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Congress Chairman
Co-chairman Prof. Abdulla Shehab
Prof. Dr. Galal E Nagib Elkilany ,MD. PhD,FESC,FISCU , Egypt
MD, A.Professor Department of Internal Medicine Faculty of Medicine and Health Sciences United Arab Emirates University Consultant Interventional Cardiologist at Al Ain and Al Noor Hospitals, United Arab Emirates
Consultant and professor of cardiology ,UAE Distinguished Fellow of International Society of Cardiac Ultrasound , USA Fellow of European Society of Cardiology President ISCU Middle East Chapter
Dear Colleague, On behalf of the; International Society of Cardiovascular Ultrasound (USA), M.O.H., UAE,Gulf Medical College UAE, United Arab Emirates University-Cardiology Department ,and European Association of Cardiovascular Imaging , we are pleased to invite you to the 6th International Congress of Cardiology and Cardiovascular Imaging to be held on 23th – 24th October 2015 Taj Hotel Dubai, UAE.
Finally , an attractive workshops will included illustrative live demonstration on Cath. Closure of cardiac defects and management of valvular heart disease to learn the latest in available therapeutics and technology that help you get the best possible care for your patient. It is therefore our great pleasure to welcome you to Dubai City, that will be the host city for this important International Congress of Cardiology‌ We look forward to the pleasure of meeting you in Dubai City, UAE
Welcome to 6 ICC
The excellent scientific program encompassing various aspects of interest to practicing physicians and surgeons have been planned through the association of the leading cardiologists in the UAE and include invited lecturers and debates as well as presentations of oral abstracts, scientific posters from several international centers throughout the world. The emphasis will be on the latest advances in Cardiovascular Imaging and Intervention. Over the past two decades, Percutaneous Coronary Intervention, Valve Replacement and Repair and Echocardiography has taken significant strides including improvement of ultrasound image resolution and development of myocardial contrast echocardiography, Tissue Doppler Imaging, speckle tracking echo cardiography and live/real time three and four Dimensional Echo cardiography. We also bring you a neutral interface with the leaders in Interventional Cardiology in coronary artery disease in diabetics , recent advances in management of diabetes mellitus and early diagnosis of cardiac dysfunction among diabetic patients by different imaging techniques..
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Day 1
Hall A
23rd October, 2015 09:00 – 10:30
SESSION 1 Symposium On “ obesity, diabetes, dyslipidemia and hypertension: the fatal quartet”. Abdullah Shehab , UAE Mohamed Ayman Abdelhai , Egypt
Chairpersons
Krasimira Hristova , Bulgaria Abdelbaset Essawy , UAE Mohammed Ibrahim , UAE
09:00 – 09:20
Women and Heart Disease: Focus on Diabetes, Metabolic Syndrome, and Obesity Susan Laing , USA
09:20 – 09:40
Remodeling of the kidneys and the heart in Diabetes Mellitus Jaipaul Singh, UK
09:40 – 10:00
Epigenetic Inheritance of Metabolic syndrome Ram Singh, India
10:00 – 10:20
Epicardial Adipose Tissue, Obesity and Inflammation in Atherosclerosis Devendra K. Agrawal , USA
10:20 – 10:30
Open discussion
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Day 1
Hall A
23rd October, 2015
10:30 – 12:00
SESSION 2 Epidemiology, Prediction & Prevention of Cardiovascular Events Among Diabetics : Navin Nanda , USA Vito Maurizio Parato, Italy
Chairpersons
Ram Singh , India Abdulmajeed Alzubaidi, UAE Devendra Agrawal , USA
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10:30 – 10:42
Prevalence of Vascular disease in type 2 diabetes Banshi Saboo, India
10:42 – 10:54
Statin therapy in Diabetes Osama Sanad , Egypt
10:54 – 11:06
How to control hyperglycemia and its adverse effects Toru Takahashi , Japan
11:06 – 11:18
Role of coronary flow reserve in predicting the outcome of patients with diabetes Fausto Rigo, Italy
11:18 – 11:30
Diabetes Mellitus: A disease of the brain J.P Sharma , India
11:30 – 11:42
Omega 3 puffa in patients with endothelial dysfunction and metabolic syndrome Jan Fedacko, Slovakia
11:42 – 11:54
The Early Diagnostic of The Risk of Atrial Fibrillation in Ischemic Patients Krassimira Hristova , Bulgaria
11:54 – 12:00
Open discussion
12:00 – 13:30
lunch & prayer
Day 1
Hall A
23rd October, 2015
13:30 – 14:30
SESSION 3 Interactive session : clinical case presentations entailing the management of a diabetic patient with multiple cardiovascular risk factors : Susan Laing , USA Rajeef Gupta , UAE
Chairpersons
Abdulrahman Abu Baker , UAE Osama Sanad , Egypt Anuj Maheshwari , India
13:30 – 13:45
Gene Therapy to Prevent Restenosis following Coronary Intervention Devendra K. Agrawal , USA
13:45 – 13:55
Fujairah Hospital Complex Coronary Intervention Abdullah AlHajiri , UAE
13:55 – 14:05
Ca2+ cycling proteins, methylglyoxal and diabetes mellitus Keshore BIDASEE , USA
14:05 – 14:20
predictors of contrast induced nephropathy in diabetics Francesco Pelliccia, Italy
14:20 – 14:30
Recent clinical trials of PCSK9 inhibiters in ACS Daniel Pella , Slovakia
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Day 1
Hall A
23rd October, 2015
14:30 – 16:30
SESSION 4 - Management of acute coronary syndrome among diabetics “Symposium”: Ousama Mahdi , UAE
Moderators
A. Shehab , UAE University Essam Soliman Atta , GMC,UAE Hisham Nmr , UAE
14:30 – 14:45
UAE University Experience in management of ACS in DM Abdulla Shehab, UAE
14:45 – 15:00
ESC :How to Prevent Periprocedural Myocadial Damage at time of PCI in Diabetics Francesco Pelliccia , Italy
15:00 – 15:15
Shaikh Khalifa Specialized Hospital RAK Choong Won Goh, Korea
15:30 – 15:45
SKMC Experience In CAD Intervention In DM AbdulMajeed AlZubaidi , UAE
15:45 – 16:00
How important it was the decision making to treat patient with acute MI. Ousama Mahdi , UAE
16:15 – 16:30
Intervention in AF in AlQassimi Hospital Mohamed Magdy , UAE
Mayo Clinic 16:30 – 16:45
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Critical Care Ultrasound and CERTAIN: A Global Approach Rahul Kashyap , USA
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Workshop
Hall B
23rd October, 2015 14:15 – 15:15
Workshop 1 VIP room - Workshop
Chairpersons
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Nawal AlMutawa , UAE Musab Mohammed Ali , UAE Hamdy El-Qawasmie , UAE
14:15 – 14:35
Diabetes Opportunities for a Cure Nawal Al-Mutawa , UAE
14:35 – 14:50
Modern Therapy in Diabetics with CAD in Adult Ousama Almaraghi , Kuwait
14:50 – 15:05
Diabetes and Cardiovascular Diseases Banshi Saboo , India
15:05 – 15:20
Modern Therapy of Diabetic Child to Prevent the Progression to Atherosclerosis and Multi-Organ Damage Ezzat Altaher , UAE
Workshop
Hall B
23rd October, 2015 15:20 – 17:25
Workshop 2 “Echocardiography 2D and 3D ECHO Clinical Sinario [Valvular HD & Cardiomyopathy assessment]
Chairpersons
Ehab Esheiba , UAE Navin Nanda , USA Hosam Zaki , UAE Mohammed Ayman , Egypt
15:20 – 15:40
Problems With Prosthetic Mitral Valves : the role of Echo Mohamed Ayman , Egypt
15:40 – 16:00
Echocardiography and preoperative assessment of mitral valve disease - focus on real time 3D TEE Nikolaos Tzemos , Greece
16:00 – 16:25
2D/3D-TEE role during intervention in cardiac defects Hani Mahmoud , KSA
16:25 – 16:45
CMR and cardiomyopathies. What is the general cardiologist should know Nikolaos Tzemos , Greece
16:45 – 17:25
Role of Echo in Intervention : TAVI and Mitral Clip Hani Mahmoud , KSA
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Day 2
Hall A
24rd October, 2015 09:00 – 10:30
SESSION 5 Imaging session: Evaluation of chest pain among diabetics
Chairpersons
Galal E Nagib El-Kilany , UAE Hosam Zaki , UAE Mohamed Ibrahim , UAE Ousama Mahdi , UAE Jaipaul Singh , UK
09:00 – 09:20
Cardiac MRI in Acute Myocardial Infarction Sabino Iliceto , Italy
09:20 – 09:40
Tissue Doppler echo in diabetes Galal E Nagib Elkilany , UAE - President ISCU Chapter ME
09:40 – 10:00
New quantitative Methods in 2D and 3D Cardiac Ultrasound Bernhard Mumm , Germany
10:00 – 10:20
The future of stress testing focus on stress CMR (perfusion and dobutamine) Nikolaos Tzemos , Greece
10:20 – 10:30
Open discussion
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Day 2
Hall A
24rd October, 2015 10:30 – 12:00
SESSION 6 Prediction of Diabetic Patients At Risk for Major Cardio vascular Events :
Chairpersons
Dr. Yosra Alsalami , UAE Prof. A . Shehab , UAE Virendra Kumar Misra , UAE
Moderators
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Fatemeh Nabavizadeh , UAE Fabiola Sozzi , Italy Krasimira Hristova , Bulgaria
10:30 – 10:45
MSCT Diabetes in young and asymptomatic patients: how to stratify and to personalize the risk? Fausto Rigo , Italy
10:45 – 11:00
Cardiac Ultrasound Echocardiographic detection of early diabetic myocardial disease: From stress to strain Bernhard Mumm , Germany
11:00 – 11:15
Carotid US Novel Mechanisms underling Instability of Atherosclerotic Plaques in Carotid Artery Devendra K. Agrawal , USA
11:15 – 11:30
Carotid Ultrasound for Risk Stratification in Patients with Diabetes and Pre diabetes Susan Laing , USA
11:30 – 11:45
Cardiac MRI for the detection of arrhythmia myocardial substrates Sabino Iliceto , Italy
11:45 – 12:00
“Strain” in early detection of Diabetic Cardiomyopathy Issam Mikati , USA
Day 2
Hall A
24rd October, 2015 12:15 – 13:30
SESSION 7 Preclinical detection of Cardiac Dysfunction & Arteriopathy among Diabetics
Chairpersons
Abdulmajeed Alzubaidi , UAE Fausto Rigo , Italy Jan Fedacko , Slovakia Toru Takahashi , Japan Osama Sanad , Egypt
12:15 – 12:30
Creighton University , Omaha USA : Molecular Imaging –Imaging of Vulnerable Atherosclerotic Plaque Devendra K. Agrawal , USA
12:30 – 13:00
M. del Soccorso Hospital – UNIVPM Systolic and diastolic dysfunction in patients with diabetes without known heart disease Vito Maurizio Parato , Italy
13:00 – 13:15
North Western University , Chicago , USA Is assessment of LV ejection fraction outdated in diabetes and other conditions? Issam Mikati , USA
13:15-13:30
University of Russia, Moscow PHYSIOLOGICAL LIMITS OF CORONARY RISK FACTORS AMONG STUDENTS FROM THE FIVE CONTINENTS Sergey Shastun , Russia
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Day 2
Hall A
24rd October, 2015 14:30 – 16:30
SESSION 8 ESC-European Advances in Imaging Techniques :Multi Modality Imaging in Atherosclerosis and Cardiomyopathy
Chairpersons
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Mohamed Ayman , Egypt Devendra K. Agrawal , USA Virendra Kumar Misra , UAE Ousama Mahdi , UAE Banshi Saboo , India
14:30 - 14:45
MRI and Atherosclerosis Jan Fedacko , Slovakia
14:45 - 15:00
Strain and Strain Rate Imaging Vito Maurizio Parato , Italy
15:00 - 15:15
What can coronary CT scan add in the evaluation of the vulnerable plaque? Fabiola Sozzi , Italy
15:15 - 15:30
How to assess HCM - multimodality cardiac imaging Nikolaos Tzemos , Greece
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Workshop
Hall B
24rd October, 2015 15:30 - 17:00 15:30 - 16:00
Moderators
Workshop (3) two and three Dimensional echocardiography & Allied Techniques Live Echo Case
Sabino Iliceto , Italy Mohammed Ayman Abdelhai , Egypt Fausto Rigo , Italy
16:00 - 17:00
Chairpersons
Vito Maurizio Parato , Italy Bernhard Mumm , Germany Sherif Bathalah , UAE 3D echo in the assessment of atrial septal pouch: Implications in occurrence of stroke Hani Mahmoud , KSA Introduction to adult congenital heart disease Marc G Cribbs , USA Complex congenital heart disease in adults, and pregnancy Marc G Cribbs , USA
Hall A 15:30 - 16:30
Oral Abstracts Presentation [Best Abstracts] Chairman: Abdullah Shehab , UAE Fateme Nabavizadeh , UAE Virendra Kumar Misra , UAE Osama Sanad , Egypt Keshore BIDASEE , USA
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Gene Transfer to Reduce Cardiovascular Complications in Diabetes Prof. Keshore R. Bidasee, USA
Vice-Chair of Graduate Program Associate Professor (tenured) Department of Pharmacology and Experimental Neuroscience
The prognostic importance of admission serum uric acid in patients admitted with acute myocardial infarction that were treated conservatively. Prof. Kashif Bin Naeem, UAE
A therapeutic answer for the controversy of insulin-cardioprotection among dysglycemic patients Prof. Abdullah M Nasrat , KSA
PREDICTORS OF LEFT VENTRICULAR SYSTOLIC DYSFUNCTION IN PATIENTS WITH FIRST ACUTE ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION UNDERGOING PRIMARY ANGIOPLASTY Prof. Wael Sayed , Kuwait
Attitude and Practice Towards the Use of Beta-Blockers among Medical Students, KSA, 2015 Prof. Nehal Anam Ahmad , KSA
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Coronary Artery Bypass Grafting After Percutaneous Intervention Has Higher Early Mortality: A Meta-AnalysisNS Verma Prof. Salah eldien Altarabsheh , Jordan
POOR NUTRITION IN FETUS AND LOW BIRTH WEIGHT AS RISK FACTOR OF CVDS AND TYPE 2 DIABETES IN ADULT LIFE Prof. Sergey Shastun , Russia
ROLE OF HAPTOGLOBIN GENE POLYMORPHISM AND SERUM HEMEOXYGENASE 1 LEVEL IN TYPE DIABETIC PATIENTS WITH AND WITHOUT NEPHROPATHY Syeda Nuzhat Nawab , Pakistan
Incomplete RV Tissue Doppler Imaging Changes after Transcatheter Closure of ASD in Pediatric Age Prof. Hayat Nassar , Iraq
Pre Diabetes and Cardiovascular Risk Prof. Abdelbaset Hasan, UAE
Russian Recent Trial
Prof. Alexey Yurevich Abramov , Russia
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International Speakers & Chairpersons
Prof. Mohamad Ayman Abdel-Moniem, Egypt
Professor of Cardiology- Faculty of Medicine, Alexandria University since September 2005 (The present position). Director of the Adult EchocardiographyLaboratory. Faculty of Medicine, Alexandria University
Prof. Dr. Krasimira Hristova , MD,PhD, FESC, Sofia ,Bulgaria Professor in University National Heart Hospital Department of Noninvasive Functional Diagnostic and Imaging
Prof. Dr. Abdelbaset Essawy , UAE
Prof of Internal Medicine AlAzhar University Egypt Adjunct Prof of Internal Medicine RAKMHSU UAE
Prof. Dr. Susan Laing , MD, USA
Professor, Division of Cardiology/Department of Internal Medicine Director of Echocardiography University of Texas Health Science Center-Houston Memorial Hermann Hospital – Texas Medical Center
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International Speakers & Chairpersons
Prof. Dr. Jaipaul Singh , UK
Professor of Physiology and Research Degree Tutor (RDT)
Prof. Dr. Ram Singh, India
Certified Nutrition specialist [USA] Fellowship [FICN, FACN, FCCP,FACC,FRS] Halberg Hospital , Moradabad , India
Prof. Dr. Devendra K. Agrawal , USA
Senior Associate Dean for Clinical &Translational Research, Director of the Center for Clinical and Translational Science, The Peekie Nash Carpenter Endowed Chair in Medicine, Professor of Biomedical Sciences, Internal Medicine, and Medical Microbiology and Immunology at Creighton University School of Medicine, Omaha,
Prof. Dr. Navin C. Nanda, M.D , USA
MD, FACC, FAHA, FISCU(D), FICA, FACA, FICP (Hon), FIAE, FICMU (Hon), FACIP, FCSC (S), FIACS, FICC (Hon) Distinguished Professor of Medicine and Cardiovascular Disease University of Alabama at Birmingham, Birmingham, Alabama USA President of ISCU, USA
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International Speakers & Chairpersons
Prof. Dr. Vito Maurizio Parato, Italy
Cardiology Consultant of National Health System , Italy Director of Chest Pain Unit , Cardiology Unit , at Mazzoni Hospital.
