Comparative Trends in Ischemic Heart Disease Admissions, Presentation and Outcomes Due to the COVID-19 Pandemic: First Insights From a Tertiary Medical Center in Pakistan.

Introduction COVID-19 has manifested a striking disarray in healthcare access and provision, particularly amongst patients presenting with life-threatening ischemic heart disease (IHD). The paucity of data from low-middle income countries has limited our understanding of the consequential burden in the developing world. We aim to compare volumes, presentations, management strategies, and outcomes of IHD amongst patients presenting in the same calendar months before and during the COVID-19 pandemic. Methods We conducted a retrospective cross-sectional analysis at the Aga Khan University Hospital, one of the premier tertiary care centres in Pakistan. Data were collected on all adult patients (>18 years) who were admitted with IHD (acute coronary syndrome (ACS) and stable angina) from March 1 to June 30, 2019 (pre-COVID) and March 1 to June 30, 2020 (during-COVID), respectively. Group differences for continuous variables were evaluated using student t-test or Mann-Whitney U test. The chi-squared test or Fisher test was used for categorical variables. Values of p less than 0.05 were considered statistically significant. P-value trend calculation and graphical visualization were done using STATA (StataCorp, College Station, TX). Results Data were assimilated on 1019 patients, with 706 (69.3%) and 313 (30.7%) patients presenting in each respective group (pre-COVID and during-COVID). Current smoking status (p=0.019), admission source (p<0.001), month of admission (p<0.001), proportions ACS (p<0.001), non-ST-elevation-myocardial-infarction (NSTEMI; p<0.001), unstable angina (p=0.025) and medical management (p=0.002) showed significant differences between the two groups, with a sharp decline in the during-COVID group. Monthly trend analysis of ACS patients showed the most significant differences in admissions (p=0.001), geographic region (intra-district vs intracity vs outside city) (p<0.001), time of admission (p=0.038), NSTEMI (p=0.002) and medical management (p=0.001). Conclusion These data showcase stark declines in ACS admissions, diagnostic procedures (angiography) and revascularization interventions (angioplasty and coronary artery bypass graft surgery, CABG) in a developing country where resources and research are already inadequate. This study paves the way for further investigations downstream on the short- and long-term consequences of untreated IHD and reluctance in health-seeking behaviour.

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.

Drug-Eluting Balloon for Management of Coronary In-Stent Restenosis in a South Asian Population: Experience From a Tertiary-Care Hospital in Pakistan.

BACKGROUND: Emerging evidence suggests that the South Asian (SA) population has an increased rate of in-stent stenosis (ISR) after percutaneous coronary intervention (PCI) when compared with other ethnicities. Drug-eluting balloons (DEBs) have emerged as a viable option for the treatment of ISR. However, data describing the outcomes of DEB-PCI in the SA population are limited. Since the magnitude of the problem is high in the SA population, it is essential to evaluate the outcomes of DEB-PCI for ISR. METHODS: In this cohort study, we investigated the incidence of target-lesion revascularization (TLR) and major adverse cardiac event (MACE) after PCI with DEB for ISR at 1 year and at long-term follow-up in Pakistani patients. From January 2010 to January 2019, a total of 147 ISR lesions in 112 patients were treated with DEB-PCI at our center. RESULTS: The incidence of clinically driven TLR and MACE after a 1-year follow-up was 15.2% and 16.1%, respectively. At mean long-term follow-up of 2.73 ± 2.14 years, the TLR and MACE rates were 26.8% and 35.7%, respectively. The major predictors for TLR were diffuse and occlusive ISR types, DEB for a recurrent restenosis lesion, and the presence of ≥3 traditional cardiovascular disease risk factors. CONCLUSIONS: The high rates of follow-up TLR and MACE reported in this study may suggest that the outcomes of DEB-PCI for ISR in the SA population may be unsatisfactory. With the increasing use of DEBs, it is imperative to further investigate DEB-PCI outcomes in the SA population with large, prospective studies.

Jailed balloons for side branch protection: a review of techniques and literature: Jailed balloons for side branch protection.

Coronary bifurcation lesions are commonly encountered, and side branch compromise is a major complication of these bifurcation interventions. Jailing a wire in the side branch is the most common method of significant side branch protection. Jailing a balloon in the side branch is a less well known and seldom practiced strategy of side branch preservation but tends to have lower occlusion rates as compared to conventional jailed wires. Various modifications have been applied to the original jailed balloon technique to further improve side branch patency. Complications arising from this technique have been limited to case reports only and relate mainly to calcified vessels.

