1 Research Progress on the Relationship between Serum Cystatin C and Heart Failure , Zhang Fuya, Gao Fengmin, Zhang Xianmeng, Fu Beijing, Wen Xin
Heart failure (HF) is caused by many factors that lead to myocardial damage, myocardial remodeling of ventricular overload, dysfunction of cardiac diastolic and systolic function, and insufficient blood volume of cardiac circulation. The process of myocardial remodeling is accompanied by myocardial cell ischemia, necrosis, apoptosis, progressive interstitial cell fibrosis and other pathological processes, which is a clinical syndrome in the final stage of various heart diseases, it has high morbidity and mortality, which is a serious threat to human health [1]. Early detection of HF and effective treatment to reduce its morbidity and mortality is particularly important. In recent years, it has been found that Cystatin C (Cys C) is closely related to the occurrence, development and prognosis of HF, and may be an independent predictor of HF. This article reviews the research progress on the relationship between serum Cys C and HF, as well as the pathogenesis, diagnosis, severity and prognosis of Cys C in HF
2 Venous Congestion Due To Large Arteriovenous Anastomoses , Vladimir Ermoshkin*
Abstract Aims: Mortality from cardiovascular disease (CVD) is very high. Medicine is considered that most of heart diseases have unknown etiology and mechanism. Made is an attempt to analyze the mechanism of the CVD. Why does theoretical cardiology have such a low success rate during more than 100 years? What is the true reason, for example, venous plethora, hemorrhoids, prostatitis, endometriosis and some others? How to prevent hypertension? Methods: Search in the literature, participation in medical conferences in Russia (2012-2016), Australia, Brisbane, Arrhythmia-2016, correspondence with leading Russian cardiologists, publishing of my original articles. Results: My group succeeded in demonstrating the fact that the modern theoretical cardiology has significant errors. With the use of Cardiocode device our group managed to prove the presence of large arteriovenous anastomoses (AVA) in quite healthy individuals. Sudden opening of AVA lumen leads to a sharp decrease in arterial pressure. When closing the AVA, usually in a few seconds, arterial pressure increases again. It seems that such manipulations of AVA are provided by nature to protect the vessels of peak values of arterial pressure. It becomes clear that the long-term incorrect performance of AVA, especially in case of unhealthy lifestyle, usually leds to two big problems. The first problem is a periodic disorder in heart rhythm, sometimes with lethal outcome, caused by heart excitation by means of pulse mechanical waves which pass along the vessels’ contour and return to heart. The second problem: metabolism disorders caused by long-term increase in both system and local venous pressure. An attempt to substantiate the reasons of venous hyperemia and small pelvis organs diseases in humans is made herein. Conclusions: I think that taking into account a great experience accumulated by modern official medicine and a great number of clinical studies and using my theory it will be possible to make a breakthrough in cardiovascular disease treatment including venous hyperemia.
3 Perceval S and Coronary Artery Bypass Grafting, Contradiction or Full Harmony? , Sara Badia* , Elisabet Berastegui, M Luisa Cámara, Luis Delgado, Claudio Fernández, Ignasi Julià, Bernat Romero, Anna Llorens, Paula Albaladejo and Xavier Ruyra
Abstract Background / Study Objective: Coronary artery disease is very common in patients who are referred to aortic valve replacement. Concomitant coronary artery bypass grafting (CABG) procedure does not necessarily contradict with the use of last generation sutureless bioprostheses, but, publications about this combined approach are very limited. The objective of this study is to describe the results of aortic valve replacement plus CABG using Perceval S aortic sutureless bioprostheses in our Center. Methods: From our database we retrospectively described the outcomes of 42 patients who underwent aortic valve replacement with a last generation sutureless bioprostheses (Perceval S) plus CABG at the same procedure. We used a combination of arterials (left internal mammary artery (LIMA), right internal mammary artery (RIMA) and radial artery) and saphenous vein for the coronary artery bypass grafting. Most of the patients received 1 bypass (range: 1-3). Mean age: 78,19 ± 5,1. Male 64,3%, female 35,7%. Cardiovascular risk factors: Hypertension 97,6%; Diabetes 38,1%, Dyslipidemia 69%, peripheral vascular disease 38,2%, prior stroke 9,5%, chronic renal failure 40,5%, obstructive pulmonary disease 21,4% of the patients. Mean Logistic EuroScoreI/II: 16,68/10,73% (expected mortality). Results and Conclusions: Excellent results were achieved in patients undergoing aortic valve replacement with Perceval S sutureless bioprostheses and concomitant coronary artery bypass grafting. Although high aortotomy is needed for Perceval S implantation, is possible to perform proximal anastomosis for saphenous grafts properly. Perceval S is a feasible alternative for patients with aortic valve stenosis and coronary artery disease, with shorter cross-clamp and extracorporeal circulation times and low rate of complications.
4 Left Ventricular Diastolic Dysfunction Detected By Speckle Tracking In Hypertensive Patients with Preserved Ejection Fraction , Kamal Ahmed Marghani, Yasser Abd Al Galel Omar and Hosam Hussien Kamel Abdalghany
Abstract Objectives: To detect early diastolic dysfunction in the left ventricle in hypertensive patients with preserved ejection fraction using 2D speckle tracking echocardiography. Methods: This is a prospective study that was carried on (30) hypertensive patients referred to Al Azhar university hospital outpatient clinic for evaluation and treatment of hypertension and (20) age and sex matched healthy volunteers as a control group. All subjects underwent convential echocardiographic examination and Assesment of diastolic dysfunction by speckle tracking. Conclusion: Impairment of diastolic function detected by speckle tracking in hypertensive patients (with and without LVH)
5 Effect of Low-Level Electrical Stimulation of the Arotic Root Ventricular Ganglionated Plexi on Electrical and Structural Remodling in Dogs with Heart Failure , Hong-Tao Wang, Fei-Fei Su, Di Zeng, Boyuan-Fan, Jun Li and Qiang-sun Zheng
Abstract Low-level electrical stimulation (LL-ES) of aortic root ventricular ganglionated plexi (GP) was proved to be antiarrhythmic in the initiation of AF mediated by autonomic nervous system. However,it is still uncertain whether LL-ES of the ventricular GP can reverse the structural remodeling of myocardial fibrosis and atrial enlargement following heart failure by attenuating the sympathetic tone. Therefore,this review will give an general argument on this topic
6 Arteriovenous Anastomoses and Cardiovascular Diseases , Vladimir I. Ermoshkin*
Abstract Aim: Why are most of the cardiovascular diseases (CVD) with unknown etiology? An attempt to solve the riddle, An attempt to study the unknown role of the arteriovenous anastomoses (AVA), an attempt to finally clarify the causes of cardiac arrhythmia. Methods: Medical consultations, information search in literature, participation in medical conferences, correspondence with scientists, discussions with Russian leading cardiologists. Results: The official medicine: arteriovenous anastomosis (fistulas) - an abnormal connection between an artery and a vein. Normally, blood flows from arteries into the capillaries and then into the veins. Most cardiologists agree that the role of small or large AVA in human circulatory system is still poorly understood. We have found that along with the positive role, the anastomoses, especially large AVA, periodically have pathological effects on the cardiovascular system. The device “Cardiocode” was used for testing. Large arteriovenous anastomoses (AVA) can be opened under the influence of stress or physical loads. Periodically, the pressure change in the arteries and veins. Vena cava expands, its wall’s tone increases and pulse waves start to path through the AVA along the elastic walls of the vena cava to the right atrium and to the neck veins. Mechanical impulses can excite heart from various points of the atria or ventricles, disrupting the sinus rhythm. The result is the following: extrasystoles appear, tachycardia attacks, at the same time the blood flow is blocked on almost all the peripheral segments of circulatory system, edemata appear. Increased venous pressure stops the capillary circulation, which eventually leads to heart failure, even in a healthy heart. Severe metabolic disorders, it appears that leads to disease comorbidity, to venous congestion, to disease pelvic, to heart failure, to sudden cardiac death (SCD). Conclusions: I think we are approaching in the understanding of CVD. The absence of special breathing exercises, drinking large amounts of beer, smoking, lack of exercise and presence of large AVA can sometimes lead to a variety of diseases, to metabolic diseases. To get rid of the attacks of cardiac arrhythmias and the prevention of SCD we need to find some way to suppress the mechanical waves running through AVA, as “reentry” phenomenon has a mechanical nature. It is necessary to continue studying the AVA to develop new measures for neutralizing the pathological events associated with the open AVA.
7 A Catastrophe Caused by Central Venous Catheter Insertion – A Case Report , Abdallah Almaghraby* , Yehia Saleh, Basma Hammad, Mahmoud Abdelnaby, Judy Rizk, Mohammed Seleem, Sanaa Ashour
Introduction Central venous catheterization (CVC) is a routine technique done in critical care and emergency departments for monitoring patients and giving certain parenteral medications in special conditions. Most common complications associated with CVCs are infection, hematoma, hemothorax, pneumothorax and superior or inferior vena cava trauma while rare complications include cardiac arrhythmias, air embolism and loss of the guide wire [1]. We are reporting a case of unrecognized loss of CVC guide wire that caused a very rare unexplained cardiac complication.
8 Management of Resistant Pericarditis in an End Stage Renal Disease Patient - Case Presentation , Dor Lotan1,5, Yishay Wasserstrum1,5, Marcus Hallerstrom2 , Yafim Brodov 3,5, Yehuda Adler4,5, Gad Segal1,5 and Amir Dagan1,5
Case Presentation A 75 year old female receiving dialysis 3 times weekly due to end-stage renal disease (ESRD), secondary to polycystic kidney disease, presented to the emergency room. She complained of right upper quadrant pain together with pleuritic chest pain. The chest pain worsened on deep inspiration and on lying down flat, but improved on sitting up and bending forwards. An abdominal ultrasound, performed due to a known liver cyst, revealed a solid dense lesion, which was not indicative of a cyst. There was the suspicion that the lesion may have been infectious or hemorrhagic in nature. As a result the patient was admitted to the surgical department for further evaluation. Due to her failure to respond to antibiotic treatment a PET-CT with F-18-FDG was ordered. The studies revealed increased mediastinal absorption between her large vessels and pericardium as well as a small pericardial effusion. Her serum CRP peak was 236.83 mg/l, the troponin was negative and her blood urea was 42 mg/dl (15-45 mg/dl). The ECG did not show any typical changes of pericarditis. However, treatment for pericarditis was initiated. Due to her ESRD she was started on prednisone, which had an immediate symptomatic and laboratory response. Her CRP declined to 5.1 and a tapering protocol of prednisone was initiated.
9 Insights into Cardiovascular Diseases: The Vicious Platelet-Immune System Loop , Sulagna Bhattacharya# , Angika Bhasym# and Prasenjit Guchhait
Abstract Cardiovascular disease (CVD) is the leading cause of death today and a burden on a country’s economic growth. Management of this disease continues to depend on dietary control and statins. However, the disease burden refuses to decline. It is probably because treatment regime addresses the effect and not the cause. Augmented LDL level has been traditionally perceived as the major risk factor contributing to the development of atherosclerosis, the main cause of several coronary ailments. Recent research also suggests that pre-existing chronic inflammation leads to oxidation of LDL and thus makes it pathogenic. This inflammatory repertoire, apart from leukocytes, also includes the anucleated cell fragments called platelets. Platelets conventionally associated with clotting phenomenon, also express array of inflammatory mediators creating a crucial link between immune response and thrombotic complications. In this review we will examine the role of inflammation as a primary causative agent of atherosclerotic as well as non-atherosclerotic cardiovascular diseases.
10 Rituximab in Takayasu Arteritis, a Case Report , Mohammad Bagher Owlia* and Ali Dehghan
Abstract Takayasu Arteritis (TAK) is a subgroup of large vessel vasculitis involving major branches of aorta. Corticosteroids are the mainstay of treatment. However, several other steroid-sparing agents are used to control vessel wall inflammation in TAK. Some biologic agents are used as new targeted agents. Several reports denote clinical efficacy of tumor necrosis factor alpha (TNF-α) and interleukin 6 (IL-6) blocking agents in management of TAK. While few studies are devoted to report B cell depletion in inflammation in TAK, we report a 34-year-old woman with established diagnosis of TAK treated with rituximab with good clinical and laboratory control.
11 Should Interventional Cardiologist use Aspiration Thrombectomy? , Shaimaa Mostafa* and Vector Fadllaah
If there was a broken-down car on your street blocking traffic, would you rather hire a tow truck to remove it, or hire a bulldozer to smash it into smaller pieces? Asked Joshua Allen-Dicker [1]. Many randomized controlled trial examined whether removal of a coronary artery thrombus (the tow truck method) prior to stent placement improved 30 day mortality in STEMI patients as compared to placement of a stent without first removing the thrombus (the bulldozer method) [1]. In fact, this is a possible complication during primary PCI, resulting in microvascular obstruction and no-reflow phenomenon. The presence of a visible thrombus at the time of primary PCI in patients with STEMI is associated with poor procedural and clinical outcomes [2]. Physiologically, the tow truck method makes sense: removal of the thrombus prior to placing a stent should reduce distal embolization of thrombus fragments and improve overall myocardial recovery [1]. Several randomized trials have demonstrated the efficacy and safety of pretreatment with manual thrombectomy during primary percutaneous coronary intervention [3]. There are some unanswered questions about thrombus aspiration including whether there is truly a mortality benefit, which subgroups may or may not benefit from aspiration and whether patients with a large thrombus burden are better treated with mechanical thrombectomy and should an interventional cardiologist use thrombecto-my as a default strategy before primary PCI? [4]. The literature and clinical practice clearly show that the impact of thrombectomy on all outcomes is linked to multiple factors during STEMI, in particular time from symptom onset to PCI, infarct-related coronary artery and intracoronary thrombus burden [5]. Sianos, et al. have shown that both angiographic and clinical outcomes are poorer in patients with a large thrombus burden as it is associated with a greater frequency of major adverse cardiac events and is a strong independent predictor of late mortality [6].
