Cardiovascular Health and Disease in the Pakistani American Population.

PURPOSE OF REVIEW: This narrative review seeks to elucidate clinical and social factors influencing cardiovascular health, explore the challenges and potential solutions for enhancing cardiovascular health, and identify areas where further research is needed to better understand cardiovascular issues in native and American Pakistani populations. RECENT FINDINGS: The prevalence of cardiometabolic disease is high not only in Pakistan but also among its global diaspora. This situation is further complicated by the inadequacy of current cardiovascular risk assessment tools, which often fall short of accurately gauging the risk among Pakistani individuals, underscoring the urgent need for more tailored and effective assessment methodologies. Moreover, social determinants play a crucial role in shaping cardiovascular health. The burden of cardiovascular disease and upstream risk factors is high among American Pakistani individuals. Future research is needed to better understand the heightened risk of cardiovascular disease among Pakistani individuals.

HydroDynamic contrast Recanalization (HDR): Description of a new crossing technique for coronary chronic total occlusions.

BACKGROUND: Intraplaque delivery of contrast has been utilized during percutaneous coronary interventions (PCI) of chronic total occlusions (CTO) to delineate anatomy and to facilitate wire crossing. Its utility as a tool to accomplish primary crossing of CTOs has not been described or validated. AIMS: We describe a new technique leveraging the diagnostic and therapeutic roles of intraplaque contrast injection to accomplish primary crossing of CTOs: HydroDynamic contrast Recanalization (HDR). METHODS: HDR is an antegrade crossing method for coronary CTOs based on the synergistic use of contrast microinjections and polymer jacketed wires. We present a retrospective, first-in-man, case series utilizing HDR for CTO PCI in patients with favorable CTO anatomy (visible proximal segment and identifiable distal target). The primary outcome was procedural success. The secondary outcome was any procedural complications. RESULTS: A total of 43 patients with 45 CTOs underwent CTO PCI with HDR. Mean patient age was 64.3 ± 11 years. The mean Japanese CTO and PROGRESS CTO scores were 2.3 ± 0.7 and 1.8 ± 0.7, respectively. CTO complexity was high, with an ambiguous or blunt cap in 34 occlusions (76%); lesion length ≥ 20 mm in 27 occlusions (60%); and moderate/heavy calcification in 36 occlusions (80%). Procedural success using HDR was 100%. There were no complications. CONCLUSIONS: This study shows the utility of HDR in CTO PCI. HDR appears to be a safe and promising new contrast-based primary crossing technique in selected patients. This strategy warrants further evaluation in larger prospective studies.

Presentation, management, and early outcomes of young acute coronary syndrome patients- analysis of 23,560 South Asian patients from 2012 to 2021.

BACKGROUND: There is dearth of literature addressing early outcomes of acute coronary syndrome (ACS) among young patients, particularly South Asians descent who are predisposed to premature coronary artery disease (CAD). Therefore, we compared presentation, management, and early outcomes of young vs. old ACS patients and explored predictors of in-hospital mortality. METHODS: We extracted data of 23,560 ACS patients who presented at Tabba Heart Institute, Karachi, Pakistan, from July 2012-June 2020, from the Chest pain-MI-Registry™. We categorized data into young ≤ 45 and old ACS patients > 45 years. Chi-sq/Fischer exact tests were used to assess the difference between presentation, disease management, and in-hospital mortality between both groups. Logistic regression was used to determine odds ratio along with 95% confidence interval of factors associated with early mortality. RESULTS: The younger patients were 12.2% and women 23.5%. The prevalence of dyslipidemia (34.5% vs. 22.4%), diabetes (52.1% vs. 27.4%), and hypertension (68.3% vs. 42.9%) was higher in older patients. Family history of premature CAD (18.1% vs. 32.7%), smoking (40.0% vs. 22.9%), and smokeless tobacco use (6.5% vs. 8.4%) were lower in older patients compared to younger ones. Younger patients were more likely to present with STEMI (33.2% vs. 45%). The median symptom-to-door time was 125 min longer (p-value < 0.01) in the young patients compared to the older age group. In-hospital mortality (4.3% vs. 1.7%), cardiac arrest (1.9% vs. 0.7%), cardiogenic shock (1.9% vs. 0.9%), and heart failure (1% vs. 0.6%) were more common in older patients. After adjusting for other factors, younger age (AOR 0.6, 95% CI 1.5-3.7) had significantly lesser odds of in-hospital mortality. Other factors associated with early mortality included women, family history of premature CAD, STEMI, Killip class III and IV, coronary angiography, revascularization, CABG, and use of aspirin and beta blockers within the first 24 h. CONCLUSION: We found every tenth ACS patient was younger than 45 years of age despite a lesser number of comorbidities such as hypertension and diabetes. Overall, the in-hospital prognosis of young patients was more favorable than that of older patients. The study emphasizes the need for tailored primary prevention programs for ACS, considering the varying risks among different age groups.