Prof. Osama Sanad Arafa Afifi, MD, Egypt
Professor and Head of Cardiology department, Benha Faculty of Medicine, Benha University, Benha, Egypt.
Prof. Dr. Toru TAKAHASHI, Ph.D, Japan
Professor in Okayama University Japan
Prof. Fausto Rigo,MD FESC , Italy
Head of Division of Cardiology dell’Angelo Hospital
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International Speakers & Chairpersons
Prof. Jan Fedacko, MD, PhD , Slovakia
Assistant Professor, at Department of Medicine and Centre of Excellence in Atherosclerosis Research at Louis Pasteur University Hospital and Medical Faculty of Pavol Jozef Safarik University in Kosice, Slovakia
Prof. Keshore R. Bidasee, USA
Vice-Chair of Graduate Program Associate Professor (tenured) Department of Pharmacology and Experimental Neuroscience
Prof. Francesco Pelliccia, Italy
Professor of Cardiology, Attending Cardiologist, Division of Cardiology, Interventional Cardiology Unit, ‘Sapienza’ University School of Medicine Rome, Italy
Prof. Abdulla Shehab, UAE
MD, A.Professor Department of Internal Medicine Faculty of Medicine and Health Sciences United Arab Emirates University Consultant Interventional Cardiologist at Al Ain and Al Noor Hospitals, United Arab Emirates
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International Speakers & Chairpersons
Prof. Dr. Choong-Won Goh, MD , Korea Consutant Cardiologist at SKSH , RAK
Prof.Dr. Ousama Almaraghi , Kuwait Consultant Diabetologist ,KW
Prof. Dr. Nikolaos Tzemos , Greece
Staff Cardiologist/Director of Research and Education Cleveland Clinic Abu Dhabi, Heart and Vascular Institute, United Arab Emirates
Dr. Hani Mohamed Mahmoud, KSA
MBBCh, MSc, FASE EACVI/Club35 Committee member Adult Cardiologist, Prince Sultan Cardiac Center, Al-Hassa, Saudi Arabia
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International Speakers & Chairpersons
Dr. Galal Eldin Nagib El-Kilany, UAE
M.B.Ch.B., MSc , MD, PhD , FESC , FISCU Consultant & Professor of Cardiology ,GMC Distinguished Fellow : International Society of Cardiovascular Ultrasound, USA President ISCU Middle East Chapter Associate Editor, Journal of Molecular and Translational Research , “JMTR�, Creighton University School of Medicine, USA Fellow of European Society of Cardiology ,France
Dr.Sabino Iliceto, Italy
Head of the Department of Cardiac, Thoracic and Vascular Sciences and the Division of Cardiology of the University Hospital of Padua, University of Padua, Italy
Prof.Dr. Bernhard Mumm, Germany
President & COO at TomTec Imaging Systems, Munich , Germany
Prof. Dr.Fatemeh Nabavizadeh MD , UAE
Consultant cardiologist in Emirates hospital and Burjeelhospital ,asnon invasive cardiologist
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International Speakers & Chairpersons
Prof. Fabiola Sozzi, MD, Italy
Member of ESC , France PhD , Erasmus University , Rotterdam , Holland Milan Policlinico , Milan,Italy
Prof. Dr. Sergey Shastun , Russia
Russia Professor in medical institute People Friendship University of Russia
Dr. Ousama Mahdi, UAE
head of interventional cardiology department - University Hospital of Sharjah Sharjah University, UAE
Dr. Mohammed Ibrahim , UAE
Senior Consultant Cardiologist Head of Medical Department, Kuwait Hospital , Sharjah Professor college of medicine Sharjah University, UAE
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International Speakers & Chairpersons
Prof. Dr,Issam Mikati
Associate Professor of Medicine , Northwestern Memorial Hospital , Division of Cardiology , Chicago , USA
Dr. J.P Sharma , India
Consultant Internal Medicine , Halberg Hospital UP India
Dr. Rajeef Gupta , UAE
Consultant Cardiologist at Kalba Hospital , UAE
Dr. Abdulrahman Abu Baker , UAE
Consultant Cardiologist , AlFujairah Hospital
Dr. Anuj Maheshwari , India
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International Speakers & Chairpersons
Dr. Daniel Pella , Slovakia
Executive Director of the Int Coll of Cardiology , Slovakia
Dr. Essam Soliman Atta , GMC,UAE Ass.Medical Director GMC , AJMAN , UAE
Dr. Hisham Nmr , UAE
Specialised cardiologist , Kalba Hospital ,UAE
Dr. Abdulla Anuami , UAE
Consultant Interventional Cardiology & Medical Director at Zayed Military Hospital , AbuDhabi , UAE
Dr. Mohamed Magdy , UAE
Consultant Cardiologist ,EPS , Al-Qassimi Hospital ,UAE Ass .Professor of Cardiology , Cairo University
Prof.Dr.Rahul Kashyap , USA
Clinical Research Specialist | Assistant Professor of Anesthesiology | Department of Anesthesia / Critical Care Division | Associate Director | Critical Care Research Fellows | 35
International Speakers & Chairpersons
Dr. Nawal AlMutawa , UAE
Consultant Endocrinologist , Al-Qassimi Hospital , Sharjah , UAE
Dr. Musab Mohammed Ali , SKSH , RAK , UAE
Dr. Hamdy El-Qawasmie , UAE
Dr. Ezzat Altaher , UAE
Consultant Pediatrician , Dibba , Al Fujairah
Dr. Ehab Esheiba ,UAE
MBBCh, DM, MSc (Cardiology), MRCP UK, FRCP Edin, GradDip HPE. Clinical Assistant Professor and Head of Cardiology Department. Gulf Medical College Hospital and Research Centre. Gulf Medical University
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International Speakers & Chairpersons
Dr. Hosam Zaki , UAE Consultant Cardiologist , Dubai Hospital, UAE
Dr. Yosra Alsalami , UAE
Ass. Medical Director , DIBBA Hospital
Dr. Virendra Kumar Misra , UAE
Consultant Cardiologist at Shaikh Khalifa Medical City , AbuDhabi, UAE
Prof. Dr.Marc Garret Cribbs, USA
Professor of Medicine and DIRECTOR OF ALABAMA ADULT CONGENITAL HEART DISEASE PROGRAM, ALABAMA UNIVERSITY -BIRMINGHAM , USA
Abdulmajeed Alzubaidi, UAE
Consultant Interventional Cardiologist & Medical Director of Shaikh Khalifa Medical City , AbuDhabi,UAE
Hayat Nassar , Egypt
Ass. Lecturer , Cairo University , Pediatric Cardiology
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Magnetic resonance imaging (MRI)- Option for early detection of atherosclerosis ? Jan Fedacko 1st Department ofInternalMedicine,Centre ofExcellencyforAtherosclerosisResearch Pavol Jozef SafarikUniversity and Louis PasteurUniversityHospital, Trieda SNP 1, 041 90 Kosice, Slovakia Despite advances in our understanding of the pathophysiology, pathogenesis, and new treatment modalities, the absence of an adequate non-invasive imaging tool for early detection limits both the prevention and treatment of patients with various degrees and anatomical localizations of athero thrombotic disease. An ideal clinical imaging modality for atherosclerotic vascular disease should be safe, inexpensive, non-invasive or minimally invasive, accurate, and reproducible, and the results should correlate with the extent of atherosclerotic disease and have high predictive values for future clinical events High-resolution magnetic resonance imaging (MRI) has emerged as the most promising technique for studying atherothrombotic disease in humans in vivo. Most importantly, MRI allows for the characterization of plaque composition, i.e. the discrimination of lipid core, fibrosis, calcification, and intraplaque haemorrhage deposits. Magnetic resonance imaging also allows for the detection of arterial thrombi and in defining thrombus age. Magnetic resonance imaging has been used to monitor plaque progression and regression in several animal models of atherosclerosis and in humans. Emerging MRI techniques capable of imaging biological processes, including inflammation, neovascularization, and mechanical forces, may aid in advancing our understanding of the atherothrombotic disease. Thus, MRI opens new strategies ranging from screening of high-risk patients for early detection and treatment as well as monitoring of the target lesions for pharmacological intervention. Identification of subclinical atherosclerosis and early treatment initiation has the potential to surpass conventional risk factor assessment and management in terms of overall impact on cardiovascular morbidity and mortality JanFedacko, MD, PhD. 1st Department ofInternalMedicine, Centre of Excellency for Atherosclerosis Research Pavol Jozef Safarik University and Louis Pasteur University Hospital, Trieda SNP 1, 041 90 Kosice, Slovakia tel. + 421 55 640 3869 fax: + 421 55 7996395 mobile: + 421 911 315 924 e-mail: janfedacko@hotmail.com, jan.fedacko@upjs.sk
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METABOLIC SYNDROME AND DIABETES MELLITUS: A DYSFUNCTION OF THE BRAIN J P Sharma, Ram B Singh, BanshiSaboo,KrasimiraHristova Halberg Hospital and Research Institute, Moradabad, India, Diabetes Care and Hormone Center, Ahamadabad, National University Heart Hospital, Sofia, Bulgaria. Background. Metabolic syndrome and type 2 diabetes have become major health problems in both developing and developed countries but their exact pathogenesis is not known. Method. Perspectives, rather than formal review, were derived from a structured literature search essentially based on selected key words, vide infra, using Medline, PubMed and other personal bibliographies. Results. Increased consumption of energy and physical inactivity in association with gene expression are common predisposing factors for obesity, metabolic syndrome and type 2 diabetes. These risk factors may interact with brain,s hypothalamus and vagus nerve in the pathogenesis of obesity which results in to metabolic syndrome and diabetes.. Increase in oxidative stress due to diet and lifestyle induced autonomic dysfunction and deficiency of w-3 fatty acid and flavanol in the tissues may damage the arcuate nucleus, pro-opiomelanocortin(POMC) neurons, insulin receptors and insulin like growth factors and neuropeptide- Y release in the brain causing there dysfunction. The role of liver and beta cells of the pancreas and their interactions with the hypothalamus, rotrolateralmedula and vagus nerve are important mechanisms to explain the behavioural factors in the pathogenesis of obesity and metabolic syndrome. It seems that a neuronal pathway consisting of the afferent vagus from the liver and efferent sympathetic nerves to adipose tissues and beta cells of pancreas, appear to be involved in the regulation of energy expenditure, systemic insulin sensitivity, glucose metabolism, and fat distribution between the liver and the peripheral tissues. In this mechanism, the liver conveys information regarding energy balance to the brain via the afferent vagus, whereas leptin could be a humoral signal to the brain from the adipocytes. The brain receives information from several tissues and organs via both humoral and neuronal pathways, which it integrates to produce an appropriate response; sympathetic nervous system activation and or parasympathetic modulation to maintain energy homeostasis. The role of w-6/w-3 fatty acids ratio on interactions of the liver-pancreas and the brain emphasizes on mind-body connection in the pathogenesis of obesity and related disorders; diabetes mellitus, metabolic syndrome and cardiovascular diseases. Treatment of neuropsychiatric diseases such as dementia, depression and aggression as well as type 2 diabetes mellitus and coronary atherosclerosis with Ď&#x2030;-3 fatty acid rich Mediterranean diet may be protective by their direct effect as well as by their influence on the autonomic function, hypothalamic and vagal connections; arcuate nucleus and POMC neurons. Conclusions. Liver and pancreas appear to interact via vagus nerve and hypothalamic connections; via arcuate nucleus and POMC neurons and other humoral mechanisms. These interactions can influence energy metabolism and food intake to maintain energy homeostasis which may have an independent effect on the development of metabolic syndrome and diabetes. Omega-3 fatty acids may also have an independent effect on liver-pancreatic beta cells and brain connections. Dr J P Sharma,MD,FICN Visiting Consultant Cardiologist Halberg Hospital and Research Institute, Civil Lines, Moradabad-10(UP) Email:â&#x20AC;?Dr. J.P Sharmaâ&#x20AC;?<gyandeep_seohara@yahoo.co.in,>rbs@tsimtsoum.net
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Aggressive management of diabetes mellitus and acute corononary syndrome Abdulla Shehab MD, UAE University Objective: 1. CV risk in patients with DM (and ACS) 2. Is CV risk modifiable in patient with DM? 3. More aggressive Rx for patients with DM? 4. Coronary revascularization 5. Antithrombotic therapies 6. Risk factor modification
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SINGHâ&#x20AC;&#x2122;S VERBAL AUTOPSY QUESTIONNAIRE FOR ASSESSMENT OF CAUSES OF DEATH, IN COUNTRIES WHERE AUTOPSY IS NOT POSSIBLE DUE TO RELIGIOUS CONSIDERATIONS. Divyank Sharma, J P Sharma, R B Singh; Jan Fedacko, Viola Vargova, Adarsh Kumar, Varun Mohan, Daniel Pella Halberg Hospital and Research Institute, Moradabad, India PJ Safaric University, Kosice, Slovakia; Government Medical College, Amritsar, Indiadkagr@creighton.edu Introduction:The exact causes of death in many countries, are not known because autopsy studies are difficult to conduct due to religious considerations. There are rapid changes in diet and lifestyle amongst social classes causing changes in the pattern of risk factors and mortality. In the present study, we attempt to develop a verbal autopsy questionnaire based on medical records and, interview of the family member, for assessment of causes of death, social class, tobacco consumption and dietary intakes among urban decedents in north India. Methods: For the period 1999-2001, we studied the randomly selected records of death of 2222 (1385 men and 837 women) decedents, aged 25-64 years, out of 3034 death records overall from the records at Municipal Corporation, Moradabad. Families of these decedents were contacted individually to find out the causes of death, by scientistadministered, informed-consented, verbal autopsy questionnaire, completed with the help of the spouse and local treating doctor practicing in the appropriate health care region. Clinical data and causes of death were assessed by a questionnaire based on available hospital records and a modified WHO verbal autopsy questionnaire. Dietary intakes of the dead individuals were estimated by finding out the food intake of the spouse from 3- day dietary diaries and by asking probing questions about differences in food intake by the decedents. Tobacco consumption of the victim was studied by a questionnaire administered to family members. Social classes were assessed by a questionnaire based on attributes of per capita income, occupation, education, housing and ownership of consumer luxury items in the household. The diagnoses of overweight and obesity were based on new WHO and International College of Nutrition criteria. Results. Cardiac diseases (23.4%, n=520) including coronary disease (10.0%), valvular heart disease (7.2%, n=160), diabetic heart disease (2.2%, n=49), sudden cardiac death and inflammatory cardiac disease, each (2.0%, n=44) were the most common causes of deaths as reported via modified verbal autopsy questionnaire. Brain diseases including stroke (7.8%, n=175) and inflammatory brain disease were reported among 1.9% (n=42) victims. Thus, NCDs (37.0%, n=651); circulatory diseases (31.2%, n=695) including stroke and cardiac diseases, and malignant neoplasms (5.8%, n=131) emerged as most common causes of death. Injury and accidents (14.0%, n=313) including fire, falls and poisonings were also common. Miscellaneous causes of death were observed among 8.5% (n=189) of victims. Pregnancy and perinatal causes (0.72%, n=15) were not commonly recorded in our study. Renal diseases (11.2%, n=250), pulmonary diseases (22.3%, n=495) and liver diseases (4.8%, n=107) were commonly recorded causes of death. It is clear that causes of death related to various body systems can be more accurately assessed by the modified verbal autopsy questionnaire. Circulatory diseases as the cause of mortality were significantly more common among higher social classes 1-3 than in lower social classes 4 and 5 who died more often, due to infections. Risk factors of deaths; coronary disease, stroke, hypertension, diabetes and obesity were significantly more common among higher social classes 1-3 and among victims with higher body mass index(BMI) compared to social class 4 and 5 who had lower BMI. Conclusions. This study indicates that causes of deaths, social classes, tobacco intake and dietary intakes, can be accurately assessed by a modified verbal autopsy questionnaire based on medical records and interview of the family members. Circulatory diseases, injury-accidents and malignant diseases have become the major causes of death in India, apart from infections. CORRESPONDENCE:DrDivyankSharma,MBBS (PG Scholar) Fellow, Halberg Hospital and Research Institute,
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Predictors of contrast induced nephropathy in diabetics Francesco Pelliccia MD, PhD, FESC, FACC, Interventional Cardiology Sapienza ‘University’ of Rome – IT Contrast induced nephropathy (CIN) is one of the major complications of procedures that foresee the use of contrast media and is associated with a poor long-term clinical outcome. In particular, in patients undergoing diagnostic and/ or therapeutic coronary angiography it has been shown to occur in up to 20–25%, especially in high-risk patients, who, due to the improvement in stent technology and antithrombotic therapies, represent a yearly growing proportion of patients revascularized percutaneously. The pathogenesis of CIN is the result of endothelial dysfunction, cellular toxicity from the contrast agent and tubular apoptosis resulting from hypoxic damage or reactive oxygen species. The use of contrast media superimposed acute vasoconstriction, caused by the release of adenosine and endothelin, with the reduction in renal blood flow to the outer medulla, consequent medullary hypoxia, ischemic injury and death of renal tubular cells. Hyperglycaemia leads to increased endothelin and angiotensin levels, causing intrarenal vasoconstriction; it also modifies the regulation of intrarenal blood flow increasing the medullary lactate level, reducing pH and oxygen delivery and increasing reactive oxygen species and oxidative stress. It is known that diabetes mellitus is an independent risk factor for CIN, as diabetes is an important predisposing factor for CIN, particularly in patients with renal functional impairment. Renal hypoxia, combined with the generation of reactive oxygen species, plays a central role in the pathogenesis of CIN, and the diabetic kidney is particularly susceptible to intensified hypoxic and oxidative stress following the administration of contrast media. The pathophysiology of this vulnerability is complex and involves various mechanisms, including a priori enhanced tubular transport activity, oxygen consumption, and the generation of reactive oxygen species. The regulation of vascular tone and peritubular blood flow may also be altered, particularly due to defective nitrovasodilation, enhanced endothelin production, and a particular hyperresponsiveness to adenosine-related vasoconstriction. A better understanding of these mechanisms and their control in the diabetic patient may initiate novel strategies in the prevention of contrast nephropathy in these susceptible patients.
