Impact of educational intervention on hypertension management by primary care physician: A randomized control trial.

Objective: The current study aimed to observe hypertension educational intervention's effect on general physicians (GPs) to improve blood pressure control and patient outcomes indirectly. Methods: This randomized control trial includes 42 GPs divided into 2 groups. GPs in group 1 receive face-to-face education with structured educational material on hypertension management strategies by a senior cardiologist. GPs in group 2 receive the print version of education material. The data was collected from six major cities in Pakistan. GPs with at least three years of experience in the broad primary care disciplines, with ages above 18 years, were included in the study. Results: A total of 42 physicians (21 from each group) completed questionnaires, while out of 420 hypertension patients, 105 newly diagnosed and already diagnosed patients enrolled under physicians of both groups. The educational material did just as well at informing clinicians as the face-to-face group intervention did and both the interventions had a significant effect on knowledge and BP control. Conclusion: After the 3-month follow-up, both interventions, including face-to-face and educational approaches, demonstrated significant effectiveness in improving knowledge and blood pressure control. Innovation: The study shows that hypertension educational intervention's effect on general physicians indirectly improves blood pressure control and patient outcomes. And emphasize for developing a hypertension educational program targeted at general physicians.

Left atrial appendage thrombus with severe mitral stenosis: Responders and non-responders to anticoagulation.

INTRODUCTION AND OBJECTIVE: Mitral stenosis (MS) is one of the most frequently observed valvular heart lesions in developing countries and is due to different etiologies. The effects of anticoagulation in different types of left atrial appendage (LAA) are unknown. The current study aimed to determine the resolution of LAA thrombus on transesophageal echocardiography (TEE) after three months of optimal anticoagulation in patients with different types of LAA at baseline cardiac computed tomography of patients with severe MS. METHODS: This prospective cohort study observed the frequency of LAA thrombus resolution after three months of anticoagulation therapy in patients with severe MS. The response rate in different morphologies of LAA and locations was also assessed. Thrombus resolution after three months of warfarin therapy was assessed on repeat TEE. RESULTS: A total of 88 patients were included, mean age 37.95±11.87 years. Repeat TEE showed thrombus resolution in only 27.3% of patients. The rate of thrombus resolution was 8/12 (66.7%), 4/28 (14.3%), 8/36 (22.2%), and 4/12 (33.3%) for patients with cactus, cauliflower, chicken wing, and windsock LAA type, respectively. The resolution rate was 0/12 (0%), 4/44 (9.1%), and 20/32 (62.5%) for patients with thrombus in the base, body, and tip of the LAA, respectively. CONCLUSION: The cactus type of LAA morphology and thrombus at the LAA tip responded well to three months of anticoagulation, however, patients with thrombus in the LAA base and body and cauliflower and chicken wing morphology were non-responders and could benefit from early referral for surgical management.

Expert recommendations for the management of iron deficiency in patients with heart failure in Asia.

BACKGROUND: Iron deficiency is a common comorbidity in heart failure (HF) and is independently associated with a worse quality-of-life and exercise capacity, as well as increased risk of hospitalization, regardless of anemia status. Although international guidelines have provided recommendations for the management of iron deficiency in patients with HF, guidelines in Asia are less established, and practical use of guidelines for management of iron deficiency is limited in the region. METHODS: A panel comprising cardiologists from China, Hong Kong, India, Japan, Malaysia, Pakistan, Philippines, Singapore, South Korea, Taiwan, and Thailand convened to share insights and provide guidance for the optimal management of iron deficiency in patients with HF, tailored for the Asian community. RESULTS: Expert opinions were provided for the screening, diagnosis, treatment and monitoring of iron deficiency in patients with HF. It was recommended that all patients with HF with reduced ejection fraction should be screened for iron deficiency, and iron-deficient patients should be treated with intravenous iron. Monitoring of iron levels in patients with HF should be carried out once or twice yearly. Barriers to the management of iron deficiency in patients with HF in the region include low awareness of iron deficiency amongst general physicians, lack of reimbursement for screening and treatment, and lack of proper facilities for administration of intravenous iron. CONCLUSIONS: These recommendations provide a structured approach to the management of iron deficiency in patients with HF in Asia.

