Intravascular ultrasound-guided versus angiography-guided percutaneous coronary intervention in acute coronary syndromes (IVUS-ACS): a two-stage, multicentre, randomised trial.

BACKGROUND: Intravascular ultrasound-guided percutaneous coronary intervention has been shown to result in superior clinical outcomes compared with angiography-guided percutaneous coronary intervention. However, insufficient data are available concerning the advantages of intravascular ultrasound guidance for patients with an acute coronary syndrome. This trial aimed to investigate whether the use of intravascular ultrasound guidance, as compared with angiography guidance, improves the outcomes of percutaneous coronary intervention with contemporary drug-eluting stents in patients presenting with an acute coronary syndrome. METHODS: In this two-stage, multicentre, randomised trial, patients aged 18 years or older and presenting with an acute coronary syndrome at 58 centres in China, Italy, Pakistan, and the UK were randomly assigned to intravascular ultrasound-guided percutaneous coronary intervention or angiography-guided percutaneous coronary intervention. Patients, follow-up health-care providers, and assessors were masked to random assignment; however, staff in the catheterisation laboratory were not. The primary endpoint was target vessel failure, a composite of cardiac death, target vessel myocardial infarction, or clinically driven target vessel revascularisation at 1 year after randomisation. This trial is registered at ClinicalTrials.gov, NCT03971500, and is completed. FINDINGS: Between Aug 20, 2019 and Oct 27, 2022, 3505 patients with an acute coronary syndrome were randomly assigned to intravascular ultrasound-guided percutaneous coronary intervention (n=1753) or angiography-guided percutaneous coronary intervention (n=1752). 1-year follow-up was completed in 3504 (>99·9%) patients. The primary endpoint occurred in 70 patients in the intravascular ultrasound group and 128 patients in the angiography group (Kaplan-Meier rate 4·0% vs 7·3%; hazard ratio 0·55 [95% CI 0·41-0·74]; p=0·0001), driven by reductions in target vessel myocardial infarction or target vessel revascularisation. There were no significant differences in all-cause death or stent thrombosis between groups. Safety endpoints were also similar in the two groups. INTERPRETATION: In patients with an acute coronary syndrome, intravascular ultrasound-guided implantation of contemporary drug-eluting stents resulted in a lower 1-year rate of the composite outcome of cardiac death, target vessel myocardial infarction, or clinically driven revascularisation compared with angiography guidance alone. FUNDING: The Chinese Society of Cardiology, the National Natural Scientific Foundation of China, and Jiangsu Provincial & Nanjing Municipal Clinical Trial Project. TRANSLATION: For the Mandarin translation of the abstract see Supplementary Materials section.

Predilation Ballooning in High Thrombus Laden STEMIs: An Independent Predictor of Slow Flow/No-Reflow in Patients Undergoing Emergent Percutaneous Coronary Revascularization.

Background: Distal embolization due to microthrombus fragments formed during predilation ballooning is considered one of the possible mechanisms of slow flow/no-reflow (SF/NR). Therefore, this study aimed to compare the incidence of intraprocedure SF/NR during the primary percutaneous coronary intervention (PCI) in patients with high thrombus burden (≥4 grade) with and without predilation ballooning for culprit lesion preparation. Methodology. This prospective descriptive cross-sectional study included patients with a high thrombus burden (≥4 grades) who underwent primary PCI. Propensity-matched cohorts of patients with and without predilation ballooning in a 1 : 1 ratio were compared for the incidence of intraprocedure SF/NR. Results: A total of 765 patients with high thrombus burden undergoing primary PCI were included in this study. The mean age was 55.75 ± 11.54 years, and 78.6% (601) were males. Predilation ballooning was conducted in 346 (45.2%) patients. The incidence of intraprocedure SF/NR was significantly higher (41.3% vs. 27.4%; p < 0.001) in patients with predilation ballooning than in those without preballooning, respectively. The incidence of intraprocedure SF/NR also remained significantly higher for the predilation ballooning cohort with an incidence rate of 41.3% as against 30.1% (p=0.002) for the propensity-matched cohort of patients without predilation ballooning with a relative risk of 1.64 (95% CI: 1.20 to 2.24). Moreover, the in-hospital mortality rate remained higher but insignificant, among patients with and without predilation ballooning (8.1% vs. 4.9%; p=0.090). Conclusion: In conclusion, predilation ballooning can be associated with an increased risk of incidence of intraprocedure SF/NR during primary PCI in patients with high thrombus burden.