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How to Prevent Periprocedural Myocadial Damage at time of PCI in Diabetics Francesco Pelliccia MD, PhD, FESC, FACC, Interventional Cardiology Sapienza â&#x20AC;&#x2DC;Universityâ&#x20AC;&#x2122; of Rome - IT Myocardial injury during coronary intervention occurs in 10-40% of diabetic cases and is often characterized by a slight increase in the markers of myocardial necrosis, without symptoms, electrocardiographic changes or impairment of cardiac function. However, even small increases in creatine kinase (CK)-MB levels are an expression of a true and detectable infarction and may be associated with a higher follow-up mortality, particularly in patients with diabetes. The cause of CK-MB elevation in case of procedural complications is obvious; however, most cases of minor CK-MB elevation occur in patients with uncomplicated procedures with excellent final angiographic results. It has been suggested that the main mechanism explaining the occurrence of myocardial necrosis during otherwise successful coronary intervention may be distal microembolization of plaque components, an enhanced inflammatory state or total plaque burden and/or instability. Different treatments have been proposed to prevent myocardial injury during coronary intervention in diabetes, including nitrate infusion, intracoronary beta-blockers, adenosine and IIb/IIa inhibitors, but most of these have not been routinely introduced into clinical practice. Previous observational studies suggested a beneficial effect of pre-treatment with statins in this setting; the ARMYDA (Atorvastatin for Reduction of Myocardial Damage During Angioplasty) trial is the first prospective, randomized, placebo-controlled study, evaluating the effects of 7-day therapy with 40 mg/day of atorvastatin on postprocedural release of markers of myocardial damage in patients with stable angina undergoing percutaneous intervention. In this study therapy with atorvastatin was associated with an 80% risk reduction in the occurrence of periprocedural myocardial infarction, as well as with a significant reduction in post-intervention peak levels of all markers of myocardial damage. Further investigations have shown that novel drugs might help to prevent myocardial injury at time of percutaneous coronary intervention in patients with diabetes, including clopidogrel, celecoxib and ranolazine. The mechanisms underlying the beneficial effects of the abovementioned drugs may be an inflammatory action reducing myocardial injury necrosis due to microembolization, an improvement in endothelial function on microcirculation, and direct myocardial protection.
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RECENT CLINICAL TRIALS OF PCSK9 INHIBITERS; EVOLOCUMAB AND ALIROCUMAB ON CARDIOVASCULAR EVENTS RB Singh, Jan Fedacko, GalalElkilany, KrasimiraHristova Halberg Hospital and Research Institute, Moradabad, India, PJ Safaric University, Kosice, Slovakia, National Heart Hospital, Sofia, Bulgaria Several randomized, controlled trials have been published in which efficacy and safety of PCSK9 inhibiters in reducing lipids has been established. Recently evolocumab and alirocumab which are leading PCSK9 inhibiters have been tried in multicenter studies to demonstrate their efficacy and safety and effect on cardiovascular events (1,2).In both trials using evolocumab and alirocumab, the investigators assessed adjudicated cardiovascular events; death, myocardial infarction, unstable angina, coronary revascularization, stroke, transient ischemic attack, and heart failure, as a prespecified exploratory analysis (1,2). In the evolocumab trials, which included two open-label, randomized trials, the authors enrolled 4465 patients, mean age 58 years, (1324 patients in OSLER-1 and 3141 patients in OSLER-2) who had completed 1 of 12 phase 2 or 3 studies (1). The eligible patients were randomly assigned in a 2:1 ratio to receive either evolocumab (140 mg every 2 weeks or 420 mg monthly) plus standard therapy or standard therapy alone. Of the 4465 patients, 2976 received evolocumab plus standard therapy and 1489 received standard therapy alone for a median duration of follow-up of 11.1 months. Results of the combined data from the these trials revealed that evolocumab significantly reduced the concentration of LDL cholesterol by 61%, from a median of 120 mg per deciliter to 48 mg per deciliter compared with standard therapy alone (P<0.001). The rate of cardiovascular events at 1 year was reduced from 2.18% in the standard-therapy group to 0.95% in the evolocumab group (hazard ratio in the evolocumab group, 0.47; 95% confidence interval, 0.28 to 0.78; P=0.003). Alirocumab is another monoclonal antibody that inhibits PCSK9 levels and has been demonstrated to decrease LDL cholesterol levels in patients who are receiving statin therapy (2). In this recent randomized trial involving 2341 high risk patients with LDL cholesterol levels of 70 mg per deciliter (1.8 mmol per liter) or more, patients were receiving treatment with statins at the maximum tolerated dose, with or without other hypolipidemic agent. Patients were randomly assigned in a 2:1 ratio to receive alirocumab (150 mg) or placebo as a 1-ml subcutaneous injection every 2 weeks for 78 weeks (3). After 24 weeks, the difference between the alirocumab and placebo groups in the mean percentage change from baseline in calculated LDL cholesterol level was â&#x2C6;&#x2019;62 percentage points (P<0.001). After 78 weeks, the rate of major cardiovascular events (death from nonfatal myocardial infarction, fatal or nonfatal ischemic stroke, or unstable angina requiring hospitalization was significantly lower with alirocumab than with placebo (1.7% vs. 3.3%; P=0.02). It is clear that treatment with alirocumab, when added to statin therapy at the maximum tolerated dose, can significantly reduce LDL cholesterol levels with a significant decline in the rate of cardiovascular events. The FOURIER study (NCT01764633) is an ongoing trial that is intended to provide a definitive assessment of the cardiovascular benefit of evolocumab. It is a randomized, placebo-controlled trial involving 27,500 high-risk patients with cardiovascular disease who are receiving background statin therapy; the primary end point is a composite of cardiovascular death, myocardial infarction, hospitalization for unstable angina, stroke, or coronary revascularization. Similar trials of alirocumab and bococizumab to evaluate cardiovascular outcomes are in progress (NCT01663402, NCT01975376, and NCT01975389). Correspondence Prof Dr Ram B Singh,MD,FICC Halberg Hospital and Research Institute, Civil Lines, Moradabad (UP)244001,India, rbs@tsimtsoum.net
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REFERENCES. 1.Sabatine MS, Guigliano RP, Wiviott SD and The Open-Label Study of Long-Term Evaluation against LDL Cholesterol (OSLER) Investigators.Efficacy and safety of evolocumab in reducing Lipids and cardiovascular events. N Engl J Med 2015; 372:1500-1509April 16, 2015DOI: 10.1056/NEJMoa1500858 2.Robinson JG, Farnier M, Krempf M, Bergeron J et al, for the ODYSSEY LONG TERM Investigators. Efficacy and safety of alirocumab in reducing lipids and cardiovascular events. N Engl J Med 2015; 372:1489-1499April 16, 2015DOI: 10.1056/ NEJMoa1501031 3.Stein, EA.Mellis S, Yancopoulos GD, Stahl N, Logan D, Smith WB, Lisbon E, Gutierrez M, Webb C, Wu R, Du Y, Kranz T, Gasparino E, Swergold GD. Effect of a monoclonal antibody to PCSK9 on LDL cholesterol. N. Engl. J. Med. 2012;366, 1108â&#x20AC;&#x201C;1118. 4.Roth EM, Taskinen MR, Ginsberg HN, et al. Monotherapy with the PCSK9 inhibitor alirocumab versus ezetimibe in patients with hypercholesterolemia: results of a 24 week, double-blind, randomized Phase 3 trial. Int J Cardiol. 2014;176:5561. 5.Saboo B, Singh RB, Fedacko J, Hristova K, Elkilany G, Istavan T, RaiM,Wilson DW. Proproteinconvertasesubtilisin/kexin type 9 (pcsk9) inhibitors. World Heart J 2015;7(in press) 6.Shehab A, Elkilany G, Singh RB, Hristova K, Chaves H, Cornelissen G, Otsuka K. Coronary risk factors in South West Asia. Editorial, World Heart J 2015; 7: (novapublishers.com, NY, USA) 7.Singh RB, Sharma JP, Rastogi,V et al. Prevalence of coronary artery diseases and coronary risk factors in rural and urban populations of north India. Euro Heart J 1997; 18: 1728-1735. 8. Pella D, Thomas N, Tomlinson B, Singh RB. Prevention of coronary artery disease: the South Asian paradox. Lancet 2003; 361:79-80.
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Epicardial Adipose Tissue, Obesity and Inflammation in Atherosclerosis Devendra K. Agrawal Professor, Director and Senior Associate Dean Center for Clinical & Translational Science Creighton University School of Medicine, Omaha, NE, USA dkagr@creighton.edu Objective: Epicardial adipose tissue (EAT), composed of adipocytes and inflammatory, stromal-vascular and nerve tissues, is present in close proximity to the adventitia of coronary arteries and the underlying myocardium. EAT functions as both endocrine organ and inflammatory tissue, secreting hormones, cytokines and chemokines, which can infiltrate from the EAT to induce vascular dysfunction and atherosclerotic diseases. We examined if obesity-induced inflammatory phenotype of epicardial fat is exacerbated by vitamin D deficiency leading to endothelial dysfunction and enhanced intimal hyperplasia and restenosis following coronary intervention. Methods: Yucatan microswine were fed with high fructose and high cholesterol diet. Complete blood count with differentials and metabolic panel were regularly run to examine lipid levels. Animals were subjected to angioplasty and intravascular stenting in atherosclerotic coronary arteries. Degree of coronarystenosis was examined by angiography and optimal coherence tomography (OCT) followed by histopathological and immunohistochemical examination of the EAT and excised coronary arteries to examine inflammatory cells, quantify intimal thickness, lumen area, intima-media ratio, plaque development, plaque ulceration and thrombosis. Vasodilation and vasoconstriction in the coronary arteries was examined in the presence and absence of attached epicardial adipose tissue. Results: Swine fed with high fructose high cholesterol diet developed obesity and many signs of metabolic syndrome. There were accelerated lesions in the coronary arteries following coronary intervention of the atherosclerotic coronary arteries with intimal hyperplasia and restenosis. In the EAT and coronary arteries, there was significant infiltration of CD68+ cells, minimal immunostaining to CD206, a marker for M2 macrophages, which was increased in the adipocytes of vitamin D-supplemented swine. The contractile response to serotoninwas much higher and vasodilatory response was lower in coronary arteries of atherosclerotic swine in the vitamin D-deficient group than in vitamin D-supplemented group. Vitamin D-deficiency was associated with increased infiltratory infiltrates and decreased SOCS3 expression in EAT. Conclusion: Thus, high fructose high cholesterol diet accelerates coronary artery lesions and develops inflammatory phenotype of EAT, which is enhanced by vitamin D deficiency. (Supported by NIH R01HL120659)
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Mortality trends in patients admitted with acute myocardial infarction managed with initial conservative strategy. Kashif Bin Naeem MRCP(UK), Dip Am Echo Board Purpose: Acute myocardial infarction (AMI) ia a common cause of mortality and morbidity worldwide. Although enough data exists to warrant early invasive strategy for these patients, hospitals without percutaneous coronary intervention (PCI) facility still manage these patients with initial conservative treatment. We analyzed the outcome of AMI patients presenting to our center without PCI facility that were treated with initial conservative strategy. Methods: A retrospective analysis of 125 consecutive patients admitted with AMI (Non-ST-elevation and ST-elevation MI) to our center was performed. All patients who fulfilled the criteria according to the Universal Definition of Myocardial Infarction were included. Patients who discharged against medical advice after admission were excluded. Data was analyzed for in-patient mortality, adverse events like heart failure, cardiogenic shock and cardiac arrest, and transfer to a PCI center for urgent revascularization. Results: A total of 125 patients were included. Eleven patients were excluded who self-discharged against medical advice. Of 114 patients, mean age was 51 years (range 27-93), 92% were male, 37% were diabetics and 42% were hypertensives. 56% were diagnosed as non-ST-elevation MI and 44% were diagnosed as ST-elevation MI. Initial treatment included aspirin (99%), clopidogrel (100%), beta-blockers (75%), ACE-inhibitors (77%), statins (93%), glycoprotein 2b3a inhibitors for high-risk non-STEMI (49%) and fibrinolysis with IV tenecteplase (40%) for STEMI patients. In-hospital mortality was 6.1%. 16 patients (14%) were transferred to the PCI center for urgent revascularization due to ongoing ischemia. 18% developed heart failure, 9.6% had cardiogenic shock, and 1.7% had cardiac arrest. 79.8% of patients were discharged home in a stable condition after conservative treatment. Conclusion: Although urgent revascularization remains the treatment of choice in patients with AMI, efficient initial medical treatment remains the cornerstone of management. The mortality in our center without PCI facility is comparable to the overall mortality in the region including PCI center (1). 1 Emad Ahmed et al, Cardiology Research and Practice. Vol 2014, article ID 464323, DOI 10.1155/2014/464323
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Gene Therapy to Prevent Restenosis Following Coronary Intervention Devendra K. Agrawal Professor, Director and Senior Associate Dean Center for Clinical & Translational Science Creighton University School of Medicine, Omaha, NE, USA dkagr@creighton.edu Objective: Neointimal hyperplasia and restenosis following interventional procedures, including percutaneous transluminal coronary balloon angioplasty and intravascular stenting, remain a significant clinical problem. Drug-eluting stents cause less intimal hyperplasia and less late luminal loss, but inhibit re-endothelialization of the stented segment making it more susceptible to thrombosis. Thus, there is trade-off between restenosis and late stent thrombosis requiring longer periods of anti-platelet therapy. Clearly, Clearly, an additional therapeutic approach would be useful to prevent intimal hyperplasia and provide long-term symptom-free control of coronary artery disease.Here, we report our novel findings on the effect of SOCS3 gene therapy. Methods: Yucatan microswine were fed with high cholesterol diet for 24 weeks. Serum lipids, complete metabolic panel and blood counts with differentials were regularly measured. Animals were subjected to angioplasty and intravascular stenting in atherosclerotic coronary arteries. The SOCS3 gene was delivered using pAAV2/9-SM22ď Ą-SOCS3-GFP vector (U Penn Vector Core Gene Therapy Program)locally to the site of interventional procedure. In the control group, pAAV2/9-SM22ď Ą-GFP vector was delivered. After 20-24 weeks, degree of coronarystenosis was examined by angiography and optimal coherence tomography (OCT) followed by histopathological examination of excised coronary arteries to quantify intimal thickness, lumen area, intima-media ratio, plaque development, plaque ulceration and thrombosis. Immunohistochemistry was performed for inflammatory markers in the coronary arteries. Complete blood profile and circulating inflammatory markers were evaluated to examine potential immunogenicity of the AAV vector. Results: Coronary intervention of the atherosclerotic coronary arteries initially increased the lumen area. However, 20-24 weeks later, there was significant amount of intimal hyperplasia and restenosis (60-80% area stenosis) following both angioplasty and intravascular stenting. TheSOCS3transgenesignificantly attenuated the development of intimal hyperplasia and restenosis (15-25% area stenosis) following angioplasty. Surprisingly, there was no effect of SOCS3 gene therapy in stented arteries.There was no significant difference in the values of WBCs, RBCs, Hb, Hct, MCV, MCH, MCHC, RDW and platelet count between the pre-coronary intervention and post-coronary intervention following AAV2/9 vector administration between any of the three experimental groups.There was no effect of AAV2/9 vector + SOCS3 on plasma fibrinogen, serum amylase and C-reactive protein. Conclusion: The AAV 2/9 vector + SOCS3 gene does not induce inflammatory or immune responses. The findings support the potential application of SOCS3 gene therapy in preventing intimal hyperplasia and restenosis of coronary arteries following angioplasty. (Supported by NIH R01HL104516)