12 How to develop a simply frailty score for predicting postoperative morbidity in cardiac surgery , Berastegui Garcia E1 *, Badia Gamarra S1 , Camara Rosell ML1 , Casas García I2 , ALbaladejo Da Silva P1 , Delgado Ramis L1 , Fernandez Gallego C1 , Julia Almill I1 , Llorens Ferrer A1 , Moret Ruiz E3 , Romero Ferrer B1 , Ruyra Baliarda X1 and Oller Sales B4
Abstract Introduction: Ageing and elderly people have greater risk. Physical state and frailty status represent an important risk and must be considered before cardiac surgery. More than one third of current surgeries are performed in patients older than 70 years. This is a factor to keep on mind in our routine evaluation. Currently an accepted definition for frailty is not well established. It has been considered as a physiological decline in multiple organ systems, decreasing the patient’s capacity to withstand the stresses of surgery and disease. The aim of our study was to determinate a correlation between preoperative features and the morbidity after cardiac surgery in aortic valve replacement population. Methods: We selected the 70 years old patients or older who underwent an elective aortic valve replacement. We collected prospectively all preoperative features and frailty traits (Barthel Test; Gait Speed test, Handgrip) also taking into account blood parameters like albumin level and hematocrit previous to the surgery, hospital admissions within 6 months, and we analyze the demographics and medical history of the patients. We compare patients who undergo to stented prosthesis, sutureless or Transcatheter prostheses (TAVI) procedure and follow up. Results: Two hundred patients were enrolled. The mean age was 78 years all. The predicted mortality with Logistic euroScore I was 12,8% with a real mortality lower than expected (3,5%). Pre-surgery frailty in our population was associated with a Gait Speed higher of 7 seconds, Barthel less of 90%, anemia with Hematocrit <32%, albumin level< 3,4g/dl, chronic renal failure, preoperative re-admission and artery disease. The TAVI group had higher morbidity, no differences statistically significant between Stented and sutureless prosthesis group. Frail individuals had longer hospital stays, readmissions and respiratory/ infectious complications. The mortality at 6 months /one year follow up was 4,1 % /0 % respectively; and morbidity (pacemaker implant, respiratory events, readmission); at 6 months /one year of follow up was 13,47 % to 3%. Conclusions: Elderly and frailty population present more complications after a cardiac surgery. A simple frailty score must be considered in cardiac population to avoid increased morbidity
13 Predictors of Left Atrial Thrombus and Short-Term Recurrence of Arrhythmia in Patients Undergoing Electrical Cardioversion for Atrial Fibrillation, a Single-Centre Experience , Callan Gavaghan*
Abstract Background: Systemic thromboembolism is a serious complication of electrical cardioversion. Even in the absence of such complications there exists a significant rate of arrhythmia recurrence post cardioversion. Aims: The aim of this study was to identify factors that may aid clinicians in identifying those patients at increased risk of atrial thrombus formation and short-term arrhythmia recurrence. Methods: One-hundred and twelve patients were retrospectively identified across a 2.5 year period as having undergone electrical cardioversion at the Gold Coast University Hospital for atrial fibrillation or atrial flutter. Demographic, clinical and echocardiogram data was analysed to identify potential predictors of thrombus, unsuccessful cardioversion and arrhythmia recurrence. Results: Cardioversion was successful in 87.6% of patients. Cardioversion was more successful initially in males (p<0.01) and those with reduced atrial volume (p<0.01) and higher left ventricular ejection fraction (p<0.01). Arrhythmia recurrence within 3 months occurred in 57.7% of patients. Recurrence was more likely in those with congestive heart failure (p<0.05) and a longer pre-cardioversion duration of arrhythmia (p<0.05). Spontaneous echo contrast was observed in 3 (2.6%) of patients, whilst left atrial thrombus was observed in 7 (6.2%) of patients. Potential predictors of thrombus were congestive heart failure (p<0.05) and increased left atrial volume (p<0.01). Conclusions: This retrospective study identified a number of factors that may useful in the clinical setting in predicting cardioversion success, both initially and short-term, in addition to predicting thrombus formation.
14 Adipose Triglyceride Lipase Single Nucleotide Polymorphism is Associated with Heart Failure Development after Acute Myocardial Infarction in Patients with Dyslipidemia , Masahiko Hara1 , Daisaku Nakatani1 , Shinichiro Suna1 , Sen Matsumoto1 , Toshihiro Tanaka2 and Yasuhiko Sakata1,3
Abstract Introduction: There is limited information on the incidence of diabetes despite INDIA being the Global capital for Diabetes. Though much of data is available in patients already diagnosed with diabetes but data regarding the new onset diabetes in the subset of Acute coronary syndrome (ACS) is very limited. Materials and methods: This was a Cohort study in which 200 consecutive ACS patients were included. Lab data about their FBS; PPBS; Lipid profile & Hba1c, BMI , BP and their clinical status was collected at the time of admission, after discharge at 2 weeks, 6 weeks & 3,6 & 12 months post ACS. Results: In study 85% were males. Mean age was 56 years. Prevalence of various atherosclerotic risk factors in study population matched the regional prevalence of them. 20% (n=40) developed New onset diabetes (NOD), 2.5% (n=5) developed Impaired fasting Glucose, 6% (n=12) developed Impaired glucose tolerance in and 1.5% (n=3) developed both Impaired fasting glucose and Impaired Glucose tolerance over a follow up period of 1 year. MACE rates & Revascularisation rates were significantly higher in NOD population. NOD patients had significantly higher BMI, waist circumference, BP, TG, LDL and Low HDL. NOD patients were on Higher dosage of statins, diuretics and Beta blockers. Conclusion: The study highlights two important things, first incidence of new onset diabetes in acute coronary syndrome patients is High, Second new onset diabetes has a significant impact on the clinical outcome of ACS patients
15 Study of New onset Diabetes Mellitus in Acute Coronary Syndrome Patients , Ashish Singhal1 *, Surbhi Gupta2 , Ankur Singhal3 and A George Koshy1
Abstract Introduction: There is limited information on the incidence of diabetes despite INDIA being the Global capital for Diabetes. Though much of data is available in patients already diagnosed with diabetes but data regarding the new onset diabetes in the subset of Acute coronary syndrome (ACS) is very limited. Materials and methods: This was a Cohort study in which 200 consecutive ACS patients were included. Lab data about their FBS; PPBS; Lipid profile & Hba1c, BMI, BP and their clinical status was collected at the time of admission, after discharge at 2 weeks, 6 weeks & 3,6 & 12 months post ACS. Results: In study 85% were males. Mean age was 56 years. Prevalence of various atherosclerotic risk factors in study population matched the regional prevalence of them. 20% (n=40) developed New onset diabetes (NOD), 2.5% (n=5) developed Impaired fasting Glucose, 6% (n=12) developed Impaired glucose tolerance in and 1.5% (n=3) developed both Impaired fasting glucose and Impaired Glucose tolerance over a follow up period of 1 year. MACE rates & Revascularisation rates were significantly higher in NOD population. NOD patients had significantly higher BMI, waist circumference, BP, TG, LDL and Low HDL. NOD patients were on Higher dosage of statins, diuretics and Beta blockers. Conclusion: The study highlights two important things, first incidence of new onset diabetes in acute coronary syndrome patients is High, second new onset diabetes has a significant impact on the clinical outcome of ACS patients
16 Valvular Heart Disease And “Nonvalvular Atrial Fibrillation” Coumadin or a Novel Oral Anticoagulant Variables to Consider , John D Rozich
Abstract Clinicians treating atrial fibrillation must initially identify and ultimately verify whether this rhythm fits within the definition of “non-valvular” atrial fibrillation (NVAF). The spectrum of structural heart disease can render this process a challenge as what is meant by NVAF is continually evolving. Phenotypic variants in valvular heart disease including repaired valvular injury have undergone definitional updates pertaining to NVAF. This has produced inconsistencies in each subsequent authoritative guideline often further confusing practitioners. At issue is whether a vitamin K dependent antagonist (VKA) exemplified by warfarin, or one of the new novel oral anticoagulants (NOACs) is appropriate to treat NVAF in a patient with a form of valvular heart disease. The present effort is a practical review of the current clinical landscape wherein practitioners struggle to advise and treat patients with optimal anticoagulation therapy with NVAF as currently defined. It is also a review of why certain valvular conditions may actually still fit within the definition of NVAF allowing NOAC use.
17 Examination of Facial Shape Changes Associated with Cardiovascular Disease Using Geometric Morphometrics , Rose Chinly Mae H. Ortega*, Christine Cherry E. Solon, Olive S. Aniez and Lucilyn L. Maratas
Abstract Facial investigations using geometric morphometrics has been used in many studies to affirm that a particular disease can attribute to an individual’s facial morphology. A landmark based geometric morphometric analysis was used in this study to asses if facial shape changes are associated with cardiovascular diseases (CVD) and if facial morphology of the CVD individuals differs from the normal ones. In the Municipality of Cantilan, Surigao del Sur, frontal face images taken from 32 cardiovascular disease patients and 32 normal individuals were examined using forty-one manually positioned landmarks. Result showed that facial morphology of the CVD group differs from non-CVD group. Procrustes ANOVA showed significant values for the individual symmetry and directional asymmetry. The analysis of structure by the Principal Components reveals particular variations and the scatter plot of the residual asymmetry shows distinct differences between CVD and non-CVD. Therefore, cardiovascular diseases contribute to facial shape changes and that development of facial morphology differs between CVD and non-CVD group
18 External Counterpulsation (ECP) Therapy as an Effective Treatment among Patients with Heart Failure undergoing Cardiac Rehabilitation , JS Ho*, FY Chee, ZJ Huang, CH Koh and SY Tan
Abstract Background: External counterpulsation (ECP) is a noninvasive procedure using lower limbs pressure cuffs to improve coronary artery blood flow and offload the heart. There is currently no data on the effects of ECP among patients undergoing cardiac rehabilitation (CR). This pilot study aims to determine whether ECP improves exercise capacity among patients with heart failure or post acute myocardial infarction undergoing cardiac rehabilitation. Methods: This is a prospective randomised-controlled pilot study of the effect of ECP in patients with mild to moderate heart failure or post-acute myocardial infarction undergoing CR. Eligible patients were randomised at ratio of 1:1 to either combination of CR and ECP or CR only. All subjects received up to 16 sessions of conventional CR. For the combination arm, subjects received up to 16 one-hour sessions of one-hour ECP therapy following each CR session. All underwent baseline cardiopulmonary testing (CPET) and NT-Pro BNP determination and after completion of study. Results: A total of 4 patients were enrolled in the study from June 2016 to Jan 2017. Two were randomised to combination arm and two into CR arm. Post treatment VO2MAX improved 12 % in the combination arm (23.3±5.6 ml/min/kg from20.8±5.3 ml/min/kgat baseline) compare to 5% in the CR arm (23.0±6.2 ml/min/kg from21.9±2.3 ml/min/kg at baseline). There were no significant difference in the post treatment VO2MAX between groups, p=0.97. There was a 16% increased in post treatment maximum oxygen pulsein the combination group (14.4±1.0ml/beat from12.4±0.5ml/beat at baseline) compare to a 7.8% increased in the CR group (12.4±2.2ml/beat from11.5±1.4ml/beat at baseline). Interestingly, NT proBNP level worsened post treatment in the combination group (447.5±563.6 pre treatment to 472.7±560.5 post treatment), whereas improved in the CR only group (950.5±522.9 pre treatment to 327.5±202.6 post treatment). Conclusion: Cardiac Rehabilitation is known to improve exercise capacity among heart failure patients. ECP can further enhanced maximum oxygen consumption and maximum oxygen pulse in patients with mild to moderate degree of heart failure or post myocardial infarction undergoing cardiac rehabilitation. More studies with larger numbers are needed to prove this benefit of ECP
19 Hypertension and Takayasu Disease , BENALLAL Souad1 *and BOUAYED Mohamed Nadjib2
Abstract Introduction: Takayasu’s disease (TD) is a primary, inflammatory, rare, segmental and multifocal arteritis of the aorta and its branches, of unknown etiopathogenesis. Hypertension is a major complication, sometimes revealing the disease, whose mechanisms are multiple, dominated by the lesion of the aorta and renal arteries. Patients and methods: We report a series of 63 cases treated for Takayasu’s disease resulting from a monocentric, retrospective study from April 2oo6- July 2014, with an average age of 30 years with a female predominance of 83%. Result: In our series: 51 patients with hypertension, including 29 (57%) resistant hypertension (under tri see quadritherapy). In 87% of cases lesion of the supra aortic trunk, 29% with aortic lesions and renal arteries, 7.93% with isolated renal arteries and 7% with aortic coarctation cases, valvular heart disease in 7% of cases. Association with tuberculosis in 7.93% of cases and a dysthyroidism in 11.1% of cases. That 49% benefited from surgical treatment. Discussion: Involvement of the aorta and renal arteries seen in half of patients with TD is the leading cause of hypertension. In general, hypertension is severe, not or poorly controlled by medical treatment and is accompanied by cardiac and renal repercussions. Conclusion: Hypertension is common during TD; it is a poor prognostic factor, more serious than the cause is renovascular. Early diagnosis and appropriate therapy will help to prevent a handicap, which is sometimes major for these patients, most of whom are young. Surgical treatment of renal and aortic lesions of TD is indicated when there is severe hypertension, not or poorly controlled by heavy medical treatment, and the indications should be weighed well. The spontaneous evolution in these patients is burdened with a not insignificant mortality. Management and therapeutic decisions must be multidisciplinary.
20 Clinical Presentation and Prognosis in Heart Failure Patients with Reduced Ejection Fraction: A Prospective One-Year Follow-Up Study in National Cardiovascular Center Harapan Kita, Indonesia , Rarsari Soerarso1 , Hansen Angkasa2 , Gladys Kusumowidagdo2 , Catherine J. Josephine2 , Mohammad Risandi P2 and Bambang B. Siswanto1 *
Abstract Background: Systolic heart failure (HFrEF) is characterized by ejection fraction of <40% and causes significant mortality and morbidity rate. We seek to characterize Indonesian patients’ clinical presentation (low to middle income country), oneyear outcome and prognostic factors of HFrEF patients. Methods and Results: Prospective cohort with consecutive sampling method was done in National Cardiovascular Center Harapan Kita (NCCHK), Jakarta from October 2013 to March 2014. NCCHK is a national heart referral center for 34 provinces in Indonesia. Data was obtained from medical records of HFrEF patients enrolled in ASIAN-HF study. Oneyear follow up was done via medical record or phone interview. Data was analyzed using SPSS version 23. Ninety HFrEF subjects (57.3±1.17 years) were obtained. Angina was more commonly seen in higher EF group (21-40%; p=0.016). At one-year, 22.2% died. Lower EF group had higher rate of death (p>0.05). Age, rales and elevated JVP were predictive of death regardless of EF (p<0.05). Conclusions: Angina was more commonly seen in higher EF group. Signs of congestion are associated with poorer prognosis. Low EF (<20% vs 21-40%) had clinically high rate of death (26.7% vs 13.3%, p>0.05).
21 Arterial Hypertension in Patients Aged 15 Years and Over in the Cardiology Department of Sikasso Hospital in Mali: About 250 Cases , Sangaré Zoumana1,2*, Traore Abdoulaye Kissima1 , Coulibaly Adama1 , Doumbia Modibo1 , Mingou Joseph Salvador2 , Traore Ousmane1 , Birwe Leon1 , Traore Salia1 , Dioma Elie1 , Sarr Abdoul Wahab1 , Sanogo Drissa1 , Bodian Malick2 , Menta Ichaka3 and Kane Adama4
Abstract Introduction: High blood pressure is a global public health problem due to its high prevalence and multiple complications that often lead to major disability. It is a major cardiovascular risk factor for often late diagnosis. It is emerging in Africa, particularly in Mali. Objective: To determine the epidemiological, diagnostic and progressive aspects of high blood pressure in patients 15 years of age or older. Patients and methods: This is a descriptive cross-sectional study over a two-year period (June 1, 2008 to May 31, 2010) in the Cardiology Department of Sikasso Hospital in any patient aged 15 years and over admitted for high blood pressure. Results: Two hundred and fifty patients were selected, representing a hospital prevalence of 18.2%. High blood pressure was most common in patients 50 years of age and older (65.6%), followed by those 19 to 49 years of age (30%) and those 15 to 18 years of age. The average age of the population was 50 years (15-92 years) with a male predominance of 61.6% and a sex ratio of 1.6. The predominance of traditional housewives and farmers was 30% and 26.4%. The notion of a family history of high blood pressure was found in 56.4% of cases. High blood pressure grade 3 according to the classification of the World Health Organization was mostly found in our patients (64%). Biological abnormalities were dominated by hyperglycemia (14%), hypercreatininemia (8%). The main clinical manifestations were headache (40%), dyspnea (20%) and vertigo (16%). On physical examination, there were mainly signs of heart failure (50%), arrhythmia (12%), heart murmur (28%), hemiplegia (10%). The electrocardiogram showed left ventricular hypertrophy in 79.2% of cases, left atrial hypertrophy (16.4%), repolarization disorder (3.2%), atrial fibrillation (1.2%). Chest x-rays showed cardiomegaly in 67.2%. Echocardiographic abnormalities were left ventricular hypertrophy (64.8%), left atrial dilation (16.4%), left ventricular systolic dysfunction (14.4%). Therapeutically, diuretic combination with conversion enzyme inhibitors was the most prescribed treatment (58%), followed by combination of calcium channel blockers and conversion enzyme inhibitors (15.6%), calcium channel blockers (18%), conversion enzyme inhibitors (4.4%), beta-blockers (4%). The low-salt diet and physical activity were constantly recommended. Complications were hypertensive retinopathy (33.2%), heart failure (25.2%), stroke (24.8%), renal failure 4.8%. Conclusion: High blood pressure is a major public health problem. This work identified a high hospital prevalence of high blood pressure in patients aged 15 years and older with a clear male predominance. Late diagnosis is responsible for serious complications that often lead to major disabilities.
