Bangladesh Heart Journal

Association Between Neutrophil to Lymphocyte Ratio and Severity of Coronary Artery Disease in Acute Myocardial Infarction Patients

Tania Easmin — 2024-01-04

Background: Acute myocardial infarction is one of the leading causes of death across the world. Determination of severity is important in patients with acute myocardial infraction for the therapeutic decision making. Neutrophil to Lymphocyte Ratio (NLR) has been proposed as a new prognostic marker in patients with acute MI. Several international studies have found to compare the relation between NLR and severity of coronary artery disease. In these studies, they demonstrated that the NLR is higher in severe CAD. In our country no such study has been done yet to predict the severity of coronary artery disease by estimating NLR in acute MI patients. Moreover, NLR is cheap, easily available, non-invasive and routinely done procedure.

Objectives: This study was conducted to find out the association of NLR to severity of CAD in acute MI patients.

Methods: This observational cross sectional analytical study was carried out in the Department of Cardiology, Dhaka Medical College Hospital, SSMC and Mitford Hospital and NICVD, Dhaka from March 2021 to February, 2022. Patients with acute MI (STEMI and NSTEMI) were approached for this study according to inclusion and exclusion criteria. They were divided into two groups according to NLR: Group A NLR >2.5 and Group B NLR ≤2.5. Coronary angiogram was done during index hospitalization. The severity of coronary artery disease was assessed by Vessel score and Gensini score. According to Gensini score was non severe (≤50) severe (>50).

Results: Among 70 patients in our study 30 (42.8%) were in the high NLR group (Group A) and 40 (57.14%) were in low NLR group (Group B). In group A mean NLR was 5.15 ± 2.21 and in group B mean NLR was 1.65 ± 0.35, this difference was statistically significant. Severe coronary artery disease in terms of vessel score and Gensini score was significantly higher in group A than group B (p value 0.001). We found strong positive correlation between NLR and Gensini score (r= 0.7, p= 0.001), and moderate positive correlation between NLR nad vessel score (r= 0.5, p= 0.001). With the increase of NLR, vessel score and Gensini score increases demonstrating more severe CAD. Simple logistic regression analysis of variables of interest revealed that hypertension (p=0.003), diabetes mellitus (p=0.008), dyslipidaemia (p=0.007), WBC count(p=0.034), Neutrophil count (p=0.000), Lymphocyte count (p=0.000), NLR (p=0.000), LVEF (p=0.001) were independent predictor of severe coronary artery disease with odds ratio (OR) being 5.32, 3.88, 4.42, 1.00, 1.20, 0.834, 2.28, 0.805 respectively. In multivariate logistic regression analysis, after adjustment of confounding, hypertension (p=0.028, OR=5.87) and NLR (P=0.004, OR=1.81) remain independent predictor of severe CAD. In ROC curve analysis, the AUC of NLR for predicting severity of CAD is 0.8 with p value < 0.001, 95% CI (0.78-0.96) and with 75% sensitivity and 86.5% specificity. So, from this study, it is evident that NLR is directly associated with coronary artery disease severity.

Conclusion: Increased NLR was associated with angiographically severe coronary artery disease in acute Myocardial Infarction patients, and this association is independent of conventional cardiovascular risk factors.

Bangladesh Heart Journal 2024; 39(1): 1-9

Association of Left Atrial Volume Index with Adverse In-Hospital Outcome in Patients with St-Elevated Acute Myocardial Infarction

Abu Md Towab — 2024-01-04

Background: Coronary heart disease is the leading cause of death worldwide, with acute STEMI being the most severe manifestation. Left atrium (LA) plays a major role in left ventricular performance. LA function is a surrogate marker of LV diastolic dysfunction. In recent past, several studies conducted in different parts in the world have focused on the effect of ASTEMI on the volume and function of left atrium. So, assessment of left atrial volume index (LAVI) by 2D echocardiography in patients who have suffered an acute STEMI helps to predict the adverse cardiovascular outcome.

Objective: The aim of the study is to assess the LAVI for prediction of adverse in-hospital outcomes following acute STEMI patients admitted in a tertiary care hospital.