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Novel Mechanisms Underlying Instability of Atherosclerotic Plaques in Carotid Artery Devendra K. Agrawal Professor, Director and Senior Associate Dean Center for Clinical & Translational Science Creighton University School of Medicine, Omaha, NE, USA dkagr@creighton.edu Atherosclerosis is a multi factorial chronic inflammatory disease resulting in development of atheroma and plaque. Thromboembolism may result from rupture of thin fibrous cap and subsequent ischemic stroke. The precise mechanism of plaque rupture remains to be defined. Triggering receptor expressed on myeloid cells-1 (TREM-1) expressed on immune cells amplify inflammation. Toll-like receptors (TLRs) induced by stimulation of pattern recognition receptors are involved in the pathogenesis of various cardiovascular diseases. However the role of TLR4 in the destabilization of carotid plaques in atherosclerosis remains unknown. The mRNA expression of TREM-1 and TLR4 by qPCRwas increased significantly in symptomatic compared to asymptomatic patients with carotid stenosis in both tissue extracts and isolated vascular smooth muscle cells (VSMCs). The immunofluorescence for TREM-1 and TLR4 was greater in tissue sections of plaques from symptomatic compared to asymptomatic patients, which confirmed our results of the qPCR. The mRNA transcripts for MMP1 and MMP9 were increased and that of collagen I and IIIwere decreased in VSMCs from symptomatic compared to asymptomatic patients with carotid stenosis. Inhibitors of NF-kB decreased the expression of TREM-1, TLR4 and MMP9 and increased mRNA transcripts of collagen type I and III in VSMCs of symptomatic compared to asymptomatic patients with carotid stenosis. These findings suggest the role of TREM-1 and TLR4 in the pathophysiology and stability of atheroma in carotid stenosis. Collectively, these data demonstrate that selective blockade of TLR4 and/or TREM-1 may contribute to the development of new therapies and promising targets for stabilizing atherosclerotic plaques. (Supported by NIH R01HL073349)
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USA : Molecular Imaging â&#x20AC;&#x201C;Imaging of Vulnerable Atherosclerotic Plaque Devendra K. Agrawal Professor, Director and Senior Associate Dean Center for Clinical & Translational Science Creighton University School of Medicine, Omaha, NE, USA dkagr@creighton.edu Atherosclerotic plaque rupture is a crucial factor in the development of myocardial infarction and stroke. It is, therefore, critical to identify and image vulnerable atherosclerotic plaques. Indeed, chronic inflammation plays a key role both in the development of atherosclerosis and plaque instability. In this presentation, the images of the atherosclerotic vulnerable plaques taken by optimal coherence tomography and 4D-ECHO will be presented both in coronary and carotid arteries of atherosclerotic swine. The findings suggest the high predictability detecting instability of atherosclerotic plaques using of non-invasive 4D-ECHO. The data from the ECHO and optimal coherence tomography correlated well with the histology of the carotid and coronary arteries. (Supported by NIH R01HL112597)
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Predictors Of Left Ventricular Systolic Dysfunction In Patients With First Acute St-Segment Elevation Myocardial Infarction Undergoing Primary Angioplasty Wael Sayed - Mohamed Aljarallah - Ahmed Taha - Asem Abdulla - Aymen Gaballa Sabah Al-Ahmed Cardiac Center, Kuwait Presentation Type Poster Presentation Title PREDICTORS OF LEFT VENTRICULAR SYSTOLIC DYSFUNCTION IN PATIENTS WITH FIRST ACUTE ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION UNDERGOING PRIMARY ANGIOPLASTY Author Dr. Wael Sayed Email address dr.waelmrcp@yahoo.com Mobile 0096550931305 Abstract PREDICTORS OF LEFT VENTRICULAR SYSTOLIC DYSFUNCTION IN PATIENTS WITH FIRST ACUTE ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION UNDERGOING PRIMARY ANGIOPLASTY Wael Sayed1. Mohamed Aljarallah1. Ahmed Taha1. Asem Abdulla1. Aymen Gaballa1. 1Sabah Al-Ahmed Cardiac Center, Kuwait BACKGROUND The degree of left ventricular systolic dysfunction (LVSD) determines the prognostic outcome of STEMI. OBJECTIVE To define different variables related to LVSD in patients with first STEMI referred for primary PCI. METHODS The sample included 288 patients from January 2013 till December 2014. Demographic, clinical, laboratory and angiographic data were collected prospectively into a computerized registry. Patients were divided into four groups by degree of LV systolic function (normal, mild, moderate, severe) and compared for different variables. RESULTS LVSD was associated more with females (p=0.029), anterior STEMI (p=0.004), longer symptom to door time, longer door to balloon time, more than Killip class II on presentation (0.001), extend of CAD (p=0.021), and high peak creatine kinase. There were no significant correlations between LVSD and age, DM, hypertension, dyslipidemia, technique of PCI or use of aspiration device. On bivariate analysis, symptom to door time (r=-0.312, P<0.001), door to balloon time (r=-0.327, P<0.001) and peak creatine kinase (r=-0.202, P=0.003) were the most significant independent predictors of LVSD. Patients with LVSD had higher in-hospital mortality (p=0.001). CONCLUSION LVSD after first STEMI can be predicted by female gender, anterior STEMI, Killip class on presentation, symptom to door time, door to balloon time and the size of infarction assessed by peak creatine kinase. Patients with LVSD had higher in-hospital mortality.
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POOR NUTRITION IN FETUS AND LOW BIRTH WEIGHT AS RISK FACTOR OF CVDS AND TYPE 2 DIABETES IN ADULT LIFE NS Verma, Poonam Singh, Rajesh Singh, RB Singh Teerthankar Mahaveer University, Halberg Hospital and research Institute, Moradabad,India Background. Mothers eating an unhealthy diet during pregnancy may be putting their children at risk of developing long term, irreversible health issues including obesity, greater levels of cholesterol and blood sugar in adult life. The Tromsa heart study proposed that poor social conditions in childhood may be risk factor of obesity, diabetes and cardiovascular diseases(CVDs) in later life. Further evidence indicate that gestational obesity and diabetes may be associated with obesity in babies leading CVDs and diabetes in later life. Thus, both; undernutrition as well as overnutrition among mothers may have adverse effects on health of off-springs. The present review highlights the available evidence. Methods. Internet search and discussion with colleague. Results: Approximately 25 years ago, David Barker proposed that fetus and infant size were determinants of adult health. ‘Barker’s hypothesis’ was based on the correlation of measurements of the weights of babies at birth as an index of fetal health and intrauterine growth. He also considered growth in infancy at 1 year and morbidity; CVDs, hypertension, stroke, diabetes and hyperlipidaemia and mortality in later life. There is evidence that low birth weight is related to increased risk of coronary artery disease (CAD) in adults and recently has been associated with vascular endothelial dysfunction in children as well as in young adults. This is most marked in individuals with lower risk factor profiles and may be relevant to the pathogenesis of atherosclerosis in later life. Low birth weight has been related to mortality from CAD and to the development of hypertension and diabetes. These associations may be due to an effect of prenatal growth directly on the pathogenesis of early atherosclerosis, by “programming” the development of risk factors or due to altered “stability” of established atherosclerotic lesions. Vascular endothelial dysfunction is important in the development of all the CVDs associated with early growth. Endothelial dysfunction is a risk factor for atherosclerosis. The prenatal factors related to poor nutrition may have a direct effect on the vascular wall that is relevant to atherogenesis from remarkably early in life. Recent studies have shown that there is a relation between birth weight and endothelium-dependent flow-mediated dilation (FMD) in children in the first decade of life before the acquisition of a significant risk factor burden. The effect of prenatal influences and classic postnatal risk factors and their interaction on vascular function remains unclear but may due to epigenetic inheritance. Epigenetic damage due to prenatal influences could act to amplify the effects of classic risk factors in adults, similar to the interaction between raised cholesterol level with smoking, or increased susceptibility in their presence. It seems that “Developmental programming” also referred to as “fetal origins of adult disease” or the “Barker Hypothesis”, which is the basis for the observation is based on nutritional maladaptation by which low birth weight is not only associated with immediate morbidities for the neonate but also leads to later risk for adult diseases. There may be critical time periods during fetal and postnatal development, when an individual is sensitive to environmental stressors, which become worst due to poor nutritional status of the fetus. Alteration to an individual’s metabolism related to conservation during the early periods of “plasticity”, can remain permanent. The adaptations that occur during critical periods of fetal and postnatal development promote survival in an inadequate environment (ie, poor nutrition or growth restriction) due to a thrifty genotype. However, these subjects, later-in-life, on exposure to nutritional abundance and growth can cause metabolic disturbances that promote the development of diseases such as hypertension, obesity, and diabetes.
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Other hypothesis for the associations between in utero exposures and adult disease is that there are shared genetic risk factors and interactions with epigenetic markers such as methylation of DNA, that impact both early and laterlife outcomes. It is also supported by the â&#x20AC;&#x153;fetal insulin hypothesisâ&#x20AC;?, which posits that the same genetic factors that predispose to decreased fetal insulin secretion in utero may also affect insulin resistance in adulthood. It is possible that the intrauterine milieu influences the development of the fetus as well as also the reproductive fitness of that fetus such that subsequent generations may continue to be affected. In experiments, female rodents fed a low protein diet give birth to offspring with low birth weight, reduced insulin sensitivity, and high cholesterol. These females also give birth to offspring with metabolic conditions, despite being fed a normal diet which acts as unhealthy diet for them. It seems that metabolic conditions in the generation indicates that even in the absence of the original environmental stressor (poor nutrition), these offspring remain susceptible to metabolic conditions through transgenerational epigenetic inheritance. Conclusion. Malnutrition during pregnancy can influence the current as well future health of the fetus resulting in to greater susceptibility to CVDs and type 2 diabetes in later adult life. It is possible that maladaptation, thrifty genotype and epigenetic inheritance are important mechanisms for the transmission of chronic diseases between generations that are inherited to the subsequent generations.
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University of Russia, Moscow PHYSIOLOGICAL LIMITS OF CORONARY RISK FACTORS AMONG STUDENTS FROM THE FIVE CONTINENTS Sergey Shastun People,s Friendship University of Russia, Moscow, Russia. Author :Dr Sergey Shastun,MD Department of Normal Physiology, People,s Friendship University of Russia, Coronary risk factors (CRF) and coronary artery disease have become a worldwide problem. Major CRFs are hypercholesterolemia, type 2 diabetes mellitus, tobacco intake and hypertension but the pathological limits of blood cholesterol, blood pressures and blood glucose are poorly understood. The physiological limits of these risk factors are also not very well defined, although, these are much lower than desirable limits of these risk factors. We have studied student volunteers from the five continents which indicate that these risk factors are significantly higher in European, South Asian and American students compared to students from Africa.
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CV Risk factors in Moscow students from various climatic/geographical regions. Ram Bahadur Singh, Hugo Chaves, Peter Nyurango, Jacobs Sheehama, Sergey Shastun, Rajesh Agarval, Leonid Tell Halberg Hospital and Research Institute, Civil Lines, Opp. Wilsonia College, Moradabad10(UP)244001,India
Chair of 8th ICCD, Recife NamibiaUNAM SoMBrazil aug 13-15,2015 Founding Dean School of Medicine Deputy Associate Dean
NamibiaUNAM SoMFounding Dean School of Medicine Deputy Associate Dean
Russian Peoples’ Friendship University
Russian Peoples’ Friendship University
Beybetshilik 000010 Astana 49 Astana Medical
Keywords:Cardiovascular risk factors; Ethnicity;coronary heart disease (CHD) risk factor; Stress Index (SI);(TC); TRG; HDL; Glucose; BMI;climatic and geographical regions. Background.In today’s world, young people must become a powerful force on the world stage, determines the prospects of world civilization. Modern education in medical school places high demands on the students, including the state of their health. Premorbid control system and strengthening physical health and functional reserves of cardiovascular system of the body of students from different climatic regions is very urgent health problem. At the same time the movement of the climate regions of contrasting places special demands on the body of students. Of particular relevance to this problem gets Peoples’ Friendship University students who came to study in Moscow from more than 153 countries in Asia, Africa and Latin America. Coronary heart disease (CHD) risk in young adults aged 18–24 y is underestimated despite the high prevalence of CHD risk factors (Burke JD, Reilly RA, Morrell JS, Lofgren IE. The University of New Hampshire’s Young Adult Health Risk Screening Initiative. J Am Diet Assoc. 2009;109:1751–8.) and early signs of atherosclerosis in this age group. Despite the considerable number of works devoted to the study of risk factors for heart disease at a young age, working, studying ethnic characteristics risk of cardiovascular disease at a young age are rare(AdvNutr, March; vol. 5: P. 177-187, 2014). Our research was undertaken to expand our understanding of the factors associated with racial/ethnic disparities in cardiovascular disease (CVD) risk factors (Stress Index (SI), hypercholesterolemia (TC), TRG, HDL, Glucose, BMI etc.), to assess the potential differences in the CVD risk factors by race/ethnicity, and to update and complement the existing data on the ethnic peculiarities of the risk of cardiovascular disease. Early detection is critical to identify individuals at risk. This fact allows for a causal preventive treatment under understanding CVD risk and race/ethnicity that blocks the progression of coronary heart disease (CHD). Objective. Identify markers (predictors) the risk of cardiovascular diseases among Russian of Friendship of Peoples University (PFU) students of different ethnic groups, who arrived for the study of different climatic / geographic regions of our planet. Materials and Methods:The study was composed of four groups of students’ first and second year education: (from: Africa, Latin America, South Еast Asia and Residents of Moscow).There were examined 87 healthy volunteers of the 1st and 2nd year of study malesDuring Summer Time.. The basic parameters of cardiovascular system were investigated with method of variability of heart rate (HRV). Determination of basic biochemical parameters of lipid and carbohydrate metabolism was carried out using biochemical analyzer Cholestec, USA. Register the following medical indications: SI - StressIndex (SI= АМо/2*Мо*MxDMn) BMI = Body Mass Index (BMI=(weight in kilograms/height in meters2). The Spectral Asymmetry T-wave (βt).Fazagraf.Сarries an additional diagnostic value (Fainzilberg L.S., 1996). Statistical processing of received material was carried out by a computer program:STATISTICA (Stat Soft Inc., US). Results.Main results of investigations are presented with the table №1. Table № 1.CV Risk factors in Moscow students from various climatic/geographical regions.