Safety and tolerability of Sacubitril/Valsartan in heart failure patient with reduced ejection fraction.

BACKGROUND: Angiotensin receptor blocker and a neprilysin inhibitor (ARNI) has emerged as an innovative therapy for patients of heart failure with reduced ejection fraction (HFrEF). The purpose of this study was to assess the safety and tolerability of Sacubitril/Valsartan in patient with HFrEF in Pakistani population. METHODS: This proof-of-concept, open label non-randomized clinical trial was conducted at a tertiary care cardiac center of Karachi, Pakistan. Patients with HFrEF were prescribed with Sacubitril/Valsartan and followed for 12 weeks for the assessment of safety and tolerability. Safety measures included incidence of hypotension, renal dysfunction, hyperkalemia, and angioedema. RESULTS: Among the 120 HFrEF patients, majority were male (79.2%) with means age of 52.73 ± 12.23 years. At the end of 12 weeks, four (3.3%) patients died and eight (6.7%) dropped out of the study. In the remaining 108 patients, 80.6% (87) of the patients were tolerant to the prescribed dose. Functional class improved gradually with 75.0% (81) in class I and 24.1% (26) in class II, and only one (0.9%) patient in class III at the end of 12 weeks. Hyperkalemia remains the main safety concern with incidence rate of 21.3% (23) followed by hypotension in 19.4% (21), and renal dysfunction in 3.7% (4) of the patients. CONCLUSIONS: Sacubitril/Valsartan therapy in HFrEF patients is safe and moderately tolerated among the Pakistani population. It can be used as first line of treatment for these patients. TRIAL REGISTRATION: NCT05387967. Registered 24 May 2022-Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT05387967.

The outcome of primary percutaneous coronary intervention in patients with stent thrombosis.

BACKGROUND: Primary percutaneous coronary intervention (PCI) is a recommended management strategy for patients with de novo ST-segment elevation myocardial infarction (STEMI). Still, the efficacy of primary PCI in-stent thrombosis (ST) induced STEMI is unclear. The aim was to assess the clinical characteristics and the in-hospital outcomes of patients undergoing primary PCI for STEMI caused by acute, sub-acute, or late ST. METHODS: A sample of hundred consecutive patients who presented with STEMI due to ST were included in this study. The angiographic evidence of a flow-limiting thrombus or total vessel occlusion (thrombolysis in myocardial infarction (TIMI) flow grade 0 to II) at the site of the previous stent implant was taken as ST. Primary PCI was performed, and all enrolled patients and in-hospital mortality were observed. RESULTS: Male patients were 69, and the mean age was 58.9 ± 7.78 years. ST was categorized as acute in 40 patients, sub-acute in 53, and late in the remaining seven patients. Killip class III/IV was observed in 45 patients. Dissection was observed in 25, under deployment in 74, and/or malposition in 24 patients. Thrombus aspiration was performed in 97, plain old balloon angioplasty in 76, and stenting in 22 patients. Final TIMI III flow was achieved in 32 patients. During a mean hospital stay of 4.93 ± 2.46 days, the mortality rate was 27%. CONCLUSION: In-hospital mortality after primary PCI was observed in more than 1/4th of the patients with STEMI due to ST undergoing primary PCI.

Left ventricular aneurysmectomy in a young female with pseudoaneurysm of unknown etiology.

