Explaining the trends in coronary heart disease mortality in Barbados: 1990–2012

OBJECTIVE: To describe the relative contributions of medical treatments and major cardiovascular risk factors to the decline in coronary heart disease (CHD) mortality from1990 to 2012 in Barbados. SUBJECTS AND METHODS: We used the IMPACT CHD mortality model to estimate the effect of improvement in uptake or efficacy of medical/surgical treatments, versus changes in major CHD risk factors on mortality trends. We obtained death data from the World Health Organization(WHO) mortality database and population denominators, stratified by age and gender from the Barbados Statistical Service. Cardiovascular risk factors and treatment data were obtained from published studies, population-based risk factor surveys, Barbados’ national myocardial infarction registry and retrospective chart reviews. RESULTS: In 1990, the age-standardized CHD mortality rate was 109.5 per 100 000, falling to 55.3 in 2012, representing a 46.1% decline in CHD deaths. This resulted in139 fewer deaths observed in 2012 versus the number expected had the rate remained as in 1990. The model indicated that 61% (n = 84) of these deaths were prevented or postponed (DPPs) because of implementation of treatment. Changes in risk factors accounted for 14% of the overall decline (19 DPPs). Improvements in cholesterol, physical inactivity, smoking and fruit/vegetable intake accounted for 51 DPPs; worsening systolic bloodpressure, diabetes and obesity levels were responsible for 32 additional deaths in 2012. CONCLUSIONS: Treatments accounted for approximately two-thirds of the mortality reduction. More effective prevention policies are urgently needed.

Self-monitoring of blood glucose improved glycemic control and the 10-year coronary heart disease risk profile of female type 2 diabetes patients in Trinidad and Tobago

BACKGROUND and AIM: The risk of death from coronary heart disease (CHD) in women with diabetes is more than three times that of non-diabetic women. We assessed the difference in CHD risk levels of Afro-Caribbean diabetic women provided with facilities for self-monitoring of blood glucose and their counterparts without such facilities. MATERIALS and METHODS: Forty-nine patients who never used gluco-meters were studied as intervention (23) and control (26) groups. The intervention group was trained on self-monitoring of blood glucose. At baseline, BP, anthropometric indices, and fasting blood glucose of all patients were measured. Subsequently, the intervention patients were provided with gluco-meters, testing strips, and advised to self-monitor fasting and postprandial blood glucose every other day for 6 months. CHD risk was determined with the United Kingdom Prospective Diabetes Study risk engine calculator. RESULTS: The age, duration of diagnosis of diabetes, BP, and anthropometric indices were similar in the two groups (all, P > 0.05). The majority of the patients were unemployed or retired with only primary education. After 3 months, the HbA 1c levels of the control patients did not change (8.3 ñ 0.4% vs. 7.8 ñ 0.4%, P > 0.05) whereas the HbA 1c levels of the intervention patients reduced significantly from the baseline at 3 (9.2 ñ 0.4% vs. 7.4 ñ 0.3%, P <0.001) and 6 (9.2 ñ 0.4% vs. 7.3 ñ 0.3%, P <0.001) months. The 10-year CHD risk level of the intervention group was remarkably reduced from the baseline level after 6 months (7.4 ñ 1.3% vs. 4.5 ñ 0.9%) of the study. CONCLUSION: Provision of facilities for self-monitoring of blood glucose in Afro-Caribbean women with type 2 diabetes improves both their glycemic control and CHD risk profile.

Prediction of 10-year coronary heart disease risk in Caribbean type 2 diabetic patients using the UKPDS risk engine

