Search

Spontaneous coronary artery dissection is an underdiagnosed cause of acute coronary syndrome, often occurring in younger females. Such a diagnosis should always be considered in this demographic. In this case report, we focus on the importance of optical coherence tomography in the diagnosis and management of this condition in the elective setting. [ABSTRACT FROM AUTHOR]

Objectives: To validate the application of ETT screening and to assess the extent of CAD in serving soldiers. Study Design: Comparative cross-sectional. Place and Duration of Study: Study was conducted in AFIC/NIHD, from Oct 2018 to Jun 2019. Methodology: Conducted in AFIC/NIHD for the duration of 9 months. Cases with abnormal ETT at screening were further worked up with Computed Tomographic (MSCT) Angiography. Those having critical disease underwent Coronary angiogram. All cases with severe or more disease, were worked for revascularization. Chi-square test was used to find association between ETT and its diagnostic yield and management modalities. A p-value <0.05 was taken as significant. Results: A total of 256 cases with abnormal ETT were studied with 57.8% (148) cases from age group of 35-45 years. Majority of the cases 203 (76.6%) had normal CT angiography and 26 (10.2%) cases had any pattern of critical disease and 9 (3.5%) cases had calcium. Out of 256 cases 36 (14.06%) were proceeded with further work up with coronary angiogram. 31 out of these 36 cases revealed any pattern of critical CAD with 19 (7.4%) proceeded to Percutaneous Coronary Intervention (PCI) and 14 (5.5%) were offered Coronary Artery Bypass Grafting (CABG). Results show statistically significant association between diagnostic techniques and treatment modality. Conclusion: The application of ETT screening for diagnosis of occult CAD is helpful. [ABSTRACT FROM AUTHOR]

Objective: This study was to determine the frequency of retinopathy in newly diagnosed type-II Diabetics. Study Design: Cross sectional descriptive study. Place and Duration of Study: It was conducted at Department of medicine, Military Hospital (MH), Rawalpindi from 1st Jan 2012 to 30 Jun 2012. Material and Methods: We included 200 patients of type-II DM from both genders diagnosed in last 03 months from both outdoor and indoor departments in the age range of 40 to 70 years by consecutive sampling. All patients having co morbidities affecting retina were excluded. Informed written consent was taken before enrollment. Formal approval of the study was taken from hospital ethical committee. Ocular Fundoscopy was performed with WelchAllyn Ophthalmoscope (REF 11470) as per standard protocols and both eyes were examined. The grade of DR (diabetic retinopathy) awarded as per highest changes in any of the two eyes. All tests were carried by a single person to avoid inter-observer variations. Findings of ocular fundoscopy were confirmed by ophthalmologist. All data was analyzed by using SPSS version 11. Results: Out of 200 subjects 63.5% were male and 36.5% were female. Age ranged from 40 to 70 years with mean age of 51.05+ 6.910 years. 29 (14.5%) subjects had Diabetic retinopathy. Out of 29 patients, 24 (82.8%) had preproliferative and 5 (17.2%) had proliferative diabetic retinopathy. Conclusion: A significant proportion of diabetic patients have retinopathy at the time of diagnosis of their disease which is more common in males and with increasing age. It is recommended to thoroughly screen the newly diagnosed diabetics for early detection of diabetic retinopathy and its management involving early referral to eye specialist. [ABSTRACT FROM AUTHOR]