Methods: This Hospital based prospective observational study was conducted in the department of cardiology in DMCH over 1-year period. Patients with acute STEMI admitted in the CCU of DMCH were approached for inclusion in the study. Clinical and echocardiographic parameters were collected within 48 hours of admission. LA volume is measured and then indexed to body surface area called LA volume index (LAVI) and the population was divided according to LAVI. The study comprised of 150 acute STE-MI patients and were divided into two groups, including 75 patients in each group. Patients with LAVI>34 ml/m2and LAVI≤34 ml/m2 were assigned as Group I and Group II respectively & followed up for adverse in-hospital outcome. All necessary information were recorded in a pretested case record form. Statistical analyses were done by SPSS 17.0.

Result: The mean age was 57.7 ± 7.0 years ranging from 39 to 80 years. Most of the patients were male 109 (72.7%). Majority of the patients had anterior wall ( anterior, antero-septal & extensive anterior) myocardial infarction (85%).It was observed that patients with LAVI>34 ml/m2(Group I) had more adverse in-hospital outcomes than patients with LAVI≤34 ml/m2( Group II) (46.7% vs 14.7 % ;p< 0.001 ).By multivariate logistic regression analysis, LAVI>34 ml/m2 emerged as an independent significant predictor of adverse in-hospital outcome(Odds Ratio 6.55,95% confidence interval: 2.069 – 20.735, p = 0.001 )

Conclusion: In patients with acute STEMI, with LAVI>34 ml/m² had more adverse in-hospital outcomes than patients with LAVI≤34 ml/m². So early assessment of LAVI by echocardiography is useful to predict adverse in-hospital outcome.

Bangladesh Heart Journal 2024; 39(1): 10-16

Hospital Outcome of Hypertensive Non-ST Elevation Myocardial Infarction Patients in Diabetic and Non-Diabetic Groups

Muhitul Matin — 2024-01-04

Objective: Acute myocardial infarction is one of the leading causes of all acute emergencies and is becoming an important public health problem in the developing countries. Non-ST elevation myocardial infarction (NSTEMI) is more heterogeneous in their presentation and may be poorly characterized in clinical practice, leading to greater variation in diagnosis and treatment. Patients with diabetes and hypertension who develop a NSTEMI are at increased risk for poor hospital outcome. This study is aimed to assess the differences between hypertensive diabetic and hypertensive non-diabetic patients with NSTEMI and to evaluate the prognostic impact of selected clinical and laboratory parameters on the occurrence of hospital complications.

Methods: This was a cross-sectional analytical study. All the adult hypertensive patients of newly diagnosed NSTEMI with or without diabetes mellitus admitted in Ibrahim Cardiac Hospital & Research Institute, Dhaka who fulfilled the inclusion and exclusion criteria were enrolled. The study population comprised of 100 hypertensive patients with their first NSTEMI, and were divided into two groups according to the presence of type 2 diabetes mellitus. Group I (n = 40) patients were diabetic and Group II (n = 60) were non-diabetic. Hospital outcome of the study population was recorded. The incidence of in hospital adverse clinical events in the two groups was compared by using the odds ratio of the two binomial proportion analyses.

Results: Among 100 hypertensive NSTEMI patients, 40% were diabetic (Group I) and 60% were non-diabetic (Group II). Mean age was 58.1±10.2 years in case of diabetic group (Group I) and 56.3±10.5 years in non-diabetic group (Group II) ranging from 30-70 years. Male patients (66%) were predominant in the study. Most common clinical presentation was chest pain which was 77.5% in Group I and 83.3 % in Group II followed by sweating (12.5% and 16.7%), dyspnea (10.0% and 11.7%), syncope (5.0% and 6.7%) and atypical chest pain (2.5% and 3.3%) respectively. Smoking was the commonest risk factor which was 62.5% in Group I and 75% in Group II followed by dyslipidemia (32.5% and 36.7%), family history of IHD (30% and 23.3%) and obesity (22.5% and 13.3%) respectively. Diabetic hypertensive patients had significantly higher heart rate, hypertensive peaks and more episodes of asymptomatic ST segment depression. Most common in hospital complications were heart failure (30% and 16.7%), arrhythmias (22.5% and 6.7%), renal failure (10% and 5.0%), cerebral ischemia (7.5% and 1.7%), death (7.5% and 3.3%) and cardiogenic shock (5.0% and 3.3%) in Group I and Group II respectively.

Conclusion: In hospitals, adverse clinical events were more frequent in diabetic hypertensive individuals compared to non-diabetics.

