Search results for: coronary artery bypass graft

Authors: Sally Shepherd, Jessica Wong, David Read

Abstract:

Traumatic brachiocephalic artery aneurysm is a rare injury that typically occurs as a result of a blunt chest injury. A 19-year-old female sustained a head-on, high speed motor vehicle crash into a tree. Upon release after 45 minutes of entrapment, she was tachycardic but normotensive, with a significant seatbelt sign across her chest and open deformed right thigh with weak pulses in bilateral lower limbs. A chest XR showed mild upper mediastinal widening. A CT trauma series plus gated CT chest revealed a grade 3a aortic arch transection with brachiocephalic pseudoaneurysm. Endovascular repair of the brachiocephalic artery was attempted post-presentation but was unsuccessful as the first stent migrated to the infrarenal abdominal aorta and the second stent across the brachiocephalic artery origin had a persistent leak at the base. She was transferred to Intensive Care for strict blood pressure control. She returned to theatre 5 hours later for a median sternotomy, aortic arch repair with an 8mm graft extraction, and excision of the innominate artery pseudoaneurysm. She had an uncomplicated post-operative recovery. This case highlights that brachiocephalic artery injury is a rare but potentially lethal injury as a result of blunt chest trauma. Safe management requires a combined Vascular and Cardiothoracic team approach, as stenting alone may be insufficient.

Keywords: blunt chest injury, Brachiocephalic aneurysm, innominate artery, trauma

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Authors: Adel Yasky, Waseem Al-Talalwah, Shorok Al Dorazi, Roger Soames

Abstract:

The internal pudendal artery is a standard branch of the anterior division of the internal iliac artery. The current study includes 41 cadavers to investigate the origin and branches of the internal pudendal artery and its clinical significances. The internal pudendal artery arose directly from the anterior division of the internal iliac artery in 48.3% while it arose indirectly in 48.5%. However, the internal pudendal artery arose from the posterior division of internal iliac artery in 1.6%. Moreover, it arose internal iliac artery bifurcation site in 1.6%. Further, the internal pudendal artery supplied the urinary bladder in 17.1%. Also, the internal pudendal artery supplied the rectum 33.5% respectively. It gave uterine and vaginal arteries in 9.4% and 7.8% respectively. Finally, it supplied the sciatic nerve via giving lateral sacral branch in 1.6%. Internists, surgeons and radiologists have to be aware of the variability to decrease iatrogenic injury. Therefore, unnecessary proximal ligation should be avoided at the site of indirect origin of the internal pudendal artery to prevent sciatic neuropathy. Further, intrapelvic bleeding as result of laceration of internal pudendal branches during hysterectomy, prostatectomy or proctectomy should be expected. Therefore, this study increases the awareness of surgeons leading to minimize iatrogenic faults,

Keywords: internal pudendal artery, inferior gluteal artery, superior gluteal artery, internal iliac artery, impotence, decreased libido

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Authors: Shazia Anwer Bukhari, Madiha Javeed Ghani, Muhammad Ibrahim Rajoka

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Objective: Biochemical, environmental, physical and genetic factors have a strong effect on the development of coronary disease (CAD). Plasma homocysteine (Hcy) level and DNA damage play a pivotal role in its development and progression. The aim of this study was to investigate the predictive strength of an oxidative stress, clinical biomarkers and total antioxidant status (TAS) in CAD patients to find the correlation of homocysteine, TOS and oxidative DNA damage with other clinical parameters. Methods: Sixty confirmed patients with CAD and 60 healthy individuals as control were included in this study. Different clinical and laboratory parameters were studied in blood samples obtained from patients and control subjects using commercially available biochemical kits and statistical software Results: As compared to healthy individuals, CAD patients had significantly higher concentrations of indices of oxidative stress: homocysteine (P=0.0001), total oxidative stress (TOS) (P=0.0001), serum cholesterol (P=0.04), low density lipoprotein cholesterol (LDL) (P=0.01), high density lipoprotein-cholesterol (HDL) (P=0.0001), and malondialdehyde (MDA) (P=0.001) than those of healthy individuals. Plasma homocysteine level and oxidative DNA damage were positively correlated with cholesterol, triglycerides, systolic blood pressure, urea, total protein and albumin (P values= 0.05). Both Hcy and oxidative DNA damage were negatively correlated with TAS and proteins. Conclusion: Coronary artery disease patients had a significant increase in homocysteine level and DNA damage due to increased oxidative stress. In conclusion, our study shows a significantly increase in lipid peroxidation, TOS, homocysteine and DNA damage in the erythrocytes of patients with CAD. A significant decrease level of HDL-C and TAS was observed only in CAD patients. Therefore these biomarkers may be useful diagnosis of patients with CAD and play an important role in the pathogenesis of CAD.

Keywords: antioxidants, coronary artery disease, DNA damage, homocysteine, oxidative stress, malondialdehyde, 8-Hydroxy-2’deoxyguanosine

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Authors: Aziza Barnawi

Abstract:

Background: Regular exercise reduces risk factors associated with cardiovascular diseases. Over the past decade, exercise interventions have been introduced to reduce the risk of and prevent coronary artery disease (CAD). Elevated low-density lipoproteins (LDL) contribute to the formation of atherosclerosis, its manifestations on the endothelial narrow the coronary artery and affect the endothelial function. Therefore, flow-mediated dilation (FMD) technique is used to assess the function. The results of previous studies have been inconsistent and difficult to interpret across different types of exercise programs. The relationship between exercise therapy and lipid levels has been extensively studied, and it is known to improve the lipid profile and endothelial function. However, the effectiveness of exercise in altering LDL levels and improving blood flow is controversial. Objective: This review aims to explore the evidence and quantify the impact of exercise training on LDL levels and vascular function by FMD. Methods: Electronic databases were searched PubMed, Google Scholar, Web of Science, the Cochrane Library, and EBSCO using the keywords: “low and/or moderate aerobic training”, “blood flow”, “atherosclerosis”, “LDL mediated blood flow”, “Cardiac Rehabilitation”, “low-density lipoproteins”, “flow-mediated dilation”, “endothelial function”, “brachial artery flow-mediated dilation”, “oxidized low-density lipoproteins” and “coronary artery disease”. The studies were conducted for 6 weeks or more and influenced LDL levels and/or FMD. Studies with different intensity training and endurance training in healthy or CAD individuals were included. Results: Twenty-one randomized controlled trials (RCTs) (14 FMD and 7 LDL studies) with 776 participants (605 exercise participants and 171 control participants) met eligibility criteria and were included in the systematic review. Endurance training resulted in a greater reduction in LDL levels and their subfractions and a better FMD response. Overall, the training groups showed improved physical fitness status compared with the control groups. Participants whose exercise duration was ≥150 minutes /week had significant improvement in FMD and LDL levels compared with those with <150 minutes/week.Conclusion: In conclusion, although the relationship between physical training, LDL levels, and blood flow in CAD is complex and multifaceted, there are promising results for controlling primary and secondary prevention of CAD by exercise. Exercise training, including resistance, aerobic, and interval training, is positively correlated with improved FMD. However, the small body of evidence for LDL studies (resistance and interval training) did not prove to be significantly associated with improved blood flow. Increasing evidence suggests that exercise training is a promising adjunctive therapy to improve cardiovascular health, potentially improving blood flow and contributing to the overall management of CAD.

