Leveraging Clinical Digitized Data to Understand Temporal Characteristics and Outcomes of Acute Myocardial Infarctions at a Tertiary Care Medical Centre in Pakistan from 1988-2018 - Methods and Results.

Background and Objective: Few data exist on trends in acute myocardial infarction (AMI) patterns spanning recent epidemiological shifts in low middle-income countries (LMICs). To understand temporal disease patterns of AMI characteristics and outcomes between 1988-2018, we used digitized legacy clinical data at a large tertiary care centre in Pakistan. Methods: We reviewed digital health information capture systems maintained across the Aga Khan University Hospital and obtained structured elements to create a master dataset. We included index admissions of patients >18 years that were discharged between January 1, 1988, and December 31, 2018, with a primary discharge diagnosis of AMI (using ICD-9 diagnoses). The outcome evaluated was in-hospital mortality.Clinical characteristics derived from the electronic database were validated against chart review in a random sample of cases (k 0.53-1.00). Results: The final population consisted of 14,601 patients of which 30.6% (n = 4,470) were female, 52.4% (n = 7,651) had ST elevation MI and 47.6% (n = 6,950) had non-ST elevation MI. The median (IQR) age at presentation was 61 (52-70) years. Overall unadjusted in-hospital mortality was 10.3%. Across the time period, increasing trends were noted for the following characteristics: age, proportion of women, prevalence of hypertension, diabetes, proportion with NSTEMI (all ptrend < 0.001). In-hospital mortality rates declined significantly between 1988-1997 and 2008-2018 (13.8% to 9.2%, p < 0.001). Conclusions: The patterns of AMI have changed over the last three decades with a concomitant decline in in-hospital mortality at a tertiary care centre in Pakistan. Clinical digitized data presents a unique opportunity for gaining insights into disease patterns in LMICs.

12-Month clinical outcomes of amphilimus drug eluting stents in an all-comers South-East Asian registry.

BACKGROUND: Amphilimus-eluting stent (AES) is a novel polymer-free drug eluting stent that combines sirolimus with fatty acid as antiproliferative drug and has shown promising results in percutaneous coronary intervention.We evaluated the clinical safety and efficacy of AES in an all-comers South-East Asian registry. METHODS: Between May 2014 to April 2017, 268 patients (88% male, mean age 60.1 ±â€¯10.8 years) with 291 coronary lesions were treated with AES. The primary endpoint was major adverse cardiac events (MACE) ie a composite of cardiovascular mortality, myocardial infarction (MI) and target lesion revascularization (TLR) at 12-month follow-up. RESULTS: The majority of patients presented with acute coronary syndrome (75%) and 75% had multi-vessel disease on angiography. Diabetes mellitus was present in 123 patients (46%). The most common target vessel for PCI was left anterior descending artery (43%) followed by right coronary artery (36%), left circumflex (10%) and left main (6%).The majority of lesions were type B-C (85%) by ACC/AHA lesion classification. An average of 1.25 ±â€¯0.5 AES were used per patient, with mean AES diameter of 3.1 ±â€¯0.4 mm and average total length of 34.8 ±â€¯19.4 mm.At 12-month follow-up, 4% of patients developed MACE. MACE was mainly driven by cardiovascular mortality (1.5%), MI (2%) and TLR (1.5%). The rate of stent thrombosis was 1.5%. CONCLUSION: In a contemporary all-comers South-East Asian registry with high rate of diabetes mellitus, AES was found to be efficacious with a low incidence of MACE observed at 12-month follow-up.

Causes of delay in door-to-balloon time in south-east Asian patients undergoing primary percutaneous coronary intervention.

OBJECTIVE: To evaluate causes and impact of delay in the door-to-balloon (D2B) time for patients undergoing primary percutaneous coronary intervention (PPCI). SUBJECTS AND METHODS: From January 2009 to December 2012, 1268 patients (86% male, mean age of 58 ± 12 years) presented to our hospital for ST-elevation myocardial infarction (STEMI) and underwent PPCI. They were divided into two groups: Non-delay defined as D2B time ≤ 90 mins and delay group defined as D2B time > 90 mins. Data were collected retrospectively on baseline clinical characteristics, mode of presentation, angiographic findings, therapeutic modality and inhospital outcome. RESULTS: 202 patients had delay in D2B time. There were more female patients in the delay group. They were older and tend to self-present to hospital. They were less likely to be smokers and have a higher prevalence of prior MI. The incidence of posterior MI was higher in the delay group. They also had a higher incidence of triple vessel disease. The 3 most common reasons for D2B delay was delay in the emergency department (39%), atypical clinical presentation (37.6%) and unstable medical condition requiring stabilisation/computed tomographic imaging (26.7%). The inhospital mortality was numerically higher in the delay group (7.4% versus 4.8%, p = 0.12). CONCLUSIONS: Delay in D2B occurred in 16% of our patients undergoing PPCI. Several key factors for delay were identified and warrant further intervention.

Preliminary experience with drug-coated balloon angioplasty in primary percutaneous coronary intervention.

