Cardiovascular Journal of Africa - Volume 24, Issue 9, 2013
Volumes & issues
Volume 24, Issue 9, 2013
Left ventricular rupture after double valve replacement in a patient with myocarditis due to myasthenia gravis : online article - case reportSource: Cardiovascular Journal of Africa 24, pp 1 –3 (2013) http://dx.doi.org/10.5830/CVJA-2013-056More Less
Myasthenia gravis is an autoimmune disease characterised by weakness of the skeletal muscles, with remissions and exacerbations due to antibodies acting on the acetylcholine receptors. This leads to the characteristic defect transmission in the neuromuscular junction. Treatment includes anticholinesterase agents, thymectomy, and immunosuppression. Surgical thymectomy can induce remission or improvement, allowing for reduction in the immunosuppressive treatment. The case of an 84-year-old female patient with myasthenia gravis, aortic valve stenosis, mitral valve regurgitation and myocarditis is described. The development of myocarditis was related to inflammatory cell infiltration, and progressive and additive focal cellular necrosis associated with reactive myocardial fibrosis. After replacement of the mitral valve, complications arose when a rupture of the left ventricular posterior wall occurred, which caused massive bleeding and sudden death on the operating table.
Mini-sternotomy approach for aortic valve replacement in a patient with osteogenesis imperfecta : online article - case reportSource: Cardiovascular Journal of Africa 24, pp 4 –7 (2013) http://dx.doi.org/10.5830/CVJA-2013-070More Less
Osteogenesis imperfecta (OI) is a heritable disorder of the connective tissue. Cardiovascular involvement is rare, related mainly to aortic valve regurgitation. Open-heart surgery in these patients is associated with increased morbidity and mortality rates as a result of tissue friability and bone brittleness as well as platelet dysfunction. We present a patient with OI who underwent successful aortic valve replacement with a mini-sternotomy approach.
Antiphospholipid syndrome in a young Nigerian girl presenting with gangrenous toes : online article - case reportSource: Cardiovascular Journal of Africa 24, pp 8 –11 (2013) http://dx.doi.org/10.5830/CVJA-2013-073More Less
We report on a 21-year-old Nigerian girl with toe gangrene, which is one of the most unlikely forms of presentation of antiphospholipid syndrome among Africans. The essence of this case report is to raise awareness that, although antiphospholipid syndrome typically presents in Africans in association with a pregnancy-related event or a neuropathology, it should be considered as a differential diagnosis in all African patients with unexplained vasculitis. A high index of suspicion and early treatment will prevent toe amputations and reduce mortality rates.
Source: Cardiovascular Journal of Africa 24, pp 12 –16 (2013) http://dx.doi.org/10.5830/CVJA-2013-075More Less
Kounis syndrome has been defined as an acute coronary syndrome that manifests as unstable vasospastic or non-vasospastic angina, and even as acute myocardial infarction. It is triggered by the release of inflammatory mediators following an allergic insult or patient ill health, drug intake or environmental exposure. We report on a patient who was admitted to our hospital and diagnosed with unstable angina or acute myocardial infarction - according to analytical parameters, electrocardiographic abnormalities, and/or coronary angiography - in the context of progesterone as inducing factor. The results of a laboratory study revealed electrocardiogram changes, and increased myocardial enzymes, IgE antibodies and eosinophils. The patient experienced recurring chest pain, acute myocardial infarction, and cardiogenic shock after taking progesterone capsules; her medication history of progesterone clearly correlated with the onset of chest pain, which suggested that the cause of the vasospasm may have been related to progesterone use. We did not include patients with a history of bronchial asthma or allergic constitution. Nevertheless, the case suggests there is a correlation between Kounis syndrome and progesterone as inducing factor.
