Ischemia Trial: Does the Cardiology Community Need to Pivot or Continue Current Practices?

PURPOSE OF REVIEW: For decades, the standard of care for stable ischemic heart disease (SIHD) has been an ischemia-centric approach based on largely observational data suggesting a survival benefit of revascularization in patients with moderate-or-severe ischemia. In this article, we will objectively review the evolution of the ischemia paradigm, the trial evidence comparing revascularization to medical therapy in SIHD, and what contemporary practice should be in 2022. RECENT FINDINGS: Randomized trials, including COURAGE and, most recently, the ISCHEMIA trial, have shown no reduction in "hard outcomes" like death and myocardial infarction (MI) in SIHD compared to medical therapy. The trial excluded high-risk patients with left main disease, low ejection fraction (EF) < 35%, and severe unacceptable angina. Irrespective of the severity of ischemia and the extent of coronary artery disease (CAD), revascularization did not offer any prognostic advantage over medical therapy. On the other hand, there was a durable improvement in symptoms. While there are many caveats to the ISCHEMIA trial, the overall strengths of the trial outweigh these limitations. The findings of ISCHEMIA are consistent with previous trials. It is time for the cardiology community to pivot towards medical therapy as the initial step for most patients with SIHD. Physicians should have the "COURAGE" to embrace "ISCHEMIA" and be comfortable with treating ischemia medically.

High-Risk "Protected" Percutaneous Coronary Intervention with Mechanical Circulatory Support in a Non-Surgical Center - An Early Asian Experience.

High-risk "protected" percutaneous coronary intervention (PCI) using mechanical circulatory support (MCS) devices, particularly the Impella axial pump, has emerged as a viable treatment option for high-risk patients with satisfactory clinical outcomes. High-risk and complex interventions have mostly remained within the domain of surgical centers. We report on an early "protected" PCI experience using MCS with the Impella flow pump at a high-volume PCI hospital without on-site surgery. A total of 5 patients underwent elective "protected" PCI utilizing MCS with Impella at our institution. The mean left ventricular ejection fraction was 28 ± 10% and all patients had triple vessel coronary artery disease with the majority having a high SYNTAX score. Device implantation and procedural success were achieved in all cases with no intraprocedural or access site complications. All patients were alive at 30 days and clinically well. The Impella unloads the ventricle, improves forward cardiac output and lowers myocardial oxygen demand, thereby improving mean arterial pressure and coronary perfusion. Device insertion is relatively quick and the "learning curve" is short, centering mainly around managing large bore access. Our limited experience suggests that not only is high-risk PCI with Impella support feasible in a non-surgical center, but that it may be crucial to enable success.

Drug-Coated Balloons: A Safe and Effective Alternative to Drug-Eluting Stents in Small Vessel Coronary Artery Disease.

BACKGROUND: Drug-coated balloons (DCB) have been used to treat de novo small vessel coronary disease (SVD), with promising results and shorter dual antiplatelet therapy (DAPT) duration compared to drug-eluting stents (DES). We compared safety and effectiveness of the two treatments at 1 year. METHODS: We reviewed 3,613 angioplasty cases retrospectively from 2011 to 2013 and identified 335 patients with SVD treated with device diameter of ≤2.5 mm. DCB-only angioplasty was performed in 172 patients, whereas 163 patients were treated with second-generation DES. RESULTS: DCB patients had smaller reference vessel diameter (2.22 ± 0.30 vs. 2.44 ± 0.19 mm, P < 0.001) and received smaller devices (median diameter 2.25 vs. 2.50 mm, P < 0.001) compared to the DES group. DES-treated vessels had larger acute lumen gain (1.71 ± 0.48 mm) than DCB (1.00 ± 0.53 mm, P < 0.001). Half the patients had diabetes mellitus. While there were more patients presenting with acute coronary syndrome (ACS) in the DCB group (77.9% vs. 62.2%, P = 0.013), they received shorter DAPT (7.4 ± 4.7 vs. 11.8 ± 1.4 months, P < 0.001) than the DES group. The 1-year composite major adverse cardiac event rate was 11.6% in the DCB arm and 11.7% in the DES arm (P = 1.000), with target lesion revascularization rate of 5.2% and 3.7%, respectively, (P = 0.601). CONCLUSIONS: In this high-risk cohort of patients, DCB-only angioplasty delivered good clinical outcome at 1 year. The results were comparable with DES-treated patients, but had the added benefit of a shorter DAPT regime.

