Role of primary closure in the management of early cases of typhoid intestinal perforation, in our set up

To see the benefits of primary closure in typhoid intestinal perforation in early cases, regarding morbidity and mortality in KPK. Prospective study. Study was performed at teaching hospital of KMU-IMS, Kohat from March 2006 to March 2014. In this prospective study, we included 76 cases of single perforation of less than 24 hours in terminal ileum in typhoid fever patients, these patients had primary closure in 2 layers. Data was collected on a structured proforma. Patients' data included demography, clinical features, investigation post-operative complications, hospital stay and follow up. 76 cases were included in the study over 8 years. Mean age was 24 +/- 10.32 years with m:f ratio of 1:2.6. In 100 % cases pain abdomen, fever, tenderness in either right iliac fossa or generalized in the abdomen were observed. Widal test, Typhidot and blood culture was positive in 51 ,54 and 58 out of 76 patients in same order. Wound sepsis was a common post-operative complication 12/76 [15%] other post-operative complications were pulmonary infection, abdominal dehiscence, intra peritoneal abscesses and Intestinal haemorrhage. Mean duration of hospital stay was 13.34 +/- 4.20 days. Mortality was 1.3% Two layer primary closure is an effective procedure having good results. Both morbidity and mortality are low and associated with reasonable length of hospital admission

Culprit artery characteristics and severity of angiographic thrombus burden in primary percutaneous coronary intervention in patients presenting with ST elevation myocardial infarction

The purpose of study was to characterize culprit artery characteristics in terms of presence of thrombus burden in patients with acute myocardial infarction using prevalent parameters of thrombus estimation. Descriptive study. Adult cardiology departments of Armed Forces Institute of Cardiology / National Institute of Heart Diseases [AFIC/NIHD] from 1[st] October 2011 to 31[st] September 2012. We studied 119 patients treated with primary percutaneous coronary intervention for ST- segment myocardial infarction. Bare metal stents were used in all patients as per hospital protocol. Thrombus burden [TB] was graded [G] as GO = no thrombus, G1= possible thrombus, G2 = small [greatest dimension <, 1/2 vessel diameter [VD]], G3 = moderate [>1/2 but <2 VD], G4 large [>2 VD], G5 = unable to assess TB due to vessel occlusion. Patients with G5 were reassessed after passage of guide wire or small balloon for thrombus burden. Frequency of major adverse cardiac events [MACE]-defined as death, myocardial infarction and infarct- related artery revascularization was recorded for the pen-procedural period which was defined in our study up to 72 hours. Overall, in hospital MACE was 8.4%. Large thrombus burden is a significant predictor for mortality and MACE

Efficacy and safety of transradial approach in primary PCI for STEMI

To determine the efficacy and safety of transradial approach in primary percutanous intervention in acute ST segment elevation myocardial infarction. Descriptive study Emergency reporting [ER] department of Armed Forces Institute of Cardiology National Institute of Heart Diseases [AFIC/NIHD] from Dec 2011 to Dec 2013 Retrospective data of 354 patients had been collected through records. All the patients presented with acute myocardial infarction to emergency reporting [ER] department of Armed Forces Institute of Cardiology National Institute of Heart Diseases were included in the study. All the patients underwent primary coronary intervention through transradial route. All patients received IIB IIIA inhibitors bolus and infusion. The primary end points were procedure success and local access site hematoma and secondary end points were major bleeding requiring blood transfusion and door to balloon time. The mean age of the patient was 64 +/- 18 years, there were 251 [70.9%] males and female were 103 [29.1%]. Radial access site cannulation time was 194 +/- 22 sec and door to balloon time was 78 +/- 14 min. Procedural success was 349 [98.6%]. Forearm hematoma was noted in 4 [1.12%]. No major bleeding requiring transfusion was noted. Primary percutanous intervention [PPCI] via transradial [TRI] route in acute STEMI patients can be achieved with high success and low complications in our population. The clinical outcome is matching with local and international data

