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Background: To find out the frequency and pattern of left main stem (LMS) stenosis among patients who had coronary angiography in a tertiary care hospital. Methodology: The cross-sectional observational study was carried out for the duration of six months. Total number of 123 patients referred for coronary angiography to the department of cardiac catheterization (Cath Lab). All patients underwent coronary angiography, diagnosis of LMS stenosis was made. Pattern of LMS (ostial or distal) and vessel involvement was also observed. Results: Mean age of patients was 51.12±10.44 years. There were 81 (65.85%) males and 42 (34.15%) female patients. There were 39 (31.71%) obese, 50 (40.65%) patients were diabetics, hypertension was found in 83 (67.48%) patients, and 46 (37.40%) were smokers. LMS disease was found in 15 (12.20%) patients. Ostial LMS was found in 05 (4.07%) and distal LMS in 10 (8.13%) patients. Conclusion: There is a high prevalence of left main disease. Majority of patients with LMS have distal lesions.

Objectives: To determine frequency of left main stem (LMS) and triple vessel coronary artery disease (3VCAD) in patients of Non-ST-elevation myocardial infarction (NSTEMI) and to compare the frequency of LMS and 3VCAD in patients with NSTEMI with or without ST elevation in lead aVR. Methodology: Total 346 patients with NSTEMI having age 30-70 years were included in this descriptive cross-sectional study. The data on demographic details was collected. All patients underwent electrocardiography (ECG) and cardiac specific troponin-I assessment. Patients were categorized as NSTEMI with or without ST-elevation in lead aVR. Coronary angiography was performed in all patients and angiographic findings were noted. Results: Mean age of patients was 51.87±10.03 years. There were 218 (63.01%) males and 128 (36.99%) female patients. 182 (52.60%) patients of NSTEMI had ST elevation in aVR. LMS disease was found in 53 (29.10%) patients with ST elevation in aVR. Sensitivity, specificity, positive predive value and negative predictive value of ST elevation in aVR for LMS disease was 62.35%, 50.57%, 29.12% and 80.49% respectively. 3 VCAD was found in 54 (29.70%) with ST elevation in aVR. Sensitivity, specificity, positive predive value and negative predictive value of ST elevation in aVR for 3VCAD was 77.14%, 53.52%, 29.67% and 90.24% respectively. Conclusion: NSTEMI patients with ST elevation in aVR may have higher chances of having LMS disease or 3VCAD. There is high negative predictive value for ST elevation in aVR to predict LMS disease or 3VCAD.

Objectives: To find out the prevalence of undiagnosed atrial fibrillation and the risk factors associated with atrial fibrillation in patients with complaints of palpitations having normal sinus rhythm on electrocardiogram. Methodology: The descriptive cross-sectional study was carried out from 1st of January 2017 to 31st of December 2020 at Department of Cardiology, Chaudhary Pervaiz Elahi Institute of Cardiology, Multan. All the patients presented with the complaints of palpitations for six months with normal sinus rhythm on standard 12 lead electrocardiogram were included in the study. After written informed consent, a Holter monitor was applied for 48 h. Data regarding gender, age, diabetes mellitus, hypertension, smoking, obesity, stable ischemic heart disease, valvular or nonvalvular structural heart defect and hyperthyroidism was collected on a preformed Performa for each patient. Presence of atrial fibrillation was noted on Holter monitoring. Results: Total 1891 patients were studied over the period of 4 years. The mean age of the studied population was 55.99 ±16.28 years. There was male dominance with 70.3% (n=1329) males and 29.7% (n=562) females. 12.50% (n=236) patients had been diagnosed with atrial fibrillation on Holter monitoring. Age group of patients with age more than 75 years has high burden of atrial fibrillation (31.34%). Conclusion: A large number of studied population has been diagnosed with atrial fibrillation on Holter monitoring who presented with palpitation and have normal sinus rhythm on electrocardiogram.