22 A Booby Trap Mitral Valve , Ahmed Al Bulushi, Ahmed Hashim Gurani and Abdolazeem Elnour*
Abstract The mitral valve and the mitral annulus can be considered a surgical trap by many uncommon surgical situations mainly in infective endocarditis, previous surgical intervention of the mitral valve, and/or calcification. All these scenarios can create a dangerous surgical Pathways and difficulties in replacing a prosthetic valve or annuloplasty ring. All mitral structural unit can be affected such as anterior or posterior mitral annulus, intervalvar fibrous body, sub-annular and Supra-annular tissues. This type of damage to the mitral valve can cause and lead to surgical challenges to any cardiac surgeons. We are presenting a case which reflects all these challenges clinically and surgically and our novel technique (modified anterior atrium sliding technique that we used to deal with it)
23 Spironolactone Versus Eplerenone as Adjunctive Treatment in Patients with Heart Failure , Mohammad A.K.Hasan* and Hossam Kandil
Abstract Background: The goals of treatment in patients with heart failure (HF) are to improve their clinical status, functional capacity, and quality of life, prevent hospital admission and reduce mortality. Aim of the work: This work aims to evaluate spironolactone versus eplerenone as an adjunctive therapy regarding tolerability in patients with HF (NYHA II to IV) already on anti-failure treatment with beta Blockers (BB) and/or ivabradine and their effect on major adverse cardiac events. Study design: 100 patients were recruited and randomized into 2 groups (n=50/group); group 1 received spironolactone 25mg/d that was titrated to 100mg/d if tolerated, while group 2 received eplerenone 25mg/d that was titrated to 50mg/d if tolerated. Follow up of: symptoms, signs, potassium level, BNP, renal functions, systolic function and side effects was done over 3 months in 3 visits. Results: After 3 months it was found that 39 patients (78%) in each group showed good or marked improvement, with non significant P-value. Regarding side effects, the spironolactone group showed incidence of hyperkalemia in 6 patients (12%) in the spironolactone group; with 0% incidence in the other group with significant P-value (P<0.001). On the other hand 5 patients (10%) had gynecomastia in the spironolactone group with 0% incidence in the eplerenone group with significant P-value (P<0.001). Conclusion: spironolactone and eplerenone are both effective but the eplerenone is much more safer than spironolactone when added as an adjunctive therapy in patients with HF and are kept on full medical therapy including BBs.
24 Cardio Vascular Disease and its Prevention , Purusharth kumar sharma
Types of CVD ? CORONARY ARTERY DISEASE ? BLOOD PRESSURE ? CARDIAC ARREST ? CONGESTIVE HEART FAILURE ? CONGENITAL HEART DISEASE ? PERIPHERAL ARTERY DISEASE ? ARRHYTHMIA Cause of CVD • The major cause of coronary artery disease , cardiac arrest , congestive heart failure and peripheral artery disease is THE BLOCKAGE OR OBSTRUCTION IN THE ARTERY WHICH IS CAUSE BY PLAQUE • THIS PLAQUE MAINLY OCCUR DUE TO LDL I .e low density lipo protein Dissolve the Plaque (Method) • Now we should dissolve the plaque in such a way so it should not form again. • And should be dissolved with more effect and very less side effect • If the medicine taken by the patient for long time then also it should have less side effect Method • Commiphora wightii in Hindi is known as guggul • In this Guggul there is a compound called Guggulsterone is present • This compound is Phytosteroid in nature • This compound is having two stereoisomers E AND Z In this E sterio isomers is very effective • As it boost or we can say it will catalyze an enzyme called cytochrome p 450 heme enzyme. which is a protein enzyme and heme as co factor and term p 450 explain that the peak level of absorption of wavelength is 450 nm for this enzyme • This enzyme is primarily present in inner membrane of mitochondria and in endoplasmic reticulum.
25 Treatment of Acute Iliofemoral Deep Vein Thrombosis; Does Catheter Directed Thrombolytic Therapy Change Outcomes? , Ayman M. Fakhry1 , El-Sayed A. Abd El-Mabood2,3, Waleed A. Sorour4 , Ayman M. Abdelmofeed2 , Taher H. Elwan2,5, Ahmed Fouad Ahmed2 Mohamed E. Abd Ellatief 2 and Saied ELMOKKADEM
Abstract Background: Iliofemoral deep vein thrombosis (DVT) is associated with severe post-thrombotic morbidity when treated with anticoagulation alone. Catheter- directed thrombolysis (CDT) allows early removal of thrombus and reduces valvular reflux and Post-thrombotic Syndrome (PTS). Patients and methods: This prospective randomized multi-center controlled two- arm blind study was conducted in 6 centers on 252 patients with iliofemoral DVT. Patients were randomly allocated by using simple random allocation cards method into two groups; Group (A): CDT followed by oral anticoagulation (N=126 (50%)), Group (B): Standard DVT therapy (N=126 (50%)). Follow-up was for 24 months. Results: Patients of group (A) significantly complained less pain at 10 & 30 days (P-Value: 0.02 & 0.04 respectively). Also there was significant decrease in leg circumference in group (A) at 10 & 30 days (P-Value: 0.001 & 0.03 respectively). Patency of iliac vein segment was significantly higher in group (A) during the 24 months follow up (P-Value <0.001 (HS)). Patients in group (A) developed less PTS at six months, at one year and at two years (P-Value: 0.024, 0.017 and 0.035 respectively). Better Quality of life was observed in group (A) (P-Value: 0.003). Conclusion: Addition of catheter-directed thrombolysis in the treatment of acute iliofemoral DVT; was safe and tolerated by most of the patients with better effect to reduce leg pain & circumference. It was considered a protecting weapon to prevent post-thrombotic syndrome and so improve quality of life and was related to achievement of higher iliac vein patency and less reflux.
26 FMTVDM Quantitative Imaging Replaces Current Qualitative Imaging for Coronary Artery Disease and Cancer, Increasing Diagnostic Accuracy and Providing PatientSpecific, Patient-Directed Treatment , Richard M. Fleming1 *, Matthew R. Fleming1 , Tapan K. Chaudhuri2 and Andrew McKusick1,3
Keywords: FMTVDM, Quantification, Nuclear Medicine, Nuclear Cardiology, Cancer, FDA, uBiome, Biomarkers The time for practicing medicine by merely looking at a qualitative picture of someone’s heart, chest or mammogram, or by taking a patients blood sample to measure cholesterol or inflammation levels and then letting the Doctor decide if they think you have heart disease or cancer, has ended. So too has the period of time for treating someone merely based upon mammography (x-rays), CT, MRI, PET, SPECT/planar imaging or any other test that requires your physician to qualitatively interpret what they think they see, and then decide you do or don’t have a medical problem. In 2018, CMS, ASNC and the SNMMI all called for improvements in diagnostic testing. These three groups emphasized the need to develop and implement quantitative imaging to replace the current qualitative imaging, with the primary endpoint being to reduce clinical mistakes and save time, money and lives. To address these clinical errors, the first author began working in 1989 on the intrinsic errors within our diagnostic tests, beginning with coronary arteriography [1]. Continued work lead to the discovery and development of both the “Inflammation and Heart Disease” and “Angina” theories, resulting in a shift in thinking that cholesterol was the sole cause of heart disease, to the understanding that coronary artery disease (CAD) is an inflammatory process which builds up in the walls of the arteries of the heart, making the arteries less able to relax (dilate), to delivery more blood to regions of the heart when needed, thereby producing angina [2-5].
27 A Comparative Open Labelled Study on Ivabradine and Bisoprolol Prescribed in Combination Versus Maximum Dose Titration of Bisoprolol in Patients with Systolic Heart Failure and Left Ventricular Systolic Dysfunction , Sadia Akram1 *, Niaz Ali1 , Miqdad A Khan2 , Natasha Baloch1 , Hasan A Khan2 and Najaf A Khan2
Abstract Background: Increased resting heart rate is associated with cardiovascular outcomes in patients with heart failure and reduced ejection fraction (HFrEF). Despite high volume prescribers of beta blockers patients does not achieve recommended target heart rate. The primary objective of this study was to assess the efficacy of ivabradine as adjunct therapy with beta blockers in south east Asian population systolic heart failure and left ventricular systolic dysfunction. Methodology: This single center, open labelled, randomized study included 113 patients in sinus rhythm with HFrEF and left ventricular systolic dysfunction from outpatient department. Ivabradine was initiated in 45% patients with SR. Patients with LVEF < 35% by Teichholz method, NHYA class II-III, sinus rhythm and resting HR > 70 bpm, already on bisoprolol 5 mg were divided into 2 groups; Group 1 (n= 56) patients were uptitrated to bisoprolol 10 mg and Group 2 (n= 57) patients received ivabradine 5 mg b.i.d in addition to bisoprolol 5 mg. Blood samples for NTproBNP level, an ECG, echocardiogram, NYHA functional class, systolic and diastolic BP were taken at baseline and at the end of 6 months follow-up in both groups Results: After 6 months HR decreased significantly from 94.82±7.03 to 68.75±5.35 bpm (p < 0.0001), with more patients in NHYA functional Class I than Class II and III and decrease in BNP level from 969.8.3±348.9 to 348.6±230.2 pg/ml (p < 0.0001) in group 2 patients. A significant increase in LVEF was observed with the addition of ivabradine from 31.40±5.37 to 41.68±5.33 % (p < 0.0001). However, mean systolic and diastolic blood pressure was not affected by the addition of ivabradine. Conclusion: This study concludes that patients with HFrEF demonstrated good tolerability, efficacy and NYHA functional class with the combination of ivabradine and bisoprolol therapy
28 Left Atrial Myxoma A Clinical Case , Juan Francisco Pérez Salúm
Cardiac tumors are generally benign. But its danger lies not in its potential malignancy, but in its location. These tumors settle inside the cardiac cavities, at the origin or mouth of the great vessels or even on the valves. This can obviously lead to life-threatening complications, either due to mechanical causes or disturbances in the electrical conduction of the heart. Cardiac tumors are very rare and occur in both neonates and the elderly. These tumors can be confused with thrombi, abscesses or vegetations, so a correct diagnosis is essential [1]. Echocardiography is a very important diagnostic tool and its appearance allowed the early diagnosis of these tumors, which were previously diagnosed only post mortem [2]. Here I present a case of a Japanese 66 years old female, in treatment since March 2013 for hyperthyroidism, in use of metimazol 5 mg/24 hs, propanolol 10 mg/24 hs. She is not diabetic, nor hypertensive, but she has dyslipidemia [3]. She denies allergies. The patient does not have history of ethylic intake and she does not smoke. The functional class (NYHA) is II/ IV. Syncope in one opportunity eight years ago. Previous surgeries: appendectomy, two cesareans. At 28 October 2014, by 5 P.M, the patient had felt left hand paralysis. She went to a Clinician, who recommended attention by a Neurologist. The Neurologist asked for a IRM where he saw an old and another new lacunar ischemia. He had ordered an echocardiography and vascular Doppler of Carotid and Vertebral arteries. The patient begun clopidogrel 75 mg + aspirin 100 mg/24 hs and atorvastatine 80 mg/24 hs.
29 Coronary Artery Bypass Surgery or Interventional Cardiology? Why not both? Let’s go for Hybrid Coronary Revascularization , Khalida Soomro*
Abstract The options for coronary artery disease have greatly expanded during the course of the last two and half decades with the advent of hybrid technology in the 1990s. The hybrid option for treating cardiac disease implies using the technology of both interventional cardiology and cardiac surgery to offer the patients the best available treatments for coronary artery disease while minimizing the risks of the surgery, example can be a patient with a partial blockage in one coronary artery and a complete blockage in another. In this case, a combination revascularization approach might work best to restore blood flow to the heart muscle. An interventional cardiologist inserts a stent into one coronary artery to open it up, and then a surgeon grafts a bypass vessel to let blood flow around the other blockage. Hybrid Cardiac Surgery a collaborative approach reduces risk of complication, shorten recovery times and improve outcomes This fragmented approach to care is starting to change to a much-needed innovation in hospital design by set up including all the equipment needed for diagnostic imaging, minimally invasive procedures, and traditional surgery, the key requirement is productive collaboration of heart team comprising heart surgeons, interventional cardiologists, and other specialists by working together in the same space, at the same time. Although indications and patient selection of these procedures are still to be defined but high-risk patients have already been shown to benefit from hybrid approaches, In conclusion, HCR is can be used to treat multi-vessel CAD with favourable early results, though growth in the field is limited by surgical experience and success with minimally invasive techniques, should be performed in high volume centers.
30 The Correct Replacement for the Wrong Starling’s law is the Hydrodynamic of the Porous Orifice (G) Tube: The Complete Physics and physiological Evidence with Clinical Relevance and Significance , Ahmed N Ghanem
Abstract Introduction and objective: To report the complete evidence that Starling’s law is wrong and the correct replacement is the hydrodynamic of the G tube. New physiological evidence is provided with clinical relevance and significance. Material and methods: The physics proof is based on G tube hydrodynamic. Physiological proof is based on study of the hind limb of sheep: running plasma and later saline through the artery compared to that through the vein as regards the formation of oedema. The clinical significance is based on 2 studies one prospective and a 23 case series on volumetric over load shocks (VOS). Results: Hydrodynamic of G tube showed that proximal, akin to arterial, pressure induces suction “absorption” not “filtration”. In Poiseuille’s tube side pressure is all positive causing filtration based on which Starling proposed his hypothesis, The physiological evidence proves that the capillary works as G tube not Poiseuille’s tube: Oedema occurred when fluids are run through the vein but not through the artery. There was no difference using saline or plasma proteins. The wrong Starling’s law dictates the faulty rules on fluid therapy inducing VOS and causing ARDS. Conclusion: Hydrodynamic of the G tube challenges the role attributed to arterial pressure as filtration force in Starling’s law. A literature review shows that oncotic pressure does not work either. The new hydrodynamic of G tube is proposed to replace Starling’s law which is wrong on both forces. The physiological proof and relevance to clinical importance on the pathogenesis of clinical syndromes are discussed.