Acute hyperglycemia, a rabble-rouser or innocent bystander? A prospective analysis of clinical implications of acute hyperglycemia in STE-ACS patients.

BACKGROUND: Acute hyperglycemia is considered an independent prognosticator of both in-hospital and long-term outcomes in patients with acute coronary syndrome (ACS). This study aimed To analyze the incidence of acute hyperglycemia and its impact on the adverse in-hospital outcome in patients with STE-ACS undergoing primary percutaneous coronary intervention (PCI). METHODS: In this study, we enrolled patients presenting with STE-ACS and undergoing primary PCI at a tertiary care cardiac center. Acute hyperglycemia was defined as random plasma glucose (RBS) > 200 mg/dl at the time of presentation to the emergency room. RESULTS: Of the 4470 patients, 78.8% were males, and the mean age was 55.52 ± 11 years. In total, 39.4% (1759) were found to have acute hyperglycemia, and of these, 59% (1037) were already diagnosed with diabetes. Patients with acute hyperglycemia were observed to have a higher incidence of heart failure (8.2% vs. 5.5%; p < 0.001), contrast-induced nephropathy (10.9% vs. 7.4%; p < 0.001), and in-hospital mortality (5.7% vs. 2.5%; p < 0.001). On multivariable analysis, acute hyperglycemia was found to be an independent predictor of mortality with an adjusted odds ratio of 1.81 [1.28-2.55]. Multi-vessel disease (1.73 [1.17-2.56]), pre-procedure left ventricular end-diastolic pressure (LVEDP) (1.02 [1.0-1.03]), and Killip class III/IV (4.55 [3.09-6.71]) were found to be the additional independent predictors of in-hospital mortality. CONCLUSIONS: Acute hyperglycemia, regardless of diabetic status, is an independent predictor of in-hospital mortality among patients with STE-ACS undergoing primary PCI. Acute hyperglycemia, along with other significant predictors such as multi-vessel involvement, LVEDP, and Killip class III/IV, can be considered for the risk stratification of these patients.

Human knockouts and phenotypic analysis in a cohort with a high rate of consanguinity.

A major goal of biomedicine is to understand the function of every gene in the human genome. Loss-of-function mutations can disrupt both copies of a given gene in humans and phenotypic analysis of such 'human knockouts' can provide insight into gene function. Consanguineous unions are more likely to result in offspring carrying homozygous loss-of-function mutations. In Pakistan, consanguinity rates are notably high. Here we sequence the protein-coding regions of 10,503 adult participants in the Pakistan Risk of Myocardial Infarction Study (PROMIS), designed to understand the determinants of cardiometabolic diseases in individuals from South Asia. We identified individuals carrying homozygous predicted loss-of-function (pLoF) mutations, and performed phenotypic analysis involving more than 200 biochemical and disease traits. We enumerated 49,138 rare (<1% minor allele frequency) pLoF mutations. These pLoF mutations are estimated to knock out 1,317 genes, each in at least one participant. Homozygosity for pLoF mutations at PLA2G7 was associated with absent enzymatic activity of soluble lipoprotein-associated phospholipase A2; at CYP2F1, with higher plasma interleukin-8 concentrations; at TREH, with lower concentrations of apoB-containing lipoprotein subfractions; at either A3GALT2 or NRG4, with markedly reduced plasma insulin C-peptide concentrations; and at SLC9A3R1, with mediators of calcium and phosphate signalling. Heterozygous deficiency of APOC3 has been shown to protect against coronary heart disease; we identified APOC3 homozygous pLoF carriers in our cohort. We recruited these human knockouts and challenged them with an oral fat load. Compared with family members lacking the mutation, individuals with APOC3 knocked out displayed marked blunting of the usual post-prandial rise in plasma triglycerides. Overall, these observations provide a roadmap for a 'human knockout project', a systematic effort to understand the phenotypic consequences of complete disruption of genes in humans.

