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Small-vessel disease (SVD) is an important subset of the population with coronary artery disease which may account for up to 30–70% according to different series. The challenges of SVD interventions are first to detect the true small-vessel size along with the true length of the lesion by intravascular imaging, then to decide about the interventional strategies as there is difficulty in delivering the stent to the lesion, dissections, under expansions of the stent during percutaneous coronary intervention with increased incidence of restenosis, and need for revascularization on the long term as well. Special attention is to be paid to this subset of patients of SVD as the treatment strategies need to be improvised than simple balloon dilatation or stenting with drug-eluting stents. At present, drug-coated or eluting balloon emerging as an improvised strategy for treating these patients with intravascular imaging. This article concentrates on the latest updates in SVD treatment.

Critical appraisal of scientific publications is an important skill that must be acquired by the contemporary cardiologists. The preliminary step to a good critical appraisal is a sound understanding of the important aspects of a trial. In this issue of the Ibrahim Cardiac Medical Journal’s “Journal Scan”, we are first providing a brief summary of late-breaking randomised controlled trials published and presented at American College of Cardiology (ACC) Scientific Sessions 2021, and EuroPCR 2021, both of which were held virtually. We look at the important points to be derived from both potentially practice-changing trials, as well as key neutral trials of relevance in the above-mentioned meetings. In keeping with a critical appraisal format, each trial is introduced with its background and aims, PICO (Population, Intervention, Comparator, Outcomes) Criteria, main results and concluding remarks. Ibrahim Card Med J 2021; 11 (1): 86-95

Racism and racial bias influence the lives and cardiovascular health of minority individuals. The fact that minority groups tend to have a higher burden of cardiovascular disease risk factors is often a result of racist policies that restrict opportunities to live in healthy neighbourhoods and have access to high-quality education and healthcare. The fact that minorities tend to have the worst outcomes when cardiovascular disease develops is often a result of institutional or individual racial bias encountered when they interact with the healthcare system. In this review, we discuss bias, discrimination, and structural racism from the viewpoints of cardiologists in Canada, the United Kingdom, and the US, and how racial bias impacts cardiovascular care. Finally, we discuss proposals to mitigate the impact of racism in our specialty. RÉsumÉ: Le racisme et la discrimination raciale influent sur la vie et la santé cardiovasculaire des membres des minorités. Le fait que les groupes minoritaires tendent à présenter plus de facteurs de risque de maladies cardiovasculaires est souvent le résultat de politiques racistes qui restreignent les possibilités de vivre dans des quartiers sains et d’avoir accès à une éducation et à des soins de santé de grande qualité. Le fait que les minorités tendent à afficher les pires résultats lorsqu’une maladie cardiovasculaire se manifeste est souvent le résultat d’une discrimination raciale systémique ou individuelle à l’œuvre dans leurs interactions avec le système de santé. Dans le présent article, nous traitons de la discrimination et du racisme structurel du point de vue de cardiologues du Canada, du Royaume-Uni et des États-Unis. Nous abordons également l’incidence de la discrimination raciale sur les soins cardiovasculaires. Enfin, nous proposons certaines mesures visant à atténuer l’effet du racisme dans notre spécialité.

Objective: To evaluate in-hospital and 1-year outcomes of primary percutaneous coronary intervention (PPCI) in elderly patients with ST-elevation myocardial infarction (STEMI). Methods: All patients aged ≥ 65 years presenting with STEMI and undergoing PPCI at Ibrahim Cardiac Hospital & Research Institute, Bangladesh from January 2015 to August 2017 were consecutively included in the study based on predefined eligibility criteria. Data pertaining to angiographic characteristics, procedural variables, in-hospital and 1-year outcome variables were recorded and analyzed with the help of descriptive statistics and Chi-square Test. Results: The mean age of the patients was 69.2 ± 5.2 (range: 65-85) years with male to female ratio being 4:1. The patients were predominantly diabetic (78%) followed by hypertensive (74%) and dyslipidaemic (70%) smoker (54%). Half of the patients presented with anterior myocardial infarction (MI), 30% had inferior MI, 12% with right ventricular (RV) extension and 8% with inferolateral extension. About one-quarter (24%) had arrhythmia with complete heart block (CHB). The culprit arteries were LAD (50%), followed by RCA (42%) and LCx (8%). Nearly half (46%) had single vessel disease, 34% double and 20% triple vessel disease. Majority (80%) received a single stent and 20% required two stents with mean diameter and length of the stents were 2.9 ± 0.4 mm and 27.3 ± 7.9 mm respectively. Intracoronary eptifibatide was used in 20% cases. In terms of left ventricular ejection fraction (LVEF), 58% and 28% had mild and moderate LV systolic dysfunction respectively. The mean duration of hospital stay was 4.0 ± 1.9 days. About 18% required repeat hospitalization. Overall, 7(14%) patients died (4 during their stay in the hospital due to cardiac cause and 3 during follow up due to non-cardiac causes). At 1 year follow up, in-stent restenosis was seen in 1 case followed by target vessel revascularization (TVR). The Association between age and outcome revealed that advanced age (age ≥ 75 years) was an important predictor of in-hospital and one-year outcome with Relative Risk (RR) of having unfavorable outcome was > 5-fold (95% CI: 1.6-19.5) in patients of advanced age than that in patients of age < 75 years (p = 0.008). Conclusion: Primary PCI is a feasible treatment option for elderly Bangladeshi patients presenting with STEMI with fewer in-hospital and 1-year follow up deaths. Adverse cardiovascular events are even less. Advanced age (age ≥75 years) is an important determinant of adverse cardiovascular events including mortality, probably because of more medical co-morbidities associated with advanced age. Ibrahim Card Med J 2020; 10 (1&2): 18-26