Multivessel Percutaneous Coronary Intervention in a Patient With Bernard-Soulier Syndrome.

Bernard-Soulier syndrome, a congenital bleeding disorder, can rarely present with atherosclerosis and thrombosis. Acute coronary syndrome in such patients present a unique challenge as no standard set of guidelines exist for successful treatment. (Level of Difficulty: Intermediate.).

A Curious Case of Intermittent Left Bundle Branch Block Associated with Cough.

A handful of cases of voluntary control of left bundle branch block (LBBB) have been described in the literature. We report the case of a middle-aged man who was found to have LBBB on baseline electrocardiogram (ECG) which disappeared on coughing and then reappeared with the same maneuver. Subsequent myocardial perfusion scan showed reduced count in the anteroseptal region likely attributed to LBBB. It is possible that the intermittent conduction changes may be due to the alteration in the vagal tone associated with cough as reflected in the change in the PR interval on the ECG.

The medically managed patient with severe symptomatic aortic stenosis in the TAVR era: Patient characteristics, reasons for medical management, and quality of shared decision making at heart valve treatment centers.

BACKGROUND: Little is known about patients with severe symptomatic aortic stenosis (AS) who receive medical management despite evaluation at a heart valve treatment center. OBJECTIVE: We identified patient characteristics associated with medical management, physician-reported reasons for selecting medical management, and patients' perceptions of their involvement and satisfaction with treatment selection. METHODS AND RESULTS: Of 454 patients evaluated for AS at 9 established heart valve treatment centers from December 12, 2013 to August 19, 2014, we included 407 with severe symptomatic AS. Information was collected using medical record review and survey of patients and treating physicians. Of 407 patients, 212 received transcatheter aortic valve replacement (TAVR), 124 received surgical aortic valve replacement (SAVR), and 71 received medical management (no SAVR/TAVR). Thirty-day predicted mortality was higher in patients receiving TAVR (8.7%) or medical management (9.8%) compared with SAVR (3.4%) (P<0.001). Physician-reported reasons for medical management included patient preference (31.0%), medical futility (19.7%), inoperability/anatomic infeasibility (11.3%), and inadequate vascular access (8.5%). Compared with patients receiving AVR, medically managed patients were less likely to report that they received enough information about the pros and cons of treatment options (P = 0.03), that their physicians involved them in treatment decisions (P<0.001), and that final decisions were the right ones (P<0.001). CONCLUSIONS: Patient preference was the most common physician-reported reason for selecting non-invasive AS management, yet patients not undergoing AVR after valve center evaluation reported being less likely to receive sufficient education about treatment options and more likely to feel uncertain about final treatment decisions. Greater attention to shared decision making may improve the experience of care for this vulnerable group of patients.

A balloon-expandable sheath facilitates transfemoral TAVR in patients with peripheral vascular disease and tortuosity.

OBJECTIVES: We sought to perform transcatheter aortic valve replacement (TAVR) via the transfemoral approach in patients with peripheral arterial disease (PAD), small caliber ileofemoral vessels and vascular tortuosity. BACKGROUND: For patients with increased surgical risk, TAVR is associated with a higher 1-year survival rate than surgical aortic valve replacement (SAVR). Transfemoral vascular access for TAVR results in superior outcomes versus procedures performed via other routes in terms of mortality, morbidity and healthcare economics. In many patients, the ability to safely perform the procedure via the transfemoral approach is limited by narrow, diseased and tortuous ileofemoral vasculature. METHODS: We employed the SoloPath Balloon Expandable TransFemoral Access System (Terumo Med. Corp., Tokyo, Japan) to perform transfemoral TAVR in five patients with PAD, small caliber ileofemoral vessels and vascular tortuosity. RESULTS: We report our experience using this balloon-expandable sheath during 5 cases of transfemoral TAVR in patients with inhospitable ileofemoral vasculature of mean diameter ⩽ 5.8 mm. The unexpanded sheath's malleable structure and hydrophilic coating permitted deployment despite severe stenoses and tortuosity. Subsequent inflation to 18 Fr facilitated successful TAVR. Postprocedural angiography demonstrated no significant vascular access complications. In one case, the entire procedure was performed percutaneously, without common femoral artery surgical cutdown. CONCLUSIONS: The SoloPath sheath system permits transfemoral TAVR in patients with PAD small caliber ileofemoral vessels and vascular tortuosity. The transfemoral balloon-expandable sheath allowed these patients to avoid the increased morbidity and mortality risks associated with direct aortic or transapical access.

