Comparison of thrombolytic therapy for acute myocardial infarction in patients aged < 35 and > 55 years.

There are differences in the risk factor profile and coronary anatomy of young patients who develop coronary artery disease compared with those of older ones. There is an absence of data in published reports regarding the response to thrombolytic therapy and the outcome of acute myocardial infarction in young patients. Sixty-two patients aged < 35 years (group 1) were compared with 58 aged > 55 years (group 2) who presented with acute myocardial infarction and were treated with intravenous streptokinase. Group 1 had a significantly higher incidence of smoking (p = 0.0009) and a lower incidence of diabetes mellitus (p = 0.002) than did group 2. Fifty-eight patients in group 1 and 40 in group 2 were studied by angiography at a similar time (5 to 6 days) after admission. Patients in group 1 had a better left ventricular ejection fraction (55 +/- 13% vs 49 +/- 13%; p = 0.03), but similar patency rates of the infarct vessel (74 vs 73%) compared with those of group 2. Group 1 also had a higher incidence of insignificant disease (22.5 vs 2.5%; p = 0.008) and a lower incidence of 3-vessel disease (10 vs 37.5%; p = 0.004). This suggests that there are differences in the risk factor profiles and coronary anatomy of young patients compared with those of older ones. Despite similar benefits from thrombolytic therapy in the form of a patient infarct vessel, there may be differences in the long-term outcome among these patients.

Non-Q- and Q-wave infarction after thrombolytic therapy with intravenous streptokinase for chest pain and anterior ST-segment elevation.

The clinical features of patients treated with streptokinase for chest pain and anterior ST-segment elevation who subsequently develop non-Q-wave infarction are unknown. Of the 75 consecutive patients who initially presented with chest pain and ST-segment elevation in the anterior leads (V1-V6, I, aVL) and were treated with intravenous streptokinase (time from symptoms to treatment averaged less than 3 hours), 32 (43%) developed a non-Q-wave and 43 (57%) a Q-wave myocardial infarction. Twenty seven of 32 patients (84%) from the non-Q-wave group and 39 of 43 (91%) from the Q-wave group were studied by angiography at 5.16 +/- 2.88 days after the onset of myocardial infarction. Left ventricular end-diastolic pressure was 13 +/- 6 vs 20 +/- 7 mm Hg (p less than 0.001), left ventricular ejection fraction was 60 +/- 8 vs 49 +/- 14% (p less than 0.001) and the infarct vessel patency rate was 85 vs 72% (p = 0.44) in patients with a non-Q versus a Q-wave infarction, respectively. In summary, when patients presenting with chest pain and ST-segment elevation are treated with streptokinase, a significant portion of these symptoms will evolve into a non-Q-wave infarction. Patients with a non-Q-wave infarction will have a better preserved left ventricular function than patients who develop a Q-wave infarction. This suggests the need for equal distribution of such patients in randomized trials of thrombolytic therapy for acute myocardial infarction to avoid misinterpreting data between groups.

Effectiveness of amiodarone on ventricular arrhythmias during and after acute myocardial infarction.

A randomized, placebo-controlled study examined the effect of amiodarone on the incidence of ventricular arrhythmias after acute myocardial infarction (AMI). Two hundred patients with AMI were randomized to receive amiodarone, 200 mg every 8 hours for 1 month, followed by 200 mg/day, or placebo, starting 48 hours after the onset of chest pain. Twenty-four-hour Holter monitoring was performed on day 1, repeated after 8 days and subsequently at 3-month intervals. One hundred seventy-two patients were followed for 6 to 42 months and monitor data were available at 6 to 9 months in 129 patients. Amiodarone was well tolerated, with no serious side effects; 12 patients were withdrawn from therapy. At 6 to 9 months more than 1 ventricular premature complex per hour was present in 3 of the 59 amiodarone-treated patients (5%) and 24 of the 70 placebo-treated patients (34%) (p less than 0.02). Complex arrhythmias (multifocal, early cycle, repetitive, bigeminy, trigeminy or ventricular tachycardia) were present in 5 of 59 of the amiodarone-treated patients (8%) and 20 of 70 placebo-treated patients (28%) (p less than 0.005). Sixteen patients in the amiodarone group and 11 in the placebo group died (difference not significant). Thus, amiodarone can reduce the frequency and complexity of ventricular arrhythmias after AMI, but it is unlikely that this will result in a substantial beneficial effect on post-AMI mortality risk.

