Predicting the Length of Stay of Cardiac Patients Based on Pre-Operative Variables-Bayesian Models vs. Machine Learning Models.

Length of stay (LoS) prediction is deemed important for a medical institution's operational and logistical efficiency. Sound estimates of a patient's stay increase clinical preparedness and reduce aberrations. Various statistical methods and techniques are used to quantify and predict the LoS of a patient based on pre-operative clinical features. This study evaluates and compares the results of Bayesian (simple Bayesian regression and hierarchical Bayesian regression) models and machine learning (ML) regression models against multiple evaluation metrics for the problem of LoS prediction of cardiac patients admitted to Tabba Heart Institute, Karachi, Pakistan (THI) between 2015 and 2020. In addition, the study also presents the use of hierarchical Bayesian regression to account for data variability and skewness without homogenizing the data (by removing outliers). LoS estimates from the hierarchical Bayesian regression model resulted in a root mean squared error (RMSE) and mean absolute error (MAE) of 1.49 and 1.16, respectively. Simple Bayesian regression (without hierarchy) achieved an RMSE and MAE of 3.36 and 2.05, respectively. The average RMSE and MAE of ML models remained at 3.36 and 1.98, respectively.

PAKistan Study of prEmature coronary atHerosclerosis in young AdulTs (PAK-SEHAT): a prospective longitudinal study protocol investigating the prevalence, severity and determinants of atherosclerotic cardiovascular disease in the young adult Pakistani population.

INTRODUCTION: Atherosclerotic cardiovascular disease (ASCVD) is a major cause of morbidity, mortality and health expenditures worldwide. Despite having higher ASCVD in the Pakistani population, data on subclinical coronary atherosclerosis in young Pakistanis remain scarce. The PAKistan Study of prEmature coronary atHerosclerosis in young AdulTs (PAK-SEHAT) aims to assess the prevalence, severity and determinants of subclinical coronary atherosclerosis among Pakistani men (35-60 years) and women (35-65 years) free of clinically symptomatic ASCVD and will assess 5-year rates of ASCVD events. METHODS AND ANALYSIS: PAK-SEHAT is an ongoing prospective cohort study with 2000 participants from all provinces of Pakistan who will be interviewed at the baseline along with phlebotomy, measurement of carotid intima-media thickness (CIMT) and coronary CT angiography (CCTA). Phlebotomy will be repeated at 2.5 years, whereas CIMT and CCTA will be repeated at 5 years. We will report the frequency of maximal coronary stenosis ≥50% and ≥70%, number of coronary vessels with plaque and the number of coronary segments affected per participant on CCTA. We will use Cox proportional hazards regression models to evaluate the association between baseline characteristics and incident ASCVD events during follow-up. These associations will be presented as HRs with 95% CIs. ETHICS AND DISSEMINATION: The study protocol was approved by the Tabba Heart Institute Institutional Review Board (THI/IRB/FQ/22-09-2021/016). All study procedures are consistent with the principles of the Declaration of Helsinki. Findings of the study will be disseminated via peer-reviewed publications and conference presentations. TRIAL REGISTRATION NUMBER: NCT05156736.

Predictors of Non-Obstructive Coronary Artery Disease in Patients Undergoing Elective Coronary Angiography.

Background: Appropriate patient selection for coronary angiography (CAG) is essential to minimize the unnecessary risk of morbidities and exposure to radiation and iodinated contrast. This becomes even more relevant in low-to-middle-income settings where most health expenditures are out-of-pocket due to lack of medical insurance. We determined predictors of non-obstructive coronaries (NOC) in patients undergoing elective CAG. Methods: CathPCI Registry®, single-center data was extracted for 25,472 patients who had CAG over an eight year period. After excluding patients for compelling conditions or known CAD, 2,984 (11.7%) patients were included in this study. Non-Obstructive Coronaries was defined as <50% left main coronary artery and major epicardial vessel stenosis. Multiple Cox proportional algorithm was employed to report prevalence ratios (PR) of predictors of NOC along with 95% confidence interval. Results: Mean age of patients was 57.9 ± 9.7 years, 23.5% were women. Preprocedural non-invasive testing (NIT) was performed in 46% of the patients; of which 95.5% reported to be positive but only 67.3% were stratified as high risk. Of 2,984 patients undergoing elective CAG, 711 (24%) had NOC. Predictors of NOC included younger age <50 years (PR: 1.3, CI: 1.0-1.5), Women (1.8, 1.5-2.1), low (1.9, 1.5-2.5) and intermediate risk stratification (1.3, 1.0-1.6) on Modified Framingham Risk Score and inappropriate (2.7, 1.6-4.3) and uncertain (1.3, 1.1-1.6) classification of CAG on Appropriate Use Criteria. Patients with heart failure as an indication of CAG (1.7, 1.4-2.0) and No NIT or positive low risk NIT (1.8, 1.5-2.2) were more likely to have NOC. Conclusion: Approximately one out of four patients undergoing elective CAG had NOC. Yield of diagnostic catheterization can be improved by adjudicating NIT especially in younger patients, women, patients with heart failure as an indication of CAG, patients classified as inappropriate on Appropriate Use Criteria and patients categorized as low or intermediate risk on MFRS.

