Correlation of Glycosylated Hemoglobin and Complexity of Coronary Artery Disease among Aged ≥45 Years Population with Diabetes Mellitus

Objective: Cardiovascular diseases are 1.7 times more prevalent in patients with diabetes mellitus. The aim behind this study was to examine the correlation of glycosylated hemoglobin and complexity of coronary artery disease among middle aged population with diabetes mellitus Patients and Methods: This was a clinical prospective hospital-based comparative study carried out in the department of the cardiology department of Isra University Hospital Hyderabad for 10 months. 153 participants with diabetes mellitus having age ≥45 years both male and female and undergoing their first coronary angiography were included. Data were entered and analyzed by using Statistical Package for the Social Sciences version 21.0. Results: A total of 153 patients were finally analysed. Patients were divided into two groups; group I (HbA1c <6.5%, normal) and group II (HbA1c >6.5%, impaired). The mean age was slightly higher in group II 54.60 as compared to group I 53.65 years, respectively. The Syntax score was correlated with HbA1c levels in patients older than 45 years of age (r = 0.001; p >0.05). Moreover, the higher HbA1c levels were observed in every three categories of Syntax score but they were insignificantly associated with each other in patients with diabetes mellitus and having age more than 45 years. Conclusion: The HbA1c is insignificantly correlated with the complexity of coronary artery disease in diabetic patients having age more than 45 years. While only two factors, hypertension and increased triglycerides are significantly different among the HbA1c groups.

May Measurement Month 2019: an analysis of blood pressure screening results from Pakistan-South Asia

High blood pressure (BP) is well recognized as a huge health problem worldwide and is often described as a silent killer. To develop awareness and screening of this health issue globally, the International Society of Hypertension created ‘May Measurement Month (MMM)’ a campaign to provide BP screening and advice to interested participants. This screening and awareness campaign in Pakistan is a continuation of the efforts of the first MMM programme in Pakistan in 2017. This study was conducted in May and June 2019. This public based cross-sectional study included and screened 6919 individuals of either gender and aged ≥18 years, after informed consent. Information about prior diagnosis and treatment of hypertension with history about comorbidities and life-style were taken by a standard pre-designed form. Participants also asked about previous participation in MMM 2017/18. Arterial BP was measured using the OMRON digital BP apparatus and three successive readings were taken. Hypertension was defined as a systolic BP ≥140 mmHg or a diastolic BP ≥90 mmHg or taking antihypertensives. Participants had a mean age of 45.8 years and 47.1% had never had their BP checked. Of all those screened, 3601 (52.1%) participants had hypertension, of whom 56.2% were aware of their diagnosis, 49.5% were on antihypertensive medication and 19.8% had controlled BP (&lt;140/90 mmHg). Of the 1783 participants on antihypertensive medication, 40.0% had controlled BP. In Pakistan, there are still low levels of awareness, counselling and screening about high BP. Further large-scale studies are required in this region to evaluate these problems and link them with potential solutions.

May Measurement Month 2017: an analysis of the blood pressure screening campaign results in Pakistan—South Asia

Elevated blood pressure (BP) is a growing burden worldwide, leading to over 10 million deaths each year. May Measurement Month (MMM) is a global initiative aimed at raising awareness of high BP and to act as a temporary solution to the lack of screening programs worldwide. Hypertension is a global health concern for developing countries. In Pakistan, apart from few population-based studies which evaluated the prevalence of hypertension, there is no current nationally representative study (the latest nationwide survey was conducted more than two decades ago). Pakistan Hypertension League, in accordance with the International Society of Hypertension directive under the banner of the May Measurement Month 2017 (MMM17) campaign, carried out a nationwide cross-sectional survey of volunteers aged ≥18 in May 2017 through its 14 regional chapters. Blood pressure measurement recorded through digital apparatus, the definition of hypertension (≥140/90 mmHg or being on BP-lowering treatment) and statistical analysis followed the standard MMM protocol. A total of 5333 individuals were screened during the MMM17 campaign with mean age 45.0 (11.6). Males had a higher rate (66.3%, n = 3536) in those screened than females (33.0%, n = 1757). A total of 55.2% (n = 2943) people had hypertension. This result shows very high rates of hypertension in Pakistani people. Therefore, there is an urgent need for federal implementation of BP screening as well as awareness programs across the nation.

Influence of maternal factors and mode of induction on labour outcomes: a pragmatic retrospective cohort study

Since recent research indicates that other modalities are at a minimum non-inferior to the NICE-recommended hormonal agent prostaglandin E₂ (PGE₂), a retrospective cohort study was conducted on 1971 consecutively induced singleton pregnancies. Multinominal regression analysis showed that the odds ratio (OR) for vaginal delivery with balloon-mediated labour induction (84% vaginal deliveries; OR 1.6; 95% CI 0.7-3.5) is similar to the PGE₂ agents propess (81%; OR 1.2; 95% CI 0.68-1.98) and prostin (79%; OR 0.99; 95% CI 0.55-1.79) when using a triple multi-agent induction as a reference. On the other hand, combining the propess and prostin (60% vaginal deliveries; OR 0.45; 95% CI 0.21-0.96) and attempting quadruple combinations of the induction modalities (56%; OR 0.37; 95% CI 0.16-0.85) yields significantly poorer outcomes. However, compared to the known factors associated with increased caesarean section rates, such as an increased maternal age, nulliparous pregnancies and a history of caesarean section, the differential impact of different induction modalities appear less pronounced. Impact statement What is already known on this subject? Recent published data from controlled clinical trials have shown that other labour-inducing agents, including balloon catheters, are as effective as prostaglandin E₂ (PGE₂) in achieving a vaginal delivery. What do the results of this study add? The data from this pragmatic retrospective cohort study supports the findings of others that the use of a balloon is as effective as PGE₂. It also demonstrates that regular clinical practice can differ from an experimental environment, with patients receiving multiple induction modalities in a daily practice. Both the combination of different PGE₂ medications and a quadruple labour induction approach are associated with poorer results, as measured by the vaginal delivery rate. The data presented here also confirms that a nulliparous status, a maternal age and a history of caesarean section are associated with reduced odds of achieving a vaginal delivery. What are the implications of these findings for clinical practice and/or further research? The body of evidence showing favourable results with a balloon induction is growing. Furthermore, there are limits to the effectiveness of combining the different induction modalities. Maternal and perinatal factors associated with a risk of caesarean section further complicate labour induction management.