Clinical characteristics, management, and 5-year survival compared between no standard modifiable risk factor (SMuRFless) and ≥ 1 SMuRF ACS cases: an analysis of 15,051 cases from Pakistan.

BACKGROUND: There has been an increase in Acute Coronary Syndrome (ACS) patients without standard modifiable risk factors i.e. hypertension, diabetes, dyslipidemia, and tobacco use (SMuRFless) compared to the patients with ≥ 1 SMuRF but this has not been studied in South Asia despite them being a high-risk population. We conducted a comparative analysis of first episodes of ACS cases admitted to a tertiary cardiac center in Pakistan between SMuRFless and ≥ 1 SMuRF patients for clinical presentation, management, in-hospital, and 5-year mortality. METHODS: We undertook a retrospective study and data of 15,051 patients admitted at Tabba Heart Institute (THI) with the first episode of ACS was extracted from Chest Pain-MI™, and the CathPCI Registry® registry affiliated with the National Cardiovascular Data Registry (NCDR®), USA. Logistic regression and Cox proportional algorithm yielded odds ratio (OR) and hazard ratios (HR) with 95% confidence interval (CI) for associated factors of in-patient and 5-year mortality. RESULTS: There were 15% SMuRFless cases and in-hospital mortality was 4.1% in SMuRFless vs. 3.9% in the ≥ 1 SMuRF group (p-0.59), the difference remained insignificant after adjusting for age, gender, Killip class, multivessel disease, type of ACS, percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) (Adjusted OR:1.1 [0.8, 1.3]. Unadjusted 5-year mortality was 40% lower in the SMuRFless group but the difference was insignificant after adjusting for age, gender, disease at presentation, its severity, and management (Adjusted HR 0.7 95% CI[0.5, 1.0]). STEMI, NSTEMI, Killip class, and multivessel disease increased the risk of overall 5-year mortality. CONCLUSION: In-hospital and 5-year mortality was not different between the SMuRFless and ≥ 1 SMuRF group, there is a need to understand mediators of immediate and long-term mortality risk in SMuRFless patients.

Global Cardiovascular Research: Gaps and Opportunities.

PURPOSE OF REVIEW: Cardiovascular disease (CVD) is the leading cause of morbidity and mortality worldwide. CVDs contribute to a large health and economic burden on a global scale. We aim to describe the current landscape of global cardiovascular research, highlight significant findings, and identify potential opportunities for further studies. RECENT FINDINGS: There has been remarkable research output regarding cardiovascular health in recent decades. Large-scale collaborative studies have made impactful strides in identifying modifiable risk factors and forming evidence-based guidelines to facilitate improved cardiovascular care and outcomes. However, there are significant CVD disparities between high- and low- income countries which require interventions to mitigate these inequalities. Encouraging collaborative partnerships, strengthening research capacity in low-resource settings, and promoting equity in research are fundamental strategic approaches to help improve global cardiovascular research.

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.

Multicoagulant resistant pseudothrombocytopenia.

