Areca Nut Chewing and the Risk of Re-hospitalization and Mortality Among Patients With Acute Coronary Syndrome in Pakistan / 예방의학회지

OBJECTIVES: Areca nut is widely consumed in many parts of the world, especially in South and Southeast Asia, where cardiovascular disease (CVD) is also a huge burden. Among the forms of CVD, acute coronary syndrome (ACS) is a major cause of mortality and morbidity. Research has shown areca nut chewing to be associated with diabetes, hypertension, oropharyngeal and esophageal cancers, and CVD, but little is known about mortality and re-hospitalization secondary to ACS among areca nut users and non-users. METHODS: A prospective cohort was studied to quantify the effect of areca nut chewing on patients with newly diagnosed ACS by categorizing the study population into exposed and non-exposed groups according to baseline chewing status. Cox proportional hazards models were used to examine the associations of areca nut chewing with the risk of re-hospitalization and 30-day mortality secondary to ACS. RESULTS: Of the 384 ACS patients, 49.5% (n=190) were areca users. During 1-month of follow-up, 20.3% (n=78) deaths and 25.1% (n=96) re-hospitalizations occurred. A higher risk of re-hospitalization was found (adjusted hazard ratio [aHR], 2.05; 95% confidence interval [CI], 1.29 to 3.27; p=0.002) in areca users than in non-users. Moreover, patients with severe disease were at a significantly higher risk of 30-day mortality (aHR, 2.77; 95% CI, 1.67 to 4.59; p < 0.001) and re-hospitalization (aHR, 2.72; 95% CI, 1.73 to 4.26; p < 0.001). CONCLUSIONS: The 30-day re-hospitalization rate among ACS patients was found to be significantly higher in areca users and individuals with severe disease. These findings suggest that screening for a history of areca nut chewing may help to identify patients at a high risk for re-hospitalization due to secondary events.

Imbalances of Pro-inflammatory cytokines in myocardial infarction patients

To assess levels of Interleukin-1 Beta and CRP, in Diabetic and Non-diabetic Myocardial Infarction patients, prior to and post angioplasty. 200 patients were recruited in the study. MI patients between the age of 40 and 60 years.Patients came to NICVD with complaints of chest pain, positive Troponin T test and ECG was the confirmatory test for MI. They were divided into 2 groups 100 patients each. First group comprised of MI patients without DMT-II and second group comprised of MI patients with DMT-II. Serum triglycerides, cholesterol, LDL and HDL, FBS, by enzymatic kits, Insulin by RIA. HbA1C, Interleukin-1 Beta and CRP by ELIZA. Interleukin1Beta and CRP were significantly higher [P<0.001] in patients at the time of the infarction, prior to angioplasty as compared post angioplasty levels in both groups, which indicate their importance in development of ischemia and MI. FBS and Insulin were significantly higher [P<0.001], while HDL and HbA1C were significantly lower [P<0.001] in MI without DMT-II when compared to MI with DMT-II. BMI, SBP pressure were significantly higher [P<0.001] in MI patients with DMT-II when compared with MI patients without DMT-II. Interleukin1Beta and CRP were found to be significantly higher prior to angioplasty as compared to post angioplasty levels in both groups which confirms their role in development of ischemia and MI

Endovascular treatment of carotid-internal jugular venous fistula in a bomb blast victim

Carotid-internal jugular venous fistula is one of the rarest presentations among victims of bomb blast injuries. Treatment of such fistula is open surgery with high mortality and morbidity. Endovascular treatment with covered stent seems to have an optimal result with low complications. We present a case report of a bomb blast victim having carotid-jugular venous fistula with hemodynamic compromise. The patient was successfully managed with endovascular graft stent. There was an optimal result with no immediate and long-term complications

Regression of right ventricular systolic pressure after successful percutaneous mitral commissurotomy in patients with isolated severe mitral stenosis

Objective: To know the regression of right ventricular pressure after successful percutaneous transluminalmitral commissurotomy [PTMC] in patients with severe isolated mitral stenosis

Methods: This descriptive study was performed in inpatient and outpatient department of National Institute of Cardiovascular Disease from 1[st] February 2016 to 31[st] August 2016. Echocardiography of all patients with successful PTMC were recorded 24 hours and 06 months following PTMC to see for Regression of right ventricular pressure along with other baseline echocardiographic parameters

