Resurgence of Shoshin beriberi during the COVID-19 pandemic.

This report describes two patients who presented with severe type B lactic acidosis and shock, initially thought to be due to bowel ischaemia/myocardial infarction and pulmonary sepsis, respectively. This led to a delay in the diagnosis of thiamine deficiency. In both cases there was a dramatic response to intravenous thiamine, confirming the diagnosis of Shoshin beriberi. Both patients admitted to drinking home-brewed alcohol during the time of COVID-19 restrictions on alcohol consumption. These cases highlight the need for early diagnosis and immediate empirical treatment with intravenous thiamine in patients presenting with unexplained severe metabolic acidosis and circulatory shock.

The effect of lifestyle modification on depression among myocardial infarction patients after revascularisation.

BACKGROUND: Patients with coronary artery disease (CAD) are prone to depression, and its presence is associated with poor adverse cardiac outcomes. Although lifestyle modification (LSM) has been shown to be beneficial in managing depression in patients with CAD, it is not known whether the mode of cardiac intervention [(coronary artery bypass graft surgery (CABG) versus percutaneous coronary intervention (PCI)] influences the outcome. OBJECTIVES: We examined the prevalence of depression among myocardial infarction (MI) patients after revascularisation and compared the effect of LSM on incidence of depression in patients who underwent CABG versus PCI. METHODS: We evaluated the risk-factor profile, depression characteristics and lifestyle changes of 100 consecutive participants undergoing coronary revascularisation over a 15-month period (January 2017 to May 2018). The Beck depression inventory II (BDI-II) was used to assess depression and the Goldin leisure-time exercise (GLTE) questionnaire to assess physical activity (PA). RESULTS: One hundred patients were recruited (mean age: males 60.73 ± 4.52 years, females 60.29 ± 3.64 years) but five dropped out, leaving 95 patients for complete analysis. Most of the patients were low-income earners [53 (53.0%)], and 21 (21.0%) had tertiary-level education. The majority had multiple CAD risk factors and co-morbidities (79.0%). Prior to the LSM programme, 51 patients (51.0%) had depression and depressive traits [CABG 34 (66.7%) vs PCI 17 (33.3%), p = 0.047]. After LSM the overall prevalence of depression and depressive traits fell to 33 patients (34.7%) [PCI eight (23.0%) vs CABG 25 patients (72.0%), p = 0.001]. The mean depression scores also fell from 21.11 ± 7.75 to 14.98 ± 9.61 (p = 0.002). At baseline, PCI patients were more physically active compared to CABG patients [three (60.0%) vs two patients (40.0%), respectively, p = 0.715]. After LSM, more PCI patients undertook PA compared to CABG subjects [24 (60.0%) vs 14 patients (35.0%), respectively, p = 0.012]. The PA score was also higher among the PCI group compared to the CABG group [14.16 ± 9.73 vs 9.40 ± 10.94, respectively, p = 0.024]. In fully compliant subjects, the benefit derived was similar regardless of the mode of intervention [OR 1.10, 95% CI: 0.78-4.23, p = 0.191]. Using multivariate analysis, the main predictors of depression and depressive traits were female gender (OR 3.29, 95% CI: 1.51-11.03, p = 0.008), CABG (OR 1.86, 95% CI: 1.68-5.77, p = 0.003), heart failure (OR 2.65, 95% CI: 5.87-13.62, p = 0.000), kidney failure (OR 1.41, 95% CI: 1.30-5.23, p = 0.041), atrial fibrillation (OR 1.60, 95% CI: 1.40-4.77, p = 0.023), low PA (OR 1.97, 95%, CI: 11.23-33.20, p = 0.000), previous history of depression (OR 8.99, 95% CI: 1.90-7.89, p = 0.002) and low income (OR 2.21, 95% CI: 1.40-2.85, p = 0.000). CONCLUSIONS: Depression and depressive traits are common among subjects undergoing coronary revascularisation, more so among CABG than PCI participants. LSM reduced the prevalence of depression and depressive traits, with fully compliant CABG versus PCI groups deriving nearly the same benefits from the LSM regime. No significant reduction in incidence of depression was recorded among LSM partly compliant patients. This study suggests that failure to implement lifestyle changes and engage in PA are major barriers to managing depression after coronary revascularisation.

