Association of the BB genotype of the ABO gene with the risk of acute myocardial infarction in hospital-based study.

Objectives: The ABO gene locus has been identified to be associated with myocardial infarction in patients with coronary heart disease. The primary focus of this hospital-based study was to explore the relationship of ABO blood groups and ABO genotypes with acute myocardial infarction (AMI) in Karachi, Pakistan. Methods: In a comparative cross-sectional study, an equal number of adult AMI patients and healthy controls (n=275 in each group; age range 30-70 years, both males and females) were recruited from the Aga Khan University and NICVD, Karachi, with informed consent. The blood samples were analyzed for ABO blood groups and other biomarkers. PCR followed by RFLP techniques were employed for determining the ABO genotypes. Multinomial regression was used to evaluate the association of genotypes with the risk of AMI. Results: Thirteen different combinations of ABO genotypes were observed while the O2O2 and A2A2 genotypes were not detected. No significant association based on the distribution of blood groups A, B, O and AB among AMI patients and healthy individuals was observed. The odds of AMI were 3.32 times in subjects with BB genotype as compared to subjects with OO genotypes after adjustment of age, gender, body mass index, heart rate, total cholesterol, and waist circumference [AOR (95% CI) =3.32 (1.36-8.08), p-value =0.008]. Conclusion: Our hospital-based study indicates that ABO genotype BB was significantly associated with the risk of AMI. This harmful effect of the BB genotype could have a possible relationship with AMI's development in the Pakistani population.

Glucose levels compared with diabetes history in the risk assessment of patients with acute myocardial infarction.

BACKGROUND: Both a history of diabetes mellitus and elevated inhospital glucose levels predict death after acute myocardial infarction (AMI). However, only diabetes history (and not glucose levels) is routinely considered in AMI risk assessment. METHODS: We conducted a post hoc analysis of 2 randomized controlled trials of AMI with ST-segment elevation to compare the prognostic value of inhospital glucose levels with diabetes history in 30,536 subjects. Average inhospital glucose (mean of glucose levels at admission, 6 hours, and 24 hours), diabetes history, and death at 30 days (occurring in 2,808 subjects) were documented. RESULTS: Average glucose predicted 30-day death (OR 1.10 per 1-mmol/L [18-mg/dL] increase, 95% CI 1.09-1.11, P < .0001); this was unchanged after adjusting for diabetes history. In contrast, diabetes history alone predicted 30-day death (OR 1.63, 95% CI 1.48-1.78, P < .0001), but not after adjusting for average glucose (OR 0.98, 95% CI 0.88-1.09, P = .72). The C-indices (areas under the receiver operating characteristic curves) for 30-day death were 0.54 for diabetes history alone, 0.64 for average glucose alone, and 0.64 for glucose plus diabetes. Higher glucose levels predicted death in patients with and without diabetes history, but this relationship was more steep in nondiabetic subjects such that their rate of 30-day death (13.2%) matched that of diabetic patients (13.7%) when average glucose was > or =144 mg/dL (8 mmol/L) (P = .55 after multivariable adjustment). CONCLUSIONS: Although diabetes history is routinely considered in the risk stratification of AMI patients, inhospital glucose levels are a much stronger predictor of death and should be incorporated in their risk assessment. Patients with AMI with inhospital glucose > or =144 mg/dL have a very high risk of death regardless of diabetes history.

N-acetyl-beta-D-glucosaminidase in acute myocardial infarction.

The objective of the study was to investigate whether the lysosomal enzyme, N-Acetyl-beta-D-glucosaminidase (NAG) activity is increased in plasma of patients with acute myocardial infarction (AMI) and to determine if there is any association between plasma levels of NAG and severity of myocardial infarction (MI). NAG activity in plasma was monitored in 69 patients with AMI and 135 normal healthy subjects using a spectrofluorimetric method. A modified Aldrich ST elevation score was used to gauge the severity of MI in terms of size of the infarct. Plasma NAG levels in AMI patients and normal healthy subjects were found to be 10.92+/-7.5 U/l and 6.8+/-2.2 U/l, respectively. These two mean value when compared by Student's t-test were significantly different P = 0.0001. No statistically significant differences in NAG activity were observed in patients in terms of gender, age, location of infarct, time from onset of chest pain to blood sampling in the hospital and size of the infarct.