Management of patients with acute myocardial infarction complicated by ventricular septal rupture - AFIC study

The aim of this study was to report management; peri-procedural and short term results of patients hospitalized with acute myocardial infarction [MI]complicated by ventricular septal rupture [VSR] considered high risk or unfit for surgical repair at AFIC-NIHD. Quasi experimental study Adult and paediatric cardiology departments of Armed Forces Institute of Cardiology / National Institute of Heart Diseases [AFIC/NIHD] from 1[st] January 2012 to 31[st] August 2013. We included 12 patients with post myocardial infarction VSR with mean age of 59 years [41-85 years], who underwent elective transcatheter closure. The entry criteria for trans-catheter closure after initial medical stabilization was 1] patients with ventricular septal rupture up to 20 mm size with significant left to right shunting [Qp/Qs >1.5] 2] defect anatomy and location thought to be suitable for device closure or otherwise considered high risk or unfit for surgical closure. The time from the onset of infarction to the index procedure ranged between 4 to 20 days [mean 10.83 days]. There were ten patients in acute phase [2 weeks or less] and two presented in sub-acute phase [> 2 weeks]. Ten patients were in NYHA class III and one each in class II and IV. A successful device implantation occurred in all patients except in one in whom second attempt failed. The defect size ranged 4-18 mm [mean 9.25 mm] and the devices ranging from 8-22 mm [mean 13.3 mm] were implanted. The procedure time ranged from 90-140 min [mean 105 min]. In all patients Qp/Qs was more than 2 and decreased to less than two after the procedure. Six surviving patients are in NYHA class II and doing well. One patient died one hour after the procedure whereas one patient died twelve hour after the closure because of re-infarction. One patient developed another VSR leak 3 days after the procedure and device closure was attempted again but the device could not be deployed. He subsequently died awaiting surgery. Primary trans-catheter closure of post-infarction ventricular septal rupture may be an alternative to surgery in patients with suitable anatomy and high risk or unfit for surgery

Procedural outcome of primary PCI inst-segment elevation myocardial infarction at Afic and Nihd Rawalpindi - Pakistan

To determine the procedural outcome of primary percutaneous coronary interventions [PCI] in ST segment elevation myocardial infarction. A quasi-experimental study. Armed Forces Institute of Cardiology and National Institute of Heart Diseases, a tertiary care cardiac institute from November 2011 to September 2013. Total 228 patients who underwent primary percutaneous intervention [primary PCI] were included in this study. A pre designed performa was prospectively filled which included demographic and procedural variables. Procedural success and in hospital mortality were recorded. The mean age was 59 +/- 10.88 years. There were 205 [89.9%] males, 80 [35.1%] patients were found to be diabetic, 47 [20.6%] hypertensive, and 90 [39.5%] patients were smokers. Family history of ischemic heart disease was positive in 51 [22.4] patients. Anterior, inferior and lateral myocardial infarction were present in 137 [60.1%], 90 [39.5%] and 1 [0.4%] patients respectively. The Median time from the onset of symptoms to the arrival in the hospital was 122.5 +/- 142.57 and median door to balloon time was 60 +/- 22.88 min. Left anterior descending [LAD] was the commonest infarct related artery accounting for culprit artery in 138 [60.5%] followed by right coronary artery [RCA] and left circumflex artery [LCX] in 72 [31.6%] and 18 [7.9%] cases respectively. Procedural success was achieved in 222 [97.4%] patients. Six [2.6%] patients died in the hospital. High success rate with low mortality rates can be achieved in our set up. However more studies and long term follow up is required to validate our results

Role of aspiration thrombectomy in primary PCI for STEMI - myth or reality?

