GIK Papers

These are the results of MeSh search for the terms Pakistan and Coronary artery disaease and
Coronary disease .
1. J Pak Med Assoc. 2011 Apr;61(4):340-2. Coronary artery disease in patients undergoing valve replacement at a tertiary care cardiac centre. Shaikh AH, Hanif B, Hasan K, Adil A, Hashmani S, Raza M, Qazi HA, Mujtaba I. Tabba Heart Institute, Karachi. OBJECTIVE: To determine the prevalence of coronary artery disease in patients undergoing valve surgery at a tertiary care cardiac centre. METHODS: The medical records of 144 consecutive patients who underwent mitral, aortic or dual (mitral and aortic) valve replacement surgery at the Tabba Heart Institue between January 2006 to December 2008 were retrospectively reviewed. All patients underwent coronary angiogram. Significant coronary artery disease (CAD) is defined as coronary stenosis of > or = 50%. RESULTS: There were 74 (51.4%) males and 70 (48.6%) females in the study. The mean age was 51.64 +/- 11 years. Of all, 73 (50.7%) underwent mitral valve replacement, 47 (32.6%) had aortic and 24 (16.7%) had dual valve replacement. Out of 144 patients, 99 (68.8%) had < 50% coronary stenosis and remaining 45 (31.3%) had > or = 50% stenosis. In patients who had undergone mitral valve replacement (MVR), significant coronary disease was found in 32.9%, whereas in patients who had undergone aortic valve replacement (AVR) and dual valve replacement (DVR) the prevalence of coronary disease was 31.9% and 25% respectively. CONCLUSIONS: Our results suggest that the overall prevalence of coronary artery disease in patients undergoing valve surgery in our population is comparable with prevalence reported in international data.
PMID: 21465968 [PubMed - indexed for MEDLINE]
2. J Pak Med Assoc. 2010 Jun;60(6):512-3. Hypercholesterolaemia: an emerging dilemma. Shaikh F, Zubair MM. PMID: 20527662 [PubMed - indexed for MEDLINE]
3. Am J Prev Med. 2010 Apr;38(4):439-42. Knowledge gaps and misconceptions about coronary heart disease among U.S. South
Asians. Kandula NR, Tirodkar MA, Lauderdale DS, Khurana NR, Makoul G, Baker DW. Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA. n-kandula@northwestern.edu BACKGROUND: Although South Asians are at higher risk for coronary heart disease (CHD) than most other U.S. racial/ethnic groups, very little research has addressed this disparity. PURPOSE: As a first step in developing culturally targeted CHD prevention messages for this rapidly growing community, this study examined South Asians' knowledge and beliefs about CHD. METHODS: Analyses, conducted in 2009, were based on data collected from January to July 2008 in a cross-sectional study population of 270 South Asian adults in Illinois. Interviews were conducted in English, Hindi, or Urdu using a standardized questionnaire. Multivariate regression models were used to examine the associations between sociodemographics and CHD knowledge and attitudes about preventability. RESULTS: Eighty-one percent of respondents had one or more CHD risk factors. Most participants (89%) said they knew little or nothing about CHD. Stress was the most frequently mentioned risk factor (44%). Few mentioned controlling blood pressure (11%); cholesterol (10%); and diabetes (5%) for prevention. Fifty-three percent said that heart attacks are not preventable. Low education level, being interviewed in Urdu or Hindi, and low level of acculturation were associated with less knowledge and believing that CHD is not preventable. CONCLUSIONS: A majority of South Asians in this study believed that CHD is not preventable and had low awareness of modifiable risk factors. As a first step, CHD education should target the knowledge gaps that may affect risk factor control and behavior change. Educational messages may need to be somewhat different for subgroups (e.g., by education and language) to be maximally effective.
PMCID: PMC2844724 PMID: 20307813 [PubMed - indexed for MEDLINE]
4. J Pak Med Assoc. 2010 Mar;60(3):201-4. Etiological patterns of stroke in young patients at a tertiary care hospital. Samiullah S, Humaira M, Hanif G, Ghouri AA, Shaikh K. Department of Medicine, Liaquat University of Medical and Health Sciences, Jamshoro, Hyderabad Sindh. OBJECTIVE: To observe frequency of various causes of stroke in patients of young
(15-35 years) age. METHODS: This Descriptive case series study was conducted in all Medical Units of Liaquat University Hospital (LUH) Jamshoro, Hyderabad, from August 2006 to February 2008 and included 50 patients of stroke aged 15-35 years, irrespective of sex and community. Data of these patients was collected through a pre-designed proforma by completing a comprehensive history, detailed examination and carrying out basic and relevant investigations. Patients suffering from hypoglycaemia, space occupying lesions, transient ischaemic attack or psychosis were excluded from the study. The collected data was analyzed on SPSS version 16.0. RESULTS: Out of total number of 113 acute strokes, 50 patients fulfilling inclusion criteria were selected, comprising 30 males and 20 females. Forty-three (86%) patients suffered from ischaemic strokes while seven (14%) had haemorrhagic strokes. Infective meningitis including Tuberculosis meningitis and Bacterial meningitis was the leading cause of stroke (34%). The second most common cause was cardio-embolism (20%) comprising Valvular heart diseases (14%), Cardiomyopathies (4%) and atrial myxoma (2%).Hypertension was found in 14% cases. Pregnancy related causes (including Pregnancy induced hypertension and puerperal sepsis) were 12%. Systemic lupus erythematous and nephritic syndrome was 4% each. Various causes which constitute 4% or less were grouped together as miscellaneous and they include hyperhomocysteinaemia, and hyperlipidaemias. CONCLUSIONS: Common cause of stroke detected was infective meningitis (Tuberculosis and Bacterial). Predominant cause of haemorrhagic stroke was Hypertension. Stroke in young age occurred predominantly in males. Cardio embolism, pregnancyinduced hypertension and puerperal sepsis were other major causes.
5. Pak J Pharm Sci. 2009 Apr;22(2):230-3. Report: frequency of aspirin resistance in patients with coronory artery disease in Pakistan. Akhtar N, Junaid A, Khalid A, Ahmed W, Shah MA, Rahman H. Department of Cardiology, Shifa International Hospital, H-8/4 Islamabad. Aspirin resistance is an emerging clinical entity. However the data available on aspirin resistance in Asian population is scarce. This study was initiated to prospectively evaluate the frequency of aspirin resistance in patients with stable coronary artery disease (CAD) in Pakistan. A cross sectional prospective study was conducted in cardiology and hematology departments at Shifa International Hospital, Islamabad from January to December 2007. Two hundred and fifty patients were enrolled from cardiology out patient department having met the specific inclusion criteria. Details were entered on a pre-designed questionnaire and aspirin response assay was performed on IMPACT-R (Dia Med AG
1785 Cressier Morat, Switzerland). Data was analyzed using SPSS V12. Aspirin resistance was observed in 12% of patients. 73.2% of study population were male and 26.8% were female, with a mean age of 57.2 years. There was no significant correlation of aspirin resistance with traditional risk factors like diabetes mellitus (DM), hypertension or dyslipidemia. 84% of aspirin non responders were taking 75 mg per day and 16% were on 150 mg per day. A positive trend was noted between aspirin resistance and cigarette smoking. Aspirin resistance is a real phenomenon in Pakistani population with an estimated frequency of 12%. Large scale prospective randomized trials with long term follow up are needed to assess the impact of different doses and the clinical significance of this biochemical entity.
6. J Ayub Med Coll Abbottabad. 2009 Apr-Jun;21(2):56-9. Oxidative stress and level of-iron indices in coronary heart disease patients. Ahmad M, Khan MA, Khan AS. Department of Biochemistry, Institute of Chemical Sciences, University of Peshawar, Pakistan. mahmad29@hotmail.com OBJECTIVE: Oxidative stress is characterized by an increased concentration of oxygen free radicals which can cause a critical, or even an irreversible, cell injury. The study was designed to determine and compare the levels of oxidative stress and iron indices in Coronary Heart Disease and healthy individuals. MATERIAL AND METHODS: Blood malondialdehyde, iron, total iron-binding capacity, transferrin saturation and ferretin levels were determined in 140 Coronary Heart Disease and 100 healthy subjects. RESULTS: Values of blood malondialdehyde, iron, transferrin saturation and ferretin were observed to be significantly increased with exception of total iron-binding capacity, which was significantly decreased (p < 0.005) in Coronary Heart Disease patients when compared with normal healthy controls. CONCLUSION: Elevated serum malondialdehyde, iron concentration and body iron stores in patients reveal a possible role of iron indices in the development of coronary atherosclerosis. Therefore, it is suggested by this study that levels of malondialdehyde and biochemical markers of body iron stores can be used as an early investigative tool for assessing the oxidative stress in coronary heart disease.
7. J Pak Med Assoc. 2009 Jan;59(1):3-5.
Uncompensated tooth loss in cardiac patients of Punjab Institute of Cardiology, Lahore. Bokhari SA, Khan AA, Azhar M, Shahbaz MQ. Department of Oral Health Sciences, Federal Postgraduate Medical Institute, Sheikh Zayed Hospital Complex, Lahore. OBJECTIVE: To observe replacement of missing teeth with artificial teeth in subjects with and with out cardiac diseases and find its possible association with coronary heart diseases (CHD). METHODOLOGY: Consecutive patients aged 20 and above with coronary heart disease and accompanied healthy subjects with tooth loss were examined for oral prosthesis after having a verbal consent, over a one month period in a cross-sectional study at Punjab Institute of Cardiology, Lahore. Chi-square and T- test were applied to analyze variables in subjects with and without coronary heart disease. RESULTS: Among 1694 subjects found with tooth loss, 1473 (86.95) subjects had no oral prosthesis; 817 (87.37%) were among the 935 cardiac patients and 656 (86.42%) among 759 healthy subjects. Oral prosthesis was found in 86 (8.05%) males and 32 (5.11%) females with coronary heart diseases. Of the healthy population, 46 (4.30%) males and 57 (9.10%) females had oral prosthesis. Statistical association for prosthesis was insignificant among cardiac patients and healthy subjects. CONCLUSION: No association of uncompensated tooth loss with cardiac diseases was observed in this study. Although a large majority of cardiac patients and healthy subjects were observed with uncompensated tooth loss which was statistically insignificant.
8. J Ayub Med Coll Abbottabad. 2009 Jan-Mar;21(1):58-61. Estimation of heritability of familial hypercholesterolemia among 335 family members of five hypercholesterolemic probands of Pakistani population. Imtiaz F. Department of Biochemistry, Dow International Medical College, Dow University of Health Sciences, Karachi, Pakistan. fauziaku@yahoo.com BACKGROUND: Familial hypercholesterolemia is an autosomal dominant disorder, caused by mutation in Low-density lipoprotein receptor (LDL-R) gene. METHODS: Cross-sectional study conducted to recruit the population of Karachi-Pakistan, screened for familial hypercholesterolemia. A total of 1523
hypercholesterolemic individuals have taken part in the study, five were found to be familial hypercholesterolemia. Their lipids profile was estimated and a family pedigree was drawn. RESULTS: Parent-offspring correlation, coefficient of linear regression, and heritability is calculated by using SPSS 12.0. A significant positive correlation of cholesterol was found among parents and their offspring (r = 0.511, p = 0.01, n = 76). Coefficient of linear regression analysis also showed that parents-offspring relationship was highly significant at p < 0.01 with b = 0.438. Relationship between Father-Son, Father-Daughter, Mother-Son and Mother-Daughter were highly significant with b = 0.794, 0.41, 0.766 and 0.56 respectively. CONCLUSION: The heritability among the parents and their offspring showed that genetic factors are major determinant of the familial resemblance in serum cholesterol among the Pakistani population living in the metropolitan area of Karachi.
9. J Immigr Minor Health. 2009 Oct;11(5):415-21. Epub 2008 Sep 24. Coronary artery diseases in South Asian immigrants: an update on high density lipoprotein role in disease prevention. Dodani S. Medical College of Georgia, EC 4503 Health Sciences Building, 997 St Sebastian Way, Augusta, GA 30812, USA. sdodani@mcg.edu Over the past several years, the overall prevalence and incidence of cardiovascular diseases (CVD) including coronary artery diseases (CAD) have declined in the United States (US) and in many developed countries. However, among South Asian in general and South Asian immigrants (SAIs) in particular, a disturbing trend toward high rates of CAD has been noted. This trend is associated with a high prevalence of conventional risk factors and metabolic syndrome in this population, yet these conventional risk factors may not account for the greater CAD risk among SAIs. A search for additional markers is warranted, to enable early detection and prevention of CAD in this high risk group. High density lipoprotein (HDL) is one of the predictor of CAD and is considered to be cardio-protective. However, some of the recent studies have shown that HDL is not only ineffective as an antioxidant but, paradoxically, appears to be pro-oxidant, and has been found to be associated with CAD. Such HDL is called dysfunctional HDL. We present here an overview CAD and CAD risk factors in general and dyslipidemias in particular in SAIs. In addition, the evolving theories on dysfunctional HDL and its impact on CAD are also briefly presented.
10. J Coll Physicians Surg Pak. 2008 May;18(5):270-3. Triglyceride profile in dyslipidaemia of type 2 diabetes mellitus. Khan SR, Ayub N, Nawab S, Shamsi TS. Department of Biochemistry, Karachi Medical and Dental College, Karachi, Pakistan. sohailrafi425@hotmail.com OBJECTIVE: To evaluate ratios of serum triglycerides and cholesterol levels which may indicate postprandial lipid handling and to assess their role as prospective markers of dyslipidaemia in type 2 diabetes mellitus. STUDY DESIGN: Comparative, observational study. PLACE AND DURATION OF STUDY: Bismillah Taqee Hospital, Karachi from July 2002 till December 2003. PATIENTS AND METHODS: The study comprised 160 subjects, including 83 known type 2 diabetics (45 males, 38 females) and 77 age-matched controls (45 males, 32 females). Fasting blood samples were analysed for serum triglycerides and total cholesterol, using automated chemistry analyzer. HDL-C was determined by precipitation method and LDL-C and VLDL-C were estimated by Friedewalds formula. LDL/HDL ratio and TG/HDL ratios were also calculated. The mean values for male and female diabetics were compared with that for the male and female non-diabetics respectively and tested for significance by paired t-test. RESULTS: Serum triglycerides and VLDL were raised in both male and female diabetics. No significant differences were observed in levels of serum total cholesterol, LDL, HDL and the LDL/HDL ratio. The mean value of the TG/HDL ratio for male diabetics was higher than that for the male non-diabetics (p=0.39). A statistically significant difference was found in the TG/HDL ratios for the female diabetics and non-diabetics (p<0.05). CONCLUSION: In this study, type 2 diabetics showed marked hypertriglyceridaemia and raised TG/HDL ratio. The dyslipidaemia of diabetes predisposes to development of coronary heart disease and, therefore, evaluation of the TG:HDL ratio may provide a good tool to monitor and manage the lipid abnormalities in diabetics.
11. Heart Lung. 2008 Mar-Apr;37(2):91-104. Causal attributions, lifestyle change, and coronary heart disease: illness beliefs of patients of South Asian and European origin living in the United Kingdom. Darr A, Astin F, Atkin K.
Centre for Research in Primary Care, Institute of Health Sciences and Public Health Research, University of Leeds, Leeds, United Kingdom. Comment in Evid Based Nurs. 2008 Oct;11(4):127. OBJECTIVE: We examined and compared the illness beliefs of South Asian and European patients with coronary heart disease (CHD) about causal attributions and lifestyle change. METHODS: This was a qualitative study that used framework analysis to examine in-depth interviews. SAMPLE: The study comprised 65 subjects (20 Pakistani-Muslim, 13 Indian-Hindu, 12 Indian-Sikh, and 20 Europeans) admitted to one of three UK sites within the previous year with unstable angina or myocardial infarction, or to undergo coronary artery bypass surgery. RESULTS: Beliefs about CHD cause varied considerably. Pakistani-Muslim participants were the least likely to report that they knew what had caused their CHD. Stress and lifestyle factors were the most frequently cited causes for CHD irrespective of ethnic grouping, although family history was frequently cited by older European participants. South Asian patients were more likely to stop smoking than their European counterparts but less likely to use audiotape stress-relaxation techniques. South Asian patients found it particularly difficult to make dietary changes. Some female South Asians developed innovative indoor exercise regimens to overcome obstacles to regular exercise. CONCLUSION: Misconceptions about the cause of CHD and a lack of understanding about appropriate lifestyle changes were evident across ethnic groups in this study. The provision of information and advice relating to cardiac rehabilitation must be better tailored to the context of the specific needs, beliefs, and circumstances of patients with CHD, regardless of their ethnicity.
12. Int J Cardiol. 2008 Aug 1;128(1):5-16. Epub 2008 Feb 5. Vascular risk factors in South Asians. Tziomalos K, Weerasinghe CN, Mikhailidis DP, Seifalian AM. Department of Clinical Biochemistry, Vascular Prevention Clinic, Royal Free Hospital, Royal Free University College Medical School, University of London, London, UK. South Asians originate from the Indian sub-continent (India, Pakistan, Bangladesh, Sri Lanka and Nepal) and represent one fifth of the world's population. Several studies suggested that South Asians have an increased risk of developing coronary heart disease (CHD) when compared with European populations.
We review the role of traditional and emerging risk factors in the increased CHD risk in South Asians. The high prevalence of insulin resistance and type 2 diabetes mellitus in South Asians may be a major cause for their elevated vascular risk. However, other established and emerging risk factors are also overrepresented in South Asians. Large-scale prospective studies could determine the relative contribution of established and emerging vascular risk factors in South Asians. There is an urgent need for trials in South Asians that will evaluate clinical outcomes following treatment of these risk factors.
