CARDIOVASCULAR JOURNAL OF AFRICA: VOLUME 28, ISSUE
2, MARCH/APR 2017
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- Title: From the Editor’s Desk
Authors: Patrick Commerford
From: Cardiovascular Journal of Africa, Vol 28, Issue 2, March/April
Published: 2017
Pages: 71
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- Title: Awareness of hypertension
guidelines and the diagnosis and evaluation of
hypertension by primary care physicians in
Nigeria
Authors: OK Ale, RW Braimoh
From: Cardiovascular Journal of Africa, Vol 28, Issue 2, March/April
Published: 2017
Pages: 72-76
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DOI Number:10.5830/CVJA-2016-048
DOI Citation Reference Link: dx.doi.org/10.5830/CVJA-2016-048
Background: The availability of numerous hypertension guidelines seems not to have impacted significantly on the burden of hypertension. We evaluated awareness of hypertension guidelines among primary-care physicians (PCPs) in Nigeria and its relationship to hypertension diagnosis and work up.
Methods: Anonymous self-administered questionnaires were filled in by PCPs categorised into two groups: hypertension guideline aware (GA) and unaware (GU).
Results: The 403 participating PCPs had a mean age and experience of 40 ± 11.34 and 14 ± 11.10 years, respectively, with 46.7% (n = 188) of them being GA. Out of the 19 questions assessed, GA and GU PCPs performed better in seven and two questions, respectively, while the two subgroups had a similar performance in 10 questions. The performance of the PCPs in government and private practice was similar.
Conclusions: There is a gap between guideline recommendations and hypertension care in Nigeria that is further widened by PCPs’ unawareness of the guidelines. Popularising hypertension guidelines among PCPs may significantly improve hypertension care and reduce the burden of disease.
- Title: The role of genetics in coronary artery bypass surgery
patients under 30 years of age
Authors: S Sarikaya, E Aydin, Y Ozen, T Ozer, K Kirali, MB Rabus
From: Cardiovascular Journal of Africa, Vol 28, Issue 2, March/April
Published: 2017
Pages: 77-80
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DOI Number:10.5830/CVJA-2016-042
DOI Citation Reference Link: dx.doi.org/10.5830/CVJA-2016-042
Aim: We undertook genetic assessment of coronary artery disease (CAD) in 20 patients aged 30 years or less undergoing coronary artery bypass grafting (CABG) surgery, to investigate the prognostic value of pre-defined genes.
Methods: Twenty patients, who underwent CABG surgery between December 2001 and May 2013, were retrospectively analysed to find out the role their genetic make-up played in their disease. We used three genetic diagnostic tests, the plasminogen activator inhibitor (PAI)-1 gene, the A1/A2 polymorphism of glycoprotein IIIa (GpIIIa) gene, and common polymorphisms of the methylenetetrahydrofolate reductase (MTHFR) gene.
Results: The mean age of patients was 26.35 ± 3.51 (19–30) years, and 90% were male (n = 18). One patient had diabetes, three had hypertension, 11 (55%) had dyslipidaemia and 16 (80%) were smokers. Eight of the patients (40%) had left ventricular ejection fraction (LVEF) < 50%, and functional capacity was poor in only two (10%) patients (NYHA III– IV). Follow up was completed in all patients (100%). We found five homozygous and 11 heterozygous mutations in the MTHFR gene, which predisposes individuals to coronary artery disease or deep-vein thrombosis. Eight patients were found to have a GpIIIa gene polymorphism, which is associated with increased risk of myocardial infarction (MI). Fifteen patients had a polymorphism in the promoter region of the PAI-1 gene, which is a major inhibitor of the fibrinolytic system.
Conclusion: MTHFR C677T polymorphism, and GpIIIa and PAI-1 genes are risk factors for CAD. In young patients, genetic studies promise to revolutionise early diagnosis, treatment and prevention of CAD and MI.
- Title: The role of coronary artery
collaterals in the preservation of left
ventricular function: a study to address a
longstanding controversy
Authors: NO Ajayi, EA Vanker, KS Satyapal
From: Cardiovascular Journal of Africa, Vol 28, Issue 2, March/April
Published: 2017
Pages: 14-18
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DOI Number: 10.5830/CVJA-2016-054
DOI Citation Reference Link: dx.doi.org/10.5830/CVJA-2016-054
Introduction: The functional significance of coronary artery collateral (CAC) vasculature in humans has been debated for decades and this has been compounded by the lack of a standard, systematic, objective method of grading and documenting CAC flow in man. CACs serve as alternative conduits for blood in obstructive coronary artery disease. This study aimed to evaluate the impact of CACs on left ventricular function in the presence of total coronary arterial occlusion.