Results: A total of 99 patients with severe isolated mitral stenosis who had undergone successful PTMC were studied. Females were 65[65.7%] and males 34[34.3%]. Mean age was 27.44 +/- 6.26 years. TTE performed before and after PTMC showed significant difference in mean mitral valve area [0.89cm +/- 0.089cm[2] vs. 1.68 +/- 0.128 cm[2], p valve <0.001] and mean left atrial diameter [4.66 +/- .82cm vs. 4.46 +/- 0.65cm]. Mean mitral valve gradient pre PTMC was significantly higher [16.38 +/- 2.51 mm of Hg] than that of post PTMC 24 hours [4.75 +/- 1.31 mm of Hg] and Post PTMC 06 months [5.22 +/- 1.21 mm of Hg], p valve <0.001. Mean right ventricular systolic pressure [RVSP] pre PTMC was significantly higher 62.3 +/- 10.91 mm of Hg than that of post PTMC 24 hour's 57.51 +/- 9.67 mm of Hg and post PTMC 06 moths 46.49 +/- 7.8mm of Hg, p value 0.001. Mean LVEF 50.14 +/- 5.82

Conclusion: There was a significant regression of right ventricular pressure following successful PTMC in mid-term [06 months] follow up of severe isolated mitral stenosis patients

Endovascular treatment of a post catheterization pseudoaneurysm: a stitch in time saves nine

External iliac artery [EIA] pseudoaneurysms are a well-known complication after arterial catheterization procedures. Most develop as a result of high femoral puncture. Small asymptomatic pseudoaneurysms are usually of no consequence but large symptomatic pseudoaneurysm carries a significant risk of rupture with serious life-threatening consequences and needs to be treated. We report here a case of EIA pseudoaneurysm in a 60 year old male patient after a cardiac catheterization procedure. CT angiography demonstrated a large pseudoaneurysm arising from the EIA and compressing the urinary bladder. Patient complained of abdominal pain and felt dizzy and required transfusions due to rapidly developing anaemia secondary to blood loss. Conventional angiography revealed free extravasation of contrast from the EIA. Percutaneous intervention through femoral access was performed by deploying a covered stent which effectively sealed off the perforation site with no evidence of contrast extravasation

Exploring the protein-protein interaction networks related to hepatitis C virus

Hepatitis C virus [HCV] stands as a health problem experienced across the globe leading to chronic or acute liver disease such as cirrhosis, hepatocellular carcinoma and various others. It is a complex disease with extensive genetic heterogeneity with little known about the interactions of complex intra- and intercellular processes. The evolving tools in the application of network science to identify diseases have paved a way for the study of complex diseases at system level. This study focuses on identifying the significant proteins and the biological regulatory pathways involved in hepatitis C virus and performing topological analysis of the PPIs derived by the proteins encoded by the susceptible genes in order to look for the molecular connectivity between these pathways

Efficacy of intracoronary bolus administration of tiroflban in acute coronary syndrome patients with no-reflow phenomenon during percutaneous coronary intervention [PCI]

Currently in acute coronary syndrome, PCI is most common strategy. No-reflow phenomenon [NR] is one of serious complication. Aim of this study was to evaluate role of intracoronary bolus administration of tiroflban in acute coronary syndrome patients with no-reflow during PCI. It is prospective and observational study. It is multicenter study, conducted in Karachi, Pakistan from August 2011 to July 2013. Total of 62 patients of acute coronary syndrome underwent for PCI and developed no-reflow, received intracoronary bolus tiroflban were included. The angiographic definition of successful reperfusion should include both TIMI 3 flow as well as MBG 2 or 3. No-reflow, assesed by thrombolysis in myocardial infarction [TIMI] flow and myocardial blush grade [MBG] during treatment. Data were entered and analyzed using SPSS-16 software. Statistical significance was defined as p-value <0.05. Out of 62 patients, 43 were males .The mean age was 51 +/- 13, range from 37 to 70 years. TIMI flow 1 and 11 seen in 17, 37 patients while MBG 1 and 11 seen in 20 and 33 patients before intracoronary bolus administration of tiroflban. After bolus administration of tiroflban, TIMI flow 111 was seen in 61[98.387 %] out of 62 patients while MBG 11 and 111 was also noted in 61[98.387 %] out of 62 patients. It showed better Thrombolysis In Myocardial Infarction flow grades and TIMI myocardial perfusion grades [OR 0. 22, 95% CI 0 .12 -0 .39, p-value <0.001] immediately after intracoronary bolus administration of tiroflban in-reflow phenomenon patients during PCI. In patients with ACS, Intracoronary bolus adminstration of tiroflban is effective drug to improve no-reflow during percutaneous coronary intervention especially when patient blood pressure is at lower-side

Glomerular filtration rate rather than serum creatinine should be used for recognizing patients at risk for development of contrast induced nephropathy