Objective: The objective of the study was to assess the frequency of clot in left atrium by transesophageal echocardiographic diagnostic procedure (TEE) in patients with rheumatic severe mitral stenosis (MS) in those patients in whom transthoracic echocardiographic diagnostic procedure (TTE) did not observe any clot in left thrombus. Methodology: The descriptive cross-sectional study was carried out on 369 patients with rheumatic severe MS. Patients having mitral valve are of 1.5 cm2 or less planned for PMV were included in study. Non-cooperative patients were excluded. It was decided to do TEE on a similar day before the intervention to assess LA thrombus. Results: The mean age of the included patients was 45.65 ±11.54 years. There were 122 (33.1%) male patients and 247 (66.9%) female patients. In this study, clot in LA was diagnosed in 29.5% patients having negative TTE. LA clot was found in 33 male patients (30.3%) and 76 female patients (69.7%). Conclusion: There is a high risk of missing LA thrombus on transthoracic echocardiography, therefore we recommend performing TEE in patients with normal TTE study before the procedure.

Objectives: The purpose of our study was to determine the frequency of left main stem disease on coronary angiography in patients with non-ST segment elevation myocardial infarction (NSTEMI). By studying the exact frequency of the left main stem (LMS) disease in NSTEMI patients in our population, we will be able to better risk stratify and plan further management for this group of patients. Methodology: This cross-sectional study was conducted at the Department of Cardiology, Chaudhry Pervez Elahi Institute of Cardiology (CPEIC), Multan from 14-June-2017 to 13-Dec-2017. Total 248 patients with NSTEMI were included in the study. Coronary angiography was done in all selected patients. Diagnosis of LMS disease was made when stenosis in the LMS artery was more than half of the diameter of the left main coronary artery. Results: There were 80.6% male and 19.4% female patients with a mean age 49.39±7.23 years. In this study, 37.1% patients were found with left main stem disease. Among LMS disease patients, there was 82.6% male and 17.4% female patients. 55.4% of patients were aged 50 years and above. 40.2% were smokers and 33.7% were diabetic. No significant association of LMS was found with the age group (p=0.66), gender (p=0.54), smoking status (p=0.54) and diabetes mellitus (p=0.95). Conclusion: In this study, we found a high frequency of LMS disease in our population. This subset of patients with NSTEMI requires early re-vascularization. This also signifies a need to re-evaluate our screening programs and management protocols related to coronary artery disease.

Objective: To determine the potential risk factors in patients aged under 40 years with a positive Exercise Tolerance Test (ETT).Study Design: Prospective study.Place and Duration of Study: The study was carried out at the Department of Cardiology Choudhary Pervaiz Elahi Institute of Cardiology (CPEIC), Multan, Pakistan, from 1st January 2021 to 1st March 2022.Materials and Methods: The study included 285 patients with positive ETT, selected through non-probability consecutive sampling. Patients were grouped into two age brackets: 20-30 and 31-40. Patients were advised to stop taking nitrates, calcium channel blockers and beta blockers a day before the test. The patients were investigated for potential risk factors that caused the positivity of EET.Results: The study was conducted on 285 patients. The age of the participants was 30.12±5.64 years. There were 185 (64.9%) males and 100 (35.1%) females. The BMI was .32±1.38 kg/m2. Obesity was recorded in 38 (13.3%) patients, 85 (29.8%) had a family history, 63 (22.1%) had dyslipidemia, hypertension in 58 (20.4%), 32 (11.2%) had a smoking history, and 56 (19.6%) had diabetes mellitus. Diabetes Mellitus (p=0.00) and dyslipidemia (p=0.004) were found to be the most significant risk factors in patients aged between 31-40 years with positive EET.Conclusion: Diabetes mellitus and dyslipidemia are the most significant causes of positive EET in patients aged between 31-40 years.

