Coronary artery bypass graft outcome: the Trinidad and Tobago experience

The study is a retrospective review of the demographic, clinical, angiographic, and operative data of the first 205 consecutive CABG operations performed by Caribbean Heart Care at the Eric Williams Medical Sciences Complex (EWMSC), Trinidad and Tobago, between November 1993 and December 1997. The aim of the study was to determine the in hospital and intermediate term follow up results. The mean age of patients was 59 ñ 10 years and 78 percent male. Sixty-four percent were of East Indian descent, whereas, 16 percnt were of Africian descent. Forty-eight percent of the patients were hypertensive, 46 percent were diabetic, 33 percent had hyperlipidaemia, 20 percent had a recent history of cigarette smoking and 16 percent were obese. Sixty-five percent had a positive family history of ischaemic heart disease. The average time interval between angiography and surgery was 2.3 months. At the time of angiography, 63.5 percent of patients had Canadian Cardiac Society (CCS) class 3 or 4 angina. The mean ejection fraction was 61 ñ 15 percent. Wall motion abnormalities were seen in 67 pecent of patients. Significant stenoses of the left anterior descending artery, right circumflex artery, circumflex and ramus coronary arteries were present in 91 percent, 78 percent, 54 percent and 5 percent, respectively. Many patients (67 percent) had severe diffuse disease on angiography. The mean intensive care stay was 2.2 ñ 0.8 days. In hospital mortality was 3.9 percent (8/205). THe most frequent post operative complicaton was haemorrhage (2.6 percent). Acute renal failure occurred in 2.1 percent; pulmonary collapse, 1.6 percent; 1 percent and cardiac arrest , 1 percent. Both sternal wound infections and systemic sepsis occurred in 0.5 percent. Intermediate term follow-up data were obtained for 92 percent (189/205). The duration of follow-up ranged from 1 to 5 years (mean 3.7 years). During the follow up period, 7 patients (3.4 percent) died. Angina severity was reduced from a mean CCS score of 2.61 ñ 0.95 before CABG ot 1.22 ñ 0.55 at the time of follow up (p<0.0001). Overall 4-year mortality compared favourably with data from international studies. Among survivors, quality of life improved as evidenced by the reduction in the mean angina score.(Au)

Problems in interpreting electrocardiograms (ECGs) and questionnaires for effort pain in rural Jamaica

In a rural area in Jamaica, 522 men aged 35-64 years participated in a cardiovascular survey and were followed-up for 13 years. The results revealed the difficulties encountered in evaluating ECGs and questionnaires for effort pain in the diagnosis of ischaemic heart disease in a community. ECG patterns involving Q/QS, ST or T-items were at first interpreted as evidence of myocardial ischaemia. Further studies showed that most of these ECGs were associated with hypertension or may have been normal variants. Some were related to other abnormalities but few could be confidently ascribed to cardiac ischaemia. A questionnaire for chest pain on effort administered at the first survey appeared to have suggested a high prevalence of angina pectoris. Subsequent questionnaires, exercise tolerance tests, examination of medical records and mortality rates demonstrated that a apositive response to the questionnaire was seldom diagnostic of angina, which was rarely seen clinically. Valvular and coronary heart disease, and idiopathic cardiomegaly were much less important in this community than hypertension which was a major risk factor for overall mortality (AU)

Reappraisal of cardiovascular surveys in Jamaica: use of submaximal exercise tests for clinical investigation

Assertions that idiopathic cardiomegaly or an obscure form of ischaemic heart disease are common in Jamaica have been based on a high prevalence in community surveys of unexplained electrocardiographic abnormalities and of positive responses to a questionnaire for ischaemic heart pain. Thirty-one men, aged 42-62 years, in whom these abnormalities had been found in a previously surveyed rural community, were recalled for clinical examination and exercise tests and compared with 18 control subjects. No clinical abnormalities were found. The heart rates during standard work and maximum oxygen uptake of subjects and controls were similar, and indicated, on average, excellent exercise performance consistent with their heavy physical activity in daily life. None complained of chest pain at near maximal exertion, and the previous diagnosis of angina pectoris was judged to have been mistaken. Most of the electrocardiographic abnormalities at rest were minor or isolated and did not change on exercise. Significant changes in exercise occurred in 4 subjects, in whom inverted T waves and ST depression became less obvious than at rest, but the cause of these abnormalities was not found. Though idiopathic cardiomegaly and ischaemic heart disease do not occur in Jamaica, their incidence is not known but there is no evidence that they are as widespread as has been previously asserted. Interpretations of answers to questionnaires and of electrocardiograms obtained in population surveys should be made with caution. From this study we have no evidence on whether the electrocardiographic changes were related to ethnic or environmental factors. (AU)

Longitudinal study of heart disease in a Jamaican rural population. 2. factors influencing mortality

The relationship between cardiovascular characteristics and mortality was investigated in an epidemiological study of heart disease in a representative adult rural community in Jamaica. Of 449 men and 469 women followed up for 5 years, 36 men and 28 women died and the data concerning their status as regards arterial pressure, electrocardiographic abnormalities, and histories of effort pain at the initial survey have been analysed. Cardiovascular disease, and heart disease in particular, was the major cause of death in this population. Blood pressure levels exceeding 160/95 mm Hg had been recorded in about one third of the men and half the women who died and a clear trend was found between overall mortality and arterial pressure. Symptoms of effort pain and ECG abnormalities compatible with myocardial ischaemia, both of which were unexpectedly common, appeared to have independent prognostic significance. The prognosis of each was worse when associated with hypertension; hypertension unaccompanied by either effort pain or ECG "ischaemic" abnormality, on the other hand, caused no excess mortality in either sex within the period of follow-up. Although classical myocardial infarction was confirmed to be relatively infrequent, myocardial disorders with many of the features of ischaemic heart disease are and important cause of death in rural Jamaicans.(AU)

Myocardial disease in a rural population in Jamaica

This survey has revealed an unexpectedly high prevalence of angina pectoris and of electrocardiographic abnormalities usually interpreted as due to myocardial ischaemia or focal myocardial damage. The rarity of myocardial infarction caused by coronary artery occlusion in Jamaicans, as well as the lack of any clear relationship between myocardial damage and age, the association with high serum globulin levels, and the apparently increased prevalence in those with haemoglobinopathies suggest that its etiology is different from that of ischaemic heart disease due to atheroma of the coronary arteries. This study has raised a number of questions of which the most important concern the pathogenesis of the condition and its importance in terms of prognosis; it forms the base line for longitudinal investigation that may resolve some of the outstanding questions (AU)