Coronary artery spasm : role in acute myocardial ischaemia

Coronary artery spasm is an accepted cause of transient myocardial ischaemia in patients with variant angina. The electrocardiographic abnormality, ST segment elevation, which is a hallmark of this syndrome, resembles that seen experimentally when the animal coronary artery is ligated and clinically, when the human coronary artery is totally occluded by a balloon angioplasty catheter. Coronary artery spasm is defined as a severe localized constriction sufficiently profound to cause transient total or sub-total occlusion of an epicardial coronary artery resulting in myocardial ischaemia. Coronary artery spasm has also been suggested to play an important role in the pathophysiology of myocardial ischaemia throughout the wide clinical spectrum of coronary artery disease including effort angina, unstable angina, acute myocardial infarction and sudden death.peer-reviewe

Atrial fibrillation : a common arrhythmia with possible dire consequences

The diagnosis of atrial fibrillation (AF) is clinched on the electrocardiogram with the finding of fine baseline oscillations, absent P waves and irregular ventricular rhythm.1 It is the most common type of arrhythmia requiring medical care, with a prevalence of 1-2%.2 More than half of AF episodes are detected by continuous ambulatory ECG monitoring. Although uncommon in the younger age groups, less than 0.5% in 40-50 year olds, it affects 5-15% of the population by the age of 80 years.peer-reviewe

The long and winding road: the management of Acute Coronary Syndromes in Malta

The treatment of acute coronary syndromes in Malta has been revolutionized over the past decade by the introduction of the catheterization laboratory. With the set-up of on-call cardiac invasive teams for primary percutaneous coronary interventions in ST-elevation myocardial infarction, Malta may be counted among the elite cardiac centres. The recent completion of numerous multicentre international clinical trials has led to an upheaval in the strategy and armamentarium for the treatment of acute coronary syndromes.peer-reviewe

‘Twiddling’ of the pacemaker resulting in lead dislodgement

Twiddler’s syndrome is a rare condition in which patient manipulation of the pulse generator within its pocket may result in coiling of the lead and lead dislodgement, thereby causing pacemaker malfunction. Retraction of the electrode may cause phrenic nerve stimulation resulting in diaphragmatic stimulation and a sensation of abdominal pulsations. As the leads are further wrapped around the generator, rhythmic arm twitching may occur as a result of pacing of the brachial plexus.1 Twiddler’s syndrome was first described by Bayliss et al in 1968 as a complication of pacemaker implantation.2 It has also been reported with implantable cardioverter-defibrillators (ICDs)3 and cardiac resynchronisation therapy (CRT).4 This is a case report of an elderly lady with Twiddler’s syndrome resulting in pacemaker malfunction secondary to lead retraction, who emphatically denied any manipulation of her device. She subsequently underwent lead repositioning and appropriate counselling.peer-reviewe

Relationship of hyperglycaemia, hypoglycaemia, and glucose variability to atherosclerotic disease in type 2 diabetes

Objective: Type 2 diabetes mellitus (T2DM) is known to be associated with increased cardiovascular risk. The aim of this study was therefore to investigate the independent effects of hyperglycaemia, hypoglycaemia, and glucose variability on microvascular and macrovascular disease in T2DM. Methods. Subjects with T2DM of 7.8mmol/L (β=15.83, p=0005) was the sole independent predictor of albuminuria in generalised linear regression. Conclusions. This study demonstrates that hypoglycaemia is associated with the occurrence of atherosclerotic disease while hyperglycaemia is associated with microvascular disease in a Caucasian population with T2DM of recent duration.peer-reviewe

Transcatheter device closure of atrial septal defect and patent foramen ovale in Malta

Significant atrial septal defects (ASD) are closed, surgically or through a transcatheter device, in order to avoid pulmonary hypertension in late life. A patent foramen ovale (PFO) may need to be closed because of transient shunt reversal resulting in transient ischaemic events or stroke. We report the Maltese experience to date in transcatheter closure of these defects. A total of 46 ASDs and 51 PFOs have been successfully closed at our unit (total 97), with very low complication rates, rates that compare very favourably with results from larger international centres.peer-reviewe

