Ghada Youssef

BACKGROUND: Worsening renal function is a frequent finding in patients with acute decompensated heart failure (ADHF) and is a powerful independent prognostic factor for adverse outcomes. The link between abdominal congestion and worsening renal function in such patients is not yet fully addressed.

OBJECTIVE: To evaluate the role of abdominal congestion in the early prediction of worsening renal function in hospitalized patients with acute decompensated heart failure.

METHODS: This was a prospective study that enrolled 100 patients with a diagnosis of ADHF and received intravenous diuretic therapy. Intra-abdominal pressure (IAP), splenic Doppler impedance indices and serum prouroguanylin were measured on admission, 24 h after admission and on discharge. Patients were then divided into 2 groups: those who developed WRF (WRF group), and those who did not (non-WRF group). Worsening renal function was defined as an increase in serum creatinine level ≥0.3 mg/dL above baseline admission value. Intrabdominal pressure was measured transvesically using standard Foley catheter. Splenic Doppler impedance indices (resistivity and pulsatility indices) were measured using splenic Doppler ultrasound.

RESULTS: Among recruited patients (age: 54.73 ± 13.1 years, 72% are male), there was a significant decline in IAP (6.67 mmHg vs 8.36 mmHg, p = 0.001) and significant rise in splenic resistivity index (0.69 vs 0.67, p = 0.002) before discharge compared to admission values. The median level of serum prouroguanylin before discharge showed significant decline compared to admission level (29.2 vs 34.6 ng/l, p = 0.006). WRF developed in 37 (37%) patients. Independent predictors of WRF during hospitalization were high splenic arterial resistivity index 24 h after admission, high intra-abdominal pressure (≥8 mmHg) 24 h after admission, and low LVEF on admission.

CONCLUSION: In ADHF patients receiving diuretic therapy, transvesical measurement of intra-abdominal pressure and splenic resistivity index by splenic Doppler early after admission can help to identify patients at increased risk of WRF near discharge.

BACKGROUND: Arterial stiffness is strongly linked to the pathogenesis of heart failure and the development of acute decompensation in patients with stable chronic heart failure. This study aimed to compare arterial stiffness indices in patients with heart failure with reduced ejection fraction (HFrEF) during the acute decompensated state, and three months later after hospital discharge during the compensated state.

RESULTS: One hundred patients with acute decompensated HFrEF (NYHA class III and IV) and left ventricular ejection fraction ≤ 35% were included in the study. During the initial and follow-up visits, all patients underwent full medical history taking, clinical examination, transthoracic echocardiography, and non-invasive pulse wave analysis by the Mobil-O-Graph 24-h device for measurement of arterial stiffness. The mean age was 51.6 ± 6.1 years and 80% of the participants were males. There was a significant reduction of the central arterial stiffness indices in patients with HFrEF during the compensated state compared to the decompensated state. During the decompensated state, patients presented with NYHA FC IV (n = 64) showed higher AI (24.5 ± 10.0 vs. 16.8 ± 8.6, p < 0.001) and pulse wave velocity (9.2 ± 1.3 vs. 8.5 ± 1.2, p = 0.021) than patients with NYHA FC III, and despite the relatively smaller number of females, they showed higher stiffness indices than males.

CONCLUSIONS: Central arterial stiffness indices in patients with HFrEF were significantly lower in the compensated state than in the decompensated state. Patients with NYHA FC IV and female patients showed higher stiffness indices in their decompensated state of heart failure.

BACKGROUND: Atrial fibrillation is the most commonly encountered arrhythmia. Several antiarrhythmic agents are effective in restoring and maintaining sinus rhythm.

AIM OF THE WORK: To compare the efficacy and rapidity of conversion of recent onset atrial fibrillation using oral propafenone versus intravenous infusion of amiodarone.

METHODS: The study included 200 patients with recent onset atrial fibrillation. Patients were equally divided into 2 groups; group A where intravenous infusion amiodarone was given and group B where oral propafenone was administrated. The effectiveness and the time needed for conversion of atrial fibrillation to sinus rhythm were compared in both groups.