13. J Public Health (Oxf). 2008 Mar;30(1):45-53. Epub 2007 Nov 27. Using routine data to measure ethnic differentials in access to coronary revascularization. Mindell J, Klodawski E, Fitzpatrick J. London Health Observatory, London SW1E 6QT, UK. j.mindell@ucl.ac.uk BACKGROUND: Ethnic inequalities in access to health services are difficult to monitor and address because of limited data. Within the health service, ethnicity data have been poor quality, partly because they are not seen as useful. METHODS: The analysis related age- and sex-standardized coronary revascularization procedures to defined measures of need, using proportional ratios derived from Hospital Episode Statistics records for London residents admitted to any hospital nationally in 2002-03 or 2003-04. RESULTS: Although 2001 Ethnicity Categories were mandatory for the NHS from April 2001, by 2003-04 >20% of coronary heart disease (CHD) records still had no ethnic category coded. Hospital admission for CHD and revascularization by ethnicity varied widely, following known patterns of CHD incidence and mortality. There is much less variation between ethnic groups when comparing revascularization rate relative with CHD admission rates (whether all or emergencies). However, Bangladeshi patients had only two-thirds [proportional ratio 66.8, 95% confidence interval (CI) 60.7-73.3] and Black Caribbean and Black African patients four-fifths (proportional ratios 80.5, 72.0-89.9 and 80.7, 68.0-95.2, respectively) the revascularization rate in comparison with apparent need as the general population. CONCLUSION: Even with imperfect data, the analysis of routine data can identify inequalities that warrant further investigation.
14. J Invasive Cardiol. 2007 Oct;19(10):417-23.
Outcomes of primary percutaneous coronary intervention at a joint commission international accredited hospital in a developing country -- can good results, possibly similar to the west, be achieved? Jafary FH, Ahmed H, Kiani J. Department of Medicine, Section of Cardiology, Aga Khan University Hospital, P.O. Box 3500, Stadium Road, Karachi 74800, Pakistan. jafary@pobox.com BACKGROUND: Primary percutaneous coronary intervention (PCI) is the treatment of choice following ST-elevation myocardial infarction (STEMI). There is limited adoption and a paucity of data on outcomes following primary PCI in developing countries. The objective of this study was to describe the procedural and clinical outcomes of patients undergoing PCI for STEMI at a Joint Commission International Accreditation (JCIA) certified hospital in Pakistan and make a comparison with outcomes from the West. METHODS: We conducted a retrospective cohort study at a tertiary care university hospital in Karachi, Pakistan. A total of 277 consecutive patients undergoing primary PCI between January 2001 and December 2005 were reviewed. Exclusion criteria included preceding fibrinolytic therapy and STEMI due to stent thrombosis. Cox proportional hazards models were constructed. The primary outcome was mortality. RESULTS: Procedural success was 97.1%. Inhospital mortality was 8.3% (43.9% in cardiogenic shock, 2.1% in non-shock patients), comparing very favorably with the published literature from developed countries. Multivariate predictors of death included (hazards ratio, 95% confidence interval) age (1.42 [1.14-1.76]), mechanical ventilation (8.35 [2.82-24.73]), cardiogenic shock (2.80 [1.04-7.55]), prior CABG (9.78 [1.15-83.13]) and ejection fraction (0.96 [0.92-0.99]). CONCLUSIONS: We conclude that excellent outcomes for a critical illness like STEMI can be achieved in a developing country at a JCIA-certified hospital, possibly similar to those seen in the West. There is a strong need for making the practice of primary PCI more widespread in developing nations. More outcomes data are needed from similar hospitals in the region to determine whether our results are generalizable.
15. Int J Cardiol. 2008 Aug 1;128(1):77-82. Epub 2007 Aug 8. Waist circumference, metabolic syndrome and coronary artery disease in a Pakistani cohort. Wierzbicki AS, Nishtar S, Lumb PJ, Lambert-Hammill M, Crook MA, Marber MS, Gill J.
Department of Chemical Pathology, St Thomas' Hospital, Lambeth Palace Road, London SE1 7EH, United Kingdom. Anthony.Wierzbicki@kcl.ac.uk BACKGROUND: Metabolic syndrome (M-IRS) is common in Asians. This study investigated the relationship of two definitions of M-IRS to atherosclerosis in Indian Asians with suspected coronary arterial disease (CAD). METHODS: 400 patients with chest pain selected for the presence or absence of angiographic disease were recruited from a tertiary referral centre in Pakistan into a prospective case-control study. Patients were categorized by the National Cholesterol Education Program adult treatment panel 3 (NCEP) and International Diabetes Federation (IDF) definitions of the metabolic syndrome and the relationship of these to the presence of CAD and extent of atheroma burden was investigated. RESULTS: M-IRS was present in 53% by IDF criteria and in 44% using the Asian criteria for NCEP. The 2 populations identified were only 69% concordant. No relationship existed between the presence of NCEP M-IRS and atheroma burden. In contrast, the presence of IDF M-IRS was associated with CAD (65 vs. 34%; RR=1.88; p<0.001) and angiographic disease burden (28 [0-224] vs. 0 (0-198); RR=1.83; p<0.001). This association persisted (beta=18.4; p<0.001) after correction for C-reactive protein (beta=8.67; p<0.001), lipoprotein (a) (beta=8.14; p=0.002), and estimated glomerular filtration rate (beta=-0.22; p=0.01). Differences in presumed underlying factors were found in the 2 populations identified by the definitions though both agreed on the separate weightings given to blood pressure and HDL-C/apolipoprotein A1. CONCLUSIONS: The specific Asian IDF and NCEP definitions of M-IRS show limited concordance in Pakistanis. The IDF criteria in contrast to the NCEP criteria are associated with the presence of CAD even after allowing for other risk factors identified in this population.
16. Heart. 2008 Apr;94(4):408-13. Epub 2007 Jul 23. Coronary artery disease epidemic in Pakistan: more electrocardiographic evidence of ischaemia in women than in men. Jafar TH, Qadri Z, Chaturvedi N. Clinical Epidemiology Unit, Department of Community Health Sciences and Medicine, Aga Khan University, Stadium Road, Karachi, Pakistan. tazeen.jafar@aku.edu Indo-Pakistani populations have one of the highest risks of coronary artery disease (CAD) in the world. A population-based, cross-sectional survey was conducted on 3143 adults aged >or=40 years from 12 randomly selected communities in Karachi, Pakistan. Apart from smoking, women had more CAD risk factors (diabetes, hypertension, obesity, dyslipidaemia) than men. Definite CAD (history
and Q waves on ECG) was more prevalent in men than in women (6.1% vs 4.0%; p = 0.009). In contrast, ischaemic and major ECG changes were twice as prevalent in women as in men (29.4% vs 15.6%, and 21.0% vs 10.5%; p<0.001 for each, respectively). All measures of CAD were strongly predicted by the metabolic syndrome, but that failed to account for the greater prevalence of ECG abnormalities in women than in men. The findings indicate that one in five middle-aged adults in urban Pakistan may have underlying CAD. Women are at greater risk than men. Trial registration number: NCT00327574.
17. Br J Community Nurs. 2007 Jan;12(1):13-8. Engaging women from South Asian communities in cardiac rehabilitation. Vishram S, Crosland A, Unsworth J, Long S. Northumbria University, Newcastle-upon-Tyne. shelina.visram@northumbria.ac.uk This study sought to describe experiences and perceptions of cardiac rehabilitation among a sample of women from South Asian communities. Data were collected via eight semi-structured interviews with staff and a focus group discussion with nine clients from a community-based, culturally sensitive cardiac rehabilitation service. A number of individual, cultural and practical barriers to participation were identified. Facilitators centred on whether the format and content of the sessions could be considered "appropriate". For example, a women's dance group proved to be successful through the selection of a familiar local venue, supportive session leader, and activity that was felt to be both enjoyable and beneficial. This study has shown that it is possible to engage hard-to-reach groups in cardiac rehabilitation and physical activity. Further work is needed to explore whether this research is applicable in other ethnic groups and whether the lessons learned could be successfully incorporated into mainstream health services.
18. J Pak Med Assoc. 2007 Jan;57(1):46-8. Shall we become vegetarian to minimize the risk of coronary heart disease? Shiwani AH, Aziz A, Shiwani MH. PMID: 17319423 [PubMed - indexed for MEDLINE]
19. Can J Cardiol. 2006 Aug;22(10):841-7. Use of cardiovascular medical therapy among patients undergoing coronary artery bypass graft surgery: results from the ROSETTA-CABG registry. Okrainec K, Pilote L, Platt R, Eisenberg MJ. Department of Epidemiology and Biostatistics, McGill Univeristy, Montreal, Quebec. INTRODUCTION: Secondary prevention is needed following coronary artery bypass graft (CABG) surgery to reduce the subsequent risk of unstable angina, myocardial infarction and death. However, little research exists on the use of cardiovascular medical therapy in CABG surgery patients. The objective of the present study is to describe the use of cardiovascular medical therapy among patients discharged after CABG surgery. METHODS: The use of acetylsalicylic acid, clopidogrel, warfarin, antilipid agents, beta-blockers, calcium channel blockers, nitrates and angiotensin-converting enzyme (ACE) inhibitors was examined among 320 patients enrolled in the Routine versus Selective Exercise Treadmill Testing After Coronary Artery Bypass Graft Surgery (ROSETTA-CABG) Registry. Logistic regression identified the determinants of medication use at 12 months following CABG surgery. RESULTS: Most patients were male, hyperlipidemic and underwent CABG surgery for relief of angina symptoms. At admission, discharge and at 12 months, acetylsalicylic acid was used in 71%, 92% and 87% of cases, respectively, and some form of antiplatelet agent was used in 74%, 94% and 89% of cases, respectively. The use of antilipid agents remained constant, from 55% at admission to 57% at discharge. However, 24% of patients were not receiving antilipid agents at 12 months. The use of beta-blockers was 57% at admission, 71% at discharge and 64% at 12 months. The use of calcium channel blockers and nitrates decreased modestly from admission to discharge and remained stable at approximately 20% and 22%, respectively, at 12 months. ACE inhibitor use remained stable, from 33% at admission to 38% at 12-months. Hyperlipidemia, hypertension, obesity and pre-CABG surgery left ventricular ejection fraction less than 40% were all found to be important determinants of 12-month medication use. Importantly, the use at discharge was an important determinant of 12-month use of for each medication examined in the present study. CONCLUSIONS: The use of antilipid agents, beta-blockers and ACE inhibitors was found to be too low among post-CABG surgery patients, who are known to benefit from their use, and the use of nitrates was too high. Discharge from hospital provides a unique opportunity for physicians to modify the use of cardiovascular medical therapy among patients undergoing CABG surgery.
PMCID: PMC2569013
20. J Pak Med Assoc. 2006 Jun;56(6):282-5. Hyperhomocysteinemia and coronary artery disease in Pakistan. Iqbal MP. Department of Biological and Biomedical Sciences, Aga Khan University Hospital, Karachi. The relative risk of developing coronary artery disease (CAD) in Pakistani men is highest in early ages. Majority of those suffering from CAD belong to the lower middle socioeconomic stratum of the society. Mild hyperhomocysteinemia (concentration of plasma homocysteine between 15-25 micromol/l) is very commonly seen in Pakistani patients with acute myocardial infarction (AMI) as well as in normal healthy subjects. There appears to be a lack of association between hyperhomocysteinemia and CAD in Pakistani population. There is also no evidence of association of methylenetetrahydrofolate reductase 677C>T mutation with CAD in this population. High prevalence of deficiency of folate and vitamin B6 appears to be the major causes of hyperhomocysteinemia in Pakistani population. Deficiencies of micronutrients (folate, vitamin B6 and possibly vitamin B12) along with mild hyperhomocysteinemia, perhaps, act synergistically with other classical risk factors in Pakistani population to further increase the risk of CAD.
21. East Mediterr Health J. 2005 May;11(3):258-72. Coronary heart disease risk-factor profile in a lower middles class urban community in Pakistan. Aziz K, Aziz S, Patel N, Faruqui AM, Chagani H. Department of Cardiology, National Institute of Cardiovascular Diseases, Karachi, Pakistan. nicvdedo@khi.comsats.net.pk Erratum in East Mediterr Health J. 2006 Jan-Mar;12(1-2):80. We determined the risk-factor profile and prevalence of coronary heart disease in Metroville, a lower middle class urban community in Karachi, and compared them to the Pakistan health survey PNHS 1990-94, and the US health and nutrition survey 1988-94 NHANES111. Subjects < 18 years and pregnant women were excluded as were
people with extreme ranges BMI [corrected] heart rate, height and waist. The prevalence of hypertension was 23% in men and women, hypercholesterolaemia was 17% in men and 22% in women (P < 0.001). Hyperglycaemia was present in 5% of men and women and obesity in 33% of men and 47% of women (P < 0.001). Compared to PNHS, the prevalences of obesity, hypertension, hypercholesterolaemia and WHR were higher in our population. Mean values of BMI [corrected] cholesterol, WHR were higher in the US population while mean values were lower for diastolic blood pressure and blood glucose.
22. BMC Public Health. 2005 Nov 25;5:124. Cardiovascular health knowledge and behavior in patient attendants at four tertiary care hospitals in Pakistan--a cause for concern. Jafary FH, Aslam F, Mahmud H, Waheed A, Shakir M, Afzal A, Qayyum MA, Akram J, Khan IS, Haque IU. Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan. jafary@pobox.com BACKGROUND: Knowledge about coronary heart disease (CHD) and its risk factors is an important pre-requisite for an individual to implement behavioral changes leading towards CHD prevention. There is scant data on the status of knowledge about CHD in the general population of Pakistan. The objective of this study was to assess knowledge of CHD in a broad Pakistani population and identify the factors associated with knowledge. METHODS: Cross sectional study was carried out at four tertiary care hospitals in Pakistan using convenience sampling. Standard questionnaire was used to interview 792 patient attendants (persons accompanying patients). Knowledge was computed as a continuous variable based on correct answers to fifteen questions. Multivariable linear regression was conducted to determine the factors independently associated with knowledge. RESULTS: The mean age was 38.1 (+/- 13) years. 27.1% had received no formal education. The median knowledge score was 3.0 out of a possible maximum of 15. Only 14% were able to correctly describe CHD as a condition involving limitation in blood flow to the heart. Majority of respondents could identify only up to two risk factors for CHD. Most commonly identified risk factors were stress (43.4%), dietary fat (39.1%), smoking (31.9%) and lack of exercise (17.4%). About 20% were not able to identify even a single risk factor for CHD. Factors significantly associated with knowledge included age (p = 0.023), income (p < 0.001), education level (p < 0.001), residence (p < 0.001), a family history of CHD (p < 0.001) and a past history of diabetes (p = 0.004). Preventive practices were significantly lacking; 35%, 65.3% and 84.6% had never undergone assessment of blood pressure, glucose or cholesterol respectively. Only a minority felt that they would modify
their diet, stop smoking or start exercising if a family member was to develop CHD. CONCLUSION: This is the first study assessing the state of CHD knowledge in a relatively diverse non-patient population in Pakistan. There are striking gaps in knowledge about CHD, its risk factors and symptoms. These translate to inadequate preventive behavior patterns. Educational programs are urgently required to improve the level of understanding of CHD in the Pakistani population.
23. Diabetes Res Clin Pract. 2006 Jan;71(1):101-2. Epub 2005 Aug 19. High prevalence of obesity and associated risk factors in urban children in India and Pakistan highlights immediate need to initiate primary prevention program for diabetes and coronary heart disease in schools. Misra A, Vikram NK, Sharma R, Basit A. PMID: 16112243 [PubMed - indexed for MEDLINE]
24. Ethn Dis. 2005 Summer;15(3):429-35. Distribution and determinants of coronary artery disease in an urban Pakistani setting. Dodani S, MacLean DD, LaPorte RE, Joffres M. Department of Epidemiology; University of Pittsburgh, Pittsburgh, PA 15101, USA. sud0@pitt.edu Erratum in Ethn Dis. 2006 Winter;16(1):309. MacLean, David D [added]; LaPorte, Ronald E [added]; Joffres, Michel [added]. OBJECTIVE: We assessed the distribution of coronary artery disease (CAD) and its association with the major biological risk factors and behaviors among Pakistanis presenting at a tertiary care hospital in Karachi, Pakistan. METHOD: An epidemiologic cross-sectional study was conducted at the Aga Khan University Hospital (a teaching hospital) in Karachi, Pakistan. A total of 600 adult (> or =18 years of age) patients visiting family practice clinics for general check-up were included. The association of biological risk factors with CAD (smoking, obesity [body mass index (BMI)], hypertension, family history of ischemic heart diseases [IHD], sedentary lifestyle, diabetes mellitus, total cholesterol, low density lipoprotein [LDL] levels, high density lipoprotein [HDL]
levels, and triglycerides) were assessed. RESULTS: On univariate analysis, age > or =40 years, early menopause, BMI > or =29.9 kg/m2, diabetes, high cholesterol, and positive family history of IHD were independently associated with CAD. We found age > or =40 years, diabetes, and positive family history of IHD strongly related with CAD on multivariate analysis. CONCLUSION: Looking at the strong association of major risk factors with CAD, the unique characteristics of Pakistanis must be studied in depth, with focus on high-risk groups.