31 Giant Mediastinal Ganglioneuroma in a Female Child , Yasser A El Sayed1 *, Moh Fathy2 , Moh Salem3 , Alaa Eisa4 , Ashraf Enait5 , Kerolos Emad6 , Bothinah A Al Haseeb7 , Mona Atef8
Abstract We report an eight year female patient admitted to the department of pediatrics at Abbasia Pulmonary Hospital at Cairo, Egypt. The child was complaining of pain on the right lower chest and upper abdome. On evaluation by CT of the chest, there was a huge posterior mediastinal mass occupying more than three quarters of the right hemithorx. Preoperative histopathology using CT guided needle biopsy revealed ganglioneuroma. The tumor was resected completely via right standard posterolateral thoracotomy without complications. Postoperative histopathology confirmed the diagnosis of ganglioneuroma. Keywords: Ganglioneuroma, Posterior mediastinum, Pediatrics. Introduction Gangioneuromas are rare benign neurgenic tumors which arises from neural crest cells that represents the final maturation stag of neuroblasts [1]. The incidence of ganglioneuoma was reported to be 1 in 1,000,000 and thought to develop de novo rather than by maturation of existing neuroblastoma [2]. There are no known risk factors, however the tumors may be associated genetic problems, such as neurofibromatosis type 1 [3]. Ganglioneuromas are commonly classified as pediatric mediastinal tumors occurring in females more than males with a ratio about 3: 1 [4]. Most of the cases are asymptomatic and usually discovered accidentally.
32 Parasympathetic and Sympathetic Nervous System Monitoring and Anxiety-Like Symptoms: Improved Differentiation and Improved Outcomes , Colombo J1 *, Murray GL2 , Pinales JM3 , Acosta C3 , Lill R3 , Friedman MJ4 and DePace NL5
Abstract Anxiety disorders (DSM-5) and disorders having anxiety laden symptoms (e.g., PTSD and attention disorders) often include several physiologic symptoms which involve the Parasympathetic and Sympathetic nervous systems (P&S). Our research has identified four P&S disorders that are associated with these symptoms: 1) Sympathetic Excess (SE) secondary to Parasympathetic Excess (PE) as an abnormal stress response, 2) Sympathetic Withdrawal (SW) upon assuming headup posture (standing) associated with Orthostatic Dysfunction, 3) SE upon standing associated with Syncope, and 4) Autonomically mediated cardiac arrhythmia, including Sinus Arrhythmia. All four disorders involve poor brain profusion which is known to contribute to Anxiety-like symptoms. They also contribute to (sub-clinical) depression, another frequent co-morbidity. Resting and challenge P&S responses were assessed noninvasively using the ANSAR Medical Technologies, Inc. (Philadelphia, PA) software (ANX 3.0 autonomic function monitor). Patients diagnosed with Anxiety or Anxiety-like symptoms from a large cardiology practice serving both urban and rural areas were followed with more than one assessment over four years (an average of 3.3 assessments per patient; 50.5% Female; average age of 57 years). Patients diagnosed with Anxiety or Anxiety-like symptoms, with one of the four P&S disorders were also treated for their P&S disorder. Relieving P&S dysfunction within this cohort reduced Anxiety or Anxiety-like symptoms by over 45%. P&S guided therapy for patients with Anxiety or Anxiety-like symptoms, may reduce the burden of Anxiety, improve patient outcomes and quality of life, reduce the risk of suicide, aid the psychiatrist in focusing on the etiology of Anxiety, and reduce healthcare costs.
33 Antioxidants Effect Changes in Systemic Parasympathetic and Sympathetic Nervous System Responses and Improve Outcomes , Acosta CR1 , DePace NL2 , DePace NL3 , Kaczmarski K3 , Pinales JM3 and Colombo J4 *
Abstract Parasympathetic and Sympathetic (P&S) imbalance is associated with increased morbidity and mortality risk, including heart failure, coronary artery disease, atrial and ventricular arrhythmias, hypertension and orthostatic disorders, and syncope. Most cardiac medications effect only one or the other of the P&S nervous systems, including: β-blockers, α-blockers, α-agonists, and anti-cholinergics. Non-pharmaceutical treatments also affect the P&S nervous systems; however, nonpharmaceutical treatment is rarely addressed or studied, despite significant evidence-based data demonstrating normalization of Sympathovagal Balance. Fifty consecutive patients from a busy suburban cardiology practice were enrolled in a supplement study. Patients were provided supplements that included 200mg of Alpha-Lipoic Acid (ALA) and 100mg of Co-Enzyme Q10 (CoQ10) which they were instructed to take twice a day, one each with breakfast and dinner. P&S Monitoring (Physio PS, Inc., Atlanta, GA, USA) and Quality of Life (QoL) questionnaires were administered at three month intervals. The combination of supplements, ALA and CoQ10, had a positive effect on the P&S nervous systems as measured directly and also indicated by improvements in BP, HR and reported QoL. The study indicates these supplements help to improve both the resting and challenge P&S responses and resultant physiology. The results suggest antioxidant therapy is a potential complimentary therapy to pharmacological management of patients with poorly controlled BP (i.e., hypertension and possible hypotension) as well as in patients with tachycardia or palpitations. This is a hypothesis generating study of significant importance in an often neglected area of cardiovascular disease in which additional research and studies are needed.
34 Ejection Fraction and Espvr: A Study in the Mechanics of Left Ventricular Contraction , Rachad Mounir Shoucri*
Abstract The end-systolic pressure-volume relation (ESPVR) is the relation between pressure Pm and volume Vm in the heart left ventricle when the myocardium reaches its maximum state of activation during contraction near end-systole. Relations between the ejection fraction (EF), parameters describing the ESPVR and the areas under the ESPVR are derived in this study for a linear model of the ESPVR. An important feature of the model is the inclusion of the active pressure generated by the myocardium during an ejecting contraction (also called isovolumic pressure Piso) in the mathematical expression of the linear ESPVR. Criteria that can help in understanding the problem of heart failure with normal or preserved ejection fraction (HFpEF) are discussed. Applications to clinical data published in the literature are presented, the applications show the consistency of the mathematical formalism used. When ratios of pressures are used, the calculation can be carried out with clinical data measured in a non-invasive way (the ratio of pressures can be calculated). This study shows that the EF is just one index of several indexes that can be derived from the ESPVR for the assessment of the ventricular function, and that using bivariate (or multivariate) analysis of data is superior to univariate analysis for the purpose of classification and segregation between different clinical groups.
35 A Clinical Report on the Relationships Between Metabolism and Obesity, Type 2 Diabetes, Cardiovascular Risk by Using the GH-Method: Math-Physical Medicine , Gerald C Hsu
Introduction By using the GH-Method: math-physical medicine and big data on one particular patient (the author), this clinical paper describes the relationship between his metabolic state and medical conditions, including obesity, type 2 diabetes (T2D), and cardiovascular risk. Method The obese patient was diagnosed with T2D, hyperlipidemia, and hypertension over 25 years ago and suffered five cardiac episodes from 1994 to 2006. For this study, approximately 1.5M detailed metabolic conditions and lifestyle data (1/1/2012 - 12/31/2018) were collected and processed; advanced mathematics, physics concepts, engineering modeling, and artificial intelligence (AI) were utilized rather than following the traditional biology and chemistry approach as research tools. The author defined two new terms: Metabolism Index (MI) and General Health Status Unit (GHSU) to evaluate his overall metabolism and associated chronic diseases.
36 Hepatocellular Carcinoma with Vascular Invasion and Cardiac Metastasis Causing Progressive Liver and Renal Failure: A Case Report and Literature Review , Yaser Khalid1 *, Neethi Dasu1 , Troy Randle2 , Debashis Reja3 , Adrian Pearson2 , Kirti Dasu4 , Kailash Lal5 , Richard Walters5 and Nishant Parikh1
Abstract Hepatocellular carcinoma (HCC) is the most common primary tumor of the liver and eighth-most common cancer. The most frequent sites of metastasis are the lungs, the bones, the lymphatics, and the brain. An isolated metastasis of a HCC to the right atrium and inferior vena cava (IVC) is extremely rare. Here we discuss a case of a 61-year-old female who presented with two weeks of generalized weakness and was found to have advanced stage HCC with metastasis to the IVC and right atrium of her heart. We recommend that echocardiography should be routinely performed for all patients with advanced HCC because if metastasis to the right atrium is not detected early enough, the clinical course will be complicated by many unexpected cardiovascular complications that can be fatal. Currently the prognosis for this disease is very poor so further investigation into surgical and medical treatments needs to occur
37 Transcatheter Closure of Atrial Septal Defect with Amplatzer Device in Adolescence and Adults: Short Term Results: MCVTC Experience , Raja Ram Khanal*, Arun Sayami, YD Bhatta, Ratna Mani Gajurel, Ravi Sahi , Chandramani Poudel, Hemant Shrestha, Surya Devkota and Sanjeev Thapa
Abstract Introduction: Atrial septal defect (ASD) is one of the common congenital heart diseases accounting for 8% to 10% of total congenital heart disease at birth and one of the most common diseases in adulthood. Ostium Secundum (OS) ASD has been successfully closed surgically for over several decades. But even though the results are better, it is associated with discomfort, morbidity, and a thoracotomy scar. Transcatheter closure in these patients has advanced rapidly in recent years and represents a growing field in invasive cardiology. Methods: This prospective study was conducted at Manmohan cardiothoracic vascular and transplant center, Maharajgung, Kathmandu, Nepal. Fifty-two (52) patients with a diagnosis of OS ASD assessed for device closure. Patients underwent transthoracic and trans oesophageal echocardiography for the defect location, size, number, and associated anomalies. All patients with OS ASD fulfilling the inclusion criteria enrolled for device closure. The procedure conducted under fluoroscopy and transesophageal guidance. The cases were followed up at 3 and 6 months, reassessed clinically and by echocardiography for any complications. Results: The patients with ASD who enrolled in this study belonged to the age group of 14 to 63 years. The device closure attempted in 46 patients, and the remaining six patients excluded from the procedure due to unsuitable anatomy after GA guided TEE done. Among 46 patients, 44 (95%) had successful device closure. The mean age of the patient was 35.7+ 10 and 33 (71.7%) female, with 13 (28.3%) males. Conclusions: The transcatheter device closure of ASD in adolescents and adults has a high success rate with fewer complications and found to be safely documented during immediate and short term follow up. However, long terms follow up is required to conclude it.
38 An Observational Study to Assess Outcome of NSTEMI Patients with Raised Serum Uric Acid Level in a Tertiary Care Hospital of Bangladesh , Chakma PJ1 , Barua M2*, Kuryshi SA3 , Barua B4, Roy MS5
Abstract Background: Non-ST segment elevation myocardial infarction (NSTEMI) is the commonest form of ACS and a leading global cause of premature morbidity and mortality. Evidences link serum uric acid with short and long-term major adverse outcomes (MACE) in patients with NSTEMI. Objective: To see in-hospital outcome of NSTEMI patients with raised serum uric acid level. Methodology: This cross-sectional observational study was conducted in the Department of Cardiology, Sylhet MAG Osmani Medical College Hospital, Sylhet during the period from July, 2017 to June, 2019. Fifty NSTEMI patients with raised serum uric acid (>7mg/dl in male; >6mg/dl in female) level (Group A) and fifty NSTEMI patients with normal serum uric acid level (group B) admitted within 24 hours of symptom onset were consequently enrolled. In-hospital complications and mortality were recorded while continuing standard treatment for the event. Results: The mean age was 60.82 (SD 9.62) years in group A and 49.90 (SD 10.40) years in group B. The mean age of the patients of group A was significantly higher than patients of Group B (p<0.001). Male preponderance was in both groups (84.0% versus 80.0%; p=0.603). Diabetes mellitus (52.0% versus 22.0%; p=0.002), hypertension (78.0% versus 52.0%; p=0.039) and dyslipidaemia (48.0% versus 12.0%; p<0.001) were more frequent in group A than that of group B. But smoking status (70.0% versus 66.0%; p=0.668), family history of CAD (10.0% versus 26.0%; p=0.476) did not differ significantly. Killip class did not differ significantly between group A and group B (p=0.127). In-hospital mortality was 5 (10.0%) patients in group A and 2 (4.0%) patients in group B; did not reach the level of significance (p>0.05) and complications such as post MI angina, cardiogenic shock, acute left ventricular failure, re-infarction, sinus tachycardia, sinus bradycardia, atrial flutter, atrial fibrillation, bundle branch block, ventricular tachycardia, ventricular fibrillation did not differ significantly between the two groups (p>0.05). Conclusion: There is no significant difference between in-hospital outcome (mortality and complications) of NSTEMI patients with raised and normal serum uric acid level.
39 Post PCI with stenting Follow-Up in Women for 7 Years in Public Sector Tertiary Care Cardiac Unit. Retrospective Study , Khalida Soomro1*, Zaman baloch2
Abstract Introduction: Despite of the fact that there is continual improvement in diagnostic and therapeutic procedures in catherization Lab introduction of better catheter techniques and new-generation stents and with the acquisition of knowledge from largescale clinical trials Still women appear to have a higher in-hospital mortality after PCI with stenting and during long term follow up specially in developing countries of South Asia the, Reason could be multi-factorial in women. The objectives: The goals of treatment in PCI with stenting in Women is to improve quality of life, to prevent CHD from becoming symptomatic, prevent myocardial infarction, cardiac death and heart failure, the approaches to achieve these goals at the societal or individual level in this regards differ among various countries, the data that have been published are often limited due to the relatively small number of western women. It is important to collect data in under developed countries on outcomes of long term follow up of women with AMI after PCI with stenting to change the global perception of treatment of women with myocardial infarction. Material and Method: Out of 3300 patients, underwent successful PCI with stenting during 2010 to 2016 in Cath Lab of cardiology department of Dow University of Health and Sciences Karachi Pakistan , 577 patients with Sciences Karachi Pakistan, 577 patients with Myocardial infarction within 7 days were included in study and they constitute the present followup population. Additional data regarding noncardiac comorbid diseases and Risk factors were obtained along with crucial aspects of women’s health, such as menopausal status, use of hormonal contraceptives, Follow-up was planned after 1 month and then with annualy for 7 years. The primary end point of study were the long-term rate of major adverse cardiac events (i.e. death, Infarction, and repeat revascularization). The secondary end points were the individual components of the major adverse cardiac events and stent thrombosis. Result: This observational study was conducted by reviewing the record of cases performed and getting information on follow up visits of patients for 7 years from June 2010 to June 2016, out of total 3300 procedure 577 patients were included in the study who underwent PCI with stenting with in the 7 day of Myocardial infarction consisting of 346 patient from urban and 237 people from Rural areas of Sindh Balochistan Provinice of Pakistan Revascularization with stenting was performed in 313 patients 40-50 years of age followed by 219 patients 56-70 years of age in comparison to 23 in older group > 70 years and 22 in younger age < 40 years ,In 528 (91.5%)patients PCI with BMS, in 28 (4.8%)patients DES alone and in 21 (3.6%)patients with BMS and DES performed The odds of short-term mortality were significantly higher among older post - menopausal group compared to premenopausal patients <55 . I3 patients (5 patients during hospitalization) and 8 patients died within 30 days after PCI. Total 57((9.8%) patient died during7 years follow up, 31 (58.5%) cases due to comorbid conditions, and remaining 27 patients death was due to myocardial infarction in 13 (39.4%). Arrhythmias in 5 (9.4%) and worsening of heart Failure in 8 (42.1%) elderly patients. Patient had complete Closure of Target Vessel, 28 (4.8%) had Re PCI on 7 years follow up and CABG was performed in 13 (2.2%). Patients main reason could be noncompliance of therapy in 71 (12.3%) in patients. Conclusion: Ideally a Women patient who has undergone coronary stent implantation should be cared for by the primary cardiologist who by working closely together for long term outcomes in different developing countries of South Asia to collect the data which will change the perception about the treatment of Myocardial infarction in women globally and help in making guidelines.