Objective: To determine the in-hospital outcomes of primary percutaneous coronary intervention approach in a tertiary care cardiac center. Study Design: Retrospective observational descriptive study. Place and Duration of Study: Pakistan Naval Ship Shifa Hospital, Karachi Pakistan, from Jan 2018 to Dec 2019. Methodology: A total of 143 consecutive ST-elevation myocardial infarction patients presented to the ER within 24 hours of the onset of chest pain were included in this study. We included patients of both genders, aged >20 years and met the diagnostic criteria of ST-elevation myocardial infarction. Patients with cardiogenic shock, puncture site infection were excluded from the study. Results: Average age of patients was 54.2 ± 12.7 years (min-max age=24-92 years). Majority 130 (90.9%) of cases were males, while 55 (38.5%) patients had diabetes, 52 (36.4%) were hypertensive, 38 (26.6%) were smokers, family history of CAD was found in 10 (7%) cases and 8 (5.6%) cases had prior percutaneous coronary intervention or coronary artery bypass graft. Mostly 64.3% procedures were performed by trans-radial approach. Mean ± SD door-to-balloon time was 60.31 ± 29.8 minutes. About 72% patients received primary percutaneous coronary intervention within ≤60 min and 40 (28%) cases received primary percutaneous coronary intervention with door-to-balloon time >60 min. This study shown 100% success rate with zero mortality only one patient developed arrhythmia during procedure. Conclusion: Primary percutaneous coronary intervention through trans-radial approach was safe option with excellent success rates in terms of both morbidity & mortality rates. [ABSTRACT FROM AUTHOR]

Objective: To determine the frequency of disorders leading to sudden cardiac death (SCD). Study Design: Cross-sectional study. Place and duration of study: Pathology Lab in collaboration with the Cardiology Department, AFIC & NIHD, Rawalpindi Pakistan, from Jan 2017 to Dec 2018. Methodology: A total of 305 cases of sudden cardiac death reported within the last 24 hours of a death to AFIC Rawalpindi were included consecutively. Cases with a history of extracardiac diseases leading to sudden death were excluded. Most of the included cases were diagnosed phenotypically based on clinical examination, biochemistry, ECG, echocardiography, angiography, thallium scan, electro-physiological studies, cardiac CT scan, MRI and routine autopsy whenever recommended. Results: Out of 305 cases, 197 (65%) were males and 108 (35%) females. Disorders leading to SCD were found in 178 (58.3%) cases due to ischemic heart disease (IHD), aortic dissection (0.7%), hypertrophic cardiomyopathy (HCM) (0.3%), dilated cardiomyopathy (DCM) (10.5%), congenital heart disease (12.1%) and valvular heart disease (7.9%). While in cardiac channelopathies, catecholaminergic polymorphic ventricular tachycardia (CPVT) in 5 (1.6%) and congenital long QT syndrome (LQTS) in 2 (0.7%) cases. However, 24 (7.9%) cases remained as sudden unexplained deaths (SUD). Conclusion: In our setup, ischemic heart disease and dilated cardiomyopathy were the commonest causes of sudden cardiac death, followed by congenital heart disease and valvular heart diseases. [ABSTRACT FROM AUTHOR]

Objective: To determine whether a planned 2-stent double kissing crush technique is superior to provisional stenting patients presenting with true distal LM bifurcation lesions. Study Design: Cross-sectional comparative study. Place and Duration of Study: Armed Forces Institute of Cardiology/National Institute of Heart Diseases, Rawalpindi Pakistan, from Dec 2020 to May 2021. Methodology: A total of 70 patients enrolled in the study presented with true distal LM bifurcation lesions (Medina 1, 1, 1 or 0, 1, 1). Patients were randomized to PS or DK crush technique. The primary end-point was peri hospital and 1 month composite rate target lesion failure (TLF): target vessel myocardial infarction (TVMI), cardiac death, stent thrombosis (ST), target vessel revascularization (TVR). Routine clinical follow up done at 2 weeks and 4 weeks followed by 3 and 6 months thereafter. Results: A total of 70 patients fulfilling the inclusion criteria were enrolled in the study. The patient population was divided into two groups. Group A participants underwent DK crush technique while group B participants underwent provisional stenting. In group A [DK crush technique] 16 (45.7%) patients presented with Non-ST elevation MI followed by 14 (40%) who presented with chronic coronary syndrome (CCS) while in group B [Provisional stenting] 13 (37.1%) presented with chronic coronary syndrome followed by 9 (25.7%) who presented with non-ST elevation MI. Conclusion: LM-PCI is an acceptable procedure in patients with true distal LM bifurcation lesions who are candidates for PCI. This study also showed that DK-Crush has good periprocedural and angiographic outcomes and superior to PS in complex LMCAD lesions. PS is an acceptable option in simple distal LMCAD. [ABSTRACT FROM AUTHOR]

