Effectiveness of Cardiac Rehabilitation on Health-related Quality of Life in Patients with Myocardial Infarction in Pakistan.

OBJECTIVE: To find out the effectiveness of cardiac rehabilitation in patients with myocardial infarction in Pakistan. STUDY DESIGN: Randomised controlled trial. PLACE AND DURATION OF STUDY: Cardiac Rehabilitation Unit, Lady Reading Hospital, Peshawar, Pakistan, from July to December 2016. METHODOLOGY: Patients suffering first myocardial infarction (MI) were randomly allocated to usual care or cardiac rehabilitation in a 1:1 ratio. Cardiac rehabilitation comprised two phases: 1-2 weeks during hospital stay followed by 6-7 weeks outpatient structured exercise programme. Two generic health related quality of life (HRQoL) outcomes (General Health Questionnaire (GHQ) and Self-Rated Health (SRH)) and one post-MI specific tool (MacNew QLMI) were measured at baseline and at 8 weeks follow-up among both groups. Lower SRH and GHQ scores and higher MacNew QLMI scores indicate better health status. Data were analysed using STATA 14. RESULTS: Out of 206 participants, 195 (94.6%) were analysed at the end of trial. The mean age was 53 +8.3 years. In the cardiac rehabilitation group, the mean SRH score changed from 3.97 +0.9 at baseline to 2.36 +0.8 at follow-up (p<0.001). The mean GHQ of the cardiac rehabilitation group was 21.26 +5.5 at baseline and it decreased significantly to 7.43 +4.2 at follow-up (p<0.001). The MacNew QLMI of the cardiac rehabilitation group increased from 3.61 +1.07 to 5.62 +0.5 (p<0.001). The multivariate regression of all three HRQoL measures confirmed better HRQoL following cardiac rehabilitation compared with usual care (all p<0.001). CONCLUSION: Cardiac rehabilitation following MI was effective in terms of improving HRQoL and can be implement in Pakistan as it produced significant improvements in HRQoL.

ELECTIVE PERCUTANEOUS CORONARY INTERVENTIONS--A COMPARISION OF EFFICACY OF CLOPIDOGREL AND PRASUGREL.

BACKGROUND: Percutaneous coronary interventions are almost always preceded by the loading dose of platelets inhibiter drugs such as clopidogrel or prasugrel and followed by maintenance therapy to decrease the mortality and morbidity due to stent thrombosis. This study was conducted to compare the efficacy of clopidogrel and prasugrel for inhibiting platelet aggregation among patients undergoing elective percutaneous coronary intervention. METHODS: This randomized controlled trial study was done in Department of Cardiology, Postgraduate Medical Institute Govt. Lady Reading Hospital Peshawar. A total of 148 patients were randomly allocated to either group-A containing 74 patients using clopidogrel or group-B containing 74 patients using prasugrel RESULTS: Group-A had 55 (74.3%) male and 19 (25.7%) females while group-B had 56(75.7%) males and 18 (24.3%) females (p=0.85). Mean age was 54.9 +/- 11.2 years in group-A and was 57.7 +/- 8.7 years in group-B (p=0.09). Mean body weight was 71.8?6.4 Kg in group-A and 70.8 +/- 6.3 Kg in group-B (p=0.35). Mean Baseline platelet aggregation before drug administration was 10.43 +/- 1.9 ohm in group-A while 10.12 +/- 2.2 ohm in group-B (p=0.36). Mean Follow up platelet aggregation 6 hours after drug administration was 5.88 +/- 2.9 in group-A while it was 3.47 +/- 1.8 ohm in group-B (p=0.001). Mean Difference between basal and follow up platelet aggregation +/-SD was 52.9649 +/- 24.77 in group-A while it was 82.25 +/- 14.34 in group-B (p=0.001). 63(85.15%) of group-A had inhibition of platelets aggregation >10% as compare to 72(97.3%) of group-B had inhibition of platelets aggregation >10% (p=0.009). CONCLUSION: Prasugrel is more efficacious than clopidogrel in term of inhibition of platelets aggregation.

FREQUENCY OF ABDOMINAL OBESITY AND ITS ASSOCIATION WITH DIABETES MELLITUS AMONG PEOPLE OF PESHAWAR.

