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BACKGROUND: The incidence of bleeding complications in patients with venous thromboembolism (VTE) on new oral anticoagulants (NOACs) has not been widely studied in contemporary clinical practice in Africa. The purpose of this study was to determine the rates of major bleeding, clinically relevant non-major bleeding (CRNM) and minor bleeding associated with NOAC use METHODS: A retrospective review was carried out of patients diagnosed with venous thromboembolism and treated with NOACs at the Aga Khan University Hospital, Nairobi, from January 2014 to December 2019. Clinical and outcome data were collected from medical records and the hospital mortality database. All patients with VTE aged > 18 years and initiated on NOACS were recruited. Patients with missing information were excluded. They were followed up from the time of commencement of oral anticoagulation to completion of therapy, or to the time of the first major bleed, CRNM or minor bleeding. Data on bleeding were obtained from the hospital database and through telephone interviews. Unadjusted rates of the first major bleeding event or CRNM were calculated as the number of bleeding events per 100 person-years. RESULTS: Two hundred and forty-three patients with VTE were recruited and 222 (91.4%) were initiated on rivaroxaban, 12 (4.9%) on dabigatran and nine (3.7%) on apixaban, with a median follow up of 213 [interquartile range (IQR): 119–477] days. The median age of the patients was 57 (IQR: 45–71) years. A total of 64 bleeding events were identified in 50 (20.6%) patients. Overall, the incidence rate for bleeding events was 17.24 per 100 patient-years. The incidence rate of major bleeding was 3.79 per 100 person-years. Gastrointestinal bleeding was the most common major bleeding site. There were more females with bleeding events (70.7%) compared to males. Anaemia and the use of aspirin and other antiplatelets were associated with a higher incidence of major and CRNM bleeding [relative risk (RR) = 3.77, confidence interval (CI) = 1.37–10.39, p = 0.005 and RR = 8.89, CI = 2.06–38.33, p = 0.0003, respectively]. CONCLUSIONS: Most of these bleeds were minor, with the gastrointestinal tract being the most common source of major bleeding and menorrhagia being the commonest cause of bleeding. Anaemia and the use of aspirin were associated with a higher incidence of major bleeding.

BACKGROUND: In a South African bi-ethnic cohort, defensive (DefS)/social support/avoidance coping strategies have been shown to influence cardiac troponin T (cTnT) levels through different stress signalling pathways. Personality traits (extraversion, neuroticism, conscientiousness, openness to experience, agreeableness) partially control stress coping responses and may affect prospective cardiac responses. Hence in this cohort, we aimed to examine relationships between personality traits and coping strategies, and to assess associations between cTnT changes over time, personality traits and coping strategies. METHODS: A cohort of African and Caucasian male and female teachers (n = 359) participating in both phases of the Sympathetic activity and Ambulatory Blood Pressure in Africans (SABPA) study, was prospectively followed for three years. Personality traits (Basic Traits Inventory) and coping (Coping Strategy Indicator) scores were determined. Fasting serum samples for cTnT determination were collected. Established hypertension-related cTnT cut-off points of 4.2 pg/ml (Africans) and 5.6 pg/ml (Caucasians) were applied. RESULTS: Higher neuroticism and lower conscientiousness scores were found in the Africans than in the Caucasians (p < 0.05). Both traits correlated with all three coping strategies in Caucasians, but only with DefS and avoidance coping in Africans. Over a period of three years, cTnT levels decreased in both races. Compared to Africans, Caucasians showed a greater recovery from the ethnic-specific cTnT cut-off point over time. In the Africans with high DefS scores, cTnT level changes were inversely associated with conscientiousness (adjusted R2 = 0.14; β = –0.26). In Caucasians scoring high in avoidance coping, conscientiousness (odds ratio 0.84) and neuroticism (odds ratio 0.90) showed a lower likelihood of predicting the cTnT cut-off point. CONCLUSION: In both races, conscientiousness may contribute to healthier stress coping responses and protect against cardiac ischaemia and risk of hypertension.

OBJECTIVE: To examine the clinical profile and treatment outcomes of infective endocarditis (IE) at a tertiary hospital in KwaZulu-Natal. METHODS: A 10-year retrospective analysis was conducted on cases of definite IE (modified Duke criteria). RESULTS: Ninety-seven subjects (HIV infected, n = 12) satisfied the study criteria (mean age 29.7 ± 15.6 years, M:F 1.4:1). Underlying rheumatic heart disease was present in 84.5% and severe dyspnoea in 67.0% of cases. Staphylococcus aureus was the commonest pathogen isolated (18.6%). Heart failure was present in 61.9% and vegetations were identified in 85 (87.6%) subjects, resulting in 41 (42.3%) embolic events. The clinical profile and outcomes were similar in the HIV-positive and -negative patients. Surgery was performed in 73 subjects (surgical mortality rate 9.5%, total mortality rate 26.4%). Multivariate analysis identified acute-onset IE [odds ratio (OR) 251.46, 95% confidence interval (CI) 1.18–5343.63, p = 0.043], vegetation size > 15 mm (OR 222.60, 95% CI 1.04–4730.34, p = 0.043) and medical management only (OR 20.89, 95% CI 2.12–200.06, p = 0.037) as predictors for increased in-hospital mortality. CONCLUSION: IE affects young people with underlying rheumatic heart disease and is associated with high morbi-mortality attributable to advanced disease at presentation and to haemodynamic failure resulting from valve destruction due to acute onset of aggressive infection.

BACKGROUND: Open-heart surgery is associated with severe postoperative pain. Adequate analgesia after open-heart surgery improves patients’ early postoperative recovery, extubation, ambulation and early discharge from hospital. Regional anaesthesia techniques are the new hope for adequate postoperative analgesia after cardiac surgery and are widely used for early pain management in the first six hours. METHODS: A total of 100 patients with the American Society of Anesthesiologists physical status classification I–III, aged 18 years and over, undergoing open-heart surgery with sternotomy for coronary artery bypass grafting or valve replacement under general anaesthesia, were included in this study. For postoperative analgesia, 50 patients with pectoral nerve (PECS II) block and 50 with parasternal (PS) block were consecutively enrolled in one of the groups at the end of the surgery and compared in terms of sedation scores, ventilation duration, pain scores at rest after extubation, block duration, total morphine consumption and complications. RESULTS: The block duration in the PS group was statistically significantly higher than in the PECS II group (p = 0.001, p < 0.05, respectively). The visual analogue scale scores at rest in the fourth and sixth hours were statistically significantly higher in the PECS II group than in the PS group (p = 0.001, p = 0.001, p < 0.01). Cumulative morphine consumption in the PECS II group was statistically significantly higher than in the PS group in the fourth, sixth, 12th and 24th hours (p = 0.001, p = 0.001, p = 0.001, p = 0.001, p = 0.001, p < 0.01, respectively). CONCLUSION: PS block provided longer block duration with lower postoperative pain and sedation scores than the PECS II block, with lower cumulative morphine consumption.

OBJECTIVE: Plethysmography can be used in the diagnosis and evaluation of chronic venous disease in the lower extremities. This study aimed to evaluate the applicability and reliability of strain-gauge plethysmography (SDP) in the functional assessment of chronic venous disease. METHODS: This descriptive study was conducted between 2016 and 2021 at a single centre. Four hundred and thirtytwo patients with symptomatic chronic venous disease were included in the study. All participants were diagnosed initially with Doppler ultrasonography. SGP was then performed to evaluate venous outflow capacity, venous reflux and muscle pump function. RESULTS: The average age was 45.16 ± 12.54 years (median age 46 years; range 20–78 years), and 239 (55.3%) women and 193 (44.7%) men were included in the study. The age groups, diagnosis, pathological distribution and risk factors were quantitatively determined according to gender. Localisation and lateralisation statistics of the pathologies are given. SGP measurements, including venous volume (V), venous emptying (VE), expelled volume ratio in four seconds (EV4/V), half refilling time (t½) and refilling volume (RV) of each lower extremity, were done individually to compare the involved extremity with the normal contralateral side. SGP measurements of each affected lower limb were also compared separately by gender, age group and disease onset. The correlation between t½ values and skin discolouration or oedema of the affected limb was examined. Finally, receiver operating characteristic curve analyses of the V, VE, EV4/V, t½ and RV values were done, and the cut-off values of each parameter were defined accordingly. CONCLUSION: High reliability and consistent results indicate that SGP is a practical and sensitive test for quantitative functional assessment of patients with chronic venous disease. It can be used as an effective method in diagnosing and following up chronic venous disorders. As there are no currently accepted cut-off values, we suggest that ours can be used as new reference values for SGP measurements.