Source: Cardiovascular Journal of Africa 24 (2013)More Less
Articles in this issue range from epidemiology and determinants of risk factors for non-communicable diseases, namely, the prevalence of hypertension in Nigeria (Murthy et al., page 344), to obesity in South African woman (Micklesfield et al., page 369) and risk determination of cardiovascular events in persons with diabetes mellitus (Kengne, page 376). Interesting cardiac perfusion abnormalities are addressed in three articles (Tasolar et al., Celik et al. and Chang et al., pages 355, 357, e12), which are complimented by an article on congenital coronary anomalies (Karabay et al., page 351) as detected by CT-scanning. Furthermore, two ways of creating a shunt for renal dialysis purposes using the basilica vein is discussed by Ozcan et al. (page 364).
Prevalence and risk factors for hypertension and association with ethnicity in Nigeria : results from a national survey : cardiovascular topicsSource: Cardiovascular Journal of Africa 24, pp 344 –350 (2013) http://dx.doi.org/10.5830/CVJA-2013-058More Less
Background: Non-communicable diseases are now a global priority. We report on the prevalence of hypertension and its risk factors, including ethnicity, in a nationally representative sample of Nigerian adults recruited to a survey of visual impairment.
Methods: A multi-stage, stratified, cluster random sample with probability proportional to size procedures was used to obtain a nationally representative sample of 13 591 subjects aged ≥ 40 years. Of these, 13 504 (99.4%) had a blood pressure measurement.
Results: The prevalence of hypertension was 44.9% [95% confidence interval (CI): 43.5-46.3%]. Increasing age, gender, urban residence and body mass index were independent risk factors (p < 0.001). The Kanuri ethnic group had the highest prevalence of hypertension (77.5%, 95% CI: 71.0-84.0%).
Conclusions: The high prevalence of hypertension in Nigeria is a cause for concern and suggests that it is inevitable that the impact of hypertension-related ill health is imminent, with the accompanying financial and societal costs to families and the state of Nigeria.
Source: Cardiovascular Journal of Africa 24, pp 351 –354 (2013) http://dx.doi.org/10.5830/CVJA-2013-066More Less
Objective: This study aimed to assess the incidence of coronary anomalies using 64-multi-slice coronary computed tomography (MSCT).
Methods: The diagnostic MSCT scans of 745 consecutive patients were reviewed.
Results: The incidence of coronary anomalies was 4.96%. The detected coronary anomalies included the conus artery originating separately from the right coronary sinus (RCS) (n = 8, 1.07%), absence of the left main artery (n = 7, 0.93%), a superior right coronary artery (RCA) (n = 7, 0.93%), the circumflex artery (CFX) arising from the RCS (n = 4, 0.53%), the CFX originating from the RCA (n = 2, 0.26%), a posterior RCA (n = 1, 0.13%), a coronary fistula from the left anterior descending artery and RCA to the pulmonary artery (n = 1, 0.13%), and a coronary aneurysm (n = 1, 0.13%).
Conclusions: This study indicated that MSCT can be used to detect common coronary anomalies, and shows it has the potential to aid cardiologists and cardiac surgeons by revealing the origin and course of the coronary vessels.
Endothelial nitric oxide synthase levels and their response to exercise in patients with slow coronary flowSource: Cardiovascular Journal of Africa 24, pp 355 –359 (2013) http://dx.doi.org/10.5830/CVJA-2013-072More Less
Background: Endothelial dysfunction plays a key role in the aetiopathogenesis of slow coronary flow (SCF) even if there is no obstructive epicardial lesion. Reduced plasma levels of endothelial nitric oxide synthase (eNOS) are an important indicator of endothelial dysfunction. We aimed to determine plasma levels of eNOS and their relationship with exercise in patients with SCF.
Methods: Twenty-two patients with SCF in at least one coronary artery and 17 healthy individuals were included in this study. The TIMI frame count method was used to determine SCF. Plasma levels of eNOS before and after effort were determined in the patient and control groups.