Vitamin D receptor gene polymorphism TaqI (rs731236) and its association with the susceptibility to coronary artery disease among Pakistani population.

BACKGROUND: Coronary artery disease (CAD) is a leading cause of mortality in Pakistan and also worldwide. Vitamin D receptor (VDR) regulates the transcription of many genes and has a significant impact on inflammation and the morphology of cardiac cells. Genetic variation in the VDR gene such as the TaqI polymorphism (rs731236) may have an impact that causes adverse effects. Accordingly, it is important to determine possible association of the TaqI polymorphism (rs731236) with CAD. METHODS: The study included blood samples from 1016 subjects: 516 from CAD patients and 500 from age- and gender-matched controls. Genomic DNA was extracted by standard salting out method. Targeted variation was amplified by an allele-specific polymerase chain reaction (PCR). PCR products were examined and genotyped on agarose gel electrophoresis represented by an amplified product size of 148 bp followed by Sanger sequencing to validate variations. RESULTS: Serum vitamin levels, as observed using enzyme-linked immunosorbent assay, were found to be insufficient in both CAD patients (20.52 ± 0.06 ng/ml) and controls (21.6981 ± 0.05 ng/ml). The TaqI polymorphism (rs731236) T>C was found to be significantly associated with CAD (p < 0.0001). The odds ratio showed that the risk increases by 1.8-fold with variant C allele. Dominant, co-dominant and over dominant genetic model analyses suggested that the TC genotype might be a risk factor involved in the possible association with susceptibility to CAD. CONCLUSIONS: The TaqI polymorphism (rs731236) in the coding region may affect the function of the receptor by altering the binding site, which might participate in an inflammatory response and increase the risk for developing susceptibility to CAD.

Genome-wide analysis of blood lipid metabolites in over 5000 South Asians reveals biological insights at cardiometabolic disease loci.

BACKGROUND: Genetic, lifestyle, and environmental factors can lead to perturbations in circulating lipid levels and increase the risk of cardiovascular and metabolic diseases. However, how changes in individual lipid species contribute to disease risk is often unclear. Moreover, little is known about the role of lipids on cardiovascular disease in Pakistan, a population historically underrepresented in cardiovascular studies. METHODS: We characterised the genetic architecture of the human blood lipidome in 5662 hospital controls from the Pakistan Risk of Myocardial Infarction Study (PROMIS) and 13,814 healthy British blood donors from the INTERVAL study. We applied a candidate causal gene prioritisation tool to link the genetic variants associated with each lipid to the most likely causal genes, and Gaussian Graphical Modelling network analysis to identify and illustrate relationships between lipids and genetic loci. RESULTS: We identified 253 genetic associations with 181 lipids measured using direct infusion high-resolution mass spectrometry in PROMIS, and 502 genetic associations with 244 lipids in INTERVAL. Our analyses revealed new biological insights at genetic loci associated with cardiometabolic diseases, including novel lipid associations at the LPL, MBOAT7, LIPC, APOE-C1-C2-C4, SGPP1, and SPTLC3 loci. CONCLUSIONS: Our findings, generated using a distinctive lipidomics platform in an understudied South Asian population, strengthen and expand the knowledge base of the genetic determinants of lipids and their association with cardiometabolic disease-related loci.

Angiographic profile and outcomes of Pakistani women with ST elevation myocardial infarction.

OBJECTIVE: To evaluate the angiographic profile and outcome of primary percutaneous coronary intervention in female patients with acute myocardial infarction. METHODS: The cross-sectional study was conducted at the National Institute of Cardiovascular Diseases, Karachi, from July 1, 2017, to March 31, 2018, and comprised of female patients presenting with acute myocardial infarction who underwent primary percutaneous coronary intervention and got enrolled in the National Cardiovascular Data Registry. Follow-up calls were made 1 year post-intervention and outcomes were noted. Data were analysed using SPSS 21. RESULTS: Of the 522 female patients with a mean age of 57.41±11.14 years, 334(64%) were hypertensive, 202(38.7%) diabetic, 16(3.1%) had a family history of coronary artery disease, and 9(1.7%) were smokers. Single-vessel disease was observed in 183(35.1%) patients, and three-vessel disease in 144(27.6%). Post-procedure thrombolysis in myocardial infarction flow (0-II) was observed in 29(5.6%) patients, bleeding in 2(0.4%), and in-hospital mortality was in 22(4.2%). Telephonic follow-up was successfully conducted in 436(87.5%) of the discharged patients, and, of them 15(3.4%) had expired and recurrence was reported by 10(2.3%) patients and 8(80%) of them underwent re-intervention. CONCLUSIONS: More than half the female patients had multi-vessel disease and bifurcation lesion was observed in more than three-fourth of the sample.