Community-based interventions to promote blood pressure control in a developing country: a cluster randomized trial.

BACKGROUND: Despite convincing evidence that lowering blood pressure decreases cardiovascular morbidity and mortality, the hypertension burden remains high and control rates are poor in developing countries. OBJECTIVE: To assess the effectiveness of 2 community-based interventions on blood pressure in hypertensive adults. DESIGN: Cluster randomized, 2 x 2 factorial, controlled trial. (ClinicalTrials.gov registration number: NCT00327574) SETTING: 12 randomly selected communities in Karachi, Pakistan. PATIENTS: 1341 patients 40 years or older with hypertension (systolic blood pressure >or=140 mm Hg, diastolic blood pressure >or=90 mm Hg, or already receiving treatment). MEASUREMENTS: Reduction in systolic blood pressure from baseline to end of follow-up at 2 years. INTERVENTION: Family-based home health education (HHE) from lay health workers every 3 months and annual training of general practitioners (GPs) in hypertension management. RESULTS: The age, sex, and baseline blood pressure-adjusted decrease in systolic blood pressure was significantly greater in the HHE and GP group (10.8 mm Hg [95% CI, 8.9 to 12.8 mm Hg]) than in the GP-only, HHE-only, or no intervention groups (5.8 mm Hg [CI, 3.9 to 7.7 mm Hg] in each; P < 0.001). The interaction between the main effects of GP training and HHE on the primary outcome approached significance (interaction P = 0.004 in intention-to-treat analysis and P = 0.044 in per-protocol analysis). LIMITATIONS: Follow-up blood pressure measurements were missing for 22% of patients. No mechanism was detected by which interventions lowered blood pressure. CONCLUSION: Family-based HHE delivered by trained lay health workers, coupled with educating GPs on hypertension, can lead to significant blood pressure reductions among patients with hypertension in Pakistan. Both strategies in combination may be feasible for upscaling within the existing health care systems of Indo-Asian countries. PRIMARY FUNDING SOURCE: Wellcome Trust.

Disproportionately high risk of left ventricular hypertrophy in Indo-Asian women: a call for more studies.

OBJECTIVE: Indo-Asians have one of the highest rates of cardiovascular disease worldwide. Estimates and determinants of left ventricular hypertrophy (LVH) in this population are not known. We sought to determine the prevalence of and risk factors for LVH in Karachi, Pakistan. METHODS: We conducted a population-based cross-sectional study on 320 randomly selected adults from the general population aged 40 years or above. LVH was defined as increased left ventricular mass index (LVMI) on echocardiogram (>115 g/m(2) in men and >95 g/m(2) in women) employing the adjusted Devereux equation. Multivariable models were built and logistic regression analysis was done for the primary outcome of LVH. RESULTS: Mean age of subjects was 52.7 (10.4) years, 50% were women. Mean LVMI (SD) was 72.0 (19.2) [median 71.1] g/m(2) in men and 75.7 (25.9) [median 72.9] g/m(2) in women. The overall prevalence of LVH was 21.9% in women and 2.5% in men (P < 0.001). The factors (odds ratio, 95% CI) independently associated with LVH were women versus men (11.35, 3.79-34.02), systolic blood pressure > versus

Prognosis of hospitalized new-onset systolic heart failure in Indo-Asians--a lethal problem.

