Trends in stroke and acute myocardial infarction in Barbados, 2009–2013

OBJECTIVE: To describe trends in incidence, mortality and 28-day case fatality rate (CFR) for stroke and acute myocardial infarction (MI) in Barbados during the first 5 years of the Barbados National Registry for Chronic Non-communicable Disease (BNR). DESIGN AND METHODS: BNR data on strokes and acute MIs diagnosed nationwide were collected prospectively from data sources including public and private healthcare providers. Analyses included annual incidence and mortality rates per 100,000 (IR and MR), and 28 day post-event CFR, with 95% CI and trend estimation (fitting models to data using Poisson regression). RESULTS: Approximately 593 strokes and 349 acute MIs were registered annually with the BNR between 2009 and 2013, with a small 5-year decline in acute MI IR and a small 5-year increase in stroke IR by 2013. The MR for acute MI showed a small 5-year decline, but stroke MR increased significantly over the 5 years, from 78.9 (95%CI 68.8–90.0) in 2009 to 131.7 (118.8–145.8) in 2013 (p<0.03). Similar trends to MR were seen in CFR for both stroke and acute MI. CONCLUSION: We are cautiously optimistic about the (albeit non-significant) decline in IR, MR and CFR for acute MI, which could imply improvements in healthcare service provision. However, despite little change in stroke annual incidence, significant MR increase highlights the need for improved stroke care in Barbados. Thrombolysis for acute ischaemic stroke has only been available since the new stroke unit was implemented in late 2013; continued monitoring will allow assessment of this important initiative.

Epidemiology, risk analysis and clinical outcomes of acute myocardial infarction in Trinidad

Cardiovascular (CVS) disease is a global phenomenon and in Trinidad and Tobago, a small island developing country, remains the leading cause of death since the 1940's. It accounts for a proportional mortality of 25%.The main contributors are ischemic heart disease and stroke (1). Because CVS disease has global implications, the evaluation of the diverse outcomes of acute myocardial infarction (AMI) using population based hospital discharge databases is an important activity. The aim of this study is to describe the epidemiological features of acute myocardial infarction (AMI) and outcomes in patients admitted for tertiary care in Trinidad.

Cardiorespiratory fitness, all-cause mortality, and risk of cardiovascular disease in Trinidadian men--the St James survey

BACKGROUND: This study examined whether cardiorespiratory fitness is a risk factor for cardiovascular disease, myocardial infarction, and all-cause mortality in a low- to middle-income Trinidadian community of African, South Asian Indian, and European origin. Those of Indian descent have a distinctively high rate of myocardial infarction. METHODS: The St James Study is a prospective total community survey located in Port-of-Spain, Trinidad, West Indies. A random sample of 626 men aged 35-69 years, without angina of effort, previous myocardial infarction, partial or complete atrio-ventricular conduction defect, complete heart block, or exercise-induced asthma, was used for the assessment of cardiorespiratory fitness by cycle ergometry. Surveillance for morbidity and mortality was maintained for an average of 7.3 years. RESULTS: When the subjects were grouped into those with an age- and fat-free mass-adjusted peak oxygen uptake above and below the mean of 60.4 mmol/min (1.34 l/min), the hazard ratios (below/above) (95% confidence interval) for all-cause mortality, cardiovascular disease incidence, and incidence of myocardial infarction, after allowance for conventional cardiovascular risk factors, were 2.08 (1.23-3.52), 2.13 (1.22-3.69), and 2.36 (0.84-6.67), respectively. For those unable to achieve a level of work requiring an oxygen uptake of 67 mmol/min (1.5 l/min) during progressive exercise, the respective hazard ratios were 3.49 (1.57-7.76), 2.29 (1.21-4.33), and 5.45 (1.22-24.34). Indian ethnicity remained a predictor of myocardial infarction after allowance for cardiorespiratory performance. CONCLUSION: Low cardiorespiratory fitness is a risk factor for cardiovascular disease morbidity and mortality in the low- to middle-income developing community of Trinidad.