An Unbiased Lipid Phenotyping Approach To Study the Genetic Determinants of Lipids and Their Association with Coronary Heart Disease Risk Factors.

Direct infusion high-resolution mass spectrometry (DIHRMS) is a novel, high-throughput approach to rapidly and accurately profile hundreds of lipids in human serum without prior chromatography, facilitating in-depth lipid phenotyping for large epidemiological studies to reveal the detailed associations of individual lipids with coronary heart disease (CHD) risk factors. Intact lipid profiling by DIHRMS was performed on 5662 serum samples from healthy participants in the Pakistan Risk of Myocardial Infarction Study (PROMIS). We developed a novel semi-targeted peak-picking algorithm to detect mass-to-charge ratios in positive and negative ionization modes. We analyzed lipid partial correlations, assessed the association of lipid principal components with established CHD risk factors and genetic variants, and examined differences between lipids for a common genetic polymorphism. The DIHRMS method provided information on 360 lipids (including fatty acyls, glycerolipids, glycerophospholipids, sphingolipids, and sterol lipids), with a median coefficient of variation of 11.6% (range: 5.4-51.9). The lipids were highly correlated and exhibited a range of associations with clinical chemistry biomarkers and lifestyle factors. This platform can provide many novel insights into the effects of physiology and lifestyle on lipid metabolism, genetic determinants of lipids, and the relationship between individual lipids and CHD risk factors.

Angiographic characteristics and in hospital outcome of young patients, age up to 40 versus more than 40 years undergoing primary percutaneous coronary intervention.

OBJECTIVE: To compare angiographic characteristics and outcomes of primary percutaneous coronary intervention between young and old patients presenting with acute ST Elevation Myocardial Infarction. METHODS: The prospective observational study was conducted at the National Institute of Cardiovascular Diseases, Karachi, from December 17, 2016, to June 16, 2017, and comprised acute ST-Elevation Myocardial Infarction patients undergoing primary percutaneous coronary intervention (PCI). Data was collected on demographic, angiographic, and in-hospital outcomes. Those <40 years were considered young. Data was analysed using SPSS 21. RESULTS: Of the 415 patients, 50(12%) were young. Proportion of male was higher among the young (p=0.02) and so was the case with positive family history (p=0.002). The young had lesser cases of diabetes (p=0.028) and hypertension (p=0.034). Single vessel disease was more common among young (p<0.001). No significant difference was observed in post-procedure outcome related to age (p>0.05). CONCLUSIONS: Acute Myocardial Infarction in young was more likely associated with male gender, positive family history and less likely with hypertensive and diabetic status.

Procedural determinants of fluoroscopy time in patients undergoing cardiac catheterization.

BACKGROUND & OBJECTIVE: Due to increase in number of cardiac catheterization procedures safety concerns is an issue nowadays. Multiple diagnostic modalities use radiations, which also put a patient at higher cumulative radiation exposure. Therefore steps should be taken to minimize radiation exposure during cardiac catheterization. Hence determination of factors which prolong FT will result in better understanding of problem. This retrospective study was undertaken to determine factors responsible for prolong fluoroscopy time in patients undergoing coronary artery catheterization. METHODS: This retrospective study was conducted at catheterization Laboratory National Institute of Cardiovascular Diseases, Karachi from June 2014 to June 2015. Patients of either gender, aged between 18 to 90 years undergoing cardiac catheterization procedures were included. Radiation exposure time was measured in terms of fluoroscopy time. RESULTS: A total of 957 patients were included in this study out of which 731 were of diagnostic Coronary Angiograms (CA) and 226 were of Percutaneous Coronary Intervention (PCI). The mean age of the study participants was 54.12±10.89 years and majority 734(76.6%) were male. Mean fluoroscopy time (FT) in the patients subjected to PCI was 9.61±6.07 minutes while in cases for CA 4.17±4.13 minutes. FT for CA was observed significantly dependent on procedural access, operator's experience, and LV angiogram. While FT for PCI was found dependent on number of stents deployed during the procedure. CONCLUSION: For invasive coronary angiographic procedures radial route increased fluoroscopy time. For percutaneous coronary intervention femoral and radial route fluoroscopy time were not significantly different.