Keywords: exercise training, low density lipoprotein, flow mediated dilation, coronary artery disease

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Authors: Nawaf Al-Kharashi, Waseem Al-Talalwah, Shorok Al Dorazi, Roger Soames

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Superior gluteal artery is one of the largest branches of posterior division of the internal iliac artery. It passes between the lumbosacral and first sacral root to escape from the pelvic cavity through the grater sciatic foramen just above the piriformis. The current study includes 41 cadaver investigates the origin and branch of the superior gluteal artery and clarify the clinical significance. In present study, the superior gluteal artery arises from the posterior division of the internal iliac artery directly in 82.5% whereas it arises indirectly as from the sciatic artery in 15.9%. However, it is congenital absence in 1.6% which is compensated by sciatic artery. The sciatic nerve gains vascular supply from superior gluteal artery in two ways either during its course or giving lateral sacral artery in 27% and lumbar branches in 1.6%. It also supplies the adductors group and iliacus via giving obturator artery in 14.3% and in 1.6% respectively. The superior gluteal artery usually passes between lumbosacral trunk and first sacral root in 82.5% whereas it does not passes the sciatic roots as it arises behind them in 15.9%. With a variability of the superior gluteal artery origin, there is a variability of sciatic nerve roots supply. Further, the superior gluteal artery arising from sciatic artery behind the sciatic roots carries a high risk of intra-pelvic bleeding in case of posterior pelvic fracture. Prolonged ligation of the superior gluteal artery which gives lateral sacral artery may result in sciatic neuropathy. Therefore, surgeons have to be aware of the superior gluteal artery variation in origin, course and branches to reduce the iatrogenic faults.

Keywords: internal pudendal artery, inferior gluteal artery, superior gluteal artery, internal iliac artery. sciatic neuropathy, sciatic nerve

Procedia PDF Downloads 327

Authors: Anish Desai, Reshmi Pillai, Nilesh Mahajan, Hitesh Chopra, Vishal Mahajan, Ajay Grover, Ashish Kohli

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Surgical Site Infection (SSI) is hospital acquired infection of growing concern. This study presents the efficacy and cost-effectiveness of triclosan-coated suture, in reducing the burden of SSI in India. Methodology: A systematic literature search was conducted for economic burden (1998-2018) of SSI and efficacy of triclosan-coated sutures (TCS) vs. non-coated sutures (NCS) (2000-2018). PubMed Medline and EMBASE indexed articles were searched using Mesh terms or Emtree. Decision tree analysis was used to calculate, the cost difference between TCS and NCS at private and public hospitals, respectively for 7 surgical procedures. Results: The SSI range from low to high for Caesarean section (C-section), Laparoscopic hysterectomy (L-hysterectomy), Open Hernia (O-Hernia), Laparoscopic Cholecystectomy (L-Cholecystectomy), Coronary artery bypass graft (CABG), Total knee replacement (TKR), and Mastectomy were (3.77 to 24.2%), (2.28 to 11.7%), (1.75 to 60%), (1.71 to 25.58%), (1.6 to 18.86%), (1.74 to 12.5%), and (5.56 to 25%), respectively. The incremental cost (%) of TCS ranged 0.1%-0.01% in private and from 0.9%-0.09% at public hospitals across all surgical procedures. Cost savings at median efficacy & SSI risk was 6.52%, 5.07 %, 11.39%, 9.63%, 3.62%, 2.71%, 9.41% for C-section, L-hysterectomy, O-Hernia, L-Cholecystectomy, CABG, TKR, and Mastectomy in private and 8.79%, 4.99%, 12.67%, 10.58%, 3.32%, 2.35%, 11.83% in public hospital, respectively. Efficacy of TCS and SSI incidence in a particular surgical procedure were important determinants of cost savings using one-way sensitivity analysis. Conclusion: TCS suture led to cost savings across all 7 surgeries in both private and public hospitals in India.

Keywords: cost Savings, non-coated sutures, surgical site infection, triclosan-coated sutures

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Authors: Narottam Puri, Bishnu Panigrahi, Narayan Pendse

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Background: Clinical Outcomes are the globally agreed upon, evidence-based measurable changes in health or quality of life resulting from the patient care. Reporting of outcomes and its continuous monitoring provides an opportunity for both assessing and improving the quality of patient care. In 2012, International Consortium Of HealthCare Outcome Measurement (ICHOM) was founded which has defined global Standard Sets for measuring the outcome of various treatments. Method: Monitoring of Clinical Outcomes was identified as a pillar of Fortis’ core value of Patient Centricity. The project was started as an in-house developed Clinical Outcomes Reporting Portal by the Fortis Medical IT team. Standard sets of Outcome measurement developed by ICHOM were used. A pilot was run at Fortis Escorts Heart Institute from Aug’13 – Dec’13.Starting Jan’14, it was implemented across 11 hospitals of the group. The scope was hospital-wide and major clinical specialties: Cardiac Sciences, Orthopedics & Joint Replacement were covered. The internally developed portal had its limitations of report generation and also capturing of Patient related outcomes was restricted. A year later, the company provisioned for an ICHOM Certified Software product which could provide a platform for data capturing and reporting to ensure compliance with all ICHOM requirements. Post a year of the launch of the software; Fortis Healthcare has become the 1st Healthcare Provider in Asia to publish Clinical Outcomes data for the Coronary Artery Disease Standard Set comprising of Coronary Artery Bypass Graft and Percutaneous Coronary Interventions) in the public domain. (Jan 2016). Results: This project has helped in firmly establishing a culture of monitoring and reporting Clinical Outcomes across Fortis Hospitals. Given the diverse nature of the healthcare delivery model at Fortis Network, which comprises of hospitals of varying size and specialty-mix and practically covering the entire span of the country, standardization of data collection and reporting methodology is a huge achievement in itself. 95% case reporting was achieved with more than 90% data completion at the end of Phase 1 (March 2016). Post implementation the group now has one year of data from its own hospitals. This has helped identify the gaps and plan towards ways to bridge them and also establish internal benchmarks for continual improvement. Besides the value created for the group includes: 1. Entire Fortis community has been sensitized on the importance of Clinical Outcomes monitoring for patient centric care. Initial skepticism and cynicism has been countered by effective stakeholder engagement and automation of processes. 2. Measuring quality is the first step in improving quality. Data analysis has helped compare clinical results with best-in-class hospitals and identify improvement opportunities. 3. Clinical fraternity is extremely pleased to be part of this initiative and has taken ownership of the project. Conclusion: Fortis Healthcare is the pioneer in the monitoring of Clinical Outcomes. Implementation of ICHOM standards has helped Fortis Clinical Excellence Program in improving patient engagement and strengthening its commitment to its core value of Patient Centricity. Validation and certification of the Clinical Outcomes data by an ICHOM Certified Supplier adds confidence to its claim of being leaders in this space.