BACKGROUND: Increased body weight is a major risk factor for the metabolic syndrome which is a cluster of coronary heart disease risk factors, like: hypertension, diabetes mellitus and dyslipidaemia. This study was conducted to determine the frequency of abdominal obesity and diabetes mellitus in the population of Peshawar and association between them. METHODS: This was a cross sectional study, performed by the Cardiology Department, Lady Reading Hospital Peshawar, in the population of Peshawar. All participants were interviewed in detail regarding known risk factors for coronary artery disease. Waist circumference (≥102 cm in male and ≥88 cm in females) was used as the surrogate marker for abdominal obesity in already diagnosed patients of type-2 diabetes mellitus. RESULTS: A total of 2548 individuals were included, 71.1% were male. Mean age was 37.94±12.59 years. Mean waist circumference was 90.25±13.45cm in males and 90.52±12.52cm in females. Diabetes was present in 4.4% of the participants and abdominal obesity in 56.6% Among the male, abdominal obesity was present in 39.4% and diabetes in 2.9%. Out of 39.4% males with abdominal obesity, 2% were diabetic. Out of 38.6% males with no abdominal obesity, 0.9% was diabetic. Amongst the total 559 (21.1%) female subjects, 17.2% were having abdominal obesity and 1.4% was diabetics. Among 123 (4.8%) females with no abdominal obesity, 0.1% was diabetic. A positive association was established between abdominal obesity and diabetes mellitus with a significant p-valve (<0.05). CONCLUSION: Abdominal obesity is more common in the local population of Peshawar and associated with type-2 diabetes mellitus.

Radiation exposure in different cardiac catheterization procedures in cath lab.

BACKGROUND: Interventional procedures render cardiologolists and their team members to high doses of radiations. This study was conducted to assess the radiation exposure in various cardiac catheterization procedures. METHODS: This descriptive cross sectional study was conducted at the catheterization laboratory of Lady Reading Hospital Peshawar from November 2008 to December 2009. Patients were categorized into four groups for procedures a. coronary angiography, b. percutaneous coronary intervention (PCI), c. permanent pacemakers (PPM) and d. percutaneous transvenous mitral commisurotomy (PTMC), two groups for operators (consultants and trainees), and three groups for various accesses (femoral, radial and sub-clavian). RESULTS: A total of 99 patients undergoing cardiac catheterization were studied. Coronary angiography was performed in 52 (52.5%) patients, PCI in 32 (32.3%)), pacemakers in 6 (6.1%), and PTMC in 9 (9.1%) patients. Consultants did 72 (72.7%) procedures and trainees did 27 (27.3%) procedures. Through radial access, 22 (22.2%) procedures were performed, 71 (71.7%) through femoral, and 6 (6.1%) through sub-clavian. The mean radiation dose for coronary angiography was (4907.862 +/- 15231.6358 microGym2), PCI (10375.16 +/- 16083.4385 microGym2), pacemakers (1406.823 +/- 785.489 microGym2), and PTMC (1157.91 +/- 760.437 microGym2). The mean radiation dose for radial (6147.33 +/- 8480.37 microGym2), femoral (6512.58 +/- 16566.73 microGym2), and sub-clavian was (1406.82 +/- 785.48 microGym2). While for various operators consultants (7489.5 +/- 16925.55 microGym2), and trainees (2475.25 +/- 1178.86 microGym2). The mean time for radial (8.59 +/- 7.28 min), femoral (6.95 +/- 6.43 min) and sub-clavian was (8.24 +/- 4.81 min). The mean time for coronary angiography (4.56 +/- 5.32 min), PCI (11.44 +/- 6.92 min), PPM (8.24 +/- 4.81 min), and PTMC (8.28 +/- 5.01 min). CONCLUSIONS: Radiation dose varies substantially across different groups by different operators and different routes.

Quantification of diagnostic accuracy using nitrate enhanced Tc-99m sestamibi gated myocardial SPECT in assessing myocardial viability: prospective analysis.

