1. 1. Bangladesh journal ofCardiologyVol.01, No.03, March 2010 Oicial Publication of Labaid Cardiac HospitalThe association between percutaneous coronary intervention (PCI) and subsequent myonecrosis has been recognized for many years.Its incidence varies from 10-40%,depending on clinical,angiographic and proceduralcharacteristics,adjunctive therapy.PCI related myonecrosis occurs frequentlyand predicts short term risk of death.It has been suggested that a signicant rise in the biomarker eg creatine kinase-MB (CK-MB) fraction >3-5 times theupper limit of normal may identify those patients who merit a longer duration CHIEF PATRON of observation in the hospital after elective PCI.No-reow phenomenon is a Dr_AM3hamim leading cause of myonecrosis during PCI and is caused by the variablecombination of four pathogenetic components:1. Distal atherothrombotic (; |-| A|R| /| AN,ED| TOR| A|_ ()0|/ |l/ ||TTEE embolization;2. lschaemic injury;3. Reperfusion injury;and 4. Susceptibility of Dr_ M_ . Ja| a|uddin,FCPS coronary microcirculation to injury.Several pharmacological strategies includingnitropruside,adenosine,verapamil,atrial natriuretic peptide and nicorandil EDITORIAL BOARD have been tested in the management of no-reow phenomenon.Adenosine is Dr.l/ latiurahman,FHCP an endogenous nucleoside mainly produced by the degradation of adenosine Dr-Abdul Zah9l. FRCP triphosphate,which antagonizes platelets and neutrophils,reduces calcium DE A- P- M-_S0hl3bUZZ3m3":FCP3 overload and oxygen free radicals and induces vasodilatation.In this issue of DE A- K~ Mlahr PhD Bangladesh journal of Cardiology Rahman et al presented their initial experience DE Faklul Islam MD of the effects of intracoronary adenosine administration on myonecrosis duringDr.Reyan Anis,FHCPDr.Lutfor Rahman,MSDr.M.Alimuzzaman,FCPSDr.Salauddin Ahmed Selim,DAelective PCI.In their study 12.5% patients in adenosine group had more than 2 times elevation of CK-MB level after the procedure whereas 53.84% patients in the control group had more than 2 times elevation of CK-MB and the differenceDr_ A_ H_ M Abul Monsurl D Card was statistically signicant.EDITOR This issue ofjournal also highlights LV aneurysm repair and long-term results DL Bare Chakrabonyl FRCP after successful mitral balloon valvuloplasty.Dor procedure (endoventricular circular patch plasty repair of the left ventricle with associated coronary As3|3TANT ED| TOR grafting) is a relatively new surgical technique that applies to patients with Dr_ Mahbuborahmanl FACC ventricular dysfunction after an infarction for either akinesia or dyskinesia.Dr_ Fahmida Zaman,D Card Haider et al's experience of 50 cases of Dor procedure and their short term out come and Momenuzzaman et al's ndings of long-term results after successful CHIEF EXECUTIVE percuteneous transvenous mitral commisurotomy (PTMC) in 1033 patients are Dr.(Brig Gen) MGHZOOFA.lVl0ll8h (Held) both distinctively deductive and intellectually informative.While the former intheir series found 30 days mortality rate to be 5.7% and 37 patients had had SECRETARY:PUBUCAHON COMMHTEE event free survival during 6 months follow-up,the latter in theirs observed that A| 'Emla" Chowdhull 96% patients had successful PTMC and only 5 patients died due to proceduralcomplications and 15 patients developed cardiac tamponade which was E/ [|jr| T]aF: ]lLrLRSEK: ::n Lenin managed medically.Rheumatic mitral stenosis is a common disease in Mr Musufekui Salehin Mithun developing countries like Bangladesh and PTMC should be the treatment of Md Abdul Manna choice for suitable symptomatic mitral stenosis. ADDRESS OF CORRESPONDENCE Editor,Bangladesh Journal of Cardiology,Labaid Cardiac Hospital,House 1, Road 4, Dhanmondi,Dhaka 1205, BanglTel :B802B61D793B,967D2103, lax :B80028B17372, Mobile :01819425302. Email :baren_chakrabor1y@yah
2. 2. ContentsMarch,2010; Vol.01, No.03Bangladesh journal of Cardiology Contemporary CardiologyManagement of Chronic Stable Angina:Optimal Medical Therapy versus Percutaneous Coronary Intervention - What we learntom recent trialsF Zaman,B Chakraborly,A SahelCurrent Approaches to Myocardial No-Reow Phenomenon During PClAPM Sohrabuzzaman,AK SharmaEnhanced External Counterpulsation (EECP) in the Treatment ofAngina and Heart Failure- Current Status and RecommendationsAK Sharma,A Khayer,_] KabirTissue Doppler Imaging :Technical Principles And Its Clinical Applications to Assess Ventricular Function and lncoordinationF Zaman,A Monsur,M A Rahman168-169170-175176-178179-181Original ArticlesReview Articleslntracoronary Adenosine Reduces the Incidence of Myonecrosis During Elective Percutaneous Coronary InterventionM Rahman,APM Sohrabuzzaman,S Nazneen,SDM Taimur,S S Pathan,H AhmedLVAneurysm Repair:Experience in Apollo Hospitals DhakaZ Haider,N M Zahangir,S Ahmed,A K Shamsuddin K Z Haque,P Dutta,A SandeepLong Term Results After Successful Mitral Balloon Valvuloplasty Experience of 1033 PatientNAM Momenuzzaman,F Begum,F Malik,N Ahmed,Badiuzzaman KN Khan,AM Shaque,F Haque,DD Adhikary,MU Amin KM Sohail,ZM Illius,Z Haque183-189190-193194-200Role of Echo-Doppler in Heart Failure $. K. Parashar201-208
