Are BP readings taken after a patient-physician encounter in a real-world clinic scenario the lowest of all the readings in a clinic visit

To determine the difference in Blood Pressure [BP] readings taken before, during and after the clinic encounter. Descriptive study. Cardiology Clinic, The Aga Khan University Hospital, Karachi, from January to August 2013. Hypertensive and normotensive participants aged >/= 18 years were recruited. Pre-clinic BP was measured by a nurse and in-clinic BP by a physician. After 15 minutes, two post-clinic BP readings were taken at 1 minute interval. All readings were taken using Omron HEM7221-E. Out of 180 participants, males were 57% and 130 [71%] were hypertensive. Mean SBP [Systolic BP] taken preclinic, in-clinic, post-clinic 1 and post-clinic 2 were: 126 +/- 20 mmHg, 131 +/- 23 mmHg, 126 +/- 20 mmHg and 121 +/- 21 mmHg respectively [p < 0.001]. Mean DBP [Diastolic BP] taken pre-clinic, in-clinic, post-clinic 1 and post-clinic 2 were 77 +/- 12 mmHg, 81 +/- 13 mmHg, 79 +/- 12 mmHg and 79 +/- 11 mmHg respectively [p < 0.001]. BP taken in the post-clinic setting may significantly be the lowest reading in a clinic encounter, making in-clinic BP unreliable to diagnose or manage hypertension

Diuretic induced hyponatremia in hypertensive patients

Diuretics are the recommended antihypertensive by several international guidelines. This study was designed to determine the association of hyponatremia in hypertensive patients on diuretic therapy. This was a case control study conducted at the Aga Khan University Hospital, Karachi in adult inpatients [> 18 years] who were known hypertensive. Cases were defined as hypertensives with hyponatremia and controls were defined as hypertensives without hyponatremia. Outcome was hyponatremia. Exposed were those using diuretics. Out of 1800 hypertensive patients sampled by the ICD-9-Coding; 1191 [66%] fulfilled the inclusion criteria. Cases n [%] were 553 [46.4] and controls were 638 [53.5]. Among 553 cases [%] 180 [32.5] were exposed [on diuretics] and in controls 189 [29.6] were exposed [on diuretics] p=0.15. The association of hyponatremia with diuretic use was not significant with OR=1.11 [95% CI=0.86 - 1.45, p=0.40], after adjusting for chronic kidney disease, ischemic heart disease and chronic liver disease, in the final model. Diuretics were not associated with hyponatremia in hypertensive adult patients in this study

Better physician-patient communication; an important milestone in control of hypertension, a multicenter study from Karachi, Pakistan

Control of hypertension is an important cornerstone in prevention of cardiovascular morbidity and mortality. This study was designed to compare physician encounter score in patients with controlled and uncontrolled hypertension. It was conducted at three tertiary care hospitals in Karachi. Patients were categorized into controlled and uncontrolled hypertension based on their initial blood pressure readings on presentation. Primary outcome variable was control of hypertension and physician encounter score [a composite score of 12 item question] was the main candidate variable. Higher scores reflected favorable encounter with physician. Mean age of participants was 57.7 +/- 12 years; 224 [50.1%] were men. Controlled hypertension was present in 72.3% [323] and uncontrolled hypertension was present in 27.4% [124]. Mean physician encounter score in uncontrolled hypertensive was 7.25 +/- 2.64 versus 7.83 +/- 2.22 [p=0.02] in controlled hypertensive. Patient-physician encounter is an important milestone in control of hypertension in hypertensive patients and directly translates into better adherence to antihypertensives in these patients

Validity and reliability testing: Urdu translated modified response to symptoms questionnaire

To determine validity and reliability of the Urdu translated, modified "Response to symptoms questionnaire" [RSQ] among acute coronary syndrome [ACS] patients in Karachi. A qualitative, tool validation study. Two tertiary care hospitals in Karachi, the Aga Khan University Hospital, Karachi and the Karachi Institute of Heart Diseases, from December 2010 to April 2011. After making certain modifications, the original tool in English was translated into Urdu. Next, five cardiology experts evaluated the tool for its content and face validity. Test retest and inter rater reliabilities were computed for the RSQ using 5% of the total sample size of the parent study. Sufficient conceptual and semantic equivalence was found between the Urdu and English versions of the modified RSQ. Content validity index was calculated to be 1 for both relevance and linguistic clarity. Test retest and inter rater reliabilities were calculated to be 95.9% and K = 0.97, respectively. The Urdu translated modified RSQ has sufficiently acceptable content validity, test retest and inter rater reliability; hence, it should be used by the researchers for the evaluation of factors associated with pre-hospital delay among Urdu speaking ACS patient populations

Emergency evaluation of acute chest pain

To determine the sensitivity and specificity of initial clinical assessment about the diagnosis of acute coronary syndrome [ACS] in patients presenting with acute chest pain by a cardiology resident in the emergency room and assess the 30-day outcome of patients with ACS and non ACS. Cohort study. The study was conducted in the emergency department and cardiac care units of the Aga Khan University in 2006-07. A total of 202 patients, who presented to the emergency room with chest pain, were given an initial ECG and troponin check. Patients were assigned to initial ACS and non-ACS groups by the cardiology resident. After cardiac workup, patients were assigned to final ACS/final non ACS group. They were followed for outcome after 30 days of initial presentation. Sensitivity and specificity, if initial workup was determined, keeping final assessment after cardiac workup as the gold standard. Out of the 202 patients, 61.9% were males. Their mean age was 54.05 +/- 13 years. Sixty eight percent were placed in the initial ACS group and 30.7% were placed in the initial non ACS group. After workup, 36% were placed in the final ACS group and 28.7% in the final non-ACS group and 35% were undecided. The sensitivity of initial assessment of ACS by the cardiology resident was 100%. However, the specificity was 54.2%. In the 30-day outcome, one patient [1.3%] died in the ACS group due to myocardial ischemia while no patient died from the non ACS group. Initial assessment about ACS by cardiology resident based on character of chest pain, ECG and troponin I is highly sensitive. However, the specificity is low