Serum Creatinine [SCr], widely used for renal function assessment is not an accurate measurement. SCr can be within normal range even when there is substantial nephropathy. The objective was to observe the incidence of contrast induced nephropathy [CIN] with normal SCr and low glomerular filtration rate [GFR]. This was a cross-sectional, observational study involving patients undergoing coronary angioplasty. During a period of 6 months, 64 patients having SCr ? 1.4mg/dl and a GFR of < 80ml/min were selected who underwent elective coronary angioplasty. SCr was measured again after 48 hours of the procedure. CIN was defined as a > 25% increase in SCr from the preprocedure level. For statistical analysis, SPSS version 10 was used to calculate one way Anova was used for comparing variables between CIN and No-CIN groups, while paired t-test was applied for comparison between pre and post procedure SCr. Out of 64 patients, CIN was seen in 14 patients [21.8%]. After the procedure, significant difference was seen in the mean creatinine levels [p < 0.001]. The before and after experiment creatinine values also showed a significant difference [p < 0.05]. SCr along with calculated GFR should be used to assess patients for underlying renal insufficiency undergoing contrast procedures like coronary angioplasty. Patients with low GFR and normal SCr have a significant risk of developing CIN. Identifying such patients before hand can help us decrease the overall incidence of CIN by administering timely prophylactic measures

School health services in Rawalpindi cantonment

To study the existing infrastructure provided for public as well as private school health services in Rawalpindi cantonment. A descriptive study. The study was carried out in Rawalpindi cantonment from Aug 2008 to Feb 2009. The study was carried out in two different categories of schools comprising public and private schools. The results of the study did not depict an encouraging picture and 100% of schools, whether public or private, had no medical officer / school nurse employed. School health system assessment and a comparison of public and private sector schools showed that no organized services are available for the students and most of the schools lacked fully available services of a medical officer and the concept of annual or periodic examination required still more concrete efforts

Health management information system in district health care

To study the existing Health Management Information System being practiced in Basic Health Unit and recommend measures to improve. Descriptive cross sectional study. Basic health unit. This study was conducted in Basic Health Units of Tehsil Taxilla from January to December 2008 in district Rawalpindi. Patients and Subjects were the staff working at basic health units dealing with data entry. Structured questionnaire was developed and data was collected by interview. The findings of the study revealed that although timeliness of reporting was 100% but only 70% were accurate. It was found out that 84% of the information was being analysed and 64% of the reporting facilities were getting feedback. There was no use of the information for decision making. The results of the study demonstrated that the timeliness of reporting is up to the mark but the processing of the information conveyed by the basic health unit on health management information system indicators is not being carried out at the executive district officer health office Rawalpindi. Thus not making any use of the information available for planning health activities and decision making

Assessment of Renal insufficiency in patients with normal serum creatinine levels undergoing angiography

To determine the frequency of patients with underlying renal insufficiency having normal serum creatinine level proceeding for coronary angiography. A total of 693 patients from September 2009 to February 2010 undergoing diagnostic coronary angiography at the National Institute of Cardiovascular Diseases [NICVD] with normal serum creatinine

Gender distribution of coronary artery lesions in patients aged 50 years and below

Objective: this study was designed to compare the gender differences in the pattern of coronary artery lesions in young Pakistani population

Material and Methods: a series of 120 consecutive patients [60 females/60 males], 50 years or less of age, with significant coronary artery lesions, were analyzed and compared for distribution of significant lesions in coronary arteries at National Institute of Cardiovascular Diseases, [NICVD] Karachi

Results: the mean age of female patients was 45 + 5.8 years and male patients 44 + 5.9 years. Single vessel disease [SVD], mid-LAD [left anterior descending artery] lesion and ejection fraction were significantly higher in females. In males, a higher trend for triple vessel disease was observed. In both genders with single vessel disease, the predominant vessel involved was left anterior descending artery. Almost equal incidence of double vessel disease [DVD] was noted in both genders

High risk coronary artery anomalies in 5131 adult patients undergoing coronary arteriography at Nicvd Karachi

To evaluate the frequency, origin, course and clinical significance of coronary anomalies. Single centre, descriptive study. The study was carried out at National Institute of Cardiovascular Diseases, [NICVD] Karachi, from January 2003 to July 2004. All adult patients [n=5131] undergone during study period for coronary arteriography included. Coronary arteriograms were evaluated for coronary anomalies by author. Patients with low risk coronary anomalies were excluded from study. Seventy two percent were males and 28% females; the mean age of patients was 54 years with a range of 26 years to 70 years. Fifty five percent were present with chestpain,33.3% with shortness of breath and 11.1% with palpitation. Total frequency was seen in 0.35%; out of them 88.8% have anomalous origin and distribution while 11.11% have coronary artery fistula. Left circumflex, LAD, left main coronary artery arise from right sinus of valsalva with frequency of 0.155, 0.058 and 0.058% respectively. In 0.058% of patients RCA arise from left sinus while 0.038% patients LAD arise from non coronary sinus. Coronary fistula noted in 0.038% patients. Clinicians, cardiologists and cardiac surgeons may consider coronary anomalies to be interesting rarities. The proper recognition determine the proper course of action for their management

