Houry Puzantian

Delay in seeking health care for acute coronary syndromes in a Lebanese sample

Early treatment of patients with acute coronary syndromes (ACS) is crucial to reduce morbidity and mortality. The purpose of this study was to examine delay in seeking care for ACS symptoms in a Lebanese sample and identify predictors of delay. Medical record reviews and interviews using the Response to Symptoms Questionnaire were conducted with 204 ACS patients in coronary care within 72 hours of admission. Median time from symptom onset to hospital arrival was 4.5 hours. Higher education, presence of dyspnea, intermittent symptoms, and waiting for symptoms to go away predicted longer delays, whereas intensity of symptoms and active response (going to the hospital) predicted shorter delays. The findings suggest lack of knowledge of ACS symptoms and the need for public education in this regard.

Parental consanguinity and family history of coronary artery disease strongly predict early stenosis

BACKGROUND Coronary artery disease (CAD) is a multifactorial disease with acquired and inherited components. AIM We investigated the roles of family history and consanguinity on CAD risk and age at diagnosis in 4284 patients. The compounded impact of diabetes, hyperlipidemia, hypertension, smoking, and BMI, which are known CAD risk factors, on CAD risk and age at diagnosis was also explored. METHODS CAD was determined by cardiac catheterization. Logistic regression and stratification were performed to determine the impact of family history and consanguinity on risk and onset of CAD, controlling for diabetes, hyperlipidemia, hypertension, smoking, and BMI. RESULTS Family history of CAD and gender significantly increased the risk for young age at diagnosis of CAD (p<0.001). Consanguinity did not promote risk of CAD (p=0.38), but did affect age of disease diagnosis (p<0.001). The mean age at disease diagnosis was lowest, 54.8 years, when both family history of CAD and consanguinity were considered as unique risk factors for CAD, compared to 62.8 years for the no-risk-factor patient category (p<0.001). CONCLUSIONS Family history of CAD and smoking are strongly associated with young age at diagnosis. Furthermore, parental consanguinity in the presence of family history lowers the age of disease diagnosis significantly for CAD, emphasizing the role of strong genetic and cultural CAD modifiers. These findings highlight the increased role of genetic determinants of CAD in some population subgroups, and suggest that populations and family structure influence genetic heterogeneity between patients with CAD.

Assessing procedural pain in children with cancer in Beirut, Lebanon

This study describes the relationship between different indicators of pain, including self-reports, behavioral observations, and physiological measures, in children with cancer undergoing invasive procedures. Forty-five children between the ages of 4 and 10 years were evaluated while undergoing Port-a-Cath access. The study was conducted in the outpatient clinics of the Children’s Cancer Center in Beirut, Lebanon. Children used 2 self-report measures of pain (the Wong-Baker FACES Pain Rating Scale and an adaptation of the FACES, the DOLLS). Parents and nurses assessed the child’s pain on the FACES and the child’s distress on the Observational Scale of Behavioral Distress-Revised. Nurses recoded behavioral observations as well as physiological responses to pain. There was a high degree of consistency between the self-reports and moderate to high correlations between self-reports, behavioral parameters, and physiological parameters, suggesting that accurate pain assessments can be made by both nurses and parents. The results also demonstrate adequate validity and reliability of the DOLLS scale in a Lebanese population, in addition to being the preferred assessment tool for all the children in the study.

Improving women's cardiovascular health: a position statement from the International Council on Women's Health Issues.

Cardiovascular disease (CVD) is the number one killer of women worldwide, and it remains the primary cause of death and disability in both developed and developing countries. The International Council on Womens Health Issues is an international nonprofit association dedicated to the goals of promoting the health, health care, and the well-being of women. Based on the outcomes of a facilitated discussion at its 18th biannual meeting, delegates aim to raise awareness about the potent influence of gender-specific factors on the development, progression, and outcomes of CVD. Key recommendations for decreasing the burden of CVD are also discussed.

Identifying predictors of high sodium excretion in patients with heart failure: A mixed effect analysis of longitudinal data

Background: A low-sodium diet is a core component of heart failure self-care but patients have difficulty following the diet. Aim: The aim of this study was to identify predictors of higher than recommended sodium excretion among patients with heart failure. Methods: The World Health Organization Five Dimensions of Adherence model was used to guide analysis of existing data collected from a prospective, longitudinal study of 280 community-dwelling adults with previously or currently symptomatic heart failure. Sodium excretion was measured objectively using 24-hour urine sodium measured at three time points over six months. A mixed effect logistic model identified predictors of higher than recommended sodium excretion. Results: The adjusted odds of higher sodium excretion were 2.90, (95% confidence interval (CI): 1.15–4.25, p<0.001) for patients who were obese; 2.80 (95% CI: 1.33–5.89, p=0.007) for patients with diabetes; and 2.22 (95% CI: 1.09–4.53, p=0.028) for patients who were cognitively intact. Conclusion: Three factors were associated with excess sodium excretion and two factors, obesity and diabetes, are modifiable by changing dietary food patterns.

The i allele of the angiotensin converting enzyme I/D polymorphism confers protection against coronary artery disease

BackgroundMutations in genes regulating lipid metabolism, vasoactivity, and coagulation are important modulators of coronary artery disease (CAD). ObjectiveThis study investigated the association between allelic variants of the angiotensin converting enzyme (ACE), methytetrahydrofolate reductase, plasminogen activator inhibitor-1 and factor V genes and CAD. MethodsClinical, biochemical, and angiographic information were collected from 300 patients who underwent cardiac catheterization and their DNA was genotyped by restriction fragment length polymorphism. ResultsThe frequency of the D allele of the ACE gene was significantly higher than the I allele in patients with more than 70% stenosis in any vessel. Among patients with more than 70% stenosis, carriers of the D allele were 2.8 times more likely to be males. The presence of the ACE I allele was negatively associated with CAD with (P=0.02 ,OR=0.38.) ConclusionThis study describes a protective role of the ACE I allele in individuals who may be at risk of developing CAD.

