Accelerated 2 hour regimen of streptokinase for pulmonary embolism

To assess the safety and efficacy of accelerated 2 hour regimen of streptokinase [SK] in acute massive pulmonary embolism. The primary end point of study was immediate hemodynamic improvement and safe discharge from the hospital. Quasi-experimental study. Armed Forces Institute of Cardiology - National Institute of Heart Diseases [AFIC-NIHD], March 2010 to Sept 2010. Twenty five patients referred to AFIC-NIHD Rawalpindi with recent symptoms [<5 days] suggestive of acute massive pulmonary embolism were considered for entry into the study. On confirmation of acute massive pulmonary embolism, they were thrombolysed with 1.5 million units of streptokinase over two hours followed by unfractionated heparin infusion intravenously at a dose of 1,000 IU/h. They were observed for immediate hemodynamic and clinical improvement and followed up till discharge from the hospital. Safety of Streptokinase was assessed by observing for major bleed [requiring blood transfusion]/fatal bleeding/intracranial haemorrhage confirmed on CT scan or anaphylaxis secondary to accelerated regimen. Mean age of the patients was 55 years [range 24 to 85 years] and 60% [15] were males and 40% [10] were females. CT pulmonary angiogram in all 25 cases confirmed massive pulmonary embolism. Streptokinase 1.5 million units were given to all 25 patients in infusion form over a period of 2 hours followed by unfractionated heparin infusion at 1000 IU/hour. No bleeding complication was observed in any of these cases. Eighteen [72%] patients showed immediate hemodynamic and clinical improvement but 28% [7] expired on the same day. Average hospital stay of the patients was 6 days. Mortality of patients with massive pulmonary embolism is high even after thrombolysis. Accelerated 2 hour regimen of streptokinase can be routinely used in patients with massive pulmonary embolism without obviously compromising efficacy or safety but further randomized controlled trials to compare the two SK regimens are required to better predict the efficacy and outcome of the two regimens

Double stick approach for chronic total occlusion of coronary arteries

To describe experience of double stick access to arterial system with contralateral injection of the opposite artery to visualize the distal cross filling vessel when a totally occluded vessel has no antegrade flow. A Quasi-experimental study. Armed Forces Institute of Cardiology / National Institute of Heart Disease Rawalpindi from Jan 2009 to Aug 2010. Retrospective analysis of 20 coronary angiograms performed for CTO at the cardiac catheterization laboratory of AFIC/NIHD were included in the study. Double stick access was gained through femoral artery in the groin 1cm apart. Twenty patients with chronic total occlusions underwent PCI with contralateral injection technique. Out of them 70% were male and 30% were female. The mean age was 53.65 years. Multivessel coronary artery disease was seen in 45% of patients. Left anterior descending artery lesion was present in 60%, while right coronary artery lesion in 40%. There was no LCX lesion. Single wire was used in 55% of cases while 40% required a second wire which was stiffer and heavier than the previous one. Pilot 50 was successful in 70% and 10% required cross it 200. Predilation was done in all cases using multiple balloons. DES was used in 93.75% cases of CTO. The procedure was successful in 80% while in 20% it was unsuccessful. There was no death during the procedure, nor any other periprocedural or access site complications. We conclude that double stick approach with contralateral injection is a safe and effective way to cross total occlusion

Initial experience of fractional flow reserve in 30 patients with moderate coronary artery lesions at armed forces institute of cardiology