Purpose This study aimed to assess the relationship between the cardiac rhythm response to ibutilide infusion after pulmonary vein isolation and the recurrence of long-term atrial arrhythmias. Methods One hundred and thirty-eight patients with non-paroxysmal atrial fibrillation who had had their first catheter ablation were retrospectively included. All patients whose atrial fibrillation did not terminate after pulmonary vein isolation were administered intravenous ibutilide (1.0 mg). Those with termination of atrial fibrillation after ibutilide administration were defined as responders (n = 86); those without termination of atrial fibrillation, as non-responders ( n = 52). The primary endpoint was any documented recurrence of atrial arrhythmia lasting more than 30 seconds after the initial catheter ablation. Results Conversion of atrial fibrillation to sinus rhythm, directly or via atrial flutter, with ibutilide administration was achieved in 62.3% of patients. A longer duration of atrial fibrillation was associated with failed termination of atrial fibrillation (odds ratio 1.009, 95% confidence interval 1.002-1.017, p = 0.011). During a median follow-up period of 610 days (interquartile range 475-1 106) post ablation, non-responders (n = 24, 46.2%) had a higher recurrence rate of atrial arrhythmia than the responders (n = 26, 30.2%; log-rank, p = 0.011) after the initial catheter ablation. Multivariate Cox regression analysis revealed that non-responders (hazard ratio 1.994, 95% confidence interval 1.117-3.561, p = 0.020) was significantly correlated with recurrence of atrial arrhythmias. Conclusions In patients whose atrial fibrillation persisted after pulmonary vein isolation, the response to ibutilide administration could predict the recurrence of atrial arrhythmias after catheter ablation, which may be useful for risk stratification for recurrence of atrial fibrillation and individualised management of atrial fibrillation.

BACKGROUND: Pre-operative neurodevelopmental assessment in children with congenital heart disease may assist in the early identification of children at risk for or presenting with developmental delays. This study determined the pre-operative neurodevelopmental status of young children undergoing cardiac surgery in central South Africa. Feasibility and clinical value of pre-operative assessment were also evaluated. METHODS: Children 30 months and younger, scheduled to undergo cardiac surgery, were recruited into this prospective observational analytical study. Neurodevelopmental status was assessed using the Bayley-III and neuromotor examination. Variables associated with developmental performance were determined using ANOVAs. Sociodemographic and medical information were collected using a self-developed questionnaire. Pre-operative neurodevelopmental assessment was completed for 40 children at a median age of 7.4 months, including 30 children without and 10 with Down syndrome. Mean cardiac disease severity was moderate. The inclusion rate for pre-operative developmental assessment was 68%, limited mainly by environmental barriers. RESULTS: Children with Down syndrome had significantly poorer motor (p < 0.0001), cognitive (p < 0.0001) and language performance (p < 0.001) compared to children without Down syndrome. Apart from Down syndrome, disease severity (p = 0.02), younger age at first cardiac surgery (p < 0.01) and growth failure (p = 0.04) were significantly associated with poorer cognitive, language and motor performance, respectively. Just more than half of the children without (n = 16) and all children with Down syndrome (n = 10) scored below one standard deviation of the test mean score (scores < 85) on at least one of the Bayley-III subscales, meeting the criteria for referral to rehabilitation therapies, including physiotherapy, occupational therapy and/or speech therapy. CONCLUSION: Pre-operative neurodevelopmental assessment may be of high importance in South Africa to identify children at developmental risk, facilitating early referral to rehabilitation therapies.

The 15th biennial Pan-African Society of Cardiology (PASCAR) congress held in Mombasa, Kenya, in November 2021, convened in its legacy of being the largest Pan-African conference on cardiovascular diseases (CVDs). The congress brough together members of cardiovascular societies from across the continent in the shared mission of advancing cardiovascular health in Africa. In partnership with the Kenyan Cardiac Society (KCS), the specific aims of the PASCAR conference were to (1) advance knowledge on CVDs in the region; (2) share local data, clinical cases, challenges and solutions and reinforce collaborative capacity initiatives in research and workforce training; (3) engage with policy makers to address health-system issues affecting access to CVD care in Africa; and (4) bring together local and international thought leaders in cardiovascular medicine to strengthen the partnerships between PASCAR, KCS, other African cardiac societies and key global stakeholders. Due to the COVID-19 pandemic, this congress demonstrated great success in providing both an in-person and a virtual platform of attendance, therefore making this an inaugural hybrid PASCAR congress, with inclusive and widespread participation from across the globe. We highlight the key areas of focus, various educational programmes and innovative initiatives that shaped the 15th PASCAR congress, including expert consensus on the future directions for advancing CVD care in Africa.

BACKGROUND: Platelet dysfunction has been shown to play a role in postoperative bleeding, however it is not clear whether immature platelets (IP) can induce appropriate homeostasis to prevent excessive bleeding in patients undergoing coronary artery bypass grafting (CABG). The aim of this study was to evaluate the postoperative change in IP count (IPC), IP fraction (IPF) and mean platelet volume (MPV), and to examine their relationship with postoperative bleeding and blood transfusion. METHODS: One hundred and forty-nine consecutive patients undergoing elective CABG were included in this prospective study. All CABGs were performed by the same surgical team in a standardised method, utilising the on-pump technique. IPC, MPV and IPF were measured pre-operatively, after the completion of surgery, and at the postoperative first, third and fifth days. The primary outcome measure of this study was whether the need for transfusion was associated with IP, IPF, MPV and platelet count. RESULTS: There was a significant decrease of 7.77% in IPC on the day of the operation. Pre-operative IPC and IPF were correlated with postoperative drainage (p < 0.001), intraoperative blood transfusion (p < 0.001) and intensive care unit blood transfusion (p < 0.001). Pre-operative haemoglobin levels were significantly correlated with length of hospital stay. However, neither pre-operative IPC nor IPF were associated with length of hospital stay. Postoperative IPC was however associated with the length of hospital and intensive care unit stay (p = 0.008 and p = 0.009, respectively). CONCLUSION: Pre-operative IPC and IPF were significantly correlated with postoperative drainage and blood transfusion frequency. In patients undergoing CABG, these can be seen as serious guiding parameters in the estimation of postoperative bleeding.

Aim The aim of this study was to determine the prevalence and predictors of dyslipidaemia in adults in Nigeria. Methods Using the WHO criteria, we determined dyslipidaemia using serum lipid levels of 3 211 adult Nigerians, aged at least 18 years, obtained between March 2017 and February 2018 from two communities (rural and urban) in a state from each of the six geopolitical zones of Nigeria. Results The overall prevalence of low high-density lipoprotein cholesterol (l-HDL), elevated low-density lipoprotein cholesterol (e-LDL), hypertriglyceridaemia (h-TG) and hypercholesterolaemia (h-CHL) were 72.5,13.6, 21.4 and 7.5%, respectively. The adjusted odds of h-CHL [odds ratio (95% confidence interval) 1.47 (1.10-1.95)], h-TG [1.89 (1.48-2.41)] and e-LDL [1.51 (1.03-2.15)] increased with obesity. Being a rural dweller increased the odds of h-TG [1.55 (1.29-1.85)], e-LDL [1.38 (1.10-1.73)] and l-HDL [1.34 (1.14-1.58)]. The odds of h-CHL [2.16 (1.59-2.95)], h-TG [1.21 (1.01-1.47)], e-LDL [1.42 (1.13-1.80)] and l-HDL [0.78 (0.65-0.93)] increased with hypertension. Diabetes mellitus doubled only the odds of h-TG [2.04(1.36-3.03)]. Conclusion The prevalence of dyslipidaemia, particularly low HDL-C, is high among adult Nigerians.

