Short term clinical outcomes of Everolimus-eluting stents in patients with stable angina pectoris

Background and Objective: Everolimus-eluting stents, compared with bare metal stents, reduced the risk of restenosis in clinical trials with strict inclusion and exclusion criteria. The objective of this study was to determine the three months clinical outcomes of Everolimus Eluting Stents in patients with stable angina pectoris in Pakistani population

Methods: It was a descriptive cross-sectional study and the data was collected from Catheterization Laboratory Cardiology Department Lady Readings Hospital Peshawar. Our study included all the patients with stable coronary artery disease who had received Everolimus eluting stents from August, 2013 to April, 2014. Total study duration was 09 months. The primary end points were the rate of target vessel revascularization, myocardial infarction at three months. All those patients who received Everolimus coronary stents were recalled after three months from the index procedure and enquired about target vessel revascularization [TVR], myocardial infarction and hospitalization over the last three months. Data analysis was done using SPSS version 16

Results: Our study included 378 patients with stable ischemic heart disease who underwent revascularization with Everolimus eluting stent.These patients were followed up for a period of 3 months for target vessel revascularization [TVR] and myocardial infarction [MI]. Mean age was 57.04+/-9.307, males were [72%]. Left Anterior Descending [LAD] and Left circumflex [LCx] were the predominant vessels vascularized. Mean length of Everolimus eluting stent was 21.91+/- 4.6 while mean diameter of stent was 2.90+/-0.248. Thirteen [3.4%] patients had TVR and 14 [3.7%] patients had MI during three months follow up after PCI. TVR and MI were prevalent in patients who received longer Everolimus stents as compared to those who received shorter stents at three months, and the difference between the two was statistically significant

Conclusion: Short-term results from this study suggest that real-world outcomes among 378 patients are comparable to those reported in other registries and trials, and safety outcomes as measured by rates of TVR, MI were low. The long-term safety of Everolimus-eluting stents needs to be ascertained in large, randomized trials

Nonfasting Apo-lipoprotein B and triglyceride levels as a predictor of coronary heart disease in type II diabetic patients

Background and Objectives: Lipoprotein-A has been recognized as a risk factor for ischemic heart diseases. Myocardial infarction [MI] is common complication of ischemic heart disease. Diabetes play an incremental role in the development of coronary artery disease [CAD], however still there are conflicting data regarding the relationship of Lipoprotein-B and MI. We therefore wanted to evaluate the relationship of Lipo-B, MI and diabetes mellitus. Our objective was to determine the non-fasting Apo-lipoprotein B and triglycerides level among type II diabetic patients with ischemic heart disease and to compare with type II diabetic without ischemic heart disease

Methods: This was cross sectional study where two groups of patients were recruited in the study, Group-I included patient with Ischemic Heart Disease and diabetes while Group-II comprised of diabetes without Ischemic Heart Disease. Age, sex and basic demographic matching was done between the two groups. Data were collected using random sample. The comparative approach was used to see the role of diabetes in the elevation of Apo-lipoprotein B level, which is a risk factor for Ischemic heart diseases

Results: Two hundred forty eight patients [Cases: 123 Diabetic with myocardial infarction and [Control: 125 Diabetic without myocardial infarction] were included in the study. Mean Apo-B among diabetic patients with myocardial infarction was high [68.3+/-24.23 ng/ml] compared to non-cardiac patients [49.97+/-33.880 ng/ml] with a p <0.000. Marked difference was also observed in triglycerides levels where it was found very high [301.4+/-55.1 mg/dL] in patients of diabetes with myocardial infarction as compared to subjects without MI [137.7+/-84.7 mg/dL]. There was positive correlation between Apo-lipoprotein and Triglycerides [P value=039]

Conclusion: Based on the study result it was concluded that Apo-lipoprotein and triglycerides in diabetic patients with myocardial infarction, had higher levels compared to diabetic patients without Myocardial infarction and this could be a consequence of increase in age, insulin resistance and deficiency of insulin in the body. We also found positive correlation between Apolipoprotein and Triglycerides