Objective: The objective of our study was to assess the reduction in severe pulmonary hypertension after PTMC in patients of severe mitral stenosis. Methodology: One hundred twenty-four patients of severe mitral stenosis with severely elevated pulmonary pressures more than 50 mmHg between 15 to 60 years of age of either gender undergoing elective PTMC at Chaudry Pervaiz Elahi Institute of Cardiology, Multan were included in this study. Post PTMC pulmonary pressures were noted 24 hours after PTMC. Results: Mean age of the patients was 35.45 ± 10.38 years. Diabetes mellitus was found to be present in 39/124 (31.5%), hypertension in 40/124 (32.3%) while no comorbidities were found in 62/124 (50%). Mean baseline pulmonary artery systolic pressure was found to be 72.61 ± 8.11 mmHg while mean pulmonary artery systolic pressure after PTMC was found to be 45.09 ± 6.06 mmHg. The pulmonary artery systolic pressure fallen from baseline by 37.92 ± 4.19 mmHg after the commissurotomy. Transvenous mitral commissurotomy was found to be effective with a minimum 1/3rd reduction in 119/124 (96%) while it was ineffective in 5/124 (4%) of the patients. Conclusion: Therefore, we conclude that balloon valvotomy is a useful procedure which results in a significant reduction in mean pulmonary artery systolic pressure irrespective of age, gender or comorbidities.

Introduction The Killip classification system was introduced for clinical assessment of patients with acute myocardial infarction (MI). It stratifies individuals according to the severity of their post-MI heart failure. This system provides effective stratification of long-term and short-term outcomes in patients with acute MI and influences the treatment strategies. Revalidation of Killip class in our local population is mandatory. We planned this study to increase cardiologist's readiness to tackle the risks associated with increased mortality in each class post ST-segment elevation MI (STEMI). Objectives were to determine the frequency of Killip classes I, II, III, and IV and in-hospital mortality in each Killip class in patients with left ventricular failure secondary to STEMI. Methods A retrospective cross-sectional study was conducted in the Department of Cardiology, Jinnah Hospital, Lahore, over a period of three years. Patients with STEMI were stratified using Killip classification, and validation was performed by determining the within 15 days in-hospital mortality in each Killip class. Results The frequency (percentage) of patients with STEMI in each Killip class from I to IV was 395 (81.4%), 46 (9.5%), 27 (5.6%), and 17 (3.5%), respectively, while the in-hospital mortality in each Killip class came out to be 39 (9.9%), 4 (8.7%), 25 (92.6%) and 17 (100%), respectively. The presence of diabetes, history of smoking, and body mass index (BMI) of more than 30 kg/m2 were significant contributors to mortality, along with higher Killip class and age of presentation. Conclusions It is concluded that the Killip classification system is a valid tool for risk stratification for patients after STEMI, especially in resource-limited countries.

Objectives: Revalidation of Killip class in our local population is mandatory. We planned this study to increase cardiologist readiness to tackle the risks associated with increased mortality in each class post ST elevation myocardial infarction (STEMI). Objectives were to determine frequency of Killip class I, II, III, IV and in-hospital mortality in each Killip class in patients with left ventricle failure secondary to STEMI.Results: This cross-sectional Study was conducted in Department of Cardiology, Jinnah Hospital. Patients with STEMI were stratified using Killip Class and validation was performed by determining the within 15 days in-hospital mortality in each Killip class. Patients with chronic disease were excluded. The frequency (percentage) of patients with STEMI in each killip class from I to IV was 395 (81.4%), 46 (9.5%), 27(5.6%) and 17(3.5%) respectively while in-hospital mortality came out to be, 39 (9.8%), 4 (8.6%), 25 (92.5%), and 17(100%), in Killip class I, II, III and IV respectively. Presence of diabetes, history of smoking and BMI more than 30kg/m2 were significant contributor to mortality along with higher Killip class and age of presentation. It is concluded that Killip class is a valid tool for risk stratification for patients after STEMI.

Introduction Left ventricular thrombus (LVT) formation is a prominent complication of acute myocardial infarction (AMI). Accurate and prompt detection of the condition is important as it poses a high risk for thromboembolic events that can be arrested by systemic anticoagulation. The purpose of our study was to evaluate the frequency of LVT formation in thrombolyzed and non-thrombolyzed patients with AMI to ascertain the current magnitude of the problem in the local population. Methods The study was conducted at the Chaudhry Pervaiz Elahi Institute of Cardiology in Multan, Pakistan. A total of 281 patients of either gender aged between 30-65 years with anterior wall myocardial infarction (AWMI; both thrombolyzed and non-thrombolyzed) were included in the study. Once they were enrolled in the study, all the relevant baseline investigations were performed. A detailed history was taken and examinations were done; serial ECG and echocardiography were performed till discharge from the hospital on the third day of hospitalization to record the final outcome of the study, i.e., LVT formation. Results The mean age of the patients was 55.54 ± 7.26 years. Overall, LVT formation was noted in 65 cases (23.1%), of which 11 (16.9%) were thrombolyzed patients and 54 (83.1.1%) were non-thrombolyzed. A significant association of LVT was noted with age, hypertension, family history, and duration of symptoms. Conclusion We found a high frequency of LVT formation among patients with AWMI who have not undergone thrombolytic therapy. It was observed that LVT was notably associated with advanced age, hypertension, and other comorbidities. Early presentation to the hospital and thrombolysis reduce the risk of developing LVT, which in turn can reduce morbidity and mortality in such patients.

