Differing radiation exposure in scrub technicians and rotating staff in Cardiac catheterization laboratory: occupation matters.

BACKGROUND: Radiation exposure is a significant hazard associated with invasive Cardiology, with most studies based on primary operator exposure. This prospective, observational study aimed to find out over lead radiation exposure as effective dose acquired by non-physician staff comprising scrub technicians and rotating staff in the cath laboratory. Effective dose (ED) measured per procedure via Raysafe i2®dosimeter badges worn by both rotating staff and scrub technicians over lead aprons along with dose area product (DAP), fluoroscopy time (FT) and procedure time (PT) in minutes was collected prospectively over forty-six invasive Cardiology procedures. RESULTS: This study shows that rotating staff acquire higher ED in comparison with their scrub technician colleagues in diagnostic, interventional and electrophysiology cases. However, a statistically significant difference in radiation exposure of both staff groups was demonstrated in diagnostic and interventional Cardiology procedures, with p values of 0.04 and 0.01, respectively. CONCLUSIONS: These findings highlight occupational role and mobility around fluoroscopic sources as major factors in radiation exposure, which should be addressed within current radiation protection practices.

Comparison of Clinical Outcomes of Calcified and Non-Calcified Coronary Artery Lesion Intervention Under IVUS Guidance.

OBJECTIVE: To evaluate the clinical results of intravascular ultrasound (IVUS)-guided intervention for calcified coronary artery lesions. STUDY DESIGN: Observational study. Place and Duration of the Study: Department of Medicine, The Aga Khan University Hospital, Karachi, from January 2013 to January 2020. METHODOLOGY: A cohort of 134 consecutive patients who underwent intravascular ultrasonography-guided assessment of coronary arteries were included. Patients were divided into two groups: those with coronary artery calcification (CAC, n=77) and those without (non-CAC, n=57). The two groups were compared for their clinical characteristics, management, in-hospital events, follow-up, and major adverse cardiovascular events (MACEs). RESULTS: The mean follow-up duration was 40.3 ± 30.1 months. Most of the patients were male (n=97, 72.3%), and the mean age was 63.1 ± 12.9 years. In the CAC group, age was the most common risk factor, followed by dyslipidaemia (n=68, 88%), hypertension (n=64, 83%), and Diabetes mellitus (n=44, 57%). CAC group patients were more commonly presented with acute coronary syndrome (n=59, 76.6%), had prior PCI (n=40, 52%), had more LM disease (n=34, 44%, p=0.005), and a significant number of prior stent-ISR (n=27, 35%, p=0.024). Those who had CAC had higher MACE. CONCLUSION: Patients with CAC had more co-morbidities and commonly presented with acute coronary syndrome. MACEs frequency was recorded higher in the CAC group although the results were not statistically significant. KEY WORDS: Coronary artery calcification, Intravascular imaging, Coronary artery disease, Target vessel revascularisation, Percutaneous coronary intervention.

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.

Acute Myocardial Infarction After Coronavirus Vaccine: A Rare Adverse Effect.

A 61-year-old male presented to the emergency department with left arm and jaw pain for three hours which started 90 minutes after receiving the first dose of Moderna vaccine for coronavirus disease 2019 (COVID-19). He had a prior history of ischemic heart disease. Initial investigations confirmed the diagnosis of acute coronary syndrome. The patient was managed for non-ST-elevation myocardial infarction and percutaneous coronary intervention to the right posterior descending artery was done, and he was discharged after two days of hospital stay. As the patient was doing well for many years and was compliant with medications, this event was likely triggered by the coronavirus vaccine. Healthcare providers should be aware of the side effects of the vaccine and further investigations should be carried out in high-risk patients before vaccination. However, worldwide coronavirus vaccination programs play a significant role to halt this pandemic and these rare adverse side effects of the vaccine should never discourage people from the vaccination but monitoring of evolving data by the concerned authorities is very important so that these events can be prevented in future.

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.

Distal transradial artery access for coronary angiography in a patient having rheumatoid arthritis-related severe arthropathies.

Conventional radial access has become the default access for coronary angiography. Sometime, it is difficult to take a conventional radial access, especially in patients having severe arthropathies leading to limited wrist joint mobility. In such scenarios, distal transradial access (dTRA) can be adopted. We describe a case of an elderly male patient having rheumatoid arthritis with arthropathies. He presented to us with unstable angina; coronary angiogram was advised for ischaemia assessment. Right dTRA was adopted due to severe joint deformity at wrist joint, limiting joint extension. A successful coronary angiogram was performed via the right dTRA without major discomfort and complications. Haemostasis was secured with TR band radial artery compression device. In this case report, we have evaluated the importance of practising dTRA in a patient with severe arthropathies.

