Association between quantitative troponin T levels and angiographic findings in unstable angina and non st elevation myocardial infarction

Background: Patients with elevated Troponin T levels had more complex lesion characteristics in baseline coronary angiogram. Cardiac troponin T positive patients had predominantly multi vessel disease, greater coronary narrowing and frequently complex lesion morphology

Objective: To determine the association between quantitative Troponin T levels and angiographic findings in unstable angina/non ST elevation MI

Patient and Methods: The study population was composed of 210 consecutive patients with clinical diagnosis of unstable angina, admitted at Punjab Institute of Cardiology, Lahore. Samples for troponin T levels were obtained 6-12 hours after the onset of chest pain. Patients were grouped into quartiles according to the level of troponin T measured. Coronary angiography was performed in every patients before discharge. All coronary angiograms were evaluated without knowledge of clinical or Troponin T status

Results: The mean age was 53.3 +/- 10.49. 165[76%] were males. Left main disease [LMD] was present in 13.3% [n=28]. Three vessels, two vessels and single vessel disease was present as 41.4%, 27.1% and 26.7% respectively. Normal coronary angiogram was noted in 4.8%. More than 70% luminal narrowing at least in 1 vessel was present in 95.2% of the patients, 3.3% has calcification, 67.6% has occlusion and 6.2% had visible thrombus as well

Conclusion: Our study has demonstrated that there was a significant association between elevated quantitative Troponin T levels and number of diseased vessels. Therefore, Troponin T positive patients should be evaluated by coronary angiography to know the severity of the disease

Influence of circadian variations on onset and in-hospital outcome of first acute myocardial infarction

To evaluate the influence of circadian variations on the onset and in-hospital outcome of first acute myocardial infarction [AMI]. After fulfilling the inclusion criteria 425 patients presenting with new onset acute myocardial infarction were studied. The study patients were divided into 4 groups according to time of onset of symptoms. Group I consisted of 67[15.8%] patients presenting during 0-6 hours interval, Group II 118[27.7%] patients presenting during 6:0l-12 hours, Group III 144[33.9%] patients presenting in 12:01-18 hours and Group IV comprised of 96[22.6%] patients having onset of AM1 during 18:0l-24 hours. Cardiovascular risk factors and in-hospital outcome were compared between the groups by applying Chi Square test. Two peaks of onset of symptom were observed, first between 12:0l-18 hours 144[33.9%] patients and the second between 6:0l-12 hours 118[27.7%] patients. The trough was early morning time 0-6 hours when only 67[15.8%] patients had acute MI. Mean age of the study population was 54.5 +/- 12.3 years. There were 337[79.3%] males and 88[20.7%] females. There were 114[26.8%] diabetics, 138[32.5%] hypertensives and 215[50.6%] smokers. Majority of patients 168[39.5%] presented 3-6 hours after the onset of symptoms. Overall 100[23.5%] patients presented to the hospital within 3 hours of onset of symptoms. Overall 173[40.7%] patients had anterior wall myocardial infarction followed by Anterospetal wall myocardial infarction in 147[34.6%] patients. In Group IV patients there was more 9[6.3%] tendency of presenting in advanced Killip class followed by Group I1 7[5.9%] and 4[2.8%] in Group 111 p<0.485. Overall 201[47.3%] patients received streptokinase therapy. Overall in-hospital mortality was 62[14.5%], mortality was higher 22[18.6%] in Group 11, followed by 14[14.6% in Group IV, 19[13.2%] in Group III and 8[11.9%] in Group I p<0.113. Left ventricular failure was the common cause 45[10.6%] of in-hospital mortality. The onset time of AMI has bimodal appearance with an early peak at 12:0l-18 hours and a second lesser peak at 6:0l-12 hours. In-hospital mortality was higher in patients presenting between 6:0l-12 hours because of more frequency of advanced killip class at the time of presentation in this Group

Usefulness of st segment depression limited to the recovery phase of exercise stress test