The effects of HIV/AIDS on the clinical profile and outcomes post pericardiectomy of patients with constrictive pericarditis: a retrospective review.

OBJECTIVE: The clinical profile and surgical outcomes of patients with constrictive pericarditis were compared in HIV-positive and -negative individuals. METHODS: This study was a retrospective analysis of patients diagnosed with constrictive pericarditis at Inkosi Albert Luthuli Central Hospital, Durban, over a 10-year period (2004-2014). RESULTS: Of 83 patients with constrictive pericarditis, 32 (38.1%) were HIV positive. Except for pericardial calcification, which was more common in HIV-negative subjects (n = 15, 29.4% vs n = 2, 6.3%; p = 0.011), the clinical profile was similar in the two groups. Fourteen patients died preoperatively (16.9%) and three died peri-operatively (5.8%). On multivariable analysis, age (OR 1.17; 95% CI: 1.03-1.34; p = 0.02), serum albumin level (OR 0.63; 95% CI: 0.43-0.92; p = 0.016), gamma glutamyl transferase level (OR 0.97; 95% CI: 0.94-0.1.0; p = 0.034) and pulmonary artery pressure (OR 1.49; 95% CI: 1.07-2.08; p = 0.018) emerged as independent predictors of pre-operative mortality rate. Peri-operative complications occurred more frequently in HIV-positive patients [9 (45%) vs 6 (17.6%); p = 0.030]. CONCLUSIONS: Without surgery, tuberculous constrictive pericarditis was associated with a high mortality rate. Although peri-operative complications occurred more frequently, surgery was not associated with increased mortality rates in HIV-positive subjects.

Atherosclerotic disease is the predominant aetiology of acute coronary syndrome in young adults.

OBJECTIVES: Few studies have evaluated young adults in their third and fourth decades with coronary artery disease (CAD). This study evaluated the clinical and angiographic profile of young adults ( < 35 years) with CAD. METHODS: A 10-year (2003-2012) retrospective chart review was performed on patients less than 35 years diagnosed with CAD at Inkosi Albert Luthuli Central Hospital, Durban. RESULTS: Of the 100 patients who met the study criteria, the majority were male (90%), of Indian ethnicity (79%), and presented with acute coronary syndrome (93%). Smoking (82%), dyslipidaemia (79%) and dysglycaemia (75%) were the most prevalent risk factors. Almost half of the subjects (48%) met criteria for the metabolic syndrome. Angiographic findings revealed multi-vessel (42%), single-vessel (36%) and non-occlusive disease (20%); only two subjects had normal epicardial vessels. Disease severity was influenced by dyslipidaemia (p = 0.002) and positive family history (p = 0.002). Non-coronary aetiologies were identified in 19% of subjects. CONCLUSION: Atherosclerotic disease associated with risk-factor clustering was highly prevalent in young adults with CAD.

Maternal cardiac haemodynamics in severe pre-eclampsia complicated by acute pulmonary oedema: A review.

AIM: To establish alterations in maternal cardiac haemodynamics and function using electrocardiography and echocardiography in severe pre-eclampsia complicated by acute pulmonary oedema. METHODS: An extensive literature search including any research articles, randomised control trials, observational study, case report or expert or consensus statement pertaining to severe pre-eclampsia, eclampsia, hypertensive crises of pregnancy, pulmonary oedema, maternal cardiac haemodynamics, Holter monitoring and maternal echocardiography was done. Electronic search strategies included searching the MEDLINE, EMBASE, Cochrane Library and Pubmed databases. RESULTS: Toxic substrates from a chronically ischaemic placenta and elevated maternal cathecolamines leads to widespread elevated systemic vascular resistance, endothelial cell damage and increased left ventricular afterload all of which combine to result in left ventricular hypertrophy with impaired ventricular filling reflected as significant diastolic dysfunction, increased left ventricular end systolic and end diastolic volumes, increased left ventricular stroke work, myocardial ischaemia and resultant ventricular arrhythmias, in particular ventricular tachycardia. These factors could lead to cardiac failure in severe pre-eclampsia, either in combination or in independently of each other depending on the magnitude of the angiogenic imbalances, degree of elevated systemic vascular resistance, degree of impaired myocardial relaxation and diastolic filling anomalies, gene-environment interaction and degree of possible pre-existing or potential cardiovascular dysfunction. CONCLUSION: Comprehensive maternal echocardiographic and electocardiographic assessment should be incorporated in the work-up of severe pre-eclampsia to stratify these cases, to enable clinicians to choose the appropriate acute hypertensive drug therapy and plan optimal management pathways.