Anti-streptokinase titers and response to streptokinase treatment in Pakistani patients.

In order to investigate whether anti-streptokinase (anti-SK) antibody titers have any effect on response to standard dose (1.5 million units) streptokinase (SK) therapy in patients with acute myocardial infarction, anti-SK titers in plasma were determined in 97 such patients. These patients were classified as "responders" or "non-responders" on the basis of a criteria which involved resolution of chest pain in less than 90 min after the start of thrombolysis, greater than 50% reduction of ST segment elevation in two contiguous leads showing maximum elevations in a 12-lead tracing, reperfusion arrythmias and slope of increase in creatine kinase over a 90-min period after initiation of thrombolysis. Anti-SK antibody levels in plasma were determined in these patients as well as in 50 normal healthy subjects by dissolution of clot method. Mean+/-S.D. anti-SK levels among responders, non-responders and normal healthy subjects were found to be 0.21+/-0.12, 0.25+/-0.22 and 0.21+/-0.15 million units, respectively. A comparison of these mean values by one-way ANOVA revealed no statistical difference (P=0.68). However, when compared with the reported values for a Western population, these values were found to be significantly higher (P<0.03). Whereas, compared to the reported values for an Indian population, these were significantly lower (P<0.0001). 42% of patients appeared to have responded to SK treatment, while 21% were found to be non-responders. There was no association between response to SK and anti-SK titers in these patients suggesting that the standard dose of SK (1.5 million units) may be quite appropriate for the Pakistani population requiring SK treatment for the first time.

Survival of patients treated with intra-aortic balloon counterpulsation at a tertiary care center in Pakistan - patient characteristics and predictors of in-hospital mortality.

BACKGROUND: Intra-aortic balloon counterpulsation (IABC) has an established role in the treatment of patients presenting with critical cardiac illnesses, including cardiogenic shock, refractory ischemia and for prophylaxis and treatment of complications of percutaneous coronary interventions (PCI). Patients requiring IABC represent a high-risk subset with an expected high mortality. There are virtually no data on usage patterns as well as outcomes of patients in the Indo-Pakistan subcontinent who require IABC. This is the first report on a sizeable experience with IABC from Pakistan. METHODS: Hospital charts of 95 patients (mean age 58.8 (+/- 10.4) years; 78.9% male) undergoing IABC between 2000-2002 were reviewed. Logistic regression was used to determine univariate and multivariate predictors of in-hospital mortality. RESULTS: The most frequent indications for IABC were cardiogenic shock (48.4%) and refractory ischemia (24.2%). Revascularization (surgical or PCI) was performed in 74 patients (77.9%). The overall in-hospital mortality rate was 34.7%. Univariate predictors of in-hospital mortality included (odds ratio [95% CI]) age (OR 1.06 [1.01-1.11] for every year increase in age); diabetes (OR 3.68 [1.51-8.92]) and cardiogenic shock at presentation (OR 4.85 [1.92-12.2]). Furthermore, prior CABG (OR 0.12 [0.04-0.34]), and in-hospital revascularization (OR 0.05 [0.01-0.189]) was protective against mortality. In the multivariate analysis, independent predictors of in-hospital mortality were age (OR 1.13 [1.05-1.22] for every year increase in age); diabetes (OR 6.35 [1.61-24.97]) and cardiogenic shock at presentation (OR 10.0 [2.33-42.95]). Again, revascularization during hospitalization (OR 0.02 [0.003-0.12]) conferred a protective effect. The overall complication rate was low (8.5%). CONCLUSIONS: Patients requiring IABC represent a high-risk group with substantial in-hospital mortality. Despite this high mortality, over two-thirds of patients do leave the hospital alive, suggesting that IABC is a feasible therapeutic device, even in a developing country.

Myoglobin--a marker of reperfusion and a prognostic indicator in patients with acute myocardial infarction.

