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Introduction Stent thrombosis (ST) is a serious and potentially life-threatening complication of primary or complex high-risk percutaneous coronary intervention (PCI). Multiple factors are said to precipitate ST, related to the patient's clinical comorbidities, lesion characteristics, operative technique, and post-procedural care. The older-generation stents were thought to be involved in early ST. Though the new generation of drug-eluting stents decreases the incidence of early and late ST, patients are still at risk of very late stent thrombosis (VLST). Objective To evaluate the frequency, risk factors, and outcomes of definite ST in developing and resource-constrained countries like Pakistan, where PCIs, including primary PCI, complex PCI, and PCI in high-risk populations, are performed routinely. Methods This observational cross-sectional study included all patients who underwent primary and complex high PCI between 2012 and 2017 at TABBA Heart Institute (THI), Karachi, Pakistan. Results We included a total of 6587 patients in our study, and among the enrolled sample size, 22 (0.33%) had definite ST. Acute stent thrombosis (AST) was found in seven patients, sub-acute stent thrombosis (SAST) in 10, late stent thrombosis (LST) in two, and VLST were observed in three patients. The basic characteristics of our study ST population were as follows: mean age was 58 years, 95.5% were male, 4.5% were female, nine patients (40%) had diabetes mellitus, 15 patients (68%) had hypertension, 11 (50%) had dyslipidemia, and four patients were smokers (18%). Conclusion The frequency, risk factors, and rate of mortality of definite ST in the Pakistani population who underwent primary and complex high-risk PCI reflect nearly equal statistics observed in other studies. As seen in other international studies, the incidence rate of VLST was higher in our population.

Background and objective Transradial access (TRA) has become the preferred route for percutaneous coronary interventions (PCI), and this site is often a chink in the armor for staged PCI. In this study, we aimed to evaluate the incidence and predictors of radial artery occlusion (RAO) after TRA. Methods We conducted a retrospective study involving 1,307 patients who underwent PCI at the Tabba Heart Institute (THI) in Karachi, Pakistan from August 2018 to June 2019. TR band was used for hemostasis after PCI. Results The primary outcome of our study was RAO, which was observed in 11.3% of the study subjects. On multivariate analysis, female gender [odds ratio (OR): 1.79, 95% CI: 1.21-2.64], cardiovascular instability (OR: 2.5, 95% CI: 1.22-5.11), dyslipidemia (OR: 0.61, 95% CI: 0.4-0.92), and a higher number of diseased vessels were found to be predictors of RAO (p=0.004). Conclusion RAO is often an asymptomatic complication of TRA. To ensure radial artery patency, a carefully thought-out management plan and follow-up must be devised for high-risk patients.

Introduction Patients presenting to the emergency department with a non-ST segment elevation myocardial infarction (NSTEMI) frequently have unremarkable electrocardiography (ECG) reports, alluding to the unreliable nature of ECG in diagnosing NSTEMI. This study aims to assess the burden of NSTEMI in acute coronary syndrome (ACS) with unremarkable ECG, elucidating that in patients presenting with acute retrosternal chest pain, NSTEMI should not be excluded unless cardiac enzyme levels are assessed. Methods All patients who fulfilled the inclusion criteria in the Department of Cardiology, Tabba Heart Institute, Karachi were included. After obtaining informed written consent, a detailed history was taken. Clinical examination was consequently performed, and an ECG, along with the cardiac enzymes implicated in ACS, such as troponin I, was evaluated. The proportion of normal ECGs in the context of an NSTEMI was duly noted. Result A total of 215 patients with ACS presenting within 24 hours of the onset of symptoms, on a background of unremarkable ECG reports, were included. One hundred thirty-eight (64.2%) were males and 77 (35.8%) were females, with the mean age being 54.3 + 7.6 years. A confirmed diagnosis of NSTEMI was made in 49 (22.8%) of the total cases. Conclusion The frequency of patients presenting with an NSTEMI within 24 hours of the onset of symptoms, and having normal ECG findings, was strikingly high in patients presenting to the Tabba Heart Institute, Karachi, Pakistan. These findings were more common in males and in older patients.