The aim of this prospective study was to assess myocardial viability with nitrate-enhanced Tc-99m sestamibi gated single-photon emission computed tomography in patients with known coronary artery disease. We enrolled 48 consecutive patients (39 men, 9 women) aged 24-82 years, with coronary artery disease and history of myocardial infarction. A Tc-99m sestamibi study was conducted at rest as baseline, followed by a nitrate-enhanced study the next day. Of 960 segments analyzed, 244 of 480 in the left anterior descending coronary artery territory showed viability on the baseline study, and 276 were viable according to the nitrate-enhanced study. Similarly, of 192 right coronary segments analyzed, 148 showed viability on the baseline study compared to 153 on the nitrate study. Of 288 left circumflex territory segments analyzed, 206 showed viability on the baseline study compared to 241 on the nitrate study. The overall improvement of viability with the nitrate study was 12.04%. On the gated studies, the overall improvement with nitrate was 2.02%. The gated study also allowed grading of wall motion and thickness. It was concluded that nitrate-augmented Tc-99m sestamibi myocardial imaging significantly improved the detection of hibernating myocardium, with gated images further improving the accuracy of detection in borderline cases.

Comparative analysis of type of myocardial infarction in patients with successful or unsuccessful streptokinase thrombolysis following ST elevation myocardial infarction.

OBJECTIVE: To study the effect of thrombolytic therapy in term of success and failure on the type of ST elevation MI, using streptokinase. MATERIAL AND METHODS: This was a comparative study, conducted at Department of Cardiology, Lady Reading Hospital, Peshawar, from October 2006 to October 2007. Patients with first acute myocardial infarction were divided into group A (successful thrombolysis) and group B (unsuccessful thrombolysis) using ECG criteria. RESULTS: Total number of patients were 200. Group A included 136 (68%) patients and group B included 64 (32%) patients. There were total 88 (44%) patients of anterior MI with 47 patients in group A and 41 patients in group B (34.6% vs 64.0%, p < 0.001). There were total 110 (55.0%) patients of inferior MI with 88 patients in group A and 22 patients in group B (64.7% vs 34.4%, p < 0.001). Lateral myocardial infarction was diagnosed in 2 (1%) patients with 1 patient each in group A and group B (0.7% vs 1.6%, p = 0.583). CONCLUSION: Anterior MI was associated with a higher rate of thromblysis failure while inferior MI and lateral wall MI was associated with a higher rate of successful thrombolysis.

Comparison of enoxaparin and dalteparin with unfractionated heparin in the treatment of non-ST elevated acute coronary syndrome.

BACKGROUND: The term non-ST elevated Acute Coronary Syndrome (ACS) encompasses unstable Angina (USA) and non-ST segment elevated Myocardial Infarction (NSTEMI), both of which may end up in death or a fatal/non-fatal Myocardial Infarction (MI). Unfractionated heparin (UFH) has been shown to reduce death and MI in patients with USA and NSTEMI. Of late, there has been a great interest in the role of low molecular weight heparins (LMWHs) in the two conditions and they have been found to be at least as effective as or even more effective than UFH. METHODS: A total of 90 patients who presented to CCU of Khyber Teaching Hospital. Peshawar with USA or NSTEMI, from June 2008 to June 2009, were enrolled into the study. An equal number of patients were randomly assigned to one of the three arms for 5 days each: Group A received enoxaparin, group B received dalteparin and group C received UFH. The primary end points of the study were all cause mortality, STEMI, refractory USA, recurrent USA or a major bleed. The secondary end point was minor bleeding. RESULTS: At the end of the study, there were 2 deaths each in the dalteparin and UFH group, whereas no such event was recorded in the enoxaparin group. Two patients had STEMI in the UFH group but none in the other two groups. CONCLUSION: LMWHs are far more superior to unfractionated heparin.

Assessment of left ventricular systolic and diastolic function by tissue Doppler imaging after acute myocardial infarction.

