Electrocardiogram (EKG) knowledge and interpretation proficiency among healthcare professionals in Pakistan: a prospective cross-sectional study.

Background: Electrocardiogram (EKG) is a commonly used diagnostic tool for the evaluation of the electrical activity of the heart. The purpose of this study was to assess the knowledge and interpretation proficiency of EKG among healthcare professionals (HCPs) in Pakistan. Methods: This prospective cross-sectional study was conducted among HCPs working in different healthcare settings. A structured questionnaire was used to assess the participants' theoretical knowledge and ability to interpret EKG findings. The data were analyzed using descriptive statistics and χ2 tests. The study indicates that EKG knowledge and interpretation proficiency among HCPs in Pakistan is unsatisfactory. The inadequacy of training periods of EKG training sessions and insufficient participation of HCPs in offered training opportunities put forward the need for the formation and introduction of better structured and efficient EKG training programmes. Results: A total of 511 HCPs participated in the study, 28% of whom reportedly had received formal training for EKG interpretation. About 80% of the participants correctly identified theoretical questions pertaining to EKG, while 58% of the participants were able to accurately interpret EKG findings, and most HCPs (69.9%) read fewer than ten EKGs per week. Conclusion: This study demonstrates a lack of expertise and a poor understanding of EKG in HCPs of Pakistan. The low level of EKG knowledge and interpretation proficiency among HCPs may lead to diagnostic errors and poor patient outcomes. Therefore, efforts should be made to improve EKG education and training among HCPs in Pakistan.

Cardiac contractility modulation: A new horizon in the management of heart failure with preserved ejection fraction (HFpEF).

Cardiac contractility modulation (CCM) is a new therapy that has shown promising results in heart failure with preserved ejection fraction (HFpEF) management. This therapy involves the use of a device that delivers electrical signals to the heart during the refractory period, enhancing cardiac contractility without changing heart rate or rhythm. This short article explores the potential of CCM as a new horizon in the management of HFpEF, highlighting its mechanism of action, clinical trials, and future directions for research. Overall, CCM has emerged as a promising therapy for improving the outcomes of patients with HFpEF and provides hope for the development of more effective treatments in the future.

Association between contrast-enhanced adenosine-stress perfusion cardiac magnetic resonance imaging and invasive coronary angiogram for the detection of coronary artery disease: A retrospective analysis.

Objective: The objective of this study was to determine the diagnostic value of stress perfusion CMR for the detection of coronary artery disease. Methods: The was a retrospective cross sectional study in which 43 subjects were included from Cardiac MRI unit in the Hayatabad Medical Complex, Peshawar for study from 1st April 2020 to 30th November 2020. All the subjects who had been referred for stress perfusion CMR with suspected CAD were included in the study. Cardiac MRI both at rest and with adenosine stress perfusion was performed which was followed by invasive coronary angiography. Result: A total of 43 patients were enrolled for the detection or exclusion CAD who underwent stress perfusion CMRI and invasive coronary artery angiography. The study revealed strong and statistically significant association between positive stress perfusion CMR and positive coronary angiogram vs negative stress perfusion CMR and negative coronary angiogram (p= value 0.0001). Conclusions: Stress perfusion CMRI can be considered as a first line, relatively safe, noninvasive test with significant accuracy to diagnose coronary artery disease in patients with suspected CAD without subjecting these patients to invasive coronary angiogram.

White Matter Stroke Masquerading as Subarachnoid Hemorrhage After High-Risk Percutaneous Coronary Intervention: A Case Report.