25. J Pak Med Assoc. 2004 Dec;54(12):642. Coronary heart disease risk factor profile of children in a country with developing economy--an issue that needs prompt attention. Khuwaja AK, Nasir A. Comment on J Pak Med Assoc. 2004 Jul;54(7):364-71. PMID: 16104497 [PubMed - indexed for MEDLINE]
26. Am Heart J. 2005 Aug;150(2):221-6. Heart disease epidemic in Pakistan: women and men at equal risk. Jafar TH, Jafary FH, Jessani S, Chaturvedi N. Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan. tazeen.jafar@aku.edu OBJECTIVE: We conducted this study to determine the prevalence of coronary artery disease (CAD) and its risk factors in Karachi, Pakistan. BACKGROUND: Migrant South Asians residing in the West have one of the highest rates of CAD in the world. Estimates of disease in nonmigrant populations are conflicting. METHODS: We conducted a population-based cross-sectional survey on 320 randomly selected adults aged > or = 40 years. Coronary artery disease was defined as the composite outcome of (1) abnormalities indicative of definite or probable CAD based on the Minnesota classification of electrocardiogram or (2) past history of heart attack. RESULTS: The overall prevalence of CAD (95% CI) was 26.9% (22.3%-32.0%): 23.7% (17.8%-30.9%) in men vs 30.0% (23.4-37.5%) in women (P = .12). Risks did not
differ substantially by age group. The factors (odds ratio, 95% CI) independently associated with CAD were current tobacco use (2.12, 1.21-3.73), systolic blood pressure (1.08, 1.02-1.15, for each 5 mm Hg increase), and proteinuria (2.49, 1.04-5.95). Coronary artery disease odds for women vs men (1.38, 0.84-2.62) increased to 1.60 (0.93-2.75), when adjusted for key risk factors. CONCLUSIONS: One in 4 middle-aged adults in Pakistan has prevalent CAD. Risks are uniformly high in the young and in women. Concerted efforts are needed to prevent the epidemic of cardiovascular disease in South Asia, focusing on hypertension, diabetes, smoking, and dyslipidemia.
27. Heart. 2005 Aug;91(8):1003-7. Metabolic syndrome and risk of coronary heart disease in a Pakistani cohort. Wierzbicki AS, Nishtar S, Lumb PJ, Lambert-Hammill M, Turner CN, Crook MA, Marber MS, Gill J. Department of Chemical Pathology, St Thomas's Hospital, London SE1 7EH, UK. anthony.wierzbicki@kcl.ac.uk OBJECTIVE: To assess the relation of the metabolic insulin resistance syndrome (M-IRS) with coronary heart disease (CHD) in Pakistani patients. SUBJECTS: 200 patients with angiographic disease (CHD(+)) matched with 200 patients with chest pain without occlusive disease (CHD(-)). DESIGN: Prospective case-control study. SETTING: Tertiary referral cardiology unit in Pakistan. RESULTS: M-IRS was present in 37% of CHD(+) versus 27% of CHD(-) patients by criteria for white patients or 47% versus 42%, respectively, by Asian criteria (p < 0.001). After adjustment for other risk factors, M-IRS was not a significant predictor for CHD or angiographic disease. Age (p = 0.03), smoking (p < 0.001), diabetes-years (p = 0.003), sialic acid (p = 0.01), and creatinine (p = 0.008) accounted for the excess risk of CHD. Similarly, age (p = 0.005), creatinine (p < 0.001), cigarette pack-years (p = 0.02), diabetes-years (p = 0.003), and sialic acid (p = 0.08) were predictors of greater angiographic disease. M-IRS differed between Pakistani and white patients, as waist circumference correlated weakly (r = -0.03-0.08, p = 0.45-0.52) with triglycerides, high density lipoprotein cholesterol, systolic blood pressure, or glucose. Sialic acid was the only inflammatory marker associated with M-IRS. CONCLUSIONS: Despite strong associations between individual risk factors associated with M-IRS and a univariate association between M-IRS and CHD in native Pakistanis, the principal discriminant risk factors in this group are age, smoking, inflammation, diabetes-years, and impaired renal function. The poor sensitivity of M-IRS for CHD reflects the high underlying prevalence of M-IRS, thus reducing sensitivity, confounding by other urban lifestyle traits, or a lack
of association of waist circumference with M-IRS risk factors. The definition of M-IRS may have to be revised to increase its power as a discriminant risk factor for CHD in Pakistani populations.
28. J Pak Med Assoc. 2004 Dec;54(12 Suppl 3):S14-25. The National Action Plan for the Prevention and Control of Non-communicable Diseases and Health Promotion in Pakistan--Cardiovascular diseases. Nishtar S, Faruqui AM, Mattu MA, Mohamud KB, Ahmed A. Armed Forces Institute of Cardiology, Rawalpindi. The National Action Plan for Non-Communicable Disease Prevention, Control and Health Promotion in Pakistan (NAP-NCD) incorporates prevention and control of cardiovascular diseases (CVD) as part of a comprehensive and integrated non-communicable Disease (NCD) prevention effort. In this programme, surveillance of cardiovascular risk factors is part of an integrated population-based NCD surveillance system. The population approach to CVD prevention is a priority area in this programme with a focus on broad policy measures and behavioural change communication. The former include revision of the current policy on diet and nutrition to expand its focus on under-nutrition; the development of a physical activity policy; strategies to limit the production of, and access to, ghee as a medium for cooking and agricultural and fiscal policies that increase the demand for, and make healthy food more accessible. The programme focuses attention on improving the quality of prevention programmes within primary and basic health sites and integrates concerted primary and secondary prevention programmes into health services as part of a comprehensive and sustainable, scientifically valid, and resource-sensitive programme for all categories of healthcare providers. It promotes screening for raised blood pressure at the population level and screening for dyslipidaemia and diabetes in high-risk groups only. It highlights the need to ensure the availability of aspirin, beta blockers, thiazides, ACE inhibitors, statins and penicillin at all levels of healthcare. The programme points out the need to conduct clinical end-point trials in the native Pakistani setting to define cost-effective therapeutic strategies for primary and secondary prevention of CVDs. Emphasis is laid on building capacity of health systems in support of CVD prevention and control and building a coalition or network of organizations to add momentum to CVD prevention and control efforts.
29. J Public Health (Oxf). 2004 Sep;26(3):250-8. How physically active are South Asians in the United Kingdom? A literature review. Fischbacher CM, Hunt S, Alexander L. Public Health Sciences, University of Edinburgh, Edinburgh EH8 9AG. colin.fischbacher@ed.ac.uk BACKGROUND: Moderate physical activity is protective against coronary heart disease (CHD) and diabetes, both important public health problems among UK South Asian (Indian, Pakistani and Bangladeshi) ethnic groups. We assessed the evidence that physical activity is lower in South Asian groups than in the general population. METHODS: We carried out a systematic literature review of studies describing levels of physical activity and fitness in UK South Asians using MEDLINE, EMBASE, the Cochrane databases, hand searching of relevant journals and review of reference lists. RESULTS: We identified 12 studies in adults and five in children. Various methods were used to assess physical activity and fitness, but all the studies reported lower levels among South Asian groups. The differences were substantial, particularly among women and older people. For example, the Health Survey for England found that Indian, Pakistani and Bangladeshi men were 14, 30 and 45 per cent less likely than the general population to meet current guidelines for physical activity. Limited information was provided about translation and adaptation of questionnaires. CONCLUSION: Levels of physical activity were lower in all South Asian groups than the general population and patterns of activity differed. No studies used validated measures. Insufficient attention has been paid to issues of cross-cultural equivalence. With these caveats, low levels of physical activity among UK South Asian ethnic groups may contribute to their increased risk of diabetes and CHD. Closer attention to validity, translation and adaptation is necessary to monitor changes and assess the effectiveness of interventions to increase physical activity.
30. J Public Health (Oxf). 2004 Sep;26(3):245-9. Prevalence and awareness of risk factors and behaviours of coronary heart disease in an urban population of Karachi, the largest city of Pakistan: a community survey. Dodani S, Mistry R, Khwaja A, Farooqi M, Qureshi R, Kazmi K.
Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Room 309, 3512, Fifth Avenue, Pittsburg, PA 15213, USA. sud9@pitt.edu Comment in J Public Health (Oxf). 2005 Sep;27(3):309-10. OBJECTIVES: To estimate the prevalence and awareness of risk factors and risk behaviours of coronary heart disease (CHD) in the lower middle class residing in urban localities of Karachi, a mega city of Pakistan. METHODS: The design consisted of a cross-sectional community based survey in the lower middle class urban localities of Karimabad, Garden and Kharardar in Karachi, Pakistan. One thousand four hundred adults (18 years and above) registered with the Aga Khan Development Network (AKDN) participated in the survey. Life style, self-reported risk variables, blood pressure and anthropometric measurements were recorded. RESULTS: Prevalence of hypertension, high cholesterol and diabetes were 38.5, 10.7 and 9.1 per cent, respectively. 52.2 per cent of the sample was overweight or obese; 64.8 per cent never exercised; 11.9 per cent had two or more major risk factors of CHD. CONCLUSION: The communities studied showed a very high prevalence of hypertension, obesity and a sedentary life style. Despite a high literacy rate, awareness regarding CHD risk factors was low. This underlines the need for measures to increase awareness regarding CHD and its risk factors and a healthy lifestyle in the developing countries.
31. J Pak Med Assoc. 2004 Jul;54(7):364-71. Evaluation and comparison of coronary heart disease risk factor profiles of children in a country with developing economy. Aziz K, Aziz S, Faruqui AM, Patel N, Chagani H, Hafeez SA, Ghuari SA, Memon MF, Ashraf T, Sultana H. Department of Cardiology, National Institute of Cardiovascular Diseases, Karachi. Comment in J Pak Med Assoc. 2004 Dec;54(12):642. OBJECTIVE: To define the risk factors (RF) profile and prevalence rates of high risk factors in an urban Pakistani community and compare it to the RF profile and prevalence rates of Pakistan National Health Survey. METHODS: The present study included RF relevant data of 400 house hold children selected by open invitation as a part of Metroville Health Study (MHS), a risk factor modification study which was a cooperation between National Heart Lung
Blood institute (NHLBI) USA and National Institute of Cardiovascular Diseases Pakistan. The base line data of 389 girls and 417 boys age 5-17 was included. PMRC data of 5067 and NHANES III survey data of 10,252 US children was used for comparison with MHS. RF analyzed were height weight, SBP, DBP, BMI and serum cholesterol. Comparisons between MHS and PMRC and US were made by using two tailed student t test and of high RF were defined as those exceeding US standards and expressed as percentages. RESULTS: The RF factor profile of urban Metroville children was worse than the national average of PMRC children. Except for diastolic blood pressure in both boys and girls and SBP in PMRC boys, all other RF were less than US children. Prevalence rates were higher in urban Metroville community, i.e., MHS compared to the PMRC which represents national average data. CONCLUSION: RF profile of Pakistani children has been presented and effect of urbanization demonstrated by comparing the PMRC and MHS RF profile. Hypertension in Pakistani children has emerged as a single most important RF requiring urgent prevention.
32. Acta Cardiol. 2004 Aug;59(4):417-24. CAD risk factors and acute myocardial infarction in Pakistan. Saleheen D, Frossard P. Department of Biological and Biomedical Sciences, The Aga Khan University, Stadium road, Karachi, Pakistan. danishsaleheen@yahoo.com OBJECTIVE: Acute myocardial infarction (AMI) in adult patients under the age of 45 is relatively unusual. Recent studies have shown a higher prevalence of AMI in young South Asian migrants. Data on South Asians in South Asia on cardiovascular disease (CVD) patients is lacking. The purpose of this study is to look at the classical risk factors of coronary artery disease (CAD) in young men and women and their older counterparts who presented to the emergency service of the Aga Khan university hospital (AKUH) and were diagnosed with AMI. METHODS: 976 consecutive patients admitted to AKUH with AMI between January 2000-December 2002 were divided into two groups: < 45 years (young) and > 45 years (old). Demographic factors, clinical symptoms and presence of risk factors for CAD were recorded with the help of pre-tested data extraction forms. RESULTS: Young patients represented 16.1% of all patients with AMI. 93.1% of the young patients were men. Young male patients were more likely to be smokers and have high cholesterol levels as compared to their young female counterparts. Young AMI patients when compared to old AMI patients, were more likely to have hypertension, positive family history of coronary artery disease, high cholesterol, high LDL and high triglycerides. CONCLUSION: In this study, the risk factor profile between young and old patients
and between the two genders was found to be different. Thus adult management protocols for AMI should be different from the ones for older patients and gender difference should also be considered.
33. J Pak Med Assoc. 2004 May;54(5):261-6. Risk factors and behaviours for coronary artery disease (CAD) among ambulatory Pakistanis. Iqbal SP, Dodani S, Qureshi R. Department of Family Medicine, The Aga Khan University, Karachi. OBJECTIVE: To determine the frequency and distribution of various risk factors and behaviours for coronary artery disease (CAD) among ambulatory Pakistanis. METHODS: It is a cross-sectional descriptive study carried out at the Aga Khan University Hospital, a teaching hospital in Karachi. All the subjects were adults (18-60 years) presenting at the general checkup clinic with no history or evidence of CAD by convenient sampling method. Demographic variables included risk factors and behaviors including diabetes, hypertension, dyslipidemia, family history of heart disease, obesity, smoking and sedentary lifestyle. RESULTS: Among 370 ambulatory Pakistanis, the proportions of major risk factors for CAD were: sedentary life style 72%, family history 42%, dyslipidemia 31%, obesity 24%, hypertension 19% and diabetes mellitus 15%. Diabetes, hypertension and dyslipidemia were poorly controlled in the study population. Proportions of the three major risk factors (smoking, hypertension and dyslipidemia) occurring singly, doubly and all three together in the study population were found to be 39%, 11% and 1%, respectively. Data were also analyzed for risk factors by comparing those with and without family history of CAD to eliminate any bias. The results were not statistically significant except for the sedentary life style (P=0.016). CONCLUSION: There is a high prevalence of CAD risk factors in this study population. Modifiable risk factors like diabetes, hypertension and high cholesterol need better control. Preventive screening programs and healthy lifestyle behaviours need to be emphasized upon in the community.
34. Curr Med Res Opin. 2004 Jan;20(1):55-62. Waist-hip ratio and low HDL predict the risk of coronary artery disease in Pakistanis.
Nishtar S, Wierzbicki AS, Lumb PJ, Lambert-Hammill M, Turner CN, Crook MA, Mattu MA, Shahab S, Badar A, Ehsan A, Marber MS, Gill J. Heartfile, 1 Park Road, Chak Shahzad, Islamabad, Pakistan. sania@heartfile.org OBJECTIVE: To establish risk factor causal associations for coronary artery disease (CAD) in the native Pakistani population. METHODS: We conducted a hospital-based, case-control study of 200 cases with angiographically documented CAD and 200 age- and sex-matched controls without angiographic evidence of CAD. Patients on lipid lowering therapy were excluded. Lifestyle, anthropometric and biochemical risk factors were assessed in both groups. RESULTS: The presence of CAD was associated with current, past or passive smoking, a history of diabetes and high blood pressure, a positive family risk factors in this study; levels were below history of CAD, body fat percentage, waist-hip ratio (WHR), low apolipoprotein A1 or low HDL, lipoprotein (a), glucose, insulin, insulin resistance, C-reactive protein (CRP), total cholesterol to HDL ratio (TC/HDL) and creatinine on univariate conditional logistic regression analysis. In multiple regression analysis, significant independent associations were found with low HDL (OR 0.11; 95% CI 0.04-0.34; p < 0.001) positive family history (OR 1.79; 95% CI 1.09-2.93; p = 0.02), CRP (OR 1.45; 95% CI 1.19-1.75; p < 0.001) and WHR (OR 1.04; 95% CI 1.01-1.08; p = 0.01). Angiograms were also quantified for the extent and severity of CAD by the Gensini scoring system. Quantitative angiographic data showed associations with age (p = 0.01), the duration of diabetes (p = 0.04), WHR (p = 0.06), low HDL (p < 0.001), lipoprotein (a) (p = 0.001), creatinine (p < 0.001) and CRP (p = 0.007). Results indicate that total and LDL cholesterol were not significant currently accepted thresholds for treatment. CONCLUSIONS: The cardiovascular risk profile in this population is consistent with metabolic syndrome where low HDL and WHR can be used to predict the risk of CAD. Results suggest the need to redefine the currently practised approach to CAD management in this population to fit local needs.
35. J Pak Med Assoc. 2003 Sep;53(9):396-400. Risk factors for cardiovascular disease in school children--a pilot study. Khuwaja AK, Fatmi Z, Soomro WB, Khuwaja NK. Department of Community Health Sciences, Aga Khan University, Karachi. OBJECTIVE: To assess the frequencies of risk factors for cardiovascular disease in school children. The information may help in designing interventions aimed at
modifying unhealthy lifestyle in children, which may reduce the later incidence of cardiovascular disease in adults. METHODS: A cross-sectional study was conducted on 206 students (ages 14-18 years), enrolled in higher secondary school. Students were interviewed about their lifestyles, family history of cardiovascular disease and its risk factors. Moreover, they were assessed for height, weight and blood pressure. RESULTS: Twenty nine percent of the children were physically inactive, 31% were taking unhealthy diet daily, 21% were overweight (BMI > or = 25) and 6% were smokers. History of paternal smoking was reported by 36% of the children, and among them 76% of fathers smoked in the presence of their children. Family history of cardiac disease, hypertension and diabetes were positive in 4%, 23% and 16% of the children respectively. Overall, 58% of the children had at least one modifiable risk factor. CONCLUSION: Majority of the children had modifiable risk factors for cardiovascular disease. Prevention efforts are required early in life, using strategies for behavioral modification and health promotion.