Aim In this study, we aimed to investigate the effect of vacuum-assisted closure therapy on venous stasis wound healing in patients with chronic venous leg ulcers. Methods Vacuum-assisted closure therapy was applied on a total of 14 venous leg ulcers. All patients had post-thrombotic syndrome. Quantitative wound culture samples were obtained before the procedure and local wound assessments were performed. The primary outcome measures included wound healing as assessed by a local wound examination during each dressing change and the rate and velocity of ulcer reduction. Wound healing was defined as the complete closure of the ulcer, while rapid wound healing was defined as a ≥ 30% reduction in the ulcer size by week four. Results No surgical debridement or surgical corrective procedure was applied in any patient. The mean length of hospital stay was 32.3 days. The mean number of vacuum-assisted closure therapies for each case was 17.8 and the mean time to dressing change was 72.3 hours. Multidrug-resistant Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus were detected in three and four patients, respectively. Wound culture results became negative after a mean duration of vacuum-assisted closure therapy of 12.1 days. None of the patients needed antibiotic therapy until the procedure was completed. Compared to baseline, the mean ulcer reduction rates were 46.4% for the first six applications and 72.8% for the subsequent applications. Conclusions Our study results suggest that vacuum-assisted closure therapy promotes rapid wound healing in patients with severe post-thrombotic syndrome with venous stasis leg ulcers, and reduces the need for antibiotics by reducing the biological burden.

INTRODUCTION: Venous insufficiency caused by varicose veins, especially in the lower extremities, is widespread and can cause severe complications. Anaesthesia is essential for any surgical approaches in varicose vein surgery. This study evaluated the effect of single-dose epidural anaesthesia on postoperative pain scores and length of hospitalisation after varicose vein surgery, comparing it with general anaesthesia. METHODS: The study was conducted on a total of 100 patients, aged 18 years and older, with the American Society of Anesthesiologists (ASA) physical status classification I–III, undergoing unilateral lower-extremity stripping due to varicose veins within a six-month period at the Prof Dr Cemil Taşçioğlu City Hospital Anesthesiology and Reanimation Service. Fifty patients with single-dose epidural anaesthesia were consecutively included in the EA group. For comparison, 50 patients who were operated on under general anesthesia were included in the GA group. RESULTS: The groups showed statistically significant differences between the 30th-minute and first-, second-, fourth- and sixthhour visual analogue scale (VAS) scores (p = 0.001; p < 0.01). Patients with epidural anaesthesia had lower 30th-minute VAS scores compared to those administered general anaesthesia. There were statistically significant differences identified between the groups for the additional analgesia requirements of patients (p = 0.001; p < 0.01). Subjects with epidural anaesthesia had lower additional analgesic requirements than those administered general anaesthesia. CONCLUSION: Epidural anaesthesia provided adequate anaesthesia with more effective postoperative analgesia compared to patients operated on under general anaesthesia and receiving multimodal analgesia for postoperative analgesia.

Introduction Over the past two decades, the incidence of acute rheumatic fever (ARF) and chronic rheumatic heart disease (RHD) have dramatically declined in wealthier regions of the world as a result of preventative programmes, improved living standards and access to cardiac surgery. Nevertheless, ARF and RHD are still public health problems in less-developed regions of the world such as Oceania, south Asia and sub-Saharan Africa. Aim We report on clinical, therapeutic and prognostic aspects as well as the difficulties encountered during this first series of surgery for rheumatic valve disease in Mali. Methods This was a prospective, descriptive study conducted at the Andre Festoc Cardiac Surgery Centre from September 2018 to August 2019. Results The frequency of patients having been operated on for rheumatic valve disease was 44.73% (68 patients). The mean age of the patients was 18 ± 10 years with extremes of five and 60 years. The gender ratio was 0.7. The delay to treatment was between one and three years for 39.7% of the patients. The main diagnoses found were: mitral regurgitation in 50% of patients, mitral stenosis in 16.2% and aortic regurgitation in 10.3%. Pulmonary artery systolic pressure was 35-50 mmHg in 19.1% of patients and more than 50 mmHg in 25%. The median cardiopulmonary bypass time was 132 minutes (60-276) and median extubation time was three hours (0-96). The main complications were cardiac, renal, neurological, respiratory, gastrointestinal and infectious. In the immediate postoperative period, we recorded three deaths, which is a mortality rate of 4.4%. Conclusions Humanitarian efforts have led non-governmental organisations (NGOs) to launch surgical programmes in low-and middle-income countries in an attempt to fill the gap in these fragile healthcare systems. Cardiac surgery requires much expertise from the medical staff, as well as many material and financial resources. Empowerment of the local team is a challenge that is being realised since taking these essential steps of companionship with the NGO la Chaine de l'Espoir.

OBJECTIVE: The aim of this study was to determine the haemodynamics of the intrarenal arteries from the relationship between resistivity index (RI) and kidney function, and to identify the predictors of high RI among patients with diabetic nephropathy (DN) and those with diabetes mellitus (DM) without DN. METHODS: This was a cross-sectional survey of 133 participants, comprising 40 subjects with DM without DN, 53 with DM with DN and 40 healthy controls. Information obtained was demographics, lifestyle, medical and medication histories, while anthropometric and blood pressure measurements were taken. Albuminuria and estimated glomerular filtration rate were determined and RI was measured using a Doppler ultrasound scan. RESULTS: The mean intrarenal artery RIs were higher among the patients with DM without DN (0.60 ± 0.04) and the group with DM with DN (0.61 ± 0.04) than in the controls (0.56 ± 0.04) (p = 0.02). Glycated haemoglobin (HbA(1c)) predicted high RI in the DM without DN group (OR 2.81; CI: 1.73–9.03) while hypertension (OR 3.60; CI: 1.06–12.22) predicted high RI in the DM with DN group. CONCLUSION: Elevated intrarenal artery RI was prevalent among patients with DM without DN and those with DM with DN, while elevated HbA(1c) level and hypertension predicted elevated RI in subjects with DM without DN and those with DM with DN.

Background Corona virus disease 2019 (COVID-19) is a multi-systemic illness that can present with cardiac complications. This report describes the preliminary findings of cardiac manifestations seen in patients managed in three centres in Lagos, Nigeria. Methods Ten patients, part of an ongoing study of patients admitted in three centres in Lagos, Nigeria, with COVID-19 diagnosed with reverse transcriptase polymerase chain reaction (RT-PCR) or serology were retrospectively studied for cardiac manifestations. Results The mean (SD) age was 52.5 ± 18.79 years (with a minimum of 17 years and maximum of 79 years). Six patients were female and four were male. Hypertension was seen in 70%, diabetes in 50% and obesity in 60% of patients. All had elevated inflammatory markers. Only four patients had bilateral pneumonia. The rest had only cardiac manifestations. Six patients presented with de novo heart failure and one had decompensated heart failure. A set of three patients had individually fulminant myocarditis, probable pulmonary embolism and stress cardiomyopathy, respectively. Conclusions This study shows that co-morbidities are common in patients with COVID-19 and cardiac complications. The array of cardiac complications is large, with the commonest being heart failure.

INTRODUCTION: The increasing prevalence of cardiovascular risk factors in South African rural communities is well reported. However, the prevalence of cardiovascular disease (CVD) leading to hospital admission and related in-hospital mortality in rural and semi-rural hospitals is unknown. METHODS: We conducted a retrospective review of hospital records for patients admitted to the Department of Internal Medicine at Dora Nginza Hospital in Port Elisabeth, South Africa between 1 April and 31 October 2016. The study focused on patients who received a primary diagnosis of CVD. RESULTS: During the seven-month study period, 4 884 patients were admitted to the unit, 1 325 of whom received a primary diagnosis of CVD, giving a prevalence of 27%. Patients with CVD had a mean (standard deviation) age of 60 (± 15) years, 32% of this patient population was younger than 55 years and 65% were female. Furthermore, 94% had a background medical history of systemic hypertension and 30% of diabetes mellitus. The three leading cardiovascular causes of hospital admission were stroke (38%), hypertensive heart disease plus heart failure (33%), and hypertensive emergency/urgency (18%). In-hospital outcome: 12.4% of patients admitted for CVD died during the index hospitalisation and strokes were responsible for 70% of the deaths. CONCLUSION: The prevalence of CVD in this cohort was high and accounted for significant morbidity and mortality. Systemic hypertension was a leading risk factor in our cohort and we need to intensify efforts to diagnose and treat systemic hypertension.