Endovascular Therapy for Large Vessel Vasculopathy in HIV-infected Patients.

OBJECTIVES: To evaluate outcomes after endovascular treatment of patients with aneurysmal or occlusive vasculopathy in HIV-infected patients. METHODS: Retrospective analysis of a prospective database of treatment outcomes in patients with HIV related vasculopathies between April 2005 and September 2015. RESULTS: Sixty HIV patients presented with post-traumatic pseudoaneurysm formation (n = 7), aneurysmal disease (n = 24) or occlusive disease (n = 29 (48%)). The majority were male (42/60 (70%)), with a mean age of 43.9 years (SD ± 12.6). All seven patients with a post-traumatic pseudoaneurysm were treated by insertion of a covered stent (n = 6) or coiling (n = 1). All were successfully treated at 30 days, but only one patient returned for late surveillance. 23/24 patients who underwent insertion of a stent graft/covered stent for aneurysmal disease returned for 30 day review (one asymptomatic stent graft occlusion). Only 11 patients attended for late surveillance; 9/11 were asymptomatic with patent stent grafts. Late stent occlusion occurred in two (no further action (n = 1), major limb amputation (n = 1). In the 29 patients who underwent endovascular treatment for occlusive disease, 9 (31%) had immediate treatment failure (including 8 amputations (28%)). Of the sixteen who returned for serial review, 8 (50%) suffered further complications including 4 amputations. Overall, 12/29 treated patients (41%) ultimately underwent amputation. CONCLUSIONS: In the immediate short term, an 'endovascular first' strategy was associated with good outcomes in HIV patients with aneurysmal disease. By contrast, outcomes were poor in HIV patients with occlusive disease. Whether this relates to the underlying natural history of HIV occlusive vasculopathies remains unclear. One major problem in trying to formulate meaningful management strategies is a generalised reluctance for HIV patients to return for surveillance.

Management of pulmonary hypertension.

Pulmonary arterial hypertension (PAH) is a potentially lethal disease mainly affecting young females. Although the precise mechanism of PAH is unknown, the past decade has seen the advent of many new classes of drugs with improvement in the overall prognosis of the disease. Unfortunately the therapeutic options for PAH in South Africa are severely limited. The Working Group on PAH is a joint effort by the South African Heart Association and the South African Thoracic Society tasked with improving the recognition and management of patients with PAH. This article provides a brief summary of the disease and the recommendations of the first meeting of the Working Group.

An echocardiographic study of infective endocarditis, with special reference to patients with HIV.

OBJECTIVE: The aim was to describe the echocardiographic features of patients with infective endocarditis (IE), and to compare the manifestations of IE in HIV-positive versus HIV-negative patients. METHODS: The study was prospective in nature and screened patients referred to Inkosi Albert Luthuli Hospital (IALCH) with suspected IE between 2004 and 2007. Only patients with a definite diagnosis of IE according to the modified Duke criteria were enrolled for the purpose of the study. Inkosi Albert Luthuli hospital is an 842-bed tertiary referral centre, serving a KwaZulu-Natal population of 10 million people, who are of various races. RESULTS: During this period, 91 patients were screened for IE. Seventy-seven (HIV infected, n = 17) satisfied the criteria for a definite diagnosis of IE. Blood cultures were positive in 46% of cases. The commonest organism was S aureus. Most patients had advanced valve disruption with heart failure and high peri-operative mortality. The clinical profile in the HIV-infected patients was similar to the that of the non-infected patients. The prevalence of echocardiographic complications (abscesses, aneurysms, perforations, fistulae and chordal ruptures) was 50.6% in the whole group. Except for the presence of leaflet aneurysms and root abscesses in four advanced (CD4 counts > 250 /mm(3)) HIV-infected cases, complications were not more frequent in the HIV-infected group. CONCLUSION: There was a high rate of culture-negative cases in this study, probably related to prior antibiotic usage; in this setting the modified Duke criteria have diagnostic limitations. No significant differences in the clinical presentation of infective endocarditis were noted between HIV-infected and HIV-negative patients.