BACKGROUND: The extent to which health care systems have adapted to the COVID-19 pandemic to provide necessary cardiac diagnostic services is unknown.OBJECTIVES: The aim of this study was to determine the impact of the pandemic on cardiac testing practices, volumes and types of diagnostic services, and perceived psychological stress to health care providers worldwide.METHODS: The International Atomic Energy Agency conducted a worldwide survey assessing alterations from baseline in cardiovascular diagnostic care at the pandemic's onset and 1 year later. Multivariable regression was used to determine factors associated with procedure volume recovery.RESULTS: Surveys were submitted from 669 centers in 107 countries. Worldwide reduction in cardiac procedure volumes of 64% from March 2019 to April 2020 recovered by April 2021 in high- and upper middle-income countries (recovery rates of 108% and 99%) but remained depressed in lower middle- and low-income countries (46% and 30% recovery). Although stress testing was used 12% less frequently in 2021 than in 2019, coronary computed tomographic angiography was used 14% more, a trend also seen for other advanced cardiac imaging modalities (positron emission tomography and magnetic resonance; 22%-25% increases). Pandemic-related psychological stress was estimated to have affected nearly 40% of staff, impacting patient care at 78% of sites. In multivariable regression, only lower-income status and physicians' psychological stress were significant in predicting recovery of cardiac testing.CONCLUSIONS: Cardiac diagnostic testing has yet to recover to prepandemic levels in lower-income countries. Worldwide, the decrease in standard stress testing is offset by greater use of advanced cardiac imaging modalities. Pandemic-related psychological stress among providers is widespread and associated with poor recovery of cardiac testing.

Background: Percutaneous coronary intervention (PCI) to anomalous coronary arteries remain a challenge in current practice, but can be overcome with appropriate techniques and devices. The objective of this study is to explore the challenges and techniques for success in PCI of anomalous origin of right coronary artery from left sinus of Valsalva (RCA-LSV) through the trans-radial route. Methods: This study consisted of 13 patients who underwent PCI for an angiographically significant stenosis in RCA-LSV between November 2017 to March 2020. The procedural details including numbers of catheters used, access, hardware, techniques, duration of procedure, volume of contrast and complications were recorded and statistically analysed. Results: The most frequent site for RCA-LSV is at the level of left main stem (LMS) (53.8%), with 30.8% being just above the LMS level and 5.4% being just below the LMS level. Male to female ratio was 5.5:1. Mean age was 53.7±6.7 (range;42-64) years. 76.9% of our patients were diabetic, 92.3% hypertensive, 84.6% dyslipidaemic, smoker & CKD were 23.1% each. PCI was done successfully in 100% cases. Our default route was transradial for coronary angiography. Angioplasty was performed through trans-radial route in 92.3% and transfemoral in 7.7%, with a single case requiring switch over from radial to femoral route. The average number of guide catheters used was (2±1.0), (range:1-4). We used 4 guide catheters in 2 cases, while the rest of the cases were done by single guide catheter. The guide catheter hooked the coronary ostium selectively and off ostium in 46.2% cases each, while in 7.6% cases it was deeply engaged. Anchoring wire to enhance the guide support was used in 7.7% of cases. The mean duration of the procedure was 33.8 minutes (range: 15-65 minutes), the mean volume of contrast used was 61.5 (range:30-150) ml. We used single stent in 61 % cases and two stents in 39 % cases. Average stent diameter was 2.9 (range;2.5-3.50) mm, length was 28.6 (range;12-43) mm. From among a range of guides used for angioplasty, Judkin’s left (JL) and Judkin’s Right (JR) successfully cannulated the RCALSV in 76.9% & 23.1% respectively. We used Ikari Left (IL) guide catheter in RCA-LSV associated with subclavian tortuosity to enhance guide support. Majority of the lesions stented were of ACC/AHA classification of Type A & B lesions (38.5% each), followed by Type C (23%) lesion. Conclusion: To the best of our knowledge, this is the first report of transradial PCI to RCA-LSV in Bangladesh, describing our experiences and techniques, with locally available hardware. PCI of RCA-LSV through radial route is technically challenging but feasible with reasonable amount of contrast and radiation. Proper localization of ostium and selection of suitable guide catheter like JL or IL is the key to success. Bangladesh Heart Journal 2020; 35(1) : 28-38

