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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 28, No 3, May/June 2017
166
AFRICA
(GINA) 2012.
13
The study was continued with the patients in
whom asthma was controlled with this treatment protocol.
One hundred and seventy-four patients were excluded because
of uncontrolled BA, incompatibility with this protocol, severe
asthma in whom intravenous/oral corticosteroid treatment or
hospitalisation was required, need for salbutamol use in the
control visit at the end of the second week, recurrence of the
asthma attack, requirement for salbutamol treatment within six
months, interruption of all triple treatment protocol at the end of
fourth month, need for montelukast treatment for more than six
months and lack of control echocardiography. Finally, 66 patients
who had been given salbutamol 100 mcg inh 4
×
1 for 14 days,
montelukast 5 mg tablets 1
×
1 for one month and budesonide 200
mcg inh 2
×
1 for six months were included in this study.
The right and left atria and ventricles were assessed
using conventional transthoracic echocardiography and
two-dimensional (2D) speckle tracking echocardiography. The
initial echocardiographic evaluation was performed in the first
six hours. The echocardiographic assessments were repeated by
the same operators at the post-treatment sixth month. The pre-
and post-treatment parameters were compared with each other.
All participants gave an informed consent and the study
protocol was approved by the local ethics committee.
Chest X-ray, complete blood count, CRP and other
biochemical parameters were evaluated in order to exclude
conditions such as infection, bronchitis and bronchiectasis which
can mimic asthma.
In accordance with the GINA 2012 guideline,
13
bronchial
asthma was diagnosed in the presence of 12% or more
reversibility in forced expiratory volume 1 (FEV1) and 15%
or more reversibility in peak expiratory flow (PEF) with the
use of a salbutemol inhaler in the patients who had episodic
breathlessness, coughing, chest congestion, wheezing and forceful
expirium in their history. Only the patients with moderate and
severe bronchial asthma were included. Mild bronchial asthma
patients were excluded from the study.
Patients were assessed based on attack frequency over the
previous three months for classification into controlled and
uncontrolled asthma. Furthermore, their current level of asthma
control was based on reduced lung function (PEFR), frequency
of using reliever treatment, frequency of daytime symptoms,
nocturnal symptoms or awakening because of asthma and any
limitation of daily activities, including exercise.
Controlled asthma was defined as normal or near normal
lung function results, no (
≤
two times/week) need for reliever
treatment, no (
≤
two times/week) daytime symptoms, nonocturnal
symptoms or awakening because of asthma, no limitation of
daily activities including exercise and no exacerbation. Partially
controlled asthma was also regarded as uncontrolled asthma.
The patient was diagnosed as partially controlled asthma in the
presence of any of the following criteria: reduced lung function
<
80% of predicted or personal best, any limitation of activity,
night-time cough, daytime symptoms more than twice per week
and using rescue treatment more than twice per week. The
condition was defined as uncontrolled asthma in the presence of
three or more of the above criteria. Information on the patient’s
age, gender, duration of bronchial asthma, and current treatment
was obtained from each subject and checked against their case
notes.
Conventional transthoracic echocardiographic imaging was
performed by a double-blinded experienced operator while the
patients were in the left lateral position and according to the
recommendations of the American Echocardiography Society
(AES).
14
Left ventricular ejection fraction (LVEF, Simpson’s
method), left ventricular systolic end-diameter, left ventricular
diastolic end-diameter, left ventricle posterior wall thickness,
interventricular septum thickness, left atrium diameters and
volumes, and left ventricle volumes were evaluated. In addition
to these echocardiographic assessments, M-mode, 2-D images,
and colour-flow Doppler recordings of all patients were taken
using a 2.5–3.5-MHz transducer of the echocardiography device
(Philips IE33, Philips Medical Systems, Andover, MA).
After routine echocardiographic investigation, recordings of
the ascending aorta were obtained from 3 cm above the aortic
valve by the M-mode. Aortic diameters were calculated as the
distance between the anterior and posterior wall inner edges of
the aorta at systole and diastole. Systolic diameter of the aorta
(AS) was recorded when the aortic wall was fully open. Diastolic
diameter of the aorta (AD) was recorded simultaneously when the
QRS peak was seen on electrocardiographic (ECG) recordings.
Measurements were taken during five consecutive pulses and
the mean was calculated. Echocardiographic assessments were
repeated after three months of therapy and compared with the
values recorded before therapy.
Aortic elasticity parameters were considered as markers of
aortic function. Aortic systolic (AS) and aortic diastolic (AD)
indices for each patient were calculated by dividing the systolic
and diastolic aortic diameters by body mass index. Using these
indices, elastic characteristics of the aorta were calculated as
follows:
•
Pulse pressure (mmHg)
=
SBP – DBP
•
Aortic strain (%)
=
100 (AS – AD)/AD
•
Distensibility (cm
2
/dyn/10
3
)
=
2 (AS – AD)/PP
•
Aortic stifness index (ASI)
=
ln (SBP/DBP)/(AoS − AoD)/AoD
Where SBP
=
systolic blood pressure, DBP
=
diastolic blood
pressure, PP
=
pulse pressure, AoS
=
aortic root end-systolic
diameter, AoD
=
aortic root end-diastolic diameter.
Statistical analysis
Continuous variables were expressed as mean
±
SD or median
(interquartile range). Categorical variables were expressed
as percentages. An analysis of normality of the continuous
variables was performed with the Kolmogorov–Smirnov test. To
compare parametric continuous variables, paired samples
t
-test
was used. To compare non-parametric continuous variables,
the Mann–Whitney
U
-test or the Kruskal–Wallis test was
used. Two-tailed
p
-values
<
0.05 were considered as statistically
significant. All statistical studies were carried out with the SPSS
program version 20.0 for Windows.
Results
The mean age of the patients was 11.6
±
2.0 years (age range: 9–15
years) and 50% were males. Baseline characteristics are shown in
Table 1. Echocardiographic and haemodynamic assessments did
not show any difference between pre- and post-treatment values
of heart rate (90.8
±
7.7 and 89.5
±
7.0 bpm,
p
=
0.320), systolic
blood pressure (103.8
±
10.6 and 102.6
±
9.0 mmHg,
p
=
0.280),
diastolic blood pressure (65
±
7.2 and 66
±
8.1 mmHg,
p
=
0.765),