Updates in the management of Dyslipidaemia in the high and very high risk individual for CV risk reduction.

Cardiovascular disease (CVD) has been the main cause of mortality and an important cause of morbidity in Malaysia for several years. To reduce global cardiovascular (CV) risk in the population, primary preventive strategies need to be implemented. Hypercholesterolaemia is one of the major risk factors for CVD. This paper is an expert review on the management of hypercholesterolemia focusing on high and very high risk individuals. In low and Intermediate risk individuals, therapeutic lifestyle changes (TLC) and a healthy lifestyle alone may suffice. In high and very high risk individuals, drug therapy in conjunction with TLC are necessary to achieve the target LDL-C levels which have been shown to slow down progression and sometimes even result in regression of atherosclerotic plaques. Statins are first-line drugs because they have been shown in numerous randomized controlled trials to be effective in reducing CV events and to be safe. In some high risk individuals, despite maximally tolerated statin therapy, target Low Density Lipoprotein Cholesterol (LDL-C) levels are not achieved. These include those with familial hypercholesterolaemia and statin intolerance. This paper discusses non-statin therapies, such as ezetimibe and the newer Proprotein convertase subtilisin/kexin type 9 Inhibitors (PCSK9-i).

Torsade de pointes and sudden death associated with diabetic autonomic diarrhoea--a case report.

A 68-year-old diabetic and hypertensive woman presented with chronic autonomic diarrhoea, syncope and palpitations which were associated with QT prolongation and recurrent episodes of torsade de pointes. She was on glibenclamide, indapamide and probucol (for type V hyperlipidaemia). Despite intravenous infusions of potassium, lignocaine and amiodarone, the unstable rhythm persisted. However, intravenous magnesium sulphate with small doses of intravenous propranolol terminated the torsade de pointes. She was stabilised but following discharge she relapsed, and upon re-admission, succumbed to intractable ventricular fibrillation. Early recognition and aggressive treatment of this condition is emphasised. Multiple aggravating factors ie autonomic diarrhoea resulting in severe potassium and magnesium depletion, kaliuretic effect of indapamide, probable QT prolongation associated with diabetic autonomic neuropathy and probucol; probable underlying coronary artery disease and heightened emotional and sympathetic discharge could have contributed to this very unstable ventricular arrhythmia and sudden death.

Association of diabetic autonomic neuropathy with painless myocardial ischaemia induced by exercise.

Silent myocardial ischaemia is now well-recognised in patients with symptomatic coronary artery disease. Its pathogenesis remains speculative, though diminished sensitivity to pain is thought to be one of the mechanisms involved. Because cardiovascular autonomic dysfunction occurs frequently in diabetic patients, we postulate that it contributes towards painless myocardial ischaemia among them. Forty consecutive diabetic (type II) male patients and ten normal volunteers were studied. Using 5 previously-validated noninvasive tests for autonomic dysfunction, 14 of these diabetic men had definite autonomic neuropathy (at least 2 abnormal tests). All 50 subjects were then exercised on a motor-driven treadmill to either exhaustion or chest pains. Thirty-three diabetic subjects were tested positive, with significant (greater than 1 mm) ST segment depression over at least 2 contiguous leads. Of these, 18 were associated with typical angina but the other 15 stopped because of fatigue or exhaustion (ie painless). Thirteen subjects who had definite autonomic neuropathy (AN+) had positive exercise ECG tests-10 had painless ischaemia, and only 3 had angina. This contrasted with 15 patients who had painful ischaemia and 5 who had painless ischaemia among the group without (AN-)autonomic dysfunction (p = 0.0047, Fisher's exact test). There were no significant differences among the various groups for peak rate-pressure-product, all subjects attaining similar maximal oxygen consumption states during which ischaemic ST segment changes were noted (painful AN+: 21917 +/- 4753; painless AN+: 20117 +/- 6752; painful AN-: 16544 +/- 4063; painless AN-: 22220 +/- 4341, p = NS).(ABSTRACT TRUNCATED AT 250 WORDS)

Sexual morbidity after myocardial infarction.

Sixty five patients were interviewed on an average of 42 months after a myocardial infarction. Using a semi structured interview, they were systematically questioned on their usual sexual activity just before their infarction and at the time of follow up. All were married men with a mean age of 54.4 years and had resumed a normal active life. Forty six (70%) reported a decrease in frequency of sexual intercourse (mean 6.9 times/month before infarction and 0.8 times/month at time of interview, p less than 0.01). The majority had difficulty in discussing sex with their doctors because of impaired doctor-patient communication, cultural factors and lack of privacy. Discussion concerning sex should be initiated as soon as the patient is stable and pertinent advice is the key to better sexual adjustment after myocardial infarction.