Bangladesh Heart Journal 2024; 39(1): 17-23

Correlation Between HbA1c, Serum Magnesium (Mg) and Lipid Profile in Type 2 Diabetic Foot Ulcer and without Foot Ulcer Patients – A Cross-Sectional Study

Laila Sultana — 2024-01-04

Introduction : Diabetes mellitus, especially Type 2, is a common metabolic problem in Bangladesh with serious complications like diabetic foot ulcer. The relationship between HbA1c, serum magnesium, and lipid profile in type 2 DFU patients was examined in this study.

Aim of the study: The aim of this study was to examine the correlation between HbA1c, serum Magnesium, and lipid profile in type 2 diabetic foot ulcer and without foot ulcer patients.

Methods: This cross-sectional study was conducted in the Department of Biochemistry and Molecular Biology, BIRDEM Academy, Dhaka, Bangladesh during the period from January 2018 to December 2018

Result: In total 120 respondents who were adult male and female were included in the study. In our study, we found that the majority of our patients (58.3%) were aged between 41-50 yrs. in group II. We found the percentage of male and female participants were 66.7% and 33.3% in group I and 51.7% and 48.3% in group II respectively. The negative correlation was found between serum magnesium with fasting plasma glucose and Triacylglycerol in group I. The significant positive correlation was found between serum Mg and HDL-c (r=0.443; p<0.01) in group I.

Conclusion: Diabetes Mellitus, notably Type 2, poses challenges in Bangladesh, including Diabetic Foot Ulcer (DFU). This study explores links between HbA1c, serum magnesium, and lipid profile in Type 2 DFU patients, potentially guiding early interventions and improving diabetic care outcomes.

Bangladesh Heart Journal 2024; 39(1): 24-30

Efficacy and Safety of Fondaparinux Versus Enoxaparin in The Management of Unstable Angina and NSTEMI

Md Mahfuzur Rahman — 2024-01-04

Background: Unstable angina (UA) and Non-ST elevation myocardial infarction (NSTEMI) impose significant health and economic burden on Bangladesh. Anticoagulants are recommended as standard therapy by various clinical practice guidelines. Recent studies have shown fondaparinux's superiority over enoxaparin in patients with UA & NSTEMI, especially in bleeding reduction. The description of this finding has not yet been documented in any study from Bangladesh. This study aimed to evaluate the efficacy and safety of fondaparinux compared with enoxaparin in the management of UA & NSTEMI.

Methods: This prospective observational study included 177 patients (fondaparinux=87, enoxaparin=90) with UA and NSTEMI admitted to the Department of Cardiology of Abdul Malek Ukil Medical College Hospital, Noakhali, Bangladesh. The primary outcome was to determine whether fondaparinux was non-inferior to enoxaparin in preventing the composite of death, new myocardial infarction, and refractory ischemia, readmission in the hospital for heart failure within six months after anticoagulant therapy. The primary safety outcome was to evaluate the rates of major bleeds in the two groups.

Results: The minor (6.9% versus 20%, p=0.002) and major (0% versus 3.3%, p=0.002) bleeding events were less frequently observed with Fondaparinux than enoxaparin. Myocardial ischemia (3.4% vs. 14.4%, p=0.011) and recurrent ischemia (11.5% vs. 24.4%, p=0.025) were less frequent in Fondaparinux than in the enoxaparin group. Fondaparinux was associated with a reduced number of deaths in 3 months (6.2% vs. 12.5%) and 6 months (5.1% vs. 13.3%) without any statistical significance (p>0.05). In the fondaparinux group, 20.7% of patients experienced a composite event within 6 months, compared with 40% of patients in the enoxaparin group (OR:0.659, 95% CI 0.500-0.867, p=0.005).

Conclusion: Similarly, to recently published data in international literature, fondaparinux proved superior to enoxaparin for the Bangladeshi population, with a significant reduction of combined events and bleeding in patients with UA & NSTEMI.

Bangladesh Heart Journal 2024; 39(1): 31-37

Bacterial Isolation from Wound Swab and Pus with their Antibiotic Susceptibility Pattern in a Tertiary Care Hospital of Bangladesh

Ferdush Jahan — 2024-01-04

Background: Wound infection is a global health problem, plays an important role in development of chronicity, delaying wound healing associated with long hospital stay.

Objective: This study was aimed to identify the bacterial pathogens present in infected wounds and characterize their resistance profile to the most common antibiotics used in the therapy.