A left ventricular pseudoaneurysm is formed when there is free wall rupture of the myocardial wall with discontinuity and roof covered by pericardium mural thrombus or fibrous tissue without any myocardium. A left ventricular pseudoaneurysm is a rare and life-threatening event. We report a young 22-year-old female with unknown etiology of a pseudoaneurysm, who was previously managed as a psychiatric case and for musculoskeletal pain. On subsequent investigation and confirmation with cardiac magnetic resonance imaging, aneurysmectomy was done. This is a rare case in a young 22-year-old woman with a ventricular pseudoaneurysm of unknown etiology. Considering the high risk for rupture of a ventricular pseudoaneurysm, surgical resection was mandatory with no complications intra- and post-procedure.

Coronary Artery Anomalies in Tetralogy of Fallot Patients Undergoing CT Angiography at a Tertiary Care Hospital.

Background The aim of this study was to determine the frequency of coronary artery anomalies (CAAs) in Tetralogy of Fallot (TOF) patients undergoing computed tomography (CT)-angiography in a tertiary care hospital. Methodology In this observational study, we included consecutive TOF patients undergoing CT-angiography without prior history of cardiac surgery or congenital heart disease. CAAs were defined based on either origin or course of the artery. Results Out of 441 TOF patients, the prevalence of CCAs was 3.6% (16), of which 13 were below 18 years of age. Anomalous left main artery was observed in six (1.4%) patients, followed by left anterior descending artery and right coronary artery, observed in four (0.9%) patients each, and two (0.5%) patients had a single coronary artery originating from the left coronary cusp with an interarterial course. Conclusions CAAs were observed in a significant number (3.6%) of TOF patients. A CT-angiographic assessment before surgical correction would help identify the exact anatomy for better surgical planning to minimize complications.

Risk of Atherosclerotic Cardiovascular Diseases in various Ethnicities of Pakistan.

OBJECTIVE: To estimate the risk of atherosclerotic cardiovascular diseases (ASCVD) in various ethnicities of Pakistan using Astronaut Cardiovascular Health and Risk Modification (Astro-CHARM) risk calculator and the Pooled Cohort Equations (PCE). METHODS: Individuals of both gender between 40 to 65 years of age without pre-existing coronary artery disease from residents of Karachi were recruited through snowball sampling technique. Study was conducted at the National Institute of Cardiovascular Diseases, Karachi, Pakistan during January to June 2019. Ethnicity of the participants was categorized based on their mother tongue. Ten-year risk of ASCVD event was estimated using Astro-CHARM Calculator and PCE. RESULTS: Mean age of a total of 386 individuals was 49(±7.1) years and 45.3% (175) were females. Urdu-speaking individuals were 33.4%(129) of the sample, while, 18.4%(71) Pushtoons, 14%(54) Sindhi, 13%(50) Punjabi, 2.6%(10) Balochi, and remaining 18.7%(72) were of other ethnicities. High risk (≥7.5%) individuals were 20.7% (80/386) as per PCE and 11.1% (43/386) as per Astro-CHARM. As per Astro-CHARM, Sindhis' had the least risk of ten-years ASCVD event among all the ethnicities, while, Urdu-speakings' had the highest risk with mean rank of 145.18 vs. 216.50, p-value=0.001. CONCLUSION: A significant 10-years risk of first ASCVD event was observed in our population. ASCVD risk is alarmingly high in some ethnicities, such as Urdu-speaking, owing to the increased prevalence of traditional modifiable risk factors, such as diabetes and smoking.

Differences in Angiographic Profile and Immediate Outcome of Primary Percutaneous Coronary Intervention in Otherwise Risk-Free Young Male Smokers.

