Clinical Profile and Approach to Osteal LAD Lesion During Primary Angioplasty in Myocardial Infarction (PAMI)

Isolated Coronary Artery Stenoses (CAS) involving the ostium of the Left Anterior Descending (LAD) artery is very challenging, especially in a setting of primary Angioplasty in Myocardial Infarction (PAMI). Intimal atherosclerosis in the Left Main Coronary Artery (LMCA) bifurcation is primarily in area of low shear stress which is the lateral wall, close to the LAD and Left Circumflex (LCx). Thus, carina is usually free of disease, which can explain why single-stent strategy can be successful. However, precise stent placement is often difficult due to unwanted stent movement within vessel or its proximity to side branches. A decision must be made at the outset, to decide on the approach to be employed, to treat osteal LAD lesions. Limited data is available on patients undergoing primary PCI of osteal LAD lesions. Here, we present our experience and problems encountered during the management of osteal LAD lesions in the setting of PAMI.

Management of Metabolic Acidosis in the Post-Cardiac Surgical Patient

The base deficit is the best way to evaluate severity of Metabolic Acidosis (MA). It indicates a value corresponding to the number of mmol/L below 24 of the measured bicarbonate concentration. Base deficit between 0 and 5 mmol/L indicates that the patient is not at risk of immediate harm. Arterial blood gases are typically measured every 2-4 hours following cardiac surgery and there is always a trend in base deficit changes to consider. Where the base deficit is diminishing, this indicates that the patient is improving, whereas when it is worsening, the opposite is true. Base deficits between 5 and 10 indicate that a serious problem is present which requires urgent correction. Where the base deficit is greater than 10, cardiac arrest may occur, and such patients require constant supervision by a doctor if active management is being pursued. Where the base deficit is persistently greater than 15, survival is extremely unlikely. This degree of acidosis is associated with widespread disruption of mitochondria at cellular level. The mitochondria often do not recover even if the precipitating cause of the MA is corrected, in which case the patient develops fatal multisystem organ failure. The management of MA in post-cardiac surgical patients is indivisibly bound up in optimizing circulatory physiology. We have not expounded on how this foundational knowledge should be applied but without it the management of MA in this patient population will be severely hampered.

Maintenance (r) Alpha Lipoic Acid Reduces Sudden Cardiac Death in Geriatric Diabetes Mellitus II Patients

Background: Diabetes carries a two-fold risk of Sudden Cardiac Death (SCD). Diabetic Autonomic Neuropathy (DAN), often progressing to Cardiovascular Autonomic Neuropathy (CAN, critically low parasympathetic tone [P]), increases death 3.5-fold over 5 years, half sudden or non-renal. Oxidative stress is a major cause of DAN. Also, increased sympathetic tone (S), High Sympathovagal Balance [SB>2.5] increases SCD risk. Objective: Dysautonomic diabetic II patients were treated with the antioxidant (r) Alpha Lipoic Acid (ALA), autonomic function followed, and Sudden Death (SD) compared to untreated patients. Methods: 133 patients (mean age 66y/o) with DAN or CAN, diagnosed using the ANX 3.0 Autonomic Monitor (Physio PS, Inc., Atlanta, GA) was offered (r)-ALA: 83 agreed (Group 1), and 50 refused (Group 2). P and S were re-measured up to 3 times/yr (mean f/u 6.31 yrs); SCDs were recorded. Results: A 43% Relative Risk Reduction (RRR) in SCD occurred with (r)-ALA (25% SCD Group 1 vs. 44% SCD Group 2, p=0.0076). Initial to final patients with high SB or CAN were 21.7%-12% (p=0.010), 10.8%-15.7% (p=0.045), Group 1 vs. 24%-22% (p=ns), 6%-12% (p=0.083), Group 2. Only Group 1 survivors increased mean resting P. The progressive increase in P’s decline, increasing CAN risk, in the other patients correlated with mortality (p<0.001) and (r) ALA dose. Initially, Group 1 had insignificantly less high SB (p=0.449) and significantly more CAN (p=0.013) vs. Group 2. Finally, Group 1 had significantly less high SB (p=0.0967) vs. Group 2, also improving to insignificantly more CAN (p=0.261). Conclusion: (r)-ALA was associated with a 43% RRR of SCD and favorable P and S changes.