Objective: To determine the incidence of radial artery spasm and various predictors leading to radial artery spasm during coronary angiography/angioplasty in Armed Forces Institute of Cardiology/National Institute of Heart Diseases Rawalpindi. Study Design: Cross sectional study. Place and Duration of Study: Department of Interventional Cardiology, Armed Forces Institute of Cardiology & National Institute of Heart Diseases Rawalpindi, from Aug to Nov 2020. Methodology: This study enrolled 272 patients who were to under go the procedure of coronary angiography/percutaneous coronary intervention either already admitted or came for out-patient procedure. Coronary angiography/percutaneous coronary intervention was done via trans radial approach and the study participants were observed for development of radial artery spasm. The patients were managed according to the department protocol. Results: The frequency of radial artery spasm was 30 (11%). No statistically significant association was found between radial artery spasm and various predictors such as age, hypertension and diabetes mellitus (p>0.05), except female gender (p<0.05). Conclusion: Radial artery spasm is a common complication of trans radial approach for coronary angiography/percutaneous coronary intervention particularly in females undergoing the procedure. [ABSTRACT FROM AUTHOR]

Background: Cytokine release syndrome (CRS) plays a pivotal role in the pathophysiology and progression of Coronavirus disease-2019 (COVID-19). Therapeutic plasma exchange (TPE) by removing the pathogenic cytokines is hypothesized to dampen CRS. Objective: To evaluate the outcomes of the patients with COVID-19 having CRS being treated with TPE compared to controls on the standard of care. Methodology: Retrospective propensity score-matched analysis in a single centre from 1st April to 31st July 2020. We retrospectively analyzed data of 280 hospitalized patients developing CRS initially. PSM was used to minimize bias from non-randomized treatment assignment. Using PSM 1:1, 90 patients were selected and assigned to 2 equal groups. Forced matching was done for disease severity, routine standard care and advanced supportive care. Many other Co-variates were matched. Primary outcome was 28 days overall survival. Secondary outcomes were duration of hospitalization, CRS resolution time and timing of viral clearance on Polymerase chain reaction testing. Results: After PS-matching, the selected cohort had a median age of 60 years (range 32–73 in TPE, 37–75 in controls), p = 0.325 and all were males. Median symptoms duration was 7 days (range 3–22 days' TPE and 3–20 days controls), p = 0.266. Disease severity in both groups was 6 (6.6%) moderate, 40 (44.4%) severe and 44 (49%) critical. Overall, 28-day survival was significantly superior in the TPE group (91.1%), 95% CI 78.33–97.76; as compared to PS-matched controls (61.5%), 95% CI 51.29–78.76 (log rank 0.002), p<0.001. Median duration of hospitalization was significantly reduced in the TPE treated group (10 days vs 15 days) (p< 0.01). CRS resolution time was also significantly reduced in the TPE group (6 days vs. 12 days) (p< 0.001). In 71 patients who underwent TPE, the mortality was 0 (n = 43) if TPE was done within the first 12 days of illness while it was 17.9% (deaths 5, n = 28 who received it after 12th day (p = 0.0045). Conclusion: An earlier use of TPE was associated with improved overall survival, early CRS resolution and time to discharge compared to SOC for COVID-19 triggered CRS in this selected cohort of PS-matched male patients from one major hospital in Pakistan. [ABSTRACT FROM AUTHOR]