Gender Differences in Clinical Outcomes After Percutaneous Coronary Intervention-Analysis of 15,106 Patients from the Cardiac Registry of Pakistan Database.

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 (p <0.05).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.

Management and outcome of post-myocardial infarction ventricular septal rupture-A Low-Middle-Income Country Experience.

BACKGROUND: Ventricular septal rupture (VSR) is a rare complication after acute myocardial infarction (AMI) especially in the reperfusion era but its associated mortality has remained high. This case series evaluated in-hospital and intermediate-term mortality in VSR patients. Additionally, we also analyzed risk factors, clinical presentation, intervention, and predictors of in-hospital mortality in VSR patients. METHODS: Data of 67 patients with echocardiography confirmed diagnosis of VSR from January 2011 to April 2020 was extracted from hospital medical records. Records were also reviewed to document 30 day and 1-year mortality, recurrent heart failure admission, repeat myocardial infarction, and revascularization. In addition, telephonic follow-up was done to assess health-related quality of life(HRQOL) assessed by KCCQ-12. SCAI shock classification was used to categorize severity of cardiogenic shock. Univariate and multivariable logistic regression was used to determine predictors of in-hospital mortality. Survival function was presented using the Kaplan-Meier survival curve. RESULTS: Mean age of patients was 62.7 ± 11.1 years, 62.7% were males. 65.7% of the patients presented more than 24 hours after MI and did not receive reperfusion therapy. Median time from AMI to VSR diagnosis was 2 (1-5) days. VSR closure was attempted in 53.7% patients. In-hospital mortality was 65.7%. At univariate level, predictors of in-hospital mortality were non-surgical management, basal VSR, right ventricular dysfunction, early VSR post-MI, and severe cardiogenic shock at admission (class C, D, or E). Adjusted predictors of in-hospital mortality included non-surgical management, basal VSR and advanced cardiogenic shock. There were 5 deaths during median followup of 44.1 months. HRQOL in patients available on followup was good (54.5%) or excellent (45.5%). CONCLUSION: High in-hospital mortality was seen in VSR patients. VSR closure is the preferred treatment to get long-term survival, however, timing of repair as well as severity of cardiogenic shock plays a significant role in determining prognosis.

Outcomes and complications of percutaneous device closure in adults with secundum atrial septal defect.

OBJECTIVE: To assess immediate outcome and complications of Amplatzer septal occluder percutaneous device for closure of secundum atrial septal defect in adults, and to determine regression in right ventricular size, reduced pulmonary arterial systolic pressure and incidence of device embolization at follow-up. METHODS: The single-cohort, ambi-directional, observational study was conducted at the Tabba Heart Institute, Karachi, from January 2013 to July 2018, and comprised patients admitted consecutively for percutaneous atrial septal defect closure. Pre-closure trans-oesophageal echocardiogram was performed in all cases to ensure adequacy of defect margins necessary for device stability. Immediate procedure success and complications were determined by trans-oesophageal echocardiogram, while transthoracic echo was done on follow-up. Data was analysed using SPSS 21. RESULTS: Of the 64 patients, 41(71.9%) were females. The overall mean age was 36.6±14 years. Median size of atrial septal defect was 21mm (interquartile range: 17-26mm). Immediate success was observed in 59(92.2%) patients, and there were 5(8%) acute device embolization events. Small residual atrial septal defect was found in 4(6.3%) cases. On 20-month follow-up, 54(84.4%) patients showed improved symptoms. Repeat transthoracic echo was performed in 39(60.1%) cases, and there were no late embolic events or residual atrial septal defect. Right ventricular size normalized in 34(89.5%) cases, mean pulmonary arterial systolic pressure reduced significantly compared to pre-closure measurement (p<0.001). CONCLUSIONS: Percutaneous atrial septal defect closure was found to be safe and effective in adults with secundum atrial septal defect. Timely closure resulted in improved symptoms, right ventricular remodelling and reduced pulmonary arterial systolic pressure at intermediate-term follow-up.