Cigarette smoking and ventricular arrhythmia in coronary heart disease.

With use of 24-hour ambulatory electrocardiographic monitoring, the effect of 1 hour of cigarette smoking on cardiac rhythm in 73 patients with coronary heart disease was studied. Fifteen subjects had no arrhythmia; 37 subjects had fewer than 2 atrial or ventricular premature complexes (APCs or VPCs)/hour, with APCs possibly related to smoking in 2 and VPCs related to smoking in 1. Nineteen subjects had more than 2 VPCs/hour (range 4 to 368) and had 16 +/- 29 VPCs/hour (+/- standard deviation) less during than before smoking (p less than 0.05), associated with an increase in heart rate of 4.6 +/- 6.8 beats/min (p less than 0.01). In none of the 9 subjects with unifocal VPCs did multiform beats develop during or after smoking, whereas 3 of 10 subjects with multiform VPCs had only unifocal beats during and immediately after smoking. In 1 of these 19 subjects, frequent APCs developed during smoking. One other subject had frequent APCs unaffected by smoking and another had sinoatrial block, which disappeared during smoking on 1 of 3 monitorings. In conclusion, no sustained or high-grade ventricular arrhythmia was provoked by smoking; although APCs may have been related to smoking in a few persons, the frequency and complexity of VPCs tended to be reduced in these subjects with coronary artery disease.

Incidence of congenital heart disease in Qatari children.

We surveyed the incidence of congenital heart disease in 49887 native live born children in the period between 1984 to 1994 in Qatar. Each child with clinically suspected congenital heart disease underwent echocardiographic examination. Magnetic resonance imaging, cardiac catheterization and surgical intervention were done at the discretion of the patient's pediatric cardiologist. Virtually no postmortem examinations were performed. Children with congenital heart disease were entered into a computerized database and were then followed for 1-11 years. Congenital heart disease was diagnosed in 610 of 49,887 children for an incidence of 12.23/1000 live births. The reasons for the high incidence were high proportion of small muscular ventricular septal defects discovered before the time of their spontaneous closure, referral to and follow up by a single group of pediatric cardiologists, location of the pediatric cardiology service in the same setting where nearly all of the deliveries took place, freely available health care service, and echocardiographic examination of every child with a clinical diagnosis of congenital heart disease.

Does hospitalization for congestive heart failure occur more frequently in Ramadan: a population-based study (1991-2001).

OBJECTIVE: Over one billion Muslims fast worldwide during the month of Ramadan. Fasting during Ramadan is essentially a radical change in lifestyle for the period of one lunar month, so it is important to see the response of congestive heart failure patients to this change. Our objective in this study is to investigate whether Ramadan fasting has any effect on the number of hospitalization for congestive heart failure (CHF) in a geographically defined population. METHODS: We conducted a retrospective review of clinical data study on all Qatari patients in Qatar for a period of 10 years (January 1991 through December 2001) who were hospitalized with heart failure. Patients were divided according to the time of presentation in relation to the month of Ramadan, 1 month before, during and 1 month after Ramadan. The number of hospitalization for CHF in various time periods was analyzed. The age of presentation, gender, cardiovascular risk factor profiles (smoking status, hypertension, hypercholesterolemia, diabetes, pre-existing coronary heart disease) and outcome were analyzed. RESULTS: Of the 20,856 patients treated during the 10-year period, 8446 of them were Qataris with 5095 males and 3351 females. Overall, 2160 Qatari patients were hospitalized for CHF and their mean age and standard deviation was 64.2 +/- 11.5 years, 52.4% were hypertensives, 18.5% had hypercholestrolemia, 17.7% were current smokers and 56.5% were diabetics. The overall mortality was 9.7%. The number of hospitalization for CHF was not significantly different in Ramadan (208 cases) when compared to a month before Ramadan (182 cases) and a month after Ramadan (198 cases); p > 0.37). There was no significant difference found in the baseline clinical characteristics or mortality (11.5%, 7.7% and 9.6%, respectively; p > 0.43) in patients presenting in various time periods. CONCLUSION: This population-based study demonstrates that no significant difference was found in number of hospitalization for CHF while fasting in Ramadan when compared to the non-fasting months.