To determine the diagnostic value of ST segment depression limited to recovery phase of Exercise Tolerance Test [ETT]. An observational cross-sectional study. The study was carried out at Punjab Institute of Cardiology, Lahore, from March to August 2007 for a period of 6 months. In this study, 100 patients were selected with purposive non-probability sampling technique and were divided into two groups, group A having ST segment depression during exercise phase of ETT, and group B having ST segment depression only in recovery phase after undergoing ETT according to Bruce protocol. The patients were subjected to coronary angiography later on. The chi-square or Fischer's exact test of significance was applied at 0.05 level of significance to compare the coronary angiographic finding between two groups. Diagnostic value of ST segment depression was computed keeping angiographic finding as gold standard. There were no major differences between the two groups regarding angiographic finding. Significant coronary artery stenosis [>50% narrowing] was found in 68 [93%] patients of group A and 23 [85%] patients of group B [p=0.18]. Three vessel disease was found in 30 [41%] patients in group and 7 [26%] patients in group B [p=0.08]. Left main stem disease was found in 5 [6.8%] patients of group A and 1 [3.7%] patient of group B. Normal coronaries were found in 6% of patients among group A and 14% of patients among group B[p=0.12]. Specificity, sensitivity, Positive Predictive Value [PPV] and Negative Predictive Value [NPV] of ST segment depression in recovery phase was 55, 25, 85 and 6 percent respectively [95%Cl; 1.16-2.25]. In patients undergoing exercise stress test, ST segment depression occurring only in recovery phase of ETT has a diagnostic value largely comparable with that of ST segment depression induced during exercise phase of ETT. Thus careful evaluation of ST segment depression occurring only in recovery phase may add significantly to the clinical information derived from the results of ETT

Coronary artery disease; pattern of clinical and angiographic findings in young males

This study was designed to evaluate the pattern of clinical presentation, risk factors and angiographic findings in young males representing with acute myocardial infarction [AMI]. This cross-sectional descriptive study was conducted at the Cardiology Department, Punjab Institute of Cardiology, Lahore from May 2005 till February 2006. After fulfilling the inclusion criteria 200 male patients

Localization of accessory pathways according to AP Fitzpatrick ECG criteria in patents with Wolff-Parkinson-White Syndrome in our population

The objective of this prospective study was to localize the accessory pathways [AP] in patients with Wolff Parkinson White syndrome [WPW] using algorithm laid down by AP Fitzpatrick, in our population. 500 consecutive patients with the most pre-excited 12 lead ECG in sinus rhythm visiting emergency department were analyzed. Delta wave frontal plane vector, polarity in VI, height in leads I, II and III and sum of delta waves polarities in II, III and aVF. R wave size in leads I, II, III, VI; R/S ratio in leads I, aVL, V1; S wave size in V1 and QRS axis and duration; QRS horizontal plane transition zone were the main EGG variables used to localize the accessory pathway. The most discriminative characteristics were combined to form the following steps. Step 1, location of the transition lead [R and S waves are equiphasic] in the chest leads and R>S wave by > or < 1mV, this divides the pathways into right and left sided. Step 2, sum of delta waves polarities in leads II, III and aVF, this divides the pathways into Septal or lateral locations. Among 500 patients, 409[81.8%] patients had WPW syndrome while 91[18.2%] patients had WPW pattern, Mean age of study population was 34.23 +/- 12.5 years. There were 327[65.4%] males and 173[34.6%] females with a male to female ratio of 3:1. Three hundred [60%] patients had right sided accessory pathways while 190[38%] had left sided AP. Among right sided AP Right posteroseptal pathway was the most common location 87[28.8%] comprising [17.7%] of total population. Left antero-lateral pathway was the most common location not only among left sided pathways 95[50%] but also in total study population [19.4%]. The AP Fitzpatrick ECG criteria for localization of the accessory pathways on surface ECG is an excellent non invasive method for determination of the site of accessory pathway with very high sensitivity, specificity and predictive accuracy. It is an excellent tool before planning invasive electrophysiological study in WPW syndrome