Impact of stent length and diameter on short term clinical outcomes of drug eluting stents in patients with stable coronary artery disease

Background and Objective: The risk of restenosis and other adverse cardiovascular events with bare-metal stents have increased with smaller stent diameters and longer stent lengths. However, the exact impact of stent size on the short-term outcomes of drug-eluting stent [DES] implantations has not been much classified in Pakistani population. This study was designed to evaluate the impact of size [length and diameter] of Drug Eluting Stents on Clinical outcomes in patient with stable coronary artery disease at three months of implantation in Pakistani Population

Methods: This is a prospective study which was carried out in the Department of Cardiology, Lady Reading Hospital Peshawar from April 2011 and July 2012. All consecutive patients with stable coronary disease undergoing Percutaneous Intervention [PCI] with DES implantation at Cardiology Unit Lady Reading Hospital, were included prospectively. Clinical outcomes [Myocardial infarction [Ml], unstable angina[UA], and positive ETT] at three months stratified by 3 tertiles of stent length and diameter each, were measured in patients who underwent PCI with DES for coronary artery lesions. All patients were followed and reassessed after three months from the index procedure. Exercise Tolerance Test [ETT] was performed on every patient and recorded on proforma. Data analysis was done using SPSS software version 16

Results: A total of 376 patients were included prospectively in this study

The mean age was 57+/-9.313 years. Male patients were 271[72.1%]. Mean length of drug eluting stent was 27.313+/-7.235 mm while mean diameter of stent was 2.90+/-0.2483mm. There were slightly higher rates of Ml, U.A and positive ETT in the longest stent length tertile [>28mm] compared with the shortest stent length tertile [<22mm] at three months, but they were statistically not significant. We also observed that for DES, there was no clear relationship between stent diameter and outcome for any of the clinical outcome variables

Conclusion: In our single-center prospective study, stent length and diameter defined in tertiles, had no impact on the short-term clinical outcomes of DES in patients with stable coronary artery disease

Imaging changes after breast reconstruction with fat grafting - retrospective study of 90 breast cancer

Objective: To evaluate the breast imaging changes after fat grafting and its impact on cancer follow up

Methods: This is a retrospective observational study conducted on patients who underwent fat grafting for breast reconstruction. We reviewed mammographic and ultrasound images of patients. Fisher's exact test was used to analyze results. The level of significance was set at P < 0.05

Results: A total of ninety patients with breast cancer had fat grafting. Fifty eight patients for defects following post mastectomy reconstruction and 32 for wide local excision defects. The mean follow up was 37.4 months. Benign lumps were identified in 23/90 cases [25 percent].Mammograms were reported as BIRADS I in 21/32 cases [72 percent] and BI-RADS II in 8/32 cases [28 percent]. BI-RADs III score was reported in two patients on further follow up imaging, both were re-classified as BI-RADS II after biopsy. A total of eight patients [8.9 percent] required biopsy. No local recurrences or new cancers were observed in any patients

Conclusion: Our study suggests radiological changes after fat grafting are almost always benign with no adverse outcome on cancer follow up