Methods: The study group included the coronary angiographic records of 97 patients (mean age: 59 ± 8 years). CACs were graded from 0–3 based on the collateral connection between the donor and recipient arteries. Left ventricular function was computed from the ventriculogram and expressed as ejection fraction (EF).
Results: The mean EF of the patients with grades 0, 1, 2 and 3 CACs were calculated as 50.4, 47, 60.5 and 70%, respectively. A significant difference was recorded in the mean EF calculated for the different CAC grades (p = 0.001). There was a significant positive correlation (p < 0.001; r = 0.478) between the mean EF and the CAC grades.
Conclusion: The patients with better coronary collateral grades had a higher mean EF. Therefore, as the grade of CACs increased, there was an improvement in their ability to preserve left ventricular function.
- Title: Obesity in Botswana: time for new cut-off points for
abdominal girth?
Authors: CL Onen
From: Cardiovascular Journal of Africa, Vol 28, Issue 2, March/April
Published: 2017
Pages: 86-91
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DOI Number: 10.5830/CVJA-2016-060
DOI Citation Reference Link: dx.doi.org/10.5830/CVJA-2016-060
Introduction: Country-specific cut-off points for defining central obesity in black Africans are long overdue.
Methods: Anthropometric data from 215 (51.4%) male and 203 (48.6%) female patients seen in Gaborone between 2005 and 2015 were analysed to establish appropriate cut-off points for waist circumference (WC) corresponding to a body mass index (BMI) of 30 kg/m2. Relative risks for cardiometabolic disorders were calculated for different BMI and WC categories using MedCalc®. The subjects’ mean age was 50.0 ± 10.8 years and 80.6% were Batswana.
Results: Only 7.2% of patients had a BMI < 25 kg/m2, 27.3% were overweight and 65.5% were obese; mean BMI was 34.9 ± 6.5 kg/m2 in the women versus 31.0 ± 4.9 kg/m2 in the men(p < 0.0001). New cut-off points of 98 cm in men and 85 cm in women emerged. Different weight and WC categories appeared not to confer increased relative risk of hypertension, dysglycaemia or dyslipidaemia.
Conclusion: The proposed WC cut-off values, if validated, should set the pace for larger studies across sub-Saharan Africa.
- Title: Comparative analysis of
anthropometric indices of obesity as correlates
and potential predictors of risk for
hypertension and prehypertension in a population
in Nigeria
Authors: CJ Ononamadu, CN Ezekwesili, OF Onyeukwu, UF Umeoguaju, OC Ezeigwe, GO Ihegboro
From: Cardiovascular Journal of Africa, Vol 28, Issue 2, March/April
Published: 2017
Pages: 92-99
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DOI Number: 10.5830/CVJA-2016-061
DOI Citation Reference Link: dx.doi.org/10.5830/CVJA-2016-061
Background: Obesity is a well-established independent risk factor for hypertension and other cardiometabolic disorders. However, the best anthropometric index of obesity that predicts or associates strongly with hypertension and related conditions remains controversial and inconclusive.
Objective: This study compared the performance of eight anthropometric indices of obesity: body mass index (BMI), ponderal index (PI), waist circumference (WC), hip circumference (HC), waist–hip ratio (WHR), waist–height ratio(WHtR), body adiposity index (BAI) and conicity index (CI) as correlates and potential predictors of risk of hypertension and prehypertension in a Nigerian population, and also the possible effect of combining two or more indices in that regard.
Methods: This church-based, cross-sectional study was conducted in Anambra state, south-eastern Nigeria from 2012 to 2013. A total of 912 persons (436 male and 476 female) drawn randomly from three major cities (Awka, Onitsha and Nnewi) in the state participated in the study. Information on demography, medical history and lifestyle were obtained using a well-structured and validated questionnaire. The systolic/diastolic blood pressure and anthropometric measurements were taken by well-trained personnel. The resulting data were analysed using descriptive statistics, logistic regression, Poisson regression and receiver operating characteristic curve analysis.