Background Premature ventricular contraction (PVC) is considered one of the most common arrhythmias in clinical practice. The aetiology of PVC is still unclear, however increased sympathetic activity, electrolyte misbalance and cardiomyopathies are considered the main causes of PVCs. In this study we were trying to find out whether there was any association between PVC burden and elevated left ventricular (LV) filling pressure. Methods A total of 100 patients (age: 58.6 ± 7.5 years, 52 males) with frequent PVCs observed on 24-hour Holter monitoring (> 1%) and normal LV ejection fraction (LVEF) (> 50% on echocardiography) were enrolled. Clinical characteristics and echocardiographic parameters, including E/E' to assess LV filling pressure of the patients, were compared with those of an age- and gender-matched control group (n = 100, age: 57.4 ± 7.5 years, 50 males). Results Mean E' was significantly higher in the controls (7.9 ± 3.1 cm/s) than the cases (6.4 ± 1.9 cm/s) (p = 0.010) while mean E/E' was significantly higher in the cases (12.5 ± 5.3) than the controls (10.9 ± 5.7) (p = 0.044), reflecting significantly different LV diastolic function. However LVEF by M-mode and biplane imaging showed no significant difference between the groups. Conclusion Patients with frequent PVCs were associated with high LV filling pressure, which was significantly different from LV filling pressure in the control group.

Background Clamp application is safe and widely used in the visceral organs. This raises the question: why not use clamping in orthopaedic, oncological, fracture and revision surgeries of areas where tourniquets are not suitable. This experimental animal study aimed to compare tourniquet and arterial clamp applications with regard to their histological effects and inflammatory responses on a molecular level, on the artery, vein, nerve and muscle tissue. Methods Twenty-one rabbits were divided into three groups (group I: proximal femoral artery clamp; group II: proximal thigh tourniquet; and group III: control group). In the clamp group, the common femoral artery was clamped with a microvascular clamp for two hours. In the tourniquet group, a 12-inch cuff was applied to the proximal thigh for two hours at 200 mmHg. The common femoral artery, vein, nerve, rectus femoris and tibialis anterior muscles were excised and analysed in all groups. Results Artery and vein endothelial injuries were found in the clamp and tourniquet groups (relative to the control group, p ≤ 0.001 and p = 0.007, respectively). However, no difference was found between the clamp and tourniquet groups regarding vessel wall injury. Conclusions We found there were no differences in incidence of vessel, muscle and nerve injury when comparing the tourniquet and clamp applications. For surgical procedures that are unsuited to a tourniquet, arterial clamping can be selected, resulting in close-to-tourniquet vessel injury rates but without tourniquet-related complications.

Objectives Epicardial adipose tissue (EAT) aromatase converts androstenedione and other adrenal androgens into oestrogens. The locally produced oestradiol (E2) may have cardiovascular protective effects. Little is known about the relationship between EAT aromatase level and coronary heart disease (CHD). Here, we compared EAT aromatase levels in CHD versus non-CHD patients and assessed the relationship between EAT aromatase levels and lesion degree in the coronary arteries. Methods EAT and blood specimens were obtained from patients undergoing thoracotomy prior to cardiopulmonary bypass. Serum E2 levels were obtained from our hospital laboratory. EAT aromatase expression was determined by RT-qPCR and ELISA assays. All patients underwent coronary angiography and the level of coronary lesions was evaluated with the SYNTAX score. Results Compared with non-CHD patients, CHD patients had lower EAT aromatase mRNA and protein levels. In the CHD patients, EAT aromatase and oestrogen levels negatively correlated with the severity of coronary artery disease. Conclusions Our data revealed that reduced EAT aromatase levels correlated with coronary atherosclerotic lesions. Reduced EAT aromatase protein levels may aggravate the severity of atherosclerosis. Future studies should investigate the mechanisms regulating aromatase expression in epicardial fat.

AIM We aimed to explore the value of peripheral blood neutrophil-to-lymphocyte ratio (NLR) for the clinical diagnosis and prognosis of elderly patients with chronic heart failure (CHF) and atrial fibrillation (AF). METHODS A total of 248 eligible patients were followed up for five years, and divided into major adverse cardiovascular event (MACE) and non-MACE groups. The independent predictive factors for MACE were explored by multivariate logistic regression analysis. Based on quartile of NLR, they were divided into groups A to D. The duration of MACE was analysed using Kaplan-Meier survival curves. The diagnostic value of NLR for MACE was evaluated by receiver operating characteristic curves. RESULTS Higher age, low-density lipoprotein cholesterol and NLR, lower left ventricular ejection fraction, diabetes and NYHA heart function class III and IV were independent predictive factors for MACE. The incidence of MACE rose with increasing NLR. Groups A to D had significantly different rates of acute myocardial infarction, severe arrhythmia and cardiac death (p < 0.05). The average duration of MACE in groups A to D were 49.31, 45.27, 43.63 and 40.34 months, respectively. CONCLUSIONS The sensitivity and specificity of NLR for diagnosis of MACE were 72.39 and 86.18%, respectively. NLR was an independent predictive factor for MACE in these elderly patients with CHF and AF.

OBJECTIVES: Left atrial appendage (LAA) morphology is a powerful predictor of thrombogenesis of the left atrium (LA) in patients with non-valvular atrial fibrillation (NVAF). However, it remains unknown whether LAA morphology is useful for stroke risk stratification in patients with NVAF. METHODS: A total of 555 atrial fibrillation patients were divided into thrombus and non-thrombus groups according to transoesophageal echocardiography. We analysed the correlation between LAA morphology and the CHADS(2) score. We determined the L(2)CHADS(2) score and compared the ability to predict LA/LAA thrombosis of the CHADS(2), L(2)CHADS(2) and CHA(2)DS(2)-VASc scores from the area under the curve (AUC). RESULTS: The odds ratio of non-chicken wing LAA morphology was 11.48. Non-chicken wing LAA morphology was significantly correlated with LA/LAA thrombosis. We incorporated LAA morphology into the CHADS(2) score and named it the L(2)CHADS(2) score. The AUC of the L(2)CHADS(2) score (0.767) in predicting LA /LAA thrombosis was significantly higher than that of the CHADS(2) (0.558) or CHA(2)DS(2)-VASc scores (0.557). The positive and negative predictive values of the L2CHADS(2) score (13.1 and 98.7%) were higher than those of the CHADS(2) (8.7 and 94.2%) and CHA2DS2- VASc scores (6.9 and 6.9%). CONCLUSIONS: Non-chicken wing LAA morphology was a powerful predictor of LA/LAA thrombosis in NVAF patients. The AUC, sensitivity and specificity of the L(2)CHADS(2) score were higher than those of the CHADS(2) and CHA(2)DS(2)-VASc scores.

Aim: Flow-mediated dilatation (FMD) and retinal vascular analysis (RVA) may assist in predicting cardiovascular disease (CVD) but are poorly characterised in South Africa. We recorded baseline FMD and retinal vascular widths in healthy participants, and investigated associations with cardiovascular risk factors. Methods: Endothelial function (measured with FMD), microvascular structure (evaluated via fundus image analysis) and major CVD risk factors were assessed in 66 participants from Cape Town. Results: Median FMD% was 9.6%, with higher values in females. Mean retinal arteriolar and venular widths were similar to 156 and similar to 250 mu m, respectively. FMD was not associated with CVD risk factors. Hypertension was associated with narrower retinal arterioles and venules. Conclusions: We report novel baseline FMD data in healthy South African adults from the Western Cape, and show that retinal microvascular calibres are associated with blood pressure. Our baseline FMD and RVA data could serve as a reference for future studies in South Africa.

