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   Table of Contents - Current issue
January-June 2021
Volume 3 | Issue 1
Page Nos. 1-47

Online since Monday, June 28, 2021

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When will this pandemic end? p. 1
Govindan Vijayaraghavan
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Chronic coronary syndrome: A review of the literature Highly accessed article p. 3
Salman Hussain, Maraam AlRashed, Rajesh Rajan, Mohammed Al-Jarallah, Peter A Brady, Biji Soman, Raja Dashti
Chronic coronary syndrome (CCS) is a newly proposed entity by the European Society of Cardiology that replaces stable coronary artery disease (CAD), which is defined as a progressive process of plaque accumulation in coronary circulation with associated functional changes. CCS has replaced stable CAD to raise awareness that despite the clinically silent nature of the disease, there are progressive pathological changes occurring in the coronary arteries. This has allowed clinicians to review the current various diagnostic modalities, methods of risk stratifying patients based on different models and the various management options available, including lifestyle modifications, pharmacological therapies, and revascularization. With the emergence of this new entity, great emphasis has been placed on the consolidation of our comprehension of the dynamic character of the disease and the preventative actions that aim to reduce the cardiovascular disease burden.
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Compliance with guideline-recommended management in patients with non-st-elevation acute coronary syndromes: Findings from the gulf COAST registry p. 8
Hamdan Alajmi, Mohammad Zubaid, Wafa Rashed, Ibrahim Al-Zakwani
Background: Evaluation of management practices and adherence to treatment guidelines are essential components of improved health-care delivery. Despite the improvement in the implementation of guidelines, the medical management of acute coronary syndrome (ACS) remains suboptimal worldwide. The aim of the present study was to determine medication use patterns, recent trends, and prescription predictors of adherence to guideline-based therapies for non-ST-elevation ACS (NSTE-ACS) in the Middle East. Methods: We evaluated the use of a quadruple evidence-based medication (EBM) combination consisting of the concurrent use of dual antiplatelet therapy, β-blockers, and lipid-lowering agents at discharge among patients (n = 2782) with NSTE-ACS in four Middle Eastern countries. Results: A total of 56% (n = 1626) of the patients received all four guideline-recommended medications at hospital discharge. An adjusted model demonstrated that male sex, diabetes, dyslipidemia, prior percutaneous coronary intervention, prior myocardial infarction, prior coronary artery bypass graft, admission to a catheterization-equipped hospital, and smoking were positively correlated with EBM prescription on discharge. Conversely, cardiogenic shock, heart failure, renal impairment, higher GRACE risk score, and bleeding negatively correlated with concurrent use of the quadruple EBM combination. Conclusion: Nearly half of NSTE-ACS patients in the Middle East do not receive the quadruple EBM combination. Efforts are needed to bridge this gap between practice and guidelines.
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The Impact of mineralocorticoid receptor antagonist use on all-cause mortality in acute heart failure patients p. 14
Ibrahim Al-Zakwani, Mohammed Al-Jarallah, Rajesh Rajan, Kadhim Sulaiman, Raja Dashti, Bassam Bulbanat, Alawi A Alsheikh-Ali, Prashanth Panduranga, Khalid F AlHabib, Jassim Al Suwaidi, Wael Al-Mahmeed, Hussam AlFaleh, Abdelfatah Elasfar, Ahmed Al-Motarreb, Mustafa Ridha, Nooshin Bazargani, Nidal Asaad, Haitham Amin, Amar M Salam
Background: The impact of mineralocorticoid receptor antagonist (MRA) use in acute heart failure (AHF) patients in the Middle East is not well studied. The objective of this study was to examine the impact of MRA therapy on all-cause mortality in AHF patients in the Middle East stratified by left ventricular ejection fraction. Methods: Data were analyzed from 3792 consecutive patients admitted to 47 hospitals in 7 Middle Eastern countries. Results: The overall mean age was 59 ± 15 years and 62% (n = 2353) were male. At discharge, MRA therapy was prescribed in 34% (n = 1301) of the patients. A total of 54% (n = 2048) of the patients had AHF with reduced ejection fraction (EF) (HFrEF) (<40%), 23% (n = 880) had HF with mid-range EF (HFmrEF) (40%–49%), and 23% (n = 864) had HF with preserved EF (HFpEF) (≥50%). MRA therapy was associated with lower cumulative all-cause 3-month mortality in those with HFrEF (adjusted odds ratio [aOR], 0.55; 95% [confidence interval (CI): 0.37–0.80: P = 0.002), those with HFmrEF (aOR, 0.43; 95% CI: 0.19–0.99: P = 0.047), and in those with HFpEF (aOR, 0.45; 95% CI: 0.22–0.92: P = 0.029) when compared to those that were not on MRA therapy. MRA therapy was also associated with lower cumulative all-cause 12-month mortality in those with HFrEF (aOR, 0.65; 95% CI: 0.49–0.86: P = 0.002) and in those with HFmrEF (0.52; 95% CI: 0.29–0.91: P = 0.021). Conclusion: MRA therapy was associated with lower all-cause mortality at 3 months and at 12 months in AHF patients with reduced and mid-range EF in the Middle East.