Managed successfully: Iatrogenic aortic dissection during primary percutaneous coronary intervention.

Iatrogenic aortic dissection caused by primary percutaneous coronary intervention (PCI) is a rare but potentially fatal complication; therefore prompt recognition of this life-threatening condition is crucial. We present herein a case of a 70-year-old lady who underwent primary PCI for transmural myocardial infarction of left anterior descending artery territory. Manipulation of the extra backup (EBU) guiding catheter during an attempt to cannulate the left system resulted in an aortic dissection. The patient was managed conservatively with strict monitoring in the coronary care unit (CCU), and underwent serial evaluation with non-invasive imaging studies including a computed tomography angiography (CTA). On the 3rd post-procedure day, she developed cerebrovascular accident from which she recovered completely. Repeat CT angiogram showed complete resolution of the ascending aortic dissection. Initial follow-up was conducted at 2 weeks and the patient was doing well.

Safety of primary percutaneous coronary intervention with and without (selective) thrombus aspiration.

OBJECTIVE: To determine the safety and efficacy of selective thrombus aspiration during Primary Percutaneous Coronary Intervention (PCI). METHODS: This observational prospective study was conducted in the catheterization laboratory of a tertiary care cardiovascular centre. A total of 150 consecutive patients who underwent primary PCI were enrolled. Aspiration was done only when thrombus burden was considered significant. After completion of procedure angiographic and electrocardiographic signs were recorded and clinical follow up was documented up to 1 year. RESULTS: No significant difference among the groups was found in age, height, weight and other risk factors like Hypertension, Diabetes Mellitus and Smoking. In general, left anterior descending artery was culprit in - 65% of patients and more than 90% of culprit vessels had visible thrombus. Multivessel disease was present in 38% of patients and 22.7% had past history of myocardial infarction. Out of 150 patients 117 (78%) underwent thrombus aspiration. No significant difference was found in ST resolution within 60 minutes (72.6 vs 81.8%; P < 0.285) and myocardial blush grade II & III (41.9 vs 27.3%; P < 0.128). No difference in event free survival was observed among the two groups (80.3 vs 84.8%; P < 0.708) at one year. CONCLUSION: Selective thrombus aspiration in definite thrombus laden arteries and no aspiration in low or negligible thrombus burden vessels may be a safe and effective strategy in patients undergoing primary PCI. Overall poor risk profile of our patients as compared to western population necessitates further evaluation of this matter in randomized studies.

Preventive strategies to fight complications during percutaneous multitrack balloon valvotomy "refining the technique".

BACKGROUND: Percutaneous mitral valvuloplasty (PMV) is still the treatment of choice in selected cases of mitral stenosis (MS). Multitrack balloon (MTB) catheter is one of the techniques used for PMV with optimal results. We describe a novel refinement of appropriate balloon sizing and wire placement to reduce mitral regurgitation (MR) and Left ventricular (LV) apical perforation, respectively. METHODS: Ninety four consecutive patients with moderate to severe rheumatic mitral stenosis (MS) were selected for PMV with MTB catheter. Balloon sizing was done by effective balloon dilatation area (EBDA), using standard geometric formula. 0.35" PMV wire was placed in aortic arch /ascending aorta (AA) to avoid LV apical perforation. RESULTS: Mild MR was present in 28(29.8%). Post-procedure MR was present in 50(53.2%). Out of 50 MR cases 44(88%) had mild and 6(12.0%) had moderate MR. No patient had severe MR. With placement of wire in AA and arch of aorta none of the patients developed complication of LV apical perforation. CONCLUSION: EDBA as balloon sizing for multitrack system can be used to reduce severity of mitral regurgitation. Placement of PMV guide wire in Aortic arch/AA ascending aorta can eliminate/substantially reduce dreadful complication of LV perforation.