Results: The mean values of all the anthropometric indices studied increased from normotension, through prehypertension to hypertension in both genders. BMI, WC, HC and CI were significantly higher (p < 0.05) in females than males. All the anthropometric indices studied were significantly (p < 0.001 except for CI) correlated with systolic and diastolic blood pressure. BMI, WHtR, WC and PI (with higher correlation coefficients for blood pressure) showed the best potential to predict hypertension and prehypertension in the study: BMI (cut-off = 24.49, AUC = 0.698; cut-off = 23.62, AUC = 0.659), WHtR (cut-off = 0.55, AUC = 0.682; cut-off = 0.5, AUC = 0.636), WC (cut-off = 91.44, AUC = 0.692; cut-off = 82.55, AUC = 0.645), PI (cut-off = 14.45, AUC = 0.670; cut-off = 13.69, AUC = 0.639), in males; and BMI (cut-off = 24.44, AUC = 0.622; cut-off = 28.01, AUC = 0.609), WHtR (cut-off = 0.51, AUC = 0.624; cut-off = 0.6, AUC = 0.572), WC (cut-off = 96.62, AUC = 0.616; cut-off = 96.52, AUC = 0.584), PI (cut-off = 16.38, AUC = 0.619; cut-off = 17.65, AUC = 0.599), in females for hypertension and prehypertension, respectively. In predicting hypertension risk, WC and WHtR did not significantly improve the performance of BMI in the models when included using our decision rule. Overall, CI had a very poor discriminatory power for both conditions in this study.
Conclusion: BMI, WHtR, WC and PI emerged the best predictors of hypertension risk, and BMI, WC and PI of prehypertension risk in this study. The combination of high-performing anthropometric indices in a model did not improve their performance. Therefore we recommend the simultaneous but independent use of BMI and either WC or WHtR for predicting hypertension, and BMI and WC for prehypertension risk, bearing in mind that both types of index (abdominal and general obesity) account for different forms of obesity.
- Title: Chicken or the egg: ST elevation in lead aVR or SYNTA X score
Authors: L Cerit
From: Cardiovascular Journal of Africa, Vol 28, Issue 2, March/April
Published: 2017
Pages: 100-103
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DOI Number: 10.5830/CVJA-2016-062
DOI Citation Reference Link: dx.doi.org/10.5830/CVJA-2016-062
Background: ST-segment elevation in lead aVR (STEaVR) anticipates left main and/or three-vessel disease (LM/3VD) in patients with acute coronary syndromes. STEaVR is generally reciprocal to and accompanied by ST-segment depression (STD) in the precordial leads. SYNTAX score (SS) is an angiographic scoring system and is widely used to evaluate the severity and complexity of coronary artery disease. The purpose of our study was to assess the relationship between STEaVR and SS.
Methods: We performed a retrospective analysis of 117 patients with non-ST-segment elevation acute coronary syndrome (NSTEACS). Electrocardiograms at presentation were reviewed, especially for ST-segment elevation of ≥ 0.05 mV in lead aVR and STD of ≥ 0.05 mV in more than two contiguous leads. All lesions causing ≥ 50% stenosis in a coronary artery with a diameter of ≥ 1.5 mm were included in the SS calculation. SS was divided into two groups: ≥ 23: high, < 23: low.
Results: Among the 117 patients, 80 (68.4%) had STEaVR and 37 (31.6%) did not. Patients with STEaVR had a higher SS and higher rate of LM/3VD (85 vs 67.6%, p < 0.001; 86.2 vs 72.9%, p = 0.03, respectively) than those without STEaVR. On multivariate analysis, STEaVR [odds ratio (OR) 1.85; 95% confidence interval (CI): 1.20–3.97, p = 0.03] and STD in leads V1–V4 (OR 2.14; 95% CI: 1.46–4.23, p = 0.002) were independent predictors of a high SS.
Conclusion: This study demonstrated that STEaVR was an independent predictor of a high SS.