Cases of acute coronary syndrome and presumed cardiac death prior to arrival at an urban tertiary care hospital in Pakistan during the COVID-19 pandemic.

BACKGROUND: A reduction in overall acute coronary syndrome (ACS) cases, increases in the severity of ACS presentation, and increased rates of out-of-hospital cardiac arrest (OHCA) have been reported from multiple countries during the COVID-19 pandemic. The attributed factors include COVID-19 infection, fear of COVID-19 and resultant avoidance of health care facilities, and restrictions on mobility. Pakistan, a country with a high burden of cardiovascular disease (CVD) and challenges related to health care access, will be expected to demonstrate these same findings. Therefore, we compared ACS hospitalization, ACS severity, and patients who have already died (dead on arrival, or DOA) due to presumed OHCA at a tertiary cardiac hospital during pre-pandemic and intra-pandemic periods in Pakistan. METHODS: Standardized data elements were extracted from the charts of patients with ACS, and telephonic verbal autopsies (VA) using a validated tool were conducted for patients who were arrived DOA. As a comparison, cases during the same months prior to the COVID-19 were analyzed for respective waves. Events were counted, and proportions and frequencies are reported for each time period. RESULTS: A total of 4,480 ACS cases were reviewed; 1,216 cases during March-July 2019, 804 cases in the same months of 2020 (33.8% decrease); 1,304 cases in August 2019-January 2020 and 1,157 in the corresponding months of 2020 and 2021 (11.2% decrease). There was no observed change in the baseline characteristics of patients with ACS or their symptom-to-door time, and in-hospital mortality was unchanged across all time periods. There were 218 DOA cases in pre-pandemic months and 360 cases during the pandemic. The pre-pandemic rate of DOA was 12/1000 emergency patients (95% CI 10-13) compared to 22/1000 (95% CI 22-27) during the pandemic (30/1000in the 1st wave and 17/1000 during 2nd wave). On VA, CVD was found to be the major cause of death during both time periods. CONCLUSION: At a cardiac hospital in Pakistan, the COVID-19 pandemic was associated with a reduction in ACS hospitalization and an increased DOA rate.

Randomized trial comparing radial hemostasis techniques; catechol conjugated chitosan pad (InnoSEAL) versus pneumatic compression band.

OBJECTIVES: Primary objectives: to compare radial artery occlusion rate (RAO) after cardiac catheterization between catecholamine-chitosan pad (InnoSEAL) and pneumatic compression device (PCD) and to compare difference in hemostasis time and radial monitoring termination time between two arms. Secondary objectives: to compare radial site bleeding and ease of use of two methods by cath-lab technicians. BACKGROUND: Hemostatic pads may be an effective alternative to PCD with lesser chance of access site complications with advantage of shortened compression time. METHODS: Patients (N = 606) undergoing trans-radial, diagnostic or interventional procedures were randomized to either InnoSEAL arm or PCD. RAO was assessed using US Duplex; performed 6-24 hr posthemostatic device removal. Time to hemostasis was recorded as per defined protocols. Ease of use among cath-lab technicians was assessed through 5 point Likert scale. RESULTS: Data of 597 patients was analyzed (299 InnoSEAL, 298 PCD). RAO rate was 8.5% in InnoSEAL and 9.4% in PCD arm (p value >.05). The pooled median hemostasis time and time to termination of radial monitoring was 42 versus 225 min and 50 versus 240 min in InnoSEAL and PCD arms, respectively (p value: <.01). There was no difference in Grade I/II hematoma (InnoSEAL: 1.3% vs. PCD: 3.4%). InnoSEAL was marginally acceptable compared to PCD by technicians. CONCLUSION: Hemostasis time is significantly shorter in InnoSEAL arm with reasonable acceptability to its usage among cath lab staff. RAO and bleeding complications are comparable between the arms. Based on our findings, it seems feasible to include Chitosan based hemostasis pad routinely in cath lab.