Considering the context of percutaneous coronary artery angiography (PCI), stroke is a rare but severe complication and is associated with high morbidity and mortality. A computed tomography (CT) scan of the brain is an indispensable imaging modality to diagnose ischemic stroke changes following PCI. A 75-year-old female who presented with sudden onset chest pain was diagnosed with anterior-wall myocardial infarction which required primary PCI. However, an hour following the procedure, she suddenly developed drowsiness, confusion, and hemiparesis. Non-contrast CT showed hyperdense signals in posterior falx and tentorium cerebelli suggesting subarachnoid hemorrhage (SAH) as well as low attenuation signals in bilateral periventricular region suggestive of microvascular ischemic changes. It was critical to decide about the continuation of dual antiplatelet therapy (DAPT), aspirin and P2Y12 inhibitor, as soon as possible. Based on the clinical presentation and mixed picture on the CT scan, a second opinion was sought by a multidisciplinary team, which concluded that the findings were consistent with white matter stroke and DAPT was resumed. The hemiparesis improved gradually with the reversal of CT scan findings. There is a lack of reported literature about ischemic stroke and SAH following high-risk PCI and what should be the best approach in ambiguous cases. The management of white matter stroke and SAH is contrasting, particularly in deciding whether to continue the DAPT after PCI; hence it is critical to diagnose them promptly. Thus, this case highlights the importance of differentiating SAH from white matter stroke for prompt treatment of post-PCI complications to ensure positive outcomes.

Giant Sinoatrial Nodal Artery Aneurysm with Fistula into the Right Atrium Treated by Partial Resection and Plication: A Case Report.

Coronary artery aneurysms (CAAs) occur when an artery dilates 1.5 times the reference vessel. They occur most commonly because of atherosclerosis. CAAs are a rare phenomenon, and it is even rarer to find a giant CAA, which is roughly defined as a size 400% above the reference vessel. Giant CAAs are commonly found in the right coronary artery. The sinoatrial nodal artery (SNA) is among the least common sites for CAA involvement. Sometimes, communication exists between the aneurysm and a chamber of the heart or a great vessel. The consequences of the fistula depend on its size. Because of the rarity of the condition, guidelines are not well developed. However, small CAAs can be managed conservatively, whereas giant CAAs require resection, ligation, and bypass grafting. CAAs have a predilection for males and the elderly. We describe a 40-year-old South Asian woman presenting with mild dyspnea on exertion of 1 year's duration. Echocardiography showed a 60×60 mm cystic sac, subsequently confirmed by computerized tomography, which showed 3 large aneurysms (70×61 mm) and 3 small aneurysms in the SNA. Coronary angiography illustrated that the SNA branched off the left main coronary artery, and the aneurysm communicated with the right coronary artery. The aneurysm was partially resected and plicated.

Concomitant Coronary Artery Disease and Persistent Left Superior Vena Cava in a Patient Presenting With Symptomatic Sinus Bradycardia: A Case Report.

Persistent left superior vena cava (PLSVC) is a congenital venous anomaly. It is frequently associated with other cardiac anomalies. The presence of dual superior vena cava is due to the lack of development of the left cardinal vein in utero. The coronary sinus gets dilated as a result of increased blood flow to the right heart and may be seen on echocardiography. This case describes a 50-year-old lady who presented to the emergency department with lightheadedness, nausea, and vomiting for one day, and her electrocardiogram showed a heart rate of 30 beats per minute. A temporary pacemaker was placed. She had a history of asymptomatic PLSVC diagnosed six months ago through percutaneous coronary intervention. A permanent pacemaker was passed through PLSVC to access the right ventricle and she was discharged home after five days of an uneventful hospital course. Clinicians should be aware of this rare congenital anomaly and its potential complications, particularly in patients with unexplained syncope or bradycardia. Further research is needed to better comprehend the clinical presentation, diagnostic evaluation, and management of PLSVC-related cardiac abnormalities.

Association of Epicardial Fat Volume with Coronary Artery Ectasia and Coronary Artery Disease.

Epicardial fat may play an important role in the pathogenesis of coronary artery disease (CAD). We investigated the relationship between coronary artery ectasia (CAE) and epicardial fat volume (EFV). This retrospective study included 506 patients with CAE (group 1), 500 with CAD (group 2), and 500 patients with normal coronaries as controls (group 3). The pericardium was traced manually from the edge of the pulmonary trunk to the last measured by computed tomography slice containing images of the heart to obtain a region of interest. EFV was significantly higher in patients with CAD than in those with CAE (87.94 ± 22.18 vs 61.33 ± 12.75 mL; P < .001). Patients with normal coronaries had EFV of 56.62 ± 9.82 mL. Multivariate logistic regression analysis showed that male gender [Odds ratio (OR) (95% confidence interval (CI)): 1.220 (1.015-1.682), P = .042], diabetes [OR (95% CI): 1.036 (1.008-1.057); P = .002], and smoking [OR (95% CI): 3.043 (1.022-9.462); P = .005] were significantly associated with CAE. The receiver operating characteristic (ROC) curve showed that EFV had strongest diagnostic value for detecting CAD rather than CAE [AUC .502 P = .074 (95% CI: .311-.784)]. This study demonstrated that EFV is an independent predictor for CAE and CAD. However, sensitivity and specificity for detecting CAE is low when compared with CAD.