The objective of the study was to determine the outcome of thrombus aspiration in Primary coronary intervention [PCI] for ST elevation myocardial infarction [STEMI]. Case Series The study was carried out in Armed Forces Institute of Cardiology - National Institute of Heart Diseases [AFIC-NIHD] over a period of twelve months from January 2013 to December 2013. Data of 30 patients who underwent aspiration thrombectomy during primary PCI for STEMI by the transradial approach was collected. Inclusion criteria were chest pain suggestive of myocardial ischemia lasting longer than 30 min accompanied by ST- segment elevation or new left bundle branch block on the ECG within 12 h of symptom onset. Patients with previous CABG, cardiogenic shock or requiring TPM placement were excluded from this study. A 6F sheath was placed inside the radial artery, and cardiac catheterization was performed. Angiographic and electrocardiographic signs of myocardial reperfusion were assessed. Study endpoints included TIMI III flow and ST-segment resolution at the end of the procedure. Mean age of the patients was 52 years [range 37-77 yrs] and 63% [n= 19] were males and 37% [n=11] were females. The right radial artery was used in 90% of cases. Thrombus aspiration catheter used was 6 F Thrombuster II [70%] and Hunter [30%].There was significant improvement in markers of myocardial reperfusion with achievement of ST-segment resolution and TIMI 3 flow in 28 patients [93%]. No case of vascular complications such as major access site bleeding, vascular perforation, radial artery occlusion, forearm ischemia, compartment syndrome or MACE was observed. Thrombus aspiration [TA] is applicable in the majority of patients undergoing primary PCI for myocardial infarction with ST-segment elevation, and it improves early markers of myocardial reperfusion

Successful implantation of percutaneous left ventricular assist device [impella 2.5] in AFIC/NIHD - first time in Pakistan

Impella 2.5 is a miniaturized percutaneously inserted left ventricular assist device [LVAD] that can be placed via a retrograde approach across the aortic valve using a femoral arterial access. It helps in reducing the cardiac workload and provides circulatory assistance and protection to the myocardium and vital organs in patients with severe left ventricular systolic dysfunction. It has been used in patients with heart failure, cardiogenic shock [CS], and high-risk patients undergoing percutaneous intervention [PCI].We report here our experience using an Impella 2.5 catheter in a patient with high-risk percutaneous intervention [PCI]

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

Procedural analysis of patients with stent thrombosis [ST]

To analyze the procedural details of patients presenting as ST and undergoing PCI. Descriptive study. Armed Forces Institute of Cardiology - National Institute of Heart Diseases [AFIC-NIHD] from Jan 2007 to Dec 2010. A descriptive, single center study done at AFIC Rawalpindi from Jan 2007 to Dec 2010. During this period patients with prior stenting who presented to AFIC E/R with acute ischaemic symptoms with ECG changes and had angiographically confirmed ST were studied. Their procedural details [index PCI and ST procedure] were analyzed. Over this four year study period, 7694 coronary angioplasties were carried out and 12871 stents [10633 DES and 2238 BMS] were implanted. Amongst these, 32 patients [28 males and 4 females] later had angiographically confirmed ST and were treated with PCI. Mean age was 51.57 years. Dual antiplatelet therapy [DAPT] non-compliance was not a contributory factor in our study. Coronary distribution involved in ST included 20 cases of LAD, 7 of LCX and 5 of RCA territory. Thirteen [40%] patients had overlapping stents, 11 [34.4%] had direct stenting. Average diameter of stents with ST was 2.86 mm and the average length was 24.17 mm. Incidence of ST was higher in BMS as compared to DES [p0.003]. Of these 32 patients, 14 [43.75%] were treated with further stenting whereas 18 [56.25%] underwent POBA only. Telephonic follow up after second PCI was possible in only 15 cases, out of which five [33.33%] deaths were reported on the day of thrombotic procedure. ST has a high mortality and there was an overall higher frequency of ST in BMS compared to DES. Acute and subacute ST were mainly related to BMS whereas late ST was more common in DES. However PCI technique i.e direct stenting and overlapping stents, was a major predictor of stent thrombosis

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

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

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

Effect of post-myocardial infarction streptokinase [SK] therapy, on myocardial viability - evaluation with thallium- 201 single photon emission computed tomography [TL-201 SPECT]