36. Eur J Clin Invest. 2003 Aug;33(8):686-92. Predictors of lipoprotein(a) levels in a European and South Asian population in the Newcastle Heart Project. Tavridou A, Unwin N, Bhopal R, Laker MF. Department of Pharmacology, ELPEN Pharmaceutical Co. Inc., Pikermi, Attika, Greece. t_annika@hotmail.com BACKGROUND: Understanding of the higher susceptibility of South Asians to coronary heart disease is limited. One explanation is the combination of high prevalence of insulin resistance with higher lipoprotein(a) levels. MATERIALS AND METHODS: Lipoprotein(a) levels and genotypes in three South Asian groups aged 25-74 years (Indian, Pakistani, Bangladeshi) were compared with a European population in a cross-sectional study. Biochemical measurements included lipids, apolipoprotein A1 and B, glucose, insulin and fibrinogen. Insulin sensitivity was calculated using the homoeostasis model assessment method (HOMA). RESULTS: There was no significant difference in lipoprotein(a) levels between South Asian and European men. South Asian women combined had higher lipoprotein(a) levels than European women, a difference probably resulting from higher lipoprotein(a) levels in Pakistani women compared with Indian and Bangladeshi women. Fasting insulin and HOMA were negatively associated with Lp(a) in South Asians though the associations were statistically significant only in men. There were only modest associations between most cardiovascular risk factors and Lp(a). Twenty-seven apolipoprotein(a) size alleles were detected in the three South Asian groups ranging from 16 to 43 kringle-IV repeats. The
apolipoprotein(a) size polymorphism explained 23% of the variability in lipoprotein(a) levels in South Asians. CONCLUSIONS: There were few nongenetic predictors of lipoprotein(a) levels in South Asians and Europeans. The lack of difference in Lp(a) between the South Asian and European men and the fact that differences between the women seemed to be confined to the Pakistani group offer little support to the hypothesis that higher Lp(a) levels contribute to the increased risk of heart disease in South Asians. Our findings do not support the hypothesis that susceptibility to heart disease in South Asians results from a combination of high insulin resistance and high Lp(a) levels.
37. J Pak Med Assoc. 2002 Sep;52(9):436-9. Prevalence of depression in patients with coronary artery disease in a tertiary care hospital in Pakistan. Bokhari SS, Samad AH, Hanif S, Hadique S, Cheema MQ, Fazal MA, Gul M, Bukhari SS, Khan AS. Aga Khan University. OBJECTIVE: To determine the prevalence of depression in patients with coronary artery disease (CAD) in a tertiary care hospital setting in Pakistan. METHODS: One hundred and fifty four patients of CAD (115 males and 39 females) were randomly selected from the outpatient department and wards of the National Institute of Cardiovascular Diseases, Karachi and were scored for depression via the Hospital Anxiety and Depression Scale. Basic demographic data and disease variables were also collected. RESULTS: The point prevalence of depression in the sample was 37% (31.3% males and 53.8% females). Female sex, income level below Rs. 5000 per month, low education level, outpatient, single earning family member and hypertension were few variables associated positively with depression (p < 0.05). Only one patient was receiving treatment for depression by his cardiologist. CONCLUSION: Depression is prevalent in CAD patients in Pakistan. Economic conditions may pose an additional threat on these patients. Treating physicians (especially cardiologists) need to be aware of this co-morbidity so as to be able to diagnose and adequately manage such patients.
38. J Pak Med Assoc. 2002 Sep;52(9):402-7.
Urbanisation and activity pattern of south Asian children. Hakeem R, Thomas J, Badruddin SH. Department of Food and Nutrition, RLAK Government College of Home Economics, Karachi. OBJECTIVE: To compare the physical activity level and total energy expenditure of 10-12 year old school children living at different levels of urbanization. METHOD: All the participating children kept a three-day record of their activities, for every fifteen-minutes, in specially designed diaries. Activities were grouped according to intensity that was determined on the basis of Physical Activity Ratio (PAR). After calculating the average time spent in a day, in activities of varying intensity, overall Physical Activity Level (PAL) of each subject was calculated by factorization method. After measuring bodyweight using a standard equation Basal Metabolic Rate (BMR) of the subjects was calculated. Total Energy Expenditure (TEE) was assessed on the basis of PAL and BMR of each child. SUBJECTS: Physical activity level of six groups of 10-12 year old children, representing various urbanization categories, was studied. Three groups of children were recruited from Punjab, Pakistan: rural, middle income urban and high income urban, and they were assigned urbanization rank (UR) 1, 2 and 3. Another three groups of children were recruited from Slough, UK: British Pakistani, British Indian, and British Caucasian and they were assigned urbanization rank 4, 5 and 6 respectively. RESULTS: Physical activity level decreased significantly with the urbanization rank only among girls of Pakistani origin (UR 1-4). Pattern of gender differences in activity level was different in rural and urban children. Rural girls were slightly more active than rural boys, whereas in urban areas boys were significantly more active than girls. Because of lower bodyweight the less urbanized children in spite of having higher PAL had a lower mean TEE as compared to the more urbanized groups. CONCLUSION: The activity level of rural children having access to formal education and television could not be expected to be very different from their urban counterparts. Inactivity of urban girls needs particular attention. Because of lower caloric requirements, on similar diets, less urbanized groups may succumb to overweight more easily than the urbanized groups. Participation in active games may present a substitute to decreased involvement in moderately active work and play activities.
39. BMJ. 2002 Oct 19;325(7369):903. Heterogeneity among Indians, Pakistanis, and Bangladeshis is key to racial inequities.
Bhopal RS. Comment on BMJ. 2002 Mar 2;324(7336):511-6. PMCID: PMC1124394 PMID: 12386051 [PubMed - indexed for MEDLINE]
40. J Public Health Med. 2002 Jun;24(2):95-105. Ethnic and socio-economic inequalities in coronary heart disease, diabetes and risk factors in Europeans and South Asians. Bhopal R, Hayes L, White M, Unwin N, Harland J, Ayis S, Alberti G. University of Edinburgh, Medical School. raj.bhopal@ed.ac.uk BACKGROUND: The aim of this study was to test the hypothesis that in Europeans and South Asians (Indians, Pakistanis, Bangladeshis) alike, worse socio-economic status is associated with a higher prevalence of coronary heart disease (CHD), glucose intolerance (impaired glucose tolerance and diabetes) and related risk factors (the predicted direction of association). METHODS: Cross-sectional data were analysed from a community-based prevalence study seeking associations between social class, education and Townsend deprivation score and ECG evidence of CHD, glucose tolerance test and 12 cardiovascular risk factors. The study population consisted of South Asians (n = 684) comprising Indians (n = 259), Pakistanis (n = 305) and Bangladeshis (n = 120), and Europeans (n = 825), aged 25-74 years in Newcastle. The analysis examined up to 84 associations for each ethnic group. Interactions between ethnicity and socio-economic variables were examined using regression analysis. The main outcome measure was the number of associations in the predicted direction. RESULTS: Europeans fared better in some indicators of socio-economic position, South Asians in others. Indians were socio-economically advantaged compared with Pakistanis and Bangladeshis. Most measures of socio-economic position were associated with health measures in the predicted direction in Europeans [71/84 (85 per cent) associations, 25 statistically significant] and less so in the South Asians combined [58/84 (69 per cent) associations, 12 statistically significant]. In South Asian men 25/42 (60 per cent) of associations were as predicted, seven significantly so, in women 33/42 (79 per cent) were, five being statistically significant. There were apparent differences between Indians 152/78 (67 per cent) of associations as predicted, seven statistically significant], Pakistanis [41/84 (49 per cent), four statistically significant] and Bangladeshis [39/79 (49 per cent), one statistically significant]. In Indians, Townsend deprivation score was mostly associated as predicted [23/27 (85 per cent), five associations statistically significant], more so than social class [14/27 (52 per
cent), none statistically significant]. In South Asian men and women combined, associations with anthropometric [18/24 (75 per cent)], biochemical [15/18 (83 per cent)], and lifestyle 114/18 (78 per cent)] measures were often as predicted, but those with blood pressure (4/12, 33 per cent) and CHD and glucose intolerance (7/12, 58 per cent) were less often so. Interactions between socio-economic position and ethnicity were found. CONCLUSIONS: The European pattern of inequalities is being established in South Asian men and women, possibly at a different pace in different subgroups. Future studies of inequalities should be large, separate Indian, Pakistani and Bangladeshi populations, study men and women separately and track changes over time.
41. Ann Behav Med. 2002 Spring;24(2):113-21. Cardiovascular stress responses among Asian Indian and European American women and men. Stoney CM, Hughes JW, Kuntz KK, West SG, Thornton LM. Department of Psychology, The Ohio State University, Columbus 43210-1222, USA. stoney.1@osu.edu Asian Indians have approximately 3 times the rate of coronary artery disease as do age-matched European Americans, but the increased risk cannot be explained by the presence of known physiological and behavioral risk factors. One previous study suggested that Asian Indians have diminished vasoactive responses to isoproterenol, but no published study has examined responses to psychological stressors. The purpose of this study was to test the hypothesis that the vasomotor response to stress, as indexed by hemodynamic measures, would be exaggerated in Asian Indian men and women, relative to European American individuals. Thirty-seven Asian Indian and 43 European American men and women were tested in a standard reactivity protocol, whereas heart rate, blood pressure, and cardiac impedance measures were assessed. Asian Indian men and women had significantly smaller changes in systolic blood pressure and mean arterial pressure during the stressors, relative to European American men and women. Asian Indian women, but not men, had significantly smaller diastolic blood pressure and total peripheral-resistance index changes to the stressors, relative to the other 3 groups. These data are in contrast to our expectation of decreased tendency of Asian Indians to vasodilate during psychological stress but do suggest that sex and Asian Indian ethnicity interact to influence vascular reactivity to stressors.
42. Atherosclerosis. 2001 Jun;156(2):457-61. Impaired fibrinolysis and increased fibrinogen levels in South Asian subjects. Kain K, Catto AJ, Grant PJ. Academic Unit of Molecular Vascular Medicine, G-Floor, Martin Wing, Leeds General Infirmary, LS1 3EX, Leeds, UK. k.kain@leeds.ac.uk The potential role of haemostatic risk markers is largely unexplored in South Asians, who have increased morbidity and mortality from cardiovascular disease and an increased prevalence of insulin resistance. To investigate differences in thrombotic risk markers between South Asian and White populations, 42 Asian and 50 White males and 96 Asian and 80 White females, clinically free from vascular disease, were recruited. Venous blood samples were taken for measures of haemostasis and determination of blood lipids. South Asian females showed lower fasting blood glucose than White females (4.6 vs. 4.8 mmol/l, P<0.008). In the South Asian population, total cholesterol was lower in females, with a similar trend in males (females 5.0 vs. 5.5 mmol/l, P<0.001; males 5.1 vs. WM 5.5 mmol/l, P=0.09), but no difference in triglyceride levels. South Asian subjects of both genders had markedly higher levels of fibrinogen (females 3.3 vs. 2.8 mg/dl, P<0.0005; males 3.0 vs. 2.5 mg/dl P<0.002) and PAI-1 activity (females 14.6 vs. 8.7 ng/ml, P<0.0005, males 21.3 vs. 12.2 ng/ml, ) P<0.0005). Factor VII:C was lower in both South Asian groups (females 110.9 vs. 122.4%, P<0.005; males 103.3 vs. 125%, P<0.0005). Factor XII was lower in South Asian females and there were no differences in Factor XII levels in male populations. These results suggest that elevated PAI-1 and fibrinogen in Asians of both genders may contribute to the increased vascular risk experienced in this population; however, the role of dyslipidaemia and Factor VII are not clear in these processes.
43. J Pak Med Assoc. 2001 Jan;51(1):22-8. Urbanisation and coronary heart disease risk factors in South Asian children. Hakeem R, Thomas J, Badruddin SH. Department of Food and Nutrition, RLAK Government College of Home Economics, Karach. BACKGROUND: Coronary Heart Disease (CHD) and other Non Communicable Diseases (NCDs) are increasing globally. Comparison of various sections of the South Asian populations living at different levels of urbanization can help in understanding
the role of demographic transition in the increased prevalence of these diseases in urbanized populations. OBJECTIVE: To compare the prevalence of certain CHD risk factors in 10-12 year old school children living at different levels of urbanization. METHOD: Differences in height, Body Mass Index (BMI), Waist Hip Ratio (WHR), Fasting Blood Glucose (FBG) and Total Blood Cholesterol (TBC) were studied. SUBJECTS: Anthropometric and biochemical measurements of six groups of 10-12 year old children, representing various urbanization categories, were studied. Three groups of children were recruited from Punjab, Pakistan: rural, middle income urban and high income urban and they were assigned urbanization rank (UR) 1, 2 and 3. Another three groups of children were recruited from Slough, UK: British Pakistani, British Indian, and British Caucasian and they were assigned urbanization rank 4, 5 and 6 respectively. RESULTS: Proportion of children having high CHD risk increased with urbanization rank. Increase in BMI and TBC with urbanization status was steadier than the increase in FBG and WHR. Stunting which have been found to have a positive association with obesity and increased risk of CHD was higher among the less urbanized groups. BMI and TBC of the urbanized South Asian groups were lower, but FBG was higher than the British Caucasian, who served as controls. CONCLUSION: These findings support the hypothesis that high CHD death rate among South Asians in UK may have its origin in the genetic predisposition to diabetes but are not likely to be solely due to this factor. The environmental factors like under nourishment in early life, adoption of urbanized life style or a combination of both could be the major determinants of CHD morbidity and mortality.
44. J Public Health Med. 2000 Sep;22(3):375-85. What is the risk of coronary heart disease in South Asians? A review of UK research. Bhopal R. Department of Epidemiology and Public Health, School of Health Sciences, University of Newcastle upon Tyne. Raj.Bhopal@ed.ac.uk OBJECTIVE: The aim of this study was to systematically review the evidence that coronary heart disease risk is higher in South Asians than in comparative 'white' populations, particularly seeking studies of incidence. METHODS: A systematic literature review was carried out using a personal research literature collection, MEDLINE 1966-1998 and citations from references. RESULTS: Of 19 studies, none reported disease incidence. Most studies reported prevalence, mortality rates or health care utilization data. Most studies were on people born on the Indian subcontinent, thus omitting the British-born. Several
did not report on women. The strongest evidence of an excess of CHD in South Asians came from mortality data comparing those born in the Indian subcontinent with the whole population of England and Wales. In South Asians coronary heart disease is common and important, but neither the actual disease rates nor the excess risk in relation to the 'white' population are known. Both prevalence and mortality data suggested that the frequency of coronary heart disease in Indians, Pakistanis and Bangladeshis differed. CONCLUSION: Estimates of South Asians' excess risk of coronary heart disease are imprecise and may be too high (if there are data errors) or too low (for comparison with the general population blunts ethnic variations). South Asians are a heterogeneous group yet most studies of CHD report on Bangladeshis, Indians and Pakistanis combined. Indians probably have less CHD than Bangladeshis and Pakistanis. Cohort studies on CHD in South Asians are needed and these should be designed so that data can be combined for future systematic reviews.
45. Am J Clin Nutr. 1999 Dec;70(6):1112-3. Coronary artery disease risk factors in south Asian and American premenopausal women. Singh RB. Comment on Am J Clin Nutr. 1999 Apr;69(4):621-31. PMID: 10584059 [PubMed - indexed for MEDLINE]
46. BMJ. 1999 Jul 24;319(7204):215-20. Heterogeneity of coronary heart disease risk factors in Indian, Pakistani, Bangladeshi, and European origin populations: cross sectional study. Bhopal R, Unwin N, White M, Yallop J, Walker L, Alberti KG, Harland J, Patel S, Ahmad N, Turner C, Watson B, Kaur D, Kulkarni A, Laker M, Tavridou A. Department of Epidemiology and Public Health, Medical School, University of Newcastle, Newcastle upon Tyne NE2 4HH. OBJECTIVE: To compare coronary risk factors and disease prevalence among Indians, Pakistanis, and Bangladeshis, and in all South Asians (these three groups together) with Europeans. DESIGN: Cross sectional survey. SETTING: Newcastle upon Tyne.
PARTICIPANTS: 259 Indian, 305 Pakistani, 120 Bangladeshi, and 825 European men and women aged 25-74 years. MAIN OUTCOME MEASURES: Social and economic circumstances, lifestyle, self reported symptoms and diseases, blood pressure, electrocardiogram, and anthropometric, haematological, and biochemical measurements. RESULTS: There were differences in social and economic circumstances, lifestyles, anthropometric measures and disease both between Indians, Pakistanis, and Bangladeshis and between all South Asians and Europeans. Bangladeshis and Pakistanis were the poorest groups. For most risk factors, the Bangladeshis (particularly men) fared the worst: smoking was most common (57%) in that group, and Bangladeshis had the highest concentrations of triglycerides (2.04 mmol/l) and fasting blood glucose (6.6 mmol/l) and the lowest concentration of high density lipoprotein cholesterol (0.97 mmol/l). Blood pressure, however, was lowest in Bangladeshis. Bangladeshis were the shortest (men 164 cm tall v 170 cm for Indians and 174 cm for Europeans). A higher proportion of Pakistani and Bangladeshi men had diabetes (22.4% and 26.6% respectively) than Indians (15.2%). Comparisons of all South Asians with Europeans hid some important differences, but South Asians were still disadvantaged in a wide range of risk factors. Findings in women were similar. CONCLUSION: Risk of coronary heart disease is not uniform among South Asians, and there are important differences between Indians, Pakistanis, and Bangladeshis for many coronary risk factors. The belief that, except for insulin resistance, South Asians have lower levels of coronary risk factors than Europeans is incorrect, and may have arisen from combining ethnic subgroups and examining a narrow range of factors.
47. Lancet. 1998 Apr 11;351(9109):1105. Folate deficiency, neural tube defects, and cardiac disease in UK Indians and Pakistanis. Michie CA, Chambers J, Abramsky L, Kooner JS. Comment in Lancet. 2000 Jan 8;355(9198):147. PMID: 9660590 [PubMed - indexed for MEDLINE]
48. Diabetes Care. 1997 Jul;20(7):1093-100. The relationship of concentrations of insulin and proinsulin-like molecules with coronary heart disease prevalence and incidence. A study of two ethnic groups.