Methods: This observational study was conducted from January, 2023 to June, 2023 in a tertiary care hospital in Dhaka, Bangladesh. A total of 220 wound swabs and pus samples were collected from the outpatient and inpatient department of this hospital with skin and soft tissue infection. Samples were inoculated on appropriate media and cultured and the isolates were identified by standard procedure as needed. Antimicrobial susceptibility testing was done by disc diffusion method according to ‘The Clinical Laboratory Standard Institute Guidelines’.

Results: Out of 220 cases 165(75%) were Male and 55(25%) were female. Majority of the patients 77(35%) were in the age group of 21-31 years. Of the total 220 isolates, 156(70.91%) were culture positive cases. Among the isolated organisms, predominant bacteria was Pseudomonas spp 76(48.22%) followed by Klebsiella 27(17.31%), Escherichia coli 19(12.18%), Proteus 13(8.33%), Staphylococcus aureus 12(7.69%) and Acinetobacter 9(5.77%). Among the gram negative isolates, Pseudomonas was highly sensitive to colistin(88.15%), followed by piperacillin-Tazobactam(77.63%)and Imipenem(50%) and low sensitivity found in ceftriaxone(14.47%), Amoxiclav(13.16) and Clotrimoxazole (13.16%). Klebsiella found sensitive to colistin (90.47%), Piperacillin-Tazobactam (85.71%), Imipenem (76.19%), Gentamycin (71.43%). Escherichia coli shows low sensitivity to almost all the drug except Imipenem (94.74%), Piperacillin-Tazobactam (84.21%) and colistin(84.21%). Stapylococcus aureus show sensitivity to linezolid (100%), vancomycin (91.67%) and Ciprofloxacin (61.67%).

Conclusion: Antibiotic sensitivity pattern of various isolates will guide for appropriate selection of the antibiotic against wound infection and reduce the spread of resistance bacteria.

Bangladesh Heart Journal 2024; 39(1): 38-43

Correlation Between Magnitude of ST Segment Elevation and the Proximal Right Coronary Artery Lesion in Acute Inferior Myocardial Infarction

Adyle Mahmood — 2024-01-04

Introduction: The determination of the probable site of occlusion within RCA in acute inferior MI is very important because proximal occlusions are likely to cause greater myocardial damage and an early invasive strategy may be planned in such cases. Furthermore, identification of infarct-related artery and its site in acute inferior myocardial infarction not only guide decision regarding the urgency of revascularization but also guide to avoid therapy that may adversely affect the outcome.

Objective: To predict the site of lesion in right coronary artery in acute inferior myocardial infarction by the magnitude of ST segment elevation in inferior leads (II, III and aVF).

Methodology: This cross-sectional study was conducted in the Department of Cardiology, Sylhet MAG Osmani Medical College Hospital, from January 2014 to December 2015. A total of 50 consecutive patients with inferior MI who present within 12 hours of symptom onset and received fibrinolytic therapy were selected according to inclusion and exclusion criteria. Using 12-lead ECG, height of ST segment elevation in leads II, III and aVF were measured & coronary angiography(CAG) was performed during index hospital period .CAG which showed culprit lesion in RCA were only taken for the study. The sum of STsegment elevation in inferior leads were then correlated with the proximal lesion in RCA.

Results: The age of the patients ranged from 31 to 70 years with the mean age of 51.1 (SD 9.2) years. Majorities (88%) of the patients were male and ratio of male to female was 7.33:1.Out of 50 patients, 26(52%) had the lesion in proximal, 19 (38%) in mid and 05 (10%) in distal RCA. Patients with proximal RCA lesion showed a mean ST segment elevation of 12.5(SD 1.07) mm, with mid RCA lesion 8.5 (SD 0.80) mm and distal RCA lesion 6.5(SD 0.42) mm. There was a positive correlation of sum of ST segment elevation in inferior leads II, III and aVF to the proximal lesion in RCA (r=0.923, P < 0.05).

Conclusion: From the study it is concluded that the magnitude of ST segment elevation in inferior leads (II,III, aVF) can predict site of lesion in RCA in acute inferior wall myocardial infarction; the greater the sum of the height of ST segment elevation in inferior leads, the higher is the probability of lying the lesion in proximal right coronary artery.

Bangladesh Heart Journal 2024; 39(1): 44-48

Unlocking the Secrets of Valvular Heart Disease: A Journey through the World of Imaging Modalities

Md Toufiqur Rahman — 2024-01-04

Valvular heart disease is a prevalent and clinically significant condition with potential complications and adverse outcomes if left untreated or poorly managed. Accurate assessment of valve structure, function and hemodynamics is crucial for effective evaluation and management of valvular heart disease. In this systematic review, we provide a comprehensive overview and comparison of imaging modalities used in the assessment of valvular heart disease.