Introduction Cigarette smoking is a well-established risk factor for the development and progression of coronary artery disease (CAD) and it is strongly related to cardiac morbidity and mortality. Therefore, this study aimed to compare the angiographic profile and immediate clinical outcomes in young male smokers and non-smokers without any other cardiac risk factors presented with ST-elevation myocardial infarction (STEMI). Methods This study includes young (≤40 years) male patients presented without cardiac risk factors other than smoking. Angiographic profile and immediate outcome of primary percutaneous coronary intervention (PCI) were collected from the hospital database. Results A total of 580 young male patients were included in this study, 51.2% (297) were smokers. Baseline characteristics and presentation were similar for smoker and non-smoker groups. Angiographic profile was not significantly different for smokers in terms of pre-procedure thrombolysis in myocardial infarction (TIMI) flow (p = 0.373), the number of vessels involved (p = 0.813), infarct-related artery (p = 0.834), and left ventricular dysfunction (p = 0.311). Similarly, in-hospital outcomes of primary PCI were not significantly different in smokers. Post-procedure no-reflow was in 3.4% vs. 2.8%; p = 0.708, acute stent thrombosis in 1.7% vs. 0.4%; p = 0.114 and in-hospital mortality in 1.0% vs. 1.4%; p = 0.657 of the smoker and non-smoker group, respectively. Conclusion Our study concludes smoking has no significant impact on the angiographic profile and immediate clinical outcomes of primary PCI after STEMI in young males, without any other conventional cardiac risk factors. With these findings, further multicenter prospective studies are needed to identify other potential causes in such patients.

Comparative assessment of clinical profile and outcomes after primary percutaneous coronary intervention in young patients with single vs multivessel disease.

BACKGROUND: Even though percutaneous coronary intervention (PCI) improved the survival of patients with acute myocardial infarction, still multivessel coronary artery disease remains an important factor burdening prognosis and it is being associated with a worse prognosis compared to single-vessel disease (SVD). AIM: To compare the clinical profile and outcomes after the primary PCI in young patients with SVD vs multivessel disease (MVD). METHODS: The retrospective cohort of patients were divided into two groups: SVD and MVD group. The study population consisted of both male and female young (≤ 45 years) patients presented with ST-elevation myocardial infarction (STEMI) at the National Institute of Cardiovascular Disease, Karachi, Pakistan and undergone primary PCI from 1st July 2017 to 31st March 2018. Pre and post-procedure management of the patients was as per the guidelines and institutional protocols. RESULTS: A total of 571 patients with STEMI, ≤ 45 years were stratified into two groups by the number of vessels involved, 342 (59.9%) with SVD and 229 (40.1%) with MVD. The average age of these patients was 39.04 ± 4.86 years. A lower prevalence of hypertension and diabetes was observed in SVD as compare to MVD group (25.1% vs 38%, P < 0.01; 11.7% vs 27.5%, P < 0.001) respectively. While, smoking was more prevalent among the SVD group as compare to MVD group (36.3% vs 28.4%, P = 0.05). The high-C Lesion was observed in a significantly higher number of younger patients with MVD as compared to SVD group (48.8% vs 39.2%, P = 0.021). Post-procedure thrombolysis in myocardial infarction flow grade was found to be not associated with the number of diseased vessels with a P value of 0.426 and thrombolysis in myocardial infarction flow grade III was observed in 98% vs 96.5% of the patients is SVD vs MVD group. CONCLUSION: The MVD comprised of around 40% of the young patients presented with STEMI. Also, this study shows that diabetes and hypertension have a certain role in the pathogenesis of multivessel diseases, therefore, preventive measures for diabetes and hypertension can be effective strategies in reducing the burden of premature STEMI.

Ten years risk assessment of atherosclerotic cardiovascular disease using Astro-CHARM and pooled cohort equation in a south Asian sub-population.

