CARDIOVASCULAR JOURNAL OF AFRICA: VOLUME 31, ISSUE
6, NOVEMBER/DECEMBER 2020
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- From The Editor's Desk
Author: P Commerford
From: Cardiovascular Journal of Africa, Vol 31, Issue 6 November/December 2020
Page: 285
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- Title: The safety and efficacy of pharmaco-mechanical thrombolysis in lower-extremity deep venous thrombosis
Authors: Emced Khalil, Sedat Ozcan
From: Cardiovascular Journal of Africa, Vol 31, Issue 6 November/December 2020
Pages: 286-290
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DOI Number: 10.5830/CVJA-2020-020
DOI Citation Reference Link: dx.doi.org/10.5830/CVJA-2020-020
Objective: The aim of this study was to investigate the impact of accelerated pharmaco-mechanical thrombolysis (PMT) with low-dose second-generation urokinase for the management of cases with lower-extremity deep venous thrombosis (DVT), and to compare its efficacy in subjects with acute and subacute DVT.
Methods: Thirty-five patients with acute (< 15 days) or subacute (15–30 days) DVT who underwent PMT in a tertiary centre were enrolled in this single-arm, prospective study. Following the placement of a temporary vena cava filter, urokinase (200 000 IU) was administered into the occlusion through a multi-hole catheter for 15 to 20 minutes. Control venography was performed to assess venous flow and the rate of acute recanalisation. Percutaneous balloon dilatation and stent placement were carried out in case of a residual iliac vein stenosis of > 50%. Any residual thrombi were suctioned with an aspiration catheter. The primary outcome measures of this study were the percentages of vessel patency and PTS in the third month after PMT.
Results: Complete recanalisation was noted in 23 (66%) patients, while two (6%) had poor recanalisation. The rate of minor complications was 14%. None of the subjects experienced major complications, such as intracranial haemorrhage or pulmonary embolism. No mortality was recorded during the three months of follow up. Control duplex ultrasonography in the third month revealed that the target vein was patent in all subjects. None of the subjects experienced PTS during follow up. In addition, the percentage of acute complete recanalisation was significantly higher in subjects with acute DVT compared to those with subacute DVT (95 vs 27%, p < 0.001).
Conclusion: PMT with an accelerated regimen of low-dose urokinase provided excellent efficacy in the resolution of thrombus and prevented the development of PTS in the midterm when used for the management of lower-extremity DVT.
- Title: NT-proBNP and metabolic risk factors in a bi-ethnic cohort: the Ambulatory Blood Pressure in African prospective cohort study
Authors: Amra Jujić, Olle Melander, Peter M Nilsson, Leoné Malan, Artur Fedorowski, Martin Magnusson
From: Cardiovascular Journal of Africa, Vol 31, Issue 6 November/December 2020
Pages: 291-297
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DOI Number: 10.5830/CVJA-2020-017
DOI Citation Reference Link: ddx.doi.org/10.5830/CVJA-2020-017
Background: We explored the association of N-terminal probrain natriuretic peptide (NT-proBNP) with metabolic traits in a bi-ethnic African–Caucasian cohort.
Methods: Baseline examinations of the Sympathetic activity and Ambulatory Blood Pressure in African (SABPA) prospective cohort study were performed between 2008 and 2009, and re-examination after a three-year follow up in South African teachers (black African, n = 194; Caucasian, n = 203).
Results: Each one standard deviation increment of NT-proBNP was significantly inversely associated with body mass index (β –1.01), glycated haemoglobin (β –0.14 %), waist circumference (β –1.82), HOMA-IR (β –0.47), insulin (β –1.66) and triglyceride levels (β –0.04). Each one standard deviation increment of NT-proBNP was also associated with reduced odds of incident diabetes, and subjects within the highest quartile of NT-proBNP were at lowest risk (OR: 0.24; 95% CI: 0.06–0.96; p = 0.041).
Conclusions: In the SABPA cohort, Africans and Caucasians had similar NT-proBNP levels; however, the associations for Africans were stronger. Those findings suggest that BNP may affect the propensity for metabolic disturbances differently in Africans and Caucasians.
- Title: The contribution of plasma uric acid to the risk of stroke in hypertensive populations
Authors: Jing Shi, Guanyun Yan, Liming Cao, Xue Li, Yiwei Zhang, Suhua Zhao, Changyi Wang, Jianping Ma, Xiaolin Peng, Hongen Chen, Fulan Hu, Ran Wang
From: Cardiovascular Journal of Africa, Vol 31, Issue 6 November/December 2020
Pages: 298-303
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DOI Number: 10.5830/CVJA-2020-023
DOI Citation Reference Link: dx.doi.org/10.5830/CVJA-2020-023
Background: There is limited available evidence of a relationship between uric acid (UA) level and stroke in hypertensive populations worldwide. We aimed to estimate the relationship between UA level and stroke in Chinese hypertensive populations.