Results: Basal eNOS levels in the patient group were lower than in the control group (p = 0.040), and plasma eNOS levels after exercise decreased more significantly in the patient group compared to the control group (p = 0.002). Median decreases of eNOS in response to exercise were higher in the SCF group than in the control group (p < 0.001), and the decrease observed in the control group was not statistically significant (p = 0.35). There were significantly negative correlations between TIMI frame count and plasma levels of eNOS at baseline and after exercise (r = -0.51, p = 0.015, r = -0.58, p = 0.005, respectively). Moreover, there was also a positive correlation between the rate-pressure product and plasma levels of eNOS after exercise in patients with SCF (r = 0.494, p = 0.019).
Conclusion: Our findings indicate an important pathophysiological relationship between the severity of SCF in which endothelial dysfunction plays a role in its pathogenesis and the level of circulating plasma levels of eNOS.
Source: Cardiovascular Journal of Africa 24, pp 360 –363 (2013) http://dx.doi.org/10.5830/CVJA-2013-076More Less
Aim: Oxidative stress, which is widely recognised as an important feature of many diseases, can be defined as an increased formation of reactive oxygen species or decreased antioxidant defense. In this study we measured plasma vitamin E levels and total antioxidant activity (AOA) in patients with slow coronary flow (SCF).
Methods: The plasma vitamin E levels and AOA were measured in 40 patients with angiographically diagnosed SCF. Forty subjects with normal coronary flow (NCF) served as the control group. SCF and NCF were analysed, and blood samples were taken for plasma vitamin E levels and AOA. Plasma vitamin E levels and AOA in patients with SCF were evaluated and compared to those of patients with NCF.
Results: There was no significant difference between the two groups in terms of plasma AOA, lipid profile and C-reactive protein (CRP) levels but there was a significant difference in vitamin E levels between the two groups (p = 0.001).
Conclusion: Vitamin E levels were found to be lowered in patients with SCF compared to the NCF group. The association between smoking and vitamin E levels is worth further investigating in larger samples.
Source: Cardiovascular Journal of Africa 24, pp 363 –368 (2013)More Less
The Academy of Science of South Africa (ASSAf) recognised top South African scientists at its prestigious annual awards ceremony in Pretoria on 23 October 2013. ASSAf annually awards up to two ASSAf Science-for-Society gold medals for outstanding achievement in scientific thinking to the benefit of society. This year, Prof Olive Shisana was recognised for her contributions in the campaign to understand and contain HIV/AIDS in South Africa.
Comparison of one- and two-stage basilic vein transposition for arterio-venous fistula formation in haemodialysis patients : preliminary resultsSource: Cardiovascular Journal of Africa 24, pp 364 –368 (2013) http://dx.doi.org/10.5830/CVJA-2013-077More Less
Objective: This study aimed to compare the results of one- and two-stage basilic vein transposition (BVT) in haemodialysis patients.
Methods: This was a non-randomised, retrospective study between January 2007 and January 2012 on 96 patients who were diagnosed with end-stage renal failure (ESRF) (54 males, 42 females; mean age 43.6 ± 14 years) and underwent one- or two-stage BVT in our clinic. All patients who were not eligible for a native radio-cephalic or brachio-cephalic arterio-venous fistula (AVF) were scheduled for one- or two-stage BVT after arterial (brachial, radial and ulnar) and venous (basilic and cephalic) Doppler ultrasonography. Patients were retrospectively divided into two groups: group 1, basilic vein diameter > 3 mm and patients who underwent one-stage BVT; and group 2, basilic vein diameter < 3 mm and patients who underwent two-stage BVT. In group 1, the basilic vein with a single incision was anastomosed to the brachial artery, followed by superficialisation. In group 2, the basilic vein was anastomosed to the brachial artery and they underwent the superficialisation procedure one month postoperatively. Fistula maturation and postoperative complications were assessed.