Keywords: clinical outcomes, healthcare delivery, patient centricity, ICHOM

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Authors: Ashwin Rai, Rajalakshmi Rai, Rajanigandha Vadgoankar

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Lingual artery is the chief artery of the tongue and the neighboring structures pertaining to the oral cavity. At the carotid triangle, this artery arises from the external carotid artery opposite to the tip of greater cornua of hyoid bone, undergoes a tortuous course with its first part being crossed by the hypoglossal nerve and runs beneath the digastric muscle. Then it continues to supply the tongue as the deep lingual artery. The aim of this study is to draw surgeon's attention to the course of lingual artery in this area since it can be accidentally lesioned causing an extensive hemorrhage in certain surgical or dental procedures. The study was conducted on 44 formalin fixed head and neck specimens focusing on the anatomic relations of lingual artery. In this study, we found that the lingual artery is located inferior to the digastric muscle and the hypoglossal nerve contradictory to the classical description. This data would be useful during ligation of lingual artery to avoid injury to the hypoglossal nerve in surgeries related to the anterior triangle of neck.

Keywords: anterior triangle, digastric muscle, hypoglossal nerve, lingual artery

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Authors: Scott Ashby, Emily Granger, Mark Connellan

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Objectives: 1) To identify if emergency coronary angiography improves outcomes in studies examining OHCA from assumed cardiac aetiology? 2) If so, is it indicated in all patients resuscitated following OHCA, and if not, who is it indicated for? 3) How effective are investigations for screening for the appropriate patients? Background: Out-of-hospital cardiac arrest is one of the leading mechanisms of death, and the most common causative pathology is coronary artery disease. In-hospital treatment following resuscitation greatly affects outcomes, yet there is debate over the most effective protocol. Methods: A literature search was conducted over multiple databases to identify all relevant articles published from 2005. An inclusion criterion was applied to all publications retrieved, which were then sorted by type. Results: A total of 3 existing reviews and 29 clinical studies were analysed in this review. There were conflicting conclusions, however increased use of angiography has shown to improve outcomes in the majority of studies, which cover a variety of settings and cohorts. Recommendations: Currently, emergency coronary angiography appears to improve outcomes in all/most cases of OHCA of assumed cardiac aetiology, regardless of ECG findings. Until a better tool for screening is available to reduce unnecessary procedures, the benefits appear to outweigh the costs/risks.

Keywords: out of hospital cardiac arrest, coronary angiography, resuscitation, emergency medicine

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Authors: M. Y. Lee, S. H. Park, S. M. Yu, H. S. Jo, C. G. Song

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Photoacoustic imaging is the imaging technology that combines the optical imaging with ultrasound. It also provides the high contrast and resolution due to optical and ultrasound imaging, respectively. For these reasons, many studies take experiment in order to apply this method for many diagnoses. We developed the real-time photoacoustic tomography (PAT) system using linear-ultrasound transducer. In this study, we conduct the experiment using swine and detect the blood of carotid artery and femoral artery. We measured the blood of femoral and carotid artery of swine and reconstructed the image using 950nm due to the HbO₂ absorption coefficient. The photoacoustic image is overlaid with ultrasound image in order to match the position. In blood of artery, major composition of blood is HbO₂. In this result, we can measure the blood of artery.

Keywords: photoacoustic tomography, swine artery, carotid artery, femoral artery

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Authors: Hala O. El-Mesallamy, Salwa M. Suwailem, Mae M. Seleem

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Visfatin and apelin are two new adipokines that recently gained a special interest in diabetes research. This study was conducted to study the interplay between these two adipokines and their correlation with other inflammatory and biochemical parameters in type 2 diabetic (T2D) postmenopausal women with CAD. Visfatin and apelin were measured by enzyme-linked immunoassay (ELISA). Visfatin was found to be significantly higher in the following groups: T2D patients without CAD, non-obese and obese T2D patients with CAD when compared to control group. Apelin was found to be significantly lower in non-obese and obese T2D patients with CAD when compared to control group. Visfatin and apelin were found to be significantly associated with each other and with other biochemical parameters. The current study provides evidence for the interplay between visfatin and apelin through the inflammatory milieu characteristic of T2D and their possible role in the pathogenesis of CAD complication of T2D.

Keywords: apelin, coronary artery disease, inflammation, type 2 diabetes, visfatin

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Authors: Ramya Rathan, Miral N. F. Salama

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The variations in the arteries have been drawing attention of anatomists for a long time because of their clinical significance. The brachial artery is the principal artery of the arm which is the continuation of the axillary artery from the lower border of the Teres Major. It terminates into the radial and ulnar arteries below the elbow joint at the neck radius. The present study aims at exploring the clinical significance of the high termination of the brachial artery. During the routine cadaveric dissection of the arm, for the undergraduate students of medicine at our university, we observed a high bifurcation of the radial and the ulnar artery at the midshaft of the humerus. The median nerve was seen passing between these two junctions. Further, the course and the relations of this artery were studied. The accurate knowledge regarding these kinds of variation in the blood vessels is mandatory for planning of designing. General physicians, surgeons and radiologists should keep in mind the variations in the branching pattern of the arteries in their daily medical, diagnostic and therapeutic procedures to avoid complications in diagnostic and surgical procedures.