BACKGROUND: Atherosclerotic cardiovascular diseases (ASCVD) are on the rise in low and middle-income countries attributed to modern sedentary lifestyle and dietary habits. This has led to the need of assessment of the burden of at-risk population so that prevention measures can be developed. The objective of this study was to assess ten years risk assessment of ASCVD using Astro-CHARM and Pooled Cohort Equation (PCE) in a South Asian sub-population. METHODS: A total of 386 residents of all six districts of Karachi with no ASCVD were enrolled in the study through an exponential non-discriminative referral snowball sampling technique. The inclusion criteria consisted of age 40 years or above and either gender. Study participants were enrolled after obtaining informed written consent and those study participants who were found to have either congenital heart disease or valvular heart diseases or ischemic heart disease were excluded from the study based on initial screening. For the calculation of 10 years risk of ACVD based on Astro-CHARM and PCE, the variables were obtained including medical history and coronary artery calcium and C-reactive protein measurements. RESULTS: Mean estimated 10-year risk of fatal or non-fatal myocardial infarction or stroke as per the Astro-CHARM was 13.98 ± 8.01%, while mean estimated 10-year risk of fatal or non-fatal myocardial infarction or stroke as per the PCE was 22.26 ± 14.01%. Based on Astro-CHARM, 11.14% of the study participants were labeled as having high risk, while PCE estimated 20.73% of study participants as having high risk of ASCVD. CONCLUSION: Despite the fact that our findings showed substantial differences in ten-year risk of ASCVD between Astro-CHARM and PCE, both calculators can be used to develop a new population and specific risk estimators for this South Asian sub-population. Our study provides the first step towards developing a risk assessment guided decision-making protocol for primary prevention of ASCVD in this population.

Frequency of Thrombolysis in Myocardial Infarction III Flow in Patients With Primary Percutaneous Coronary Intervention: Not All Culprit Vessels Are Completely Occluded in ST Elevation Myocardial Infarction.

Background ST elevation myocardial infarction (STEMI) is classically characterized by total occlusion of the culprit coronary artery. However during primary percutaneous coronary intervention (PCI) thrombolysis in myocardial infarction (TIMI) 0 flow is not observed in all patients' culprit arteries in angiographic views. This study was conducted to find out the frequency of TIMI flow in acute STEMI patients in view of the above concept. The aim of this study was to evaluate the frequency of pre-procedural TIMI III flow in those patients who underwent primary PCI for acute STEMI in a public sector hospital in Karachi, Pakistan. Methodology This study is an audit of already saved data in the catheterization laboratory of the National Institute of Cardiovascular Diseases (NICVD), Karachi, that was collected prospectively from January 2016 to December 2018. These data were collected after taking consent from those patients who presented to hospital within 12 hours of symptoms and underwent primary PCI. Data were entered and analyzed on Statistical Package for the Social Sciences (SPSS) version 19 (IBM Corp., Armonk, NY, USA). Results A total of 8018 patients were included in this study who presented with STEMI and underwent primary PCI. Out of them 80.9% were males. Hypertension was the leading risk factor in 54.1% (4340) of patients. TIMI III flow was present in 11.4% of patients before primary PCI, while TIMI 0, I and II flow were present in 57.1%, 15.1%, and 16.3% of patients respectively (p<0.001). Fourteen percent of patients with TIMI III flow were of age group 51 to 60 years. Among those who had TIMI III flow, 11.2% were those with door to balloon time of <90 minutes. In 11% of cases, left anterior descending (LAD) artery had TIMI III flow as compared to other vessels (p<0.001). The length of the lesion was significantly smaller in patients who had TIMI III flow compared to those who had TIMI 0-II flow. Conclusions This study revealed that not all patients with acute STEMI had totally occluded culprit coronary artery but some of them had angiographic TIMI I-III flow in the infarct-related artery. Further studies are needed to find the reason for re-establishment of flow in the culprit vessel in STEMI patients before PCI.

Perceptions and Practices towards Medication Non-Adherence among Hypertensive Patients: An Observational Study.