Clinical Utility of S.T.O.N.E, Guy's Scoring System, and Renal Stone Complexity Scoring in Predicting Outcome of Single-Tract Percutaneous Nephrolithotomy.

BACKGROUND: Several imaging-based scores have been developed to predict postoperative stone-free state (SFS) and complications. This study aimed to assess the accuracy of the S.T.O.N.E., Guy Scoring System (GSS), and Seoul National University Renal Stone Complexity (S-ReSCS) scores in predicting the outcomes of single-tract percutaneous nephrolithotomy (ST-PCNL). This scoring system holds paramount importance for low-income and low-middle-income countries (LMICs), as it is inexpensive and cost-effective for the healthcare system. METHODOLOGY: This retrospective study was carried out with 147 participants. Based on the preoperative computerized tomographic (CT) scan, each patient's S.T.O.N.E. score, GSS, and S-ReSCS were recorded. The modified Clavien grading system was used to document intra- and postoperative complications. RESULTS: The mean age of the sample population was 45 years. SFS was achieved in 110 (74.8%) patients. The number of calyces involved (p = 0.008), S.T.O.N.E. scoring (p = 0.001), GSS (p = 0.008), and S-ReSCS (0.001) correlated well with the SFS. Forty-nine (33.33%) patients developed complications. The most common complications fell within Clavien grade II. No statistical significance was noted between the S.T.O.N.E. score, GSS, and S-ReSCS with the modified Clavien grading system. CONCLUSION: The S.T.O.N.E. scoring, GSS, and S-ReSCS have a high predictive value for achieving SFS in ST-PCNL. In addition, findings from LMICs are comparable with those from the rest of the world.

Echocardiographic assessment before and after Percutaneous Transvenous Mitral Commissurotomy in patients with Rheumatic Mitral Stenosis.

OBJECTIVES: To determine the changes produced in mitral valve morphology after Percutaneous Trans-Venous Mitral Commissurotomy. METHODS: Patients with mitral stenosis who underwent PTMC at the cardiology department of Lady Reading Hospital, Peshawar, Pakistan, from 2006-2016 were included in this study. All the data were manually obtained from the electronic medical record (M.F.E.). Wilkin's echocardiographic scoring system was used to assess the severity of mitral valve thickness, leaflet mobility, valvular calcification, and Subvalvular disease. The student t-test was used for mean comparison. P-value < 0.05 was considered significant. RESULTS: Of the total 229 patients, males were 96(41.9%), and females were 133(58.1%). The mean [SD] age of the patients was 25 ± 11years. The total Wilkin score was 7 ±1.5. 151(65.9%) were in New York Heart Association (NYHA) functional class III, and 78(34.1%) were in NYHA class IV. There was no immediate change after PTMC in systolic myocardial velocities (SV) measured at the lateral tricuspid annulus. The 2D mitral valve area increased from 0.98±0.94 cm2 to 1.78 ± 0.44 cm2 (P=0.001). Left Atrium diameter was 5.16±0.75 mm prior to PTMC, significantly decreased to 4.7± 0.7 mm (p=0.005) after PTMC. Ejection fraction (Left Ventricular Ejection Fraction) changed from 60.45± 8.25 mm Hg to 62.76±10 mm Hg (p=0.001). Mean Right Ventricular Ejection Fraction (RVEF) of patients before PTMC was 48.7 ± 4.7%, did not change significantly immediately after PTMC. CONCLUSION: PTMC is associated with significant changes in mitral valve morphology in terms of splitting of the fused mitral commissures, increased MVA, improved leaflet excursion, and splitting of the subvalvular structures.