Keywords: brachial artery, high termination, radial artery, ulnar artery

Procedia PDF Downloads 148

Authors: Waseem Al Talalwah, Shorok Al Dorazi, Roger Soames

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The inferior gluteal artery is a prominent branch of the anterior trunk of internal iliac artery. It escapes from the pelvic cavity through the greater sciatic foramen below the lower edge of piriformis. In gluteal region, it provides several muscular branches to gluteal maximus and articular branch to hip joint. Further, it provides sciatic branch to sciatic nerve. Current study investigates the origin of the inferior gluteal artery of 41 cadavers in Centre for Anatomy and Human Identification, University of Dundee, UK. It arose from the anterior trunk in 37.5% independently and 45.7% dependently as with the internal pudendal artery. Therefore, it arose from the anterior trunk in 83.2%. However, it found to be as a branch of the posterior trunk of internal iliac artery in 7.7% which is either a direct branch in 6.2% as or indirect branch in 1.5%. Beside the inferior gluteal artery arose with internal pudendal artery as from GPT of anterior division in 45.7%, it arose from the GPT arising from the internal iliac artery bifurcation site in 1.5%. Further, the inferior gluteal artery arose from the trunk with internal pudendal and obturator arteries in 1.5% referred as obturatogluteopudendal trunk. Occasionally, it arose from the sciatic artery in 1.5%. In few cases, the inferior gluteal artery found to be congenital absence in 4.6% which is compensated by the persistent sciatic artery. Therefore, radiologists have to aware of the origin variability of the inferior gluteal artery to alert surgeons. Knowing the origin of the inferior gluteal artery may help the surgeons to avoid iatrogenic sciatic neuropathy in pelvic procedures such as removing prostate or of uterine fibroid. Further, it may also prevent avascular necrosis of femur neck as well as gluteal claudication.

Keywords: inferior gluteal artery, internal iliac artery, sciatic neuropathy, gluteal claudication

Procedia PDF Downloads 329

Authors: K. H. Reeta, Bhavana Prasher, Mitali Mukerji, Dhwani Dholakia, Sangeeta Khanna, Archana Vats, Shivam Pandey, Sandeep Seth, Subir Kumar Maulik

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Introduction Research has demonstrated a connection between coronary artery disease (CAD) and genetics. We did a deep literature mining using both bioinformatics and manual efforts to identify the susceptible polymorphisms in coronary artery disease. Further, the study sought to validate these findings in an Asian population. Methodology In first phase, we used an automated pipeline which organizes and presents structured information on SNPs, Population and Diseases. The information was obtained by applying Natural Language Processing (NLP) techniques to approximately 28 million PubMed abstracts. To accomplish this, we utilized Python scripts to extract and curate disease-related data, filter out false positives, and categorize them into 24 hierarchical groups using named Entity Recognition (NER) algorithms. From the extensive research conducted, a total of 466 unique PubMed Identifiers (PMIDs) and 694 Single Nucleotide Polymorphisms (SNPs) related to coronary artery disease (CAD) were identified. To refine the selection process, a thorough manual examination of all the studies was carried out. Specifically, SNPs that demonstrated susceptibility to CAD and exhibited a positive Odds Ratio (OR) were selected, and a final pool of 324 SNPs was compiled. The next phase involved validating the identified SNPs in DNA samples of 96 CAD patients and 37 healthy controls from Indian population using Global Screening Array. ResultsThe results exhibited out of 324, only 108 SNPs were expressed, further 4 SNPs showed significant difference of minor allele frequency in cases and controls. These were rs187238 of IL-18 gene, rs731236 of VDR gene, rs11556218 of IL16 gene and rs5882 of CETP gene. Prior researches have reported association of these SNPs with various pathways like endothelial damage, susceptibility of vitamin D receptor (VDR) polymorphisms, and reduction of HDL-cholesterol levels, ultimately leading to the development of CAD. Among these, only rs731236 had been studied in Indian population and that too in diabetes and vitamin D deficiency. For the first time, these SNPs were reported to be associated with CAD in Indian population. Conclusion: This pool of 324 SNP s is a unique kind of resource that can help to uncover risk associations in CAD. Here, we validated in Indian population. Further, validation in different populations may offer valuable insights and contribute to the development of a screening tool and may help in enabling the implementation of primary prevention strategies targeted at the vulnerable population.

Keywords: coronary artery disease, single nucleotide polymorphism, susceptible SNP, bioinformatics

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Authors: N. Haj Salem, M. Belhadj, S. Ben Jomâa, S. Saadi, R. Dhouieb, A. Chadly

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Introduction: Sudden death in young is seen as a dramatic phenomenon requiring knowledge of its impact and determining their causes. Aim: We aim to study the epidemiological characteristics of sudden death in young, and to discuss the mechanism and the importance of autopsy in these situations. Material and methods: We performed a retrospective cohort study using autopsy data from the department of forensic medicine at the University Hospital of Fattouma Bourguiba, Monastir-Tunisia. A review of all autopsies performed during 23 years was done. In each case, clinical information and circumstances of death were obtained. We have included all sudden death in persons aged between 1 year and 35 years for the male and from one year to 45 years for female. We collected 312 cases of sudden death during the studied period. The collected data were processed using SPSS 20. The significance level was set at 0.05. Results: Thirty-two cases of cardiac ischemic sudden death have been collected. Myocardial infarction was the second cause of sudden death in young patients. There was a male predominance. The most affected subjects were aged between 25-45 years. The death occurred more frequently at rest. Coronary artery disease has been discovered in twenty-four cases (75%). A severe coronary artery disease was observed in two children with medical history of familial hypercholesterolemia. The myocardial infarction occurred in healthy coronary arteries in eight cases. An anomalous course of coronary arteries, in particular, myocardial bridging, was found in eight cases (25%). Toxicological screening was negative in all cases. Second cause of death was hypertrophic cardiomyopathy. Neurological and respiratory causes of death were implicated respectively in 10% and 15%. Conclusion: Identifying epidemiological characteristics of sudden death in this population is important for guiding approaches to prevention that must be based on dietary hygienic measures and the control of cardiovascular risk factors.

