The clinician's guide to the cardiovascular examination

A detailed examination of the cardiovascular system is indispensable to the full appreciation of the cardiac status. Yet, because this fundamental aspect of cardiology is so inadequately presented by many of the major texts, students often fail to grasp the essentials. The author not only brings a rich knowledge of the subject to his task, but also a wide experience of teaching and a firm conviction that the prime purpose of the undergraduate pre-clinical curriculum is to provide information on which the student may build. The student who masters this information will be well prepared for the clinical years and suitably equipped for more advanced studies

Satisfaction among patients attending a specialist medical clinic

OBJECTIVE: To determine the level of satisfaction among patients attending the Cardiac Specialists Clinic at the University Hospital of the West Indies (UHWI), Mona. METHOD: A 25-item pre-tested questionnaire was administered to a purposive sample (n=39), men (n=10) and women (n=29), 43.3 percent of a total population (n=90) attending the clinic in May and June 2001. Their median age was 59 years, range 31-90 years. RESULTS: There were no significant differences between the responses of the men and the women. Respondents travelled a median of eight miles, range 2-183 miles, to attend the clinic, and waited for a median of four hours, range 1-8 hours, before receiving attention. They had attended the clinic a median of four times. Despite this, they reported a high level of satisfaction with all categories of hospital personnel (median rating: 8/10). They, however, rated the caring behaviour of the physicians significantly higher than that of nurses (z=3.2, p<0.001). The majority (71.8 percent) regarded the clinic fees as "reasonable". Fifty percent were eligible for the Drugs for the Elderly Programme but only 21.5 percent were on it. This programme is not offered at the UHWI hospital pharmacy. Only two persons rated the overall facilities as "excellent". They all would recommend the services of the clinics to friends and relatives for "good treatment from knowledgeable doctors and nurses" and "cleanliness of the surroundings". CONCLUSION: Overall, patients were satisfied with the services. The waiting time and time taken to find the dockets were the areas of greatest concern. (AU)

Fifty years of clinical examinations at the University of the West Indies

The University of the West Indies was founded at Mona, Jamaica in 1948. After fifty two years, the format of the final Bachelor of Medicine clinical examination in Medicine and Therapeutics has been radically revised. The change from the traditional to an evidence-based, objective structured clinical examination (OSCE) was undertaken in November/December 2000. Assessment drives learning and both the methods chosen for assessment and the manner in which they are applied determine how students learn. The philosophical underpinnings of the change in format are discussed in this paper. (AU)

Intracoronary stent implantation in Jamaica: the initial experience

Intracoronary stent implantation resulted in the complete or near complete dilatation of high gread occlusions of the left anterior descending coronary arteries in the four patients in whom it was undertaken. Intracoronary stent implatation is a useful adjuct to Percutaneous Transluminal Angioplasty (PTCA) and is applicable in selected patients with symptomatic ischaemic heart disease in a developing country with limited health resources like Jamaica. This is so since financial data presented here document the significant savings this technique (when appropriately utilised) could realise compared to the use of baloon angioplasty alone. (AU)

Beta-adrenergic blockade in the treatment of congestive heart failure

Although chronic sympathetic activation provides inotropic and chronotropic support to the failing heart, such activation may also have deleterious effects, including the direct cardiotoxic effects of catecholamines, activation of the renin-angiotensin-adosterone system and an increase in myocordial oxygen demand. These observations indicate that beta-blockade might be beneficial in the treatment of heart failure. This suggestion is receiving growing support from clinical trials, which show that beta-blockade improves the clinical and functional status of patients with heart failure resulting from dilated cardiomyopathy or ischaemic heart disease. These trials have also indicated beta blocking agents are much safer in patients with heart failure than was previously thought, provided that they are introduced at a low dose and titrated carefully. Newer beta blocking agents have ancillary properties that may be important in the treatment of heart failure. Bucindolol and carvedilol have vasodilating effects that may upload the failing heart, and carvedilol also has antiproliferative and antioxidant properties not shared by other beta blocking agents. Carvedilol is the only beta blocking agent that has reduced overall mortality in patients with heart failure in controlled clinical trials, and it also reduces hospitalization and improves the global assessment of patients. A large comparative trial against other beta blocking agents to confirm that these benefits are unique to carvedilol is about to be launched. Further clinical experience is required to determine the optimum use of carvedilol in the treatment of heart failure. The results obtained so far with carvedilol suggest that the management of heart failure is about to undergo a significant change