To evaluate our initial experience of Fractional Flow Reserve [FFR] for decision making in coronary revascularization in moderate lesions. A descriptive study. Armed Forces Institute of Cardiology/National Institute of Heart Diseases from August 2009 to August 2010. A total of 30 consecutive patients who underwent FFR at AFIC/NIHD from August 2009 to August 2010. These were the cases in which decision regarding PCI was difficult on visual assessment alone as experienced operators differed in their opinion. A 0.014" FFR wire was used and pressure gradients across the lesions were noted A total of 30 patients with 44 moderate lesions on coronary angiography were evaluated in our initial experience. Amongst these, 27 [61.4%] LAD lesions were studied [20 lesions had an FFR > 0.80 while 7 [15.9%] had an FFR 0.80 or less]. Seven [15.9%] lesions of LCX were evaluated [5 had an FFR > 0.80 and 2 had 0.80 or less]. Seven [15.9%] lesions were of RCA [4 had an FFR >0.80, 3 had 0.80 or less]. One case of LMS lesion was found to be non-critical. Two [4.5%] vein graft lesions were included of which one was found to be angiographically critical, [FFR 0.72]. Out of the total 44 lesions studied 14 [31.82%] lesions were critical with an FFR 0.80 or less, which were stented. Thus 30 stents were saved. This reduced the cost, as well as the un-necessary hazards and risks associated with PCI and the issue of difference in opinion was put to rest. We thus conclude that FFR is a very important tool in guiding the interventionist for planning PCI in moderate lesions

Relationship between BMI and severity of coronary artery disease in female population of Pakistani origin

Objective: To assess relationship between BMI and severity of coronary artery disease in female population of Pakistani origin

Design: Cross sectional observational study

Place and Duration of Study: Armed Forces Institute of Cardiology-National Institute of Heart Diseases [AFIC-NIHD], 1st February 2010 to 31st August 2010 Patients and Methods: The study population included 132 female patients undergoing coronary angiography. Obesity was classified according to the BMI using the National Institutes of Health [NIH] criteria as Normal [BMI 21-24 kg/m2], overweight [BMI 25-29 kg/m2], obesity class I [BMI 30-34 kg/m2], Obesity class II [BMI 35 to 39 kg/m2 and obesity class III [BMI 40 or above kg/m2]. Coronary angiography data were obtained from the Siemens Queries software system, which maintains the database including detailed angiographic findings of all patients at this institution. Significant lesions were defined as those with>70% diameter narrowing of coronary arteries [>50% for the left main coronary artery]. We attempted to quantify the "severity of CAD" by ascertaining the prevalence of high-risk coronary anatomy [HRCA, defined as>50% stenosis of the left main coronary artery and/or significant three-vessel coronary artery disease]

Results: Comparing overall obese [BMI >/= 30] vs. non obese groups, a statistically significant low prevalence of HRCA was encountered in the obese group [26 of 56, 46.4% vs. 54 of 76, 79.5% p<0.05] We concluded that obesity is associated with less severe coronary artery disease in women population of Pakistani origin

Relationship between BMI and severity of coronary artery disease in female population of Pakistani origin

To assess relationship between BMI and severity of coronary artery disease in female population of Pakistani origin. Cross sectional observational study. Armed Forces Institute of Cardiology - National Institute of Heart Diseases [AFIC-NIHD], 1st February 2010 to 31st August 2010. The study population included 132 female patients undergoing coronary angiography. Obesity was classified according to the BMI using the National Institutes of Health [NIH] criteria as Normal [BMI 21-24 kg/m2], overweight [BMI 25-29 kg/m2], obesity class I [BMI 30-34 kg/m2], Obesity class II [BMI 35 to 39 kg/m2 and obesity class III [BMI 40 or above kg/m2]. Coronary angiography data were obtained from the Siemens Queries software system, which maintains the database including detailed angiographic findings of all patients at this institution. Significant lesions were defined as those with >70% diameter narrowing of coronary arteries [>50% for the left main coronary artery]. We attempted to quantify the "severity of CAD" by ascertaining the prevalence of high-risk coronary anatomy [HRCA, defined as >50% stenosis of the left main coronary artery and/or significant three-vessel coronary artery disease]. Comparing overall obese [BMI >/= 30] vs. non obese groups, a statistically significant low prevalence of HRCA was encountered in the obese group [26 of 56, 46.4% vs. 54 of 76, 79.5% p < 0.05]. We concluded that obesity is associated with less severe coronary artery disease in women population of Pakistani origin