Background & objective : Coronary artery bypass graft (CABG) surgery has given symptomatic and structural release of coronary atherosclerotic heart disease. CABG has been performed frequently for more than 30 years in Bangladesh. But there are no nationwide studies on the rate of survival in Bangladesh. The present study was undertaken to find the post CABG surgery survival outcomes and association between risk factors and survival over long time span. Methods: We studied 650 consecutive patients’ post-operative clinical data retrospectively and survival outcome data were collected prospectively who had CABG surgery from 2010 to 2015 in Ibrahim Cardiac Hospital & Research Institute. Of the 650 patients, 84(12.9%) died after a median follow up of 4.9 years. Demographic, clinical, operative and postoperative characteristics were then compared between survived and died patients to find the factors associated with survival. Result: Analysis revealed that younger patients were more likely to survive [RR = 1.1(95% CI = 1.0-1.2)] longer than those who have had their CABG at or > 55 years (p = 0.001). Males generally had a higher likelihood of survival [RR = 1.1(RR = 1.1(95% CI = 0.9-1.2)] than their female counterparts (p = 0.038). Non-diabetics tend to have a better survival [RR = 2.3(95% CI = 1.3-3.9)] than diabetics (p = 0.001). Non-smokers also have a higher chance of longer survival [RR = 1.5(95% CI = 0.9-2.2)] than the smokers. CABG patients without CKD enjoyed longer survival [RR = 1.4(95% CI = 0.9-2.2)] than CABG patients with CKD (p = 0.006). None of the operative and postoperative factors but hospital stay was associated with longer survival. The survived patients had a shorter mean hospital stay than the patients who died (p = 0.001). Analyses of the causes of death revealed heart disease to be the predominant cause (38%) followed by stroke (12%), CKD (8%) and other causes like cancer, liver disease etc. (42%). Conclusion: Younger, male, non-smoker, non-diabetic patients may enjoy long-term survival following CABG surgery. Prediction of long-term survival can be used to determine the most appropriate post-discharge care strategies. This would undoubtedly help both patients and doctors to implement behavioral and therapeutic modifications to optimize benefit from surgery. Ibrahim Card Med J 2019; 9 (1&2): 8-15