Beta-adrenergic blockade in the treatment of congestive heart failure

Although chronic sympathetic activation provides inotropic and chronotropic support to the failing heart, such activation may also have deleterious effects, including the direct cardiotoxic effects of catecholamines, activation of the renin-angiotensin-adosterone system and an increase in myocordial oxygen demand. These observations indicate that beta-blockade might be beneficial in the treatment of heart failure. This suggestion is receiving growing support from clinical trials, which show that beta-blockade improves the clinical and functional status of patients with heart failure resulting from dilated cardiomyopathy or ischaemic heart disease. These trials have also indicated beta blocking agents are much safer in patients with heart failure than was previously thought, provided that they are introduced at a low dose and titrated carefully. Newer beta blocking agents have ancillary properties that may be important in the treatment of heart failure. Bucindolol and carvedilol have vasodilating effects that may upload the failing heart, and carvedilol also has antiproliferative and antioxidant properties not shared by other beta blocking agents. Carvedilol is the only beta blocking agent that has reduced overall mortality in patients with heart failure in controlled clinical trials, and it also reduces hospitalization and improves the global assessment of patients. A large comparative trial against other beta blocking agents to confirm that these benefits are unique to carvedilol is about to be launched. Further clinical experience is required to determine the optimum use of carvedilol in the treatment of heart failure. The results obtained so far with carvedilol suggest that the management of heart failure is about to undergo a significant change(AU)

The prophylaxis of acute rheumatic fever in a pair of monozygotic twins: the public health implications

Recurrent acute rheumatic fever and rheumatic heart disease can be prevented by antibiotic intervention. We report the case of genetically identical twins, one of whom had overt rheumatic fever, received penicillin prophylaxis and did not have rheumatic heart disease. The other must have had inapparent rheumatic fever, received no chemotherapy prophylaxis and proceeded to develop rheumatic heart disease. A greater clinical and laboratory vigilance is required for the diagnosis of acute rheumatic fever in the asymptomatic identical twin of a patient with rheumatic fever. This case provides further evidence of a genetic predisposition of rheumatic fever and demonstrates the continued value of penicillin in the prophylaxis of acute rhuematic fever. It emphasises the need to maintain the integrity of preventive programmes against rheumatic fever worldwide. Studies which explores the HLA and other genetic linkages with rheumatic fever should be encouraged.(AU)

The development of invasive cardiology at the University of the West Indies

The development of invasive cardiology at the University of the West Indies encompasses four relatively distinct periods: the early years (1961-1975), the period of development (1975-1988), the period of absence (1988-93) and the modern era (1994 to the present). During the early years, invasive procedures were carried out in the general X-Ray Department using a Phillips 6 Channel Cardioscope and a Single Plane Angiographic Machine. The period of development was heralded by the completion of a new, separate cardiac laboratory within the X-Ray Department. In addition, it was characterised by an increase in the number of patients studied, and the availability of BiPlane Angiography. Equipment failure in the late 1980s precipitated the cessation of cardiac catheterisation at the University of the West Indies in 1988 and no invasive procedures were performed in the period 1988-1993. (The availability of up to date colour flow doppler echocardiographic facilities during this period greatly facilitated pre-operative diagnosis of congenital and valvular heart disease.) The re-opening of a cardiac catheterisation facility in early 1994 was accompanied by major advances with the availability of cine-angiography. Additionally, during this period, interventional cardiology was introduces with balloon percutaneous transluminal coronary angioplasty, and balloon valvuloplasty (mitral and pulmonary) being successfully performed on several patients. Future development of invasive cardiology at UWI will see an increase in efficiency of the operation of the cardiac laboratory and expansion of the therapeutic armamentarium in interventional cardiology.(AU)

Percutaneous balloon mitral valvuloplasty for severe rheumatic mitral stenosis in Jamaica: the initial experience