Purpose Obesity is associated with the development of risk factors for cardiovascular disease (CVD) and polyphenols have been shown to possess ameliorative effects against obesity-induced CVD risk factors. Rooibos (Aspalathus linearis) is rich in polyphenols, therefore we investigated the cardioprotective effects of aspalathin-rich green rooibos (GRT) on obesity-induced CVD risk factors in obese Wistar rats. Methods Adult male Wistar rats (n = 20 per group) were fed a control or a high-fat diet (HFD) for 16 weeks and treated with GRT (60 mg/kg/day) for six weeks. Blood pressure was monitored throughout. Vascular reactivity was measured and Western blots of cell-signalling proteins (eNOS, AMPK and PKB) were performed in aortic tissues. Effects on oxidative stress were determined by measuring antioxidant enzyme activity and thiobarbituric reactive substance (TBARS) levels in the liver. Results HFD animals had (1) increased blood pressure, (2) impaired vasodilation, (3) attenuated PKB and AMPK expression, (4) decreased antioxidant enzyme activity, (5) increased malondialdehyde (MDA) levels, and (6) increased phosphorylated eNOS levels. Treatment with GRT extract significantly alleviated these obesity-induced CVD risk factors. Conclusions Supplementation with GRT extract alleviated cardiovascular risk factors in the HFD animals, suggesting a therapeutic potential for GRT in obesity-induced cardiovascular risk.

Aim The aim was to assess the safety and efficacy of rotational atherectomy followed by drug-eluting balloon (DEB) in patients with a high risk of bleeding. Methods A retrospective review was carried out of hospital records of consecutive patients who underwent the hybrid procedure. Results The average age of the 23 patients was 74 years. Risk factors for bleeding included renal failure (35%), oral anticoagulation use (26%) and peptic ulcer disease (35%). All patients had procedural success. No bleeding was reported over the 24-month follow-up period. Dual antiplatelet therapy was stopped successfully in six patients (26%) at three months. Two patients had confirmed target-lesion failure (restenosis). Two patients died over the study period but the cause of death was not known to be cardiovascular disease related. Conclusions For patients at high risk of bleeding who require rotablation, the use of a drug-eluting balloon may be a safe, effective alternative.

OBJECTIVES: Low or high sympatho–adrenal–medullary axis (SAM) and hypothalamic–pituitary–adrenal axis (HPA) dysregulation reflect chronic stress. Retinal vessel dynamics may relate to SAM, HPA activity and stroke risk. Our objectives were therefore to assess the relationships between retinal vessel, SAM and HPA responses, and to determine stroke risk. METHODS: A prospective bi-ethnic gender cohort (n = 275, 45 ± 9 years) was included. Urine/serum/saliva samples for SAM [norepinephrine:creatinine ratio (u-NE)] and HPA [adrenocorticotrophic hormone (ACTH), cortisol] were obtained at baseline, three-year follow up and upon flicker light-induced provocation. Diastolic ocular perfusion pressure was measured as a marker of hypo-perfusion. Retinal arterial narrowing and venous widening calibres were quantified from digital images in the mydriatic eye. A validated stress and stroke risk score was applied. RESULTS: An interaction term was fitted for venous dilation in u-NE tertiles (p ≤ 0.05) and not in u-NE median/quartiles/ quintiles. Independent of race or gender, tertile 1 (low u-NE) had a 112% increase in u-NE, decreases in cortisol, and no changes in ACTH over three years (positive feedback). Tertile 3 (high u-NE) contradictorily had decreases in u-NE and cortisol, and increases in ACTH (negative feedback). In tertile 1, reduced arterial dilation, and faster arterial vasoconstriction and narrowing were related to higher SAM activity and hypo-perfusion (p ≤ 0.05), whereas delayed venous dilation, recovery and widening were related to cortisol hypo-secretion (p ≤ 0.05). In tertile 1, delayed venous recovery responses predicted stress and stroke risk [odds ratio 4.8 (1.2–19.6); p = 0.03]. These associations were not found in u-NE tertiles 2 and 3. CONCLUSIONS: In response to low norepinephrine, a reflex increase in SAM activity occurred, enhancing arterial vasoconstriction and hypo-perfusion. Concomitant HPA dysregu- lation attenuated retinal vein vasoactivity and tone, reflecting delayed vein recovery responses and non-adaptation to stress. These constrained vein recovery responses are indicative of increased chronic stress and stroke risk.

This is a review of 114 patients with atrial fibrillation who had left atrial appendage occlusion with an Amplatzer cardiac plug over a nine-year period done by a single operator. This shows that the procedure can be safely performed with a very low rate of major complications (< 1%) and a zero procedural mortality rate. Long-term follow up over an average of 38.5 months showed a 65% reduction in actual versus predicted stroke rate. This is similar to that seen with oral anti-coagulants and other published trials and registries involving left atrial appendage occlusion.

Background There is limited available evidence of a relationship between uric acid (UA) level and stroke in hypertensive populations worldwide. We aimed to estimate the relationship between UA level and stroke in Chinese hypertensive populations. Methods A total of 4 710 essentially hypertensive Chinese patients, including 307 with stroke, were recruited consecutively by cluster sampling from 60 communities in Shenzhen from April 2010 to September 2011. Demographic characteristics, UA level and stroke diagnosis were collected from every participant. Logistic regression analysis was used to estimate the association between UA level and stroke. Results The study population comprised 2 361 females and 2 349 males, with a mean age of 58 ± 11.75 years. There were significant associations between UA level and stroke and ischaemic stroke (IS) risk for females in the crude model (M0), model 1 (M1) and model 2 (M2), with increasing odds ratios (OR) as the quartiles (Q) increased. The odds of stroke risk was highest in Q4 in M2 (UA > 396 µmol/l, OR: 3.05, 95% CI: 1.74-5.36 and OR: 3.19, 95% CI: 1.74-5.85), but not for males in M0, M1 and M2. A significant dose-response relationship existed between UA level and stroke, and between UA level and IS for females but not for males. Hyperuricaemia (HU) was also significantly associated with stroke and IS for females but not for males. Taking negative uric acid, homocysteine, triglycerides, total cholesterol and low-density lipoprotein cholesterol (UA-Hcy-TG-TC-LDL-C-) as the reference, the combinations of UA+Hcy+TG-TC-LDL-, UA+Hcy+TG+TC+LDL-C- and UA+Hcy+TG+TC+LDL-C+ were significantly associated with the risk of stroke for females (OR = 2.48, 7.85 and 3.04). Conclusions High UA level could significantly increase stroke risk in female hypertensive patients. Female hypertensive patients may benefit from managing UA at normal levels for stroke prevention.

OBJECTIVE: The aim of this study was to investigate the impact of accelerated pharmaco-mechanical thrombolysis (PMT) with low-dose second-generation urokinase for the management of cases with lower-extremity deep venous thrombosis (DVT), and to compare its efficacy in subjects with acute and subacute DVT. METHODS: Thirty-five patients with acute (< 15 days) or subacute (15–30 days) DVT who underwent PMT in a tertiary centre were enrolled in this single-arm, prospective study. Following the placement of a temporary vena cava filter, urokinase (200 000 IU) was administered into the occlusion through a multi-hole catheter for 15 to 20 minutes. Control venography was performed to assess venous flow and the rate of acute recanalisation. Percutaneous balloon dilatation and stent placement were carried out in case of a residual iliac vein stenosis of > 50%. Any residual thrombi were suctioned with an aspiration catheter. The primary outcome measures of this study were the percentages of vessel patency and PTS in the third month after PMT. RESULTS: Complete recanalisation was noted in 23 (66%) patients, while two (6%) had poor recanalisation. The rate of minor complications was 14%. None of the subjects experienced major complications, such as intracranial haemorrhage or pulmonary embolism. No mortality was recorded during the three months of follow up. Control duplex ultrasonography in the third month revealed that the target vein was patent in all subjects. None of the subjects experienced PTS during follow up. In addition, the percentage of acute complete recanalisation was significantly higher in subjects with acute DVT compared to those with subacute DVT (95 vs 27%, p < 0.001). CONCLUSION: PMT with an accelerated regimen of low-dose urokinase provided excellent efficacy in the resolution of thrombus and prevented the development of PTS in the midterm when used for the management of lower-extremity DVT.

