Can Sound Public Health Policies Stem the Tide of Burgeoning Epidemic of Cardiovascular Disease in South Asians?

PURPOSE OF REVIEW: To revisit the importance of prevention strategies and policies in reducing the burden of ischemic heart disease in South Asian countries. RECENT FINDINGS: South Asia has seen rapid growth in its population with variable improvement in health indicators such as life expectancy at birth over the last three decades. Parallel to these improvements, there has been a stark rise in noncommunicable diseases (NCDs) but without a commensurate improvement in infrastructure/policies and health system interventions to address NCDs. South Asia is the epicenter of the cardiovascular disease (CVD) epidemic in Asia. It has a population that manifests accelerated atherosclerosis at a younger age. Poverty, lower health literacy, lack of health-promoting behaviors, poor urban design, rising air pollution, weak health systems, and lack and poor implementation of existing policies contribute to the continued rise in the incidence of CVD and the associated case fatality rates. A relatively young population presents an opportunity for implementation of prevention measures now which if not adequately utilized will result in an exponential rise in the CVD burden. There is a large gap between policymaking and implementation in this part of the world. Economic realities further constrain coverage of prevention policies; and therefore, stronger collaboration between governments, stakeholders, civil society, and regional and international funding agencies is needed to universally implement prevention strategies in South Asia.

Prognosis of Zero Coronary Artery Calcium Score in Symptomatic Patients of South Asian Descent - an Experience from a Tertiary Care Center in Pakistan.

Introduction: The absence of CAC in asymptomatic individuals is associated with a very low incidence of cardiovascular events. Of symptomatic patients, 1-2% with zero CAC score have non-calcified coronary artery atherosclerosis, and at least one third of cardiovascular events occur in individuals with zero CAC. South Asians (SA) have proportionally higher case fatality rates for CVD, relatively younger age of presentation, and accelerated rate of atherosclerosis when compared with other ethnic groups. Methods: All consecutive patients who underwent a CTCA to evaluate angina or angina-equivalent symptoms during the study duration were enrolled retrospectively. Patients with prior myocardial infarction, history of revascularization, and congenital heart disease were excluded. MACE was defined as the total of cardiac death, non-fatal myocardial infarction, and/or non-elective revascularization. Results: A total of 534 patients were enrolled after final exclusion. The mean age was 53 years ± 11. Males constituted 68.4% of the study population. Dyslipidemia was the most common co-morbid condition identified (50%), followed by diabetes (18.4%) and hypertension (3.6%). At least 28.8% of patients with zero CAC scores had the presence of coronary artery disease (soft plaque) of any degree. Obstructive CAD (>50%) was present in 5.8% of patients. Follow-up was available for 61.4% of patients. On a mean follow-up of 96.6 months ± 49.8 (range 21-194 months), all-cause MACE was observed in 8.8% of patients. The most common MACE was angina (3.96%) and all-cause mortality (3%). The baseline characteristics and MACE did not differ in patients with and without obstructive CAD. The baseline characteristics did not differ significantly between patients with and without MACE. Conclusion: The incidence of soft plaque in this SA cohort is higher than that reported in international studies. However, in symptomatic SA, a CAC score of zero carries a good long-term prognosis, irrespective of the degree of CAD.

Best management of patients with malignant pericardial effusion: A comparative study between imaging-guided pericardiocentesis and surgical pericardial window.