Keywords: autopsy, cardiac death, sudden death, young

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Authors: Eva Kirzner

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Based on outcome studies published over the past two decades, in 2018, the ACC/AHA published new guidelines for the management of hypercholesterolemia that incorporate the use of coronary artery calcium (CAC) scanning as a decision tool for ascertaining which patients may benefit from statin therapy. This use is based on the recognition that the absence of calcium on CAC scanning (i.e., a CAC score of zero) usually signifies the absence of significant atherosclerotic deposits in the coronary arteries. Specifically, in patients with a high risk for atherosclerotic cardiovascular disease (ASCVD), initiation of statin therapy is generally recommended to decrease ASCVD risk. However, among patients with intermediate ASCVD risk, the need for statin therapy is less certain. However, there is a need for new outcome studies that provide evidence that the management of hypercholesterolemia based on these new ACC/AHA recommendations is safe for patients. Based on a Pub-Med and Google Scholar literature search, four relevant population-based or patient-based cohort studies that studied the relationship between CAC scanning, risk assessment or mortality, and statin therapy that were published between 2017 and 2021 were identified (see references). In each of these studies, patients were assessed for their baseline risk for atherosclerotic cardiovascular disease (ASCVD) using the Pooled Cohorts Equation (PCE), an ACC/AHA calculator for determining patient risk based on assessment of patient age, gender, ethnicity, and coronary artery disease risk factors. The combined findings of these four studies provided concordant evidence that a zero CAC score defines patients who remain at low clinical risk despite the non-use of statin therapy. Thus, these new studies confirm the use of CAC scanning as a safe tool for reducing the potential overuse of statin therapy among patients with zero CAC scores. Incorporating these new data suggest the following best practice: (1) ascertain ASCVD risk according to the PCE in all patients; (2) following an initial attempt trial to lower ASCVD risk with optimal diet among patients with elevated ASCVD risk, initiate statin therapy for patients who have a high ASCVD risk score; (3) if the ASCVD score is intermediate, refer patients for CAC scanning; and (4) and if the CAC score is zero among the intermediate risk ASCVD patients, statin therapy can be safely withheld despite the presence of an elevated serum cholesterol level.

Keywords: cholesterol, cardiovascular disease, statin therapy, coronary calcium

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Authors: Waseem Al Talalwah, Shorok Al Dorazi, Roger Soames

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Persistent sciatic artery is a rare anatomical vascular variation resulting from a lack of regression of the embryonic dorsal axial artery. The axial artery is the main artery supplying the lower limb during development in the first trimester. The current research includes 206 sciatic artery cases in 171 patients between 1864 and 2012. It aims to identify the risk factor of sciatic artery aneurysm in congenital limb anomalies. Sciatic artery aneurysm was diagnosed incidentally in amniotic band syndrome (ABS) existing with no congenital anomaly in 0.7% or with double knee in 0.7%, with the tibia in 0.7% and with hemihypertrophy or soft tissue hypertrophy in 1.4%. Therefore, the current study indicates a relationship the same gene responsible for the congenital limb deformities may be responsible for non-regression of the sciatic artery. Furthermore, pediatricians should refer cases of congenital limb anomalies for vascular evaluation prior to corrective surgical intervention.

Keywords: amniotic band syndrome, congenital limb deformities, double knee, sciatic artery, sciatic artery aneurysm , soft tissue hypertrophy

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Authors: Mehrdad Sheikhvatan, Mohammad Ali Boroumand, Mehrdad Behmanesh, Shayan Ziaee

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Contradictory results have been obtained regarding the role of integrin, beta 3 (ITGB3) gene polymorphisms in occurrence of acute myocardial infarction (MI) in patients with coronary artery disease (CAD). Hence, we aimed to assess the association between 1565C/T polymorphism of ITGB3 gene and increased risk for acute MI in patients who suffered premature CAD in Iranian population. Our prospective study included 1000 patients (492 men and 508 women aged 21 to 55 years) referred to Tehran Heart center during a period of four years from 2008 to 2011 with the final diagnosis of premature CAD and classified into two groups with history of MI (n = 461) and without of MI (n = 539). The polymorphism variants were determined by PCR-RFLP technique by entering 10% of randomized samples and then genotyping of the polymorphism was also conducted by High Resolution Melting (HRM) method. Among study samples, 640 were followed with a median follow-up time 45.74 months for determining association of long-term major adverse cardiac events (MACE) and genotypes of polymorphisms. There was no significant difference in the frequency of 1565C/T polymorphism between the MI and non-MI groups. The frequency of wild genotype was 69.2% and 72.2%, the frequency of homozygous genotype was 21.3% and 18.4%, and the frequency of mutant genotype was 9.5% and 9.5%, respectively (p=0.505). Results were also similar when adjusted for covariates in a multivariate logistic regression model. No significant difference was also found in total-MACE free survival rate between the patients with different genotypes of 1565C/T polymorphism in both MI and non-MI group. The carriage of the 1565C/T polymorphism of ITGB3 gene seems unlikely to be a significant risk factor for the development of MI in Iranian patients with premature CAD. The presence of this ITGB3 gene polymorphism may not also predict long-term cardiac events.

Keywords: coronary artery disease, myocardial infarction, gene, integrin, beta 3, polymorphism

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Authors: Waseem Al Talalwah, Shorok Ali Al Dorazi, Roger Soames

Abstract:

The inferior gluteal artery is a largest branch of the anterior division of internal iliac artery. It escapes from the pelvic cavity through the greater sciatic foramen below the lower edge of piriformis. In gluteal region, it provides several muscular branches to gluteal maximus and articular branch to hip joint. Further, it provides sciatic branch to sciatic nerve. Present study explores the origin of the inferior gluteal artery of 41 cadavers in Centre for Anatomy and Human Identification, University of Dundee, UK. It arose directly from the anterior division of internal iliac artery in 39% and 45.7% indirectly as with the internal pudendal artery. Further, it arose indirectly from anterior division with internal pudendal and obturator arteries in 1.5% referred as obturatogluteopudendal trunk in 1.5%. Therefore, it arose from the anterior division of the internal iliac artery in 86.2%. However, it found to be as a branch of the posterior division of internal iliac artery in 7.7% which is either a direct branch in 6.2% as or indirect branch (as from the sciatic artery) in 1.5%. It neither arose from anterior or posterior division in 1.5% as from gluteopudendal trunk arising from the internal iliac artery bifurcation site. In few cases, the inferior gluteal artery found to be congenital absence in 4.6% which is compensated by the persistent sciatic artery. Therefore, radiologists have to aware of the origin variability of the inferior gluteal artery to alert surgeons. Knowing the origin of the inferior gluteal artery may help the surgeons to avoid iatrogenic sciatic neuropathy or gluteal claudication due to prolonged ligation in pelvic procedures such as removing prostate or of uterine fibroid.