The introduction highlights the background and significance of valvular heart disease, emphasizing its impact on cardiovascular health, global prevalence, and associated complications. Furthermore, it emphasizes the importance of imaging modalities in the evaluation and management of valvular heart disease, discussing their role in providing crucial information for accurate diagnosis, risk stratification, treatment planning, and monitoring.

The objective of this review article is to summarize the strengths, limitations and diagnostic accuracy of different imaging modalities in valvular heart disease assessment. We present detailed discussions on echocardiography, computed tomography (CT) imaging, nuclear imaging techniques and emerging imaging modalities, such as 3D echocardiography, strain imaging and fusion imaging. Each section explores the specific role of the imaging modality, its advantages, limitations and diagnostic accuracy in the evaluation of valvular heart disease.

Additionally, we provide a comparative analysis of these imaging modalities, highlighting their strengths, weaknesses and specific indications. The integration of multiple imaging modalities for a comprehensive evaluation in specific scenarios is also discussed, emphasizing the complementary roles of different modalities in optimizing diagnostic accuracy and treatment planning.

The review concludes with implications for clinical practice and future research directions. It underscores the importance of selecting the appropriate imaging modality or combination of modalities based on individual patient characteristics and clinical needs. Furthermore, it highlights the potential clinical impact of emerging imaging techniques and the need for standardization, cost-effectiveness studies, and further research to optimize the utilization of imaging modalities in valvular heart disease management.

Bangladesh Heart Journal 2023; 39(1): 49–56

Evaluation & Assessment of Chest Pain among Dyslipidemic Out-Door Patients without Prior Clinical Ischemic Heart Disease

Md Nazmul Haque — 2024-01-04

Dyslipidemia is a significant risk factor for atherosclerotic cardiovascular diseases, including ischemic heart disease. However, hypercholesterolemia patients without a history of clinical ischemic heart disease (IHD) may experience chest pain that presents diagnostic and management challenges. This review aims to summarize the existing literature and assess the prevalence of chest pain in this specific patient without having previous heart disease.

Bangladesh Heart Journal 2024; 39(1): 57-62

A Rare Case Series: Cardiac Myxoma and their Versatile Presentation

Poppy Bala — 2024-01-04

Background: Although rare, cardiac myxomas are the most common primary cardiac tumor with an incidence of 0.5 per million per year. Clinical presentation is variable and ranges from intracardiac obstruction, embolization to the pulmonary and systemic circulation, heart failure or constitutional symptoms. Surgical resection is the only effective treatment to prevent its debilitating and catastrophic complication.

Case summary: Here, three atypical presentations as well as three different locations of cardiac myxomas were reported. First one is a rare case of ST-elevated myocardial infarction due to myxoma that originated from the left ventricle. One case involved right sided myxomas with pulmonary embolism. The third case involved huge left atrial myxoma combined with recurrent syncope. All three cases were almost misdiagnosed due to their atypical presentation. Echocardiography was the primary tool for detecting and diagnosing these cases. Subsequently all three patients underwent successful resection of myxoma. We also review clinical presentations and diagnostic characteristics of cardiac myxomas.

Conclusion: Rare cardiac myxomas may have various clinical and imaging features. Physicians especially other non-cardiologist must increase their awareness of this disease and engage in the early diagnosis. Echocardiography is the diagnostic procedure of choice. The long-term survival after surgical resection is excellent and recurrence is rare.

Bangladesh Heart Journal 2024; 39(1): 63-68

Successful Excision of the Left Ventricular Thrombus in a Young Stroke Patient

Md Sayedur Rahman Khan — 2024-01-04

In this case report, a 29-year young male patient who presented with a history of right sided hemiparesis for 12 hours with no apparent cause. He showed no cough, palpitations, breathlessness, chest pain, syncope, or loss of vision. He had no relevant family history but had a history of two times admission in a National Neuroscience hospital for stroke. Echocardiography showed a freely mobile LV apical mass with hypokinetic apical septum and apex. He underwent successful removal of the mass via the LA roof. The postoperative TEE was normal. Histopathological examination of the resected mass revealed organized thrombus and patient had a satisfactory outcome.

Bangladesh Heart Journal 2024; 39(1): 69-72