Introduction and objective Effective risk stratification is integral to the management of acute coronary syndromes. The Thrombolysis in Myocardial Infarction (TIMI) risk score for ST-segment elevation myocardial infarction (STEMI) is based on eight high-risk parameters that can be used at the bedside for risk stratification of patients presenting with STEMI. This study was designed to determine the frequency of cardiac complications of anterior wall STEMI assessed on TIMI risk score and to compare the rate of cardiac complications according to the TIMI score. Materials and methods An observational case series study was conducted in the Department of Cardiology at Sandeman Provincial Hospital in Quetta, Pakistan. The study duration was six months, from September 22, 2016 to March 23, 2017. A total of 369 patients were selected who had anterior wall myocardial infarction and received thrombolytic therapy, according to the inclusion and exclusion criteria. The TIMI score was calculated by proforma at the time of admission. Patients were divided into three groups: low-risk, moderate-risk, and high-risk TIMI groups. The frequency of complications of anterior wall myocardial infarction at the time of discharge was compared among these groups. Results The study included 285 male patients (77.2%) and 84 (22.8%) female patients. A total of 174 (47.2%) patients were smokers, 79 (21.4%) were obese, and 93 (25.2%) had hyperlipidemia. Of the 369 patients, 205 (55.6%) were included in the low-risk group, 150 (40.7%) in the moderate-risk group, and 14 (3.8%) in the high-risk group. Post-myocardial infarction arrhythmias were noted in 33 (16.09%) patients in the low-risk group and six (4%) patients in the moderate-risk group. Left ventricular dysfunction was noted in 158 (77.07%) patients in the low-risk group, 78 (52%) patients in the moderate-risk group, and seven (50%) patients in the high-risk group. Cardiogenic shock occurred in seven (3.41%) patients in the low-risk group, 47 (31.33%) patients in the moderate-risk group, and 0 (0%) patient in the high-risk group. Death occurred in seven (3.41%) patients in the low-risk group, 19 (12.66%) patients in the moderate-risk group, and seven (50%) patients in the high-risk group. Conclusion TIMI scoring provides a better assessment in terms of complications caused by STEMI. The complications include the mechanical and electrophysiology of the heart.

Coronary artery anomalies (CAAs) are rare findings and usually diagnosed incidentally on coronary angiograms for other cardiac conditions in most cases. However, coronary anomalies are being increasingly reported with the invention of more advanced cardiac imaging techniques. The CT of the heart structure is the best modality to diagnose and track the exact course of the anomalous artery and to guide in proper management. Anomalous course of the right coronary artery (RCA) between the aorta and pulmonary artery may cause compression and require surgical intervention given the risk of myocardial ischemia and sudden death. In this report, we discuss the case of a 69-year-old female with no prior cardiac comorbidities. The patient had been referred from the primary care office for cardiac clearance to undergo bilateral knee replacement surgery. On further inquiry, she reported a history of murmur and stated that she had been having dyspnea on exertion over the last six months. Precordial examination revealed a 2/6 ejection systolic murmur. Transthoracic echocardiogram showed severe aortic stenosis. For further evaluation, she underwent a coronary angiogram, which showed right dominant coronary system, normal left main with no stenosis, a large septal branch that had anomalously originated from left main and coursing all the way to the apex, and the RCA originating from the mid-portion of the left descending artery. The cardiac CT scan showed the exact course of the anomalous origin of the RCA from the mid-left anterior descending artery (LAD). The RCA coursed anteriorly to the main pulmonary artery/right ventricular outflow tract to reach the right atrioventricular groove. The patient underwent transcatheter aortic valve replacement (TAVR) and was discharged in stable condition.