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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

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

> ”…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 …

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

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