OBJECTIVE: Primary prevention of Coronary Heart Disease (CHD) in diabetic patients should be based on absolute CHD risk calculation. This study was aimed to determine the levels of 10-year CHD risk in Caribbean type 2 diabetic patients using the diabetes specific United Kingdom Prospective Diabetes Study (UKPDS) risk engine calculator. SUBJECTS AND METHODS: Three hundred and twenty-five (106 males, 219 females) type 2 diabetic patients resident in two Caribbean Islands of Tobago and Trinidad met the UKPDS risk engine inclusion criteria. Records of their sex, age, ethnicity, smoking habit, diabetes duration, systolic blood pressure, total cholesterol, HDL-cholesterol and glycated haemoglobin were entered into the UKPDS risk engine calculator programme and the absolute 10-year CHD and stroke risk levels were computed. The 10-year CHD and stroke risks were statistically stratified into <15%, 15-30% and >30% CHD risk levels and differences between patients of African and Asian-Indian origin were compared. RESULTS: In comparison with patients in Tobago, type 2 diabetic patients in Trinidad, irrespective of gender, had higher proportion of 10-year CHD risk (10.4 vs. 23.6%, P<0.001) whereas the overall 10-year stroke risk prediction was higher in patients resident in Tobago (16.9 vs. 11.4%, P<0.001). Ethnicity-based analysis revealed that irrespective of gender, higher proportion of patients of Indian origin scored >30% of absolute 10-year CHD risk compared with patients of African descent (3.2 vs. 28.2%, P<0.001). CONCLUSIONS: The results of the study identified diabetic patients resident in Trinidad and patients of Indian origin as the most vulnerable groups for CHD. These groups of diabetic patients should have priority in primary or secondary prevention of coronary heart disease.

Insulin resistance, leptin and monocyte chemotactic protein-1 levels in diabetic and non-diabetic Afro-Caribbean subjects

AIM: To determine how the levels of leptin and monocyte chemotactic protein-1 (MCP-1) are associated with insulin resistance (IR) in obese, non-obese, diabetic and non-diabetic subjects. METHODS: 112 type 2 diabetics and 43 non-diabetics were studied fasting. Anthropometric indices were measured and glucose, insulin, leptin and MCP-1 were measured in blood. IR was calculated. RESULTS: MCP-1 level was significantly higher in diabetics than non-diabetics irrespective of gender (p < 0.05). Irrespective of diabetes status, the serum leptin concentration was significantly higher (p < 0.05) in obese and females subjects than in non-obese and male subjects respectively. There were no significant correlations between IR and MCP-1 or leptin in all subgroups of subjects studied. General linear modelling analysis showed that only diabetes state significantly predicted MCP-1 levels (p < 0.05) whereas non of the factors predicted leptin levels (p > 0.05). CONCLUSION: Routine measurement of leptin and MCP-1 would be potentially useful in assessment of patients for the metabolic syndrome or coronary heart disease especially in black population.

A heretical view of the American Heart Association's nutritional dogma [abstract]

The dogma is as follows: no more than 33 percent of the calories in the diet should come from fat, and of those no more than 33 percent should come from saturated fat. Because of the saturated fats in eggs and butter, both of these foods are unsuitable. Diets that do not conform to these standards raise serum cholesterol levels and thereby promote coronary heart disease (CHD). However, serum cholesterol is not correlated with dietary cholestorol. diet or drug regimes that reduce serum cholesterol do not reduce mortality. Blood lipoprotein a, the best single predictor of CHD, correlates not at all with fat in the diet but inversely with ascorbic acid. Low-fat diets do not protect against CHD type 2. In practice, they are almost always high-carbohydrate, and often high-sucrose diets. Such diets promote obesity, Type-2 diabetes mellitus, and the production of advanced glycosylation end-products, which in turn promote hypertension and CHD. Because of the need for essential fatty acids, all diets should include unsaturated fatty acids. However, as quantities rise above optimum the unsaturated acids promote greater free radical damage and require increasing amounts of oil-soluble anti-oxidants to counteract this effect. Eggs are excellent food, containing, in addition to protein, carbohydrate, fat and all the vitamins, minerals and essential fatty acids needed to produce a chicken. They do not promot CHD. Nutritionally, butter is much better than margarine which contains large amounts of trans fatty acids, that interfere with the metabolism of essential fatty acids, raise low density lipoprotein and triglycerides and lower high density lipoprotein. The best is a low-carbohydrate diet with little sucrose and adequate levels of vitamins, minerals and essential fatty acids. (AU)

Predictors of mortality in patients with left ventricular failure [abstract]