The Feasibility of Blood Pressure Control with Autonomic-Assisted Hypertension Therapy Versus JNC 8 Therapy

Background: Over one billion people have Hypertension (HTN); mortality and morbidity are increasing. The Parasympathetic and Sympathetic (P&S) nervous systems prominently affect the onset and progression of HTN, yet P&S measures are not used to assist in management. Our objective was to determine the feasibility of HTN control using P&S-guided to JNC 8 HTN therapy. Methods: 46 uncontrolled HTN patients were randomized prospectively to P&S-assisted management, adjusting JNC 8 therapy using the ANX 3.0 Autonomic Monitor and adding (r) Alpha Lipoic Acid (Group 1) vs. JNC 8 (Group 2). Results: The two Groups were similar in: 1) age (mean 66 vs. 70 y/o for Groups 1 and 2, respectively; 2) initial resting home Blood Pressure (BP, Group 1 mean=162/90 mmHg vs. Group 2 mean=166/87 mmHg, 3) initial resting office BP Group 1 mean=151/75 mmHg vs. Group 2 mean=155/73 mmHg, and 4) ethnicity. Upon follow-up (mean=8.35 mo.): 1) mean resting home BPs were 145/77 mmHg (Group 1, 74% of patients at JNC 8 goal) vs. 155/83.5 mmHg (Group 2, 30.4% at JNC 8 goal), and 2) mean resting office BPs were 138/71 mmHg (Group 1) vs. 146/65 mmHg (Group 2). At the studys conclusion, Group 1 Sympathetic tone was lower than that for Group 2 both at rest and upon standing, and Group 1 Parasympathetic tone was higher than that for Group 2 both at rest and upon standing. Conclusion: P&S-assisted HTN therapy is feasible, resulting in improved BP control, through healthier P&S tone on fewer prescription medications.

Commentary Letter: Pneumopericardium Following Blunt Trauma

Pneumopericardium is presence of air within the pericardial space. It is rare complication of blunt or penetrating chest trauma and may also occur iatrogenically. A case report of pneumopericarium caused by blunt chest trauma, condition was diagnosed by chest CT (Computed Tomography) scan; patient was vitally stable and managed conservatively with spontaneous resolution of pneumopericardium 10 days after admission.

Vasomotor Center? A Possible Role in the Treatment of Hypertension

The global burden of hypertension and associated co-morbidities (cardiac failure, renal failure), is constantly rising despite the availability of newer drugs. Therefore, this study was planned to review the role of VMC (Vasomotor Center) in hypertension along with adding stress-relieving methods in lifestyle measures to prevent an epidemic of hypertension. For this purpose textbook of physiology, and various reference studies were used. The text-book of physiology suggests the location of VMC (Lower pons and medulla) and its functioning related to blood pressure regulation. It receives a signal from baroreceptors and produces either a decrease or an increase in blood pressure. The VMC is influenced by the cerebral cortex and hypothalamus. The pathophysiology suggests that possibly chronic stress, mental overwork disturbs the cortical influences to hypothalamus and shifts VMC to a higher level and that results in high basal sympathetic discharge and increased LV ejection force along with shifting of baroreceptors and renal mechanism to a new higher level which brings the blood pressure or whole body vasculature to the same high level resulting in hypertension. The repetition of the same process shifts BP even higher. The centrally acting drugs, mental rest, sound sleep and stress relieving methods like yoga, Vipassana, etc. may help to reduce cortical impulses and to bring VMC back to normal. VMC will automatically correct various BP control mechanisms and bring back BP to normal. Thus continuous efforts are needed to remove precipitating factors of hypertension. The methods to relieve stress and exhaustion must be employed in lifestyle for hypertension besides JNC guidelines.

Surgical Repair of VSD and their Short Term Outcome in a Tertiary Care Hospital

Background: Ventricular Septal Defect (VSD) is the commonest congenital cardiac anomaly in Bangladesh. For this reason, patch repair of VSD is commonly performed cardiac surgery here. Aim: To observe the short term outcome of patch repair of VSD. Methods: 50 consecutive patients were enrolled in the study by purposive sampling who received treatment for isolated VSD in Department of Paediatric Cardiac Surgery of Dhaka Shishu Hospital, Dhaka, Bangladesh. They underwent ventricular patch repair from January, 2017 to December, 2017. A prospective observational cross-sectional study was conducted for this 12 months period. A pre-structured, interview and observation based, peer reviewed data collection sheet was prepared. Data regarding Sociodemographic, clinical, surgical and outcome profile were recorded. Data were compiled, edited and analyzed with SPSS version 23. Data were presented as mean and standard deviation, frequency percentage and median with range. Results: The mean birth weight of 50 patients was 2.8 kg (range: 2.1-3.5 kg) whereas the median of gestational age was 38 weeks. Among these 50 patients, 22 (44%) and 28 (56%) were boys and girls respectively. The indication of surgery was volume load, failure to thrive and repeated respiratory tract infection. Out of 50 patients, 46 (92%) had perimembranous variety. On the contrary, 4 (8%) experienced Double committed type of VSD. The mean Bypass time and Aortic cross-clamp time were recorded as 70 ± 13.7 minutes and 35 ± 6.85 minutes respectively. Out of 50 patients who underwent ventricular patch repair, 2 (4%) experienced pneumothorax, 1 (2%) got chylothorax and 1 (2%) had transient heart block. Total 45 (90%) patients showed uneventful outcome. Conclusion: Contemporary results of ventricular patch repair in case of VSD showed unparallel outcome with extremely low morbidity in our perspective.