Background & objective: Coronary Artery Disease (CAD) is a devastating life-threatening condition which varies with respect to age and sex. In Bangladesh a large number of patients currently undergoes coronary angiography for a variety of indications. Due to physiological changes after menopause, the females are more prone to develop CAD. So, the risk factors and pattern of CAD in female are subject change with changing ages. The objective of this study was to compare the risk factors and pattern of CAD in female patients of different age groups. Methods: This cross-sectional analytical study was conducted at Ibrahim Cardiac Hospital & Research Institute (ICHRI), Dhaka, Bangladesh between September 2005 to August 2016. All female patients (n = 7,627) who underwent coronary angiography during the period were included. They were identified from ICHRI dedicated Cath-lab Database. The patients were divided into three groups based on their age (Group-I ≤45 years, Group-II from age 46 to age 60 and Group-III from age 60 years onwards). A stenosis of ≥ 70% in any of the three major coronary arteries like Left Anterior Descending (LAD), Right Coronary Artery (RCA) and Left Circumflex Artery (LCX) was considered as significant stenosis, while a stenosis of ≥ 50% in left main stem (LMS) was considered significant for left main disease. The data pertaining to their risk factors and angiographic profile were compared among the three age groups to find the association of risk factors and angiographic pattern of the CAD at different age groups. Result: All the risk factors (diabetes, hypertension, dyslipidaemia and CKD) demonstrated their significant presence in Group II and III compared to those in Group I, while they were almost identical between Group II and III. More than 40% of the patients were overweight in all age groups and around 20% were obese including a negligible proportion with morbid obesity. ST-segment elevation MI, NSTEMI (Non-ST-elevation myocardial infarction), prior MI (Myocardial infarction), and ALVF (Acute left ventricular failure) were significantly higher in Group III than the two other groups had. However, unstable angina was significantly higher in age-group I & II and atypical chest pain in Group I. Incidence of Single vessel disease (SVD) was considerably higher in group II. Double vessel diseases DVD), Triple vessel disease (TVD), LM disease was significantly higher in group III compared to two other groups. Normal CAG (Coronary angiography) finding was higher among group I, although it was not significantly different from other two groups. Conclusion: The study concluded that the prevalence of conventional risk factors including overweight/obesity is almost similar between middle-aged and elderly women, while they are significantly lower in early middle-aged group. The elderly women usually present with STEMI (ST-elevation myocardial infarction), non-STEMI, stable CAD, ALVF, while middle-aged women commonly present with UA (Unstable Angina) and early middle-aged women with atypical chest pain. Severe CAD including and LM disease is relatively common in elderly women than those in their early middle-aged and middle-aged cohorts. Coronary artery disease advances with advancing age. Health-care providers should not underestimate the cardiac health of women. Ibrahim Card Med J 2019; 9 (1&2): 60-66

The challenges to academic and professional development and career advancement of women in cardiology (WIC), imposed by the pandemic, not only impinge the female cardiologists' "leaky pipeline" but also make the "leakiness" more obvious. This consensus document aims to highlight the pandemic challenges WIC face, raise awareness of the gender equity gap, and propose mitigating actionable solutions derived from the data and experiences of an international group of female cardiovascular clinicians and researchers. This changing landscape has led to the need for highly specialized cardiologists who may have additional training in critical care, imaging, advanced heart failure, or interventional cardiology. Although women account for most medical school graduates, the number of WIC, particularly in mentioned sub-specialties, remains low. Moreover, women have been more affected by systemic issues within these challenging work environments, limiting their professional progression, career advancement, and economic potential. Therefore, it is imperative that tangible action points be noted and undertaken to ensure the representation of women in leadership, advocacy, and decision-making, and increase diversity in academia. Strategies to mitigate the negative impacts of the pandemic need to be taken during this COVID-19 pandemic to ensure WIC have a place in the field of Cardiology. 35212510

Graphical abstract

Vaccination coverage rates across Asian American subpopulations with atherosclerotic cardiovascular disease (ASCVD) and diabetes mellitus is not well-studied. We used data from the National Health Interview Survey (NHIS) from 2006 to 2018 and included participants with a history of ASCVD or diabetes. Vaccination coverage in White were compared with Chinese, Asian Indian, Filipino, and "other Asian" (Japanese, Korean, and Vietnamese) adults using univariable and multivariable logistic regression models. We included 50,839 participants, mean age 62.7 ± 0.1 years, 46.3% women, 89.1% US-born. Filipino (59%) and Asian Indian (56%) adults were less likely to receive influenza vaccine than "other Asians" (66%), Chinese (65%), and White (60%) participants (P0.001). In multivariable adjusted models, Chinese (OR = 1.66, 1.02-2.69), Asian Indian (OR = 1.50, 1.07-2.10), and "other Asian" ethnicity (OR = 1.81, 1.38-2.36) were associated with higher odds of receiving influenza vaccination compared with White. Influenza vaccine coverage remains suboptimal across all studied races/ethnicities.

Background: Limited contemporary data exist regarding the impact of SYNTAX score on procedural outcomes undergoing primary percutaneous coronary intervention(PCI) in acute STEMI patients. Objectives: To evaluate the significance of the SYNTAX score for predicting procedural outcome after primary PCI in patient with acute STEMI. Methods: This perspective observational study was conducted in the department of cardiology, National Institute of Cardiovascular Diseases, Dhaka, Bangladesh from September, 2015 to September, 2016. 42 patients with acute STEMI who underwent primary PCI were considered for the study. But 2 patients were excluded from the study due to failure of primary PCI. The patients were divided into two groups: Group I (low Syntax score d”22) and Group II (high Syntax score > 22). The Syntax score of all patients were calculated from an initial coronary angiogram before primary PCI. Procedural outcome was observed in between two groups. Results: Among study patients 57.5% were in SYNTAX score d”22 (Group I) and 42.5% were in SYNTAX score >22 (Group II). Among traditional cardiovascular risk factors diabetes was significantly more prevalent in the Group II than Group I ( 82.4% vs 34.8%, p  0.003). Angiographic profile revealed maximum (69.6% vs 17.6%) culprit lesion in LAD artery in Group I and maximum culprit lesion (64.7% vs 21.7%) in RCA in Group II, these were the statistically significant between Group I and Group II (P

