Acute Pulmonary Embolism: Presentation, Diagnosis, Management and Factors Impacting Clinical Outcome in a Tertiary Cardiac Centre in Pakistan.

OBJECTIVE: To evaluate the presentation, diagnosis, management and outcome of acute pulmonary embolism for assessing the factors impacting mortality in such patients. STUDY DESIGN: Descriptive study. PLACE AND DURATION OF STUDY: Rawalpindi Institute of Cardiology, Rawalpindi, Pakistan, from July 2015 to July 2018. METHODOLOGY: Patients presenting with clinical suspicion of pulmonary embolism were subjected to a diagnostic algorithm consisting of Wells Rule, D-Dimer testing, echocardiography and CT pulmonary angiogram. Patients diagnosed with pulmonary embolism were subdivided into massive and submassive pulmonary embolism groups. Most patients diagnosed with massive pulmonary embolism were treated with streptokinase injection. For those diagnosed as submassive pulmonary embolism, the standard therapy remained anticoagulation with intravenous heparin, both the subsets of patients were further put on oral warfarin. Clinical outcome was defined as combined end-point including death during hospital stay, recurrence of PE and meed for repeat thrombolysis. RESULTS: A total of 174 patients diagnosed with pulmonary embolism were studied. The mean age was 49.1 +14.8 years (range 23-88 years) with 109 (62.6%) patients being male. The in-hospital clinical course was uneventful in 144 (83%) patients. Twenty-two patients (12.6%) patients died, of whom 3 died from major bleeding, one from cancer, and 18 from the pulmonary embolism process (14 patients from refractory shock and 4 patients from recurrent PE). A total of 8 (4.6%) had fatal or non-fatal recurrent PE. In patients who had echocardiography both pre- and post-thrombolysis, initial RV dysfunction was reversible in 136 (78%) within 48h following thrombolytic therapy. By univariate analysis, only shock (SBP) and delay in diagnosis for more than 6 hours were associated with adverse event. CONCLUSION: Early diagnosis by doing urgent CTPA in patients with suspected acute PE is the cornerstone in reducing mortality in acute PE patients.

Peripartum Cardiomyopathy in a Pakistani Cohort.

OBJECTIVE: To describe the demographics, risk factors, and clinical presentation in Pakistani patients with peripartum cardiomyopathy. STUDY DESIGN: A descriptive observational study. PLACE AND DURATION OF STUDY: Rawalpindi Institute of Cardiology, Rawalpindi, from June 2014 to June 2015. METHODOLOGY: Seventy patients meeting criteria of peripartum cardiomyopathy were included in the study. Adetailed history, physical examination and investigations were done. Epidemiologic data, risk factors, New York Heart Association (NYHA) class and echocardiographic findings were recorded. Statistical analyses were done using SPSS version 19. RESULTS: The mean age was 28.66 ±4.57 years. Mean parity and weight was 3.04 ±1.7 and 60.97 ±12.40 Kg, respectively. Fifty-five (78.6%) cases were diagnosed in the postpartum period. Thirty-three (50.8%) and 31 patients (44.7%) presented in NYHA- III and IV classes, respectively. Pregnancy-induced hypertension was seen in 16 (22.9%) cases, diabetes in 6 (8.6%), and twin pregnancy in 2 (2.9%) cases. The mean hemoglobin and brain natriuretic peptide (BNP) was 11.26 ±1.61 gm/dl and 1583.70 ±1237.65 pg/ml, respectively. Echocardiography showed mean ejection fraction of 21.74 ±7.45%. Left ventricle systolic and diastolic diameters were 53.71 ±9.74 mm and 63.37 ±8.48 mm, respectively. CONCLUSION: Peripartum cardiomyopathy was seen in younger women with higher parity and pregnancy induced hypertension, often manifesting in the postpartum period with NHYAclass III and IV status.

Hyperdominant Left Anterior Descending Artery: ARare Coronary Artery Anomaly.

The posterior descending artery supplying the posterior one-third of the inter ventricular septum usually arise from the right coronary artery (RCA) or the left circumflex artery (LCx). Posterior descending artery arising from the left anterior descending artery is a rare anomaly. A66-year man presented with chest pain, ECG changes, and raised biomarkers. A diagnosis of non-STelevation myocardial infarction was made. Coronary angiogram, done on the next day, revealed the posterior descending artery as a continuation of the left anterior descending artery (LAD) beyond the crux and a rudimentary right coronary artery. The left anterior descending artery had subcritical stenosis in proximal course (confirmed on fractional flow reserve) and was advised medical treatment.