We retrospectively reviewed the clinical presentation and five-year mortality of 64 consecutive adults who underwent echocardiography at the Eric Williams Medical Sciences Complex between January 1992 and December 1994 with a left ventricular ejection fraction < 40 percent. The mean age was 60ñ12 years and 68 percent of patients were male. The prevalence of diabetes mellitus and hypertension was 40 percent and 46 percent, respectively. The mean left ventricle ejection fraction was 30ñ9 percent. The most common primary cost of left ventricular failure was coronary artery disease (CAD) in 47 percent, idiopathic dilated cardiomyopathy (9 percent), hypertensive heart disease (9 percent), alcohol related dilated cardiomyopathy (8 percent) and valvular heart disease (6 percent). Angiotensin converting enzyme inhibitors were prescribed in 85 percent of cases, diuretics (82 percent), digoxin (61 percent), warfarin (18 percent), beta blockers (10 percent), and amiodarone (8 percent). Survival data were available for 84 percent. Mortality was 53 percent at 5 years. Independent predictors of mortality were age, the use of beta blockers and left ventricular internal diameter. In conclusion, CAD was the most common cause of left ventricular failure. Five-year mortality was high, particularly in elderly patients with marked ventricular dilatation. (AU)

Diabetes: a Caribbean concern

We have asked many doctors in the Caribbean which clinical conditions cause them the most concern. The three topics that have probably been mentioned most often are cardiovascular disease, diabetes, and asthma. Readers have asked us to carry more information on the management of these illnesses. Hypertension and asthma have already been the subject of special supplements in Caribbean Health. Now, in this issue of the journal we are pleased to be publishing a similar supplement devoted to diabetes (AU)

Spontaneous coronary artery dissection in a thirty two year old woman. A case report and a review of the literature

A case of spontaneous coronary artery dissection, an extremely rare condition, is reported in a thirty two year old woman. The pathological and clinical features as well as the management of this condition are discussed. Recent postulates with regard to aetiology and pathogenesis are emphasized. (AU)

The application of rapid analytical systems and sensors to the detection of cancers and other diseases

There is an advantage in combining knowledge of biosensor technology with that of immunological and molecular methods. This may enhance early diagnosis of cancers and other diseases and thus ultimately contribute to a better prognosis.(Au)

Intracoronary stent implantation in Jamaica: the initial experience

Intracoronary stent implantation resulted in the complete or near complete dilatation of high gread occlusions of the left anterior descending coronary arteries in the four patients in whom it was undertaken. Intracoronary stent implatation is a useful adjuct to Percutaneous Transluminal Angioplasty (PTCA) and is applicable in selected patients with symptomatic ischaemic heart disease in a developing country with limited health resources like Jamaica. This is so since financial data presented here document the significant savings this technique (when appropriately utilised) could realise compared to the use of baloon angioplasty alone. (AU)

Stenting of partial and total cornary occlusions in Trinidad and Tobago

In order to evaluate the efficacy and safety of coronary stenting, we reviewed the first 32 consecutive patients (34 vessels) who underwent elective coronary stenting during the period August 1999 to August 2000 inclusive at the Digital Lab installed at the Eric Williams Medical Complex, Trinidad and Tobago. Aspirin, heparin and ticlopidine were used routinely. Abciximab was used in selected cases (38 percent). The mean age of patients was 55 ñ 10 years. Eighty-one percent were male, 52 percent were hypertensive and 21 percent diabetic. Sixty-five percent had severe angina. Prior Coronary Artery Bypass Grafting (CABG) was performed in 3 percent and previous Percutaneous Transluminal Coronary Angioplasty (PTCA) in 3 percent. Multivessel disease was present in 43 percent. The mean left ventricular ejection fraction was 53 ñ 12 percent. The culprit lesion was located in either the native left anterior descending (LAD) coronary artery (53 percent), right coronary artery (RCA) (31 percent), circumflex artery 13 percent and saphenous vein graft (3 percent). The mean baseline diameter stenosis was occluded vs 50 percent for 8 totally occluded vessels. For the total occlusions, procedural sucess was inversely related to the duration of the occlusion. There were no cases of death, acute vessel closure, Q-wave myocardial infarction, repeat PTCA or emergency Coronary Artery Bypass Graft (CABG) during and following the procedure. Distal embolization occurred in one patient. The mean duration of hospital stay was one day (for 30 outpatient cases). One patient had recurrence of symptoms with a negative stress test. No patient underwent repeat angiography during the first year of follow-up. Coronary stents were successfully implanted at a tertiary care facility in the Caribbean with low in-hospital morbidity and mortality. Stents markedly reduced the diameter stenosis of the coronary lesion during PTCA. The incidence of clinical restenosis was low. Coronary revascularisation can be successfully achieved by coronary stenting in the Caribbean (AU)

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)