Six months after the patients stayed home : a nationwide study of cardiac mortality and readmissions following the first wave of the COVID-19 pandemic in Malta

Background The first COVID-19 wave resulted in a significant decline in acute cardiac admissions (ACAs) and delays to hospital presentation in Malta, as well as an excess of out-of-hospital cardiac arrests. The aim was to investigate the impact of the observed delays in presentation in 2020 on mortality and cardiac readmissions at six months. Methods All ACAs between 28th February and 30th April 2020 (first wave of COVID-19 in Malta) were included, and the corresponding 2019 period was used as a control. ACA was defined as an unplanned admission of an adult (aged ≥16 years) under the care of a cardiologist. Outcomes over the six months following the index ACA included death, cardiac readmission, and planned cardiac intervention at discharge. The term ‘death’ referred to all-cause mortality. Cardiac readmissions referred to unplanned admissions for acute cardiac pathology following the index ACA. During sub-analyses, ACAs were divided into acute coronary syndrome (ACS) and non-ACS. A first analysis compared the frequency of deaths, cardiac readmissions, and planned interventions between the 2019 and 2020 cohorts. A second analysis investigated differences in six-month survival and freedom from readmission between the two cohorts. Both analyses were followed by a subanalysis. Results There were 330 ACAs among the 2019 cohort and 220 in 2020. There were no significant differences between the 2019 and 2020 cohorts in all-cause mortality (2019, 8.8% vs 2020, 8.2%, p=0.466) and Kaplan-Meier survival estimates at a six-month follow-up (2019, 169.06 days (95% CI 164.95-173.17) vs 2020, 168.27 days (95% CI 162.82-173.72), p=0.836), including subgroup analysis for non-ACS (2019, 168.52 days (95% CI 163.08-173.96) vs 168.11 days (95% CI 160.93-175.30), p=0.952) and ACS patients (169.81 days (95% CI 163.54-176.09) in 2019 vs 168.45 days (95% CI 160.17-176.73) in 2020, p=0.739). A significantly higher number of patients from the 2019 cohort (75/319, 23.5%) required readmission compared to 2020 (32/212; 15.1%) (p=0.02). Similarly, there was shorter freedom from cardiac readmission among 2019 patients (mean 150.98 days (95% CI 144.63-157.33)) compared to 2020 patients (mean 158.66 days (95% CI 151.58-165.74, p=0.024). During sub-analysis, the difference in freedom from readmission was significant only for non-ACS patients (mean of 145.45 days (95% CI 136.58-154.32) in 2019 vs 158.92 days (95% CI 149.19-168.64) in 2020, p=0.018). Analysis of cardiac interventions during the six months post-index ACA discharge showed significantly more planned cardiac interventions in 2019 (52/319; 16.3%) compared to 2020 (20/212; 9.4%) (p=0.027). Conclusions A delay in presentation of ACAs during COVID-19 in Malta resulted in lower readmission rates and increased freedom from readmissions, with no excess in all-cause mortality at a six-month follow-up. The reasons for the optimistic outcomes of patients admitted during the first wave of COVID-19 may be multifactorial. Reasons may include ongoing fear of hospital presentation, a more holistic approach to patients’ in-hospital care during 2020 aimed at reducing further hospital contact post-discharge, and a selection bias secondary to an excess of out-of-hospital cardiac arrests during the initial wave of COVID-19. Further studies will be required to truly assess the collateral impact of non-COVID-19-related illness. Public education on cardiovascular health is vital and must be emphasized during the pandemic.peer-reviewe