OBJECTIVE: To evaluate left ventricular systolic and diastolic function by Tissue Doppler imaging after acute myocardial infarction. METHODS: It was a hospital based, prospective descriptive study, from 1st July 2010 to 31st Dec. 2010. Total of 200 patients having acute myocardial infarction underwent detailed tissue Doppler imaging (TDI) echocardiographic examination for evaluation of left ventricular systolic and diastolic function on day 3, in echocardiographic section of Govt. Lady Reading Hospital, Peshawar. Peak systolic (Sm), peak early diastolic (Em) and peak late diastolic (Am) velocities were recorded at 4 different sites of the mitral annulus. The ejection fraction and pulse wave TDI diastolic parameters were also recorded. Using SPSS version 16 data was analysed, frequencies and Mean +/- SD were determined for categorical and numerical variables, respectively. A p-value < or = 0.05 was considered significant. RESULTS: Total study sample was 200 patients having acute myocardial infarction (MI). The sample was divided into 4 groups, i.e., anterior MI, inferior MI, septal MI, and lateral MI. There were 122 men and 78 women and the mean age was 42 +/- 5 SD. There was a marked reduction in Sm velocity at mitral annulus, especially at the infarction sites. The mean peak systolic velocity from 4 mitral annulus sites was well correlated with ejection fraction (p = 0.0001). Similar to systolic velocities, Em velocity was also reduced, especially at the infarction sites. The mean peak early diastolic velocity from 4 mitral annulus sites was well correlated with ejection fraction (p = 0.0001). The mean Em velocity was correlated well with isovolumic relaxation time (IVRT). There was no correlation between mean Em velocity and deceleration time (DT). CONCLUSION: Tissue Doppler Imaging is a reliable, accurate and easily reproducible modality of echocardiography. The reduced peak systolic velocity and reduced peak early diastolic velocity seems to be an expression of regionally reduced systolic and diastolic functions, respectively. While the reduced mean systolic velocity and reduced mean early diastolic velocity from 4 mitral annulus sites are expressions of globally reduced systolic and diastolic functions, respectively and were correlated well with the ejection fraction.

Changing trend of presentation of acute coronary syndrome in Peshawar over the last sixteen years.

BACKGROUND: Once considered as disease of the affluent and developed countries, coronary artery disease is emerging as epidemic in the developing world in general and South Asia in particular. OBJECTIVE: To observe the trend of presentation of acute coronary syndrome in the local population over the last 16 years. MATERIAL AND METHODS: Clinical audit from 1995 to 2010 was carried out in which the data was retrieved from the computerised database of the Department of Cardiology, Lady Reading Hospital Peshawar. The period was divided into four quartiles, and the data of each quartile was analyzed for the total number of admissions, the type of ACS, whether ST-elevated MI or non-ST elevated ACS (comprising unstable angina and non-STEMI), age, gender and mortality. RESULTS: The total admissions into the unit in the first quartile (1995-1998) were 23,827, in the second quartile (1999-2002) 29,005, in the third quartile (2003-2006) 33,206 and in the fourth quartile (2007-2010) were 40,110. Total ACS brunt constituted 8340 (35%), 10,384 (35.8%), 12,180 (36.68%) and 14,920 (37.2%) patients respectively. The mean age of patients was 49.70 +/- 6.4 years, 48.21 +/- 7.2 years, 47.38 +/- 7.1 years and 46.81 +/- 6.2 years respectively. Women were 2356 (28.25% of the total ACS burden) in the first quartile, increasing to 3554 (34.225%), 4817 (39.55%) and 6281 (42.1%) in the following quartiles. STEMI constituted 45.88% (3826) of the total ACS presentations in the first quartile, 47.24% (4905) in the second, 49.55% (6035) in the third and 49.87% (7440) in the last quartile. The mortality rate, however, remained constant throughout (8.4% to 8.8%). CONCLUSION: An increasing trend is seen in the burden of CAD in the local population with increasing presentation as STEMI. It is also evident that CAD is occurring at younger ages and more so in the female population.

Does BMI affect cholesterol, sugar, and blood pressure in general population?