The feasibility of a porcine model of acute coronary occlusion and reperfusion using off-pump coronary artery bypass grafting

We developed an open-chest porcine model of acute coronary occlusion and surgical reperfusion, and attempted to prevent intra-operative ischaemic ventricular fibrillation (VF) by a Retrograde Intracoronary Glyceryl trinitrate (RIG) infusion into the occluded vessel. Five Yorkshire pigs (weight 50ñ 1.1kg), randomized into 3 groups, underwent median sternotomy under general anaesthesia. One pig (Group 1, control) underwent sternotomy and pericardiotomy only. Four pigs underwent acute left anterior descending (LAD) coronary occlusion. Two pigs were not reperfused (Group 2). Two pigs underwent surgical reperfusion (Group 3) via left internal mammary artery (LIMA) grafting to the LAD using the Off-Pump Coronary Artery Bypass (OPCAB) technique. Ischaemic injury was assessed using 7-lead electrocardiography (EGG) and transthoracic/epimyocardial echocardiography (ECHO). Group 1: transient intraoperative hypotension and VF occurred. Successful resuscitation and 10-week survival (until sacrifice) with normal left ventricular (LV) function was achieved. Group 2: there were ECG and ECHO evidence of acute LV ischaemic dysfunction in both pigs. The surviving pig had persistent anterior hypokinesis at 8« months. The other died intra-operatively following progressive ischaemic LV dysfunction despite resuscitative attempts. Group 3: the surving pig had normal LV function at 8 months. Initial anterior LV akinesis normalized within 7 days. The other developed post-occlusion haemodynamic instability and died intra-operatively despite reperfusion. In this porcine model, acute LAD artery occlusion modified by the novel RIG infusion technique, followed by surgical reperfusion (OPCAB) is feasible. This model would facilitate further development of OPCAB surgical expertise and understanding of the pathophysiology of ischaemia-reperfusion injury.(Au)

Fatty acid composition and possible health care effects of coconut constituents

The link between excessive composition of dietary saturated fats and coronary heart disease (CHD) is now well established. Because of its high content of saturated fatty acids, the composition of foods containing coconut oil may therefore be a risk factor for CHD. While the fatty acid composition of coconut oil is well established, relatively little is known about the other constituents of coconut: the milk, water, cream and meat fractions. In this study, we show that while the water fraction is low in lipid content, the milk contains about 24 percent of the fat content of oil and the cream and meat fractions about 34 percent. The other coconut constituents contain significant amounts of medium-chain triglycerides that are formed from fatty acids of chain length 8:0 to 14:0. It is these fatty acids, primarily 14:0, that are thought to be atherogenic. On the other hand, medium-chain triglycerides provide a ready source of energy and may be useful in baby foods or in diet therapy. Nevertheless, the possible negative effects of the saturated acids and the absence of the essential fatty acid linolenic acid from all coconut constituents suggest that the coconut milk, oil and cream should not be used on a regular basis in adults. (AU)

Two-Year Mortality and its determinants following acute myocardial infarction in Trinidad and Tobago

The purpose of this study was to determine the occurrence of coronary artery disease risk factors in patients presenting with acute myocardial infarction(AMI) to a tertiary care institution in Trinidad and to determine the factors associated with increased mortality following AMI. All patients admitted to the Eric Williams Medical Sciences Complex (EWMSC) between January 1 and December 31, 1996, with a diagnosis of AMI were identified using the hospital admissions and discharge diagnosis databases. Demographic, clinical and laboratory variables were extracted from the hospital case records of patients with confirmed AMI. Sixty-one AMI patients (38 men) were admitted during the study period. Mean age of admittance was 60 ñ 11 years with an ethnic case mix of thirty-nine (62 percent) of East Indian descent, eight (13 percent) of African descent, twelve (20 percent) mixed ethnicity and three of Caucasian descent. Thirty patients (49 percent) were hypertensive. Thirty-two patients (53 percent) were diabetic and eighteen patients (30 percent) gave a history of cigarette smoking. The mean left venticular ejection fraction was 53 ñ 14 percent. The mean serum cholesterol from 29 patients was 228.2 ñ 49.0 mg/dl. Increasing age, female gender, an ejection fraction less than 40 percent, non treatment with streptokinase and in-hospital ventricular fibrillation were associated with poor survival. Multiple regression analyses identified three independent predictors of mortality. These were gender (p = 0.04), in-hospital ventricular fibrillation (p = 0.001) and an ejection fraction less than 40 percent (p = 0.02). Diabetes mellitus, hypertension, hyperlipidaemia and cigarette smoking were prevalent amongst patients presenting with AMI. Ventricular function was a major determinant of two-year mortality following AMI. Aggressive risk factor modification is recommended to prevent both first and recurrent coronary events.(AU)