Yudkin JS, Denver AE, Mohamed-Ali V, Ramaiya KL, Nagi DK, Goubet S, McLarty DG, Swai A. Department of Medicine, University College London Medical School, U.K. OBJECTIVE: To define the potential role of proinsulin-like molecules as risk factors for cardiovascular disease. RESEARCH DESIGN AND METHODS: Fasting concentrations of proinsulin, des-31,32-proinsulin, and insulin, and of insulin 2 h after a 75-g glucose load, were measured in 1,034 nondiabetic europid subjects and 257 south Asian subjects and related to prevalent coronary heart disease (Minnesota-coded electrocardiographic criteria or ischemic chest pain). In 137 south Asian subjects, the fasting concentrations were related to incident coronary heart disease over a 6.5-year follow-up. RESULTS: The standardized odds ratios for prevalent coronary heart disease were as follows: fasting insulin, 1.29 (1.11-1.49), P = 0.0006; 2-h insulin, 1.25 (1.08-1.45), P = 0.003; proinsulin, 1.23 (0.99-1.53), P = 0.058; and des-31,32-proinsulin, 1.32 (1.03-1.69), P = 0.026. The odds ratios were similar in the two ethnic groups. These relationships became insignificant when controlling for age, sex, and BMI. The standardized odds ratios for incident coronary heart disease were as follows: fasting insulin, 0.99 (0.63-1.55), P = 0.97; proinsulin, 1.13 (0.72-1.78), P = 0.59; and des-31,32-proinsulin, 1.00 (0.61-1.63), P = 1.00. CONCLUSIONS: We have found similar relationships between concentrations of proinsulin-like molecules and prevalent coronary heart disease, as are observed for insulin in these nondiabetic subjects, although these molecules comprise only approximately 10% of all insulin-like molecules. It appears biologically implausible that these relationships represent cause and effect.
49. Ciba Found Symp. 1996;201:54-64; discussion 64-7, 188-93. Metabolic consequences of obesity and body fat pattern: lessons from migrant studies. McKeigue PM. Department of Epidemiology and Population Sciences, London School of Hygiene and Tropical Medicine, UK. Prevalence of non-insulin-dependent diabetes mellitus and mortality from coronary heart disease are higher in people of South Asian (Indian, Pakistani and Bangladeshi) descent living in urban societies than in other ethnic groups. The high prevalence of diabetes is one manifestation of a pattern of metabolic
disturbances related to central obesity and insulin resistance, which includes raised plasma very low density lipoprotein triglyceride and low plasma high density lipoprotein-cholesterol. Average waist/hip circumference ratios are higher in South Asians than in Europeans of similar body mass index: in this respect South Asians differ from other populations such as Pima Indians where high prevalence of non-insulin-dependent diabetes mellitus occurs in association with generalized obesity. The high rates of coronary heart disease in South Asians are most easily explained by the effects of this central obesity/insulin resistance syndrome, although ethnic differences in fasting lipids are unlikely to account fully for the excess risk. In Afro-Caribbean migrants, the prevalence of diabetes is almost as high as in South Asians but the lipid disturbances characteristic of the insulin resistance syndrome do not occur to the same extent. This may account for the low rates of coronary heart disease in this group.
50. Int J Cardiol. 1995 Mar 3;48(3):287-93. Dietary fat purchasing habits in whites, blacks and Asian peoples in England--implications for heart disease prevention. Lip GY, Malik I, Luscombe C, McCarry M, Beevers G. University Department of Medicine, City Hospital, Birmingham, England. The mortality and morbidity from coronary heart disease (CHD) is higher in people of South Asian origin than in whites, but is significantly lower in the black (Afro-Caribbean origin) community in the United Kingdom. To investigate whether this may be related to differences in fatty food intake, we performed a questionnaire survey of the weekly food purchasing habits and preparation methods in white, black (Caribbean) and Asian households in Birmingham. We interviewed 224 housewives from three ethnic groups (84 white, 76 black/Afro-Caribbean and 72 Asian). The highest quantity of fat in foods purchased per week was found in the Asian population (median 1409 g/week per person, interquartile range (IQR) 850-1952), which was significantly greater than black subjects, who had the lowest quantity of fat in foods purchased (1012 g/week per person, IQR 835-1388) (Mann-Whitney test:median differences 300.5, 95% C.I. 23.3-600.4, P = 0.029). The median quantity of fat in foods purchased by the white households was intermediate, at 1186 g/week per person (IQR 861-1711). There was a higher quantity of fat in foods purchased in the lower social classes (IV and V) in both the white and Asian populations. Butter, egg and milk consumption was significantly greater in Asians; with ghee consumption almost exclusive amongst this group (98%). Amongst whites and blacks, the commonest food preparation methods were grilling, boiling or poaching; whilst amongst Asians, frying was more common (chi 2 = 81.25, d.f. = 4, P < 0.0001).(ABSTRACT TRUNCATED AT 250
WORDS)
51. Am J Clin Nutr. 1994 May;59(5):1069-74. Relationship of hyperinsulinemia to dietary intake in south Asian and European men. Sevak L, McKeigue PM, Marmot MG. Department of Epidemiology and Population Sciences, London School of Hygiene and Tropical Medicine, UK. In South Asians (Indians, Pakistanis, and Bangladeshis) settled overseas, high rates of coronary disease and non-insulin-dependent diabetes occur in association with central obesity and insulin resistance. To examine whether these disturbances were related to diet, we measured 7-d weighed intakes in 173 South Asian and European men aged 40-69 y in London. In South Asians compared with Europeans, respectively, mean energy intake was lower (9.5 vs 10.8 MJ/day, P < 0.001), total fat intake was lower (36.5% vs 39.2% of energy intake, P = 0.007), starch intake was higher (28.0% vs 21.5% of energy, P < 0.001), polyunsaturated fatty acid intake was higher (8.2% vs 7.0% of energy, P = 0.02), and dietary fiber intake was higher (3.2 vs 2.0 g/MJ, P < 0.001). Elevated serum insulin concentrations at 2 h postglucose were associated positively with carbohydrate intake (P = 0.001) and inversely with alcohol intake (P = 0.006), but not with saturated fatty acid intake. The high coronary risk in South Asian people is not explained by any unfavorable characteristic of South Asian diets.
52. Postgrad Med J. 1994 May;70(823):315-8. Are Indo-origin people especially susceptible to coronary artery disease? Shaukat N, de Bono DP. University Department of Cardiology, Glenfield General Hospital, Leicester, UK. PMCID: PMC2397609 PMID: 8016000 [PubMed - indexed for MEDLINE]
53. Br Heart J. 1993 Jun;69(6):572.
Coronary heart disease in Indians, Pakistanis, and Bangladeshis: aetiology and possible prevention. Singh RB, Niaz MA. Comment on Br Heart J. 1992 May;67(5):341-2. PMCID: PMC1025176 PMID: 8343328 [PubMed - indexed for MEDLINE]
54. Br Heart J. 1992 May;67(5):341-2. Coronary heart disease in Indians, Pakistanis, and Bangladeshis: aetiology and possibilities for prevention. McKeigue PM. Comment in Br Heart J. 1993 Jun;69(6):572. PMCID: PMC1024851 PMID: 1389723 [PubMed - indexed for MEDLINE]
55. J Clin Epidemiol. 1989;42(7):597-609. Coronary heart disease in south Asians overseas: a review. McKeigue PM, Miller GJ, Marmot MG. Department of Community Medicine, University College, London, England. Coronary heart disease rates have been reported in several parts of the world to be unusually high in people originating from the Indian subcontinent. High coronary disease rates appear to be common to South Asian groups of different geographical origin, religion, and language. This presents a challenge to the understanding of coronary heart disease: the high rates in South Asians are not explained on the basis of elevated serum cholesterol, smoking or hypertension. Low plasma HDL cholesterol, high plasma triglyceride levels and high prevalence of non-insulin-dependent diabetes have been consistently found in South Asians overseas: this probably reflects an underlying state of insulin resistance. Further studies are needed to determine whether this metabolic disturbance can account for the high rates of coronary heart disease in South Asians, and to identify possibilities for prevention.PMID: 2668448 [PubMed - indexed for MEDLINE]
Search results for cardiac bimarkers and Pakistan: 1. J Pak Med Assoc. 2010 Jun;60(6):423-8. Correlation of cardiac troponin I levels (10 folds upper limit of normal) and extent of coronary artery disease in non-ST elevation myocardial infarction. Qadir F, Farooq S, Khan M, Hanif B, Lakhani MS. Department of Cardiology, Tabba Heart Institute, Karachi, Pakistan. OBJECTIVE: To determine the correlation of cardiac troponin I (cTnI) 10 folds upper limit of normal (ULN) and extent of coronary artery disease (CAD) in Non-ST-elevation myocardial infarction (NSTEMI). METHODS: A cross-sectional study was conducted on 230 consecutive NSTEMI patients admitted in Tabba Heart Institute, Karachi between April to December 2008. cTnI was measured using MEIA method. All patients underwent coronary angiography in the index hospitalization. Stenosis > or = 70% in any of the three major epicardial vessels was considered significant CAD. Extent of CAD was defined as significant single, two or three vessel CAD. Chi-square test was applied to test the association between cTnI levels and CAD extent. RESULTS: Out of 230 patients, in 111 patients with cTnI levels < or = 10 folds upper limit of normal (ULN), 25 (22.52%) had single vessel, 40 (36%) had two vessel and 34 (30.6%) had three vessel significant CAD, whereas in 119 patients with cTnI levels > 10 folds ULN, 23 (19.3%) had single vessel, 37 (31.1%) had two vessel and 55 (46.2%) had three vessel significant CAD. The results suggest that there was an insignificant association between the cTnI levels and single vessel, two vessel and the overall CAD extent (p = 0.35, p = 0.21 and p= 0.13 respectively), however there was a statistically significant association between the cTnI levels and three vessel CAD (p < 0.04). CONCLUSION: Higher cTnI levels are associated with an increased proportion of severe three vessel CAD involvement. Prompt identification and referral of this patient subset to early revascularization strategies would improve clinical outcomes.
2. J Ayub Med Coll Abbottabad. 2009 Jul-Sep;21(3):46-50. Baseline leukocyte count and acute coronary syndrome: predictor of adverse cardiac events, long and short-term mortality and association with traditional risk factors, cardiac biomarkers and C-reactive protein. Munir TA, Afzal MN, Habib-ur-Rehman. Shifa College of Medicine, Shifa International Hospital, Islamabad, Pakistan.
tahirahmadmunir1@hotmail.com BACKGROUND: The elevated WBC count has been accepted as part of healing response following myocardial infarction as well as a predictor of adverse cardiovascular events. The study was designed to find out correlation between WBC count and coronary risk factors, cardiac biomarkers, C-reactive protein (CRP), incidence of adverse cardiac events and mortality in patients of ACS in Pakistan. METHODS: One hundred and thirty-three patients of ACS were stratified according to WBC categories, WBC1 (< 7000/mm3), WBC2 (7100-10,000/mm3) and WBC3 (> 10,000/mm3). The WBCs were counted on admission by Sysmex cell counter, CRP by immunoturbidimetric method, and CK-MB and Trop-I by enzyme immunoassay. Adverse cardiac events and mortality were recorded for 12 months of follow up period. RESULTS: Long-term mortality in patients with ACS was 6.4% in WBC1, 18.2% in WBC2 and 40.9% in WBC3 categories, while short term mortality was 2.6%, 3.0% and 18.2% in WBC1, WBC2, and WBC3 categories respectively. Relative to patients in lower 2 WBC categories, patients in the highest category were 7 times more likely to die during 30 days (HR 7.83, p = 0.017) and more than 9 times during the total follow up period (HR 9.42, p < 0.001). Cox regression analysis showed WBC3 a strong independent predictor of mortality (HR 6.36, p = 0.016). WBC count showed a positive correlation with coronary risk factors, cardiac biomarkers and CRP. CONCLUSION: WBC count is a strong independent predictor of mortality in patients with ACS and has positive correlation with coronary risk factors, cardiac biomarkers and CRP.
3. Eur J Epidemiol. 2009;24(6):329-38. Epub 2009 Apr 30. The Pakistan Risk of Myocardial Infarction Study: a resource for the study of genetic, lifestyle and other determinants of myocardial infarction in South Asia. Saleheen D, Zaidi M, Rasheed A, Ahmad U, Hakeem A, Murtaza M, Kayani W, Faruqui A, Kundi A, Zaman KS, Yaqoob Z, Cheema LA, Samad A, Rasheed SZ, Mallick NH, Azhar M, Jooma R, Gardezi AR, Memon N, Ghaffar A, Fazal-ur-Rehman, Khan N, Shah N, Ali Shah A, Samuel M, Hanif F, Yameen M, Naz S, Sultana A, Nazir A, Raza S, Shazad M, Nasim S, Javed MA, Ali SS, Jafree M, Nisar MI, Daood MS, Hussain A, Sarwar N, Kamal A, Deloukas P, Ishaq M, Frossard P, Danesh J. Center for Non-Communicable Diseases, Karachi, Pakistan. ds436@medschl.cam.ac.uk The burden of coronary heart disease (CHD) is increasing at a greater rate in South Asia than in any other region globally, but there is little direct evidence about its determinants. The Pakistan Risk of Myocardial Infarction Study (PROMIS) is an epidemiological resource to enable reliable study of genetic, lifestyle and other determinants of CHD in South Asia. By March 2009, PROMIS had recruited over 5,000 cases of first-ever confirmed acute myocardial infarction (MI) and over
5,000 matched controls aged 30-80 years. For each participant, information has been recorded on demographic factors, lifestyle, medical and family history, anthropometry, and a 12-lead electrocardiogram. A range of biological samples has been collected and stored, including DNA, plasma, serum and whole blood. During its next stage, the study aims to expand recruitment to achieve a total of about 20,000 cases and about 20,000 controls, and, in subsets of participants, to enrich the resource by collection of monocytes, establishment of lymphoblastoid cell lines, and by resurveying participants. Measurements in progress include profiling of candidate biochemical factors, assay of 45,000 variants in 2,100 candidate genes, and a genomewide association scan of over 650,000 genetic markers. We have established a large epidemiological resource for CHD in South Asia. In parallel with its further expansion and enrichment, the PROMIS resource will be systematically harvested to help identify and evaluate genetic and other determinants of MI in South Asia. Findings from this study should advance scientific understanding and inform regionally appropriate disease prevention and control strategies.
4. Angiology. 2007 Jun-Jul;58(3):269-74. Plasma levels of B-type natriuretic Peptide in patients with unstable angina pectoris or acute myocardial infarction: prognostic significance and therapeutic implications. Ahmed W, Zafar S, Alam AY, Ahktar N, Shah MA, Alpert MA. Department of Cardiology, Shifa International Hospital, Islamabad, Pakistan. Plasma B-type natriuretic peptide (BNP) levels were obtained from 146 patients with unstable angina pectoris, non-ST-segment elevation myocardial infarction (MI), or ST-segment elevation MI to determine their value in predicting the presence of new heart failure, recurrent MI or ischemia, or death 1 month after the index event. Patients with elevated plasma BNP levels (>80 pg/mL) had a significantly higher incidence of new heart failure and all-cause mortality than those with a normal plasma BNP level (<or=80 pg/mL). Early revascularization with percutaneous intervention or coronary artery bypass grafting significantly reduced the incidence of new heart failure and all-cause mortality in patients with an elevated plasma BNP level, but had no effect on individual outcomes in the normal plasma BNP subgroup.
1. J Pak Med Assoc. 2009 Dec;59(12):819-22. Admission creatine kinase as a prognostic marker in acute myocardial infarction. Kazmi KA, Iqbal SP, Bakr A, Iqbal MP. Department of Medicine, Aga Khan University, Karachi, Pakistan. OBJECTIVES: To investigate the prognostic significance of creatine kinase (CK) in Pakistani patients suffering from acute myocardial infarction (AMI) and to find out if CK combined with troponin T (TnT) could be a better predictor for long-term adverse cardiac event. METHODS: One hundred and eighty six consecutive patients with AMI who were eligible for streptokinase (SK) treatment were included in this prospective cohort study. The relationship between their serum/plasma CK and TnT levels at the time of admission and clinical outcome was investigated over a mean follow up of 24.12 +/- 3.75 months. RESULTS: Admission CK was found to be associated with subsequent cardiac event and mortality (P < 0.01 and P < 0.04 respectively). Admission CK was also mildly associated with time interval between onset of symptoms to SK treatment (correlation coefficient 'r' = 0.23). Odds of encountering a cardiac event in AMI patients with above-normal CK levels (adjusted for gender) were 3.46 times higher than the odds in patients with normal CK levels. Similarly, odds of mortality in patients with positive TnT were 4.6 times the odds in patients with negative TnT. The two biochemical markers, CK and TnT, together did not provide any further information about prognosis of the disease. CONCLUSION: Admission CK is a better prognostic marker for a subsequent cardiac event, while TnT is a better predictor of mortality over a mean follow up of nearly 2 years. Together, they do not improve predictability of an adverse cardiac event.