Understanding kidney function assessment: The basics and advances

Purpose: Multiple kidney function assessment modalities are available, but their appropriateness is constantly questioned. This review provides practitioners with in‐depth understanding of kidney function assessment methods, their clinical utility, and comparisons. Data sources: PUBMED search was conducted by relevant subject headings. Conclusions: Glomerular filtration rate (GFR) is the best indicator of kidney function. Exogenous compounds like inulin help measure GFR, but endogenous substances (like creatinine) are more convenient, although exhibiting greater variability. Cystatin C is advocated as a functional marker; its clinical significance is under study. Proteinuria adds value to GFR estimation. There are commonly used equations estimating GFR like the creatinine‐based Cockcroft–Gault and the modification of diet in renal disease. The new creatinine‐based Chronic Kidney Disease Epidemiology Collaboration (CKD‐EPI) equation demonstrates higher accuracy of patient classification in earlier stages of disease. Recently, the Chronic Renal Insufficiency Cohort (CRIC) study has devised an equation combining serum creatinine and cystatin C in longitudinal modeling of kidney function. Implications for practice: Current GFR estimation methods have limitations, and are useful for populations they have been tested in. Practitioners should be well informed on emerging equations that provide greater accuracy in CKD diagnosis; this would help implement appropriate prevention and intervention strategies.

Circulating Dephospho-Uncarboxylated Matrix Gla-Protein Is Associated With Kidney Dysfunction and Arterial Stiffness

BACKGROUND Large artery stiffening is increased in advanced chronic kidney disease (CKD) but likely develops progressively in earlier stages of CKD. Active matrix Gla-protein (MGP) is a potent vitamin K-dependent inhibitor of vascular calcification. A recent animal model demonstrated intrinsic abnormalities in vitamin K metabolism even in early CKD, but whether early human CKD is associated with vascular vitamin K deficiency is unknown. METHODS We enrolled 137 adults without HF with varying degrees of renal function: normal estimated glomerular filtration rate (eGFR; >90 ml/min; n = 59), mildly reduced eGFR (stage 2 CKD: eGFR = 60-89 ml/min; n = 53) or at least moderately reduced eGFR (stage 3-5 CKD; eGFR < 60 ml/min; n = 25). Carotid-femoral pulse wave velocity (CF-PWV) was measured with carotid and femoral tonometry. Dephospho-uncarboxylated matrix gla-protein (dp-ucMGP) was measured with enzyme-linked immunosorbent assay (ELISA) (VitaK; Maastricht University; The Netherlands). RESULT Dp-ucMGP levels were progressively increased with decreasing renal function (eGFR ≥ 90: 247 pmol/l; eGFR 60-89: 488 pmol/l; eGFR < 60: 953 pmol/l; P < 0.0001). These differences persisted after adjustment for multiple potential confounders (eGFR ≥ 90: 314 pmol/l; eGFR 60-89: 414 pmol/l; eGFR < 60: 770 pmol/l; P < 0.0001). In a multivariable model adjusted for various confounders, dp-ucMGP was a significant independent predictor of CF-PWV (β = 0.21; P = 0.019). In formal mediation analyses, dp-ucMGP mediated a significant relationship between eGFR and higher CF-PWV (β = -0.16; P = 0.005), whereas no significant dp-ucMGP-independent relationship was present (β = -0.02; P = 0.80). CONCLUSIONS CKD is associated with increased (inactive) dp-ucMGP, a vitamin K-dependent inhibitor of vascular calcification, which correlates with large artery stiffness. Further studies are needed to assess whether vitamin K2 supplementation represents a suitable therapeutic strategy to prevent or reduce arterial stiffening in CKD.

Investigating the Effect of Glucose on Aortic Pulse Wave Velocity Using Pancreatic Clamping Methodology

Aortic stiffness, determined by carotid-femoral pulse wave velocity (cfPWV), independently predicts cardiovascular outcomes. Recent studies suggest that glucose levels influence arterial stiffness indices. It is not clear, however, whether glucose affects cfPWV independently of glucoregulatory hormones. The aim of this study was to utilize a pancreatic clamping approach to determine whether plasma glucose independently predicts cfPWV. Healthy participants (N = 10) underwent pancreatic clamping to control glucose at varying concentrations using a 20% dextrose infusion while suppressing endogenous glucagon, insulin, and growth hormone by octreotide and replacing the hormones intravenously to achieve basal concentrations. Tonometric cfPWV, blood pressure, heart rate, plasma glucose, glucagon, insulin, growth hormone, and vasoactive biomarkers were measured. Plasma glucose levels of 150 mg/dl at 1 hr and 200 mg/dl at 2 hr postbaseline were achieved. There were no significant changes in cfPWV (5.8 m/s at 0 hr, 5.9 m/s at 1 hr, and 5.9 m/s at 2 hr) with increased glucose levels. There were small increases in insulin secretion. A definitive role for glucose in cfPWV modulation was not determined; there is a potential role for insulin as a cfPWV modulator. Continued efforts in clarifying the independent roles of glucose and insulin can elucidate novel vessel-related targets for cardiovascular disease prevention and management in patients with impaired glucose tolerance and diabetes.