心血管疾患と診断

Objective: We sought to determine if the outcome benefit of beta blockade in the ACS population is associated with baseline HR, discharge HR, or a reduction in HR.

Background: ACC guidelines recommend a resting HR goal of 50 to 60 bpm in ACS patients. This recommendation is not based on study outcomes, but rather on expert opinion. Evidence-based clinical trials investigating ideal target heart rate of beta blocker (BB) therapy in the ACS population are lacking.

Methods: A retrospective analysis was performed of all ACS patients who underwent coronary angiography (with or without percutaneous coronary intervention) at Providence Hospital from September 2006 to August 2011 excluding patients with any contraindication to BB therapy. Discharge HR was used as the predictor variable for outcomes in these patients.

Results: A total of 912 patients (403 ST elevation myocardial infarction MI (STEMI) and 509 Non STEMI patients were included. Discharge HR was divided into quintiles: quintile 1 (48 - 64 bpm), quintile 2 (65 - 70), quintile 3 (71 - 76), quintile 4 (77 - 83) and quintile 5 (84 - 119). There was a statistically significant difference seen between the quintile 1 composite endpoint and the other quintile endpoints. (p value <0.05) No differences were seen across quintiles in median TIMI risk index score at admission, systolic and diastolic blood pressure or beta-blocker dose at discharge. Patients in quintile 1 fared better overall with the observation of worse outcomes in patients with a discharge heart rate less than 55.

Conclusion: In those with ACS, particularly STEMI and NSTEMI, a lower discharge HR conferred a decreased composite endpoint at 24 months with the best outcomes seen at a resting HR between 55-65. Further studies are needed to investigate the clinical benefit of optimal HR reduction in this population beyond 2 years.

Objectives: The clinical profile among patients with acute coronary syndromes (ACS) is not well reported in Qatar. To determine the clinical characteristics and profile of patients having acute coronary syndromes presenting to a private tertiary hospital in Qatar.

Methods: Retrospective study conducted at a large tertiary center. Successive cases presenting with ACS to the coronary-care unit between January 2009 and December 2013 were included. Cases were grouped into ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation myocardial infarction/unstable angina (NSTEMI/UA) for the purpose of analysis.

Results: Among 451 patients treated for ACS, 327(72.7%) were males and 123(27.3%) females. 36 (8%) patients had STEMI, 269 (59.8%) NSTEMI and 145(32.2%) had unstable angina. 343 (76.2%) had hypertension, 228 (50.7%) had diabetes mellitus and 195(43.3%) were smokers. In 238(52.9%) patients the time of onset and reaching hospital was between 12 am to 6 am. More than 70% patients with ACS were in the age group of 41 to 60 years of age.

Conclusions: In a varied, multi ethnic and rapidly growing economy of Qatar the number of males suffering ACS far exceeds the females. A high prevalence of cardiovascular risk factors implies a continuing burden of cardiovascular morbidity and mortality. Improving the lifestyles of patients in the region will be crucial for improving long-term outcomes. Appropriate vision and emphasis is required for the management of cardiovascular risk factors and cardiovascular disease in this part of the world. The patient profile and characteristics including the risk profile helps us to understand the demographic variation and prevalence in our mix of multi ethnic, migrant and expat population utilizing the private healthcare sector services.

It has been estimated that 2.2 million people in United States have paroxysmal or persistent atrial fibrillation. The incidence has increased 13% over the past 20 years and it seems to be on the rise. The most feared complication of atrial fibrillation is systemic thromboembolic events. Mitral stenosis and atrial fibrillation is risk factors for cardiac thrombus formation. We report an interesting case in which a 69-year-old male with rheumatic mitral stenosis, atrial fibrillation and congestive heart failure developed rapidly worsening dyspnea on anticoagulation. Subsequent investigation demonstrated impaired left ventricular systolic function, severe mitral valve stenosis and a large left atrial thrombus.

Since the patient’s symptoms had worsened rapidly during a relatively short period of time, we hypothesize that the thrombus was obstructing blood flow through the left atrium and was causing the patient’s symptoms. Mitral valve stenosis, itself, is a risk factor for thromboembolic events. Combined with atrial fibrillation and left ventricular systolic dysfunction, slow flow in the left atrium may contribute to thrombus formation.

