Search

There is a scarcity of data on gender differences in outcomes during and after percutaneous coronary intervention (PCI) in the South Asian population. We assessed the gender differences in in-hospital mortality and complications in patients who underwent PCI. We conducted a cross-sectional study of 15,106 patients from the CROP (Cardiac Registry of Pakistan) CathPCI database. Logistic regression was used to determine factors associated with in-hospital mortality (primary outcome), access site hematoma, and bleeding complications. Approximately 19.6% were women. Women were older (mean age = 57.3 vs 54.4 years) and had a higher prevalence of diabetes (49.3% vs 32.6%), hypertension (72.8% vs 56.4%), peripheral arterial disease (1.5% vs 1%), and cerebrovascular accident (1.2% vs 0.8%) than men (p0.05).Unadjusted in-hospital mortality was higher in women than in men (odds ratio [OR]: 1.6, 95% confidence interval [CI] 1.1 to 2.2); however, after adjusting for age, hypertension, diabetes, history of cerebrovascular accident, and ST-elevation myocardial infarction at presentation in the multiple logistic regression model, in-hospital mortality was comparable between men and women (adjusted OR [AOR] 1.2, 95% CI 0.8 to 1.7). The results remained consistent after propensity score matching of 5,904 patients (2,952 in each group, OR 1.3, 95% CI 0.9 to 2.0 for in-hospital mortality). Bleeding complications (1.2% vs 0.4%, AOR 2.6, 95% CI 1.4 to 4.5) and access site hematoma (2% vs 0.6%, AOR 2.8, 95% CI 1.8 to 4.5) were higher in women than in men. In conclusion, the incidence of in-hospital mortality was higher for women versus men, but adjusted risks were similar, likely driven by a greater co-morbidity burden among women.

Middle-aged male known case of hypothyroidism presented with shortness of breath and hypoxia. Echo showed large RA myxoma with ASD causing right to left shunt.

Introduction. Some groups of Asian Americans, especially Asian Indians, experience higher rates of atherosclerotic cardiovascular disease (ASCVD) compared with other groups in the U.S. Barriers in accessing medical care partly may explain this higher risk as a result of delayed screening for cardiovascular risk factors and timely initiation of preventive treatment. Methods. Cross-sectional data were utilized from the 2006 to 2015 National Health Interview Survey (NHIS). Barriers to accessing medical care included no place to seek medical care when needed, no healthcare coverage, no care due to cost, delayed care due to cost, inability to afford medication, or not seeing a doctor in the past 12 months. Results. The study sample consisted of 18,150 Asian individuals, of whom 20.5% were Asian Indian, 20.5% were Chinese, 23.4% were Filipino, and 35.6% were classified as “Other Asians”. The mean (standard error) age was 43.8 (0.21) years and 53% were women. Among participants with history of hypertension, diabetes mellitus, or ASCVD (prevalence = 25%), Asian Indians were more likely to report delayed care due to cost (2.58 (1.14,5.85)), while Other Asians were more likely to report no care due to cost (2.43 (1.09,5.44)) or delayed care due to cost (2.35 (1.14,4.86)), compared with Chinese. Results among Filipinos were not statistically significant. Conclusions. Among Asians living in the U.S. with cardiovascular risk factors or ASCVD, Asian Indians and Other Asians are more likely to report delayed care or no care due to cost compared with Chinese.

Aim: To determine the predictors of no-reflow in patients undergoing Primary Percutaneous Coronary Intervention (PPCI) for acute ST elevation myocardial infarction (STEMI) at Tabba Heart Institute Karachi. Study duration: The study was carried out from September 2020 to September 2021. Methods: An observational study that was conducted at Tabba heart Institute Karachi. All patients with acute ST elevation myocardial infarction (STEMI) presenting within 12 hours of symptoms who undergoing primary PCI were included in the study. The patients were categorized Angiographically as no –reflow (with Thrombolysis in Myocardial Infarction (TIMI)

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.