Clinical Outcomes of Physiologically-guided Revascularisation.

OBJECTIVE: To assess the clinical outcomes of revascularisation based on fractional flow reserve (FFR) and/or instantaneous wave-free ratio (iFR). STUDY DESIGN: Descriptive study. PLACE AND DURATION OF STUDY:  Department of Medicine, The Aga Khan University Hospital, Karachi from January 2012 to January 2020. METHODOLOGY:  A cohort of patients having moderate to severe coronary stenosis, undergoing coronary revascularisation based on invasive physiological assessment (FFR or iFR) were assessed. The participants were divided into the revascularisation-deferred group and the revascularization-performed group, based on the physiological results. Cox-proportional hazard model building was done, using a stepwise approach by assessing all plausible interactions and considering p-value ≤0.05 as statistically significant. RESULTS:  The frequency of major adverse cardiac event (MACE) and target vessel revascularisation was 8.4% and 3.2% in the revascularisation-performed group as compared to 6.4% and 3.2% in the revascularisation-deferred group. In adjusted models, no statistically significant difference was noted in MACE when comparing the revascularisation-performed group with a deferred group. CONCLUSION:  Revascularisation guided by invasive physiological assessment with FFR or iFR is clinically safe and led to better resource utilisation. Key Words: Fractional flow reserve, Instantaneous wave-free ratio, Invasive physiological assessment, Low-middle income country.

Clinical Outcomes and Prevalence of Intravascular Ultrasound Use at a Tertiary Care Hospital in a South Asian Country.

OBJECTIVES: Intravascular ultrasound (IVUS) plays a pivotal role in the current era of coronary interventions. We aimed to determine the prevalence of IVUS use and clinical outcomes of IVUS-guided percutaneous treatment of coronary arteries lesions in a South Asian country. MATERIAL AND METHODS: It is a retrospective observational study, a total of 134 consecutive patients having done IVUS, was enrolled from January 2013 to March 2020 at a single center. RESULTS: Out of 134 patients, 97 (72.4%) were male with a mean age of 63.1 ± 12.9 years. The prevalence of IVUS in our center was 3.0%. The most frequent comorbidity observed was dyslipidemia, n = 111 (82.8%). Non-ST-elevation myocardial infarction, n = 50 (37.3%), was the common mode of presentation. On coronary angiogram, the left main (LM) disease was found in n = 46 (34.3%), however, single-vessel disease, n = 51 (38.1%), was most commonly noted. IVUS utilization was higher in the left anterior descending, n = 94 (70.1%), followed by LM, n = 46 (34.3%). The LM mean minimal luminal area was 6.0 ± 2.6 mm2 and minimal luminal diameter was 4.53 mm ± 0.6 (mean). The coronary artery dissection was noted in n = 15 (11.2%). The mean duration of follow-up in our study was 40.3 ± 30.1 months. Major adverse cardiac events (MACEs) were recorded in n = 13 (9.7%), which included heart failure, n = 4 (3%). Cardiovascular death and target vessel revascularization occurred in n = 3 (2.2%). CONCLUSION: IVUS results in a significant decrease in MACE. Our data might support the broader use of IVUS in both developed and in our part of the world.

Prognostic significance of ischaemic electrocardiographic changes during stress testing in patients with normal nuclear myocardial perfusion imaging.

OBJECTIVE: To evaluate cardiovascular outcomes in patients with normal nuclear myocardial perfusion imaging, but ischaemic electrocardiogram changes during pharmacological or exercise stress tests. METHODS: The retrospective study was conducted at the Aga Khan University Hospital, Karachi, and comprised data of patients who underwent either pharmacological or exercise stress myocardial perfusion scan and had a normal scan with ischaemic electrocardiogram changes between January 2013 and December 2014. All cardiac events, including angina, myocardial infarction, heart failure, coronary revascularisation and cardiac death, as well as non-cardiac deaths were noted. Data was analysed using STATA 14.2. RESULTS: Of the 2770 patients whose data was initially checked, 296(10.6%) developed ischaemic electrocardiogram changes during the stress test but had normal myocardial perfusion scan. Of them, 181(61%) patients were male, and the overall mean age was 62±15 years. Follow-up data was available for 280(94.5%) of these patients, with a mean follow-up of 48±7 months. Of these patients, 8(2.8%) died, and 1(0.3%) of them died due to inferior wall myocardial infarction. Myocardial infarction was found in 2(0.7%) patients, and 1(0.3%) patient was hospitalised with heart failure. Also, 12(4.3%) patients underwent revascularization for stable angina, 9(3.2%) underwent percutaneous transluminal coronary angioplasty, and 3(1.07%) needed coronary artery bypass grafting. CONCLUSIONS: Ischaemic electrocardiographic changes during stress testing in patients with normal myocardial perfusion scan were not associated with adverse outcomes, and the risk of cardiovascular events was relatively low for an intermediate follow-up period.