HLA DQ alpha genotype and allele frequencies in Qatari population.

Genotype and allele frequencies of HLA DQ alpha locus were determined in a Qatari population sample using polymerase chain reaction (PCR) amplified DNA fragment and hybridization to allele specific oligonucleoid probes in a reversed dot blot format. Among the 200 individuals studied 21 genotypes representing products of 6 HLA DQ alpha alleles have been differentiated, and the frequencies ranged from 0.0775 to 0.2825. The observed and expected genotypes values provide a complete fit to the Hardy-Weinberg equilibrium. The power of discrimination is 0.9321 and chance of paternity exclusion is 60.9% in the Qatari population.

Analysis of the short tandem repeat (STR) locus HumVWA in a Qatari population.

Polymerase chain reaction (PCR), amplified DNA fragments and denaturing polyacrylamide gel electrophoresis were used to investigate the STR locus HumVWA in a Qatari population sample (n = 200). Seven alleles were identified with frequencies ranging from 0.0125 to 0.3175. The distribution of genotypes fits the Hardy-Weinberg equilibrium. The HumVWA system shows a power of discrimination of 0.9290 and a chance of paternity exclusion of 60.1% in the population studied.

Contrast echocardiography in the evaluation of interatrial septal defect.

One hundred twenty-four adult patients consecutively referred for suspected interatrial septal defect (IASD) were studied with contrast echocardiography. In 58 the study eliminated altogether the diagnosis of any significant cardiac defect. Fifteen patients had other forms of cardiac abnormalities with no shunting of blood, and 51 patients had echocontrast study positive for interatrial shunting; 48 of these were subsequently proven by cardiac catheterization to have IASD. Echocontrast provided a highly sensitive and specific means of both diagnosing IASD and eliminating this diagnosis.

Double-chambered right ventricle and Down's syndrome: a proposed new association.

Twenty-two cases of double-chambered right ventricle studied in detail from two different centers comprise the study population. Of these, 5 have trisomy-21 Down's syndrome; these five cases, comprising nearly 25% of the entire study group, were essentially evenly divided between the two centers. This unexpectedly high percentage of Down's syndrome associated with such an unusual cardiovascular malformation, albeit among a small population, is likened to the currently recognized and similar association of Down's syndrome and atrioventricular cushion deformities.

Acute rheumatic fever in an Arabian Gulf country--effect of climate, advantageous socioeconomic conditions, and access to medical care.

An eleven-year study of the incidence and consequences of acute rheumatic fever was carried out in a country in which a uniform climate together with national characteristics of insularity, wealth, and unrestricted access to free medical care contribute prominently to the epidemiologic milieu. Study subjects were 86 children, aged four to fourteen years, satisfying criteria for acute rheumatic fever. Study methods included clinical evaluation, standard laboratory studies, and echocardiography. A declining incidence of rheumatic episodes, ranging from 1.06 to 18.6/100,000 population (average 11.2/100,000), was identified. The course of the episode was generally mild. Arthritic findings predominated (92%), followed by carditis identified clinically in 43% and, with the addition of echocardiography, in 71%. Residual valvular regurgitation, as a longer term consequence, persisted in 46% of those with auscultatory confirmation of valvulitis. No recurrences were identified. Comparison with countries of similar socioeconomic status revealed relatively unimportant differences. Comparison with nearby disadvantaged countries identified striking contrast. It may be concluded that among the contributing factors, for the improvement in the incidence and sequelae of a rheumatic episode, are an advantaged socioeconomic environment and accessibility to unlimited medical care.

Clinical and angiographic features of patients with an occluded versus a patent infarct vessel after intravenous streptokinase for acute myocardial infarction.