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From the data presented in Table No. 1 shows that in the entire surveyed group have a functional stress the cardiovascular system of varying severity. SI values and βt are substantially higher than the physiological norm. These facts, together with the presence of varying degrees of severity dislipoproteidemias indicate the presence of risk factors for cardiovascular diseases in the surveyed groups. Conclusions:The most significant predictive value to identify risk factors for cardiovascular disease among surveyed ethnic groups of students have indicators such as the value of the SI and βt, and various kinds of dislipoprteidemy. The risks of developing heart disease vary across different ethnic groups, according to our new research presented at 8th ICCD Recife, Brazil, 13-15, August 2015. Africans students have the highest CV risk across all all races and ethnic groups in our research. Ethnicity should be incorporated into CVD assessment. Ethnic-specific CVD prevention and treatment strategies need to be further developed. Diseases of the heart are the No. 1 killer around the world, and stroke is the No. 1 killer. We are strongly believes that learning more about these diseases is the best way to reduce disability and death. That’s why our research is an association-wide priority 57
Cardiovascular Diseases: Dietary Composition and Kinetics Toru Takahashi, Miki Tokunaga, Ram B. Singh, Fabien De Meester, Douglas W Wilson Department of Nutrition School of Nutrition & 3Internal Medicine, and Health Science, Dietetics, Kanagawa Halberg Hospital and Fukuoka Womenâ&#x20AC;&#x2122;s University of Human Research Institute, India University, Japan Services, Japan
Tsim Tsoum Institute, Krakow, Poland
Hon. Senior Fellow, School of Medicine, Pharmacy and Health, Durham University, UK
Cardiovascular diseases (CVDs) are either positively or negatively associated with common salt, carotenoids, flavonoids, fibers, and n-3 fatty acids in diets in multifarious ways based on epidemiological evidence. For example, the n-6/n-3 fatty acids ratio was 1-2:1 in Greece prior to 1960. However, the n-6/n-3 fatty acids ratio has been increased to 20-25:1 in modern Eastern Europe, which is obviously too high. We need to substitute n-6 with the beneficial n-3 fatty acids to change the incidence of CVDs. However, most of vegetable oils mainly consist of n-6 fatty acids. Only flaxseed and perilla oils in vegetable oils mainly consist of n-3 fatty acids. Flaxseed oil includes more than 40% of n-3 fatty acids. Perilla oil includes more than 60% of n-3 fatty acids. In Japan, consumption of perilla oil is increasing rapidly. Conjugated linoleic acid also decreases the risk of CVDs. Conjugated linoleic acid is present in milk, milk products, and beef oils. Questionable is the discrimination between vegetable and animal oils which does not make sense in expressing relationships between fats and CVDs. This year, guidelines on the intake of cholesterol in the US and Japan has changed. For people with CVDs cholesterol intake affects their symptoms. However, for people without CVDs the upper limitation of cholesterol intake has been eliminated at long last, because evidence of risk of dietary cholesterol on CVDs is obscure. These are also indirect effects of diets. High hemoglobin A1c (HbA1c) levels are strongly associated with an increased risk of CVDs in people with and without diabetes. Controlling blood glucose levels would affect the incidence rate of CVDs. Blood glucose levels in postprandial period can be controlled by diets. For example, both viscous substrates and particulate matter in diets reduce postprandial blood glucose levels. Blood glucose is also affected by a) particles which are indigestible and b) insoluble substances in diets such as fibers, resistance protein, and droplets of oil. Particles and viscous substrates in diets reduced diffusion of water in the lumen of the intestine leading to decreased diffusion of glucose in the lumen, which induce a lower absorption rate of glucose and lower postprandial blood glucose levels. The contribution of particles on controlling blood glucose is not discussed in this presentation. However, the impact of particles on blood glucose levels would be larger than that of viscous substrates. This presentation will review dietary factors associated with CVDs particularly the dietary exposure arising from dietary rat models carried out in our laboratories in Japan, and their potential influence on CVDs.
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Systolic and diastolic dysfunction in patients with diabetes without known heart disease Vito Maurizio Parato Politecnica delle Marche University, San Benedetto del Tronto, Ascoli, Italy Epidemiologic studies have shown that patients with diabetes mellitus have a two to four folds increased risk of cardiovascular mortality. With regard to heart failure, the Framingham study revealed that the risk for congestive heart failure is greatly increased in patients with diabetes, and this is independent of underlying coronary artery disease and other cardiovascular risk factors. Moreover, numerous reports have identified LV diastolic dysfunction using echocardiography as a major early feature of myocardial damage in patients with diabetes .Indeed, diastolic parameters are related to prognosis in diabetic patients without overt heart disease. Although the exact causes of LV myocardial damage in patients with diabetes (so called diabetic cardiomyopathy) remain unclear, several factors such as a metabolic abnormality, autonomic dysfunction, myocardial fibrosis and reduced perfusion due to small vessel disease, have been reported as potential mechanisms of myocardial damage in diabetic patients. Recently, a new paradigm for heart failure with preserved ejection fraction has been proposed; a systemic pro inflammatory state due to diabetes and comorbidities causes coronary microvascular endothelial inflammation, and this reduces nitric oxide bioavailability, cyclic guanosine monophosphate content, and protein kinase G activity in adjacent cardiomyocytes. Furthermore, low proteinkinase G activity favors muscle fiber hypertrophy development and increases resting tension because of hypophosphorylation of titin, and both stiff cardiomyocytes and interstitial fibrosis contribute to the development of high diastolic LV stiffness and heart failure. This novel paradigm supports our findings, and the measurement of CFR by echocardiography may be a non invasive practical tool to assess coronary endothelial function in the clinical setting.
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Imaging in the diabetic patient: Strain and Strain Rate Imaging Vito Maurizio Parato Politecnica delle Marche University, San Benedetto del Tronto, Ascoli,Italy Left ventricular (LV) circumferential strain (εCC) and longitudinal strain (εLL), assessed by Speckle Tracking Echocardiography (STE), are indices of systolic function: shortening is indicated by negative strain, and thus, the more negative the strain, the better the LV systolic function. They have been used to demonstrate subclinical ventricular dysfunction in several clinical disorders. MetabolicSyndrome (MetSyn) ischaracterized by a cluster of cardiovascular (CV) riskfactorsincludingatherogenicdyslipidemia, abdominalobesity, hyperglycemia, elevatedblood pressure, and proinflammatory and prothrombotic state.Itaffectsabout 25% of the population, beingassociated with an increasedrisk of developingdiabetes, CV morbidity and mortality. Previous studies using carotid intima-media thicknessmeasured with ultrasound, coronary artery calcium, Teiindex, and tissue Doppler have shown the presence of subclinical CV disease (CVD) in participants with MetSyn. Recently, speckle tracking echocardiography (STE) has been introduced as a new non-invasive method for assessing left ventricular (LV) myocardial shortening or strain. The method is angle-independent, does not require contrast agents, and has been validated against sono micrometry and magnetic resonance imaging (MRI).It has been used to demonstrate subclinical ventricular dysfunction in various clinical disorders such as diabetes . Subclinical CVD has been demonstrated in subjects with MetSyn and type 1 diabetes. Gong et al. have used tissue Doppler to analyzeεLL in Chinese participants with MetSyn. In African-American and Caucasian participants, they have demonstrated that mean systolic εLLwas lower in participants with MetSynthan in controls. In a study published by Cerqueira de Almeida AL (Arq Bras Cardiol, 2014 apr; 102(4):327), using STE analysis, longitudinal as well as circumferential myocardial functions were reduced, as indicated by lowerεLL and εCC in participants with MetSynas compared with those without MetSyn. As MetSynis more prevalent in African-Americans and Caucasians than in the Chinese population, a more general
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3D echo in the assessment of atrial septal pouch: Implications in occurrence of stroke Navin C Nanda President of ISCU , USA An atrial septal pouch results from incomplete fusion of the septum primum and the septum secundum and depending on the site of fusion the pouch can be left sided or right sided . The incremental value provided by live/real time three-dimensional transesophageal echocardiography over the two-dimensional technique include detection of atrial septal pouches not found by two-dimensional transesophageal echiocardiography, detection of two pouches in the same patient and larger pouch measurements of size because the atrial septal pouch can be observed en face. Additionally, the volume of the atrial septal pouch and of thrombi present in the pouch can be computed by three-dimensional echocardiography which is a superior parameter of characterizing size as compared to individual dimensions. The thrombi contained in left sided atrial septal pouches have been known to cause embolic strokes. Hence it is important to diagnose them by echocardiography. Most of them are found by transesophageal echocardiography..
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STATINS AND DIABETES Osama Sanad Benha University , Egypt Intensive-dose statin therapy has been shown to reduce cardiovascular risk more than low dose therapy, thus supporting more aggressive treatment of LDL-C in higher-risk patients specially diabetics. A large meta-analysis published in 2010, included 91,140 participants in 13 major statin trials stated that new onset diabetes occurred in 2,226 (4.89%) of the statin recipients and in 2,052 (4.5%) of the placebo recipients, an absolute difference of 0.39%, or 9% more (odds ratio [OR] 1.09; 95% confidence interval [CI] 1.02â&#x20AC;&#x201C;1.17. Rosuvastatin trials were statistically significant in favor of a higher diabetes risk . Nonsignificant trends were noted for atorvastatin and simvastatin trials. Less so for pravastatin and for lovastatin. No clear difference between lipophilic statins and hydrophilic statins . This may suggest that there is a stronger effect with more potent statins or with greater lowering of LDL-C. Metaregression analysis in this study demonstrated that diabetes risk with statins was higher in older patients , not influenced by body mass index and not influenced by the level that LDL-C was lowered. Some but not all statins increase insulin levels and decrease insulin sensitivity in a dose-dependent fashion. Some statins decrease adiponectin and may worsen glycemic control through loss of adiponectinâ&#x20AC;&#x2122;s proposed protective antiproliferative and antiangiogenic properties We need to interpret this informaton cautiously. Many potentially confounding factors are involved, and rigorous prospective trials are needed to examine this issue. The benefit of preventing serious cardiovascular events seems to outweigh the higher risks of diabetes and poorer glycemic control, and we should continue to give statins to patients at moderate to high risk, including those with diabetes, with vigilance for these side effects.
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Latest Advances in the Assessment of Right Ventricular Function Bernhard Mumm TomTec Imaging Systems, Munich, Germany Introduction: The clinical impact of the Right Ventricle (RV) has gained a growing awareness in hypertension, congestive heart failure, cardiomyopathy and congenital heart disease. Two-dimensional Echocardiography has several limitations to assess right ventricular shape and function. As the RV has a very complex shape (crescentic, heavy trabeculated) with its separate inflow and outflow portions, 2D methods are not well suited for assessing RV function. Therefore, cardiac MRI has been the gold standard for a three-dimensional evaluation of the RV. Meanwhile 3D Echo can match the quantification accuracy of MRI for the assessment of right ventricular function in children and adults. Methods: New 3D Echocardiography techniques allow a quantitative evaluation of complex structures like the RV. Recently, a simplified 3D speckle tracking method (TomTec 4D RV Function 2.0) has been developed, requiring minimal operator input for the RV segmentation. This analysis tool allows an easy, fast, accurate and reproducible functional analysis of the RV based on transthoracic or transesophageal 3D Echo data. It provides a comprehensive evaluation of the RV including chamber volumes and function and RV longitudinal strain of the RV free wall and septum. Standard 2D geometry measurements of the RV (TAPSE and FAC) are automatically derived in addition to the 3D measurements out of the 3D Echo data. Conclusion: This 3D Echo based RV quantification compares well with cardiac MRI and is a cost saving alternative to MRI.
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Is Latent Diabetes Mellitus a factor in the Development of Precocious Coronary Artery Disease in South East Asians? Navin C. Nanda President of ISCU , USA Myocardial infarction and other signs and symptoms of coronary artery disease develop at least a decade earlier in south east Asians as compared to their western counterparts. It is not unusual to see patients from India and surrounding countries presenting with typical myocardial infarction in their twenties and early thirties. In addition, the prevalence of coronary artery disease is much more common in this population as compared to the West. Both of these findings in South East Asians are well documented. Genetic predisposition superimposed on life style factors is likely the reason for this precocious development of coronary artery disease. Previous studies done as far back as 1967 have shown development of hyperglycemia immediately following acute myocardial infarction to be very common in this group of patients. This resolves spontaneously in a few weeks but some go on to develop overt diabetes mellitus which was not present prior to myocardial infarction. It is possible that these patients already had latent diabetes which was unmasked by the stress caused by myocardial infarction.
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Speckle Tracking Echocardiography Navin C. Nanda President of ISCU , USA Traditionally, left ventricular (LV) systolic function has been evaluated echocardiographically by assessing inward motion of the ventricular walls during systole and estimating the ejection fraction. With the advent of Doppler echocardiography, mitral inflow velocities were used to gain an understanding of LV diastolic function. Subsequently, with the realization that the LV also shortened longitudinally with the base moving towards the apex in systole an attempt was made to study this motion using Doppler by filtering out high frequency signals from blood components and retaining only high amplitude waves from wall motion (tissue Doppler imaging). However, for accurate estimation of longitudinal motion by this technique, the ultrasonic beam needs to be kept parallel to wall motion with the Doppler intercept angle close to zero. This becomes a challenge with the LV walls moving in and out of the ultrasound beam throughout the cardiac cycle. Also, a hypokinetic segment may go undetected because the adjacent normally moving segment may pull it with it, the so-called tethering effect. Because of this, attention has focused on using two-dimensional echocardiography, which does not have the angle insonation problem of Doppler, to derive various markers of segmental and global muscle deformation, in particular thickening and shortening parameters. The two-dimensional technique called speckle tracking echocardiography (2D STE) is based on the premise that the equipment can follow small groups of myocardial pixels called speckles (produced by the interaction of the ultrasonic beam with the myocardium) because each group has a unique ultrasonic signature enabling it to be tracked throughout the cardiac cycle. A potential problem does exist with this modality. Because each twodimensional image represents only a thin slice through the LV, it is easy for the group of speckles (called kernels) to move out of the examining plane and in some instances the equipment may be tracking a similar but not the same group of pixels during the cardiac cycle, this could introduce errors in measurements. A potential solution is using three-dimensional echocardiography (3DE) which provides a large pyramidal shaped section of the heart increasing the chances of interrogating the same group of speckles throughout the cardiac cycle. Comparing to 2D STE data to a variety of modalities has allowed for validation of the technique. This has included validation by comparison with tissue Doppler imaging, hemodynamics, tagged magnetic resonance imaging, and sonomicrometry studies.1,2,3 The intra- and inter-observer reproducibility of STE is superior to tissue Doppler but it is still not in the ideal range and there are highly significant inter-vendor differences. Despite these limitations, the technique has been found useful in assessing various parameters of LV segmental and global function in a variety of clinical scenarios.
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Prosthetic valve malfunction and infective endocarditis: The Role of Echocardiography Mohamed Ayman Abdelhai Professor of Cardiology , Alexandria University A large variety of prosthetic valves have been developed with the aim of improving hemodynamic function, increasing durability, and reducing complications. Nevertheless, there is no ideal valve, and all prosthetic valves are prone to dysfunction. Different types of prosthesis have been developed including the mechanical valves (bileaflet, tilting disc and caged ball), biological valves (stented and stentless) and lastly the percutanous valves. Essential parameters in the comprehensive evaluation of prosthetic valve function include:clinical information as (date of valve replacement, type and size of the prosthetic valve, height, weight, body surface area, symptoms and related clinical findings) hand in hand with valve imaging by transthoracic echocardiographyexamination (TTE) shortly after surgery. This should include 2Decho, Doppler data and color Doppler flow. Echocardiographic assessment should be comprehensive covering the following Doppler parameters;Peak early velocity, mean gradient;heart rate at the time of Doppler examination , pressure half-time, DVI and estimation of the EOA ( by continuity equation) . The added value of transoesophgeal echocardiography(TEE) is to detect prosthesis related complications like vegetations, thrombus, pannus and perivalvular regurgitation. TEE can overcome the problem of masking and shadowing artifact induced be the prosthesis. TEE is also superior in the detection, localizationand assessment of prosthetic regurgitation. 3D TEE has improved visualization and assessment of prosthetic valves as well as their associated complications, such as endocarditis and paravalvular regurgitation.
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New Quantitative Methods in 2D and 3D Ultrasound Bernhard Mumm TomTec Imaging Systems, Munich, Germany 2D Echo is the primary screening tool in cardiac imaging. It is easy to use, small, mobile and cost efficient. It provides a high temporal resolution. Three-dimensional echocardiography (3DE) has been developed during the last 15 to 20 years. Within the last 10 years its clinical value has been proven in many publications around the world. The technological improvements in computer speed, transducer technology and the integration into the ultrasound systems have significantly increased the clinical role of 2D/3D Echo. Started mainly as a qualitative technology, 3DE more and more became a precise quantitative tool. Meanwhile 3DE can match the quantification accuracy of MRI and CT. Methods: New quantitative 2D and 3D techniques allow for a better quantitative evaluation of cardiac structures and function e.g. of heart chambers like the left or right ventricle (LV, RV) as well as valvular structures. Such analysis tools feature advanced automatic contour detection and tracking algorithms for an easy, fast, accurate and highly reproducible global and regional functional analysis of e.g. the left and right ventricle based on 2D or 3D Echo. New speckle tracking methods are used for Myocardial Deformation Imaging and strain assessment of the myocardial muscle. Conclusion: New quantitative 2D and 3D Echocardiography techniques allow a better qualitative and quantitative evaluation of cardiac structures and function.
