Non-invasive investigations in heroin users and non-users - a case control study

Objective: To compare heroin users with their age and gender matched relatives as regards non-invasive investigations like chest x-ray, electrocardiography [ECG] and 2D-echocardiography

Study Design: Case control study

Place and Duration of Study: Armed Forces Institute of Cardiology-National Institute of Heart Diseases, Rawalpindi, from Feb 2010 to Jul 2010

Material and Methods: Sixty one heroin users [cases] and their 100 non-substance abuser age and gender matched relatives [controls] were included through non-probability consecutive sampling. Chest x-ray [CXR], 12-lead electrocardiography [ECG] and two-dimensional echocardiography [2D-ECHO] were done of each one and the result was interpreted by respected consultants. The data were analyzed on SPSS version 15. Descriptive statistics of mean and standard deviation [SD] were described for quantitative variables while frequency and percentages for qualitative variables. Independent samples t-test compared quantitative variables while for qualitative variables chi-square test was used. Ninety five percent confidence intervals were calculated for all variables

Results: Statistically significant differences were noted between cases and controls as regards chest X-ray. A total of 10% cases had findings consistent with tuberculosis [TB] as compared to 3% controls [p=0.045]. There was however no cardiac abnormality in any study subject. Significant 12-lead ECG findings other than normal were noticed in 12 [19.7%] heroin users as compared to 10 [10%] controls [p=0.083]. In 12 lead ECG, the predominant finding was t wave inversion in leads AVF and III. According to 2D-echocardiography [2D-echo] reports, 15 [24.6%] heroin users [cases] and 17 [17%] controls had abnormal findings [p=0.242]. We report no vegetations on any cardiac valve

Conclusion: On radiological and cardiac parameters, heroin users are a different population as compared to the non-heroin users. The knowledge about variations on non-invasive investigations not only helps the healthcare workers to optimize treatment regarding rehabilitation but also facilitate diagnosis and treatment

Peripartum cardiomyopathy in a Pakistani cohort

Objective: To describe the demographics, risk factors, and clinical presentation in Pakistani patients with peripartum cardiomyopathy

Study Design: A descriptive observational study

Place and Duration of Study: Rawalpindi Institute of Cardiology, Rawalpindi, from June 2014 to June 2015

Methodology: Seventy patients meeting criteria of peripartum cardiomyopathy were included in the study. A detailed history, physical examination and investigations were done. Epidemiologic data, risk factors, New York Heart Association [NYHA] class and echocardiographic findings were recorded. Statistical analyses were done using SPSS version 19

Results: The mean age was 28.66 +/-4.57 years. Mean parity and weight was 3.04 +/-1.7 and 60.97 +/-12.40 Kg, respectively. Fifty-five [78.6%] cases were diagnosed in the postpartum period. Thirty-three [50.8%] and 31 patients [44.7%] presented in NYHA - III and IV classes, respectively. Pregnancy-induced hypertension was seen in 16 [22.9%] cases, diabetes in 6 [8.6%], and twin pregnancy in 2 [2.9%] cases. The mean hemoglobin and brain natriuretic peptide [BNP] was 11.26 +/-1.61 gm/dl and 1583.70 +/-1237.65 pg/ml, respectively. Echocardiography showed mean ejection fraction of 21.74 +/-7.45%. Left ventricle systolic and diastolic diameters were 53.71 +/-9.74 mm and 63.37 +/-8.48 mm, respectively

Conclusion: Peripartum cardiomyopathy was seen in younger women with higher parity and pregnancy induced hypertension, often manifesting in the postpartum period with NHYA class III and IV status

Clinical safety and parameters of maximum oxygen uptake [VO[2] max] testing in Pakistani patients with heart failure