- Title: Relationship between Vitamin D and the development of atrial
fibrillation after on-pump coronary artery bypass graft surgery
Authors: L Cerit, H Kemal, K Gulsen, B Ozcem, Z Cerit, H Duygu
From: Cardiovascular Journal of Africa, Vol 28, Issue 2, March/April
Published: 2017
Pages: 104-107
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DOI Number: 10.5830/CVJA-2016-064
DOI Citation Reference Link: dx.doi.org/10.5830/CVJA-2016-064
Background: Vitamin D deficiency is associated with many diverse cardiovascular disorders, such as hypertension, heart failure, stroke, coronary artery disease and atrial fibrillation. The relationship between Vitamin D and the development of atrial fibrillation after coronary artery bypass surgery (CABG) has not been studied. Therefore, we assessed the relationship between Vitamin D and the development of postoperative atrial fibrillation (POAF) after CABG.
Methods: Medical records of consecutive patients who underwent CABG surgery were retrospectively reviewed for the development of atrial fibrillation in the postoperative period. Vitamin D, other biochemical parameters, and clinical and echocardiographic parameters were evaluated in all patients. The independent variables for the development of postoperative atrial fibrillation were defined and their predictive values were measured.
Results: The study group consisted of 128 patients, of whom 41 (32%) developed POAF. Age, diabetes mellitus, chronic obstructive pulmonary disease, history of transient ischaemic attack/stroke, heart failure, left atrial diameter, platelet:largecell ratio, and creatinine, urea, uric acid, calcium and potassium levels were identified as important variables for the development of POAF. However, with logistic regression analysis, chronic obstructive pulmonary disease (OR: 28.737, 95% CI: 0.836–16.118, p < 0.001), heart failure (OR: 15.430, 95% CI: 0.989–7.649, p = 0.006), diabetes mellitus (OR: 11.486, 95% CI: 0.734–11.060, p = 0.001) and left atrial diameter (OR: 1.245, 95% CI: 0.086–6.431, p = 0.011) appeared as independent variables predicting the development of POAF.
Conclusion: In our study, although there was a significant negative correlation between Vitamin D and left atrial diameter, Vitamin D level was not an independent predictor for POAF.
- Title: Factors associated with early mortality in haemodialysis
patients undergoing coronary artery bypass surgery
Authors: D Çevirme, T Adademir, M Aksüt, T Örki, KC Çakalağaoğlu, M Alp, K Kırali
From: Cardiovascular Journal of Africa, Vol 28, Issue 2, March/April
Published: 2017
Pages: 108-111
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DOI Number: 10.5830/CVJA-2016-066
DOI Citation Reference Link: dx.doi.org/10.5830/CVJA-2016-066
Introduction: Coronary artery bypass grafting (CABG) results in higher morbidity and mortality rates in end-stage renal disease (ESRD) patient populations than in patients with normal renal function. This study aimed to identify the early results of CABG performed on ESRD patients, and the factors that affected the mortality rates of those patients.
Methods: A retrospective evaluation of our hospital database revealed 84 haemodialysis-receiving patients who underwent CABG during the years 2006 to 2012. Mortality was observed in 21 patients (group 1), and this group was compared with the remaining patients (group 2) for peri-operative parameters such as age, EuroSCORE, functional capacity, myocardial infarction, use of inotropes and completeness of revascularisation.
Results: The study included 60 male (71.4%) and 24 female patients (28.6%); the participants’ mean age was 59.50 ± 9.93 years. The pre-operative additive EuroSCORE was 7.96 ± 2.88 (range: 2–18). Pre-operative functional capacity was impaired in 35.7% of the patients [New York Heart Association (NYHA) classes III–IV]. Mean age and preoperative EuroSCORE values of group 1 were significantly higher than those of group 2. Impaired functional capacity (NHYA classes III–IV) was also associated with mortality (OR: 3.333; 95% CI: 1.199–9.268).
Fifty-four patients (64.3%) underwent on-pump CABG procedures, and 30 (35.7%) underwent off-pump CABG procedures. The study found no statistically significant difference in mortality rates between these two techniques. Mortality occurred in 12 patients (22.2%) in the on-pump group and in nine (30%) in the off-pump group. Complete revascularisation was performed on 46 patients (85.2%) in the on-pump group and seven (23.3%) in the off-pump group (p < 0.001).
Conclusion: Advanced age, impaired NYHA functional capacity and pre-operative hypertension were determinative for early-term surgical mortality. An on-pump surgical technique is recommended to ensure completeness of revascularisation.