Gender comparison of coronary risk factors and clinical presentation in young pakistani patients with coronary artery lesions

This cross-sectional study was designed to compare the gender prevalence of coronary risk factors and clinical presentation in young Pakistani patients with coronary artery lesions for defining high risk groups. A series of 120 consecutive patients [60 females/60 males] 50 years or less of age, with significant coronary artery lesions, were compared in different clinical subsets and coronary risk factors at National Institute of Cardiovascular Diseases, Karachi. The mean age of female patients was 45 +/- 5.8 years and male patients 44 +/- 5.9 years. On gender comparison: Significantly higher percentage of females presented with unstable angina and functional class III while males presented with post myocardial infarction angina, stable angina and functional class II. Diabetes mellitus was more common in females while smoking and dyslipidemia in males. Females with unstable angina had higher percentage of single vessel disease and isolated left circumflex disease while males presented with post myocardial infarction angina and greater percentage of right coronary artery lesion. Single and double vessel disease was significantly high in diabetic females compared to diabetic males. In males high serum cholesterol were associated with single vessel disease. Triple vessel disease was more common in hypertensive females and in males with family history of coronary artery disease. Within diabetics, multi-vessel disease was more common than single vessel disease. Single vessel disease was higher in non-diabetics. However, non-diabetic males had higher percentage of both single and double vessel disease has a trend for proximal lesions. Diabetes mellitus increases possibility of multi-vessel disease in both genders. Hypertension in females while high serum cholesterol and family history of coronary artery disease in males had significantly higher percentage of multi-vessel disease compared with their gender counterpart. Smoking was not a risk factor in females in the study population

Competency profile of locally manufactured clopidogrel lowplat and foreign manufactured clopidogrel plavix in patients of suspected ischemic heart disease [CLAP-IHD]

The primary objective of this study was to test the hypothesis that the antiplatelet effects of loading dose of locally manufactured clopidogrel Lowplat referred as drug [B] 600 mg [8 tablets] given once is comparable to the antiplatelet effects of loading dose of foreign manufactured clopidogrel Plavix referred as - drug [A] 600 mg [8 tablets] given once in patients with suspected ischemic heart disease. This was a double blind, randomized, cross over, study, to compare the safety and efficacy of study drug [B] versus [A] in adult subjects suffering from suspected ischemic heart disease presented at National Institute of Cardiovascular Disease [NICVD], Karachi. Mean platelet aggregation inhibition by drug [B] was 60.7% [p<0.001], while with drug [A] it was 57.8% [p<0.001], using 20 umol/LADP, which is statistically significant and comparable. Clopidogrel 600 mg as loading dose was well tolerated. Both drugs were equally effective in reducing the platelet aggregation. CLAP-IHD confirmed that drug [B] and [A] are equally effective and comparable antithrombotics in Pakistani population. The cost benefit of drug [B] should be made beneficial to the patients

frequency of HBV, HCV and HIV in patients undergoing percutaneous mitral valvuloplasty

Objective: Determine the frequency of Hepatitis B, C and HIV in patients undergoing mitral valvuloplasty with multitrack balloon catheters

Methods: This was a cross sectional study in which 100 consecutive patients of both sexes underwent percutaneous Mitral Valvuloplasty with multi track balloons catheters at the National Institute of Cardiovascular Diseases Karachi from January 2003 to December, 2004. The Viral markers of Hepatitis B Surface Antigen and Antibodies against Hepatitis C and HIV was done in all patients undergoing PTMC prior to procedure

Results: Out of 100 patients undergoing PTMC with multi track balloon catheters, 78 patients were females while 22 of them were males. Screening of these patients showed that 14% of them were Sero positive for HBV while 8% positive for HCV. None of screened patients were HIV positive

Conclusion: 1] The frequency of hepatitis B, C and HIV in patients undergoing PTMC [14% and 8%], as compared to normal population [2.56% for HBsAg] and [5.31% for anti-HCV] respectively. 2] In our country most of patients are non-affording and we have to reuse balloon catheters, so it should be mandatory to screen hepatitis B, C and HIV before undergoing invasive procedures. Balloon used in seropositive patients should be discarded. 3] National guidelines regarding reuse of various hardwire and other preventive measures are mandatory for patient's safety