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

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.

Physical activity, smoking, and genetic predisposition to obesity in people from Pakistan: the PROMIS study.

BACKGROUND: Multiple genetic variants have been reliably associated with obesity-related traits in Europeans, but little is known about their associations and interactions with lifestyle factors in South Asians. METHODS: In 16,157 Pakistani adults (8232 controls; 7925 diagnosed with myocardial infarction [MI]) enrolled in the PROMIS Study, we tested whether: a) BMI-associated loci, individually or in aggregate (as a genetic risk score--GRS), are associated with BMI; b) physical activity and smoking modify the association of these loci with BMI. Analyses were adjusted for age, age(2), sex, MI (yes/no), and population substructure. RESULTS: Of 95 SNPs studied here, 73 showed directionally consistent effects on BMI as reported in Europeans. Each additional BMI-raising allele of the GRS was associated with 0.04 (SE = 0.01) kg/m(2) higher BMI (P = 4.5 × 10(-14)). We observed nominal evidence of interactions of CLIP1 rs11583200 (P(interaction) = 0.014), CADM2 rs13078960 (P(interaction) = 0.037) and GALNT10 rs7715256 (P(interaction) = 0.048) with physical activity, and PTBP2 rs11165643 (P(interaction) = 0.045), HIP1 rs1167827 (P(interaction) = 0.015), C6orf106 rs205262 (P(interaction) = 0.032) and GRID1 rs7899106 (P(interaction) = 0.043) with smoking on BMI. CONCLUSIONS: Most BMI-associated loci have directionally consistent effects on BMI in Pakistanis and Europeans. There were suggestive interactions of established BMI-related SNPs with smoking or physical activity.

Validation of Grace Risk Score in predicting in-hospital mortality in patients with non ST-elevation myocardial infarction and unstable angina.

OBJECTIVE: To validate the global registry of acute coronary event (grace) risk score in a Pakistani population at Tabba Heart Institute Karachi in patients with non ST-Elevation Myocardial Infarction (NSTEMI) and Unstable Angina (UA). METHODS: In this prospective Observational registry study, 530 adults hospitalized patients with a diagnosis of Non-ST-Elevation Myocardial Infarction and unstable angina were enrolled between March 2012 and August 2012 at the Tabba Heart Institute, Karachi, Pakistan. For each patient, the grace risk score was calculated and its discrimination evaluated and correlated with in-hospital mortality using the Kendall's tau-b bivariate correlation test. Each patient was grouped either into high, intermediate or low risk groups according to their GRS. RESULTS: A total of 530 patients with NSTEMI and UA were included; the overall mean grace risk score in our population was 131.87 +/- 41.56. The GRACE Risk Score showed good discrimination, with Area under the ROC curve of 0.803 (95% CI 0.705-0.902, P < 0.001). During the in-hospital stay, total of 19 (3.6%) patients died, and out of those 15 (8.4%) patients belonged to high risk group. CONCLUSION: GRACE RS strongly validates the in-hospital mortality among our patient population presenting with a wide spectrum of complications. However, more multicentre registries on a larger population with long-term follow up are required to study detailed trends in our population.

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.

Epidemiology and outcomes of out of hospital cardiac arrest in Karachi, Pakistan - A longitudinal study.

