Qt interval prolongation and ventricular arrhythmias in patients with chronic heart failure

To determine the association of QTc interval prolongation with ventricular arrhythmias in patients with chronic heart failure. Descriptive study. This study was conducted at Armed Forces Institute of Cardiology/National Institute of Heart Diseases, Rawalpindi, Pakistan from April 2013 to August 2013. Fifty three heart failure patients were monitored for 48 hours using ambulatory holter electrocardiography recorders. Digital ECG data was analyzed for QTc interval along with frequency and severity of arrhythmias. Association of prolonged QTc interval with ventricular arrhythmias and severity of arrhythmias was analyzed. Cardiac arrhythmias were observed in 79.2% patients. QT analysis revealed that 69.8% patients had prolonged QTc interval, 86.4% patients with prolonged QTc had ventricular arrhythmias. Of these 66% patients were found to have severe ventricular arrhythmias. Comparison of mean QTc interval of our study population with a reference value showed significantly higher QTc interval of our study group than the test value. Arrhythmia frequency and severity significantly increases with an increase in QTc interval in heart failure demonstrating association of prolonged QTc interval with high risk of severe ventricular arrhythmias and sudden cardiac death in chronic heart failure

Correlation of global registry of acute coronary events [GRACE] with the angiographic severity and extent of coronary artery disease in patients with non- ST elevation acute coronary syndrome

To determine whether the GRACE risk score correlates with the angiographic extent and severity of coronary artery disease in patients with NSTE-ACS undergoing cardiac catheterization. We conducted a cross sectional descriptive study in 154 patients with NSTE-ACS admitted at AFIC-NIHD from 1[st] April to 30[th] September 2011. For each patient the GRACE risk score was calculated by using specific variables collected at admission. The extent and severity of coronary artery disease was evaluated on angiography for each patient. A total of 154 patients were included in the study. The average age of the patients was 55.81years. Majority [75%] of the patients was male and 25% were females. The mean GRACE score was 132.85. Overall 40 patients had low, 54 had intermediate, and 60 had high GRACE risk score. Among patients with low score 28 had SVCAD, 4 patients had DVCAD and none of the patients had TVCAD. In the intermediate group 24 patients had SVCAD, 18 had DVCAD and 6 had TVCAD whereas among the high GRACE risk score 4 patients had SVCAD, 24 had DVCAD and 32 had TVCAD. Regarding the severity of coronary artery disease; among the low GRACE risk score patients; 8 had subcritical and 32 had critical CAD. In the intermediate GRACE risk score subset of patients, 6 had subcritical and 48 had critical CAD and none of the patients of high GRACE risk score had subcritical CAD and all 60 patients had critical CAD. GRACE risk score is a valuable noninvasive tool in predicting the extent and severity of CAD

Culprit artery characteristics and severity of angiographic thrombus burden in primary percutaneous coronary intervention in patients presenting with ST elevation myocardial infarction

The purpose of study was to characterize culprit artery characteristics in terms of presence of thrombus burden in patients with acute myocardial infarction using prevalent parameters of thrombus estimation. Descriptive study. Adult cardiology departments of Armed Forces Institute of Cardiology / National Institute of Heart Diseases [AFIC/NIHD] from 1[st] October 2011 to 31[st] September 2012. We studied 119 patients treated with primary percutaneous coronary intervention for ST- segment myocardial infarction. Bare metal stents were used in all patients as per hospital protocol. Thrombus burden [TB] was graded [G] as GO = no thrombus, G1= possible thrombus, G2 = small [greatest dimension <, 1/2 vessel diameter [VD]], G3 = moderate [>1/2 but <2 VD], G4 large [>2 VD], G5 = unable to assess TB due to vessel occlusion. Patients with G5 were reassessed after passage of guide wire or small balloon for thrombus burden. Frequency of major adverse cardiac events [MACE]-defined as death, myocardial infarction and infarct- related artery revascularization was recorded for the pen-procedural period which was defined in our study up to 72 hours. Overall, in hospital MACE was 8.4%. Large thrombus burden is a significant predictor for mortality and MACE