Quality of life assessment after successful percutaneous transmitral commissurotomy and ascertain its relationship with gender / Evaluación de la calidad de vida tras comisurotomía mitral percutánea exitosa y determinación de su relación con el sexo

Abstract Background: percutaneous transmitral commissurotomy has become an ideal treatment option for mitral stenosis due to its less adverse events and more favorable outcomes. Patients improve symptomatically after percutaneous transmitral commissurotomy but we have minimal available data about the quality of life after percutaneous transmitral commissurotomy. Objective: to assess the quality of life after percutaneous transmitral commissurotomy through WHOQol scoring covering different aspects of life, to determine its correlation with a net gain in mitral valve area (MVA) and to ascertain its association with gender. Methods: it was a prospective cohort study carried out for a period of 15 months. A total of 100 patients with mitral stenosis who had successful percutaneous transmitral commissurotomy done were enrolled in the study. Among the total included, 4 patients were lost to follow up and data were collected from 96 patients. Quality of life was assessed before the procedure, at 1 month and 3 months follow up after percutaneous transmitral commissurotomy using WHOQol scoring questionnaire. Results: among 96 patients, 64 (67%) were females and 32 (33%) were males. WHOQol scoring improved significantly after percutaneous transmitral commissurotomy from 32.8±8.9 to 54.6±11.2 and 62.8± 9.7, after one month and 3 months respectively. There was a significant association between net gain of MVA and WHOQol scoring with an R value of 0.46 and p value of 0.03. There was no difference in group comparison of all the six domains between male and female patients. Conclusion: successful percutaneous transmitral commissurotomy improves the quality of life in mitral stenosis patients regardless of their gender and has a positive correlation with a net gain in mitral valve area.

Resumen Antecedentes: La comisurotomía mitral percutánea se ha convertido en una opción terapéutica ideal para la estenosis mitral, debido a efectos menos adversos y a resultados más favorables. Los pacientes mejoran sintomáticamente tras la realización de esta técnica, aunque se dispone de escasos datos acerca de la calidad de vida tras su puesta en práctica. Objetivo: Evaluar la calidad de vida tras la comisurotomía mitral percutánea mediante la puntuación WHOQol, que cubre diferentes aspectos de la vida, para determinar su correlación con la ganancia neta del área valvular mitral (AVM), y determinar su asociación con el sexo. Métodos: Estudio prospectivo de cohorte durante un periodo de 15 meses, en el que se incluyeron 100 pacientes con estenosis mitral a quienes se les practicó con éxito comisurotomía mitral percutánea. De entre el total incluido, se perdieron 4 pacientes durante el estudio, por lo que se recolectaron datos de los 96 pacientes restantes. La calidad de vida se evaluó antes del procedimiento, y transcurridos un mes y tres meses de seguimiento, utilizando el cuestionario de puntuación WHOQol. Resultados: De los 96 pacientes, 64 (67%) eran mujeres y 32 (33%) varones. La puntuación WHOQol mejoró considerablemente tras la realización de la comisurotomía mitral percutánea, con valores de 32,8±8,9 a 54,6±11,2 y 62,8± 9,7, transcurridos uno y 3 meses, respectivamente. Se produjo una asociación significativa entre la ganancia neta de AVM y la puntuación WHOQol, con un valor R de 0,46 y un valor p de 0,03. No se produjo diferencia alguna en cuanto a la comparación grupal de los seis dominios entre varones y mujeres. Conclusión: La comisurotomía mitral percutánea exitosa mejora la calidad de vida de los pacientes de estenosis mitral, independientemente del sexo, y tiene una correlación positiva con la ganancia neta del área valvular mitral.

Comparing the sodium excreting efficacy of furosemide and indapamide combination against furosemide and metolazone combination in congestive heart failure patients: A randomized control trial.