Background & objective: Coronary artery disease (CAD) is increasingly prevalent among female population, particularly in South Asia, and a large number of female patients currently undergo coronary angiography for a variety of indications. The objective of this study was to investigate the clinical and angiographic characteristics of female patients undergoing coronary angiogram, in a tertiary cardiac center in Bangladesh. Methods: This retrospective observational study was conducted at Ibrahim Cardiac Hospital & Research Institute, Dhaka, Bangladesh during the period from 1st September 2005 to 31st August 2016. A total of 7,627 female patients who underwent coronary angiography were included. Obstructive coronary artery disease (CAD) was defined as a stenosis ≥70% in at least one of the three major coronary arteries or a stenosis ≥50% in left main stem. Result: Nearly two-thirds (64.4%) of patients comprised of age group of 41-60 years with mean age of the patients being 55.4 ± 10.2 years. Unstable angina (38.2%) was the commonest indication for coronary angiography followed by stable ischemic heart disease (25.1%), non-ST segment elevation myocardial infarction (12.8%), ST segment elevation myocardial infarction (9.3%), left ventricular failure (7.5%), post-myocardial infarction angina (6%) and atypical chest pain (1.3%). Over three quarters were hypertensive 68.3% were diabetic and 29% and dyslipidemiac. Over 40% of the patients were overweight and 20% were obese. On trans-thoracic echocardiography, 65.2% had normal left ventricular (LV) systolic function; 17.6% and 9.9% had mild and moderate LV systolic dysfunction respectively. Nearly 30% had normal epicardial coronary arteries on angiography, while 17.4%, 16.5% and 37.2% had triple vessel disease (TVD), double vessel disease (DVD) and single vessel disease (SVD) respectively. Following angiography, 33.4% were advised PCI, 30.2% optimal medical management and 15.3% CABG. A few (3.2%) were advised for revascularization either by CABG or PCI. Conclusion: Unstable angina is the most common indication for coronary angiography among Bangladeshi females. A clustering of risk factors for CAD such as hypertension, diabetes and overweight or obesity are observed in them. Of the obstructive CADs, SVD is the most frequent finding, indicating that females undergoing CAG are likely to have diffuse CAD, although left main disease is not uncommon in this population. Further comparative studies with matched male population are recommended to find the differences in clinical and angiographic findings with respect to sex. Ibrahim Card Med J 2017; 7 (1&2): 9-14

Background Early revascularization and treatment is key to improving clinical outcomes and reducing mortality in acute myocardial infarction (AMI). In low- and middle-income countries such as Bangladesh, timely management of AMI is challenging, with pre-hospital delays playing a significant role. This study was designed to investigate pre-hospital delay and its associated factors among patients presenting with AMI in the capital city of Dhaka. Methods This retrospective cohort study was conducted on 333 patients presenting with AMI over a 3-month period at two of the largest primary reperfusion-capable tertiary cardiac care centres in Dhaka. Of the total patients, 239(71.8%) were admitted in the National Institute of Cardiovascular Diseases, Dhaka and 94(28.2%) at Ibrahim Cardiac Hospital & Research Institute, Dhaka Data were collected from patients by semi-structured interview and hospital medical records. Pre-hospital delay (median and inter-quartile range) was calculated. Statistical significance was determined by Chi-square test. Multivariate logistic regression analysis was done to determine the independent predictors of pre-hospital delay. Results The mean age of the respondents was 53.8±11.2 years. Two-thirds (67.6%) of the respondents were males. Median total pre-hospital delay was 11.5 (IQR-18.3) hours with median decision time from symptom onset to seeking medical care being 3.0 (IQR: 11.0) hours. Nearly half (48.9%) of patients presented to the hospital more than 12 hours after symptom onset. On multivariate logistic regression analysis, AMI patients with absence of typical chest pain [OR 5.21; (95% CI: 2.5–9.9)], diabetes [OR: 1.7 (95% CI: 1.0–2.9)], residing/staying > 30 km away from nearest hospital at the time of onset [OR: 4.3(95% CI = 2.3–7.2)] and belonged to lower and middle class [OR: 1.9(95% CI = 1.0–3.5)] were significantly associated with pre-hospital delays. Conclusion Acute myocardial infarction (AMI) patients with atypical chest pain, diabetes, staying far away from nearest hospital and belonged to lower and middle socioeconomic strata were significantly associated with pre-hospital delays. The findings could have immense implications for improvements about timely reaching of AMI patients to the hospital within the context of their sociodemographic status and geographic barriers of the city.