Association of serum vitamin D levels and TaqIrs731236 among patients with hypertensive coronary heart disease.

The development of cardiovascular diseases (CVD) is influenced through multiple risk factor and hypertension. It may increase the risk of cardiac events, and has a significant impact when combined with other risk factors including low levels of vitamin D and genetic variations like single nucleotide variations (SNV) (TaqIrs731236) in vitamin D receptor (VDR) gene. Blood samples from 500 study participants gathered including 250 hypertensive coronary heart disease patients, 250 age and gender matched healthy controls. To isolate genomic DNA, conventional salting out procedure used followed by amplification of targeted variations through Amplification Refractory Mutation System- Polymerase Chain Reaction (ARMS-PCR) Assay. The amplicon consists of 148 base pairs which was visualized on 2 % agarose gel electrophoresis and confirmed by DNA sequencing. The compared clinical parameters including systolic blood pressure (SBP), diastolic blood pressure (DBP), body mass index (BMI), high density lipoproteins (HDL), low density lipoproteins (LDL), cholesterol, triglycerides found significantly different among patients when compared with controls (P < 0.001). The Vitamin D exhibited insufficient levels at different stages of hypertension which were statistically, found significantly associated among patients with hypertensive coronary heart disease showing compared to controls (P < 0.001). The genotype association SNV (TaqIrs731236) T > C showed significant association with hypertensive coronary heart disease compared to healthy controls (Chi-Square χ2 = 60.75 and P < 0.00001). Further, the odds ratio of allelic association for risk allele (C) showed the strength of association with risk of disease, which increases by 2.02 times(P = 0.01). The results suggest that (TaqIrs731236) T > C as genetic predisposition factor, may contribute to develop the risk of hypertensive coronary heart disease. Hypertension as a risk factor along with insufficient levels of vitamin D and SNV (TaqIrs731236) as genetic variations may have been an important contributor to disease risk of hypertensive coronary heart disease.

Prodromal Symptoms in Patients Presenting With Myocardial Infarction.

Background Prodromal symptoms are warning signs of an impending acute myocardial infarction (AMI). However, they are often overlooked by both patients and primary clinicians, and little is known about them. Therefore, this study aims to assess the frequency and types of prodromal symptoms in patients with AMI. Methodology This descriptive cross-sectional study was conducted at a tertiary care cardiac center. Consecutive patients diagnosed with AMI within the last week were evaluated for prodromal symptoms. The prodromal symptoms included chest pain, chest heaviness, chest burning, palpitations, fatigue, sleep disturbance, shortness of breath (SOB), dizziness, anxiety, sudden heat or cold, back pain, and vomiting. Results In a sample of 242 patients, 79.6% were males, with a mean age of 54.7 ± 12.2 years, and 179 (74%) were diagnosed with ST-segment elevation myocardial infarction (STEMI). Among the participants, 142 (58.7%) showed no prodromal symptoms. Among those with prodromal symptoms, chest pain was the predominantly reported prodromal symptom with a frequency of 68%, followed by chest heaviness at 44%, palpitations at 42%, shortness of breath at 34%, and chest burning at 27%. Unusual fatigue in 23% and sleep disturbance in 22% of the patients were also reported. Conclusion The findings from this study revealed that prodromal symptoms were present in a significant proportion of acute myocardial infarction (MI) cases, with more than four in 10 patients reporting these early warning signs. The most commonly observed prodromal symptoms were chest pain, chest heaviness, palpitations, shortness of breath, and chest burning. The timely identification of these symptoms can help prevent infarction, thereby reducing the burden of heart failure and other related mortalities.

Impact of COVID-19 on cardiovascular clinics: Are we ready for telemedicine?