To determine the parameters of maximum oxygen uptake [VO[2] max] in a Pakistani systolic heart failure cohort and its safety in a clinical setting. Descriptive study. Armed Forces Institute of Cardiology, National Institute of Heart Diseases, Rawalpindi, from June 2011 to January 2013. Maximum oxygen uptake test was performed in patients with severe heart failure, who could perform the VO[2] max treadmill test. Age, Body Mass Index [BMI] ejection fraction, VO[2] max and respiratory exchange ratios and their correlations were determined. Out of 135 patients, 77% [n=104] were males, with a mean age of 45.9 +/- 15.7 years. Weight of patients ranged from 30 kg to 107 kg [mean 63.29 +/- 13.6 kg]; mean BMI was 23.16 +/- 4.56 kg/m2. All patients presented with either NYHA class of III [50.3%; n=68] or IV [49.7%; n=67]; mean ejection fraction was 22.54 +/- 5.7% [10 - 35%, IQ:20 - 25]. The VO[2] max of the patients ranged from 3 to 32 ml/kg/minute [mean 12.85 +/- 4.49 ml/kg/minute]. Respiratory exchange ratio was over 1 for all patients [1.12 - 1.96, mean = 1.36 +/- 0.187]. There was a negative correlation with age [r = 0.204; p = 0.028] whereas a positive correlation was found with exercise time [r = 0.684; p = 0.000], hemoglobin [r = 0.190; p = 0.047] and ejection fraction [r = 0.187; p = 0.044]. Cardiopulmonary exercise testing in a high-risk heart failure cohort is safe and provides information beyond the routine clinical evaluation of heart failure patients

Description and follow-up of patients with coronary perforations during percutaneous coronary interventions at AFIC-NIHD

This study was conducted to determine the frequency and describe the lesion characteristics, clinical factors, device responsible and outcomes for coronary perforations at Armed Forces Institute of Cardiology - National Institute of Heart Diseases [AFIC -NIHD] on all patients undergoing percutaneous coronary interventions [PCI] from 2007 to May 2012. A total of 13,366 PCI procedures were performed during this period; coronary perforation occurred in 16 cases [0.001%]. All patients had elective PCI. Fifty percent [n = 8] patients had type C lesions. Grade III perforations were seen in 10 patients. Seven perforations were caused by angiography wires. None of the perforations was related to atherectomy devices. Six patients needed pericardiocentesis. There were 3 in-hospital deaths. One patient needed CABG. At followup, all patients who had been discharged were alive. The frequency of coronary perforations was very low. Old age and type C lesions were identified as a risk factor for coronary perforations. Grade III [or greater] perforation was a predictor of mortality. Patients who are discharged to home generally had better outcomes.

Validation of the Seattle heart failure model [SHFM] in heart failure population

To determine the effectiveness of Seattle Heart Failure Model [SHFM] in a Pakistani systolic heart failure cohort in predicting mortality in this population. Cohort study. The Armed Forces Institute of Cardiology - National Institute of Heart Diseases, Rawalpindi, from March 2011 to March 2012. One hundred and eighteen patients with heart failure [HF] from the registry were followed for one year. Their 1-year mortality was calculated using the SHFM software on their enrollment into the registry. After 1-year predicted 1-year mortality was compared with the actual 1-year mortality of these patients. The mean age was 41.6 A +/- 14.9 years [16 - 78 years]. There were 73.7% males and 26.3% females. One hundred and fifteen patients were in NYHA class III or IV. Mean ejection fraction in these patients was 23 A +/- 9.3%. Mean brain natriuretic peptide levels were 1230 A +/- 1214 pg/mL. Sensitivity of the model was 89.3% with 71.1% specificity, 49% positive predictive value and 95.5% negative predictive value. The accuracy of the model was 75.4%. In ROC analysis, AUC for the SHFM was 0.802 [p < 0.001]. SHFM was found to be reliable in predicting one-year mortality among patients with heart failure in the Pakistani patients

Superior vena cava thrombosis with peripartum dilated cardiomyopathy

A 30 years multiparous female with history of emergency caesarean section 10 days back was referred to us with cough, severe breathlessness at rest, orthopnea with pain in neck and arms. Clinical examination revealed signs of heart failure. Echocardiography showed ejection fraction of 15%, with no right ventricular strain. A diagnosis of peripartum cardiomyopathy was made. Doppler ultrasound of neck veins showed bilateral internal jugular vein thrombosis. Subsequent multislice CT examination showed thrombosis of superior vena cava and both internal jugular veins [with collateral formation] and pulmonary embolism. There were no mediastinal abnormalities on the CT scan. Her thrombophilia screen and CT scan brain was normal. She was managed in collaboration with cardiologist. Following treatment with subcutaneous enoxaparin therapy and warfarin her symptoms of upper limb pain improved. She responded very well to medical therapy for heart failure with marked improvement of NYHA functional class