Effect of cholesterol level on platelet aggregability in normal individuals

The aim of present study was to find the effect of cholesterol level on platelet aggregability in normal individuals. This study was conducted in Cardiology department, Lady Reading Hospital, Peshawar in September-October 2007. Normal individuals aged 18 years or above were randomly included. Patients who were suffering from any cardiovascular or other diseases were excluded. Those who were taking ante-platelets, anti coagulants and lipid lowering drugs were also excluded. Thus a total of 101 individuals were examined, after taking informed written consent. Fasting blood samples were taken from each patient. Total cholesterol was measured in hospital laboratory, while platelet aggregation was measured with chronolog whole-blood platelet aggregometer [WBA]. A total of 101 patients were examined. Their mean age was 51.24 +/- 8.23 years. Male were 60[59.41%] and female were 41[40.59%]. Mean platelet aggregability of these individuals was 7.87 +/- 4.40 ohms. Mean cholesterol was 163.47 +/- 20.75 mg/dl. When age was correlated with aggregability, both had a weak negative correlation. Pearson correlation coefficient was -.018 [p=0.855]. When age was correlated with cholesterol, again both have a weak negative correlation. Pearson correlation coefficient was -.152 [p=0.129]. When aggregability was correlated with cholesterol, both have a significant positive correlation. Pearson correlation coefficient was +0.269 [p=0.006]. Platelet aggregability is increased in patients with high cholesterol. These patients may need higher doses of anti platelets and more aggressive treatment of lipids to avoid vascular events

Contraception; awareness, knowledge and misconceptions regarding the combined oral contraceptive pill amongst parous women

The uptake of oral contraceptive pill as a method of contraception is very low in Pakistan with a high discontinuation rate. This study aimed to assess the knowledge of contraception seeking, married women in Pakistan about the oral contraceptive pill. Gynaecology clinic and family planning department Military hospital Rawalpindi. 1[st] Oct 2011 to 31[st] Dec 2011. 102 eligible women completed a cross-sectional survey that consisted of a detailed questionnaire which was completed by the interviewer to assess the womens' level and source of knowledge concerning the risks and benefits of the oral contraceptive pill. 102 eligible women participated in the survey. Mean age was 33 and mean parity was 4.01.Majority belonged to low income group 42[41%] and 33% had a fair socioeconomic status. Majority 35[34%] had low education level and 11[10.8%] were graduate or more. Majority 49[48%] scored intermediate on knowledge score with 33[32.5%] scoring poorly. Overall only 15% were aware of cancer preventing powers and 70% of non contraceptive virtues of the pill. Misconception rates were particularly high in this study sample with 46[45%] having high misconception scores.96.6%% of the respondents were convinced that pill leads to obesity.58[57%] of the overall subjects felt that pill use could be considered but lack of self efficacy could lead to problems with compliance. Knowledge about pill efficacy and advantages was low and misbelieve regarding safety and side effects was high. More education regarding safety and health benefits is needed to improve acceptance and compliance

Comparative analysis of type of myocardial infarction in patients with successful or unsuccessful streptokinase thrombolysis following st elevation myocardial infarction

To study the effect of thrombolytic therapy in term of success and failure on the type of ST elevation MI, using streptokinase. This was a comparative study, conducted at Department of Cardiology, Lady Reading Hospital, Peshawar, from October 2006 to October 2007. Patients with first acute myocardial infarction were divided into group A [successful thrombolysis] and group B [unsuccessful thrombolysis] using ECG criteria. Total number of patients were 200. Group A included 136 [68%] patients and group B included 64 [32%] patients. There were total 88 [44%] patients of anterior MI with 47 patients in group A and 41 patients in group B [34.6% vs 64.0%, p<0.001]. There were total 110 [55.0%] patients of inferior MI with 88 patients in group A and 22 patients in group B [64.7% vs 34.4%, p<0.001]. Lateral myocardial infarction was diagnosed in 2 [1%] patients with 1 patient each in group A and group B [0.7% vs 1.6%, p=0.583]. Anterior MI was associated with a higher rate of thromblysis failure while inferior MI and lateral wall MI was associated with a higher rate of successful thrombolysis.