To evaluate the effect of post-myocardial infarction Streptokinase therapy on myocardial viability, employing Thallium-201 single photon emission computed tomography [TL-201 SPECT]. Retrospective, experimental study. The Nuclear Cardiology Department, Armed forces Institute of Cardiology / National Institute of Heart Diseases, Rawalpindi, from 1[st] April 2009 to 31[st] October 2009. Male patients, who had suffered from acute myocardial infarction [AMI], in an area supplied by the left anterior descending [LAD] artery, had infarct-related electrocardiogram [ECG] changes and received or did not receive Streptokinase therapy, were included. Those with a normal ECG, or history of revascularization, or non-ST elevation MI, or more than on MIs, were excluded. The patients were divided into groups 1 [who received Streptokinase] and 2 [who did not receive Streptokinase]. Each group contained 42 patients and all underwent scintigraphic viability study through intravenous injection of 3.0 mCi [123 MBq] of TL-201, followed by rest-redistribution SPECT imaging on a dual head, dedicated cardiac gamma camera system [Philips Cardio MD [registered sign]]. Emory's cardiac toolbox [registered sign] and AutoQUANT [registered sign] were used for data processing and quantitative estimation of viable myocardium. Empirical scores from 0 to 2 were assigned to each of the scans, in the order of increasing viability, and these were compared across the two groups. Group 1 contained 42 patients [age range = 38 to 80 years, mean = 53.98 +/- 11.26 years], in whom empirical viability scoring was done. Score 0 was seen in 2 patients, score 1 was seen in 15 patients and score 2 was seen in 25 patients from this group. Group 2 also contained 42 patients [age range = 38 to 80 years, mean = 56.71 +/- 9.05 years], in whom viability score of 0 was seen in 3 patients, score 1 was seen in 11 patients and score 2 was seen in 28 patients from this group. Age difference between the two groups was statistically insignificant [p = 0.223]. The myocardial viability results analysed by 3 x 2 contingency table applying chi- square [X[2]] test also showed no significant difference between groups 1 and 2 [p= 0.611]. This study did not find any significant difference in myocardial viability - post- myocardial infarction - in patients who received or did not receive Streptokinase therapy

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

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

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

Role of distal protection device in prevention of distal embolization during PCI of saphenous vein grafts at AFIC/NIHD; an experience of 26 cases

Failure of Saphenous vein grafts [SVG], an almost universally used conduit in coronary artery bypass grafting [CABG] patients, is a common problem. Distal embolization during percutaneous coronary intervention [PCI] of SVG can have serious consequences. Use of embolization protection devices [EPD] has resulted in lesser incidence of such complications. Spider Rx is a distal protection filter device, experience and results of use of this device are presented. This study was conducted at the interventional cardiology department of Armed Forces Institute of Cardiology National Institute of Heart Diseases during a period from Feb 2007 to May 2009. All patients having indications for PCI, angina CCS class I to IV, to vein grafts more than three years after CABG was included. Patients with acute myocardial infarction and totally occluded SVGs were excluded. No flow or slow flow phenomenon and pre and post procedure CKMB, at six and twenty four hours, levels were measured. Spider RX distal embolization protection is easy to use and its use resulted in embolization protection comparable to that of other devices reported in literature

Prevalence of cad in females with hypertension and diabetes mellitus presenting with chest

Objective: to analyze the prevalence of coronary artery disease [CAD] in hypertensive and diabetic Pakistani female population admitted to cardiac ward in a tertiary care cardiac hospital [AFIC-NIHD] Rawalpindi] with chest pain suspected of cardiac origin

Design: prospective observational study

Place of study: armed Forces Institute of Cardiology-NIHD Rawalpindi, Pakistan

Patients and methods: we studied 100 consecutive female patients admitted from Jan 2005 onwards, to cardiac female ward of AFIC with chest pain suspected of cardiac origin and then undergoing diagnostic coronary angiography The patient population included cases admitted directly from emergency reception, from OPD and those admitted to CCU but kept in ward due to non-availability of beds in CCU. We recorded the ages, blood pressures, blood sugar levels and angiographic findings

