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)

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)

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)

Coronary artery bypass surgery in Trinidad: morbidity and mortality - Poster abstract

OBJECTIVE: To determine whether Coronary artery bypass grafting (CABG) in Trinidad influenced morbidity and mortality. METHOD: Retrospective review of the demographic, clinical and angiographic data of the first 205 consecutive CABG operations performed by Caribbean Heart Care at the Eric Williams Medical Sciences Complex, Trinidad, between November 1993 and December 1997. RESULTS: The mean age was 59 ñ 10 years and 74 percent were males. The average time interval between angiography and surgery was 2.3 months. At the time of angiography, 69 percent of patients had class 3 or 4 angina (CCS). The mean ejection fraction was 63 ñ 13 percent. Many patients (64 percent) had severe diffuse disease on angiography. The in-hospital mortality was 8/205 (3.9 percent). Follow-up data were obtained for 189/205 (92 percent). The duration of follow-up ranged from 1 to 5 years. During the follow-up period, 7/189 patients. (3.4 percent) died. Angina severity before and after surgery was determined in 174 surviving patients. Angina severity was reduced from a mean CCS score of 2.61 ñ 0.95 before CABG to 1.22 ñ 0.55 after CABG (p<0.0001). CONCLUSION: Overal 4-year mortality compared favourably with data from international studies. Amongst survivors, quality of life improved as evidenced by the reduction in the mean angina score.(AU)

Coronary stents: a safe and effective intervention for treating coronary artery disease

Percutaneous Transluminal Coronary Angioplasty (PTCA) is a less invasive form of coronary revascularisation than Coronary Artery Bypass Grafting (CABG). The major limitation of PTCA is renarrowing of the dilated lesion (restenosis), which may occur in up to one-third of cases. Stents are the only new devices proven to lower the restenosis rate. To evaluate the efficacy and safety of coronary stent implantation, we reviewed the charts of the first 121 patients (133 stents) undergoing coronary stenting using the J & J Stent at Emory University Hospital. Age of the patients studied (yrs; mean ñ SD) was 60.5 ñ 10.5. 77 percent were male, 46 percent were hypertensive and 27 percent were diabetic. 82 percent had class 3 or 4 angina. Prior surgical revascularisation was performed in 66 percent, previous PTCA in 55 percent and previous PTCA to stented vessel in 19.5 percent. Multivessel disease was present in 74 percent. The mean ejection fraction was 52 ñ 11.8 percent. The target lession was located in- a saphenous vein graft in 60.3 percent. The mean baseline diameter stenosis was 80.2 ñ 11.2 percent and this was reduced to 8.8 ñ 8.2 percent after stenting. The stent/s were successfully deployed in 98.6 percent of cases. In hospital clinical success was defined as procedural success in the absence of in-hospital death (0.8 percent), Q-wave myocardinal infarct (MI) (1.7 percent), repeat PTCA (3.3 percent), or emergent CABG (2.5 percent). At a mean follow up of 2.5 years the incidence of death was 11 percent, subsequent MI (15.2 percent), CABG (26.6 percent) and repeat PTCA (39.6 percent). Restenosis was defined as more than 50 percent residual diameter stenosis of the previously dilated coronary segment on follow up angiography. Follow up angiography was performed in 34 of the 121 stented patients because of recurrence of symptoms or a positive stress test. 16 patients had restenosis (15 percent of 121 patients). Coronary stents can be successfully implanted with low hospital morbidity and mortality. Stents markedly reduce the diameter stenosis of the coronary lesion during PTCA. The incidence of restenosis after stenting is low.(AU)

Systolic left ventricular dysfunction detected by echocardiography: demographics and aetiology - abstract

The aim of this retrospective study was to determine the demographic features and causes of heart failure in patients presenting a tertiary care institution: 65 patients aged >16 years with an ejection fraction (EF) < 40 percent, undergoing echocardiography during a two-year period, 1992-94, were included in the study. The mean age was 60 ñ 12 years, 68 percent were male, 50 percent and 42 percent were African and East Indian, respectively. The prevalence of diabetes and hypertension was 40 percent and 45.3 percent respectively. The majority of patients were in NYHA class II or III. The mean left ventricular ejection fraction (LVEF) was 29.7 ñ 8.6 percent. There was no correlation between NYHA class and LVEF at initial presentation. The underlying causes of heart failure were coronary artery disease (CAD) (42 percent), idiopathic dilated cardiomyopathy (10.9 percent), hypertensive heart disease (9.4 percent), alcohol related dilated cardiomyopathy (7.8 percent), valvular heart disease (7.8 percent), myocarditis (1.6 percent) and hypertrophic cardiomyopathy (1.6 percent). The dominant primary cause could not be determined in 18.8 percent. LVEF was similarly depressed in the two major ethnic groups and in the ischaemic and non-ischemic cardiomyopathy groups. We concluded that CAD was the most common cause of LV systolic dsyfunction and that LVEF was not related to ethnicity, aetiology or severity of symptoms. (AU)

Clinical spectrum of lupus nephritis and ethnic differences on presentation at Port-of-Spain General Hospital - abstract

Over the period 1980-1989, a retrospective study of 77 patients presenting to the Renal Unit with SLE nephritis was undertaken. The overwhelming majority of patients were female (85.7 per cent) presenting at a mean age of 28 years. The ethnic distribution showed that 63 per cent of patients were of African and 19.5 per cent of East Indian descent; 1.3 per cent had a positive family history of SLE. The predominance of Africans in this study is different from the Renal Clinic population where there is equal representation of the major ethnic groups and is also different from the population of patients with significant proteinuria attending the Renal Clinic. The difference in presentation between the two major ethnic groups in this study should be further evaluated in a prospective study, using case controls (AU)