We evaluated the clinical feasibility of using drug-coated balloon (DCB) angioplasty in patients undergoing primary percutaneous coronary intervention (PPCI). Between January 2010 to September 2014, 89 ST-elevation myocardial infarction patients (83% male, mean age 59 ± 14 years) with a total of 89 coronary lesions were treated with DCB during PPCI. Clinical outcomes are reported at 30 d follow-up. Left anterior descending artery was the most common target vessel for PCI (37%). Twenty-eight percent of the patients had underlying diabetes mellitus. Mean left ventricular ejection fraction was 44% ± 11%. DCB-only PCI was the predominant approach (96%) with the remaining 4% of patients receiving bail-out stenting. Thrombolysis in Myocardial Infarction (TIMI) 3 flow was successfully restored in 98% of patients. An average of 1.2 ± 0.5 DCB were used per patient, with mean DCB diameter of 2.6 ± 0.5 mm and average length of 23.2 ± 10.2 mm. At 30-d follow-up, there were 4 deaths (4.5%). No patients experienced abrupt closure of the infarct-related artery and there was no reported target-lesion failure. Our preliminary experience showed that DCB angioplasty in PPCI was feasible and associated with a high rate of TIMI 3 flow and low 30-d ischaemic event.

Clinical Efficacy and Safety of SeQuent Please Paclitaxel-Eluting Balloon in a Real-World Single-Center Registry of South-East Asian Patients.

BACKGROUND: Drug eluting balloon (DEB) is a new therapeutic option for treatment of obstructive coronary lesions in percutaneous coronary intervention (PCI). There is limited data on the safety and efficacy of DEB in Asian patients in contemporary clinical registries. We evaluated the clinical efficacy and safety of SeQuent Please paclitaxel-eluting balloon in our cohort of South-East Asian patients in real world clinical practice. METHODS: Between January 2010 to November 2012, 320 patients (76% male, mean age 61.3 ± 11.2 years) with a total of 337 coronary lesions were treated with SeQuent Please drug-eluting balloon (DEB). The primary endpoint was major adverse cardiac events (MACE) ie a composite of cardiovascular death, target vessel related myocardial infarction (MI) and target lesion revascularization (TLR) at 9 months follow-up. RESULTS: The majority of patients presented with acute coronary syndrome (76%).The most common indication for the use of DEB was small vessel disease (54%) followed by instent restenosis (21%), bifurcation lesions (6%) and others (19%). An average of 1.23 ± 0.5 DEB were used per patient, with mean DEB diameter of 2.6 ± 0.6 mm and average total length of 24.0 ± 11.1 mm.At 9 months follow-up, 5.3% of patients developed MACE. MACE was mainly driven by TLR(4%) followed by target vessel related myocardial infarction (2.6%) and cardiovascular death (1%). CONCLUSION: SeQuent Please DEB was a safe and effective treatment modality in our cohort of South-East Asian patients with a low incidence of MACE observed at 9 months follow-up.

Deliverability of integrity coronary stents in severely tortuous coronary arteries: a preliminary experience.

BACKGROUND: Stent delivery failure occurs in 4% of all percutaneous coronary interventions (PCIs) and >90% of these failures are due to vessel tortuosity and/or calcification. Stent performance of the newly launched Integrity coronary stent has markedly improved due to its novel manufacturing process utilizing continuous sinusoid technology. We sought to evaluate the deliverability of Integrity coronary stents in severely tortuous coronary lesions in real-world clinical practice. METHODS: From January to August 2011, a total of 35 patients (25 males; mean age, 60.7 ± 11.4 years) with obstructive coronary artery disease involving severely tortuous coronary vessels underwent PCI with Integrity coronary stents. RESULTS: The most common target vessel for PCI was left circumflex artery (54.3%) followed by right coronary artery (42.8%) and left anterior descending (2.9%), with 37.1% of lesions located distally. Mean stent diameter was 3.04 ± 0.51 mm and mean stent length was 20.5 ± 6.6 mm. Acute procedural success was achieved in 33 patients (94%) using conventional PCI techniques. Predilatation was performed in 31 patients (89%) and buddy wires were used in 12 patients (34.3%). For the 2 cases (6%) in which stent delivery failed, Heartrail catheters were used as a bailout to facilitate stent delivery. There were no peri- or postprocedural adverse events. CONCLUSION: This early experience with Integrity coronary stent in severely tortuous coronary arteries yielded a promising result in terms of stent deliverability. It could potentially shorten PCI procedural time in this technically challenging subgroup of patients.

Radial artery spasm during transradial cardiac catheterization and percutaneous coronary intervention: incidence, predisposing factors, prevention, and management.

Transradial cardiac catheterization and percutaneous coronary intervention are increasingly being performed worldwide in elective and emergency procedures, with many centers adopting the transradial route as their first choice of arterial access. One of the most common complications encountered during transradial procedures is radial artery spasm. This article reviews the current literature on the incidence, predisposing factors, preventive, and treatment measures for radial artery spasm.

Good visibility of TITAN-2 coronary stents demonstrable on cardiac computer tomographic angiography: a report of 2 cases.

Numerous studies have sought to assess stent patency by cardiac computer tomographic angiography (CCTA) in comparison with invasive coronary angiography in patients who had undergone percutaneous coronary stenting. Even with newer generation scanners, CCTA has been of limited value in the assessment of the revascularized patient. The main reason being blooming artifact from metallic stents often obscures stent luminal dimension, making the stented segment unassessable. We report on a novel finding of good visibility of TITAN-2 coronary stents demonstrable on CCTA for 2 patients and discuss the possible mechanism and potential implications of this observation.