Major adverse cardiovascular events in patients undergoing percutaneous coronary intervention or coronary artery bypass graft with underlying chronic kidney disease.

OBJECTIVE: To assess early and late outcome in severe chronic kidney disease patients undergoing revascularisation. METHODS: The retrospective ambi-directional cohort study was conducted at Tabba Heart Institute, Karachi, and comprised data from May, 2012, to July,2016, related to severe chronic kidney disease patients with creatinine clearance <30ml/min or end-stage renal disease on haemodialysis who had undergone coronary artery bypass graft / percutaneous coronary intervention. Early outcome was in-hospital major adverse cardiac event, like mortality, stroke and new haemodialysis. Late outcome was major adverse cardiac event, like mortality, stroke, re infarction and re-revascularisation. Data was analysed using Stata 12.1. RESULTS: Of the 228 patients with mean age of 64.2±10.8 years, 109(47.8%) with a maen age of 65.4±11.6 had undergone percutaneous coronary intervention, and 119(52.2%) with a mean age of 64.2±10.8 years had undergone coronary artery bypass graft. Overall mortality was 36(15.8%) patients; 15(13.7%) percutaneous coronary intervention, 21(17.6%)coronary artery bypass graft (p>0.05). Predictors of in-hospital adverse events were coronary artery bypass graft and cardiogenic shock (p<0.05). Follow-up was available in 181(94.3%) patients with a mean duration of 22.0±13.9 months. Heart failure and post-procedure stroke were independent predictors of late outcome (p<0.05). CONCLUSIONS: Among patients with severe chronic kidney disease or end stage renal disease undergoing revascularisation, percutaneous coronary intervention PCI was performed in patients with less complex anatomy or as emergency for acute ST-elevation myocardial infarction. Coronary artery bypass graft patients had higher early mortality, but improved late survival.

Combination of InnoSEAL plus TR band compared with TR band alone for radial artery outcomes in patients undergoing transradial coronary intervention (InnoSEAL-II): an open-label randomised controlled trial (protocol).

INTRODUCTION: About 2%-30% of cardiac catheterisation procedures get complicated by radial artery occlusion (RAO). Ensuring patent haemostasis appears to be an important factor in reducing RAO. Currently employed method is a radial compression device (RCD) such as transradial band (TRB) that take hours to achieve haemostasis and cause discomfort to the patients. Haemostatic pads offer an alternative to RCD with reduced time to achieve haemostasis. Our trial aims to determine the non-inferiority of the catecholamine chitosan-based pad (InnoSEAL haemostatic pad) used in conjunction with TRB (InnoSEAL +TRB) when compared with the TRB alone in reducing composite adverse access site outcomes. METHODS AND ANALYSIS: It will be an open-label, parallel, randomised controlled trial on 714 adult patients (325 in each arm) undergoing coronary procedure using transradial approach at a cardiac health facility over 7 months duration. InnoSEAL patch along with TRB will be used to control bleeding in intervention arm and TRB alone in control arm, which is the standard practice. Study primary outcomes include RAO and haematoma; secondary outcomes are compression time, patient discomfort, time to discharge and ease of use of the intervention technique by the healthcare staff. χ2 test will be used to compare the categorical outcomes between two arms and student's t-test for continuous outcomes. A p value of <0.05 will be considered significant. ETHICS AND DISSEMINATION: Ethical approval for the study has been obtained from the Institutional Review Board of Tabba Heart Institute number IORG0007863. Findings will be disseminated through seminars and scientific publications. TRIAL REGISTRATION NUMBER: NCT04380883; Pre-results.

Frequency, predictors and prognosis of worsening renal function in patients admitted with acute heart failure.