Streptokinase in a COVID-19-positive patient with STEMI in a PPCI centre: a local experience.

Primary percutaneous coronary intervention is the recommended modality of treatment for acute ST-elevation myocardial infarction (STEMI). However, different countries now have different consensus about treatment of patients with STEMI during the COVID-19 pandemic. In this report, we describe a case of SARS-CoV-2-positive patient admitted with pneumonia. During hospital stay in COVID-19 designated special care, the patient developed inferoposterior wall myocardial infarction (MI) without haemodynamic instability and was treated successfully with thrombolytics (streptokinase) without any severe complications. To decrease the risk of in-hospital exposure to COVID-19 infection among the staff, in circumstances where there is no negative-pressure catheterisation laboratory and there is shortage in medical staff, thrombolytics can be used as a modality of treatment in low-risk, haemodynamically stable MI during this pandemic, as recommended by different cardiac societies. However, this needs further studies in order to reach local and international consensus.

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.

Long-Term Clinical Outcomes of Percutaneous Coronary Intervention in Saphenous Vein Grafts in a Low to Middle-Income Country.

Background Revascularization of saphenous vein grafts (SVGs) is challenging and debated for the last few decades. The percutaneous revascularization of SVGs was reported to have poorer long-term outcomes than native coronary artery revascularization. Purpose We aim to study the peri-procedural complications and long-term outcomes of the percutaneous revascularization of SVGs in a low-middle-income country. Methods In this retrospective study, we included 110 patients who underwent percutaneous revascularization from January 2011 to March 2020 and followed them retrospectively for long-term outcomes and major adverse cardiovascular events. Results The mean age was 71 ±9, and 81% were male. The most common reason for the presentation was non-ST segment elevation myocardial infarction (NSTEMI) (46%). The mean follow-up period of the study was 48±27 months. The most common comorbidity was hypertension (86%). A drug-eluting stent (80%) was placed in most of the patients, followed by a bare-metal stent (BMS) (14%) and percutaneous balloon angioplasty (POBA) (6%). We did not find any significant difference in major adverse cardiac events (MACE) (P=0.48), target vessel revascularization (TVR) (p=0.69), and target lesion revascularization (TLR) (p=0.54) with drug-eluting stent (DES) as compared to either BMS or POBA. The mean period from coronary artery bypass grafting (CABG) to SVG percutaneous coronary intervention (PCI) was 15± 5.5 years. Multivariate Cox regression analysis showed that an acute coronary syndrome (ACS) event, stroke, and female sex were independently associated with MACE. Conclusion The long-term outcomes of SVG PCI are not affected by the types of stents. Female gender, ACS, and stroke are the independent predictors of MACE after SVG PCI, and statin therapy has a positive impact on the long-term outcomes of SVG PCI.

Reorganising for COVID-19 Pandemic: A Review of Structural Modifications by the Department of Internal Medicine in Low to Middle-income Countries.

Scientists classified the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) as a novel coronavirus on January 7, 2020. The World Health Organization (WHO) acknowledged the SARS-CoV-2 outburst a public health emergency of international concern on January 30, 2020. Since its origin, this virus has disrupted the best healthcare systems, economies, and strained financial resources; and for underdeveloped countries' healthcare systems, the virus has become a crisis. To tackle the potential hazards from this virus, our Department restructured the services that not only helped us to cope with the pandemic, but also provided an example to copy for other contemporary institutes. This article aims to describe the measures and structural changes undertaken by the Internal Medicine Department, Aga Khan University Hospital (AKUH), Karachi, Pakistan. Key Words: COVID-19, Internal medicine, Structural modifications, Pandemic.

Myocarditis mimicking acute coronary syndrome - the role of cardiac magnetic resonance imaging in the diagnosis.

Myocarditis is an inflammatory disease of myocardium with a wide range of clinical presentations. Myocarditis may mimic acute coronary syndrome (ACS) and adequate differential diagnosis is not possible by conventional tests. Cardiac magnetic resonance (CMR) has emerged as a leading imaging modality in the diagnosis of myocarditis in such patients. Here, we report three cases of myocarditis mimicking ACS with normal coronary arteries. CMR was used for confirming the diagnosis of myocarditis in all three patients presented here.