Thrombolytic therapy in the Caribbean

Over the past 30 years, mortality from acute myocardial infarction (MI) has decreased substantially in developing countries. While this decline is attributed, in part to a reduction in coronary risk factors, some reports have identified improved theraputic management as being equally responsible for decline. Currently available treatment for patients presenting with ST segment elevation MI (MIs associated with complete occlusion of a coronary artery) includes the concomitant administration of aspirin ƒ-blockers, angiotensin-converting enzyme (ACE) inhibitors, and either thrombolytics or primary percutaneous transluminal angioplasty (PTCA) (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)

False positive troponin I in a case of metastatic small cell bronchogenic carcinoma complicated by pulmonary thromboembolism

From the search for the ultimate cardiac marker have emerged the cardiac troponin, which have offered high sensitivity and specificity for myocardial damage. Troponin I had arguably been the best of this group, but even this marker is not infallible. We present the case of an elderly women who died shortly after being diagnosed with acute myocardial infarction on the basis of elevated Troponin I. Autopsy revealed a small cell lung cancer complicated by pulmonary thromboembolism. There was no evidence of myocaridal infarction. Explanations for false elevation of serum Troponin I are proposed.(Au)

Management of acute myocardial infarction in the public sector in the Bahamas

In 1996 and 1997, 52 patients were admitted to the Princess Margaret Hospital, Nassau, Bahamas, with a confirmed diagnosis of acute myocardial infarction (AMI). The average time to presentation after the onset of symptoms was 18 hours, with 56 percent of patients presenting within 12 hours. Risk factors identified for ischaemic heart disease were hypertension (77 percent), obesity (62 percent), diabetes mellitus (35 percent), tobacco smoking (25 percent), a family history of coronary heart disease (17 percent) and hypercholesterolaemia (8 percent). Medications administered in the treatment of AMI included oral nitrates (96 percent), intravenous heparin (90 percent), beta-blockers (65 percent), morphine (15 percent) thrombolytic agents (8 percent) and lignocaine (4 percent). In hospital post myocardial infarction complications were angina (23 percent), arrhythmias (12 percent) and cardiac failure (10 percent). The average hospital stay was eight days, with a mortality rate of 19 percent. These results show that there is considerable room for improvement, particularly in the use of thrombolytic therapy, to ensure that all patients receive optimal acute and post myocardial infarction care. (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)

A study of the use of aspirin in the secondary prevention of myocardial infarction in Trinidad and Tobago

OBJECTIVE: To determine the knowledge, attitude to and practice of aspirin prescribing by physicians, dispensing by pharmacies and usage by patients in the secondary prevention of myocardial infarction (MI) during the period September 1998 to August 1999. DESIGN AND METHODS: 119 doctors registered with the Trinidad and Tobago Medical Association were administered a questionnaire via a telephone interview on their prescription of aspirin in the secondary prevention of MI. Ninety-four registered pharmacies were administered a similar questionnaire to assess availability of aspirin. Seventy-three patients attending the San Fernando General Hospital (SFGH) and 82 patients from the Eric Williams Medical Sciences Complex (EWMSC) Cardiology clinic with a history of MI were each administered a questionnaire on their use of aspirin. RESULTS: Forty-three doctors (36.1 percent, 95 percent CI: 27.5-45.4) prescribed the recommended dose of 75-100 mg of aspirin for the secondary prevention of MI. Of the 82 patients interviewed from EMSC, 28 (34.2 percent) were taking the recommended dose, as compared with 11 (15.19 percent) patients from SFGH. Throughout Trinidad and Tobago, only 51 pharmacies (54.3 percent, 95 percent CI 43.7-64.6) stocked the required dose. CONCLUSIONS: The prescribing habits, availability and use of the recommended dose of aspirin in the secondary prevention of MI are unacceptable and clearly indicate an urgent need to improve the management of MI.(Au)

Anticardiolipin antibodies in women with thromboembolic disorders and in primiparae