Cardiovascular haemodynamics in pre-eclampsia using brain naturetic peptide and tissue Doppler studies.

AIM: To determine early haemodynamic changes in preeclampsia (PE) using tissue Doppler echocardiography and brain natriuretic peptide (BNP), and to relate these changes to obstetric outcomes. METHODS: Consenting primigravidae patients in the third trimester of pregnancy were included in the study, which was carried out in a large regional hospital in Durban, South Africa; 115 primigravidae (52 pre-eclamptics and 63 normotensive pregnant patients) attending the maternity unit including the antenatal clinics at the study site were studied. The patients, matched for maternal and gestational age, were examined during pregnancy and within the puerperium. Transthoracic echocardiography (TTE), tissue Doppler imaging (TDI), umbilical artery Doppler and laboratory investigations were performed. RESULTS: BNP levels were significantly increased in the antepartum period [23.8 (2-184.1) vs 6.0 (0.5-45.2) pmol/l; p < 0.0001] and during labour [15.0 (1.8-206.4) vs 8.7 (1.9-24.8) pmol/l; p < 0.01] in the pre-eclamptic group compared to the normotensive controls. In the postpartum period, mean BNP levels were 4.2 (1.7-51.4) and 5.95 (2.2-38.7) pmol/l in the preeclamptic and normotensive groups, respectively (p > 0.05). Tissue Doppler Em/Ea ratios were elevated in the pre-eclamptic compared to the normotensive group (11.02 ± 5.6 vs 9.16 ± 2.6; p < 0.05). Mean left atrial size was larger (38 mm) in the pre-eclamptic group than in the normotensive group (35 mm) but this difference was not significant (p > 0.05). The umbilical artery resistance index was significantly higher in the pre-eclamptic group compared to the normotensive group (0.68 ± 0.06 vs 0.63 ± 0.05; p < 0.001). There was an increased rate of Caesarean sections performed in the pre-eclamptic group (n = 24) compared to the normotensive group (n = 18; p < 0.001). There were two stillbirths in the pre-eclamptic group and none in the normotensive group. As expected, birth weight (2.6 ± 0.8 kg vs 3.14 ± 0.42 kg; p < 0.0001) was lower in the pre-eclamptic group compared to the normotensive group. CONCLUSION: In pregnancies complicated by pre-eclampsia, BNP levels were increased in comparison to normotensive pregnancies and this was accompanied by early changes in left ventricular diastolic function as determined by the tissue Doppler Em/Ea ratios. These changes reverted to baseline values, as indicated by return of BNP levels in the pre-eclamptic group to levels seen in the normotensive group. These changes were associated with an increased Caesarean section rate and lower birth weights in pre-eclamptic mothers.

Telomeres and atherosclerosis.

In humans and other multicellular organisms that have an extended lifespan, the leading causes of death are atherosclerotic cardiovascular disease and cancer. Experimental and clinical evidence indicates that these age-related disorders are linked through dysregulation of telomere homeostasis. Telomeres are DNA protein structures located at the terminal end of chromosomes and shorten with each cycle of cell replication, thereby reflecting the biological age of an organism. Critically shortened telomeres provoke cellular senescence and apoptosis, impairing the function and viability of a cell. The endothelial cells within atherosclerotic plaques have been shown to display features of cellular senescence. Studies have consistently demonstrated an association between shortened telomere length and coronary artery disease (CAD). Several of the CAD risk factors and particularly type 2 diabetes are linked to telomere shortening and cellular senescence. Our interest in telomere biology was prompted by the high incidence of premature CAD and diabetes in a subset of our population, and the hypothesis that these conditions are premature-ageing syndromes. The assessment of telomere length may serve as a better predictor of cardiovascular risk and mortality than currently available risk markers, and anti-senescence therapy targeting the telomere complex is emerging as a new strategy in the treatment of atherosclerosis. We review the evidence linking telomere biology to atherosclerosis and discuss methods to preserve telomere length.

The time-course changes of NT-proBNP and tissue Doppler indices in patients undergoing mitral valve replacement.