Coronary sinus shocking lead as salvage in patients with advanced CHF and high defibrillation thresholds.

BACKGROUND: We report a series of three patients whose implantable cardioverter-defibrillators (ICD) implants were unsuccessful due to inability to achieve defibrillation thresholds (DFT) at maximum available energy after failure of standard modification and enhancement procedures. All patients had advanced cardiomyopathy. METHODS: Use of the coronary sinus (CS) for left ventricular (LV) shocking electrode placement resulted in acceptable DFTs in each patient. The position of the shocking coil in all three patients was posterior, and in two patients alongside a left ventricular CS pacing lead. The best shocking configuration tested was LV (CS) + CAN (Anode) to RV (cathode) in each patient. The short- and long-term outcomes of these patients is presented and discussed. CONCLUSION: This approach is suggested as a salvage option for those problematic patients who have unacceptable DFT results at implantation of an endovascular ICD system.

The genetics of statin-induced myopathy.

OBJECTIVE: Our goal was to use genetic variants to identify factors contributing to the muscular side effects of statins. BACKGROUND: Statins (3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors) are usually well tolerated medications, but muscle symptoms, ranging from mild myalgia to clinically important rhabdomyolysis are an important side effect of these drugs and a leading cause of noncompliance. Recent results suggest that genetic factors increase the risk of statin-related muscle complaints. We performed a systematic review of the medical literature to determine genetic factors associated with statin myopathy. METHODS: We identified English language articles relating statin myopathy and genetic diseases and gene variants via a PubMed search. Articles pertinent to the topic were reviewed in detail. RESULTS/CONCLUSIONS: Our review suggests that some patients are susceptible to statin myopathy because of pre-existing subclinical inherited muscular disorders, or genetic variation in statin uptake proteins encoded by SLCO1B1 or the cytochrome P enzyme system. Variations in genes affecting pain perception and polymorphism in vascular receptors may also contribute to statin myopathy. None of the variants identified in this review suggested novel metabolic mechanisms leading to statin myopathy.

Is self-reported "moderate" drinking in the cardiovascular benefit range associated with alcoholic behavior? A population based study.

This article aims at identifying a threshold number of drinks per day beyond which there is a high risk of developing alcoholic behavior that would enable physicians to more confidently support the use of alcohol for cardiovascular risk prevention. In a randomly selected, population-based sample of 2,042 adults 45 years or older, we graded alcohol drinking behavior using the Self-Administered Alcoholism Screening Test, quantified alcohol amount by questionnaire, and assessed the prevalence of cardiovascular disease (coronary, peripheral, or cerebrovascular disease) by medical record review. Although optimal alcohol use (< or = 2 drinks/day) was associated with reduced odds of cardiovascular disease, 43% of alcoholics and 82% of problem drinkers reported alcohol use in the optimal range as well. The association of alcohol use in the optimal range with alcohol-related behavioral problems supports the reluctance in physicians from recommending alcohol use for cardiovascular benefit, not withstanding the underreporting of alcohol use by alcoholics.

Preoperative statins for the prevention of atrial fibrillation after cardiothoracic surgery.

OBJECTIVE: Recent studies have suggested that statins reduce atrial fibrillation after cardiothoracic surgery, but the use of proven prophylactic strategies such as beta-blockers and amiodarone in these studies was not provided. Therefore, we sought to determine whether preoperative statin use could reduce the incidence of post-cardiothoracic surgery atrial fibrillation in a population who already had a high background use of beta-blockers and appreciable use of prophylactic amiodarone. METHODS: Patients undergoing cardiothoracic surgery from the randomized, controlled Atrial Fibrillation Suppression Trials I, II, and III were evaluated in this nested cohort evaluation. The patients' demographics, surgical characteristics, medication use, and incidence of post-cardiothoracic surgery atrial fibrillation (atrial fibrillation > 5 minutes duration) were uniformly and prospectively collected as part of Atrial Fibrillation Suppression Trials I, II, and III. Multivariate logistic regression was used to calculate adjusted odds ratios with 95% confidence intervals. RESULTS: Overall, 331 patients (59.6%) received a statin preoperatively and 224 patients (40.4%) did not. The study population had an average age of 67.8 +/- 8.6 years, 77.1% were male, 14.6% had valve surgery, 6.1% had a history of atrial fibrillation, 12.6% had a history of heart failure, 84.0% received postoperative beta-blockade, and 44.1% received postoperative prophylactic amiodarone. In total, 174 patients (31.4%) developed post-cardiothoracic surgery atrial fibrillation. Upon multivariate logistic regression, statin use was associated with a reduction in post-cardiothoracic surgery atrial fibrillation (adjusted odds ratio: 0.60; 95% confidence interval 0.37-0.99). Higher intensity statin dosing (equivalent of > or = 40 mg of atorvastatin) seemed to be associated with the greatest reductions in post-cardiothoracic surgery atrial fibrillation (adjusted odds ratio: 0.45; 95% confidence interval 0.21-0.99). CONCLUSIONS: In a population with appreciable beta-blocker and amiodarone use, adjunctive preoperative statin use was still associated with a 40% reduction in patients' odds of developing post-cardiothoracic surgery atrial fibrillation.