2. Heart. 2005 Aug;91(8):1003-7. Metabolic syndrome and risk of coronary heart disease in a Pakistani cohort. Wierzbicki AS, Nishtar S, Lumb PJ, Lambert-Hammill M, Turner CN, Crook MA, Marber MS, Gill J. Department of Chemical Pathology, St Thomas's Hospital, London SE1 7EH, UK. anthony.wierzbicki@kcl.ac.uk OBJECTIVE: To assess the relation of the metabolic insulin resistance syndrome (M-IRS) with coronary heart disease (CHD) in Pakistani patients. SUBJECTS: 200 patients with angiographic disease (CHD(+)) matched with 200
patients with chest pain without occlusive disease (CHD(-)). DESIGN: Prospective case-control study. SETTING: Tertiary referral cardiology unit in Pakistan. RESULTS: M-IRS was present in 37% of CHD(+) versus 27% of CHD(-) patients by criteria for white patients or 47% versus 42%, respectively, by Asian criteria (p < 0.001). After adjustment for other risk factors, M-IRS was not a significant predictor for CHD or angiographic disease. Age (p = 0.03), smoking (p < 0.001), diabetes-years (p = 0.003), sialic acid (p = 0.01), and creatinine (p = 0.008) accounted for the excess risk of CHD. Similarly, age (p = 0.005), creatinine (p < 0.001), cigarette pack-years (p = 0.02), diabetes-years (p = 0.003), and sialic acid (p = 0.08) were predictors of greater angiographic disease. M-IRS differed between Pakistani and white patients, as waist circumference correlated weakly (r = -0.03-0.08, p = 0.45-0.52) with triglycerides, high density lipoprotein cholesterol, systolic blood pressure, or glucose. Sialic acid was the only inflammatory marker associated with M-IRS. CONCLUSIONS: Despite strong associations between individual risk factors associated with M-IRS and a univariate association between M-IRS and CHD in native Pakistanis, the principal discriminant risk factors in this group are age, smoking, inflammation, diabetes-years, and impaired renal function. The poor sensitivity of M-IRS for CHD reflects the high underlying prevalence of M-IRS, thus reducing sensitivity, confounding by other urban lifestyle traits, or a lack of association of waist circumference with M-IRS risk factors. The definition of M-IRS may have to be revised to increase its power as a discriminant risk factor for CHD in Pakistani populations.
3. Clin Cardiol. 2004 Mar;27(3):144-50. Myoglobin--a marker of reperfusion and a prognostic indicator in patients with acute myocardial infarction. Iqbal MP, Kazmi KA, Mehboobali N, Rahbar A. Department of Biological & Biomedical Sciences, The Aga Khan University, Karachi, Pakistan. perwaiz.iqbal@aku.edu BACKGROUND: Early noninvasive identification of patients with occluded infarct-related arteries after thrombolysis has important prognostic and therapeutic implications. Recent reports indicate that plasma kinetics of cardiac marker proteins could be very useful in diagnosis of myocardial reperfusion. Although angiographic assessment remains the ideal procedure for determining patency, it is expensive, invasive, not within the reach of most patients in developing countries, and the long-term follow-up data are still sparse. HYPOTHESIS: The present study was undertaken to investigate whether plasma
kinetics of myoglobin in conjunction with clinical markers and another biochemical marker, creatine kinase, could be used to predict myocardial reperfusion more accurately and to investigate the correlation between myoglobin release after thrombolysis and mortality in patients with acute myocardial infarction (AMI) over a follow-up period of 18 months. METHODS: Eighty-three consecutive patients with AMI receiving streptokinase treatment were studied for plasma kinetics of myoglobin in conjunction with clinical markers and creatine kinase to predict reperfusion and were followed for a period of 18 months. RESULTS: Increased baseline mean +/- standard deviation levels of myoglobin were observed among "nonresponders" to streptokinase treatment compared with "responders" (469 +/- 386 microg/l vs. 270 +/- 211 microg/l). There was significantly more release of myoglobin following thrombolytic treatment among the responders than among the nonresponders (mean ratio of myoglobin levels at 90 min to 0 min 6.01 +/- 9.2 vs. 1.03 +/- 0.64). In a follow-up of 61 patients over a period of 18 months, 31% mortality was observed in the nonresponder group compared with 11.7% in the responder group. In responders, the mean ratio of myoglobin levels at 90 and 0 min was significantly less among those who died (p = 0.019) than among those who survived. CONCLUSION: A myoglobin release profile in combination with other clinical markers offers inexpensive, noninvasive, and a reasonably reliable way of assessing coronary artery patency after thrombolytic treatment.
4. Trop Doct. 2003 Jan;33(1):18-22. Admission troponin T as a prognostic marker and it relationship to streptokinase treatment patients with acute myocardial infarction. Kazmi KA, Iqbal MP, Rahbar A, Mehboobali N. Department of Medicine, The Aga Khan University, Stadium Road, Karachi 74800, Pakistan. The relationship between the admission troponinT (TnT) level and the response to streptokinase (SK) was examined in 76 patients with acute myocardial infarction (AMI). Of 27 TnT positive patients, 10 (37%) showed a response to SK as suggested by a non-invasive criterion for reperfusion, while 24 (49%) were 'responders' among 49 TnT negative patients. There appeared to be a trend towards a better response to SK in the TnT negative group but the difference lacked statistical power due to the small sample size. The mean time-interval between the onset of symptoms and thrombolytic treatment among TnT positive 'non-responders' was significantly (P < 0.005) higher than the TnT negative 'non-responders' (5.23 + 3.42 h versus 2.38 +/- 1.37 h). An 18 month follow up on 61 patients revealed a higher mortality (33%) among TnT positive patients than TnT negative patients
(10%). Mortality among TnT positive 'non-responders' was significantly higher (P = 0.0494) than mortality among TnT-negative 'non-responders' (43% versus 9%), indicating that TnT positive patients, non-responsive to SK were at a greater risk of cardiac death. The data suggest that the admission TnT level can be of value in risk stratification of patients with AMI.
These are the results of MeSh search for the terms Troponin I and Coronary artery disaease and Coronary disease . 1. J Coll Physicians Surg Pak. 2010 Feb;20(2):74-8. Emergency evaluation of acute chest pain. Almas A, Parkash O, Hameed A, Islam M. Department of Medicine, The Aga Khan University, Karachi. aysha.almas@aku.edu OBJECTIVE: To determine the sensitivity and specificity of initial clinical assessment about the diagnosis of acute coronary syndrome (ACS) in patients presenting with acute chest pain by a cardiology resident in the emergency room and assess the 30-day outcome of patients with ACS and non ACS. STUDY DESIGN: Cohort study. PLACE AND DURATION OF STUDY: The study was conducted in the emergency department and cardiac care units of the Aga Khan University in 2006-07. METHODOLOGY: A total of 202 patients, who presented to the emergency room with chest pain, were given an initial ECG and troponin check. Patients were assigned to initial ACS and non-ACS groups by the cardiology resident. After cardiac workup, patients were assigned to final ACS/final non ACS group. They were followed for outcome after 30 days of initial presentation. Sensitivity and specificity, if initial workup was determined, keeping final assessment after cardiac workup as the gold standard. RESULTS: Out of the 202 patients, 61.9% were males. Their mean age was 54.05+13 years. Sixty eight percent were placed in the initial ACS group and 30.7% were placed in the initial non ACS group. After workup, 36% were placed in the final ACS group and 28.7% in the final non-ACS group and 35% were undecided. The sensitivity of initial assessment of ACS by the cardiology resident was 100%. However, the specificity was 54.2%. In the 30-day outcome, one patient (1.3%) died in the ACS group due to myocardial ischemia while no patient died from the non ACS group. CONCLUSION: Initial assessment about ACS by cardiology resident based on character of chest pain, ECG and troponin I is highly sensitive. However, the specificity is low.
2. Clin Chim Acta. 2010 Jun 3;411(11-12):812-7. Epub 2010 Feb 24. High-sensitive cardiac troponin I (hs-cTnI) values in patients with stable cardiovascular disease: an initial foray. Schulz O, Reinicke M, Berghoefer GH, Bensch R, Kraemer J, Schimke I, Jaffe AS.
Interventionelle Kardiologie Spandau, Berlin, Germany. Erratum in Clin Chim Acta. 2010 Sep 6;411(17-18):1395-6. BACKGROUND: How to use the information from novel high sensitivity troponin assays in stable cardiac patients is unclear. Preliminary data from randomized controlled trial analyses suggest it helps with risk stratification. We investigated the determinants, diagnostic impact and prognostic value of a novel high-sensitive cardiac troponin I (hs-cTnI) assay in patients with stable cardiac disease. METHODS: hs-cTnI was measured with a pre-commercial assay in 222 outpatients after clinical testing before cardiac catheterization. Mean follow-up was 1103+/-299 days. RESULTS: hs-cTnI was detectable in all patients (median (interquartile range) 6.20 (4.85;8.25) ng/l). Creatinine (p<0.001), systolic wall stress (p=0.004), the presence of myocardial impairment (p=0.049) and coronary artery stenosis > or = 70% (p=0.050) were predictors of hs-cTnI concentration. hs-cTnI values could not distinguish elevations due to myocardial abnormalities from those related to coronary artery abnormalities. Patients with elevations above the 99th percentile had a higher rate of hospitalizations but otherwise prognosis was not predicted robustly by hs-cTnI values. CONCLUSION: Stable cardiovascular patients have detectable hs-cTnI concentrations irrespective of their underlying disease. In this heterogeneous group of patients with diverse etiologies for cardiac disease, values were not helpful in distinguishing the etiology of the elevations or in predicting prognosis.
3. Coron Artery Dis. 2010 Mar;21(2):78-86. Impact of multivessel coronary artery disease on early ischemic injury, late clinical outcome, and remodeling in patients with acute myocardial infarction treated by primary coronary angioplasty. Tarantini G, Napodano M, Gasparetto N, Favaretto E, Marra MP, Cacciavillani L, Bilato C, Osto E, Cademartiri F, Musumeci G, Corbetti F, Razzolini R, Iliceto S. Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy. giuseppe.tarantini.1@unipd.it OBJECTIVE: The mechanism through which multivessel coronary artery disease (MVD) adversely affects the outcome of patients with ST-elevation myocardial infarction (STEMI) is poorly characterized. We assessed whether the impact of MVD on outcome of STEMI patients is because of ischemic damage after primary percutaneous coronary intervention (PPCI) or to late ischemic events.
METHODS: From August 2005 to 2007, 288 STEMI patients treated by (bare metal) stent-PPCI were prospectively enrolled. The ischemic injury early after PPCI (evaluated by multiparametric approach) and the incidence of late adverse cardiovascular events were compared between the two groups. RESULTS: Compared with single vessel coronary artery disease, MVD patients (n=134) were older, with higher prevalence of diabetes, prior MI, anterior MI and higher collateral score. Myocardial perfusion as assessed by myocardial blush and SigmaST-segment resolution was similar in the two groups as well as the infarct size and microvascular obstruction as assessed by Troponin I and by the delayed enhancement of cardiac magnetic resonance. At clinical (98% complete) and echocardiogaphic (94% complete) follow-up (median 32 months) MVD patients showed a higher incidence of re-MI (6.1 vs. 1.3%), and urgent revascularization (8.3 vs. 2.7%) and worse left ventricular remodeling than single vessel disease patients. At propensity adjusted analysis MVD was an independent predictor of re-MI (odds ratio: 5.7) and ventricular remodeling (odds ratio: 2.2). CONCLUSION: The impact of MVD on clinical outcome and remodeling of STEMI patients is not because of the extent of ischemic damage observed after PPCI, but to recurrent ischemic events during follow-up.
4. Am J Cardiol. 2009 Nov 1;104(9):1210-5. Relation of troponin I levels following nonemergent percutaneous coronary intervention to short- and long-term outcomes. Feldman DN, Minutello RM, Bergman G, Moussa I, Wong SC. New York Presbyterian Hospital, Weill Cornell Medical College, New York, USA. dnf9001@med.cornell.edu Increases of creatine kinase (CK) and CK-MB cardiac enzymes after nonemergent percutaneous coronary intervention (PCI) have been associated with an increased risk of cardiovascular events during follow-up. However, there are limited data about the incidence and prognostic significance of an isolated increase of cardiac troponin I (cTnI) without an increase in CK-MB after PCI. The aim of this study was to evaluate the impact of an isolated cTnI increase on long-term survival in patients undergoing nonemergent PCI with normal CK-MB levels after PCI. Using the 2004/2005 Cornell Angioplasty Registry, we evaluated the clinical outcomes in 1,601 patients (undergoing elective or urgent PCI) with normal preprocedure cTnI and CK-MB and normal CK-MB levels after the procedure. Patients were divided into 2 groups based on the presence of cTnI increase after PCI. The mean follow-up period was 24.6 +/- 7.6 months. An increase in cTnI was observed in 831 patients (51.9%). Drug-eluting stents were used in 87% of patients and glycoprotein IIb/IIIa inhibitors were administered in 48% of patients. Incidence of in-hospital major adverse cardiovascular events was low, 0.1% versus 0% (p =
1.000), in patients with versus without cTnI increases, respectively. By 2 years of follow-up, Kaplan-Meier survival rates were 94.1% versus 96.4% (log-rank p = 0.020) in those with versus without cTnI increases, respectively. By multivariate Cox regression analysis, an increase in cTnI after PCI (hazard ratio 1.62, 95% confidence interval 1.01 to 2.59, p = 0.047) was an independent predictor of increased long-term mortality. In conclusion, an isolated increase in cTnI after nonemergent PCI is common, not associated with more frequent adverse in-hospital outcomes compared to patients with normal cTnI, and provides long-term prognostic information regarding mortality.
5. Cardiology. 2009;114(4):292-7. Epub 2009 Aug 20. Prediction of hemodynamically significant coronary artery disease using troponin I in hemodialysis patients presenting with chest pain: A case-control study. Badero OJ, Salifu MO. Division of Cardiology, SUNY Downstate Medical Center Brooklyn, Brooklyn, NY 11203, USA. OBJECTIVES: Controversy exists regarding utility of cardiac troponin I (cTnI) in predicting significant coronary artery disease (CAD) in hemodialysis (HD) patients with chest pain and no acute ischemia on electrocardiogram (non-ST segment elevation myocardial infarction, non-STEMI). We sought to determine if cTnI elevation predicts significant CAD (>70% stenosis) in these patients. METHODS: Ninety patients with non-STEMI referred for cardiac catheterization were included, divided equally into HD and non-HD groups. RESULTS: Mean age and baseline characteristics were not significantly different between groups, except for left ventricular hypertrophy which was higher in HD patients (56 vs. 27%, p = 0.012). Initial cTnI correlated with obstructive CAD and was stratified into <0.3 and >0.3 ng/ml. By logistic regression, cTnI >0.3 ng/ml was not predictive of CAD in HD patients [odds ratio = 0.87 (95% CI 0.19-4.0), p = 0.8], while non-HD patients had an increased risk of CAD if first cTnI was >0.3 ng/ml [odds ratio = 1.461 (95% CI 1.01-2.11), p = 0.04] as expected. Sensitivity, specificity, negative and positive predictive values of cTnI in predicting obstructive CAD were better in non-HD patients. CONCLUSION: cTnI in these patients had no predictive value for obstructive CAD. This contrasts with the general population, suggesting a higher index of suspicion for high-grade CAD irrespective of cTnI levels in HD patients.
6. W V Med J. 2009 Jul-Aug;105(4):29-32. Elevated cardiac troponins in sepsis: what do they signify? Smith A, John M, Trout R, Davis E, Moningi S. Robert C. Byrd Health Sciences Center, WVU, Charleston, USA. Serum troponins are sensitive markers used to diagnose acute coronary syndrome in association with signs and symptoms of chest pain and EKG changes. Cardiac troponins are elevated in 85% of patients with sepsis in the absence of acute coronary syndrome. Small studies have shown that elevated troponin levels identify patients with sepsis who are at increased risk of mortality. The purpose of this study was to (1) identify the outcome of cardiac troponin positive sepsis patients in our hospital, (2) determine whether the traditional cardiac risk factors predispose septic patients for positive troponin and (3) evaluate the cardiac interventions done for troponin positive patients. CONCLUSION: In our study, patients with elevated troponins had a higher mortality. Hypertension (HTN) and Coronary Artery Disease (CAD) increased the risk of mortality in troponin positive patients. Several interventions were performed including medications, echocardiogram, and cardiology consultation. Treatment medications did not improve mortality rates.
7. Am J Cardiol. 2009 Jun 1;103(11):1622-3. Prognostic significance of small troponin I rise after a successful elective percutaneous coronary intervention of a native artery. Testa L, Latini RA, Agostoni P, Banning AP, Bedogni F. Comment on Am J Cardiol. 2009 Mar 1;103(5):639-45. PMID: 19463526 [PubMed - indexed for MEDLINE]
8. Coron Artery Dis. 2009 May;20(3):245-50. Combination of C-reactive protein and cardiac troponin I for predicting adverse cardiac events after sirolimus-eluting stent implantation. Huang W, Lei H, Liu Q, Ma KH, Qin S, Chang J, Jia FP, He Q, Zuo Z. Department of Cardiology, First Affiliated Hospital, Chongqing Medical
University, Chongqing, China. AIMS: We assessed the predictive value of a combination of C-reactive protein (CRP) and cardiac troponin I (cTnI) in a 2-year prospective study in patients undergoing sirolimus-eluting stents (SES) implantation. METHODS AND RESULTS: CRP and cTnI levels were examined 1 day before and after SES implantation in 322 patients. CRP level greater than 3.0 mg/l (defining the high serum CRP levels) and cTnI level greater than 1.0 microg/l (defining the high serum cTnI levels) were considered abnormal. Major adverse cardiac events were defined as nonfatal myocardial infarction (MI), target vessel revascularization (TVR), and cardiac death. After 2+/-0.2 years of follow-up, there were 11 MI, 19 TVR, and 11 cardiac deaths. After adjustment for relevant risk factors, the combination of high CRP and cTnI remained predictive of adverse cardiac events, with the presence of both elevated CRP and cTnI associated with the highest risks of MI [relative risk (RR): 4.0, 95% confidence interval (CI): 2.3-6.4], TVR (RR: 3.3, 95% CI: 2.8-5.3), and cardiac death (RR: 4.2, 95% CI: 2.6-6.0). The presence of either a high CRP or cTnI was associated with an intermediated risk of MI (RR: 1.7, 95% CI: 1.2-2.2), TVR (RR: 1.5, 95% CI: 1.2-2.7), and cardiac death (RR: 2.8, 95% CI: 2.2-3.6). CONCLUSION: The combination of elevated CRP and cTnI increased the risk of adverse cardiac events, demonstrating the additive impacts of active inflammation and myocardial injury on prognosis after SES implantation.