Background Myocardial infarction is a life-threatening event, and timely intervention is essential to improve patient outcomes and mortality. Previous studies have shown that the time to thrombolysis should be less than 30 minutes of the patient's arrival at the emergency room. Pain-to-needle time is a time from onset of chest pain to the initiation of thrombolysis, and door-to-needle time is a time between arrival to the emergency room to initiation of thrombolytic treatment. Ideally, the target for door-to-needle time should be less than 30 minutes; however, it is unclear if the door-to-needle time has a significant impact on patients presenting later than three hours from the onset of pain. As many of the previous studies were conducted in first-world countries, with established emergency medical services (EMS) systems and pre-hospital ST-elevation myocardial infarction (STEMI) triages and protocols, the data is not completely generalizable to developing countries. We, therefore, looked for the impact of the shorter and longer door-to-needle times on patient outcomes who presented to the emergency room (ER) with delayed pain-to-needle times (more than three hours of pain onset). Objective To determine the impact of delayed pain-to-needle time (PNT) with variable door-to-needle time (DNT) on in-hospital complications (post-infarct angina, heart failure, left ventricular dysfunction, and death) in patients with ST-elevation myocardial infarction (STEMI) who underwent thrombolysis. Methods and results A total of 300 STEMI patients who underwent thrombolysis within 12 hours of symptoms onset were included, which were divided into two groups based on PNT. These groups were further divided into subgroups based on DNT. The primary outcome was in-hospital complications between the two groups and between subgroups within each group. The pain-to-needle time was ≤3 hours in 73 (24.3%) patients and3 hours in 227 (75.7%) patients. In-hospital complications were higher in group II with PNT3 hours (p0.05). On subgroup analysis, in-hospital complications were higher with longer door-to-needle time in group II (p0.05); however, there was no difference in complications among group I. Conclusion Our study is consistent with the fact that shorter door-to-needle time, even in patients with delayed PNT (3 hours), has a significant impact on in-hospital complications with no difference in mortality.

Objectives: To date, no optimal way of organizing and delivering care to hypertensive patients at the primary care level has been identified, due to which a significant number of patients fail to meet the treatment goals. The current study aimed to observe hypertension educational intervention's effect on general physicians (GPs) to indirectly improve blood pressure control and patient outcomes. Methodology: In this randomized control trial, GPs were divided into 2 groups, and both groups were asked to fill hypertension awareness questionnaire at baseline and after randomization. GPs of the group I received (1 day) face-to-face education with structured educational material on hypertension management strategies. GPs of group II received the print version of educational material (structured educational material) on strategies for structured hypertension management. Both GPs recruited 10 (5 newly diagnosed + 5 already diagnosed patients) from the study site. The patient was asked to fill hypertension awareness questionnaire at baseline and share a 12-hour blood pressure measurement. GPs and patients were reassessed after 3 months of intervention. Results: The Primary endpoint was achieved successfully, i.e., significant change between Pre & Post change blood pressure control. Both the Secondary endpoints were met with a notable change in practice specific to hypertension management as well as knowledge enhancement among GPs and patients regarding hypertension management. Conclusion: The overall effect of hypertension educational intervention for general physicians has indirectly improved blood pressure control and patient outcomes. The results of this study provide a foundation for developing a hypertension educational program targeted at general physicians.

Pseudo thrombocytopenia is the estimation of low platelet counts by a Hematology analyzer in spite of lack of shortage in platelets. EDTA-induced pseudo thrombocytopenia, commonly seen in clinical practice, occurs mainly due to anti platelet antibodies. Pseudo thrombocytopenia is seen in normal healthy individuals as well as in other disorders like cardiovascular, liver, autoimmune diseases and malignancy. We are presenting a case of multi coagulant resistant dependent thrombocytopenia. The purpose of the case report is to review approaches to pseudo thrombocytopenia. The case has coagulant resistant dependent thrombocytopenia in association with Anasarca and was a known case of cardiomyopathy with severely dilated left atrium, left ventricle &right atrium. Keywords: Pseudo platelet aggregation, multicoagulant resistant thrombocytopenia, pseudo thrombocytopenia. Continuous...

Objective The Asian American population in the U.S. comprises various, ethnically diverse subgroups. Traditionally, this population has been studied as a single, aggregated group, potentially masking differences in risk among subgroups. Analyses using disaggregated data can help better characterize the health needs of different Asian subpopulations and inform targeted, effective public health interventions. We assessed the prevalence of cardiovascular disease (CVD) risk factors and atherosclerotic CVD (ASCVD) and their associations with socioeconomic factors among Chinese, Asian Indian, Filipino and Other Asian subjects, compared with non-Hispanic White (NHW) subjects in the U.S. Methods : Cross-sectional study using data from 298,286 adults from the National Health Interview Survey (NHIS) from 2007 to 2018. We utilized chi-squared tests to compare characteristics across subgroups. Weighted proportions and unadjusted and adjusted logistic regression models were utilized to examine the associations between Asian subgroups, self-reported CVD risk factors and self-reported ASCVD, as well as between socioeconomic factors within each Asian subgroup. Results : Asian Indian subjects had the highest prevalence of diabetes (12.5%), while Filipino subjects had the highest prevalence of hyperlipidemia (27.7%), hypertension (29.8%) and obesity (19.8%). Despite this, the prevalence of self-reported ASCVD was lower in all Asian groups compared with NHWs. Chinese subjects had the lowest odds of having each of the CVD risk factors assessed. Conclusion : We found considerable heterogeneity in the distribution of risk factors as well as ASCVD among Asian subgroups in the US. Compared with health system or community-based reports, the prevalence of risk factors and ASCVD may be underestimated in some Asian NHIS subgroups. There is an urgent need for efforts to improve recruitment of Asian participants of heterogeneous socioeconomic backgrounds in national surveys, as well as to perform a thorough assessment of risk factors and disease in this population, not relying solely on self-report., Graphical abstract Image, graphical abstract