Results: 100 female patients were studied with a mean age of 56 years [range 33-76 years]. Out of these 100 patients, 8 [8%] had only diabetes mellitus, 39 [39%] had only hypertension and 27[27%] patients had combined diabetes mellitus and hypertension while 26 patients [26%] did not have any of these risk factors. Coronary angiogram revealed that 28% patients had normal coronary arteries while 72% had coronary artery disease [CAD]. In our study out of 72 patients who had angiographic ally proven CAD 4 pt's [5.5%] were between 30 and 40 year of age, 11 [15%] between 41 and 50 years, 25[35%] between 51 and 60 years, 24[33%] between 61 and 70 years and another 8 pt's [1.1%] were over 70 years of age. All eight diabetics [100%] had CAD while 26 out of 39 hypertensives [67%] had CAD. Out of 27 patients who had both DM and HTN, 23 [85%] had angiographic ally proven CAD. Out of 26 patients who neither had DM nor HTN, 15 [58%] still had CAD

Conclusion: we conclude that increasing age along with hypertension and diabetes mellitus are the most significant risk factors for CAD in Pakistani females

Deployment of inferior vena cava filters; efficacy and safety

Objective: to study the patient's profile, indications and procedural success of placement of Inferior Vena Cava [IVC] filters at AFIC/NIHD Rawalpindi, Pakistan

Design: a retrospective observational study

Place and Duration of Study: the patients were studied in the department of Interventional Cardiology of AFIC/NIHD from May 2004 to Jun 2005

Material and Methods: 16 patients of either sex who revealed clinical and investigative evidence of recurrent pulmonary embolism [PE] due to deep vein thrombosis [DVT] of lower limbs were selected. All efforts including history, physical examination and laboratory investigations were carried out in order to ascertain the etiology. A note was made of the associated conditions, past and family history of DVT and PE. IVC filter was deployed through femoral vein in all patients as a lifesaving treatment modality. The procedure was uncomplicated and all patients had smooth post procedural recovery

Results: through femoral vein, IVC filters [Trap Ease Cordis J and J] were successfully deployed below the renal veins. In one patient, another filter was deployed immediately below the tricuspid valve

Conclusion: IVC filter placement is a simple, safe and effective procedure in stabilizing patients who have recurrent pulmonary embolism

Hyperventilatory capacity - a predictor of altitude sickness

The aim of the study was to document link between hyperventilatory capacity and risk for developing acute mountain sickness [AMS]. This study was carried out at Karakorum Mountain ranges [Northern areas of Pakistan] from March till July 2004. 54 healthy male subjects were enrolled in this study. Arterial oxygen saturation [SpO[2]] of the subjects was measured by the pulse oximeter at rest and after 1 minute of voluntary hyperventilation at an altitude of 2833 meters. Symptoms of acute mountain sickness [AMS] were recorded on a questionnaire by using the Lake Louise consensus scoring system 24 hours after ascent to high altitude. Mean pre hyperventilation oxygen saturation [SpO[2]] was 94.07 + 0.26% whereas SpO2 after 01 minute of hyperventilation was 98.61 + 0.14% that was significantly increased [p<0.001]. The mean increase in percent oxygen saturation of hemoglobin after one minute of hyperventilation [hyperventilatory capacity] for the study group was 4.61 + 0.24% while the mean symptom score was 2.06 + 0.26. It was noted that 19 [35.2%] subjects did not develop AMS whereas 34[63.0%] subjects had mild AMS and only one subject developed moderate AMS. There was no case of severe AMS. The data reveals significant [P<0.01] association between hyperventilatory capacity and development of the symptoms of AMS [r= - 0.664]. It is evident that individuals with greater hyperventilatory capacity manifest less number of symptoms of mountain sickness. It is concluded that post hyperventilation increase in oxygen saturation at lower altitude may help to predict the susceptibility of subjects to develop high altitude sickness