Objectives: The pathophysiology of isolated coronary artery ectasia (CAE) involves atherosclerosis and inflammation. Eosinophils and lymphocytes have been found to play a significant role in inflammation, atherosclerosis and endothelial dysfunction. Many studies have explored the relationship between isolated CAE and systemic inflammation. However, there are no data regarding the relationship between eosinophil-to-lymphocyte ratio (ELR) and isolated CAE. Therefore, this study analysed the relationship between ELR and isolated CAE. Methods: All patients who underwent coronary angiography between January 2009 and June 2018 were investigated retrospectively. Of 16 240 patients, 232 patients with isolated CAE (141 males) and 247 age- and gender-matched control subjects (130 males) with normal coronary angiography (NCA) were enrolled in this study. Baseline demographic and laboratory data were obtained from the hospital database. The severity of isolated CAE was determined according to the Markis classification, vessel count and diffuseness of ectasia. Results: Patients with angiographic isolated CAE had significantly elevated white blood cell (WBC) and eosinophil counts and ELR values compared to patients with NCA [8.11 ± 1.75 vs 7.49 ± 1.80 × 109 cells/l, p < 0.0001; 0.22 (0.13-0.32) vs 0.19 (0.12-0.28) × 109 cells/l, p = 0.02; 0.11 (0.06-0.17) vs 0.08 (0.05-0.12), p < 0.0001. The ELR value for Markis I was significantly higher than for Markis IV (p = 0.04), and three-vessel isolated CAE was significantly higher than onevessel isolated CAE (p = 0.04). Additionally, the ELR value for diffuse ectasia (Markis class I, II and III) was significantly higher compared to focal (Markis class IV) ectasia (p = 0.02). In receiver operating characteristics (ROC) analyses, it was determined that an ELR value > 0.099, measured in isolated CAE patients at application, had a predictive specificity of 60.3% and a sensitivity of 56.5% (area under the curve: 0.604, 95% confidence interval: 0.553-0.655, p < 0.0001). Conclusions: Patients with isolated CAE had higher blood eosinophil counts and ELR. Furthermore, the ELR was significantly correlated with severity of isolated CAE. These findings demonstrate that ELR may have a significant role in the aetiopathogenesis of isolated CAE. WOS:000587657400003 Q4

Background Dyslipidaemia is a major modifiable risk factor for atherosclerotic cardiovascular disease. At the time the study was conducted, guidelines recommended a low-density lipoprotein cholesterol (LDL-C) target of less than 1.8 mmol/l and a reduction of at least 50% if the baseline LDL-C was between 1.8 and 3.5 mmol/l in patients with either very high cardiovascular risk or established atherosclerosis. In South Africa, there is a paucity of data on attainment of LDL-C goal in patients with very high cardiovascular risk who are on maximum tolerated statin with or without ezetimibe. Objective The aim was to assess the percentage of very high cardiovascular risk South African patients with dyslipidaemia not reaching an LDL-C goal of less than 1.8 mmol/l, despite maximum tolerated statin with or without ezetimibe. Methods This was a multi-centre, observational, cross-sectional study conducted at 15 private healthcare sector sites and one public sector site. Adults (> 18 years) with very high cardiovascular risk of familial hypercholesterolaemia receiving stable, maximum-tolerated statin therapy for at least four weeks prior to their latest lipid profile were enrolled into the study, and electronic case report forms were completed after written informed consent was provided. LDL-C goal attainment was modelled, first assuming an increase in the statin dose to the registered maximum, followed by the addition of ezetimibe or a PCSK9-inhibitor. Results In total, 507 patients were screened, of whom 492 were eligible for study participation. One patient was excluded from the analysis because of a missing LDL-C value. Most participants were male (male 329, 67%; female 162, 33%). Most patients were either obese (223, 46.0%) or overweight (176, 36.3%). Hypertension and diabetes mellitus were frequent co-morbidities and were found in 381 (77.6%) and 316 (64.4%) patients, respectively. Eighty (16.3%) patients reported current smoking. Only 68 (13.8%) patients were taking ezetimibe in addition to a statin. Reasons for not using ezetimibe included no requirement for ezetimibe in the opinion of the treating physician (229, 48.7%), cost (149, 31.7%), Physician's choice (39, 8.3%), or other (53, 11.3%). Only 161 (32.8%) of the patients attained their goal LDL-C level. In our modelling analysis, increasing the statin dose to the registered maximum and adding ezetimibe brought an additional 34.5% of patients to goal, while adding a PCSK9-inhibitor, irrespective of any other changes to lipid-lowering therapy brought over 90% of not-at-goal patients to goal. Conclusions Most study participants were not at LDL-C goal despite maximum-tolerated statin, highlighting the need for treatment intensification in this high-risk population. Although intensifying treatment by adding a PCSK9-inhibitor brought more patients to goal, the initial addition of ezetimibe would be more reasonable, given the cost of PCSK9-inhibitors.

OBJECTIVE: The aim of this study was to investigate the effects of heroin addiction, which is an important social and health problem, on right cardiac function. METHODS: A total of 85 individuals were included in the study. The study group comprised 45 patients smoking heroin and the control group was 40 healthy individuals with no drug addiction. Patients injecting heroin were excluded. Echocardiographic evaluation of patients using heroin was performed and compared with those in the control group. RESULTS: The right ventricle and pulmonary artery diameters in the heroin group were found to be higher compared to the control group. The myocardial performance index (MPI) was higher and more abnormal in the heroin group (0.48 ± 0.22 vs 0.39 ± 0.11, p < 0.05) whereas isovolumic acceleration (IVA) of the right ventricle was significantly lower in the heroin group (2.92 ± 0.69 vs 3.4 ± 0.68 m/s2, p < 0.01). No significant difference was observed between the groups with regard to the right ventricular ejection fraction (RVEF) (59.6 ± 2.5 vs 60.6 ± 2.3%, p = 0.08), tricuspid annular plain systolic excursion (TAPSE) (24.1 ± 4.2 vs 24.5 ± 2.4 mm, p = 0.7), tissue Doppler imaging S wave (TDI-S) (13.7 ± 2.1 vs 13.8 ± 2.1 cm/s, p = 0.86) and right ventricular fractional area change (RVFAC) (42.7 ± 8.3 vs 43.9 ± 3.5%, p = 0.4). Multivariate and univariate regression analyses revealed independent correlation between the pulmonary artery diameter and RVIVA, and heroin addiction. CONCLUSION: Heroin addiction negatively affected right ventricular function and more attention should be paid to the cardiac function of these patients.

The objective was to investigate and evaluate the short-term efficacy and safety of levosimendan in patients with chronic systolic heart failure. Forty-nine patients with chronic systolic heart failure during acute decompensation were randomly divided into a levosimendan group (26 cases) and a control group (23 cases). The control group received only routine treatment, while the levosimendan group received a levosimendan bolus with a load of 12 µg/kg, in addition to the same routine treatment as the control group. After 48 hours of treatment, N-terminal pro B-type natriuretic peptide (NT-proBNP) levels in the levosimendan group were significantly lower than those in the control group. In addition, the left ventricular ejection fraction (LVEF) and New York Heart Association (NYHA) cardiac function scores of the levosimendan group were significantly higher and more improved than those of the control group seven days after treatment, but there was no significant difference in the left ventricular end-diastolic diameter between the two groups. Furthermore, 48 hours after treatment, there were no significant differences in potassium, haemoglobin, haematocrit and creatinine levels between the levosimendan and control groups. During the whole hospitalisation, there was one case of sudden death in the control group and one case of palpitations in the levosimendan group, and no hypotension or severe hypokalaemia occurred in either group. Levosimendan significantly improved NT-proBNP and LVEF in patients with chronic systolic heart failure, and improved NYHA cardiac function classification without significant cardiovascular events. Levosimendan is therefore effective and safe in the short-term treatment of chronic systolic heart failure.