Introduction: As the leading cause of death globally, atherosclerotic cardiovascular disease (ASCVD) carries substantial cost burden for patients and the healthcare system. Although overall mortali...

IntroductionProvisional stenting using drug-eluting stent is effective for simple coronary bifurcation lesions. Kissing balloon inflation using conventional non-compliant balloon is the primary treatment of side branch (SB) after main vessel (MV) stenting. Drug-coating balloon (DCB) is reported to be associated with less frequent clinical events in in-stent restenosis and small vessel disease. The importance of DCB in bifurcation treatment is understudied. Accordingly, this trial is designed to investigate the superiority of DCB to non-compliant balloon angioplasty for SB after provisional stenting in patients with true coronary bifurcation lesions.Methods and analysisThe DCB-BIF trial is a prospective, multicentre, randomised, superiority trial including 784 patients with true coronary bifurcation lesions. Patients will be randomised in a 1:1 fashion to receive either DCB or non-compliant balloon angioplasty if SB diameter stenosis >70% after MV stenting. The primary endpoint is the composite of major adverse cardiac event at the 1-year follow-up, including cardiac death, myocardial infarction (MI) or clinically driven target lesion revascularisation. The major secondary endpoints include all-cause death, periprocedural MI, spontaneous MI, clinically driven target vessel revascularisation, in-stent restenosis, stroke and individual component of the primary endpoint. The safety endpoint is the risk of stent thrombosis.Ethics and disseminationThe study protocol and informed consent have been reviewed and approved by the Institutional Review Board of all participating centres. The written informed consent for participation in the trial will be obtained from all participants. The results of this study will be published in a peer-reviewed journal and disseminated at conferences.Trial registration numberNCT04242134.

In 1977, the first successful coronary angioplasty was performed by Andreas Gruentzig using a double-lumen balloon catheter. This pivotal event spurred major advances in the field of percutaneous coronary intervention (PCI) over the subsequent four decades, including in the setting of myocardial infarction (MI) where primary PCI is now the established gold standard therapy. Nonetheless, although reperfusion is the cornerstone of management of acute MI, the role of various adjunctive therapies also needs to be recognized as these have had a substantial influence in improving both morbidity and mortality. This chapter serves to revisit the key historical milestones that have helped shape the modern management of acute MI.

To calculate the frequency and distribution of occluded coronary artery in patients with recent non-ST elevation myocardial infarction undergoing coronary angiography, and to compare major adverse cardiovascular events during hospitalisation with patients suffering from non-occluded coronary artery.The cross-sectional analytical study was conducted at Tabba Heart Institute, Karachi, from July2013 to March 2014. Patients of both gender and all ages undergoing angiography with non-ST elevation myocardial infarction were included. Data on patient demographics, angiographic findings and in-hospital complications was collected. Frequency of occluded vessels and their distribution was reported. Multivariate logistic regression modelling was used to examine variables associated with an occluded coronary artery in non-ST elevation myocardial infarction. Major adverse cardiovascular events were compared between patients of occluded and non-occluded coronary aetery. A two sided p-value of0.05 was taken as significant.In 703 patients studied, occluded coronary artery was present in 277(39%). Predictors of having an occluded coronary artery were increasing age (57.6±11.2 vs. 60.0±10.0; p: 0.03) and low left ventricular ejection fraction (43.9±12.2 vs. 50.1±10.1; p: 0.000). There was no significant difference in terms of major adverse cardiovascular events in patients with occluded and non-occluded coronary arteries (Hazard Ratio: 0.53, 95% confidence interval: 0.14-1.98; p=0.33).Totally occluded coronary vessel is a frequent finding in non-ST elevation myocardial infarction, highlighting the need for angiography and re-vascularisation to salvage at-risk myocardium in selected patients.