Our aims were to determine if the presence of anticardiolipin antibodies (aCL) is an independent risk factor for venous thromboembolism (VTE), myocardial infarction (MI) and stroke (CVA) and to estimate the prevalence of aCL among primiparae and its influence on pregnancy outcome. aCL antibody concentration and isotype were measured using an anticardiolipin ELISA. 50 cases of VTE, CVA and MI along with 149 age-matched controls were recruited from a hospital based case control study. Ages ranged from 15 to 49 years. 1,212 primiparae with uncomplicated pregnancies were recruited from clinics in Kingston and St. Andrew. aCL antibodies were present in 16/50 (32 percent) of CVA, VTE and MI cases and in 23/149 (15.4 percent) of the controls (X = 6.5, p = 0.0107). The estimated relative risk for VTE, CVA and MI associated with aCL antibodies is 2.58 (OR = 2.58; 95 percent CI 1.15-5.77). Among the primiparae 137/807 (16.9 percent) were aCL positive. The impact of aCL antibody presence on pregnancy outcomes has not yet been assessed. aCL antibodies confer a significant risk of VTE, CVA, and MI among women 15-49 years old.(AU)

Myocardial infarction in Antigua: 1990 to 1995

Between January 1990 and May 1995, 117 patients were admitted to the Intentsive Care at Holberton Hospital, Antigua, for chest pain due to suspected acute myocardial infarction. 39 (45 percent) of 86 patients whose records were available for retrospective review had confirmed (27 patients) or probable (12 patients) acute myocardial infarction. Risk factors identified among the patients included hypertension, diabetes, tobacco smoking, hypercholesterolaemia and obesity. On admission, 82 percent were Killip class I and 18 percent were Killip class II. Medications in the Intensive Care Unit included nitrates, aspirin, calcium and channel blockers, beta-adrenergic blockers, heparin and angiotensin converting enzyme inhibitors (21 percent). No thrombolytic agents were available. THe average hospital stay was 10 days and the in-hospital mortality rate was 13 percent. These data indicate that early mortality from acute myocardial infarction can be reduced in developing countries by early admission to an Intensive Care Unit and use of drugs known to be effective in its treatment.(AU)

Patterns of coronary artery irrigation around the inter-ventricular septum - abstract

382 angiograms obtained from the Department of Invasive Cardiology and Cardiac Surgery, Queen Elizabeth Hospital, Barbados, were investigated to determine coronary arterial patterns around the inter-ventricular septum. The hearts were classified according to the origin of the posterior descending artery (PDA) and the left anterior descending artery (LAD) into types I, II, III and IV, according to a classification modified from that first proposed by D.B.Effler. Correlations were made between the parameters and the results were analysed statistically. In the study, 87 percent of the angiograms were right dominant, 8.2 percent left dominant and 2.1 percent co-dominant. Eleven percent (11.3 percent ) had LAD type I,43 percent had LAD type II, 37.5 percent had LAD type III and 1.5 percent had LAD type IV. 74.1 percent of left dominant heart had a LAD type III. One patient with a left dominant heart had a LAD type IV. Those patients with LAD type IV or LAD type III in a left dominant heart demonstrate an increase in the imbalance of the supply to the inter-ventricular septum. They may be at risk of increased morbidity due to inferior wall infraction and post infraction septal defects if the LAD becomes diseased. Such patients, when identified, should therefore be monitored in the long term to investigate their outcome(AU)

Plasma fibronectin kinetics during uncomplicated acute myocardial infarction

Plasma fibronectin (Fbn) was assessed daily in 9 men admitted to the cardiology care unit for uncomplicated acute myocardial infarction (AMI). In a control group of twenty healthy men, plasma Fbn was 0.290ñ 0.0417g/l-1 (meanñSD). In 6 hypertensive AMI patients, Fbn levels were increased to a maximum of 0.461ñ0.0294 g/l-1 at day five (5.5 ñ 0.84 days) and returned to the range of the control group values 56 ñ 32.8 afterwards. Three normotensive patients had higher Fbn results without returning to the control group range at the end of the hospitalization (0.734 ñ 0.209 gl-1). Plasma Fbn could in part be implicated in the repair process and/or in the limitation of the cardiac necrosis extension. Moreover, it seems that a link exists between plasma Fbn kinetics and hypertension and/or normotension during uncomplicated AMI. (AU)