- Title: Presentation and mortality of
patients hospitalised with acute heart failure
in Botswana
Authors: JC Mwita, MJ Dewhurst, MGMD Magafu, M Goepamang, B Omech, KL Majuta, M Gaenamong, TB Palai, M Mosepele, Y Mashalla
From: Cardiovascular Journal of Africa, Vol 28, Issue 2, March/April
Published: 2017
Pages: 112-117
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DOI Number: 10.5830/CVJA-2016-067
DOI Citation Reference Link: dx.doi.org/10.5830/CVJA-2016-067
Introduction: Heart failure is a common cause of hospitalisation and therefore contributes to in-hospital outcomes such as mortality. In this study we describe patient characteristics and outcomes of acute heart failure (AHF) in Botswana.
Methods: Socio-demographic, clinical and laboratory data were collected from 193 consecutive patients admitted with AHF at Princess Marina Hospital in Gaborone between February 2014 and February 2015. The length of hospital stay and 30-, 90- and 180-day in-hospital mortality rates were assessed.
Results: The mean age was 54 ± 17.1 years, and 53.9% of the patients were male. All patients were symptomatic (77.5% in NYHA functional class III or IV) and the majority (64.8%) presented with significant left ventricular dysfunction. The most common concomitant medical conditions were hypertension (54.9%), human immuno-deficiency virus (HIV) (33.9%), anaemia (23.3%) and prior diabetes mellitus (15.5%). Moderate to severe renal dysfunction was detected in 60 (31.1%) patients. Peripartum cardiomyopathy was one of the important causes of heart failure in female patients. The most commonly used treatment included furosemide (86%), beta-blockers (72.1%), angiotensin converting enzyme inhibitors (67.4%), spironolactone (59.9%), digoxin (22.1%), angiotensin receptor blockers (5.8%), nitrates (4.7%) and hydralazine (1.7%). The median length of stay was nine days, and the in-hospital mortality rate was 10.9%. Thirty-, 90- and 180-day case fatality rates were 14.7, 25.8 and 30.8%, respectively. Mortality at 180 days was significantly associated with increasing age, lower haemoglobin level, lower glomerular filtration rate, hyponatraemia, higher N-terminal pro-brain natriuretic peptide levels, and prolonged hospital stay.
Conclusions: AHF is a major public health problem in Botswana, with high in-hospital and post-discharge mortality rates and prolonged hospital stays. Late and symptomatic presentation is common, and the most common aetiologies are preventable and/or treatable co-morbidities, including hypertension, diabetes mellitus, renal failure and HIV.
- Title: The effect of proximal anastomosis on the expansion rate of a
dilated ascending aorta in coronary artery bypass surgery: a prospective study
Authors: AY Balcı, U Vural, R Aksoy, MDF Özdemir, S Satılmış, M Kızılay, M Şenocak, H Şaşkın, İ Kayacıoğlu, İ Yekeler
From: Cardiovascular Journal of Africa, Vol 28, Issue 2, March/April
Published: 2017
Pages: 118-124
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DOI Number: 10.5830/CVJA-2016-071
DOI Citation Reference Link: dx.doi.org/10.5830/CVJA-2016-071
Background: This study was designed to determine the short- and long-term effects of proximal aortic anastomosis, performed during isolated coronary artery bypass grafting (CABG) in patients with dilatation of the ascending aorta who did not require surgical intervention.
Methods: The study was performed on 192 (38 female and 160 male patients; mean age, 62.1 ± 9.2 years; range, 42–80 years) patients with dilatation of the ascending aorta who underwent CABG surgery between 1 June 2006 and 31 May 2014. In group 1 (n = 114), the saphenous vein and left internal mammarian artery grafts were used, and proximal anastomosis was performed on the ascending aorta. In group 2 (n = 78), left and right internal mammarian artery grafts were used, and proximal aortic anastomosis was not performed. Pre-operatively and in the first and third years postoperatively, the ascending aortic diameter was measured and recorded using transthoracic echocardiography at four different regions (annulus, sinus of Valsalva, sinotubular junction and tubular aorta).