Trans-radial primary percutaneous coronary intervention in ST-elevation myocardial infarction

To study the effect of trans-radial approach [TRA] on achievement of a door-to-balloon time [DBT] of

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

Accelerated 2 hour regimen of streptokinase for pulmonary embolism

To assess the safety and efficacy of accelerated 2 hour regimen of streptokinase [SK] in acute massive pulmonary embolism. The primary end point of study was immediate hemodynamic improvement and safe discharge from the hospital. Quasi-experimental study. Armed Forces Institute of Cardiology - National Institute of Heart Diseases [AFIC-NIHD], March 2010 to Sept 2010. Twenty five patients referred to AFIC-NIHD Rawalpindi with recent symptoms [<5 days] suggestive of acute massive pulmonary embolism were considered for entry into the study. On confirmation of acute massive pulmonary embolism, they were thrombolysed with 1.5 million units of streptokinase over two hours followed by unfractionated heparin infusion intravenously at a dose of 1,000 IU/h. They were observed for immediate hemodynamic and clinical improvement and followed up till discharge from the hospital. Safety of Streptokinase was assessed by observing for major bleed [requiring blood transfusion]/fatal bleeding/intracranial haemorrhage confirmed on CT scan or anaphylaxis secondary to accelerated regimen. Mean age of the patients was 55 years [range 24 to 85 years] and 60% [15] were males and 40% [10] were females. CT pulmonary angiogram in all 25 cases confirmed massive pulmonary embolism. Streptokinase 1.5 million units were given to all 25 patients in infusion form over a period of 2 hours followed by unfractionated heparin infusion at 1000 IU/hour. No bleeding complication was observed in any of these cases. Eighteen [72%] patients showed immediate hemodynamic and clinical improvement but 28% [7] expired on the same day. Average hospital stay of the patients was 6 days. Mortality of patients with massive pulmonary embolism is high even after thrombolysis. Accelerated 2 hour regimen of streptokinase can be routinely used in patients with massive pulmonary embolism without obviously compromising efficacy or safety but further randomized controlled trials to compare the two SK regimens are required to better predict the efficacy and outcome of the two regimens

Effect of a regimen of optimal medical therapy on brain natriuretic peptide [bnp] levels in heart failure in the Pakistani population

To document the effect of optimal medical therapy [OMT] on BNP levels in heart failure in Pakistani population. In this Quasi experimental study, 75 consecutive stage C heart failure patients that had not been on OMT were included. These patients had been referred to AFIC-NIHD Heart Transplantation Department for assessment regarding heart transplantation. Initial assessments were carried out in hospital. Patients who were on OMT already were excluded. The prescription [carvedilol, lisinopril, spironolactone] was introduced as in patient as per pre defined protocol after clinical, imaging and lab evaluation. The patients were followed up in clinic and the dose escalation was done at regular intervals in out patients department. Clinical and lab variables were collected included BNP levels before starting treatment and 4 weeks after treatment. Males were 75% and females were 25%. Mean age was 38.69 +/- 12.98 years [range 18-70 years]. Mean Ejection fraction was 23.9% [range 15 - 34%]. At one month clinical status of all patients improved except one. The patients had improved from NYHA class-III to NYHA class-II of dyspnoea. The mean baseline BNP level was 1331 pg/ mL, and the BNP level 4 weeks after the OMT trial was 951.9 pg/mL. This reduction was statistically significant [p=0.016]. OMT improves the BNP levels within a span of one month in patients with advanced systolic heart failure. This also correlated with the clinical improvement in the patients, and it was observed that BNP levels helped to monitor patients objectively and adjust OMT

Follow up of the patients treated with the mguard stent system in percutaneous coronary intervention at AFIC- NIHD

The objective of this study was to conduct a follow up of the patients treated with the MGuard Stent used in Percutaneous Coronary Intervention [PCI] in the setting of acute coronary syndromes at AFIC-NIHD

Introduction: The consequences of distal embolisation during PCI in acute coronary syndrome can vary from a simple sluggish flow to myocardial infarction and death. A number of protection devices reduce distal embolisation, but they add complexity and cost to the procedure. The MGuard stent is a unique innovation to counter the phenomenon