BACKGROUND: Systolic heart failure (SHF), particularly when requiring hospital admission carries a poor prognosis. There is a paucity of data in Indo-Asians on outcomes of SHF, among whom the burden of cardiovascular disease is consistently rising. The purpose of this study was to determine the frequency and predictors of mortality and morbidity amongst patients admitted with new-onset SHF at a tertiary care hospital in Pakistan. METHODS AND RESULTS: Hospital charts of 196 patients with a diagnosis of new or recent onset (<3 months) SHF (ejection fraction [EF] <40%) were reviewed. Patients who died during the admission, those with life-limiting concomitant disease, and those without follow-up were excluded. Survival was calculated according to the Kaplan-Meier method. Hazards ratios (HR) and 95% confidence intervals (CI) were calculated using Cox's regression model. Mean age (SD) was 61 (12.8) years. Majority (77%) had a prior ischemic heart disease. Mean EF (SD) was 25% (8.7). Median follow-up period was 379 days. Fifty-four (27.5%) patients died (at least 12 [22.2%] sudden deaths) and 102 (52%) experienced combined event of death or repeat hospitalization for SHF. Factors independently associated with death included (HR [95% CI]), serum sodium (0.94 [0.90-0.97]), admission pulse (1.02 [1.01-1.04]), systolic blood pressure (0.98 [0.97-0.99]), and severe mitral regurgitation (1.90 [1.03-3.48]). CONCLUSIONS: Admission for new or recent onset SHF predicts a grave 1-year prognosis in Indo-Asians. Measures to prevent ischemic heart disease and its sequelae are essential because developing nations simply cannot afford to treat and manage heart failure.

High prevalence of lack of knowledge of symptoms of acute myocardial infarction in Pakistan and its contribution to delayed presentation to the hospital.

BACKGROUND: We conducted an observational study to determine the delay in presentation to hospital, and its associates among patients experiencing first Acute Myocardial Infarction (AMI) in Karachi, Pakistan. METHODS: A hospital based cross-sectional study was conducted at National Institute of Cardiovascular Disease (NICVD) in Karachi. A structured questionnaire was used to collect data. The primary outcome was delay in presentation, defined as a time interval of six or more hours from the onset of symptoms to presentation to hospital. Logistic regression analysis was performed to determine the factors associated with prehospital delay. RESULTS: A total of 720 subjects were interviewed; 22% were females. The mean age (SD) of the subjects was 54 (+/- 12) years. The mean (SE) and median (IQR) time to presentation was 12.3 (1.7) hours and 3.04 (6.0) hours respectively. About 34% of the subjects presented late. Lack of knowledge of any of the symptoms of heart attack (odds ratio (95% CI)) (1.82 (1.10, 2.99)), and mild chest pain (10.05 (6.50, 15.54)) were independently associated with prehospital delay. CONCLUSION: Over one-third of patients with AMI in Pakistan present late to the hospital. Lack of knowledge of symptoms of heart attack, and low severity of chest pain were the main predictors of prehospital delay. Strategies to reduce delayed presentation in this population must focus on education about symptoms of heart attack.

General practitioners' approach to hypertension in urban Pakistan: disturbing trends in practice.

BACKGROUND: Control of blood pressure (BP) remains suboptimal worldwide. The objective of this study was to determine whether (primary) general practitioners' (GPs) approach to high BP is in accordance with international guidelines. METHODS AND RESULTS: We conducted a cross-sectional survey of 1000 randomly selected GPs from urban areas in Pakistan during 2002. A rigorously developed questionnaire on (1) type of practice and (2) detection, (3) evaluation, (4) treatment, and (5) source of information about high BP was administered by trained medical personnel. A total of 1051 GPs were approached, and 1000 (95%) consented to enroll; 766 were male and 655 had been in practice > or =10 years. The average number of patients (SD) seen per day was 48.2 (42.7). Overall, 30.6% (29.0% to 32.3%) and 79.7% (78.3% to 81.0%) of GPs used incorrect BP cutoffs to diagnose hypertension in patients <60 and > or =60 years, respectively. Appropriate therapy for hypertension in the elderly was initiated by only 34.7% (33.0% to 36.3%) of GPs. The use of sedatives either alone (23.8%) or in combination with antihypertensive agents as first-line medication for lowering BP was reported by 45.0% (43.2% to 46.7%). Thiazide diuretics were rarely prescribed (4.2%). Sublingual antihypertensive agents were prescribed by 68.7% (67.1% to 70.3%) of GPs for treating very high levels of BP. The practices of recent graduates from medical school were not better than those of older graduates. CONCLUSIONS: GPs in Pakistan underdiagnose and undertreat high BP, especially in the elderly. Our findings underscore the need for urgent revision of teaching curricula in medical schools with regard to the risks, complications, and management of hypertension, as well as the initiation of widespread and intensive continuing medical education for all physicians involved in the management of patients with hypertension. Particular efforts are needed to encourage the use of low-cost thiazide diuretics as antihypertensive agents in developing countries.