Methods: A total of 4 710 essentially hypertensive Chinese patients, including 307 with stroke, were recruited consecutively by cluster sampling from 60 communities in Shenzhen from April 2010 to September 2011. Demographic characteristics, UA level and stroke diagnosis were collected from every participant. Logistic regression analysis was used to estimate the association between UA level and stroke.
Results: The study population comprised 2 361 females and 2 349 males, with a mean age of 58 ± 11.75 years. There were significant associations between UA level and stroke and ischaemic stroke (IS) risk for females in the crude model (M0), model 1 (M1) and model 2 (M2), with increasing odds ratios (OR) as the quartiles (Q) increased. The odds of stroke risk was highest in Q4 in M2 (UA > 396 μmol/l, OR: 3.05, 95% CI: 1.74–5.36 and OR: 3.19, 95% CI: 1.74–5.85), but not for males in M0, M1 and M2. A significant dose–response relationship existed between UA level and stroke, and between UA level and IS for females but not for males. Hyperuricaemia (HU) was also significantly associated with stroke and IS for females but not for males. Taking negative uric acid, homocysteine, triglycerides, total cholesterol and low-density lipoprotein cholesterol (UA-Hcy-TG-TC-LDL-C-) as the reference, the combinations of UA+Hcy+TG-TC-LDL-, UA+Hcy+TG+TC+LDL-C- and UA+Hcy+TG+TC+LDL-C+ were significantly associated with the risk of stroke for females (OR = 2.48, 7.85 and 3.04).
Conclusion: High UA level could significantly increase stroke risk in female hypertensive patients. Female hypertensive patients may benefit from managing UA at normal levels for stroke prevention.
- Title: Relationship between physical activity and carotid intima–media thickness among teachers in South Africa: the SABPA study
Authors: Tamrin Veldsman, Mariette Swanepoel, Makama A Monyeki, Johanna S Brits, Leoné Malan
From: Cardiovascular Journal of Africa, Vol 31, Issue 6 November/December 2020
Pages: 304-313
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DOI Number: 10.5830/CVJA-2020-024
DOI Citation Reference Link: dx.doi.org/10.5830/CVJA-2020-024
Objective: To determine the relationship between objectively measured physical activity (PA) and carotid intima–media thickness (CIMT) in teachers in South Africa.
Methods: A cross-sectional study was conducted among 215 teachers aged 25 to 65 years (mean age 49.67 ± 8.43 years) who participated in the Sympathetic Activity and Ambulatory Blood Pressure in Africans (SABPA) prospective cohort study. Ultrasound CIMT imaging was done using the SonoSite Micromaxx over seven consecutive days. Other measurements obtained included body mass index (BMI), waist circumference, 24-hour ambulatory blood pressure, and C-reactive protein (CRP) and fasting blood total cholesterol levels. Data were analysed using Statistical Package for Social Sciences (SPSS) version 25.
Results: The prevalence of obesity according to BMI and sedentary behaviour was above30%; hypertension was 38.9% and low-grade inflammation (CRP) was 41.1%. Male teachers showed higher mean values for CIMT than female teachers (0.75 ± 0.16 vs 0.66 ± 0.12 mm; p ≤ 0.05). A borderline negative association existed between CIMT and mean sevenday awake metabolic equivalent of task (r = –0.19; p = 0.08) in female teachers in the light-PA group. CIMT was inversely associated with total energy expenditure (r = –0.31; p = 0.05) in sedentary male teachers.
Conclusion: Participation in light PA was associated with lower CIMT values in female teachers. Given the health implications of cardiovascular disease risk among teachers, PA intervention studies are recommended to determine effective interventions to provide information on how to decrease the progression of subclinical atherosclerosis in this population.
- Title: Determination of optimal cut-off values for waist circumferences used for the diagnosis of the metabolic syndrome among Batswana adults (ELS 32)
Authors: DM Tladi, L Mokgatlhe, S Shaibu, T Nell, R Mitchell, CJ Mokgothu, T Gabonthone, O Hubona
From: Cardiovascular Journal of Africa, Vol 31, Issue 6 November/December 2020
Pages: 314-318
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DOI Number: 10.5830/CVJA-2020-025
DOI Citation Reference Link: dx.doi.org/10.5830/CVJA-2020-025
Background: To date, no definitive waist circumference (WC) cut-off values for abdominal obesity (AO) have been established for sub-Saharan Africa, including Botswana. Therefore, the classification of AO among these populations is based on European values. For accurate diagnosis of the metabolic syndrome (MetS), cut-off values reflective of the population investigated must be used. Objective: The study was an attempt to determine optimal cut-off values for AO among Batswana adults.