BACKGROUND: Higher BMI in child hood is also associated with an increase risk for coronary heart disease in adulthood. Impaired glucose tolerance is highly prevalent in children and adolescents with severe obesity. Positive correlations between BMI and glucose, lipids and BP have previously been reported. The objective of this study was to find the correlation of BMI with cholesterol and sugar level in general population. METHODS: This study was a part of 'Peshawar Heart Study', performed at Cardiology Department, Lady Reading Hospital, Peshawar in 2008-2009. Individuals with different ages, gender, professions, socioeconomic class were randomly selected from general population. Random blood sugar and cholesterol was measured with strip method. Height and weight of each individual was recorded and BMI calculated. All individuals were asked about any current medical illness and whether they were performing any exercise or not. Using SPSS-13, descriptive statistics were used for frequencies. Bivariate correlations were used for measuring correlation between BMI, sugar and cholesterol. Partial correlations were used to factor out the effect of other variables. RESULTS: A total of 2,270 individuals, 1,798 (79.2%) male and 472 (20.8%) female were examined. Mean age was 38.47 +/- 12.66. Mean BMI was 26.38 +/- 4.97. Mean RBS was 113.7 +/- 47.145. Mean cholesterol was 168.47 +/- 28.23. Exercise was performed by 929 (40.90%) individuals. Diabetes was present in 113 (5.0%) and history of high cholesterol in 25 (1.1%) persons. When bivariate correlation analysis were done systolic BP, diastolic BP, RBS and cholesterol had positive correlation with BMI [correlation coefficient of 0.317 (p < 0.000), 0.319 (p < 0.000), 0.125 (p < 0.000) and 0.205 (p < 0.000) respectively]. These variables also showed a positive correlation among themselves. After factoring out the effects of age, exercise, gender and current medical status on the above correlations, the correlation of RBS and cholesterol with BMI decreased to 0.025 (p = 0.232) and 0.135 (p < 0.000) respectively and between sugar and cholesterol decreased to 0.018 (p = 0.401). CONCLUSION: In general population BMI is positively correlated with RBS and cholesterol. With the effect of age, sex, exercise and current medical status, this correlation is reduced.

Frequency of anxiety and psychosocial stressful events in patients with acute myocardial infraction.

BACKGROUND: The impact of psychological factors in acute coronary events is only now emerging. A growing body of evidence attests to the influence of emotional and stress-related psychosocial factors in the aetiology of Coronary Artery Disease (CAD) and morbidity and mortality among individuals with coronary heart disease. The objectives were to look for the frequency of anxiety and psychosocial stressful events in patients with acute myocardial infarction. METHODS: Two hundred consecutive patients of Acute Myocardial Infarction (AMI) without complications who presented to the Coronary Care Unit of Cardiology Department, Lady Reading Hospital Peshawar, and 200 healthy controls among relatives of patients were assessed on Holmes Rahe Social scale (HRS) and Hospital Anxiety and Depression Scale (HADS) scale for the presence of anxiety and stressful life events in period preceding AMI. RESULTS: Sixty-three percent of the patients were male in both groups. Mean age of patients was 59 years while that of controls was 52 years. For scores of anxiety on HADS, 34% of the controls had normal score compared to of the 19% AMI group (p<0.001), while 57% of the AMI patients had abnormal score compared to 39% of the control group (p<0.001). The number events reported on HRS scale in patients with AMI were significantly more (4.2 +/- 2) compared to the number of events (2.7 +/- 1.6) in the control group with (p<0.001). Scores for the number of events on HRS scale were significantly less (98 +/- 64) in controls compared to (158 +/- 5.8) in group with AMI (p<0.001). Anxiety was diagnosed in 70% of the female patients compared to 50% of the male patients. CONCLUSION: Significant number of patients with acute myocardial infarction when assessed on standard scales had anxiety and stressful life events in the weeks preceding the event. These were more common in female than male patients.

Frequency of left atrial and appendage clot in patients with severe mitral stenosis.

BACKGROUND: Left atrial thrombus is common in patients with mitral stenosis and atrial fibrillation; but how frequent it is in our population? The objective of study was to see the frequency of left atrial and appendage clot on trans-oesophageal echocardiography in symptomatic patients with severe mitral stenosis planned for PTMC. METHODS: Trans-oesophageal echocardiographic data retrieved from computer database Cardiology department, Lady Reading Hospital, Peshawar from August 1998 to Mach 2008. Patients admitted for PTMC under went trans-oesophageal echocardiography for detection of left atrial and appendage clot and quantification of mitral regurgitation. Data was analyzed on SPSS. RESULTS: Out of 1544 patients, males were 608 (39.4%), females were 936 (60.6%). Mean age was 30.84 +/- 12.6. Mean age of males was 30.56 +/- 13.1 years and females were 31.02 +/- 12.6 years. Minimum age was 8 years and maximum was 76 years. The mean LA size was 43.82 +/- 2.12 mm.Atrial fibrillation was observed in 289 (18.7%).Overall clot was seen in 224 (14.5%) patients. Left atrial appendage clot seen in 202 (89.73%).LA clot seen in 9 (4.02%). LAA/LA clot seen in 14 (6.25%). No significant difference was observed for clot among the gender distribution (p=0.42). Significant correlation was observed for clot in patients with AF and LA size > or = 45 mm, (p>0.001). CONCLUSION: The frequency of left atrial and appendage clots on trans-oesophageal echocardiography in patients with severe mitral stenosis is common and more frequent in patients with AF and LA size > or = 45 mm.