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Identification of altered serum proteins in rheumatic heart diseases through mitral stenosis and the potential clinical implications p. 20
Nancy Bright Arul Joseph Raj, Shanavas Syed Mohamed Puhari, Panneerselvam Gomathi, Andiappan Rathinavel, Govindan Sadasivam Selvam
Background: Rheumatic heart disease (RHD) results from group A beta-hemolytic streptococcal pharyngeal infection is an autoimmune sequela of acute or recurrent episodes of acute rheumatic fever (ARF). This study is focused on identifying heart tissue-specific proteins implicated in the secondary immunopathogenesis of RHD. Methods: Sera from 49 RHD patients and 32 controls were probed in 2DE to study the differential expression of proteins. After 2DE, the spots were analyzed and identified using ESI-MS. A total of 1082 protein spots were detected in RHD patients and controls. Results: Two protein spots were significantly down-regulated (p≤0.01) and 34 protein spots were significantly up-regulated (p≤0.01) compared to controls. The differentially expressed protein spots were trypsin-digested and identified as hyaluronan-mediated motility receptor (RHAMM), troponin 1, janus kinase and microtubule interacting protein 1 (Jakmip 1), nuclear ubiquitous casein and cyclin-dependent kinase substrate 1, basal body-orientation factor 1 and muscle-related coiled-coil protein. A positive correlation was established with the up-regulated and down-regulated expression of these proteins suggests them as potential biomarker for RHD. Conclusion: This study highlights rheumatic mitral stenosis and regurgitation, an active inflammatory process and provides novel information about the proteins thereby elaborates the knowledge of physiology and etiology of this disease.
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Hypomagnesemia as a cardiometabolic risk marker in type 2 diabetes mellitus: Implications for Sub-Saharan Africa p. 29
Taoreed Adegoke Azeez, Oyebola Oluwagbemiga Sonuga
Background: Diabetes mellitus is a metabolic disorder associated with increased cardiovascular mortality. However, studies have suggested a possible link between hypomagnesemia and cardiovascular risk, but these studies are scanty in sub-Saharan Africa. This present study aimed to investigate the association between plasma magnesium and cardiovascular risk factors among type 2 diabetes patients. Methods: Seventy type 2 diabetes patients, with equal gender distribution, in a tertiary hospital in Nigeria were recruited. Ethical approval was obtained. Anthropometric measures were done as recommended. Plasma magnesium and fasting lipid profiles measured using standard protocols. Results: The mean age of the participants was 53.34 ± 9.57 years. The mean duration of diabetes mellitus among the participants was 6.29 ± 2.78 years. Central obesity and hypertension are the most prevalent cardiovascular risk factors among patients with type 2 diabetes. About 38.6% of the participants had suboptimal glycemic control. Nearly 64.3% had dyslipidemia. The frequency of hypomagnesemia among the participants was 25.7%. Hypomagnesemia was significantly associated with the presence of dyslipidemia (P = 0.042) and suboptimal glycemic control (P = 0.001). Conclusion: Hypomagnesemia is associated with cardiometabolic risk factors. Therefore, plasma magnesium could be used as a cheap marker of cardiovascular risk in low-resource settings like sub-Saharan Africa.