Metabolic syndrome in patients with ischemic heart disease

To determine the frequency of metabolic syndrome in patients with Ischemic Heart Disease [IHD]. Cross-sectional, descriptive study. Cardiology Department of Punjab Institute of Cardiology, Lahore, from June 2006 to June 2007. A total of 100 subjects with ischemic heart disease, fulfilling the inclusion criteria, were enrolled in the study. Demographic data [age and gender] and the 5 component conditions of the metabolic syndrome were noted. Subjects were physically assessed for the abdominal obesity, based on waist circumference. Fasting blood samples for glucose and lipid profile in first 24 hours after acute coronary insult were drawn and tested in central laboratory. Variables were processed for descriptive statistics. In this study population, 68% were male and 32% were female with mean age of 52 +/- 13.6 years in men and 56 +/- 12.5 years in women. Frequency of metabolic syndrome was 32% in men and 28% in women. It increased with age. The highest rate of metabolic syndrome was in men diagnosed as STEMI [odds ratio: 3.39, 95% Cl=1.36-8.41]. Frequency of metabolic syndrome was high among the patients with IHD. It supports the potential for preventive efforts in persons with high-risk of IHD

Mid-term results of endarterectomy in advanced coronary artery disease

To compare the angiographic results of patency of endarterectomized vessels vs non endarterectomized vessels and their associated grafts after one year of coronary artery bypass grafting. Study was conducted at the Cardiology Department, Punjab Institute of Cardiology, Jail Road, Lahore from 1st October 2004 till 30th July 2006. Consecutive patients were included in the study after undergoing coronary artery bypass grafting and coronary endarterectomy in the hospital. All the patients included in the study were followed up prospectively after 1, 3, 6, 9 and 12 months of coronary artery bypass grafting and angiographic studies were performed at the end of 1 year of follow-up. The mean age of the study population was 55.8 +/- 10.1 years. There were 64 [85.3%] males and 11 [14.7%] females. Hypertension and family history of ischemic heart disease both were present in 40 [53.3%] patients. Diabetes mellitus was present in 23 [30.7%] patients while 38 [50.6%] patients were smokers. A total of 266 grafts were applied to these 75 patients. Of these 181 grafts wee applied to non-endarterectomized vessels and 85 to endarterectomized vessels. Follow-up angiography revealed 6 [3.3%] blocked grafts in a total of 181 non endarterectomized vessels. Of the 85 endarterectomized vessels, 4 [4.7%] grafts with their parent vessels were blocked. Graft patency was not significantly different between endarterectomized and non-endarterectomized grafts [95.3% vs 96.6%] p<0.11. All patients receiving LIMA to LAD had patent grafts at the end of one year. The blocked grafts were all SVGs

Significance of perfusion defects on dipyridamole thallium cardiac SPECT in patients with left bundle branch block

Left Bundle Branch Block [LBBB] is a known cause of false positive results in myocardial perfusion studies. We aimed at investigation of correlation between degree of severity of perfusion defect on cardiac Single Photon Emission Computed Tomography [SPECT] and presence of coronary artery disease on angiography in patients with LBBB. This was an analytical study and was carried out at Department of Nuclear Cardiology and Department of Cardiac Catheterisation of Punjab Institute of Cardiology, Lahore from January 2007 to April 2007. In this study patients having LBBB without known coronary artery disease [CAD] referred for myocardial perfusion studies to the Nuclear Cardiology Department from outpatient, indoor and emergency departments were included. Thallium201 stress/rest Single-Photon Emission Tomography [SPECT] acquisition scanning was performed. The myocardial perfusion pattern was classified as normal, fixed defect and reversible defect. Coronary angiography was used to confirm CAD only in patients with abnormal scan. Thirty consecutive patients having LBBB were studied. All patients underwent myocardial perfusion imaging using dipyridamole pharmacologic stress. Fourteen patients [47%] revealed normal Thallium201 uptake and distribution at the septum. Reversible defects were noted in 13 [43%] patients. Fixed defects were noted in 3 [10%] patients. Among four patients with mild perfusion defects only 1 [25%] had significant coronary artery disease. In patients with moderate perfusion defects, coronary angiogram was positive for significant coronary artery disease in 1 [33%] patient. In six patients having severe perfusion defects significant coronary artery disease was noted in 5 [83%] patients. All patients with fixed defects had significant coronary artery disease. False positive studies were found to be significantly greater in patients with reversible defects particularly with mild to moderate defects. Conclusions: Patients with left bundle branch block showing moderate to severe reversible perfusion defects on dipyridamole thallium cardiac SPECT have high likelihood of coronary artery disease