Results: The mean diameter of the basilic vein was statistically significantly higher in group 1 (3.46 ± 0.2 mm) than in group 2 (2.79 ± 0.1 mm) (p < 0.05). In terms of postoperative complications, thrombosis, haemorrhage and haematoma were significantly higher in group 1 (34, 36 and 17%, respectively) than in group 2 (23, 14 and 6%, respectively) (p < 0.05). The rate of fistula maturation was significantly lower in group 1 (66%), compared to group 2 (77%) (p < 0.05). Time to fistula maturation was significantly shorter in group 1 (mean 41 ± 14 days), compared to group 2 (mean 64 ± 28 days) (p < 0.05).
Conclusion: Two-stage BVT was superior to one-stage BVT due to its lower rate of postoperative complications and higher fistula maturation, despite its disadvantage of late fistula use. Although the diameter of the basilic vein was larger in patients who underwent one-stage BVT, we observed that one-stage BVT was disadvantageous in terms of postoperative complications and fistula maturation.
Socio-cultural, environmental and behavioural determinants of obesity in black South African women : review articlesSource: Cardiovascular Journal of Africa 24, pp 369 –375 (2013) http://dx.doi.org/10.5830/CVJA-2013-069More Less
South Africa (SA) is undergoing a rapid epidemiological transition and has the highest prevalence of obesity in sub-Saharan Africa (SSA), with black women being the most affected (obesity prevalence 31.8%). Although genetic factors are important, socio-cultural, environmental and behavioural factors, as well as the influence of socio-economic status, more likely explain the high prevalence of obesity in black SA women. This review examines these determinants in black SA women, and compares them to their white counterparts, black SA men, and where appropriate, to women from SSA. Specifically this review focuses on environmental factors influencing obesity, the influence of urbanisation, as well as the interaction with socio-cultural and socio-economic factors. In addition, the role of maternal and early life factors and cultural aspects relating to body image are discussed. This information can be used to guide public health interventions aimed at reducing obesity in black SA women.
The ADVANCE cardiovascular risk model and current strategies for cardiovascular disease risk evaluation in people with diabetesAuthor Andre Pascal KengneSource: Cardiovascular Journal of Africa 24, pp 376 –381 (2013) http://dx.doi.org/10.5830/CVJA-2013-078More Less
Purpose: To critically examine existing approaches to cardiovascular disease (CVD) risk evaluation in people with diabetes, and discuss the use of accurate and validated absolute CVD risk tools as an appropriate basis for CVD prevention in people with diabetes.
Methods: This was a narrative review using evidence from the ADVANCE study and all relevant publications identified via PubMed MEDLINE.
Results: There is sufficient evidence that diabetes does not confer a CVD risk equivalent to that in non-diabetic people with existing CVD in all circumstances. In people with diabetes, CVD risk follows a gradient. Reliably capturing this gradient depends on an adequate combination of several risk factors. Many global CVD risk tools applicable to people with diabetes have been developed. Those derived from older cohorts are less accurate in contemporary populations and many newer tools have not been tested. The ADVANCE risk engine, recently developed from the large multinational ADVANCE study, showed acceptable performance on the ADVANCE population and largely outperformed the popular Framingham risk equation when tested on the multinational DIAB-HYCAR cohort of people with type 2 diabetes.
Conclusions: The high-risk status conferred by diabetes does not preclude estimation of absolute CVD risk using tools such as the ADVANCE risk engine and its use as the basis for initiating and intensifying CVD preventative measures. Adopting such an accurate and validated tool will likely improve prescriptions and outcomes of diabetes care.
Source: Cardiovascular Journal of Africa 24, pp 382 –384 (2013) http://dx.doi.org/10.5830/CVJA-2013-054More Less
We report on two cases presenting with a rare combination of Ebstein's anomaly and Down's syndrome. The first patient presented with respiratory distress, mild cyanosis and right heart failure immediately after delivery. The symptoms improved with heart failure medication. The patient remained asymptomatic on follow up. The second patient was diagnosed antenatally with marked apical displacement of the tricuspid valve and a very small functional right ventricle compared to the left ventricle. At birth, the patient presented with an extreme form of Ebstein's anomaly with severe cyanosis, marked right heart failure and ductal-dependent pulmonary blood flow. The patient died within days of birth.