9. Am J Cardiol. 2009 Mar 1;103(5):639-45. Epub 2009 Jan 17. Prognostic significance of small troponin I rise after a successful elective percutaneous coronary intervention of a native artery. De Labriolle A, Lemesle G, Bonello L, Syed AI, Collins SD, Ben-Dor I, Pinto Slottow TL, Xue Z, Torguson R, Suddath WO, Satler LF, Kent KM, Pichard AD, Lindsay J, Waksman R. Department of Internal Medicine, Division of Cardiology, Washington Hospital Center, Washington, DC, USA. Comment in Am J Cardiol. 2009 Jun 1;103(11):1622-3. Rev Cardiovasc Med. 2009 Summer;10(3):178-9. Cardiac troponin I is a sensitive marker of myonecrosis. Data regarding the prognostic value of troponin I increase after percutaneous coronary intervention (PCI) are conflicting. A recent American College of Cardiology/American Heart Association statement defined a troponin I increase >3 times the 99th percentile as periprocedural myocardial infarction (MI). We sought to evaluate whether or
not, in patients with a successful elective PCI judged on angiographic and clinical criteria, the postprocedural increase of troponin I could predict 1-year outcomes. A cohort of 3,200 consecutive patients with successful elective PCI was studied. End points included death/MI and major adverse cardiac events at 1 year. A troponin I increase >97.5th percentile was observed in 1,402 patients (43.8%, mean 0.32 ng/ml, range 0.01 to 4.94). A total of 751 patients (23.4%) had a troponin I increase >3 x 99th percentile. Troponin I status was associated with more complex coronary disease (19.6% vs 16.4%, p <0.005) and multivessel PCI (2.1 vs 1.6, p <0.001). At 1 year, there was no difference in death/MI (2.8% vs 3.5%, p = 0.3) or in major adverse cardiac events (9.6% vs 10.4%, p = 0.5) according to the level of troponin I increase. The lack of association between troponin I increase after PCI and outcome was found when troponin I increase was used as a continuous or a categorical variable. Logistic regression models failed to find any threshold from which troponin I increase could affect outcome. In conclusion, a small troponin I increase after a successful elective PCI was not infrequent and did not affect outcome in our study. The definition of periprocedural MI may be too strict. Measurement of troponin I after a successful PCI is questionable.
10. Clin Chem. 2009 Jan;55(1):109-16. Epub 2008 Nov 6. Clinical performance of two highly sensitive cardiac troponin I assays. Venge P, James S, Jansson L, Lindahl B. Department of Medical Sciences, Clinical Chemistry, University of Uppsala. per.venge@akademiska.se BACKGROUND: The aim of this study was to compare the clinical performance of 2 sensitive cTnI assays with 10% CV imprecision below the 99th percentile upper reference limit. METHODS: We measured cardiac troponin and N-terminal pro-brain natriuretic peptide (NT-proBNP) concentrations in a random sample of the Global Use of Strategies To Open Occluded Coronary Arteries (GUSTO) IV cohort (n = 1251). Outcome data of 1-year mortality and the composite endpoint DMI [death and/or myocardial infarction (MI) within 30 days] were available in all patients. The 99th percentile of a healthy population was estimated from the Sweden Women and Men and Ischemic Heart Disease (SWISCH) cohort (n = 442). We measured cardiac troponin I (cTnI) using the Access AccuTnI (Beckman Coulter) and Centaur TnI Ultra (Siemens Healthcare Diagnostics) and NT-proBNP using the Elecsys 2010 (Roche Diagnostics). RESULTS: Applying the 10% CV cutoff, the sensitivity of the Access AccuTnI assay in identifying DMI and death was higher than that of the Centaur TnI Ultra (P = 0.02 and P < 0.001), and the AccuTnI assay also identified more patients at risk (P < 0.001) and with poor outcome. Applying the 99th percentile cutoffs, AccuTnI
identified more patients at risk than the Centaur TnI (P < 0.001) and with significant differences in outcome. Significantly more patients with cardiac troponins below the cutoffs as measured by Centaur TnI had increased NT-proBNP concentrations (P < 0.001) compared with AccuTnI. CONCLUSIONS: The AccuTnI assay identified more patients at risk than the Centaur cTnI Ultra assay. Our results demonstrate the clinical potential of high-sensitivity cardiac troponin assays for the identification of patients at risk of dying from cardiovascular disease.
11. Ren Fail. 2008;30(4):357-62. Cardiac findings in asymptomatic chronic hemodialysis patients with persistently elevated cardiac troponin I levels. Katerinis I, Nguyen QV, Magnin JL, Descombes E. Dialysis Unit, Hopital Cantonal, Fribourg, Switzerland. BACKGROUND: The prevalence and significance of higher than normal cardiac troponin I (cTnI) levels in asymptomatic chronic hemodialysis (HD) patients remains a source of discussion. The aim of the present study was to evaluate the prevalence of higher than normal cTnI levels in asymptomatic HD patients, as determined by the last generation of immunoassay, and to perform further cardiological investigations in those patients with persistently elevated cTnI levels. METHODS: All chronic HD patients in our center who had exhibited no symptoms of coronary artery disease (CAD) during the previous four weeks were screened. cTnI levels were determined before dialysis in all patients using the last generation AccuTnI assay (UniCel DxI 800, Beckman Coulter). The cTnI levels of those patients with elevated cTnI at the screening evaluation were then measured monthly for six months. We were thus able to identify a group of patients with persistently elevated cTnI levels (> 3 consecutive months) who subsequently underwent cardiac echography and dipyridamole-exercise (D-E) thallium testing. If stress myocardial ischemia was detected, a coronary angiography was then performed. RESULTS: Fifty patients (32 males) were included: mean age 62.8 +/- 13.6 years, 20 (40%) with a history of CAD, and 21 (42%) diabetic. At the initial screening, the mean cTnI concentration was 0.05 +/- 0.06 microg/L and the cTnI levels were higher than normal (> 0.09 microg/L) in six patients (12%). In the follow-up, the cTnI normalized immediately in two patients but remained persistently elevated (range, 0.10-0.48 microg/L) in four (8%). These four patients (all males, one diabetic) had a mean age of 70.2 +/- 6.6 years, and all had heart failure with a history of severe CAD with previous myocardial infarction (n = 4), coronary stenting (n = 3), and/or bypass (n = 2). D-E thallium imaging showed reversible
myocardial ischemia in all. The stress ischemia involved one to four cardiac segments and was slight to moderate in three patients and severe in the diabetic patient. A coronary angiogram was performed in all patients, and showed lesions of variable severity: severe three-vessel CAD with severe systolic dysfunction in two patients (including the diabetic), and non-critical/peripheral coronary stenosis in the other two. CONCLUSIONS: Among the asymptomatic HD patients in our center, we identified four (8%) with persistently elevated cTnI levels, as determined using the last generation AccuTnI assay. All of them had a history of severe CAD with heart failure and exhibited reversible myocardial ischemia upon D-E thallium imaging; coronary angiography revealed coronary lesions of variable severity. Overall, our data indicate that persistent low-grade cTnI elevation occurs in HD patients having longstanding severe cardiac disease, but, from our data, it is difficult to reach a conclusion as to the best clinical approach for this group of patients.
12. J Thromb Thrombolysis. 2008 Oct;26(2):132-7. Epub 2007 Dec 7. Postmortem cardiac troponin-I levels predict intramyocardial damage at autopsy. Vargas SO, Grudzien C, Tanasijevic MJ. Department of Pathology, Children's Hospital, Harvard Medical School, Boston, MA, USA. Serum cardiac troponin levels are now widely used in the diagnosis of myocardial infarct (MI) and injury in living patients, but their utility in postmortem diagnosis has not been established. We evaluated postmortem cardiac troponin-I (cTnI) levels in serum from 53 hospital patients undergoing autopsy and correlated the levels with anatomic findings at postmortem examination. Among patients with nonischemic cardiac disease, those with intramyocardial disease (e.g., cardiac transplant rejection, intramyocardial tumor) had significantly higher cTnI levels than those with disease confined to the pericardium (e.g., epicardial tumor implants, pericarditis) (p = 0.004). No correlation was found between recent MI and cTnI level. There was also no correlation between cTnI level and the presence of chronic ischemic features, a history of cardiopulmonary resuscitation, or postmortem interval. We conclude that cTnI is detectable in postmortem serum samples and, although its levels did not correlate specifically with ischemia or infarction in our series, its levels appear to correlate significantly with intramyocardial injury. Use of cardiac troponin in the postmortem diagnosis of cardiac disease may be warranted.
13. Circulation. 2007 Oct 23;116(17):1907-14. Epub 2007 Oct 1. Persistent cardiac troponin I elevation in stabilized patients after an episode of acute coronary syndrome predicts long-term mortality. Eggers KM, Lagerqvist B, Venge P, Wallentin L, Lindahl B. Department of Medical Sciences, Cardiology, University Hospital Uppsala, S-751 85 Uppsala, Sweden. kai.eggers@akademiska.se BACKGROUND: In patients with non-ST-elevation acute coronary syndrome, any troponin elevation is associated with an increased risk for cardiovascular events. However, the prevalence and prognostic importance of persistent troponin elevation in stabilized patients after an episode of non-ST-elevation acute coronary syndrome are unknown and were therefore assessed in this study. METHODS AND RESULTS: Cardiac troponin I (cTnI) was measured in 1092 stabilized patients at 6 weeks and 3 and 6 months after enrollment in the FRagmin and Fast Revascularization during InStability in Coronary artery disease (FRISC-II) trial. cTnI was analyzed with the Access AccuTnI assay with the application of different prognostic cutoffs. Outcomes were assessed through 5 years. Elevated cTnI levels >0.01 microg/L were found in 48% of the study patients at 6 weeks, in 36% at 6 months, and in 26% at all 3 measurements. cTnI elevation was associated with increased age and other cardiovascular high-risk features. The lowest tested cTnI cutoff (0.01 microg/L) was prognostically most useful and was independently predictive of mortality (hazard ratio, 2.1 [95% confidence interval, 1.3 to 3.3]; P=0.001) on multivariable analysis adjusted for cardiovascular risk factors and randomization to an invasive versus noninvasive treatment strategy, whereas it was related to myocardial infarction only on univariate analysis. CONCLUSIONS: Persistent minor cTnI elevation can be detected frequently in patients stabilized after an episode of non-ST-elevation acute coronary syndrome with the use of a sensitive assay. Elevated cTnI levels >0.01 microg/L predict mortality during long-term follow-up. Our results emphasize the importance of further troponin testing in non-ST-elevation acute coronary syndrome patients after hospital discharge.
14. J Card Surg. 2007 Sep-Oct;22(5):394-400. Evaluation by cardiac troponin I: the effect of ischemic preconditioning as an adjunct to intermittent blood cardioplegia on coronary artery bypass grafting. Ji B, Liu M, Liu J, Wang G, Feng W, Lu F, Shengshou H.
Department of Cardiopulmonary Bypass, Cardiovascular Institute & Fuwai Hospital, PUMC & CAMS, Beijing, China. buj4@psu.edu OBJECTIVE: Ischemic preconditioning (IPC) is commonly regarded as having a powerful internal protective effect on the organs. The mechanism of IPC is not clear yet, and the controversy over the benefits and protocol of IPC still continues. In this study, we used the sensitive and specific biochemical marker: cardiac troponin-I (CTnI) to evaluate whether IPC as an adjunct to intermittent cold blood cardioplegia (CBC) could reduce myocardial injury, as opposed to simple CBC during coronary artery bypass grafting (CABG). METHODS: From May 2003 to December 2003, 40 patients with three vessel coronary artery disease (CAD) and stable angina, receiving first-time elective CABG, were randomly divided into two equal groups: IPC plus CBC (IPC + CBC group, n = 20); and CBC (CBC group, n = 20). The patients in IPC + CBC group received two cycles of ischemia (two min) and reperfusion (three min) before myocardial arrest induced by CBC. The patients in CBC group received 10-minute normothermic cardiopulmonary bypass (CPB) before CBC arrest. Clinical outcomes were observed during and after the operation. Serial venous blood samples were obtained before induction, after CPB, and postoperatively 6, 12, 24, and 72 hours. Hemodynamic indexes were obtained before and after the bypass by the radial catheter and Swan-Ganz catheter. RESULTS: In both groups, there were no differences regarding operative parameters. Compared to the baseline, the level of CTnI increased after CPB, peaked 6-12 hours (p < 0.01). Compared to IPC + CBC group, plasma concentrations of CTnI in CBC group were significantly higher at 6 and 12 hours (p < 0.05). CI recovery in IPC + CBC group was more significant than CBC group at 12 and 24 hours (p < 0.05). IPC + CBC also shortened the time of postoperative mechanical ventilation (p < 0.05) after surgery. CONCLUSION: Compared to the simple CBC in lower-risk CABG patients, IPC as an adjunct to CBC reduced CTnI release, improved heart function after surgery, and shortened the time of recovery in CAD patients.
15. J Thromb Thrombolysis. 2008 Jun;25(3):239-46. Epub 2007 Jun 16. Effects of persistent platelet reactivity despite aspirin therapy on cardiac troponin I and creatine kinase-MB levels after elective percutaneous coronary interventions. Gulmez O, Yildirir A, Kaynar G, Konas D, Aydinalp A, Ertan C, Ozin B, Muderrisoglu H. Department of Cardiology, Baskent University Faculty of Medicine, Ankara, Turkey. gulmezoyku@yahoo.com
BACKGROUND: Creatinine kinase-MB (CK-MB) and cardiac troponin I (cTnI) elevations are highly specific for myonecrosis after percutaneous coronary intervention (PCI). Aspirin is used to prevent thrombotic complications. Several studies have shown that some individuals exhibit a reduced or completely missing antiplatelet response to aspirin. The aim of this study is to investigate the effects of platelet reactivity despite aspirin therapy on CK-MB and cTnI levels after elective percutaneous coronary interventions despite 600 mg loading dose of clopidogrel. METHODS: One hundred fourteen (mean age 61.2+/-9.3 years, 78.1% male) patients receiving 300 mg daily enteric coated aspirin for at least 7 days with documented coronary artery disease were included in the study. Platelet reactivity despite aspirin was measured by platelet function analyzer (PFA)-100 collagen/epinephrine cartridge. Blood samples for CK-MB and cTnI were obtained before and at 6, 24, and 36 h after the PCI. Persistent platelet reactivity was defined when collagen/epinephrine closure time<165 s. RESULTS: A total of 87 (76.4%) patients were noted to have normal platelet reactivity (Group A), and 27 (23.6%) had persistent platelet reactivity (Group B). The elevations of CK-MB and cTnI levels were statistically significant within the groups (both P<0.001). However, there were no significant differences in the CK-MB and cTnI levels of the groups at baseline and after PCI for all studied hours. CONCLUSION: Persistent platelet reactivity was not associated with increased risk of CK-MB, cTnI elevations in low-to-intermediate risk PCI patients.
16. Clin Chem Lab Med. 2006;44(8):1022-9. Evaluation of the analytical performance of the advanced method for cardiac troponin I for the AxSYM platform: comparison with the old method and the Access system. Storti S, Prontera C, Parri MS, Iervasi A, Vittorini S, Emdin M, Zucchelli GC, Longombardo G, Migliorini P, Clerico A. CNR Institute of Clinical Physiology, University of Pisa, Pisa, Italy. BACKGROUND: The determination of cardiac troponins is routinely used for rule in/out, risk stratification, and follow-up of patients with acute coronary artery syndrome. We evaluated the analytical and clinical performance of the advanced immunoassay for troponin I (cTnI) carried out on an AxSYM platform (Abbott Diagnostic Division) and compared these characteristics to those of the previous version of this assay and to cTnI on the Access 2 immunoassay system (Beckman Coulter, Inc.). METHODS: We assayed plasma samples from healthy subjects (n=66) and cardiac patients (n=132) using AxSYM Plus system assays called the old (OLD AxSYM) and
advanced TnI (ADV AxSYM) methods and using an Access system. RESULTS: An improvement in analytical sensitivity (detection limit) was observed for the advanced cTnI AxSYM compared to the previous method (0.014 vs. 0.31 microg/L), while the cTnI value for the 10% CV (i.e., functional sensitivity) was 0.41 microg/L for the ADV and 1.9 microg/L for the OLD method. The kinetics of cTnI release was similar, as evaluated in 25 patients with typical acute myocardial infarction (AMI). A close linear relationship was found between the two methods on the AxSYM system (OLD cTnI=7.436+6.858 ADV cTnI; R=0.968, n=214) and with the Access system (OLD AxSYM=7.154+7.9 Access, R=0.876, n=158; ADV AxSYM=0.23+1.209 Access, R=0.927, n=160). However, wide bias was found between the OLD and ADV AxSYM methods (mean difference 118.4 microg/L, p<0.0001), while more similar results were found between the ADV AxSYM and Access methods (mean difference 2.6 microg/L, corresponding to a mean percentage difference of 17%, p<0.0001). In 106 patients with symptomatic rheumatoid arthritis with high rheumatoid factor (RF) concentration, the mean cTnI measured by the ADV AxSYM method was 0.009+/-0.031 mug/L (range 0-0.23 microg/L) with a significant correlation (R=0.316, p=0.001) between cTnI and RF values. Furthermore, in 60 of these serum samples the cTnI concentration was also measured using the Access method; significant correlation with the values found by the ADV AxSYM method was observed (R=0.468, p=0.0002). CONCLUSIONS: The present study indicates that the AxSYM Troponin-I ADV immunoassay shows improved analytical sensitivity compared to the OLD AxSYM method, as well as very similar clinical results to those determined using the Access method.
