Essam Baligh

Clinical Relevance of Carotid Atherosclerosis among Egyptians: A 5-Year Retrospective Analysis of 4,733 Subjects

Background and Purpose: The prevalence of carotid artery stenosis has been studied in several cohorts and groups of populations. Prevalence estimates were mostly based on ultrasound studies, because duplex ultrasound is accurate, reproducible and inexpensive to diagnose and follow up patients with arterial disorders. The purpose of our study was to describe the pattern of carotid artery disease in a large sample of Egyptians. Methods: We analyzed the data of 4,733 Egyptian subjects, who underwent extracranial carotid duplex scanning at the vascular laboratories of Cairo University Hospitals from January 1, 2003, to January 1, 2008. Demographic, clinical data and causes of referral were correlated with ultrasound findings. Results: Atherosclerotic carotid artery disease was present in 41% of the study population in the form of intimal thickening in 835 (17.6%), <50% stenosis in 983 (20.8%), 50–69% stenosis in 81 (1.7%), ≧70% stenosis in 38 (0.8%) and occlusion of internal carotid artery in 3 (0.06%) patients. Nonatherosclerotic disease was detected in 9 (0.2%) patients only. Significant and clinically relevant stenosis ≧50% was detected in 19 (2.5%) of the atherosclerotic symptomatic subjects. Multivariate stepwise logistic regression analysis selected age, diabetes mellitus, hypertension, smoking and dyslipidemia as independent predictors of the presence of carotid atherosclerotic disease. Conclusion: Hemodynamically significant and clinically relevant extracranial atherosclerotic carotid disease is rare among Egyptians. Risk factors for carotid atherosclerosis are the same as in societies where carotid disease is more prevalent.

Left ventricular diastolic dysfunction in patients with chronic obstructive pulmonary disease: Impact of methods of assessment

The prevalence of left ventricular (LV) diastolic dysfunction in patients with chronic obstructive pulmonary disease (COPD), using different echocardiographic parameters, varies widely in the literature. The highest prevalence of LV diastolic dysfunction was detected using the mitral inflow indexes that are commonly altered in these patients due to the associated tachycardia, reduced preload, and ventricular septal shift. In this study, we aimed at evaluating the impact of the used echocardiographic method of assessment on the prevalence of LV diastolic dysfunction in patients with COPD and normal LV systolic function.

Familial history of hypertension as a predictor of increased arterial stiffness in normotensive offspring

Background Increased arterial stiffness can be used as a prognostic marker of arterial hypertension. The relationship between arterial stiffness and arterial hypertension seems to be reciprocal. Objective Evaluation of changes of the arterial elastic prosperities in normotensive subjects, with and without parental history of hypertension. Subjects and Methods One hundred and ten normotensive individuals, aged 20–30 years, were divided into two groups: group-A (n = 57) and group-B (n = 53) subjects with positive and negative parental history of hypertension, respectively. Systolic, diastolic and pulse pressures were measured using mercury sphygmomanometer. The elastic properties of the ascending aorta and the common carotid arteries were assessed using M-mode echo and B-mode imaging, respectively. Stiffness index of the digital volume pulse (SIDVP) was measured in the right index finger using photoplethysmography. Results Group A subjects showed higher aortic stiffness index (p = 0.002), carotid stiffness index (p = 0.001), carotid pulse wave velocity (p ⩽ 0.001) and stiffness index of digital volume pulse (p = 0.001). Group A subjects showed lower aortic distensibility (p = 0.001), aortic strain (p = 0.004), changes in aortic diameter (p = 0.022), carotid distension (p = 0.026), carotid distensibility coefficient (p ⩽ 0.001) and carotid compliance coefficient (p = 0.002). Conclusion The aortic and carotid stiffness parameters and SIDVP were higher in normotensive offspring of hypertensive parents. This finding could direct the attention towards the increased cardiovascular risk in this group and thus prompt earlier and tighter prevention of cardiovascular risk factors.

Carotid atherosclerosis in Egypt: what is beyond?