OBJECTIVE: To calculate frequency of worsening renal failure (WRF) in patients with acute decompensated heart failure (ADHF), to evaluate predictors of WRF and to assess its effect on in-hospital and 12 month adverse outcomes. METHODS: A single center observational prospective study was conducted on consecutive patients admitted with ADHF from Sept 2016 - February 2017. Follow-up was done for 12 months post discharge. Data were obtained from electronic medical records and telephonic calls. Early adverse outcome was composite of hospital mortality, prolonged length of stay (LOS) >4days or new need for haemodialysis. Intermediate term adverse event was composite of 12 months all-cause mortality or re-hospitalization. RESULTS: Total of 247 ADHF patients were admitted. Mean age was 67.6±33.4 years. Males were 163 (65.9%). WRF was found in 57 (23.1%) patients. Predictors of WRF were age>70years, furosemide dose>400mg and admission eGFR <60ml/min. The odds of composite in-hospital outcomes were four times higher in WRF compared to stable renal function (38.6% versus 13.2%, (p<0.01) but were mainly driven by prolonged LOS (4.2 vs. 2.2 days respectively). Follow up was available for 230(97%). Intermediate term outcome was not different between two groups on log rank test. CONCLUSIONS: WRF is a significant problem in ADHF, is common in elderly patients, with baseline impaired renal function and is associated with high requirement of diuretics and prolonged hospital stay. Composite of mortality or HF hospitalization at 12 months was not different between the two groups.

Clinical characteristics and in-hospital outcome in percutaneous coronary interventions with ST elevation myocardial infarction patients developing acute kidney injury.

OBJECTIVE: To find predictors, incidence and hospital mortality of acute kidney injury in ST elevation myocardial infarction patients undergoing percutaneous coronary interventions. METHODS: The retrospective cross-sectional study was conducted at Tabba Heart Institute Karachi, and comprised data from June 2013 to December 2017 of ST elevation myocardial infarction patients undergoing percutaneous coronary interventions during index admission. Acute kidney injury was defined as serum creatinine ≥0.3 mg/dl 48hrs after percutaneous coronary intervention, and was further graded into stages I-III and the need for haemodialysis. Predicted acute kidney injury risks were calculated using Mehran and National Cardiovascular Data Registry risk scores. Stata 14 was used for statistical analysis. RESULTS: Of the 2766 cases evaluated, the incidence of acute kidney injury was found in 543(19.6%) case. Diabetes, pre-percutaneous coronary intervention heart failure, ejection fraction <40%, post-percutaneous coronary intervention thrombolysis in myocardial infarction flow<3, glomerular filtration rate<60 ml/min and increased contrast volume were significant predictors of acute kidney injury. Hospital mortality was reported in 144(5.2%) cases. CONCLUSION: Acute kidney injury is a serious complication in ST elevation myocardial infarction patients undergoing percutaneous coronary interventions and is related to adverse hospital outcomes. Pre-procedural risk scores may underestimate acute kidney injury in such patients.

Mortality and deciding factors for no revascularization in cardiogenic shock patients; a cross sectional study.

OBJECTIVE: To assess the frequency of acute coronary syndrome patients with cardiogenic shock and not undergoing revascularisation, their in- hospital outcome and reasons underlying management decisions. METHODS: The retrospective cross-sectional study was conducted at Tabba Heart Institute, Karachi, and comprised data from July 2013 to December 2017 of acute coronary syndrome with hypotension and not having under gone revascularisation. Data was analyzed using Stata 12.1. RESULTS: Of the 383 patients, 55(14.3%) did not undergo revascularisation. Overall mean age was 63.2±9.8years. Overall mortality was 45(81.8%). Revascularisation was intended in 28(51%) patients of whom 19(68%) died before undergoing cardiac catheterisation. Another 9(32%) patients died after cardiac catheterisation but before revascularisation. Common clinical reasons in the remaining 27(49%) patients not considered for revascularisation were hypoxic brain injury secondary to cardiac arrest, patient refusal, perceived patient frailty, multi-organ failure, sepsis or pre-existing stroke/ malignancy. CONCLUSIONS: Cardiogenic shock complicating myocardial infarction not treated by revascularization had a very poor early outcome. In the two-third of patients before treatment was initiated, there was cardiac arrest with failed resuscitation or poor recovery.

In-hospital management and intermediate term outcomes in stable patients with ST segment elevation myocardial infarction presenting between 12-48 hours of symptom onset versus 2-7 days after the onset of chest pain; a single center study.