RESULTS: The success of conversion of atrial fibrillation to sinus rhythm was 83% in group A and 85% in group B, p-value = 0.699. The time elapsed from drug administration till conversion of atrial fibrillation was 9.07 ± 5.04 hours in group A versus 3.9 ± 1.54 hours in group B, p-value = 0.001. In both groups, patients who showed failed conversion had a significantly larger left atrial diameter and a significantly higher high sensitivity C-reactive protein (hsCRP) level.

CONCLUSION: Oral propafenone was faster than parenteral amiodarone in the conversion of recent onset atrial fibrillation to sinus rhythm. Patients with failed conversion had a bigger left atrial diameter and a higher hsCRP when compared to patients with successful conversion.

BACKGROUND: Hypertensive patients' compliance to the clinic's follow-up visits is associated with a better blood pressure control. The aim of this study was to detect the reasons of non-compliance to office visits in Egyptian hypertensive patients.

RESULTS: This is an observational, prospective, cross-sectional research study where patients were enrolled from the registry of the specialized hypertension clinics of 9 university hospitals. Those who attended less than 3 office visits, throughout the registry period, were considered non-compliant and were contacted through the phone. A simple questionnaire was prepared, which included questions about the reasons of non-compliance to follow up. There were 3014 patients eligible for inclusion in this study but only 649 patients (21.5%) completed the questionnaire. Patients claimed that the reasons of non-compliance to the follow up visits in the specialized hypertension clinics were as follows: 444 patients (68.4%) preferred to follow up elsewhere mostly in pharmacies, 53 patients (8.2%) claimed that the healthcare service was unsatisfactory, 94 patients (14.5%) were asymptomatic, and 110 patients (16.9%) said that the clinic was far from their homes. Despite non-compliance to office visits, 366 patients (59.2%) were compliant to their antihypertensive medications and 312 (48.1%) patients were compliant to salt restriction. About 34% of patients used herbs, mainly hibiscus, as adjuvant to their antihypertensive medications.

CONCLUSIONS: Reasons for non-compliance to office visits in hypertensive patients were either patient-related, or healthcare-related. To improve patients' compliance, physicians need to educate their patients about hypertension, patients need to follow their doctors' instructions as regard medications, salt restriction and scheduled office visits, and governments need to provide better and cheaper healthcare services.

Hypertension (HTN) is a common health problem and a major cardiovascular risk factor. Accurate measurement of blood pressure (BP) is mandatory for proper diagnosis and follow-up. The aim of this study was to evaluate the accuracy of mercury sphygmomanometer BP-measuring devices in public hospitals in Cairo, Egypt. Fifty public hospitals were included, and 10% of all mercury sphygmomanometer devices in each hospital were tested. Assessment included physical condition (e.g., mercury status, lid of the device, state of the rubber tubes), leakage rate, and calibration accuracy (as compared with a reference device). Devices were approved as accurate when they could successfully pass all three assessment tests. The total number of sphygmomanometer devices was 465. The overall pass rate was 1.3% (six devices). Twenty-five (5.2%) devices passed all of the physical tests, 50 (10.8%) passed the leakage test, and 50 (16.5%) passed the calibration accuracy test. There were 162 (34.8%) devices that showed a high leakage rate (>80 mmHg) and thus were not tested for calibration accuracy. In conclusion, most of the mercury sphygmomanometer devices in hospitals are neglected and not checked regularly for any errors. A plan should be made to gradually replace those failed devices with new, validated, and well-calibrated devices, preferably devices that do not contain mercury.

BACKGROUND: Chronic heavy cigarette smoking can affect the right ventriclular function. The standard echocardiography may not show early right ventricular functional changes, and a more sensitive measure is needed. The aim of this work was to evaluate the subtle subclinical effects of chronic heavy cigarette smoking on the right ventricular function. The study included 55 healthy asymptomatic chronic heavy cigarette smokers (smoking history of at least 5 pack-years and a daily cigarette consumption of at least 1 pack) and 35 healthy non-smoking control subjects. Patients underwent a full clinical assessment and a conventional as well as a 2D-speckle tracking transthoracic echocardiography of the right ventricle and data was compared between the 2 groups.