Background: Out-of-hospital cardiac arrest (OHCA) is a major cause of morbidity and mortality globally, with survival outcomes remaining poor particularly in many low- and middle-income countries. We aimed to establish a pilot OHCA registry in Karachi, Pakistan to provide insights into OHCA patient demographics, pre-hospital and in-hospital care, and outcomes. Methods: A multicenter longitudinal study was conducted from August 2015-October 2019 across 11 Karachi hospitals, using a standardized Utstein-based survey form. Data was retrospectively obtained from medical records, patients, and next-of-kin interviews at hospitals with accessible medical records, while hospitals without medical records system used on-site data collectors. Demographics, arrest characteristics, prehospital events, and survival outcomes were collected. Survivors underwent follow-up at 1 month, 6 months, 1 year, and 5 years. Results: In total, 1068 OHCA patients were included. Mean age was 55 years, 61.1 % (n = 653) male. Witnessed arrests accounted for 94.9 % of the cases (n = 1013), whereas 89.4 % of the cases (n = 955) were transported via non-EMS. Bystander CPR was performed in 10.3 % (n = 110) cases whereas pre-hospital defibrillation performed in 0.4 % (n = 4). In-hospital defibrillation was performed in 9.9 % (n = 106) cases despite < 5 % shockable rhythms. Overall survival to discharge was 0.75 % (n = 8). Of these 8 patients, 7 patients survived to 1-year and 2 to 5-years. Neurological outcomes correlated with long-term survival. Conclusion: OHCA survival rates are extremely low, necessitating public awareness interventions like CPR training, developing robust pre-hospital systems, and improving in-hospital emergency care through standardized training programs. This pilot registry lays the foundation for implementing interventions to improve survival and emergency medical infrastructure.

Primary percutaneous coronary intervention for ST elevation myocardial infarction complicated by cardiogenic shock.

OBJECTIVE: To determine the outcomes of primary percutaneous coronary intervention for ST elevation myocardial infarction complicated by cardiogenic shock. METHODS: The retrospective study was conducted at the Tabba Heart Institute, a private-sector facility in Karachi. It reviewed the medical records of 56 consecutive patients between January 2009 and June 2011 with acute ST elevation myocardial infarction complicated by cardiogenic shock and subjected to primary percutaneous coronary intervention. The primary end point was in-hospital mortality and its predictors. SPSS 14 was used for statistical analysis. RESULTS: The mean age of the study patients was 63 +/- 11.7 years; 38 (68%) were male; 32 (57%) were hypertensive; and 39 (69%) were diabetic. Most infarcts were anterior in location (n = 36; 64%). Besides, 33 (59%) required ventilatory support. Intra-aortic balloon pump was placed in 30 (54%), and 33 (59%) patients had multivessel coronary artery disease. In-hospital mortality occurred in 26 (46%). Multivariate logistic regression analysis showed that age > 60 years (p < 0.05), diabetes (p < 0.01) and left ventricular ejection fraction < 40% (p < 0.01) were independent predictors of in-hospital mortality. CONCLUSIONS: Results emphasise the need of aggressive management of patients with cardiogenic shock utilising primary percutaneous coronary intervention as a reperfusion strategy to improve clinical outcomes.

Transradial primary percutaneous coronary intervention - experience from a tertiary care cardiac centre.

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

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.

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.

Coronary aneurysm complicated by acute myocardial infarction.

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

Factors affecting outpatient cardiac rehabilitation attendance after acute myocardial infarction and coronary revascularization--a local experience.

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

Frequency and Predictors of Radial Artery Occlusion in Patients Undergoing Percutaneous Coronary Intervention.

Background and objective Transradial access (TRA) has become the preferred route for percutaneous coronary interventions (PCI), and this site is often a chink in the armor for staged PCI. In this study, we aimed to evaluate the incidence and predictors of radial artery occlusion (RAO) after TRA. Methods We conducted a retrospective study involving 1,307 patients who underwent PCI at the Tabba Heart Institute (THI) in Karachi, Pakistan from August 2018 to June 2019. TR band was used for hemostasis after PCI. Results The primary outcome of our study was RAO, which was observed in 11.3% of the study subjects. On multivariate analysis, female gender [odds ratio (OR): 1.79, 95% CI: 1.21-2.64], cardiovascular instability (OR: 2.5, 95% CI: 1.22-5.11), dyslipidemia (OR: 0.61, 95% CI: 0.4-0.92), and a higher number of diseased vessels were found to be predictors of RAO (p=0.004). Conclusion RAO is often an asymptomatic complication of TRA. To ensure radial artery patency, a carefully thought-out management plan and follow-up must be devised for high-risk patients.