Background: The clinical course of malignancies is frequently complicated by third spacing in body cavities, including pericardial effusion. What remains the optimal management for malignant pericardial effusion is a dilemma. Aim: We aimed to compare 30-day outcomes of imaging-guided pericardiocentesis and surgical pericardial window in patients with malignant pericardial effusion. Methods: A retrospective observational study was done at a tertiary care hospital. We reviewed hospital record files of 91 consecutive patients admitted with malignant pericardial effusion from January 2010 to December 2019 and requiring imaging-guided pericardiocentesis or pericardial window. Results: A total of 71 patients were included in the final analysis. Most patients were male (68%). The mean age was 45 years. Hypertension was the most common comorbid condition. Lymphoma or leukemia (39%) was the most common cause of malignant pericardial effusion followed by lung cancer (28%). About 57.7% of patients underwent pericardiocentesis, and the remainder underwent surgical pericardial window (42.3%). The overall procedural success was 97.2%, and the overall mortality was 5.6%. The success rate was similar when pericardiocentesis was compared with the surgical pericardial window (p = 0.22). The length of hospital stay was higher in patients undergoing pericardial window (p = 0.007), whereas the re-accumulation rate was higher in the pericardiocentesis group (0% versus 34%, p < 0.001). Patients undergoing pericardial window had higher odds of major bleeding requiring transfusions. Conclusion: There is a higher rate of recurrence following isolated pericardiocentesis but a comparable mortality difference between the two procedures. Complication rates can be reduced by improving surgical technique and peri-operative management. Meticulous surgical care, infection precautions, and good glycemic control in this immunocompromised subset can preserve the pericardial window as a better management option. Relevance to Patients: Pericardial window is a promising and effective management option for patients with recurrent malignant pericardial effusion, but it comes at the cost of bleeding and infection. More extensive trials are needed to understand better the long-term outcomes of pericardial window or pericardiocentesis in patients with malignant effusion.

Cardiac magnetic resonance features and outcomes of patients with non-compaction cardiomyopathy - A retrospective follow-up from Pakistan.

Background: The exact prevalence of left ventricle non-compaction cardiomyopathy (LVNC) in south Asians is not known and phenotypic CMR characteristics, clinical features, and outcomes of LVNC remain unknown for the SA population. Objective: To evaluate clinical characteristics, cardiac magnetic resonance imaging features, and outcomes of patients with left ventricle non-compaction. Methods: This was a retrospective study of 294 patients undergoing cardiac MRI (CMR) for evaluation of cardiomyopathy from 2011 to 2020. Patients were stratified based on the presence or absence of left ventricle non-compaction (LVNC). Clinical characteristics, CMR features, and outcomes were evaluated. Results: Out of 294 patients, 18 patients had LVNC, with a prevalence of 6.1%. The mean age was 32 ± 13 years, and the majority were males (78%). The mean EF by echo was 36 ± 14 and by CMR was 31 ± 16 and the mean LV mass was 151 g. The mean LVEDV was 290 ± 154 and the mean LVESV was 211 ± 126. LGE was present in 33% of patients. The majority had uniform LV non-compaction (56%) followed by predominantly anterolateral and apical involvement (28%). Mitral regurgitation was the most common valvular pathology (33%). On follow-up of 37 months, the majority experienced at least one all-cause MACE (69%), while 14% of patients experienced mortality on follow-up. When compared with dilated cardiomyopathy patients without LVNC, the subjects were younger (p = 0.002) and had higher EF by an echocardiogram (0.001) and a lower arrhythmia hospitalization (p = 0.039). No difference was observed in overall MACE outcomes, mortality, and CMR features. Conclusion: The prevalence of LVNC is low in the studied population. Patients with LVNC have younger age, higher EF by echocardiogram, and lower arrhythmia hospitalization when compared with patients with dilated cardiomyopathy without evidence of LV non-compaction. The presence of LVNC does not confer an increased risk of MACE.

Takotsubo Like Cardiomyopathy with Concomitant Pheochromocytoma: A Rare Presentation.

Pheochromocytoma classically presents with headache, diaphoresis, palpitations and, raised blood pressure. Rarely, it manifests as cardiomyopathy. Herein, we present a case of a 42-year woman who presented with heart failure and on work-up was found to have pheochromocytoma leading to Takotsubo-like cardiomyopathy. The biochemical profile revealed raised serum metanephrines and normetanephrines. CT abdomen showed a left adrenal mass. Within two weeks of presentation and before surgical excision of the mass, she recovered from cardiomyopathy. After medical optimisation, the patient underwent elective adrenalectomy, which on histological evaluation revealed pheochromocytoma. Key Words: Cardiomyopathy, Pheochromocytoma, Adrenal mass.

Clinical characteristics and prognostic factors of atrial fibrillation at a tertiary center of Pakistan - From a South-Asian perspective - A cross-sectional study.