Knowledge of modifiable risk factors of heart disease among patients with acute myocardial infarction in Karachi, Pakistan: a cross sectional study.

BACKGROUND: Knowledge is an important pre-requisite for implementing both primary as well as secondary preventive strategies for cardiovascular disease (CVD). There are no estimates of the level of knowledge of risk factor of heart disease in patients with CVD. We estimated the level of knowledge of modifiable risk factors and determined the factors associated with good level of knowledge among patients presenting with their first acute myocardial infarction (AMI) in a tertiary care hospital in Karachi, Pakistan. METHODS: A hospital based cross-sectional study was conducted at the National Institute of Cardiovascular Disease, a major tertiary care hospital in Karachi Pakistan. Patients admitted with their first AMI were eligible to participate. Standard questionnaire was used to interview 720 subjects. Knowledge of four modifiable risk factors of heart disease: fatty food consumption, smoking, obesity and exercise were assessed. The participants knowing three out of four risk factors were regarded as having a good level of knowledge. A multiple logistic regression model was constructed to identify the determinants of good level of knowledge. RESULTS: The mean age (SD) was 54 (11.66) years. A mere 42% of our study population had a good level of knowledge. In multiple logistic regression analysis, independent predictors of "good" level of knowledge were (odds ratio [95% confidence interval]) more than ten years of schooling were 2.5 [1.30, 4.80] (verses no schooling at all) and nuclear family system (verses extended family system) 2.54 [1.65, 3.89]. In addition, Sindhi ethnicity OR [3.03], higher level of exercise OR [2.76] and non user of tobacco OR [2.53] were also predictors of good level of knowledge. CONCLUSION: Our findings highlight the lack of good level of knowledge of modifiable risk factors for heart disease among subjects admitted with AMI in Pakistan. There is urgent need for aggressive and targeted educational strategies in the Pakistani population.

Heart disease epidemic in Pakistan: women and men at equal risk.

OBJECTIVE: We conducted this study to determine the prevalence of coronary artery disease (CAD) and its risk factors in Karachi, Pakistan. BACKGROUND: Migrant South Asians residing in the West have one of the highest rates of CAD in the world. Estimates of disease in nonmigrant populations are conflicting. METHODS: We conducted a population-based cross-sectional survey on 320 randomly selected adults aged > or = 40 years. Coronary artery disease was defined as the composite outcome of (1) abnormalities indicative of definite or probable CAD based on the Minnesota classification of electrocardiogram or (2) past history of heart attack. RESULTS: The overall prevalence of CAD (95% CI) was 26.9% (22.3%-32.0%): 23.7% (17.8%-30.9%) in men vs 30.0% (23.4-37.5%) in women (P = .12). Risks did not differ substantially by age group. The factors (odds ratio, 95% CI) independently associated with CAD were current tobacco use (2.12, 1.21-3.73), systolic blood pressure (1.08, 1.02-1.15, for each 5 mm Hg increase), and proteinuria (2.49, 1.04-5.95). Coronary artery disease odds for women vs men (1.38, 0.84-2.62) increased to 1.60 (0.93-2.75), when adjusted for key risk factors. CONCLUSIONS: One in 4 middle-aged adults in Pakistan has prevalent CAD. Risks are uniformly high in the young and in women. Concerted efforts are needed to prevent the epidemic of cardiovascular disease in South Asia, focusing on hypertension, diabetes, smoking, and dyslipidemia.

Cardiovascular health knowledge and behavior in patient attendants at four tertiary care hospitals in Pakistan--a cause for concern.