OBJECTIVE: To compare efficacy and safety of indapamide-furosemide combination against metolazone-furosemide combination in refractory heart failure patients. METHODS: The randomised controlled trial was conducted at Rehman Medical Institute, Peshawar, Pakistan, from January 1 to June 30, 2018, and comprised refractory heart failure patients who were randomised into two groups using lottery method Group 1 received intravenous furosemide 40mg Q12hr with metolazone 5mg Q24hr, while group 2 received intravenous furosemide 40mg Q12hr with indapamide 2.5mg Q24hr. Both groups were assessed for urinary sodium excretion, total urine output and decrease in weight on day one, day three and day five of admission. SPSS 22 was used for data analysis. RESULTS: Of the 150 patients, there were 75(50%) in each of the two groups. Mean age in group 1 was 64.8}11.2 years, while it was 66.3}12.9 years in group 2. Both groups showed increased urinary sodium excretion and total urine output (p>0.05). Hypokalaemia was the most common adverse event 66%. Mean hospital stay was not significantly different between the groups (p>0.05). CONCLUSIONS: There was no significant differences between adverse events and efficacy between patients receiving either indapamide-furosemide combination or metolazone-furosemide combination.

Correlation of hyper-homocysteinemia with coronary artery disease in absence of conventional risk factors among young adults.

OBJECTIVE: Coronary artery disease is major cause of mortality and morbidity. Homocysteine has long been postulated as an underlying factor for atherosclerosis leading to coronary artery disease, yet its role in young patients is uncertain. This study was aimed to analyze the correlation between plasma homocysteine and coronary artery disease among young adults in the absence of conventional risk factors. METHODS: It was a case-control study carried out at Rehman Medical Institute, Peshawar, Pakistan from October 1, 2016, to September 30, 2017. Universal sampling technique was adopted and 158 participants were included. A total of 30 participants were in the control group and 128 were in the patient group, who had moderate to severe stenosis in either single or multiple major coronary arteries on coronary angiography and aged <40 years. RESULTS: Cases and controls had similar characteristics but differed significantly in serum homocysteine concentration. In the control group, the mean plasma homocysteine concentration of 6.3 (±2.05) µmol/L and in the patient group a mean plasma homocysteine concentration of 44.5 (±14.01) µmol/L was observed. All the patients with moderate to severe stenosis in single or major coronary arteries had raised plasma homocysteine concentrations. Among 128 patients, 15 (11.7%) had moderate increase, 109 (85.2%) had intermediate increase, and four (3.1%) had severe increase in plasma homocysteine levels. Single vessel coronary artery disease was observed in 118 (92.2%) patients, whereas 10 (7.8%) had more than one major coronary artery involvement. CONCLUSION: Hyper-homocysteinemia has positive correlation with coronary artery disease among young adults in the absence of conventional risk factors.

Cardiovascular risk factors of hypertension, smoking and obesity: Emerging concerns among Pathan and Persian young adults?

Background: Hypertension was considered as a disease of the elderly but due to unhealthy dietary and lifestyle changes its incidence has increased in younger population. Smoking and obesity are emerging concerns the world is facing globally in younger age groups. This study is therefore aimed to identify these cardiovascular risk factors among Pathan and Persian young adults. Methods: It was a cross-sectional study carried out at multiple undergraduate, postgraduate educational institutes and hospitals using non-probability convenient sampling among young adults aged between 15 to 40 years for a period of six months from Apr 1st, 2017 to Sep 30th, 2017. Mean±SD was calculated for continuous variables and categorical variables were expressed as frequencies. Chi-square test and Fisher exact test were used for statistical analysis. Results: A total of 708 subjects were included. Mean±SD age was 26.12±3.7 years. Out of 708, 300(42.37%) were smokers with 209 (29.52%) active and 91 (12.85%) passive smokers. Among smokers, 216 (30.5%) were males while 84 (11.87%) were females. A total of 432 (61.02%) subjects were not doing any exercise, and 636 (89.83%) were consuming junk food. A total of 165 (23.3%) subjects were overweight, and 15 (2.1%) were obese. Stage-1 hypertension was present in 72 (10.2%), while 16 (2.25%) subjects had stage-2 hypertension. Conclusion: There is an increased prevalence of cardiovascular risk factors which includes hypertension, smoking, and obesity among Pathan and Persian young adults.