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Basic aspects of 2D and 3D strain imaging Navin C. Nanda M.D., DSc (Med) (Hon), DSc (Hon) FACC, FAHA, FISCU (D) Basically, strain means deformation, As far as the myocardium is concerned, it means shortening of cardiac muscle best seen in LV short axis (radial strain) and apical four chamber views (transversal strain). Since the muscle increases in thickness during systole as compared to diastole, it is designated by a positive (+) sign and the radial/transversal strain curve is plotted above the baseline. During systole, the LV also shortens in long axis with the base predominantly moving towards the apex (longitudinal strain) and since there is a decrease in longitudinal length, it is denoted by a negative (-) sign and the curve is plotted below the base line. In LV short axis, the circumferential length also decreases in systole (circumferential strain) and therefore is also given a negative (-) sign and is depicted below the baseline in graphical representation. A combination of longitudinal and circumferential strain is available only with 3-dimensional imaging and is called area strain. Strain rate represents the rate of myocardial thickening, shortening or decrease in circumference. Assessment of global longitudinal strain is generally found most useful in clinical practice but is hampered by intervendor differences and less than optimal reproducibility. Currently, the above parameters are most commonly measured by speckle tracking imaging (traditional method or velocity vector imaging). Approximate normal values, some of which are not fully established yet are given in Table 1 below.
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CMR and cardiomyopathies. What is the general cardiologist should know Nikolaos Tzemos Greece , Cleveland clinic UAE Cardiac myopathies affect a significant portion of patients with heart failure. Given the impact of these disease to younger population there is the need to accurately diagnose and therefore tailor individual and disease specific treatment to these cardiomyopathies. In the last 5 years several advances in technology has brought refinement to the cardiac imaging techniques. One of the most promising is cardiac CMR. The combination of various sequences during cardiac imaging not only defines better cardiac anatomy but also provides much needed tissue characterization. The latter leads to better risk stratification and improved outcome. The discussion will focus onto hypertrophic cardiomyopathies, arrhythmogenic right ventricular cardiomyopathy and LV non compaction.
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Echocardiography and preoperative assessment of mitral valve disease - focus on real time 3D TEE Nikolaos Tzemos Greece , Cleveland clinic UAE Transthoracic echocardiography (TTE) remains the primary diagnostic modality for evaluation of mitral disease. In the recent years, transesophageal echocardiography (TEE) has become also an important adjunct in selected patients when more detailed visualization of the mitral valve morphology and of the left atrium is needed. Perhaps, the most studied subject upon the use of TEE is mitral regurgitation (MR). MR is broadly classified as primary, related to structural abnormalities of the valve itself, or secondary, due to impaired leaflet coaptation associated with underlying left ventricular disease or left atrial disease. Defining the morphology of the valve and the precise mechanism of regurgitation has gained importance in the modern era of surgical and percutaneous mitral valve repair. The important role transesophageal echocardiography (TEE) plays in the evaluation of mitral regurgitation is due to the proximity of the TEE transducer to the left atrium. In situations that impede transthoracic echocardiography provides an unobstructed view. TEE provides enhanced views of the mitral valve, which now include three-dimensional (3D) reconstruction to provide detailed information as to the nature of the underlying pathology. The TEE also provides information that is adjunctive to the TTE in determining the severity, feasibility of repair and assessment of LV function.
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The future of cardiac stress imaging Nikolaos Tzemos Greece , Cleveland clinic UAE Coronary artery disease is the most common cause of mortality and morbidity around the globe. Assessment of myocardial perfusion to diagnose ischemia is commonly performed in symptomatic patients prior to referral for cardiac catheterization. Among other noninvasive imaging modalities, cardiac MRI (CMR) is emerging as a highly sensitive and specific test for myocardial ischemia and infarction. CMR has the unique capability to provide a comprehensive cardiovascular evaluation in one session previously available only by combining multiple modalities. It offers superior spatial resolution in the assessment of ischemia and the function and structure of both ventricles and valves. It can also directly characterize whether ischemic tissue is viable or nonviable, thereby providing information as to whether a patient is likely to benefit from invasive catheterization and/or revascularization. Resting perfusion on CMR is used to evaluate for microvascular obstruction, which is shown to predict adverse left ventricular remodeling and cardiac events after acute myocardial infarction.Studies have demonstrated that each component of a comprehensive CMR examination (i.e., stress perfusion, LGE, flow, left ventricular structure and function) add incremental prognostic information over each other,suggesting each component to be additive rather than redundant in predicting risk. The future of MRI is no longer just over the horizon. Accumulating body of literature demonstrating the present ability and certain potential of a technology that will be the cornerstone for cardiovascular imaging in the next millennium
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Echocardiographic detection of early diabetic myocardial disease: From stress to strain Bernhard Mumm TomTec Imaging Systems, Munich, Germany Introduction: Diabetes mellitus is associated with heart failure and Left ventricular (LV) dysfunction through its association with hypertension and coronary artery disease. Left ventricular hypertrophy, hypertension, sudden cardiac death and unrecognized myocardial infarctions are common comorbidities of diabetes mellitus. Methods: Echocardiography techniques are used for an evaluation of cardiac function and detection of early diabetic myocardial disease. Standard Echo measurements are here LV diameters, wall thicknesses, LV mass, fractional shortening, LV volumes and ejection, measured in 2D or better in 3D. Stress Echocardiography can be another diagnostic tool to evaluate cardiac function. Newer analysis tools feature automatic contour detection and myocardial tracking for a fast, accurate and highly reproducible global and regional functional analysis of LV myocardial strain. Conclusion: Echocardiography is the primary screening tool in cardiac imaging and can be used for detection of early diabetic myocardial disease. New 2D and 3D Echocardiography techniques allow a better qualitative and quantitative evaluation of cardiac function. Using such techniques, diabetic patients without evident heart disease show evidence of systolic dysfunction and increased myocardial reflectivity. Based on strain measurements, LV longitudinal systolic and diastolic function were impaired in patients with diabetes mellitus.
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New Concepts in the evaluation of left ventricular function Navin C. Nanda President of ISCU , USA Controversies exist regarding the orientation and function of muscle fibers in the heart. In the helical model introduced by Torrent Guasp and popularized by Dr. Buckberg, an eminent cardiac surgeon, a single myocardial muscle band consisting of helical fibers is folded upon itself. In this model, the cardiac muscle is formed of three layers. The inner (descending segment) and outer oblique (ascending segment) layers each occupy a quarter of the total muscle mass whereas the middle layer which wraps around two-thirds of the ventricles transversely sparing the apex occupies approximately half of the total cardiac muscle mass.7 This complex arrangement of muscle fibers results in not only inward thickening of the LV walls and longitudinal shortening, but also rotation and translation motion. All these movements are important and contribute to normal functioning of the ventricles. Contraction of the outer layer (ascending segment) leads to counterclockwise rotation of the apex in systole. During the same time, the base of the ventricle rotates in an opposite clockwise direction. Opposite movements occur in diastole with the apex rotating clockwise (presumably due to contraction of the inner/descending segment) and the base in a counterclockwise direction. The algebraic difference between apical and basal rotations is called the twist. Twist divided by the length between the base and apex of the LV is called torsion. Twist and torsion can be calculated between any two LV segments. Thus when evaluating LV function, both systolic and diastolic, it is important to take into account the twist motion of the LV. It may not be enough to evaluate only the LV ejection fraction and the longitudinal function. Approximate LV rotation parameters taken from the literature are given in Table 1 below. Table 1. Approximate normal left ventricular rotation parameters by two-dimensional speckle tracking echocardiography from the literature.
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Women and Heart Disease: Focus on Diabetes, Metabolic Syndrome, and Obesity Susan Laing, MD Professor, Division of Cardiology/Department of Internal Medicine Director of Echocardiography,University of Texas Health Science Center-Houston,USA While the number of deaths in males has been steadily declining over the past 15-20 years, the number of cardiovascular deaths for women remained flat or increased slightly during the 1980s and 1990s. This has been partly attributed to the obesity epidemic. To reduce the risk of cardiovascular disease in women, efforts have focused on modifying the metabolic risk factors that permeate obesity, diabetes, and the metabolic syndrome. In addition, there are specific health issues unique to women including pregnancy, polycystic ovary syndrome, oral contraceptive therapy use, and menopause that need to be taken into consideration in risk factor modification and clinical management of cardiovascular diseases. The 2011 AHA/ACC guidelines added a history of pregnancy-induced hypertension, gestational diabetes, and preeclampsia to the risk classification for women at risk for cardiovascular disease to underscore the need to include these factors when assessing risk in women.This discussion will providea review of issues that clinicians should consider when caring for women to improve their risk of heart disease.
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Carotid Ultrasound for Risk Stratification in Patients with Diabetes and Pre diabetes Susan Laing Professor, Division of Cardiology/Department of Internal Medicine Director of Echocardiography,University of Texas Health Science Center-Houston,USA The number of persons with diabetes mellitus is expected to double worldwide in the next 25 years and it is predicted that more than 350 million individuals will be affected by diabetes mellitusby 2030. The majority of complications of diabetes mellitus are related to cardiovascular disease, and there is significant interest in identifying at risk individuals before occurrence of a first cardiovascular event. Carotid intima-media thickness is a validated and accessible diagnostic tool to evaluate cardiovascular risk which can be used as a proxy of cardiovascular disease outcomes. Furthermore, abnormal carotid intima-media thickness has been demonstrated even in persons with pre-diabetes, underlining its utility in risk stratification along the continuum of patients with impaired glucose tolerance. This discussion with review the state of the art regarding the use of carotid ultrasonography for risk stratification in persons with diabetes and prediabetes.
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Cardiac MRI for detection of arrhythmia myocardial substrates. Sabino Iliceto Head of department of Thoracic and Vascular Sciences and the Division of Cardiology of the University Hospital of Padua, University of Padua, Cardiac magnetic resonance imaging (CMR) can provide beyond functional and morphological information a complete in vivo tissue characterization. Heart disease is accompanied by structural remodeling and involves changes in cell size (hypertrophy), fiber disarray, increased collagen deposition and sometimes replacement fibrosis. Detection of scar (LGE) in heart muscle by gadoliniumenhanced CMR has been validated by Kim et al. with specific pattern and distribution for each cardiomyopathy. Beyond diagnostic purposes, CMR has been demonstrating an added prognostic role in risk stratification for arrhythmias and sudden cardiac death (SCD). Fibrosis and scar area represent a substrates of arrhythmias reentry, electrical conduction slowing and arrhythmia vulnerability. In dilated cardiomyopathy, the prevalence of myocardial fibrosis is about 35%. In this subgroup of patients, the risk of ventricular arrhythmias/sudden cardiac death is 5 folders than patients without scar, becoming an independent predictor of arrhythmic risk beyond ejection fraction (EF), even if only EF is considered in risk stratification management like as a mechanical index can predicted electrical storm. In the hypertrophic cardiomyopathy, a continuous relationship is evident between LGE by percent left ventricular mass and SCD event risk. Moreover the extent of LGE was associated with an increased risk of SCD events about 1.5/10% increase in LGE even after adjustment for other relevant disease variables. In patients presenting with mitral valve prolapse sometimes are reported ventricular arrhythmias and by literature can be associated a SCD. Our group recently demonstrated that the presence of fibrosis nearby valve inserctional point is associated with the occurrence of ventricular arrhythmias. This could be represent a marker of risk in patients considered otherwise healthy. In conclusion post contrast CMR thanks to its capability in detecting scar and necrosis area provides additional information for assessing arrhythmic event risk in patients beyond other well-known risks factors or in patients otherwise judged to be at low risk.
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Cardiac MRI in Acute Myocardial Infarction Sabino Iliceto Head of department of Thoracic and Vascular Sciences and the Division of Cardiology of the University Hospital of Padua, University of Padua, Cardiac magnetic resonance imaging (CMR) represents a non-invasive technique with increasing applications in AMI providing the assessment of function, perfusion and tissue characterization in a highly reproducible manner during a single examination. Cine CMR for evaluation of cardiac volumes, mass, and systolic function is considered a gold standard compared with other imaging modalities, even if to valuate regional myocardial function and thickening. Beyond morphologic and functional data, the added value of this technique is the tissue characterization. Myocardial oedema in the acute phase of myocardial infarction can be visualized as a bright signal on T2-weighted images, defining ‘myocardium at risk’. It provides information about the so called “salvaged myocardium” quantified retrospectively by comparing T2-weighted edematous area and necrotic area in post contrast images. So hypokinetic/akinetic segments with local tissue edema and no myocardial necrosis represent the stunned myocardium that could improve its contractility since coronary revascularization. Delayed post-contrast sequences are currently used to identified irreversible necrotic area visualized as white area on post contrast images (LGE). In the context of white LGE regions (infarcted myocardium) may coexist dark hypoenhanced areas, traditionally referred to as microvascular obstruction (MVO). Sometimes inside the hyperenhancement on edematous area the presence of a hypoenhancement core suggesting intramyocardial haemorrhage complicating MVO area. CMR features of no-reflow also have prognostic significance in terms of negative clinical outcome and adverse left ventricular remodeling. Even if the ‘dark zones’ on MRI indicate poor prognostic significance, the real mechanism underlying these features is not yet well understood in human AMI, since no-reflow represents a complex time-sensitive phenomenon, which remains to be fully understood.
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Modern Therapy in Diabetics with CAD in Adult Ousama Almaraghi M.B.CH.B , AEX ,EGYPT,MS, Internal Medicine, ALEX,EGYPT Diabetes Diploma Leicester , UK.,Dialectologist in NAEEM DIABETIC CLINIC, JAHRA-KUWAIT There are about 378 million people live with diabetes all over the world. Diabetes mellitus has been well described as a cardiovascular risk factor in developed countries. In the Framingham study the incidence of CAD is double in diabetic men compared to non-diabetics and three times higher in diabetic women compared to non-diabetics (1). It is estimated that CVD accounts for 65% of all deaths in persons with diabetes. (2) Although strict glycemic control unequivocally reduces the microvascular complications of diabetes mellitus, the macrovascular benefits of intensive therapy have been difficult to establish, with conflicting results from large clinical trials.(3,4) When we start prescribe medicine to a diabetic patient we should consider individualization of Hba1c% according to other risk factors like, age of the patient, duration of disease, other comorbid conditions ,presence of macro or microvascular complications with avoidance of hypoglycemia and gaining weight.(5) Over the last 10 years, a lot of different compounds have actually been introduced to the market, today we will focus on 3 of them actually -- the dipeptidyl peptidase-4 (DPP-4) inhibitors, the glucagon-like peptide-1 (GLP-1) receptor agonists, and the sodium glucose cotransporter 2 (SGLT2) inhibitors -- they have been on the market now for almost 10 years, but it is those that are often discussed when we need to add something to metforminas it works with different mechanism of action and can control blood sugar without hypoglycemia and gaining weight and may even reduce weight that are very important in diabetic patient with CAD . Most of these drugs according to FDA’s requirements there are a lot of trials with a large cardiovascular data showing a significant reduction of Hba1c% with no cardiovascular harm ,but for cardiovascular benefits require further study. 1-Kannel WB, McGee DL: Diabetes and cardiovascular risk factors: the Framingham study. Circulation 1979; 59: 8-13. 2-Centers for Disease Control and Prevention. National Diabetes Fact Sheet. 2007 [Accessed September 2010]. 3-Singh A, Donnino R, Weintraub H, Schwartzbard A. Effect of strict glycemic control in patients with diabetes mellitus on frequency of macrovascular events. Am J Cardiol. 2013;112:1033–1038. 4--Stratton IM, Adler AI, Neil HA, Matthews DR, Manley SE, Cull CA, Hadden D, Turner RC, Holman RR. Association of glycaemia withmacrovascular and microvascular complications of type 2 diabetes (UKPDS 35): prospective observational study. BMJ. 2000;321:405–412. 5-Ismail-Beigi F, Moghissi E, Tiktin M, Hirsch IB, Inzucchi SE, Genuth S. Individualizing glycemic targets in type 2 diabetes mellitus: implications of recent clinical trials. Ann Intern Med. 2011;154:554-559.