Comparison of enoxaparin and dalteparin with unfractionated heparin in the treatment of non-st elevated acute coronary syndrome

Background: The term non-ST elevated Acute Coronary Syndrome [ACS] encompasses unstable Angina [USA] and non-ST segment elevated Myocardial Infarction [NSTEMI], both of which may end up in death or a fatal/non-fatal Myocardial Infarction [MI]. Unfractionated heparin [UFH] has been shown to reduce death and MI in patients with USA and NSTEMI. Of late, there has been a great interest in the role of low molecular weight heparins [LMWHs] in the two conditions and they have been found to be at least as effective as or even more effective than UFH. Methods: A total of 90 patients who presented to CCU of Khyber Teaching Hospital, Peshawar with USA or NSTEMI, from June 2008 to June 2009, were enrolled into the study. An equal number of patients were randomly assigned to one of the three arms for 5 days each: Group A received enoxaparin, group B received dalteparin and group C received UFH. The primary end points of the study were all cause mortality, STEMI, refractory USA, recurrent USA or a major bleed. The secondary end point was minor bleeding. Results: At the end of the study, there were 2 deaths each in the dalteparin and UFH group, whereas no such event was recorded in the enoxaparin group. Two patients had STEMI in the UFH group but none in the other two groups. Conclusion: LMWHs are far more superior to unfractionated heparin. Keywords: Acute Coronary Syndrome, Coronary Artery Disease, Atherosclerosis, Unstable Angina, Myocardial Infarction, Unfractionated Heparin, low-molecular weight heparin

Assessment of left ventricular systolic and diastolic function by tissue doppler imaging after acute myocardial infarction

Objective: To evaluate left ventricular systolic and diastolic function by Tissue Doppler imaging after acute myocardial infarction. Methods: It was a hospital based, prospective descriptive study, from 1st July 2010 to 31st Dec. 2010. Total of 200 patients having acute myocardial infarction underwent detailed tissue Doppler imaging [TDI] echocardiographic examination for evaluation of left ventricular systolic and diastolic function on day 3, in echocardiographic section of Govt. Lady Reading Hospital, Peshawar. Peak systolic [Sm], peak early diastolic [Em] and peak late diastolic [Am] velocities were recorded at 4 different sites of the mitral annulus. The ejection fraction and pulse wave TDI diastolic parameters were also recorded. Using SPSS version 16 data was analysed, frequencies and Mean +/- SD were determined for categorical and numerical variables, respectively. A p-value =0.05 was considered significant. Results: Total study sample was 200 patients having acute myocardial infarction [MI]. The sample was divided into 4 groups, i.e., anterior MI, inferior MI, septal MI, and lateral MI. There were 122 men and 78 women and the mean age was 42 +/- 5 SD. There was a marked reduction in Sm velocity at mitral annulus, especially at the infarction sites. The mean peak systolic velocity from 4 mitral annulus sites was well correlated with ejection fraction [p=0.0001]. Similar to systolic velocities, Em velocity was also reduced, especially at the infarction sites. The mean peak early diastolic velocity from 4 mitral annulus sites was well correlated with ejection fraction [p=0.0001]. The mean Em velocity was correlated well with isovolumic relaxation time [IVRT]. There was no correlation between mean Em velocity and deceleration time [DT]. Conclusion: Tissue Doppler Imaging is a reliable, accurate and easily reproducible modality of echocardiography. The reduced peak systolic velocity and reduced peak early diastolic velocity seems to be an expression of regionally reduced systolic and diastolic functions, respectively. While the reduced mean systolic velocity and reduced mean early diastolic velocity from 4 mitral annulus sites are expressions of globally reduced systolic and diastolic functions, respectively and were correlated well with the ejection fraction. Keywords: Tissue Doppler imaging, ejection fraction, peak systolic velocity, peak early diastolic velocity, deceleration time, isovolumic relaxation time

Changing trend of presentation of acute coronary syndrome in peshawar over the last sixteen years