Myocardial infarction at 30, 25 and even 20 years of age: chaos in prevention and prevention in order - abstract

A 20-year-old patient develops myocardial infarction (MI) after playing hockey, with another acute event at the age of 30 years despite normal coronary arteries. A 25-year-old non-smoker awakes with chest pain and major anterior MI. A 35-year-old develops stress-induced, threatened major anterior MI. A 45-year-old patient with stable, mild coronary artery disease at catheterization develops MI after a dispute. Patients develop acute coronary syndromes unexpectedly and unpredictably. A few patients with risk factors and a few young patients with few or no usual risk factors developing acute coronary events are presented. Such events may lead an already sceptical public to the notion of futility in risk modification or chaos in prevention. Chaos and Complexity, a new science based on mathematics and physics of nonlinear systems as most of medicine is, offers a model for understanding unexpected events in clinical medicine. Unpredictability is inherent because of the interrelatedness of local and distant events and sensitive dependence on initial conditions where small causes lead to huge effects, and thus variable clinical outcomes. Understanding chaos, complexity and the newer concepts of pathogenesis and acute risk factors should keep prevention, despite unpredictability

Thrombolytic therapy in acute myocardial infarction in Barbados: report of initial experience with intravenous streptokinase - abstract

It has been shown in the last decade, that intravenous throbolytic therapy is associated with a significant reduction in mortality, when given early in the course of an acute myocardial infarction (MI). Streptokinase, a bacterial-derived protein plasminogen activator, was approved for use at the Queen Elizabeth Hospital in June 1990 and thrombolytic therapy for acute MI commenced in October 1990. During the next 13 months, 129 patients were admitted to the Queen Elizabeth Hospital with the diagnosis of acute MI, and 35 of these (27 percent) received intravenous streptokinase. Nine other patients who received streptokinase were subsequently proven not to have infarcted. Forty-three per cent (43 percent) of the patients received thrombolytic therapy within six hours of the onset of symptoms, the ideal window period for treatment. Using non-invasive clinical criteria, reperfusion was suspected in 77 percent of patients. No major complications were seen. Three (3) patients had mild allergic reactions, and mild hypotension and bradycardia were seen in 19 patients. One patient who did not have an acute MI but an acute aortic dissection developed a hemiparesis which resolved within a week. There were 6 deaths recorded, all thought to be unrelated to streptokinase, but rather due to the extensive nature of the infarct. We have reported on a protocol-controlled series of patients given thrombolytic therapy for acute MI in Barbados, and have concluded that it can be given safely and effectively in carefully selected patients (AU)

Suspected acute myocardial infarction: intravenous beta-blockade outside the coronary care unit: a pilot study

Shortage of Coronary Care Unit (CCU) beds prompted a study (I) to determine the number of patients with a suspected acute myocardial infarction (SAMI) who could not be placed in the CCU, but qualified for intravanous (IV) B-Blocker therapy, and (II) to assess the safety of such therapy in a general medical ward. During a six-month period, 34 patients with chest pain and E.C.G. changes of SAMI could not be placed in the CCU. Criteria for exclusion from B-Blocker therapy were the presence of >= 1 of the following: (1) age > 70 years, (2) Systolic B.P. < 100 mmHg, (3) Heart rate < 60 /min., (4) Cardiac failure, (5) Heart block, (6) Poor peripheral circulation, (7) Asthma or chronic bronchitis, and (8) Prior therapy with B-Blocker or calcium antagonists. 15 (44 percent) patients were excluded from therapy based on the above criteria. 19 (56 percent) received 5-10 mg atenolol IV within 3-10 hours of onset of chest pain and atenolol 100 mg daily was started immediately and continued indefinitely. 12 of these patients had an anterior wall, and 3 an inferior wall infarction. 3 developed congestive cardiac failure and none required anti-arrhythmic therapy. There were 2 deaths - 1 from ventricular asystole, and the other from cardiogenic shock 8 and 12 hours respectively after IV atenolol. While this small-scale study highlights the need for more CCU beds for optimum care, our results suggest that selected patients with SAMI managed in the general medical wards can still safely obtain the benefits of IV B-Blockade. (AU)