Background & objective: Left bundle branch block (LBBB), resulting in an alteration of the normal sequence of activation in the left ventricle, commonly occurs in patients with underlying heart disease particularly coronary artery disease (CAD), but it may also be associated with progressive conducting system disease in an otherwise structurally normal heart. The aim of this study was to evaluate the clinical and angiographic profile of patients presenting with LBBB. Materials & Methods: This study was a cross-sectional observational study. A total of 542 patients of LBBB (as evident by ECG) who underwent coronary angiography from 1st September 2005 to 31st August 2016 were identified from the records of Cath Lab database of Ibrahim Cardiac Hospital & Research Institute and were selected for the study. LBBB was defined as a QRS complex duration ≥120 ms with a broad notched or slurred R wave in leads I, aVL, V5 and V6. Results: Majority (95.8%) of the patients was over 40 years of age with mean age being 59.7 ± 10.7 years (range: 25-95 years). Nearly 60% of the patients were male, 62.2% diabetic and 69.7% hypertensive. Over one-third (37.1%) of patients had moderate left ventricular (LV) systolic dysfunction (ejection fraction 30-44%) and 7% had severe LV systolic dysfunction. Over half (51.9%) had normal body mass index. Unstable angina (45.8%) was the most common indication for angiography. Other indications included non-ST segment elevation myocardial infarction (17.2%), ST segment elevation myocardial infarction (11.3%), stable coronary artery disease (SCAD) (9.8%), prior myocardial infarction (13.3%) and atypical chest pain (2.6%). Nearly 60% of the patients had obstructive coronary artery disease and the rest (40.6%) had normal epicardial coronaries on angiography. Among those with obstructive CAD, 4.1% had left main disease, 20.5% had triple vessel disease (TVD), 14.4% double vessel disease (DVD) and 9.5% single vessel disease (SVD). Conclusion: There is an optimum prevalence of CAD among LBBB patients, with TVD being predominant. LBBB cases with normal coronaries are no less. The latter cases suggest an alternative cause for LBBB. Thus, the usual diagnosis of CAD in patients with presumably new onset LBBB may be over-estimated in clinical practice. Ibrahim Card Med J 2016; 6 (1&2): 14-19

Background & objective: Middle East (ME) countries bear a heavy burden of coronary artery disease (CAD). A good number of Bangladeshi workers every year go to ME countries for earning their livelihood. To accustom with the changed working environment of the new country, they have to change their life-style, which among others includes food behavior as well. As such they become more vulnerable to non-communicable diseases or their risk factors like, diabetes, hypertension, dyslipidaemia and CAD than ever before. A sizable portion of these workers when return to their own country carry coronary artery diseases (CADs) at an unusually low age. But the health issues of the Bangladeshi expatriates in ME are yet not well reported. This study investigates if Bangladeshi workers while staying in ME countries are accustomed to unhealthy life-style which pushes them to increased risk for CADs. Materials & Methods: This cross-sectional study was conducted on 79 male Bangladeshi expatriates in ME with CAD who underwent coronary angiogram (CAG) in Ibrahim Cardiac Hospital and Research Institute (ICHRI) in the year 2015. Detailed demographic, behavioural (particularly food behavior during their stay in ME) clinical and angiographic profile of these patients were studied. The risk factors studied were life-style, BMI, smoking habit, presence of diabetes, hypertension, dyslipidaemia and family history of CAD. The outcome variable was severity of CAD in terms of single, double and triple vessel diseases. Results: The mean age the study subjects were 47.8 ± 8.5 years. Over half (53%) belonged to low income family and 73.4% were secondary or below secondary level educated. Among them 63.3% were diabetics, 58.2% hypertensive, 59.9% dyslipidaemic, 34.2% current smoker and 54.4% overweight or obese. Over 40% used to take food at restaurant regularly or frequently with 27% having excessive carbohydrate and 30% excessive fatty food including the traditional fatty meal ‘Kapsa’. These patients presented with stable angina (40.5%), unstable angina (8.9%) or had history of myocardial infarction (50.7%). Coronary angiogram revealed 43.0% with single vessel disease (SVD), 27.9% double vessel disease (DVD) and 29.1% triple vessel disease (TVD). Prevalence of smoking was significantly higher in TVDs (56.5%) than that in DVDs (27.3%) and SVDs (23.5%) (p = 0.043). Diabetes was also more frequently associated with TVDs than do with DVDs and SVDs (p = 0.007). Conclusion: Adopting healthy life-style and early screening and management of cardiovascular risk factors in these expatriates is crucial for long term favorable outcome. Ibrahim Card Med J 2016; 6 (1&2): 8-13