OBJECTIVE: To evaluate hospital management, revascularisation and intermediate-term major adverse cardiac events amongst ST elevation myocardial infarction patients and to compare them in early and late presentations. . METHODS: The retrospective study was conducted at Tabba Heart Institute, Karachi, and comprised data from July 2013 to December 2016. ST elevation myocardial infarction patients presenting between 12-48 hours of symptom onset were designated as early-late, while those presenting 2-7 days after the onset of symptoms were designated as late-late. Data included related to patients admitted consecutively with >12hrs of chest pain without immediate reperfusion. Major adverse cardiac events were composite of death, re- myocardial infarction, need for revascularisation or heart failure. SPSS 19 was used for data analysis. RESULTS: Out of 234, patients, 110(47%) were early-late and 124(53%) were late-late. Overall mean age was 58.5±12.2years, and 188(80.3%) subjects were men. Anterior all myocardial infarction was in 134(57.3%) cases. Non-invasive assessment for ischaemia/viability was performed in 96(41%) cases and angiography in 196(83.8%). Early-late were revascularised more frequently 53(48.2%) than late-late 49(39.5%) (p>0.05). Median follow-up was 23 months (interquartile range: 13-34 months). Major adverse cardiac events occurred in 45(19.6%) patients but there was no significant difference between earlylate and late-late patients (p>0.05). CONCLUSIONS: Revascularisation was found to have favourable impact on intermediate-term adverse cardiac events.

Management, hospital outcome and revascularization trends in non-ST elevation myocardial infarction with high GRACE risk score.

OBJECTIVE: To assess clinical characteristics, management strategies and in-hospital outcome among high-risk patients of non-ST elevation myocardial infarction. METHODS: The retrospective cross-sectional study was conducted at Tabba Heart Institute, Karachi, and comprised data from July 2013 to December 2016 of adult non-ST elevation myocardial infarction patients who had first cardiac event having Global Registry of Acute Coronary Eventsrisk score>140. Subcategories were formed on the basis of score range 140-159, 160-189 and ?190.Stata 12.1 was used for data analysis. RESULTS: Of the 817 patients, 567(69.4%) were men. Overall, mean age was 66.3}9.3 years. Coronary angiography was performed in 692(84.4%). With higher risk score categories, there was less frequent use of guideline directed medical therapy, coronary angiography and percutaneous or surgical revascularisation (p<0.05 each). Overall mortality was 59(7.2%). Mortality rates increased with increase in risk score subcategory (p<0.05). Multivariable model identified higher risk score category, no revascularisation and lack of guideline directed medical therapy as significant independent predictors of mortality (p<0.05 each). CONCLUSIONS: Mortality increased with higher risk score category. Paradoxically, high-risk patients were less likely to receive guideline directed medical therapy, to undergo coronary angiography and revascularisation, possibly suggesting a risk aversion approach by the treating physicians.

Frequency and factors related to not receiving acute reperfusion therapy in patients with ST elevation myocardial infarction; a single specialty cardiac center.

OBJECTIVE: To determine the frequency of no reperfusion therapy, its reasons, hospital management and intermediate-term outcome s of ST- elevation my ocardial in farction patients . METHODS: The retrospective ambi-directional observational study was conducted at Tabba Heart Institute, Karachi, and comprised record of ST-elevation myocardial infarction patients without immediate reperfusion therapy with symptom onset time of 12 hours who presented between January 2013 and December 2017. Prospective follow-up of all patients was performed till June 2018. Coronary angiography, non-invasive stress tests, medications and late revascularisation were explored. Predictors of hospital mortality and major adverse cardiovascular events at follow-up were analysed. Data was analysed using SPSS 19. RESULTS: Of the 1977 records evaluated, 218(11%) patients of mean age 60.3±12.4 years did not receive immediate reperfusion therapy. Coronary angiography was done in 163(74.7%) patients of whom 45(27.6%) were taken for immediate procedure. Besides, 26 (11.9%) patients died during hospital stay. Predictors of hospital mortality were no revascularisation (odds ratio: 24.1, 95% confidence interval: 1.3-500), cardiogenic shock (odds ratio: 65, 95% confidence interval: 5.7-745) and tachycardia (odds ratio: 17, 95% confidence interval: 1.2-254.5) at presentation. Predictor of major adverse cardiovascular events was guideline-directed medical therapy (hazard ratio 2.6, 95% confidence interval: 1.16-6.2) at discharge, while revascularisation was not a significant predictor (p>0.05). CONCLUSION: A huge number of salvageable ST-elevation myocardial infarction patients failed to receive reperfusion therapy. There is a huge potential of improvement in ST-elevation myocardial infarction care in terms of increasing community awareness, prompt reperfusion therapy and usage of optimal medical therapy.