RESULTS: The mean age was 32.9 ± 7.2 years in smokers and 30.9 ± 7.9 years in non-smokers (p = 0.227). The 2 groups showed comparable conventional right ventricular systolic and diastolic functions. Smokers showed a significantly lower (less negative) right ventricular global longitudinal strain (- 19.0 ± 3.2% vs. - 24.5 ± 3.5%, p < 0.001). Patients with a higher daily cigarette consumption showed a poorer right ventricular global longitudinal strain (p = 0.014).

CONCLUSION: Chronic heavy cigarette smoking can adversely affect the right ventricular function, a finding that can be easily missed by conventional echocardiography and can be better detected by the right ventricular speckle tracking.

BACKGROUND: Blood pressure (BP) shows short-term variability within the 24 h, which can only be assessed with 24-h ambulatory blood pressure monitoring (ABPM). It is of utmost importance to control BP throughout the night to reduce incidence of hypertension complications. The purpose of this study is to evaluate the effect of timing and frequency of antihypertensive medications on the average nighttime and 24-h blood pressure control.

RESULTS: The study enrolled 199 hypertensive patients with controlled office blood pressure; 135 (67.8%) patients were on once daily antihypertensive medication (group 1) while 64 (32.2%) patients were on twice daily doses (group 2). The mean office SBP was 128.7 ± 7.8 mmHg in group 1 vs 129.6 ± 6.6 mmHg in group 2, (p = 0.421). ABPM readings for both groups were as follows: mean daytime SBP was 125.4 ± 11.6 mmHg vs 130.1 ± 12.9, p = 0.011; mean nighttime SBP was 117.0 ± 12.4 mmHg vs 123.1 ± 13.9 mmHg, p = 0.002, and mean 24-h SBP was 122.7 ± 10.6 mmHg vs 127.5 ± 12.0, p = 0.005. The prevalence of non-dipping was 68.9% in group 1 vs 70.3% in group 2 patients, p = 0.8 (the mean dipping ratio was 0.93 ± 0.08 in group 1 vs 0.95 ± 0.07 in group 2, p = 0.198). The prevalence of masked hypertension was higher in group 2 (28.1% vs 43.8%, p = 0.029).

CONCLUSION: Taking an extra antihypertensive pill at night did not show a decrease in the nighttime or the average 24H blood pressure in hypertensive patients with controlled office BP. On the contrary, patients who used twice daily antihypertensive medications seem to have higher nighttime and 24-h SBP, although the dipping ratio was comparable in both groups.

OBJECTIVES: The purpose of this work was to study maternal and fetal outcomes of women with uncorrected congenital heart disease (CHD).

BACKGROUND: Globally, CHD is an important cause of maternal morbidity and mortality in women reaching reproductive stage. Data are lacking from larger cohorts of women with uncorrected CHD.

METHODS: The 10-year data from the European Society of Cardiology EORP ROPAC (EURObservational Research Programme Registry of Pregnancy and Cardiac disease) registry of women with uncorrected CHD were analyzed.

RESULTS: Of 5,739 pregnancies in 53 countries, 3,295 women had CHD, 1,059 of which were uncorrected cases. Of these, 41.4% were from emerging countries. There were marked differences between the cardiac defects in uncorrected cases versus those in corrected CHD cases with primary shunt lesions (44.7% vs. 32.4%, respectively), valvular abnormalities (33.5% vs. 12.6%, respectively), and Tetralogy of Fallot and pulmonary atresia (0.8% vs. 20.3%, respectively; p < 0.001). In patients with uncorrected CHD, 6.8% were in modified World Health Organization risk class IV, approximately 10% had pulmonary hypertension (PH), and 3% were cyanotic prior to pregnancy. Maternal mortality and heart failure (HF) in the women with uncorrected CHD were 0.7% and 8.7%, respectively. Eisenmenger syndrome was associated with a very high risk of cardiac events (65.5%), maternal mortality (10.3%), and HF (48.3%). Coming from an emerging country was associated with higher pre-pregnancy signs of HF, PH, and cyanosis (p < 0.001) and worse maternal and fetal outcomes, with a 3-fold higher rate of hospital admissions for cardiac events and intrauterine growth retardation (p < 0.001).