Efficacy and safety of transradial approach in primary PCI for STEMI

To determine the efficacy and safety of transradial approach in primary percutanous intervention in acute ST segment elevation myocardial infarction. Descriptive study Emergency reporting [ER] department of Armed Forces Institute of Cardiology National Institute of Heart Diseases [AFIC/NIHD] from Dec 2011 to Dec 2013 Retrospective data of 354 patients had been collected through records. All the patients presented with acute myocardial infarction to emergency reporting [ER] department of Armed Forces Institute of Cardiology National Institute of Heart Diseases were included in the study. All the patients underwent primary coronary intervention through transradial route. All patients received IIB IIIA inhibitors bolus and infusion. The primary end points were procedure success and local access site hematoma and secondary end points were major bleeding requiring blood transfusion and door to balloon time. The mean age of the patient was 64 +/- 18 years, there were 251 [70.9%] males and female were 103 [29.1%]. Radial access site cannulation time was 194 +/- 22 sec and door to balloon time was 78 +/- 14 min. Procedural success was 349 [98.6%]. Forearm hematoma was noted in 4 [1.12%]. No major bleeding requiring transfusion was noted. Primary percutanous intervention [PPCI] via transradial [TRI] route in acute STEMI patients can be achieved with high success and low complications in our population. The clinical outcome is matching with local and international data

Frequency and angiographic characteristics of coronary artery ectasia in patients undergoing coronary angiograms at AFIC and NIHD

To determine the frequency and angiographic characteristics of coronary artery ectasia in the patient population of AFIC and NIHD. Descriptive Study Armed Forces Institute of Cardiology and National Institute of Heart Diseases, Rawalpindi from Jan 2007 to Dec 2011. All coronary angiograms done during the period were included in the study. The reports of coronary angiograms of those patients who were diagnosed to have coronary artery ectasia were left circumflex artery reviewed to assess the distribution of ectasia in different coronary arteries. Concomitant significant coronary artery stenosis left ventricular [LV] systolic function and history of revascularization were also documented. Over the study period, a total of 41,459 patients underwent coronary angiograms. 548 [1.32%] patients were diagnosed to have coronary artery ectasia. Out of these 467 [85.21%] patients were males and 81 [14.78%] were females. Their mean age was 53.7 years. Left anterior descending [LAD] was the coronary artery, most commonly affected by ectasia followed by left circumflex artery [LCx] and Right coronary artery [RCA]. Twenty three patients also had ectasia of left main stem. Four Hundred and three [73.54%] patients also had concomitant occlusive coronary artery disease and 19.52% patients had history of coronary revascularization either by percutaneous coronary intervention [PCI] or coronary artery bypass grafting [CABG]. Coronary artery ectasia is not a benign disorder as it could present as acute coronary syndrome having its own morbidity and mortality

Frequency of common modifiable risk factors in patients with myocardial damage undergoing single vessel coronary angioplasty

To determine the frequency of common modifiable risk factors in patients with myocardial damage undergoing single vessel coronary angioplasty. Descriptive study. Armed forces Institute of Cardiology / National institute of Heart Disease Rawalpindi from June 2012 to Nov 2013. Hundred patients undergoing elective single vessel percutaneous coronary angioplasty were evaluated with creatinine kinase and creatinine kinase MB levels before, after 8 hours and 24 hours following coronary angioplasty. The detailed performa was filled from each patient covering the necessary variables. Out of 100 patients 22% had raised creatinine kinase at 8 hours and 43% had raised creatinirie kinase after 24 hours following coronary angioplasty. Whereas 19% patients and 38% patients had raised creatinine kinase MB levels at 8 hours and 24 hours following the procedure respectively. No patient had rise of creatinine kinase or creatinine kinase MB more than 3 times of normal limits in the study. Among patients with raised CK-MB highest frequency was of diabetes mellitus, raised LDL levels, smoking and hypertension. Patients with raised CK-MB levels after 1[st] day of coronary angiography had diabetes mellitus [84%], raised LDL levels [79%], smoking [68%] and hypertension [58%]

Heart rate variability from 24 hours versus 72 hours holter monitoring in patients with mitral valve prolapse