3. 3. ContentsMarch,2010; Vol.01, No.03Pathophysiology and Management of Coronary Artery Aneurysm- A ReviewM Rahman,SDM Taimui;S NazneenContents Continue209-213Case ReportsFirst Alcohol Septal Ablation for Hypertrophic Obstructive Cardiomyopatliy in Bangladesh - A Case ReportR Anis,N Islam,PHL KaoRepair Of Post Myocardial Infarction Ventricular Septal Rupture - A Case ReportK M Tarik,M Alimuzzaman,A P M SohrabuzzamanComplete Closure of a Coronary Artery-Venous Fistula by Coil Embolization : A Case ReportMA Rahman,S Hoque,PHL KaoAnomalous origin of the Right Coronary Artery om Left Coronary sinus.Angiographic Diagnosis in a Patient with Coronary Artery Disease MAKAkanda,MK Kabir,SKYAli,MM Rahman,L BegumPrimary PCI in Acute Anterior Wall MI with Huge Thrombus G SengottuveluRadiofrequency Ablation of Pulmonary Atrial Fibrillation by Segmental Catheter Technique -First Successful Experience in BangladeshSM Hassain,APM Sohrabuzzaman,M Munawar,A Saxena,B Chakraborty214-218219-221222-225226-228229-231232-234Glimpses from 3rd International Conference on Cardiology and Cardiac Surgery 8 1st Dhaka Live'2009Information for Author(s) and Guidelines for Submission of Article235-241244-244
4. 4. l 68 Zaman E C/ iakraborly B,So/ ielABangladesh j Cardiol,2010; 1(3):168-9Management of Chronic Stable Angina:Optimal Medical Therapy versus Percutaneous Coronary Intervention - What we learnt from recent trialsF Zaman,B Chakraborty,A Sahel Labaid Cardiac Hospital,Dhaka,BangladeshPercutaneous Coronary Intervention (PCI) has opened a new era in the treatment of patients with stable coronary artery disease.During past 30 years,the use of PCI has become common in the initial management strategy for patients with stable coronary artery disease,even though treatment guidelines advocate an initial approach with intensive medical therapy,a reduction of risk factors and lifestyle intervention.More than 4000,000 PCIs are done for this indication each year in the United States.Although evidence from early randomized trials has shown that PCI provides substantial angina relief compared with medical therapy,more recently published trials have challenged this conventional wisdom. Initial management of patients with chronic stable angina continues to be vigorously debated amongst the Cardiologists.Despite the lack of superiority and lack of robust data to support percutaneous coronary intervention (PCI) as the initial management of stable angina,PCI remains one of the most commonly performed procedures5. But recently published Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation ( COURAGE) trial and Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI-2D) trial reignited the controversy of the benet of routine initial PCI over Optimal Medical Therapy (OMT)3'4. Recent registry data indicate that approximately 85% of all PCI procedures are undertaken electively in patients with stable coronary artery disease and 15% for Acute Coronary Syndromes (ACS).PCI reduces the incidence of death and myocardial infarction in patients who present with ACS but similar benet has not been documented in patients with chronic stable angina.COURAGE trial randomized 2287 patients who had objective evidence of myocardial ischaemia and signicant coronary artery disease at 50 US and Canadian hospitals.Patients with stable coronary artery disease and those in whom initial Canadian Cardiovascular Society (CCS) class IV angina subsequently stabilized medically were included in the study.Entry criteria included stenosis of at least 70% in at least one proximal epicardial coronary Dr Fahmicla Zaman,D Carcl, junior Consultant,CarcliologyDr Baren Chakraborty FRCPSenior Consultant Cardiologist & Chief,Medical Education and Research Dr Atikuzzaman Sohel,D Card,junior Consultant,CardiologyCorrespondence:Di Falimicla Zaman,D.Carcljunior Consultant,Cardiology,Labaid Cardiac Hospital House-l,Road- 4, Dhanmondi,Dhaka 1205, Bangladesh Tel:880286107938, E-mail:fahiiiidazamaii@hotmail. coinartery and objective evidence of myocardial ischaemia or at least one coronary