BACKGROUND: There is lack of large data from South-Asian region on atrial fibrillation and it is imperative that clinical presentation, prognostic factors, management pursued, and outcomes are known for this part of the world. Once collective evidence for the region is known, region-specific guidelines can be laid forward. OBJECTIVES: To evaluate clinical characteristics and prognostic factors of atrial fibrillation at a tertiary care center of Pakistan. METHODS: This was a retrospective study conducted at a tertiary care center of Pakistan. Period of study ranged from July-December 2018. All hospitalized patients who were admitted with atrial fibrillation as a primary or associated diagnosis were enrolled. RESULTS: A total of 636 patients were enrolled. The mean age was 68.5 ± 12 years and 49.5% (315) were male. 90.6% of the patients were admitted via emergency room. Majority (59.9%) had previously known AF and 40% developed new-onset AF during the hospital stay. Hypertension was the most common co-morbid condition (85.4%) followed by Diabetes Mellitus (40.1%). At least 9% had rheumatic heart disease. The median CHA2DS2VASc and HASBLED scores were 4 and 2 respectively. More than one-third of patients had sepsis as a primary diagnosis (36.8%). The in-hospital mortality of patients with atrial fibrillation was 6.7%. Patients with new-onset AF had higher mortality. Sepsis and stroke were independently associated with a higher mortality. There was no significant difference in median CHA2DS2VASc and HASBLED scores for patients with new-onset and previously known AF. On discharge, 83% of the eligible patients received oral anticoagulation. CONCLUSION: There was higher prevalence of chronic co-morbid conditions in the studied population leading to a higher CHA2DS2VASC Score. Sepsis and stroke were independently associated with higher in-hospital mortality.

Lateral ST-elevation myocardial infarction after donation of COVID-19 convalescent plasma in a naïve donor.

A 34-year-old man presented with central chest pain heralded by bilateral arm numbness, tingling and pain soon after donation of 1000 mL of COVID-19 convalescent plasma (CP). ECG showed ST-elevation in lateral leads and coronary angiogram showed large thrombus in diagonal branch of the left anterior descending artery. The patient underwent successful thrombus aspiration and percutaneous coronary intervention of diagonal branch. In this report, we describe a case of coronary thrombosis leading to ST-elevation myocardial infarction in a naïve plasma donor after donation of COVID-19 CP.

Clinical Characteristics, Cardiac Magnetic Resonance Features, and Outcomes of Patients with Dilated Cardiomyopathy - An Experience from a South Asian Country.

OBJECTIVES: The objectives of the study were to evaluate the clinical presentation, cardiac magnetic resonance (CMR) features, and outcomes of patients with dilated cardiomyopathy (DCM). MATERIAL AND METHODS: A retrospective study was conducted at a tertiary care center of Pakistan. All patients who underwent CMR for further evaluation of DCM during the period of 2011-2019 and in whom CMR confirmed the diagnosis of DCM, were included in the study. Patients were followed up in the year 2020 for all-cause mortality and cardiovascular hospitalizations. RESULTS: A total of 75 patients were included in the study. The mean age was 38.7 ± 13 with the majority (n = 57, 76%) being male. Dyspnea was the most common presenting symptom (n = 68, 90.7%). The mean left ventricle ejection fraction (LVEF) by CMR was 29.3 ± 12 and mean left ventricle stroke volume (LVSV) was 66.5 ± 31. Late gadolinium enhanced (LGE) was present in 28 (37.3%) patients. Follow-up was available in 61 patients with the mean follow-up duration of 39.7 ± 27 months. Most patients (40, 65.6%) experienced all-cause major adverse cardiovascular events (MACE) during the follow-up and mortality was observed in 10 (16.4%) patients. LVSV by CMR (P = 0.03), LVEF by CMR (P = 0.02), and presence of pericardial effusion (PE) (P = 0.01) were significantly associated with all-cause MACE. On multiregression analysis, SV by CMR was associated with all cause MACE (P = 0.048). The presence of LGE was associated with higher mortality (P = 0.03). CONCLUSION: LVSV, LVEF by CMR, and PE were significantly associated with all-cause MACE. LGE was associated with higher mortality. Our cohort had a relatively younger age of presentation and diagnosis, and a greater mortality on follow-up, when compared with other regions of the world.

Clinically isolated aortitis presenting as inferior ST-elevation myocardial infarction due to an unruptured sinus of Valsalva aneurysm: a rare and forgotten cause of acute coronary syndrome in a young patient with no evidence of systemic vasculitis.