Methods: The receiver operating characteristic curve was used to determine the optimal cut-off values for predicting at least two other risk factors of the MetS. Data were used from a descriptive cross-sectional study employing a complex multi-stage cluster sampling. Demographic and anthropometric measurements (weight and height, waist and hip circumferences), blood pressure, and blood glucose, triglycerides, high-density lipoprotein cholesterol and total cholesterol levels were collected from 384 men and 416 women in Gaborone and the surrounding villages.
Results: The ability of waist circumference to predict at least two other risk factors of the MetS gave cut-off values of ≥ 91.0 cm (sensitivity 69.1% and specificity of 90.8%, area under the curve 0.85) for men and ≥ 82.3 cm (sensitivity of 88.6% and specificity of 58.9%, area under the curve of 0.76) for women.
Conclusion: There is a difference between the cut-off values for Europeans with those determined for Batswana adults. Inconsistencies in cut-off values used have the potential for undesirable consequences for cardiovascular risk stratification and prioritisation of preventative strategies for AO and the MetS. The need to determine population-, ethnic- and gender-based cut-off values for AO for Batswana adults has never been more paramount.
- Title: Prognostic value of admission hyperglycaemia in black Africans with acute coronary syndromes: a crosssectional study
Authors: Hermann Yao, Arnaud Ekou, Thierry Niamkey, Camille Touré, Charles Guenancia, Isabelle Kouamé, Christelle Gbassi, Christophe Konin, Roland N’Guetta
From: Cardiovascular Journal of Africa, Vol 31, Issue 6 November/December 2020
Pages: 257-261
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DOI Number: 10.5830/CVJA-2020-028
DOI Citation Reference Link: dx.doi.org/10.5830/CVJA-2020-028
Aim: The aim of the study was to determine the relationship between acute hyperglycaemia and in-hospital mortality in black Africans with acute coronary syndromes (ACS).
Methods: From January 2002 to December 2017, 1 168 patients aged ≥ 18 years old, including 332 patients with diabetes (28.4%), consecutively presented to the intensive care unit of the Abidjan Heart Institute for ACS. Baseline data and outcomes were compared in patients with and without hyperglycaemia at admission (> 140 mg/dl; 7.8 mmol/l). Predictors for death were determined by multivariate logistic regression.
Results: The prevalence of admission hyperglycaemia was 40.6%. It was higher in patients with diabetes (55.3%). In multivariate logistic regression, acute hyperglycaemia (hazard ratio = 2.33; 1.44–3.77; p < 0.001), heart failure (HR = 2.22; 1.38–3.56; p = 0.001), reduced left ventricular ejection fraction (HR = 6.41; 3.72–11.03; p < 0.001, sustained ventricular tachycardia or ventricular fibrillation (HR = 3.43; 1.37–8.62; p = 0.008) and cardiogenic shock (HR = 8.82; 4.38–17.76; p < 0.001) were predictive factors associated with in-hospital death. In sub-group analysis according to the history of diabetes, hyperglycaemia at admission was a predictor for death only in patients without diabetes (HR = 3.12; 1.72–5.68; p < 0.001).
Conclusion: In ACS patients and particularly those without a history of diabetes, admission acute hyperglycaemia was a potentially threatening condition. Appropriate management, follow up and screening for glucose metabolism disorders should be implemented in these patients.
- Title: PASCAR commentary on the International Society of Hypertension global guidelines 2020: relevance to sub-Saharan Africa
Authors: ESW Jones, Albertino Damasceno, Elijah N Ogola, Dike B Ojji, Anastase Dzudie, BL Rayner
From: Cardiovascular Journal of Africa, Vol 31, Issue 6 November/December 2020
Pages: 325-330
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DOI Number: 10.5830/CVJA-2020-055
DOI Citation Reference Link: dx.doi.org/10.5830/CVJA-2020-055
Abstract: Hypertension guidelines have been based on country-specific data until the publication of the International Society of Hypertension (ISH) global guidelines. The major differences between the ISH global guidelines and other international guidelines are the stratified recommendations to accommodate differences in available resources between countries and within countries. This is a key and novel proposal in the new ISH guidelines. There is the separation of optimal versus essential criteria for diagnosis and treatment according to availability of resources. This guideline includes recommendations for sub-Saharan Africa. The Pan-African Society of Cardiology (PASCAR) continues to promote awareness and recommendations on hypertension in Africa. This commentary provides a summary and discussion of the global guidelines in order to clarify the position of PASCAR.