Keywords: inferior gluteal artery, internal pudendal, sciatic nerve, sciatic artery, gluteal claudication, sciatic neuopathy

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Authors: Svetlana V. Topolyanskaya, Tatyana A. Eliseeva, Olga N. Vakulenko, Leonid I. Dvoretski

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Introduction: Limited data are available on osteoporosis in centenarians. Therefore, we evaluated bone mineral density in long-living patients with coronary artery disease (CAD). Methods: 202 patients hospitalized with CAD were enrolled in this cross-sectional study. The patients' age ranged from 90 to 101 years. The majority of study participants (64.4%) were women. The main exclusion criteria were any disease or medication that can lead to secondary osteoporosis. Bone mineral density (BMD) was measured by dual-energy X-ray absorptiometry. Results: Normal lumbar spine BMD was observed in 40.9%, osteoporosis – in 26.9%, osteopenia – in 32.2% of patients. Normal proximal femur BMD values were observed in 21.3%, osteoporosis – in 39.9%, and osteopenia – in 38.8% of patients. Normal femoral neck BMD was registered only in 10.4% of patients, osteoporosis was observed in 60.4%, osteopenia in 29.2%. Significant positive correlation was found between all BMD values and body mass index of patients (p < 0.001). Positive correlation was registered between BMD values and serum uric acid (p=0.0005). The likelihood of normal BMD values with hyperuricemia increased 3.8 times, compared to patients with normal uric acid, who often have osteoporosis (Odds Ratio=3.84; p = 0.009). Positive correlation was registered between all BMD values and body mass index (p < 0.001). Positive correlation between triglycerides levels and T-score (p=0.02), but negative correlation between BMD and HDL-cholesterol (p=0.02) were revealed. Negative correlation between frailty severity and BMD values (p=0.01) was found. Positive correlation between BMD values and functional abilities of patients assessed using Barthel index (r=0,44; p=0,000002) and IADL scale (r=0,36; p=0,00008) was registered. Fractures in history were observed in 27.6% of patients. Conclusions: The study results indicate some features of BMD in long-livers. In the study group, significant relationships were found between bone mineral density on the one hand, and patients' functional abilities on the other. It is advisable to further study the state of bone tissue in long-livers involving a large sample of patients.

Keywords: osteoporosis, bone mineral density, centenarians, coronary artery disease

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Authors: Swati Swati, Yuhang Chen, Robert Reuben

Abstract:

Coronary stents are devices resembling the shape of a tube which are placed in coronary arteries, to keep the arteries open in the treatment of coronary arterial diseases. Coronary stents are routinely deployed to clear atheromatous plaque. The stent essentially applies an internal pressure to the artery because its structure is cylindrically symmetrical and this may introduce some abnormalities in final arterial shape. The goal of the project is to develop segmented circumferential arterial compliance measuring devices which can be deployed (eventually) in vivo. The segmentation of the device will allow the mechanical asymmetry of any stenosis to be assessed. The purpose will be to assess the quality of arterial tissue for applications in tailored stents and in the assessment of aortic aneurism. Arterial distensibility measurement is of utmost importance to diagnose cardiovascular diseases and for prediction of future cardiac events or coronary artery diseases. In order to arrive at some generic outcomes, a preliminary experimental set-up has been devised to establish the measurement principles for the device at macro-scale. The measurement methodology consists of a strain gauge system monitored by LABVIEW software in a real-time fashion. This virtual instrument employs a balloon within a gelatine model contained in a split cylinder with strain gauges fixed on it. The instrument allows automated measurement of the effect of air-pressure on gelatine and measurement of strain with respect to time and pressure during inflation. Compliance simple creep model has been applied to the results for the purpose of extracting some measures of arterial compliance. The results obtained from the experiments have been used to study the effect of air pressure on strain at varying time intervals. The results clearly demonstrate that with decrease in arterial volume and increase in arterial pressure, arterial strain increases thereby decreasing the arterial compliance. The measurement system could lead to development of portable, inexpensive and small equipment and could prove to be an efficient automated compliance measurement device.

Keywords: arterial compliance, atheromatous plaque, mechanical symmetry, strain measurement

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Authors: Mohammadjavad Sotoudeheian, Navid Farahmandian

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Kawasaki disease (KD) is the primary cause of acquired pediatric heart disease as an acute vasculitis. In children with prolonged fever, rash, and inflammation of the mucosa KD must be considered as a clinical diagnosis. There is a persuasive suggestion of immune-mediated damage as the pathophysiologic cascade of KD. For example, the invasion of cytotoxic T-cells supports a viral etiology and the inflammasome of the innate immune system is a critical component in the vasculitis formation in KD. Animal models of KD propose the cytokine profiles, such as increased IL-1 and GM-CSF, which cause vascular damage. CRP and IFN-γ elevated expression and the upregulation of IL-6, and IL-10 production are also described in previous studies. Untreated KD is a critical risk factor for coronary artery diseases and myocardial infarction. Vascular damage may encompass amplified T-cell activity. SMAD3 is an essential molecule in down-regulating T-cells and increasing expression of FoxP3. It has a critical effect in the differentiation of regulatory T-cells. The discrepancy of regulatory T-cells and pro-inflammatory Th17 has been studied in acute coronary syndrome during KD. However in the coronary artery damaged lymphocytes and IgA plasma cells are seen at the lesion locations, the major immune cells in the coronary lesions are monocytes/macrophages and neutrophils. These cells secrete TNF-α, and activates matrix metalloprotease (MMP)-9, reducing the integrity of vessels and prompting patients to arise aneurysm. MMPs can break down the components of the extracellular matrix and assist immune cell movement. IVIG as an effective form of treatment clarified the role of the immune system, which may target pathogenic antigens and regulate cytokine production. Several reports have revealed that in the coronary arteries, high expression of MMP-9 in monocyte/macrophage results in pathologic cascades. Curcumin is a potent antioxidant and anti-inflammatory molecule. Curcumin decreases the production of reactive oxygen and nitrogen species and inhibits transcription factors like AP-1 and NF-κB. Curcumin also contains the characteristics of inhibitory effects on MMPs, especially MMP-9. The upregulation of MMP-9 is an important cellular response. Curcumin treatment caused a reverse effect and down-regulates MMP-9 gene expression which may fund the anti-inflammatory effect. Curcumin inhibits MMP-9 expression via PKC and AMPK-dependent pathways in Human monocytes cells. Elevated expression and activity of MMP-9 are correlated with advanced vascular lesions. AMPK controls lipid metabolism and oxidation, and protein synthesis. AMPK is also necessary for the MMP-9 activity and THP-1 cell adhesion to endothelial cells. Curcumin was shown to inhibit the activation of AMPKα. Compound C (AMPK inhibitor) inhibits MMP-9 expression level. Therefore, through inactivating AMPKs and PKC, curcumin decreases the MMP-9 level, which results in inhibiting monocyte/macrophage differentiation. Compound C also suppress the phosphorylation of three major classes of MAP kinase signaling, suggesting that curcumin may suppress MMP-9 level by inactivation of MAPK pathways. MAPK cascades are activated to induce the expression of MMP-9. Curcumin inhibits MAPKs phosphorylation, which contributes to the down-regulation of MMP-9. This study demonstrated that the potential inhibitory properties of curcumin over MMP-9 lead to a therapeutic strategy to reduce the risk of coronary artery involvement during KD.