Aim The aim of this study was to evaluate the temporal relationship between mitochondrial oxidative phosphorylation and mitophagy in rat hearts subjected to ischaemia/reperfusion. Measurements were made at specific points during the experimental protocol (snapshot approach) and by assessments of mitophagic flux, using chloroquine pre-treatment. Methods Isolated working rat hearts were subjected to 25 or 30 minutes of global ischaemia/10 minutes of reperfusion. Half of each group received chloroquine (10 mg/kg, intraperitoneally) one hour before experimentation. Mitochondria were isolated after stabilisation, ischaemia and reperfusion, and oxidative phosphorylation was measured polarographically. Mitochondrial mitophagy markers were detected by Western blot analysis. Results Mitochondrial oxygen uptake (state 3) and oxidative phosphorylation rate were reduced by ischaemia and increased by reperfusion. Chloroquine pre-treatment increased both parameters. Using a snapshot approach, exposure to ischaemia ± reperfusion had little effect on mitochondrial PINK1, Parkin and p62/SQSTM1 expression. Ischaemia reduced Rab9 expression, and reperfusion upregulated the phosphor DRP1, phosphor/total DRP1 ratio and Rab9 levels. Chloroquine significantly reduced PINK1, p62/SQSTM1, Rab9 and particularly Parkin expression during reperfusion, without an effect on mitochondrial total and phospho DRP1 levels. Conclusions Ischaemia/reperfusion-induced changes in mitochondrial oxidative phosphorylation function occurred concomitantly with changes in mitophagic flux. Pre-treatment with chloroquine profoundly affected mitochondrial function as well as the pattern of mitophagy during ischaemia/reperfusion.

Introduction Mechanical heart valve (MHV) prostheses increase the risk of thromboembolic complications. While warfarin anticoagulation reduces this risk, its use increases the risk of bleeding. We sought to estimate the rate of thromboembolic and bleeding complications among patients with MHVs at a tertiary hospital in Botswana. Factors associated with bleeding and thromboembolic complications are also described. Methods This retrospective cohort study involved a cohort of patients with MHV at Princess Marina Hospital who were operated on before September 2017. The study documented bleeding and thromboembolic events since the valve replacement, patients' demographic information, co-existing medical conditions, drug history and details of valve replacement. Using the recent international normalised ratio (INR) results, each patient's time in therapeutic range (TTR) was calculated to assess the level of anticoagulation control. Results The study enrolled 142 patients with a mean (SD) age of 42 (12) years and a median (IQR) duration since valve replacement of four years (1.8-10.0). The median (IQR) TTR was 29.8% (14.1-51.0) and only 14.8% of the patients had an optimal anticoagulation control. The rates of major bleeding and thromboembolic complications were 1.5 per 100 person-years and 2.80 per 100 person-years, respectively. A longer duration of warfarin use was associated with an increased risk of both bleeding (p = 0.008) and thromboembolic complications (p = 0.01). Conclusions Bleeding and thromboembolic complications were common in MHV prosthesis patients in this study. Long duration of anticoagulation, albeit sub-optimal control, was a risk factor for bleeding and thromboembolic complications in these patients. Therefore, long-term efforts are necessary to address these complications and possibly improve the quality of life of these patients.

Objective This study compared resting blood pressure (BP) using ambulatory BP monitoring (ABPM) responses in two groups of subjects trained in land exercise (LE) and aquatic exercise (AE), and assessed post-exercise hypotension (PEH) using ABPM, after land- and aquatic-based exercises. Methods ABPM (24 hours) was used to measure the baseline BP in elderly hypertensive women trained in LE and AE and the PEH induced by exercise. For this, 40 subjects were evaluated at rest and after a land- or aquatic-based exercise session (aerobic: 75% of reserve heart rate combined with resistance exercise). Results The daytime BP was lower for AE [systolic BP (SBP) 124 ± 1.0 mmHg, diastolic BP (DBP) 70 ± 1.5 mmHg] than for LE (SBP 134 ± 0.9 mmHg, DBP 76 ± 0.9 mmHg), but there were no differences at night-time. The aquatic exercise-induced PEH in the second hour was maintained at the 24th hour post-exercise. For land exercise-induced PEH, it was maintained at the 12th hour post-exercise. The SBP and DBP were lower at the 24th hour for AE than for LE. Conclusions Elderly hypertensive people trained in AE had lower baseline BP during the daytime. SBP and DBP values were lower for individuals trained in AE, and their PEH was more rapid and longer lasting after AE.

OBJECTIVES: Previous reports have suggested an association between hypothyroidism and macrovascular complications in type 2 diabetes (T2DM) but the association with microvascular complications is not well documented. This study aimed to determine whether there were significant differences in these complications in patients with T2DM with and without hypothyroidism. METHODS: This was a retrospective, cross-sectional, case– control study from a single centre specialising in diabetes in South Africa. T2DM was defined by American Diabetes Association criteria. The cases were all patients treated for hypothyroidism and the controls were clinically and biochemically confirmed euthyroid, who were under follow up between 1 January and 1 July 2016. Chronic kidney disease (CKD) was defined as an estimated glomerular filtration rate (eGFR) of < 60 ml/min, determined by the CKD-epidemiology collaboration equation (CKD-EPI) and/or albumin/creatinine ratio > 3 mg/mmol. Diabetic retinopathy (DR) was defined as the presence of aneurysms, bleeds, exudates and new vessel formation on the retina examined by an ophthalmologist. Diabetic peripheral neuropathy (DPN) was defined as the presence of symptoms, loss of 128-Hz sensation and abnormal 10-gm monofilament. Cardiovascular disease (CVD) was defined as the presence of major adverse cardiovascular events (MACE). RESULTS: There were 148 cases and 162 controls. Compared to the controls, the cases were older (65.6 vs 59.4 years, p < 0.00001), more likely to be female (67.6 vs 39.5%, p < 0.0001) and white (89.2 vs 79.6%, p = 0.02), have a lower HbA1c level (7.5 vs 8.2%, p = 0.0001), eGFR (64.4 vs 72.7 ml/min, p = 0.0006) and triglyceride level (2.18 vs 2.55 mmol/l, p = 0.04), have a higher high-density lipoprotein cholesterol level (1.13 vs 1.02 mmol/l, p = 0.001), a longer duration of diabetes (14.8 vs 11.6 years, p = 0.001) and using fewer antidiabetic agents (1.82 vs 2.19, p = 0.001). There was a higher prevalence of CKD (44 vs 57.8%, p = 0.03) and CVD (59.3 vs 45.3, p = 0.06), and a trend towards higher DR (66.7 vs 47.6, p = 0.09). There was no difference in body mass index, hypertension, low-density lipoprotein cholesterol level (all patients received statin therapy), DPN and amputations. After adjusting for confounding factors, there was no association between CKD and DR, and hypothyroidism, but the trend to association with CVD persisted (OR 1.97. p = 0.07). CONCLUSIONS: Hypothyroidism in T2DM was not associated with microvascular disease after adjusting for confounding factors. There was a nearly two-fold risk of CVD. The study is limited by the retrospective and observational design.

OBJECTIVE: To investigate whether salidroside (Sal) protected the rat heart from exhaustive exercise-induced injury by inducing nuclear factor erythroid 2-related factor 2 (Nrf2) expression. METHODS: Forty-eight male Sprague-Dawley rats were divided into four groups (n = 12 rats per group): the control, the exhaustive swimming (ES) group, the low-dose Sal plus acute exhaustive swimming (SLE) group, and the high-dose Sal plus acute exhaustive swimming (SHE) group. In the SLE and SHE groups, 15 and 30 mg/kg Sal were administered, respectively, once a day. The rats in the control and ES groups were administered the same amount of physiological saline, respectively, once a day. On the 14th day, the rats in the ES, SLE and SHE groups underwent exhaustive swimming training once. Then cardiac function parameters and electrocardiograms were recorded. Biomarkers of myocardial injury in the serum and oxidative stress factors in the myocardial tissue were evaluated using ELISA tests. The levels of Nrf2, nuclear Nrf2 and Kelch-like ECH-associated protein 1 (Keap1) messenger RNA and proteins were assessed in the myocardium using q-PCR and Western blotting, respectively. RESULTS: Compared to the control group, the ES group showed remarkable increases in serum brain natriuretic peptide (BNP), cardiac troponin I (cTnI) and reactive oxygen species levels, but significant decreases in catalase and glutathione levels (p < 0.05). Compared to the ES group, the Sal treatment decreased serum BNP and cTnI levels and alleviated the changes in levels of oxidative stress-related factors. After treatment with Sal, nuclear and intracellular levels of Nrf2 protein were increased in the myocardial cells, while the level of Keap1 protein was decreased (p < 0.05). CONCLUSION: Sal protected the heart from exhaustive exerciseinduced injury, and it may improve cardiac function and cardiac bioelectricity in exhausted rats by inducing Nrf2 expression.