Background The present study broadly evaluates the adherence to pharmacotherapy, perceptions, and practices among ambulatory hypertensive patients attending a cardiac institution in Karachi, Pakistan. Methods A cross-sectional, single-center study was conducted at the National Institute of Cardiovascular Diseases Karachi, Pakistan. The study continued from 4 July 2019 to 3 September 2019. A total of 200 patients with a primary diagnosis of hypertension (HTN) were recruited for the study. The data was collected through a questionnaire based on a nine-item modified adherence predictor scale to assess medication adherence. Along with the demographic details patients smoking status, history of comorbidities and past complications were noted. Results It was found that the mean age of the study population was 56.45±12.36 years. A total of 62.5% of patients were taking medication daily while 15.5% were consuming medications intermittently and only 6.5% patients were not adherent at all. Around 35% patients preferred follow-up visits once in a month. Besides this, 35.5% patients never monitored their blood pressure while more than half of the studied population believed that their BP has mostly been controlled and skipped the prescribed medication. Conclusion The study indicated that the perception and awareness among the hypertensive patients regarding their medical condition are suboptimal. Concerted strategies like health education program and campaigns must be launched in order to help the sufferers.

Formal model of the interplay between TGFß1 and MMP-9 and their dynamics in hepatocellular carcinoma.

Transforming growth factor beta1 (TGFß1) and matrix metalloproteinase-9 (MMP-9) have been associated with migration and invasion in hepatocellular carcinoma (HCC). Recent studies have suggested a positive feedback loop between TGFß1 and MMP-9 mediated by the PI3K signaling pathway that confers acquired invasion and metastasis in HCC via induction of the epithelial-mesenchymal transition (EMT), which grows into invasive carcinoma. But the potential molecular mechanism of this loop on HCC has not been clarified yet. Therefore, this study is designed to explore the association between the two entities and their key determinants such as NFκB, TIMP-1, and hepatic stellate cells (HSCs). Hence, a qualitative modeling framework is implemented that predict the role of biological regulatory network (BRN) during recovery and HCC metastasis. Qualitative modeling predicts discrete trajectories, stable states, and cycles that highlight the paths leading to disease recovery and homeostasis, respectively. The deadlock stable state (1, 1, 1, 1, 1) predicts high expression of all the entities in the BRN, resulting in the progression of HCC. The qualitative model predicts 30 cycles representing significant paths leading to recovery and homeostasis and amongst these the most significant discrete cycle was selected based on the highest betweenness centralities of the discrete states. We further verified our model with network modeling and simulation analysis based on petri net modeling approach. The BRN dynamics were analyzed over time. The results implied that over the course of disease condition or homeostasis, the biological entities are activated in a variable manner. Taken together, our findings suggest that the TGFß1 and the MMP-9 feedback loop is critical in tumor progression, as it may aid in the development of treatment strategies that are designed to target both TGFß and MMP-9.

Clinical, Angiographic Characteristics and In-Hospital Outcomes of Smoker and Nonsmoker Patients After Primary Percutaneous Coronary Intervention.

BACKGROUND: Smoking is a well-established cardiac risk factor there is dearth of Local data regarding clinical and angiographic characteristics of smoker patients. OBJECTIVES: This study was planned to assess the differences in the clinical characteristics, angiographic characteristics, and in-hospital outcomes of smokers and nonsmokers after primary percutaneous coronary intervention at a tertiary care hospital in Karachi, Pakistan. METHODS: We included patients between 40 and 80 years of age diagnosed with ST-segment elevation myocardial infarction who underwent primary percutaneous coronary intervention from July 1, 2017, to March 31, 2018. Clinical and angiographic characteristics and in-hospital outcomes were obtained from the cases submitted to the National Cardiovascular Data Registry's CathPCI (Catheterization-Percutaneous Coronary Intervention) Registry from our site. RESULTS: A total of 3,255 patients were included in this study. Smokers consist of 25.1% (817) of the total sample. A high majority of smokers were male, 98.8% (807), and smokers were relatively younger as compared to nonsmokers with a mean age of 52.89 ± 10.59 versus 55.98 ± 11.24 years; p < 0.001. Smokers had higher post-procedure TIMI (Thrombolysis In Myocardial Infarction) flow grade III: 97.8% (794) versus 95.53% (2,329); p = 0.037, and they had a relatively low mortality rate: 2.69% (22) versus 3.16% (77); p = 0.502. CONCLUSIONS: Smokers were predominantly male and around 3 years younger than nonsmokers. Diabetes mellitus and hypertension were less common among smokers and single-vessel disease was the more common angiographic finding for smokers as compared to 3-vessel disease for nonsmokers. No statistically significant differences in in-hospital outcomes were observed. ST-segment elevation myocardial infarction in smokers despite younger age and the low atherosclerotic risk profile, in our region, emphasize the need for nicotine addiction management and smoking cessation campaigns at large and for pre-discharge counseling.