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Patterns and Predictors of Left Ventricular Hypertrophy in Nigerians with chronic kidney disease p. 33
Okorie Kalu Kalu, Onwukwe Chikezie Hart, Chikezie Nkiru Ifeoma, Nwagbara Chukwudi Thaddeus, Offia Kalu, Osuji Charles Ukachukwu
Background: Chronic kidney disease (CKD) impacts hugely on cardiovascular morbidity and mortality. Nigerian data on patterns and predictors of left ventricular hypertrophy (LVH) in persons living with CKD are scarce. The objective of the study is to describe the patterns and predictors of LVH in Nigerians with CKD. Methods: Recruitment and clinical assessment of adult Nigerians with CKD were done using standard procedures. Statistical analysis was done using appropriate statistical software. Results: Fifty-seven participants were involved in this study. Concentric and eccentric LVH occurred in 50% and 25% of the predialysis CKD patients, respectively, while 24% and 36% of the maintenance dialysis CKD patients had concentric and eccentric LVH, respectively. LVH patterns in dialysis-naive individuals were not significantly different from LVH patterns in persons on dialysis. The significant predictors of LVH in study participants were proteinuria, anemia, hypoalbuminemia, estimated glomerular filtration rate <30 mL/1.73 m2/min, and hypertensive nephrosclerosis. High calcium-phosphate product was a significant predictor of LVH in only participants on dialysis. Conclusion: This study showed no significant difference in LVH patterns among predialysis and maintenance dialysis CKD patients. Indices of deteriorating renal function were significant predictors of LVH in both categories of CKD patients. Early screening and treatment of significant risk factors of LVH are required in reducing CVD burden among CKD patients.
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An intriguing case of neonatal arrhythmia: An experience with antiarrhythmics and direct current cardioversion p. 39
Suksham Jain, Anam Siddiqui, K Raghavendra Rao, Deepak Chawla
In the fetal and early neonatal period, clinically significant arrhythmias are remarkably rare whose medical management has been an area of dilemma in terms of safety and efficacy. We present a case of a hemodynamically stable female neonate presenting to us with atrial tachycardia with morphology of atrial fibrillation (AF) and atrial flutter (AFl). After a poor response to multiple antiarrhythmics, direct current cardioversion (DCC) was the final solution. Short-term maintenance therapy with oral propranolol was given with no recurrence. Hence, stepwise approach to infants with AFl can lead to an excellent prognosis with a low risk of recurrence.
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Atrioventricular synchrony with a leadless pacemaker p. 42
Marc R Iskandar, Peter A Brady
Leadless pacemakers are more frequently used today. One of their latest advances is their ability to provide atrioventricular synchrony via a single-chamber device. Our aim is to give an example of the function of this type of pacemaker and the patients likely to benefit from it.
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Thromboembolism and anticoagulation therapy among the COVID-19 patients p. 44
Tarun Kumar Suvvari, Satwik Kuppili, LV Simhachalam Kutikuppala
Coronavirus disease 2019 (COVID-19), which is caused due to severe acute respiratory syndrome coronavirus 2 (SARS CoV-2), can be complicated with coagulopathy through disseminated intravascular coagulation (DIC) in severe stages leading to profuse morbidity and mortality. The prothrombotic character of DIC can potentiate a higher risk of venous thromboembolism (VTE), whose incidence among COVID-19 patients in intensive care units appears to be a bit higher and severe. The prevalence of VTE was high in the COVID-19 patients due to inflammation and stasis of blood vessel endothelium resulting from viral infection. D-dimer monitoring can help in early recognition, proper treatment, and better prognosis in the high-risk COVID-19 patients. Recent studies show that anticoagulant therapy reduces the mortality in severe COVID-19 patients with sepsis-induced coagulopathy or markedly elevated d-dimer. Direct oral anticoagulants or low-molecular-weight-heparin can be administrated in hospitalized COVID-19 patients to minimize thrombosis risk. However, constant observation on anticoagulant therapy and post-discharge thromboprophylaxis in COVID-19 patients is recommended.
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Retraction: Incidence, predictors, and mortality of in-hospital stroke after acute coronary syndrome in the Middle East p. 47

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