Results: A statistically significant difference was found between the groups for the number of grafts used and the duration of aortic cross-clamping and cardiopulmonary bypass. No significant intergroup difference was seen for the mean diameter of the ascending aorta (p > 0.05). Annual changes in the aortic diameter were found to be extremely significantly different in both groups (p = 0.0001). Mean values of the aortic diameter at the level of the sinotubular junction and tubular ascending aorta, mean aortic diameters (p = 0.002 and p = 0.0001, respectively), annual increase in diameter (p = 0.0001 and p = 0.0001, respectively), and mean annual difference in diameter (p = 0.0001 and p = 0.0001, respectively) at one and three years postoperatively were statistically significantly different between the groups.
Conclusion: In patients with ascending aortic dilatation who did not require surgical intervention and who had proximal anastomosis of the ascending aorta and underwent only CABG, we detected statistically significant increases in the diameter of the sinotubular junction and tubular aorta up to three years postoperatively.
- Title: The integrated effect of moderate exercise on coronary heart
disease
Authors: MJ Mathews, EH Mathews, GE Mathews
From: Cardiovascular Journal of Africa, Vol 28, Issue 2, March/April
Published: 2017
Pages: 125-133
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DOI Number: 10.5830/CVJA-2016-058
DOI Citation Reference Link: dx.doi.org/10.5830/CVJA-2016-058
Background: Moderate exercise is associated with a lower risk for coronary heart disease (CHD). A suitable integrated model of the CHD pathogenetic pathways relevant to moderate exercise may help to elucidate this association. Such a model is currently not available in the literature.
Methods: An integrated model of CHD was developed and used to investigate pathogenetic pathways of importance between exercise and CHD. Using biomarker relative-risk data, the pathogenetic effects are representable as measurable effects based on changes in biomarkers.
Results: The integrated model provides insight into higherorder interactions underlying the associations between CHD and moderate exercise. A novel ‘connection graph’ was developed, which simplifies these interactions. It quantitatively illustrates the relationship between moderate exercise and various serological biomarkers of CHD. The connection graph of moderate exercise elucidates all the possible integrated actions through which risk reduction may occur.
Conclusion: An integrated model of CHD provides a summary of the effects of moderate exercise on CHD. It also shows the importance of each CHD pathway that moderate exercise influences. The CHD risk-reducing effects of exercise appear to be primarily driven by decreased inflammation and altered metabolism.
- Title: Pacemaker syndrome with sub-acute left ventricular systolic
dysfunction in a patient with a dual-chamber pacemaker: consequence of lead
switch at the header
Authors: MR Khurwolah, BZ Vezi
From: Cardiovascular Journal of Africa, Vol 28, Issue 2, March/April
Published: 2017
Pages:134-136
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DOI Number: 10.5830/CVJA-2016-081
DOI Citation Reference Link: dx.doi.org/10.5830/CVJA-2016-081
Abstract: In the daily practice of pacemaker insertion, the occurrence of atrial and ventricular lead switch at the pacemaker box header is a rare and unintentional phenomenon, with less than five cases reported in the literature. The lead switch may have dire consequences, depending on the indication for the pacemaker. One of these consequences is pacemaker syndrome, in which the normal sequence of atrial and ventricular activation is impaired, leading to sub-optimal ventricular filling and cardiac output. It is important for the attending physician to recognise any worsening of symptoms in a patient who has recently had a permanent pacemaker inserted. In the case of a dual-chamber pacemaker, switching of the atrial and ventricular leads at the pacemaker box header should be strongly suspected. We present an unusual case of pacemaker syndrome and right ventricular-only pacinginduced left ventricular systolic dysfunction in a patient with a dual-chamber pacemaker..
- Title: Successful surgical treatment of a subtotal descending aortic
occlusion
Authors: M Puślecki, B Perek, S Stefaniak, A Siniawski, G Oszkinis, M Jemielity
From: Cardiovascular Journal of Africa, Vol 28, Issue 2, March/April
Published: 2017
Pages:e1-e3
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DOI Number: 10.5830/CVJA-2016-012
DOI Citation Reference Link: dx.doi.org/10.5830/CVJA-2016-012
Abstract: We present the case of a 33-year-old man with middle aortic syndrome. The final diagnosis was established with magnetic resonance imaging. He underwent a successful aorto-aortic bypass. Two-year follow-up imaging showed the new graft was patent, with no abnormalities at the anastomosis sites. At the last follow-up examination he was asymptomatic with no neurological dysfunction.
