Open Access Original Research Article

Maternal Risk Factors Predisposing to Congenital Heart Disease: A study in South India

Jayavelan Ramkumar, Benjamin M. Sagayaraj, Nidhi Sharma

Cardiology and Angiology: An International Journal, Page 1-7
DOI: 10.9734/CA/2018/44524

Background: Congenital Heart Diseases (CHD) are defined as malformations of the heart and great vessels that develop in utero which may manifest at birth or later in childhood. They can be caused by numerous genetic and environmental factors. Genetic factors are nonmodifiable. However, identification of modifiable environmental risk factors is important to develop population based prevention strategies to reduce the incidence of CHD.

Objectives: The primary objective of the study was to find an association of the maternal lifestyles with CHD in new-borns. The secondary outcome of the study was to identify maternal factors that can be modified for the primary prevention of CHD.

Materials and Methods: This prospective study involved cardiovascular system examination of newborns after delivery in term gestations in 1394 singleton pregnancies. The maternal risk factors considered were age, prepregnancy Body Mass Index (BMI), consanguineous marriage, caffeine intake, diabetes, stress and intake of periconceptional Folic acid tablets.

Results: In this study, 22 (1.58%) out of 1394 pregnancies resulted in Congenital Heart Defects. Teenage pregnancy (p value= 0.0002), consanguineous marriage (p value=0.0004), overt diabetes mellitus (p value=0.0001), caffeine intake (p value=0.0031), prepregnancy BMI>24(p value=0.0001), maternal stress (p value<0.0001, history of previous congenital malformations (p value=0.004) and non intake of folic acid tablets in the first trimester (p value=0.0023 were found to be the most likely risk factor associated with CHD.

Conclusion: Community education programmes should be initiated in the high-risk population to prevent teenage pregnancies and consanguineous marriages. Maternal counseling for periconceptional control of blood glucose, adequate weight maintenance, intake of folic acid tablets, avoidance of stress and caffeine is needed to prevent CHD.


Open Access Original Research Article

Vascular Endothelial Growth Factor Study of Placenta in Preeclampsia

Jayavelan Ramkumar, Benjamin M. Sagayaraj, Nidhi Sharma

Cardiology and Angiology: An International Journal, Page 1-9
DOI: 10.9734/CA/2018/43655

Background: Preeclampsia is defined as new onset hypertension and albuminuria in previously normotensive pregnant women after 20 weeks of pregnancy. There is no cure; management is reliant on a structured antenatal surveillance programme and antihypertensives. Recent advances in immune histochemistry study of placenta have elucidated an increased Vascular Endothelial Growth Factor (VEGF) expression in various placental bed disorders like recurrent pregnancy loss, preeclampsia, fetal growth restriction, preterm and abruption placenta. Increased release of VEGF family proteins has been attributed to atherosis and placental hypoxia. However, some studies have found normal VEGF concentrations in placenta in these disorders of feto-maternal interphase.

Objectives: The study aims to analyse the VEGF expression in placental biopsy from preeclampsia and normotensive pregnancies.

Materials and Methods: This prospective study involved the gross and immune histology examination of human placenta after 31-40 weeks gestation period in 20 singleton preeclampsia pregnancies. Twenty placentas of normotensive pregnancies were taken as controls.

Results: In the present study, VEGF density was more in the placentas from preeclampsia pregnancies as compared to placenta from a normal pregnancy. The mean weight of placenta was smaller in preeclampsia group. Additionally, the fetal capillaries were also small in diameter and lumen was collapsed. The pulsatility index of uterine artery supplying the placenta was also higher in preeclampsia pregnancies. The high velocity blood flow can mechanically damage the tender fetal villi floating in the intervillous space. This damage collapses the fetal capillaries as evidenced by the smaller diameter of fetal capillaries in the placental biopsy.

Conclusion: Placental hypoxia in cases of preeclampsia is a potent stimulus for VEGF expression. Nevertheless, the increased VEGF expression should be seen in the light of collapsed fetal vessels in a small placenta.


Open Access Original Research Article

Plasma and Erythrocyte Membrane Plasmalogens in Patients with Coronary Heart Diseases Undergoing Percutaneous Intervention

Takeshi Arita, Taku Yokoyama, Shohei Moriyama, Kei Irie, Mitsuhiro Fukata, Keita Odashiro, Toru Maruyama, Seira Hazeyama, Shiro Mawatari, Takehiko Fujino, Koichi Akashi

Cardiology and Angiology: An International Journal, Page 1-11
DOI: 10.9734/CA/2018/44602

Aims: Plasmalogens are unique phospholipid of biological membrane and is considered to play a potent role of intrinsic antioxidant. Atherosclerosis is associated with oxidative stress, but the correlation between plasmalogens and atherosclerosis is debatable. Therefore, this study aimed to assess the plasma and erythrocyte membrane phospholipids profile in patients with coronary heart diseases (CHD) undergoing percutaneous coronary intervention (PCI).