Electromagnetic Interference (EMI) and arrhythmic events in ICD patients undergoing gastrointestinal procedures.

BACKGROUND: The objective was to determine the effect of electromagnetic interference (EMI) in patients undergoing gastrointestinal endoscopy. The implantable cardioverter-defibrillator (ICD) is the primary therapeutic modality for patients at risk for sudden cardiac death. One potential problem with ICDs is interactions with electrical devices and medical procedures causing EMI or triggering arrhythmic events. Endoscopy frequently employs electrocautery (EC) for diagnosis and treatment of gastrointestinal diseases. Current guidelines advise inactivating ICDs before any surgical procedure. There is limited information on management of ICDs during endoscopy with or without EC. We prospectively evaluated patients with ICDs undergoing endoscopic procedures at our institution. METHODS AND RESULTS: Forty-one ICD patients underwent 52 gastrointestinal endoscopies over 17 months. The mean age of the population was 66 years (51-83). There were 28 men and 13 women. Thirteen patients had single chamber devices, 25 had dual chamber devices, and 2 had biventricular ICDs. The mean tachyarrhythmia detection rate programmed was 164.7 bpm (125-188). Eighteen procedures (43.9%) required biopsy, coagulation, or polypectomy. Of these, 10 (55%) required the use of EC. Only unipolar EC with mean current 19.6 mA was used. All ICDs were programmed to detection-only with therapies off. Sensitivity was left at nominal programmed settings. Post procedure interrogation showed no detection of EMI or tachyarrhythmic events. CONCLUSIONS: Our study shows no EMI or arrhythmic events triggered during endoscopic procedures in patients with pectorally implanted transvenous ICDs. Routine practice of programming ICDs off for gastrointestinal procedures may not be necessary. However, larger studies are needed before change in current recommendations.

Effect of preoperative angiotensin converting enzyme inhibitor or angiotensin receptor blocker use on the frequency of atrial fibrillation after cardiac surgery: a cohort study from the atrial fibrillation suppression trials II and III.

BACKGROUND: Two recent meta-analyses demonstrated that angiotensin converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) reduce the risk of developing new-onset atrial fibrillation (AF) by nearly 50%. However, the ability of ACEIs or ARBs to prevent postoperative atrial fibrillation (POAF) after cardiac surgery has not been adequately evaluated. OBJECTIVE: To evaluate the impact of preoperative ACEI or ARB use on the incidence of POAF after cardiac surgery. METHODS: Patients undergoing coronary artery bypass grafting and/or valvular surgery from the (atrial fibrillation suppression trials II and III (AFIST II and III) randomized, controlled trials were evaluated in this cohort evaluation. Data in respect to patient demographics, surgical characteristics, medication utilization and the incidence of POAF (defined as AF lasting at least 5 min in duration documented by telemetry) were all uniformly and prospectively collected as part of AFIST II and III. Multivariate logistic regression was utilized to calculate adjusted odds ratios with 95% confidence intervals. RESULTS: A total of 338 patients were evaluated of which 175 (51.8%) received an ACEI or ARB preoperatively and 163 (48.2%) did not. The study population was 65.7+/-9.1 years of age, 77.8% were male, 11.2% underwent valve surgery, 3.6% had prior AF, 10.1% had heart failure and 84.0 and 37.9% received postoperative beta-blockade and prophylactic amiodarone, respectively. In total, 110 (32.5%) patients developed POAF. Upon multivariate logistic regression, the preoperative use of an ACEI or ARB was not found to be associated with a statistically significant reduction in POAF (adjusted odds ratio; 0.71, 95% CIs 0.42-1.20). CONCLUSIONS: Although preoperative ACEI or ARB use reduced the odds of developing POAF by 29%, this association with not found to be statistically significant. A study with approximately 600 subjects would be needed to discern if ACEIs or ARBs truly impact POAF.