Differentiating Characteristics and Responses to Treatment of New-Onset Heart Failure With Preserved and Reduced Ejection Fraction in Ambulatory Patients.

Background: Differences in clinical presentation and therapy outcomes between heart failure with preserved ejection fraction (HFpEF) and heart failure with reduced ejection fraction (HFrEF) have been reported but described mainly among hospitalized patients. Because the population of outpatients with heart failure (HF) is increasing, we sought to discriminate the clinical presentation and responses to medical therapy in ambulatory patients with new-onset HFpEF vs. HFrEF. Methods: We retrospectively included all patients with new-onset HF treated at a single HF clinic in the past 4 years. Clinical data and electrocardiography (ECG) and echocardiography findings were recorded. Patients were followed up once weekly, and treatment response was evaluated according to symptoms resolution within 30 days. Univariate and multivariate regression analyses were performed. Results: A total of 146 patients were diagnosed with new-onset HF: 68 with HFpEF and 78 with HFrEF. The patients with HFrEF were older than those with HFpEF (66.9 vs. 62 years, respectively, P = 0.008). Patients with HFrEF were more likely to have coronary artery disease, atrial fibrillation, or valvular heart disease than those with HFpEF (P < 0.05 for all). Patients with HFrEF rather than HFpEF were more likely to present with New York Heart Association class 3 - 4 dyspnea, orthopnea, paroxysmal nocturnal dyspnea or low cardiac output (P < 0.007 for all). Patients with HFpEF were more likely than those with HFpEF to have normal ECG at presentation (P < 0.001), and left bundle branch block (LBBB) was observed only in patients with HFrEF (P < 0.001). Resolution of symptoms within 30 days occurred in 75% of patients with HFpEF and 40% of patients with HFrEF (P < 0.001). Conclusions: Ambulatory patients with new-onset HFrEF were older, and had higher incidence of structural heart disease, in comparison to those with new-onset HFpEF. Patients presenting with HFrEF had more severe functional symptoms than those with HFpEF. Patients with HFpEF were more likely than those with HFpEF to have normal ECG at the time of presentation, and LBBB was strongly associated with HFrEF. Outpatients with HFrEF rather than HFpEF were less likely to respond to treatment.

A case report of isolated rheumatic tricuspid regurgitation and pericarditis.

Rheumatic fever (RF) is a complex syndrome in which the human body develops antibodies against ß-haemolytic streptococcus, and triggers inflammation in various organs. RF valvulitis mostly affects the mitral valve (MV) and, to a lesser extent, the aortic valve (AV). Isolated rheumatic tricuspid valve (TV) disease and pericarditis is extremely rare and is not well described in the RF guidelines. The current case demonstrates the echocardiographic findings of TV valvulitis of RF and describes the presentation and electrocardiogram (ECG) changes in pericarditis. We present the case of a 16-year-old male patient who developed upper respiratory tract infection followed by typical pericarditis chest pain. The patient had no history of joint pain or swelling, but was found to have a tricuspid regurgitation (TR) murmur upon examination. Laboratory investigations revealed an elevated erythrocyte sedimentation rate, and elevated C-reactive protein and antistreptolysin O titres. ECG showed a wide-spread 1.5 mm upward concave ST-segment elevation. In echocardiography, the TV opened well with markedly thickened leaflets and severe TR, while the MV and AV were normal in both structure and function. The diagnosis of RF was established and treatment with high-dose aspirin and antibiotics was initiated. The treatment led to resolution of the chest pain. Our case highlights that the physical and lab findings of rheumatic TR are similar to those of rheumatic mitral regurgitation, with the exception of a high-velocity jet. Similarly, the presentations of rheumatic pericarditis are similar to other types and may also respond to high-dose aspirin. Finally, physicians should be familiar with both the common and rare complications of RF because the guidelines have placed Middle East region among the high-risk countries.

The Structure and the Outcome of Telephone-Based Cardiac Consultations During Lockdown: A Lesson From COVID-19.