Obesity is a complex disease caused by the interplay of genetic and lifestyle factors, but identification of gene-lifestyle interactions in obesity has remained challenging. Few large-scale studies have reported use of genome-wide approaches to investigate gene-lifestyle interactions in obesity.In the Pakistan Risk of Myocardial Infraction Study, a cross-sectional study based in Pakistan, we calculated body mass index (BMI) variance estimates (square of the residual of inverse-normal transformed BMI z-score) in 14 131 participants and conducted genome-wide heterogeneity of variance analyses (GWHVA) for this outcome. All analyses were adjusted for age, age(2), sex and genetic ancestry.The GWHVA analyses identified an intronic variant, rs140133294, in the FLJ33544 gene in association with BMI variance (P-value=3.1 × 10(-8)). In explicit tests of gene × lifestyle interaction, smoking was found to significantly modify the effect of rs140133294 on BMI (Pinteraction=0.0005), whereby the minor allele (T) was associated with lower BMI in current smokers, while positively associated with BMI in never smokers. Analyses of ENCODE data at the FLJ33534 locus revealed features indicative of open chromatin and high confidence DNA-binding motifs for several transcription factors, providing suggestive biological support for a mechanism of interaction.In summary, we have identified a novel interaction between smoking and variation at the FLJ33534 locus in relation to BMI in people from Pakistan.

Background Multiple genetic variants have been reliably associated with obesity-related traits in Europeans, but little is known about their associations and interactions with lifestyle factors in South Asians. Methods In 16,157 Pakistani adults (8232 controls; 7925 diagnosed with myocardial infarction [MI]) enrolled in the PROMIS Study, we tested whether: a) BMI-associated loci, individually or in aggregate (as a genetic risk score - GRS), are associated with BMI; b) physical activity and smoking modify the association of these loci with BMI. Analyses were adjusted for age, age2, sex, MI (yes/no), and population substructure. Results Of 95 SNPs studied here, 73 showed directionally consistent effects on BMI as reported in Europeans. Each additional BMI-raising allele of the GRS was associated with 0.04 (SE = 0.01) kg/m2 higher BMI (P = 4.5 × 10−14). We observed nominal evidence of interactions of CLIP1 rs11583200 (Pinteraction = 0.014), CADM2 rs13078960 (Pinteraction = 0.037) and GALNT10 rs7715256 (Pinteraction = 0.048) with physical activity, and PTBP2 rs11165643 (Pinteraction = 0.045), HIP1 rs1167827 (Pinteraction = 0.015), C6orf106 rs205262 (Pinteraction = 0.032) and GRID1 rs7899106 (Pinteraction = 0.043) with smoking on BMI. Conclusions Most BMI-associated loci have directionally consistent effects on BMI in Pakistanis and Europeans. There were suggestive interactions of established BMI-related SNPs with smoking or physical activity. Electronic supplementary material The online version of this article (doi:10.1186/s12881-015-0259-x) contains supplementary material, which is available to authorized users.

To validate the global registry of acute coronary event (grace) risk score in a Pakistani population at Tabba Heart Institute Karachi in patients with non ST-Elevation Myocardial Infarction (NSTEMI) and Unstable Angina (UA).In this prospective Observational registry study, 530 adults hospitalized patients with a diagnosis of Non-ST-Elevation Myocardial Infarction and unstable angina were enrolled between March 2012 and August 2012 at the Tabba Heart Institute, Karachi, Pakistan. For each patient, the grace risk score was calculated and its discrimination evaluated and correlated with in-hospital mortality using the Kendall's tau-b bivariate correlation test. Each patient was grouped either into high, intermediate or low risk groups according to their GRS.A total of 530 patients with NSTEMI and UA were included; the overall mean grace risk score in our population was 131.87 +/- 41.56. The GRACE Risk Score showed good discrimination, with Area under the ROC curve of 0.803 (95% CI 0.705-0.902, P0.001). During the in-hospital stay, total of 19 (3.6%) patients died, and out of those 15 (8.4%) patients belonged to high risk group.GRACE RS strongly validates the in-hospital mortality among our patient population presenting with a wide spectrum of complications. However, more multicentre registries on a larger population with long-term follow up are required to study detailed trends in our population.