BACKGROUND: Knowledge about coronary heart disease (CHD) and its risk factors is an important pre-requisite for an individual to implement behavioral changes leading towards CHD prevention. There is scant data on the status of knowledge about CHD in the general population of Pakistan. The objective of this study was to assess knowledge of CHD in a broad Pakistani population and identify the factors associated with knowledge. METHODS: Cross sectional study was carried out at four tertiary care hospitals in Pakistan using convenience sampling. Standard questionnaire was used to interview 792 patient attendants (persons accompanying patients). Knowledge was computed as a continuous variable based on correct answers to fifteen questions. Multivariable linear regression was conducted to determine the factors independently associated with knowledge. RESULTS: The mean age was 38.1 (+/- 13) years. 27.1% had received no formal education. The median knowledge score was 3.0 out of a possible maximum of 15. Only 14% were able to correctly describe CHD as a condition involving limitation in blood flow to the heart. Majority of respondents could identify only up to two risk factors for CHD. Most commonly identified risk factors were stress (43.4%), dietary fat (39.1%), smoking (31.9%) and lack of exercise (17.4%). About 20% were not able to identify even a single risk factor for CHD. Factors significantly associated with knowledge included age (p = 0.023), income (p < 0.001), education level (p < 0.001), residence (p < 0.001), a family history of CHD (p < 0.001) and a past history of diabetes (p = 0.004). Preventive practices were significantly lacking; 35%, 65.3% and 84.6% had never undergone assessment of blood pressure, glucose or cholesterol respectively. Only a minority felt that they would modify their diet, stop smoking or start exercising if a family member was to develop CHD. CONCLUSION: This is the first study assessing the state of CHD knowledge in a relatively diverse non-patient population in Pakistan. There are striking gaps in knowledge about CHD, its risk factors and symptoms. These translate to inadequate preventive behavior patterns. Educational programs are urgently required to improve the level of understanding of CHD in the Pakistani population.

Preoperative use of intra-aortic balloon counterpulsation in very high-risk patients prior to urgent noncardiac surgery.

The optimal management of high-risk patients requiring urgent or emergency noncardiac surgery when the options for further testing and evaluation are limited, is unclear. The focus of most of the literature, including the American College of Cardiology/American Heart Association guidelines, has been on patients undergoing elective as opposed to urgent surgery. A few reports have suggested the use of intra-aortic balloon counterpulsation as a strategy to help carry such patients through the procedure. We describe three such very high-risk patients who successfully underwent emergency surgery with prophylactic insertion of an intra-aortic balloon pump without any adverse cardiac events or device-related complications. Our experience, as well as that of others suggests that preoperative intra-aortic balloon counterpulsation is a useful (and safe) approach to help very high-risk patients undergo urgent and emergency noncardiac surgery. Randomized trials are needed to assess whether balloon counterpulsation offers an incremental benefit over aggressive preoperative beta blockade.

The thrombus laden coronary artery--forget the fancy stuff, just aspirate it!

"No-reflow" is an important complication of percutaneous coronary intervention (PCI) in the setting of acute myocardial infarction and is associated with worse outcomes. Visible thrombus on the angiogram is a significant risk factor for "no-reflow". A variety of strategies have been employed to prevent this phenomenon including intracoronary vasodilators and distal protection systems. Randomized trials have not revealed any superiority of distal protection devices despite the theoretical rationale to their use. We describe a case of a thrombus-laden right coronary artery in which PCI would have likely resulted in significant "no-reflow". A simple aspiration catheter was used to significantly reduce the thrombus burden. Subsequent stenting was performed with no adverse events. This case illustrates the benefit of a less fancy approach to the thrombus-filled coronary artery - just aspirate it! Randomized trials are needed to test the role of simple aspiration prior to stenting in thrombus-laden coronary arteries.

Contrast nephropathy in high-risk patients undergoing coronary angiography and intervention.

OBJECTIVE: To determine the incidence of contrast nephropathy in high-risk patients undergoing coronary angiography and percutaneous coronary intervention (PCI), and to define the characteristics of this cohort. DESIGN: Discriptive study. PLACE AND DURATION OF STUDY: The Aga Khan University Hospital, Karachi from January to December 2002. PATIENTS AND METHODS: One hundred and fifteen patients with serum creatinine greater than 1.4mg/dl who underwent coronary angiography or PCI were included. All patients received non-ionic contrast dye. Acute contrast nephropathy was defined as rise in serum creatinine of 0.5mg/dl within 48 hours following the index procedure. Means and standard deviations were calculated for continuous variables and frequencies for categorical variables. RESULTS: Mean age of patients was 62.3 years +/- 8.83. Mean pre-contrast creatinine was 1.9 +/- 0.9 mg/dl. Eleven (9.65%) patients developed contrast nephropathy. 4.4% of patients with serum creatinine < 2.0 developed contrast nephropathy compared to 42.9% of patients with creatinine > 4.0(p-value 0.001). 11.9% diabetic patients developed nephropathy compared to 6.3% of non-diabetics(p-value 0.355). 11.4% of hypertensive and 3.7% of non-hypertensive patients developed contrast-nephropathy (p-value 0.454). 12.9% of low dose group(<100 ml) and 5.7% of high dose group (>100 ml) developed nephropathy (p-value 0.188). Mean serum creatinine in low dose group was higher (3.0 mg/dl vs. 1.7 mg/dl). CONCLUSION: The incidence of contrast nephropathy in this study was similar to that reported in literature. Risk of CIN was found to be significantly proportional to the severity of baseline renal disease. Trends towards higher risk of CIN were seen in patients with diabetes and hypertension. Higher incidence of CIN in patients receiving low-dose contrast was confounded by higher baseline serum creatinine in that group.