Transmyocardial Laser Revascularization: Saudi Experience

One hundred transmyocardial revascularization procedures were performed between February 1994 and January 1996, using the C02 Heart Laser on 90 patients with stable angina and 10 with unstable angina. This was the sole therapy in 98 cases and utilized in combination with open-heart surgery in 2 others. Most patients (96) had this procedure without having undergone previous coronary artery bypass graft surgery; 66 patients were deemed to have nongraftable vessels, while 34 patients had coronary artery anatomy that was favorable to bypass graft surgery but elected to undergo laser revascularization instead. The majority (86%) were male and ages ranged from 30 to 82 (mean 55) years. At 12 months after the procedure, 92% of patients reported that they were free of angina, while mean exercise tolerance increased from 7 minutes preoperatively to 15 minutes, and metabolic equivalent units rose from 4.8 to 10.2. The average increase in Karnofsky performance score was 51%, and oxygen consumption improved by 93%. The increase in left ventricular ejection fraction was not statistically significant. Most patients resumed work within 18 days of the procedure. Consumption of antianginal medication was reduced to minimal in 83% of the patients at the end of one year. There were 10 deaths in the series, chiefly in patients with extremely low ejection fractions. We conclude that the application of this rapidly evolving procedure as a primary therapy in ungraftable patients, appears to be safe and deserving further study.

Early experience with transmyocardial laser revascularization

Conventional treatment of coronary artery disease consists of either Coronary Artery Bypass Grafting (CABG), medical therapy or percutaneous transluminal coronary angioplasty (PTCA) or a combination. However, certain group of patients do not even qualify for CABG. Transmyocardial Laser Revascularization (TMR) is a unique new surgical modality specially for that sub group of patient population who have small and diffuse coronary artery disease not suitable for grafting. King Fahad Heart Center initiated its TMR program in February, 1994 and until February, 1996, 100 patients under went the TMR procedure. Eighty-one were males and 19 females with a mean average age of 55 years. Seventy-nine patients had 3 vessel disease (VD) and 66 patients had non-graftable small vessels. Ten patients had left ventricular ejection fraction (LVEF) less than 30%. All the patients underwent a strict protocol of follow-up. The pre and post TMR assessment at six months and 12 months follow-up showed an increase in LVEF at six and 12 months as compared to pre TMR level. The exercise time also increased from a base line level at six months and showed further improvement at 12 months which was statistically significant (p < 0.05) along-with VO2 max, which also showed improvement. Clinically, haemodynamically and symptomatically these patients showed significant improvement and use of anti-anginal drugs (87%) was reduced to minimum. Isotope myocardial perfusion scan on 15 segment viability score showed an improvement from pre TMR level of 33.8 to 45.9 at post TMR 12 months follow up. The surgical mortality in this high risk TMR population was 10%. TMR was found to be a reasonable alternative to medical treatment in patients with angina due to diffuse and or small vessel disease or occluded previous grafts not amenable to CABG.

Thrombotic obstruction of bileaflet mechanical prosthetic heart valves: early diagnosis and management

BACKGROUND

Thrombosis of mechanical prosthetic heart valves (TMPHV) is one of the major complications that accounts for the highest morbidity and mortality related to Bileaflet Mechanical Prosthetic Heart Valves (BMPHV).

MATERIALS AND METHODS

During the last six years we had ten cases of bileaflet mechanical valve thrombosis. All patients had undergone emergency surgical interventions except one who developed systemic embolization and massive brain insult immediately after admission for surgery and died two months later. We divided the patients in two groups, first group includes five patients who came in acute pulmonary edema and emergency operation was done either to replace the thrombosed BMPHV (in two) or successful thrombectomy was achieved (in three) and all of them have survived. The second group (four patients) presented with cardiogenic shock and required emergency femoro-femoral bypass. Two patients survived after thrombectomy and the other two could not come off bypass after changing the TMPHV and in spite of Intra-aortic balloon pump, they died 24 and 48 hours after the procedure. All patients received intravenous heparin on admission. Preoperative i.v. Streptokinase was given in two cases, of which one required thrombectomy and the other had valve replacement and died 24 hours later.

RESULTS

Early diagnosis and operation still had the best results in TMPHV though thrombolytic therapy was successful in few reported early presented cases. All patients who had thrombectomy of the TMPHV have survived without any morbidity. Follow up of survived patients ranged between two months and six years with a mean of 24.1 months. It is worth attempting thrombectomy of the thrombosed BMPHV rather than re-replacement which carries higher morbidity and mortality, because of the longer ischemic arrest during operation which further depletes the energy of the myocardium.

CONCLUSIONS

Though this is a small number of patients to make a definite conclusion, thrombectomy was more feasible in CarboMedics Prosthetic Heart Valves, since its in situ rotation that allows reorientation of its leaflets and declotting of valve hinge to be performed.