To compare recorded heart rate variability from 24 hours with that recorded from 72 hours holter monitoring in patients with mitral valve prolapse. Cross sectional study. Department of Clinical Cardiac Electrophysiology Armed Forces Institute of Cardiology/National Institute of Heart Diseases, Rawalpindi from May 2007 to March 2008. Patients from 15 to 38 years of age with confirmed diagnosis of mitral valve prolapse on 2 dimensional echocardiography were included. Patients with acute myocardial infarction [MI], Ischemic heart disease, diabetes mellitus or hypertension were excluded. Total 37 patients were included in the study through non-probability consecutive sampling. All these patients underwent 72 hours holter monitoring using Reynolds medical holter monitors 'life card CF'. Statistical time domain measures of heart rate variability i.e. standard deviation of all NN intervals [SDNN], standard deviation of the averages of NN intervals [SDANN] and square root of the mean of the squares of differences between adjacent NN intervals [RMSSD]. Mean values of SDNN, SDANN and RMSSD from 24 hours holter monitoring were 141.62 ms, 125.16 ms and 28.40 ms whereas those recorded from 48 hours of holter monitoring were 136.94 ms, 122.37 ms and 26.46 ms respectively. Difference between none of the variables from the two recordings was significant. Heart rate variability remains the same irrespectively of the length of holter monitoring

Management of patients with acute myocardial infarction complicated by ventricular septal rupture - AFIC study

The aim of this study was to report management; peri-procedural and short term results of patients hospitalized with acute myocardial infarction [MI]complicated by ventricular septal rupture [VSR] considered high risk or unfit for surgical repair at AFIC-NIHD. Quasi experimental study Adult and paediatric cardiology departments of Armed Forces Institute of Cardiology / National Institute of Heart Diseases [AFIC/NIHD] from 1[st] January 2012 to 31[st] August 2013. We included 12 patients with post myocardial infarction VSR with mean age of 59 years [41-85 years], who underwent elective transcatheter closure. The entry criteria for trans-catheter closure after initial medical stabilization was 1] patients with ventricular septal rupture up to 20 mm size with significant left to right shunting [Qp/Qs >1.5] 2] defect anatomy and location thought to be suitable for device closure or otherwise considered high risk or unfit for surgical closure. The time from the onset of infarction to the index procedure ranged between 4 to 20 days [mean 10.83 days]. There were ten patients in acute phase [2 weeks or less] and two presented in sub-acute phase [> 2 weeks]. Ten patients were in NYHA class III and one each in class II and IV. A successful device implantation occurred in all patients except in one in whom second attempt failed. The defect size ranged 4-18 mm [mean 9.25 mm] and the devices ranging from 8-22 mm [mean 13.3 mm] were implanted. The procedure time ranged from 90-140 min [mean 105 min]. In all patients Qp/Qs was more than 2 and decreased to less than two after the procedure. Six surviving patients are in NYHA class II and doing well. One patient died one hour after the procedure whereas one patient died twelve hour after the closure because of re-infarction. One patient developed another VSR leak 3 days after the procedure and device closure was attempted again but the device could not be deployed. He subsequently died awaiting surgery. Primary trans-catheter closure of post-infarction ventricular septal rupture may be an alternative to surgery in patients with suitable anatomy and high risk or unfit for surgery

Microbial spectrum of cardiac implantable electronic device infections - a tertiary cardiac center experience