Objective: To share our experience of percutaneous trans-catheter aortic valve implantation in patients with severe symptomatic aortic stenosis. Study Design: A retrospective cross sectional study. Place and Duration of Study: The study was conducted at Armed Forces Institute of Cardiology/National Institute of Heart Diseases (AFIC/NIHD) Rawalpindi, from Mar 2015 to Feb 2020. Methodology: Retrospective analysis of all consecutive patients who underwent percutaneous trans-catheter aortic valve implantation was done to assess its immediate, short and long term outcome and safety. Twenty patients have undergone trans-catheter aortic valve implantation since 2015 in the institute. Base line blood chemistry including creatinine clearance, ultra-sonography abdomen, carotid Doppler, chest X-ray, High-Resolution Computed Tomography chest was done in all cases as part of the protocol. Mean age of the patients was 73 ± 7.91. There were sixteen males (80.0%) and four females (20.0%). All patients under went procedure through transfemoral route. Valve structure and peripheral vasculature for suitability of the procedure was assessed by computerized coronary tomographic angiography with TAVI protocol. In eleven patients aortic valve was trileaflet (55.0%) and in remaining nine it was bicuspid (45.0%). Mean gradient across the valve pre-procedure was 56.37 ± 9.14. Thirteen patients (65.0%) presented with angina/dysnoea NYHA III, 6 patients with syncope (30.0%) and one (5.0%) had heart failure. Two patients had undergone previous coronary artery bypass surgery. Procedure was carried out under general anesthesia in all patients except one. Balloon expandable Edwards Sapienvalve was implanted in two patients and self-expandable Core Valve/Evolut R in eighteen patients. Results: Seventeen patients underwent the procedure successfully with reduction of the mean gradients immediately after valve implantation to less than 15 mmHg recorded in the cath labangiographically subsequently complemented by transthoracic echocardiography. There were 3 deaths during the index hospitalization. Two occurred in the catheterization laboratory, one death was due to development of severe acute aortic regurgitation and second was due to acute coronary obstruction. Third death occurred due to acute kidney injury after seven days. Five patients died in next three months during follow up. One patient required permanent pacemaker because of development of left bundle branch block and second degree atrio-ventricular block post procedure. Conclusion: Transcatheter aortic valve implantation in patients with severe symptomatic aortic stenosis is a very effective and procedurally safe option and reasonable alternative to surgical valve replacement in high operative risk individuals. [ABSTRACT FROM AUTHOR]

Objective: Cardiac Implantable Electronic Devices are being implanted more commonly now compared to the past. Due to the rise in implantation rate complication have also considered to increase. One of the dreadful complications is devices infection. This study was conducted to assess retrospectively the rate of device infection and risk factors associated with it. Study Design: Observational study. Place and Duration of Study: AFIC/NIHD, Rawalpindi, from Jan 2018 to Jan 2019. Methodology: A total of 356 patients who underwent cardiac devices implantation. Their records were studied and all the patients who developed device infections were further reviewed in detail. Demographic details, clinical, laboratory data and imaging records were evaluated. Patients were classified into different categories of infections based on predefined criteria according to the guidelines. Risk factors were also taken into account. Results: Out of 356 devices 14 got infected and infection rate was 3.9%. Generator site infection was seen in 6 followed by generator erosion in 5 while 2 had pocket site infection with bacteremia and 1 developed pocket site infection with lead/valvular endocarditis. Dual chamber permanent pacemakers were infected the most. Denovo devices had high infection rate compared to replacement. Microbes were identified in 3 patients. Conclusions: Our findings suggest that the increasing incidence of Cardiac Implantable electronic devices infection in current clinical settings was multifactorial. Care should be taken at every step starting from preoperative, intraoperative to postoperative stage for prevention of device infection. [ABSTRACT FROM AUTHOR]