Frequency of pericardial effusion in patients with first myocardial infarction and its effects on in-hospital morbidity and mortality.

BACKGROUND: Pericardial effusion (PE) is not an uncommon finding in serial echocardiographic evaluation of patients with AMI, especially when infarction is anterior and extensive. The objective of this study was to determine the frequency of pericardial effusion after first myocardial infarction and its effects on in-hospital morbidity and mortality. METHODS: This descriptive study was performed in the Department of Cardiology, PGMI, LRH Peshawar, from July 2007 to December 2007. Main outcome measure was frequency of pericardial effusion. RESULTS: Out of 200 patients with first acute myocardial infarction (AMI), mean age was 56 +/- 18 (28-90 years). Majority of patients (31.5%) were in the age range of 51-60 years. Males were 65.5% and 34.5% were females. Pericardial effusion was found in 4.5% patients on day 0, in 12.5% patients on day 2 and in 15% patients on day 4. Left ventricular failure was documented in 19 (9.5%) patients without and 42 (21%) patients with pericardial effusion (p<0.05%). Cardiogenic shock was reported in 5 (2.5%) patients without and 16 (8%) in patients with pericardial effusion and mitral regurgitation was found in 3 (1.5%) patients in each group. Death was recorded in 1 (0.5%) patient without pericardial effusion and was 1.5% (n=3) in patients with pericardial effusion. CONCLUSIONS: Pericardial effusion was seen in one third of the patients with first acute myocardial infarction. In acute phase of myocardial infarction, the chances of development of pericardial effusion increases as the time passes. Left ventricular failure was the commonest in-hospital morbidity followed by cardiogenic shock and mitral regurgitation. In-hospital mortality was more in patients with pericardial effusion.

Outcome of balloon pulmonic valvuloplasty with 18 months follow up.

OBJECTIVE: To determine the immediate and intermediate term outcome of balloon pulmonic valvuloplasty by echocardiography. METHODS: This study was conducted in the Department of Cardiology Postgraduate Medical Institute Lady Reading Hospital (LRH), Peshawar from July 1999 to January 2003. Patients with severe pulmonic valve stenosis who underwent balloon pulmonic valvuloplasty during this period were included in the study. Forty Patients fulfilling the study inclusion criteria were followed up to 18 months by two dimensional and Doppler echocardiographic examinations at 6 months interval. Patients with dysplastic valve leaflets or for whom 18 months follow up data was not available were excluded from the study. Echocardiographic data was collected prospectively. Echocardiographic hemodynamic data was analysed initially and at all three follow up visits, using descriptive statistics and paired t-test. RESULTS: Total 64 balloon pulmonic valvuloplasty procedures were performed during this period. Forty patients fulfilled the study inclusion criteria and the remaining 24 patients were excluded from the study. Mean age of the patients was 13.05 +/- 8.22 years, ranging from 1-33 years. Pre-peak pulmonic valve gradient reduced from 100.9 +/- 29.20 mmHg to 31.38 +/- 15.99 mmHg (p < 0.0001) immediately after balloon pulmonic valvuloplasty. Pulmonic valve gradient at day 1 (31.38 +/- 15.99) reduced significantly at 18 months (18.88 +/- 10.24) (p < 0.0001). Complication encountered during the procedure was transient ventricular tachycardia or multiple premature ventricular contractions. CONCLUSION: Balloon pulmonic valvuloplasty is safe and effective in reducing pulmonic valve gradient acutely and the benefit persists till 18 months. Further fall in pulmonic valve gradient is seen in intermediate term follow up.