Background: Once considered as disease of the affluent and developed countries, coronary artery disease is emerging as epidemic in the developing world in general and South Asia in particular. Objective: To observe the trend of presentation of acute coronary syndrome in the local population over the last 16 years. Material and Methods: Clinical audit from 1995 to 2010 was carried out in which the data was retrieved from the computerised database of the Department of Cardiology, Lady Reading Hospital Peshawar. The period was divided into four quartiles, and the data of each quartile was analyzed for the total number of admissions, the type of ACS, whether ST-elevated MI or non-ST elevated ACS [comprising unstable angina and non-STEMI], age, gender and mortality. Results: The total admissions into the unit in the first quartile [1995–1998] were 23, 827, in the second quartile [1999–2002] 29, 005, in the third quartile [2003–2006] 33, 206 and in the fourth quartile [2007–2010] were 40, 110. Total ACS brunt constituted 8340 [35%], 10, 384 [35.8%], 12, 180 [36.68%] and 14, 920 [37.2%] patients respectively. The mean age of patients was 49.70 +/- 6.4 years, 48.21 +/- 7.2 years, 47.38 +/- 7.1 years and 46.81 +/- 6.2 years respectively. Women were 2356 [28.25% of the total ACS burden] in the first quartile, increasing to 3554 [34.225%], 4817 [39.55%] and 6281 [42.1%] in the following quartiles. STEMI constituted 45.88% [3826] of the total ACS presentations in the first quartile, 47.24% [4905] in the second, 49.55% [6035] in the third and 49.87% [7440] in the last quartile. The mortality rate, however, remained constant throughout [8.4% to 8.8%]. Conclusion: An increasing trend is seen in the burden of CAD in the local population with increasing presentation as STEMI. It is also evident that CAD is occurring at younger ages and more so in the female population

Pattern of coronary artery disease with no risk factors under age 35 years

Coronary artery disease [CAD] is no more deemed to be an ailment of the 4[th] or 5[th] decade; rather an earlier age incidence is not infrequently encountered in our population. However, there are a few data regarding CAD in young adults, and much about its underlying pathology still remains undetermined. The objective of this study was to delineate the coronary arterial disease pattern in adults under the age of 35 years, but having no known coronary risk factors. This prospective study was conducted at the Cardiology Departments of all 3 public sector tertiary care hospitals in Peshawar from Jun 2008 to Dec 2009. After having excluded the traditional risk factors for CAD, patients under the age of 35 years with objective evidence of CAD were subjected to percutaneous coronary angiography. Out of a total of 104 patients, 85 [81.73%] patients were men, and 19 [18.27%] were women. The mean age of the whole group was 32.66 +/- 3.237 [22-35] years. Significant CAD [>50% diameter narrowing of at least one major coronary artery] was found in 87 [83.7%] patients while 17 [16.3%] patients had non-atherosclerotic coronary artery disease, including 12 [11.53%] patients having normal coronary arteries, 1 [1%] patient had anomalous origin of right coronary artery [RCA], 1 [1%] patient had coronary arteritis, 2 [1.92%] patients had coronary artery ectasia, and 1 [1%] patient had a myocardial bridge over left anterior descending artery [LAD]. Among the patients with significant CAD, the prevalence rate of one, two and three vessel disease was 54 [51.9%], 22 [21.2%] and 11 [10.6%] respectively. Almost 50% of the lesions occurred in LAD followed by 25% in RCA and 20% in circumflex, while only one patient [1%] had isolated significant CAD of left main coronary artery. Osteal segments were involved in 10%, proximal in 61%, mid in 21% and distal segments in 7% of the lesions. In the younger age group, CAD is mostly a disease of men, single vessel CAD predominates with LAD involvement mostly, predominant osteal to proximal segment involvement of vessels, and a much higher incidence of normal coronaries and non-obstructive CAD is met with

Comparison of effect of locally available brands of clopidogrel on platelet aggregation in patients with coronary artery disease