17. Coron Artery Dis. 2006 May;17(3):249-53. Prognostic factors in patients with minor troponin-I elevation but without acute myocardial infarction. Lee SH, Yoon SB, Jung JH, Choi SH, Lee N, Cho GY, Oh DJ, Rhim CY, Lee KH. Cardiology Division, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea. shl1106@hallym.ac.kr OBJECTIVES: Although cardiac troponin I is widely used as a marker for myocardial infarction, its minor elevations are also observed in other clinical situations, and the prognostic factors in such clinical settings have not been well established. The aim of this study was to identify predictors of mortality in patients with minor troponin elevations without an acute myocardial infarction. METHODS: We consecutively enrolled 134 patients from the emergency department with a peak troponin I level greater than the lower limit of detectability (0.04 ng/ml) but less than the 10% coefficient of variation cutoff value for diagnosis of myocardial infarction (0.26 ng/ml). These patients had chest pain or
nonspecific symptoms of a circulatory abnormality but lacked the traditional features of an acute myocardial infarction. End point was defined as death from all causes. Cox regression analysis was used to test relations between clinical and biochemical variables and the outcome. RESULTS: During the follow-up of 7.6+/-7.4 months, 12 patients died. Age, log creatine kinase myocardial isoform, and log C-reactive protein were found to be significantly correlated with death. After adjusting for possible confounders in the multivariate model, age (hazard ratio 1.09, confidence interval 1.02-1.16, P=0.012), log creatine kinase myocardial isoform (hazard ratio 13.11, confidence interval 2.01-85.52, P=0.007), and log C-reactive protein (hazard ratio 1.64, confidence interval 1.02-2.56, P=0.041) were identified as independent predictors of mortality. CONCLUSIONS: Creatine kinase myocardial isoform and C-reactive protein levels and age can be integrated to risk-stratify patients with minor troponin I elevation for reasons other than acute myocardial infarction.
18. Eur Heart J. 2006 Mar;27(5):547-52. Epub 2006 Jan 13. Effects of metoprolol therapy on cardiac troponin-I levels after elective percutaneous coronary interventions. Atar I, Korkmaz ME, Atar IA, Gulmez O, Ozin B, Bozbas H, Erol T, Aydinalp A, Yildirir A, Yucel M, Muderrisoglu H. Department of Cardiology, Faculty of Medicine, University of Ba kent, Ankara, Turkey. iatar@tkd.org.tr AIMS: Beta-blockers (BBs) have been shown to improve survival and reduce the risk of re-infarction in patients following myocardial infarction. There are conflicting data about the effects of BB therapy on cardiac biomarkers after percutaneous coronary interventions (PCIs). The aim of the study was to investigate the effects of BB use on cardiac troponin-I (cTnI) levels in patients who had undergone elective PCI. METHODS AND RESULTS: In this prospective study, 287 patients with coronary artery disease were included. Patients were randomized either to BB or control groups prior to the intervention. Blood samples for cTnI were obtained before and at 6, 24, and 36 h after the procedure. Of the 287 patients included, 143 received metoprolol succinate 100 mg/day, and 144 received no BB and served as the control group. Baseline clinical characteristics of both groups, except for history of coronary artery bypass graft surgery, were similar. We observed no significant difference in the elevation of cTnI levels between the two groups after PCI (BB group, 17 patients, 11.9%; control group, 10 patients, 6.9%; P=0.2). CONCLUSION: Metoprolol succinate therapy seems to have no cardioprotective effect in limiting troponin-I rise after PCI.
19. Atherosclerosis. 2005 Sep;182(1):161-7. Epub 2005 Mar 5. Association of inflammatory biomarkers and cardiac troponin I with multifocal activation of coronary artery tree in the setting of non-ST-elevation acute myocardial infarction. Zairis MN, Lyras AG, Bibis GP, Patsourakos NG, Makrygiannis SS, Kardoulas AD, Glyptis MP, Prekates AA, Cokkinos DV, Foussas SG. Department of Cardiology, Tzanio Hospital, Afentouli Street, Piraeus 18536, Greece. zairis@hellasnet.gr We evaluated the possible association of the serum levels of C-reactive protein (CRP), serum amyloid A (SAA), fibrinogen, and cardiac troponin I (cTnI) with the presence of complex angiographic characteristics throughout the coronary artery tree in 519 consecutive patients with non-ST-elevation acute myocardial infarction (NSTEMI). Blood samples were obtained in the first 12h of NSTEMI invasion and all patients underwent in-hospital coronary angiography. Coronary lesions were classified as complex lesion (CL) or non-CL according to Ambrose criteria. Serum levels of CRP (p<0.001), SAA (p<0.001), or fibrinogen (p=0.001), but not of cTnI (p=0.9), were significantly related to the presence of multiple (> or =2) CLs. On the contrary, serum levels of cTnI (p<0.001), but not of CRP (p=0.5), SAA (p=0.9), or fibrinogen (p=0.9), were significantly associated with the severity of coronary artery disease. The results of the present study suggest that elevated levels of inflammatory biomarkers are associated with a generalized activation of coronary artery tree while elevated cTnI levels are associated with the severity of coronary artery disease in the setting of NSTEMI. It seems that inflammatory biomarkers and cTnI reflect different aspect of the process involved in unstable coronary artery disease.
20. Scand Cardiovasc J. 2004 May;38(2):75-9. Troponin must be measured before and after PCI to diagnose procedure-related myocardial injury. Gustavsson CG, Hansen O, Frennby B. Department of Cardiology, University Hospital, S-205 02 Malm, Sweden. CG@Gustavsson.se
OBJECTIVE: To evaluate troponin I >99th percentile of normal as a criterion for myocardial injury after percutaneous coronary intervention (PCI). DESIGN: Troponin I and creatine kinase monobasic (CK-MB) were measured in 327 patients before and after percutaneous transluminal coronary angioplasty (PTCA) with stent implantation. RESULTS: Troponin I was elevated before PCI in 100 of a total of 222 patients with acute coronary syndrome (ACS). In 91 of these 100 patients, troponin I was elevated also after PCI but actual increases in troponin I concentrations from before to after PCI were found in only 32 patients. The increase of troponin I correlated with post-procedural CK-MB whereas post-procedural troponin I levels did not correlate. In the 122 patients with ACS but normal/normalized troponin I before PCI and in 105 patients with stable coronary artery disease post-procedural troponin I appeared to be a reliable indicator of myocardial infarction (MI), however more sensitive than CK-MB. CONCLUSION: Troponin I after PCI is sensitive to pre-procedural concentrations. To avoid false positive MI diagnoses we thus suggest that troponin I should be measured before as well as after the procedures and only actual increases should be regarded as indicating procedure-related MI.
21. Clin Nephrol. 2004 Jan;61(1):40-6. Single and serial measurements of cardiac troponin I in asymptomatic patients on chronic hemodialysis. Roberts MA, Fernando D, Macmillan N, Proimos G, Bach LA, Power DA, Ratnaike S, Ierino FL. Department of Nephrology, Austin Health, Heidelberg, Victoria, Australia. AIMS: Coronary artery disease is the major cause of death in patients with end-stage renal failure on dialysis. This study aimed to assess the predictive value of a single cardiac troponin I (cTnI), and also the kinetics of serial values. METHODS: Since cTnI is a potential biomarker of cardiac outcome, the present study examined single cTnI measurements (n = 88 patients) and its predictive value for future cardiac events, and a kinetic substudy of serial weekly cTnI measured for 8 weeks (n = 57) in a group of patients on hemodialysis. RESULTS: Single cTnI measurements: 9 patients (10.2%) had a detectable cTnI at baseline and 79 patients (89.8%) had a negative baseline cTnI. There were no significant differences in age, sex, history of ischemic heart disease, diabetes, smoking or dyslipidemia between patients with detectable and negative cTnI. At the end of 9 months, the rate of combined primary endpoints, which included myocardial infarction, cardiac death and cardiac revascularization, was
significantly higher in the patients with a detectable baseline cTnI (55.6%), compared to patients with a negative cTnI (6.3%) (p = 0.0007). Serial weekly cTnI measurements: significant fluctuations in cTnI were noted over time; 27% of patients with an undetectable cTnI measured at baseline had subsequent detectable levels in the serial follow-up. CONCLUSION: A single detectable cTnI in asymptomatic patients on hemodialysis defines patients at high risk of future cardiac events. However, the incidence of detectable cTnI levels is markedly increased when serial weekly measurements are performed. The clinical significance of detectable serial measurements of cTnI is the focus of ongoing studies.
22. Med Sci Monit. 2003 Dec;9(12):CR519-22. Severity of coronary artery disease in patients with acute coronary syndrome without ST segment elevation is related to baseline troponin I and ST-segment depression. Gil M, Zarebi ski M, Adamus J. Medical Department, Eli Lilly Polska, Warsaw, Poland. BACKGROUND: Risk assessment for patients admitted with acute coronary syndrome (ACS) is usually based on the past medical history, along with several clinical and biochemical criteria. We hypothesised that stratification of patients with ACS according to the presence of ST-segment depression and results of a qualitative troponin I test would identify subjects with more severe disease who may benefit from an earlier, more aggressive strategy. MATERIAL/METHODS: The study group consisted of 115 patients hospitalized for typical chest pain (>5 min) occurring within the last 24 hours, with coronary angiography. Blood was drawn for routine biochemistry and qualitative troponin I testing, and ECG was performed on admission. RESULTS: Patients were classified according to the presence of ST segment depression (ST) and the troponin I test results (T) into three categories: group A, consisting of 34 patients with ST+/T+; group B, consisting of 84 patients with either ST+/T- or ST-/T+; and group C, consisting of 7 subjects with ST-/T-. This stratification correlated significantly with the extent of coronary artery disease (p=0.0004). Significant coronary artery stenosis was significantly more prevalent in patients from groups A and B than in C (p<0.002). No difference in the patients' medical history, apart from more frequent AMI within the past 10 days in group A (p=0.009) was found between groups. CONCLUSIONS: Admission assessment of ECG and troponin I tests in patients with ACS may identify subjects with significant coronary artery disease, who are at high risk and could benefit from aggressive therapy.
23. J Am Coll Cardiol. 2003 Nov 19;42(10):1767-76. Heart rate variability and cardiac troponin I are incremental and independent predictors of one-year all-cause mortality after major noncardiac surgery in patients at risk of coronary artery disease. Filipovic M, Jeger R, Probst C, Girard T, Pfisterer M, Grke L, Skarvan K, Seeberger MD. Department of Anesthesia, University of Basel/Kantonsspital, Switzerland. mfilopvic@uhbs.ch OBJECTIVES: The aim of this study was to determine whether perioperative measurements of heart rate variability (HRV) and cardiac troponin I (cTnI) add additional prognostic information to established risk scores for first-year mortality in patients at risk of coronary artery disease (CAD) undergoing major noncardiac surgery. BACKGROUND: In cardiac-risk patients undergoing major noncardiac surgery, the short- and long-term prognoses are mainly influenced by perioperative cardiac complications. Heart rate variability and cTnI are important prognostic markers in patients with congestive heart failure and myocardial infarction. METHODS: In a prospective study, 173 patients with CAD or at high risk of CAD undergoing major noncardiac surgery were followed up for one year. The main outcome measure was all-cause mortality. In addition to clinical parameters and established risk scores, HRV and cTnI were assessed perioperatively. RESULTS: Twenty-eight (16%) patients died within one year. Multivariate logistic regression analysis revealed three findings that were independently associated with death within the first year after surgery: the revised cardiac risk index (odds ratio 6.2 [95% confidence interval 1.6 to 25], depressed HRV before induction of anesthesia (16.2 [2.8 to 94]), and elevation of cTnI on postoperative day 1 or 2 (9.8 [3.0 to 32]). CONCLUSIONS: Depressed HRV before induction of anesthesia and elevated cTnI postoperatively are independent and powerful predictors of one-year mortality for patients at risk of CAD undergoing major noncardiac surgery and add incremental prognostic information to established risk scores that only consider preoperative information.
24. Clin Chem. 2003 Jun;49(6 Pt 1):880-6. Clinical and analytical performance of the liaison cardiac troponin I assay in
unstable coronary artery disease, and the impact of age on the definition of reference limits. A FRISC-II substudy. Venge P, Johnston N, Lagerqvist B, Wallentin L, Lindahl B; FRISC-II Study Group. Department of Medical Sciences, University of Uppsala, SE-751 85 Uppsala, Sweden. per.venge@clm.uas.lu.se Comment in Clin Chim Acta. 2007 Jun;381(2):182-3. BACKGROUND: Measurements of cardiac troponins are currently used as the standard for the detection of myocardial injury. None of the current assays complies with the new requirements on assay imprecision as proposed by the European Society of Cardiology/American College of Cardiology. Our aim was to evaluate the clinical and analytical performance of the Liaison cardiac troponin I (cTnI) assay. METHODS: EDTA-plasma was used, and cardiac troponins were assayed with the first-generation AxSYM assay, the second-generation AccuTnI assay, the third-generation Elecsys assay, and the first-generation Liaison assay. RESULTS: In a 6-day imprecision study, the Liaison cTnI assay had mean CV < or =10% at 0.027 microg/L and < or =20% at 0.015 microg/L. The 99th percentile of the upper reference limit (URL) of a reference population was 0.041 microg/L (age range, 41-76 years). Individuals <60 years had a significantly (P = 0.001) lower 99th percentile, 0.022 microg/L. The FRISC-II study participants with cTnI > or =0.041 microg/L had a poorer outcome relating to death/acute myocardial infarction than those with cTnI <0.041 microg/L (P <0.001). Treatment with low-molecular-weight heparin (dalteparin) or an invasive strategy reduced cardiac events only in patients with concentrations >0.041 microg/L (P = 0.002 and 0.02, respectively). Comparison with the AccuTnI assay showed that a large cohort of the patients with poor prognosis was identified by the AccuTnI assay but not by the Liaison cTnI assay. CONCLUSION: The Liaison cTnI assay is a sensitive assay with a CV < or =10% at the 99th percentile URL. The ability to detect age-related differences among apparently healthy individuals is unique among today's commercial assays. The results indicate that different assays seem to identify different patient cohorts for cardiac risk in the lower range of cTnI concentrations.
25. Heart Dis. 2002 Jul-Aug;4(4):216-9. Does the serum cardiac troponin I level increase with stress test-induced myocardial ischemia? Choragudi NL, Aronow WS, Prakash A, Kurup SK, Chiaramida S, Lucariello R.
Division of Cardiology, Westchester Medical Center, Valhalla, New York, USA. To evaluate the sensitivity of the serum cardiac troponin I level in detecting stress test-induced myocardial ischemia, the authors conducted a prospective study including patients admitted for chest pain to the telemetry floor of Our Lady of Mercy Medical Center at Bronx, NY. Consecutive 134 telemetry patients that agreed to participate in this study were included. All of these patients had a nuclear stress test and were divided into various groups based on the prestress test probability of having coronary artery disease. To assess serum cardiac troponin I levels, blood samples were drawn before and after stress testing and compared with the stress test results. Overall, 30 patients (22%) had reversible perfusion defects on stress images, and none (0%) had increased serum cardiac troponin I levels. One patient of 18 patients (6%) in group C with negative stress test results had an elevated serum cardiac troponin I level after the stress test, but none of group A or group B patients had elevated troponin I levels. These data show that serum cardiac troponin I levels do not increase with stress test-induced myocardial ischemia.
26. Am J Cardiol. 2002 May 1;89(9):1111-3. Intravascular ultrasound findings in patients with acute coronary syndromes with and without elevated troponin I level. Fuchs S, Stabile E, Mintz GS, Pappas CK, Maehara A, Gruberg L, Satler LF, Pichard AD, Kent KM, Weissman NJ. Cardiovascular Research Institute and the Cardiac Catheterization Laboratories, Washington Hospital Center, Washington, DC 20010, USA. shmuel.fuchs@medstar.net PMID: 11988203 [PubMed - indexed for MEDLINE]
27. Int J Cardiol. 2002 Apr;83(1):43-6. Plasma fibrinogen and troponin I in acute coronary syndrome and stable angina. Gil M, Zarebi ski M, Adamus J. Registrar, Department of Cardiology, Military Hospital, Warsaw, Poland. mgil@mp.pl We aimed to determine whether there is a stratification among patients with different stages of coronary artery disease with respect to plasma fibrinogen levels, and to assess diagnostic value of plasma fibrinogen in comparison to
troponin I in patients with acute coronary syndrome. Fifty-one consecutive patients presenting to our department with acute coronary syndrome within the last 24 h and 52 patients with stable angina with no episode of unstable disease within the last month were analysed. Forty-nine patients with acute coronary syndrome in which both troponin I and fibrinogen levels were present were further evaluated. Blood was collected on admission for routine laboratory tests. Statistical analysis was done using Student's t-test, Pearson correlation and chi-square test, P<0.05 being considered statistically significant. Plasma fibrinogen levels (g/l) were significantly higher in patients presenting with unstable than with stable angina (3.87+/-1.2 vs. 3.26+/-0.65 P=0.002). We have found significant correlation between fibrinogen and troponin I levels in unstable patients (r=0.43, P=0.0015). In patients with acute coronary syndrome an increased inflammation and cardiac injury seem to coexist and correlate. These results seem to confirm the role of this acute phase protein in the pathophysiology of acute coronary syndrome.

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38. J Pak Med Assoc. 2002 Sep;52(9):402-7.

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53. Br Heart J. 1993 Jun;69(6):572.

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