Background In response to COVID-19, Saudi Arabia as many countries, implemented "lockdown" to contain the epidemic. This resulted in suspension of all outpatient services. The reliability of the alternative telecommunication cardiac services during that time is not well studied. Accordingly, the objective of this study is to describe the structure of the telephone-based cardiac consultation (TBCC) and to explore its outcome. Methods This is a cross-sectional study that has a prospective follow up on patients who underwent medical intervention. During the period of lockdown, Alre'aiah health care society in Almadinah Almunawwarah, Saudi Arabia, provided a community health service. This was achieved by announcing telephone numbers for consultations in most specialties. This study includes all TBCC of a single cardiologist. Detailed demographic data, medical, social and drug histories of the patients were collected in charts. Individuals were requested to measure blood pressure (BP) and heart rate (HR) at the time of TBCC. Accordingly, cardiovascular assessment and appropriate intervention were executed. Patients who needed medical intervention were followed up in one week. The data were analyzed using appropriate statistical methods. Results From 01 April till 15 June 2020, a total of 168 individuals sought TBCC. Their median age was 51.5 ± 12.7 years, and (57.1%) were females. Healthy individuals constituted (33.9%), and (59.9%) were non-smokers. The most common reported medical illnesses were hypertension (27.3%), diabetes (23.8%), heart failure (16.1%), and coronary artery disease (14.9%). Palpitations were encountered by 58 patients. None of them had high-risk features or cardiac disease. Stress, excessive smoking, and caffeine intake were thought to be responsible for palpitations in 52 individuals who were reassured and educated, and newly diagnosed hypertension was established prospectively in eight patients and they were started on medications. Chest pain was reported by 51 individuals. The diagnosis of typical angina was made in nine patients and they were instructed to seek emergency care. Atypical angina pain was established in 10 cases who were advised to seek formal consultation once lockdown ends. Reassurance was achieved in 32 individuals who had features of non-angina pain. Uncontrolled hypertension was reported by 32 patients. Blood pressure control was achieved prospectively in 70% of these patients who followed up by adjusting their antihypertensive drugs. Twenty-seven patients with heart failure complained of worsening shortness of breath. New York Heart Association (NYHA) class 1-2 was reported by 21 patients, and they were managed by doubling diuretic dose, 19 of them followed back and reported significant improvement. NYHA class 3-4 was established in 6 patients and they were instructed to seek emergency care. Conclusions When standard face-to-face cardiac consultations are compromised, a structured TBCC is considered feasible, seems effective, and promising alternative method of delivering the utmost cardiac care to the community. When conducted properly, it is useful to triage patients.

Zamzam water is pathogen-free, uricosuric, hypolipidemic and exerts tissue-protective effects: relieving BBC concerns.

Zamzam water is the most frequently used drinking water by millions of people in Saudi Arabia. It is carried all the time by millions of pilgrims to their home countries as gifts to close and near relatives and friends. Safety of constituents of Zamzam water is a vital health topic. British Broadcasting Corporation (BBC) raised many health concerns regarding the high serum arsenic and nitrate contents in Zamzam water that may cause cancer. It is role of scientific research to present scientific facts to relieve such concerns. Arsenic is a carcinogen while nitrate causes methemogloinemia that affect oxygen carriage by haemoglobin. An ethical committee approval was obtained. Eighteen white albino mice (40-45 g) were used in this study. Three experimental groups were allocated (six mice per group): tap water group, distilled water group and Zamzam water group. Our data revealed that Zamzam water exerts tissue-protective effects that contradict malignancy. Our data proved that Zamzam water is pathogen-free causing no bacterial growth on CLED agar colonies. Zamzam water consumption for three consecutive months in mice was quite safe for the general health and significantly decreased serum uric acid (p < 0.05) (possibly due to Zamzam-induced urine alkalinisation facilitating uric acid excretion). Regular Zamzam water consumption significantly decreased serum cholesterol (p < 0.05) and serum triglycerides (p < 0.05). Hypolipidemic effects of Zamzam water may be due to its high mineral content facilitating increased lipids metabolism. Our data confirmed safety of prolonged use of Zamzam water comparable to other drinking water types regarding the metabolic and synthetic functions of the liver. Nitrates in Zamzam water are thought to be an original constituent that may be useful (exerting vasodilation, antithrombotic, and immunoregulatory effects) and not harmless. This may occur due to high Zamzam content of calcium, magnesium and selenium. Histologically, our data confirmed that Zamzam water was quite safe to renal parenchyma and comparable to other types of drinking water. In conclusion, health concerns raised by BBC regarding Zamzam water safety were a good chance for fruitful scientific research investigations that confirmed safety and beneficial effects of Zamzam water for human health.