Anticoagulant effect of clopidogrel is of utmost importance in coronary artery disease, especially in prevention of coronary stent thrombosis. Recently, many new local brands of clopidogrel have been launched, with unknown efficacy. This study was conducted with the aim to compare two locally prepared clopidogrel brands, in terms of the effect of a loading dose of 600 mg on inhibition of platelet aggregation in patients with coronary artery disease. This was a double blind randomised study. Sample population consisting of 35 patients, were admitted at Lady Reading Hospital, Peshawar, for the management of coronary artery disease. Baseline platelet aggregation of all these patients was measured. These patients were divided in two groups randomly. Group-A consisting of 18 patients was given brand 'A' clopidogrel 600 mg, while Group-B consisting of 17 patients was give brand 'B' of clopidogrel 600 mg. The platelet aggregation of both groups was then measured at baseline, and at 2, 4, and 6 hours after taking the loading dose of 600 mg. Platelet aggregation time at baseline in Group-A was 2.61 +/- 2.28 sec. and in Group-B it was 2.24 +/- 1.52 sec. [p=0.57]. After 2 hours of clopidogrel administration in Group-A the platelet aggregation time was 1.44 +/- 1.58 sec. and in Group-B it was 1.53 +/- 1.107 sec. [p=0.85]. Platelet aggregation time after 4 hours in Group-A was 0.28 +/- 0.57 sec. and in Group-B 1.06 +/- 1.03 sec. [p=0.009], and after 6 hours it was 0.00 +/- 0.00 sec. in Group-A and in Group-B it was 0.59 +/- 0.71 sec. [p=0.001]. The two brands of clopidogrel had a significant difference in their effect on inhibition of platelet aggregation. Different brands of clopidogrel may not be equally effective

Frequency and predictors of renal artery stenosis in patients with coronary artery disease

Renal artery stenosis [RAS] is a common finding in patients undergoing coronary angiography. We designed this study to look for the frequency and any predictors of renal artery stenosis in patients with coronary artery disease [CAD]. A total of 201 consecutive patients with CAD confirmed by coronary angiography underwent an abdominal aortogram in the same sitting to screen for RAS. Patient demographics and co-morbidities were analysed for any association with RAS. Forty-one of the patients were female [20.4%]; ninety patients were hypertensive [44.8%]; 49 patients [24.4%] were smokers; 19 patients [9.5%] had renal insufficiency; 88 patients [43.8%] had high cholesterol levels; 44 patients [21.9%] were diabetic. Thirty-two patients [15.9%] had single coronary artery disease, 59 patients [29.4%] had two vessel disease, and 110 patients [54.7%] had three vessel disease. Significant renal artery stenosis [>/= 0.50% stenosis] was present in 26 patients [12.9%]. Among the variables studied, only female gender was found to be associated with a higher frequency of renal artery stenosis [24.39% vs 10.0%, p=0.01]. The frequency of renal artery stenosis in patients with coronary artery disease is 12.9%. Female gender is associated with a higher frequency of renal artery stenosis in patients with CAD

Radiofrequency catheter ablation for supraventricular tachycardias: experience at Peshawar

Drug therapy is mostly employed in the management of supraventricular tachycardias [SVTs]. However, radiofrequency catheter ablation has been found to be highly effective and safe in the treatment of SVTs. The current study is aimed at sharing our experience of 320 patients who presented with SVTs, and were treated with radiofrequency catheter ablation. This descriptive study was carried out in the Cardiac Electrophysiology Laboratory of Lady Reading Hospital, Peshawar from October 2006 to December 2009. Standard 4-wire electrophysiological study was carried out to identify the mechanism of SVT in 320 consecutive patients. Radiofrequency catheter ablation was used to interrupt the tachycardia circuit. Out of a total 320 patients who underwent electrophysiologic study, 168 were found to have atrioventricular nodal re-entry as underlying mechanism; 121 patients were having accessory pathway responsible for re-entry [of these 95 presented with orthodromic reciprocating tachycardia and 26 as antidromic reciprocating tachycardia]; 19 patients were having focal atrial tachycardia, 4 atrial fibrillation and 8 atrial flutter as the underlying cause for SVT. Radiofrequency catheter ablation was used with an overall success of 94% and a complication risk of complete AV block in 0.3% and recurrence rate of 3%. Radiofrequency catheter ablation is safe and highly effective mode of treatment of SVTs