40 Prevalence and Associated Factors of Hypertension among Assosa town, WesternEthiopia, 2018 , Lalisa M Gadisa*
Abstract Background: Hypertension, the global first and third risk for mortality and disease burden respectively, is recording an increment in Sub-Saharan Africa countries. This study aimed to identify prevalence and its associated risk factor of Hypertension in the Assosa town. Objective: To identify prevalence and factors associated with hypertension in the study area to increase it’s prevention and control methods. Methods & materials: Institutional based cross sectional study design with quota non-probability sampling technique was conducted among patients visited OPD units ofAssosa General Hospital (AGH) andAssosa Health Center(AHC) fromMarch to June 2018. All outpatients were included. To collect data, pre-tested structured questionnaire and face to face interviews were used. Components ofstatisticalresearch software SPSS version-21 like frequency table, chi-square test of independence & logistic regression was used to enter, analyze, summarize and characterize disease and associated factors data. Result: The study was conducted among 194 participants(152 from AGH and 42 from AHC) with 102 males and 92 females. Prevalence of hypertension among patients visited outpatient units of Assosa General Hospital and Assosa Health Center was 17.5%, and was slightly highest in male than female. Associated factors for hypertension among patients visited OPD units of AGH & AHC were history of hypertension in the family (CI=95% and COR=4.497(1.133-17.844) and being private employee (CI=95% and COR=0.0017(0.001-0.407). Conclusion & recommendation: Prevalence of HTN in the Assosa town, was low and influenced by some risk factors like work status and previousfamily history of hypertension. Even if usual usage ofsalt and using vegetable oil was not associated factor, being private employee were independent factor of HTN. In-depth study is recommended for further investigation. To increase preventative methods of HTN, health education supported by mass media, illustrative posters and anotherstrategies at every government & non government work sector are recommended.
41 Covid-19: Who is at Risk and How to Risk Stratify for Poor Outcome? , Syed Raza*
Introduction The SARS-COV-2 is not even 90 days old and much is already known about it by scientists and healthcare professionals across the globe. However, there are still areas of knowledge gap and uncertainty. This has left us with many unanswered questions and members of public in fear and confusion. First, very little is known about the original source of this virus and the other modes of transmission of infection in addition to droplet. Whether it is air borne or has orofecal transmission in addition is still for anybody to guess. It is also not clear as to what proportion of patients of COVID-19 exhibit no symptoms but has the potential to transmit the infection. There are many claims that have been circulating on the internet, social media and print media regarding the treatment and therapeutic options that are available to fight this deadly virus. The fact however is, that there is no fact in these statements. These claims come from studies which are only observational, anecdotal and have paucity of data from a very small study population and very short follow up. There is virtually no scientific study design and therefore will be unacceptable by healthcare scientific community at large. These claims and statements therefore are not only false and misleading but also dangerous.
42 Outcome of Plasma Fibrinogen Level and Postoperative Bleeding Following OPCAB Surgical Patients , Abu Jafar Md Tareq Morshed1*, Md Zanzibul Tareq2 , Md Aslam Hossain3 , Md Rezwanul Hoque4 , Md Samir Azam Sunny5 , Md Amirul Islam6 , Md Nasif Imtiaz7 , Debasish Das8 , Md Noor-E-Elahi Mozumder9 , Nazrana Martuza10
Abstract Background: Bleeding is a major concern after cardiac surgery and also a significant cause of morbidity and mortality. Postoperative mediastinal bleeding in patients undergoing cardiac surgery is still one of the most common complications. Objective: To find out Outcome of Plasma Fibrinogen Level and Postoperative Bleeding Following OPCAB Surgical Patients. Methods: This comparative cross-sectional study was carried out at the Department of Cardiac Surgery in BSMMU hospital from March, 2017 to August, 2019. The study population was 60, with 2 (two) groups having 30 patients in each. Patients from both the groups underwent OPCAB. Statistical analysis of different characteristics between the patients of both groups was done to draw a conclusion. Results: This study total sixty (60) patients who underwent off-pump coronary artery bypass graft surgery were evaluated in this study. Postoperative care at ICU was given to the patients of both groups as per standard hospital protocol. The findings of the study obtained from data analysis presented in the following pages. Among the study population mean age in group A was 55.43±8.53 years and in group B was 59.63±6.86 years. The difference in age between two groups was statistically significant (p<0.05). There was no statistical significance of gender between the two study groups (p>0.05). The mean BMI in group A was 24.13±2.49 kg/m² and that in group B was 24.62±3.71 kg/m². The findings were statistically not significant (p>0.05). Shows the comparison of postoperative variables between group A and B patients. Amount blood loss in 1st 12 hours immediate after surgery in group A and B were 185.67±35.20 ml and 219.67±57.32 ml respectively. Post-operative blood transfusion in group A and B were 2±0.53 units and 2.5±0.68 units respectively, which was statistically significant (p<0.05. There were no postoperative thromboembolic events, cardiac ischemic incidents, re-exploration and mortality. The most valuable predictor for increased postoperative bleeding after OPCAB. Conclusion: In conclusion the efficacy were no postoperative thromboembolic events, cardiac ischemic incidents, re-exploration and mortality. Pearson co-efficient correlation test showed an inverse relationship between plasma fibrinogen level and postoperative bleeding following OPCAB. Fibrinogen concentration level was associated with increased postoperative bleeding in patients undergoing off-pump coronary artery bypass grafting surgical patients
43 Screening of Secondary Hypertension in Private Clinic in Karachi, Pakistan: A Randomised Study , Khalida Soomro1*, Muhammad Ali Soomro2
Abstract Hypertension hasbeen recognized as aglobalhealth concern fordeveloping countries.Secondary hypertension(SH)including endocrine hypertension has been reported to be uncommon and is scarcely described in many of these countries. There is no current nationally representative study. Therefore, we estimated the prevalence of SH among hypertensive patients in private clinic by screening. The goal of the cross-sectional study conducted from May 2017to June2018 was to estimate the prevalence of hypertension inPakistani population based on data collected fromthe screening held at private clinic inKarachi. From the initial screening of 566 patients, we suspected 437 (M:187), (F:250) patients to have secondary hypertension and conducted tests for the cause of hypertension, measured plasma aldosterone concentration, plasma renin activity, serum cortisolconcentrationandplasmacatecholamine concentration.Asasecondary screening,wereferredpatientsforfurosemide plus upright test, captopril renography, dexamethasone suppression test, abdominal ultrasonography (US), abdominal CT. and arteriography investigations. These tests clearly demonstrated that the prevalence of Secondary Hypertension was 8.1% among 437 patients investigated. 42 were found to have Renal parenchymal disease; 25 were having Acute Renal Failure; 15 patients had Calculi; 29 patients had chronic glomerulonephritis leading to CRF and 3 had reno vascular hypertension. Further, 2 cases with aortic coarctation were found on arteriography; 1 patient had primary aldosteronism; 5 had primary hyperparathyroidism; 6 patients had hyperthyroidism and 11 had Hypothyroidism. In seven cases of hydronephrosis (two known and five newly detected) we could not determine whether the hypertension was caused by the hydronephrosis. The prevalence of curable SH among hypertensive subjects was higher in this screening study, conducted in majority of cases with simple tests. The rates of blood pressure screening in Pakistan are worryingly low; the underlying disease in hypertensive patientsshould be treated appropriately to avoid long-term use of antihypertensive drugs and risks of atherosclerotic complication. This calls for the establishment of a nationwide program on screening to improve detection, awareness and treatment of hypertension.
44 Atrial Fibrillation Ablation: When and Why? , John D Rozich
Abstract Ablation of Atrial Fibrillation (AF) has quickly become an alternative strategy to impact the adverse symptoms and outcomes associated with or caused by AF. Early reports in 1998 demonstrated spontaneous initiation of AF by ectopic beats originating in the Pulmonary Veins (PVs) followed rapidly by showing that Radio Frequency (RF) circumferential ablation around the orifices of the PVs could “electrically disconnect” the PVs from the Left Atria (LA). This resulted in the explosive growth utilizing this procedure for AF Ablation (AFA) across a wide demographic spectrum of recipients. Foreseeable healthy debates have surfaced as to who best benefits and who may actually suffer complications or harm from AFA utilizing present techniques. Disagreement also persists as to whether AFA fundamentally and universally reduces stroke, death, hospitalization or does it initiate a more nuanced set of outcomes. The present effort asks the simple question: Has AFA matured to the point of requisite explicative review? Is it time now to peel back the layers and identify which cohort will be optimally served by AFA and perhaps which ones need demonstration of benefit? The present brief review suggests that prudent employment of AFA must now identify disparities in the variables reflected in these cohort outcomes. This will enable judgment in the use of AFA and the achievement of optimal outcomes.
45 Improved Patient Outcomes by Normalizing Sympathovagal Balance: Midodrine and Parasympathetic and Sympathetic Monitoring , Nicholas L DePace1 , Aaron I Vinik2 , Cesar R Acosta3 , Jeysel M Pinales4 , Michael Yayac5 , Joseph Colombo*5
Abstract A function of the Parasympathetic and Sympathetic (P&S) nervous systems is to maintain proper tissue perfusion, including of the heart and brain upon head-up postural change standing. Orthostatic dysfunction (OD) is associated with pooling of blood in the lower extremities, insufficient vascular support of the heart, and poor brain perfusion. Abnormal P&S responses to standing help to guide therapy for the individual patient. Midodrine is often the primary recommendation to correct P&S dysfunction upon standing. P&S Monitoring (Physio PS, Inc, Atlanta, GA) differentiates OD-subtypes in 2727 cardiology patients, serially tested. P&S Monitoring non-invasively, independently, and simultaneously measures P&S activity, including the normal P-decrease followed by an S-increase with head-up postural change (standing). S-Withdrawal (SW) and P-Excess (PE) are two types of autonomic dysfunction that are associated with OD. SW differentiates OD from Syncope (an S- excess with stand, e.g. Vasovagal Syncope). PE often masks SW by inflating the S-response to stand. OD based solely on BP and HR responses to provocation remains difficult to differentiate, especially early in its development and difficult to track upon follow-up. The latter is important to ensure relief of not only the abnormal BP response to stand (e.g. Orthostatic Hypotension) or HR (e.g. Postural Orthostatic Tachycardia Syndrome) but the SW or PE as well. SW underlies the majority of Dysautonomia patients with lightheadedness (whether masked or not, 82.0%, p=0.0061). Midodrine relieves SW and ultimately Lightheadedness and associated symptoms within 9 months (75.4%, p=0.0323). P&S Monitoring provides more information, enabling earlier and more specific diagnosis and therapy for improved patient outcomes. P&S dysfunction upon standing may be most well relieved by very low doses of oral vasoactive medications such as Midodrine (Proamatine), Mestinon (Pyridostigmine), or Northera (Droxidopa). In this study we focus on Midodrine.
46 Research Progress on the Relationship between Lipoprotein Associated Phospholipase A2 and Coronary Atherosclerotic Heart Disease , Zhang Xianmeng1 , Gao Fengmin*1, Zhang Fuya2 , Fu Beijing2 , Wen Xin2
Abstract Coronary atherosclerotic heart disease is a common disease which seriously endangers human health. The incidence rate is increasing year by year and the age of onset is becoming younger. As a kind of Inflammatory factors of vascular, Lipoprotein associated Phospholipase A2 (Lp-PLA2) can promote the progress of inflammation and coronary atherosclerosis, and its serum level can reflect the stability of atherosclerotic plaque. Among the risk factors of coronary heart disease, Lp-PLA2, as a supplement to the traditional risk factors, has a significant reference value for the prediction of coronary heart disease. More and more studies have found that Lp-PLA2 has a significant potential value in evaluating the prognosis of coronary heart disease, especially in acute coronary syndrome patients. This review summarizes the research progress of Lp-PLA2 on the pathogenesis, detection methods, independent risk factors of predicting coronary heart disease and the treatment and prognosis evaluation of coronary heart disease.
47 Clinical Significance of Spot Urinary Chloride Concentration Measurements in Patients with Acute Heart Failure: Investigation on the Basis of the ‘TubuloGlomerular Feedback’ Mechanism , Hajime Kataoka
Abstract Urinary chloride (Cl) is the key electrolyte for regulating renin secretion at the macula densa under the ‘tubulo-glomerular feedback’. Whether or not Cl filtrated into the urinary tubules actually associates with plasma renin activity (PRA) in clinical heart failure (HF) remains unclear. Data from 29 patients with acute worsening HF (48% men; 80.3±12 years) were analyzed. Blood and urine samples were immediately obtained before decongestive therapy after the patients rested in a supine position for 20-min. Clinical tests included peripheral blood tests, serum and spot urinary electrolytes, b-type natriuretic peptide (BNP), plasma neurohormones, and fractional urinary electrolyte excretion. In the 29 patients, urinary Cl concentrations inversely correlated with logarithmically transformed PRA (R2 =0.41, p=0.0002). The correlation was weaker in worsening chronic HF patients (R2 =0.32, p=0.01) compared with de novo HF patients (R2 =0.70, p=0.0026). Patients were divided into 2 groups according to the median urinary Cl concentration, a low group and a high group. Compared with the high group (100~184 mEq/L; n=14), the low group (4~95 mEq/L; n=15) exhibited more renal (serum creatinine; 1.45±0.63 vs 1.00±0.38 mg/d, p=0.029) and cardiac (log BNP; 2.99±0.3 vs 2.66±0.32 pg/mL, p=0.008 p=0.008) impairment, and higher PRA (3.42±4.7 vs 0.73±0.46 ng/mL/h, p=0.049), and lower fractional excretion of urinary Cl (1.34±1.3 vs 5.33±4.1%, p<0.0001). The present study provides clinical data on the possible functioning of urinary Cl involved in the mechanism of ‘tubulo-glomerular feedback’, and thus advances our understanding of the clinical meanings of the significance of urinary Cl concentration measurement.
48 Plasma Renin Activity after Diuretic Treatment in Patients with Stable Heart Failure: With Special Reference to its Association with Electrolyte Chloride , Hajime Kataoka
Abstract A recent study reported an intimate association between urinary chloride (Cl) and plasma renin activity (PRA) in acute heart failure (HF) status, reflecting normal functioning of the ‘tubulo-glomerular feedback’ mechanism. Whether the ‘tubuloglomerular feedback’ mechanism functions normally in stable HF status, however, is unclear. This study examined whether the ‘tubulo-glomerular feedback’ mechanism functions normally under resolution of worsening HF after decongestive therapy. Data from 26 patients with acute HF and its recovery after decongestive therapy were analyzed. Clinical tests included measurement of peripheral blood tests, serum and spot urinary electrolytes, plasma neurohormones, and fractional urinary excretions of electrolytes. In a total of 26 patients, PRA increased after acute HF treatment (from 1.64±2.0 to 5.48±6.1 ng/ mL/h, p=0.002). Changes in the serum logPRA and urinary Cl concentration from worsening to its recovery tended to be inversely correlated (R2 =0.12, p=0.085) and logPRA and the serum Cl concentration at recovery were inversely correlated (R2 =0.23, p=0.01). When divided into 2 groups (n=13 in each) according to the median PRA, the group with greater PRA changes showed a larger decrease in the urinary Cl concentration (from 110±44 to 72.8±38, p=0.03). The group with higher PRA at recovery showed a lower serum Cl concentration than the group with lower PRA at recovery (102±6.5 vs 107±4.2 mEq/L, p=0.04). In conclusion, the association between PRA and the serum/urinary Cl concentration is blunted in stable HF under-decongestive therapy, possibly due to the physiologic status under full cardiovascular medication compared with that in acute HF status.