Al-hijamah (the triple S treatment of prophetic medicine) exerts cardioprotective, tissue-protective and immune potentiating effects in thalassemic children: a pilot clinical trial.

Thalassemia is a major health problem in affected children due to iron overload, increased oxidative stress, atherogenic lipid profile and tissue-damage. This study aims at investigating the cardioprotective and tissue-protective benefits of Al-hijamah and their impact on cell-mediated immunity for treating thalassemic children. This study aimed also at investigating the tissue-clearance principle of Taibah mechanism: whenever pathological substances are to be cleared from the human body, Al-hijamah is indicated. Al-hijamah was done to thalassemic children (15 males and 5 females having a mean age of 9.07 ± 4.26 years) using sterile disposable sets in a complete aseptic hospital environment. Prior ethical committee agreement (in addition to written patient's consents) was obtained from Tanta Faculty of Medicine, Egypt. Twenty thalassemic children received iron chelation therapy plus Al-hijamah for one session (30-60 minutes) versus an age and sex-matched thalassemic control group treated with iron chelation therapy only. Al-hijamah is a quite safe outpatient hematological procedure that significantly decreased serum cholesterol (from 129.75 ± 3.67 to 103.5 ± 4.18 mg/dl) and decreased serum triglycerides (from 109.25 ± 8.96 to 91.95 ± 7.22 mg/dl). Interestingly, Al-hijamah exerted significant tissue-protective effects (it decreased serum GPT from 98.65 ± 12.27 to 71.65 ± 32.78 U/L and serum GOT from 96.35 ± 14.33 to 69.35 ± 34.37 U/L). Al-hijamah-induced ferritin excretion caused decreased serum ferritin (high serum ferritin negatively correlated with cell mediated immunity). Al-hijamah exerted cardioprotective and tissue-protective and hypolipidemic effects. Al-hijamah decreased serum cholesterol and is cardioprotective for thalassemic patients as it protects against atherogenesis and atherosclerosis. Medical practice of Al-hijamah is strongly recommended in hospitals. Al-hijamah cleared blood significantly from causative pathological substances e.g. serum ferritin resulting in enhanced cell-mediated immunity (in agreement with the evidence-based Taibah mechanism).

Functional and Structural Impact of ATP-Binding Cassette Transporter A1 R219K and I883M Gene Polymorphisms in Obese Children and Adolescents.

INTRODUCTION: Obesity is a serious medical condition that affects children and adolescents. ATP-binding cassette transporter A1 (ABCA1) protein is known to mediate the transport of intracellular cholesterol and phospholipids across the cell membranes. Thus, we aimed to investigate the association between ABCA1 gene polymorphisms and overweight/obesity risk, and to evaluate their relation to the lipid profile. MATERIALS AND METHODS: The study included in silico analysis of ABCA1 gene and protein. Two genetic variants in ABCA1 gene-R219K (rs2230806; G/A) and I883M (rs2066714; A/G)-were genotyped in 128 normal weight and 128 overweight/obese subjects using polymerase chain reaction-restriction fragment length polymorphism technology. Anthropometric and biochemical assessments were performed. RESULTS: Our findings suggest that the heterozygote GA genotype of R219K polymorphism increased susceptibility to obesity under the heterozygous model (odds ratio 2.75, 95 % CI 1.01-6.12; p = 0.014) compared with the control group. This susceptibility could be gender-specific, with higher risk among females. In addition, the A variant was associated with a higher degree of obesity (p < 0.001). On the other hand, individuals with the G variant of I883M polymorphism showed lower susceptibility to obesity under all genetic models (allelic, homozygote, heterozygote, dominant, and recessive models; p < 0.05), with no observed association with body mass index or degree of obesity. However, both single nucleotide polymorphisms (SNPs) showed significant differences in lipid levels among patients with different genotypes. CONCLUSIONS: The study results suggest that R219K and I883M SNPs of the ABCA1 gene may play a role in susceptibility to obesity in our Egyptian population; the former increases susceptibility and phenotype severity, and the latter is protective. Larger epidemiological studies are needed for validation of the results.