Although percutaneous balloon mitral valvuloplasty has been performed in the Caribbean before, there has not been any detailed description in the English-speaking West Indian Medical literature hitherto. This report provides a description of the first four case of percutaneous balloon mitral valvuloplasty performed in Jamaica(AU)

Percutaneous transluminal coronary angioplasty (PTCA) in Jamaica: preliminary results

This is the first detailed report from the Anglophone Caribbean of percutaneous transluminal coronary angioplasty (PTCA). The procedure resulted in complete dilatation of the occluded vessels in the five patients in whom it was undertaken, with significant improvement in exercise duration in the Bruce protocol (p<0.001; 95 percent CI 2.5 to 4.1 minutes) in the four patients who were studied. PTCA can be undertaken in developing countries with limited resources, and should be offered to selected patients with symptomatic coronary artery disease who need a revascularisation procedure.(AU)

Cardiac problems in diabetic pregnancies

Cardiac disease in pregnancy at the University Hospital of the West Indies (UHWI), Mona, occurs as a clinically significant problem, but it aetiology is usually rheumatic or congenital. As is the case elsewhere, coronary artery disease occurring in a non-diabetic pregnancy at UHWI is a rarity. The presence of diabetes mellitus increases the risk of coronary artery disease; however, even in diabetic pregnancy clinical manifestations of coronary disease are most unusual and we have accumulated no significant clinical experience. In spite of this lack of experience at present, it would be of value to speculate concerning the future. An increased incidence of coronary disease in women of childbearing age is a distinct possibility for the future and the application of presently available therapeutic modalities (and new techniques to the pregnant patient should provide interesting challenges (AU)

The echocardiographic features of polymyositis - abstract

Two dimensional echocardiography with doppler studies were performed in 30 patients at the UWI with the diagnosis of dermatomyositis/polymyositis established by the usual clinical and investigative criteria. This was done in order to elucidate the echocardiographic features of this condition which had not been clearly defined before. There were 25 females and 5 males, age range 28-65 years (mean - 48 years), with the majority of patients (70 percent) being in the 41 - 70 year age group. No valvular abnormalities were observed, and left ventricular internal dimension in systole LVIDs-1.9-3.7 cm, mean-2.8cm) and contractility (ejection fraction - range 43 - 89 percent, mean - 69 percent) were normal. No regional wall motion abnormalities were observed. Only 3 patients (10 percent) had evidence of global reduction in systolic function. There was hypertrophy of the interventricular septum in 9 patients (30 percent), and in the left ventricular posterior wall in 6 patients (20 percent). The dimensions of the left atrium (2.6-3.7 cm; mean - 3.2 cm), aorta (2.5-3.6 cm; mean 3.2 cm) and right ventricle (range 1.6-2.5 cm; mean - 2.1 cm) were normal. Doppler studies did not reveal any significant valvular regurgitation, and pulmonary artery velocities documented normal mean pulmonary artery pressures (mean 18 mm Hg) in all patients. Left ventricular diastolic function as indicated by E/A ratios (0.55-1.39;mean-1.23) from mitral valve inflow studies was normal. Conclusion: Echocardiographic doppler studies in patients with dermatomyositis/polymyositis were largely normal apart from minor degrees of left ventricular hypertrophy in a minority of patients (AU)

The development of echocardiography at the UWI - abstract

Echocardiography was first performed at University Hospital of the West Indies in 1981. The M-mode technique was employed, utilizing a Smith-Kline-French echocardiograph with a strip chart recorder. Two-dimensional echocardiographic studies began to be offered in 1984, utilizing a General Electric (General Ultrasound) machine sited in the X-ray Department. The resolution of the images obtained, however, was limited. From 1988 to 1989, better resolution was attained by the use of an Ultramark 4 echocardiograph which the Medical Research Council Laboratories (Jamaica) allowed use of for University Hospital patients. Basic pulsed wave doppler capability could also be offered. In 1989, the UWI Department of Medicine obtained an Ultramark 6 echocardiograph which allowed full two-dimensional imaging, pulsed and continuous wave doppler and colour flow mapping. Between July 1989 and December 1992, 5,276 echocardiograms (50 percent males, 50 percent females) were performed, using this machine, and a wide variety of cardiovascular diagnoses were made. Future plans include the development of transoesophageal echocardiography at the UHWI which will greatly expand diagnostic capabities (AU)