Improvements in coronary stents have made planned direct coronary stenting technically feasible, though safety, acute success, cost-effectiveness, and long-term results remain to be determined. Sequential patients eligible for direct stenting were prospectively characterized and treated with either direct or secondary stenting. Major adverse cardiovascular events (MACE) such as cardiac death, myocardial infarction (MI), target vessel ischemia, or revascularization (TVR) were followed for 6 months post-PCI. Enrollment included 128 direct (1.38 lesions/patient) and 69 secondary (1.39 lesions/patient) stented patients. Direct stenting was successful in 99% (with 5% crossover to secondary stenting) without major procedural complications and with a similar rate of vessel wall dissection or no-reflow phenomenon (2.3% vs. 2.1%; P > 0.05) as the secondary stenting group. There was a trend toward less postprocedural CPK-MB elevation in the nonacute MI patients with direct vs. secondary stenting (3% vs. 11%, respectively). At 6 months, there were no statistically significant differences in overall MACE. Direct stenting has a high success rate, low complication rate, and durable long-term results. Procedural cost and time savings, less contrast use and radiation exposure make direct stenting attractive in properly selected patients. Cathet Cardiovasc Intervent 2001;54:158–163. © 2001 Wiley-Liss, Inc.

To determine the outcomes of primary percutaneous coronary intervention for ST elevation myocardial infarction complicated by cardiogenic shock.The retrospective study was conducted at the Tabba Heart Institute, a private-sector facility in Karachi. It reviewed the medical records of 56 consecutive patients between January 2009 and June 2011 with acute ST elevation myocardial infarction complicated by cardiogenic shock and subjected to primary percutaneous coronary intervention. The primary end point was in-hospital mortality and its predictors. SPSS 14 was used for statistical analysis.The mean age of the study patients was 63 +/- 11.7 years; 38 (68%) were male; 32 (57%) were hypertensive; and 39 (69%) were diabetic. Most infarcts were anterior in location (n = 36; 64%). Besides, 33 (59%) required ventilatory support. Intra-aortic balloon pump was placed in 30 (54%), and 33 (59%) patients had multivessel coronary artery disease. In-hospital mortality occurred in 26 (46%). Multivariate logistic regression analysis showed that age60 years (p0.05), diabetes (p0.01) and left ventricular ejection fraction40% (p0.01) were independent predictors of in-hospital mortality.Results emphasise the need of aggressive management of patients with cardiogenic shock utilising primary percutaneous coronary intervention as a reperfusion strategy to improve clinical outcomes.

To determine the outcomes of primary percutaneous coronary intervention via transradial approach in a tertiary care cardiac centre.The study retrospectively reviewed the medical records of 160 consecutive patients who presented to Tabba Heart Institute, a private-sector facility in Karachi, between January 2009 and January 2011 with acute ST-elevation myocardial infarction and treated with primary percutaneous coronary intervention via transradial approach. The primary end-points were in-hospital mortality and procedural success. Secondary end-points were access site bleeding complication and 30-day outcomes (mortality, myocardial infarction and congestive cardiac failure).The mean age of the patients was 55.9+/-11.7 years and 126 (79%) were males. The procedural success was 98% (n=157). Three (1.8%) patients died during hospitalisation. Forearm haematoma (5cm) was observed in three (1.8%) patients. No mortality was observed in 30-day follow-up after discharge, while myocardial infarction and congestive cardiac failure were 1.25% (n=2) and 4% (n=6) respectively.High procedural success and favourable clinical outcomes matching the international data can be achieved in our patients undergoing primary percutaneous coronary intervention via transradial approach.

The case of a 55 years old, hypertensive, obese female is presented, who came to the emergency department with inferoposterior ST segment elevation myocardial infarction (STEMI) with right ventricular infarction. After thrombolytic therapy, she reperfused but had anginal symptoms on minimal activity. The patient underwent coronary angiogram which showed aneurysmal right coronary artery (RCA) with 60% stenosis and thrombus in mid portion and distal bifurcation of RCA with TIMI III distal blood flow. Left main coronary artery was normal. Left anterior descending (LAD) and Left circumflex (LCX) arteries were also aneurysmal and non obstructive. The patient was started on intravenous heparin and warfarin in view of aneurysmal coronary arteries and large thrombus burden. The patient was discharged home in one week and is doing well at follow up.