Objective: The need for telemedicine was felt more than ever during the COVID-19 pandemic, which impacted health care worldwide. Therefore, this study aimed to determine the difficulties faced by patients in visiting the cardiac outpatient department during COVID-19, along with assessing the awareness and acceptability of telemedicine. Methods: In this cross-sectional study, selected patients presenting to outpatient department of a tertiary care cardiac hospital were interviewed regarding the difficulties faced by patients in visiting the outpatient department during COVID-19 and their awareness and acceptability of telemedicine using a self-designed structured questionnaire. Results: Of the 403 patients, 58.3% were male, the mean age was 53.04 ± 11.73 years, and most (77.7%) were urban residents. Ischemic heart disease was present in 69.5%, followed by hypertension (38.7%) and heart failure (29.3%). A total of 26.6% required emergency room visits. Limited appointments (55.6%) was the most common problem faced by patients during COVID-19, followed by financial issues (17.1%), fear of acquiring infection (13.4%), and limited mobility due to lockdown (22.6%). Only 12.2% were aware of telemedicine, 4.5% had previously used it, and 41.2% were willing to opt for telemedicine in the future. No internet access (39.2%) was the key barrier to the usage of telemedicine, followed by a lack of free medicine (39%) and a lack of a smart device (31.5%). Conclusion: Limited appointments due to COVID-19 restrictions has made it difficult for patients to visit the clinics, which has led to increased emergency room visits. Telemedicine awareness was found to be limited; however, many patients were willing to adopt it provided their limitations could be overcome.

Age and gender-based categorization of very premature, premature, and non-premature acute myocardial infarction: A comparison of clinical and angiographic profile and in-hospital outcomes.

BACKGROUND: In this study, we aimed to assess and compare the distribution of demographic and clinical characteristics and composite adverse clinical outcomes after primary percutaneous coronary intervention (PCI) among "very premature", "premature", and "non-premature" patients with "ST-segment elevation acute coronary syndrome (STE-ACS)" presented at a tertiary care center. METHODS: We included consecutive patients diagnosed with STE-ACS undergoing primary PCI. The "very premature" was defined as ≤40 years for males and ≤ 45 years for females, "premature" as <55 years for males and < 65 years for females, and "non-premature" as ≥55 years for males and ≥ 65 years for females. Clinical characteristics, angiographic patterns, and hospital course were compared among the three groups. RESULTS: In a sample of 4686 patients, 78.8%(3691) were male, and the average age was 55.6 ± 11 years. In total, 12%(561) were categorized as very premature, 38.3%(1797) as premature, and 49.7%(2328) as non-premature. The distribution of clinical characteristics in very premature, premature, and non-premature groups were as follows; hypertension in 44.6% vs. 53.5% vs. 54.9%; p < 0.001, diabetes in 30.3% vs. 36.8% vs. 35.5%; p = 0.018, smoking in 29.6% vs. 23.3% vs. 26.3%; p = 0.005, obesity in 19.4% vs. 18.4% vs. 15.3%; p = 0.008, single vessel diseases in 58.8% vs. 37.8% vs. 28.8%; p < 0.001, and composite adverse clinical outcomes in 14.1% vs. 16.7% vs. 21.8%; p < 0.001, respectively. CONCLUSION: In conclusion, we have a substantial burden of premature STE-ACS. Very premature STE-ACS was found to be associated with a better prognosis, but a substantial burden of composite adverse clinical outcomes was also observed.

Increasing Incidence of ST-Elevation Acute Coronary Syndrome in Young South Asian Population, a Challenge for the World? An Assessment of Clinical and Angiographic Patterns and Hospital Course of Premature Acute Myocardial Infarction.