Place and Duration of the Study: Vascular laboratory of Heart Center, Kyushu University Hospital, Fukuoka, Japan, from February to August 2016.

Methodology: The plasma concentrations and erythrocyte membrane contents of phospholipids were quantified in patients with CHD (n = 30, group A) and age-matched controls (n = 38, group B) using high-performance liquid chromatography with evaporative light scattering detection method.

Results: Plasma concentrations of plasmalogens in group A were significantly lower than those in group B. Similar findings were obtained from relative contents of plasmalogens in the erythrocyte membrane. Multiple regression models for plasmalogens yielded phospholipids other than plasmalogen as determinants of plasmalogens.

Conclusions: This cross-sectional study indicated that plasma and erythrocyte membrane plasmalogens are reduced in patients with CHD undergoing PCI. Further longitudinal studies are required to elucidate the clinical role of intrinsic plasmalogens as a laboratory marker of oxidative stress and extrinsic plasmalogens as a novel therapy for atherosclerosis.


Open Access Original Research Article

Does Testosterone Therapy Increase Risk of Cardiovascular Events among Men? A Meta-analysis

Nader Makki, Wassef Karrowni

Cardiology and Angiology: An International Journal, Page 1-16
DOI: 10.9734/ca/2018/v7i421317

Importance: There has been increasing interest in use of testosterone therapy (TT) beyond patients with hypogonadism to include younger men without documented hormone measurements for the purpose of improving libido, sexual function, bone density, and body mass. However, there is no conclusive data about safety of TT due to lack of adequately powered randomized clinical trials (RCTs) specifically designed for this purpose.

Objective: To examine the overall risk of cardiovascular events associated with TT via meta-analysis of published randomized and observational studies.

Data Sources: We searched MEDLINE, EMBASE, CINAHL, the Cochrane Controlled Trials Register and the National Institute of Health Clinical database from 1966 to 2014.

Study Selection: Out of the initial 2,800 studies identified, we obtained a total of 34 studies for detailed analysis after applying our inclusion/exclusion criteria. Two reviewers used eligibility criteria to assess all titles, abstracts, and full texts and resolved disagreements by discussion.

Data Extraction and Synthesis: One reviewer did data abstractions and quality assessments, which were confirmed by a second reviewer. Data were then collected and analyzed using random and fixed effect model, as appropriate. Risk estimates were extracted as adjusted hazard ratios (HRs) from included studies.

Main Outcome and Measures: Association of TT with cardiovascular events as a primary endpoint and association of TT with ischemic heart disease, all-cause mortality and cerebrovascular events as secondary endpoints.

Results: TT was associated with increased incidence of cardiovascular events (adjusted hazard ratio (HR) = 1.41, 95% CI = 1.19-1.67, p = 0.0004), all-cause mortality (adjusted HR = 1.29, 95% CI = 1.03-1.62, p = 0.02), and ischemic heart disease (adjusted HR=1.51, 95% CI = 1.05-2.18, p = 0.02) but there was no clear association with cerebrovascular events (adjusted HR=0.91, 95% CI = 0.66-1.25, p=0.54).  Subgroup analyses of our primary endpoint by study type (randomized versus observational studies) did not change our results (adjusted HR=1.40, 95% CI = 1.05-1.87, p = 0.02 and adjusted HR=1.54, 95% CI = 1.09-2.17, p = 0.01 respectively). Additional analysis using meta-regression and sensitivity analyses to account for factors such as history of prior CV events, indication for TT and duration of follow up did not change our results. However, we did notice lack of association between CV events and Intramuscular testosterone.

Conclusions and Relevance: TT may be associated with an increased risk of all-cause mortality, cardiovascular events, and ischemic heart disease. These findings support the need for an adequately powered randomized study.


Open Access Original Research Article

Vectorcardiographic Investigation of Brugada ECG Unmasked by Recording at Higher Intercostal Space

Takeshi Arita, Shioto Yasuda, Taku Yokoyama, Shohei Moriyama, Kei Irie, Mitsuhiro Fukata, Keita Odashiro, Toru Maruyama, Koichi Akashi

Cardiology and Angiology: An International Journal, Page 1-12
DOI: 10.9734/CA/2018/45362

Aims: Brugada syndrome is characterised by ST segment elevation in right precordial leads and associated sometimes with idiopathic ventricular fibrillation leading to sudden cardiac death. Although ECG recording at higher intercostal space unmasks Brugada syndrome, the vectorcardiographic (VCG) mechanisms of this unmasking remain unknown.

Place and Duration of Study: Noninvasive ECG laboratory of Heart Center, Kyushu University Hospital, Fukuoka, Japan, from November 2013 to April 2015.