> ”…whether ‘tis nobler in the mind to suffer the slings of outrageous fortune, or take arms against a sea of troubles and by opposing, end them” Hamlet, William Shakespeare Coronavirus disease (COVID-19) is currently on a rampant second wave across the globe. The United Kingdom (UK) has the highest death rate in Europe.1 The UK also has the most diverse population in Europe: 14% of the UK population are from black, Asian and minority ethnic (BAME) groups known to have greater consequences of the COVID-19 infection and subsequent worse mortality.2 In an observational UK study comparing linked acute coronary syndrome data during the COVID-19 infection lockdown (February to May 2020) with the same time period in the preceding 3 years (2017–2019), Rashid and colleagues report troublesome findings. Specifically, higher in-hospital and 7-day mortality rates for acute myocardial infarction in BAME populations during the COVID-19 pandemic than in white populations.3 These disproportionate rates reflect alarming patterns of healthcare delivery to, and outcomes observed in, minority ethnic populations across the globe, and mirror the well-described disparities seen in multiethnic populations of the United States (USA).4 But do these differences qualify as race-based health inequities? Is the UK health service now complicit in the provision of disparate care? In their paper, Rashid et al report that BAME patients during COVID-19 lockdown were more likely to present with ST segment elevation myocardial infarction, out of hospital cardiac arrest and cardiogenic shock.3 These important differences in disease acuity might easily account for poorer outcomes and would direct focus towards healthcare-seeking behaviours, rather than disparate care, as targets of intervention. However, delays in the management of acute coronary syndrome presentations, a reduction in invasive angiography in non-ST segment elevation myocardial infarction and less …

Objective: Coronary arteries in diabetic patients were found to be narrower than in non-diabetic subjects. The aim of the study was to compare the coronary arteries diameter between diabetic and non-diabetic patients undergoing percutaneous coronary intervention (PCI) using stent diameter for greater accuracy.Methods: This was a randomized observational study. From a dedicated database, we retrospectively analysed all consecutive patients of both gender who underwent PCI in the cardiac catheterization laboratory of Ibrahim Cardiac Hospital and Research Institute, Dhaka, Bangladesh, from January 2011 to December 2012. Patients who required left main coronary artery stenting were excluded from this study. Patients were divided into two groups; diabetics and non-diabetics. We calculated the coronary artery diameter according to the diameter of the stent, achieved at the final pressure at which the stent was deployed. The diameter which was achieved at a given atmospheric pressure was taken from the attached booklet provided with the stent packaging. If post dilatation was required then the diameter achieved by the non-compliant balloon after post dilatation was taken as the reference diameter of the artery.Results: A total of 571 patients, 333 in diabetic and 238 in non-diabetic group were included in the study. Proximal segments of left anterior descending (LAD) coronary artery in diabetics and non-diabetics were 2.99±0.44 vs 3.14±0.50 mm (p=0.00) while mid and distal segments were 2.90±0.38 vs 3.10±0.42 mm (p=0.00) and 2.25±0.39 vs 2.42±0.45 mm (p=0.00) respectively. Various segments of proximal left Circumflex (LCx) coronary artery in diabetics and non-diabetics were 2.98±0.21 vs 3.01±0.25 mm (p=0.39) while distal circumflex were 2.35±0.40 vs 2.49±0.43 mm (p=0.00) respectively. Proximal segments of right coronary artery (RCA) in diabetic and nondiabetics were 3.0±0.28 vs 3.28±0.25 mm (p=0.00) while mid and distal segments were 2.97±0.26 vs 3.19±0.25 mm (p=0.00) and 2.43±0.51 vs 2.87±0.32 mm (p=0.00) respectively. The number of stents (1.34±0.87 vs 1.30±0.65; p=0.40) and type of stent utilized (DES & non DES: 87.3 & 12.7% vs 85.2 & 14.8%; p=0.50) between diabetic & non-diabetic groups were not significantly different; however the total stent length (23.1±13.3 vs 21.5±9.52 mm; p=0.03) in diabetic group was significantly longer.Conclusions: The diameter of LAD, distal circumflex and right coronary arteries were significantly narrower in diabetic than non-diabetic subjects.Bangladesh Heart Journal 2017; 32(1) : 23-28