Sleep measures and cardiovascular disease in type 2 diabetes mellitus

Objective: The objective of this study was to assess whether poor sleep is independently associated with cardiovascular disease in people with type 2 diabetes mellitus (T2DM). Methods: A cross-sectional study was performed in subjects with T2DM aged between 40 and 80 years. Sleep assessment was achieved by actigraphy and Pittsburgh Sleep Quality Index (PSQI) score. Results: The study population comprised 108 subjects with T2DM. The mean age was 64.9 years, the median diabetes duration was 6 years and 73.1% were men. No association was shown between sleep parameters as assessed by actigraphy and T2DM-associated micro- and macrovascular complications. However, sleep quality as assessed by PSQI was significantly associated with macrovascular disease in univariate analysis. Multivariate logistic regression analysis showed red blood cell distribution width (RDW) (odds ratio (OR) 1.79, p=0.018) and good sleep quality (OR 0.35, p=0.017) to be independently associated. Binary logistic regression analysis revealed that body mass index (BMI) (OR 1.11, p=0.024), RDW (OR 1.95, p=0.007) and Center for Epidemiologic Studies Depression score (OR 1.06, p=0.012] were independently associated with abnormal carotid intima-media thickness (CIMT). Conclusions: Poor sleep quality and higher RDW levels are associated with macrovascular disease in a T2DM population. Increased BMI as well as depression also appear to have an independent role in subclinical atherosclerosis, as assessed by CIMT.peer-reviewe

Antiplatelet and anticoagulant therapy for non-ST-elevation acute coronary syndromes in a general hospital

Aim: To audit compliance with the 2011 European Society of Cardiology (ESC) guidelines for prescribing antiplatelet and anticoagulant therapy in patients diagnosed with non-ST-elevation acute coronary syndromes (NSTE-ACS). Methods: Five-month audit at Cardiac Catheterisation Suite, Mater Dei Hospital, Malta. A data collection form for inpatients diagnosed with NSTE-ACS was developed, psychometrically evaluated and completed for each patient by the investigator. Comparative analysis to assess whether these patients were being managed according to the guidelines was undertaken. Results: 165 patients were recruited; 73% were male, 37% were between 66 and 75 years and 44% were active smokers. The most common risk factors for cardiovascular disease in these patients were hypertension (27%), dyslipidemia and obesity (both 16%). 41% of the patients underwent a percutaneous coronary intervention, either ad hoc (34%) or elective (7%). Compliance to guidelines for prescription of aspirin and clopidogrel 300mg loading dose was 95% and 88% respectively. Compliance to guidelines for prescription of aspirin and clopidogrel 75mg daily maintenance dose was 97% and 96% respectively. Compliance to guidelines for prescription of proton pump inhibitors (PPIs) in patients receiving dual antiplatelet therapy (DAPT) was only 19%; 81% of the patients were prescribed omeprazole against guideline recommendations. Compliance to guidelines for prescription of anticoagulation therapy was 95% with respect to prescription of heparin treatment in combination with DAPT. Compliance to guidelines for prescription of enoxaparin was 81%. Compliance to guidelines for other antiplatelet and anticoagulant drugs recommended in the guidelines, including ticagrelor, prasugrel, glycoprotein IIb/IIIa receptor antagonists, fondaparinux and bivalirudin, was not measured. Conclusions: Prescription of antiplatelet and anticoagulant therapy for NSTE-ACS in Malta is predominantly in accordance with ESC guidelines. Alternative antiplatelet and anticoagulant drugs and PPIs should be included in the Maltese hospital formulary to improve NSTE-ACS management in line with guideline recommendations.peer-reviewe

Smoking ban : a long-term analysis of the Malta paradox in a population of over 400,000 subjects

Objectives: The introduction of laws that make indoor public areas and workplaces smoke-free has resulted in a significant reduction in the incidence of acute coronary syndromes (ACS). Malta was the second European country to introduce the smoking ban legislation in April 2004. The purpose of the study was to investigate the impact of the smoking ban in Malta on ACS morbidity and mortality. Methods: The number of ACS hospital admissions and the number of cardiovascular deaths were retrospectively analysed. The annual data for 5 years prior to and following the introduction of the Tobacco Act were obtained according to age-groups for both genders. Poisson regression analyses were performed to assess for decline in ACS admission and cardiovascular death. Results: The ACS admission rate increased throughout the 5 years following the introduction of the smoking ban. There was no change in mortality rate in the 5 years following the legislation, except in 2007 when a small but significant decline was noted. Conclusions: The Malta smoking ban did not have a significant impact on cardiovascular mortality and ACS admissions rates, indicating the need for proper enforcement of the public smoking ban and increase in public awareness regarding the adverse effects of smoking.peer-reviewe