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EFFECT OF OMEGA-3 POLYUNSATURATED FATTY ACIDS SUPPLEMENTATION ON ENDTHELIAL FUNCTION IN PATIENTS WITH METABOLIC SYNDROME J. Fedačko,L. Štovková, T. Lopuchovský, J. Pella, L. Merkovská, L. Jedličková, D. Pella Aim: Evaluation of role of supplementation of omega-3 polyunsaturated fatty acids on endothelial function in patients with metabolic syndrome. Methods: Total of 40 patients with metabolic syndrome were enrolled. We evaluated endothelial function in subjects before and after three-month treatment with omega-3 polyunsaturated fatty acids in dose 2.4g daily (800mg 3 times a day). Using the Endo-PAT2000 device (Itamar Medical Ltd. Caesarea, Israel), reactive hyperemia index – a parameter of endothelial function and augmentation index– a parameter of arterial stiffness were measured. Plasmatic level of glutation peroxidase, homocysteine, apolipoprotein B and lipoprotein (a) were also evaluated. Results: The average values of reactive hyperemia index before the treatment with n-3PUFA was 1,62± 0,42 , whereas 1.96 ± 0.62 at the end of the study (p<0.005). Augmentation index was 14.66 ± 19.55 and 9.21 ± 15.64 after the treatment (p=0.003). We also observed statistically significant decrease of apolipopoteinB (0,94 ± 0,36 vs 1,13 ± 0,35, p = 0,0001), Lipoprotein (a) ( 0,30 ± 0,29 vs. 0,29 ± 0,33, p=0,000) a homocysteine (19,31 ± 5,29 vs. 13,78 ± 3,05, p = 0,0001) and increase of the glutathionperxidase plasma levels (41,65 ± 8,90 vs. 45,20± 8,01), p=0.000. Conclusion: We have observed significant improvement of the endothelial function in subjects with metabolic syndrome treated with omega-3 polyunsaturated fatty acids in dose 2.4g daily. Key words: metabolic syndrome, endothelial dysfunction, omega-3 fatty acid
Coronary computed tomography and plaque morphology Fabiola B. Sozzi
Consultant Cardiologist ,Cardiology Unit, Policlinico Hospital, Milan, Italy Current guidelines encourage the use of coronary computed tomographic angiography (CTA) as the first-line imaging modality for the diagnosis of patients with low and intermediate likelihood for coronary artery disease. CTA could also provide useful information on high-risk vulnerable plaques. It has been suggested that cardiac CTA enables characterization of differences in plaque composition in stable and unstable angina pectoris and this has led to expectations about potential prediction of plaque rupture. CTA can identify and characterize atherosclerotic plaques in the coronary arteries, and several studies have demonstrated associations between the presence of coronary artery disease on a CTA and future cardiovascular events. The majority of acute coronary syndromes occur without warning due to rupture of coronary atherosclerotic plaques. Coronary lesions prone to rupture reveal several high-risk features that can be identified before the development of devastating clinical events, using modern imaging modalities. Recent advances in coronary CTA allow the identification, quantification, and risk stratification of coronary plaques. In recent studies plaque composition represented a long-term predictor of cardiac events. Sozzi et al demonstrated that non-calcified and mixed plaques carry a worse prognosis compared to calcified plaques. Unquestionably, attempts to identify high-risk plaques by CTA provide a unique opportunity to implement targeted preventive measures and improve prognosis. The concept of vulnerable plaque is based on the premise that certain coronary plaques are more prone to disruption or thrombosis than others, leading to a symptomatic acute coronary event.
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Incomplete RV Tissue Doppler Imaging Changes after Transcatheter Closure of ASD in Pediatric Age Hala Agha, Sonia El-Saiedi , Mohamed Shaltoot, Hala Hamza, Hayat Nassar, Doaa Abdel-aziz,Amira Esmat El Tantawy
Original Article Pediatric Cardiology, October 2015, Volume 36, Issue 7, pp 1523-1531, First online: 17 May 2015 Background Published data showing the intermediate effect of transcatheter device closure of Atrial Septal Defect (ASD) in the pediatric age group are scarce. Patients & Methods The study included 37 consecutive patients diagnosed as ASD secundum by transthoracic echocardiography and TEE and referred for transcatheter closure at Cairo University Specialized Pediatric Hospital, Egypt, from October 2010 to July 2013. Thirty-seven age- and sex-matched controls were selected. TDI was obtained using the pulsed Doppler mode, interrogating the right cardiac border (the tricuspid annulus) and lateral mitral annulus, and myocardial performance index (MPI) was calculated at 1-, 3-, 6- and 12-month post-device closure. Objectives To assess effects of transcatheter closure of ASD on right and left ventricular functions by TDI and measure percent of variation within the first month Results Transcatheter closure of ASD and echocardiographic examinations were successfully performed in all patients. There were no significant differences between two groups as regards the age, gender, weight or BSA. TDI showed that patients with ASD had significantly prolonged isovolumetric contraction, relaxation time and MPI compared with control group. Decreased tissue Doppler velocities of RV and LV began at one-month post-closure compared with the controls. Improvement in RVMPI and LVMPI began at 1-month post-closure, but they are still prolonged till 1 year. Reverse remodeling of right and left ventricles began 1 month after transcatheter ASD closure, but did not completely normalize even after 1 year of follow-up by tissue Doppler imaging. Fig 1: RV (Anterior wall) changes in relation to control group Fig 2: LV (Mitral annulus) changes in relation to control group Fig 3: MPI changes in relation to control group Fig 4: Percent of variation of E’ peak velocity changes after 1 month Fig 5: Percent of variation of A’ peak velocity changes after 1 month Fig 6: Percent of variation of S’ peak velocity changes after 1 month Conclusion Significant TDI changes of right and left ventricles begins one month after transcatheter ASD closure and need more than one year of follow-up. 0 0.02 0.04 0.06 0.08 0.1 0.12 0.14 0.16 0.18 Before After 1m After 6m After 12m controls Peak E’ Peak A’ Peak S’ RV (Anterior wall)
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ROLE OF HAPTOGLOBIN GENE POLYMORPHISM AND SERUM HEMEOXYGENASE 1 LEVEL IN TYPE II DIABETIC PATIENTS WITH AND WITHOUT NEPHROPATHY Syeda Nuzhat Nawab Pakistan Presentation Type Slides Presentation Title ROLE OF HAPTOGLOBIN GENE POLYMORPHISM AND SERUM HEMEOXYGENASE 1 LEVEL IN TYPE II DIABETIC PATIENTS WITH AND WITHOUT NEPHROPATHY Author Dr. Syeda Nuzhat Nawab Email address nuzhat85_5@hotmail.com Mobile 923343163021 Abstract Diabetic Nephropathy (DN) is one of the major microvascular complications which occur in the later stage of diabetes. The development and progression of diabetic nephropathy are related to the degree of glycemic control, oxidative stress and may also be influenced by the genetic factors. Oxidative stress has been suggested to play a main role in the pathogenesis of type 2 diabetes mellitus and its complications. As a consequence of this increased oxidative status, a cellular-adaptive response initiates that requires functional chaperones, antioxidant production, and protein degradation. The haptoglobin-hemeoxygenase-1 pathway is an efficient captor-receptor enzyme system to circumvent the hemoglobin induced toxicity during the physiological and pathological hemolysis. In this pathway, haptoglobin binds with the free hemoglobin to form Hp-Hb complex. Uptake of this complex by the macrophages is followed by degradation of heme in lysosome in the presence of hemeoxygenase-1 (HO-1) enzyme. The clearance of heme from extravascular compartment is dependent on the functional properties of Hp proteins encoded from three different genotypes; Hp1-1, Hp1-2 and Hp2-2. Hence, the Hp genotype is an independent risk factor for diabetic nephropathy. Diabetic patients with Hp 2-2 genotype are more likely to develop nephropathy as compared to those with Hp 1-2 and Hp1-1. Along with Hp genotypes, serum level of HO-1 enzyme is also considered as a strong antioxidant system and protects the body from diabetic insult by reducing the oxidative stress and inflammation. The purpose of the present study was to investigate the allelic and genotypic frequency of haptoglobin gene, serum HO-1 levels and occurrence of diabetic nephropathy in type II diabetes mellitus and to find the possible correlation of serum HO-1levels with other biochemical parameters. The study was undertaken in case-control settings, a total of 1031 individuals including 347 T2DM patients, 317 diabetic nephropathy patients and 367 non diabetic healthy individuals were enrolled in order to assess the risk of nephropathy in diabetic patients. The blood samples were collected after getting informed consent. Hp genotyping was conducted using PCR-RFLP technique and serum HO-1 concentration were measured using sandwich ELISA. The frequency of homozygous Hp 2-2 genotype was significantly higher in DN (p<0.001) and T2DM (p<0.05) patients as compared to the control group. It was also found that Hp1-1 genotype have significant association with controls in comparison with patients. The diabetic patients who were homozygous for Hp 2-2 genotype were found to be more prone to develop nephropathy. Serum analysis showed that HO-1 concentrations were significantly lower in DN (p<0.001) and T2DM patients (p<0.001) as compared to controls. Moreover, lower serum concentration of HO-1 negatively correlated with age (p<0.01), duration of disease (p<0.05), blood glucose levels (p<0.05), HbA1C (p<0.05) and serum iron level (p<0.05), and correlated positively with HO-1 and serum bilirubin levels in diabetic nephropathy patients. Results of the current study suggested that Hp2-2 genotype and lower serum HO-1 level may be considered to be major susceptibility factors associated with development and progression of nephropathy in diabetic patients. In addition, significantly negative association between hyperglycemia with serum HO-1 emphasized the pathogenic mechanism of oxidative stress produced in diabetic nephropathy patients. Furthermore, serum HO-1 level and Hp 2-2 genotype may be good prognostic factors for the development of nephropathy in the course of diabetes mellitus. Future research on the use of antioxidant therapy may result in a new approach to the treatment and prevention of diabetic nephropathy.
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Case Report: Atrioventricular re-entry tachycardia with underlying Ebsteins Anomaly in an adult Somaya A. M. Albhaisi UAE We present a case of Ebsteins Anomaly (EA) with secundum atrial septal defect (ASD) presented with tachycardia, dyspnea and ECG revealed a wide QRS complex. During electrophysiology studies patient developed atrial fibrillation (AF) requiring 2 direct current (DC) shocks to return to sinus rhythm. This attack prompted the decision to undergo radiofrequency ablation of patients WPW accessory pathway, the procedure however was interrupted due to desaturation and further AF requiring DC conversion. Patient was placed on flecainide and after a period without symptoms was discharged. On follow up patients symptoms had worsened, and a repeat RFA was successful. Five days later, cone reconstruction of tricuspid valve, with closure of secundum ASD was performed with intra-operative cryoablation of atrial focus of SVT. Follow up echocardiogram revealed no residual ASD; mild tricuspid regurgitation remained without stenosis.
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A Huge left ventricle pseudo aneurysm Basma Hammad Egypt A 34 year old male patient presented with a progressive exertional dyspnea associated with paroxysmal nocturnal dyspnea and rapid palpitation over one month following history of blunt chest trauma, patient had no history of syncope or angina. The patient is an intravenous (IV) drug abuser. He had no history of Diabetes Milletus, hypertension or dyslipidaemia. He has no family history of ischemic heart disease. The physical examination revealed a regular pulse 90Bpm, blood pressure was 120/70 mmHg. The neck venous pressure was elevated, the apical impulse was weak and there was a to-fro murmur heard all over the precordium. Trans-thoracic echo study revealed: There is a defect in the left ventricular apex the defect is communicating with a huge cavity with evidence of bidirectional flow across the defect. Multi detector computed tomography with contrast examination revealed: normal coronaries. There is a large Left ventricle (LV) contrast filled pseudo aneurysm about 10x22cm communicating with LV cavity. There are another two large pericardial cysts surrounding the right atrium and right ventricle of well delineated walls. Cardiac magnetic resonance (CMR) assessment revealed that the pericardial cysts walls are hyper enhanced , with hyper intense signal suggestive of encysted hemorrhagic effusion. The LV apical pseudo aneurysm wall is composed of pericardium with no myocardial tissues in and systolic flow expansion of the aneurysm is noted. LV Pseudo aneurysm resection as well as the pericardial cysts excision were done and surgeons reported that the cysts were encysted hemorrhagic effusion. Diagnosis of LV pseudo aneurysm is difficult . The improvement in noninvasive techniques allow accurate diagnosis which of therapeutic and prognostic implications.CMR is more sensitive than Echo in diagnosis of LV pseudo aneurysm
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A case of fatal obstructive shock Abdallah Almaghraby Egypt Introduction : Cardiac tumours and tumour thrombi can present in a way mimicking pulmonary embolism and can lead to fatal obstructive shock. Case report : A 31-year-old-male patient, a non-smoker with no cardiovascular risk factors, diagnosed with left ankle synovial cell sarcoma in 2010 and hence underwent localized excision successfully. In 2011 during a routine follow up, computed tomography (CT) revealed recurrence involving the left inguinal lymph nodes and lung metastasis. Subsequently the patient underwent excisional biopsy of the inguinal lymph lodes that confirmed the diagnosis. Hence, the patient received 6 months of chemotherapy followed by another 6 months of radiotherapy. Unfortunately, the treatment did not cure his condition but has successfully halted the progression of the lung metastatic involvement. The patient started complaining of dyspnea with less than daily effort 4 months prior to presentation that progressed to dyspnea at rest 1 week prior to presentation. On the day of presentation, he started developing dizziness on minimal effort that was closely related to cough and straining. Hence, the patient sought medical advice and was admitted to our institution for proper evaluation. His physical examination revealed a toxic look, cyanotic tinge of lips, pallor, blood pressure was 100/70 mmHg, heart rate was 100 bpm, respiratory rate was 26 cycle/minute , grade II clubbing was noted in all his limbs. Chest and heart examination revealed diminished air entry over the right lung apex, a pansystolic murmur was heard on the tricuspid area with accentuated pulmonary component of the second heart sound. Electrocardiogram revealed sinus tachycardia, laboratory workup was unremarkable except for a hemoglobin of 9.2 g/dl, blood gases showed evident hypoxemia with respiratory alkalosis and chest X-Ray revealed average cardiothoracic ratio with evident right lung apical mass. Echocardiography showed a huge fleshy mass measuring about 4 x 4 cm occupying the right ventricle and its outflow tract bulging into the right atrium with very limited blood flow to the pulmonary arteries, and the left ventricular systolic function was normal. The patient was planned for CT angiography for proper evaluation of the extent of his disease but unfortunately, he stared complaining of acute respiratory distress and was diagnosed as obstructive shock. Central venous line was inserted through a right transjugular approach for infusing vasopressors, within minutes he developed asystole, resuscitation was initiated but in vain. After removing the central line, its pores were noted to be clogged by solid tissues, hence it was sent for pathological analysis that revealed several rows of small sarcomatous cells that is consistent with metastasis from the ankle synovial sarcoma. Conclusion : Cardiac tumors represent a relatively rare, yet challenging diagnosis. Secondary tumors are seen more frequently than primary tumors. Most of primary cardiac tumors are benign in origin, with primary malignant tumors accounting for 25% of cases. Metastatic tumors usually arise from breast, lung, kidney cancer, melanomas, and lymphomas. Synovial sarcomas predominantly occur in para-articular soft tissues of the extremities of young adults and adolescents, its occurrence in the myocardium as a primary tumor is a rare entity.