Routine Measurements of Cardiac Parasympathetic and Sympathetic Nervous Systems Assists in Primary and Secondary Risk Stratification and Management of Cardiovascular Clinic Patients

Objective: To review our studies of the ease and importance of Parasympathetic and Sympathetic (P&S) measures in managing cardiovascular patients. Background: The autonomic nervous system is responsible for the development or progression of Hypertension (HTN), orthostasis, Coronary Disease (CAD), Congestive Heart Failure (CHF) and arrhythmias. Finally, new technology provides us with rapid, accurate P and S measures critically needed to manage these patients much more successfully. Methods: Using the ANX 3.0 autonomic monitor, P&S activity was recorded in 4 studies: 163 heart failure patients in total, mean follow-up (f/u) 12-24.5 months; 109 orthostasis patients, f/u 2.28 years and 483 patients with risk factors or known HTN, CAD or CHF, f/u 4.92 yrs. All were on guideline-driven therapy. Results: 59% of CHF patients had dangerously high Sympathovagal Balance (SB) or Cardiac Autonomic Neuropathy (CAN) and Ranolazine markedly improved 90% of these, improved left ventricular ejection fraction in 70% of patients on average 11.3 units, and reduced Major Adverse Cardiac Event (MACE) [Acute Coronary Syndromes (ACS), death, acute CHF, Ventricular Tachycardia/Ventricular Fibrillation (VT/VF)] 40%. 66% of orthostatic patients corrected with (r) Alpha Lipoic Acid ([r]ALA); non-responders had the lowest S-tone. In the 483 patient study, SB>2.5 best predicted MACE when compared to nuclear stress and echocardiography (sensitivity 0.59 or 7.03 [CI (Confidence Interval) 4.59-10.78], specificity 0.83, positive predictive value 0.64 and negative predictive value 0.80). Conclusion: Parasympathetic and sympathetic measures significantly improve care of cardiovascular patients.

Prevalence of Hyperuricemia and its Association with Other Cardiovascular Risk Factors in Adult Yemeni People of Sana'a City

Objective: Hyperuricemia is a metabolic problem that has become increasingly common worldwide over the past several decades. Its prevalence is increased in both advanced and developing countries including Yemen. The aim of this cross sectional study was to investigate the prevalence of hyperuricemia in sample of Yemeni adult individual and its relationship to certain cardiovascular risk factors namely obesity, hypertension, serum glucose, total cholesterol, high serum triglyceride, Low High Density Lipoprotein (HDL-C) and high Low Density Lipoprotein (LDL-C). Methodology: A sample of 600 adult Yemeni people aged equal or over 18 years was randomly chosen to represent the population living in Sanaa City during a period of two years from April 2017 to August 2018. All the study groups undergo full clinical history and examination includes measurement of BP and BMI, WC and the following laboratory investigation (FBS, Basal serum uric acid level, total cholesterol, serum TG, HDL and LDL). Results: The prevalence of hyperuricemia in this study was 8.8% (11,6% male and 6.4% female). The serum uric acid level in this study was significantly correlated with age, Waist Circumference (WC), SBP, DBP, FBS, T-cholesterol, TG and LDL but not with HDL. Conclusion: There is strong relationship between serum uric acid level and other cardiovascular risk factors.

Healing Myocarditis from a Hypertrophied Heart with Multifocal Fibrosis Mimicking Cardiomyopathy

We report the case of an 18 year old man who unexpectedly died of healing myocarditis. His heart was hypertrophied with multifocal fibrosis which can be a common histological feature of primary and secondary cardiomyopathy as well as the healing phase of myocarditis. However, the pattern of myocardial fibrosis, inflammation with myonecrosis, sparing of the right ventricular myocardium, and cardiomyocytes features in the remaining areas of the heart were considered as the key elements in determining a diagnosis of myocarditis. This case illustrates that meticulous histologic examination and the analysis of the histologic findings in the hypertrophied heart with multifocal fibrosis can be helpful to make a correct diagnosis.