CONCLUSIONS: Marked differences between cardiac conditions in pregnant women with uncorrected CHD and those in corrected CHD were found, with a markedly worse outcome, particularly in women with Eisenmenger syndrome and from emerging countries.

Data regarding the prevalence and characteristics of cardiovascular (CV) risk factors among Egyptian hypertensive patients are limited. Nationwide Specialized Hypertension Clinics (SHCs) were initiated for screening, investigating, and treating hypertensive patients. This study aimed to determine the clinical characteristics and the CV risk profile of hypertensive Egyptians attending SHCs. Data from 4701 hypertensive patients were collected from the SHCs of nine university hospitals representing the different geographical regions of Egypt. Data collection started in October 2014 and ended in September 2017. Data included blood pressure (BP) measurements, clinical data, socio-demographic characteristics, anthropometric measurements, and cardiovascular risk profiles. The patients' mean age was 51.8 ± 11.5 years, 58.7% were older than 50 years, and 58.5% were females. The mean office systolic and diastolic BP values were 145.2 ± 22.4 and 88.7 ± 12.9 mmHg, respectively. Regarding CV risk factors, 58.6% were obese, 23.4% were smokers, and 25.1% had diabetes mellitus. Obesity was more prevalent in females than males (65.7% vs. 53.0%, p < 0.001, respectively), while dyslipidaemia and smoking were significantly more common in male patients. The highest levels of BP and the highest global risk were observed in the inhabitants of the Delta region, despite their younger age. In conclusion, this study revealed a high prevalence of modifiable CV risk factors among a cohort of Egyptian hypertensive patients attending SHCs. The pattern of the risk factors across the different geographic regions may be attributed to rapid urbanization. Governmental and community-based approaches are needed for better control of hypertension and its associated CV risk factors.

BACKGROUND: Few data are available on the characteristics of infective endocarditis (IE) cases in Egypt. The aim of this work is to describe the characteristics and outcomes of IE patients and evaluate the temporal changes in IE diagnostic and therapeutic aspects over 11 years.

RESULTS: The IE registry included 398 patients referred to the Endocarditis Unit of a tertiary care facility with the diagnosis of possible or definite IE. Patients were recruited over two periods; period 1 (n = 237, 59.5%) from February 2005 to December 2011 and period 2 (n = 161, 40.5%) from January 2012 to September 2016. An electronic database was constructed to include information on patients' clinical and microbiological characteristics as well as complications and mortality. The median age was 30 years and rheumatic valvular heart disease was the commonest underlying cardiac disease (34.7%). Healthcare-associated IE affected 185 patients (46.5%) and 275 patients (69.1%) had negative blood cultures. The most common complications were heart failure (n = 148, 37.2%), peripheral embolization (n = 133, 33.4%), and severe sepsis (n = 100, 25.1%). In-hospital mortality occurred in 108 patients (27.1%). Period 2 was characterized by a higher prevalence of injection drug use-associated IE (15.5% vs. 7.2%, p = 0.008), a higher staphylococcal IE (50.0% vs. 35.7%, p = 0.038), lower complications (31.1% vs. 45.1%, p = 0.005), and a lower in-hospital mortality (19.9% vs. 32.1%, p = 0.007).

CONCLUSION: This Egyptian registry showed high rates of culture-negative IE, complications, and in-hospital mortality in a largely young population of patients. Improvements were noted in the rates of complications and mortality in the second half of the reporting period.