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A case of giant left atrium Yehia Saleh Egypt Introduction: Giant left atrium (GLA) is a rare condition that is usually secondary to neglected rheumatic heart disease. Compression of the surrounding structures is the main concern. We are reporting a case presenting with GLA measuring about 160 mm in diameter with an estimated volume of 2.5 liters using Echocardiography and a maximum diameter of 200 mm using computed tomography. Case report: A 65-year-old female patient with history of rheumatic heart disease. Hence, she underwent mitral valve replacement via a tilting disk 25 years ago. She is known to be chronic atrial fibrillation, and she suffers from dyspnea with more than daily effort as long as she can recall. Drug history includes warfarin, bisoprolol and furosemide. The patient started complaining of progression of her dyspnea in the past 3 weeks, hence she presented to our institution. Upon presentation, her blood pressure was 100/70 mmHg, heart rate was 90 bpm showing irregular irregularity and neck examination revealed bilateral congested neck veins with prominent systolic venous pulsations. Chest and heart auscultation revealed a well heard mechanical click, a pansystolic murmur heard over the tricuspid area, accentuated pulmonary component of the second heart sound and diminished air entry over the right lung base. Electrocardiography revealed atrial fibrillation, Laboratory workup showed that she was adequately anticoagulated but otherwise unremarkable, chest X-ray showed significant cardiomegaly, tracheal shift to the right and obliteration of the right basal lung field. Echocardiography showed slightly dilated left ventricular dimensions with preserved systolic function, well-functioning mitral valve prosthesis, severe tricuspid regurgitation, severe pulmonary hypertension and a giant left atrium measuring about 160 mm with an estimated volume of 2.5 liters. Subsequently, Computed tomography revealed that the left atrium is hugely dilated occupying a considerable amount of the hemithorax measuring 200 x 155 x 182 mm and causing subtotal collapse of the right lower lobe. Despite the name of the left atrium the chamber is located in the middle of the chest; it is the most posterior chamber of the heart and it abuts the spine and esophagus. When the left atrium enlarges it moves to the right occupying the right hemithorax. Overall, clinically when the right border of the heart touches the right thoracic wall, it might be due to GLA, right atrial tumors, congenital abnormalities, tumors of the mediastinum, right pleural effusion or even pericardial effusion. Hence, Echocardiography is mandatory prior to any invasive procedures such as pericardiocentesis or pleurocentesis. The patient was managed conservatively, and she reported improvement of her symptoms after uptitrating the furosemide. In our opinion, isolated left atrial reduction surgery was unjustified as the risk of the procedure outweighed its benefit. There are no guidelines regarding intervention on lone giant left atrium without significant mitral valve affection, however intervention is usually limited to significant compressive symptoms. In case of GLA in addition to significant mitral affection, most surgeons fix the mitral valve only unless there is compressive symptoms, presence of a thrombus in the left atrium or history of thromboembolism. GLA was historically defined by the left atrium touching the lateral chest wall in chest X-ray, however after introduction of echocardiography several authors have redefined it to greater than 6 cm. Ates et al reported the largest left atrium shown by Echocardiography with a diameter of 187 mm. While Sinatra et al reported the largest left atrium shown by magnetic resonance measuring 200 mm in maximum diameter. Several complications may arise from compression of the surrounding structures such as hemodynamic compromise resulting from compression of the left ventricular wall, respiratory disturbance resulting from compression of the left main bronchus or right lung collapse. In addition to compression of the esophagus leading to dysphagia. Rarely it may compress the left laryngeal nerve leading to hoarseness of voice. Conclusion: GLA is a rare disorder that results from mitral valve disease, most commonly secondary to rheumatic heart affection, however due to better screening in the developing countries its incidence is declining. . To our knowledge, this case is one of the largest left atria reported in the literature up to date.
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A case of longstanding dyspnea Abdallah Almaghraby Egypt
Background: Amyloidosis refers to a rare group of disorders caused by the extracellular deposition of insoluble abnormal fibrils, called amyloid, which are composed of a variety of serum proteins. Cardiac involvement can occur, with or without clinical symptoms, as a part of systemic amyloidosis or as a localized phenomenon, and is usually associated with poor prognosis. Case report: A 33-year-old man presented with a 6 months history of dyspnea class II-III, orthopnea & paroxysmal nocturnal dyspnea. He was a heavy smoker with no past medical history, he sought medical advice at a pulmonologist where he was treated as chronic obstructive pulmonary disease but was slight improvement of his symptoms. Just a week before presentation he started to suffer from bilateral symmetrical lower limb oedema that was gradually increasing, also he started to suffer from attacks of dizziness & pre-syncope. On examination his blood pressure was 100/70 mmHg, heart rate was 90 beats per minute, he was tachypneic with bilateral diminishes air entry on the basal lung fields, S3 galloping is heard on cardiac auscultation and bilateral soft lower limb oedema. His electrocardiogram (ECG) was showing normal sinus rhythm. Echocardiography showed a picture of cardiac amyloidosis with impaired systolic and diastolic functions with restrictive filling pattern. The patient was planned for right heart catheterization for invasive pressure measurements and endomyocardial biopsy but he was found dead one day later in his room. Conclusion: This case demonstrates the necessity to exclude cardiac cause of dyspnea even in patients with no cardiovascular risk factors.
Coronary Artery Bypass Grafting After Percutaneous Intervention Has Higher Early Mortality: A Meta-Analysis salah eldien altarabsheh Jordan BACKGROUND: We compared early adverse events and midterm survival between primary coronary artery bypass grafting (pCABG) and CABG in patients with percutaneous intervention (secondary CABG, sCABG) because data on this topic are very limited. METHODS: A systematic review of published literature was done to obtain original studies fulfilling the search criteria. The end points studied were early mortality, stroke, renal failure, myocardial infarction, and the need for an intra-aortic balloon pump. A randomeffect inverse variance weighted analysis was performed. The results are presented as risk ratios (RR) (95% confidence interval); p < 0.05 was considered statistically significant. RESULTS: Fourteen studies (84,983 pCABG patients and 14,775 sCABG patients) were included in the systematic review. Early mortality was lower with primary CABG (RR 1.54 [1.19-2]; p = 0.007). The incidence of myocardial infarction was also less with pCABG than with sCABG. (RR 1.46 [1.04-2.06]; p = 0.06). Patients undergoing pCABG were 14% (0% to 55%; p = 0.04). Less likely to need an intra-aortic balloon pump. Although renal failure was lower with pCABG (RR 1.254 [1.047-1.502]; p = 0.014), the stroke rates were comparable in both cohorts (p = 0.95). Renal failure was favorable in the primary CABG cohort. Early stroke was comparable between the two cohorts (p = 0.95). The pooled hazard ratios demonstrated comparable survival at the end of 3 years (p = 0.36). CONCLUSIONS: Patients undergoing CABG after prior percutaneous therapy have a higher incidence of myocardial infarction and mortality in the postoperative period. However, midterm survival is comparable in both cohorts.
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patterns of left ventricular global longitudinal strain in diabetic patients by speckle Ahmed Abdelwahab Elgohary Egypt
Introduction: Diabetic patients with normal left ventricular ejection fraction are frequently associated with diastolic dysfunction .Speckle tracking is more sensitive than LVEF in detection subclinical LV systolic dysfunction. Aim: Detection of different patterns of global longitudinal strain in diabetic patients using global longitudinal strain by speckle tracking. Methods: fifty two diabetic patients had been referred from internal medicine clinic after they had been tested for HBA1c test and stratified into two groups Group 1: it include26 DM patients with controlled blood sugar. Group 11: it include26 DM patients with uncontrolled blood sugar The two groups had been subjected to the following diagnostic workup: Full medical history, full clinical examination, laboratory assessment , twelve lead resting ECG ,Stress ECG, Echocardiography study, Traditional Tissue Doppler imaging ,Assessment of global longitudinal strain. Patients with IHD, Systolic dysfunction, CHD ,valvular, Arrhythmia, HOCM ,Pericardial, major systemic disease had been excluded. Result: there was significant statistical difference in GLS, Age , Diabetic Type ,Diabetic Duration,2HPP Blood sugar, E/é in controlled DM compared to uncontrolled DM (p<0.05),there was no significant difference in Gender ,FBS. EF, E/A in controlled DM compared to uncontrolled DM. • Conclusion:Diabetic duration was strongly correlated with reduction of global Longitudinal strain. Poor blood glucose control, as indicated by HbA1c>6.5%, leads to reductions in LV global longitudinal systolic strain, which is associated with preclinical LV dysfunction. • Key words:Diabetes,speckle tracking,left ventricular function,strain.
Attitude and Practice Towards the Use of Beta-Blockers among Medical Students, KSA, 2015 Nehal Anam KSA Attitude and Practice Towards the Use of Beta-Blockers among Medical Students, KSA, 2015. Background: Stress and anxiety before and during exams represent major problems for medical and non medical students. The use of self medication to alleviate anxiety is increasing among medical students. Objectives: To assess the use of OTC medicine in terms of BB before and during exams among students at Taibah College of Medicine, Madinah, Saudi Arabia. Subjects and Methods: A cross-sectional study was conducted at College of Medicine Taibah University, Madinah, Saudi Arabia. The study recruited 450 medical students of all study years. The data were collected through a self-administered structured questionnaire. The questionnaire consisted of demographic data and data about students’ attitude and use of BB before and during exams. The collected data were analyzed using appropriate statistical methods. The level of statistical significance was defined as P ≤ 0.05. Results: The mean age of the studied 450 students was 21.8 ± 1.7 years, of them 41.3% were male and 58.7% were female and more than one half of them (55.5%) were followed the academic years. The use of BB among the studied students was 9.3%, with significant difference by students’ sex and study year. The higher percent of BB use was found among female (14.7%) and clinical year (17.5%) students. About two thirds of the users (28 students) reported that they use BB according to their friends’ advice, while 24% (10 students) used BB according to medical prescription. Most of the students using BB reported that they start to take BB during the clinical years (78.8%), with most of them were taking BB before and during internal medicine, pediatrics and surgery exams. Conclusions: The study finding revealed relatively low level of use of BB among the studied students compared to the use of other OTC medicine among students reported in other studies. However, the inappropriate practices of BB as self medication among these students was alarming both the Saudi Health authorities and for the studied faculty administrators. Key words: Beta blockers, Practice, Self medication, Students, Saudi Arabia.
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Influence of Helicobacter pylori on the dramatic spread of diabetes mellitus worldwideby speckle tracking Abdullah M Nasrat KSA Objective: Demonstration of an influence of Helicobacter pylori in the dramatic spread of Diabetes mellitus (DM) among many patients during the last two decades. Background: The flare up of a lot of medical challenges related to H. pylori through immune or different unknown reasons made the medical world believe that H. pylori eradication should be a necessary attempt.1 These H. pylori-related medical problems are sufficient to render the matter that H. pylori can reside hidden somewhere in the body be taken seriously. The spread of DM is rising in a dramatic way as the fire spreading in hey especially in developing countries giving the term “diabetic epidemic” an actual credibility.2 H. pylori could migrate or get forced to migrate to the colon leading to accumulation of profuse toxic amounts of ammonia unopposed or buffered by any acidity leading to biological stress to the body that could predispose to stress diabetes among disadvantaged susceptible people.3,4 Design: Prospective study. Patients& Methods: 18 cases of newly discovered DM associated with a definite history of H. pylori dyspepsia were included in this study. The study was held in Balghsoon Clinic in Jeddah during the period between May, 2011 and October, 2013. Traditional measures were used for the relief of dyspeptic symptoms, eradication of H. pylori, colon care and colon clear. Results: All patients expressed dramatic relief of their dyspeptic symptoms and the diabetic condition has been successfully and permanently corrected in 16 patients. Conclusion: In the light of the accurate determination of recent findings and statistics, a revision of the current guidelines for the management of H. pylori and newly discovered DM may be needed. It may be incorrect that the current world’s burden of DM is on the account of type II diabetes. It seems that the antibiotic violence has obliged a domestic bug to become wild in sequels instead of getting rid of it. References 1. Volk WA, Gebhardt BM, Hammarskjold M-L, Kadner RJ. Essential of Medical Microbiology. Lippincott – Raven. 1996; 5th Ed: 377. 2. Al-Nozha MM, Al-Maatouq MA, Al-Mazrou YY, Al-Harthi SS, Arafah MR, Khalil MZ, Khan NB, et al. Diabetes mellitus in Saudi Arabia. Saudi Med J 2004 Nov; 25(11): 1603-10. 3. Farinha P, Gascoyne RD. Helicobacter pylori and MALT Lymphoma. Gastroenterology 2005 May; 128(6) : 1579-605. 4. Nasrat AM. The world misconception and misbehavior towards Helicobacter pylori is leading to major spread of illness. The 7th Anti-Aging Medicine World Congress, Monte-Carlo, Monaco, 2009 Mar. Available from URL, www.euromedicom.com
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A therapeutic answer for the controversy of insulin-cardioprotection among dysglycemic patients Abdullah M Nasrat KSA Aim: Demonstration of the cardio-protective effect of cupping therapy in dysglycemia. Background: The controversy of insulin cardio-protection among dysglycemic patients is a confusing challenge.1,2 Glucose/insulin disproportion is a major reason for accumulation of acidic toxic metabolites in the body leading to the current controversy about insulin role in cardio-protection.2 The micro-capillary dysfunction, improper tissue perfusion with blood and accumulation of the acidic metabolites in the myocardium are leading to each other and could contribute to progression into major cardiac events.1,3 Withdrawal of these metabolites could disturb this vicious circle and offer the answer for the controversy of insulin cardio-protection in dysglycemia. Suction in cupping therapy works specifically on the blood trapped within the tissues together with the acidic metabolites which are believed to be functionally obliged to it. Skin scratching with repeated suction delivers nitric oxide to the area which is a potent cardio-protectant in health and disease.4,5 Patients& Methods: 7 diabetic patients on insulin with recurrent moderate chest tightness due to variable grades of myocardial ischemia refused coronary catheterization; a session of basic cupping therapy on the back and chest was employed. Results: Dramatic symptomatic relief and clinical recovery has been documented in 6 patients. Conclusion: Cupping blood-let out therapy could lead to correction of ischemic myocardial situations. REFERENCES: 1. Shimokawa H, Yasuda S. Myocardial ischemia: current concepts and future perspectives. J Cardiol 2008 oct; 52(2): 67-78. Epub 2008 Sep 4. 2. Yu Q, Gao F, Ma XL. Insulin says NO to cardiovascular disease. Cardiovasc Res 2011 Feb 15; 89 (3):516-24.Epub 2010 Nov 4. Review 3. Ozben B, Erdogan O. The role of inflammation in acute coronary syndromes. Inflamm Allergy Drug Targets 2008 Sep; 7 (3):136-44. 4. Nasrat AM. Role of blood-let out cupping therapy in taming the wild hepatitis B Virus. The International Congress of Aesthetic Dermatology and Preventive medicine, Paris, 2010 Oct. Available from URL, www.euromedicom.com 5. Nasrat AM. Role of blood-let out cupping therapy in angina and angina risk management, emergency Vs elective. The 22nd International scientific session of Saudi Heart Association, Riyadh, 2011 Jan. Available from URL, www.sha. org.sa
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Improvement of idiopathic cardiomyopathy after colon clear Abdullah M Nasrat KSA Aim: Demonstration of the effect of colon-clear on idiopathic myocardial dysfunction. Background: H. pylori colonized the stomach since an immemorial time. H. pylori could migrate or get forced to migrate to the colon leading to accumulation of toxic amounts of ammonia.1-3 The association of H. pylori and some cardiovascular diseases like myocarditis and cardiomyopaty has been sufficiently reported. The role played by the increased mucosal production of inflammatory mediators (cytokines) induced by H. pylori among patients with ischemic heart diseases has been also illustrated.4-6 The clinical association of gastritis and carditis is controversial.4 Active lymphocytic myocarditis and myocardial dysfunction has been described in a young woman infected with H. pylori; an immune influence has been emphasized as a possible etiology. It has been also reported in literature that a possible role of autoimmunity induced by H. pylori in cardiomyopathy can not be excluded.6 Patient& method: Three young female patients with history of H. pylori dyspepsia has developed myocarditis complicated by cardiomyopathy as confirmed by echocardiography and MRI. Colon-clear with a potent natural purge was employed. Results: Symptomatic improvement and clinical recovery to sinus rhythm and normal left ventricular ejection function was documented. Conclusion: Toxic myocarditis rather than viral could be the pathologic etiology behind many cases of idiopathic cardiomyopathy; hence it could be prevented or at least progress of the disease could be stopped. Colon-clear can be simple and safe measure in improving changes in myocardial function developing in association with H. pylori due to inflammatory, toxic or immune reasons. REFERENCES: 1. Farinha P, Gascoyne RD. Helicobacter pylori and MALT Lymphoma. Gastroenterology 2005 May ; 128(6) : 1579-605. 2. Matsuo S, Mizuta Y, Hayashi T, et al. Mucosa-associated lymphoid tissue lymphoma of the transverse colon: a case report. World J Gastroenterol 2006 Sep 14; 12 (34): 5573-6. 3. Nasrat AM. The world misconception and misbehavior towards Helicobacter pylori is leading to major spread of illness. The 7th Anti-Aging Medicine World Congress, Monte-Carlo, Monaco, 2009 Mar. Available from URL, www.euromedicom.com 4. Owen DA. Gastritis and casrditis. Mod Pathol 2003 Apr; 16 (4):325-41. Review. 5. Bilinska ZT, Grzybowski J, Szajewski T, et al. Active lymphocytic myocarditis treated with murine OKT3 monoclonal antibody in a patient presenting with intractable ventricular tachycardia. Tex Heart Inst J 2002; 29 (2): 113-7. 6. Klausz G, Tiszai A, LĂŠnĂĄrt Z, et al. Helicobacter pylori-induced immunological responses in patients with duodenal ulcer and in patients with cardiomyopathies. Acta Microbiol Immunol Hung. 2004;51(3):311-20.
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