Objective: To determine the relative efficacy of intravenous heparin as compared to intra-arterial heparin used during transradial coronary angiography for the prevention of radial artery occlusion. Study Design: Comparative cross-sectional study. Place and Duration of Study: Study was conducted at the Department of Cardiology, AFIC/NIHD Rawalpindi, Pakistan, from Jul 2019 to Dec 2019. Methodology: A total number of 144 patients were considered for the study using the consecutive sampling technique who were undergoing diagnostic coronary angiography. Patients were divided into the intra-arterial group (n=72) who received 50 IU/kg of unfractionated heparin (maximal dose 5,000 U) intra-arterially, and an intravenous group (n=72) received the similar dose through intravenous route. All patients were administered 100 mcg of nitroglycerin to minimize radial artery spasm. Coronary Angiography was performedusing a 6F introducer sheath and diagnostic catheters. Early radial artery occlusion (RAO) at 24 hours after the procedure was detected by performing the plethysmographic (reverse Barbeau's) and doppler USG evaluation. Chronic RAO was assessed 30 days after the procedure by performing the same tests. Data was collected through a predesigned proforma and analyzed using SPSS 23. A p-value of less than 0.05 was considered as significant. Results: Early RAO was found in 4 (5.6%) of the patients from the intra-arterial groupand 5 (6.9%) of the intravenous group. The difference was found to be statistically insignificant (p-value 0.731). Chronic RAO was observed in 3 (4.4%) of the intra-arterial group as compared to 4 (6%) of the intravenous group. This difference was also statistically insignificant (p-value 0.683) for chronic RAO. Conclusion: Intra-arterial and intravenous heparin administration providedsimilar efficacy to prevent RAO. [ABSTRACT FROM AUTHOR]

Objective: To develop association between the angiographically significant coronary artery disease (CAD) and atherosclerotic disease in the carotid, iliac and femoral arteries as measured by ultrasound. Study Design: Descriptive cross-sectional study. Place and Duration of Study: This study was conducted at Adult cardiology department of AFIC/NIHD Rawalpindi for a period of six-months, from Jan 2019 to Jun 2019. Methodology: Patients fulfilling the inclusion criteria were recruited in present study after their informed consent. Coronary angiography was performed by standard right-left diagnostic via the right radial or right femoral artery with a 6-French sheath. After angiogram patients with CAD were assessed for the atherosclerotic lesions in carotid and lower limb arteries, by ultrasound duplex scanning (UDS) performed by classified radiologist. The recorded variables were entered and analysed in SPSS. Results: The mean age of the studied patients was 61.3 ± 10.725 years. A total of 100 patients underwent coronary angiography: 1 vessel was involved in 7% of patients, 2 vessels in 18%, 3 vessels in 62% and 3 vessel with LMS in 13%. Detecting peripheral atherosclerotic lesions by ultrasound duplex scan (UDS), increased intima-media thickness (IMT) or plaques in carotid arteries were found in 58 patients (58%). In lower limb arteries, IMT or plaques were present in patients (38%) and a stenosis >70% in 5 patients (5%). Severity of coronary artery disease (CAD) was correlated to extra-coronary atherosclerosis: Carotid and lower limb arterial atherosclerosis. Linear regression analysis revealed that the coronary artery disease is significantly related to lower extremities peripheral artery disease (p=0.001) and carotid Doppler findings (p=0.007). Our results showed that carotid artery stenosis and severe PAD (diffused atherosclerotic stenosis and complete occlusion in all segments) indicates coronary pathology significantly. Conclusion: It is useful to screen the peripheral circulation by non-invasive tests, such as UDS in patients with multi-vessel CAD. Patients with extra-coronary atherosclerosis and angiographically confirmed ischemic heart disease need aggressive therapy for secondary prevention and a careful follow-up. [ABSTRACT FROM AUTHOR]