Transulnar access for coronary angiography and intervention

To assess the safety and efficacy of a transulnar approach for coronary catheterization. Descriptive study. Armed Forces Institute of Cardiology - National Institute of Heart Diseases [AFIC-NIHD], October 2009 to January 2010. Twenty five patients underwent coronary catheterization by the transulnar approach. Patients were selected for ulnar approach coronary angiography if they had a weak radial pulse with a stronger palpable ulnar pulse with a positive reverse Allen's test [< 10 sec]. No attempt was made at cannulating radial artery in the same sitting. A 6F sheath was placed inside the ulnar artery as per standard Seldinger technique, and cardiac catheterization or angioplasty was performed. The patients were examined before discharge from the hospital for any access site complications. Mean age of the patients was 48 years [range 30 to 62 years] and 80% [n= 20] were men and 20% [n=5] were females. Successful puncture was achieved in 100% [25/25]. One out of twenty five patients had same sitting PCI with stenting to LAD and LCX. No case of arterial spasm, haematoma, pseudoaneurysm, vascular perforation or loss of pulse was observed. We conclude that the transulnar approach is a safe and efficacious alternative for diagnostic and therapeutic coronary intervention in presence of weakly palpable radial artery and a stronger palpable ulnar artery with positive reverse Allen's test

Transradial access for coronary angiography: a single operator's experience of 500 cases

The purpose of the present study was to assess the feasibility, success, and safety of the transradial approach [TRA] for diagnostic coronary angiography. Descriptive study. The study was carried out in Armed Forces Institute of Cardiology-National Institute of Heart Diseases [AFIC-NIHD] over a period of ten months from June 2009 to March 2010. We collected data of 500 consecutive patients who underwent coronary catheterization by the transradial approach. Transradial access was performed only if the Alien's test was normal [positive]. Patients with previous CABG or requiring right heart catherization were excluded from this study. Study endpoints included procedure success rate, vascular complications at access site, and major adverse cardiac and cerebrovascular events during hospitalization. Mean age of the patients was 52 years [range 33-77 yrs] and 72.8% [n= 364] were men and 27.2% [n=136] were females. The vast majority of cases [98.4%] were elective. The right radial artery was used in 98% of cases. Procedural success was achieved in 90.6% cases [453/500]. No case of vascular complications such as major access site bleeding, vascular perforation, radial artery occlusion, forearm ischemia, compartment syndrome or MACE was observed. Transradial access for coronary angiography is a safe, effective and elegant alternative to transfemoral access

Transradial access for pci: a novel approach / changing trends of vascular access

Vascular complications associated with femoral artery access for interventional cardiological procedures may increase morbidity especially in patients receiving anticoagulants, aspirin, clopidogrel and platelet glycoprotein IIb/ IIIa receptor inhibitors. The use of radial arterial access reduces the incidence of access site bleeding complications. The purpose of the present study was to assess the feasibility, success, and safety of the transradial approach [TRA] for PCI. Single-centre, Prospective observational study. The study was carried out in Armed Forces Institute of Cardiology - National Institute of Heart Diseases [AFIC-NIHD] over a period of six months from july 2009 to december 2009. We collected data of 100 consecutive patients who underwent PCI by the transradial approach. Transradial access was performed only if the Allen's test was normal [positive], suggesting the presence of an adequate collateral circulation from the ulnar artery. Patients with previous CABG with LIMA grafting, ACS with cardiogenic shock or requiring TPM placement were excluded from this study. Study endpoints included procedure success rate, vascular complications at access site, and major adverse cardiac and cerebrovascular events during hospitalization. Mean age of the patients was 53 years [range 31-79 yrs]. Procedural success was achieved in 100% cases. Right TR approach was used in 99% cases. Number of target lesions treated was 239 with multivessel PCI done in 61% cases. DES was used in 72%cases and BMS was used in 28% cases. Maximum no of target lesions treated included LAD 114[47.6%], followed by RCA 50 [20.9%],LCX 41[17.1%],OM branch 25[10.4%],Diagonal branch 9[10.4%]. No case of vascular complications such as major access site bleeding, vascular perforation, radial artery occlusion, forearm ischemia or compartment syndrome was observed. There were no procedural myocardial infarctions or deaths, and no patient was referred for emergency bypass surgery. We conclude that the transradial access for PCI is a safe and effective alternative to transfemoral access. It adds to patients comfort and convenience and offers coronary intervention with the potential of less vascular complications