Prevalence and predictors of paroxysmal atrial fibrillation on Holter monitor in patients with stroke or transient ischemic attack.

BACKGROUND AND PURPOSE: Our aims were to quantify the yield of Holter monitor for detection of paroxysmal atrial fibrillation (PAF) in patients with stroke and TIA, and to determine potential predictors of PAF to allow more focused testing. METHODS: We reviewed records of 1128 consecutive patients attending a university stroke clinic from September 2005 to September 2006 and identified 426 patients with definite TIA or stroke. We abstracted clinical, cardiac imaging, and neuroimaging data. Logistic regression analysis was performed to determine independent predictors of PAF on Holter monitor. RESULTS: Overall, 413 of 426 patients (65 ± 15 years; male, 49.8%) with a definite TIA (53%) or stroke (47%) underwent Holter monitoring for a mean of 22.6 hours. PAF occurred in 39 patients (9.2%) all older than age 55 years. PAF lasting > 30 seconds was evident in 11 patients (2.5%). The other 28 patients had PAF < 30 seconds (6.5%). In multivariate analyses, number of acute (odds ratio [OR], 1.7 for each 1 lesion increase; 95% confidence interval [CI], 1.2-2.6; P = 0.0047) and chronic (OR, 1.6 for each 1 lesion increase; 95% CI, 1.2-2.3; P = 0.0001) infarcts on brain CT, number of chronic infarcts on MRI (OR, 3.0 for each 1 lesion increase; 95% CI, 1.7-5.1; P < 0.0001), and any acute cortical infarct on imaging (OR, 5.8; 95% CI, 1.9-17.8; P = 0.0023) were associated with PAF. CONCLUSIONS: PAF is present in 9.2% of patients with definite stroke or TIA. Age older than 55 years and presence of acute or chronic brain infarcts on neuroimaging are strongly associated with PAF.

Is visual interpretation of coronary epicardial flow reliable in patients with ST-elevation myocardial infarction undergoing primary angioplasty? Insights from the angiographic substudy of the Assessment of Pexelizumab in Acute Myocardial Infarction (APEX-AMI) trial.

BACKGROUND: Accurate estimation of coronary epicardial flow in patients with ST-elevation myocardial infarction (STEMI) is crucial to evaluating the effect of therapy and predicting outcome. Whether operator bias exists in visual estimation of TIMI flow grade among patients with STEMI undergoing primary percutaneous coronary intervention (PCI) remains uncertain. Hence, we examined this issue in the angiographic substudy of the Assessment of Pexelizumab in Acute Myocardial Infarction (APEX-AMI) trial. METHOD: TIMI flow grade of the infarct-related artery was assessed before and after PCI by visual estimation of local investigators (LI) and by an independent core laboratory (CL). We evaluated agreement between the CL and LI and the relationship between post-PCI TIMI flow grade and 90-day outcomes (mortality; death/congestive heart failure/shock). RESULTS: Of 922 patients with independent CL estimation of TIMI flow grade, there was moderate agreement in the pre-PCI assessment (kappa = 0.56) and poor agreement post-PCI (kappa = 0.36); moreover, these disparities were directionally different before versus after PCI. Disagreement between LI and CL occurred in 167 patients pre-PCI (19%) and in 123 (14%) patients post-PCI. LI TIMI grades consistently underestimated flow pre-PCI in 63% and overestimated flow post-PCI in 78% of patients relative to the CL. Core laboratory estimation of post-PCI TIMI flow grade provided better prediction of 90-day mortality and death/congestive heart failure/shock than that of LI. CONCLUSION: Significant quantitative and directional variation existed in TIMI flow grades assessed by LI versus a CL in nearly a fifth of the patients. Core laboratory interpretation post-PCI provides better prediction of clinical outcomes. These data deserve consideration when interpreting angiographic data from STEMI patients without CL estimation.