To determine factors affecting cardiac rehabilitation attendance after myocardial infarction and coronary revascularization.A cross-sectional study was conducted on 416 patients admitted in Tabba Heart Institute, Karachi from December 2010 to May 2011. Patients admitted with diagnosis of acute myocardial infarction (AMI) or who underwent elective coronary artery bypass graft surgery (CABG) or percutaneous coronary intervention (PCI) procedures were offered cardiac rehabilitation (CR). Out of these, patients who enrolled in 6 weeks outpatient CR programme were followed for number of CR sessions and their socio-demographic and clinical data were collected. Data was analyzed by Statistical Package for Social Sciences (SPSS) software, version 15.0. Chi-square test was applied to test association between categorical variables and Student's t-test for continuous variables.Out of 416 patients identified, only 151 patients (36.2%) enrolled and attended the CR programme. Of the 151 attendees, 111 (73.4%) patients subsequently completed more than 6 weeks of outpatient CR programme. We found significant association between CR attendance and easy access to the programme, elective CABG procedure, employment status, presence of diabetes or hypertension and baseline level of exercise (all por = 0.01). No association was found between CR attendance and patient age, gender, body mass index or different economic groups.Attendance rates of patients attending outpatient CR programme after AMI or coronary revascularization procedures are suboptimal. Patients who underwent elective CABG surgery and had easy access to the CR programme had better attendance. Factors contributing to poor attendance rates at CR programmes in developing countries need to be explored and subsequently addressed.

To determine the correlation of Duke treadmill score (DTS) with gated single photon emission computed tomography-myocardial perfusion imaging (SPECT-MPI) in patients evaluated for chest pain.A retrospective study was conducted at Tabba Heart institute. Two hundred consecutive patients, referred to the nuclear cardiology laboratory for evaluation of chest pain by using stress myocardial perfusion imaging (MPI) from January 2008 to August 2008 were included. Duke Treadmill Score (DTS) was calculated after exercise testing and categorized as low, moderate and high DTS groups. Subsequent gated SPECT-MPI was performed and stratified according to severity of perfusion defect. Spearmans rho (non parametric test) was applied to determine the correlation between DTS and SPECT-MPI RESULTS: The overall result showed positive linear correlation between DTS and MPI (p =0.001). Out of 200 patients, 136 (68%) had low DTS, 51 (25.5%) had moderate and 13 (6.5%) had high DTS respectively. In low DTS group 129 (95%) patients had low risk MPI and 7 (5%) had intermediate risk MPI. In moderate risk DTS group 25 (49%) had low risk MPI whereas 15 (29.5%) and 11 (21.5%) had intermediate and high risk MPI respectively. In high DTS group all 13 patients had high risk MPI.On the basis of our findings it can be hypothesized that patients with high DTS can be referred for coronary angiography without imaging and patients with low DTS can be followed on medical management. However for definite conclusion diagnostic accuracy needs to be determine in further studies.

The case of a 20 years old male, diagnosed as supracristal ventricular septal defect (VSD) for last 6 years is being presented. He came in emergency department with decompensated congestive cardiac failure. After initial stabilization, he underwent transthoracic echocardiogram which showed large supracristal VSD, severely prolapsing right coronary cusp, severe aortic regurgitation and severe pulmonary hypertension. Right heart catheterization was performed which documented reversible pulmonary vascular resistance after high flow oxygen inhalation. He underwent VSD repair, right coronary cusp was excised and aortic valve was replaced by mechanical prosthesis. Post operative recovery was uneventful. He was discharged home in one week.

To determine the association of the pro-brain natriuretic peptide (NT-proBNP) plasma levels with twodimensional echocardiographic determination of left ventricular dimensions and ejection fraction (EF) in acute dyspneic patients.An observational cross-sectional study.Tabba Heart Institute, Karachi, from January to June 2010.One hundred patients were selected by consecutive purposive non-probability sampling who had presented with acute dyspnoea. NT-proBNP levels were assessed by commercial tests (Roche Diagnostics). The clinical diagnosis of congestive heart failure (CHF), echocardiographic assessment of left ventricular dimensions and function were compared with NT-proBNP levels. Receiver operating characteristic (ROC) curve was estimated for NT-proBNP and compared. The chi-square test was applied for categorical and student's t-test for numerical data at 0.05 levels of significance were used to compare patients with and without heart failure. Further comparative analysis between groups on the basis of ejection fraction was done by one way ANOVA test.Seventy-nine patients (79%) had CHF as a cause of their dyspnoea. Patients with CHF were older (61.9 ± 14 years vs. 58.6 ± 14 years, p=0.368), had a lower EF (36.9% vs. 61%, p0.0001), had a higher LV dimensions, left ventricular end diastolic dimension - LVEDD (49.94 ± 5.6 vs. 42 ± 7.9 mm, p0.0001), left ventricular end systolic dimension - LVESD (37.31 ± 6 vs. 29.21 ± 10.9 mm, p0.0001) and a higher NT-proBNP (10918 ± 1228 vs. 461 ± 100 pg/mL, p0.0001) than patients without CHF. NT-proBNP values increased with the severity of ventricular impairment. Significant differences were found between patients with LVEF25 % and patients with moderate ventricular impairment (LVEF = 26 - 40%) and mild ventricular impairment (LVEF = 41-60%, p0.001). The group of patients with LV dilation, had significantly higher BNP levels than those with normal LVEDD (12416 ± 1060 pg/ml vs. 6113 ± 960, p = 0.009) and LVESD (10416 ± 1160 vs. 4513 ± 960 pg/ml, p = 0.008). Area under ROC curve for the diagnosis of CHF was significantly higher for NT-proBNP (AUC 0.99, p0.003). The sensitivity of NT-proBNP value of300 pg/mL for the diagnosis of CHF was 100% and specificity was 42%. A cut-point of 300 pg/mL NT-proBNP had 100% negative predictive value to exclude acute CHF.NT-proBNP is strongly associated with two-dimensional echocardiographic determination of left ventricular dimensions and EF in identifying CHF in patients with acute dyspnoea.