BACKGROUND: In severe mitral regurgitation, a subset of patients who are asymptomatic may develop left ventricular decompensation before changes in echocardiographic parameters become evident. Since N-terminal brain natriuretic peptide (NT-proBNP) is used to detect early heart failure, we hypothesised that NT-proBNP would be activated in patients with mitral regurgitation. METHODS: Patients submitted to surgery were prospectively evaluated over eight months in the Department of Cardiology at Inkosi Albert Luthuli Central Hospital. Control patients with severe mitral regurgitation were obtained from the outpatient clinic. In order to define their value in identifying left ventricular decompensation, NT-proBNP levels and tissue Doppler imaging (TDI) indices were simultaneously measured and compared with conventional echocardiographic indices at baseline and this was repeated at one week and at six weeks after valve replacement. RESULTS: Mean NT-proBNP levels were markedly elevated pre-operatively in all surgical cases compared to controls (p = 0.0001). The diastolic E-mitral/E-annulus ratio, measured using TDI, was higher in the study group, indicating higher left ventricular filling pressure present in the study group. NT-proBNP levels increased further at one week after surgery and subsided at the six-week follow-up visit to levels similar to the control group. The TDI diastolic ratio also decreased at one week, and increased slightly again at the six-week follow up. These changes were accompanied by significant reduction in left atrium and left ventricular chamber dimensions with an increase in the ejection fraction from one to six weeks. CONCLUSION: Marked differences in mean NT-proBNP levels and TDI ratios between the study and control groups suggest that using TDI and NT-proBNP assays may detect covert left ventricular decompensation.

WH Craib: a critical account of his work - with reference to : a study of the electrical field surrounding skeletal muscle, W.H. Craib.

One hundred years after its introduction, the ECG remains the most commonly used cardiovascular laboratory procedure. It fulfils all the requirements of a diagnostic test: it is non-invasive, simple to record, highly reproducible and can be applied serially. It is the first laboratory test to be performed in a patient with chest pain, syncope or cardiac arrhythmias. It is also a prognostic tool that aids in risk stratification and clinical management. Among the many South Africans who have made remarkable contributions in the field of electrocardiography, Don Craib was the first to investigate the changing patterns of the ECG action potential in isolated skeletal muscle strips under varying conditions. It was during his stay at Johns Hopkins Hospital in Baltimore and Sir Thomas Lewis laboratory in London that Craib made singular observations about the fundamental origins of electrical signals in the skeletal muscle, and from these developed his hypothesis on the generation of the action potential in the electrocardiogram. His proposals went contrary to scientific opinion at the time and he was rebuffed by the scientific community. Frank Wilson subsequently went on to develop Craib's doublet hypothesis into the dipole theory, acknowledging Craib's work. Today the dipole theory is fundamental to the understanding of the spread of electrical activation in the myocardium and the genesis of the action potential.

The Implications of HIV Infection on the Management of Valvular Heart Disease in Southern Africa

There is very limited information on the disease profi le and treatment approaches in HIV patients with valvular heart disease (VHD) in developing countries. HIV infection impacts on patients with VHD in three settings: HIV/ Aids as a comorbid disease in patients with underlying valve disease; infective endocarditis secondary to immunosuppression; and non-infective valve involvement from myocardial failure or from marantic endocarditis. The clinical presentation of infective endocarditis does not differ between HIV and non-HIV patients; with the exception that intravenous drug abuse is a common cause in specific populations. While peri-operative mortality and morbidity is high in acute infective endocarditis; surgical interventions do not increase the postoperative risk for complications or death and should therefore not be withheld. There is also little evidence to suggest that HIV or antiretroviral drugs increase the rate of cardiac-related pregnancy complications or that pregnancy may alter the course of HIV infection. Since antiretroviral therapy has been associated with considerable improvement in clinical status prior to surgery; as well as in long term outcomes; all patients with valve disease in whom intervention is likely should undergo HIV testing and staging so that highly active antiretroviral treatment (HAART) may be instituted timeously. Conclusion: The high prevalence of HIV in our population makes consideration of this comorbidity an essential facet in the routine evaluation and management of patients with VHD. There is solid evidence that these patients do no worse than non-HIV patients undergoing medical treatment or percutaneous/surgical intervention - open-heart surgery may be offered safely to patients with HIV if proper precautions are taken

Cardiac disease in pregnancy.