Cardiovascular problems in the hypertensive diabetic patient

Cardiovascular disease is a major cause of morbidity and mortality in patients with diabetes and has become the subject of intensive recent investigation. One hundred years following the initial description of the relationship between diabetes and anginal chest pain, major scientific organizations in the United States have come together and focused much attention on this topic. The importance of heart disease and diabetes has been emphasised in a recent American Heart Association Scientific Statement and accompanying editorial written jointly by the American Diabetes Association (ADA), the National Heart, Lung and Blood Institute, the Juvenile Diabetes Foundation International, the National Institute of Diabetes and Digestive and Kidney Diseases, and the American Heart Association. Hypertension is not only a risk factor for the development of cardiovascular disease, but is also a strong, independent predictor of renal disease and retinopathy. Cardiovascular problems that result from diabetes and hypertension include stroke, coronary artery disease, hypertensive cardiomyopathy, and congestive heart failure. (AU)

Association of PON2 variation with birth weight in Trinidadian neonates of South Asian ancestry

Variation in the PON1 and PON2 genes has been shown to be associated with coronary heart disease risk in adults of South Asian origin. In this group, low birth weight is also associated with coronary heart disease risk. We therefore hypothesized that variation in PON1 and PON2 genes may be associated with variation in birth weight. This relationship was examined in 90 consecutive Trinidadian neonates of different ethnic origins. We found that variation in PON2 was significantly associated with variation in birth weight in Trinidadian neonates of south Asian origin. Among the neonates of South Asian origin, those who were homozygous for PON A148/A148 had significantly lower birth weight, by approximately 00 g, compared with those with the other two genotypes (P < 0.05). For neonates of south Asian origin, PON2 A148/A148 homozygotes were significantly more prevalent in those comprising the lowest tertile for birth weight than those comprising the highest tertile (0.41 versus 0.24, P < 0.05). There were no significant associations of PON variation with any phenotype in other ethnic groups. We conclude that among neonates of South Asian origin, homozygosity for PON2 A148/A148, is associated with significantly lower birth weight. This suggests that genetic factors in the fetus may be important determinants of neonatal birth weight and possibly of more distal adult phenotypes, such as coronary heart disease.(AU)

Nutrient intakes among UK African-Caribbeans: changing risk of coronary heart disease [letter]

Present findings in a food-frequency questionnaire (FFQ) given to Caribbean-born people of African descent, to try and determine why this section of the population has lower rates of coronary heart disease (COD). Findings; statistics; Greater consumption of fruits and vegetables found in the people who answered the FFQ.(AU)

Differences in food and nutrient intake by age, place of birth and patterns of food choice in British African-Caribbean population sample

Epidemiological studies examining differences in disease patterns between migrant and resident populations suggest lifestyle factors including diet may be responsible. This paper reports an exploration of the food and nutrient intake of a randomly selected African-Caribbean (AfC) population sample resident in Manchester, UK. A quantitative food frequency questionnaire developed specifically for this population was interview administered. Over 80 percent of those invited completed the questionnaire (102 men, 153 women; mean age 54 and 49 years, respectively). Subjects following a traditional West Indian diet had a lower percent energy provided by fat compared to those following a non-traditional diet (men: traditional 30.4 percent vs. non-traditional 33.1 percent; women: traditional 32.6 percent vs 31.6 percent non-traditional). Those subjects born in the Caribbean (mean age 59 years) had a lower percent energy provided by fat compared to younger (mean age 30 years) UK born AfC subjects (31 percent vs 35 percent for both men and women). At present the AfC population is consuming a diet lower in fat than the majority white population and one that is in line with Government recommendations that no more than 35 percent of food energy is to be provided by fat. This could be an explanation for the lower rates of coronary heart disease (CHD) seen in the British AfC population. However, as younger AfC are selecting a more European type diet, higher in fat, this could result in change in CHD risk.(AU)