Hypertrophic cardiomyopathy, coronary ectasia myocardial bridging and internal cardioverter defibrillator implantation

Hypertrophic Cardiomyopathy is one of the causes of sudden cardiac death. Here we present one case with Hypertrophic Cardiomyopathy with ectatic vessel and myocardial bridging who later underwent Internal Cardioverter Defibrillator implantation

Competency profile of locally manufactured clopidogrel lowplat and foreign manufactured clopidogrel plavix in patients of suspected ischemic heart disease [CLAP-IHD]

The primary objective of this study was to test the hypothesis that the antiplatelet effects of loading dose of locally manufactured clopidogrel Lowplat referred as drug [B] 600 mg [8 tablets] given once is comparable to the antiplatelet effects of loading dose of foreign manufactured clopidogrel Plavix referred as drug [A] 600 mg [8 tablets] given once in patients with suspected ischemic heart disease. This was a double blind, randomized, cross over, study, to compare the safety and efficacy of study drug [B] versus [A] in adult subjects suffering from suspected ischemic heart disease presented at National Institute of Cardiovascular Disease [NICVD], Karachi. Mean platelet aggregation inhibition by drug [B] was 60.7% [p<0.001], while with drug [A] it was 57.8% [p<0.001], using 20 micro mol/L ADP, which is statistically significant and comparable. Clopidogrel 600 mg as loading dose was well tolerated. Both drugs were equally effective in reducing the platelet aggregation. CLAP-IHD confirmed that drug [B] and [A] are equally effective and comparable antithrombotics in Pakistani population. The cost benefit of drug [B] should be made beneficial to the patients

Frequency of dyslipidemia in normotensive diabetics

As diabetes mellitus has been declared CHD equivalent we conducted the study with the idea of the presence of clustering of risk factors. These risk factors may appear mild when considered individually, but when added together, they can raise the risk for heart disease significantly. We specially looked the level of various fractions of lipid -in -type 1-and type 2 diabetes mellitus. This cross sectional comparative study was conducted on 100 diabetic patients [50 patients of type-1 and 50 patients of type-2 diabetes mellitus] selected by convenience, who presented in OPD, Department of Medicine, Bahawal Victoria Hospital, Bahawalpur and Qazi Diabetic Clinic located in the premises of Medical Colony Bahawalpur. Study included diabetic patients of all groups and from both sexes. Patients with at least one year history of diabetes mellitus. Among the 100 patients suffering from diabetes mellitus, 68 [68%] were males and 32 [32%] were females. Having 18 to 60 years, in type 1 average age 39.18 +/- 9.86, in type 2 average age was 53.64 +/- 9.95 years. Level of serum total cholesterol was 211.91 +/- 40.19 mg% in type 1, 229.54 +/- 55.60 mg% in type 2. Level of serum triglycerides was 217 +/- 62.34 mg% in type 1 and it was 352.54 +/- 181.47 mg% in type 2. Level of serum LDL-C was 131.82 +/- 32.17 mg% in type 1 and 134.08 +/- 38.48 mg% in type 2. Level of serum HDL-C was 38.88 +/- 3.88 mg% in type 1 and 38,82 +/- 3.62 mg% in type-2. Dyslipidemias were more common in female diabetic patients. Duration of diabetes showed linear correlation with dyslipidemias. We found elevated levels of serum triglycerides and total cholesterol, decreased HDL-C and disturbed values of LDL-C in both types of diabetes mellitus. So all the diabetics should be educated about dyslipidemias and their serum lipid levels should be checked regularly. Primary prevention can minimize the complications resulting due to diabetic dyslipidemias

Local experience of intravascular ultrasound [IVUS] in intermediate coronary artery lisions

To evaluate intermediate lesions by Intravascular ultrasound [IVUS] for its severity. Design: Observational study. Place and duration of study: Patients undergoing coronary angiography at catheterization laboratory, National Institute of Cardiovascular Diseases Karachi, in the period between 01-01-2000 to 15-03-2001. Seventeen patients with intermediate coronary artery lesions with interobserver discrepancy underwent IVUS study. Out of seventeen patients with intermediate lesions, 70% had LAD [Left Anterier Descending] Lesions 24% had RCA [Right Coronary Artery] and 6% had Cx [Left Circumflex Artery] lesion. IVUS showed severe lesion in all the patients. IVUS revealed that intermediate lesions visualized by coronary angiography had severe lesions