This study was a retrospective review of patient charts of a relatively large number of patients with cardiac disease in pregnancy in a developing country. Ninety-five patients were evaluated; the majority (n = 36) were in the age group 21-25 years. Rheumatic heart disease was the commonest aetiology; eight women required balloon mitral valvuloplasty and one had a valve replacement at 32 weeks' gestation. There were no maternal deaths but morbidity was high; 13 patients were admitted in cardiac failure, nine had atrial fibrillation and three required intensive-care management. There were 86 live births of the 97 deliveries. Cardiac disease in pregnancy is associated with high maternal morbidity and adverse foetal outcomes; this was related to late presentation and problems with anticoagulation. Clinical assessment remains a key factor in timeous referral and appropriate investigations.

Cardiac Disease in Pregnancy : Cardiovascular Topic

This study was a retrospective review of patient charts of a relatively large number of patients with cardiac disease in pregnancy in a developing country. Ninety-five patients were evaluated; the majority (n = 36) were in the age group 21-25 years. Rheumatic heart disease was the commonest aetiology; eight women required balloon mitral valvuloplasty and one had a valve replacement at 32 weeks' gestation. There were no maternal deaths but morbidity was high; 13 patients were admitted in cardiac failure; nine had atrial fibrillation and three required intensive-care management. There were 86 live births of the 97 deliveries. Cardiac disease in pregnancy is associated with high maternal morbidity and adverse foetal outcomes; this was related to late presentation and problems with anticoagulation. Clinical assessment remains a key factor in timeous referral and appropriate investigations

Metabolic syndrome in young Asian Indian patients with myocardial infarction.

OBJECTIVES: This study assessed the prevalence of the metabolic syndrome and its impact on hospital outcomes in young South African Indians (< or = 45 years) with acute myocardial infarction (AMI) using both the National Cholesterol Education Programme Adult Treatment Panel III (NCEP ATP III) and the International Diabetes Federation (IDF) definitions. METHODS AND RESULTS: The study population comprised 389 patients with AMI. The metabolic syndrome as defined by the NCEP ATP III criteria was found in 235 (60%) patients and in 223 (57%) according to the IDF criteria, with only a 79% concordance between the two definitions. However, when ethnic-specific waist circumference cut-offs proposed by the IDF were used as a criterion for obesity in the NCEP ATP III definition, the number of patients with the metabolic syndrome increased significantly to 270 (69%) (p < 0.001). Elevated fasting blood glucose was the major NCEP ATP III determinant present in 86% of individuals. All determinants for both definitions were found more frequently in patients with the metabolic syndrome (p < 0.001). Although 44% of patients had triple-vessel disease on cardiac catheterization studies, the frequency of adverse cardiovascular events during hospital stay was low, and was uninfluenced by the presence or absence of the metabolic syndrome. CONCLUSION: The metabolic syndrome is a common finding in young Indian patients with AMI who frequently present with extensive atherosclerotic disease. Adverse event rate during hospital stay was low, and was unrelated to the presence of the metabolic syndrome. There was no significant difference in the prevalence rate of the metabolic syndrome as determined by either the NCEP ATP III or IDF definitions, but there was only a moderate level of agreement between the two definitions. Inclusion of ethnic-specific waist circumference cut-offs as the determinant of obesity in the NCEP definition may identify more accurately individuals at increased cardiometabolic risk and improve predication of the metabolic syndrome.

Prognostic value of N-terminal-pro-brain natriuretic peptide measurements in patients with acute coronary syndromes.

