-13) were enrolled in the study. After obtaining 12-lead surface ECG of all cases, P max and P min P-wave durations were measured and the differences between them were taken as PD (PD=P max-P min). Left atrium diameter, left ventricular end systolic and end diastolic diameters were measured and left ventricular ejection fraction was determined by echocardiography. Pulse wave mitral flow velocities were measured from the apical 4-chamber view. Mitral early diastolic velocity (E), late diastolic velocity (A), E/A, E deceleration time and isovolumetric relaxation time were determined. In comparison of the 2 groups there was no statistically significant difference among age, sex, systolic and diastolic blood pressure, resting heart rate and body mass index of the cases. Although PD and P max were significantly higher in diabetic patients, there was no difference between P min values (33+/-12 vs 28+/-10, p=0.02; 99+/-12 vs 93+/-10, p=0.011; 66+/-9 vs 65+/-10, p=NS; respectively). CONCLUSIONS: DM might increase PD even without ischemia, hypertension and left ventricular hypertrophy.

The relationship between angiotensin-converting enzyme (insertion/deletion) gene polymorphism and left ventricular remodeling in acute myocardial infarction.

BACKGROUND: The development of left ventricular remodeling after acute myocardial infarction is a predictor of heart failure and mortality. The genetic influence on cardiac remodeling in the early period after acute myocardial infarction, is however, unclear. The aim ofthis study was to investigate the relationship between angiotensin-converting enzyme (ACE) gene polymorphism and left ventricular remodeling in the early period in patients with anterior myocardial infarction. METHOD: The study population consisted of 142 patients with their first attack of acute anterior myocardial infarction. Echocardiographic examinations were performed within 24 h of the first attack (first evaluation) and on the fifth day of acute myocardial infarction (second evaluation). Left ventricular end systolic and diastolic diameters, left ventricular end systolic and diastolic volumes, ejection fraction, mitral flow velocities (E, A, E/A), deceleration time, isovolumic relaxation time and myocardial performance index were calculated. ACE I/D polymorphism was determined using polymerase chain reaction amplification. RESULTS: On the basis of polymorphism of the ACE gene, the patients were classified into the three groups: group 1, deletion/deletion (n=59) genotype, group 2 insertion/deletion (n=69), and group 3 insertion/insertion (n=14) genotype. When the first and second sets of echocardiographic results of the groups were compared, all parameters were not different among three groups. In group analysis, Left ventricular systolic diameters, left ventricular diastolic diameters, left ventricular end diastolic diameters, left ventricular ejection fraction and myocardial performance index between first and second echocardiographic results were significantly different in deletion/deletion group and only myocardial performance index and left ventricular ejection fraction in insertion/deletion group (P<0.05). CONCLUSIONS: ACE gene polymorphism may influence early cardiac remodeling after acute myocardial infarction. Patients with the deletion/deletion-insertion/deletion genotype may be particularly more sensitive to ACE-I treatment possibly owing to the more prominent role of the renin-angiotensin system.

Association between A/C1166 gene polymorphism of the angiotensin II type 1 receptor and biventricular functions in patients with acute myocardial infarction.

BACKGROUND: Although there have been several association studies of angiotensin II type 1 receptor (AT1R, A/C1166) gene polymorphism in clinical endpoints such as myocardial infarction (MI), hypertension, aortic stiffness, and left ventricular mass, the relationship between AT1R polymorphism and biventricular function in acute anterior MI has not been studied before. METHODS AND RESULTS: The study group comprised 132 consecutive patients who were admitted to the coronary care unit with their first acute anterior MI. Systolic and diastolic diameters, volumes, inflow properties, ejection fraction and myocardial performance index of both ventricles were measured. AT1R polymorphism was determined using polymerase chain reaction amplification. Based on A/C1166 polymorphism of AT1R, the patients were classified into 3 groups: group 1, A/A (n=91) genotype, group 2 A/C (n=28), and group 3 C/C (n=13) genotype. When the left ventricular and right ventricular echocardiographic functions were compared, all parameters of the 3 groups were found to be similar. No difference was detected in either the genotype distribution or allele frequencies between the patients and the controls for AT1R. CONCLUSIONS: The results suggest that A/C1166 polymorphism of AT1R did not influence the risk of either acute MI or biventricular function after anterior MI.