To determine the prevalence of coronary artery disease in patients undergoing valve surgery at a tertiary care cardiac centre.The medical records of 144 consecutive patients who underwent mitral, aortic or dual (mitral and aortic) valve replacement surgery at the Tabba Heart Institue between January 2006 to December 2008 were retrospectively reviewed. All patients underwent coronary angiogram. Significant coronary artery disease (CAD) is defined as coronary stenosis ofor = 50%.There were 74 (51.4%) males and 70 (48.6%) females in the study. The mean age was 51.64 +/- 11 years. Of all, 73 (50.7%) underwent mitral valve replacement, 47 (32.6%) had aortic and 24 (16.7%) had dual valve replacement. Out of 144 patients, 99 (68.8%) had50% coronary stenosis and remaining 45 (31.3%) hador = 50% stenosis. In patients who had undergone mitral valve replacement (MVR), significant coronary disease was found in 32.9%, whereas in patients who had undergone aortic valve replacement (AVR) and dual valve replacement (DVR) the prevalence of coronary disease was 31.9% and 25% respectively.Our results suggest that the overall prevalence of coronary artery disease in patients undergoing valve surgery in our population is comparable with prevalence reported in international data.

To determine the safety and success of transradial coronary angiography and angioplasty in a Pakistani population.This was a prospective study on 264 consecutive patients undergoing transradial coronary angiography (TRCAG) and angioplasty (TRCAP) at Tabba Heart Institute, Karachi between November to December 2008. All patients enrolled in the study underwent Allen's test to ensure dual arterial supply to the hand. Modified Allen's test was performed only when Allen's test was abnormal. Patients were excluded from the study if they had abnormal Allen's and modified Allen's test, were on haemodialysis or had abnormal serum creatinine level. The main outcome measures were success rate and complications of TRAG and TRCAP.The mean age was 57 +/- 11.08 years with 199 (75.4%) males and 64 (24.6%) females. A total of 182 (76.3%) coronary angiographies and 82 (76.8%) coronary angioplasties were preformed from the trans-radial route in the study period. Overall procedural success rate was 94% for TRCAG with mean procedure time of 23.74 +/- 6.26 minutes and mean fluoroscopy time of 5.65 +/- 2.3 minutes. The success rate for TRCAP was 93.6% with mean procedure time of 62 +/-10.6 minutes and mean fluoroscopy time of 15.78 +/- 8.90 minutes. Only 1 patient had mild forearm haematoma and asymptomatic radial artery occlusion occurred in 4 (1.5%) study patients.Trans-radial artery cannulation is a safe and successful route for performance of coronary procedures. It can be used as an acceptable alternate to transfemoral approach.

To determine clinical indications and one month outcome of Percutaneous Coronary Interventions (PCI) in a tertiary care centre.We prospectively conducted a descriptive study on 259 symptomatic coronary artery disease patients, who underwent primary, rescue or elective PCI with stent deployment at the Tabba Heart Institute, from May 2005 to September 2006. The primary objective of the study was to identify--stable angina, unstable angina, Non-ST elevation myocardial infarction (NSTEMI), ST elevation myocardial infarction (STEMI), congestive heart failure (CHF) and cardiogenic shock) and thirty days outcome of PCI in terms of mortality, peri-procedural myocardial infarction, re-infarction and stent thrombosis. This was done according to the standard guidelines of Canadian Cardiovascular Society and New York Heart Association classification. The patients were followed for one month and complications were noted.The mean age of sample was 54.9 +/- 10.6 years. The indications were stable angina (32.4%), unstable angina (13.9%), NSTEMI (18.9%), STEMI (35.1%), CHF (5.4%) and cardiogenic shock (1.5%). The outcome was mortality (2.7%), peri-procedure MI (0.4%), re-infarction (3.08%), cardiogenic shock (1.5%) and stent thrombosis (4.3%).Our clinical indications and outcome are comparable with international findings. Stable angina was a major indication and stent thrombosis was the major complication observed, particularly after primary percutaneous intervention for STEMI.