Introduction Non-ST segment elevation myocardial infarction (NSTEMI) is becoming more common than ST segment elevation myocardial infarction (STEMI) and data regarding presence of underlying multivessel coronary artery disease (MVCAD) in these patients is consistent in locoregional population that leads to lethal delays in proper management. Therefore, in the current study, we aimed to evaluate the frequency of MVCAD in NSTEMI with markedly raised troponin T levels. This will help to identify patients that should be labeled as high risk and must be referred for coronary revascularization on priority basis, so that clinical outcomes can be improved in these patients. Methods This cross-sectional research study was carried out at Chaudhary Pervaiz Elahi Institute of Cardiology, Multan over a period of one year. A total of 326 patients with history of chest discomfort within past 48 hours of presentation or angina equivalent symptoms and cardiac troponin T more than 500 ng/l were included in the study. Coronary angiography was done within 72 hours of same hospital admission. The outcome variable i.e. MVCAD was determined. Results Mean age of patients was 50.74 ± 7.75 years with range of 30 to 60 years. MVCAD was found in 107 (32.82%) patients, whilst there was no MVCAD in 219 (67.18%) patients. Moreover, no significant association of MVCAD was noted with age or smoking. Conclusion We found presence of MVCAD in a considerable number of patients presenting with NSTEMI. The key to detect the underlying presence of MVCAD in these patients is lifted troponin T levels. Therefore, we conclude that any patient with elevated troponin T levels, even in the absence of ST segment elevation, should undergo cardiac catheterization to detect presence of MVCAD as this subset of patients can benefit from early revascularization including coronary artery bypass graft (CABG) surgery.

Objectives Radial artery occlusion is a silent complication of a transradial approach to cardiac catheterization that may complicate subsequent transradial procedures in patients undergoing cardiac catheterization. A transradial band reduces vascular complications and provides brisk, powerful and effective haemostasis. The purpose of this study was to assess the frequency of radial artery occlusion in 180 patients undergoing transradial coronary catheterization.Results The mean age of the study cohort was 54.19 ± 12.30 years. Radial artery occlusion was found in 14 (7.8%) patients. When stratifying by age group and sex, there was no significant difference in radial artery occlusion between age groups and sex. It was likewise found that comorbidities such as diabetes mellitus, hypertension and smoking, increased the risk of radial artery occlusion however this was observed to be significant only for diabetes mellitus. We therefore conclude that a transradial pneumatic pressure band is an extremely helpful and safe strategy to prevent radial artery occlusion.

Objectives Ki67 is the most commonly used marker to evaluate proliferative index in breast cancer, however no cutoff values have been clearly defined for high ki67 index. Cancer management should be according to loco-regional profile; therefore, we aimed to determine ki67 index in 1951 cases of intrinsic breast cancer subtypes and its association with other prognostic parameters in our set up. Results Triple negative breast cancers showed highest ki67 index (mean 50.9 ± 23.7%) followed by Her2neu (mean 42.6 ± 21.6%) and luminal B cancers (mean 34.9 ± 20.05%). Metaplastic and medullary breast cancers significantly showed higher ki67 index as compared to ductal carcinoma, NOS. No significant association of ki67 index was noted with any of the histologic parameters in different subtypes of breast cancer expect for tumor grade. Although, ki67 index is a valuable biomarker in breast cancer, however no independent prognostic significance of ki67 could be established in our study.