Keywords: MMP-9, coronary artery aneurysm, Kawasaki’s disease, curcumin, AMPK, immune system, NF-κB, MAPK

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Authors: Young S. Bang, Dong H. Yoon, Seung H. Yoo

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Emergency Core Coolant Bypass (ECC Bypass) has been regarded as an important phenomenon to peak cladding temperature of large-break loss-of-coolant-accidents (LBLOCA) in nuclear power plants (NPP). A modeling scheme to address the ECC Bypass phenomena and the calculation of LBLOCA using that scheme are discussed in the present paper. A hydraulic form loss coefficient (HFLC) from the reactor vessel downcomer to the broken cold leg is predicted by the computational fluid dynamics (CFD) code with a variation of the void fraction incoming from the downcomer. The maximum, mean, and minimum values of FLC are derived from the CFD results and are incorporated into the LBLOCA calculation using a system thermal-hydraulic code, MARS-KS. As a relevant parameter addressing the ECC Bypass phenomena, the FLC to the break and its range are proposed.

Keywords: CFD analysis, ECC bypass, hydraulic form loss coefficient, system thermal-hydraulic code

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Authors: Halimah Al Hifzi, Waseem Al-Talalwah, Shorok Al Dorazi, Hassan Al Mousa, Zainab Al-Hashim, Roger Soames

Abstract:

The obturator artery is one branches of anterior division of the internal iliac artery. It passes on the lateral wall of pelvis to escape into thigh region via obturator foremen. Based on previous research studies, it found to be extremely variable in origin and course. It may arise from internal or external iliac artery. The current study includes 82 dissected specimens to investigate the origin of the obturator artery and explain the clinical importance. The obturator artery arises from the internal iliac artery in 75% either from its anterior or posterior division in 46.9% or 25% respectively. Further, it arises neither from the anterior nor posterior division of the internal iliac artery but it arises between them in 3.1%. In 25%, the obturator artery arises from the external iliac artery. In case of aneurysmectomy of posterior division, carries a high risk of insufficient of vascular supply for demand structures such as proximal adductors attachment and hip joint. Therefore, vascular surgeons have to pay attention to the posterior division being an origin of the obturator artery beside its usual three classical branches: superior gluteal, iliolumbar and lateral sacral arteries. Further, the obturator artery arising from the external iliac system is in great dangerous of laceration in case of anterior pelvic fracture. Therefore, it may lead to haemorrhagic shock threatening life.

Keywords: obturator artery, external iliac, internal iliac artery, anterior division, posterior division, superior gluteal, iliolumbar and lateral sacral, pubic fracture, aneurysm, shock

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Authors: Abeer Ahmed Abdelhamed

Abstract:

Introduction: Postoperative pulmonary complications (PPCs) are the most common complications observed and managed after abdominal or cardiothoracic surgery. Hypoxemia, atelectasis, pleural effusion, or diaphragmatic dysfunction, are often a source of morbidity in cardiac surgery patients, and are more common in patients receiving unilateral or bilateral internal mammary artery (IMT) grafts than patients receiving saphenous vein (SV) grafts alone. Purpose: The aim of this work was to investigate the effect of Threshold load inspiratory muscle training on pulmonary gas exchange and maximum inspiratory pressure (MIP) in patient undergoing coronary revascularization. Subject: Thirty three male patients eligible for coronary revascularization were selected to participate in the study. Method: They were divided into two groups(17 patients in the intervention group and 16 patients in the control group), the interventional group received inspiratory muscle training at 30% of their maximum inspiratory pressure throughout the hospitalization period in addition to routine post operative care. Result: The results of this study showed a significant improvement on maximum inspiratory pressure(MIP), Arterial-alveolar pressure gradient (A-a gradient) and oxygen saturation in the intervention group. Conclusion: Inspiratory muscle training using threshold mode significantly improves maximum inspiratory pressure, pulmonary gas exchange tested by alveolar-arterial gradient and oxygen saturation in Patients undergoing coronary revascularization.

Keywords: coronary revascularization, inspiratory muscle training, maximum inspiratory pressure, pulmonary gas exchange

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Authors: Muhammad Kamran Hanif Khan, Fahad Mushtaq

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Background: In both developed and underdeveloped countries, coronary artery disease (CAD) is a serious cause of death and disability. Cardiovascular disease (CVD) is becoming more prevalent in emerging countries like Pakistan due to the spread and acceptance of Western lifestyles. Material and Methods: An observational cross-sectional investigation was conducted, and data collection relied on a random cluster sampling method. The sample size for this cross-sectional study was calculated using the following factors: estimated true proportion of 17.5%, desired precision of 2%, and confidence interval of 95%. The data for this study was collected from a sample of 1387 adults. Results: The average age of those living in rural areas is 55.24 years, compared to 52.60 years for those living in urban areas. The mean fasting blood glucose of the urban participants is 105.28 mg/dL, which is higher than the mean fasting blood glucose of the rural participants, which is 102.06 mg/dL. The mean total cholesterol of the urban participants is 192.20 mg/dL, which is slightly higher than the mean total cholesterol of the rural participants, which is 191.97 mg/dL. CAD prevalence is greater in urban areas than in rural areas. ECG abnormalities prevalence is 16.1% in females compared to 12.5% in men. Conclusion: The prevalence of CAD is more common in urban areas than in rural ones for all of the measures of CAD used in the study.

Keywords: CVD prevalence, CVD risk factors, rural area, urban area

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Authors: Fae Princess Bermudez

Abstract:

Background: One of the least significant leads on a 12-lead electrocardiogram is the augmented right lead (aVR), as it is not as specific compared to the other leads. In this case series, the value of lead aVR, which is more often than not ignored, is highlighted. Three cases of aVR ST segment elevation on 12-lead electrocardiogram are described, with the end outcome of demise of all three patients. The importance of immediate revascularization is described to improve prognosis in this group of patients. Objectives: This case series aims to primarily present under-reported cases of isolated aVR ST-segrment elevation myocardial infarction (STEMI), their course and outcome. More specific aims are to identify the criteria in determination of isolated aVR STEMI, know its clinical significance, and determine appropriate management for patients with this ECG finding. Method: A short review of previous studies, case reports, articles and guidelines from 2011-2016 was done. The author reviewed available literature, sorted out those that proved to be significant for the presented cases, and described them in conjunction with the aforementioned cases. Findings: Based on the limited information on these rare or under-reported cases, it was found that isolated aVR STEMI had a poorer prognosis that led to significant mortality and morbidity of patients. The significance of aVR ST-elevation was that of an occlusion of the left coronary artery or a severe three-vessel disease in the presence of an Acute Coronary Syndrome. Guidelines from American Heart Association/American College of Cardiology Foundation in 2013 already recognized ST-elevation of lead aVR in isolation as a STEMI; hence, recommended that patients with this particular ECG finding should undergo reperfusion strategies to improve prognosis. Conclusion: The indispensability of isolated aVR ST-segment elevation on ECG should alert physicians, especially Emergency physicians, to the high probability of Acute Coronary Syndrome with a very poor prognosis. If this group of patients is not promptly managed, demise may ensue, with cardiogenic shock as the most probable cause. With this electrocardiogram finding, physicians must be quick to make clinical decisions to increase chances of survival of this group of patients.