- Title: Posterior infarction: a STEMI easily missed
Authors: Lina Hähnle, Charle Viljoen, Julian Hoevelmann, Robert Gill, Ashley Chin
From: Cardiovascular Journal of Africa, Vol 31, Issue 6 November/December 2020
Pages: 331-334
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DOI Number: 10.5830/CVJA-2020-059
DOI Citation Reference Link: dx.doi.org/10.5830/CVJA-2020-059
Abstract: Anterior ST-segment depression encompasses important differential diagnoses, including ST-segment elevation myocardial infarction, non-ST-segment elevation myocardial infarction and pulmonary embolism. Diagnostic accuracy is crucial, as this has important therapeutic implications. This ECG case report reviews the electrocardiographic changes seen in patients with chest pain and anterior ST-segment depression.
- Title: Coronavirus disease 2019 (COVID-19) and simultaneous acute anteroseptal and inferior ST-segment elevation myocardial infarction
Authors: Mustafa Yolcu, Fusun Gunesdogdu, Metin Bektas, Derya Turan Bayirli, Kivanc Serefhanoglu
From: Cardiovascular Journal of Africa, Vol 31, Issue 6 November/December 2020
Pages: 335-338
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DOI Number: 10.5830/CVJA-2020-016
DOI Citation Reference Link: dx.doi.org/10.5830/CVJA-2020-016
Abstract: Coronavirus disease 2019 (COVID-19) is a recently recognised pandemic spreading rapidly from Wuhan, Hubei, to other provinces in China and to many countries around the world. The number of COVID-19-related deaths is steadily increasing. Acute ST-segment elevation myocardial infarction (STEMI) is a disease with high morbidity and mortality rates, and primary percutaneous coronary intervention is usually recommended for the treatment. A patient with diabetes mellitus and hypertension for five years was admitted to the emergency unit with symptoms of fever, cough and dyspnoea. These symptoms were consistent with viral pneumonia and a COVID PCR test was performed, which tested positive three days later. The patient had chest pain on the eighth day of hospitalisation. On electrocardiography, simultaneous acute inferior and anterior STEMI were identified. High levels of stress and increased metabolic demand in these patients may lead to concomitant thrombosis of different coronary arteries, presenting with two different STEMIs.
- Title: Persistent cardiac arrest caused by profound hypokalaemia after large-dose insulin injection in a young man with type 1 diabetes mellitus: successful rescue with extracorporeal membrane oxygenation and subsequent ventricular assist device
Authors: Ying-Hsiang Wang, Chien-Sung Tsai, Yi-Ting Tsai, Chih-Yuan Lin, Hsiang-Yu Yang, Jia-Lin Chen, Po-Shun Hsu
From: Cardiovascular Journal of Africa, Vol 31, Issue 6 November/December 2020
Pages: 339-342
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DOI Number: 10.5830/CVJA-2020-018
DOI Citation Reference Link: dx.doi.org/10.5830/CVJA-2020-018
Abstract: A 28-year-old man who had a history of type 1 diabetes mellitus with poor medication compliance was referred to the emergency department of our institute with suspected diabetic ketoacidosis. The patient developed sudden cardiac arrest following continuous insulin administration. Laboratory data revealed severe hypokalaemia. Cardiopulmonary resuscitation was performed immediately for 63 minutes. Although his spontaneous circulation resumed, the haemodynamics remained unstable. Peripheral extracorporeal membrane oxygenation was therefore employed for mechanical circulatory support. Echocardiography under these conditions revealed generalised hypokinesia of the bilateral ventricles. The left ventricular ejection fraction was only 10–15%. The chest film revealed bilateral pulmonary congestion. The patient developed multiple organ dysfunction, including acute kidney injury, liver congestion and persistent pulmonary oedema, although the hypokalaemia resolved. A temporary bilateral ventricular assist device (Bi-VAD) was used for superior systemic perfusion and unloading of the bilateral ventricles after 16 hours of extracorporeal membrane oxygenation support. After the start of maintenance using the Bi-VAD, extracorporeal membrane oxygenation was discontinued and the inotropic agents were tapered down immediately. Subsequently, the haemodynamics stabilised. All the visceral organs were well perfused with Bi-VAD support. Subsequent echocardiography demonstrated recovery from the myocardial stunning, with the left ventricular ejection fraction returning to 50–60%. The Bi-VAD was gradually weaned and successfully removed 12 days after implantation. The patient had an uneventful recovery and was discharged without organ injury. Over one year of follow up in our out-patient clinic, adequate cardiac function and improved diabetes control were found.