Percutaneous Coronary Intervention Under Cover of Left Ventricular Assist Device (Impella 2.5).

Impella 2.5 is a temporary left ventricular assist device that is being increasingly used in high risk Percutaneous Coronary intervention (PCI). It reduces the cardiac workload and provides assistance to myocardium and vital organs in states of severe left ventricular dysfunction and cardiogenic shock. We report the first case of successful percutaneous coronary stenting performed in a high risk patient using impella 2.5. A 65-year old diabetic and hypertensive male with a known double vessel coronary artery disease and a reduced left ventricular function (ejection fraction, 20%) was admitted with intractable angina. He was on optimal medical treatment for 2 months. His coronary angiogram done 2 months back had revealed double vessel coronary artery disease (subtotally occluded co-dominant left circumflex and moderate 60% stenosis in left anterior descending artery and a normal co-dominant right coronary artery). He was considered a high risk both for Coronary Artery Bypass Graft (CABG) surgery and PCI due to co-morbidities and reduced left ventricular function. As he had failed a trial of optimal medical therapy and the cardiac surgeon's reluctance for surgery, the patient and his family was counseled for high risk PCI with left ventricular assist device using the impella 2.5.

Clinical Safety and Parameters of Maximum Oxygen Uptake (VO2Max) Testing in Pakistani Patients With Heart Failure.

OBJECTIVE: To determine the parameters of maximum oxygen uptake (VO2max) in a Pakistani systolic heart failure cohort and its safety in a clinical setting. STUDY DESIGN: Descriptive study. PLACE AND DURATION OF STUDY: Armed Forces Institute of Cardiology, National Institute of Heart Diseases, Rawalpindi, from June 2011 to January 2013. METHODOLOGY: Maximum oxygen uptake test was performed in patients with severe heart failure, who could perform the VO2max treadmill test. Age, Body Mass Index (BMI) ejection fraction, VO2max and respiratory exchange ratios and their correlations were determined. RESULTS: Out of 135 patients, 77% (n=104) were males, with a mean age of 45.9 ±15.7 years. Weight of patients ranged from 30 kg to 107 kg (mean 63.29 ±13.6 kg); mean BMI was 23.16 ±4.56 kg/m2. All patients presented with either NYHA class of III (50.3%; n=68) or IV (49.7%; n=67); mean ejection fraction was 22.54 ±5.7% (10 - 35%, IQ:20 - 25). The VO2 max of the patients ranged from 3 to 32 ml/kg/minute (mean 12.85 ±4.49 ml/kg/minute). Respiratory exchange ratio was over 1 for all patients (1.12 - 1.96, mean = 1.36 ±0.187). There was a negative correlation with age (r = -0.204; p = 0.028) whereas a positive correlation was found with exercise time (r = 0.684; p = 0.000), hemoglobin (r = 0.190; p = 0.047) and ejection fraction (r = 0.187 ; p = 0.044). CONCLUSION: Cardiopulmonary exercise testing in a high-risk heart failure cohort is safe and provides information beyond the routine clinical evaluation of heart failure patients.

Description and follow-up of patients with coronary perforations during percutaneous coronary interventions at AFIC-NIHD.

This study was conducted to determine the frequency and describe the lesion characteristics, clinical factors, device responsible and outcomes for coronary perforations at Armed Forces Institute of Cardiology - National Institute of Heart Diseases (AFIC -NIHD) on all patients undergoing percutaneous coronary interventions (PCI) from 2007 to May 2012. A total of 13,366 PCI procedures were performed during this period; coronary perforation occurred in 16 cases (0.001%). All patients had elective PCI. Fifty percent (n = 8) patients had type C lesions. Grade III perforations were seen in 10 patients. Seven perforations were caused by angiography wires. None of the perforations was related to atherectomy devices. Six patients needed pericardiocentesis. There were 3 in-hospital deaths. One patient needed CABG. At followup, all patients who had been discharged were alive. The frequency of coronary perforations was very low. Old age and type C lesions were identified as a risk factor for coronary perforations. Grade III (or greater) perforation was a predictor of mortality. Patients who are discharged to home generally had better outcomes.

Validation of the Seattle Heart Failure Model (SHFM) in heart failure population.