49 Mental Stress and Multiple Risk Factors of Cardiovascular Diseases with Regional Variations in Women of Urban and Rural Areas of Sindh, Pakistan , Khalida Soomro1*, Muhammad Ali Soomro2
Abstract Introduction: The high prevalence of risk factors in women in developing countries of South Asia appears to have been translated into early and severe CHD in contrast to their counterpart in the first world nations, which has been related to obesity and insulin resistance and genetically determined increased lipoprotein Lp(a) levels. Mental stress due to urbanization, sedentary life style and physical inactivity may be the most important factor initiating obesity and the clustering of all other risk factors hypertension, dyslipidaemia and (WHR). These risk factors vary in different regions of South Asia. Aims and Objectives: Our aim of the study was to describe and analyse differences between the frequency of risk factors such as psychological stress due to, socio-economical aspects, life style especially physical activity, and health behaviours which may contribute in the course of CAD in women of both rural and urban areas of Pakistan because no such significant data is available in women with CAD. Study Design: This descriptive cross-sectional comparative study was conducted in Cardiology Department of Dow University of Health and Sciences Karachi, Pakistan, from March 2014 to March 2016 by filling a questionnaire and laboratory data. The study group comprised female subjects around 577 (Urban 347 {60.1%} and Rural 230 {39.9%}) women ranged from 25-65 years of age who underwent coronary angiography and had definite coronary atherosclerotic diseases. Our study was conducted by examining the psychological stress in women of both areas and its strength of association with frequency of other risk factors in female patients of urban and rural areas with definite CHD taking account the difference in age and education level into account. Result: Analysis of this study conducted at department of Cardiology in Dow University Karachi from March 2014 to March 2017 revealed that the women of rural area were comparatively more physically active then women of urban area. Prevalence of mental stress, hypertension, diabetes, obesity, higher BMI, hyperlipidaemia (especially TC) waist and hip circumference of both areas were found to be different after adjustment made for age. A considerable association was found between psychological stress and other factors in ischemic heart disease patients showing the p-value (p=0.043). Psychological stress was found 82% in both groups and (13%) women had no stress rated as normal more in rural (26%) vs (04%) in urban population. Physical inactivity in women with CHD was found in 92% urban in contrast to 45% in rural population, (p=0.009). Hypertension prevalence was more in urban 253 in comparison to 151 women in rural area. Diabetes Mellitus was also found more in urban than rural population, especially in age below 50, 79 (23%) urban vs 60 (26%) in rural population. Women beyond 50 years of age, 85 (24%) urban vs 64 (27%) rural area had prevalence of obesity comparatively higher in urban residents 71 (20%) than 44(%) in rural dwellers and 32 (9%) urban vs 16 (7%) in rural women in age range below 50 years. Higher waist circumstance was observed more in urban residents (4.8 cm) whereas BMI was more (1.8 unit) in women of rural area than urban women. Prevalence of smoking and nicotine chewing was relatively higher in urban population in below 50 years of age with 30 (09%) urban vs 13 (05%) in rural women and in age beyond 50, 11 (03%) urban vs 10 (04%) in rural women was witnessed. Average total cholesterol, serum triglycerides and LDL were found to be higher in urban compared to rural area residents and HDL was comparatively lower in urban area group. Mean cholesterol level was seen at average of 353 mg% in urban vs 223 mg% in rural population. Serum cortisol level showed significant variation in urban group 19.1 vs 14.2 in rural group (sample, as well as serum fibrinogen was raised more raised in urban population). Conclusion: Our study shows increased prevalence of mental stress and physical inactivity in female residents of urban area leading to Higher blood pressure, DM, dyslipidaemia and central obesity specially in Waist circumference than rural area. The mental stress induced by excessive demands of work at home and at working place with too little control is not unique to women of urban areas.
50 Treatment of Iatrogenic Coronary Artery Dissection in Resource Constraint in Cath-Lab, A Retrospective Study , Khalida Soomro1*, Muhammad Ali Soomro2
Abstract Introduction: Coronary Artery Dissection is a well-known serious complication of invasive procedures (e.g. coronary angiography, balloon angioplasty and surgical cardioplegia) and is due to mechanical injury of the arterial wall by interventional devices used during procedures needing skilled operator to manage it timely. Objective: We wanted to look at these large tears that can dramatically affect blood flow and result in severe complications to understand where they happen most and how efficient are we at managing them for our patients in limited resources of the Cath-labs in developing countries. Methods: We reviewed the record of 28 (3.4%) cases of large dissection found in 806 patients who underwent coronary angioplasty in Cath lab of Cardiology Department of Dow University of Health Sciences Karachi. We analyzed as per American College of Cardiology/American Heart Association (ACC/AHA) criteria of the type of lesion, chronic total occlusion, calcification, intra-procedural dissection, and vessel site, related complications and management strategies. Results: Among the 806 patients that underwent per-cutaneous coronary intervention during 3 years (2014-2017) period at Cath-lab of Cardiology Department of Dow University of Health Sciences Karachi, 28 (3.4%) patients were found to have extensive dissection. Out of 10 patients who had immediate angioplasty and stenting for closure of dissection 8 patients were successfully treated and 2 (7.1) died during procedures. 8 (28.5%) needed immediate coronary artery bypass surgery. 10 (35.7%) out of the 28 (3.4%) patients were managed by further hospitalization with medical treatment out of them 3 patients needed angioplasty procedures. There were no late deaths. Conclusion: Coronary artery dissection remains a common occurrence during PCI since pre-stent procedures and clinical sequelae have been minimized by the routine use of coronary stents. Rapid recognition and attention to the angiographic appearance of the dissection is essential to the successful management of this complication. None the less, patients with extensive dissection who are free from the manifestation at the end of the procedure can be managed conservatively. Attempts should be made to stabilize extensive dissection during coronary angioplasty so that surgical intervention can be delayed or avoided altogether if possible.
51 Heart Disease in Women , Sudha Bansode
Abstract All women face the threat of heart disease. Knowing the symptoms and risks unique to women, as well as eating a hearthealthy diet and exercising, can help protect you. Heart disease is often thought to be more of a problem for men. However, it’s the most common cause of death for both women and men in the United States. Because some heart disease symptoms in women can differ f Heart attack symptoms for women. The most common heart attack symptom in women is the same as in men some type of chest pain, pressure or discomfort that lasts more than a few minutes or comes and goes. But chest pain is not always severe or even the most noticeable symptom, particularly in women. Women often describe it as pressure or tightness. And, it’s possible to have a heart attack without chest pain. Women are more likely than men to have heart attack symptoms unrelated to chest pain, such as: Neck, jaw, shoulder, upper back or abdominal discomfort, Shortness of breath, Pain in one or both arms, Nausea or vomiting, Sweating, Lightheadedness or dizziness, unusual fatigue, Indigestion. These symptoms may be vague and not as noticeable as the crushing chest pain often associated with heart attacks. This might be because women tend to have blockages not only in their main arteries but also in the smaller ones that supply blood to the heart-a condition called small vessel heart disease or coronary microvascular disease. Women tend to have symptoms more often when resting, or even when asleep, than they do in men. Emotional stress can play a role in triggering heart attack symptoms in women. Because women don’t always recognize their symptoms as those of a heart attack, they tend to show up in emergency rooms after heart damage has occurred. Also, because their symptoms often differ from men’s, women might be diagnosed less often with heart disease than men are. If you have symptoms of a heart attack or think you’re having one, call for emergency medical help immediately. Don’t drive yourself to the emergency room unless you have no other options. Rom those in men, women often don’t know what to look for.
52 Poor Trends in Glycemic, Weight and Blood Pressure Control during Screening in Population among Small town of Karachi , Khalida Soomro1*, Sumera Nasim2 , Muhammad Ali Soomro3
Abstract Introduction: Diabetes is common cause of mortality in adults globally due to the increase in the risk of vascular complications. Pakistanis are an ethics group having an inherent predilection to develop diabetes. But this rise in incidence and prevalence is associated with demographics a social pattern, life style, unawareness due to low-literacy rate thus leading to obesity in the country. The high number of people in the pre-diabetic state or with undiagnosed diabetes represents large pool of individuals in rural areas than urban areas. Aims and Objective: Knowing the prevalence of these comorbidities like Diabetes, obesity and Hypertension contributing with each other is important for determining the size of the population that may benefit from strategies that reduce blood pressure and weight while controlling blood glucose. Prevention and control need to be structured at all levels of prevention and through the Promotion of early detection of diabetes through screening and diabetes education. Material and Methods: All persons aged 20-70 years attending the medical camps organized in small towns near to Karachi during (2017 June-2021 June) were tested for diabetes for free with help of Sindh Graduate Association and Go Red for Women Program Pakistan Cardiac Society. Data on their age, gender, height, weight, diabetes status and blood pressure were also taken. Basal mass Index was calculated and stratified as per WHO classifications. 2120 persons were screened but complete data for 1289 persons was available for analysis. Result: Out of 1289 screened people who attended the medical camps, 377 were known diabetics with mean age was 47.5 years with 66% being above 40. 60.2% had poor glycemic control using an optimum of <7.8 mmol/L, 54.59% had poor glycemic control with blood sugars exceeding 10 mmol/L. patients with HBA1c<7%, 50% being hypertensive in spite of the treatment. 62% of women were either overweight or obese then 33.3% in men. BMI above 30 kg/m2 as measure of obesity was found in 32%. in all those who were known diabetics. 12% (92) of those not known to have diabetes had either impaired glucose tolerance or were newly diagnosed diabetics. Conclusion: In our Study the Large proportion of diabetics were found with poor glycemic control. The majority of known diabetes patients were also at risk due to owning overweight, obesity and poorly controlled blood pressure, Emphasis should be on the promotion of early detection of diabetes through screening and diabetes education in under develop areas of Pakistan.
53 Percutaneous Coronary Interventions in Elderly Patients: Experience from a Tertiary Care Center from Developing Country , Sumera Nasim1*, Naresh Kumar2 , Aysha Zahidie3 , Ishaq Mohammed4 , Khalil Rehman5
Abstract Objective of the study: To assess the outcome of Percutaneous coronary intervention in elderly in terms of success and complications. Methods: Retrospective data review of 887 consecutive cases of percutaneous interventions done at Karachi institute of heart diseases from 2015-2020. We divided the patients in three age groups younger (<65 years, n=592); older (65 to 75 years, n=201); and elderly (>=75 years, n=94). Immediate and six months outcomes of in hospital vascular complications, death, myocardial infarction, repeat target lesion revascularization and stroke were compared between these groups. Result: The vascular complications was in three groups (relative risk 3.2% vs 2.9% vs 4.3% with p=0.56) respectively. The relative risk of periprocedural Myocardial infarction in elderly/older patients was not higher than young patients with (OR of 0.6 with 95% CI 0.3 vs 1.4 with P=0.35), so was the need of repeat target revascularization with (OR of 0.3 95% CI 0.2 vs -1.6 with P=0.85), the risk of stroke following procedure was minimal (OR of 0.7 95% CI 0.4 vs 1.6 P=0.4). The in-hospital mortality was higher in elderly with (OR with 95% CI 1.0 vs 2.0 vs 3.4 P=0.03) in three groups. The six months outcomes of myocardial infarction in elderly were also not higher than younger pts (OR 0.7 vs 0.4 P=0.58). so was the need for repeat target revascularization (OR 0.5 vs 0.3 P=0.6). The six-month mortality in three groups was high in elderly (OR with 95% CI 1.5% vs 3.4% vs 4% with P value of 0.04). Conclusion: The procedure success in elderly patients was similar to younger patients, but in hospital and six months mortality was higher in elderlies.
54 Effects on Cerebral Oxygen Balance in Coronary Artery Bypass Grafting: A Comparison of Conventional and Minimal Extracorporeal Circulation , Zihao Liu1#, Ling Zhang2#, Yan Liu3 , Hui Liu1 *
Abstract Objective: To investigate the cerebral oxygen balance difference between minimal extracorporeal circulation (MECC) and conventional extracorporeal circulation (CECC) during coronary artery bypass grafting. Methods: 20 patients undergoing coronary artery bypass grafting with cardiopulmonary bypass (CPB) were divided into two groups, the CECC group (n=10) and the MECC group (n=10). Blood withdrawn from radial artery and right jugular vein were analyzed at the following timepoints: during the anesthesia induction (T1), before CPB (T2), the initiation of CPB (T3), aorta crossclamped (T4), after temperature decreased (T5), during stable hypothermia (T6), initiation of rewarming (T7), aorta unclamped (T8), after weaning of CPB (T9), end of the operation (T10).The artery oxygen content (CaO2 ) and cerebral oxygen extraction ratio (OER) were calculated. The mean artery pressure (MAP), hemoglobin (Hb), nasopharyngeal temperature (NPT), and pump perfusion flow were recorded during the operation. Results: (1) MAP and Hb of MECC group were significantly higher than those in the CECC group from T3 to T10 (P<0.05); perfusion flow in MECC group during CPB was significantly lower than those in CECC group (P<0.05); NPT in MECC group was significantly higher than those in CECC group (P<0.05). (2) During T3-T4 and T8-T9, jugular venous oxygen saturation in CECC group was significantly lower than those in MECC (P<0.05); OER in CECC group was significantly higher than those in MECC group (P<0.05). (3) The arterial lactic acid and venous lactic acid in these two groups were decreased gradually from T3 to T10. Thearteriovenous difference in lactic acid in CECC group were higher than those in MECC group during T3-T4 and T8-T9 (P<0.05). Conclusion: Patients undergoing coronary artery bypass grafting with MECC enjoy more stable blood pressure, less intense hemodilution and lighter temperature disturbance than those with CECC, which indicating a better cerebral oxygen balance in CABG.
55 Role of Natriuretic Terminal Pro B-type Natriuretic Peptide (NT-Pro-BNP) in Diagnosis of Heart Failure in Acute Exacerbation of Chronic Obstructive Pulmonary Disease (COPD), Retrospective Cohort Study Conducted in Karachi, Pakistan , Khalida Soomro1*, Muhammad Ali2
Abstract Introduction: COPD and heart failure effecting millions of people in the world where as combinedly becomes deadlier and affecting the major population of different regions of world, also increasing the rate of morbidity and mortality. Diagnosis of heart failure in COPD patients or COPD in heart failure patient is very difficult for cardiologist and pulmonologist. Objective: Acute exacerbation of COPD concomitant with Heart failure is among the diseases responsible for increasing the Mortality, morbidity, economic burden on patients, health care system and to see the impact on gender-based incidence Early use of NT-Pro-BNP is evaluated in COPD patients for diagnosis of heart failure in Pakistan due to socio-cultural and economical differences this study was conducted. Methods: The study was conducted in 7th Day Karachi Adventist hospital from Nov 2020 to Nov 2021, retrospective cohort study in admitted patients with acute exacerbation of COPD. Qualitative variables including gender, age groups, smoking status, symptoms and clinical finding were recorded. Data was entered and analyzed in statistical package for social sciences (SPSS) version 22. Quantitative variables including age in years, duration of COPD, NT-Pro-BNP level and ejection fraction was presented in mean and standard deviation. For the determination of association between qualitative variables chi-square test was used. Results: In our study heart failure was reported in 89 (85.5%) patients of AECOPD on the basis of Pro -BNP level with Heart Failure & COPD without Heart Failure in 15 (14.4%) patients by using NT-Pro-BNP as a marker of heart Failure. independent sample was used for calculating mean difference (8042.2),95 %CI (1060.7-23.0) and P-value 0.02 *between patients of COPD with heart failure and without HF P-value shows significant difference between Pro BNP level of COPD with heart failure and without Heart failure. Gender of Patients with COPD was male in 61 (58.6%) patients and female in 43 (41.3%). Mean age of the patient with acute exacerbation of COPD was 70.0±11.2 (40-98) years. Age distribution of patients with acute exacerbation of COPD in male vs female was in age group <50 years was 4 (3.8%) vs 1 (0.9%), in age group 50-75 years was 50 (48%) vs 22 (21.1%), and in age group <75 years was 20 (19.2%) vs 7 (6.7%) shows male patients more suffering than women in all age groups. On history and clinical examination Symptoms of shortness of breathing and Coughing were more in male then female. Mean ejection fraction of patients with acute exacerbation of COPD without HF minimum E.F was 40% and maximum was 70% with mean 26%. COPD with HF minimum E.F was 20% and maximum was 70% with mean 52% ±16.6 (20-70%). Mean Pro-BNP level of patients with acute exacerbation of COPD was 7498 ±12221 (17-36000) pg/ml. Chi-square test value was 0.122 and P-value was 0.7. Conclusion: It was concluded from this study that the level of NT-Pro-BNP in patients with acute Exacerbation of COPD. diagnosed with Heart Failure was significantly high as compared to patient of acute exacerbation without Heart Failure especially high in males than females. Early diagnosis of heart failure in COPD patients will be helpful in early initiation of heart failure, medication, decreasing the hospital admissions, hospital stay and cost burden on patients and health care system of low socio-economical countries.