A 21-year-old man presented with chest pain, diaphoresis and dyspnoea. Electrocardiogram (ECG) showed inferior ST-elevation myocardial infarction. Troponin I was positive. Patient underwent left heart catheterisation, which revealed normal epicardial coronary arteries except for right coronary artery which could not be engaged. CT coronary angiogram was done, which revealed large right sinus of Valsalva aneurysm giving rise to a pinched out right coronary artery. Patient underwent composite graft replacement of aortic valve, aortic root and ascending aorta along with a saphenous vein graft to right coronary artery. He was discharged in stable condition on fifth postoperative day. Biopsy of the aneurysmal tissue was suggestive of vasculitic aetiology. There was no evidence of systemic vasculitis and Magnetic Resonance Angiography (MRA) screen was negative for Takayasu's arteritis. Our patient was, hence, diagnosed with clinically isolated aortitis leading to ST elevation myocardial infarction due to an unruptured sinus of Valsalva aneurysm.

Reverse Takotsubo Cardiomyopathy Following A Case Of Suspected Meningoencephalitis And Literature Review.

Reverse Takotsubo cardiomyopathy is a rare variant of stress cardiomyopathy. A 22-year-old male presented with altered mentation and fever. He was intubated due to low Glasgow Coma Scale. CT head plain showed diffuse cerebral oedema. Patient had raised troponin-I and echocardiogram revealed reduced ejection fraction with hyperdynamic apical segments and akinetic basal to mid segments suggestive of reverse Takotsubo cardiomyopathy (rTCM). Association of rTCM with neuropsychiatric disorders such as intracranial/epidural haemorrhages and anorexia nervosa has been defined. However, it is rare to have rTCM with meningoencephalitis.

COVID-19 BBIBP-CorV vaccine and transient heart block - A phenomenon by chance or a possible correlation - A case report.

IMPORTANCE: Bradyarrhythmia during COVID19 illness carries prognostic significance. Electrophysiological side effects of COVID19 vaccine remain largely unknown. It is imperative to report nature of cardiovascular side effects of the vaccine. CASE PRESENTATION: An 80 years-old-man presented with complains of dizziness, trepidation and shortness of breath following his first shot of COVID-19 BBIBP-CorV (Sino-pharm). ECG on arrival showed 2:1 atrioventricular block with an underlying old left bundle branch block. The AV block changed into Mobitz type-I over the course of next 2 days and into a sinus 1:1 conduction on fourth day of presentation. However, our patient underwent permanent pacemaker implantation due to the underlying conduction tissue disease and intermittent 2:1 AV block during the hospital stay. CLINICAL DISCUSSION: It is likely that patients with an already diseased conduction system are at an increased risk of worsening of AV block following inoculation of the vaccine. Vaccine associated AV blocks are likely to be reversible. Presence of prior coronary artery disease and electrical abnormalities are important considerations. CONCLUSION: COVID-19 vaccine may have added side effects in subjects with known heart disease. Humoral response towards the vaccine might interfere with the conduction system of the heart and more so in patients with diseased and scarred myocardium.

Comparing sensitivity and specificity of pacemaker ID application and cardiac rhythm management device-finder application in identifying cardiac implantable electronic device manufacturer using chest radiograph - An observational study.

BACKGROUND: Smartphone-based applications to identify cardiac implantable electronic devices (CIED) are extremely useful in circumstances, where urgent device interrogation is needed, and a device identification card is not available. Few studies have provided insights regarding the utility of these applications. We have studied two widely available applications i.e., Pacemaker ID app (PMIDa) or Cardiac Rhythm Management Device-Finder (CRMD-f) to identify device manufacturers in CIEDs. METHODS: 547 patients who underwent CIED implantation from the year 2016-2020 in our institute were enrolled. There were 438 Medtronic and 109 St. Jude's devices. All chest radiographs were de-identified and resized into 225*225 pixels focusing on the CIED. PMIDa and CRMD-f applications were used to identify the CIED. Accuracy, sensitivity, specificity, negative predictive value, and positive predictive value for both applications were calculated and compared. RESULTS: Overall, CRMD-f application has higher specificity (93.58 vs. 82.5%) but lower sensitivity (53.6 vs. 55%) than PMIDa. The accuracy of both applications was comparable (61.6% vs. 60.5%). Accuracy varied with CIED model and type tested, and radiograph projection used. Accuracy is greatest with Cardiac-Resynchronization-Therapy (CRT) devices for both applications, followed by a single lead pacemaker. CONCLUSION: CRMD-f has higher accuracy and specificity for CIED manufacturer identification. Both PMIDa and CRMD-f are specific tools to identify CIED but have low sensitivity.

