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