Even though, our patient was anticoagulated, the stability of oral anticoagulation therapy is essential. We want to highlight one particular group of patients, classified as high risk, in which close clinical follow-up and more intense anticoagulation might be of benefit. Also, the possibility of thrombus formation in the left atrium should be considered when there is a sudden change in symptoms

A 74-year-old woman required surgical treatment of severe aortic valve stenosis and two-vessel coronary artery disease consisted of a significant stenosis of the left anterior descending branch and right coronary ostium. She had previously undergone radical mastectomy and radiation therapy for left breast cancer. Severe dermal sclerosis and subcutaneous tissue defect at the chest midline, which would cause poor wound healing because of insufficient blood flow, precluded conventional median sternotomy and a left mini-thoracotomy. Therefore, we selected a hybrid treatment approach using a combination of surgery and percutaneous coronary intervention. We performed aortic valve replacement and coronary bypass grafting to the right coronary artery using a right parasternal approach followed by percutaneous coronary intervention of the left anterior descending artery on postoperative day 13. Wound healing was quite satisfactory

The indices to measure the deformation of the myocardium by non-invasive techniques has proven to be a decisive modality. Done by strain and strain rate, both of these approaches allow comprehensive assessment of myocardial function and thereby broadening the spectrum of its clinical applications. They provide an early detection and quantification of myocardial dysfunction of different etiologies, assess the viability of the myocardium and finally the data provided by strain and strain rate are helpful for therapeutic decisions as well as useful for follow-up evaluations of post cardiac interventions. Their feasibility in measurement of the parameters however is marred by technical challenges, susceptible to artifacts as well as observer variability.

In this review the discussion elucidates the concepts of deformation imaging and also portrays comparatively two major deformation imaging methods (TDI-derived and speckle tracking 2D-strain derived). The focus shall be on the development of the technique and its limitations, together with current status of potential clinical applications. Despite the fact that further exploration is still awaited to bring an objectivity to the evaluation of the cardiovascular disease, presently considering of its applicability, these new tools of non-invasive cardiology have generated a great deal of interest amongst the cardiologist.

Isolated right ventricular (RV) myocardial infarction (MI) is an extremely rare phenomenon and may be difficult to recognize. Also, it is rare to observe ST elevation in anterior leads caused by isolated, transient small acute marginal branch occlusion. We described the case of an acute RV MI with transient ST segment elevation in precordial leads from V1 to V4, due to isolated RV branch occlusion during right coronary artery stenting.

Background: Transcatheter Aortic Valve Implantation (TAVI) is a therapeutic option for patients presenting with severe aortic stenosis and in whom surgery is contraindicated. Pre-procedural Pulmonary Hypertension (PH) has been shown to be a factor of poor prognosis in surgical and TAVI studies.

Aims: We sought to evaluate the clinical impact and prognostic implications of the presence of post-TAVI PH.

Methods: The outcome of post-TAVI Pulmonary Artery Systolic Pressure (PASP) was studied in 58 high-risk patients with severe symptomatic aortic stenosis, by assessing clinical presentation and prognosis and determining predictive factors.

Results: Post-TAVI PH (PASP>40 mmHg) affected 43% of patients at 6 months. Despite excellent aortic results in both groups, patients with post-TAVI PH were more symptomatic, with were severer according to the New York Heart Association classification (class III or IV), higher cardiovascular mortality and more frequent readmission for cardiac failure. On univariate analysis, factors for elevated PASP were: female sex, history ofmyocardial infarction, pacemaker implantation and permanent pacing, atrial fibrillation, and degree of mitral regurgitation. On multivariate analysis, only atrial fibrillation remained an independent factor for post-TAVI PH.

Conclusion: PH is frequently present after TAVI and allows identification of a subgroup of patients with poorer clinical presentation and cardiovascular prognosis. Further studies and especially complementary myocardial investigation seem necessary.

The resting 12-lead Electrocardiogram (ECG) is very useful in the diagnosis, prognosis and treatment of heart failure. There are limited data on the prevalence of ECG abnormalities in heart failure in Ghana. This retrospective study was therefore designed to determine the prevalence of ECG abnormalities among heart failure patients attending a cardiac clinic at the Komfo Anokye Teaching Hospital (KATH), Kumasi, Ghana. Medical records of 398 patients diagnosed with heart failure were selected from the cardiac clinic, using simple random sampling. The demographic, clinical and chest X-ray characteristics of the patients were examined. The 12-lead resting ECGs were obtained from 394 of the patients. The ECGs were abnormal in 93% (n=367) of the patients. The main ECG abnormalities included: left ventricular hypertrophy (43.7%), left axis deviation (39.6%), left bundle branch block (19.2%), and left atrial enlargement (25.6%). Arrhythmias seen included: ventricular extrasystoles (11.2%), atrial fibrillation (8.9%), complete heart block (5.3%), and ventricular tachycardia (3.6%).

In conclusion, our study has shown that ECG abnormalities are very common among heart failure patients attending cardiac clinic in Kumasi, Ghana