56 The Effect of Iron Deficiency and Supplementation on Players Performance: In Case of Lemo and Ambericho Super League Football Clubs , Samson Getu1*, Gezahegn Tsegaye2
Abstract This study was aimed to examine the effect of iron deficiency and supplementation on player’s performance: in case of lemo and Ambericho super league football clubs. Experimental study design was employed. Sampling size determination and sampling technique was used purposive sampling technique method and sampling size was determined by classifying player’s age level. The instrument of data collection was anthropometric (age, height, weight and BMI) measured by meter and kilogram, cardiovascular endurance test measured by 12-minute run test and Astrand tridmile test resting heart rate measured by counting heart beat after interval training. The analyses were carried out by using paired sample T test to analyze player’s hematological change and performance change before and after supplementations by using. The result show that there is significant change was scored on hematological and performance efficiency after supplementation of Iron and 12-week training. Based on the result football players in addition to daily food menu they should have supplement iron with managed training intensity
57 Cystic Adventitial Popliteal Disease: Personal Experience and Literature Review , Luca Garriboli*, Claudia Fedelini, Tommaso Miccoli, Michele Bedetti, Gianguido Pruner
Abstract Background: Cystic adventitial disease (CAD) primarily affects arteries and is described as a rare vascular disorder characterized by fluid accumulation in the adventitial layer of a vessel which may cause luminal narrowing or even complete occlusion. Nowadays different pathogenetic theories exist as well as different treatment solution. Case Report: We report two cases of cystic adventitial disease of the popliteal artery treated over the last 4 years in healthy men. Both experienced the sudden onset of intermittent calf claudication; one also presented blue toe syndrome. In both cases the diagnose was confirmed after open surgery and histological evaluation. Complete resection and autologous vein bypass were performed in one case; complete resection and direct end to end anastomosis in the others. Discussion: Cystic adventitial disease is a rare vascular disorder with different interesting theories on its aetiology. Treatment options include percutaneous ultrasound-guided aspiration, endovascular approaches and open surgical cyst excision with or without direct reconstruction. In our Institution, we faced two popliteal CAD cases; open surgery represented the treatment strategy for both: in the first case an autologous vein bypass was performed, while in the second case the artery contiguity was restored with an end-to-end anastomosis. Both patients experienced full relief of symptoms without any recurrence of the disease. Conclusion: Even if rare, popliteal artery CAD has to be suspected in young healthy patients who refer the sudden onset of acute or sub-acute symptoms related to peripheral arterial occlusive disease. Differential diagnose between popliteal entrapment syndrome and popliteal aneurysms is not always easy. When CAD is suspected or diagnosed a conventional surgical approach is recommended.
58 Heart Involvement in Hemoglobinopathies: Two Case Reports and Brief Review of Literature , Wael Yaakoubi*, Manel Ben Hlima, Sana Ouali, Fathia Mghaith, Med Sami Mourali
Abstract Hereditary haemoglobin disorders, also termed haemoglobinopathies, include mainly beta-thalassemia and sickle cell disease and represent the most common monogenic disorders in human. Cardiac complications are still a leading cause of mortality and morbidity in patients with haemoglobinopathy, have dramatically reduced in patient populations receiving modern regular therapy and follow-up.
59 Gender Difference in Lipid Profile in Hypertensive Patients’ Hospital-Based Study , Rehman Khalil1 , Sumera Nasim2*, Naresh Kumar3
Abstract Background and objectives: Hypertension and dyslipidemia are the integral components of metabolic syndrome. It has emerged as cause of substantial mortality in both genders. The objective of the study was to find out the prevalence of dyslipidemia in both gender and difference in pattern of lipid profile in hypertensive patients. Methods: This was an observational study conducted in 2018 to 2019 at Sir Syed university Hospital Karachi Pakistan. Sample size of 250 diagnosed cases of hypertension (comprising equal number of males and females) were collected. The lipid values were interpreted in normal or high-risk category by applying NCEP ATPIII criterion. Fasting sample were collected for sugar and lipid profile. Anthropometric, demographic and biochemical data was tabulated. Categorical variables were displayed as mean ± standard deviation and percentage respectively, compared with chi-square test. Student 't' test was use to assess the difference for the lipid profile at 5% significance level. The prevalence of dyslipidemia was estimated for men and women, and pattern in lipid profile were compared. The factors associated with dyslipidemia in both genders were calculated by multiple logistic regression expressed as odd Ratio with 95% confidence interval (C.I). To evaluate the effect of age on dyslipidemia we made four age groups 25-65 years and lipid pattern was compared. Results: Dyslipidemia was found 63% of hypertensive group, 72% women were dyslipidemia than 54% men and pattern of lipid in males showed low LDL and high cholesterol and in females’ high triglycerides and low HDL. The Predictors of dyslipidemia in female were old age, BMI kg/m2 high blood pressure level, depression and lack of physical activity and in men smoking intake of fried, salty food, smoking and obesity with increasing age. Females have more triglycerides total cholesterol and low HDL compared to men. Conclusion: Dyslipidemia was more found in women with hypertension but as the age increasing more women have dyslipidemia. while treating hypertensive patient’s lipid lowering management gender heterogeneity should be considered.
60 Central Diabetes Insipidus Caused by Therapeutic Hypothermia after Cardiopulmonary Resuscitation with Carbon Monoxide Poisoning , Lei Shi1 , Ye Tian2 , Xiao-dong Fan2 , Hai-jing Song2*, Wen-min Shi3 , Qin Sun1 , Fei Ren1
Abstract Central Diabetes Insipidus (DI) usually has hypernatremia and increased urine output as the main clinical manifestations. It is also a rare complication of therapeutic hypothermia after cardiopulmonary resuscitation and carbon monoxide poisoning, but it may be fatal if it is not recognized in time. This case describes a patient who experienced cardiac arrest due to carbon monoxide poisoning, and then successfully restored his spontaneous heart rate after cardiopulmonary resuscitation. However, the patient experienced unexpected hypernatremia and increased urine output during therapeutic hypothermia, and was diagnosed with central DI as a complication of cerebral edema. After treatment, he eventually developed spontaneous breathing and corrected electrolyte imbalances.Central DI should be taken seriously as a possible complication of increased urine output during therapeutic hypothermia after carbon monoxide poisoning cardiopulmonary resuscitation, and pituitary vasopressin should be used to treat central DI.
61 Long-Covid Syndrome: A Multi-Organ Disorder , Nicholas L DePace1,2,3, Joe Colombo1,3,4*
Abstract Long-COVID Syndrome, a multi-organ disorder, that persists beyond 12 weeks post-acute SARS-CoV-2 Infection COVID-19. Here we provide a definition for this syndrome and discuss the organs that are involved. The involvement of multiple organs is due to that fact that angiotensin converting enzyme-2 receptors (the entry points for the virus), inflammation and oxidative stress (the immediate effects of the virus) effect all systems of the body. We suggest that this is then perpetuated by a resulting autonomic dysfunction. Since the autonomic dysfunction also effects all systems of the body, the initial infection is compounded and perpetuated by the resulting autonomic dysfunction underlying the Long-COVID Syndrome. We discuss the symptoms and suggest therapies that target the underlying autonomic dysfunction to relieve the symptoms, rather than merely treating symptoms. In addition to treating the autonomic dysfunction, the therapy also treats chronic inflammation and oxidative stress. To fully document the autonomic dysfunction, a full assessment of the autonomic nervous system is recommended, including Cardio-Respiratory Monitoring. Specific measurements of Parasympathetic and Sympathetic activity, both at rest and in response to challenges, connects all symptoms of Long-COVID to the documented autonomic dysfunction(s)
62 Oral Vasoactive Medications: A Summary of Midodrine and Droxidopa as Applied to Orthostatic Dysfunction , Nicholas L DePace1,2,4, Aaron I Vinik3 , Cesar R Acosta1 , Howard J Eisen2 , Joe Colombo1,4,5,6*
Abstract This is a summary of the uses and applications of two vasoactive drugs, Midodrine (ProAmatine) and Droxidopa (Northera), in the treatment of Orthostatic Dysfunction (OD) disorders, including Neurogenic Orthostatic Hypotension, Postural Orthostatic Tachycardia Syndrome (POTS). This summary based on 15 years of experience monitoring and serially treating over 4000 patients with OD from all around the world and supportive literature. OD caused by an abnormal (decrease) in α-adrenergic, or α-Sympathetic, activity when assuming a head-up posture (e.g., sitting or standing). OD symptoms typically include lightheadedness, brain-fog, neurocognitive loss, fatigue, sleep difficulties, anxiety, and Syncope. Decreasing α-adrenergic activity upon head-up postural change often underlies OD and may be relieved with vasoactive medications. Midodrine and Droxidopa are the only medications that are FDA approved and approved for NOH. Except for their specific uses with NOH, these medications are used off-label with other forms of OD, including POTS, Orthostatic Hypotension, Orthostatic Intolerance and Vasovagal Syncope when co-morbid with OD. This summary will expand the knowledge of Midodrine and Northera, describe their advantages and disadvantages, and describe their comparative data. Hope this summary will help to make the clinician more comfortable diagnosing these disorders as well as using these treatments for this large population of patients with poor Quality of Life and poor functioning.
63 The Efficacy and Safety of the Off-Label Dose of Direct Oral Anti-Coagulants Treatment in Patients with Atrial Fibrillation in China , Peng Zhou1#, Meng Wang2#, Rongchen Liu1 , Yangjie Yu1 , Wei Chen1 , Yunzhi Ma1 , Hengyang Wang1 , Maieryemu Waresi1 , Vladimir Melnikov2 , Xinping Luo1 , Jian Li1*
Abstract Background: Atrial fibrillation (AF) is the most common arrhythmia in clinical practice. Anti-coagulation therapy, especially direct oral anti-coagulants (DOACs) is an indispensable therapy for AF. Considering the increased risks of bleeding, the off-label dose of DOACs has been applied in East Asia. However, the efficacy and safety of off-label dose of DOACs is controversial. Here, we investigate its efficacy and safety in AF patients in China. Methods: This is a retrospective cohort study. Patients diagnosed with AF between January 2015 and December 2015 were recruited. Participants were divided into three groups according to DOACs dose: standard dose of anti-coagulation (SAG) group, off-label dose of DOACs (OFL) group and non-anti-coagulation (NCG) group. Primary endpoint event was all-cause mortality. Secondary endpoint events included thromboembolic events, acute coronary syndrome, major bleeding and any rehospitalization. All endpoints were collected in 2020. Results: 296 patients were included in this study. All-cause mortality in NCG (52%) group was the highest among these three groups (p<0.001), and there was no significant difference between OFL (14%) and SAG group (19%, p=0.601). Compared to SAG group (1.8%), patients in OFL group (16.2%) had higher risk of stroke and thromboembolic events (p<0.001). The incidence of other events including major bleeding (p=0.597) were similar between SAG group (8.1%) and OFL group (5.4%). Conclusions: Off-label dose of DOACs shows no overall benefits in the occurrence of thromboembolic risk compared to the standard dose of DOACs in AF patients in China. Collectively, standard dose of DOACs should be advocated in China.
64 The Psychological Experience of Elder Mothers Raising a Second Child: A Qualitative Study , Yurong Ge1*, Xin Zhang2 , Jingyuan Zheng3 , Fen Zeng3 , Ike Kitili4 , Qianyi Chen3
Abstract Objective: To explore the psychological changes that may take place in older women with a second child from conception to birth. The study has several aims, including the provision of protection of the overall health level of these women; the maintenance of women's position in the labor market; and the promotion of the implementation of the "comprehensive twochild" policy. Methods: Semi-open interviews conducted on older women pregnant with their second child. These women recruited from three tertiary hospitals in one province in western China. The interview content analyzed using the qualitative research method of Japanese scholar Kinoshita Yasuhito's revised version of grounded theory. Results: Four themes extracted from the psychological experience of the older women with a second child; these were Life choice; the mixed feelings of motherhood; the backbone of a family; Second children should be cautious. Conclusion: Older women with a second child face physical, psychological, life, and other pressures. To ensure the implementation of the "comprehensive two-child" policy, the Chinese government should speed up the establishment of a fertility support system, including education, medical investment, women’s employment rights protection, and pension burden. Establish and improve relevant policies
65 Using Thrombin Time to Evaluate the Efficacy of Anticoagulant Therapy for Acute Cerebral Infarction , Qianqian Li, Tingjiao Liu, Yan Gao, Xinxin Guo, Ying Jia, Qian Shi, Shanshan Yang*
Abstract Background: Although intravenous thrombolysis therapy considered as a significant progress in the treatment of acute ischemic stroke, there are limited effective treatments for patients with onset ischemic symptom that beyond six hours during acute ischemic stroke. In this study, we investigated the effectiveness of the intravenous argatroban therapy in acute ischemic stroke patients who cannot be treat with intravenous thrombolysis due to the limited time window. Methods: One hundred and eighty patients with acute ischemic stroke that had beyond six hours ischemic symptom were admit to our hospital and analyzed retrospectively. ELISA measured levels of activated partial thromboplastin time (aPTT), prothrombin time (PT) and thrombin time (TT) in peripheral blood of these patients at 24 hours post initial therapy. Results: We found that plasma TT prolonged after 24 hours of argatroban treatment. Activated partial thromboplastin time (aPTT) showed slightly increased prolongation after 24 hours of argatroban treatment. PT also showed slightly prolonged after treatment; however, there was no difference from the basal line. We further investigated the relationship between the level of TT and the clinical effectiveness and safety of intravenous argatroban therapy. We found that when TT was between 40 and 80 seconds, intravenous argatroban effectively promoted the complete recovery rates without increasing the risk of hemorrhage. Conclusion: Our study implies that TT assay might be useful for guiding regular dose of agratroban for therapy.