Drug coated balloon angioplasty in elderly patients with small vessel coronary disease.

BACKGROUND: Coronary angioplasty in advanced age is associated with higher rate of comorbidities and complications. Drug coated balloon only angioplasty (DCBA) has emerged as an alternative to treat small vessel coronary disease (SVCD), of reference vessel diameters <2.8 mm, with shorter duration of dual antiplatelet (DAPT). This is the first study to assess the DCBA efficacy in an elderly population with SVCD. METHODS AND RESULTS: We performed a prospective study of 447 patients (334 patients aged <75 and 113 patients aged ⩾75 years old) acquired from the SeQuent Please Small Vessel 'Paclitaxel-Coated Balloon Only' registry. In the older age group, more patients have hypertension (89% versus 77%; p = 0.006), renal insufficiency (21% versus 6%; p < 0.001), atrial fibrillation (17% versus 7%; p = 0.001), and calcified lesions (33% versus 20%; p = 0.006). At 30 days, there was one myocardial infarction requiring target lesion revascularization (TLR) in the younger group. No major adverse cardiac event (MACE) was observed in the older group. At 9 months, the MACE rate in the younger group was 4.2% and 6.1% in the older group (p = 0.453), with TLR rates at 3.9% and 3.0% (p = 0.704) respectively. There was no cardiac death observed. CONCLUSION: DBCA in the elderly with SVCD is as safe and effective compared with younger patients despite more complex anatomy and comorbidities.

Ethnic subgroup differences in hypertension in Pakistan.

OBJECTIVE: Cardiovascular risks are globally elevated in South Asians, but this masks important ethnic subgroup differences in risk factors, such as hypertension, which have not been fully explored. We conducted this study to explore the variations in hypertension within ethnic subgroups among South Asians. DESIGN: Cross-sectional survey [National Health Survey of Pakistan (NHSP) (1990-1994)]. SETTING: Population based. PARTICIPANTS: A total of 9442 individuals aged 15 years or over. METHODS: Data on sociodemographic and clinical variables were collected. Distinct ethnic subgroups - Muhajir, Punjabi, Sindhi, Pashtun and Baluchi - were defined by mother tongue. MAIN OUTCOME MEASURE: Hypertension defined as systolic blood pressure >or= 140 mmHg or diastolic blood pressure >or= 90 mmHg, or currently receiving antihypertensive therapy. RESULTS: The age-standardized prevalence of hypertension was highest among Baluchis (25.3% in men and 41.4% in women), then Pashtuns (23.7% in men and 28.4% in women), Muhajirs (24.1% in men and 24.6% in women), and lowest among Punjabis (17.3% in men and 16.4% in women) and Sindhis (19.0% in men and 9.9% in women) (P = 0.001). While hypertension was more prevalent in urban (22.7%) versus rural dwellers (18.1%) [odds ratio (OR) 1.34; 95% confidence interval (CI), 1.20, 1.49], this difference was no longer significant after adjusting for body mass and waist circumference (OR 1.03; 95% CI, 0.91, 1.16). However, ethnic differences persisted after adjusting for major sociodemographic, dietary and clinical risk factors (unadjusted OR for Baluchi versus Sindhi, 2.92; 95% CI, 2.20-3.89; adjusted OR, 2.71; 95% CI, 1.97-3.75). CONCLUSIONS: A threefold difference in prevalence of hypertension exists between people of South Asian descent, which, unlike the urban/rural difference, cannot be accounted for by measured risk factors. Further study would provide valuable etiological and therapeutic clues.