OBJECTIVE: To determine the effectiveness of Seattle Heart Failure Model (SHFM) in a Pakistani systolic heart failure cohort in predicting mortality in this population. STUDY DESIGN: Cohort study. PLACE AND DURATION OF STUDY: The Armed Forces Institute of Cardiology - National Institute of Heart Diseases, Rawalpindi, from March 2011 to March 2012. METHODOLOGY: One hundred and eighteen patients with heart failure (HF) from the registry were followed for one year. Their 1-year mortality was calculated using the SHFM software on their enrollment into the registry. After 1-year predicted 1-year mortality was compared with the actual 1-year mortality of these patients. RESULTS: The mean age was 41.6 ± 14.9 years (16 - 78 years). There were 73.7% males and 26.3% females. One hundred and fifteen patients were in NYHA class III or IV. Mean ejection fraction in these patients was 23 ± 9.3%. Mean brain natriuretic peptide levels were 1230 ± 1214 pg/mL. Sensitivity of the model was 89.3% with 71.1% specificity, 49% positive predictive value and 95.5% negative predictive value. The accuracy of the model was 75.4%. In ROC analysis, AUC for the SHFM was 0.802 (p < 0.001). CONCLUSION: SHFM was found to be reliable in predicting one-year mortality among patients with heart failure in the Pakistani patients.

Superior vena cava thrombosis with peripartum dilated cardiomyopathy.

A 30 years multiparous female with history of emergency caesarean section 10 days back was referred to us with cough, severe breathlessness at rest, orthopnea with pain in neck and arms. Clinical examination revealed signs of heart failure. Echocardiography showed ejection fraction of 15%, with no right ventricular strain. A diagnosis of peripartum cardiomyopathy was made. Doppler ultrasound of neck veins showed bilateral internal jugular vein thrombosis. Subsequent multislice CT examination showed thrombosis of superior vena cava and both internal jugular veins (with collateral formation) and pulmonary embolism. There were no mediastinal abnormalities on the CT scan. Her thrombophilia screen and CT scan brain was normal. She was managed in collaboration with cardiologist. Following treatment with subcutaneous enoxaparin therapy and warfarin her symptoms of upper limb pain improved. She responded very well to medical therapy for heart failure with marked improvement of NYHA functional class.

Trans-radial primary percutaneous coronary intervention in ST-elevation myocardial infarction.

OBJECTIVE: To study the effect of trans-radial approach (TRA) on achievement of a door-to-balloon time (DBT) of ² 90 minutes in primary PCI percutaneous Coronary intervention (PPCI) for ST-elevation myocardial infarction (STEMI). STUDY DESIGN: Case series. PLACE AND DURATION OF STUDY: Armed Forces Institute of Cardiology - National Institute of Heart Diseases (AFIC -NIHD), Rawalpindi, from October 2011 to August 2012. METHODOLOGY: Systems goal for door-to-balloon time (DBT - time elapsed between first medical contact and restoration of flow in the infarct related artery [IRA]) was set at < 90 minutes. Procedural success was defined as restoration of TIMI 3 flow in the IRA with less than 30% residual stenosis and discharge from hospital. Non-infarct related arteries were not treated. Bleeding episodes were defined by TIMI definitions. RESULTS: For vascular access for PPCI in a total of 207 patients, TRA was 91.3% (n = 189), transfemoral approach (TFA) 6.3% (n = 13) and brachial 2.4% (n = 5). Males represented 90.3% of cases and 7% were females. Mean age was 55 ± 10.86 years. Procedural success rate was 97.1%. Mean DBT was 54.1 minutes. DBT was less ² 60 and 90 minutes in 75% and 94.2% of patients respectively. DBT ² 89.50 minutes was achieved in 90% of patients. The difference in DBT between the different access groups was not markedly different between the three groups. There were 6 (2.9%) in-hospital deaths and no major bleeds. CONCLUSION: TRA for PPCI poses no hindrance to achieving a DBT of < 90 minutes in PPCI for STEMI. Furthermore, the in-hospital mortality rates are acceptable and within rational limits.

Total cardiovascular risk approach to improve efficiency of cardiovascular prevention in resource constrain settings.