Keywords: AVR ST-elevation, diffuse ST-segment depression, left coronary artery infarction, myocardial infarction

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Authors: S. Alireza Mirghasemi, Javad Parvizi, Narges R. Gabaran, Shervin Rashidinia, Mahdi M. Bijanabadi, Dariush G. Savadkoohi

Abstract:

Background: The anterior cruciate ligament is one of the most frequent ligament to be disrupted. Surgical reconstruction of the anterior cruciate ligament is a common practice to treat the disability or chronic instability of the knee. Several factors associated with success or failure of the ACL reconstruction including preoperative laxity of the knee, selection of the graft material, surgical technique, graft tension, and postoperative rehabilitation. We aimed to examine the biomechanical properties of any graft type and initial graft tensioning during ACL reconstruction using 3-dimensional computational finite element simulation. Methods: In this paper, 3-dimensional model of the knee was constructed to investigate the effect of graft tensioning on the knee joint biomechanics. Four different grafts were compared: 1) Bone-patellar tendon-bone graft (BPTB) 2) Hamstring tendon 3) BPTB and a band of gracilis4) Hamstring and a band of gracilis. The initial graft tension was set as “0, 20, 40, or 60N”. The anterior loading was set to 134 N. Findings: The resulting stress pattern and deflection in any of these models were compared to that of the intact knee. The obtained results showed that the combination of a band of gracilis with the former graft (BPTB or Hamstring) increases the structural stiffness of the knee. Conclusion: Required pretension during surgery decreases significantly by adding a band of gracilis to the proper graft.

Keywords: ACL reconstruction, deflection, finite element simulation, stress pattern

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Authors: Sohrab Jafarpour, Hamed Farokhi, Mohammad Rahmati, Alireza Gholipour

Abstract:

In the current study, a nonlinear fluid-structure interaction (FSI) biomechanical model of atherosclerosis in the left anterior descending (LAD) coronary artery is developed to perform a detailed sensitivity analysis of the geometrical features of an atheroma plaque. In the development of the numerical model, first, a 3D geometry of the diseased artery is developed based on patient-specific dimensions obtained from the experimental studies. The geometry includes four influential geometric characteristics: stenosis ratio, plaque shoulder-length, fibrous cap thickness, and eccentricity intensity. Then, a suitable strain energy density function (SEDF) is proposed based on the detailed material stability analysis to accurately model the hyperelasticity of the arterial walls. The time-varying inlet velocity and outlet pressure profiles are adopted from experimental measurements to incorporate the pulsatile nature of the blood flow. In addition, a computationally efficient type of structural boundary condition is imposed on the arterial walls. Finally, a non-Newtonian viscosity model is implemented to model the shear-thinning behaviour of the blood flow. According to the results, the structural responses in terms of the maximum principal stress (MPS) are affected more compared to the fluid responses in terms of wall shear stress (WSS) as the geometrical characteristics are varying. The extent of these changes is critical in the vulnerability assessment of an atheroma plaque.

Keywords: atherosclerosis, fluid-Structure interaction modeling, material stability analysis, and nonlinear biomechanics

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Authors: Ali Kassem, Yhea Kishik, Ali Hassan, Mohamed Abdelwahab

Abstract:

Introduction: Accelerated coronary and peripheral vascular atherosclerosis is one of the most common and chronic complications of diabetes mellitus. A recent aspect of coronary artery disease in this condition is its silent nature. The aim of the work: Detection of the prevalence of silent myocardial ischemia (SMI) in Upper Egypt type 2 diabetic males and to select male diabetic population who should be screened for SMI. Patients and methods: 100 type 2 diabetic male patients with a negative history of angina or anginal equivalent symptoms and 30 healthy control were included. Full medical history and thorough clinical examination were done for all participants. Fasting and post prandial blood glucose level, lipid profile, (HbA1c), microalbuminuria, and C-reactive protein were done for all participants Resting ECG, trans-thoracic echocardiography, treadmill exercise ECG, myocardial perfusion imaging were done for all participants and patients positive for one or more NITs were subjected for coronary angiography. Results Twenty nine patients (29%) were positive for one or more NITs in the patients group compared to only one case (3.3%) in the controls. After coronary angiography, 20 patients were positive for significant coronary artery stenosis in the patients group, while it was refused to be done by the patient in the controls. There were statistical significant difference between the two groups regarding, hypertension, dyslipidemia and obesity, family history of DM and IHD with higher levels of microalbuminuria, C-reactive protein, total lipids in patient group versus controls According to coronary angiography, patients were subdivided into two subgroups, 20 positive for SMI (positive for coronary angiography) and 80 negative for SMI (negative for coronary angiography). No statistical difference regarding family history of DM and type of diabetic therapy was found between the two subgroups. Yet, smoking, hypertension, obesity, dyslipidemia and family history of IHD were significantly higher in diabetics positive versus those negative for SMI. 90% of patients in subgroup positive for SMI had two or more cardiac risk factors while only two patients had one cardiac risk factor (10%). Uncontrolled DM was detected more in patients positive for SMI. Diabetic complications were more prevalent in patients positive for SMI versus those negative for SMI. Most of the patients positive for SMI have DM more than 5 years duration. Resting ECG and resting Echo detected only 6 and 11 cases, respectively, of the 20 positive cases in group positive for SMI compared to treadmill exercise ECG and myocardial perfusion imaging that detected 16 and 18 cases respectively, Conclusion: Type 2 diabetic male patients should be screened for detection of SMI when aged above 50 years old, diabetes duration is more than 5 years, presence of two or more cardiac risk factors and/or patients suffering from one or more of the chronic diabetic complications. CRP, is an important parameter for selection of type 2 diabetic male patients who should be screened for SMI. Non invasive cardiac tests are reliable for screening of SMI in these patients in our locality.

Keywords: C-reactive protein, Silent myocardial ischemia, Stress tests, type 2 DM

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