Percutaneous transvenous mitral commissurotomy; outcome of in patients of mitral stenosis

To compare the clinical, echocardiographic and angiographic variables after PTMC in patients of mitral stenosis having echo score < 8 and >/= 8. Cardiology ward and echocardiography department of the Punjab Institute of Cardiology, Lahore. The study was conducted from 15[th] of January 2006 till 30[th] of July 2006. It was a comparative study. Two hundred consecutive patients of mitral stenosis undergoing PTMC were studied. Patients were divided in to two groups. Group I consisted of patient having echo score <8, while Group II contained patients having echo score >=8. The immediate clinical follow-up of 200 patients who underwent PTMC procedure was studied. Patients were divided into 2 groups, Echo-Sc <8 [n=136] and Echo-Sc >/= 8 [n=64]. PTMC resulted in an increase in mitral valve area from 1.0 +/- 0.3 to 2.0 +/- 0.6 cm[2] in patients with Echo-Sc<8 and from 0.8 +/- 0.3 to 1.6 +/- 0.6 cm[2] in patients with Echo-Sc >/= 8 [P<0.0001]. Procedural success was 83.5% for the overall group, with patients with Echo-Sc <8 having a higher procedural success [93.4% versus 62.5%; P<0.0001]. Thirty three [16.5%] patients had unsuccessful procedures. There was 1 [0.5%] in-hospital death. Severe post- PTMC MR [>/= 3 grade] occurred in 19 [9.4%] patients, with grade III in 12 [6%] and grade IV in 7 [3.5%]. Emergent MVR was required in 3 [1.5%] of 200 patients. Pericardial tamponade occurred in 2 [1%] patients. Thromboembolic events [stroke] occurred in 2 [1%] patients in the overall population. Finally 1 [0.5%] patient developed complete atrioventricular block. Patients with echo score less than 8 have a favourable outcome in terms of procedural success and post procedure complications as compared to patients with echo score >/= 8

In hospital outcome of acute myocardial infarction [ST segment elevation type] in diabetics and non diabetics

To evaluate the in-hospital mortality and complications of acute myocardial infarction in diabetic and nondiabetic patients. Descriptive study. Coronary Care Unit and Cardiology Ward of Nishtar Hospital, Multan from 1st October 2002 till 15th May 2003. Four hundred and forty-eight [448] consecutive patients who fulfilled the inclusion criteria were studied while they were admitted to the hospital. Patients were divided into two groups of diabetics and non-diabetics depending on the presence of diabetes mellitus. In-hospital mortality and complications were compared between the two groups by Chi-square method. Diabetic patients presented in more advanced Killip class as 32[26.7%] patients presented in Killip class II, 13[10.8%] patients presented in Killip class III and 6[5%] patients presented in Killip class IV. In the non-diabetic group, 68[20.7%], 24[7.3%] and 11[3.4%] patients presented in these Killip classes respectively [p<0.042]. The total in-hospital mortality was 17%. Mortality was 28[23.3%] in diabetics and 48[14.6%] in non-diabetics [p<0.03]. In-hospital mortality was almost double in diabetics as compared to non-diabetics. Mechanical complications were observed in 42[35%] patients in diabetic group and 80[24.4%] patients in non-diabetic group. Left ventricular failure was the most commonly observed mechanical complication. Electrical complications were observed in 84[70%] diabetic and 162[49.4%] non-diabetic patients [p<0.205]. In patients with acute myocardial infarction, presence of diabetes mellitus was associated with worse inhospital outcome leading to increased mortality and complications as compared to non-diabetic patients