OBJECTIVES: To determine the population distribution of cardiovascular risk in eight low- and middle-income countries and compare the cost of drug treatment based on cardiovascular risk (cardiovascular risk thresholds ≥ 30%/≥ 40%) with single risk factor cutoff levels. STUDY DESIGN AND SETTING: Using World Health Organization (WHO) and the International Society of Hypertension risk prediction charts, cardiovascular risk was categorized in a cross-sectional study of 8,625 randomly selected people aged 40-80 years (mean age, 54.6 years) from defined geographic regions of Nigeria, Iran, China, Pakistan, Georgia, Nepal, Cuba, and Sri Lanka. Cost estimates for drug therapy were calculated for three countries. RESULTS: A large fraction (90.0-98.9%) of the study population has a 10-year cardiovascular risk <20%. Only 0.2-4.8% are in the high-risk categories (≥ 30%). Adopting a total risk approach and WHO guidelines recommendations would restrict unnecessary drug treatment and reduce the drug costs significantly. CONCLUSION: Adopting a total cardiovascular risk approach instead of a single risk factor approach reduces health care expenditure by reducing drug costs. Therefore, limited resources can be more efficiently used to target high-risk people who will benefit the most. This strategy needs to be complemented with population-wide measures to shift the cardiovascular risk distribution of the whole population.

Clinical profile of patients presenting with acute ST elevation myocardial infarction.

OBJECTIVE: To identify risk factors and clinical profile of the patients presenting with acute ST Elevation Myocardial Infarction (STEMI). METHODS: This prospective observational study was carried out from April to September 2005. The 300 consecutive patients presenting with typical electrocardiographic changes of acute ST elevation myocardial infarction to the Emergency Department of our hospital were recruited in the study. The physician (a fellow) on duty assessed the patients and documented the predefined independent variable and patients characteristics. The clinical history revealed information about age, gender, risk factors, modes of presentation and duration of symptoms. The details of physical examination including anthropometric data, vital signs and complete systemic evaluation were recorded. The regions of infarction and rhythm disturbances were also documented. RESULTS: This study was predominantly male dominated 234 (78%) patients, with a mean age of 58 +/- 11 years. Cigarette smoking was identified as a major risk factor in 138 (46%) patients. The least common risk factor i.e. obesity (BMI >25) was present in 12 (4%) patients. Majority of the patients, 282 (94%) presented with typical chest pain and within first six hours of onset of symptoms 216 (72%). Most of the patients 240 (80%) had normal examination at presentation and 60 (20%) had signs of Left Ventricle Failure. Isolated inferior and anterior myocardial infarction was noted in 138 (46%) and 48 (16%) patients respectively. Normal electrocardiographic rhythms at presentation were observed in 282 (94%) patients. CONCLUSION: Acute myocardial infarction was more common in adult males with smoking being the major risk factor. Most of the patients presented with typical chest pain and within six hours of onset of symptoms. The majority of patients demonstrated normal physical examination and cardiac rhythm. Inferior myocardial infarction was the most common lesion.

Myocardial damage in successful single vessel coronary angioplasty as assessed by creatinine kinase and its myocardium band isoenzyme levels.

OBJECTIVE: To determine the frequency of myocardial damage in elective, successful, single vessel percutaneous coronary angioplasty by assessing myocardial band (MB), creatinine kinase levels and to find out the association of common modifiable risk factors with myocardial damage in patients undergoing single vessel coronary angioplasty. STUDY DESIGN: Descriptive. PLACE AND DURATION OF STUDY: Armed Forces Institute of Cardiology / National Institute of Heart Disease, Rawalpindi, from September 2006 to September 2007. PATIENTS AND METHODS: Fifty patients undergoing elective and successful single vessel percutaneous coronary angioplasty were evaluated with creatinine kinase and creatinine kinase MB levels before and after 8 hours and 1st day following coronary angioplasty. Studied variables included the length of stent deployed, maximum deployment pressure and total balloon inflation time, apart from hypertension, cholesterol level, smoking and diabetes mellitus. RESULTS: Out of 50 patients, 9 had raised creatinine kinase at 8 hours (18%) and 10 had raised creatinine kinase (20%) on 1st day following coronary angioplasty, 7 (14%) patients and 8 (16%) patients had raised creatinine kinase MB levels at 8 hours and 1st day following coronary angioplasty respectively. The rise of either was equal to or more than 3 times the normal limits. Modifiable risk factors, significantly associated with myocardial damage, were diabetes mellitus (p=0.006) and LDL levels (p=0.009) in patients undergoing single vessel coronary angioplasty. CONCLUSION: Successful elective, uncomplicated, single vessel coronary angioplasty resulted in some myocardial damage evident by mild rise in cardiac enzymes but rise of creatinine kinase MB above 3 times of normal, which signifies percutaneous coronary angioplasty-related myocardial infarction, was not seen. There was a significant association between diabetes mellitus, LDL levels and myocardial damage in patients undergoing coronary angioplasty but no significant association was found between hypertension, smoking and myocardial damage.