Despite early treatment with thrombolytic agents for acute myocardial infarction, a significant portion of patients fail to achieve a patent infarct artery. To study the various factors related to achieving patency in the infarct vessel, 201 patients who received streptokinase within six hours of symptoms were studied. All patients underwent cardiac catheterization during the same hospitalization at 5.40 +/- 3.26 days after admission. Forty-five (22.4%) patients were found to have an occluded infarct artery (group 1) and 156 (77.6%) had a patent infarct vessel (group 2). There was no difference in the time from onset of symptoms to receiving streptokinase between the two groups. The two groups were similar to each other with regard to age, gender, history of myocardial infarction or angina, and major risk factors for coronary disease. Coagulation parameters before and after streptokinase therapy, reflecting the lytic state, were similar in both groups. The left ventricular end diastolic pressure was significantly higher and the left ventricular ejection fraction was significantly lower in group 1 than in group 2. These observations suggest that despite early initiation of thrombolytic therapy in patients with acute myocardial infarction, a significant portion of patients fail to achieve a patent infarct artery. This failure cannot be explained by the observed clinical parameters or the lytic state after streptokinase.

Coronary angiography in Qatar: the first ten years.

Cardiac catheterization in Qatar was initiated in July 1982. In ten years, a total of 3900 procedures were performed at Hamad General Hospital. Computerized data registry has been maintained since 1982. Isolated coronary angiography was done in 2911 patients; of these, 2635 (90.5%) were men, and 276 (9.5%) were women, the average age of the patients was 47+/-9.2 years (range, twenty-five to eighty-eight). Patients' nationality was Qatari in 492 (17%), and other Arabs in 610 (21%), and 1512 (52%) were from the Asian subcontinent. Myocardial infarction was the most common indication (43%). Single-vessel disease was found in 638 (22%), two-vessel disease in 630 (22%), three-vessel disease in 950 (33%), and nonsignificant coronary artery disease in 693 (24%) patients. Morbidity related to the coronary angiography was reported in 147 (5%) patients, but there was no mortality related to the procedure. In 822 (28%) patients, the age was forty years or younger. The angiographic findings of these younger patients were compared with those of the older ones. Younger patients were usually men of Asian subcontinental origin with a recent myocardial infarction (MI). Often, they had normal coronary arteries or single-vessel disease. Patients of Asian subcontinent origin were usually young male patients with a recent MI, who receive streptokinase, and have single-vessel disease.

Clinical and angiographic features of patients from the Indian subcontinent treated with intravenous streptokinase for acute myocardial infarction: experience in Qatar.

The authors reviewed their experience with 245 patients who were treated with intravenous streptokinase for acute myocardial infarction at an average time of less than three hours from the onset of chest pain. Of these, 148 patients were from the Indian subcontinent (Group 1) and the remaining (Group 2) were predominantly from an Arabic background. Group 1 patients were younger and had lower serum cholesterol and fibrinogen levels than the Group 2 patients. Group 1 patients had a lower incidence of previous myocardial infarction (p = 0.0006) and antecedent angina pectoris (p = 0.017). A patency rate of 77.5% was seen in all patients studied at 5.37 +/- 2.96 days after admission and was similar in both the groups. Group 1 patients had a lesser extent of coronary artery disease (p = 0.01) manifested as a higher incidence of single-vessel disease (p = 0.06) and a lower incidence (p = 0.06) of three-vessel obstruction. The overall mortality for the initial hospitalization was 2.18% and showed no difference between the two groups. Patients from the Indian subcontinent presenting with acute myocardial infarction appear to be a unique population in that they are younger, have a somewhat lower cardiac risk profile, and have less extensive coronary artery disease than their Arabic counterparts.

Chest trauma causing acute myocardial infarction.

We report a case in which blunt chest injury during football match caused an intimal tear in the left anterior descending coronary artery resulting into acute anterior wall myocardial infarction.

Prevalence of unrecognized diabetes mellitus in patients admitted with acute coronary syndrome.

We assessed the prevalence of unrecognized diabetes mellitus (DM) in patients with acute coronary syndrome (ACS) as determined by elevated glycosylated hemoglobin (HbA1c), fasting plasma glucose (FPG), and random plasma glucose (RPG) levels. This prospective study recruited 583 patients admitted with ACS without previous diagnosis of DM during 1-year period. Glycosylated hemoglobin was checked for most patients especially those with high values of FPG and or RPG. Patients were classified according to their glycemic state into 123 (21.1%) with DM, 82 (14.1%) with prediabetes, and 57(9.8%) with stress hyperglycemia, while 321 (55%) were classified as nondiabetics. Glycosylated hemoglobin estimation in the setting of ACS was helpful in the diagnosis of DM to eliminate the effect of stress-induced hyperglycemia that might accompany this condition.