BACKGROUND: The aim of this study was to examine the prognostic value of admission N-terminal-pro-brain natriuretic peptide (NT-proBNP) measurements for the outcome of adverse events, and to compare it with that of cardiac troponin T in the assessment of risk in patients with acute coronary syndrome (ACS) during the hospital stay and at six months following hospital discharge. METHODS: The study population consisted of 200 Asian Indian patients admitted with a diagnosis of ACS to the Coronary Care Unit at RK Khan Hospital, Durban, South Africa. A reference group comprising 100 healthy Indian individuals drawn from the same community and who did not suffer from cardiovascular disease was also analysed. RESULTS: The majority of patients presented with ST segment elevation myocardial infarction (STEMI) (71%), whereas 14.5% had non-ST segment elevation MI (NSTEMI), and the remaining 14.5% had unstable angina. Patients had multiple risk factors for coronary heart disease (CHD) including hypertension (59%), hypercholesterolaemia (59%), smoking (57%), diabetes mellitus (51%), obesity (46%), and a strong family history of CHD (55%). NT-proBNP levels were significantly increased in patients with STEMI (p = 0.005) and NSTEMI (p = 0.002) who developed adverse events during their hospital stay, compared with those who did not. At the six-month followup, although NT-proBNP levels were higher in patients with STEMI and NSTEMI who developed adverse events, these differences were not statistically significant. No differences in troponin T levels were detected in patients with STEMI and NSTEMI who developed adverse events, compared to those who did not, either during the hospital stay, or at six months after release. At hospital admission, 24% of patients with unstable angina who had elevated NT-proBNP levels and normal troponin T concentrations developed adverse events, compared to 38% at six months. NT-proBNP levels in the reference group were comparable with those reported in other populations. CONCLUSION: This study demonstrated that elevation in admission NT-proBNP levels is an important determinant of acute and intermediate cardiac risk in patients with ACS. NT-proBNP concentrations were superior to those of troponin T as prognostic markers in both STEMI and NSTEMI. In a low-risk group of patients with unstable angina and negative troponin T concentrations, elevated NT-proBNP levels constituted a risk for the development of adverse cardiovascular events. Therefore, NT-proBNP should be included in the risk assessment of ACS to provide guidance for further therapeutic strategies.

Dyslipidaemia among black patients with type 2 diabetes.

OBJECTIVE: To analyse the lipid profile of black patients with type 2 diabetes mellitus (type 2 DM) irrespective of duration or control of the disease. METHODS: This cross-sectional study evaluated the lipid profile of 62 black patients with type 2 DM. Clinical examination, fasting blood specimens for biochemistry, and urine analysis for proteinuria was determined in all patients. RESULTS: Only 25% of patients had adequately controlled blood pressure (BP < 140/90). Mean fasting plasma glucose (FPG) was 10.9 mmol/l (HbA1c: 10.6%). Mean body mass index (BMI) was 32.5. The total number of patients with diabetic dyslipidaemia (DD) was 56 (90.3%). Significant differences between men and women were noted for high-density lipoprotein cholesterol (HDL-C) (0.99 vs 1.22 mmol/l, p = 0.005) and triglycerides (TG) (2.7 vs 1.8 mmol/l, p = 0.045), respectively. The commonest isolated abnormality was high LDL-C (66.1%) followed by low HDL-C (60.7%) and then high TG (57.1%). CONCLUSION: Over 90% of the black patients with type 2 DM displayed one or more features of DD affecting all major subclasses of cholesterol and triglyceride. The most frequent abnormality depicted by these patients was not the 'typical' DD (i.e. low HDL and high TG) often reported in other ethnic groups.

Demographic data and outcome of acute coronary syndrome in the South African Asian Indian population.

Significant differences in the prevalence of coronary heart disease (CHD) exist with respect to gender, age and ethnicity. The disease has been reported to be higher in Indian populations that have emigrated from the Indian subcontinent. The aim of this study was to examine differences in major cardiovascular risk factors and clinical outcome in South African Asian Indians of different age groups and gender, who presented with acute coronary syndromes (ACS). The study cohort consisted of 2 290 consecutive patients, admitted between 1996 and 2002, who were divided into three age subgroups: young ( 45 to 65 years; 21%). All three age groups were predominantly male, but this was more evident in the younger (88%) and middle age groups (71%), and became less striking as the proportion of females increased with age. Smoking was more common in young men compared with young women (p < 0.01). Diabetes mellitus (21%) and hypertension (18%) were seen less frequently in young patients but this was confined to men only. Total cholesterol was elevated in 65 to 70% of all patients while high-density lipoprotein (HDL) levels were significantly lower in men compared with women for all age subsets. Hospital mortality was extremely low in young (1%) and middle-aged patients (2%), but was expectedly higher in older patients (8%; p < 0.0001). A family history of CHD was the most common familial vascular disease seen. Young patients were more often subjected to diagnostic and therapeutic interventions. They had more aggressive disease, with 48% of those subjected to angiographic studies having triple vessel disease (TVD), and 14% undergoing coronary artery bypass grafting (CABG). Triple vessel disease was also detected most commonly in middle-aged (64%) and old patients (75%). In conclusion, significant differences in risk factor status were found in South African Indians between genders and for different age groups. Also, young Indians in this study differed markedly from other young population groups with CHD, in that they frequently had premature atherosclerosis with diffuse and aggressive disease.