Objective: The objective of this study was to conduct an angiographic follow up of the patients treated with the MGuard Stent used in Percutaneous Coronary Intervention [PCI] in the setting of acute coronary syndromes at AFIC-NIHD. Patients and Methods: The study was conducted in AFIC-NIHD. Between April 2010 to date 21 patients were treated with a total of 25 MGuard stents. Inclusion criteria included de novo lesions in saphenous vein grafts or native vessels with angiographic evidence of thrombus activity or lesion instability and a potential for distal embolization, all in the setting of acute coronary syndromes

Results: All patients were male. Mean age was 46.23 years [range 32-70 years]. All patients were admitted with acute coronary syndromes. Most lesions had complex morphological features and all had some thrombus activity. The MGuard stent was deployed successfully in all cases and without any complications. Secondary endpoints [TIMI-III flow and myocardial blush grade 3] were met in all cases. There was no elevation of cardiac enzymes post procedure in any patient.On follow up Nine patients [42%] had critical ISR [2 of these were total occlusions] and all required repeat intervention.One patient died within 30 days of PCI

Conclusion: These preliminary results show that the MGuard stent is a safe option for patients undergoing PCI in de novo coronary artery lesions in the setting of acute coronary syndrome with thrombus burden and saphenous vein graft stenosis. However the long term follow up of these patients shows significant ISR which needs to be clarified with a larger sample size

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

Follow up of the patients treated with the mguard stent system in percutaneous coronary intervention at afic - NIHD

The objective of this study was to conduct a follow up of the patients treated with the MGuard Stent used in Percutaneous Coronary Intervention [PCI] in the setting of acute coronary syndromes at AFIC - NIHD. The consequences of distal embolisation during PCI in acute coronary syndrome can vary from a simple sluggish flow to myocardial infarction and death. A number of protection devices reduce distal embolisation, but they add complexity and cost to the procedure. The MGuard stent is a unique innovation to counter the phenomenon. The objective of this study was to conduct an angiographic follow up of the patients treated with the MGuard Stent used in Percutaneous Coronary Intervention [PCI] in the setting of acute coronary syndromes at AFIC - NIHD. The study was conducted in AFIC - NIHD. Between April 2010 to date 21 patients were treated with a total of 25 MGuard stents. Inclusion criteria included de novo lesions in saphenous vein grafts or native vessels with angiographic evidence of thrombus activity or lesion instability and a potential for distal embolization, all in the setting of acute coronary syndromes. All patients were male. Mean age was 46.23 years [range 32-70 years]. All patients were admitted with acute coronary syndromes. Most lesions had complex morphological features and all had some thrombus activity. The MGuard stent was deployed successfully in all cases and without any complications. Secondary endpoints [TIMI - III flow and myocardial blush grade 3] were met in all cases. There was no elevation of cardiac enzymes post procedure in any patient.On follow up Nine patients [42%] had critical ISR [2 of these were total occlusions] and all required repeat intervention.One patient died within 30 days of PCI. These preliminary results show that the MGuard stent is a safe option for patients undergoing PCI in de novo coronary artery lesions in the setting of acute coronary syndrome with thrombus burden and saphenous vein graft stenosis. However the long term follow up of these patients shows significant ISR which needs to be clarified with a larger sample size

Follow up of the patients treated with the mguard stent system in percutaneous coronary intervention [pci] at afic-nihd

The objective of this study was to conduct a clinical and angiographic follow up of the patients treated with the MGuard Stent used in PCI in the setting of acute coronary syndromes. The study was conducted in AFIC-NIHD Rawalpindi, from April 2010 and October 2010 twenty one patients were treated with a total of 25 MGuard stents. Patients included were those having de novo lesions in saphenous vein grafts or native vessels with angiographic evidence of thrombus and lesion instability with a potential for distal embolization in the setting of acute coronary syndromes. All patients were male. Mean age was 46.23 years [range 32-70 years]. Fourteen patients were admitted with ST elevation MI, 4 with Non-ST elevation MI, and 3 with unstable angina. Two vein grafts were stented while the rest were de novo lesions in native coronary arteries. The mean vessel diameter was 3.0mm [2.5- 3.5]. The stent length ranged from 12 to 39 mm. MGuard stent was deployed successfully with no complications of PCI [distal embolization]. Secondary endpoints [TIMI- III flow and myocardial blush grade 3] were met in all cases. One patient died within 30 days of PCI. On follow up 9 patients [42%] had critical ISR [2 of these were total occlusions] and all required repeat intervention. Total MACE events were 47% [1 death and 9 TLR]. Angiographic follow up of MGuard stent at 6 month showed significant ISR which needs to be clarified with a larger sample size