Survival of patients treated with intra-aortic balloon counterpulsation at a tertiary care center in Pakistan - patient characteristics and predictors of in-hospital mortality.

BACKGROUND: Intra-aortic balloon counterpulsation (IABC) has an established role in the treatment of patients presenting with critical cardiac illnesses, including cardiogenic shock, refractory ischemia and for prophylaxis and treatment of complications of percutaneous coronary interventions (PCI). Patients requiring IABC represent a high-risk subset with an expected high mortality. There are virtually no data on usage patterns as well as outcomes of patients in the Indo-Pakistan subcontinent who require IABC. This is the first report on a sizeable experience with IABC from Pakistan. METHODS: Hospital charts of 95 patients (mean age 58.8 (+/- 10.4) years; 78.9% male) undergoing IABC between 2000-2002 were reviewed. Logistic regression was used to determine univariate and multivariate predictors of in-hospital mortality. RESULTS: The most frequent indications for IABC were cardiogenic shock (48.4%) and refractory ischemia (24.2%). Revascularization (surgical or PCI) was performed in 74 patients (77.9%). The overall in-hospital mortality rate was 34.7%. Univariate predictors of in-hospital mortality included (odds ratio [95% CI]) age (OR 1.06 [1.01-1.11] for every year increase in age); diabetes (OR 3.68 [1.51-8.92]) and cardiogenic shock at presentation (OR 4.85 [1.92-12.2]). Furthermore, prior CABG (OR 0.12 [0.04-0.34]), and in-hospital revascularization (OR 0.05 [0.01-0.189]) was protective against mortality. In the multivariate analysis, independent predictors of in-hospital mortality were age (OR 1.13 [1.05-1.22] for every year increase in age); diabetes (OR 6.35 [1.61-24.97]) and cardiogenic shock at presentation (OR 10.0 [2.33-42.95]). Again, revascularization during hospitalization (OR 0.02 [0.003-0.12]) conferred a protective effect. The overall complication rate was low (8.5%). CONCLUSIONS: Patients requiring IABC represent a high-risk group with substantial in-hospital mortality. Despite this high mortality, over two-thirds of patients do leave the hospital alive, suggesting that IABC is a feasible therapeutic device, even in a developing country.

Rheolytic thrombectomy in patients with massive pulmonary embolism: a report of two cases and review of literature.

We present two cases of massive pulmonary embolism with persistent systolic hypotension but both have contraindications for thrombolysis. Therefore, rheolytic thrombectomy using AngioJet was performed and immediate haemodynamic improvement was achieved including blood pressure and symptoms. According to guidelines, catheter embolectomy or fragmentation may be considered as alternative to surgical treatment in massive pulmonary embolism patients when thrombolysis is absolutely contraindicated or has failed. Percutaneous catheter-based interventional techniques include thrombus fragmentation, rheolytic thrombectomy, suction thrombectomy and rotational thrombectomy. With the existing literature review and our case, rheolytic thrombectomy for treatment of massive pulmonary embolism using AngioJet achieves a high procedural success rate (approximately 90%) n terms of improvement of haemodynamics, pulmonary perfusion and angiographic result but low complication rate.

Clinical outcomes of intracoronary eptifibatide bolus only versus intracoronary bolus and intravenous infusion of eptifibatide in primary percutaneous coronary intervention.

Intracoronary bolus of eptifibatide during percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI) has been shown to result in higher local platelet glycoprotein IIb/IIIa receptor occupancy with improved microvascular perfusion. It is unclear whether intracoronary administration of eptifibatide in a larger patient population results in favourable clinical outcomes. We evaluated the safety and efficacy of two regimens of intracoronary eptifibatide (bolus only versus bolus followed by intravenous infusion) in patients undergoing primary PCI for ST-elevation MI. They were divided into two groups: Group A (n=67) who received fixed-dose intracoronary eptifibatide bolus only and Group B (n=88) who received intracoronary bolus and continuous intravenous infusion of eptifibatide for 18 h. The preliminary findings from our registry showed that both regimens were associated with good angiographic outcomes, few bleeding events and low in-hospital major adverse cardiac events. A large prospective randomized, multi-centre trial is needed to confirm our observation.