BACKGROUND: Early noninvasive identification of patients with occluded infarct-related arteries after thrombolysis has important prognostic and therapeutic implications. Recent reports indicate that plasma kinetics of cardiac marker proteins could be very useful in diagnosis of myocardial reperfusion. Although angiographic assessment remains the ideal procedure for determining patency, it is expensive, invasive, not within the reach of most patients in developing countries, and the long-term follow-up data are still sparse. HYPOTHESIS: The present study was undertaken to investigate whether plasma kinetics of myoglobin in conjunction with clinical markers and another biochemical marker, creatine kinase, could be used to predict myocardial reperfusion more accurately and to investigate the correlation between myoglobin release after thrombolysis and mortality in patients with acute myocardial infarction (AMI) over a follow-up period of 18 months. METHODS: Eighty-three consecutive patients with AMI receiving streptokinase treatment were studied for plasma kinetics of myoglobin in conjunction with clinical markers and creatine kinase to predict reperfusion and were followed for a period of 18 months. RESULTS: Increased baseline mean +/- standard deviation levels of myoglobin were observed among "nonresponders" to streptokinase treatment compared with "responders" (469 +/- 386 microg/l vs. 270 +/- 211 microg/l). There was significantly more release of myoglobin following thrombolytic treatment among the responders than among the nonresponders (mean ratio of myoglobin levels at 90 min to 0 min 6.01 +/- 9.2 vs. 1.03 +/- 0.64). In a follow-up of 61 patients over a period of 18 months, 31% mortality was observed in the nonresponder group compared with 11.7% in the responder group. In responders, the mean ratio of myoglobin levels at 90 and 0 min was significantly less among those who died (p = 0.019) than among those who survived. CONCLUSION: A myoglobin release profile in combination with other clinical markers offers inexpensive, noninvasive, and a reasonably reliable way of assessing coronary artery patency after thrombolytic treatment.

Admission troponin T as a prognostic marker and it relationship to streptokinase treatment patients with acute myocardial infarction.

The relationship between the admission troponinT (TnT) level and the response to streptokinase (SK) was examined in 76 patients with acute myocardial infarction (AMI). Of 27 TnT positive patients, 10 (37%) showed a response to SK as suggested by a non-invasive criterion for reperfusion, while 24 (49%) were 'responders' among 49 TnT negative patients. There appeared to be a trend towards a better response to SK in the TnT negative group but the difference lacked statistical power due to the small sample size. The mean time-interval between the onset of symptoms and thrombolytic treatment among TnT positive 'non-responders' was significantly (P < 0.005) higher than the TnT negative 'non-responders' (5.23 + 3.42 h versus 2.38 +/- 1.37 h). An 18 month follow up on 61 patients revealed a higher mortality (33%) among TnT positive patients than TnT negative patients (10%). Mortality among TnT positive 'non-responders' was significantly higher (P = 0.0494) than mortality among TnT-negative 'non-responders' (43% versus 9%), indicating that TnT positive patients, non-responsive to SK were at a greater risk of cardiac death. The data suggest that the admission TnT level can be of value in risk stratification of patients with AMI.

Transcatheter closure of small-to-large patent ductus arteriosus with different devices: queries and challenges.

UNLABELLED: Transcatheter closure of patent ductus arteriosus (PDA) has been in place for more than three decades. We share our experience with the newer devices. PATIENTS AND METHODS: Ninety-eight patients, with a mean age of 64 +/- 11 months (range 7 months to 54 years), underwent attempted transcatheter closure of PDA. Thirty-seven patients were infants and 10 were adults. Two patients had residual PDA after surgical ligation. There were 66 females and 32 males. RESULTS: Sixty-six patients were symptomatic and 32 were asymptomatic. Cardiac catheterization showed significant pulmonary hypertension in 18. The mean size of the PDA on aortogram was 3.1 +/- 1.4 mm (range 1.1 to 11 mm). Seven patients were referred for surgical ligation. The PDAs of 37 patients were closed using coil devices, 52 with Amplatzer duct occluders (ADO) and two with Amplatzer muscular VSD devices. One patient had a very large PDA which was embolized and retrieved surgically. One patient required occlusion with two coils. The occlusion rate in the catheterization laboratory with coils was 84 +/- 7%, and 83% with ADO. After 1 week, the occlusion rate for coils was 96%, and 99% with ADO. One patient with a large PDA requiring a 14/12 ADO was left with a mild gradient of 9 mmHg in the aorta at the end of the procedure. None of our patients had stenosis of the left pulmonary artery. CONCLUSION: Transcatheter closure of PDA is the preferred alternative to surgical ligation, which should be reserved for small infants and premature babies or large unfavorably-shaped ducts.