Clinical and procedural predictors and short-term survival of the patients with no reflow phenomenon after primary percutaneous coronary intervention.

OBJECTIVES: In the present study, we analysed the incidence of no-reflow phenomenon, its clinical and procedural predictors, and associated in-hospital outcomes for the patients undergoing primary percutaneous coronary intervention (PCI). BACKGROUND: No-reflow phenomenon after primary PCI is a procedural complication associated with adverse post-procedure outcomes. METHODS: Data for this study were extracted from global registry, NCDR®, the site of National Institute of Cardiovascular Disease (NICVD), Karachi from July 2017 to March 2018. The demographic, clinical, and procedural characteristics, and in-hospital outcomes were analysed for the patients with and without no-reflow after primary PCI. RESULTS: Of total of 3255 patients, no-reflow phenomenon was found in 132 (4.1%) patients and it was associated with significantly higher in-hospitality mortality (6.8% vs. 2.9%; p = 0.01), cerebrovascular accident (1.5% vs. 0%; p < 0.001), post procedure bleeding (2.3% vs. 0.5%; p = 0.009), and cardiogenic shock (3.8% vs. 1.2%; p = 0.011). The multivariate analysis showed advanced age [odds ratio = 1.63, 95% confidence interval 1.09-2.44, p = 0.018], diabetes [1.66, 1.14-2.42, p = 0.009], prior history of CABG [8.70, 1.45-52.04, p = 0.018], low pre-procedure TIMI flow grade [2.04, 1.3-3.21, p = 0.002], longer length of target lesion [1.51, 1.06-2.16, p = 0.023], and 10 fold raised troponin I [1.55, 1.08-2.23, p = 0.018] were the independent predictors of no-reflow. CONCLUSIONS: In this selected group of patients, the no-reflow phenomenon after primary percutaneous coronary intervention is not that uncommon. It is associated with an increased risk of adverse post-procedure hospital course including mortality. Pathophysiology of the no-reflow phenomenon is complex and opaque, however, it can be predicted based on certain clinical and procedural characteristics.

Performance of the TIMI risk score in predicting mortality after primary percutaneous coronary intervention in elderly women: Results from a developing country.

BACKGROUND: Despite women undergoing primary percutaneous coronary intervention (PPCI) having a higher rate of adverse outcomes than men, data evaluating prognostic risk scores, especially in elderly women, remains scarce. This study was conducted to validate the predictive value of Thrombolysis in Myocardial Infarction (TIMI) risk score in elderly female patients. MATERIALS AND METHODS: This was a retrospective analysis of elderly (>65 years) female patients who underwent PPCI for ST-elevated myocardial infarction (STEMI) from October 2016 to September 2018. Patients' demographic details and elements of TIMI risk score including age, co-morbidities, Killip classification; weight, anterior MI and total ischemic time were extracted from hospital records. The primary outcome was in-hospital mortality and post-discharge mortality reported on telephonic follow-up. RESULTS: A total of 404 elderly women with a median age of 70 years were included. The mean TIMI score was 5.25±1.45 with 40.3% (163) patients of TIMI score > 5. In-hospital mortality rate was 6.4% (26) and was found to be associated with TIMI score (p<0.001). The in-hospital mortality rate increased from 3.1% at TIMI score of 0-4 to 34.6% at the score of 8. On follow-up (16.43±7.40 months) of 211 (55.8%) patients, the overall mortality rate was 20.3%, and this was also associated with TIMI score (p<0.001). The mortality rate increased from 5.6% at the score of 0-4 to 54.5% at the score of 8. The predictive values (area under the curve) of TIMI risk score for in-hospital and post-discharge mortality were 0.709 (95% CI 0.591-0.827; p <0.001) and 0.689 (95% CI 0.608-0.770; p <0.001), respectively. CONCLUSION: Increased adverse outcomes were observed with higher TIMI risk score for in hospital and post-discharge follow-up. Therefore, the prognostic TIMI risk score is a robust tool in predicting both in-hospital as well as post-discharge mortality in elderly females.