In-Hospital outcomes in acute coronary syndrome patients with concomitant severe chronic kidney disease undergoing percutaneous coronary intervention.

OBJECTIVE: To determine in-hospital mortality and major adverse cardiac events (MACE) in acute coronary syndrome (AMI) patients with underlying severe chronic kidney disease (CKD) undergoing percutaneous coronary intervention (PCI). METHODS: We conducted a retrospective cohort study from June'2013-December'2017 at Tabba Heart Institute, Karachi. Data was drawn from institutes' database modeled after US National Cardiovascular data CathPCI registry. All AMI (STEMI: ST-elevation myocardial infarction and NSTEMI: non-ST-elevation myocardial infarction) patients undergoing PCI with creatinine clearance <30ml/min or ESRD on hemodialysis were included in the study. RESULTS: During 54 months study period, 160 severe CKD patients underwent PCI. Mean age was 62.9±12.2 years. Men were 61.9%, hypertensive (81.3%) and diabetic (63.8%). Excluding dialysis patients, Creatinine clearance was 21.1±6.6ml/min/1.73m2. STEMI were 46.9% and 61.9% were Killip I. Mean SYNTAX score was 16.6±7.3. MACE occurred in 32.5% patients, of which 6(11.5%) had new hemodialysis and mortality: 17.5% were deceased. MACE predictor were cardiogenic shock (OR: 2.81, 95%CI: 1.17-6.74) and prior heart failure (OR: 6.84, 95%CI: 1.39-33.74), Predictor of mortality was cardiogenic shock or cardiac arrest (OR: 7.90, 95%CI: 2.95-21.17). CONCLUSION: Severe CKD patients undergoing PCI for AMI have drastically poor outcomes therefore individualization and patient-centric care management is mandatory.

Prevalence of non-acute ischaemic cardiomyopathy in a Pakistani cohort.

Heart failure with reduced left ventricular ejection fraction (HFrEF) is a frequently encountered clinical scenario. Coronary angiography (CAG) is usually performed to assess obstructive epicardial coronary artery disease (CAD) and the resultant ischaemia as causes of HFrEF. OBJECTIVES: To determine the frequency of obstructive CAD (OCAD) in patients with HFrEF and its independent predictors and outcomes. METHODS: Retrospective observational study in Tabba Heart Institute on patients who underwent CAG during the past 4 years. Patients with prior known CAD or revascularisation were excluded. OCAD was defined as per the criteria from Felker et al. Regression modelling was performed to evaluate the predictors of OCAD. Survival was compared between the groups using the log rank test. RESULTS: Out of 2235 patients who underwent CAG, 260 had HFrEF as a primary indication for CAG and, of these, 119 (45.8%) had OCAD. Major predictors of OCAD were age >50 years at presentation (OR 2.0, 95% CI 1.1 to 3.7), presence of chest pain (OR 4.3, 95% CI 2.3 to 8.1), family history of premature CAD (OR 2.8, 95% CI 1.3 to 5.9) and utilisation of non-invasive (NIV) stress testing before CAG (OR 3.6, 95% CI 1.8 to 7.1). Survival was significantly lower (log rank p<0.001) in patients with OCAD with no revascularisation compared with OCAD with revascularisation or those who had non-obstructive CAD, and the latter two groups had comparable survival. CONCLUSIONS: OCAD is detected in nearly half of the patients with reduced left ventricular systolic function undergoing CAG. Clinical judgement based on thorough history and use of NIV stress testing can help in appropriate patient selection for this test.

Frequency and distribution of angiographically occluded coronary artery and in-hospital outcome of patients with Non ST elevation myocardial infarction.

OBJECTIVE: 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. METHODS: 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 of < 0.05 was taken as significant. RESULTS: 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). CONCLUSIONS: 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.