Objective: To study the demography and risk factors in patients with acute ST elevation myocardial infarction undergoing primary PCI in a tertiary care center of Pakistan. Study Design: Retrospective cross-sectional study. Place and Duration of Study: Rawalpindi Institute of Cardiology from Jan 2017 to Dec 2017. Methodology: All patients diagnosed with acute ST elevation myocardial infarction (STEMI) and selected for primary PCI between Jan 2017 to Dec 2017 were included in the study. The Statistical package for social science SPSS version 11 was used for data analysis. Continuous variables are expressed as mean ± SD. The traditional cardiovascular risk factors (smoking, hypertension, and diabetes mellitus) were noted as percent. The regions of infarction (anterior, inferior and combination) and the left ventricular ejection fraction in percentage were also documented. Descriptive analysis was mainly used. Results: Total of 818 patients diagnosed with acute ST elevation myocardial infarction (STEMI) and selected for primary PCI between. The mean age was 51.1 ± 11.4 years (range 23-91 years) with staggering 699 (85.5%) patients being male. Majority (31%) of the patients (n=341) were hypertensives and an almost equal percentage 30% (n=331) were chronic smokers. 15% of the patients (n=166) were diabetic and 9% of the patients (n=95) had a strong family history of ischemic heart disease. 7% of the patients (n=77) had dyslipidemia and interestingly 8% of the patients (n=85) were both hypertensives and diabetics. Conclusion: The potentially modifiable risk factors, especially smoking, had high prevalence in patients with STEMI living in around Rawalpindi district. Similarly uncontrolled hypertension also contributed to acute STEMI in about one third of the patients. [ABSTRACT FROM AUTHOR]

Objective: To determine the frequency of occurrence of long QTc in patients presenting with acute hemorrhagic and ischemic stroke. Study Design: Descriptive cross sectional study. Place and Duration of Study: Department of Medicine, Combined Military Hospital, Malir from, Jan 2017 till Jul 2017. Material and Methods: Administration permission from concerned authorities and ethical committee was taken. All cases of stroke, regardless of sex, ethnicity, religion and socioeconomic status fulfilling the inclusion and exclusion criteria taken from the emergency department, had informed consent from the patients except for cases in shock, confusion or coma where it was taken from the next of kin. Pertinent history and laboratory tests taken to fulfill the inclusion and exclusion criteria, including CT scan head or MRI brain whichever available. ECG was recorded by a nursing staff, interpreted by me and QTc measured by Bazett’s formula. The values were entered in the predesigned performa. Results: Total 184 patients were included according to the inclusion criteria of the study. Mean age (years) in the study was 61.63 ± 5.20. There were 143 (77.7) male and 41 (22.3) female patients. Frequency of occurrence of long QTc in patients presenting with acute hemorrhagic and ischemic stroke was 135 (73.4) and 49 (26.6) respectively. Conclusion: The study concludes that frequency of patients with QTc prolongation in patients with stroke is higher in our setup. This Prolonged QTc is a useful predictor of impending clinical deterioration and may provide an opportunity for early intervention to reduce severe loss. [ABSTRACT FROM AUTHOR]

Objective: To determine the frequency of disorders leading to sudden cardiac death (SCD). Study Design: Cross-sectional study. Place and duration of study: Pathology Lab in collaboration with the Cardiology Department, AFIC and NIHD, Rawalpindi Pakistan, from Jan 2017 to Dec 2018. Methodology: A total of 305 cases of sudden cardiac death reported within the last 24 hours of a death to AFIC Rawalpindi were included consecutively. Cases with a history of extracardiac diseases leading to sudden death were excluded. Most of the included cases were diagnosed phenotypically based on clinical examination, biochemistry, ECG, echocardiography, angiography, thallium scan, electro-physiological studies, cardiac CT scan, MRI and routine autopsy whenever recommended. Results: Out of 305 cases, 197 (65%) were males and 108 (35%) females. Disorders leading to SCD were found in 178 (58.3%) cases due to ischemic heart disease (IHD), aortic dissection (0.7%), hypertrophic cardiomyopathy (HCM) (0.3%), dilated cardiomyopathy (DCM) (10.5%), congenital heart disease (12.1%) and valvular heart disease (7.9%). While in cardiac channelopathies, catecholaminergic polymorphic ventricular tachycardia (CPVT) in 5 (1.6%) and congenital long QT syndrome (LQTS) in 2 (0.7%) cases. However, 24 (7.9%) cases remained as sudden unexplained deaths (SUD). Conclusion: In our setup, ischemic heart disease and dilated cardiomyopathy were the commonest causes of sudden cardiac death, followed by congenital heart disease and valvular heart diseases. [ABSTRACT FROM AUTHOR]