Compliance to antihypertensive therapy

To determine compliance, factors affecting compliance to antihypertensive therapy and to compare compliant and non-compliant groups, in a tertiary care setting. Analytical [cross-sectional] study. The outpatient clinics at the Aga Khan University from May 2004 to February 2005. Two hundred patients presenting to the outpatients clinic were included. All patients 18 years and above, who had stage 1 and 2 hypertension, had one clinic visit to a medicine clinic, 6 months prior to presentation and started on antihypertensive medicines, were included. Sixtysix percent were males and 33.5% were females. Mean age was 58.1[ +/- 12] years and mean duration of hypertension was 7.2 [ +/- 6.7] years. Fifty-seven percent were compliant and 43% were noncompliant. In the noncompliant group, 53.4% had mild noncompliance, 24.4% had severe non-compliance, while 22% had moderate noncompliance. Factors of noncompliance were 56.8% missed doses due to forgetfulness, 12.7% deliberately missed their doses, 11.6% could not take the medicine due to side effects, 10.4% did not take the dose due to increased number of tablets, 4.6% were not properly counseled by the physician and 3.48% did not take medicines due to cost issues. The mean systolic blood pressure was 126 +/- 19.2 mmHg in the compliant group while it was 133 +/- 16.5 mmHg in the noncompliant group [p-value 0.004]. The mean diastolic blood pressure in the compliant group was 76 +/- 11.9 mmHg, while in the noncompliant group it was 81.9 +/- 10.9 mmHg [p-value 0.001]. Compliance to antihypertensive therapy in a tertiary care center is significantly good. Forgetfulness was the major reason for noncompliance. The mean blood pressure control was better in the compliant group

Ventricular tachycardia: a hospital perspective

To describe the etiology and outcome in patients with ventricular tachycardia in our patient population. A descriptive study. The study was conducted at the Aga Khan University Hospital from November 2002 to October 2003. Subjects and We enrolled 58 patients who presented to the emergency room with clinical and electrocardiographic evidence of ventricular tachycardia [VT] and/or who developed it during the inpatient stay at the Aga Khan University Hospital. Medical records were retrieved through the computerized data retrieval system. Patients above 18 years of age were included. Those with a pacemaker or who developed VT during electrophysiological testing were excluded. A pre-designed proforma was filled for all patients who fulfilled the inclusion criteria. All patients were worked up for etiological causes of ventricular tachycardia. Outcomes in the form of death or discharge were recorded. There were 58 patients who suffered ventricular tachycardias during the study period. These included 70.7% [42] males and 29.3% [16] females. Mean age of the patients was 57.06 +/- 11.84 years. Emergency room admissions accounted for 55.2% and ventricular tachycardia was seen in 44.8% during the inpatient stay. Unresponsiveness was the presenting symptom in 25.9%, chest pain in 24.1%, palpitations in 13.8% and ghabrahat in 12.1% patients. Myocardial ischemia was seen in 43.5% of the patients while 23.2% had cardiomyopathy, followed by 33.3% miscellaneous. Out of the patients who had myocardial ischemia [43.5%], 76.6% had non-ST elevation myocardial infarction, 20% patients had ST elevation myocardial infarction and 3.3% had unstable angina. Hemodynamic instability was noted in 50%, who subsequently required defibrillation. The mortality among these patients with VT was 13.7%. Myocardial ischemia was most commonly seen in patients with ventricular tachycardia in our group of patients. Ventricular tachycardia is associated with a significant mortality of 13.7%

Acute myocardial infarction in a young patient

Myocardial infarction [MI] is considered to be the disease of the fifth and sixth decade as seen in the West but an earlier age incidence is not infrequently encountered in the South Asian population. However, occurrence of MI in the teen-age still remains a rare happening. We are reporting a case of a teenager, who suffered a myocardial infarction with cardiogenic shock and pulmonary edema on two separate occasions with ECG and biochemical evidence of myocardial infarction. An exercise stress test done in between the two episodes was negative at a workload of 13.5 METs. A coronary angiogram done after the second event revealed normal coronary arteries and a preserved left ventricular systolic and segmental function. Except for low HDL [high density lipoprotein] and mildly raised homocysteine levels, the patient did not have other conventional or novel risk factors for coronary artery disease

Control of early morning sickness of pregnancy by acupressure technique

To evaluate the effect of acupressure wrist bands on nausea and vomiting of early pregnancy Methodology: Ninety pregnant women of gestational age between 7-12 weeks were randomly recruited for a double blind, cross over, placebo controlled trial. Women were randomly divided into two groups. Two types of bands were used i.e., pressure band and placebo band for a ten days long trial, organized in two steps of four days each and a two days wash out period in between the steps. Result: Acupressure at Neiguan point has an antiemetic effect and this effect is more than that achieved by placebo band. More than 60% positive effect was found with pressure band as compared to 30% with placebo band. Acupressure may be used to treat pregnant women suffering from early morning sickness with a success rate of more than 60% by applying pressure at P6 point