Pulmonary artery pressure and the acute chest syndrome in homozygous sickle cell disease

OBJECTIVE; to investigate whether attacks of acute chest syndrome affected pulmonary artery pressure in patients homozygous for sickle cell disease. MAIN OUTCOME MEASURES: Pulmonary artery pressure, assessed by non-invasive echocardiographic techniques. PATIENTS; 20 patients with homozygous sickle cell disease with a history of at least six episodes of acute chest syndrome and in 20 age, sex, and height matched controls with homozygous sickle cell disease without a history of acute chest syndrome. RESULTS: There was no difference in any of the echocardiographic or Doppler indices between these two groups. CONCLUSIONS: Repeated attacks of acute chest syndrome by the mean age of 12 ( range eight to 16 ) years have not had a discernible effect upon pulmonary artery pressure (AU)

Cardiovascular disease and steroid hormone contraception in Jamaica - abstract

Since hormone contraception became widely available in the early 1960s, there has been concern about its safety. On the other hand, its role in fertility management is crucial. Several reports suggest an association between hormonal contraception and cardiovascular disease, including venous thromboembolism, strokes and myocardial infarction. As part of a WHO multicentre study, we have examined the possible association between hormonal contraceptive use and cardiovascular disease in the Jamaican population. Since February 1988, all women from 20 years to 44 years old at last birthday, admitted to any hospital in Kingston and St. Andrew for venous thromboembolism, stroke or myocardial infarction were interviewed. Women were eligible for study, if this was the first episode of such an event and they were not pregnant or puerperal and had not had surgery or confinement to bed in the previous six weeks. Information on all hormonal contraceptive use was elicited during this interview and relevant clinical information from patient records. Three age-matched controls admitted within two months of the case's admission and 2 community controls living in the same neighbourhood were selected. To December 1988, there have been 51 cases: 25 with thromboembolic disease and 26 with strokes. No myocardial infarctions were detected; 188 controls have been required. Use of hormonal contraception, past or present, was not shown to be associated with increased risk of these cardiovascular events. Contraceptive use was reported by 66 per cent of cases and 60 percent of controls. Current use (within the past 3 months) was reported in 25 percent of cases and 26 percent of controls. A history of hypertension was present more often among cases (14 percent versus 3 percent, p < 0.01). We have failed to show any association between the use of hormonal contraception and cardiovascular events in young Jamaican females. Hypertension has emerged as the only discriminating risk factor (AU)

Gender-related renal damage in severe essential hypertension in black patients - abstract

Malignant nephrosclerosis occurs twice as often in black Barbadian males as in their female counterparts. We therefore examined the possibility that renal impairment might occur more commonly in black males than in black females with severe hypertension. Between January 1982 and May 1987, 106 patients (67 females and 39 males) were referred to the Renal/Hypertension Clinic of the Queen Elizabeth Hospital for management of "intractable" hypertension. Patients whose diastolic blood pressures fell below 90 mm Hg on two-drug therapy were dropped from the study as were patients with secondary hypertension. Of the 46 patients requiring 3 drugs for blood pressure control, 28 were female and 18 were male. Assessment of renal function was made in these patients, using the formula of Cockcroft and Gault for estimation of creatinine clearance. Renal impairment was diagnosed when estimated creatinine clearance was more than 20 percent below the mean value given by Kampmann et al for adults at different ages. Left ventricular mass index was determined by echocardiography in 27 females and all males, and left ventricular hypertrophy was diagnosed when LVMI was greater than 132 g/m2 in males and greater than 109 g/m2 in females. Echocardiographic diagnosis of left ventricular hypertrophy was made in 22 females (85 percent) and in 13 males (73 percent); there was no difference with respect to the prevalence of left ventricular hypertrophy (chi-square test). In contrast, when age, gender, weight and body surface area were allowed for in the estimation of creatinine clearance, there was a gender-related difference in the prevalence of renal insufficiency. Seventeen females and all 18 males had renal insufficiency (p<0.002; Fisher's exact probability test). In this series of patients with severe essential hypertension, males appear more susceptible than females to the development of renal impairment (AU)