Ventricular conduction defect in isolated noncompaction of the ventricular myocardium.

A 9-month-old boy and 4-month-old girl presented with severe heart failure. The electrocardiogram showed complete and "incomplete" left bundle branch block, respectively. In both infants noncompaction of the ventricular myocardium was diagnosed with two-dimensional echocardiography. These cases are thought to be the first descriptions of the occurrence of left bundle branch block with noncompaction of the ventricular myocardium. Noncompaction of the ventricular myocardium should be added to the list of the causes for left bundle branch block in children.

Frequency distribution of D1S80 (MCT118) locus polymorphism in a Qatari population.

The genotype and allele frequencies at the D1S80 locus were determined in a Qatari population sample (n = 300) using the polymerase chain reaction with subsequent electrophoretic separation of the amplified DNA fragments. Twenty-two different alleles containing 15-39 repeats of the basic 16-bp unit and 78 genotypes were distinguished; the alleles with 18 and 24 repeat units were the most common, with frequencies of 0.2117 and 0.4233, respectively. The observed and expected genotype values show no significant deviation from Hardy-Weinberg equilibrium. The power of discrimination for the D1S80 locus in the Qatari population is 0.9137, and the chance of exclusion is 59.01%.

Pulmonary arterio-venous fistula in a child: a rare cause of congenital cyanosis.

A 12-year-old girl with a solitary pulmonary arterio-venous fistula (P.A.V.F.) affecting the R.L.L. is reported. The cyanosis was noted since birth and increased with age. The diagnosis was confirmed by right heart catheterization and pulmonary arteriography. Preoperatively, her hematocrit was 73%, paO2 36 mm Hg and no bruit was heard. The treatment consisted of a right lower lobectomy. One year postoperatively, the patient has normal activities, is asymptomatic and has no evidence of residual disease. A short review of the literature on the subject of P.A.V.F. is included and indicates the relative rarity of surgical treatment of this disease in childhood.

Occurrence of valvar heart disease in acute rheumatic fever without evident carditis: colour-flow Doppler identification.

OBJECTIVE: To determine the frequency of occurrence of mitral and aortic valvar regurgitation in rheumatic children in whom there was no evidence of carditis acutely or at an earlier attack. DESIGN: Colour flow Doppler imaging was used in a non-randomised study of sequentially admitted children who met the criteria for acute rheumatic fever without clinically evident carditis and patients in whom the disease was quiescent after a previous attack of rheumatic fever. Two separate control groups were used for comparison of the echocardiographic findings, and a group of patients with confirmed rheumatic carditis was included for comparison of acute phase and antistreptococcal reactants. SETTING: A general hospital with the only paediatric inpatient department in Qatar. PATIENTS: From November 1988 to October 1990, 11 children were studied during the acute rheumatic period. In seven additional children the disease was quiescent when they were studied 18 to 36 months after a documented episode of acute rheumatic fever in which there was no evidence of carditis. The control patients were all studied during the same period. MAIN OUTCOME MEASURE: Detection of mitral and aortic regurgitation in patients without clinical evidence of rheumatic carditis in the acute or quiescent stages of the disease. RESULTS: Mitral or mitral and aortic regurgitation was found in 10 of the 11 children studied in the acute rheumatic period. None had a murmur or other evidence of carditis. In all the cases studied the valvar insufficiency was mild. Four of the children studied late in the quiescent period had either aortic or mitral insufficiency by colour flow Doppler evaluation; two children who had previously had valvar insufficiency no longer showed this, and one child without positive findings in the acute phase remained without insufficiency. None of the non-rheumatic control subjects showed mitral or aortic regurgitation. CONCLUSIONS: Colour flow Doppler imaging is a useful method of identifying subclinical mitral and aortic valvar disease at all stages of rheumatic fever when carditis cannot be otherwise detected and is a valuable addition to current diagnostic criteria.