Takayasu arteritis (TA) is a chronic granulomatous vasculitic disease of the aorta and its major branches, predominantly affecting young females of Asian origin. Also known as Aortic arch syndrome, the condition has been better documented as the ‘Pulse less disease’ leading to claudication, bruits, absent or reduced brachial or radial pulses and aortic incompetence. However, a ‘prepulseless’ stage of TA exists, characterized by non-specific constitutional symptoms, hypertension and raised inflammatory markers. We report the case of an 18- year-old Bangladeshi female presenting with hypertension, moderate to severe aortic regurgitation (AR) and fever, diagnosed and treated as a case of pre-pulseless TA.J Bangladesh Coll Phys Surg 2017; 35(2): 91-96

Tuberculosis (TB) and Human Immunodeficiency Virus (HIV) have been closely linked since the emergence of the Acquired Immune Deficiency Syndrome(AIDS). Worldwide, TB is the most common opportunistic infection affecting HIV-seropositive individuals,and it remains the most common cause of death in patients with AIDS. By producing a progressive decline in cell-mediated immunity, HIV alters the pathogenesis of TB, greatly increasing the risk of disease from TB in HIV-coinfected individuals, and leading to more frequent extrapulmonary involvement, atypical radiographic manifestations, and paucibacillary disease, which can impede timely diagnosis. Although HIV-related TB is both treatable and preventable, incidence continues to climb in developing nations, wherein HIV infection and TB are endemic and resources are limited. We report the case of a 45 year old gentleman who presented with generalized lymphadenopathy, whose lymphnode biopsy was consistent with TB; however following poor response to anti-TB treatment, he was found to be serologically positive for HIV.J Bangladesh Coll Phys Surg 2016; 34(3): 168-171

Multiple publications have addressed the under-representation of women in the cardiology workforce, and indeed in leadership positions and procedural subspecialities, despite gender parity among medical school graduates. The work–life balance does not appear to be the only determining factor since other specialties such as obstetrics have a adequate representation of women. Vlachadis Castles et al report the results from their online survey of 452 female doctors (both trainees and specialists) from Australia and New Zealand, 13% of whom were women in cardiology. Female cardiologists reported working longer hours and more on-call commitments; significantly fewer women in cardiology reported a balanced life, or that cardiology was family friendly or female friendly, despite a greater earning capacity and an overwhelming majority agreeing that they were professionally challenged whilst intellectually stimulated in their jobs. Our editorial addresses the deterrents to women in cardiology seeking leadership opportunities in all areas including academic, administrative and research positions.

Superior mesenteric artery (SMA) aneurysm is a rare vascular entity and may present with a wide range of symptoms. They are often symptomatic, presenting with thromboembolic intestinal angina. They have a high risk of rupture and may present with gastro-intestinal bleeding, associated with high morbidity and mortality. We report the case of a 14year-old boy who presented with chronic abdominal pain and weight loss, in which SMA aneurysm was diagnosed after radiological evaluation. He underwent successful excision of aneurysmal sac along with aorto-mesenteric bypass using polytetrafluoroethylene (PTFE) graft, and had an uneventful recovery.Cardiovasc. j. 2016; 8(2): 161-164

Williams Syndrome is described in children presenting with Supra-valvular Aortic Stenosis (SVAS) and typical dysmorphic 'Elfin facies' with characteristic neurocognitive profile. SVAS, a congenital narrowing of the ascending aorta, occurs sporadically but can also occur as a component of Williams Syndrome, with which it shares similar genetic microdeletion of the elastin gene on chromosome 7qll.23, responsible for the vasculopathy as well as certain morphological features of the syndrome. We report the case of a 5 year old girl, who presented with chest pain and a heart murmur, along with typical 'Elfinfacies', whose investigation led to the diagnosis of SVAS presenting with Williams Syndrome. Ibrahim Cardiac Med J 2014; 4(1): 42-47

not availableJ Bangladesh Coll Phys Surg 2015; 33(4): 232-234

not availableJ Bangladesh Coll Phys Surg 2015; 33(1): 55-57

not availableJ Bangladesh Coll Phys Surg 2014; 32: 241-243

not available DOI: http://dx.doi.org/10.3329/jom.v16i1.22371 J MEDICINE 2015; 16 : 64-66