Initial experience with the novel mguard stent system for percutaneous coronary intervention at AFIC-NIHD

To assess the efficacy of the MGuard Stent in Percutaneous coronary Intervention [PCI] in the setting of acute coronary syndromes. Interventional case series. Distal embolisation during PCI occurs in acute coronary syndrome from the thrombus occluding the artery. The consequences can vary from a simple sluggish flow to myocardial infarction and death. A number of protective devices reduce distal embolisation, but they add complexity and cost to the procedure. The balloon expandable MGuard stent is a unique innovation to counter the phenomenon. We sought to study its efficacy in the proposed indications. The study was conducted in AFIC - NIHD. Between April and July 2010, 18 patients were included and a total of 21 MGuard stents were deployed. Inclusion criteria were de novo lesions in saphenous vein grafts or native vessels with angiographic evidence of thrombus activity or lesion instability and a potential for distal embolisation in the setting of acute coronary syndromes. Use of filter wires or other proximal or distal protective devices was not allowed in the study. Primary end point included the incidence of MACE [composite if cardiac death, non-fatal MI and need for TLR] up to 30 days after the procedure. Secondary endpoints included restoration of TIMI grade 3 flow and myocardial blush grade 3 at the end of the procedure. All patients were male. Mean age was 45.61 years [range 32-70 years]. All were admitted with acute coronary syndrome. Most lesions had complex morphological features and all had some thrombus activity. The MGuard stent was deployed successfully in all cases and without any complications. Secondary endpoints [TIMI- grade III flow and myocardial blush grade 3] were met in all cases. There was no elevation of cardiac enzymes post procedures in any patient, and no MACE was reported at 30 days [primary end point]. These preliminary results show that the MGuard stent is a safe option for patients undergoing PCI in the setting of acute coronary syndrome with thrombus burden and saphenous vein graft stenosis

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

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

Acute myocardial infarction; significance of 1 [st] set of CK-MB in diagnosis

To assess the reliability of the first set of CK-MB in establishing diagnosis of acute myocardial infarction in different subgroups of the patients according to their time of presentation after symptom onset. Prospective observational study was carried out in Armed Forces Institute of Cardiology/National Institute of Heart Diseases [AFIC/NIHD] Rawalpindi, from April to September 2005. We studied 300 consecutive cases presenting with typical electrocardiographic changes of acute ST Elevation Myocardial Infarction of the Emergency and Reception department of AFIC/NIHD [confirmed later on as acute STEMI with raised serial serum cardiac enzymes levels]. We documented values of CK-MB at the time of presentation in different subgroups of the patients according to duration of symptom onset. This study was predominantly male dominated [approximately 78%], with a mean age of 58 +11 years. Majority of patients i.e. 216 [72%] presented within first 6 hours of onset of symptoms, 60 [20%] within 6-12 hrs, 6[2%] within 12-24 hrs and 18 [6%] after 24 hrs of onset of symptoms. Overall serum cardiac enzymes sent at the time of presentation revealed that 126 [42%] patients had normal CK-MB [<24U/L] and another 66 [22%] had a minimal rise in CK-MB [25-49U/L]. Only 108 [36%] patients 3 had serum CK-MB levels more than double the normal value. Amongst the patients presenting within the first 6 hours of onset of symptoms, 104 [48%] had normal CK-MB values, 48 [22%] had a minimal rise [<49 U/L] and only 64 [30%] had a significant rise in CK-MB levels i.e. more than double the normal values or more than 5% of CK value. Out of 60 patients who presented within 6-12 hours of onset of symptoms, 54 [90%] had more than double the normal value of CK-MB and 6 [10%] had mild rise in CK-MB. All the patients [100%] who presented within 12-24 hours of onset of symptoms i.e. 6 [2%] and more than 24 hours 18 [6%] had significant rise in CK-MB. This study shows that the first set of CK-MB alone has very little value in diagnosing acute myocardial infarction especially in the patients who presented within 6 hours of onset of symptoms. Reliability of CK-MB in diagnosing acute myocardial infarction greatly improves to the maximum in those patients who present more than six hours after symptom onset