The objective of the study was to determine the microbiological spectrum of cardiac implantable electronic device [CIED] infections. Case series Armed Forces Institute of Cardiology / National Institute of Heart Diseases AFIC/NIHD from January 2011 to Nov 2013. A total of 15 pus samples from patients with possible CIED infection out of 814 patients with implantable CIEDs were processed. Thirteen patients with positive cultures out of fifteen were included in the study. Clinical evidence of CIED infection included signs of inflammation and purulent drainage. A CIED infection was microbiologically confirmed based on culture yield. Blood cultures were carried out in all patients with suspected CIED infection along with trans-oesophageal echocardiography [TOE], wherever clinically indicated to exclude bacteremia and lead endocarditis. Sixty nine percent of patients with culture proven CIED infection were females and 31% were males. The mean age of patients was 61 years [range 53-70 years]. Devices included 11 PPMs, 1 ICD and 1 CRT. The most frequent organisms were gram-positive [77% of isolates]; with Coagulase-negative Staphylococci [CoNS] predominating in particular Methicillin Resistant Staphylococcus epidermidis [MRSE] in 46.4% cases followed by Methicillin Sensitive Staphylococcus epidermidis [MSSE] in 15%. Non tuberculous Mycobacterium fortuitium was isolated from pus in two patients; with PPM and ICD implants respectively. MRSA was isolated in only 01 PPM infection with evidence of lead endocarditis on TOE. Pseudomonas species was isolated from pus in one patient with CRT implant. CIED infections are more often caused by Staphylococci predominantly CoNS, although atypical Mycobacteria can be implicated

Procedural outcome of primary PCI inst-segment elevation myocardial infarction at Afic and Nihd Rawalpindi - Pakistan

To determine the procedural outcome of primary percutaneous coronary interventions [PCI] in ST segment elevation myocardial infarction. A quasi-experimental study. Armed Forces Institute of Cardiology and National Institute of Heart Diseases, a tertiary care cardiac institute from November 2011 to September 2013. Total 228 patients who underwent primary percutaneous intervention [primary PCI] were included in this study. A pre designed performa was prospectively filled which included demographic and procedural variables. Procedural success and in hospital mortality were recorded. The mean age was 59 +/- 10.88 years. There were 205 [89.9%] males, 80 [35.1%] patients were found to be diabetic, 47 [20.6%] hypertensive, and 90 [39.5%] patients were smokers. Family history of ischemic heart disease was positive in 51 [22.4] patients. Anterior, inferior and lateral myocardial infarction were present in 137 [60.1%], 90 [39.5%] and 1 [0.4%] patients respectively. The Median time from the onset of symptoms to the arrival in the hospital was 122.5 +/- 142.57 and median door to balloon time was 60 +/- 22.88 min. Left anterior descending [LAD] was the commonest infarct related artery accounting for culprit artery in 138 [60.5%] followed by right coronary artery [RCA] and left circumflex artery [LCX] in 72 [31.6%] and 18 [7.9%] cases respectively. Procedural success was achieved in 222 [97.4%] patients. Six [2.6%] patients died in the hospital. High success rate with low mortality rates can be achieved in our set up. However more studies and long term follow up is required to validate our results

Role of aspiration thrombectomy in primary PCI for STEMI - myth or reality?

The objective of the study was to determine the outcome of thrombus aspiration in Primary coronary intervention [PCI] for ST elevation myocardial infarction [STEMI]. Case Series The study was carried out in Armed Forces Institute of Cardiology - National Institute of Heart Diseases [AFIC-NIHD] over a period of twelve months from January 2013 to December 2013. Data of 30 patients who underwent aspiration thrombectomy during primary PCI for STEMI by the transradial approach was collected. Inclusion criteria were chest pain suggestive of myocardial ischemia lasting longer than 30 min accompanied by ST- segment elevation or new left bundle branch block on the ECG within 12 h of symptom onset. Patients with previous CABG, cardiogenic shock or requiring TPM placement were excluded from this study. A 6F sheath was placed inside the radial artery, and cardiac catheterization was performed. Angiographic and electrocardiographic signs of myocardial reperfusion were assessed. Study endpoints included TIMI III flow and ST-segment resolution at the end of the procedure. Mean age of the patients was 52 years [range 37-77 yrs] and 63% [n= 19] were males and 37% [n=11] were females. The right radial artery was used in 90% of cases. Thrombus aspiration catheter used was 6 F Thrombuster II [70%] and Hunter [30%].There was significant improvement in markers of myocardial reperfusion with achievement of ST-segment resolution and TIMI 3 flow in 28 patients [93%]. No case of vascular complications such as major access site bleeding, vascular perforation, radial artery occlusion, forearm ischemia, compartment syndrome or MACE was observed. Thrombus aspiration [TA] is applicable in the majority of patients undergoing primary PCI for myocardial infarction with ST-segment elevation, and it improves early markers of myocardial reperfusion