Noninvasive cardiac risk evaluation before elective abdominal aortic aneurysm surgery--clinical value of the Goldman index and echocardiography.

Cardiac complications comprise as much as 50% of perioperative vascular surgical morbidity and mortality. Using the Goldman multifactorial index for evaluating cardiac risk pre-operatively, 53 consecutive patients who underwent abdominal aortic aneurysm surgery were prospectively studied. Forty patients (75.5%) were also evaluated with echocardiography for assessment of left ventricular function. There were 14 (23.7%) peri-operative events, of which nine (17.0%) were acute myocardial infarctions--two of whom died (3.8%). The minor complications included three with hypovolaemic renal failure, and one each with acute respiratory failure and cerebrovascular accident. Patients with Goldman cardiac risk index (CRI) classes III and IV were associated with significantly higher risks of peri-operative complications (p less than 0.001), i.e. 77.8% and 66.7% respectively, compared with class II (22.7%) and class I (nil). Echocardiographic left ventricular shortening fraction (LVFS) of less than 28% helped identify high risk groups in all classes, although its positive predictive value was low (42.3%). Combining LVFS less than 28% with Goldman CRI categories II to IV improved the sensitivity to 91.7% and the positive predictive value to 61.1%. Careful pre-operative assessment using the simple Goldman index and echocardiography is helpful in identifying higher risk patients who would benefit from pre-operative stabilisation and more rigorous perioperative hemodynamic monitoring preferably including intensive care (ICU) management, so as to reduce cardiac complications.

Torsade de pointes and syncopal attacks in a 26-year old woman with congenital complete heart block and prolonged QT interval.

A 26-year old woman with congenital complete heart block and prolonged QT interval presented for the first time with syncopal attacks associated with torsade de pointes in adulthood. Cardioversion followed by overdrive pacing was needed to finally control the unstable rhythm. During episodes of non-capture, paraoxysms of torsade de pointes leading to ventricular flutter were recorded by a 24-hour ambulatory electrocardiographic monitoring. Beta-blockade and permanent ventricular pacing finally abolished both the syncopal attacks and the torsade phenomena. The prognosis of congenital complete heart block associated with QT prolongation resembles that of the Romano-Ward syndrome. Recognition of this variant would facilitate earlier treatment of this rare but potentially lethal disorder.

Cigarette smoking and the risk of myocardial infarction, and acute non-infarct coronary events among Malaysian women.

In a prospective case-control study over a two-year period involving 1006 women, 264 women with acute myocardial infarction (AMI), 305 with non-infarct acute coronary syndromes (CAD) were compared with 437 women with no coronary heart disease (Controls), to determine the relationship between cigarette smoking and other risks factors with coronary heart disease. A history of current cigarette smoking was strongly associated with the risk of coronary events for both AMI And CAD (p less than 0.001). 23.9% of patients with acute coronary syndromes were current smokers, compared with only 12.8% among controls. Overall, women smokers had about a two-fold increase in risk for all coronary events. Younger women smokers (less than 40 years) and those between 61-70 years had particularly higher risks (10.3 and 2.7 times respectively (p less than 0.01, p less than 0.02). A dose-response pattern of increased AMI risks (from 2.0 to 2.9 times) among women smokers was also found, corresponding to the number of cigarettes smoked per day (p less than 0.05). Other significant coronary risk factors established were: postmenopausal status (OR 6.5), diabetes mellitus (OR 5.1), hypertension (OR 1.6), family history of premature coronary heart disease less than 50 years (OR 1.3) and use of oral contraceptive pills (OR 1.4). Our results thus emphasize that cigarette smoking is an important determinant of acute coronary events even among Malaysian women.

Myocardial infarction, circadian rhythm and delay in hospital admission.

Circadian variations have been observed in the onset of acute coronary syndromes including acute myocardial infarction. We studied 422 acute myocardial infarction patients who presented to the coronary care unit of General Hospital Kuala Lumpur. Of the 318 (75.4%) patients whose data was complete, a circadian rhythm with bimodal peak was demonstrated. The second quarter of the day i.e. 6.00 a.m. to 12 noon was shown to have a significantly increased frequency of onset of acute myocardial infarction (p less than 0.05). Time delay in presenting to the hospital was also determined. This showed that 56.8% of acute myocardial infarction patients presented early, within four hours of the onset of symptoms. By six hours, more than 71% had sought hospital care. This early presentation to the hospital may offer a realistic opportunity for optimal thrombolytic therapy should this treatment modality be offered as routine to infarct patients.