Outcomes of Primary Percutaneous Coronary Intervention through a Transradial Approach in a Tertiary Care Cardiac Center.

Background Transradial approach for percutaneous coronary intervention (PCI) is gaining popularity due to lesser bleeding and other access site related complications. This study aims to determine the in-hospital outcomes of primary PCI through a transradial approach in a tertiary care cardiac center. Methods Consecutive patients with ST-segment elevation myocardial infarction presenting within 12 hours with symptoms without a previous history of thrombolytic therapy, coronary angioplasty, or cardiac surgery were included in the study. All patients underwent a diagnostic angiogram followed by primary PCI of the infarct-related artery through a radial route and were kept under observation during the hospital stay for forearm hematoma or mortality. Results A total of 180 patients were included in this study, with a mean age of 52.04±7.31 years. Majority (87.2%) of the patients were male, and diabetes (72.8%) was the most commonly observed co-morbid condition followed by hypertension (67.2%). Hospital mortality rate was 3.9% (7 patients), and post-procedure forearm hematoma was noted in 5.6% (10 patients). An increased mortality rate was found to be associated with age above 50 years (7.1% vs. 0.0%; p=0.012) and non-hypertension (8.5% vs. 1.7%; p=0.026). An increased incidence of forearm hematoma was found to be associated with age above 50 years (10.2% vs. 0.0%; p=0.002), diabetic mellitus (7.6% vs. 0.0%; p=0.047), hyperlipidemia (11% vs. 0.0%; p=0.001), and non-smoking (10.2% vs. 0.0%; p=0.003). Conclusion Our study showed that primary PCI through a transradial approach is a safe option with excellent success rates in terms of both mortality rates and morbidity such as forearm hematoma.

Measurement of interatrial septal thickness by echocardiography in patients with moderate to severe rheumatic mitral stenosis undergoing percutaneous balloon mitral valvuloplasty.

BACKGROUND: Longstanding severe rheumatic mitral stenosis (MS) is associated with changes in the atrial chamber dimensions. It is not known whether there is an increased thickness of the inter-atrial septum (IAS) in patients with severe rheumatic mitral stenosis. The objective of this study was to evaluate pre-procedural IAS thickness by echocardiography in patients with moderate to severe rheumatic mitral stenosis undergoing percutaneous balloon mitral valvuloplasty (PBMV). METHODS: The thickness of the IAS was measured by transesophageal echocardiography (TEE) in 86 patients between 14 and 65 years of age. Patients with moderate to severe rheumatic mitral stenosis undergoing percutaneous mitral balloon valvuloplasty (PMBV) at the National Institute of Cardiovascular Diseases (NICVD), Karachi were recruited for this study. IAS thickness was measured by TEE using standard views and 3 different phases of cardiac cycles were evaluated. RESULTS: Out of 86 patients, almost three fourths (73.3%) were between 14 and 29 years of age and two thirds (62.8%) were females. Mean IAS thickness was 2.56 (SD 0.92) mm at anterior region (AR), 1.89 (SD 0.75) mm at fossa ovalis (FO), and 2.95 (SD 0.97) mm at posterior region (PR). None of the demographic and clinical groups showed any statistically significant difference in IAS thickness. CONCLUSIONS: Inter-atrial septum (IAS) thickness measurement does not change in the presence of moderate to severe rheumatic mitral stenosis as compared to the reported normal values of IAS thickness in cadaveric hearts.