66 Inhalation of Heliox as a Potential Treatment for the Acute Respiratory Distress Syndrome (ARDS) caused by Covid-19 , Juan Ma1 , Yuan Shi2 , Qing Mao3 , Hui-min Liu3*
Abstract Corona virus disease 2019 (COVID-19) is currently a global pandemic It presents as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) due to COVID-19 infection. Despite the widespread use of symptomatic, antiviral, and supportive treatment, the daily death toll from COVID-19 is still rising. The most common lethal complication is acute respiratory distress syndrome (ARDS). Mechanical ventilation is one of the necessary support methods of treating ARDS. Heliox (Heliumoxygen mixture) inhalation can reduce respiratory work of breathing, improve oxygenation, improve lung compliance, and effectively optimize the treatment of ARDS. Heliox also has potential anti-inflammatory, neuroprotective, and cardiac effects, and could reduce the inflammatory storm caused by SARS-CoV-2. This article reviews the properties of heliox, the therapeutic mechanism for ARDS, and the effects of heliox on inflammation, nerves, and the heart. Conclusion we suggests that heliox is a potential treatment for COVID-19.
67 Hybrid Coronary Revascularization Vs Traditional Coronary Artery Bypass Graft: A Better Revascularization Modality , Sumera Nasim1*, Khalid Galal2 , Waleed Shaker3
Abstract Background: Hybrid coronary revascularization (HCR) represents a minimally invasive revascularization strategy in which the durability of the internal mammary artery to left anterior descending combined with percutaneous coronary intervention with drug eluting stents(DES)to treat remaining lesions in different coronary arteries. Objective: To compare the complication like bleeding, nephropathy and hospital stay MACCE defined as death, stroke, myocardial infarction (MI), stroke, and repeat revascularization in hospital and one year follow up. Methods: It was correctional study done UAE in 2018- 2019 patient with multi vessel disease who consented with insurance approval were included and decision for which patient went HCR or CABG arm by heart team, patient underwent HCR we used stage manner first LIMA – LAD followed by multi vessel PCI after 24 hrs. And patient were discharged on day 5 of admission Results: 15 patients underwent hybrid revascularization bleeding rate was high with OR OF 1.0 with 95% C.I of 0.8-1.3 with p value of 0.03, risk of Nephropathy was higher in HCR group with odd ration 1.2 (0.6-1.5) with p value of 0.04 the mean length was 5 vs 7 Days One stroke in CABG group and MACE was HCR with ODD ratio of 1.2 (95% CI 0.8-1.5 with p value of 0.04 observed till one year no in hospital death one year follow up. Three patients died of MACE in CABG and one patient in HCR group
68 Comparison of Minimally Invasive Mitral Valve Surgery vs Open Mitral Valve Replacement , Sumera Nasim1*, Saif Naveed2 , Muhammad Aadil Qasim2
Abstract Objective: To establish the advantages of invasive mitral valve surgery over open heart mitral valve surgery in treating patients with mitral valve pathologies. Material and Methods: A literature search was done on PubMed, google scholar, and Embase using search terms like open ‘invasive mitral valve surgery’, ‘mitral clip’, ‘sternotomy’, and ‘annuloplasty.” The time limit was set to 5 years ago and the language set to English. After searching, a quick screening of the title and abstract was done for relevance. The selected papers were then used in this review. Results: The minimally invasive mitral valve surgery was shown to have significantly greater survival rates across all post-surgical time frames as well as lower short-term mortality rates. Mini MVS was also shown to be more effective in treating infective endocarditis and is a highly impractical operation for patients with left ventricular dysfunction or other cardiomyopathies. The Minimally Invasive Mitral valve surgery (Mini MVS) proved to cause fewer mortalities and clearly showed a lower number of complications; the complications that exist are highly preventable. In addition, the mini MVS is more effective in treating patients with mitral regurgitation. Conclusion: This review confirms that employing the minimally invasive MVS procedure for patients with mitral valve pathologies is more effective than the standard open heart MVS in terms of post-surgery mortalities and hospital stay times. It is also more effective in treating patients with preexisting cardiomyopathies. However, sufficient training should be done to prevent complications from arising. The mitraliclp device should be further developed to prevent complications that arise due to the clip attachment.
69 Analysing the Status and Strategy Dimensions of the Sport Organizational Structure in the South Ethiopia Sport Commission Office, Samson Getu
Background: The structure of an organization is significant because it determines how employees and volunteers interact in terms of job tasks, decision-making procedures, the need for collaboration, levels of responsibility, and reporting mechanisms. Specialization, standardization and centralization are three structural dimensions that have long been used to define organizational traits and arrangements. Objective: To analyse the status and strategy dimension of the sport organizational structure in the south Ethiopia sport commission office. Methods: An institutional based descriptive survey research approach was conducted at the south Ethiopia sport commission office. Data were collected by using a self-administered questionnaire. Study participants were allocated proportionally based on their profession by using a purposive sampling method. Data were entered and analysed by using SPSS version 20.0. Descriptive statistics frequency and percent were used to describe the analysis of variables in the study area. Result: In this study, the status and strategy dimensions of the sport organizational structure in South Ethiopia sport commission office, like work specializations implemented were only (60.4%), departmentalization (62.3%), chain of command that there was no reporting trial between managers and employers (43.3%). The wide type of control was (64.2%), the status of centralization was (62.2%) and decentralization was only (24.5%). Conclusion: According to the findings of the current study, the status and strategy dimension of the sport organizational structure in the South Ethiopia sports commission office is very low. Factors affecting departmentalization include work type, employer’s field of study, different task process and environmental risk. Factors affecting the span of control competencies of subordinate, nature of work, quality of planning, communication techniques, organizational structure, organizational culture, and complexity of organizations were independent predictors of strategic dimension in sport organizational structurePreparing and providing programmed continuously on the job, organizing seminars and up on hire training on strategic dimensions of sport organizational structure should be crucial. To enhance the span of control adminsterative personnel should practice direct control of supervisors and subordinates. In chain of command, administrative personnel and employers should follow reporting trials between the employers and upper managers.
70 Tacrolimus-induced Reversible Cerebral Vasoconstriction Syndrome after Heart Transplant: Case Report, Koichi Inoue*, Satoshi Kainuma, Daisuke Yoshioka, Koichi Toda, Shigeru Miyagawa
We describe the case of a patient with a recurrent severe headache that occurred after heart transplant surgery. She was diagnosed with reversible cerebral vasoconstriction syndrome (RCVS) since typical imaging was seen through brain contrast computed tomography. Tacrolimus, an immunosuppressant, was suspected as the cause of the RCVS. The treatment was switched to cyclosporine, after which there was rapid improvement of her symptoms. This case highlights the importance of an immediate diagnosis to switch immunosuppressants to relieve symptoms and prevent progression to severe neurological dysfunction.
71 Transcatheter Aortic Valve Implantation (TAVI) Versus Surgical Aortic Valve Replacement (SAVR): A Retrospective Analysis from a Tertiary Care Hospital, Muhammad Ammad Khan*, Ghanwa Alam
Objective: To compare the post-operative complication rate in Transcatheter Aortic Valve Implantation [TAVI] vs Surgical Aortic Valve Replacement [SAVR] within one week of the operation. Methods: This is a retrospective cohort study in which two separate cohorts of patients would be included. The first group is of patients who undergo traditional open-heart surgery at our hospital for valve replacement, whereas the other cohort would be of patients who undergo valve replacement procedure using TAVI. Records of all the patients who underwent TAVI and SAVI in the last 5 years preceding the survey and fulfilling our inclusion criteria would be included in our study using purposive sampling method until the desired sample size is achieved. The inclusion criteria include patients who underwent primary valve replacement surgery at our institute through either of these procedures, patients who remained admitted in the hospital for at least one week and whose medical records are readily available at the hospital. Results: A higher Postoperative Complication Rate observed with SAVR compared with TAVI. The Myocardial Infarction, Acute kidney failure and Stroke reported higher after SAVR compared to TAVI. Conclusion: TAVI is a safer and more reliable procedure for Patients suffering from Aortic Stenosis.
72 Impact of Covid-19 in the Field of Cardiology in Karachi Pakistan, Khalida Soomro1*, Zaman Baloch M2
The COVID-19 pandemic caused by the Corona-virus has brought new changes to the worldwide healthcare system. Healthcare delivery is experiencing drastic changes due to the pandemic. This unprecedented surge in COVID-19 infections led many governments around the world to implement population lifestyle changes to limit the spread of infection. To identify the differences in demographics, clinical characteristics, admission, diagnostic and therapeutic procedures, affect cardiovascular services and changes adopted in hospital’s emergency room triage. We analyzed key performance services offered in cardiology department in tertiary care hospitals. There has been a more than 50% drop in the number of Cardiac patients presenting to the cardiac dept. of these hospital. All areas of cardiology service provision sustained significant reductions, which included outpatient clinics, investigations, procedures and cardiology community services such as heart failure and cardiac rehabilitation. In line with government guidelines, cardiology services had to alter the delivery of care by adopting virtual clinic models, redeployment of staff to the acute medical services and rescheduling of non-urgent procedures. Dealing with the increased COVID-associated CV risk burden and becoming acquainted with potential new e-cardiology approaches aimed at integrating the cardiology practice are relevant new challenges brought by severe acute respiratory syndrome coronavirus 2 infection and its sequelae in Middle-income countries like Pakistan.
73 Effect of Levosimendan on the Prognosis of Cardiac Surgery in Patients with Cardiac Insufficiency, Heya Na, Xianen Fa*, Yuyang Zhou, Xiangyang Li, Rui Zhu, Lei Liu, Bing Liu
Objective: To retrospectively analyze the effect of levosimendan on the survival and prognosis of cardiac surgery patients with LVEF
74 The Effectiveness of Applying for Formative Assessment Objective Structured Clinical Examination (OSCE) for Undergraduate Students in Faculty of Medicine King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia , Rajaa Fahad Allhiani*, Sumaiah Abdulwahab, Sultan Hassan Alamri
The use of formative and summative assessment for students have been always a concern for medical professionals such as teachers and students especially when students are at graduating level. This can be supported with increasing the effectiveness and comprehensiveness of the students with appropriate clinical training using a defined structure with questionnaire-based system defined in the methodology to support student’s skills using clinical competencies to form perspective. It has been found that with Objective Structured Clinical Examination can be used as the method to assess the adequacy to support clinical skills of medical students following their competence level. This can be used to support a variety of tests to work on underpinning emergency procedures to interpret investigational data to ensure in-depth and breadth coverage of clinical skills following 5thyear medical students.
75 Pharmaceutical Atrial-Ventricular Optimization in Diastolic Dysfunction: A Clinical Concept Application of Materials Engineering To Myocardial Pathophysiology, Benjamin W Cooper1, Yoel Schwartzmann2, John R Dylewski3*
The cardiac cycle can be divided into two main phases: ventricular contraction (systole) and ventricular relaxation (diastole), at both a macroscopic (Atria and Ventricular) and microscopic level (Actin: Myosin myofilament) [1]. A novel model is elucidated in this paper incorporating the principles of biomechanics, physiology, anatomy and electrophysiology to clinically redefine diastology. The ventricular diastolic phase divided into sub phases. During normal electrophysiological and hemodynamic conditions, the ventricular diastolic phase starts with the closure of the ventricular outflow tract valves (aortic and pulmonic) (S2). One of the three possible intraventricular diastolic vacuum phases follows known as the isovolumic relaxation phase (IVRT). Once the atrio-ventricular valves open, blood flows from the atria to the ventricles passively (producing the e wave) with subsequent active filling of the ventricles with atria contraction (producing the a wave).
76 Temporal Changes in Key Signal Transduction Pathways Mediating Muscle Protein Synthesis with Adaptive and Maladaptive Right Ventricular Hypertrophy in Pulmonary Arterial Hypertension, Ryan C Middleton1,3, Mario Fournier1, Russell G Rogers1, Brandon S Grimes2, Xuan Xu2, Michael I Lewis1,2*
Pulmonary Arterial Hypertension (PAH) is a progressive disease characterized by occlusive remodeling of pulmonary arteries < 500 micron and increased pulmonary vascular resistance. With the onset of PAH, the right ventricle (RV) of the heart adapts to the increased afterload pressure by undergoing adaptive hypertrophic remodeling to maintain adequate blood flow. However, for unknown reasons, maladaptive influences ensue, resulting in impaired RV function with progressive decompensation and right heart failure. Using a rodent model of PAH, key signaling pathways mediating cardiac muscle protein synthesis in the RV were evaluated during both the adaptive hypertrophy phase, with preserved right heart function, and the decompensated maladaptive phase, in which right heart failure (RHF) was present. Analysis of protein and gene expression changes in PAH animals identified three key signaling pathways involved in the shift toward maladaptive right heart failure: i) PI3K/Akt/mTOR; ii) GSK-3; iii) MAPK/ERK, as well as IGF-1 regulation. During adaptive hypertrophy, significant increments of phosphorylated proteins in the three signaling pathways were observed with increases in RV fibrosis and decreased capillarity found. In the maladaptive phase, mTORC1 and its downstream effector p-70S6K were significantly activated, contributing to the decreased LC3-I/II ratio, a marker of autophagy inhibition together with further significant RV muscle fibrosis and greater capillary rarefaction. We propose that autophagy inhibition in conjunction with other maladaptive processes reported in the decompensated RV muscle contributes to the genesis of overt RHF in PAH, and that a continuum of changes characterizes the adaptive and maladaptive phases in the RV muscle.
77 Empagliflozin Treatment for Patients with Heart Failure with Preserved Ejection Fraction-A Systematic Review , Sara Abou Al-Saud
Objective: The goal of this systematic review is to determine the effectiveness of empagliflozin in managing patients with heart failure with preserved ejection fraction (HFpEF) as compared with a placebo. Methods: Web of Science, Cochrane, PubMed, and Scopus databases were searched for articles from 2000 to November 2022. Reference lists of articles were manually screened. Trials that recruited patients with HFpEF and reported the effects of empagliflozin were included. Endnote X9 software was used for study screening process. Results: 14 papers out of 1235 found were selected for full-text reviews. The systematic review included nine papers that were all randomized controlled trials. According to the findings of individual trials, empagliflozin is more effective and has a statistically insignificant safety advantage over a placebo. Conclusion: Empagliflozin treatment for HFpEF patients appears to be both safe and efficient when compared to a placebo, according to data of moderate quality
78 Clinical-Epidemiological Profile of Congenital And Acquired Heart Diseases Admitted To A Private Hospital, Gustavo Foronda1, Vanessa Ferreira Amorim de Melo2*, Samia Medeiros Barbar3, Renata Fogarolli4, Carlos Eduardo Tossuniam5 and Santiago Raúl Arrieta6
To characterize the clinical-epidemiological profile of children with heart diseases (congenital, acquired and arrhythmias), conducted by the pediatric cardio group of a private general hospital, from January 2016 to March 2020. Method Retrospective longitudinal observational interference study, with quantitative design, carried out in a private hospital. A total of 502 patients were selected according to the following inclusion criteria: patients who had congenital heart disease, acquired heart disease and arrhythmia, all managed by the pediatric cardiomyopathy group. Descriptive analysis of absolute and relative frequencies were represented through tables and graphs. Results Of the 502 patients included in the study, 86.5% had congenital heart disease, 7.7% acquired heart disease and 5.8% arrhythmias. 50.2% were female, 49.6% male and 0.2% were not defined so far. Prematurity occurred in 19.3% of cases, presence of syndromes in 31.2 % and associated comorbidities in 34.7%. In total, 530 procedures were performed, of which 77% were surgeries, 18.5% hemodynamic procedures and 4.5% hybrid procedures. A risk score called RACHS-1 (adjusted risk for surgery and congenital heart disease) was used to categorize the surgeries. There was a predominance of category 3 (38.4%), followed by category 2 (28.6%), category 1 (18.2%), category 4 (9.6%) and category 6 (5.2%). Conclusions The complexity of the profile of the found heart diseases reiterates that measures are needed for an integrated approach of different specialties and professionals for the treatment of these patients.