To determine the doppler derived mean gradients of St Jude mechanical prosthesis in early postoperative period in patients undergoing valve replacement at a tertiary care cardiac centre.Medical records of 190 consecutive patients who underwent 233 mitral, aortic or dual (mitral and aortic) valve replacement by St Jude bileaflet mechanical prosthesis at Tabba Heart Institute, between March 2006 to December 2008 were reviewed. Doppler derived mean gradients were assessed predischarge and recorded.There were 98 (51.5%) males and 92 (48.5%) females in the study cohort. The mean age was 40 +/- 14 years. Of the total, 101 (53%) had mitral, 46 (24.2%) had aortic and 43 (22.6%) patients had dual valve replacement. Doppler derived mean gradient was assessed across 144 mitral and 89 aortic St Jude mechanical prosthesis. Doppler derived mean gradient for St Jude mitral prosthesis was 3.5 mm Hg and for St Jude aortic prosthesis was 10.2 mm Hg.The study determines baseline gradients across mitral and aortic St Jude mechanical prosthesis in our population. These can be used as reference gradients to assess St Jude prosthetic valve function in patients who did not have early postoperative doppler assessment.

To determine the correlation of cardiac troponin I (cTnI) 10 folds upper limit of normal (ULN) and extent of coronary artery disease (CAD) in Non-ST-elevation myocardial infarction (NSTEMI).A cross-sectional study was conducted on 230 consecutive NSTEMI patients admitted in Tabba Heart Institute, Karachi between April to December 2008. cTnI was measured using MEIA method. All patients underwent coronary angiography in the index hospitalization. Stenosisor = 70% in any of the three major epicardial vessels was considered significant CAD. Extent of CAD was defined as significant single, two or three vessel CAD. Chi-square test was applied to test the association between cTnI levels and CAD extent.Out of 230 patients, in 111 patients with cTnI levelsor = 10 folds upper limit of normal (ULN), 25 (22.52%) had single vessel, 40 (36%) had two vessel and 34 (30.6%) had three vessel significant CAD, whereas in 119 patients with cTnI levels10 folds ULN, 23 (19.3%) had single vessel, 37 (31.1%) had two vessel and 55 (46.2%) had three vessel significant CAD. The results suggest that there was an insignificant association between the cTnI levels and single vessel, two vessel and the overall CAD extent (p = 0.35, p = 0.21 and p= 0.13 respectively), however there was a statistically significant association between the cTnI levels and three vessel CAD (p0.04).Higher cTnI levels are associated with an increased proportion of severe three vessel CAD involvement. Prompt identification and referral of this patient subset to early revascularization strategies would improve clinical outcomes.

We are reporting the case of a 57 years old male, hypertensive, diabetic, dyslipidaemic who presented with exertional angina. He had a coronary artery bypass surgery, one year ago. He underwent left heart catheterization with graft study which showed critical native triple vessel disease with patent arterial graft to left anterior descending and occluded venous grafts to obtuse marginal and right coronary artery. The procedure was complicated by catheter induced dissection of the ascending aorta. Three days later he developed cholesterol emboli syndrome, that was treated symptomatically.

To determine the association of prolonged ST segment depression after an exercise test with severity of coronary artery disease.A cross sectional study of 100 consecutive patients referred to the cardiology laboratory for stress myocardial perfusion imaging (MPI) conducted between April-August 2008. All selected patients were monitored until their ST segment depression was recovered to baseline. ST segment recovery time was categorized into less and more than 5 minutes. Subsequent gated SPECT-MPI was performed and stratified according to severity of perfusion defect. Association was determined between post exercise ST segment depression recovery time (5 minutes and5 minutes) and severity of perfusion defect on MPI.The mean age of the patients was 57.12 +/- 9.0 years. The results showed statistically insignificant association (p0.05) between ST segment recovery time of5 minutes and5 minutes with low, intermediate or high risk MPI.Our findings suggest that the commonly used cut-off levels used in literature for prolonged, post exercise ST segment depression (5 minutes into recovery phase) does not correlate with severity of ischaemia based on MPI results.