Risk factors for stroke; a prospective hospital based study

The stroke is third leading cause of death in world and most patients die with an acute event in stroke. Various clinical variables have been investigated as risks factors of stroke. The study was aimed to identify these risks factors for stroke. This prospective study included 205 consecutive patients of stroke admitted in Combined Military Hospital/Sheik Khalifa Bin Zyad Hospital Muzaffarabad Azad Kashmir. The risk factors of stroke were investigated. Examination included clinical, neurological evaluation, laboratory tests, and brain CT. The follow-up at 14 days were done for all patients. Patients included were with acute first ever stroke onset of 48 hours of hospital admission. All patients completed a structured questionnaire and a physical examination and most provided blood for relevant investigations. Two hundred and five cases stroke sub-types were [n=156, 76%, with ischemic stroke [CI]; n=49, 24%, with intra-cerebral hemorrhagic stroke [ICH]. The significant risk factors for all stroke were: Hypertension [p=0.003], diabetes [p=<0.001], Hypercholesterolemia [p=0.686]; atrial fibrillation [p=0.445], cardiac diseases [p=0.938], smoking [p=0.926] for brain infarction and hypertension [p=0.002], diabetes [p=<0.001], Hypercholesterolemia [p=0.018]; atrial fibrillation [p=0.449], cardiac diseases [p=0.749], smoking [p=0.829] for hemorrhagic stroke. Age significance [CI; p=0.247 vs. ICH; p=0.013] and age category significance were [CI; p=<0.001 vs. ICH; p=0.871] for subtype of stroke. High mRS [p<0.001] low GCS score [p<0.001] on admission were associated with worst outcome for both stroke subtype. These risk factors were all significant for CI as well as ICH. This study signifies the association of risks factors with acute stroke. Targeted interventions that reduce these risk factors could substantially reduce the burden of stroke

Use of exercise tolerance test and thallium stress test in the diagnosis of ischemic heart disease in soldiers

To determine the role of Exercise Tolerance Test [ETT] and Thallium Stress Test [TST] in the detection of Coronary Artery Disease [CAD] among soldiers. Descriptive study. This study was conducted at Combined Military Hospital [CMH], Multan, Pakistan, from 2002 to 2004. There were 291 male soldiers between ages 30 and 45 years who presented with chest pain and had normal resting ECG. All patients were subjected to ETT. Positive ETT cases had Coronary Angiogram [CA] as the gold standard. Negative cases were subjected to TST. Normal CA cases also had TST to rule out microvascular disease. Those with normal ETT and positive CAD risk factors also had TST. Those with negative TST had CA as service requirement. All 291 cases had ETT, 130 cases were found positive, 161 had negative ETT. When CA was done on 130 positive cases, 95 had CAD [true positive, TP] and 35 had normal coronaries [false positive, FP]. Out of the 161 negative ETT cases, 128 had normal coronaries [true negative, TN] and 33 had CAD [false negative, FN]. TST was conducted on 196 cases, out of which 78 cases were found positive and 118 had negative TST. When subjected to CA, out of 78 positive cases, 30 had CAD [TP] and 48 had normal coronaries [FP]. Out of 118 negative TST cases, 115 had normal coronaries [TN] and 3 had CAD [FN]. ETT was found to have sensitivity of 74.2%, specificity of 78.5%, Positive Predictive Value [PPV] of 73.1%, Negative Predictive Value [NPV] of 79.5% and test accuracy of 76.6%. TST had sensitivity of 90.9%, specificity of 70.6%, PPV of 38.5%, NPV of 97.5% and accuracy of 74.0%. TST was found to be more sensitive and less specific than ETT in the diagnosis of CAD

Normal exercise tolerance test in a patient with severe left main coronary artery disease

A 31 years old soldier reported in emergency reception [ER] with history of left sided atypical chest pain since one day. Smoked 5 cigarettes a day for last 5 years. There was no ischemic heart disease, hypertension or diabetes in the personal or family history. Two electrocardiograms recorded at ER showed no abnormality apart from hyper acute T waves. After intramascular injection of diclofenac sodium 75 mg at emergency reception he was admitted in CCU [coronary care unit] and treated as a case of unstable angina pectoris. Treatment included intravenous nitrates, heparin @ 1000 iu/hr, oral metoprolol 100 mg OD and disprin 150 mg OD. Serial electrocardiograms recorded during three consecutive days in CCU showed no change from the initial ECG [electrocardiogram]. Cardiac enzymes showed a rise in CPK [creatinine phosphokinase] but there was no meaningful rise in CK-MB or LDH on three consecutive days. Patient developed low grade fever on second and third day of his stay in CCU along with mild leukocytic response. His random blood sugar, total cholesterol and lipoproteins, Triglycerides were within normal limits with mild neutrophilia. X-ray chest was also normal. Echocardiogram showed normal sized cardiac chambers with ejection fraction 70%, fractional shortening 35% and no evidence of regional wall motion abnormality. On fourth day a graded ETT was planned as per Bruce protocol. He achieved 85% of target heart rate in stage 4 after 12 minutes. There was no ischemic electrocardiogram change or arrhythmia during exercise and recovery period. As per ACC/AHA guidelines, radioisotope thallium scan or coronary angiogram was not performed. Patient was discharged with reassurance and advise to quit smoking and prevent other risk factors. After 5 days his dead body was brought to CMH, Multan. There was a short history of epigastric discomfort and chest pain followed by collapse and death in a private clinic at Mian Chunu. An autopsy was carried out that disclosed critical coronary artery disease. It was found that left main coronary artery had atheromatous plaque occluding 95% of lumen with thrombus inside, totally occluding the vessel. Left anterior descending artery [LAD] was 50% blocked in the middle and left circumflex artery [LCx] had 30% disease. There was an extensive area of myocardial infarction on gross and microscopic examination