IJS readers may be interested to know that intravenous (IV) thrombolysis has been used as a standard therapy in acute ischaemic stroke (IS) (1, 2). In the United States, tissue plasminogen activator (tPA) was approved for the treatment of acute IS in 1996, but its use has only recently been accepted by the Department of Medicine of Ho Chi Minh city (HCMC) in 2005. Since 2006, there are three hospitals in HCMC offering thrombolysis for acute IS. The major obstacles for treatment are the cost of drug and the limited therapeutic window, which requires public awareness and organised emergency management. The cost of thrombolysis in Vietnam is not subsidised by government or private insurance; therefore, it is only available for patients who can afford to pay for the drug. The three major stroke units in HCMC managed a total of 6171 patients with acute IS between May 2006 and May 2009. Of these, 121 patients (2%) received IV-tPA based on the inclusion and exclusion criteria of the NINDS study (1). Our study sample had a mean age of 57-years, and 46% were men. Hypertension was the most common vascular risk factor (61%), followed by atrial fibrillation (21%) and diabetes mellitus (17%). The leading TOAST (3) stroke subtype was cardioembolism (35%). The median admission NIHSS score was 12 (range, 5–23), and the median time from symptom onset to administration of an IV-tPA bolus was 143 min. The usual dosage of rt-PA was 0 9 mg/kg. However, in patients who could not afford complete costs of the drug, the dosage was lowered to 0 6–0 9 mg/kg (maximum 50 mg) based on previous data showing that low-dose IVrt-PA administered to Asian patients resulted in relatively good efficacy and safety compared with regular-dose therapy in Western patients (4, 5). Seventy-three (60 3%) patients received standard dose and 48 (39 7%) patients received lower dose (mean calculated IV-tPA dose for these patients was 0.62 mg/kg, range 0 6–0 86 mg/kg). We found that 52 (43%) of patients receiving rt-PA showed an mRS 0–1 at 3-months after receiving IV alteplase therapy, comparable with figures from NINDS (39%) (1). Symptomatic intracranial haemorrhage within 36 h occurred in only (4 1%) of treated patients and 10 (8%) of treated patients died within 3-months of stroke. The majority of patients with IS presenting to our stroke units were ineligible for treatment as only 8 7% of our patients arrived within 3 h. The principal reasons for this may be a lack of awareness of stroke symptoms and a poorly developed ambulance system. Moreover, 5% of eligible patients did not give consent because of a fear of excessive bleeding risk. Our study provides further confirmatory evidence of the safety and feasibility of IV-tPA for treatment in Asian patients with acute IS. More needs to be done to improve public awareness and organisation of services to enable more people to be eligible for treatment.

Right Ventricular Function After Creation of Atriovenous Fistula in Patients With End Stage Renal Disease

BACKGROUND Right ventricular (RV) dysfunction is associated with increased risk of heart failure and mortality in end stage renal disease (ESRD) patients. Accumulating evidence suggests an association between atriovenous fistula (AVF) and RV dysfunction; however, there is no adequate data on the relation between AVF characteristics and risk of RV dysfunction after AVF creation. METHODS The study included 30 ESRD patients (median age: 44years, 17 male) who had their first autogenous mature AVF. Before and 6months after AVF creation the following were measured: myocardial performance index of RV (MPI-RV) using tissue Doppler imaging echocardiography and flow rate (Qa), feeding artery and receiving vein diameters using colour-flow Doppler ultrasound. Change (Δ) in MPI-RV was calculated by subtracting follow-up value from baseline value. Worsening RV function was defined as Δ MPI-RV>0.015 and high AVF flow as Qa≥950ml/min. RESULTS Compared to patients with lower AVF flow, patients with higher flow showed increased Δ in MPI-RV (0.12 vs. -0.03, p=0.04), basal RV diameter (0.3 vs. -0.02cm, p=0.014), left ventricular end diastolic volume index (9.9 vs. 0ml/m2, p=0.004) and left atrial volume index (3 vs. 1ml/m2, p=0.016). Among all clinical, echocardiographic and AVF-related parameters, univariate predictors of worsening of RV function were: high Qa, upper arm AVF, and large feeding artery diameter at baseline. Δ MPI-RV showed significant correlations with feeding artery diameter at baseline (r=0.46, p=0.01), and Qa (0.37, p=0.04) and no significant correlation with pulmonary artery pressures. Qa≥950ml/min, feeding artery diameter at baseline≥4mm and upper arm AVF can predict worsening of RV function with 73%, 73%, 75% sensitivity and 67%, 67%, 70% specificity, respectively. CONCLUSIONS In patients with ESRD, higher AVF flow adversely affects RV remodelling, manifested as increased size and worsening function. Predictors of worsening of RV function are: higher AVF flow rate, AVF in the upper arm, and large feeding artery diameter.