Background This article aims to explain the rationale and design for developing an evidence-based scorecard to monitor country-level implementation of the 71st World Health Assembly resolution on rheumatic fever and rheumatic heart disease (RHD) in Africa. Rationale A scorecard provides a simple and reliable tool for tracking progress over time and establishing accountability mechanisms. Methods Development of the scorecard will incorporate engaging RHD stakeholders identified and categorised at a country level. We will conduct individual interviews to understand the barriers and facilitators to implementing the resolution. The Delphi technique will facilitate structured group discussions to develop appropriate indicators. Indicators will be linked to the resolution's goals to create strategic lines of action, to inform the scorecard. The scorecard will be quantitatively validated in real-life settings. Discussion We deem that the rigor of the development process of this study will produce an evidence-based scorecard that is fit for purpose across Africa.

BACKGROUND: During pulmonary arterial hypertension (PAH)- targeted therapies for patients with idiopathic pulmonary arterial hypertension (IPAH), regular follow up to evaluate treatment efficacy is essential. Serum biomarkers can reflect various pathobiological processes in IPAH and have the advantages of being non-invasive, simple to carry out and low cost. The aim of our study was to evaluate whether serum biomarkers could serve as non-invasive markers to reflect haemodynamic changes after PAH-targeted therapies in patients with IPAH. METHODS: A total of 31 eligible patients aged 38.1 ± 12.1 years (25 were female) were included in this study. Changes in haemodynamic parameters and several serum biomarkers (cardiac markers, serum uric acid, high-sensitivity C-reactive protein, hepatic and kidney function markers) were compared before and after at least six months of PAH-targeted therapies. The time interval between the blood assays and right heart catheterisation was within five days. RESULTS: After at least six months of PAH-targeted therapies, the N-terminal pro-brain natriuretic peptide (NT-proBNP) level decreased from 579 (191–905) to 135 pg/ml (60–395) (p < 0.01), high-sensitivity cardiac troponin T (hsTnT) level decreased from 0.009 (0.006–0.012) to 0.007 ng/ml (0.005– 0.01) (p < 0.01), and serum uric acid level decreased from 381.5 ± 131.4 to 327.2 ± 110.0 μmol/l (p = 0.011). The change in NT-proBNP level was positively correlated with changes in pulmonary vascular resistance (r = 0.538, p < 0.01) and mean pulmonary arterial pressure (r = 0.440, p = 0.013). The change in hsTnT level was positively correlated with the change in mean right atrium pressure (r = 0.504, p < 0.01). The change in serum uric acid level was negatively correlated with that of cardiac index (r = –0.471, p < 0.01). CONCLUSION: NT-proBNP, hsTnT and serum uric acid levels can be used as non-invasive tools for evaluating the efficacy of PAH-targeted medications for IPAH patients. The role of these biomarkers in the follow up should be emphasised.

Background Tetralogy of Fallot (TOF) is the leading cyanotic congenital heart disease. We commenced open-heart surgery at the Obafemi Awolowo University Teaching Hospitals Complex (OAUTHC), Ile-Ife, Nigeria in 2016. Objectives To review the incidence, pattern, management and treatment outcomes of TOF at the OAUTHC. Methods A retrospective audit was undertaken of hospital records, including echocardiograms of patients with TOF seen from January 2016 to February 2020 at the Paediatric Cardiology Unit, OAUTHC. Results Seventy-two patients (37 boys and 35 girls) aged 0.17-22 years had TOF. Thirty-three (45.8%) had surgery; 31 (93.9%) corrective surgery and two (6.1%) a modified Blalock-Taussig shunt. Complications following surgery included cardiac dysfunction, post-transfusion malaria, pulmonary regurgitation, pericardial effusion and death (15%). Thirty-nine (54.2%) patients had conservative medical management. Complications included polycythaemia and thrombotic stroke, and 14 (35.9%) patients died. Conclusions TOF is associated with significant morbidity and mortality in developing countries. Early and safe corrective surgery is desirable.

Background Little is known about the clinical profile and management of patients with acute coronary syndromes (ACS) in the South African public sector. Methods We conducted a retrospective study of patients presenting with ACS to a secondary-level healthcare facility in Cape Town during a one-year period to study the clinical profile and management of these patients. Results Among the 214 patients in this cohort, 48 (27.5%) had ST-segment elevation myocardial infarction (STEMI), 43 (24.7%) had non-ST-segment elevation myocardial infarction and 83 (47.7%) unstable angina pectoris. We identified high rates of >12-hour delays in first medical contact after symptom onset (46%) and inaccurate ECG diagnosis of STEMI (29.2%), which were associated with low rates of thrombolysis (39.6%). High rates of non-adherence and ACS recurrence were also observed. Conclusion To address the local challenges in ACS management highlighted in this study, we propose the development of a regional referral network prioritising access to expedited care and primary reperfusion interventions in ACS.

Introduction Chronic inflammation promotes aortic valve calcification. It is known that epicardial fat is a source of inflammation. The aim of this study was to investigate the relationship between epicardial fat thickness, cardiac conduction disorders and outcomes in patients undergoing transcatheter aortic valve implantation (TAVI). Methods During a three-year period, 45 patients with severe aortic stenosis who underwent TAVI were recruited to the study. Data were collected retrospectively. Epicardial fat was defined as the adipose tissue between the epicardium and the visceral pericardium. Mean epicardial fat thickness was determined by multi-slice computed tomography, which was performed before the procedure. Results The average thickness of epicardial fat was 13.06 ± 3.29 mm. This study failed to reveal a significant correlation between epicardial fat thickness and post-procedural left bundle branch block, right bundle branch block, paravalvular aortic regurgitation and pacemaker implantation rates (p > 0.05). Conclusions The results of this study failed to show a significant relationship between epicardial fat thickness, cardiac conduction disorders and outcomes, however further studies with larger sample numbers are required to explore the relationship.

OBJECTIVES: The aim of this study was to determine the success rates of left atrial radiofrequency cardiac ablation for atrial fibrillation during heart valve surgery. METHODS: This was a three-year retrospective study of 53 patients who had valve surgery and cardio-ablation. Immediate and long-term overall outcomes were analysed at three, six, nine, 12 and 24 months. The results were tested for significance by comparing to a chance outcome (50:50 probability) using the Z-test for the normal approximation of the binomial distribution. RESULTS: A total of 56.9% of patients converted immediately to sinus rhythm, with that number increasing over time. Pre-operative poor ejection fraction was the only predictor of low success rates following ablation. Long-term rhythm was determined by the patient’s rhythm between three and six months. CONCLUSIONS: Concomitant left atrial ablation during valve surgery is effective in treating atrial fibrillation. Routine use of anti-arrhythmic medication after surgical ablation is not recommended.

OBJECTIVE: The aim of this study was to analyse the understanding of heart failure (HF) by the general public and find the best way to raise people’s awareness of this issue. METHODS: This prospective, survey-based registry involved 501 people over 18 years old. The survey included information on the participants’ gender, education, place of residence, medical history, involvement in any area of healthcare, and having relatives suffering from HF. The participants were divided into three age groups, young (< 40 years), middle aged (40–65 years) and elderly (> 65 years), and two groups, depending on whether the participant’s relative was a HF sufferer or not. CONCLUSION: Despite an increasing prevalence of heart failure, the general public still has insufficient knowledge on symptoms, causes and treatment methods of this disease. New methods of disseminating information should be considered in order to stop an escalating problem of low awareness of heart failure.