Cardiovascular fellow-in-training feedback on virtual and simulator-based learning experience during Covid-19 pandemic in a low to middle income country - A cross-sectional study.

BACKGROUND: COVID-19 pandemic has introduced us to a greater need of virtual learning platforms and has resulted in less clinical exposure for fellows-in-training. Virtual and simulator-based learning is not widely available in LMIC. It is imperative to analyze feedback of CV fellow-in-training regarding this mode of learning before large scale implementation. METHODOLOGY: This was an observational study conducted between July-August 2020. A multicentered survey was conducted. Survey questionnaire was disseminated to FIT (fellow-in-training) via Google Forms. The questionnaire contained a total of 24 questions about virtual and simulator-based learning during the pandemic. RESULTS: A total of 68 FIT responded to the survey. The mean age was 29.9 years. There were 37% females and 63% males. Majority (75%) agreed that it was easier for them to reach for online sessions than physical sessions. 60% FIT were confident in asking questions or giving comments during the online sessions. 57.4% FIT felt it easier to go through cardiovascular imaging/illustrations via online platforms. 50% (34) were confident that if online sessions had to continue, they would have enough academic learning before they graduated from the program and 54.4% (37) wanted online sessions to continue even beyond the pandemic days. 37.5% (18 out of 48) agreed that the simulator-based teaching was helping them practice skills in times of less clinical exposure. CONCLUSION: COVID-19 pandemic has significantly impacted cardiovascular FIT learning curve because of less hands-on and lack of physical teaching sessions. LMIC have lack of robust e-learning platforms. Virtual learning is convenient for academic learning with growing acceptance amongst fellows. FIT from LMIC are less acquaint to simulator-based teaching and there is a need to invest in simulator-based cardiovascular teaching in LMIC.

Impact of COVID-19 on Cardiovascular Disease Presentation, Emergency Department Triage and Inpatient Cardiology Services in a Low- to Middle-Income Country - Perspective from a Tertiary Care Hospital of Pakistan.

Aims: To identify the changes in cardiovascular disease presentation, emergency room triage and inpatient diagnostic and therapeutic pathways. Methods: We conducted a retrospective cohort study at the Aga Khan University Hospital, Karachi. We collected data for patients presenting to the emergency department with cardiovascular symptoms between March-July 2019 (pre-COVID period) and March-July 2020 (COVID period). The comparison was made to quantify the differences in demographics, clinical characteristics, admission, diagnostic and therapeutic procedures, and in-hospital mortality between the two periods. Results: Of 2976 patients presenting with cardiac complaints to the emergency department (ED), 2041(69%) patients presented during the pre-COVID period, and 935 (31%) patients presented during the COVID period. There was significant reduction in acute coronary syndrome (ACS) (8% [95% CI 4-11], p < 0.001) and heart failure (↓6% [95% CI 3-8], p < 0.001). A striking surge was noted in Type II Myocardial injury (↑18% [95% CI 20-15], p < 0.001) during the pandemic. There was reduction in cardiovascular admissions (coronary care unit p < 0.01, coronary step-down unit p = 0.03), cardiovascular imaging (p < 0.001), and procedures (percutaneous coronary intervention p = 0.04 and coronary angiography p = 0.02). No significant difference was noted in mortality (4.7% vs. 3.7%). The percentage of patients presenting from rural areas declined significantly during the COVID period (18% vs. 14%, p = 0.01). In the subgroup analysis of sex, we noticed a falling trend of intervention performed in females during the COVID period (8.2% male vs. 3.3 % female). Conclusions: This study shows a significant decline in patients presenting with Type I myocardial infarction (MI) and a decrease in cardiovascular imaging and procedures during the COVID period. There was a significant increase noted in Type II MI.