stenosis of at least 80% and classic angina without provocative testing.Two thirds of the patients had multivessel coronary artery disease.The primary outcome was death from any cause and nonfatal myocardial infarction during a follow-up period of 2.5 to 7.0 years (median 4.6).There were 211 primary events in the PCI group and 202 events in the medical therapy group.The 4.6-year cumulative primary event rates were 19.0% in the PCI group and 18.5% in the medical-treated group.There was no signicant differences between the PCI group and the medical-treated group in the composite of death,myocardial infarction and stroke.COURAGE concluded that as an initial management in patients with stable coronary artery disease,PCI did not reduce the risk of death,myocardial infarction or other major cardiovascular events when added to OMT3. Patients with type 2 diabetes mellitus have a higher risk of cardiovascular events and death than those without diabetes.Recently published BARI2D trial addressed the issue whether prompt revascularization would reduce long term rates of death and cardiovascular events as compared with medical therapy.This trial randomized 2368 patients with both type 2 diabetes and coronary artery disease to undergo either prompt revascularization with intensive medical therapy or intensive medical therapy alone.At 5 years,rates of survival did not differ signicantly between the revascularization group (88.3%) and the medical- therapy group (87.8%).The rates of freedom from major adverse cardiovascular events also did not differ signicantly among the groups:77.2% in the revascularization group and 75.9% in the medical treatment group.In the PCI stratum,there was no signicant difference in primary end points between the revasculaization group and the medical therapy group.In both COURAGE and BARI 2D trial there were no signicant difference in the rates of death and major cardiovascular events between patients undergoing prompt revascularization and those undergoing medical therapy. The plaque morphology and vascular remodeling associated with ACS and stable coronary artery disease are different.Vulnerable plaques (precursors of ACS) tend to have thin brous caps,large lipid cores,fewer smooth- muscle cells,more macrophages,and less collagen,as compared with stable plaques,and associated with
5. 5. Zaman I-, Chakraborty B,Sahel/ loutward (expansive) remodeling of the coronary artery wall,causing less stenosis of the coronary lumen.As a result,vulnerable plaques do not usually cause signicant stenosis before rupture and the precipitation of ACS6. By contrast stable plaques tend to have thick brous cap,small lipid cores,more smoothmuscle cells,fewer macrophages,and more collagen and ultimately associated with inward (constrictive) remodeling that narrows the coronary lumen.These lesions produce ischaemia and anginal symptoms and are easily detected by coronary angiography but less likely to result in an ACS6.In 2002, the American College of Cardiology / American Heart Association guidelines for management of chronic stable angina recommended coronary revascularization for symptom relief in patients with refractory symptoms despite OMT or for survival benet in patients at high clinical risk of death,based on noninvasive testing (moderate to large areas of reversible ischaemia with or without LV dysfunction) or on angiography (left main stem,3-vessel,or proximal anterior descending artery disease)7. Despite the recent furor over PCI versus OMT generated primarily by the COURAGE and BARI 2D trial these basic recommendations of ACC/ AHA guidelines remain logical and reasonables.In stable coronary artery disease OMT proved as benecial as PC] in elderly patients and also in those with high risk features,although at the expense of high crossover rates in the medical therapy arm9. A valid question arising from COURAGE,BARI 2D and other trials is whether current use of coronary revascularization and in particular PCI,is appropriate or excessive.Only 44.5% of patients have noninvasive stress testing before PC] in the United States and inappropriate use of PCI may be as high as 43% in patients with stable coronary artery disease3".Even in those with extensive,multivessel involvement and inducible ischaemia,provided that intensive,multifaceted medical therapy is instituted and maintained, as an initial management approach,OMT without routine PC] can be implemented safely in the majority of patients with stable coronary artery disease.However,approximately one third of these patients may subsequently require revascularization for