The incidence of premature ischemic heart disease (IHD) is increasing because of urbanization, a sedentary lifestyle, and various other unexplored factors, especially in South Asia. This study aimed to assess the distribution of premature ST-elevation acute coronary syndrome (STE-ACS) with its clinical and angiographic pattern along with hospital course in a contemporary cohort of patients who underwent primary percutaneous intervention at a tertiary care center in the South Asian region. We included consecutive patients of either gender diagnosed with STE-ACS and who underwent primary percutaneous intervention. Patients were stratified based on age as ≤40 years (young) and >40 years (old). Clinical characteristics, angiographic patterns, and hospital course were compared between the 2 groups. Of the total of 4,686 patients, 466 (9.9%) were young (≤40 years). Young patients had a lower prevalence of hypertension (40.8% vs 54.5%, p <0.001), diabetes (26.6% vs 36.4%, p <0.001), metabolic syndrome (14.8% vs 24%, p <0.001), history of IHD (5.8% vs 9.3%, p = 0.013) and a higher frequency of smoking (33% vs 24.7%, p <0.001), positive family history (8.2% vs 3.2%, p <0.001), and single-vessel involvement (60.1% vs 33.2%, p <0.001). The composite adverse clinical outcome occurrence was significantly lower in young patients (14.2% vs 19.5%, p = 0.006). On multivariable analysis, history of IHD in young, whereas age, Killip class III/IV, intubated, arrhythmias on arrival, diabetes, history of IHD, pre-procedure left ventricular end-diastolic pressure, ejection fraction <40%, and slow flow/no-reflow during the procedure were found to be the independent predictors of adverse clinical outcome in old patients. In conclusion, we have a substantial burden of premature STE-ACS, mostly in male patients potentially driven by smoking and positive family history. Despite favorable pathophysiology, with mostly single-vessel hospital courses of STE-ACS in the young equally lethal in nature.

Techniques to Treat Slow-Flow/No-Reflow During Primary Percutaneous Coronary Intervention.

OBJECTIVE: The aim of this study was to compare TIMI flow after administering intracoronary (IC) medications through various routes for the treatment of slow flow/no-reflow during primary PCI. METHODS: Two independent parallel cohorts of the patients who underwent primary PCI for STEMI and developed slow/no-reflow were recruited. Selection of cohort was based on the route of administration of IC medications as proximal or distal. Post administration TIMI follow was compared between the two cohorts. RESULTS: A total of 100 patients were included in both, proximal and distal, cohort. Distribution of angiographic, clinical and demographic characteristics was not significant between the two cohorts except prevalence of hypertension, and diabetes mellitus. Frequency of hypertension, and diabetes mellitus were 45 % vs.70 %; p < 0.001 and 28 % vs. 44 %; p = 0.018 among patients in distal and proximal cohort respectively. Final TIMI III flow was achieved in significantly higher number of patients in distal cohort with the frequency of 88 % vs. 76 %; p = 0.027 as compared to proximal cohort. CONCLUSION: Administration of IC medication via distal route is observed to be more effective for the treatment of slow flow/no-reflow during primary PCI. Distal route via export catheter or perforated balloon technique should be preferred wherever feasible.

One-year major adverse cardiovascular events among same-day discharged patients after primary percutaneous coronary intervention at a tertiary care cardiac centre in Karachi, Pakistan: a prospective observational study.

OBJECTIVE: Knowledge regarding the short-term outcomes after same-day discharge (SDD) post primary percutaneous coronary intervention (PCI) is lacking. In this study, we evaluated 1-year major adverse cardiovascular events (MACE) among SDD patients after primary PCI. DESIGN: 1-year follow-up analysis of a subset of patients from an existing prospective cohort study. SETTING: Tertiary care cardiac hospital in Karachi, Pakistan. PARTICIPANTS: Consecutive patients, from August 2019 to July 2020, with ST segment elevation myocardial infarction who had undergone primary PCI with SDD (within 24 hours) after the procedure by the treating physician and with at least one successful follow-up up to 1 year. OUTCOME MEASURE: Cumulative MACE during follow-up at the intervals of 1 week, 1 month, 6 months and 1 year. RESULTS: 489 patients were included, with a gender distribution of 83.2% (407) male patients and a mean age of 54.58±10.85 years. Overall MACE rate during the mean follow-up duration of 326.98±76.71 days was 10.8% (53), out of which 26.4% (14/53) events occurred within 6 months of discharge and the remaining 73.6% (39/53) occurred between 6 months and 1 year. MACE was significantly higher among patients with a Zwolle Risk Score (ZRS) ≥4 at baseline, with an incidence rate of 21.9% (16/73) vs 8.9% (37/416; p=0.001) in patients with ZRS≤3 (relative risk 2.88 (95% CI 1.5 to 5.5)). CONCLUSION: A significant burden of short-term MACE was identified among SDD patients after primary PCI; most of these events occurred after 6 months of SDD, mainly among patients with ZRS≥4. A systematic risk assessment based on risk stratification modalities such ZRS could be a viable option for SDD patients with primary PCI.