Methodology: Twelve-lead digital ECG was recorded at standard (4th) and higher (3rd and 2nd) intercostal space in 5 patients with Brugada syndrome. The ECG data were transformed automatically to the VCG data based on the corrected three orthogonal Frank leads (X, Y and Z) and three vector loops of P, QRS and T waves were constructed and projected to the three (horizontal, frontal and right sagittal) orthogonal planes.

Results: ST elevation in the standard right precordial leads (V1 to V3) was augmented by the 12-lead ECG recorded at higher intercostal space. Saddle back ST elevation was often converted to coved type ST elevation by this invent. QRS loop was open in all 5 patients, and the maximum J-point vector showed right anterosuperior direction, whereas T loop showed left anteroinferior direction. The J-point vector faced toward and the maximum T vector faced backward the right precordial ECG electrodes, which was accentuated by shifting them to the higher intercostal space.

Conclusion: Unmasking of Brugada ECG was explained well even in this small-sample study by the spatial relationship between the orientations of ST-T vector and the standard right precordial ECG electrodes positioned at the higher intercostal space.


Open Access Original Research Article

Cardiovascular Health and Disease Risk Status in Type II Diabetics

I. C. Ezema, R. N. Ativie, M. A. Omoirri, U. A. Ezugwu, O. B. Ugwele

Cardiology and Angiology: An International Journal, Page 1-6
DOI: 10.9734/CA/2018/45274

Often linked with several complications and comorbidities, studies have shown Diabetes mellitus (DM) as a common, chronic disease across the globe. This study was designed to explore the CVD risk factors among Type 2 DM patients in a tertiary hospital in South-East, Nigeria. Seventy two (72) participants [36 hyperglycaemics (Type II DM) and 36 normoglycaemics (control)] were drawn from the University of Nigeria Teaching Hospital, Enugu State. Socio-demographic data, anthropometric parameters, percentage body fat and ankle-brachial indices were obtained. Other Variables such as age, height, weight, heart rate, body mass index (BMI) and waist-hip ratios (WHR) were recorded as well. The study found, using the one-way Analysis of variance (ANOVA), a significant difference (p < .05) in percentage body fat and heart rate between groups (hyperglycaemics and normoglycaemics). A gender-dependent significant difference was also observed in ankle-brachial index between normoglycaemics, with an accompanying insignificant difference for ankle-brachial index, BMI and WHR in both groups. Life style patterns with increased physical activity levels that will combat cardiovascular risks is highly recommended. The continuous monitoring of cardiovascular (Blood pressure, pulse rates) health indicators is also encouraged.

Open Access Original Research Article

Fetal Echocardiography: A Screening Tool for Congenital Heart Disease in Maternal Diabetes

Jayavelan Ramkumar, Nidhi Sharma

Cardiology and Angiology: An International Journal, Page 1-11
DOI: 10.9734/CA/2018/46200

Background: The imbalance of the adipoinsular axis has been shown recently to predispose to cardio renal syndromes. Epigenetics, which deals with the metabolic influences on genetic signaling, is a new concept. Diabetes during gestation can also cause an inflammatory response in placenta. The levels of leptin/adiponectin in the neonate of a mother with diabetes can affect post insulin signaling leading to fuel mediated teratogenicity. The reactive oxidative species generated at the maternal-fetal interface can alter inhibitory or permissive gene expression resulting in chromatin epigenetic remodeling of genes in multiple organs dysfunction, including the pancreas, kidney, heart, and the muscle. The fetal cardiac malformations can be mediated by these modifications of the transcriptome.

Objectives: The primary objective of the study was to explore the relationship between maternal type II diabetes mellitus and gestational diabetes with congenital heart disease in new-borns. The secondary outcome of the study was to do pre-conception counseling and emphasize the importance of peri-conceptional sugar control.

Materials and Methods: This prospective study involved cardiovascular system examination of 229 single pregnancies with pre-gestational and gestational diabetes (19 pregnant women were lost for follow up in control group). Two hundred twenty nine non-diabetic women of were taken as matched controls. The case and control group were comparable with no significant differences in maternal age, ethnicity and parity. Diabetic pregnant women were also offered fetal echocardiography at 24-28 weeks of gestation in second trimester.

Results: In this study, 1 out of 78 gestational diabetes and 7 out 132 pregnancies with type 2 diabetes mellitus resulted in Congenital Heart Defects. Overt diabetes mellitus (p value significant) as compared to gestational diabetes was found to be a more likely risk factor associated with CHD. There were two cases of Ventral Septal Defect (VSD) in non-diabetic pregnant women diagnosed postnatally.

Conclusion: Community education programmes should be initiated in high-risk population to promote better fetal surveillance in diabetic mothers for early in utero detection of cardiac defects. Maternal counseling for peri-conceptional control of blood glucose, adequate weight maintenance, intake of Insulin and exercise is needed to prevent CHD. Fetal echocardiography is a useful tool to screen high-risk fetus that require tertiary neonatal set up and emergency cardiac surgical interventions.