symptom control or for subsequent development of ACS3. Given the lack of clear benet from early PCl, the practice in most United States centers of linking a coronary artery disease diagnosis through coronary angiography to therapeutic PCI is potentially problematic.Current evidence does not support the routine early addition of PCI to OMT in the treatment of patients with chronic stable angina4'. The COURAGE and BARI 2D trial results have sparked intense debate within the cardiology community,particularly among many interventional cardiologists who have suggested that clinical practice should not be changed based on the results of only one or two research trials.But the recent data support the concept that in patients with stable angina,OMT alone compares favorably with a therapeutic strategy combining OMT with PCI3" Current evidence does not support the routine early addition of PCI to OMT.Therefore,cardiologists should reconsider the practice of performing routine PCI after diagnostic angiography in patients who have not had thel69 Bangladesh _] Cardiol,2010; 1(3):168-9opportunity to receive a trial of OMT alone.Thus,the treatment pendulum may be swinging back to the understanding that best practice today requires the judicious use ofinterventional and medical therapies in the appropriate patient population. References1. Wijeysundera HC,Nallamothu BK,Krumholz HM et al.Meta-analysis:Effects of Percutaneous CoronaryIntervention versus Medical therapy on angina.Ann Intern Med 2010;152:370-9.2. Feldman DN,Gade CL,Slotwiner A] et al.Comparison of outcomes of percutaneous coronary interventions in patients of three age groups (80 years) (from the New York State Angioplasty Registry) Am ] Cardiol 2006;955:1334-9.3. Boden WE,O'Rourke RA,Teo KK et al. For the COURAGE Trial Research Group.Optimal medical therapy with orwithout PCI for stable coronary artery disease. N Englj Med 2007;356:1503-16.4. The BARI 2D Study Group.A randomized trial of therapies for type 2 diabetes and coronary artery disease.N Englj Med 2009;360:2503-15.5. Anwar T,Boden WE .Evolving concepts in selecting optimal strategies for the management of patients with stable coronary artery disease:pharmacologic or revascularization therapy.Current Opinion in Cardiology 2009;24(6):591-5.6. Naghavi M,Libby P,Falk E et al.From vulnerable plaque to vulnerable patient:a call for new denitions and risk assessment strategies.Circulation 2003;108:166472.7. Gibbons R],Abrams ],Chatterjee K et al.ACC/ AHA 2002 guidelines update for the management of chronic stable angina-summary article:a report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines (Committee on the management of patients with chronic stable angina) .Am Coll Cardiol 2003;41:159-68.8. Cassar A,Holmes DR,Rihal CS et al.Chronic coronary artery disease:diagnosis and management.Mayo Clin Proc 2009;84(12):1130-46.9. Sanz _l,Moreno PR,Fuster V.The year of atherosclerosis.]Am Coll Cardiol 2010;55(14):1487-98.10. Hemingway H,Chen R,junghans C et al.Appropriateness criteria for coronary angiography in angina:reliability and validity.Ann Intern Med 2008;l49(4):221-31.11. Maron D],Spertus _]A,Mancini GB et al.Impact of an initial strategy of medical therapy without percutaneous coronary intervention in high risk patients from the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation trial.Am j Cardiol 2009;104:1055-62.,, JL_r/ :91;/ pang;Lil" JgxiuIE? !
6. 6. l 70 S0/irabuzzaman APM,S/ mrma AKBangladesh j Cardiol,2010; 1(3):170-5Current Approaches to Myocardial No-ReflowPhenomenon During PCIAPM Sohrabuzzaman,AK Sharma Labaid Cardiac Hospital,Dhaka,BangladeshIntroductionMyocardial no-reow is a phenomenon in which myocardial ischemia and reduced antegrade ow occur despite the absence of proximal stenosis,spasm,dissection,embolism of major distal branches during percutanous coronary intervention (PCI)l.In another word no-reow phenomenon means failure of restoration of myocardial ow despite removal of epicardial coronary obstruction.No-reow usually manifest as a failure of the affected artery to opacify after angioplasty or stenting of the occluded segment during acute myocardial infarction (AMI),or as a reduction of ow in the affected artery after PCI of a nonoccluded segment.No reow is associated with a worse prognosis and shown to be independent predictor of death,myocardial infarction and impaired left ventricular function after PCI.The 30 days mortality of patients who developed no-reow phenomenon has been estimated to be 27.5% in comparison to 5.3% (P20% of patients undergoing primary angioplasty for AMI and in